ADULT EDUCATORS' ROLE IN THE REHABILITATION OF PHYSICALLY DISABLED ADULTS by MARIE-LOUISE HOLDEN B . S c , U n i v e r s i t y of B r i t i s h Columbia, 1968 A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF ARTS i n the Facu l t y of Educat ion We accept t h i s t h e s i s as conforming to the requ i red standard THE UNIVERSITY OF BRITISH COLUMBIA June, 1974 In presenting t h i s t h e s i s i n p a r t i a l f u l f i l m e n t of the requirements f o r an advanced degree at the U n i v e r s i t y of B r i t i s h Columbia, I agree that the L i b r a r y s h a l l make i t f r e e l y a v a i l a b l e f o r reference and study. I f u r t h e r agree that permission f o r extensive copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the Head of my Department or by h i s r e p r e s e n t a t i v e s . I t i s understood that copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain s h a l l not be allowed without my w r i t t e n permission. Department of Educat ion Facu l ty o f Educat ion The U n i v e r s i t y of B r i t i s h Columbia Vancouver 8 , Canada J u l y 3 1 , 1974 i ABSTRACT The purposes o f t h i s study were to i n v e s t i g a t e the psychosoc ia l needs o f the c h r o n i c a l l y d i sab led and t o determine the ex tent t o which the a d u l t educator could f u r t h e r expand the educa t iona l o p p o r t u n i t i e s which could p a r t i a l l y f u l f i l l these needs. Due t o l i m i t e d research by a d u l t educators i n t h i s f i e l d , most of the l i t e r a t u r e i n v e s t i g a t e d and c o n s u l t a t i o n s conducted were i n o ther d i s c i p l i n e s . I n the chron ic care f i e l d , medical personnel were v i s i t e d , extended care and r e h a b i l i t a t i o n cent res were i n s p e c t e d , d i sab led persons were i n t e r v i e w e d , and f a c i l i t i e s f o r the d i s a b l e d at u n i v e r s i t i e s i n Vancouver, B.C. were s t u d i e d . F i n a l l y , a four -month f i e l d study was undertaken a t an extended care h o s p i t a l i n V i c t o r i a , B.C. The f i e l d s tudy fo l l owed "A Model f o r Research and E v a l u a t i o n on R e h a b i l i t a t i o n " proposed by Suchman. The l i t e r a t u r e revealed t h a t the number o f p h y s i c a l l y d isab led has increased i n t h i s century w i t h a cor responding r i s e i n t h e i r psychosoc ia l needs. I n prev ious c e n t u r i e s the numbers o f c h r o n i c a l l y d i s a b l e d were few and the medical o r i e n t a t i o n was towards the p h y s i c a l aspect o f d isease. This p r a c t i c e has p e r s i s t e d to the present day. Owing to these increases and to the f a c t t h a t t h e r e appears t o be i n s u f f i c i e n t t ime f o r the complete care o f the p a t i e n t , both p h y s i c a l and p s y c h o s o c i a l , the psychosoc ia l needs cannot be adequately met by phys ic ians and nurses. These needs are now recogn ized , and they appear t o be predominate ly s o c i a l . S o c i o l o g i s t s and a d u l t educators should p a r t i c i p a t e to prevent these needs f rom becoming p s y c h o l o g i c a l . i i Three f a c t o r s t h a t may determine the outcome o f r e h a b i l i t a t i o n a r e : M o t i v a t i o n , goals and i n t e g r a t i o n and these aspects are i l l u s t r a t e d i n the case h i s t o r i e s s t u d i e d . The a d u l t educators must recognize the importance of t h e i r r o l e i n ach iev ing these f a c t o r s w i t h the d i s a b l e d . Un l i ke Sweden, no comprehensive e f f o r t has been made i n Nor th America t o p rov ide educat ion f o r the d i s a b l e d . Some u n i v e r s i t i e s and a d u l t educa t iona l f a c i l i t i e s have been mod i f i ed and serv ices supp l ied to the d isab led but few a d u l t educators o f f e r se rv ices t o these people ou ts ide of i n s t i t u t i o n s and yet the va lue of educa t i on , whether i t be f o r se l f -en r i chmen t or v o c a t i o n a l r e h a b i l i t a t i o n , cannot be overemphasized. Even i n the b r i e f f i e l d study a t S t . Mary 's Extended Care H o s p i t a l the b e n e f i t s o f adu l t educat ion i n a i d i n g r e h a b i l i t a t i o n were demonstrated. I t i s concluded t h a t t he re might be two main causes f o r t h i s o v e r s i g h t by a d u l t educators . The f i r s t i s t h a t t he re i s no i n c l u s i v e r e g i s t r y o f d i s a b l e d , t h e r e f o r e , the ex ten t o f the problem might not be apparent . The second i s t h a t t h e r e are no courses f o r a d u l t educators on the medical problems o f the d isab led and a d u l t educators are thereby i l l - p r e p a r e d to a s s i s t i n r e h a b i l i t a t i o n . I t i s recommended t h a t the P r o v i n c i a l Government r e g i s t e r a l l the d i s a b l e d ; t ha t the Canadian Adu l t Educat ion A s s o c i a t i o n f a m i l i a r i z e i t s members w i t h t h i s problem; and t h a t i t suggest f u r t h e r research and study i n t h i s a rea . Courses should be organized by Cont inu ing Educat ion Departments a t U n i v e r s i t i e s , Co l leges , Adu l t Educat ion Centres o r by Correspondence. i i i Adu l t Educat ion Research Centres should f u r t h e r exp lo re the r o l e of adu l t educators i n the f i e l d . Adu l t Educat ion Departments should s t ress the removal of a l l p h y s i c a l b a r r i e r s f rom e d u c a t i o n a l f a c i l i t i e s . Correspondence courses and personal con tac ts should be i n i t i a t e d and main ta ined i n the home by the a d u l t educator o r v o l u n t e e r . Counse l l i ng i n regard t o a d u l t educa t ion should a lso be a v a i l a b l e . The above recommendations would make i t p o s s i b l e f o r a d u l t educators to c o n t r i b u t e t o the r e h a b i l i t a t i o n o f the d i s a b l e d . i v ACKNOWLEDGEMENT S In appreciation for the guidance given by Dr. James E. Thornton, for the in t e r e s t shown and assistance given by Miss Marilyn Dutton and Mr. Paul Thiele and to Mrs. Vera Mclver R.N., Miss Margaret Hood, Doctor Peter Bunton and a l l personnel i n the health care f i e l d who contributed to my further understanding of the problems of the ph y s i c a l l y disabled. And p a r t i c u l a r appreciation to a l l those p h y s i c a l l y disabled who pa r t i c i p a t e d i n t h i s study and whose patient and cheerful responses made the wr i t i n g of t h i s thesis a most rewarding experience; DEDICATION v i TABLE OF CONTENTS PAGE ABSTRACT i ACKNOWLEDGEMENTS i v DEDICATION v CHAPTER I. INTRODUCTION 1 A. Problem under Study 2 B. How the Problem Developed 3 C. The Purpose of the Study 6 D. Li m i t a t i o n of the Study 6 E. D e f i n i t i o n of Terms . 7 F. Methodology 8 G. Plan of the Study 8 Footnotes 10 II . PSYCHOSOCIAL NEEDS OF THE PHYSICALLY DISABLED 11 A. The Needs of a Patient with a Chronic D i s a b i l i t y 11 B. The Relationship of Physicians i n the Care of the Chronic 13 C. The Relationship of Nursing Personnel i n the Care of the Chronic 15 D. The Involvement of So c i a l S c i e n t i s t s i n the Care of the Chronic 17 E. Summary 19 Footnotes 21 v i i CHAPTER PAGE I I I . FACTORS IN THE REHABILITATION OF THE PHYSICALLY DISABLED 23 A. Motivation i n the Disabled 23 B. Goals for the Disabled 25 C. Integration f o r the Disabled 29 D. Summary 34 Footnotes 36 CHAPTER IV. EDUCATIONAL PROGRAMMES FOR THE PHYSICALLY DISABLED 38 A. Post Secondary Education Programmes 39 1 . U n i v e r s i t i e s and Colleges i n Sweden 39 2. U n i v e r s i t i e s i n the U.S.A 39 U n i v e r s i t y of Missouri at Columbia 39 U n i v e r s i t y of I l l i n o i s and Southern I l l i n o i s U n iversity 40 U n i v e r s i t y of C a l i f o r n i a at Berkeley 41 3. U n i v e r s i t i e s i n Canada 41 University of Alberta, Edmonton, Alberta 41 Simon Fraser U n i v e r s i t y Burnaby, B.C 41 U n i v e r s i t y of B r i t i s h Columbia, Vancouver, B.C 42 43 B. Adult Education Programmes 43 1 . North America 2. England 46 3. Sweden 48 v i i i C. Summary 49 Footnotes 51 CHAPTER PAGE V. CHRONIC CARE PHILOSOPHY IN PRACTICE 54 A. F i r s t Study i n 1969 i- 55 B. Second Study i n 1973 55 1. Use of Educational Process 55 2. Use of a Model for Assessment 58 3. D i v i s i o n of Study into Four Phases .. 58 4. Report On Hospital i n Phase I 59 5. Report on Residents Assigned i n Phases I I , I I I & IV 62 6. Follow-up Report on Residents Assigned 68 7. Conclusion of the Study 68 C. Summary 70 Footnotes 74 VI. CONCLUSIONS AND RECOMMENDATIONS 76 A. Conclusions 76 B. Recommendations 80 1. P r o v i n c i a l Government 80 2. Canadian Adult Education Association 80 3. Adult Education Departments 80 4. University of B r i t i s h Columbia ... 81 Footnotes 83 i x PAGE B ib l i og raphy 84 CHAPTER I INTRODUCTION P r i o r to the twentieth century, the physical needs of the i l l were emphasized but a f t e r the turn of the century, other needs of the i l l were given increased attention, r e s u l t i n g i n s o c i a l s c i e n t i s t s becoming ac t i v e i n the health care f i e l d . During the f i r s t h a l f of t h i s century, t h e i r e f f o r t s concentrated on s a n i t a t i o n and contagious disease c o n t r o l . As these conditions have l a r g e l y been brought under c o n t r o l , s o c i a l s c i e n t i s t s have dire c t e d t h e i r a ttention from the physical to psychosocial aspects of disease."