Open Collections

UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Social services for mental patients and their families : an examination of social work functions, and… Heuser, Alexander Peter 1954

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

Item Metadata

Download

Media
831-UBC_1955_A5 H5 S6.pdf [ 6.56MB ]
Metadata
JSON: 831-1.0106429.json
JSON-LD: 831-1.0106429-ld.json
RDF/XML (Pretty): 831-1.0106429-rdf.xml
RDF/JSON: 831-1.0106429-rdf.json
Turtle: 831-1.0106429-turtle.txt
N-Triples: 831-1.0106429-rdf-ntriples.txt
Original Record: 831-1.0106429-source.json
Full Text
831-1.0106429-fulltext.txt
Citation
831-1.0106429.ris

Full Text

SOCIAL SERVICES FOR MENTAL PATIENTS AND THEIR FAMILIES An Examination of Social Work Functions, and Criteria for the Establishment of a Social Service Department in a Saskatchewan Mental Hospital (Weyburn). by ALEXANDER PETER HEUSER Thesis Submitted in Partial Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL WORK in the School of Social Work Accepted as conforming to the standard required for the degree of Master of Social Work School of Social Work 1954 The University of British Columbia iv Abstract This study reviews the procedures, standards, and admin-istrative requirements inherent in the setting up of a Social Service Department in a mental hospital. Recommenda-tions for a future Social Service Department are based upon: (a) standards for adequate social service as recommended by the American Psychiatric Association and other professional personnel, and (b) the experience of some existing depart-ments in Canada. The latter include: (a) the Social Ser-vice Departments at the Crease Clinic of Psychological Medi-cine and the Provincial Mental Hospital, Essondale, British Columbia, and (b) the After Care Department of the Ontario, Hospital, London, Ontario. This study has also incorporated the information and findings contained within four previous Master of Social Work theses, dealing with (a) the analysis of social work services in a mental hospital, (b) adminis-trative aspects of a social service department in a mental hospital, (c) post-discharge problems of mental patients. The study has examined social work functions in a mental hospital, including: social services rendered during admis-sion, social services rendered during the period of treatment, social services rendered during rehabilitation and convales-cence. To ensure effective provision of these social ser-vices, the study has outlined "job descriptions" for each social work position within a Social Service Department. Three selected Social Service Departments were examined on the basis of: (a) administrative structure, (b) personnel, and (c) services rendered. Methods used include direct ob-. servation, interviews and correspondence with administrative personnel, an examination of information in annual reports and relevant professional ar t i c l e s . The projected department i s divided into three distinct sections: (a) an Admissions Section; (b) a Continuing Case-work Section: and (c) an Out-Patient Section. To ensure ade-quate administration and service, such a department requires twenty appropriately-qualified personnel: sixteen social workers at the direct service level; three social workers, each as Casework Supervisor of a Section; and one social worker as the Director of Social Service. * % -:£• TABLE OP CONTENTS Chapter 1. Changing Concepts in the Care of the  Mentally 111. Development of mental hospitals and why they developed. Introduction of social work into the psychiatric setting. Saskatchewan's psychiatric services. The area served. Method of the study Chapter 2. Social Work Functions in a Mental Hospital Factors in social adjustment which c a l l for social treatment. Social work function today. Social ser-vices during admission. Social services during treat-ment. Social services during rehabilitation and con-valescence. What do social workers do? Social case-work techniques. Evaluation of social services ren-dered Chapter 3. An Examination of Some Social Service  Departments The Social Service Departments, Essondale, British Columbia. The After Care Department, London, Ontario. Comparison of departments: administrative structure; personnel Chapter 4. A Social Service Department for the Sask-atchewan Hospital A recommended administrative structure. Respon-s i b i l i t i e s of the Director of Social Service. Res-ponsibilities of Casework Supervisors: Admissions Section Casework Supervisor; Continuing Casework Section Casework Supervisor; Out-Fatient Section Case-work Supervisor. Responsibilities of a Social Worker. Appendices: A. Total Staff and Ratio to Patients, Mental Hospitals in Saskatchewan, 1932 to 1953. B. Recommended Qualifications for Social Service Personnel. C. Recommended Maximum Caseload. D. Bibliography. i i i Page TABLES AND CHARTS IN THE TEXT (a) Tables Table 1. Rural and Urban Population, Ontario, Saskatchewan, British Columbia, 1951 25 Table 2. Racial Origin Representation i n : Ontario, Saskatchewan, British Columbia, 1951 26 Table 3. Report of Admissions Section, Social Service Department, Crease Clinic, April 1952 to March, 1953 64 Table 4. Report of Continuing Casework Service Section, Social Service Department, Crease Cl i n i c , A p r i l , 1952 to March, 1953 ..... 65 Table 5. Report of Admissions Section, Social Service Department, Provincial Mental Hospital, Apr i l , 1952 to March, 1953 66 Table 6. Report of Continuing Casework Section, Social Service Department, Provincial Mental Hospital, A p r i l , 1952 to March, 1953 67 (b) Charts Fig. 1. Administrative Structure, Crease Clinic and Provincial Mental Hospital Social Service Departments, showing their uni-disciplined make up 82-A Fig. 2. After Care Department, Ontario Hospital, London, showing i t s multi-disciplined make-up, numbers of personnel, qualifications of personnel 82-A Fig. 3 Recommended Administrative Structure, Social Service Department, Saskatchewan Hospital 91 ACKNOWLEDGEMENTS I wish to express my thanks to Mr. J.E. Gamble, Director of the After Care Department of the Ontario Hos-p i t a l located at London, Ontario; and also to the social workers at the Crease Clinic of Psychological Medicine and the Provincial Mental Hospital, Essondale, British Columbia, for their interest and co-operation in making available the information contained within the present thesis. I want to thank Miss Alice K. Carroll, Provincial Supervisor of Psychiatric Social Work, Mental Health Services, B r i -tish Columbia, for her help in the formulation of "job descriptions" for social service personnel. I wish also to acknowledge my indebtedness to Dr. Leonard C. Marsh and Mr. Arthur C. Abrahamson of the School of Social Work for their constructive suggestions and their encouragement. I also wish to thank Mr. Jack A. E l l i s , fellow student, for his proof-reading of the present thesis. SOCIAL SERVICES FOR MENTAL PATIENTS AND THEIR FAMILIES An Examination of Social Work Functions, and Criteria for the Establishment of a Social Service Department in a Saskatchewan Mental Hospital (Weyburn). CHAPTER 1 CHANGING CONCEPTS IN THE CARE OP THE MENTALLY ILL The interest, thinking and practice regarding men-tal il l n e s s and psychotic persons, has in the past had a much different origin than psychiatric interest has today. The most striking change in this respect has been the gradual replacement of the custodial concept by the concept of treat-ment. "If the last decade of the nineteenth century saw the significant change in nomenclature from 'asylum* to •hospi-t a l ' , the twentieth century has witnessed a transformation in fact as well as in name."1 Development of Mental Hospitals and Why They Developed In ancient times, magical conceptions were assoc-iated with the person who exhibited behaviour which differed from that of most people. Irregular behaviour was attributed to e v i l s p i r i t s who invaded the human body and were dwelling therein. Faith was placed in pagan healing gods, whom they f e l t could expel these e v i l spirits from the a f f l i c t e d person. Altars and permanent temples were set up where the mentally i l l could go and meet the healing gods and through divine communication be relieved of indwelling e v i l s p i r i t s . 1 Deutsch, Albert, The Mentally 111 in America; Double-day, Doran and Co., Inc., New York, 1^3?, p. 440. - 2 -"One of the most outstanding of these temples of healing was established at Epidauros i n Greece, i n the s i x t h i century B.C.n I t included a u x i l i a r y temples and a stadium which seated over twelve thousand persons. Within the sacred enclosure were a bathing p a v i l i o n and two gymnasia. On the grounds were a large and a t t r a c t i v e grove where the patients walked or sat under the trees. Statues of f r i e n d l y d e i t i e s and famous physicians were placed there, as well as tablets inscribed with encouraging accounts of cures already effected. The Holy Precinct was pervaded by an a i r of sa n c t i t y , and spe c i a l e f f o r t was made to preserve an atmosphere of cheer-fulness and to arouse hope. Following a period of f a s t i n g i n preparation f o r meeting the healing gods, the patient was robed i n white; and as darkness f e l l he made offe r i n g s , heard prayers and f e l l asleep. During the night, a p r i e s t i n the disguise of a god v i s i t e d the patient, and with the help of a serpent he would apply a remedy to the patient. When the patient awoke, the p r i e s t offered him in t e r p r e t a t i o n of the divine communication which occurred during the patient*s sleep. When Greece came under Roman domination, the ten-dency toward magic and miracles increased. The v i s i t a t i o n of the priest during sleep began to include leaping upon the patient and beating him i n a hope to expel the e v i l s p i r i t s . 1 Zilboorg and Henery, A History of Medical Psychology. W.W. Norton and Co., New York, 1941, p. 559. - 3 -This particular temple of healing at Epidauros existed and remained in operation for over eight hundred years. After faith in pagan healing gods faded away, many centuries passed during which time no care whatsoever was provided for the mentally i l l person. Until about the fourth century A.D., the mentally i l l person or "lunatic" as he was then called, wandered about being the subject of ridicule and physical cruelty. Persons suffering from the more excited states of i l l n e s s , were often chained to stakes and flogged. Human contact with the mentally i l l did not exist. The f i r s t record of an institution being established for the care of the mentally i l l , dates back to the latter part of the fourth century A.D. The f i r s t institution of this kind of which there is a record was called a "morotrophium", or house for lunatics; i t was in operation in Byzantium in the fourth century A.D. A similar institution was in existence in Jerusalem, according to a record bearing the date of 491 A.D.I The asylum era was then underway, and in spite of the harsh practices carried on within them, the asylum was a step for-ward in the care of the mentally i l l . The mental patient did have a right to be protected from the ridicule and cruelty of the community. Asylums for the mentally i l l did not become common until the twelfth century, and many were actually cloisters. Bethlehem Hospital in London i s said to be the oldest hospital in Europe which has been in con-tinuous service. It was founded in 1247 but did not "receive lunatics" until 1377, at which time some few patients were transferred from a store 1 I b i q - * P- 5 6 1 -- 4 -house situated near to the palace of the King. Bethlehem Hospital, which later became known as "Bedlam Hospital" following the inception of a psychiatric unit there, was o f f i c i a l l y under the management of a royal chaplain, a consistent absentee whose duties were performed by the jani-tor.1 Toward the end of the eighteenth century the asylums in most European countries were beginning to emerge from the deplorable state in which they had been for cen-turies as a result of suspicion, ignorance, and neglect of the mental patient. Great reformers such as Pinel in France, and Tuke in England ran the risk of they themselves being confined to an asylum, by pleading to the masses and the then existing government bodies for reform within the asylums. In 1793, Pinel after succeeding to gain the government's sanction, liberated over f i f t y patients from chains and dungeons. In-human restraint and confinement began to be replaced by outdoor walks and workshops. The concept of treatment had begun to replace the centuries old concept of detention. Tuke, a merchant in England, was aroused by the mysterious death of a patient in the York Asylum, when i t became known that the relatives were not permitted to v i s i t her. This incident prompted Tuke to approach the Society of Friends in 1792, and as a result the York Retreat was est-ablished. A milder more appropriate attitude toward mental patients prevailed here. Restraint and abuse were replaced - 5 -by kindness and tolerance and early forms of occupational therapy. Tuke attempted to make known to the public the nature of the conditions within the asylums. It would seem that with a revelation of such conditions, a revolution in hospital care would be inevitable. Many changes did occur as a result of Tuke's work: incompetent attendants and ad-ministrators were discharged of their duties, l i v i n g condi-tions in hospitals improved some, and a move was made to-ward the creation of legislation for the protection of the mental patient. Exposure of wrong attracts interest, but reconstruction depends upon the constant efforts of those who do not forget the emotional impact from the exposure of wrong. For this reason, the f i r s t half of the nineteenth century passed before the mental institutions emerged from medieval darkness. North American Development i Mentally i l l persons on this continent were f i r s t conceived of as being a public nuisance, and on occasions measures were taken to r i d the community of them. The f i r s t approach taken toward the mental patient was to have him confined with those persons under custody for criminal or c i v i l offence. The f i r s t institutions designated speci-f i c a l l y for the care of mental patients on this continent, were erected at Williamsbourg in the United States in 1773, and at Saint John, New Brunswick, in Canada in 1836. - 6 -The development of mental hospitals in North America was similar to the development in Europe, with one exception. On this continent, the mental patient was f i r s t cared for in j a i l s and almshouses, and later in government sponsored institutions. The mental patient in Europe how-ever, f e l l to the care of cloisters intermediary to alms- . houses which were preceded by magical temples of healing; . and the government sponsored institution. The process of hospital development on this continent was probably much quicker than in other countries, because i t occurred a cen-tury later and thus profited from the experiences of earlier reformers. Benjamin Franklin, the Quaker movement, Dr. Benjamin Rush, and Dorothea Dix are the pioneer reformers of the movement toward better hospital conditions.in North America. Toward the end of the nineteenth century thirteen of the foremost mental hospital superintendents in the United States, met and founded what in 1921 became known as the American Psychiatric Association. This organization attempted to formulate standards for mental hospital f a c i l i t i e s , as well as hospital personnel. Another aim of this organizat-ion was to organize the psychiatric knowledge then available, and to build solidly upon i t . Shortly before the close of the nineteenth century sci e n t i f i c discoveries in medicine, psychiatry, biology, physiology and psychology revealed the interdependence between mind and body. These discoveries stimulated a new outlook in the approach to mental disorders. Emil Kraepelin and Wilhelm Griesinger classified mental diseases according to their symptoms. Sigmund Freud and his followers opened up new hope for the treatment of mental i l l n e s s , through the knowledge of the unconscious. Freud's theory of psycho-analysis caused a revolutionary change in psychiatry a l l over the world. The psychiatric schools of Jung, Adler, and Rank also contributed theories of human behaviour and mental i l l n e s s . Dr. Adolf Meyer introduced the psycho-biological theory of psychiatry. Social psychiatry was taught by such leaders as Southard, Hoch, Gessell, and Karl Menninger. The contributions of these pioneers of social psychiatry emphasized that mental illness and emotional dis-turbances are not exclusively due to organic conditions, but are also due to factors in the environment. Counseling and direct modification of environmental stresses gained re-cognition as a means to the prevention and cure of mental illnes s . Until the close of the nineteenth century, mental hospitals did not segregate the acute treatable illnesses from those more chronic cases. Since the turn of the cen-tury however, and as a result of an increased understanding of psychiatry, segregation of acute illnesses which require continuous treatment has become an accepted practice. This is being accomplished through the establishment of the cot-tage type structure of hospital, and also through the use of reception units where intensive treatment i s done. The need for further sub-grouping within this broad dichotomy has been - 8 ~ apparent for many years, but i s only recently becoming a reality . Separate institutions are being established for the care of epileptic and mentally retarded patients. The most recent sub-group to receive special consideration because of their common need is the senile group. A few provinces—notably British Columbia and Alberta—have sep-arated senile patients from other cases requiring con-tinued treatment.1 In North American mental hospitals, there have been advances made since the turn of the century in respect to the number and qualifications of hospital 2 personnel. The number of medical doctors has increased, and members from other professions have joined the physician forming the "treatment team." During the f i r s t World War, the Department of Soldiers Re-Establishment proved the therapeutic value inherent in occupational therapy programs. The second and third decades of this century mark the intro-duction of psychologists and social workers into the Canadian psychiatric hospital, although social workers had become a part of the treatment team in American hospitals as early as 1914. The mental hygiene movement has also played an important role in the development of mental hospital service. 1 Mental Health Services in Canada, General Series Memorandum No. 6, Research Division, Department of National Health and Welfare, Ottawa, July 1954, p. 10. 2 v. supra, p. 22. ^ Mental Health Services in Canada, op. c i t . . p. 13. - 9 -In 1904 Clifford Beers recovered from a mental illness of three years 1 duration. The experiences which he encountered during his three years in a mental hospital, stimulated him on to found an organization for the improvement of the care and treatment of the mentally i l l . In 1908 the mental hygiene movement was founded, and one year later the National Committee for Mental Hygiene was formed with Clifford Beers as i t s Chairman. Since i t s inception, the National Committee has conducted surveys on existing mental health services and the need for an extension of these services in the community, and has also acted as an advisory committee to government bodies on mental health matters. In Canada, the Canadian Mental Health Association serves in a similar capacity to the National Committee for Mental Hygiene. During World War I the mental hygiene movement became immersed in the problems of the mentally disabled soldier, and in their attempt to promote mental health in the community—their primary objective, the National Commit-tee sponsored the present Smith School of Social Work.1 This was the f i r s t School of Social Work which offered train-ing for social work practice in relation to psychiatry. Many students graduated from this School with training which en-abled them to perform social work in mental hospitals, out-patient psychiatric clinics and child guidance c l i n i c s . The mental hygiene movement played a major role in interpreting - 10 -the need for social workers in psychiatric treatment settings, and was instrumental in making i t possible for this need to be partially met. Many innovations in hospital administration have occurred since the turn of the century. Mental hospital management has been placed under the direction of government boards or departments, while hospital personnel matters are dealt with by Public Service Commissions. The procedures of parole and follow-up care have come to be used much more ex-tensively. Boarding out programs are being established for those patients who do not require active treatment but who do have a residuum of their i l l n e s s . During the past two decades mental hospitals on this continent have increasingly become a part of the com-munity. Mental hospitals are now being opened for public inspection. They are being used more and more as training centres for mental hygiene, where nurses, internes, psycho-logists, social workers and volunteers receive training in mental hygiene principles. Mental hospital development can thus be divided into three phases: (1) Prom ancient times to the fourth cen-tury A.D. This phase was characterized by the magic and superstition which surrounded the mental patient. (2) From the fourth century to the eighteenth century. This phase was characterized by the establishment of asylums, and the state assuming responsibility for the provision of custodial care for the mentally a f f l i c t e d . (3) From the eighteenth - 11 -century to the present time. This might be referred to as the "phase of enlightenment". The mental patient began to be recognized as a sick person, and i t began to be realized that a cure could be effected in many cases through proper treatment. During the early part of the third phase the main attention was focused on the improvement of the phy-sical f a c i l i t i e s in mental hospitals, and also toward a more humane type of custodial care rather than physical and mental abuse which had been common until after the turn of the eighteenth century. However, toward the end of the eighteenth century the new psychiatric theories set new goals for hospital reformers, and "treatment" became a watch-word as well as "better custodial care." This new emphasis on treatment meant that hospital personnel including ad-ministrators, doctors, attendants and nurses were faced with having to change their concepts regarding the care of the mentally i l l , to a concept which includes treatment and return of the patient to the community. Psychiatric treatment along with the assistance given by professional social workers and other services, can help many patients recover from their i l l n e s s . This i s not sufficient however. Even though community thinking and feeling toward mental illness has become much more understanding, due in great part to the mental hygiene movement, the patient's return to the community i s s t i l l a threatening experience for him. The mental patient requires help in returning to the community and also assistance to - 12 -remain there. Unless the mental hospital i s prepared to enlist the help of members from that profession which i s trained to carry the responsibility in this area, that hospital cannot be said to have accepted i t s complete new role. In actual fact i t has remained an institution whose only function i s to care for the mentally i l l . Introduction of Social Work Into the Psychiatric Setting Social work has always dealt with personal and social suffering. Specific personal and social adjustment problems were encountered through direct contact with large numbers of impoverished people. The inevitable result of such a large number of contacts, was the grouping or c l a s s i -fication of specific social adjustment problems. When i t was realized that social adjustment problems could be clas-s i f i e d , the way was paved for the establishment of specific kinds of agencies, designed to study and handle specific kinds of problems. Around the human i l l s which are the concern of social work have developed many specialized areas of a c t i v i t y . 