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Rehabilitation of paraplegic patients : the origins and development of work at the Western Rehabilitation… Holt, Kenneth Arthur 1952

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REHABILITATION OF PARAPLEGIC PATIENTS. The origins and development of work at the Western R e h a b i l i t a t i o n C l i n i c and the rol e of the S o c i a l Worker. by KENNETH ARTHUR HOLT Thesis Submitted i n P a r t i a l Fulfilment of the Requirements f o r the Degree of MASTER OF SOCIAL WORK i n the School of S o c i a l Work. Accepted as conforming to the standard required for the Degree of MASTER OF SOCIAL WORK School of S o c i a l Work 1952 The University of B r i t i s h Columbia - i i -TABLE OF CONTENTS Page Chapter 1. The Requirements of a Complete R e h a b i l i t a t i o n Programme . . . . . . . 1 The goal o f - r e h a b i l i t a t i o n , i t s implications. The group to be studied, p o l i o m y e l i t i s , treatment; traumatic i n j u r y , treatment. What r e h a b i l i t a t i o n means. The patients' l i m i t a t i o n s . The frame of reference f o r r e h a b i l i t a t i o n . Co-ordination of treatment. Chapter 2. The Development and the Programme p r i o r to January. 194.9. 15 The Vancouver General Hospital. Vancouver Occupational Industries; a u x i l i a r y services. Hospital S o c i a l Service Department. P r o v i n c i a l Welfare Services. Workmen's Compensation Board. Kinsmen Clubs. Canadian Paraplegic Association. The "Walking School." The R e h a b i l i t a t i o n Process. Records of "Betty" and "Sadie." Western Society fo r R e h a b i l i t a t i o n . Chapter 3. The Development and Programme since January. 19A9. 36 B r i t i s h Columbia Hospital Insurance Scheme- Western Society f o r Reh a b i l i t a t i o n , structure f a c i l i t i e s . Government p a r t i c i p a t i o n . S o c i a l Worker-placement o f f i c e r . "Betty," "Tommy," and government p a r t i c i p a t i o n . Mr. "Jones" and vocational t r a i n i n g . "Mary" and r e h a b i l i t a t i o n diagnosis. "George" and Workmen's Compensation Board. Mr. "T" and Mr. "A" and the Marpole Infirmary. Alan and the implications of paraplegia and how they are met. Co-ordination. Recent changes i n process. Chapter 4- Evaluation. 68 Process: personnel and agency: community organization, hospital S o c i a l Service Department, National Employment Service, i n t e r p r e t a t i o n . - i i i -ABSTRACT, It i s commonly said that r e h a b i l i t a t i o n i s not the prerogative of any one group or person. This thesis surveys the method by which the achievements of the r e h a b i l i t a t i o n programme developed by the Department of Veterans' A f f a i r s were made available to those c i v i l i a n s who suffer paraplegia or quadriplegia. It traces the changes i n the e x i s t i n g programme as i t altered from one which was s o l e l y medical i n nature, to one which provides services for ph y s i c a l , s o c i a l and vocational e f f e c t s of the person's i l l n e s s . The recognition of the non-physical aspects of i l l n e s s also helps to emphasize that a handicapped person i s a human being and, as such, i s a member of society. These non-physical aspects are not only his own r e a c t i o n to his physical conditions, but a l s o the reactions of the society i n which he l i v e s . The problem i n developing t h i s r e h a b i l i t a t i o n programme has been getting the support and close co-operation of interested people and agencies i n the community How the problem has been met so f a r i s examined by a survey of the r o l e of the agencies concerned i n t h i s p a r t i c u l a r programme. The changing procedures are i l l u s t r a t e d by means of case records of patients who were c l i e n t s of the S o c i a l Service Department of the Vancouver General Hospital, The records used are those which best i l l u s t r a t e the degree to which the programme was an integrated r e h a b i l i t a t i v e process. The t r a n s i t i o n from a medical treatment programme to a t o t a l r e h a b i l i t a t i o n programme has not yet been completed; a medical, rather than a r e h a b i l i t a t i v e , diagnosis i s s t i l l used to e s t a b l i s h e l i g i b i l i t y f o r tra i n i n g at the R e h a b i l i t a t i o n Centre, L i t t l e use has been made of casework services, because the s o c i a l worker-placement o f f i c e r i s doing work which should be done by the General Hospital and the National Employment Service, The study concludes by suggesting that the next steps required are; to have vocational placement done s o l e l y by the Special Placement Section of the National Employment Service; to have the General Hospital S o c i a l Service Department provide casework service to the patients i n the ho s p i t a l ; to interpret to the personnel involved, the r o l e of each person and agency i n the programme, and to further co-ordinate the a c t i v i t i e s of the various agencies using the f a c i l i t i e s at the * R e h a b i l i t a t i o n Centre by discussing common problems of r e h a b i l i t a t i o n and the needs of patients with the members of t h e i r a u x i l i a r i e s . - i v -ACKNOWLEDGMENTS I wish to thank the f a c u l t y members of the School of S o c i a l Work for t h e i r excellent c r i t i c i s m and help, and also Mr. E. Desjardin f o r his kind co-operation i n supplying both information and advice. I wish also to thank a l l those people who so f r e e l y supplied the information as to the role of the i r own agency. - V -REHABILITATION OF PARAPLEGIC PATIENTS. Chapter 1 THE REQUIREMENTS OF A COMPLETE REHABILITATION PROGRAMME. The Western Society f o r R e h a b i l i t a t i o n was incorporated under the Societies Act of B r i t i s h Columbia i n 1947- The Society's aims were to construct, equip, and operate a r e h a b i l i t a t i o n centre f o r severely disabled orthopaedic patients. The planning followed the recommendations of the Baruch Committee on Physical Medicine (New York), and the experiences, which the four Department of Veterans' A f f a i r s R e h a b i l i t a t i o n Centres i n Canada encountered. The Baruch Committee has stated that "the goal of r e h a b i l i t a t i o n i s to achieve the maximum function of the in d i v i d u a l and to prepare him p h y s i c a l l y , mentally, s o c i a l l y , and vocationally f o r the f u l l e s t possible l i f e compatible with his a b i l i t i e s and d i s a b i l i t i e s This d e f i n i t i o n has been accepted by the Western Society f o r Reh a b i l i t a t i o n as the goal f o r i t s services* This d e f i n i t i o n implies several things. . F i r s t , i t implies that r e h a b i l i t a t i o n i s an integrated process. It i s a process which deals with four of the major components of the patient as a person. It i s concerned with his physical condition, his p o s i t i o n as a member of society, his mental outlook on l i f e , and his occupational placement. Secondly, i t implies that a patient may react to his new p o s i t i o n i n such a way that his outlook on l i f e may have to be altered before he can l i v e the - 2 -" f u l l e s t possible l i f e compatible with his a b i l i t i e s and d i s a b i l i t i e s " . . T h i r d l y , i t implies that the patient's p o s i t i o n i n society, or i n his family, may be altered as a r e s u l t of his physical d i s a b i l i t y . I t recognizes that i t may be necessary f o r a patient to change his occupation, i f he had one, or require s p e c i a l t r a i n i n g to give him a degree of economic independence. F i n a l l y , i t recognizes that the process of r e h a b i l i t a t i o n started i n a treatment centre can continue a f t e r the patient i s discharged. I t i s an attempt to prepare him, while he i s there, i n such a way that he may reach the ultimate goal of the r e h a b i l i t a t i o n process: a maximum l e v e l of functioning i n his home, at his work, and i n society* O r i g i n a l l y , the name of the Society was The Western Society f o r Physical R e h a b i l i t a t i o n , Ms t h e i r programme developed, and more of the non-physical aspects of r e h a b i l i t a t i o n were introduced, the word "physical" was dropped, because i t implied that the Centre was a medical centre, when, i n r e a l i t y , i t has become a centre f o r r e h a b i l i t a t i o n . In t h i s t h e s i s , preparing a person mentally i s taken to mean that, as a r e s u l t of face-to-face r e l a t i o n s h i p s i n his d a i l y l i f e , he may come to see himself as a member of society who i s functioning at his ma ximum capacity. He w i l l r e a l i z e , a l s o , that by so functioning, he i s f u l f i l l i n g h is o b l i g a t i o n to society. Preparing a person s o c i a l l y i s taken to mean that his ultimate placement w i l l not cause an unjust burden to be. - 3 -placed on his family, and that society w i l l accept him fo r what he has to o f f e r . This d e f i n i t i o n implies that a person who was ph y s i c a l l y well enough would not he discharged to his home i f his mental attitude was. such that the other members of the family might be adversely affected- Conversely, i f a person required nursing home care because of his physical condition, he would not necessarily be placed there i f his family could not accept such a plan. " A b i l i t i e s and d i s a b i l i t i e s " are taken as including the assets and l i a b i l i t i e s i n the patient physical condition, his mental outlook, and his s o c i a l and vocational p o s i t i o n . The GSroun to be Studied. The present study i s concerned with the r e h a b i l i t a t i o n of those patients who are c l a s s i f i e d as paraplegics and quadriplegics. Paraplegia i s the complete or p a r t i a l motor pa r a l y s i s of the lower extremities, or 1 of the lower part of the body . Quadriplegia involves a l l four extremities and the lower part of the body. There i s a complete or p a r t i a l l o s s of sensation i n the case of traumatic paraplegia and quadriplegia, including l i g h t touch, pain, heat, cold and v i b r a t i o n . At the same time, the i n t e r n a l organs, such as the bladder and bowels, may become p a r a l y t i c j and the skin, due to a lack of sensation and disturbed c i r c u l a t i o n , becomes l i a b l e to pressure sores. The causes of the paralysis are ei t h e r s p i n a l cord i n j u r i e s , or damage to the central nervous 1. GC\ingras, G* W ^ " M J 3 I W - J ? r m n f t h p P ^ 3 ? 1 ^ Patient", Treatment Service B u l l e t i n , Feb.1947, Vol*4, No. 2, p.5. system by virus attack. In this study, the patients who are paraplegic as a result of a disease have been stricken with poliomyelitis. They have been left with varying degrees of residual paralysis or weakness as a result. The fact that there are differences in the degree of the physical handicap will affect the ultimate placement of the patient. This thesis will not attempt to evaluate the success of the rehabilitation programme as i t has developed. It will be concerned with the degree of help the patient receives in adjusting mentally, socially and vocationally. Poliomyelitis. "Poliomyelitis is an acute viral disease, which, in its most characteristic form, Involves variousr parts of the central nervous system, particularly the motor neurons of the spinal cord, producing varying degrees of weakness and paralysis of the voluntary 1 muscles". In the majority of cases, "polio" is in a mild form, and does not show signs of central nervous system involvement in the upper respiratory or gastro-intestinal system. It is world-wide in its distribution, and there is evidence that shows i t existed over 5,000 years ago. It was f i r s t noted in a recognized medical record, t h a t was written in Sweden, in 1784- Apparently, polio existed for thousands of years without being 1. Harrison, T.R.(ed.) The Principles of Internal  Medicine. The Blakinstone Company, Toronto, 1950, p.1067. - 5 -recognized. Tbere are three factors which account for the delay in recognizing this disease. First, there are the recent advances in medical science, which emphasizes observation and recording. Secondly, until seventy years ago, there were few epidemics of polio. Doctors only had to deal with isolated cases. The epidemics have been increasing in the last seventy years, and the improved means of communication resulted in news of the epidemics being brought to a great many people. News of those epidemics which terrified sections of the United States , at the turn of the century was presented to the public by means of daily news reports. The third reason why polio was not recognized for such a long period of time, is because the epidemics are limited to the United States, Canada, Holland, Australia, New Zealand and the Scandinavian countries. There were, then, no records of epidemics in the writings of the ancient world. In 1937, in the city of Toronto, a serious epidemic of polio occurred. Special clinics were established to spray the nasal passages of 5,000 children. It had been found* by Dr^ Edwin Schultz that, by spraying 1 the nasal passages of monkeys with zinc sulphate , polio could be prevented. Although this stopped the virus in monkeys, i t did not in human beings. The control group of 5,000, was compared to 6,300 children who had not received 1. Berg, R.H. Polio and Its Problems. J.B. Lippincott Co., Montreal, 19A8, p*37* treatment. The difference between the attack rates in 1 the two groups did not exceed one per cent. The doctors knew that nerve cells are damaged by the polio virus. This knowledge led them to dispute the claims of Sister Kenny that polio was primarily a skin infection, which did not affect the 2 nerve cells. Few doctors disputed the value of her treatment. Unfortunately, some doctors did dismiss her approach entirely because of this error. The press tended to emphasize the disagreement between these doctors and Sister Kenny. In North America, the doctors followed the practice of English doctors, and immobilized the affected limbs. Instead of conserving the muscles, as was hoped for, i t too often resulted in the muscles withering from disuse. These results tended to create the impression, in the public's mind, that polio always left the patient a cripple. Possibly, the fight against the disabling aspects of polio which Franklin Delano Roosevelt waged has been the greatest source of inspiration to those people who have attempted to salvage the victims of polio. Here was a grown man, who was a victim of a disease commonly known as "infantile paralysis". Here, 1. Berg, R.H. Polio and Its Problems. J.B. Lippincott Co., Montreal, 194-8, p.43. 2. Ibid, p.126. also, was a man not p i t i e d for his d i s a b i l i t y , but respected for his ability. President Roosevelt was severely crippled by poliomyelitis. He was not particularly handicapped by i t . R. H. Berg reports that, "Of a l l the victims of poliomyelitis, fully f i f t y per cent of those who succumb to acute attacks will recover completely. They will show no trace of muscle weakness or loss of power. Of the.remaining f i f t y per cent, almost a half will recover, with, perhaps, just a trace of weakness or muscular paralysis. Of the remaining twenty-five per cent, from three to ten per cent will die. Thus, we have left about fifteen or twenty per cent of all.the acute cases who will be left with severe and permanent 1 paralysis. It is assumed that the percentages i n Canada will be about the same. The importance of this group i s , not because of its size in numbers, but because of the cost of hospital care, equipment, and retraining. In the f i r s t case to be presented later in this thesis, the hospital b i l l s from 1947 to 1951 nave 2 amounted to over $22,000. Case #4 shows that, by investing $3,500 in rehabilitation, the Welfare Department of British Columbia is expected to save $17,500 during this man's lifetime. These figures are not cited to illustrate that a rehabilitation programme is responsible for a saving of money, in contrast to the 1. Berg, R.H. Polio, p. 122. 