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Social casework in the mental hospital : a quantitative analysis of social casework services at the Crease… Schlesinger, Ernest 1954

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SOCIAL CASEWORK IN THE MENTAL HOSPITAL A Quantitative Analysis of S o c i a l Casework Services at the Crease C l i n i c of Psychological Medicine, 1953. by ERNEST SCHLESTNGER Thesis Submitted i n P a r t i a l Fulfilment of the Requirements f o r the Degree of MASTER OF SOCIAL WORE i n the School of S o c i a l Work Accepted as conforming to the standard required f o r the degree of Master of Social, Work School of S o c i a l Work 1954 The University of B r i t i s h Columbia i v ABSTRACT This study makes a definitive survey of the social services made available to mental patients at the Crease Clinic of Psychological Medicine during the year of 1953. The purpose of the survey was to describe as clearly as possible the actual social services provided by social caseworkers to patients undergoing short-term treatment at a mental hospital. In order to analyze the nature of typical social casework help, i t was necessary to define the specific com-ponents making up services to the mentally i l l and their fam-i l i e s . Since there i s apparently no available standard, a special classification of services was devised for the pre-sent study. This was achieved by visualizing the social needs of tbe patient and his family as he moves through his period of hospitalization, from admission to discharge. A questionnaire l i s t i n g these services was prepared, and was answered by the patients* social workers. The patients studied were fey people selected by a routine sampling pro-cedure. An examination of the casework help to the pat-ients revealed that 25 out of 64, and 29 of their families, received help through face-to-face interviews with the so-c i a l worker. A l l the patients were helped through diagnos-t i c planning at ward rounds, and 44 were further assisted through a therapeutic use of social resources by the social worker. The specific services to the patients and the spe-c i f i c services to the relatives were shown to be similar in frequency. In both instances most of the services were aimed at helping people with their discomforts in social relationships. In conclusion, the study points out some of the problems i n the screening of patients for social casework help, including the d i f f i c u l t y of giving effective service with insufficient staff. Also emphasized i s the necessity for social agencies to f a c i l i t a t e research through standar-dization of recording, because of the need for farther de-velopment i n quantitative and analytical evaluation of ser-vices which are not clearly understood by the general pub-l i c , and even by some professional people. V ACKNOWLEDGEMENTS I wish to express ray appreciation to the social workers at the Crease Clinic of Psychological Medicine and at the Provincial Mental Hospital for their interest and co-operation in obtaining the data for the present thesis. I particularly want to thank Miss Dorothy R. Begg, Case-work Supervisor at the Crease C l i n i c , for her help i n de-vising a classification of social services in a mental hospital. I also wish to acknowledge 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 i TABLE OF CONTENTS Chapter 1. R e s p o n s i b i l i t i e s of the S o c i a l Worker i n a Page Mental Hospital R e s p o n s i b i l i t i e s of the s o c i a l caseworker. Case-work techniques. The Crease C l i n i c — i t s function. The Crease C l i n i c S o c i a l Service r e f e r r a l p o l i c y . Pur-pose and assumptions of present study. C r i t e r i a of sel e c t i o n . 1 Chapter 2. S o c i a l Services f o r the Patients at a Mental  Hospital C l a s s i f i c a t i o n of s o c i a l services; d i r e c t ser-vices to patients and the implications; d i r e c t services to p a t i e n t s 1 r e l a t i v e s and the implications; i n d i r e c t services to patients and t h e i r r e l a t i v e s 20 Chapter 3. Patients Who Come to the Crease C l i n i c C l a s s i f i c a t i o n of patients. Who are the patients? Their age and sex d i s t r i b u t i o n ; t h e i r marital status; t h e i r length of h o s p i t a l i z a t i o n ; and t h e i r condition upon discharge. D i f f e r e n t i a l d i s t r i b u t i o n of s o c i a l services amongst patients 43 Chapter 4. Summary and Implications Summary and assessment. Selection vs. f u l l s o c i a l service coverage.. S o c i a l services are personal. Research i n s o c i a l work. Steps i n evaluative research. Stan-dardization of recording 61 Appendices: A, Questionnaire Used i n Survey. .................. 73 B. Bibliography. 74 TABLES AND CHARTS IN THE TEXT (a) Tables Table 1. Direct s o c i a l services to 64 mental patients and t h e i r f a m i l i e s , Grease C l i n i c , 1953 22 Table 2. C l a s s i f i c a t i o n of d i r e c t s o c i a l services to 64 patients, Crease C l i n i c , 1953 2 6 Table 3. C l a s s i f i c a t i o n of d i r e c t s o c i a l services to r e l a t i v e s of 64 patients, Crease C l i n i c , 1933.. 33 i i i Page Table 4. C l a s s i f i c a t i o n of i n d i r e c t s o c i a l services to 64 patients and t h e i r r e l a t i v e s , Crease C l i n i c , 1953 39 Table 5. Length of h o s p i t a l i z a t i o n of 64 patients according to condition on discharge from the Crease C l i n i c , 1953 51 Table 6. Direct s o c i a l services to 64 patients ac-cording to age and sex, Crease C l i n i c , 1953 54 Table 7. S o c i a l services to 64 patients according to age and sex, Crease C l i n i c , 1953 II'i.'iI 55 Table 8. S o c i a l services to 64 patients according to t h e i r marital status, Crease C l i n i c , 1953.... 37 Table 9. S o c i a l services to 64 patients according to the length of h o s p i t a l i z a t i o n at the Crease C l i n i c , 1953 58 Table 10. S o c i a l services to 64 patients according to t h e i r condition upon discharge, Crease C l i n i c , 1953 59 (b) Charts Pig. 1. Age D i s t r i b u t i o n of a group of 64 patients at the Crease C l i n i c , 1953 46a. CHAPTER I RESPONSIBILITIES OF THE SOCIAL WORKER IN A MENTAL HOSPITAL Teamwork in the hospital for the mentally i l l i s a process whereby a l l members of the treatment team work to-gether to bring about the treatment and rehabilitation of the patient. Each member of the team i s competent to con-tribute a special understanding of the patient's health and welfare problems through his professional knowledge and s k i l l s i n some area of human li v i n g . At the Crease Clinic of Psychological Medicine i n British Columbia (the base from which the present study was made), the team consists of the doctor, the psychologist, the nurse, the social case-worker, the social group worker, and the occupational and recreational therapists. The contributions that the social caseworker can make in the mental hospital are manifold. They are based on his knowledge of the social, cultural and psychological development and pathology of the human personality, and on his knowledge of social resources. This knowledge differs from that of either the applied sociologist or the psy-chiatrist. The social caseworker sees a social case as *a l i v i n g event within which there are always economic, - 2 -physical, mental, emotional and social factors in varying proportions. A social case i s composed of internal and external, or environmental factors. 1 , 1 Special s k i l l i n i n -terviewing and i n the use of social resources are also pe-culiar to the profession of social work. They are directed in "such a way as to arouse and conserve the psychological energies of the c l i e n t — a c t i v e l y to involve him i n the use of services (casework services) towards the solution of his dilemma. » 2 In the mental hospital, the goals of the social caseworker are the social treatment of the patient; the re-habilitation of the patient and his family; and the preven-tion of further mental breakdown in the patient. (Treatment, i n this survey, defines the process whereby the patient i s helped to overcome or live with his i l l n e s s . Rehabilitation, on the other hand, represents a l l the other processes whereby tbe patient and bis family are restored to a more satisfac-tory adjustment internally and to the community. More speci-f i c a l l y , i t i s the restoration "of the handicapped to the ful l e s t physical, mental, social, vocational and economic 3 usefulness of which they are capable." ) These three goals of social casework p r a c t i c e -treatment, rehabilitation and prevention—are achieved by Gordon Hamilton, Theory and Practice of Social Case  Work. Columbia-University Press, New York, 1951, pp. 3-4. 2 Ibid., p. 24. 3 Maya Riviere, Rehabilitation of the Handicapped. National Council of Rehabilitation, New York, 1949, p. i i i . • 3 • helping the patient to make constructive change within him-self Insofar as he i s able and willing, and by helping to change, alter or better mobilize the environment for him. The emphasis in many state hospitals i s on the second tech-nique of help because of time limitations. Clarification i s a casework technique which i n most instances can be achieved only through a prolonged intensive casework relationship, i n which the patient i s supported to recognize and to accept in varying degrees his own and other people's behaviour. However, with the growth i n understanding of mental hygiene throughout the f i r s t half of the twentieth century, the social worker's responsibilities have increased consid-erably from the environmental "after-care 1* help to discharged mental patients, which was his f i r s t responsibility i n the mental hospital setting. His responsibilities have grown so that he i s now involved at every phase of the patients' and their families' needs. Six types or stages of responsibility may be distinguished. (1) Admission Services. When the patient f i r s t enters the hospital for the mentally i l l , the soeial worker's responsibilities are similar to those of a caseworker i n any other hospital. Entering such an institution i s often a frightening experience to the mental patient. The hospital i s a new setting for him and one about which he has heard many gruesome stories. Further, he i s afraid of the medical treatment and may attempt to resist i t . He w i l l want to go home, particularly since he often does not, or does not want . 4 -to, realize that he i s i l l . He w i l l feel confused about the reason for his hospitalization, and may become upset by the behaviour of the other patients and by the manner of l i f e in an institution. The caseworker attempts to reassure him against these fears, helps him make a more satisfactory adjust-ment to the hospital, and tries to gain his co-operation i n treatment. (2) Diagnostic Services. Another responsibility of the caseworker within the mental hospital i s to help himself and other staff members arrive at a comprehensive diagnosis. The social worker achieves this by a diagnostic study which he obtains through a casework relationship with the patient and his relatives. This study includes the patient's marital, vocational, educational and religious adjustments, achieve-ments and failures; the patient's childhood experiences; the patient's social environment—its strengths and weaknesses; an assessment of the inter-relationships between the patient and his family as well as other groups of people; and the history of the present i l l n e s s . Through this diagnostic study, the caseworker arrives at a social diagnosis which i s of assistance in planning for future social casework services to the patient and his family with a view to meeting unmet social needs. The social study and the social diagnosis also give the treatment team an accurate assessment of the pat-ient's personality and social environment, and thereby f a c i -l i t a t e the team's diagnostic services, and treatment and re-habilitation plans for the patient. • 5 -(3) Treatment Services. Although some authorities seem to doubt the usefulness of the social worker participa-ting in the treatment process, 1 the writer i s convinced that the social caseworker i s competent to take on some treatment responsibilities. The criticisms of his contributions per-haps arise out of a lack of public awareness of the case-worker's a b i l i t y for helping people. His s k i l l of starting with the client, and moving at the client's speed, as well as his s k i l l of working with people under environmental* , hospital pressures, i s particularly important with mental patients, and i s often overlooked by c r i t i c s . The social worker offers understanding. He shows a friendly interest i n the patient. He helps the patient hold on to r e a l i t y by stressing real things, but does not disclaim the patient's delusions. Instead, he accepts them as being real to the patient; moves on to more factual mat-er i a l as soon as possible; and attempts to get the patient interested in environmental r e a l i t i e s again. This i s i n keeping with his professional competency, i.e. the social worker works only with those problems of which the patient i s conscious: he avoids unearthing unconscious thoughts from the patient. The patient i s further helped to express his f e e l -ings; and i f he i s strong enough emotionally, he i s encour-aged to look at his attitudes and problems a l i t t l e more 1 Paul H. Hoch. editor. Failures i n Psychiatric  Treatment. Grunne and Stratton, Hew York, 1948. - 6 -searchingly, so that he w i l l have a better understanding of himself and his situation, and w i l l know how to handle him-self next time he i s under stress* He w i l l be helped to think more clearly about bis future and w i l l be encouraged in any reasonable decision that he makes. If needed, he w i l l be helped in building up a sense of personal worth by support from the social worker and support stimulated by the case-worker i n the social environment. The latter i s achieved by gaining the interest of relatives and others i n the patient. Direct environmental help to the patient on the ward i s also an important factor in the work of a psychia-t r i c hospital social worker. The mental il l n e s s hampers the patient in meeting rea l i t y situations, and i n facing his res-ponsibilities to bimself and to others. Consequently, the social caseworker often finds i t necessary to lessen tbe bur-den for the patient by assuming some of the patient's respon-s i b i l i t i e s . (4) Pre-convalescence Services. As soon as the patient recovers sufficiently to discontinue the medical treatment, further services are offered to him. Besides tbe services given to the i l l person during his treatment period, the social worker at this time has an integrative job in looking at a l l existing resources in the community, and using tbe resources which w i l l be most beneficial to the patient on his return to society. These social resources w i l l be used in a way that i s diagnostically related to the - 7 -underlying problems of the patient, and can be made avail-able to the patient and his relatives at any time daring his treatment and rehabilitation. Another integrative job of the social caseworker daring the period of pre-convalescence i s that of knitting together a l l the services which exist i n various departments of the hospital to the use of the patient. The emphasis, as before, remains client-centered. The patient plans for him-self; and the social worker encourages and stimulates him to think of a l l the poss i b i l i t i e s open to him, and supports him in his