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The social problems of discharged mental patients referred to a public assistance agency in 1954: a… Johnson, Emily Alice 1956

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THE SOCIAL PROBLEMS OF DISCHARGED MENTAL PATIENTS REFERRED TO A PUBLIC ASSISTANCE AGENCY DI 195^ A Study of the Problems of Fifteen Discharged Mental Patients and the Services Provided to Them by the Social Service Departments of the Crease Clinic and the City Social Service Department ty EMILY ALICE JOHHSON Thesis Submitted in Partial Fulfilment of the Requirements Corresponding to the Master of Social Work Course in the School of Social Work. / Accepted as conforming to the required standard SCHOOL OF SOCIAL WORK 1956 The Ifeiveraity of British Columbia - i i i -ABSTRACT The subject of t h i s study i s to examine the problems of a group of discharged mental p a t i e n t s and the s e r v i c e s provided to them by t h e i r r e f e r r a l to a p u b l i c a s s i s t a n c e agency. The study has examined the p a r t i c u l a r problems presented i n f i n a n c i a l need, accommodation, and f a m i l y d i f -f i c u l t i e s , and has attempted to assess whether p u b l i c a s s i s t a n c e s e r v i c e s are adequate to e f f e c t c o n t i n u i n g im-provement, i n a c l i n i c a l sense, i n the p a t i e n t ' s psycho* l o g i c a l adjustment. W i t h i n the p e r i o d , January 1 s t , 19%k-, to December 31st, 19£1+, f i f t e e n p a t i e n t s were refe r r e d ' b y the Crease C l i n i c S o c i a l Service Department, Essondale, B r i t i s h Columbiaj to the C i t y S o c i a l Service Department, Vancouver, B r i t i s h Columbia, as being in. need of f i n a n c i a l a s s i s t a n c e . Teh of the p a t i e n t s were i n r e c e i p t of a s s i s t a n c e at the time of t h e i r admission'to the Crease C l i n i c . At t h i s p o i n t t h e i r cases were closed by the C i t y S o c i a l Service Department. Upon discharge from the Crease' C l i n i c 4. r e - a p p l i c a t i o n to the a s s i s t a n c e agency was necessary. This c o n s t i t u t e d r e -r e f e r r a l and they were thus included i n t h i s study. By the use of two Schedules^ and through personal com-munication w i t h the A d m i n i s t r a t o r s of the S o c i a l Service Department o f the Crease C l i n i c , and the S o c i a l S e r v i c e Department, data were obtained about the p a t i e n t s ' psycho-!-s o c i a l background, the problems presented, and the s e r v i c e s given by the p s y c h i a t r i c h o s p i t a l s o c i a l workers, and the Assistance Agency S t a f f . The f i n d i n g s i n d i c a t e d that shortage of s o c i a l work s t a f f , and heavy caseloads, may i n c e r t a i n severe problem cases, r e s u l t i n uncoordinated and inadequate s e r v i c e . The need f o r a more adequate d e f i n i t i o n of r e s p o n s i b i l i t y i n p r o v i d i n g A f t e r - C a r e S e r v i c e s through j o i n t h o s p i t a l and.community pla n n i n g , was evident, p a r t i c u l a r l y ' l h the cases where the p s y c h o l o g i c a l d i f f i c u l t i e s of the p a t i e n t s , remained un* modified by the s e r v i c e s given. This i s s t r e s s e d because of the p o l i c y of the C i t y S o c i a l S e r v i c e Department to c l o s e t h e i r cases when f i n a n c i a l need i s no longer r e q u i r e d , i n the cases mentioned the p s y c h o l o g i c a l problems would appear to r e - a c t i v a t e p s y c h o s o c i a l d i f f i c u l t i e s . An example of'a; r e f e r r a l p o l i c y has been '.suggested" to e f f e c t c l o s e r l i a i s o n betweeri the agencies, A suggestion t h a t the C i t y S o c i a l Service Department consider plans t o promote prev e n t a t i v e s e r v i c e s to f a m i l i e s and i n d i v i d u a l s w i t h r e h a b i l i t a t i v e p o t e n t i a l . 1 See Appendix, pp. 91*92. * i v -ACMOWLEDGMEHTS I wish to express my a p p r e c i a t i o n to Miss A.K. C a r r o l l , Miss F. McGubbin, Mr, J.A, Chambers and Miss M. Gourley f o r t h e i r h e l p f u l suggestions, and to Mr. A.C. Abrahamson and Mr. A. Marriage of the School of S o c i a l Work F a c u l t y , The u n i v e r s i t y of B r i t i s h Columbia, f o r t h e i r constant support and c o n s t r u c t i v e c r i t i c i s m . - i i -TABLE OP CONTENTS Page Chapter 1. Mental I l l n e s s and R e h a b i l i t a t i o n Mental i l l n e s s f i g u r e s . R e h a b i l i t a t i o n of the I mentally 111. S c i e n t i f i c c o n t r i b u t i o n s to modem techniques of r e h a b i l i t a t i o n . M e n t a l l y i l l and t h e i r , treatment, p r i n c i p l e s and problems. Concepts of pub-l i c welfare philosophy. Post-discharge problems of mental p a t i e n t s . S o c i a l A s sistance i n these consider-a t i o n s . Method and approach of t h i s study. ............ 1 Ghapter 2. P s y c h i a t r i c and S o c i a l Casework Fa c t o r s I n t r o d u c t i o n . S o c i a l casework c o n s i d e r a t i o n s . I P s y c h i a t r i c c l a s s i f i c a t i o n s which i n f l u e n c e treatment. The f u n c t i o n of the team at the Crease C l i n i c . The S o c i a l Service Department. R e f e r r a l p o l i c i e s between agencies. P r e s e n t a t i o n of f i f t e e n cases s t u d i e d . Con-c l u s i o n and f i n d i n g s . 21 Ghapter 3. P u b l i c A s s i s t a n c e Considerations i n the  Gases Studied. Government r e s p o n s i b i l i t y to provide welfare s e r v i c e s . Development of G i t y S o c i a l S e r v i c e Department. S t a f f o r g a n i z a t i o n a l s t r u c t u r e . R e f e r r a l p o l i c i e s which a f f e c t a s s i s t a n c e concepts. P r e s e n t a t i o n of f i f t e e n cases st u d i e d . Conclusion and F i n d i n g s . $0 Chapter k> Discharged Mental P a t i e n t s and Plans f o r Their Care. Purpose of this present study. S o c i a l work p r a c t i c e and the need f o r research. Human aspects of S o c i a l Welfare programmes. The p a t i e n t and h i s r e t u r n to the cbinraunlty. Example from three cases. Need f o r A f t e r * I Care Services and c l e a r l y d e f i n e d statements of p o l i c y between agencies. Example of r e f e r r a l p o l i c y ^ Recom-mendations a r i s i n g from the study. ...................... 72 Appendices: A. Schedule used a t the Grease C l i n i c . B. Schedule used a t the C i t y S o e i a l Service Department G. Brochure of the C i t y of Vancouver S o c i a l S ervice Department. D. B i b l i o g r a p h y THE SOCIAL PROBLEM Off DISCHARGED MENTAL PATIENTS REFERRED TO A PUBLIC ASSISTANCE AGENCY IN 19Sii A Study of the problems of F i f t e e n Discharged Mental P a t i e n t s and the Ser v i c e s Provided to Them by the S o c i a l .Service Departments of the Crease C l i n i c and the C i t y S o e i a l S e r v i c e Department CHAPTER 1 MENTAL ILLNESS AND REHABILITATION Mental I l l n e s s F i g u r e s Mental i l l n e s s I s Canada's most serious h e a l t h problem. Between the years 19l|-8 and 1 9 5 2 , admissions to p u b l i c mental h o s p i t a l s showed an increase of over 6,j>00 p a t i e n t s . I t i s estimated t h a t over 60,000 mentally i l l and m e ntally d e f e c t i v e persons are p a t i e n t s i n I n s t i t u t i o n s , and t h a t a t any given date mental h o s p i t a l p a t i e n t s aceount f o r almost one-half of a l l persons h o s p i t a l i s e d i n Canada. 1 This t o t a l does not Include the thousands who, each year, seek a i d at Out-Patient C l i n i c s i n g e n e r a l h o s p i t a l s } i t does not i n c l u d e the c h i l d r e n who r e c e i v e h e l p through c h i l d guidance c l i n i c s e r v i c e s ; i t does not i n c l u d e those who seek a s s i s t a n c e from p r i v a t e p r a c t i t i o n e r s . I t has been v a r i o u s l y estimated by informed sources i n Canada and the United S t a t e s , t h a t one out of every t e n persons l i v i n g i n these c o u n t r i e s w i l l at some time r e q u i r e a s s i s t a n c e i n f a c i n g h i s everyday problems. I n B r i t i s h Golumbia, on March 3 1 s t , 19$k, the t o t a l number of p a t i e n t s i n residence i n various i n s t i t u t i o n s of the P r o v i n c i a l Mental H e a l t h S e r v i c e s was 6 , 2 ^ 3 , an increase of 215 over the previous year. The y e a r l y c o s t 1 "Mental Health Services In Canada," Research D i v i s i o n , Department of N a t i o n a l H e a l t h and Welfare, Ottawa, J u l y , 1 9 5 4 , P« 1 . was #8,765,016.01, w i t h the cos t per c a p i t a of #1,424.53, or d a i l y per c a p i t a c o s t of #3.90. During the same year the admissions to the Grease C l i n i c were 1,256. Of the t o t a l number of admissions, 591+ p a t i e n t s , o r 48 per cent, were admitted t o the C l i n i c on a vol u n t a r y b a s i s , whichi i n d i c a t e s a b e t t e r a t t i t u d e on the p a r t of the general p u b l i c toward mental i l l n e s s and a l s o a gr e a t e r r e a d l * ness t o seek h e l p f o r the problems. T h i s , of course, r e s u l t s i n the p a t i e n t s r e c e i v i n g h e l p f o r t h e i r prob-lems at an e a r l y stag© i n the course o f i l l n e s s . 2 While i t i s recognized t h a t modern p s y c h i a t r i c knowledge and d i a g n o s t i c treatment f a c i l i t i e s have made i t p o s s i b l e f o r the e a r l y d e t e c t i o n o f mental i l l n e s s , the i n c r e a s i n g numbers of admissions t o mental h o s p i t a l s and c l i n i c s r e f l e c t the i n a b i l i t y of modem f a c i l i t i e s to meet the growing numbers of the mentally i l l i n our communities. The e f f i c i e n t f u n c t i o n i n g o f a modern s o c i e t y i s dependent on the p r o v i s i o n of f a c i l i t i e s f o r the raaintenane© of good p h y s i c a l and mental h e a l t h f o r c i t i z e n s . The r e s t o r * a t i o n of the i l l to u s e f u l n e s s I s e s s e n t i a l not only f o r the i n d i v i d u a l ' s own w e l l being, but a l s o to ensure the c o n t i n -uance of the n a t i o n ' s i n d u s t r i a l development, and the maintenance o f the economic and s o c i a l order. Thus i t w i l l be r e a d i l y understood that the treatment and r e h a b i l i t a t i o n of 60,000 mentally 111 c i t i z e n s i s of v i t a l concern to the 1 Mental H e a l t h S e r v i c e s , Province o f B r i t i s h Columbia, Annual Keport, 1954, PP« ^21 and R .33. 2 I b i d . . p. E . 3 9 . - 3 -growth of Canadian s o c i e t y . S c i e n t i f i c C o n t r i b u t i o n to Modern Techniques of R e h a b i l i t a t i o n One c o n t r i b u t i o n which modern p s y c h i a t r y has provided i s the foundation f o r the understanding and o r d e r l y c l a s s i f i -c a t i o n of mental diseases. This c o n t r i b u t i o n has been r e f l e c t e d i n the development of modern p s y c h i a t r i c c l i n i c s . The c l i n i c s have counteracted the popular conception of the complete I s o l a t i o n of the mentally i l l from the community. Recent medical r e s e a r c h In the area of chemo-therapy has not o n l y r e s u l t e d i n breaking through the world of the mentally i l l , but has a l s o brought b e t t e r c o n t r o l and manage* ment f a c i l i t i e s f o r the p a t i e n t w i t h i n the h o s p i t a l ward and toward speedier r e h a b i l i t a t i o n of many chronic mental c o n d i t i o n s . Modern concepts of p s y c h i a t r i c n u r s i n g , developing i n c o o r d i n a t i o n w i t h these f a c i l i t i e s , are c o n t r i b u t i n g to the treatment and care of the mentally 111, and by u s i n g I n d i v i d u a l and group aspects of r e h a b i l i t a t i v e techniques, plays a v i t a l p a r t i n the p r e p a r a t i o n f o r the r e t u r n o f the p a t i e n t t o the community. S o c i a l work has provided understanding about i n d i v l -u a l and s o c i a l problems which give r i s e t o s t r e s s w i t h i n i n d i v i d u a l s and w i t h i n the s o c i a l order i n which they l i v e . The s o e i a l work p r o f e s s i o n s t r e s s e s t h a t the o r g a n i z a t i o n of S o c i a l s e r v i c e s i s most e f f e c t i v e l y and humanely used when i n d i v i d u a l , group and community problems are s t u d i e d c a r e f u l l y w i t h a view to determining t h e i r c ausation. The r o l e and f u n c t i o n of the s o c i a l worker i s a c o n t r i b u t i o n t o the team concept of r e h a b i l i t a t i o n . A study of the problems of the mentally i l l w i l l r e v e a l t h a t a l l d i s o r d e r s of p e r s o n a l i t y , are compounds of d i s t u r b e d r e l -a t i o n s h i p s i n which b i o l o g i c a l , p s y c h o l o g i c a l and s o c i a l processes are always present and interwoven. P e r s o n a l i t y disturbances may be p r e c i p i t a t e d toy one o r by a, combination of these processes, whether the impetus stems from p h y s i c a l i l l n e s s * an emotional c r i s i s , o r d i s r u p t i o n of f a m i l y o r v o c a t i o n a l c o n t i n u i t y . Every aspect of an i n d i v i d u a l ' s l i f e s i t u a t i o n may be thrown out of balance when one o f these pro-cesses I s d i s t u r b e d . Swithun Bowers, an accepted a u t h o r i t y on s o c i a l work t h i n k i n g and p r a c t i c e , has s t a t e d t h a t : ...the r o o t s of personal s e c u r i t y are to be found i n . the i n d i v i d u a l ' s s o c i a l and communal l i f e . The s o c i a l s e r v i c e s are c o n s i s t e n t l y and c o n s t a n t l y engaged i n strengthening these r o o t s . H o s p i t a l i z a t i o n i s necessary when as a r e s u l t o f i n n e r and outer s t r e s s e s , the i n n e r t u r m o i l of a f r e t t e d mind prod-uces s e r i o u s Inadequacies i n r e l a t i o n s h i p . ! The p a t i e n t , a human bei n g , i s i n v o l v e d a t a l l times i n a complicated system o f human r e l a t i o n s h i p s . Harry Stack S u l l i v a n has d e s c r i b e d p s y c h i a t r y as the study of the processes t h a t i n v o l v e o r go on between people. S o c i a l work a l s o concentrates on the d i s c i p l i n e d use of 1 Bowers, Swithun, S o c i a l S e r v i c e s f o r the M e n t a l l y I I I * -T h e i r Place i n the F i e l d of S o c i a l Work. B e t t e r S o e i a l Ser-v i c e s f o r M e n t a l l y 111 P a t i e n t s , American A s s o c i a t i o n of P s y c h i a t r i c S o e i a l Workers, Inc., Hew York, 1955* P» 2. r e l a t i o n s h i p s . Gordon Hamilton has s a i d t h a t "Casework i s grounded In the a r t and science of r e l a t i o n s h i p . " ^ "Pace to face r e l a t i o n s a c t i v a t e i n t e l l e c t u a l and emotional pro-cesses, s e t a t t i t u d e s and s o c i a l i z e the i n d i v i d u a l . T h e s o c i a l worker, by h i s t r a i n i n g and s k i l l , I s thus able t o understand the needs of the p a t i e n t who has s u f f e r e d from " s e r i o u s symptomatic inadequacies i n r e l a t i o n s h i p . " - * The o b j e c t i v e of p s y c h i a t r i c treatment i s rehab-i l i t a t i o n * the r e t u r n of the p a t i e n t to h i s f a m i l y , and t o h i s f u n c t i o n i n g i n the environment i n an adequate and s a t i s -f y i n g way. I t i s w i t h i n th® p a t i e n t ' s world of human and s o c i a l r e l a t i o n s h i p s that r e h a b i l i t a t i o n i s f i n a l l y achieved. The s o c i a l worker's c o n t r i b u t i o n to the mental p a t i e n t w i t h i n the framework of p s y c h i a t r i c treatment and r e h a b i l i t a t i o n i s by use o f s o c i a l casework and s o c i a l groupwork techniques to f a c i l i t a t e the conscious adjustment of i n d i v i d u a l s to t h e i r s i t u a t i o n by means o f I n d i v i d u a l r e l a t i o n s h i p s , group exper-i e n c e s , and the p r o v i s i o n of s o c i a l resources. Thus the j o i n t focus of the p s y c h i a t r i s t and the s o c i a l worker i s th© r e h a b i l i t a t i o n of the p a t i e n t , and w i t h h i s re-establishment i n the community a f t e r a p e r i o d o f d i s r u p t i o n of normal l i v i n g due to mental i l l n e s s . An acceptable d e f i n i t i o n of r e h a b i l i t a t i o n i s the general statement o f the N a t i o n a l C o u n c i l on R e h a b i l i t a t i o n , 1 Hamilton, Gordon, Theory and P r a c t i c e o f S o c i a l Casework. Columbia B h i v e r s i t y Press, New York, Revised E d i t i o n 19^3, p.2?. 2 I b i d . , p. 27. 3 Bowers, pp.. T_cit. — 6 — New York, to the effect that rehabilitation Is the restor-ation of the handicapped to the fu l l e s t physical, mental, social, vocational, and economic usefulness of which they are capable. In th© broad sense rehabilitation includes the entire process of a patient's treatment in hospital and his return to routine c i v i l i a n l i v i n g . In this aspect for example: .«.the rehabilitation of the mentally i l l begins immediately upon admission to hospital and a l l sub* sequent examination, treatment, nursing care* psy-chotherapy, and social work (casework and groupwork) are aimed at promoting normal social integration* and preparing the patient and relatives to make an accepted adjustment.! The term social rehabilitation, as used in this study, w i l l refer to the aspect of treatment which embraces plans for the post-discharge period when the patient i s referred to a public assistance agency. Prior to 1901 Canada had Isolated rehabilitation programmes in existence which provided services to specific groups of people. The Department of Veterans Affairs' Rehabilitation programme was restricted to the handicapped veteran. In February 1901* the National Advisory Committee on th© Rehabilitation of Disabled Persons was set up by Order-in*Couneil. The f i r s t meeting of this committee was held in February 1902, and was served by representatives 1 Psychiatric Services, Physicians Manual. Mental Health Services, Province of B r i t i s h Columbia, Chapter 12. - 7 from v o l u n t a r y agencies 9 organized l a b o u r , employer groups, the medical p r o f e s s i o n , r e p r e s e n t a t i v e s of u n i v e r s i t i e s and o t h e r s , A F e d e r a l Coordinator was appointed j, and each province was empowered t o e s t a b l i s h p r o v i n c i a l c o o r d i n a t o r s . On A p r i l 1st, 1955, the Government o f B r i t i s h Columbia appointed Mr* C . l . Bradbury as P r o v i n c i a l Coordinator, who i s d i r e c t l y r e s p o n s i b l e t o the Deputy M i n i s t e r of Health. Mr. Bradbury administers the p r o v i s i o n s under Schedule R, a set of r e g u l a t i o n s governing the op e r a t i o n of i n d i v i d u a l and s p e o i a l c l a s s p r o j e c t s f o r the t r a i n i n g or r e t r a i n i n g of d i s a b l e d persons under the p r o v i s i o n s o f the f e d e r a l -p r o v i n c i a l r e h a b i l i t a t i o n programme. This sehedul© i s attached to and forms p a r t o f the F e d e r a l - P r o v i n c i a l V o c a t i o n a l T r a i n i n g Agreement under the p r o v i s i o n s of the "Voc a t i o n a l T r a i n i n g Go-ordination A c t , R.S.C. 1952* G 286, as amended by S.G. 1953-1954, 0 * 4 5 * " The V o c a t i o n a l T r a i n -i n g Agreement a p p l i e s to seven schedules governing the operation of var i o u s types of t r a i n i n g p r o j e c t s . The D i s -a b i l i t y Allowances A c t , 1955, l i m i t s allowances to persons t o t a l l y and permanently d i s a b l e d . Under Schedule R, however, a d i s a b l e d person may apply f o r r e h a b i l i t a t i o n a i d . At pre-sent the P r o v i n c i a l Mental H e a l t h Service® make l i m i t e d use of the f a c i l i t i e s under t h i s scheme* I n some cases the C i t y S o c i a l S e r v i c e Department has provided f i n a n c i a l a s s i s t a n c e w h i l e the p a t i e n t r e c e i v e s v o c a t i o n a l t r a i n i n g * This s e r v i c e has r e c e n t l y been Incorporated i n t o the r e h a b i l i t a t i o n prog-ramme of B r i t i s h Columbia. The P r o v i n c i a l Coordinator, however,- has no way of p r o v i d i n g medical treatment d u r i n g the t r a i n i n g p e r i o d , and must request the A s s i s t a n c e Agency to c a r r y on w i t h medical coverage. This i s not always granted and i s subject t o i n d i v i d u a l c o n s i d e r a t i o n . M e n t a l l y 111 and T h e i r Treatment. P r i n c i p l e s and Problems I n order t o i d e n t i f y the r e h a b i l i t a t i v e o b j e c t i v e s of the Grease C l i n i c w i i c h uses the resource of the C i t y S o c i a l S e r v i c e Department, an examination of current l i t e r -a t ure on r e h a b i l i t a t i o n concepts I s i n order. One such concept discussed by Stanton and Sehwarta i s what they 1 . term "the unknown f a c t o r . H This I s recognised by a l l medical p r a c t i t i o n e r s . S p e c i a l i z e d types of treatment are a v a i l a b l e I n mental h o s p i t a l s and c l i n i c s , yet i t i s known that many p a t i e n t s recover "spontaneously." A study under-2 taken i n 1903 by the S o c i a l S e r v i c e S t a f f of the erease C l i n i c i n d i c a t e d the average l e n g t h of p a t i e n t h o s p i t a l i z a t -i o n was s i x to e i g h t weeks. To accept t h a t these p a t i e n t s were discharged upon "improvement" suggests t h a t t h i s may have been due to s e v e r a l f a c t o r s . We know that mechanical therapy alone cannot r e p a i r the d y s f u n c t i o n i n r e l a t i o n s h i p s which has taken p l a c e . Psychotherapy u s i n g th® concept of r e l a t i o n s h i p between the p s y c h i a t r i s t and the p a t i e n t would 1 Stanton, A l f r e d H . , and Schwartz, M o r r i s S., The Mental  Hospital,•-' M v i a t o c k P u b l i c a t i o n s Md,, 1901|.. 2 Pepper, Gerald S o c i a l Worker P a r t i c i p a t i o n I n the  Treatment of the M e n t a l l y I I I . Master o f S o c i a l Work T h e s i s , U n i v e r s i t y of B r i t i s h Columbia, B.C., 1903. - 9 -enable improvement, but the time o f s t a y f o r treatment i s g e n e r a l l y too short t o make use o f t h i s method. The t h e s i s of the lon g research p r o j e c t by Stanton and Schwartz 1 main* t a i n s t h a t many p a t i e n t s improve "spontaneously" due to the type o f contacts which they make w i t h other p a t i e n t s i n the i n s t i t u t i o n ( s t a f f and p a t i e n t s ) . 2 C a u d i l l et a l , u s i n g the technique of concealed p a r t i c i p a t i o n , have described the way i n which p a t i e n t s Inducted new p a t i e n t s i n the r o l e of being a p a t i e n t . Observation was made t h a t pressure was exerted toward con-f o r m i t y w i t h the values and standards of t h i s i n f o r m a l group. H o s p i t a l personnel ( s t a f f , p a t i e n t s , v o l u n t e e r workers), and v i s i t o r s i n t h e i r v a r i o u s c o n t a c t s , become interwoven and Incorporated i n t o t h i s i n t a n g i b l e unknown f a c t o r , thereby forming a p a r t o f the "thera p e u t i c community'' which thus c o n s t i t u t e s p a r t of the s o c i a l and c u l t u r a l determinants of the p a t i e n t ' s behaviour. Idward Stainbrook,^ has st a t e d the concept t h a t i f the mental h o s p i t a l o r c l i n i c i s a "community organized f o r therapeutic l i v i n g , we must r e l y upon the s o c i a l sciences f o r enlightenment as w e l l as upon the p s y c h o l o g i c a l and p h y s i o l o g i c a l systems of theory." 1 Stanton and Schwartz, l o c , c i t . 2 C a u d i l l , W i l l i a m , R e d l l c k , F r e d e r i c k C , Gilmore, Helen R ., and Brody, E'.B.* " S o c i a l S t r u c t u r e and I n t e r a c t i o n Processes on a P s y c h i a t r i c Ward," American J o u r n a l of Ortho-p s y c h i a t r y , X X I I , 1952, pp. 3lif-33^ h 3 Stalnbrook, Idward, "Human A c t i o n i n the S o c i a l System of the P s y c h i a t r i c .Hospital."Better S o c i a l S e r v i c e s f o r the  Menta l l y 1 1 1 . American A s s o c i a t i o n of P s y c h i a t r i c S o c i a l Workers, 1 9 5 5 , p. 19. 10 Walter E. Barton r e c a l l s that Dr. Abraham Myerson of the Boston State H o s p i t a l , who developed the " t o t a l push" treatment, was convinced t h a t the r e g r e s s i o n o f schizophrenia was the r e s u l t of h o s p i t a l i z a t i o n , not because of the r e g r e s -s i o n o f th© disease i t s e l f . H© a l s o accepted th© theory t h a t the r e g r e s s i v e d e t e r i o r a t i o n of schizophrenia could be prevented i f the h o s p i t a l environment o f f e r e d the r i g h t k i n d of pressures and s t i m u l i . 1 The Boston State H o s p i t a l i s conducting a e e r i e s of I n v e s t i g a t i o n s which have relevance f o r better understand-2 i n g o f the ward as a " t h e r a p e u t i c cOMnanity," and which are a l s o r e l a t e d to programmes of r e h a b i l i t a t i o n . To quote Dr. Barton: There i s cumulative proof i n the work of Maxwell Jones, Stanton, Schwartz, R e d l i c h , O a u d i l l and iaany others t h a t a p o s i t i v e t h e r a p e u t i c e f f e c t a r i s e s from the i n t e r a c t i o n process between i n d i v i d u a l s and groups that form the h o s p i t a l ward s e t t i n g . The p a t t e r n of h o s p i t a l o r g a n i z a t i o n i s changing as a r e s u l t of these new i n s i g h t s . 