*" Ling and O'Malley point out that t h i s psychosocial concept of disease i s not new, having i t s o r i g i n with Hippocrates, and that i t 2 has been a l t e r n a t i v e l y emphasized and neglected. It appears never to have been emphasized as much as i n t h i s century because of the growing number of disabled r e q u i r i n g long term care. Along with the increase i n research i n the psychosocial aspects of disease by s o c i o l o g i s t s , psychologists and s o c i a l anthropologists, the emergence of adult educators i s noted among the s o c i a l s c i e n t i s t s interested i n the health care f i e l d . At some u n i v e r s i t i e s physical modifications and s p e c i a l f a c i l i t i e s , have made i t possible f o r wheel-chair students and b l i n d students to attend. At the University of B r i t i s h Columbia, for example, a s p e c i a l l i b r a r y for students with sight defects and perceptual d i f f i c u l t i e s makes i t unique i n North America. - 2 -Although some educational f a c i l i t i e s are av a i l a b l e i n chronic care h o s p i t a l s and two minor f i e l d studies i n adult education have been undertaken i n one, there does not appear to be a co-ordinated programme by adult educators to p a r t i c i p a t e i n the education of the disabled i n North America. A. PROBLEM UNDER STUDY The physical needs of the c h r o n i c a l l y disabled appear, f o r the most part, to be recognized and adequately met by the medical profession but the psychosocial are not. "Even the p r a c t i t i o n e r ' s t r a d i t i o n a l o r i e n t a t i o n and involvement with the patient and h i s professional reward system may require considerable r e s t r u c t u r i n g as treatment extends not only temporally, but sociopsychologically as 3 w e l l " , Litman states. Also, the government programmes concentrate on vocational r e h a b i l i t a t i o n and employability. Therefore, the psychosocial needs of the c h r o n i c a l l y disabled appear to be overlooked and educational opportunities are not being extended, on an equal basis to a l l who are disabled. "In short, unless a handicapped person i s capable of leaving h i s home, has some means of transportation, can attend a school with no a r c h i t e c t u r a l b a r r i e r s to h i s mobili t y , has no great p h y s i c a l problems which render him 'undesirable' i n the classroom, has no major problem i n communication and has unusual drive and motivation, he i s not very 4 l i k e l y , at present, to be educated." - 3 -B. HOW THE PROBLEM DEVELOPED I n t h i s century we are conf ron ted w i t h growing numbers o f i n j u r i e s i n c u r r e d i n war, i n d u s t r y and t r a f f i c . Advances i n medicine have made i t poss ib le t o su rv i ve many>e acc idents and i l l n e s s e s . Th is i s exemp l i f i ed i n the s t a t i s t i c s t h a t the Uni ted States p o p u l a t i o n has grown by about 2 . 5 - f o l d s ince the t u r n o f the century but the p o p u l a t i o n o f o lde r persons has grown by 7 - f o l d i n the same t ime and i s a c c e l e r a t i n g . Among these s u r v i v i n g acc idents and i l l n e s s e s are m i l l i o n s of people who s u f f e r d i s a b i l i t y . I n the Un i ted S t a t e s , i t i s es t imated t h a t the re are 25,620,000 d i s a b l e d 6 and i n Canada, 2 , 5 0 0 , 0 0 0 . 7 The t rend i s e x e m p l i f i e d by the t o t a l number of members (See F igure 1 ) , the number o f new i n j u r i e s r e s u l t i n g i n d i s a b i l i t y (See Figure 2) and a char t of new i n j u r i e s (See F igure 3 ) , showing major causes, i n the 1972 Annual Report of the Canadian Parap leg ic A s s o c i a t i o n , B r i t i s h Columbia D i v i s i o n . I t i s t o be noted t h a t the b u l k o f new cases were the r e s u l t o f motor v e h i c l e and i n d u s t r i a l a c c i d e n t s , the former p redominat ing . Among the members l i s t e d i n 1971 were 230 non d i sab led and 927 d i s a b l e d . Thus a f f l u e n t s o c i e t i e s o f t e n not on ly produce a h igh l e v e l of w e l f a r e r e s u l t i n g i n improved medical and s o c i a l b e n e f i t s , but a lso an increased f l o w o f t r a f f i c r e s u l t i n g 8 i n more d i sab led people. Figure 1 A Membership Graph Canadian Parap leg ic A s s o c i a t i o n B. C. D i v i s i o n Number o f Members NO 00 ON O rH CM co < t LO NO 00 ON O rH CM m LO u-i NO NO NO NO NO NO NO NO \D NO ON ON ON O l ON ON ON ON ON ON ON ON ON ON ON ON ON rH T—1 rH rH H H rH rH rH rH rH rH rH rH rH rH rH Year Number o f Persons *Source: Canadian Paraplegic A s s o c i a t i o n B r i t i s h Columbia Annual Report 1972 Figure 2 New I n j u r y Growth Year Parap leg ics and Quadr ip leg ics i n B r i t i s h Columbia CM CO < f LO NO 00 ON O rH CM NO NO NO NO vO NO NO NO ON ON ON ON ON ON ON ON ON ON ON rH rH rH rH rH rH rH rH rH rH rH - 5 -FIGURE 3 New Inj u r i e s Chart 1972 Paraplegics and Quadriplegics i n B r i t i s h Columbia CD TYPES o rH CD cd a OF CD •H r4 CD cfl rH i—i 4J CD CO rH rH rH u o CO 4J CO cfl CD DISABILITY cfl CU O -H 3 5-1 rH 0) o 4-1 rH 4-> XI O rH CO CO O O CD C P< n) •H •H H fx< S > M C/3 Pn Q PARAPLEGICS 54 45 9 19 15 1 6 4 8 QUADRIPLEGICS 25 22 3 13 6 4 3 - -TOTAL 79 67 12 32 211 5 9 4 8 Source: Canadian Paraplegic Association B r i t i s h Columbia D i v i s i o n Annual Report 1972 - 6 -C. THE PURPOSE OF THE STUDY The purposes o f t h i s study are t o i n v e s t i g a t e the psychosoc ia l needs of the c h r o n i c a l l y d isab led and t o determine the ex ten t t o which the a d u l t educator can f u r t h e r expand the educa t iona l o p p o r t u n i t i e s which w i l l p a r t i a l l y f u l f i l l these needs. The study w i l l p o i n t out how psychosoc ia l needs o f t e n become predominant over p h y s i c a l and are o f t e n inadequate ly d e a l t h w i t h i n the l o n g - t e r m d i sab led p a t i e n t s . I t w i l l i l l u s t r a t e how a d u l t educators can a s s i s t and have ass i s ted the d i sab led i n educa t iona l f a c i l i t i e s , a t home or i n h e a l t h care f a c i l i t i e s i n Nor th Amer ica, England and Sweden. I t w i l l i n d i c a t e t h a t i f a d u l t educators are to a s s i s t competent ly i n the r e h a b i l i t a t i o n f i e l d , they must undertake s tud ies d i r e c t e d by exper ts such as p s y c h i a t r i s t s , medical s o c i o l o g i s t s and occupa t iona l t h e r a p i s t s . And i t w i l l i l l u s t r a t e the va lue o f f i e l d s tud ies f o r a d u l t educators i n order t h a t they can apply the t h e o r e t i c a l knowledge rece ived and ga in the exper ience necessary to understand and a i d the d i s a b l e d . D. LIMITATION OF THE STUDY There has been l i t t l e research by a d u l t educators w i t h the d i s a b l e d , t h e r e f o r e most of the l i t e r a t u r e i n v e s t i g a t e d and i n t e r v i e w s conducted were i n o ther d i s c i p l i n e s . Often the va lue o f educat ion i n the r e h a b i l i t a t i o n o f the d isab led i s recognized but the v iewpo in t o f educators , i n t h i s p a r t i c u l a r a r e a , i s l a c k i n g . - 7 -E. DEFINITION OF TERMS The f o l l o w i n g d e f i n i t i o n s are s p e c i f i e d f o r t h i s s tudy as d i f f e r e n t connota t ions are suggested i n the l i t e r a t u r e . D i s a b i l i t y : Handicap: Psychosocia l Factors A d i s a b i l i t y i s any p h y s i c a l impairment wh ich , though i t may impede, w i l l not be an obs tac le t o an i n d i v i d u a l ' s achievement o f a s p e c i f i c goal or goa l s ; A handicap i s a p h y s i c a l impairment which i s an obs tac le to an i n d i v i d u a l ' s achievement o f a s p e c i f i c goal or goa ls . The term psychosoc ia l i nc ludes p s y c h o l o g i c a l and s o c i o l o g i c a l f a c t o r s as a s i n g l e e n t i t y which are i n e x t r i c a b l y in te rwoven. R e a l i t y o r i e n t a t i o n i s a technique designed to re-educate a person who shows s igns o f memory l oss and con fus ion f o l l o w i n g an acc ident or an i l l n e s s . At i t s s imples t fo rm, i t uses c e r e b r a l f u n c t i o n s t h a t are s t i l l 9 i n t a c t . 