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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 Q u a n t i t a t i v e A n a l y s i s of S o c i a l Casework S e r v i c e s a t the Crease C l i n i c o f P s y c h o l o g i c a l M e d i c i n e , 1953.  by ERNEST SCHLESTNGER  T h e s i s Submitted i n P a r t i a l F u l f i l m e n t of the Requirements f o r the Degree o f MASTER OF SOCIAL WORE i n t h e School o f S o c i a l Work  Accepted as conforming t o t h e standard r e q u i r e d f o r the degree o f Master o f S o c i a l , Work  School  o f S o c i a l Work  1954 The U n i v e r s i t y o f B r i t i s h Columbia  iv  ABSTRACT  This study makes a d e f i n i t i v e survey of the s o c i a l services made available to mental patients at the Crease C l i n i c of Psychological Medicine during the year of 1953. The purpose of the survey was to describe as c l e a r l y as possible the actual s o c i a l services provided by s o c i a l caseworkers to patients undergoing short-term treatment at a mental h o s p i t a l . In order to analyze the nature of t y p i c a l s o c i a l casework help, i t was necessary to define the s p e c i f i c components making up services to the mentally i l l and t h e i r fami l i e s . Since there i s apparently no a v a i l a b l e standard, a special c l a s s i f i c a t i o n of services was devised f o r the present study. This was achieved by v i s u a l i z i n g the s o c i a l needs of tbe 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. A questionnaire l i s t i n g these services was prepared, and was answered by the patients* s o c i a l workers. The patients studied were fey people selected by a routine sampling procedure. An examination of the casework help to the patients revealed that 25 out of 64, and 29 of t h e i r f a m i l i e s , received help through face-to-face interviews with the soc i a l worker. A l l the patients were helped through diagnost i c planning at ward rounds, and 44 were further assisted through a therapeutic use of s o c i a l resources by the s o c i a l worker. The s p e c i f i c services to the patients and the spec i f i c services to the r e l a t i v e s were shown to be s i m i l a r i n frequency. In both instances most of the services were aimed at helping people with t h e i r discomforts i n s o c i a l relationships. In conclusion, the study points out some of the problems i n the screening of patients f o r s o c i a l casework help, including the d i f f i c u l t y of giving e f f e c t i v e service with i n s u f f i c i e n t s t a f f . Also emphasized i s the necessity f o r s o c i a l agencies to f a c i l i t a t e research through standardization of recording, because of the need f o r f a r t h e r development i n quantitative and a n a l y t i c a l evaluation of services which are not c l e a r l y understood by the general publ i c , and even by some professional people.  V  ACKNOWLEDGEMENTS  I wish to expressrayappreciation to the s o c i a l workers at the Crease C l i n i c of Psychological Medicine and at the Provincial Mental Hospital f o r t h e i r i n t e r e s t and co-operation i n obtaining the data f o r the present thesis. I p a r t i c u l a r l y want to thank Miss Dorothy R. Begg, Casework Supervisor at the Crease C l i n i c , f o r her help i n dev i s i n g a c l a s s i f i c a t i o n of s o c i a l services i n a mental hospital. I also wish to acknowledge indebtedness to Dr. Leonard C. Marsh and Mr. Arthur C. Abrahamson of the School of S o c i a l Work f o r t h e i r constructive suggestions and t h e i r encouragement.  » *»  ii TABLE OF CONTENTS Chapter 1. R e s p o n s i b i l i t i e s o f t h e S o c i a l Worker i n a Mental H o s p i t a l  Page  R e s p o n s i b i l i t i e s o f the s o c i a l caseworker. Casework t e c h n i q u e s . The Crease C l i n i c — i t s f u n c t i o n . T h e Crease C l i n i c S o c i a l S e r v i c e r e f e r r a l p o l i c y . Purpose and assumptions o f p r e s e n t study. C r i t e r i a o f selection.  1  Chapter 2. S o c i a l S e r v i c e s f o r the P a t i e n t s a t 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; direct serv i c e s t o p a t i e n t s and t h e i m p l i c a t i o n s ; d i r e c t s e r v i c e s t o p a t i e n t s r e l a t i v e s and t h e i m p l i c a t i o n s ; i n d i r e c t s e r v i c e s t o p a t i e n t s and t h e i r r e l a t i v e s 1  20  Chapter 3. P a t i e n t s Who Come t o the Crease C l i n i c C l a s s i f i c a t i o n o f p a t i e n t s . Who a r e t h e p a t i e n t s ? T h e i r age and sex d i s t r i b u t i o n ; t h e i r m a r i t a l s t a t u s ; t h e i r l e n g t h o f h o s p i t a l i z a t i o n ; and t h e i r c o n d i t i o n upon d i s c h a r g e . 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 s e r v i c e s amongst p a t i e n t s  43  Chapter 4. Summary and I m p l i c a t i o n s Summary and assessment. S e l e c t i o n v s . f u l l s o c i a l s e r v i c e coverage.. S o c i a l s e r v i c e s a r e p e r s o n a l . Research i n s o c i a l work. Steps i n e v a l u a t i v e r e s e a r c h . Standardization of recording  61  Appendices: A, Q u e s t i o n n a i r e Used i n Survey. .................. B. B i b l i o g r a p h y .  73 74  TABLES AND CHARTS IN THE TEXT (a)  Tables  T a b l e 1. D i r e c t s o c i a l s e r v i c e s t o 64 mental p a t i e n t s and t h e i r f a m i l i e s , Grease C l i n i c , 1953 Table 2. C l a s s i f i c a t i o n o f d i r e c t s o c i a l s e r v i c e s t o 64 p a t i e n t s , Crease C l i n i c , 1953 T a b l e 3. C l a s s i f i c a t i o n o f d i r e c t s o c i a l s e r v i c e s t o r e l a t i v e s o f 64 p a t i e n t s , Crease C l i n i c , 1933..  22 2  6  33  iii Page T a b l e 4. C l a s s i f i c a t i o n o f i n d i r e c t s o c i a l s e r v i c e s t o 64 p a t i e n t s and t h e i r r e l a t i v e s , Crease C l i n i c , 1953  39  T a b l e 5. Length of h o s p i t a l i z a t i o n o f 64 p a t i e n t s a c c o r d i n g t o c o n d i t i o n on d i s c h a r g e from the Crease C l i n i c , 1953  51  T a b l e 6. D i r e c t s o c i a l s e r v i c e s t o 64 p a t i e n t s a c c o r d i n g t o age and sex, Crease C l i n i c , 1953  54  Table 7. S o c i a l s e r v i c e s t o 64 p a t i e n t s a c c o r d i n g t o age and sex, Crease C l i n i c , 1953 II'i.'iI  55  Table 8. S o c i a l s e r v i c e s t o 64 p a t i e n t s a c c o r d i n g t o t h e i r m a r i t a l s t a t u s , Crease C l i n i c , 1953....  37  T a b l e 9. S o c i a l s e r v i c e s t o 64 p a t i e n t s a c c o r d i n g t o the l e n g t h o f h o s p i t a l i z a t i o n a t the Crease C l i n i c , 1953  58  T a b l e 10. S o c i a l s e r v i c e s t o 64 p a t i e n t s a c c o r d i n g t o t h e i r c o n d i t i o n upon d i s c h a r g e , 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 o f a group o f 64 p a t i e n t s a t the Crease C l i n i c , 1953  46a.  CHAPTER I  RESPONSIBILITIES OF THE SOCIAL WORKER IN A MENTAL HOSPITAL  Teamwork i n the hospital f o r the mentally i l l i s a process whereby a l l members of the treatment team work together to bring about the treatment and r e h a b i l i t a t i o n of the patient.  Each member of the team i s competent to con-  tribute a s p e c i a l understanding of the patient's health and welfare problems through h i s professional knowledge and s k i l l s i n some area of human l i v i n g .  At the Crease C l i n i c  of Psychological Medicine i n B r i t i s h Columbia (the base from which the present study was made), the team consists of the doctor, the psychologist, the nurse, the s o c i a l caseworker, the s o c i a l group worker, and the occupational  and  recreational therapists. The contributions that the s o c i a l caseworker can make i n the mental h o s p i t a l are manifold. h i s knowledge of the s o c i a l , c u l t u r a l and  They are based on psychological  development and pathology of the human personality, and h i s knowledge of s o c i a l resources.  This knowledge d i f f e r s  from that of e i t h e r the applied s o c i o l o g i s t or the psychiatrist.  on  The s o c i a l caseworker sees a s o c i a l case as  *a l i v i n g event within which there are always economic,  - 2 physical, mental, emotional and s o c i a l factors in varying proportions.  A s o c i a l case i s composed of i n t e r n a l and  external, or environmental f a c t o r s .  Special s k i l l i n i n -  1,1  terviewing and i n the use of s o c i a l resources are also c u l i a r to the profession of s o c i a l work.  They are  i n "such a way as to arouse and conserve the  pe-  directed  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 h o s p i t a l , the goals of the s o c i a l caseworker are the s o c i a l treatment of the patient; the r e h a b i l i t a t i o n of the patient and his family; and the prevention of further mental breakdown i n the patient.  (Treatment,  i n t h i s survey, defines the process whereby the patient i s helped to overcome or l i v e 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 b i s family are restored to a more s a t i s f a c tory adjustment i n t e r n a l l y and to the community.  More speci-  f i c a l l y , i t i s the restoration "of the handicapped to the f u l l e s t physical, mental, s o c i a l , vocational and economic 3  usefulness of which they are capable." ) These three goals of s o c i a l casework p r a c t i c e treatment, r e h a b i l i t a t i o n and prevention—are achieved by Gordon Hamilton, Theory and Practice of S o c i a l Case Work. Columbia-University Press, New York, 1951, pp. 3-4. I b i d . , p. 24. Maya Riviere, Rehabilitation of the Handicapped. Council of Rehabilitation, New York, 1949, p. i i i . 2  3  National  • 3 • helping the patient to make constructive change within hims e l f Insofar as he i s able and w i l l i n g , and by helping t o change, a l t e r or better mobilize the environment f o r him. The emphasis i n many state hospitals i s on the second technique of help because of time l i m i t a t i o n s .  Clarification i s  a casework technique which i n most instances can be achieved only through a prolonged intensive casework r e l a t i o n s h i p , i n which the patient i s supported to recognize and to accept i n varying degrees h i s own and other people's behaviour. However, with the growth i n understanding of mental hygiene throughout the f i r s t h a l f of the twentieth century, the s o c i a l worker's r e s p o n s i b i l i t i e s have increased considerably from the environmental "after-care * help to discharged 1  mental patients, which was h i s f i r s t r e s p o n s i b i l i t y i n the mental hospital s e t t i n g .  His r e s p o n s i b i l i t i e s have grown so  that he i s now involved at every phase of the patients' and t h e i r f a m i l i e s ' needs.  S i x types or stages of r e s p o n s i b i l i t y  may be distinguished. (1) Admission Services.  When the patient f i r s t  enters the hospital f o r the mentally i l l ,  the s o e i a l worker's  r e s p o n s i b i l i t i e s are s i m i l a r to those of a caseworker i n any other h o s p i t a l .  Entering such an i n s t i t u t i o n i s often a  frightening experience to the mental patient.  The hospital  i s a new s e t t i n g f o r him and one about which he has heard many gruesome s t o r i e s .  Further, he i s a f r a i d of the medical  treatment and may attempt to r e s i s t i t .  He w i l l want to go  home, p a r t i c u l a r l y since he often does not, or does not want  .  to, r e a l i z e that he i s i l l .  4  -  He w i l l f e e l confused about the  reason f o r h i s h o s p i t a l i z a t i o n , and may  become upset by the  behaviour of the other patients and by the manner of l i f e i n an i n s t i t u t i o n .  The caseworker attempts to reassure him  against these fears, helps him make a more s a t i s f a c t o r y adjustment to the h o s p i t a l , and t r i e s to gain h i s co-operation i n treatment. (2) Diagnostic Services. Another r e s p o n s i b i l i t y of the caseworker within the mental hospital i s to help himself and other s t a f f members a r r i v e at a comprehensive diagnosis. The s o c i a l worker achieves t h i s by a diagnostic study which he obtains through a casework r e l a t i o n s h i p with the patient and h i s r e l a t i v e s .  This study includes the patient's m a r i t a l ,  vocational, educational and r e l i g i o u s adjustments,  achieve-  ments and f a i l u r e s ; the patient's childhood experiences; the patient's s o c i a l environment—its strengths and weaknesses; an assessment of the i n t e r - r e l a t i o n s h i p s between the patient and h i s family as well as other groups of people; and the h i s t o r y of the present i l l n e s s .  Through t h i s diagnostic  study, the caseworker a r r i v e s at a s o c i a l diagnosis which i s of assistance i n planning f o r future s o c i a l casework services to the patient and h i s family with a view to meeting unmet s o c i a l needs.  The s o c i a l study and the s o c i a l diagnosis also  give the treatment team an accurate assessment of the patient's personality and s o c i a l environment, and thereby f a c i l i t a t e the team's diagnostic services, and treatment and r e h a b i l i t a t i o n plans f o r the patient.  • 5 (3) Treatment Services. Although some a u t h o r i t i e s seem to doubt the usefulness of the s o c i a l worker p a r t i c i p a ting i n the treatment process,  1  the writer i s convinced that  the s o c i a l caseworker i s competent to take on some treatment responsibilities.  The c r i t i c i s m s of h i s contributions per-  haps a r i s e out of a lack of public awareness of the caseworker's a b i l i t y f o r helping people.  His s k i l l of s t a r t i n g  with the c l i e n t , and moving at the c l i e n t ' s speed, as well as h i s s k i l l of working with people under environmental* , hospital pressures, i s p a r t i c u l a r l y important with mental patients, and i s often overlooked by c r i t i c s . The s o c i a l worker o f f e r s understanding.  He shows  a f r i e n d l y i n t e r e s t i n the patient. He helps the patient hold on to r e a l i t y by s t r e s s i n g r e a l things, but does not disclaim the patient's delusions.  Instead, he accepts them  as being r e a l to the patient; moves on to more f a c t u a l mate r i a l as soon as possible; and attempts to get the patient interested i n environmental r e a l i t i e s again.  This i s i n  keeping with h i s professional competency, i . e . the s o c i a l 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 h i s f e e l ings; and i f he i s strong enough emotionally, he i s encouraged to look at h i s attitudes and problems a l i t t l e more Paul H. Hoch. e d i t o r . F a i l u r e s i n Psychiatric Treatment. Grunne and Stratton, Hew York, 1948. 1  - 6 -  searchingly, so that he w i l l have a better understanding of himself and h i s s i t u a t i o n , and w i l l know how s e l f next time he i s under stress*  to handle him-  He w i l l be helped to  think more c l e a r l y about b i s future and w i l l be encouraged i n any reasonable decision that he makes.  I f needed, he w i l l be  helped i n building up a sense of personal worth by support from the s o c i a l worker and support stimulated by the caseworker i n the s o c i a l environment.  The l a t t e r i s achieved  by gaining the i n t e r e s t of r e l a t i v e s and others i n the patient. Direct environmental help to the patient on the ward i s also an important f a c t o r i n the work of a psychiat r i c hospital s o c i a l worker.  The mental i l l n e s s hampers the  patient i n meeting r e a l i t y s i t u a t i o n s , and i n facing h i s resp o n s i b i l i t i e s to bimself and to others.  Consequently, the  s o c i a l caseworker often f i n d s i t necessary to lessen tbe burden f o r the patient by assuming some of the patient's responsibilities. (4) Pre-convalescence Services.  As soon as the  patient recovers s u f f i c i e n t l y to discontinue the medical treatment, further services are offered to him.  Besides  tbe services given to the i l l person during h i s treatment period, the s o c i a l worker at t h i s time has an i n t e g r a t i v e job i n looking at a l l e x i s t i n g resources i n the community, and using tbe resources which w i l l be most b e n e f i c i a l to the patient on h i s return to society.  These s o c i a l  resources  w i l l be used i n a way that i s d i a g n o s t i c a l l y r e l a t e d to the  - 7 -  underlying problems of the patient, and can be made a v a i l able to the patient and h i s r e l a t i v e s at any time daring h i s treatment and r e h a b i l i t a t i o n . Another integrative job of the s o c i a l caseworker daring the period of pre-convalescence i s that of k n i t t i n g together a l l the services which e x i s t i n various departments of the h o s p i t a l to the use of the patient. before, remains client-centered.  The emphasis, as  The patient plans f o r him-  s e l f ; and the s o c i a l worker encourages and stimulates him to think of a l l the p o s s i b i l i t i e s open to him, and supports him i n h i s decisions.  The s o c i a l worker also helps the patient  with problems and anxieties which so often accompany the patient's thoughts about h i s discharge from the h o s p i t a l . In addition, i f the patient needs and wants farther casework services a f t e r discharge from the h o s p i t a l , he i s made aware of any follow-up  services that are a v a i l a b l e to him.  (5) Convalescence Services. When the patient i s eventually discharged from the h o s p i t a l , he leaves a protective environment f o r the bustle, i r r i t a t i o n s and problems of society.  