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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 Rehabilitation 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 in Partial Fulfilment of the Requirements for the Degree of MASTER OF SOCIAL WORK in, the School of Soeial Work Accepted as conforming to the standard required for the degree of Master of Social Work School of Social Work 195^ The University of Br i t i s h Columbia i i i Abstract The return of the patient to the community i s the goal of institutional treatment programs for mentally i l l persons. The attention and effort made i n recent years toward improved care of mental patients i n hospital has also Included consideration of the material and emotional needs of the patient at the point of leaving the hospital. 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 role of social 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 rehabilitation service for discharged mental patients. The method used in the study was to 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 this 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 Clini c and i n the community at large whereby the recorded needs might be met, A selection of case summaries was made to ill u s t r a t e some typical problems. The factual material illustrated the variety and frequency of rehabilitation needs 0 For the mental patient these included not only material needs for housing and a job, but also intangible needs for support and help with continuing emotional stress* The interrelationship of outer material needs and inner emotional problems was noted. It was found that needs for housing and a job were a problem for 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 for meeting needs revealed significant gaps and limitations i n the provision of subsidized boarding care and i n the financing of vocational training. An over-all deficiency was apparent i n the numbers of professionally trained soeial workers*, In the concluding chapter there i s suggested an operational definition of rehabilitation: a process whereby needs are met which enable the patient to become re-established as a citi z e n . There i s a discussion of ways and means of narrowing the gap between needs and resources, and of the role of the social worker i n community action. The development of social welfare resources for discharged mental patients i s related to 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 rehabilitation and with mental health maintenance. i v Acknowledgements I wish to express my thanks and appreciation to a l l those whose Interest and active help have made t h i s study possible, I p a r t i c u l a r l y acknowledge with gratitude the d i r e c t i o n , c r i t i c i s m s and counsel of the following persons: Dr, Leonard C. Marsh and Miss Muriel C u n l l f f e , of the School of S o c i a l Work, University of B r i t i s h Columbia; Dr, F.E. McNair, C l i n i c a l D i r ector, and the members of the S o c i a l Service Department of the Crease C l i n i c of Psychological Medicine, Essondale, B r i t i s h Columbia, i i TABLE OF CONTENTS Chapter 1* Mental Illness and Rehabilitation Page Mental illness and soeial welfare. Historical antecedents. Social work i n mental hospitals. Social work at Essondale. Modern concept of rehabilitation. Post-discharge problems of Crease C l i n i c patients. Method of Study 1. Chapter 2. common Needs i n Rehabilitation The common needs of people. The sample group. Problems of housing. Needs i n vocational adjustment. Extra-mural treatment needs. Rehabilitation as a process of meeting needs. • 29* Chapter 3. Resources for Meeting Needs The caseworker's use of resources. Hospital personnel. Existing community f a c i l i t i e s i n Greater Vancouver and i n rural areas. Some specialized resources© Illustrations from four typical cases. • • • • 53. Chapter W. The Development of a Comprehensive  Rehabilitation Service Summary of findings. Resources within the hospital. Developing resources i n the community. Administrative auspices. The social worker and community action. Conclusion • • • • • • • • 77. Appendices: A. Sample Schedule Form. B. Bibliography. TABLES Table 1, Rehabilitation needs of 100 male patients discharged from Crease C l i n i c . 38. Table 2. Destination of discharged patients for whom after-care was not indicated. . . . . . . . . . . 39. Table 3. Patients with more than one need. • • • *K>* V The Rehabilitation of Discharged Mental Patients Chapter 1 Mental Illness and Rehabilitation 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 society c Generally speaking, concern for the care and treatment of mentally i l l persons has developed his t o r i c a l l y at a slower pace than concern with physical break-downs i n health. The reasons for this slower pace appear to be that the causes of physical illness are easier to detect, and also that fears and superstitions are generated by some of the more bizarre manifestations of so-called insanity. These fears and superstitions have been considerably but not totally resolved by the contributions of modem psychiatry, which provides a foundation for understanding and orderly classification of mental diseases. This: basis of understanding liberated the dynamic i n man's social consciousness so that social welfare philosophy and leadership could be positively directed and mobilized to meet the needs of the: mentally sick. iL resultant trend was the tendency to counter-act any popular feeling o f physical and emotional isolation of the mental institution from the conimunity. The attitude was cultivated that the mental hospital was a community resource to which mentally disturbed citizens could come for treatment and afterward return to their homes, A great deal of emphasis; i n recent decades has "been directed to institutional treatment, and only more recently has- specific attention become focussed on comprehensive programs for post-hospital care and re-establishment. In this paper mental illness i s seen within the philosophical framework of social welfare, wherein r e l i e f for the mentally distressed Is dispensed by community agencies on a basis of self respect. There are various ways of approaching the subject of mental il l n e s s , but i n general the social worker views such illn e s s as symptomatic of mental or emotional disturbance resulting in i n -a b i l i t y to participate normally in social relationships. Since the problem i s not essentially one of unusual overt behavior but i s concerned with basic personality functioning and social r e l -ationships, i t follows that treatment and restorative programs for the mentally i l l are seen in this context. Such programs take cognizance of the underlying factors contributing to the personality disturbance. We seek to understand the various underlying factors f-physiological, psychological,; sociological, etc.- i n terms of their dynamic inter-relationships, i n order to aid the person who i s mentally i l l to achieve greater harmony within himself and in relationship to his fellows. According to social welfare concepts, bringing aid 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 right to aid in 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. Historical Antecedents The "basis for the rational and scie n t i f i c treatment of diseases including the insane, was l a i d by Hippocrates (1+60-370 B.C.), known as "the father of medicine". The therapy buil t upon this basis by the humane Greek medical pioneers was succeeded for many centuries by a superstitious mixture of astrology, alchemy, magic ri t e s , with the accompanying belief i n demoniacal possession and the practice of burning "witches". The early colonists carried 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 for handicapped persons In these early days was based not so much upon humane considerations as upon social expediency and economy, with a general attitude of coldness and contempt, rather than sympathy and understanding. The introduction and development of welfare measures came in the latter part of the eighteenth century i n the wake of pro-gressive forces released by the p o l i t i c a l and social revolutions i n America and France (1776 and 1789). In America, many of the early experiments in social welfare were initiated by the Quakers. In 1773. the f i r s t separate institution for the insane in America was established at Williamsburg, Virginia!. The reform measures, of this revolutionary era were given added impetus by three pioneers in psychiatry: Rush i n America, Deutsch, Albert, The Mentally 111 in America.; A History of Their Care and Treatment from Colonial Times. Columbia Univer-sity Press.; New York; 19^6. known as "the father of American psychiatry"; Pinel in France, who had the chains removed from the insane and started treatment based on kindness and sympathy; and Tuke in England, who provided a protected institution for patients who were treated as guests rather than inmates. At the beginning of the Nineteenth Century, profound social forces were i n ferments the repercussions of the Industrial Revolution; the Poor Law Reform movement i n Great Britain; and reform studies in the United States. Supplementing the "rational reform" measures of men like Pinel, Tuke, and Rush, there appeared in 18^1 the unique person-al i t y of Dorothea Lynde Dix, with whom i s associated "moral reform". As a retired school teacher nearing forty, her career as a reformer started with the instruction of a Sunday School class i n a j a i l i n Boston. Her protest against the treatment there, especially 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, Britain, Canada and Europe. In nearly every instance, her inspection and campaign led to the erection of anew hospital or the enlargement of an existing one. It was the significant advances at the turn of the twentieth century which heralded the coming of age of psychiatry i n America. Along with the rise of reform movements, p o l i t i c a l , economic, social: there was a striving for new goals in the f i e l d of social 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 training for staff, and i n research; the rise of out-patient departments and psychopathic hospitals, and the beginnings of the employment of social casework techniques in 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 patient 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 National Committee f o r Mental Hygiene, Beers set himself to the task of di r e c t i n g public attention to the prevention of mental sickness and to setting up arrangements f or a working partnership between the public and psychiatry. He succeeded i n awakening the public conscience and i n gearing the resultant emotional energy to a p r a c t i c a l program of medical and s o c i a l engineering which continues to the present time. This movement had far-reaching repercussions not only i n r a i s i n g standards of care for mentally i l l persons, but also i n the stim-u l a t i o n of public and professional education i n mental hygiene, i n the opening of doors f o r the integration of mental hygiene thought, philosophy, and practice into 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 industry. S o c i a l Work i n Mental Hospitals The re l a t i o n s h i p of s o c i a l work with psychiatry 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 factor i n the develop-ment of the profession of s o c i a l work. The re l a t i o n s h i p had i t s formal beginning i n 1906 with the employment of s o c i a l workers i n Manhattan State Hospital, New York C i t y , where s o c i a l workers v i s i t e d patients' families: to obtain Information needed by the 1 ps y c h i a t r i s t s about t h e i r patients' l i v e s . Later the function of _ • • ' • ' ~" ' " Lucas, Leon. "Psychiatric S o c i a l Work". So c i a l Work.Year Book. 1951. American Association of So c i a l Workers, New York. p. 360. 6 preparing families for return of patients t o their homes was added. Impetus to this trend was provided by the dynamic approach o f Dr. A. Meyer, a psychiatrist who insisted i t was not enough to study the individual, as an isolated unit and that i t was as impor-tant to study the environment from whence he came and to which he might return. As social workers became the established contact between the hospital and the community they were also involved in 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 this period, one of the most serious questions con-fronting social workers was the readjustment of mental patients returning from hospitals to normal community l i f e , and this concern has remained to the present day. It was the early experience of social workers that patients discharged as cured often were- unable to readjust themselves to community l i v i n g . Without auxiliary aid, 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 hospitalized. Often he was hindered with new obstacles, one of the most d i f f i c u l t of which was 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 his affairs at the point where his temporary illness had interrupted his normal routine, the recovered mental patient was a marked man. He had been "crazy", and according to the popular legend, "once insane, always insane". Consequently his relations with acquaintances and even with his family were likely to be strained. Under this strain some minds gave way again* resulting in the person becoming socially inadequate or having to be readmitted to a mental institution. Another concern of the social worker was the fact that frequently when a. patient has improved enough to be returned to the community, his 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 find i t impossible to get employ-ment at once so as to be self-supporting. "Often, i n such instances there, remained only one of two choices for the hospital superin-tendent, neither of which could be a satisfactory ones the patient could be retained in the hospital or be transferred to the poor-house, where he might spend the rest of his l i f e as an unhappy 1 public dependent." This situation posed a. problem i n social welfare for 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 earliest attempts at solution to the problem of the care of the discharged mental patient arose from "the after-care move-ment", which had i t s beginnings in Germany in 1829, and was intro-duced to America during the 1890s. "The principle behind this movement was to provide adequate financial, medical and moral assistance to patients discharged from mental hospitals, i n order to aid their adjustment to the outer world and to check -Deutsch, op c i t , p.289. 8 1 relapses due to social handicaps." It 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 social worker in America consisted of aiding the Manhattan After-Care Committee. Other hospital d i s t r i c t after-care committees were soon organized, their major purpose being to find suitable homes and employment for needy ex-patients, to render other social services as needed, and to exercise general supervision over them during the period immediately following their discharge. "Such were the beginnings of direct collabor-2 ation between social workers and psychiatrists in America." The integration of social work with mental health services received added stimulation during and following World War 1. The services of social workers were desired for the program of treatment and rehabilitation of returning soldiers suffering from war neuroses and psychoses. The need for trained psychiatric social workers was so acute that the National Committee for Mental Hygiene proposed the establishment of a training school for such social workers. In Canada the f i r s t course was inaugurated at the University of Toronto in 1919. During these years the association of social work with psy-chiatry was one of the factors in bringing about a shift of emph-asis on the part of social workers in their approach to social need. Their focus of concern shifted from the broader environ-mental factors underlying social i l l s to the developing of case-work technioxues arising from a deeper understanding of individual Ibid, p.289. 2 Ibid, p.290. 9 personality afforded by dynamic psychiatry. There was a gradual modification from an exclusive interest in external problems 1 toward inclusion 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, social workers effected a comfortable balance of sociological and psychological factors; in their approach to human needs. The learning gained by psychiatric social workers i n the mental health f i e l d was u t i l i z e d by other specialists i n the general f i e l d of social work. Bri t i s h Columbia In colonial days the problem of caring for mentally i l l 2 persons was solved easily by sending the patients back to Britain. For a time, arrangements were made for the shipment of patients to California to be cared for in institutions there; Later, patients were kept i n gaols or i n the Royal Hospital i n Victoria. British Columbia became a province in 1871 and in the following year the Royal Hospital became the f i r s t o f f i c i a l mental hospital in the new province. Due to overcrowding, new quarters were f i r s t acquired on the present site of the Woodlands School in 1877-78; and a new institution was later established at Essondale in 1910. The administration of the early hospitals l a i d emphasis on kind and humane treatment of patients.. An attempt was made to I ' Garrett, Annette. "Historical Survey of the Evolution of Casework". Journal of Social Casework. June, 19^9. 2: Sources of the information in the following two sections are Master of Social Work Theses by Birch, Sophie (1953); Clark, Richard (I9V7); and Pepper, Gerald (1953). See bibliography for t i t l e s . 