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The rehabilitation of discharged mental patients : analysis of the rehabilitation needs and resources… Sutherland, Robert Murray 1954

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THE REHABILITATION OF DISCHARGED MENTAL PATIENTS An Analysis of the R e h a b i l i t a t i o n Needs and Resources of a Sample Group of Male Patients Leaving Crease C l i n i c , 1952-53•  hy  ROBERT MURRAY SUTHERLAND  Thesis Submitted i n P a r t i a l Fulfilment of the Requirements f o r the Degree of MASTER OF SOCIAL WORK in, the School of S o e i a l Work  Accepted as conforming to the standard required f o r the degree of Master of S o c i a l Work  School of S o c i a l Work  195^  The University of B r i t i s h Columbia  iii Abstract The return of the patient to the community i s the goal of i n s t i t u t i o n a l treatment programs f o r mentally i l l persons. The attention and e f f o r t made i n recent years toward improved care of mental patients i n h o s p i t a l has also Included consideration of the material and emotional needs of the patient at the point of leaving the h o s p i t a l . This study examines the discharge situations of male patients treated at the Crease C l i n i c of Psychological Medicine at Essondale; and describes the r o l e of s o c i a l workers i n patients* re-establishment i n the community. The needs and problems revealed by the study are examined i n the perspective of a comprehensive r e h a b i l i t a t i o n service f o r discharged mental patients. The method used i n the study was t o compile pertinent information from the ease records of 100 male patients discharged i n a recent year. The information was extracted from the case records by means of a schedule. From t h i s Information was tabulated some of the common needs of patients leaving Crease C l i n i c , An analysis was then made of resources within the C l i n i c and i n the community at large whereby the recorded needs might be met, A s e l e c t i o n of case summaries was made to i l l u s t r a t e some t y p i c a l problems. The f a c t u a l material i l l u s t r a t e d the v a r i e t y and frequency of r e h a b i l i t a t i o n needs For the mental patient these included not only material needs f o r housing and a job, but also intangible needs f o r support and help with continuing emotional stress* The i n t e r r e l a t i o n s h i p of outer material needs and inner emotional problems was noted. I t was found that needs f o r housing and a job were a problem f o r approximately one patient i n f i v e ; and that the proportion of patients who required help with inner stresses was approximately one i n three. An examination of the resources available f o r meeting needs revealed s i g n i f i c a n t gaps and l i m i t a t i o n s i n the provision of subsidized boarding care and i n the financing of vocational t r a i n i n g . An o v e r - a l l deficiency was apparent i n the numbers of p r o f e s s i o n a l l y trained s o e i a l workers*, 0  In the concluding chapter there i s suggested an operational d e f i n i t i o n of r e h a b i l i t a t i o n : a process whereby needs are met which enable the patient to become re-established as a c i t i z e n . There i s a discussion of ways and means of narrowing the gap between needs and resources, and of the r o l e of the s o c i a l worker i n community action. The development of s o c i a l welfare resources f o r discharged mental patients i s r e l a t e d t o a network of community f a c i l i t i e s concerned both with c i v i l i a n r e h a b i l i t a t i o n and with mental health maintenance.  iv  Acknowledgements  I w i s h t o express my thanks and a p p r e c i a t i o n t o a l l those whose I n t e r e s t and a c t i v e h e l p have made t h i s study p o s s i b l e , I p a r t i c u l a r l y acknowledge w i t h g r a t i t u d e t h e d i r e c t i o n , c r i t i c i s m s and c o u n s e l o f t h e f o l l o w i n g p e r s o n s : Dr, Leonard C. Marsh and Miss M u r i e l C u n l l f f e , o f t h e S c h o o l o f S o c i a l Work, U n i v e r s i t y o f B r i t i s h Columbia; Dr, F . E . McNair, C l i n i c a l D i r e c t o r , and the members o f t h e S o c i a l S e r v i c e Department o f t h e 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 , E s s o n d a l e , B r i t i s h Columbia,  ii TABLE OF CONTENTS Chapter 1*  Mental I l l n e s s and R e h a b i l i t a t i o n  Page  Mental i l l n e s s and s o e i a l welfare. H i s t o r i c a l antecedents. S o c i a l work i n mental h o s p i t a l s . S o c i a l work at Essondale. Modern concept of r e h a b i l i t a t i o n . Post-discharge problems of Crease C l i n i c patients. Method of Study Chapter 2.  1.  common Needs i n R e h a b i l i t a t i o n  The common needs of people. The sample group. Problems of housing. Needs i n vocational adjustment. Extra-mural treatment needs. R e h a b i l i t a t i o n as a process of meeting needs. • Chapter 3 .  29*  Resources f o r Meeting Needs  The caseworker's use of resources. Hospital personnel. E x i s t i n g community f a c i l i t i e s i n Greater Vancouver and i n r u r a l areas. Some specialized resources© I l l u s t r a t i o n s from four t y p i c a l cases. • • • • Chapter W.  53.  The Development of a Comprehensive R e h a b i l i t a t i o n Service  Summary of f i n d i n g s . Resources within the h o s p i t a l . Developing resources i n the community. Administrative auspices. The s o c i a l worker and community action. Conclusion • • • • • • • •  77.  Appendices: A. B.  Sample Schedule Form. Bibliography. TABLES  Table 1,  R e h a b i l i t a t i o n needs of 100 male patients discharged from Crease C l i n i c .  38.  Table 2.  Destination of discharged patients f o r whom after-care was not indicated. . . . . . . . . . .  39.  Table 3 .  Patients with more than one need. • •  • *K>*  V  The R e h a b i l i t a t i o n of Discharged Mental Patients  Chapter 1  Mental I l l n e s s and R e h a b i l i t a t i o n  Hie maintenance of good physical and mental health, and the restoration of the i l l to a state of well-being has long been an organized concern of s o c i e t y  c  Generally speaking, concern f o r  the care and treatment of mentally i l l persons has developed h i s t o r i c a l l y at a slower pace than concern with p h y s i c a l breakdowns i n health.  The reasons f o r t h i s slower pace appear to be  that the causes of physical i l l n e s s are easier to detect, and also that fears and superstitions are generated by some of the more bizarre manifestations of so-called i n s a n i t y .  These fears and  superstitions have been considerably but not t o t a l l y resolved by the contributions of modem psychiatry, which provides a foundation f o r understanding and orderly c l a s s i f i c a t i o n of mental diseases. This: basis of understanding l i b e r a t e d the dynamic i n man's s o c i a l consciousness so that s o c i a l welfare philosophy and leadership could be p o s i t i v e l y directed and mobilized to meet the needs of the: mentally sick.  iL resultant trend was the tendency to counter-  act any popular f e e l i n g o f physical and emotional i s o l a t i o n of the mental i n s t i t u t i o n from the conimunity.  The attitude was cultivated  that the mental h o s p i t a l was a community resource to which mentally disturbed c i t i z e n s could come f o r treatment and afterward return  to t h e i r homes,  A great deal of emphasis; i n recent decades has  "been directed to i n s t i t u t i o n a l treatment, and only more recently has- s p e c i f i c attention become focussed on comprehensive programs f o r post-hospital care and re-establishment.  In t h i s paper mental  i l l n e s s i s seen within the philosophical framework of s o c i a l welfare, wherein r e l i e f f o r the mentally distressed Is dispensed by community agencies on a basis of s e l f respect. There are various ways of approaching the subject of mental i l l n e s s , but i n general the s o c i a l worker views such i l l n e s s as symptomatic of mental or emotional disturbance r e s u l t i n g i n i n a b i l i t y to participate normally i n s o c i a l r e l a t i o n s h i p s .  Since  the problem i s not e s s e n t i a l l y one of unusual overt behavior but i s concerned with basic personality functioning and s o c i a l r e l ationships, i t follows that treatment and restorative programs f o r the mentally i l l are seen i n t h i s context.  Such programs  take cognizance of the underlying f a c t o r s contributing to the personality disturbance.  We seek to understand the various  underlying f a c t o r s - p h y s i o l o g i c a l , psychological,; s o c i o l o g i c a l , f  e t c . - i n terms of t h e i r dynamic i n t e r - r e l a t i o n s h i p s , i n order to aid the person who i s mentally i l l to achieve greater harmony within himself and i n r e l a t i o n s h i p to h i s fellows. According to s o c i a l welfare concepts, bringing a i d to the mentally i l l rests on the philosophical premise that every human being i s of worth, to be accorded dignity, and having a r i g h t to aid i n time of need.  The needs of the mentally i l l have always  been d i f f i c u l t to comprehend f u l l y , and society has not always acknowledged even basic dependency needs as worthy of humane  3 consideration. H i s t o r i c a l Antecedents The "basis f o r the r a t i o n a l and s c i e n t i f i c treatment of diseases including the insane, was l a i d by Hippocrates ( +60-370 B.C.), 1  known as "the father of medicine".  The therapy b u i l t upon t h i s  basis by the humane Greek medical pioneers was succeeded f o r many centuries by a superstitious mixture of astrology, alchemy, magic r i t e s , with the accompanying b e l i e f i n demoniacal possession and the practice of burning "witches".  The early colonists c a r r i e d  over with them from Europe to America these same superstitions regarding mental i l l n e s s .  Probably because of concern with the  immediate problems of existence, public provision f o r handicapped persons In these early days was based not so much upon humane considerations as upon s o c i a l expediency and economy, with a general attitude of coldness and contempt, rather than sympathy and understanding. The introduction and development of welfare measures came i n the l a t t e r part of the eighteenth century i n the wake of progressive forces released by the p o l i t i c a l and s o c i a l revolutions i n America and France (1776 and 1789).  In America, many of the  early experiments i n s o c i a l welfare were i n i t i a t e d by the Quakers. In 1773. the f i r s t separate i n s t i t u t i o n f o r the insane i n America was established at Williamsburg, Virginia!. The reform measures, of t h i s revolutionary era were given added impetus by three pioneers i n psychiatry: Rush i n America,  Deutsch, Albert, The Mentally 111 i n America.; A History o f Their Care and Treatment from C o l o n i a l Times. Columbia Univers i t y Press.; New York; 19^6.  known as "the father of American psychiatry"; P i n e l i n France, who had the chains removed from the insane and started treatment based on kindness and sympathy; and Tuke i n England, who provided a protected i n s t i t u t i o n f o r patients who were treated as guests rather than inmates.  At the beginning of the Nineteenth Century,  profound s o c i a l forces were i n ferments the repercussions of the I n d u s t r i a l Revolution; the Poor Law Reform movement i n Great B r i t a i n ; and reform studies i n the United States. Supplementing  the " r a t i o n a l reform" measures of men  like  P i n e l , Tuke, and Rush, there appeared i n 18^1 the unique persona l i t y of Dorothea Lynde Dix, with whom i s associated "moral reform". As a r e t i r e d school teacher nearing f o r t y , her career as a reformer started with the i n s t r u c t i o n of a Sunday School class i n a j a i l i n Boston.  Her protest against the treatment there, e s p e c i a l l y  of the insane persons who were "locked up", started her on a crusade that eventually took her on inspection tours of the mental hospitals i n the United States, B r i t a i n , Canada and Europe.  In  nearly every instance, her inspection and campaign l e d to the erection of anew h o s p i t a l or the enlargement  of an e x i s t i n g one.  It was the s i g n i f i c a n t advances at the turn of the twentieth century which heralded the coming of age of psychiatry i n America. Along with the r i s e of reform movements, p o l i t i c a l , economic, s o c i a l : there was a s t r i v i n g f o r new goals i n the f i e l d of s o c i a l welfare.  Relative to the care of the mentally sick there were  developed new f a c i l i t i e s and techniques i n professional t r a i n i n g for s t a f f , and i n research; the r i s e of out-patient departments and psychopathic hospitals, and the beginnings of the employment of s o c i a l casework techniques i n the care and treatment of the  5  mentally i l l .  Climaxing these progressive developments was the  founding of the Mental Hygiene Movement i n 1909 by C l i f f o r d Beers, a former mental p a t i e n t who wrote a s t r i k i n g account of h i s own experiences i n h i s book "A Mind That Found I t s e l f " .  Forging as  an instrument the N a t i o n a l Committee f o r Mental Hygiene, Beers set himself t o the task of d i r e c t i n g p u b l i c a t t e n t i o n t o the prevention of mental sickness and t o s e t t i n g up arrangements f o r a working partnership between the p u b l i c and p s y c h i a t r y . He succeeded i n awakening the p u b l i c conscience and i n gearing the r e s u l t a n t emotional energy t o a p r a c t i c a l program of medical and s o c i a l engineering which continues t o the present time.  This  movement had f a r - r e a c h i n g repercussions not only i n r a i s i n g standards of care f o r mentally i l l persons, but a l s o i n the s t i m u l a t i o n of p u b l i c and p r o f e s s i o n a l education i n mental hygiene, i n the opening of doors f o r the i n t e g r a t i o n of mental hygiene thought, philosophy, and p r a c t i c e i n t o such d i s c i p l i n e s and f i e l d s as medicine, s o c i a l work, education, r e l i g i o n and i n d u s t r y . S o c i a l Work i n Mental H o s p i t a l s The r e l a t i o n s h i p of s o c i a l work w i t h p s y c h i a t r y i n the t r e a t ment of the mentally i l l was a s i g n i f i c a n t f a c t o r i n the development of the p r o f e s s i o n of s o c i a l work.  The r e l a t i o n s h i p had i t s  formal beginning i n 1906 w i t h the employment of s o c i a l workers i n Manhattan State H o s p i t a l , New York C i t y , where s o c i a l workers v i s i t e d p a t i e n t s ' families: t o o b t a i n Information needed by the 1 p s y c h i a t r i s t s about t h e i r p a t i e n t s ' l i v e s . Later the f u n c t i o n of _  1951.  •  •  '  •  '  ~"  '  "  Lucas, Leon. " P s y c h i a t r i c S o c i a l Work". S o c i a l Work.Year Book. American A s s o c i a t i o n of S o c i a l Workers, New York. p. 360.  6 preparing f a m i l i e s f o r return of patients t o their homes was added.  Impetus to t h i s trend was provided by the dynamic approach  o f Dr. A. Meyer, a p s y c h i a t r i s t who  i n s i s t e d i t was not enough to  study the individual, as an i s o l a t e d unit and that i t was  as impor-  tant to study the environment from whence he came and to which he might return.  As s o c i a l workers became the established contact  between the h o s p i t a l and the community they were also involved i n making provision for the indigent insane, and i n looking after families of breadwinners incapacitated by mental i l l n e s s . During t h i s period, one of the most serious questions confronting s o c i a l workers was  the readjustment of mental patients  returning from hospitals to normal community l i f e , and t h i s concern has remained to the present day.  I t was  s o c i a l workers that patients discharged  the early experience of as cured often were- unable  to readjust themselves to community l i v i n g .  Without a u x i l i a r y  a i d , patients might experience another mental breakdown and require readmittance to the hospital.. The environmental conditions to be met upon return to society were never quite the same as when the patient was f i r s t h o s p i t a l i z e d . Often he was hindered with obstacles, one of the most d i f f i c u l t of which was  new  the stigma of  insanity with which the patient of an asylum was branded. -Whereas the patient cured of pneumonia or typhoid or appendicitis might return to take up h i s a f f a i r s at the point where h i s temporary i l l n e s s had interrupted h i s normal routine, the recovered mental patient was  a marked man.  He had been "crazy", and according  the popular legend, "once insane, always insane".  to  Consequently  his r e l a t i o n s with acquaintances and even with h i s family were  l i k e l y to be strained.  Under t h i s s t r a i n some minds gave way  again* r e s u l t i n g i n the person becoming s o c i a l l y inadequate or having to be readmitted to a mental i n s t i t u t i o n . Another concern of the s o c i a l worker was the fact that frequently when a. patient has improved enough to be returned to the  community, h i s discharge had to be delayed because of socio-  economic d i f f i c u l t i e s .  There might not be any home or family to  whom he could go, or he might f i n d i t impossible to get employment at once so as to be self-supporting.  "Often, i n such instances  there, remained only one of two choices f o r the h o s p i t a l superintendent, neither of which could be a s a t i s f a c t o r y ones the patient could be retained i n the h o s p i t a l or be transferred to the poorhouse, where he might spend the rest of h i s l i f e as an unhappy 1  public dependent."  T h i s s i t u a t i o n posed a. problem i n s o c i a l  welfare f o r the solution of which no medium or agency existed. There were no f a c i l i t i e s whereby the recovered patient could be given comprehensive help and advice to enable him to start on the  road to independence. The e a r l i e s t attempts at solution to the problem of the care  of the discharged mental patient arose from "the after-care movement", which had i t s beginnings i n Germany i n 1829, and was duced to America during the 1890s.  intro-  "The p r i n c i p l e behind t h i s  movement was to provide adequate f i n a n c i a l , medical and moral assistance to patients discharged from mental h o s p i t a l s , i n order to a i d t h e i r adjustment to the outer world and to check  -  Deutsch, op c i t , p.289.  8 1 relapses due to s o c i a l handicaps." I t i s interesting to note that the i n i t i a l assignment of what was probably the f i r s t psychiatric s o c i a l worker i n America consisted of aiding the Manhattan After-Care Committee.  Other h o s p i t a l d i s t r i c t after-  care committees were soon organized, t h e i r major purpose being to f i n d suitable homes and employment f o r needy ex-patients, to render other s o c i a l services as needed, and to exercise general supervision over them during the period immediately following t h e i r discharge.  "Such were the beginnings of d i r e c t c o l l a b o r 2  ation between s o c i a l workers and p s y c h i a t r i s t s i n America." The integration of s o c i a l work with mental health services received added stimulation during and following World War  1.  The services of s o c i a l workers were desired f o r the program of treatment and r e h a b i l i t a t i o n of returning soldiers suffering from war neuroses and psychoses.  The need f o r trained psychiatric  s o c i a l workers was so acute that the National Committee f o r Mental Hygiene proposed the establishment of a t r a i n i n g school f o r such s o c i a l workers. the  In Canada the f i r s t course was inaugurated at  University of Toronto i n 1919. During these years the association of s o c i a l work with psy-  chiatry was one of the factors i n bringing about a s h i f t of emphasis on the part of s o c i a l workers i n t h e i r approach to s o c i a l need.  Their focus of concern shifted from the broader environ-  mental factors underlying s o c i a l i l l s to the developing of casework technio ues a r i s i n g from a deeper understanding of i n d i v i d u a l x  I b i d , p.289. 2 I b i d , p.290.  9 personality afforded by dynamic psychiatry.  There was a gradual  modification from an exclusive i n t e r e s t i n external problems  1  toward i n c l u s i o n of treatment of personality d i f f i c u l t i e s .  In  dealing with the socio-economic problems precipitated by the Great Depression, s o c i a l workers effected a comfortable balance of s o c i o l o g i c a l and psychological factors; i n t h e i r approach to human needs.  The learning gained by psychiatric s o c i a l workers i n the  mental health f i e l d was u t i l i z e d by other s p e c i a l i s t s i n the general f i e l d of s o c i a l work. B r i t i s h Columbia In c o l o n i a l days the problem of caring f o r mentally  ill 2  persons was solved e a s i l y by sending the patients back to B r i t a i n . For a time, arrangements were made f o r the shipment of patients to C a l i f o r n i a to be cared f o r i n i n s t i t u t i o n s there;  Later,  patients were kept i n gaols or i n the Royal Hospital i n V i c t o r i a . B r i t i s h Columbia became a province i n 1871 and i n the following year the Royal Hospital became the f i r s t o f f i c i a l mental h o s p i t a l i n the new province.  Due to overcrowding, new quarters were  f i r s t acquired on the present  s i t e of the Woodlands School i n  1877-78; and a new i n s t i t u t i o n was l a t e r established at Essondale i n 1910. The administration of the early hospitals l a i d emphasis on kind and humane treatment of patients..  I  '  An attempt was made to  Garrett, Annette. " H i s t o r i c a l Survey of the Evolution of Casework". Journal of S o c i a l Casework. June, 19^9. 2: Sources of the information i n the following two sections are Master of S o c i a l Work Theses by B i r c h , Sophie (1953); Clark, Richard (I9V7); and Pepper, Gerald (1953). See bibliography for titles.  10  provide patients with comfortable l i v i n g quarters and a p l e n t i f u l supply of nourishing food. The h o s p i t a l personnel kept i n mind that patients would be returning to t h e i r homes; every e f f o r t  was  put f o r t h to keep a l i v e t h e i r i n t e r e s t i n a c t i v i t i e s i n which they would normally p a r t i c i p a t e outside the h o s p i t a l .  