Hany of the patients f i n d t h i s 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 f o r these stresses and f o r the follow-up services i s of immeasurable value.  Although the Act Relating to C l i n i c s of  Psychological Hedicine of B r i t i s h Columbia makes no provis1  B r i t i s h Columbia, Revised Statutes of. 1948, ch.52.  - 8 -  i o n f o r an e x t e n s i o n  o f casework s e r v i c e s t o t h e discharged  p a t i e n t , sach s e r v i c e s a r e i n f a c t given t o s e l e c t e d p a t i e n t s . These s e r v i c e s a r e e i t h e r made a v a i l a b l e by the Crease C l i n i c s o c i a l worker i f the p a t i e n t i s l i v i n g i n t h e G r e a t e r Vancouver a r e a ,  o r by t h e p r o v i n c i a l S o c i a l Welfare Branch o f the  a r e a i n which the p a t i e n t l i v e s i f the p a t i e n t l i v e s the G r e a t e r Vancouver a r e a . gives supportive  outside  I n e i t h e r c a s e , a s o c i a l worker  and s u s t a i n i n g  help.  I n addition., t o g i v i n g casework h e l p t o t h e p a t i e n t d u r i n g t h e c o n v a l e s c e n t p e r i o d , the C l i n i c s o c i a l worker conf e r s with tbe p a t i e n t ' s d o c t o r about t h e p a t i e n t ' s and adjustment a t home.  Reports on the p a t i e n t ' s  progress progress  from the S o c i a l Welfare Branch workers a r e d i s c u s s e d  with the  d o c t o r too, and a w r i t t e n statement on t h e r e s u l t s o f t h i s d i s c u s s i o n i s sent back t o the Branch as p a r t o f the general c o n s u l t a t i o n s e r v i c e t o the F i e l d worker. (6)  Family Services.  The s o c i a l worker a l s o has  r e s p o n s i b i l i t i e s t o the p a t i e n t ' s f a m i l y , f o r t h e i r w e l f a r e i s an important f a c t o r i n t h e p a t i e n t ' s r e h a b i l i t a t i o n . F i r s t , the support o f the f a m i l y can be a s u s t a i n i n g , b e n e f i c i a l i n fluence  t o the p a t i e n t w h i l e he i s i n h o s p i t a l .  Secondly,  the p a t i e n t w i l l e v e n t u a l l y r e t u r n t o h i s f a m i l y i n most c a s e s , and the n e c e s s i t y o f t e n a r i s e s o f t h e need t o h e l p improve f a m i l y r e l a t i o n s h i p s t o prevent f u t u r e mental breakdowns of the p a t i e n t .  T h i r d l y , the i l l n e s s o f one o f i t s  members o f t e n has a d e v a s t a t i n g  e f f e c t on t h e f a m i l y .  - 9 When the p a t i e n t e n t e r s the h o s p i t a l , r e l a t i v e s a r e f r e q u e n t l y more confused and upset than he i s .  They may he  a f r a i d o f and may not understand the p a t i e n t ' s i l l n e s s . They may have n e e d l e s s f e a r s that the p a t i e n t i s b e i n g  "put away  f o r l i f e , " o r may need h e l p t o f a c e t h e f a c t t h a t the p a t i e n t w i l l remain i l l  f o r an extended p e r i o d .  They may f e e l respon-  s i b l e f o r the p a t i e n t ' s breakdown, and may be a f f e c t e d by g u i l t f e e l i n g s about committing the p a t i e n t t o the h o s p i t a l ; or they may show r e l i e f a t g e t t i n g r i d o f the r e s p o n s i b i l i t y o f c a r i n g f o r the p a t i e n t , and may decide t o break a l l t i e s with him because they f i n d h i s b i z a r r e behaviour too p a i n f u l to f a c e a g a i n .  A l l these f e e l i n g s and a t t i t u d e s have a d i s -  r u p t i n g i n f l u e n c e on the p a t i e n t and the e f f e c t i v e f u n c t i o n i n g of the f a m i l y .  The s o c i a l worker can g i v e r e a l i s t i c a s -  surance and support t o the f a m i l y , and encourage i t t o p a r 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 o f the patient.  He i s a l s o i n the p o s i t i o n t o h e l p the f a m i l y with  the m a t e r i a l and emotional i s s u e s which i t may encounter. These i s s u e s that may c o n f r o n t i l y a r e many and v a r i e d .  the p a t i e n t ' s fam-  They may c e n t r e around the a c c e p t -  ance o f the p a t i e n t and h i s i l l n e s s ; they may c e n t r e the problems which may have always been present and  have been i n s t r u m e n t a l  around  i n the f a m i l y ,  i n c o n t r i b u t i n g towards the p a t -  i e n t ' s mental breakdown, and a r e , perhaps, h a v i n g an i n c a p a c i t a t i n g e f f e c t on other members o f the f a m i l y ; o r they may be the d i r e c t r e s u l t o f the s e p a r a t i o n o f 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 o f t e n a b l e t o h e l p t h e f a m i l y cope with these problems so that they can l e a d 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 a l s o make a v a i l a b l e t o the f a m i l y o t h e r s o -  c i a l s e r v i c e s such a s S o c i a l A s s i s t a n c e and f o s t e r home c a r e . To summarize, t h e s o c i a l caseworker  has r e s p o n s i b i -  l i t i e s both t o t h e p a t i e n t and t h e p a t i e n t ' s f a m i l y .  H i s ser-  v i c e s a r e p r i m a r i l y aimed a t the treatment and r e h a b i l i t a t i o n o f the s i c k person, and a t t h e p r e v e n t i o n o f the r e c u r rence o f tbe p a t i e n t ' s i l l n e s s ; but t o a c h i e v e t h i s , h e l p has to  be extended  f r e q u e n t l y t o the f a m i l y , t o o .  There a r e f o u r  common "casework p r o c e s s e s o r groups o f t e c h n i q u e s ' 1  1  used by the  s o c i a l worker t o h e l p people. Casework Techniques F i r s t , there a r e the techniques which a r e a p p l i e d through t h e 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 developed between t h e c l i e n t and the s o c i a l caseworker.  These a r e t h e techniques  which form t h e s e r v i c e s which a r e o f an e m o t i o n a l l y support i v e and s u s t a i n i n g nature f o r the c l i e n t .  S u p p o r t i v e and  s u s t a i n i n g h e l p i n c l u d e s such techniques a s r e a s s u r i n g t h e p a t i e n t , a c c e p t i n g h i s behaviour, showing understanding and f r i e n d l i n e s s , s u p p o r t i n g and encouraging, sympathizing, and o t h e r 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 t o h e l p t h e c l i e n t F l o r e n c e H o l l i s , "The Techniques J o u r n a l o f S o c i a l Casework. June 1949. 1  o f Casework,"  - 11 -  gain s t r e n g t h and m o b i l i z e h i s own r e s o u r c e s Secondly, there a r e techniques t i o n of the c l i e n t ' s conscious problems.  to help  himself.  involving c l a r i f i c a These  techniques  are t h e ones used i n h e l p i n g the c l i e n t t o understand hims e l f and h i s environment.  Through t h i s knowledge, which i n  casework i s u s u a l l y s e l f - a c q u i r e d , the p a t i e n t i s helped t o modify h i s a t t i t u d e s , to a d j u s t t o h i s s u r r o u n d i n g s ,  and t o  be a b l e t o meet s t r e s s 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 o f techniques tk*  i n giving information t o ^ c l i e n t .  comprises those  I n t h e mental h o s p i t a l ,  g i v i n g i n f o r m a t i o n i s an extremely important s o c i a l worker.  used  f u n c t i o n o f the  He i s n o t o n l y c a l l e d upon t o e x p l a i n t o t h e  p a t i e n t and r e l a t i v e s t h e f u n c t i o n s o f the S o c i a l S e r v i c e Department, but must o f t e n be a b l e t o g i v e i n f o r m a t i o n on v a r i o u s aspects o f h o s p i t a l l i f e .  The many misunderstandings  which e x i s t about mental i l l n e s s and mental h o s p i t a l s have t o be d e a l t w i t h .  I n a d d i t i o n , t h e caseworker a d v i s e s the p a t -  i e n t and h i s f a m i l y o f s o c i a l r e s o u r c e s i n t h e community. He may i n f o r m the p a t i e n t ' s f a m i l y o f f i n a n c i a l h e l p i t can r e c e i v e from other s o c i a l agencies and may r e f e r i t t o t h e proper agency f o r a s s i s t a n c e ; o r he may a d v i s e the p a t i e n t how to get v o c a t i o n a l c o u n s e l l i n g , how t o go about f i n d i n g employment, how t o continue with h i s e d u c a t i o n , how t o get f u r t h e r casework s e r v i c e s when he i s d i s c h a r g e d from the hospital, etc.  -  12  Environmental h e l p , a f o u r t h t e c h n i q u e , can be d i v i d e d i n t o two  categories.  I t can be e i t h e r p s y c h o l o g i c a l l y  e n a b l i n g as w e l l as being h e l p f u l i n other ways, or i t can  be  h e l p f u l to the c l i e n t without n e c e s s a r i l y b e i n g p s y c h o l o g i c a l l y enabling.  The  former i s a casework s e r v i c e ; the l a t t e r i s an  incidental service.  The  s k i l l e d caseworker w i l l attempt to  make a l l environmental s e r v i c e s i n t o e n a b l i n g experiences f o r the c l i e n t , because as a p r o f e s s i o n a l person h i s s e r v i c e s should  be compatible with a sound s o c i a l  diagnosis.  A l l the f o u r casework p r o c e s s e s l i s t e d above have one  t h i n g i n common.  help himself.  The  They are aimed a t h e l p i n g the  client  s o c i a l caseworker's p r o f e s s i o n a l goal i s  to h e l p the i n d i v i d u a l to b e t t e r adjustments i n h i s s o c i a l r e l a t i o n s h i p s with o t h e r s .  1  Every p a t i e n t 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 s t r e n g t h s and weaknesses, o r t u r m o i l and harmony.  Simi-  l a r l y , every f a m i l y 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 p i g e o n - h o l i n g  and  g e n e r a l i z i n g , and  because they  b e l i e v e that the uniqueness of each i n d i v i d u a l i s o f t e n a v i t a l p a r t of h i s i n n a t e 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 P s y c h o l o g i c a l M e d i c i n e The  Crease C l i n i c o f P s y c h o l o g i c a l M e d i c i n e i s p a r t  of the B r i t i s h Columbia p r o v i n c i a l mental h o s p i t a l system. ' Mary Richmond, The York, 1930, p. 398^ x  t i o n , Mew  Long View. R u s s e l Sage Founda-  - 13 The C l i n i c has been designed and equipped a s a d i a g n o s t i c and a c t i v e treatment c e n t r e f o r the m e n t a l l y i l l .  1  To ensure  t h a t i t s h a l l c a r r y out the i n t e n d e d f u n c t i o n , s t a t u t o r y p r o v i s i o n has been made l i m i t i n g the d u r a t i o n o f a p a t i e n t ' s treatment p e r i o d t o f o u r c a l e n d a r months, commencing with t h e date o f admission.  I f a t t h e end o f the treatment p e r i o d i n  the C l i n i c , the m e d i c a l s t a f f i s o f the o p i n i o n t h a t the p a t i e n t r e q u i r e s a d d i t i o n a l treatment, t h e r e i s a s t a t u t o r y p r o v i s i o n t o permit t h e p a t i e n t t o 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 H o s p i t a l i n accordance with t b e p r o o v i s i o n s o f the Mental H o s p i t a l A c t . Procedure f o r tbe admission t o the Crease C l i n i c has been kept a s simple as p o s s i b l e .  Admissions a r e o f two t y p e s :  (1) c e r t i f i c a t i o n by two m e d i c a l p r a c t i t i o n e r s ; and (2) v o l u n t a r y a p p l i c a t i o n by t h e p a t i e n t , approved  by a p h y s i c i a n on  the b a s i s that he i s o f the o p i n i o n t h a t t h e p a t i e n t ' s c o n d i t i o n i s such a s t o render t h e p a t i e n t capable o f making v o l u n t a r y a p p l i c a t i o n f o r treatment.  The f i r s t , o r r e g u l a r admis-  s i o n s , a r e somewhat more common than the v o l u n t a r y ones.  ..  S i n c e the maximum p e r i o d o f treatment i n the C l i n i c i s l i m i t e d t o f o u r months, p h y s i c i a n s a r e requested t o c e r t i f y f o r admission o n l y those p a t i e n t s who, i n t h e i r o p i n i o n , have  \  -  What f o l l o w s i s a p a r t i a l summary from the P o l i c y Manual o f t h e 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 S t a t u t e s o f . c h . 207.  A c c o r d i n g t o t h e B r i t i s h Columbia Annual Report o f the Mental H e a l t h S e r v i c e s f o r 1953, t h e r e were 687 r e g u l a r admissions and 534 v o l u n t a r y admissions between A p r i l 1 s t , 1952 and March 31st, 1953.  - 14 a reasonable p r o s p e c t f o r r e c o v e r y and d i s c b a r g e i n the f o u r months' p e r i o d .  S p e c i f i c a l l y , the f o l l o w i n g types o f p a t i e n t s  a r e c o n s i d e r e d a c c e p t a b l e f o r admission t o the C l i n i c : (1) e a r l y p s y c h o t i c s , (2) p a t i e n t s with p s y c h o n e u r o s i s , (3) p a t i e n t s with psychosomatic  d i s a b i l i t i e s , and  (4) a l l p s y c h o t i c p a t i e n t s except those who have been i l l  f o r a l o n g time, and those demonstra-  t i n g marked d e t e r i o r a t i o n and h a v i n g a poor prognosis. On t h e o t h e r hand, some types o f p a t i e n t s a r e cons i d e r e d u n s u i t a b l e f o r admission and treatment i n t h e Crease Clinic.  These i n c l u d e : p a t i e n t s with s e n i l e dementia,  i e n t s with a r t e r i o s c l e r o t i c dementia,  pat-  mentally defective  people, c h r o n i c r e c u r r e n t p s y c h o t i c s , drug a d d i c t s without p s y c h o s i s , and a l c o h o l i c s without p s y c h o s i s .  I n t h i s connec-  t i o n , the A c t R e l a t i n g t o C l i n i c s o f P s y c h o l o g i c a l M e d i c i n e empowers the person i n charge o f the C l i n i c t o d e c l i n e t o admit any person t o the C l i n i c , i f t h e r e a r e adequate r e a s o n s , n o t w i t h s t a n d i n g the f a c t t h a t the person has been c e r t i f i e d under the A c t . Crease C l i n i c S o c i a l S e r v i c e R e f e r r a l  Policy  I n p r a c t i c e , most h o s p i t a l s f i n d i t d i f f i c u l t t o o f f e r adequate s o c i a l s e r v i c e s because o f u n a v a i l a b i l i t y o f t r a i n e d p e r s o n n e l which p r e c l u d e s s t a f f i n g t o r e c o g n i z e d standards, and because o f f i n a n c i a l l i m i t a t i o n s w i t h i n the t o t a l administration.  Many p a t i e n t s 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 r e l a t i o n s h i p , but the s o c i a l worker, because of high caseloads, i s too pressed f o r time to o f f e r it. At the Crease C l i n i c , because of t h i s shortage i n personnel, tbe process of screening patients f o r casework services has become important.  I f a l l the patients were to  be covered by the Social Service Department, casework services would be spread so t h i n l y over the general population of the C l i n i c , that patients would not benefit through them. The attempt to give complete s o c i a l service coverage  was,  therefore, abandoned soon a f t e r the C l i n i c was opened, though i t i s a goal at which the S o c i a l Service administration i s s t i l l aiming.  For the present, the p o l i c y of o f f e r i n g ser-  vices to the patients most l i k e l y to p r o f i t from them has been adopted, but i n practice such a p o l i c y i s often d i f f i c u l t to follow. Referrals to the Department come from various 2  sources.  Most r e f e r r a l s are made during "ward rounds."  Other patients are referred d i r e c t l y 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 The S o c i a l Service Department at the Crease C l i n i c consists of tbe administrator, two supervisors and s i x caseworkers. The number of patients admitted to the C l i n i c between A p r i l 1st, 1952 and March 31st, 1953, was 1221. 1  2  "Ward rounds" i s a periodic meeting of members of the treatment team. During these meetings newly admitted patients are discussed d i a g n o s t i c a l l y , and treatment and r e h a b i l i t a t i o n plans f o r these patients are decided upon.  - 16"casework s e r v i c e s . are  I n a d d i t i o n , some p a t i e n t s o r r e l a t i v e s  seen by the i n t a k e worker a t the time the p a t i e n t i s a d -  m i t t e d t o the C l i n i c . Par-pose and Assumptions o f P r e s e n t Study The present survey i s one of a s e r i e s o f s t u d i e s b e i n g conducted on the S o c i a l S e r v i c e Departments  o f the P r o -  v i n c i a l Mental H o s p i t a l and o f the Crease C l i n i c o f the Psychol o g i c a l M e d i c i n e a t E s s o n d a l e , B r i t i s h Columbia, by Master o f S o c i a l Work s t u d e n t s a t the S c h o o l o f S o c i a l Work a t the U n i v e r s i t y o f B r i t i s h Columbia.  1  I t makes t h e assumption t h a t  casework h e l p i s f r e q u e n t l y o f v a l u e t o the p a t i e n t and h i s f a m i l y i n the treatment and r e h a b i l i t a t i o n p r o c e s s .  The r e s -  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 p a t i e n t ' s s o c i a l adjustment a r e v e r y s i m i l a r t o the r e s p o n s i b i l i t i e s o f the  d o c t o r f o r the p a t i e n t ' s p h y s i o l o g i c a l c o n d i t i o n ^ .  the  t e n e t s i n medicine i s t o use a l l the a v a i l a b l e m e d i c a l  knowledge and s k i l l  One o f  on the p a t i e n t , knowing t h a t n e i t h e r t h i s  knowledge n o r s k i l l w i l l always cure the p a t i e n t .  Mr. A. may  p r o s p e r from i n s u l i n therapy, w h i l e Mr. B. w i l l remain unchanged from i d e n t i c a l treatment.  