decisions. The social worker also helps the patient with problems and anxieties which so often accompany the patient's thoughts about his discharge from the hospital. In addition, i f the patient needs and wants farther casework ser-vices after discharge from the hospital, he i s made aware of any follow-up services that are available to him. (5) Convalescence Services. When the patient i s eventually discharged from the hospital, he leaves a protec-tive environment for the bustle, i r r i t a t i o n s and problems of society. Hany of the patients find this return to community and family l i f e extremely d i f f i c u l t and threatening. To help them retain the gains they have made at the hospital and to help them make further gains, i t has been found that preparing them for these stresses and for the follow-up services i s of immeasurable value. Although the Act Relating to Clinics of Psychological Hedicine of British Columbia1 makes no provis-British Columbia, Revised Statutes of. 1948, ch.52. - 8 -ion f o r an extension of casework services to the discharged patient, sach services are i n f a c t given to selected patients. These services are eithe r made available by the Crease C l i n i c s o c i a l worker i f the patient i s l i v i n g i n the Greater Van-couver area, or by the p r o v i n c i a l S o c i a l Welfare Branch of the area i n which the patient l i v e s i f the patient l i v e s outside the Greater Vancouver area. In either case, a s o c i a l worker gives supportive and sustaining help. In addition., to giving casework help to the patient during the convalescent period, the C l i n i c s o c i a l worker con-fer s with tbe patient's doctor about the patient's progress and adjustment at home. Reports on the patient's progress from the S o c i a l Welfare Branch workers are discussed with the doctor too, and a written statement on the r e s u l t s of t h i s discussion i s sent back to the Branch as part of the general consultation service to the F i e l d worker. (6) Family Services. The s o c i a l worker also has r e s p o n s i b i l i t i e s to the patient's family, f o r t h e i r welfare i s an important f a c t o r i n the patient's r e h a b i l i t a t i o n . F i r s t , the support of the family can be a sustaining, b e n e f i c i a l i n -fluence to the patient while he i s i n h o s p i t a l . Secondly, the patient w i l l eventually return to h i s family i n most cases, and the necessity often a r i s e s of the need to help improve family r e l a t i o n s h i p s to prevent future mental break-downs of the patient. T h i r d l y , the i l l n e s s of one of i t s members often has a devastating e f f e c t on the family. - 9 -When the patient enters the h o s p i t a l , r e l a t i v e s are frequently more confused and upset than he i s . They may he a f r a i d of and may not understand the patient's i l l n e s s . They may have needless fears that the patient i s being "put away f o r l i f e , " or may need help to face the fac t that the patient w i l l remain i l l f o r an extended period. They may f e e l respon-s i b l e f o r the patient's breakdown, and may be affected by g u i l t f e e l i n g s about committing the patient to the hos p i t a l ; or they may show r e l i e f at getting r i d of the r e s p o n s i b i l i t y of caring f o r the patient, and may decide to break a l l t i e s with him because they f i n d h i s bizarre behaviour too painful to face again. A l l these f e e l i n g s and attitudes have a d i s -rupting influence on the patient and the e f f e c t i v e function-i n g of the family. The s o c i a l worker can give r e a l i s t i c as-surance and support to the family, and encourage i t to par-t i c i p a t e a c t i v e l y i n the treatment and r e h a b i l i t a t i o n of the patient. He i s also i n the po s i t i o n to help the family with the material and emotional issues which i t may encounter. These issues that may confront the patient's fam-i l y are many and varied. They may centre around the accept-ance of the patient and h i s i l l n e s s ; they may centre around the problems which may have always been present i n the family, and have been instrumental i n contributing towards the pat-ient's mental breakdown, and are, perhaps, having an incapa-c i t a t i n g e f f e c t on other members of the family; or they may be the d i r e c t r e s u l t of the separation of one of the members of the f a m i l y — i . e . the p a t i e n t — f r o m the t o t a l u n i t . Through - 10 -casework support and c l a r i f i c a t i o n , the s o c i a l worker i s often able to help the family cope with these problems so that they can lead a more s a t i s f a c t o r y l i f e f o r themselves and f o r the patient. He can also make available to the family other so-c i a l services such as S o c i a l Assistance and f o s t e r home care. To summarize, the s o c i a l caseworker has responsibi-l i t i e s both to the patient and the patient's family. H i s ser-vices are pri m a r i l y aimed at the treatment and r e h a b i l i t a -tion of the s i c k person, and at the prevention of the recur-rence of tbe patient's i l l n e s s ; but to achieve t h i s , help has to be extended frequently to the family, too. There are four common "casework processes or groups of techniques 1' 1 used by the s o c i a l worker to help people. Casework Techniques F i r s t , there are the techniques which are applied through the interpersonal r e l a t i o n s h i p developed between the c l i e n t and the s o c i a l caseworker. These are the techniques which form the services which are of an emotionally suppor-t i v e and sustaining nature f o r the c l i e n t . Supportive and sustaining help includes such techniques as reassuring the patient, accepting h i s behaviour, showing understanding and f r i e n d l i n e s s , supporting and encouraging, sympathizing, and other u t i l i z e d means i n i n t e r v i e w i n g — a l l to help the c l i e n t 1 Florence H o l l i s , "The Techniques of Casework," Journal of S o c i a l Casework. June 1949. - 11 -gain strength and mobilize h i s own resources to help himself. Secondly, there are techniques i n v o l v i n g c l a r i f i c a -t i o n of the c l i e n t ' s conscious problems. These techniques are the ones used i n helping the c l i e n t to understand him-s e l f and h i s environment. Through t h i s knowledge, which i n casework i s usually self-acquired, the patient i s helped to modify h i s a t t i t u d e s , to adjust to his surroundings, and to be able to meet stress s i t u a t i o n s r e a l i s t i c a l l y . The t h i r d type of techniques comprises those used tk* i n giving information t o ^ c l i e n t . In the mental h o s p i t a l , giving information i s an extremely important function of the s o c i a l worker. He i s not only c a l l e d upon to explain to the patient and r e l a t i v e s the functions of the S o c i a l Service Department, but must often be able to give information on various aspects of hospital l i f e . The many misunderstandings which e x i s t about mental i l l n e s s and mental hospitals have to be dealt with. In addition, the caseworker advises the pat-ient and h i s family of s o c i a l resources i n the community. He may inform the patient's family of f i n a n c i a l help i t can receive from other s o c i a l agencies and may r e f e r i t to the proper agency f o r assistance; or he may advise the patient how to get vocational counselling, how to go about f i n d i n g employment, how to continue with h i s education, how to get further casework services when he i s discharged from the hos-p i t a l , etc. - 12 Environmental help, a fourth technique, can be div-ided i n t o two categories. I t can be e i t h e r psychologically enabling as well as being h e l p f u l i n other ways, or i t can be he l p f u l to the c l i e n t without necessarily being psychologically enabling. The former i s a casework service; the l a t t e r i s an i n c i d e n t a l service. The s k i l l e d caseworker w i l l attempt to make a l l environmental services i n t o enabling experiences f o r the c l i e n t , because as a professional person h i s services should be compatible with a sound s o c i a l diagnosis. A l l the four casework processes l i s t e d above have one thing i n common. They are aimed at helping the c l i e n t help himself. The s o c i a l caseworker's professional goal i s to help the i n d i v i d u a l to better adjustments i n h i s s o c i a l r e -lationships with others. 1 Every patient i s an i n d i v i d u a l , d i f f e r e n t from other i n d i v i d u a l s . He has h i s own combination of strengths and weaknesses, or turmoil and harmony. Simi-l a r l y , every family i s unique i n i t s c o n s t e l l a t i o n and i t s i n t e r a c t i o n of members. " I n d i v i d u a l i t y " has become the motto of s o c i a l workers because they have r e a l i z e d the dangers i n -herent i n pigeon-holing and generalizing, and because they believe that the uniqueness of each i n d i v i d u a l i s often a v i t a l part of h i s innate d i g n i t y and i n f i n i t e worth as a human being. The Crease C l i n i c of Psychological Medicine The Crease C l i n i c of Psychological Medicine i s part of the B r i t i s h Columbia p r o v i n c i a l mental ho s p i t a l system. ' x Mary Richmond, The Long View. Russel Sage Founda-t i o n , Mew York, 1930, p. 398^ - 13 -The C l i n i c has been designed and equipped as a diagnostic and active treatment centre f o r the mentally i l l . 1 To ensure that i t s h a l l carry out the intended function, statutory pro-v i s i o n has been made l i m i t i n g the duration of a patient's treatment period to four calendar months, commencing with the date of admission. I f at the end of the treatment period i n the C l i n i c , the medical s t a f f i s of the opinion that the pat-ient requires additional treatment, there i s a statutory pro-v i s i o n to permit the patient to be c e r t i f i e d f o r committal to the P r o v i n c i a l Mental Hospital i n accordance with tbe pro-o visi o n s of the Mental Hospital Act. Procedure f o r tbe admission to the Crease C l i n i c has been kept as simple as possible. Admissions are of two types: (1) c e r t i f i c a t i o n by two medical p r a c t i t i o n e r s ; and (2) volun-tary application by the patient, approved by a physician on the basis that he i s of the opinion that the patient's condi-ti o n i s such as to render the patient capable of making volun-tary a p p l i c a t i o n f o r treatment. The f i r s t , or regular admis-sions, are somewhat more common than the voluntary ones. .. Since the maximum period of treatment i n the C l i n i c i s l i m i t e d to four months, physicians are requested to c e r t i f y f o r admission only those patients who, i n t h e i r opinion, have \ - — What follows i s a p a r t i a l summary from the Poli c y Manual of the B r i t i s h Columbia S o c i a l Welfare Branch. 2 B r i t i s h Columbia, Revised Statutes of. ch. 207. According to the B r i t i s h Columbia Annual Report of  the Mental Health Services f o r 1953, there were 687 regular admissions and 534 voluntary admissions between A p r i l 1st, 1952 and March 31st, 1953. - 14 -a reasonable prospect f o r recovery and discbarge i n the four months' period. S p e c i f i c a l l y , the following types of patients are considered acceptable f o r admission to the C l i n i c : (1) early psychotics, (2) patients with psychoneurosis, (3) patients with psychosomatic d i s a b i l i t i e s , and (4) a l l psychotic patients except those who have been i l l f o r a long time, and those demonstra-t i n g marked deterioration and having a poor prognosis. On the other hand, some types of patients are con-sidered unsuitable f o r admission and treatment i n the Crease C l i n i c . These include: patients with s e n i l e dementia, pat-ient s with a r t e r i o s c l e r o t i c dementia, mentally defective people, chronic recurrent psychotics, drug addicts without psychosis, and al c o h o l i c s without psychosis. In t h i s connec-t i o n , the Act Relating to C l i n i c s of Psychological Medicine empowers the person i n charge of the C l i n i c to decline to ad-mit any person to the C l i n i c , i f there are adequate reasons, notwithstanding the fact that the person has been c e r t i f i e d under the Act. Crease C l i n i c S o c i a l Service Referral P o l i c y In practice, most hospitals f i n d i t d i f f i c u l t to o f f e r adequate s o c i a l services because of u n a v a i l a b i l i t y of trained personnel which precludes s t a f f i n g to recognized standards, and because of f i n a n c i a l l i m i t a t i o n s within the t o t a l administration. Many patients and t h e i r f a m i l i e s may - 15 never see a caseworker. Others could possibly use a more intensive casework relationship, but the social worker, because of high caseloads, i s too pressed for time to offer i t . At the Crease C l i n i c , because of this shortage i n personnel, tbe process of screening patients for casework services has become important. If a l l the patients were to be covered by the Social Service Department, casework ser-vices would be spread so thinly over the general population of the C l i n i c , that patients would not benefit through them. The attempt to give complete social service coverage was, therefore, abandoned soon after the Clinic was opened, though i t i s a goal at which the Social Service administration i s s t i l l aiming. For the present, the policy of offering ser-vices to the patients most l i k e l y to profit from them has been adopted, but i n practice such a policy i s often d i f f i c u l t to follow. Referrals to the Department come from various 2 sources. Most referrals are made during "ward rounds." Other patients are referred directly by the patient's doctor at the C l i n i c , by the nurse, or by some community agency. In some cases, the patient himself or his family may request 1 The Social Service Department at the Crease Clinic consists of tbe administrator, two supervisors and six case-workers. The number of patients admitted to the Clinic bet-ween April 1st, 1952 and March 31st, 1953, was 1221. 2 "Ward rounds" i s a periodic meeting of members of the treatment team. During these meetings newly admitted patients are discussed diagnostically, and treatment and re-habilitation plans for these patients are decided upon. - 16"-casework services. In addition, some patients or r e l a t i v e s are seen by the intake worker at the time the patient i s ad-mitted to the C l i n i c . Par-pose and Assumptions of Present Study The present survey i s one of a serie s of studies being conducted on the S o c i a l Service Departments of the Pro-v i n c i a l Mental Hospital and of the Crease C l i n i c of the Psycho-l o g i c a l Medicine at Essondale, B r i t i s h Columbia, by Master of S o c i a l Work students at the School of S o c i a l Work at the Uni-v e r s i t y of B r i t i s h Columbia. 