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Social worker participation in the treatment of the mentally ill : a study of the current program at… Pepper, Gerald Wesley 1953

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SOCIAL WORKER PARTICIPATION IN THE TREATMENT OF THE MENTALLY ILL.. A Study of the Current Program at the P r o v i n c i a l Mental Hospital and the Crease C l i n i c of Psychological Medicine, Essondale, B.C. by GERALD WESLEY PEPPER. Thesis Submitted i n P a r t i a l Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL WORK i n the School of So c i a l Work. Accepted as conforming to the standard required for the degree of Master of S o c i a l Vfork School of So c i a l Work 1953 The University of B r i t i s h Columbia. ABSTRACT. Evolution i n the improved treatment of the mentally i l l has been slow, and even today there i s much v a r i a t i o n i n hos-p i t a l s and communities. One of the most recent developments towards more e f f e c t i v e treatment i s the use of the treatment team. The members of t h i s team, as a rule, are: doctor, nurse, psychologist, occupational'therapist and s o c i a l worker. Each one of these professional d i s c i p l i n e s shares h i s knowledge of the patient with the others, so that a l l areas of the patient's l i f e can be given f u l l consideration. This thesis examines the role of the s o c i a l worker i n the treatment team that works v/ith the mentally i l l i n two treatment centres - the P r o v i n c i a l Mental Hospital and the Crease C l i n i c of Psychological Medicine at Essondale, B.C. The study was undertaken to point up the s o c i a l worker's area of competence and show where i t can be used to the best advantage i n the mental h o s p i t a l program. The material used to evaluate the program was obtained through interviews with members of the s o c i a l service s t a f f , by attendance at s t a f f meetings, reviewing, records of past s t a f f , meetings, and by examining reports that have been prepared by various members of the s t a f f on t h e i r casework a c t i v i t i e s . The study was meant to be more of a q u a l i t a t i v e analysis and because of t h i s a minimum of s t a t i s t i c a l material has been included. . An examination of the treatment program shows that the s o c i a l worker o f f e r s casework services to the patient and. h i s family from the time of the patient's admission to the H o s p i t a l or the C l i n i c u n t i l long a f t e r h i s discharge. S p e c i f i c a l l y , t h i s means that s o c i a l service i s available, to the patient from the time of h i s reception; while he i s under treatment on the ward; at the time that he i s preparing f o r h i s return to h i s home; and also a f t e r his discharge i n the form of counsell-ing or r e h a b i l i t a t i o n services. The s o c i a l worker o f f e r s further services i n the areas of education and t r a i n i n g (of s o c i a l work and other professional s t a f f ) ; i n research, -prim-a r i l y to point out the needs i n t h e i r own area of the t r e a t -ment program; and also i n community in t e r p r e t a t i o n . P a r t i c -i p a t i o n , to a l i m i t e d extent, i s seen i n h o s p i t a l administration In concluding the study, i t was pointed up that there i s a need fo r more p a r t i c i p a t i o n i n the administrative aspects of treatment, the importance of s o c i a l workers on the wards was stressed, and an increased emphasis on.the r e h a b i l i t a t i o n of the patient was recommended. - r V AOKNOWIJBDG-EMEMTS. I w i s h t o acknowledge i n d e b t e d n e s s t o t h e s o c i a l w o r k e r s i n the S o c i a l S e r v i c e D e p a r t m e n t s a t the P r o v i n c i a l M e n t a l H o s p i t a l and the C r e a s e C l i n i c o f P s y c h o l o g i c a l M e d i c i n e f o r t h e i r i n t e r e s t and c o - o p e r a t i o n i n t h e p r e p a r a t i o n o f t h i s t h e s i s . The d i r e c t i o n and encouragement o f M i s s A . C a r r o l l , P r o v i n c i a l S u p e r v i s o r o f P s y c h i a t r i c S o c i a l Work, D r . L e o n a r d C . M a r s h and M i s s M u r i e l G u n l i f f e o f t h e S c h o o l o f S o c i a l Work i s acknow-l e d g e d w i t h g r a t i t u d e . TABLE OF CONTENTS. Chapter 1. Sooial Work i n Hental Hospitals. Page. The teamwork approach. The s o c i a l worker's contribution to treatment. H i s t o r i c a l background. The beginnings at Essondale. The role of the s o c i a l worker today. Method of present study. Present organization at Essondale. 1 Chapter I I . The Soc i a l Worker i n Hospital Administration. The general administration at Essondale. Administration of the S o c i a l Welfare Branch. Duties of the P r o v i n c i a l Sup-ervisor of Psychiatric S o c i a l Work. P a r t i c i p a t i o n of the s o c i a l worker i n hospital administration. 22 Chapter I I I . Admissions Procedure and Service. Beginnings of the Admissions Sections at Essondale. Ser-vices offered by the Admissions Sections. Duties of the Supervisor of the Admissions Sections. The Admissions Sect-i o n at the Mental Hospital. D i s p o s i t i o n of r e f e r r a l s . The Admissions Section at Crease C l i n i c 38 Chapter IV. Continuing Oasework. Beginnings of the Continuing Casework Sections. Duties of the Supervisors of the Continuing Casework Sections. Continuing casework services. Community interp r e t a t i o n , research and education. Continuing services on special wards. Continuing Casework Section at Crease C l i n i c . Re-h a b i l i t a t i o n study. 56 Chapter V. Recapitulation and Assessment. Contribution'to administration. Additional services. R e h a b i l i t a t i o n recommendations 89 Appendices: A. P o l i c i e s with F i e l d Services. B. Duties of Pr o v i n c i a l Supervisor. C. Orientation for Nurses. D. Orientation for In-Service Workers. E. Orientation for New Workers. F. Bibliography. CHARTS IN THE TEXT Page. Figure 1. Administrative Structure at the P r o v i n c i a l Mental Hospital and Crease C l i n i c . 24 Figure 2. Lines of r e s p o n s i b i l i t y i n the S o c i a l Welfare Branch. . < 26 Figure 3. Areas of r e s p o n s i b i l i t y of the P r o v i n c i a l Supervisor of Psychiatric S o c i a l Work. 27 Figure 4. Supervisors at the P r o v i n c i a l Mental Hospital and the Crease C l i n i c 31 Figure 5. Admissions sections at the P r o v i n c i a l Mental Hospital and the Crease C l i n i c . 39 Figure 6. Continuing Casework Sections at the P r o v i n c i a l . . Mental Hospital and the Crease C l i n i c 57 SOCIAL WORKER PARTICIPATION IN THE TREATMENT OE THE MENTALLY ILL. Chapter 1 - S o c i a l Work i n Mental Hospitals. The primary function of the mental h o s p i t a l i s for the care and treatment of persons suffering from mental i l l -ness. The e f f o r t s of a l l personnel employed by the hospit a l , whether i n an administrative, professional or c l e r i c a l p o s i t -ion, are directed towards helping these persons to recover from t h e i r i l l n e s s . The present trend i n treatment i n the mental ho s p i t a l i s a process that i s commonly c a l l e d the "teamwork approach". The professional 'personnel who are d i r e c t l y concerned with the treatment, namely the doctor, psychologist, nurse, s o c i a l work-er, and occasionally the occupational therapist, form the team that i s working together. Each contributes h i s s p e c i f i c s k i l l to the treatment so that every aspect of the patient's l i f e -b i o l o g i c a l , psychological and s o c i o l o g i c a l - i s given f u l l consideration i n treatment planning. In other words, the pat-ient i s treated as a whole. The goal of treatment i s seen as return to community l i v i n g with the f u l l e s t u t i l i z a t i o n of a l l possible resources f o r the personal, s o c i a l and vocational r e h a b i l i t a t i o n of the patient. The s o c i a l worker's s p e c i f i c contribution to t h i s treatment l i e s i n h i s understanding of the s o c i a l and emotion-a l factors that are a f f e c t i n g the l i f e of the patient. Em-bodied i n t h i s understanding i s a knowledge of human behav-i o r ; of psycho pathology; of;, d i f f e r e n t i a l diagnosis; of commun-i t y l i v i n g and i t s impact on the i n d i v i d u a l and his family; of the i n t e r - p l a y of family l i f e and i t s impact on the i n d i v i d -ual; and of the use of the helping r e l a t i o n s h i p and the under-standing of what accepting help commonly means to people. Along with these factors he "brings to the treatment team, a comprehensive acquaintance with community resources and s k i l l i n using them to service the i n d i v i d u a l and h i s family. I t has only "been since the early twentieth century that the s o c i a l worker has been able to make his contribution to the treatment of the mental patient during h i s h o s p i t a l i z -a t i o n. P r i o r to t h i s time the' s o c i a l worker's contact was primarily a f t e r discharge when the patient was i n need of assistance to become re-established i n the community. But r e -admissions helped the medical profession to see that treatment of the patient alone would not cure his mental i l l n e s s . Some-one was needed who could provide an accurate picture of the external stresses that the patient had to face, and a s s i s t i n helping him to meet these stresses with confidence. The s o c i a l worker with his casework s k i l l s , was the person to do t h i s . H i s t o r i c a l Background. The long story of the inhuman treatment of the mental-l y i l l i s well known. For over a century and a h a l f the events which worked enlightened innovations are few and f a r between. The year 1792, when the French Revolution was at i t s height, i s usually regarded as the date that a new attitude was s t a r t -ed towards the person suffering from mental i l l n e s s . I t was - 3 -i n that year, i n two d i f f e r e n t c i t i e s , one i n France and one i n England, that two men were beginning s i m i l a r reforms i n the treatment of mental i l l n e s s . . In Paris (France) two p r i n c i p a l i n s t i t u t i o n s f o r the mentally i l l had been established, the B i c e t r e f o r male "luna t i c s " , and the S a l t p e t r i e r e for females. At t h i s time therapeutic treatment was e n t i r e l y lacking, but thanks to P h i l l i p e P i n e l , a formerly obscure physician, these two i n -s t i t u t i o n s were transformed i n a manner which resulted i n a new approach to the treatment of mental i l l n e s s . P i n e l had the. chains removed from the insane and started treatment based on kindness and sympathy. There was a minimum of mechanical r e s t r a i n t and the beginnings of i n t e l l i g e n t understanding. In the same year that P i n e l started his reforms, a similar though f a r l e s s dramatic step, was being taken by the Quakers of York, England under the leadership, of one of t h e i r numbers, William Tuke. A b u i l d i n g was erected f o r the care of the insane. The main objectives i n t h i s new i n s t i t u t i o n were; to provide a protected environment for the patients; to emphas-ize employment and exercise that would be conductive to mental health; to treat the patients as guests rather than, inmates. Kindness and consideration formed the keystone of the whole t h e o r e t i c a l structure. The influence of P i n e l and the Quakers was l a t e r seen elsewhere. While P i n e l exercised the stronger influence i n the European countries i t was Tuke's work that played the more important role in America. A special institution for the mentally i l l was opened at Erankford, Pennsylvania in 1817 called the "Friends' Asylum" and i t i s believed that the origin-a l proposal for this institution came from a minister of the Quaker faith, Thomas Scattergood, who had spent six years trav-elling i n Britain, had met Tuke and been very impressed with his institution. One of the f i r s t attempts at classification of mental illness was made here. About the same time as the "Friends' Asylum" opened similar institutions arose i n other states. The Bloomingdale Asylum was completed i n New York, the leader behind this move being Thomas Eddy, a Quaker merchant who had kept i n touch with progress abroad and had written to Tuke about his hospital. One of the interesting features of Eddy's plan was that he i n -sisted on keeping a history of his patients during their stay in the asylum. About 1830, i n America, a vigorous movement started for the erection of suitable state hospitals for the insane.1 This movement saw it's impact i n the opening of the State Lun-atic Hospital in Worehester, Massachusetts in 1833, and in the following ten years at least nine public hospitals for the i n -sane were opened in the United States. The year 1841 saw a new figure enter the struggle for improved treatment of the mentally i l l i n the person of a re-tired school teacher, Dorothea Lynde Dix. Her career as a - 5 -reformer started with the instruction of a Sunday school in the East Cambridge j a i l i n Boston. Her protest against the treatment there, especially of the insane persons who were locked up, started her on a crusade that eventually took her on inspection tours of the mental hospitals in the United States, Britain, Canada and Europe. In nearly every i n -stance, her inspection and campaign led to the erection of a new hospital or the enlargement of an existing one. A l l these, significant though they were i n themselves, were almost isolated developments. Public understanding, re-form on a national scale, and the beginnings of professional training for staff waited un t i l the twentieth century for achievement on the North American continent. The primary step was taken by a former mental patient, C l i f f o r d Whittingham Beers. After his discharge he wrote a detailed account of his experiences in several mental hospitals. In his book, A Mind • That.-Found I t s e l f , 1 he was able to bring out some of the short-comings of the mental hospitals in the United States and ex-pose the conditions under which the mentally i l l were made to suffer. This book, now virtually, an American classic, was instrumental i n helping to found the Mental Hygiene movement in the United States. Throughout this period, when work became focused on the improved treatment of the mentally i l l , social workers con-stantly came in contact with the subject of mental disorder i n 1. C l i f f o r d W. Beers, A Mind That Found Itself. Doubleday & Company, Garden City, New York - lyua. - 6 -i t s social aspects. Provision for the indigent insane con-stituted one of their major tasks. There was also the problem of looking after the families of individuals who had been the breadwinners before being incapacitiated by mental i l l n e s s . One of the most serious questions confronting social workers was the readjustment of mental patients returning from hospitals to normal community l i f e . It often happened that a patient, discharged as cured, was unable to readjust himself to commun-it y existence. Such a person, unaided, might break down with consequent readmittance to the hospital perhaps permanently this time. The environmental conditions he met upon returning to society were never quite the same as when he was f i r s t hospit-alized. He was invariably burdened with new handicaps, one of the heaviest of which, was the stigma of insanity with which the patient of an asylum was branded. Commonly, when a patient had improved enough to be returned to the community, his discharge had to be delayed be-cause of socio-economic d i f f i c u l t i e s . There might not be any home or family to which he could be sent, or he might find i t impossible to get employment. There was no medium or agency through which the recovered patient could be given the i n i t i a l help and advice to enable him to start on the road of independ-ence. The f i r s t solution to the problem of the care of the discharged mental patient came in the ''after-care movement". This movement had been seen f i r s t in Nassau, Germany where i t - 7 -was introduced by a Doctor Lindpainter, dir e c t o r of the Iber- . t bach Asylum, and i n France a Societe de patronage was founded by a Doctor F a l r e t f o r the same purpose. A s i m i l a r society, c a l l e d the Guild of the Friends of the Infirm i n Mind, was es-tablished i n England. Later, the State Charities Aid Associat-ion of New York authorized i t s committee on the insane "to i n -augurate and maintain, f o r convalescents leaving hospitals who may be f r i e n d l e s s , a system of after-care whereby they may be strengthened i n health, protected and cared for u n t i l able, to support themselves". 1 The plan was held i n abeyance u n t i l 1906, but at that time the Manhattan After-Care Committee of the State C h a r i t i e s Aid Association was formed and an after-care agent was employed. The f i r s t instance i n America of the actual employment of a s o c i a l worker i n a h o s p i t a l occurred i n 1905 when Miss E d i t h N. Burleigh started her work at the Massachusetts General Hospital under the d i r e c t i o n of Doctor James J. Putnam. In the following year, a s o c i a l worker was employed i n the psychopathic wards of the Bellevue Hospital (New York) f o r the purpose of a s s i s t i n g patients who were recovering from mental i l l n e s s . In 1913 the Boston Psychopathic Hospital began i t s S o c i a l Service department under the leadership of Doctor E. Southard and Miss Mary C. J a r r e t t . When the F i r s t World War began, i t was clear to those who had seen the importance of the s o c i a l service i n c i v i l i a n hospitals that s o c i a l workers would be needed for army 1. Deutsch, Albert, The Mentally 111 i n America, Columbia University Press, New York, 1937, p. 291. - 8 -hospitals, especially on wards where psychiatric work was be-ing undertaken. To meet this need, plans to enlarge the train-ing course, at the Boston Psychopathic Hospital, for social workers going into psychiatric work, were proceeding, but i t was found possible to combine with Smith College i n a course of the same type which was given under the auspices of a committee of the National Committee for Mental Hygiene. Similar courses, conceived as emergency measures or as permanent developments of the curriculum, were soon offered by other Schools of Social Work i n New York, Philadelphia and Chicago. In Canada the f i r s t course was inaugurated at the University of Toronto i n 1919. Essondale. The impact of the new ideas that had begun in the treat-ment of the mentally i l l was also f e l t i n B r i t i s h Columbia. The result was improved treatment i n the mental hospitals and also the inclusion of the social worker into the treatment planning. In 1905 Doctor C.E. Doherty became the new medical superintendent of the Public Hospital for the insane at New West-minster, B.C. He proceeded along lines of practice that were being established i n the more modern mental hospitals. A l l patients were classified according to the seriousness of their illn e s s . After a sojourn in the receiving ward those considered curable were segregated from the so-called incurable; the feeble and the infirm were sent to special quarters, while the conval-escents were assigned to quiet quarters with ample lib r a r i e s , reading and amusement rooms. Absolute rest in bed was encouraged - 9 -for the acute cases and the principle was "to see that they receive every care, treatment and attention that the sick should receive." A l l patients not physically incapacitiated were en-couraged to take exercise in the open air, both summer and winter, and regular concerts and dances, were held. The annual report of the hospital i n 1907 declared that "kind and humane treatment i s enforced i n every department; mechanical restraints of a l l kinds have been abolished; the physically sick receive special diets according to their needs; a l l engage i n open a i r exercise, both summer and winter, while everything i s done during leisure hours to divert the patient from his trouble." 2 The year 1906 was an important date in the development of the care of the mentally i l l i n B r i t i s h Columbia because' " i n that year Henry Esson Young, a medical doctor, became Provincial Secretary and served i n that capacity for many years. This able and socially-minded minister made the mental hospital at New Westminster one of his most v i t a l concerns, and he was largely responsible' for building the new institution at Essondale, B.C. 3 the name, Essondale, being chosen i n his honour." This new hospital was started i n 1908 and two years later opened i t s doors, at f i r s t for male patients only. 1. B.C. Sessional Papers, Annual Report of the Public Hospital  for the Insane. 1907, p. F.7. 2. Ibid, p.F.7. 3. Clark, James R., Care of the Mentally 111 in B r i t i s h Columbia, Master of Social Work Thesis, University of B r i t i s h Columbia, 1947, p. 44.. - 1 0 -In 1919 the Canadian National Committee for Mental Hygiene, founded the previous year, made a survey of B r i t i s h Columbia at the request of the Provincial Secretary. The study was carefully and thoroughly conducted and included an examin-ation of conditions i n connection with both the insane and mental defectives. In the foreword to the report the committee stated that i t had received the utmost co-operation from those in charge of the various institutions. Its impression was that the people of B r i t i s h Columbia were f u l l y alive to the importance of mak-ing social reforms and the province was generally to be congrat-ulated on the progress made i n the care and treatment of the i n -sane. In the report the Committee stressed the need for a social service department in connection with the institutions at New Westminster and Essondale. It was f e l t that a well organ-ized social service department was a primary need, and that the employment of trained social workers would effect a real economy to the government as patients could be placed on probation thus relieving the hospital of the burden of maitenance. The year 1926 saw Doctor A.L. Crease appointed as Medical Superintendent of the Mental Hospitals in B r i t i s h Columbia, and in the f i r s t of his annual reports to the Depart-ment of the Provincial Secretary he recommended the setting up of a Social Service department to serve the mental hospitals in the province. It was not u n t i l four years later that this recommendation was followed up when, in 1930, the Canadian Nat-ional Committee for Mental Hygiene installed a social worker, - 11 -Miss Josephine Kilburn, i n the Provincial Mental Hospital at Essondale for one year at their expense. The chief aim and purpose of this new department was to "secure more detailed i n -formation regarding the home l i f e and conditions of the patients which heretofore had not been obtainable. Such information was of value because any contributing factor to the patient's breakdown could be looked into prior to his return home, other- ; wise his improvement might not be lasting. A follow-up of a patient after discharge and assistance in the re-establishment in the community was another function of the Social Service department."-^ Miss Kilburn's one year of service was enough to convince the government of the value of her-services and she was put on the regular staff. With the introduction of the Social Service department a new aspect of treatment was opened up, not only to the patients themselves, but also to their families. The Social Worker's Role Today. The functions performed by social workers, particularly in mental institutions, have undergone considerable evolution i n their turn. In recent years there has been a good deal of con-solidation and clar i f i c a t i o n of their roles. In the treatment of the mentally i l l , the role of the social worker depends in the f i r s t place, of course, on the type of mental institution i t s e l f ; but, i n a l l cases, whatever the role, the goal i s the same - re-turn to community living and obtaining an optimum adjustment. 1. Birch, Sophie, An Aid i n the Rehabilitation of Mental Hospital  Patients. Master of Social Work Thesis, University of B r i t i s h Columbia, 1953, p. 9. - 12 -To e n a b l e t h e p a t i e n t t o a t t a i n t h i s g o a l t h e s o c i a l w o r k e r may have t o d e a l w i t h a wide range o f s o c i a l and p e r s o n -a l p r o b l e m s . To enumerate them would be t o name the whole gamut o f human i l l s - f a i l u r e s and f r u s t r a t i o n s , s u c h as unemployment, p o o r h o u s i n g , n e e d f o r money o r m e d i c a l c a r e , need f o r h e l p i n p l a n n i n g f o r t h e c a r e o f c h i l d r e n and h e l p w i t h d i s t u r b e d i n t e r -p e r s o n a l r e l a t i o n s h i p s . I n o r d e r t o h e l p t h e s e p e o p l e , who a t l e a s t m o m e n t a r i l y a r e u n a b l e to cope w i t h t h e i r a f f a i r s , the s o c i a l w o r k e r must know the t e n s i o n i n t h e i r l i v e s , what c a n be done about i t , and how t h e p e r s o n o r the t e n s i o n s can be c h a n g -e d . , He must a l s o u n d e r s t a n d how the p e r s o n f e e l s , how he c a n be h e l p e d w i t h t h e s e f e e l i n g s , and how t h e p e r s o n ' s way o f r e -s p o n d i n g s e r v e s h i m i n the l i g h t o f h i s p r e s e n t l i f e p r e s s u r e s , p a s t e x p e r i e n c e s , a n d f u t u r e a s p i r a t i o n s . I t i s t h i s u n d e r -s t a n d i n g o f t h e i n d i v i d u a l and o f what t h e p r o b l e m means t o h i m t h a t e n a b l e s t h e s o c i a l w o r k e r t o m o d i f y e i t h e r e x t e r n a l o r i n -t e r n a l p r e s s u r e s , o r b o t h , so t h a t t h e i n d i v i d u a l may be r e l i e v -ed o f s t r e s s e s and p a r t i c i p a t e i n the r e c o v e r y o f s e l f r e l i a n c e . Whether t h e i n d i v i d u a l ' s p r o b l e m o r i g i n a t e s i n , o r i s c o m p l i c a t e d b y , t h e e x t e r n a l s i t u a t i o n the s o c i a l w o r k e r may be c a l l e d upon t o r e n d e r s e r v i c e s w h i c h meet p r a c t i c a l r e a l i t y n e e d s . These s e r v i c e s , when r e n d e r e d w i t h p r o p e r r e g a r d f o r f e e l i n g s , may ease a n x i e t i e s , g i v e new c o n f i d e n c e and e n a b l e t h e i n d i v i d u a l t o manage h i s a f f a i r s c o m p e t e n t l y . I n a d d i t i o n t o p r o v i d i n g c o n c r e t e s e r v i c e s the s o c i a l w o r k e r may be o f a s s i s t a n c e t o t h e p e r s o n b y h e l p i n g h i m t o c l a r i f y h i s i n d e c i s -- 13 -i o n s , o r t o d i s c h a r g e f e e l i n g s , and a l s o t o u n d e r s t a n d f e e l -i n g s t h a t a r e o b s t r u c t i n g c o n s t r u c t i v e a c t i o n o r i n d u c i n g d e -s t r u c t i v e b e h a v i o r . The w o r k e r may a l s o h e l p h i m t o u n d e r s t a n d h i s g e n e r a l s i t u a t i o n b e t t e r , o r h e l p p e o p l e who a r e s i g n i f i c a n t i n t h e p a t i e n t ' s l i f e . The s o c i a l w o r k e r ' s main c o n t r i b u t i o n l i e s i n h i s u n d e r s t a n d i n g o f human i n t e r - r e l a t i o n s h i p s and h i s a b i l i t y t o s t r e n g t h e n t h e h e a l t h y a s p e c t s o f t h e p a t i e n t ' s p e r -s o n a l i t y b y h e l p i n g h i m t o a d j u s t t o t h e r e a l i t i e s o f a changed and l i m i t e d s i t u a t i o n . To e n a b l e t h e p r o f e s s i o n a l s k i l l s o f the s o c i a l w o r k e r t o be most e f f e c t i v e i n t h e t r e a t m e n t o f t h e m e n t a l l y i l l i t i s i m p o r t a n t t h a t he p a r t i c i p a t e w i d e l y i n the h o s p i t a l p r o g r a m . S e p a r a t e p r o f e s s i o n a l d i s c i p l i n e s i n t h e same p l a c e do n o t i n t h e m s e l v e s make a h o s p i t a l t e a m . I n t e g r a t i o n i s i m p o r t a n t a t t h e a d m i n i s t r a t i v e l e v e l f o r p r o p e r program p l a n n i n g , and the s e t t i n g o f p o l i c i e s w i t h i n , w h i c h the t r e a t m e n t teams w i l l o p e r -a t e . The d e v e l o p m e n t , b y the m e d i c a l s t a f f , o f a p o s i t i v e a t t i t u d e towards s o c i a l work w i l l depend on t h e i r knowledge o f the c o n t e n t o f p r o f e s s i o n a l S o c i a l Work t r a i n i n g . T h i s i s g a i n -ed as much t h r o u g h p a r t i c i p a t i o n i n the a d m i n i s t r a t i v e a s p e c t s o f t h e h o s p i t a l as b y a c t u a l c o - o p e r a t i o n i n t r e a t m e n t s e r v i c e s t o p a t i e n t s . I n r e l a t i o n t o the d i r e c t t r e a t m e n t s e r v i c e s t o t h e p a t i e n t the s o c i a l worker s h o u l d work c l o s e l y w i t h h i m from t h e moment he e n t e r s t h e h o s p i t a l u n t i l he i s f i n a l l y r e - e s t a b l i s h e d i n the community. T h i s means t h a t the s o c i a l w o r k e r i s i n c o n -- 14 -tact with the patient through intake and reception, the t r e a t -ment program, pre-convalescent care and convalescent c a r e . 