10 provide patients with comfortable livi n g quarters and a plentiful supply of nourishing food. The hospital personnel kept in mind that patients would be returning to their homes; every effort was put forth to keep alive their interest in activities i n which they would normally participate outside the hospital. It was recognized that the family played an important part in the rehabilitation of the patient as i t was f e l t that the "attention and care arising from family affection was conducive to restoration of mental 1 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 well as a more progressive philosophy in the care of patients. The principle 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 introduced. In 1919 the Canadian National Committee for Mental Hygiene, following Its survey of the mental institutions, suggested the employment of social 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 six month t r i a l basis and i f their adjustment proved satisfactory during that period, they were discharged i n f u l l . The committee f e l t that the recovery would be more lasting i f the patients could be assisted in their rehabilitation by social workers, thus obviating a possible return to the hospital. In 1930 the Committee installed in the position of social worker Report of the Medical Superintendent of the Provincial  Asylum for 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 Provincial Government to establish a social service department. The chief aim and purpose of the new department was to secure more detailed information regarding the home l i f e and conditions of the patients which heretofore had not been available. Another function of the dep-artment was a. follow-up service to patients after discharge to assist in their re-establishment in the community. Social Work at Essondale The nature of the responsibility for treatment which i s allocated to the psychiatric social worker i s determined by several factors: the type of mental institution, i t s organization and auspices, i t s training or research emphasis, and the philosophy and s k i l l of the staff. The Group for the Advancement of Psychiatry of the American Psychiatric Association considers that the treat-ment of the mentally i l l i s primarily a community responsibility and that the mental hospital i s a treatment f a c i l i t y of the comm-unity, rather than i t s dump-pile for 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 level the treatment of patients in both the Provincial Mental Hospital and the Crease Cli n i c of Psychological Medicine i s considered to be "a total push relation-ship situation" which i s patient centered. It includes the whole of physical medicine as well as the more specific therapies per-taining to psychiatry. It i s the treatment philosophy of Provincial _ Group for the Advancement of Psychiatry. "The Psychiatric Social Worker in 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 essential. Patients need in their treatment the f u l l co-operation of the physiotherapist, the occupational therapist, the recreational therapist, the psychotherapist, and the assistance 1 of the social worker, both during and following hospitalization. "The function of the psychiatric social worker i s to contribute his knowledge and casework s k i l l in such a way that i t i s purpose-f u l l y related to psychiatry, the total treatment program of the hospital, hospital organization and administration, and to the contributions of a l l other professions and departments in the 2 hospital."' A corollary i s that the quality 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 social worker must know the sources of tension in their lives. He must understand what the person feels, how he deals with his feelings, how this way of responding serves him in the light of his present l i f e pressures, past experience and future aspirations. It i s this understanding of the individual and what the problem means to him that enables the social worker to modify either external or internal pressures, or both, so that the individual may be relieved of stresses and participate in the recovery of self-reliance. Part of the s k i l l _ B r i t i s h Columbia, Psychiatric Services Physicians Maunal. 1950. 2 B r i t i s h Columbia, Annual Report of the Mental Health Service. Queen's Printers; Victoria, B.C.; 1951; p.^ M-. 13 of the social worker i s in estimating the patient's capacity for self-help, and in his 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 situation. The social worker understands that the patient i s a part of a dynamic social group involved at a l l times in a complicated system of interpersonal relationships and during the patient's treatment period in hospital the social worker i s concerned with a l l aspects of the patient's relationship with medical and nursing staff, with other patients, family, friends and community. To be f u l l y effective in helping, the social worker should work closely with the patient from the moment he enters the hospital 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 relatives i s the intake 1 study and evaluation of the patient and his i l l n e s s . The intake and reception process also involves interpretation of hospital f a c i l i t i e s to patients and their families, as well as assistance to families who have problems arising out of the patient's admission, such as feelings about having a mentally i l l relative or fear of the hospitalization and the treatment. At Essondale at the present time caseworkers are assigned to the Admissions Sections of the Provincial 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 : "~ : ' . Annual Report of the Mental Health Services, op c i t , p.H-6. 2 Pepper, op c i t , chapter 2 0 lift-The social information', obtained by the social worker when the patient i s admitted i s rapidly made available to other members of the treatment team, thus accelerating the formulation of provisional diagnosis, of i n i t i a l treatment plans,, and the mobili-zation of a l l services within the hospital for the treatment of the new patiento In the Social Service Department, the treatment period i s considered in three phases or aspectst active therapy in hospital; pre-convalescent planning prior to discharge; and the convalescent or probationary period after the patient has l e f t the hospital or c l i n i c . The contact with the patient on the ward i s directed towards building a supportive, understanding relationship, through which the patient i s helped to hold onto whatever reality functioning he may possess. Interest in wife, children or parents i s kept alive; and the patient i s helped to do something about those problems of which he i s most aware and concerned. Interviews with relatives are directed toward keeping up the family's interest in the patient. This i s done by familiar-izing the relatives- with the nature of the il l n e s s , the treatment, the hospital and c l i n i c routines; by helping relatives with their own feelings concerning mental il l n e s s , and f i n a l l y through support and cl a r i f i c a t i o n the relative i s encouraged to participate positively in plans for the patient's discharge. In assisting the patient's family, the social worker frequently contacts community resources such as family child and assistance-giving agencies. Prior to discharge, the social worker starts to prepare the patient for leaving the hospital,and c l i n i c and he w i l l discuss 1 5 with the patient his feeling about leaving, and returning to his family and to employment. The patient i s encouraged to make week-end v i s i t s to his home so that the transition from hospitalization w i l l be gradual, and problems that arise on these v i s i t s can be ironed out before f i n a l discharge. The social worker*s role in the f i n a l or post-discharge phase of the treatment process i s to assist i n the re-establish-ment of the patient in the community. The patient i s helped to retain the gains made in hospital; to locate satisfactory employ-ment and accommodation; to become reconciled to those changes in his own abi l i t y and i n the circumstances of his l i f e , which the illness may have brought about. As well, family, friends, employers and community agencies are prepared for the patient's return to routine l i v i n g ; and necessary interpretation of the patient's needs in his extra-mural treatment i s provided. From the point of view of organization, the various phases; of treatment are the responsibility of the Continuing Services Sections of the Social Service Departments of the Provincial Mental Hospital and the Crease Clinic respectively. It should be noted that the public welfare agency of the city of Vancouver, and also the public welfare agency of the Province -Social Welfare Branch - provide social assistance as an aid in rehabilitation. Outside the Greater Vancouver area,s the Social 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 after discharge. 16 Modern Concept of Rehabilitation Public acceptance of social welfare goals has advanced to include the aims of rehabilitation of disabled citizens. Concern with the problem has been so great that the word rehabilitation i t s e l f has become hackneyed - almost beyond the point of practical specific meaning. Popular references are made to the "rehabili-tation" of the blind, 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 citizen, so handicapped that he cannot "pull his own weight", immediately becomes a problem of the community in 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 hospital r gaol or treatment Institution because the aim of the treatment programs of these agencies of the community i s to see the patient through to maximum social integration into the community. A gen-eral definition of rehabilitation i s the statement of the Rational Council on Rehabilitation, New York, to the effect that rehabilitation "Is the restoration of the handicapped to the fulle s t physical, mental, social,, vocational and economic use-fulness of which they are capable." Rehabilitation has to do with a person's re-establishment in the community after a period of disruption of normal living due to some disabling condition or dislocating circumstance. In the broad sense, rehabilitation includes the entire process of a patient's treatment i n hospital and his return to routine c i v i l i a n l i v i n g . In this sense, for example, the rehabilitation of the mentally i l l begins immediately upon admission to hospital, 17 and a l l subsequent examination, treatment, nursing care, psycho-therapy and social casework are aimed at promoting a normal social integration and preparing the patient and the relatives 1 to make an accepted adjustment. For the purposes of this; study the term rehabilitation i s used to refer to the latter portion of the treatment goals, which embraces plans and programs for the post-discharge period after the patient has l e f t the hospital. Rehabilitation services are dispensed under various administrative auspices - some by the hospital and some by specialized rehabili-tation agencies. A survey of available literature shows that programs for the rehabilitation of physically and mentally handicapped persons vary widely both in the comprehensiveness of the services and in 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 vision; the acceptance, and the participation of the whole community; and secondly, the financial capacity of a community to provide services. Rehabilitation, like public health, i s 2 purchasable. There are programs u t i l i z i n g the medical, social, psychological, economic, educational, and vocational aspects of rehabilitation. 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 rehabilitation centres, schools, and sheltered workshops. I n i t i a l l y the programs were r ! ^ — — = • — — Psychiatric Services Physicians Manual, op c i t , Chapter 1 2 . 2 Hamilton, Kenneth,"A Sound Rehabilitation Program". Proceedings of the Canadian Conference of Social Work. Vancouver, B.C.; 1 9 5 0 ; p. 1 3 2 . 18 developed by individual practitioners in various professional fields* Many were financed by private, philanthropic societies such as the American Red Cross Society, Blind Institutes, and so forth. As such private programs have become more widely recognized, i t has become common for governmental support to be made available by financial grants. Some countries, such as Great Britain, New Zealand, and the United States, have set up governmental rehabilitation programs which have included medical treatment, vocational training, and employment placement of individuals on a national basis as a function of government. Government sponsored rehabilitation programs were f i r s t developed to meet the needs of physically handicapped persons who had an employment problem. For example, in the United States the Vocational Rehabilitation Act, 1920, was 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 results achieved by existing hospitals and c l i n i c s , and the return of the patient to self-support. The financing of the program was put on a permanent basis by the Social Security Act 1935* During World War 2 as a result of the revelations of Selective Service of the incidence of mental disorders i n the c i v i l i a n population, the scope of rehabilitation services was extended by the Barden-La Follette Act (19^3) to include the psychiatrically disabled person. This meant that every psychiatrically disabled person could get help in job finding, vocational guidance, vocational training, and occupational counselling, whether he was a veteran or a c i v i l i a n . I ~ ' Rennie, Thomas A.C.-, Burling,T., and Woodward, L.E. "Vocational Rehabilitation of the Psychiatrically Disabled". Mental Hygiene. A p r i l , 19^9. 19 At the present time, the federal government makes grants to the states for 100 percent of the necessary program costs of adminis-tration and vocational guidance and placement services, and for 50 percent of other case service costs such as medical and psych-i a t r i c examinations, medical treatment, training, and maintenance during the period of the rehabilitation process. The program i s administered by the Office of Vocational Rehabilitation of the Federal Security Agency. It is; observed that with respect to the dominant precipitating factor in disability (physical, mental), vocational rehabilitation programs were f i r s t developed for the physically disabled due to the ease of defining "d i s a b i l i t y " for this 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 rehabilitation program, namely that for physically handicapped veterans, under the Depart-ment of Veterans Affairs;. The Department has u t i l i z e d private organizations for certain types of handicaps such as blindness, deafness and paraplegia, but there i s not yet a comprehensive scheme for c i v i l i a n s . There are; a number of organizations both public5and private, working with various types of handicapped children and adults,-for example the Workmen's Compensation Board, T.B. after-care; National Society for the Deaf and Hard of Hearing; the Canadian Paraplegic Association; the Canadian National Institute for the Blind; the Canadian Arthritis and Rheumatism Society; provincial societies for Crippled Children and Cerebral Palsy. The National Advisory Committee on Rehabilitation of Disabled I 20 Persons was set up by Order-in-Council i n December 1951* This Canadian Committee aims to develop a national program to provide civ 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 federal Rehabilitation Grants to the provinces has been initiated. To date, Saskatchewan i s the only province which has developed c i v i l i a n rehabilitation programs. Br i t i s h Columbia has enacted social welfare legislation which permits the develop-ment 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 hospital departments for the rehabilitation of the mentally i l l are a new development in Canada. The most ambitious undertaking at present i s the After-Gare Department of, the Ontario Hospital, London. This department was organized i n September 19*+9> with the financial support and encouragement of the Ontario Department of Health and with financial assistance from the Federal Department of Health. It i s headed by a psychiatric social worker, and the team includes three additional social workers, four nurses, and two psychologists. The hospital psychiatrists serve as consultants. The Department ut i l i z e s a down-town building to serve as offices, consulting rooms, and as club rooms and recreation centre for former patients 1 who may reside in 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 in a l l aspects of mental health,; Including the rehabilitation of discharged mental patients i s the Canadian. Mental Health Association. The Association i s a voluntary society of citizens 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 for those who are mentally disabled. There are five provincial Divisions of the Association. In 1953 the Saskatchewan Division enlisted the aid of a Junior Chamber of Commerce to assist i n the rehabilitation of discharged mental patients in occupational settings. Post-discharge Problems of Crease Clinic Patients The Crease Clinic of Psychological Medicine, opened at Esson-dale, B.C. on January 1 , 1 9 5 1 , was designed and equipped to serve as a diagnostic and active treatment centre for 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 limited to four calendar months. Admissions are there-fore encouraged only of those patients who are considered to have a. reasonable prospect for recovery and discharge i n the four months period. Patients with a less favourable prognosis are referred to the Provincial Mental Hospital. A patient may be adm-itted to Crease Clinic either by voluntary application or by certification of two medical practitioners. The only patients who lose control of their affairs are those deemed unfit by their attending physicians to carry out this function; i n which case the Inspector of Municipalities i s notified and acts as committee. The general environment of the building i s attractive, with tasteful furnishings, and varied and plentiful recreational 22 and occupational services. Every effort i s made to render early hospitalization i n the Clinic as similar to hospitalization for physical illness; as possible. What kinds of problems and situations are experienced by these patients when they leave the Clinic? How has their absence affected their families, their jobs,, their acceptance i n their neighbourhood? To whom may they be referred for assistance in meet-ing their needs i n getting re-established i n their homes and comm-unities? How adequate are community f a c i l i t i e s for aiding needy patients i n their rehabilitation 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 