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SOCIAL SERVICE ON A LOCKED WARD IN A STATE MENTAL HOSPITAL

A T h esis P re se n te d to t h e F a c u l t y o f t h e G r a d u a te S c h o o l o f S o c i a l Work The U n i v e r s i t y o f S o u th e r n C a l i f o r n i a

In * P a rtia l F u lfillm e n t o f t h e R e q u ir e m e n ts f o r t h e D eg ree M a s te r o f S o c i a l Work

by D o ro th y T i l l e r J u n e 1950

UMI Number: EP66369

All rights reserved INFORMATION TO ALL USERS The quality of this reproduction is dependent upon the quality of the copy submitted. In the unlikely event that the author did not send a complete manuscript and there are missing pages, these will be noted. Also, if material had to be removed, a note will indicate the deletion.

Dteswtaton Publishing

UMI EP66369 Published by ProQuest LLC (2014). Copyright in the Dissertation held by the Author. Microform Edition © ProQuest LLC. All rights reserved. This work is protected against unauthorized copying under Title 17, United States Code

ProQuest' ProQuest LLC. 789 East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 4 8 1 0 6 - 1346

This thesis , w ritten under the direction of the candidate’s F ac u lt y C o m m it te e and a p p r o v e d by all its m e m be rs , has been pr es e nt e d to and a c ce pt e d by the F a cu lt y of the Grad ua te S c ho ol of Soc ial W o r k in pa r ti al fulfilment of the re­ quirements f o r the degree of

MASTER OF SOCIAL WORK

D ean

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Thesis o/....P.ORQ33K...TILLBR.

F aculty C om m ittee

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.A . Chairma

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U

TABLE OF CONTENTS CHAPTER I.

PAGE

INTRODUCTION.......................... . ...................................................... The p ro b lem

1

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

1

The s e t t i n g ............................................................................

2

F ocus o f t h e s t u d y ...............................................................

5

D evelopm ent o f t h e s t u d y ................................................ II. III.

HISTORY AND STATUS OF PSYCHIATRIC SOCIAL WORK

.

.

10

BY THE SOCIAL WORKER DURING WARD OFFICE HOURS.

.

16

PRESENTATION OF THE CASES OF THE PATIENTS SEEN

D if f ic u lty in e s ta b lis h in g a p o in t o f c o n ta c t f o r p u rp o se fu l i n t e r r a c t i o n because o f p a t i e n t s 1 p o o r r e l a t i o n t o r e a l i t y ........................

17

A tte m p ts t o p o i n t up r e a l i t y f a c t o r s w i t h p a t i e n t s u n a b le t o a c c e p t t h e i r need f o r h o sp ita liz a tio n ..................................................................

19

C o n s i d e r a t i o n o f h o s p i t a l r e g u l a t i o n s an d p ro ced u res a s th e y a f f e c t e d th e p a t i e n t s 1 d a i l y l i v i n g i n an d l e a v i n g t h e h o s p i t a l . . .

20

C o n s i d e r a t i o n o f p ro b le m s o u t s i d e t h e h o s ­ p ita l ..........................................................................................

27

Help i n c o n s t r u c t i v e u s e o f h o s p i t a l i z a t i o n

.

A s s i s t a n c e i n p l a n n i n g to w a r d l e a v i n g t h e h o s p i t a l ................................................................................. IT .

6

.

30 34

WARD INVOLVEMENT AND VALIDITY OF THE PLAN OF WARD OFFICE HOURS...................................................................

41

Ward i n v o l v e m e n t ................................ The p h y s i c i a n .......................................................................

W41

iii CHAPTER

PAGE The a t t e n d a n t .................................................................................

42

The p a t i e n t s ........................................................................................ 43 V a lid ity o f th e V.

p l a n o f w ard o f f i c e h o u r s ...................

43

SUMMARY AND CONCLUSIONS..................................................................

47

LIST OF TABLES TABLE I.

PAGE

A re a s o f S o c i a l S e r v i c e t o P a t i e n t s on a L ocked Ward a t N orw alk S t a t e H o s p i t a l f o r t h e P e r i o d 1 1 - 2 2 -4 9 t o 1 - 3 1 - 5 0 ..................................

45

CHAPTER

I

INTRODUCTION Modern p s y c h i a t r y no l o n g e r s e e s t h e m e n t a l l y i l l p e r ­ son o n l y a s a n i n d i v i d u a l s u f f e r i n g fro m a p s y c h o p a t h o l o g i c a l 1 p r o c e s s b u t a s an i n d i v i d u a l i n r e l a t i o n t o h i s e n v i r o n m e n t. W h e th er t h e e n v iro n m e n t b e a community o r a m e n ta l h o s p i t a l , h i s a d ju stm e n t a f f e c t s h i s w e ll b e in g .

The more d y n a m ic a lly

o r i e n t e d t h e t h e r a p e u t i c p ro g ra m o f a h o s p i t a l i s , t h e g r e a t ­ e r th e r e c o g n i tio n o f th e need f o r th e p s y c h i a t r i c s o c i a l w o rk e r w i t h h e r f o c u s on t h e p a t i e n t ’ s im m e d ia te r e a l i t y p r o b le m s i n u s i n g t h e h o s p i t a l f a c i l i t i e s i n movement to w a r d r e t u r n i n g t o t h e community an d r e h a b i l i t a t i o n .

In t h i s a re a

o f th e p a t i e n t ’ s needs as a s o c ia l b ein g , th e p s y c h ia tr ic s o c i a l w o rk e r f u n c t i o n s a s p a r t o f t h e w hole t r e a t m e n t p r o 2

cess. THE PROBLEM T h i s s t u d y , u n d e r t a k e n i n a s t a t e m e n ta l h o s p i t a l , i s 1 Group f o r t h e Advancement o f P s y c h i a t r y , nThe P s y c h i a t r i c S o c i a l W orker i n t h e P s y c h i a t r i c C l i n i c a l T eam ,” ( I n t e r i m R e p o r t o f C om m ittee on P s y c h i a t r i c S o c i a l Work, C i r ­ c u l a r L e t t e r # 1 4 9 , T o p ek a, K a n s a s , J u l y 2 6, 1 9 4 9 ) , P* 4* 2 H e n r i e t t a D e W itt, ”The F u n c t i o n o f t h e S o c i a l W orker i n t h e T o t a l T r e a tm e n t P rogram i n a S t a t e M e n ta l H o s p i t a l , ” A m erican J o u r n a l o f P s y c h i a t r y . 1 0 5 :2 9 9 , O c t o b e r , 194&*

an a t t e m p t t o d i s c o v e r w h at p a t i e n t s on a l o c k e d w ard i n t h e h o s p i t a l need th e s e r v ic e s o f th e s o c i a l w o rk er.

S in c e t h e

m ethod o f f i n d i n g p a t i e n t s who n e e d s o c i a l s e r v i c e i s e x p e r i ­ m e n t a l , e v a l u a t i o n o f t h e e f f e c t i v e n e s s i s made.

On t h e b a ­

s i s o f s o c i a l s e r v ic e b e in g o f f e r e d t o t h i s p a r t i c u l a r gro u p o f p a t i e n t s , t h e f o c u s o f t h e s t u d y i s on t h e h e l p f u l n e s s o f t h e s o c i a l w o rk e r t o t h e p a t i e n t s who a v a i l e d t h e m s e l v e s o f se rv ic e . The s t r u c t u r e f o r t h e d e v e lo p m e n t o f t h i s s t u d y was r e g u l a r w e e k ly o f f i c e h o u r s h e l d by t h e s o c i a l w o rk e r on a l o c k e d w ard i n su c h a h o s p i t a l .

L i t t l e i s known o f t h e n e e d s

o f t h e p a t i e n t who f r e q u e n t l y d o es n o t know o f t h e e x i s t e n c e o f t h e S o c i a l S e r v i c e D e p a rtm e n t a n d who i s h a n d ic a p p e d by h a v in g t o s t a y c l o s e t o t h e ward b e c a u s e o f h i s i l l n e s s .

The

r e a s o n s why p a t i e n t s on open w ard s n e e d t h e s e r v i c e s o f t h e s o c i a l w o rk e r a r e more g e n e r a l l y known b e c a u s e o f t h e i r f r e e ­ dom an d a b i l i t y t o make p e r s o n a l a p p l i c a t i o n .

T h u s, o p p o r t u ­

n i t y t o make an a p p o in tm e n t w i t h t h e s o c i a l w o rk e r was o f f e r ­ ed t o p a t i e n t s on a l o c k e d w a rd . THE SETTING The C a l i f o r n i a S t a t e D ep a rtm en t o f M e n ta l H ygiene TTi s r e s p o n s i b le f o r th e m e n ta l h e a l t h o f th e c i t i z e n s o f th e

S ta te o f C a lif o rn ia .”

3

3 I t s fu n c tio n s in c lu d e th e o p e ra tio n

o f h o s p i t a l s f o r t h e c a r e and t r e a t m e n t o f t h e m e n t a l l y i l l as w e ll a s th e p ro v is io n o f s e r v ic e s o f a p re v e n tiv e n a tu r e . The s e t t i n g o f t h i s s t u d y , N orw alk S t a t e H o s p i t a l , i s one o f t h e f a c i l i t i e s o f t h e D e p a rtm e n t f o r t h e c a r e and t r e a t m e n t o f th e m e n ta lly i l l ,

a d m i t t e d v o l u n t a r i l y o r by a p p l i c a t i o n

o f t h e H e a l t h O f f i c e r o r c o m m itted by t h e S u p e r i o r C o u r t . A l c o h o l i c an d d r u g a d d i c t s a n d s e x u a l p s y c h o p a th s a r e a l s o a d m itte d . One d i v i s i o n o f t h e D e p a rtm e n t i s t h e B u re a u o f S o c i a l Work w h ic h a d m i n i s t e r s ua l l s o c i a l s e r v i c e s t o h o s p i t a l p a ­ t i e n t s u n d e r t h e j u r i s d i c t i o n o f t h e S t a t e D e p a rtm e n t o f Menk t a l H y g ie n e , e x c e p t t h o s e g i v e n by r e s i d e n t w o r k e r s . ” T h is B u re a u i s e x t r a m u r a l s o c i a l s e r v i c e a s c o n t r a s t e d w i t h t h e s o c i a l s e r v i c e d e p a r t m e n ts l o c a t e d i n t h e h o s p i t a l s , w hose w o rk ers a re i n t e g r a l p a r t s o f t h e h o s p i t a l s t a f f s .

The p r i ­

mary f u n c t i o n o f t h e B u reau o f S o c i a l Work i s t h e s u p e r v i s i o n o f p a t i e n t s who a r e on c o n v a l e s c e n t l e a v e , o r l e a v e o f a b ­ s e n c e , fro m a h o s p i t a l , p r i o r t o d i s c h a r g e from t h e j u r i s d i c 3

S t a t i s t i c a l R e p o r t o f D e p a rtm e n t o f I n s t i t u t i o n s . Y ea r E n d in g 6 -3 0 -A 5 ~'( S t a t e o Y “C a l i f o r n i a : C a l i f o r n i a S t a t e P r i n t i n g O f f i c e ) , p . 153* 4 M anual o f B u reau o f S o c i a l W ork. Los A n g e le s O f f i c e ( S t a t e D e p a rtm e n t o f M e n ta l H y g ie n e ) .

4 t i o n o f t h e D e p a rtm e n t o f M e n ta l H y g ie n e . The w ard c h o s e n f o r t h e s t u d y i s known a s a " b e t t e r w a rd !t, t h e p a t i e n t s b e i n g d e s c r i b e d a s " c h r o n i c an d q u i e t " . T h e re a r e no f a c i l i t i e s f o r s e c l u s i o n o r r e s t r a i n t .

The p a ­

t i e n t s a r e men r a n g i n g i n ag e from 19 t o 79 y e a r s o f a g e . The d i a g n o s e s o f t h e i r i l l n e s s e s c o v e r a l l c l a s s i f i c a t i o n s o f m e n ta l i l l n e s s .

In a d d itio n , th e r e a re n o n -p sy c h o tic p a t i e n t s

a s m e n tio n e d a b o v e . The w ard o r g a n i z a t i o n o f t h e h o s p i t a l i s on t h e c o t ­ t a g e p la n c o v e r i n g a n a r e a o f a p p r o x i m a t e l y f i v e s q u a r e c i t y b lo c k s.

A lth o u g h t h e w ard p o p u l a t i o n c a p a c i t y i s 54 t h e g e n ­

e r a l i n c r e a s e i n t h e number o f p e o p l e n e e d in g h o s p i t a l i z a t i o n makes i t n e c e s s a r y f o r 75 p a t i e n t s t o l i v e on t h e w a rd .

A-

b o u t 30 o f t h e s e p a t i e n t s a r e c o n s i d e r e d w e l l enough t o be a b l e t o work on s u p e r v i s e d d e t a i l j o b s on t h e h o s p i t a l g r o u n d s . The r e m a in in g 45 p a t i e n t s spen d a l l o f t h e i r tim e on t h e w a rd , some o f them p e r f o r m i n g c h o r e s i n c o n n e c t i o n w i t h t h e m ain ­ te n a n c e o f t h e w ard .

F o r p a t i e n t s who come fro m d i s t u r b e d

w a r d s , a t r a n s f e r t o t h i s w ard means a s t e p i n t h e p r o c e s s o f g e t t i n g ready t o le a v e th e h o s p i t a l , f o r i t i s g e n e r a lly th e l a s t s t e p i n t h e l i n e o f lo c k e d w a rd s b e f o r e g o in g t o an o p en w a rd . P a t i e n t s r e m a i n i n g on t h e ward sp e n d m ost o f t h e i r ti m e i n t h e day room o c c a s i o n a l l y r e a d i n g , w r i t i n g o r p l a y i n g c h e c k ­ e r s , dom inoes o r a s i m i l a r game.

Smoking i s p e r m i t t e d i n t h e

5 l a v a t o r y o r c o u r t y a r d w h ere p a t i e n t s g o , w e a t h e r an d s u f f i ­ c ie n t a tte n d a n t personnel p e rm ittin g .