1 Intake i s the process of making ho s p i t a l services available to persons i n the community who can benefit by hospit-a l care. I t s greatest value i s seen i n the formation of the t r a v e l l i n g c l i n i c , but i n the hospital i t s e l f i t has an import-ant function as the s o c i a l worker on Intake i s able to a s s i s t i n the inter p r e t a t i o n of the hos p i t a l f a c i l i t i e s and program to the prospective patient and his family; a s s i s t the family with problems that may arise from the patient's admission to the hospi t a l ; to formulate plans, with the assistance of other com-munity s o c i a l agencies, which might make admission l e s s urgent or occasionally prevent unnecessary or i l l advised admissions; and to attempt to e s t a b l i s h a re l a t i o n s h i p with the family that w i l l encourage them,to maintain a po s i t i v e , non-rejecting attitude during the period of care. Reception i s the process of helping the patient to accept h i s h o s p i t a l i z a t i o n , of r e l i e v i n g the fears and threats inherent i n the experience of compulsion and r e s t r a i n t . The s o c i a l worker's function i n reception usually includes part-i c i p a t i o n with other h o s p i t a l personnel i n explanation of routine, and helping the patient to understand that the worker serves as a l i n k between him, h i s family and the community. Also the so c i a l worker helps the family with anxiety that surmounts when one of i t s members enters a mental h o s p i t a l ; helps the family 1« G-.A.P. Report #2, The Psych i a t r i c S o c i a l Worker i n the  Psychia t r i c Hospital, Topeka, Kansas,. January, 1948. - 15 -t o u n d e r s t a n d t h e t r e a t m e n t u s e d ; and whenever p o s s i b l e g a t h e r s p r e l i m i n a r y e v a l u a t i v e m a t e r i a l about the p a t i e n t , h i s r e l a t i o n -s h i p s , h i s e x p e r i e n c e s and h i s i l l n e s s f r o m e i t h e r t h e p a t i e n t o r h i s f a m i l y . An u n d e r s t a n d i n g p e r s o n , w h i c h t h e s o c i a l w o r k e r i s , who can h e l p the f a m i l y t o r e a l i z e t h e n e c e s s i t y o f t r e a t m e n t and o b t a i n t h e i r c o - o p e r a t i o n i s v e r y i m p o r t a n t . I t i s t h e b e g i n n i n g i m p r e s s i o n s t h a t h e l p t o ease t h e f e a r s t h a t v e r y o f t e n accompany e n t r a n c e t o a m e n t a l h o s p i t a l , and s e t t h e p a t t e r n f o r f u t u r e c o n t a c t s w i t h t h e f a m i l y . The t r e a t m e n t p r o g r a m u s u a l l y means e v e r y c o n t a c t t h a t t h e p a t i e n t has d u r i n g h i s s t a y i n the h o s p i t a l . T h i s i n c l u d e s t h e p e o p l e he m e e t s , d o c t o r s , n u r s e s , p s y c h o l o g i s t , o c c u p a t i o n a l t h e r a p i s t s , t h e o t h e r p a t i e n t s , a s n w e l l as s o m a t i c t h e r a p i e s . The s o c i a l w o r k e r i s c o n c e r n e d w i t h e v e r y a s p e c t o f t h e p a t i e n t ' s r e l a t i o n s h i p s w i t h i n t h e h o s p i t a l , as w e l l as t h o s e w i t h h i s fam-i l y and community. B e s i d e s r e g u l a r v i s i t s t o t h e p a t i e n t on t h e w a r d , and c o n f e r e n c e s w i t h o t h e r team members r e g a r d i n g t h e p a t -i e n t ' s p r o g r e s s , i t i s t h e c l e a r c u t f u n c t i o n o f t h e s o c i a l w o r k e r t o p r e v e n t any d i s r u p t i o n i n t h e c o n t i n u i t y o f t h e f a m i l y -p a t i e n t r e l a t i o n s h i p . The p a t i e n t comes from the f a m i l y and w i l l p r o b a b l y r e t u r n t o i t , t h e r e f o r e the s o c i a l worker has t o make r e g u l a r v i s i t s t o members o f the f a m i l y t o d i s c u s s t h e p a t i e n t w i t h them, encourage them t o v i s i t t h e h o s p i t a 1, and h e l p them w i t h t h e p r o b l e m o f any d i s t u r b a n c e - o f f a m i l i a r i t y so t h a t t h e y can a c c e p t t h e p a t i e n t as t h e y f i n d h i m . ' I t i s t h i s l a t t e r a c t i v i t y o f t h e s o c i a l w o r k e r t h a t c o n t r i b u t e s much t o r e d u c i n g t h e l e n g t h o f the p a t i e n t ' s s t a y i n the h o s p i t a l . - 16 -The t r e a t m e n t program, f o r the i n d i v i d u a l p a t i e n t , i s u s u a l l y shaped b y t h e changes i n h i s i l l n e s s , b u t t h e p r i m a r y t r e a t m e n t p l a n i s f o r m u l a t e d a t ward r o u n d s , s h o r t l y a f t e r t h e p a t i e n t ' s e n t r a n c e t o h o s p i t a l . A t ward r o u n d s t h e members o f t h e t r e a t m e n t team meet t o g e t h e r t o d i s c u s s t h e b e s t p o s s i b l e p l a n f o r t h e p a t i e n t ' s r e c o v e r y . E a c h p r o f e s s i o n a l d i s c i p l i n e c o n c e r n e d p r e s e n t s the i n f o r m a t i o n t h a t he has o b t a i n e d and o u t -l i n e s the r o l e he f e e l s he c a n p l a y i n t h e t r e a t m e n t p l a n s . When a p l a n has b e e n f o r m u l a t e d i t i s n o t r i g i d l y a d h e r e d t o , b u t i s changed as t h e n e c e s s i t y i s seen b y the team members. Changes i n t r e a t m e n t p l a n s a r e u s u a l l y d i s c u s s e d i n s p e c i a l c o n f e r e n c e s o f the team members, t h e c o n f e r e n c e b e i n g a r r a n g e d b y w h i c h e v e r member f e e l s t h e n e c e s s i t y f o r a change. Towards t h e t e r m i n a t i o n o f t r e a t m e n t t h e s o c i a l w o r k e r b r i n g s s e r v i c e s t o t h e p a t i e n t t h a t w i l l p r e p a r e h i m f o r h i s d i s c h a r g e . T h i s p r e - c o n v a l e s c e n t c a r e s h o u l d be an i n t e g r a l p a r t o f the t r e a t m e n t p r o c e s s w i t h i n t h e h o s p i t a l . I t c o n s i s t s o f d i s c u s s i n g w i t h t h e p a t i e n t h i s p l a n s f o r t h e f u t u r e , and h i s f e e l i n g s t o w a r d s l e a v i n g t h e h o s p i t a l and r e t u r n i n g t o f a m i l y and community l i f e . I f p r o p e r l y c a r r i e d out t h e p a t i e n t w i l l l o o k f o r w a r d t o h i s . d i s c h a r g e f r o m the c a r e o f t h e h o s p i t a l . The s o c i a l w o r k e r b r i n g s s e r v i c e s o f a c o n v a l e s c e n t o r p r o b a t i o n a r y n a t u r e t o t h e p a t i e n t as he l e a v e s t h e h o s p i t a l . C o n v a l e s c e n t c a r e i s the r e - e s t a b l i s h m e n t o f t h e p a t i e n t i n t h e community. D u r i n g t h i s p e r i o d o f c o n v a l e s c e n t c a r e t h e p a t i e n t * u s u a l l y r e m a i n s t h e r e s p o n s i b i l i t y o f t h e h o s p i t a l a u t h o r i t i e s , u n l e s s h o s p i t a l p o l i c y s t a t e s o t h e r w i s e . The s o c i a l w o r k e r - 17 -a s s i s t s i n the discharge of t h i s r e s p o n s i b i l i t y by exercising continued supervision of the patients and by attempting to make available a l l community resources which can help i n his readjust-ment. This might involve sueh things as i n t e r p r e t a t i o n to the family regarding the patient's i l l n e s s ; helping patient to re-gain h i s economic security by a s s i s t i n g i n locating contacts f o r work, or encouraging the in t e r e s t and acceptance of former em-ployees whenever possible. Probation i s a function f o r which the s o c i a l worker assumes extensive r e s p o n s i b i l i t y . With completion of the s o c i a l worker's role with the patient i t does not mean that h i s job ends there. He s t i l l has important r e s p o n s i b i l i t i e s , outside of the patient sphere, i n education and t r a i n i n g , research, and community i n t e r p r e t a t i o n . The primary educational r e s p o n s i b i l i t y of the s o c i a l work department i s towards students of S o c i a l Work, but within the h o s p i t a l the s o c i a l worker must interpret the content of h i s own professional a c t i v i t i e s . He should attempt to broaden the knowledge of the medical, nursing and other professional s t a f f i n such areas as: inter-personal relationships of parents and children; s o c i a l and economic stresses and t h e i r impact on the family l i f e of the patient; the a v a i l a b i l i t y of s o c i a l , health, employment, recreational, educational, vocational and other ' community resources. There are two main areas of research which should be of interest to the s o c i a l worker i n the mental h o s p i t a l . The f i r s t i s p a r t i c i p a t i o n i n projects developed by the medical s t a f f - 18 -such as f o l l o w up s t u d i e s o f v a r i o u s g r o u p s o f p a t i e n t s and s t u d i e s i n s o c i a l p a t h o l o g y . The second i s t h e e v a l u a t i o n o f the e f f e c t i v e n e s s o f t h e a c t i v i t y o f the s o c i a l work d e p a r t m e n t , s u c h as t h e r e f i n e m e n t o f p r o c e d u r e s i n casework, and e x p l o r i n g t r e n d s i n community r e l a t i o n s a f f e c t i n g m e n t a l h e a l t h . The d u t i e s and r e s p o n s i b i l i t i e s o f t h e s o c i a l w o r k e r b o t h i n t h e h o s p i t a l and t h e community p l a c e h i m i n a v e r y a d -v a n t a g e o u s p o s i t i o n t o d e v e l o p c o n s t r u c t i v e a t t i t u d e s towards t h e r e c o g n i t i o n and t r e a t m e n t o f m e n t a l i l l n e s s , and t o s e c u r e t h e p a r t i c i p a t i o n o f l a y g r o u p s i n t h e development o f f a v o r a b l e a t t i t u d e s t o w a r d s m e n t a l h o s p i t a l c a r e . W i t h p a t i e n t s c o n t i n -u a l l y r e t u r n i n g t o the community t h e r e i s a r e a l and u r g e n t n e e d f o r an i n f o r m e d p u b l i c t o d e v e l o p a w a r e n e s s , a c c e p t a n c e , and u n d e r s t a n d i n g o f t h e s e p a t i e n t s ' p r o b l e m s , and t h e s o c i a l w o r k -e r i n h i s d a i l y c o n t a c t s has a g r e a t r e s p o n s i b i l i t y t o i n i t i a t e t h i s awareness b y e x p l a i n i n g t h e needs o f t h e m e n t a l l y i l l . Method o f t h i s S t u d y . The e v o l u t i o n i n i m p r o v e d t r e a t m e n t o f the m e n t a l l y i l l has b e e n s l o w , and even t o d a y i t v a r i e s f r o m h o s p i t a l t o h o s p i t -a l , community t o community a c c o r d i n g t o t h e n e e d s , f i n a n c e s , s t a f f a v a i l a b l e , and t h e degree o f e n l i g h t e n m e n t . A s f o r t h e s o c i a l w o r k e r , h i s p a r t i c i p a t i o n v a r i e s s i m i l a r l y , b u t b e c a u s e o f c l a r -i f i c a t i o n o f h i s f u n c t i o n and p r o p e r d e f i n i n g o f h i s a r e a o f com-petence he i s g r a d u a l l y coming i n t o h i s own i n the f i e l d o f t r e a t -ment o f the m e n t a l l y ' i l l . The p r e s e n t s t u d y examines the p a r t i c i p a t i o n o f t h e - 19 -s o c i a l w o r k e r i n t h e programs o f two l o c a l t r e a t m e n t c e n t e r s -t h e C r e a s e C l i n i c o f P s y c h o l o g i c a l M e d i c i n e and the P r o v i n c i a l M e n t a l H o s p i t a l a t E s s o n d a l e , B . C . B o t h t h e h o s p i t a l and the c l i n i c were i n c l u d e d as t h e y a r e c l o s e l y r e l a t e d i n t h e i r p h y -s i c a l s e t t i n g and t r e a t m e n t s e r v i c e s t o p a t i e n t s . Though t h e c l i n i c i s n o t a c t u a l l y c a l l e d .a m e n t a l h o s p i t a l , i t was d e s i g n e d and e q u i p p e d t o f u n c t i o n a s a d i a g n o s t i c and a c t i v e t r e a t m e n t c e n t r e f o r m e n t a l i l l n e s s . The main t y p e s o f p a t i e n t s a c c e p t e d a r e : e a r l y p s y c h o t i c s , p s y c h o n e u r o t i c s , t h o s e w i t h p s y c h o s o m a t i c d i s a b i l i t i e s , and a l s o a l l p s y c h o t i c s , e x c e p t t h o s e o f l o n g s t a n d i n g d u r a t i o n d e m o n s t r a t i n g marked d e t e r i o r a t i o n , and h a v -i n g a p o o r p r o g n o s i s . The o r i g i n a l p l a n , a n h i s t o r i c a l s t u d y , was abandoned as i t was f e l t t h a t a g r e a t e r c o n t r i b u t i o n c o u l d be made b y a n e x a m i n a t i o n o f the p r e s e n t p r o g r a m . Some h i s t o r y has s t i l l b e e n i n c l u d e d so t h a t t h e more r e c e n t developments c o u l d be p o i n t e d u p . The s t u d y has b e e n l i m i t e d t o - m o r e o f a q u a l i t a t i v e a n a l y -s i s , and f o r t h i s r e a s o n a minimum o f s t a t i s t i c a l m a t e r i a l has b e e n i n c l u d e d . E v a l u a t i o n o f t h e s o c i a l work p a r t i c i p a t i o n r e q u i r e d c o n s i d e r a t i o n o f , n o t o n l y t h e a c t u a l job o f t h e c a s e w o r k e r , b u t o f h i s p o s i t i o n as i t i s a f f e c t e d b y t h e a d m i n i s t r a t i o n o f t h e h o s p i t a l . I t i s c l a r i f i c a t i o n i n the l a t t e r a r e a t h a t s i m p l i f -i e s - t h e job o f the s o c i a l w o r k e r and e n a b l e s h i m t o u s e , t o the g r e a t e s t e x t e n t , h i s p r o f e s s i o n a l t r a i n i n g i n t h e t r e a t m e n t p r o -gram. F o r t h i s r e a s o n a s e c t i o n d e a l i n g s p e c i f i c a l l y w i t h t h e administrative set-up has been included. The material used to evaluate the program was obtained through interviews with the members of the Social Service staff, by attendance at staff meetings, reviewing records of past staff meetings, and examining reports that have been prepared by various members of the staff on their casework a c t i v i t i e s . To give a complete picture, and a basis of comparison, the role of the social worker, as i t was seen after a study of a number of hospitals in the United States, 1 has been outlined in this chapter. The study w i l l continue with a short outline of the present organizational structure, and then turn to con-sideration of the administrative aspects, and the actual part-icipation of the social worker in the treatment services. Finally the material w i l l be assessed, and the needs, i f any, pointed up. Social Service Departments. The Social Service department at the Provincial Mental Hospital gradually increased the number of social workers on i t s staff following Miss Kilburn's appointment u n t i l by the time of her retirement on December 30, 1950 and the opening of the Crease Clinic of Psychological Medicine on January 1st, 1951 there was a total of thirteen workers at the Hospital. But the opening of Crease Clinic greatly extended the area of responsibility of the Social Service department at the Mental Hospital. The job of the social worker had to be re-1. Ibid, p. 1€ - 21 -evaluated and consideration given to the division of labour within the department so that participation in administrative work and service to the.patients would not only be more effect-ive but also more inclusive. By the summer of 1951 an Admissions Section had been started in both the Crease Clinic and the Mental Hospital, and by May 1952,a decision was reached whereby the existing Social Service staff was divided into separate Social Service Depart-ments - one in the Mental Hospital, the other at Crease Clinic -and each consisting of an Admissions Section and a Continuing Casework Section. During this re-evaluation i t was seen that up u n t i l this time the social worker had been primarily concerned with securing a history of the patient's background, evaluating social data and i t s relation to the patient's mental concepts, and to a limited degree, working with the patient's relatives and community agencies. The new divisions in the department meant that the above mentioned services were offered plus case-work services around admission of the patient, during the treat-ment period, including pre-convalescent planning, and to some extent after discharge either in the form of probation or re-ferral services. -22-Chapter II - The Social Worker in Hospital Administration* The Provincial Mental Hospital and the Grease Clinic of Psychological Medicine at Essondale are part of the Active Treatment Services of the Provincial Mental Health Services. The Mental Health Services are administered by the Provincial Secretary. Between the minister (Provincial Secretary) who passes on broad over-all policies, and. the Director of Mental Health Services, (known i n 1930 as the Director of Mental Hy-giene and Provincial Psychiatry) who i s responsible for carry-ing out and directing these policies for a i l branches of the Mental Health Services, there i s a Deputy Provincial Secretary. This officer serves to interpret government policy'to the Director and thereby provides the functional basis for Mental Health Service a c t i v i t i e s . Likewise a l l requirements and problems of the Mental Health Services are assessed by the Deputy in conference with Services officers and are presented to the Minister for the government's action. To assist the Director of Mental Health Services i n the administration of his duties, there i s a Deputy Director of Mental Health Services, and also a Senior Medical Superin-tendent. The latter i s responsible to the Director for a l l medical matters within the organization. This medical officer has authority over a l l hospitals within the Mental Health Services and i s particularly concerned with inter-hospital ac-t i v i t i e s . Under the Senior Medical Superintendent come special Medical Superintendents who are appointed to the different - - 23 -branches i n the Mental Health Services. The P r o v i n c i a l Mental Hospital and the Crease C l i n i c are administratively linked t o -gether under a Deputy Medical Superintendent. C l i n i c a l work i n the two treatment centers i s under the d i r e c t i o n of a C l i n i -c a l D i r e c t o r . These two o f f i c e r s (Deputy Medical Superintend-ent and C l i n i c a l Director) are i n charge of a l l medical depart-ments within the H o s p i t a l and C l i n i c . (It i s "at t h i s point that a h o s p i t a l administration chart often breaks down as matters c l i n i c a l and matters administrative are often i n t e r -locked and i t i s d i f f i c u l t to know the channels through which the s t a f f members can take t h e i r problems for c l a r i f i c a t i o n " . " 1 " There i s some broad understanding within the S o c i a l Service De-partment that where such things as finances, accommodation and equipment are concerned they w i l l be dealt,, with through the administrative l i n e , and a l l things concerning s o c i a l work as an i n t e g r a l force w i l l go through the c l i n i c a l l i n e . Even where t h i s broad p o l i c y has been evolved there i s s t i l l some d i f f i c u l t y encountered by the S o c i a l Service Departments. The main prob-lem appears to be that the administrative structure at the Hospital and C l i n i c i s s t i l l i n process, and c l a r i f i c a t i o n i s slowly forthcoming as the duties of each person are more clear-l y outlined.) The S o c i a l Service Departments at the P r o v i n c i a l Mental Hospital and the Crease C l i n i c function within the above administrative structure under the d i r e c t i o n of the P r o v i n c i a l . 1. B.C. P s y c h i a t r i c Service Physician's Manual, 1950, Sec.2, p. 3 - 2 4 — S u p e r v i s o r o f P s y c h i a t r i c S o c i a l W o r k . , A c h a r t o f t h i s a d m i n i s -t r a t i v e s e t - u p i s s e e n as f o l l o w s , Department o f P r o v i n c i a l S e c r e t a r y 1 I P r o v i n c i a l S e c r e t a r y " ) | D e p u t y P r o v i n c i a l S e c r e t a r y 'I D i r e c t o r o f M e n t a l H e a l t h S e r v i c e s " ! { D e p u t y D i r e c t o r o f M e n t a l H e a l t h S e r v i c e s I S e n i o r M e d i c a l S u p e r i n t e n d e n t " ] I D e p u t y M e d i o a l S u p e r i n t e n d e n t " ! I C l i n i c a l D i r e c t o r | P r o v i n c i a l S u p e r v i s o r o f P s y c h i a t r i c S o c i a l Work F i g u r e I - A d m i n i s t r a t i v e S t r u c t u r e a t t h e P r o v i n c i a l M e n t a l H o s p i t a l and C r e a s e C l i n i c . A l t h o u g h t h e S o c i a l S e r v i c e D e p a r t m e n t s , f o r a d m i n i s t -r a t i v e p u r p o s e s , come u n d e r t h e M e n t a l H e a l t h S e r v i c e s t h e y a r e a c t u a l l y a p a r t o f t h e S o c i a l W e l f a r e B r a n c h o f t h e Department 25 — o f H e a l t h and W e l f a r e . S o c i a l w o r k e r s a r e p l a c e d a t t h e H o s -p i t a l and C l i n i c "by t h e S o c i a l W e l f a r e B r a n c h , i n l i e u o f t h e two c e n t e r s d e v e l o p i n g t h e i r own s o c i a l s e r v i c e d e p a r t m e n t s . B y t h i s a r r a n g e m e n t , p a t i e n t s who have received' ' t r e a t m e n t a r e a b l e t o make use o f t h e e x i s t i n g s o c i a l s e r v i c e - o fra - f a m i l y o r s o c i a l a s s i s t a n c e n a t u r e p r o v i d e d b y the S o c i a l W e l f a r e B r a n c h , and t h e M e n t a l H e a l t h S e r v i c e s are a b l e t o use t h e F i e l d S e r -v i c e o f t h e S o c i a l W e l f a r e B r a n c h f o r a s s i s t i n g i n t r e a t m e n t o f p a t i e n t s who do not r e s i d e w i t h i n the c i t y o f V a n c o u v e r o r t h e G r e a t e r V a n c o u v e r a r e a . (The F i e l d S e r v i c e i s t h a t p a r t o f t h e S o c i a l W e l f a r e B r a n c h t h a t b r i n g s s e r v i c e s o f a g e n e r a l -i z e d n a t u r e t o t h e o u t l y i n g d i s t r i c t s i n t h e P r o v i n c e . ) 1 The c h i e f e x e c u t i v e o f t h e S o c i a l W e l f a r e B r a n c h i s t h e D e p u t y M i n i s t e r o f W e l f a r e . He i s r e s p o n s i b l e t o t h e M i n -i s t e r o f H e a l t h and W e l f a r e f o r t h e r u n n i n g o f the S o c i a l W e l -f a r e B r a n c h , as w e l l as t h e a d m i n i s t r a t i o n o f a l l s o c i a l l e g i s -l a t i o n u n d e r t h e j u r i s d i c t i o n o f the B r a n c h . The s o c i a l w e l -f a r e s e r v i c e s r e l a t e d t o o t h e r d e p a r t m e n t s - e . g . P r o v i n c i a l M e n t a l H e a l t h S e r v i c e s - a r e a l s o under h i s a d m i n i s t r a t i v e d i r e c t i o n . I n t h i s l a t t e r r e g a r d t h e D e p u t y M i n i s t e r works i n c l o s e c o l l a b o r a t i o n w i t h t h e D e p u t y P r o v i n c i a l S e c r e t a r y on m a t t e r s o f p o l i c y . A s s i s t i n g the D e p u t y M i n i s t e r o f W e l f a r e w i t h t h e d e -t a i l i n v o l v e d i n t h i s a l l - o v e r a d m i n i s t r a t i o n a r e t h e D i r e c t o r o f W e l f a r e and t h e A s s i s t a n t D i r e c t o r o f W e l f a r e . T h e s e t h r e e 1.' See A p p e n d i x A . — 26 ^ comprise what i s called the General Administration of the Branch. The Director and the Assistant Director share the work involved, the former being responsible for releasing a l l policies with respect to expenditures and services, and the latter being re-sponsible for the personnel of the Branch, office procedures, and standards of professional services. Because the Provincial Supervisor of Psychiatric Social Work at Essondale i s appointed by the Social Welfare Branch, receives personnel from them, and must have knowledge of their policies and services, i t i s important that she work closely with the General Administration. Diagrammatically the contact between these people would be seen as, \ Department of Health and Welfare I I Minister of Health and Welfare { I Deputy Minister of Welfare I I c Director of Welfare Provincial Supervisor of Psychiatric Social Work Figure 2 - Lines of responsibility i n the Social Welfare Branch. She also has duties 1 that extend beyond the Social 1. See Appendix B. Service Departments at Essondale, as she i s responsible for the organization, planning, policies and services of the Social Service Departments at Woodlands School (New Westminster) and the two Child Guidance Clinics operated by the province and centred i n Vancouver and Victoria. Provincial Supervisor of Psychiatric Sooial Work I Sooial Service Departments | Woodlands School Mental Hospital and Crease Clinic 1 Child Guidance Clinics Figure 5.° Areas of responsibility of the Provincial Supervisor of Psychiatric Social Work. The duties of the Provincial Supervisor in a l l areas of the Mental Health Services are very.important, but as this study i s primarily concerned with the participation of the soc-i a l worker at the Provincial Mental Hospital and the Crease Clin i c consideration i s given only to her work in this area. The Provincial Supervisor's duties include, 1. Responsibility for the organization, administration and co-ordination of the social service program within the Provincial Mental Hospital and Crease C l i n i c . This involves, a. Consulting and informing the Hospital and Clin i c admin-istration, and the General Administration of the Social Welfare Branch about staff and policy matters, needs within the depart-ments, and the development of the services. Also consulting — 28 -and s u p e r v i s i n g s t a f f i n t h e s e m a t t e r s . b . M a k i n g out r e p o r t s , s t a t i s t i c s , and w o r k i n g out s c h e d u l e s and measures t o improve t h e s t a n d a r d , o f w o r k . c . R e s p o n s i b i l i t y t o see t h a t the p o l i c i e s and p r o c e d u r e s t h a t a r e s e t down b y t h e M e n t a l H o s p i t a l and C r e a s e C l i n i c a d -m i n i s t r a t i o n , w i t h r e g a r d t o t h e S o c i a l S e r v i c e D e p a r t m e n t s , a r e c a r r i e d o u t . d . W o r k i n g w i t h o t h e r members o f t h e t r e a t m e n t team ( d o c t o r s , n u r s e s , p s y c h o l o g i s t s , and o c c u p a t i o n a l t h e r a p i s t s ) on p o l i c y and t r e a t m e n t d e c i s i o n s i n t h e a r e a s o f s h a r e d r e s p o n s i b i l i t y . T h i s i n c l u d e s c o n s i d e r a b l e c o n s u l t a t i o n w i t h the heads o f s p e c -i f i c d e p a r t m e n t s , a s w e l l a s o t h e r members o f t h e t r e a t m e n t team, i n r e g a r d s t o case p r o b l e m s and c o - o r d i n a t i o n o f w o r k . 2. P a r t i c i p a t i o n i n d i a g n o s t i c and c o n s u l t a t i v e s e r v i c e s where a s e n i o r p e r s o n i s r e q u i r e d t o keep i n t o u c h w i t h t h e work b e i n g done • 3. To c o n f e r on i n t e r - a g e n c y p o l i c y . T h i s i n c l u d e s , i n t e r p r e t -i n g t h e f u n c t i o n s o f t h e M e n t a l H o s p i t a l and C r e a s e C l i n i c t o o t h e r community a g e n c i e s , and c o - o r d i n a t i o n o f p o l i c y and a c t i v -i t i e s i n r e l a t i o n t o o t h e r community s e r v i c e s . A n example o f t h i s i s t h e i n t e g r a t i o n o f t h e s o c i a l work s t u d e n t p r o j e c t a t t h e M e n t a l H o s p i t a l , w h i c h i n v o l v e s c o n s u l t a t i o n w i t h t h e S u p e r -v i s o r o f t h e s t u d e n t u n i t . 4. I n r e l a t i o n t o the s o c i a l work s t a f f h e r d u t i e s c o n s i s t o f , a . S u p e r v i s i o n o f t h e casework s u p e r v i s o r s i n p o l i c y m a t t e r s , h a n d l i n g o f s t a f f p r o b l e m s , casework methods and s k i l l s , and - 29 -major problems i n case handling. . b. Assist, i n the procedure of intake and assignment of cases. This involves consultations with the Supervisor of Casework i n Admissions, p s y c h i a t r i s t s and i n d i v i d u a l s o c i a l service s t a f f members. 5. An interpretive and educational job. This includes the set-t i n g up, i n co-operation with other s o c i a l service s t a f f , of teaching and orientation programs f o r Nurses, 1 S o c i a l workers from the S o c i a l Welfare Branch and In-Service Training s t a f f . (In-Service s t a f f are prospective s o c i a l workers, having no formal t r a i n i n g , who take the In-Service Training course of the Soc i a l Welfare Branch p r i o r to'entering the F i e l d Service. These workers are not employed on the s t a f f at the P r o v i n c i a l Mental Hospital and the Crease C l i n i c but do have a short per-iod at the Hospital and C l i n i c where the treatment services and the p a r t i c i p a t i o n of the s o c i a l workers i n the program i s out-li n e d f o r them.) Also interpreting the C l i n i c and the Hospital services to professional and lay groups i n the community through meetings, a r t i c l e s and lectures. 6. Overall r e s p o n s i b i l i t y to organize and introduce' methods f o r s o c i a l work s t a f f t r a i n i n g and development on the job. There are two important methods for s t a f f development being used at the Mental Hospital and Crease C l i n i c . The f i r s t i s the weekly s t a f f meeting. These meetings are c a r e f u l l y planned under the 1. See Appendix C. 2. See Appendix D. - 30 -g u i d a n c e o f a p l a n n i n g committee o f two p e r s o n s , e l e c t e d b y t h e s t a f f , p l u s the Casev/ork S u p e r v i s o r s . P r o b l e m s a r e d i s c u s s e d , on a g r o u p b a s i s , i n a d m i n i s t r a t i v e m a t t e r s , on o r g a n i z a t i o n o f t h e t o t a l s o c i a l s e r v i c e program, c a r r y i n g out o f t h e p r o g r a m , a n d . a l s o on d a i l y p r o b l e m s i n the s o c i a l w o r k e r ' s a r e a . T h r o u g h t h e s e m e e t i n g s t h e w o r k e r s a r e k e p t up t o d a t e on a l l m a t t e r s w i t h w h i c h t h e y a r e c o n c e r n e d , and i n ways w h i c h t h e y can i n c r e a s e t h e i r s k i l l s and be more h e l p f u l t o the p a t i e n t . The second method o f s t a f f development i s the o r i e n -t a t i o n p r o g r a m 1 t h a t i s now i n e f f e c t . T h i s o r i e n t a t i o n o f a l l new s t a f f , w h i c h t a k e s s i x . w e e k s , had t o be d e v i s e d b e c a u s e n o t • a l l new s o c i a l w o r k e r s coming i n t o t h e s e r v i c e have had e x p e r i -ence i n a p s y c h i a t r i c s e t t i n g , and t h e r e f o r e a r e not i n any p o s -i t i o n t o know t h e m s e l v e s whether s o c i a l work i n t h i s t y p e o f s e t t i n g i s what t h e y want o r n o t . I t i s i m p o r t a n t t h a t a l l new-comers be w e l l o r i e n t e d i n t h e b e g i n n i n g t o o f f s e t t h e s e d e f - , i c i e n c i e s , and be . s l o w l y i n t r o d u c e d ' t o t h e p r o b l e m s o r s i t u a t -i o n s t h a t may a r i s e . W i t h the combined r e s p o n s i b i l i t i e s t h a t t h e P r o v i n c i a l S u p e r v i s o r has i n t h e M e n t a l H e a l t h S e r v i c e s as a w h o l e , and a l s o s p e c i f i c a l l y ' a t t h e P r o v i n c i a l M e n t a l H o s p i t a l and t h e G r e a s e C l i n i c , i t i s easy t o u n d e r s t a n d why t h e d i v i s i o n o f the S o c i a l S e r v i c e D e p a r t m e n t s was u n d e r t a k e n as soon as p o s s i b l e a f t e r h e r a p p o i n t m e n t . New d i v i s i o n s i n casework s e r v i c e s meant t h e a d d i t i o n o f more casework s u p e r v i s o r s who were a b l e t o t a k e o v e r 1. See A p p e n d i x E . some of the responsibilities for casework supervision, and i n -tegration between the hospital and community services. Assist-ing the Provincial Supervisor with this work are three casework supervisors, one at the Mental Hospital, one at Crease Cli n i c , and the third i s responsible for the supervision of the Admiss-ions casework i n both treatment centres. The duties of these supervisors i s dealt with in the following sections, but a chart of their relation to the Provincial Supervisor i s seen as follows, Provincial Supervisor of Psychiatric Social Work Admissions Casework Supervisor at both the Hospital and the Cl i n i c Continuing Case-work Supervisor at the Mental Hospital  Continuing Case-work Supervisor at the Crease Clinic, Figure 4 - Supervisors at the Provincial Mental Hospital and the Crease C l i n i c . Participation in Program Planning. The organization within the Social Service Departments at Essondale i s quite satisfactory, i n spite of staff short-ages; there i s considerable integration and co-operation between the Sections of the Departments; the Departments operate as a s p e c i f i c a l l y d e s i g n a t e d a d m i n i s t r a t i v e u n i t w i t h t h e P r o v i n -c i a l S u p e r v i s o r a c t i n g on an a d m i n i s t r a t i v e l e v e l w h i c h p r o -v i d e s d i r e c t l i a i s o n w i t h the D e p u t y M e d i c a l S u p e r i n t e n d e n t and the C l i n i c a l D i r e c t o r o f t h e H o s p i t a l arid C l i n i c . W i t h t h i s d e f i n e d s t r u c t u r e i t s h o u l d be p o s s i b l e f o r t h e P r o v i n c i a l S u p e r v i s o r o f P s y c h i a t r i c S o c i a l Work t o meet h e r r e s p o n s i b i l -i t i e s f o r t h e o r g a n i z a t i o n and c o - o r d i n a t i o n o f the s o c i a l s e r -v i c e p r o g r a m so t h a t i t f u l f i l l s t h e needs o f t h e p a t i e n t s , and t h e community t h a t the h o s p i t a l s e r v e s . T h i s i s the g o a l t h a t t h e S o c i a l S e r v i c e D e p a r t m e n t s a r e s t r i v i n g t o w a r d s , b u t b e f o r e i t can be a c c o m p l i s h e d t h e r e i s one more a d m i n i s t r a t i v e p r o -v i s i o n t h a t i s r e q u i r e d , - " t h e i n c l u s i o n o f t h e d i r e c t o r o f s o c i a l work i n a d m i n i s t r a t i o n s t a f f m e e t i n g s and p a r t i c i p a t i o n i n d i s c u s s i o n s o f h o s p i t a l p o l i c i e s w h i c h p e r t a i n t o t h e t r e a t -ment and w e l f a r e o f p a t i e n t s . The r e s p o n s i b i l i t y o f s o c i a l s e r v i c e t o a d m i n i s t r a t i o n cannot be f u l l y met i f t h e d i r e c t o r o f t h e s o c i a l s e r v i c e department f u n c t i o n s on a l e s s w e l l - d e -f i n e d b a s i s . " 1 I n e v a l u a t i n g t h e H o s p i t a l and C l i n i c program i n r e l a t -i o n t o t h i s p o i n t , i t was found t h a t i n some a r e a s , s u c h as c l i n i c a l m a t t e r s , the members o f t h e t r e a t m e n t team come t o g e t h -e r a t ward r o u n d s and t h i s r e s u l t s i n j o i n t p l a n n i n g and t r e a t -ment. The C l i n i c a l D i r e c t o r sends out memos t o a 11 c o n c e r n e d when t h e r e a r e m a t t e r s i n t h e c l i n i c a l t r e a t m e n t t h a t a r e t o be 3S.&.A.P. R e p o r t , N o . 2, o p . c i t . , p . 