I t was  recognized  that the family played an important part i n the r e h a b i l i t a t i o n of the patient as i t was  f e l t that the "attention and care a r i s i n g  from family a f f e c t i o n was 1  conducive to r e s t o r a t i o n of mental  health". The turn of the 2 0 t h Century saw a more organized approach to the treatment of the mentally i l l as w e l l as a more progressive philosophy  i n the care of patients.  The p r i n c i p l e of  segregation  and the use of hydrotherapy are i l l u s t r a t i v e of progressive measures which were gradually In 1919  introduced.  the Canadian National Committee f o r Mental Hygiene,  following I t s survey of the mental i n s t i t u t i o n s , suggested the employment of s o c i a l workers i n connection with the Mental Hospital, with a view to increasing the numbers of patients to be placed on probation.  As early as 1 9 0 1 ,  patients had been allowed to leave  the hospital"on a s i x month t r i a l basis and i f t h e i r adjustment proved s a t i s f a c t o r y during that period, they were discharged i n full.  The committee f e l t that the recovery would be more l a s t i n g  i f the patients could be assisted i n t h e i r r e h a b i l i t a t i o n by s o c i a l workers, thus obviating a possible return to the h o s p i t a l . In 1930 the Committee i n s t a l l e d i n the p o s i t i o n of s o c i a l worker Report of the Medical Superintendent of the P r o v i n c i a l Asylum f o r the Insane, New Westminster. B.C., for the year ending December 3 1 , lb"97.  11  at Essondale Miss Josephine Kilburn, Registered Nurse; and the following year she was retained by the P r o v i n c i a l Government to e s t a b l i s h a s o c i a l service department.  The chief aim and purpose  of the new department was to secure more d e t a i l e d information regarding the home l i f e and conditions of the patients which heretofore had not been a v a i l a b l e . artment was a. follow-up  Another function of the dep-  service to patients a f t e r discharge to  a s s i s t i n t h e i r re-establishment  i n the community.  S o c i a l Work at Essondale The nature of the r e s p o n s i b i l i t y f o r treatment which i s allocated to the psychiatric s o c i a l worker i s determined by several f a c t o r s : the type of mental i n s t i t u t i o n , i t s organization and auspices, i t s t r a i n i n g or research emphasis, and the philosophy and s k i l l of the s t a f f .  The Group f o r the Advancement of Psychiatry  of the American Psychiatric Association considers that the t r e a t ment of the mentally i l l i s primarily a community r e s p o n s i b i l i t y and that the mental h o s p i t a l i s a treatment f a c i l i t y of the community, rather than i t s dump-pile f o r the disposal of human wreckage. 1  The goal of treatment i s seen as return to community l i v i n g . At the administrative l e v e l the treatment of patients i n both the P r o v i n c i a l Mental Hospital and the Crease C l i n i c of Psychological Medicine i s considered  to be "a t o t a l push r e l a t i o n -  ship s i t u a t i o n " which i s patient centered.  I t includes the whole  of physical medicine as well as the more s p e c i f i c therapies per-  _  taining to psychiatry.  I t i s the treatment philosophy  of P r o v i n c i a l  Group f o r the Advancement of Psychiatry. "The Psychiatric S o c i a l Worker i n the Psychiatric Hospital". Report Number 2 . January 1 9 ^ .  12 Mental Health Services that the problems of mental disease w i l l never be solved by any one group of professional workers, and the co-operation and coordination of a l l groups both professional and otherwise i s e s s e n t i a l . Patients need i n t h e i r treatment the f u l l co-operation of the physiotherapist, the occupational therapist, the r e c r e a t i o n a l therapist, the psychotherapist, and the assistance 1 of the s o c i a l worker, both during and following h o s p i t a l i z a t i o n . "The function of the psychiatric s o c i a l worker i s to contribute his  knowledge and casework s k i l l i n such a way  that i t i s purpose-  f u l l y r e l a t e d to psychiatry, the t o t a l treatment program of the h o s p i t a l , h o s p i t a l organization and administration, and to the contributions of a l l other professions and departments i n the 2 hospital."'  A c o r o l l a r y i s that the q u a l i t y of the treatment  afforded patients i s wholly dependent upon how  ably the various  professions can work together. In order to help mental patients, the s o c i a l worker must know the sources of tension i n t h e i r l i v e s .  He must understand what  the person f e e l s , how he deals with h i s f e e l i n g s , how responding serves him i n the l i g h t of h i s present l i f e past experience  and future aspirations.  t h i s way  of  pressures,  I t i s t h i s understanding  of the i n d i v i d u a l and what the problem means to him that enables the s o c i a l worker to modify either external or i n t e r n a l pressures, or both, so that the i n d i v i d u a l may  be r e l i e v e d of stresses and  participate i n the recovery of s e l f - r e l i a n c e .  _  1950.  Part of the  skill  B r i t i s h Columbia, Psychiatric Services Physicians Maunal.  2 B r i t i s h Columbia, Annual Report of the Mental Health Service. Queen's P r i n t e r s ; V i c t o r i a , B.C.; 1951; p.^M-.  13  of the s o c i a l worker i s i n estimating the patient's capacity f o r s e l f - h e l p , and i n h i s a b i l i t y to strengthen  the healthy aspects  of the patient's personality by helping him to adjust to the r e a l i t i e s of a changed and limited s i t u a t i o n . The s o c i a l worker understands that the patient i s a part of a dynamic s o c i a l group involved at a l l times i n a complicated  system of interpersonal  relationships and during the patient's treatment period i n h o s p i t a l the s o c i a l worker i s concerned with a l l aspects of the patient's relationship with medical and nursing s t a f f , with other patients, family, friends and community. To be f u l l y e f f e c t i v e i n helping, the s o c i a l worker should work c l o s e l y with the patient from the moment he enters  the  h o s p i t a l u n t i l he i s f i n a l l y re-established i n the community. One  of the i n i t i a l services to patients and r e l a t i v e s i s the intake 1  study and evaluation of the patient and h i s i l l n e s s .  The  intake  and reception process also involves i n t e r p r e t a t i o n of h o s p i t a l f a c i l i t i e s to patients and their f a m i l i e s , as well as assistance to f a m i l i e s who  have problems arising out of the patient's  admission, such as f e e l i n g s about having a mentally or fear of the h o s p i t a l i z a t i o n and the treatment.  ill  relative  At Essondale  at the present time caseworkers are assigned to the Admissions Sections of the P r o v i n c i a l Mental Hospital and the Crease C l i n i c , a l l workers being under the supervision of an Admissions 2 Casework Supervisor.  —  1 2  :  "~  :  '  .  Annual Report of the Mental Health Services, op c i t , p.H-6. Pepper, op c i t , chapter 2  0  lift-  The s o c i a l information', obtained by the s o c i a l worker when the patient i s admitted i s rapidly made available to other members of the treatment team, thus accelerating the formulation of p r o v i s i o n a l diagnosis, of i n i t i a l treatment plans,, and the m o b i l i zation of a l l services within the h o s p i t a l f o r the treatment of the new patiento  In the S o c i a l Service Department, the treatment  period i s considered i n three phases or aspectst  active therapy  i n h o s p i t a l ; pre-convalescent planning p r i o r to discharge; and the convalescent or probationary period after the patient has l e f t the h o s p i t a l or c l i n i c .  The contact with the patient on the  ward i s directed towards building a supportive, understanding r e l a t i o n s h i p , through which the patient i s helped to hold onto whatever r e a l i t y functioning he may possess.  Interest i n wife,  children or parents i s kept a l i v e ; and the patient i s helped to do something about those problems of which he i s most aware and concerned.  Interviews with r e l a t i v e s are directed toward keeping  up the family's i n t e r e s t i n the patient. This i s done by familiari z i n g the relatives- with the nature of the i l l n e s s , the treatment, the h o s p i t a l and c l i n i c routines; by helping r e l a t i v e s with t h e i r own f e e l i n g s concerning mental i l l n e s s , and f i n a l l y  through  support and c l a r i f i c a t i o n the r e l a t i v e i s encouraged to p a r t i c i p a t e p o s i t i v e l y i n plans f o r the patient's discharge.  In a s s i s t i n g  the patient's family, the s o c i a l worker frequently contacts community resources such as family c h i l d and assistance-giving agencies. P r i o r t o discharge, the s o c i a l worker starts to prepare the patient f o r leaving the hospital,and c l i n i c and he w i l l discuss  15  with the patient h i s f e e l i n g about leaving, and returning to h i s family and to employment.  The patient i s encouraged to  make week-end v i s i t s to h i s home so that the t r a n s i t i o n from h o s p i t a l i z a t i o n w i l l be gradual, and problems that a r i s e on these v i s i t s can be ironed out before f i n a l  discharge.  The s o c i a l worker*s r o l e i n the f i n a l or post-discharge phase of the treatment process i s to a s s i s t i n the r e - e s t a b l i s h ment of the patient i n the community.  The patient i s helped to  r e t a i n the gains made i n h o s p i t a l ; to locate s a t i s f a c t o r y employment and accommodation; to become reconciled to those changes i n h i s own a b i l i t y and i n the circumstances of h i s l i f e , which the i l l n e s s may have brought about.  As w e l l , family, f r i e n d s ,  employers and community agencies are prepared f o r the patient's return to routine l i v i n g ; and necessary interpretation of the patient's needs i n h i s extra-mural treatment i s provided. From the point of view of organization, the various phases; of treatment are the r e s p o n s i b i l i t y of the Continuing  Services  Sections of the S o c i a l Service Departments of the P r o v i n c i a l Mental Hospital and the Crease C l i n i c respectively.  I t should  be noted that the public welfare agency of the c i t y of Vancouver, and also the public welfare agency of the Province S o c i a l Welfare Branch - provide s o c i a l assistance as an aid i n rehabilitation.  Outside the Greater Vancouver area, the S o c i a l s  Welfare Branch also gives casework services throughout the patient's i l l n e s s , including intake studies, family casework, and follow-up  services a f t e r discharge.  16 Modern Concept of R e h a b i l i t a t i o n Public acceptance of s o c i a l welfare goals has advanced to include the aims of r e h a b i l i t a t i o n of disabled c i t i z e n s .  Concern  with the problem has been so great that the word r e h a b i l i t a t i o n i t s e l f has become hackneyed - almost beyond the point of p r a c t i c a l s p e c i f i c meaning.  Popular references  are made to the " r e h a b i l i -  t a t i o n " of the b l i n d , of paraplegics, of the tuberculous, of discharged prisoners, of injured workmen, of aged persons. Rehabilitation i s a concern of the community because the disabled c i t i z e n , so handicapped that he cannot " p u l l h i s own  weight",  immediately becomes a problem of the community i n which he has roots and w i l l presumably  seek re-adjustment.  Rehabilitation  and after-care: i s more intimately the concern of the h o s p i t a l  r  gaol or treatment I n s t i t u t i o n because the aim of the treatment programs of these agencies of the community i s to see the patient through to maximum s o c i a l integration into the community.  A gen-  e r a l d e f i n i t i o n of r e h a b i l i t a t i o n i s the statement of the Rational Council on R e h a b i l i t a t i o n , New York, to the e f f e c t that r e h a b i l i t a t i o n "Is the restoration of the handicapped to the f u l l e s t physical, mental, social,, vocational and economic usefulness of which they are capable." R e h a b i l i t a t i o n has to do with a person's re-establishment i n the community after a period of disruption of normal l i v i n g due to some disabling condition or d i s l o c a t i n g circumstance. In the broad sense, r e h a b i l i t a t i o n includes the entire process of a patient's treatment i n h o s p i t a l and h i s return to routine civilian living.  In t h i s sense, f o r example, the r e h a b i l i t a t i o n  of the mentally i l l begins immediately upon admission to h o s p i t a l ,  17 and a l l subsequent examination, treatment, nursing care, psychotherapy and s o c i a l casework are aimed at promoting a normal s o c i a l integration and preparing the patient and the r e l a t i v e s  1 to make an accepted adjustment.  For the purposes of this; study  the term r e h a b i l i t a t i o n i s used to r e f e r to the l a t t e r  portion  of the treatment goals, which embraces plans and programs f o r the post-discharge period after the patient has l e f t the h o s p i t a l . R e h a b i l i t a t i o n services are dispensed under various  administrative  auspices - some by the h o s p i t a l and some by specialized r e h a b i l i t a t i o n agencies. A survey of available l i t e r a t u r e shows that programs f o r the r e h a b i l i t a t i o n of physically and mentally handicapped persons vary widely both i n the comprehensiveness of the services and i n the administrative  auspices by which the programs are implemented.  Primary factors affecting comprehensiveness are f i r s t of a l l the breadth of v i s i o n ; the acceptance, and the p a r t i c i p a t i o n of the whole community; and secondly, the f i n a n c i a l capacity of a community to provide services. Rehabilitation, l i k e public health, i s 2 purchasable.  There are programs u t i l i z i n g the medical, s o c i a l ,  psychological,  economic, educational,  of r e h a b i l i t a t i o n .  and vocational aspects  Such programs are available to the handicapped  through the f a c i l i t i e s of c l i n i c s , community services, foster and domiciliary homes, hospitals and r e h a b i l i t a t i o n centres, schools, and  sheltered workshops.  r  ^ — —  !  =  I n i t i a l l y the programs were  •  —  —  Psychiatric Services Physicians Manual, op c i t , Chapter 1 2 . 2  Hamilton, Kenneth,"A Sound R e h a b i l i t a t i o n Program". Proceedings of the Canadian Conference of S o c i a l Work. Vancouver, B.C.;  1950;  p.132.  18 developed by i n d i v i d u a l p r a c t i t i o n e r s i n various professional fields*  Many were financed by private, philanthropic s o c i e t i e s  such as the American Red Cross Society, B l i n d I n s t i t u t e s , and so f o r t h .  As such private programs have become more widely  recognized,  i t has become common f o r governmental support to be  made available by f i n a n c i a l grants. Great B r i t a i n , New  Some countries, such as  Zealand, and the United States, have set up  governmental r e h a b i l i t a t i o n programs which have included medical treatment, vocational t r a i n i n g , and employment placement of individuals on a national basis as a function of government. Government sponsored r e h a b i l i t a t i o n programs were f i r s t developed to meet the needs of p h y s i c a l l y handicapped persons who had an employment problem.  For example, i n the United  the Vocational R e h a b i l i t a t i o n Act, 1920,  was  States  passed to provide  services other than physica 1 restoration services, with a view to f i l l i n g the gaps between the r e s u l t s achieved by e x i s t i n g hospitals and c l i n i c s , and the return of the patient to s e l f support.  The financing of the program was put on a permanent  basis by the S o c i a l Security Act 1935*  During World War  r e s u l t of the revelations of Selective Service of the  2 as a  incidence  of mental disorders i n the c i v i l i a n population, the scope of r e h a b i l i t a t i o n services was  extended by the Barden-La F o l l e t t e  Act (19^3) to include the p s y c h i a t r i c a l l y disabled person.  This  meant that every p s y c h i a t r i c a l l y disabled person could get help i n job f i n d i n g , vocational guidance, vocational t r a i n i n g , and occupational counselling, whether he was  I  ~  a veteran or a c i v i l i a n .  ''  Rennie, Thomas A.C.-, Burling,T., and Woodward, L.E. "Vocational R e h a b i l i t a t i o n of the P s y c h i a t r i c a l l y Disabled". Mental Hygiene. A p r i l , 19^9.  19  At the present time, the f e d e r a l government makes grants to the states f o r 100 percent of the necessary  program costs of adminis-  t r a t i o n and vocational guidance and placement services, and f o r 50 percent of other case service costs such as medical and psychi a t r i c examinations, medical treatment, t r a i n i n g , and maintenance during the period of the r e h a b i l i t a t i o n process.  The program i s  administered by the O f f i c e of Vocational R e h a b i l i t a t i o n of the Federal Security Agency. I t is; observed that with respect to the dominant p r e c i p i t a t i n g f a c t o r i n d i s a b i l i t y (physical, mental), vocational r e h a b i l i t a t i o n programs were f i r s t developed f o r the p h y s i c a l l y disabled due to the ease of defining " d i s a b i l i t y " f o r t h i s group as compared to the d i f f i c u l t y i n measuring the handicaps accompanying mental and emotional disorders. Ganada has had one comprehensive r e h a b i l i t a t i o n program, namely that f o r p h y s i c a l l y handicapped veterans, under the Department of Veterans Affairs;.  The Department has u t i l i z e d private  organizations f o r c e r t a i n types of handicaps such as blindness, deafness and paraplegia, but there i s not yet a comprehensive scheme f o r c i v i l i a n s .  There are; a number of organizations both  public5and p r i v a t e , working with various types of handicapped children and adults,-for example the Workmen's Compensation Board, T.B.  after-care; National Society f o r the Deaf and Hard of  Hearing; the Canadian Paraplegic Association; the Canadian National I n s t i t u t e f o r the B l i n d ; the Canadian A r t h r i t i s  and  Rheumatism Society; p r o v i n c i a l societies f o r Crippled Children and Cerebral Palsy. The National Advisory Committee on R e h a b i l i t a t i o n of Disabled  I  20 Persons was  set up by Order-in-Council i n December 1951*  This  Canadian Committee aims to develop a n a t i o n a l program to provide c i v i l i a n s the same services as are now  available to veterans.  A Federal Coordinator has been appointed and a system of f e d e r a l R e h a b i l i t a t i o n Grants to the provinces has been i n i t i a t e d . To date, Saskatchewan i s the only province which has developed c i v i l i a n r e h a b i l i t a t i o n programs.  B r i t i s h Columbia  has enacted s o c i a l welfare l e g i s l a t i o n which permits the development of such a program within i t s public assistance scheme.  In  practice, however, public welfare o f f i c i a l s tend to u t i l i z e existing private agency resources rather than to develop  new  f a c i l i t i e s to meet the needs of handicapped persons. Specialized agencies or h o s p i t a l departments f o r the r e h a b i l i t a t i o n of the mentally i l l are a new  development i n Canada.  The most ambitious undertaking at present i s the After-Gare Department of, the Ontario H o s p i t a l , London.  This department was  organized i n September 19*+9> with the f i n a n c i a l support and encouragement of the Ontario Department of Health and with f i n a n c i a l assistance from the Federal Department of Health.  It  i s headed by a psychiatric s o c i a l worker, and the team includes three a d d i t i o n a l s o c i a l workers, four nurses, and two psychologists. The h o s p i t a l p s y c h i a t r i s t s serve as consultants.  The Department  u t i l i z e s a down-town building to serve as o f f i c e s , consulting rooms, and as club rooms and recreation centre f o r former patients 1 who may reside i n the d i s t r i c t . i  ,  _  —  -  Stevenson, Dr. G.H. "Rehabilitation of the Mentally 111". Ontario Medical Review. Volume 19, Number 11; November 1952.  21 An agency interested i n a l l aspects of mental health,; Including the r e h a b i l i t a t i o n of discharged mental patients i s the Canadian. Mental Health Association.  The Association i s a voluntary society  of c i t i z e n s dedicated to the task of preventing mental and emotional i l l n e s s , helping children and adults to achieve better mental health, and improving treatment f o r those who disabled.  are  mentally  There are f i v e p r o v i n c i a l Divisions of the Association.  In 1953 the Saskatchewan D i v i s i o n e n l i s t e d the aid of a Junior Chamber of Commerce to a s s i s t i n the r e h a b i l i t a t i o n of  discharged  mental patients i n occupational settings. Post-discharge  Problems of Crease C l i n i c Patients  The Crease C l i n i c of Psychological Medicine, opened at Essondale, B.C.  on January 1 ,  1951,  was  designed and equipped to serve  as a diagnostic and active treatment centre f o r the early cases of m ental i l l n e s s ; primarily early psychoses and psychoneuroses. By statutory provision, the duration of a patient's treatment period i s l i m i t e d to four calendar months.  Admissions are there-  fore encouraged only of those patients who  are considered to have  a. reasonable prospect f o r recovery and discharge i n the four months period.  Patients with a less favourable prognosis are  referred to the P r o v i n c i a l Mental Hospital.  A patient may  be adm-  i t t e d to Crease C l i n i c either by voluntary application or by c e r t i f i c a t i o n of two medical p r a c t i t i o n e r s . The only patients who  lose control of t h e i r a f f a i r s are those deemed u n f i t by  t h e i r attending physicians to carry out t h i s function; i n which case the Inspector of M u n i c i p a l i t i e s i s n o t i f i e d and acts as committee.  The general environment of the building i s a t t r a c t i v e ,  with t a s t e f u l furnishings, and varied and p l e n t i f u l r e c r e a t i o n a l  22 and occupational services.  