Social Service Department at the C l i n i c , which assumes, major responsibility for the welfare of patients in the transitional period following discharge. Some characteristic problems i n rehabilitation from Crease Clin i c are related to the short-term nature of hospitalization, and to the fact that voluntary admission can be terminated within five days- notice given by the patient. It has been found in experience that the average length of stay of patients •1 actually Is approximately two months. These circumstances limit the time available whereby the Clinic staff can assess the patient's; social situation, and formulate a post-discharge plan. A majority of the patients are rehabilitated directly back to their families or friends with the assistance of adequate 1 Pepper, op c i t , Chap. h. 23 social casework before and during the actual rehabilitation placement. The problems of this group may not be related direct-ly to their illness but may be primarily associated with the physical.disruption of routine family living resulting from the absence in hospital of- the housewife, the mother or the bread-winner. The family member's absence from home may have: added problems: and responsibilities for a wife or husband, privation for the children; and supportive casework help i s requested i n fa 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 staff, however, that there are many patients who do not possess family, friends or financial resources.; or whose family and friends are disinterested or actually hostile or resentful.. These patients require more ext-ensive help and support from the Clinic i n becoming securely established in an emotionally healthy environment. This group has a, wide variety of needs. Fi 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 in the communityi money, food, clothing,, shelter, a job,a-;meaningful relationship with some interested person or persons. For a. person who has been hospitalized for a mental or nervous disorder, the return to the community i s often a. threat-ening experience; and to lack the security of friends and adequate finances enhances thia feeling of distress and uncertainty, and in turn increases the possibility of a relapse and a return to hospital. These patients may look to their discharge with a l l the insecurity of a person recovering from an i l l n e s s , or they may prefer to regard themselves as never having been sick, but in 2h either event they are fearful of the rejecting attitudes of society. There are also many patients who leave the hospital with a residuum of the mental disorder or upset which led to their hospitalization. These patients have received treatment and have made a. certain recovery, enabling them to return to the community ; but they have retained a certain mental, handicap which adds to their problems of re-establishment. Of the total of 1172 patients discharged from Crease Clinic i n 1952-53, for example, the psych-i a t r i c condition of those described as "improved" numbered 727, or more than one half; the remainder of those discharged being described as "recovered", "unimproved^, or "without psychosis and unclassified". Such patients may retain feelings of undue submissiveness, or depression, or anxiety, or fear of people. Sometimes these feelings are related to an unresolved marital conflict,; or an unsatisfactory work adjustment which precipitated the breakdown but remains unsolved. Sometimes the feelings are the end result of years of emotional deprivation or conflict with parents. The inner problems of these patients may be of such severity that they cannot be further reduced by known methods of psychiatric therapy; but they are persons whose l i f e can be made more comfortable by a kinder environment or by the sympathetic understanding and interest of the social worker who continues to see him. The discharged mental patient who i s inwardly weakened or handicapped in his a b i l i t y to make wise decisions or to get along well with family or fellow employees, needs help i n meeting the 25 additional external stress of securing accomodation, a job, and of functioning independently in our complex society. For such a person with a severe mental handicap, the psychiatrist sometimes recommends sheltered accomodation, protective work placement or financial subsidization i n maintenance., The patient thus would have a transitional experience or period of convalescence between the protective hospital setting: and complete independent manage-ment of his aff a i r s in the community. But i f community resources are lacking to make possible the implementation of such recommen-dations, what i s to be done and where i s the patient to go? Frequently i t i s for the individual social worker to seek the best available compromise solution and to help the patient as well as he can to adjust to a limiting situation. Theme of the Thesis A trend in 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 for mental health care in B r i t i s h Columbia, cal l s for attempts to prevent or to solve the problems while people live i n their own homes and before hospitalization becomes necessary. When institutional treatment i s indicated the Crease Cli n i c rec-eives patients who w i l l be absent from their homes for short-term hospitalization; and the Provincial Mental Hospital receives patients for whom long-term hospitalization (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 for day patients would be available on an.out-patient basis. This out-patient department would f i l l the gap between the general hospitals and the Crease C l i n i c . It would f u l f i l l the need for 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 services, as i s the, case at the Provincial Mental Hospital. Consequently the follow-up services at present undertaken by social 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 social service 1. staff Indicated that the lack of a central office in the Clinic to mobilize a l l the rehabilitation resources of the community, together with the rapid turn-over and short stay of the patients, resulted i n inadequate preparation for rehabilitation, with readmissions being one of the f i n a l results. An additional limiting factor in discharge planning Is that the average length of stay of patients i s approximately two months. Due partly to the pressure of work on the Clinic social workers and to the lack of a central rehabilitation office, i t frequently happens that a careful evaluation of a patient*s potentialities, 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 rehabili-1 Pepper, op c i t . 27 tation service for discharged mental patients. It seeks to ascer-tain the prevalence of patient need i n three areas of adjustments housing, vocational s k i l l s and training, and problems of inner stress requiring casework services. It then makes a descriptive survey of available resources within the hospital and in 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 arbitrarily chosens housing and a job being basic needs; and problems of inner stress being a need indicated by the records of the Social Service Department and the writer's own experience. This selection i s confirmed by much current reference material on rehabilitation. 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 Clinic during a recent year, and only those who were referred to the Social Service Department during their hospitalization. Pertinent information relative to the three categories of need was extracted from case records by means of a schedule, an outline of which appears in 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 levels of employment. "Needs" are those denoted either by the recommenda-tions of the treatment team or arising from the patient's own request for service. Other needs, no matter how obvious, are not considered in the present study i f no recommendation or request was made about them. 28 It 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 staff members who have contact with the patient. The f i l e includes the ward notes of the doctors, the daily records of nursing and treatment staffs, the psychological reports, social service notes, and reports of the rehabilitation officer. The material for this study was obtained primarily from the reports of the psychiatrist, the social worker and the rehabilitation officer. Chapter 2 Common needs in Rehabilitation. Human experience has been described as the interaction of the individual and his total environment; and living as "the process of accommodating our changed and unchanged selves to 1 changed and unchanged surroundings," From this viewpoint a person 1s l i f e w i l l be successful or not, according as his power of accommodation i s equal to or unequal to the strain of fusing and adjusting internal and external changes. It i s assumed that human beings have certain needs and that the dynamic for the interaction of individual and environment i s found in a person's striving to meet these needs. The. striving i s part of the urge for survival, of the w i l l to grow and improve; and on this the whole idea of rehabilitation i s based. The fundamental needs of man have been variably stated by theologians, philosophers, scientists, 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 for him to secure a liv i n g , establish a " ~ " Menninger, Karl A., The Human Mind. Alfred A. Knopf; New York; I 9 V 7 . P.19. Quotation from Samuel Butler. 30 home, raise children* enjoy leisure, 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 his unique way of meeting his needs within the framework of his environment; i t i s a manifestation of his attempt to adjust so that he may be as comfortable as possible. Because some of his internal needs may conflict with others, because he may be frustrated in meeting his needs by the external world of reality, and because he does not live i n isolation but i n a social milieu, the, attainment of a comfortable, personal adjustment not only i s an achievement of considerable magnitude but i s also a relative matter. The quality of human adjustment i s relative when measured in terms of the psychological concept of maturity. Life may become qualitatively richer and more meaningful. The mature person has found a pattern of behaviour which permits him to live constructively in his social world, and which enables him to develop his unique potentialities. When we speak of human experience as the interaction of the individual with his outer and inner environment, and of human behaviour as the end product of the process of achieving satisfaction of needs, we are presuming the operation within individual persons of a dynamic coordinator,-the "I",-a medium of adjustment between the individual and the outer world. In psychoanalytical terms this executive function is included i n the concept of the ego. The ego represents the attempts of the person Wilson G. and Ryland G., Social Group Work Practice. Houghton M i f f l i n Company; Boston; 19^9; P-17. 31 to keep harmonious the relationship between the primitive instinc-tual urges or drives (concept of the i d ) , the conscience or c r i t i c (concept of the superego), and the reality world. The various methods used by the ego to keep a balance or to attain "wholeness" in the psychic structure are called mental mechanisms. This entire theoretical structure i s a professional attempt to comprehend the functional unity of the various components of person-a l i t y . It serves as a useful tool 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 his environment may be successful, in the sense that he achieves an adjustment; satisfactory to himself and to others; or i t may be unsuccessful,; in the sense that he has failed to achieve an adjustment satis-factory to himself and to his fellows. The basis for success or failure.rests in the variations and combinations of the factors noted: the individual's power of adjustment, and the pressures or strains to which the individual i s exposed i n his environment. When failures in adjustment become too great for the individual or too noticeable to his fellows, he comes or i s sent to a person who can help him with his material needs or with problems of inner stress. Assistance i s available from the professional groups concerned with helping people to a more satisfactory adjust-ment: doctors, clergymen, teachers, social workers. Persons whose adjustment has been unsatisfactory may be distinguished from the theoretical norm of adjustment by their unusual behaviour represented by two different types of reaction to ,3 2 f a i l u r e : One type of reaction to failure i s seen in a person who finds himself incapable of f u l f i l l i n g the requirements of his particular situation and attempts adjustment by resorting to "psychological f l i g h t " from the situation. A second type of reaction i s that of attacking the situation directly. Both ways of reacting are disastrous: one resulting i n damage to the personality, the latter i n damage to the situation. The former type of behaviour i s exemplified in the form of character t r a i t s such as seclusiveness, timidity, fears, suspicions, some forms of physical i l l n e s s , excessive dependency, and other emotional symp-toms included i n the category of poor mental health. The latter reaction may represent a pattern of delinquency and crime. Both reaction patterns may be said to result from a failure i n the adaptive capacity of the ego to resolve the environmental pressures impinging upon the personality. Crime or social misbehaviour may represent an attack upon the environment; mental i l l health, a retreat from i t . A third reaction i s that of neurotic adjustment. This i s a complicated behaviour pattern wherein a person i s neither able to express his drives and meet his needs by direct action, nor successfully to repress the wishes. So he expresses them in symptoms which partially or indirectly or symbolically gratify his need, and at the same time serve as a form of self-punishment for and denial of gratification. The development of such dis-advantageous substitutions cause him suffering which counter-balances his secret pleasure. 33 The mature person does not resort to f l i g h t or attack or waste psychic energy in neurotic frustration, but rather learns to accept the limitations of the present situation and to live with them, at the same time joining with others in remedial social action programs. The emotional problems presented by patients in a psychiatric treatment centre are apt to be extreme examples of the reaction patterns so far outlined. Delinquent persons frequently become inmates of gaols and penitentiaries and may be referred for psychiatric assessment. Persons classified as psychotic or psy-choneurotic may become patients, in mental hospitals. The psychoses are the most extreme of a l l emotional disorders,, wherein the ego partially or totally has given up the function of estimating the external world and making adaptions to i t . In psychoanalytic phrasing, the ego of the psychotic distorts reality and allows instinctual impulses to find expression either directly or sym-bolical l y . The psychoneurotic: patient has become so frustrated by inner neurotic conflicts that normal routine living i s not tolerable, and in some cases treatment by professionally trained people may be called for. 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 history of a sample of one hundred male patients admitted to the Crease Clinic,in;a recent year. The f i s c a l year April 1 , 1 9 5 2 , to March 3 1 , 1953? was chosen. A schedule was used to collect together a l l pertinent 3^ Information on individual patients, and to record what reh a b i l i -tation services were recommended by the psychiatrist, or carried out by the social worker. The sample; group of one hundred patie-nts was selected by considering every f i f t h case (male and female) referred to the Social 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 this means were disregarded,, so as to arrive at a round figure of 100, for ease of tabulation. The maximum, period of treatment of these patients was four months, the average being two months. The ages of the group ranged from boys in their teens to men in their seventy's. The educational level of the group was f a i r l y high for those reporting this inform-ation; the larger proportion having completed at least Grade 8. The occupational experience of the men was widely representative, ranging from unskilled manual work to persons practicing a profession. A l l cases in the sample had been referred to a social worker. This means that the worker i s responsible for such social services as may be indicated during the period of hospitalization. It i s also expected that in a joint assessment with the psychia-t r i s t , patient needs relating to discharge w i l l be provided for, and appropriate services offered to meet needs in the post-discharge period. Some limitations i n the method of study may be noted. Probably the biggest practical limitation was lack of detailed or standardized recording on the unit f i l e s . Data was secured from the ward notes of the psychiatrist, the summaries of the rehabilitation officer, and the social service notes. Only those 35 needs indicated in these records were tabulated, although i t may-be that some rehabilitation problems actually experienced were not recorded. Furthermore, i t sometimes happened in a particular case record that whereas an expression of concern or an actual recommendation was made by the psychiatrist for a certain form of post-discharge care, no record was available as to whether or not the recommendation was carried out. As well, often no account was given as to the reasons for a particular recommendation, or in what instances a compromise plan was agreed upon because of lack of resources for carrying out an "ideal" plan for post-discharge care. Generally speaking, the pattern of recording observed i n the sample group i s that in a brief f i n a l statement by the psychiatrist or social worker there i s mention, of what plans were made for the patient when he was; discharged. The brief statement may contain a general reference to the fact that the rehabilitation officer or social worker were helping the pati-ent find a job or accommodation, or that the social worker