P la n n e d r e c r e a t i o n a l

a c t i v i t y on t h e w ard c o n s i s t s o f a b in g o game one n i g h t a w eek.

T h ere i s o p p o r tu n ity f o r p a r t i c i p a t i o n i n th e c h o ir f o r

th o se i n t e r e s t e d .

Many a l c o h o l i c p a t i e n t s a t t e n d m e e ti n g s o f

A l c o h o l i c s Anonymous h e l d e s p e c i a l l y f o r h o s p i t a l p a t i e n t s . P a t i e n t s who a r e n o t a p t t o a t t e m p t e s c a p e a t t e n d w i t h s u p e r ­ v i s i o n a w e e k ly m o tio n p i c t u r e show, d a n c e s and s p e c i a l e n t e r ­ t a i n m e n t s a t t h e r e c r e a t i o n a l h a l l on t h e h o s p i t a l g r o u n d s . W eekly v i s i t s t o t h e w ard h av e r e v e a l e d a r a t h e r c o n ­ s i s t e n t p i c t u r e o f i n a c t i v i t y on t h e p a r t o f p a t i e n t s .

O cca­

s i o n a l l y t h e r e a r e o n e o r two p u s h in g a b l o c k up an d down t h e l o n g h a l l r u n n i n g b e tw e e n t h e two d o r m i t o r i e s .

The c h a i r s i n

t h e day room a r e o c c u p ie d by p a t i e n t s , some s i t t i n g , sle e p in g .

some

A few c h a i r s s tr e w n i n t h e h a l l a r e u s u a l l y o c c u ­

p i e d f o r l a c k o f s p a c e i n t h e d ay room .

The d i n i n g room i s

u s e d by r e l a t i v e s an d f r i e n d s v i s i t i n g p a t i e n t s . FOCUS OF THE STUDY The S o c i a l S e r v i c e on t h e w ard b e g a n on 1 1 -2 2 -4 9 *

A l­

th o u g h t h e s e r v i c e h a s b e e n c o n t i n u o u s t h r o u g h A p r i l , 1950 ( e x c e p t f o r two weeks a t C h r i s t m a s t i m e ) , t h e s t u d y i s c o n c e r n ­ ed w i t h t h e p a t i e n t s s e e n up t o and i n c l u d i n g 1 - 3 1 - 5 0 .

If a

p a t i e n t e s t a b l i s h e d a w o rk in g r e l a t i o n s h i p w i t h t h e s o c i a l

6 w o rk er d u r in g t h i s p e r io d , a lth o u g h t h e in te r v ie w s c o n tin u e d b ey o n d 1 - 3 1 - 5 0 , t h e c a s e h a s b ee n i n c l u d e d i n t h e s t u d y . On t h e b a s i s o f t h e r e c o r d e d c a s e m a t e r i a l , an a t t e m p t w i l l be made t o f o r m u l a t e a n s w e rs t o t h e f o l l o w i n g q u e s t i o n s : (1 ) F o r w h at d i d t h e p a t i e n t s come? an d i n w h at way? how?

(2 ) How many w ere h e l p e d

(3) D id t h e w ard become in v o l v e d ?

I f so,

(4 ) I s t h e r e v a l i d i t y i n s e r v i c e b e i n g made a v a i l a b l e i n

t h i s way? DEVELOPMENT OF THE STUDY B e c a u se t h i s k i n d o f s e r v i c e was an i n n o v a t i o n on t h e w ard , some t h o u g h t w en t i n t o t h e b e s t mode o f p r e s e n t a t i o n and in te rp re ta tio n .

At a s c h e d u l e d c o n f e r e n c e o f w ard p h y s i c i a n ,

w ard c h a r g e a t t e n d a n t , s o c i a l s e r v i c e s u p e r v i s o r , an d s o c i a l w o r k e r , t h e f o l l o w i n g p r o p o s e d p l a n was p r e s e n t e d : R e g u l a r w ee k ly o f f i c e h o u r s w i l l be h e l d on t h e w ard by t h e s o c i a l w o rk e r who can b e a p p r o a c h e d by any p a t i e n t w a n t i n g t o u s e t h e s e r v i c e s h e h a s t o o ffer. I t i s p r o p o s e d t h a t t h e s o c i a l w o rk e r i n t r o ­ d u ce h e r s e l f t o t h e p a t i e n t s d u r i n g a lu n c h h o u r an d a t t h i s tim e i n d i c a t e some o f t h e a r e a s w here p a ­ t i e n t s m ig h t f i n d h e r s e r v i c e h e l p f u l . The f u n c t i o n o f t h e s o c i a l w o rk e r w i t h t h e p a ­ t i e n t s w ould be t o h e l p t h e p a t i e n t d e a l w i t h r e a l i ­ t y p ro b le m s b o t h i n s i d e and o u t s i d e t h e h o s p i t a l . T h ese p ro b le m s w ould t e n d t o f a l l i n t h e f o l l o w i n g areas: 1.

S ta tu s in th e h o s p ita l a . f e e l i n g s a b o u t h o s p i t a l i z a t i o n and m e n ta l illn e ss b . u n h ap p in ess in d a ily l i v i n g a t th e h o s p i t a l

7 c. d i f f i c u l t y in a c c e p tin g h o s p it a li z a t io n in a p o s i t i v e way d . q u e s t i o n s a b o u t u n f i n i s h e d b u s i n e s s on t h e o u ts id e — p e rs o n a l b e lo n g in g s, p r o p e r ty , em ployment 2.

L e a v in g t h e h o s p i t a l a . f e e l i n g s a b o u t l e a v i n g t h e h o s p i t a l — w a n t­ i n g a n d n o t w a n ti n g t o l e a v e b . c o n c e r n a b o u t w here t o g o , howf i n a n c i a l n e e d s can b e m et c . who w i l l s i g n him o u t d . c o n c e r n a b o u t "w hat p e o p l e w i l l t h i n k "

3.

S ta tu s o f r e la tiv e s a . v i s i t i n g and n o n - v is iti n g b . w o rry and c o n c e r n o v e r t h e w e l l - b e i n g o r fin a n c ia l s itu a tio n o f re la tiv e s c . r e a c t i o n s o f r e l a t i v e s t o m e n ta l i l l n e s s

S i t u a t i o n s s i m i l a r to th e s e co u ld be r e f e r r e d d i ­ r e c t l y by p a t i e n t s t o t h e s o c i a l w o rk e r o r by t h e w ard p h y s ic ia n to th e s o c i a l w o rk er. H o p e f u lly t h e s o c i a l w o rk e r h e l p s t h e p a t i e n t s t r e n g t h e n t h e h e a l t h y a s ­ p e c ts o f h is p e r s o n a lity in o rd e r to d e a l w ith th e p ro b le m s he p r e s e n t s . From p a t i e n t s m ig h t come a l l k i n d s o f r e q u e s t s t h a t f a l l w i t h i n t h e a r e a o f t h e w ard p h y s i c i a n — w ard c h a n g e s , l e a v e o f a b s e n c e , g ro u n d p a r o l e an d ev en s o m a tic c o m p l a i n t s . T h e se r e q u e s t s w ould be t a k e n up w i t h t h e w ard p h y s i c i a n w i t h whom t h e s o c i a l w o rk e r w ould be h a v i n g r e g u l a r c o n f e r e n c e s . I n t e r v i e w s w i t h p a t i e n t s w i l l be l i m i t e d t o one h o u r e a c h a l t h o u g h many m ig h t be l e s s . At t h e i n c e p ­ t i o n o f t h e p l a n t h r e e h o u r s p e r week a t a s p e c i f i c and r e g u l a r tim e w ou ld b e s p e n t on t h e w a rd . I f i t a p p e a r s l a t e r t h a t more t i m e i s n e e d e d , a d d i t i o n a l a r ­ r a n g e m e n ts c o u ld b e made f o r o t h e r h o u r s on t h e w a rd . Where p a t i e n t s a r e on g ro u n d p a r o l e , o f f i c e a p p o i n t ­ m e n ts c o u ld be made. I n t e r v i e w i n g t i m e o f n e c e s s i t y w i l l be l i m i t e d t o a maximum o f s i x h o u r s w e e k ly b e ­ cause o f th e tim e in v o lv e d i n s tu d y in g r e c o r d s , r e ­ c o r d i n g i n t e r v i e w s , c o n f e r e n c e s w i t h w ard p h y s i c i a n s an d s o c i a l s e r v i c e s u p e r v i s o r . G e n e r a l a p p r o v a l a n d u n d e r s t a n d i n g w ere e x p r e s s e d

6 about th e p la n .

A f t e r d i s c u s s i o n , t h e d ay c h o s e n f o r t h e o f ­

f i c e h o u r s was a n o n - v i s i t i n g d a y .

The c h a r g e a t t e n d a n t

o f f e r e d t h e u s e o f h i s o f f i c e a s a l l o w i n g t h e m ost p r i v a c y a l t h o u g h i t was r e c o g n i z e d t h a t t h e r e w ou ld b e , o f n e c e s s i t y , in t e r r u p t i o n s o f te le p h o n e c a l l s . In th e c o n s id e r a tio n o f th e s o c ia l w o rk er’ s in tr o d u c ­ t i o n t o t h e p a t i e n t s , i t was r e c o g n i z e d a s b e i n g a d v i s a b l e t o i n t e r p r e t t h e s e r v i c e a s s im p ly a s p o s s i b l e .

W ith a g e n e r a l

a r e a o f f u n c t i o n d e f i n e d f o r th e m , i t was f e l t t h a t t h e r e w ould be some t e s t i n g by e a c h p a t i e n t r e s p o n d i n g t o f i n d o u t f o r h i m s e l f w h at t h e s o c i a l w o rk e r c o u ld d o .

A c c o r d in g l y ,

f iv e days b e fo re th e s t a r t o f th e o f f i c e h o u rs, th e fo llo w in g i n t r o d u c t i o n was made i n t h e w ard d i n i n g room w h i l e t h e p a ­ t i e n t s w ere e a t i n g lu n c h : My name i s M rs. T i l l e r and I am a s o c i a l w o rk e r a t th e h o s p ita l. T h e re i s a S o c i a l S e r v i c e D e p a r t ­ m ent h e r e an d t h e r e a r e some p a t i e n t s who come t o o u r o f f i c e s t o s e e u s . S in c e t h e r e a r e v e r y few o f you who a r e a b l e t o do t h i s , we a r e b r i n g i n g S o c i a l S e r v i c e t o you on t h e w ard t o s e e i f we can b e h e l p ­ f u l t o y o u . B e g in n in g n e x t T u e sd a y , November 22nd, I w i l l b e h e r e from 1 2 :3 0 t o 3 :3 0 p .m . i n t h e a t t e n ­ d a n t ’ s o f f i c e — an d I w i l l come e a c h T uesday a f t e r th a t. I w i l l b e h e r e t o h e l p y o u w i t h w h at I can a s a s o c i a l w o r k e r — t h i n g s c o n c e r n in g y o u a b o u t y o u r d a i l y l i f e i n t h e h o s p i t a l . We f i n d t h a t f r e q u e n t ­ l y i f some o f t h e s e t h i n g s ca n be t a l k e d o v e r , you can g e t w e l l s o o n e r . T h e re w i l l p r o b a b l y be some t h i n g s t h a t you w i l l s e e me a b o u t w h ere I am n o t a b l e t o be h e l p f u l . I w i l l t r y t h e n t o h e l p you u n d e r s t a n d why I c a n ’t o r

9 f i n d w h ere I can be h e l p f u l * As we s t a r t t h e s e o f ­ f i c e h o u r s , I won’t b e a b l e t o s e e m ore t h a n s i x o f you e a c h Tuesday* E ac h one o f y ou who w a n ts w i l l have an o p p o r t u n i t y t o make an a p p o i n tm e n t a l t h o u g h you may h av e t o w a it* S in c e p a t i e n t s a r r a n g e d w i t h t h e c h a r g e a t t e n d a n t f o r a p p o i n tm e n ts w i t h t h e s o c i a l w o r k e r , new com ers on t h e w ard w ere a d v i s e d by t h e c h a r g e a t t e n d a n t o f t h i s s e r v i c e on t h e w ard t h a t was a v a i l a b l e t o th e m .

I t was r e c o g n i z e d t h a t i n

s p i t e o f i n t e r p r e t a t i o n o f t h e s e r v i c e , i t w ould be by i n d i ­ v i d u a l e x p e r i e n c e t h a t t h e p a t i e n t w ould d i s c o v e r f o r h i m s e l f w here an d how t h e s o c i a l w o rk e r m ig h t be h e l p f u l . R e c o g n iz in g t h a t i n h e r e n t i n t h e f u n c t i o n o f t h e w ard p h y s ic ia n i s h is r e s p o n s i b i l i t y f o r d ir e c tin g tr e a tm e n t, th e c o n f e r e n c e s o f t h e s o c i a l s e r v i c e s u p e r v i s o r and s o c i a l w ork­ e r w i t h t h e w ard p h y s i c i a n to o k p l a c e r e g u l a r l y e v e r y w eek. T h ese c o n f e r e n c e s w ere o r g a n i z e d f o r p l a n n i n g an d d i s c u s s i o n a b o u t p a t i e n t s whom t h e s o c i a l w o rk e r had i n t e r v i e w e d a few days p re v io u s to th e co n feren ce. At t h e i n c e p t i o n o f t h i s s e r v i c e , t h e s o c i a l w o rk e r was a s e c o n d y e a r s t u d e n t i n f i e l d p la c e m e n t an d new i n o r i e n ­ t a t i o n t o t h e m e n ta l h o s p i t a l s e t t i n g .

The c a s e w o rk m ethod

d e m o n s t r a t e d m ig h t u n d e r s t a n d a b l y n o t be a s s k i l l f u l a s t h a t o f a c o m p l e t e l y t r a i n e d a n d more e x p e r i e n c e d w o r k e r .

CHAPTER II HISTORY AMD STATUS OF PSYCHIATRIC SOCIAL WORK The p r o f e s s i o n o f p s y c h i a t r i c s o c i a l work had i t s b e ­ g in n in g s in th e p s y c h ia tr ic h o s p it a l .