Every e f f o r t i s made to render early  h o s p i t a l i z a t i o n i n the C l i n i c as similar to h o s p i t a l i z a t i o n  for  physical illness; as possible. What kinds of problems and situations are experienced by these patients when they leave the C l i n i c ?  How has t h e i r absence  affected t h e i r f a m i l i e s , t h e i r jobs,, t h e i r acceptance i n t h e i r neighbourhood?  To whom may they be referred for assistance i n meet-  ing t h e i r needs i n getting re-established i n t h e i r homes and communities?  How adequate are community f a c i l i t i e s f o r aiding needy  patients i n t h e i r r e h a b i l i t a t i o n after discharge from the hospital? These are questions that are being given thoughtful consideration by the treatment team at Crease C l i n i c .  They are questions of  particular concern to the S o c i a l Service Department at the C l i n i c , which assumes, major r e s p o n s i b i l i t y f o r the welfare of patients i n the t r a n s i t i o n a l period following discharge. Some c h a r a c t e r i s t i c problems i n r e h a b i l i t a t i o n from Crease C l i n i c are related to the short-term nature of h o s p i t a l i z a t i o n , and to the fact that voluntary admission can be terminated within f i v e days- notice given by the patient.  I t has been found  i n experience that the average length of stay of patients •1  actually Is approximately two months.  These circumstances  l i m i t the time available whereby the C l i n i c s t a f f can assess the patient's; s o c i a l s i t u a t i o n , and formulate a post-discharge plan. A majority of the patients are r e h a b i l i t a t e d d i r e c t l y back to t h e i r f a m i l i e s or f r i e n d s with the assistance of adequate 1  Pepper, op c i t , Chap. h.  23  s o c i a l casework before and during the actual r e h a b i l i t a t i o n placement.  The problems of t h i s group may not be related d i r e c t -  l y to t h e i r i l l n e s s but may be primarily associated with the physical.disruption of routine family l i v i n g r e s u l t i n g from the absence i n h o s p i t a l of- the housewife, the mother or the breadwinner.  The family member's absence from home may have: added  problems: and r e s p o n s i b i l i t i e s for a wife or husband, p r i v a t i o n for the c h i l d r e n ; and supportive  casework help i s requested i n  f a c i l i t a t i n g the family's return to more stable equilibrium. It i s the experience of the s t a f f , however, that there are many patients who do not possess family, friends or f i n a n c i a l resources.; or whose family and f r i e n d s are d i s i n t e r e s t e d or actually h o s t i l e or resentful.. These patients require more extensive help and support from the C l i n i c i n becoming securely established i n an emotionally healthy environment. has a, wide v a r i e t y of needs.  This group  F i r s t of a l l there are a multitude  of very basic dependency needs which must be met before they are re-established i n the communityi money, food, clothing,, shelter, a job,a-;meaningful r e l a t i o n s h i p with some interested person or persons.  For a. person who has been h o s p i t a l i z e d f o r a mental or  nervous disorder, the return to the community i s often a. threatening experience; and to lack the security of f r i e n d s and adequate finances enhances t h i a f e e l i n g of d i s t r e s s and uncertainty, and i n turn increases the p o s s i b i l i t y of a relapse and a return to hospital.  These patients may look to t h e i r discharge with a l l  the i n s e c u r i t y of a person recovering from an i l l n e s s , or they may prefer to regard themselves as never having been s i c k , but i n  2h  either event they are f e a r f u l of the rejecting attitudes of society. There are also many patients who leave the h o s p i t a l with a residuum of the mental disorder or upset which led to t h e i r hospitalization.  These patients have received treatment and have  made a. c e r t a i n recovery, enabling them to return to the community ; but they have retained a certain mental, handicap which adds to t h e i r problems of re-establishment.  Of the t o t a l of 1172 patients  discharged from Crease C l i n i c i n 1952-53, f o r example, the psychi a t r i c condition of those described as "improved" numbered 727, or more than one h a l f ; the remainder of those discharged being described as "recovered", "unimproved^, or "without psychosis and u n c l a s s i f i e d " .  Such patients may r e t a i n f e e l i n g s of undue  submissiveness, or depression, or anxiety, or fear of people. Sometimes these f e e l i n g s are related t o an unresolved m a r i t a l conflict,; or an unsatisfactory work adjustment which precipitated the breakdown but remains unsolved.  Sometimes the f e e l i n g s are  the end r e s u l t of years of emotional deprivation or c o n f l i c t with parents.  The inner problems of these patients may be of such  severity that they cannot be further reduced by known methods of psychiatric therapy; but they are persons whose l i f e can be made more comfortable by a kinder environment  or by the sympathetic  understanding and interest of the s o c i a l worker who continues to see him. The discharged mental patient who i s inwardly weakened or handicapped  i n h i s a b i l i t y to make wise decisions or to get along  w e l l with family or fellow employees, needs help i n meeting the  25  additional external stress of securing accomodation, a job, and of functioning independently i n our complex society.  For such a  person with a severe mental handicap, the p s y c h i a t r i s t sometimes recommends sheltered accomodation, protective work placement or f i n a n c i a l subsidization i n maintenance.,  The patient thus would  have a t r a n s i t i o n a l experience or period of convalescence between the protective h o s p i t a l setting: and complete independent management of h i s a f f a i r s i n the community.  But i f community resources  are lacking to make possible the implementation of such recommendations, what i s to be done and where i s the patient to go? Frequently i t i s f o r the i n d i v i d u a l s o c i a l worker to seek the best available compromise solution and to help the patient as w e l l as he can to adjust to a l i m i t i n g s i t u a t i o n . Theme of the Thesis A trend i n the manner of coping with the incidence of mental disease has been to accent the maintenance of good mental health and to bring closer to community awareness the treatment f a c i l i t i e s set up to restore the health of the mentally sick.  The master  design f o r mental health care i n B r i t i s h Columbia, c a l l s f o r attempts to prevent or to solve the problems while people l i v e i n t h e i r own homes and before h o s p i t a l i z a t i o n becomes necessary. When i n s t i t u t i o n a l treatment i s indicated the Crease C l i n i c receives patients who w i l l be absent from t h e i r homes f o r short-term h o s p i t a l i z a t i o n ; and the P r o v i n c i a l Mental Hospital receives patients f o r whom long-term h o s p i t a l i z a t i o n (and consequently a. long absence from home) i s indicated.  One of the next planned  steps i s the establishment of a. Day Hospital where active treatment  26 f o r day patients would be available on an.out-patient b a s i s . This out-patient department would f i l l the gap between the general hospitals and the Crease C l i n i c .  I t would f u l f i l l the  need f o r further follow-up treatment and supervision of patients discharged from Crease C l i n i c . At the present time, however, patients are discharged i n f u l l from Crease C l i n i c , and there is no administrative provision for probationary s e r v i c e s , as i s the, case at the P r o v i n c i a l Mental H o s p i t a l .  Consequently the follow-up services at present  undertaken by s o c i a l workers represent an extension of the c l i n i c a l of the Crease Clinic: into a necessarily limited out-patient department service.  A recent study undertaken by the s o c i a l service  1. staff  Indicated that the lack of a c e n t r a l o f f i c e i n the C l i n i c  to mobilize a l l the r e h a b i l i t a t i o n resources of the community, together with the rapid turn-over and short stay of the patients, resulted i n inadequate preparation f o r r e h a b i l i t a t i o n , with readmissions being one of the f i n a l r e s u l t s .  An a d d i t i o n a l  l i m i t i n g factor i n discharge planning Is that the average length of stay of patients i s approximately  two months.  Due p a r t l y to  the pressure of work on the C l i n i c s o c i a l workers and to the lack of a c e n t r a l r e h a b i l i t a t i o n o f f i c e , i t frequently happens that a c a r e f u l evaluation of a patient*s p o t e n t i a l i t i e s , a b i l i t i e s , aptitudes and special needs cannot be undertaken preceding  discharge.  The present study considers the limited out-patient services now  available within the perspective of a comprehensive r e h a b i l i 1  Pepper, op c i t .  27  t a t i o n service f o r discharged mental patients.  I t seeks to ascer-  t a i n the prevalence of patient need i n three areas of  adjustments  housing, vocational s k i l l s and t r a i n i n g , and problems of inner stress requiring casework services.  I t then makes a descriptive  survey of available resources within the h o s p i t a l and i n the community at large, with respect to these three selected areas of need.  Of the many kinds of problems and needs experienced  by discharged patients, the three areas of adjustment have been a r b i t r a r i l y chosens housing and a job being basic needs; and problems of inner stress being a need indicated by the records of the S o c i a l Service Department and the writer's own  experience.  This s e l e c t i o n i s confirmed by much current reference material on r e h a b i l i t a t i o n . In order to make the study more manageable, the scope of the thesis i s limited to an examination of the case records of male patients only; also those who were discharged from Crease C l i n i c during a recent year, and only those who were referred to the S o c i a l Service Department during t h e i r h o s p i t a l i z a t i o n .  Pertinent  information r e l a t i v e to the three categories of need was extracted from case records by means of a schedule, an outline of which appears i n the Appendix.  A f u l l year's sample was decided upon,  so as to include employment needs at a l l seasons and l e v e l s of employment.  "Needs" are those denoted either by the recommenda-  tions of the treatment team or a r i s i n g from the patient's own request f o r service.  Other needs, no matter how obvious, are not  considered i n the present study i f no recommendation or request was made about them.  28 I t may "be noted that the case records or unit f i l e s of patients are a comprehensive compilation of the impressions and services of professional s t a f f members who have contact with the patient. The f i l e includes the ward notes of the doctors, the d a i l y records of nursing and treatment s t a f f s , the psychological reports, s o c i a l service notes, and reports of the officer.  The material f o r t h i s study was  rehabilitation  obtained primarily from  the reports of the p s y c h i a t r i s t , the s o c i a l worker and the rehabilitation officer.  Chapter 2  Common needs i n Rehabilitation.  Human experience has been described as the i n t e r a c t i o n of the  i n d i v i d u a l and h i s t o t a l environment; and l i v i n g as "the  process of accommodating our changed and unchanged selves to  1 changed and unchanged surroundings,"  From t h i s viewpoint a  person s l i f e w i l l be successful or not, according as h i s power 1  of accommodation i s equal to or unequal to the s t r a i n of fusing and  adjusting i n t e r n a l and external changes.  I t i s assumed that  human beings have c e r t a i n needs and that the dynamic f o r the i n t e r a c t i o n of i n d i v i d u a l and environment i s found i n a person's s t r i v i n g to meet these needs. for  The. s t r i v i n g i s part of the urge  s u r v i v a l , of the w i l l to grow and improve; and on t h i s the  whole idea of r e h a b i l i t a t i o n i s based. The fundamental needs of man have been variably stated by theologians, philosophers, s c i e n t i s t s , and statesmen. They include - as well as the physical needs of food, clothing, and shelter - "an opportunity to grow up free to make choices which w i l l make i t possible f o r him to secure a l i v i n g , e s t a b l i s h a "~  "  Menninger, K a r l A., The Human Mind. A l f r e d A. Knopf; New York; I 9 V 7 . P . 1 9 . Quotation from Samuel Butler.  30 home, r a i s e children* enjoy l e i s u r e , and f e e l at home i n the  1  universe."  The need to he loved i s part of the basic human  psychological structure.  The individual's behaviour represents  h i s unique way of meeting h i s needs within the framework of h i s environment; i t i s a manifestation of h i s attempt to adjust so that he may be as comfortable as possible.  Because some of h i s  i n t e r n a l needs may c o n f l i c t with others, because he may be frustrated i n meeting h i s needs by the external world of r e a l i t y , and because he does not l i v e i n i s o l a t i o n but i n a s o c i a l m i l i e u , the, attainment of a comfortable, personal adjustment not only i s an achievement matter.  of considerable magnitude but i s also a r e l a t i v e  The quality of human adjustment i s r e l a t i v e when measured  i n terms of the psychological concept of maturity. become q u a l i t a t i v e l y r i c h e r and more meaningful.  L i f e may  The mature  person has found a pattern of behaviour which permits him to l i v e constructively i n h i s s o c i a l world, and which enables him to develop h i s unique p o t e n t i a l i t i e s . When we speak of human experience as the i n t e r a c t i o n of the i n d i v i d u a l with h i s outer and inner environment, and of human behaviour as the end product of the process of achieving s a t i s f a c t i o n of needs, we are presuming the operation within i n d i v i d u a l persons of a dynamic coordinator,-the "I",-a medium of adjustment between the i n d i v i d u a l and the outer world.  In  psychoanalytical terms t h i s executive function i s included i n the concept of the ego. The ego represents the attempts of the person Wilson G. and Ryland G., S o c i a l Group Work Practice. Houghton M i f f l i n Company; Boston; 1 9 ^ 9 ; P - 1 7 .  31 to keep harmonious the relationship between the primitive i n s t i n c t u a l urges or drives (concept of the i d ) , the conscience or c r i t i c (concept of the superego), and the r e a l i t y world.  The various  methods used by the ego to keep a balance or to a t t a i n i n the psychic structure are c a l l e d mental mechanisms.  "wholeness" This  entire t h e o r e t i c a l structure i s a professional attempt to comprehend the functional unity of the various components of persona l i t y . I t serves as a u s e f u l t o o l and means of communication for professional persons i n defining personality problems and prescribing programs of treatment. The outcome of the person's contact with h i s environment may be successful, i n the sense that he achieves an adjustment; s a t i s f a c t o r y to himself and to others; or i t may be unsuccessful,; i n the sense that he has f a i l e d to achieve an adjustment s a t i s factory to himself and to h i s fellows.  The basis f o r success or  f a i l u r e . r e s t s i n the variations and combinations of the factors noted: the individual's power of adjustment, and the pressures or strains to which the i n d i v i d u a l i s exposed i n h i s environment. When f a i l u r e s i n adjustment become too great f o r the i n d i v i d u a l or too noticeable to h i s fellows, he comes o r i s sent to a person who can help him with h i s material needs or with problems of inner stress.  Assistance i s available from the professional  groups concerned with helping people to a more s a t i s f a c t o r y adjustment: doctors, clergymen, teachers, s o c i a l workers.  Persons  whose adjustment has been unsatisfactory may be distinguished from the t h e o r e t i c a l norm of adjustment by t h e i r unusual behaviour represented by two d i f f e r e n t types of reaction to  ,3  2  f a i l u r e : One type of reaction to f a i l u r e i s seen i n a person who finds himself incapable of f u l f i l l i n g the requirements of h i s p a r t i c u l a r s i t u a t i o n and attempts adjustment by resorting to "psychological f l i g h t " from the s i t u a t i o n .  A second type of  reaction i s that of attacking the s i t u a t i o n d i r e c t l y .  Both ways  of reacting are disastrous: one r e s u l t i n g i n damage to the personality, the l a t t e r i n damage to the s i t u a t i o n .  The former  type of behaviour i s exemplified i n the form of character t r a i t s such as seclusiveness, t i m i d i t y , f e a r s , suspicions, some forms of physical i l l n e s s , excessive dependency, and other emotional symptoms included i n the category of poor mental health.  The l a t t e r  reaction may represent a pattern of delinquency and crime.  Both  reaction patterns may be said to r e s u l t from a f a i l u r e i n the adaptive capacity of the ego to resolve the environmental pressures impinging upon the personality.  Crime or s o c i a l misbehaviour  may represent an attack upon the environment; mental i l l health, a retreat from i t . A t h i r d reaction i s that of neurotic adjustment.  This i s a  complicated behaviour pattern wherein a person i s neither able to express h i s drives and meet h i s needs by d i r e c t action, nor successfully to repress the wishes.  So he expresses them i n  symptoms which p a r t i a l l y or i n d i r e c t l y or symbolically g r a t i f y h i s need, and at the same time serve as a form of self-punishment f o r and denial of g r a t i f i c a t i o n .  The development of such d i s -  advantageous substitutions cause him suffering which counterbalances h i s secret pleasure.  33 The mature person does not resort to f l i g h t or attack or waste psychic energy i n neurotic f r u s t r a t i o n , but rather learns to accept the l i m i t a t i o n s of the present s i t u a t i o n and to l i v e with them, at the same time joining with others i n remedial s o c i a l action programs. The emotional problems presented by patients i n a psychiatric treatment centre are apt to be extreme examples of the reaction patterns so f a r outlined.  Delinquent persons frequently become  inmates of gaols and p e n i t e n t i a r i e s and may be referred f o r psychiatric assessment.  Persons c l a s s i f i e d as psychotic or psy-  choneurotic may become patients, i n mental h o s p i t a l s .  The  psychoses  are the most extreme of a l l emotional disorders,, wherein the ego p a r t i a l l y or t o t a l l y has given up the function of estimating the external world and making adaptions to i t .  In psychoanalytic  phrasing, the ego of the psychotic d i s t o r t s r e a l i t y and allows i n s t i n c t u a l impulses to f i n d expression either d i r e c t l y or symbolically.  The psychoneurotic: patient has become so frustrated  by inner neurotic c o n f l i c t s that normal routine l i v i n g i s not t o l e r a b l e , and i n some cases treatment by professionally trained people may be c a l l e d f o r . The Sample Group Studied In order to ascertain the nature and approximate frequency with which post-discharge needs and problems are  encountered,  i t was decided to review the discharge h i s t o r y of a sample of one hundred male patients admitted to the Crease C l i n i c , i n ; a recent year. was chosen.  The f i s c a l year A p r i l 1,  1 9 5 2 , to March 3 1 ,  1953?  A schedule was used to c o l l e c t together a l l pertinent  3^ Information on i n d i v i d u a l patients, and to record what r e h a b i l i t a t i o n services were recommended by the p s y c h i a t r i s t , or c a r r i e d out by the s o c i a l worker. nts was  The sample; group of one hundred p a t i e -  selected by considering every f i f t h case (male and female)  referred to the S o c i a l Service Department during the period concerned.  The number of male patients turned out to be lo9,  and the f i r s t nine selected by t h i s means were disregarded,, so as to arrive at a round figure of 100, f o r ease of tabulation. The maximum, period of treatment of these patients was four months, the average being two months. boys i n t h e i r teens to men l e v e l of the group was  The ages of the group ranged from  i n t h e i r seventy's.  The  educational  f a i r l y high f o r those reporting t h i s  inform-  ation; the larger proportion having completed at least Grade 8. The occupational experience  of the men was widely representative,  ranging from u n s k i l l e d manual work to persons p r a c t i c i n g a profession. A l l cases i n the sample had been referred to a s o c i a l worker. This means that the worker i s responsible f o r such s o c i a l services as may be indicated during the period of h o s p i t a l i z a t i o n . It i s also expected that i n a joint assessment with the psychiat r i s t , patient needs r e l a t i n g to discharge w i l l be provided f o r , and appropriate services offered to meet needs i n the postdischarge  period.  Some l i m i t a t i o n s i n the method of study may be noted. Probably the biggest p r a c t i c a l l i m i t a t i o n was  lack of detailed  or standardized recording on the u n i t f i l e s .  Data was  secured  from the ward notes of the p s y c h i a t r i s t , the summaries of the r e h a b i l i t a t i o n o f f i c e r , and the s o c i a l service notes.  Only those  35 needs indicated i n these records were tabulated, although i t maybe that some r e h a b i l i t a t i o n problems actually experienced were not recorded.  Furthermore, i t sometimes happened i n a p a r t i c u l a r  case record that whereas an expression of concern or an actual recommendation was made by the p s y c h i a t r i s t f o r a certain form of post-discharge care, no record was not the recommendation was  available as to whether or  carried out.  As w e l l , often no account  was given as to the reasons f o r a p a r t i c u l a r recommendation, or i n what instances a compromise plan was  agreed upon because of  lack of resources f o r carrying out an " i d e a l " plan for postdischarge care.  