Similarly, social  workers  Mr. G e r a l d Pepper, a t p r e s e n t h i m s e l f a s o c i a l worker a t t h e C l i n i c , has a l r e a d y completed a g e n e r a l study of the h i s t o r y and the o r g a n i z a t i o n a l s t r u c t u r e o f t h e Departments i n h i 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 M e n t a l l y 111. Master o f S o c i a l Work T h e s i s . U n i v e r s i t y of B r i t i s h Columbia, 1953. Two o t h e r s t u d i e s a r e b e i n g conducted c o n c u r r e n t l y with t h i s survey. The f i r s t , an examinat i o n o f the S o c i a l S e r v i c e r e f e r r a l p o l i c y and p r a c t i c e a t the Crease C l i n i c , i s b e i n g performed by Mr. Eugene Elmore. The second, a study by Mr. H u r r a y S u t h e r l a n d , i s a s u r v e y o f r e h a b i l i t a t i v e s o c i a l s e r v i c e s and r e s o u r c e s a v a i l a b l e t o male p a t i e n t s d i s c h a r g e d 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 b r i n g i n g to bear t h e i r knowledge and  s k i l l on the p a t i e n t , although they are at the same time  aware t h a t some of the p a t i e n t s are not perhaps capable of b e n e f i t i n g from or a c t u a l l y w i l l r e f u s e casework s e r v i c e s . Both p r o f e s s i o n s have t h e i r f a i l u r e s i n treatment, and  both  p r o f e s s i o n s a r e c o n t i n u a l l y r e - e v a l u a t i n g these f a i l u r e s and attempting t o develop t h e i r knowledge and crease  the number of people who The  s k i l l s to  cannot be e f f e c t i v e l y  purpose of the present  de-  helped.  1  study i s to examine quanti-  t a t i v e l y tbe s o c i a l casework s e r v i c e s which were g i v e n to a r e p r e s e n t a t i v e group o f p a t i e n t s and  t h e i r f a m i l i e s at  Crease C l i n i c up to the time of t h e i r d i s c h a r g e . casework s e r v i c e s  9  the  By " S o c i a l  t h i s s t u d y denotes a l l the s e r v i c e s which  the s o c i a l worker o f f e r s to the p a t i e n t and  his family,  which a r e aimed a t h e l p i n g both the p a t i e n t and t a i n a h a p p i e r adjustment to each other and  and  the f a m i l y a t -  to s o c i e t y .  C r i t e r i a of S e l e c t i o n In s e l e c t i n g p a t i e n t s f o r the measurement o f s o c i a l s e r v i c e s at the C l i n i c , two c r i t e r i o n was  c r i t e r i a were emphasized.  to get a sample which would be  The  first  representative,  yet s m a l l enough f o r c a r e f u l case a n a l y s i s w i t h i n the time at the w r i t e r ' s d i s p o s a l .  The  second c r i t e r i o n , i n deference t o  the f a c t 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 c o n s t a n t l y changing a d m i n i s t r a t i v e p o l i c i e s , was  to s e l e c t as  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 r e g a r d i s F a i l u r e s i n P s y c h i a t r i c Treatment, e d i t e d by Paul H. Hoch, p u b l i s h e d by Grune and S t r a t i o n , New York, 1948. 1  - 18  r e c e n t a sample as p o s s i b l e .  -  1  To keep the sample s m a l l  r e p r e s e n t a t i v e , the s e l e c t i o n was mitted  limited  to p a t i e n t s  ad-  to the C l i n i c w i t h i n a s i x months' p e r i o d , c h o o s i n g every  tenth p a t i e n t admitted d a r i n g that span of time. 1953,  and  to September 30th, 1953,  which the sample was  was  April  1st,  chosen as the p e r i o d from  s e l e c t e d , because i t ensured t h a t a l l  the p a t i e n t s were r e c e n t l y admitted, but a t the same time r u l e d out the p o s s i b i l i t y of the p a t i e n t not h a v i n g yet been charged from the  Clinic.  D a r i n g the above-mentioned p e r i o d , 636 admitted to the Crease C l i n i c .  The  people were  patients are l i s t e d  name i n the C l i n i c ' s Admission Book a c c o r d i n g admission.  dis-  by  to the date o f  By s e l e c t i n g every t e n t h p a t i e n t admitted between  A p r i l 1st and September 30th, 1953, c o n s i s t s of 64 people, and  the sample thus  obtained  i s probably representative of  range of s e r v i c e s g i v e n but not c e r t i f i a f t L y of the  the  total  2 Clinic  population. I n f o r m a t i o n on these p a t i e n t s was  ber o f sources.  The  S o c i a l S e r v i c e Department's r e c o r d s  used f o r the p r e l i m i n a r y i n f o r m a t i o n . supplied s u f f i c i e n t isfactory was  information  These r e c o r d s  were  usually  t o make i t obvious t h a t a s a t -  c l a s s i f i c a t i o n according  impossible.  taken from a num-  to s o c i a l work d i a g n o s i s  However, i n a t t e m p t i n g to a n a l y z e the  social  s e r v i c e s given t o p a t i e n t s , the S o c i a l S e r v i c e f i l e s were found ^ T h e Crease C l i n i c was opened on January 1 s t , 1951. The season o f the year from which the sample been s e l e c t e d has p o s s i b l y some d i s t o r t i n g e f f e c t . 2  has  -  19  -  to be lacking i n the s p e c i f i c information being sought, and of necessity another way of getting the required information had to be devised.  A questionnaire which asked f o r the pertinent  information was prepared (Appendix A). patients' s o c i a l workers.  I t was answered by the  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 s e c u r i n g treatment f o r t h e i r  illness.  The treatment, as noted i n the f i r s t c h a p t e r , i s the combined e f f o r t of a number of d i s c i p l i n e s - - n u r s i n g , medicine, psyc h i a t r y , s o c i a l work, o c c u p a t i o n a l and r e c r e a t i o n a l therapy, t h e o l o g y , and psychology.  A l l the p a t i e n t s get a v a r i e t y of  s e r v i c e s from members of these d i s c i p l i n e s .  F o r i n s t a n c e , the  d o c t o r s and p s y c h i a t r i s t s g i v e medical and p s y c h o - t h e r a p e u t i c s e r v i c e s , the clergymen  g i v e s p i r i t u a l s e r v i c e s , and the psy-  c h o l o g i s t s f u r t h e r treatment through t h e i r assessment patient's personality.  o f the  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 c h a p t e r has o u t l i n e d  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 w e l l as l i s t i n g the casework p r o c e s s e s used i n h e l p i n g people.  The present chapter w i l l examine the s o c i a l  which a r e used i n meeting tbe s o c i a l worker's to the p a t i e n t s and t h e i r  responsibilities  relatives.  Not a l l p a t i e n t s get s o c i a l s e r v i c e s . t h r e e main reasons f o r t h i s . term h o s p i t a l .  services  There are  F i r s t l y , the C l i n i c i s a s h o r t -  Many of the p a t i e n t s s t a y o n l y a b r i e f  period,  - 21 -  and a r e d i s c h a r g e d before the s o c i a l worker has the o p p o r t u n i t y t o see them.  I n o t h e r c a s e s , the p a t i e n t i s d i s c h a r g e d suddenly,  and without the knowledge o f the s o c i a l worker.  Secondly, some  p a t i e n t s , because o f the n a t u r e o f t h e i r i l l n e s s , r e s i s t o r a r e unable t o respond t o s o c i a l casework.  T h i r d l y , a s mentioned  p r e v i o u s l y , the S o c i a l S e r v i c e Department has i n s u f f i c i e n t s t a f f t o g i v e adequate  s e r v i c e s and a t the same time o f f e r case-  work h e l p t o a l l the p a t i e n t s a t the C l i n i c .  A t the p r e s e n t  time, t h e S o c i a l S e r v i c e Department tends t o s e l e c t f o r casework the p a t i e n t s t o whom i t can be o f g r e a t e s t a s s i s t a n c e i n t h e s h o r t e s t p o s s i b l e time.  Out of the 1221 p a t i e n t s admitted bet-  ween A p r i l 1 s t , 1952, and March 31st, 1953, 573 were r e f e r r e d to the Department f o r b r i e f s e r v i c e s .  Of t h e s e , 318 were  s e r v e d by t h e Admissions S e c t i o n o f the S o c i a l S e r v i c e Department, and r e c e i v e d casework s e r v i c e s o f an e n a b l i n g and supp o r t i v e nature over a b r i e f p e r i o d .  E l e v e n hundred  patients  were r e f e r r e d f o r c o n t i n u e d s o c i a l casework s e r v i c e s .  1  How-  ever, o n l y 508 o f these p a t i e n t s were s e r v e d by the Depart° 2 ment because  o f the reasons l i s t e d above.  Out o f the 64 p a t i e n t s i n t h e present sample, a l l r e c e i v e d some s o c i a l s e r v i c e s ; but these v a r i e d c o n s i d e r a b l y from person t o person.  Approximately 45.4$ ( o r 29 o f the p a t -  i e n t s and t h e i r r e l a t i v e s ) r e c e i v e d o n l y immediate d i a g n o s t i c p l a n n i n g s e r v i c e s a t ward rounds. The other 56.6$ o f the group F o r a f u l l d e s c r i p t i o n o f the d i f f e r e n c e s between b r i e f and c o n t i n u i n g s o c i a l s e r v i c e s , see G e r a l d Pepper, o p . c i t . . pp. 51-55, 61-68. F i g u r e s from B r i t i s h Columbia, Annual Report o f t h e Mental H e a l t h S e r v i c e s . 1953. 2  -  T a b l e 1.  22  D i r e c t S o c i a l S e r v i c e s to 64 Mental P a t i e n t s and T h e i r F a m i l i e s (Crease C l i n i c ,  Direct S o c i a l Services  1953)  1  Percentage of P a t i e n t s Receiving Services  Patients Receiving Services  D i r e c t S e r v i c e s to . P a t i e n t s only  6  .9.3.,.  D i r e c t S e r v i c e s to Relatives only  10  15.6  Direct Services P a t i e n t s and  19  29.7  No D i r e c t S e r v i c e s  29  45.4  Total  64  100.0  to Relatives  ( o r 35 p a t i e n t s and t h e i r f a m i l i e s ) r e c e i v e d s e r v i c e s through the f a c e - t o - f a c e casework r e l a t i o n s h i p .  Table i i n d i c a t e s the  d i r e c t s o c i a l s e r v i c e s ( o r the s e r v i c e s emanating from the t o - f a c e r e l a t i o n s h i p between the caseworker and g i v e n t o the p a t i e n t s and  their relatives.  the c l i e n t )  In s i x cases,  e c t s e r v i c e s were extended to the p a t i e n t and not tives.  In ten other c a s e s ,  i a l s e r v i c e s , bat  face-  to the  dirrela-  the r e l a t i v e s r e c e i v e d d i r e c t soc-  the p a t i e n t was  not seen by the s o c i a l worker.  A f a l l i n t e g r a t i o n of s e r v i c e s to the p a t i e n t and h i s r e l a t i v e s was  achieved  with 19 p a t i e n t s , because both the  patient  and h i s f a m i l y were r e c e i v i n g d i r e c t s e r v i c e s . Such i n t e g r a t i o n , The source f o r T a b l e 1 and a l l the t a b l e s t h a t low i s a sample count of the p a t i e n t s under study. 1  fol-  - 23 however, i s f r e q u e n t l y i m p o s s i b l e i s too i l l outside  because e i t h e r the  patient  f o r d i r e c t s e r v i c e s or the p a t i e n t ' s f a m i l y  the G r e a t e r Vancouver area.  I n the l a t t e r  lives  instance,  an i n t e g r a t i v e job i s o c c a s i o n a l l y achieved through the  local  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 s e r v i c e s which the caseworker p r o v i d e s f o r the p a t i e n t s and  their families?  The  goals  of  the s o c i a l worker at the mental h o s p i t a l , p r e v i o u s l y mentioned, were seen to be the treatment, and as w e l l as the p r e v e n t i o n ient.  The  r e h a b i l i t a t i o n of the  of f u r t h e r mental breakdown o f the  problems of the p a t i e n t s and  a l s o been p o i n t e d  out.  the s o c i a l s e r v i c e s .  I t now  pat-  t h e i r r e l a t i v e s have  remains to d e s c r i b e and  They can be d e s c r i b e d  (1) d i r e c t s e r v i c e s to p a t i e n t s ; r e l a t i v e s ; and  patient,  measure  under three  headings:  (2) d i r e c t s e r v i c e s to p a t i e n t s '  (3) i n d i r e c t s e r v i c e s to p a t i e n t s and  their r e l -  atives. " D i r e c t s e r v i c e s to p a t i e n t s " are those s e r v i c e s which are given  through the i n t e r v i e w s  between s o c i a l worker  and  patient.  S i m i l a r l y , " d i r e c t s e r v i c e s to p a t i e n t s * r e l a t i v e s "  are those s e r v i c e s which are obtained by the r e l a t i v e s of p a t i e n t s through casework i n t e r v i e w s .  the  " I n d i r e c t s e r v i c e s " are  those s e r v i c e s which are f o r the w e l f a r e of the p a t i e n t or h i s r e l a t i v e s , and  c o n s i s t of a d i a g n o s t i c use  within or outside  the C l i n i c .  v i c e s i s not a l t o g e t h e r  of s o c i a l resources  T h i s d i v i s i o n of casework s e r -  e x c l u s i v e except by d e f i n i t i o n ,  cause, f o r example, d i r e c t s e r v i c e s to the p a t i e n t c o u l d  bebe  = 24 -  considered  as i n d i r e c t services to the patient's k i n .  As a  c l a s s i f i c a t o r y device, however, the d i v i s i o n proved very useful. Direct Services to Patients Direct services to patients as defined f o r t h i s study includes a l l the services which the s o c i a l worker provides through the medium of the interview between the patient the worker.  and  These services have been divided f o r the purpose  of analysis into four groups. I. zation.  Support around anxieties r e l a t e d to h o s p i t a l i -  This includes help with fears concerning the physical  s e t t i n g of the h o s p i t a l , e.g. the locked doors; fears about the medical treatment; anxieties about the s t a f f ; and anxieties about the other patients. II.  Support around anxieties related to family pro-  blems during h o s p i t a l i z a t i o n . This concerns mainly help with those fears of the patient which are caused by the break-up of the family because of the i l l n e s s of one of i t s members. Specif i c a l l y , these anxieties are caused by f i n a n c i a l problems, d i f f i c u l t i e s about the care of children, and immediate problems i n family r e l a t i o n s h i p s . III. plans.  Support around anxieties r e l a t e d to discharge  When the patient i s ready f o r discharge, planning f o r  his future becomes an important part of the s o c i a l worker's job.  This consists of environmental and emotional support.  "Environmental support" covers a wide range of p r a c t i c a l needs, namely: employment, housing, housekeeper services, f i n a n c i a l  25 problems, and  s o c i a l and r e c r e a t i o n a l m a t t e r s .  The  second,  "emotional s u p p o r t , " c o n s i s t s o f h e l p i n g the p a t i e n t cope with h i s f e a r s r e l a t e d to the l o s s of h o s p i t a l s e c u r i t y , and resuming f a m i l y r e l a t i o n s h i p s .  to  I t also includes preparation  the p a t i e n t f o r f o l l o w - u p s e r v i c e s  1  made a v a i l a b l e by the  v i n c i a l S o c i a l Welfare Branch or by the S o c i a l S e r v i c e  of  pro-  Depart-  ment of the Crease C l i n i c . IV.  Casework s e r v i c e s based on the emotional needs  of the p a t i e n t . T h i s c a t e g o r y o f s e r v i c e s may  seem to be some-  what of a " c a t c h - a l l " c a t e g o r y , because the caseworker's work should at a l l times be based on the emotional needs o f client.  the  However, the phrase, as used here, does not have such  a broad scope.  I t r e f e r s o n l y to those s e r v i c e s which h e l p  the p a t i e n t accept environmental r e a l i t y , h e l p him s c i o u s 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 , and  c l a r i f y conhelp  him  2 accept h i s p e r s o n a l l i m i t a t i o n s . Of a l l these f o u r c a t e g o r i e s of d i r e c t s e r v i c e s the p a t i e n t , the most frequent  to  s e r v i c e s are the ones "based on  the emotional needs of the p a t i e n t " (Table 2 ) .  Twenty of  the  25 p a t i e n t s r e c e i v i n g d i r e c t s e r v i c e s r e c e i v e d h e l p i n accepti n g environmental r e a l i t y .  T h i s i s not  s u r p r i s i n g because  "Follow-up" s e r v i c e s are casework s e r v i c e s extended to the p a t i e n t a f t e r h i s d i s c h a r g e from the h o s p i t a l . o Group work s e r v i c e s based on the emotional needs of the p a t i e n t are b e i n g o f f e r e d at the C l i n i c s i n c e Febr u a r y , 1954. However, at the time the p a t i e n t s under s t u d y were h o s p i t a l i z e d , there was as y e t no group worker at the Clinic.  - 26 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 t o 64 P a t i e n t s . Crease C l i n i c .  Direct S o c i a l Services  I  IT  the p h y s i c a l s e t t i n g (e.g. the m e d i c a l treatment the s t a f f other p a t i e n t s  (Number of JTimes S e r vice Given to  14 20 11 14  l o c k e d doors)  Support around a n x i e t i e s r e l a t e d to f a m i l y problems d u r i n g h o s p i t a l i z a t i o n : (1) (2) (3)  III  to P a t i e n t s  Support around a n x i e t i e s r e l a t e d Hospitalization: (1) (2) (3) (4)  Services 1953.  f i n a n c i a l problems care of c h i l d r e n immediate t r o u b l e s i n f a m i l y  10 12 22  relationships  Support around a n x i e t i e s r e l a t e d to d i s c h a r g e plans: (a) Environmental (1) employment (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 a l  I  (b) Emotional . TT7 a n x i e t y r e l a t e d to l o s s of h o s p i t a l security (2) f e a r s about resumption o f f a m i l y relationships (3) preparation f o r follow-up s e r v i c e s IV  9  4 4  10 21  3 8 14  Casework s e r v i c e s based on tbe emotional needs of the p a t i e n t : (1) (2) (3)  help i n help i n in help i n  a c c e p t i n g environmental r e a l i t J c l a r i f y i n g conscious problems interpersonal relationships accepting personal l i m i t a t i o n s  Total direct s o c i a l services  to  patients  20 18 18  1 232  - 27 most mental p a t i e n t s 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 f u n c t i o n 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 and need h e l p i n t h i s a r e a . t a t i o n s was  situations,  Help i n accepting personal l i m i -  extended to 18 p a t i e n t s because such  are a l s o common amongst mental p a t i e n t s .  