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 takes p lace when there i s recovery t o the maximum t o which a person i s capable of f u n c t i o n i n g . R e a l i t y O r i e n t a t i o n : - 8 -F. METHODOLOGY Personnel and d isab led persons at extended care h o s p i t a l s , r e h a b i l i t a t i o n cent res and u n i v e r s i t i e s , and at home and work were i n t e r v i e w e d . F a c i l i t i e s f o r the d i sab led a t u n i v e r s i t i e s i n Vancouver, B.C. were s t u d i e d . A four month f i e l d study was undertaken a t an extended care h o s p i t a l i n V i c t o r i a , B.C. There were f i v e sub jec ts i nvo lved i n the study and th ree d i f f e r e n t educa t iona l processes were used as i n t e r v e n i n g v a r i a b l e s i n t h e i r r e h a b i l i t a t i o n . There were two o f these people t a k i n g correspondence courses, two p a i n t i n g and one p r a c t i c i n g bas ic p r i n t i n g , coun t ing and r e a d i n g . The study fo l l owed "A Model f o r Research and Eva lua t i on on R e h a b i l i t a t i o n " proposed by Suchman. G. PLAN OF THE STUDY The needs of the c h r o n i c a l l y i l l , the a t t i t u d e of phys ic ians and n u r s i n g pe rsonne l , and the i nc reas ing involvement o f s o c i a l s c i e n t i s t s i n the care of the c h r o n i c a l l y i l l are discussed i n Chapter I I . I n Chapter I I I , the study then cons iders some key f a c t o r s and the r o l e of educat ion i n the r e h a b i l i t a t i o n of the d i s a b l e d . The importance o f m o t i v a t i o n , goals and i n t e g r a t i o n are discussed and case h i s t o r i e s are o u t l i n e d . I n Chapter I V , u n i v e r s i t y e f f o r t s of some u n i v e r s i t i e s which have mod i f i ed campuses to overcome p h y s i c a l b a r r i e r s and which have - 9 -supp l ied necessary se rv ices f o r the d i sab led are considered and a d u l t educa to rs ' c o n t r i b u t i o n and p r e p a r a t i o n i n the r e h a b i l i t a t i o n o f the d isab led are assessed. F i e l d s tud ies at an extended care h o s p i t a l are discussed i n Chapter V. Case s tud ies about educa t iona l e f f o r t s w i t h p a t i e n t s are presented. I n Chapter V I , f i n a l l y , conc lus ions and recommendations are submit ted about the a d u l t educators ' r o l e i n the r e h a b i l i t a t i o n o f the c h r o n i c a l l y d i s a b l e d . - 10 -CHAPTER I FOOTNOTES "'"Gerald Gordon et a l . , Disease, the Individual and Society, (New Haven, Conn.: College and University Press, 1968), pp. 10-89. 2 Thomas M. Ling and C.J.S. O'Malley, R e h a b i l i t a t i o n a f t e r I l l n e s s and Accident, (London: B a l l i e r e , T i n d a l l and Cox, 1958), pp. 5-9. 3 Theodor J . Litman, "Introduction", i n The Sociology and So c i a l Psychology of D i s a b i l i t y and R e h a b i l i t a t i o n , (New York: Random House, 1970), Constantine S a f i l i o s - R o t h s c h i l d , pp. x - x l . 4 L o u i s F. Saylor, "Residential Care Needs: A Report to the C a l i f o r n i a State L e g i s l a t u r e " , ERIC Research i n Education, Vol. 6, No. 1 (January 1971) : 43. "*C. E i s d o r f e r , "A Philosophy for Extended Care", Seminar on Extended Care. (Vancouver, B.C.: B r i t i s h Columbia Hospitals' Association, 26-27 February 1973), p. 4. President's Task Force on the P h y s i c a l l y Handicapped, "A National E f f o r t for the P h y s i c a l l y Handicapped", ERIC Research i n Education, Vol. 6, No. 7 (July 1971): 30. 7Voluntary Association f o r Health and Welfare of B r i t i s h Columbia, Report of the Committee on A r c h i t e c t u r a l B a r r i e r s i n Respect to Building Standards for the Handicapped 1970. Supplement No. 5 to the National Building Code of Canada, p. 10. Q Bengt Mollstedt, Public Health i n Sweden, (Stockholm: The Swedish I n s t i t u t e , 1972), p. 31. American P s y c h i a t r i c Association, R e a l i t y Orientation (Washington, D.C.: American.Psychiatric Association, 1969), p. 2. "^Edward A. Suchman, "A Model for Research and Evaluation on R e h a b i l i t a t i o n " , i n Marvin B. Sussman (ed.), Sociology and R e h a b i l i t a t i o n ; (Washington, D.C. : American S o c i o l o g i c a l Association, 1965), pp. 52-70. CHAPTER I I PSYCHOSOCIAL NEEDS OF THE PHYSICALLY DISABLED The needs of a person w i t h a ch ron ic d i s a b i l i t y o f t e n d i f f e r f rom those o f a person w i t h an acute i l l n e s s . Usua l l y the same p h y s i c a l and psychosoc ia l needs are p resen t , however, the emphasis i s changed. I n the care of the c h r o n i c a l l y i l l the psychosoc ia l needs are o f t e n predominant. Phys ic ians and nurses are main ly occupied w i t h c a r i n g f o r the p h y s i c a l needs of the p a t i e n t , however, as a r e s u l t , the psychosoc ia l needs, p a r t i c u l a r l y of the l ong - te rm d i s a b l e d , are o f t e n not met. Therefore s o c i a l s c i e n t i s t s are becoming more invo lved i n the h e a l t h care f i e l d . A. THE NEEDS OF A PATIENT WITH A CHRONIC DISABILITY When a person s u f f e r s an i l l n e s s or i n j u r y which i s o f comparat ive ly shor t d u r a t i o n and has few, i f any, r e s i d u a l e f f e c t s , t he re i s l i t t l e adjustment necessary. A l though the d i s a b l i n g f a c t o r may be p a i n f u l , cause expense and w o r r y , and d i s l o c a t i o n f rom f a m i l y , f r i e n d s and work, i t w i l l u s u a l l y be o f temporary d u r a t i o n and the person can f o r e s e e , w i t h a reasonable degree o f s u r e t y , h i s r e t u r n to h i s former way of l i v i n g . Th is i s h i s goal and a lso t h a t o f the medical team c a r i n g f o r h im. The c l a s s i c h o s p i t a l model o f care has i t s emphasis on the acute phase of an i l l n e s s , on shor t term acute care where the p a t i e n t ' s s e l f r e l i a n c e i s not encouraged."*" Th is i s the acute care phi losophy (See Phase 1 of F igure 4 ) • I t recognizes t h a t psychosoc ia l needs are always present i n a l l people and increase i n t imes o f s t r e s s , such as i l l n e s s or i n j u r y . But i n t h i s phase they u s u a l l y do not a t t a i n the s i g n i f i c a n c e o f p h y s i c a l needs. For example, a t t h i s s tage , the psychosoc ia l needs are met by v i s i t s of r e l a t i v e s and f r i e n d s , by the knowledge he w i l l be r e t u r n i n g t o h i s home and t o h i s work. He views h i s present p l i g h t as on ly a temporary inconvenience. An i l l n e s s t h a t i s of longer d u r a t i o n may be approaching a chron ic or t e r m i n a l phase and psychosoc ia l and p h y s i c a l needs w i l l o f t e n v i e f o r impor tance; an awareness o f l o s s and p h y s i c a l d i scomfor t w i l l n e c e s s i t a t e an ad-jus tment to b o t h . This r e q u i r e s a long term acute care ph i losophy (See Phase 2 of F igure 147) . F i n a l l y , an i l l n e s s o f long d u r a t i o n enters the chron ic phase. Except f o r t e r m i n a l i l l n e s s , Wesson exp la ins t h a t as the chron ic phase o f an i l l n e s s man i fes ts i t s e l f the emphasis should be on r e h a b i l i t a t i v e care where m o t i v a t i o n to master d i s a b i l i t i e s must be mob i l i zed and where the p a t i e n t takes an a c t i v e p a r t i n a j o i n t endeavour 2 w i t h the s t a f f . This i s the chron ic care ph i losophy (See Phase 3 o f F igure A1)- For the p a t i e n t f u r t h e r adjustment i s necessary and psy-chosoc ia l needs may become predominant as he recognizes t h e r e w i l l be no r e t u r n to the s t a t u s quo of h i s l i f e p r i o r to d i s a b i l i t y . - -13 -FIGURE 4-? PHASE 1 HEALTH CARE* PHASE 2 PHASE 3 Acute Care Philosophy PHYSICAL CARE Psychosocial Care Long Term Acute Care Philosophy PHYSICAL CARE PSYCHOSOCIAL CARE Care _^ Chronic Care Philosophy PSYCHOSOCIAL CARE Physical Care Categories are r e v e r s i b l e , for an acute i l l n e s s may develop into a chronic phase and chronic i l l n e s s may develop an acute phase, chronic phas If we are to achieve a balanced environment when developing psychosocial care programmes for the disabled, the emphasis must be on the s o c i a l needs. Although between 34.6%and 43.7 percent of male and female claimants f o r d i s a b i l i t y b enefits i n a sample of phy s i c a l d i s a b i l i t y benefits i n the United States showed an elevation i n the neurotic t r i a d (hypochondriasis, depression and hysteria) and had 3 moderate to severe psychoneuroses or personality disorders , Wright states that the disabled do not present as many psychological problems as believed. The problems are of s o c i a l o r i g i n a f f e c t i n g the psycholo-4 g i c a l adjustment of the i n d i v i d u a l . . B. THE RELATIONSHIP OF PHYSICIANS IN THE CARE OF THE CHRONIC For the decade 1963-1973, Dr. Szasz, the Director of the - 14 -D i v i s i o n o f I n t e r p r o f e s s i o n a l Educat ion o f the U n i v e r s i t y o f B r i t i s h Columbia, s ta ted t h a t the psychosoc ia l needs were being recognized more by the medical p r o f e s s i o n . yButh\ / ' * • R e l a t i v e s >r S o c i a l ' / A c t i v i t i e s , . Home \ t o o d Healttt \ / Job T r a v e l \ > / 7 \ FIGURE 5 T h e o r i z e d P r o g r e s s i o n from " N o r m a l " L i f e to D i s a b l e d w i t h P o s s i b l e Complete Withdrawal and the Role Educators may P l a y to Prevent o r A l l e v i a t e W i t h d r a w a l . y\ .*;Th't rpV..'.' • * '•' * r\ Frji,ehds...'JA. i>,:Re 1 at i ve s_v _ \ v ,'Ae t i v i t i e s/;;-i :Hqra4v'... •• '-.y^'v.''! ;-x e o 6 a , - x , V i - i N^/'rJobV4-' T.ra-ve'i^-'.^:^y' X _'. I n t r o s p e c t i o n ' ' -• Complete_Withd,rawal ,.