3 The f o r c e f u l n e s e o f t h i s t h i n k i n g , however, suggests the n e c e s s i t y of a c l o s e examination of community resources, to determine whether they are so designed, that the p a t i e n t continues t o r e c e i v e the benefits" promoted by t h i s concept. E a r l i e r d e t e c t i o n o f mental i l l n e s s and new concepts of 1 Barton, Walter E., "The P s y c h i a t r i c H o s p i t a l as a Thera-p e u t i c Community," B e t t e r S o c i a l Services f o r the M e n t a l l y 111, American A s s o c i a t i o n o f P s y c h i a t r i c S o c i a l Workers, 19^0, p. 19. ^ I b i d . . pp. li|-15>. 3 I b i d . . p. 16. — 11 -treatment c r e a t i n g Increase i n the numbers of p a t i e n t s r e q u i r -in g h o s p i t a l i z a t i o n , may n e c e s s i t a t e h o s p i t a l a d m i n i s t r a t o r s to regard c e r t a i n aspects of community resources, as p a r t or a c o n t i n u a t i o n of the " t h e r a p e u t i c community" concept. Community resources would thus i n f a c t enable the p a t i e n t to " b r i d g e " more s u c c e s s f u l l y h i s adaptation from the h o s p i t a l community to the wider community i n which he must p a r t i c i p a t e and f u n c t i o n . For the p a t i e n t who has been mentally i l l , there i s g e n e r a l l y a wide g u l f between h i s l i f e i n the hos-p i t a l and h i s subsequent l i f e i n the community* Some p a t i e n t s are able to b r i d g e the gap between h o s p i t a l and community} many are not, C a r e f u l assessment of the p a t i e n t s i s necessary to a s c e r t a i n t h i s . This demands enough p r o f e s s i o n a l treatment personnel so t h a t each p a t i e n t can be known i n a t o t a l -t h e r apeutic way. A l s o needed i s a c l o s e communication i n an i n t e g r a t e d , cooperative way of a l l community s e r v i c e s , r e -a l i g n e d to c l i e n t s 1 needs* and the h e a l t h o f the community. There are l i m i t a t i o n s as t o numbers and p r o f e s s i o n a l personnel and i n l e g i s l a t i o n s which* i n the case of the Crease C l i n i c , l i m i t s the treatment pe r i o d t o four months and makes no p r o v i s i o n f o r screening p a t i e n t s i n the community who need h o s p i t a l care. These f a c t o r s are m o t i v a t i n g the present Mental H e a l t h Services A d m i n i s t r a t i o n t o plan w i t h Community Agency A d m i n i s t r a t i o n s and C i t i z e n Leaders toward the exten-s i o n and development of e x i s t i n g community resources f o r the use of the p a t i e n t i n h i s r e h a b i l i t a t i o n . . For example; the * 12 -Mental Health S e r v i c e s A d m i n i s t r a t i o n i s a c t i v e l y planning w i t h the Canadian Mental H e a l t h A s s o c i a t i o n , the Community Chest and Council of Greater Vancouver, B r i t i s h Columbia, Concepts of P u b l i c Welfare Philosophy Many attempts have been made to d e f i n e the p h i l -osophy of p u b l i c w e l f a r e programmes. Sarah R i l e y o f f e r s the d e f i n i t i o n o f a p h y s i c a l l y h e a l t h y standard f o r p u b l i c a s s i s t a n c e r e c i p i e n t s as one I n c l u d i n g : ...adequate n u t r i t i o n , s h e l t e r from the elements, warm and p r o t e c t i v e c l o t h i n g , s u f f i c i e n t heat, water and l i g h t . S u f f i c i e n t household s u p p l i e s and equipment f o r e a t i n g and s l e e p i n g , and maintaining reasonable s a n i t a t i o n , and necessary medical and de n t a l c a r e . l As Jackson p o i n t s out: . . . p h y s i c a l standards alone may not be s u f f i c i e n t . P u b l i c A s s i s t a n c e r e c i p i e n t s should a l s o l i v e on a mentally h e a l t h y l e v e l , which i m p l i e s reasonable education f o r the c h i l d r e n , community a c t i v i t i e s f o r a d u l t s , an opportunity to improve the a b i l i t y and c a p a c i t y f o r Work and to c a r r y out the d u t i e s of c i t i z e n s h i p . . , . I f they do not get these they w i l l become or r a i s e second c l a s s c i t i z e n s . 2 I t has been suggested that there are fo u r b a s i c concepts which, i n e f f e c t c o n s t i t u t e the philosophy of an e f f e c t i v e p u b l i c a s s i s t a n c e r e h a b i l i t a t i o n programme. These a r e : 1. That r e c o g n i t i o n be made of the e s s e n t i a l worth and d i g n i t y of each I n d i v i d u a l a p p l i c a n t . 2. That the c l i e n t has w i t h i n h i m s e l f the p o t e n t i a l a b i l i t y to u t i l i z e these s o c i a l s e r v i c e s , w i t h h e l p I f necessary, and become an asset t o the community. Jackson, Douglas L., " S o c i a l A s s i s t a n c e P u b l i c A s s i s -tance P o l i c y , A Review of Contemporary L e g i s l a t i o n and P r a c t i c e i n B r i t i s h Columbia, w Master of S o c i a l Work Thesis« U n i v e r s i t y of B r i t i s h Columbia, Vancouverj B.C., 1950, p.""op. I b i d . i p. 86 . * 13 -3 . That everyone has the r i g h t t o a s a t i s f y i n g and e f f e c t i v e e x i s t e n c e . 4 . That as a l l persons are not created equal, the community must provide equal opportunity through medium of the s o c i a l s e r v i c e s t o compensate f o r t h i s variance of s t a t u s . ! The same w r i t e r , W i l l i a m Hooson, n o t e s , however, that i t would seem to be t r u e that r e h a b i l i t a t i o n i n the p u b l i c a s s i s t a n c e s e t t i n g can only be a f f e c t i v e and as f a r -s i g h t e d as the personnel who are employed t o do the work. 2 *F.P* Kahn, M.S., responding w i t h h i s observations noted on the t w e n t i e t h anniversary o f the passing of the S o c i a l S e c u r i t y Aet, U n i t e d States of America, s t a t e s t h a t : ...there are many I n d i v i d u a l s , I n c l u d i n g members of S o c i a l Welfare Departments* who f i n d i t neces-sary to b e l i e v e that people are I n need because of t h e i r own personal f a i l u r e , . and who f i n d i t d i s t u r b i n g to have someone p o i n t out that need I s u s u a l l y created by f a i l u r e s of S o c i e t y and of the economic system, and that S o c i e t y has a r e s -p o n s i b i l i t y to provide decently f o r c a s u a l t i e s . 3 The w r i t e r concludes that " a s s i s t a n c e should provide I n a manner that preserves an i n d i v i d u a l ' s d i g n i t y , f o s t e r s h i s s t r e n g t h s , and p l a c e s upon him the r e s p o n s i b i l i t y f o r the c o n t r o l of h i s a f f a i r s . " ^ 1 Hooson, W i l l i a m , "The R e h a b i l i t a t i o n of the P u b l i c A s s i s t a n t R e c i p i e n t s , " P a r t s I and I I , Master o f S o c i a l Work Th e s i s , U n i v e r s i t y of B r i t i s h Columbia, Vancouver, B.C., 1952, p. 99. 2 J&Mi» P* 100. 3 Kahn, J.P., " A t t i t u d e s Toward R e c i p i e n t s of P u b l i c A s s i s t a n c e . " S o c i a l Casework. XXXVI, No. 8 October, 1955. ^ Loc. c i t . - Ik* Post Discharge Problems of Mental P a t i e n t s The Grease C l i n l e o f P s y c h o l o g i c a l Medicine, opened at Basondale, B r i t i s h Columbia, on January 1 s t , 1951» was designed and equipped to serve as a d i a g n o s t i c and treatment centre f o r the e a r l y cases of mental i l l n e s s j p r i m a r i l y e a r l y psychosis and psyehoneuroses. By s t a t u t o r y p r o v i s i o n * the duration of a p a t i e n t ' s treatment p e r i o d i s l i m i t e d to f o u r calendar months* I t was hoped that admissions would i n c l u d e only those p a t i e n t s who Were considered to have a reasonable prospect of recovery to be discharged w i t h i n the fo u r month period* A p a t i e n t may be admitted to the Crease C l i n i c e i t h e r by v o l u n t a r y a p p l i c a t i o n o r by c e r t i f i c a t i o n of two medical p r a c t i t i o n e r s . Any p a t i e n t who l o s e s c o n t r o l o f h i s a f f a i r s i s deeraed u n f i t by h i s p h y s i c i a n t o c a r r y out t h i s f u n c t i o n . I n such a case the Inspector of Municipal-^ I t l e s i s n o t i f i e d and a c t a as " O f f i c i a l Committee." Some c h a r a c t e r i s t i c problems i n r e h a b i l i t a t i o n from the Grease C l i n i c are r e l a t e d to the short-term nature of h o s p i t a l -i z a t i o n and because v o l u n t a r y admission can be terminated w i t h i n f i v e days' n o t i c e g i v e n by the p a t i e n t . Mention has already been made that the average l e n g t h o f stay i s gen-e r a l l y of two months d u r a t i o n . I t i s the experience o f the S o c i a l S e r v i c e Depart-ment s o c i a l workers t h a t many p a t i e n t s do not have f a m i l y , f r i e n d s or f i n a n c i a l resources a v a i l a b l e when they leave the c l i n i c j or t h e i r f a i a i l y and f r i e n d s are d i s i n t e r e s t e d or h o s t i l e and r e s e n t f u l toward them, and w i l l , t h e r e f o r e , be u n w i l l i n g to a i d i n the r e h a b i l i t a t i o n process. These p a t i e n t s r e q u i r e e i t h e r i n t e n s i v e or extensive h e l p and support from the c l i n i c i n becoming s e c u r e l y e s t a b l i s h e d In an emotionally h e a l t h y environment. There are many b a s i c s o c i a l and p s y c h o l o g i c a l dependency needs which must be met before these p a t i e n t s are r e - e s t a b l i s h e d i n the communitys money, food, c l o t h i n g * s h e l t e r , employment and a meaningful r e l a t i o n s h i p t i l t h some* one who w i l l understand t h e i r deep b a s i c needs. The r e t u r n t o the community f o r a person who has been h o s p i t a l i z e d f o r a mental d i s o r d e r i s o f t e n a t h r e a t e n i n g experience. To l a c k adequate resources i n f i n a n c e s , home, r e l a t i v e s o r i n t e r e s t e d f r i e n d s Increases the p a t i e n t ' s f e e l i n g o f a n x i e t y , and i n s e c u r i t y . The p o s s i b i l i t y o f a r e l a p s e and r e t u r n to h o s p i t a l becomes very r e e l . There are p a t i e n t s who leave the c l i n i c w i t h a residuum of th© mental d i s o r d e r which l e d to t h e i r h o s p i t a l i z a t i o n . The i n n e r p s y c h o l o g i c a l problems of these p a t i e n t s may be of such s e v e r i t y t h a t they cannot be r e s o l v e d by knoim methods of p s y c h i a t r i c therapy. The s t r e s s e s of these p a t i e n t s can be eased, although o f t e n not r e s o l v e d , i n making an adjustment to l i f e , by manipulation o f t h e i r environment to h e l p them f e e l more comfortable i n t h e i r adaptation and by the warm support* encouragement, and - 16 a c t i v e I n t e r e s t of a s o c i a l worker* The discharged mental p a t i e n t who I s inwardly weakened or handicapped i n h i e a b i l i t y t o meet the e x i g e n c i e s of h i s s i t u a t i o n , needs and l o o k s f o r h e l p i n meeting the i n n e r arid outer s t r e s s e s i n v o l v e d i n m a i n t a i n i n g h i m s e l f , as i n s e c u r i n g accommod-a t i o n , and o b t a i n i n g f i n a n c i a l a s s i s t a n c e u n t i l he can become s e l f - s u p p o r t i n g and able t o f u n c t i o n Independently i n our complex s o c i e t y . I t would be r e a s s u r i n g t o many of these p a t i e n t s i f t he coramunlty* f o r example, could provide a period o f s h e l t e r e d accommodation, s h e l t e r e d work t r a i n i n g and p l a c e -ment, or adequate f i n a n c i a l s u b s i d i s a t i o n i n maintenance* w h i l e they ar© being helped toward r e h a b i l i t a t i o n . T h i s need not be permanent. I t i s merely a humane r e h a b i l i t a t i v e step toward p r o d u c t i v i t y , s o c i a l usefulness and personal s a t i s f a c t i o n . S o c i a l A s s i s t a n c e and These Considerations P a t i e n t s r e f e r r e d to a p u b l i c a s s i s t a n c e agency to be e l i g i b l e , must be without means of f i n a n c i a l support. The very nature o f t h i s requirement may h i n d e r the p a t i e n t ' s r e h a b i l i t a t i v e chances. P o o r l y administered welfare s e r -v i c e s may a l s o c o n t r i b u t e to a remission of h i s c o n d i t i o n . To r e c e i v e a s s i s t a n c e i n B r i t i s h Columbia, an i n d i v i d u a l must f u l f i l l the c o n d i t i o n s o f the 1936 '•Residence and Res-p o n s i b i l i t y A c t , " which i n the case of p a t i e n t s t o be discharged from the Grease C l i n i c must be determined by - 17 th© s o c i a l workers i n t h e i r pre-discharge assessment. For c h r o n i c a l l y i l l p a t i e n t s who are hot r e s i d e n t s of B r i t i s h Columbia, plans f o r t h e i r r e p a t r i a t i o n t o t h e i r former provinces are entered i n t o before discharge becomes an i s s u e . The passage of the S o c i a l A s s i s t a n c e Act i n 1946 made l e g a l p r o v i s i o n f o r t h e i ...granting of a i d to the i n d i v i d u a l whether a d u l t o r minor or to f a m i l i e s who through mental or p h y s i c a l i l l n e s s or other exigency are unable to provide i n whole o r i n p a r t by t h e i r e f f o r t s , through other s e c u r i t y measures or from income and other resources, n e c e s s i t i e s e s s e n t i a l to maintain o r a s s i s t i n main-t a i n i n g a reasonable normal and h e a l t h y standard.! The concept, a reasonable normal and h e a l t h y standard, i s u n f o r t u n a t e l y dependent upon th© un p r e d i c t a b l e f l u x e s In the standard o f l i v i n g . I t has been s a i d t h a t p u b l i c a s s i s t a n c e r e l i e v e s immediate s t r e s s e s of i n d i v i d u a l f i n -a n c i a l need, of i n d i v i d u a l housing arrangements, and o f p h y s i c a l s t r e s s e s , a l l of which aggravate an i n d i v i d u a l ' s sense of p s y c h o l o g i c a l w e l l - b e i n g . The present study questions whether the s e r v i c e s provided b y the C i t y S o c i a l S e r v i c e Department are extended beyond the above frame of reference to provide treatment s e r v i c e s to a s s i s t the i n d i v i d u a l i n h i s p s y c h o l o g i c a l adjustment. Method and Approach of t h i s Study * The study i s an outgrowth of a s e r i e s of theses w r i t t e n about the S o c i a l S e r v i c e s provided w i t h the P r o v i n c i a l Hooson, op., c i t . , . p. 1 1 . - 18 -Mental Health S e r v i c e s . B i r c h s t u d i e d The V i s t a , as a resource i n r e h a b i l i t a t i o n . Pepper^ studied s o c i a l work p a r t i c i p a t i o n i n the treatment of the mentally i l l . Suther-land^" discussed r e h a b i l i t a t i o n s e r v i c e s f o r the mentally i l l * and S c h l e s i n g e r ^ c l a s s i f i e d the s o c i a l s e r v i c e s provided to p a t i e n t s , and/or t h e i r r e l a t i v e s . The present study w i l l examine the p a r t i c u l a r prob-lems presented i n f i n a n c i a l need, accommodation employment, and f a m i l y d i f f i c u l t i e s of a group of discharged mental p a t i e n t s r e f e r r e d to a p u b l i c a s s i s t a n c e agency because of f i n a n c i a l need. The study w i l l examine the cases of the r e f e r r e d p a t i e n t s t o assess whether p u b l i c a s s i s t a n c e s e r -v i c e s are adequate t o e f f e c t c o n t i n u i n g improvement i n th© ps y c h o l o g i c a l adjustment i n the c l i n i c a l sense of a d i s -charged mental p a t i e n t . 1 B i r c h , Sophie, "An A i d i n the R e h a b i l i t a t i o n of Mental H o s p i t a l P a t i e n t s , Master of S o c i a l Work The s i s . U n i v e r s i t y of B r i t i s h Columbia, Vancouver, B.C., 1953. " p The V i s t a i s an a u x i l i a r y s e r v i c e of the P r o v i n c i a l Men-t a l H o s p i t a l and the Crease C l i n i c and was o r i g i n a t e d to meet the need of p a r t i c u l a r women p a t i e n t s who are ready to leave h o s p i t a l , but who have no resources of f a m i l y , f r i e n d s and fi n a n c e s to see them through the i n i t i a l p e r i o d w h i l e o b t a i n -employment and accommodation. 3 Pepper, Gerald W . , " S o c i a l Work P a r t i c i p a t i o n i n the Treat-ment of the M e n t a l l y 111," Master of S o c i a l Work Thesis. U n i v e r s i t y of B r i t i s h Columbia, Vancouver, B.C., 1903. ^ Sutherland, Murray Robert, "The R e h a b i l i t a t i o n of D i s * charged Mental P a t i e n t s , " Master of S o e 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, Vancouver, B.C., 1951}.. ^ S c h l e s i n g e r , E r n e s t , " S o c i a l Casework I n the Mental Hos-p i t a l , " Master of S o c i a l Work The s i s . U n i v e r s i t y o f B r i t i s h Columbia, Vancouver, B.C.,19014.. * • 19 -Th© cases Here selected in accordance with the following c r i t e r i a : a) A l l cases referred to the City Social Service Department between January 1st, 195*4 and December 3ist, 19$kf for financial aid. b) Gases referred for Nursing Home placement ar© not included in the study. 1 Schedules were used to obtain data from the pat* lent*a f i l e s . Other data were obtained through personal communication with the administration of the Social Service Department of the Crease C l i n i c t issondale, B r i t i s h Columbia, and from the administration of the City Social Service Department, Vancouver, British Columbia. To obtain cl a r i t y and to present the focus of the problems as seen by the two agencies, the cases numbered 1 to 1|> w i l l f i r s t be presented in Chapter 2 with the data obtained from the psychiatric hospital. In Chapter 3 the same cases w i l l be presented with data obtained from the f i l e s of the Assistance Agency* The observations at the end of the presentation of each ease are the personal opin-ions of the writer of this study. Chapter 4 w i l l discuss the implications of certain of the findings and w i l l make suggestions to provide better coordination of services between the two agencies for the discharged mental patient. The suggestion that the City Social Service Department ' " i " '' "L "" IJI" "" " 11 L'"'' 1 1 ' " 11 " • "" See Appendices A and B. • 2 0 -consider p r o v i d i n g comprehensive casework s e r v i c e s beyond f i n a n c i a l a i d to s p e c i a l l y screened and s e l e c t e d c l i e n t s , p a r t i c u l a r l y f a m i l i e s and c l i e n t s where r e h a b i l i t a t i o n i s p o s s i b l e , i s considered as a pre v e n t a t i v e measure, and i s i n accordance w i t h suggestions presented by the Report on An Ad m i n i s t r a t i v e Survey of the C i t y of Vancouver. The study has concluded w i t h a suggestion f o r a f u r t h e r research study at the C i t y S o c i a l Service Department* "Report on An A d m i n i s t r a t i v e Survey of the M u n i c i p a l Government, C i t y of Vancouver, P u b l i c A d m i n i s t r a t i o n  S e r v i c e . Chicago, 1 9 5 5 * pp* 1 1 2 - 1 2 1 * CHAPTER 2. PSYGBIATli 0 A I D SOCIAL WORK CONSIDERATIONS III TEE FIFTEEN CASES STUDIED I n t r o d u c t i o n I n order to give adequate c o n s i d e r a t i o n to tooth the p s y c h i a t r i c and s o c i a l work f a c t o r s i n the c o n d i t i o n of p a t i e n t s discharged from a p s y c h i a t r i c h o s p i t a l t o the l o c a l cosaaanity, i t I s necessary i n t h i s chapter to give b r i e f c o n s i d e r a t i o n to the f o l l o w i n g pointss 1. S o c i a l Casework Aspects. 2. P s y c h i a t r i c c l a s s i f i c a t i o n s whieh i n f l u e n c e the c u r r e n t p r a c t i c e o f s o c i a l work i n th© p s y c h i a t r i c hos-p i t a l : , 3. P e r t i n e n t r e g u l a t i o n s governing the admission and treatment of p a t i e n t s i n the l o c a l p s y c h i a t r i c h o s p i t a l . 4. P o l i c i e s of the S o c i a l S e r v i c e Department i n the p s y c h i a t r i c h o s p i t a l , w i t h reference to r e f e r r a l p o l i c i e s . 0. A count of the d i s o r d e r s , l e n g t h of stay and th© s o c i a l adjustment problems of the p a t i e n t s who are studied I n t h i s t h e s i s . 6. Conclusions. S o c i a l Casework Considerations S o c i a l casework i s a -systematic process of s o e i a l study, s o c i a l diagnosis' and s o c i a l treatment. The process - 22 embodied three b a s i c p r i n c i p l e s , which are inherent i n s o e i a l casework p r a c t i c e . As s t a t e d by Mary J , McCormick, they are t h a t : ,..human p e r s o n a l i t y i s capable of m o d i f i c a t i o n and change which can be self-determined and s e l f - d i r e c t e d ; the p r o f e s s i o n a l nature o f the client-caseworker r e l a t i o n s h i p i s the primary medium of g i v i n g h e l p ; the c l i e n t ' s present must be observed I n r e l a t i o n to the past out o f which i t s p r i n g s , and the f u t u r e toward which i t s t r i v e s , I S o c i a l study seeks t o understand what causes and s t r e s s e s are r e s p o n s i b l e f o r the problem, but a l s o i n c l u d e s the assessment of whatever p o s i t i v e resources, e x t e r n a l and i n t e r n a l , p s y c h o l o g i c a l and p h y s i c a l are a t the c l i e n t ' s d i s p o s a l . Thus the procedure of h e l p i n g a person i s p o s i t i v e , f o r the productive use of the c l i e n t ' s own i n n e r and outer resources I s the p i v o t through which the h e l p i n g process evolves . The d e f i n i t i o n of s o c i a l casework as sta t e d by Mary J . McCormick t r a c e s t h i s concept. The e n t i r e process i s d i r e c t e d toward the human person, and i s c a r r i e d on f o r the purpose of g i v i n g s e r v i c e t h a t c o n t r i b u t e s t o the w e l l being o f t h a t p e r s o n . . T h e character of the s e r -v i c e I t s e l f may vary according to the c a p a c i t i e s and l i m i t a t i o n s o f the p a r t i c u l a r I n d i v i d u a l f o r whom i t i s intended. This means t h a t a t a l l times i t w i l l embrace the attempt to develop whatever personal resources such an i n d i v i d u a l possesses f o r meeting and s o l v i n g h i s own problem. At other times, s e r v i c e w i l l be d i r e c t e d toward augmenting those personal resources through the use of McCormick, Mary J , , "The Old and New i n Casework, S o c i a l Casework. V o l . XXXV, No. 1 0 , December, 1951+. - 23 f a c i l i t i e s which e x i s t w i t h i n the s o c i a l order. I n e i t h e r event, the aim of casework i s always the same, that i s , to preserve human d i g n i t y through meeting human needs.1 I n f i n d i n g h i m s e l f at the centre of many psycho-s o c i a l s t r e s s e s , the c l i e n t may be unaware of aspects i n h i s p e r s o n a l i t y which i m p a i r h i s f u n c t i o n i n g . I f h i s ego i s strong and supported by w e l l s t r u c t u r e d defense mechanisms, he w i l l be able to meet h i s problem w i t h p o s i t i v e resources* On the other hand a weak ego, and c r i p p l i n g defense mechanisms w i l l add to h i s s t r e s s e s . I n c o n s i d e r i n g a p s y c h o s o c i a l d i a g n o s i s , the caseworker must c l e a r l y understand the p e r s o n a l i t y s t r u c -t u r e of the c l i e n t , and what p s y c h o l o g i c a l f a c t o r s and defense laechanlsms are i n v o l v e d . Th© c l i e n t ' s w i l l i n g n e s s and a b i l i t y t o use h e l p w i l l a l s o i n f l u e n c e the d i a g n o s i s . A l b e i t a c l i e n t may express w i l l i n g n e s s to use h e l p , the extent o f the damage to h i s p e r s o n a l i t y and f u n c t i o n i n g a b i l i t y may s e r -i o u s l y impede th© treatment o f h i s adjustment. I n i t i a l d i a g -n o s t i c Impressions are reshaped and r e v i s e d i n the c o n t i n u i n g treatment proeees, which i t s e l f ls> i n t u r n , continuously adapted t o the t e c h n i c a l knowledge gained about the c l i e n t as 2 t h i s knowledge grows sharper and more define d . Sound study of th© problem and d e a r d i a g n o s i s l a , however, e n t i r e l y dependent upon a d i s c i p l i n e d use o f the p r o f e s s i o n a l i n t e r p e r s o n a l 1 McCormlck, Mary j ' . . . Thomlstlc Philosophy i n S o c i a l Oasework. Golumbia U n i v e r s i t y Press, Hew York, 1947, p. 3. 