2. Kinsmen Brief to British Columbia Hospital Insurance Service, 1951, p . l . - 8 -cost of maintenance where an inadequate programme existed. They show merely that the medical costs of caring f o r a severely disabled post p o l i o patient are great. So are the r e h a b i l i t a t i o n costs. Traumatic In.1urv to the Central Nervous System. World War I produced the f i r s t large number of paraplegics and quadriplegics who were paralyzed as a r e s u l t of i n j u r y . Few of them l i v e d long enough to reach a base h o s p i t a l , because.of the transportation d i f f i c u l t i e s . Of those who d i d , most died within a few years. Medical complications arose because of the long bed r e s t required. Pressure sores meant a loss of body f l u i d ; i n a b i l i t y to properly empty the bladder l e d to genito-urinary i n f e c t i o n s , and the long periods of l y i n g s t i l l led to the formation of c a l c u l i causing kidny i n f e c t i o n . Added to these dangers was the lessening of resistance due to 1 persistent ;and severe pain. During World War I I , the introduction of the a n t i b i o t i c drugs and the rapid evacuation to base hospitals meant that a f a r higher percentage of these men returned to Canada. The e f f o r t s to r e h a b i l i t a t e these -men has l e d to rapid advance i n si m i l a r programmes during the l a s t few years. Those who were injured as a r e s u l t of war service are being cared f o r by the Department of Veterans' A f f a i r s . The group studied are those who have been injured i n i n d u s t r i a l 1. Gingras, G. " R e h a b i l i t a t i o n of the Paraplegic Patient", Treatment Service B u l l e t i n . February 1947, Vol.11, No.2, p.2. accidents, at home, and at play. In the fight against poliomyelitis, effort on a national scale has teen concentrated on trying to control the disease. The rehabilitative aspects have been left largely to local groups. For traumatic paralysis, due to war injury, single governmental departments have been responsible for establishing a rehabilitative programme in North America. In the f i r s t instance, there was widespread public awareness of what the disease did. In the second, there was l i t t l e public knowledge, because the numbers were not large, but a single agency was faced with the problem of rehabilitating these men. What Rehabilitation Means In studying the development of a rehabilitation programme in Vancouver, emphasis must be placed on the degree to which those programmes are truly rehabilitative. Rehabilitation is not a method of doing 1 something , that is, "a system of procedure or conscious regularity", as "method" is defined in the Oxford dictionary. It is a "phenomenon which shows a continuous change in time, whether slow or rapid". It is not what is done for a person, but what is offered to a person for his own use. Because each patient reacts as an individual to his disability, rehabilitation is an individualized process. The degree of his reaction to his disability, plus society's reaction and his family 's reaction to that 1. Hamilton, K» Counseling the Handicapped in the Rehabilitation Process. The Ronald Press Company, gewYork, 1947, p.63v - 1 0 -d i s a b i l i t y , determines the extent to which he i s handicapped. A* man who can no longer support his family may f e e l completely worthless i f providing f o r his family was his way of showing his love f o r them. For such a person, i l l n e s s could have great s o c i a l i m plications. Deafness might w e l l mean the end of a career f o r a musician, yet i t could be a blessing to a r i v e t e r i n a b o i l e r f a c t o r y . D i s a b i l i t i e s ^ then, could force a person to seek new employment, or could permit him to carry on as before. Paraplegia might be a s l i g h t handicap to an accountant, who could resume his former job without suffering any loss of "status" or income. Paraplegia could cause great anxiety to a logger, who lacked the education f o r a sedentary job; a job which could weH mean a lower standard of l i v i n g f o r his fa m i l y . The Patient. Permanent d i s a b i l i t y i n v a r i a b l y produces dependency, whether temporary or permanent. For a paraplegic or a quadriplegic patient, "recovery" i s a 1 matter of adjustment to the d i s a b i l i t y . There i s no "cure". The patient i s dependent, at f i r s t , on the doctor to save his l i f e . Later, he depends on the doctor to restore his physical a b i l i t y to the highest possible l e v e l . Seldom can he pay the hos p i t a l b i l l s , and often his family must seek f i n a n c i a l help. For a long time, he i s completely dependent on those around him. He i s bathed, 1 . Hamilton, K . R e h a b i l i t a t i o n , p.4 9 -- 11 -shaved, fed, turned In bed, and requires help i n order to eliminate .body waste. He cannot plan f o r the future without help. He depends l a r g e l y on the knowledge others have of the community i n order to s t a r t making those plans. Yet, somehow, he must not lose his desire to be an independent person. Confidence i n his own a b i l i t y must be maintained. This can seldom be achieved unless those around him, those who are helping him, see him as an i n d i v i d u a l . Knowledge of the patient comes from the nurses 1 observations of him from day to day; information gathered by the S o c i a l Service Department of his previous l i f e and his place i n his family; information gathered by his vocational counsellor, and from the findings of psychometric tests i f they are needed. In a hos p i t a l s e t t i n g , about the only thing which i s not done f o r him i s h i s thinking. It i s influenced by both his past and the present. The way i n which he reacts may not seem at a l l i n t e l l i g e n t . He may be rude and extremely c r i t i c a l of those who are tr y i n g to help him. He may blame his i l l n e s s f o r t h i s , whereas, i n r e a l i t y , i t i s his fear of being discharged i n t o a fr i e n d l e s s world as a c r i p p l e . This fear may make him r e j e c t a l l e f f o r t s towards independency. The Frame of Reference f o r R e h a b i l i t a t i o n . No matter how a paraplegic or quadriplegic patient reacts to his d i s a b i l i t y , he could never j o i n the army as a s o l d i e r , because of his physical diagnosis. No matter how s l i g h t h is physical d i s a b i l i t y , he could never - 12 -be independent unless he wanted to; nor could he be employed on a competitive basis i f he did not have s u f f i c i e n t t r a i n i n g to do the job; nor could he be employed regardless of his physical d i s a b i l i t y , h is re a c t i o n to i t , or his vocational t r a i n i n g , i f there was no job i n the community fo r him. His d i s a b i l i t y w i l l i n v a r i a b l y create c e r t a i n handicaps f o r him. Hamilton has defined a handicap as "the cumulative r e s u l t of the obstacles which d i s a b i l i t y interposes between the 1 i n d i v i d u a l and his maximum fun c t i o n a l l e v e l " . The goal of r e h a b i l i t a t i o n i s , therefore, focused on the patient 2 and his handicap, and not on his d i s a b i l i t y . Armed with the knowledge he has about the patient as a person, each member of the r e h a b i l i t a t i o n team uses his own p a r t i c u l a r s k i l l s to help the patient help himself. In a phrase, i t .3 i s applied casework. Because his handicap i s i n a single u n i t , the patient, the r e h a b i l i t a t i o n process must be ... co-ordinated. It i s not possible f o r one s p e c i a l i s t , t o work with his d i s a b i l i t y , and when that i s done, f o r another to work with his family, at which time yet another steps i n to remove In h i b i t i n g reactions from his thoughts, and he, i n turn, signals the s t a r t of the vocational r e t r a i n i n g * I t i s his body that i s crippled, his family that s u f f e r s , his 1. Hamilton. R e h a b i l i t a t i o n , p.17. 2. Ibid, p.19. 3. Ibid, p.8. - 13 -place i n society and industry that has changed. Co-ordination between the various d i s c i p l i n e s i s necessary, because one diagnosis alone seldom constitutes the r e h a b i l i t a t i o n diagnosis. The r e h a b i l i t a t i o n diagnosis i s compiled from the p h y s i c a l , 1 s o c i a l , mental and vocational diagnoses. The r e h a b i l i t a t i o n process should s t a r t as soon as poss i b l e . This i s apparent when we r e a l i z e that the physical or medical diagnosis i s part of the, t o t a l process. There Is no set time f o r the other aspects of the process to be introduced, because ... r e h a b i l i t a t i o n i s so i n d i v i d u a l i z e d - Hamilton states that i t should begin at the time of recognition of any permanent d i s a b i l i t y that w i l l constitute a handicap. This d e f i n i t i o n does not l i m i t " d i s a b i l i t y " to "physical d i s a b i l i t y " alone- Dr. G. Gingras, Director of Physical Medicine at Queen Mary's Veterans' Hospital, Montreal, has stated that the paraplegic r e h a b i l i t a t i o n programme, which took two years under the "salvage" or "case f i n d i n g " method, can now be achieved i n four months where the f a c i l i t i e s f o r preventing the "deterioration" of the 2 patient as a person are brought into play at once. How have the various aspects of r e h a b i l i t a t i o n , as outlined above, been met i n the 1. Hamilton, R e h a b i l i t a t i o n , p.8. 2. Letourneau, C.U. R e h a b i l i t a t i n g the Handicapped. The R e h a b i l i t a t i o n Society f o r Cripples, Montreal, 1951, p.L4 r development of the r e h a h i l i t a t i o n programme f o r paraplegic and quadriplegic patients i n Vancouver? In order to examine t h i s programme, i t w i l l be divided into two major headings- The f i r s t includes the.resources, and the second, the process- The resources, public and private, w i l l be studied i n order to determine why they originated and what services they o f f e r e d . Added to t h i s survey of resources w i l l be i l l u s t r a t i v e cases, which w i l l t r y t o show why changes i n the concept of r e h a b i l i t a t i o n as each new resource was created, or an ex i s t i n g one al t e r e d i t s p o l i c y . There i s l i t t l e w r i t t e n material concerning the o r i g i n and function of the agencies. The information has been l a r g e l y gathered through a series of interviews with personnel of each agency discussed. The "cases" used are taken from the f i l e s of the S o c i a l Service Department of the Vancouver General H o s p i t a l . The information . obtained from there i s supplemented through interviews with various personnel, such as occupational t h e r a p i s t s , the physiotherapists, placement o f f i c e r s from d i f f e r e n t agencies, and r e h a b i l i t a t i o n o f f i c e r s . C h a p t e r 2. THE DEVELOPMENT AND THE PROGRAMME PRIOR TO JANUARY. 19A9-The Vancouver General Hospital was founded in 1902, as a voluntary, non-profit institution. It operates as an "open" hospital; this means, in part, that i t accepts a l l people who are in need of acute medical care. It undertakes the treatment of infectious diseases, and its services are available regardless of a person's race, colour, creed, or ability to pay. The cost of this free service was met, until 1949, by grants from the City of Vancouver and the Provincial Government, though these-grants have been discontinued since the inauguration of the British Columbia Hospital Insurance Scheme, except for the work of the Out-Patients' Department* Free service of this nature is not for indigent people only. It is also available i f there is evidence that the responsibility for meeting the hospital b i l l s will prove to be too great a burden for the patient or his family. Ah example of this policy was seen in the record of Alan, discussed in a later chapter. Alan's father was earning approximately $250.00 per month. He owned his own home, and was buying a car. There was only one other child in </; -c. the family. Alan had contracted poliomyelitis ten years earlier, and was left with some paralysis of one leg. It was apparent that the many small medical b i l l s this family had been faced with during the last ten years had made i t impossible for them to save any money. Because of this, and their apparent willingness to pay what they could towards his retraining at the Western Society for Rehabilitation, he was taken on as a staff-non-pay patient. This meant that he would get free hospital and doctors1 care for the remainder of his stay, and the hospital would absorb his b i l l , which was over $2,000. Vancouver Occupational Industries. The so-called Vancouver Occupational Industries was started in 1930 as an auxiliary service for the hospital patients. The purpose i t was to serve was two-fold; to provide the long-term patients with a means of occupying their enforced idleness usefully, and to give them some occupational training. As its programme developed, a plan for paying wages to the.trainees was instituted, and a committee was formed later to help the trainees secure employment. One of the qualifying criteria for retraining was that the patient had to be indigent. By 1939,-its policy had altered, and i t was then functioning as a convalescent workshop. Its aims were to retrain those patients who were forced, because of illness, to change their occupation, and- to build up "work tolerance", so that the patients would be better prepared for work elsewhere. This agency was not able to operate effectively, because the applicants were not screened carefully enough before they were accepted for training at the workshop. It tended to become a place of permanent -1-7 - , . employment for people who could never work in a competitive market. Added to the problem of having too low a rate of turn-over, was the inability to obtain well-trained instructors during the war-time prosperity who would work for $100 per month. In 1945, twenty-seven disabled people, who showed no signs of ever being able to work in a competitive market, were laid off because the agency could not afford to pay them their maintenance of $28 per month. Later in the same year, the agency ceased to exist, because i t was losing money. The faults of its programme were; improper screening, no periodical examination of its programme, and the belief that i t could be self-supporting when i t was only open to disabled indigents. From the time that the Vancouver Occupational Industries closed, until the 1st of September, 1947, there were no occupational therapy or handicrafts taught to the patients. For most of the patients, this was of l i t t l e consequence, for they w$re not in the hospital long. For the paraplegic and quadriplegic patients, this was important, for they spent months, and often years, in the hospital. In 1947, the paraplegic and quadriplegic patients were on