I n 1906 i n t h e M anhat­

t a n S t a t e H o s p i t a l i n New York a n d i n 1910 i n t h e B o s to n P s y c h o p a t h i c H o s p i t a l s o c i a l w ork was a f u n c t i o n w i t h i n t h e 5 h o s p ita l se rv ic e . F o llo w in g t h e s e b e g i n n i n g s t h e s c h o o l s o f s o c i a l work o r g a n i z e d c u r r i c u l a f o r t h e s p e c i a l i z e d t r a i n i n g o f s o c i a l w o rk e rs f o r s u c h w o rk .

B e fo r e a s u f f i c i e n t num ber

o f p e o p l e c o u l d be t r a i n e d , W orld War I o p en e d many o p p o r t u n i ­ t i e s f o r p la c e m e n t i n g o v ern m e n t h o s p i t a l s p r o v i d i n g g e n e r a l m e d i c a l c a r e and t r e a t m e n t f o r n e r v o u s and m e n ta l d i s o r d e r s . T h is i n f l u x o f u n t r a i n e d a n d p a r t l y t r a i n e d w o r k e r s , n e c e s ­ s i t a t e d l a r g e l y by demand f o r th e m , l e n t l i t t l e opm ent o f p r o f e s s i o n a l p r a c t i c e .

to th e d e v e l­

T h e re was l i t t l e

o p p o rtu n i­

t y f o r t h e o r d e r l y s t u d y o f t h e p o s i t i o n o f t h e s o c i a l w o rk e r

6

fu n c tio n in g d ir e c tly w ith in th e f i e l d o f p s y c h ia try . At t h e c l o s e o f W orld War I , p s y c h i a t r i c s o c i a l work fo u n d i t s e l f s h i f t i n g away fro m t h e n e u r o p s y c h i a t r i c h o s p i t a l s

G roup f o r t h e Advancement o f P s y c h i a t r y , tfThe P s y c h i ­ a t r i c S o c i a l W orker i n t h e P s y c h i a t r i c H o s p i t a l , w ( R e p o r t Mo. 2 , T o p ek a, K a n s a s , J a n u a r y , 1 9 4 $ ) , P« 1*

6 Y ork:

L o i s M e r e d ith F r e n c h , P s y c h i a t r i c S o c i a l Work (New The Commonwealth F und, 1 9 4 0 ) , p p . 4-5*

11 t o t h e c h i l d g u id a n c e and m e n ta l h y g ie n e c l i n i c s *

In g e n e ra l,

i t was o c c u p i e d w i t h l e a r n i n g a b o u t p s y c h o l o g i c a l p r o c e s s e s . E m ph asis was p l a c e d upon t h e s e c u r i n g o f h i s t o r i e s i n o r d e r to u n d e rsta n d i n d i v i d u a l s .

W o rkers t r a i n e d an d e x p e r i e n c e d

i n p s y c h i a t r i c a g e n c i e s w ere i n g r e a t demand by v a r i o u s o t h e r o r g a n i z a t i o n s w h ich s o u g h t a m eans o f b r i n g i n g t o t h e i r s t a f f s a new p o i n t o f v ie w t o a i d i n d e a l i n g w i t h o l d an d b a f f l i n g human p r o b le m s , a d e e p e r u n d e r s t a n d i n g o f p s y c h o l o g i c a l p r o ­ c e s s e s an d new t e c h n i q u e s t o u n lo c k t h e c l o s e d d o o r o f com7 p l e x i t i e s i n c a s e work s i t u a t i o n s . The p ro g ra m o f s o c i a l work i n m e n t a l h o s p i t a l s was s e r ­ i o u s l y a f f e c t e d by t h i s t r e n d .

The h o s p i t a l s became u s e d l e s s

an d l e s s by s c h o o l s o f s o c i a l work a s t r a i n i n g c e n t e r s f o r s t u d e n t s , and h o s p i t a l s o c i a l w o rk e rs l e f t t h e i r em ploym ent f o r work i n c h i l d g u id a n c e c l i n i c s and community a g e n c i e s . The l o c a t i o n o f m e n t a l h o s p i t a l s , u s u a l l y m i l e s from a p o p u l a ­ t i o n c e n t e r , was u n a t t r a c t i v e .

S e c o n d ly , p s y c h i a t r i c h o s p i t a l

p s y c h i a t r y was f r e q u e n t l y r e g a r d e d a s t a k i n g t h e " o l d ” c l a s s i ­ c a l a p p r o a c h t o m e n t a l d i s e a s e a s o p p o se d t o t h e "new” dynam ic a p p r o a c h c o n c e r n e d w i t h t h e d e v e lo p m e n t o f t h e p e r s o n a l i t y i n r e l a t i o n t o h i s e n v i r o n m e n t a l s i t u a t i o n an d g e n e r a l l y r e g a r d i n g t h e c o n t r i b u t i o n o f s o c i a l work i m p o r t a n t l y . — 7 ----------------

I b id ., p. $ I b i d . , p. 9.

The i n e v i -

12 t a b l e r e s u l t h a s b e e n t h a t t h e m e n ta l h o s p i t a l s h a v e n o t b een u t i l i z e d f o r t h e s t u d y o f s o c i a l f a c t o r s an d o f s o c i a l t r e a t ­ m ent i n m e n ta l d i s e a s e . I n t h e e n s u in g y e a r s s o c i a l work i t s e l f h a s d e v e lo p e d a more c l e a r c o n c e p t o f i t s

f u n c tio n s and h as r e f i n e d i t s

t e c h n i q u e s and s k i l l s i n r e l a t i o n t o h e l p i n g p e o p l e .

W ith

t h e c l a r i f i c a t i o n o f i t s s t a t u s a n d i t s m eth o d s o f h e l p i n g , s o c i a l work h a s a t t a i n e d t h e p o s i t i o n w here i t ca n t a k e r e ­ s p o n s i b i l i t y f o r i t s p e r f o rm a n c e i n t h e m e n ta l h o s p i t a l , and fo r in te g ra tio n of i t s

s e r v ic e w ith o th e r s e r v ic e s .

T h a t t h e n ee d f o r s o c i a l s e r v i c e e x i s t s now a s i t d i d i n t h e e a r l y 1900*s i s i n d i s p u t a b l e .

D r. F ra n k T a llm a n , D i­

r e c t o r o f t h e C a l i f o r n i a S t a t e D e p a rtm e n t o f M e n ta l H ygiene has sa id : " I w ould l i k e t o p o i n t o u t t o you t h a t t h e r e a r e two b a s i c t r a g e d i e s i n t h e l i v e s o f t h e m e n t a l l y i l l and t h e m a l a d j u s t e d . The f i r s t i s f e a r ; t h e se c o n d i s t h e a w f u l t r a g e d y o f f e e l i n g t h e l o n e l i ­ n e s s t h a t comes from an e m o tio n a l i n a b i l i t y t o make c o n t a c t w i t h t h e g r o u p . P e r h a p s now you w i l l c l e a r ­ l y s e e why a l l t h e a g e n c i e s w i t h i n t h e S t a t e h o s p i ­ t a l m ust be g e a r e d t o e r a d i c a t i n g t h e s e t r a g i c f e e l i n g s and s i n c e we a r e d e a l i n g w i t h t h e m is e r y o f a human b e i n g i t i s o n ly r i g h t t h a t we b e p e r m i t ­ t e d t o u s e a l l t h e t o o l s a t o u r command and a t t h e e a r l i e s t p o s s i b l e moment. P a t i e n t s i n m e n ta l h o s ­ p i t a l s a r e i n d i v i d u a l s j u s t a s we a r e . They a r e e n t i t l e d t o t h e same i n a l i e n a b l e r i g h t s w h ic h above a l l i n c l u d e d i g n i t y o f p e r s o n an d t h e r i g h t t o be human. I n f a c t , t h e y h av e a r i g h t t o be i l l an d s o c i e t y d o e s n o t y e t f u l l y g r a n t them t h a t . "9

F ra n k F . T a llm a n , M .D ., " A d d r e s s , " ( u n p u b l i s h e d p a p e r r e a d b e f o r e t h e C a l i f o r n i a C i t i z e n s * C om m ittee f o r M e n ta l Hy­ g i e n e , I n c . , o f Los A n g e le s , Los A n g e le s , C a l i f o r n i a , O c to b e r 24, 19 4 9 ), p . 3 .

13 I n e l a b o r a t i o n o f t h i s , t h e C om m ittee on P s y c h i a t r i c S o c i a l Work o f t h e Group f o r t h e Advancement o f P s y c h i a t r y su g g e ste d t h a t th e tr e a tm e n t o f th e m e n ta lly i l l i s p r im a r i­ l y a community r e s p o n s i b i l i t y w i t h t h e h o s p i t a l a t r e a t m e n t f a c i l i t y o f t h e com m unity.

T r e a tm e n t i n t h e h o s p i t a l i s r e ­

g a r d e d a s a t o t a l i n s t i t u t i o n a l p r o c e s s , r o o t e d i n m e d ic a l r e s p o n s i b i l i t y w i t h e a c h s t a f f member c o n t r i b u t i n g t o t h e t o t a l p r o c e s s on t h e b a s i s o f a l l o c a t e d r e s p o n s i b i l i t y and

10 d is c ip lin e d p ro fe ssio n a l a ttitu d e s . F o r many y e a r s s o c i a l w o r k e r s h av e b e e n a p a r t o f t h e c o n v a l e s c e n t p ro g ra m s o f m e n ta l h o s p i t a l s h e l p i n g i n t h e a d ­ j u s t m e n t o f t h e p a t i e n t i n t h e com m unity.

The GAP R e p o r t

m e n tio n e d ab o v e i n d i c a t e s t h a t t h e r e h a s b ee n l a c k o f c l a r i t y i n t h e f u n c tio n o f s o c i a l w o rk ers w ith in th e h o s p i t a l ; t h a t f r e q u e n t l y t h e i r a r e a o f a c t i v i t y i s n o t com m ensurate w i t h 11

t h e i r e x p e r i e n c e and t r a i n i n g . In re c o g n itio n o f th e r o le o f th e s o c ia l se rv ic e fu n c­ t i o n a s p a r t o f t h e t r e a t m e n t p ro g ra m o f a m e n ta l h o s p i t a l , t h e GAP C om m ittee recommended t h a t t h e u t i l i z a t i o n o f s o c i a l s e r v i c e b e l i m i t e d t o p r o p e r l y d e f i n e d c a s e work f u n c t i o n s , 10

Group f o r t h e Advancement o f P s y c h i a t r y , "The P s y c h i ­ a t r i c S o c i a l W orker i n t h e P s y c h i a t r i c H o s p i t a l , " ( R e p o r t No. 2 , T o p ek a, K a n s a s , J a n u a r y , 194& ), P* 2 . 11

I b i d . , p. 3.

14 an d t h a t c a s e work a c t i v i t i e s be i n t e g r a t e d i n t o t h e t o t a l 12 p ro g ra m o f h o s p i t a l t r e a t m e n t . As s t a t e m e n t a l h o s p i t a l s become community t r e a t m e n t f a c i l i t i e s r a t h e r t h a n i n s t i t u t i o n s f o r c u s t o d i a l c a re * t h e r e t u r n o f t h e p a t i e n t t o t h e community i s i m p l i e d upon h i s a d m is s io n t o t h e h o s p i t a l .

The s o c i a l w o rk e r i s s e e n a s t h e

l i a i s o n b e tw e e n t h e h o s p i t a l and t h e com m unity.

In such a

s e t t i n g t h e s o c i a l w o rk e r w ork s w i t h t h e p a t i e n t t h r o u g h o u t h i s h o s p i t a l e x p e r i e n c e i n a r e s p o n s i b l e r e l a t i o n s h i p when e n v i r o n m e n t a l p r o b le m s and p ro b le m s i n r e l a t i o n s h i p b lo c k h i s movement t h r o u g h t h e h o s p i t a l . T h is new a p p r o a c h t o t r e a t m e n t c o n s i d e r s t h e p a ­ t i e n t a s an i n d i v i d u a l i n r e l a t i o n t o h i s e n v i r o n ­ m e n t. I t a l s o r e c o g n i z e s h i s a b i l i t y t o u s e t h e h o s p it a l c o n s tr u c tiv e ly th ro u g h th e u t i l i z a t i o n o f h i s own d r i v e to w a r d r e c o v e r y . W ith t h e r e c o g n i t i o n o f th e p a t i e n t f s needs as a s o c i a l b e in g a s w e ll as h i s n e e d f o r t r e a t m e n t , c l i n i c a l te a m w ork b e g i n s t o b e v a l i d a s an a p p r o a c h t o t h e r a p y i n a m e n ta l h o s ­ p ita l. The r o l e o f t h e p s y c h i a t r i c s o c i a l w o r k e r i n t h i s c l i n i c a l te a m i s p r i m a r i l y r e l a t e d t o t h e p a ­ t i e n t s w e l l n e s s an d a b i l i t y t o h e l p h i m s e l f i n h i s movement t h r o u g h t h e h o s p i t a l , j u s t a s t h e r o l e o f th e p s y c h ia tr is t i s p rim a rily r e la te d to th e t r e a t ­ ment o f t h e p a t i e n t s i l l n e s s . The s o c i a l w o rk e r h e l p s t h e p a t i e n t a s h e can u s e h e l p w ith h i s im m e d ia te p r o b le m s i n r e l a t i o n s h i p s from t h e t i m e o f a d m issio n , th ro u g h h i s h o s p i t a l e x p e rie n c e , to p la n ­ n i n g w i t h him to w a r d l e a v i n g an d r e h a b i l i t a t i o n , t h u s f a c i l i t a t i n g t h e w h o le t r e a t m e n t p r o c e s s . 13 12

Loc. c i t .

13

D e W itt, 0 £ . c i t . , p . 3 0 0 .

15 W i th in t h e m e n ta l h o s p i t a l t h e s o c i a l w o rk e r p e r f o r m s s e r v i c e s t h a t m eet p r a c t i c a l r e a l i t y n e e d s .

When t h e s e s e r ­

v i c e s a r e r e n d e r e d i n r e l a t i o n t o f e e l i n g s an d ways o f r e ­ s p o n d in g , a n x i e t y may b e e a s e d , new c o n f i d e n c e g a i n e d and t h e p a t i e n t may become b e t t e r a b l e t o manage h i s own a f f a i r s .