Generally speaking, the pattern of recording  observed i n the sample group i s that i n a b r i e f f i n a l statement by the p s y c h i a t r i s t or s o c i a l worker there i s mention, of what plans were made f o r the patient when he was; discharged. b r i e f statement may  The  contain a general reference to the fact that  the r e h a b i l i t a t i o n o f f i c e r or s o c i a l worker were helping the p a t i ent f i n d a job or accommodation, or that the s o c i a l worker would o f f e r follow-up casework services to support the patient i n a p a r t i c u l a r aspect of h i s adjustment.  I t sometimes happens that  no comments can be found referring to the s p e c i f i c s o c i a l circumstances  at the point of discharge.  Other l i m i t a t i o n s are inherent i n the categories chosen i n the schedule.  For example, information on education  was  obtained from the admission form, which includes no more than reference to the grade completed i n school.  As the major concern  was not i n t h i s area of adjustment, further d e t a i l s as. to s p e c i a l i z a t i o n or to personal reaction to education were not drawn from s o c i a l or medical histories..  In the employment  :  36  categories, arbitrary d i v i s i o n s were made between s k i l l e d and u n s k i l l e d manual labour.  For example, a farmer was considered  " s k i l l e d manual labour"-, whereas a farm hand, was l i s t e d as "unskilled manual labour". For people referred to Social Welfare Branch o f f i c e s , the unit f i l e s did not always specify the post-discharge needs i n the same categories chosen i n the schedule.  Most were referred f o r  long-term casework service, the primary-need i n some cases being for f i n a n c i a l assistance.  Consequently i n the tabulation a l l  r e f e r r a l s to S o c i a l Welfare Branch are included i n the one category, without s u b - c l a s s i f i c a t i o n under job placement  or housing.  Two groupings i n the schedule are of those cases which d i d not contain a recommendation f o r , or otherwise did not require, post-discharge^services from Crease C l i n i c .  For example, one  group i s composed of those patients discharged to the community who returned d i r e c t l y to t h e i r homes without a i d ; and the second includes those who were discharged d i r e c t l y to an i n s t i t u t i o n or h o s p i t a l . . Some patients are discharged, to the P r o v i n c i a l Mental Hospital f o r further treatment; some to general hospitals for  surgery or other therapy; some to T.B. s a n i t o r i a f o r  specialized care; and some to c o r r e c t i o n a l i n s t i t u t i o n s such as the Boys' I n d u s t r i a l School.  Approximately one male patient i n  seven i s admitted to the P r o v i n c i a l Mental Hospital at the point 1  of discharge from the C l i n i c . are  Also included i n t h i s category  patients who l e f t the C l i n i c without permission,, or patients 1  '  !  """  Source: Annual Report of Mental Health Services. 1953; op c i t , p.155.  37  admitted under voluntary papers who made t h e i r own plans and gave the prescribed f i v e days notice requesting t h e i r discharge. A small number of patients were subject to deportation immediately  at the time of discharge.  proceedings  As a l l cases i n t h i s  sample had been referred to a s o c i a l worker, i n each instance s o c i a l services would be available to f a c i l i t a t e the discharge. When the patient was being discharged to another h o s p i t a l or i n s t i t u t i o n he would be helped to anticipate the move, and i f a s o c i a l worker was available i n the agency to which he was going, . t h i s worker would be alerted to the patient's a r r i v a l and probable need.  In a l l instances the r e s p o n s i b i l i t y of Crease C l i n i c  s o c i a l workers terminated at the date o f discharge. The information thus: gathered comprises a basic table f o r the present study (Table 1 ) .  I t needs c a r e f u l explanation.  The results indicate that close to one-third of the men discharged from Crease C l i n i c , (31 per cent), have r e l a t i v e s or friends with whom they can l i v e when they leave the h o s p i t a l .  It i s  assumed that these patients are able to turn to t h e i r r e l a t i v e or f r i e n d f o r any help they might require i n a p r a c t i c a l way, or i n the form of encouragement and support.  Although  follow-up  contact by a s o c i a l worker was not provided, t h i s does not mean that no s o c i a l problems existed.  The probable i n t e r p r e t a t i o n i s  that the patient was considered capable of self-help and of independent management of h i s a f f a i r s , without extra support from C l i n i c personnel. Of the group of 100 patients, 8 had more than one need at the point of discharge, and these needs are indicated i n Table 3 .  38  Table- 1.  R e h a b i l i t a t i o n Needs of 100 Male Patients Discharged from Crease C l i n i c  Rehabilitation Needs  A.  B.  C.  Post-discharge situations f o r which after-care was not indicated sdischarged to third-party care :miscellaneous  Relating to material needs Requiring shousing :30b placement -from r e h a b i l i t a t i o n o f f i c e r -from s o c i a l work s t a f f .vocational t r a i n i n g  Relating to inner stresses Requiring casework services rfrom s o c i a l work s t a f f -short-term contact -long-term contact  Persons  Problems  31 18  h 6  h 1  2  ^5  9  6 1  2  6  8  13:  13  jfrom other s o c i a l agency  8  8  D.  No record of discharge s i t u a t i o n  3  E.  Other  h  sfrom S o c i a l Welfare Branch s t a f f  Total  100 -  52  39  Table 2.  Destination of Discharged Patients For Whom After-Care Was Not Indicated  Destination  Persons  Discharged to t h i r d party care Discharged to own  care  31  8  Discharged and admitted to Prov'l Mental Hospital  k  Discharged and admitted to general hospitals  3  Discharged and admitted to . Boys' I n d u s t r i a l School  1  Deported  1  In care of Dep't of Indian A f f a i r s  1  Total  ^9  Table 3.  Patients With More Than One Need  Needs  Persons  Job: and housing Job and help with inner stress  3  Housing and help with inner stress:  1  Total  8  That only 8 patients had more than one problem may at f i r s t seem s u r p r i s i n g , f o r patients who have suffered a mental breakdown have multitudes  of problems and experience many  inner and outer stresses which have weakened t h e i r ego.  In the  records: however, i t i s generally the case that the doctor or s o c i a l worker singles out the primary obstacle confronting the patient.  I t can be assumed therefore, that t h i s i s the main  problem, but not necessarily the only problem.  I t can be assumed  also that the doctor and s o c i a l worker have made an assessment of the patient's s i t u a t i o n ; and have reported that he lacks a p a r t i c u l a r basic need such as housing or a job; or that he w i l l need some extra emotional support i f the danger of a future  hi breakdown i s to be lessened. Housing I f the sample cases are representative, more than one~f i f t h (21 per cent) require environmental aid i n getting a place to stay, finding a. job, or obtaining t r a i n i n g i n some vocation.  Five requests were made on behalf of patients who were  destitute of housing resources and who were t o t a l l y dependent on receiving aid from C l i n i c personnel before they could leave the hospital.  Every person needs a place to stay, and adequate  housing i s therefore an obvious and immediate need of every patient when he leaves the Crease C l i n i c .  For.the patient who  has h i s own home, or has money to rent a room, or who has understanding and accepting f r i e n d s or r e l a t i v e s with whom to l i v e , many of the problems of accomodation are eliminated.  But patients  are referred to the s o c i a l worker for help i n t h i s area of adjustment when a deficiency of some sort i s apparent.  The  referred patient may not have any money to rent a room; he may have no f r i e n d s or family members i n the vicinity;; or the family may have nothing to do with the patient, leaving him to make h i s own arrangements as best he can.  Frequently the patient's l i f e  s i t u a t i o n i s such that he must return to l i v e with a wife or husband or parent, when strained r e l a t i o n s h i p e x i s t s which may have been the p r e c i p i t a t i n g or contributing factor i n h i s i l l n e s s . In such a s i t u a t i o n the s o c i a l worker w i l l assume a helping role both with the patient and h i s r e l a t i v e , so that the l i v i n g arrangement w i l l provide as few stresses and s t r a i n s f o r the patient as  \2  possible.  The present study did not undertake a. q u a l i t a t i v e  investigation of the patient's housing, as to whether or not i t was s a t i s f a c t o r y . The f i v e requests r e f e r to patients who d i d not have even a room to which to go. I t i s sometimes the case that a discharged  patient's  adjustment would be f a c i l i t a t e d by some degree of care and supervision by r e l a t i v e s or boarding house operators.  Occasionally  a greater degree of supervision i s required by patients who cannot manage t h e i r own a f f a i r s completely and are unable to support themselves f u l l y i n employment, and f o r these a. foster home type of care Is recommended by the p s y c h i a t r i s t . Locating suitable housing i s predominantly a p r a c t i c a l service, although some form of counselling or modification of the attitudes of others i s frequently c a l l e d f o r as w e l l .  I t was  o r i g i n a l l y planned to subdivide t h i s category according to the factors of f i n a n c i a l need and need for supervision, However, on examination of the sample group of cases, recorded  information  was either lacking or was not s u f f i c i e n t l y refined to make possible a sub-classification. Needs i n Vocational Adjustment This study considered three components of vocational need: job placement, t r a i n i n g or r e - t r a i n i n g , and sheltered employment. I f the figures are representative 16 per cent of the discharged men have needs i n t h i s area.  Only one of the 16 was f o r t r a i n i n g .  The need f o r job placement means that the patient's primary problem i s finding a job, rather than indecision as to choice of vocation. Vocational services to meet t h i s need include finding a job f o r the patient, seeing that he i s placed i n the job, and i d e a l l y  ^3  •  should include subsequent contact with the patient and his, employer to ascertain i f the placement i s mutually s a t i s f a c t o r y . A need f o r vocational t r a i n i n g or re-training; may  he  indicated when the patient himself expresses: a desire for i t , or when such t r a i n i n g i s recommended "by the treatment team. example, a. young patient may  have made a choice i n favor of a  p a r t i c u l a r trade but lack t r a i n i n g f o r i t . may  For  A middle-aged patient  have some basic s k i l l s i n a. p a r t i c u l a r l i n e of work but require  r e - t r a i n i n g or "brush-up" courses to place him i n a better position to compete i n the employment market, £L need f o r protective work placement r e f e r s to a patient who  i s capable of l i v i n g i n the: community and of doing a job of  work, but whose mental and emotional state i s such that he i s incapable of withstanding competitive  employment.  the normal stresses and demands of Somewhat s u r p r i s i n g l y , examination of  the case records of the sample group of patients f a i l e d to reveal mention of t h i s p a r t i c u l a r need.  I t would appear either that  t h i s problem occurs infrequently, or that such a. recommendation i s not considered  (and therefore not recorded) by the treatment  team due to t h e i r awareness that resources i n the community to meet the need are l i m i t e d or completely lacking;.  I t may  be  that t h i s type of placement i s of more frequent significance f o r patients of a mental h o s p i t a l with more serious and more incapacitating forms of mental i l l n e s s than are usual  i n the  Grease C l i n i c . The nature and the extent of the help which patients  may  require i n vocational adjustment varies widely, f o r many factors  1+4  are involved. For every person, a s a t i s f y i n g work experience i s a major part of good mental health.  Not only i s work  necessary f o r the support of oneself and one's family, hut i t i s an important outlet f o r many natural impulses such as competitiveness and aggression.  For some, success at work  i s a compensation f o r weakness i n other areas.  Work sometimes  brings people into close and f r i e n d l y relationships with others. I t may  also be a creative a c t i v i t y which s a t i s f i e s basic  emotional needs.  To some people; work brings recognition and  prestige.  Young people often look upon a job as a symbol of  maturity.  Older people who  continue at work after the usual  time f o r retirement f e e l that they are u s e f u l and contributing members of society and not a burden. expected that a man  In Canadian culture i t i s  should work, and i n a b i l i t y to hold a job  becomes a r e f l e c t i o n upon his adequacy.  Unemployment affects  not only the man but also h i s wife and children; the.results being not only f i n a n c i a l hardship but also a wounding of pride, with feelings of g u i l t and shame.  Satisfying work , then, i s  as important f o r most people as are food, sleep, and recreation; and few people who  do not work are: genuinely happy.  Despite i t s importance  i n good mental health, many people  have d i f f i c u l t y i n achieving a s a t i s f y i n g work experience. Many young people are uncertain about t h e i r choice of a vocation or lack knowledge of what preparation i s needed to achieve t h e i r goal.  Some never f i n d a r e a l l y s a t i s f y i n g work placement.  In an i n d u s t r i a l setting i t i s d i f f i c u l t f o r workers to have the f e e l i n g that they are more than anonymous "cogs i n a great machine"; and management-labour r e l a t i o n s need strengthening  H-5 so that workers f e e l they are useful members of society. In times of depression or seasonal unemployment there are not enough jobs to go around.  A man who i s unable to f i n d work i s unable  to support himself or h i s family.  Unemployment therefore may  have devastating e f f e c t s upon a man's sense of worth and usefulness as an independent and contributing member of society. The hazards and d i f f i c u l t i e s . i n achieving a good vocational adjustment are frequently accentuated f o r those who are discharged from a psychiatric c l i n i c .  Unsatisfactory work i t s e l f  may have: been a contributing factor i n the onset of the mental i l l n e s s , .and when such a person returns to the community he w i l l need to e f f e c t a more s a t i s f a c t o r y resolution of t h i s problem i f the gains i n psychiatric treatment are to be implemented and retained.  Emotional problems may have reduced a patient's  working e f f i c i e n c y , blocked the achievement of his maximum p o t e n t i a l i t i e s f o r work, caused a patient to overreach himself In vocational expectations, or prevented the f u l l s a t i s f a c t i o n which work might bring.  personal  Patients sometimes bring  to the Crease C l i n i c t h e i r anxieties about employment, lack of work s k i l l s or status; t h e i r worries about personal relationships on jobs; t h e i r confusions  about the kind of vocation to choose  or the kind of job to look f o r ; and t h e i r convictions that they had greater or lesser a b i l i t i e s than they required on t h e i r present  jobs.  These expressions  of concern are r e l a t e d to t h e i r  problems i n s o c i a l and interpersonal r e l a t i o n s h i p s . Vocational adjustment i s only a part, but an important part , of the patient's t o t a l adjustment to h i s environment.  he In i t s broadest' terms, psychiatric treatment i s aimed to improve t h i s t o t a l adjustment, and one of the t e s t s of e f f e c t i v e t r e a t ment i s a patient's a b i l i t y to cope with employment stresses. One  of the p r a c t i c a l d i f f i c u l t i e s i s that h o s p i t a l i z a t i o n ,  even f o r a few weeks or months, may mean loss of a job and necessity of locating a new  one after discharge.  returns to the same job he may  the  I f a patient  be apprehensive of the response  of h i s fellow employees to h i s mental i l l n e s s , and, fearing that he w i l l be stigmatized, he may going back.  even refuse to consider  Many patients r e t a i n a residuum of their mental  i l l n e s s , so that they are handicapped i n t h e i r a b i l i t y to manage t h e i r own  a f f a i r s , look for work, or to get along with fellow-  workmen.  These patients are f e a r f u l of, and are quick to sense  any r e j e c t i o n by employers or anyone e l s e .  They may  have grave  doubts as to whether or not they can contribute anything  in a  job s i t u a t i o n . Vocational counselling of such mentally  handi-  capped persons requires patience, understanding and encouragement by the counsellor i n helping each p t l e h t to reach h i s a  best p o s s i b i l i t i e s .  We  own  cannot discuss i n further d e t a i l here  the t e c h n i c a l casework processes which may be u t i l i z e d by  the  s o c i a l worker i n helping patients i n t h e i r vocational adjustment, other than to note the unique vocational problems presented by discharged mental patients. Reference material dealing with the vocational r e h a b i l i t a t i o n of psychiatric patients indicates that the largest number who  w i l l need and p r o f i t by vocational services are young  people, l a r g e l y schizophrenics, who work h i s t o r y .  have l i t t l e or no  previous  These young!patients need plenty of time to f i n d  47 t h e i r work goals.  Accurate information should he given them  about the s a t i s f a c t i o n s and d i s s a t i s f a c t i o n s to be expected from d i f f e r e n t kinds of work.  This group of patients are apt to be  u n r e a l i s t i c and t h e i r f i r s t plans are often impracticable. In p r a c t i c e , discussing work plans i s a fundamental means of testing on a r e a l i t y basis the patient's readiness to return to the community.  Much patience i s c a l l e d f o r i n helping the  patient to a f i n a l plan of h i s own.  I t has been found i n some  instances that the counselling process takes two-and-one-half times as long f o r the emotionally handicapped as for the 1 physically handicapped. The aim i n vocational counselling i s to help the patient to a work goal i n which h i s maximal p o t e n t i a l i s reached i n terms of i n t e l l e c t u a l c a p a c i t i e s , s k i l l s and aptitudes, vocational interest or preference, physical condition, and p s y c h i a t r i c disability.  To accomplish t h i s aim, the counsellor, from the  point of view of good professional s o c i a l work p r a c t i c e , w i l l work i n close collaboration with people i n other d i s c i p l i n e s . For example, at the Crease C l i n i c , the s o c i a l worker or r e h a b i l i t a t i o n o f f i c e r i d e a l l y would have the assessment of the p s y c h i a t r i s t of the patient's c a p a b i l i t y to function under the stresses and strains of a p a r t i c u l a r work placement.  He would  also have the assessment of the psychologist as to the patient's i n t e l l e c t u a l capacities and work aptitudes, so as. to indicate 1  ' ' ' Rennie, T.A.C., Burling, T., and Woodward, L.E., "Rehabilit a t i o n of the P s y c h i a t r i c a l l y Disabled". Mental Hygiene. A p r i l , 1949. !  1+8 .  his  c a p a b i l i t y f o r a p a r t i c u l a r job or h i s need f o r vocational  training.  The s o c i a l worker's assessment of the psychosocial  s i t u a t i o n reveals some of the s o c i a l , family and p r a c t i c a l considerations i n planning.  P a r t i c u l a r work settings must be  understood and related to the patient's personality and s o c i a l situation.  Details to be considered  i n work settings are the  physical set-up, the relationship with s t a f f and supervisors, hours of employment, degree of r e s p o n s i b i l i t y , and the nature and l e v e l of work and production requirements.  A l l t o l d , the  process of vocational counselling i s a highly personalized one of matching the unique needs and capacities of a p a r t i c u l a r patient to a work goal.  I t i s a professional undertaking which,  may require many hours of interviews, and which c a l l s f o r much s k i l l , good judgement, and adaptability on the part of the counsellor. A s a t i s f y i n g work experience i s such an important factor i n mental health, that time and e f f o r t are j u s t i f i e d to ensure the best possible vocational adjustment of the discharged mental patient.  A good work adjustment will, heighten h i s sense of  worth and contribute to h i s o v e r - a l l adjustment, thus a s s i s t i n g him to maintain the gains i n treatment he has received i n hospital.  As already noted, the vocational needs of patients are  not a l l the same, so that i n d i v i d u a l help i s required.  Vocational  services may include help i n finding a job, help i n choosing a vocation and i n getting t r a i n i n g f o r i t , help i n settlement i n a protective work placement, or follow-up  contact and  encouragement after a placement has been made.  Planning f o r a  h9 patient's vocational future should begin at the time of a patient's admission.  Primary r e s p o n s i b i l i t y i s with the p s y c h i a t r i s t , but  the entire h o s p i t a l s t a f f should be a l e r t to the patient's probable need f o r a job after h i s treatment i s concluded. Extra-mural Treatment Heeds: There are a number of patients receiving casework services during t h e i r stay i n the h o s p i t a l whose mental and emotional equilibrium at the time of discharge i s such that continued encouragement and support i s required to strengthen them. Judging from the present study, t h i s i s true of nearly one i n three of discharged patients already referred f o r casework. Thirty one requests f o r t h i s type of after-care were recorded, as shown i n Section C. of Table 1.  As noted e a r l i e r i n t h i s  study, post-discharge casework services are frequently recommended by the p s y c h i a t r i s t to a s s i s t patients i n re-establishing themselves and i n maintaining the treatment gains made i n the Clinic.  For the purposes of t h i s t h e s i s , extra-mural treatment  by s o c i a l workers includes e f f o r t s i n the r e l i e f of i n t e r n a l stress, when predominant concern i s the provision of emotional support rather than a p r a c t i c a l service.  