*'•'•' Fantasy . * / ' * . : ' • ' - 58 -2. Use of a Model f o r Assessment A model f o r research and e v a l u a t i o n on r e h a b i l i t a t i o n by Suchman was used, however, the p r e c o n d i t i o n i n g v a r i a b l e was not i nco rpo ra ted owing to the f a c t t h a t i t was not poss ib le to o b t a i n 4 enough i n f o r m a t i o n p r i o r to d i s a b i l i t y on t h i s group o f peop le . (See F igure v6"~) FIGURE &1 MODEL FOR ASSESSMENT P r e c o n d i t i o n i n g Independent Va r i ab le V a r i a b l e PRE-EXISTING CONDITIONS _V DISABILITY I n t e r v e n i n g Va r iab le Dependent V a r i a b l e -i REHABILITATION ~* CONSEQUENCES 3. D i v i s i o n o f Study i n t o Four phases. Phase I Overview o f the h o s p i t a l , t h r e e weeks, June 1-22 1 . General Phi losophy of the H o s p i t a l 2. Residents and S t a f f 3. Methods o f Car ing f o r the P a t i e n t s - 59 -Phase II F a m i l i a r i z a t i o n of residents assigned, seven weeks, June 25 - August 10 1. Study of Medical History 2. Recreation - Car Rides, Bowling, Planters, etc. 3. R e a l i t y Therapy 4. Mealtime i n Separate Dining Room Phase III Educational process to be added to those a c t i v i t i e s i n Phase I I , complying with a b i l i t i e s and i n t e r e s t s of the resident, f i v e weeks, August 13 - September 14. 1. Short Correspondence Course on B.Cg^ 2. Correspondence Course on Painting. 3. P r a c t i c e on re-learning to p r i n t , read and count. Phase IV Re-integration with population of the h o s p i t a l , two weeks, September 17-30. 1. Recreation 2. Mealtime 3. Continuation of Correspondence Courses D. Report on Hospital i n Phase I. General Overview of the Hospital At the P r i o r y Hospital an e f f o r t i s made to have as "homey" an atmosphere as possible. Nursing personnel do not wear uniforms, v i s i t i n g hours are not regulated, c h i l d r e n and animals are allowed to v i s i t and the residents are dressed i n adaptable regular c l o t h i n g and i n the lounge or a c t i v i t y room as much as possible. Mental stimulation i s encouraged. A l l rooms have calendars and clocks and d i f f e r e n t colours are used on doors i n order that the resident may i d e n t i f y her room. The day s t a r t s e a r l y , the resident i s washed and dressed and given f r u i t j u i c e . She then goes into the dining room for breakfast, followed by exercise and r e a l i t y o r i e n t a t i o n - 60 -i n a s u i t a b l e group. I n the summer the re are such a c t i v i t i e s as bus r i d e s , barbecues and bow l ing . At o ther t i m e s , those who are able make hobby i t ems , decora t ions f o r Christmas and presents f o r c r i p p l e d c h i l d r e n . Community involvement i s encouraged, f o r example, the P r i o r y has a m i n i a t u r e rodeo, hot dogs and s o f t d r i n k s are served and the members o f the community are i n v i t e d . The r e s i d e n t s are a lso taken out t o the highway t o watch the l o c a l parade and were o b v i o u s l y d e l i g h t e d when the sen io r R.C.M.P. o f f i c e r sa lu ted them; thus they i n t e r a c t w i t h the community. I n a l l these a c t i v i t i e s the re i s an e f f o r t to f u l f i l l the th ree ca tegor ies o u t l i n e d i n Chapter I I I , t h a t o f s t i m u l a t i n g m o t i v a t i o n , se rv ing a purpose f o r a c t i v i t i e s , and making e f f o r t s at i n t e g r a t i o n . Bu t , even w i t h these e f f o r t s , t h e r e i s some s e g r e t a t i o n . The h o s p i t a l i s e i g h t mi les from the c i t y and set back f rom the highway. A l s o , a l l r e s i d e n t s are women, t h e r e f o r e i t i s not a "no rma l " p o p u l a t i o n . Even husband and w i f e may be separated owing to the f a c t t h a t sexes are separated o r d i f f e r e n t l e v e l s of care are r e q u i r e d . They are then p laced i n " a p p r o p r i a t e " accomodation. For example, one n i n e t y - t w o year o l d husband was at a board ing home across the road w h i l e h i s e i g h t - e i g h t year o l d w i f e was at the extended care h o s p i t a l . Residents could a lso be ou ts ide more o f t e n . At the present t i m e , a l l o u t s i d e areas are access ib le on ly by ramp but as some r e s i d e n t s cannot be l e f t unattended o u t s i d e , t h e r e were many f i n e days - 61 -when they were i n s i d e . I f the l a r g e p a t i o w i t h umbrel las and t a b l e s were made l e v e l w i t h t h e i n s i d e f l o o r , r e s i d e n t s cou ld be o u t s i d e and ye t remain i n f u l l v iew from i n s i d e . Th is would make i t easy to wheel them i n t o a t tend to personal needs and back out aga in . A l s o , i n t e r a c t i o n between r e s i d e n t s was not encouraged as much as i t might have been. This i s most impor tant as s t a f f and v o l u n t e e r s change and the r e s i d e n t s form the s t a b l e p o p u l a t i o n . The r e s i d e n t s were d i v i d e d i n t o two groups the f i r s t , apparen t l y s u f f e r e d l i t t l e r e t r o g r e s s i o n or w i t h d r a w a l . They a te i n a smal l d i n i n g room which a l lowed some contac t du r i ng a c t i v i t i e s and mealt imes but each day they had a "happy hour" which was conducted by a vo lun tee r or a member o f the s t a f f , read ing f rom newspapers, conduct ing d i s c u s s i o n s , b a k i n g , e t c . The r e s i d e n t s were arranged i n a s e m i - c i r c l e around the person conduct ing the sess ion . Nothing was done t o break up the group and have d iscuss ions among the peers so n e a r l y a l l conversa t ion was d i r e c t e d t o he r ; the shyer ones never had much chance to p a r t i c i p a t e . The second group was main ly composed of r e s i d e n t s who were s u f f e r i n g v a r y i n g degrees o f r e t r o g r e s s i o n , w i thd rawa l and c o n f u s i o n . There were two t a b l e s i n t h e i r a c t i v i t y room on which e i g h t were able to have meals. The o thers were placed around the pe r iphe ry of the room w i t h i n d i v i d u a l t r a y s and t h e r e f o r e l i t t l e chance f o r i n t e r a c t i o n , f o r the persons i n t h e i r l i n e of v i s i o n were too f a r away. A l though i t - 62 -would be l e s s convenient to look a f t e r t h e i r needs, i f the chairs were placed i n small groups there would have been more c o n v i v i a l i t y and more chance for s o c i a b i l i t y even when conversation made l i t t l e sense. In summary, the p o s i t i v e aspects f a r outweighed the negative i n these general observations of the f i r s t two weeks. 5. Report on Residents Assigned i n Phases I I , III & IV a. General Means of R e h a b i l i t a t i o n The report i s made on an i n d i v i d u a l b a s i s . The means of r e h a b i l i t a t i o n which were common to a l l are l i s t e d . ( i ) The selected residents were seated i n t h e i r own dining room for a l l meals, the group with i t s own table set with a table c l o t h and s i l v e r . ( i i ) They were taken on such outings as car r i d e s , "walks", i n the garden, barbecues, bowling, they set up planters with the gardener and v i s i t e d at the home for the r e t i r e d nearby. ( i i i ) They attended general a c t i v i t i e s of the h o s p i t a l which were of i n t e r e s t to them. (iv) Each day each member had a personalized o r i e n t a t i o n session. These could not be given as a group because of the d i s p a r i t y i n l e v e l s of function and i n t e r e s t . (v) They were often given sensory stimulation. T a c t i l e was sometimes the only means of communication. Besides t a c t i l e , such as holding hands, putting an arm around t h e i r shoulders or giving them plants and s o i l to f e e l when arranging planters, v i s u a l and auditory means were used. It was found that speaking to them and s i t t i n g i n front of them were more h e l p f u l than t e l e v i s i o n or movies where they would often doze when not c a l l e d upon to respond. - 63 -b. I n d i v i d u a l Means o f R e h a b i l i t a t i o n Phase I I , I I I & IV (F igure 6) Resident No. 1 H i s t o r y D i s a b i l i t y Rehab i l i t a t i o n Goal: Means: Consequences: Born i n 1905. Resident o f the h o s p i t a l s ince 1968. Park inson 's Disease, w e l l managed on the med ica t ion o f L-Dopa. Able to walk but subj ect to f a i n t n e s s and spasms o f the eyes. Gets f i t s of depress ion . Restore s e l f esteem, a s , accord ing to s t a f f r e p o r t s , t h i s r e s i d e n t had two changes i n her environment i n the l a s t few years . Her r e l a t i o n s w i t h her f a m i l y had been s t r a i n e d and her p o s i t i o n i n the h o s p i t a l had been changed. I n p r i o r years she had been prominent owing t o her progress and c a p a b i l i t y but now was inconspicuous owing t o the change i n p o p u l a t i o n . A s s i s t w i t h the r e s t o f the group assigned who were obv ious ly not as capable . Take correspondence course on B r i t i s h Columbia f o r which she would rece ive a d ip loma. Her s e l f esteem was r e - i n f o r c e d i n the group as she was capable of a i d i n g the o t h e r s , s e t t i n g the t a b l e , h e l p i n g them eat and j o i n i n g them i n a c t i v i t i e s , i n a l l o f which she was obv ious l y s u p e r i o r . She completed the correspondence course and rece ived her diploma b u t , a long w i t h her o