1 Some of these areas l i e entirely within the f i e l d of social work i t s e l f : the family welfare agencies, with breakdown in family l i f e as the starting point for activity and the maintaining of wholesome family l i f e as the primary purpose; and the child welfare agencies, with the dependent child as the starting point and the insurance 1 Lois French, Psychiatric Social Work, The Commonwealth Fund, U.Y., 1940, p. 1. - 13 -of care, protection, and influences necessary for normal growth as the purpose. Other areas represent combined efforts of social work and other professions; probation which i s social work operating in the agencies that deal with delinquency and crime; medical social work, which operates within the f i e l d of medicine; and, more recently, psychiatric social work.1 In order to avoid confusion of terms, i t might be well to state here that psychiatric social work i s not a separate and distinct f i e l d of i t s own, but that i t is 2 social work practiced in relation to psychiatry, in an agency framework established for the purpose of treating emotional, psychological and nervous disorders. As Dr. E.E. Southard and Mary C. Jarrett state in their book The Kingdom of Evils f i t i s a "new emphasis rather than a new function". In this study, the writer w i l l use the term "social work", rather than "psychiatric social work". Dr. Alfred Meyer has stated that "before our pre-sent day type of social work was organized, psychiatry here and there had for probably a century done a kind of social o work under the name of after-care". In the United States 1 Loc. c i t . 9 Lucas, Leon, "Psychiatric Social Work", Social Work  Yearbook, 1951, American Association of Social Workers, New York", 1951, p. 359. 3 Alfred Meyer M.D., "Historical Sketch and Outlook of Psychiatric Social Work", Hospital Social Service, 5, p. 221, April 1922. - 14 "as f a r back as I860" mention was made i n the annual reports of several state h o s p i t a l s , of the recognition of the e x i s -tence of " s o c i a l problems" during the post-discharge period. As early as 1894, Dr. Stedman of the American Neurological Association found through the use of a e i r e u l a r l e t t e r to association members, that a majority had a d e f i n i t e b e l i e f i n the great advantage l i k e l y to r e s u l t from after-eare. A very e x p l i c i t statement of the need f o r s o c i a l work i n the practice of psychiatry was made i n 1902, by Dr. Theodore Kellogg, a superintendent of a mental h o s p i t a l . Insanity p r a c t i c a l l y i s loss of power of con-formity to the s o c i a l medium i n which the patient l i v e s . This power i s regained i n convalescence gradually, and i t i s a part of psychotherapy to furn i s h a normal personal environment to which the patient i s to p r a c t i c e adjustment. 3 These are among the f i r s t evidences of the con-K vergence of these two pr o f e s s i o n s — p s y c h i a t r y and s o c i a l work-in a combined attempt to r e l i e v e mental s u f f e r i n g . I t i s a point of in t e r e s t that the need f o r s o c i a l work i n the p s y c h i a t r i c s e t t i n g became apparent to the medical pro-fession before s o c i a l work as a profession s p e c i f i c a l l y of-fered to help i n the treatment of the mentally i l l . Pos-s i b l y t h i s i n t e r e s t i n s o c i a l work on the part of the 1 French, Of), c i t . . p. 33. 2 I b i d - « P» 33. o Southard, Dr. E.E. and J a r r e t t , Mary C., The Kingdom  of E v i l s . HacMillan, N. Y., 1922, p. 519. - 15 p s y c h i a t r i s t was stimulated by a change within psychiatry i t s e l f . With the torn of the nineteenth century, the emphasis i n psy c h i a t r i c thinking turned from the " c l a s s i c a l approach*—the diagnosis and c l a s s i f i c a t i o n of mental d i s e a s e s — to the "dynamic approach"—a concern with the growth and change of the personality i n r e l a t i o n to the environmental s i t u a t i o n . The emphasis having turned to the development of personality in r e l a t i o n to the environment, psychiatry f i r s t began to use s o c i a l workers f o r help i n understanding the environment. A corresponding i n t e r e s t was awakening i n s o c i a l work. So c i a l workers saw that the new "dynamic psychiatry" could offer them a great deal of help i n understanding attitudes and behaviour—both of which had always been more or l e s s b a f f l i n g to s o e i a l workers. "In the development of a new profession, from time to time new i n t e r e s t s come to the f r o n t , dominate the scene f o r a while, and gradually become assimilated i n t o the main body of experience." 1 This has been the process i n the development of the broad f i e l d of s o c i a l work. In the days of the Poor Law, pioneer s o c i a l workers turned t h e i r attention to the economic needs of people. This was quite natural, as the economic features of s o c i a l disorder are the most conspicuous-food and shelter are the most obvious needs. I b i d . . p. 517 - 16 -As s o c i a l workers assisted impoverished people with these obvious needs, i t became apparent to them that s o c i a l maladjustment was not the r e s u l t of external pressure alone. Emotional c o n f l i c t or i n t e r n a l pressure, and the i n t e r * relatedness of i n t e r n a l and external pressures, soon became recognized. S o c i a l workers soon r e a l i s e d that the i n d i v i d u a l i s tremendously hampered i n his attempt at coping with his external s i t u a t i o n i f he i s divided within himself. For example, a person looking for em-ployment w i l l be f a r less e f f i c i e n t i n dealing with his d i f f i c u l t task i f there i s something i n himself that desires to be dependent upon others; he has to f i g h t an i n t e r n a l enemy together with the external one. When one s o c i a l need i s studied and provisions are established to meet i t , other s o c i a l problems are e i t h e r unearthed or else have been obvious a l l along but now i n comparison with an answered need become much more apparent. From the very elementary meeting of economic needs of people, s o c i a l workers moved on to deal with the neglected c h i l d ; disharmonious marriages; juvenile and adult offenders; the s o c i a l components of physical i l l n e s s ; since the turn of the century they have been concerned with the s o c i a l components of mental i l l n e s s . S o c i a l work as practiced i n r e l a t i o n to general medicine came to the fore i n the early nineteenth century. Eventually the knowledge gained from the drawing together of these two professions, was assimilated i n t o the main body i " 1 ' Waelder, Robert, "The S c i e n t i f i c Approach to Casework with Special Emphasis on Psychoanalysis", P r i n c i p l e s and  Techniques i n S o c i a l Casework. Cora Kasius, E d i t o r , Family Service Association of America, 1950, p. 28. -17 -of s o c i a l work knowledge and thinking. The same process has been taking place between psychiatry and s o c i a l work. Tbe s o c i a l work profession has been very much aware of t h i s , as i n 1919, the National Conference of S o c i a l Work had as t h e i r guest speaker, the i n s p i r e r of medical s o c i a l work—Br. Richard Cabot. In his address to s o c i a l workers, he s a i d , s o c i a l work i s now a new f o r c e , new, not i n name but i n e f f i c i e n c y of energy—the force represented by p s y c h i a t r i c s o c i a l work. 1 In t h i r t y years, I have never seen anything so important as the eruption of p s y c h i a t r i c s o c i a l work int o s o c i a l work.2 At the f i r s t meeting of the National Conference of S o c i a l Work, held i n 1874, the f i r s t subject considered was "The Duty of the State Toward the Insane Poor". This paper was delivered to the conference by a state hospital superintendent. The f i r s t organized plan of s o c i a l work i n r e l a t i o n to psychiatry occurred i n 1880 i n England with the Society f o r the After-care of the Insane. Ia the beginnings, i t engaged i t s e l f giving f r i e n d l y supervision to discharged patients from mental hospitals. In the United States, the f i r s t attempt at organized s o c i a l work i n r e l a t i o n to psy- * c b i a t r y occurred i n 1905 with the s t a f f i n g of a s o c i a l worker at the Neurological C l i n i c at the Massachussetts General Hospital i n Boston. In 1911 the Manhattan State Hospital » — — — " :  By " p s y c h i a t r i c s o c i a l work", Dr. Cabot means the new ps y c h i a t r i c point of view i n s o c i a l work which resulted from s o c i a l workers working with p s y c h i a t r i s t s . 2 Southard and J a r r e t t , op. c i t . . p. 522. 3 I b i d . , p. 519. 18 became the f i r s t state-hospital to employ a s o c i a l worker. Within three years, fourteen state hospitals employed s o c i a l workers, and many were beginning to think i n terms of S o c i a l Service Departments rather than i n terms of a s o c i a l worker. The Boston Psychopathic Hospital served as a pioneer i n t h i s respect. In 1912 the Boston Psychopathic Hospital opened, under the d i r e c t i o n of Dr. E.E. Southard. In 1913 Hiss Mary C. J a r r e t t became di r e c t o r of s o c i a l service and began the or-ganization and d e f i n i t i o n of function of a new department i n the h o s p i t a l . One of the f i r s t , S o c i a l Service Departments i n a Canadian mental hospital was organized i n 1931 at the Prov-i n c i a l Mental Hospital, Essondale, B r i t i s h Columbia. Ont-a r i o hospitals f i r s t u t i l i z e d the services of the community welfare workers, made available through l o c a l agencies. Be-cause of the pressing need f o r mental health services within the community and fo r the provision of follow-up care to discharged patients, the Af t e r Care Department at the Ont-a r i o H o s p i t a l , London, was established i n 1949. At the pre-sent time, most Canadian mental hospitals have a s o c i a l worker on permanent s t a f f , but do not have organized S o c i a l Service Departments. With the outbreak of war i n 1914, the need f o r s o c i a l work i n the armed forces became paramount. Host of the very few trained workers transferred from the c i v i l i a n hospitals to army hospitals. Unfortunately, t h i s transfer of - 19 -s o c i a l work personnel did not reverse i t s e l f at the close of the war. Daring the 1930*s and 1940*3, c h i l d guidance c l i n i c s began to be established throughout the United States and were being st a f f e d by young p s y c h i a t r i s t s . The c h i l d guidance c l i n i c movement attracted a majority of the s o c i a l workers who had had t r a i n i n g and experience i n p s y c h i a t r i c work. Many who had served i n army hospitals were attracted to community agencies which were o f f e r i n g more generous s a l a r i e s than were the state hospitals at that time. Tbe consequent r e s u l t was almost a complete discontinuation of s o c i a l work practiced i n the mental hospital s e t t i n g . Within the past f i v e years there has been a renewed interest i n v i t a l i z i n g and expanding the treatment services i n the state hospitals. Hence, s o c i a l workers i n the p s y c h i a t r i c f i e l d are once again d i r e c t i n g t h e i r attention to work i n mental hospitals. Saskatchewan's Psych i a t r i c Services There i s l i t t l e recorded about psychiatry i n the area now known as Saskatchewan, before the formation of that province i n 1905. U n t i l 1914 p s y c h i a t r i c patients from thi s area were treated at the Brandon Mental Ho s p i t a l , Brandon Manitoba. In 1914 the f i r s t Saskatchewan Hospital was b u i l t near the town of Ba t t l e f o r d . Due to conditions of over-crowding, i t soon became evident that a second i n s t i t u t i o n was needed. The Saskatchewan Hospital, then known as the "Weyburn Mental Hospital*, was constructed i n Weyburn i n 1921. - 20 -Upon completion of the b u i l d i n g , a s p e c i a l t r a i n was chart-ered which transported about f i v e hundred patients from the i n s t i t u t i o n at Battleford to the new i n s t i t u t i o n . A number of nurses and attendants were transferred to the new i n s t i t u t i o n to provide cus t o d i a l care f o r those f i v e hundred patients, some of whom are s t i l l h o s p i t a l i z e d there. In 1929 the Government of Saskatchewan appointed the Hincks Commission to study the psy c h i a t r i c services, and to make recommendations for t h e i r improvement. This Commission was l e d by Dr. Clarence Hincks, Director of the National Com-mittee f o r Mental Hygiene. Dr. McKerracher, former Director of the Saskatchewan Psych i a t r i c Services Branch, discusses some of the findings of that Commission: With approximately 1,000 patients i n each i n s t i t u t i o n , over-crowding was stressed as being of major import-ance. Each ho s p i t a l had a superintendent, two addit-i o n a l medical doctors, each a ward s t a f f of 110 un-trained personnel and one registered nurse. There was no formal t r a i n i n g program f o r nurses....The Commission strongly recommended the construction of a nurses' res-idence at the Weyburn Hospital, and i t a l s o stressed the need f o r the removal of the mental defectives from the hospital to a s u i t a b l y constructed i n s t i t u t i o n . Other items on t h i s 1936 blueprint were mental health c l i n i c s , p s y c h i a t r i c units i n general hospi t a l s , provision f o r public education i n the f i e l d of mental hygiene, and f o r research i n psyehiatry.1 The depression years hampered the f u l f i l m e n t of many of these recommendations, but during the past f i f t e e n years many new psy c h i a t r i c services have been made available to the people. Improvements i n the two already operating hospitals have been made. Plans f o r future improvements i n the t o t a l p s y c h i a t r i c 1 McKerracher, D.G., "Some H i s t o r i c a l Aspects of Psychia-t r i c Developments i n Saskatchewan", Saskatchewan P s y c h i a t r i c  Services Journal, Saskatchewan Department or FUDIIC aeaitn, A p r i l , 1952, p. 3. - 21 service program are constantly under consideration. The "mental hospital program" i n 1914 was e n t i r e l y under the r e s p o n s i b i l i t y of the "Department of Public Works". This included construction, maintenance, and therapeutic a c t i v i t i e s . Following the release of the Commission*s Report i n 1930, a l l the p s y c h i a t r i c services of the province were placed under the d i r e c t i o n of Dr. McNeill as "Commissioner of Mental Services". In 1931 the "medical and nursing s t a f f " were placed under the d i r e c t i o n of the "Department of Public Health", but the maintenance remained a Public Works respon-s i b i l i t y . In 1946, however, these r e s p o n s i b i l i t i e s were also turned over to the Department of Public Health. 1 By 1946, the Saskatchewan Hospital, Weyburn, had a population of about 2,600 patients. This desperate s i t u a t i o n was temporarily r e l i e v e d by the a c q u i s i t i o n of a former Royal Canadian A i r Force b u i l d i n g near Weyburn, which now accom-modates approximately eight hundred mentally retarded patients. This i n s t i t u t i o n i s known as the Saskatchewan Training School f o r Mental Defectives, and i s about to be moved from i t s temporary accommodation to a newly constructed cottage-style h o s p i t a l . The removal of these patients from the hospital f a c i l i t a t e d a decrease i n population to about two thousand patients. Since then the population i n the hospital has r e -mained f a i r l y constant. Improvements within the Saskatchewan Hos p i t a l , Weyburn, include: the purchase of increasing amounts Ibid,. p. 5. - 22 -of hospital equipment; plans for alterations of the out-dated architectural design of the building; the construction of a new Tuberculosis Unit and also a Nurses' Residence. There have also been improvements of personnel. The number of doctors has been greatly increased. A Nurses' Training Program has been established within the hospital, with an annual graduation class of Registered Psychiatric Nurses. Occupational, recreational, and physiotherapy de-partments have been initiated. A Research Unit has been de-veloped within the hospital. A c l i n i c a l psychologist has been appointed to permanent staff. With the increasing num-ber of graduate nurses and doctors, the ratio of patients to staff has decreased markedly. (See Appendix A.) For example, the ratio between patients and doctors in psychiatric hospi-tals in Saskatchewan in 1932 was three hundred twenty patients to one doctor. In 1953 however, this ratio had decreased to one hundred f i f t y patients to one doctor. It i s also i n -dicated in Appendix A, that i t i s only in recent years that physiotherapists, recreational therapists, psychologists, and social workers have been appointed to mental hospital staffs. Out-patient clinics were also established. The Regina Mental Health Clinic was started in 1947, being the f i r s t out-patient psychiatric service to be established in the province. In addition to the one psychiatrist, the Clinic was staffed by one psychologist and one social worker. The McNeill Clinic at Saskatoon was established in the f a l l of 1949; i t was the second full-time out-patient service in the - 23 province. The demands of private p r a c t i t i o n e r s f o r con-s u l t a t i o n services l e d to the establishment of Saskatchewan*s f i r s t part-time out-patient c l i n i c , and i t was established i n Moose Jaw i n 1943. Other part-time e l i n i c s were l a t e r opened at Yorkton, Swift Current, Weyburn, As s i n i b o i a , North B a t t l e -ford and Prince Albert. These c l i n i c s , have l i m i t e d t h e i r a c t i v i t y to consultation and diag-nosis. One of the more successful functions has been the establishment of very good rel a t i o n s h i p s with p r a c t i c i n g physicians. Another has been the screening of patients f o r r e f e r r a l to the d i f f e r e n t treatment centres. The Moose Jaw C l i n i c has since taken on a f u l l - t i m e treatment program, with a s t a f f consisting of two p s y c h i a t r i s t s , one psy-chologist and one s o c i a l worker. As a r e s u l t of the Hincks Commission, a twenty-seven bed p s y c h i a t r i c unit was established i n the Regina General Hospital i n 1946, as a part of province's p s y c h i a t r i c services program. This unit l a t e r became known as the "Munroe Wing*. A r e s i d e n t - t r a i n i n g program was set up and approved by the Royal College of Physicians and Surgeons. Recently, a new psy c h i a t r i c unit has been established i n the new University Hospital i n Saskatoon. In summary, the two mental hospitals were the'only psychiatric services a v a i l a b l e to the residents of Saskatchewan u n t i l the year 1947. Since that time two short term treatment 1 I b i d . . P. 7. 