Ward West 3 of the SemiPrivate Pavilion. While there, they had the services of a well-organized, industrious Women's Auxiliary. The Auxiliary provided such services as letter writing, reading to people who could not hold books, running the library, making purchases for the patients, and many other small but important jobs. On the 1st of September, 194-7, Miss E. Gait, a graduate in Arts and Crafts from St. Anne de Bellevue Military Hospital, was added to the hospital staff. She was to work primarily with the paraplegics and quadriplegics. Her duties were to be directed to "getting the patients in a receptive mind so they would accept further rehabilitation". In teaching leatherwork, weaving, moulding, etc., no emphasis was placed on output. The work was to stimulate their, interests and to provide a diversion from the dull daily routine of the hospital ward". In 194-8, i t was decided to move the paraplegic and quadriplegic patients from the Semi-Private Pavilion to the third floor of the Infectious Diseases Hospital (IDH3), and Miss Gait moved with them. The Women's Auxiliary, however, did not. They did not know that Ward IDH3 was a non-infectious ward, and evidently no-one bothered to t e l l them; consequently, there was no-one to look after the library, run the canteen wagon, write letters, look after the bank accounts of quadriplegics, read to them, or do their personal shopping. Miss Gait undertook these duties, along with her other ones. In addition to these jobs, she has also developed others; she arranges for the annual outing to the Hobby Show at the Pacific National Exhibition, arranges for a "movie" to be shown on the ward every two weeks, and helps the physiotherapists make devices so that patients can feed themselves. In addition to this, she arranges dinner - 1 9 -p a r t i e s In her room. In t h i s work, she has the close co-operation of the D i e t e t i c Department, who a l s o recognize that these parties help the patients to overcome t h e i r self-consciousness r e s u l t i n g from t h e i r awkward eating habits, and a l s o provide a type of s o c i a l contact which i s over and above the ward contact. (Many of the patients are i n private rooms). S t i l l another s o c i a l a f f a i r she arranges i s the monthly birthday party. This i s sponsored by the Mount Pleasant Branch of the Canadian Legion (117) , and i s held once a month. F r u i t and cigarettes are provided t o a l l the patients, and also a birthday cake, which i s inscribed with the names of a l l the patients having birthdays i n that month. The patients whose birthdays are i n that month gather around the table i n the occupational therapy room, and hold a j o i n t birthday party. Later, a piece of cake i s given t o each patient on the ward. The work done by Miss Gait c e r t a i n l y r e l i e v e s much of the monotony f o r the patients, and i l l u s t r a t e s the great number of services required, apart from the nursing and medical care, to get the patients i n a receptive mind to accept further r e h a b i l i t a t i o n . On the ward, she has the close co-operation of the nurses, aides and o r d e r l i e s , but, because t h e i r duties take up so much of t h e i r time, they cannot help to the extent they would l i k e t o . Many of the patients need to be l i f t e d , turned, bathed and fed by the s t a f f . Because of t h i s , the s t a f f ' s work i s harder than on most of the other hospital wards. This leads to a f a i r l y high turnover i n staff, particularly i n the case of orderlies. Many of them do not stay on the ward long enough to become a part of Hiss Gait's programme. There i s , however, one group of patients for which very l i t t l e i s done. This is the group of infants who are recovering from poliomyelitis. These children do not f a l l within the scope of this thesis, but i t i s obvious that the nurses, orderlies and nurses' aides cannot spend time playing with these children. Unless the Women's Auxiliary is asked to provide some sort of nursery play-time for them, these children w i l l continue to s i t i n their cribs day after day-The role of the Social Service Department i n the Vancouver General Hospital i s now quite different from what i t was ten years ago. Originally, i t s function was that of a placement agency. The chief task was to arrange for nursing home or boarding home placements for those patients who no longer required acute medical care. Another job i t performed was that of arranging for the purchase of appliances for patients who could not pay for them. The social workers would find out the legal residence of the patients, as defined i n the Residence and Responsibilities Act. They would then write to the Welfare Department i n the responsible community and ask them to assume their share of the cost. This procedure did not take as long as might be Imagined, for, under the Hospitals Act, such letters must be replied to within fourteen days. Unfortunately, the role of the S o c i a l Service Department on Ward 3DH3 was l a r g e l y r e s t r i c t e d to such d u t i e s . A's the s t a f f of the S o c i a l Service Department increased, some casework was done on an intensive basis, but the major po r t i o n of the work i s the routine type described above. The other major area i n which the Department works i s that of t r y i n g to in t e r e s t various agencies i n the community to obtain, or provide, better f a c i l i t i e s f o r the patients a f t e r t h e i r discharge. This has been done by interpreting to the agencies, or friends and r e l a t i v e s of patients, the needs of patients a f t e r discharge, or through s p e c i f i c requests on behalf of an i n d i v i d u a l p a t i e n t . The Department has attempted to interpret h o s p i t a l routines to interested people, and indicate to them how they can be of help t o the patients during and a f t e r t h e i r period of h o s p i t a l i z a t i o n . P r o v i n c i a l Welfare Services. Under the terms of the "Soc i a l Assistance Act", assistance may be given i n money or i n "kind!!. Section 'C* l i s t s i n s t i t u t i o n a l , nursing, boarding or fo s t e r home caije as "kind". Sections 'E* and fF» l i s t counselling services and Health Services. Section *G! of t h i s i n t e r p r e t a t i o n of the Act i s of p a r t i c u l a r i n t e r e s t to the present study, f o r i t l i s t s , "occupational t r a i n i n g , r e t r a i n i n g , or therapy f o r indigent persons and mentally or p h y s i c a l l y handicapped persons". P h y s i c a l l y handicapped, persons were not given occupational t r a i n i n g or r e t r a i n i n g under t h i s Act. "22 " What was given was the payment of S o c i a l Allowance to unemployable persons and t h e i r dependents, and the pr o v i s i o n of nursing-home and boarding-home care- The cost for thi s care was met j o i n t l y by the P r o v i n c i a l Government (80$) and the responsible municipality (20$). The Residence and Resp o n s i b i l i t y Act sets out the conditions under which a municipality i s responsible f o r the care of i t s residents. The cost of t h i s care, as i t comes within the S o c i a l Allowance Act, i s not the same as the per diem rate which i s charged against a municipality under the Hospitals Act. The P r o v i n c i a l Government was not attempting to restore working capacities; i t was providing assistance to people who appeared to be c h r o n i c a l l y incapacitated. Workmen*_s Compensation Board. The f i r s t Workmen1 s Compensation Act was passed i n 1902. The Act, which came into e f f e c t at that time, gave a workman, who was injured "in any accident a r i s i n g out of and i n the course of his employment", the r i g h t to sue his, employer f o r damages i f his i n j u r y was caused by the personal negligence or w i l f u l act of the employer. In 1916, th i s unsatisfactory Act was repealed, and replaced by a new Compensation Act, which created the Workmen's Compensation Board. This Board was charged with assessing the cost of the burden of accidents on the in d u s t r i e s , and at the same time i t was to inspect and regulate accident-prevent ion equipment. The function of the Workmen's Compensation Act was two-fold; to provide insurance, and to prevent accidents. In the Sloan Report of 194-2, a further idea was incorporated; that of "23 -r e h a b i l i t a t i o n . The argument used for broadening the programme from one of a mere system of insurance, to include r e h a b i l i t a t i o n , was that accident prevention was not s t r i c t l y a part of an insurance programme, and i t formed a large part of the Board's work. The report states that "everyone probably would agree that prevention i s better than cure, and cure i s better than compensation. Therefore, when prevention f a i l s to prevent, we must give a t t e n t i o n to cure". The Workmen1 s Compensation Act protects the worker against having to work with unsafe machinery. It provides him with a pension i n the event that he i s permanently disabled. Through i t s p o l i c y of paying a worker f o r his d i s a b i l i t y and not f o r the r e s u l t i n g handicap, even following r e h a b i l i t a t i o n , the Act offers s e c u r i t y . The r e h a b i l i t a t i o n services offered to him give him an incentive towards bettering his f i n a n c i a l p o s i t i o n . They are not given as an uncertain a l t e r n a t i v e to the s e c u r i t y of a f i x e d income. A r e h a b i l i t a t i o n section on these l i n e s was added to the Workmen's Compensation Board i n March, 1943. This section must work within a yearly budget of $75,000, and i t s services are open only to those who suffer permanent p a r t i a l impairment, which prevents them from returning to t h e i r former occupations. They are e l i g i b l e f o r r e t r a i n i n g , providing t h e i r i n j u r i e s resulted from accidents occurring on or subsequent to March 18th, 1943. I t i s expected that the Sloan Report, now before the l e g i s l a t u r e , w i l l s u b s t a n t i a l l y Increase their budget. T h e r e l m r . e s i x r e h a b i l i t a t i o n o f f i c e r s . employed by the Workmen's Compensation Board. Their function i s to see that the injured workmen get,the services they require i n order to be r e h a b i l i t a t e d . Their work i s c h i e f l y that of co-ordination and counselling. .Close co-operation between the r e h a b i l i t a t i o n section and the various agencies i n the community i s e s s e n t i a l . Use i s made of such agencies as the S o c i a l Service Department of the Vancouver General Hospital; the Rotary Counselling Service; the f a c i l i t i e s at the Western Society f o r R e h a b i l i t a t i o n , the Vancouver Vocational I n s t i t u t e , and correspondence courses from the Department of Education i n V i c t o r i a , To f a c i l i t a t e t h i s close co-ordination, they work c l o s e l y with each of the larger h o s p i t a l s . One i s stationed i n V i c t o r i a to serve a l l Vancouver Island claimants, and another i s stationed at the "Board's" physiotherapy department on Second Avenue. . The Board does not provide casework help, but r e l i e s on various agencies i n the community to o f f e r t h i s service i f i t i s thought to be needed. This help cannot always be provided to the degree required, because the e f f o r t s of the r e h a b i l i t a t i o n o f f i c e r and the s o c i a l workers cannot always be e f f e c t i v e l y integrated. In the present programme of r e h a b i l i t a t i o n offered by the Compensation Board, one aspect of r e h a b i l i t a t i o n i s , consequently, l a r g e l y neglected. That aspect i s the s o c i a l implications the i l l n e s s has f o r the p a t i e n t . In 1945, two more organizations were added to the programme. These were the Kinsmen's C h a r i t i e s and the Canadian Paraplegic Association, Both are interested i n obtaining the best, possible care f o r paraplegic patients. One worked to unify the services In the various communities and the other to extend the speci a l i z e d services of the Department of Veterans 1 A f f a i r s , Kinsmen Clubs, During World War I I , the number of Kinsmen Clubs In Canada had increased i n number by 75$, During t h i s time, they were a l l engaged i n a united e f f o r t j the Milk f o r B r i t a i n Fund, In 194-5, following the end of the war, t h i s work stopped, and the Kinsmen's Club of Vancouver decided that they would survey the welfare programmes ex i s t i n g i n the Province, to see what services they could best provide. They found that, with p o l i o patients, the incidence i s low, approximately 1/lOth of Ifo of the population, (In B r i t i s h Columbia, this amounts to f i f t y cases per year, although about every ten years the number runs up to about two hundred cases) , I t did not appear that the costs would be too great, f o r they would be augmenting the services which were a v a i l a b l e . Their survey showed that nothing was being done i n the Province to r e h a b i l i t a t e ..people with r e s i d u a l p a r a l y s i s r e s u l t i n g from p o l i o , except to provide medical and hospital treatment. I t demonstrated a shortage of funds, a lack of equipment, and a lack of trained s t a f f . Physical retraining was being done at the Physical Medicine Department of the Vancouver General Hospital only. This survey, which was financed by the Kinsmen, and made by Dr. Alan Brown of Toronto, recommended that a programme of assistance to residual paralysis polio patients be considered. In planning such a programme, Dr. G. F. Strong asked the Kinsmen to join in the establishment of a centre to provide such services, and this was considered by the Club. From 1945 to 194-8, the Kinsmen's Club of Vancouver raised $69,000. A l l of this was spent,on equipment, such as wheel chairs and braces for the patients, as requested by doctors; for vocational training, as requested by the Social Service Department of the Vancouver General Hospital; and on the training of three physiotherapists. These physiotherapists were to work at the Vancouver General Hospital for three years in return for their training. Through one of their members, who is a doctor, the Kinsmen gained the co-operation of the Vancouver General Hospital. A Polio Board of doctors was created, and each polio suspect was cared for by a member of this Board. This arrangement tends to greatly reduce the size of doctors' b i l l s for the patients. It Is interesting to note that the Kinsmen do hot use the appeal of a crippled child in their money-raising drives. Their scrap-book of newspaper publicity f o r the l a s t two years shows only four a r t i c l e s and pictures about c h i l d r e n . It i s not a fund to combat " I n f a n t i l e p a r a l y s i s " , as i t i s i n the United States. It i s an appeal to r a i s e money f o r a cause which they consider w i l l be supported because of i t s inherent merit, and does not need to depend on an emotional basis f o r success. Their p r i n c i p a l means of r a i s i n g money i s through a mail. . subscription campaign. Separate from t h i s campaign are the many l o c a l campaigns which attempt to r a i s e ten cents per wage earner i n the community. This i s done by tag days, dances, Sunday shows, bo t t l e d r i v e s , small r a f f l e s , d i s p l a y windows with c o l l e c t i o n cans, whist drives, and various other schemes. In a l l of these e f f o r t s , the advertisements