14

W ith t h e d e v e lo p in g r e a l i z a t i o n t h a t e a r l y t r e a t m e n t o f m e n ta l i l l n e s s i s p r o f i t a b l e , t h e r e a r e i n c r e a s i n g num bers o f p e o p le re c o g n iz in g th e need f o r h o s p i t a l i z a t i o n .

The p r e ­

s e n t p u b l i c f a c i l i t i e s a r e o f t e n o v e r c r o w d e d , u n d e r s t a f f e d and so m e tim es i n a d e q u a t e .

The u s e o f t h e p s y c h i a t r i c s o c i a l w ork­

e r , w ith th e a b i l i t y to re n d e r h e lp in p a t i e n t s ’ c o n s tr u c tiv e u s e o f h o s p i t a l i z a t i o n can s p e e d r e c o v e r y and h a s t e n r e t u r n t o t h e com m unity.

14

Group f o r t h e A dvancement o f P s y c h i a t r y , ”The P s y ­ c h i a t r i c S o c i a l W orker i n t h e P s y c h i a t r i c H o s p i t a l , ” ( R e p o r t No. 2 , T o p ek a , K a n s a s , J a n u a r y , 194& ), P* 2.

CHAPTER

III

PRESENTATION OF THE CASES OF THE PATIENTS SEEN BY THE SOCIAL WORKER DURING WARD OFFICE HOURS D u rin g t h e p e r i o d 1 1 - 2 2 - 4 9 t o 1 - 3 1 - 5 0 , 30 p a t i e n t s w ere s e e n by t h e s o c i a l w o r k e r .

Of t h e s e , IB w ere s e e n o n c e , e i g h t

w ere s e e n two o r t h r e e t i m e s and f o u r w ere s e e n s i x and more tim e s.

T w e n ty - s ix o f t h e s e came o f t h e i r own a c c o r d , and f o u r

w ere r e f e r r e d by t h e w ard p h y s i c i a n . A n a ly s is o f th e c o n te n t o f th e i n t e r v i e w s , w ith th e f o ­ c u s on t h e s e r v i c e r e n d e r e d , d i s c l o s e d c e r t a i n s i m i l a r i t i e s . T h e se s i m i l a r i t i e s made p o s s i b l e t h e d i v i s i o n o f t h e s e p a t i e n t s in to s ix groups.

E ac h o f t h e 30 p a t i e n t s s e e n seemed t o f i t

i n t o on e o f t h e s e g r o u p s .

I n some

i n s t a n c e s i t was d i f f i c u l t

t o make a c l e a r - c u t d i f f e r e n c e b e tw e e n t h e g r o u p s .

S om etim es

a p a t i e n t c o n c e r n e d a b o u t h o s p i t a l i z a t i o n a l s o was c o n c e r n e d a b o u t p ro b le m s on t h e o u t s i d e o r a b o u t l e a v i n g t h e h o s p i t a l . Where t h e r e was m u l t i p l e c o n c e r n , t h e w r i t e r h a s u s e d t h e p r i n ­ c ip a l c o n te n t o f th e in te rv ie w s to in d ic a te th e a re a s o f s e r ­ v ic e .

T h ese d i v i s i o n s w ere a s f o l l o w s :

P o in t o f c o n ta c t f o r p u rp o se fu l i n ­ t e r a c t i o n d i f f i c u l t to e s ta b lis h because o f th e p a t i e n t s 1 poor r e l a ­ ............................................. 6 tio n to r e a l i t y . . . . . . . . A tte m p ts t o p o i n t up r e a l i t y f a c ­ t o r s w ith p a t i e n t s u n ab le t o a c c e p t t h e i r n e e d f o r h o s p i t a l i z a t i o n .............................................. 2

17 C o n sid e ra tio n o f h o s p it a l re g u la ­ t i o n s and p r o c e d u r e s a s t h e y a f ­ f e c te d th e p a t i e n t s ’ d a ily l i v i n g i n an d l e a v i n g t h e h o s p i t a l . . .

14

C o n s i d e r a t i o n o f p r o b le m s o u t s i d e t h e h o s p i t a l ...........................................

5

H elp i n c o n s t r u c t i v e u s e o f h o s ­ p i t a l i z a t i o n ...........................................

1

A s s i s t a n c e i n p l a n n i n g to w a r d le a v in g th e h o s p ita l . . . .

2

In th e fo llo w in g s e c tio n th e g e n e ra l c h a r a c t e r i s t i c s o f e a c h g ro u p have b e e n i n d i c a t e d an d a summary o f t h e con ­ t a c t s w i t h one p a t i e n t i n e a c h g r o u p w i t h some e v a l u a t i o n o f t h e h e l p f u l n e s s o f t h e w o r k e r h a s b ee n p r e s e n t e d . DIFFICULTY IN ESTABLISHING A POINT OF CONTACT FOR PURPOSEFUL INTERRACTION BECAUSE OF PATIENTS’ POOR RELATION TO REALITY I n t h i s g ro u p o f s i x , m e n ta l i l l n e s s h ad b e e n o f l o n g sta n d in g .

The p e r i o d o f h o s p i t a l i z a t i o n r a n g e d fro m f i v e t o

six te e n y e a rs.

F o u r o f t h e s e p a t i e n t s w ere c o n c e r n e d w i t h

l e a v i n g , on e w i t h h o s p i t a l r e g u l a t i o n s and one w i t h g e t t i n g ’’i n f o r m a t i o n a b o u t s o c i o l o g i c a l p r o g r e s s ” .

The i n t e r v i e w s

w i t h t h e s e p a t i e n t s showed no i n s i g h t i n t o t h e i r i l l n e s s o r a s y s te m o f d e l u s i o n s b ecom ing c o n f u s e d w i t h t h e i r r e q u e s t s . E ach o f t h e s i x p a t i e n t s was s e e n o n c e .

The f o l l o w i n g i s an

exam ple o f t h i s g r o u p : Mr. H ouse, a 4 $ - y e a r ~ o ld s i n g l e man, had b e e n i n th e h o s p ita l fiv e y e a rs . He was d ia g n o s e d a s an a l -

lg c o h o lic w ith p s y c h o s is , K o rsak o ff p a t t e r n . A fte r one y e a r i n t h e h o s p i t a l , he was t r i e d on a work p l a c e m e n t ^ t h a t l a s t e d j u s t a few d a y s an d s i n c e t h a t tim e h a s b e e n on t h e w ard c o n t i n u o u s l y , w ork­ in g as a d ish w a sh e r. He came t o s e e t h e s o c i a l w o rk e r a b o u t g e t t i n g r e l e a s e d fro m t h e h o s p i t a l s i n c e he f e l t he had b e e n t h e r e f a r b ey o n d t h e 90 d a y s m ost a l c o h o l i c s s t a y . He w an te d t h e w o r k e r t o com m unicate w i t h t h e Ju d g e who c o m m itte d him i n o r d e r t o a r r a n g e t h e r e l e a s e . Mr. H. c o u ld n o t r e l a t e i n any way t o h i s b e i n g i l l an d n e e d i n g h o s p i t a l i z a t i o n , t h o u g h t t h e o n ly r e a s o n he was k e p t i n t h e h o s p i t a l was b e c a u s e he was t h e b e s t d i s h w a s h e r t h e y had e v e r h a d . He t a l k ­ ed a b o u t r e l a t i v e s he had on t h e o u t s i d e a s b e i n g a " s e c r e t ” o f h i s . As t h e w o rk e r i n t e r p r e t e d t h e h o s p i t a l p o l i c y a b o u t l e a v e r e g u l a t i o n s , he seemed i n d i f f e r e n t an d n o t i n t e r e s t e d an y l o n g e r i n h i s o r ­ ig in a l re q u e st. I t i s d i f f i c u l t to e v a lu a te th e h e lp f u ln e s s o f th e so ­ c i a l w o rk e r w i t h t h i s g ro u p o f p a t i e n t s b e c a u s e o f t h e i r l a c k o f i n s i g h t and p o o r r e l a t i o n t o r e a l i t y .

I t i s w o r th c o n s i d ­

e r i n g t h a t t h e y w ere a b l e t o a c c e p t , i n some way, t h e f u n c t i o n o f t h e s o c i a l w o rk e r and h e r i n a b i l i t y t o h e l p them b e c a u s e t h e y d i d n o t make a d d i t i o n a l a p p o i n t m e n t s t o s e e h e r t o ren ew t h e i r re q u e sts.

T h e r e c o u ld be some s p e c u l a t i o n t h a t a few

o f t h e s e p a t i e n t s came o u t o f c u r i o s i t y b e c a u s e o f t h e i n t e r ­ e s t shown by o t h e r p a t i e n t s . 15

Work l e a v e p la c e m e n t i s a t h e r a p e u t i c work p l a n i n a p r o t e c t e d e n v iro n m e n t f o r p a t i e n t s who a r e n o t y e t r e a d y t o a d j u s t i n th e c o m p e titiv e l i v i n g o u ts id e an i n s t i t u t i o n . The p a t i e n t w orks f o r h i s room and b o a r d , an d a s m a ll s a l a r y , u s ­ u a l l y i n a s a n a t a r i u m , h o s p i t a l o r p r i v a t e home. B o th t h e e m p lo y e r and t h e p a t i e n t a r e s u p e r v i s e d by t h e B u re a u . M anual o f B u re a u o f S o c i a l Work, Los A n g e le s O f f i c e ( S t a t e D e p a rtm e n t o f M e n ta l H y g ie n e ) .

19 ATTEMPTS TO POINT UP REALITY FACTORS WITH PATIENTS UNABLE TO ACCEPT THEIR NEED FOR HOSPITALIZATION The two p a t i e n t s i n t h i s g ro u p had a f a i r r e l a t i o n t o r e a l i t y b u t no i n s i g h t .

T h e se p a t i e n t s came t o a s k t h e s o c i a l

w o rk e r f o r h e l p i n l e a v i n g t h e h o s p i t a l b e c a u s e t h e y f e l t t h e y w ere u n j u s t l y h o s p i t a l i z e d .

The w o r k e r ’ s a c t i v i t y was co n ­

c e r n e d w i t h p o i n t i n g up r e a l i t y f a c t o r s i n t h e commitment and h o s p i t a l i z a t i o n p ro c e d u re s w ith th e id e a t h a t th e p a t i e n t s m ig h t i n some way r e a c h a m e a su re o f a c c e p t a n c e o f h o s p i t a l i z a ­ tio n .

B o th o f t h e s e p a t i e n t s w ere s e e n tw ic e *

The f o l l o w i n g

i s a summary o f t h e c o n t a c t s w i t h Mr. O aks: M r. O aks, a 6 0 - y e a r - o l d m a r r i e d man, had b ee n a p a t i e n t i n t h e h o s p i t a l f o r t e n m o n th s . P r i o r t o t h i s , he was h o s p i t a l i z e d f o r t h r e e y e a r s i n a V.A. n e u r o p s y c h i a t r i c h o s p i t a l fro m w h ic h he was t r a n s ­ f e r r e d t o N o rw a lk . H is d i a g n o s i s was d e m e n ti a p r a e cox. I n Mr. O . ’ s f i r s t c o n t a c t w i t h t h e s o c i a l w o rk e r he t a l k e d o f h i s b e i n g h e l d a t t h e h o s p i t a l u n d e r p r o t e s t an d e x p r e s s e d many g r a n d i o s e i d e a s o f h i s s t a t u s m aking i t i m p o s s i b l e f o r him t o p a r t i c i p a t e . i n any way i n t h e h o s p i t a l . He w an te d t h e s o c i a l w o rk e r t o l o c a t e a n o te b o o k c o n t a i n i n g v a l u a b l e l e t ­ t e r s an d m a t e r i a l he h a d w r i t t e n . S i n c e he had n o t s e e n h i s w i f e f o r t h r e e m o n th s , he w a n te d t o know i f sh e was d e a d o r a l i v e . The w o rk e r a g r e e d t o do w hat sh e c o u ld t o f i n d o u t a b o u t t h e n o te b o o k an d M rs. 0 . C o r r e s p o n d e n c e was i n i t i a t e d w i t h M rs. 0 . i n d i ­ c a t i n g Mr. . O . ’ s c o n c e r n a b o u t n o t s e e i n g h e r and s u g ­ g e s t i n g an a p p o in tm e n t w i t h t h e s o c i a l w o r k e r . M rs. 0 . a n s w e re d p r o m p t l y , e x p l a i n i n g h e r i n a b i l i t y t o make an a p p o i n tm e n t b e c a u s e o f work com m itm ents an d g i v i n g an a c c o u n t o f t h e u n p l e a s a n t n e s s o f v i s i t s t o Mr. 0 . I n an e x c h a n g e o f l e t t e r s , s e v e r a l q u e s t i o n s M rs. 0 . had a b o u t t h e h o s p i t a l an d Mr. O . ’ s b e l o n g ­ i n g s w ere t a k e n c a r e o f by t h e s o c i a l w o r k e r .

20 I n t h e s e c o n d i n t e r v i e w w i t h Mr. 0 . , h i s v i s i t w i t h M rs. 0 . i n t h e i n t e r i m seemed u n i m p o r t a n t t o him . He t a l k e d a t some l e n g t h a b o u t t h e i n j u s t i c e o f h i s b e i n g i n t h e h o s p i t a l . A lth o u g h t h e w o rk e r a t t e m p t e d t o r e l a t e h i s s t a t e m e n t s t o h i s many c o n ­ t a c t s w i t h d o c t o r s who had a p p r o v e d h i s t r e a t m e n t a n d h o s p i t a l i z a t i o n , t h e r e seem ed t o be no way t h a t he c o u l d r e c o g n i z e h i s i l l n e s s . He was a d v i s e d a t t h i s tim e t h a t t h e n o te b o o k he had m e n tio n e d b e f o r e h ad b e e n l o c a t e d a n d w ould be s e n t t o him on t h e w ard . T h e r e seemed l i t t l e

t h a t t h e s o c i a l w o rk e r c o u ld do t o

h elp th e s e p a t i e n t s in th e a c c e p ta n c e o f t h e i r h o s p i t a l i z a t i o n . The r e c a l l i n g o f e x a m i n a t i o n s an d d e c i s i o n s o f p s y c h i a t r i s t s an d t h e c o u r t i n no way i n f l u e n c e d t h e i r a s s u m p tio n t h a t t h e y w ere n o t m e n t a l l y i l l .