would : offer follow-up casework services to support the patient i n a particular aspect of his adjustment. It sometimes happens that no comments can be found referring to the specific social circumstances at the point of discharge. Other limitations are inherent in the categories chosen in the schedule. For example, information on education was obtained from the admission form, which includes no more than reference to the grade completed in school. As the major concern was not i n this area of adjustment, further details as. to specialization or to personal reaction to education were not drawn from social or medical histories.. In the employment 36 categories, arbitrary divisions were made between skilled and unskilled manual labour. For example, a farmer was considered "skilled manual labour"-, whereas a farm hand, was lis t e d as "unskilled manual labour". For people referred to Social Welfare Branch offices, the unit f i l e s did not always specify the post-discharge needs i n the same categories chosen in the schedule. Most were referred for long-term casework service, the primary-need in some cases being for financial assistance. Consequently in the tabulation a l l referrals to Social Welfare Branch are included in the one cate-gory, without sub-classification under job placement or housing. Two groupings in the schedule are of those cases which did not contain a recommendation for, 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 directly to their homes without aid; and the second includes those who were discharged directly to an institution or hospital.. Some patients are discharged, to the Provincial Mental Hospital for further treatment; some to general hospitals for surgery or other therapy; some to T.B. sanitoria for specialized care; and some to correctional institutions such as the Boys' Industrial School. Approximately one male patient in seven i s admitted to the Provincial Mental Hospital at the point 1 of discharge from the C l i n i c . Also included in this category are patients who l e f t the Clinic 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 their own plans and gave the prescribed five days notice requesting their discharge. A small number of patients were subject to deportation proceedings immediately at the time of discharge. As a l l cases in this sample had been referred to a social worker, in each instance social 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 hospital or institution he would be helped to anticipate the move, and i f a social worker was available in the agency to which he was going, . this worker would be alerted to the patient's arrival and probable need. In a l l instances the responsibility of Crease Clinic social workers terminated at the date of discharge. The information thus: gathered comprises a basic table for the present study (Table 1). It needs careful 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 relatives or friends with whom they can live when they leave the hospital. It i s assumed that these patients are able to turn to their relative or friend for any help they might require in a practical way, or in the form of encouragement and support. Although follow-up contact by a social worker was not provided, this does not mean that no social problems existed. The probable interpretation i s that the patient was considered capable of self-help and of independent management of his affairs, without extra support from Clinic 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. Rehabilitation Needs of 100 Male Patients  Discharged from Crease Clinic Rehabilitation Needs Persons Problems A. Post-discharge situations for which after-care was not indicated sdischarged to third-party care :miscellaneous 3 1 18 B. Relating to material needs Requiring shousing :30b placement -from rehabilitation officer -from social work staff .vocational training h 6 h 1 ^5 9 6 1 C. Relating to inner stresses Requiring casework services rfrom social work staff -short-term contact -long-term contact 2 6 2 8 sfrom Social Welfare Branch staff 13: 13 jfrom other social agency 8 8 D. No record of discharge situation 3 E. Other h Total 100 - 52 39 Table 2. Destination of Discharged Patients For Whom After-Care Was Not Indicated Destination Persons Discharged to third party care 31 Discharged to own care 8 Discharged and admitted to Prov'l Mental Hospital k Discharged and admitted to general hospitals 3 Discharged and admitted to . Boys' Industrial School 1 Deported 1 In care of Dep't of Indian Affairs 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 surprising, for patients who have suffered a mental breakdown have multitudes of problems and experience many inner and outer stresses which have weakened their ego. In the records: however, i t i s generally the case that the doctor or social worker singles out the primary obstacle confronting the patient. It can be assumed therefore, that this i s the main problem, but not necessarily the only problem. It can be assumed also that the doctor and social worker have made an assessment of the patient's situation; and have reported that he lacks a particular 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 If the sample cases are representative, more than one~-f i f t h (21 per cent) require environmental aid in getting a place to stay, finding a. job, or obtaining training in some voc-ation. Five requests were made on behalf of patients who were destitute of housing resources and who were totally dependent on receiving aid from Cli 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 his own home, or has money to rent a room, or who has under-standing and accepting friends or relatives with whom to l i v e , many of the problems of accomodation are eliminated. But patients are referred to the social worker for help i n this 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 friends or family members in the vicinity;; or the family may have nothing to do with the patient, leaving him to make his own arrangements as best he can. Frequently the patient's l i f e situation i s such that he must return to live with a wife or husband or parent, when strained relationship exists which may have been the precipitating or contributing factor in his i l l n e s s . In such a situation the social worker w i l l assume a helping role both with the patient and his relative, so that the living arrange-ment w i l l provide as few stresses and strains for the patient as \2 possible. The present study did not undertake a. qualitative investigation of the patient's housing, as to whether or not i t was satisfactory. The five requests refer to patients who did not have even a room to which to go. It i s sometimes the case that a discharged patient's adjustment would be fa c i l i t a t e d by some degree of care and supervision by relatives or boarding house operators. Occasionally a greater degree of supervision i s required by patients who can-not manage their own affairs completely and are unable to support themselves f u l l y i n employment, and for these a. foster home type of care Is recommended by the psychiatrist. Locating suitable housing i s predominantly a practical service, although some form of counselling or modification of the attitudes of others i s frequently called for as well. It was originally planned to subdivide this category according to the factors of financial need and need for supervision, However, on examination of the sample group of cases, recorded information was either lacking or was not sufficiently refined to make possible a sub-classification. Needs in Vocational Adjustment This study considered three components of vocational need: job placement, training or re-training, and sheltered employment. If the figures are representative 16 per cent of the discharged men have needs in this area. Only one of the 16 was for training. The need for 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 this need include finding a job for the patient, seeing that he i s placed in the job, and ideally • ^3 should include subsequent contact with the patient and his, employer to ascertain i f the placement is mutually satisfactory. A need for vocational training or re-training; may he indicated when the patient himself expresses: a desire for i t , or when such training i s recommended "by the treatment team. For example, a. young patient may have made a choice in favor of a particular trade but lack training for i t . A middle-aged patient may have some basic s k i l l s in a. particular line of work but require re-training or "brush-up" courses to place him in a better position to compete in the employment market, £L need for protective work placement refers to a patient who i s capable of living in 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 the normal stresses and demands of competitive employment. Somewhat surprisingly, examination of the case records of the sample group of patients f a i l e d to reveal mention of this particular need. It would appear either that this problem occurs infrequently, or that such a. recommendation i s not considered (and therefore not recorded) by the treatment team due to their awareness that resources i n the community to meet the need are limited or completely lacking;. It may be that this type of placement i s of more frequent significance for patients of a mental hospital with more serious and more incapacitating forms of mental illness 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, for many factors 1+4 are involved. For every person, a satisfying work experience is a major part of good mental health. Not only i s work necessary for the support of oneself and one's family, hut i t i s an important outlet for many natural impulses such as competitiveness and aggression. For some, success at work i s a compensation for weakness in other areas. Work sometimes brings people into close and friendly relationships with others. It may also be a creative activity which satisfies 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 for retirement f e e l that they are useful and contributing members of society and not a burden. In Canadian culture i t is expected that a man should work, and i n a b i l i t y to hold a job becomes a reflection upon his adequacy. Unemployment affects not only the man but also his wife and children; the.results being not only financial hardship but also a wounding of pride, with feelings of guilt and shame. Satisfying work , then, i s as important for 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 in achieving a satisfying work experience. Many young people are uncertain about their choice of a vocation or lack knowledge of what preparation i s needed to achieve their goal. Some never find a really satisfying work placement. In an industrial setting i t i s d i f f i c u l t for workers to have the feeling that they are more than anonymous "cogs i n a great machine"; and management-labour relations need strengthening H-5 so that workers feel 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 find work i s unable to support himself or his family. Unemployment therefore may have devastating effects 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 for 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 in the onset of the mental il l n e s s , .and when such a person returns to the community he w i l l need to effect a more satisfactory resolution of this problem i f the gains in psychiatric treatment are to be implemented and retained. Emotional problems may have reduced a patient's working efficiency, blocked the achievement of his maximum potentialities for work, caused a patient to overreach himself In vocational expectations, or prevented the f u l l personal satisfaction which work might bring. Patients sometimes bring to the Crease Clinic their anxieties about employment, lack of work s k i l l s or status; their worries about personal relationships on jobs; their confusions about the kind of vocation to choose or the kind of job to look for; and their convictions that they had greater or lesser a b i l i t i e s than they required on their present jobs. These expressions of concern are related to their problems in social and interpersonal relationships. Vocational adjustment i s only a part, but an important part , of the patient's total adjustment to his environment. he In i t s broadest' terms, psychiatric treatment i s aimed to improve this total adjustment, and one of the tests of effective treat-ment i s a patient's a b i l i t y to cope with employment stresses. One of the practical d i f f i c u l t i e s i s that hospitalization, even for a few weeks or months, may mean loss of a job and the necessity of locating a new one after discharge. If a patient returns to the same job he may be apprehensive of the response of his fellow employees to his mental i l l n e s s , and, fearing that he w i l l be stigmatized, he may even refuse to consider going back. Many patients retain a residuum of their mental il l n e s s , so that they are handicapped in their a b i l i t y to manage their own affairs, look for work, or to get along with fellow-workmen. These patients are fearful of, and are quick to sense any rejection by employers or anyone else. They may have grave doubts as to whether or not they can contribute anything in a job situation. Vocational counselling of such mentally handi-capped persons requires patience, understanding and encourage-ment by the counsellor i n helping each p atleht to reach his own best p o s s i b i l i t i e s . We cannot discuss in further detail here the technical casework processes which may be u t i l i z e d by the social worker in helping patients in their vocational adjustment, other than to note the unique vocational problems presented by discharged mental patients. Reference material dealing with the vocational rehabili-tation of psychiatric patients indicates that the largest number who w i l l need and profit by vocational services are young people, largely schizophrenics, who have l i t t l e or no previous work history. These young!patients need plenty of time to find 47 their work goals. Accurate information should he given them about the satisfactions and dissatisfactions to be expected from different kinds of work. This group of patients are apt to be unrealistic and their f i r s t plans are often impracticable. In practice, discussing work plans i s a fundamental means of testing on a reality basis the patient's readiness to return to the community. Much patience i s called for i n helping the patient to a f i n a l plan of his own. It has been found in some instances that the counselling process takes two-and-one-half times as long for the emotionally handicapped as for the 1 physically handicapped. The aim in vocational counselling i s to help the patient to a work goal i n which his maximal potential i s reached i n terms of intellectual capacities, s k i l l s and aptitudes, vocational interest or preference, physical condition, and psychiatric d i s a b i l i t y . To accomplish this aim, the counsellor, from the point of view of good professional social work practice, w i l l work i n close collaboration with people in other disciplines. For example, at the Crease C l i n i c , the social worker or rehabilitation officer ideally would have the assessment of the psychiatrist of the patient's capability to function under the stresses and strains of a particular work placement. He would also have the assessment of the psychologist as to the patient's intellectual capacities and work aptitudes, so as. to indicate 1 ' ' ! ' Rennie, T.A.C., Burling, T., and Woodward, L.E., "Rehabili-tation of the Psychiatrically Disabled". Mental Hygiene. Ap r i l , 1949. 