14. -• 33 -considered, and i n any decisions around treatment he informs the i n d i v i d u a l departments of the decisions that are made. Also the P r o v i n c i a l Supervisor of Psychiatric S o c i a l Work and the Casework Supervisors meet with the Di r e c t o r of Mental Health Services from time to time on s p e c i a l matters. But i n the general administrative matters that concern the Hospital-, and C l i n i c the S o c i a l Service Departments are not included. An outstanding example of t h i s i s the Hospital Council. The Hospital Council i s an important organization i n determining o v e r - a l l p o l i c y . Matters.that transcend the f i e l d s of several services and require s p e c i a l co-operation and con-s u l t a t i o n are usually referred to t h i s body f o r consideration. I t i s established, by statute, i n the Department of the Provin-c i a l Secretary and i s composed of the Dir e c t o r of Mental Health Services, the Senior Medical Superintendent, the Deputy Medical Superintendent, the C l i n i c a l Director, the D i r e c t o r of Nurs-ing, the Chief P s y c h i a t r i c Male Nurse, the Business Manager, and the Administrative Assistant. These members comprise the per-manent or basic Hospital Council and are augmented, when necess-ary, by the appropriate department heads, e.g. i f the subject of the discussion was food the d i e t i c i a n would be present. In t h i s way the Dir e c t o r i s assisted i n coming to major decisions by the advice and consideration of a group of s p e c i a l i s t s . Likewise, a l l departments concerned are kept f u l l y informed and are b r i e f e d by the Director and Council i n carrying out new techniques and duties. The Hosp i t a l Council meets at the c a l l - 34 -of the Di r e c t o r . The business at hand may originate i n the Dire c t o r ' s o f f i c e or at the request of a department head or s t a f f member.1 From t h i s description of the Hospital Council's s t r -ucture and function i t i s evident that the S o c i a l Service De-partments are only included when matters dealing s p e c i f i c a l l y with s o c i a l service are being considered. This may seem l o g i c a l , but i t i s the s o c i a l worker who has the most d i r e c t contact be-tween the ho s p i t a l and the community. As the ho s p i t a l i s a treatment f a c i l i t y of the community i t seems important that the s o c i a l worker attend the meetings to present the views of the community, and to point out the needs and resources that are seen outside of the ho s p i t a l s e t t i n g . Another instance where there i s lack of p a r t i c i p a t i o n by the S o c i a l Service s t a f f i s i n the noon meetings of the med-i c a l s t a f f . These meetings are held d a i l y so that i n d i v i d u a l doctors can discuss the treatment of s p e c i f i c patients. The r e -h a b i l i t a t i o n o f f i c e r , who i s not a member of the S o c i a l Service Departments, i s one of the two non-medical persons included i n these discussions, the other being the administrative a s s i s t a n t . Again i n the Thursday evening meetings f o r medical s t a f f develop-ment the So c i a l Service Departments are not represented. Doc-tor s , psychologists, and nursing s t a f f attend regularly; but, only on one occasion was the P r o v i n c i a l Supervisor of Psychiat-1. B.C. Psy c h i a t r i c Services Physician's Manual, op. c i t . p. 2|. - 35 -r i c Social Work invited. This was to discuss the structure and function of the Departments, and has been the only represent-ation to date. Exclusion of the Social Service Departments from the Hospital Council and from various staff meetings, at which patient treatment i s considered, constitutes a lack of integ-ration between the various departments in the Hospital and Clinic setting. Administration, to be sound, must be the bus-iness of the entire staff, as i t i s "the sum of a l l their act-i v i t i e s and more than that; i t i s a total operation having im-plications bigger and broader than the stake of the individuals involved. The ultimate test of i t s success w i l l be the quality of service which eventuates, and the degree of public response to that service." 1 The Social Service Departments are progressing rapidly and i t i s possible that With the extension of good casework practice there w i l l be increased recognition of the social work-er's contribution i n a l l areas of treatment and program plann-ing. The f i n a l point to consider in the administrative pic-ture i s i n the co-operation between the two controlling depart-ments - the Social Welfare Branch and the Department of the Provincial Secretary. As there i s no defined or established policy between the two the Provincial Supervisor provides the main l i a i s o n . It i s her job to i n i t i a t e new areas of social 1. Vasey, W., "Partnership Between Administrator and Staff in Developing Sound Welfare Programs," Social Casework. f o l . XXXIII, A p r i l 1952, p. 137. - 3.6i -s e r v i c e t o p a t i e n t s t h r o u g h j o i n t p l a n n i n g w i t h t h e H o s p i t a l and C l i n i c a d m i n i s t r a t i o n , and a t the same time to a r r a n g e w i t h t h i s a d m i n i s t r a t i o n f o r c l e r i c a l s t a f f and w h a t e v e r space i s a v -a i l a b l e f o r t h e new s e r v i c e . A f t e r t h i s j o i n t c o n f e r r i n g w i t h t h e D i r e c t o r o f M e n t a l H e a l t h , t h e D e p u t y D i r e c t o r and C l i n i c a l D i r e c t o r a t E s s o n d a l e , t h e P r o v i n c i a l S u p e r v i s o r has t o go t o t h e A s s i s t a n t D i r e c t o r o f W e l f a r e and a d v i s e as t o what t h e p e r -s o n n e l needs w i l l be i n t h e n e w - s e r v i c e . G e t t i n g s u c h p e r s o n n e l a p p o i n t e d i s d i f f i c u l t b e c a u s e o f ' t h e s h o r t a g e o f a v a i l a b l e s o c i a l w o r k e r s . The S o c i a l W e l f a r e B r a n c h has a d i f f i c u l t t i m e s u p p l y i n g t h e demand f o r new w o r k e r s j and e a c h d i v i s i o n o f t h e B r a n c h has t o be a l l o t t e d p a r t o f the a v a i l a b l e s u p p l y . The f a c t t h a t no d e f i n i t e i n t e r - d e p a r t m e n t a l p o l i c y f o r c o - o p e r a t -i o n has b e e n worked out between the S o c i a l W e l f a r e B r a n c h and t h e Department o f t h e P r o v i n c i a l S e c r e t a r y means t h a t much o f the P r o v i n c i a l S u p e r v i s o r ' s t i m e i s spent i n t e r p r e t i n g r e q u e s t s o f needs and s e r v i c e s o f one department t o the o t h e r - t i m e t h a t c o u l d be spent i n f u r t h e r community i n t e r p r e t a t i o n , and h e l p -i n g t o work out c o - o p e r a t i o n and i n t e g r a t i o n i n t h e d e p a r t m e n t s a t t h e P r o v i n c i a l M e n t a l H o s p i t a l and t h e C r e a s e C l i n i c . The a d m i n i s t r a t i o n o f l a r g e i n s t i t u t i o n s s u c h as t h e two a t E s s o n d a l e i s a b i g r e s p o n s i b i l i t y . M a i n t a i n i n g adequate t r e a t m e n t f a c i l i t i e s and a t the same t i m e c a r e f u l n e s s i n the s p e n d i n g o f p u b l i c money a r e prime c o n s i d e r a t i o n s . T h e r e f o r e i t i s i m p o r t a n t t h a t a l l d e p a r t m e n t s w i t h i n the H o s p i t a l and C l i n i c p a r t i c i p a t e as f u l l y as p o s s i b l e i n the a d m i n i s t r a t i v e aspects so that each realizes i t s responsibilities. The social worker can be very helpful in giving the administration a clear-er picture of the patient and his needs, the needs of the com-munity, and the areas in which the program development would be most helpful to both the patient and the community. The. social worker i s the person best equipped, by his training, to present the social needs to the administration. In the finan-c i a l area, i t i s the social worker who reduces expenses by making i t possible for the patient to leave the treatment cen-tre and s t i l l have a f u l l y qualified person i n touch with him, and to assist him i n re-establishment. Cutting down the length of stay also increases the number of patients that can be treat-ed. Adequate administration of the hospitals should result in properly defined functions, and the integration of each sep-arate- department into the total hospital administration.. This integration i s necessary because i n the mental hospital setting there should be a multi-disciplined approach to treatment; to make this possible there must be a similar approach to adminis-tration, with proper allocations of responsibility i n accord-ance with s k i l l s . - 38 -Chapter I I I - Admissions Procedure and Service. There i s no more important time at which the s o c i a l worker can o f f e r his services to the patient entering a hospital for the treatment of mental i l l n e s s than right at the time of the patient's admission. I t i s then that the s o c i a l worker can help to ease the fears and anxieties of both the patient and his r e l a t i v e s , which may be more prevalent than at any other period of his i l l n e s s . So that t h i s service would be a v a i l a b l e , the Admissions Sections of the S o c i a l Service Departments at Essondale were started. F i r s t i n A p r i l 1951, a s o c i a l worker was designated at the Crease C l i n i c to handle newly admitted patients and t h e i r r e l a t i v e s . In September, of the same year, a worker with s i m i l a r duties was appointed to the P r o v i n c i a l Mental Ho s p i t a l . In the l a t t e r instance only a part time ser-vice was offered as the worker also carried cases i n the Con-tinuing Casework Section. By July 195£, a second worker was assigned to t h i s job at the Mental Hospital. He also carried cases i n long-term treatment. As the function of t h i s new Sect-ion was better understood, by the Hospital personnel, the job of the Admissions worker increased and the need f o r a f u l l time worker was r e a l i z e d . In September 1952, a s o c i a l worker was appointed to the Admissions Section at the Mental Hospital on a f u l l time b a s i s . S i m i l a r l y , at Crease C l i n i c , the number of r e f e r r a l s to the Admissions Section had increased. E a r l y i n 1953 a sec-ond s o c i a l worker was added to t h i s Section, with a view to i n -- .39- -creasing to four workers at such time as professional staff he-came available. Also an Admissions Casework Supervisor was ap-pointed to supervise the caseworkers in the Admissions Sections of both the Clinic and the Hospital. The present set-up i s shown diagrammatically as, Provincial Supervisor of Psychiatric Social Work Admissions Casework Supervisor at Mental Hospital and Crease Clinic Admissions Case-Workers at the Mental Hospital Admissions Case-Workers at the Crease Clinic Figure 5 - Admissions sections at the Provincial Mental Hospital and the Crease C l i n i c . The Admissions Sections at the Provincial Mental Hos-p i t a l and the Crease Clinic have three broad functions, 1. A casework service at in-take. 2. A casework service on reception of the patient. 3. A screening service by which patients are selected for continuing social services. Social Service at Intake. The services offered by the caseworker at intake con-sists mainly of interpretation to prospective patients and r e l -atives about the f a c i l i t i e s which exist at the Hospital and Clinic - 40 — for the care and treatment of patients; interpreting also to community agencies or individuals inquiring about the treatment and f a c i l i t i e s ; helping the relative and prospective patient to use other services that exist i n the community which might post-pone or prevent the admission of the patient. The intake worker may also help the relative and patient himself to understand the f a c i l i t i e s of the Hospital or Clin i c , and to relieve his anxiety and uncertainty about coming. Social Service at Reception. The service of assisting i n the reception of the pat-ient into the Hospital or Clinic usually involves outlining the services and f a c i l i t i e s to the patient's family, the patient him-self, or any interested person who has accompanied him; helping the family with the fears and anxieties that arise when one of i t s members i s about to receive treatment; helping the family to understand this treatment; whenever possible to gather inform-ation abbut the patient, his relationships, experiences, and his illnes s from either the patient or his relatives; also referring the relative according to the need to the continuing social ser-vices,' with the idea that through the growth of an understand-ing, supportive relationship the relative may be helped to under-stand the patient and to assist i n the treatment and rehabil-itation. Screening Service. At the Mental Hospital and Crease Cli n i c there are two forms of screening. The f i r s t has developed within the Social - 41 — Service Departments themselves and involves the social worker making a social diagnosis and ascertaining the a b i l i t y of the patient and relatives to use the social service available. I f the Admissions worker feels that the patient can use further social service contact the case i s assigned to a Continuing Service worker, i f not the case i s closed as far as social ser-vice i s concerned. The second, which i s s t i l l i n the develop-mental stage, consists in screening at ward rounds. In the l a t -ter case the social worker on Admissions might bring to ward rounds the social diagnosis indicating whether he i s of the opin-ion that social service should be extended or not. This opinion may be changed as each member of the hospital team (doctor, psychologist or nurse) brings what he knows of the patient, the patient's illn e s s or how the patient i s responding to treatment. It does happen through the ward rounds that social service may open a case on which they i n i t i a l l y did not see where service by the case worker could have been helpful. In the screening at ward rounds various things are taken into consideration such as types of i l l n e s s , chronicity and sev-erity, a b i l i t y of the patient to use social services, resources available for the use of the patient, and whether the patient i s going to be short-term and has family resources, for instance, social services would not be extended. Also the non-English speaking patient without relatives, and transients (for example, seamen from other countries who are ordinarily repatriated to their ship) would not be extended services. Previous admissions » 42 -o f t h e p a t i e n t a r e a l s o c o n s i d e r e d i n t h e s c r e e n t o C o n t i n u i n g casework s e r v i c e s . S e r v i c e s t o r e l a t i v e s a r e d e c i d e d upon and t h e s o c i a l d i a g n o s i s i s made w i t h i n t h e S o c i a l S e r v i c e D e p a r t m e n t s i n t h e A d m i s s i o n s S e c t i o n s . The s e r v i c e t o r e l a t i v e s i s c o n s i d e r e d t o b e . t h e e x c l u s i v e r e s p o n s i b i l i t y o f the s o c i a l w o r k e r s and i t i s t h e i r r e s p o n s i b i l i t y t o d e c i d e w h e t h e r t h i s s h o u l d be o f f e r e d . A l t h o u g h the A d m i s s i o n s S e c t i o n s i n t h e H o s p i t a l and C l i n i c o f f e r a s i m i l a r s e r v i c e i n i n t a k e , r e c e p t i o n and s c r e e n -i n g , t h e r e i s a d i f f e r e n c e t h a t s h o u l d be p o i n t e d u p . The C r e a s e C l i n i c i s a s h o r t - t e r m t r e a t m e n t c e n t r e . The maximum p e r i o d t h a t t h e p a t i e n t c a n r e m a i n i s f o u r months. B e c a u s e o f t h i s s t i p u l a t i o n t h e r e i s a r a p i d t u r n o v e r o f p a t i e n t s and t h e A d m i s s i o n s w o r k e r has t o be as s e l e c t i v e as p o s s i b l e r e g a r d i n g . t h e c a s e s t h a t can use f u r t h e r casework s e r v i c e s i n t h e s h o r t t i m e a v a i l a b l e . A l s o many o f the cases have t o be r e f e r r e d on t o t h e C o n t i n u i n g Casework S e c t i o n s b e f o r e the A d m i s s i o n s w o r k -e r has seen t h e r e l a t i v e s o r b e e n a b l e t o make a f u l l e v a l u a t i o n o f t h e need f o r s o c i a l s e r v i c e s . I n t h e M e n t a l H o s p i t a l t h e s i t u a t i o n i s d i f f e r e n t . B e i n g a t r e a t m e n t c e n t r e where t h e p a t i e n t u s u a l l y r e m a i n s f o r a p e r i o d o f s e v e r a l months t o y e a r s the A d m i s s i o n s w o r k e r has more t i m e t o c o n t a c t the r e l a t i v e s , see t h e p a t i e n t , ..and e v a l -u a t e t h e s i t u a t i o n b e f o r e r e f e r r a l i s made t o C o n t i n u i n g C a s e -work S e r v i c e s . T h i s does n o t mean t h a t t h e work i n t h i s S e c t i o n i s any e a s i e r t h a n a t the C l i n i c , b u t i t does mean t h a t s c r e e n -- "43-^ ing to further s o c i a l services i s better and less preliminary-material has to be gathered by the worker giving continued services. Duties of the Admissions Casework Supervisor. P r i o r to the appointment of a Casework Supervisor f o r the Admissions Sections, the workers doing the Admissions job were under the supervision of the casework supervisors i n the . Continuing Casework Sections. Because of the rapid expansion of the work i n Admissions the necessity of having a supervisor f o r t h i s area alone was soon r e a l i z e d by the P r o v i n c i a l Super-v i s o r of Psychiatric S o c i a l Work. In January 1 . 953 , a Casework Supervisor was appointed for the Admissions Sections i n the Hospital and C l i n i c . Her duties consist of supervision of the casework s k i l l s of the caseworkers i n the admissions process; r e s p o n s i b i l i t y f o r integrating the teamwork approach within the Hospital and C l i n i c by i n t e r p r e t i n g to the medical, nursing, and c l e r i c a l s t a f f t h e i r r e s p o n s i b i l i t i e s for getting r e l a t i v e s to the Admissions workers so that s o c i a l services may be i n i t i a t e d as soon as possible a f t e r the patient's a r r i v a l ; r e s p o n s i b i l i t y for d i r e c t i n g and supervising the F i e l d Service s t a f f of the S o c i a l Welfare Branch regarding the admission of patients, and t h e i r r e s p o n s i b i l i t y to the family at the time of admission; int e r p r e t i n g , to community agencies, the services of the C l i n i c and the Hospital, also the p o l i c y and procedure f o r admission on behalf of t h e i r c l i e n t s ; as well as acting i n an i n t e r p r e t i v e and guidance role to the community agencies. Besides these, 44 --the Casework Supervisor i n Admissions has r e s p o n s i b i l i t y f o r the screening of cases into the Continuing Casework Sections. This i s f a c i l i t a t e d by serving on a screening committee made up of the P r o v i n c i a l Supervisor and the Continuing Caseworker super-v i s o r s , and attendance at a l l ward rounds. P r o v i n c i a l Mental Hospital. At the time of the opening of the Admissions Section at the P r o v i n c i a l Mental Hospital the s o c i a l worker was i n -structed to a s s i s t the duty doctor i n any way possible during the actual admissions procedure, and to interview r e l a t i v e s and escorts a f t e r the new patient was taken to the ward. He attempt-ed to be present during each admission; and, besides interview-ing, he prepared a. v i s i t i n g sheet for the r e l a t i v e or escort, and also completed the " l i v i n g body receipt" which i s a form that has to be completed when a patient i s escorted to the H o s p i t a l . The committal papers were also reviewed to see i f they were i n order and i f the patient had ever been hosp i t a l i z e d before. The Admissions worker's function regarding patients who came i n by ambulance unaccompanied or whenever escorted only,, by police, was primarily c l e r i c a l although i t was some-times h e l p f u l , depending on the patient's condition, to reassure him about his h o s p i t a l i z a t i o n and ask about h i s d a i l y needs. As the work of the Admissions Section progressed, the c l e r i c a l functions were taken over by other Hospital personnel and the Admissions worker concentrated on s p e c i f i c casework ser-v i c e s i n intake and reception, plus screening of cases to Con-- 4 5 - -t i n u i n g s e r v i c e s . A t p r e s e n t t h e A d m i s s i o n s S e c t i o n c o n s i d e r s i t s f u n c t i o n t o he t h e e s t a b l i s h m e n t o f a p u r p o s e f u l casework r e l a t i o n s h i p w i t h t h e p a t i e n t s and t h e i r r e l a t i v e s t o enable them t o a c c e p t a l o n g t e r m h o s p i t a l i z a t i o n and t r e a t m e n t , and t o h e l p them l o o k i n t o t h e a v a i l a b l e r e s o u r c e s f o r t h e r e h a b i l i t -a t i o n o f t h e p a t i e n t . The A d m i s s i o n s S e c t i o n a t the P r o v i n c i a l M e n t a l H o s p i t a l r e c e i v e s r e f e r r a l s f r o m a v a r i e t y o f s o u r c e s , 1. The f i r s t g r o u p , f r o m w h i c h t h e l a r g e s t number o f r e f e r r a l s i s r e c e i v e d , i s t h e g r o w i n g number o f young p a t i e n t s b e i n g t r e a t -ed f o r m e n t a l i l l n e s s . The m a j o r i t y o f t h e s e p a t i e n t s a r r i v e f r o m G r e a s e C l i n i c where the f o u r months h o s p i t a l i z a t i o n has p r o v e n i n a d e q u a t e . The r e f e r r a l s from t h i s g r o u p u s u a l l y re - r , q u i r e l o n g - t e r m casework p l a n s w i t h b o t h t h e p a t i e n t and h i s f a m i l y . When s u c h p a t i e n t s a r e t r a n s f e r r e d f r o m C r e a s e C l i n i c , t h e A d m i s s i o n s w o r k e r d i s c u s s e s t h e p a t i e n t w i t h the C l i n i c ' s C o n t i n u i n g c a s e w o r k e r , and t o g e t h e r t h e y p l a n t h e c o n t i n u a t i o n o f s e r v i c e t o t h e p a t i e n t and h i s f a m i l y . O f t e n t h e s e p a t i e n t s a r e so d i s t u r b e d t h a t t h e y a r e n o t a b l e t o a c c e p t casework h e l p on t h e w a r d , b u t the r e l a t i v e s , who have b e e n f a c e d w i t h t h e p r o b l e m o f c o m m i t t i n g t h e s e p a t i e n t s t o t h e M e n t a l H o s -p i t a l , need a g r e a t d e a l o f h e l p i n u n d e r s t a n d i n g t h e h o s p i t -a l ' s f u n c t i o n . A l s o i n t h e s e r e f e r r a l s t h e A d m i s s i o n s w o r k e r a n a l y z e s the f i l e and p r e p a r e s a summary, t o d a t e , o f t h e work done w i t h t h e p a t i e n t . I n t h i s way t h e c o n t i n u i n g c a s e w o r k e r a t t h e M e n t a l H o s p i t a l has t h e p a s t work f o c u s e d f o r h i m , and - , 4 6 -he i s i n a better p o s i t i o n to continue the work that was s t a r t -ed at the C l i n i c . 2. The second group, from which r e f e r r a l s are accepted, are the older persons who need treatment for mental i l l n e s s . In-cluded i n t h i s group are a number of readmissions where in t e r i m information i s required. Often these patients, have had a r e -mission i n t h e i r i l l n e s s for a matter of two or three years, and i t i s valuable for the doctor and s o c i a l worker to know what t h e i r behaviour was l i k e during t h i s period and also the circum-stances that precipitated reoccurence of t h e i r i l l n e s s . 3. The t h i r d group of r e f e r r a l s i s through the admission, to the P r o v i n c i a l Mental Hospital, of mentally d e f i c i e n t children, f o r transfer to Woodlands School. In the past, the p o l i c y has 4.-been that a l l children being placed i n the Woodlands School had to be admitted to the Mental Hospital and then transferred l a t -er. Recently there has been a change i n t h i s procedure and now children under s i x years of age are admitted d i r e c t l y to the School. This has considerably decreased the number of r e f e r r a l s from t h i s source. When children are placed v i a the Mental Hos-p i t a l there i s usually a b r i e f - s e r v i c e to r e l a t i v e s required at t h i s time. The committal of t h e i r c h i l d through the Mental Hos-p i t a l i s almost always a most disturbing experience for them, even though valuable help and int e r p r e t a t i o n has, i n many cases, heen given to the parents by the workers i n the F i e l d Service or other agencies. The Admissions worker helps the parents with t h e i r feelings by getting them to discuss t h e i r fears about the committal to the Mental Hospital, and explaining the function and services of the Hospital to them. In some instances the work-er has given longer service to parents who have "been unable to face committing t h e i r c h i l d f o r transfer to the School. Such would be the case when the parents have been seen by the s o c i a l worker from the Woodlands School So c i a l Service Department, and have accepted the plan for placement of t h e i r c h i l d i n V/oodlands School but are unable to accept the committal through the Prov-i n c i a l Mental Hos p i t a l . 4. A small group of r e f e r r a l s i s received through the doctor i n charge of the Alc o h o l i c C l i n i c at the H o s p i t a l . A s o c i a l h i s -tory may be required to a s s i s t i n the assessment of the patientJ's s u i t a b i l i t y for p a r t i c i p a t i o n i n group psychotherapy, and a few of these r e f e r r a l s have been transferred to the Continuing,Case-work Section for casework services to the patient's family. >\ A few r e f e r r a l s are also received from patients committed by Order-in-Council whose families often need very extensive case-work support. Order-in-Council patients are prisoners from Oakalla j a i l or the B.C. Penitentiary who are committed by the Courts f o r mental examination and treatment. 5. Some r e f e r r a l s come d i r e c t l y from the doctors during the admission of the patient, but these are very infrequent because the Admissions worker gives coverage at the time of the patient's reception. 6„ Another group of r e f e r r a l s i s made through the doctors at the West Lawn b u i l d i n g . (The patients at the P r o v i n c i a l Mental :4B -Hospital are housed i n three d i f f e r e n t buildings, namely "West Lawn" for men patients who are considered c h r o n i c a l l y i l l ; "East Lawn" for women patients who are considered chronically i l l ; and "Centre Lawn" where both men and women patients are admitted and receive treatment u n t i l such time as they are d i s -charged or' transferred to one of the f i r s t two mentioned b u i l d -ings.) At present, due to s t a f f shortages, there are no s o c i a l workers assigned to the wards on the West Lawn Bui l d i n g s , con-sequently the Admissions Section handles a l l r e f e r r a l s from t h i s b u i l d i n g . In the East Lawn b u i l d i n g , regular weekly ward rounds are held and r e f e r r a l s f o r s o c i a l services are numerous. 7. Remaining r e f e r r a l s . The Admissions Section r e l i e s a great deal on co-operation of other members of the h o s p i t a l s t a f f . The Psychiatric Nurses at the Centre Lawn b u i l d i n g admitting desk are constantly on the look-out to channel r e l a t i v e s and i n -terested friends to the s o c i a l worker. The' Admissions worker also attempts to make regular v i s i t s to the wards. These v i s i t s help to develop good inter-departmental r e l a t i o n s . . Each week the worker t r i e s to interview patients i n the Occupational Therapy department as well as.on the wards. Some r e f e r r a l s are opened from this source, because patients during the s o c i a l i z a t -ion period i n Occupational Therapy are often more able to discuss their.anxiety about families, t h e i r i l l n e s s , and the future and what i t holds for them. Regularly each week, ward rounds are held on the mens and womens wards i n the Centre Lawn building, where the Admiss-- 4 9 -ions worker i s stationed. Referrals were commonly made from these-ward rounds at one time, hut there has been a sharp de-crease due to the screening of a l l patients upon Admission, and s o c i a l service studies have usually been started on selected cases before ward rounds are held. D i s p o s i t i o n of Refer r a l s , When a r e l a t i v e accompanies a patient to the Hospital, the Admissions worker endeavours to see him at the time of the patient's a r r i v a l , but i t may happen that further appointments have to be made before a l l necessary information has been ob-tained. This may include one or two interviews according to the needs of the case. Cases are therefore held over at the Admiss-ions Section u n t i l a l l the information that i s required has been obtained, and from t h i s information the case i s then focused f o r continuing services. As the s o c i a l workers at the Mental Hos p i t a l are r e s -ponsible f o r a l l services to patients within the C i t y of Van-couver and the Greater Vancouver area, the Admissions worker must screen a l l f i l e s and make appointments f o r interviews ac-cordingly. This i s a routine task which necessitates a summary of the committal papers, and of the information on the f i l e . I d e a l l y the Admissions worker aims to see the f i l e s within two or three days following the patient's admission, so that i n t e r -views with the r e l a t i v e s can be arranged i f they are within • the stated area, but t h i s i s becoming more d i f f i c u l t due to the increasing number of.admissions and also the increase i n r e f e r r a l s . 50 When patients are admitted from other areas of B r i t i s h Columbia' a l l f i r s t l e t t e r s to the F i e l d Service are written by the Admissions worker. This also involves a car e f u l summary of a l l the information on the f i l e so that the F i e l d Service has every assistance i n the task of obtaining a s o c i a l h i s t o r y or other information desired. These cases then remain i n the Admissions Section u n t i l the F i e l d Service worker r e p l i e s to the request. When information i s received from the F i e l d Ser-vice the Admissions worker evaluates the t o t a l patient a nd family s i t u a t i o n , and where required i n i t i a t e s casework services through a further l e t t e r to the F i e l d Service. F i e l d Service i s often required to give i n t e r p r e t a t i o n of mental i l l n e s s to the patient's family as few r e l a t i v e s ac-cept i t without considerable d i f f i c u l t y . I f a patient i s to r e -turn to h i s home environment casework interviews with the r e l -atives w i l l help to focus r e h a b i l i t a t i o n plans f o r the patient. In the area of help to r e l a t i v e s the F i e l d worker i s able to give i n t e r p r e t a t i o n and support around the anxiety, uncertain-l y , and g u i l t feelings that often ari s e from committing a per-son to the Hospital, and t h i s i s instrumental i n helping them to make v i s i t s to see the patient l a t e r on. Following the sending of the second l e t t e r to the F i e l d Service, these cases are then transferred to the Contin-uing Casework Section where extended contact with the patient, r e l a t i v e s or the F i e l d may be maintained. Since the present Admissions Section was organized (September 1952) a monthly average of 115 patients have been ad-- 51 -mitted to the Mental Ho s p i t a l . During the f i r s t three months of 1953, r e f e r r a l s to the Admissions worker have been made i n thirty-one per cent of newly admitted patients. Of these re-f e r r a l s , t h i r t y per cent have been transferred out to Contin-uing Services, f o r t y per cent were carr i e d over i n the Admiss-ions Section u n t i l a l l information had been c o l l a t e d , and t h i r t y -per cent were closed. Crease C l i n i c of Psychological Medicine. The Admissions Section at Crease C l i n i c began as a separate e n t i t y during A p r i l 1951, and because i t was a new de-velopment there was no attempt to define a r i g i d p o l i c y or pro-cedure. Since that time, i t has remained, purposely, as f l e x -i b l e as possible i n order that the department can f e e l i t s way and develop to meet the needs of the short-term stay that i s c h a r a c t e r i s t i c of Crease C l i n i c . Routine r e f e r r a l s are received i n the Admissions Sect-ion from the following sources, 1. The admitting desk. 2. The reception desk. (Switchboard.) 3. The medical s t a f f . Both from the admitting desk and from private r e f e r r a l . 4. Upon requests from r e l a t i v e s . 