Factors affecting readiness of leave patients in using after-care services as seen in initial interviews

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FACTORS AFFECTING READINESS OF LEAVE PATIENTS IN USING AFTER-CARE SERVICES AS SEEN IN INITIAL INTERVIEWS

A Thesis Presented to the Facility of the Graduate School of Social Work The University of Southern California

In Partial Fulfillment of the Requirements for the Degree Master of Social Work

by George Foley Benson June 1950

UMI Number: EP66323

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$u, iso & T h is thesis, w r it t e n u n d e r the d ir e c tio n o f the c a n d id a te ’ s F a c u lt y

C o m m itte e a n d a p p r o v e d

by a l l its m em bers, has been p resen ted to and accep ted by the F a c u lt y o f the G ra d u a te S c h o o l o f S o c ia l W o r k in p a r t i a l f u l f i l m e n t o f the re ­ q u ire m e n ts f o r the degree o f

MASTER OF SOCIAL WORK

D ean

Thesis o

f

.........

F a c u lty Com m ittee

... Chairman

OnA

TABLE OF CONTENTS CHAPTER I.

PAGE

THE PROBLEM AND DEFINITIONS OF TERMS USED . . .

1

The problem........ . . . .............. . ♦

2

Statement of the problem

• • • • . . . . •

2

Interest in the study . . . . . . . . . . .

3

Setting of the study

7

•

Definition of terms •

9

Indefinite leave of absence

9

Supervision •

10

The worker

10

. . . . . ....................

The B u r e a u ................... . . . . .

11

The concept of resistance • • • . . . . . • •

11

.

The use of authority in c a s e w o r k

IS

Selection of the sample • • • . • • » • • • » Randomness and skewness

of the sample . . .

Organization of the remainder of the thesis II.

22

.

2I* 29

SCHEDULE AND BROCHURE: PURPOSES AND METHOD OF CONSTRUCTION...............

35

Purpose and method of construction of the Brochure

•

Possible effects of the form letter . . . . .

35 1*2

Purpose and method of construction of the S c h e d u l e ......... Scoring the sample

-44 49

iii CHAPTER III.

PAGE

ILLNESS, HOSPITAL, AND TREATMENT FACTORS AFFECTING READINESS TO USE BUREAU SERVICES . . . . . . .

52

Diagnosis

52

. . . . . . . . . . . . . . . . . .

Medical treatment

. . . . . . . . . . . . . .

Length of hospitalization

. . . . . . . . . .

Hospital where patient received treatment. . . IV.

55

60 62

AGE, EDUCATION, EMPLOYMENT, AND MARITAL STATUS FACTORS AFFECTING READINESS TO USE BUREAU SERVICES Age

. ........

. .

. . . . . . . .

............

66

Education

...

68

. . . . . . .

71

Job classification . . . . . . . . . . . . . .

73

Employment status and work record

75

Marital status . .

V.

66

........

..

. . . . . .

PREPARATION AND INTERVIEW FACTORS AFFECTING READINESS TO USE BUREAU SERVICES . . . . . . . Preparation received prior to contact

'79

....

79

Setting of interview • • • • • . • • • . . . .

86

Length of interview

89

Time lapse between release and initial interview

• • . • . . . . • • • • •

92

Manner of initiatingcontact

94

Other factors affectingreadiness

98

iv CHAPTER VI.

PAGE

CONCLUSIONS AND AREAS REQUIRING FURTHER S T U D Y ........................... Summary . . . . . . . . . . . . . . . . . . . .

104

Conclusions

106

Age, education, employment, and marital status factors

• . . . . . • • . • • • • •

Illness, hospital, and treatment factors

. .

10 S

.

Ill

Preparation and interview factors . . . . . Areas requiring further

106

study

113

BIBLIOGRAPHY ........................ . . . . . . . .

116

APPENDIX . . . . . . . . . . . . . . . . . . . . . . .

118

LIST OF TABLES LGE Age, Sex and Marital Status of Patients in the Sample

............... . .

31

Education and Job Classification of Patients in the Sample

. . .

32

Employment Status and Work Record of Patients in the Sample

. * ......... .

33

Hospital, Illness, and Treatment Factors of Patients in the Sample

34*

Diagnosis and Readiness to Use Bureau Services

53

Type of Treatment Received and Readiness to Use Bureau Services

*

53

Length of Hospitalization and Readiness to Use Bureau Services • .

61

Hospital Where Treatment Was Received and Readiness to Use Bureau Services. . . .

63

Age of Patient and Readiness to Use Bureau Services . . . . . . . . . . . .

67

School Grade Completed and Readiness to Use Bureau Services

69

Marital Status and Readiness to Use Bureau Services

72

vi lGE

Patients1 Usual Occupation and Readiness to Use Bureau Services. . . . . . . . . .

74

Current Employment Status and Readiness to Use Bureau Services

76

•

Work Record and Readiness to Use Bureau Services. . . . .

...

. . . . . . . . .

78

Preparation Received Prior to Contact . . .

80

Initiating Contact

81

. . . . . . . .

..

..

PatientsTUse of Agency

82

Time and Place Factors of the Interview . .

83

Preparation Received Prior to Contact and Readiness to Use Bureau Services

. . . .

85

Setting of Interview and Readiness to 88

Use Bureau Services • Length of Interview and Readiness to Use

91

Bureau Services • Time Lapse Between Date of Release and Date of First Interview and Readiness to Use Bureau Services

. . . . . . • .

93

Manner of Establishing Contact and Readiness to Use Bureau Services

. • .

95

Sex of Worker and Patient and Readiness to Use Bureau Services

. . . . . .

* .

99

vii TABLE XIX.

PAGE Distance of Work from the Bureau and Readiness to Use Bureau Services. . . . . .

XX.

102

Distance of Residence from the Bureau and Readiness to'Use Bureau Services

.....

103

CHAPTER I THE PROBLEM AND DEFINITIONS OF TERMS USED This is a descriptive case study of a selected group of patients on indefinite home leave from state hospitals in Southern California,

Attention in the study was focused

on these patients* readiness or unreadiness to use the extramural services offered hy a caseworker exercising a major function in extramural care.

After these patients

were released from their respective hospitals, they continued, technically, to be patients, and as such were seen by a psychiatric social worker for supervision and other ser­ vices they needed or requested.

Essentiality the relationship

is an authoritative one, at least to begin with, for the workers herein described are made responsible by the State Department of Mental Hygiene for supervision of all such patients. A great many patients going on leave of absence — probably the majority —

do not understand that they will

continue to be patients for some time.

Their discovery of

the need for continued contact with a social worker repre­ senting the hospital produces varied reactions, often of a negative nature.

It was to investigate the extent and nature

of these reactions, and factors which might positively modify them, that this study was undertaken.

2 I.

THE PROBLEM

Statement of the problem.

It is the purpose of this

study to investigate the readiness of patients on indefinite leave of absence from state hospitals to use a social worker’s services, as seen in initial interviews.

Since these

services are in effect an extension of the hospital as an extramural phase of treatment, and since furthermore some use of them is virtually mandatory, the patients’ under­ standing of the nature of the services was assumed to be a large factor in their readiness to use them.

Specifically

sought were the attitudes and problems the patient brought up in the initial interview with a field worker representing the hospital. Physical, psychological, social and environmental factors which might have a bearing on the patients’ atti­ tudes toward the service, or any aspect of it, will be examined separately.

Special attention will be paid to prep­

aration patients may have received prior to the initial interview for the extramural services of the Department of Mental Hygiene, and to practices used in establishing contact. Other factors will be examined in the following areas: 1 ) illness, hospitalization and treatment factors; 2) age,

education, marital status and employment factors.

In each

case the factor in question will be studied for its effect on

3 patients’ readiness to use the services of a field worker representing the hospital from which the patient came* Interest in the study* Early in the field work ex­ perience, it was noted that patients manifested considerable surprise, reluctance and even overt hostility to the extra­ mural phase of treatment.

Staff workers confirmed that this

was the rule rather than the exception.

Explanations offered

for this varied so widely that further help was sought from the literature.

There proved to be little direct coverage of

the subject. The readiness or lack of readiness the patient shows has not been adequately isolated as a social work concept in the literature.

Its negative and more subconscious com­

ponents have been dealt with to some extent under the heading resistance*

This has been treated by writers in the pro—

fessional journals, but not many such articles apply to the field of after-care contact with leave patients. Much of the resistance manifested by patients In the early phases of contact may arise from the authoritative nature of the agency (See section on setting of the study, p. 7.). In nearly all such settings, t?the client invests in the worker herself all the authoritative aspects of the agency.!,Ju Thus -1 G. F. Steinlein, 1!Case Brk in a Psychiatric Hos­ pital: Some Hostility Factors,” Journal of Psychiatric Social Work, 17:77-79, Winter 1947-4S.

4 what appears to he poor

abilityto use any or all services of

extramural care facilities, may be the hostility to the worker engendered by her authoritative attributes.

It is con­

fusing to the patient to relate to a worker who not only exercises legal supervisory powers, but who also offers help with problems which the

patient isfree to use or reject.

the nature of the case,

the patient at first is probably

In

only able to see the worker as a follow-up or parole officer throughout the leave period.

This is a blow to.the patient*s

confidence, an overshadowing threat that he might not be as well as he thought when he was released from the hospital. Resistance and hostility follov»r. The problem of helping the patient to use the agency* s services is especially hard where he denies he is or was ill. This is especially frequent in illness with paranoid coloring, where the patient is virtually unable to see the worker in a helping light since the worker is often incorporated into the o persecutory system. Acceptance of the illness under these conditions is a positive feature, a real step toward taking help.

This being so, the patient should be helped to express

his hostility as a first step toward understanding and relieying it .3 2 R. M. Brickner, "The Paranoid,** IV in "Roundtable on Treatment of Aggression," American Journal of Orthopsychiatry 13: July, 1943. 3 Steinlein, op. cit., p. 78.

5 Throughout the nation,this resistance of the leave patient to extramural treatment services has aroused wide and sustained interest.

But judging by the scarcity of litera­

ture on the subject, it has been handled empirically, rather than by a concerted research effort.

One line of thought,

and the one bearing most closely on the present study, is that such resistance may be a manifestation of the degree of preparation for after-care which the patient may have been given in the hospital.

The ^present study is in part a

follow-up of two kinds of such preparation; face-to-face interpretation by a resident worker, and printed literature interpreting extramural care.

The latter is used where the

former is impracticable. Ideally every patient going on leave should be seen by a social worker to prepare him for continued contact with another social worker representing the hospital.

In practice,

several factors act as barriers against this goal:

(^IJ The

size of present day hospital populations has grown more rapidly than the resident Social Service staff.

The resident

workers are thus unable to prepare each patient for extra­ mural treatment;

(2) The movement of patients from ward to

ward in the hospital, and into and out of the hospital, is often so rapid that the resident worker has no opportunity to contact them;

(3) In many cases resident physicians have had

inadequate experience in the use of Social Service as an aid

to effective after-care.

They often do not refer in time

those patients who need the service, or may refer some cases for services not genuinely within the function of a social worker, or in such a way as not fully to exploit the workers1 specialized training. These conditions have stimulated search for some other means of preparing the patient for leave, and for the more adequate use of the field worker while on leave.

The De­

partment of Mental Hygiene corresponded with departments in other states caring for the mentally ill, to ascertain what methods they were using to meet this problem.

The results of

this correspondence showed a disparity; interest in the sub­ ject was national, but little had been done.

(See Appendix,

p. 118, for form letter sent to all states.) The Department therefore authorized the composition of a piece of literature for issue to patients going on leave. This literature, hereafter referred to as the Brochure (See Appendix, pp. 119 ff.), is now in use at a state hospital in the Los Angeles area, and several of the patients in this study received a copy.

Their reactions to it, and its prob­

able effectiveness, are treated in the later part of the study.

Plans for revision of the present Brochure, and

consideration of making such a project state-wide, are now under way at the Bureau. That the successful construction and use of such a

7 Brochure would have considerable consequence for mental hy­ giene seems apparent.

If it only partially lightened the

work of scarce resident workers; if it only partially speeded the patient*s relationship to the extramural worker; if it only partially broke through the fright and resentment of the patient and helped him to use the service he needs, it would justify far more effort and expense than it is now being given.

Hence even such a limited follow-up as this study

gives the Brochure could be significant and timely. Betting of the study.

The study was conducted from

the Los Angeles Regional Office of the Bureau of Social Work, California State Department of Mental Hygiene.

The

staff of the Bureau of Social Work, herein called the Bureau, are psychiatric social workers and are referred to throughout the study as field workers.4

primarily they supervise and

serve by casework method patients on leave from southern hospitals of the state.

They also provide direct or referral

service for families of patients both in and on leave from hospitals.

T,When patients go on indefinite leave of absence,

they automatically become the responsibility of the Bureau for supervision and casework services.**^

Should patients

4 For definition of the Bureau, refer to section on DEFINITION OF TERMS, p. 10. Manual of‘the Bureau of Social Work, p. 1.

reject the offer of optional services, Bureau responsibility is restricted to supervision and reporting only. In the following discussion only such definitions as apply to leave patients are included, since the study deals only with services to patients on leave, and not their families, nor does it deal with numerous other services provided by the Bureau.

Thus, for purposes of this study,

only two major functions of the Bureau are considered; supervision, and direct services to leave patients. In the great majority of cases, contact with tne pa­ tient or his family is initiated by the worker.

This may be

by phone, but more often a form letter is used.

tSee Ap­

pendix, pil22.) . Preceding or following the sending of this letter, the patient may phone in for an appointment or may walk in.

More likely he will do nothing till the worker

calls.- Should the worker call and find the patient not at home, he leaves his card with a note announcing the time of his next visit.

Should a patient not be contacted after

every reasonable effort, he is placed in the category of r,whereabouts unknown.11 As soon as a patient leaves the hospital, a field worker is assigned to the case.

The workers have a geo­

graphically allotted case load, and the patients place of residence thus determines his assignment to a given worker. In earlier years in California, social workers were

9 attached to and worked out of the hospitals, and were directly responsible to their respective hospital admin­ istrations.

The centralization of extramural treatment

facilities in urban offices offers many advantages for more effective service, but has introduced some special problems. The workers now represent all, instead of one hospital; and they are in less frequent -and direct contact with the medical staff in the clinical sense.

This administrative

organization presents to its staff a complex working situation, offering some of the opportunities and the problems of both the medical and non-medical setting.

But

both in philosophy and practice, the Bureau is an integral part of the Department of Mental Hygiene, and its services are genuinely an extension of the hospital.

And since the

hospitals do have resident workers, a complex interaction between resident worker and field worker is added to the inter-professional relationships required of social workers in medical settings. II.

DEFINITION OF TERMS

Indefinite leave of absence. Hereafter this is re­ ferred to simply as leave, and means nthe release of a patient from the hospital to a responsible person for an indefinite period, usually a year.

Approval of the medical

staff is necessary, and the hospital continues responsibility

for the patient through the bureau until the patient is dis­ charged or needs to be returned to the hospital*"6

For pur­

poses of this study, leave is considered to be home leave only, where the responsible person signing out the patient lives in the home.

To avoid redundance, the terms 11after­

care” and 11extramural” treatment are used as practically synonymous with the leave period. Supervision.

As previously noted, the Bureau is

charged by the department with responsibility for supervising the patient on leave from a state hospital.

Throughout the

period of leave the worker must be in contact with the patient1s situation.

In practice, supervision is not

sharply separated from help with material problems or those involving interpersonal relationships, but in those cases where the patient resists all offer of help from the field worker, the worker maintains a supervisory role, limited to the evaluative and reporting functions.