1+8 . his capability for a particular job or his need for vocational training. The social worker's assessment of the psychosocial situation reveals some of the social, family and practical considerations in planning. Particular work settings must be understood and related to the patient's personality and social situation. Details to be considered in work settings are the physical set-up, the relationship with staff and supervisors, hours of employment, degree of responsibility, and the nature and level of work and production requirements. A l l told, the process of vocational counselling i s a highly personalized one of matching the unique needs and capacities of a particular patient to a work goal. It i s a professional undertaking which, may require many hours of interviews, and which calls for much s k i l l , good judgement, and adaptability on the part of the counsellor. A satisfying work experience is such an important factor in mental health, that time and effort are justified to ensure the best possible vocational adjustment of the discharged mental patient. A good work adjustment will, heighten his sense of worth and contribute to his over-all adjustment, thus assisting him to maintain the gains in treatment he has received in hosp-i t a l . As already noted, the vocational needs of patients are not a l l the same, so that individual help i s required. Vocational services may include help in finding a job, help in choosing a vocation and in getting training for i t , help in settlement in a protective work placement, or follow-up contact and encouragement after a placement has been made. Planning for a h9 patient's vocational future should begin at the time of a patient's admission. Primary responsibility i s with the psychiatrist, but the entire hospital staff should be alert to the patient's probable need for a job after his treatment i s concluded. Extra-mural Treatment Heeds: There are a number of patients receiving casework services during their stay in the hospital 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, this i s true of nearly one in three of discharged patients already referred for casework. Thirty one requests for this type of after-care were recorded, as shown in Section C. of Table 1. As noted earlier in this study, post-discharge casework services are frequently recommend-ed by the psychiatrist to assist patients in re-establishing themselves and in maintaining the treatment gains made in the Cli n i c . For the purposes of this thesis, extra-mural treatment by social workers includes efforts in the r e l i e f of internal stress, when predominant concern i s the provision of emotional support rather than a practical service. In some instances these casework services are more or less brief and transitory in nature, contact being maintained for only a few weeks u n t i l the patient i s settled comfortably in his home and job. Hence-forth the patient i s expected to be able to manage independently without casework support or help from the social worker. In other instances, when inner and outer stresses upon the patient 50 are anticipated and are expected to remain for several months, long-term casework services may be recommended by the psychiatrist. These services are in the nature of extra support from the Clinic,, the aim being to alleviate the possibility of a relapse and subsequent re-admission to the C l i n i c . Because of the inter--relatedness of factors in human experience, such casework support may touch upon a. wide variety of human problems: marital conflict, unsatisfactory vocational adjustment, financial burdens, and so forth. Help may also be required by the patient whose emotional or mental disturbance continues to handicap him in making adjust-ments 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 Social Service Department at Crease Clinic i s such that extra-mural services to patients residing in the Greater Vancouver area are given by the Clinic social workers. In the present sample there are 10 requests of this nature. Patients whose residence i s outside Greater Van-couver are served by the d i s t r i c t or amalgamated offices of Social Welfare Branch. In the latter instance, supervisory and consultative help with the psychiatric aspects of post-discharge care of patients i s provided by the social workers at Crease C l i n i c , who have access to psychiatric consultation. The sample contained 13 requests for this service. This investigation distinguishes four categories of follow-up casework services. The f i r s t two categories refer to services given by Crease Clinic social workers. Of these, the phrase "short-term service" 5 1 designates contacts limited in 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 distinguish the referrals of cases for service to Social Welfare Branch offices, and referrals to other social agencies in Vancouver or elsewhere. "Other social agencies" includes the Provincial Probation Service Vancouver City Social Service Department, and children*s and family agencies. Eight requests in the sample f e l l into this category. Referrals are made to other social agencies when the predominant problem relates-to the function of the particular agency. If service i s required with the psychiatric aspects of after-care, the case i s usually carried on a joint basis with the Crease Clinic Department. The remainder of the sample reveals the proportion of patients who are discharged directly to another hospital or institution. The destination of these patients who did not receive post-discharge service from Crease Clinic staff i s shown in Table 2 . There were 8 patients who were discharged on an independent basis, who established themselves without reliance on friends or family or hospital personnel, and who carried out their own plans and living arrangements without follow-up contact from Crease C l i n i c . Of the remaining 1 0 patients:, V.were comm-itted to the Provincial Mental Hospital; 3 were admitted to general hospitals for medical or surgical therapy; one was admitted to the Boy's Industrial School; one was deported; and one was discharged in care of the Department of Indian Affairs. 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 Cl i n i c against advice and one died in hospital. Rehabilitation a Process of Meeting Needs The figures which have now been reviewed provide a highly significant cross-section of the kinds of situations faced by the discharged mental patient, and the relative frequency with which certain types of problems are experienced. They give practical meaning to "rehabilitation", the process whereby the needs are met which enable the patient to become re-established as a citizen. 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 in the face of outer pressures and inner turmoil. If the sample of cases studied are representative, the proportion of discharged patients for whom the outer press-ures of material needs are a significant problem i s approximately one in f i v e ; and the proportion of patients who require help with inner stresses i s approximately one in three. During a patient's stay i n hospital, 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 hospital doors the aid of helping persons i s required to meet the material and emotional needs of the proportion of patients noted. How, and by whom these needs are met, w i l l be considered in the following chapter. Chapter 3 Resources For Meeting Heeds The v a r i e t y and frequency of the r e h a b i l i t a t i o n needs of patients discharged from Crease C l i n i c i s well I l l u s t r a t e d by the f a c t u a l material i n the foregoing chapter. How f a r they can be met depends on, (a) the resources which the patient has when he comes to the C l i n i c , (b) any changes i n h i s s i t u a t i o n during h i s period of treatment, and, (c) what the s o c i a l worker can mobilize f o r him, or help him use, on discharge* The s o c i a l worker i s the s t a f f member who serves as a l i n k between the C l i n i c and the community; and i t i s therefore l a r g e l y through h i s e f f o r t s that comprehensive s o c i a l services are mobilized to meet needs* Whereas i t i s not within the scope of t h i s study to discuss i n d e t a i l the t e c h n i c a l casework processes which may be used i n bringing s o c i a l services to discharged mental patients, i t i s h e l p f u l to note some broad c l a s s i f i c a t i o n s of casework treatment methods which are generally accepted i n the profession of 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 aiding patients; but to present a picture of some of the concrete discharge problems, the needs covered under the i n c l u s i v e term "casework services to discharged 5V patients" are broken down into several categories* In social work professional literature 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, treatability, agency function and so forth. These factors i n c l -ude the building of a professional relationship; the establish-ment of confidence; the reduction of anxiety by acceptance and support; the maintenance of focus on specific goals desired by the client; the support of constructive defences and work with the relatively healthy part of the client's personality; and the use of practical resources* Interviewing and the use of relationship are basic common factors i n a l l casework* Because personal and social combinations shift and overlap, a l l of the techniques noted may be used i n one particular case, but weighted differently i n another. A diff 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 social problem. On this common basis, i t i s possible and helpful to make a simple classification of casework treatment methods into three divisions: one, administration of a practical service; two, environmental manipulation; three, direct treatment. In the f i r s t of these the primary focus i n assisting the client i s 1 '• ! !  Austin, Lucille N., "Trends i n Differential Treatment i n Social Casework". Journal of SocialCasework. June, 19^8, Hamilton, Gordon. Theory and Practice of Social Casework. Columbia University Press; New York; 1951; Chapter 9. " H o l l i s , Florence, Women in Marital Conflict; A Casework Study* Family Service Association of America; New York; 19^9; Chapter XI. 55 the worker*s choice and use (on the basis of s o c i a l diagnosis and through the medium of the casework relationship) of a s o c i a l resource afforded by the community. Examples of p r a c t i c a l ser-v i c e s are providing f i n a n c i a l a i d , locating housing, and procuring l e g a l help or medieal care. By means of such services the c l i e n t i s aided towards r e a l i z i n g independence, s e l f - h e l p , s e l f -awareness, and r e s p o n s i b i l i t y , so that he can continue to con-tr i b u t e something to the solution of h i s problem; or, i f he i s not able to do so, to be sustained i n appropriate ways. The second method referre d to i s sometimes termed " s o c i a l therapy* 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 techn-iques are employed to help the c l i e n t , but with emphasis upon changes i n the s o c i a l s i t u a t i o n . "In general, such environmental modification i s undertaken by the caseworker only when environmental pressures upon the c l i e n t are beyond the l a t t e r ' s c o n t r o l but can be modified by the caseworker, or when such pressures are much more l i k e l y to y i e l d to change when handled 1 d i r e c t l y by the worker rather than by the c l i e n t himself*" Examples of such arranged situations are homemaking services, group experiences, substitute family care, and vocational or educational adjustments. Also included i n t h i s method of t r e a t s ment i s the modification of attitudes toward the c l i e n t of s i g n i f i c a n t persons i n h i s l i f e : parent, teacher t spouse, or employer. In d i r e c t treatment, the purpose of interviewing i s to I ™ ^ H o l l i s , op c i t , p.14?. 56 induce or re-inforce attitudes favorable to maintenance of emotional equilibrium, to making constructive decisions, and to growth or change. This method of treatment comprises three c l o s e l y r e l a t e d yet distinguishable treatment processes to which may be applied the terms " c l a r i f i c a t i o n " , "psychologcal support", and "insight development*. Direct, treatment leading to psychotherapy, i s Intensive therapy. On a le s s intensive l e v e l , d i r e c t treatment i s sometimes re f e r r e d to as counselling, a form of treatment probably more frequently used i n casework with discharged mental patients. "Counselling i s intended to help a person i n a r a t i o n a l way to sort out the issues i n h i s s i t u a t i o n , to c l a r i f y h i s problem and h i s c o n f l i c t s with r e a l i t y , to discuss the f e a s i b i l i t y of the various courses of action, and to free the c l i e n t r e a l i s t i c a l l y to assume the 2 r e s p o n s i b i l i t y of making a choice," I f the 100 cases studied are representative, the main problem of approximately 21 per cent of the male patients discharged from Crease C l i n i c i s material need of housing or a job. The chief need of approximately 31 per cent of the patients i s help with inner problems of emotional s t r e s s . Patients with these needs receive help 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 of community services mobilized on t h e i r behalf by these s t a f f members. The s o c i a l worker's body of knowledge and — j — i - • = An enlargement of these terms may be found i n H o l l i s , op c i t , Chapter XI, 2 Hamilton, op c i t , p.250. 57 acquired s k i l l r e l a t e s both to casework help available through a worker-patient r e l a t i o n s h i p , and also to the s k i l l e d use of community resources f o r t h e benefit of the c l i e n t . The s o c i a l worker i s active i n both areas of i n t e r n a l and external s t r e s s , helping the patient by locating work and housing, and also helping the patient to hold to h i s treatment gains through i n d i v i d u a l and family casework services. There are many ways of helping i n these two areas, one of the major ways being to put the patient i n touch with the community agency which can best meet h i s p a r t i c u l a r need* Public welfare and s o c i a l assistance agencies can be of great help i n providing f i n a n c i a l support, i n securing accommodation; and i n the case of the S o c i a l Welfare Branch, i n the provision of casework services outside the Greater Vancouver area. Children's and family agencies can be of v i t a l service when the patient's problem r e l a t e s more sp e c i -f i c a l l y to c h i l d and family welfare. Thirteen per cent of the cases studied were referre d to S o c i a l Welfare Branch, and 8 per cent to other s o c i a l agencies i n the community. In a discussion of available resources i n meeting patient needs i n r e h a b i l i t a t i o n , we require some i n d i c a t i o n of the adequacy of such resources from the two sources noteds h o s p i t a l personnel and e x i s t i n g community f a c i l i t i e s . Job Placement Job placement i s a personalized service which Involves finding 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 patient, getting the person into the job, and following up by making contact with the patient and employer. In the Crease C l i n i c , men patients may get help of t h i s kind from the s o c i a l worker or from the 58 r e h a b i l i t a t i o n o f f i c e r . In the year 1952 there were f i v e ease-workers and one casework supervisor In the Continuing Casework Section of the S o c i a l Service Department, which i s responsible f o r a l l r e h a b i l i t a t i o n services, of which job placement i s one, (How these s t a f f members compare i n number with approved personnel standards w i l l be discussed l a t e r . ) The present r e h a b i l i t a t i o n o f f i c e r i s a trained s o c i a l worker who was appointed to the Hen's D i v i s i o n of the R e h a b i l i t a t i o n Department i n February 1950. His primary function i s that of job place-ment and the lo c a t i o n of temporary housing f o r a se l e c t i o n of male cases from both the P r o v i n c i a l Mental Hos p i t a l and the Crease C l i n i c . The chief community resource available to s o c i a l workers i n job placement of patients i s the National Employment Service, with of f l e e s located i n Vancouver, New Westminster, and i n some larger r u r a l centres i n the province. The Service i s divided into various sections: farm placement, general labour, trades, and professional employment. There are also S p e c i a l Placements Sections i n the Vancouver and New Westminster o f f i c e s , which receive r e f e r r a l s of those patients who present an employment handicap, including discharged mental patients with a continuing p s y c h i a t r i c d i s a b i l i t y . Some patients prefer to go the Employ-ment Service o f f i c e on t h e i r own. Some f e e l Insecure about going alone and the s o e i a l worker makes the preliminary contact, accompanies the patient f o r an interview with the Placement Source: Interview with Addison, Mr. D. t 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 . 59 Officer, and provides casework support during the placement process. When referral i s made to the Special Placements Section, the social worker making the referral communicates to the Place-ment Officer a general picture of the kind of person the patient i s , with as much information as to his vocational preferences and needs as i s available. The Placement Officer needs to know whether the patient has f u l l y recovered, i f further treatment i s planned, and how the residual of the patient's illn e s s may affect his functioning i n employment. The Placement Officer then endeavors to place the Individual by personal contact with the prospective employers. Personnel Officers and employers may be contacted directly by the social worker, although in general practice soeial workers act on the premise that the National Employment Service i s the appropriate and specialized community agency to provide service i n job location. Patients who reside In rural parts of the province where no Employment Service office i s located are referred to the f i e l d offices of the Social Welfare Branch for help i n job placement i n their home community. Approximately 35 per cent 1 of patients come from outside the Greater Vancouver area. A limited amount of money i s available through the Business Office of the C l i n i c to assist patients at the time of discharge to maintain themselves u n t i l the f i r s t pay from their job i s received. The maximum allowance per patient i s $20. A stated 1 ! " Pepper, op c i t . 60 gratuity may be authorized for a particular patient by the attending psychiatrist. For those patients who are e l i g i b l e , the Unemployment Insurance Commission may provide financial aid during the post-discharge period before employment i s actually located. It i s generally agreed by the Crease C l i n i c staff that community resources for 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 social workers to serve the numbers of patients who need help i n finding a job. Vocational Training The consideration of vocational training or re-training i s particularly appropriate for patients In the younger age brackets who have no trade or acquired s k i l l , for those i n whom a poor vocational.adjustment contributed to their 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-ional training: (a) the educational f a c i l i t i e s ; and (b) the necessary funds for tuition and for maintenance during the training period. Lack of community, educational f a c i l i t i e s Is seldom a hindrance, and a wide variety of courses and training are available i n Greater Vancouver at five different sources* These include the Vancouver Vocational Institute, operated by the Vancouver Board of School Trustees, and offering a wide selection of f i r s t class trade training. Part of the Institute's service i s to help trainees Into positions of employment. There 61 are several business colleges o f f e r i n g commercial t r a i n i n g ; and also p r i v a t e l y operated matriculation schools• The Vancouver School Board sponsors night school classes during winter months* There axe a wide v a r i e t y of correspondence courses available under the auspices of the Department of Education, private engineering schools, and the University of B r i t i s h Columbia Department of Extension* Patients who have adequate funds to finance t h e i r t r a i n i n g need help only i n a r r i v i n g at a eholee of vocation and i n r e g i s -t e r i n g at the appropriate t r a i n i n g school. But when funds are not available from the patient or h i s family, plans f o r vocational t r a i n i n g must be deferred u n t i l the patient saves the necessary money. The Crease C l i n i c has no funds available f o r t h i s purpose, nor at the present time are funds provided by governmental bodies*. Whereas c e r t a i n government a i d f o r vocational t r a i n i n g Is provided a l i m i t e d number of persons with major ph y s i c a l handi-caps, the terms of reference of the scheme are not as yet s u f f i c i e n t l y broad to include persons with a p s y c h i a t r i c dis° 1 a b i l i t y * In 19^2, the Vocational Training Co-ordination Act was passed and administered by the Federal Department of Labour through i t s vocational t r a i n i n g branch* Under the Act, various t r a i n i n g projects are c a r r i e d on by means of agreements between the Federal Government and the provinces . Schedule "M* of the j — — • • ' — Sources: 1. Interview with Miss R. Kickley, Secretary of D i v i s i o n f o r Guidance of Handicapped, Community Chest and Council of Greater Vancouver. 