concentrate on the aspect of rehabilitation;. r e h a b i l i t a t i o n which i s f o r society's benefit, not just an act of p i t y . Canadian Paraplegic Association. The Canadian Paraplegic Association was founded i n 1945. O r i g i n a l l y , i t was comprised s o l e l y of veterans, but, as-; soon as i t was founded, the members voted to undertake to extend the achievements of the Department of Veterans' programme to c i v i l i a n s . Through s o l i c i t i n g membership from interested people, i t undertook to finance c i v i l i a n paraplegics i n the Department of Veterans' A f f a i r s Hospitals, on a repayment b a s i s . As the veterans were r e h a b i l i t a t e d , and moved out into the community, more non-veterans were brought i n , u n t i l eventually they out-numbered the veterans. Lindhurst Lodge, i n Toronto, which had o r i g i n a l l y been given to the Department of Veterans' A f f a i r s , to be used as a r e h a b i l i t a t i o n centre, was made over as a g i f t , f or a nominal $ 1 , to the Canadian Paraplegic Association, The Western D i v i s i o n of the Association was being formed at the same time as the Western Society, As i t was expected to be easier to raise funds f o r a l o c a l society than f o r a national association, the Western D i v i s i o n of the Paraplegic Association did not continue i t s organizational d r i v e . It agreed to a i d i n the formation of the Western Society and has continued to give active support to the Society. The ^Walking School". In 194-6, another step towards the establishment of a r e h a b i l i t a t i o n centre was taken when a walking school of the orthopaedically disabled was formed. This School was run by Martin Berry, a s p e c i a l i s t who ran a sim i l a r school i n C a l i f o r n i a . He used the f a c i l i t i e s of the Department of Physical Medicine at the Vancouver General Hospital* It functioned as a physical r e t r a i n i n g centre only. Most of the paraplegics who attended these lessons were financed by the Workmen's Compensation Board. This i s i n keeping with t h e i r p o l i c y of u t i l i z i n g a l l e x i s t i n g resources i n the community to r e h a b i l i t a t e a worker. Those p o l i o patients who could not pay for t h e i r own t r a i n i n g or equipment were financed by the Kinsmen Club. As well as the private patients, those financed by the Kinsmen Club, and those financed by the Workmen's Compensation Board, there were a small number of non-pay patients instructed. The programme at this time needed to be revised. First, the facilities were overcrowded. Secondly, the programme lacked unity. The Walking School was using the facilities of the General Hospital, but i t did not come under the Hospital's jurisdiction. Use was being made of the Hospital's Social Service Department for a few of the patients. Patients were being financed by the Kinsmen's Club and the Workmen's Compensation Board. There is no evidence available which would indicate that there was any co-ordination of effort. The school appeared, to be accepted by the agencies as a part of the hospital. However, because a great number of the referals came from outside sources, i t was important that there be close co-ordination between the 1 agencies. Apparently, this was never achieved. The Rehabilitation Process. What the rehabilitation programme offered to patients prior to January, 1949, can be illustrated by looking at the Social Service Department records of two patients. The f i r s t record used is that of Betty. j She was an attractive, twenty-year-old g i r l , who was stricken with polio in 1930. At that time, there was l i t t l e medical knowledge on how to repair the damage caused by the disease, or on how to utilize effectively what muscle power she had l e f t . Her record shows what could happen to any person who was severely disabled'by polio "twenty years ago. 1. The Head of the Hospital Social Service Department summed up its programme with the comment that, "It illustrated the need for the Western Society for Physical Rehabilitation". - 30;' ~ It also illustrates how various agencies were used, at f i r s t , in an unintegrated way, and later, in a co-ordinated effort, to rehabilitate this g i r l . She was admitted to hospital in 1930 and remained in hospital until January, 1938. While in hospital, she painted miniatures, copied from larger paintings, which she sold through the Vancouver Occupational Industries. She was removed to a nursing home, through arrangements with the City Social Service Department, in 1938. In 194-0, she was moved home, where she was cared for by a younger sister. She is described in the record as being extremely demanding of this sister. She stayed at home for five years. In 194-5, her sister was being married, and her husband refused to consider having this patient in their home. Apparently, her original discharge to the nursing home was arranged by her doctor, for the record shows no referal at that time. Her move home, and later to a City nursing home, was arranged for by the City Social Service Department, apparently. She was brought over to Mr. Berry's Walking Class to see i f she could benefit from i t . At the time, she was unable to dress herself, due to partial quadriplegia; she could not go to the toilet by herself, or get from her bed to a wheel-chair. It was judged that she would be able to learn to care for herself i f she attended the School, and so she was enrolled. The cost of transportation was paid for by the Hospital. A wheel-chair, a brace, and a drop-foot splint, were provided by the Kinsmen, on request of the doctors and the Social Service Department. The Women's Auxiliary, of the Hospital also provided a leg brace. On May 27th, 194-7, she was re-admitted to the Hospital, on the grounds that the competitive attitude on the ward would be better than l i f e in the nursing home. The Kinsmen financed an Art Course for her, at the request of her "board" doctor . The Social Service Department acted on behalf of the Kinsmen in arranging for accommodation for this course to be taught. Her Art instructor found that the g i r l was extremely good at painting miniatures, but felt that her long stay, in hospital had completely killed any creative ability she might have had. Her progress towards physical recovery was slow, but she continued to show fairly steady improvement. She stayed in hospital until January, 1952. The later years, of her stay are discussed in the next chapter. Case #2. This is the record of "Sadie". She was a thirty-year-old g i r l , who had been stricken with polio in 1938, whilst living on the prairies. She was living in Vancouver with her married brother at the time of her referal in September, 194-7. This record illustrates the confusion which arose between agencies during the time the Walking School was in use. It was arranged to have ber brought to the Walking School by taxi, but no-one had considered whether or not she could get into a taxi. She could not, and so i t was necessary to admit her to hospital in October, 194-7, in order that she might attend the School. The g i r l was referred to - 32 -the hospital by the Kinsmen's Club, and was referred to the Walking School by the City Social Service Department. She applied to the Kinsmen for $1,300, for treatment and three months1 hospitalization. This was granted. However, she was admitted by the hospital as a staff-non-pay patient, and It was only when the head nurse objected to her staying out overnight that the confusion as to who was paying for her treatment was eliminated. From 1938 to 194-7, she had been living with her married brother. She helped with the serving, and similar jobs, whilst sitting in her wheel-chair. She would get out of her wheel-chair onto her hands and knees, and scrub and wax the floors, although she was paralyzed from the waist down. Her progress at the Walking School was very good, and in February, 194-8, she was discharged to her brother's home. The City Social Service Department dontinued to pay for her transportation to the Walking School for the next few months. By this time, she was walking well with crutches and leg braces, and appeared to have reached her maximum physical recovery. She- was granted Social Allowance by the City, but that ended in October, 194-8, when the patient married. These two cases illustrate the- typical procedure followed prior to 194-9. In discussing these records with various staff members, the lack of co-ordination was very apparent. Questions on finances, discharge plans, -33 : ; -etc., were answered with, "I do not know who paid f o r i t " , or, "We were not consulted; I imagine i t was the C i t y " . The records on "Betty" indicate that, f o r seven years, she was ho s p i t a l i z e d , during which time she was "pampered by the s t a f f " and was known as "the sweetheart of the ward". This over-indulgence apparently l e d to her demanding attitude at home. The f i v e years she .spent at home well i l l u s t r a t e s the difference between placements; that i s , moving a patient out of the h o s p i t a l , and the type of planning which must be done i n a sound r e h a b i l i t a t i o n programme. Good r e h a b i l i t a t i o n demands that the family a l s o be considered. Family s o l i d a r i t y must not be jeopardized because of the assumption that patients would be happier at home. There i s no record i n either f i l e of conferences, which would indicate a r e h a b i l i t a t i o n diagnosis was formed. Procedure was not integrated. The programme could only be described as a medical treatment plan. It was not a r e h a b i l i t a t i o n programme, i n the f u l l e s t acceptable sense. The Founding of the Western Society f o r R e h a b i l i t a t i o n . In 194-7, Dr. F. G. Strong, who had arranged fo r Martin Berry to come from C a l i f o r n i a , c a l l e d a meeting of f i f t e e n interested people i n the community, to see i f i t was possible to obtain community support f o r the establishment of a r e h a b i l i t a t i o n centre. The plan was f o r a centre which would serve a l l severely orthopaedically disabled people. Two of the people at t h i s meeting were from the Kinsmen's Club. Dr. Strong explained, what he wanted, and i l l u s t r a t e d what the p o s s i b i l i t i e s of r e t r a i n i n g were, by showing motion pictures taken at Shaughnessy H o s p i t a l . Dr. Strong said that he could r a i s e the money for the i n i t i a l buildings, but that a b u i l d i n g alone was not enough. Mr. Percy White, of the Kinsmen's Club, said that i t was not wise to ask the subscribers f o r money without showing them what such a centre had to o f f e r . He suggested that, i f the land was..purchased, and information was c o l l e c t e d on what would be necessary, the subscribers would give t h e i r money more w i l l i n g l y . This plan was accepted, and the land was purchased by the Kinsmen's Club. The purpose of the programme was to be to extend the achievements of the Department of Veterans* A f f a i r s programme f o r paraplegics to c i v i l i a n s . Various committees were established to investigate the need for, such a centre, to plan the construction, t o r a i s e the money, and to study d i f f e r e n t programmes. The main sources of information were the Baruch Committee of Physical Medicine (Hew York) and the Department of Veterans' A f f a i r s . Building and programme plans were obtained, and these were altered to f i t l o c a l needs. Mr. E. Desjardin, who i s a paraplegic himself, supplied information about the Centres i n Winnipeg and Toronto. Some of the s t a f f of the centre were engaged before the centre was completed, and they also contributed t h e i r ideas. In the summer of 1948, construction of unit one of the centre was started, and on January 2nd, 1949* the centre was o f f i c i a l l y opened* I t provided accommodation f o r t h i r t e e n resident trainees and four resident s t a f f members. The f u l l - t i m e s t a f f t o t a l l e d s i x . It was being supported by the Federal and P r o v i n c i a l governments, the Kinsmen's Glub, i t s own Women's A u x i l i a r y , and the Western Branch of the Canadian Paraplegic Association, as well as private contributors. Chapter 3 . THE DEVELOPMENT AND THE PROGRAMME SINCE JANUARY. 194,9. The year 194-9 saw two important additions to the r e h a b i l i t a t i o n programme. One was the Western Society f o r Rehabilitation;, the other was the introduction of Hospital Insurance. The changes that occurred i n the programme with the introduction of Hospital Insurance were not many, but they had important economic and s o c i a l implications. Hospital Insurance applies generally only to those people who are c l a s s i f i e d as acute medical cases. Under the o r i g i n a l r u l i n g , a p o l i o patient was said to be acutely i l l f o r only two weeks.. If his doctors reported that he required further hospital care, the benefits were usually extended; i f his benefits were extended, the patient was no longer permitted to..go home f o r the weekend. To do so, he would have to be discharged from the h o s p i t a l . I f a patient was well enough to go home f o r the weekend, then i t was argued that he was not "acutely" i l l , and h o s p i t a l payments were stopped. On September 6th, 1951, the B.C. P o l i o Fund submitted to b r i e f to the B r i t i s h Columbia Hospital Insurance Inquiry Commission. The b r i e f was incorporated i n t o the Commission's report i n i t s e n t i r e t y , and, as a r e s u l t , p o l i o patients are now e n t i t l e d to benefits for a minimum period of three months. This period can be extended, as i t was under the previous arrangement. o - 37-T h e r e a r e f o u r economic i m p l i c a t i o n s a r i s i n g o u t o f the a d m i n i s t r a t i o n o f t h e H o s p i t a l I n s u r a n c e scheme- P r i o r t o i t s i n t r o d u c t i o n , the Kinsmen had p a i d -some o f t h e h o s p i t a l h i l l s f o r t h e p o l i o p a t i e n t s - The r e c o r d o f " S a d i e " shows t h a t t h e s e c o s t s c a n . b e g r e a t - I n t h e o r y , e v e r y p a t i e n t would be e n t i t l e d t o H o s p i t a l I n s u r a n c e b e n e f i t s , f o r i t i s a u n i v e r s a l c o m p u l s o r y s c h e m e , b u t , a c c o r d i n g t o the T r e a s u r e r ' s R e p o r t o f the 4 9 t h A n n u a l R e p o r t o f the V a n c o u v e r G e n e r a l H o s p i t a l , f o r 1950, " o f . t h e more t h a n 3 2 , 6 0 0 p a t i e n t s a d m i t t e d t o the h o s p i t a l i n 1950, some 17.2$ o f t h o s e a d m i t t e d d i d n o t have h o s p i t a l I n s u r a n c e c o v e r a g e . T h i s p l a c e d a s e r i o u s b u r d e n o n t h e h o s p i t a l ' s f i n a n c e s , f o r t h e h o s p i t a l does n o t r e f u s e a d m i s s i o n t o anyone i n need o f a c u t e m e d i c a l c a r e . " T h i s f r e e work done b y t h e h o s p i t a l c a n n o t be i n c l u d e d i n t h e d a i l y r a t e s ' c h a r g e d . To a g g r a v a t e t h i s s i t u a t i o n f u r t h e r , t h e f i n a n c i a l g r a n t s o b t a i n e d f r o m the P r o v i n c e and the C i t y o f V a n c o u v e r were d i s c o n t i n u e d when H o s p i t a l I n s u r a n c e came i n t o e f f e c t , e x c e p t f o r o u t - p a t i e n t s ' s e r v i c e s . The economic p o s i t i o n o f t h e h o s p i t a l i s worse t h a n I t was b e f o r e h o s p i t a l i n s u r a n c e was i n t r o d u