2 Somberg, Robert M., and Le Vinson, Frances T., Diagnosis  and Process I n Family C o u n s e l l i n g . Family S e r v i c e A s s o c i a t i o n of America, Hew York, U.Y., 1951, p. 33. - 24• -r e l a t i o n s h i p . The casework r e l a t i o n s h i p i s the dynamic i n t e r -a c t i o n of f e e l i n g s and a t t i t u d e s between the caseworker and th© c l i e n t , w i t h the purpose of h e l p i n g the c l i e n t achieve a b e t t e r adjustment between h i m s e l f and h i s environment.! This unique " r e l a t i o n s h i p " i s the breath and essence o f case-work f o r i t I s a l i v i n g process w i t h a s p e c i f i c purpose, that o f enabling a human being meet a problem which has created d i f f i c u l t i e s f o r him. " R e l a t i o n s h i p " takes l i f e from the I n t e r n a l i n t e r a c t i o n of the back and f o r t h movement of the a t t i t u d e s and f e e l i n g s which flow between the c l i e n t and the p r o f e s s i o n a l worker. In times of s t r e s s every human being wants the h e l p and support t h a t another human being can g i v e . T h i s n a t u r a l d e s i r e f o r a s s o c i a t i o n i n times of t r o u b l e leads t o a p e c u l i a r form of r e l a t i o n s h i p which case-workers see as a medium through which a person i s enabled t o f i n d new ways of l o o k i n g a t h i s problem and o f ha n d l i n g h i m s e l f . This r e l a t i o n s h i p as i t develops w i t h i n the easework s e t t i n g , i s d i f f i c u l t t o d e s c r i b e , and the s p e c i f i c f a c t o r s t h a t d i s t i n g u i s h I t from other human a s s o c i a t i o n s are not e a s i l y i s o -l a t e d . However, according to Hamilton, the handling of I t I s what c h a r a c t e r i s t i c a l l y g i v e s the p r o f e s s i o n a l q u a l i t y to any s o c i a l service,2 The t r a n s l a t i o n of diagnosis Into a working oper-a t i o n a l f o r c e — t r e a t m e n t , takes place i n t h i s working r e l a t i o n s h i p . The treatment r e l a t i o n s h i p I t s e l f i s the v i t a l I n t e g r a t i v e f a c t o r f o r the elements of d i a g -n o s i s , and f o r the union of diagnosis and treatment.3 1 B i e s t e k , F e l i x P . * "An A n a l y s i s o f the Casework R e l a t i o n -s h i p , " S o c i a l Casework. V o l . XXXV, Ho. 2* February, 1954-2 McCormick, Mary J . . B j a ^ o e t i c Casework I n the Thomistic  Patte r n * Columbia u n i v e r s i t y Press"," Hew" I t S , " 1 9 5 ^" p,1Q1.'""'' 3 Romberg, O P . alt.-,- p. 4 5 . - 25 * S o c i a l Workers concentrate on the r e l a t i o n s h i p and make use of the c l i e n t ' s s t r e n g t h , tout they never ignore the pathology which the i n d i v i d u a l presents. Human needs may be met from the many resources provided by the s o c i a l order. The p s y c h i a t r i c h o s p i t a l i s a p a r t i c u l a r type of agency provided t o give care to the men-t a l l y i l l . To the caseworker i a t h i s s e t t i n g , the present i n g problem i s the p a t i e n t ' s I l l n e s s , i n mental I l l n e s s , many b a s i c problems may u n d e r l i e the p r e s e n t i n g problem, and may be d e r i v e d from unconscious c o n f l i c t s w i t h i n the I n d i v i d u a l * While the caseworker i s aware of t h i s process, i t i s not w i t h i n the competence of casework to d e a l w i t h i t . The caseworker I s concerned w i t h the conscious r e a l i t y problems which confront the p a t i e n t i n h i s day t o day l i v i n g , and which may be of t a n g i b l e or i n t a n g i b l e q u a l i t y . Casework treatment may o f f e r t a n g i b l e s e r v i c e s through agency or com-munity resources. I n u s i n g these resources, the c l i e n t may a l s o be helped t o face h i s conscious ©motional c o n f l i c t , and be enabled t o achieve a more s a t i s f y i n g adjustment. Having presented a b r i e f d e s c r i p t i o n of the dynamics of casework p r a c t i c e , i t I s i n order t o move to di s c u s s the purpose of th© present chapter, which I s to examine the p s y c h o s o c i a l problems which u n d e r l i e and are r e l a t e d t o th© problems of mental i l l n e s s , and the s o c i a l s e r v i c e s provided f o r them d u r i n g t h e i r treatment In th© Crease C l i n i c , and through r e f e r r a l t o the C i t y S o c i a l <•> 26 Service Department. I t i s f i r s t necessary t o o f f e r com-ments about p s y c h i a t r i c c l a s s i f i c a t i o n s w i t h i n which the framework of treatment i n a l l aspects i s o f f e r e d to p a t i e n t s i n p s y c h i a t r i c h o s p i t a l s * and to mention b r i e f l y the f u n c t i o n o f the Crease C l i n i c . P s y c h i a t r i c . , C l a s s i f i c a t i o n s which Influence Treatment Diagn o s t i c c l a s s i f i c a t i o n according t© the B r i t i s h Columbia Mental H e a l t h S e r v i c e s Annual Report, l i s t s f o r t y -two c a t e g o r i e s w i t h psychosis under f o u r d e f i n i t i o n s , and f o r t y c a t e g o r i e s without psychosis under f o u r d e f i n i t i o n s . Henderson and G i l l e s p i e , quoting the American c l a s s i f i c a t i o n , l i s t seventy-two c l a s s i f i c a t i o n s of mental i l l n e s s w i t h psychosis under eleven d e f i n i t i o n s , and eighteen c l a s s i f i c a t i o n s without psychosis under two d e f i n i t i o n s , 1 The B r i t i s h c l a s s i f i c a t i o n i s c o n s i d e r a b l y s m a l l e r . I n the c l a s s i f i c a t i o n or naming of mental i l l n e s s , S t r e c k e r notes t h a t " p s y c h i a t r y s t r i v e s to c l a s s i f y diseases and d i s o r d e r s o f the i n v i s i b l e mind and p e r s o n a l i t y f u n c t i o n i n g . " ^ This o b v i o u s l y presents one of the most complex and I n t r i c a t e tasks t o p s y c h i a t r y . Yet as St r e c k e r p o i n t s out p s y c h i a t r i c c l a s s i f i c a t i o n does not always adequately describe a given mental i l l n e s s . I t i s not w i t h i n the competence of s o c i a l work to d i s c u s s the frame of reference of a p s y c h i a t r i c 1 Henderson and G i l l e s p i e , A Text Book of P s y c h i a t r y . Oxford u n i v e r s i t y Press, London, 1 9 5 1 . p* 2 2 . S t r e c k e r , Idward A., B a s i c P s y c h i a t r y . Random House, Hew York, 1 9 5 2 , p. 3. - 27 -d i a g n o s i s , o r to r a i s e questions about p s y c h i a t r i c c l a s s i -f i c a t i o n s , except t o note t h a t the gamut of human problems, the r e s u l t of i n n e r and outer s t r e s s e s * which o f t e n r e s u l t i n some form o f mental I l l n e s s * are o f t e n marked by nebulous and Indeterminate c h a r a c t e r i s t i c s . I t i s therefore not always p o s s i b l e t o impose upon these nebulous c h a r a c t e r i s t i c s some standardized c l a s s i f i c a t i o n . The r e h a b i l i t a t i o n o f a discharged mental p a t i e n t to the community i s the major r e s p o n s i b i l i t y of Idle s o e i a l worker. To achieve t h i s the worker must have knowledge about the complexity of the p r e c i p i t a t i n g problems of the i l l n e s s * r e s u l t i n g i n h o s p i t a l care, and must a l s o be aware of the p o i n t where the v a r i a t i o n o f the p s y c h o s o c i a l problem d i f f e r s from the c l a s s i f i c a t i o n of a p s y c h i a t r i c d i a g n o s i s . I t t h e r e f o r e f o l l o w s t h a t the p r e c i p i t a t i n g cause o f a r e f e r r a l to a mental i n s t i t u t i o n l e i n f l u e n c e d by many f a c t o r s which cannot be contained i n any one c l i n i c a l g e n e r a l i z a t i o n . The F unction of the Team at the Crease C l i n i c The f u n c t i o n of the team a t the Crease C l i n i c i s to provide treatment and care to those i n d i v i d u a l s who s u f f e r from e a r l y mental I l l n e s s . Treatment and care of the mentally 111 i s the combined e f f o r t of a number of d i s c i p l i n e s , medicine, n u r s i n g , p s y c h i a t r y , psychology, education, theology, o c c u p a t i o n a l and r e c r e a t i o n a l therapy and s o c i a l work. According to s t a t u t o r y p r o v i s i o n the d u r a t i o n of a p a t i e n t ' s treatment p e r i o d I s l i m i t e d to - 28 -four months. In s p e c i a l situations the C l i n i c a l Director may extend treatment f o r a further period. Should the patient not respond to treatment within t h i s period, statutory provision permits c e r t i f i c a t i o n to the Provin-c i a l Mental Hospital i n accordance with the provisions of the Mental Hospitals A c t , 1 should r e l a t i v e s coneur. The S o c i a l Service Department a t the Crease C l i n i c The S o c i a l Service Department at the time of the study was s t a f f e d by seven s o c i a l workers, three serv-ing In the admission and b r i e f service section, and four i n the continuing section. Owing to l i m i t e d s t a f f available no section deals primarily with h a b i t a t i o n . Schlesinger^ has described the S p e c i f i c services which the caseworker provides to the patient and his family. His d e f i n i t i o n s of (i) d i r e c t services to patients; ( i i ) d i r e c t services to patients* r e l a t i v e s ; and ( i i i ) i n d i r e c t services to patients and t h e i r r e l a t i v e s , have been accepted by the Grease C l i n i c S o c i a l Service Department as an adequate d e f i n i t i o n of the services given. In 1954* 60% of the patients admitted were assessed and were given b r i e f casework or s o c i a l service help; some \±0% of the patients admitted were screened Into the continuing section f o r more intensive casework help. 1 Revised States of B r i t i s h Columbia, Chapter 20?. 2 Schlesinger, Ernest, " S o c i a l Casework i n the Mental Hospital," Master of Social Work Thesis. University of B r i t i s h Columbia, Vancouver, B.C., 1953. — 29 — The c r i t e r i a f o r s e l e c t i o n of t h i s U.0 per cent were; 1. A l l c h i l d r e n and adolescents. 2. Expectant mothers. 3. S i t u a t i o n s i n v o l v i n g the p r o t e c t i o n and care of c h i l d r e n . 4* Family s i t u a t i o n s i n which there were m a r i t a l d i f f i c u l t i e s . R e h a b i l i t a t i o n problems, i n c l u d i n g s i n g l e and unattached men and women, having no resources i n f a m i l y and f r i e n d s , or i n t e r e s t e d community agencies. Oases screened out f o r other than b r i e f s e r v i c e s of a l i a i s o n w i t h community resources are the f o l l o w -i n g cases: 1. P a t i e n t s w i t h whom community agencies were a c t i v e . l 2. Older p a t i e n t s w i t h organic i l l n e s s , or who were very p s y c h o t i c , whose s o e i a l and p s y c h i a t r i c problems were of l o n g standing. These p a t i e n t s were u s u a l l y a c t i v e w i t h community agencies. I n a l l these instances s e r v i c e of a l i a i s o n nature i s extended. In the cases of those not known to com-munity agencies, r e l a t i v e a , f r i e n d s , or the p a t i e n t h i m s e l f were seen and were r e f e r r e d to community resources. 3. Re-admissions to the C l i n i c where S o e i a l Service had been a c t i v e during previous adraisslon(s), and where the p a t i e n t had not responded to any degree to the s e r v i c e o f f e r e d , % . G r o s s l y p s y c h o t i c p a t i e n t s who are unable to respond to any known, o r a v a i l a b l e p s y e h i a t r i e t treatment.2 The p o l i c y o f o f f e r i n g s e r v i c e s to p a t i e n t s most l i k e l y t o p r o f i t from them has been adopted, but i n p r a c t i c e ! w I n these instances the agency knowing th a t t h e i r c l i e n t had entered h o s p i t a l would commuhieate w i t h the S o c i a l Ser-v i c e Department. A v a i l a b l e to these agencies Upon w r i t t e n request would be the r e p o r t of the Medical Superintendent regarding the i l l n e s s and treatment of t h e i r c l i e n t . A l s o a v a i l a b l e upon t h e i r request would be a conference during the treatment p e r i o d . Although t h i s p o l i c y has hot been w r i t t e n down, i t has been discussed between the a d m i n i s t r a t -ions o f the Crease C l i n i c S o c i a l S e r v i c e Department and the G i t y S o c i a l S e r v i c e Department."* Personal communication w i t h the P r o v i n c i a l Supervisor of P s y c h i a t r i c S o c i a l Work, Miss A.K. C a r r o l l . 2 Personal communication w i t h the P r o v i n c i a l Supervisor of P s y c h i a t r i c S o c i a l Work, Miss A.&. C a r r o l l . - 30 -such a p o l i c y i s o f t e n d i f f i c u l t t o f o l l o w . A c a r e f u l screening process may not always prove e f f e c t i v e . The f a c t o r o f urgency o r emergency i s o f t e n evident I n human problems, and cause considerable d i f f i c u l t y i n p r o v i d i n g s e r v i c e s to meet them. R e f e r r a l P o l i c i e s between Agencies Tb"~le r e l e v a n t here to mention r e f e r r a l p o l i c i e s between agencies g e n e r a l l y , f o r r e f e r r a l i s an e s s e n t i a l p a r t of casework p r a c t i c e . The ©volution of the p o l l e y of I n t e r a g e n c y r e f e r r a l i s p a r t of the h i s t o r i c a l process of s o c i a l work. The development of r e f e r r a l p o l i c i e s between agencies I s the outcome not o n l y of a d m i n i s t r a t i v e con-s u l t a t i o n , but a l s o incorporates the l i v e l y p a r t i c i p a t i o n of the s o c i a l work s t a f f through s t a f f development. Gordon Hamilton has s t a t e d that one o f the b a s i c concepts to be mastered by s o c i a l workers " I s that o f the generic aspects of v a r i o u s agency and i n s t i t u t i o n a l s e t t i n g s . " 1 Miss Hamilton continues t h a t the " d i v i s i o n of labour becomes pos« s i b l e o n l y when there I s a c l e a r sense of the t o t a l needs and the r e l a t e d p a r t s of the necessary s e r v i c e , w i t h each separate agency accepting r e s p o n s i b i l i t y f o r d i s t i n c t i v e l i n e of p r a c t i c e * ' I t i s n o t \ p o s s l b l e t o create a design f o r any permanent agency s t r u c t u r e i n a s h i f t i n g c u l t u r a l Scene. "Agency f u n c t i o n s must be a l t e r e d to meet the p r e s -1 Hamilton, Gordon, Theory and P r a c t i c e of S o c i a l Oase-work, Columbia U n i v e r s i t y P r e s s , Hew York, 1953* p. 115. 2 I b i d . . p. 11?. - 31 sure of new problems, new needs, new resources and new »1 t e c h n i c a l and s p e c i a l i z e d knowledge." S o c i a l problems are so complexed and s o c i a l treatment i s so v a r i e d that r i g i d p s y c h o s o c i a l c l a s s i f i c a t i o n s cannot be formed to con-t a i n the gamut o f human problems w i t h which s o c i a l casework p r a c t i c e I s confronted. Th© b a s i c s e r v i c e s and resources f o r s o e i a l work, however, must be conve n i e n t l y grouped and arranged f o r Hiaximum a v a i l a b i l i t y and b e n e f i t t o c l i e n t s . The u n i f y i n g p r i n c i p l e i s the c h a r a c t e r i s t i c p r o f e s s i o n a l process, not the good natured o r grudging cooperation of unselected department heads. The present r e f e r r a l p o l i c i e s between the Crease C l i n i c S o c i a l S e r v i c e Department, and the C i t y S o c i a l Ser-v i c e Department, r e f l e c t the p r i n c i p l e s and concepts men-tioned above. The a d m i n i s t r a t i o n of the Crease C l i n i c S o c i a l Service Department has s t r i v e n Constantly to a r r i v e at c l e a r l y formulated r e f e r r a l p o l i c i e s w i t h the community agencies. A manual of p o l i c y I s p r e s e n t l y i n the process of c o m p i l a t i o n and w i l l c o n t a i n p r i n c i p l e s of t h i s p o l i c y . With respect t o inter-agency p o l i c i e s between the C l i n i c S o c i a l S e r v i c e Department and the C i t y S o c i a l Service Department, since 1901 case conferences have been h e l d between th© two agencies, the purpose of which has 1 Hamilton, Theory and Practic© o f S o c l a l Casework, p.122. 2 Loc. c i t . been c l a r i f i c a t i o n of some of the c h a r a c t e r i s t i c s of mental i l l n e s s , and the s o c i a l problems i n v o l v e d i n r e f e r r a l s to the S o c i a l A s s i s t a n c e Agency. In 19f?3 C i t y S o c i a l S e r v i c e workers v i s i t e d the mental h e a l t h s e r v i c e s at the Woodlands sch o o l , the P r o v i n c i a l Mental H o s p i t a l , and the Crease C l i n i c . The o r i e n t a t i o n of those workers reviewed the par-pose and f u n c t i o n o f the C l i n i c , the s o c i a l s e r v i c e s a v a i l -able to p a t i e n t s and t h e i r r e l a t i v e s , and the kind of i l l -nesses which would determine e l i g i b i l i t y f o r admission to the C l i n i c . This d i s c u s s i o n of p o l i c y was discontinued w h i l e the D i r e c t o r of Welfare was away on e d u c a t i o n a l leave, and was not re«commenced again because of s t a f f shortages. However, most of the C i t y S o c i a l Service Department cases are screened out because Crease C l i n i c S o c i a l Service Department i s r e s p o n s i b l e f o r 80 per cent of a l l p a t i e n t s admitted, t h e r e f o r e s e r v i c e i s g i v e n where a p o s i t i v e r e s -ponse i s most l i k e l y . 1 The p a r t i c i p a t i o n o f the Crease C l i n i c S o c i a l Service s t a f f i n r e g u l a r s t a f f development programmes has a l s o c o n t r i b u t e d to c l a r i f i c a t i o n o f the r e f e r r a l p o l i c y . A d m i n i s t r a t i v e r e p r e s e n t a t i v e s from community agencies have attended Crease C l i n i c s t a f f meetings to d i s c u s s the p o l i c i e s o f t h e i r r e s p e c t i v e agencies. With the present p o l i c y , the Admissions S o c i a l Worker of the 1 Personal communication w i t h the P r o v i n c i a l Supervisor o f P s y c h i a t r i c S o e i a l Work, Miss A . l . C a r r o l l . - 33 -Crease C l i n i c , a f t e r d i a g n o s t i c screening o f the needs of the p a t i e n t , determines e l i g i b i l i t y f o r r e f e r r a l to the C i t y S o e i a l S e r v i c e Department. Th© c l i n i c a l assessment at Ward Rounds h e l d w i t h i n ten days to two weeks a f t e r admission i s designed to focus the treatment and r e h a b i l -i t a t i v e resources. During the past year the p a r t i c i p a t i o n o f the Intake Worker and the Supervisor has increased con-» s i d e r a b l y a t Ward Rounds. At any given Ward Rounds the r e h a b i l i t a t i o n plans may be discussed of any p a t i e n t i n the C l i n i c , r e g a r d l e s s of whether h i s o r her name i s on the l i s t o f p a t i e n t s scheduled f o r d i s c u s s i o n at the p a r t i c u l a r time. The doctors a l s o use t h i s medium to d i s c u s s plans and prob-lems inherent i n the r e h a b i l i t a t i o n of any p a t i e n t . I n pre-Ward Round and Ward Round screening the C l i n i c attempts to provide a long term s e r v i c e f o r those p a t i e n t s whose ps y c h o s o c i a l prognosis i s somewhat o p t i m i s t i c . The c r i t e r i a of s e l e c t i o n now places more emphasis upon the younger group o f p a t i e n t s , w i t h l e s s emphasis on the f i f t y and ovor age groups. Although t h i s may appear t o be d i s -c r i m i n a t i o n because o f age, the p o s s i b i l i t y of e f f e c t i n g any adequate r e h a b i l i t a t i o n p l a n f o r the o l d e r person w i t h a lo n g h i s t o r y of contact w i t h s o e i a l agencies i s l i m i t e d . 1 1 Personal coimaunleation w i t h the P r o v i n c i a l Super-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, Miss A. K. C a r r o l l . - 3k «• R e f e r r a l to the G i t y S o c i a l Service departments may provide a v i t a l step i n the " t o t a l push" procedure. The treatment r e s p o n s i b i l i t i e s of the S o c i a l worker w i l l l e a d him to seek to enable the p a t i e n t and h i s r e l a t i v e to accept r e f e r r a l to a p u b l i c a s s i s t a n c e agency. To f a c i l i -t a t e the r e f e r r a l or to c l a r i f y c e r t a i n aspects of the problem, a telephone d i s c u s s i o n between the C l i n i c and agency s o c i a l workers may take place as a f i r s t step. The completed r e f e r r a l i n w r i t i n g must co n t a i n the r e l e v a n t p s y c h o s o c i a l i n f o r m a t i o n , i n c l u d i n g a medical statement from the doctor w i t h a d e s c r i p t i o n of the medical symptoms, expected l e n g t h of h o s p i t a l i z a t i o n and prognosis, upon l e a v i n g the c l i n i c the r e f e r r e d p a t i e n t i s o f t e n given f i n a n c i a l a s s i s t a n c e which w i l l m a i n t a i n him u n t i l h i s c l a i m w i t h the s o c i a l a s s i s t a n c e agency i s e s t a b l i s h e d . C e r t a i n p a t i e n t s , whose sepa r a t i o n from the c l i n i c may produce f e a r and i n s e c u r i t y f o r them, are accompanied to the C i t y S o c i a l S e r v i c e Department, Post discharge c o n s u l t -a t i o n may a l s o be i n d i c a t e d , but I s not common procedure, except i n those cases where the p a t i e n t may show symptoms of r e g r e s s i o n . With t h i s d i s c u s s i o n we are now ready to examine the p s y c h i a t r i c d i s o r d e r s , the s o c i a l f a c t o r s , and the s o c i a l casework s e r v i c e s i n the cases of f i f t e e n p a t i e n t s who are s t u d i e d i n t h i s t h e s i s . The i n f o r m a t i o n used i n t h i s study has been taken from the p a t i e n t s ' f i l e I n accordance w i t h a schedule, which has provided the data - 3 5 -used In the short summary of the p s y c h o s o c i a l f a c t o r s i n the i l l n e s s ; the s o c i a l s e r v i c e s provided, and the casework techniques employed i n each of the f i f t e e n cases. The observations noted are those of the author of t h i s study. The cases are numbered 1 to 1.5. P r e s e n t a t i o n of the F i f t e e n Gases Studied Case 1. P s y c h i a t r i c Statements A v o l u n t a r y male p a t i e n t , who has s u f f e r e d from rheumatoid a r t h r i t i s made a s u i c i d a l attempt f o l l o w i n g depression. Discharged a t nineteen weeks, diagnosed, "Reactive Depression—Rheumatoid A r t h r i t i s * " Condition:"Improved." S o c i a l Work Statements This f i f t y - t h r e e year o l d s i n g l e l a b o u r e r , i r r e g u l a r l y employed, a p e r i o d i c a l c o h o l i c , had severed a l l connections w i t h h i s f a m i l y since the age o f f i f t e e n * He had b r i g h t normal i n t e l l i g e n c e , graduated from school w i t h grade e i g h t . I n d i v i d u a l s o c i a l problems were r e l a t e d t o h i s f i n a n c i a l s i t u a t i o n , unemployment insurance, employment, housing and a l c o h o l i c a d d i c t i o n . The p a t i e n t was r e f e r r e d t o S o c i a l S e r v i c e Department f i v e days before discharge. Attempts to f i n d employment f o r him by the R e h a b i l i t a t i o n O f f i c e r were u n s u c c e s s f u l . He was escorted to the C i t y S o c i a l S e r v i c e Department by a s o c i a l worker and given f i f t e e n d o l l a r s . The opportunity i n i n t e r v i e w s t o d i s c u s s h i s f e a r of dependency enabled him to face more r e a l i s t i -c a l l y h i s need to aceept h e l p . Casework Techniques Employed! a) F i v e face to face I n t e r v i e w s j b) p s y c h o l o g i c a l support enabled him t o accept r e f e r r a l t o a p u b l i c a s s i s t a n c e agency; c) environmental h e l p a l s o included two contacts w i t h the unemployment In s -urance Commission, two contacts w i t h the Vancouver Seneral O u t - P a t i e n t - A r t h r i t i s C l i n i c , the o b t a i n i n g of a medieal c e r t i f i c a t e s t a t i n g the p a t i e n t ' s uneraployabllity, i*Mch was forwarded t o the C i t y S o c i a l S e r v i c e Department w i t h the L e t t e r o f R e f e r r a l . Observations i P a t i e n t who was thought t o be severely maladjusted, although f r u s t r a t e d by h i s dependent c o n d i t i o n , was helped to aceept r e a l i s t i c a l l y h l 3 need f o r temporary r e l i e f and was supported to apply to the A s s i s -tance Agency. 36 Case 2. Psychiatric Statements A "voluntary" male patient suffered for fifteen years from functional pains and vomit-ing, described as anxious and tense* Discharged at seven and a half weeks, diagnosed, "Psychoneurosis with somatic symptoms—-Gastric neurosis. 