2. Recommendations f o r a Comprehensive Rehabil-i t a t i o n Programme f o r the Phy s i c a l l y Handicapped i n the Province  of B r i t i s h Columbia. Community Chest and Council of Greater 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 originally voted for training of unemployed persons. It i s now being used, i n some degree, to provide vocational training for a limited number of persons with major handicaps. Authority has been granted from the Director of Technical and Vocational Training, Provincial Government, to the Division for Guidance of Handicapped of the Community Chest and Council of Greater Van-couver, to recommend such handicapped persons as they deem f i t for vocational re-training. The Consultative Committee of this Division i s comprised of physicians, social workers, placement officers, a psychologist, vocational counsellors and rehabilit-ation officers; and screens applicants for a programme of vocational training. Recently, another agreement was proposed under the Vocational Training Co-ordination Act, known as Schedule "R". Should this agreement become implemented by legislation, there w i l l be a definite means by which handicapped persons can be given training i n addition to many other benefits* Schedule "R" sets forth what are deemed to be the essential requirements and conditions of a special schedule for the training of disabled persons. It would appear therefore that a: very serious and fundamental gap in community resources exists i n this area of vocational training. The f a c i l i t i e s for training are available; but they are limited to those who have ready capital, and they exclude persons who are financially 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 into the l a t t e r income bracket. I t may he that i n the future the terms of reference of schemes of governmental aid f o r vocational r e h a b i l i t a t i o n w i l l be extended to include selected patients with mental or emotional handicaps. I t w i l l be r e c a l l e d that i n the United States, r e h a b i l i t a t i o n services to the p h y s i c a l l y disabled were f i r s t provided under the Vocational R e h a b i l i t a t i o n Act of 1920. The scope of the Act was gradually enlarged u n t i l i n 19^3 the psychiatric a l l y d i s -abled were included i n a j o i n t state-federal program© Housing Patients who are w e l l enough to manage t h e i r own a f f a i r s and who can a f f o r d to pay rent i n advance, are usually quite able to f i n d suitable housing on t h e i r own* Some patients need the helping hand of the s o c i a l worker i n getting established In a good boarding house* There are many good boarding homes i n the community and they are a valuable resource to the person who can care f o r himself* A l l boarding homes* where there are more than two people, are licensed under the Welfare I n s t i t u t i o n s Licensing Act of the province. Patients who require help i n f i n d i n g a place to stay are frequently those without funds* 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 assistance; and i f they are simultaneously i n e l i g i b l e f o r unemployment insurance b e n e f i t s * 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 patients need a place to stay while they locate a job and u n t i l they receive t h e i r f i r s t pay cheque* Some male patients are placed d i r e c t l y from the C l i n i c with mining and 64 logging firms, with arrangements worked ont in advance for transportation directly to the camp, and for maintenance and clothing u n t i l the f i r s t cheque comes in. The small gratuity of up to twenty dollars which can he given to the patient on discharge on the authorization of the psychiatrist i s sometimes not sufficient to get a person started i n day-labouring jobs. The hospital maintains hotel accomodation with meals to the extent of two rooms (one in Vancouver and one in New Westminster)} which are always available to the rehabilitation officer for temporary placement. Low cost housing i s available at the Salvation Army Hostel i n Vancouver for those patients who are able to pay their own way. One solution of the housing problems for patients who are without funds i s the provision of f a c i l i t i e s for subsidized boarding care. An example of this type of care i s a special institution called "The Vista", which i s maintained by the provincial government as a mid-way home between hospital and community. This f a c i l i t y i s limited to female patients and to a bed capacity of seven. No separate housing unit of this sort i s available for men, although recommendations for i t s establish-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 eligible for social 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. If a patient's mental illness after he leaves the hospital i s a source of disturbance to himself or to others, certain specialized f a c i l i t i e s or housing arrangements are called for. 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 for some patients to adjust satisfactorily i n such a setting. These specialized arrangements do not exist at present, and such f a c i l i t i e s can be found only through effort by the social worker i n direct contact with an individual boarding home operator. Family Care At the present time, no special administrative arrangement or agency exists to carry on a program of family care for dis-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 his own for care. This type of placement may be used for a particular group of patients when the outlook for their recovery i s not hopeful. They may be patients who have responded to hospital treatment to such an extent that i t i s f e l t they can adjust to livin g under close supervision i n a home and benefit from the individual attention which comes from family l i f e . Family care i s also used for some patients who have responded so well to Intensive hospital treatment that they are placed in Crutcher, Hester B., Foster Home Care for Mental Patients* The Commonwealth Fund; New York; 19TC • 66 homes as a therapeutic measure with the purpose of hastening t h e i r recovery. Requests made to C l i n i c s o c i a l workers f o r t h i s type of care are dealt with on an Individual basis. The worker himself may seek out a home and arrange f o r the patient to l i v e there; or the worker may request the co-operation and assistance of S o c i a l Welfare Branch o f f i c e s or municipal public welfare agencies. The S o c i a l Welfare Branch o f f i c e s do not maintain a roster of suitable homes, but they are acquainted with 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 to honour a s p e c i f i c request on behalf of a discharged patient from Crease C l i n i c . Casework Services Casework services to patients following t h e i r discharge are given by the s t a f f of the S o c i a l Service Department at Crease C l i n i c , who may also re f e r patients to community s o c i a l ageneies f o r t h i s type of service. As at present organized, the Department at Crease C l i n i c i s divided Into two sections: the Admissions Section, dealing with Intake and b r i e f services to patients; and the Continuing Service Section, responsible f o r services to patients on the ward, pre-convalescent planning, and follow-up casework services i n the post-discharge period. The Admissions Section i s composed of one casework supervisor and two s o c i a l workers; and the Continuing Service Section i s com-posed of one supervisor and f i v e workers; making a t o t a l of seven workers. The American Psych i a t r i c Association has established c e r t a i n 67 personnel standards for psychiatric hospitals and c l i n i c s * The personnel ratios c a l l for at least one social worker to every 80 new admissions per year, and at least one social worker to each 60 patients on convalescent status or family care. Administrative and supervisory social workers should be provided 1 i n the ratio of one supervisor to every five caseworkers. Due to the fact that the Social Service Department at Crease Clinic does not distinguish in-patient and convalescent care in the assignments of social workers, an exact comparison with Assoc* latlon standards i s not feasible. 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 ratios, would c a l l for 15 social workers. This figure does not include social workers who would be assigned to patients on convalescent status and family care. On the basis of these figures, the present social service staff 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 Social Welfare Branch offices would entail an independ-ent research project of considerable magnitude and i s beyond the scope of this, thesis. The assessment would provide a pertinent 2 — : : -"Standards for Psychiatric Hospitals and Cl i n i c s " . American Psychiatric Association. November 1951* 68 topic for a future study and analysis. Crease C l i n i c social workers may refer patients to community social agencies for a casework service of a specialized or particular nature, on a division of labour basis. These community agencies provide family, children's, and child-guidance types of service. Cases may be held jointly with the community agency, with the hospital soeial worker being responsible for the psych-l a t r i e supervision of the patient* and the community agency worker assuming responsibility for problems of child care, legal separ-ation, and so forth. Some cases may be elosed by the hospital social worker at the point of referral to a community ageney i f follow-up psychiatric supervision i s not indicated. For present purposes i t i s not necessary to undertake a comprehensive survey of the many community agencies available. An outline of the services which the community of Greater Vancouver has established to meet the needs and problems of i t s 1 citizens i s printed by the Community Chest and Council* It can be noted however that the public welfare agency of the City of Vancouver (City Social Service Department), and also the public welfare agency of the province (Social Welfare Branch), are providing the Provincial Mental Health Services valuable rehab-2 i l i t a t i o n services. The City Social Service Department provides financial aid to Individuals and families who are e l i g i b l e . The 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^. 69 Social Welfare Branch gives casework services as well as social assistance i n helping patients to re-establish themselves. Schedule A, which follows, contains short summaries of five typical cases, each i l l u s t r a t i n g a particular cluster of problems i n rehabilitation* The meeting of the needs presented i n the case summaries ca l l s for the discriminating application of the resources so far discussed* The examination of the res-ources available In Br i t i s h Columbia indicates that gaps and limitations exist, especially i n the provision of subsidized boarding care and financial aid, and also i n the numbers of social 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 to have access to a compre-hensive rehabilitation service* The development of this service w i l l be discussed In the succeeding chapter. Schedule A - Five Typical 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 hospitalization for mental i l l n e s s , even for a short period* may be disruptive of routine family li v i n g * Sam S. was a 61 year old married man who was admitted as a cer t i f i e d patient to the C l i n i c In an 1 extreme anxiety state. He was overtalkative, hyperactive and restless. The diagnosis was "manic depressive - manic". In a month* s time he was discharged to his home as recovered from a The summaries i n this 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 to safeguard the confidentiality of the redords. 70 psychotic episode, Mr, S, lived on the outskirts of a small c i t y , where he and his wife operated an auto court. The children were married and livi n g i n their own homes, Mr, and Mrs, S, were financially 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 psychiatrist advised that due to the patient's tendency to worry, he should he relieved of as much responsibility 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 his physical activity, A social worker interviewed Mrs. S. with a view to assessment of her a b i l i t y to shoulder a larger measure of responsibility, and In order to learn more details about the operation of the business. It 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 relieved of physical labour, Casework services were focussed on counselling Mrs, S. i n planning for her husband's return home; and i n helping Mr, S, to accept with as much equanimity as possible, the relinquish-ment of some responsibilities he ordinarily assumed as head of the household. Case 2 - Tom T. ^ The case of T om T. illustrates the extent of need of those patients Who, at the time of discharge, lack financial resources and also the help of relatives In becoming established i n the community, Tom was a 21 year old single man who was admitted to the C l i n i c under voluntary papers, and who remained for a four months period of treatment. His diagnosis was that of 7 1 "mixed schizophrenia". Background information indicated that he had been born and brought up i n a r u r a l community i n Eastern Canada, He had l o s t the use of one eye when a boy. He had worked at numerous jobs, and i t was reported that he had been unable to hold any steady employment. There was a h i s t o r y of petty t h e f t , Tom had a r e t i c e n t manner, and he found i t d i f f i -c u l t to t a l k about himself. During h i s h o s p i t a l i z a t i o n a report on the man's parents was received, to the e f f e c t that they appeared to have no r e a l i n t e r e s t i n the patient, and suggesting that he not return there, Tom's contacts i n t h i s province were li m i t e d to a r e l i g i o u s group and a f r i e n d i n Vancouver. He was without funds« Although i t was expected that Tom would always have many problems i n adjustment and that i n h i s r e l a t i o n s h i p s with people he would probably remain withdrawn and unstable, he had become a l i t t l e more sociable during h i s period of treatment and there were no complaints.of petty thievery. On the basis of the information available i t was decided that discharge planning should aim at Tom's re-establishment i n or near Vancouver, where he would be close to h i s f r i e n d and r e l i g i o u s group. The needs of t h i s young man were therefore quite comprehensive. There were h i s immediate needs f o r a place to stay, a job with which to support himself, and s u f f i c i e n t cash to purchase meals u n t i l he got paid. Perhaps of more long-run importance i n maintaining a state of good mental health, was h i s need to e s t a b l i s h r e l a t i o n s h i p with someone who Would show in 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 period of moving from the h o s p i t a l to h i s new-found accommodation, he needed the support and 7 2 encouragement of the 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 of those patients who leave the h o s p i t a l with a r e s i d u a l of the mental disorder or upset which l e d to t h e i r h o s p i t a l i z a t i o n i s the case of Bon D. 