1 I t makes the assumption that casework help i s frequently of value to the patient and h i s family i n the treatment and r e h a b i l i t a t i o n process. The res-p o n s i b i l i t i e s which the s o c i a l worker assumes f o r the patient's s o c i a l adjustment are very s i m i l a r to the r e s p o n s i b i l i t i e s of the doctor f o r the patient's physiological condition^. One of the tenets i n medicine i s to use a l l the avail a b l e medical knowledge and s k i l l on the patient, knowing that neither t h i s knowledge nor s k i l l w i l l always cure the patient. Mr. A. may prosper from i n s u l i n therapy, while Mr. B. w i l l remain un-changed from i d e n t i c a l treatment. S i m i l a r l y , s o c i a l workers Mr. Gerald Pepper, at present himself a s o c i a l worker at the C l i n i c , has already completed a general study of the hi s t o r y and the organizational structure of the De-partments i n hi s S o c i a l Worker P a r t i c i p a t i o n In"the Treatment  of the Mentally 111. Master of So c i a l Work Thesis. University of B r i t i s h Columbia, 1953. Two other studies are being con-ducted concurrently with t h i s survey. The f i r s t , an examina-t i o n of the So c i a l Service r e f e r r a l p o l i c y and practice at the Crease C l i n i c , i s being performed by Mr. Eugene Elmore. The second, a study by Mr. Hurray Sutherland, i s a survey of r e h a b i l i t a t i v e s o c i a l services and resources available to male patients discharged from the Crease C l i n i c . » 17 o have the r e s p o n s i b i l i t y of bringing to bear t h e i r knowledge and s k i l l on the patient, although they are at the same time aware that some of the patients are not perhaps capable of benefiting from or a c t u a l l y w i l l refuse casework services. Both professions have t h e i r f a i l u r e s i n treatment, and both professions are continually re-evaluating these f a i l u r e s and attempting to develop t h e i r knowledge and s k i l l s to de-crease the number of people who cannot be e f f e c t i v e l y helped. 1 The purpose of the present study i s to examine quanti-t a t i v e l y tbe s o c i a l casework services which were given to a representative group of patients and t h e i r f a m i l i e s at the Crease C l i n i c up to the time of t h e i r discharge. By "Social casework s e r v i c e s 9 t h i s study denotes a l l the services which the s o c i a l worker offers to the patient and h i s family, and which are aimed at helping both the patient and the family a t -t a i n a happier adjustment to each other and to society. C r i t e r i a of Selection In s e l e c t i n g patients f o r the measurement of s o c i a l services at the C l i n i c , two c r i t e r i a were emphasized. The f i r s t c r i t e r i o n was to get a sample which would be representative, yet small enough f o r c a r e f u l case analysis within the time at the writer's disposal. The second c r i t e r i o n , i n deference to the fact that Crease C l i n i c i s a young f l e x i b l e i n s t i t u t i o n with constantly changing administrative p o l i c i e s , was to s e l e c t as 1 Of p a r t i c u l a r i n t e r e s t i n t h i s regard i s F a i l u r e s  i n Psychiatric Treatment, edited by Paul H. Hoch, published by Grune and S t r a t i o n , New York, 1948. - 18 -recent a sample as p o s s i b l e . 1 To keep the sample small and representative, the s e l e c t i o n was l i m i t e d to patients ad-mitted to the C l i n i c within a s i x months' period, choosing every tenth patient admitted daring that span of time. A p r i l 1st, 1953, to September 30th, 1953, was chosen as the period from which the sample was selected, because i t ensured that a l l the patients were recently admitted, but at the same time ruled out the p o s s i b i l i t y of the patient not having yet been d i s -charged from the C l i n i c . Daring the above-mentioned period, 636 people were admitted to the Crease C l i n i c . The patients are l i s t e d by name i n the C l i n i c ' s Admission Book according to the date of admission. By s e l e c t i n g every tenth patient admitted between A p r i l 1st and September 30th, 1953, the sample thus obtained consists of 64 people, and i s probably representative of the range of services given but not certi f i a f t L y of the t o t a l 2 C l i n i c population. Information on these patients was taken from a num-ber of sources. The S o c i a l Service Department's records were used f o r the preliminary information. These records usually supplied s u f f i c i e n t information to make i t obvious that a sat-i s f a c t o r y c l a s s i f i c a t i o n according to s o c i a l work diagnosis was impossible. However, i n attempting to analyze the s o c i a l services given to patients, the S o c i a l Service f i l e s were found ^The Crease C l i n i c was opened on January 1st, 1951. 2 The season of the year from which the sample has been selected has possibly some d i s t o r t i n g e f f e c t . - 19 -to be lacking in the specific information being sought, and of necessity another way of getting the required information had to be devised. A questionnaire which asked for the pertinent information was prepared (Appendix A). It was answered by the patients' social workers. The information so obtained was supplemented by and checked against the information gleaned from the Social Service records. CHAPTER 2 SOCIAL SERVICES FOR THE PATIENTS AT A MENTAL HOSPITAL The people who come to the Crease C l i n i c do so f o r the primary purpose of securing treatment f o r t h e i r i l l n e s s . The treatment, as noted i n the f i r s t chapter, i s the combined e f f o r t of a number of dis c i p l i n e s - - n u r s i n g , medicine, psy-chia t r y , s o c i a l work, occupational and recreational therapy, theology, and psychology. A l l the patients get a v a r i e t y of services from members of these d i s c i p l i n e s . For instance, the doctors and p s y c h i a t r i s t s give medical and psycho-therapeutic services, the clergymen give s p i r i t u a l services, and the psy-chologists further treatment through t h e i r assessment of the patient's personality. S o c i a l services are a part of t h i s t o t a l treatment programme. The f i r s t chapter has outlined the r e s p o n s i b i l i t i e s of the s o c i a l worker i n t h i s programme, as well as l i s t i n g the casework processes used i n helping people. The present chapter w i l l examine the s o c i a l services which are used i n meeting tbe s o c i a l worker's r e s p o n s i b i l i t i e s to the patients and t h e i r r e l a t i v e s . Not a l l patients get s o c i a l services. There are three main reasons f o r t h i s . F i r s t l y , the C l i n i c i s a short-term h o s p i t a l . Many of the patients stay only a b r i e f period, - 21 -and are discharged before the s o c i a l worker has the opportunity to see them. In other cases, the patient i s discharged suddenly, and without the knowledge of the s o c i a l worker. Secondly, some patients, because of the nature of t h e i r i l l n e s s , r e s i s t or are unable to respond to s o c i a l casework. Th i r d l y , as mentioned previously, the S o c i a l Service Department has i n s u f f i c i e n t s t a f f to give adequate services and at the same time o f f e r case-work help to a l l the patients at the C l i n i c . At the present time, the S o c i a l Service Department tends to se l e c t f o r casework the patients to whom i t can be of greatest assistance i n the shortest possible time. Out of the 1221 patients admitted bet-ween A p r i l 1st, 1952, and March 31st, 1953, 573 were referred to the Department f o r b r i e f services. Of these, 318 were served by the Admissions Section of the S o c i a l Service Depart-ment, and received casework services of an enabling and sup-portive nature over a b r i e f period. Eleven hundred patients were referred f o r continued s o c i a l casework s e r v i c e s . 1 How-ever, only 508 of these patients were served by the Depart° 2 ment because of the reasons l i s t e d above. Out of the 64 patients i n the present sample, a l l received some s o c i a l services; but these varied considerably from person to person. Approximately 45.4$ (or 29 of the pat-ients and t h e i r r e l a t i v e s ) received only immediate diagnostic planning services at ward rounds. The other 56.6$ of the group For a f u l l description of the differences between b r i e f and continuing s o c i a l services, see Gerald Pepper, o p . c i t . . pp. 51-55, 61-68. 2 Figures from B r i t i s h Columbia, Annual Report of the  Mental Health Services. 1953. - 22 Table 1. Direct S o c i a l Services to 64 Mental  Patients and Their Families (Crease C l i n i c , 1953) 1 Direct S o c i a l Services Patients Receiving Services Percentage of Patients Re-c e i v i n g Services Direct Services to .Patients only 6 .9.3.,. Direct Services to Relatives only 10 15.6 Direct Services to Patients and Relatives 19 29.7 No Direct Services 29 45.4 Total 64 100.0 (or 35 patients and t h e i r f a m i l i e s ) received services through the face-to-face casework r e l a t i o n s h i p . Table i indicates the d i r e c t s o c i a l services (or the services emanating from the face-to- face r e l a t i o n s h i p between the caseworker and the c l i e n t ) given to the patients and t h e i r r e l a t i v e s . In s i x cases, d i r -ect services were extended to the patient and not to the r e l a -t i v e s . In ten other cases, the r e l a t i v e s received d i r e c t soc-i a l services, bat the patient was not seen by the s o c i a l worker. A f a l l i ntegration of services to the patient and h i s r e l a -t i v e s was achieved with 19 patients, because both the patient and h i s family were re c e i v i n g d i r e c t services. Such i n t e g r a t i o n , 1 The source f o r Table 1 and a l l the tables that f o l -low i s a sample count of the patients under study. - 23 -however, i s frequently impossible because either the patient i s too i l l f o r d i r e c t services or the patient's family l i v e s outside the Greater Vancouver area. In the l a t t e r instance, an integrative job i s occasionally achieved through the l o c a l S o c i a l Welfare Branch. C l a s s i f i c a t i o n of Services What are the s p e c i f i c services which the caseworker provides f o r the patients and t h e i r families? The goals of the s o c i a l worker at the mental h o s p i t a l , previously mentioned, were seen to be the treatment, and r e h a b i l i t a t i o n of the patient, as well as the prevention of further mental breakdown of the pat-i e n t . The problems of the patients and t h e i r r e l a t i v e s have also been pointed out. I t now remains to describe and measure the s o c i a l services. They can be described under three headings: (1) direct services to patients; (2) d i r e c t services to patients' r e l a t i v e s ; and (3) i n d i r e c t services to patients and t h e i r r e l -a t i v e s . "Direct services to patients" are those services which are given through the interviews between s o c i a l worker and patient. S i m i l a r l y , "direct services to patients* r e l a t i v e s " are those services which are obtained by the r e l a t i v e s of the patients through casework interviews. "Indirect s e r v i c e s " are those services which are f o r the welfare of the patient or his r e l a t i v e s , and consist of a diagnostic use of s o c i a l resources within or outside the C l i n i c . This d i v i s i o n of casework ser-vices i s not altogether exclusive except by d e f i n i t i o n , be-cause, f o r example, d i r e c t services to the patient could be = 24 -considered as indirect services to the patient's kin. As a classificatory device, however, the division proved very use-f u l . Direct Services to Patients Direct services to patients as defined for this study includes a l l the services which the social worker provides through the medium of the interview between the patient and the worker. These services have been divided for the purpose of analysis into four groups. I. Support around anxieties related to hospitali- zation. This includes help with fears concerning the physical setting of the hospital, e.g. the locked doors; fears about the medical treatment; anxieties about the staff; and anxieties about the other patients. II. Support around anxieties related to family pro-blems during hospitalization. This concerns mainly help with those fears of the patient which are caused by the break-up of the family because of the illness of one of i t s members. Speci-f i c a l l y , these anxieties are caused by financial problems, d i f -f i c u l t i e s about the care of children, and immediate problems i n family relationships. III. Support around anxieties related to discharge  plans. When the patient i s ready for discharge, planning for his future becomes an important part of the social worker's job. This consists of environmental and emotional support. "Environmental support" covers a wide range of practical needs, namely: employment, housing, housekeeper services, financial 25 -problems, and s o c i a l and recreational matters. The second, "emotional support," consists of helping the patient cope with his fears related to the loss of hospital security, and to resuming family r e l a t i o n s h i p s . I t also includes preparation of the patient f o r follow-up s e r v i c e s 1 made ava i l a b l e by the pro-v i n c i a l S o c i a l Welfare Branch or by the S o c i a l Service Depart-ment of the Crease C l i n i c . IV. Casework services based on the emotional needs  of the patient. This category of services may seem to be some-what of a " c a t c h - a l l " category, because the caseworker's work should at a l l times be based on the emotional needs of the c l i e n t . However, the phrase, as used here, does not have such a broad scope. I t r e f e r s only to those services which help the patient accept environmental r e a l i t y , help him c l a r i f y con-scious problems i n interpersonal r e l a t i o n s h i p s , and help him 2 accept h i s personal l i m i t a t i o n s . Of a l l these four categories of d i r e c t services to the patient, the most frequent services are the ones "based on the emotional needs of the patient" (Table 2). Twenty of the 25 patients r e c e i v i n g d i r e c t services received help i n accept-ing environmental r e a l i t y . This i s not s u r p r i s i n g because "Follow-up" services are casework services ex-tended to the patient a f t e r h i s discharge from the h o s p i t a l . o Group work services based on the emotional needs of the patient are being offered at the C l i n i c since Feb-ruary, 1954. However, at the time the patients under study were ho s p i t a l i z e d , there was as yet no group worker at the C l i n i c . - 26 -Table 2. C l a s s i f i c a t i o n of Direct S o c i a l Services  to 64 Patients. Crease C l i n i c . 