I t was i n t e r e s t i n g t o n o t e t h a t n e i t h ­

e r o f t h e s e p a t i e n t s had e v e r a t t e m p t e d t o e s c a p e .

T ry in g t o

h e l p them a c c e p t h o s p i t a l i z a t i o n met w i t h no e v i d e n t s u c c e s s . The c o n t a c t s , w i t h M rs. O ak s, a l t h o u g h by c o r r e s p o n d e n c e o n l y , seemed more h e l p f u l t o h e r t h a n t h e i n t e r v i e w s a p p a r e n t l y w ere t o M r. O aks. CONSIDERATION OF HOSPITAL REGULATIONS AND PROCEDURES AS THEY AFFECTED THE PATIENTS1 DAILY LIVING IN AND LEAVING THE HOSPITAL The s t a t u s o f m e n t a l h e a l t h o f t h e I k p a t i e n t s i n t h i s g ro u p v a r i e d . p sy c h o tic .

Some w ere m e n t a l l y i l l an d some w ere n o n -

The c o n d i t i o n o f m e n ta l h e a l t h d i d n o t seem t o

h in d e r t h e i r p a r t i c i p a t i o n in th e in te rv ie w s .

Of t h e t o t a l

num ber i n t h i s g r o u p , e i g h t w ere s e e n o n c e , t h r e e w ere s e e n

21 t w i c e , two w ere s e e n t h r e e t i m e s and o n e w as s e e n s i x tim e s * T h re e p a t i e n t s r a i s e d t h e q u e s t i o n o f when and how t h e y c o u ld g e t g ro u n d p a r o l e .

B ecau se t h e s e t h r e e had s p e c i ­

f i c com m itm ents, one f o r a l c o h o l i s m , on e f o r s e x u a l p s y c h o ­ p a t h y and one f o r d r u g a d d i c t i o n , i t was p o s s i b l e f o r t h e s o ­ c i a l w o rk e r t o e x p l a i n t h e u s u a l h o s p i t a l p r o c e d u r e . i n f o r m a t i o n s a t i s f i e d th e m . o f need f o r f u r t h e r s e r v ic e .

T h is

T h e re seem ed t o be no i n d i c a t i o n The w o rk e r s u g g e s t e d a r e t u r n

a p p o in tm e n t i f a n y t h i n g f u r t h e r a b o u t t h e h o s p i t a l c o n c e r n e d th e m . F o u r p a t i e n t s i n t h i s g ro u p came t o i n q u i r e a b o u t w ork p la c e m e n t o r j o b s when t h e y w ere a b l e t o l e a v e t h e h o s p i t a l . The d e t a i l s o f t h i s way o f l e a v i n g t h e h o s p i t a l w ere e x p l a i n e d by t h e w o r k e r .

S e v e r a l q u e s t i o n s t h e p a t i e n t s had a b o u t t h e

h o u r s o f w o rk , k i n d s o f work an d w ages w ere a n s w e re d .

The p a ­

t i e n t s seem ed t o a c c e p t t h e h e l p i n g w i t h s u c h a way o f l e a v i n g by t h e s o c i a l w o rk e r an d t h e d e c i s i o n a b o u t i n i t i a t i n g su c h l e a v e p l a n by t h e w a rd p h y s i c i a n . One o f t h e s e 1 4 p a t i e n t s came t o t h e s o c i a l w o rk e r v e r y much d i s t u r b e d o v e r t h e w i t h d r a w a l by t h e h o s p i t a l a d m i n i s t r a ­ t i o n o f p e r m i s s i o n t o v i s i t on t h e g r o u n d s a n d t o p a r t i c i p a t e i n G le e C lub a c t i v i t y .

A lth o u g h t h e r e was n o t a g r e a t d e a l

t h e s o c i a l w o r k e r c o u l d do i n t h e way o f h e l p i n g him a c c e p t h i s l o s s , he d i d u s e t h e tim e w i t h t h e s o c i a l w o rk e r t o e x -

22 p r e s s a g r e a t d e a l o f r e s e n t m e n t an d h o s t i l i t y to w a r d t h e h o s ­ p ita l.

T h i s p a t i e n t was c o m m itte d a s a s e x u a l p s y c h o p a t h ,

h ad b e e n h o s p i t a l i z e d f o r two y e a r s and saw t h e c u r t a i l m e n t o f h is p r iv ile g e s as a c lo s in g o f th e door to th e o u ts id e th a t had b e e n p a r t i a l l y o p en e d by h i s h a v i n g some p r i v i l e g e s and re sp o n sib ility . One p a t i e n t who had b e e n i n C a l i f o r n i a l e s s t h a n a y e a r p r i o r t o h i s commitment had b e e n t o l d upon a d m i s s i o n t h a t he w ould be d e p o r t e d t o an e a s t e r n s t a t e .

When two

m o n th s e l a p s e d and he h e a r d n o t h i n g , he came t o s e e t h e s o ­ c i a l w o rk e r a b o u t i t .

The s o c i a l w o rk e r was h e l p f u l o n l y i n

t h a t sh e was a b l e t o t e l l him w h at t h e s t a t u s o f t h e d e p o r t a ­ t i o n p r o c e e d i n g s was an d t h a t s h e w ould k e e p him a d v i s e d i f t h e r e w ere any c h a n g e . F o u r o f t h e t o t a l o f 14 came t o i n q u i r e a b o u t p r o c e ­ dures f o r le a v in g th e h o s p ita l.

One w a n te d t o know how t o

a r r a n g e a v i s i t w i t h a r e l a t i v e on C h r is t m a s Day w h ic h was i n ­ i t i a t e d by t h e s o c i a l w o r k e r .

The f o u r o t h e r s w a n te d t o know

a b o u t l e a v e an d s i g n i n g o u t p r o c e d u r e s .

The w o rk e r d e f e r r e d

t o t h e w ard p h y s i c i a n r e g a r d i n g t h e ti m e a p a t i e n t c o u ld l e a v e b u t i n d i c a t e d t h a t when a way f o r l e a v i n g n e e d e d t o be w orked o u t , t h e p a t i e n t c o u ld s e e k h e r h e l p . One p a t i e n t , c o m m itte d a s a d r u g a d d i c t , o u t how l o n g he w o u ld h av e t o be h o s p i t a l i z e d .

came t o f i n d He a l s o had

23 q u e s t i o n s a b o u t work a s s ig n m e n t a n d -w a rd r e s i d e n c y .

As i t

became c l e a r t h a t kn o w led g e o f t h e s e p r o c e d u r e s became a p r o b ­ lem t o him , he ch o se t o s e e t h e s o c i a l w o rk e r r e g u l a r l y .

The

s u p a a r y o f i n t e r v i e w s w i t h t h i s p a t i e n t showed t h e a p p r o p r i a t e u s e o f t h e s o c i a l w o rk e r by a p a t i e n t whose . a n x i e t y was h e i g h t e n e d by kn ow ledg e o f h o s p i t a l p r o c e d u r e s .

The f o l l o w i n g

i s a summary o f t h e s i x i n t e r v i e w s w i t h Mr. G ra p e t Mr. G ., a 5 2 - y e a r - o l d s i n g l e man, was co m m itte d t o t h e h o s p i t a l a s a d r u g a d d i c t , o r i g i n a l l y i n O c to b e r 194#• A f t e r a m o n th , he e l o p e d an d was r e t u r n e d a b o u t a m onth l a t e r . He e l o p e d a g a i n a f t e r f o u r m o nths i n t h e h o s p i t a l an d was r e t u r n e d f i v e m o nth s l a t e r . When he made an a p p o i n tm e n t t o s e e t h e s o c i a l w o rk e r on t h e w a rd , he had b e e n i n t h e h o s p i t a l f o r t h r e e m o n th s . At t h e tim e o f t h e f i r s t i n t e r v i e w , Mr. G. seemed n e rv o u s, d ep ressed and d isc o u ra g e d . He n e e d e d a s h a v e , was u n t i d i l y d r e s s e d i n h o s p i t a l c l o t h e s . He came t o f i n d o u t how lo n g he w ou ld h ave t o s t a y i n t h e h o s p i t a l a n d how l o n g he w ould h av e t o be on a l o c k e d w a rd . I n d i s c u s s i n g some o f t h e s e t h i n g s , Mr. G. c o m p la in e d a b o u t n o t g e t t i n g o u t s i d e a t a l l , w o rk in g o n l y on t h e w ard w i t h t h e h o u s e k e e p in g c h o r e s . He l o o k e d t h i n , s a i d he had b e e n l o s i n g w e i g h t . He h ad no u p p e r t e e t h an d c o u l d n o t e a t a l l o f t h e fo o d serv ed . I n o r d e r t h a t he m ig h t h av e s o m e th in g t o go o n , t h e w o rk e r s a i d sh e w ould f i n d o u t how l o n g he w ould h ave t o s t a y i n t h e h o s p i t a l an d on t h e w a rd . Mr. G. was q u ic k t o s a y he d i d n ’t w an t t o be any t r o u b l e t o t h e w o r k e r . An a p p o i n tm e n t was made f o r t h e f o l l o w i n g w eek. By t h e t i m e o f t h e se c o n d i n t e r v i e w , Mr. G. was w o rk in g i n t h e I n d u s t r i a l Shop b u t d i s l i k e d t h e w o rk . H is p h y s i c a l a p p e a r a n c e was much a s i t had b e e n t h e p r e v i o u s w eek. When he was t o l d t h a t h i s commitment was f o r from e i g h t m onths t o two y e a r s , he d i d n ’t s e e how he c o u l d s t a y ev e n t h e e i g h t m o n th s . The w o rk e r i n ­ d ic a te d t h a t a lth o u g h th e h o s p i t a l ta k e s p re v e n tiv e s t e p s , sh e t h o u g h t Mr. G. c o u l d d e c i d e t o l e a v e a g a i n i f he

2k w a n t e d ♦ She h e l p e d him t o exam ine t h e n e g a t i v e and p o s it iv e a s p e c ts o f h is le a v in g w ith o u t th e sa n c tio n o f t h e h o s p i t a l . Mr. G. commented a b o u t t h e w o r k e r ’s h e l p i n " g e t t i n g t h i n g s l i n e d u p " . He w a n te d t o be a b l e t o g e t h i s d i s a b i l i t y i n s u r a n c e money t h a t had a c c u m u la te d f o r him and he t h o u g h t he w a n te d " t o g e t t h e o b l i g a t i o n o v e r w i t h " . As h e was l e a v i n g t h e i n t e r v i e w , he b r o u g h t up t h e q u e s t i o n o f who w ould s i g n him o u t s i n c e he had no r e l a t i v e s o r c l o s e f r ie n d s n earb y . I n t h e w ee k ly c o n f e r e n c e w i t h t h e ward p h y s i c i a n , w hat had gone on w i t h M r. G. was s h a r e d , e s p e c i a l l y h i s t r y i n g t o t a k e h o ld o f t h e h o s p i t a l i z a t i o n an d some o f h i s c o m p l a i n t s a b o u t h i s p h y s i c a l c o n d i t i o n , jo b and w ard p l a c e m e n t . B e f o r e t h e n e x t i n t e r v i e w Mr. G. was t r a n s f e r r e d t o an o pen w ard a n d t o a jo b i n t h e p a s t e u r i z i n g p la n t. He came t o t h e w o r k e r ’ s o f f i c e f o r t h e i n ­ t e r v i e w , lo o k e d l e s s w o r r i e d and d i s c o u r a g e d . He was w e a r in g a c l e a n w h i t e s t a r c h e d s h i r t , a p o l o g i z ­ ed f o r b e i n g a l i t t l e l a t e b e c a u s e h e s to p p e d t o ch an ge c l o t h e s , was s o r r y n o t t o be s h a v e d b u t he g o t up a t 5 : 3 0 a .m . t o go t o h i s new j o b , d i d n ’t have t i m e . He g a i n e d f i v e po un ds i n l e s s t h a n a w eek, had good f o o d a n d d r a n k l o t s o f m ilk a n d crea m . I n t a l k i n g a b o u t t h e i n d e f i n i t e n e s s o f h i s s t a y , he r e i t e r a t e d t h a t h e w a n te d t o l e a v e "by t h e f r o n t g a t e " and a s k e d many q u e s t i o n s a b o u t h o s p i t a l p r o c e ­ dure f o r le a v in g . He f r e e l y d i s c u s s e d many a s p e c t s o f t h e h o s p i t a l i z a t i o n t h a t had b e e n h a r d f o r him w i t h p a r t i c u l a r e m p h a s is on h i s b e i n g p l a c e d on a w ard w i t h v e r y d i s t u r b e d p a t i e n t s f o r two m o n th s . He e x p r e s s e d f e e l i n g s o f d i s g u s t and d i s t a s t e an d d i s ­ l i k e o f a u t h o r i t y when he t h o u g h t p r e j u d i c e was show n. T h e re was some d i s c u s s i o n a b o u t t h e c o n t i n ­ u a t i o n o f t h e i n t e r v i e w s — and w h e t h e r M r. G. w a n t­ ed t h i s ' . He w a n te d t o c o n t i n u e b e c a u s e he s t i l l fo u n d i t d i f f i c u l t t o c o n t i n u e w i t h t h e h o s p i t a l , th o u g h t t h e w o r k e r was t h e m ost u n d e r s t a n d i n g p e r ­ son he had e v e r m e t, a n d c o u ld h e l p h im . At t h e f o u r t h i n t e r v i e w , Mr. G . ’ s p e r s o n a l a p p e a r ­ a n c e was much a s i t h ad b e e n l a s t t i m e . He had g a i n e d more w e i g h t , f e l t b e t t e r , a p o l o g i z e d a g a i n f o r n o t b e in g shav ed . He b r o u g h t i n many o f h i s f e e l i n g s a b o u t t h e h o s p i t a l , how d e p r e s s i n g and gloomy t h e g ro u n d s seem ed t o him and e x p r e s s e d a g a i n