5. From outside agencies and interested p a r t i e s . The Admissions worker attempts to give service immed-i a t e l y on request because i t i s recognized that the needs of the patient and his r e l a t i v e s at the time of admission are usually acute. The f i r s t two sources of r e f e r r a l have operated most e f f i c i e n t l y , so that most parties who are admitted during o f f i c e hours, and accompanied by r e l a t i v e s , are seen immediately by the Admissions worker. S i m i l a r l y , r e l a t i v e s v i s i t i n g during • the i n i t i a l period of the patient's stay i n the C l i n i c are care-f u l l y screened by the reception desk and ref e r r e d to the Admiss-ions worker on the occasion of t h e i r f i r s t v i s i t to the C l i n i c . By interviewing r e l a t i v e s at the'time of the patient's admiss-ion into the C l i n i c the worker i s able to obtain s o c i a l h i s -tory information, and to help with any f e e l i n g s of fear or an-x i e t y that a r i s e . On a l l occasions the Admissions worker i n -forms the r e l a t i v e s that, i f further s o c i a l services are r e -quired:,: another s o c i a l worker i n the Continuing Casework Sect-ion w i l l be carrying the patient while he i s receiving t r e a t -ment at the C l i n i c . This helps the r e l a t i v e s to accept the next worker and speeds the casework process, which i s an important factor i n short-term treatment. As a rule the Admissions worker attempts to dictate any information, that he has obtained, within a day or two. In t h i s way the information i s available for the doctor, as well as the Continuing Service worker within a few days of the pat-ie n t ' s a r r i v a l at the C l i n i c . Along with the casework services that are offered i n intake and reception, the Admissions workers are responsible f o r d i r e c t i n g and supervising F i e l d Services i n the procedure f o r the admission of patients;' also for i n t e r p r e t i n g , to community agencies, the services of the C l i n i c and the p o l i c i e s i n admiss-ions. Workers i n the Admissions Section must also, along with the Admissions Casework Supervisor*, attend ward rounds every Monday and ?ifednesday. The purpose of these rounds i s to present the information that has been gathered, by each member of the treatment team, on selected patients. Treatment plans are formulated at t h i s time. I f a patient i s discussed and the soc-i a l worker who has been working on the case i s v i s i t i n g i n the d i s t r i c t , and therefore not available, the Admissions worker must present the information f o r him, and also channel any com-munications regarding the patient back to the worker concerned. I t i s at these ward rounds that the Admissions Case-work Supervisor and the Admissions workers are able to screen further the cases already i n S o c i a l Service, as well as screen-ing those cases that are referred by the medical s t a f f at the ward rounds. This screening i s a very important function be-cause of the severe shortages i n s t a f f which means that the s o c i a l workers cannot be engaged i n any area i n which there i s l i k e l y to be l i t t l e a b i l i t y on the part of the patients and r e l -atives to use s o c i a l services. The screening out of the afore-mentioned depends, of course, upon the fac t that the patient has resources i n family and friends which are available to him at the point of discharge from the C l i n i c . I f not, services would be extended to him i n the best possible way. At present the Admissions Section at Crease C l i n i c i s - 54 -s t i l l i n a state of evolution*, Although the s t a f f has increas-ed there i s s t i l l not the f u l l coverage of r e f e r r a l s that was hoped for, and some patients have to be referred on the contin-uing caseworkers before.preliminary evaluative material can be gathered. The main reason for t h i s lack i s that the two work-ers now responsible for admissions are on alternate s h i f t s , and thus two workers are never on duty at the same time except on V/ednesdays. This w i l l be p a r t l y overcome when these workers are r e l i e v e d of the r e s p o n s i b i l i t y of carrying a few of the cases that should be referred to the Continuing Casework Sect-ion, and can devote f u l l time to Admissions services. A f u r -ther complication i s seen i n the lack of office.accommodation. There i s s t i l l only one Admissions o f f i c e . Obviously, two interviews cannot be conducted at the same time, and therefore before the hoped-for maximum service can be given there i s need f o r more o f f i c e space. Though the work of the Admissions Section, for the above reasons, has been l i m i t e d i t has proved very valuable to the workers i n the Continuing Casework Section. Although the evaluation of the s o c i a l s i t u a t i o n by the admissions worker i s made hurriedly, i t has been found to be most accurate i n l a t e r work. E a r l y evaluation of the strengths within the patient and his family by the Admissions study allows the continuing case-worker to discuss the case with the doctor and the Casework Supervisor, thus the continuing caseworker begins to work sim-ultaneously with the other members of the team and a time l a p -- 55 -se i s prevented. The patient's r e l a t i v e s have been found to be more accepting of s o c i a l services when the Admissions worker has prepared them for Continuing Casework services. Also during the continuing caseworker's day i n the d i s t r i c t , the r e l -atives who arrive at the C l i n i c unexpectedly can be seen by the Admissions worker; and the development of the Admissions Sect-ion has re l i e v e d the continuing caseworker from answering div-erse i n q u i r i e s previously relayed by the switchboard. The Admissions Section i s s t i l l a f l e x i b l e structure, with no attempt to make i t s t a t i c , i n the hope that i t w i l l gradually evolve towards higher standards of service. I t i s growing slowly as circumstances i n the C l i n i c setting permit, i n the meantime adjusting to other members of.the treatment team, and t r y i n g to interpret to them the r i g h t f u l and p r o f i t -able use of s o c i a l service i n terms of services to patients i n the worker's own area of competence. - 56 -Chapter IV - Continuing Casework. After c a r e f u l screening by the Admissions workers at the P r o v i n c i a l Mental Hospital or the Crease C l i n i c of Psych-o l o g i c a l Medicine, patients, who are l i k e l y to benefit from a longer period of casework services are referred to the s o c i a l workers i n the Continuing Casework Sections. The Continuing Casework Section at the Mental H o s p i t a l i s the hub of the i n i t i a l s o c i a l service department that was set up at Essondale. At present there are seven caseworkers and one Casework Supervisor i n t h i s section. Of these, the Casework Supervisor and three of the workers have t h e i r Master of S o c i a l Work t r a i n i n g , three have Bachelor of S o c i a l Work t r a i n i n g , and one i s an In-Service trained person who does a d i f f e r e n t i a t e d job v/ith patients receiving Old Age Assistance and gives consultation to the clerk v/orking v/ith patients r e -ceiving Old Age Security. The Continuing Casework Section at Crease C l i n i c , as stated previously, was separated from the Con-tinuing Casework Section of the Mental Hospital i n May 1952. At present, there are f i v e caseworkers and one Casework Super-v i s o r covering the work i n t h i s Section. The Casework Super-v i s o r and one caseworker have t h e i r Master of S o c i a l Work de-gree, the remaining four have Bachelor of S o c i a l Work t r a i n i n g . A chart of the organization of the Continuing Case-work Sections would be seen as, P r o v i n c i a l Supervisor of Psyc h i a t r i c S o c i a l Work Continuing Casework Supervisor at Mental Hospital Continuing Caseworkers Continuing Casework Supervisor at Crease C l i n i c Continuing Caseworkers Figure B - Continuing Casework Sections at the P r o v i n c i a l  Mental Hospital and the Crease C l i n i c . Continuing Casework Supervisors. When patients and t h e i r f a m i l i e s are referred to the Continuing Casework Sections, the Continuing Casework Super-visors take over the r e s p o n s i b i l i t y f o r supervision of the work that i s done by the s o c i a l workers. The duties of these people are extensions of.the work that i s started by the Admissions Casework Supervisor, and consists i n p a r t i c i p a t i o n i n super-v i s i o n of casework services, i n t e r p r e t a t i o n and teamwork. There i s a s l i g h t difference i n t h e i r work due to the difference i n function between the C l i n i c , a short-term treatment centre, and the Mental Hospital, where long-term treatment i s undertaken. F i r s t i n the area of services to casework s t a f f , the Supervisors have r e s p o n s i b i l i t y f o r the supervision of the case-workers i n the Continuing Casework Sections. This involves helping the caseworkers with plans f o r treatment of the patient while he i s on the ward, when r e h a b i l i t a t i o n i s being consider-- 58 -ed, and through, and following the period of discha rge. The discharge planning involves future d i r e c t work with the patient or r e f e r r a l to another agency. I f the patient i s to-be r e f e r -ed to another agency i n the Vancouver area, the Supervisor i s expected to attend such conferences as may be indicated for thorough discharge planning. Should the patient be leaving the Vancouver area, the F i e l d Service of the S o c i a l Welfare Branch might be brought into the picture. For example, i n the case of a patient leaving the P r o v i n c i a l Efental Hospital, and going to another part of the province, the F i e l d Service would be r e -sponsible f o r his care during the normal s i x months probationary period. For a patient leaving Crease C l i n i c , where there i s no such probation period, there would be c a r e f u l screening by the Casework Supervisor so that already excessive case loads of the F i e l d Service are not unnecessarily overburdened with cases from the Psychiatric Services. The Casework Supervisors also act as l i a i s o n s between » the Continuing Caseworkers and the P r o v i n c i a l Supervisor, help-ing to c l a r i f y problems i n the area of administration, r e v i s i o n of policy, and the extension of services. Secondly, the Casework Supervisors i n the Continuing Sections have duties i n r e l a t i o n to the S o c i a l Welfare Branch. This may be i n t e r p r e t a t i o n , when necessary, of the casework services that are offered i n both the Hospital and C l i n i c ; g i v -ing information about the admitting of patients, and explaining •: the discharge services that are offered. The Continuing Case-- 5 9 -work Supervisors must also attend the twice yearly meeting of the F i e l d Consultants of the S o c i a l ¥/elfare Branch, f o r the pur-pose of discussing p o l i c y and co-operation between the F i e l d Services and the S o c i a l Service Departments at the Mental Hos-p i t a l and Crease C l i n i c . These meetings are held at Essondale. Within the area of teamwork with other professional d i s c i p l i n e s , the Continuing Casework Supervisors have responsib-i l i t y to i n i t i a t e inter-agency conferences regarding treatment and services to patients i n the Hospital and C l i n i c , and also between other d i s c i p l i n e s (doctors, nurses, psychologists, occupational therapists) within the Hospital and C l i n i c s e t t i n g . They also attend ward rounds and present s o c i a l work thinking i n any cases that are discussed. This l a t t e r area i s p r i m a r i l y the concern of the Continuing Casework Supervisor at the Crease C l i n i c . Ward rounds at the Mental Hospital are attended, i n the majority of cases, by tlie Admissions Caseworker who does the screening of patients before r e f e r r a l to the Continuing Casework. Supervisor. The Continuing Casework Supervisor does attend ward rounds on two s p e c i f i c wards i n the womens' b u i l d i n g , (East Lawn) but i n these instances she accompanies the specific.work-er who i s appointed to the ward. The Continuing Casework Supervisor must also advise the continuing caseworkers of any information that was presented on t h e i r s p e c i f i c patients at ward rounds. Once again t h i s i s r e -lated primarily to Crease C l i n i c where- the worker does not attend ward rounds i f i t i s his day i n the d i s t r i c t . In such - 60 -instances information on patients i s given by the Casework Supervisor, and any decisions are relayed back to the -casework-er by her. Also the Continuing Casework Supervisor must ac-company the caseworker to the Medical C l i n i c on Thursday morn-ing when patients are presented and t h e i r treatment discussed. This C l i n i c i s attended by doctors, psychologists and s o c i a l workers. I f the continuing caseworker, whose patient i s being presented, i s not able to attend, any information from the soc-•'ial work area i s presented by his Casework Supervisor. The Continuing Casework Supervisors have considerable r e s p o n s i b i l i t y i n the educational area, and they are assisted i n t h i s by the P r o v i n c i a l Supervisor of Psychiatric S o c i a l Work, and the Admissions Casework Supervisor. F i r s t i n Nursing educat-i o n , 1 they give orientation t o ' a l l parts of the S o c i a l Service Departments and explain the s o c i a l worker's p a r t i c i p a t i o n i n treatment. Secondly, they are active i n the o r i e n t a t i o n program for the In-Service workers. 2 Next with regards to S o c i a l Work students from the University of B r i t i s h Columbia, they attend and possibly participate i n the teaching c l i n i c s ; and with res-pect to s o c i a l workers joining the Hospital or C l i n i c s t a f f , the Continuing Casework Supervisors are responsible f o r o u t l i n -ing the areas of r e s p o n s i b i l i t y of the new workers, and arrang-ing schedules so that the workers can attend ward rounds and 1. Appendix G, op. c i t . p. 29. 2. Appendix D, op. c i t . p. 29 3. Appendix E, op. c i t . p. 30 teaching c l i n i c s . The Continuing Casework Supervisors also act i n an advisory capacity at the meetings of the planning committee f o r the weekly s t a f f meetings; and during Mental Health Week, the Continuing Casework Supervisors, i n co-operation with other s t a f f members, are responsible for the planning of Open House at Crease C l i n i c . The s o c i a l worker's part i n Open House i s to i n t e r p r e t , to the public, the function of the S o c i a l Service Departments i n the treatment of the mentally i l l at Essondale. The Continuing Casework Supervisors also act.with the P r o v i n c i a l Supervisor i n the formulation of p o l i c i e s . Continuing Casework Services. S o c i a l workers i n the Continuing Casework Sections en-gage i n casework services which can be related to three aspects of the patient's i l l n e s s . F i r s t there are the services offered with regards to the t o t a l treatment plan for the patient; second-l y the services geared to the pre-convalescent period; t h i r d l y , services given during the convalescent or probationary period a f t e r the patient has l e f t the Hospital or C l i n i c . S o c i a l work contact, with the patient on the ward i s directed towards b u i l d i n g a supportive, understanding relation-* ship,- through which the ; patient i s helped to hold onto whatever r e a l i t y functioning that he may possess. Interest i n his wife, children, or parents i s kept a l i v e ; also the patient i s helped to do something about those problems of which he i s most aware and concerned. To take a simple example, the s o c i a l worker often has patients who are extremely upset about t h e i r h o s p i t a l i z a t i o n , and convulsive treatment. He helps them to t a l k about t h e i r fears i n thiis area, explains the function of the h o s p i t a l , and encourages them to discuss t h e i r fear of the treatment with t h e i r doctor and nurses. By getting the patient to discuss his f e e l -ings about the treatment with the medical s t a f f , he usually i s more relaxed and does not f e e l he i s being ignored during the actual mechanical treatment period. Interviews are also directed towards keeping up the family's interes t i n the patient by a l l a y i n g the often intense fear of the patient that grew previous to the period of hos-p i t a l i z a t i o n . This i s done by f a m i l i a r i z i n g the r e l a t i v e s with the nature of the i l l n e s s , the treatment, and the Hospital and. C l i n i c routines; by helping r e l a t i v e s with t h e i r own feelings concerning mental i l l n e s s , and by helping them to express the feelings of g u i l t that they often have concerning t h e i r contrib-ution to the patient's i l l n e s s . F i n a l l y through support and c l a r i f i c a t i o n the r e l a t i v e i s helped to see what he can do t o -wards treatment and the r e h a b i l i t a t i o n of the patient. The s o c i a l worker has an important job during the hos-p i t a l i z a t i o n i n conferences with the doctors regarding formul-ation and re-formulation of treatment plans; and also interviews with the psychologists, nursing s t a f f , and occupational therapist i n the i n t e r e s t s of the patient and h i s a b i l i t y to use h o s p i t a l treatment to the greatest advantage. P r i o r to the termination of the treatment the..social worker s t a r t s to prepare the patient f o r leaving the Hospital or C l i n i c , There i s much discussion with the patient on how he feels about leaving the h o s p i t a l , and returning to h i s family and former employment. Also the patient i s encouraged to make week-end v i s i t s to h i s home so that the break from hospitaliz--ation w i l l be gradual, and problems that arise on these v i s i t s can be ironed out before f i n a l discharge. The pre-convalescent treatment i s focused on helping the patient to look forward to his return to community l i v i n g . The f i n a l period of the treatment where services are offered i s during the convalescent or probationary period. Patients are, referred for s o c i a l work help at the time of conval-escence more than any other. During t h i s period the s o c i a l workers help i s focused on the re-establishment of the patient i n the community; helping the patient to hold onto h i s treatment gains; helping the patient to become self-supporting through assistance i n locating work and accommodation; supporting fam-i l y , r e l a t i v e s , and friends i n understanding the patient and those changes which the i l l n e s s may have brought about; whenever possible, to help the patient himself to l i v e comfortably with, and s e t t l e f o r , those changes i n his a b i l i t y to plan, of which the i l l n e s s •may have been the cause. Many of the patients carry with them a varying r e s i d u a l of t h e i r i l l n e s s which necessitates protective family l i v i n g and work placement, as well as f i n a n c i a l help f o r maintenance. The s o c i a l worker has an important role i n i n t e r p r e t i n g these - 64 -needs of the patient to the community, so that more resources w i l l he opened up to meet these needs. During the past f i s c a l year, (1952-53) 675 patients were referred to the S o c i a l Service Departments at Essondale f o r help with problems around discharge. Of t h i s number 297 were • from the P r o v i n c i a l Mental Hospital, and the remaining 378 from Crease C l i n i c . As a rule r e h a b i l i t a t i o n i s not a service that i s extended at the C l i n i c , but because of lack of community r e -sources the S o c i a l Service Department has had to extend i t s e l f i nto a necessarily out-patient department. The continuing caseworker, from the time the patient i s referred u n t i l h i s f i n a l discharge or c l o s i n g of s o c i a l work treatment, i s concerned with a l l aspects of the patient's r e -lat i o n s h i p s with medical and nursing s t a f f , with other patients, and with family, friends and the community. The l a t t e r three areas are very important today f o r the period of h o s p i t a l i z a t i o n tends to be shorter, more intensive, and given over to s p e c i a l -ized and s p e c i f i c treatment methods. Family and community must assume increasing r e s p o n s i b i l i t y for the s o c i a l treatment of the patient following discharge. Additi o n a l Services. Besides the aforementioned casework functions the s o c i a l workers, i n both the Continuing and Admissions Sections, have d e f i n i t e r e s p o n s i b i l i t i e s i n the areas of education, r e -search, and community i n t e r p r e t a t i o n . In the education and t r a i n i n g program within the Hos-- 6 5 -p i t a l i t i s the s p e c i f i c r e s p o n s i b i l i t y * of the s o c i a l worker to interpret the content of his own professional a c t i v i t i e s . For the past three f i s c a l years, under Federal Mental Health G-rants, twenty-eight s o c i a l work students have had t h e i r f i e l d place-ment i n the P r o v i n c i a l Mental Hospital and Crease C l i n i c . Although dir e c t r e s p o n s i b i l i t y f o r supervision of these students i s with the School of S o c i a l Work, t r a i n i n g Supervisor, plans f o r the general introduction and orientation to the S o c i a l Ser-vice Departments, Hospitals-Clinic and community agencies were evolved with the p a r t i c i p a t i o n of the S o c i a l Service Depart-ments. Introduction of students to inter-departmental co-oper-ation between S o c i a l Service and other departments of the Hos-p i t a l and C l i n i c , and the p o l i c i e s r e l a t i n g to t h i s i s the re s -p o n s i b i l i t y of the S o c i a l Service Departments. The Departments attempt to.help the students f e e l at home i n the setting by work-ing c l o s e l y with them, sharing i n s t a f f meetings and i n s p e c i a l studies. . The S o c i a l Service Departments' contribution to the education of non-social work s t a f f , 1 such as nursing has been geared to lecture periods and orientation. The content, of which, has been aimed at the professional a c t i v i t i e s of the soc-i a l worker, as well as sharing the knowledge of the S o c i a l Work profession i n the areas of i n t e r - f a m i l i a l , i n t e r - c u l t u r a l r e l a t -ionships, present day stresses on family l i f e , and the resources 1 . Appendix C, op. c i t . p. 29. - 66 -within the S o c i a l Service f i e l d . Another r e s p o n s i b i l i t y of the S o c i a l Service Depart-ments i n education and t r a i n i n g i s i n the professional develop-ment of the S o c i a l Service s t a f f . To t h i s end there are regular weekly s t a f f meetings, regular supervision of casework, and ac-cess to the important periodicals of the day. The s p e c i f i c con-tent of the educational and tr a i n i n g program i s determined by the S o c i a l Service Departments i n conformity with administrat-ive p o l i c y . Research i s an important part of the work i n the Soc-i a l Service Departments, although i t has been somewhat limited due to shortages of s t a f f and the rapid expansion of the s o c i a l work program into the treatment planning area. Nevertheless there have been some important studies undertaken. Recently a survey was made by the s o c i a l vrarkers of t h e i r own p a r t i c i p a t i o n i n i n i t i a t i n g conferences between psychology and s o c i a l work i n the area of planning f o r treatment of patients. The conclusions reached were int e r e s t i n g and informative. I t was found that the Psychology Department were very w i l l i n g to co-operate, and that conferences to date had been very meaningful to both members of the team. Also, that i n any conference held with a medical doc-tor present he tended to dominate and sway the treatment plan. Lastly, that as a whole the Psychology department had been used very l i t t l e i n an integrative way, but a beginning had been made i n i n i t i a t i n g such team conferences. This was encouraging as the team approach to psychiatric treatment i s e s s e n t i a l . - 67 -A study was also made by the s o c i a l workers, of the r e h a b i l i t a t i o n process. 1 The method of case analysis was used. The study consisted of surveying the present s i t u a t i o n regard-ing r e h a b i l i t a t i o n , the d i f f i c u l t i e s encountered i n time con-sumed, the element of emergency, duplication of ground.covered, resources available and t h e i r use, resources lacking, the fru s -t r a t i o n s and f a i l u r e s that Y/ere met, and the reasons f o r the l a t t e r . The aim was to point out present and future needs, the needs f o r evaluation and selection on the part of the medical and s o c i a l service s t a f f s , and i f possible to evaluate the l e g -itimacy of a request f o r a special person on the s t a f f to deal with r e h a b i l i t a t i o n . This study was successfully completed and the appointment of a person for r e h a b i l i t a t i o n shown to be most necessary. I t i s hoped that more such studies w i l l be under-taken as the work of the Departments increase, as they might be very valuable i n pointing up duplication of services as were found i n the r e h a b i l i t a t i o n , process. The s o c i a l worker has an important contribution to make i n community in t e r p r e t a t i o n . He i s the main l i a i s o n between the h o s p i t a l and the community. As he goes about his work learn -ing the functions and services of l o c a l agencies, securing i n -formation from d i f f e r e n t sources, and e n l i s t i n g the help and int e r e s t of various people, he has an opportunity to work towards 1. B r i t i s h Columbia, Annual Report of the Mental Health Ser- vic e s , Queens Pri n t e r s , V i c t o r i a , 1952, p. 51 *v 68 -a better understanding of the general program of the mental hos-p i t a l or c l i n i c , and towards better working r e l a t i o n s h i p s . Often i n carrying out s o c i a l plans, the s o c i a l worker finds l i m i t a t i o n s i n community resources. Aiding i n the development of these re-sources i s a r e s p o n s i b i l i t y of the s o c i a l worker. He can do t h i s by p a r t i c i p a t i n g i n the a c t i v i t i e s of the community•and helping to point out needs and how they can be met. Much of the s o c i a l worker's p a r t i c i p a t i o n i n i n t e r p r e t -ation i s through work with Councils of S o c i a l Agencies, Commun-i t y Chests, and other c i v i c or professional organizations i n -volved i n community planning. In such groups he helps to co-ordinate the h o s p i t a l services v/ith other community resources, points up the need fo r new h o s p i t a l and related services, and helps i n developing them as community requirements are under-stood. The s o c i a l worker also contributes i n i n t e r p r e t a t i o n through re l a t i o n s with i n d i v i d u a l s , representation on committees, and i n public speeches and appearances. The s k i l l of the s o c i a l worker i n dealing with families and other i n d i v i d u a l s , who i n -fluence the patient, i s e s p e c i a l l y adaptable to i n t e r p r e t i n g , to the community, the needs of the mentally i l l . Continuing Casework Section at the Mental Hospital. Patients entering the Mental Hospital, who are'trans-ferred from the Admissions to the Continuing Casework Section, are always the ones who are expected to benefit from long term treatment. .The primary r e s p o n s i b i l i t y of t h i s Section l i e s i n bringing services to the patients while i n hospital with prob.f - 69 -ation services as the f i n a l goal. Though the usual plan i n Continuing Casework Services at the Mental Hospital has been for the worker to carry approx-imately f o r t y patients, with these patients being on a v a r i e t y of wards, there have been very s i g n i f i c a n t developments i n two special instances, which were new to the Continuing Casework Section. This was the appointment of two s o c i a l workers to work s p e c i f i c a l l y on two special wards. I t might be pointed out here that t h i s was an important development as the appointment of s o c i a l workers to s p e c i f i c wards i s a goal that has been set., fo r the future developmental program of s o c i a l work.at Esson-dale, and these two instances were the f i r s t attempts at estab-l i s h i n g such a program. A social, worker operating at t h i s l e v e l works c l o s e l y with the charge nurse, p s y c h i a t r i s t , psychologist and occupational therapist, and t h i s can be considered the ultimate i n present teamwork i n mental ho s p i t a l s . The following two reports of s o c i a l workers on s p e c i f i c wards i l l u s t r a t e s i t s value to the patient, and the movement to integration which was possible i n some patients because of the nearness to them of t h i s service. Continuing Services on H-5. (A Continued Treatment Ward) In November 1952, at the request of the p s y c h i a t r i s t i n charge of the ward, a s o c i a l worker was assigned- to work v/ith the patients on H-5. This ward i s classed as a long-term, or continued treatment ward, and i s i n the Wornens' b u i l d i n g . (East.;Lawn) Much of the treatment program i s directed towards - 70 -helping the patient to assume work: r e s p o n s i b i l i t y within the Hospital, such as i n the Nurses' homes, i n the kitchen, on the wards, and i n . I n d u s t r i a l Therapy. The 175 patients on the ward consist of "burnt-out",schizophrenics, extremely deteriorated schizophrenics, mental defectives, e p i l e p t i c s , and lobotomy patients who have.shown no improvement since being operated on some time ago. Of these 175 patients only 12 receive active treatment, and t h i s i s electro-convulsive therapy when needed. Cases are opened by the s o c i a l worker i n several ways. A patient may ask to see. the worker. Usually the request i s either to leave the Hospital or to help her obtain outside em-ployment. In many cases the patient i s not well enough for dis ' r charge and i n such instances the worker attempts to bring ser-vices to the patient i n other areas, as services around money, clothes, or v i s i t s to r e l a t i v e s . In order to bring these ser-vices, the worker must interpret to the patient the nature o f s o c i a l services, and then an attempt i s made to encourage the patient to use them. Cases are opened also by r e f e r r a l from the ward psych-i a t r i s t at ward rounds. These rounds are attended by the C l i n -i c a l D i r ector, ward psychiatrist-, nursing supervisor of the bu i l d i n g , charge nurse on H-5, the occupational therapist, the Continuing Casework supervisor and the s o c i a l worker. These ward rounds are.an important example of teamwork i n treatment planning. The charge, nurse on H-5 may make the r e f e r r a l . This -•71 i s done when a patient has asked her to get i n touch with the worker, or requests some spe c i a l service within the responsib-i l i t y of S o c i a l Service. A l l 175 cases have not been opened on H-5, but be-cause of the way i n which r e f e r r a l s come, often by the patient herself, a l l 175 are p o t e n t i a l l y active cases. At present f o r -t y cases have been opened, t h i r t y of which are being given an active treatment service. Although there are extremely deteriorated schizophren-ics' and old lobotomy patients who do not move from the ward, there i s a f a i r l y good discharge rate. Over December, January and February about one patient was discharged every ten days, and i n these cases the worker gives a r e h a b i l i t a t i v e service. Some of those to whom the worker i s now t r y i n g to bring a rehab-i l i t a t i v e service are perhaps best described as "dispossessed". This i s something that can e a s i l y happen to people who have been i n the Hospital for a long time, and where r e l a t i v e s and friends are no longer interested. Sometimes what would seem to be lack of i n t e r e s t i s perhaps more c o r r e c t l y seen as an a t t i t -ude of hopelessness i n which the r e l a t i v e s f e e l there i s nothing that they can do for the patient. To awaken the family's i n t e r -est i n helping the patient has been part of the s o c i a l worker's r e s p o n s i b i l i t y . I f r e l a t i v e s are not available such places as selected f o s t e r or boarding homes would be most b e n e f i c i a l , . es p e c i a l l y to patients who may continue to have a r e s i d u a l of t h e i r i l l n e s s but could s t i l l function f a i r l y well outside. - 72 - -One of the main points that has come up i n this.ward worker experiment has been the need f o r selected homes for r e h a b i l i t -'. ation purposes. . Treatment "services brought to ward H-5 by the s o c i a l worker can best be i l l u s t r a t e d by actual case presentations, •• Miss L. i s a 22, year old g i r l whose diagnosis was given as schizophrenia with suicide and escape tendencies. Because of the l a t t e r she could not be given parole p r i v i l e g e s . She was referred to the s o c i a l worker at ward rounds. I t was hop-ed by the Hospital team that some day she would be able to have more freedom, possibly parole; as a beginning of t h i s , the soc-i a l worker was asked to encourage the patient to attend Occup-a t i o n a l Therapy classes. The s o c i a l worker made regular v i s i t s to the patient, was successful i n getting her to attend these classes, and she i s beginning to show more in t e r e s t i n her surroundings than previously. Mrs. W. i s a 55 year old woman whose diagnosis was given as simple schizophrenia. This patient was w e l l enough to work i n the Nurses* homes, but was not well enough to be discharged. She had a ' s i s t e r l i v i n g i n the c i t y and was anxious to have her v i s i t the H o s p i t a l . The s o c i a l worker v i s i t e d the s i s t e r at her home and found her quite discouraged and unhappy about the ' patient's condition. I t was necessary for the s o c i a l worker to see the s i s t e r several times and give her considerable sup--port, and in t e r p r e t a t i o n . The woman was f i n a l l y able to come to the Hospital to v i s i t the patient. The result has been a - 7 3 -much happier r e l a t i o n s h i p between the patient and her s i s t e r , and also improvement i n the patient's attitude towards her hos- -p i t a l i z a t i o n . Miss B. i s an e p i l e p t i c , f i f t y years of age. She was also diagnosed as paranoidal schizophrenic. . This patient was extremely apathetic and h o s t i l e , and she refused to take part i n Occupational Therapy., or i n any of the ward a c t i v i t i e s . She was referred to the s o c i a l worker at ward rounds, and i t was hoped that the worker might help to draw her out of her h o s t i l e apathy. The worker v i s i t e d her re g u l a r l y and was able to estab-l i s h a good casework r e l a t i o n s h i p . Through t h i s r e l a t i o n s h i p and the s p e c i f i c service of answering a l e t t e r for the patient, she was f i n a l l y able to attend Occupational Therapy classes, and her h o s t i l e attitude i s slowly diminishing. The teamwork on H-5 i s very important i n planning f o r the patients. A review of the patient's progress i s made at ward rounds i n which the worker, along v/ith other members of the Hospital team, presents.; information and contributes ideas which w i l l increase the knowledge that each member has of the patient and help them i n treatment plans. The s o c i a l worker's primary r e s p o n s i b i l i t y has been four f o l d : (a) to e s t a b l i s h a casework re l a t i o n s h i p so that the patient can move i n a meaningful way to a c t i v i t i e s (such as Occupational Therapy); (b) to act as a l i a i s o n between the Hospital and the patient's r e l a t i v e s ; (c) to bring to the ps y c h i a t r i s t pertinent information regarding family relationships; (d) to secure and bring into play rehab-- 74 -i l i t a t i v e sources f o r the patient. Continuing Services on E-5. (A r e h a b i l i t a t i o n ward.) In September 1952, the P r o v i n c i a l Supervisor of Psych-i a t r i c S o c i a l Work and the Continuing Casework Supervisor at the P r o v i n c i a l Mental Hospital i n co-operation with the ward ps y c h i a t r i s t decided to appoint, a s o c i a l worker to concentrate s p e c i f i c a l l y on. ward E-5. This ward i s primarily f o r female patients who are being prepared f o r entrance back into the community. There are usually 25 to 30 patients on the ward, and they are sent here from a l l parts of the H o s p i t a l . The wom-en a l l have certain p r i v i l e g e s , such as being able to walk out-side during the day, and there are various a c t i v i t i e s on the ward i t s e l f . For this.reason some of the patients who have been i n the Hospital for a number of years f i n d i t very d i f f i -c u l t to leave since, i n t h e i r view, they have a l l the comforts that the outside world can provide with none of the stresses. The organization of the s o c i a l service p a r t i c i p a t i o n began v/ith a meeting of nursing, psychiatry, and the s o c i a l worker. The function of the S o c i a l Service Bepartment was i n -terpreted to the other d i s c i p l i n e s at t h i s time with emphasis on the r e h a b i l i t a t i o n aspect. Following t h i s the s o c i a l work-er was introduced to a l l the patients on the ward, and the psy-c h i a t r i s t explained the role that the s o c i a l worker v/ould be playing i n t h e i r future plans. I t was arranged with the Charge-nurse on E-5 that the s o c i a l worker receive a l i s t of the patients on the ward each - 75 -time i t was made up. This allows her to read the f i l e s of any new patients "before seeing them,, and also to discuss, with her Supervisor, the ro l e that she w i l l he playing i n each patient's treatment. The p s y c h i a t r i s t i s also consulted on the patient's readiness f o r r e h a b i l i t a t i o n services, and together the psy-c h i a t r i s t and s o c i a l worker discuss the occupation that w i l l best f i l l the patient's needs. . The worker then makes arrange-ments for regular weekly v i s i t s to the patient, and concen-trates on helping the patient with her feelings concerning d i s -charge from the Hospital, the work she would l i k e to undertake, and also with any other problems that a r i s e i n the s o c i a l work-er's area of treatment. The rate of planning i s at a l l times discussed with the p s y c h i a t r i s t and the nursing s t a f f . I t i s these regular meetings with the members of the treatment team that makes, i t possible to determine exactly when the move from the Hospital can be made. Any decisions are given to the C l i n i c a l D i r e c t o r who sets the date for the patient's move to " V i s t a " . 