difficulties  C l a r i f i c a t i o n of  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 another frequent s e r v i c e . who  The p a t i e n t s a r e o f t e n  was persons  have never been a b l e to f e e l comfortable with other  people.  T h e i r 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 c o n t r i b u t i n g to t h e i r e v e n t u a l mental breakdown. These d i f f i c u l t i e s i n s o c i a l r e l a t i o n s h i p s are v i o u s l y given much a t t e n t i o n by the s o c i a l worker at the Clinic.  obCrease  I n d i s c h a r g e p l a n n i n g , 21 of the 25 p a t i e n t s g e t t i n g  d i r e c t s e r v i c e s d i s c u s s e d s o c i a l and r e c r e a t i o n a l  difficulties  and p l a n s 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 s e r v i c e s , f i n a n c i a l  employment problems were most f r e q u e n t l y d i s c u s s e d .  and  However,  i n both these i n s t a n c e s , o n l y t w o - f i f t h s of the p a t i e n t s r e 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 got such h e l p .  P l a n n i n g around hous-  i n g and around housekeeper s e r v i c e s were even l e s s f r e q u e n t . The  i n f r e q u e n c y of the l a t t e r i s probably because o n l y f a m i l i e s  i n which the mother i s i l l  seem to be i n need of housekeeper  services. A l s o s u r p r i s i n g l y i n f r e q u e n t was  h e l p with a n x i e t i e s  of the p a t i e n t about d i s c h a r g e from the C l i n i c .  Less  than  t h r e e - f i f t h s of the p a t i e n t s r e c e i v i n g d i r e c t s e r v i c e s were  prepared f o r f o l l o w - u p s e r v i c e s o f the p r o v i n c i a l S o c i a l Welf a r e Branch o r o f the S o c i a l S e r v i c e Department i t s e l f . of resuming f a m i l y r e l a t i o n s h i p s were d i s c u s s e d  Fears  1  with o n l y  eight  p a t i e n t s , w h i l e l o s s o f h o s p i t a l s e c u r i t y a s a problem came to the a t t e n t i o n o f the caseworkers w i t h only t h r e e  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 z a t i o n and a l l i t s i m p l i c a t i o n s was launched i n t o more f r e quently.  The m e d i c a l treatment caused, n u m e r i c a l l y ,  est a n x i e t i e s .  the g r e a t -  Here, twenty o r f o u r - f i f t h s o f the p a t i e n t s  needed reassurance and support.  The c o n f l i c t with and the  f e a r o f o t h e r p a t i e n t s , 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 direct social services.  Of s i m i l a r frequency was casework sup-  p o r t t o overcome the f r u s t r a t i o n s and f e a r s o f p a t i e n t s l i v i n g i n a h o s p i t a l with locked mented group l i v i n g . i e t y to patients.  doors and with somewhat r e g i -  The s t a f f , a l s o , was a source o f anx-  F i r s t , t h e r e were the people who because o f  t h e i r i l l n e s s f e l t persecuted o r f e a r f u l of people and  about  generally;  secondly, there were complaints by some p a t i e n t s o f not  g e t t i n g enough a t t e n t i o n from the s t a f f .  E l e v e n people r e -  c e i v e d some form o f s e r v i c e from the caseworker i n t h i s a r e a . A c a 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 s c r e e n i n g p a t i e n t s f o r convalescence s e r v i c e s . T h i s was nec e s s a r y because between 68$ and 75% o f a l l p a t i e n t s e n t e r i n g the Crease C l i n i c a r e from the Vancouver a r e a , and t h e r e b y 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 s e r v i c e s l i e s l a r g e l y with t h e l i m i t e d s o c i a l s e r v i c e s t a f f of the C l i n i c . Other reasons why so few p a t i e n t s a r e prepared f o r follow-up s e r v i c e s a r e , amongst o t h e r s , (1) the p r e c i p i t o u s d i s c h a r g e s o f some p a t i e n t s , (2) the d e c i s i o n of the treatment team t h a t such s e r v i c e s s h o u l d n o t be given, and (3) |he l a e k o f s o c i a l r e s o u r c e s i n the p a t i e n t ' s home community. 1  - 29 A n a t u r a l consequence o f the h o s p i t a l i z a t i o n o f these people was the break up o f t h e i r f a m i l i e s .  Most pat-  i e n t s a r e members o f a f a m i l y , and become anxious about what t h e i r absence means t o i t .  T h i s i s r e f l e c t e d i n the request  f o r s o c i a l s e r v i c e s a t the Crease C l i n i c .  Almost a l l the pat-  i e n t s who r e c e i v e d casework h e l p had a n x i e t i e s about immediate problems i n t h e i r f a m i l y r e l a t i o n s h i p s (22 o f the 25 p a t i e n t s ) . Twelve o f the p a t i e n t s sought h e l p with the c a r e of t h e i r dren.  chil-  F a m i l y f i n a n c i a l problems were not v e r y o f t e n d i s c u s s e d  s i n c e most o f the p a t i e n t s were h o s p i t a l i z e d f o r o n l y a s h o r t p e r i o d d u r i n g which many o f them were p r o b a b l y e n t i t l e d to s i c k n e s s b e n e f i t s from t h e i r employer, o r were c a r e d f o r i n some o t h e r way.  Only t e n p a t i e n t s d i s c u s s e d 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. The above s e r v i c e s a r e the d i r e c t s o c i a l s e r v i c e s 1  to p a t i e n t s extended by the s o c i a l workers of the Crease to the 64 p a t i e n t s comprising the sample under study.  Clinic  Many o f  the s e r v i c e s most f r e q u e n t l y given have something i n common-they c e n t r e around r e l a t i o n s h i p s with o t h e r people.  Such s e r -  v i c e s a r e : - h e l p i n c l a r i f y i n g c o n s c i o u s 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 , h e l p with immediate and f u t u r e anxi e t i e s around f a m i l y r e l a t i o n s h i p s , support i n a c c e p t i n g environmental r e a l i t i e s , h e l p with d i f f i c u l t i e s with the s t a f f and o t h e r p a t i e n t s , and support i n p l a n n i n g s o c i a l and r e c r e a t i o n a l c o n t a c t s upon d i s c h a r g e from the C l i n i c . Less frequent a r e s e r v i c e s concerned  with  concrete  matters such as f i n a n c i a l problems, housing, housekeeper s e r -  - 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 p s y c h o l o g i c a l l y s u p p o r t i v e .  The  e a r l y mental  h o s p i t a l s o c i a l workers were mainly concerned with a f t e r - c a r e and  i t s associated  problems, such as housing and  employment.  Though these remain an important t a s k f o r the s o c i a l worker, h i s job has  increased  with the g r e a t e r knowledge and  skills  which the p r o f e s s i o n has accumulated through the y e a r s .  The  a b s t r a c t a s p e c t s o f h i s work—many of the s e r v i c e s 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 i n c r e a s i n g amount of the caseworker's time. D i r e c t S o c i a l S e r v i c e s to P a t i e n t s ' R e l a t i v e s D i r e c t s o c i a l s e r v i c e s to p a t i e n t s ' r e l a t i v e s i n clude a l l those s e r v i c e s which the caseworker g i v e s the medium o f the i n t e r v i e w  to the r e l a t i v e s .  through  These s e r v i c e s  have been d i v i d e d f o r the purpose of a n a l y s i s i n t o the  follow-  i n g f o u r groups. I.  Support around a n x i e t i e s r e l a t e d to the  pat-  i e n t 's h o s p i t a l i z a t i o n . T h i s group of s e r v i c e s c o n s i s t s o f casework h e l p with f e a r s the r e l a t i v e s have about the s e t t i n g of the h o s p i t a l and  physical  i t s e f f e c t upon the p a t i e n t ,  and  support to l e s s e n the f e a r s c o n c e r n i n g the m e d i c a l treatment. II. ient's i l l n e s s .  H e l p around the i n a b i l i t y to accept the T h i s concerns the discomfort  pat-  r e l a t i v e s often  i  The  L o i s Meredith French, P s y c h i a t r i c S o c i a l Work. Commonwealth Fund, New York, 1940.  - 31 -  f e e l about committing tbe patient to a mental h o s p i t a l ,  their  uneasiness about being the "cause" of the patient's breakdown, t h e i r shame at having mental i l l n e s s i n the family, and t h e i r concern about the symptoms of the patient's i l l n e s s . Ill.  Support around s o c i a l problems i n the home.  This includes help with f i n a n c i a l 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 between family members). 17.  Casework services based on the emotional needs  of the patient's r e l a t i v e s . Again t h i s group might appear to be a " c a t c h - a l l " category f o r a l l the services which have not been covered i n the other three groups, because casework services should be based on the emotional needs of people.  How-  ever, f o r the purposes of the present study, the category has been delineated to include only support about personal anxiet i e s , support i n accepting the patient as he or she i s , 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 , and preparation f o r follow-up services. As with the patients, among the most frequent services extended to the r e l a t i v e s was t h e i r emotional needs."  "casework help based on  C l a r i f y i n g the r e l a t i v e s ' conscious  problems i n interpersonal relationships occurred i n twelve cases. xieties.  More frequently.extended was help with personal anThese involved a considerable amount of work on the  part of the s o c i a l worker since, as some of the s o c i a l h i s t o r i e s indicate, the r e l a t i v e s often have numerous personal  - 32 -  d i f f i c u l t i e s which have a b e a r i n g on the p a t i e n t and h i s  ill-  ness.  diffi-  Because these p e r s o n a l  d i f f i c u l t i e s u s u a l l y cause  c u l t i e s f o r the p a t i e n t upon h i s discharge his  from the C l i n i c to  f a m i l y , r e l a t i v e s were prepared i n t h i r t e e n cases f o r the  follow-up  s e r v i c e s o f the p r o v i n c i a l S o c i a l Welfare Branch o r  of the S o c i a l S e r v i c e Department a t the Crease C l i n i c . The most frequent  of the "casework s e r v i c e s based on  emotional needs" proved t o be support t o r e l a t i v e s i n h e l p i n g them understand and accept the p a t i e n t as he i s .  Of the 29  groups o f 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 s e r v i c e s , 23 were helped i n t h i s way.  Understanding and a c c e p t i n g  the p a t i e n t  on the p a r t o f 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 p a t i e n t and h i s f a m i l y .  I t h e l p s the f a m i l y over-  come t h e i r r e l u c t a n c e t o v i s i t the p a t i e n t , and h e l p s a c o n s t r u c t i v e f o r c e i n the p a t i e n t ' s  them be  rehabilitation.  Understanding and a c c e p t i n g the p a t i e n t i s imposs i b l e without understanding and a c c e p t i n g h i s i l l n e s s .  Tbe  symptoms o f mental i l l n e s s c r e a t e much concern f o r the p a t i e n t ' s r e l a t i v e s , and i n 20 cases t h i s was d i s c u s s e d with them by the s o c i a l worker.  They a r e u s u a l l y b a f f l e d by and a f r a i d  of what i s happening t o the p a t i e n t , and a r e o f t e n f e a r f u l o f what he may do.  Almost as f r e q u e n t l y g i v e n a t t e n t i o n by the  s o c i a l worker a r e the r e l a t i v e s * f e e l i n g s o f d i s c o m f o r t h a v i n g committed the p a t i e n t t o the C l i n i c .  They f e e l  about that  t h e y a r e d e s e r t i n g the p a t i e n t a t 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 t o him.  They a r e a l s o  concerned about what the p a t i e n t t h i n k s o f them f o r having him  - 33 -  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 o f 64 P a t i e n t s . Crease C l i n i c . 195?: — 1  Direct S o c i a l Services  to Relatives  Number o f times Serv i c e Given  I Support around a n x i e t i e s r e l a t e d t o p a t i e n t ' s hospitalization: (1) (2)  the p h y s i c a l s e t t i n g the m e d i c a l treatment  I I Help around i n a b i l i t y t o accept illness: (1) (2) (3) (4)  9 21 patient's  discomfort about committal d i s c o m f o r t about b e i n g "cause** o f i l l n e s s shame a t mental i l l n e s s i n f a m i l y concern about symptoms o f i l l n e s s  18 11 8 20  I I I Support around s o c i a l problems i n the home: (1) (2) (3)  f i n a n c i a l problems care of c h i l d r e n disharmony i n f a m i l y r e l a t i o n s h i p s  8 10 25  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) (2) (3) (4)  support around p e r s o n a l a n x i e t i e s support i n understanding and a c c e p t i n g p a t i e n t as he/she i s h e l p i n c l a r i f y i n g c o n s c i o u s problems i n interpersonal relationships preparation f o r follow-up s e r v i c e s  T o t a l d i r e c t s o c i a l services to r e l a t i v e s  21 23 12 13 199  - 34• "locked  up." Discomfort about being the "cause* of the patient's  i l l n e s s , and shame at having mental i l l n e s s i n the family are not as frequently encountered by the s o c i a l worker, but are more serious indications of weakness i n 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 s o l i d a r i t y . ient i s i l l and h i s family i s concerned about him.  The  pat-  However,  discomfort about supposedly being the cause of the patient's mental breakdown, indicates self-depreciation on the part of the r e l a t i v e s or actual serious disharmony within the family. Eleven groups of r e l a t i v e s had such discomforts.  Further,  the  caseworkers, working with the sample under study, helped eight families overcome t h e i r shame at having mentally i l l members. The preoccupation  with "the disgrace" of having mental i l l n e s s  within the family i s again a sign of lack of strength within the family, as well as i n d i c a t i n g an unhealthy attitude to the patient.  The family, i n cases l i k e t h i s , i s apt to see  the  patient as someone harming them rather than seeing him as someone i n need of t h e i r continuing i n t e r e s t and assistance.  It  i s perhaps an i n d i c a t i o n of them l o s i n g sight of the patient as a person. In the group of services centred around the s o c i a l 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 i n family r e l a t i o n s h i p s .  Over f i v e - s i x t h s of the f a m i l i e s r e c e i v i n g d i r e c t s o c i a l ser-  vices were helped i n t h i s manner.  I t indicates that the fami-  l i e s r e c e i v i n g casework help frequently have considerable i n ternal disharmony.  The care of the children needed the s o c i a l  worker's attention i n only ten cases of contact with r e l a t i v e s , while f i n a n c i a l problems were of even l e s s s i g n i f i c a n c e — b e cause of other sources of f i n a n c i a l assistance, and because many patients are not the bread-winners of the f a m i l i e s receiving the services. In looking over the figures of Table 3, which l i s t s the d i r e c t s o c i a l services to the r e l a t i v e s , the outstanding item appears to be the number of r e l a t i v e s r e c e i v i n g help to a l l e v i a t e t h e i r personal anxieties.  Besides the service of  helping to lessen the fears the r e l a t i v e s have about the health and welfare of the patient, a most common service offered by the S o c i a l Service Department i s support to reduce personal fears and to reduce c o n f l i c t s i n family r e l a t i o n s h i p s . As with the services to the patients, here again much of the s o c i a l worker's job centres on the discomforts  of the i n d i v i -  dual i n h i s adjustment with himself and with other people. Generally, the services to the patient and the services to the r e l a t i v e s of the patient are not much d i f f e r e n t , although the i n d i v i d u a l i z e d problems are to a degree. For instance, the i l l n e s s and the h o s p i t a l i z a t i o n of the patient does not mean the same thing to the patient as i t does to the r e l a tive.  The patient gets upset by the physical s e t t i n g of the  h o s p i t a l , while the r e l a t i v e s get upset by speculations of the  -  36  e f f e c t of the h o s p i t a l s e t t i n g on the p a t i e n t .  Most of  the  s e r v i c e s to the p a t i e n t s are aimed at h e l p i n g them a d j u s t o t h e r people.  For instance, planning  f o r the s o c i a l and  c r e a t i o n a l l i f e of the p a t i e n t i s a n u m e r i c a l l y ect s o c i a l s e r v i c e to p a t i e n t s a t the C l i n i c .  to re-  important Most of  dir-  the  s e r v i c e s to the r e l a t i v e s , on the o t h e r hand, are aimed a t h e l p i n g them understand and  accept the p a t i e n t .  T h i s , how-  ever, f r e q u e n t l y n e c e s s i t a t e s h e l p i n g the r e l a t i v e s with t h e i r personal  anxieties.  By s t r e n g t h e n i n g  the ego  of the  family  members, the p a t i e n t ' s f a m i l y can become a s t r o n g source of support to the The  patient. high i n t e g r a t i o n of s e r v i c e s to p a t i e n t s and  to  t h e i r f a m i l i e s (54.3$ of the cases r e 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 k i n d of  s e r v i c e s o f f e r e d to the s i c k and  the  their relatives i s indicative  o f the g e n e r i c nature of casework.  The  problems with which  c l i e n t s come t o s o c i a l work agencies have b a s i c no matter whether the c l i e n t i s a b l i n d man,  similarities,  a person  recover-  i n g from a mental breakdown, a husband whose w i f e i s m e n t a l l y ill,  a delinquent  boy,  or an unmarried mother.  