2 Loc. c i t . - 24 -units and several out-patient c l i n i c s have been established. Recorded history indicates that s o c i a l workers have been i n -eluded on the treatment team, i n the out-patient services and the short term treatment centres since t h e i r inception. S o c i a l workers were not employed i n the mental hospitals u n t i l 1950. The f i r s t one, Hrs. M. McEachern, was assigned i n J u l y 1950 to the Saskatchewan Hospital, Weyburn, so that s o c i a l services might be provided to the patients and t h e i r r e l a t i v e s . The administrative d i f f i c u l t i e s inherent i n hav-ing a s o c i a l worker responsible to the Department of So c i a l Welfare and R e h a b i l i t a t i o n , and the Department of Public Health soon became apparent. On A p r i l 1, 1951 th i s p o s i t i o n at the hospital was transferred from the Department of S o c i a l Wel-fare and Rehabilitation to the Department of Public Health. The Area Served The Saskatchewan Hospital, Weyburn, i s located on the north western frin g e area of the c i t y of Weyburn, which i s situated i n the south eastern corner of the province. In actual surface area, the Saskatchewan Hospital, Weyburn, serves about one-third of the province. Because of the sparse settlement in northern regions of the province, the Sask-atchewan Hospital, B a t t l e f o r d , serves an area approximately twice as large as the area served by the hospital at Weyburn; although the t o t a l population served by each hospital i s approximately equal. - 25 -The population of Saskatchewan i s predominantly r u r a l . The high percentage of r u r a l l i v i n g people i n Sask-atchewan, as compared to Ontario and B r i t i s h Columbia, i s indicated i n Table 1. Table 1. Rural and Urban Population, •Ontario, Saskatchewan, B r i t i s h Columbia 1951. ~ Population Ontario Saskatchewan B r i t i s h Columbia Rural (p.c.) 29.3 69.7 31.9 Urban (p.c.) 70.7 30.3 68.1 Total Population 4,598,000 832,000 1,165,000 Source: The Canada Year Book, 1954. Only t h i r t y per cent of the population of Saskatchewan re-sides i n urbanized areas. There i s evidence that urban stresses are more predisposing to mental i l l n e s s , and i n general, the processes of s o c i a l and economic adjustment are more complex. I t seems that there are v a r i e t i e s of mental i l l n e s s more l i k e l y to be found i n r u r a l and i s o l a t e d areas. These factors w i l l therefore be an influence upon the Saskatchewan caseload. The population of Saskatchewan, l i k e that of Ont-a r i o and B r i t i s h Columbia consists of people of many and varied r a c i a l o r i g i n s . Table 2 shows a percentage represent-ation of the various r a c i a l groups, present i n a l l three prov-inces. - 26 -Table 2. Racial Origin Representation i n : Ontario, Saskatchewan, British Columbia, 1^51. Racial Origin Ontario Saskatchewan British Columbia British 67.2 42.3 66.0 French 10.4 6.2 3.6 German 9.8 16.3 4.8 Italian 1.9 0.1 1.5 Jewish 1.6 0.3 0.4 Netherlanders 2.1 3.6 2.9 Polish 1.9 3.1 1.4 Russian 0.4 2.3 1.9 Scandinavian 0.8 7.5 5.6 Ukrainian 2.0 9.4 1.9 Indian and Eskimo 0.8 2.7 2.5 Other 1.1 6.2 7.5 Total 100.0 100.0 100.0 Source: The Canada Year Book. 1954. The "Anglo Saxon" group has the largest representation in a l l three provinces, but by comparison, Saskatchewan has the smallest "Anglo-Saxon" representation and the largest rep-resentation of other ethnic groups. In Ontario, the groups of French and German ra c i a l origins are represented by ten and nine per cent of the total population respectively. A l l other ethnic groups in Ontario are each represented by less than two per cent of the total population. Like Ontario, British Columbia's population includes only small minority representations. In Saskatchewan, persons of German racial origin are numerous enough to represent the second largest ethnic group. French, Scandinavian, and Ukrainian groups make up six, seven, and nine per cent of the total population res-pectively. There are several other groups each having a - 27 -representation of less than three per cent of the t o t a l population. The Netherland, P o l i s h . Russian, Scandinavian, Ukrainian, Indian and Eskimo groups are larger i n Saskat-chewan than either Ontario or B r i t i s h Columbia. This points up the f a c t that of the three provinces, Saskatchewan has the greatest percentage of t o t a l population comprised i n minority groups. To the extent that s o c i a l adjustment i s more d i f f i c u l t f o r persons with d i f f e r e n t c u l t u r a l hack-grounds, t h i s a l s o w i l l a f f e c t the patterns of i l l n e s s found in Saskatchewan. Method of the Study The main purpose of this study i s to examine the procedures, standards, and the administrative implications of s e t t i n g up a S o c i a l Service Department i n a mental hospi-t a l . The Social Service Departments reviewed are: (1) the S o c i a l Service Departments at the Crease C l i n i c of Psycho-l o g i c a l Medicine and also the P r o v i n c i a l Mental Hospital at Essondale, B r i t i s h Columbia and (2) The A f t e r Care Depart-ment associated with the Ontario Hospital, located i n London, Ontario. A comparative study i s made of these departments according to t h e i r development, administrative structure, and the services which they render. Recommendations f o r an anticipated S o c i a l Service Department at the Saskatchewan Hospital, Weyburn, are based on t h i s review. The study w i l l acquaint the reader, and p a r t i c u l a r l y the Administrators of the Saskatchewan P s y c h i a t r i c Services 28 Branch with already e x i s t i n g Social Service Departments; and i n e s t a b l i s h i n g a So c i a l Service Department at the Saskat-chewan Hospital, the Psy c h i a t r i c Services Branch might p r o f i t from the past experience of other Canadian hos p i t a l s . I t i s deli b e r a t e l y intended that t h i s study should serve i n part as a handbook f o r the p r a c t i c i n g s o c i a l worker so that he might better understand his r o l e as a member of the t r e a t -ment team. Such an exposition should also be an a i d i n i n -terpreting s o c i a l work functions to members of other profes-sions. Because of the great s i m i l a r i t y between the Saskat-chewan Hospital, Weyburn, and the Saskatchewan Hospital, B a t t l e f o r d , the recommendations made within this study w i l l be equally applicable to the Battleford i n s t i t u t i o n . Wherever s p e c i f i c reference i s not required, the study r e f e r s to the "Saskatchewan Hospital" rather than to the Saskatchewan Hos-p i t a l , Weyburn. The methods of research used i n t h i s study include: d i r e c t observation by the writer wherever possible; i n t e r -views with personnel within these departments; correspondence with administrative personnel within these departments who because of distance were unable to be interviewed by the writer; many other resources were drawn upon, such as other . Social: Work Theses of the University of B r i t i s h Columbia, annual reports of the various departments and hospita l s , and a r t i c l e s i n professional journals i n psychiatry and s o e i a l 29 work. Direct observation was an important method, as the writer served his fieldwork placement in the Social Service Department of the Crease Clinic. CHAPTER 2 SOCIAL WORK FUNCTION IN A PSYCHIATRIC HOSPITAL Growth of s o c i a l work practice i n p s y c h i a t r i c hospitals has been slow. S o c i a l work has, however, become an i n t e g r a l part of the professional team i n the care and treatment of mental i l l n e s s , i n s p i t e of the f a c t that s o c i a l work function i n such a s e t t i n g i s not very broadly known. An examination of the work which s o c i a l workers do i n p s y c h i a t r i c hospitals shows that t h e i r r e s p o n s i b i l i t i e s may be c l a s s i f i e d according to the three main phases of the patient*s treatment and return to the community. These are: (a) admission and diagnosis, (b) treatment, and (c) d i s -charge and convalescent care. Factors i n S o c i a l Adjustment Which C a l l f o r S o c i a l Treatment Many of the factors i n s o c i a l adjustment which c a l l f o r some form of s o c i a l work help, have been determined by Mr. Ernest Schlesinger, 1 who conducted a quantitative analysis of the services rendered by the S o c i a l Service Department, Crease C l i n i c of Psychological Medicine, Essondale, B r i t i s h Columbia. That study found that the following are the areas with which s o c i a l workers are concerned, i n the care and treatment of the mentally i l l : Sehlesinger, Ernest, S o c i a l Casework i n the Mental Hospital. Master Of S o c i a l Work Thesis, Uni v e r s i t y of B r i t i s h Columbia, 1954. 31 A. Work With The Patient, I, Pears and worries about being ho s p i t a l i z e d . (a) Fear of the physical s e t t i n g . (b) Pear of other patients. (e) Fear of the hospital s t a f f . I I . S o c i a l problems consequent to h o s p i t a l i z a t i o n . (a) F i n a n c i a l d i f f i c u l t i e s . (b) Adequate care f o r dependent c h i l d r e n . (c) Pear of permanent separation from family and f r i e n d s . I I I . Pears and worries which a r i s e out of conscious r e a l c o n f l i c t s . (a) Fear of accepting unpleasant s i t u a t i o n s of which he i s aware. (b) Worry a r i s i n g out of possible misunderstand-ings between; husband and wife. parents and t h e i r c h i l d r e n , s i b l i n g s , and misunderstandings a r i s i n g within the s o c i a l group to which the patient belongs. (c) Fear of accepting one's own l i m i t a t i o n s . IV. Fears and worries about leaving hospital and resuming former cares and r e s p o n s i b i l i t i e s . (a) Environmental. (1) Employment uncertainties. (2) Housing d i f f i c u l t i e s . (3) Heed for continued help i n keeping house, i n the case of married women. (4) Need f o r recr e a t i o n a l and l e i s u r e -time outlets. (b) Emotional. (1) Pear of loss of safety f e l t i n ho s p i t a l . (2) Pear of being unable to perform one's former job. (3) Pear of not being l i k e d by one*s family and friends. B. Work With The Patient's Relatives. I. Fear of one's r e l a t i v e being placed i n an i n s t i t u t i o n about which they know l i t t l e . (a) Pear of the physical s e t t i n g . (b) Fear of their r e l a t i v e being placed among "crazy" people. I I . Shame over having a mentally i l l r e l a t i v e . (a) Feeling of discomfort about commital. (b) Feeling of discomfort about being "cause" of i l l n e s s . - 32 -(c) Shame of mental I l l n e s s i n the family. (d) Fear and concern about strange behaviour of patient p r i o r to admission. I I I . S o c i a l problems consequent to h o s p i t a l i z a t i o n . (a) F i n a n c i a l problems. (b) Adequate care for dependent c h i l d r e n . (e) Fear of patient not returning to them. IV. Feelings of fear and discomfort i n the presence of the patient. (a) Not knowing how to v i s i t with a mental patient. (b) Not being able to l i k e the patient as he/she i s . (c) Worry a r i s i n g out of possible misunderstand-ings between them and the patient. (d) Fear of not knowing how to deal with the patient when he/she returns home. I t can thus be seen that the s o c i a l problems or " r e a l i t y problems", which hinder s o c i a l adjustment are ordinary l i f e experiences. They are to the p a r t i c u l a r person at a par-t i c u l a r time i n t h e i r l i f e , a causation f o r a degree of i n -capacitation i n s o c i a l adjustment. The aim of s o c i a l work i s to a s s i s t people who are experiencing r e a l i t y problems, toward a more comfortable s o c i a l adjustment. S o c i a l Work Function Today The provision of professional s o e i a l services to the patient d i r e c t l y , i s a r e l a t i v e l y new area of s o c i a l work. As was pointed out e a r l i e r i n t h i s study, s o c i a l work f i r s t entered the broad f i e l d of care and treatment of the mentally i l l i n England i n 1880, i n the form of a f t e r care programs fo r discharged patients. In America the f i r s t s o c i a l worker to be s t a f f e d by a mental h o s p i t a l , i n i t i a t e d an a f t e r care program at the Boston Neurological C l i n i c i n 1905. This 33 social worker's responsibilities were soon extended to include another important responsibility of social work—that of ob-taining background information about the patient and his soc-i a l adjustment prior to his admission. Over the years, social workers became more competent to relieve numerous emotional problems of distress, and were able to make a unique con-tribution toward the treatment of the patient's illness. In progressive institutions for the care and treatment of the mentally i l l , social workers were encouraged to participate in the teamwork approach to mental illness. The growth of Social Service Departments in the mental hospitals has been slow. The reason for this slow-ness in growth might be attributed to the fact that hosp-ita l workers are continually dealing with people whose mental suffering is much more severe than that of people who receive help from other agencies. Such a milieu does tend to have a distressing effect upon hospital workers, as is borne out in the fact that in the United States, only one of twenty social workers will accept a position in a psychiatric setting. Another significant factor which tends to discourage social workers from accepting positions in mental hospitals, is the multi-disciplined structure and the inherent difficulties of promoting collaborative teamwork. The majority of social workers prefer to work in agencies where social work itself is the discipline of authority. The hospital social worker carries large caseloads, and is unable to escape from the 34 great numbers of legitimate demands placed upon him by phy-s i c i a n s , nurses, the patient's r e l a t i v e s and the patients themselves. Because of the great shortage of s o c i a l workers, suitable r o t a t i o n schemes to permit provision of s o c i a l ser-vices on week-ends and statutory holidays i s often impos-s i b l e , the r e s u l t being that a s o c i a l worker i s often c a l l e d upon during off-duty hours to see anxious r e l a t i v e s , who were unable to v i s i t the hospital during work hours. Be-cause of t h i s , many s o c i a l workers prefer employment i n agencies where demands made upon them are fewer i n number, of a l e s s urgent nature and where these demands come from fewer sources. The pronounced stigma formerly attached to mental hospitals resulted i n t h e i r being constructed i n out-of-the-way l o c a l i t i e s , which appear much les s a t t r a c t i v e to s o c i a l workers who can obtain employment i n urban centres. Dr. A.L. Crease was appointed as Senior Medical Superintendent of the B r i t i s h Columbia Mental Health Ser-vices i n 1926. In his f i r s t Annual Report to the P r o v i n c i a l Secretary, he recommended the s e t t i n g up of a S o c i a l Service Department at the P r o v i n c i a l Mental Hospital, Essondale. In 1930, Dr. Crease's recommendation had s t i l l not been acted upon, so the National Committee on Mental Hygiene sponsored Miss Kilburn f o r one year as s o c i a l worker at the P r o v i n c i a l Mental Hospital. Her duties were to include: securing s o c i a l information regarding the patient's family, making plans for patients being discharged and providing these - 35 patients with follow-up care. By the close of that year, the hospital administrators were so thoroughly convinced of the value of such a personnel, that Kiss Kilburn was made a mem-ber of permanent staff. Hiss Kilburn did a great deal in laying the firm base upon which the present department has developed. She served as director of that f i r s t Canadian Social Service Department i n a mental hospital for twenty years. When she retired i n 1950 the department consisted of thirteen social workers.1 At Essondale, British Columbia, the f i r s t noted social worker participation in admission, treatment and con-valescent procedures occurred soon after Miss A.K. Carroll»s appointment in 1951, as the Provincial Supervisor of Psy-chiatric Social Work. At that time Admission Sections were established within the Social Service Departments at the Crease Clinic and the Mental Hospital, and casework services were extended to both patients and their relatives. Casework services were extended to include not only admission, but also treatment and convalescent procedures, as well as the customary services of history taking and providing follow-up care. At the Ontario Hospital, London, the After Care Department was established to provide follow-up care for a l l patients discharged from that hospital. The only profes-1 Pepper, Gerald W., Sociar Worker Participation in  Treatment of the Mentally 111. Master of Social Work Thesis, University of British Columbia, 1954, p. 21. - 36 -sional social services which are offered by this department during the patient's stay in hospital, are those which may be given to the patient's relatives. The need for casework service to the patient from the time of admission to the time of referral to the After Care Department, was expressed by the Director of that department in a paper written by himself entitled After Care Program. Ontario Hospital. London. In this paper, Mr. Gamble states: The lack of co-ordination between After Care and the Hospital i s a major problem. The answer in part at least to this problem i s another worker who would participate in admission and reception procedures and would establish a relationship with the patient from the earliest possible moment in his hospital-ization and integrate i t with his hospital treatment program and his post-hospital treatment from the f i e l d worker of the After Care Department. In a letter received from the Director of the After Care Department, dated January 1955, he states: Recently we have added to our staff and to our pro-gram the services of a caseworker within the hos-p i t a l whose function i s casework with patients from admission to the point when they leave the hospital and are referred to one of our f i e l d workers. Social Services Daring Admission Being admitted to a mental hospital i s always a very frightening and d i f f i c u l t experience. Because of the lack of public education about mental health, many emo-tionally sick people postpone seeking treatment so as to. avoid the stigma which public thinking tends to associate with mental i l l n e s s . Consequently, when admission to a hospital becomes a necessity, that individual's feelings of 37 -failure and shame are enhanced through his failure to over-come his problems secretly. In the case of mental i l l n e s s , the patient or possibly his relatives very often feel a sense of responsibility for the il l n e s s . This contributes usually to the d i f f i c u l t i e s experienced on or at the time of ad-mission to a mental hospital. In addition, the mentally i l l person is often sick because he i s hyper-sensitive to l i f e experiences. Because he i s very sensitive, and especially so at the time of il l n e s s , admission to a strange environment creates many fears within him. Often the patient's relatives have many reservations in having a family member admitted to a mental hospital. Their reservations may be due to one or several reasons. They may have guilt feelings about the patient's illness and fear that the doctor w i l l "take sides" with the patient against them. They may fear the public's reaction to them, i f i t becomes known that a member of the family i s receiving psy-chiatric treatment. They may want to r i d themselves of the patient, and feel uncomfortable because of this real wish. At the point of admission, the social worker is com-petent to offer professional social services, which may be of help to both the patient and his relatives. A warm, accept-ing, sympathetic, and understanding talk with a social worker at this time may go far in relieving anxiety and fear over admission. The social worker i s trained not only to accept people with their individual d i f f i c u l t i e s , but also to have a - 38 -knowledgable grasp of human behaviour and adjustment prob-lems. The s o e i a l worker at intake i s often the f i r s t person who i s w i l l i n g to l i s t e n to and accept the patient's problem as the patient sees i t . 1 This has been found to be a very-e f f e c t i v e means f o r r e l i e v i n g feelings of g u i l t , f e a r and h o s t i l i t y ; so that both the patient and his r e l a t i v e s are able to p a r t i c i p a t e i n the prescribed plan of treatment. At the time of admission, " i t a l s o i s important to determine whether any s o c i a l ' f i r s t - a i d ' measures are neces-sary. Thus, i t i s important to know i f the patient's family have enough to eat, i s properly clothed, has adequate s h e l -ter , has economic provision to supply these very basic and e s s e n t i a l needs which are necessary f o r s u r v i v a l and f o r maintenance of simple dignity while the patient i s hos-p i t a l i z e d . " Should the patient be the parent of dependent chil d r e n , i t i s important that the necessary provisions be made for t h e i r adequate protection. "These so-called ' f i r s t -a i d * measures may seem l i k e simple things about which s o e i a l Should the patient see his problems i n terms of a de-l u s i o n a l system, the s o c i a l worker w i l l have received con-firmation on t h i s from the doctor, and w i l l not discuss the patient's delusions, but w i l l help the patient to hold on to r e a l i t y by str e s s i n g r e a l things. The s o e i a l worker w i l l focus the interview onto more f a c t u a l material as soon as possible and attempt to arouse the patient's i n t e r e s t i n environmental r e a l i t i e s which are f e l t not to be too threat-ening for the patient. This i s i n keeping with the s o c i a l worker's professional competency—he works only with those problems of which the patient i s conscious. 2 Abrahamson, A.C., "The Role and Responsibility of the Social Worker i n Corrections", Unpublished Paper, School of Soeial Work, University of B r i t i s h Columbia, pp. 2-3. 3 9 workers need f e e l no apology." The help which a s o c i a l worker can give both to the patient, and to the patient*s r e l a t i v e s i n s e t t l i n g the immediate problems which a r i s e out of the patient's temporary absence from the family u n i t , has proven to be very h e l p f u l i n enabling patients to enter hospital and accept medical treatment. Knowledge and s k i l l i n s o c i a l work i s not merely a matter of providing s o c i a l ' f i r s t - a i d * measures. Screening eases f o r r e f e r r a l to continuing casework service i s now be-coming a very important r e s p o n s i b i l i t y of the s o c i a l worker at the time of a patient's admission to h o s p i t a l . Because of the shortage of s o c i a l service personnel i n mental hos-p i t a l s and a l s o because not a l l patients are able to use s o c i a l work help, i t i s important that screening be care-f u l l y done, so as to ensure the greatest possible e f f i c i e n c y in the provision of s o c i a l services. At the Crease C l i n i c and the P r o v i n c i a l Mental Hospital at Essondale, B r i t i s h Columbia, this screening process i s c a r r i e d out by the In-take S o c i a l Worker of the Admissions Section. A second screening i s done at Ward Rounds, where both the doctor and the s o c i a l worker p a r t i c i p a t e i n the screening process. At the Ontario H o s p i t a l , London, Ontario, each ease i s pre-sented at a General Conference three weeks following the patient's admission. The d i r e c t o r of the A f t e r Care Depart-ment attends these conferences and together with the medical 40 staff determines those oases which w i l l l i k e l y require, and be able to use social services following discharge. The screening process involves formulating a •soc-i a l work diagnosis'. A social work diagnosis i s not a single word or phrase, but rather a descriptive statement which includes at the very least: A (a) brief identifying informa-tion; (b) the presenting problem and the other stresses of the patient and his family i n generalized terms; and (c) a brief personality characterization. The social worker achieves a social work diagnosis through a social study, which is done through a casework relationship with the patient and relevant persons, also through collateral contacts for which the patient has given permission. This social study includes the patient's marital, vocational, educational, religious and psychosexual adjustments; achievements and failures; the patient's childhood experiences; the patient's social environment—its strengths and weaknesses; an assessment of the patient's interpersonal relationships with family members, members of his social group, his employer; and the history and nature of onset of the present i l l n e s s . A social study and consequent social diagnosis can provide for us "an excellent picture of the individual's social functioning, and social situation, a good picture of one's current emotional function-ing including his dominant character t r a i t s , symptoms, and i - i i H o l l i s , Florence, "Casework Diagnosis - What and Why", Smith College Studies in Social Work, Vol. XXIV, No. 3 (June T 9 - 5 4 ) , p. i : — 41 -defences. It can throw considerable light on the major social factors which bear on the patient's i l l n e s s and can give us some useful indication of psychological factors in this development.1,1 It can thus be seen that the social work diagnosis i s unique onto i t s e l f , in that i t relies on an understanding of the total family or the social group of which the patient i s a member. Interacting forces within the family and social group must be considered along with the interacting forces within the individual, i n understand-ing causation and in setting r e a l i s t i c treatment goals. Be-cause the social work diagnosis focuses attention on the patient's social environment, the social worker can assist the doctor and other hospital disciplines in arriving at a comprehensive diagnosis. Social Services During Treatment Treatment of the mental patient commences at the moment when the patient i s received into the hospital. At that time, the patient leaves an environment, the demands of which he i s no longer able to cope with; and enters into an environment which i s less demanding and of a protective nature--the psychiatric hospital. The patient i s not merely placed within a physical plant, he is placed in a hospital which i s staffed by many people whose energies are concentrated on the treatment and rehabilitation of each patient. Bach 1 Ibid., p. 2. - 42 -and every staff member whether he be doctor, nurse, psy-chologist, social worker, or the gardener, and whether his contact with the patient be casual or planned, i s carrying out a treatment function which may have fundamental or superficial value, depending on i t s meaning to the i n -dividual patient. Even simple gestures such as a warm smile or a friendly greeting from any member of the staff often has therapeutic value for the patient. However, "warmth of interest for the patient and a willingness to offer a relationship to him are only conditions to success-i f u l treatment". Within this condition for treatment, each discipline with i t s particular orientation and unique s k i l l s must participate in the total treatment plan in order to do an adequate job. Because treatment of the mentally i l l has become a multi-disciplined approach, and also because each of the participating disciplines has sometimes failed to define i t s own function, the inevitable result has been a lack of inter-disciplinary understanding and acceptance, the consequent result being poor cooperation between a l l member-disciplines of the treatment team. The failure of each discipline to differentiate " i t s psychological help-ing procedures from those available to the other discip-lines, has hindered c l a r i f i c a t i o n of function based upon 1 Schmidl, F r i t z , "A Study of Techniques Used in Sup-portive Treatment", Social Casework, Dec. f51, p. 491. - 43 -the potential and desirable uniqueness of different profes-sional orientations". 