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 c e r t a i n mental handicap which adds to t h e i r problems of r e - e s t a b l i s h -ment* Don D* was an Id year o l d single man who was admitted to the Crease C l i n i c under voluntary papers, and who remained f o r three month's treatment* The diagnosis was "pathological personality - schizoid personality". He was admitted i n a tense and anxious state; and h i s complaints included those of nervousness, I n a b i l i t y to concentrate on h i s work, and extreme i r r i t a b i l i t y * During h i s stay In the C l i n i c i t became apparent that h i s basic problem was h i s i n a b i l i t y to get along with people. The problem appeared to be rooted i n unsatisfactory boyhood rela t i o n s h i p s with h i s parents* There had been continual q u a r r e l l i n g between h i s parents f o r a l l of h i s l i v i n g memory* He was the only c h i l d i n the family* Don's mother tended to be overly-protective and s o l i c i t o u s of him; h i s father being a r i g i d person whose constant c r i t i c i s m and lack of praise was f e l t by the patient as severe r e j e c t i o n . Don was unhappy at home, but although he had made one or two attempts, he had been unable to emancipate himself from h i s parents, e i t h e r p h y s i c a l l y or emotionally* During h i s h o s p i t a l i z a t i o n , Don's tension and anxiety subsided* There were some ind i c a t i o n s of modification 73 i n the r e j e c t i n g manner of the f a t h e r ; and a f t e r one o r two week-end leaves at home, Bon was discharged, on the understanding that the s o e i a l worker would continue to see both Bon and, h i s parents. He returned to l i v e with h i s parents, where i t soon, became evident that the modification i n the attitude of the father was s u p e r f i c i a l and short - l i v e d , Bon's tension and anxiety began to mount, and t h i s was shown by qua r r e l l i n g at home and d i s s a t i s f a c t i o n at work. I t was therefore apparent that a long-term contact with the s o c i a l worker was c a l l e d f o r , Bon was not able to bring himself to leave home, nor was he able to l i v e comfortably i n such close r e l a t i o n s h i p with h i s parents, Bon needed help to resolve the long-standing c o n f l i c t s i n r e l a t i o n -ships with parents, which made i t d i f f i c u l t f o r him to get along with f r i e n d s , employers, and members of the opposite sex. Case V - C a r l C. C a r l G, i s an example of a discharged patient who needed s p e c i a l consideration i n job placement and l i v i n g arrangements, C a r l was a 22 year o l d single man who was found wandering about the countryside In a dazed condition, and who was admitted to Crease C l i n i c as a c e r t i f i e d patient. He was a lonely,withdrawn, in d e c i s i v e young man, with feelings.of unhappiness and h o s t i l i t y toward h i s parents. The diagnosis was "simple schizophrenia"; and he was discharged as "unimproved" a t the end of three months* C a r l was the youngest of f i v e c h i l d r e n . His older s i b l i n g s were w e l l established, but indicated t h e i r unwillingness to have C a r l stay with them, because he asked " f o o l i s h questions". The f a t h e r was a brusque, professional man, who was impatient 7* with C a r l ' 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 In the way of-performance than C a r l was able to produce• The mother was described as an eccentric person, with a mildly elated manner*, neither parent seemed able to accept t h e i r son's mental i l l n e s s or to recognize h i s unusual behaviour as due to the i l l n e s s * The parents recommended that C a r l get established away from home, but although they offered some f i n a n c i a l a i d , they made no concrete plan f o r h i s r e - e s t a b l i s h -ment* Because of the father's harsh manner and the tenseness i n the home generally, the p s y c h i a t r i s t considered that i t would be therapeutic i f C a r l was r e h a b i l i t a t e d away from home* A supervised f o s t e r home s i t u a t i o n was recommended* C a r l was not considered a candidate f o r long-term treatment at the P r o v i n c i a l Mental Ho s p i t a l ; but neither was he we l l enough to earn a l i v i n g s t e a d i l y should he be discharged from the C l i n i c * He required some guidance i n the management of money; and a work s i t u a t i o n with few demands and stresses* Whereas remuneration from employment was considered important from the point of view of Carl's self-esteem, i t was of secondary consider-ation to h i s personal f e e l i n g of comfort about any work under-taken* C a r l therefore needed s p e c i a l consideration i n becoming established i n a fo s t e r home or boarding home with some supervision; and i n obtaining employment where he could earn money but where competitive pressures and demands were at a minimum. Lacking a f e e l i n g of warmth and acceptance from parents or family, C a r l needed the support of a r e l a t i o n s h i p with a s o c i a l worker over an extended period of time* 75 Case 5 ° Lee L. The special problems presented by Lee L., a 16 year old adolescent, il l u s t r a t e some of the lacks in community f a c i l i t i e s for residential treatment of emotionally disturbed children, Lee was a ward of a children's agency and was admitted to Crease Clinie as a certified patient with a diagnosis of "primary behaviour disorder in a teen-age boy". For several years he had presented symptoms of aggressive and delinquent behaviour, which brought about his admission to the Boys' Industrial School, He was admitted to the Crease Cli n i c "for assessment, evaluation and recommendations as to future planning". I n i t i a l l y his behaviour was no problem on the ward. He was restless and active but not to a degree considered beyond normal for an adolescent. Later he became a considerable problem, creating disturbances by annoying older patients, so that i t was necessary to r e s t r i c t his privileges on the ward. He was sullen, defiant, and r e b e l l -ious i n his manner. He had d i f f i c u l t y i n forming relationships with people but did relate to staff members to some extent. S t i l l later he became quieter and more co-operative, and seemed to modify somewhat bis. defiant behaviour. It was the psychiatrist's judgement that Lee's behaviour was related to emotional deprivation i n early years. The psychiatrist's report stated that the C l i n i c was not organized to deal with this type of problem, since i t required a special environment suitable to the patient's age, and a much longer period of treatment than the four months available at the Crease C l i n i c , It was also stated that i t was unlikely that the boy 76 at that time could adjust in any of the usual foster homes; and that he would require a special home where both parents were experienced and willing to accept a hoy as seriously disturbed as Lee, It would appear that this i s the type of problem which has been met i n some of the United States through residential treatment centres and specialized foster homes for emotionally disturbed children. Chapter h The Development of a Comprehensive R e h a b i l i t a t i o n Service In recent decades the manifestation of Intensive, widespread, and sustained public i n t e r e s t i n mental ho s p i t a l s has done much to break down the walls of i s o l a t i o n that tended to separate mental patients from the community. This public i n t e r e s t has been stimulated and nurtured through such media of mass communication as the press, radio and movies. As w e l l , more d i r e c t contact of i n d i v i d u a l s with mental ho s p i t a l s has resulted from the Inauguration of "Open House 1 1 p o l i c i e s by h o s p i t a l a u t h o r i t i e s , and from the development of h o s p i t a l v i s i t i n g plans i n co-operation with the Canadian Mental Health Association. Within mental I n s t i t u t i o n s themselves there has been a change i n the approach to patients from one wherein c u s t o d i a l care i n an "asylum" was predominant, to a public health approach wherein treatment and return to the community became the dominant concern. The focus of attention i n t h i s thesis has been i n the problems, and programmes mobilized to meet them, of male patients returning to the community upon discharge from Crease C l i n i c . The study shows that there are both common and d i s t i n c t i v e aspects of the r e h a b i l i t a t i o n of mentally i l l , as distinguished from p h y s i c a l l y i l l , persons. The common aspects of the 78 rehabilitation process relate 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 practical assumptions include recognition and acceptance of each individual as a self-respect-ing person no matter what his state of health; recognition of the right of every person to a "health and decency" standard of livi n g and to opportunities to experience satisfying human relationships; recognition that the rights of the individual and of society are inter-related; recognition that progress i n social welfare arises from broad community understanding as well as from creative contributions by Individuals and profe-ssional groups. Community resources include agencies and groups contributing services to meet human needs i n a l l their variety and complexity: medical, educational, social, vocational* In this study, rehabilitation i s considered to be more than the possession of vocational s k i l l s and needs, and to include a l l aspects of the patient's total adjustment to l i f e . As a member of his own profession and as a responsible cit i z e n , the social worker recognizes the relationship between the interests and needs of the mental patient and those of the community i n which he liv e s ; and he takes responsibility for participating i n social action to obtain resources for the unmet needs. Whereas i n the case of physical ailments the rational resources and emotional strength of the individual can help him adjust and adapt to a changed self or a changed situation, the patient a f f l i c t e d with a mental disturbance i s limited i n 79 his a b i l i t y to u t i l i z e these adaptive resources and strengths. As well, in the case of mental illness 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, rehabilitative efforts on behalf of the mentally sick 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 this reason, an arm of treat-ment must extend beyond the walls of the C l i n i c into the homes and communities of i t s patients. This function i s carried out by C l i n i c social workers, under the direction of psychiatrists. 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 illness i s treated at an earlier, less debilitating stage, and that the residual effects of the illness are less limiting. Indications of this are seen i n the fact that the sample f a i l e d to show any need for 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 called for 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 Provincial Mental Hospital. One suggestion to develop this type of resource i s to foster the establishment of homes for group living by religious, cultural, or ethnic 1 groups i n the community. The probable channels for such I ~~ ~~ From an interview with Dr. F.E.McNair, C l i n i c a l Director. 80 community undertakings are the Canadian Mental Health Association* and the Health D i v i s i o n , Community Chest and Council of Greater Vancouver. Again, In Crease C l i n i c the rapid turn-over of patients and the average stay of two months, c a l l f o r rapid assessment of post-discharge needs of patients, and a d a p t a b i l i t y i n f i t t i n g resources to needs. The b r i e f time which s t a f f have to help the patient i s a l i m i t i n g f a c t o r i n mobilizing comprehensive help. What we 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 , -including personality and vocational assessment and the carrying through of a plan, » requires more than two months of planning and working with a patient both during and following h o s p i t a l -i z a t i o n . I t may be that a w e l l - s t a f f e d out-patient department to whom patients could be r e f e r r e d , would be the means of extend-ing and carrying to f r u i t i o n the blueprint f o r r e h a b i l i t a t i o n marked out by the treatment team at Crease C l i n i c . At the 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 n e c e s s a r i l y r e s t r i c t e d to © very few i n d i v i d u a l s ; and post-discharge help f o r the majority of patients i s l i m i t e d to minimal help In r e -establishment. Of the selected r e h a b i l i t a t i o n needs of patients studied, resources are f a i r l y adequate f o r patients requiring help i n f i n d i n g a job. Major gaps i n resources were apparent In the financing of vocational t r a i n i n g , and i n the provision of subsidized boarding home care. An o v e r - a l l deficiency e x i s t s In the numbers of professionally trained s o c i a l workers. A l i m i t a t i o n of the study i s that In actual practice human 81 needs are not neatly separable and cannot be segmented. Rehabil-l t a t l o n Is a highly i n d i v i d u a l i z e d service, wherein many community services are mobilized and co-ordinated to meet the peculiar needs and capacities of an actual c l i e n t . This kind of personalized service i s " t a i l o r made" f o r each Individual d i s -charged mental patient. I t i s not exclusively any one kind of professional service, such as medical service, s o c i a l service or vocational service. In the Grease C l i n i c the team approach i n planning under the d i r e c t i o n of the doctor, i s followed as cl o s e l y as possible. In actual p r a c t i c e , the s o c i a l worker and the r e h a b i l i t a t i o n o f f i c e r are the professional team members who have contact In the community outside the hospitals. Of these, the s o c i a l worker i s profe s s i o n a l l y trained to help patients cope with l i f e stresses. From the s o c i a l worker's point of view, any help given, whether p r a c t i c a l or supportive i n nature, i s given on the basis of an integrated understanding of the facto r s operative i n the patient's l i f e s i t u a t i o n . The focus i s held to the patient who has a problem within a set of s p e c i f i c circumstances. On the basis of a dynamic understanding of the patient's l i f e s i t u a t i o n the worker i s aware of the unique need of the patient f o r a p a r t i c u l a r kind of housing, or fo r a work placement of a c e r t a i n nature, or f o r help i n a p a r t i c u l a r s o c i a l r e l a t i o n s h i p . Consequently discrimination i s a c r i t e r i o n . f o r the professional administration of any service. Without an understanding of the dynamics, environmental treatment becomes merely symptomatic. 82 As at present organized the Men's Division of the Depart-ment of Rehabilitation functions specifically in the areas of job placement and temporary housing for patients about to be discharged« It would appear that the practice of providing jobs or housing as a service i n i t s e l f i s a limited manner of meeting the t o t a l needs of patients and i s uncongenial to the casework principles above* This study gives primary consider-ation to the incidence of patient need for particular services. An evaluation of the services given i s an area for 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 il l n e s s and rehabilitation, some general suggestions can be put forward as to ways and means of alleviating the present deficiencies i n resources. I t i s also possible to point up the probable direction of movement i n the development of a comprehensive rehabilitation program which includes the dis-charged mental patient. Effective future progress i n this f i e l d w i l l follow a road between two extremes. One extreme i s the tendency to "do nothing" u n t i l a l l facts 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 psychiatric care as indicating that new horizons are easily 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 discernible well-defined areas of activity. These areas of activity include the adaptation of established services as well as the creation of new ones, i n favour of more 83 comprehensive help f o r the mental patient returning to the community. Because the Grease C l i n i c i s regarded as a treatment resource of the community, and because post-discharge 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 , suggestions f o r the future must pertain both to the h o s p i t a l and to the community* Within the h o s p i t a l i t s e l f , one of the f i r s t aids to progressive development of r e h a b i l i t a t i o n services i s the e x i s t -ence of smooth, workable and well-defined channels of communica-t i o n between the various l e v e l s of h o s p i t a l administration. At the present time workable channels of communication e x i s t to deal with matters i n the c l i n i c a l treatment of patients. For example, the members of the treatment team come together at Ward Rounds f o r j o i n t planning. The C l i n i c a l Director sends out memoranda to a l l concerned when there are matters i n the 1 c l i n i c a l treatment to be considered. However i t i s axiomatic that 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 post-discharge care r e s t s with the top l e v e l s of h o s p i t a l administration. The implementation of the treatment philosophy and. p o l i c i e s of administration i s the coneern and r e s p o n s i b i l i t y of professional s t a f f members. Since s o c i a l workers have the most d i r e c t contact with community agencies, and are most d i r e c t l y active i n post-discharge care of patients, i t follows that channels of communication must not only reach down from h o s p i t a l administra-t i o n to the S o c i a l Service Department, but also proceed up from the Department i f administration i s to be f u l l y aware Pepper, op c i t , Chapter 2. 84 of this sector of patient need. It would appear that the appropriate lines of communication for this inter-change are through the Hospital Council to the Social Service Department. The Hospital Council i s an advisory body established to discuss over-all policy, to deal with matters that transcend the fie l d s of several services and that require the special co-operation and consultation of department heads. Another means whereby present personnel resources may be adapted toward assisting patients on discharge i s i n the use of group methods i n preparing patients for discharge. As a l l patients are not at present routinely referred to Social Service by use of group methods a social worker could help prepare patients for leaving the hospital; help them to anticipate, and plan how to 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 to use this help to meet their own needs. As well, just prior to discharge, a l l patients might routinely be referred by the psychiatrist for an interview with a social worker, so that an assessment of their readiness for discharge, from a social as well as from a psychiatric point of view, might be made. This would be particularly imp-ortant for those patients who had not previously been referred to the Continuing Casework Section of the Department. A suggest tion has been made elsewhere that rehabilitation services i n the Cl i n i c be centralized and that one person be appointed to bring together information on community resources i n reha b i l i -1 tation. 1 ~ • — — — Ibid, Chapter 4. 