25 a g r e a t d e a l o f h o s t i l i t y and an g e r about th e e x p e r­ i e n c e on t h e d i s t u r b e d ward* He commented t h a t he t o l d so many t h i n g s a b o u t h i m s e l f i n t h e i n t e r v i e w s , t h o u g h t a b o u t th em so much a f t e r he l e f t . L ast tim e he was d e c i d e d a n d s t i l l was d e t e r m i n e d t o b e a d e ­ cent re sp e c te d p erso n . He f e l t a l o t had h a p p e n e d t o him s i n c e he f i r s t saw t h e w o r k e r , n o t o n l y t h e w ard ch a n g e and j o b . I n some d e t a i l he t o l d a b o u t h i s f i r s t e x p e r i e n c e w i t h d r u g s , e x p l a i n i n g t h e la n g u a g e o f t h e a d d i c t s a s he w ent a l o n g a n d a b o u t h i s p o l i c e r e c o r d . W ith t h e chang e o f w a rd , t h e r e had b e e n a ch an ge o f p h y s i c i a n . The w o rk e r had c o n f e r r e d w i t h t h e new p h y s i c i a n a b o u t h e r a c t i v i t y w i t h Mr. G. and h i s p r o g r e s s . When Mr. G. r a i s e d t h e q u e s t i o n o f when he c o u ld l e a v e t h e h o s p i t a l , t h e w o rk e r s u g g e s t e d he m ig h t d i s c u s s t h i s w i t h h i s w ard p h y s i c i a n . I f he n e e d e d h e l p w i t h l e a v e p l a n s , t h e w o rk e r i n d i c a t e d sh e m ig h t b e a b l e t o h e l p . Mr. G. came t o t h e f i f t h i n t e r v i e w l o o k i n g v e r y w e ll. I n a d d i t i o n t o h i s c l e a n c l o t h e s , he was f r e s h l y sh a v e d a n d e s p e c i a l l y p l e a s e d t h a t t h e w ard p h y s i c i a n had t o l d him he was t o come t o s t a f f i n a w eek . The w o rk e r d i s c u s s e d t h e s t a f f c o n f e r e n c e w i t h him and h e l p e d him t o b r i n g o u t h i s f e e l i n g s a bout i t . H is p l a n f o r l e a v i n g was e s s e n t i a l l y t h e same w h e th e r i t was f o r d i s c h a r g e o r l e a v e o f a b ­ s e n c e . W ith t h e i n t r o d u c t i o n o f h i s f e e l i n g s a b o u t l e a v i n g , Mr. G. t h o u g h t t h a t i n s p i t e o f a l l t h e n e g ­ a t i v e p a r t s o f t h e h o s p i t a l — t h e d i s t u r b e d w ard e x ­ p e r i e n c e , an d f e e l i n g " s t u c k 11, he had h ad t h e o p p o r ­ t u n i t y t o go o v e r t h i n g s f o r h i m s e l f . B e in g a t t h e h o s p i t a l he had g o t t e n down t o r e a l t h i n g s — he r e a l ­ i z e d how o l d he was i n te r m s o f t h e sp a n o f l i f e h e h ad l i v e d ( t a k i n g d r u g s g av e him m is ta k e n i d e a s o f t h e p a s s a g e o f t i m e ) ; h e knew w hat he h ad done w i t h h is l i f e . As he saw i t , he even knew h i s p ro b le m — i t was t o d e c i d e w h e th e r he c o u ld ch a n g e f o r g o o d , k e e p away fro m d r u g s . He. d i d n ’t t h i n k he had t o go b a c k t o t h e c a u s e s o f i t ; t h o u g h t t h a t j u s t know ing now t h a t he d i d n ’t w an t t o go b ac k t o th em was en o u g h . So many p e o p l e he knew had s a i d a man a s o l d a s he who had t h e h a b i t f o r a s lo n g a s h e , c o u l d n ’t do th a t. At p r e s e n t h e d i d n ’t f e e l t h a t i t made much d iffe re n c e . He t a l k e d a b o u t t h e l o s t an d f o r g o t t e n f e e l i n g when he f i r s t r e t u r n e d t o t h e h o s p i t a l t h i s tim e a n d com pared i t t o t h e f e e l i n g he had on t h e o u t s i d e b e c a u s e he was an a d d i c t . S in c e t h e i n t e r ­ v ie w s w i t h t h e s o c i a l w o r k e r , he w an te d t o f e e l t h a t

26 he b e l o n g e d . He f e l t good a b o u t h i m s e l f , d i d n ’t f e e l h e h ad t o l o o k b a c k a t h i s l i f e anym ore, t h o u g h t he c o u l d s t a r t from h e r e . He knew he had l o t s o f p r o b le m s b u t t h o u g h t he c o u l d h a n d l e th em w i t h o u t r u n n i n g t o d r u g s . The w o r k e r ’ s comments a ro u n d t h i s w ere a b o u t h i s c o n s t r u c t i v e u s e o f t h e h o s p i t a l an d t h e r e a l i s t i c p i c t u r e he had o f w h at was i n s t o r e f o r him . On t h e m o rn in g o f t h e d ay o f t h e l a s t i n t e r v i e w , Mr. G. came b e f o r e S t a f f . He was d r e s s e d i n new c l o t h e s he had p u r c h a s e d , a c co m p a n ied by an a t t e n ­ d a n t , i n a n e a r b y to w n . He was a p p r o v e d f o r d i s ­ c h a r g e . L a t e r i n t h e d a y he was s e e n by t h e s o c i a l w o rk e r who, a t t h e s u g g e s t i o n o f t h e w ard p h y s i c i a n , a d v i s e d him o f t h e S t a f f d e c i s i o n . T h i s p l e a s e d him n o tic e a b ly . He was i n t e r e s t e d i n know ing t h e w ork­ e r ’ s o p i n i o n o f how he had c o n d u c te d h i m s e l f a t S t a f f an d sh e commented t h a t h i s a n s w e r s a n d p a r t i c i p a t i o n i n g e n e r a l w ere h o n e s t and f r a n k . S i n c e one o f t h e q u e s t i o n s was a b o u t t a k i n g d r u g s , he w a n te d t h e w ork­ e r t o know t h a t h e d i d n ’t i n t e n d t o go b a c k t o them . I f he c o u ld g e t a jo b so o n , he w o u ld be a b l e t o k e e p away from th em more e a s i l y . He t a l k e d a g a i n a b o u t th e in te r v ie w s w ith th e w o rk er, ab o u t a l l th e t a l k ­ i n g h e h ad d one an d t h e way t h e w o rk e r u n d e r s t o o d w hat he was s a y i n g o r t r y i n g t o s a y an d had n e v e r o n ce t o l d him w hat t o do o r t h i n k . He m e n tio n e d t h a t he h ad b e e n p i c k e d up when v e r y lo w , h e l p e d t o l i f t h i m s e l f up a n d was c a r r i e d a l o n g u n t i l he was now r e a d y t o l e a v e . L e a v in g , he w as s t i l l up h i g h an d f e l t s u r e h e c o u l d s t a y t h e r e . H is p l e a s u r e a t l e a v i n g seemed a p p a r e n t a n d h e t a l k e d a b o u t t h i s — to g e th e r w ith h is m is sin g th e in te r v ie w s . The s o c i a l w o r k e r ’ s c o n t a c t s w i t h Mr. G rape seem ed t o b e h e l p f u l t o him i n s e v e r a l a r e a s .

T h a t he was a b l e t o s h a r e

h i s f e e l i n g s ab o u t th e p o s s i b i l i t y o f e lo p in g w ith a c c e p ta n c e from t h e w o r k e r h e l p e d him i n r e a c h i n g a m e a s u re o f a c c e p t a n c e o f h is h o s p ita liz a tio n .

He became a b l e t o u s e t h e w ard t r a n s ­

f e r , t h e p a s t e u r i z i n g p l a n t jo b an d t h e s o c i a l w o r k e r t o e f ­ f e c t some change f o r h i m s e l f b e c a u s e h e was b e t t e r a b l e t o s e e

27 some p o s i t i v e g a i n s f o r h i m s e l f i n i t .

H is c h a n g ed p h y s i c a l

a p p e a r a n c e a n d p e r f o r m a n c e i n t h e h o s p i t a l was i n m ark ed con ­ t r a s t t o w hat i t had b e e n .

The c o n t e n t o f t h e i n t e r v i e w s i n ­

d i c a t e d t h a t f u l f i l l i n g t h e h o s p i t a l o b l i g a t i o n an d e n t e r i n g i n t o t h e r e l a t i o n s h i p w i t h t h e s o c i a l w o rk e r a s p a r t o f t h e h o s p i t a l , g ave him a r e a l f e e l i n g o f a c c o m p lis h m e n t; t h a t on t h e b a s i s o f t h i s f e e l i n g o f c h a n g e , o f f i n a l l y c o m p le t in g w h at he had t w i c e b e f o r e a t t e m p t e d , he had a g r e a t e r d e t e r m i n a ­ t i o n t o change h i s l i f e on t h e o u t s i d e . M e w in g t h i s g ro u p o f p a t i e n t s a s a w h o le , i t can be s a i d t h a t t h e s o c i a l w o r k e r 1s a c t i v i t y was c o n c e r n e d w i t h r e ­ l i e v i n g t h e v a r y i n g d e g r e e s o f a n x i e t y t h e y w ere e x p e r i e n c i n g * I n a few i n s t a n c e s , t h e s e c u r i n g o f t h i s i n f o r m a t i o n from a re p re s e n ta tiv e o f th e

h o s p i t a l was s a t i s f y i n g .

I n some i n ­

s t a n c e s , t h i s k n o w led g e b r o u g h t f o r t h some h o s t i l i t y an d n e g ­ a tiv e re a c tio n .

W ith t h e s o c i a l w o r k e r ’ s h e l p , p a t i e n t r e ­

so lv e d th e s e f e e l i n g s i n t o c o n s t r u c t i v e ch a n n e ls o f u se o f h o sp ita liz a tio n .

Knowledge a n d u s e o f p r o c e d u r e s can be h e l p ­

f u l in e lim in a tin g a n x ie ty .

F r e q u e n t l y , t h e u s e o f t h e know­

l e d g e o f how g ro u n d p a r o l e an d o pen w ard t r a n s f e r a r e e f f e c t ­ e d , can become an i n c e n t i v e o r dynam ic f o r r e c o v e r y . CONSIDERATION OF PROBLEMS OUTSIDE THE HOSPITAL T h e re w ere f i v e p a t i e n t s who came t o t h e s o c i a l w o rk e r a b o u t p ro b le m s on t h e o u t s i d e .

A l l o f t h e s e p a t i e n t s had b e e n

28 h o s p i t a l i z e d f o r f o u r m o nths an d l e s s . w i t h j o b s t h a t w ere a v a i l a b l e f o r th e m .

Two w ere c o n c e r n e d One o f t h e s e , an a l ­

c o h o l i c , e s c a p e d from t h e h o s p i t a l b e f o r e a s c h e d u l e d s e c o n d ap p o in tm e n t.

The o t h e r p a t i e n t was g r a n t e d a l e a v e o f a b s e n c e

fro m t h e h o s p i t a l and i t i s assum ed he r e t u r n e d t o t h e j o b he m e n tio n e d . One p a t i e n t , an a l c o h o l i c , i n t h i s g ro u p was c o n c e r n e d ab o u t a n o tic e o f t r i a l f o r su sp e n sio n o f h i s c h a u f f e u r ’s l i ­ cense.

The l i c e n s e was i m p o r t a n t t o him a s a means o f e a r n i n g

a l i v i n g upon r e l e a s e fro m t h e h o s p i t a l .

U s in g t h e s e r v i c e s

o f a r e p r e s e n t a t i v e o f t h e D e p a rtm e n t o f M otor V e h i c l e s a s s i g n ­ ed t o w o rk in g w i t h t h e h o s p i t a l , t h e s o c i a l w o rk e r was a b l e t o s e c u r e a n s w e rs t o a l l o f t h e q u e s t i o n s t h e p a t i e n t h a d .

The i n ­

f o r m a t i o n s e c u r e d f o r t h e p a t i e n t was h o p e l e s s a s f a r a s r e t a i n ­ i n g h i s l i c e n s e was c o n c e r n e d an d he was h e l p e d t o e x p r e s s h i s fe e lin g s about i t .

W ith c o n t i n u e d s o b r i e t y a s a means o f s e ­

c u rin g th e r e tu r n o f th e l i c e n s e , th e p a t i e n t ac c e p te d th e de­ c i s i o n , g a v e no i n d i c a t i o n t h a t he w a n te d f u r t h e r h e l p . A n o th e r p a t i e n t was d i s t u r b e d a b o u t how h i s f a m i l y was *

g o in g t o manage f i n a n c i a l l y w i t h p ay m e n ts on a home an d f u r n i ­ tu re .

The w o rk e r a r r a n g e d t o s e e t h e p a t i e n t ’ s w if e t o d i s ­

c o v e r t h a t t h e s i t u a t i o n was n o t a s p r e c a r i o u s a s t h e p a t i e n t th o u g h t.

The p a t i e n t ’ s w i f e , l e a r n i n g o f h i s c o n c e r n t h r o u g h

t h e s o c i a l w o r k e r , a d v i s e d him o f t h e f i n a n c i a l p l a n s sh e had m ade.

T h i s p a t i e n t was s e e n t w i c e .

29 The f i f t h p a t i e n t , Mr. F i r , was s e e n t w i c e by t h e s o ­ c i a l w o rk e r f o r h e l p i n a r r a n g e m e n t s a b o u t d i s a b i l i t y i n s u r ­ ance.