1 The following quotation attempts to distinguish between the therapy (psychological helping procedures) practiced by psychiatrists and that practiced by social workers. Psychotherapy aims to help the patient achieve a different organization within the self. Through this reorganization and reintegration the patient is enabled to respond to other people, to enter inter-relationships, to manage his situation with a more reliable sense of what i s real in himself and in them. Social work, on the other hand, works with whatever powers the patient has to decide and act for himself in his immediate situation. In a psychiatric setting, we might say that the therapy practiced by the psychiatrist aims to assist the patient to recover and reorganize the power in himself, to get hold of i t again; and the social worker helps the patient to exercise this power and learn how to use i t in gaining more satisfactory control of his l i v i n g . The two funct-ions are complementary and equally important. The patient can not stay in the magic c i r c l e of therapy even within the hospital: even within the hospital there is an environment which he has to meet and with which he has to cope. Whatever new power is developed within him, he has to find a way of using in behalf of his own recovery. He has to find a way of functioning differently with the new strength, and to leave this to chance may result in an arrest or a relapse of his inner progress. The social worker rea l l y uses the outer necessities for l i v i n g that confront the patient as the basis for helping him; even as the psychiatrist uses the patient's desire to find a way out of inner fear and pain as the therapeutic dynamic.2 Coleman, Jules V., M.D., "Distinguishing Between Psy-cotherapy and Casework", Journal of Social Casework. June, 1949, p. 245. Marcus, Grace, "A Further Consideration of Psychia-t r i c Social Work", National Conference of Social Work. Columbia University Press, 1946, pp. 339-40. - 44 -Of many social casework definitions formulated, the one by Mary J. McCormick is selected because of i t s c l a r i t y : The entire process is directed toward the human person and is carried on for the purpose of giving service that contributes to the well-being of that person.... The character of the service i t s e l f may vary according to the capacities and limitations of the particular individual for whom i t i s intended. This means that at times i t w i l l embrace the attempt to develop whatever personal resources such an i n -dividual possesses for meeting and solving his own problem. At other times, service w i l l be directed toward augmenting those personal resources through the use of f a c i l i t i e s that exist within the social order. In either event, the aim of casework i s a l -ways the same, that i s , to preserve human dignity through meeting human needs within the protected setting of hospital.I The social work treatment process has as i t s purpose the provision of social services which w i l l contribute to-ward the well-being of the individual, and consequently enable him to meet and cope more successfully with his real i t y problems. A rea l i t y problem may be one or several of the ordinary l i f e experiences, and the social work treatment process used i s always essentially the same. Social work treatment in the f i e l d of public as-sistance begins when the breadwinner of a family i s no longer able to cope with reality in the sense that he i s no longer able to provide for himself and family. This ina b i l i t y to provide, i s to him a reality problem. The social order may offer financial assistance to this family McCormick, Mary J . , Thomistic Philosophy in Social  Casework. Columbia University Press, N.Y., 1947, p. 3. - 45 -through a public assistance agency, so that the im-mediate reality problem of family finance is met. This however, is only a social first-aid treatment measure. His inability to provide may be the result of factors ex-ternal to him such as physical incapacitation; or i t may be due to factors within him such as worry and fear as-sociated with marital matters, unpleasant interpersonal relationships with fellow workers, fear aroused through misconceptions. Further social services may be provided to this family through the treatment process, so that these more basic reality problems might be overcome, even though they are of an intangible nature. Social work practiced in direct relation to psy-chiatry, is essentially the same. The presenting prob-lem is the patient*s illness, for which the social order has again provided a particular type of agency—the psy-chiatric hospital. Similarly to the above mentioned case, there are more basic problems underlying the presenting problem. These may be of an unconscious conflictual nature, with which the social worker does not deal. They may also be conscious reality problems, which in turn may be of a tangible or an intangible nature. The l i f e situation frequently presents problems in which a l l the elements of the conflict are on a conscious level; but in which the individual can not find or decide upon an effective course of act-- 46 -ion. This can r e s u l t i n symptoms as incapacit-a t i n g as those that a r i s e primarily from uncon-scious c o n f l i c t . ! Many of these have been enumerated i n the e a r l i e r part of th i s chapter. The s o c i a l worker i s concerned with these r e a l i t y problems which confront the patient i n his day to day l i v i n g , because he uses them as a basis f o r helping the patient toward a more s a t i s f a c t o r y s o c i a l adjustment. The s o c i a l worker o f f e r s two broad types of ser-v i c e s : (1) tangible services or s o c i a l f i r s t - a i d mea-sures and (2) help with conscious emotional c o n f l i c t . Both types of service are i n actual f a c t inseparable, in that the s o e i a l worker can not at one time o f f e r tangible services, and at another time carry out s o c i a l treatment. Soeial workers may render s p e c i f i c services or give suggestions about the handling of c r i t i c a l problems at any point i n the treatment contaet, but i n so doing, i t i s th e i r primary concern to r e l i e v e the patient fs f e e l i n g whieh i s necessary to enable the1 patient to u t i l i z e these services and suggestions i n a growth d i r e c t i o n . . . . Treat-ment i n any ease implies a meeting of the needs of the i n d i v i d u a l . This involves diagnostic s k i l l and the capacity f o r r e l a t i o n s h i p . The nature of treatment i s not pre-determined by the s o c i a l worker, but i s determined by the response of the individual.2 Not a l l patients within p s y c h i a t r i c hospitals are able to use a l l of the services whieh a s o c i a l worker can A Welker, Edmund, M.D., "The Effectiveness of the Psy-c h i a t r i c S o c i a l Worker i n the Treatment S i t u a t i o n " , Mental Hygiene, 1947, p. 597. o Towle, Charlotte, "Factors i n S o c i a l Treatment," National Conference of S o c i a l Work, 1936, pp. 179-80. - 47 -0 offer. In some cases, the illness is so incapacitating to the patient, that his potentiality for relationship i s almost completely lost u n t i l the psychiatrist i s able to "assist the patient to recover and reorganize the power in himself.* 1 During the time that the illn e s s i s as incapacitating as this, the social worker can contribute toward the creation of a condition for successful treat-2 ment. He can see the patient on the ward at regular i n -tervals, and by so doing, provide the patient with a regul-arly occurring personal event so as to help him grasp on to r e a l i t y . The social worker can offer acceptance and understanding. He can show a friendly interest in the patient. He can help the patient hold on to r e a l i t y , by stressing real things which are not too threatening to the patient. The social worker does not disclaim the pat-ient's delusions. Instead he accepts them as being real to the patient, moves onto more factual material as soon as possible, and attempts to arouse the patient's interest in environmental reali t y . This i s i n keeping with the social worker's area of competency—he deals only with those problems of which the patient i s conscious. Along with helping the patient hold on to r e a l i t y , the social 1 Marcus, op. c i t . . p. 339. 2 v. infra, p. 13. - 48 -worker offers the patient reassurance that his/her dependents are being cared for, i f need be, through social services provided by the social order. For example: Mr. X. was admitted to hospital follow-ing what the doctor diagnosed as being a •schizo-phrenic reaction 1. Mr. X. is thirty-five years of age, is married and has an eight year old daughter. In an interview with the patient*s wife, the worker learned that the patient i s very fond of his daugh-ter. When discussing the case with the doctor, the worker learned that the patient has delusions in regard to his committal to hospital. The pat-ient feels that his wife had tried to poison him by placing poison in his food, but when he refused to eat the food which she had prepared for him, she had two men take him away and lock him up. When the social worker saw the patient, and was told of these circumstances which he thought had led to his admission, the worker listened sympath-et i c a l l y . However, as soon as could gently be done, the worker advised that he had seen his l i t t l e g i r l recently, and that she seems l i k e a very nice l i t t l e g i r l . As the patient seemed to grasp on to this, the worker went on to say that Mrs. X. and Joan were both well and are planning to v i s i t him soon. The social worker must f i r s t establish a relation-ship with the patient, before he can help him to direct newly restored ego-strength into satisfying interpersonal relationships, and more effective courses of action in deal-ing with his r e a l i t y problems. A social work relationship implies an emotional interplay between the patient and the worker, or the patient's relative and the worker, which is directed in such a way that the patient or relative ex-periences acceptance and understanding. As the patient experiences a non-critical atmosphere, he gains a feeling of security whieh enables him to express his feelings and - 49 -attitudes, and by so doing gain self-understanding and self-acceptance. In working with relatives, this accepting and non-critical atmosphere enables them to overcome f e e l -ings which have been preventing their acceptance of the patient and his il l n e s s . During the patient's hospitalization, he is s t i l l within an environment which places demands upon him, even though i t i s protective and less complex than that from which he came prior to admission. Even in the hospital environment, the patient experiences r e a l i t y problems with which the social worker can help him to cope, thus enabling him to participate in the total treatment plan. Through the social worker's help in dealing with rea l i t y problems within the protected hospital environment, the patient i s enabled to deal with those reality problems associated with normal community l i v i n g . If the social worker can help the patient with the social problems related to work and playing in this protected environment, he may prepare the patient to meet social problems in the wider community, with more understanding of himself and others....Through the social worker's continuous support and acceptance of the patient's 'sick' and 'well 1 s e l f ; through his non-judgmental and understanding attitude, his know-ledge of the obstacles standing in the way of the patient's social adjustment, and his help in getting over these hurdles one by one; the patient may gain increased self-confidence and courage to face the world outside.1 "It i s this relatedness aspect of personal prob-lems to situations which i s the concern of social workers."' Garland, Ruth, "The Psychiatric Social Worker in the Mental Hospital", Mental Hygiene. 1947, pp. 289-90. 2 Coleman, op. c i t . . p. 247. - 50 This however, does not imply that the social worker does not deal with the patient's conscious feelings, and the impact of his personality upon reality situations in which he is a functioning social being. If the patient i s strong enough he i s helped to look more searchingly at his a t t i -tudes so that he w i l l better understand himself in relation to his situations and thus be better equipped to deal with them. Augmenting the personal strengths within the individual patient and/or relative sometimes necessitates the enlistment of help from community resources on behalf of that individual. "Mental illness i s often all-pervasive, so that help in many social areas i s required, with the hospital social worker offering his s k i l l s concurrently" 1 with social workers who are working within the framework of var-ious community agencies. For example; Mr. S. i s admitted to hospital, and the psychiatrist feels that long term treatment i s in -dicated. In an interview with Mrs. S. (patient's wife) shortly after the time of the patient's ad-mission, the social worker finds that in addition to feelings of fear and shame associated with the pat-ient's i l l n e s s , Mrs. S. and her children are with-out financial security. On discovering this d i f f i -culty within the home, the social worker discusses with Mrs. S., the possibilities of her contacting the local Social Assistance agency with the view to obtaining financial help. It was only with feelings of shame that Mrs. S. didapply for financial help. Mrs. S. was now faced with two r e a l i t y problems: (1) the fact of the patient's illn e s s and hospit-alization, and (2) accepting financial help because of her husband's il l n e s s . The hospital social worker Garland, op. c i t . , p. 291. - 51 -offered help in the former, the Soeial Assistance agency social worker offered help in the latter. Sometimes the hospital social worker does not work concurrently with the social worker from the community soeial agency. Instead, he prepares the patient during his stay i n hospital so that he might feel free to use the social services of another agency, following his discharge from hospital. For example; Mr. A. is admitted to hospital, and re-receives short term treatment. In interviews with the patient and his wife, the soeial worker learned that for some time there has been considerable mari-tal discord in this marriage. The hospital social worker w i l l only deal with those matters directly related to the patient's hospitalization, at the same time preparing both the patient and Mrs. A., so that they might feel free to accept social work help from a Family Counseling agency following discharge, as both expressed concern over the possible effect of their constant quarrelling upon their three small children. The social worker is concerned with the patient's interpersonal relationships, consequently, he i s interested in the patient's relatives and relevant associates, in so far as their thinking and attitudes affect the patient's mental condition. The social worker can offer acceptance and understanding to the patient's relatives, and thus enable them to express their feelings of fear, h o s t i l i t y and possible guilt in relation to the patient and his i l l -ness. Through this release of feeling in a non-critical atmosphere, they are enabled to accept the patient, the ill n e s s , and thus help the patient to participate in pres-cribed treatment procedures. The social worker can help - 52 -the relatives in this way, to "make of this ending, a new beginning for the patient and for themselves in bringing about changes which w i l l create a more favorable psycho-logical and social environment."1 As Helen Witmer states, to sense what a person i s trying to say, to create a situation in which he can say i t and to keep one's own feelings and opinions from inter-fering with another person's expression of emotions and attitudes requires a great s k i l l and disciplined sensi-t i v i t y and a flexible use of one's relationship with a patient or his/her relative. The social worker's approach to the patient i s unique. Minna Field, Assistant Chief of Social Service at the Montefiore Hospital, New York, describes the social worker's approach as follows: The social worker's approach differs from that of the other members of the treatment team, his rela-tives or his friends. While the very nature of their functions imposes upon the other members of the treat-ment team the obligation to exercise authority, and while the attitude of family members and friends may be colored by their own emotional reactions, the social worker can remain free from the need to pre-scribe any particular line of action and from emo-tional entanglement. Rather, the social worker's approach i s governed by an attempt to see the prob-lem as the patient sees i t , to allow the patient to move at his own pace, and to make his own deci-sions toward a goal that he helped to set for himself. Such an approach can be carried out only when i t i s rooted in the genuine appreciation of the intr i n s i c worth and dignity of the human being regardless of the stage of his ill n e s s or the degree Of incapacit-ation i t produces. For the patient, such an approach Ibid., p. 292 - 53 -assumes particular significance in the light of an illn e s s that tends to undermine his feelings of usefulness and status.1 Social Services During Rehabilitation . Public acceptance of social welfare goals has ad-vanced to include the aims of rehabilitation of a l l dis-abled persons. Concern with the problem has been so great, that the word rehabilitation has become very broad in i t s meaning, including a l l the various types of help given to those citizens who for any reason are not able to be self-sufficient. "Rehabilitation and after care i s more in -timately the concern of a hospital or treatment i n s t i t -ution because the aim of these agencies of the community i s to see the patient through to maximum social integration 2 into the community." A general definition of rehabilita-tion i s the statement made by the National Council on Re-habilitation, New York, to the effect that rehabilitation is the restoration of the handicapped to the f u l l e s t  physical, social, vocational and economic usefulness of which they are capable. In a sense, "rehabilitation" in the psychiatric setting i s similar and identical to "treatment", in that 1 Field, Minna, "Role of the Social Worker in a Modern Hospital", Social Casework. November 1953, p. 399. This paper was presented at the International Congress of Hospitals in London, May 1953. 2 Sutherland, Murray S., The Rehabilitation of Discharged  Mental Patients, Master of Social work Thesis, University of British Columbia, 1954, p. 16. - 54 -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 . Similarly, i t could be said that treatment i s identical with rehabilitation, because rehabilitation i s the result of successful treatment. For the purpose of this study, the term rehabilitation i s used to refer to the latter portion of the treatment goal, which includes plans and programs for that period following the patient's discharge from hospital. There are several factors during this pre-convalescent period and post-discharge period which do point up the need for social treatment. During conval-escence , the patient i s preparing himself for leaving the protected environment of the hospital and for returning to the complexities of l i f e within a family, vocational, and soeial setting. There are many real i t y problems inherent in making the adjustment from hospital l i v i n g to livin g in the community. Mr. Murray Sutherland conducted a survey of the post-discharge problems of mental patients. 