In some instances  these casework services are more or less b r i e f and t r a n s i t o r y i n nature, contact being maintained f o r only a few weeks u n t i l the patient i s settled comfortably i n h i s home and job.  Hence-  f o r t h the patient i s expected to be able to manage independently without casework support or help from the s o c i a l worker.  In  other instances, when inner and outer stresses upon the patient  50  are anticipated and are expected to remain f o r several months, long-term casework services may be recommended by the p s y c h i a t r i s t . These services are i n the nature of extra support from the Clinic,, the aim being to a l l e v i a t e the p o s s i b i l i t y of a relapse and subsequent re-admission to the C l i n i c .  Because of the i n t e r -  -relatedness of factors i n human experience, such casework support may touch upon a. wide variety of human problems: m a r i t a l c o n f l i c t , unsatisfactory vocational adjustment, f i n a n c i a l burdens, and so forth.  Help may  also be required by the patient whose emotional  or mental disturbance continues to handicap him i n making adjustments to c i v i l i a n l i v i n g .  This kind of treatment  represents  an extension into the community of the treatment f a c i l i t i e s of the Crease C l i n i c . The structure and function of the S o c i a l Service Department at Crease C l i n i c i s such that extra-mural services to patients residing i n the Greater Vancouver area are given by the C l i n i c s o c i a l workers. t h i s nature.  In the present sample there are 10 requests of  Patients whose residence i s outside Greater Van-  couver are served by the d i s t r i c t or amalgamated o f f i c e s of S o c i a l Welfare Branch.  In the l a t t e r instance, supervisory and  consultative help with the psychiatric aspects of post-discharge care of patients i s provided by the s o c i a l workers at Crease C l i n i c , who have access to psychiatric consultation. The sample contained 13 requests for t h i s service.  This investigation  distinguishes four categories of follow-up casework services. The f i r s t two categories r e f e r to services given by Crease C l i n i c s o c i a l workers.  Of these, the phrase "short-term service"  51  designates contacts limited i n duration to less than one month following discharge;  "long-term service" w i l l indicate contacts  of longer duration than one month.  We w i l l also d i s t i n g u i s h the  r e f e r r a l s of cases for service to S o c i a l Welfare Branch o f f i c e s , and r e f e r r a l s to other s o c i a l agencies i n Vancouver or  elsewhere.  "Other s o c i a l agencies" includes the P r o v i n c i a l Probation Service Vancouver C i t y S o c i a l Service Department, and children*s and family agencies. category.  Eight requests i n the sample f e l l into t h i s  Referrals are made to other s o c i a l agencies when the  predominant problem relates-to the function of the p a r t i c u l a r agency.  I f service i s required with the psychiatric aspects of  after-care, the case i s usually c a r r i e d on a joint basis with the Crease C l i n i c Department. The remainder of the sample reveals the proportion of patients who institution.  are discharged d i r e c t l y to another h o s p i t a l or The destination of these patients who  did not  receive post-discharge service from Crease C l i n i c s t a f f i s shown i n Table 2 .  There were 8 patients who were discharged on an  independent basis, who  established themselves without  on friends or family or h o s p i t a l personnel, and who  reliance  carried out  t h e i r own plans and l i v i n g arrangements without follow-up contact from Crease C l i n i c .  Of the remaining 1 0 patients:, V.were comm-  i t t e d to the P r o v i n c i a l Mental Hospital; 3 were admitted to general h o s p i t a l s f o r medical or s u r g i c a l therapy; one  was  admitted to the Boy's I n d u s t r i a l School; one was deported; and one was discharged i n care of the Department of Indian A f f a i r s . In 3 instances the unit f i l e s f a i l e d to indicate the  52 destination of the patient at the point of discharge, what plans were made, or whether or not a post-discharge  service was required.  Three patients l e f t the C l i n i c against advice and one died i n hospital. R e h a b i l i t a t i o n a Process of Meeting Needs The figures which have now been reviewed provide a highly s i g n i f i c a n t cross-section of the kinds of s i t u a t i o n s faced by the discharged mental patient, and the r e l a t i v e frequency with which c e r t a i n types of problems are experienced.  They give  p r a c t i c a l meaning to " r e h a b i l i t a t i o n " , the process whereby the needs are met which enable the patient to become re-established as a c i t i z e n .  For the mental patient i t i s not only a question  of having a. house and a job;: i t i s a matter of attaining a comfortable equilibrium i n the face of outer pressures and inner turmoil.  I f the sample of cases studied are representative,  the proportion of discharged  patients f o r whom the outer  press-  ures of material needs are a s i g n i f i c a n t problem i s approximately one i n f i v e ; and the proportion of patients who require help with inner stresses i s approximately one i n three.  During a  patient's stay i n h o s p i t a l , the role of helping persons i s to help release the healing forces at work within the personality which are struggling to achieve harmony, wholeness and happiness. When the patient leaves the h o s p i t a l doors the aid of helping persons i s required to meet the material and emotional needs of the proportion of patients noted. are met,  w i l l be considered  How, and by whom these needs  i n the following  chapter.  Chapter 3  Resources F o r Meeting Heeds  The v a r i e t y and frequency o f the r e h a b i l i t a t i o n p a t i e n t s d i s c h a r g e d from Crease C l i n i c i s w e l l  needs o f  Illustrated  by the f a c t u a l m a t e r i a l i n the f o r e g o i n g c h a p t e r .  How f a r  they can be met depends on, (a) the r e s o u r c e s which the p a t i e n t has when he comes t o the C l i n i c , (b) any changes i n h i s situation  d u r i n g h i s p e r i o d o f t r e a t m e n t , and, ( c ) what the  s o c i a l worker can m o b i l i z e f o r him, o r h e l p him u s e , on d i s c h a r g e * The s o c i a l worker i s the s t a f f member who between the C l i n i c and the community; largely  serves as a l i n k  and i t i s t h e r e f o r e  t h r o u g h h i s e f f o r t s t h a t comprehensive s o c i a l  are m o b i l i z e d t o meet needs*  services  Whereas i t i s n o t w i t h i n the  scope o f t h i s study t o d i s c u s s i n d e t a i l the t e c h n i c a l casework p r o c e s s e s which may be used i n b r i n g i n g s o c i a l s e r v i c e s t o d i s c h a r g e d mental p a t i e n t s , i t i s h e l p f u l t o note some broad c l a s s i f i c a t i o n s o f casework treatment methods which are g e n e r a l l y accepted i n the p r o f e s s i o n o f s o c i a l work.  A l l of  these methods may be u t i l i z e d by the s o c i a l worker i n h i s over« a l l e f f o r t i n a i d i n g p a t i e n t s ; but t o p r e s e n t a p i c t u r e o f some o f the c o n c r e t e d i s c h a r g e problems, t h e needs covered under the i n c l u s i v e  term "casework s e r v i c e s t o d i s c h a r g e d  5V  p a t i e n t s " are broken down into several  categories*  In s o c i a l work professional l i t e r a t u r e i t i s recognized that casework In any area of treatment i s composed of clusters of basic techniques} depending on the problem, the aim, t r e a t a b i l i t y , agency function and so f o r t h . ude  These f a c t o r s i n c l -  the b u i l d i n g of a professional r e l a t i o n s h i p ; the e s t a b l i s h -  ment of confidence; the reduction of anxiety by acceptance and support; the maintenance of focus on s p e c i f i c goals desired by the c l i e n t ; the support of constructive defences and work with the r e l a t i v e l y healthy part o f the c l i e n t ' s personality; and the use of p r a c t i c a l resources*  Interviewing  and the use  of r e l a t i o n s h i p are basic common f a c t o r s i n a l l casework* Because personal and s o c i a l combinations s h i f t and overlap, a l l of the techniques noted may be used i n one p a r t i c u l a r case, but weighted d i f f e r e n t l y i n another.  A d i f f e r e n t i a l use of  techniques i s employed i n Individual cases on the basis of diagnosis of the s o c i a l problem. On t h i s common basis, i t i s possible and h e l p f u l to make a simple c l a s s i f i c a t i o n of casework treatment methods into three d i v i s i o n s : one, administration of a p r a c t i c a l service; two, environmental manipulation; three, d i r e c t treatment.  In the  f i r s t of these the primary focus i n a s s i s t i n g the c l i e n t i s  1  '•  !  !  Austin, L u c i l l e N., "Trends i n D i f f e r e n t i a l Treatment i n S o c i a l Casework". Journal of SocialCasework. June, 19^8, Hamilton, Gordon. Theory and Practice of S o c i a l Casework. Columbia University Press; New York; 1951; Chapter 9 . " H o l l i s , Florence, Women i n M a r i t a l C o n f l i c t ; A Casework Study* Family Service Association of America; New York; 19^9; Chapter XI.  55 the worker*s c h o i c e and use  (on the b a s i s o f s o c i a l d i a g n o s i s  and through the medium o f the casework r e l a t i o n s h i p ) o f a r e s o u r c e a f f o r d e d by the community.  Examples o f p r a c t i c a l s e r -  v i c e s are p r o v i d i n g f i n a n c i a l a i d , l o c a t i n g housing, l e g a l h e l p o r medieal c a r e .  social  and  procuring  By means o f such s e r v i c e s the  c l i e n t i s a i d e d towards r e a l i z i n g independence, s e l f - h e l p , awareness, and r e s p o n s i b i l i t y , tribute  self-  so t h a t he can continue t o con-  something t o the s o l u t i o n o f h i s problem; o r , i f he i s  n o t a b l e t o do so, t o be s u s t a i n e d i n a p p r o p r i a t e ways. The  second method r e f e r r e d t o i s sometimes termed  "social  t h e r a p y * or " i n d i r e c t t r e a t m e n t w h e r e i n common casework t e c h n i q u e s a r e employed t o h e l p the c l i e n t , but w i t h emphasis upon changes i n the s o c i a l s i t u a t i o n .  "In g e n e r a l , such  environmental  m o d i f i c a t i o n i s undertaken by the caseworker o n l y when environmental  p r e s s u r e s upon the c l i e n t are beyond the  latter's  c o n t r o l but can be m o d i f i e d by the caseworker, or when such p r e s s u r e s are much more l i k e l y t o y i e l d t o change when handled 1 d i r e c t l y by the worker r a t h e r than by the c l i e n t h i m s e l f * " Examples o f such arranged  s i t u a t i o n s are homemaking s e r v i c e s ,  group e x p e r i e n c e s , s u b s t i t u t e f a m i l y c a r e , and v o c a t i o n a l o r e d u c a t i o n a l adjustments.  A l s o i n c l u d e d i n t h i s method o f t r e a t s  ment i s t h e m o d i f i c a t i o n o f a t t i t u d e s toward the c l i e n t o f s i g n i f i c a n t persons i n h i s l i f e : p a r e n t , t e a c h e r  t  spouse, o r  employer. I n d i r e c t treatment,  I  ™  the purpose o f i n t e r v i e w i n g i s t o  ^  H o l l i s , op c i t , p.14?.  56 induce or r e - i n f o r c e a t t i t u d e s f a v o r a b l e t o maintenance o f e m o t i o n a l e q u i l i b r i u m , t o making c o n s t r u c t i v e d e c i s i o n s , and t o growth o r change.  T h i s method o f treatment comprises t h r e e  c l o s e l y r e l a t e d y e t d i s t i n g u i s h a b l e treatment p r o c e s s e s t o which may  be a p p l i e d the terms " c l a r i f i c a t i o n " , " p s y c h o l o g c a l  support", and " i n s i g h t development*.  D i r e c t , treatment  l e a d i n g t o psychotherapy, i s I n t e n s i v e t h e r a p y .  On a l e s s  i n t e n s i v e l e v e l , d i r e c t treatment i s sometimes r e f e r r e d t o as c o u n s e l l i n g , a form o f treatment p r o b a b l y more f r e q u e n t l y used i n casework w i t h d i s c h a r g e d mental  patients.  intended t o h e l p a person i n a r a t i o n a l way  "Counselling i s  t o s o r t out the  i s s u e s i n h i s s i t u a t i o n , t o c l a r i f y h i s problem and h i s c o n f l i c t s w i t h r e a l i t y , t o d i s c u s s the f e a s i b i l i t y o f the v a r i o u s courses o f a c t i o n , and t o f r e e the c l i e n t r e a l i s t i c a l l y t o assume the  2 r e s p o n s i b i l i t y o f making a c h o i c e , " I f the 100 cases s t u d i e d are r e p r e s e n t a t i v e , the main problem o f approximately 21 per cent o f the male p a t i e n t s d i s c h a r g e d from Crease C l i n i c i s m a t e r i a l need o f housing o r a job.  The c h i e f need o f approximately 31 per cent o f the  p a t i e n t s i s h e l p w i t h i n n e r problems o f emotional s t r e s s . P a t i e n t s w i t h these needs r e c e i v e h e l p e i t h e r i n d i r e c t  service  from the s o c i a l worker and r e h a b i l i t a t i o n o f f i c e r , or as a r e s u l t o f community s e r v i c e s m o b i l i z e d on t h e i r b e h a l f by these s t a f f members.  —j  The s o c i a l worker's body o f knowledge and  — An enlargement op c i t , Chapter X I ,  i • = o f these terms may be found i n H o l l i s ,  2  Hamilton, op c i t , p.250.  57 acquired  s k i l l r e l a t e s b o t h t o casework h e l p a v a i l a b l e through  a w o r k e r - p a t i e n t r e l a t i o n s h i p , and  a l s o t o the s k i l l e d use  community r e s o u r c e s f o r t h e b e n e f i t o f the c l i e n t .  The  of  social  worker i s a c t i v e i n b o t h areas o f i n t e r n a l and e x t e r n a l s t r e s s , h e l p i n g the p a t i e n t by  l o c a t i n g work and h o u s i n g , and  also  helping  the p a t i e n t to h o l d t o h i s treatment g a i n s through i n d i v i d u a l and  f a m i l y casework s e r v i c e s .  i n these two  a r e a s , one  There are many ways o f  helping  o f the major ways b e i n g t o put  the  p a t i e n t i n touch w i t h the community agency which can b e s t meet his  p a r t i c u l a r need*  P u b l i c w e l f a r e and  s o c i a l assistance  agencies  can be o f great h e l p i n p r o v i d i n g f i n a n c i a l support, i n securing  accommodation; and  i n the case o f the S o c i a l W e l f a r e  Branch, i n the p r o v i s i o n o f casework s e r v i c e s o u t s i d e G r e a t e r Vancouver a r e a .  Children's  the  and f a m i l y a g e n c i e s can  be  o f v i t a l s e r v i c e when the p a t i e n t ' s problem r e l a t e s more s p e c i f i c a l l y t o c h i l d and  family welfare.  T h i r t e e n per cent o f  the cases s t u d i e d were r e f e r r e d t o S o c i a l Welfare Branch,  and  8 per cent t o o t h e r s o c i a l a g e n c i e s i n the community.  a  In  d i s c u s s i o n o f a v a i l a b l e r e s o u r c e s i n meeting p a t i e n t needs i n r e h a b i l i t a t i o n , we  r e q u i r e some i n d i c a t i o n o f the  o f such r e s o u r c e s from the two and e x i s t i n g community Job  adequacy  sources noteds h o s p i t a l p e r s o n n e l  facilities.  Placement Job placement i s a p e r s o n a l i z e d  s e r v i c e which I n v o l v e s  f i n d i n g a p a r t i c u l a r job f o r a p a r t i c u l a r p a t i e n t , g e t t i n g person i n t o the  job, and f o l l o w i n g up by making c o n t a c t  the p a t i e n t and  employer.  may  I n the Crease C l i n i c , men  the  with  patients  get h e l p o f t h i s k i n d from the s o c i a l worker or from the  58 rehabilitation officer.  I n t h e year 1952 there were f i v e ease-  workers and one casework s u p e r v i s o r I n t h e C o n t i n u i n g  Casework  S e c t i o n o f t h e S o c i a l S e r v i c e Department, which i s r e s p o n s i b l e f o r a l l r e h a b i l i t a t i o n s e r v i c e s , o f which job placement i s one, (How  t h e s e s t a f f members compare i n number w i t h approved  personnel  standards w i l l be d i s c u s s e d l a t e r . ) The p r e s e n t  r e h a b i l i t a t i o n o f f i c e r i s a t r a i n e d s o c i a l worker who was appointed  t o t h e Hen's D i v i s i o n o f t h e R e h a b i l i t a t i o n Department  i n F e b r u a r y 1950.  H i s primary f u n c t i o n i s t h a t o f job p l a c e -  ment and t h e l o c a t i o n o f temporary h o u s i n g f o r a s e l e c t i o n o f male c a s e s from b o t h t h e P r o v i n c i a l M e n t a l H o s p i t a l and t h e Crease C l i n i c . The  c h i e f community resource  a v a i l a b l e t o s o c i a l workers  i n job placement o f p a t i e n t s i s t h e N a t i o n a l Employment S e r v i c e , w i t h o f f l e e s l o c a t e d i n Vancouver, New Westminster, and i n some l a r g e r r u r a l c e n t r e s i n the p r o v i n c e .  The S e r v i c e i s d i v i d e d  i n t o v a r i o u s s e c t i o n s : farm placement, g e n e r a l l a b o u r , and p r o f e s s i o n a l employment.  trades,  There a r e a l s o S p e c i a l Placements  S e c t i o n s i n the Vancouver and New Westminster o f f i c e s , which r e c e i v e r e f e r r a l s o f those p a t i e n t s who present a n employment handicap, i n c l u d i n g d i s c h a r g e d mental p a t i e n t s w i t h a c o n t i n u i n g psychiatric disability.  Some p a t i e n t s p r e f e r t o go t h e Employ-  ment S e r v i c e o f f i c e on t h e i r own. going  Some f e e l Insecure about  alone and the s o e i a l worker makes the p r e l i m i n a r y  contact,  accompanies t h e p a t i e n t f o r an i n t e r v i e w w i t h the Placement  S o u r c e : I n t e r v i e w w i t h Addison, Mr. D. R e h a b i l i t a t i o n O f f i c e r . Crease C l i n i c . t  59 O f f i c e r , and provides casework support during the placement process.  When r e f e r r a l i s made to the Special Placements Section,  the s o c i a l worker making the r e f e r r a l communicates t o the Placement O f f i c e r a general picture of the kind of person the patient i s , with as much information as t o h i s vocational and needs as i s a v a i l a b l e .  preferences  The Placement O f f i c e r needs to know  whether the patient has f u l l y recovered, i f further treatment i s planned, and how the r e s i d u a l of the patient's i l l n e s s may a f f e c t h i s functioning i n employment.  The Placement O f f i c e r  then endeavors to place the Individual by personal contact with the prospective employers. Personnel O f f i c e r s and employers may be contacted  directly  by the s o c i a l worker, although i n general practice s o e i a l workers act on the premise that the National Employment Service i s the appropriate and s p e c i a l i z e d community agency to provide service i n job l o c a t i o n . Patients who reside In r u r a l parts of the province where no Employment Service o f f i c e i s located are referred t o the f i e l d o f f i c e s of the S o c i a l Welfare Branch f o r help i n job placement i n t h e i r home community.  Approximately 35 per cent  1 of patients come from outside the Greater Vancouver area. A l i m i t e d amount of money i s available through the Business O f f i c e of the C l i n i c to a s s i s t patients at the time of discharge to maintain themselves u n t i l the f i r s t pay from t h e i r job i s received.  1  The maximum allowance per patient i s $20. !  Pepper, op c i t .  A stated  "  60 gratuity may be authorized f o r a p a r t i c u l a r patient by the attending p s y c h i a t r i s t .  For those patients who are e l i g i b l e ,  the Unemployment Insurance Commission may provide f i n a n c i a l a i d during the post-discharge period before employment i s a c t u a l l y located. I t i s generally agreed by the Crease C l i n i c s t a f f that community resources f o r job placement are f a i r l y adequate, and that l i t t l e d i f f i c u l t y i s experienced i n placing patients except during periods of seasonal unemployment.  However i t i s f e l t  that there are too few s o c i a l workers to serve the numbers of patients who need help i n f i n d i n g a job. Vocational Training The consideration of vocational t r a i n i n g or r e - t r a i n i n g i s p a r t i c u l a r l y appropriate f o r patients In the younger age brackets who have no trade or acquired s k i l l , f o r those i n whom a poor vocational.adjustment contributed to t h e i r i l l n e s s , and for  those whose personalities are appreciably altered by the  mental i l l n e s s .  Two kinds of resources are required i n vocat-  i o n a l t r a i n i n g : (a) the educational f a c i l i t i e s ; and (b) the necessary funds f o r t u i t i o n and f o r maintenance during the t r a i n i n g period.  Lack of community, educational f a c i l i t i e s Is  seldom a hindrance, and a wide v a r i e t y of courses and t r a i n i n g are available i n Greater Vancouver at f i v e d i f f e r e n t sources* These include the Vancouver Vocational I n s t i t u t e , operated by the Vancouver Board of School Trustees, and o f f e r i n g a wide s e l e c t i o n of f i r s t c l a s s trade t r a i n i n g .  Part of the I n s t i t u t e ' s  service i s to help trainees Into positions of employment.  There  61 a r e s e v e r a l b u s i n e s s c o l l e g e s o f f e r i n g commercial t r a i n i n g ; and a l s o p r i v a t e l y operated m a t r i c u l a t i o n s c h o o l s •  The Vancouver  S c h o o l Board sponsors n i g h t s c h o o l c l a s s e s d u r i n g w i n t e r months* There axe a wide v a r i e t y o f correspondence courses a v a i l a b l e under the a u s p i c e s o f the Department o f E d u c a t i o n , p r i v a t e e n g i n e e r i n g s c h o o l s , and the U n i v e r s i t y o f B r i t i s h Columbia Department o f E x t e n s i o n * P a t i e n t s who  have adequate funds t o f i n a n c e t h e i r  training  need h e l p o n l y i n a r r i v i n g a t a eholee o f v o c a t i o n and i n r e g i s t e r i n g a t the a p p r o p r i a t e t r a i n i n g s c h o o l .  But when funds are  not a v a i l a b l e from the p a t i e n t o r h i s f a m i l y , p l a n s f o r v o c a t i o n a l t r a i n i n g must be d e f e r r e d u n t i l the p a t i e n t saves the money.  