1 (The V i s t a R e h a b i l i t a t i o n Home i s located i n Vancouver, and i s op-erated under the P r o v i n c i a l Mental Health Services. I t i s used as the f i r s t step i n giving selected female patients an opport-unity to adjust away from the Hospital or C l i n i c , preparatory ,.to a more permanent plan being made for them.) I t i s important that the 'Social worker be n o t i f i e d of the s p e c i f i c date that 1 . B i r c h , op. c i t . p. 4 l . - 76 t h e p a t i e n t i s l e a v i n g f o r t h e V i s t a Home, as a summary o f t h e p a t i e n t ' s h i s t o r y has t o he f o r w a r d e d , and a l s o the w o r k e r has t o e x p l a i n the f u n c t i o n o f t h e V i s t a t o t h e p a t i e n t . Once t h e p a t i e n t has "been .moved she i s n o t v i s i t e d b y t h e s o c i a l w o r k e r f o r a c o u p l e o f d a y s ; t h i s a l l o w s h e r some t i m e t o "become a d -j u s t e d "before f u r t h e r s t e p s f o r r e h a b i l i t a t i o n a r e t a k e n . W i t h r e g a r d s t o the p a t i e n t ' s employment, i t i s f u l l y e x p l a i n e d t o h e r t h a t the s o c i a l w o r k e r w i l l be.. c o n t a c t i n g . - t h e S p e c i a l Placement D i v i s i o n o f t h e N a t i o n a l Employment S e r v i c e , and t h a t n e c e s s a r y i n f o r m a t i o n w i l l be g i v e n t o t h e s p e c i a l placement o f f i c e r t h e r e . I n t h i s way, t h e p a t i e n t i s h e l p e d t o • feel t h a t she w i l l be m e e t i n g someone a t t h e Employment S e r v i c e , who u n d e r s t a n d s h e r s i t u a t i o n . The move from the H o s p i t a l i s a b i g s t e p f o r most o f the p a t i e n t s ; a l t h o u g h t h e y may have a c -c e p t e d t h e p r o p o s e d appointment t o the N a t i o n a l Employment S e r -v i c e w h i l e i n t h e h o s p i t a l , d o u b t s o f t e n a r i s e when t h e y f i n a l l y m o v e - t o V i s t a . B e c a u s e o f t h e s e f e e l i n g s , t h e s o c i a l w o r k e r u s u a l l y accompanies t h e p a t i e n t on the i n i t i a l v i s i t ; t h e n i f t h e p a t i e n t does n o t a p p e a r t o o u p s e t , f u r t h e r v i s i t s can be made a l o n e . V i s i t s t o V i s t a a r e u s u a l l y made w e e k l y w h i l e t h e p a t i e n t i s t h e r e , b u t f o l l o w i n g t h e a c c e p t a n c e o f a job t h e w o r k e r c a r r i e s out the u s u a l p r o b a t i o n a r y v i s i t s once a month f o r s i x months, u n l e s s o t h e r w i s e s p e c i f i e d . S e r v i c e s t h a t are b r o u g h t t o the p a t i e n t on E-5 can be seen i n t h e f o l l o w i n g i l l u s t r a t i o n s : . M r s . T . was a f o r t y y e a r o l d woman w i t h f o u r c h i l d r e n , - 77 -ages ranging from ten to eighteen years. She was diagnosed as a paranodial schizophrenic and had been i n the Hospital f o r two years at the time of her r e f e r r a l to the s o c i a l worker. Her husband and children l i v e d i n the i n t e r i o r of the province, but refused to help with the patient's treatment i n any way, and -did not want her to return home. - Mrs. T. had become very de-pendent on the Hospital and refused'to participate i n any plans for discharge. The s o c i a l worker v i s i t e d her once or twice weekly for a period of three months; there was a d i s t i n c t cliang i n the patient's attitude to leaving the Hospital, and f i n a l l y she moved to V i s t a . She was v i s i t e d regularly by the s o c i a l worker, and with the help of the National Employment Service, found a job as a housekeeper. She did well at t h i s job- and r e -mained at i t u n t i l she became adjusted to l i v i n g outside of the Hospital; then she found a job in' a laundry, without the help of the s o c i a l worker or the Employment Service. On the l a s t probationary v i s i t that the worker made, the patient, was happy i n her new work, and was looking for larger l i v i n g quarters as her oldest daughter was planning on moving into the c i t y to l i v e with her. Mrs. E. was a sixty-two year old woman, whose diagnosis had also been given as paranoidal schizophrenic. At the time of her r e f e r r a l to the s o c i a l worker, she had been i n the Hos-p i t a l f o r three years. As t h i s was the t h i r d committal i n twenty years, her husband and f i v e children were no longer i n -t e r e s t e d i n her, and would not accept any r e s p o n s i b i l i t y f o r lie -.78 -c a r e . The p a t i e n t was aware o f h e r f a m i l y ' s f e e l i n g and d i d n o t want t o see them, so p l a n s were made f o r h e l p i n g h e r t o he r e h a b i l i t a t e d w i t h o u t t h e i r h e l p . The s o c i a l w o r k e r v i s i t e d h e r on t h e ward f o r s e v e r a l weeks, and c o n c e n t r a t e d on h e l p i n g h e r t o overcome h e r f e a r s o f . l e a v i n g t h e H o s p i t a l , and b u i l d i n g up h e r i n t e r e s t i n t h e o u t s i d e w o r l d . F i n a l l y t h e p a t i e n t was a b l e t o move t o V i s t a . She r e m a i n e d t h e r e f o r s i x weeks, and t h e n moved t o a home where she was t o . w o r k as a h o u s e k e e p e r . T h i s job she found w i t h the h e l p o f t h e N a t i o n a l Employment S e r -v i c e , b u t a f t e r two months she found a job as a h e l p e r i n a b o a r d i n g house on h e r own.. The p a t i e n t had f o r m e r l y had a b o a r d -i n g house and was v e r y happy i n t h i s t y p e o f work. R e g u l a r v i s i t s a r e s t i l l b e i n g made b y t h e s o c i a l w o r k e r and i t a p p e a r s t h a t t h e p a t i e n t w i l l soon be a b l e t o be g i v e n h e r f u l l d i s -c h a r g e , as she has made a v e r y good adjustment f o r a p e r s o n o f h e r a g e . M r s . L. was a f o r t y - f o u r y e a r o l d woman w i t h a d i a g n o s i s o f m a n i c - d e p r e s s i v e p s y c h o s i s . She had b e e n i n t h e H o s p i t a l f o r two y e a r s when she was p l a c e d on E - 5 and r e f e r r e d t o t h e s o c i a l w o r k e r f o r h e l p w i t h r e h a b i l i t a t i o n . H e r husband had d i e d two y e a r s p r e v i o u s t o h e r h o s p i t a l i z a t i o n , and h e r son had b e e n l o o k e d a f t e r b y h e r s i s t e r s i n c e t h a t t i m e . D u r i n g h e r p e r i o d i n the H o s p i t a l , t h e p a t i e n t had become e x t r e m e l y dependent and was a f r a i d t o l e a v e . The s o c i a l w o r k e r v i s i t e d h e r once a week f o r a p e r i o d o f f o u r months, - h e l p i n g h e r t o overcome h e r f e a r o f l e a v i n g t h e H o s p i t a l and b u i l d i n g up h e r c o n f i d e n c e . A t t h e - 7 9 -end o f t h i s t ime the p a t i e n t was a b l e t o move t o V i s t a . A s she had t a k e n a t y p i n g c o u r s e d u r i n g h e r h o s p i t a l p e r i o d , she was a b l e t o o b t a i n a job as a s h i p p i n g c l e r k t h r o u g h t h e N a t i o n a l Employment S e r v i c e . She a l s o found a room f o r h e r s e l f , and com-p l e t e l y p a i n t e d i t b e f o r e moving i n . A f t e r b e i n g on h e r job f o r l e s s t h a n . a month she h a s r e c e i v e d a p r o m o t i o n , i s a t t e n d i n g B u s i n e s s s c h o o l two n i g h t s w e e k l y , and making a most s a t i s f a c t -o r y a d j u s t m e n t . The s o c i a l w o r k e r i s , a t p r e s e n t , making p r o b -a t i o n v i s i t s , and i n e a c h c o n t a c t t h e p a t i e n t has r e m a i n e d c h e e r f u l i n h e r o u t l o o k , and shows no s i g n s o f r e g r e s s i o n . The. e x p e r i m e n t , a t the H o s p i t a l , i n a s s i g n i n g s o c i a l w o r k e r s t o s p e c i a l wards has shown t h e i m p o r t a n c e o f h a v i n g t h e s o c i a l w o r k e r i n c l o s e c o n t a c t w i t h b o t h h i s p a t i e n t s and t h e a c t u a l members o f t h e h o s p i t a l t e a m . B e i n g a b l e t o work p r i m -a r i l y w i t h one d o c t o r d i s p e n s e s w i t h the e v e r p r e s e n t p r o b l e m o f s o c i a l w o r k e r s and d o c t o r s t r y i n g t o a r r a n g e c o n s u l t a t i o n t i m e . I f a s o c i a l w o r k e r c a r r i e s p a t i e n t s on many wards tie has t o c o n t a c t the p s y c h i a t r i s t u n d e r whom e a c h p a t i e n t i s r e c e i v -i n g t r e a t m e n t . The r e s u l t i s much d e l a y i n s t a r t i n g s o c i a l s e r -v i c e s , and the c u t t i n g down o f t h e t i m e t h a t c o u l d be g i v e n t o t h e p a t i e n t h i m s e l f . A s p e c i f i c worker t o e a c h ward i s a b i g s t e p towards t h e "teamwork a p p r o a c h " w h i c h i s so i m p o r t a n t i n t h e t o t a l push r e l a t i o n s h i p t h a t I s n e c e s s a r y i n t h e t r e a t m e n t o f m e n t a l i l l n e s s . C o n t i n u i n g Casework S e c t i o n a t G r e a s e C l i n i c . When t h e S o c i a l S e r v i c e Department a t C r e a s e C l i n i c - 80. -was separated from that of the P r o v i n c i a l Mental Hospital i t was expected, i n r e l a t i o n to the average admissions, that during the ensuing f i s c a l year about 1200 patients would be admitted to the C l i n i c . Therefore, i t was figured that the seven soc-i a l workers and the Casework Supervisor on the s t a f f could take r e s p o n s i b i l i t y f o r one hundred percent coverage of a l l patients' needs i n the s o c i a l service while on the wards, and as s i x t y -f i v e percent (780) of these would be admitted from the Greater Vancouver area the s t a f f of seven would have f u l l r e s p o n s i b i l i t y f o r casework services to both patients and r e l a t i v e s coming from t h i s area. The remaining t h i r t y - f i v e percent (420) of the patients would come from outside of the Greater Vancouver area, and f o r t h i s group the s t a f f of seven would undertake casework services to patients on the ward, as w e l l as serving i n an informative, supervisory or consultative capacity to.the F i e l d Service which would be giving a family service to the r e l a t i v e s of t h i s group. In December 1952, i t was ascertained that since the setting up of the department at Crease C l i n i c , there had been an average of 101 patients admitted per month, with t h e i r t r e a t -ment periods ranging from six weeks to four months. One of the seven workers had been dealing s t r i c t l y v/ith admissions, and a second worker was appointed to t h i s section also. The remain-ing f i v e caseworkers i n the Section were to cover a l l the con-tinuing casework. In an analysis covering the l a s t three months period - 81 -(January - March, 1953) the s o c i a l workers i n the Continuing Casework Section at Crease C l i n i c have been assigned f i f t y - o n e new cases each, almost one new case per working day. As the average length of stay per patient i s two" months, the demands i n s k i l l can be seen when i t i s r e a l i z e d that during t h i s short time the worker i s responsible fdr casework with the patient on the ward; casework with f a m i l i e s ; r e s p o n s i b i l i t y for'the form-u l a t i o n of a convalescent ( r e h a b i l i t a t i o n ) plan; l i a i s o n with the F i e l d Service i n a number of cases; and following the- pat-ien t ' s discharge the Continuing Service worker i s active with a large number of former patients giving follow-up family and psychiatric s o c i a l services. • v . • I t has been i n t e r e s t i n g to note that about h a l f of the patients admitted from the Greater Vancouver area are i n need of family services from s i x to eighteen months following, t h e i r discharge from Crease C l i n i c . Therefore, the Continuing case-workers have had to extend t h e i r services into an u n o f f i c i a l out-patient department as there are no agencies i n the.Vancouver area that can meet the needs of such a large group, though some, such as.the Family Welfare Bureau of Greater Vancouver, and the Vancouver C i t y S o c i a l Service Department have been very h e l p f u l when possible. In the l i g h t of the extensive job that the s o c i a l work-er i s carrying out i n the short-term treatment at the Crease C l i n i c i t can be seen what an important member he i s of. the treatment team. The other members are concerned with the pat-- 82- -ient during h i s actual period on the ward, but i t i s the s o c i a l worker who w i l l be i n contact with.him from the time of h i s admission u n t i l long a f t e r h is discharge. With a gradual i n -crease i n admissions seen, as the C l i n i c becomes, better known, the s o c i a l worker's p a r t i c i p a t i o n w i l l increase accordingly, and though the s o c i a l worker on Admissions i s doing a very important job, i t i s the Continuing caseworker whose area i s being ex-' tended from the ward to the community. This means that h i s time i s divided between treatment on the ward and i n r e h a b i l i t a t i o n planning. I t is.apparent that some solution w i l l be needed to remedy t h i s s i t u a t i o n i n the near future, and possibly-one of the best ways to do so would be further d i v i s i o n of the present Continuing Caseworker Section into two parts, one consisting of ward'workers,- and the other of r e h a b i l i t a t i o n workers. This would mean that the S o c i a l Service Department at the C l i n i c would be i n three parts, 1. Admissions Section. (Intake and Reception) 2. Continuing Casework Section. (Treatment and Pre-Convalescent) 3. R e h a b i l i t a t i o n Section. (Convalescent) Through t h i s d i v i s i o n , the ward worker would become part of ward l i f e the same as doctors, nurses and occupational ther-a p i s t s . Relatives could be seen during t h e i r v i s i t s to the pat-ient, and both r e l a t i v e s and patient could be helped- to f e e l that the f i n a l t r ansfer to the r e h a b i l i t a t i o n worker woul& mean that the patient was vastly improved and ready to resume l i f e i n the - 83 -community. The f e e l i n g t h a t t r a n s f e r t o t h e r e h a b i l i t a t i o n w o r k e r showed improvement i n c o n d i t i o n w o u l d h e l p t o make t h i s s o r t o f a g o a l f o r the p a t i e n t and do much towards t h e b u i l d -i n g o f an e a r l y r e l a t i o n s h i p between p a t i e n t a n d ' w o r k e r . The job o f t h e r e h a b i l i t a t i o n w o r k e r w o u l d be t o h e l p t h e p a t i e n t become r e - e s t a b l i s h e d i n the community, c a r r y out any f o l l o w - u p p l a n s and o f f e r f a m i l y s e r v i c e s i f n e c e s s a r y . The d i v i s i o n o f the C o n t i n u i n g Casework S e c t i o n i n t h i s way would a l s o mean t h e a p p o i n t m e n t o f a competent f u l l y q u a l i f i e d s u p e r v i s o r t o c o - o r d i n a t e t h e work o f t h e r e h a b i l i t a t i o n s t a f f . T h i s p e r s o n w o u l d a l s o p l a y an i m p o r t a n t p a r t i n community e d -u c a t i o n and t h e b r i n g i n g , t o g e t h e r o f a l l p o s s i b l e r e s o u r c e s i n t h e community f o r the use o f d i s c h a r g e d p a t i e n t s . The above m e n t i o n e d p l a n c o u l d a l s o be c o n s i d e r e d f o r t h e C o n t i n u i n g Casework S e c t i o n a t the P r o v i n c i a l M e n t a l H o s -p i t a l , a t s u c h t ime as f u l l y t r a i n e d s t a f f i s a v a i l a b l e . The s t r e s s s h o u l d be put on f u l l y t r a i n e d s t a f f - p r e f e r a b l y t h e M a s t e r o f S o c i a l Work - as i n . t h i s way t h e s o c i a l w o r k e r i s as q u a l i f i e d as any member o f t h e t r e a t m e n t team t h a t p a r t i c i p a t e s i n the t o t a l t r e a t m e n t o f t h e m e n t a l l y i l l p e r s o n . A l s o he w i l l t h o r o u g h l y u n d e r s t a n d h i s own a r e a o f competence as d i f f e r e n t -i a t e d from t h a t o f t h e p s y c h i a t r i s t , p s y c h o l o g i s t , n u r s e and o c c u p a t i o n a l t h e r a p i s t . I t i s t h i s u n d e r s t a n d i n g o f e a c h o t h e r ' s a r e a t h a t does much t o keep t h e work o f t h e team from o v e r l a p p i n g and a l s o t o see where each member's c o n t r i b u t i o n adds t o t h e f i n a l d i s c h a r g e o f t h e p a t i e n t . - 84 -R e h a b i l i t a t i o n Study. , The fact that the present s o c i a l work s t a f f are con-stantly aware of the d i f f i c u l t i e s and time spent i n the rehab-i l i t a t i o n and convalescent care of the patient i s indicated i n a recent study that was undertaken, by them, on the r e h a b i l i t -ation process. 1 The purpose of the study was to present the s i t u a t i o n confronting s o c i a l service s t a f f i n the r e h a b i l i t a t i o n process, and to point up some of the needs for present and future changes i n p o l i c y . A t o t a l of 50 cases involving aspects of r e h a b i l i t -ation undertaken i n the l a s t six months were studied by a com-mittee chosen from the s o c i a l work s t a f f . The cases were an-alyzed under these headings; accommodation, employment, finan-c i a l , re-admissions, r e f e r r a l to other agencies, r e f e r r a l to f i e l d agencies, and vocational t r a i n i n g . Accommodation appeared to be the primary problem i n r e h a b i l i t a t i o n . As V i s t a can take care of only a l i m i t e d number of patients there i s need for more boarding homes with varied degrees of supervision to be available during the interim per-iod of job hunting. Some patients require constant supervision, some require a boarding home with or without other patients, and some w i l l make best use of completely independent accommodation. At present because of the emergency r e f e r r a l the workers too frequently accept, i n desperation, any accommodation which i s 1. Annual Report, op. c i t . p. 67. - 8 5 -a v a i l a b l e , with, the r e s u l t t h a t a p a t i e n t might f i n d h e r s e l f o c c u p y i n g a s i n g l e , b a r e room i n an u n d e s i r a b l e downtown d i s - " t r i c t , R e a d m i s s i o n s a r e t h e n a t u r a l r e s u l t o f such p o o r accomm-o d a t i o n . The case a n a l y s i s r e v e a l e d a g r e a t d u p l i c a t i o n o f s e r -v i c e i n the a r e a o f employment. E a c h w o r k e r i n t e r v i e w s t h e N a t i o n a l Employment S e r v i c e on i n d i v i d u a l c a s e s , and t h e r e i s d u p l i c a t i o n i n making i n d i v i d u a l c o n t a c t s w i t h v a r i o u s p o t e n t -i a l e m p l o y e r s . R e p e a t e d t r i p s i n t o town and t o t h e v a r i o u s . o f f i c e s were found t o be t i m e consuming and c o s t l y . G - r e a t e r s e l e c t i v i t y was a l s o needed on t h e p a r t o f the d o c t o r and s o c -i a l w o r k e r i n p a t i e n t s who were p l a c e d i n j o b s , as a t p r e s e n t t h e r e were t o o many r e f e r r a l s and hence p o o r placement and r e -a d m i s s i o n i s s e e n . A t p r e s e n t many p a t i e n t s a r e w i t h o u t funds on d i s c h a r g e , and f u n d s a r e u r g e n t l y r e q u i r e d f o r : (a) immediate payment o f b o a r d ; (b) t r a n s p o r t a t i o n ; (c) f e e s f o r job f i n d i n g t h r o u g h a g e n c i e s t h a t charge s u c h f e e s ; (d) v o c a t i o n a l t r a i n i n g . The l a c k o f funds f o r any o r a l l o f t h e a bove s e v e r e -l y r e s t r i c t s p l a n n i n g f o r a p a t i e n t and f o r c e s t h e a c c e p t a n c e o f even u n s a t i s f a c t o r y work i n o r d e r t h a t t h e p a t i e n t may s u b s i s t . A t p r e s e n t , t h e C i t y S o c i a l S e r v i c e Department c o - o p e r a t e s i n many c a s e s b y p r o v i d i n g s o c i a l a s s i s t a n c e f o r a month o r two w h i l e t h e p a t i e n t , w i t h the s o c i a l w o r k e r ' s h e l p , e x p l o r e s r e -s o u r c e s . Community r e s o u r c e s i n t h e f o r m o f o t h e r a g e n c i e s a r e - 8 6 -h e l p f u l i n some c a s e s and n o t i n o t h e r s . The p r o b l e m t o date a p p e a r s t o be t h e need f o r more c o - o p e r a t i o n between the h o s -p i t a l and t h e community t o u n c o v e r r e s o u r c e s f o r the r e h a b i l i t -a t i o n o f t h e p a t i e n t t h r o u g h o t h e r a g e n c i e s . The F i e l d S e r v i c e has b e e n h e l p f u l i n r e h a b i l i t a t i o n , as w o r k e r s c o n s t a n t l y c o n t a c t them r e g a r d i n g p a t i e n t s r e t u r n i n g t o t h e i r d i s t r i c t s . A n e v a l u a t i o n o f the p a t i e n t ' s c o n d i t i o n , s u g g e s t i o n s as t o t h e t y p e o f l i v i n g and work p l a c e m e n t s a r e i n c l u d e d . T h i s p r a c t i c e w i l l need t o c o n t i n u e on a n i n d i v i d u a l b a s i s . V o c a t i o n a l t r a i n i n g has b e e n used as a r e s o u r c e , i n r a r e i n s t a n c e s , b u t t h i s i s l i m i t e d due;;to t h e s h o r t a g e o f funds f o r s u c h t r a i n i n g . The r e a s o n s f o r t h e r e a d m i s s i o n o f p a t i e n t s a p p e a r e d t o be m o s t l y p o o r s e l e c t i v i t y o f t h e p a t i e n t s who were t o be r e -h a b i l i t a t e d ; i n s u f f i c i e n t n o t i c e g i v e n t o t h e s o c i a l w o r k e r so t h a t a s t u d y c o u l d be made o f t h e p a t i e n t ' s c h a n c e s i n t h e com-m u n i t y ; b e c a u s e o f i n s u f f i c i e n t t i m e t o f i n d accommodation and employment, and t h e l a c k o f f u n d s . Some i n t e r e s t i n g c o n c l u s i o n s were a r r i v e d a t . t h r o u g h t h e case a n a l y s i s method. F i r s t , t h a t ' a l a r g e p e r c e n t a g e o f t h e s o c i a l w o r k e r ' s t i m e was p r e s e n t l y t a k e n up i n an e f f o r t t o d i s -c o v e r r e s o u r c e s f o r t h e l a r g e number o f r e f e r r a l s . When s u c h r e f e r r a l s a r e r e c e i v e d , w o r k e r s a r e r e q u i r e d t o d r o p t h e i r o t h e r work and a r r a n g e f o r p a t i e n t ' s r e m o v a l from t h e h o s p i t a l . T h e r e i s no c e n t r a l o f f i c e i n the h o s p i t a l a t p r e s e n t h a v i n g a know-87 l e d g e o f community r e s o u r c e s and w o r k e r s a r e r e q u i r e d t o e x p l o r e accommodation and j o b s on an i n d i v i d u a l b a s i s . The r e s u l t i s d u p l i c a t i o n b y d i f f e r e n t w o r k e r s and b y e a c h w o r k e r on d i f f e r -ent c a s e s . Much t i m e i s spent on t r a v e l , t e l e p h o n e c a l l s and i n s e p a r a t e i n t e r v i e w s w i t h p o t e n t i a l e m p l o y e r s o r l a n d l a d i e s . The p a r t i a l remedy f o r s u c h a s i t u a t i o n i s t h e a p p o i n t -ment o f a s e n i o r r e h a b i l i t a t i o n s u p e r v i s o r on s t a f f . H i s o r h e r d u t i e s would i n c l u d e h a v i n g a v a i l a b l e a l l r e s o u r c e s known 1 f o r accommodation, j o b s and f u n d s , and a l s o t o a c t i n - a - p u b l i c r e -l a t i o n s c a p a c i t y t o e n l a r g e and i n c r e a s e t h e s e r e s o u r c e s . T h i s p e r s o n would t h e n be c o n s u l t e d b y i n d i v i d u a l w o r k e r s w h i c h w o u l d e l i m i n a t e t h e p r e s e n t d u p l i c a t i o n and o v e r l a p p i n g o f work and would f r e e w o r k e r s t o c o n t i n u e w i t h casework s e r v i c e s t o p a t i e n t s . I n s h o r t , t h e r e h a b i l i t a t i o n w o r k e r would have an o v e r a l l p i c t -u r e o f the day t o day community r e s o u r c e s w h i c h w o u l d t h e n be a v a i l a b l e t o t h e s o c i a l w o r k e r whenever c o n f r o n t e d w i t h p l a n n i n g f o r a p a t i e n t s r e h a b i l i t a t i o n . To complete t h i s i m p r o v e d method o f r e h a b i l i t a t i o n t h e r e i s a l s o need f o r g r e a t e r c a r e i n d i s c h a r g e p l a n n i n g , and f o r advance n o t i c e from m e d i c a l s t a f f c o n t e m p l a t i n g d i s c h a r g e o f a p a t i e n t . A c a r e f u l e v a l u a t i o n o f t h e p a t i e n t ' s p o t e n t i a l s , a b i l -i t i e s and a p t i t u d e s s h o u l d be made b e f o r e p r o c e e d i n g w i t h d i s -charge p l a n n i n g ; t h i s e v a l u a t i o n s h o u l d be done on a team b a s i s w i t h t h e m e d i c a l , s o c i a l s e r v i c e , and p s y c h o l o g y d e p a r t m e n t s a c t i n g t o g e t h e r . T h i s c o u l d be e x p e c t e d t o r e s u l t i n t h e r e d -u c t i o n o f r e a d m i s s i o n s . L i k e w i s e , s o c i a l w o r k e r s c o u l d g i v e - 88 -better service i n the whole area because they would be r e l i e v e d of emergency r e h a b i l i t a t i o n s and would "be able to save much time by turning to the r e h a b i l i t a t i o n person to discuss resource p o s s i b i l i t i e s . The above study, by the s o c i a l workers, i s important, not only because i t points to improved treatment services to the patient but i t also brings out the workers interests i n team-work with other d i s c i p l i n e s , community organization and i n t e r -pretation, and research. - 89 -Chapter "V" - Recapitulation and Assessment. From t h i s study of the p a r t i c i p a t i o n of the s o c i a l worker i n the treatment of the mentally i l l i t i s possible to see the importance of such a person's contribution i n t h i s area. The s o c i a l worker's role consists of bringing casework services to the patient from the time of h i s admission to the Hospital or C l i n i c u n t i l long a f t e r his discharge. To enable these casework services to operate at t h e i r maximum e f f i c i e n c y , and be of most help, the s o c i a l worker works clo s e l y with the doc-tor , nurse, psychologist and occupational therapist or as t h i s group i s more commonly called "the treatment team." Each fun-ct i o n of the s o c i a l worker's s k i l l i s useful i n the treatment of the patient only so f a r as i t i s purposely related to the s k i l l s and services of the other professions. To continue with t h i s teamv/ork-in-treatment further, the s o c i a l worker finds the teamwork aspect important i n other areas such as working closely with other community agencies and the F i e l d Services. Interpretation of the role that the comm-unity can play i n the treatment of the mentally i l l i s most important; at the same time the hospital s o c i a l worker has to be aware of the function of community agencies so that r e f e r r -a l s are to the best advantage of both patient and agency. The l i m i t a t i o n s of each agency must be r e a l i z e d so that heavy case loads are not unnecessarily increased, and therefore a l l ser-vices slowed down. Close co-operation between the s o c i a l work-- 90 -e r s h e l p s t o p o i n t out t h e needs and r e s o u r c e s i n e a c h s p e c i f i c a r e a , and e n a b l e s t h e a v a i l a b l e r e s o u r c e s t o be u s e d t o the f u l l e s t a d v a n t a g e . T h i s a s p e c t o f teamwork i s most I m p o r t a n t . A d m i n i s t r a t i o n . W i t h i n the H o s p i t a l and C l i n i c the p a r t i c i p a t i o n o f the s o c i a l w o r k e r i s somewhat l i m i t e d i n t h e a r e a o f h o s p i t a l a d m i n i s t r a t i o n . T h i s i s p o s s i b l y due t o the l a c k o f u n d e r -s t a n d i n g on the p a r t o f the g e n e r a l a d m i n i s t r a t i o n o f t h e c o n -t r i b u t i o n t h a t t h e s o c i a l w o r k e r c o u l d make. The e x t e n d e d r e s p o n s i b i l i t y i n each a r e a o f the p a t i e n t ' s t r e a t m e n t s h o u l d make t h e s o c i a l w o r k e r one o f the k e y member i n a l l and any m e e t i n g s a r o u n d h o s p i t a l p o l i c y and t r e a t m e n t p l a n n i n g . What o t h e r member o f t h e t r e a t m e n t team i s as c o n c e r n e d w i t h as many a r e a s o f the p a t i e n t ' s t r e a t m e n t as the s o c i a l w o r k e r ? From p r i m a r i l y an o u t s i d e c o n t a c t he has moved, i n t h e s h o r t p e r i o d s i n c e the o p e n i n g o f C r e a s e C l i n i c , t o assume r e s p o n -s i b i l i t y i n r e c e p t i o n and a d m i s s i o n and on the w a r d . T h i s com-p l e t e s t h e c y c l e o f s e r v i c e s t o t h e p a t i e n t - f r o m t h e t i m e t h e p a t i e n t l e a v e s h i s home e n v i r o n m e n t u n t i l he i s once a g a i n e s t a b l i s h e d i n s o c i e t y , he has c o n t a c t w i t h t h e s o c i a l w o r k e r . T h i s e x t e n d e d c o n t a c t b y the s o c i a l w o r k e r makes h i m t h e p e r -son most l i k e l y t o be a b l e t o e v a l u a t e t h e h o s p i t a l program from a l l a n g l e s , and a s s e s s the i n t e