1 A majority of patients are discharged directly baek to their families or friends with the assistance of adequate soeial casework before and during the actual re-habilitation placement. The problems of this group may not be primarily associated with their illness but may be i ~ — " 1 Information contained in the three proceeding para-graphs is taken from: Sutherland, Murray R., Rehabilit-ation of the Discharged Mental Patient. Master of Social Work Thesis, University of British Columbia, 1954, pp. 22-25. - 55 -directly associated with the physical disruption of routine family l i v i n g resulting from the absence in hospital of the housewife, the mother or the bread-winner. The family member's absence from the home may have added problems and responsibilities for a wife or husband, privation for the children; and supportive case-work help i s requested in f a c i l i t a t i n g the family's return to more stable equilibrium. It has been found, however, that there are many patients who do not possess family, friends, or financial resources; or whose family and friends are disinterested or actually hostile or resentful. These patients require more extensive help and support from the social worker in becoming more securely established in an emotionally healthy environment. This group has a wide variety of needs. First of a l l , there are a multitude of basic dependency needs which must be met before they are re-established in the community: money, food, clothing, shel-ter, a job, a meaningful relationship with an interested person or persons. For a person who has been hospital-ized for a mental or nervous disorder, the return to the community i s often a threatening experience; and to lack the security of friends and adequate finances enhances this feeling of distress and uncertainty, and in turn i n -creases the possibility of a relapse and a return to hos-p i t a l . These patients may look to their discharge with - 56 -a l l the insecurity of a person recovering from an il l n e s s , or they may prefer to regard themselves as never having been sick, but in either event they are fearful of the rejecting attitudes of society. There are also many patients who leave the hosp-i t a l with a residuum of the mental disorder or the upset which led to their hospitalization. These patients have received treatment and have made a certain recovery, enabl-ing them to return to the community; but they have retained a certain mental handicap which adds to their problems of re.establishment. Such patients may retain undue feelings of submissiveness, or depression, or anxiety, or fear of people. Sometimes these feelings are related to an un-resolved marital conflict, or an unsatisfactory work ad-justment which precipitated the breakdown but remained un-solved. Sometimes the feelings are the end result of years of emotional deprivation or conflict with parents. The inner problems of these patients may be of such severity that they cannot be further reduced by known methods of psychiatric therapy; but they are persons whose l i f e can be made more comfortable by a kinder environment or by the sympathetic understanding and interest of the social worker who continues to see them. This type of patient needs help in meeting the additional stresses of securing accommodation, a job, and of functioning as best he can in our complex society. For such a person with a severe - 57 ~ mental handicap, the psychiatrist sometimes recommends sheltered accommodation, a protected work placement or financial subsidization in maintenance. But i f com-munity resources are lacking to make possible the im-plementation of such recommendations, the social worker must seek out the best available compromise solution and help the patient as best he can to adjust to a limit -ing situation. What Do Social Workers Do? The social work treatment process is a method of assisting persons who are experiencing d i f f i c u l t y in making a satisfactory social adjustment. In a psychiatric setting, the entire process i s patient-focused, with the purpose of providing him or her with those social services requisite for a more comfortable way of l i f e . It has been seen that there are many factors in social adjust-ment, which might at some time c a l l for some form of social work help. It might be restated that these factors in social adjustment which c a l l for social work help are nor-mal l i f e experiences, which are to that particular person at that particular time a cause for temporary incapacit-ation. The patient's relatives and significant persons in his or her l i f e often require help in making a more comfort-able adjustment to the patient and the il l n e s s . Social work respects people's rights. Therefore when helping the patient's relatives, the social worker only deals with - 58 -those conscious feelings which have a direct bearing on the patient's i l l n e s s . At the time of the patient's admission to hos-p i t a l , the social worker i s often able to help the patient feel less frightened of l i v i n g in a new place. He i s often able to help the patient's relatives feel more comfortable about having a family member admitted to a mental hospital, and about the patient's temporary absence from the family unit. The social worker i s able to do this by helping the relatives to maintain a standard of li v i n g and simple dig-nity, both of which are.essential for survival. This i s accomplished through the administering of or arrangement for social f i r s t - a i d measures such as financial help, care for children, vocational help; to say nothing of the i n -tangible types of help, such as encouragement and reas-surance. During the time immediately following admission, the social worker with his professional orientation toward social l i v i n g , is able to assist the doctor by contributing toward a comprehensive diagnosis, and the formulation of a total treatment plan. During treatment, the patient i s s t i l l a part of an environment, and must conform with certain demands that the hospital environment places on him. The social worker through his acceptance of the patient and support of his - 59 -or her strengths, helps the patient overcome l i t t l e r e a l -i t y problems one by one, u n t i l the patient feels capable of dealing with the complexities of a family, vocational, and social setting. The social worker helps the patient to adjust as comfortably as possible to the hospital routine, and serves as a link between the patient and his or her family. As psychiatric treatment progresses, and the patient regains ego-strength, the social worker helps the patient to decide and act for him or herself in re-lation to the immediate situation. During rehabilitation and convalescence. the social worker s t i l l using the patient's immediate situat-ion as a basis for helping him or her, assists the patient to re-establish him or herself in an environment whieh i s as emotionally healthy as possible. Help is often re-quired in restoring the equilibrium of the family unit which had become disturbed because of the patient's temp-orary absence. Patients who retain a residuum of their illness need social work help so that the best possible adjustment to a limiting situation can be made. Social Casework Techniques The Family Service Association of America, an organization consisting of a representation of a l l Amer-ican Family Welfare agencies, has made the statement that - 60 -social casework techniques are three in number. They are: (1) environmental modification (2) psychological support and (3) c l a r i f i c a t i o n . Some social workers speak of "use of the relationship" as being another technique. The worker-patient relationship i s the basis for a l l social work help, so i s therefore a part of the three mentioned techniques. Environmental Modification Modification of the patient's environment occurs when "steps are taken by the caseworker to change the en-vironment in the patient's favor by the worker's direct i action." For example: Mrs. L., a middle aged woman who does not have any children, is experiencing d i f f i c u l t y in making a satisfactory adjustment to the incap-acitation of one arm and one limb, resulting from injuries sustained in an automobile accident. Ex-treme financial insecurity in this family unit arose out of heavy medical expenses and also Mr. L.*s loss of employment. These environmental pres-sures eventually resulted in Mrs. L. experiencing a mental breakdown and being admitted to a mental hospital. In an interview with the patient, the worker sensed the great fear which the patient had of having to remain in hospital because of her i n -a b i l i t y to perform her household duties and their i n a b i l i t y to pay a housekeeper. The doctor re-commended an early discharge of the patient from hospital. In working with both the patient and her husband, the worker was able to help Mr. L. make Hol l i s , Florence, "The Techniques of Social Case-work", Principles and Techniques in Social Casework, Cora Kasius, Editor, Family Service Association of Am-erica, 1950, p. 413. - 61 -use of an employment service, agency, which helped him to locate part-time work. The worker also helped this family to make ap-plication to the local Social Assistance agency for financial help so that they might employ a house-keeper. Through modification of the excessive en-vironmental pressures, which were financial in this case, both the patient and her husband were enabled to work through a re a l i t y problem toward a more sat-isfying social adjustment. Psychological support This casework technique involves "supporting the positive, constructive aspects of the personality through guidance, release of tension, and through direct encourage-ment of attitudes that w i l l enable the client to function more comfortably and r e a l i s t i c a l l y . " 1 For example: Mrs. M., a young married woman and mother of three small children was admitted to hos-p i t a l for psychiatric treatment following an at-tempted suicide. Psychiatric and psychological as-sessments indicate the patient to be emotionally immature, especially in the sexual sphere. In spite of her immaturity, i t was f e l t that Mrs. M. was capable of being a good mother. During early contact with the doctor and the social worker, the patient expressed a great deal of ho s t i l i t y toward her husband, and also expressed the fear of having more children. At this time, the patient saw her fear of future pregnancies as being the "only stumbling block" of her marriage. The patient i n -sisted that i f she could not be made s t e r i l e that she could not return to her family. The worker ac-cepted the patient's feelings of ho s t i l i t y and dis-satisfaction, seeing her position as being a d i f f i -cult one. Through acceptance, the worker helped the patient to discuss her feelings further, and as social treatment progressed, Mrs. M.was enabled to Casework Glossary. Abrahamson, Exner McCrae, School of Social Work, University of British Columbia, (mimeo-graphed), June 1954. - 62 -move on to recognize and discuss other rea l i t y prob-lems in her marriage, such as poor housing, l i t t l e opportunity for recreation, and an unsatisfactory interpersonal relationship with her mother-in-law. During social treatment, the worker supported the patient*s strengths which were her a b i l i t y to be a good mother and housekeeper. The worker also helped the patient to see herself as being indepen-dent from her mother-in-law and reassured her that she and her husband had the right to make their own decisions. Clarification This casework technique attempts to "make clear. It i s helping the patient through mutual rational and i n -tellectual discussion to more clearly understand himself, the people with whom he associates, and the circumstances he faces. 1 , 1 For example: Miss R. is a twenty seven year old stenographer, who has been discharged from hospital, but according to psychiatric assessment, retains a residuum of her illness in that she is super-sensitive in interpersonal relationships. Miss R. contacted the Out-patient Service worker in her region. She discussed with the worker how she often f e l t slighted at the office, of how her acquaint-ances were attempting to drop her, and how they were indirectly c r i t i c a l of her. The worker helped Miss R. to see that a friend»s . invitation to a third person to accompany them on a tri p to the museum did not mean that the friend was trying to break off the relationship with Miss R. Clarification of misunderstandings were accomplished through the worker and Miss R. discussing each i n -cident carefully; the worker asking questions about details, and about Miss R.*s interpretation of these happenings; to help her re-evaluate them more re a l i s -t i c a l l y . Ibid.. Casework Glossary - 63 -Evaluation of Social Services Rendered An evaluation of the various Social Service Departments under examination w i l l show the areas into which social workers are directing their energies; and also the percentage coverage of the total population of. the respective institutions. A l l material related to the Social Service Departments at the Crease C l i n i c , of Psychological Medicine, and the Provincial Mental Hospital, Essondale, British Columbia, i s taken from the British Columbia Mental Health Services Annual Report for the year ending March 81, 1953. The writer regrets not being able to show s t a t i s t i c a l l y the work which i s being done by the After Care Department of the Ontario Hos-p i t a l , London, but Mr. J.E. Gamble, director of that de-partment, replied to the writer's request for such i n -formation as follows: We do not produce any annual reports, as such, from the After Care Departments. However, i t may interest you to know that we are now i n -volved in an evaluation of this rehabilitation unit. It i s to be a comprehensive survey of our work over the past five years. Social Service Department, Crease Clinic Table 3 records the year's work of the two social workers on admissions. Of 1,221 patients ad-mitted to the Cli n i c , 573 (46.9 per cent) were extended social services at the time of reception into the Cl i n i c . - 64 -Table 3. Report of Admissions Section. Social Service  Department. Crease C l i n i c . A p r i l . 1952 to  March. 1953. Apr. May June July A U R . Sept.j Oct. Nov. Dec. Jan. Feb. Mar. Total Total admissions. Crease Clinic 107 120 119 83 86 92 | 94 89 88 129 108 106 1,221 Referrals for social-history study 21 25 32 21 29 23 | 26 17 81 121 99 78 573 Interviews with patients at time of admission - 13 25 23 33 21 22 | 24 20 51 36 32 24 324 Interviews with psychiatrists and nursing at time of admission 25 27 32 26 22 24 | 28 29 103 101 89 85 591 Interviews with other agencies 15 18 21 28 19 23 | 20 12 9 7 11 16 199 Brief services to patients and relatives 14 19 10 17 11 12 | 15 . : 14 54 47 23 82 318 Ward rounds following admission 1 clinics on admission 12 8 8 4 4 8 1 1 1 12 12 8 8 8 12 104 Source: Mental Health Services. B r i t i s h Columbia, Annual Report, for the year ending March 31, 1953. Some 318 (55.55 per cent) of these 573 patients and their families were carried i n the Admissions Section for a short period of time receiving casework services of an enabling supportive nature. The table further indicates that the Admissions Section undertook 591 conference inter-views with psychiatrists and nurses, to a furtherance of a collaborative working relationship, in the light of the best possible services for the patient. Table 4 shows that 1,100 patients were carried actively with the Continued Casework Section. Some 5,155 interviews (49.5 per cent of a l l interviews) were extended to the patient and his family during the period of hos-pi t a l care. Of these 5,155 interviews, 1,590 interviews (30.8 per cent) were extended to the patient, and 1,385 interviews (26.8 per cent) to the patient's family. Some - 65 -Table 4. Report ofContinuing Casework Service Section. Social Service Department, CreaseClinio, A p r i l . 1952 to March. TQ-5X 1  Interviews with patient Interviews with family -Conferences with psychiatry Conferences with nursing Conferences with other disciplines : Conferences with other agencies Total number of interviews Total number of patients referred Total number of ward rounds and clinics,. Treatment Pre-conva-lescence Convales-cence Total 1,590 1,385 1,635 272 48 225 948 368 795 236 40 336 5,155 | 2,723 768 681 699 18 368 3,306 2,434 3,129 508 106 ,929 2,534 | 10,412 Source: Mental Health Services, British Columbia, Annual Report, for the year ending March 31, 1953. 2,723 interviews (26.2 per cent of a l l interviews) were extended to the patient and his family in planning for discharge. Of these 2,723 interviews, 948 interviews (34.8 per cent) were directed to the patient, and 368 interviews (13.5 per cent) to the patient's family. Some 2,534 interviews (24.4 per cent of a l l interviews) were extended to the patient and his family following the pat-ient »s discharge in f u l l from the Clinic. Of these 2,534 interviews, 768 interviews (30.3 per cent) were directed to the patient, and 681 interviews (26.9 per cent) to the patient's family. - 66 -Social Service Department, Provincial Mental Hospital Table 5 records the year's activity of the social worker on admissions at the Provincial Mental Hospital. Table 5. Report of Admissions Section, Social Service  Department. Provincial Mental Hospital. A p r i l . 1952 to March. 1953. " _ — i . . - —^ Apr. May June July Aug. Sept. Oct. Nov. Dec. Jan. Feb. Mar. Total Total admissions. Provincial Mental Hospital 86 105 101 133 112 102 147 101 107 116 101 121 1,332 Referrals for social-history study 32 41 • 3 7 : 51. 46 40 61 57 34 48 40 37 524 Interviews with patients at lime of 1' 11- 18 20 17 23 ,42 :•• 31 21 14 12 38 254 Interviews with psychiatrists at time of .11 . .-'9 15 9 6 7 13 18 21 16 8 23 156 Brief social services to -relatives and 15 20 24 18 21 17 37 25 14 23 1 20 27 261 Further interviews with relatives . 11 29 18 11 30 34 33 37 42 15 17 31 308 Ward rounds following admission clinics on admission.... ^, 4 6 10 j 4 4 8 8 .12 10 12 . io 12 100 ~ — ,.• , • ~ . - _ . — ^ i . . . ., J .. . — _ -Source: Mental Health Services. British Columbia, Annual Report, for the year ending March 31, 1953. The table shows that an average of 111 patients are admitted to the Provincial Mental Hospital monthly. Some 524 patients (39 per cent) of a l l admissions are extended social ser-vices at the time of their reception into hospital. The table further shows that 261 families received brief case-work service during the early stages of hospitalization. The collaborative function of the social worker at the time of admission i s indicated in his 156 interviews held with psychiatrists, and his attendance at 100 ward rounds. - 67 -Table 6. Report of Continuing Casework Section. Social Service Department, Provincial Mental Hospital. April 1952 to March 1953. Treatment Pre-conva-lcsccncc Conva-lescence Total Interviews with patient \ Interviews with family 1,116 1,327 474 270 867 471 2,457 2,068 Conferences with psychiatry _ _ „...._.... Conferences with nursing „ 1,341 525 636 258 375 57 2,352 840 138 60 9 207 Conferences with community agencies 42 27 • 15 • 84 Total number of interviews . . . 4,489 1,725 1.794 8,008 Total number of patients referred - . 607 Total number of ward rounds and clinics 108 Source: Mental Health Services, British Columbia, Annual Report, for the year ending March 31, 1953. Table 6 records the total number of patients (607) referred to the Continuing Casework Section of Social Ser-vice Department of the Provincial Mental Hospital. During the treatment period 607 patients and their families re-ceived casework services involving 4,489 interviews. Some 24.8 per cent of these were directly with the patient, 29.5 per cent with the patient's family and friends, 29.8 per cent with psychiatrists, 14.7 per cent with nursing, occupational therapy, etc.; and 0.93 per cent with community agencies. During the period of pre-convalescence, when social casework services are directed toward assisting the patient to formulate discharge plans, 1,725 interviews were extended to the patients and the family. Of these, 27.4 per cent were carried out with the patient, 15 per cent - 68 -with the patient's family, 36.8 per cent with psychiatry, 18.4 per cent with nursing, occupational therapy, etc.; and 1.5 per cent with community agencies. Convalescent care i s the re-establishment of the patient in the community. During this period the patients on probation remain the responsibility of the hospital. Some 768 patients were referred to Social Service, involving 1,794 interviews by the social workers directed toward help-ing these patients. Of these, 37.2 per cent were directly with the patient, 26.2 per cent with the patient's family, 20.9 per cent with psychiatry, 3.7 per cent with nursing, occupational therapy, etc.; and 0.83 per cent with community agencies. The practicing social worker rendering social services does not work under the direction of a psychiatrist, but contributes the knowledge and s k i l l of his own profes-sion in an independent capacity. Administratively, of course, he makes this contribution as an integral part of the hospital structure and unites his independent contri-bution with that made by members of other professions to form a related whole to the end of helping the hospital f u l f i l l the purpose of improved health to the patients. The social work profession i s traditional for the emphasis which i t places upon social work being prac-ticed within an administrative framework. The social work profession i s also noted for the emphasis which i t places upon the supervision of those personnel who are on the 69 -direct service level of administration. In most mental hospitals, rather large social service departments are required. To ensure the most efficient u t i l i z a t i o n of social service personnel, and to ensure the best possible provision of service to the patient from the time of his admission through to re-habilitation, i t i s evident that an administratively sound structured social service department i s essential. CHAPTER III AN EXAMINATION OF EXISTING SOCIAL SERVICE DEPARTMENTS The main purpose of this chapter i s to examine the procedures, standards, and the administrative im-plications of setting up a Social Service Department in a mental hospital. The Social Service Departments which w i l l be examined are: (1) the Social Service Departments at the Crease Clinic of Psychological Medicine and also the Provincial Mental Hospital at Essondale, British Col-umbia and (2) the After Care Department associated with the Ontario Hospital, London, Ontario. A comparative study i s made of these departments according to their de-velopment, administrative structure, and personnel. On the basis of their examination, recommendations can be formulated for an anticipated Social Service Department at the Saskatchewan Hospital, Weyburn. The Social Service Departments. Essondale The impact of humane emphasis in the treatment of mental illness was also f e l t in British Columbia, result-ing in newer methods of treatment in the mental hospitals and later the inclusion of social workers on the treatment team. 71 -In 19G5 Dr. C.E. Doherty, the new medical superin-tendent at the Public Hospital for the Insane in New West-minster, attempted to foster and nurture policies and treatment procedures which were being established in more modern mental hospitals. Each department was encouraged "to see that the patients receive the best care, treatment, and attention that the sick should receive." The year 1906 was important in the development of care for the mentally i l l in British Columbia. Henry Esson Younge, M.D., became Provincial Secretary and served in this capacity for many years. This able and socially-minded Minister made the mental hospital at New Westminster one of his most v i t a l concerns. His efforts were largely re-sponsible for the new institution at Essondale, British 2 Columbia. Dr. A.L. Crease was appointed Medical Superin-tendent of mental hospitals in British Columbia in 1926. In the f i r s t of his annual reports to the Provincial Sec-retary, Dr. Crease recommended the setting up of a Social Service Department to serve the mental hospitals in the province. Many years prior to this, the need for established social services to the patients and their relatives was Pepper, Gerald W., Social Worker Participation in the Treatment of the Mentally 111. Master of Social Work Thesis, University of British Columbia, 1953, p. 9. o Clarke, James R., Care of the Mentally 111 in British  Columbia. Master of Social Work Thesis, University of British Columbia, 1947, p. 44. - 72 -recognized, but at that time, no consideration was given to the possibility of these services being provided by professional social workers. It had been recognized that the family played an important part in the rehabilitation of the patient as early as 1897. It was then f e l t that the "care and attention arising from family affection was conducive to restoration of mental health". It was not unt i l 1930, however, that Dr. Crease*s recommendation was acted upon by the provincial Secretary. A social worker, Miss Josephine Kilburn, was sponsored at the Provincial Mental Hospital by the Canadian National Committee for Mental Hygiene, for one year. The chief aim and purpose of this new Social Ser-vice Department was to secure more detailed information re-garding the home l i f e and condition of the patient which heretofore had not been obtainable. A follow-up of a pat-ient after discharge and assistance in the re-establishment in the community was another function of the Social Service Department.2 Miss K i l b u r n ^ one year of service convinced the government of the value of social services and she was made a member of the permanent staff. A new aspect of treat-ment was thus opened up not only to the patients, but to the , • Report of the Medical Superintendent of the Provincial Asylum for the Insane, New Westminster, British Columbia, for the year ending December 31, 1897. 