1953. Direct S o c i a l Services to Patients (Number of JTimes Ser-vice Given I Support around anxieties r e l a t e d to H o s p i t a l i z a t i o n : (1) the physical s e t t i n g (e.g. locked doors) (2) the medical treatment (3) the s t a f f (4) other patients 14 20 11 14 IT Support around anxieties r e l a t e d to family problems during h o s p i t a l i z a t i o n : (1) f i n a n c i a l problems (2) care of chi l d r e n (3) immediate troubles i n family r e l a t i o n s h i p s 10 12 22 I I I Support around anxieties related to discharge plans: (a) Environmental (1) employment (2) housing (3) housekeeper services (4) f i n a n c i a l problems (5) s o c i a l and recreational I 9 4 4 10 21 (b) Emotional . TT7 anxiety r e l a t e d to loss of hospital security (2) fears about resumption of family relationships (3) preparation f o r follow-up services 3 8 14 IV Casework services based on tbe emotional needs of the patient: (1) help i n accepting environmental r e a l i t (2) help i n c l a r i f y i n g conscious problems i n interpersonal r e l a t i o n s h i p s (3) help i n accepting personal l i m i t a t i o n s J 20 18 18 Total d i r e c t s o c i a l services to patients 1 232 - 27 -most mental patients present d i f f i c u l t y i n t h e i r a b i l i t y to function i n r e l a t i o n to t h e i r i n d i v i d u a l r e a l i t y s i t u a t i o n s , and need help i n t h i s area. Help i n accepting personal l i m i -tations was extended to 18 patients because such d i f f i c u l t i e s are also common amongst mental patients. C l a r i f i c a t i o n of conscious problems i n inter-personal re l a t i o n s h i p s was another frequent service. The patients are often persons who have never been able to f e e l comfortable with other people. Their s o c i a l l i f e has been unhealthy and unhappy, which i s probably an added s t r e s s , i f not the main one contributing to t h e i r eventual mental breakdown. These d i f f i c u l t i e s i n s o c i a l r elationships are ob-viously given much attention by the s o c i a l worker at the Crease C l i n i c . In discharge planning, 21 of the 25 patients getting d i r e c t services discussed s o c i a l and recreational d i f f i c u l t i e s and plans f o r a l l e v i a t i n g such d i f f i c u l t i e s with the caseworker. Of the other environmental discharge services, f i n a n c i a l and employment problems were most frequently discussed. However, i n both these instances, only two-fifths of the patients receiv-ing d i r e c t s o c i a l services got such help. Planning around hous-ing and around housekeeper services were even l e s s frequent. The infrequency of the l a t t e r i s probably because only families i n which the mother i s i l l seem to be i n need of housekeeper services. Also s u r p r i s i n g l y infrequent was help with anxieties of the patient about discharge from the C l i n i c . Less than t h r e e - f i f t h s of the patients receiving d i r e c t services were prepared f o r follow-up services of the p r o v i n c i a l S o c i a l Wel-fare Branch or of the S o c i a l Service Department i t s e l f . 1 Fears of resuming family r e l a t i o n s h i p s were discussed with only eight patients, while l o s s of hospital security as a problem came to the attention of the caseworkers with only three patients. Work with c l i e n t s who were f e a r f u l about h o s p i t a l i -zation and a l l i t s implications was launched into more f r e -quently. The medical treatment caused, numerically, the great-est anxieties. Here, twenty or f o u r - f i f t h s of the patients needed reassurance and support. The c o n f l i c t with and the fear of other patients, another major matter, was discussed with the s o c i a l worker i n t h r e e - f i f t h s of the cases r e c e i v i n g d i r e c t s o c i a l services. Of s i m i l a r frequency was casework sup-port to overcome the fr u s t r a t i o n s and fears of patients about l i v i n g i n a hos p i t a l with locked doors and with somewhat r e g i -mented group l i v i n g . The s t a f f , also, was a source of anx-i e t y to patients. F i r s t , there were the people who because of t h e i r i l l n e s s f e l t persecuted or f e a r f u l of people generally; and secondly, there were complaints by some patients of not getting enough attention from the s t a f f . Eleven people r e -ceived some form of service from the caseworker i n t h i s area. 1 A ca r e f u l s e l e c t i o n p o l i c y has been i n s t i t u t e d f o r screening patients f o r convalescence services. This was ne-cessary because between 68$ and 75% of a l l patients entering the Crease C l i n i c are from the Vancouver area, and thereby d i r e c t r e s p o n s i b i l i t y f o r o f f e r i n g follow-up services l i e s l a r g e l y with the l i m i t e d s o c i a l service s t a f f of the C l i n i c . Other reasons why so few patients are prepared f o r follow-up services are, amongst others, (1) the precipitous discharges of some patients, (2) the decision of the treatment team that such services should not be given, and (3) |he laek of s o c i a l resources i n the patient's home community. - 29 -A natural consequence of the h o s p i t a l i z a t i o n of these people was the break up of t h e i r f a m i l i e s . Most pat-ients are members of a family, and become anxious about what t h e i r absence means to i t . This i s r e f l e c t e d i n the request f o r s o c i a l services at the Crease C l i n i c . Almost a l l the pat-ient s who received casework help had anxieties about immediate problems i n t h e i r family relationships (22 of the 25 patients). Twelve of the patients sought help with the care of t h e i r c h i l -dren. Family f i n a n c i a l problems were not very often discussed since most of the patients were hos p i t a l i z e d f o r only a short period during which many of them were probably e n t i t l e d to sickness benefits from t h e i r employer, or were cared f o r i n some other way. Only ten patients discussed t h e i r f i n a n c i a l d i f f i c u l t i e s with the s o c i a l worker. The1 above services are the d i r e c t s o c i a l services to patients extended by the s o c i a l workers of the Crease C l i n i c to the 64 patients comprising the sample under study. Many of the services most frequently given have something i n common--they centre around rel a t i o n s h i p s with other people. Such ser-vices are:- help i n c l a r i f y i n g conscious problems i n i n t e r -personal r e l a t i o n s h i p s , help with immediate and future anx-i e t i e s around family r e l a t i o n s h i p s , support i n accepting en-vironmental r e a l i t i e s , help with d i f f i c u l t i e s with the s t a f f and other patients, and support i n planning s o c i a l and recrea-t i o n a l contacts upon discharge from the C l i n i c . Less frequent are services concerned with concrete matters such as f i n a n c i a l problems, housing, housekeeper ser-- 30 -vices. Compared to the work of the f i r s t caseworkers employed i n mental h o s p i t a l s , the s o c i a l worker's job today i s becoming i more and more psychologically supportive. The early mental hos p i t a l s o c i a l workers were mainly concerned with after-care and i t s associated problems, such as housing and employment. Though these remain an important task f o r the s o c i a l worker, his job has increased with the greater knowledge and s k i l l s which the profession has accumulated through the years. The abstract aspects of his work—many of the services that flow out of the c l i e n t - s o c i a l worker r e l a t i o n s h i p — a r e demanding ant increasing amount of the caseworker's time. Direct S o c i a l Services to Patients' Relatives Direct s o c i a l services to patients' r e l a t i v e s i n -clude a l l those services which the caseworker gives through the medium of the interview to the r e l a t i v e s . These services have been divided f o r the purpose of analysis into the follow-ing four groups. I. Support around anxieties r e l a t e d to the pat- ient 's h o s p i t a l i z a t i o n . This group of services consists of casework help with fears the r e l a t i v e s have about the physical s e t t i n g of the h o s p i t a l and i t s e f f e c t upon the patient, and support to lessen the fears concerning the medical treatment. I I . Help around the i n a b i l i t y to accept the pat- ient's i l l n e s s . This concerns the discomfort r e l a t i v e s often i Lois Meredith French, Psychiatric S o c i a l Work. The Commonwealth Fund, New York, 1940. - 31 -feel about committing tbe patient to a mental hospital, their uneasiness about being the "cause" of the patient's breakdown, their shame at having mental illne s s in the family, and their concern about the symptoms of the patient's i l l n e s s . I l l . Support around social problems in the home. This includes help with financial problems of the family, help with problems around the care of children i n tbe family, and help with d i f f i c u l t i e s i n family relationships (disharmony bet-ween family members). 17. Casework services based on the emotional needs  of the patient's relatives. Again this group might appear to be a "catch-all" category for a l l the services which have not been covered in the other three groups, because casework ser-vices should be based on the emotional needs of people. How-ever, for the purposes of the present study, the category has been delineated to include only support about personal anxie-ties, support i n accepting the patient as he or she i s , help in clarifying conscious problems i n interpersonal relationships, and preparation for follow-up services. As with the patients, among the most frequent ser-vices extended to the relatives was "casework help based on their emotional needs." Clarifying the relatives' conscious problems in interpersonal relationships occurred in twelve cases. More frequently.extended was help with personal an-xieties. These involved a considerable amount of work on the part of the social worker since, as some of the social his-tories indicate, the relatives often have numerous personal - 32 -d i f f i c u l t i e s which have a bearing on the patient and h i s i l l -ness. Because these personal d i f f i c u l t i e s usually cause d i f f i -c u l t i e s f o r the patient upon h i s discharge from the C l i n i c to his family, r e l a t i v e s were prepared i n thirteen cases f o r the follow-up services of the p r o v i n c i a l S o c i a l Welfare Branch or of the S o c i a l Service Department at the Crease C l i n i c . The most frequent of the "casework services based on emotional needs" proved to be support to r e l a t i v e s i n helping them understand and accept the patient as he i s . Of the 29 groups of r e l a t i v e s r e c e i v i n g d i r e c t s o c i a l services, 23 were helped i n t h i s way. Understanding and accepting the patient on the part of the r e l a t i v e s improves the s o c i a l r e l a t i o n s h i p between the patient and his family. I t helps the family over-come t h e i r reluctance to v i s i t the patient, and helps them be a constructive force i n the patient's r e h a b i l i t a t i o n . Understanding and accepting the patient i s impos-s i b l e without understanding and accepting h i s i l l n e s s . Tbe symptoms of mental i l l n e s s create much concern f o r the pat-ient's r e l a t i v e s , and i n 20 cases t h i s was discussed with them by the s o c i a l worker. They are usually b a f f l e d by and a f r a i d of what i s happening to the patient, and are often f e a r f u l of what he may do. Almost as frequently given attention by the s o c i a l worker are the r e l a t i v e s * feelings of discomfort about having committed the patient to the C l i n i c . They f e e l that they are deserting the patient at a c r u c i a l time i n h i s l i f e , and that they have done an i n j u s t i c e to him. They are also concerned about what the patient thinks of them f o r having him - 33 -Table 3. C l a s s i f i c a t i o n of Direct S o c i a l Services  to Relatives of 64 Patients. Crease C l i n i c . 195?: 1 — Direct S o c i a l Services to Relatives Number of times Ser-vice Given I Support around anxieties r e l a t e d to patient's h o s p i t a l i z a t i o n : (1) the physical s e t t i n g (2) the medical treatment 9 21 I I Help around i n a b i l i t y to accept patient's i l l n e s s : (1) discomfort about committal (2) discomfort about being "cause** of i l l n e s s (3) shame at mental i l l n e s s i n family (4) concern about symptoms of i l l n e s s 18 11 8 20 II I Support around s o c i a l problems i n the home: (1) f i n a n c i a l problems (2) care of children (3) disharmony i n family relationships 8 10 25 IV Casework services based on the emotional needs 21 23 12 13 of the r e l a t i v e s : (1) support around personal anxieties (2) support i n understanding and accepting patient as he/she i s (3) help i n c l a r i f y i n g conscious problems i n interpersonal r e l a t i o n s h i p s (4) preparation f o r follow-up services Total d i r e c t s o c i a l services to r e l a t i v e s 199 - 34• -"locked up." Discomfort about being the "cause* of the patient's i l l n e s s , and shame at having mental illness in the family are not as frequently encountered by the social worker, but are more serious indications of weakness in the family structure than the former two problems. Discomfort about committal, and concern about the symptoms of the patient's i l l n e s s are quite natural occurrences and a sign of family solidarity. The pat-ient i s i l l and his family i s concerned about him. However, discomfort about supposedly being the cause of the patient's mental breakdown, indicates self-depreciation on the part of the relatives or actual serious disharmony within the family. Eleven groups of relatives had such discomforts. Further, the caseworkers, working with the sample under study, helped eight families overcome their shame at having mentally i l l members. The preoccupation with "the disgrace" of having mental illne s s within the family i s again a sign of lack of strength within the family, as well as indicating an unhealthy attitude to the patient. The family, in cases l i k e this, i s apt to see the patient as someone harming them rather than seeing him as some-one in need of their continuing interest and assistance. It i s perhaps an indication of them losing sight of the patient as a person. In the group of services centred around the social problems i n the patient's home, the most important category was that of help with d i f f i c u l t i e s in family relationships. Over five-sixths of the families receiving direct social ser-vices were helped i n this manner. It indicates that the fami-l i e s receiving casework help frequently have considerable i n -ternal disharmony. The care of the children needed the social worker's attention in only ten cases of contact with relatives, while financial problems were of even less significance—be-cause of other sources of financial assistance, and because many patients are not the bread-winners of the families receiv-ing the services. In looking over the figures of Table 3, which l i s t s the direct social services to the relatives, the outstanding item appears to be the number of relatives receiving help to alleviate their personal anxieties. Besides the service of helping to lessen the fears the relatives have about the health and welfare of the patient, a most common service offered by the Social Service Department i s support to reduce personal fears and to reduce conflicts i n family relationships. As with the services to the patients, here again much of the social worker's job centres on the discomforts of the i n d i v i -dual in his adjustment with himself and with other people. Generally, the services to the patient and the ser-vices to the relatives of the patient are not much different, although the individualized problems are to a degree. For instance, the illness and the hospitalization of the patient does not mean the same thing to the patient as i t does to the rela-tive. The patient gets upset by the physical setting of the hospital, while the relatives get upset by speculations of the - 36 e f f e c t of the hospital s e t t i n g on the patient. Most of the services to the patients are aimed at helping them adjust to other people. For instance, planning f o r the s o c i a l and re-creational l i f e of the patient i s a numerically important d i r -ect s o c i a l service to patients at the C l i n i c . Most of the services to the r e l a t i v e s , on the other hand, are aimed at helping them understand and accept the patient. This, how-ever, frequently necessitates helping the r e l a t i v e s with t h e i r personal anxieties. By strengthening the