85 Within the Social 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 hospital without follow-up aid. The recording of a pre-dlscharge social study of these patients by a social worker would Include an assessment of the environment to which the patient i s returning, and determine the relative s t a b i l i t y of the family constellation, as well as the positive and nega-tive factors i n the patient's social relationships and economic situation. In the case records studied i n the sample, there was frequently insufficient evidence as to whether or not a thorough rehabilitation assessment was made, or as to the factors operative i n the decision against follow-up service. More det-ailed and standardized recording of such information i s called for in order to determine and classify deficiencies i n personnel and resources. This information would be useful i n interpreting to appropriate community and governmental sources the require-ments of the Cl i n i c i f a positive approach to rehabilitation i s to be implemented i n action* Development of Resources Within the Community The development of rehabilitation resources i s determined not only by what happens in the hospital, but also by the part-icipation of hospital personnel i n community planning. The social worker's responsibility to patients rests not alone in use of casework s k i l l s to bring help, but also embraces efforts i n the sphere of soeial action. The soeial worker i s i n a position to bring into focus the lacks of community resources. 0 As a professional person and citizen he i s also obligated to 86 help the community plan wisely to meet these needs. To help effectively in this way the social worker requires a wide know-ledge of federal, provincial and local planning, as well as vision as to how a needed project should develop, both now and in the future. As a result of the preliminary study i n this thesis, a number of topics are indicated as requiring efforts i n social action; further research being required to determine classification and priority of projects. The need for more financial aid i s apparent i n order to help patients whose lack of adjustment i s accentuated by shortage of funds. An examin-ation of rehabilitation resources shows that financial aid i s especially required to secure vocational training, and for 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 for special forms of accomodation: subsidized boarding homes or a "vista" for males; at least a few foster homes for mental patients; specialized foster homes and/or a residential treatment institution for emotionally disturbed young people. Access to sheltered workshops and to protective work placements may be required for a limited number of patients discharged from Crease C l i n i c . The need for more trained social workers i s well known: i t i s a problem s t i l l exercising the concern of hospitals, professional associations, Universities and Schools of Social Work, and the community generally. The development of programs for the rehabilitation of mental patients i s related to the development of wider community programs concerned both with c i v i l i a n rehabilitation and with 87 mental health maintenance. For example, resources for accomod-ation and job placement helpful 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 alcoholic, the tuberculous. As well, the battle for better mental health i n the community i s fought on many fronts, of which institutional psychiatric treatment i s only one. From the point of view of sound professional practice, the social worker's concern with the rehabilitation segment of mental health maintenance should be r e a l i s t i c a l l y integrated with more inclusive social welfare measures. For example, specialized foster homes or residential treatment f a c i l i t i e s for emotionally disturbed children are types of projected resources which are of interest not only for Crease C l i n i c personnel but also to members of soeial agencies, general hospitals, and child guidance c l i n i c s , who have experience in dealing with disturbed children. Traditionally and constitutionally, the development of public health, welfare and social services i n Canada has been regarded as a matter primarily for municipal and provincial action. Nevertheless, many of the earliest welfare undertakings i n Canada have been in i t i a t e d , not by provincial or municipal governments, but by voluntary organizations led by public-spirited citizens. As the worth of these programs was proven and as the financial burden of carrying them became too great for private philanthropy, municipal governments, f i r s t of a l l , responded to appeals for help by granting financial assistance without assuming administrative responsibility. Gradually the necessity 88 for taking over certain of the undertakings as a direct adminis-trative responsibility of the municipal authorities became apparent* Financial, and subsequently, administrative responsi-b i l i t y for certain health and welfare services was Imperceptibly shifted from voluntary to municipal auspices* This process repeated Itself at the municipal-provincial level. Finally the federal government responded to the development of public opinion i n favor of a larger measure of social security, and began to assume direct administrative as well as financial responsibility for special social service programmes. For example, federal grants to 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 this process of shifting responsibility for social services i s seen In the development of the Vista as a rehabilitation home for women patients from the Provincial Mental Hospital and Crease C l i n i c . The Vista was f i r s t opened under private auspices i n 1944 and was taken over by the 2 Provincial Government i n 1947. Voluntary community agencies may participate i n the develop-ment of needed social services through the establishment of study committees and action groups. At the present time a special committee of the Community Chest and Council of Greater Vancouver i s studying the question of treatment f a c i l i t i e s for emotionally disturbed children. Another committee of the Council " ~1 ' ~ ~~ ' " ~ " ~~ The Canada Year Book. 1952-53. 2 Sophie Birch, op c i t . 89 i s making a study of sheltered workshops. The Social 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 social services i n the community come into being as an extension of present governmental programs. The Provincial Government has announced projected plans for the construction of a Day Hospital where active-treatment for ment-al 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 hospital. I t i s also expected that social workers w i l l be participating 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 rehabilitation specifically, recent develop-ments at several levels of government indicate a growing interest and attention to problems of rehabilitation for handicapped persons. In December, 1951, the National Advisory Committee on Rehabilitation of Disabled Persons was set up by Order i n Council to review existing rehabilitation f a c i l i t i e s i n Canada and to assess the possibility of co-ordinating existing f a c i l i t i e s more f u l l y . The Committee was established to provide central guidance to a l l provinces on matters pertaining to the development of an over-all network of services for a l l disabled persons i n Canada. On May 1, 1953, the Federal Government made available to the provinces eertain health grants to assist the provinces in the development of provincial rehabilitation programs. Under the appropriations funds were made available 90 for (1) training of professional rehabilitation workers, (2) medical rehabilitation equipment, (3) rehabilitation health services* Spear-heading the development of a provincial rehabilitation program i n B r i t i s h Columbia has been the Community Chest and Council of Greater Vancouver. In 1952 the Council for Guidance of Handicapped was Incorporated into the Community Chest and Council* and became known as the Division for Guidance of Handi-capped. The terms of reference of this Division pertain to physically handicapped persons only. Its functions are to co-ordinate the many agencies and the work of many professional people active i n the task of helping to rehabilitate physically disabled persons* In December, 1953, the Division for Guidance of Handicapped compiled a brief of recommendations for a comprehensive rehabilitation program for the physically handi-capped i n the province of B r i t i s h Columbia. This brief was presented to the Provincial Government and contained the results of the Division's careful survey of the community resources presently available, the gaps and deficiencies in the present structure, and the needs for a comprehensive, all-inclusive, long-range rehabilitation program* Summarized i n the brief are the resources of several organizations which are helping i t s clients to f u l l physical, mental, psycho-social, vocational and economic rehabilitation, as well as an enumeration of the f a c i l -i t i e s , conditions and personnel deemed necessary to make the organization's program work effectively* It may be that In due time the federal-provincial plan for 91 r e h a b i l i t a t i o n w i l l make provision f o r persons with ps y c h i a t r i c d i s a b i l i t i e s . In the United States, 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 provided f o r p h y s i c a l l y disabled, l a t e r included psychiatric d i s a b i l i t i e s ; and t h i s course of events may be repeated i n t h i s country. The goal i n the development of s o c i a l welfare resources i s to ensure i n the community a network of 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 to meet themselves. The process of s o c i a l action i s the mobilization of group e f f o r t i n the i n t e r e s t s of s o c i a l welfare. Some of the needs of patients discharged from Crease C l i n i c are d i s t i n c t i v e and require s p e c i a l i z e d f a c i l i t i e s ; some of these needs are the common needs of other s i c k and disturbed persons. Our concern f o r mental patients i s the development of f a c i l i t i e s and the administrative and organizational techniques through which our knowledge and our s k i l l s can be applied. Conclusion The mentally s i c k were at one time the outcast and the wanderers of society, objects of f e a r , persecution or d i s i n t e r e s t . In due time, when expediency was the apparent c r i t e r i o n of community a t t i t u d e s , the insane were lodged p r i v a t e l y , or i n gaols, or i n houses f o r the poor. A developing s o c i a l welfare philosophy resulted i n the assumption by the state of respon-s i b i l i t y f o r the custody and care of the mentally handicapped i n separate state-supported h o s p i t a l s . The r i s e of modern psychiatry and the m u l t i - d i s c i p l i n e approach to treatment, with i t s goal of returning the mental patient to the community as a 92 participating member of i t , brings to 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 practical programs to achieve the goal society has set for i t s e l f . Progress has been made i n philosophy and concepts; much has been accomplished i n hospital care which requires only expansion; but in the provision of a. comprehensive plan for rehabilitation, much new ground has yet to be covered: In a developing philosophy and concept of practice, i n building a body of knowledge and methodology, and in provision of a variety of community resources which may be Integrated into the social fabric. Not u n t i l the discharged mental patient i s able to make his way effectively i n his home and community and has been restored to his optimal state of health, w i l l the process of rehabilitation be complete. 93 Appendix A Items of Information Compiled from Sample Cases (One i n five 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. Marital Status K Education 5. Occupation 6. Diagnosis 7. Means of admission 8. Condition on discharge 9. Length of hospitalization Discharge Situation A. Discharged to third party care B. Needed housing Needed job placement Needed vocational training C. Needs relating to inner stress (a) Greater Vancouver area s short-term contact : long-term contact (b) Outside Greater Vancouver (c) Beferral to social agency D. Discharged to their own care E. Miscellaneous F„ No record of discharge situation G» Other 9^ Appendix B Bibliography 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 S o c i a l Casework. XXIX. June 19M-8. B i r c h , Sophie, An Aid i n the R e h a b i l i t a t i o n of Mental  Ho s u i t a l Patients. Master of S o c i a l Work Thesis; U n i v e r s i t y of B r i t i s h Columbia; Vancouver, B.C.; 1953* B r i t i s h Columbiaj Annual Reports of the Mental Health  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, Psychiatric Services Physicians  Manual. 1950. C a r r o l l , A l i c e K. "Post-discharge Care of Schizophrenic Patients". Unpublished Manuscript. Clark, Richard James, Care of the Mentally 111 i n B r i t i s h  Columbia. Master of S o c i a l Work Thesis; University of B r i t i s h Columbia; Vancouver, B.C.; 19**7« Clow, H o l l i s E„, "Psychiatric Factors i n the R e h a b i l i t a t i o n of the Ageing". Mental Hygiene. October 1950. Crutcher, Hester B. Foster Home Care f o r Mental Patients. The Commonwealth Fund; New York; 19Mif. Dentsen, Albe r t . "Recent Trends i n Mental Hos p i t a l Care". National Conference of S o c i a l Work. 1950. Deutsch, Albert, The Mentally 111 i n America:A History of t h e i r Care and Treatment from C o l o n i a l Times;. Columbia University Press; New York; 19H6. DeWitt, Henrietta B. "Family Care as a Focus f o r S o c i a l Casework i n a State Mental Hospital". Mental Hygiene. October 19HV. Dominion Bureau of S t a t i s t i c s . Census of Mental  I n s t i t u t i o n s . June 195l« Dominion of Canada. Annual Reports of the Department  of National Health and Welfare. 1951-52. Elledge, Caroline H. The R e h a b i l i t a t i o n of the Patient. J.P. Lippincott Company; Philadelphia; 19J+87 95 F e l i x , Robert H. "Developing a Federal Mental Health Program", National Conference of S o c i a l Work, 1946. Colombia University Press, 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 National Mental Health Program". - National Conference of S o c i a l Work* 1947. Columbia University Press, New York, ' Freeman. Henry. "Casework with Families of Mental Hospital Patients". Journal of S o c i a l Casework. March 1947. Garland, Ruth. "The Psychiatric S o c i a l Worker i n a Mental Ho s p i t a l " . Mental Hygiene. A p r i l 1947. 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• Garrett, James F., E d i t o r . Psychological Aspects of  Physical 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 of Psychiatry, "The Psyc h i a t r i c S o c i a l Worker i n the Psyc h i a t r i c Hospital"• Report No. 2, January 1946e Hamilton, Gordon. Theory and Practice of S o c i a l Casework. Columbia University Press; New York; 1951* Hincks, C M . " C l i f f o r d W. Beers". Mental Hygiene. October 194j« 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 t A Casework Study, Family Service Association of America; New York; 1949, Hooson, William. The R e h a b i l i t a t i o n of Public Assistance  Recipients; Parts 1 and 11, Master of S o c i a l Work Thesis; University of B r i t i s h Columbia; Vancouver, B.C.; 1952* Levine, Norma. "The Mental Patient i n the Community from the View-point of the Family Agency", Mental Hygiene. A p r i l 1947. Ling, T.M.; Zausmer, D.M.; and Hope, M. "Occupational R e h a b i l i t a t i o n of Psychiatric Cases". American Journal of  Psychiatry, September 195*2. Malzberg, Benjamin. "Mental I l l n e s s and the Economic Value of a Man". Mental Hygiene. October 1950 o Menninger, E a r l A. The Human Mind B A l f r e d A, Knopf; New York; 1947. 96 Myers. T.A. Mental Hospitals In B.C. The Daily C o l o n i s t ; V i c t o r i a , B.C.; January 1953. Noyes, Arthur P. Modern C l i n i c a l Psychiatry. W.B. Saunders Company; Philadelphia; 1953* Pepper, Gerald W. S o c i a l Worker P a r t i c i p a t i o n i n the  Treatment or the Mentally 111. Master of S o c i a l Work Thesis; university of 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. "Vocational R e h a b i l i t a t i o n of Neuropsychiatrie Patients". Occupations. February 1950* Proceedings of the Canadian Conference of S o c i a l Work. Vancouver, B.C. 1950. ' Proceedings of the Second B i e n n i e l Western Regional  Conference of S o c i a l WorkI 1949. Rennie. T.A.C. and Bozeman, Mary F. Vocational Services  f o r P s y c h i a t r i c C l i n i c Patients. 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 of the Psyc h i a t r i c a l l y Disabled". Mental Hygiene A p r i l 1949« -Richardson, Henry B. Patients Have Families. The Commonwealth Fund; New York; 1945; Chapter 9 . Rockower, L.W. '•The Development of a Vocational R e h a b i l i t a t i o n Program f o r the Neuropsychiatrie". Mental  Hygiene. A p r i l 19*9. Schmidl, F r i t z . "A Study of Techniques Used i n Supportive Therapy". S o c i a l Casework. December 1951* Schmidl, F r i t z . "The Psychotic Patient»s Adjustment to the Community". Journal of Psychiatric S o c i a l Work. A p r i l 1953• Sensenich, Helene. "Teamwork i n R e h a b i l i t a t i o n " . American Journal of Public Health. August 1950. Sheltered Workshops and Homebound Programs; A Handbook on Their Establishment and Standards of Operation. The National Committee on Sheltered Workshops and Homebound Programs; New York; 1952* Standards f o r Psychiatric Hospitals and C l i n i c s . American Psychiatric Association; 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 for the Disabled". Public Affairs Pamphlet No. 197. New York. 1953. The Canada Year Book. 1952-53• "The National Advisory Committee on the Rehabilitation of Disabled Persons". Canadian Welfare. March 15» 1952* United Kingdom. Health Services i n Britain. United Kingdom Information Office. 1952* Upham, Frances. A Dynamic Approach to Illness. Family Service Association of America; New York; 194-9* Vanuxam, Mary. "Rehabilitation of the Mentally Handicapped". Mental Hygiene. October 1953• p.681. "Vocational Rehabilitation of Physically Handicapped Persons". International Labour Office. Geneva. March 1952* Whitman, Samuel. "Organizing for Mental Health i n the Community". National Conference of Social Work. 1950; Columbia University Press; New York* Wilson, G. and Ryland G. "Physical and Emotional Illness and Handicaps". Social Group Work Practice. 1949; Houghton M i f f l i n Company, Boston, p. 115* Wise, Carroll A, "The Relation of the Mental Hospital to the Community". Mental Hygiene. New York. July 1945© 

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