It i s also  g e n e r i c i n that the casework method i n t o t o i s a p p l i c a b l e all  to  these people i n h e l p i n g 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 o t h e r people and  with themselves.  There i s s p e c i f i c knowledge r e l e v a n t  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 h o s p i t a l s h o u l d have.  He must be f a m i l i a r with a l l the a s p e c t s o f the hos-  pital setting—the  treatment regime, the h o s p i t a l r e g u l a t i o n s ,  -  etc.  37  -  However, the o v e r - a l l knowledge, the s k i l l s and tech-  niques of forming a h e l p f u l client-worker  r e l a t i o n s h i p , and  the diagnostic use of s o c i a l resources remain the same i n a l l branches of s o c i a l casework.  "Support around personal  anxie-  t i e s , " "support i n helping" people "understand and accept" other people, "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 , " "support around problems i n the home"—whether environmental or emotional—are f a m i l i a r to a l l up-to-date public or private s o c i a l work agencies.  These ser-  vices are not the sole property of the mental h o s p i t a l s o c i a l worker.  As a matter of f a c t , many s o c i a l workers who do not  work i n a mental hospital are also involved i n the other services more s p e c i f i c a l l y aimed at the mental patient and h i s relatives.  In B r i t i s h Columbia, s o c i a l workers i n the provin-  c i a l S o c i a l Welfare Branch are often c a l l e d upon to a l l e v i a t e r e l a t i v e s ' anxieties about the h o s p i t a l i z a t i o n of the patient, and to help the r e l a t i v e s understand and accept the patient as he i s . Also when, a f t e r assessment, the primary problems appear to be those with which other s o c i a l agencies are p a r t i c u l a r l y equipped to deal through stated service p o l i c y — e.g. family services a n c i l l a r y to those brought to patients and f a m i l i e s by the s o c i a l workers i n a h o s p i t a l setting-—the patients are referred to the other agency following discharge from the C l i n i c .  This agency continues giving the services  which were i n i t i a t e d by the S o c i a l Service Department of the Clinic.  - 38 Indirect Services Indirect services to patients and t h e i r r e l a t i v e s are a l l those services which are f o r the welfare of the patient and h i s 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 .  These services  have been divided into three sections. I. Consultations with other professional people at the C l i n i c . S p e c i f i c a l l y , these consultations took place at ward rounds on which a member of each of the treatment professions i s present; and i n d i v i d u a l l y with doctors, nurses, psychologists, the r e h a b i l i t a t i o n o f f i c e r , and occupational and recreational therapists. II.  Consultations with people outside the C l i n i c .  These consist of any form of communication between the Crease C l i n i c S o c i a l 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 h i s r e l a t i v e s . III.  Diagnostic studies at intake.  These studies  are a c o l l e c t i o n of diagnostic facts about the patient's personality development, and s o c i a l and material environments. Of the f i r s t group of i n d i r e c t services, the most frequent service of the s o c i a l worker occurs at ward rounds. Generally, every patient i s discussed at ward rounds soon a f t e r h i s admission to the C l i n i c . ment plans are usually started.  I t i s here that the t r e a t Consequently, patients are  often referred to the S o c i a l Service Department a t t h i s time.  - 39 T a b l e 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 P a t i e n t s and t h e i r R e l a t i v e s . Crease C l i n i c . '  I n d i r e c t S o c i a l S e r v i c e s t o P a t i e n t s and their Families  I  C o n s u l t a t i o n w i t h i n the h o s p i t a l : (1) (2) (3) (4) (5) (6) (7)  II  i n ward rounds with d o c t o r s with nurses with p s y c h o l o g i s t s with the r e h a b i l i t a t i o n o f f i c e r with the o c c u p a t i o n a l t h e r a p i s t s with the r e c r e a t i o n a l t h e r a p i s t s  64 44 24 6 3 13 2  C o n s u l t a t i o n s with people o u t s i d e the h o s p i t a l : (1) (2) (3) (4) (5)  H I  umber o f Dimes is e r v i c e jiven  with with with with with  members o f Casework agencies members o f group work agencies employers t h e N a t i o n a l Employment S e r v i c e boarding home o p e r a t o r s  Diagnostic studies at intake  T o t a l i n d i r e c t s e r v i c e s to p a t i e n t s and t h e i r families  18 1 4 4 1  30  214  - 40  Consultations and important s e r v i c e . and  -  with the d o c t o r s are another  frequent  These c o n s u l t a t i o n s between the  doctor  the s o c i a l worker keep each informed about the other's  t a t i v e diagnoses (medical  and  s o c i a l r e s p e c t i v e l y ) of the  i e n t , and about the needs of the p a t i e n t and relatives.  They c o - o r d i n a t e  t h e i r work i s p u r p o s e f u l purposes.  and  nine p a t i e n t s and  that  c o n s t r u c t i v e r a t h e r than a t  cross-  the sample under  i n such c o n s u l t a t i o n s .  Of these  44,  t h e i r r e l a t i v e s r e c e i v e d no f u r t h e r s e r v i c e s  from the S o c i a l S e r v i c e Department w h i l e the p a t i e n t was C l i n i c , e i t h e r because i t was ill  pat-  the needs o f h i s  t h e i r treatment p l a n s so  Of a l l the p a t i e n t s comprising  study, 44 were d i s c u s s e d  ten-  decided  i n the  that the p a t i e n t was  to b e n e f i t from casework h e l p or because the p a t i e n t  l e f t the C l i n i c before the s o c i a l worker was  too had  a b l e to see  him.  The  r e l a t i v e s of these people r e c e i v e d no s e r v i c e s f o r reasons  not  stated. Not  q u i t e as frequent  as c o n s u l t a t i o n s with the phy-  s i c i a n s were c o n s u l t a t i o n s with n u r s e s . p a t i e n t s were d i s c u s s e d  Twenty-four of  with the n u r s i n g s t a f f .  c o n s u l t a t i o n s , the s o c i a l worker and  From these  the nurse were a b l e  get a b e t t e r understanding of the p a t i e n t , and able t o be o f g r e a t e r h e l p to him.  the  The  to  thereby were  c o n s u l t a t i o n s were  p a r t i c u l a r l y u s e f u l to the s o c i a l worker, f o r the nurse  has  the o p p o r t u n i t y  day.  to observe and  Consultations occupational  t a l k to the p a t i e n t each  with the r e h a b i l i t a t i o n o f f i c e r ,  t h e r a p i s t s , the r e c r e a t i o n a l t h e r a p i s t s , and  the  -  41  the psychologists are not very frequent. therapists were consulted concerning  The  occupational  thirteen of the pat-  i e n t s 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 i n occupational and recreational therapy, and to get information on how  the patient i s making use of these resources.  The  r e h a b i l i t a t i o n o f f i c e r (there i s only one at present) was  con-  sulted about three of the patients. ing male patients who  His job consists of help-  are referred to him to f i n d employment  upon discharge from the C l i n i c .  The psychologists  with the s o c i a l worker about s i x patients.  conferred  As a r e s u l t of  these consultations, both the s o c i a l worker and the psychol o g i s t 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 i n d i r e c t s e r v i c e s — c o n s u l t a t i o n s with people outside the C l i n i c — i s a more occasional service than the consultations with members of the C l i n i c s t a f f . u a l l y , such c o n s u l t a t i o n s — b y  l e t t e r , telephone, or face-to-  f a c e — o f t e n occur a f t e r the patient has been discharged, i n such cases, have not been included i n the present Eighteen  Act-  but,  study.  of the patients were discussed with other s o c i a l  casework agencies i n 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 f o r the same reason.  Only one patient was discussed with a group  work agency.  Another p a t i e n t found accommodations t o l i v e i n ,  a f t e r the s o c i a l worker had helped him by c o n t a c t i n g boarding home o p e r a t o r s . All relatives  these i n d i r e c t  s o c i a l s e r v i c e s t o p a t i e n t s and  p o i n t out the important  l i a i s o n p o s i t i o n t h a t the  s o c i a l worker h o l d s w i t h i n the mental h o s p i t a l .  He p l a n s w i t h  the o t h e r h o s p i t a l s t a f f and with o u t s i d e s o c i a l r e s o u r c e s f o r the treatment and e v e n t u a l r e h a b i l i t a t i o n Through c a r e f u l l y  of the p a t i e n t .  arranged p l a n s he can b r i d g e the gap between  the l i f e a t the h o s p i t a l and a t home f o r the p a t i e n t . the i n d i r e c t  Without  s o c i a l s e r v i c e s , some p a t i e n t s would l e a v e the  C l i n i c not knowing where t o e a t o r s l e e p .  Others would n o t  seek the s e r v i c e s of another s o c i a l agency, whereby they a r e a b l e t o f i n d h e l p i n o b t a i n i n g the n e c e s s i t i e s o f l i f e , and h e l p in  a l l e v i a t i n g t h e s t r e s s e s which c o u l d d r i v e them t o mental  i l l n e s s again. The i n d i r e c t  s o c i a l s e r v i c e s a l s o show the impor-  tance o f teamwork, not o n l y between members o f the h o s p i t a l s t a f f , but between the h o s p i t a l s t a f f and the s o c i a l in  resources  the community i n which t h e p a t i e n t and h i s f a m i l y a r e l i v i n g .  The f i e l d s o c i a l worker o f the S o c i a l Welfare Branch must be kept informed on the progress o f the p a t i e n t a t the C l i n i c , i f he i s expected to be o f h e l p t o the p a t i e n t and t o t h e f a m i l y in  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  s h o u l d keep the s o c i a l worker a t t h e C l i n i c informed about developments a t home so t h a t t h e l a t t e r can r e a l i s t i c a l l y r e a s s u r e and p l a n with the p a t i e n t .  .,  CHAPTER 3  PATIENTS WHO COME TO THE CREASE CLINIC  C l a s s i f i c a t i o n o f the P a t i e n t s Because t h e purpose o f the present  study i s a s u r -  vey o f s o c i a l and not m e d i c a l s e r v i c e s , the o r i g i n a l to c l a s s i f y patients according  plan,  t o m e d i c a l d i a g n o s i s , was  abandoned.' A compromise had t o be made, however, t o take advantage o f the o p p o r t u n i t y against  for cross-classifying  the s o c i a l s e r v i c e s r e c e i v e d .  patients  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 d i a g noses, and t h i s had t o be abandoned f o r the f o l l o w i n g reason. In t h e f i r s t p l a c e , a l l the p a t i e n t s s e l e c t e d 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 t o f a l l i n t o one broad c a t e g o r y — t h a t o f "emotional inadequacy."  R e l a t i v e s are apt a t f i r s t  t o des-  c r i b e the p a t i e n t a s "the l a s t p e r s o n " they would have believed  t o become m e n t a l l y  ill.  L a t e r , however, they w i l l  o f t e n see the p a t i e n t a s a person who has always attempted t o be s e l f - s u f f i c i e n t , "keeping h i s problems t o h i m s e l f " — i n other words, b e i n g unable t o form c l o s e i n t e r p e r s o n a l ships.  Or, they w i l l d e s c r i b e  relation-  the p a t i e n t as a man who has  always been "happy," but who, on c l o s e r i n s p e c t i o n , has always  - 44 been d r i v e n t o be l i k e d by other people because he f e l t i n secure i n h i s s o c i a l r e l a t i o n s h i p s . d e s c r i b e d by t h e i r r e l a t i v e s ,  Other p a t i e n t s a r e  "now that we t h i n k o f i t , " as  always h a v i n g had an " i n f e r i o r i t y complex," b e i n g etc.  withdrawn,  Of c o u r s e , whether such emotional inadequacy i s c h a r a c -  t e r i s t i c o f the mental p a t i e n t alone i s d o u b t f u l ; some form of emotional inadequacy i s evident i n e v e r y man's l i f e emotional m a t u r i t y i s a matter o f degree.  because  Because o f t h i s and  because of the f a c t that a l l p a t i e n t s seem to f a l l i n t o the " e m o t i o n a l l y inadequate" group, the n e c e s s i t y a r i s e s t o break down "emotional inadequacy" i n t o s m a l l e r components i f i t i s t o he used f o r c l a s s i f i c a t o r y purposes. surement  U n f o r t u n a t e l y , mea-  and a n a l y s i s o f the term "emotional inadequacy"  tends t o be s u p e r f i c i a l , u n l e s s done v e r y 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 t o determine cause and e f f e c t . Each i n d i v i d u a l case has t o be e v a l u a t e d s e p a r a t e l y , and p r e c i s e eval u a t i o n n e c e s s i t a t e s adequate  information.  E v e n t u a l l y , 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 a c c u r a c y  should be sought a s f a r as p o s s i b l e .  The second  criterion  demanded that the c l a s s i f i c a t i o n s h o u l d p o s s i b l y have some r e l a t i o n s h i p t o the s e r v i c e s extended by the S o c i a l S e r v i c e Department a t the Crease C l i n i c .  The people c o m p r i s i n g t h e group  under study were c l a s s i f i e d i n the f o l l o w i n g ways:  according  L o u i s J . Lehrman, "Logic o f D i a g n o s i s , " S o c i a l Casework. May 1954, pp. 192-199. 1  - 45 to age,  sex and m a r i t a l s t a t u s ; the l e n g t h of h o s p i t a l i z a -  t i o n ; and the c o n d i t i o n upon d i s c h a r g e . age  Of these,  sex and  d i f f e r e n c e s had the most obvious c o r r e l a t i o n with t h e s o -  c i a l s e r v i c e s extended, and have t h e r e f o r e been used i n c r o s s c l a s s i f y i n g the s e r v i c e s .  A l s o 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 s e r v i c e s , was t h e c o n d i t i o n o f the p a t i e n t s upon d i s charge, as t h i s comes c l o s e s t to i n d i c a t i n g t h e " f i n i s h e d p r o d u c t " of the work of the s t a f f a t t h e C l i n i c . Who A r e t h e P a t i e n t s ? The  group under s t u d y c o n s i s t s o f 25 men and 39  w o m e n — f i g u r e s that proved t o be on the whole  proportionate  t o the admission f i g u r e s f o r the p e r i o d from which the sample was  s e l e c t e d (237 men and 399 women).  The Crease C l i n i c has  always had more female p a t i e n t s than male, while the P r o v i n c i a l Mental H o s p i t a l has c o n s i s t e n t l y had more men than women.  1  Whether female mental p a t i e n t s have a b e t t e r prog-  n o s i s f o r improvement than male p a t i e n t s , and thereby a r e admitted t o the Crease C l i n i c more f r e q u e n t l y , i s not known. There i s the p o s s i b i l i t y t h a t women seek p s y c h i a t r i c h e l p l i e r i n t h e i r i l l n e s s than men.  ear-  I t seems t o be c u l t u r a l l y un-  masculine t o go t o t h e d o c t o r with minor t r o u b l e s , and wives p r o b a b l y have g r e a t e r d i f f i c u l t y p e r s u a d i n g t h e i r husbands t o see the doctor  than v i c e v e r s a ; p o s s i b l y , a l s o , the bread-  winner needs t o c a r r y on longer before aid  and h o s p i t a l i z a t i o n .  r e s o r t i n g t o medical  However, the d u r a t i o n o f the i l l -  ness has f r e q u e n t l y a d e c i s i v e i n f l u e n c e on the p r o g n o s i s . B r i t i s h Columbia, Annual Report o f the Mental H e a l t h S e r v i c e s . 1953. 1  - 46 The  sooner the p a t i e n t undergoes treatment, the f a s t e r and  more e f f e c t i v e h i s r e c o v e r y . man  -  of about 50, who  1953,  has had  time he had  was  One  1  patient, f o r instance, a  admitted to the Crease C l i n i c i n  b i z a r r e s u s p i c i o n s s i n c e 1936.  T h i s was  come under treatment, though f o r years he had  p r o w l i n g around h i s e s t a t e with a shot-gun t o defend from unknown people. nic,  he was  The  age  was  himself Cli-  poor.  grouping of the p a t i e n t s comprising  between the ages of 25 and  Over two-thirds  45.  the  o f the group are  Approximately 60$  i e n t s a r e over the age of 35 and  of the  pat-  o n l y seven are under the  age  However, d e s p i t e the high p r o p o r t i o n of o l d e r people  i n the sample, o n l y f o u r t e e n had i n a mental i n s t i t u t i o n .  age  been  A f t e r a b r i e f p e r i o d at the Crease  sample i s a l s o i n t e r e s t i n g .  of 50,  first  t r a n s f e r r e d to the P r o v i n c i a l Mental H o s p i t a l  because h i s prognosis  of 25.  the  been p r e v i o u s l y h o s p i t a l i z e d  Of these, sevejfa were over the  which c o n s t i t u t e s over 50%  of the p a t i e n t s w i t h i n  group|. s i x were between the ages of 30 and  50; and  age that  one  was  fourteen years o l d . The m a r i t a l s t a t u s o f the group i s as f o l l o w s : are married, one  37  20 are s i n g l e , 3 are widowed, 3 are d i v o r c e d ,  i s separated.  Of the 20 p a t i e n t s who  and  are s i n g l e , o n e - h a l f  are over t h i r t y years o l d , o f whom seven are male.  Whether  these people are s i n g l e because t h e i r emotional i n s t a b i l i t y makes them u n d e s i r a b l e  W i l l i a m S. S a d l e r , Modem P s y c h i a t r y . C.V. S t . L o u i s , 1945, p. 475. 1  Co.,  p a r t n e r s , or because o f t h e i r  inability Mosby  Fig. 