ego of the family members, the patient's family can become a strong source of support to the patient. The high integration of services to patients and to t h e i r f a m i l i e s (54.3$ of the cases re c e i v i n g d i r e c t s o c i a l s e r v i c e s ) , and the s i m i l a r i t y i n frequency and kind of the services offered to the s i c k and t h e i r r e l a t i v e s i s i n d i c a t i v e of the generic nature of casework. The problems with which c l i e n t s come to s o c i a l work agencies have basic s i m i l a r i t i e s , no matter whether the c l i e n t i s a b l i n d man, a person recover-i n g from a mental breakdown, a husband whose wife i s mentally i l l , a delinquent boy, or an unmarried mother. I t i s also generic i n that the casework method i n toto i s applicable to a l l these people i n helping them overcome t h e i r d i f f i c u l t i e s i n l i v i n g with other people and with themselves. There i s s p e c i f i c knowledge relevant to the s e t t i n g which a caseworker employed i n a p s y c h i a t r i c hospital should have. He must be f a m i l i a r with a l l the aspects of the hos-p i t a l s e t t i n g — t h e treatment regime, the h o s p i t a l regulations, - 37 -etc. However, the over-all knowledge, the s k i l l s and tech-niques of forming a helpful client-worker relationship, and the diagnostic use of social resources remain the same i n a l l branches of social casework. "Support around personal anxie-t i e s , " "support in helping" people "understand and accept" other people, "help i n clarif y i n g conscious problems in interpersonal relationships," "support around problems in the home"—whether environmental or emotional—are familiar to a l l up-to-date public or private social work agencies. These ser-vices are not the sole property of the mental hospital social worker. As a matter of fact, many social workers who do not work in a mental hospital are also involved i n the other ser-vices more specifically aimed at the mental patient and his relatives. In British Columbia, social workers in the provin-c i a l Social Welfare Branch are often called upon to alleviate relatives' anxieties about the hospitalization of the patient, and to help the relatives understand and accept the patient as he i s . Also when, after assessment, the primary problems appear to be those with which other social agencies are parti-cularly equipped to deal through stated service p o l i c y — e.g. family services ancillary to those brought to patients and families by the social workers in a hospital setting-—the patients are referred to the other agency following discharge from the Cl i n i c . This agency continues giving the services which were initiated by the Social Service Department of the Clin i c . - 38 -Indirect Services Indirect services to patients and their relatives are a l l those services which are for the welfare of the pat-ient and his relatives, and consist of a diagnostic use of social resources within or outside the Cl i n i c . These services have been divided into three sections. I. Consultations with other professional people at the Clinic. Specifically, these consultations took place at ward rounds on which a member of each of the treatment profes-sions i s present; and individually with doctors, nurses, psy-chologists, the rehabilitation officer, and occupational and recreational therapists. II. Consultations with people outside the Cl i n i c . These consist of any form of communication between the Crease Clinic Social Service Department and casework agencies, group work agencies, employers, the National Employment Services, and boarding home operators with the purpose of helping the patient and his relatives. III. Diagnostic studies at intake. These studies are a collection of diagnostic facts about the patient's per-sonality development, and social and material environments. Of the f i r s t group of indirect services, the most frequent service of the social worker occurs at ward rounds. Generally, every patient i s discussed at ward rounds soon after his admission to the Cli n i c . It i s here that the treat-ment plans are usually started. Consequently, patients are often referred to the Social Service Department at this time. - 39 -Table 4. C l a s s i f i c a t i o n of Indirect_ S o c i a l Services to  64 Patients and t h e i r Relatives. Crease C l i n i c . ' Indirect S o c i a l Services to Patients and umber of t h e i r Families Dimes i service jiven I Consultation within the h o s p i t a l : (1) i n ward rounds 64 (2) with doctors 44 (3) with nurses 24 (4) with psychologists 6 (5) with the r e h a b i l i t a t i o n o f f i c e r 3 (6) with the occupational therapists 13 (7) with the recreational therapists 2 II Consultations with people outside the hospital: (1) with members of Casework agencies 18 (2) with members of group work agencies 1 (3) with employers 4 (4) with the National Employment Service 4 (5) with boarding home operators 1 H I Diagnostic studies at intake 30 Total i n d i r e c t services to patients and t h e i r f a m i l i e s 214 - 40 -Consultations with the doctors are another frequent and important service. These consultations between the doctor and the s o c i a l worker keep each informed about the other's ten-t a t i v e diagnoses (medical and s o c i a l respectively) of the pat-i e n t , and about the needs of the patient and the needs of h i s r e l a t i v e s . They co-ordinate t h e i r treatment plans so that t h e i r work i s purposeful and constructive rather than at cross-purposes. Of a l l the patients comprising the sample under study, 44 were discussed i n such consultations. Of these 44, nine patients and t h e i r r e l a t i v e s received no further services from the S o c i a l Service Department while the patient was i n the C l i n i c , e i t h e r because i t was decided that the patient was too i l l to benefit from casework help or because the patient had l e f t the C l i n i c before the s o c i a l worker was able to see him. The r e l a t i v e s of these people received no services f o r reasons not stated. Not quite as frequent as consultations with the phy-si c i a n s were consultations with nurses. Twenty-four of the patients were discussed with the nursing s t a f f . From these consultations, the s o c i a l worker and the nurse were able to get a better understanding of the patient, and thereby were able to be of greater help to him. The consultations were p a r t i c u l a r l y useful to the s o c i a l worker, f o r the nurse has the opportunity to observe and t a l k to the patient each day. Consultations with the r e h a b i l i t a t i o n o f f i c e r , the occupational therapists, the recreational therapists, and - 41 the psychologists are not very frequent. The occupational therapists were consulted concerning thirteen of the pat-ients while the recreational therapists were seen only with regard to two of the patients. The purpose of these contacts i s to plan ways of introducing and getting the patient interested in occupational and recreational therapy, and to get informa-tion on how the patient i s making use of these resources. The rehabilitation officer (there i s only one at present) was con-sulted about three of the patients. His job consists of help-ing male patients who are referred to him to find employment upon discharge from the C l i n i c . The psychologists conferred with the social worker about six patients. As a result of these consultations, both the social worker and the psycho-logist get a better understanding of the emotional d i f f i c u l t i e s of the patient. The second group of indirect services—consultations with people outside the C l i n i c — i s a more occasional service than the consultations with members of the Clinic staff. Act-ually, such consultations—by letter, telephone, or face-to-face—often occur after the patient has been discharged, but, i n such cases, have not been included in the present study. Eighteen of the patients were discussed with other social casework agencies in order to improve services to the patient and his family. Employers were contacted with reference to four patients seeking employment. Pour other patients were discussed with the National Employment Services for the same reason. Only one patient was discussed with a group work agency. Another patient found accommodations to l i v e i n , a f t e r the s o c i a l worker had helped him by contacting boarding home operators. A l l these i n d i r e c t s o c i a l services to patients and r e l a t i v e s point out the important l i a i s o n p o s i t i o n that the s o c i a l worker holds within the mental h o s p i t a l . He plans with the other h o s p i t a l s t a f f and with outside s o c i a l resources f o r the treatment and eventual r e h a b i l i t a t i o n of the patient. Through c a r e f u l l y arranged plans he can bridge the gap between the l i f e at the hos p i t a l and at home f o r the patient. Without the i n d i r e c t s o c i a l services, some patients would leave the C l i n i c not knowing where to eat or sleep. Others would not seek the services of another s o c i a l agency, whereby they are able to f i n d help i n obtaining the necessities of l i f e , and help i n a l l e v i a t i n g the stresses which could drive them to mental i l l n e s s again. The i n d i r e c t s o c i a l services also show the impor-tance of teamwork, not only between members of the hos p i t a l s t a f f , but between the hos p i t a l s t a f f and the s o c i a l resources i n the community i n which the patient and h i s family are l i v i n g . The f i e l d s o c i a l worker of the S o c i a l Welfare Branch must be kept informed on the progress of the patient at the C l i n i c , i f he i s expected to be of help to the patient and to the family i n the home community. S i m i l a r l y , the d i s t r i c t o f f i c e worker should keep the s o c i a l worker at the C l i n i c informed about de-velopments at home so that the l a t t e r can r e a l i s t i c a l l y re-assure and plan with the patient. ., CHAPTER 3 PATIENTS WHO COME TO THE CREASE CLINIC C l a s s i f i c a t i o n of the Patients Because the purpose of the present study i s a sur-vey of s o c i a l and not medical services, the o r i g i n a l plan, to c l a s s i f y patients according to medical diagnosis, was abandoned.' A compromise had to be made, however, to take advantage of the opportunity f o r c r o s s - c l a s s i f y i n g patients against the s o c i a l services received. An attempt was made to formulate a c l a s s i f i c a t i o n based s o l e l y on s o c i a l work diag-noses, and t h i s had to be abandoned fo r the following reason. In the f i r s t place, a l l the patients selected f o r the present study about whom there was s u f f i c i e n t information a v a i l a b l e , seem to f a l l into one broad category—that of "emotional inadequacy." Relatives are apt at f i r s t to des-cribe the patient as "the l a s t person" they would have be-lie v e d to become mentally i l l . Later, however, they w i l l often see the patient as a person who has always attempted to be s e l f - s u f f i c i e n t , "keeping h i s problems to h i m s e l f " — i n other words, being unable to form close interpersonal r e l a t i o n -ships. Or, they w i l l describe the patient as a man who has always been "happy," but who, on closer inspection, has always - 44 -been driven to be l i k e d by other people because he f e l t i n -secure i n hi s s o c i a l r e l a t i o n s h i p s . Other patients are described by th e i r r e l a t i v e s , "now that we think of i t , " as always having had an " i n f e r i o r i t y complex," being withdrawn, etc. Of course, whether such emotional inadequacy i s charac-t e r i s t i c of the mental patient alone i s doubtful; some form of emotional inadequacy i s evident i n every man's l i f e because emotional maturity i s a matter of degree. Because of t h i s and because of the f a c t that a l l patients seem to f a l l into the "emotionally inadequate" group, the necessity a r i s e s to break down "emotional inadequacy" into smaller components i f i t i s to he used f o r c l a s s i f i c a t o r y purposes. Unfortunately, mea-surement and analysis of the term "emotional inadequacy" tends to be s u p e r f i c i a l , unless done very c a r e f u l l y . 1 The d i f f i c u l t y l i e s i n t r y i n g to determine cause and e f f e c t . Each i n d i v i d u a l case has to be evaluated separately, and precise eva-lu a t i o n necessitates adequate information. Eventually, two c r i t e r i a f o r c l a s s i f i c a t i o n were devised. The f i r s t c r i t e r i o n was that s i m p l i c i t y and accuracy should be sought as f a r as possible. The second c r i t e r i o n demanded that the c l a s s i f i c a t i o n should possibly have some r e -lati o n s h i p to the services extended by the S o c i a l Service De-partment at the Crease C l i n i c . The people comprising the group under study were c l a s s i f i e d i n the following ways: according 1 Louis J . Lehrman, "Logic of Diagnosis," S o c i a l  Casework. May 1954, pp. 192-199. - 45 -to age, sex and marital status; the length of h o s p i t a l i z a -tion; and the condition upon discharge. Of these, sex and age differences had the most obvious c o r r e l a t i o n with the so-c i a l services extended, and have therefore been used i n cross-c l a s s i f y i n g the services. Also used f o r c r o s s - c l a s s i f i c a t i o n with the services, was the condition of the patients upon d i s -charge, as t h i s comes closest to i n d i c a t i n g the "finished pro-duct" of the work of the s t a f f at the C l i n i c . Who Are the Patients? The group under study consists of 25 men and 39 women—figures that proved to be on the whole proportionate to the admission figures for the period from which the sample was selected (237 men and 399 women). The Crease C l i n i c has always had more female patients than male, while the Provin-c i a l Mental Hospital has consistently had more men than women.1 Whether female mental patients have a better prog-nosis f o r improvement than male patients, and thereby are admitted to the Crease C l i n i c more frequently, i s not known. There i s the p o s s i b i l i t y that women seek p s y c h i a t r i c help ear-l i e r i n th e i r i l l n e s s than men. I t seems to be c u l t u r a l l y un-masculine to go to the doctor with minor troubles, and wives probably have greater d i f f i c u l t y persuading t h e i r husbands to see the doctor than vice versa; possibly, also, the bread-winner needs to carry on longer before r e s o r t i n g to medical ai d and h o s p i t a l i z a t i o n . However, the duration of the i l l -ness has frequently a decisive influence on the prognosis. 1 B r i t i s h Columbia, Annual Report of the Mental  Health Services. 1953. - 46 -The sooner the patient undergoes treatment, the f a s t e r and more e f f e c t i v e h i s recovery. 