ther d u t i e s , i t was d i f f i c u l t to ass ign any p o s i t i v e gains a t t r i b u t a b l e to a d e f i n i t e v a r i a b l e , however, persona l assessment would favour the f i r s t , her p o s i t i o n as leader i n the group. - 64 -F i n a l l y , she was able to re-integrate well at the end of the summer. Resident No. 2 History D i s a b i l i t y Born i n 1883. Resident of the h o s p i t a l since A p r i l , 1973. A r t e r i o s c l e r o s i s . Disoriented and extremely agitated much of the time. R e h a b i l i t a t i o n Goal: To improve s o c i a l i z a t i o n with s t a f f and peers. To c o n t r o l a g i t a t i o n and improve r e c o l l e c t i o n of r e l a t i v e s . Means: by he Consequences: Besides the general means of r e h a b i l i t a t i o n l i s t e d , she had many pictures of friends and r e l a t i v e s shown to her and discussed with her. A pi c t u r e of her farm was placed by her bed. Her s o c i a l i z a t i o n was improved as evidenced by the fac t that many of her s o c i a l graces returned. At f i r s t , at the dining table, she would take the food from others and use any u t e n s i l s but at the end of two weeks, she was keeping her place t i d y , f o l d i n g her s e r v i e t t e and never touching others' food. She offered her desserts to others, enjoyed going for rid e s i n the car and out i n the garden and talked with others. Over a few weeks, i n r e a l i t y therapy sessions, she remembered her dead husband, asked about s i b l i n g s and spoke of her ch i l d r e n , but did not remember when the l a t t e r saw her. She recognized photographs of friends and r e l a t i v e s and a picture of her farm. She remembered her name and wished to be ca l l e d by a "nickname". It i s mentioned that progress i n r e h a b i l i t a t i o n i s made when the person assumes h i s i d e n t i t y by remembering his name.7 Although her mental improvement was noticeable under the personal therapy she s t i l l became extremely agitated and usually, by l a t e afternoon, could not be consoled. At the end of July, she died from pneumonia. - 65 -Resident No. 3 H i s t o r y Born i n 1885. Resident of the h o s p i t a l s ince 1971. D i s a b i l i t y Unable t o walk because of the e f f e c t s of a s t r o k e . Spoke on ly g i b b e r i s h . Had days when she could not be aroused. R e h a b i l i t a t i o n Goal: To improve s o c i a l i z a t i o n . To be able t o communicate i n t e l l i g i b l y . To be ab le t o use u t e n s i l s w i t h which t o read and w r i t e . To s t i m u l a t e her i n o rder t h a t she stayed awake each day. To i n t e r a c t p l e a s i n g l y w i t h peers and s t a f f . Means: Besides the general means o f r e h a b i l i t a t i o n l i s t e d , a r e - e d u c a t i o n a l process was used, t h a t of r e a d i n g , w r i t i n g and c o u n t i n g . Consequences: I n the second phase of the s tudy , as a r e s u l t o f s t i m u l a t i o n i n the form of personal a t t e n t i o n , car r i d e s , "wa lks " i n the garden and o t h e r s , t h i s r e s i d e n t became a l e r t most o f the t i m e . She p r o g r e s s i v e l y improved i n her speech, f rom the g i b b e r i s h she spoke i n i t i a l l y , t o sens ib le and p l a i n words, f o r example, by J u l y 6, she c a l l e d " n u r s e " . The f o l l o w i n g week she spoke s e n s i b l y a l l the t ime I had her out w i t h the group f o r a car r i d e but re fused t o say any th ing when she re tu rned to the h o s p i t a l . By J u l y 20, she was speaking many i n t e l l i g i b l e sentences and expanding her environment by t a l k i n g w i t h o ther r e s i d e n t s , t h e i r f r i e n d s and r e l a t i v e s . I n the t h i r d phase, she cont inued to be a l e r t and t a l k a t i v e a l though much was s t i l l g i b b e r i s h . She was never un res -pons ive . She at tended movies, c h o r a l groups and church s e r v i c e s . She - 66 -commented when another member of the group appeared to be s u f f e r i n g and even n o t i c e d a change i n h a i r s t y l e of another . She has been read ing her name, p r i n t i n g , count ing and even c o r r e c t e d me on the p ronounc ia t i on of her name. I n r e c o g n i z i n g her name she evidenced the f i r s t step i n her r e h a b i l i t a t i o n 8 but i n coming back t o r e a l i t y , the unpleasant as w e l l as the p l e a s a n t , are r e c a l l e d . At t imes she would remember - ' her l i f e l o n g companion, a s i s t e r who was dead, and would cry and c a l l her name. I n the f o u r t h phase, she appears to be i n t e g r a t i n g w e l l . Resident No. 4 H i s t o r y D i s a b i l i t y Born i n 1901. Resident o f the h o s p i t a l s ince 1968. Stroke r e s u l t i n g i n r i g h t s ided hemip leg ia and aphas ia . Heart c o n d i t i o n . Signs of w i t h d r a w a l . R e h a b i l i t a t i o n Goals: Means: I n t e r a c t i o n w i t h s t a f f , peers and o t h e r s . Hold head u p r i g h t . Improve speech. A t tend group a c t i v i t i e s . Besides the genera l means o f r e h a b i l i t a t i o n l i s t e d , s p e c i a l a t t e n t i o n was g iven i n an at tempt t o ga in conf idence and encourage i n t e r a c t i o n , fFor example, she was spoken t o o f t e n and ample t ime a l lowed f o r r e p l y and r e p e t i t i o n of r e p l y i f not unders tood. A h a l t e r was designed t o f i t over her head and used f o r t h ree minutes th ree t imes a day to help her t o ho ld her head i n the c o r r e c t p o s i t i o n . She was taken out around grounds and h o s p i t a l where she would meet o thers r a t h e r than remain i n the T.V. room by h e r s e l f . - 67 -She was moved to more c h e e r f u l surroundings as a l l the p a t i e n t s i n t h i s ward were very i l l . A vo lun tee r was approached t o make r e g u l a r v i s i t s to he r . A correspondence course was arranged w i t h her pe rm iss ion . Consequences: I n the second phase, s ince j o i n i n g the group and be ing g iven l o t s o f encouragement, she was t r y i n g to s i t w i t h her head up. She had i n i t i a t e d smi les and s t a r t e d a conversa t ion w i t h the nurse i n which she t o l d her a l l about a bus t r i p she had taken on the p r i o r day. She a lso spoke of her husband, s t a t i n g t h a t he was dead. She had re fused to admit t h i s i n a p r i o r conve rsa t i on . I n the t h i r d phase, she completed the course on B r i t i s h Columbia. I t appeared p a r t i c u l a r l y u s e f u l to t h i s l a d y , not because o f the course c o n t e n t , but f o r the f a c t i t drew o thers i n t o conversa t ion w h i l e we went over the lessons i n the a c t i v i t y room, i n the ward o r ou ts ide i n the garden. Fel low r e s i d e n t s , nurses and v i s i t o r s i n q u i r e d what we were do ing . I n t e r e s t i n g conversat ions f o l l o w e d and o f t e n the lesson was f o r g o t t e n . I n the f o u r t h phase, she appears to be i n t e g r a t i n g w e l l . She has shown some improvement, o f t e n s m i l i n g and speaking w i t h me. However, i t i s n o t i c e d t h a t she does not i n t e r a c t w i t h peers and she very r a r e l y i n i t i a t e s conversa t ion w i t h nurses. Resident No. 5 H i s t o r y : Born i n 1885. Resident of the h o s p i t a l s ince J u l y 26, 1973. D i s a b i l i t y : Post f r a c t u r e d femur. P a r t i a l l y deaf . - 68 -R e h a b i l i t a t i o n Goals: Means: Consequences: As she does n o t h i n g , encourage her to use her l a t e n t a b i l i t i e s , p a i n t i n g and p l a y i n g the p iano . Have her p lay the piano i n the a c t i v i t y room f o r shor t sessions a few t imes a day. Have her take a correspondence course on p a i n t i n g f o r p leasu re , j o i n e d by another who a lso used to water co lour as a hobby. She was not w i t h the group l o n g , having come to the h o s p i t a l at the end o f J u l y . She appeared t o have p leasure w i t h her piano p l a y i n g and to enjoy her p a i n t i n g f o r shor te r per iods of t ime . Of the two, the piano p l a y i n g appeared the more b e n e f i c i a l . 6. Fol low-up Report on Residents Assigned. A Report on Residents i n the Study was obta ined on 14 December 1973. Resident No. 5 had broken her h ip aga in i n October, 1973 and had been removed to another h o s p i t a l . However, Vera Mclver repor ted t h a t the o the rs appeared t o have main ta ined much of the improvement evidenced du r ing the s tudy . 