6 Condition: "Improved." Social Work Statements This fifty-four year old painter, with a history of tuberculosis, was In reeelpt of social assistance prior to admission to the Crease Clinic. Patient stated that he had education to grade ten at the age of fourteen, but had "missed several grades because of poor eyesight." Patient was married In 1928* there were three children of the marriage, ages twenty-five, twenty*two, and a fifteen year old boy l i v i n g with patient's wife (from whom he had been legally separated since 1900). A long history of marital tensions* with separations and re-unions, resulted in exacerbation of patient's functional symptoms. Case was screened by social worker during the f i r s t week of admission. Individual social problems were related to his financial situation, employment, and a disturbed family situation. Upon dis-charge he was declared capable of f u l l time employment* Casework Techniques Employed: a) Communication by l e t t e r containing information of patient's illness and social condition was forwarded to the City Soeial Service Department. Observations: This is a case of a long involved marital Situation when for periods the "legal separation," was not observed by patient and his wife. During his stay in the Clinic, patient appears to have withdrawn himself from his family. The case was known to the Assistance Agency at the time of patient's admission to the Gllnic. Case 3. Psychiatric Statement: A "certifi e d " male patient, suffered from migraine headaches, and was depressed about his wife's pregnancies. For six months prior to admission he was reported to give evidence of paranoidal trends, believing people were talking about him. Discharged at seventeen weeks, diagnosed, wManIc*Depressive*Depressed." Condition: "Improved." Social Work Statements This forty-nine year old garage attendant was married with four small children, ages 4, 3* eighteen months, and one month. Patient was bom In Russia, had a very deprived childhood, with grade six education, and had been working since he was eleven. At the ag© of forty*four, patient married a woman twenty years his junior. With l i t t l e or no training he had been - 37 -s t e a d i l y employed. I n d i v i d u a l s o e i a l problems were r e l a t e d to the f i n a n c i a l and m a r i t a l s i t u a t i o n s . S o c i a l S e r v i c e recorded notes dated one week a f t e r h i s admission I n d i c a t e d t h a t p a t i e n t expressed f e e l i n g s o f personal Inadequacy, and was thought t o show i n a b i l i t y t o r e l a t e to people. Con-sequently no I n d i v i d u a l casework was extended t o him o r to h i s w i f e . P a t i e n t ' s w i f e was seen and the r e f e r r a l to the As s i s t a n c e Agency was discussed w i t h her.1 Casework Techniques Employed; a) Pace to face Interview w i t h p a t i e n t ' s w i f e (was not recorded on the f i l e ) ; b) Environmental h e l p through l e t t e r of r e f e r r a l to the As s i s t a n c e Agency. Observations t The in f o r m a t i o n i n d i c a t e s a deep f a m i l y d i s o r d e r . Both marriage partners experienced e a r l y d e p r i v a t i o n . This f a m i l y was not p r e v i o u s l y known to the As s i s t a n c e Agency, and although they were a l e r t e d about the s i t u a t i o n i n v o l v i n g the care o f f o u r young c h i l d r e n , an inter-agency c o n s u l t a t i o n would have been i n order. Case k. P s y c h i a t r i c .Statement i A "volu n t a r y " male p a t i e n t s u f f e r e d from severe asthmatic a t t a c k s , was s a i d to have d i f f i c u l t i e s i n h i s 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 . D i s -charged a t seventeen weeks, diagnosed " P a t h o l o g i c a l per* s o n a i i t y . " Conditions "Improved." S o c i a l Work Statements This f i f t y - o n e year o l d s i n g l e unemployed fishermen of average I n t e l l i g e n c e , ' and grade e i g h t education a t fourteen* could not adequately d i s c u s s h i s c o n d i t i o n w i t h a s o c i a l worker. He had no r e l a t i v e o r f r i e n d s , the r e s u l t o f gradual d e t e r i o r a t i o n i n h i s emotional c o n d i t i o n . H i s i n d i v i d u a l s o c i a l prob-lems were f i n a n c i a l , housing, and he was i n need o f l e i s u r e time a c t i v i t i e s . S o c i a l S e r v i c e a c t i v i t y was a t the f i f t e e n t h week of h o s p i t a l i z a t i o n , at the c o n c l u s i o n of a p e r i o d of psychotherapy. 2 1 The d i s c u s s i o n w i t h the p a t i e n t or h i s r e l a t i v e of the r e f e r r a l t o the A s s i s t a n c e Agency was not c l e a r from the recordings I n c e r t a i n cases. Personal communication w i t h the P r o v i n c i a l Supervisor of P s y c h i a t r i c S o c i a l Work* Miss A.K. C a r r o l l , I n d i c a t e s t h a t although i t i s not always S p e c i f i c a l l y recorded i n the f i l e * a l l p a t i e n t s who are r e f e r r e d t o a community agency are interviewed at l e a s t once, and the r e f e r r a l discussed w i t h them. 2 personal communication from the P r o v i n c i a l Supervisor of P s y c h i a t r i c S o c i a l Work, Miss A.K. C a r r o l l * T h i s i n f o r m a t i o n was not evident to th© w r i t e r of t h i s study. - 38 Casework Techniques Employed: a) C o n s u l t a t i o n w i t h the medical p r o f e s s i o n ; b ) R e f e r r a l t o the Assistance Agency and i n f o r m a t i o n t o the S o c i a l Service Department, Vancouver General H o s p i t a l . 1 Observations: T h i s p a t i e n t received psychotherapy and was not seen by a s o c i a l worker u n t i l t h i s was concluded when he was r e f e r r e d f o r h e l p through the Assistance Agency. d Case £. P s y c h i a t r i c Statement: A "voluntary" female p a t i e n t , s a i d to s u f f e r from insomnia, confusion, and to be worried about an "extremely d i f f i c u l t f i n a n c i a l s i t u a t i o n . , Discharged at seventeen weeks, diagnosed "Anxiety S t a t e . " C o n d i t i o n : "Improved." S o c i a l Work Statement: This f i f t y - s e v e n year o l d widow, having no c h i l d r e n or r e l a t i v e s , was considered to be a chronic medical and s o c i a l problem f o r the past twenty years. P a t i e n t has l i v e d on a f l o a t house most of her l i f e , and was w e l l known t o C i t y S o c i a l S ervice Department p r i o r t o her admission. Her i n d i v i d u a l s o c i a l problems were f i n a n c i a l and poor p h y s i c a l c o n d i t i o n . She was seen by a s o c i a l worker one day before discharge, to c l a r i f y w i t h her date of discharge and t r a n s p o r t a t i o n f a c i l i t i e s to Vancouver. P a t i e n t had a poor psy c h o s o c i a l prognosis, and was considered u n s u i t a b l e f o r admission to the Crease C l i n i c . Casework Techniques Employed: a) One face to face i n t e r v i e w ; b) Environmental help ( t r a n s p o r t a t i o n arrangements) and r e f e r r a l t o the As s i s t a n c e Agency. Case 6. P s y c h i a t r i c Statement: A " c e r t i f i e d " female pat-i e n t , described as confused, vague, and w i t h f a u l t y judgment. Discharged a t eighteen weeks, diagnosed " S e h i z o - A f f e c t i v e Psychosis." C o n d i t i o n : "Improved." S o c i a l Work Statement: A f o r t y year o l d medical s e c r e t a r y , whose record i n d i c a t e d deep psychosocial con-f l i c t . P a t i e n t who had grade eleven education and one year at u n i v e r s i t y , appeared to have been i n v o l v e d i n s e v e r a l i l l i c i t r e l a t i o n s h i p s , r e s u l t i n g i n the b i r t h of three i l l e g i t i m a t e c h i l d r e n , the o l d e s t aged eighteen. P a t i e n t was married d u r i n g the war at the age of twenty-eight and was divorced a f t e r three years, seeing her husband on few occasions. P a t i e n t had poor r e l a t i o n s h i p s w i t h her f a m i l y , being c l o s e s t to her f a t h e r who died of a b r a i n tumour when 1 Personal communication from the P r o v i n c i a l Supervisor of P s y c h i a t r i c S o c i a l Work, Miss A.K. C a r r o l l * This inform-a t i o n was not evident t o the w r i t e r of t h i s study. Loc. c i t * 39 -p a t i e n t was twenty»two. She q u a r r e l l e d f r e q u e n t l y w i t h her mother and b r o t h e r , a m i n i s t e r o f ' r e l i g i o n * who was cl o s e t o the'mother. ; •'Individual s o e i a l problems were,'..-.. • f i n a n c i a l , employment, housing, and'alcoholism* S o c i a l s e r v i c e became aetiv© at the t h i r d week of patient*© • h o s p i t a l i s a t i o n . . . •' Casework,..Techniques. -Jknl©yeds a) Face'to face-interyiewsnEo COTsTder^discharge"''' p l a n s . E x p l o r a t i o n of broth e r * s i n t e r e s t t o h e l p p a t i e n t * which* because of h i s own f a m i l y s i t u a t i o n , he was unable to g i v e j b) S o c i a l s e r v i c e r e p o r t t o Th© V i s t a and r e f e r r a l to C i t y S o c i a l S e r v i c e Department, who agreed t o g i v e f o l l o w up s e r v i o e s upon patient*© t r a n s f e r to The V i s t a . Observations. E a r l y screening i n t h i s case f©cussed 'd'SeMrge' planning e f f e c t i v e l y * '. P a t i e n t was' known to the A s s i s t a n c e Agency at th© time o f admission* . Case: 7. ' P s y c h i a t r i c " Statement:- A- " c e r t i f i e d " ' stale p a t i e n t S u f f e r i n g frofe asthma and m a l n u t r i t i o n , whose poor p h y s i c a l condition'wee :'thought' to contribute: to''Ms' mental: d e t e r i o r -a t i o n . Paranoid Ideas l e d to f i g h t s and p o l i c e I n t e r * vehtlon.. Biecha#g©^- a t eight'weeks* diagnosed, "Paranoid S t a t e . " C o n d i t i o n : "Improved*" .Social Work'..Statement:'' 'This f I f t y * e l g h t year ©Id s i n g l e labourer "©'f' P o l i i f a v o r i g i n * had' grade' s i x " education a t f o u r t e e n years. P a t i e n t had a f a i r l y good work re c o r d u n t i l three year©, before admission*: when he s u f f e r e d from asthmatic a t t a c k s * " He' was khown"-to the Aesiatanc©'Agency du r i n g t h i s p e r i o d * He had no known f a m i l y o r f r i e n d s and''had moved'from numerous boarding.'houses* because'hie • e r r a t i c behavior i n v o l v e d him I n f i g h t s w i t h other boarders* H i s i n d i v i d u a l s o c i a l problems were ' f i n a n c i a l , , .employment, and housing. ' Casework. Technlquofli a) Admission' screening-**:' b) Envlronmentai h e l p ( l e t t e r to the A s s i s t a n c e Agency)» ' Observations:•' This p a t i e n t was i n r e c e i p t of as-sistaaee when admitted t o the C l i n i c . The contact from the"'City l o c i a l " S e r v i c e 'Was through t h e i r ' m e d i c a l s e c t i o n t o a medical contact a t the Crease C l i n i c , "This patient'appears' to' be~-stiff©ring' 'from a chronic c o h d i t i o n which I n d i c a t e s long term care. Case: 6. P s v c h i a t r i e Statement. A " c e r t i f i e d " feuiale patieh't* was depressed about her husband1© Suic i d e three years p r i o r t o admission, and s a i d t o be " h a l l u c i n a t i n g . " Discharged a t nine weeks* diagnosed* "Paranoid S c h i z o * phrenla Chronic," Conditions "Improved.'* # ij.0 # S o c i a l Work Statements This s i x t y year o l d widow of F i n n i s h o r i g i n , attempted to support h e r s e l f as a mas-seuse since her husband 1s s u i c i d e three years p r i o r to her admission. P a t i e n t owned her own home, and was now i n c a p -able o f c o n t i n u i n g her own support. Her married daughter, age t h i r t y - f i v e , wanted p a t i e n t placed i n a n u r s i n g home. P a t i e n t was very upset by her daughter's a t t i t u d e , ahd was considered m e d i c a l l y to be capable of accepting responsib-i l i t y f o r her own care. Her i n d i v i d u a l s o c i a l problems were, f i n a n c i a l , housing, and f e a r t h a t the community would not accept a discharged mental p a t i e n t . Casework Techniques Employeds a) Face to face i n t e r v i e w s enabled p a t i e n t 'to accept ' r e f e r r a l to the C i t y S o c i a l S e r v i c e Department, and the f a c t t h a t s o e i a l a s s i s -tance would h e l p her remain i n her own home, appeared to modify her f e a r .of 'return to the community j b) L e t t e r o f r e f e r r a l to C i t y S o c i a l S e r v i c e Department* , " Observations.*' Casework helped t h i s p a t i e n t main-t a i n independence, and f a c i l i t a t e d her r e t u r n to the community.1 Case 9 . P s y c M a t r i c v S t a t e m e h t i A " c e r t i f i e d " female p a t i e n t , depressed, complained of many somatic complaints* Discharged a t s i x weeks, diagnosed " P a t h o l o g i c a l Person-a l i t y - A n t i S o c i a l ? Conditions "Improved*" S o c i a l Work Statements This fifty*?seven year o l d widow who es^erienced childhood d e p r i v a t i o n , and spent most of her e a r l y l i f e i n orphanages'. P a t i e n t had been most promiscuous, and had entered i n t o s e v e r a l common-law r e l a t i o n s h i p s . She was well-known to the A s s i s t a n c e Agency, and a t the time of her admission was i n r e c e i p t of a s s i s -tance* She had no known f a m i l y o r r e l a t i v e s , and had i r r e g u l a r employment as a domestic. Her I n d i v i d u a l s o e i a l problems were f i n a n c i a l , and housing* S o c i a l s e r v i c e became a c t i v e a t the t h i r d week of p a t i e n t ' s stay In h o s p i t a l . Casework Techniques Employeds a) Face to face i n t e r v i e w ; b) L e t t e r o f r e f e r r a l t o me A s s i s t a n c e Agency. Observations This I s a n o t h e r case of chronic p s y c h o l o g i c a l and s o c i a l problems where the p a t i e n t has 1 "This I l l u s t r a t e s the S e r v i c e given t o a p a t i e n t i n a c l a s s which o r d i n a r i l y would be screened out. I n t h i s instance the need f o r s u p e r v i s i o n , a place t o l i v e would n e c e s s i t a t e opening the ease f o r casework s e r v i c e s to the daughter and s e r v i c e s to the mother*" I b i d * - kx been known to the A s s i s t a n c e Agency f o r a long p e r i o d . Case 10. P s y c h i a t r i c Statement; A " c e r t i f i e d " male p a t i e n t admitted from O a k a l l a , where he was s a i d to be e x h i b i t i n g b i z a r r e behaviour. He was p o o r l y adjusted. Discharged at two weeks, diagnosed " P a t h o l o g i c a l P e r s o n a l i t y , A n t i - S o c i a l . " Conditions "Unimproved." S o c i a l Work Statement; T h i s t h i r t y - f o u r year o l d married p r i s o n e r was admitted from O a k a l l a , where he was s e r v i n g sentence f o r a s s a u l t i n g h i s w i f e . P a t i e n t who had a below average i n t e l l i g e n c e w i t h grade s i x education, had a poor work record as an u n s k i l l e d l a b o u r e r . He was married f o r t h i r t e e n years w i t h three c h i l d r e n , ages t h i r -teen, ten, and f i v e . P a t i e n t d i d not adjust w e l l to t r e a t -ment i n the C l i n i c . H i s i n d i v i d u a l s o c i a l problems were f i n a n c i a l , and m a r i t a l d i f f i c u l t i e s . Although the couple f r e q u e n t l y s t a t e d t h e i r I n t e n t i o n to separate permanently, they were ambivalent about t h i s . Casework Techniques Employed s Face to face i n t e r -view w i t h p a t i e n t * s.wife; b) Environmental ( r e f e r r a l to the A s s i s t a n c e Ageney and contact w i t h the J u v e n i l e and f a m i l y C o u r t ) . Observation; S o c i a l s e r v i c e c o n t a c t was upon the day o f p a t i e n t ' s d i s c h a r g e . Although a two page l e t t e r was forwarded t o the A s s i s t a n c e Agency and the p s y c h o - s o c i a l i m p l i c a t i o n s were w e l l focussed, the s i t u a t i o n i n t h i s f a m i l y d e t e r i o r a t e d r a p i d l y a f t e r the p a t i e n t ' s discharge from the Crease C l i n i c and the o l d e s t boy was i n need of p r o t e c t i o n from t h i s p a t i e n t . Although i t I s f u r t h e r noted th a t many s o c i a l agencies had been involved i n h e l p i n g t h i s f a m i l y p r i o r to the p a t i e n t ' s committal to Oakalla P r i s o n and h i s admission to the Crease C l i n i c , t h i s w r i t e r observes t h a t the r e s p o n s i b i l i t y f o r j o i n t agency planning i n t h i s . case, appears to have been missed by a l l agencies concerned* Case 11* P s y c h i a t r i c Statement? A "v o l u n t a r y " female p a t i e n t who made a s u i c i d a l attempt, and s a i d to have been promiscuous f o r some yea r s . Discharged at seven weeks, diagnosed, " P a t h o l o g i c a l P e r s o n a l i t y - Inadequate." Conditions "Unim-proved ." S o c i a l Work Statements This t h i r t y - o n e year o l d divorced woman',1'' who h a d n o "friends" or known r e l a t i v e s i n Vancouver, and was unable to give a permanent c i t y address. For c o n f i r m a t i o n of these obs e r v a t i o n s , please t u r n to the case p r e s e n t a t i o n i n Chapter 3* * 42 * P a t i e n t who had grade ten education had l i v e d mainly by p r o s t i t u t i o n . Her e i g h t year o l d c h i l d was placed f o r adoption s h o r t l y a f t e r b i r t h . P a t i e n t had made s e v e r a l f u t i l e s u i c i d a l attempts. S o c i a l s e r v i c e became a c t i v e at two weeks o f p a t i e n t ' s h o s p i t a l i z a t i o n . P a t i e n t ' s i n d i v i d u a l s o c i a l problems were, f i n a n c i a l , employment, and promiscuous behaviour. Casework Techniques Employeds a) B r i e f face to face i n t e r v i e w ; b) L e t t e r of r e f e r r a l to the As s i s t a n c e Agency. Observationss This p a t i e n t ' s long h i s t o r y of d i f -f i c u l t y prevents her use of p s y c h i a t r i c o r casework s e r -v i c e s . Case 12; P s y c h i a t r i c Statements A " c e r t i f i e d " female pat-l e n t , s u f f e r i n g from hypertension and g a s t r o - l h t e s t l n a l d isturbance, who was very h o s t i l e . Discharged at eight weeks. C o n d i t i o n : "Improved," S o c i a l Work Statements This f i f t y - n i n e year o l d widow, who was separated from her a l c o h o l i c husband, s i x -teen years p r i o r to 'his death. There were ho c h i l d r e n of the marriage. P a t i e n t had grade twelve education, but a very poor work record as a domestic h e l p e r . Three years p r i o r to h o s p i t a l i z a t i o n p a t i e n t was a r e s i d e n t i n a board-i n g home and i n r e c e i p t of s o e i a l a s s i s t a n c e . She f e l t that the tensions i n the boarding home c o n t r i b u t e d t o her i l l n e s s . S o e i a l , s e r v i c e became a c t i v e at two weeks of her h o s p i t a l i z a t i o n . Her improvement i n the c l i n i c was such as to suggest her t r a n s f e r to Th© V i s t a f o r r e h a b i l i t a t i o n . Her i n d i v i d u a l s o e i a l problems were f i n a n c i a l , employment, and housing. Casework Techniques Employeds a ) Face to face i n t e r v i e w s ; b) Environmental ( L e t t e r of r e f e r r a l to the As s i s t a n c e Agency). Observations: Casework was w e l l focussed toward r e h a b i l i t a t i o n p lanning, and c l a r i f i e d t h a t a worker from the C i t y Agency would g i v e follow-up s e r v i c e when p a t i e n t was t r a n s f e r r e d to The V i s t a . Case 13. P s y c h i a t r i c Statements A "voluntary" male p a t i e n t , s u f f e r e d from headaches, l o s s of weight and poor memory. Discharged a t eleven weeks, diagnosed "Depressive Reaction -Chronic B r a i n Syndrome." C o n d i t i o n : "Improved, prognosis guarded." 43 -S o c i a l Work Statement is This: f i f t y year o l d Single unemployed ' f i t t e r , . had 1 grade twelve education, at f i f t e e n . P a t i e n t had no f r i e n d s or r e l a t i v e s i n B r i t i s h / C o l u m b i a * .ie gave l i t t l e : i n f o r m a t i o n about'himself' beyond f a c t s about, his'-status a n d ' ' e l i g i b i l i t y f o r s o e i a l a s s i s t a n c e , " l e i n d i c a t e d an e a r l y unhappy f a m i l y l i f e and a l o n e l y ' e x i s -tence, l i s memory f a i l u r e • and' c l i n i c a l symptoms'indicate a. chronic b r a i n •syndrome•;' H i s I n d i v i d u a l s o e i a l problems were f i n a n c i a l , .and .housing. He was" seen by a s o e i a l worker at the t h i r d week of M s , h o s p i t a l i s a t i o n . -' Casework.Technlquee'...Sme^o^edt a) "Face'to face 'interviews7~b)'"j^tf©r'"'©f' r e f e r r i l ' to"'the A s s i s t a n c e Agency. ; Obsery^tion.s.t This patient'appears to Mvo* a l o n g h i s t o r y of'poor adjustment' and.poor p h y s i c a l c o n d i t i o n which would prevent h i s use. o f p s y c h i a t r i c , o r casework s e r -vices.. Case ,1a.. Psychiatric...StatementA " v o l u n t a r y " male p a t i e n t who' was' deserlbls'^^ had.' frequent 'crying s p e l l s about a' head i n j u r y . ' • He had been unable to" Work "•• because'of i l l n e s s . ' 'Discharged 'at three'weeks., diagnosed, "Reactive Depression." Condition? "Unimproved*" .Social^ Work'. Statements ' This • p a t i e n t i s a f o r t y year o l d married man with'"two c h i l d r e n , ages seven" and"', three,' He had been' i n ""receipt" of'" s o c i a l ' assistance' 'froia • tlme'to' time* I n d i v i d u a l " s o c i a l problems' were,, f i n a n c i a l , employment, and-a severe,, m a r i t a l disturbance* "Casework-.Technl<pe a)'"Face" to-face" interview}'""bj 'Letter"of r e f e r r a l " t o t h e A s s i s t a n c e Agency. "- Qbeer.^fitioiie-i This " p a t i e n t and h i s ' family'were known-to' the A s s i s t a n c e Agency prior-'to- h i s admission to tlie C l i n i c . " The writer*"observed that an"inter-agency ' conference would have more c l e a r l y f o c u e s e d the" d i f f i c u l t i e s i n ' t h i s severe m a r i t a l - s i t u a t i o n i n which the -case' ©f two ' •Small"children was involved.- 'As noted elsewhere i n 'this chapter* t h i s could have- been requested by the Ass i s t a n c e Agency. Case' Iff. P s y c h i a t r i c Statement.}.; A " ' " c e r t i f i e d " ' B i a l e ' p a t i e n t * who was SeieMB^© p ' "ai" 're aggressive f o r the past year. Discharged, at' twelve"weeks,, diagnosis,. "Schisophrenic Reaction," C o n d i t i o n * •"iiaproved.*" . 'S-'oelal Work ^ Statement s ' This married t h i r t y - o n e • year old'. qualif'ie^' ' 'plm|er^naS three children.* ages Seven-,, three and two years. P a t i e n t changed h i s jobs f r e q u e n t l y — 44 «• which, aggravated a'severe marital disturbance and affected the ease of three small children. In tfe4r;.adgdsaipn screen-ing i t was f e l t that patient and his wife were not amenable to casework. Later the ease was transferred to a continuing service worker when patient's wife was seen for four inter-views. Casework Techniques Employed: a) Casework inter-views with patient's wife; b) Phone c a l l to the Assistance Agency. Observations: Inter-agency consultation would have c l a r i f i e d aspects of this severe marital disturbance in which the case of three young children was involved; Conclusions and Findings The records of a group of fifteen patients have been examined with reference to personal and social stresses, diagnosed psychiatric classifications and soeial rehabilit-ation in terms of what was available in 1954 considering staff shortages and public resources. The findings noted in the studyof these cases are: Of the fifteen patients studied, 9 were male and 6 female. Their ages ranged from 5 patients between the ages of 31 to 4°J 2 patients between the age® of kl to 50 years; and 8 patients between the ages of 5 l to 60 years. Their marital status was; k were married, k were single and 7 were separated either by death or divorce. The k married patients had dependent families. 1. Psychiatric classifications: Reactive-Depression, 3 patients; Schizophrenic Reaction, 2 patients; Psycho-neurosis, 3 patients; Pathological Personality, k patients; - kS -Paranoid-Schizophrenia., 2 p a t i e n t s ; Manic-Depressive-Depressed* 1 patient„ 2. P r e c i p i t a t i n g ; Causes of Admission: The records of the p a t i e n t s show t h a t more than one c o n d i t i o n c o n t r i b u t e d to the cause of admission, Thus while a p a t i e n t may have attempted s u i c i d e , he may a l s o have been Upset and depressed because o f a d i s t u r b i n g p h y s i c a l c o n d i t i o n . Other p a t i e n t s may have shown evidence of depression, y e t have been in v o l v e d i n severe f a m i l y disturbances. C l a s s i f i c a t i o n of the most common v a r i a b l e revealed that Depression appeared to be the p r e c i p i t a t i n g cause i n the admission of 6 p a t i e n t s ; p h y s i c a l complaints which created p s y c h o l o g i c a l d i f f i c u l t i e s were noted i n the admission statement of $ p a t i e n t s ; s u i c i d a l attempt, I p a t i e n t ; p e r s o n a l i t y d i f f i c u l t i e s , 1 p a t i e n t ; confused behaviour, 1 p a t i e n t ; and b i z a r r e behaviour, 1 p a t i e n t . 3. Admission C l a s s i f i c a t i o n s : 8 p a t i e n t s were admitted by " c e r t i f i c a t i o n , " and 7 p a t i e n t s by "voluntary" admission, k' Length of Time i n H o s p i t a l : 2 p a t i e n t s were i n h o s p i t a l under $ weeks; 8 p a t i e n t s remained i n h o s p i t a l from 6 to 10 weeks; 2 p a t i e n t s stayed i n h o s p i t a l I I to l£ weeks; and 3 p a t i e n t s were i n h o s p i t a l 16 to 20 weeks. 5 . S o c i a l Service A c t i v i t y at the P o i n t of Time  i n H o s p i t a l : 12 p a t i e n t s received s o c i a l s e r v i c e under j? weeks of t h e i r h o s p i t a l i z a t i o n ; 1 p a t i e n t a t 6 to 10 weeks; 1 p a t i e n t at-.11 to 1$ weeks; and 1 p a t i e n t at 16 to 20 weeks. * 4 6 -6. I n d i v i d u a l S o c i a l Problems.; The 1$ p a t i e n t s a l l had f i n a n c i a l d i f f i c u l t i e s . S i x of the p a t i e n t s had, i n a d d i t i o n * employment problems. S i g h t p a t i e n t s were a l s o concerned w i t h housing d i f f i c u l t i e s . Seven p a t i e n t s a l s o had m a r i t a l and f a m i l y d i s o r d e r s . Two p a t i e n t s were a l s o con-cerned about a l c o h o l a d d i c t i o n * and one p a t i e n t had no f r i e n d s or r e l a t i v e s . Thus i t l a seen t h a t of the group one p a t i e n t o n l y was concerned p r i m a r i l y w i t h f i n a n c i a l d i f f i c u l t i e s . Saaework Techniques Employed: F i f t e e n p a t i e n t s r e c e i v e d f a c e to face i n t e r v i e w s w i t h a s o c i a l worker* and were given i n d i r e c t environmental h e l p through r e f e r r a l t o the C i t y S o c i a l S e r v i c e Department, B l r e o t environmental h e l p was g i v e n t o two p a t i e n t s I n the form of f i n a n c i a l h e l p u n t i l h i s e l i g i b i l i t y was e s t a b l i s h e d , and by e s c o r t i n g him to the A s s i s t a n c e Agency; t r a n s p o r t a t i o n was arranged from the h o s p i t a l f o r another p a t i e n t . Contact was maintained  w i t h other agencies i n three cases. D i r e c t Services were given t© f i f t e e n p a t i e n t s . D i r e c t S e r v i c e s were given to p a t i e n t s * r e l a t i v e s i n f o u r cases. Observations: f e n cases of the group studied were known to the A s s i s t a n c e Agency p r i o r to the p a t i e n t ' s admission to the C l i n i c , I n these cases the Intake S o c i a l Worker would assume tha t a p s y c h o * s o c l a l assessment had been completed by the C i t y S o c i a l Service Department. Unless any - k-7 -o f these p a t i e n t s were to be c a r r i e d on a long term b a s i s by the doctor and s o e i a l workers at the C l i n i c , a f u l l h i s t o r y would not be obtained. Frequently, because the C i t y S o c i a l Service Department i s unaware of t h e i r c l i e n t * s admission to the Crease C l i n i c , no psyeho-soeial statement was r e c e i v e d from them i n these t e n cases, although, i n some i n s t a n c e s , t h i s had been requested. 