2 Birch, Sophie, An Aid in the Rehabilitation of Mental Patients, Master of Social Work Thesis, University of British Columbia, 1953, p. 9. - 73 -patients' families as well. The Social Service Department gradually increased to a total of thirteen social workers by December 30, 1950, when Miss Kilburn retired. The Crease Clinic of Psychological Medicine was opened early in 1950. This new treatment centre increased the area of responsibility of the then existing Social Ser-vice Department. At this time two problems became paramount for the Social Service Department: (1) the number of social workers in the department was far too few to carry casework responsibility for both the Provincial Mental Hospital and the Crease Clini c ; (2) the matter of division of labour within the department became a matter of concern so that participation in administrative work and services to the patientsi would not only be more effective but also more inclusive. By the summer of 1951 an Admissions Section had been started in both the Crease Cli n i c and the Mental Hospital. In May, 1952 the existing Social Service Depart-ment was divided into two separate departments—one at the Crease C l i n i c , the other in the Mental Hospital. Each department consisted of an Admissions Section and a Con-tinuing Casework Section. During this re-evaluation i t was seen that up until this time the social worker had been primarily concerned with securing a social history of the patient's background, evaluating social data and i t s relation to the patient's mental concepts, and to a limited degree, working with the patient's relatives and community - 74 -agencies. The new division in the department meant that the above mentioned services were offered plus casework services at the time of the patient's admission, during the treatment period, including pre-convalescent planning, and to some extent after discharge either in the form of probation or referral services. The After Care Department, Ontario Hospital. London The province of Ontario has gone about the pro-vision of mental hospital service, very differently from British Columbia. Rather than having one large i n s t i t u t -ion to serve the entire province, Ontario has distributed smaller hospitals throughout the province, each serving i t s specified area. They are several in number, but the present study w i l l only consider the Ontario Hospital located in London, and i t s After Care Department. In the early years, the Ontario Hospital, Lon-don, was operated in much the same way as a l l mental hos-pital s . The patient was admitted to hospital and when he had recovered, he was returned to the same environment from which he had come, and in which he became i l l . There was no consideration of the possibility that modified environmental factors might prevent the patient's re-admission to hospital. The f i r s t move toward extending mental health services into the community surrounding the Ontario Hos-p i t a l , London, was made in 1931, with the establishment - 75 -of a Travelling Mental Health Clinic. This c l i n i c con-sisted of one psychiatrist, two psychologists, and two social workers. The purpose of the c l i n i c was detection and prevention of mental illness in i t s early stages. This travelling c l i n i c is s t i l l servicing the geographic area served by the Ontario Hospital, London. The travelling c l i n i c , because i t was the only mental health service in the community, had to take on responsibilities for which i t was not created. Since many patients leave the hospital before they are completely re-covered from their i l l n e s s , and also because many discharged patients carry a residuum of their i l l n e s s ; the travelling c l i n i c soon became a post-discharge treatment unit as well as a unit for the detection and prevention of mental i l l -ness. The inevitable result was an over-loading of respon-s i b i l i t y upon the very limited resources of the travelling c l i n i c . In about 1945, Dr. 6.H. Stevenson, then the Sup-erintendent of the Ontario Hospital, began to consider the possibility of creating a post-discharge treatment unit as such. Dr. Stevenson f e l t that this treatment f a c i l i t y should be somewhat akin to the travelling c l i n i c in i t s administrative structure and the personnel included on the team. Its purpose was to f a c i l i t a t e the continuance of treatment following discharge, to offer rehabilitative ser-vices; and consequently decrease the number of "relapses and re-admissions to hospital, ; so that the unfortunate - 76 -handicap of mental illne s s and the cruel and undeserved stigma so long associated with mental illne s s might more quickly be overcome."1 Dr. Stevenson's blueprint for the After Care De-partment included a psychiatrist as director, junior psy-chiatrists, psychologists, social workers, and public health nurses. Pull time psychiatrists for the After Care Department were unobtainable, so the new department did not conform to the plan which i t s originator had l a i d down. In the absence of f u l l time psychiatrists on the team, psy-chiatrists from the hospital were made consultants to the After Care Department. With the support and encouragement of the Ont-ario Department of Public Health, and with financial assistance from the Ontario Department of Health and the Federal Department of Health, a rehabilitation team was organized at the Ontario Hospital, London, in September 1949, which i s known as the After Care Department. It i s headed by Mr. J.E. Gamble, M.S.W,, a psychiatric soeial worker.3 In September, 1949, the After Care Department began with two social workers and three public health nurses. Since that time, we have added to our staff a psychologist and have supplemented the number of nurses and social workers, so that now we have on our staff one psychologist, three public health nurses and two psychiatrically trained nurses and three social workers. It i s hoped that eventually an oc-cupational therapist w i l l be added to the team, as well as a placement o f f i c e r . 4 Stevenson, G.H., M.D., "Rehabilitation of the Mentally 111," Ontario Medical Review, November 1952, p. 424. 2 Personal interview with Dr. G.H. Stevenson, former Sup-erintendent, Ontario Hospital, London, Ontario. q Stevenson, op. c i t . . p. 423, 4 Gamble, J.E., "The After Care Program - Ontario Hos-p i t a l " , October 1952, Unpublished Paper, - 77 -The After Care Department i s located in downtown London, because i t s primary purpose is that of meeting the needs of post-discharge patients. A large portion of the Fed-eral Mental Health Grant, allocated to the Ontario Depart-ment of Health for the setting up of this "pilot re-habilitation centre for mental patients", was devoted to the purchasing and furnishing of a large home. This house has been converted into offices and interviewing rooms for the After Care Department, as well as club rooms and recreation rooms for discharged patients who might re-side within the v i c i n i t y . Comparison of Social Service Departments In addition to the difference in age and ex-perience of these two departments, they di f f e r markedly from each other in administrative structure. They also differ in personnel make-up. There is also a great d i f -ference in department function, as was discussed in Chapter 2. Administrative Structure. One basic difference between these two departments is the independent nature of the After Care Department as compared with the Social Service Department at Essondale in relation to a provin-c i a l program of psychiatric social services, and also in respect to administrative leadership. The After Care Department is associated with the Ontario Hospital, London, — 78 — serving patients and their families from this hospital only, whereas the Social Service Departments at Essondale are a part of a provincial program set up for the provision of social services to those referred for psychiatric treatment from the entire population. Administratively, the After Care Department has i t s own director, who is responsible for the direction of the After Care Department only. By comparison, the Social Service Departments at Essondale, are only a part of the social treatment services of the Provincial Mental Health Services. Within the Provincial Mental Health Services, there are also the social treat-ment f a c i l i t i e s of the Child Guidance Clinics and also the Social Service Department at the Woodlands School for Mental Defectives. A l l of these social treatment f a c i l i -ties operate as separate units, but each i s a part of the total provincial mental health program. A l l are under the direction of the Provincial Supervisor of Psychiatric Social Work. Both departments carry similar responsibilities for maintaining liaison with community agencies, so that a l l available resources might be made accessible for use by the patient and his family. Both departments see their role as assisting the mental patient and his relatives to make a more comfortable adjustment to real i t y problems which contribute toward mental illness and also those real -i t y problems which arise out of mental i l l n e s s . If there are resources in the community which w i l l help the patient - 79 -and relatives in making a better social adjustment, both departments see a referral to that particular agency as being their function. Another major difference between the After Care Department and the Social Service Department at Essondale l i e s in the fact that department personnel are under the jurisdiction of different government bodies. A l l person-nel of the After Care Department are under the j u r i s -diction of the Ontario Department of Health. Each staff member i s a provincial C i v i l Servant, and i s subject to the C i v i l Service classifications and salary stipulations. Members of the Social Service Department at Essondale are also provincial C i v i l servants, and subject to C i v i l Ser-vice classifications and salary stipulations. They perform work in the Mental Health Services Division of the Depart-ment of the Provincial Secretary, but at the same time are members of the Department of Health and Welfare, Social Welfare Branch. A l l members of the Social Service Depart-ment at Essondale, are under the jurisdiction of the Social Welfare Branch, but are loaned to the Mental Health Ser-vices Division. The result of such a dual type of adminis-tration i s that a great deal of time i s spent in interpret-ing the needs and services of one department to another. A l l members of the After Care Department are under the jurisdiction of that government department in which they function; this i s a more clear-cut type of administration. - 80 -Because of geographical distance, centralized men-ta l hospital service such as i s found in British Columbia curtails the amount of professional social services which can be given to the patient's relatives. Decentralized mental hospital service such as i s found in Ontario, makes i t administratively possible for the After Care Depart-ment to maintain close contact with the patient's family during hospitalization, and also with the patient follow-ing his discharge from hospital. Within three weeks following admission of a patient to the Ontario Hospital, his case i s presented at a general conference at which time members of the treat-ment team contribute what they know about the patient and his i l l n e s s , and a l l participate in deciding upon a treat-ment plan. The Director of the After Care Department at-tends these conferences, thus serving as a liaison be-tween the hospital and the After Care Department which operates quite apart from the hospital. Following the conference the director of the After Care Department assigns each patient to a member of the department. Each member of the department is called a "worker" regardless of his pro-fessional orientation, and is assigned to a sub-region of the total area served by the hospital. Cases are then as-signed on the basis of the patient's having residence within a particular worker's region. The worker maintains a periodic contact with the patient. He w i l l " v i s i t the patient's family with the purpose of understanding the - 81 -family background and preventing any economic, marital or other problems consequent to hospitalization". 1 At the time of patient's discharge from hospital, the worker becomes active in working with the patient and i s expected to return the patient to his home, and provide a l l the necessary follow-up services, so as to help the patient, re-establish himself in the community. Each worker is ex-pected to provide a l l those services which each of his patients might require. If a specific type of service is needed, and one which the worker is not professionally trained to give, he i s expected to seek guidance from a worker who has been trained to offer that type of service. In contrast to the After Care Department, the Social Service Department at Essondale i s a uni-disciplined department, being staffed by professionally trained social workers, who provide social services to the patient during admission, treatment, and rehabilitation procedures. If the Social Service Department i s unable to provide these services, due to distance, the f i e l d service of the Social Welfare Branch is responsible for carrying out this ser-vice as a part of their defined function. The f i e l d ser-vice is also a uni-disciplined department, made up of trained social workers. Gamble, loc. c i t . - 82 -Personnel A basic difference between the After Care Department and the Social Service Departments at Esson-dale, i s the fact that the former i s a multi-disciplined structure, while the latter is a uni-disciplined structure. Figure 1 shows the division of labour within the Social Service Departments at Essondale, and the number of soc-i a l workers included in each department and section. The qualifications of a l l personnel are consistent with the recommended standards set down by the American Psych-i a t r i c Association. (See Appendix B.) As indicated in Figure 1, a l l members of the departments are qualified social workers. It can be seen that the Social Service Departments at both Crease Clinic and the Provincial Mental Hospital are under the direction of one person, the Provincial Supervisor of Psychiatric Social Work. Each department i s divided into an Admissions Section and a Continuing Casework Section. One supervisor is responsible for the super-vision of the Intake Workers in both Admissions Sections. Both departments have a supervisor who is responsible for the work carried out in each Continuing Casework Section. Figure 2 illustrates the multi-disciplined structure of the After Cars Department. In addition, Figure 1. Administrative Structure f Crease Cli n i c and  Provincial.Mental Hospital Social Service  Departments, showing their uni-disciplined  make-up" Provincial Supervisor of Psychiatric Social Work Provincial Mental Hospital Social Service Department Continuing Casework Section, Supervisor Crease Clinic Social Service Department Continuing Casework Section, Supervisor Intake Sections, Supervisor K ' Intake Worker (1) Intake Workers (2) Continuing Casework Continuing Casework,.\ Workers v ; Workers  Note: It should be noted that the number of social ser-vice personnel indicated includes only those positions which are occupied. Several more social work positions have been established, but are as yet vacant. Figure 2. After Care Department, Ontario Hospital, London, showing i t s multi-disciplined make-up, numbers  of personnel, qualifications of personnel. Director B.A., M.S.W. After Care Department Psychologist (1) Public Health Nurse (3) M.A. Reg.N.  Social Workers (3) Psychiatric Nurse (2) B.A., M.S.W. R.P.N. Social Worker, B.A., M.S.W.(1) based at the Ontario Hospital i t shows the number of personnel in the department, as well as the particular professional orientation of each. The After Care Department operates quite apart from the hos-p i t a l , but recently one social worker has been placed in the hospital in order that social services might be pro-vided during the admission and treatment procedures. This worker is under the direct supervision of the director of the department. Figure 2 indicates that the After Care Depart-ment is made up of members from four different professions; namely social work, psychology, general nursing, and psy-chiatric nursing. It i s shown that a l l members of the department are responsible to the director who serves as a liaison between the hospital and the After Care Depart-ment. In summary, i t has been found through an ex-amination of these three Social Service Departments, that there are similarities as well as differences between them. A l l three departments are similar in purpose, although the After Care Department differs from the Social Service De-partments at Essondale in respect to the area of con-centrated effort; the former placing emphasis on conval-escent care, the latter emphasizing the importance of offering social work help to the patient during admission and treatment procedures as well as during convalescence. A further similarity i s that both the After Care Depart-ment and the Social Service Departments at Essondale have - 84 -a director as administrator of the department. In both cases, this person i s responsible to the C l i n i c a l Director or the hospital Superintendent. There are great d i f f e r -ences in these departments in respect to internal adminis-trative structure, personnel, and lines of responsibility of the staff to a government department. Division of labour in the After Care Department i s based on geograph-i c a l sub-divisions, while in the Social Service Departments at Essondale division of labour is based upon the type of service which is given. With the developmental history, administrative structure, standards, and personnel of these departments in mind, the study w i l l make recommendat-ions as to the type of social service department which would be suitable for provision of social services to the pat-ients receiving treatment at the Saskatchewan Hospital, as well as to their families. CHAPTER IV A SOCIAL SERVICE DEPARTMENT FOR THE SASKATCHEWAN HOSPITAL This study has made three assumptions. They are: (1) that there i s a need for a Social Service Department at the Saskatchewan Hospital, in fact in any mental hospital; (2) that social work services are of value to the patient in a mental hospital, and are also needed for his family in the treatment and rehabilitation process; arid (3) theory i s always ahead of practice, and that this must always be the case so that growth and development might occur. As the profession of social work develops, and successfully inter-prets i t s e l f to other better established disciplines, this discrepancy w i l l become narrowed down to a degree wide enough to stimulate research and planning, and narrow enough to prevent feelings of discouragement by i t s members. The study w i l l now proceed to project a suitable Social Service Department for the Saskatchewan Hospital. A l l recommendations made for a future Social Service Depart-ment in the Saskatchewan Hospital are based upon: (1) stand-ards recommended by the American Psychiatric Association, and (2) upon the experience of already existing departments which have been examined in this study. - 86 -With the possibility of an increasing number of social workers being employed at the Saskatchewan Hospital, the need for a sound organizational structure becomes very apparent. Social work should operate as a specifically designated administrative department with a director of social services responsible to the C l i n i c a l Dir-ector, or i n hospitals where there is no such posi-tion, on an administrative level which provides direct liaison with the Superintendent of the hos-p i t a l . This administrative provision should require the inclusion of the director of social work in ad-ministrative staff meetings and participation in decisions of hospital policy which pertains to the treatment and welfare of patients. The responsib-i l i t y of social service to administration can not be f u l l y met i f the director of the Social Service De-partment functions on a less well defined basis.... The practice of social workers being called on... or attending informal or formal meetings, does not produce the most effective kind of administrative relationship. For continuity and effectiveness, especially in the event of changing personnel, a clearly defined administrative structure is consid-ered an essential.1 A Recommended Administrative Structure As the Group for the Advancement of Psychiatry Report suggests, and after carefully examining social ser-vice departments in other hospitals, i t i s recommended that a Social Service Department have a Director of Social Ser-vice as i t s administrator. Since the C l i n i c a l Director of the Saskatchewan Hospital, i s responsible for a l l c l i n i c a l matters, the Director of Social Service should be , The Psychiatric Social Worker in the Psychiatric Hospital , American Psychiatric Association, Report #2, 1948. - 87 directly responsible to him. A suitable Social Service Department for the Sask-atchewan Hospital would include approximately twenty social workers, according to recommended standards lai d down by the American Psychiatric Association. (See Appendix C.) The recommended number of social workers required for the adequate provision of social work services to patients and their families, points up the need for departmental struct-ures which w i l l ensure integration within the department, and integration of the department with the total hospital structure. If the remaining nineteen social workers were a l l made responsible to the Director of Social Service, integrated lines of authority and responsibility would be impossible. The result would be the Director's having to settle numerous detailed matters with nineteen different persons, thus leaving himself l i t t l e time for more complex administrative matters. With such a line structure, no delegation of authority and responsibility could be possible. In addition, there could be no specialization of labour (of services) in the department as a whole. To