Periodic reports

to the hospital on the patient*s progress are made.

Super­

vision is in itself a helping process even if the worker*s other resources are not used by the patient. The worker.

This term is applied to a psychiatric

social worker in the Bureau, i.e., a field worker dealing with (for purposes of this study) patients on indefinite 6 Manual of the Bureau of Social Work, p. 6 .

11 home leave.

When for any reason workers in the hospital

are referred to, the term "resident worker11 is used. The Bureau. This term refers to the Los Angeles Regional Office of the Bureau of Social Work.

The Bureau

of Social Work is an administrative division of the State Department of Mental Hygiene, and is charged by the Depart­ ment with supervising and rendering other services, as re­ quired, to post-institutional patients. III.

THE CONCEPT OF RESISTANCE

Since much of the following study depends on an understanding of patients in their readiness and ability to use casework services, an attempt was made to find a treat­ ment of this subject in the literature.

Usually, reference

to such readiness is considered in its negative aspect of resistance to using help. Readiness or lack of.readiness to take help are not exactly comparable to resistance in its psychoanalytic meaning.

The latter is more correctly limited to a complex

subconscious phenomenon, and the former is more in the area of’conscious attitudes or behavior.

Nor has the factor of

resistance ever been satisfactorily isolated or quantified. The present study does not attempt so to quantify resistance or its dynamics, nor are the findings on cases in the sample adequate for a treatment off.this concept.

Yet there does

12 seem sufficient connection between resistance and what this study terms readiness to take and use help to warrant a di­ gression for extended discussion of the concept. There is another way of illustrating the relationship between the concept of resistance and nunreadiness” as used in this study.

The feelings and behavior stemming from the

personal dynamics of the patient, as these are mobilized around taking help, may be termed resistance; those stemming from verifiable factors in the process which began with in­ ability to solve the problem, and are studied at the moment of first contact with the caseworker, may be termed unreadi­ ness. We are concerned here with manifest behavior of patients (in initial interviews) which reflect their re­ actions to certain experiences in the illness and treatment process.

Our findings attempt to isolate the more important

of these experiences, and hopefully will suggest methods and procedures for increasing the patient* s readiness to relate to a social worker.? One of the primary concepts in social work concerns the feeling an applicant has toward taking help.

His feeling

of inadequacy at having to ask for help often makes him pre­ pare for the possibility that he will not receive it (**I won*t 7 For a distinction between tangible and psychological services and methods, see Virginia p. Robinson, 11The Dynamics Supervision under Functional Controls. University of PennsylvamaHFress, Philadelphia 1949, pp. 21 ff.

let myself be hurt.”).

The keynote of his feeling is

anxiety lest he be hurt, either in being refused help, or in being given it in a way that is painful to .him.

So he

resists taking help and what this implies in terras of re­ lating himself to a worker in the Department.

And a patient

whose need for help has been so great that he required a mental hospital may not like to think of using help from an agency which is an extension of that hospital in the community — illness.

the fthelp” having been imposed on him by his

Bather than admit to himself that he has need of

help, he will in various ways manifest avoiding behavior. This may be termed resistance.

It is a defense mechanism

against the need for taking help, and may show up in the agency setting as simple hostility to worker, or agency, or both.

It is examined here in a specific manifestation of

readiness or unreadiness to use the services of a particular agency, and only those rfcauses” of it are considered .which are known to have occurred in, or were related to, the in­ stitutional process. It is generally conceded that where resistance occurs it must be dealt with soon.

If not dealt with, the client

may go to other sources, including quacks, for help, since these have the advantage of being able to promise him anything.^ ~B Wm. H. Wilsnack, ”Handling Resistance in Social Case Work,” American Journal of Orthopsychiatry. 16^297, April, 1946.

Mere friendliness and the promise of assistance are not enough to allay resistance, since it is the result of anxiety£ something about the agency, or the worker, or the patients own need for help is threatening to him. The Bureau* s clientele comes from hospitals which, although among the best in the nation, are lacking in staff and equipment.

Under the crowded conditions in most of them,

the patient*s experience has sometimes reinforced the tenor and disruption of the illness itself.^

This experience may

be reinforced by the negative attitude of the public toward mental illness, which most patients share.

Hence many pa­

tients, when first seen by a worker, are anxious, hostile, . and resistant.

The Bureau staff uses a variety of careful

procedures for avoiding the creating of resistance, but despite these precautions, initial resistance is usually present. One author, in dealing with this phenomenon in a child guidance clinic setting, feels that by using the fol­ lowing technique, resistance can be kept to a minimum: 1.

letters and phone calls to be kept innocuous.

2. Problems and crises to be handled in inter­ views only. 3.

The time between first contact and first

9 For a modern, exhaustive treatment of the subject of facilities in tax-supported hospitals, see Albert Deutsch, The Mentally II!}. in America, (second edition^ Mew York: Columbia University Press, 1949.)

15 interview to be kept as brief as possible. 4.

No insistence on intake procedures or inter­ viewing formality. 5. Acquaint clients early with the purpose and procedure of casework. 6 . Reassurance to be given about confidentiality of interview material.

7. Client to be prepared in advance for what is likely to occur in future interviews. 8 . Client to be made to feel that the workerfs interest in him is for his own sake.

9. The inefficiency rather than the inadequacy of the client* s handling of his affairs shall be stressed. 10. Where resistance appears as an obvious tactic, it should be pointed out and interpreted.!^ Where, in spite of these precautions, resistance is present or later develops, then it mus be dealth with directly.

The worker must assure the client that his

anxiety is groundless, that- he may safely express emotion; the worker must take initiative by being outgoing and making fewer demands on the client.

Even where, under this treat­

ment the client may withdraw from discussion, the worker must not.-^ The study cited does not go into the mode of dealing with resistance arising out of the treatment process ex­ perienced by the patient before he comes to the agency. 10 Ibid. li Ibid.

Thus

16 the present study, while mainly confirming the findings of the article, carries them into a different area.

The

studies differ in that while Wilsnack dealt-- with that aspect of resistance arising out of unconscious behavior of a more primary nature, this one treats more conscious and readily perceived behavior assumed to be directly related to facts that began within the illness and treatment process. For this reason, the term unreadiness has been used in preference to resistance. In our study, patients on leave have fears of the hospital, or of being returned to the hospital by the worker; and fears of the meaning of their illness.

It is almost too

much to ask at first that the patient can believe the worker* s role is to help him stay out of the hospital rather than to return him.

Hence the focus of this study is on factors

affecting or creating resistance at the point the client comes into the Department.

Although some indications for

dealing with resistance may be suggested by the material, this is not the primary purpose of this thesis, but rather the understanding of its characteristics in patients and its causes with relation to the total.treatment program. What is the meaning of resistance?

It seems likely

that, as Wilsnack claims, it is self-defense against anticipated danger;^ in the case of the leave patient, 12 Wilsnack, op. cit.

17 this danger most likely means return to the hospital.

Since

the hospital is in this case the only feasible treatment of their illness, it may further mean they do not regard hos­ pitalization as treatment but as a threat.

Carrying this

idea further, it means they do not believe themselves to have been ill.

But, as will be shown in the material in the

following chapters, resistance appears in patients who admit they are ill, as well as in those who do not.

This

study begins with a hypothesis about initial resistance^ that it is not only a phenomenon of the clientfs psycho­ logical make-up or need for security, but also an attitude expressing his degree of understanding of the nature of the agency and the services it offers.

This is heightened or

lowered by specific factors in the illness and treatment experience.

Expressed in terms of an equation, we might use

the following: resistance is patient behavior varying directly with the degree of authority he conceives the agency as possessing or with the degree and quality of his under­ standing of the agency.

Its initial amount will be a

function of the patient1s experiences in the illness and treatment process. It cannot be forgotten or overlooked in the patient group selected for study that these patients are dealing, and have been dealing, with an authoritative agency.

They

got into a hospital because they were ill, but the process by which they got there involved being taken by a sheriff

before a court, which ordered them taken by the sheriff to the hospital. signed out on

Followinghospitalization, the patient is leave by a person who agrees to act in a

capacity responsible under a statute to a specified state agency.

(For heave of Absence Agreement Forms, see Ap­

pendix, pp. 123f.) On leave he remains a patient of the hos­ pital, and is pital.

supervised by a worker representing the hos­

Most patients therefore see in the worker initially

not one whose helping services they may ask for or reject, but a person they must satisfy in order to maintain freedom outside the hospital. In practice, the worker*s authority is not so ex­ tensive nor is it applied so directly.

But the patient

does not know this, and hence we must regard the patient potentially as seeing the worker in the role of parole of­ ficer —

a title which psychiatric social workers are given

In many localities to this d.ay.

This concept the patient

has of the worker may have been modified by any of the factors considered in this thesis, and it Is the contention of the author, implied in the hypothesis expressed, that the more factors modifying this concept, the greater readiness (less resistance) the patient will show in using the optional services offered, along with supervision. The use of authority in casework.

Casework as

considered in this study is a part of psychiatric treatment,

19 and may be considered an adjunct to or aspect of psychiatric care.

This does not mean caseworkers practice psychiatry: it

means casework help is prescribed by a psychiatric staff as a portion of treatment during the extramural period.

In

general, ”. . . psychiatry cannot be practiced by command and often it is better for everybody concerned if a patient with a non-disabling psychiatric symptom is allowed to go vwLthout examination rather than be forced . . . if the patient1s need is great enough, he will come back to the service, finding reassurance in the fact that his individuality was respected during the course of his first contact.f,i3 Thus if, when the worker first contacts the leave patient her finds considerable unreadiness to using Bureau services, it may be better not to insist on too regular or too fre­ quent contacts. Referral by authority —

in this case by legal

requirement that the patient be supervised —

poses a very

different problem in helping the patient establish a re­ lationship than would be the case in a family agency.

The

fact that a patient comes to a psychiatric agency in an authoritative setting in no way assures that he believes he has a psychiatric problem, or that he believes he can be treated at the agency.

The referral seems to him to be an

issue he cannot evade, a tacit command that he appear or be 13 Bertram M. Beck. Short-Term Therapy in an Authori­ tative Setting (New York, F a m p y “Eer vice Association or AmerXc a, pampnlet, 194w > P-

20 seen.

Still, the needs of a sick person are such that he

probably wants to have the dependency and attention paid to him which are inherently part of the social worker1s ser­ vices.

That is, if he knows what a social worker is. According to Beck‘d patients who accept agency ser­

vice on some basis are: (1 ) those with some insight into their illness; (2 ) those who are without insight or desire for help, but who come out of an emotional need they feel the agency may fulfill; (3) those who wish to use the agency for their own conscious ends, as if saying, **I don’t care what they think I need, 1*11 string along with them if it will get me what I want.fT Implicit in this is that the client invests in the worker himself all the authoritative aspects of the agency and hence needs to be helped to use the agency voluntarily, to become more and more able to cope with social situations which might jeopardize his adjustment. In the area where the patient* s use of the agency is not voluntary, just as much help must be given, but with frank acknowledgment of the responsibility of the Bureau for supervision. The phenomenon of the non-voluntary referral is bound to have a measurable effect on the client’s initial ability to use casework services.

Such referrals are found

in probation and parole activities, child guidance clinics, ^

Beck, 0£. eit., pp. 9, 10.

21 general hospitals, and as in the present study psychiatric hospitals and clinics.

In each case there is given to the

worker a power to initiate contact and sustain it, with the sanction of the community, and with the object in mind of bringing about a better adjustment of the persons involved. In carrying out felt responsibility to the client, all workers have some protective functions and can make use of the same skills and resources. ftCasev?ork and protective services are not apart but rather operate from a common base . . . in non-voluntary referrals, the social worker has to meet the resistance and handle it without the advantage of having already established a re­ lationship. This is what makes the protective* case so difficult, yes, and so threatening to the worker.**15 Yifisgerhof goes on to stress the importance for the worker of keeping clear her identification with the authoritative aspects of the agency; if she does not do so from, the beginning, she will need to use it more and more directly in later,handling of the case. Actually, there is some authority inherent in every worker-client relationship, and there will be more or less resistance around that authority.

The many factors which

modify or augment this manifestation will be dealt with at length in this thesis. 3*5 Helen A. 'Wisgerhof, Case Work in Non-voluntary Referrals. Journal of Social Case Work, November, 1946, pp. 2 7 8 , 2 7 9 .

22 IV.

SELECTION OF THE SAMPLE

Nearly all the eases used were selected from Norwalk and Patton State Hospitals.

Cases from the latter were

used only because insufficient schedules were available from Norwalk patients alone, desirable as it might have been to limit, the study to a single hospital.

Had this

been done, the important variables of differential hospital policies, facilities, and treatment procedures would have been held constant.

But as the possible effects of these

are more properly a subject for medical research than social work research, it need have no effect on the method of ex­ ploration of the present study. Norwalk was selected, and is preferable, by virtue of its greater accessibility.

Like Patton and Camarillo,

it admits and treats an undifferentiated population of major mental disorders.

It was the site selected for a test study

of the Leave of Absence Brochure, which is a further reason why the study should have been limited to that hospital had this been possible.

(For discussion of the Brochure, see

Chapter II, especially pp. 37 ff.

Brochure is reproduced in

full in Appendix, pp. 119 ff*) Patton patients presented one advantage for purposes of controlling the factor of patients1 contact with a social worker prior to going on leave.

It is the policy at Patton

23 that each patient be seen by a resident social worker before going on leave, for the purpose of interpreting to the patient the nature of extramural care by the Bureau.

Thus Patton

patients as a group form the major.portion of schedules checked !,Yes" on question 19 and checked ,fYestt on Supplementary Schedule question 17-A. Cases were further selected according to illness. It was decided to limit the study to major functional disorders only, since organic impairments might have introduced be­ havior less clearly understood, and which might have mani­ fested itself as resistance to casework contact while on leave; or conversely, to deceptively good use of such con­ tact.

Actually, there is no way of knowing whether patients

with disorders of organic origin would relate differently to a worker than those with disorders of functional origin.

As

this, too, is more properly a subject for medical research, it was felt more likely to heighten the accuracy of results if all cases were alike in this regard.

Gases.of functional

illness were chosen rather than organic ones also because there are more of them, and it was easier to get a sample of meaningful size from this group.^ All the cases are under forty-four years of age.

This

16 For explanation of symptoms, treatment, prognosis, etc., in the major functional psychoses comprising the illness of patients in the sample, consult Strecker, E. A., Ebaugh, F. F. G., and Ewalt, J. R., Practical Clinical Psychiatry. Philadelphia.:; The Blakiston Company, 6 th edition, 194?•

is directly related to the reasoning in the preceding paragraph, and this age-limit was set to reduce the possibil­ ity of involutional or organic disorders affecting the be­ havior seen in the first interview.

As the entire subject

of involutional period mental illness is still in dispute medically, it seemed safer to eliminate cases which showed signs of this kind.

The simplest way of accomplishing this

was to limit the age of the sample. In the T!Instructions for Schedule,” cited infra, it will be noted that workers were instructed to fill our sched­ ules only on patients released after October 1, 1949.

The

reasoning here was that the Brochure began to be issued at Norwalk January 2, 1950, and hence the patient group re­ leased at Norwalk between these two dates would furnish one of the major groups of patients with regard to the kind of preparation received for after-care.

The various groups are

listed in Table XIII, p. 85, and are here repeatedr 1. Patients seen by resident worker in face-toface interview for purposes of referral and inter­ pretation of Bureau services. 2.

Patients given the Brochure for this purpose.

3. Patients who learned of the Bureau from other sources. 4- Patients who had no preparation for the Bureau before they left the hospital. Randomness and, skewness of the sample.