7. Conclusion o f the Second Study There are some d i f f i c u l t i e s i n a r r i v i n g at a s c i e n t i f i c assessment f o r any study of t h i s t y p e . F i r s t l y , i t i s d i f f i c u l t t o measure behavior i n t imes o f i l l n e s s , t h e r e f o r e the study has been t h e o r e t i c a l and d e s c r i p t i v e , but - 69 -not a n a l y t i c a l . Conclusions were ob ta ined f rom the w r i t e r ' s observa t ions r e - i n f o r c e d by members of the h o s p i t a l s t a f f . Secondly , . i n i t i a l l y t he re was not s u f f i c i e n t t ime or o p p o r t u n i t y t o study the r e s i d e n t s assigned be fo re new r e h a b i l i t a t i o n measures were under taken. T h i r d l y , i t was not p o s s i b l e to determine the pre-morb id c o n d i t i o n o f the r e s i d e n t s as the re i s l i t t l e record p r i o r t o d i s a b i l i t y ; t h e r e f o r e the p r e c o n d i t i o n i n g v a r i a b l e was omi t ted f rom Suchman's model f o r assessment. F o u r t h l y , i t was not f e a s i b l e to i s o l a t e any p o s i t i v e ga in and a t t r i b u t e i t to any s p e c i f i c a c t i v i t y , such as educa t ion , as many o ther i n t e r v e n i n g v a r i a b l e s were a lso i nvo l ved such as the in tense persona l i n t e r e s t shown t o these r e s i d e n t s who were p a r t of the s tudy . I n c o n c l u s i o n , the r e s i d e n t s appeared to b e n e f i t f rom the s p e c i a l care they rece ived and not to form any dependency which would have to be te rmina ted at the end o f the s tudy . A l though they had to be t r e a t e d w i t h some concessions owing t o t h e i r s t a t e o f h e a l t h , t h i s was accomplished by r e s p e c t i n g them and r e l a t i n g t o them as mature peop le . The d isc repanc ies i n t h i s type o f study are apparent , f o r example, the smal l sample chosen f o r the study and the shor t t ime engaged i n the study but the p o s i t i v e r e s u l t s obta ined would i n d i c a t e the va lue of more leng thy and i n t e n s i v e i n v e s t i g a t i o n . - 70 -An observa t ion was made of o t h e r s , i n the area of psychology, who at tempted a study here w i t h o u t the necessary medical background. As s t a t e d by Dr. S z a s z , e d u c a t o r s are not u t i l i z e d i n the D i v i s i o n of I n t e r p r o f e s s i o n a l Educat ion at U n i v e r s i t y of B r i t i s h Columbia because they u s u a l l y l a c k the medical background. This could a lso app ly to psycho log i s t s and s o c i o l o g i s t s , f o r i n any medical f i e l d i t i s necessary t o have some unders tanding o f the medical aspects i n order t o f u n c t i o n i n a p o s i t i v e manner. Observat ions here r e i n f o r c e d h i s s ta tement , f o r example, one student m i s i n t e r p r e t e d the hand l ing of h i s cases as being p rogress ive ins tead o f ev idenc ing dependency and depress ion . As a r e s u l t t h e r e was r e t r o g r e s s i o n i n the p a t i e n t s under h i s c a r e . I I I . Summary Knowing t h a t many s tud ies have shown tha t h igher m o r b i d i t y and 12 m o r t a l i t y ra tes occur when the e l d e r l y enter i n s t i t u t i o n s , e f f o r t s are made here to s o f t e n the trauma of d i s l o c a t i o n . However, no s tud ies were l oca ted comparing the l e n g t h of s tay o f the e l d e r l y i n v a r i o u s types of i n s t i t u t i o n s , reasons f o r t e r m i n a t i o n and i n d i c a t i o n s of the k ind of care which appears t o r e s u l t i n happier and longer l i v e s . The summer of 1973 study was d i r e c t e d at the r e a c t i v a t i o n programme of the P r i o r y and the va lue of psychosoc ia l care f o r long term cases was e x e m p l i f i e d by these peop le . Educat ion was one v a r i a b l e used 13 as the re i s a need f o r d i v e r s i o n a l a c t i v i t i e s i n the f i e l d o f g e r i a t r i c s and educat ion and r e - e d u c a t i o n can be among them. Government programmes - 71 -i n the States are sa id to have been designed to meet v o c a t i o n a l needs and the re i s need t o improve and ma in ta in the p h y s i c a l c o n d i t i o n o f 14 e l d e r l y s t roke p a t i e n t s . This may apply t o any d i s a b i l i t y . The P r i o r y H o s p i t a l does much to a c t i v a t e the r e s i d e n t s and to meet t h e i r psychosoc ia l needs. However, some d e f i c i e n c i e s i n extended h o s p i t a l care were no ted . For i n s t a n c e , each h o s p i t a l should have a l l l e v e l s o f care and bo th sexes, more c l o s e l y approx imat ing the ou ts ide community. I f a t a l l p o s s i b l e , husbands and wives should not be separated. Couples who have l i v e d toge ther many years f i n d themselves alone when o f t e n they need each o ther the most. An e l d e r l y couple v i s i t i n g at the h o s p i t a l sa id they feared some i l l n e s s t h a t would separate them. Death i s i n e v i t a b l e but premature s e p a r a t i o n , i n the name o f e f f i c i e n c y or economy, can be d e t r i m e n t a l . A l s o , h o s p i t a l s should be p laced where the a c t i v i t i e s o f the community may be observed by the r e s i d e n t s , day by day, not as an excurs ion t r e a t . W i t h i n t h i s h o s p i t a l , t h e r e should a lso be an area reserved f o r r e s i d e n t s to be alone i f they wished sec lus ion f o r a shor t t i m e . Now they are always w i t h o t h e r s , t he re i s no p lace t o d i s p l a y emotions or f o r peace fu l s o l i t u d e , even t h e i r rooms are shared w i t h o t h e r s . There used t o be a chapel f o r r e f u g e , but even t h i s space has been u t i l i z e d f o r d i n i n g and a c t i v i t y a rea . - 72 -As f a r as the s t a f f i s concerned, t h e r e was a tendency and evidence t h a t s t e r e o t y p i n g takes p l a c e , w i t h r e s u l t a n t expectancies t h a t a d e f i n i t e response was to be expected f rom c e r t a i n types o f i l l n e s s . For example, one woman was i n t e a r s and bo th the nurse and a c t i v i t i e s c o - o r d i n a t o r s t a t e d t h a t the reason was she was a s t roke case. When spoken t o , her depress ion a t t h i s t ime was due to the f a c t her husband, who was i n a board ing home, had been taken to h o s p i t a l . There fo re , t h e r e should be g rea te r understanding t h a t many r e a c t i o n s are "normal " i n any s t r e s s f u l s i t u a t i o n , depress ion may be caused by the r e s u l t s o f d i s a b i l i t y , f o r example, by the f a c t of separa t i on f rom loved ones, worry over them and f r u s t r a t i o n at p h y s i c a l d i s a b i l i t y and not n e c e s s a r i l y a t t r i b u t e d t o the cause o f d i s a b i l i t y . A l s o , the s t a f f should t r e a t the d isab led l i k e the "normal " p o p u l a t i o n . They should accept some o f the r e s p o n s i b i l i t y f o r t h e i r ac t i ons and not be over indu lged but does t h i s a lso mean t h a t they are not to rece ive l i t t l e personal a t t e n t i o n s which would be g iven ou ts ide an i n s t i t u t i o n , take l i t t l e t ime and make the a t tendant a f r i e n d r a t h e r than a custodian? For example, when a r e s i d e n t i n the main d i n i n g room had a spasm i n her eyes which made i t imposs ib le f o r her t o e a t , a wet c l o t was g iven to her to p lace over her eyes, then she was l e f t a lone . I t was not long before she removed i t , put on her glasses and f i n i s h e d her d i n n e r . The nurses be l i eved she was be ing s p o i l e d , ye t she was on ly g iven a l i t t l e c o n s i d e r a t i o n and r e c o g n i t i o n t h a t she had a d i f f i c u l t y and t h a t someone cared . - 73 -Nurses should a lso take care not to i n i t i a t e a s i t u a t i o n t h a t cannot be ma in ta ined . As has been exp la ined i n the case h i s t o r i e s , Resident No. 1 , had been the ob jec t o f s p e c i a l a t t e n t i o n u n t i l the a r r i v a l of more r e s i d e n t s w i t h equal c a p a b i l i t i e s d ispersed t h i s a t t e n t i o n among o thers and had a d e l e t e r i o u s e f f e c t on her . A s o c i o l o g i s t aware of medical problems might be u s e f u l i n c l a r i f y i n g these issues and a i d i n g nurses to a t t a i n a more s e n s i t i v e approach and s t i l l to avo id indu lgence. I n regard to the care o f r e s i d e n t s , Vera Mclver"*"^ b e l i e v e s t h a t nurses should use judgment and accept r e s p o n s i b i l i t y , a t t imes , whether j u s t i f i e d or n o t , f o r any nega t i ve behaviour o f r e s i d e n t s . By her example, she does much t o preserve the d i g n i t y o f the r e s i d e n t s and ma in ta in e q u i l i b r i u m among t h i s ve ry f r a g i l e p o p u l a t i o n . She has nurses aides a t t h i s h o s p i t a l t r a i n e d i n t h e i r ph i losophy and, d e s p i t e the few d e f i c i e n c i e s no ted , they d i s p l a y an understanding of many of the problems o f the c h r o n i c a l l y i l l . This i s most impor tant as the problems o f the e l d e r l y are o f t e n s o c i a l and p s y c h o l o g i c a l r a t h e r than medical and t e c h n i c a l " ^ as has been demonstrated i n t h i s t h e s i s f o r a l l l o n g -term d i s a b l e d , regard less of age. - 74 -FOOTNOTES CHAPTER V E. G. Q. Van T i l b u r g , Review o f B.C.H.A. Report on Extended Care, T r a n s c r i p t of Seminar on Extended Care, (Vancouver, B.C. : February 26-27, 1973) , pp. 86 and 88. 2 Vera Mc lver , R.N. , D i r e c t o r o f H o s p i t a l Serv ices , S t . Mary 's P r i o r y H o s p i t a l , V i c t o r i a , B.C. , " R e b i r t h o f an I d e n t i t y " , unpubl ished r e p o r t o f a study done a t the h o s p i t a l , February 1969, pp. 1-9. Mar ie-Lou ise Holden, Graduate Student , Adu l t Educat ion Research Cent re , U n i v e r s i t y o f B r i t i s h Columbia, F i e l d Study, S t . Mary 's P r i o r y H o s p i t a l , V i c t o r i a , B.C. , June 1 - September 30, 1973. 