c e d , b e c a u s e o f t h e s e r v i c e s i t e x t e n d s t o s t a f f - n o n - p a y p a t i e n t s . The B r i t i s h C o l u m b i a P o l i o F u n d , w h i c h c o n s i s t s o f f o r t y - f o u r K i n s m e n ' s Committees and f o u r o t h e r c o m m i t t e e s , f o u n d t h a t about t h i r t y p e r c e n t o f the p o l i o p a t i e n t s were n o t c o v e r e d under t h e h o s p i t a l I n s u r a n c e scheme. They u n d e r t o o k t o pay t h e i n s u r a n c e premiums f o r 3 8 " those p o l i o patients who are not e n t i t l e d to insurance benefits- Their concern was l a r g e l y f o r the c h i l d r e n whose parents had not provided insurance f o r them- They believed that the argument put forward by the Board of P o l i o doctors, i - e - , that i t was a person's moral o b l i g a t i o n to pay his premiums, was not suff icient».to meet the case- They would not accept the implication that a c h i l d might be denied necessary treatment because i t s father had not met his obligations-There i s yet another economic e f f e c t of the hospital insurance administration- When a patient i s ruled to be no longer e l i g i b l e for hospital insurance, he or his family i s n o t i f i e d to that e f f e c t - Unfortunately, several months may elapse between the time that a patient i s no longer covered by the insurance plan, and the time he i s n o t i f i e d - His f i r s t i n k l i n g of the s i t u a t i o n may well be a s o c i a l worker's v i s i t to discuss finances- The anger which i s aroused by the r u l i n g i s often intensified by the delay i n n o t i f i c a t i o n - The knowledge that he has been ruled to be no longer acutely i l l i s not as disturbing to the patient as the f a c t that he owes the h o s p i t a l several hundred d o l l a r s - Nor i s i t as disturbing as the implication that his condition has been c l a s s i f i e d as chronic by a person who has never seen him-The Western Society for R e h a b i l i t a t i o n . The opening of the R e h a b i l i t a t i o n Centre eliminated the need f o r the Walking School- To avoid a d u p l i c a t i o n of e f f o r t and services, the Western D i v i s i o n of - 39 -the Canadian Paraplegic Association became i n a c t i v e . Their advice and help are s t i l l a v a i l a b l e , as they s t i l l f u n c t i o n i n an advisory capacity, and hold t h e i r meetings i n the R e h a b i l i t a t i o n Centre- This arrangement has the e f f e c t of keeping th e i r association membership functioning- By so doing, i t tends to maintain the interest of the people who were o r i g i n a l l y attracted to i t - Because the p o l i c y of the society has been directed towards giving service to a l l orthopaedically disabled persons, other organizations s i m i l a r to the Paraplegic A s s o c i a t i o n have been asked to e s t a b l i s h t h e i r office's, at the Centre. The Cerebral Palsy Association of B r i t i s h Columbia have their o f f i c e s and treatment rooms at the R e h a b i l i t a t i o n Centre. The B r i t i s h Columbia D i v i s i o n of the Canadian A r t h r i t i c - a n d Rheumatism Society a l s o have their medical branch there, and use the pools, tanks and r e s i d e n t i a l accommodation.. Apart from avoiding a d u p l i c a t i o n of services, t h i s arrangement offers an excellent opportunity to increase the number of community contacts. People who are interested i n the A r t h r i t i c Society, those who are interested i n the Cerebral Palsy Association, and those interested i n the Paraplegic Association, could be t o l d of the broader needs of any r e h a b i l i t a t i o n programme. Their tasks might then a l t e r from fund-raising f o r t h e i r p a r t i c u l a r organization, to taking an active part i n an o v e r a l l r e h a b i l i t a t i o n programme. Their r o l e i n that programme would be one which would consolidate community a c t i v i t y . At the time of w r i t i n g , three of these groups are co-ordinated i n some areas. There i s a medical advisory board, comprised of doctors from each group. There i s also the close co-ordination between the s t a f f , f o r both the A r t h r i t i c Society and the Cerebral Palsy Association pay f o r the use of the equipment. Co-ordination amongst the s t a f f Is achieved through t h e i r working together and, more formally, through weekly case conferences. These conferences, which are chaired by the Medical Director, are attended by the physiotherapists, the physical t r a i n i n g i n s t r u c t o r , the brace-maker, and the s o c i a l worker-placement o f f i c e r . The patients' progress i s discussed, and each team member presents his point of view about needed changes. Unit One of the R e h a b i l i t a t i o n Centre Khas accommodation f o r t h i r t e e n resident trainees. A l l resident trainees must be capable of s e l f - c a r e , which means they must be able to dress, get i n and out of bed, feed themselves, and go to the bathroom themselves. These requirements are not as d i f f i c u l t to meet as they might appear, because the building i s designed for people i n wheel-chairs. The wash-basins are low, as are the coat-hangers and l i g h t switches. The rooms are a l l designed so that the trainees can navigate around e a s i l y i n the wheel-c h a i r s . The beds, the t o i l e t s and the showers are equipped with bars, which enable the trainees to p u l l themselves out of t h e i r wheel-chairs. The other group of trainees are the non-res i d e n t s . They usually come to the R e h a b i l i t a t i o n Centre f o r a part of each day. Usually, they are brought to and from the Centre in the ear which has been provided by the British Columbia government, and is maintained by the Women's Auxiliary. Each trainee is brought to the Centre on a three-months t r i a l basis, and at the end of that time, his progress is evaluated, and he is either discharged, or his training period is extended. A person will be discharged as a result of not having shown any physical improvement, for i t is judged that he will not benefit from further treatment, and is no longer a suitable candidate for the Centre. The limited space and staff makes i t imperative to enrol only those people who can be assisted. Even with careful screening, i t became obvious that the fac i l i t i e s were not adequate. In the Spring of 1950, Unit Two was added. This included, a laundry room for the trainees, a remedial pool, two hubbard tanks, a library, a dispensary, a physical medicine department, a playroom, speech therapy and physical medicine department for the Cerebral Palsied children, as well as administration offices and more bedrooms for .residential trainees. This unit, which was planned with Unit One, was opened in November, 1950. . So well had the plans for Unit One been worked out, that only a few very minor changes in construction were necessary. Expansion in staff members also took place when Unit Two was opened. Originally, the Rehabilitation Centre had planned to have its own brace shop. They were unable to secure the services of a skilled bracemaker, and were uncertain of just what work there would be for him to do. Arrangements were made to secure braces from the Prosthetic Services Department of Shaughnessy Hospital (D.V.A.) They soon learned what types of prosthesis they would require, and so i t was decided to hire a f u l l - t i m e bracemaker. However, there were none avail a b l e , and so i t was necessary to t r a i n one. This was done at Shaughnessy Hospital (D.V.A.) and, l a t e r , Sunnybrook Hospital i n Toronto (D.V.A.). His training.was financed by means of a National Health Grant. The Third Annual Report of the Society t e l l s of t h e i r a c t i v i t y i n securing as much f i r s t - h a n d knowledge as possibl e . In this respect, the Medical Director and other key personnel t r a v e l l e d to s i m i l a r centres i n Eastern Canada and the United S t a t e s . The report a l s o includes the recognition of the necessity of securing the services of a s o c i a l worker-placement o f f i c e r . His function would be to act as l i a i s o n between the various agencies, to do job and home placement, and to work with the patients and t h e i r f a milies on a casework b a s i s . He also was to have an intake interview with each trainee, to acquaint them with the building and programme. Casework would be carried on as a part of the treatment, only i f the patients came to him with s p e c i f i c problems, or i f they are referred by the Medical Director f o r s p e c i f i c problems. Government P a r t i c i p a t i o n . Both the P r o v i n c i a l and the Federal Governments have contributed grants to the R e h a b i l i t a t i o n Centre. The P r o v i n c i a l and Municipal Governments have paid allowances to the patients and th e i r f a m i l i e s , and have provided nursing home or boarding home care. Section »G' of the "Soci a l Assistance l e t " , which l i s t s "occupational t r a i n i n g , r e t r a i n i n g , or therapy f o r indigent persons or mentally or ph y s i c a l l y handicapped persons", was not made a part of the P r o v i n c i a l Welfare Services p o l i c y u n t i l September 19th, 1951- The delay was l a r g e l y due to the-reluctance of Mu n i c i p a l i t i e s to pay,their share of the cost - twenty per cent. The P r o v i n c i a l Welfare,Department d i d finance three " t e s t " or " p i l o t " cases, which were a l l ruled to be p r o v i n c i a l r e s p o n s i b i l i t i e s i n accordance with the Residence and R e s p o n s i b i l i t i e s Act. Later, the C i t y of V i c t o r i a and the C i t y of Vancouver each accepted a "case" as their r e s p o n s i b i l i t y . The method by which aid was requested from the two Municipalities, was, quite d i f f e r e n t . The Vancouver g i r l had just completed her education at the University of B r i t i s h Columbia. Her father was opposed to accepting any help from the Welfare Department- It was through the e f f o r t s of the hospital S o c i a l Service Department that he would agree to accept such a i d , and that the C i t y of Vancouver would grant i t . When the " C i t y " had agreed to pay t h e i r twenty per cent of the cost, they n o t i f i e d the hospital S o c i a l Service Department. The V i c t o r i a resident was a forty-two-year-old man, who had been gradually worsening, physically, as a r e s u l t of p o l i o , since January, 194-9* He was admitted to the hospital in December of that year. In November, 1950, as a resident patient in the hospital, he started to take out-patient's training at the Rehabilitation Centre. This was at his own expense. It consisted of going up to the Centre each afternoon in their car for remedial exercises. The Medical Director of the Rehabilitation Centre approached the Assistant Provincial Health Officer for financial help on the patient's behalf- He,, in turn, referred the request to the Deputy Minister of Health, who passed i t on to the Deputy Minister of Welfare- ' He made contact with the City of Victoria, who agreed to assist for one year, as soon as the patient's assets were down to $500. This was achieved by the summer, and he was accepted as a City of Victoria responsibility as of the 1st of July, 1951-There was another scheme-for government participation about the same time. This was a plan which would have had the City of Vancouver and the Provincial Government each paying the'cost .of financing four beds. In April of 1951, two patients were transferred from the hospital under the arrangement. However, the plan was dropped, and the cost of their training was met from other sources. Because the negotiations between the City of Vancouver and the Provincial Government started in July, the" "City" did accept the cost of retraining these people -as of July 1st,*' 1951-There was very l i t t l e change in the programme as far as the patients were concerned, during this period. L i f e i n the hospital was much the same as before. , There was the added physical t r a i n i n g at the R e h a b i l i t a t i o n Centre. The patients who went up f o r the afternoon were very enthusiastic i n t h e i r praise f o r the Centre. The f a c t that the physiotherapists from the Centre came to the h o s p i t a l to treat a large number of the hospital patients seems to have prevented any f e e l i n g that one of the groups was p r i v i l e g e d . The t r a i n i n g , apart from muscle exercises, also included learning how to get i n and out of bed and how to dress. There are very d i f f i c u l t tasks f o r paraplegic and quadriplegic p a t i e n t s . The patients who were not going to the Centre could see the struggle and e f f o r t that was necessary i n order to l e a r n s e l f - c a r e . Before they could go t o the Centre, they, too, had to struggle to get out of bed; a struggle which often ended i n f a i l u r e and exhaustion. It was t h e i r determination, aided by the patience, reassurance and understanding of the physiotherapists, which was to s t a r t them on t h e i r way to physical recovery. In July, 1951, a s o c i a l worker was added to the s t a f f i n the R e h a b i l i t a t i o n Centre. As part of his work, he accompanies the Medical Director of the Centre during ward rounds at the Hospital. The Medical Director introduces him to the patients who are considered to be l i k e l y candidates for the R e h a b i l i t a t i o n Centre. Apparently, t h i s d e c i s i o n i s reached on the basis of a physical diagnosis. Under th i s arrangement, the Centre worker i s not l i k e l y to see those patients who are u n l i k e l y to be candidates f o r the Centre. In some instances, such people may be referred by the Medical Director to his worker, who w i l l , i n turn, r e f e r them to the ho s p i t a l S o c i a l Service Department. There i s close co-operation 7/ith the S o c i a l Service Department i n working with these patients. There i s one d i f f i c u l t y here which needs to be overcome. The P o l i o Foundation c o l l e c t s money to help p o l i o victims, yet a l l p o l i o patients do not know of the fund's existence, as not a l l of them are seen by the s o c i a l workers. The hospital maintains that i t is up to the patient to decide whether or not he wants to ta l k to a representative of the P o l i o Foundation. A means of over-coming t h i s d i f f i c u l t y would be to have the P o l i o Foundation p r i n t a small two- or three-paged booklet, explaining t h e i r r o l e . This could be extended, to outline a l l the resources at the patient's d i s p o s a l . This would ensure that each p o l i o patient knows that the fund i s avai l a b l e , and th e i r enquiries would be a means of contact for the S o c i a l Service Department, The Case of "Betty" (continued). The record of Betty shows that a complete r e h a b i l i t a t i o n process was not automatically created with the opening of the R e h a b i l i t a t i o n Centre, yet her f i n a l placement was achieved as a r e s u l t of the improved services which developed during the period of her t r e a t -ment there. Soon aft e r the Centre opened, Betty became an out-patient there. In January, 194-9, the hospital Social Service Department requested the City of Vancouver to pay for her training at the Centre, This was refused. In March, a similar request was made to the Director of Welfare, but this, too, was refused. Betty continued to go to the Centre, five afternoons