The patients

range in age from 17 to 44 , with average age of 23 years.

25 In this respect they are typical of patients in United States state hospitals suffering from major functional dis­ orders, being slightly under the national average of 30 y e a r s . B u t they do not follow a normal curve of dis­ tribution over their age range, being rather evenly spread over the entire range.

This is not necessarily atypical,

however, as functional psychoses have their major incidence in the age range covered by the present sample. There are 21 males and 18 females in the sample, which roughly corresponds to the sex ratio of functional psychotic patients in California state hospitals as of 1942•^

These cover what seems to be a representative

group of occupationss unskilled laborers, factory machine tenders, tradesmen, white collar workers, minor professionals, and housewives.

No literature could be found giving a

breakdown of state.hospital patients by occupation, hence it is not known if the sample is skewed in this regard. Half the patients have poor work records, as would be ex­ pected in a group of people with illness of such early onset and long duration as the major functional psychoses. The sample consists of 28 cases of dementia praecox, as against 11 cases of other illness.

This is at variance

Patients in Mental Institutions. 1942, United States Department of Commerce, Bureau of the Census, (1945) United States Government Printing Office, Washington, D. C., Table XIII, p. 20 18 Ibid., Table 8 , p. 6 6 .

with the national average for first admissions to state hospitals which gives a ration of 1,000 cases of dementia praecox to approximately 700 of other major functional p s y c h o s e s .^

This disparity is perhaps explained by the

small size of the sample, as the patients here were selected from those who had been seen by field workers in no par­ ticular order.

Furthermore, our sample has paranoid

dementia praecox as the largest single grouping, nearly eqdal to the number of all other cases put together.

Al­

though Bureau staff members confirm that this is normal among their case loads, no breakdown exists in the literature consulted for the various sub-classifications of dementia praecox (schizophrenia)

which might indicate

whether so striking a preponderance represents a normal selection. The duration of hospital stay of the sample ranged from one month to two years, with a fairly bell-shaped 19 Ibid.. Table 40, p. 131 20 Brown, J. F., The Fsvchodynamics of Abnormal Be­ havior, (Hew York: McGraw-Hill Book Co., Inc., 1940), Ch. XVI. 21 A. H. Maslow and Bela Mittelman, Principles of Abnormal Psychology. (Hew York: Harper & Bros., Publishers, 1941) Ch. XXVII & XXVIII. 22 Edward A. Strecker, Franklin G. Ebaugh and Jack R. Ewalt, Practical Clinical Psychiatry. (Philadelphia: The Blakiston Co., 6th Edition, 1947) Ch. V & VI. ^ Patients in Mental Institutions 1942, Part I. Washington, D. C .t United States Government Printing Office, 1945.

27 distribution.

The average length of stay was just slightly

under six months.

It must be borne in mind that this is

for first admissions only, as the average duration of hos­ pital life for patients with schizophrenic disorders is sixteen years, and for patients with manic-depressive disorders, almost half of this.24

A great variety of

factors influence the length of stay of patients other than the degree or rate of their recovery.

Among these might be

cited the willingness of families to receive them and the adequacy of facilities the family or community has for their care and readjustment outside the institution.

As nearly

as can be surmised then, the spread of months of stay in the hospital is fairly typical for first admissions to state hospitals. As regards marital status of the patients, 14 are single, 13 married, and 12 divorced. 16 marriages in 100 ended in

Since in 1935 about

d iv o r c e ^ ,

and the rate has

risen only slightly since, our sample is most atypical when compared to the general population in this respect.

But it

must be remembered that these are patients with severe mental disorders, and it is reasonable to assume that they 24 j „ p . Brown, op. pit., p. 316. 25 Constantine Panunzio, Major Social Institutions. New York, The Macmillan Co., 1939, Table 19, p. 179•

28 cannot, by the very nature of their illness, sustain a mar­ riage as well as the normal person.

While it is not the

function of this study to correlate divorce and mental ill­ ness, nor to verify the incidence of divorce among the mentally ill, it should be borne in mind, that the primary symptom in the social picture of mental illness is disruption of and inability to sustain social relationships.

Thus, a

high rate of broken homes would be expected in the sample, and also, since "readiness to use extramural services” means ability to enter and sustain a relationship with a social worker, it is expected that even under the most favorable circumstances found by the study, readiness to enter and use the relationship will be lower than in a family agency, where only a percentage of the clientele are mentally ill. In general, divorced and separated people are the largest group of first admissions to mental hospitals in the United States2^ in the age ranges covered by the sample. They are followed by single people, with married persons having the lowest ratio of first admissions.

Since the

sample follows this order, if not the ratios given by the 1930 Census in the reference quoted, we may assume the 2° Ogburn, William F., and Nimkoff, Meyer F., Sociology. New York, Houghton Mifflin Co., 1940, Fig. 35, p. 229.

29 sample .to be accurate enough a selection as regards marital status. In educational level, the patients range from 5th grade through 2 years of college, with an equal number above and below the 10th grade.

Since the national average for

the urban population is 9 th grade, and for the rural popu­ lation 8 th grade,27 our sample is better educated than a cross-section of the national population in their age range. However, the State of California itself has a higher than national average, and hence we may assume our sample to be typical and random for the state, as regards educational level. For a detailed picture of the sample in regard to all factors described above, consult Tables I-A, B, C, and

D. V.

ORGANIZATION OF REMAINDER OF THE THESIS

Chapter II will outline the purposes of the Brochure constructed by the Forms Committee of the Bureau and will discuss briefly the manner of its composition and issue at Norwalk State Hospital.

This chapter will also present the

27 Kolb, J. H., and Brunner, Edmund de S., A Study of Rural Society. 3rd edition, Bostons Houghton Mifflin Co., 19457 Table 77, p. 439.

30 purposes and method of construction of the Schedule and Sup­ plementary Schedule used for tabulating data on each case.

(For samples of the Schedule and Supplementary Schedule, see Appendix, pp* 125 ff.) Three chapters will be devoted to an analysis and discussion of the various factors derived from the Schedule which seem to have had major influence on patients1 ability and readiness to engage in the casework relationship with a Bureau worker.

The final chapter will summarize the

findings and drawT conclusions, as well as suggest avenues for further inquiry.

Findings are summarized in tables

found at appropriate points throughout the text. The bibliography will be rather restricted, as the topic selected has not been extensively treated in the literature, and the method of study is such that more emphasis is placed on the original material itself than on theoretical treatment of the subject.

TABLE I-A AGE, SEX AND MARITAL STATUS OF PATIENTS IN THE SAMPLE

Number of cases

AGE

25 or under 26 to 35 36 or over

Male Female MARITAL STATUS

Single Married, no children Married with children Divorced or separated

II 12 16 21 18 14 4 9 12

32

TABLE I—B EDUCATION AND JOB CLASSIFICATION OF PATIENTS IN THE SAMPLE

Number of cases

SCHOOL GRADE COMPLETED JOB CLASSI­ FICATION

8 th grade or less 9 th to 11 th grade

High school graduate Some college Housewife Unskilled or semi-skilled Skilled and white-collar Minor professionals

11 10

9 6

13 16 7 5

33

TABLE I-C EMPLOYMENT STATUS AND WORK RECORD OF PATIENTS IN THE SAMPLE

Number of cases

EMPLOYMENT STATUS

Employed full or part time Unemployed

10 21

WORK RECORD

Steady at one 30b Fairly steadyj several jobs Intermittent Seldom or never worked

13 4 10

3

34

TABLE I-D HOSPITAL, ILLNESS, AND TREATMENT FACTORS OF PATIENTS IN THE SAMPLE

Number of cases

HOSPITAL

Norwalk Patton

27 12

DIAGNOSIS

Dementia praecox, paranoid Dementia praecox, other Manic-depressive Other

17 11 5

Less than 10 .EST* 11-20 EST 21 or -more EST Custodial care only Collateral medicine and surgery***

11 12

TREATMENT RECEIVED

LENGTH OF HOSPITAL­ IZATION

1 to 3 to 5 to 7 to More

3 months 5 months 7 months 9 months than 9 months

6

8 8

13 4 16 8

4 7

* EST = electro-shock treatment ** Treatment for other than the admitting illness

CHAPTER II SCHEDULE AND BROCHURE: PURPOSES AND METHOD OF CONSTRUCTION Since the Brochure forms one of the major factors in this study affecting patients1 readiness to use Bureau services; and since the Schedule is the device by which all the material for the study was obtained —

a detailed dis­

cussion of them is pertinent for a better understanding of the findings. Purpose

and method of construction of the Brochure.

As previously explained, all patients who go on leave from state hospitals of California are under the supervision of the Bureau.

A worker from the Bureau must keep in contact

with their situation for purposes of supervision.

At such

contact the worker also makes available services the patient is free to reject or use.

It must be obvious that in al­

most every patientTs situation there are social problems created by and incident to the illness which might respond to skilled help from a caseworker.

Such help would be a

direct aid in total treatment of the illness.

But for a

variety of reasons many patients do not wish such help, even where

it would be of obvious benefit. Workers

in the Bureau uniformly reported that the

majority of their patients had not known that a primary

36 condition of leave was supervision by a field worker.

They

were surprised, resentful, and rejecting in many cases of any offer of help, continuing contact only because they had no choice.

It seemed a fair assumption that part of their

resentment might be their ignorance of the existence or need for such a service.

Hence in those cases where a

resident worker had seen them prior to leaving the hospital, and had interpreted the Bureau to them, there ought to have been a greater acceptance and readiness to use the services of a caseworker.

To test this assumption was one of the

major considerations for which the present study was under­ taken. During visits to the hospitals to discuss with resi­ dent workers their policies in interpreting the nature of leave and Bureau services, the following information was obtained: 1* Each worker at each hospital had a potential case load of one to three thousand patients, as (,at time of visit) no hospital had more than two workers, and hospital patient populations varied from 2,500 to 6 ,500 . 2 . Case-finding was a major problem, as no hospital had a routine method of referring patients for Social Service contact.

3. In some cases doctors had no adequate under­ standing of psychiatric social work, nor training in the best use of the special skills of social workers. 4 . The relationship and cooperation between resident Social Service staff and the Bureau is a process wrhich, while relatively efficient, constantly

needs to be rebuilt and enriched with the special ex­ periences ol both. Thus problems constantly may arise in which resident and field worker need to interpret each otherfs services to patients or families, or to refer cases to each other. With so wide an area of services, such pressing shortages of staff, and at date of present writing so short a period of organized and standardized interrelationships, the functions of mutual interpretation and referral are not always ef­ ficient. 5. The resident workers1 time is taken up with other duties besides casewrork with patients about to leave the hospital, with the result that interpre­ tation of the kind here considered was on a very limited, selective basis. Since these facts reflected a reality stemming from legislative and administrative policies of long standing, there was no method in the short run whereby they could be changed.

Resident workers agreed that every patient going

on leave should have adequate interpretation of the conditions of leave, and should be helped to make use of the field worker on social problems incident to their illness.

But

they saw no way, short of very substantial increases in the size of resident Social Service staff, whereby this could be effected. With this in mind, the Forms Committee of the hos Angeles Regional Office of the Bureau (of which the author was a member) suggested to the Supervisor of Extramural Care, Bureau of Social Work, and to the Director of the Department of Mental Hygiene that literature be composed and distributed to patients going on leave of absence, with the following objectives in mind:

38 1. An interpretation in lay language of the con­ ditions of leave. 2 . Encouragement to patients to use the services of a social worker during the period of extramural care, and an explanation of the functions of a social worker in this phase of treatment.

With their approval, and that of the superintendents of local hospitals, the Committee constructed a Brochure to be issued at one southern hospital as a test study.

Should this

Brochure prove successful, it is contemplated making it a standard form of the California, state hospital system, to be routinely issued to all patients going on leave.

It was,

in short, to be a substitute for face-to-face interviews b y ; resident workers, because the latter were physically incapable of contacting each patient. It was agreed by the Committee that the Brochure should: 1.

have a title page, to wit:

After You Go ......

2 . be a very small booklet, four 5x 8 pages on both sides. 3 . be in sympathetic and personalized language, with very simple, direct speech. 4.

omit factual information, but stress that the social worker was the person to see about getting the information needed. 5 . have a single thought on each page. 6 . have the addresses and phone numbers of each southern office of the Bureau as the final page.

While work on the Brochure was in progress, the Committee attempted to make use of the experience in this

39 line of other agencies throughout the nation serving the mentally ill.

A form letter (See Appendix, p. 118.) was

composed and sent to the appropriate agencies of other states, asking them for samples of literature they used for this purpose, and evaluations of such literature.

Replies

to the letter were fairly adequate and prompt but revealed that no agency reported a successful example of such a brochure.

In fact, no agency actually had in use such a

document as the Brochure, although virtually all said one was vitally needed.

Most of the replies requested that the

Bureau1s Brochure be sent to them. The project then seemed a correct, temporary solution to a vital need;: interpretation intramurally of the conditions of leave and of the social services available during the leave period.

While it should be thought of as only a

stop—gap, not a supplantation, of the more desirable inter­ pretation by m. resident worker, the wide interest in it con­ firmed the Bureau’s own experience. The language of the Brochure was held to reality; the patient is and was ill, and return to the hospital was a possibility which existed.

The latter, as previously

mentioned, is an emotion-inducing subject. Throughout the booklet the Committee was faced with the problem of identifying for the patient the social worker’s connection to the hospital.

This was crucial in

an agency which was centrally located, and bore no visible resemblance to the hospital staff.

Thus the repetition, al­

most to the point of poor usage, of ,fthe hospital asks,” ”the hospital wants,” and ”the hospital will keep in touch” was adopted.

In this way, the geographical separation of

hospital and Bureau, and the difference in title of psychia­ trist and social worker would not confuse the patient.

He

would see the worker always as ”the hospital staff,” a part of medical treatment. No more difficult task confronts the social worker than explaining in concise terms to lay people what it is a social worker does.

Multiply this problem by the arti­

facts of a special setting, and the fact that the person reading the Brochure is 3ust recovering from a severe per­ sonality disturbance —

or may not be recovered at all.

Most

of the document is devoted to interpreting what the worker does, where he is, and what the patient-yrorker relationship can be.

Notice that although on page 4 of the Brochure

”heip with feelings” is made the primary service, the list of services on page 5 omits reference to this directly. Instead, page 5 is divided into the two kinds of uses the patient can make of the social workerr

(1 ) supervision,

in which contact on certain items is mandatory; and (2 ) help with personal and emotional problems, in which use is optional.

This is a reflection of the agency itself, which

41 is directed to provide supervision, but which is authorized at discretion to provide other social services. Whether or not the Brochure is correctly composed is at this date unknown, nor will it be known even by study of the findings of this thesis, which is only indirectly and in part a follow-up of the effects of the Brochure. The Brochure was ready in mimeographed form for the pilot study at Norv/alk State Hospital, selected for accessi­ bility and the interest of its Social Service staff in the project.

These resident workers also contributed process-

recorded interviews on patients seen for face-to-face interpretation of the Bureau.

These interviews trace in

tangible form the differences in reactions of patients having had such preparation from those not knowing of the Bureau^ and may also be compared to the intermediate group who received the Brochure. Three hundred copies of the Brochure were delivered to Norwalk, issue to have begun January 2, 1950.

Instructions

for issue were given the Business Office of the hospital (For copy of these instructions, see Appendix, p. 128.), and also typed forms on which the names of all patients receiving the Brochure were to be entered. mailed each week to the Bureau.

One of these forms was The resident workers kept

lists of all patients given personal interpretation of the Bureau before going on leave, and sent these to the Bureau.