1 Recording; I n 6 of the f i f t e e n cases s t u d i e d , the recording on the f i l e s d i d not i n d i c a t e th© process of the s e r v i c e that was g i v e n . I n other cases I t was a l s o d i f f i c u l t t o assess the s e r v i c e s . For example, i t was not c l e a r t h a t each p a t i e n t had been seen d i r e c t l y w i t h regard t o the r e f e r r a l t o the A s s i s t a n c e Agency. The P r o v i n c i a l Supervisor of P s y c h i a t r i c S o c i a l Work, Miss A.K. C a r r o l l , a d v i s e s t h a t a l l p a t i e n t s were interviewed at l e a s t once and the r e f e r r a l to the A s s i s t a n c e Agency was discussed w i t h them. I n s e v e r a l cases, the main f i l e s d i d not con-t a i n a completed copy o f the s o c i a l s e r v i c e notes. The f i l -i n g system a t the Crease C l i n i c does not c o n t a i n c o r r e s -pondence i n the main f i l e which a l s o adds to the d i f f i c u l t y o f o b t a i n i n g data. Much i n f o r m a t i o n which i s i m p l i c i t i n the b r e v i t y o f r e c o r d i n g to the workers, creates a d i f f e r e n t i n t e r p r e t a t i o n f o r someone who i s reading the f i l e . Inter-Aaeacy Conferencess In f o u r of the f i f t e e n cases s t u d i e d there appeared evidence of severe f a m i l y 1 Personal communication from the P r o v i n c i a l Supervisor of P s y c h i a t r i c S o c i a l Work, Miss A.K. C a r r o l l . 2 Loc. c i t . - 4 8 * disturbance. These are Gases 3 , 1 0 , 1 4 , and 15>. Cases 10 and 14 were known to the A s s i s t a n c e Agency p r i o r to the p a t i e n t ' s admission. Cases 3 and 15 were not known. Case 10 presented severe d l s f f l c u l t l e s i n the care of the c h i l d r e n . I t i s not w i t h i n the purpose o f t h i s study to suggest which agency should have accepted r e s p o n s i b i l i t y f o r f u r t h e r c o n s u l t a t i o n i n these cases, except to note that inter-agency c o n s u l t a t i o n may have I n d i c a t e d which community resource could give s e r v i c e where such chronic f a m i l y s i t -u a t i o n s e x i s t e d , or have shown the need f o r c l o s e r l i a i s o n i n such cases. The f i f t e e n cases s t u d i e d show evidence of chronic p s y c h o - s o c i a l disturbances, and poor p s y c h o l o g i c a l and s o c i a l adjustment. Many were unable to use p s y c h i a t r i c or case-work h e l p . S o c i a l s e r v i c e h e l p was given t o them by the Crease C l i n i c S o c i a l S e r v i c e Department which attempted to improve t h e i r adjustment s i t u a t i o n s . The records o f these f i f t e e n p a t i e n t s have been examined w i t h reference to per-sonal and s o c i a l s t r e s s e s , diagnosed p s y c h i a t r i c c l a s s i f i * c a t i o n s , and s o e i a l r e h a b i l i t a t i o n i n terms of what was a v a i l a b l e i n 1954 c o n s i d e r i n g s t a f f shortages and public resources. The chapter has d e a l t more s p e c i f i c a l l y w i t h the p a t i e n t i n the c l i n i c a l s e t t i n g of the p s y c h i a t r i c h o s p i t a l . Since p s y c h o s o c i a l r e h a b i l i t a t i o n must continue f o r a p e r i o d a f t e r discharge from h o s p i t a l , i t i s necessary to g i v e f u r -t h e r c o n s i d e r a t i o n to t h i s aspect, i n a d d i t i o n to what has * 4 9 -already been mentioned In t h i s chapter. Chapter 3 w i l l , t h e r e f o r e , consider the s e r v i c e s given to the f i f t e e n pat-i e n t s w h i l e under the care of the C i t y S o c i a l S ervice Department. CHAPTER 3. PUBLIC ASSISTANCE CONSIDERATIONS IN SOCIAL SERVICES TO FIFTEEN DISCHARGED PSYCHIATRIC PATIENTS Government R e s p o n s i b i l i t y to Provide Welfare S e r v i c e s The highest i d e a l s of a forward l o o k i n g p h i l o -sophy has r e s p e c t f o r the r i g h t s o f the I n d i v i d u a l t o s e l f -determination. Such a philosophy considers that a l l human resources must be conserved and strengthened% that i n times o f s t r e s s and l a c k o f l i v e l i h o o d , p r o v i s i o n be made f o r s o c i a l , emotional, and economic s e c u r i t y , Western democratic government has a r e s p o n s i b i l i t y to provide f o r the welfare of the people. Gross need and economic I n s e c u r i t y i s o f t e n r e l a t e d to p e r s o n a l i t y maladjustment as w e l l as to the econ-omic system, unmet needs, personal i n s e c u r i t y , and i n a b i l i t y to make adjustment i n r e l a t i o n s h i p s , not o n l y o f t e n leads to mental i l l n e s s , but to severe economic d i s t r e s s f o r a l l concerned i n the problem.. The r e l a t i o n s h i p between mental h e a l t h and p u b l i c a s s i s t a n c e i s therefore r e c o g n i z a b l e . The present chapter w i l l c onsider the s e r v i c e s which provide f o r a group of f i f t e e n p a t i e n t s , who, because of economic need Clack o f f i n a n c i a l support), which determined e l i g i -b i l i t y , were r e f e r r e d upon discharge from the Crease C l i n i c to the C i t y S o c i a l S e r v i c e Department. - Si -Development o f C i t y S o c i a l S e r v i c e Department Almsgiving and some form of organised c h a r i t y can be traced to e a r l y recorded h i s t o r y . I n v e s t i g a t i o n of l i v i n g standards r e f l e c t e d a gradual change i n a t t i t u d e s toward poverty and the poor. The widespread poverty i n the depression of 1930 onwards 9 again r e f u t e d the a t t i t u d e that poverty was due to personal f a u l t weakness of cha r a c t e r , and i n d i v i d u a l l a z i n e s s . I t i s r e l e v a n t t o mention that the i n v e s t i g a t i o n s of Charles Booth, l8lj.0~19l6. reported i n h i s work " L i f e and Labour of the People of London," attempted to show the num-e r i c a l r e l a t i o n which poverty and misery bear t o r e g u l a r earnings, and to describe the general c o n d i t i o n s under which each c l a s s l i v e d . 1 The f i n d i n g s o f the i n v e s t i g a t i o n s of Booth, Rowntree, B e a t r i c e and Sydney Webb, and many others who examined the c o n d i t i o n s of the poor, have exerted i n f l u e n c e s upon the philosophy and c o n d i t i o n s which have developed to meet th© exigencies of people i n f i n a n c i a l and other needs. The e a r l y beginnings of Vancouver*s C i t y S o e i a l S e r v i c e Department In 1906 attempted t o meet c o n d i t i o n s which r e s u l t e d from th© depression. Pood and lodgings t o the i n d i g e n t poor were provided under the d i r e c t i o n of the 1 I n h i s study Booth d i v i d e d the pop u l a t i o n of London i n t o l i g h t groups. Four groups he defined as l i v i n g above the poverty l i n e and four below. He described the poor as l i v i n g under a s t r u g g l e to ob t a i n the n e c e s s i t i e s of l i f e and t o make both ends-meet, wh i l e the very poor l i v e d i n a st a t e of chronic want. - 52 -H e a l t h Department, The f o l l o w i n g year, v o l u n t e e r I n v e s t i g a t o r s , members of the F r i e n d l y Help S o c i e t y , were a c t i v e on behalf of the Health Department. I n 1909 the F r i e n d l y Help S o c i e t y merged w i t h the Associated C h a r i t i e s , whieh was financed by p u b l i c s u b s c r i p t i o n . A r e l i e f o f f i c e r was appointed i n 1912 under the Hea l t h Department but i t was not u n t i l the 1930* s that a s s i s t a n c e was administered t o unemployed and unemploy-able s under a department of the Council of th© C i t y of Vancouver* 1 E l i g i b i l i t y f o r r e l i e f was determined by a means t e s t administered by i n v e s t i g a t o r s ; A s s i s t a n c e was granted i n the form of g r o c e r i e s t s c r i p f o r goods, and some cash b e n e f i t s ; The establishment of a General B e l i e f S e c t i o n i n 1935 r e f l e c t s a f l e e t i n g awareness of the concepts l a t e r to be s t a t e d i n A r t i c l e 2 5 : 1 of the d e c l a r a t i o n of human r i g h t s approved by the United Nations General Assembly i December 10* 1 9 4 8 : Everyone has' the r i g h t t o a standard of l i v i n g , adequate f o r the h e a l t h of h i m s e l f and of h i s f a m i l y ; I n c l u d i n g food* c l o t h i n g , housing, and medical care,< and necessary s o c i a l s e r v i c e s , and the r i g h t t o s e c u r i t y i n the event o f unemployment, s i c k n e s s * d i s -a b i l i t y , widowhood, o l d age, or other l a c k of l i v e -l i h o o d i n circumstances beyond h i s c o n t r o l ; 1 "In 1 9 3 0 , when Unemployment R e l i e f became e f f e c t i v e and costs o f such r e l i e f were shared by Federal and P r o v i n c i a l governments, the department was d i v i d e d i n t o two s e c t i o n s - -Unemployment R e l i e f s e c t i o n and General R e l i e f s e c t i o n . The l a t t e r eared f o r unerdployables and the cos t was 100% charge on the c i t y . The changes to 'Family S e c t i o n 1 ; then to'Wel-f a r e S e c t i o n ' were more i n name than nature*" Personal com-munication through Mr. J.A. Chambers. - 03 -Mother's Allowance, S o c i a l Allowance, and Old Age Pensions were amalgamated i n 19k£.^" The present S o c i a l A s sistance A c t , passed i n 19k®$ made l e g a l p r o v i s i o n f o r the g r a n t i n g of a i d : ...to the i n d i v i d u a l , whether a d u l t or minor, or to f a m i l i e s , who through mental or p h y s i c a l i l l n e s s or other exigency are unable to provide i n whole or i n pa r t by t h e i r oim e f f o r t s , through other s e c u r i t y measures, o r from income, and other resources, neces-s i t i e s e s s e n t i a l t o maintain o r a s s i s t i n ma i n t a i n i n g a reasonable normal and he a l t h y e x i s t e n c e . The Act defines a s s i s t a n c e as meaning! a) f i n a n c i a l a i d ; b) a s s i s t a n c e i n k i n d ; e) i n s t i t u t i o n n u r s i n g , boarding, o r f o s t e r horn© care. Other p r o v i s i o n s a r e : c o u n s e l l i n g and h e a l t h s e r v i c e s , o c c u p a t i o n a l t r a i n i n g , r e t r a i n i n g or therapy f o r i n d i g e n t persons and mentally o r p h y s i c a l l y handicapped persons, and " g e n e r a l l y any form of a i d necessary t o r e l i e v e d e s t i t u t i o n and s u f f e r i n g . " The r e g u l a t i o n s o f the Act provide the l i m i t of personal property allowable t o claimants f o r a s s i s t a n c e , and s t a t e the d u t i e s of m u n i c i p a l i t i e s to provide and main-t a i n s o c i a l a s s i s t a n c e a t a reasonable l e v e l c o n s i s t e n t w i t h the c o s t of l i v i n g as r e l a t e d to standards of a s s i s -tance . L e g i s l a t i o n thus p l a c e s r e s p o n s i b i l i t y upon the C i t y of Vancouver to provide s o c i a l a s s i s t a n c e s e r v i c e s to 1 A c t u a l l y only the v i s i t i n g S t a f f s were amalgamated. Mothers Allowance continued to be administered by the Prov-» i h e i a l Mothers Allowance Board i n V i c t o r i a , and Old Age Pensions by the P r o v i n c i a l O.A.P. Board. This Is s t i l l i n e f f e c t . - 54 -c i t i z e n s who through exigency ere unable to provide f o r themselves. f l i e a u t h o r i t y which a l l o w s the p r o v i s i o n f o r the poor, i n d i g e n t , and d e s t i t u t e i s s t a t e d i n S e c t i o n 183 of the By-Laws of the Charter of the C i t y of Vancouver. I t i s r e l e v a n t here to show the trends i n p u b l i c a s s i s t a n c e cases and c o s t s by i n c l u d i n g the s t a t i s t i c s of s o c i a l a s s i s t a n c e s cases and the c o s t to the C i t y of Vancouver f o r February, 1 9 4 4 , compared w i t h the f i g u r e s f o r February, 1954 and 1955 . In February, 1944, there were 1 ? 2 2 s o c i a l a s s i s t a n c e cases of 2088 i n d i v i d u a l s . A s s i s t a n c e i n t h a t year c o s t the C i t y o f Vancouver #1? ,771*8?* The P r o v i n c i a l Oovernment bore the remaining 80 per cent of the c o s t . In February, 1 9 5 4 , 3015 s o c i a l a s s i s t a n c e eases of 4^46 i n d i v i d u a l s w i t h a t o t a l cost to the C i t y of |29 , 9 0 4 . 4 3 , and i n February, 1 9 5 5 , 3053 s o c i a l a s s i s t a n c e eases of 4 l 8 5 i n d i v i d u a l s , was a t o t a l cost to the c i t y of #38,319.00> These f i g u r e s g i v e i n d i c a t i o n not only of the extension of s e r v i c e s , g r e a t e r r e c o g n i t i o n of need and the o b l i g a t i o n of the C i t y of Vancouver to meet need, but of the i n c r e a s i n g pressures and l a r g e r case loads of the S o c i a l Work S t a f f . S t a f f O r g a n i z a t i o n a l S t r u c t u r e The establishment o f a S o c i a l Service Committee of the C i t y C o u n c i l under the chairmanship of an e l e c t e d - $$ -alderman, I s th© agency which recomraended the necessary o r g a n i z a t i o n of a S o c i a l s e r v i c e department to serve th© C i t y of Vancouver i n respect t o r e s p o n s i b i l i t y f o r g i v i n g a s s i s t a n c e t o meet need. A u t h o r i t y has been delegated by the c o u n c i l to a s i n g l e e x e c u t i v e , the A d m i n i s t r a t o r , whose d e c i s i o n i s b i n d i n g i n most cases. I n s p e c i a l cases a bylaw o f the c o u n c i l may be passed t o enable a s s i s t a n c e to be gi v e n to persons I n ra r e emergency s i t u a t i o n s . For example, i f a person a p p l i e d f o r a s s i s t a n c e having no money, but had property which might y i e l d an income i f administered e f f i c i e n t l y , a bylaw might be passed p r o v i d i n g that the person r e c e i v e a s s i s t a n c e u n t i l assets could be gained from the property. An a s s i s t a n t A d m i n i s t r a t o r and a Welfare D i r e c t o r ar© d i r e c t l y r e s p o n s i b l e t o the A d m i n i s t r a t o r and meet r e g u l a r l y twice weekly w i t h him on p o l i c i e s of the depart-ment and r e l a t e d cases. Three s e n l c r members of the agency compose the s t a f f committee which meets to consider the appeal of an a p p l i c a n t f o r s o c i a l a s s i s t a n c e , and/or t o con-s i d e r some a d d i t i o n a l allowance t o an a p p l i c a n t f o r s p e c i a l reasons. I n each ins t a n c e the case I s s t u d i e d beforehand, which i s presented by th© d i s t r i c t V i s i t o r . F o l l o w i n g t h i s procedure the coimaittee makes a d e c i s i o n on the m e r i t s of the case. Any caseworker may present a case f o r c o n s u l t a t i o n - £6 -or may ask f o r c l a r i f i c a t i o n , and f u r t h e r c o n s i d e r a t i o n of an appeal f o r a s s i s t a n c e . Every e f f o r t i s made t o consider f u l l y i n t r i c a t e f a c t o r s causing hardship and to meet the s p e c i a l circumstances c r e a t i n g need. The agency a d m i n i s t r a t i o n i s represented by " l i n e and s t a f f s t r u c t u r e . n The A d m i n i s t r a t o r formulates p o l i c y ; s t a f f operations and the e f f o r t s e f a research department combine t o suggest new measures which makes f o r more e f f e c t i v e executing of modified p o l i c y . The s t r u c t u r e l i n e s are from the A d m i n i s t r a t o r , through the a s s i s t a n t A d m i n i s t r a t o r t o the u n i t d i r e c t o r s end the d i r e c t o r s of the d i f f e r e n t a d m i n i s t r a t i v e departments. The u n i t d i r e c t o r s are t o t a l l y r e s p o n s i b l e f o r the work of t h e i r u n i t s . 2 They d i v i d e some of t h e i r r e s p o n s i b i l i t y w i t h the u n i t s u p e r v i s o r s o f casework, but are d i r e c t l y respon-s i b l e f o r the u n i t , which Includes c l e r i c a l a d m i n i s t r a t i o n and the d i r e c t s e r v i c e s to c l i e n t s . The u n i t s u p e r v i s o r s are re s p o n s i b l e f o r casework s u p e r v i s i o n , and f o r aspects of a d m i n i s t r a t i o n such as e l i g i b i l i t y and p o l i c y . Each u n i t s u p e r v i s o r c o n s u l t s monthly w i t h the D i r e c t o r of Welfare. S p e c i a l s t a f f meetings of the t o t a l department have been h e l d from time t o time. I t i s hoped by the Depart-ment tha t a r e g u l a r general s t a f f meeting scheduled to take place beginning i n the s p r i n g o f 1956, w i l l be continued. 1 Some u n i t d i r e c t o r s are graduate S o c i a l Workers* The area served I s w i t h i n the boundaries of the C i t y of Vancouver. For purposes of a d m i n i s t r a t i o n , the G i t y Is d i v i d e d i n t o f o u r u n i t s . * 57 -The department I s d i v i d e d i n t o geographical u n i t s . Most r e f e r r e d mental p a t i e n t s are seen a t Intake and r e f e r r e d to the u n i t s e r v i n g t h e i r geographical area. I n a s p e c i a l s i t u a t i o n such aS hoarding home placements, a p u b l i c h e a l t h nurse of the medical s e c t i o n becomes i n v o l v e d . The p u b l i c h e a l t h nurse i s a c o n s u l t a n t and i n t h i s c a p a c i t y i s able to achieve d i r e c t and quick c o n s u l t a t i o n w i t h the p a t i e n t ' s p h y s i c i a n a t the P s y c h i a t r i c H o s p i t a l . Medical s e r v i c e s are a v a i l a b l e f o r s o c i a l a s s i s t a n c e c l i e n t s at the Vancouver General H o s p i t a l and St. Paul's H o s p i t a l . Medical cards are i s s u e d to a l l c l i e n t s which permits them to choose t h e i r own p r i v a t e p h y s i c i a n and to r e c e i v e free drugs. P s y c h i a t r i c c o n s u l t a t i o n and S p e c i a l i s t ' s s e r v i c e s are a v a i l a b l e . I t must be recognized, however, t h a t f i n a n c i a l d e s t i t u t i o n determines e l i g i b i l i t y f o r a s s i s t a n c e , and f o r any of the s e r v i c e s a v a i l -able through the agency, unless a r e f e r r e d mental p a t i e n t q u a l i f i e s i n t h i s r e s p e c t , he would be i n e l i g i b l e f o r any other s e r v i c e * even though h i s border l i n e o r inadequate f i n -a n c i a l income created hardship and c o n t r i b u t e d to h i s pre-c a r i o u s mental s t a t e . To q u a l i f y f o r a s s i s t a n c e , he must be d e s t i t u t e and without means of subsistence. Should, however* a person have an income from another source whieh i s below the s o c i a l a s s i s t a n c e r a t e , the agency would supply f i n a n c i a l a i d up to the Stated a s s i s t a n c e r a t e , and would extend w i t h t h i s any other s e r v i c e s necessary* In eases where the r e c i p i e n t or h i s f a m i l y are unable to provide recommended - 58 -a p p l i a n c e s , such as g l a s s e s , dentures, et c e t e r a , these would be s u p p l i e d through the agency i f the c l i e n t q u a l i f i e d i n respect to f i n a n c i a l e l i g i b i l i t y . I n eases where i t i s a d v i s a b l e f o r an i l l person to remain i n h i s home, or where c h i l d r e n of a c l i e n t r e q u i r e temporary eare during the I l l -ness, housekeeper or home maker Service may be provided. I n a d d i t i o n to these s e r v i c e s , a M e t r o p o l i t a n H e a l t h Committee N u t r i t i o n i s t serves as a c o n s u l t a n t , and a s s i s t s i n the ques-t i o n of budgeting, n u t r i t i o n and s p e c i a l d i e t s . S o c i a l workers on the s t a f f i n a d d i t i o n t o e s t a b l i s h i n g and reviewing e l i g i b i l i t y of persons i n need of f i n a n c i a l a i d . provide a c o n t i n u i n g counsel-l i n g s e r v i c e , and by understanding and i n d i v i d u a l i s e d S e r v i c e , enable the c l i e n t to US© resources w i t h i n themselves and th® community t o achieve the g r e a t e s t p o s s i b l e measure of s e l f dependence.! R e f e r r a l P o l i c i e s which A f f e c t A s s i s t a n c e Concepts The r e f e r r a l o f a c l i e n t to another agency f o r Service o f t e n demands a hi g h degree o f casework s k i l l , a f f e c t -i n g smooth transference and an adequate p r e p a r a t i o n of the c l i e n t . A Department of S o c i a l A s s i s t a n c e has the primary r e s p o n s i b i l i t y f o r p r o v i d i n g f i n a n c i a l a i d , and other s e r -v i c e s which are an adjunct t o t h i s primary s e r v i c e , to a l a r g e group of i n d i v i d u a l s who may be t e m p o r a r i l y or even permanently unable to provide f o r themselves. The C i t y S o c i a l S e r v i c e Department i s so organized t h a t c l i e n t s may apply i n d i v i d u a l l y t o th© agency f o r a s s i s t a n c e . 1 C i t y S o o i a l S e r v i c e Department, unpublished statement provided by the D i r e c t o r of Welfare. 7 &-.7 Some are r e f e r r e d by cocmiunlty agencies, the v a s t m a j o r i t y of a p p l i c a n t s make personal a p p l i c a t i o n without reference from the agencies. The r e f e r r a l o f a c l i e n t from one agency to another I s an Important p a r t o f casework p r a c t i c e . There are two aspects to t h i s problem, namely, to secure the s e r * v i c e which w i l l meet the c l i e n t ' s s p e c i f i c need, and the p r o f e s s i o n a l r e l a t i o n s h i p between the workers i n v o l v e d . Reference i s here made to the r e p o r t of a Committee designed to "Study R e f e r r a l s from H o s p i t a l to S o c i a l Service Depart-ments to Community S o c i a l Agencies," under the auspices of the Council of S o c i a l Work i n M e d i c a l Care, Waited Community Ser v i c e s o f M e t r o p o l i t a n B o s t on. 1 The committee examined case m a t e r i a l which d e a l t w i t h the r e f e r r a l of cases by medical S o c i a l Workers to community agencies. As a r e s u l t of t h i s a n a l y s i s the committee a r r i v e d at two major conclusions a) r e f e r r a l of a p a t i e n t to a community agency f o r s e r v i c e I s p a r t o f casework process and should never be a r o u t i n e procedurej bj c l e a r l y defined a d m i n i s t r a t i v e p o l i c i e s and procedures r e l a t i n g t o Inter-agency r e f e r r a l are e s s e n t i a l f o r good s o c i a l work p r a c t i c e . The committee concluded t h a t a l l r e f e r r a l procedures, even those that are c h i e f l y a d m i n i s t r a t i v e i n nature, should be based on sound casework p r a c t i c e . F i f t e e n discharged mental p a t i e n t s were r e f e r r e d to the C i t y S o e i a l S e r v i c e Department f o r s o c i a l a s s i s t a n c e during 1954- Stoe s e r v i c e s which were provided t o them by 1 The s e c t i o n o f the a r t i c l e d i s c u s s i n g r e f e r r a l p o l i c y w i l l be more s p e c i f i c a l l y d e a l t w i t h i n Chapter 4 o f t h i s study. 60 -the A s s i s t a n c e Agency can now "be discussed. D i s c u s s i o n o f the S o c i a l S e r v i c e s Provided t o F i f t e e n Referred  Mental P a t i e n t s To o b t a i n data from the f i l e s of these p a t i e n t s , a (simple) schedule was used. The method of p r e s e n t a t i o n Used i n Chapter 2 to descr i b e the I l l n e s s and s o c i a l problems of the f i f t e e n p a t i e n t s w i l l be fo l l o w e d i n the present chapter to describe the s o c i a l s e r v i c e s provided to the same group Of p a t i e n t s by the C i t y S o c i a l S e r v i c e Department. Case .1. ' C l i e n t was assessed e l i g i b l e ' f o r "Support and S h e l t e r Croup l . " l R e f e r r a l to Vancouver General H o s p i t a l , A r t h r i t i s C l i n i c , was discussed w i t h him. He became accept-i n g of treatment there. An understanding, supportive r e l a t i o n -s h i p w i t h the worker created f e e l i n g s of t r u s t toward other people, and a more confiden t a t t i t u d e toward l i f e . He was not p r e v i o u s l y known t o the A s s i s t a n c e Agency. Casework Techniques Employed; a) Face to face Interviews which employed the use of a supportive r e l a t i o n -ships *>) Environmental h e l p and use o f community resources. The...case was cl o s e d upon c l i e n t r e c e i v i n g employ-ment b e n e f i t . . ' Observationss Hoted improvement i n the c l i e n t ' s m o t i v a t i o n , a b e t t e r a t t i t u d e toward h i s s i t u a t i o n , and treatment f o r h i s a r t h r i t i s was obtained. Case 2. C l i e n t was e l i g i b l e f o r "Support and S h e l t e r Croup 1, p l u s #7.50 e x t r a T.B. d i e t a r y allowance." There I s evidence i n t h i s Case of good contacts and conferences w i t h the S o e i a l S e r v i c e Department of T.B. C o n t r o l . Con* ference recommended t h a t c l i e n t be given a s s i s t a n c e as a r e h a b i l i t a t i v e measure because h i s recovery was hampered by the s t r e s s e s and s t r a i n s Created by m a r i t a l disharmony, i n f o r m a t i o n oh t h i s f i l e r egarding c l i e n t ' s w i f e ' s mental s t a t e would have been va l u a b l e to.the Crease C l i n i c . Case —: .