a week. This situation existed until shortly after the publication of the brief to the Hospital Insurance Inquiry Commission. In that brief, the Kinsmen noted that the cost of hospital care for Betty, from. January, 194-7, to September, 1951, amounted to approximately $22,4-00. This cost was being absorbed by the hospital. It was the realization of what the hospital had spent that finally led to her placement in a boarding home. The timing of her placement was not a pre-arranged step in an Integrated rehabilitation process, but her ultimate placement was a result of close co-operation between three agencies; the Rehabilitation Centre, the hospital Social Service Department, and the City Social Service Department. In November, 1951, a report was sent to the City Social Service Department, giving a summary of her history, and outlining her present abilities. A request for a boarding home placement was made at this . time. In answer to this request, a letter was received by the hospital. Social Service Department, stating in part "we have no home which would be suitable". Through the e f f o r t s of the R e h a b i l i t a t i o n Centre s o c i a l worker, a suitable home was found for her, and the C i t y agreed to pay the cost of i t , as i t would not be more than the altern a t i v e of a nursing home placement. She was taken to see th i s home by the hosp i t a l worker,.. i n January. During the next f i v e days, she was given a great deal of reassurance, and together, the plans were worked out i n grea: t d e t a i l . At the time of writ i n g , two further v i s i t s have been made by the h o s p i t a l worker, and i t appears that Betty i s s e t t l i n g down w e l l . In the very near future, her treatment at the Centre w i l l stop, as i t i s f e l t that she has reached the point of maximum recovery. Before her treatment i s discontinued, the two s o c i a l workers plan to co^ordinace th e i r services i n an e f f o r t to help her accept t h i s d e c i s i o n . Because the C i t y of "Vancouver i s paying f o r her boarding home, they, too, are included i n the planning for t h i s g i r l , f o r i t w i l l be the i r s o c i a l workers who w i l l see her once she completes her trai n i n g at the Centre. The Record of "Tommy". This i s the record of a young man, named "Tommy", who was admitted to the hospital, on August 5th, 194-7, a s a p o l i o suspect. He was l e f t with a r e s i d u a l weakness i n bother upper and lower extremities, and i n the back and neck. Bight months afte r his admittance, he was referred to the S o c i a l Service Department of the h o s p i t a l for aid i n r e h a b i l i t a t i o n plans. Later, he attended the Walking School f o r a short time. However, he did not have a wheel-chair of his own, and expressed a great deal of resentment about having to borrow one. The Kinsmen, who were financing his treatment at the Walking School, were prepared to purchase a chair f o r him but t h i s was ac t u a l l y f i n a l l y done through the Golden G3loves Association, of which he was a member. I t i s int e r e s t i n g to note that this patient came from a broken home, and was brought up by his grand-parents, and l a t e r by an aunt and uncle. He said that, as a c h i l d , he was discriminated against. He f e l t that he was excluded from the gang, because he had "buck teeth and. cross eyes". It was to overcome being "picked on" that he had taken up boxing. The s o c i a l worker's report states that, " i n his i l l n e s s , with i t s r e s u l t i n g d i s a b i l i t y , he experienced the same f e e l i n g of insec u r i t y as i n childhood; helpless over-sensitive, d i s t r u s t f u l , and with some ideas of persecution". The record shows that he was often " i r r i t a b l e " , "down i n s p i r i t s " and "pessimistic". A benefit f i g h t was put on by the Golden Gloves Association, which he attended, along with some other patients. However, when the chair arrived, i t was f a u l t y , and the patient became very c r i t i c a l of the delay i n replacing i t . I t was only after he was allowed to make, the necessary i n q u i r i e s that he showed signs of overcoming his fe e l i n g s of i n s e c u r i t y . He received one month's tr a i n i n g at the Centre, which was financed by the Kinsmen. Later, he was accepted by the P r o v i n c i a l Government as a P r o v i n c i a l r e s p o n s i b i l i t y , and they financed further treatment at the Centre. He enrolled i n a Board of Education correspondence course, to obtain his Senior Matriculation, and l a t e r , with the help of the Kinsmen's Club, he took an accountancy course. He i s now employed as an accountant. Government p a r t i c i p a t i o n meant that the services of the Centre were available to him as a c i t i z e n . It was a recognition of the r e s p o n s i b i l i t y of Public Welfare to restore the capacities of an i n d i v i d u a l . Assistance i n money, or i n "kind", i s given to restore or maintain a person's c a p a c i t i e s . This record shows how r e l i e f can be an aid i n helping a person become independent. Such use of public assistance should do a great deal to remind the public that the primary purpose of r e l i e f i s r e h a b i l i t a t i o n . If independence cannot be restored, then humane care must be provided. The Record of Mr.. "Jones". Mr. "Jones", a married man, whose normal occupation had been logging, was admitted to the hospital on March 9th, 1948. Like "Tommy", he, too, was confined to a wheel-chair, although he did not suffer any involvement i n his arms. Unfortunately, his record was not avai l a b l e , so i t was impossible to l e a r n how he was aided by the r e h a b i l i t a t i o n programme. I t i s known that he was financed at the Centre by the P r o v i n c i a l Government, and, as part of his r e h a b i l i t a t i o n programme, he attended the Vancouver Vocational I n s t i t u t e . There, he learned shoe r e p a i r i n g . He i s now working at that trade, and i s supporting his wife and family. The b r i e f to the Hospital Insurance Inquiry Commission reports that, by investing $3,500 i n r e h a b i l i t a t i o n , the S o c i a l Welfare Department of B r i t i s h Columbia i s expected to save $17,500 during t h i s man's l i f e - t i m e . This record shows the introduction of the Vocational Institute i n t o the r e h a b i l i t a t i o n programme. Patients who use the Ins t i t u t e do so to l e a r n a trade. Their progress i s marked according to the degree to which they have mastered the i r trade. Their q u a l i f i c a t i o n upon graduation i s based on their s k i l l as a tradesman, and not on the f a c t that they are confined to a wheel-chair. The emphasis i s on what the patient can do, not on what he cannot do. Because of t h i s , there i s an excellent opportunity to emphasize to an employer that the patient i s a tradesman, who i s q u a l i f i e d to do the work he i s hired f o r . He has his a b i l i t y to o f f e r his employer i n return for wages. He i s not a c r i p p l e who needs a job. The Record of "Marv", "Mary" was admitted to the hospital on December* 26th, 194-9. She was suffering from a fractured spine, following a leap from her bedroom window. She stated that she had been attempting to escape from the " d e v i l " . She i s about f o r t y years old, and i s the mother i of two c h i l d r e n . In the ho s p i t a l , her spine was set, and three weeks l a t e r she was transferred to the P r o v i n c i a l Mental Hospital. Whilst there, she was treated f o r paranoid schizophrenia. In September, she was re-admitted to the Vancouver General Hos p i t a l . Although a det a i l e d report was received from the Mental Hospital, apparently no casework treatment w a s undertaken with t h i s p a t i e n t . The h o s p i t a l S o c i a l Service Department was asked to compile a s o c i a l summary i n accordance with the p o l i c y l a i d down between the municipalities and the P r o v i n c i a l Government. This was done, and an outline of her residence, along with information on her family and f i n a n c i a l status, was submitted. This summary a l s o included a b r i e f history of her psychiatric disorder, plus a d e s c r i p t i o n of her attitude towards r e h a b i l i t a t i o n . This s o c i a l summary, plus a medical summary signed-by the Medical Director of the Centre, was sent to the C i t y S o c i a l Service Department. They contacted the responsible municipality, who accepted t h e i r cost of the treatment. The Committee which reviewed t h i s , and a l l cases, consisted of a representative of the Municipality of the C i t y of Vancouver, a representative from the P r o v i n c i a l Welfare Department, and one from P r o v i n c i a l Welfare Medical Services. The a p p l i c a t i o n was approved, and the hospital Social Service Department was n o t i f i e d , so that they could arrange f o r her transfer to the R e h a b i l i t a t i o n Centre. In October, 1951, she was transferred to the R e h a b i l i t a t i o n Centre. I t i s i n t e r e s t i n g t o note that the request f o r treatment at the Centre was, apparently, made on a medical d i a g n o s i s o n l y , i n s p i t e of the f a c t t h a t she had experienced three previous emotional break-downs. T h i s d i s r e g a r d of the emotional f a e t o r has i n f l u e n c e d the prospects of r e h a b i l i t a t i o n . Once steps f o r her t r a n s f e r from the Centre were s t a r t e d , t h i s p a t i e n t showed many signs of her previous d i s t u r b a n c e . Her present prospects of r e h a b i l i t a t i o n are r a t e d as "poor". The Record of "George". This record i l l u s t r a t e s the programme c a r r i e d on by the Workmen's Compensation Board before and a f t e r the establishment of t h e i r r e h a b i l i t a t i o n s e c t i o n . "George" was i n j u r e d on h i s f i r s t day at work. Because h i s i n j u r y occurred before March 18th, 194-3, he was not e l i g i b l e f o r r e h a b i l i t a t i o n . He was returned t o h i s home from the h o s p i t a l , where, he s t a t e s , he " s a t on the porch and watched the cars go by f o r nine y e a r s " . During t h i s time, he received h i s pension of $67 per month, plus needed medical equipment. I n a d d i t i o n , h i s f a m i l y r e c e i v e d $1.50 per day, as a nursing home f e e . I n June, 1951, he was re-admitted t o the h o s p i t a l f o r a p h y s i c a l check-up. W h i l s t he was a p a t i e n t i n the h o s p i t a l , he was r e f e r r e d t o the S o c i a l S e r v i c e Department f o r a i d i n r e h a b i l i t a t i o n p l a n s . The p a t i e n t e v i d e n t l y t o l d the Compensation Board ~ 54 " R e h a b i l i t a t i o n O f f i c e r that a s o c i a l worker was seeing him* This R e h a b i l i t a t i o n O f f i c e r sees a l l the "compensation" patients i n the hospital every F r i d a y , The outcome of t h i s arrangement was a meeting betwen the hospital S o c i a l Service Department and the Compensation Board R e h a b i l i t a t i o n Section* This meeting accomplished several things* It gave each group an opportunity of learning how the other functioned. It set up a procedure whereby there was closer co-operation between the two services, and i t was responsible f o r the Compensation Board using the services of the ho s p i t a l s o c i a l workers to deal with family problems which were af f e c t i n g the patients' progress. In keeping with the Compensation Board's p o l i c y of using a l l available resources i n the community, plans were made for George's transfer to the Reh a b i l i t a t i o n Centre, As he was not e l i g i b l e f o r r e h a b i l i t a t i o n , the goal of " s e l f - c a r e " has been set as the objective. In the process of his physical r e h a b i l i t a t i o n , community resources w i l l be explained to him, and an e f f o r t to interest him i n vocational r e t r a i n i n g w i l l be t r i e d . The Record of Mr* "T", Mr* "T" i s a sixty-year-old logger, who emigrated to Canada from Eastern Europe t h i r t y years ago. He has not heard from his family since he l e f t his home, and he has no friends here. In September> 1950, he was injured i n a logging accident, which has resulted i n f l a c c i d quadriplegia. He apparently w i l l never gain any use of his arms or l e g s . He i s i n receipt of a pension from the Workmen's Compensation'Board; however, the pension i s not large enough to pay for private nursing home care. After he had been i n hospital for a year, he was referred to the S o c i a l Service Department f o r "help i n plans f o r r e h a b i l i t a t i o n " . R e h a b i l i t a t i o n , f o r him, w i l l be nursing home care, preferably i n pleasant surroundings. In the Spring of 1952, Mr. T s t i l l had not been told that he would get no useful functioning from his arms and l e g s . The Medical Director of the R e h a b i l i t a t i o n Centre t r i e d to f i n d a suitable nursing home f o r him, that would s t i l l leave him some of his pension money. This could not be done. The Director was reluctant to use the services of the Marpole Infirmary, because the patient ivould have to sign over a l l of his income to the Pr o v i n c i a l Government. In the meantime, Mr. T i s occupying a bed i n an acute h o s p i t a l . He i s not receiving d a i l y hydrotherapy, as the s t a f f can only f i n d time to do th i s for him i n the morning, and he objects to going to the tank i n the morning. The Record of Mr. "A". Mr. "A" i s , i n his own words, a "lone wolf". He, too, i s a quadriplegic patient. His in j u r y resulted from a f a l l from a hotel window. Unlike Mr. "T", this patient's paralysis i s s p a s t i c As a r e s u l t , he i s "bothered a great deal by spasms, or involuntary muscle function of both legs* He was i n the hospital f o r seven months before being referred to the Social Service Department* The degree to which he w i l l recover i s , apparently, not known* At the time of r e f e r a l , i t was expected that he would go to the Marpole Infirmary* This plan was l a t e r changed to the R e h a b i l i t a t i o n Centre* The present plan i s to transfer him to the Infirmary. There i s another factor present, besides his physical condition* It i s one of money* He, too, would have to sign over a l l of h i s money ( i f he has any) before going to the Infirmary* The patient himself expressed a great deal of anxiety about the thought of such,a move, and even refused to discuss the word "chronic", as i t i s defined by the Hospital Insurance Services. The l a s t two records were c i t e d because they both concern the Marpole Infirmary, and the apparent reluctance of the Medical Director of the Centre to use i t s f a c i l i t i e s * His reluctance to use the Infirmary appears to be because of the government p o l i c y , which states that each inmate must sign over a l l his assets before he w i l l be admitted. The f a c i l i t i e s are regarded by the Director as being the best available i n t h i s area. The f a c i l i t i e s ar4 made so good because of the a c t i v i t i e s of an excellent Women's A u x i l i a r y * This A u x i l i a r y i s also the A u x i l i a r y to the R e h a b i l i t a t i o n Centre* They were asked to undertake the job at the Centre because of the excellent work they had done i n improving the s o c i a l l i f e of the people i n the Infirmary. To o f f s e t the danger