42 Thus, whether or not a patient mentioned such preparation, when seen in initial interview by a field worker, the kind of such preparation was known, and represents one of the control factors of the study* Possible effects of the form letter*

Shortly after

a patient goes on leave, his record is forwarded to the Bureau office and automatically assigned to the worker covering the area where the patient lives.

As soon as practicable, the

worker contacts the patient, his family, or both.

This

may be done by form letter, by phone, or by an unannounced home visit.

Or it sometimes happens that the patient con­

tacts the worker first, for help with a problem related to his adjustment outside the hospital.

The form letter is

one of the most frequent of these ways of initiating contact. It will be noted that the content of the letter (See Ap­ pendix, p. 12 2 .) aims at interpreting briefly and simply some ways the worker can be of help, exactly as the Brochure aims to do. But there is a major difference in the effects of the form letter, as contrasted with the Brochure.

The

Brochure is distributed at the hospital, and hence helps, the patient bridge the functional and administrative gap between hosj^ital and Bureau.

The form letter, on the other

hand, arrives some time after the patient has left the

43 hospital and hence is not so apt to make clear for him the connection between the two agencies.

In addition, for those

patients who had no preparation for continuing supervision or other Bureau resources available on leave, the discovery weeks after release that they must be contacted by a social worker representing the hospital can come as an unpleasant surprise.

Yet even with these disadvantages, the form

letter produces some positive results.

Patients often

answer it, indicating that they will welcome the visit and show In their letters or phone calls some grasp of agency function.

A further advantage is that it bridges the

time-gap between release from the hospital and the date when workers with heavy case loads can contact the patient per­ sonally.*! Recognition of the existence and use of the form letter appears in the construction of the Brochure, wherein the patient is told that the "hospital will keep in touch with . . . you to see how you are getting along. be done through your social worker.11

This will

But it should not be

overlooked that the form letter, like the Brochure, is an attempt to compensate for staff shortage and the diminished personal attention this allows field workers and resident workers to give their case loads. 1 These opinions were obtained from experienced staff members, when asked to evaluate their use of the form letter and its effects.

44 With regard to the effects of the form letter on the data in the present study, its effects will probably be positive on all patients save those denying their illness and resentful toward the entire treatment process.

Thus a

patient who received interpretation of after-care services from a resident worker prior to going on leave, or to whom the Brochure was issued at time of going on leave, would likely receive the form letter with foreknowledge of what it implied.

If anything, it would add to his readiness to

use the agency.

This has been taken into account in fram­

ing the Supplementary Schedule, where provision is made for possible effects of the form letter in question 18-d, ”Knew of after-care from other sources,TT and again in the workers1 Schedule in question number 11, "Before contact worker sent ___ letters.” In. conclusion, the form letter is considered one type of preparation for continued contact with a represent­ ative of the hospital, although the least desirable type when used by itself.

No attempt here is made to evaluate

its general effectiveness, style, or its administrative or professional desirability. Purpose and method of construction of the schedule. The Schedule is in two parts: the long form, to be filled out by field workers actually seeing the patients on their first face—to—face interview with the patient after his

4$ release from the hospital on leavej and the short form, or Supplementary Schedule, filled out by the researcher from the record after the long form has been handed in. The questions in the Schedule arise out of the nature of the problem to be studied —

the readiness or ability of

state hospital patients on leave of absence to use the services of the Bureau.

The questions were so phrased as

to anticipate the situation of any patient in the sample, and numerous enough to cover all the factors that were felt might affect the patientfs attitudes toward leave and the worker. identification section was designed to give all the pertinent information about the patient which was a matter of record, that is, the standard questions found on any face-sheet for a social or health agency.

Most of it

appears on the Supplementary Schedule, in order that the cooperating worker would have fewer details —

information

which was purely factual could be obtained by the researcher from the files. The work status sections of the Schedule were also supplemented by several questions on the Supplementary Schedule, since it was anticipated that the worker might not discuss or know these on the basis of the first interview. It developed, however, that in numerous cases, there was no helpful information in the records either.

A serious

46 limitation of the present study was the unanticipated scarcity of information in the records.

Hot all of the items of the

Schedule could be filled in for this reason, and some of the omissions are serious: 1. question number 4, "Present physical health." Mental hospitals normally give treatment for illness other than the admitting diagnosis, but at times these were entered in the part of the record not readily accessible to the Bureau. 2 . questions number 5 through 7 relating to patient’s work status. These were felt necessary for several reasons. If the patient were regularly employed during the day, he wou3.d be harder to con­ tact for Interviews. Hence his not coming in or his breaking appointments need not mean avoidance of the agency. Unfortunately the question was often not touched upon in the initial interview, and in many cases there was no social history which would give this information.

questions number 8 and 9 of the Supplementary Schedule are to be compared with number 2 of the Schedule.

From these

three questions we get the following information: 1. Length of hospitalization. The effects of this on patients1 readiness to use Bureau services are shown in Table IV, p. 61. 2* Time Lapse from release to first interview. The effects of this on patients1 readiness to use Bureau services are shown in Table XVI, p. 67. This is felt to be particularly important, since a rela­ tively quick follow-up on the patient after his re­ lease would logically be expected to be more acceptable to the patient than a visit paid months after. The section on initiating contact was designed to get a picture of the degree of initiative the patient used to reach the agency or, conversely, the difficulty the worker

experienced in establishing contact.

Thus if the worker

sent only one preliminary letter or phone call, or if the patient walked in, arrived on time for his first appoint­ ment, or came alone and presented specific problems, it indicates a genuine readiness to take hold of the services offered.

If, on the other hand, worker had to send several

letters, made several home calls and found no one in, and patient broke several appointments! or if contact had to be initiated by family, friends, or an agency£ and if further­ more, when seen, patient was late, came with a relative and said he had no problems —

in such cases strong resistance

to contact with the Bureau is indicated.

And, of course,

patients could manifest any degree of readiness between these two extremes. From the standpoint of workers filling out the Schedule, the most difficult section is that on patient* s attitudes. For here there is no factual data, no fixed guide by which we can measure the patientfs behavior.

We rely

here on the worker*s experience and skill in sensing what underlies a patient’s statements or activity.

While this

seems to be obvious in every casework interview, there is nevertheless in all of social work no scale of measurement by which the worker*s accuracy can be tested.

Thus a pa­

tient may say he wants help, but actually be extremely hostile, suspicious, and intent on avoiding help by every

48 means possible.

Or the exact opposite may be true.

An

added complication here is that ten different workers filled out the schedules comprising the study sample.

It is there­

fore impossible to say they are all filled out uniformly. The only way known to control this variable would have been to ask a single worker to fill out all the schedules, and this would have been unreasonable.

Yet even this would not

be a conclusive control, since a worker individualizes every interview with every patient; and he has personal reactions of some degree to each patient. from interview to interview.

Hence accuracy would vary

We must rely here on the

judgment.; of trained social workers, just as we rely for diagnosis on trained doctors, even though we know doctors often disagree on diagnoses in mental illness. At the bottom of both the Schedule and the Supple­ mentary Schedule is a section on pre-leave preparation. It should be borne in mind that the workers filling out the schedules did not know the facts of this.

In some cases they

or the patient introduced the subject of pre-leave prepara­ tion into the initial interview, but in other cases it was omitted.

But in nearly all cases it is known what kind .of

preparation the patient received, and this data appears in question number 13 of the Supplementary Schedule.

The kind

of preparation and its effects on patients1 readiness to use Bureau services are illustrated in Table XIII, p. 85*

49 All factors on which data is available from the Schedule, and which may have effects on the patient in his readiness to enter a casework relationship are treated in the following chapters and are illustrated in tables found in Chapters III, IV, and V. Scoring the sample. Each case was f,ratedn as to readiness on the basis of questions number 17-a and 17-b of the long form.

Where some doubt existed, question

number 18—e was considered.

The comments of the cooperating

field workers on questions number 17-a and 17-b were inter­ preted in the following ways Specific problems centering around help with both material matters and matters of feelings and relationship were rated as showing marked readiness to use the services. 2. (a) Specific problems centering around material matters alone, or (b) numerous problems in any combination of material or relationship areas, were rated as showing some readiness to use the services. 3. Vague problems, or none were rated as showing marked unreadiness to use the services. 4* Where there was some doubt as to just how specific or vague the problems were, question*number 18-e was consulted. If it showed a positive atti­ tude toward supervision on leave, the patient was rated as showing some readiness. If it showed a negative attitude, patient was rated as showing marked unreadiness. By a material problem is meant one dealing with a tangible matter like obtaining a driver1s license, or

50 establishing a claim for insurance.

By a matter of feelings

and personal relationships is meant counseling or support in such areas as marital disputes, feelings around marriage and having children, fears of the attitudes of others toward illness and hospitalization.2 It is recognized that this method of scoring is not infallible.

What it amounts to is rating the person, at

the time first seen by a field worker, on his willingness or ability to voice in some way problems that concerned him. Whether he. actually asked for help is not considered in the scoring, but merely whether, in the presence of the worker, the patient mentioned, inferred, or alluded to any problems that might have been of concern to him at the. time. It must be kept in mind that all other items appear­ ing in the Schedule and Supplementary Schedule are factors affecting the rating given on the basis of numbers 17-a and 17-b. The total number of cases appearing in any one table will not always equal the number of cases on which the study was based.

In some cases one patient may fall into more

than one category in the table and thus be counted twice.

Or

m

it may be that the specific factor considered in the table is absent from or not clearly stated in the record. •

Therefore,

2 Virginia P. Robinson, The Dynamics of Supervision under Functional Controls, University of Pennsylvania Press, Philadelphia, 1949, p. 21.

51 any one table may have a slightly greater or lesser number of cases.

CHAPTER III ILLNESS, HOSPITAL, AND TREATMENT FACTORS AFFECTING READINESS TO USE BUREAU SERVICES It is an accepted working rule in the practice of extramural care of the mentally ill that the paranoid pa­ tient will carry over into any relationship the basic symp­ tom of his illness, suspicion and hostility to others. Another accepted rule is that the manic-depressive patient in remission —

and following release from the hospital he

is assumed to be in remission —

is virtually indistinguish­

able from emotionally healthy persons in his relationships to others.

These assumptions are only partly borne out by

the present study, and in part refuted. Diagnosis. Of patients in the sample with diagnosis of dementia praecox, paranoid type, only two in seventeen showed genuine readiness to enter the casework relationship, and seven in seventeen showed strong rejection of the ser­ vice.

Although almost half showed some degree of readiness,

this varied from barest recognition of the social worker to asking for help with a material problem.

None of them

asked for help with problems in the area of feelings and personal relationships.

Diagnosis thus appears to be one

factor in predicting whether a given patient will readily respond to the offer of help from the Bureau.

53

TABLE II DIAGNOSIS AND READINESS TO USE BUREAU SERVICES

DIAGNOSIS

cases

Marked. readiness

Some readiness

D-P,-*- paranoid

17

2

8

7

D-P, other

11

2

6

3

Manic-depressive

5

2

1

2

Other

6

1

2

3

■^D-P - Dementia praecox, or schizophrenia

Unready

Patients with other sub-classifications of dementia praecox showed a slightly better degree of readiness to enter and make use of the casework-relationship.

Two of eleven

were markedly ready, and slightly over half showed some degree of readiness, with three being unready to use the service.

It must be kept in mind that any kind of schizo­

phrenia is characterized by poverty of skill and comfort in the area of social relationships, and the present study anticipated that the findings would be as shown: under the best conditions of dealing with schizophrenic patients, establishing a warm relationship with them is a formidable task. The findings in the case of the manic-depressive group are controversial and less conclusive. markedly unready.

Half of them were

Assuming the findings to be correct,

establishing a helping relationship with the manic-depressive group is even more difficult than with paranoid schizo­ phrenic patients.

A likely explanation here is the relatively

small group in this category of the sample, so that the findings are probably fortuitous. The same might be said of the !!other11 classification of psychoses, which here include undifferentiated disorders, primary behavior disorders, and psychosis, mixed type.

Al­

though they are unequally distributed in the three degrees of readiness to use Bureau services, the meaningfulness of

55 the figures is problematic. Medical treatment.

Patients with acute stages of the

major functional psychoses, and whose cardiac condition is not contra-indicative, are routinely prescribed electro-shock therapy.

Patients with chronic stages, or whose age and

physical condition make electro-shock therapy contra-indicated, are given custodial care and assigned work suited to their capacities about the hospital.

Informed opinion varies

widely on the effectiveness and desirability of electro-shock therapy, some authors taking the extreme stand that all forms of assaultive therapy are inexcusable brutality stem­ ming from desperate ignorance of better measures,--and vir­ tually useless as c u r e s o t h e r s that it is the treatment of choice with almost specific powers.2

Without taking any

stand on such a question, the present study merely calls at­ tention to the practice of California state hospitals in using electro-shock therapy very widely in the functional disorders.

Electro-shock therapy is quickly and simply ad­

ministered, which is a pressing need in view of the huge state hospital populations and annual new admissions in the 1 Roy M. Dorcus and G. Wilson Shaffer, Textbook of Abnormal Psychology (Baltimore: The Williams and Wilkins Company, 1945) , pp. 428 ff. 2 L. H. Smith, J. Hughes, D. W. Hastings, and B. J. Alpers, Electroshock Treatment in Psychoses. American Journal of Psychiatry, 1942, pp. 55B-6l.

56 state.

It is inexpensive not only as regards the equipment

but as regards the fewer numbers of trained staff required to administer it, as compared to insulin, metrazol, or psycho­ therapy. The various authors are fairly well in agreement, however, that electro—shock therapy is normally painless, since electricity travels faster than nerve impulses and hence the patient is in coma before pain impulses can travel.

But none of the sources cited touched upon other

factors associated with the administration of shock treat­ ment to the patient which may be as significant as pain: mass administration of the treatment is quite unpleasant to witness, and patients regularly witness it; and all forms of assaultive treatment induce forgetting. for varying periods. All persons, not only the mentally ill, may be troubled by what went on, what may have been done to them, during am­ nesic periods. around pain.

As much terror may be induced around this as This study is not directly interested in the

medical effectiveness of the treatment nor in administrative decisions involving its use.

The study considers only

possible effects on the patient which might appear in his use of a social worker representing the hospital. In Table III the assumption is made that there will be a differential effect of electro-shock therapy in pro­ portion to the number of treatments received.

However, it

should be noted that the number of treatments bears a close connection to the duration of the stay in the hospital, so that the data in Table IV should be considered simultaneously with the findings of the effects of treatment. The evidence is rather striking, in that unreadiness to use Bureau services during the period of extramural care varies almost directly in proportion to the number of shock treatments the patient received.

And those patients who,

for whatever medical reasons, received no electro-shock therapy have a sharply higher readiness to use the services. Thus, of patients receiving "less than 10," "11-20," or "21 or more” treatments, two out of eight, four out of eleven, and eight out of twelve, respectively, were unready to use Bureau services —

an almost direct gradation.

Of the custodial patients receiving no shock, none of eight cases was unready to use the services.