ensure departmental integration in a depart-ment of approximately twenty persons, i t would be essential to have at least three staff members who are directly res-ponsible to the Director of Social Service, and who in turn have several staff members who are responsible to them. An integrated department permits a classification of the - 88 -services to be rendered. It was seen at the Social Ser-vice Departments at the Crease Clinic and the Provincial Mental Hospital, Essondale, British Columbia, that social work services were categorized as to those of a "Brief Service" nature, and those of a "Continuing Treatment Ser-vice" nature. Distinct sections are set up for the pro-vision of these two types of service within each branch of social service activity. A Casework Supervisor is in charge of each, and i s responsible to the Provincial Supervisor of Psychiatric Social Work. The After Care Department of the Ontario Hospital, London, differs markedly from the Esson-dale departments in this respect. A l l members of the After Care Department are directly responsible to the Director of the department. There i s another major difference between the Social Service Departments at Essondale, Br i t i s h Columbia and the After Care Department, London, Ontario. This i s in relation to case coverage in convalescent care (post-discharge care). The After Care Department offers this type of service to a l l patients discharged from the Ontario Hospital, London. The Social Service Departments at Essondale however, provide convalescent care to only those patients who are discharged to the Greater Vancouver area, relying on the f i e l d service of the Social Welfare Branch to provide this service to those patients discharged to other areas of the province. - 89 -With a small beginning Social Service Department at the Saskatchewan Hospital, Weyburn, i t is obvious that very l i t t l e work can be done in the community with patients following their discharge from hospital. Scattered settle-ment and long distances between towns dictate some of the limitations. A direct liaison with the Department of Social Welfare and Rehabilitation w i l l , therefore, be essential, so that their f i e l d service might provide a continued con-valescent service to patients following hospitalization. The relatives of the patients often require social work help during the patient's stay in hospital, and are an equally d i f f i c u l t group to service, due to geographical distance. In establishing an adequate social service depart-ment for the Saskatchewan Hospital, Weyburn, the major prob-lem, and the one which w i l l in a l l likelihood be dealt with las t , is the setting up of a decentralized f i e l d service as an extension of the Social Service Department. Conval-escent care might then be provided to discharged patients as well as to their relatives. A goal recommended for the future i s the setting up of a decentralized f i e l d service, as an Out-Patlent Section of the Social Service Department. This would involve dividing the area served by the hos-p i t a l into sub-districts, and assigning one or two social workers to each. 1 Each d i s t r i c t would actually represent The division of the total area into sub-divisions could take the form of the present division of the area into Health Regions. - 90 -a caseload. The size of the caseload would be the basis upon which the number of social workers assigned to each sub-district would be determined. The f i e l d service would, of course, be responsible to a travelling Casework Super-visor, who would provide each f i e l d worker with the neces-sary consultation and casework supervision. This super-vision would also serve as a liaison between the f i e l d ser-vice and the hospital, and in this way contribute toward co-ordination between the specialized service sections of the department. The basic administrative principles which have been taken into consideration in laying down this proposed administrative structure for a social service department have been; (a) departmental integration (b) delegation of authority and responsibility (c) specialization of service and (d) co-ordination between specialized services. The proposed administrative structure thus takes the form of a department under the direction of a Director, and con-sisting of three sections; an Admissions Section, a Contin-uing Casework Section, and an Out-Patient Section. Each section i s under the supervision of a supervisor, who i s in turn responsible to the Director. Figure 3 illustrates the recommended administrative structure: - 91 -Figure 3. Recommended Administrative Structure, Social Service DepartmentT Saskat-chewan' Hospital. Continuing Casework Section Casework Supervisor Social Workers Swift Curren 3 | Director of Social Service Social Service Department Admiss ions Section I Gut-Patient Section Casework Supervisor Casework Supervisor Social Workers Assiniboia Moose Jaw Regma Decentralized Field Service consisting of Social Workers Yorkton I I Weyburn Figure 3 shows the departmental integration, in>that* only three persons are directly responsible to the Director of Social Service, and each is responsible for only those social workers in the Section of which they are desig-nated Casework Supervisor. With this integrated style of line structure, delegation of authority and responsibility i s made possible. The Director of Social Service i s res-ponsible for the social work of the whole department, how-ever, he can delegate authority and responsibility to each Casework Supervisor, necessary for the administration of the work of each Section. A l l three Casework Supervisors - 92 -are on the same administrative l e v e l , so co-ordination between the three department sections i s possible. As indicated i n Figure 3 the s o c i a l workers of the Admissions Section and the Continuing Casework Section carry respon-s i b i l i t y for the provision of s o c i a l services to the patients during t h e i r stay i n h o s p i t a l , as well as those r e l a t i v e s who reside within the immediate v i c i n i t y of the hospital. Social workers i n the Out-Patient Section are decentralized, one or two assigned to each mentioned sub-division depending upon the number of discharged patients r e s i d i n g in that d i v i s i o n . Out-Patient Section workers are i n the main responsible for provision of s o c i a l services to discharged patients as well as those families who are unable to v i s i t the hospital during the patient's stay there. R e s p o n s i b i l i t i e s of the Director, Social Service Department The multiple r e s p o n s i b i l i t i e s of the Director of Social Services are c l a s s i f i e d under d i s t i n c t cate-g o r i e s . 1 1 At present t h i s p o sition i s non-existent within the Saskatchewan Psychiatric Services Branch. I t should be noted that the incumbent of t h i s position i s the key-person i n the development and administration of any Social Service Department. Therefore, t h i s person should be a professionally trained s o c i a l worker, with several years of experience i n casework p r a c t i c e , as well as i n ad-ministration. For the recommended q u a l i f i c a t i o n s f o r the Director of Social Service, see Appendix B. - 93 -Administrative Responsibility (a) Responsibility for attendance at and parti-cipation in conferences held by the C l i n i c a l Director and the two Senior Psychiatrists on matters of policy pertaining to the treatment and welfare of mental patients. It is the responsibility of the Director of Social Service while at-tending such conferences, to interpret the unique services which his department can offer, and how i t operates as an integral part of the hospital's total treatment f a c i l i t i e s . (b) Responsibility for interpreting to the Clin-i c a l Director a l l planning as regards the internal structure and operation of the Social Service Department. (c) Responsibility for consulting and planning with the Cl i n i c a l Director and the Director of Psychiatric Services Branch, on the broader aspects of planning for, and the organization of further social services to patients; such as foster-care programs, a decentralized f i e l d ser-vice, social work standards and staff qualifications, per-sonnel recruitment, the needs for more extensive social services, and the needs of the social service department; such as c l e r i c a l f a c i l i t i e s , office space, automobiles, etc. Supervisory Responsibility (a) Responsibility for bringing social work consultation and direction to a l l members of the Social Service Department, and especially to the Casework - 94 Supervisors. The Director of Social Service carries the f i n a l responsibility for a l l social welfare work done in the department. He carries responsibilities for the de-velopment of the social service program, as well as advising the staff on standards of social work service and practice. (b) Responsibility to introduce methods for social work staff training and development on the job. This involves preparation of, and participation in informative staff meetings where departmental problems and policy are discussed, with the view to improving the social services available to the patients. (c) Responsibility for the arrangement for and the supervision of a c l e r i c a l unit. (d) Responsibility for participation in the direction of Volunteer programs. Caseload Responsibility (a) Responsibility for evaluation, revision, and extension of the social service program so that i t meets the needs of patients, patients' families, needs of the community, and the developmental changes in other profes-sional departments such as psychiatry, nursing, and psychology. Responsibility for Education and Interpretation (a) Some responsibility for the interpretation of the social worker's role in a mental hospital to other - 95 -departments, such as psychiatry, nursing, psychology, physio-therapy, occupational therapy, and recreational therapy, (b) Some responsibility for the promotion of the teamwork approach to the care and treatment of mental i l l -ness. (c) Responsibility for participation i n , and the encouragement of social service staff to participate in the acti v i t i e s of the professional association. (d) Responsibility for i n i t i a t i n g and conducting conferences in which case examples are used to ill u s t r a t e the role of the social worker in the care and treatment of mental patients. Community Responsibility (a) Responsibility to direct and act with a l l staff members of the Social Service Department in creating and maintaining liaison with a l l existing community re-sources in the interest of the mentally i l l patient; and to assist the development of community resources for the patient discharged from the mental hospital, as well as their families. This involves co-operatively meeting with other community agencies, evolving policies of inter-relationships and cooperation whereby community services may be brought more effectively and with f a c i l i t y to the patient. (b) Some responsibility for interpretation to community agencies and community groups of the role played - 96 -by the Social Service Department as an integral part of the total hospital program. Research Responsibility (a) Responsibility for keeping adequate records of a l l administrative activity within the department. (b) Responsibility for the keeping of work re-cords, and the preparation of annual reports on department activity and development. (c) Responsibility for stimulating and perform-ing social research. Duties of Casework Supervisors The recommended administrative structure for a Social Service Department at the Saskatchewan Hospital, included three Casework Supervisors, each in charge of a separate section within the department. The study w i l l now lay down recommended job descriptions for the Casework Supervisor positions. Admissions Section, Casework Supervisor The Admissions Section includes those social workers who provide social services, as needed, to pat-ients and their families at the point of the patient's admission. The Casework Supervisor's responsibilities for the work carried out by this section are classified in distinct categories. - 97 -Administrative Responsibility (a) Responsibility for maintaining co-ordination between this Section and the Continuing Casework Section as well as with the Out-Patient Service Section. (b) Responsibility in co-operation with the Con-tinuing Casework Section Casework Supervisor for selection of cases for referral to the Continuing Casework Section. (c) Responsibility to serve as a liaison between social service administration and the staff. This i n -volves interpretation of problems on the direct service level of administration to the Director of Social Ser-vice, and also interpreting to the staff decisions made by the Director of Social Service on matters of policy and personnel practice. (d) Responsibility for attendance at conferences held between the Director of Social Service and the Cl i n -i c a l Director on specific matters which relate to the work of the Admission Section. (e) Responsibility for attendance at conferences held between the Director of Social Service, the Cl i n i c a l Director, and the Director of Psychiatric Services Branch on matters of general policy as they relate to the work of the Admissions Section. (f) Responsibility for attendance at inter-agency conferences with the worker on the case, when community agencies are involved in social treatment with the pat-ient^ family. - 98 -Supervisory Responsibility (a) Responsibility for the supervision of the casework s k i l l s offered by intake workers during the admis-sion and reception of the patient to hospital. This ser-vice i s patient-focused and includes direct interviews with patients and their families at the point of admis-sion serving the multiple purpose of: procuring important history information for immediate use by the doctor and other hospital services; outlining hospital services and f a c i l i t i e s to the patient and his family; helping relat-ives with anxieties which are so acute at the time of patient*s admission; helping the family to understand treatment procedures; assessing family problems and pre-paring the family and the patient for referral to a worker of the Continuing Casework Section; beginning to help re-latives to support the patient throughout his period of treatment and rehabilitation; i f necessary, also guiding the continuing service worker regarding immediate problems evidenced in the family constellation. Caseload Responsibility (a) Responsibility for attendance at Medical Conference, with the purpose of receiving assessments of newly admitted patients, as are given by members of the other disciplines; and also to contribute to the con-ference, the social worker's understanding and assess-ment of the patient and his social milieu. - 99 (b) Responsibility for attendance at conferences held by the Director of Social Service for the purpose of evaluating, revising and the extension of the social service program so that i t might better meet the needs of patients and their families. Responsibility for Education and Interpretation (a) Some responsibility for promoting the team approach within the hospital setting by interpreting to the medical, nursing, and c l e r i c a l staffs their responsibility for getting the patient*s relatives to intake workers so that social services can be initiated immediately. (b) Responsibility for assuming leadership, i f necessary, in conducting informative staff meetings. Community Responsibility (a) Responsibility for interpretation to community agencies of mental hospital services, together with policy and procedure for admission on behalf of their clients. (b) Some responsibility for interpreting the work of social work in a mental hospital to community groups. (c) Responsibility for case-conferencing with community social agencies when this i s indicated. Research Responsibility (a) Responsibility for supervising the recording of intake workers* impressions of the patient*s problems and an assessment of the family situation. - 100 -(b) Responsibility for the keeping of work records, and the added responsibility of using these records s t a t i s t i c a l l y to appraise work done, and to recognize areas of unmet need. (c) Responsibility for co-operation with the Director of Social Service in stimulating and carrying out research projects. Continuing Casework Section, Casework Supervisor The Continuing Casework Section includes social workers who provide professional social services, as needed, to patients and their families throughout the patient's stay in hospital. Cases which are referred to this section of the Social Service Department are usually referred f o l -lowing an assessment of the amenability of the patient to social work help. This assessment i s usually made by the intake worker, and the Admissions Section Casework Super-visor. Often times, such a referral is a formal request from the doctor in charge. 1 When a case i s referred to the Continuing Casework Section, the acute anxieties and social problems consequent to hospitalization have usually been dealt with by the social worker of the Admissions Section. The Continuing Casework Supervisor i 3 thus in charge of the ; ; . Barsky, Anastasia, Casework in a Veterans' Hospital, Master of Social Work Thesis, University of British Colum-bia, 1954. This thesis i s an analytical study of the nature of referrals to the Social Service Department made by medical doctors. Such a study could be of assistance to a new department in establishing an effective policy of referral to Social Service. - 101 -on-going social work service to patients and their families, and has responsibilities which are classified into distinct categories. Administrative Responsibility (a) Responsibility for the selection and assign-ment of cases for continuing casework service in co-operation with the Admissions Section Casework Supervisor. This selection of cases for active social service is neces-sary because, of the impossibility of giving more than a percentage coverage due to limitations in numbers of per-sonnel. (b) Responsibility to serve as a liaison between social service staff and the Director of Social Service. This involves interpreting problems on the direct service level of administration to the Director of Social Service, and also interpreting to the staff the decisions made by the Director of Social Service on matters of policy and person-nel practice. (c) Responsibility for conferring with community agency o f f i c i a l s along with the Director of Social Service, interpreting to them the role of the Social Service Depart-ment, and also attempting to create and maintain good liaison between these agencies and the Social Service Depart-ment. (d) Responsibility for attendance at conferences * held between the Director of Social Service and the Clinical Director on matters of specific policy, as they relate to the - 102 -work of the Continuing Casework Section. (e) Responsibility for attendance at conferences held between the Director of Social Service, the C l i n i c a l Director, and the Director of Psychiatric Services Branch on matters of general policy, as they relate to the work of the Continuing Service Section. Supervisory Responsibility (a) Responsibility for the supervision of the casework s k i l l s of a l l social workers in the Continuing Casework Section. The services of this section are patient/ family-focused and include direct interviews with the patient and/or relatives during the patient's stay in hospital, serving the multiple purpose of: giving continued support and r e l i e f of fears associated with the hospital, treat-ment procedures, and those social problems within the patient's social environment which are considered to be con-ducive to the ill n e s s ; a continued study and diagnosis of the patient's social environment and his way of responding to that environment; formulation of treatment goals from the social work orientation and in collaboration with the psychiatrist and other hospital disciplines; carrying out the social work treatment process which involves s k i l l f u l administering of tangible and intangible social services to the patient and his family in such a way that they might be helped toward dealing more effectively with their reality problems, and in so doing attain a more satisfactory social adjustment; preparation of the patient and the family - 103 -for referral to a worker of the Out-Patient Section; and also guiding the out-patient worker regarding the strengths and weaknesses of the patient and his social environment. Social Work supervision like social work practice is patient and family focused—the goal being better more effective service to those served. Through supervision, the individual worker i s helped to gain a more comprehensive understanding of the social problems with which he is deal-ing and the dynamics underlying them, to gain a better un-derstanding and use of those psychological helping procedures used by caseworkers, and also to gain a higher degree of self-awareness so that he might remain as objective as pos-sible in discussing other people's emotions and attitudes. Caseload Responsibility (a) Responsibility for attendance at conferences held by the Director of Social Service for the purpose of evaluating, revising, and the extension of the social ser-vice program so that i t might better meet the needs of patients and their families. (b) Responsibility for attendance at individual case conferences along with the worker on the case, which have been called by the doctor for the purpose of formulating treatment plans. Responsibility for Education and Interpretation (a) Responsibility for assuming leadership, i f necessary, during staff meetings so as to ensure staff - 104 -development, as well as development of policy. (b) Some responsibility for the interpretation of social work function in a mental hospital to the other pro-fessional disciplines. (c) Responsibility for attending Social Work Con-ferences and Institutes, so as to maintain an awareness of current social work practices and standards outside of one*s own agency. There is a responsibility also to i n i t i a t e these new practices in one»s own agency, thus maintaining the best possible service to those served. Community Responsibility (aj Responsibility for interpretation to community agencies of mental hospital services, together with policy and procedures for admission on behalf of their clients. (b) Some responsibility for interpretation of the function of social work in a mental hospital to com-munity groups. (c) Responsibilities for meeting with the o f f i c i a l s of community agencies, with the purpose of working out social service programs which parallel one another, giving the best possible coverage to members of the community who are in need of some form of social work help. Research Responsibility (a) Responsibility for supervising the recording of a l l social work practice carried out by the members of this section. - 105 -(b) Responsibility for the keeping of work re-cords of work done by the Continuing Casework Section, and the added responsibility of using these records s t a t i s t i c a l l y to recognize areas of unmet need. (e) Responsibility for cooperation with the Dir-ector of Social Service in stimulating and performing re-search projects. Out-Patient Section, Casework Supervisor The Out-Patient Section consists of a l l the social workers included in the decentralized f i e l d service. The Out-Patient Section Casework Supervisor's responsibil-i t i e s are classified into distinct categories. Administrative Responsibility (a) Responsibility for the reporting of a l l prob-lems of policy and personnel matters within the Out-Patient Section to the Director of Social Service. He i s also res-ponsible for advising the f i e l d service staff on a l l deci-sions made by the Director of Social Service in regard to social service policy and programs, as well as new develop-ments in the other hospital departments. (b) Responsibility for promoting co-ordination be-tween the Out-Patient section and other sections of the Social Service Department, so as to ensure the best possible service to those served. (c) Responsibility for attendance at conferences held between the Director of Social Service and the C l i n i c a l - 106 -Director on matters of specific policy as they relate to the work of the Out-Patient Section. (d) Responsibility for attendance at conferences held between the Director of Social Service, the Cl i n i c a l Director, and the Director of Psychiatric Services Branch on matters of general policy as they relate to the work of the Out-Patient Section. (e) Responsibility for administrative matters in relation to departmental automobiles, insurance, office equipment and supplies for the various offices used by the Out-Patient Section, Supervisory Responsibility (a) Responsibility for the supervision of the case-work s k i l l s of a l l the social workers included in the Out-Patient Section. The service i s patient/family-focused and includes direct interviews with patients and their relatives and also significant persons in the patient's l i f e , follow-ing the patient's discharge, and serving the multiple pur-0 pose of: assisting the patient to develop a feeling of independence from the hospital setting, through helping him to resume former responsibilities within the family vocational, and social settings; helping the patient's family to accept and help the patient toward a gradual resumption of former responsibilities, thus helping the family unit to overcome the state of inequilibrium consequent to the patient's temporary absence; helping those patients who are without family or friend to become re-established in an environment - 107 -. . . . . . * as emotionally healthy as possible, necessitating the worker's purposeful use of community resources with the view to meeting the basic needs of the patient such as food, shelter, clothing, a job, and meaningful relation-ships with interested persons; helping the patient who has a residuum of his illness to adjust to a limiting situation, and l i v e as comfortably as possible. (b) Responsibility for the supervision of the case-work s k i l l s of a l l social workers included in the Out-Patient Section, in their provision of professional social services to patient's families during the patient's stay in hospital. 