—,. . —--•.,„-•:-:•••--, L.^—^ r r ..:— r Hi'iwif i igwii mi ijiT wiim'niiia r n in mm n mi»u.min HMWWU) .. r i u II wj ••.. n 1 Croup 1, 2, 3, e t c . r e f e r s t o the number of i n d i v i d u a l i n c l u d e d i n the ease. — 61 *• was p r e v i o u s l y known to the ageney p r i o r to c l i e n t ' s stay i n Crease C l i n i c , when casework s e r v i c e s w i t h the f a m i l y attempted to Improve the f a m i l y s i t u a t i o n . Casework Techniques Employed; a) Pace to face i n t e r v i e w s ; b) Environmental help* and conference w i t h a community agency focussed the p l a n f o r p a t i e n t t o l i v e apart from h i s f a m i l y u n t i l h i s p h y s i c a l h e a l t h improved. Case was c l o s e d upon p a t i e n t o b t a i n i n g employment. Observations: Continued f a m i l y s e r v i c e s to pat-i e n t and h i s w i f e might have maintained p a t i e n t ' s improve-ment. He returned to l i v e w i t h h i s wife and f a m i l y . Prognosis would i n d i c a t e that h i s p h y s i c a l and mental symptoms would be r e - a c t i v a t e d . Case 3. C l i e n t ' s f a m i l y assessed e l i g i b l e f o r "Support 0 o n l y , w h i l e c l i e n t s t i l l i n h o s p i t a l . C l i e n t ' s w i f e was very anxious about p r e s s i n g debts and l o s s of income. Finan-c i a l a i d appeared to s t a b i l i z e her. There was no r e f e r r a l or c o n s u l t a t i o n w i t h any community resource. Case was not p r e v i o u s l y known to the agency. Casework Techniques Employed; a) Face to face i n t e r v i e w s w i t h the c l i e n t ' s w i f e , and casework support enabled her to i n t e r p r e t the a s s i s t a n c e s e r v i c e to her husband who r e s i s t e d accepting h e l p . Case was c l o s e d : C l i e n t obtained employment. Observations: S t a b i l i z a t i o n of the economic s i t -u a t i o n helped t h i s f a m i l y . In t h i s case, however, there appears to be the genesis of a severe f a m i l y d i s o r d e r , and the p s y c h o l o g i c a l adjustment of f o u r young c h i l d r e n i s Involved. The case was not r e f e r r e d t o the Family Agency f o r continued s e r v i c e . This I s a case where prev e n t a t i v e h e l p would seem In order. Case 4. C l i e n t assessed e l i g i b l e f o r "Boarding Home-placement" and comforts allowances i?»00 per month. This c l i e n t was known to the agency p r e v i o u s l y when he was c o n s i d -ered incapable of h a n d l i n g money, because of gambling h a b i t s . F o l l o w i n g recommendations from the Crease C l i n i c p s y c h i a t r i s t , c l i e n t refused the s e r v i c e . The agency attempted to di s c u s s c l i e n t ' s r e f e r r a l to a neighbourhood house. He s e t t l e d i n t o a good boarding home-placement where he shared a room w i t h three other men where some of h i s heeds f o r s o c i a l l i f e were p a r t l y met. He seemed much more s e t t l e d and happier, although h i s asthma d i d not improve. Transfer to Taylor Manor was contemplated, but was not accomplished, beeause I t was considered d e t r i m e n t a l to h i s adjustment. O l i e n t was r e f e r r e d f o r treatment t o Vancouver General H o s p i t a l Out-Patient Department, and was given new c l o t h e s . Casework Techniques Employed: a) Pace to. face i n t e r v i e w s ; b) environmental h e l p ; e) R e f e r r a l to community resource. T h i s case i s s t i l l a c t i v e . Observations; There appears to be Improvement i n p a t i e n t ' s adjustment* aad he i s more outgoing. Case !>, C l i e n t was assessed e l i g i b l e f o r "Support and S h e l t e r " and was p r e v i o u s l y known to the agency. Because she had poor m o t i v a t i o n , and was l o s i n g weight because she missed meals when not w e l l , c l o s e s u p e r v i s i o n was g i v e n . C o n s u l t a t i o n w i t h the agency n u t r i t i o n i s t r e s u l t e d i n supplementary d i e t allowance o f |5*00 being g r a n t e d . 2 She was enabled to e s t a b l i s h a good r e l a t i o n s h i p w i t h the worker, who recorded a c l e a r assessment o f t h i s case. Casework Techniques Employed; a) Pace to face i n t e r -views; b) Environmental h e l p , which included c o n s u l t a t i o n w i t h and r e f e r r a l to a community resource regarding e l i g i b -i l i t y f o r the Widow's Pension. Case was closed upon c l i e n t becoming e l i g i b l e f o r Disabled Veteran's Allowance, Widow's Pension. Observations: S t a b i l i z a t i o n o f t h i s c l i e n t ' s econ-omic s i t u a t i o n . The r e e o r d i n g d i d not i n d i c a t e that e l i e n t ' s tendency to d i s r e g a r d personal care r e q u i r e d c l o s e s u p e r v i s i o n . This may have been discussed l h telephone conversation between the agency workers and not recorded. Case 6. T h i s c l i e n t was known to the agency p r i o r to admission to Grease C l i n i c . Upon r e f e r r a l she was assessed f o r "Support" only. L a t e r , because of her poor m o t i v a t i o n and a l c o h o l a d d i c t i o n , which caused p h y s i c a l d e t e r i o r a t i o n , she was placed i n a boarding home, and was given 17.00 comforts allowance. I n s e l e c t i n g the boarding home, care was taken to choose one where the owner was known to be a warm, understand-i n g person. Although she appeared to accept the c l i e n t , when d i f f i c u l t i e s arose, she requested her removal. Through the s p e c i a l Placement S e c t i o n , N a t i o n a l Employment S e r v i c e , an 1 Taylor Manor i s a Boarding Home f o r men and women, oper-ated by the C i t y S o c i a l Service Department, financed on shared b a s i s between the P r o v i n c i a l Government and the C i t y of Vancouver. 2 Supplemental d i e t i s given only on medical recommendation, and f o r s p e c i f i c medical c o n d i t i o n s . - 63 -attempt was made to place c l i e n t i n occupation. She worked for three weeks, and l i v e d i n a rooming house. Another Boarding Home was found, but because of her drinking she had to be moved. "Support and Shelter" was then given and she was helped to f i n d a housekeeping room. A second job was found, which she kept under one month. Other services provided i n t h i s case. Special shoes were supplied, dentures repaired, r e f e r r a l s to Alco-h o l i c Foundation, and St. Paul's Hospital. Recording notes Indicate that the patient continues to see the p s y c h i a t r i s t from the Grease C l i n i c . Casework Techniques Employed; a) Regular face to face Interviews, f o r t h i s e l i e n t required close supervisions b) Environmental help, which Included r e f e r r a l s to community agencies. This case i s s t i l l a ctive. Observations s Chronic psychosocial d i f f i c u l t i e s indicate poor prognosis, and that the c l i e n t w i l l be a long term subject f o r care. CaSe 7. C l i e n t was assessed f o r "Support and Shelter." He has been known to the agency since 1901, and was considered to require long term medical and f i n a n c i a l assistance because of h i s poor physical and mental state. Regular supervision of h i s condition was maintained, and eyeglasses were obtained f o r him. A statement on t h i s record indicates that i t i s thought that i n s e c u r i t y may p r e c i p i t a t e s i m i l a r mental symp-toms which were present upon h i s admission to the Crease C l i n i c . Casework Techniques Employed; a) Face to face interviews; b) Environmental help. Case i s s t i l l a c t i v e . Observationss Although t h i s c l i e n t ' s prognosis i s poor, a good attempt i s being made to maintain him i n the community. Case 8. Clie n t was assessed f o r "Support and Shelter." She was not previously known to the agency. In t h i s case "Shelter" was given, because, although c l i e n t owned her own home, she had to pay taxes of $126.00 annually. When apply-ing f o r assistance she owed #46.00 of the previous year ' s assessment, a t o t a l of #172.00 owing. During the P a c i f i c National E x h i b i t i o n , She rented her garden f o r parking pur-poses, f o r whieh she was paid #100.00, with which she paid the tax debt. She reported t h i s to the worker and the case - 6k -" was c l o s e d f o r two months, because the c l i e n t having received an income, was assessed as hot being f i n a n c i a l l y i n need. During t h i s two month p e r i o d the c l i e n t had #40.00 f o r main-tenance. Her f a m i l y could hot h e l p . C l i e n t l o s t weight and became concerned about her s i t u a t i o n . There was evidence of a good r e l a t i o n s h i p w i t h the worker who spent considerable time explaining the p o l i c y o f the agency to the c l i e n t . The C l i e n t ' s r esourcefulness was recognized and the assurance t h a t c l o s u r e would be temporary seemed to s t a b i l i z e her, and attempted to maintain the p l a n of r e h a b i l i t a t i o n f o r her. Casework Techniques Employeds a) Pace to face i n t e r v i e w s which Included p s y c h o l o g i c a l support and c l a r i -f i c a t i o n of her problem; b) Environmental h e l p . Case i s s t i l l a c t i v e . Observations s C l i e n t appeared more s t a b i l i z e d and her independence maintained. Although the two months' cl o s u r e appeared to cause some hardship, the c l i e n t main-t a i n e d a good r e l a t i o n s h i p w i t h the worker, and the improve-ment i n her mental h e a l t h was good. Case 9. / T h i s case of a d i f f i c u l t and i n v o l v e d m a r i t a l c o n f l i c t was known to the agency s i n c e 1936, Case was reopened In 1938* 1939, 1941* 1900 and 1901. The c l i e n t was assessed as e l i g i b l e f o r "Support and S h e l t e r Croup 1 and f o r casework." Contacts and r e f e r r a l s were maintained w i t h the Family Court, Vancouver General H o s p i t a l * and p s y c h i a t r i c c o n s u l t a t i o n w i t h a p r i v a t e p h y s i c i a n . The s o c i a l information IS l o n g and i n v o l v e d , s t a r t i n g i n 1936* d e s c r i b i n g d e s e r t i o n by a " c r u e l husband* non-support* frequent beatings, and q u a r r e l s * " and s e v e r a l common-law r e l a t i o n s h i p s w i t h inadequate s h i f t l e s s p a r t n e r s . Family Court attempts to o b t a i n support were not e f f e c t i v e . Occasional support to c l i e n t from husband was always reported to agency. C l i e n t ' s p e r s o n a l i t y d i f -f i c u l t i e s precluded Boarding Home-placement, and her frequent Ill-»health created a precarious p s y c h o s o c i a l s i t u a t i o n . Since discharge from Grease C l i n i c , c l i e n t has been.encouraged to f i n d baby s i t t i n g work up to the allowed sum o f #10«00*1 which appears to have given some personal s a t i s f a c t i o n and s t a b i l i z e d her mental s t a t e . She a l s o r e c e i v e d care from a p r i v a t e p h y s i c i a n which helped her. Casework Techniques Employed; a) Face to face I n t e r v i e w s ; to) Environmental support* i n c l u d i n g use of community resources. 1 T h i s would be counted as an exemption before the a d j u s t -ment mad© i n normal allowance. Personal communication w i t h Hr. J . Chambers. - 65 -The case i s s t i l l a c t i v e . Observationsi Evidence of s t a b i l i z a t i o n of the s i t u a t i o n i s noted. The worker appears to have the confidence o f the c l i e n t and a good r e l a t i o n s h i p between them seems to stem from the worker*s non-judgmental a t t i t u d e regarding c l i e n t ' s common-law r e l a t i o n s h i p s . Oase 10. This i s another very Involved case of severe m a r i t a l d i s o r d e r i n v o l v i n g the care and adjustment of three c h i l d r e n , ages t h i r t e e n , t e n , and f i v e . The case was known to the agency p r i o r to the c l i e n t ' s committal to Oakalla and the Crease C l i n i c . There i s a lon g l i s t of contacts w i t h community resources, i n c l u d i n g The F i r s t united Church S o c i a l Service Committee, The C a t h o l i c C h a r i t i e s , The F i r s t B a p t i s t Church, The Mental Health Committee, The Family S e r v i c e A s s o c i a t i o n , The C a t h o l i c C h i l d r e n ' s A i d S o c i e t y , and The Family Court, The contact w i t h the agency began when the f a m i l y l o s t t h e i r home and household e f f e e t s by f i r e . The c l i e n t was i n a very confused s t a t e , and both he and h i s w i f e were em o t i o n a l l y d i s t u r b e d . T h e i r l i g h t was being d i s -connected; they had many debts and c l i e n t was stated to be u n f i t to work. The case was presented to the Agency S t a f f Conference, but no a s s i s t a n c e was given and the f a m i l y was r e f e r r e d back to The C a t h o l i c C h a r i t i e s . On the occasion o f the present contact, c l i e n t ' s w i f e appealed f o r support f o r h e r s e l f and three c h i l d r e n . She gave a h i s t o r y of many e a r l y d i f f i c u l t i e s ; of a c o n t r o l l i n g mother who f o r c e d her t o marry c l i e n t although she was pregnant by another man. C l i e n t a l s o had a poor u p b r i n g i n g . H i s b i t t e r n e s s and r e j e c t i o n of the o l d e s t boy has caused severe d i f f i c u l t i e s f o r the c h i l d . Because c l i e n t had #60.00 back wages which he refused t o s i g n over to h i s w i f e , a s s i s t a n c e was w i t h h e l d . H i s w i f e , des-perate and harrassed by p r e s s i n g heavy debts, threatened s u i c i d e . The money was f i n a l l y obtained from the man, but two months' back rent absorbed i t . P r i o r to c l i e n t ' s d i s -charge from the Grease C l i n i c , the agency worker recorded that i t would be h e l p f u l to hold a planning conference w i t h The Family Court, and The Crease C l i n i c . T h i s was not h e l d . One week f o l l o w i n g c l i e n t ' s discharge, h i s w i f e deserted and the s i t u a t i o n d e t e r i o r a t e d r a p i d l y . The twelve year o l d boy was not attending school; he " c r i e d e a s i l y and was tense." He s t a t e d h i s f a t h e r beat him, which c l i e n t denied. F o l l o w -i n g examination by The H e a l t h Committee, the boy was taken i n t o ward-care by The C a t h o l i c C h i l d r e n ' s A i d . I t was thought that the other c h i l d r e n were safe w i t h c l i e n t . F o l l o w i n g an accide n t at work, a s s i s t a n c e was g i v e n to him u n t i l Workman's Compensation was r e c e i v e d . C l i e n t appeared s e r i o u s l y d i s -turbed, and the other two c h i l d r e n were then taken i n t o care. Casework Techniques Employedt a) Face to face i n t e r v i e w s ; b) Environmental help and use of community resources. 66 -Cas© was closed. Workman's Compensation was obtained by c l i e n t . Observations t This i s a very seriously disturbed family situation which""deteriorated rapidly after the c l i e n t ' s dishharge from the Crease C l i n i c . C l a r i f i c a t i o n and assess-ment of this problem was not c learly defined i n the early Stages of contact, although there i s adequate psychosocial data to establish diagnosis of the d i f f i c u l t i e s . Early Inter-agency consultation i n this case would have focussed planned help to safeguard the care of the children and to have prevented the trauma which was experienced by them after patient's discharge from the C l i n i c . Serious consequences could have resulted to them because of the lack of agency responsibi l i ty . Information of this situation should have, been forwarded to the Crease Cl inle and an Ihter-agency conference held. Psychiatric participation would also have been most helpful i n planning. Case.11. This c l ient was assessed e l i g i b l e for "Support and "Shelter Group 1 , " and had been known to th© agency on occasions since 1947. She has a history of inadequate adjust-ment, severe personality d i f f i c u l t i e s , and mental i l l n e s s . Client was known to five community agencies and made several attempts to maintain herself . She was anxious to participate i n vocational t r a i n i n g . The Staff Committee of the agency, after reviewing her history and medical reports, did not recommend her for r e h a b i l i t a t i o n . Patient made plans with the National Employment Service to provide the vocational course which she completed. Following a period when she seemed better motivated, patient again developed somatic symptoms. She underwent surgery and was considered unem-ployable for one month. The City Soeial Service paid Boarding Home cost for this period. Client received Com-f o r t s ' Allowance, "Casework Techniques Employed: a) Face to face intervlewsf%J"' environmentaT"h"plp and referral to community agencies. Case closed: The cl ient assessed capable of employment. Observations: The recording i n this cas© was not adequate, due to the assignment of different workers. This i s a case of an inadequate single woman whose basic personality needs were not met through casework relationship. She seemed to wander from, agency to agency, with no one agency assuming responsibil i ty for coordination of services. Case 12? This c l ient was assessed e l i g i b l e for Boarding Home care and #7.00 Comforts Allowance, which was f i r s t given i n 195>0* Contact was mad© with The Vancouver General - 6? -H o s p i t a l Women's A u x i l i a r y * to i n v e s t i g a t e the p o s s i b i l i t y of the c l i e n t f i n d i n g v o l u n t e e r occupation, as Suggested by the Crease C l i n i c , C l i n i c a l D i r e c t o r . The agency medical s e c t i o n found a good Boarding Home f o r p a t i e n t , which was l a t e r s o l d . F o l l o w i n g t h i s , her c l i e n t ' s mental symptoms became more evident, and c o n s u l t a t i o n s w i t h the c l i n i c a l d i r e c t o r e s t a b l i s h e d t h a t every e f f o r t should be made t o mai n t a i n her I n the community. Good accommodation was found. The c l i e n t became s t a b i l i z e d , and was u s e f u l i n the home. Casework Techniques Employed, a) Face t o face I n t e r v i e w s ; bT Environmental' h e l p , and c o n s u l t a t i o n w i t h community resources. The case i s s t i l l a c t i v e . Observations: The c l i e n t i s more s e t t l e d . Con* t i n n i n g p s y c h i a t r i c care through Crease C l i n i c i s maintained. Case 13. C l i e n t assessed e l i g i b l e f o r "Support and S h e l t e r . " He was not p r e v i o u s l y known to the agency. P s y c h i a t r i c con-s u l t a t i o n through Vancouver General H o s p i t a l * Out-Patient Department, was sought because c l i e n t was showing signs of r e g r e s s i o n . This c l i e n t gave a h i s t o r y of a very poor f a m i l y background. Since coming to Canada at the age of 23* he had very good employment w i t h an average wage of #400,00* when working* 111-health and l o s s o f wox»k used h i s savings. F o l l o w i n g an operation f o r mastoids* h i s mental c o n d i t i o n d e t e r i o r a t e d , and he evidenced severe symptoms o f mental 111* ness. He appears t o be a candidate f o r long term p s y c h i a t r i c care. Casework Techniques Employeds a) Face t o face i n t e r v i e w s f t ) Environmental h e l p and p s y c h i a t r i c c o n s u l t -a t i o n . The case i s s t i l l a c t i v e . Observations. The c l i e n t ' s mental h e a l t h IS deter-i o r a t i n g a n d T i e " ^ ^ " r e q u i r e committal to the P r o v i n c i a l Mental H o s p i t a l . Case 1 4 . This c l i e n t was assessed e l i g i b l e f o r "Support and Sh e l t e r Group 4 » N There was an e a r l i e r b r i e f contact w i t h the agency, though no h e l p was given* Information on t h i s record i n d i c a t e s a severe f a m i l y d i s o r d e r . Th© c l i e n t , an Inadequate, maladjusted person, appeared t o be poo r l y mot-i v a t e d , and la c k e d a b i l i t y to handle money. He changed jobs f r e q u e n t l y and was a source of a n x i e t y to h i s parents and f a m i l y . A f t e r c l o s u r e of the case a l e t t e r was received from h i s s i s t e r s t a t i n g t h a t c l i e n t was causing t r o u b l e to - 68 -h i s aged parents who are i n r e c e i p t of Old Age A s s i s t a n c e , and requested s e r v i c e to them. An agency worker phoned the s i s t e r , but r eceived no r e p l y . There was no r e f e r r a l f o r s e r v i c e t o any other agency. Casework Techniques Employed; a) Face to face i n t e r v i e w s ; b) Environmental h e l p . Case was c l o s e d : C l i e n t obtained employment. Observations: Emergency b e n e f i t met economic need. The basle problem, however, was not m o d i f i e d . This appears to be another case of severe f a m i l y d i s o r d e r , aggravated by c l i e n t ' s p e r s o n a l i t y d i f f i c u l t i e s , and h i s e s t a b l i s h e d pat-t e r n of behaviour to work f o r a short w h i l e , a f t e r which he becomes a source of a n x i e t y to h i s f a m i l y by attempting to borrow money from them to maintain h i s f a m i l y . Case; l5 . This c l i e n t was assessed e l i g i b l e f o r "Support only, Group 5." He was not p r e v i o u s l y known to the agency and was employed s t e a d i l y u n t i l ' September, 1954s when he l o s t h i s occupation through a l c o h o l a d d i c t i o n . C l i e n t ' s wife seemed r e s o u r c e f u l and attempted book-keeping work to meet mortgage payments on home. R e f e r r a l was made to N a t i o n a l Employment Ser v i c e . Casework, Technique Employed: a) Pace to'face i n t e r v i e w s ; b) Environmental h e l p and r e f e r r a l to a com-munity resource. Case was c l o s e d : C l i e n t r e c e i v e d unemployment b e n e f i t s . Observations: Emergency help s t a b i l i z e d the economic s i t u a t i o n . The b a s i c problem of f a m i l y d i s o r d e r aggravated by c l i e n t ' s d i f f i c u l t i e s , d i d not appear to be modified. This i s another case i n which the eare of small children, i s i n v o l v e d . Conclusions and F i n d i n g s The present chapter has studied the s o c i a l s i t u a t i o n s of f i f t e e n discharged mental p a t i e n t s who were r e f e r r e d to the A s s i s t a n c e Agency. The s e r v i c e s g i v e n and the casework techniques employed to meet the i n d i v i d u a l and s o c i a l s t r e s s e s of the p a t i e n t s have been examined. A l l the 69 •* eases s t u d i e d presented severe personal or f a m i l y d i s o r d e r s . F i n a n c i a l a s s i s t a n c e r e l i e v e d elements of economic d i s t r e s s , but d i d n o t and indeed cannot alone modify the depth of disturbance i n most o f the cases s t u d i e d . Other s e r v i c e s o f f e r e d by the As s i s t a n c e Agency c o n t r i b u t e d to a more comfortable environment f o r the p a t i e n t s . When a pa t i e n t was no lon g e r i n need of f i n a n c i a l a s s i s t a n c e , the C i t y S o c i a l Service Department could not continue s e r v i c e * The f i n d i n g s noted i n the study of these p a t i e n t s  are: F i f t e e n p a t i e n t s were r e f e r r e d f o r s e r v i c e and a l l became a c t i v e cases. Of these ten were p r e v i o u s l y known t o the agency, f i v e were not. F i f t e e n p a t i e n t s r e c e i v e d f i n a n c i a l a s s i s t a n c e . Four of the p a t i e n t s r e c e i v e d Boarding Home care (they were not r e f e r r e d f o r t h i s S e r v i c e ) , but were assessed as being unable t o make adequate arrangements f o r t h e i r own care. l These p a t i e n t s r e c e i v e d Comforts Allowance. Two p a t i e n t s were g i v e n E x t r a D i e t a r y Allowance, and one p a t i e n t was allowed an allowance of E x t r a Rent. One p a t i e n t received new c l o t h e s , and the dentures of one p a t i e n t were r e p a i r e d . One p a t i e n t was permitted t o consult a p r i v a t e p h y s i c i a n , f i and one p a t i e n t was provided w i t h new eyeglasses. ~i r T ~ i — ' Tffl—"TfnrT" |*1T~-"rTr-Tir"TTTTTiniTTir'nT Hfr*T 'Tr~if~i-i—nnmntmr n i n wiMinin— rumr i irrr r irrf •iwrwiiri ri'pawni nnn n—-pi nwMMiiW '•iiMHiiinnn)iiM)finii«i»niiw »wt>«MffM«WMB»M»K 1 Boarding Home care c o s t s #65.00 per month. Residents In Boarding Homes under the care of the C i t y S o c i a l S e r v i c e Department r e c e i v e #7.00 personal allowance which i s i n a d d i t i o n to the #65.00. % T h i s i s a v a i l a b l e t o a l l r e c i p i e n t s of S o c i a l A s s i s -tance without c o s t to themselves* - 70 -I n c o n s i d e r i n g the Casework Techniques I&oployed, i t i s noted that fourteen p a t i e n t s r e c e i v e d face to face i n t e r v i e w s . One p a t i e n t r e c e i v e d i n d i r e c t h elp through the i n t e r v i e w s w i t h h i s w i f e . F i f t e e n p a t i e n t s r e c e i v e d d i r e c t environmental h e l p through the contact w i t h a coxmaunlty resource. Two p a t i e n t s were noted to have been given " p s y c h o l o g i c a l s u p p o r t . * 1 Of the f i f t e e n p a t i e n t s who received a s s i s t a n c e b e n e f i t s , e i g h t p a t i e n t s showed improvement i n t h e i r psycho-l o g i c a l c o n d i t i o n , and seven d i d not. Four of the cases presented severe f a m i l y disturbances In which the care of young c h i l d r e n was Involved. Although i n three o f these cases s e r v i c e was terminated, the p s y c h o l o g i c a l c o n d i t i o n of these p a t i e n t s was not thought to show improvement. Under the s e c t i o n Observations, note i s made tha t I n most cases r e c o r d i n g was up-to-date and contained an assessment of s o c i a l data and recommendations. Data were thus e a s i l y obtained. Diganosis of the b a s i c p s y c h o l o g i c a l problems i n most cases was overlooked. Treatment i n th© main was i n meeting economic need and p h y s i c a l d i s t r e s s . C e r t a i n cases showed some attempt by the agency to improve th© p a t i e n t ' s p s y c h o l o g i c a l c o n d i t i o n . At c l o s u r e , no case was r e f e r r e d to a community agency f o r continued casework h e l p , 1 The theory could be maintained t h a t a l l the p a t i e n t s r e c e i v e d p s y c h o l o g i c a l support by meeting t h e i r economic heed. C e r t a i n l y new eyeglasses and r e p a i r of dentures would hel p . C l a s s i f i c a t i o n o f casework s e r v i c e s h e l p s t o demonstrate s y s t e m a t i c a l l y th© k i n d of casework h e l p employed, and the s e r v i c e g i v e n to the c l i e n t . - 71 although emotional need was s t i l l e v ident. This was again v e r y c l e a r i n those cases showing evidence of severe f a m i l y disturbance, and i n v o l v i n g the care of young c h i l d r e n . At the time of the study i n January, 1 9 5 S , seven p a t i e n t s were s t i l l r e c e i v i n g h e l p and e i g h t were not. I n concluding the present ehapter, i t must be Stated again, that although s o c i a l s e r v i c e h elp was given, the f u n c t i o n and p o l i c y of the agency l i m i t e d the h e l p t o r e l i e f of environmental pressures. A forward-looking philosophy considers t h a t a l l human resources must be conserved and strengthened; that I n times of s t r e s s and l a c k of l i v e l i h o o d , p r o v i s i o n must be made f o r emotional s o c i a l and economic s e c u r i t y . Every e f f o r t was made by the s t a f f of the C i t y S o c i a l Service Department t o meet economic need; In many cases, however, the s o c i a l and emotional s t r e s s e s remained unmodified* The c l i e n t s were not r e f e r r e d f o r h e l p w i t h these problems to re l e v a n t agencies. CHAPTER Jj., DISCHARGED ME1TAL PATIENTS AHD PLAUS FOR THEIR CARE Purpose of the Present Study Between January 1, 19S>4 and December 31, 1954* 1,256 r e s i d e n t s of B r i t i s h Columbia were h o s p i t a l i z e d a t the Crease C l i n i c of P s y c h o l o g i c a l Medicine. Of t h i s t o t a l group, 480 l i v e d i n Vancouver. 