1 One patient, f o r instance, a man of about 50, who was admitted to the Crease C l i n i c i n 1953, has had bizarre suspicions since 1936. This was the f i r s t time he had come under treatment, though f o r years he had been prowling around his estate with a shot-gun to defend himself from unknown people. Afte r a b r i e f period at the Crease C l i -n i c , he was transferred to the P r o v i n c i a l Mental Hospital because h i s prognosis was poor. The age grouping of the patients comprising the sample i s also i n t e r e s t i n g . Over two-thirds of the group are between the ages of 25 and 45. Approximately 60$ of the pat-ients are over the age of 35 and only seven are under the age of 25. However, despite the high proportion of older people i n the sample, only fourteen had been previously h o s p i t a l i z e d i n a mental i n s t i t u t i o n . Of these, sevejfa were over the age of 50, which constitutes over 50% of the patients within that age group|. s i x were between the ages of 30 and 50; and one was fourteen years old. The marital status of the group i s as follows: 37 are married, 20 are s i n g l e , 3 are widowed, 3 are divorced, and one i s separated. Of the 20 patients who are s i n g l e , one-half are over t h i r t y years old, of whom seven are male. Whether these people are single because t h e i r emotional i n s t a b i l i t y makes them undesirable partners, or because of t h e i r i n a b i l i t y 1 William S. Sadler, Modem Psychiatry. C.V. Mosby Co., St. Louis, 1945, p. 475. Fig. 1 Age Distribution of a Group of 64 Patients at the Crease Cli n i c , 1953. (follows page 46) 46a NUMBER OF PATIENTS ioTou, isrozfl 30T03I, j5Toy) 1,010^  Iprolfi 5010^ oven. AGE 5 5 Fig. 1. Age Distribution of a Group of 64 Patients at the Crease Clinic, 1953. : — - 47 -to form close personal relationships i s uncertain, but the case h i s t o r i e s give frequent evidence of such factors. In any case, out of 59 people over the age of 20, f i f t e e n are and always have been unattached—a seemingly high percentage (25#). Detailed information was avai l a b l e on over half the married people i n the sample. Over 50% of these had ser-ious marital d i f f i c u l t i e s . Here again i t was not always c l e a r whether the d i f f i c u l t i e s arose due to the developing mental i l l n e s s of the patient or whether the d i f f i c u l t i e s had existed since the beginning of the marriage. However, the greatest num-ber of marital d i f f i c u l t i e s centered on either symptoms of men-t a l i l l n e s s such as accusations by the patient that h i s marital partner i s u n f a i t h f u l , or on fundamental problems of dependency and submissiveness. The former i s a stage i n the developing mental i l l n e s s , while the l a t t e r i s probably one of the s t r e s -ses that forces the patient to seek refuge i n mental i l l n e s s . Where marital d i f f i c u l t i e s seemed to be a contributing f a c t o r to mental i l l n e s s , the s o c i a l h i s t o r i e s show evidence of more basic d i f f i c u l t i e s i n the patient's e a r l i e r l i f e . A case i n point i s that of a 40 year o l d married woman who was admitted to the Crease C l i n i c when she was two months pregnant. She was one of sixteen children of an Italian-Indian marriage. She has always f e l t that everyone looked down upon her and has had very strong fee l i n g s of i n f e r i o r i t y . During her marriage she had a number of promiscuous re l a t i o n s h i p s , but eventually one of tbe men she met, f e l l i n love with her. She and t h i s man - 48 -decided that she should remain with her husband f o r s i x months, a f t e r which she would make a decision as to her future. At the end of the s i x months, instead of making a decision, she became mentally i l l . To decide between the two men was too great a s t r a i n f o r her. The group of divorced people consists of three f e -male patients, a l l over the age of 35. One patient, a male was separated from h i s wife s h o r t l y before he was admitted to the C l i n i c . The two widows and the one widower of the sample are over the age of 45. The widower was admitted be-cause of hallucinations due to alcoholism, while the two widows were admitted i n an emotionally depressed state. The condition of the patients upon discharge i s of i n t e r e s t . According to the physicians' assessment, two of the patients had recovered, 51 had improved, 8 were unimproved, and three were u n c l a s s i f i e d at the time of discharge from the C l i n i c . The category "improved" seems to consist of patients whose condition has improved, but who s t i l l manifest a varying degree of symptoms of t h e i r i l l n e s s . 1 As opposed to the re-covered patients, who appeared to show no symptoms of t h e i r past i l l n e s s upon discharge (the manic-depressive patients and the a l c o h o l i c s with psychosis are often c l a s s i f i e d i n t h i s category ), the improved patient may s t i l l be s e r i o u s l y d i s -1 The c l i n i c a l f i l e s of the patients indicate t h i s . 2 Lawson G. Lowrey, Psychiatry f o r S o c i a l Workers, Columbia University Press, New York, 1946, p. 168. ~~ 49 turbed upon discharge, and may have to be re-admitted to the hospital soon a f t e r h i s return to h i s home.1 Patients s u f f e r -i n g from schizophrenia frequently seem to f a l l i n t o t h i s group or the "unimproved" group, as do many of the patients s u f f e r -ing from a serious psychoneurosis. Out of the 8 unimproved patients, s i x were schizophrenic and two were classed as psy-choneurotic (three were si n g l e and f i v e were married). The "unimproved" patients would appear to be those patients whose condition upon discharge remains unimproved from a psychiatric point of view. Lack of improvement medically does not always predicate no "improvement" i n the s o c i a l and environmental s i t u a t i o n of the patient. Generally, an improve-ment i n the psychiatric condition of the patient w i l l also be noted by the s o c i a l worker. On the other hand, there are im-provements i n the patient's economic or s o c i a l s i t u a t i o n whereby the patient i s able to return to his home—unimproved from a psy c h i a t r i c view point. An i l l u s t r a t i o n emphasizing t h i s i s i s the following: A 34 year old single man, with simple schizo-phrenia, was referred to the So c i a l Service Depart-ment f o r supportive help to a l l e v i a t e personal anx-i e t i e s and f o r help with discharge planning. His response to medical treatment was unsatisfactory. I t d i d not lead to any tangible r e s u l t s , probably because of the long-term nature of the i l l n e s s . The s o c i a l worker, r e a l i z i n g that the patient was unable to mobilize h i s own resources and to take an active part i n planning f o r h i s discharge beyond a li m i t e d point, requested the r e l a t i v e s to assume f i n a n c i a l r e s p o n s i b i l i t y , and then approached a family f r i e n d x Between A p r i l 1st, 1953 and March 31st, 1954, 810 patients were referred f o r convalescence services from the soc-i a l worker, according to the Annual Report of the S o c i a l Service Department. 2 Lawsoh G. Lowrey, op. c i t . , p. 194. - 50 -to assume supervisory r e s p o n s i b i l i t y over the pat-i e n t . Accommodation arrangements were made p r i o r to the patient's discharge. The patient i s now l i v i n g by himself and making good use of his l i m i t e d resources. He has money, i s able to budget, and l i v e s on a subsistence l e v e l without harming himself or other people. He as-sumes considerable r e s p o n s i b i l i t y f o r himself; and within h i s l i m i t a t i o n s , he functions to the maximum of h i s capacity, and leads a quiet and seclusive l i f e . P r i o r to h i s h o s p i t a l i z a t i o n , he was unable to look a f t e r himself. He remains a person who w i l l always be i n need of f i n a n c i a l assistance because of h i s i l l n e s s , but i t i s e s s e n t i a l that he be per-mitted to l i v e on his own i n the community i f he i s at a l l able to. The s o c i a l worker was able to help him lead a personally s a t i s f y i n g l i f e outside the h o s p i t a l despite the handicap of mental i l l n e s s . Fortunately, most of the patients leave the C l i n i c i n much better condition than the above patient. The length of h o s p i t a l i z a t i o n varies from i n d i v i d u a l to i n d i v i d u a l , but the average term of hospital confinement at the C l i n i c i s two months. The degree of improvement i s re l a t e d to the length of h o s p i t a l i z a t i o n only when the i l l n e s s of the patient i s taken into consideration, too. The length of h o s p i t a l i z a t i o n by i t -s e l f does not ensure recovery. In some cases—such as the manic-depressive patients—improvement i s usually speedy, and often a complete recovery i s achieved. 1 In other cases—with schizo-phrenic and some psychoneurotic patients—improvement i s often o slow and at times never comes at a l l . Residuals of the i l l -ness frequently remain i n the form of over-anxiety, an i n -appropriate tendency to become suspicious, i n a b i l i t y to hold a job, i n a b i l i t y to mix with people, etc. Lawson, G. Lowrey, op. c i t . , p. 168 2 I b i d . , p. 194. - 5 1 -Out of the eight patients unimproved on discharge from the C l i n i c (see Table 5), three stayed at the C l i n i c f o r four months or more. The three who remained at the C l i n i c f o r less than three months were admitted on a "voluntary" basis, which e n t i t l e d them to have themselves discharged from the C l i n -i c upon t h e i r own request. They l e f t the C l i n i c against the advice of the physicians. The two who remained from three to four months were discharged to the P r o v i n c i a l Mental Hospital because i t was obvious that they were i n need of a long period of h o s p i t a l i z a t i o n . Table 5. Length of Ho s p i t a l i z a t i o n of 64 Patients  According to Condition on Discharge from  Crease C l i n i c . 1953. "~ Condition of Period of stay Total patient on discharge 1 month or less 1 to 2 months 2 to 3 months 3 to 4 months over 4 months number of patients Recovered 1 1 - mm - 2 Improved 3 23 11 8 6 51 Unimproved 1 1 1 2 3 8 U n c l a s s i f i e d 1 - 2 - 1 - 3 Total 5 27 12 11 9 2 64 Patients u n c l a s s i f i e d as to condition upon d i s -charge would appear to be those who were at the C l i n i c f o r ob-servation only. o Seven of these patients were ho s p i t a l i z e d f o r four months and a few days. - 52 -Of int e r e s t i s the great number of patients d i s -charged from the C l i n i c within the f i r s t two months of t h e i r h o s p i t a l i z a t i o n . Half the patients i n the sample f a l l within t h i s group. Hany people would believe that t h i s i s an admir-able achievement, and there i s no doubt that i t i s , were i t not f o r a l i m i t a t i o n which i s beyond the control of the C l i n i c . The scanty few weeks at the hos p i t a l do l i t t l e apart from helping the patient to return to r e a l i t y from h i s delu-sions, psychosomatic ailments, etc. Psychotherapy and long-term casework services are s t i l l very l i m i t e d because of medi-c a l and s o c i a l service s t a f f shortages making such time-consuming help frequently impossible. Physical medication s t i l l remains one of the main weapons of attack on mental i l l n e s s within the C l i n i c . Early discharge to the home, there-fore, necessitates continuation of treatment i n out-patients 1 c l i n i c s , and no such c l i n i c has yet been established i n B r i t i s h Columbia. At present, the discharged patient has the So c i a l Service Department of the Crease C l i n i c and the p r o v i n c i a l S o c i a l Welfare Branch as resources; i f these do not s u f f i c e , the patient has no alternative but to return to h o s p i t a l , whereas an out-patients' c l i n i c could help him to hold on to the gains he made at the h o s p i t a l , and thereby prevent further h o s p i t a l i z a t i o n . In summary, the group of patients under study com-prises more females than males. A rather high percentage of the patients are s i n g l e , and i n the older age groups there are more single men than women. The ages of the people i n the - 53 -group run from 14 to 67, but two-thirds of the patients are between 25 and 45 years of age. Almost a l l the patients are discharged i n an improved condition a f t e r an average stay of approximately two months. Most of them leave the C l i n i c with some residuals of the i l l n e s s remaining with them. While the patient i s s t i l l i n h o s p i t a l , i t i s part of the s o c i a l worker's job to prepare the patient and his r e l a t i v e s f o r such l i m i t a -tions; he can also help them to learn to accept these without bitterness, so that they can lead as s a t i s f y i n g a l i f e as pos-s i b l e upon the discharge of the patient. D i f f e r e n t i a l D i s t r i b u t i o n of Services The second chapter examined the d i s t r i b u t i o n of soc-i a l services amongst the t o t a l patient group under study. I t was noted that although a l l the patients received s o c i a l ser-vices, some received a very l i m i t e d number; other patients were served extensively by the S o c i a l Service Department. A l l the patients received the service of diagnostic planning at ward rounds. However, 29 of the 64 patients got no further service while they were at the C l i n i c , except f o r further consulta-tions with the patient's physician ( i n nine cases). Who are the people who received further casework help, and who are the people who did not? Table 6 shows the d i s t r i b u t i o n of dire c t s o c i a l services to patients according to age and sex. The table indicates that whereas approxi-mately 29$ of the women over 35 years of age received d i r e c t services, 80% of the women tinder 35 years of age were r e c i p -ients of d i r e c t s o c i a l services, too. S i m i l a r l y , of the men - 54 -over 35 years of age, only 1% received d i r e c t s o c i a l services, while f o r the group of men under 35 years of age the figure rose to 45$. In other words, i n the sample under study, d i r e c t services to patients are more frequently offered to women than men, and to young women than older women. Table 6. Direct S o c i a l Services to 64 Patients According  to Age and Sex, Crease C l i n i c . 1953. Sex under 35 years of age over 35 years of age without services with services without services with services Total Male 6 5 13 1 25 Female 3 12 17 7 39 Total 9 17 30 8 64 Are age and sex then factors i n the sele c t i o n of pat-ient s f o r casework help? While age i s probably one of the many factors taken into consideration by the S o c i a l Service Depart-ment i n the sele c t i o n of patients f o r casework help, sex i s undoubtedly not such a fac t o r . Age i s taken in t o consideration to the extent that the older the person, the more "set" he i s i n his f e e l i n g , thinking and behaviour patterns. Consequently, he has greater d i f f i c u l t i e s i n adjusting himself to the environ-ment. His i l l n e s s , as the s o c i a l h i s t o r i e s i n dicate, i s of - 55 -longer duration, and thereby l e s s amenable to treatment. Table 7. S o c i a l Services to 64 Patients According to  Age and Sex. Crease C l i n i c . 