g r a t i o n o f needs and r e -s o u r c e s . A s t e p i n t h e d i r e c t i o n o f a c c o m p l i s h i n g more p a r t -i c i p a t i o n b y the s o c i a l work s t a f f c o u l d be made b y the a p p o i n t -- 91 merit o f an A d m i n i s t r a t i v e S u p e r v i s o r . T h i s p e r s o n w o u l d be c o n -s t a n t l y on hand t o t a k e care o f a d m i n i s t r a t i v e m a t t e r s whereas i n t h e p r e s e n t s i t u a t i o n the P r o v i n c i a l S u p e r v i s o r has t o spend s e v e r a l days a month away from t h e H o s p i t a l and C l i n i c c a r r y i n g out h e r o t h e r d u t i e s i n the M e n t a l H e a l t h S e r v i c e s . R e l e a s i n g t h e P r o v i n c i a l S u p e r v i s o r from some o f h e r a d m i n i s t r a t i v e d u t i e s a t E s s o n d a l e . would a l l o w h e r t o c o n c e n t r a t e more on i n t e r p r e t -a t i o n , t o t h e S o c i a l W e l f a r e B r a n c h and t h e M e n t a l H e a l t h S e r -v i c e s »of the r e q u e s t s and needs f o r s e r v i c e s ' o f each u n t i l s u c h t i m e as a d e f i n i t e p o l i c y between t h e two d e p a r t m e n t s can be f o r m u l a t e d . . It . w o u l d ' a l s o g i v e h e r more t i m e f o r community i n -t e r p r e t a t i o n and t h e f o r m a t i o n o f p o l i c i e s w i t h t h e community a g e n c i e s . fe. C a r r y i n g out o f t h e e s t a b l i s h e d p o l i c i e s and f u r t h e r i n t e r p r e t a t i o n on a n I n d i v i d u a l b a s i s w o u l d , as a t p r e s e n t , be t h e r e s p o n s i b i l i t y o f t h e s t a f f , b u t i t was s e e n from t h e d e s -c r i p t i o n s o f the d u t i e s o f t h e A d m i s s i o n s and C o n t i n u i n g C a s e - . work S u p e r v i s o r s t h a t t h e y a r e p a r t i c i p a t i n g , as much as t i m e a l l o w s , i n t h e job o f i n t e r p r e t a t i o n , i n t e g r a t i o n and i n i t i a t -i o n o f teamwork e s p e c i a l l y t o d e p a r t m e n t s w i t h i n the h o s p i t a l s e t t i n g , and t o a s m a l l e r e x t e n t i n the community. T h e r e f o r e someone i n an e q u a l l y i m p o r t a n t p o s i t i o n , p r e f e r a b l y the P r o v i n -c i a l S u p e r v i s o r , s h o u l d be f r e e t o h e l p i n t h i s e x t e n s i v e and i m p o r t a n t work i n t h e community. The a p p o i n t m e n t o f a n A d m i n -i s t r a t i v e S u p e r v i s o r t o t a k e o v e r some o f h e r p r e s e n t d u t i e s a t t h e P r o v i n c i a l M e n t a l H o s p i t a l and the C r e a s e C l i n i c would make - 92 -t h i s p o s s i b l e . A d d i t i o n a l S e r v i c e s , T u r n i n g t o t h e work t h a t i s done i n t h e A d m i s s i o n s and C o n t i n u i n g Casework S e c t i o n s , the i m p o r t a n c e o f t h e i r p a r t -i c i p a t i o n i n t r e a t m e n t . i s r e a d i l y s e e n . A d d i t i o n a l s o c i a l w o r k -e r s c o u l d be u s e d i n b o t h t h e A d m i s s i o n s S e c t i o n a t t h e M e n t a l H o s p i t a l and C r e a s e C l i n i c , and p l a n s f o r t h e s e a d d i t i o n s have b e e n made f o r s u c h t ime as t r a i n e d p r o f e s s i o n a l s t a f f i s a v a i l -a b l e . S o c i a l w o r k e r s on the w a r d s , o r t o b e g i n w i t h a n A d m i s s -i o n s w o r k e r , i s ' n e e d e d i n t h e Mens' B u i l d i n g (West Lawn) where t h e men p a t i e n t s , who a r e r e c e i v i n g l o n g - t e r m t r e a t m e n t , a r e h o u s e d . These p a t i e n t s have n e v e r known t h e s e r v i c e s o f a s o c -i a l w o r k e r e x c e p t i n i s o l a t e d i n s t a n c e s where t h e r e has b e e n r e -f e r r a l from a d o c t o r t o t h e A d m i s s i o n s w o r k e r a t t h e C e n t r e Lawn B u i l d i n g . I f a p l a n such as i s b e i n g c a r r i e d out on E - 5 (Womens1 B u i l d i n g ) c o u l d be e s t a b l i s h e d , i t would p o s s i b l y be f o u n d t h a t many o f t h e s e p a t i e n t s c o u l d be r e h a b i l i t a t e d i f an i n t e r e s t e d , h e l p i n g p e r s o n was a v a i l a b l e t o a s s i s t them. R e h a b i l i t a t i o n . The i m p o r t a n c e o f t h e s o c i a l w o r k e r i n t h e r e h a b i l i t -a t i o n a r e a was shown b o t h i n t h e C o n t i n u i n g Casework and i n t h e r e h a b i l i t a t i o n s t u d y t h a t was u n d e r t a k e n b y the s t a f f . The needs t h a t a r e . s e e n i n t h i s a r e a a r e f o r some f o r m o f s u b s i d i z e d b o a r d -i n g home c a r e , o r a type o f f a m i l y c a r e . The s u b s i d i z e d b o a r d i n g home c a r e i s p r i m a r i l y a need of the Grease C l i n i c for patients who have recovered from t h e i r mental i l l n e s s , and are ready to'take up t h e i r old jobs but lack a place to l i v e , and money for board and lodging u n t i l such time as a pay cheque i s received. This would eliminate the prob lem of finding places f o r the patients to stay and attempting to arrange some form of help u n t i l they get established again. Similar boarding homes were shown to be required at the Mental Hospital, but i n t h i s case the need appears to be f o r some form of family-care service f o r pre-convalescence. Family-care i s the placement of patients with f a m i l i e s , other then t h e i r own, for care and sometimes treatment. At present pat-ients who a s s i s t i n housekeeping around the Hospital are not given an opportunity to derive benefits from family-care i n which area they could contribute t h e i r housekeeping.abilities as part of the costs f o r board and maintenance. Although the r e s p o n s i b i l i t y for s e l e c t i o n of patients for family-care and t h e i r medical supervision under such care belongs to the doctor, the r e s p o n s i b i l i t y for finding a suitable home, for interpreting •the patient and his needs to the foster family, for maintaining proper standards of care and for helping the patient i n his s o c i a l readjustment i s primarily the function of the s o c i a l work er. Some plan should be worked out between the S o c i a l Welfare Branch and the Mental Health Services f o r the setting up of boarding homes or family-care, as i t would help t o ' f a c i l i t a t e the work of the s o c i a l worker during.the r e h a b i l i t a t i o n period, but primarily i t would ease the fear of the patient during his - 9 4 -r e - e n t r a n c e t o s o c i e t y , and p o s s i b l y be a b i g f a c t o r i n h e l p -i n g the p a t i e n t t o r e m a i n i n t h e community and become s u c c e s s -f u l l y r e h a b i l i t a t e d . ' Summary. T h r o u g h o u t t h i s s t u d y i t has b e e n i n d i c a t e d how the p a r t i c i p a t i o n o f the s o c i a l worker has h e l p e d i n m o s t e v e r y a r e a o f t r e a t m e n t ' f o r t h e m e n t a l l y i l l . I f h i s c o n t r i b u t i o n a p p e a r s t o be l e s s i n some a r e a s tn&n o t h e r s i t i s p r i m a r i l y due t o the l a c k o f p e r s o n n e l t o u n d e r t a k e t h e job o r b e c a u s e t h e teamwork a s p e c t i s not i n f u l l u s e . The q u a l i t y o f t r e a t m e n t a f f o r d e d t h e p a t i e n t i s w h o l l y dependent on how a b l y the v a r i o u s p r o f e s s i o n s can work t o g e t h e r , A b i l i t y t o work t o g e t h e r i n v o l v e s some knowledge and r e s p e c t f o r o t h e r p r o f e s s i o n a l s k i l l s , a n awareness o f the l i m i t a t i o n s o f ones own p r o f e s s i o n a l s k i l l , an u n d e r s t a n d i n g o f t h e dynamics o f human b e h a v i o u r , and an a -b i l i t y t o work i n t e g r a t i v e l y . The r e l a t i o n s h i p s o f t h e v a r i o u s p r o f e s s i o n s must be c o n s t a n t l y e v a l u a t e d and p u r p o s e l y d e v e l o p -ed i f t r e a t m e n t i s t o be a d e q u a t e . - 95 •-Appendix A. P O L I C Y M A N U A L I N D E X Crease C l i n i c of Psychological Medicine I. SOCIAL SERVICES, CREASE CLINIC. I I . RESPONSIBILITIES OF THE SOCIAL WORKER IN THE FIELD. (A) Correspondence. (i) Address, ( i i ) C e r t i f i e d Patients, ( i i i ) Voluntary Patients, (iv) Letters of Enquiry from the F i e l d Service, re "former Patients of Crease C l i n i c . (B ) Spe c i f i c Services Requested. (i) Interpretation to Family, ( i i ) Obtaining S o c i a l History Information, ( i i i ) Offering Case Work Services to Family, (iv) Assessing R e h a b i l i t a t i o n Resources, (v) Advising re Patients Already Known to F i e l d Service, (vi) Follow-up Service. (a) General. (b) Length of follow-up. (c) Consultation. •(d) Reports. (C j Special Categories of Patients. (i) Patients on Leave, ( i i ) Readmissions. ( i i i ) Patients Rehabilitated through V i s t a , (iv) Patients Rehabilitated through R e h a b i l i t a t i o n O f f i c e r . (v) Patients Requiring Nursing Home Placement, (vi) Juveniles, ( v i i ) Patients on S o c i a l Assistance. ( Y i i i ) Pregnant Women. III. GENERAL INFORMATION. (A) Clothing and Personal E f f e c t s . (B ) Tucke Shop and Pennington H a l l . (C) V i s i t i n g Hours. (D) F i n a n c i a l A f f a i r s . (E) C o l l e c t i o n s . (F) Transportation and Escort. - 96 -P o l i c y Manual Index (cont'd) (i) General, ( i i ) Destitute Patients. (a) Organized T e r r i t o r y , (b.) Unorganized T e r r i t o r y . P O L I C Y M A N U A L I. SOCIAL SERVICES, CREASE CLINIC: Crease C l i n i c S o c i a l Service Department undertook 100 per cent patient coverage during the f i r s t year and a h a l f of the Crease C l i n i c operation. Such services are no longer poss-i b l e and i t has been necessary to i n s t i t u t e s e l e c t i v i t y f o r con-tinued case work service. A l l Crease C l i n i c admissions are registered with S o c i a l Service Index. In order to cover as many admissions as possible, the Crease C l i n i c S o c i a l Service Department has been separated into two sections - namely: (a) Admissions and Reception Section which includes intake studies and other b r i e f services and i n -i t i a l screening of cases for r e f e r r a l to continuing case work section; (b) Continuing Case Work Section which provides i n -tensive service to patients and families during the period of h o s p i t a l i z a t i o n and discharge. Crease C l i n i c S ocial Service Department assumes f u l l r e s p o n s i b i l i t y for patients resident i n the areas of Greater Vancouver, North and West Vancouver, New Westminster, Burnaby, Coquitlam, Burquitlam, and D. L. 172. Approximately 65 per cent of admissions come from these areas. Patients resident outside these d i s t r i c t s are the r e s p o n s i b i l i t y of E i e l d Services. I I . RESPONSIBILITIES OF THE SOCIAL WORKER IN THE FIELD: In view of the fact that the maximum period of t r e a t -ment offered by Crease C l i n i c i s four months and, according to the C l i n i c s of Psychological Medicine Act, discharge i s to be effected within that time, requested service should be given p r i o r i t y and immediate attention. There i s further urgency due to the fact that a study of cases has revealed the average length of stay to be closer to two months. Although a l l patients are discharge i n f u l l , follow-up services may be requested on i n d i v -idual cases. •; (A) Correspondence. : (i) Address: A l l correspondence sent out from Crease C l i n i c S o c i a l Service Department i s under the signature of the P r o v i n c i a l Supervisor of Psychiatric S o c i a l Work. Si m i l a r l y , correspondence to the Crease C l i n i c S o c i a l Service Department should be addressed to the Provin-c i a l Supervisor, Psychiatric, S o c i a l Work. ( i i ) C e r t i f i e d Patients: Letters are sent to the F i e l d Ser-vice advising of the admission of those c e r t i f i e d pat-- 98 -C o r r e s p o n d e n c e . ( C o n t ' d . ) ( i i ) i e n t s on whom C r e a s e C l i n i c S o c i a l S e r v i c e p l a n s t o g i v e a b r i e f o r c o n t i n u i n g s e r v i c e . I n some i n s t a n -e s , case work s e r v i c e s are r e q u e s t e d o f t h e F i e l d ; i n o t h e r s , the l e t t e r s m e r e l y c o n t a i n n o t i f i c a t i o n o f t h e p a t i e n t ' s a d m i s s i o n w i t h the s u g g e s t i o n t h a t f u r t h e r s e r v i c e s may be r e q u e s t e d e i t h e r on d i s c h a r g e o r a t some p o i n t i n t h e p a t i e n t ' s t r e a t m e n t . F u r t h e r c o r r e s p o n d e n c e i s s e n t t o t h e F i e l d f r o m t i m e t o t ime on c e r t i f i e d p a t i e n t s t o whom c o n t i n u i n g s e r -v i c e s a r e b e i n g e x t e n d e d and who r e m a i n i n t h e C l i n i c f o r a p p r o x i m a t e l y t h e f o u r - m o n t h p e r i o d . A t the p o i n t o f the p a t i e n t ' s d i s c h a r g e , l e t t e r s a r e sent t o t h e F i e l d S e r v i c e a d v i s i n g o f t h e p a t i e n t ' s d i s c h a r g e and o f h i s p r o g r e s s on t r e a t m e n t w h i l e a t t h e C r e a s e C l i n i c . A t t h i s t i m e t o o c o n t i n u i n g case work s e r v i c e s may be r e q u e s t e d f o r the p a t i e n t i n r e l a t i o n t o h i s e m o t i o n a l and s o c i a l needs as e v a l u a t e d d u r i n g h i s h o s p i t a l i z a t i o n . P e r i o d i c r e p o r t s as t o h i s a d j u s t -ment i n the community w i l l a l s o be r e q u e s t e d . The case w i l l s u b s e q u e n t l y be c l o s e d as a p s y c h i a t r i c c a s e f o l l o w i n g c o n f e r e n c e s w i t h t h e d o c t o r i n w h i c h t h e v F i e l d S e r v i c e r e p o r t s and assessment o f t h e p a t i e n t ' s adjustment w i l l be g i v e n i m p o r t a n t c o n s i d e r a t i o n . ( i i i ) V o l u n t a r y P a t i e n t s : A l l c o r r e s p o n d e n c e w i t h the F i e l d c o n c e r n i n g v o l u n t a r y p a t i e n t s i s c a r r i e d out o n l y w i t h t h e p a t i e n t ' s p e r m i s s i o n . When s u c h p e r m i s s i o n i s s e c u r e d , t h e p r o c e d u r e f o l l o w s t h a t o u t l i n e d f o r c e r t -i f i e d p a t i e n t s . ( i v ) L e t t e r s o f I n q u i r y From t h e F i e l d S e r v i c e Re F o r m e r  P a t i e n t s o f C r e a s e C l i n i c : . The F i e l d S e r v i c e from time t o t i m e r e q u e s t s i n f o r m a t i o n on p a t i e n t s who were p r e v i o u s l y known t o C r e a s e C l i n i c . S u c h g e n e r a l i n -f o r m a t i o n as t h e p a t i e n t ' s name, age, m a r i t a l s t a t u s , t h e d a t e s o f a d m i s s i o n and d i s c h a r g e , t h e t y p e o f t r e a t m e n t he r e c e i v e s , d u r i n g h o s p i t a l i z a t i o n and h i s c o n d i t i o n on d i s c h a r g e may be g i v e n w i t h o u t t h e w r i t -t e n p e r m i s s i o n o f t h e p a t i e n t . The d e t a i l e d p e r s o n a l i n f o r m a t i o n may be g i v e n o n l y when t h e w r i t t e n p e r -m i s s i o n o f t h e p a t i e n t has b e e n r e c e i v e d and e n c l o s e d i n t h e l e t t e r o f r e q u e s t b y t h e F i e l d S e r v i c e and i n the base-•; o f - m i n o r s w i t h w r i t t e n p e r m i s s i o n o f p a r e n t o r g u a r d i a n . S p e c i f i c S e r v i c e s R e q u e s t e d . P a t i e n t s t o C r e a s e C l i n i c f a l l i n t o two c a t e g o r i e s -V o l u n t a r y o r C e r t i f i e d . The F i e l d S e r v i c e s a r e r e s p o n s i b l e f o r c o m p l e t i n g t h e C o l l e c t i o n Forms f o r the Department o f I n s t i t u t i o n a l Revenue f o r . a l l . c e r t i f i e d p a t i e n t s . F i e l d - 99 (B) S p e c i f i c Services Requested. (Cont'd.) Service might be requested to give s o c i a l service to pat-ients i n either category. These services could include: (i) .Interpretation to the Family of the hospital f a c i l -i t i e s and treatment pro6e&ure. ( i i ) Obtaining S o c i a l History Information. ( i i i ) Offering Case Work Services to the Family upon eval-uation of the si t u a t i o n . (iv) Assessing R e h a b i l i t a t i o n Resources. Assessing family and coimminity resources f o r patient's r e h a b i l i t a t i o n . In the case of Voluntary admission, the permission i s obtained before any request i s sent to the F i e l d . (v) Advising re Patients already known to F i e l d Service. '. Since i t i s no longer possible to of f e r 1 0 0 per cent coverage to Crease C l i n i c patients, there w i l l be patients admitted who are known to F i e l d Service but not to Crease C l i n i c S o c i a l Services. In the event that patients on whom no request for service has been received are already known to the F i e l d Services and pertinent information i s on the agency f i l e , Crease C l i n i c should automatically be n o t i f i e d of t h i s s i t -uation. The Crease C l i n i c S o c i a l Service Department w i l l then be responsible f o r clearing with patient's p s y c h i a t r i s t as to whether t h i s information i s desired and i n the event of voluntary patients w i l l obtain the patient's permission to make such a request. (vi) Follow-up Services. (a) General: Crease C l i n i c S o c i a l Service Department - - request for service would specify which services seem to be indicated and would include what i n -formation has already been obtained by Crease - C l i n i c S o c i a l Service Department. In the event • of patients being discharged to the d i s t r i c t , follow-up services are requested on an in d i v i d u a l b asis. Requests f o r such services are based upon the psychiatric and s o c i a l assessment of the pat-, ient during his h o s p i t a l i z a t i o n as well as on the so c i a l workers assessment of the patient's family. Should follow-up services be requested on pat-ients f o r whom no previous service has seemed i n -dicated, a resume of the available material i n -cluding- a copy of the intake history, i f such has been obtained, w i l l accompany the request. - 1 0 0 -S p e c i f i c Services Requested. (Cont'd.) (b) Length of follow-up services w i l l vary with d i f f -erent patients and although the p s y c h i a t r i s t s recommendation w i l l be conveyed by the l e t t e r , the "Field Service worker carrying r e s p o n s i b i l i t y fo r service would be expected to assess and eval-uate i f a longer period i s required. (c) Consultation: The Crease C l i n i c S o c i a l Service Department i s available i n a consultative capac-i t y and can procure the p s y c h i a t r i s t s advice on any psychiatric problems which might arise dur-ing t h i s r e h a b i l i t a t i o n period. Reports: When follow-up services are requested, the F i e l d Service worker i s expected to report at i n t e r v a l s on the patient's adjustment. Rec-.ommendations from the F i e l d are important factors  i n deciding when to close the case i n Psychiatric Services. With some patients the major problem i s found on "assessment to be within the area of family services with the psychiatric i l l n e s s sec-ondary. In such instances, at the time of the patients discharge from the C l i n i c the suggestion i s made by Crease C l i n i c S o c i a l Service Depart-ment that the case be closed as a psy c h i a t r i c one and opened on the basis of family service. In these cases, no further reports from the F i e l d Services are requested. This p a r t i c i p a t i o n by • F i e l d Service i s i n the area of an out-patient department to a treatment c l i n i c . S pecial Categories, of Patients. (i) Patients on Leave: Certain patients are permitted out of hospital f o r short v i s i t s during t h e i r period of treatment. Some of these patients do not return to the C l i n i c at the expiry of t h e i r v i s i t . The F i e l d Services may then be requested to v i s i t and report on the adjustment of such patients as an aid i n determin-ing whether the patient may then be discharged or should be returned to h o s p i t a l . ( i i ) Readmissions: For certa i n patients, repeated admiss-ions to.the Crease C l i n i c would not be b e n e f i c i a l ; instead, the patient should be committed f o r a longer period of treatment to the P r o v i n c i a l Mental H o s p i t a l . This i s usually indicated by l e t t e r to the F i e l d Ser-vice at the point of the patient's discharge from Crease C l i n i c , Should there then be some doubt around a s i t u a t i o n a r i s i n g i n t h i s category, advisory inform-ation may be obtained upon request. - 101 -) Special Categories of Patients. (Cont'd.) There are i n addition some patients who may be d i s -charged i n f u l l from Crease C l i n i c and committed under new papers to P.M.H. The F i e l d Service w i l l again . be. advised by l e t t e r of t h i s and of the patient's Mental Hospital number. Future correspondence may then be addressed to the Pr o v i n c i a l Supervisor, P s y c h i a t r i c S o c i a l Work, quoting t h i s new number. ( i i i ) Patients Rehabilitated Through V i s t a : The V i s t a i s a small mid-way unit situated i n Vancouver to which a li m i t e d number of women patients may be transferred f o r a short period of time as an aid i n t h e i r r e h a b i l i t a t -i o n . During t h e i r stay in. V i s t a , the Crease C l i n i c S o c i a l Service v/orker continues to give supportive ser-vices including help with employment and accommodation. There'are certain patients, who require such a period i n V i s t a as a step i n t h e i r adjustment to community l i f e but who w i l l l a t e r return to t h e i r home d i s t r i c t . The Crease C l i n i c worker would keep the F i e l d Service informed and would advise the F i e l d p r i o r to the pat-ient's discharge to the community. (iv) Patients Rehabilitated Through R e h a b i l i t a t i o n O f f i c e r : A r e h a b i l i t a t i o n o f f i c e r i s oh the s t a f f of P.M.H. and Crease C l i n i c to aid selected male patients i n em-ployment and accommodation. This i s a separate de-partment from the psychiatric s o c i a l service department. (v) Patients Requiring Nursing Home Placement: When nur-sing home placement i s to.be required upon discharge, we request t h i s service from the area from which pat-ient was admitted. I f f o r psychiatric reasons, the patient should be discharged to a nursing home in.Van-couver rather than i n the o r i g i n a l home area, the same procedure i s followed as i n the case of a request f o r s o c i a l allowance. (vi) Juveniles Admitted to Crease C l i n i c : A c e r t a i n number of juveniles have been admitted to Crease C l i n i c e i t h e r d i r e c t l y from the home or through some agency, such as the Boys' I n d u s t r i a l School, G i r l s ' I n d u s t r i a l School, Children's Aid Society and F i e l d Service. Behavior problems are not considered suitable for treatment and should not be sent to the Crease C l i n i c . I t has been the p o l i c y to assign these patients f o r continuing service during t h e i r period of h o s p i t a l i z a t i o n . Re-h a b i l i t a t i o n frequently involves a recommendation fo r fo s t e r home placement which i s not a function of the Crease C l i n i c S o c i a l Service Department. The F i e l d Ser-- 102 -(C) Special Categories of Patients. (Cont'd.) vice may therefore he ca l l e d upon to secure such place-ment and in' instances where the c h i l d i s not a ward of the Superintendent of Chi l d Welfare to obtain permiss-ion f or placement from the parents. In these instances there would he early and close collaboration between the Crease C l i n i c S o c i a l Service worker and the F i e l d Service; conferences between F i e l d Services and Crease C l i n i c s t a f f are to be preferred whenever possible. Juveniles admitted to Crease C l i n i c fromB.I.S. and G-.I-.S. are returned to these schools upon discharge. ( v i i ) Patients on S o c i a l Allowance: Patients who have been i n receipt of S o c i a l Allowance p r i o r to admission to the Crease C l i n i c are generally expected on discharge to return to the municipality assuming f i n a n c i a l re-s p o n s i b i l i t y . In those instances i n which the psychi-a t r i s t f e e ls i t to be i n the patient's best i n t e r e s t s p s y c h i a t r i c a l l y to reside i n Vancouver following d i s -charge, the F i e l d Service i n the d i s t r i c t from which the patient was admitted to the Crease C l i n i c v / i l l be contacted'with a request to arrange that s o c i a l a s s i s t -ance be administered through the C i t y o f Vancouver. The l e t t e r requesting such service w i l l be accompanied by a medical c e r t i f i c a t e from the patient's attending doctor and copies of the l e t t e r v / i l l be sent to Mr. James Sadler, Regional Administrator, Region T, and to Mr. J.I. Chambers, Administrator, C i t y S o c i a l Service Department, Vancouver. As the patient cannot be d i s -charged u n t i l such arrangements are completed, i t i s . urgent that such requests receive immediate attention. ( v i i i ) Pregnant Women: I f a pregnant woman i s admitted to Crease C l i n i c and expected to be confined while s t i l l a patient, arrangements are made f o r her to be admitted to Royal Columbian Hospital, New Westminster, and New Westminster S o c i a l Welfare Branch i s requested to make plahs:".for the c h i l d . When the woman i s married, Crease C l i n i c S o c i a l Service Department communicates with the . F i e l d Service to ascertain from the husband or r e l a t -ives what plans are being made for the c h i l d and to-direct t h i s plan through New Westminster S o c i a l Welfare Branch with a copy to Crease C l i n i c . In the case of unmarried mothers, arrangements are made fo r confine-ment i n Royal Columbian Hospital and the plans for the care of the c h i l d are' made by New We-stminster S o c i a l Welfare Branch and the d i s t r i c t o f f i c e i n the area of the patient's residence. I l l GENERAL INFORMATION: (A) Clothing and Personal E f f e c t s . - 103- -I I I General Information: (Cont'd.) As patients i n Crease C l i n i c are r a r e l y bed patients, they are enocuraged to take part i n h o s p i t a l a c t i v i t i e s , and an i n t e r e s t i n their appearance. They are expected to come to the c l i n i c provided with s u f f i c i e n t clothing of t h e i r own preference. Storage space i s l i m i t e d . Patients should not bring jewelry or other valuables. Monies and valuables are kept for the patients i n the Crease C l i n i c business o f f i c e . Patients are able to draw on t h e i r account for small purchases. (B) Tucke Shop and Pennington H a l l . Tucke Shop and Pennington H a l l , which has r e c r e a t i o n a l f a c i l i t i e s , are f o r use of patients, t h e i r r e l a t i v e s and fri e n d s . (C) V i s i t i n g Hours. V i s i t i n g Hours are from 2»00 p.m. to 4:00 p.m. d a i l y . Relatives should be advised-to check with the Crease C l i n i c s o c i a l worker or the patient's p s y c h i a t r i s t before making -the f i r s t v i s i t . (D) F i n a n c i a l A f f a i r s . The f i n a n c i a l a f f a i r s of patients c e r t i f i e d to Crease C l i n i c are placed i n the hands of the Inspector of Munic-i p a l i t i e s , V i c t o r i a , B.C., while the patient remains i n the C l i n i c . I f t h i s freezing of the patient's assets creates a hardship i n the family, adjustment may be made through d i r e c t a p p l i c a t i o n to the Inspector of M u n i c i p a l i t i e s . (E) C o l l e c t i o n s . The F i e l d Services are responsible for completing c o l -l e c t i o n forms f o r the Department of I n s t i t u t i o n a l Revenue on a l l patients who are c e r t i f i e d to Crease C l i n i c of Psy-chological Medicine. Crease C l i n i c S o c i a l Service Depart-ment w i l l be requesting case work services f o r only a small percentage of these patients. In the past, these c o l l e c t i o n forms were held i n the d i s t r i c t o f f i c e s u n t i l requests f o r service were received from the Crease C l i n i c S o c i a l Service Department. Because the Crease C l i n i c treatment s t a f f can-not complete i t s selection study within the time l i m i t set by the Col l e c t i o n s Department, t h i s w i l l no longer be the case. (F) Transportation and Escort. ( i ) General: Patients are generally expected to be r e s -- 104 -T r a n s p o r t a t i o n and E s c o r t . ( C o n t ' d . ) p o n s i b l e f o r t h e i r own t r a n s p o r t a t i o n t o and from C r e a s e C l i n i c . ( i i ) D e s t i t u t e P a t i e n t s : (a) O r g a n i z e d T e r r i t o r y : Under t h e C r e a s e C l i n i c o f P s y c h o l o g i c a l M e d i c i n e A c t t h e a r e a o f r e s i d e n c e i s r e s p o n s i b l e f o r payment o f c o s t s o f t r a n s p o r t -a t i o n t o C r e a s e C l i n i c f o r d e s t i t u t e p a t i e n t s . I n t h o s e o r g a n i z e d a r e a s p o l i c e d b y R . C . M . P . , r e s p o n s i b i l i t y f o r t r a n s p o r t i n g and e s c o r t i n g t h e d e s t i t u t e p a t i e n t i s assumed b y t h e R . C . M . P . (b) U n o r g a n i z e d ' t e r r i t o r y : The R . C . M . P . t a k e r e s p o n -s i b i l i t y f o r f u l l c o s t s o f t r a n s p o r t a t i o n and f o r e s c o r t i n g d e s t i t u t e p a t i e n t s t o C r e a s e C l i n i c . - 1 0 5 -P O L I C Y M A N U A L I N D E X Pr o v i n c i a l Mental Hospital. I. • SOCIAL SERVICES, PROVINCIAL MENTAL HOSPITAL. I I . RESPONSIBILITIES OF THE FIELD SERVICES. (A) To the Family of the Mentally 1 1 1 Patient. (i) Steps i n Helping the Family of the Mentally 1 1 1 Patient. (a) F a c i l i t a t i n g Expression of Emotion around the I l l n e s s and the Mentally 1 1 1 Person. (b) Supporting the Family i n i t s Decision to Hosp i t a l i z e . ( i i ) Goals i n Continuing Case Work Services with Fam-i l i e s of the Mentally 1 1 1 . (a) Explaining the Hospital to the Family. (b) Continuing to Help the Family with i t s Prob-lems; Help to the Family ih'''Understanding Mental I l l n e s s ; and Mental Health P r i n c i p l e s . (c) Writing up the So c i a l Study of the Patient's Family; How They See the Patient; the Stren-gths i n the Family, and How the F i e l d Ser-vices see Themselves Helping. (B ) Re s p o n s i b i l i t i e s of F i e l d Services to the Mentally 1 1 1  Patient. (C) R e s p o n s i b i l i t i e s of F i e l d Services i n Convalescent  (Probation and Rehab i l i t at ionTT ' ( i ) Steps i n Convalescent S o c i a l Services. (a) Need to Bri n g Support, Concrete A u x i l i a r y Services, and to C l a r i f y .Reality. (b) Need to Recognize with the Patient h i s Strengths; to Assess Patient's Growth i n A b i l i t y to Take on Direct ion of His Own L i f e . • (c) Need to Strengthen the Family and Interpret to.the community. (D) R e s p o n s i b i l i t i e s of F i e l d Services and Social Service  Department, P r o v i n c i a l Mental Hospital, i n Developing  an Integrated Mental Health Service for Patients and Families. - 106 -I 2. L I 9.1 M A N U A L I O I I P r o v i n c i a l Mental Hospital, I I I . S p e c i f i c Procedures. (A) Correspondence. (B) Letters of Enquiry. (C) Committal Routines. (D) Discharge of Patients. IV. SPECIAL CATEGORIES OF PATIENTS. (A) S o c i a l Allowance. (B ) Expectant Women. (C) Alc o h o l i c Patients. (D) The Patient Addicted to Drugs. V. GENERAL IJW0RMATI0N. (A) Countersigning Reports. (B) Clothing and E f f e c t s . (C) F i n a n c i a l A f f a i r s . (D) C o l l e c t i o n Reports. .