4 Edward A. Suchman, "A Model f o r Research and E v a l u a t i o n on R e h a b i l i t a t i o n " , i n Sociology and R e h a b i l i t a t i o n , e d i t e d by Marv in B. Sussman, (Washington, D.C. : S o c i o l o g i c a l A s s o c i a t i o n , 1965) , pp. 52-70. ^B.C. Correspondence Educat ion , V i c t o r i a , B .C. , " B r i t i s h Columbia, Canada's P a c i f i c P r o v i n c e " . I b i d . , " P a i n t i n g f o r P leasu re " . M u r i e l Ober leder , "Res to r ing the Aged Men ta l l y I I I Through R e a l i t y O r i e n t a t i o n " , R e a l i t y O r i e n t a t i o n , (Washington, D.C. : The H o s p i t a l and Community P s y c h i a t r i c Se rv i ce , American P s y c h i a t r i c A s s o c i a t i o n , compiled by Louise P. Stephens, August 1969) , p. 7. 8 Loc. c i t . Vera Mc lver , R.N. , D i r e c t o r of H o s p i t a l Serv ices , S t . Mary 's P r i o r y H o s p i t a l , V i c t o r i a , B.C. Telephone Communication 16, December, 1973. Theodor J . L i tman, " I n t r o d u c t i o n " , The Sociology and Soc ia l Psychology of D i s a b i l i t y and R e h a b i l i t a t i o n , Constant ine S a f i l i o s -R o t h s c h i l d , (New York: Random House, 1970) p. v i i i . - 75 -I n t e r v i e w s w i t h George Szasz, M.D., D i r e c t o r , D i v i s i o n o f I n t e r p r o f e s s i o n a l Educat ion , U n i v e r s i t y of B r i t i s h Columbia, June 1971 and 15 October 1973. 12 Barbara T. Turner , Sheldon S. Tobin and Morton A. Lieberman, " P e r s o n a l i t y T r a i t s as P r e d i c t o r s of I n s t i t u t i o n a l Adap ta t ion Among the Aged", Journa l o f Geronto logy, V o l . 27, No. 1 (1972): 61-8 . 13 Helen S. W i l l a r d and Clare S. Spackman, Occupat ional Therapy, ( P h i l a d e l p h i a : J . P. L i p p i n c o t t Company, 1971) , p. 10. 1 4 J . B. Haese, A. B. T r o t t e r and R. T. F l ynn , " A t t i t u d e s o f Stroke P a t i e n t s toward R e h a b i l i t a t i o n and Recovery" , The American Jou rna l o f Occupat ional Therapy, V o l . 24, No. 4 (May-June 1970) : 289. "^Vera Mc lver , R.N. , I n t e r v i e w August, 1973. 16 Benjamin B. We l l s , "The Long Term I m p l i c a t i o n s o f R e a l i t y O r i e n t a t i o n " , R e a l i t y O r i e n t a t i o n , (Washington, D.C. : American P s y c h i a t r i c A s s o c i a t i o n , compiled by Louise P. Stephens, August 1969) , p. 10. - 76 -CHAPTER V I CONCLUSIONS AND RECOMMENDATIONS A. CONCLUSIONS As the d isab led increase i n numbers, i t f o l l o w s t h a t t h e i r needs increase and o f t e n psychosoc ia l needs predominate over p h y s i c a l . I t i s necessary t o f u r t h e r d i f f e r e n t i a t e the psychosoc ia l i n t o psycho log i ca l and s o c i o l o g i c a l as i t i s t h e o r i z e d t h a t t he re i s more immediate necess i t y f o r the s o c i a l needs to be met; t h e r e f o r e , the emphasis on s o c i a l s c i e n t i s t s i n the chron ic care f i e l d i s f o r s o c i o l o g i s t s and a d u l t educators . F u r t h e r , they shoulddbe a p a r t of the r e h a b i l i t a t i o n team and should have courses a v a i l a b l e i n order to increase t h e i r competence i n t h i s a rea . W i t h i n the r e h a b i l i t a t i o n team, they could f u n c t i o n t o s t i m u l a t e m o t i v a t i o n , f u r n i s h goals and a i d i n the s o c i a l i z a t i o n o f the d i s a b l e d . I n order to do t h i s they would have to contac t the d i s a b l e d . Y e t , there i s no comprehensive r e g i s t r y o f the d i s a b l e d . As a r e s u l t , the p res iden t o f the Canadian Medical A s s o c i a t i o n s t a t e s t h a t P r o v i n c i a l governments do not know the number o f para lyzed p a t i e n t s o r the ex ten t of the prob lem.^ Before e s t a b l i s h i n g such a r e g i s t r y an educa t iona l campaign would have to be d i r e c t e d to the p o p u l a t i o n as a whole, f o r s t i l l today t h e r e appears to be an ou t -da ted a t t i t u d e a s s o c i a t i n g d i s a b i l i t y w i t h s t igma. - 77 -The va lue o f educat ion f o r the d i s a b l e d , whether f o r monetary ga in or personal enr ichment , i s an impor tan t ad junc t i n r e h a b i l i t a t i o n . I t may supply s o c i a l i z i n g i n f l u e n c e s ou ts ide the scope o f the content of the a c t i v i t y i t s e l f , f o r example, the study at S t . Mary 's P r i o r y H o s p i t a l i l l u s t r a t e d how educat ion encouraged i n t e r a c t i o n i n a p a t i e n t who was showing s igns o f w i t h d r a w a l . I n t h i s regard educators must look at the o v e r a l l b e n e f i t o f a l e a r n i n g endeavour and r e a l i z e t ha t any p o s i t i v e by-product may be of more va lue than the l e a r n i n g exper ience 2 i t s e l f and they must not overemphasize the m a t e r i a l p resented. With many a d u l t educa to rs , course content r a t h e r than s o c i a l involvement i s impor tant ye t i t i s o f t e n on ly the l a t t e r t h a t w i l l enhance the r e h a b i l i t a t i v e va lue o f educat ion f o r the d i s a b l e d . I t i s exper ience gained i n f i e l d s tud ies t h a t w i l l he lp to c l a r i f y t h i s i s s u e . Educators should a lso be p e r s i s t e n t i n hav ing b u i l d i n g s mod i f ied and serv ices s u p p l i e d . t o f u r t h e r . t h e i n t e g r a t i o n of the d i s a b l e d . For example,. t he re has been no concerted e f f o r t here as the re has been Sweclren3en. I n Nor th America, some u n i v e r s i t i e s have been mod i f i ed and a few a d u l t educat ion cent res but l i t t l e comprehensive e f f o r t has been made t o communicate w i t h the d i s a b l e d and supply educat ion i f d e s i r e d . I n summary, the study has i n d i c a t e d the s i g n i f i c a n c e of psychosoc ia l needs as the numbers o f c h r o n i c a l l y d i sab led increase i n t h i s century and, as these needs appear p r i m a r i l y s o c i a l , t h e i r s a t i s f a c t i o n may be p a r t i a l l y f u l f i l l e d by a d u l t educators . The - 78 -p rogress ion of these needs and the p o s i t i o n of educators are i l l u s t r a t e d (See Figure 7 ) . I t may be noted t h a t , p r i o r to the t w e n t i e t h c e n t u r y , most care was not requ i red past the acute care s tage .and , t o d a t e , i t i s noted t h a t psychosoc ia l needs of the c h r o n i c a l l y d i sab led appear to be g rea te r than acknowledged by the medical p r o f e s s i o n and the 3 medical method, t h e r e f o r e does not ho ld t h i s v iew. C u r r e n t l y , the r o l e o f the a d u l t educator should be f i r s t l y , to e s t a b l i s h the d e s i r e f o r educat ion among the d i s a b l e d , secondly , to o b t a i n the t r a i n i n g necessary to understand the medical aspects and t h i r d l y , t o supply the s e r v i c e . - 79 -FIGURE 7 PROGRESSION OF NEEDS IN THE LONG-TERM DISABLED -THE POSITION OF EDUCATORS IN THE PLAN MAKES ADEQUATE RECOVERY REMAINS INCAPACITATED I P-HYSTCAlv- Psycho Soc ia l Long Term Acute Care I Chronic Care P H Y S ^ A £ : - PSYCHO SOCIAL PSYCHOSOCIAL Psycho-l o g i c a l ! SOCIAL 77T |Educa t ion Academic : Non Academic - 80 -B. RECOMMENDATIONS 1 . PROVINCIAL GOVERNMENT That a l l d i sab led be r e g i s t e r e d by the P r o v i n c i a l Government and i n f o r m a t i o n on the d i sab led t a b u l a t e d and made a v a i l a b l e t o o r g a n i z a t i o n s i n the h e a l t h care f i e l d . I n f o r m a t i o n such as med ica l , e d u c a t i o n a l , s o c i a l and f i n a n c i a l would be i n c l u d e d . 2. CANADIAN ADULT EDUCATION ASSOCIATION That the a s s o c i a t i o n f a m i l i a r i z e adu l t educators w i t h the l a c k o f educa t iona l o p p o r t u n i t i e s f o r the d i sab led a d u l t and suggest t h a t they research the problems o f the d isab led f o r the purpose of f u r n i s h i n g educa t iona l a c t i v i t i e s to t h i s segment o f our p o p u l a t i o n . 3. ADULT EDUCATION DEPARTMENTS a) That p h y s i c a l b a r r i e r s be removed to enable attendance of d i sab led a t adu l t educat ion f a c i l i t i e s . b) That correspondence courses be made a v a i l a b l e at home, n u r s i n g homes, h o s p i t a l s , e t c . and a persona l con tac t such as an a d u l t educator or v o l u n t e e r be s u p p l i e d . c) That v o l u n t e e r s , such as r e t i r e d school teachers be organized f o r academic p u r s u i t s and l a y people f o r hobbies and s p e c i a l a c t i v i t i e s . A r e g i s t r y of such vo lun tee rs should be set up, s t a t i n g background, i n t e r e s t , l o c a t i o n , t r a n s p o r t a t i o n , t imes - 81 -a v a i l a b l e , number of persons they would be able to a s s i s t and number o f hours they would be v o l u n t e e r i n g per week. Also any pre ference i n the type o f person they would be a s s i s t i n g . d) That c o u n s e l l i n g be g iven i n regard to educa t ion . 