necessary  The Crease C l i n i c has no funds a v a i l a b l e f o r t h i s purpose,  nor a t the present time are funds p r o v i d e d by governmental bodies*. Whereas c e r t a i n government a i d f o r v o c a t i o n a l t r a i n i n g I s p r o v i d e d a l i m i t e d number o f persons w i t h major p h y s i c a l h a n d i caps, the terms o f r e f e r e n c e o f the scheme are n o t as y e t s u f f i c i e n t l y broad t o i n c l u d e persons w i t h a p s y c h i a t r i c dis° 1 ability* was  I n 19^2,  the V o c a t i o n a l T r a i n i n g C o - o r d i n a t i o n A c t  passed and a d m i n i s t e r e d by the F e d e r a l Department o f Labour  through i t s v o c a t i o n a l t r a i n i n g branch*  Under the A c t , v a r i o u s  t r a i n i n g p r o j e c t s are c a r r i e d on by means o f agreements between the F e d e r a l Government and the p r o v i n c e s . j —  —•  Schedule "M* •  o f the '  —  Sources: 1. I n t e r v i e w w i t h Miss R. K i c k l e y , S e c r e t a r y o f D i v i s i o n f o r Guidance o f Handicapped, Community Chest and C o u n c i l o f G r e a t e r Vancouver. 2. Recommendations f o r a Comprehensive R e h a b i l i t a t i o n Programme f o r the P h y s i c a l l y Handicapped i n the P r o v i n c e o f B r i t i s h Columbia. Community Chest and C o u n c i l o f G r e a t e r Vancouver. Dec. 1953*  62  Act i s an agreement between the Government of the Province of B r i t i s h Columbia and the Dominion Department of Labour and was o r i g i n a l l y voted f o r t r a i n i n g of unemployed persons.  I t i s now  being used, i n some degree, to provide vocational t r a i n i n g f o r a limited number of persons with major handicaps.  Authority has  been granted from the Director of Technical and Vocational Training, P r o v i n c i a l Government, to the D i v i s i o n f o r Guidance of Handicapped of the Community Chest and Council of Greater Vancouver, to recommend such handicapped persons as they deem f i t f o r vocational r e - t r a i n i n g .  The Consultative Committee of t h i s  D i v i s i o n i s comprised of physicians, s o c i a l workers,  placement  o f f i c e r s , a psychologist, vocational counsellors and r e h a b i l i t ation o f f i c e r s ; and screens applicants f o r a programme of vocational t r a i n i n g .  Recently, another agreement was  proposed  under the Vocational Training Co-ordination Act, known as Schedule "R".  Should t h i s agreement become implemented by  l e g i s l a t i o n , there w i l l be a d e f i n i t e means by which handicapped persons can be given t r a i n i n g i n addition to many other benefits* Schedule "R" sets f o r t h what are deemed to be the e s s e n t i a l requirements and conditions of a s p e c i a l schedule f o r the t r a i n i n g of disabled persons. I t would appear therefore that a: very serious and  fundamental  gap i n community resources exists i n t h i s area of vocational training.  The f a c i l i t i e s f o r t r a i n i n g are a v a i l a b l e ; but they  are l i m i t e d to those who have ready c a p i t a l , and they exclude persons who are f i n a n c i a l l y dependent or i n marginal income groups.  A high proportion of patients discharged from Crease  63 C l i n i c f a l l i n t o the l a t t e r income b r a c k e t . the f u t u r e the terms o f r e f e r e n c e for  I t may  he t h a t i n  o f schemes o f governmental a i d  v o c a t i o n a l r e h a b i l i t a t i o n w i l l be extended t o i n c l u d e  p a t i e n t s w i t h mental o r e m o t i o n a l h a n d i c a p s .  It will  selected  be  r e c a l l e d t h a t i n the U n i t e d S t a t e s , r e h a b i l i t a t i o n s e r v i c e s t o the p h y s i c a l l y d i s a b l e d were f i r s t p r o v i d e d under the V o c a t i o n a l R e h a b i l i t a t i o n A c t o f 1920. was  g r a d u a l l y e n l a r g e d u n t i l i n 19^3  The  scope o f the  Act  the p s y c h i a t r i c a l l y  dis-  a b l e d were i n c l u d e d i n a j o i n t s t a t e - f e d e r a l program© Housing P a t i e n t s who and who  are w e l l enough t o manage t h e i r own  can a f f o r d t o pay r e n t i n advance, are u s u a l l y q u i t e  able t o f i n d s u i t a b l e h o u s i n g on t h e i r own* the h e l p i n g hand o f the  Some p a t i e n t s need  s o c i a l worker i n g e t t i n g e s t a b l i s h e d  In a good b o a r d i n g house*  There are many good b o a r d i n g homes  i n the community and t h e y are a v a l u a b l e resource who  affairs  can care f o r h i m s e l f *  more than two  t o the  person  A l l boarding homes* where t h e r e  people, are l i c e n s e d under the Welfare I n s t i t u t i o n s  L i c e n s i n g A c t o f the P a t i e n t s who  province.  r e q u i r e h e l p i n f i n d i n g a place t o s t a y  f r e q u e n t l y those without funds*  are  I f these persons are employable  they are not e l i g i b l e f o r s o c i a l a s s i s t a n c e ; and i f they simultaneously  are  i n e l i g i b l e f o r unemployment insurance  are  benefits*  they are dependent on c h a r i t y , and t h e i r p l i g h t i s obvious* These p a t i e n t s need a p l a c e t o s t a y w h i l e they l o c a t e a and u n t i l they r e c e i v e t h e i r f i r s t pay  cheque*  job  Some male  p a t i e n t s are p l a c e d d i r e c t l y from the C l i n i c w i t h mining  and  64 logging firms, with arrangements worked ont i n advance f o r transportation d i r e c t l y to the camp, and f o r maintenance and clothing u n t i l the f i r s t cheque comes i n .  The small gratuity  of up to twenty d o l l a r s which can he given t o the patient on discharge on the authorization of the p s y c h i a t r i s t i s sometimes not s u f f i c i e n t t o get a person started i n day-labouring  jobs.  The h o s p i t a l maintains h o t e l accomodation with meals t o the extent of two rooms (one i n Vancouver and one i n New Westminster)} which are always available t o the r e h a b i l i t a t i o n o f f i c e r f o r temporary placement.  Low cost housing i s available at the  Salvation Army Hostel i n Vancouver f o r those patients who are able t o pay t h e i r own way. One  solution of the housing problems f o r patients who are  without funds i s the provision of f a c i l i t i e s f o r boarding care.  subsidized  An example of t h i s type of care i s a s p e c i a l  i n s t i t u t i o n c a l l e d "The V i s t a " , which i s maintained by the p r o v i n c i a l government as a mid-way home between h o s p i t a l and community.  This f a c i l i t y i s limited t o female patients and t o a  bed capacity of seven.  No separate housing unit of t h i s sort  i s available f o r men, although recommendations f o r i t s e s t a b l i s h ment appear i n Annual Reports of recent years.  Subsidized  boarding care can be made available through public welfare agencies to patients medically c e r t i f i e d as unemployable and who are otherwise e l i g i b l e f o r s o c i a l assistance.benefits.  This  type of care i s lacking for employable patients who need board 1  Birch* op c i t .  65 and lodging u n t i l the f i r s t pay cheque i s received. I f a patient's mental i l l n e s s a f t e r he leaves the h o s p i t a l i s a source of disturbance to himself or to others, c e r t a i n specialized f a c i l i t i e s or housing arrangements are c a l l e d f o r . For example, a moderate amount of sympathetic understanding and casual supervision by operators of boarding homes i s a l l that i s required f o r some patients to adjust s a t i s f a c t o r i l y i n such a setting.  These s p e c i a l i z e d arrangements do not e x i s t at present,  and such f a c i l i t i e s can be found only through e f f o r t by the s o c i a l worker i n d i r e c t contact with an i n d i v i d u a l boarding home operator. Family Care At the present time, no s p e c i a l administrative arrangement or agency e x i s t s to carry on a program of family care f o r d i s charged mental patients i n t h i s province.  Foster family care i s  defined as the placing of the mentally i l l patient i n a family  1 other than h i s own f o r care.  This type of placement may be used  f o r a p a r t i c u l a r group of patients when the outlook f o r t h e i r recovery i s not hopeful.  They may be patients who have responded  to h o s p i t a l treatment to such an extent that i t i s f e l t they can adjust to l i v i n g under close supervision i n a home and benefit from the i n d i v i d u a l attention which comes from family l i f e . Family care i s also used f o r some patients who have responded so w e l l to Intensive h o s p i t a l treatment that they are placed i n Crutcher, Hester B., Foster Home Care f o r Mental Patients* The Commonwealth Fund; New York; 19TC •  66 homes as a t h e r a p e u t i c measure w i t h the purpose o f h a s t e n i n g their  recovery. Requests made t o C l i n i c s o c i a l workers f o r t h i s type o f care  are d e a l t w i t h on an I n d i v i d u a l b a s i s .  The worker h i m s e l f may  seek out a home and arrange f o r t h e p a t i e n t t o l i v e t h e r e ; o r the worker may request t h e c o - o p e r a t i o n and a s s i s t a n c e o f S o c i a l Welfare Branch o f f i c e s o r m u n i c i p a l p u b l i c w e l f a r e  agencies.  The S o c i a l Welfare Branch o f f i c e s do n o t m a i n t a i n a r o s t e r o f s u i t a b l e homes, but they a r e acquainted w i t h f o s t e r homes used f o r c h i l d placement, and they w i l l make an e f f o r t t o honour a s p e c i f i c request on b e h a l f o f a d i s c h a r g e d p a t i e n t from Crease Clinic. Casework S e r v i c e s Casework s e r v i c e s t o p a t i e n t s f o l l o w i n g t h e i r  discharge  are g i v e n by t h e s t a f f o f t h e S o c i a l S e r v i c e Department a t Crease C l i n i c , who may a l s o r e f e r p a t i e n t s t o community ageneies f o r t h i s type o f s e r v i c e .  social  As a t present o r g a n i z e d , t h e  Department a t Crease C l i n i c i s d i v i d e d Into two s e c t i o n s : t h e Admissions  S e c t i o n , d e a l i n g w i t h Intake and b r i e f s e r v i c e s t o  p a t i e n t s ; and the C o n t i n u i n g S e r v i c e S e c t i o n , r e s p o n s i b l e f o r s e r v i c e s t o p a t i e n t s on the ward, p r e - c o n v a l e s c e n t p l a n n i n g , and f o l l o w - u p casework s e r v i c e s i n the p o s t - d i s c h a r g e p e r i o d . Admissions two  The  S e c t i o n i s composed o f one casework s u p e r v i s o r and  s o c i a l workers; and the C o n t i n u i n g S e r v i c e S e c t i o n i s com-  posed o f one s u p e r v i s o r and f i v e workers; making a t o t a l o f seven workers. The American P s y c h i a t r i c A s s o c i a t i o n has e s t a b l i s h e d c e r t a i n  67 personnel standards f o r psychiatric h o s p i t a l s and c l i n i c s *  The  personnel r a t i o s c a l l f o r at least one s o c i a l worker t o every 80 new admissions per year, and at least one s o c i a l worker to each 60 patients on convalescent status or family care. Administrative and supervisory s o c i a l workers should be provided 1 i n the r a t i o of one supervisor to every f i v e caseworkers.  Due  to the f a c t that the S o c i a l Service Department at Crease C l i n i c does not d i s t i n g u i s h in-patient and convalescent care i n the assignments of s o c i a l workers, an exact comparison with Assoc* l a t l o n standards i s not f e a s i b l e .  Neither i s s t a t i s t i c a l data  at hand on the number of patients on convalescent status. However, the number of new admissions to Crease C l i n i c (male and female) during the f i s c a l year of 1952*53 was 1221, which, on the basis of the standard personnel r a t i o s , would c a l l f o r 15 s o c i a l workers.  This figure does not include s o c i a l workers  who would be assigned to patients on convalescent status and family care.  On the basis of these f i g u r e s , the present s o c i a l  service s t a f f of seven would need to be more than doubled to f u l f i l the personnel standards of the American Psychiatric Association. An assessment of the volume and the standards of service given by S o c i a l Welfare Branch o f f i c e s would e n t a i l an independent research project of considerable magnitude and i s beyond the scope of this, t h e s i s . 2  —  The assessment would provide a pertinent :  :  -  "Standards f o r Psychiatric Hospitals and C l i n i c s " . American Psychiatric Association. November 1951*  68 topic f o r a future study and analysis. Crease C l i n i c s o c i a l workers may r e f e r patients t o community s o c i a l agencies f o r a casework service of a s p e c i a l i z e d or p a r t i c u l a r nature, on a d i v i s i o n of labour b a s i s .  These community  agencies provide family, children's, and child-guidance of service.  types  Cases may be held j o i n t l y with the community agency,  with the h o s p i t a l s o e i a l worker being responsible f o r the psychl a t r i e supervision of the patient* and the community agency worker assuming r e s p o n s i b i l i t y f o r problems of c h i l d care, l e g a l separation, and so f o r t h .  Some cases may be elosed by the h o s p i t a l  s o c i a l worker at the point of r e f e r r a l to a community ageney i f follow-up p s y c h i a t r i c supervision i s not indicated. For present purposes i t i s not necessary to undertake a comprehensive survey of the many community agencies a v a i l a b l e . An o u t l i n e of the services which the community of Greater Vancouver has established to meet the needs and problems of i t s 1 c i t i z e n s i s printed by the Community Chest and Council*  I t can  be noted however that the public welfare agency of the C i t y of Vancouver (City S o c i a l Service Department), and also the public welfare agency of the province  ( S o c i a l Welfare Branch), are  providing the P r o v i n c i a l Mental Health Services valuable rehab2 i l i t a t i o n services.  The C i t y S o c i a l Service Department provides  f i n a n c i a l a i d to Individuals and f a m i l i e s who are e l i g i b l e . 1  ~  ~  "  "Manual of Health, Welfare and Recreation Services of Greater Vancouver"• Community Chest and Council of Greater Vancouver. November 1952. 2 Annual Report of Mental Health Services. 1952* op c i t p.5^.  The  69 S o c i a l Welfare Branch gives casework services as w e l l as s o c i a l assistance i n helping patients t o r e - e s t a b l i s h themselves. Schedule A, which follows, contains short summaries of f i v e t y p i c a l cases, each i l l u s t r a t i n g a p a r t i c u l a r c l u s t e r of problems i n r e h a b i l i t a t i o n *  The meeting of the needs presented  i n the case summaries c a l l s f o r the discriminating a p p l i c a t i o n of the resources so f a r discussed*  The examination of the r e s -  ources available In B r i t i s h Columbia indicates that gaps and l i m i t a t i o n s e x i s t , e s p e c i a l l y i n the provision of subsidized boarding care and f i n a n c i a l a i d , and also i n the numbers of s o c i a l workers employed at Crease C l i n i c .  An extension of  present resources and the creation of new ones i s necessary i f discharged patients i n need are t o have access to a comprehensive r e h a b i l i t a t i o n service*  The development of t h i s service  w i l l be discussed In the succeeding chapter. Schedule A - Five T y p i c a l Cases Case 1 - Sam S. Case 1 i s an i l l u s t r a t i o n of ways In which h o s p i t a l i z a t i o n f o r mental i l l n e s s , even f o r a short period* may be disruptive of routine family l i v i n g *  Sam S. was a 61 year o l d married  man who was admitted as a c e r t i f i e d patient to the C l i n i c In an 1 extreme anxiety state. restless.  He was overtalkative, hyperactive and  The diagnosis was "manic depressive - manic".  In a  month* s time he was discharged t o h i s home as recovered from a The summaries i n t h i s schedule were made from case records at Crease C l i n i c , with a l l Identifying Information removed or disguised In order t o safeguard the c o n f i d e n t i a l i t y of the redords.  70 psychotic episode,  Mr, S, l i v e d on the outskirts of a small  c i t y , where he and h i s wife operated an auto court. were married and l i v i n g i n t h e i r own homes,  The c h i l d r e n  Mr, and Mrs,  S,  were f i n a n c i a l l y dependent on the returns from the auto court, from which they made an modest l i v i n g ,  At the time of discharge  the p s y c h i a t r i s t advised that due to the patient's tendency to worry, he should he r e l i e v e d of as much r e s p o n s i b i l i t y i n the business management as possible; and also that due to a heart condition, Mr, S, needed to c u r t a i l h i s physical a c t i v i t y , A s o c i a l worker interviewed Mrs. S. with a view to assessment of her a b i l i t y to shoulder a larger measure of r e s p o n s i b i l i t y , and In order to learn more d e t a i l s about the operation of the business.  I t turned out that Mrs, S, was a strong, capable  person, able to take over management of the court and to make arrangements whereby Mr, S, would be r e l i e v e d of p h y s i c a l labour, Casework services were focussed on counselling Mrs, S. i n planning f o r her husband's return home; and i n helping Mr,  S,  to accept with as much equanimity as possible, the r e l i n q u i s h ment of some r e s p o n s i b i l i t i e s he o r d i n a r i l y assumed as head of the household. Case 2 - Tom T.  ^  The case of T om T. i l l u s t r a t e s the extent of need of those patients Who,  at the time of discharge, lack f i n a n c i a l resources  and also the help of r e l a t i v e s In becoming established i n the community,  Tom was a 21 year o l d single man who was  to the C l i n i c under voluntary papers, and who a four months period of treatment.  admitted  remained f o r  His diagnosis was that of  7 "mixed s c h i z o p h r e n i a " .  1  Background i n f o r m a t i o n i n d i c a t e d t h a t  he had been born and brought up i n a r u r a l community i n E a s t e r n Canada,  He had  l o s t the use of one eye when a boy.  worked a t numerous j o b s , and i t was unable t o h o l d any petty t h e f t ,  Tom  had  r e p o r t e d t h a t he had  steady employment. had  He  There was  been  a h i s t o r y of  a r e t i c e n t manner, and he found i t d i f f i -  c u l t t o t a l k about h i m s e l f .  During h i s h o s p i t a l i z a t i o n a  r e p o r t on the man's p a r e n t s was  r e c e i v e d , t o the e f f e c t t h a t  they appeared t o have no r e a l i n t e r e s t i n the p a t i e n t , and suggesting  t h a t he not r e t u r n t h e r e ,  Tom's c o n t a c t s i n t h i s  p r o v i n c e were l i m i t e d t o a r e l i g i o u s group and a f r i e n d i n Vancouver. t h a t Tom  He was  without  funds«  Although i t was  expected  would always have many problems i n adjustment  and  t h a t i n h i s r e l a t i o n s h i p s w i t h people he would probably  remain  withdrawn and u n s t a b l e , he had become a l i t t l e more s o c i a b l e d u r i n g h i s p e r i o d o f treatment and t h e r e were no petty thievery. was  man  On the b a s i s o f the i n f o r m a t i o n a v a i l a b l e i t  d e c i d e d t h a t d i s c h a r g e p l a n n i n g should aim at Tom's  re-establishment to  complaints.of  i n or near Vancouver, where he would be c l o s e  h i s f r i e n d and r e l i g i o u s group.  The needs o f t h i s young  were t h e r e f o r e q u i t e comprehensive.  There were h i s immediate  needs f o r a p l a c e t o s t a y , a job w i t h which t o support and  himself,  s u f f i c i e n t cash t o purchase meals u n t i l he got p a i d .  Perhaps o f more long-run importance i n m a i n t a i n i n g good mental h e a l t h , was w i t h someone who  a state of  h i s need t o e s t a b l i s h r e l a t i o n s h i p  Would show i n t e r e s t and l i k i n g f o r him.  At  l e a s t i n the t r a n s i t i o n a l p e r i o d o f moving from the h o s p i t a l to  h i s new-found accommodation, he needed the support  and  72 encouragement o f t h e h o s p i t a l s o e i a l worker. Case 3 - Don  D.  I l l u s t r a t i v e o f t h o s e p a t i e n t s who  l e a v e the h o s p i t a l w i t h  a r e s i d u a l o f the mental d i s o r d e r o r upset which l e d t o t h e i r h o s p i t a l i z a t i o n i s the case o f Bon D.  These p a t i e n t s have  r e c e i v e d treatment and have made a c e r t a i n r e c o v e r y , e n a b l i n g them t o r e t u r n t o the community; but t h e y have r e t a i n e d a c e r t a i n mental handicap which adds t o t h e i r problems o f r e - e s t a b l i s h ment*  Don D* was an Id year o l d s i n g l e man  who  was  the Crease C l i n i c under v o l u n t a r y papers, and who t h r e e month's treatment*  The d i a g n o s i s was  personality - schizoid personality".  admitted t o  remained f o r  "pathological  He was  admitted i n a  tense and anxious s t a t e ; and h i s complaints i n c l u d e d those o f nervousness, I n a b i l i t y t o c o n c e n t r a t e on h i s work, and extreme irritability*  During h i s s t a y I n the C l i n i c i t became apparent  t h a t h i s b a s i c problem was h i s i n a b i l i t y t o get along w i t h people.  The problem appeared  t o be r o o t e d i n u n s a t i s f a c t o r y  boyhood r e l a t i o n s h i p s w i t h h i s p a r e n t s *  There had been c o n t i n u a l  q u a r r e l l i n g between h i s p a r e n t s f o r a l l o f h i s l i v i n g memory* He was  the o n l y c h i l d i n the f a m i l y *  Don's mother tended t o be  o v e r l y - p r o t e c t i v e and s o l i c i t o u s o f him; h i s f a t h e r b e i n g a r i g i d person whose c o n s t a n t c r i t i c i s m and l a c k o f p r a i s e  was  f e l t by the p a t i e n t as severe r e j e c t i o n .  Don was unhappy a t  home, but although he had made one o r two  attempts, he had been  unable t o emancipate h i m s e l f from h i s p a r e n t s , e i t h e r or  emotionally*  a n x i e t y subsided*  physically  During h i s h o s p i t a l i z a t i o n , Don's t e n s i o n and There were some i n d i c a t i o n s o f m o d i f i c a t i o n  73 i n t h e r e j e c t i n g manner o f the f a t h e r ; and a f t e r one o r two week-end l e a v e s a t home, Bon was d i s c h a r g e d , on t h e understanding t h a t the s o e i a l worker would continue t o see b o t h Bon and, h i s parents.  He r e t u r n e d t o l i v e w i t h h i s p a r e n t s , where i t soon,  became e v i d e n t t h a t the m o d i f i c a t i o n i n the a t t i t u d e o f the f a t h e r was s u p e r f i c i a l and s h o r t - l i v e d ,  Bon's t e n s i o n and a n x i e t y  began t o mount, and t h i s was shown by q u a r r e l l i n g a t home and d i s s a t i s f a c t i o n a t work.  