(E) Money G i f t s . (F) Parcels. (G) V i s i t i n g Hours. (H) Consultation Service. (I) Tucke Shop. (J) Pennington H a l l . (K) Transportation a nd Escort, - 107 P O L I C Y M A N U A L I. SOCIAL SERVICES, PROVINCIAL MENTAL HOSPITAL: In any one year approximately 3.911 patients are i n long-term treatment at the P r o v i n c i a l Mental Hospital. These pat-ients are i n residence i n the main buildings at Essondale and Coquitlam (East Lawn - Women's Section; West Lawn - Men's Section; the Veterans' B u i l d i n g ; and, the Homes f o r the Aged, Coquitlam.) During any one year approximately 1,370 patients are admitted to. the P r o v i n c i a l Mental Hospital. Some 902 pat-ients are discharged during any one year. The S o c i a l Work-ers i n the S o c i a l Service Department of the P r o v i n c i a l Mental Hospital are responsible f o r bringing s o c i a l services to a l l patients admitted from Vancouver, and the five outlying d i s -t r i c t s . These patients constitute from 62 per cent to 65 per cent of the entire patient-group admitted. The S o c i a l Service Department, P r o v i n c i a l Mental Hos-p i t a l , as presently constituted i s able to cover only a s e l -ected percentage of the t o t a l patient-group i n s o c i a l ser-vices, at the time of admission, during treatment and throu-ghout discharge from h o s p i t a l . Therefore, there w i l l be a percentage of the t o t a l patient-group unknown to the S o c i a l Service Department, P r o v i n c i a l Mental Hospital and because of t h i s no request f o r E i e l d Services w i l l be made.' However, i f the E i e l d Services know of the patient's admission and have information about patients i n t h i s l a t t e r group, i t would be helpful i f S o c i a l Service Department, P r o v i n c i a l Mental Hospitalrwere n o t i f i e d . This n o t i f i c a t i o n i s necess-ary i n order that S o c i a l Service Department, P r o v i n c i a l Mental Hospital, may clear as to whether the patient i s v o l -untary or committed. In the case of the voluntary patient, i t would be necessary f o r S o c i a l Service Department, Provin-c i a l Mental Hospital, to have the patient's permission be-fore the information i n the E i e l d Service records could be forwarded to the H o s p i t a l . When such information about pat-ients and t h e i r families i s forwarded, by the E i e l d Services, i t g r e a t l y enables S o c i a l Service Department, P r o v i n c i a l Mental Hospital, i n the selection of patients f o r s o c i a l services. I I . RESPONSIBILITIES 0E THE FIELD SERVICES: (A) To the Family of the Mentally 111 Patient. In the cases of patients who come to the P r o v i n c i a l Mental Hospital from outlying d i s t r i c t s , S o c i a l Service Department, P r o v i n c i a l Mental Hospital, depends upon the E i e l d Services to bring family case work services to the families of patients who often have had to meet s i t -- 1 0 8 -To the Family of the Mentally 1 1 1 Patient (Cont'd.) nations devastating to t h e i r i ntegration as a family -situations which stem d i r e c t l y from the very i l l n e s s of the patient. Often "by the time F i e l d Services become active families may actually be broken, because of the i l l n e s s of the mother, father and breadwinner. In such instances, F i e l d Services w i l l be i n the p o s i t i o n of, bringing many of the concrete a u x i l i a r y services which are brought o r d i n a r i l y to broken homes. Besides these concrete a u x i l i a r y services, the F i e l d Services w i l l b r ing case work services directed to helping the family members i n the area of the emotional trauma d i r e c t l y associated v;ith the patient's i l l n e s s . (i) Steps i n Helping the Family of the Mentally 1 1 1 Patient: (a) F a c i l i t a t i n g Expression of Emotion around the I l l - ness and the Mentally 1 1 1 person: I t i s well to remember always that the ment-a l l y i l l family member before his admission to Hospital has been becoming for sometime past l e s s and less f a m i l i a r and less and l e s s understandable to his family. He may have been verbally and phy-s i c a l l y aggressive, sometimes assaultive i n h i s home, " d i f f e r e n t to what he ever was before". This unfamiliar behaviour i s • d i s t r e s s i n g to fam-i l i e s . I f the family members have suffered from the anger and assaultiveness of the patient while he was i n the home, they may come to fear, d i s l i k e and even hate the patient. From these feelings arises, consequently, the f e e l i n g of g u i l t . (b) Supporting the Family i n i t s Decision around the  H o s p i t a l i z a t i o n : Very often the actual decision and the actual taking of the f i n a l step to committal of the pat-ient may have taxed the strength of the family em-o t i o n a l l y and physically. A f t e r the committal, family members often f e e l depressed and sorrowful because of the separation or relieved the l a t t e r with concomitant feelings of g u i l t — g u i l t which i s expressed through over-emphasis on how very nec-. essary i t was to commit. "I've t r i e d everything. I.couldn't take i t any longer. What else could I do." In the l i g h t of these feelings, i t i s not out of the ordinary for a family member to say to the F i e l d Worker, "When you put someone you love i n a mental ho s p i t a l you f e e l that you need a psy-. c h i a t r i s t yourself"; or the member might say, "I f e e l that I have l e t him down that i t was a heartless thing to do." - 109 -(b) S u p p o r t i n g t h e F a m i l y i n i t s D e c i s i o n a r o u n d the  H o s p i t a l i z a t i o n : ( C o n t ' d . ) The F i e l d W o r k e r , i n d e a l i n g v / i t h t h e f a m i l y ' s f e e l i n g s e i t h e r o f d e p r e s s i o n o r r e l i e f a r o u n d c o m m i t t a l , s h o u l d attempt t o b r i n g s u p p o r t t o t h e f a m i l y i n t h e d e c i s i o n t h e y have made. O f t e n i t i s h e l p f u l i n a l l a y i n g t h e a n x i e t y i n t h e d e p r e s s -i o n o r t h e a n x i e t y a r o u n d r e l i e f t o s h a r e w i t h t h e f a m i l y t h a t d e c i s i o n s t o commit a r e a l w a y s d i f f -i c u l t , b u t t h a t t h e y have made t h e r i g h t d e c i s i o n and t h a t t h e p a t i e n t i s i n t h e r i g h t p l a c e t o g e t t h e t r e a t m e n t he needs f o r h i s i l l n e s s . I t i s w e l l f o r the F i e l d Worker t o r e a l i z e t h a t o f t e n t h e fam-i l y making t h e d e c i s i o n t o commit does so o f t e n a g a i n s t t h e v/ i s h o f o t h e r f a m i l y members and r e l -a t i v e s , and does s o , o f t e n i n the f a c e o f s e v e r e c r i t i c i s m f r o m community. The F i e l d 'Worker may f i n d i t n e c e s s a r y t o c o n t i n u e s u c h s u p p o r t i v e c o n -t a c t w i t h the f a m i l y t h r o u g h o u t t h e p a t i e n t ' s t o t -a l p e r i o d o f h o s p i t a l i z a t i o n . ( i i ) G o a l s i n C o n t i n u i n g Case Work S e r v i c e s v / i t h F a m i l i e s  o f t h e M e n t a l l y 1 1 1 : (a) E x p l a i n i n g t h e H o s p i t a l to the F a m i l y : F a m i l i e s d e r i v e c o n s i d e r a b l e b e n e f i t i f v / i t h t h i s s u p p o r t , some u n d e r s t a n d i n g o f t h e h o s p i t a l s e t - u p , t o t a l t r e a t m e n t s e r v i c e s and h o s p i t a l r o u t i n e s i s g i v e n b y t h e F i e l d W o r k e r . O f t e n a f t e r a f a m i l y member has v i s i t e d t h e p a t i e n t i n h o s p i t a l he w i l l ask the F i e l d W o r k e r more q u e s t i o n s Which s p r i n g from a n x i e t y and f e a r . F a p t o r s such as t h e p a t i e n t h a v i n g t o l i v e i n crowded q u a r t e r s , t o mix w i t h p a t i e n t s who a p p e a r so much w o r s e , o r t h e pa t i e n t f e a r i n g h i s t r e a t m e n t and p l e a d i n g t o come home; a l l t h e s e might be r a i s e d a nd q u e s t i o n e d . The F i e l d Worker might f i n d i t - h e l p f u l t o a s s u r e t h e r e l a t i v e t h a t t h e p a t i e n t does n o t , u s u a l l y , i n t h e i n i t i a l p e r i o d o f a d m i s s i o n , o r d u r i n g t h e e a r l y s t a g e s o f h i s t r e a t m e n t , n o t i c e the d i s a d v a n t a g e s o f h o s p i t a l l i f e as much as t h e w e l l v i s i t o r d o e s . A l t h o u g h t h e r e are p a t i e n t s on h i s ward v / i t h v a r y -i n g d e g r e e s o f i l l n e s s , t h e r e w i l l be a p a t i e n t w i t h whom he c a n s t r i k e up f r i e n d s h i p . The n u r s i n g c a r e , r e s t , t h o r o u g h p h y s i c a l , d e n t a l , l a b o r a t o r y t e s t s and n e u r o l o g i c a l e x a m i n a t i o n s s h o u l d be men-t i o n e d as t h e y a r e r e a s s u r i n g t o t h e r e l a t i v e t h a t t h e H o s p i t a l does c a r e and i s i n t e r e s t e d i n t r e a t -i n g the p a t i e n t . I t i s sometimes h e l p f u l t o the r e l a t i v e t o e x p l a i n t h e t h e r a p e u t i c a s p e c t s t h e r e a r e f o r t h e p a t i e n t i n s h a r i n g ' a n d l i v i n g v / i t h o t h e r s on a - 110 -E x p l a i n i n g the H o s p i t a l to t h e F a m i l y ( C o n t ' d . ) w a r d . Sometimes a f t e r a v i s i t t o p a t i e n t , t h e r e l a t i v e may m e n t i o n t h a t he found t h e p a t i e n t d i s -c o u r a g e d and p l e a d i n g t o r e t u r n home. I n s u c h i n -s t a n c e s , F i e l d S e r v i c e s w i l l r e c o g n i z e t h a t a f t e r a c e r t a i n p e r i o d o f t r e a t m e n t , mid-way on t h e r o a d t o b e t t e r h e a l t h , t h a t i t i s n a t u r a l f o r p a t i e n t s t o want t o r e t u r n home. W i t h t r e a t m e n t , happy memories o f f a m i l y l i f e have r e t u r n e d , h u t however, r e t u r n at t h i s t i m e i s not t h e b e s t t h i n g f o r h i m . The r e l a t i v e can be h e l p e d t o see t h e i m p o r t a n t p a r t he c a n f i l l i n the p a t i e n t ' s t r e a t m e n t b y h e l p i n g h i m see t h i s a l s o . N o t e : The F i e l d Worker may g a i n t h i s u n d e r s t a n d -i n g t h r o u g h an o r i e n t a t i o n o r t h r o u g h c o n s u l t a t i o n w i t h S o c i a l S e r v i c e D e p a r t m e n t , P r o v i n c i a l M e n t a l H o s p i t a l . C o n t i n u i n g t o H e l p the F a m i l y w i t h i t s P r o b l e m s .  H e l p t o t h e F a m i l y i n U n d e r s t a n d i n g ; M e n t a l I l l n e s s ,  and M e n t a l H e a l t h P r i n c i p l e s . I n any s e r v i c e t o a f a m i l y , t h e g o a l i s t o h e l p the f a m i l y t o meet i t s p r o b l e m s as t h e y see them; t o h e l p them r e c o g n i z e t h e i r i n h e r e n t s t r e n -g t h s and a p p l y t h e s e t o t h e s o l u t i o n o f d i f f i c u l t -i e s . I n the case o f a f a m i l y w i t h a m e n t a l l y i l l p e r s o n , t h e c o n t i n u i n g s o c i a l work g o a l i s d i r e c t -ed t o the u n d e r s t a n d i n g o f m e n t a l i l l n e s s f i r s t l y , and the p a r t w h i c h f e e l i n g s o f d i s s a t i s f a c t i o n , u n c e r t a i n t y , f r u s t r a t i o n and u n w o r t h i n e s s i n r e -g a r d t o i n t e r - p e r s o n a l and i n t e r - f a m i l i a l r e l a t -i o n s h i p s p l a y i n i t . The s o c i a l s e r v i c e g o a l i s one t h a t e n a b l e s t h e f a m i l y t o u n d e r s t a n d t h e i l l -n e s s , t h e f e e l i n g s and s i t u a t i o n s w h i c h have c o n -t r i b u t e d t o i t . O f t e n a t t h i s p o i n t r e l a t i v e s w i l l come t o some r e a l i z a t i o n o f t h e i r p o s s i b l e p a r t i n c a u s a t i o n o f the i l l n e s s , and t h e n come d e n i a l s , s e l f - a c c u s a t i o n , f e e l i n g s o f shame about h a v i n g someone m e n t a l l y i l l i n t h e f a m i l y . T h e n i t i s t h a t the F i e l d Worker h e l p s t h e r e l a t i v e t o see the h o s p i t a l as a p l a c e f o r the t r e a t m e n t o f m e n t a l i l l n e s s . The F i e l d Worker w i l l r e a s s u r e t h e r e l -a t i v e t h a t e n t e r i n g the H o s p i t a l i s the b e g i n n i n g s t e p i n a t r e a t m e n t p r o c e s s , and t h a t w i t h the newer methods o f t r e a t m e n t many more p a t i e n t s a r e r e s p o n d i n g i n s u c h a way as t o be a b l e t o r e t u r n t o community t n t i m e . I t i s w e l l f o r the F i e l d Worker t o r e a s s u r e the r e l a t i v e a t t h i s t ime t h a t - I l l -Continuing to Help the Family with i t s Problems,  etc: (Cont'd.J the causes of mental i l l n e s s are many and varied; that mental i l l n e s s i s not a disgrace; that one has onl3 r to look around to see the u n i v e r s a l i t y of em-ot i o n a l problems and that i t i s only a matter of degree i n emotional stress between the person i n community with emotional d i f f i c u l t i e s and the per-son i n the Hospital v/ith emotional d i f f i c u l t i e s . I t i s true that patients when they are quite i l l f e e l more at ease, more safe and secure i n the Hospital af t e r the f i r s t strangeness has been over-come. This i s often helpful for the r e l a t i v e s to know. Through further c l a r i f i c a t i o n and support the F i e l d Service may bring help to the family to ac-hieve a more s a t i s f a c t o r y balance, or mental health outlook, and understanding. In t h i s way, the fam-i l y i s supported and made ready step by step to re-ceive the patient. In the end the patient returns to a better integrated family unit, prepared to re-ceive him with acceptance of the l e v e l of the mental health he has achieved from h i s treatment i n Hos-p i t a l . Writing up the S o c i a l Study of the Patient's Family:  How they see the Patient: the Strengths i n the Fam- i l y , and How the F i e l d Services see Themselves Help-ing,. In the past, s o c i a l h i s t o r i e s have been some-what of a routine r e s p o n s i b i l i t y of the F i e l d Ser-v i c e s . With the development of an Admission and Reception Section i n the S o c i a l Service Department, P r o v i n c i a l Mental Hospital, and because only a per-centage of patients admitted are covered by s o c i a l services, s o c i a l h i s t o r i e s w i l l be requested of the F i e l d Services only for those patients known to S o c i a l Services, P r o v i n c i a l Mental Hospital, and whose r e l a t i v e s were not able to be seen by the Ad-mission and Reception Social Worker i n the Hospital at the time of the patient's admission, or f o r the patient who was admitted unaccompanied. The pur-pose of the s o c i a l study are to a s s i s t the treatment team i n the Hospital i n the understanding of the pat-ie n t , to provide the team with diagnostic data and to supply the F i e l d V/orker himself with a s o c i a l diagnosis of the family problem, and possible t r e a t -ment leads i n case work helping of the family dur-ing the h o s p i t a l i z a t i o n of the patient. - IIS -Re s p o n s i b i l i t i e s of F i e l d Services to the Mentally 1 1 1  Patlent7 To do an adequate family case work job the F i e l d Ser-vices need to know what i s happening to the patient i n Hos-p i t a l , i n order to integrate as much as possible interested family members into the patient's treatment plan. I t i s y / e l l to r e a l i z e that the patient's treatment i s a t o t a l thing which takes i n not only hospital treatment but the understanding and intere s t of family i n his. i l l n e s s and treatment as we'll as the understanding of community and the development of i t s willingness to support the patient on his return, S o c i a l Service Department, P r o v i n c i a l Mental Hospital, w i l l provide information about the patient i n ho s p i t a l , just as the F i e l d Worker has provided Hospital with information about the patient's family group. The r e s p o n s i b i l i t i e s of F i e l d Services to the patient undoubtedly begin at the e a r l i e s t contact with his family and increase as the patient approaches convalescence. At t h i s time careful planning between So c i a l Service Depart-ment, P r o v i n c i a l Mental Hospital and F i e l d Services i s es s e n t i a l . At the time of pre-convalescent planning f o r the patient, the hospital team w i l l see s p e c i f i c needs, both i n regard to material assistance and emotional support. These w i l l be interpreted to the F i e l d by l e t t e r or i f i t i s at a l l possible by the conference method. When the F i e l d has been informed, a r e s p o n s i b i l i t y exists to inform S o c i a l Service Department, P r o v i n c i a l Mental Hospital, as to the p o s s i b i l i t y of carrying out these plans, as to the a v a i l a b i l -i t y of resources i n the F i e l d as well as to inform as to whatever alternative resources and services e x i s t . B r i e f l y , pre-convalescent planning f o r the discharge and r e h a b i l i t -ation of the patient i s j o i n t planning between Hospital and F i e l d . R e s p o n s i b i l i t i e s of the F i e l d Service i n Convalescence  (Probation and R e h a b i l i t a t i o n . T (i) Steps i n Convalescent S o c i a l Services: (a) Need to Bring Support, Concrete A u x i l i a r y Services. and to c l a r i f y RealityT I t i s i n s o c i a l services directed as to the supervision o f the discharged patient during the probationary period and i n the r e h a b i l i t a t i o n of these patients that the respon-s i b i l i t y of the ' F i e l d Services i s most fo c a l i z e d on the patient himself. Whenever possible, before the return of the patient tc. community S o c i a l Ser-vice Department, P r o v i n c i a l Mental Hospital, has prepared him for transfer to F i e l d Services. At the time of the patient's return to community he i s very often i n need of strong and consistent - 113 -Need to Bri n g Support, Concrete A u x i l i a r y Services,  and to C l a r i f y R e a l i t y . (Cont'd,) support. For some time before he i s able to take any positive steps, he may need to be very depend-ent on the F i e l d Worker as well as on his family. Many patients w i l l need a convalescent period on f i r s t leaving the Hospital. During t h i s time they w i l l need to have extended to them concrete a u x i l -i a r y services such as S o c i a l Assistance as well as supportive, and i n some instances, enabling case work services. During the early r e h a b i l i t a t i o n period, s o c i a l services are not only directed to manipulating the environment i n such a way as to make i t easy for the patient to f i n d his own way, but they are directed toward clearing what i s feas-i b l e and possible f o r him to plan and attempt for himself ( c l a r i f y i n g what i s r e a l i t y for him;. Need to Recognize with the Patient his Strengths:  to Assess Patient's Growth i n A b i l i t y to Take on  D i r e c t i o n of His Own LifeT The F i e l d Worker w i l l always be assessing the strengths of the patient i n r e a l i t y functioning and w i l l be helping him to assume as much s e l f - d i r e c t i o n as he i s capable of. Much of the aforementioned involves basic, generic p r i n c i p l e s of casework method. In the case of the person who has been mentally i l l h i s i l l n e s s may have l e f t him out of touch v/ith r e a l i t y i n ce r t a i n areas. This v / i l l mean that the s o c i a l worker w i l l need to receive from Hospital the aforementioned assessment of the patient's r e a l i t y functioning. This w i l l be dealt with i n the s p e c i f i c cases by correspondence with Social Service Department, Pro-v i n c i a l Mental Hos p i t a l . In helping patients during the probationary period i t i s well to remember that i t involves slow, careful, steady supportive help. There are no quick r e s u l t s , nor do patients get quickly well, and quickly able to take over the d i r e c t i o n of t h e i r l i v e s . To help the patient clear away some of his external d i f f i c u l t i e s , to give him an opportunity to t a l k about his d i f f i c u l t i e s , to clear v/ith him what i s feasible f o r him to plan and to do, through t h i s some change i n attitude may take place, but usually what i s accomplished i s that the patient may come to know himself for what he i s . In t h i s way he may come to accept himself, under-stand and manage himself better. Need to Strengthen the Family and Interpret to the Community. Since probation or convalescent care i s the re-establishment of the patient i n the community, dur-- 1 1 4 -(c) Need t o S t r e n g t h e n t h e F a m i l y and I n t e r p r e t t o  t h e CommunityV ( C o n t ' d . ) i n g t h e p e r i o d t h e p a t i e n t r e m a i n s f o r s i x months a r e s p o n s i b i l i t y o f t h e H o s p i t a l . The F i e l d S e r -v i c e s a s s i s t i n the d i s c h a r g e o f H o s p i t a l ' s r e s -• p o n s i b i l i t y b y s u p e r v i s i n g t h e p a t i e n t , b y a t t e m p t -i n g t o make a v a i l a b l e t o the p a t i e n t a l l p o s s i b l e community r e s o u r c e s w h i c h might h e l p i n h i s r e a d -j u s t m e n t , such as i n t e r p r e t a t i o n t o the f a m i l y r e -g a r d i n g the p a t i e n t ' s i l l n e s s , h e l p i n g t h e p a t i e n t t o r e g a i n h i s economic s e c u r i t y b y a s s i s t i n g h i m i n l o c a t i n g work and e n c o u r a g i n g t h e i n t e r e s t and a c c e p t a n c e o f f o r m e r employers w h e r e v e r t h i s i s p o s s i b l e . (D) R e s p o n s i b i l i t i e s o f F i e l d S e r v i c e s and S o c i a l S e r v i c e D e p a r t - ment , P r o v i n c i a l M e n t a l H o s p i t a l , i n D e v e l o p i n g an I n t e g r a t e d  M e n t a l H e a l t h S e r v i c e f o r P a t i e n t s a n d , F a m i l i e s . I t i s h e l p f u l i f we can see t h i s s e r v i c e as a s i n g l e . u n i t w i t h i n w h i c h S o c i a l S e r v i c e s a r e b r o u g h t t o p a t i e n t s and t h e i r f a m i l i e s b e f o r e t h e a d m i s s i o n p e r i o d , t h r o u g h o u t a d -m i s s i o n , d u r i n g t r e a t m e n t ( w i t h d i r e c t s e r v i c e t o t h e p a t i e n t on t h e ward b e i n g u n d e r t a k e n b y S o c i a l S e r v i c e D e p a r t m e n t , P r o v i n c i a l M e n t a l H o s p i t a l and s e r v i c e s t o t h e f a m i l y b e i n g u n d e r t a k e n b y the F i e l d ) . These s o c i a l , s e r v i c e s c a r r y on t o . p r e - c o n v a l e s c e n t p l a n n i n g , and f i n a l l y t h r o u g h o u t t h e p e r i o d o f c o n v a l e s c e n t c a r e . B e c a u s e o f t h e g e o g r a p h i c a l s e p a r a t i o n o f the S o c i a l S e r v i c e D e p a r t m e n t , P r o v i n c i a l . M e n t a l H o s p i t a l and F i e l d S e r v i c e s , i t i s o f utmost i m p o r t a n c e t h a t i n t e g -r a t i o n o f s e r v i c e be m a i n t a i n e d t h r o u g h c o r r e s p o n d e n c e . . I n t h i s way o n l y can adequate m i n i m a l s o c i a l s e r v i c e s be b r o u g h t t o p a t i e n t s and f a m i l i e s . The S o c i a l S e r v i c e D e p a r t m e n t , P r o v i n c i a l M e n t a l H o s p i t a l , b e c a u s e i t i s s t a t i o n e d i n t h e H o s p i t a l i s i n a p o s i t i o n t o b r i n g t o g e t h e r the s k i l l s and i d e a s o f o t h e r d i s c i p l i n e s w o r k i n g w i t h t h e p a t i e n t and to i n t e g r a t e w i t h the s o c i a l s e r v i c e s p r o v i d e d b y the F i e l d . E a c h p a t i e n t and h i s f a m i l y i s a u n i q u e e n t i t y . T h e r e can be no r u l e o f the thumb way i n t h e p r o v i s i o n o f s e r v i c e t o p a t i e n t s and t h e i r f a m i l i e s . I t i s o n l y t h r o u g h the i n t e g r a t e d s t u d y b y b o t h o f e a c h i n -d i v i d u a l p a t i e n t ' s s i t u a t i o n t h a t the u n i q u e n e s s can be u n d e r -s t o o d and the needs be met r e l a t i v e l y . I n o r d e r t o i n t e g r a t e t h e p a t i e n t s t u d y and the f a m i l y s t u d y and i n o r d e r t o i n -t e g r a t e s o c i a l work w i t h the p a t i e n t and f a m i l y complete s h a r i n g must be u n d e r t a k e n b y H o s p i t a l and F i e l d . S o c i a l S e r v i c e D e p a r t m e n t , P r o v i n c i a l M e n t a l H o s p i t a l , has a r e s p o n -s i b i l i t y i n h e l p i n g a l o n g t h i s i n t e g r a t i o n b y g i v i n g c o n s u l t -a t i o n t o the. F i e l d on r e q u e s t . T h i s s h a r i n g o r the s t u d y o f t h e p a t i e n t and h i s f a m i l y ; t h i s s h a r i n g o f t h e s o c i a l c a s e work t r e a t m e n t o f the p a t i e n t and h i s f a m i l y t h r o u g h f r e q u e n t - 115 -(D) c o r r e s p o n d e n c e i s t h e S o c i a l S t u d y , and s u p e r c e d e s i n v a l u e t o the c l i e n t s t h e f o r m a l i n f o r m a t i o n - g e t t i n g s e r v i c e w h i c h the former S o c i a l H i s t o r y O u t l i n e r e q u e s t e d . -I I I . SPECIFIC PROCEDURES. • (A) C o r r e spondence. L e t t e r s r e q u e s t i n g case work s e r v i c e may be sent from t h e S o c i a l S e r v i c e D e p a r t m e n t , P r o v i n c i a l M e n t a l H o s p i t a l t o t h e E i e l d S e r v i c e a t any p o i n t d u r i n g the p a t i e n t ' s p e r i o d i n h o s p i t a l . The t i m e a t w h i c h t h e r e q u e s t i s s e n t w i l l - d e -pend on t h e t i m e o f r e f e r r a l t o t h e S o c i a l S e r v i c e D e p a r t m e n t . F o r t h o s e p a t i e n t s who have b e e n s e l e c t e d f o r s o c i a l s e r v i c e d u r i n g t h e a d m i s s i o n p e r i o d , t h e S o c i a l S e r v i c e D e p a r t m e n t , P r o v i n c i a l M e n t a l H o s p i t a l f o r w a r d s a l l i n f o r m a t i o n w h i c h i s known t o the h o s p i t a l about t h e p a t i e n t and h i s f a m i l y a t t h a t p o i n t . S p e c i f i c a r e a s o f s e r v i c e a r e i n d i c a t e d i n t h e l e t t e r s i n s o f a r as t h e s e can be d e t e r m i n e d a t t h e t i m e o f w r i t i n g . I t i s a lways assumed, however, t h a t the F i e l d S e r -v i c e w i l l be i n a more s t r a t e g i c p o s i t i o n t o a s s e s s t h e needs o f t h e f a m i l y and w i l l g i v e a n o v e r a l l f a m i l y s e r v i c e i n a d -d i t i o n t o c o v e r i n g the s p e c i f i c a r e a s as s u g g e s t e d i n c o r r -e s p o n d e n c e . The w o r k e r ' s e v a l u a t i o n o f t h e f a m i l y s i t u a t i o n and h e r case work p l a n s s h o u l d always be i n c l u d e d i n the r e -p o r t s w h i c h a r e f o r w a r d e d t o the S o c i a l S e r v i c e D e p a r t m e n t , P r o v i n c i a l M e n t a l H o s p i t a l . R e p o r t s from the F i e l d S e r v i c e s h o u l d be sent out t o S o c i a l S e r v i c e D e p a r t m e n t , P r o v i n c i a l M e n t a l H o s p i t a l w e l l . w i t h i n a p e r i o d o f a month i n o r d e r f o r t h e s e t o be a u s e f u l p a r t i n t h e t o t a l p l a n n i n g . I n some c a s e s even g r e a t e r u r g e n c y i s i n d i c a t e d ; i n t h e c a s e s where immediate r e p o r t s a r e n e c e s s a r y t h i s i s i n d i c a t e d i n t h e l e t t e r . These r e p o r t s a r e d i s c u s s e d f u l l y w i t h o t h e r d i s -c i p l i n e s i n t h e h o s p i t a l and the j o i n t t h i n k i n g o f t h e t o t -a l t r e a t m e n t team i s i n c l u d e d i n t h e adknowledgment o f t h e r e p o r t s f r o m t h e F i e l d . When p a t i e n t s a r e d i s c h a r g e d on p r o b a t i o n , t h o s e c a s e s w h i c h have b e e n s e l e c t e d f o r s o c i a l s e r v i c e are h e l d open i n t h e S o c i a l S e r v i c e D e p a r t m e n t , P r o v i n c i a l M e n t a l H o s p i t a l u n t i l t h e s i x month p r o b a t i o n a r y p e r i o d i s t e r m i n a t e d . The S o c i a l S e r v i c e D e p a r t m e n t , P r o v i n c i a l M e n t a l H o s p i t a l t a k e s r e s p o n s i b i l i t y f o r n o t i f y i n g t h e F i e l d S e r v i c e when the p r o b a t i o n a r y p e r i o d i s t e r m i n a t e d and when t h e case i s t o be c l o s e d as a p s y c h i a t r i c c a s e . F u r t h e r s e r v i c e i s needed f o r t h e p a t i e n t s and t h e i r f a m i l i e s i n most c a s e s , T h e s e can t h e n - b e t r a n s f e r r e d t o F a m i l y S e r v i c e . A l l r e p o r t s t o the S o c i a l S e r v i c e D e p a r t m e n t , P r o v i n c i a l • M e n t a l H o s p i t a l s h o u l d be forwarded i n d u p l i c a t e as one c o p y i s r e t a i n e d i n the s o c i a l s e r v i c e f i l e s and one copy i s d e s -i g n a t e d f o r the p a t i e n t ' B , u n i t f i l e on w h i c h the m a t e r i a l from a l l d i s c i p l i n e s w i t h i n t h e h o s p i t a l i s k e p t . A l l c o r r e s -• pondence from F i e l d S e r v i c e s s h o u l d be A d d r e s s e d , P r o v i n c i a l S u p e r v i s o r , P s y c h i a t r i c S o c i a l ^ W o r k , P r o v i n c i a l M e n t a l H o s -p i t a l , E s s o n d a l e , B . C . - 116 -(B) Letters of Enquiry from the F i e l d Service i n regard to form- er patients of Pr o v i n c i a l Mental Hospital. When det a i l e d personal information i s requested con-cerning patients who were previously known to the Provin-c i a l Mental Hospital t h i s information may he given only when the written permission of the patient has "been received and enclosed i n the l e t t e r of request. In the case of minors, written permission must be given by the patient's parents or guardian. Such general information as the patient's name, age, marital status, dates of admission and discharge, the type of treatment which he received during h o s p i t a l i z a t i o n and his condition on discharge may be given without the written permission of the patient. In giving out information regarding a patient, the F i e l d Services w i l l be guided by those fundamental s o c i a l work pr i n c i p l e s regarding the ri g h t s of the c l i e n t to confident-i a l i t y i n hi s dealings with the s o c i a l worker and the agency. Therefore, before any information regarding a patient i s given to other persons or interested agencies written per-mission must be obtained from the Medical Superintendent, through the So c i a l Service Department, P r o v i n c i a l Mental Hospital. I t i s important i n the case of a former voluntary patient that permission i s obtained from him ( i f he i s well enough to give t h i s ) before proceeding to ask for inform-ation from the Hospital. Information which i s given to the F i e l d Services during the course of a patient's treatment, and probation i s for t h e i r use i n understanding the patient, h i s i n t e r - f a m i l i a l r elationships and his needs and with t h i s the F i e l d Worker i s i n a better position to see the family needs for s o c i a l services of an enabling and treatment nature. Other professions and other agencies might l i k e l y bring services not related so fundamentally to the patient's i l l -ness, or h i s family relationships, or his community r e l a t i o n -s hips; therefore, only selected s p e c i f i c and related kinds of information regarding the patient should be given. In- formation of a deep personal nature concerning the personal dynamics of the patient should not even be related to the family, or the responsible r e l a t i v e without t h i s f i r s t being  discussed with the p s y c h i a t r i s t , either i n conferende which  w i l l be arranged by the S o c i a l Service Department, Provin- LMental Hospital, or by correspondence, through the S o c i a l Service Department. S p e c i f i c i n q u i r i e s by r e l a t i v e s regarding the p a t i e n t ' s diagnosis, response to treatment and prognosis are directed through the Medical Superintendent by advising the r e l a t i v e to write himself d i r e c t l y . The medical d i s c i p l i n e c.t the -11? -P r o v i n c i a l Mental Hospital cannot assume r e s p o n s i b i l i t y f o r automatically reporting to relative's around the patient's admission, progress i n treatment, etc., but w i l l reply to a l l written requests f o r information. Committal- Routines. _ Patients between the ages of six and seventy years may be admitted to the Pr o v i n c i a l Mental Hospital d i r e c t l y when • they are accompanied by properly completed committal forms, For the patients between these sp e c i f i e d ages, there i s no waiting period; (i ) Ordinary Committal: Ordinary committal forms consist V of (1) one "A" form to be signed by a r e l a t i v e or i n t e r -ested person; (2) two "B" forms to be signed by doctors who have examined the patient; (3) one:nC5:-fom\to'b>'''-;i '. signed by.a magistrate. In most cases the doctors take the r e s p o n s i b i l i t y for guiding the pa t l e n t * s r e l a t i v e s i n the committal procedures. I t i s not recommended that "Field workers sign Committal Forms. (i i } Voluntary Committal: Patients may enter the. Provincial; --.Mental Hospital a"C t h e i r own request. This type of ; : committal has some disadvantages; i n that..Voluntary Pat-ients may leave the hospital on giving the Medical Superintendent fiv e days.notice. The patients are not always well enough to be able to make wise decisions as to the time of termination of treatment. Voluntary Committal Forms consist of (1) one "An form f i l l e d i n , but not necessarily signed by the pat-ient ; (2) one "F" form signed by the -patient and his doctor. ( I i i ) Urgency Committal: Patients maybe admitted under t h i s form because: only one medical p r a c t i t i o n e r i s available.. In t h i s s i t u a t i o n , the forms required are (1) one nAn form signed i n the usual way; (2) one ftB" form; (3) one nC" 'form. These patients are re-examined by the two private p r a c t i t i o n e r s within fourteen days of t h e i r ar-r i v a l at the P r o v i n c i a l Mental Hospital and two "B" forms,are completed at thi s time i n the usual.way (as i n Ordina ry