We are thus

given strong inclination to say electro-shock therapy has a direct and significant effect on the patient1s readiness to relate to a worker who, in representing the hospital, is a visible symbol of whatever the shock treatment meant to the patient. Thirteen cases received medical and surgical treat­ ment not directly incident to their admitting illness. tients in mental hospitals have as many, if not, more, physical illnesses than does the general unhospitalized

Pa­

58 TABLE III TYPE OF TREATMENT RECEIVED AND READINESS TO USE BUREAU SERVICES TREATMENT RECEIVED

No. of cases^

Marked readiness

Some readiness

Unready

Less than 10 EST-**

8'-

1

5

2

11-20 EST

11

2

A

5

21 or more EST

12

1

3

8

8

3

5

0

13

3

A

6

Custodial care and work only Collateral medicine and surgery***

* Total number of cases will exceed size of the sample as several patients fall in more than one category of treatment received* Thus, a patient with 11-20 EST may also, have had collateral surgery for appendectomy. However, no patient having had EST appears in the category of 11cus­ todial care and work only.” ** EST = electro-shock therapy, the basic treatment used in acute, functional (mental) disorders in state hospitals. ***- Patients in mental hospitals have as many, if not more, illnesses requiring medical and surgical treatment as the rest of the population. By collateral here is meant any medicine and surgery not directly incident to the illness for which the patient was admitted to the hospital.

59 population*

One hospital in the study (Patton) was better

equipped to give general medicine and surgery than were the others at time of writing, although this disparity is being remedied through new construction and staff increases*

The

effects of such treatment on patients1 readiness to engage in a relationship with the field worker are interestings six of the thirteen showed marked unreadiness as against none of the patients receiving custodial care only. difficult to explain.

This is

Few persons like going to surgery,

and for many persons, particularly the mentally ill, surgery of any sort can be a castrating or terrifying experience. In large institutions, rumors abound; and it has until recently been a widespread belief that chronically ill patients in California mental hospitals were sterilized on a large scale.

Thus patients emerging from surgery may

imagine themselves to have been sterilized (although only three of the cases in the sample were sterilized).

Also,

it may be assumed that with staff shortages so prevalent, patients are not always given adequate interpretation before­ hand of their need for a specific medical treatment and its relatedness or unrelatedness to their mental condition. Hence they may feel either that the doctors do not know what is the matter with them, are punishing them, or that they are in much worse shape than they had imagined.

Still

another possibility is that surgery may convince the patient

60 he was physically, not mentally ill, and hence that he has no further need of a social worker representing the hospital. But it cannot be too strongly stressed that all such explan­ ations are in the realm of speculation, and require extensive further study. Length of hospitalization.

As in the case of

electro-shock therapy, the duration of hospital life has a striking effect on the readiness of patients to use Bureau services.

The sample was broken down into five periods of

duration, from one month to more than nine months; of these groups, none in four, four in sixteen, three in eight, two in four, and four in seven, respectively, were unready to use the services, an almost directly proportional relation­ ship.

Bearing in mind the kindred findings of the effects

of shock treatment, and that length of stay and number of electro—shock treatments received are closely related, we have an interactive and reinforcing set of facts apparently predisposing a patient toward unreadiness to use extramural help from a social worker.

This is a valuable predictive

tool for the field worker in preparing plans to work with leave patients.

By a glance at the record concerning

electro-shock received and length of stay, he can be pre­ pared for the manner and difficulty of approaching such a patient.

Thus, as later findings will indicate, certain

61

TABLE IV LENGTH OF HOSPITALIZATION AND READINESS TO USE BUREAU SERVICES

MONTHS IN HOSPITAL

No. of cases

Marked readiness

Some readiness

Unready

1 to

3

4

1

3

0

3 to

5

16

3

9

4

5 to

7

8

1

4

3

7 to

9

4

1

I

2

9 and over

7

1

2

4

62 kinds of initiative in establishing contact will have to be used in dealing with patients who have been longer in hos­ pitals.

In addition, these findings give a clue to where

resident workers might place their main efforts in case-finding and interpreting after-care services to patients going on leave; those with longer hospital life needing greater help and more careful handling.

It is felt that thirty-nine cases

in this instance are sufficient to give reasonable validity to the findings. Hospital where patient received treatment.

In con­

sidering the effects on readiness, of the hospital from which the patient came, it should be stressed that no at­ tempt is made to evaluate the efficiency, policies, treat­ ment, or other aspects of these hospitals in a comparative light.

The "hospital,"

made up of, or strongly factors herein treated.

as regards readiness, is

in itself

influenced by, many of the1other Thus shock, length of stay, area of

residence, and diagnosis are all contained in "hospital,” as are the preparation the patients received for extramural help. Twenty-seven of the cases are from Norwalk; this exi cessive proportion is a variant of the fact that Norwalkis closer to the Los Angeles Regional

Office of the

Bureau,

hence the cooperating workers had more Norwalk cases.

Patton

patients are more often served by outlying sub-regional

63

TABLE V HOSPITAL WHERE TREATMENT WAS RECEIVED AND READINESS TO USE BUREAU SERVICES HOSPITAL Marked u ___________ cases_____readiness

Some Unready r e a d i n e s s ______

Patton

12

2

&

2

Norwalk

27

4

12

11

64 offices. But even making allowances for the disparity in hospital of origin, there is a striking difference in Patton and Nor­ walk patients1 readiness to use Bureau services.

Table V

shows that, respectively, ten in twelve as against sixteen in twenty-seven patients from Patton and Norwalk showed some degree of readiness to use the services.

Since treatment

procedures, number of patients per doctor, and length of stay of the patients are not significantly different, we must look beyond the medical picture for an explanation of this phenomenon.

It is the practice of the Social Service

staff at Patton to see all patients going* on leave, even if only briefly, for a clarification of the conditions of leave and interpretation of resources available during the extramural phase of treatment.

This is not the practice at

other hospitals as of the date of writing, but if the findings of this study are valid, there is good indication that such a practice might yield rich returns in extramural treatment success.

Thus we may say that the primary nhospitalff

factor encouraging readiness to use Bureau services is the kind of interpretation of such services the patient received while in the hospital. ' * These findings are even more sharply confirmed when we recall that Patton, by virtue of its equipment, offers more medical and surgical treatment to its patients than d o .

65 the other hospitals; and unreadiness of patients is directly proportional to such medical and surgical treatment.

Hence

we would normally expect Patton patients to show a higher unreadiness, yet the opposite is true*

The only known factor

of difference is then the interpretation given the patients. Accentuating still more the greater readiness of Patton patients is the fact that six of the Norwalk group were given special preparation at the researcher’s request. Take these six from the TtreadinessIT columns and the results are made much more striking.

CHAPTER IV AGE, EDUCATION, EMPLOYMENT, AND MARITAL STATUS FACTORS AFFECTING READINESS TO USE BUREAU SERVICES As previously discussed in the section dealing with the concept of resistance (See pp. 11 ff.), personal factors of the patient himself, other than factors of his illness and treatment, have some bearing on his readiness to enter a helping relationship.

Those factors readily obtained

from face sheet data in ease records will be examined in this chapter. Age.

The sample is broken down into three age

groups of ten years each.

As Table VI illustrates, these

show two in eleven, four in twelve, and seven in sixteen, respectively, unready to use Bureau services.

And con­

versely, three in eleven of those under twenty-five show marked readiness as against two in sixteen over thirty-six. In so far as resistance bears some connection to our con­ cept of readiness, WilsnaekTs contention that resistance increases with age-^ is borne out by the findings.

And the

increase is very marked after thirty-five'years’of age, with the "25 or under" age group apparently showing the most readiness. 1 Wm. H. Wilsnack, "Handling Resistance in Social Case Work," American Journal of Orthopsychiatry. 16:297, p. 299*

67

TABLE VI AGE OF PATIENT AND READINESS TO USE BUREAU SERVICES

Marked readiness

Some readiness

Unready

3

6

2

12

1

7

4

16

2

6

8

AGE IN YEARS

No. of cases

25 or under

11

26 to 35 36 or over

i

68 Explanations of this phenomenon are not found in the sources covered.

It is an accepted hypothesis of analytical

psychology that the personality grows more rigid with age and that the individual tends more strongly to avoid prob­ lems or situations he cannot control, or fears he cannot. Yet two interpretations could be placed on seeking or avoiding a source of help such as the Bureau; it could be either a withdrawal from failure or a resistance to help. The caseworker sees the patient relatively soon after he leaves the hospital, although the actual length of time varies.

(See Table XVI.)

And psychologically, younger

people attach more importance to events nearer in time, whereas with older people, ”temporally distant events ac­ quire increasing significance.”^

Thus older persons would

be more likely to want things the way they were before the illness and life disruption which followed.

The signifi­

cance for our purposes is that once we find facts which help the resident worker or the field worker to get help to the leave patient, these can be differentially applied ac­ cording to the age of the patient, as being more likely to produce positive results in relation to effort expended. it

Education.

Of four educational groups, from ”8th

grade or less” to ”some college,” unreadiness was manifested 2 Kurt Lewin, A Dynamic Theory of Personality. (Hew Yorkr McGraw-Hill Book Company, Inc., 193~, P * 87.

69

TABLE VII SCHOOL GRADE COMPLETED AM) READINESS TO USE BUREAU SERVICES*

SCHOOL GRADE COMPLETED

No. of* cases

Marked readiness

Some readiness

Unready

8th grade or less

11

3

6

2

9th to 11th grade

10

1

A

5

High school graduate

9

2

7

0

Some college

6

0

2

A

Three ease records did not record school grade completed.

70 by two of eleven, five of ten, none of nine, and four of six, respectively, i.e., the patients with twelfth grade educa­ tion showing least unreadiness, and college trained persons most negative in their reactions.

There is no clear-cut

relationship in the findings for the effects of education level on readiness to use the services, although some was expected.

Especially hard to account for is the exceptional

readiness of the high school graduate group, followed by the exceptional unreadiness of the college trained group. One might suppose those with college training, imagining themselves to be superior and independent persons, would reject the help of a social worker.

Yet !fsome college” in

the sample rarely means more than completion of junior college, and may mean no more than the difference between June graduation from high school and September enrollment in a college or junior college.

But the fact of that en­

rollment may be significant in that, with modern, free, compulsory education, almost anyone may hope to complete high school, but only a small segment of the population regularly plan on or have the opportunity to go beyond high school.

Thus, the sharp disparity between the two

groups in their readiness to use the services of a social worker may be less a reflection of their educational level than it is behavior characteristic of two quite different social classes.

The lower class have a long tradition of

71 contact with social workers % the white collar and minor pro­ fessional class have not.

It is strongly felt that there is

some connection between these factors, but the present sample is too small and the data obtained too restricted to isolate this adequately from other factors in the patients1 situation. Marital status. As discussed in the section on selection of the sample (See discussion of randomness and skewness of the sample, pp. 24 f*)> the patient sample group conforms to the usual picture of the marital status of patients in mental institutions.

Table VIII shows that

single persons are most ready to use Bureau services, with only two in fourteen unready, compared to ten in twenty-one of married with children, or separated couples.

A possible

explanation of the unreadiness of the married patients with children is to be found in the Kuehnle and Lowe article where their experience was generally that housewives with children break more appointments and are generally more difficult, since they are more concerned with tasks centering in the home than are single or childless couples.3

But

this does not explain the high degree of unreadiness of 3 Shirley E. Kuehnle and Hanna Lowe, "Use of Social Service by Mental Patients on Parole,11 Smith College Studies in Social Work. XVII:4, June, 1947, p. 233.

72

TABLE VIII MARITAL STATUS AND READINESS TO USE BUREAU SERVICES

MARITAL STATUS Single Married, no children Married? children Divorced or separated

No. of cases

Marked readiness

Some readiness

Unready

14

2

10

2

4

0

2

2

3

4

9

12

2

-

childless or separated couples.

73

Of course, this is based

on too few cases to be significant. Job classification.

Again confirming Kuehnle and

howe4 housewives show high unreadiness to use the services, with half of them falling in the nunreadyf! column of Table IX.

The industrial worker and white collar groups show the

most readiness to use the service, with the professional group last.

Four in five professionals !lunready11 was a very

unexpected finding.

This finding bears a close resemblance

to that shown in Table VII, dealing with educational level. Since all the college trained people in Table VII appear in Table IX as professionals, and both categories show re­ markably high unreadiness, some connection must be assumed. *

Lacking authority from sources covered, the explanation is offered that the greater sense of self-reliance that comes with higher

education andjob level makes the individual

less apt to

ask for help. Such persons are less willing to

seek help from a person (the worker) who they probably feel is less qualified than themselves to deal with the problems )'

in their lives, and are less accustomed to dependent kinds of reactions such as they might associate with asking help of a social worker.

Although the numbers are large enough

to make the findings seem fairly clear-cut, the entire sub­ ject of class behavior and even class identification on the

A

Ibid.

74

TABLE IX *

PATIENTS1 USUAL OCCUPATION AND READINESS TO USE BUREAU SERVICES

JOB CLASSI­ FICATION

No* of cases^

Marked readiness

Some readiness

Unready

Housewife

13

2

5

6

Unskilled and semi-skilled

16

4

8

4

Skilled and white collar

7

1

5

1

Minor profe ssionals

5

0

1

4

* As several housewives were employed, total number of cases exceeds actual size of the sample*

75 basis of education and job level is controversial.

It might

be taken as a rule of thumb that "housewives and minor pro­ fessionals will require more help in making use of a case­ worker during the extramural period." Employment status and work record.

As must be ex­

pected in a group recently released from a mental hospital with seriously crippling illness, the majority of our sample is unemployed.

It was decided to include housewives

as a separate category in Table X since they cannot really be placed in either of the other categories, and constitute a large and Important group of mental patients. An extremely high percentage of the sample has had a poor work record.

This does not prejudice the representa­

tiveness of the sample in any way, since the illness classi­ fications here dealt with (the major functional psychoses) regularly have their etiology and onset early in life, and. produce such behavior disturbances that a person suffering from them is unlikely to be a consistent worker. In general, employment status seems very slightly related to readiness to use Bureau services, that is to say, the unemployed are slightly more ready, with housewives con­ stituting a separate group, ranking below the employed in readiness.

These findings seem surprising.

An individual

able to hold a job would seem likely to be less interested

76

TABLE X CURRENT EMPLOYMENT STATUS AND READINESS TO USE BUREAU SERVICES

EMPLOYMENT STATUS

No. of cases

Marked readiness

Some readiness

Unready

Employed full or part time

10

2

6

2

Unemployed

21

3

16

2

Housewife

8

2

2

A

77 in, or less likely to feel the need for, help from a social worker than a person without one*

Not only would such a

person seem psychologically less likely to want help, but the exigencies of his working hours would make it harder for him to make use of the Bureau. seems indicated by the findings.

Yet no particular difference Hence any explanation

cited must be used with great caution.

Another possible

explanation is that persons able to get and hold a job are more able to evaluate the need and usefulness of the help a social worker can give, and to seek and make use of such help. But this apparently suitable explanation is refuted by the data from Table XI, which shows that those with the best work records are most unready to use Bureau services. The group showing most readiness is that with fair work records, rather than that with the best or worst,

in view

of such contradictory findings, it can only be stated here that the data available in the study are inadequate for proper explanation of relationship between employment and readiness to use Bureau services| and it would seem probable that theie is no connection*

78

TABLE XI WORE RECORD AND READINESS TO USE BUREAU SERVICES* WORK RECORD Steady at one job Fairly steady; several jobs Irregular; often unemployed Has seldom or never worked

No. of cases

Marked readiness

Some readiness

Unready

13

1

5

7

A

1

3

0

10

2

5

3

3

1

1

1

* Reference to work record was not found in nine cases.

CHAPTER V PREPARATION AND INTERVIEW FACTORS AFFECTING READINESS TO USE BUREAU SERVICES Heretofore we have been considering factual, medical, and more or less sociological factors concerning the pa­ tient.

But in the present chapter, factors more in the

realm of social work practices and settings are considered for their effects on readiness to use Bureau services. Tables XIIA, B, C, and D give in cross-section the activities and setting factors applicable to the sample when first seen, as well as to the workers1 opinions of the patients1 at­ titudes towards illness and supervision. Preparation received prior to contact.