of the A u x i l i a r y "becoming l e s s active as the present members leave i t , i t might be well to have a closer contact between the A u x i l i a r y members and the s t a f f at the Centre. New members to the A u x i l i a r y would c e r t a i n l y gain knowledge and i n s p i r a t i o n from talking to the s t a f f members and seeing how sympathetically they work with the patients. In such a manner, the A u x i l i a r y could make the Infirmary an extension, In s p i r i t , of the R e h a b i l i t a t i o n Centre. It .could nat o f f e r the same hope to the patients, but i t could o f f e r them a s e t t i n g , and programme, which would permit these patients to function to t h e i r maximum capacity, p h y s i c a l l y , mentally, s o c i a l l y and vocationally, for the f u l l e s t possible l i f e compatible with t h e i r a b i l i t i e s and d i s a b i l i t i e s . The Record of" Alan." The l i f e h istory of "Alan", a teen-aged boy, who has been l e f t with r e s i d u a l p a r a l y s i s i n , a l l four extremities, i l l u s t r a t e s well what post p o l i o p a r a l y s i s can mean to the patient, his family and the community. When Alan was three years o l d , he contracted p o l i o , and was l e f t with weakness i n one .leg.. He i s described by his mother as being a very independent c h i l d . He would always t r y to minimize any i l l n e s s or hurt he had. When he was six years o l d , he became enuretic and would sometimes s o i l himself. His mother "follo?;ed. medical advice" and was "hard with him". After almost a year of s t r i c t n e s s , she "could not stand i t any more" and treated him more k i n d l y . He had also developed a fear of being confined, and would almost become hysterical i f his arms were held-At school, he was picked on by other boys, and one day, whilst trying to escape from them, was struck down in the road by a wood truck- His mother described in detail the many serious falls he had during the ten years he "dragged himself around"'- During this period, he had joined the Boy Scouts, and was quite active in them, although he did not get along too well with some of the boys-On one of the f i r s t days of January, 194-9, he came in after playing a l l day in a snow-house- He "did not feel well", and in the morning his condition worsened-The family doctor was called, and diagnosed-the condition as polio, but, when he was told that Alan had polio ten years ago, he decided that i t could not be polio, and left some aspirin for him- By the end of the week, Alan?s condition was so bad that he could only move his head- His parents "reluctantly" phoned for another doctor, who, admitted him to hospital as a polio suspect-He stayed in the hospital until December, 1950- There were several instances of disagreement during this time, between the hospital staff and Alan's mother. In December, he was discharged home as an out-patient of the Rehabilitation Centre. Some of the staff members described his behaviour as "cocky", while anothe^ r felt he was a "sissy". On December 20th, he disregarded the physio-therapist's advice; tried to get off a treatment table unaided; f e l l and broke his l e g . He was re-admitted to the h o s p i t a l at that date. His parents had agreed to pay f o r his care at the Centre, but they received no b i l l f o r the two weeks he was there. In the h o s p i t a l , he was soon able to get around again i n a wheel-chair which had been bought f o r the ward by the Kinsmen. His schooling, which, was being ca r r i e d on by means of a correspondence course, and a v i s i t i n g teacher from the Department of Education, was continued. On August 3rd, 1951, he was referred to the S o c i a l Service Department f o r aid i n plans f o r r e h a b i l i t a t i o n . The worker knew nothing of his h i s t o r y , nor how t h i s i l l n e s s had affected his family. From talking to various s t a f f members, i t was learned that Alan was considered to be "a l i t t l e beast" or "a boy with too much s p i r i t " . He had pulled the hair out of the chest of a quadriplegic patient, struck another, and so annoyed other patients, that he was denied access to t h e i r room. His mother was described as being "very i n t e r f e r i n g " . She, supposedly, had t o l d him that he need,not do the exercises, and on one occasion had put a d o l l a r on the f l o o r and t o l d him he could have i t i f he could crawl to i t . It was decided that his parents should be interviewed to f i n d out more of the d e t a i l s of the boy's early l i f e experiences. This was done only once. Before further interviews could be held, notice was received from V i c t o r i a that the requested extension on his h o s p i t a l insurance benefits had been denied. It was back-dated several months, which meant that his parents owed the h o s p i t a l over $2,000. When Alan's mother learned t h i s , she became extremely angry. The worker's second v i s i t was then one i n which he encouraged her to express her resentment to the hospital s , doctors, and s o c i a l workers. She t o l d how a hospital s t a f f member said that Alan could walk i f he wanted to, and that he wet his bed just to cause them extra work. This information, and much of Alan's early h i s t o r y , was passed on to the Medical Director and the s o c i a l worker at the Centre. Alan's case was being considered by the Hospital Board for the "staff-non-pay" category. The worker discussed the costs, and the family's a b i l i t y to pay, with Alan's mother. Although his father held a steady well-paid job, i t was f e l t that the'burden of meeting t h i s b i l l might lead to a breakdown of the family, because of economic or other reasons. Their willingness to contribute towards the cost of his care at the R e h a b i l i t a t i o n Centre was a reminder that they would continue to have medical ..expenses, whidh would again leave them unable to save. The worker a l s o surveyed the physical f a c i l i t i e s i n the home, as the Medical Director was anxious to have him discharged home so he could commence out-patient treatment at the Centre. It was found that the home could be e a s i l y a l t e r e d . This was reported to the Medical Director and his worker.,; A report was a l s o submitted to the staff-non-pay Board, who decided not to ask the family to meet t h i s b i l l . Further telephone contacts were made with the worker at the Centre, because of two major problems. One - : 6 i -was to continue casework services with Alan's mother, as i t was f e l t that she was a very dependent person, who would need a l l the d e t a i l s of any plan worked out for her son. The h o s p i t a l worker agreed to continue seeing her u n t i l i t was f e l t that she could accept a transfer to a new worker. The other problem was what to do about Alan's schooling- He i could not take a l l the courses necessary by correspondence, because of his weak arms; i t was not possible to obtain a v i s i t i n g teacher; and Alan was confined to a wheel-chair, which meant that he would not be admitted to school, because the school board could not accept r e s p o n s i b i l i t y f o r him on t h i s b a s i s . Nevertheless, through the combined e f f o r t s of the two workers, and with the co-operation of the Vancouver School Board, Alan became the f i r s t student to attend school i n a wheel-chair. In September, i t was decided, i n a conference with the Medical Director, that Alan should be discharged from h o s p i t a l . Plans were made to have..him taken to the Centre from home each morning, to school at noon, and home at four i n the afternoon. Two of his courses were to be by correspondence, and the others were to be taken at school. The school timetable i s what i s known as a revolving time-table; That means that the same subject i s not taught at the same time each day. It was necessary, then, f o r the school p r i n c i p a l to make s p e c i a l arrangements for him. On the day that Alan was to be discharged, the worker went to the ward and found Alan and his mother - 62/ -there. They were both upset. The charge nurse knew nothing of discharge arrangements, for the doctor's orders were that he be discharged when the necessary arrangements were made. This was immediately cleared up, and Alan l e f t f o r home. As well as the services indicated, A lan a l s o made use of the many services provided by Miss G a i t , and he was also introduced to the leader of the handicapped Boy Scouts, who explained t h e i r function to him. On the f i r s t day that Alan attended the Centre, the ca r e f u l plans were upset. It had been arranged that Alan would eat at the Centre. The meal would be paid for by the Women's A u x i l i a r y . When a physiotherapist, who did not know of the arrangement, t o l d him he could buy milk to eat with his lunch, Alan thought he was expected to pay for his lunch. The r e s u l t was that he did not eat. This matter, and one, or two minor points concerned with his schooling, showed that i t was not p r a c t i c a l f o r a worker at the Centre to see Alan, while the h o s p i t a l worker saw his mother.. It was, therefore, decided to transfer Alan's mother to the worker at the Centre. An interview was held with her, and she was found to be agreeable to the idea. She expressed some doubt as to what Alan would be able to do af t e r he f i n i s h e d his schooling. She was t o l d of the use made by the Centre of the Rotary Counselling Service. It was explained that the tests they gave were not just i n t e l l i g e n c e t e s t s , but were d i r e c t e d towards fi n d i n g out what the person could best do, and what he would be happiest a t . The transfer to the new worker was made, and he carr i e d through t h i s suggestion, as Alan was also agreeable to i t . As a r e s u l t of the t e s t , Alan has become quite interested i n radio r e p a i r s , an occupation which would be suitable to his physical mental and vocational a b i l i t i e s . ThenEnner i n which s t a f f members at the Centre were to deal with Alan were discussed with them, and i t was f e l t that he would resent anything which would suggest that other trainees were being favoured -by the s t a f f . His attempt to get o f f the table, at which time he broke h i s l e g , was shown to be t y p i c a l of his e a r l y behaviour. His independence was also explained as being a possible means of gaining approval from his mother-Later, an instructor at the Centre mentioned that Alan appeared to be t e r r i f i e d of f a l l i n g , and consequently he would not t r y to walk. This was a l s o discussed between the s o c i a l worker and the i n s t r u c t o r , who agreed that, i n view of his ea r l y history and his recent broken l e g , he had good reason to be f e a r f u l of f a l l i n g . A second suggestion was also made; that Alan was using h i s physical condition as an attention-getting device. were Various s t a f f members,, then/asked i f they f e l t he was too demanding and, because they had not seen any i n d i c a t i o n of t h i s , the suggestion of his fear of f a l l i n g was accepted as the reason. - 64 -The record of Alan i l l u s t r a t e s to what extent a patient's family can be affected by' i l l n e s s * I t shows the necessity of agencies such as the Kinsmen's Clubs, the hos p i t a l , with i t s free services, and the R e h a b i l i t a t i o n Centre* To secure his education, a v i s i t i n g teacher's services, as well as correspondence courses, and co-operation of the Vancouver School.Board, were necessary. The choice of vocational training was l a r g e l y influenced by his psychological t e s t i n g , because the poor workmanship of his handiwork i n the hos p i t a l had given no i n d i c a t i o n of his mechanical a b i l i t y . His record also indicates the co-ordination necessary between the various treatment personnel and the various agencies involved i n his r e h a b i l i t a t i o n * The integration was both on the formal case conference l e v e l and on the informal, but important,, interchange of information during the d a i l y treatment periods-Co-ord ination* Co-ordination requires the sharing of the information one s t a f f member possesses, with other treatment personnel, i f i t w i l l influence their r e l a t i o n s h i p with, or understanding of, the patient* This implies that each treatment person knows the pa r t i c u l a r r o l e of the r e s t of the s t a f f i n order to know what information can be considered to be pertinent* One boy on the ward was considered to be a "mean, s p o i l t brat", by one of his nurses. It v/as only after the s o c i a l worker t o l d her that his objectionable behaviour started when his mother had not v i s i t e d him, as planned, but had gone to another province, and had to be traced by the p o l i c e , that the nurse could accept his behaviour as natura l . Co-ordination i s also required between the various agencies i n the community. As i n the case of personnel, the agencies, too, must possess knowledge of the various resources, and how they function within t h e i r i n d i v i d u a l agencies. The need f o r t h i s i n t e r -agency integration i s i l l u s t r a t e d by the following record. "June" was admitted to the hos p i t a l as a p o l i o suspect. Because of the d i f f i c u l t y i n diagnosing p o l i o , most p o l i o patients are given t h i s type of diagnosis on . admittance. Her condition was found to be one of h y s t e r i c a l p a r a l y s i s . She was referred to the S o c i a l Service Department f o r casework and r e h a b i l i t a t i o n help. The S o c i a l Service Department v/as faced with the problem of securing money to finance t h i s g i r l ' s vocational t r a i n i n g . They recognized that, i f she was s e l f -supporting, she was not l i k e l y to be re-admitted to h o s p i t a l . It was not possible to obtain the necessary funds, except through the Kinsmen. This was done, by sta t i n g that the g i r l was admitted as a p o l i o suspect, which was true. However, the Kinsmen subsequently learned that she did not have p o l i o , and withdrew the i r support - 66 -a f t e r the g i r l had completed part of her t r a i n i n g . Recent Changes i n Process, During the l a s t months of 1951, two major changes have occurred i n the process since Alan was discharged home. The f i r s t i s that the worker from the Centre accompanies the Medical Director on his ward rounds i n the h o s p i t a l . In t h i s way, he comes i n contact with a l l the patients, who w i l l be l a t e r transferred to the Centre, at an early date. This means the time-lag between admission to hospital and the interview with the s o c i a l worker, has been greatly diminished. This i s important, f o r someone must evaluate the patient's r e a c t i o n to his i l l n e s s . His r e a c t i o n may slow down the r e h a b i l i t a t i o n process, or severely l i m i t the degree to which he can be r e h a b i l i t a t e d . The person who makes that evaluation should be one who has the t r a i n i n g f o r such a job. The often-used argument that not a l l patients need casework i s quite true. But i t implies that someone has judged the patient's a b i l i t y to meet the f r u s t r a t i o n s of an e n t i r e l y altered world; a world that has altered almost overnight. The d e c i s i o n as to whether a patient needs casework help or not should be made by the s o c i a l workers. There i s a second aspect to having