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.  (follows page 46)  46a  NUMBER OF PATIENTS  ioTou,  AGE  isrozfl  30T03I, j5Toy) 1,010^ Iprolfi 5010^ oven. 5 5  Fig. 1.  Age Distribution of a Group of 64 Patients at the Crease C l i n i c , 1953. — :  - 47 to form c l o s e p e r s o n a l r e l a t i o n s h i p s i s u n c e r t a i n , but the case h i s t o r i e s g i v e frequent evidence of such f a c t o r s .  In  any case, out of 59 people over the age of 20, f i f t e e n  are  and always have been u n a t t a c h e d — a  seemingly high  percentage  (25#). D e t a i l e d i n f o r m a t i o n was a v a i l a b l e on over h a l f the m a r r i e d people i n the sample. ious marital d i f f i c u l t i e s .  Over 50% of these had  ser-  Here a g a i n i t was not always c l e a r  whether the d i f f i c u l t i e s a r o s e due t o the d e v e l o p i n g mental illness  o f the p a t i e n t o r whether the d i f f i c u l t i e s had  s i n c e the b e g i n n i n g of the marriage.  existed  However, the g r e a t e s t num-  ber of m a r i t a l d i f f i c u l t i e s c e n t e r e d on e i t h e r symptoms of mental  illness  such as a c c u s a t i o n s by the p a t i e n t that h i s m a r i t a l  p a r t n e r i s u n f a i t h f u l , o r on fundamental and submissiveness.  problems o f dependency  The former i s a stage i n the d e v e l o p i n g  mental i l l n e s s , w h i l e the l a t t e r  i s p r o b a b l y one of the s t r e s -  ses that f o r c e s the p a t i e n t t o seek r e f u g e i n mental  illness.  Where m a r i t a l d i f f i c u l t i e s seemed to be a c o n t r i b u t i n g 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  b a s i c d i f f i c u l t i e s i n the p a t i e n t ' s e a r l i e r  life.  p o i n t i s that of a 40 year o l d married woman who to the Crease C l i n i c  when she was  A case i n was  admitted  two months pregnant.  She  one of s i x t e e n c h i l d r e n of an I t a l i a n - I n d i a n marriage.  She  has always f e l t t h a t everyone  looked down upon her and has  v e r y s t r o n g f e e l i n g s of i n f e r i o r i t y .  D u r i n g her marriage  was  had she  had a number of promiscuous r e l a t i o n s h i p s , but e v e n t u a l l y one of  tbe men  she met,  f e l l i n l o v e with her.  She and t h i s  man  - 48 decided that she should remain w i t h her husband f o r s i x months, a f t e r which she would make a d e c i s i o n as t o her f u t u r e .  At  the end of the s i x months, i n s t e a d of making a d e c i s i o n , she became m e n t a l l y 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 d i v o r c e d people c o n s i s t s o f t h r e e f e -  male p a t i e n t s , a l l over the age was to  of 35.  One  p a t i e n t , a male  separated from h i s wife s h o r t l y before he was the C l i n i c .  The  two  sample are over the age  widows and the one widower of the of 45.  cause of h a l l u c i n a t i o n s due were admitted  admitted  The widower was  admitted  to a l c o h o l i s m , while the two  i n an e m o t i o n a l l y depressed  bewidows  state.  The c o n d i t i o n of the p a t i e n t s upon d i s c h a r g e i s of interest.  A c c o r d i n g t o the p h y s i c i a n s ' assessment, two  of the  p a t i e n t s had r e c o v e r e d , 51 had improved, 8 were unimproved, and t h r e e were u n c l a s s i f i e d a t the time of d i s c h a r g e from the Clinic.  The  c a t e g o r y "improved" seems to c o n s i s t of p a t i e n t s  whose c o n d i t i o n has improved, but who degree o f symptoms o f t h e i r i l l n e s s . covered p a t i e n t s , who  still 1  manifest a v a r y i n g  As opposed to the r e -  appeared to show no symptoms of t h e i r  past i l l n e s s upon d i s c h a r g e (the manic-depressive  patients  and the a l c o h o l i c s with p s y c h o s i s are o f t e n c l a s s i f i e d i n t h i s c a t e g o r y ), the improved p a t i e n t may 1  The  still  be s e r i o u s l y d i s -  c l i n i c a l f i l e s of the p a t i e n t s i n d i c a t e  this.  2 Lawson G. Lowrey, P s y c h i a t r y f o r S o c i a l Workers, Columbia U n i v e r s i t y P r e s s , New York, 1946, p. 168. ~~  49 turbed upon d i s c h a r g e ,  and may have to be re-admitted  h o s p i t a l soon a f t e r h i s r e t u r n t o h i s home. i n g from s c h i z o p h r e n i a  1  t o the  Patients s u f f e r -  f r e q u e n t l y seem t o f a l l i n t o t h i s group  or the "unimproved" group, as do many o f the p a t i e n t s s u f f e r i n g from a s e r i o u s psychoneurosis. p a t i e n t s , s i x were s c h i z o p h r e n i c choneurotic  Out o f the 8 unimproved  and two were c l a s s e d as psy-  (three were s i n g l e and f i v e were m a r r i e d ) .  The  "unimproved" p a t i e n t s would appear t o be those  p a t i e n t s whose c o n d i t i o n upon discharge a p s y c h i a t r i c p o i n t o f view.  remains unimproved from  Lack o f improvement  medically  does not always p r e d i c a t e no "improvement" i n t h e s o c i a l and environmental s i t u a t i o n o f the p a t i e n t .  G e n e r a l l y , an improve-  ment i n t h e p s y c h i a t r i c c o n d i t i o n o f the p a t i e n t w i l l a l s o be noted by the s o c i a l worker.  On the other hand, there a r e im-  provements i n t h e p a t i e n t ' s economic or s o c i a l s i t u a t i o n whereby the p a t i e n t i s a b l e t o r e t u r n t o h i s home—unimproved from a p s y c h i a t r i c view p o i n t .  An i l l u s t r a t i o n emphasizing t h i s i s  i s the f o l l o w i n g : A 34 year o l d s i n g l e man, with simple s c h i z o p h r e n i a , was r e f e r r e d to the S o c i a l S e r v i c e Department f o r s u p p o r t i v e h e l p to a l l e v i a t e p e r s o n a l anxi e t i e s and f o r h e l p with discharge p l a n n i n g . H i s response to medical treatment was u n s a t i s f a c t o r y . I t d i d not l e a d t o any t a n g i b l e r e s u l t s , p r o b a b l y because o f the long-term nature o f 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 t h a t t h e p a t i e n t was unable to m o b i l i z e h i s own r e s o u r c e s and t o take an a c t i v e p a r t i n p l a n n i n g f o r h i s discharge beyond a l i m i t e d p o i n t , requested the r e l a t i v e s t o 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 f a m i l y f r i e n d Between A p r i l 1 s t , 1953 and March 31st, 1954, 810 p a t i e n t s were r e f e r r e d f o r convalescence s e r v i c e s from the soci a l worker, a c c o r d i n g t o the Annual Report of the S o c i a l S e r v i c e Department. x  2  Lawsoh G. Lowrey, op. c i t . , p. 194.  - 50  -  to assume s u p e r v i s o r y r e s p o n s i b i l i t y over the pati e n t . Accommodation arrangements were made p r i o r to the p a t i e n t ' s d i s c h a r g e . The p a t i e n t i s now l i v i n g by h i m s e l f and making good use of h i s l i m i t e d r e s o u r c e s . He has money, i s a b l e to budget, and l i v e s on a s u b s i s t e n c e l e v e l without harming h i m s e l f or other people. He a s sumes c o n s i d e r a b l e r e s p o n s i b i l i t y f o r h i m s e l f ; and w i t h i n h i s l i m i t a t i o n s , he f u n c t i o n s to the maximum of h i s c a p a c i t y , and l e a d s a q u i e t and s e c l u s i v e life. P r i o r t o h i s h o s p i t a l i z a t i o n , he was unable to l o o k a f t e r h i m s e l f . He remains a person who w i l l always be i n need of f i n a n c i a l a s s i s t a n c e 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 t h a t he be p e r m i t t e d to l i v e on h i s own i n the community i f he i s at a l l a b l e t o . The s o c i a l worker was a b l e to help him l e a d a p e r s o n a l l y s a t i s f y i n g l i f e o u t s i d e the h o s p i t a l d e s p i t e the handicap of mental i l l n e s s . F o r t u n a t e l y , most of the p a t i e n t s l e a v e the C l i n i c i n much b e t t e r c o n d i t i o n than the above p a t i e n t .  The l e n g t h of  h o s p i t a l i z a t i o n v a r i e s from i n d i v i d u a l to i n d i v i d u a l , but average term of h o s p i t a l months.  the  confinement a t the C l i n i c i s two  The degree of improvement i s r e l a t e d  to the l e n g t h of  h o s p i t a l i z a t i o n o n l y when the i l l n e s s of the p a t i e n t i s taken i n t o c o n s i d e r a t i o n , too.  The l e n g t h 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 r e c o v e r y .  I n some c a s e s — s u c h  as the manic-  d e p r e s s i v e p a t i e n t s — i m p r o v e m e n t i s u s u a l l y speedy, and o f t e n a complete r e c o v e r y i s a c h i e v e d .  1  p h r e n i c and some p s y c h o n e u r o t i c  In other c a s e s — w i t h  schizo-  patients—improvement i s often o  slow and at times never comes at a l l .  R e s i d u a l s of the  ill-  ness f r e q u e n t l y remain i n the form of o v e r - a n x i e t y , an i n a p p r o p r i a t e tendency to become s u s p i c i o u s , i n a b i l i t y to h o l d a job,  i n a b i l i t y to mix with people, e t c . Lawson, G. Lowrey, op. c i t . , p. 2  I b i d . , p.  194.  168  -51 -  Out  o f the e i g h t p a t i e n t s unimproved on d i s c h a r g e  from the C l i n i c  (see Table 5 ) , three stayed a t t h e C l i n i c f o r  f o u r months o r more.  The t h r e e who remained a t the C l i n i c f o r  l e s s than three months were admitted  on a " v o l u n t a r y " b a s i s ,  which e n t i t l e d them to have themselves d i s c h a r g e d from the C l i n i c upon t h e i r own r e q u e s t .  They l e f t the C l i n i c a g a i n s t the  a d v i c e o f the p h y s i c i a n s .  The two who remained from three t o  f o u r months were d i s c h a r g e d t o the P r o v i n c i a l Mental H o s p i t a l because i t was obvious  that they were i n need o f a l o n g p e r i o d  of h o s p i t a l i z a t i o n .  Table 5.  Condition of p a t i e n t on discharge  Length o f H o s p i t a l i z a t i o n o f 64 P a t i e n t s A c c o r d i n g to C o n d i t i o n on Discharge from Crease C l i n i c . 1953. "~  1 month or l e s s  Period of stay 1 to 2 2 t o 3 3 to 4 months months months  -  Recovered  1  1  Improved  3  23  11  Unimproved  1  1  1  Unclassified  1  5  Total  over 4 months  Total number of patients  -  2  8  6  51  2  3  8  mm  2  -  1  -  27  12  11  9  3 2  64  P a t i e n t s u n c l a s s i f i e d as t o c o n d i t i o n upon d i s charge would appear to be those who were a t the C l i n i c f o r observation only. o  Seven o f these p a t i e n t s were h o s p i t a l i z e d f o r f o u r months and a few days.  - 52 Of i n t e r e s t i s the great number o f p a t i e n t s d i s charged from the C l i n i c w i t h i n the f i r s t hospitalization. t h i s group.  two months o f t h e i r  H a l f the p a t i e n t s i n the sample f a l l  within  Hany people would b e l i e v e t h a t t h i s i s an admir-  a b l e achievement, and there i s no doubt t h a t 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 c o n t r o l o f the Clinic.  The s c a n t y few weeks a t the h o s p i t a l do l i t t l e  apart  from h e l p i n g the p a t i e n t t o r e t u r n t o r e a l i t y from h i s d e l u s i o n s , psychosomatic a i l m e n t s , e t c . term casework s e r v i c e s a r e s t i l l cal  Psychotherapy and l o n g -  very l i m i t e d because o f medi-  and s o c i a l s e r v i c e s t a f f shortages making such time-  consuming help f r e q u e n t l y i m p o s s i b l e .  Physical  medication  s t i l l remains one o f the main weapons o f a t t a c k on mental i l l n e s s w i t h i n the C l i n i c .  E a r l y discharge  t o the home, t h e r e -  f o r e , n e c e s s i t a t e s c o n t i n u a t i o n o f treatment i n o u t - p a t i e n t s  1  c l i n i c s , and no such c l i n i c has y e t been e s t a b l i s h e d i n B r i t i s h Columbia.  At present,  the d i s c h a r g e d  p a t i e n t has the S o c i a l  S e r v i c e Department o f the Crease C l i n i c and t h e p r o v i n c i a l S o c i a l Welfare Branch as r e s o u r c e s ;  i f these do not s u f f i c e ,  the p a t i e n t has no a l t e r n a t i v e but t o r e t u r n t o h o s p i t a l , whereas an o u t - p a t i e n t s ' c l i n i c c o u l d h e l p him t o h o l d on to the gains he made a t the h o s p i t a l , and thereby prevent f u r t h e r hospitalization. In summary, the group o f p a t i e n t s under study comp r i s e s more females than males.  A r a t h e r high percentage o f  the p a t i e n t s a r e s i n g l e , and i n t h e o l d e r age groups there are more s i n g l e men than women.  The ages o f the people i n the  - 53 group r u n from 14 t o 67, but two-thirds between 25 and 45 y e a r s o f age. discharged  o f the p a t i e n t s a r e  Almost a l l the p a t i e n t s a r e  i n an improved c o n d i t i o n a f t e r an average s t a y o f  approximately two months.  Most o f them leave t h e C l i n i c with  some r e s i d u a l s o f t h e i l l n e s s remaining with them. While the p a t i e n t i s s t i l l i n h o s p i t a l , i t i s p a r t o f the s o c i a l worker's job t o prepare the p a t i e n t and h i s r e l a t i v e s f o r such l i m i t a t i o n s ; he can a l s o help  them t o l e a r n t o accept these without  b i t t e r n e s s , s o that they can l e a d a s s a t i s f y i n g a l i f e as poss i b l e upon the d i s c h a r g e  o f the p a t i e n t .  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 o f soc-  i a l s e r v i c e s amongst the t o t a l p a t i e n t group under study. I t was  noted that although a l l the p a t i e n t s r e c e i v e d s o c i a l  ser-  v i c e s , some r e c e i v e d a very l i m i t e d number; other p a t i e n t s were served  e x t e n s i v e l y by the S o c i a l S e r v i c e Department.  A l l the  p a t i e n t s r e c e i v e d the s e r v i c e of d i a g n o s t i c p l a n n i n g a t ward rounds.  However, 29 o f the 64 p a t i e n t s got no f u r t h e r s e r v i c e  w h i l e they were a t the C l i n i c , except f o r f u r t h e r c o n s u l t a t i o n s with t h e p a t i e n t ' s p h y s i c i a n  ( i n nine c a s e s ) .  Who a r e the people who r e c e i v e d f u r t h e r casework h e l p , and who a r e the people who d i d not?  Table 6 shows the  d i s t r i b u t i o n of d i r e c t s o c i a l s e r v i c e s t o p a t i e n t s t o age and sex.  according  The t a b l e i n d i c a t e s that whereas a p p r o x i -  mately 29$ o f the women over 35 y e a r s o f age r e c e i v e d d i r e c t s e r v i c e s , 80% o f the women tinder 35 y e a r s o f age were r e c i p i e n t s o f d i r e c t s o c i a l s e r v i c e s , too.  S i m i l a r l y , o f the men  - 54 over 35 years o f age, o n l y 1% r e c e i v e d d i r e c t s o c i a l  services,  while f o r the group o f men under 35 years o f age the f i g u r e r o s e t o 45$.  I n other words, i n the sample under study,  direct  s e r v i c e s t o p a t i e n t s a r e more f r e q u e n t l y o f f e r e d t o women than men, and t o young women than o l d e r women.  Table 6.  Sex  D i r e c t S o c i a l S e r v i c e s t o 64 P a t i e n t s A c c o r d i n g to Age and Sex, Crease C l i n i c . 1953.  under 35 years o f age  over 35 years o f age  without services  without services  with 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 f a c t o r s i n the s e l e c t i o n o f p a t i e n t s f o r casework help?  While age i s probably one o f the many  f a c t o r s taken i n t o c o n s i d e r a t i o n by t h e S o c i a l S e r v i c e Department i n the s e l e c t i o n o f p a t i e n t s f o r casework h e l p , sex i s undoubtedly  not such a f a c t o r .  Age i s taken i n t o c o n s i d e r a t i o n  to the extent t h a t the o l d e r the person, the more " s e t " he i s i n h i s f e e l i n g , t h i n k i n g and behaviour p a t t e r n s .  Consequently,  he has g r e a t e r d i f f i c u l t i e s i n a d j u s t i n g h i m s e l f t o the e n v i r o n ment.  H i s 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 d i c a t e , i s o f  - 55 -  l o n g e r d u r a t i o n , and thereby l e s s amenable to treatment.  Table 7.  S o c i a l S e r v i c e s to 64 P a t i e n t s A c c o r d i n g t o Age and Sex. Crease C l i n i c . 1953.  Social Services  under 35 years of age  over 35 y e a r s o:f age  male  male  female  Total  female  Direct Services to P a t i e n t s only  3  1  1  1  6  Direct Services to R e l a t i v e s only  1  2  3  4  10  Direct Services to P a t i e n t s and R e l a t i v e s  2  11  6  19  5  1  10  13  29  11  19  14  24  64  Indirect Services only Total  In p r a c t i c e , t h i s i s borne out by t h e number o f o l d e r p a t i e n t s being served through t h e i r r e l a t i v e s .  Table 7  i n d i c a t e s the i n t e g r a t i o n o f s o c i a l s e r v i c e s t o p a t i e n t s and t h e i r f a m i l i e s a c c o r d i n g t o sex and age.  I t shows a h i g h e r  p r o p o r t i o n o f p a t i e n t s over the age o f 35 y e a r s than under the age o f 35 years r e c e i v i n g h e l p not through d i r e c t  social  s e r v i c e s t o themselves, but through d i r e c t s o c i a l s e r v i c e s t o Because the l e n g t h o f the i l l n e s s i s r e l a t e d t o the p r o g n o s i s , long-term p s y c h o t i c s a r e thought not t o be s u i t a b l e f o r admission t o the C l i n i c as they a r e l i k e l y t o need long-term h o s p i t a l i z a t i o n .  - 56 their families.  