It will be

noted from Table XIII that almost half of the patients in the sample had face-to-face interviews with resident workers prior to leaving the hospital.

This is atypical, and repre­

sents a deliberate skewing of the sample, as the researcher attempted to balance the sample approximately equally between those who had such interviews and those who had not.

To do

this, workers in the Bureau were asked to return schedules somewhat out of the usual order in which they would have seen such patients, if these patients were known to have been seen by a resident worker.

Part of the 11face-to-face

interview** group came from each hospital, but differ somewhat

BO

TABLE XII-A PREPARATION RECEIVED PRIOR TO CONTACT

Number of cases*"*

Interviewed by resident worker Issued Brochure

19 B

Y'

Form letter and other sources No preparation

A 12

* Total number of eases exceeds size of the sample, as several patients received’more than one form of prepara­ tion.

£1

TABLE XII-B INITIATING CONTACT

Number of cases CONTACT INITIATED BY WORKER

Letter of phone call

20

Unannounced home visit

11

CONTACT INITIATED BY PATIENT

Letter or phone call

9

Walk-in

3

82

TABLE XII-C PATIENTS» USE OF AGENCY

Number of cases

PRESENTING PROBLEM

Numerous

4

Specific

19

Vague

7

None

9

Material NATURE OR AREA OF HELP REQUESTED

18

Involving personal relationships only

0

Both

9

None

9

83

TABLE XII-D TIME AND PLACE FACTORS OF THE INTERVIEW

Number of cases

SETTING OF THE INTERVIEW

Office

14

Field

25

15 minutes or less

LENGTH OF THE INTERVIEW

4

16 to 30 minutes

10

31 to 45 minutes

10

46 minutes or over

15

34 in the kind of interview they had with the resident worker. The Patton group were routinely seen before going

on leave,

and the Norwalk group were selected by the resident Social Service staff, largely from a decision that they could bene­ fit from Bureau services. An anticipated finding was that the group having had personal interpretation of the Bureau would show much higher readiness to use its services.

Sixteen out of nineteen show

some degree of readiness, only three falling in the ^unready11 column.

Of those who had no known preparation or previous

knowledge of the Bureau, five out of twelve were markedly unready. A less expected finding, and a serious one for the Bureau Brochure project, is that six out of eight of the patients receiving the Brochure were markedly unready, as against only one markedly ready.

This is even more pro­

nounced resistance to the Bureau than those having no prep­ aration at all.

In a discussion of the Brochure with staff

workers, to attempt some explanation of this finding, two principal possibilities were suggested.

One was that the

format of the Brochure was unattractive, being rough-cut green mimeograph paper with a rather poor job of mimeograph­ ing.

Hence a patient given it would not think it important

enough to read.

Another suggestion is that the language of

the Brochure 11talks down1’ to the patient.

85

TABLE XXII PREPARATION RECEIVED PRIOR TO CONTACT AND READINESS TO USE BUREAU SERVICES

PREPARATION RECEIVED

No. of cases#

Marked readiness

Some readiness

Unready

Face-to-face interview

19

4

12

3

Brochure

'8

1

1

4

0

2

2

12

1

6

5

Other sources or form letter None

6

# Total number of cas >s exceeds size of. the sample, as several patients received more than one form of preparation.

86 On the other hand, only eight patients received the Brochure, and in discussions with the workers returning schedules, it was learned that three of these were acutely disturbed when seen, hence their reactions could not be adequately judged.

And there is strong indication that of

the remaining five, most made some adequate use of the Bureau subsequent to the initial interview.

Although these

data would place the Brochure in a more favorable light, for purposes of this study the Brochure must be judged inade­ quate, and as having negative effects on patients1 readiness to use Bureau services. It should be briefly noted that of the nother sources" group, two out of four were markedly unready. While the number is too small to permit of any conclusions, this was an expected finding.

Information gathered from

rumor, letter, family members, etc., is not likely to be accurate and does not have the personal quality which would induce a patient to use the services. Setting of interview.

In the introduction to the

study (See setting of the study, pp. 7 ff.J it was pointed out that the Bureau, in cooperation with the hospital staffs, regularly makes a practice of visiting patients in the field rather than requiring patients to make office visits.

While this is at some variance with usual social

work practice, where value is placed on helping the patient

87 engage in the relationship by requiring that he exert energy to do so, the exigencies of the Bureau and its special prob­ lems seem to require more field visits* But as is apparent from Table XI?, the price paid for seeing patients in the field rather than in office interviews would seem to be rather high in terms of readiness they manifest toward using Bureau services.

Of patients

seen in the field, eleven of twenty-five proved unready, as against two of fourteen seen on office visits.

And of those

showing marked readiness, only four of twenty-five appear among patients seen on field visits, as compared to three of fourteen among patients seen in the office.

Since this

is a tested social work tenet, which the findings of this study reinforce, it should be stated that where practicable, office calls should be the rule if patients are to make maximum and. earliest use of extramural services* That this is easier said than done becomes apparent when it is realized how vast an area and number of patients the Bureau serves.

Workers and patients alike are con­

fronted by the problem of time and distance this would in­ volve in office calls.

Since the centralized location of

the Bureau represents a solution to a problem that was even more formidable when resident workers attempted to make field visits, these findings, if valid, mean that decentralization of the Bureau is indicated.

That is, workers should,

88

TABLE XIV SETTING OF INTERVIEW AND READINESS TO USE BUREAU SERVICES

SETTING OF INTERVIEW

No. of cases

Marked readiness

Some readiness

Unready

Office

U

3

9

2

Field

25

A

10

11

to make office calls more practicable for themselves and pa­ tients, be located in smaller groups in sub-regional offices nearer to the areas where their patients live and work. This negative effect of home visits is particularly noticeable where the visit is unannounced.

The element of

surprise so created here is more apt to generate hostility and defensive reactions than if at least a minimum of prep­ aratory activity were used, such as a form letter or phone call.

Unannounced home calls are more apt to identify the

worker with the unpleasant aspects of hospital experience, with the role of "parole officer" and "checker—up,,11 rather than the helping person who offers the patient real choices in how the relationship shall be begun and conducted.

Fur­

thermore, such a beginning to the relationship is apt to ac­ centuate the area of the service where the patient1s use of it is not voluntary —

.the follow-up procedure at intervals

throughout the leave.

"This is a blow to the patient1 s con­

fidence, an overshadowing threat that he might not be as well as he thought.

Resistance and hostility are immediately

created.njL Length of interview.

The reason for including this

factor was the assumption that where a patient showed some 1 C." f T Steinlein, "Case Work in a Psychiatric Hos-^ pital: Some Hostility Factors," Journal of Psychiatric Social Work, 17:78, Winter 1947-43.

readiness to use the service, a caseworker would remain longer with him in the interview to explore the problems he presented.

Thus it was felt there might be some proportional

connection between length of interview and readiness.

This

is borne out by Table XV, where of interviews lasting thirty minutes or less, ten out of fourteen of the patients showed unreadiness, as compared to only eight out of twenty-five showing unreadiness where the interview lasted longer than thirty minutes.

Again we are dealing with

well-tested social work practice, in that no serious problem can be explored even initially^ or a relationship begun with good foundations, on an interview' time of fifteen or so minutes.

This is hardly time to dispense with amenities

and give barest reasons for purpose of the visit, let alone allow the patient time to develop his ideas and share his feelings around even innocuous problems. But.it is easy to point out the obvious, and diffi­ cult to put it into practice.

With average case loads at

the Bureau in excess of 150, and large portions of workers’ time devoted to travel, conferences, or clerical procedures, there are simply not enough workers and hours to go around to give time for best social work performance.

Fortunately,

more informed legislative and administrative opinion are rectifying this vital factor in some degree, with more adequate budgets for professional staff.

None of the opinions

91

TABLE XV LENGTH OF INTERVIEW AND READINESS TO USE BUREAU SERVICES LENGTH OF INTERVIEW (minutes)

No. of cases

Marked readiness

Some readiness

Unready

4

0

1

3

16 to 30

10

0

3

7

31 to 45

10

2

5

3

46 or over

15

6

7

2

15 or less

given relative to setting of the interview or time allotted to interviews with patients is meant in any way to criticize Bureau practices, but rather to emphasize the formidable barriers a large public agency faces in giving minimum ser­ vice in an area where need is so great and resources so slender. Time lapse between release and initial interview. Table XVI presents in graphic form one of the oldest and best established social work practices$ rapid follow-up after a case is referred, as a guarantee of getting service to the applicant.

True, the patients here are not Ttappli­

cants” i most would rather never see the social worker if choice were theirs.

But they are referred just the same,

and certainly there can be no question as to their need of help.

The findings are strongly confirmativer of patients

seen in less than four weeks after release, only one was unready^ and of patients not seen till after six weeks, ten in eighteen were unready.

On the positive side, of those

seen prior to four weeks, nine in ten show some degree of readiness, as against only eight in eighteen who were not seen until after six weeks had elapsed following their re­ lease on leave from the hospital. Again we are dealing with real limitations of staff, time, and distance.

Not all patients can be seen, for any

of numerous reasons, for two months or more following release.

93

TABLE XVI TIME LAPSE BETWEEN DATE OF RELEASE AND DATE OF FIRST INTERVIEW AND READINESS TO USE BUREAU SERVICES TIME LAPSE

No. of cases

Marked readiness

Some readiness

Unready

Less than 2 weeks

A

0

4

0

2 to 4 weeks

6

1

A

1

4 to 6 weeks

11

3

5

3

More than 6 weeks

18

4

A

10

94 Also, the worker has to use case selection with regard to those patients he feels have more immediate needs, and hence cannot routinely see all.

Ideally increases in staff would

meet much of the problem in this area, but as it may be a long time before staff is really adequate in numbers, here is a challenging problem for further studys

How to tide

over patients during the time from date of release until their regular field worker can contact them. Manner of initiating contact.

The findings shown in

the discussion around setting of the interview (See pp. 86 ff.) are even more strongly confirmed by the data in Table XVII, wherein marked deviation is shown in the readiness of patients to use Bureau services, according to the manner of establish­ ing contact.

We would naturally expect that where initiative

is used by the patient to contact the worker, the patient is predisposed toward use of the service, but that so sharp a differentiation would occur was a surprising finding. Patients were divided into those (1) who had un­ announced home calls; (2 ) who had letters or phone contacts from the worker; (3 ) who phoned or wrote the worker; and (4) who walked into the office ?/ithout an appointment.

In

the order cited, they show nine of eleven, five of twenty, none of nine, and none of three unready.

Again m

the order

cited, they show marked readiness in none of eleven, four of twenty, four of nine, and three of three cases, respectively.

95

TABLE XVII MANNER OF ESTABLISHING CONTACT AND READINESS TO USE BUREAU SERVICES

INITIATED BY WORKER

INITIATED BY PATIENT

MANNER OF ESTABLISH­ ING CONTACT

No. of cases^

Unannounced home visit

11

0

2

9

Letters and phone calls

20

4

11

5

Letters and phone calls

9

4

5

0

Walk-in

3

3

0

0

Some Marked Unready readiness readiness

* Several patients phoned, wrote, or walked in, or after phoning received an unannounced home visitj hence number of cases exceecte size of sample.

96 The entire picture is one of almost perfect correlation between manner of establishing contact and readiness to use services, and is regarded as one of the most clear-cut findings of the study. In this regard, two factors stand, out.

Workers

shouXd routineXy write or phone before a home visit, and any and alX factors that might help the patient to take the initiative in establishing the contact should be studied and put into practice.

Certain of the later factors studied

may indicate how this could be done. The heavy case loads carried by Bureau staff and the extensive geographical distribution of Bureau patients make it more practicable to hold most contacts by home visit rather than by office call.

This is also done to

obviate patients1 losing work time should they be employed, and because many patients by reason of their medical con­ dition are not able to sustain an office interview. ever,- workers maintain certain office days.

How­

If the patient

should call on a day when the worker is not in, case is referred to the T1office call worker,11 a worker whose entire duties are within the office.

These duties are more akin

to intake and referral than to administering a case load. If the matter seems urgent, the office call worker gives direct service.

If less urgent, he refers to the regular

field worker, informs the patient of the workerTs proper

97 office day, etc. It would probably be better if more office visits could be held.

Thinking in social casework is fairly agreed

on the advantages of an office interview, since it provides greater opportunity for quiet, and freedom from distracting interruptions.

’ "In addition it is frequently preferred be­

cause in general when people seek out help for themselves they are more likely to make use of it. (italics mine)

The

initiative required in leaving the home and going to an office is often an indication of the ability the client has to exercise some self-direction."^

there are times

when the client is unable to come to the office; and other times when, although he genuinely feels a need for help, he may not yet be able to bring himself to seek it actively. If the interviewer is rigid about the place of interview, he may lose an opportunity to help where he is really needed. A person1s failure to come into the office may have been due to his ignorance of the nature of the service.

In such

a situation, a "sample experience" of what the agency can offer may alleviate his natural distrust of the unknown. Furthermore, in a post-institutional setting such as the Bureau, there is real need to see the patient in his home setting to evaluate his total situation.

The hospital

^Annette Garret, Interviewing; Its Principles and Methods (New York, Family Welfare Association of America, pamphlet, 1942) p. 5 6 *

98 wants and prefers that home visits sometimes be made for this reason. It is not an objective of this study to evaluate this practice of home calls.

But from the standpoints of social

work in a psychiatric setting, there is disagreement as to the value of such home calls.

In one study specifically

dealing with extramural services to leave patients, the authors made a practice of avoiding home calls except where patients were reluctant to come to the supervising agency. This reluctance they attributed mainly to fear of rehospitaiization, desire to evade supervision, and pressing home responsibilities.3

The known existence of such reluctance

influences Bureau staff in their greater use of home calls. Other factors affecting readiness.

These include sex

of worker and patient, distances of patient*s work and home from the Bureau,- as well as attitudes toward illness and hospitalization evidenced by the patient during his initial interview with the field worker. In general, it may be said that where worker and patient are of the same sex, slightly more unreadiness is apt to be present, and conversely, a little more readiness is found where they are of opposite sex.

But the differences

3 Shirley E. Kuehnle and Hanna Lowe, ffUse of Social Service by Mental Patients on Parole,1' Smith College Studies in Social Work, June, 194?, 17:4* P* 223•

99

TABLE XVIII SEX OF WORKER AND PATIENT AND READINESS TO USE BUREAU SERVICES

SEX OF WORKER AND PATIENT

No* of cases

Marked readiness

Some readiness

Male worker Male patient

4

0

3

1

Male worker Female patient

6

0

3

3

Female worker Male patient

17

5

7

5

Female worker Female patient

12

1

6

Unready

5

100 are very slight, and are not felt to be conclusive.

This

is not a difference that can be significant among so small a sample, and would tend to confirm the general social work principle that sex of the worker is not important.

The

findings, if any, are neutral, in. that while slight differ­ ences exist both for the sex-ration of worker to patient or the unreadiness of patients of male and female workers, these differences conform to no obvious pattern. A possible finding anticipated, and which was not borne out, was that, since the male in our society is more traditionally associated with authorit3?', the male workers would find more unreadiness among their .patients, since their maleness would accentuate the non-voluntary aspects of Bureau services.

But this hypothesis was not borne out.

Distance from the Bureau of patient’s home and work were included in the study when it was first conceived, as it was assumed that distance might be a real factor operating to deter — the Bureau.

or facilitate —

the patient’s readiness to use

But it developed that most of the interviews

were held in the field rather than in the office, so that distance had no tangible relation to readiness.

The factor

of distance may have some possible psychological effects, however.