1 According t o the records of the Grease C l i n i c , only f i f t e e n , or s l i g h t l y more than 3.01 per cent, who l i v e d i n Vancouver, r e q u i r e d f i n a n c i a l a s s i s t a n c e from a p u b l i c a s s i s t a n c e agency. This f i g u r e i n c l u d e s o n l y those who were l e g a l l y e l i g i b l e f o r p u b l i c a s s i s t a n c e , and would not i n c l u d e those p a t i e n t s whose f i n -a n c i a l s t r e s s was not severe enough to meet l e g a l e l i g i b i l i t y . S c h l e s i n g e r a l s o noted a low percentage of f i n a n c i a l indigence i n the group o f p a t i e n t s he s t u d i e d , n e v e r t h e l e s s , f i n a n c i a l a s s i s t a n c e s t i l l c o n s t i t u t e s one o f s e v e r a l major f u n c t i o n s In s o c i a l work p r a c t i c e , and should, t h e r e f o r e , be studied i n r e l a t i o n to severe s o c i a l adjustment problems of Canadian c i t i z e n s , i n c l u d i n g those who have been h o s p i t a l i z e d f o r mental i l l n e s s . The present study has attempted to examine the casework s e r v i c e s given to f i f t e e n discharged mental p a t i e n t s 1 Mental H e a l t h S e r v i c e s Report, op. c i t . . . p, R 84. 2 S c h l e s i n g e r , op. c i t . . p. 26. - 73 -toy two s o c i a l s e r v i c e departments w i t h i n the Greater Van-couver area of B r i t i s h Columbia* The focus o f the study has been t o examine the psy c h o s o c i a l problems of the discharged mental p a t i e n t r e f e r r e d to a P u b l i c A s s i s t a n c e Agency. The problems were c l a s s i f i e d according t o f i n a n c i a l need, accommodation, employment and emotional s t r e s s e s . The study has f u r t h e r asked how adequately the p u b l i c a s s i s t a n c e agency i s able t o meet these needs. An attempt has been made to examine the nature of the casework Ser v i c e s i n v o l v e d i n the h e l p i n g process i n the ps y c h o s o c i a l adjustment o f the p a t i e n t s studied. S o e i a l Work P r a c t i c e and t h e Heed f o r Research S o c i a l Welfare programmes are now f i r m l y entrenched w i t h i n the framework of f r e e democratic s o c i e t y . A recog-n i z e d r e s p o n s i b i l i t y of a government i s p r o v i s i o n f o r the we l f a r e o f the people, t h a t i n times of s t r e s s and l a c k of l i v e l i h o o d , p r o v i s i o n be made f o r s o e i a l , economic and emot-i o n a l s e c u r i t y . The r e s p o n s i b i l i t i e s of governments and the e v o l u t i o n of s o c i a l w e l f a r e s e r v i c e s must always be c l o s e l y a l l i e d i n respect o f the needs of people and the p r o v i s i o n o f s e r v i c e s to meet need. According t o the t h i n k i n g of a prominent s o c i a l worker,! s o c i a l work has a great c o n t r i b u t i o n to make i n 1 Altmeyer, A r t h u r J . , T r a i n i n g f o r I n t e r n a t i o n a l Respon- s i b i l i t y . Columbia U n i v e r s i t y P r e s s , New York, 1955, p. 58. - 74 * convincing the common people that democratic governments are making every e f f o r t to improve t h e i r l o t , and t h a t they are s i g n i f i c a n t p a r t i c i p a n t s i n that e f f o r t . " S o c i a l work has been recognized as b i g business i n two respeets; i t c o s t s a great deal of money and i t a f f e c t s a great number of pe o p l e . " 1 S o c i a l work holds a s i g n i f i c a n t place i n both v o l u n t a r y community e n t e r p r i s e and i n government. S o c i a l work must, t h e r e f o r e , render an account of the way i t attempts to meet the needs of people. This does not suggest that s o c i a l work and s o c i a l workers should be s i n g u l a r l y pre-occupied w i t h e i t h e r good s o e i a l work p r a c t i c e or w i t h bad s o c i a l work p r a c t i c e . The i m p l i c a t i o n of Mr. A l t m e y e ^ s statement r e f e r r e d t o e a r l i e r , as to the relevancy of t h i s study i s c l e a r s however, I n s o f a r as s o c i a l work p r a c t i c e i n a l l areas i s designed to meet need, s o c i a l workers them-selves should be w i l l i n g to make a c r i t i c a l examination of t h e i r own p r a c t i c e . Some agencies have employed experts i n research to study t h e i r easework p r a c t i c e s . In the i n t e r e s t of the growing s o c i a l work p r o f e s s i o n i t would seem that caseworkers themselves must see the value of such research and be w i l l i n g to p a r t i c i p a t e i n i t . Human Aspect of S o c i a l Welfare Programmes Human needs have been recognized i n some form i n a l l s o c i e t i e s s ince the dawn of c i v i l i z a t i o n . S o c i a l work, w h i l e , x French, David G.. An Approach to Measuring the R e s u l t s  i n S o c i a l Work. Columbia U n i v e r s i t y P r e s s . New York, 1 9 5 2 , p. 1 2 . - 70 -a comparatively "young" p r o f e s s i o n , i s , nevertheless* the modern v e r s i o n of the democratic attempt to meet human needs. The performance of s o c i a l work must therefore be judged I n r e l a t i o n to the stage o f development I t has reached, Con* s i d e r a t i o n must a l s o be given to the f a c t t h a t the s t r u c t u r e of the s e r v i c e s which brought s o c i a l work i n t o being i s , i n the main, sound—the r e s u l t o f long experience. The growth of the we l f a r e s t r u c t u r e of t h i s era represents some of mankind's most promising advances I n the s o l u t i o n of many human problems, echoing the concept spoken many years ago, Man s h a l l not l i v e by bread only. I n attempting t o meet i n d i v i d u a l need, s o c i a l work s e r v i c e s must deal w i t h the e f f e c t the need has ereated---not o n l y i n the realm of econ-omics, but what has happened i n the I n d i v i d u a l ' s c u l t u r a l and p s y c h o l o g i c a l adjustment. The p r o f e s s i o n of s o c i a l work has accumulated Some knowledge about the needs of I n d i v i d u a l s , and experience of how i n d i v i d u a l s r e a c t to s i t u a t i o n s which produce inner and outer s t r e s s e s . The record o f t a i l s must be contained I n every case f i l e of those i n d i v i d u a l s who, because of t h e i r v a r y i n g needs, Seek the h e l p of s o c i a l workers. The assessment and i m p l i c a t i o n s of t h i s knowledge and experience should not only be a v a i l a b l e to the s o c i a l work p r o f e s s i o n , but should provide the b a s i s f o r research programmes designed to improve o r modify w e l f a r e p r o j e c t s . Knowledge must be used and must be shared. Complacency which d e r i v e s s a t i s f a c t i o n from hi g h c o s t s of a w e l f a r e programme - 76 -e i t h e r i n the case of the mentally 111 or i n p u b l i c a s s i s t a n c e i s s t e r i l e u nless the programmes are designed and operated to meet the b a s i c p h y s i o l o g i c a l and p s y c h o l o g i c a l needs of people. The s e r v i c e s w i l l be i n t e r p r e t e d and used by the people a c c o r d i n g l y , S o c i a l w e l f a r e s e r v i c e s must be l i v i n g processes. The h i g h e s t i d e a l s of a p r o g r e s s i v e t h i n k i n g must i n f u s e the r e a l i s m o f s c i e n t i f i c c o n s i d e r a t i o n s i n the p r o v i s i o n of budgets and a d m i n i s t r a t i o n of s o c i a l s e r v i c e s . S o c i a l w e l f a r e s e r v i c e s , w h i l e concerned w i t h i n d i v i d u a l need, should, through research e f f o r t , o f f e r c o n s t r u c t i v e methods of d e a l i n g w i t h s o e i a l problems. To do t h i s more e f f e c t i v e l y , Welfare A d m i n i s t r a t o r s must be more concerned w i t h human we l f a r e i n the broad sense and w i t h human need wherever i t a r i s e s . Through agency research, the study of man as an I n d i v i d u a l and as a s o c i a l being, would not only provide enlightened s e r v i c e s , but xtfould a l s o a i d i n the f o r m u l a t i o n of preventive measures to meet emergency needs and s i t u a t i o n s * beyond the c o n t r o l of the i n d i g e n t and S o c i a l l y marginal i n d i v i d u a l . Such study would a l s o consider daring and courageous measures to provide r e h a b i l i t a t i o n s e r -v i c e s f o r many chro n i c p h y s i c a l and p s y c h o l o g i c a l c r i p p l e s , who* w i t h c o n s i s t e n t help* c o u l d lead more u s e f u l and s a t i s f y -i n g l i v e s . These comments are o f f e r e d as c o r o l l a r y to the f i n d i n g s o f t h i s study, w i t h r e c o g n i t i o n of the f a c t t h a t theory must be t e s t e d by p r a c t i c e , and p r a c t i c e r e f i n e d by t e s t e d t h e o r i e s ; t h a t growth and development might occur, - 77 -t h i s must always he so. E f f e c t i v e planning and sound s t r u c t u r i n g of broad s o c i a l welfare' programmes have, t h e r e f o r e , to consider how the human element can e n l i v e n the s e r v i c e s designed ,to meet the s t r e s s e s and s t r a i n s of i n d i v i d u a l s , T h i s concept a l s o a p p l i e s to th© s e r v i c e s provided i n p s y c h i a t r i c h o s p i t a l s * A l b e i t , i n s t i t u t i o n s f o r the care and treatment of the mentally i l l do not always provide environments i n which h e a l t h can be r e s t o r e d . This has been s u c c i n c t l y demon-s t r a t e d by Stanton and Swartz through research s t u d i e s , showing t h a t p a t i e n t s can be adversely a f f e c t e d by such s i t -u a t ions as disagreement about t h e i r care by s t a f f members, r e a c t i n g to the d i s t u r b e d atmosphere w i t h i n c r e a s e d a g i t -a t i o n and t e n s i o n . The P a t i e n t and H i s Return to the Community To be v a l i d and e f f e c t i v e , therapeutic e f f o r t must be r e l a t e d to the needs of the p a t i e n t and to the s p e c i f i c c o n d i t i o n s surrounding h i s i l l n e s s . I t i s o f t e n d i f f i c u l t to separate the p a r t of the problem which belongs to the p a t i e n t and the p a r t that i s r e l a t e d to h i s being a member of a f a m i l y u n i t . The f a c t o r s t h a t i n f l u e n c e him toward i l l n e s s and the f a c t o r s t h a t i n f l u e n c e him toward h e a l t h are i n t e r t w i n e d . While these f a c t o r s are known to be psy-c h o l o g i c a l s o c i a l , economic and medical, i n a c t u a l i t y i t i s d i f f i c u l t t o make c l e a r cut d i s t i n c t i o n s between them and other elements which c o n t r i b u t e t o stress,and breakdown — 78 *» i n mental h e a l t h . The review o f the cases under study demonstrated that each p a t i e n t had many d i f f i c u l t i e s and concerns which were c o n t r i b u t i n g elements i n t h e i r i l l n e s s . Treatment i n h o s p i t a l may have Improved h i s p s y c h i a t r i c syndrome, but t h i s very improvement may have created f u r -t h e r d i f f i c u l t i e s f o r him i n h i s normal s o c i a l environment out s i d e the h o s p i t a l . An example of t h i s c o n s i d e r a t i o n i s noted i n Case 4 , A f i f t y - o n e year o l d unemployed f i s h e r -man, who had s u f f e r e d from severe asthma, had no r e l a t i v e s or f r i e n d s , which was p o s s i b l y the r e s u l t o f gradual deter-i o r a t i o n i n h i s emotional c o n d i t i o n . During seventeen weeks i n h o s p i t a l , helped by psychotherapy, h i s p s y c h i a t r i c syn-drome improved and he began to r e l a t e b e t t e r to the, h o s p i t a l s t a f f and to other p a t i e n t s . He became one o f a group, ther e f o r e he was l e s s l o n e l y and s o l i t a r y . Having no f r i e n d s or r e l a t i v e s i n t e r e s t e d i n him, h i s r e t u r n to the community would be a f e a r f u l experience f o r him. One of the d i s t u r b i n g elements c o n t r i b u t i n g to h i s breakdown would be l a c k of means o f communication w i t h people In the group. Such a weak p e r s o n a l i t y would r e q u i r e Support i n making the attempt t o r e - j o i n the group. While i t might be presumed t h a t t h i s i s an i s o l a t e d case, w i t h the shortage of s o c i a l work s t a f f , a trend might be i n d i c a t e d . Por most p a t i e n t s , the t r a n s i t i o n from the h o s p i t a l to the community i s a serious and d i f f i c u l t one. Should the p a t i e n t be discharged prematurely or I f he i s not gi v e n adequate h e l p duri n g the t r a n s i t i o n p e r i o d , the p o s s i b i l i t y o f h i s re-admission to h o s p i t a l I s g r e a t l y - 79 -increased., Many p a t i e n t s may Improve i n h o s p i t a l o n l y t o r e t u r n to a s i c k environment. Hot a l l environmental s i t -u a t i o n s are c o r r e c t a b l e or amenable to m o d i f i c a t i o n * and i t may be d e s t r u c t i v e o r even harmful to'have the p a t i e n t r e t u r n to the environment where he became i l l . Case .2 g i v e s an example, of such a s i t u a t i o n * The p a t i e n t who had a long h i s t o r y of somatic complaints was unhappily married and l e g a l l y separated from h i s w i f e . The tensions i n the m a r i t a l s i t u a t i o n produced exacerbation of M s f u n c t i o n a l symptoms. A poor work h i s t o r y , w i t h inade-quate p r o v i s i o n and recourse to a s s i s t a n c e aggravated the s t r e s s e s i n t h i s f a m i l y . The p a t i e n t gave a h i s t o r y of frequent re-unions w i t h h i s w i f e and i t was noted t h a t h i s recovery was hampered w h i l e he l i v e d I n th© midst of the t u r m o i l of m a r i t a l disharmony. Before t h i s p a t i e n t was admitted to the Crease C l i n i c , much time, e f f o r t and s k i l l had been expended to pl a n support f o r t h i s man to keep him away from an environ -ment i n which he became i l l . Could t h i s have been c a r r i e d a step f u r t h e r by r e f e r r a l t o the Family Agency, both pat-i e n t and h i s w i f e may have been helped to r e s o l v e t h e i r f e e l i n g s , and the p a t t e r n of i l l n e s s and i n s t a b i l i t y d e a l t w i t h more e f f e c t i v e l y . Again i t i s recognized t h a t had more s o c i a l workers been a v a i l a b l e i n both agencies, a b e t t e r coordinated s e r v i c e 80 -could have been given to t h i s f a m i l y . Mention i s a l s o mad© of the short l e n g t h of many p a t i e n t ' s stay i n h o s p i t a l , o f t e n being discharged p r e c i p i t o u s l y which causes s t r a i n on the e x i s t i n g h o s p i t a l s e r v i c e s . Should the discharge of a p a t i e n t i n t e r r u p t or preclude the beginning of adequate discharge p l a n n i n g , a considerable problem f o r the s o c i a l worker o f t e n f o l l o w s * I n the f i r s t chapter of t h i s study, d i s c u s s i o n was made of the "unknown f a c t o r " which o f t e n i n f l u e n c e s the th e r a -p e u t i c process. The extensiveness of t h i s concept pervades the t h e r a p e u t i c process which goes beyond th© operation of the i n s t i t u t i o n . The in f e r e n c e of change i n the p a t i e n t ' s environment may prevent or impede h i s r e t u r n , eausing him to seek other resources i n h i s e f f o r t t o f i n d a place f o r h i m s e l f . I n the per i o d when h i s breakdown I n f u n c t i o n i n g was t a k i n g p l a c e , h i s behaviour may have caused a serious r i f t i n h i s r e l a t i o n s h i p s w i t h h i s f a m i l y . The f e e l i n g s of g u i l t which such s i t u a t i o n s produee may so overwhelm the p a t i e n t , that he f e e l s he cannot r e t u r n to the Intensive r e l a t i o n s h i p s w i t h i n the f a m i l y s t r u c t u r e . Frequently, too, the f a m i l y has r e s i s t a n c e to t a k i n g hira back} a l l of which adds to h i s s t r a i n and to the problem of h i s r e h a b i l i t a t i o n . Case l i j . i l l u s t r a t e s t h i s p o i n t . From the in f o r m a t i o n on the C i t y S o c i a l S e r v i c e record g i v e n by the p a t i e n t ' s r e l a t i v e s , i t Was evident t h a t h i s p o o r l y motivated p e r s o n a l i t y f u n c t i o n i n g , seen i n h i s i n a b i l i t y to handle money, h i s frequent change 81 -of jobs, and h i s I n d i s c r i m i n a t e borrowing of money had caused severe d i f f i c u l t i e s f o r h i s aged parents, h i s w i f e , and c h i l d r e n . The p a t i e n t was discharged a t three weeks, h i s c o n d i t i o n , "Unimproved." A f t e r a b r i e f p e r i o d on S o c i a l A s s i s t a n c e , he found u n s u i t a b l e employment which soon f o l d e d up. He again d i s t u r b e d h i s r e l a t i v e s whose resources were s t r a i n e d as they attempted to h e l p . A f t e r c l o s u r e of the case, the C i t y S o c i a l S e r v i c e Department re c e i v e d communication from the p a t i e n t * s s i s t e r , s t a t i n g t h a t the s i t u a t i o n had d e t e r i o r a t e d . This case appears to i l l u s t r a t e the l a c k of planned resources to h e l p w i t h the problems of what appears to be the beginning of a hard core problem f a m i l y . Prevention of p s y c h o l o g i c a l d i f f i c u l t i e s In the development of two small c h i l d r e n would seem to be a c o n s i d e r a t i o n i n such cases. Heed f o r A f t e r Care S e r v i c e s f o r P a t i e n t s There i s evident need f o r more adequate After-Care Service f o r a l l p a t i e n t s . C u r r e n t l y committees throughout North America and elsewhere are undertaking r e s p o n s i b i l i t y f o r o r g a n i z i n g and maintaining After-Care S e r v i c e s . Hos-p i t a l , . s t a f f s , s t a f f s and Boards of Community Agencies, and c i t i z e n leaders i n s o c i a l planning are banding together to t a c k l e t h i s problem. Because these programmes are so r e c e n t l y i n s t i t u t e d , and, Indeed, w i t h many of them s t i l l i n the planning phase, the gaps i n community resources as shown i n the cases stu d i e d here are evident. - 82 -The r e p o r t of the I n s t i t u t e on S o c i a l Work i n psy-c h i a t r i c h o s p i t a l s emphasizes t h i s concepts I n c r e a s i n g l y i t i s recognized t h a t the p a t i e n t ' s i l l n e s s s t a r t e d i n the community, t h a t he may need h o s p i t a l i z a t i o n d u r i n g a phase of h i s i l l n e s s , and when h o s p i t a l i z a t i o n i s no longer necessary he returns to h i s community, which has r e s p o n s i b i l i t y f o r him. There needs to be b e t t e r i n t e g r a t i o n and use of com-munity h e a l t h and welfar e resources, so that there i s l e s s need to extend the h o s p i t a l unwisely i n t o the community. The i n d i v i d u a l should be returned to h i s community as a e i t i z e n and not as a p a t i e n t . To do t h i s the h o s p i t a l a d m i n i s t r a t i o n has r e s p o n s i b i l i t y f o r making known the needs of the h o s p i t a l to the community, and f o r h e l p i n g s o c i a l and h e a l t h agen-c i e s to understand i n what way t h e i r s e r v i c e s can be h e l p f u l to the continued r e h a b i l i t a t i o n of the men-t a l l y i l l person i n h i s community.! As the h o s p i t a l i s p a r t o f the community, i t should always be considered p a r t of community planning. The present p r a c t i c e i n Vancouver o f p r o v i d i n g After-Care S e r v i c e tends to be a mixture between the psy-c h i a t r i c s o c i a l worker p r o v i d i n g s e r v i c e , and r e f e r r a l to a community agency f o r a s p e c i f i c s e r v i c e such as f i n a n c i a l a s s i s t a n c e . The study has shown tha t when f i n a n c i a l a s s i s -tance i s no longer needed by the p a t i e n t , the C i t y S o c i a l Service Department c l o s e s the case. I n Cases 3 , l l j . , and 1 5 , there appeared to be need f o r continued After-Gare S e r v i c e s to the discharged p a t i e n t because the major psy-c h o l o g i c a l d i f f i c u l t i e s remained unmodified by the s e r v i c e s already given t o them. I n cases l i j . and 1 $ , the discharged p a t i e n t appeared to continue to create d i f f i c u l t i e s f o r h i s 1 Knee, Ruth I . , E d i t o r , B e t t e r S o c i a l S e r v i c e s - f o r M e n t a l l y 111 P a t i e n t s . American A s s o c i a t i o n o f P s y c h i a t r i c S o c i a l Workers, Inc., New York, 1 9 5 3 , p. 7 3 . f a m i l y . I n urban communities, complicated questions of agency f u n c t i o n and r e s p o n s i b i l i t y f o r chronic cases, o f t e n r e s u l t i n the p a t i e n t r e c e i v i n g inadequate s e r v i c e s . R i g i d agency p o l i c i e s tend to defeat I n t e g r a t i o n of community resources. In the cases o f discharged mental p a t i e n t s , the r e s p o n s i b i l i t y f o r c l a r i f i c a t i o n must be shared by the p s y c h i a t r i c h o s p i t a l and agency a d m i n i s t r a t i o n s . To add to the d i f f i c u l t y of the i n d i v i d u a l s o c i a l worker* agencies do not have c l e a r l y defined statements of cooperative p o l i c y and f u n c t i o n . U n t i l such statements are c l e a r l y formulated, contained i n an agency p o l i c y manual, and a v a i l a b l e to other community agencies, inadequate s o c i a l s e r v i c e s w i l l continue to defeat the purpose of p r o v i d i n g s e r v i c e s to c l i e n t s . 1 This d i s c u s s i o n prepares f o r comments about r e f e r r a l p o l i c i e s between agencies. C l e a r , e f f i c i e n t , mean-i n g f u l r e f e r r a l s are r e l a t e d to sound casework p r a c t i c e , and i n v o l v e the use of the systematic process of s o c i a l study, s o c i a l diagnosis and s o c i a l treatment. The i m p l i c a t i o n i s c l e a r t h a t p a t i e n t s be r e f e r r e d to a community agency, o n l y , i f h i s needs are f o r support and casework h e l p . The agency should not be expected to provide p s y c h i a t r i c A f t e r - C a r e , The medical and p s y c h i a t r i c c o n t r o l s are not to be found i n a community agency. The cases under review i n d i c a t e the 1 I t i s the w r i t e r ' s o p i n i o n that these impressions have been v e r b a l i z e d by a l a r g e number of s o c i a l worker p r a c t i t -i o n e r s . - 8k -urgent need f o r s e r v i c e s provided i n a p s y c h i a t r i c out-p a t i e n t s c l i n i c . This s e r v i c e would, however, demand even more a v a i l a b l e s t a f f . At the present r a t e of recruitment and the l e n g t h of time, h i g h expense of t r a i n i n g , w i l l t h i s s t a f f ever be a v a i l a b l e ? Examples of R e f e r r a l P o l i c y The r e f e r r a l s of the cases under review appear to i n d i c a t e the l a c k of c l e a r l y d e f i n e d p o l i c i e s of r e f e r r a l between agencies. One r e f e r r a l study has shown t h a t ; * A. 1. H o s p i t a l S o c i a l S e r v i c e Departments should have a w r i t t e n Statement of p o l i c y oh; a) types of problems th a t are s u i t a b l e f o r r e f e r r a l to community agencies; b) s p e c i f i c methods and procedure of r e f e r r a l . 