4. UNIVERSITY OF BRITISH COLUMBIA a) That the Centre f o r Cont inu ing Educat ion organ ize a course on campus, by correspondence or at educat ion cent res f o r a d u l t educators and vo lun tee rs engaged i n the educat ion o f d i sab led a d u l t s . This course could a lso be o f use to s o c i o l o g i s t s and psycho log i s t s who are contemplat ing or are invo lved i n the medical f i e l d . For example, courses i n medical soc io logy are 4 not a v a i l a b l e at U.B.C. The courses would be an overv iew o f the needs o f the d isab led and obs tac les encountered by them as w e l l as a ids and serv ices a v a i l a b l e . I t would be designed t o i n t e r e s t the l a r g e s t number o f people i n t h i s a r e a , not t o be an i n depth study and the m a t e r i a l would be presented by a d u l t educators , s o c i o l o g i s t s , p s y c h i a t r i s t s , phys ic ians i n general p r a c t i c e , occupa t iona l t h e r a p i s t s and c o u n s e l l o r s . This course would be f e a s i b l e i f the need were es tab l i shed. " * b) That a d u l t educators contempla t ing work w i t h the d i sab led should engage i n f i e l d s tud ies at the U n i v e r s i t y o f B r i t i s h Columbia. - 82 -c) That the Adu l t Educat ion Research Centre at the U n i v e r s i t y of B r i t i s h Columbia should f u r t h e r research the r o l e t h a t a d u l t educators may p lay i n the educat ion o f the d i s a b l e d . The above recommendations would make i t p o s s i b l e f o r a d u l t educators t o engage, w i t h i n t h e i r e x p e r t i s e , i n the r e h a b i l i t a t i o n of the d i s a b l e d , bo th f rom the o r g a n i z a t i o n a l and educa t iona l s t a n d p o i n t . - 83 -FOOTNOTES CHAPTER VI "'"John Braddock, "C.M.A. head lambastes gov's, h o s p i t a l s " , Vancouver Province, 19 May 1973, p. 55. 2 Ernest E. McMahon, Robert H. Coates and Alan B. Knox, "Common Concerns: The P o s i t i o n of the Adult Education Association of the U.S.A.", Adult Education Journal, Vol. 18 (November 3, 1968): 200. 3 Interview with Peter Bunton, M.B., B.S., F.R.C.P., So c i a l P s y c h i a t r i s t , University of B r i t i s h Columbia, 22 May 1974. 4 Pat Merchak, Assistant Professor, Department of Sociology, U.B.C., telephone communication, 30 A p r i l 1974'. ^Interview with Miss M. 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"Towards a Real I n t e g r a t i o n of the Aged i n S o c i e t y " . New L ives f o r Old. Swedish I n s t i t u t e . Stockholm: 1969. Turner , Barbara T . , T o b i n , Sheldon S. and Lieberman, Morton A. " P e r s o n a l i t y T r a i t s as P r e d i c t o r s o f I n s t i t u t i o n a l Adapta t ion Among the Aged". Journa l o f Geronto logy, V o l . 27 No. 1 (1972): 61-8. Warren, V i r g i n i a B. , E d i t o r . A Treasury o f Techniques f o r Teaching A d u l t s . Washington, D.C. : Na t i ona l Educat ion A s s o c i a t i o n , 1964. W e l l s , Benjamin B. "The Long Term I m p l i c a t i o n s of R e a l i t y O r i e n t a t i o n . Washington, D.C. : American P s y c h i a t r i c A s s o c i a t i o n , 1969. Wessen, A l b e r t . "The Apparatus o f R e h a b i l i t a t i o n : An Organ iza t i ona l A n a l y s i s " . Socio logy and R e h a b i l i t a t i o n , Washington, D.C. : American S o c i o l o g i c a l A s s o c i a t i o n , 1965. 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"A N a t i o n a l E f f o r t f o r the P h y s i c a l l y Handicapped." ERIC Research i n Educat ion , V o l . 6, No. 7, J u l y 1971: 30. Say lo r , Louis F. " R e s i d e n t i a l Care Needs: A Report to the C a l i f o r n i a State L e g i s l a t u r e " . ERIC Research i n Educat ion , V o l . 6, No. 1 , January 1971: 43, Appendix E2-3. Warms, Dorothy and Hammerman, Susan. "P lann ing f o r the Decade of R e h a b i l i t a t i o n 1970-1980. New Pa t te rns of I n t e r n a t i o n a l Serv ice . F i n a l Repor t " . ERIC Research i n Educa t ion , V o l . 6, No. 4 , A p r i l 1971: 39. W i t h i n g t o n , L u c i l e F. and Sevino, Michael T. "Voca t i ona l R e h a b i l i t a t i o n o f the Severely Disabled i n a U n i v e r s i t y S e t t i n g " . ERIC Research i n Educat ion , V o l . 6, No. 4 , A p r i l 1971: 1-9. Young, Howard D. "Independent L i v i n g : A Study o f R e h a b i l i t a t i o n o f P h y s i c a l l y Handicapped Adu l t s L i v i n g i n Foster Homes, Soc ia l Work I n t e r v e n t i o n i n the Adap ta t ion to Family Environment. F i n a l Repor t " . ERIC Research i n Educa t ion , V o l . 5, No. 1 , January 1970: 222. 3. Unpubl ished M a t e r i a l Canadian Parap leg ic A s s o c i a t i o n , B.C. D i v i s i o n . Annual Report 1972. Correspondence Branch, Department o f Educat ion , Par l iament B u i l d i n g s , V i c t o r i a , B.C. " P a i n t i n g f o r Pleasure and B r i t i s h Columbia - Canada's P a c i f i c P r o v i n c e " . 1971-1973. E i s d o r f e r , C. "A Phi losophy f o r Extended Care" . T r a n s c r i p t o f Seminar on Extended Care. Vancouver, B.C. 26-27 February 1973. Mc lver , Vera. Notes f rom a Speech at the Canadian Nurses' ' A s s o c i a t i o n Convent ion, Edmonton, A l b e r t a . 26-28 June 1972. Mc lver , Vera. " R e b i r t h o f an I d e n t i t y " . A study done at S t . Mary 's P r i o r y H o s p i t a l , February 1969. Van T i l b u r g , E.G.Q. "Review o f B.C.H.A. Report on Extended Care". T r a n s c r i p t o f Seminar on Extended Care. Vancouver, B.C. 26-27 February 1973. Vo lun ta ry A s s o c i a t i o n f o r H e a l t h and Wel fare of B r i t i s h Columbia. Report of the Committee on A r c h i t e c t u r a l B a r r i e r s i n respect t o B u i l d i n g Standards f o r the Handicapped 1970. - 88 -4 . Newspaper and Magazine A r t i c l e s Ashley, Audrey M. "Timmy campaign c a l l e d obscene". Vancouver Prov ince , 19 May 1973. Bateson, Helen. "Breaking out o f P r i s o n " . Vancouver P rov ince , 5 August 1971. Braddock, John. " C M . A . head lambastes g o v ' t s , h o s p i t a l s " . Vancouver P rov ince , 26 A p r i l 1973. McMi l lan , Murray. "We S h a l l Overcome." U.B.C. Alumni C h r o n i c l e , V o l . 27, No. 2, Summer 1973. 5. Personal Communication a. Correspondence B r a t t g a r d , Sven-Olaf , M.D. Pres ident o f Fokus Soc ie ty and Pro fessor o f the U n i v e r s i t y of Goteborg, Sweden. 3 January 1973. C u l l e n , S.F. P r o v i n c i a l Co-Ordinator of R e h a b i l i t a t i o n , Government of Newfoundland and Labrador , Department o f H e a l t h , R e h a b i l i t a t i o n D i v i s i o n . 11 A p r i l 1971. C u r t i s , I d a . Resource Person f o r the Handicapped, Simon Fraser U n i v e r s i t y , Vancouver, B.C. 18 October 1973. Fenna, D. , Ph.D. U n i v e r s i t y o f A l b e r t a H o s p i t a l , Edmonton, A l b e r t a . 18 May 1973. b. Telephone Communication Dewhurst, J . F . Pub l i c Re la t ions O f f i c e r , A r t h r i t i s and Rheumatism Soc ie ty . 8 May 1973. F o s t e r , S. Tu tor Pearson H o s p i t a l , Vancouver, B.C. 12 March 1973. Houston, Robert S. A s s i s t a n t t o the Super intendent o f Design D i v i s i o n , Phys ica l P lan t^ .Un ivers i t y of B r i t i s h Columbia, Vancouver, B.C. 8 January 1974. Mc lver , Vera. D i r e c t o r o f H o s p i t a l Serv ices , S t . Mary 's P r i o r y H o s p i t a l , V i c t o r i a , B.C. 16 December 1973. - 89 -McKay, R. Project Planner, Physical Planning Plant, Simon Fraser University, Vancouver, B.C. 15, January 1974. Merchak, Pat. Assistant Professor, Department of Sociology, University of B r i t i s h Columbia, Vancouver, B.C. Telephone communication, 30 A p r i l 1974. York, Edith. Public Relations O f f i c e r , Canadian National I n s t i t u t e for the B l i n d , B r i t i s h Columbia. 14 May 1973. c. Interview Bunton, Peter. M.B., B.S., F.R.C.P. S o c i a l P s y c h i a t r i s t , University of B r i t i s h Columbia. July 1973 and 8 A p r i l 1974. Home, S y l v i a , Supervisor, Occupational Therapy, Adult Section, G.F. Strong R e h a b i l i t a t i o n Centre, Vancouver, B.C. 13 A p r i l 1973. Parker, Tonw Counsellor, Canadian Paraplegic Association, B r i t i s h Columbia D i v i s i o n , Vancouver, B.C. 10 May 1973. Smith, A. R. Public Relations O f f i c e r , G.F. Strong R e h a b i l i t a t i o n Centre, Vancouver, B.C. 3 May 1973. Smith, M. Centre for Continuing Education, Un i v e r s i t y of B r i t i s h Columbia. 15 February 1974. Szasz, George, M.D. Director, D i v i s i o n of Interprofessional Education and Associate Professor, Department of Health Care and Epidemiology, Un i v e r s i t y of B r i t i s h Columbia, July 1971 and 16 October 1973. T h i e l e , Paul. L i b r a r i a n , Crane Memorial Library, U n i v e r s i t y of B r i t i s h Columbia. June 1973 and 17 May 1974. 6. Observations by writer Vancouver General Ho s p i t a l , Department of Neurosurgery. Irene Dennis R.N. Head Nurse. June - September 1964. Vancouver General Hospital, Department of Neurosurgery, February, March, 1970, June, August, December 1971, and A p r i l , 1972. - 90 -7. F i e l d Study by w r i t e r S t . Mary 's P r i o r y Extended Care H o s p i t a l , V i c t o r i a , B.C. 1 June 1973 - 30 September 1973.