Thus a patient living close to the downtown area

is familiar with it and may object less to visiting an office downtown* while a patient living in the outlying

101 regions of the County, who rarely if ever comes to the down­ town district, may think of it as a distant and undesirable place.

But such a hypothesis is beyond the scope of this

study and Tables XIX and XX show that distance has no par­ ticular effect*

102

TABLE XIX DISTANCE OF WORK FROM THE BUREAU AND READINESS TO USE BUREAU SERVICES

DISTANCE FROM BUREAU

No. of cases-^

Marked readiness

Some readiness

Unready

1 mile or less

I

1

0

0

1 to 4 miles

2

0

1

1

4 to 10 miles

5

1

2

2

10 to 20 miles

3

X

2

0

20 miles or over

2

0

2

0

Unemployed and housewives omitted.

103

TABLE XX DISTANCE OF RESIDENCE FROM THE BUREAU AND READINESS TO USE BUREAU SERVICES

No. of eases*

Marked readiness

Some readiness

Unready

4

0

2

2

15

2

7

6

10 to 20 miles

6

3

2

1

20 miles or over

a

1

5

2

DISTANCE FROM BUREAU Less than 4 miles 4 to 10 miles

* Patients living outside Los Angeles County were omitted*

CHAPTER VI CONCLUSIONS AND AREAS REQUIRING FURTHER STUDY n; SUMMARY This study has described various factors of patients* own situations, and artifacts of agency setting and social work practice which were known or thought to have a bearing on the readiness of patients on leave from state hospitals to use the extramural services of the State Department of Mental Hygiene.

The various factors studied may be thought

of as falling into three general areas:

(1 ) illness, hos­

pitalization, and treatment factors; (2 ) factors of the patient* s personality and present situation; and (3) factors deriving from the nature of the Bureau and its casework practices. The materials of the study were drawn from schedules filled out by field workers of the Bureau staff and by the researcher.

These patients* schedules were returned on

fifty cases, and were restricted to patients under forty-five years of age with functional psychoses, to first admissions, and to those on indefinite home leave only. These controls avoid such complications as might have arisen over organic behavior reactions more properly in the field of medical than social work research, and gave

105 sufficient homogeneity to the cases to make the findings ap­ plicable to the largest group of patients in state mental hospitals.

Eleven cases were eliminated as not conforming

to these criteria, leaving thirty-nine actually used in the study. Ten workers cooperated by filling out schedules!; every single member of the entire Bureau staff contributed generously of time and knowledge.

Another large area in

which the Bureau professional and clerical staff aided was in the composition, construction, and issue of the Brochure, which makes up a significant part of the theoretical por­ tion of the study, as well as playing a major part in the portion dealing with preparation received by patients and its effects on their readiness to use the Bureau services. The resident workers at Norwalk and Pa.tton State Hospitals and the student unit at Norwalk cooperated by selection of patients to be seen and given face-to-face interpretation of the Bureau — section on preparation.

a major control in the

These workers wrote up lengthy

process interviews, corresponded, and gave helpful suggestions on the incorporation and correlation of this material into the thesis.

A sample of such a process interview, together

with a letter from this patient and the person signing his leave of absence agreement, appears in the Appendix.

These

cases contributed confirmation of a major hypothesis: that

106 readiness to use the services of a Bureau worker is vastlyincreased by preparation given him for this by a resident worker before that patient leaves the hospital. This thesis, then, involved activity of a wide range of persons in hospitals and. in the Bureau, on a pro­ ject of mutual interest to both, and having significance for the great area of after-care in mental illness. XI.

CONCLUSIONS

The findings of the study illustrate the enormous complexity of human behavior, and the innumerable factors that may go into the determination of even so small a part of it as engaging in a helping relationship.

The study

does not pretend to a comprehensive or definitive treatment of factors which may affect such engagement, but offers merely a clue to the areas in which such factors lie, and selects a group of them which seem readily isolable for examination. Age, education, employment. and marital status factors. Experience and authoritative sources predicted that older patients less easily enter into a helping re­ lationship such as that offered by a caseworker to a patient on leave from a state hospital, and these opinions were supported by the findings of this study.

But neither the

107 sources nor the study offer a tested reason why this should be, and it is considered one of the areas meriting further study. Education and occupational category were found to be only moderately important factors, in that college trained patients —

i.e., those likely to be in minor pro­

fessional capacities —

showed unreadiness.

But the next

lower bracket, high school graduates and white collar workers, showed a quite contrary reaction, being fairly ready to use the Bureau services. Employed persons were found to have better readiness than were unemployed patients and housewives.

This seems

controversial as employed people would seem harder to reach and less able to take time to use the services.

This matter

became even more at variance with reasonable expectations when it appeared that steady workers, ar.e less ready than persons with poor work records to use the services.

No

adequate explanation is offered from the data,.and this study cannot go into the sociological and psychological factors that might be at work here.

In general, these factors are

not held to be important in determining readiness. Marital status is a factor of still less importance in predicting readiness to use Bureau services, although childless couples were found to have especially marked unreadiness.

Too few such cases appeared in the sample

108 to make possible more than a guess as to the validity of these findings, and consequently this factor would merit more attention than the present study can devote• The other factors of sex of worker and patient, and of distance from the agency of the patients* residence, proved inconclusive.

In general, the sex of the worker

does not seem significant.

And the factor of distance

from the agency is less significant than it might be if most contacts were office visits.

Since the worker usually

visits the home, distance seems less important from the point of view of this study, unless we enter the realm of the effect of psychological distance.

This latter is so

involved a factor as to be beyond the scope of a study of this kind. Illness, hospital, and treatment factors.

The diag­

nosis dementia praecox, paranoid type, includes the largest group of patients likely to show unreadiness to use the Bureau services, which is a conclusion expected on the basis of the dynamics of this illness and of the experience of field workers in dealing with such patients.

An unex­

pected finding was the equally high or possibly higher un­ readiness of patients with diagnosis of manic-depressive psychosis.

Since the number of such patients in this

sample was small, and since the findings contradict expect­ ancy based on experience, this is an area requiring further

109 study. Treatment received, is found to be an important factor in readiness, as electro-shock therapy seems to arouse antipathy toward itself and toward the caseworker representing the institution where that treatment was re­ ceived.

The findings are that readiness to use Bureau ser­

vices varies inversely with the number of shock treatments received.

Patients receiving no shock are most ready to

use the Bureau. A related and reinforcing factor is the length of stay in the hospital.

Since the longer an acute case of

psychosis stays in the hospital, the more shock is likely to be given, it is to be expected on the basis of the findings above that those who stayed longest would be least ready to use Bureau services, and that is confirmed by the study.

Whether or not these two factors (number of shock

treatments and months in the hospital) are independent variables, which should be further isolated, is not known, nor is the data available on the schedules sufficient to separate these two factors.

But the findings in both seem

beyond chance, as the percentages are highly and directly graduated. Patton patients received more collateral medical and surgical treatment than patients at Norwalk, and it was shown with reasonable certainty that patients receiving

110 such treatment were much less ready to use Bureau services than those who had not.

Mo readily discernible reasons for

this can be seen, and the tentative reason was offered that patients entering for a mental illness may assume that surgery is punishment, or that they think the doctors do not' * really know what is wrong with them.

An alternative explan­

ation is that patients having had non-psychiatric medicine and surgery can attribute their mental illness to physical causes! a^d since the physical condition Is now well, they are now well.

Hence such patients can see no point in

social service follow-up to their hospitalization.

Also,

it is easier for them to feel closer to doctors than to social workers, and. less interested in a non-medical staff member representing the hospital. Patton patients, despite this factor which would seem to predispose them against readiness to use Bureau services, actually showed a much greater readiness than Norwalk patients.

And if we exclude from the Norwalk group

those who were selected by resident workers for face-to-face interpretation, and exclude" from the Patton group those who had'medicine and surgery, the differences in readiness of the two hospital groups is phenomenal*

This fact lends

strong support to the major working hypothesis of the study that readiness of the patients is strongly influenced by kind of preparation they received before leaving the

I l l

hospital. Preparation and interview factors-

The preparation

the patient received at the hospital prior to going on leave was found so closely related to readiness to use Bureau services that it might almost serve as a rule for casework practice with the mentally ill.

Almost without

exception, those patients who had seen a resident worker and received personal interpretation of the Bureau were markedly ready to use the services, whereas those who left the hospital with no preparation and no knowledge that they were to he in contact with a social worker representing that hospital showed a very high degree of unreadiness.

An

intermediate group was made up of patients who received the Brochure or learned of the Bureau from other sources*

The

finding with regard to this intermediate group is incon­ clusive because of the small number of such patients in the sample, but tends in general to show that such prepar­ ation is much less effective than personalized interpre­ tation by a resident worker.

A possible interpretation,

also, of the findings with regard to this group, is that the particular Brochure in use is not adequately constructed and must be revised for further study. The setting of the interview proved to be a factor of some importance, and the findings confirm traditional

112 social work usage and informed opinion, that where practicable, interviews should be held in the office rather than in the patientsf homes. As an extension of this, the practice of making unannounced home visits was shown to bear a high relation to unreadiness to use Bureau services, which seems obvious.

Such unexpected visits were frowned upon

quite early in dynamic casework practice, and this theoretical assumption would seem to be borne out here.

Patients who

either had letters or phone calls from the worker before such a visit, or who themselves contacted the worker, showed much higher readiness to use the services of the Bureau. The length of the interview, while apparently of less weight than setting or manner of initiating contact, did have some bearing on readiness, in that shorter inter­ views made up the group of patients showing less readi­ ness.

But this does not intimate a causal relationship,

since it might well be that the worker, finding the patient rejecting and unwilling to engage in the relationship, might have terminated earlier.

There is no ready explan­

ation of the connection between length of interview and readiness. Much more significant is the lapse of time between release from the hospital and readiness.

Here again, es­

tablished social work practice is confirmed in that the

113 more rapid the follow-up, the more ready the patient is to use the services, i.e., the more accepting of the offer of help.

And this is a factor promising to get attention by

reason of staff increases which will enable workers to serve their case loads more rapidly and more thoroughly. Another factor of significance in the study proved to be the manner of establishing contact with the patient. As was expected, patients exercising the initiative them­ selves proved most ready to use Bureau services. cases where the worker took the initiative — the larger group —

Of those

and this was

patients who received letters or phone

calls from the worker prior to contact were much more ready to use the services than were those cases where the worker made unannounced home calls.

While home visits themselves

are less desirable than office visits for initiating the helping aspect of this social work responsibility, this is not always practicable in a large public agency dealing with the mentally ill.

But indications from the findings do

seem strongly to point to the desirability of avoiding un­ announced visits wherever possible. III.

AREAS REQUIRING FURTHER STUDY

Of that group receiving collateral medicine and sur­ gery while in the hospital, the unreadiness of the manic-depressive psychosis group seems controversial and

requires more careful isolating for study than was possible within the limits of the present examination.

This would

probably require a large sample of patients with this diag­ nosis , and a control group of another diagnosis, holding as many other factors as possible constant.

Once it was

proved conclusively that manic-depressive patients were more or less ready, a further study should be undertaken on this group alone, with a view to isolating out the significant factors. Education and job classification, while felt to be less significant, require handling for their effects on readiness.

This would seem to be a more easily controlled

study than the one suggested above, since there is no dis­ agreement on school grade completed or job held, while there is at times wide disagreement on diagnoses assigned patients in state hospitals, and even where diagnoses are unanimous, patients vary widely in the degree of illness or symptom picture. Work record and employment status present contro­ versial findings, and it is strongly felt that the patient sample here is too small for definitive statements on the effects of these factors.

Since data is not easily ob­

tainable on these factors, a further study of considerable size might be required* The Brochure, being a stop—gap tool partially to

115 deal with the problem of the necessity to interpret after-care before the patient leaves the hospital, and the staff shortages which render this impracticable, should be tested and retested as a virtually necessary device.

Bridging the

gap between hospital and field worker is a major task of psychiatric social work, and involves every skill of re­ ferral and intake known to- the profession.

It is regrettable

that the present findings do not shed more light on a pro­ ject of such importance, and one on which tremendous energy was expended by field and resident workers, Bureau and hospital administrators, and medical staff. is cleart

One thing

An adequate Brochure would be better than no

preparation at all, and the task for further research here is finding how to make a better Brochure and how to test its effects more dependably.

B I B L I O G R A P H Y

116 A*

BOOKS

Brown, J. F., The Psychodynamics of Abnormal Behavior. New York:: McGraw-Hill Book Company, Inc., 19-40* 484 pp. Deutsch, Albert, The Mentally 111 in America. 2nd edition. New York: Columbia University Press, 1949. 555 pp. Dorcus, Roy M., and Shaffer, G. Wilson, Textbook of Abnormal Psychology. Baltimore: The Williams and Wilkins Company, 1945. 54? PP* Kolb, J. H., and Brunner, Edmund de S., A Study of Rural Society. 3rd edition. Bostons Houghton Mifflin Company, 194 6 . 717 pp. Maslow, A. H., and Mittelman, Bela, Principles of Abnormal Psychology. New York: Harper & Brothers Publishers, 1941* 638 pp. Ogburn, William F., and Nimkoff, Meyer F., Sociology. York, Houghton Mifflin Company, 1940. 953 pp. Panunzio, Constantine, Ma.ior Social Institutions. York: The Macmillan Company, 1939. 609 pp.

New

New

Robinson, Virginia P., The Dynamics of Supervision under Functional Controls. Philadelphia: The University of Pennsylvania Press, 1949. 154 PP* Strecker, E. A., Ebaugh, F. G., and Ewalt, J. R., Practical Clinical Psychiatry.' Philadelphia, The Blakiston Company, 6th edition, 1947. 476 pp.

117 B* : PERIODICAL ARTICLES Brickner, R. M., "The Paranoid,” IV in "Roundtable on Treatment of Aggression,” American Journal of Ortho­ psychiatry. XIII, July, 1943.

Kuehnle, Shirley E., and Lowe, Hanna, "Use of Social Service by Mental Patients on Parole," Smith College Studies in Social Work. XVII:4: 223-235, June, 1947. Smith, L. H., Hughes, J., Hastings, D. W., and Alpers, B. J, "Electroshock Treatment in Psychoses,” American Journal of Psychiatry. 1942* 558-61. Steinlein, C. F., "Case Work in a Psychiatric Hospital: Some Hostility Factors.,." Journal of Psychiatric Social Work, XVIIs 74-77, Winter, 1947-43. Wilsnack, William H., "Handling Resistance in Social Case Work," American Journal of Orthopsychiatry. XVI:297, April, 1946 • Wisgerhof, Helen A., "Case Work in Non-voluntary Referrals,” J ournal of Social Case Work. November, 1946- 278. C.

PAMPHLETS

Beck, Bertram M., Short Terra Therapy in an Authoritative Setting. New York: Family Service Association of America, 1946 . 112 pp. Garrett, Annette, Interviewing: Its Principles and Methods. New York: Family Welfare Association of America, 1942. 123 pp. v. U. S. Department of Commerce, Bureau of the Census, Patients in Mental Institutions. 1942. Washington, D. C., U. S. Government Printing Office, 1945. 252 pp.