1953. Soci a l Services under 35 years of age over o: 35 years f age Total male female male female Direct Services to Patients only 3 1 1 1 6 Direct Services to Relatives only 1 2 3 4 10 Direct Services to Patients and Relatives 2 11 6 19 Indirect Ser-vices only 5 1 10 13 29 Total 11 19 14 24 64 In practice, t h i s i s borne out by the number of older patients being served through t h e i r r e l a t i v e s . Table 7 indicates the integration of s o c i a l services to patients and t h e i r f a milies according to sex and age. I t shows a higher proportion of patients over the age of 35 years than under the age of 35 years receiving help not through d i r e c t s o c i a l services to themselves, but through dir e c t s o c i a l services to Because the length of the i l l n e s s i s r e l a t e d to the prognosis, long-term psychotics are thought not to be suitable f o r admission to the C l i n i c as they are l i k e l y to need long-term h o s p i t a l i z a t i o n . - 56 -th e i r f a m i l i e s . This indicates that with older patients there i s a greater emphasis on helping the s o c i a l environment adjust to the patient than vice versa. Despite t h i s emphasis on help-i n g r e l a t i v e s adjust to the older patients, more r e l a t i v e s of younger patients get di r e c t s o c i a l services. These services to r e l a t i v e s of younger patients are also more frequently integrated with the d i r e c t s o c i a l services to the patient. Integration of so c i a l services i s p a r t i c u l a r l y frequent amongst female patients under the age of 35. Out of 15 women under the age of 35, ele-ven received s o c i a l services f o r themselves, as well as receiv-i n g further service through casework help to t h e i r f a m i l i e s . The frequent integration of services to female patients and t h e i r f a m i l i e s suggests one of the reasons f o r the greater f r e -quency of s o c i a l work help to female patients than to male pat-i e n t s . The u n f u l f i l l e d r e s p o n s i b i l i t i e s of looking a f t e r the children and the home during the absence of the mother, raises d i f f i c u l t i e s f o r the family, and i s a source of anxiety to the mother. Of the ten married women rece i v i n g d i r e c t s o c i a l ser-vices, nine discussed t h e i r anxieties about the care of t h e i r children with the s o c i a l service worker. In addition, the families of these nine women also received d i r e c t s o c i a l ser-vices. This indicates that need as well as a b i l i t y to pros-per through casework help i s the basis on which patients are selected f o r s o c i a l services. The family i n which the mother i s absent through i l l n e s s frequently presents a more extensive need f o r services than other s i t u a t i o n s . - 57 -Table 8. S o c i a l Services to 64 Patients According to  Their M a r i t a l Status, Crease C l i n i c . 1953. S o c i a l Services Single Patients Married Patients Divorced or Separated Patients Widowed Patients Total Direct Services to Patients only 3 2 1 6 Direct Services to Relatives only 2 8 10 Direct Services to Patients & Relatives 7 9 1 2 19 Indirect Ser-vices only 8 18 2 1 29 Total 20 37 4 3 64 There seems to be no other s i g n i f i c a n t association between the marital status of the patients and the s o c i a l ser-vices (Table 8). Three out of every f i v e s i n g l e patients or t h e i r r e l a t i v e s received casework help. The married patients were helped i n just over half the cases, while two-thirds of the widowed and one-half of the separated or divorced patients were also served. Direct services to r e l a t i v e s only, were extended more frequently to the families of married patients, i n d i c a t i n g that casework help to t h i s group of patients i s le s s frequently integrated perhaps because of the i l l n e s s of the patient, than f o r the other groups. This i s further borne out by the fact that single patients received d i r e c t services more often (50$) - 58 -than married patients (30%). More frequent d i r e c t services to single people may be owing to the lack of support from a family r e l a t i o n s h i p . There also appears to be ho s i g n i f i c a n t c o r r e l a t i o n between s o c i a l services and the length of h o s p i t a l i z a t i o n of the patients (Table 9). The persons staying f o r more than four months and t h e i r r e l a t i v e s , were extended s o c i a l services most frequently (6fi$ of those staying over four months). Patients remaining within the C l i n i c f o r less than four months received casework help or were extended s o c i a l services through t h e i r f a m i l i e s i n approximately half the cases. Direct services to the patients, therefore, show an inconsistent increase with an increase i n the length of h o s p i t a l i z a t i o n of the patient. Table 9. S o c i a l Services to 64 Patients According to the Length of H o s p i t a l i z a t i o n . Crease C l i n i c . 1953T Soc i a l Services Period of Stay T o t a l 1 month or l e s s 1 to 2 months 2 to 3 months 3 to 4 months over 4 months 1 u lax Direct Services to Patients only 3 1 1 1 6 Direct Services to Relatives only 1 6 1 1 1 10 Direct Services to Patients & Relatives 2 5 5 3 4 19 Indirect Ser-vices only 3 13 5 5 3 29 Total 6 27 12 10 9 69 - 59 -Services according to the condition of the patient upon discharge (a p s y c h i a t r i c assessment) again showed no cor-r e l a t i o n (Table 10). Over half of the improved, unimproved and u n c l a s s i f i e d patients or t h e i r f a m i l i e s received casework help. The recovered patients were helped only i n h a l f the cases, but the figure f o r these i s f a r too small to draw any conclusions from. Table 10 also indicates that the "unimproved 0 Table 10. S o c i a l Services to 64 Patients According to Their Condition upon Dishcarge. Crease C l i n i c . 1953. ~ S o c i a l Services Recovered Improved Unimproved U n c l a s s i f i e d Total Direct Services to Patients only 4 1 1 6 Direct Services to Relatives only 1 7 2 10 Direct Services to Patients & Relatives 16 2 1 19 Indirect Ser-vices only 1 24 3 1 29 Total 2 51 8 3 64 patients are served as frequently as other patients. The unim-proved patient has few strengths within himself, and the s o c i a l worker seeks to f i n d f o r him further strengths i n the s o c i a l environment. Because of t h i s , a higher percentage of unimproved patients' r e l a t i v e s received d i r e c t s o c i a l services than the r e l a t i v e s of the improved. - 60 -Summary An examination of the sample under study revealed that a higher percentage of female patients than male are served by the Social Service Department. It also showed that younger people (under 35 years of age) are more frequently recipients of casework help than older people (over 35 years of age). An examination of social services according to the marital status of the patients, the length of hospitalization, and the condition of the patient upon discharge from the C l i n i c , (psychiatric assessment) proved that these factors have l i t t l e visible correlation to the giving of social services to pat-ients and their families. C H A P T E R 4 SUMMARY AMD IMPLICATIONS Summary and Assessment At tbe beginning of t h i s study, tbe r e s p o n s i b i l i t i e s of the s o c i a l caseworker i n a mental ho s p i t a l were outlined. They can involve him at every phase of the patients' and t h e i r f a m i l i e s ' s o c i a l needs. The techniques of helping people with t h e i r d i f f i c u l t i e s i n s o c i a l r elationships were described by o u t l i n i n g four d i f f e r e n t ways of giving help: supportive and sustaining help emanating from the casework r e l a t i o n s h i p , c l a r i f i c a t i o n of conscious problems, information-type of help, and environmental help. A l l these techniques of giving help are aimed at helping the c l i e n t help himself. To achieve the purpose of t h i s s t u d y — t h e analysis of s o c i a l services to mental p a t i e n t s - - i t was necessary to define the s p e c i f i c services of s o c i a l workers to patients and t h e i r r e l a t i v e s . In other words, the f i r s t task was to f i n d out what the s o c i a l worker does. Only then could a quan-t i t a t i v e statement be made as to casework help i n a mental ho s p i t a l . Since there was apparently no previous c l a s s i f i c a -t i o n of s o c i a l casework as practiced with the mentally i l l , a special c l a s s i f i c a t i o n was devised f o r the present study. This - 62 -was done by v i s u a l i z i n g the needs of the patient and h i s family as he moves through h i s period of h o s p i t a l i z a t i o n — from admission to discharge. To avoid the confusion of a long l i s t of unrelated matters, the services were grouped i n the following manners (1) d i r e c t services to patients; (2) d i r e c t services to patients' r e l a t i v e s ; and (3) i n d i r e c t services to patients and t h e i r r e l a t i v e s . Direct services to patients were defined as a l l those services which were given through the s o c i a l worker-patient interviews. Direct ser-vices to patients' r e l a t i v e s included a l l the services which were obtained by the r e l a t i v e s of the patients through case-work interviews. Indirect services were defined as those services which were f o r the welfare of the patient or h i s family, and consisted of the therapeutic use of s o c i a l r e -sources. The patients studied were 64 people who were ad-mitted to the Crease C l i n i c between A p r i l 1st, 1953, and September 30, 1953. They were selected by a routine sampling procedure. The d i s t r i b u t i o n of services among the people com-p r i s i n g the sample was shown to vary considerably from person to person. A l l of the patients received some form of i n d i r e c t service. However, only 25 of the 64 patients received d i r e c t services, while services to r e l a t i v e s were not much more f r e -quent. The present administrator of the S o c i a l Service Depart-ment stated that a l l the patients at the C l i n i c and t h e i r - 63 -r e l a t i v e s could benefit from casework help. However, because coverage of a l l patients by the S o c i a l Service Department was attempted at one time and was found to be an unworkable s i t u a t i o n f o r professional casework practice, the p o l i c y of selection was adopted. The s i t u a t i o n was unworkable because, as was seen i n Chapter 2, the tasks of the s o c i a l worker have increased considerably i n the past years with the accumulation of knowledge and techniques. The abstract aspects of his work-many of the services that emanate from the c l i e n t - s o c i a l worker r e l a t i o n s h i p — a r e demanding an increasing amount of the s o c i a l worker's time. Naturally, with t h i s increase, the s o c i a l worker can no longer carry as large a case-load as he used to, i f he i s to give the quality of service he i s q u a l i f i e d to give. I t i s l a r g e l y through a r e a l i z a t i o n of t h i s that there i s a c o n t i -nual demand by most s o c i a l service agencies f o r more s o c i a l caseworkers. With large case-loads, s o c i a l workers f i n d i t impossible to give t h e i r c l i e n t s more than sustaining help, which preserves the status quo but does no more f o r most c l i e n t s . They have the opportunity of helping only a few selected people regain the strength and s o c i a l resources needed fo r a better s o c i a l and personal adjustment. In the long view, therefore, the condition of too few caseworkers perpetuates the large case-loads. On the other hand, with enough caseworkers, case-loads w i l l be small from the beginning, and W i l l remain so, because people w i l l be helped to stand on t h e i r feet rather than be supported i n d e f i n i t e l y by one or another s o c i a l agency— - 64 -as i s so often the case today. The eventual emotional and f i n a n c i a l savings would, i t i s claimed by some a u t h o r i t i e s , outweigh many times the cost of the additional s a l a r i e s i n -curred. 1 However, u n t i l such time when there are s u f f i c i e n t caseworkers available to help a l l people with c r i t i c a l l y un-s a t i s f i e d s o c i a l and emotional needs, the p o l i c y of s e l e c t i o n seems to be the only p r a c t i c a l s o l u t i o n . Though administratively expedient, the p o l i c y of s e l e c t i o n r a i s e s a moral question f o r society, i f i t should become a permanent measure rather than a temporary p r i o r i t y system f o r the a l l o c a t i o n of scarce resources. Selection re-s u l t s i n an a r b i t r a r y system of granting s o c i a l services to i n d i v i d u a l patients, despite the p r i o r i t i e s given to those who can p r o f i t most from the services. Obviously, the 39 pat-ients not r e c e i v i n g d i r e c t s o c i a l services have also unmet s o c i a l needs. They have, e t h i c a l l y , the same r i g h t to these public services as the 24 patients receiving casework help. Equal opportunities—whether to education or to mental h e a l t h — f o r every Man i s the basis of democracy. At present, elemen-tary education i s offered to everyone who i s capable of learn-ing; however, s o c i a l services at the Crease C l i n i c are not made available to everyone who i s i n need of them and capable of using them. S o c i a l Services are Personal The study also confirmed that s o c i a l work i s no lon-ger a profession concerned primarily with giving f i n a n c i a l and 1 Stuart X. J a f f a r y , "Probation of the Adult Offen-der," The Canadian Bar Association. November 1949, pp. 1020-1040. - 65 -material a i d to people which i s so often the concept layment have of the profession. There i s , i n f a c t , s u r p r i s i n g l y l i t t l e done by the Crease C l i n i c s o c i a l worker i n r e l i e v i n g material needs. The main reason f o r t h i s seems to l i e i n the other r e-sources available to the patient and his family i n t h e i r home community. Employers provide sickness benefits, and public agencies provide f i n a n c i a l a i d . Furthermore, the patient's h o s p i t a l i z a t i o n at the C l i n i c i s frequently not so long as to cause f i n a n c i a l embarrassment, loss of employment, and d i f f i -c u l t i e s i n f i n d i n g l i v i n g accommodations. Of numerically greater importance i s the existence of the s o c i a l and psycho-l o g i c a l needs of the patient and his family which have been de-scribed i n t h i s study. Therefore, instead of being aimed at material needs, most of the services of the s o c i a l caseworker at the Crease C l i n i c are directed towards helping the patient and h i s family make adjustments i n t h e i r relationships with other people i n the s o c i a l environment. Other numerically important services of the s o c i a l caseworker were the services r e l a t e d to the hospi-t a l i z a t i o n of the patient. P a r t i c u l a r l y frequent was case-work help with anxieties of the patient and of his r e l a t i v e s about the medical treatment. Although the i n d i v i d u a l i z e d problems of the two groups were shown to be somewhat d i f f e r e n t , the services to patients and r e l a t i v e s were found to be s i m i l a r . The problems were d i f -ferent i n that they were experienced by d i f f e r e n t people—by the sick person and by his r e l a t i v e s . The s i m i l a r i t i e s of the - 66 -services to the two groups exemplified the generic founda-tions of s o c i a l work. In addition, i t was pointed out that casework services i n a mental hospital are not s i g n i f i c a n t l y d i f f e r e n t from the services of other casework agencies. These s i m i l a r i t i e s i n services should, however, not be taken as meaning "the same se r v i c e s . " The services d i f f e r i n quality and i n t e n s i t y from person to person and are not an "image" of each other. The personal quality of the casework r e l a t i o n s h i p accompanies each service, which i s given i n a way that w i l l f i t the i n d i v i d u a l c l i e n t . The i n d i r e c t services to patients and t h e i r r e l a t i v e s indicated the integrative p o s i t i o n which the s o c i a l caseworker holds between the mental hospital and the home community of the patient. Through the therapeutic use of s o c i a l resources, he brings to the aid of the patient and h i s family resources aimed at the treatment and r e h a b i l i t a t i o n of the patient, as well as the resources aimed at helping the patient to remain mentally healthy. The analysis of i n d i r e c t services also showed the extent of teamwork within the C l i n i c . There were numerous i n t e r - d i s c i p l i n e contacts to achieve purposeful treatment of the mentally i l l . "The quality of treatment afforded to the patient" i s known to be "wholly dependent on how ably the var-ious professions can work together. A b i l i t y to work together involves some knowledge and respect f o r other professional s k i l l s , an understanding of human behaviour, and an a b i l i t y - 67 -to work i n t e g r a t i v e l y . The r e l a t i o n s h i p of the various pro-fessions must be constantly evaluated and purposively developed i f treatment i s to be adequate.