the evaluation done by a s o c i a l worker. That i s one of preventitive s o c i a l work. The idea that a patient was - 67 -referred to the social worker because he had a problem, is apparently s t i l l widespread. Because social work treats through the relationship established between the patient or client and the worker, the evaluation itself includes an element of treatment. That treatment, no matter how slight, may enable the patient to adjust to his new situation. If i t does not, i t s t i l l affords the basis for building the necessary relationship between the worker and the patient. The second change has been in the adminis-tration of the Hospital Insurance Scheme. Now, the hospital is notified that a patient wi l l be cut off from benefits at a specified future date, in accordance with their policies. Also, the time i t takes to rule on whether an extension will be granted has been greatly reduced. The hospital administration now holds i t to be the doctor's responsibility to t e l l his patients about any Hospital Insurance ruling. Patients are no longer suddenly confronted with large hospital b i l l s , as they were in Ilan's case. This means that resources to pay for their hospitalization can be introduced to the patients as a part of their rehabilitation process. Aid from the government or from the Kinsmen's Clubs does not appear to be charity, granted because they are in debt. The financial help becomes one of the many aids which are extended to rehabilitate these patients. Chapter L. EVALUATION. The development of the r e h a b i l i t a t i o n programme shows two c l o s e l y r e l a t e d elements. These are, f i r s t , the development of resources in.the community, and secondly, the development of the r e h a b i l i t a t i v e process. The r e h a b i l i t a t i v e process has often been referred to as teamwork. This concept has the medical o f f i c e r as captain of the treatment team. Unfortunately, there can be authoritative captains who cannot delegate authority,as well as those who can f i t well i n t o a more passive leadership r o l e . The word "team" can imply many things. I t may connote the s k i l f u l , co-operative playing of a soccer team, or i t may suggest a team of horses who work together because they have to. To avoid the range of impressions the T/srords "captain" and "team" might suggest, the words " r e h a b i l i t a t i v e process" w i l l be used to evaluate what i s commonly c a l l e d "teamwork". The r e h a b i l i t a t i v e process i s the bringing to the c l i e n t the v a r i e t y of s k i l l s available i n the community. It i s by d e f i n i t i o n an integrated programme. The degree of int e g r a t i o n depends on two things. F i r s t , there i s the time element between the u t i l i z a t i o n of various s k i l l s . Secondly, there i s the exchange of information. Each s t a f f person should be aware of information which might a f f e c t her attitude towards the patient, or the nature of her treatment - 6 9-The physiotherapists take t h e i r instructions from the doctor, hut they report any new condition to him. In such a way, they help to change the future exercises which w i l l be ordered f o r him. Their observations can, therefore, a l t e r the prescribed treatment. The i n t e r p r e t a t i o n of s k i l l s can take place i n two settings. There i s the formal case conference, and the b r i e f informal meetings which occur i n the d a i l y contacts. Each Friday, at the R e h a b i l i t a t i o n Centre, there are formal case conferences held. A l l members of the treatment s t a f f , as well as personnel from outside agencies, attend. Three or four cases are reviewed each week i n t h i s manner. The patient's medical hi s t o r y i s reviewed, and the s t a f f members evaluate his progress or at t i t u d e , as based on t h e i r observations of his attitude towards his setting and his a b i l i t y to perform the prescribed exercises-The patient i s then brought i n and i s examined by the Medical D i r e c t o r . He supplements his diagnosis by the reports of the day-to-day progress of the patient. The patient i s asked to express any d i f f i c u l t i e s he thinks could be overcome. After the patient leaves the room, a discussion i s held by the s t a f f members, and a revised treatment schedule i s compiled. The candidates f o r these conferences are selected by the personnel. The conferences function to combine the s k i l l s and knowledge of the s t a f f . The programme adopted i s based on th e i r recommendations. It must be approved by the -e70 -Medical Director, because of his r e s p o n s i b i l i t y f o r the patient's physical well-being. The factors of time, and the pressure of workj do not permit the formal conference to be used f o r a l l patients at a l l times. Problems occur which must be met as soon as possib l e . This i s done l a r g e l y through the d a i l y contacts of the s t a f f members. Few, i f any, of these b r i e f meetings, are recorded. Because r e h a b i l i t a t i o n i s a process, the d a i l y i n t e r p r e t a t i o n of services i s more important than the formal review type of case conference. A new element i s introduced i n the in t e g r a t i o n of services, because of the f a c t that the treatment personnel work i n various s e t t i n g s . There i s the extension of the R e h a b i l i t a t i o n Centre into the h o s p i t a l , through the Medical Director, who sees most of the patients on the ward, through the physiotherapists, who give patients t h e i r exercises on the ward and i n the Centre, through the remedial physical t r a i n i n g i n s t r u c t o r , who gives mat classes at the hospital and who helps the bracemaker by getting measurements f o r the various types of s p l i n t s the patients need, and through the s o c i a l worker, who accompanies the Medical Director on ward rounds. The weekly v i s i t s of the r e h a b i l i t a t i o n o f f i c e r from the Workmen's Compensation Board are an extension of that agency i n t o the h o s p i t a l . Integration i s not merely, then, an in t e g r a t i o n of the s k i l l s and knowledge of a group of i n d i v i d u a l s . It a l s o involves an int e g r a t i o n of resources. Each department f-unctions as a part of i t s own agency. It also functions as a part of a r e h a b i l i t a t i o n programme, which i s beyond i t s agency's j u r i s d i c t i o n . What may be regarded as functioning well i n i t s own setting may be detrimental to the o v e r a l l programme, as the record of "June" i l l u s t r a t e s . This i n t e r -agency i n t e g r a t i o n has not been as close as i t should have been. The biggest f a c t o r , apparently, i s the newness of the programme. Staff members are s t i l l c r i t i c a l of the people i n various agencies, because they do not understand each other's r o l e . Those people, on examination, are found to be performing t h e i r job we l l , as i t r e l a t e s to t h e i r p a r t i c u l a r agency. P r i o r to adequate s t a f f i n g of his department by s o c i a l workers, the Medical Director was responsible f o r a l l aspects of treatment, including the s o c i a l aspects, of the patients with th e i r i l l n e s s . .. This even included securing a passport f o r a patient who was returning to Norway. This arrangement was a means of getting things done; however, i t also slowed up the process of in t e g r a t i o n . The Medical Director i s f a m i l i a r with the complexity of the programme, and r e a l i z e d that i t would take a great deal of integrating to acquaint the hospital S o c i a l Service Department with the programme. At the same time, he was faced with the necessity of keeping the programme functioning as well as p o s s i b l e . He had to choose between l i m i t i n g his services to his patients, i n order to have time to interpret the programme to the h o s p i t a l S o c i a l Service Department, and trusting that the S o c i a l Service Department would gradually l e a r n what the programme involved. He chose to help his patients, and took what steps he could to improve the programme. To ensure that the patients were seen i n the h o s p i t a l by a s o c i a l worker, he elected to have the s o c i a l worker at the Centre accompany him on ward rounds. Because t h i s s o c i a l worker i s responsible f o r o f f e r i n g casework help and f o r "placements" at the Centre, he, too, i s unable to devote much time to i n t e r p r e t a t i o n to s t a f f people- By having to do things for himself, the Director has tended to slow down the excellent process of community organization which i s c h a r a c t e r i s t i c of the Society- By using his own s o c i a l worker i n the hospital s e t t i n g , he i s getting around a lack i n the resources rather than having the h o s p i t a l extended i t s s e r v i c e s . Integration between the agencies involves more than just an understanding of r o l e of the personnel-I t includes the i n t e r e s t s of those people i n the community who are interested i n each of the agencies- Their support of the agency provides the money which permits the agency to p a r t i c i p a t e e f f e c t i v e l y i n the r e h a b i l i t a t i v e programme. Community organization i s not just the i n t e g r a t i o n of e x i s t i n g s o c i a l agencies. I t includes the people who are interested i n those agencies, and the people who are interested i n the R e h a b i l i t a t i o n Centre. The development of the programme i l l u s t r a t e d f i r s t the use of available agencies. These included the Department of Veterans 1 A f f a i r s , the Kinsmen, the Canadian Paraplegic Association, and the Vancouver General H o s p i t a l . A f t e r the establishment of the Centre, other agencies came i n to use the services of the Centre, and through contacts established there, used the o r i g i n a l agencies to better advantage. The i n c l u s i o n of other services, such as the Canadian A r t h r i t i c and Rheumatism Society and the Cerebral Palsy Association, has brought more interested groups into the group. The R e h a b i l i t a t i o n Centre has become a centre of community i n t e r e s t . The "community" i s l a r g e l y that group of people who are a c t i v e l y interested i n aiding some p a r t i c u l a r group. The future of the R e h a b i l i t a t i o n Centre w i l l depend a great deal on i t s r e l a t i o n s h i p with the larger community. To obtain wider support, i t must be se l e c t i v e i n choosing the people i t serves. It cannot hope to serve a l l handicapped patients d i r e c t l y . It can help them i n d i r e c t l y by o f f e r i n g advice, or acquainting them,with other resources i n the community. The second influencing factor w i l l be a regular evaluation of i t s programme, to see i f i t meets the implication of i t s goal. A i n o r i g i n a l confusion as to what helping a patient to achieve his maximum was, has been p a r t i a l l y cleared up. Apparently, i t was thought that the services of a psychologist was the means of preparing a patient mentally f o r r e h a b i l i t a t i o n . It was planned to hire a psychologist a f t e r i t was learned what his contribution would be- It i s s t i l l hoped to add a psychologist, but i t has now been demonstrated that, to prepare a patieht mentally, i t i s necessary to r e l i e v e him of his emotional stresses, so that he may use his mental capacities to the f u l l e s t extent- Use i s at present being made of the Rotary Counselling Service to discover l a t e n t a b i l i t i e s , and so serve as a guide to vocational r e h a b i l i t a t i o n ; and to aid i n evaluaating the patient's personality. These tests w i l l serve as a guide for case-workerr-placement o f f i c e r - So much of his time i s presently devoted, to placement, that the Counselling Service i s used c h i e f l y to a i d i n job placement or vocational r e h a b i l i t a t i o n - This s i t u a t i o n exists because there i s not a suitable agency i n the community to provide job placement f o r these people- The Special Placements Section of the National Employment Service was used o r i g i n a l l y . It was not found to be e f f e c t i v e - The opinions expressed by various r e h a b i l i t a t i o n o f f i c e r s i s that the Employment Service lacks community contacts- This lack appears to be due to two f a c t o r s . The f i r s t i s a lack of endeavour to make the contacts- The second, and more important, i s that the Employment Service i s a government o f f i c e - It was established to aid people secure employment. As a government agency, i t cannot refuse to t r y to place a person, and the r e s u l t i s that t h e i r work i s hampered by - 75-t r y i n g to help people who cannot work. A l t e r n a t i v e l y , they place him i n a job and hope he can manage i t . Unfortunately, t h i s l a t t e r choice too often means that the employer loses confidence i n the Service, and so another contact i s l o s t . Because so much time i s spent by the s o c i a l worker at the Centre on placement, l i t t l e use i s being made of intensive casework. Casework i s l i m i t e d to "environmental" and occasionally "supportive" casework. It i s hoped that a placement o f f i c e r w i l l be added to the s t a f f i n the future, to r e l i e v e the s o c i a l worker of t h i s work. He w i l l then be able to devote more time to the patients i n the hospital; work more inte n s i v e l y with the trainees i n the Centre, and o f f e r better service to the patients' f a m i l i e s . The history of "Alan" and the record of "Betty" indicate how important i t can be to extend casework services to the patient's family. The f a c t that the worker does so much of the vocational placing i s a second i n d i c a t i o n of an attempt to get around a lack i n the resources. Here, too, the s t a f f of the Centre are attempting to do the job themselves, rather than trying to have the agency i n question further develop i t s own programme. The s o l u t i o n to t h i s problem appears to l i e i n an unpublicized e f f o r t at r e h a b i l i t a t i o n which i s i n an experimental stage only. It i s a co-operative e f f o r t of various r e h a b i l i t a t i v e agencies and the Department of Education. It i s held under the auspices of the Council f o r the Guidance of the Handicapped- I f i t becomes an educative programme f o r the personnel involved, each person w i l l r e a l i z e the l i m i t a t i o n s of the various agencies- Joint e f f o r t s can then be made to correct any f a u l t s that e x i s t i n a l l phases of the r e h a b i l i t a t i o n programme- U n t i l t h i s e f f o r t i s made, there w i l l be du p l i c a t i o n of e f f o r t i n the r e h a b i l i t a t i o n of a l l the patients who come under the various r e h a b i l i t a t i o n schemes-- 77 -BIBLIOGRAPHY. 1. Berg, R.H. Poljb and, i t s Problems. J.B. Lippi n c o t t Go., Montreal, 1948* 2. Gingras, G. "Rehab i l i t a t i o n of the Paraplegic Patient", Treatment Service B u l l e t i n . February, 194*7* V o l . I I , No. 2. 3. Hamilton,. K. Counselling the Handicapped i n the  Re h a b i l i t a t i o n Process. The Ronald Brace Company, New York, 1947. 4 . Letourneau, C.U. Reha b i l i t a t i n g the Handicapped. The R e h a b i l i t a t i o n Society f o r Cripples, Montreal, 1951. 

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