The f o l l o w i n g i s a summary:

Mr. F i r , a 34 y e a r o l d m a r r i e d man, was co m m itted to th e h o s p i t a l a s a s e x u a l p sy c h o p a th . He had b ee n h o s p i t a l i z e d a b o u t on e month when he made a p p l i c a ­ tio n f o r d i s a b i l i t y in su ra n c e . H is c l a i m was d e n i e d on t h e b a s i s o f a p r e v i o u s r u l i n g o f t h e d e p a r t m e n t d e n y in g d i s a b i l i t y i n s u r a n c e t o p a t i e n t s co m m itte d a s s e x u a l p s y c h o p a t h s . The b a s i s f o r d e n i a l was t h a t commitment was b e c a u s e o f " d a n g e r t o s o c i e t y ” r a t h e r t h a n " m e n ta l d i s a b i l i t y ” . Mr. F i r had a g r e a t d e a l o f f e e l i n g a b o u t t h i s d e c i s i o n s a y i n g t h a t he a s k e d t o b e c o m m itte d t o t h e h o s p i t a l f o r t r e a t m e n t w h ich he t h o u g h t i n d i c a t e d a n i l l n e s s . The p a t i e n t a s k e d t h e s o c i a l w o rk e r t o f i n d o u t s e v e r a l s p e c i f i c t h i n g s f o r him i n o r d e r t h a t he m ig h t p r e p a r e an a p ­ p e a l o f t h e d e c i s i o n . The s o c i a l w o rk e r d i d t h i s and a l s o s h a r e d w i t h him t h e i n f o r m a t i o n t h a t t h e r e was no p r e c e d e n t t o i n d i c a t e a r e v e r s a l o f d e c i s i o n . D u rin g t h e s e i n t e r v i e w s Mr. F i r b r o u g h t up q u e s t i o n s a b o u t h o s p i t a l p r o c e d u r e and r e g u l a t i o n s . T h re e o f t h e p a t i e n t s i n t h i s g ro u p w e re h e l p e d w i t h t h e d i f f i c u l t y t h a t c o n c e r n e d them on t h e o u t s i d e .

A lth o u g h

t h e i n f o r m a t i o n s e c u r e d f o r t h e p a t i e n t s was n o t a lw a y s w hat t h e y hoped i t w ould b e , t h e r e was some h e l p g i v e n by t h e s o ­ c i a l w o rk e r i n t h e p a t i e n t ’ s a c c e p t a n c e o f t h i s .

These r e ­

q u e s t s seemed t o f a l l i n t h e a r e a o f p r a c t i c a l r e a l i t y n e e d s o r p r o b le m s .

The s e r v i c e s w ere r e n d e r e d i n r e l a t i o n t o t h e

f e e l i n g s p a t i e n t s had a b o u t them an d i n t h i s way e a s e d some a n x ie ty .

I n some i n s t a n c e s t h e c o n c r e t e s e r v i c e - p r o v i d e d a

m eans f o r f u r t h e r a w a r e n e s s o f t h e p a t i e n t o f j u s t w h at h i s l i m i t a t i o n s and r e a l i t y s i t u a t i o n b o t h i n s i d e an d o u t s i d e t h e h o s p i t a l w ere.

30 HELP IN CONSTRUCTIVE USE OF HOSPITALIZATION A lth o u g h t h e u s e o f h o s p i t a l i z a t i o n was p a r t o f t h e s o c i a l w o rk e r* s c o n t a c t w i t h o t h e r p a t i e n t s , one was r e f e r r e d s p e c i f i c a l l y f o r h e l p i n t h i s a r e a by t h e w ard p h y s i c i a n . He was se e n by t h e s o c i a l w o r k e r a t w eekly i n t e r v a l s f o r t h r e e m o n th s .

The f o l l o w i n g i s a summary:

Mr. R o s e , a 2 6 - y e a r - o l d s i n g l e man had b e e n i n t h e h o s p i t a l a b o u t two and o n e - h a l f m onths when he was r e f e r r e d by t h e w ard p h y s i c i a n f o r h e l p i n mov­ in g a lo n g . He had b e e n h o s p i t a l i z e d v o l u n t a r i l y t h r e e t i m e s p r e v i o u s l y i n a V .A . n e u r o p s y c h i a t r i c h o s p i t a l w here he was d i a g n o s e d p s y c h o n e u r o t i c , m ix­ ed ty p e ; p s y c h o p a th ic p e r s o n a l i t y w ith p a t h o lo g ic a l e m o tio n a lity . I n b o t h d i a g n o s e s , a l c o h o l i s m was i n ­ d i c a t e d a s a c o m p l i c a t i n g f a c t o r . Upon commitment t o N orw alk he was g i v e n a d i a g n o s i s o f s c h i z o p h r e n i a w i t h reco m m en d a tio n f o r e l e c t r i c sh o c k t r e a t m e n t s . At t h e tim e o f t h e f i r s t i n t e r v i e w w i t h Mr. R. he had j u s t f i n i s h e d w i t h a s e r i e s o f sh o c k t r e a t m e n t s , was e x t r e m e l y n e r v o u s , b l i n k e d h i s e y e s a l m o s t c o n ­ tin u o u s ly . H is c o n v e r s a t i o n was r a t i o n a l , a l t h o u g h h e r a m b le d a b i t t a l k i n g a b o u t some o f t h e c ir c u m ­ s t a n c e s l e a d i n g t o h i s a d m i s s i o n and w h at he would b e a b l e t o do when he g o t o u t . He was w o rk in g i n t h e a f t e r n o o n s on a g a r d e n d e t a i l on t h e h o s p i t a l g ro u n d s. H is h a i r was d i s h e v e l e d an d he had a few d a y s g ro w th o f b e a r d . H is c l o t h e s w ere u n t i d y . By t h e ti m e o f t h e s e c o n d i n t e r v i e w , he h ad g ro u n d p a r o l e and came t o t h e o f f i c e o f t h e s o c i a l w o r k e r . He was s h a v e d , h a i r n e a t l y combed. A lth o u g h t h e h o s ­ p i t a l c l o t h e s w ere worn l o o k i n g , h i s a p p e a r a n c e was t i d y and he wore a t i e . He was w e a r in g a body c a s t a s he h ad s u f f e r e d a c o m p re sse d f r a c t u r e o f a v e r t e ­ b r a d u r i n g sh o c k t r e a t m e n t . The w o rk e r h e l p e d him e x p r e s s h i s f e e l i n g s ab o u t th e s e tr e a tm e n t s in b o th p o s i t i v e and n e g a t i v e way. I n s p i t e o f a tre m e n d o u s f e a r o f th e tre a tm e n ts , i n a b i l i t y to sle e p b e fo re th em , he f e l t t h e y h ad h e l p e d him b e c a u s e he was no l o n g e r d e p r e s s e d an d i n g e n e r a l f e l t b e t t e r m e n t a l l y • He f e l t r e s i g n e d t o b e i n g i n t h e h o s p i t a l b e c a u s e he

31 c o u l d n ’t " h a n d le t h i n g s f o r h i m s e l f on t h e o u t s i d e " . The w o rk e r i n t r o d u c e d a f o c u s t o t h e c o n t i n u a t i o n o f i n t e r v i e w s on h i s h o s p i t a l e x p e r i e n c e a r o u n d ways i t m ig h t h e l p him when he g o t on t h e o u t s i d e . Mr. E . w a n te d t o a c c e p t t h e s e r v i c e on a w e e k ly b a s i s , com­ p ared t h i s ex p e rien c e to t h a t o f o th e rs w ith s o c i a l w o r k e r s , t h o u g h t t h i s w o rk e r " p u t h e r c a r d s on t h e ta b le " . By t h e n e x t i n t e r v i e w , Mr. E . had b ee n t r a n s f e r ­ r e d t o an o p en w a rd . The h o s p i t a l a d m i n i s t r a t i o n h ad a p p l i e d f o r a d i s a b i l i t y p e n s i o n f o r him a u t o m a t i c a l ­ l y an d t h e w o r k e r t o l d him a b o u t i t . T h is r e c a l l e d f o r him h i s e x p e r i e n c e a t a V.A. n e u r o p s y c h i a t r i c h o s p i t a l an d how he n e v e r c o u l d f e e l t h a t he was e n ­ t i t l e d t o money b e c a u s e he had n o t s e e n o v e r s e a s d u t y l i k e so many o f t h e v e t e r a n s i n t h e h o s p i t a l . He t a l k e d a t some l e n g t h a b o u t t h e v a r i o u s t h e r a p i e s i n w h ich he p a r t i c i p a t e d a d d i n g t h a t t h e y a l l t o l d him w h at was w rong w i t h him b u t d i d n ’t h e l p him . W ith t h e w o r k e r i n t r o d u c i n g t h e f o c u s on t h i s h o s p i ­ t a l he com pared t h e e x p e r i e n c e s , s e e i n g h i s p r e s e n t e x p e r i e n c e a s " r o c k b o tto m " , f e e l i n g he f i t i n b e t ­ te r. A lth o u g h he d i d n ’t l i k e i t , he f e l t he c o u ld a d ju st to i t . He had g a i n e d w e i g h t , f e l t b e t t e r men­ ta lly . Mr. E . t a l k e d a t some l e n g t h a b o u t t h e "show b u s i n e s s " he h ad b e e n i n an d how much he l i k e d i t . He saw i t a s a b u s i n e s s w here h e w ould do a g r e a t d eal o f d rin k in g . P r i o r t o t h e f o u r t h i n t e r v i e w , Mr. E . had b e e n a w ard ed a 1 0 0 p e r c e n t n o n - s e r v i c e c o n n e c te d d i s a b i l i t y p e n s io n ." A lth o u g h he was a b l e t o s e e v a l u e i n h a v ­ i n g money when he l e f t , he f e l t " u n d e s e r v i n g " . He ta lk e d f r e e ly about th e d is c ip li n e o f th e h o s p ita l b e i n g h e l p f u l t o him , t h a t t h e l e g a l commitment p r e ­ v e n t e d h i s s k i p p i n g o f f b e c a u s e o f t h e kn ow ledg e t h a t he w o u ld be r e t u r n e d i f he e s c a p e d . I n p r e s e n t i n g a g r e a t d e a l o f - m a t e r i a l a b o u t h i s p a s t l i f e an d t h e v a r i o u s d i a g n o s e s t h a t had b e e n g i v e n him , t h e w o rk ­ e r ’s r e l a t i n g t h i s to th e p re s e n t le d to h is d e c id in g h e " c o u l d n ’t chan g e t h e p a s t " b u t c o u ld work on t h e p re se n t. He w an te d m ost o f a l l t o a v o i d d r i n k i n g , h ad d e c i d e d n o t t o r e t u r n t o t h e show b u s i n e s s b e ­ cause o f t h i s . I n t h e f i f t h an d s i x t h i n t e r v i e w s , Mr. E . showed c o n s i d e r a b l e i n t e r e s t i n l e a v i n g t h e h o s p i t a l and i n p la n n in g f o r h is le a v e . He t a l k e d a b o u t t h e s i t u a ­

32 t i o n a t home a n d was a b l e t o s e e w here he w ould have some d i f f i c u l t i e s a s b e f o r e . L i v i n g a t home p r i o r t o h o s p i t a l i z a t i o n he had no money. T h is t i m e w i t h h i s p e n s io n he w a n te d t o c o n t r i b u t e h i s s h a r e t o t h e h o u se h o ld . He was f i n d i n g t h e h o s p i t a l more and more d i f f i c u l t . The o t h e r p a t i e n t s on t h e w ard b o t h e r e d him and he fo u n d h i m s e l f b o r e d . He h ad b e e n w o rk in g on t h e g a r d e n d e t a i l i n t h e a f t e r n o o n s and t a k i n g p h y s i c a l t h e r a p y i n t h e m o r n in g s . When t h e w o rk e r t o l d Mr. R. o f t h e h o s p i t a l p r o c e d u r e i n c o n n e c t i o n w ithe h i s l e a v e w h ich w ould n e c e s s i t a t e t h e p h y s i c a l p r e s e n c e o f h i s f a m i l y t o s i g n f o r him , he was some­ w hat t r o u b l e d n o t w a n tin g t o im pose upon them t o make a t r i p t o g e t him . A f t e r some- c o n s i d e r a t i o n , he f e l t he c o u ld w r i t e them a s k i n g a b o u t i t . He was a b le to see t h a t th e y e a r o f le a v e o f absence p r io r t o d i s c h a r g e was a good t h i n g f o r him . He knew t h a t o n e d r i n k w ould r e t u r n him t o t h e h o s p i t a l , and he d id n o t w ant to r e t u r n . I n t h e f o l l o w i n g i n t e r v i e w , Mr. R. e x p r e s s e d much o f t h e n e g a t i v e s i d e o f g o in g t o l i v e w i t h h i s f a m i­ ly . B e ca u se he h ad t o c o n t r o l h i s f e e l i n g s so much i n t h e i n t e r r a c t i o n w i t h o t h e r f a m i l y mem bers, he c o u ld s e e h i m s e l f s p e n d in g t i m e b r o o d in g w h ic h a lw a y s b e f o r e l e d t o h i s g e t t i n g d r u n k . W ith t h e w o r k e r , h e c o n s i d e r e d l i v i n g by h i m s e l f , b u t was q u ic k t o r u l e t h i s o u t b e c a u s e o f n o t l i k i n g t o b e by h i m s e l f . I t was h e r e t h a t t h e w o rk e r i n t r o d u c e d t h e p o s s i b i l i t y o f h i s u s i n g t h e s e r v i c e s o f t h e B u re a u o f S o c i a l Work i f a d j u s t i n g a t home w i t h h i s f a m i l y became a p r o b le m . W ith some h e l p fro m t h e w o r k e r , he saw h i s p r e s e n t w ard e x p e r i e n c e w i t h i t s i r r i t a t i n g f a c t o r s a s b e i n g a p r e p a r a t i o n f o r some o f w hat he m ig h t e n ­ co u n ter in h is li v i n g s it u a ti o n o u ts id e th e h o s p ita l. At t h i s t i m e , M r. R. t a l k e d a b o u t h i s f e e l i n g s a b o u t h i m s e l f upon a d m i s s i o n t o t h e h o s p i t a l , how he d i d n ’t c a r e w h ere he was ev e n when he was t o l d he w as w i t h " c r a z y people?*. W ith sh o c k t r e a t m e n t s , he ev en c a r e d l e s s w here h e w as, was v e r y m i s e r a b l e . S h o r t l y a f t e r sho ck t r e a t m e n t s , he b eg a n t o f e e l b e t t e r u n t i l now he d i d n * t l i k e l i v i n g w i t h o t h e r p a t i e n t s c h a r a c t e r ­ i z e d a s " c r a z y " . Mr. R. t a l k e d a l s o a b o u t h i s b o r e ­ dom w i t h h i s g a r d e n jo b an d s i n c e h i s i n t e r e s t i n t y p ­ in g h ad come up i n o t h e r i n t e r v i e w s , t h e w o rk e r s a i d sh e w ou ld s e e a b o u t t h e p o s s i b i l i t y o f s u c h a jo b i n t h e h o s p i t a l f o r him . The e i g h t h a n d n i n t h i n t e r v i e w s w i t h Mr. R. showed