I t was t h e r e f o r e apparent t h a t a l o n g -  term c o n t a c t w i t h t h e s o c i a l worker was c a l l e d f o r ,  Bon was  n o t able t o b r i n g h i m s e l f t o leave home, n o r was he able t o l i v e comfortably  i n such c l o s e r e l a t i o n s h i p w i t h h i s p a r e n t s ,  Bon needed h e l p t o r e s o l v e t h e l o n g - s t a n d i n g c o n f l i c t s i n r e l a t i o n s h i p s w i t h p a r e n t s , which made i t d i f f i c u l t f o r him t o g e t along w i t h f r i e n d s , employers, and members o f t h e o p p o s i t e s e x . Case V - C a r l C. C a r l G, i s an example o f a d i s c h a r g e d p a t i e n t who needed s p e c i a l c o n s i d e r a t i o n i n job placement and l i v i n g arrangements, C a r l was a 22 year o l d s i n g l e man who was found wandering about the c o u n t r y s i d e I n a dazed c o n d i t i o n , and who was admitted t o C r e a s e C l i n i c as a c e r t i f i e d p a t i e n t .  He was a  lonely,withdrawn,  i n d e c i s i v e young man, w i t h f e e l i n g s . o f unhappiness and h o s t i l i t y toward h i s p a r e n t s .  The d i a g n o s i s was "simple  schizophrenia";  and he was d i s c h a r g e d as "unimproved" a t the end o f t h r e e months* C a r l was t h e youngest o f f i v e c h i l d r e n .  H i s o l d e r s i b l i n g s were  w e l l e s t a b l i s h e d , b u t i n d i c a t e d t h e i r u n w i l l i n g n e s s t o have C a r l s t a y w i t h them, because he asked " f o o l i s h q u e s t i o n s " . The f a t h e r was a brusque, p r o f e s s i o n a l man, who was i m p a t i e n t  7* with Carl's i n s t a b i l i t y  and f l i g h t i n e s s i n employment* and who  expected more I n the way of-performance produce•  than C a r l was a b l e t o  The mother was d e s c r i b e d as an e c c e n t r i c p e r s o n , w i t h  a m i l d l y e l a t e d manner*,  n e i t h e r p a r e n t seemed a b l e t o accept  t h e i r son's mental i l l n e s s o r t o r e c o g n i z e h i s u n u s u a l behaviour as due t o t h e i l l n e s s *  The p a r e n t s recommended t h a t C a r l g e t  e s t a b l i s h e d away from home, b u t although they o f f e r e d some f i n a n c i a l a i d , they made no c o n c r e t e p l a n f o r h i s r e - e s t a b l i s h ment*  Because o f t h e f a t h e r ' s h a r s h manner and the tenseness  i n the home g e n e r a l l y , t h e p s y c h i a t r i s t c o n s i d e r e d t h a t i t would be t h e r a p e u t i c i f C a r l was r e h a b i l i t a t e d away from home* A s u p e r v i s e d f o s t e r home s i t u a t i o n was recommended*  C a r l was  n o t c o n s i d e r e d a c a n d i d a t e f o r long-term treatment a t the P r o v i n c i a l Mental H o s p i t a l ; b u t n e i t h e r was he w e l l enough t o e a r n a l i v i n g s t e a d i l y s h o u l d he be d i s c h a r g e d from t h e Clinic*  He r e q u i r e d some guidance i n t h e management o f money;  and a work s i t u a t i o n w i t h few demands and s t r e s s e s *  Whereas  remuneration from employment was c o n s i d e r e d important from the p o i n t o f view o f C a r l ' s s e l f - e s t e e m , i t was o f secondary c o n s i d e r a t i o n t o h i s p e r s o n a l f e e l i n g o f comfort about any work undertaken*  C a r l t h e r e f o r e needed s p e c i a l c o n s i d e r a t i o n i n becoming  e s t a b l i s h e d i n a f o s t e r home o r b o a r d i n g home w i t h some s u p e r v i s i o n ; and i n o b t a i n i n g employment where he c o u l d e a r n money b u t where c o m p e t i t i v e p r e s s u r e s and demands were a t a minimum.  L a c k i n g a f e e l i n g o f warmth and acceptance from p a r e n t s  or f a m i l y , C a r l needed t h e support o f a r e l a t i o n s h i p w i t h a s o c i a l worker over an extended p e r i o d o f time*  75 Case 5 ° Lee  L.  The s p e c i a l problems presented by Lee L., a 16 year o l d adolescent, i l l u s t r a t e some of the lacks i n community f a c i l i t i e s f o r r e s i d e n t i a l treatment of emotionally disturbed c h i l d r e n , Lee was  a ward of a children's agency and was  admitted to Crease  C l i n i e as a c e r t i f i e d patient with a diagnosis of "primary behaviour disorder i n a teen-age boy".  For several years he  had presented symptoms of aggressive and delinquent behaviour, which brought about h i s admission to the Boys' I n d u s t r i a l School, He was admitted to the Crease C l i n i c " f o r assessment, evaluation and recommendations as to future planning". behaviour was no problem on the ward.  Initially his  He was r e s t l e s s and active  but not to a degree considered beyond normal f o r an Later he became a considerable problem, creating  adolescent.  disturbances  by annoying older patients, so that i t was necessary to r e s t r i c t h i s p r i v i l e g e s on the ward. ious i n h i s manner.  He was  s u l l e n , defiant, and  rebell-  He had d i f f i c u l t y i n forming r e l a t i o n s h i p s  with people but d i d r e l a t e to s t a f f members to some extent. S t i l l l a t e r he became quieter and more co-operative, and seemed to modify somewhat bis. defiant behaviour. I t was  the p s y c h i a t r i s t ' s judgement that Lee's behaviour  was r e l a t e d to emotional deprivation i n early years. p s y c h i a t r i s t ' s report stated that the C l i n i c was not  The organized  to deal with t h i s type of problem, since i t required a s p e c i a l environment suitable to the patient's age, and a much longer period of treatment than the four months available at the Crease Clinic,  I t was  also stated that i t was u n l i k e l y that the  boy  76  at that time could adjust i n any of the usual f o s t e r homes; and that he would require a s p e c i a l home where both  parents  were experienced and w i l l i n g to accept a hoy as seriously disturbed as Lee, I t would appear that t h i s i s the type of problem which has been met i n some of the United States through r e s i d e n t i a l treatment centres and specialized f o s t e r homes f o r emotionally disturbed children.  Chapter h  The Development  o f a Comprehensive  Rehabilitation Service  I n r e c e n t decades the m a n i f e s t a t i o n o f I n t e n s i v e , widespread, and s u s t a i n e d p u b l i c i n t e r e s t i n mental h o s p i t a l s has done much t o break down the w a l l s o f i s o l a t i o n t h a t tended t o separate mental p a t i e n t s from the community.  This public interest  has  been s t i m u l a t e d and n u r t u r e d through such media o f mass communication  as the p r e s s , r a d i o and movies.  As w e l l , more  d i r e c t c o n t a c t o f i n d i v i d u a l s w i t h mental h o s p i t a l s h a s r e s u l t e d from the I n a u g u r a t i o n o f "Open House  11  h o s p i t a l a u t h o r i t i e s , and from the development  p o l i c i e s by of h o s p i t a l  v i s i t i n g p l a n s i n c o - o p e r a t i o n w i t h the Canadian M e n t a l H e a l t h Association.  W i t h i n mental I n s t i t u t i o n s themselves t h e r e h a s  been a change i n the approach t o p a t i e n t s from one wherein c u s t o d i a l care i n an "asylum" was predominant, t o a p u b l i c h e a l t h approach wherein treatment and r e t u r n t o the community became the dominant concern.  The f o c u s o f a t t e n t i o n i n t h i s  thesis  has been i n the problems, and programmes m o b i l i z e d t o meet them, o f male p a t i e n t s r e t u r n i n g t o the community upon d i s c h a r g e from Crease  Clinic.  The study shows t h a t t h e r e a r e b o t h common and d i s t i n c t i v e a s p e c t s o f the r e h a b i l i t a t i o n o f m e n t a l l y i l l , from p h y s i c a l l y i l l ,  persons.  as d i s t i n g u i s h e d  The common a s p e c t s o f the  78  r e h a b i l i t a t i o n process r e l a t e to the premises and concepts on which the programmes are based; and on the network of community resources upon which i t s successful accomplishment i s dependent. Some of the philosophical and p r a c t i c a l assumptions include recognition and acceptance o f each i n d i v i d u a l as a s e l f - r e s p e c t ing person no matter what h i s state of health; recognition of the r i g h t of every person to a "health and decency" standard of l i v i n g and to opportunities to experience s a t i s f y i n g human r e l a t i o n s h i p s ; recognition that the r i g h t s of the i n d i v i d u a l and of society are i n t e r - r e l a t e d ; recognition that progress i n s o c i a l welfare arises from broad community understanding as well as from creative contributions by Individuals and profes s i o n a l groups.  Community resources include agencies and groups  contributing services t o meet human needs i n a l l t h e i r v a r i e t y and complexity: medical, educational, s o c i a l , vocational* In t h i s study, r e h a b i l i t a t i o n i s considered  to be more than  the possession of vocational s k i l l s and needs, and t o include a l l aspects of the patient's t o t a l adjustment to l i f e . member of h i s own profession and as a responsible the s o c i a l worker recognizes  As a  citizen,  the r e l a t i o n s h i p between the i n t e r e s t s  and needs of the mental patient and those of the community i n which he l i v e s ; and he takes r e s p o n s i b i l i t y f o r p a r t i c i p a t i n g i n s o c i a l action to obtain resources f o r the unmet needs. Whereas i n the case of physical ailments the r a t i o n a l resources and emotional strength of the i n d i v i d u a l can help him adjust and adapt t o a changed s e l f or a changed s i t u a t i o n , the patient a f f l i c t e d with a mental disturbance  i s limited i n  79 h i s a b i l i t y to u t i l i z e these adaptive resources and strengths. As w e l l , i n the case of mental i l l n e s s i t has been found that an emotionally unsatisfactory environment sometimes contributes to the onset of the i l l n e s s .  Consequently, r e h a b i l i t a t i v e  e f f o r t s on behalf of the mentally s i c k are geared not only to strengthening the mental and emotional resources of the patient himself, but to modification of pathological aspects of the external environment as v e i l .  For t h i s reason, an arm of t r e a t -  ment must extend beyond the walls of the C l i n i c i n t o the homes and communities of i t s patients.  This function i s c a r r i e d out  by C l i n i c s o c i a l workers, under the d i r e c t i o n of p s y c h i a t r i s t s . Since admissions to Crease C l i n i c are encouraged only of the early cases of mental i l l n e s s , i t may be expected that mental i l l n e s s i s treated at an e a r l i e r , less d e b i l i t a t i n g stage, and that the r e s i d u a l e f f e c t s of the i l l n e s s are less l i m i t i n g . Indications of t h i s are seen i n the f a c t that the sample f a i l e d to show any need f o r protective work placements or sheltered forms of accomodation such as family care. Whereas i t i s the writer's experience that such protective l i v i n g  arrangements  are sometimes c a l l e d f o r i n the case of Crease C l i n i c patients, the incidence of such need i s not nearly as great as might be expected at the P r o v i n c i a l Mental Hospital.  One suggestion  to develop t h i s type of resource i s to f o s t e r the establishment of homes f o r group l i v i n g by r e l i g i o u s , c u l t u r a l , or ethnic groups i n the community.  I  ~~  1  The probable channels f o r such  ~~  From an interview with Dr. F.E.McNair, C l i n i c a l Director.  80 community u n d e r t a k i n g s are the Canadian M e n t a l H e a l t h and  Association*  the H e a l t h D i v i s i o n , Community Chest and C o u n c i l o f G r e a t e r  Vancouver. A g a i n , In Crease C l i n i c the r a p i d t u r n - o v e r o f and the  average s t a y o f two  months, c a l l f o r r a p i d assessment  o f p o s t - d i s c h a r g e needs o f p a t i e n t s , and r e s o u r c e s t o needs.  The  adaptability i n f i t t i n g  b r i e f time which s t a f f have t o h e l p  the p a t i e n t i s a l i m i t i n g f a c t o r i n m o b i l i z i n g help.  What we  comprehensive  might c a l l a major r e h a b i l i t a t i o n e f f o r t ,  i n c l u d i n g p e r s o n a l i t y and v o c a t i o n a l assessment and through o f a p l a n , » r e q u i r e s more than two and working w i t h a p a t i e n t both d u r i n g ization.  patients  I t may  the  carrying  months o f p l a n n i n g  and f o l l o w i n g h o s p i t a l -  be t h a t a w e l l - s t a f f e d o u t - p a t i e n t  department  t o whom p a t i e n t s c o u l d be r e f e r r e d , would be the means o f extendi n g and  c a r r y i n g t o f r u i t i o n the b l u e p r i n t f o r r e h a b i l i t a t i o n  marked out by the treatment team a t Crease C l i n i c . present time such major r e h a b i l i t a t i o n e f f o r t s are r e s t r i c t e d t o © v e r y few for  the m a j o r i t y  i n d i v i d u a l s ; and  At  the  necessarily  post-discharge help  o f p a t i e n t s i s l i m i t e d t o minimal h e l p In r e -  establishment. Of the  s e l e c t e d r e h a b i l i t a t i o n needs o f p a t i e n t s  studied,  r e s o u r c e s are f a i r l y adequate f o r p a t i e n t s r e q u i r i n g h e l p i n f i n d i n g a job.  Major gaps i n r e s o u r c e s were apparent In  f i n a n c i n g o f v o c a t i o n a l t r a i n i n g , and s u b s i d i z e d boarding home c a r e .  i n the p r o v i s i o n  the  of  An o v e r - a l l d e f i c i e n c y e x i s t s  In the numbers o f p r o f e s s i o n a l l y t r a i n e d s o c i a l workers. A l i m i t a t i o n o f the  study i s t h a t In a c t u a l p r a c t i c e human  81 needs a r e n o t n e a t l y s e p a r a b l e and cannot be segmented.  Rehabil-  l t a t l o n I s a h i g h l y i n d i v i d u a l i z e d s e r v i c e , wherein many community s e r v i c e s are m o b i l i z e d  and c o - o r d i n a t e d t o meet t h e  p e c u l i a r needs and c a p a c i t i e s o f an a c t u a l c l i e n t . personalized  This kind of  s e r v i c e i s " t a i l o r made" f o r each I n d i v i d u a l d i s -  charged mental p a t i e n t .  I t i s n o t e x c l u s i v e l y any one k i n d o f  p r o f e s s i o n a l s e r v i c e , such as m e d i c a l s e r v i c e , s o c i a l s e r v i c e or v o c a t i o n a l s e r v i c e .  I n t h e Grease C l i n i c t h e team approach  i n planning under t h e d i r e c t i o n o f t h e d o c t o r , i s f o l l o w e d as c l o s e l y as p o s s i b l e . and  I n a c t u a l p r a c t i c e , t h e s o c i a l worker  t h e r e h a b i l i t a t i o n o f f i c e r are t h e p r o f e s s i o n a l team  members who have c o n t a c t  I n t h e community o u t s i d e  t h e hospitals.  Of t h e s e , t h e s o c i a l worker i s p r o f e s s i o n a l l y t r a i n e d t o h e l p p a t i e n t s cope w i t h l i f e  stresses.  From t h e s o c i a l worker's  p o i n t o f view, any h e l p g i v e n , whether p r a c t i c a l o r s u p p o r t i v e i n n a t u r e , i s g i v e n on t h e b a s i s o f an i n t e g r a t e d u n d e r s t a n d i n g of the f a c t o r s operative  i n the patient's  l i f e situation.  f o c u s i s h e l d t o t h e p a t i e n t who has a problem w i t h i n s p e c i f i c circumstances.  The  a set of  On t h e b a s i s o f a dynamic u n d e r s t a n d i n g  o f t h e p a t i e n t ' s l i f e s i t u a t i o n t h e worker i s aware o f t h e unique need o f t h e p a t i e n t f o r a p a r t i c u l a r k i n d o f h o u s i n g , o r for  a work placement o f a c e r t a i n n a t u r e , o r f o r h e l p i n a  particular social relationship.  Consequently d i s c r i m i n a t i o n i s  a c r i t e r i o n . f o r the p r o f e s s i o n a l administration  o f any s e r v i c e .  Without an understanding o f t h e dynamics, environmental treatment becomes merely symptomatic.  82  As at present organized the Men's D i v i s i o n of the Department of R e h a b i l i t a t i o n functions s p e c i f i c a l l y i n the areas of job placement and temporary housing f o r patients about to be discharged«  I t would appear that the practice of providing  jobs or housing as a service i n i t s e l f i s a l i m i t e d manner of meeting the t o t a l needs of patients and i s uncongenial to the casework p r i n c i p l e s above*  This study gives primary consider-  ation to the incidence of patient need f o r p a r t i c u l a r services. An evaluation of the services given i s an area f o r further study. Ways and Means of Developing Resources From a consideration of the reference material i n the f i e l d s of mental i l l n e s s and r e h a b i l i t a t i o n , some general suggestions can be put forward as to ways and means of a l l e v i a t i n g the present d e f i c i e n c i e s i n resources.  I t i s also possible t o point  up the probable d i r e c t i o n of movement i n the development of a comprehensive r e h a b i l i t a t i o n program which includes the d i s charged mental patient.  E f f e c t i v e future progress i n t h i s  f i e l d w i l l follow a road between two extremes.  One extreme i s  the tendency t o "do nothing" u n t i l a l l f a c t s are gathered and more knowledge i s at hand concerning mental i l l n e s s .  A second  extreme i s the tendency to regard euphorically the recent advances i n p s y c h i a t r i c care as i n d i c a t i n g that new horizons are e a s i l y attainable.  Between the extremes, a r e a l i s t i c program leading  to tangible progress i s possible by breaking down the problems and needs into d i s c e r n i b l e well-defined areas of a c t i v i t y . These areas of a c t i v i t y include the adaptation of established services as w e l l as the creation of new ones, i n favour of more  83 comprehensive h e l p f o r t h e mental p a t i e n t r e t u r n i n g t o t h e community.  Because t h e Grease C l i n i c i s regarded as a treatment  r e s o u r c e o f t h e community, and because p o s t - d i s c h a r g e care i s p a r t i a l l y dependent upon community f a c i l i t i e s , s u g g e s t i o n s f o r the f u t u r e must p e r t a i n b o t h t o t h e h o s p i t a l and t o t h e community* W i t h i n the h o s p i t a l i t s e l f , one o f t h e f i r s t a i d s t o p r o g r e s s i v e development o f r e h a b i l i t a t i o n s e r v i c e s i s t h e e x i s t ence o f smooth, workable and w e l l - d e f i n e d channels o f communicat i o n between t h e v a r i o u s l e v e l s o f h o s p i t a l a d m i n i s t r a t i o n . A t the present time workable channels o f communication e x i s t t o d e a l w i t h matters i n t h e c l i n i c a l treatment o f p a t i e n t s .  For  example, t h e members o f t h e treatment team come t o g e t h e r a t Ward Rounds f o r j o i n t p l a n n i n g .  The C l i n i c a l D i r e c t o r sends  out memoranda t o a l l concerned when t h e r e a r e matters i n t h e  1 c l i n i c a l treatment t o be c o n s i d e r e d .  However i t i s axiomatic  t h a t o v e r - a l l concern and r e s p o n s i b i l i t y f o r p o s t - d i s c h a r g e care r e s t s w i t h t h e t o p l e v e l s o f h o s p i t a l a d m i n i s t r a t i o n . The implementation  o f the treatment  p h i l o s o p h y and. p o l i c i e s o f  a d m i n i s t r a t i o n i s t h e coneern and r e s p o n s i b i l i t y o f p r o f e s s i o n a l s t a f f members.  Since s o c i a l workers have t h e most d i r e c t  c o n t a c t w i t h community a g e n c i e s , and a r e most d i r e c t l y  active  i n p o s t - d i s c h a r g e c a r e o f p a t i e n t s , i t f o l l o w s t h a t channels o f communication must n o t o n l y r e a c h down from h o s p i t a l a d m i n i s t r a t i o n t o t h e S o c i a l S e r v i c e Department, b u t a l s o proceed up from the Department i f a d m i n i s t r a t i o n i s t o be f u l l y aware Pepper, op c i t , Chapter 2.  84 of t h i s sector of patient need.  I t would appear that the  appropriate l i n e s of communication f o r t h i s inter-change are through the Hospital Council to the S o c i a l Service Department. The H o s p i t a l Council i s an advisory body established to discuss o v e r - a l l p o l i c y , to deal with matters that transcend the f i e l d s of several services and that require the s p e c i a l co-operation and consultation of department heads. Another means whereby present personnel resources may be adapted toward a s s i s t i n g patients on discharge i s i n the use of group methods i n preparing patients f o r discharge.  As a l l  patients are not at present routinely referred to S o c i a l Service by use of group methods a s o c i a l worker could help prepare patients f o r leaving the h o s p i t a l ; help them to a n t i c i p a t e , and plan how t o cope with, post-discharge  experiences and  problems; t e l l them where various kinds of help are available i n the community and how t o use t h i s help to meet t h e i r own needs.  As w e l l , just p r i o r to discharge, a l l patients might  routinely be referred by the p s y c h i a t r i s t f o r an interview with a s o c i a l worker, so that an assessment of t h e i r  readiness  f o r discharge, from a s o c i a l as w e l l as from a p s y c h i a t r i c point of view, might be made.  This would be p a r t i c u l a r l y imp-  ortant f o r those patients who had not previously been r e f e r r e d to the Continuing Casework Section of the Department.  A suggest  t i o n has been made elsewhere that r e h a b i l i t a t i o n services i n the C l i n i c be centralized and that one person be appointed to bring together information on community resources i n r e h a b i l i 1 tation. 1  ~  • —  I b i d , Chapter 4.  —  —  85 Within the S o c i a l Service Department i t s e l f , i t i s suggested that a further investigation he made of the group of patients who leave the h o s p i t a l without follow-up a i d .  The recording  of a pre-dlscharge s o c i a l study of these patients by a s o c i a l worker would Include an assessment of the environment to which the patient i s returning, and determine the r e l a t i v e s t a b i l i t y of the family c o n s t e l l a t i o n , as w e l l as the p o s i t i v e and negat i v e factors i n the patient's s o c i a l relationships and economic situation.  In the case records studied i n the sample, there  was frequently i n s u f f i c i e n t evidence as to whether or not a thorough r e h a b i l i t a t i o n assessment was made, or as to the f a c t o r s operative  i n the decision against follow-up service.  