T h i s i n d i c a t e s that with o l d e r p a t i e n t s  there  i s a g r e a t e r emphasis on h e l p i n g the s o c i a l environment a d j u s t t o the p a t i e n t than v i c e v e r s a . i n g r e l a t i v e s adjust  Despite  t h i s emphasis on h e l p -  t o the o l d e r p a t i e n t s , more r e l a t i v e s o f  younger p a t i e n t s get d i r e c t s o c i a l s e r v i c e s .  These s e r v i c e s t o  r e l a t i v e s o f younger p a t i e n t s are a l s o more f r e q u e n t l y with the d i r e c t s o c i a l s e r v i c e s t o the p a t i e n t . s o c i a l s e r v i c e s i s p a r t i c u l a r l y frequent  integrated  Integration of  amongst female p a t i e n t s  under the age o f 35. Out o f 15 women under t h e age o f 35, e l e ven r e c e i v e d s o c i a l s e r v i c e s f o r themselves, as w e l l a s r e c e i v i n g f u r t h e r s e r v i c e through casework h e l p t o t h e i r f a m i l i e s . The  frequent  i n t e g r a t i o n o f s e r v i c e s t o female p a t i e n t s and  t h e i r f a m i l i e s suggests one o f the reasons f o r t h e g r e a t e r  fre-  quency o f s o c i a l work h e l p t o female p a t i e n t s than t o male p a t ients.  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 o f l o o k i n g a f t e r the  c h i l d r e n and t h e home d u r i n g the absence o f the mother, r a i s e s d i f f i c u l t i e s f o r the f a m i l y , and i s a source o f a n x i e t y t o t h e mother.  Of the t e n m a r r i e d women r e c e i v i n g d i r e c t s o c i a l  v i c e s , nine discussed  t h e i r a n x i e t i e s about the c a r e o f t h e i r  c h i l d r e n with the s o c i a l s e r v i c e worker.  I n a d d i t i o n , the  f a m i l i e s o f these nine women a l s o r e c e i v e d d i r e c t s o c i a l vices.  ser-  ser-  T h i s i n d i c a t e s that need a s w e l l as a b i l i t y t o p r o s -  per through casework help i s the b a s i s on which p a t i e n t s a r e selected f o r social services.  The f a m i l y i n which the mother  i s absent through i l l n e s s f r e q u e n t l y presents need f o r s e r v i c e s than other s i t u a t i o n s .  a more  extensive  - 57 Table 8.  Social  S o c i a l S e r v i c e s t o 64 P a t i e n t s A c c o r d i n g t o T h e i r M a r i t a l S t a t u s , Crease C l i n i c . 1953.  Divorced o r Widowed Services Single Married P a t i e n t s P a t i e n t s Separated Patients Patients  Total  Direct Services to P a t i e n t s only  3  2  Direct Services to R e l a t i v e s only  2  8  Direct Services to P a t i e n t s & Relatives  7  9  1  2  19  Indirect Serv i c e s only  8  18  2  1  29  20  37  4  3  64  Total  6  1  10  There seems t o be no other s i g n i f i c a n t a s s o c i a t i o n between the m a r i t a l s t a t u s o f the p a t i e n t s and the s o c i a l v i c e s (Table 8 ) .  ser-  Three out of every f i v e s i n g l e p a t i e n t s o r  t h e i r r e l a t i v e s r e c e i v e d casework h e l p .  The m a r r i e d p a t i e n t s  were helped i n j u s t o v e r h a l f the cases,  while two-thirds  widowed and one-half a l s o served.  of the separated  o f the  o r d i v o r c e d p a t i e n t s were  D i r e c t s e r v i c e s to r e l a t i v e s o n l y , were extended  more f r e q u e n t l y t o the f a m i l i e s o f married p a t i e n t s , i n d i c a t i n g that casework help t o t h i s group o f p a t i e n t s i s l e s s f r e q u e n t l y i n t e g r a t e d perhaps because o f the i l l n e s s o f the p a t i e n t , than f o r the other groups.  T h i s i s f u r t h e r borne out by t h e f a c t  t h a t s i n g l e p a t i e n t s r e c e i v e d d i r e c t s e r v i c e s more o f t e n (50$)  - 58 p a t i e n t s (30%).  than married  More frequent  d i r e c t s e r v i c e s to  s i n g l e people may be owing t o the l a c k o f support  from a f a m i l y  relationship. There a l s o appears t o 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 s e r v i c e s and the l e n g t h of h o s p i t a l i z a t i o n o f the p a t i e n t s (Table 9).  The persons s t a y i n g f o r more than  f o u r months and t h e i r r e l a t i v e s , were extended s o c i a l s e r v i c e s most f r e q u e n t l y (6fi$ o f those s t a y i n g over f o u r months). P a t i e n t s remaining w i t h i n the C l i n i c f o r l e s s than f o u r months r e c e i v e d casework h e l p o r were extended s o c i a l s e r v i c e s through t h e i r f a m i l i e s i n approximately h a l f the cases.  Direct s e r v i c e s to  the p a t i e n t s , t h e r e f o r e , show an i n c o n s i s t e n t i n c r e a s e with an i n c r e a s e i n the l e n g t h of h o s p i t a l i z a t i o n of the p a t i e n t .  Table  Social  9.  S o c i a l S e r v i c e s to 64 P a t i e n t s A c c o r d i n g t o the Length o f H o s p i t a l i z a t i o n . Crease C l i n i c . 1953T  Services  P e r i o d o f Stay 1 month 1 t o 2 2 to 3 3 to 4 over 4 or l e s s months months months months  Direct Services to P a t i e n t s only  Total 1 u lax  3  1  1  1  6  Direct Services to R e l a t i v e s only  1  6  1  1  1  10  Direct Services to P a t i e n t s & Relatives  2  5  5  3  4  19  I n d i r e c t Serv i c e s only  3  13  5  5  3  29  6  27  12  10  9  69  Total  - 59  -  S e r v i c e s a c c o r d i n g to the c o n d i t i o n of the p a t i e n t upon d i s c h a r g e relation and  (a p s y c h i a t r i c assessment) a g a i n showed no  (Table 10).  cor-  Over h a l f of the improved, unimproved  u n c l a s s i f i e d p a t i e n t s or t h e i r f a m i l i e s r e c e i v e d casework  help.  The r e c o v e r e d p a t i e n t s were helped  o n l y i n h a l f the  c a s e s , but the f i g u r e f o r these i s f a r too s m a l l to draw any c o n c l u s i o n s from.  Table 10.  Table 10 a l s o i n d i c a t e s t h a t the  "unimproved  S o c i a l S e r v i c e s t o 64 P a t i e n t s A c c o r d i n g to T h e i r C o n d i t i o n upon D i s h c a r g e . Crease C l i n i c . 1953. ~  Social Services  Recovered Improved Unimproved U n c l a s s i f i e d T o t a l  Direct Services to P a t i e n t s only Direct Services to R e l a t i v e s only  1  Direct Services to P a t i e n t s & Relatives  6  4  1  7  2  16  2  1  19  1  10  Indirect Services only  1  24  3  1  29  Total  2  51  8  3  64  p a t i e n t s are served as f r e q u e n t l y as other p a t i e n t s . proved p a t i e n t has few  The  s t r e n g t h s w i t h i n h i m s e l f , and the  worker seeks to f i n d f o r him f u r t h e r s t r e n g t h s i n the environment.  0  unimsocial  social  Because of t h i s , a h i g h e r percentage of unimproved  p a t i e n t s ' r e l a t i v e s r e c e i v e d d i r e c t s o c i a l s e r v i c e s 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 S o c i a l Service Department.  I t 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 s o c i a l services according to the  marital status of the patients, the length of h o s p i t a l i z a t i o n , 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 v i s i b l e c o r r e l a t i o n to the giving of s o c i a l services to patients and t h e i r f a m i l i e s .  CHAPTER  SUMMARY AMD  4  IMPLICATIONS  Summary and Assessment At tbe beginning of t h i s study, tbe  responsibilities  of the s o c i a l caseworker i n a mental h o s p i t a l were o u t l i n e d . They can i n v o l v e him a t every phase of the p a t i e n t s ' and families'  s o c i a l needs.  The  their  techniques of h e l p i n g 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 e l a t i o n s h i p s were d e s c r i b e d by outlining  four different  ways of g i v i n g h e l p :  s u p p o r t i v e and  s u s t a i n i n g h e l p 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 c o n s c i o u s problems, i n f o r m a t i o n - t y p e of h e l p , and environmental  help.  A l l these techniques of g i v i n g help  are aimed a t h e l p i n g the c l i e n t h e l p h i m s e l f . To achieve the purpose of t h i s s t u d y — t h e a n a l y s i s of s o c i a l s e r v i c e s to mental p a t i e n t s - - i t  was  necessary  to  d e f i n e the s p e c i f i c s e r v i c e s of s o c i a l workers to p a t i e n t s and  their relatives.  In o t h e r words, the f i r s t t a s k was  f i n d out what the s o c i a l worker does. t i t a t i v e statement  to  Only then c o u l d a quan-  be made as t o casework h e l p i n a mental  hospital. S i n c e there was  a p p a r e n t l y no p r e v i o u s  classifica-  t i o n of s o c i a l casework as p r a c t i c e d with the m e n t a l l y i l l , special  c l a s s i f i c a t i o n was  a  d e v i s e d f o r the present study. T h i s  - 62 -  was done by v i s u a l i z i n g the needs of the p a t i e n t and h i s f a m i l y a s he moves through h i s p e r i o d of h o s p i t a l i z a t i o n — from admission to d i s c h a r g e . long l i s t  To a v o i d the c o n f u s i o n  of a  of u n r e l a t e d matters, the s e r v i c e s were grouped i n  the f o l l o w i n g manners  (1) d i r e c t s e r v i c e s to p a t i e n t s ;  (2) d i r e c t s e r v i c e s t o p a t i e n t s ' r e l a t i v e s ; and (3) i n d i r e c t s e r v i c e s to p a t i e n t s and t h e i r r e l a t i v e s .  D i r e c t s e r v i c e s to  p a t i e n t s were d e f i n e d as a l l those s e r v i c e s which were through t h e s o c i a l worker-patient i n t e r v i e w s .  given  Direct ser-  v i c e s t o p a t i e n t s ' r e l a t i v e s i n c l u d e d a l l the s e r v i c e s which were obtained  by the r e l a t i v e s o f the p a t i e n t s through case-  work i n t e r v i e w s .  I n d i r e c t s e r v i c e s were d e f i n e d as those  s e r v i c e s which were f o r the welfare  of the p a t i e n t o r h i s  f a m i l y , and c o n s i s t e d of the t h e r a p e u t i c  use of s o c i a l r e -  sources. The mitted  p a t i e n t s s t u d i e d were 64 people who were ad-  t o t h e Crease C l i n i c between A p r i l 1 s t , 1953, and  September 30, 1953.  They were s e l e c t e d by a r o u t i n e  sampling  procedure. The  d i s t r i b u t i o n o f s e r v i c e s among the people com-  p r i s i n g the sample was shown t o vary c o n s i d e r a b l y to person. service.  from person  A l l o f the p a t i e n t s r e c e i v e d some form of i n d i r e c t  However, only 25 o f the 64 p a t i e n t s r e c e i v e d d i r e c t  s e r v i c e s , while s e r v i c e s to r e l a t i v e s were not much more f r e quent.  The present  administrator  o f the S o c i a l S e r v i c e Depart-  ment s t a t e d that a l l the p a t i e n t s a t t h e C l i n i c and t h e i r  - 63 r e l a t i v e s c o u l d b e n e f i t from casework h e l p .  However, because  coverage of a l l p a t i e n t s by the S o c i a l S e r v i c e Department was  attempted at one time and was  situation  f o r p r o f e s s i o n a l casework p r a c t i c e , the p o l i c y  s e l e c t i o n was as was  found to be an unworkable  adopted.  The s i t u a t i o n  was  of  unworkable because,  seen i n Chapter 2, the tasks of the s o c i a l worker have  i n c r e a s e d c o n s i d e r a b l y i n the past years with the of knowledge and t e c h n i q u e s .  accumulation  The a b s t r a c t a s p e c t s o f h i s w o r k -  many of the s e r v i c e s 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 i n c r e a s i n g amount of the worker's  social  time. N a t u r a l l y , with t h i s i n c r e a s e , the s o c i a l worker  can no l o n g e r c a r r y as l a r g e a c a s e - l o a d as he used t o , i f he i s to give the q u a l i t y of s e r v i c e he i s q u a l i f i e d to g i v e . is largely  through a r e a l i z a t i o n of t h i s that there i s a  It  conti-  nual demand by most s o c i a l s e r v i c e agencies f o r more s o c i a l caseworkers.  With l a r g e c a s e - l o a d s , s o c i a l workers f i n d i t  i m p o s s i b l e to g i v e t h e i r c l i e n t s more than s u s t a i n i n g h e l p , which p r e s e r v e s the s t a t u s quo  but does no more f o r most c l i e n t s .  They have the o p p o r t u n i t y of h e l p i n g only a few s e l e c t e d people r e g a i n the s t r e n g t h and s o c i a l r e s o u r c e s needed f o r a b e t t e r s o c i a l and p e r s o n a l adjustment.  I n the l o n g view, t h e r e f o r e ,  the c o n d i t i o n of too few caseworkers perpetuates case-loads.  the l a r g e  On the o t h e r hand, with enough caseworkers, case-  l o a d s w i l l be s m a l l from the b e g i n n i n g , and W i l l remain so, because people w i l l be helped than be supported  to s t a n d on t h e i r f e e t r a t h e r  i n d e f i n i t e l y by one  or another  social  agency—  - 64 as i s so o f t e n the case today.  The  e v e n t u a l emotional  and  f i n a n c i a l s a v i n g s would, i t i s claimed by some a u t h o r i t i e s , outweigh many times the c o s t of the a d d i t i o n a l s a l a r i e s i n curred.  1  However, u n t i l such time when t h e r e are s u f f i c i e n t  caseworkers a v a i l a b l e to h e l p 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 o n l y p r a c t i c a l  solution.  Though a d m i n i s t r a t i v e l y 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 q u e s t i o n f o r s o c i e t y , i f i t s h o u l d become a permanent measure r a t h e r 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 s c a r c e r e s o u r c e s .  Selection re-  s u l t s i n an a r b i t r a r y system of g r a n t i n g s o c i a l s e r v i c e s to i n d i v i d u a l p a t i e n t s , d e s p i t e the p r i o r i t i e s g i v e n to those who  can p r o f i t most from the s e r v i c e s .  O b v i o u s l y , the 39 pat-  i e n t s not r e 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 have a l s o 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  p u b l i c s e r v i c e s as the 24 p a t i e n t s r e c e i v i n g casework h e l p . Equal o p p o r t u n i t i e s — w h e t h e r f o r every Man  to education or to mental h e a l t h —  i s the b a s i s of democracy.  t a r y e d u c a t i o n i s o f f e r e d to everyone who  At p r e s e n t , elemeni s capable of l e a r n -  i n g ; however, s o c i a l s e r v i c e s at the Crease C l i n i c are not made a v a i l a b l e to everyone who  i s i n need of them and  capable  of u s i n g them. S o c i a l S e r v i c e s are P e r s o n a l The study a l s o confirmed ger a p r o f e s s i o n concerned  that s o c i a l work i s no  p r i m a r i l y with g i v i n g f i n a n c i a l  lonand  S t u a r t X. J a f f a r y , "Probation of the A d u l t O f f e n d e r , " The Canadian Bar A s s o c i a t i o n . November 1949, pp. 1020-1040. 1  - 65 m a t e r i a l a i d t o people which i s so o f t e n the concept layment have o f the p r o f e s s i o n .  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 m a t e r i a l needs.  The main reason f o r t h i s seems t o l i e i n the other r e -  sources a v a i l a b l e t o the p a t i e n t and h i s f a m i l y i n t h e i r home community.  Employers p r o v i d e  agencies provide  s i c k n e s s b e n e f i t s , and p u b l i c  financial aid.  Furthermore, the p a t i e n t ' s  h o s p i t a l i z a t i o n a t the C l i n i c i s f r e q u e n t l y not so l o n g a s t o cause f i n a n c i a l embarrassment, l o s s o f 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. g r e a t e r importance i s the e x i s t e n c e  Of n u m e r i c a l l y  o f the s o c i a l and psycho-  l o g i c a l needs o f t h e p a t i e n t and h i s f a m i l y which have been des c r i b e d i n t h i s study. Therefore,  i n s t e a d o f being aimed a t m a t e r i a l needs,  most o f the s e r v i c e s o f the s o c i a l caseworker a t the Crease C l i n i c a r e d i r e c t e d towards h e l p i n g the p a t i e n t and h i s f a m i l y make adjustments i n t h e i r r e l a t i o n s h i p s with other people i n the s o c i a l environment.  Other n u m e r i c a l l y  important s e r v i c e s o f  the s o c i a l caseworker were the s e r v i c e s r e l a t e d to the h o s p i t a l i z a t i o n o f the p a t i e n t .  P a r t i c u l a r l y frequent  was case-  work h e l p with a n x i e t i e s o f the p a t i e n t and o f h i s r e l a t i v e s about the m e d i c a l treatment. Although t h e i n d i v i d u a l i z e d problems o f the two groups were shown t o be somewhat d i f f e r e n t , the s e r v i c e s t o p a t i e n t s and r e l a t i v e s were found t o be s i m i l a r .  The problems were d i f -  f e r e n t i n that they were experienced by d i f f e r e n t p e o p l e — b y the s i c k person and by h i s 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  s e r v i c e s t o the two  -  groups e x e m p l i f i e d  t i o n s of s o c i a l work.  the g e n e r i c  In a d d i t i o n , i t was  founda-  pointed  casework s e r v i c e s i n a mental h o s p i t a l are not  out  that  significantly  d i f f e r e n t from the s e r v i c e s of o t h e r casework a g e n c i e s . These s i m i l a r i t i e s i n s e r v i c e s should, however, not meaning "the same s e r v i c e s . " and  The  services d i f f e r i n quality  i n t e n s i t y from person to person and  each o t h e r .  The  personal  be taken as  are not an  "image" of  q u a l i t y of the casework r e l a t i o n s h i p  accompanies each s e r v i c e , 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 s e r v i c e s to p a t i e n t s and  their relatives  i n d i c a t e d the i n t e g r a t i v e p o s i t i o n which the s o c i a l caseworker h o l d s between the mental h o s p i t a l and  the home community o f  the p a t i e n t .  