Committal). (iv) Committal by .Order-ln-Cpunoil: Prisoners from Oakalla and the Penitentiary are admitted by Order-in-Council by the Courts. Committal-forms MA" and "C" are submit-ted to the ho s p i t a l as soon a f t e r admission as the Court has the required information. The two "B" forms are completed "by two private p r a c t i t i o n e r s at the P r o v i n c i a l Mental Hospital a f t e r patient has been examined by them. - 118 -Committal Routines, (Cont'd.) (iv) Supplies of Committal Forms are to be found i n i n l o c a l Court Houses, and l o c a l General Hospitals. P r o v i n c i a l Mental Hospital does not supply forms to the F i e l d nor does the Hospital expedite the committals of patients. This i s the l o c a l doctor's r e s p o n s i b i l i t y . (v) Admission of Adults Over Seventy (70) years: The usual committal forms (that i s : one "A" form, two '"B" forms and one "C" form) are f i l l e d out and forwarded to the Medical Superintendent. As i n the case of children under six, sp e c i a l consideration i s given to the ap-p l i c a t i o n s of patients who are creating an acute prob-lem i n the home or who are dangerous to themselves or others. As vacancies occur, aged people are discharg-ed from the P r o v i n c i a l Mental Hospital and admitted to Home for the Aged. In a l l cases of patients over 70 there i s , however, a waiting l i s t for bed space. Therefore i t i s important f o r the F i e l d Worker to com-plete the s o c i a l study for the aged person requiring admission and to submit i t at once to Dr. B.F. Bryson, Medical Superintendent, Homes for the Aged, and also request that the patient be put on the waiting l i s t . A request should also come from the responsible, r e l a t -ive or psysician i n attendance, and sent on to Dr. B. F. Bryson. I t i s usual for the Medical Superintendent, Homes for the Aged, to contact either the responsible r e l -ative or the attending physician when a vacancy occurs. Note: The Committal Forms are only v a l i d f o r t h i r t y  d,ays,. therefore these should not be completed, u n t i l the notice of bed space has been received from the Hospital. The F i e l d Worker's s o c i a l study of the aged per-son can be abbreviated: developing the onset of the i l l n e s s and the patient's experiences and a c t i v i t i e s p r i o r to the onset. The family should be helped to understand that t h e i r aged r e l a t i v e very often may r e -spond i n such a way to treatment i n the Homes f o r the Aged so as to"lose his disturbance and i n the l i g h t of t h i s , h i s h o s p i t a l i z a t i o n i s not necessarily permanent. With the quiescence of the disturbance the family, i f able, whould be helped to make other provisions for h i s care; f o r example, i n the home of r e l a t i v e s , i n nurs-ing and boarding homes. The family should be helped to understand that shock, sometimes both ph y s i c a l l y and emotionally, might occur very often on the removal of the aged person from f a m i l i a r surroundings and on his subsequent admission - 119 -Committal Routines. (Cont'd.) to the Homes f o r the Aged. With t h i s i n mind, the F i e l d Worker should ascertain the family's wish regard-ing funeral arrangements i n the event o r , t h e i r aged r e l a t i v e ' s death. I t i s expected, that most patients, 70 years and over, admitted w i l l already be i n receipt.of Old Age Security. I f , however, the s o c i a l worker should f i n d that the prospective patient over the age of 70 years i s not i n receipt of Old Age Security and that such patient i s e l i g i b l e f o r Old Age Security, these facts should be noted and accompany the h i s t o r y which the soc-i a l worker w i l l send i n on the aged person who i s await-ing admission to the P r o v i n c i a l Mental Hospital. The necessary d e t a i l s surrounding a patient's app-l i c a t i o n f o r Old Age Security i s now considered an In-s t i t u t i o n a l Revenue function of the P r o v i n c i a l Mental Hospital and s t a f f has been provided i n the P r o v i n c i a l Mental Hospital f o r this work. Discharge of Patients. (i) "On Leave" or "On V i s i t " : The patient may leave the hospital at the d i s c r e t -ion .of the Medical Superintendent f o r short v i s i t s . While thus released the patient remains t h e ' f u l l respon-s i b i l i t y of the h o s p i t a l . I t i s sometimes arranged that the patient may be allowed away from the h o s p i t a l "on leave" for a t r i a l period before probation i s decided. In some instances, F i e l d Services might be requested to give services during the v i s i t period. ( i i ) Probation: (a) Ordinary. When the patient i s w e l l enough for re1-.' h a b i l i t a t i o n , he i s discharged on Ordinary Probat-ion. The probation period i s f o r the six month per-iod immediately following the date that the prob-ation forms are completed. While on probation, the patient may be returned to the ho s p i t a l at any time ! without further committal forms as he remains the hospital's r e s p o n s i b i l i t y during t h i s period. Sup-ervision, i s given the patient and h i s family during t h i s time by the S o c i a l Welfare Branch and inform-ation forwarded to the hospital from time to time. At the end of the six months probation period, the patient i s "Discharged i n F u l l " and ceases to be the r e s p o n s i b i l i t y of the h o s p i t a l . - 1 2 0 -( i i i ) Discharge i n F u l l : Certain patients are discharged i n f u l l on leaving Hospital. F i e l d Services may he requested to give contin-uing Family Services. IV. SPECIAL CATEG-OEES OF PATIENTS. (A) Patients on Soc i a l Allowance. Patients who have been i n receipt of S o c i a l Allow-ance p r i o r to t h e i r committal to the P r o v i n c i a l Mental Hospital are generally expected on discharge to return to the municipality assuming f i n a n c i a l r e s p o n s i b i l i t y . In those instances i n which the p s y c h i a t r i s t f e e l s i t to be i n the patient's best int e r e s t s psychologically to reside i n Vancouver, following discharge, the F i e l d Services i n the d i s t r i c t from which the patient was admitted to the P r o v i n c i a l Mental Hospital w i l l be con-tacted v/ith a request to arrange that s o c i a l assistance be administered through the C i t y of Vancouver. The l e t t e r requesting such service w i l l be accompanied by a medical c e r t i f i c a t e from the patient's attending psy-c h i a t r i s t and copies of the l e t t e r w i l l be sent to Mr. James Sadler, Regional Ad.ministrator, Region I, and to Mr. J.I. Chambers, Administrator, C i t y S o c i a l Service Department, Vancouver, As the patient cannot be d i s -charged u n t i l such arrangements are completed, i t i s urgent that such requests receive immediate attention. (B.) Expectant Women Pa t i e n t s . I f a pregnant woman patient i s admitted to the Pro-v i n c i a l Mental Hospital and expected to be. confined while s t i l l a patient, arrangements are made for her to be admitted to the Royal Columbian Hospital, New West-minster,, and New Westminster S o c i a l Welfare Branch i s requested to make plans f o r the c h i l d . When the woman patient i s married, P r o v i n c i a l Mental Hospital, S o c i a l Service Department, communicates with the F i e l d Services to ascertain from the husband or r e l a t i v e s what plans . are being made for the c h i l d and to d i r e c t t h i s plan . through New Westminster S o c i a l Welfare Branch with a copy to the S o c i a l Service Department, P r o v i n c i a l Men-t a l Hospital. In the case of unmarried mothers, arran-gements are made for confinement i n Royal Columbian Hospital and the plans.for the care of the c h i l d are made by New Westminster S o c i a l Welfare Branch and the d i s t r i c t o f f i c e i n the area of the patient's residence. - 121 -Alcoholic Patients. See Or&er-in-Council #606 dated March 17th, 1952, whereby alco h o l i c s admitted to Hospital are limited to. twenty-five and must be admitted during daylight hours. F i e l d Services before contemplating the recommendation of voluntary treatment i n Hospital f o r the A l c o h o l i c must f i r s t inquire by l e t t e r or telephone ( i f feasible) as to a v a i l -a b i l i t y of bed space. As of August 1st, 1953, a new Order-in-Council i n t r o d r ucing Form K, a new form whereby the voluntary alcoholic w i l l enter Hospital f o r a minimum of 30 days treatment, w i l l come into e f f e c t . Patients Addicted to Drugs. Hospital i s not extending admission f a c i l i t i e s to t h i s group, unless the patient addicted to drugs i s committed as psychotic. GENERAL INFORMATION. Countersigning Reports. A l l F i e l d Workers reports involving s o c i a l studies and case work Plans which are to be forwarded to S o c i a l Service Department^ P r o v i n c i a l Mental Hospital must be countersigned by the D i s t r i c t Supervisor i n the F i e l d . An exception to t h i s might be i n those instances when i t has been stated that there i s some matter of urgency i n the Hospital's r e -ceipt of the report. Clothing and Personal E f f e c t s . A great many patients i n the P r o v i n c i a l Mental Hospital are not bed patients. The development and maintaining of the patient's i n t e r e s t i n his personal appearance i s an im-portant part of the t o t a l treatment plan f o r him. Patients are expected to come to the Pr o v i n c i a l Mental Hospital pro-vided with s u f f i c i e n t and a t t r a c t i v e clothing. I t •'•is sugg-ested that three sets of washable under garments, three cot-ton s l i p s and three washable cotton dresses should^be pro-vided for women patients. This clothing should be a t t r a c t -ive yet durable because the laundry i s i n s t i t u t i o n a l and there i s no dry cleaning establishment. Three durable cot-ton night gowns, a dressing gown and house s l i p p e r s are sug-gested; also one p a i r of oxford shoes and l y l e hose. Storage space--for patients' e f f e c t s i s very l i m i t e d so that i t i s important not to exceed t h i s amount of clothing. Patients should not bring jewelry or other valuables. How-ever, should the patient arrive i n Hospital i n possession of valuables these are c a r e f u l l y l i s t e d , placed i n containers - 1 2 2 -C l o t h i n g and P e r s o n a l E f f e c t s . ( C o n t ' d . ) marked w i t h h i s name. These c o n t a i n e r s are h e l d . i n t h e v a u l t u n t i l the p a t i e n t ' s d i s c h a r g e . The P a t i e n t ' s E i n a n c i a l A f f a i r s , These are p l a c e d i n the hands o f t h e I n s p e c t o r o f M u n i c i p a l A f f a i r s , V i c t o r i a , B . C . , d u r i n g t h e p a t i e n t ' s h o s p i t a l i z a t i o n and d e p e n d i n g on c i r c u m s t a n c e s d u r i n g t h e p r o b a t i o n a r y p e r i o d . I f t h e l a t t e r c r e a t e s a h a r d s h i p f o r t h e f a m i l y , a d j u s t m e n t s can be made on a p p l i c a t i o n to t h e o f f i c e o f the I n s p e c t o r . o f M u n i c i p a l i t i e s , V i c t o r i a , B . C . C o l l e c t i o n R e p o r t s . . The F i e l d S e r v i c e s a r e r e s p o n s i b l e f o r c o m p l e t i n g t h e C o l l e c t i o n Forms f o r the Department o f I n s t i t u t i o n a l Revenue f o r a l l committed p a t i e n t s t o t h e P r o v i n c i a l M e n t a l H o s p i t a l . From t h i s t i m e o n , t h e S o c i a l S e r v i c e D e p a r t m e n t , P r o v i n c i a l M e n t a l H o s p i t a l , w i l l be r e q u e s t i n g E i e l d S e r v i c e s f o r a s m a l l p e r c e n t a g e o f t h e s e committed p a t i e n t s . I n the p a s t t h e s e c o l l e c t i o n forms were h e l d i n the D i s t r i c t O f f i c e s u n -t i l t h e r e q u e s t f o r s e r v i c e was r e c e i v e d from the H o s p i t a l . T h i s no l o n g e r w i l l be t h e case b e c a u s e o f S o c i a l S e r v i c e D e p a r t m e n t ' s p o l i c y r e g a r d i n g s e l e c t i o n o f p a t i e n t s f o r s o c -i a l s e r v i c e s . T h e r e f o r e , t h e r e w i l l , be some s i t u a t i o n s i n w h i c h a s e p a r a t e v i s i t w o u l d seem t o be i n d i c a t e d i n o r d e r t o complete the C o l l e c t i o n R e p o r t . The T r e a t m e n t s t a f f a t t h e H o s p i t a l i s u n a b l e t o complete t h e s e l e c t i o n s t u d y w i t h i n t h e t i m e l i m i t r e q u i r e d b y t h e C o l l e c t o r o f I n s t i t u t i o n a l Revenue f o r r e c e i p t o f t h e C o l l e c t i o n F o r m . Money g i f t s . These s h o u l d n o t be g i v e n t o the p a t i e n t s d i r e c t l y . I t may.be e n t r u s t e d t o the head n u r s e , o r charge n u r s e o r m a i l e d t o the M e d i c a l S u p e r i n t e n d e n t w i t h 'some i n d i c a t i o n t h a t i t i s f o r " c o m f o r t s f o r the p a t i e n t " . The p a t i e n t ' s c h r i s t i a n name, surname and ward s h o u l d be c l e a r l y r e c o r d e d i n t h e l e t t e r . P a r c e l s . A l l p a r c e l s s e n t t h r o u g h the m a i l s h o u l d be a d d r e s s e d t o the p a t i e n t f o r whom ; they a r e i n t e n d e d . A g a i n c a r e s h o u l d b e . t a k e n t o use c h r i s t i a n name, surname and the ward l e t t e r — e . g . M r s . Rose H . B r o w n , Ward E-4. The H u d s o n ' s B a y Company, E a t o n s and Woodwards a l l make d e l i v e r i e s t o the H o s p i t a l t w i c e weekly, and s t a n d i n g o r d e r s f o r e x t r a s can be l e f t w i t h t h e s e . c o m p a n i e s b y r e l a t i v e s . - 123 -Parcels. (Cont'd.) : Parcels containing home-cooking, f r u i t and wearing apparel are most appreciated by the patients. V i s i t i n g Hours are d a i l y from 2:00 - 4:00 p.m. Relatives may ask to speak to the s o c i a l worker at t h i s time; Or, i f the r e l a t i v e wants to spend some time i n discussion with the s o c i a l worker, he! should write i n d i c a t i n g the day he i n - • tends to v i s i t . T&e s o c i a l worker w i l l also arrange appoint-ments fo r r e l a t i v e s with the patient's p s y c h i a t r i s t . Consultation Service. F i e l d workers should f e e l free to consult the Social Service Department, P r o v i n c i a l Mental Hospital regarding any problems i n service to psy c h i a t r i c patients and t h e i r f a m i l i e s . Tucke Shop; There i s a Tucke Shop where patients who have ground p r i v i l e g e s may make purchases. This experience i n entering a shop again and ordering something desired has a r e a l „ therapeutic content f o r the patients. The purchases they make are charged to'the patient's "Comfort Allowance". Regular orders may be placed by r e l a t i v e s and friends i n person or may be arranged by l e t t e r to the Medical Superin-tendent or through the S o c i a l Service Department. Pennington H a l l . Pennington H a l l which has recreational f a c i l i t i e s f o r the patients i s also for the use - of patients and t h e i r v i s i t i n g r e l a t i v e s . There i s an att r a c t i v e tea room i n which patients and r e l a t i v e s can v i s i t together. Transportation and Escort. (I) General. Patients are generally expected to be respon- , sib l e f o r t h e i r own transportation to and from the Hos-p i t a l . In the case of the committed patient to Pro-v i n c i a l Mental Hospital, a responsible r e l a t i v e w i l l often undertake to assume costs. (II) . Destitute, Patients. (a) Organized T e r r i t o r y : Under the Mental Hospital's Act the area of residence i s responsible for pay-ment of cost1© of transportation to the P r o v i n c i a l Mental Hospital'for destitute patients. In those organized areas policed by R.C.M.PT, r e s p o n s i b i l -- 1 2 4 -( i i ) D e s t i t u t e P a t i e n t s . C o n t ' d . ) (a) i t y f o r t r a n s p o r t i n g and e s c o r t i n g the d e s t i t u t e p a t i e n t i s assumed b y the R . C . M . P . Those o r g a n -i z e d a r e a s h a v i n g l o c a l . c o n s t a b u l a r y t a k e r e s p o n -s i b i l i t y f o r the t r a n s p o r t i n g and e s c o r t i n g o f the d e s t i t u t e p a t i e n t . (b) U n o r g a n i z e d T e r r i t o r y : The R . C . M . P . , t a k e r e s -p o n s i b i l i t y f o r f u l l c o s t s o f t r a n s p o r t a t i o n and f o r e s c o r t i n g d e s t i t u t e p a t i e n t s t o the P r o v -i n c i a l M e n t a l H o s p i t a l . - 125 -Appendix - B. Duties of the P r o v i n c i a l Supervisor of Psychiatric S o c i a l Work. 1. In the Mental Health Services. a. Responsibility for advising the D i r e c t o r of Mental Health Services on a l l planning regarding the organizat-ion of the S o c i a l Service Departments. b. Responsibility f o r advising the Director of Woodlands School (School f o r I n t e l l e c t u a l l y Retarded Children) on the planning of the S o c i a l Service Department and s o c i a l needs throughout the i n s t i t u t i o n . c. Responsibility for advising the D i r e c t o r of C h i l d Guidance C l i n i c s on a l l planning for s o c i a l services i n the C l i n i c s . 2. In the S o c i a l Welfare Branch. a. Advisory to the Deputy Minister of Welfare, the D i r e c t o r of Welfare and the Assistant Director of Welfare, on standards of mental health services i n regards, s p e c i f -i c a l l y , to s o c i a l work services of a preventive nature and s o c i a l services of a r e h a b i l i t a t i v e nature, f o r a l l children and adults r e f e r r e d to the Mental Health Service b. Responsibility for d i r e c t i n g and advising the F i e l d Con-sultants employed within the S o c i a l Welfare Branch of the Department of Health and Welfare on p o l i c y and services within the Mental Health Services. 3. In the Community. a. To d i r e c t and act with a l l s t a f f of the S o c i a l Service Departments i n maintaining l i a i s o n and encouraging co-operation with a l l e x i s t i n g community resources i n the interests of the mentally i l l patient; and to a s s i s t i n the development of community resources for the patient discharged from the mental h o s p i t a l . The l a t t e r involves co-operatively meeting with other community agencies, evolving p o l i c i e s of i n t e r - r e l a t i o n s h i p s and co-operation whereby community services may be brought e f f e c t i v e l y and with f a c i l i t y to the patient. b; Some r e s p o n s i b i l i t y f o r i n t e r p r e t a t i o n to agencies and lay groups of the S o c i a l Services i n the Mental Health Services. c» Responsibility for consultation and d i r e c t i o n regarding /the t r a i n i n g of s o c i a l work students within the various - 1 2 6 -S o c i a l S e r v i c e D e p a r t m e n t s o f the M e n t a l H e a l t h S e r -v i c e s . T h i s t r a i n i n g i s f i n a n c e d u n d e r t h e M e n t a l H e a l t h G r a n t o f t h e f e d e r a l government, and i s d i r e c t l y s u p e r v i s e d b y t h e U n i v e r s i t y o f B r i t i s h C o l u m b i a ' s S c h o o l o f S o c i a l Work. S t a f f R e s p o n s i b i l i t y . a . R e s p o n s i b i l i t y f o r b r i n g i n g c o n s u l t a t i o n , a d v i c e and d i r e c t i o n t o t h e a d m i n i s t r a t i v e s o c i a l w o r k e r s i n t h e f o l l o w i n g u n i t s o f t h e M e n t a l H e a l t h S e r v i c e s : C h i l d G u i d a n c e C l i n i c s (Vancouver and V a n c o u v e r I s l a n d ) Woodlands S c h o o l (New W e s t m i n s t e r ) , and C r e a s e C l i n i c and t h e P r o v i n c i a l M e n t a l H o s p i t a l b o t h a t E s s o n d a l e . A l s o o v e r a l l r e s p o n s i b i l i t y f o r t h e development o f t h e whole s o c i a l s e r v i c e p r o g r a m , as w e l l as a d v i s i n g on s t a n d a r d s o f s o c i a l work s e r v i c e s and p r a c t i c e s . b . R e s p o n s i b i l i t y f o r . o r g a n i z a t i o n and a d m i n i s t r a t i o n o f t h e S o c i a l S e r v i c e D e p a r t m e n t s a t E s s o n d a l e . A l s o r e -s p o n s i b i l i t y f o r the e v a l u a t i o n , r e v i s i o n , and e x t e n s i o n o f the s o c i a l s e r v i c e program so t h a t i t meets t h e needs o f p a t i e n t s , community and the d e v e l o p m e n t a l changes i n t h e o t h e r p r o f e s s i o n a l d e p a r t m e n t s s u c h a s p s y c h i a t r y , n u r s i n g and p s y c h o l o g y w h i c h are p a r t o f t h e t r e a t m e n t team. c . O v e r a l l r e s p o n s i b i l i t y t o o r g a n i z e and i n t r o d u c e methods f o r s o c i a l work s t a f f t r a i n i n g . a n d development on t h e j o b . - 127 -Appendix - C. ' Outline of S o c i a l Work Orientation Program for Nurses (Public-Health, Post-Graduates and A f f i l i a t e s . ) S o c i a l Work i n the Setting of the Psychi a t r i c Hospital and C l i n i c . I Introduction: The Team Approach (Working together to a • purpose.) 1. D e f i n i t i o n s : a. The broad f i e l d of Soc i a l Work or S o c i a l Vi/elfare as presently defined by the study on Training f o r : S o c i a l Work by .the United "Nations Economic and S o c i a l Council. • b. D e f i n i t i o n of the Social'Worker and h i s "function. 2. Problems and Objectives of S o c i a l Work of S o c i a l Welfare. a 8 S o c i a l Services which have grown up to meet the problems. 3. Methodology of the Profession of S o c i a l Vfork. S o c i a l Work makes use of two p r i n c i p a l methods of • • professional service: a. Group action. b. Individual help.. 4. Methods, S k i l l s and Body of Knowledge used by a Social  Worker. a. Methods of Professional S o c i a l Work pra c t i s e . b. S k i l l s of the. S o c i a l Worker. c. Body of knowledge of the S o c i a l Worker. 5. The four main methods of approach to.Social Welfare  Problems. a. S o c i a l Casework. . b. S o c i a l Groupwork. c. Community Organization. d. Research. II The S o c i a l Worker i n the Psychiatric Hospital and C l i n i c  Setting. The organization, administration, p o l i c i e s and services of the So c i a l Work Departments at Essondale. -•128 -Outline f o r Psychiatric Nurses. 1. D e f i n i t i o n : The "broad f i e l d of S o c i a l Welfare as recently defined by the study on.Training for S o c i a l Work by the United Nations Economic and S o c i a l Council. 2. Problems of Social-Welfare. 3. Objectives of S o c i a l Welfare. 4. The History and Development of S o c i a l Welfare Services. a. The C h r i s t i a n E t h i c . b. E a r l y C h r i s t i a n Church - Pauline period. c. . S o c i a l Welfare under the S e i g n o r i a l System. 1. The King, church and hostelry. 2. The manorial system. 3. A l l o c a t i o n of welfare r e s p o n s i b i l i t y a f t e r the breakdown of the manorial system. 4. Elizabethian Boor Laws. A l l o c a t i o n of welfare re s p o n s i b i l i t y . -5. R e l i e f of heed.J Almshouse, indoor and outdoor • r e l i e f , indenture and apprenticeship. 6. The P u r i t a n i c a l viewpoint on welfare services. 7. Viewpoint' of'the P o l i t i c a l Theorists. 8. Growth of the great volunteers. - Shaftesbury,. E l i z a b e t h Fry, Howard, Wilberforce, Bosanquet, Florence Nightingale. 9. Era of the Sanitarions. 10. Era of the Educationalists. 11. Municipal P r o v i n c i a l and Federal R e s p o n s i b i l i t i e s . 5. The services which have grown up at Federal, Municipal l e v e l . 6. Department of Health and Welfare of B r i t i s h Columbia. A study i n the administration of a Social-Welfare Program. - 129 -- * 7. Methodology of the Profession of S o c i a l Work. 8. Methods, S k i l l s and Body Knowledge used by a S o c i a l Worker. 9. The four main methods of approach to S o c i a l Welfare Problems. 10. S o c i a l Worker i n the Psychiatric Hospital and C l i n i c Setting. - 130 -Appendix - D. ORIENTATION OF SOCIAL WORKERS FROM  SOCIAL WELFARE BRANCH. F i r s t Day. --Commencing Time; 9:30 avm. Place; Crease C l i n i c - Office 12. 9:30 to 10:00 a.m. - Review of the Act regarding C l i n i c s of Psychological Medicine and the po l i c y of co-operative services i n the Crease C l i n i c . 10:00 to 10:30 a.m. r-'Review of the Mental Hospitals Act -and the p o l i c y regarding co-operative ser- . vices at the Pr o v i n c i a l Mental H o s p i t a l . • 10:30 to 11:00 a.m. - The Homes for the Aged. 11:15 to 12:00 a.m. - The Woodlands School. 12:00 to 1:15 p.m. - LUNCH 1:25 to 2:15 p.m. - Soc i a l Casework to the Psychiatric Pat-ient and his family. Study Room -Crease C l i n i c . 2:30 to 4:30 p.m. - Study room - Crease C l i n i c (3rd floor) (1) Structures of S o c i a l Service Depart-ments. (2) Services. (3) R e s p o n s i b i l i t i e s of the E i e l d . S p e c i f i c a l l y the following w i l l be con-sidered: r e f e r r a l s ; conferences with the doctor; the intake study; l e t t e r s to the F i e l d ; the F i e l d ' s r e s p o n s i b i l i t y i n the intake study; the intake study as a part of an on-going family casework ser-vice; the necessity of the F i e l d worker to see the patient as part of a t o t a l family s i t u a t i o n ; the use of casework supervision i n psychiatric services; the use of the hospital f o r consultation centered around the patient, his t r e a t -ment and his r e h a b i l i t a t i o n planning. Second Day. 9:30 to 10:30 a.m. - Study Room, Crease C l i n i c . The Services of Intake and Reception of patients. The r e s p o n s i b i l i t y of the F i e l d and E i e l d relationships i n r e l a t i o n to t h i s proc-edure . - 131 -10:30 to 11:30 a.m. 11:00 to 18:00 a.m. 12:00 to 1:15 p.m. 1:25 to 4:30 p.m.. Study Room, Crease C l i n i c . Patient's day i n h o s p i t a l . The work of the Soci a l Worker during the patient's treatment period. S o c i a l Casework to the Psychi a t r i c Patient and his family. Study Room, Crease C l i n i c . LUNCH . Demonstration C l i n i c . (Patients with some form of mental i l l n e s s w i l l be interviewed by the doctor. As a rule S o c i a l Service i s active with cases observed.) - 132 -Appendix - E. Orientation of New S o c i a l Workers and t h e i r Induction into the  S o c i a l Service Departments of the P r o v i n c i a l Mental Hospital  and Crease C l i n i c of Psychological Medicine, Essondale, B.C. F i r s t Day Introduction to S o c i a l Service s t a f f , work-ing space, layout of grounds. B r i e f i n t r o -duction to t o t a l i t y of services offered i n the Mental Hospital, function of the S o c i a l Service Departments and r e l a t i o n s h i p to other Hospital Services. Discussion of rules and regulations regard-ing c o n f i d e n t i a l i t y , keys, behavior and demeanor. Discussion of mental i l l n e s s and i t s t r e a t -ment. Reading: 1. Manual of Psychiatric Social Service Department. 2. Lunacy Act and Crease C l i n i c Act. 3. Stern, Edith, Mental I l l n e s s :  A Guide for the Family. 4. Merininger,.W.C ., Mental Dynamics, Second Day Further discussion of hospital services; mental i l l n e s s and i t s treatment; S o c i a l Service r e s p o n s i b i l i t i e s . V i s i t to Crease C l i n i c wards and services, Third Day P r o v i n c i a l Supervisor o f P s y c h i a t r i c Social Work gives discussion of Philosophy of Psychiatric S o c i a l Service at the P r o v i n c i a l Mental Hospital and Crease C l i n i c . Attend Ward Rounds.' Study a f i l e f o r what i s i n i t so worker w i l l get a picture o f a p a r t i c u l a r patient i n a mental h o s p i t a l . F i l e to be discussed from standpoint of a l l that i s i n i t , a l l that may be conjectured and deduced, prep-aratory to further s o c i a l service a c t i v i t y . V i s i t to wards, occupational therapy, Centre Lawn Wards. - 133 -- Reading: 1. Brown J.T., Psychodynamics of Abnormal Behavior, pp~ (162-177), (186-208) 2. Noyes, A.P., Modern C l i n i c a l  Psychiatry, pp. (14-99) 3. Richardson, H.P., Patients Have  Families, pp. (165-232) Fourth Day - Study of two case f i l e s from the standpoint of dynamic evaluation and determination of So c i a l Service r e s p o n s i b i l i t y . • . Reading on s p e c i f i c i l l n e s s e s . -Discussion with Supervisbr. Reading: 1. Psychiatric S o c i a l Worker i n the  Psychiatric H o s p i t a l . - G-.A.P. Report #2, January, 1948. 2. Psychiatric S o c i a l Worker i n Esses County. 3. Notes on S o c i a l History Taking. 4. Casework with Families of Mental  Hospital Patients, Freeman, H., Journal of S o c i a l Casework, March 1947. 5. Planning f o r Psychotic Patients, M. Shea, Journal of So c i a l Case-work, December, 1950. .6. Noyes, A.P., Modern C l i n i c a l  Psychiatry, pp. (328-392) F i f t h Day - Discussion of kinds of therapy used at Crease C l i n i c and the P r o v i n c i a l Mental H o s p i t a l . Instructions on s t a t i s t i c s , daysheets, r e -ports, d i c t a t i o n . Study more case f i l e s . Reading: 1. "Caseworker*s Relation to Shock Therapy", L. Ziskind, Journal of  Soci a l Casework. December, 1948. 2, "Shock Therapy i n Schizophrenia", Polatin, N., Journal o f S o c i a l . Casework, December 1945. 3. Noyes, A.P., Modern C l i n i c a l  Psychiatry, pp. (458-474) Sixth Day - Attend S t a f f Meeting (Day varies) V i s i t ward to- observe Coma i n s u l i n . V i s i t Home f o r the Aged. V i s i t other services, other buildings. -134 -- Further reading and discussion on mental i l l n e s s and the s o c i a l worker's r e s p o n s i b i l -' i t y . Discussions on casework techniques; conferences with the physicians and v i s i t s to patients. Reading:1. Paper on Ambulatory Schizophrenia. 3. How Dangerous to the Community are Hental Hospital.Patients, Cohen and Freeman, (reprint) Seventh Day - Observe Electro-convulsive therapy. One interview assigned. Further reading* Eighth Day - Attend Ward Rounds. Further case study. • Ninth Day -Observe I n s u l i n therapy. Interview assigned. D i c t a t i o n . Discussions. Tenth Day - Interviews assigned. Gradual B u i l d i n g up of case-load u n t i l o r i e n t a t i o n period completed. Appendix - F. - 135 -BIBLIOGRAPHY.  SPECIFIC REFERENCES. Books. Beers, C l i f f o r d W., A Mind That Found It s e l f , D o u b l e d a v and Company, Garden C i t y , New York, 1908. Deutsch, Albert, The Mentally 111 In America, Columbia University Press, New York, 1937. Ti f f a n y , Francis, L i f e Of Dorothea Lynde Dix, Houghton, M i f f l i n and Company, Boston, 1891. A r t i c l e s , Reports and Other Studies. B i r c h , Sophie, An Aid i n the R e h a b i l i t a t i o n Of Mental Hosp- i t a l Patients,'Master of S o c i a l Work Thesis, University of B r i t i s h Columbia, 1953. B r i t i s h Columbia, Sessional Papers, Annual Report of the  Public Hospital For The Insane, Queens P r i n t e r , V i c t o r i a , 1907. B r i t i s h Columbia, "Psychiatric Service Physicians' Manual", 1950. Canadian National Committee for Mental Hygiene, "Report of a Survey of B r i t i s h Columbia i n 1919", Canadian  Journal of Mental Hygiene, Volume 2, A p r i l 1920. Clark, James R., Care Of The Mentally 111 In B r i t i s h Colum- b i a , Master of So 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, 1947. Group for the Advancement of Psychiatry, "The Psyc h i a t r i c S o c i a l Worker i n the P s y c h i a t r i c Hospital", Report No. 2, January, 1948. Vasey, W., "Partnership Between Administrator and S t a f f i n Developing Sound Welfare Programs", Journal of  S o c i a l Casework, V o l . XXXIII, A p r i l 1952. - 136 -GENERAL REFERENCES. Books. Cannon, Ida M., S o c i a l Work i n Hospitals:,: Russel Sage Foundation, New York, 1923. Crutcher, Hester B., A Guide For Developing Psychiatric Social Work In State Hospitals, State Hospitals Press, Utica, New York, 1933. Fink, Arthur E., The F i e l d of Soc i a l Ifork, Henry Holt and Company, New York, 1942. French, Lois M., Psychiatric S o c i a l Work, The Commonwealth Fund, New York, 1940. Richmond, Mary E., What Is S o c i a l Casework, Russel Sage Foundation, New York, 1917. A r t i c l e s , Reports and Other Studies. Bowkett, Mary F., The So c i a l Worker In The Treatment Team, Master of S o c i a l Work Thesis, U n i v e r s i t y o f B r i t i s h Columbia, 1951. B r i t i s h Columbia, Annual Report of the Mental Health Services, Queens Pri n t e r s , V i c t o r i a , 1952. B r i t i s h Columbia, Annual Reports of the S o c i a l Welfare Branch  of the Department of Health and Welfare, Kings Printers, V i c t o r i a , 1948-51. Freeman, H.J., "Casework with Families of Mental Hospital Patients", Journal of So c i a l Casework, March 1947. Frehdehthai; Kurt' "The Contribution o f the S o c i a l Work Intake Process to the Psychiatric Treatment Situ a t i o n " , Journal of Psychiatric S o c i a l Work, September, 1950. Hooey, Jane H., "S o c i a l Work; I t s Base, S k i l l s and Relat-ions to other F i e l d s " , Journal of So c i a l Casework, December, 1950. 

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