a i l e d and standardized  recording of such information  More deti s called  f o r i n order to determine and c l a s s i f y d e f i c i e n c i e s i n personnel and resources. to appropriate  This information would be u s e f u l i n interpreting community and governmental sources the require-  ments of the C l i n i c i f a positive approach to r e h a b i l i t a t i o n i s to be implemented i n action* Development of Resources Within the Community The development of r e h a b i l i t a t i o n resources i s determined not only by what happens i n the h o s p i t a l , but also by the parti c i p a t i o n of h o s p i t a l personnel i n community planning.  The  s o c i a l worker's r e s p o n s i b i l i t y t o patients rests not alone i n use of casework s k i l l s to bring help, but also embraces e f f o r t s i n the sphere of s o e i a l action.  The s o e i a l worker i s i n a  position to bring into focus the lacks of community resources. As a professional person and c i t i z e n he i s also obligated to  0  86 help the community plan wisely to meet these needs.  To help  e f f e c t i v e l y i n t h i s way the s o c i a l worker requires a wide knowledge of f e d e r a l , p r o v i n c i a l and l o c a l planning, as w e l l as v i s i o n as to how a needed project should develop, both now and i n the future.  As a r e s u l t of the preliminary study i n t h i s  t h e s i s , a number of topics are indicated as requiring e f f o r t s i n s o c i a l action; further research being required to determine c l a s s i f i c a t i o n and p r i o r i t y of projects.  The need f o r more  f i n a n c i a l a i d i s apparent i n order to help patients whose lack of adjustment i s accentuated by shortage of funds.  An examin-  ation of r e h a b i l i t a t i o n resources shows that f i n a n c i a l a i d i s e s p e c i a l l y required to secure vocational t r a i n i n g , and f o r maintenance u n t i l a job and f i r s t pay-cheque are obtained.  It  has been found i n experience that there are also needs f o r s p e c i a l forms of accomodation: subsidized boarding homes or a " v i s t a " f o r males; at l e a s t a few f o s t e r homes f o r mental patients; s p e c i a l i z e d f o s t e r homes and/or a r e s i d e n t i a l treatment i n s t i t u t i o n f o r emotionally disturbed young people.  Access to  sheltered workshops and to protective work placements may be required f o r a l i m i t e d number of patients discharged from Crease Clinic.  The need f o r more trained s o c i a l workers i s w e l l  known: i t i s a problem s t i l l exercising the concern of h o s p i t a l s , professional associations, U n i v e r s i t i e s and Schools of S o c i a l Work, and the community generally. The development of programs f o r the r e h a b i l i t a t i o n of mental patients i s r e l a t e d t o the development of wider community programs concerned both with c i v i l i a n r e h a b i l i t a t i o n and with  87  mental health maintenance.  For example, resources f o r accomod-  a t i o n and job placement h e l p f u l to discharged mental patients are required also i n aiding the re-establishment  of the a r t h r i t i c ,  the discharged prisoner, the drug addict, the a l c o h o l i c , the tuberculous.  As w e l l , the b a t t l e f o r better mental health i n  the community i s fought on many f r o n t s , of which i n s t i t u t i o n a l psychiatric treatment i s only one.  From the point of view of  sound professional p r a c t i c e , the s o c i a l worker's concern with the r e h a b i l i t a t i o n segment of mental health maintenance should be r e a l i s t i c a l l y integrated with more i n c l u s i v e s o c i a l welfare measures.  For example, s p e c i a l i z e d f o s t e r homes or r e s i d e n t i a l  treatment f a c i l i t i e s f o r emotionally disturbed c h i l d r e n are types of projected resources which are of i n t e r e s t not only f o r Crease C l i n i c personnel but also to members of s o e i a l  agencies,  general h o s p i t a l s , and c h i l d guidance c l i n i c s , who have experience i n dealing with disturbed c h i l d r e n . T r a d i t i o n a l l y and c o n s t i t u t i o n a l l y , the development of public health, welfare and s o c i a l services i n Canada has been regarded as a matter primarily f o r municipal and p r o v i n c i a l action.  Nevertheless, many of the e a r l i e s t welfare undertakings  i n Canada have been i n i t i a t e d , not by p r o v i n c i a l or municipal governments, but by voluntary organizations l e d by p u b l i c - s p i r i t e d citizens.  As the worth of these programs was proven and as the  f i n a n c i a l burden of carrying them became too great f o r private philanthropy, municipal governments, f i r s t of a l l , responded to appeals f o r help by granting f i n a n c i a l assistance without assuming administrative r e s p o n s i b i l i t y .  Gradually the necessity  88 for taking over c e r t a i n of the undertakings as a d i r e c t administ r a t i v e r e s p o n s i b i l i t y of the municipal authorities became apparent*  F i n a n c i a l , and subsequently, administrative responsi-  b i l i t y f o r c e r t a i n health and welfare services was Imperceptibly shifted from voluntary to municipal auspices*  This process  repeated I t s e l f a t the municipal-provincial l e v e l .  F i n a l l y the  f e d e r a l government responded to the development of public opinion i n favor o f a larger measure of s o c i a l security, and began to assume d i r e c t administrative as w e l l as f i n a n c i a l r e s p o n s i b i l i t y for  s p e c i a l s o c i a l service programmes.  For example, f e d e r a l  grants t o the provinces In the mental health f i e l d  totalled  1  $ 8,737,000 between May 1948 and March 1952. In example of t h i s process of s h i f t i n g r e s p o n s i b i l i t y f o r s o c i a l services i s seen In the development of the V i s t a as a r e h a b i l i t a t i o n home f o r women patients from the P r o v i n c i a l Mental Hospital and Crease C l i n i c .  The V i s t a was f i r s t opened  under private auspices i n 1944 and was taken over by the 2 P r o v i n c i a l Government i n 1947. Voluntary community agencies may p a r t i c i p a t e i n the development of needed s o c i a l services through the establishment of study committees and action groups.  At the present time a  s p e c i a l committee of the Community Chest and Council o f Greater Vancouver i s studying the question of treatment f a c i l i t i e s f o r emotionally disturbed c h i l d r e n . "  ~1  '  ~  ~~  '  Another committee of the Council  The Canada Year Book. 1952-53. 2 Sophie B i r c h , op c i t .  "~"  ~~  89 i s making a study of sheltered workshops.  The S o c i a l Service  Department at Crease C l i n i c has representation on these committees, which are both engaged i n developing community resources.  Some s o c i a l services i n the community come i n t o  being as an extension of present governmental programs.  The  P r o v i n c i a l Government has announced projected plans f o r the construction of a Day Hospital where active-treatment  f o r ment-  a l l y disturbed persons w i l l be available on an out-patient  basis.  In addition, i t i s expected that the Day Hospital w i l l aet as a screen to the Crease C l i n i c , and be able to treat many patients without admission to h o s p i t a l .  I t i s also expected that s o c i a l  workers w i l l be p a r t i c i p a t i n g members of a treatment team on much the same basis as i s now  common at Crease C l i n i c .  In the sphere of r e h a b i l i t a t i o n s p e c i f i c a l l y , recent developments at several l e v e l s of government indicate a growing i n t e r e s t and attention to problems of r e h a b i l i t a t i o n f o r handicapped persons.  In December, 1951,  the National Advisory Committee  on R e h a b i l i t a t i o n of Disabled Persons was  set up by Order i n  Council to review e x i s t i n g r e h a b i l i t a t i o n f a c i l i t i e s i n Canada and to assess the p o s s i b i l i t y of co-ordinating e x i s t i n g f a c i l i t i e s more f u l l y .  The Committee was  established to provide  c e n t r a l guidance to a l l provinces on matters pertaining to the development of an o v e r - a l l network of services f o r a l l disabled persons i n Canada.  On May  1,  1953,  the Federal Government  made available to the provinces e e r t a i n health grants to a s s i s t the provinces programs.  i n the development of p r o v i n c i a l r e h a b i l i t a t i o n  Under the appropriations funds were made available  90 for (1)  t r a i n i n g of professional  r e h a b i l i t a t i o n workers,  (2) medical r e h a b i l i t a t i o n equipment, (3) r e h a b i l i t a t i o n health services* Spear-heading the development of a p r o v i n c i a l r e h a b i l i t a t i o n program i n B r i t i s h Columbia has been the Community Chest Council of Greater Vancouver. of Handicapped was  In 1952  and  the Council f o r Guidance  Incorporated into the Community Chest  and  Council* and became known as the D i v i s i o n f o r Guidance of Handicapped.  The  terms of reference of t h i s D i v i s i o n pertain  physically handicapped persons only.  I t s functions are to  ordinate the many agencies and the work of many  In December, 1953,  co-  professional  people active i n the task of helping to r e h a b i l i t a t e disabled persons*  to  physically  the D i v i s i o n f o r Guidance  of Handicapped compiled a b r i e f of recommendations f o r a comprehensive r e h a b i l i t a t i o n program f o r the physically handicapped i n the province of B r i t i s h Columbia. presented to the P r o v i n c i a l Government and of the Division's  This b r i e f contained the  results  c a r e f u l survey of the community resources  presently available, the gaps and d e f i c i e n c i e s i n the structure,  was  present  and the needs f o r a comprehensive, a l l - i n c l u s i v e ,  long-range r e h a b i l i t a t i o n program*  Summarized i n the b r i e f  are  the resources of several organizations which are helping i t s c l i e n t s to f u l l physical, mental, psycho-social, vocational and economic r e h a b i l i t a t i o n , as w e l l as an enumeration of the  facil-  i t i e s , conditions and personnel deemed necessary to make the organization's program work e f f e c t i v e l y * It may  be that In due  time the f e d e r a l - p r o v i n c i a l  plan f o r  91 r e h a b i l i t a t i o n w i l l make p r o v i s i o n f o r persons w i t h p s y c h i a t r i c disabilities.  I n t h e U n i t e d S t a t e s , governmental r e h a b i l i t a t i o n  a i d which was f i r s t p r o v i d e d f o r p h y s i c a l l y d i s a b l e d , l a t e r i n c l u d e d p s y c h i a t r i c d i s a b i l i t i e s ; and t h i s course o f events may be repeated i n t h i s The  country.  g o a l i n the development o f s o c i a l w e l f a r e r e s o u r c e s  i s t o ensure i n the community a network o f f a c i l i t i e s f o r meeting the needs which i n d i v i d u a l s are unable t o meet themselves.  The  process o f s o c i a l a c t i o n i s t h e m o b i l i z a t i o n o f group e f f o r t i n the i n t e r e s t s o f s o c i a l w e l f a r e .  Some o f t h e needs o f p a t i e n t s  d i s c h a r g e d from Crease C l i n i c are d i s t i n c t i v e and r e q u i r e s p e c i a l i z e d f a c i l i t i e s ; some o f these needs a r e t h e common needs o f o t h e r s i c k and d i s t u r b e d persons.  Our concern f o r mental  p a t i e n t s i s t h e development o f f a c i l i t i e s and t h e a d m i n i s t r a t i v e and o r g a n i z a t i o n a l t e c h n i q u e s through which our knowledge and our s k i l l s c a n be a p p l i e d . Conclusion The m e n t a l l y s i c k were a t one time t h e o u t c a s t and t h e wanderers o f s o c i e t y , o b j e c t s o f f e a r , p e r s e c u t i o n o r d i s i n t e r e s t . I n due time, when expediency was the apparent c r i t e r i o n o f community a t t i t u d e s , t h e insane were lodged p r i v a t e l y , o r i n g a o l s , o r i n houses f o r t h e poor.  A developing s o c i a l welfare  p h i l o s o p h y r e s u l t e d i n t h e assumption  by t h e s t a t e o f r e s p o n -  s i b i l i t y f o r t h e custody and c a r e o f t h e m e n t a l l y i n separate s t a t e - s u p p o r t e d h o s p i t a l s .  handicapped  The r i s e o f modern  p s y c h i a t r y and t h e m u l t i - d i s c i p l i n e approach t o treatment,  with  i t s g o a l o f r e t u r n i n g t h e mental p a t i e n t t o t h e community as a  92  p a r t i c i p a t i n g member of i t , brings t o f u l l c i r c l e the change i n the way men and women think of mental i l l n e s s .  The change In  attitude In some areas has been revolutionary.  The present  generation i s Involved i n the development and implementation of p r a c t i c a l programs to achieve the goal society has set f o r i t s e l f . Progress has been made i n philosophy and concepts; much has been accomplished i n h o s p i t a l care which requires only expansion; but i n the provision of a. comprehensive plan f o r r e h a b i l i t a t i o n , much new ground has yet to be covered: In a developing philosophy and concept of p r a c t i c e , i n building a body of knowledge and methodology, and i n provision of a v a r i e t y o f community resources which may be Integrated into the s o c i a l f a b r i c .  Not u n t i l the  discharged mental patient i s able to make h i s way e f f e c t i v e l y i n h i s home and community and has been restored to h i s optimal state of health, w i l l the process of r e h a b i l i t a t i o n be complete.  93 Appendix A  Items of Information Compiled from Sample Cases (One i n f i v e sample of a l l patients discharged from Crease C l i n i c , 1952-53.) 1.  F i l e number  2.  Age  3.  M a r i t a l Status  K  Education  5.  Occupation  6.  Diagnosis  7.  Means of admission  8.  Condition on discharge  9.  Length of h o s p i t a l i z a t i o n  Discharge Situation A.  Discharged to t h i r d party care  B.  Needed housing Needed job placement Needed vocational t r a i n i n g  C.  Needs r e l a t i n g to inner stress (a) Greater Vancouver area s short-term contact : long-term contact (b) Outside Greater Vancouver (c) B e f e r r a l to s o c i a l agency  D.  Discharged to t h e i r own care  E.  Miscellaneous  F„  No record of discharge s i t u a t i o n  G»  Other  9^ Appendix B Bibliography A u s t i n , L u c i l l e N., "Trends i n D i f f e r e n t i a l Treatment i n S o c i a l Casework"• J o u r n a l o f S o c i a l Casework. XXIX. June 19M-8. B i r c h , Sophie, An A i d i n the R e h a b i l i t a t i o n o f M e n t a l Ho s u i t a l P a t i e n t s . 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 o f B r i t i s h Columbia; Vancouver, B.C.; 1953* B r i t i s h Columbiaj Annual R e p o r t s o f the M e n t a l H e a l t h Services. Queen's P r i n t e r s ; V i c t o r i a , B.C.; 1951-52-53* B r i t i s h Columbia, P s y c h i a t r i c S e r v i c e s Manual. 1950.  Physicians  C a r r o l l , A l i c e K. " P o s t - d i s c h a r g e Care o f S c h i z o p h r e n i c P a t i e n t s " . Unpublished Manuscript. C l a r k , R i c h a r d James, Care o f the M e n t a l l y 111 i n B r i t i s h Columbia. 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 o f B r i t i s h Columbia; Vancouver, B.C.; 19**7« Clow, H o l l i s E „ , " P s y c h i a t r i c F a c t o r s i n the R e h a b i l i t a t i o n o f the Ageing". Mental Hygiene. October 1950. C r u t c h e r , H e s t e r B. F o s t e r Home Care f o r M e n t a l P a t i e n t s . The Commonwealth Fund; New York; 19M f. i  Dentsen, A l b e r t . "Recent Trends i n M e n t a l H o s p i t a l C a r e " . N a t i o n a l Conference o f S o c i a l Work. 1950. Deutsch, A l b e r t , The M e n t a l l y 111 i n America:A H i s t o r y o f t h e i r Care and Treatment from C o l o n i a l Times;. Columbia U n i v e r s i t y P r e s s ; New York; 19H6. DeWitt, H e n r i e t t a B. "Family Care as a Focus f o r S o c i a l Casework i n a State M e n t a l H o s p i t a l " . M e n t a l Hygiene. October 19HV. Dominion Bureau o f S t a t i s t i c s . Institutions. June 195l«  Census o f M e n t a l  Dominion o f Canada. Annual R e p o r t s o f the Department o f N a t i o n a l H e a l t h and W e l f a r e . 1951-52. E l l e d g e , C a r o l i n e H. The R e h a b i l i t a t i o n o f the P a t i e n t . J.P. L i p p i n c o t t Company; P h i l a d e l p h i a ; 19J+87  95 F e l i x , Robert H. "Developing a F e d e r a l Mental H e a l t h Program", N a t i o n a l Conference o f S o c i a l Work, 1946. Colombia U n i v e r s i t y P r e s s , New York. F e l i x . Robert H. "State P a r t i c i p a t i o n i n the N a t i o n a l M e n t a l H e a l t h Program". - N a t i o n a l Conference o f S o c i a l Work* 1947. Columbia U n i v e r s i t y P r e s s , New York, ' Freeman. Henry. "Casework w i t h F a m i l i e s o f M e n t a l H o s p i t a l P a t i e n t s " . J o u r n a l o f S o c i a l Casework. March 1947. G a r l a n d , Ruth. "The P s y c h i a t r i c S o c i a l Worker i n a Mental H o s p i t a l " . M e n t a l Hygiene. A p r i l 1947. G a r r e t t , Annette, " H i s t o r i c a l Survey o f the E v o l u t i o n o f Casework". J o u r n a l o f S o c i a l Casework. June 19^9• G a r r e t t , James F., E d i t o r . P s y c h o l o g i c a l A s p e c t s o f P h y s i c a l D i s a b i l i t y . U.S. Government P r i n t i n g O f f i c e , Washington, D.C. Group f o r the Advancement o f P s y c h i a t r y , "The P s y c h i a t r i c S o c i a l Worker i n the P s y c h i a t r i c H o s p i t a l " • Report No. 2,  January 1946e  Hamilton, Gordon. Theory and P r a c t i c e o f S o c i a l Casework. Columbia U n i v e r s i t y P r e s s ; New York; 1951* Hincks, C M . October 194j«  " C l i f f o r d W. B e e r s " .  M e n t a l Hygiene.  H o l l i s . F l o r e n c e , Women i n M a r i t a l C o n f l i c t t A Casework Study, 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; New Y o r k ; 1949, Hooson, W i l l i a m . The R e h a b i l i t a t i o n o f P u b l i c A s s i s t a n c e R e c i p i e n t s ; P a r t s 1 and 11, 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 o f B r i t i s h Columbia; Vancouver, B.C.; 1952* L e v i n e , Norma. "The M e n t a l P a t i e n t i n the Community from the View-point o f the F a m i l y Agency", M e n t a l Hygiene. A p r i l 1947. L i n g , T.M.; Zausmer, D.M.; and Hope, M. " O c c u p a t i o n a l R e h a b i l i t a t i o n o f P s y c h i a t r i c Cases". American J o u r n a l o f P s y c h i a t r y , September 195*2. M a l z b e r g , Benjamin. "Mental I l l n e s s and the Economic Value o f a Man". M e n t a l Hygiene. October 1950 o  Menninger, E a r l A. New York; 1947.  The Human M i n d  B  A l f r e d A,  Knopf;  96 Myers. T.A. M e n t a l H o s p i t a l s I n B.C. V i c t o r i a , B.C.; January 1953.  The D a i l y C o l o n i s t ;  Noyes, A r t h u r P. Modern C l i n i c a l P s y c h i a t r y . Company; P h i l a d e l p h i a ; 1953*  W.B.  Saunders  Pepper, G e r a l d W. S o c i a l Worker P a r t i c i p a t i o n i n the Treatment o r 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 o f B r i t i s h Columbia; Vancouver, B.C.; 1953* P h i l l i p s , John C. and Me11a. Hugo. " V o c a t i o n a l R e h a b i l i t a t i o n o f Neuropsychiatrie P a t i e n t s " . Occupations. February 1950* Proceedings o f the Canadian Conference o f S o c i a l Work. Vancouver, B.C. 1950. ' Proceedings o f the Second B i e n n i e l Western R e g i o n a l Conference o f S o c i a l WorkI 1949. R e n n i e . T.A.C. and Bozeman, Mary F. V o c a t i o n a l S e r v i c e s f o r P s y c h i a t r i c C l i n i c P a t i e n t s . A Commonwealth Fund Book: 1952. Rennie. T.A.C; B u r l i n g . T.: and Woodward, L . E . "Vocational R e h a b i l i t a t i o n o f the P s y c h i a t r i c a l l y D i s a b l e d " . M e n t a l Hygiene A p r i l 1949« R i c h a r d s o n , Henry B. P a t i e n t s Have F a m i l i e s . Commonwealth Fund; New York; 1945; Chapter 9 .  The  Rockower, L.W. '•The Development o f a V o c a t i o n a l R e h a b i l i t a t i o n Program f o r the N e u r o p s y c h i a t r i e " . M e n t a l Hygiene. A p r i l 19*9. Schmidl, F r i t z . S u p p o r t i v e Therapy".  "A Study o f Techniques Used i n S o c i a l Casework. December 1951*  S c h m i d l , F r i t z . "The P s y c h o t i c Patient»s Adjustment t o the Community". 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• S e n s e n i c h , Helene. "Teamwork i n R e h a b i l i t a t i o n " . American J o u r n a l o f P u b l i c H e a l t h . August 1950. S h e l t e r e d Workshops and Homebound Programs; A Handbook on T h e i r E s t a b l i s h m e n t and Standards o f O p e r a t i o n . The N a t i o n a l Committee on S h e l t e r e d Workshops and Homebound Programs; New York; 1952* Standards f o r P s y c h i a t r i c H o s p i t a l s and C l i n i c s . American P s y c h i a t r i c A s s o c i a t i o n ; November 1951.  97 Stevenson. G.H. "Rehabilitation of the Mentally 111", Ontario Medical Review. Toronto, Ontario. November 1952. Switzer, Mary E* "Rehabilitation and Mental Handicaps"* Mental Hygiene, July 1946. Switzer, Mary, and Rush, Howard A. "Doing Something f o r the Disabled". Public A f f a i r s Pamphlet No. 197. New York. 1953. The Canada Year Book.  1952-53•  "The National Advisory Committee on the R e h a b i l i t a t i o n of Disabled Persons". Canadian Welfare. March 15» 1952* United Kingdom. Health Services i n B r i t a i n . Kingdom Information O f f i c e . 1952*  United  Upham, Frances. A Dynamic Approach to I l l n e s s . Service Association of America; New York; 194-9*  Family  Vanuxam, Mary. "Rehabilitation of the Mentally Handicapped". Mental Hygiene. October 1953• p.681. "Vocational R e h a b i l i t a t i o n of P h y s i c a l l y Handicapped Persons". International Labour O f f i c e . Geneva. March 1952* Whitman, Samuel. "Organizing f o r Mental Health i n the Community". National Conference of S o c i a l Work. 1950; Columbia University Press; New York* Wilson, G. and Ryland G. "Physical and Emotional I l l n e s s and Handicaps". S o c i a l Group Work Practice. 1949; Houghton M i f f l i n Company, Boston, p. 115* Wise, C a r r o l l A, "The Relation of the Mental H o s p i t a l to the Community". Mental Hygiene. New York. July 1945©  

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