* 1 Goals f o r the Future At present, the S o c i a l Service Department of the Crease C l i n i c i s faced by a number of d i f f i c u l t i e s . These can be divided into two groups: those caused by i n s u f f i c i e n t s t a f f , and those caused by lack of community resources. The f i r s t , those caused by i n s u f f i c i e n t s t a f f , are obvious from the r e s u l t s of the study. The severity of the problem i s , however, not noticed i n the present study as i t i s only concerned with soc-i a l services during the patient's h o s p i t a l i z a t i o n . Many of the patients leave the C l i n i c soon a f t e r casework help has been i n i t i a t e d , and the greater part of the s o c i a l worker's job i n such cases often follows upon the discharge of the pat-i e n t . The short-term period of h o s p i t a l i z a t i o n at the C l i n i c creates a high turn-over of patients, and many of the 1200 pat-ients admitted annually are i n need of after-care services. The second group of d i f f i c u l t i e s of the Crease C l i n i c S o c i a l Service Department, those caused by the lack of s o c i a l resources, are probably even more serious than the f i r s t . T h e r e i s a need f o r an out-patient's c l i n i c to which the patient 2 could turn f o r help a f t e r h i s discharge from h o s p i t a l . This 1 Gerald Pepper, op. c i t . . p. 94. The need f o r such a c l i n i c and f o r other s o c i a l resources i s demonstrated i n Mr. Sutherland's thesis, op. c i t . - 68 -would not necessarily r e l i e v e the Crease C l i n i c s o c i a l worker from the r e s p o n s i b i l i t y of after-care services, but would at least be a resource where the patient could get the help which the s o c i a l worker i s not competent to give. At such a c l i n i c the patient would be able to a v a i l himself of psy c h i a t r i c and other services which are at present only a v a i l a b l e i n i n s t i -t u t i o n a l settings. Besides the out-patients* c l i n i c , there i s the need f o r supervised boarding homes—particularly f o r the men—to which patients can move upon t h e i r discharge. Among other resources needed, there i s the need f o r services of volunteers to enable the patient to v i s i t h i s family and vice versa during his h o s p i t a l i z a t i o n . The long distance between the patient's home and the C l i n i c , and the rather high cost of transportation to and from the C l i n i c , often makes i t d i f f i c u l t and c o s t l y , and sometimes impossible, f o r such v i s i t s to take place. Research i n So c i a l Work The end r e s u l t of research i s new knowledge. In s o c i a l work t h i s means a knowledge of what i s being done, of what needs to be done, and how to do i t . Through research, the services being given, the effectiveness of these services, the lacks i n s o c i a l resources, the improvement i n techniques, etc. can be measured. Evaluative research, p a r t i c u l a r l y , i s needed. It i s necessary f o r the following reasons: (1) I t measures the extent of the s o c i a l service pro-gramme, i . e . the adequacy i n coverage of the people needing services, and the adequacy of the services i n being he l p f u l to - 69 -the people. (2) Through periodic assessments, i t shows the changes i n the s o c i a l service programme, and thereby makes prediction of future trends possible. (3) I t provides data to the public and to f i n a n c i a l appropriating bodies as to the need and usefulness of s o c i a l services i n the l i f e of a community. The es s e n t i a l steps i n evaluative research can be "summarized under f i v e headings: (1) i d e n t i f y i n g the goals that are being sought; (2) analysing the problems with which the a c t i v i t y , 1 * i . e . s o c i a l work, "must cope; (3) describing and standardizing the a c t i v i t y ; (4) measuring the degree of change that comes about; and (5) determining whether the change ob-served i s the r e s u l t of the a c t i v i t y or due to some other cause. In the present study, the goals of the s o c i a l worker i n the mental hospital were seen as being treatment, r e h a b i l i t a -t i o n and prevention of mental i l l n e s s . These goals were put into "operational terms" by o u t l i n i n g the r e s p o n s i b i l i t i e s of the s o c i a l worker to the patient and his family. Analyzing the problems of the patients and t h e i r r e l a t i v e s , and describ-ing and standardizing the a c t i v i t y of the s o c i a l worker were achieved i n one step. The a c t i v i t y , or services, of the soc-i a l worker were described i n Chapter 2 as the counterpart of 1 David G. French, An Approach to Measuring Results  i n S o c i a l Work. Columbia University Press, New York, 1952, p. 44. - 70 -each of the needs that the patients and t h e i r f a m i l i e s might have. Measuring the degree of change that has taken place i n the c l i e n t ' s psycho-social s i t u a t i o n was not attempted i n t h i s study. However, the psy c h i a t r i c assessment of the condition of the patient was used, and found to be an unsuitable index f o r measuring r e s u l t s i n s o c i a l work. The l a s t step i n eva-lu a t i v e research, determining cause and ef f e c t r e l a t i o n s h i p s , became thereby i r r e l e v a n t . One of the prerequisites of evaluative research i s the a v a i l a b i l i t y of information, i . e . s o c i a l casework record-ing must give the pertinent information. The Crease C l i n i c recording did not lend i t s e l f to an analysis of s o c i a l ser-vices to patients and t h e i r r e l a t i v e s . The use of a question-naire such as the one employed f o r t h i s study i s probably l e s s precise than i f "provision i s made f o r obtaining measures of re s u l t s before any services i s given." 1 Naturally, the recording at the C l i n i c was never intended f o r the purpose of research analysis only. The main purpose of recording i s and should remain that of a t o o l f o r giving more e f f e c t i v e service to the c l i e n t . However, since research i s an i n t e g r a l part of s o c i a l work, ce r t a i n adaptations could be made i n the recording to f a c i l i t a t e research. Such adaptations could be j u s t i f i e d not only f o r the long-term bene-f i t s which would emanate from the research that would then ensue, but from what i s , probably, also an e f f i c i e n t casework 1 David G. French, An Approach to Measuring Results  i n S o c i a l Work, p. 60. - 71 -practic e . The present and a number of other studies have shown that i t i s possible to analyze s o c i a l services adequately into s p e c i f i c components. Standardization into such components i s essential f o r research, and cannot be "achieved without thor-ough planning beforehand and conscious control and recording throughout treatment." 1 I f standardization i n recording can-not be j u s t i f i e d because of time l i m i t a t i o n s and high case-loads, periodic summaries and c l o s i n g summaries of treatment a c t i v i t i e s should at least be kept. Such summaries are v a l -uable not only from a research point of view, but are also useful as an a i d i n treatment; they give an accurate assess-ment of the treatment plan, and of the response of the patient to treatment. Periodic summaries with re-evaluation of the tentative s o c i a l diagnosis and of the treatment plan are pro-fe s s i o n a l practices inherent f o r constructive service to the c l i e n t . Prom a research point of view, periodic and cl o s i n g summaries are p a r t i c u l a r l y valuable i f the information they contain i s standardized. They should include some of the following informations (a) the problem or problems f o r which the c l i e n t requests help; (b) other problems which the s o c i a l worker sees i n the client * s s i t u a t i o n ; (c) a tentative s o c i a l diagnosis; (d) the treatment a c t i v i t i e s i n the past; (e) the reaction of the c l i e n t to these treatment a c t i v i t i e s ; ^"~David G. French, An Approach to Measuring Results  i n S o c i a l Work, p. 65. - 72 -( f ) evaluation of the effectiveness of and the changes being made i n the treatment plan. The information should be given i n a standardized way. For instance, the summary of the treatment plan may con-s i s t of a l i s t i n g of the areas i n which help i s being planned, e.g. help with f i n a n c i a l d i f f i c u l t i e s , help with d i f f i c u l t i e s i n adjusting to the h o s p i t a l , etc. I t may also consist of the techniques that were planned to help the c l i e n t , e.g. giving information, reassurance, support, etc. The reaction of the c l i e n t to the treatment plan can be given f o r the plan as a whole, e.g. excellent, good, f a i r , etc.; or, i f at a l l ad-mi n i s t r a t i v e l y possible, the movement of the c l i e n t towards the solution or a l l e v i a t i o n of each of h i s problems can be stated. With a l l t h i s information a v a i l a b l e , i t would be possible to analyze the problems of the c l i e n t s who come f o r help to the agency; the help they need; the services they get; and the effectiveness of these services i n a s s i s t i n g them. * * & (QUESTIONNAIRE USED IN SURVEY .Which of the f o l l o w i n g s e r v i c e s d i d you extend t o . . . . ? Flease check o f f under the appropriate column f o r each s e r v i c e l i s t e d . A D I R 3 C T S 3- R V I C E 3 T O P . A T I E N T Susnort around a n x i e t i e s r e l a t e d to h o s p i t a l i z a t i o n : (1) the p h y s i c a l s e t t i n g (locked doors, e t c . ) , (2) the. medical treatment , (3) the s t a f f (4) other p a t i e n t s w , I I Support, around a n x i e t i e s r e l a t e d t o f a m i l y problems during  h o s p i t a l i z s t i o n : (1) f i n a n c i a l problems ( f a m i l y 'without'money etc.) (2) cay-e of c h i l d r e n ., , (3) f a m i l y r e l a t i o n s h i p s (immediate a n x i e t i e s ) . I I Support around a n x i e t i e s r e l a t e d to discharge plans: (a) Environmental (1) en.' lcyment .. (2) housing ( 3) housekeeper s e r v i c e s (4) f i n a n c i a l problems ..... (5) s o c i a l and r e c r e a t i o n . DC1-(b) Emotional (1) a n x i e t y r e l a t e d to l e s s of h o s p i t a l s e c u r i t y (2) f a m i l y r e l a t i o n s h i p s (e.g. i s my wife ccinf; to understand me now?)..... (3.) p r e p a r a t i o n f o r f o l l o w u p s e r v i c e s , IV Casework s e r v i c e s based on the emotional needs of the p a t i e n t : (1) help i n accepting environmental r e a l i t y . . . (2) help i n c l a r i f y i n g conscious problems i n i n t e r p e r s o n a l r e l a t i o n s h i p s . . . . (3) • help i n a c c e p t i n g personal l i m i t a t i o n s ,:. •: -; ••••i. i.'J. L'L :•: 1 1 :ui 'i'i.i iJi Li ;:'.:•.•"„-•./• :r,T;rIT .7.Tif,1IririTh',rrr 73a B D I R E C T S E R V I C E S T O R E L A T I V E S I Support around anxieties related, to patient's h o s p i t a l i z a t i o n : « (1) the physical s e t t i n g (food, other p a t i e n t s ) . . (2) the medical treatment • II Help around i n a b i l i t y to accept . i l l n e s s : (1) uncornfort about coi'^xittal (2) uncomfort about being "cause" of i l l n e s s (3) shame at mental, i l l n e s s in family • (U) concern about symptoms of i l l n e s s ( a f r a i d of the delusions etc. of patient) III Support around s o c i a l problems in home: (1) f i n a n c i a l problems '. (2) care of c h i l d r e n . . . (3.) family r e l a t i o n s h i p s IV Casework s e r v i c e s based on the emotional needs of the r e l a t i v e s : (1) support around persons! a n r i e t i e s (2) support i n understanding and accepting patient as he/she i s . . . . . . (3) help i n c l a r i f y i n g conscious problems i n interpersonal r e l a t i o n s h i p s ' (4) preparation f o r follow-up s e r v i c e s . . . . . YES'"| NO ohTr DO 1 i-i:cw I K D I H E C - T - S E R V I C E S T C P A T I E N T S I Consultations within the h o s p i t a l : (1) ward rounds (2) doctor... (3) nurse (4) psychologist (5) r e h a b i l i t a t i o n o f f i c e r . (6) occupational t h e r a p i s t . . . . . (7) r e c r e a t i o n a l t h e r a p i s t (8) i n d u s t r i a l t h e r a p i s t . . . I I Consultations with outside resources: (1) casework agency (2) groupwork agency (3) employers,. (4) boarding home operators............... (5) r a t i o n a l Employment Services ( 6 ) other {not including family) III Diagnostic studies at intake • m a •UI.'I.Z.'I.-UULJ.I.a-i:i i.": '•: 'UL . ^ rinrirrrirtnr^trifirjrrnnr:. c-inhr BIBLIOGRAPHY Specific References Books; French, David G., An Approach to Measuring Results  in Social Work, Columbia University Press. New York, 1952. French, Lois Meredith, Psychiatric Social Work. The Commonwealth Fund, New York, 1940. Hunt, J. McV. and Kogan, Leonard S., Measuring  Results in Social Casework. Family Service Association of America, New York, 1950. Lowrey, Lawson G., Psychiatry for Social Workers, Columbia University Press, New York, 1946. Articles. Reports and Other Studies: Been, Elizabeth Brockett, "Psychiatric Social Work in Essex County," J o u r n a l o f , p s y c h i a t r i c S o c i a l Work, January, 194 7. "PsychiatricfSocial Work Possibilities i n a Mental Hospital," Journal of Psychiatric Social Work. Spring, 1949. British Columbia, Annual Report of the Mental Health  Services, Queen's Printers, Victoria, 1952. Group for the Advancement of Psychiatry, "The Psy-chiatric Social Worker in the Psychiatric Hos-p i t a l , " Report No. 2. January, 1948. Pepper, Gerald Wesley, Social Worker Participation i n the Treatment of the Mentally 111. Master of Social Work Thesis, University of British Colum-bia, 1953. Peters, P.R., "Current Practice in a State Hospital," Journal of Psychiatric Social Work, March, 1953. - 75 -General References Books; Hamilton, Gordon, Theory and Practice of S o c i a l Case  Work, Columbia University Press, New York, 1951. Kasius, Cora, editor, P r i n c i p l e s and Techniques i n So c i a l Casework, Family Service Association of America, 1950. A r t i c l e s and Reports; Beck, Samuel J . , and others, "The Psychiatric S o c i a l Worker i n Research," Journal of Psych i a t r i c  S o c i a l Work. A p r i l , 1953. Bellsmith, E t h e l B., "Recent Developments i n Treat-ment i n Mental Hospitals," Journal of Psychiatric  S o c i a l Work. March, 1952. Lehrman, Louis J . , "Logic of Diagnosis," S o c i a l Case-work, May, 1954. 

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