1 This service i s patient/family-focused and in-cludes offering support and r e l i e f of fears associated with the patient's committal to hospital; help with immediate social problems consequent to the absence of a family mem-ber; interpretation of hospital f a c i l i t i e s and help in re l i e f from fears associated with treatment procedures; help with the formulation of plans for the patient's return home; preparation of the family for their referral to other com-munity resources i f this is indicated; encouragement and arrangement for financial help, i f needed by relatives, to v i s i t the patient while he i s in hospital. (c) Responsibility for the administration and supervision of a foster-home care program. This would include the supervision of home-finding, interpretation of patients and their needs to foster-home operators, and also Those families who are unable to v i s i t the hospital due to geographical distance can receive help from the Out-Patient Section. - 108 -0 responsibility for ensuring proper care of patients who are in foster-home care. Caseload Responsibility (a) Responsibility for serving as a liaison be-tween the Out-Patient Section and other hospital depart-ments such as psychiatry, nursing, and psychology on treatment procedures. This would include the obtaining of psychiatric assessments and consultations for use by the f i e l d service. (b) Responsibility for attendance at conferences held by the Director of Social Service for the purpose of evaluating, revising, and the extension of the social ser-vice program so that i t might better meet the needs of patients and their relatives. Responsibility for Education and Interpretation (a) Responsibility for the encouragement of staff development on the job. This would involve the c i r -culation of professional knowledge and literature to each member of the f i e l d service. Due to the decentralization of the Out-Patient Section, this responsibility is of great importance. Community Responsibility (a) Responsibility for interpreting the Psy-chiatric Services of the province to the community. (b) Responsibility for assisting the f i e l d ser-vice staff to create and maintain co-operative relation-- 109 ships with a l l available community resources. (c) Responsibility for meeting with the o f f i -cials of community agencies with the view to developing programs which parallel each other, so as to ensure the greatest possible coverage of need. Research Responsibility (a) Responsibility for keeping records of the work of the Out-Patient Section, and the added respon-s i b i l i t y of using these records s t a t i s t i c a l l y for the appraisal of work done, and also as a means to recogniz-ing areas of unmet need. (b) Responsibility for the supervision of the follow-up and continued assessment of patients who have been discharged from hospital, and whose follow-up record would be of value to the Research Unit of the Saskatchewan Hospital. (c) Responsibility for cooperation with the Director of Social Service in stimulating and the per-formance of research projects. Responsibility of a Staff Social Worker The social worker offers the patient and his relatives assistance with various problems associated with: (1) the patient's social adjustment within the hospital (2) the social adjustment of patient's relatives to the patient's temporary absence from the home, as well as to the patient's illness and (3) the social adjustments - 110 -of both the patient and his relatives following discharge, in their attempt to restore the equilibrium of the family-unit which had become disrupted through the patient's temporary absence. The social work treatment process used by the social worker remains the same throughout the admission, treatment, rehabilitation, and convalescent procedures. The social work treatment process also remains the same when dealing with either the patient or his family. The responsibilities of the social worker may be classified under distinct categories. Administrative Responsibility (a) Responsibility for promoting sound adminis-trative principles and practices within the Social Service Department, thus improving the services rendered. This i n -volves: (1) recognition and respect for the proper channels of communication. (2) acceptance and execution of delegated responsibility as well as authority, in performing assigned professional duties. (3) promotion of co-ordination between de-partmental sections, ensuring a smooth flow of work through the department. (4) contribution toward improvement of hos-p i t a l services through participation in Social Service - I l l -Department staff meetings, and serving on appointed com-mittees designed to study and recommend measures for im-provement of hospital service. (b) Responsibility for the promotion of sound ad-ministrative principles and practices within the hospital's total administrative structure. This includes: (1) conferring with the doctor in charge before offering any form of social work treatment to the patient. Treatment planning should always be a process shared by a l l members of the treatment team. (2) sharing with other members of the treat-ment team a l l pertinent social information gained through direct interviews with the patient's relatives, and also from collateral sources. This involves the accurate prompt recording of a l l work done. (3) recognition of, and respect for the proper channels of communication between the Social Service Depart-ment and other hospital departments so as to promote an i n -tegrated hospital service. (4) recognition of, and respect for the lines of responsibility within other hospital departments. (5) recognition of, and constant care to remain within the social worker's area of competency* at a l l times respecting the area of competency of the other dis-ciplines . (6) procuring social information from other community agencies which are also interested in a particular - 112 -case, upon the permission of the patient. (7) supplying information to community agencies regarding a patient, upon the permission of the patient. (8) conducting inter-agency conferences with guidance from the casework supervisor. Supervisory Responsibility (a) The staff social worker does not have res-ponsibility for supervision, other than responsibility as a participant in the supervisory process, which is designed for the purpose of bringing the best possible service to the patients and their families. The social worker thus has a responsibility to make constructive use of supervision. Caseload Responsibility (a) The social worker is responsible for the pro-vision of social services to a l l patients who are assigned to him, and i s also responsible for making social services available to the patient's family. He i s responsible for providing social work treatment service through a profes-sional relationship with the patient and his family, keep-ing in mind at a l l times the rights of the person in receipt of the services. This involves direct interviews with the patient, his relatives, and significant persons in his l i f e , serving the multiple purpose ofi procuring - 113 -pertinent history information for use by the doctor; out-linin g hospital f a c i l i t i e s to the patient and his relatives; helping the patient and relatives with feelings of anxiety arising out of committal; helping the family to understand and feel more comfortable about treatment procedures; assessing family problems and contributing to a comprehen-sive diagnosis; provision of social f i r s t - a i d measures to alleviate social problems consequent to the absence of a member of the family unit; helping with the cl a r i f i c a t i o n of misunderstandings between the patient and persons within his social environment; giving continued support and r e l i e f of fears associated with the hospital, treatment procedures, and those social problems within the patient's social en-vironment which are considered to be conducive to the i l l -ness; a continued study and diagnosis of the patient's social environment and his way of responding to i t ; for-mulation of treatment goals from the social work orientat-ion and in collaboration with other members of the treatment team; carrying out the social work treatment process which involves s k i l l f u l administering of tangible and intangible social services to the patient and his family in such a way that they might be helped toward dealing more effect-ively with their reality problems and in so doing attain a more satisfactory social adjustment; assisting the pat-ient to develop a feeling of independence from the hospital setting following discharge; helping the patient to resume former responsibilities within the family, vocational, - 114 -and social settings; helping the patient's family to accept and help the patient toward a gradual resumption of former responsibilities, thus helping the family unit back to i t s normal state; helping the patient without family or friend to become re-established in an environment as emotionally healthy as possible, which necessitates the worker's pur-poseful use of community resources with the view to meet-ing the basic needs of the patient such as food, shelter, clothing, a job, and meaningful relationships with i n -terested persons; helping the patient who has a residuum of his illness to adjust to a limiting situation and l i v e as comfortably as possible. Responsibility for Education and Interpretation Xa) Responsibility for interpretation of social work function to members of the treatment team through day to day working relationships with them. (b) Responsibility for interpretation of the pro-grams of the Psychiatric Services Branch, to community agencies through inter-agency relationships, and in this way helping them to be more aware of those community re-sources of a psychiatric nature, as well as the proper pro-cedures involved in using these resources. (c) Responsibility for contributing to findings, evaluations, diagnosis, and treatment recommendations of the hospital team when referring a patient or his family to a community agency. - 115 -Community Responsibility (a) Responsibility to participate in community organization by serving on appropriate community and agency committees as a representative of the Social Ser-vice Department. Research Responsibility (a) Responsibility for keeping up to date work records. (b) Responsibility for bringing to the attention of the Casework Supervisor, suggestions as to ways of ensuring better more effective service to patients and their families. (c) Responsibility for contributing assessments of social environments, when such are requested by the Re-search Unit. Social work's orientation toward social l i v -ing enables the social worker to assist the Research Unit by helping them to maintain proportionate focus on environ-mental factors in mental i l l n e s s . (d) Responsibility for conducting follow-up interviews, and the reporting of them to the Research Unit. (e) Responsibility for constant assessment of community resources in relationship to the needs of mental patients. In summary i t might be emphasized that job des-criptions are of v i t a l importance in the efficient manage-ment and operation of any Social Service Department. It i s seen from this study that every social work position can be - 116 -formulated into consistent areas of function, namely, administrative, supervisory, caseload, education and in-terpretation, community and research responsibility. How-ever, the scope and range of responsibility in each area differs among the different social work job descriptions. The development of humanitarian aspects in the care and treatment of the mentally i l l has been slow. The social and medical reform of the twentieth century appears almost dramatic when compared with social and medi-cal reform which occurred during the period between the sixth century A.D. and the late nineteenth century. Social workers have played a large role in bringing about needed reforms, by adapting i t s services and professional s k i l l s to the alleviation of psychological and social suffering. They a l l recognize that much more s t i l l needs to be done. * * * 117 Appendix A Total Staff and Ratio to Patients. Mental  Hospitals in Saskatchewan, 1932 to J951T (a) Number of patients and staff Total Numbers 1932 1936 1946 1953 Nurses, graduate 7 14 71 318 Nurses, other 92 178 290 373 Doctors 0 8 14 15 33 Occupational Therapists 4 6 7 14 Physiotherapists — — — -3 Recreational Therapists — — — 5 Psychologists — — — 6 Social Workers ' — — 5 Patients 1 2,561 3,594 4,302 4,967 It should be noted that the term "patients" is not well defined; that i t may mean those persons receiving treatment at a particular point in time, or those persons who have received treatment during a particular period of time--one year for example. (b) Ratio of patients to staff Staff Patients per Staff Member 1932 1939 1946 1953 Nurses, graduate 366 256 61 16 Nurses, other 28 20 15 13 Doctors 320 256 287 150 Occupational Therapists 640 599 612 355 Physiotherapists mmm «• m — 1,656 Recreational Therapists mm mm mm mm 993 Psychologists — mm mm -- 821 Social Workers mm mm mmmm — — 993 Source, Canadian Mental Hospital Statistics, Annual Report. 118 Appendix B Recommended Qualifications for Social Service Personnel The recommended professional qualifications for social workers are as follows: A. Staff Social Worker Psychiatric social work positions in psychiatric hospitals should require graduate professional training in a recognized school of social work with major emphasis in psychiatric social work. Where less than f u l l y trained personnel have to be used in Social Service Departments, i t is recommended that they be designated by a completely different t i t l e which distinguishes them from professionally trained psychiatric social workers. Experience in this sub-professional position should not qualify an apprentice for a psychiatric social work position. Continued employment without professional training i s undesirable and educat-ional leaves which encourage the apprentice to complete professional training should be a recognized policy. B. Casework Supervisor The Casework Supervisor should have, in addition to a graduate degree with major emphasis in psychiatric social work, a minimum of three years experience, at least one of which shall have been in responsible working relat-ionship with a psychiatrist in a c l i n i c a l setting, during which time he has demonstrated more than ordinary com-petence. C. Director of Social Service In addition to graduate professional training with major emphasis in psychiatric social work, the Director of Social Service should have had a minimum of five years ex-perience, at least three years of which should be subsequent to professional training during which he has demonstrated leadership a b i l i t y as well as casework s k i l l s . At least two years of the five should have been in a supervisory capacity and at least three years in a psychiatric setting. Source, Social Work in a Psychiatric Hospital, The American Psychiatric Association, Report #2, 1948. 119 Appendix C  Recommended Maximum Caseload The committee on Social Work of the American Psychiatric Association has recommended c r i t e r i a for a maximum caseload for social workers in a mental hospital. The committee recommends one social worker to every 80 annual admissions, plus one social worker for every 60 patients in convalescent status or in family-care. Statistics from the Saskatchewan Hospital, Wey-burn, indicate that approximately 650 patients are admitted to hospital annually, and approximately 440 patients are discharged annually, either ttin f u l l " or "on probation". Because of the extreme d i f f i c u l t y in determining the num-ber of patients who are on convalescent status, the writer is assuming that a l l discharged patients require some form of social work help. On the basis of the recommended patient-social worker ratio, a Social Service Department which would be approved as adequate for the Saskatchewan Hospital, Weyburn, would include sixteen social workers at the direct service level of administration. Over and above this number, the American Psychiatric Association recommends one casework supervisor for every five social workers, and one social worker who would serve as director of the department. 120 Appendix D  Bibliography Abrahamson, A.C., "The Role and Responsibility of the Social Worker in Corrections", Unpublished Paper, School of Social Work, University of British Columbia. Birch, Sophie, An Aid in the Rehabilitation of Mental Pat- ients , Master of Social Work Thesis, University of BTTliTsh Columbia, 1953. Casework Glossary; Abrahamson, Exner McCrae; School of Social Work; University of British Columbia; (mimeographed); June 1954. Clarke, James R., Care of the Mentally 111 in British Columbia, Master of Social Work Thesis, University of British Columbia, 1947. Coleman, Jules V., M.D., "Distinguishing Between Psychotherapy and Casework", Social Casework, December 1951. Deutsch, Albert, The Mentally 111 inAmerica, Doubleday Doran and Co., Inc., New York, 1937. Field, Mina, "Role of the Social Worker in the Modern Hos-p i t a l " , Social Casework, November 1953. French, Lois, Psychiatric Social Work, The Commonwealth Fund, New York, 1947. Gamble, J.E., "The After Care Program—Ontario Hospital", Unpublished Paper, The After Care Department, London, Ontario, 1953. Garland, Ruth, "The Psychiatric Social Worker in the Mental Hospital", Mental Hygiene, 1947. Ho l l i s , Florence, "The techniques of Social Casework", Principles and Techniques in Social Casework, Cora Kasius, Editor, Family Service Association of America, 1950. , "Casework Diagnosis—What and Why", Smith College Studies in Social Work. Vol. XXIV, No. 3, June 1951. Lucas, Leon, "Psychiatric Social Work", Social Work Year Book, New York, 1951. 121 Marcus, Grace, "A Further Consideration of Psychiatric Social Work", National Conference of Social Work, Columbia University Press, New York, 1946. McCormick, Mary J., Thomistic Philosophy in Social Work, Columbia University Press, New York, 1947. McKerracher, D.G., M.D., "Some Historical Aspects of Psy-chiatric Developments in Saskatchewan", Saskatchewan  Psychiatric Services Journal, April 1952. Mental Health Services in Canada, General Series Memorandum No. 6, Research Division, Department of National Health and Welfare, Ottawa, July 1954. Mental Health Services, Annual Report for the year ending March 31st, 1953, Province of British Columbia, Depart-ment of the Provincial Secretary. Meyer, Alfred, M.D., "Historical Sketch and Outlook of Psy-chiatric Social Work, Hospital Social Service, April 1922. Pepper, Gerald W., Social Worker Participation in the Treat-ment of the Mentally 111, Master of Social Work Thesis, University of British Columbia, 1954. Schlesinger, Ernest, Social Casework in the Mental Hospital, Master of Social Work Thesis, University of British Columbia, 1954. Schmidl, F r i t z , "A Study of Techniques Used in Supportive Treatment", Social Casework, December 1951. Southard, E.E., and Jarrett, Mary C., The Kingdom of Ev i l s , McMillan, New York, 1922. Stevenson, G.H., M.D., "Rehabilitation of the Mentally 111", Ontario Medical Review, November 1952. Sutherland, Murray R., The Rehabilitation of Discharged Mental Patients, Master of Social Work Thesis, University of British~"Columbia, 1954. The Social Worker in the Psychiatric Hospital, The American Psychiatric Association, Report #2, 1948. The Canada Year Book, 1954, Dominion Bureau of Statistics, Information Services Division. Towle, Charlotte, "Factors in Social Treatment", National Conference of Social Work, Columbia University Press, New York, 1936. 122 Waelder, Robert, M.D., "The Scientific Approach to Casework With Special Emphasis on Psychoanalysis", Principles  and Techniques in Social Casework, Cora Kasius, Editor, Family Service Association of America, 1950, Welker, Edmund, M.D., "The Effectiveness of the Psychiatric Social Worker in the Treatment Situation", Mental  Hygiene 1947. i Zilboorg, M.D., and Henery, M.D., A History of Medical Psycho-logy, W.W. Norton and Co., New York, 1941. 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
http://iiif.library.ubc.ca/presentation/dsp.831.1-0106429/manifest

Comment

Related Items