A P P E N D I X

118 LETTER SENT TO DEPARTMENTS OF MENTAL HYGIENE AND NEURO-PSYCHIATRIC HOSPITALS IN OTHER STATES REQUESTING LITERATURE IN USE BY THEM FOR ISSUE TO PATIENTS GOING ON LEAVE OF ABSENCE

State Department of Mental Hygiene Bureau of Social Work (date)

(address)

The Superintendent _______ State Hospital Dear Doctors We are writing to ask whether your State Hospital has any literature which is routinely given to patients and relatives at the time the patients are admitted to or leave the hospital. We have found that patients and relatives have many questions concerning hospital routine, meaning of leave of absence, the responsibility of relatives, the role of the hospital, the role of the social worker, etc., and we are attempting to draft a simple brochure to meet this need. We understand that you have inaugurated many pro­ gressive procedures in your state hospital, and we would appreciate any literature, information or suggestions you may have which would help us in compiling such a brochure. Since we are in the process of drafting this material, we would appreciate receiving the information as soon as convenient. Yours very truly, BUREAU OF SOCIAL WORK William H. Wilsnack Regional Supervisor

119 THE BROCHURE (title page) A F T E R

Y OU

GO

______

.

(new page) Although, you have been il.1, you are now ready to leave the hospital. The hospital staff feel you are well enough to go. You will be on leave of absence for awhile. This booklet will help explain what leave of absence means and how you may get help with problems that may come up during that time. (over) LEAVE OF ABSENCE While you are on leave of absence, you are still a patient of the hospital. The staff is still inter­ ested in you and will want to know how you are getting along. Leave of absence is not meant to tie you down, but to help you. YsFhen you are able to get along with­ out help, you will be ready for discharge. There is no fixed time for thiss it depends on your progress. Usually it takes about a year. It may be longer or shorter. If you need further hospital care, and wish to return to the hospital, you may do so at any time while on leave of absence. (new page) LEAVE-OF ABSENCE AGREEMENT The hospital asks that the person requesting your leave of absence sign the Leave of Absence Agreement. This may be a relative, friend, or your social worker — someone who sees you often, is interested in you, and wants to help you. The hospital wants you to have close contact with someone who will give you help and attention when you need it. The hospital will keep in touch with both of you to see how you are getting along. This will be done through your social worker.

120 THE BROCHURE (continued) (over) THE SOCIAL WORKER Your social worker is the representative of the hospital in the community. He visits in the area where you live. And he has an office where you can call on him for help at any time. If he is to help you, he has to know where you are. If you change your address, be sure to let him know. Your social worker can help in two main ways — with any worries or upsetting feelings which may mar the pleasure of your return home, and with the prac­ tical matters of living outside a hospital again. Some of the specific ways he can help are on the next page. (new page) YOU WILL NEED TO SEE YOUR SOCIAL WORKER ABOUT

_

BUYING OR SELLING PROPERTY LEAVING CALIFORNIA MAKING AN APPOINTMENT TO SEE YOUR HOSPITAL DOCTOR GETTING A DISCHARGE FROM THE HOSPITAL YOU MAY ALSO WANT HELP WITH..

____ _

GETTING A JOB OR JOB TRAINING DRIVING A CAR HANDLING FINANCIAL PROBLEMS HANDLING LEGAL PROBLEMS HANDLING FAMILY PROBLEMS GETTING MEDICAL CARE IF YOU ARE PHYSICALLY ILL A list of local offices of the Department of Mental Hygiene where the social worker can be reached will be found on the back of this book. (Over) IF YOU LIVE IN

121 THE BROCHURE (continued) Los Angeles. Ventura, Kern, Ban Bernardino, Inyo or Orange Counties: Bureau of Social,Work, State Department of Mental Hygiene 315 South Broadway, Room 401 Los Angeles 12 Madison 6-1515, Extension 861 San Luis Obispo or Santa Barbara Counties: Bureau of Social Work, State Department of Mental Hygiene 1214 Mora Villa Street Santa Barbara Santa Barbara 2-0954 Imperial or San Diego Counties: Bureau of Social Work, State Department of Mental Hygiene 3525 Fourth Avenue San Diego 3 Woodcrest 2115

122 THE FORM LETTER State of California Department of Mental Hygiene Sacramento This letter is to introduce myself as the social worker who will keep in touch with you while you are on leave of absence from As you know, the doctors and other members of the hospital staff are interested in knowing how you are getting along while on leave of absence* The Bureau of Social Work keeps the hospital informed of your progress, and is ready to serve you and your family during your leave period. From time to time, I may visit you at home. In the meantime, if any problem comes up with which I might be of help, please feel free to get in touch with me. I am ordinarily in the Los Angeles office at the address shown on the letter­ head each Would you and the person who signed your leave of absence agreement please drop me a line to let me know how you are getting along now? I hope everything is going well and I am looking forward to meeting you before too long. Yours very truly, BUREAU OF SOCIAL WORK By Psychiatric Social Worker P.S.

If it is difficult to locate your home, will you please include directions, and if necessary, draw a little sketch map to assist me at the time of my first visit?

Copy to:

123 LEAVE OF ABSENCE AGREEMENT

C1) Camarillo State Hospital Camarillo, California A G R E E M E N T To the MEDICAL SUPERINTENDENT, CAMARILLO STATE HOSPITAL. The undersigned, who is related to .... ....... . a patient, confined in the Camarillo State Hospital, in the relationship o f ....... does hereby accept custody of said patient with the understanding that ..he will con­ tinue under the jurisdiction of the Division of Extramural Care of the State Department of Mental Hygiene. It is further agreed to care for and maintain h... and to see that ..he is promptly returned to the Hospital without any expense to the State in the event return is found necessary or advisable, or is so recommended by the Division of Extramural Care. Dated t h i s ...... day of *

.... 19....

Guardian, relative or friend Signed in the presence ofr

Relation

Witness

Street address

Witness

City or Town Telephone number

124 LEAVE OF ABSENCE AGREEMENT (2)

To the MEDICAL SUPERINTENDENT ....... .

State Hospital

....

California

The undersigned, who is related to a patient confined an the in the relationship of

...... . .State Hospital,

....

, does hereby accept

custody of said patient on leave of absence from your insti­ tution, and hereby agrees to care for and maintain h...; to pay all expenses of removing and returning h..., as bills for same are rendered by the hospital^ to see that .h.. is promptly returned to the hospital, in the event of such re­ turn becoming necessary or advisable. Dated this ....... day of

Witness —

19 ...

Guardian, or Relative _ _ _ _

Telephone Number

125 SCHEDULE FOR FIRST FACE-TO-FACE INTERVIEWS WlffTLEAVE PATIENTS IDENTIFICATION Date 2.seen

1* Name**.

3. Length of interview

Interview (Office_____ 2-a.heId in (Field __ 4* Present physical health

WORK STATUS 5* Employed Part time Unemployed

_

Location Hours 6.of work________________ 7.of work Present 8.income#______ per ___

9. Nature of work 10. Briefly describe work record __________ _____ ________ ____ __________ INITIATING CONTACT 11. Before contact worker

(sent )made (made

13-a* Patient broke

letters 12. Patient (by letter, phone calls initiated) by phone_J home calls contact (by walkin

appts.

13-b. Patient* s reasons ______ . _

______________ (early____ (family member 14* Contact was )friend/nabor 15-a.Patient )late____ initiated by(social agency came (on time__ )authorities_____ (early_____ X5-b. Patient)Xate_______ was (on time seen )immedTly Problems 17—a.presented by patient were

16. Patient (alone______ came or ) was seen (with _____

(numerous Matters i n _________ _ )specific 17-b.which pt. _ _ ______ (vague______ _ sought help _______ )none (specify) __________ __

SCHEDULE FOR FIRST FACE-TO-FACE INTERVIEWS WITH LEAVE PATIENTS (continued) “ PATIENTS ATTITUDES a) His illness____________ _ _ b) His commitment_____________ IB. Briefly charac­ terize patients c) Hospitalization_______ _ _ _ attitude towards; d) Treatment received --------------- --e) Supervision on leave --- --------------PRE-LEAVE PREPARATION 19* Had pa.tient contacted a social worker in hospital?

20. What was contact about?

_

21-a. Did he feel 21-b. How did he init helped?________ dicate this? _________ 22. What were patient*s reactions to the leave of absence brochure?__________________ 23. Hext appointment was first mentioned by (patient (worker^.

127 SUPPLEMENTARY SCHEDULE FOR FIRST INTERVIEWS WITH LEAVE PATIENTS 2.

1.

(hospital)

(name) 3. Age

5. Race

4. Sex

6. Diagnosis 7. Treatment received 8. Date admitted

9. Date released

10. Type of admission

_____

11. Previous admissions,

12. Marital status_____________ ___________ ___________ 13. No. children (ages)

14. School grade completed

15. I.Q.

16. Usual occupation 17. Other .iobs held a) Seen by hospital worker____________ b) Recfd preparation for after-care by hospital worker ____ 18. c) Received brochure_______ d) Knew of after-care from other sources_______ e) Had no previous knowledge of after-care_____

INSTRUCTIONS TO NORWALK STATE HOSPITAL FOR . ISSUING THE LEAVE OF ABSENCE BROCHURE: ”AFTER YOU GO.” Give one to every patient going on indefinite home leave not issue them to a) Industrial Leave patients b) Family Care Patients c) Alcoholics d) Persons other than patients As you give the patient a booklet, always do so with the following statement: ”This little booklet will tell you how you can get help with problems you may have while on leave.” Do not add to this or change it, as it Is important for the research follow-up being made on the effects of the booklet. Write the patient1s name on the sheet supplied and marked for that week.

This lis't begins at 8:00 A.M. each Monday.

At 8:00 A.M. the following Monday, mail the completed list to G. F. BENSON at the Bureau of Social Work. Stamped envelopes are provided for this purpose.

MAIL

ONE LIST EACH MONDAY. When all the booklets are used up, write a note to this effect on the last sheet used.

129 IINTERVIEW BY RESIDENT WORKER PREPARING PATIENT FOR LEAVE OF ABSENCE BUSTER M. Social Service Interview After leave of absence staff, worker walked into the hall where patient:was waiting. As she had seen him on several previous occasions, she walked up to patient, smiled and remarked TTyouTve ended up with me again.” Patient smiled back. Worker asked the attendant to please let her and patient out of the locked hall. Worker told patient that the Industrial Placement she had previously discussed with him had been delayed since there were no outside jobs available at the time. Did patient feel he would be happy now with his cousin? Pa­ tient said yes, he was quite eager to go. Worker wondered about the fact that the cousin would be unable to pay him for the work he was to do (this had come up in a previous interview)patient said he felt sure that it would not be long before he could secure work in the neighborhood and provide his own spending money. How many were in the household, worker asked? She had not remembered that there was a son in the house. Patient replied there was his cousin, her son and daughter, and the cousin’s father. Worker wondered about the financial burden the cousin would carry. Hadn’t patient mentioned that although the cousin made a fairly adequate salary, it was not sufficient to allow her to give him spending money? Patient said this was true; however, the father worked at odd jobs and pro­ vided partly for himself; the. son worked regularly and as­ sisted his mother financially. Patient felt they would all get along nicely. Worker said she would like to tell patient of the supervision he would receive while on leave. A social worker from the Los Angeles office of the Bureau would call upon him approximately.once every three months. Such supervision was not meant to tie a patient down but to as­ sist patient in any possible way in his adjustment in the community. Worker suggested patient might think of this as a period of convalescence with himself still a patient of the hospital in whom the staff was interested. The hospital was thus in touch with the patient both througn the worker and through the person signing patient out of the hospital. Could Mr. M. think now of any way he could use such

130 INTERVIEW BY RESIDENT WORKER (continued) help? Patient smiled and replied that he cou!dnTt. Worker suggested that he might want to talk over practical matters, such as an outside job; he might want to discuss a problem that was troubling him. The Bureau Worker was trained to help in many areas and would be on call for such assistance. Would patient like the telephone number and address of the Bureau? Mr. M. nodded. When worker gave this to him, she commented that patient could call the worker for an appoint­ ment if he felt he would like to talk with worker before she called upon him. Worker suggested that if patient became unhappy in his cousin1s home that he discuss this with worker; if he felt at any time that he would be happier on the Industrial Placement he could speak to the worker about such. Patient indicated that he would make use of this assistance if he felt a need of help. Worker and patient walked to the Administration Building to find Mrs. B. Worker asked if she might speak to the cousin; Mrs. B. assented. Worker briefly outlined the Bureau1s plan of supervision to Mrs. B. Worker also asked if Mrs. B. would be able to meet the financial needs of her increased household. Mrs. B. said she believed they would all get along fine. It would perhaps not be too long before patient could secure some work in the neighbor­ hood. Meanwhile, if patient wanted to come home with her, she wanted him. Worker said that was all that was neces­ sary. Patient had already been granted leave and Mrs. B. could now sign him out. Both patient and Mrs. B. thanked worker. *• Margaret McGlasson/bel MMcGbel 1-23-50

131 LETTER FROM RELATIVE OF PATIENT

Los Angeles, Calif. Feb., 1950 Dear Dr. Tuckers This is Mr.-C. speaking, Mrs. R*s. father. that Buster M. is just going 100^1

I wish to report

He is as handy around

here, as a pair of new-mittens-in-a-snow-storm. Since he has been able to re-establish himself socially, one wouldnTt know that he was the same man.

He is a great help

on anything, that is necessary to be done around the home here. He hasnrt touched a drop of drink of any nature to my knowledge| he goes to bed early, and gets up the same way.

He

has put on quite some weight, and from the smile that is on his face all the time, he appears to be as happy as a bird-out-of-a-cage1 Personally thanking you and all for his release, I am, Sincerely yours, G.E.C. P.O .Box__ Los Angeles, Calif. P.S. e I am Bister1s Uncle. Witnessed by_________ Ruby B,

_

132 LETTER FROM PATIEJSfT Sunday, Feb. 5, 1950 Dear Miss McGIassonr Just a line or two, to let you know how happy I am, and. to thank you so very much for your part in my parole from N.S.H. Before I met and talked to you I really didn11 care whether or not I ever left the hospital, I was in a rut I suppose, was working and eating, sleeping and not thinking of the future at all and then when you suggested a parole job I began to realize what changes in the last eight years had taken place out in the country and that I, as you said, wasn’t getting any younger, I began to feel as lonely as an orphan — then when Mrs. B. said she had talked to Dr. N. and that I was going to staff to be paroled to her, I just couldn’t believe it, as I had been thinking ail along about a job in some Sanitarium so you see, Miss McGlasson why I am so happy. Since I have been here I have been helping excavate under the house for a new cellar which is going to be work shop for Mrs. B ’s. son, Albert, Jr.; he is 19 years old and is working at a Television Warehouse down in L. A. When the room is finished, I plan to borrow a small corner of the shop for myself as I want to learn to do leather working belts, billfolds and so on. I am also learning to keep house and cook, believe it or not I baked a* nice white layer cake with coconut on white icing just last Thursday and it turned out rather nice, just a little soggy because I was too generous with the lemon filling. Mrs. B. gave a shower for her brother Harry and his girl friend Anne over at Eaton’s last Thursday and I was in­ vited. I gave them a nice Electric Clock which Anne was very pleased with and she received about a hundred other gifts as all the girls and boys that work with Anne and Mrs. B. were present. We served Devil’s Food Cake, Ice-cream and Coffee. The cakes were three layers with white icing covered with coconut, which I helped to bake and everyone seemed to think they were delicious, which they were. Every­ one had a swell time and the happy couple were overcome by it all. Anne cried and laughed at the same time but they were happy about it all and so was!I .

133 LETTER FROM PATIENT (continued) I have been dancing twicer, once at the Figueroa Ball­ room, and last night at the Riverside Rancho — had a swell time both places, but I enjoy television most of all. I like the ,fRasslersn better than the cowboy stories and watch them pretty near every evening. I am feeling just fine, and working just enough out­ side in the garden and cellar so that I sleep well. I want you to know that I think everything that has happened is just swell and I thank you again from the bottom of my heart for all you have done for me. Yours truly, /s/ Buster M.