2. C o n s u l t a t i o n and casework s u p e r v i s i o n , i s a d v i s -able i n complex s i t u a t i o n s o r i n s i t u a t i o n s i n v o l v i n g the q u e s t i o n of s u i t a b i l i t y o f r e f e r r a l to a p a r t i c u l a r agency o r as t o c h o i c e of agency. B. R e f e r r a l Procedures would i n v o l v e ; 1. Helping the p a t i e n t accept r e f e r r a l . 2. Preparing the r e f e r r a l agency to be r e c e p t i v e to the p a t i e n t . 3. Seeing t h a t the p a t i e n t a c t u a l l y gets to the r e f e r r a l agency. 1 Wilson, Eunice W., and B a r t l e t t , H a r r i e t M., " R e f e r r a l s from H o s p i t a l t o S o e i a l Agencies," S o c i a l Casework. V o l . 36, Ko. 6, December, 1900. 85 0. Suggested Procedures to be followed would Include; 1. When complex problems are under c o n s i d e r a t i o n a face to fae© conference between the two agencies would be necessary. 2. A l l r e f e r r a l s should be confirmed i n w r i t i n g . L e t t e r s of r e f e r r a l should s t a t e c l e a r l y the medical and p s y c h i a t r i c problem, the s o c i a l i m p l i c a t i o n s , and c l a r i f i -c a t i o n of the r e s p o n s i b i l i t y f o r each agency* 3* Gases i n which r e s p o n s i b i l i t y i s to be shared, d i v i s i o n o f r e s p o n s i b i l i t y should be c l a r i f i e d as e a r l y as p o s s i b l e , and a t frequent i n t e r v a l s as s i t u a t i o n s change. 1$.. J o i n t conferences h e l d r e g u l a r l y might be necessary to review cases r e c e i v i n g s e r v i c e , D* A p p l i c a t i o n of Gasework P r i n c i p l e s . 1. The caseworker i n the h o s p i t a l should have a c l e a r understanding o f the p a t i e n t ' s problem i f the r e f e r r a l i s to be s u c c e s s f u l . 2. The p a t i e n t should understand and accept the reason f o r r e f e r r a l and p a r t i c i p a t e i n the process. 3. The reason f o r the r e f e r r a l should b© c l e a r to the r e f e r r a l agency. Whil® t h i s r e q u i r e s accurate s o c i a l , d i a g n o s i s by the r e f e r r i n g agency, i t i m p l i e s that the r e f e r r a l agency a l s o has r e s p o n s i b i l i t y i n determining the s e r v i c e to be provided* (This should not be done when the p a t i e n t i s on th© doorstep.) 86 Jj.. Both agencies should have a c l e a r understanding of t h e i r r e s p o n s i b i l i t y a t the p o i n t of r e f e r r a l . The above c o n s i d e r a t i o n s a l s o suggest t h a t s e r i o u s r e f l e c t i o n should be given to s e l e c t i o n methods used by agencies i n g i v i n g s e r v i c e . This p a r t i c u l a r l y a p p l i e s to some of the cases o f the study. For example, a very s p e c i f i c set o f p r i o r i t i e s f o r s e l e c t i o n would e s t a b l i s h c r i t e r i a f o r g i v i n g s e r v i c e . I n v e s t i g a t i o n regarding the care of c h i l d -ren, and the c o n s i d e r a t i o n of pr e v e n t a t i v e measures on t h e i r b e h a l f would suggest major p r i o r i t y . Where severe f a m i l y disturbance i s the major d i f f i c u l t y , aggravated by f i n a n c i a l need, the c o n s i d e r a t i o n of j o i n t community s e r v i c e i n such cases poses s e r i o u s c o n s i d e r a t i o n f o r the As s i s t a n c e Agency, p a r t i c u l a r l y i n cases which ar© known to them before the mental breakdown of one of the parents. Hot a l l p u b l i c a s s i s t a n c e agencies are able to accept work w i t h f a m i l i e s . When f i n a n c i a l need was met i n the cases s t u d i e d , the case was c l o s e d and there was no record of a r e f e r r a l to a f a m i l y or c h i l d r e n ' s agency even where f a m i l y problems are i n d i c a t e d . As long as i t i s necessary f o r the p u b l i c a s s i s t a n c e agency to c l o s e the case when the p a t i e n t I s no longer i n need of f i n a n c i a l a i d , even though other s o e i a l adjustment problems are evident, s e r i o u s gaps i n community s e r v i c e s to c l i e n t s w i l l Continue to jeo p a r d i z e the p a t i e n t ' s r e h a b i l i t a t i o n . At the p o i n t when c l o s u r e seemed imminent c o n s u l t a t i o n w i t h r e l a t e d agencies may have made much needed s e r v i c e a v a i l a b l e . - 87 -Suggestions Recommended by the Study I n a l l cases s t u d i e d the C i t y S o c i a l Service Department c a r r i e d through most adequately i t s r e s p o n s i b i l i t y f o r meeting f i n a n c i a l need w i t h i n the p r o v i s i o n s of the law. I t gave adequate medical s e r v i c e s as defined by present p o l i c y . The r e c o r d i n g of the s e r v i c e s g i v e n , as formulated i n t h e i r p o l i c y , was c l e a r and the data e a s i l y obtained. Because adjustment problems shown i n the case records p o i n t out the need f o r more extensive s o c i a l work coverage i n order to meet a l l adjustment needs, the f o l l o w i n g p o i n t s are suggested. 1. That r e g u l a r c o n s u l t a t i o n between the Grease C l i n i c S o c i a l S e r v i c e Department and the C i t y S o c i a l S e r v i c e Department be recommenced, that c l e a r e r d e f i n i t i o n s of p o l i c y and r e l a t e d r e s p o n s i b i l i t y f o r s e r v i c e s may be formulated. 2. The establishment of a small s p e c i a l i z e d depart-ment, s t a f f e d by experienced p r o f e s s i o n a l s o c i a l workers to be r e s p o n s i b l e f o r a Smaller, more s e l e c t i v e caseload to g i v e comprehensive casework s e r v i c e s to e l i g i b l e f a m i l i e s ( I n c l u d i n g the e l i g i b l e f a m i l i e s of discharged mental pat-i e n t s , and e l i g i b l e discharged mental p a t i e n t s where r e h a b i l i t a t i o n I s a p o s s i b i l i t y ) . 3. An a l t e r n a t i v e to t h i s p l a n would be g r a n t i n g o f f i n a n c i a l a i d w h i l e s p e c i a l i z e d community agencies give s e r v i c e s to meet other major problems. The element of prev-e n t i o n would be recognized and u l t i m a t e economy to the - 88 agency would r e s u l t . 3. Consi d e r a t i o n of adapting the r u r a l p o l i c y of an a l l round s e r v i c e to meet urban needs. This would i n v o l v e c o n t i n u a t i o n of s e r v i c e beyond f i n a n c i a l e l i g i b i l i t y . ||. Each of the above con s i d e r a t i o n s would i n v o l v e the agency i n e s t a b l i s h i n g a very e f f i c i e n t screening and r e f e r r a l s e r v i c e . $. The establishment of and r e g u l a r c o n s u l t a t i o n w i t h a s e l e c t e d community agency committee to consider the i n v o l v e d problems In many of these cases, and to suggest methods of s e r v i c e . Conclusion The study has examined the cases of f i f t e e n d i s -charged mental p a t i e n t s who, i n 1954, were r e f e r r e d to the C i t y S o c i a l Service Department. Examination of the psycho-l o g i c a l and s o c i a l problems i n v o l v e d i n the p a t i e n t ' s hos-p i t a l i z a t i o n and eventual discharge t o the community, has revealed the n e c e s s i t y f o r the re-commencement of r e g u l a r c o n s u l t a t i o n s between the a d m i n i s t r a t i o n o f the Crease ' C l i n i c S o c i a l S e r v i c e Department, and the a d m i n i s t r a t i o n of the C i t y S o c i a l S e r v i c e Department. Because of the s p e c i a l d i f f i c u l t i e s of the d i s -charged mental p a t i e n t which i n v o l v e s A f t e r - C a r e S e r v i c e s , the study has suggested the value of a Community Resource Planning Conference between The P s y c h i a t r i c H o s p i t a l - 89 -a d m i n i s t r a t i o n and the r e p r e s e n t a t i v e s of Selected Community Agencies. The study has made suggestions whereby the C i t y S o c i a l Service Department could more adequately meet the t o t a l w e l f a r e needs of s e l e c t e d c l i e n t s , i n c l u d i n g the e l i g -i b l e discharged mental p a t i e n t . Recognition has been made of the f a c t that the C i t y S o e i a l Service Department i s meeting s p e c i f i c economic and p h y s i c a l needs, but because of present p o l i c y the p s y c h o l o g i c a l problems of most of the p a t i e n t s studied were unmodified at the c l o s u r e of the case. I n cases where severe major f a m i l y d i f f i c u l t i e s were evident, the p a t i e n t s were not r e f e r r e d to other agencies f o r continued s e r v i c e . I t i s recognized t h a t the p o l i c i e s of other commun-i t y agencies may impede t h i s , and may giv e r i s e to the need f o r c l e a r e r statements of p o l i c y from agencies. I d e a l l y the w r i t t e n statements o f p o l i c y of a l l community agencies should be f r e e l y exchanged and used i n the i n t e r e s t of b e t t e r s e r -v i c e s t o c l i e n t s . A f u r t h e r research study might be undertaken at the C i t y S o c i a l S e r v i c e Department to examine /the use made of community resources upon c l o s u r e o f a case where f u r t h e r problems are i n v o l v e d i n the p s y c h o l o g i c a l d i f f i c u l t i e s of the i n d i v i d u a l or f a m i l y concerned. I n the r e h a b i l i t a t i o n of the discharged mental p a t i e n t , the community has a l a r g e stake. P s y c h i a t r i c treatment i s a means to an end. The o b j e c t i v e i s r e h a b i l i t a t i o n , - 90 the r e t u r n of the p a t i e n t to the community and h i s f u n c t i o n -i n g i n t h a t environment In a reasonably adequate and s a t i s -f y i n g way, f o r i t i s w i t h i n the p a t i e n t ' s world of human and s o c i a l r e l a t i o n s h i p s that r e h a b i l i t a t i o n i s f i n a l l y achieved. I n progressive t h i n k i n g p u b l i c assistance programmes the o b j e c t i v e must be the prevention of dependency* and p s y c h o l o g i c a l m a l f u n c t i o n i n g that the r e h a b i l i t a t i o n of the c l i e n t to usefulness and f u n c t i o n i n g i n h i s environment i n a reasonably adequate and s a t i s f y i n g way might be achieved. "Report on A d m i n i s t r a t i v e Survey of the M u n i c i p a l Government, C i t y of Vancouver, B r i t i s h Golumbia," P u b l i c A d m i n i s t r a t i o n S e r v i c e , Chicago, 1905. This r e p o r t was not a v a i l a b l e i n time t o be used i n t h i s study. The recommendations d e a l t w i t h on pp. 112 to 121 i n d i c a t e that the suggestions made i n the present study In some measure are su b s t a n t i a t e d by the f i n d i n g s of the l a r g e r research p r o j e c t . Appendix A. Schedule Used a t the Grease C l i n i c 1. a) name and b) Number. 2. a) Sex. b) Age. 3. a) M a r i t a l S t a t u s , b) Number and ages of c h i l d r e n . Employment Record. 5>. Education. 6. a) Bate of Admission, b) Date of Discharge, c) Date of S o c i a l Service A c t i v i t y . 7. Co n d i t i o n upon Discharge. a) improved, b) Unimproved. 8. P r e c i p i t a t i n g Causes of R e f e r r a l , 9. P s y c h i a t r i c Diagnosis. 10. S o c i a l Problemss a) Employment, b) F i n a n c i a l . c) Housing, d) Family. e) Other. 11. Recording Notes. 12. Observations. * 92 Appendix B. Schedule Used at the C i t y S o e i a l Service Department 1. Eumber. 2. Known p r e v i o u s l y to the Agency* 3. C l a s s i f i c a t i o n of Problem. !{.. Other S e r v i c e s Given. a) R e f e r r a l to Other Agencies. 5. Closed o r A c t i v e a t Present Time. 6. Condition upon Clos u r e . 7. Reasons f o r Closure. 8. Recording Notes. 9. Observations. - 93 Appendix 0. Brochure o f C i t y of Vancouver S o c i a l Service Department under a u t h o r i t y of the C i t y Charter and the S o c i a l A s s i s -tance A c t , the S o e i a l S e r v i c e Department provides cash a l l o w -ances and a v a r i e t y of supplemental s e r v i c e s to c i t i z e n s i n need of and e l i g i b l e f o r f i n a n c i a l a s s i s t a n c e . The department i s provided f o r i n the budget of the C i t y of Vancouver and i s re s p o n s i b l e to the C i t y S o c i a l Services Committee. S o c i a l A s s i s t a n c e As the M u n i c i p a l P u b l i c Welfare Department, s e r v i c e s are provided to r e s i d e n t s of the c i t y of Vancouver who q u a l i f y f o r a s s i s t a n c e i n the f o l l o w i n g c a t e g o r i e s : S o c i a l Allowance Under the S o c i a l A s s i s t a n c e A c t , p r o v i s i o n i s made f o r cash allowances, on a means t e s t b a s i s , t o those who are d e s t i t u t e and unemployable, and who have r e s i d e d i n the Province of B r i t i s h Columbia f o r one year continuously. Allowances are paid monthly by cheque at the f o l l o w i n g maximum r a t e s : Grp. #45 • Grp. 2 169.50 + #5 Grp. 3 183.50 • 15 Grp. 4 #97.50 + 15 Grp. 5 #m.5o + 15 Grp. 6 f125.5o 15 + #2.00 e x t r a f o r each dependent. The cost of p r o v i d i n g t h i s a s s i s t a n c e i s shared by the M u n i c i p a l i t i e s and the P r o v i n c i a l Government. Mothers * Allowance Under the Mothers* Allowance Act, cash allowances are a v a i l a b l e , on a means t e s t b a s i s , to c e r t a i n mothers who have one or more dependent c h i l d r e n under the age of s i x t e e n , and where the husband i s unable to provide because of death, d e s e r t i o n , i l l n e s s , e t c . Allowances are paid monthly through the S o c i a l Welfare Branch, Department of Health and Welfare, V i c t o r i a , B.C. at the same maximum r a t e s as s o c i a l allowances. 9 4 -Three years* residence immediately preceding the a p p l i c -a t i o n i s r e q u i r e d . The cost of p r o v i d i n g t h i s a s s i s t a n c e i s borne by the P r o v i n c i a l Government. A p p l i c a t i o n s may be made through the C i t y S o c i a l S ervice Department. Qjd A%e A s s i s t a n c e under the Old Age A s s i s t a n c e A c t , p r o v i s i o n i s made f o r cash allowances, subject to a means t e s t , f o r those c i t i z e n s between the ages of 65 and 6 9 , who have r e s i d e d i n Canada f o r twenty years. Old Age A s s i s t a n c e I s paid at the rat e of #40.00 per month by the P r o v i n c i a l and Federal Governments, to which the P r o v i n c i a l Government adds a bonus up to #15 per month to B.C. r e s i d e n t s . A p p l i c a t i o n may be made the Old Age As s i s t a n c e Board, 4 1 1 Dansmuir S t r e e t , Vancouver. Old Age S e c u r i t y Bonus Under the Old Age S e c u r i t y A c t , p r o v i s i o n i s made f o r a cash allowance of f 4 0 . 0 0 per month without a means t e s t , to persons 70 years of age and over who have r e s i d e d i n Canada f o r twenty years. The cost of Old Age S e c u r i t y i s borne e n t i r e l y by the F e d e r a l Government, and a l l a p p l i c a t i o n s are submitted t o the D i r e c t o r of Old Age S e c u r i t y , V i c t o r i a , B.C. Forms are a v a i l a b l e a t any Post O f f i c e . To supplement Old Age S e c u r i t y , the Province provides a cost of l i v i n g bonus up to #15 .00 per month, on a means t e s t b a s i s , to those who have r e s i d e d i n B.C. f o r three years immediately preceding the date of a p p l i c a t i o n . A p p l i c a t i o n f o r bonus i s made a t the Old Age Assistance Board, J j l l Dunsmuir S t r e e t , Vancouver* D i a a b i l i t y Pension Under the Disabl e d Persons A c t , p r o v i s i o n i s made f o r the payment o f cash allowances, on a means t e s t b a s i s , to any person over the age o f 18 y e a r s , who has res i d e d i n Canada f o r 10 years immediately preceding the date of a p p l i -c a t i o n . The a p p l i c a n t must be t o t a l l y and permanently d i s -abled as o u t l i n e d I n the Act. D i s a b i l i t y Pension I s paid a t the rate of #40.00 per month by the P r o v i n c i a l and Federal Governments, to which - 95 -the P r o v i n c i a l Government adds a bonus up to #15 per month to B.C. r e s i d e n t s . B l i n d Pension Under the B l i n d Persons Allowance A c t , an allowance of 155.00 per month, i n c l u d i n g bonus, may be pa i d , on a means t e s t b a s i s , to any person over twenty-one years of age who i s b l i n d and who has r e s i d e d i n Canada f o r ten, years immediately preceding th© a p p l i c a t i o n . A p p l i c a t i o n i s made at th© Old Age As s i s t a n c e Board, I4.ll Dunsmuir S t r e e t , Vancouver. Se r v i c e s The f o l l o w i n g s e r v i c e s ar© a v a i l a b l e t o those i n r e c e i p t of S o c i a l Allowance, Mothers* Allowance, Old Age A s s i s t a n c e , Old Age S e c u r i t y Bonus, B l i n d or Disabled Persons Pension: Casework Se r v i c e s S o c i a l tforkers on the s t a f f , i n a d d i t i o n to e s t a b l i s h i n g and reviewing e l i g i b i l i t y of persons i n need of f i n a n c i a l a i d , provide a c o n t i n u i n g c o u n s e l l i n g s e r v i c e to I n d i v i d u a l s i n r e c e i p t of p u b l i c a s s i s t a n c e . I t i s the goal of the C i t y S o c i a l S e r v i c e Department to a s s i s t needy c i t i z e n s , by under-standing and i n d i v i d u a l i z e d s e r v i c e , to use resources w i t h i n themselves and community to achieve the g r e a t e s t p o s s i b l e measure of self-dependence. Medical S e r v i c e s A l l r e c i p i e n t s of allowances, on a means t e s t b a s i s , i n the cat e g o r i e s o u t l i n e d , are provided w i t h a Medical card, which e n t i t l e s them to the s e r v i c e s of t h e i r own doctor. Drugs, h o s p i t a l i z a t i o n and s p e c i a l i s t s e r v i c e s , as pre-s c r i b e d by the attending p h y s i c i a n , may a l s o be provided. I n cases where the r e c i p i e n t o r h i s f a m i l y are unable to provide recommended ap p l i a n c e s , Such as g l a s s e s , dentures, e t c . , these may be s u p p l i e d through t h i s department. Boarding and nur s i n g home care may be arranged according to the need and th© accommodation a v a i l a b l e . Dental s e r v i c e s ar© a l s o a v a i l a b l e to dependents (of l o s s than 11 years of ag©) of persons i n r e c e i p t of s o c i a l assistance. - 96 * Housekeepers I n cases where i t i s a d v i s a b l e f o r an i l l person to remain i n h i s own home, or where c h i l d r e n r e q u i r e temporary care during i l l n e s s of a parent, housekeeper or homemaker s e r v i c e s may be provided. N u t r i t i o n i s t A M e t r o p o l i t a n Health Committee n u t r i t i o n i s t serves as a consultant to the Department to a s s i s t i n questions of budgeting, n u t r i t i o n , and s p e c i a l d i e t s . Area Served The area served i s w i t h i n th© boundaries of the C i t y of Vancouver. F o r purposes of a d m i n i s t r a t i o n , the C i t y i s d i v i d e d i n t o f o u r u n i t s , l o c a t e d as f o l l o w s . Centre U n i t West Un i t East U n i t South U n i t Intake S e c t i o n . 97 -Appendix D. B i b l i o g r a p h y Aptekar, Herbert H., The Dynamics of Casework and Cou n s e l l i n g . Houghton M i f f l i n Company, San F r a n c i s c o , 1 9 5 5 . French, David Gr., An Approach to Measuring the Res u l t s i n S o c i a l Work. Columbia U n i v e r s i t y Press, New York, 1 9 5 2 . Freud, Anna, The Ego,and the Mechanisms of Defense. I n t e r n a t i o n a l U n i v e r s i t i e s Press, i n c . , New York, 1914-6. Gomberg, Robert M., and Levinson, Frances T,, Diagnosis and Process i n F a m i l y t C o u n s e l l i n g . Family S e r v i c e A s s o c i a -t i o n of America, New York, 1951. Hamilton, Gordon. Theory and P r a c t i c e of S o c i a l Casework, Columbia U n i v e r s i t y Press, New York, Revised E d i t i o n , 1 9 5 3 . Henderson and G i l l e s p i e . A Text Book of P s y c h i a t r y * Oxford U n i v e r s i t y P r e s s , London, 1951, 2nd Impression. Knee, Ruth I . , E d i t o r , B e t t e r S o c i a l S e r vices f o r Mentally 111 P a t i e n t s . American A s s o c i a t i o n of P s y c h i a t r i c S o c i a l Workers, Inc., New York, 1954* Mennlger, K a r l A., The Human Mind. A l f r e d A. Knopf, New York, 1 9 4 7 . Menniger, W i l l i a m C , You and P s y c h i a t r y , Charles Scri b n e r ' s Sons, New York, 19*53. M i l e s , A r t h u r P., An I n t r o d u c t i o n to P u b l i c Welfare. D.C. Heath and Company, B o s t o n , 1 9 4 9 . ' McCormick, Mary J.., Diagnostic. Casework In the Thomlstic  P a t t e r n . Columbia U n i v e r s i t y Press, New York, 1954* McCormick, Mary J . , Thomlstic Philosophy i n S o c i a l Casework. Columbia U n i v e r s i t y P r e s s , New York, 1947'• Noyes, Arthur P., Modem C l i n i c a l P s y c h i a t r y . W.B. Saunders Company, P h i l a d e l p h i a , 1953. Stanton, A l f r e d H., and Schwartz, M o r r i s S,, The Mental  H o s p i t a l , L a v i s t o c k P u b l i c a t i o n s , L t d . , London, 1954• A u s t i n , L u c i l l e N., "Trends i n D i f f e r e n t i a l Treatment i n S o c i a l Casework," Jo u r n a l of S o c i a l Casework, V o l . XXIX, June, 1948, Family Se r v i c e A s s o c i a t i o n of America, lex? York. A u s t i n , L u c i l l e N., " R e l a t i o n s h i p s between Family Agencies and Mental H e a l t h C l i n i c s , " S o c i a l Casework. V o l . XXXVI, No. 2 February, 1900, Family Service A s s o c i a t i o n of America, New York. Ackerman, Nathan ¥., "Mental Hygiene and S o e i a l Work, Today and Tomorrow." S o c i a l Casework. V o l . XXXVI, No. 2, February, 1950, Family S e r v i c e A s s o c i a t i o n of America, New York. Benney, C e l i a , "The Role of the Caseworker I n R e h a b i l i t a t i o n , " S o c i a l Casework. V o l . XXXVI, No. 3, March, 1900* Family Service A s s o c i a t i o n of America. New York. B l e s t e k , F e l i x P., "An A n a l y s i s of the Casework R e l a t i o n s h i p , " S o c i a l Casework. V o l . XXXV, No. 2, February, 1904* Family Service A s s o c i a t i o n of America, New York. B i r c h , Sophia, "An A i d i n the R e h a b i l i t a t i o n of Mental Hos-p i t a l P a t i e n t s , " Master of S o c i a l Work Thesis. U n i v e r s i t y of B r i t i s h Columbia, Vancouver, B.C., 1903. B r i t i s h Columbia, "Annual Report of the Mental Health Ser-v i c e s , " Queen's P r i n t e r , V i c t o r i a , B.C., 1904* C a u d i l l , W i l l i a m , et a l . , " S o c i a l Structure and I n t e r a c t i o n Processes on a P s y c h i a t r i c Ward," American Journal of  Orthopsychiatry, CCTI, 1902, C a r t e r , Genevieve, "Problem Formation i n S o e i a l Work Research, S o c i a l Casework. V o l . XXXVI, No. 7, J u l y , 1900, Family Ser v i c e A s s o c i a t i o n of America, New York. Freudehthal, Kurt, "Need f o r Research i n the Area of Treat* ment R e l a t i o n s h i p , " S o c i a l Casework. V o l . XXXVI, No. 8, October, 1900, Family Service A s s o c i a t i o n of America, New York. Garland, Ruth,, "The P s y c h i a t r i c S o c i a l Worker i n a Mental Hospital,** Mental Hygiene. A p r i l , 1947* N a t i o n a l Committee on Mental Hygiene (U.S.A.). G a r r e t t , Annette, " H i s t o r i c a l Survey of the E v o l u t i o n of Casework," Jo u r n a l o f S o e i a l Casework. June, 1 9 4 9 , Family Service A s s o c i a t i o n o f America, New York. - 99 Hooson, W i l l i a m , "The R e h a b i l i t a t i o n of the P u b l i c A s s i s t a n t R e c i p i e n t s ; P a r t I and I I , " Master of S o c i a l Work Thesis. U n i v e r s i t y of B r i t i s h Columbia, Vancouver, B. C , 1952. Jackson, Douglas L., " S o c i a l A s s i s t a n c e , P u b l i c Assistance P o l i c y , A Review of Contemporary L e g i s l a t i o n and P r a c t i c e i n B r i t i s h Columbia," Master of S o c i a l Work T h e s i s , U n i v e r s i t y o f B r i t i s h Columbia, Vancouver, B. C , 1 9 5 5 . Pepper, Gerald W., " S o c i a l Worker P a r t i c i p a t i o n i n the Treat-ment o f the M e n t a l l y 1 1 1 , " Master of S o c i a l Work Thesis* U n i v e r s i t y of B r i t i s h Columbia, Vancouver, B.C., 1953. Sch l e s i h g e r , Ernest, " S o c i a l Casework i n the Mental, H o s p i t a l , " Master of S o c i a l Work Thesis , U n i v e r s i t y of B r i t i s h Columbia, Vancouver, B.cy, 1 9 5 3 . Sutherland, Murray Robert, "The R e h a b i l i t a t i o n of Discharged Mental P a t i e n t s , " Master of S o c i a l Work Thesis. U n i v e r s i t y of B r i t i s h Columbia, Vancouver, B. C , 1954* Wilson, Eunice W., and B a r t l e t t , H a r r i e t M., " R e f e r r a l s from H o s p i t a l to S o c i a l Agencies," S o c i a l Caseifprk. V o l . XXXVI, No. 6 , December, 1 9 5 5 , Family S e r v i c e A s s o c i a t i o n of America, New York. 

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