use  Through the t h e r a p e u t i c  of s o c i a l  resources,  he b r i n g s to the a i d of the p a t i e n t and h i s f a m i l y r e s o u r c e s aimed at the treatment and  r e h a b i l i t a t i o n of the p a t i e n t ,  as  w e l l as the r e s o u r c e s aimed at h e l p i n g the p a t i e n t to remain mentally  healthy. The  a n a l y s i s o f i n d i r e c t s e r v i c e s a l s o showed  extent of teamwork w i t h i n the C l i n i c . i n t e r - d i s c i p l i n e contacts the m e n t a l l y i l l .  "The  p a t i e n t " i s known to be ious professions  the  There were numerous  to achieve p u r p o s e f u l  treatment of  q u a l i t y o f treatment a f f o r d e d to "wholly dependent on how  can work together.  i n v o l v e s some knowledge and  respect  the  a b l y the  var-  A b i l i t y to work t o g e t h e r f o r other professional  s k i l l s , an understanding of human behaviour, and an  ability  - 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 v a r i o u s p r o -  f e s s i o n s must be c o n s t a n t l y e v a l u a t e d and p u r p o s i v e l y developed if  treatment  i s to be adequate.*  1  Goals f o r the Future At p r e s e n t , the S o c i a l S e r v i c e Department of the Crease C l i n i c i s f a c e d by a number o f d i f f i c u l t i e s . be d i v i d e d i n t o two and those caused those caused  groups: those caused  These can  by i n s u f f i c i e n t  by l a c k o f community r e s o u r c e s .  The  staff,  first,  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 s e v e r i t y of the problem i s , however, not  n o t i c e d i n the present study as i t i s o n l y concerned i a l s e r v i c e s d u r i n g the p a t i e n t ' s h o s p i t a l i z a t i o n .  with  soc-  Many of  the p a t i e n t s l e a v e the C l i n i c soon a f t e r casework h e l p  has  been i n i t i a t e d , and the g r e a t e r p a r t of the s o c i a l worker's job i n such cases o f t e n f o l l o w s upon the d i s c h a r g e of the patient.  The s h o r t - t e r m p e r i o d of h o s p i t a l i z a t i o n a t the  Clinic  c r e a t e s a h i g h t u r n - o v e r of p a t i e n t s , and many of the 1200  pat-  i e n t s admitted a n n u a l l y are i n need of a f t e r - c a r e s e r v i c e s . The second group of d i f f i c u l t i e s o f the Crease S o c i a l S e r v i c e Department, those caused  Clinic  by the l a c k of s o c i a l  r e s o u r c e s , are probably even more s e r i o u s than the  first.There  i s a need f o r an o u t - p a t i e n t ' s c l i n i c to which the p a t i e n t c o u l d t u r n f o r h e l p a f t e r h i s d i s c h a r g e from h o s p i t a l . 1  G e r a l d Pepper, op. c i t . . p.  2  This  94.  The need f o r such a c l i n i c and f o r o t h e r s o c i a l r e s o u r c e s i s demonstrated i n Mr. Sutherland's t h e s i s , op. c i t .  - 68 would not n e c e s s a r i l y 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 o f a f t e r - c a r e s e r v i c e s , but would a t l e a s t be a r e s o u r c e where the p a t i e n t c o u l d get the h e l p which the s o c i a l worker i s not competent to g i v e .  At such a  c l i n i c the p a t i e n t would be a b l e to a v a i l h i m s e l f of p s y c h i a t r i c and other s e r v i c e s which a r e a t present o n l y a v a i l a b l e i n i n s t i tutional settings.  Besides t h e o u t - p a t i e n t s * c l i n i c , there i s  the need f o r s u p e r v i s e d boarding h o m e s — p a r t i c u l a r l y f o r the m e n — t o which p a t i e n t s can move upon t h e i r d i s c h a r g e .  Among  o t h e r r e s o u r c e s needed, t h e r e i s the need f o r s e r v i c e s o f v o l u n t e e r s t o enable  the p a t i e n t t o v i s i t h i s f a m i l y and v i c e  versa during h i s h o s p i t a l i z a t i o n .  The l o n g d i s t a n c e  between  the p a t i e n t ' s home and t h e C l i n i c , and t h e r a t h e r high c o s t o f t r a n s p o r t a t i o n t o and from t h e C l i n i c , o f t e n makes i t d i f f i c u l t and c o s t l y , and sometimes i m p o s s i b l e , f o r such v i s i t s to take place. Research i n S o c i a l Work The end r e s u l t o f r e s e a r c h i s new knowledge.  In  s o c i a l work t h i s means a knowledge o f what i s b e i n g done, o f what needs t o be done, and how t o do i t .  Through r e s e a r c h , t h e  s e r v i c e s b e i n g g i v e n , the e f f e c t i v e n e s s o f these s e r v i c e s , the l a c k s i n s o c i a l r e s o u r c e s , the improvement can be measured.  i n techniques, e t c .  E v a l u a t i v e r e s e a r c h , p a r t i c u l a r l y , i s needed.  I t i s necessary f o r the f o l l o w i n g reasons: (1) I t measures the extent o f the s o c i a l s e r v i c e programme, i . e . the adequacy i n coverage o f the people  needing  s e r v i c e s , and the adequacy o f the s e r v i c e s i n b e i n g h e l p f u l t o  - 69 -  the people. (2) Through p e r i o d i c assessments, i t shows the changes i n the s o c i a l s e r v i c e programme, and thereby makes p r e d i c t i o n of f u t u r e t r e n d s p o s s i b l e . (3) I t p r o v i d e s d a t a t o the p u b l i c and t o f i n a n c i a l a p p r o p r i a t i n g bodies as to the need and u s e f u l n e s s o f s o c i a l s e r v i c e s i n the l i f e of a community. The  e s s e n t i a l s t e p s i n e v a l u a t i v e r e s e a r c h can  "summarized under f i v e headings:  (1) i d e n t i f y i n g  be  the g o a l s t h a t  are being sought; (2) a n a l y s i n g the problems with which the a c t i v i t y , * i . e . s o c i a l work, "must cope; (3) d e s c r i b i n g and 1  s t a n d a r d i z i n g the a c t i v i t y ; (4) measuring the degree of change t h a t 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 o t h e r  cause. I n the present study, the g o a l s of the s o c i a l worker i n the mental h o s p i t a l were seen as b e i n g treatment, t i o n and p r e v e n t i o n of mental i l l n e s s .  rehabilita-  These g o a l s were put  i n t o " o p e r a t i o n a l 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 the s o c i a l worker to the p a t i e n t and h i s f a m i l y .  of  Analyzing  the problems of the p a t i e n t s and t h e i r r e l a t i v e s , and d e s c r i b i n g and s t a n d a r d i z i n g the a c t i v i t y of the s o c i a l worker were achieved i n one s t e p .  The a c t i v i t y , o r s e r v i c e s , of the soc-  i a l worker were d e s c r i b e d i n Chapter  2 as the c o u n t e r p a r t of  David G. French, An Approach to Measuring R e s u l t s i n S o c i a l Work. Columbia U n i v e r s i t y P r e s s , New York, 1952, p. 44. 1  - 70 each o f the needs t h a t the p a t i e n t s and t h e i r f a m i l i e s might have.  Measuring the degree o f change that has taken p l a c e i n  the c l i e n t ' s p s y c h o - s o c i a l s i t u a t i o n was not attempted i n t h i s study.  However, the p s y c h i a t r i c assessment o f the c o n d i t i o n  o f the p a t i e n t was used, and found t o be an u n s u i t a b l e f o r measuring r e s u l t s i n s o c i a l work. l u a t i v e r e s e a r c h , determining became thereby One  index  The l a s t s t e p i n eva-  cause and e f f e c t r e l a t i o n s h i p s ,  irrelevant. o f the p r e r e q u i s i t e s o f e v a l u a t i v e r e s e a r c h i s  the a v a i l a b i l i t y of i n f o r m a t i o n , i . e . s o c i a l casework r e c o r d i n g must g i v e the p e r t i n e n t i n f o r m a t i o n .  The Crease C l i n i c  r e c o r d i n g d i d not l e n d i t s e l f t o an a n a l y s i s o f s o c i a l s e r v i c e s t o p a t i e n t s and t h e i r r e l a t i v e s .  The use of a q u e s t i o n -  n a i r e such as the one employed f o r t h i s study i s p r o b a b l y  less  p r e c i s e than i f " p r o v i s i o n i s made f o r o b t a i n i n g measures o f r e s u l t s before any s e r v i c e s i s g i v e n . "  1  N a t u r a l l y , the r e c o r d i n g a t the C l i n i c was never intended f o r the purpose o f r e s e a r c h a n a l y s i s o n l y .  The main  purpose o f r e c o r d i n g i s and should remain t h a t o f a t o o l f o r g i v i n g more e f f e c t i v e s e r v i c e t o the c l i e n t .  However, s i n c e  r e s e a r c h i s an i n t e g r a l p a r t o f s o c i a l work, c e r t a i n a d a p t a t i o n s c o u l d be made i n the r e c o r d i n g t o f a c i l i t a t e r e s e a r c h . adaptations  Such  c o u l d be j u s t i f i e d not o n l y f o r the long-term bene-  f i t s which would emanate from the r e s e a r c h that would then ensue, but from what i s , probably,  a l s o an e f f i c i e n t casework  David G. French, An Approach to Measuring R e s u l t s i n S o c i a l Work, p. 60. 1  - 71 practice. The present and a number o f other s t u d i e s have shown that i t i s p o s s i b l e to analyze s o c i a l s e r v i c e s adequately s p e c i f i c components.  into  S t a n d a r d i z a t i o n i n t o such components i s  e s s e n t i a l f o r r e s e a r c h , and cannot be "achieved without  thor-  ough p l a n n i n g beforehand and conscious c o n t r o l and r e c o r d i n g throughout t r e a t m e n t . "  1  I f s t a n d a r d i z a t i o n i n r e c o r d i n g can-  not be j u s t i f i e d because o f time l i m i t a t i o n s and h i g h  case-  l o a d s , p e r i o d i c summaries and c l o s i n g summaries o f treatment a c t i v i t i e s s h o u l d a t l e a s t be kept.  Such summaries a r e v a l -  uable not o n l y from a r e s e a r c h p o i n t o f view, but a r e a l s o u s e f u l as an a i d i n treatment; ment o f the treatment to treatment.  they g i v e an a c c u r a t e  assess-  p l a n , and o f the response o f the p a t i e n t  P e r i o d i c summaries with r e - e v a l u a t i o n o f the  t e n t a t i v e s o c i a l d i a g n o s i s and of the treatment  p l a n a r e pro-  f e s s i o n a l p r a c t i c e s i n h e r e n t f o r c o n s t r u c t i v e s e r v i c e t o the client. Prom a r e s e a r c h p o i n t o f view, p e r i o d i c and c l o s i n g summaries a r e p a r t i c u l a r l y v a l u a b l e i f the i n f o r m a t i o n contain i s standardized. f o l l o w i n g informations  they  They s h o u l d i n c l u d e some o f the (a) the problem o r problems f o r which  the c l i e n t r e q u e s t s h e l p ; (b) o t h e r problems which the s o c i a l worker sees i n the c l i e n t * s s i t u a t i o n ; diagnosis;  (d) the treatment  (c) a tentative s o c i a l  a c t i v i t i e s i n the p a s t ;  r e a c t i o n o f the c l i e n t t o these treatment  (e) the  activities;  ^"~David G. F r e n c h , An Approach t o Measuring R e s u l t s i n S o c i a l Work, p. 65.  - 72 -  ( f ) e v a l u a t i o n o f the e f f e c t i v e n e s s o f and t h e changes being made i n the treatment The way.  plan.  i n f o r m a t i o n should be given i n a s t a n d a r d i z e d  F o r i n s t a n c e , the summary of the treatment  p l a n may con-  s i s t o f a l i s t i n g of the areas i n which h e l p i s b e i n g 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 , h e l p with  planned,  difficulties  i n a d j u s t i n g t o the h o s p i t a l , e t c . I t may a l s o c o n s i s t o f the techniques t h a t were planned i n f o r m a t i o n , reassurance, client  t o the treatment  t o h e l p the c l i e n t , e.g. g i v i n g  support, e t c . The r e a c t i o n o f the  p l a n can be given f o r the p l a n as a  whole, e.g. e x c e l l e n t , good, f a i r , e t c . ; o r , i f a t a l l adm i n i s t r a t i v e l y p o s s i b l e , the movement o f the c l i e n t towards the s o l u t i o n o r a l l e v i a t i o n o f each of h i s problems can be s t a t e d . With a l l t h i s i n f o r m a t i o n a v a i l a b l e , i t would be p o s s i b l e t o a n a l y z e the problems o f the c l i e n t s who come f o r h e l p to the agency; the h e l p they need; the s e r v i c e s they get; and the e f f e c t i v e n e s s o f these s e r v i c e s i n a s s i s t i n g them.  * *  &  (QUESTIONNAIRE USED IN SURVEY  .Which o f t h e f o l l o w i n g s e r v i c e s d i d you e x t e n d t o . . . . Flease A  check o f f under t h e a p p r o p r i a t e D I R 3 C T  S 3- R V I C E 3  ?  column f o r e a c h s e r v i c e TO  listed.  P.ATIE N T  DC1-  S u s n o r t around a n x i e t i e s r e l a t e d t o 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. m e d i c a l t r e a t m e n t , (3) t h e s t a f f (4) other patients w , II  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 hospitalizstion: (1) (2) (3)  .II  f i n a n c i a l problems ( f a m i l y 'without'money e t c . ) cay-e o f c h i l d r e n ., , 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 )  Support around a n x i e t i e s r e l a t e d t o d i s c h a r g e (a) E n v i r o n m e n t a l (1) (2) (3) (4) (5)  during  plans:  en.' lcyment .. housing housekeeper s e r v i c e s f i n a n c i a l problems s o c i a l and r e c r e a t i o n .  .....  (b) E m o t i o n a l (1) (2)  (3.) IV  a n x i e t y r e l a t e d t o l e s s of h o s p i t a l s e c u r i t y f a m i l y r e l a t i o n s h i p s (e.g. i s my w i f e c c i n f ; t o understand me now?)..... preparation for followup services ,  Casework s e r v i c e s based on the e m o t i o n a l needs o f t h e p a t i e n t : (1) (2)  help i n accepting environmental r e a l i t y . . . h e l p i n c l a r i f y i n g c o n s c i o u s problems i n i n t e r p e r s o n a l relationships.... (3) • h e l p i n a c c e p t i n g p e r s o n a l 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 I  D I R E C T  S E R V I C E S  TO  R E L A T I V E S  Support around a n x i e t i e s related, to p a t i e n t ' s h o s p i t a l i z a t i o n : «  II  III  (1)  the p h y s i c a l s e t t i n g  (2)  t h e medical  treatment  (1)  uncornfort about c o i ' ^ x i t t a l  (2) (3) (U)  uncomfort about b e i n g "cause" o f i l l n e s s shame a t mental, i l l n e s s i n f a m i l y concern about symptoms o f i l l n e s s ( a f r a i d delusions etc. of patient)  f i n a n c i a l problems care o f c h i l d r e n . . . family r e l a t i o n s h i p s  Casework s e r v i c e s based on t h e emotional  (3) (4)  needs o f t h e r e l a t i v e s :  T C  P A T I E N T S  Consultations within the h o s p i t a l : (1) (2) (3) (4) (5) (6) (7) (8)  ward rounds doctor... nurse psychologist rehabilitation officer. occupational therapist..... recreational therapist industrial therapist...  Consultations with outside (1) (2) (3) (4) (5) (6)  III  '.  support around p e r s o n s ! a n r i e t i e s support i n u n d e r s t a n d i n g and a c c e p t i n g p a t i e n t as he/she i s . . . . . . h e l p i n c l a r i f y i n g c o n s c i o u s problems i n i n t e r p e r s o n a l relationships ' preparation f o r follow-up s e r v i c e s . . . . .  I K D I H E C - T -S E R V I C E S  II  • of t h e  Support around s o c i a l problems i n home:  (1) (2)  I  •  Help around i n a b i l i t y t o a c c e p t . i l l n e s s :  (1) (2) (3.) IV  (food, o t h e r p a t i e n t s ) . .  resources:  casework agency groupwork agency employers,. boarding home o p e r a t o r s . . . . . . . . . . . . . . . r a t i o n a l Employment S e r v i c e s o t h e r {not i n c l u d i n g f a m i l y )  Diagnostic studies at intake • m a  •UI.'I.Z.'I.-UULJ.I.a-i:i  i.":  '•: 'UL  . ^rinrirrrirtnr^trifirjrrnnr:. c-inhr  YES'"| NO  ohTr  DOh  1  i-i:cw  BIBLIOGRAPHY  S p e c i f i c References  Books; French, David G., An Approach to Measuring Results i n S o c i a l Work, Columbia University Press. New York, 1952. French, Lois Meredith, Psychiatric S o c i a l Work. The Commonwealth Fund, New York, 1940. Hunt, J . McV. and Kogan, Leonard S., Measuring Results i n S o c i a l Casework. Family Service Association of America, New York, 1950. Lowrey, Lawson G., Psychiatry f o r S o c i a l Workers, Columbia University Press, New York, 1946. A r t i c l e s . Reports and Other Studies: Been, Elizabeth Brockett, "Psychiatric S o c i a l Work i n 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, J a n u a r y , 194 7.  " P s y c h i a t r i c f S o c i a l Work P o s s i b i l i t i e s i n a Mental Hospital," Journal of Psychiatric Social Work. Spring, 1949. B r i t i s h Columbia, Annual Report of the Mental Health Services, Queen's P r i n t e r s , V i c t o r i a , 1952. Group f o r the Advancement of Psychiatry, "The Psyc h i a t r i c S o c i a l Worker i n the Psychiatric Hosp i t a l , " Report No. 2. January, 1948. Pepper, Gerald Wesley, S o c i a l Worker P a r t i c i p a t i o n i n the Treatment of the Mentally 111. Master of S o c i a l Work Thesis, University of B r i t i s h Columbia, 1953. Peters, P.R., "Current Practice i n a State Hospital," Journal of Psychiatric S o c i a l Work, March, 1953.  - 75 -  General References  Books; Hamilton, Gordon, Theory and P r a c t i c e o f S o c i a l Case Work, Columbia U n i v e r s i t y P r e s s , New York, 1951. K a s i u s , Cora, e d i t o r , P r i n c i p l e s and Techniques i n S o c i a l Casework, F a m i l y S e r v i c e A s s o c i a t i o n o f America, 1950. A r t i c l e s and Reports; Beck, Samuel J . , and o t h e r s , "The P s y c h i a t r i c S o c i a l Worker i n Research," 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. A p r i l , 1953. B e l l s m i t h , E t h e l B., "Recent Developments i n T r e a t ment i n Mental H o s p i t a l s , " 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. March, 1952. Lehrman, L o u i s J . , "Logic of D i a g n o s i s , " work, May, 1954.  S o c i a l Case-  

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