33 a r e m a r k a b le ch a n g e i n h im . He h ad g one t o work a s a ty p is t in th e a d m in istra tiv e o f f ic e . He had an a i r o f im p o r ta n c e a b o u t him an d was e n t h u s i a s t i c about h is jo b . He was s l e e p i n g b e t t e r a n d he a t t r i ­ b u t e d t h i s t o w o rk in g h a r d a t t h e jo b an d t o t h e re m o v a l o f t h e body c a s t . I n h i s d i s c u s s i o n o f how much b e t t e r he f e l t an d how much t h e h o s p i t a l i z a t i o n h ad h e l p e d , t h e w o r k e r i n d i c a t e d t h a t s h e t h o u g h t h e had a l o t t o do w i t h g e t t i n g t h e j o b i n t h e way he had been t r y i n g t o u s e w hat was h e r e t o g e t b e t t e r an d had im p ro v e d t o t h e p o i n t w here he was a b l e t o do t h i s jo b w e l l a n d e n j o y d o in g i t . Mr. R . t h o u g h t t h i s , t o o , and commented on t h e s t r u g g l e i t had b e e n f o r him . H is f a m i l y ' s r e s p o n s e t o h i s l e a v e p l a n s c o i n c i d e d w i t h t h e tim e h i s w ard p h y s i c i a n p la n n e d t o b r i n g him t o S t a f f w h ic h w ould be i n a b o u t s i x w e e k s. I n t h e l a s t i n t e r v i e w t h e w o rk e r had w i t h Mr. R. i t was h e r i m p r e s s i o n t h a t he was m oving to w a r d t e r ­ m i n a t i o n o f h i s r e l a t i o n s h i p w i t h t h e w o r k e r . H is a d ­ j u s t m e n t t o t h e h o s p i t a l seem ed s a t i s f y i n g t o him an d h i s p l a n s f o r l e a v e w ere made. He b r o u g h t i n a g a i n h i s p r e v i o u s h o s p i t a l i z a t i o n e x p e r i e n c e w here " e v e r y t h i n g was d o n e f o r him ” a s b e i n g so d i f f e r e n t fro m t h i s e x p e r i e n c e and w i t h t h e w o r k e r ' s h e l p c o u ld s e e t h i s e x p e r i e n c e was more r e a l i s t i c f o r him i n p r e p a r a t i o n f o r t h e o u t s i d e w here t h e b u r d e n o f l i v ­ i n g and m an ag in g would f a l l upon h i m s e l f . P r o b a b ly i t was Mr. R o s e 's s t r o n g c o n s c i o u s d e s i r e t o g e t w e ll, to g e th e r w ith h i s use o f th e h o s p i t a l i z a t i o n t h a t b r o u g h t him t o t h e p o i n t o f l e a v i n g t h e h o s p i t a l .

The i n t e r ­

v ie w s d i s c l o s e d a p e r s o n who seemed c o n f u s e d , somewhat p r e ­ o c c u p i e d and b e w i l d e r e d by d i a g n o s t i c i n f o r m a t i o n t h a t had b e e n g iv e n him i n t h e c o u r s e o f p s y c h i a t r i c t r e a t m e n t .

The

in tro d u c tio n o f th e r e a l i t y fo cu s o f h is p re s e n t h o s p ita liz a ­ t i o n g ave him an o p p o r t u n i t y t o c o n c e n t r a t e h i s e f f o r t s an d e n e r g y on s o m e th in g w here h e c o u ld s e e an d f e e l c h a n g e .

Mr.

R . ' s p h y s i c a l a p p e a r a n c e an d c o n d i t i o n im p ro v e d o v e r t h e p e r i o d

34 o f t h e i n t e r v i e w s a s e v i d e n c e d by h i s g a i n i n w e ig h t a n d change in p e r s o n a l a p p e a ra n c e .

The c o n t e n t o f t h e i n t e r v i e w s

showed t h a t , a l t h o u g h some s t r u g g l e was i n v o l v e d , Mr. R . was. a b le t o u se th e e n v iro n m e n ta l a s p e c ts o f th e h o s p i t a l a s a way o f p r e p a r i n g h i m s e l f f o r l i v i n g on t h e o u t s i d e . G e n e ra lly sp e a k in g , in t h i s a re a o f th e u se o f h o s p i­ t a l i z a t i o n , i t seems t h a t m ost p a t i e n t s c o u ld be h e l p e d i f t h e i r own d r i v e to w a r d r e c o v e r y w ere s u f f i c i e n t l y s t r o n g . ASSISTANCE IN PLANNING TOWARD LEAVING THE HOSPITAL L e a v in g t h e h o s p i t a l can h av e tr e m e n d o u s s i g n i f i c a n c e f o r many p a t i e n t s .

To a l l o f th e m i t means more f re e d o m b u t

i n t h e fre e d o m i s a l s o t h e i m p l i c a t i o n o f r e t u r n i n g t o l i v i n g o u t s i d e w h ere t h e m e n ta l i l l n e s s o c c u r r e d .

Some p a t i e n t s a t ­

t a i n a maximum o f r e c o v e r y i n t h e h o s p i t a l and can a d j u s t on th e o u tsid e i f a s a tis f a c to r y liv i n g s itu a tio n i s a rran g ed . C o n t a c t s w i t h two p a t i e n t s a r o u n d l e a v i n g t h e h o s p i t a l w ere made d u r i n g t h e two m o nth s p e r i o d on t h e w a rd , o n e a s e l f r e f e r r a l and a n o t h e r r e f e r r e d by t h e w ard p h y s i c i a n .

The p a ­

t i e n t who r e f e r r e d h i m s e l f was s e e n w e e k ly by t h e s o c i a l w ork­ e r f o r a b o u t two m onths u n t i l he l e f t t h e h o s p i t a l .

W ith t h e

h e l p o f t h e w ard p h y s i c i a n , c h a r g e a t t e n d a n t and s o c i a l w ork­ e r , t h i s p a t i e n t , a l t h o u g h a t f i r s t r e l u c t a n t , w as a b l e t o a c ­ c e p t h i s t r a n s f e r t o an open w ard a s p r e p a r a t i o n f o r g e t t i n g

35 a l o n g on t h e o u t s i d e .

S in c e he had no f r i e n d s o r r e l a t i v e s

e i t h e r t o s i g n him o u t o r w i t h whom he c o u l d l i v e , t h e s o c i a l w o rk e r w orked c l o s e l y w i t h t h e J e w is h C om m ittee f o r P e r s o n a l S e r v i c e **5 on a p l a n f o r h i s s u p e r v i s i o n . D r. S ycam ore, a 4 2 - y e a r - o l d m a r r i e d man w i t h two c h i l ­ d r e n , had b e e n i n t h e h o s p i t a l s e v e n m o n ths when he was r e ­ f e r r e d t o t h e s o c i a l w o rk e r by t h e w ard p h y s i c i a n .

He had

b ee n d i a g n o s e d upon a d m i s s i o n s c h i z o p h r e n i a , p a r a n o i d t y p e , and had b e e n g iv e n a s e r i e s o f sho ck t r e a t m e n t s .

He had b e e n

on t h e same w ard d u r i n g h i s h o s p i t a l i z a t i o n , d i d no work o t h e r t h a n h e l p i n g a t m e al t i m e .

The w ard p h y s i c i a n f e l t t h a t t h e r e

h ad b e e n s u f f i c i e n t im p rov em en t i n h i s c o n d i t i o n t o w a r r a n t h i s g o in g home on w eekend v i s i t s .

B e c a u se t h e r e had b e e n co n ­

s i d e r a b l e m a r i t a l c o n f l i c t p r i o r t o h o s p i t a l i z a t i o n and b e ­ c a u s e D r. S ycam ore, a p h y s i c i a n , and h i s w if e had b e e n s e p a r ­ a t e d f o r a lm o s t two y e a r s , t h e w ard p h y s i c i a n f e l t t h e f a m i l y m ig h t n e e d some h e l p w i t h l e a v e p l a n s . T h ro u g h o u t t h e i n t e r v i e w s w i t h D r. S . he a lw a y s p r e ­ s e n t e d a n e a t , t i d y a p p e a r a n c e . D u rin g t h e f i r s t i n ­ t e r v i e w , he i n d i c a t e d he had a jo b l i n e d up w h ich was n o t i n h i s p r o f e s s i o n . W ith t h e w o r k e r ’ s h e l p he t o l d much o f h i s f e e l i n g s a b o u t n o t b e i n g a b l e t o p r a c t i c e m e d i c i n e , had i n q u i r e d i n t o t h e p r o c e d u r e f o r h i s l i ­ c e n s e r e n e w a l w h ic h d e p e n d ed on when he c o u ld be d i s ­ c h a r g e d fro m t h e h o s p i t a l an d a p p r o v e d by t h e S t a t e

T h i s a g e n c y assu m es f o r J e w i s h p a t i e n t s t h e same f u n c ­ t i o n a s t h e B u re a u o f S o c i a l Work.

B o a rd . He t a l k e d f r e e l y o f how a n x i o u s he was t o l e a v e t h e h o s p i t a l a n d a s k e d many q u e s t i o n s a b o u t l e a v e p r o c e d u r e s . The w eekend t o f o l l o w t h e i n t e r ­ v ie w he was t o h av e h i s f i r s t o v e r n i g h t l e a v e . D u rin g t h e s e c o n d i n t e r v i e w , he seemed l e s s r e ­ s p o n s i v e t h a n t h e p r e v i o u s w eek. The w o r k e r h ad t o r e p e a t some o f w hat s h e s a i d a s he seem ed t o s t a r e i n t o s p a c e . I n t h e i n t e r i m o f two w eeks b e tw e e n i n ­ t e r v i e w s , D r. S . h ad b e e n home f o r two o v e r n i g h t v i s ­ its . (D r. S . was home on a n o v e r n i g h t v i s i t t h e p r e v i o u s week d u r i n g w ard o f f i c e h o u r s ) . T h e r e had b ee n an arg u m e n t w i t h h i s w i f e who a c c u s e d him o f b ein g d e lu s io n a l. He h a d w an te d much t o h a v e a lo n g f r a n k t a l k w i t h h e r , b u t sh e became t o o u p s e t . He d e c i d e d t h a t when he w ent home he w ould n o t t a l k o r do a n y t h i n g t h a t c o u l d be m i s i n t e r p r e t e d , t h a t he w ould p l a n t o l i v e w i t h h e r a s a d i s t a n t co m p an io n . The w o rk e r r a i s e d w i t h him t h e q u e s t i o n o f how h e l p ­ f u l l i v i n g l i k e t h a t w ould be t o h i s r e c o v e r y . He la u n c h e d i n t o a d i s c u s s i o n a b o u t h i s w i f e an d h e r d e s i r e t o c o n t r o l him . D r. S . sp o ke i n some d e t a i l o f a g e n e r a l f e e l i n g o f i n d i f f e r e n c e he had a b o u t e v e ry th in g . He d i d n ’t c a r e t o s e e a n y o n e , t o g e t l e t t e r s , an d he a t t r i b u t e d t h i s f e e l i n g t o t h e r e a c ­ t io n to th e lo s s o f h is p r o f e s s io n a l lic e n s e because he h ad " p u t h i s l i f e ’ s b lo o d " i n t o h i s p r o f e s s i o n . By t h e f o l l o w i n g i n t e r v i e w , D r. S . had g ro u n d p a ­ r o l e from t h e l o c k e d w a rd . He m e n tio n e d a g a i n h i s i n d i f f e r e n c e ev e n a b o u t t h i s . T h re e d a y s p r i o r t o t h i s i n t e r v i e w , t h e w ard p h y s i c i a n i n t r o d u c e d M rs. S . t o t h e w o rk e r who, i n a b r i e f i n t e r v i e w , d e c i d e d t o s e e t h e w o r k e r w e e k ly f o r t h e c o n s i d e r a t i o n o f l e a v e p l a n s f o r D r. S . When t h e w o r k e r t o l d D r. S . a b o u t t h i s an d a t t e m p t e d t o d e a l w i t h i t i n t e r m s o f h i s f e e l i n g s a b o u t i t , h i s o n l y r e a c t i o n was s u r ­ p r i s e t h a t M rs. S . h ad n o t t o l d him a b o u t i t . He ex p ressed a s tro n g d e s ir e to le av e th e h o s p i t a l , f e e l i n g t h a t a l l i n t h e way o f r e h a b i l i t a t i o n f o r him w ould h a v e t o come on t h e o u t s i d e an d i n d i c a t i n g t h a t he r e a l l y knew t h e p a t i e n t was a lw a y s w ro n g . The w ard p h y s i c i a n had r e f e r r e d him t o O c c u p a t i o n a l T h e r a ­ py and D r. S . was r e l u c t a n t t o s t a r t a new h o s p i t a l r e gime f o r w h ic h he f e l t no n e e d . He t h o u g h t s t a y i n g w ould e n d a n g e r him t o t h e e x t e n t t h a t he m ig h t assum e t h e a t t i t u d e s and a f f e c t s o f o t h e r p a t i e n t s . D r. S. h ad t h e i m p r e s s i o n fro m t h e p r e v i o u s i n t e r v i e w t h a t t h e w o rk e r d i d n o t t h i n k t h e p l a n o f h i s b e i n g p a r o l e d

37 t o h i s w i f e was a good o n e . Not r e l a t i n g t o t h i s i m p r e s s i o n , t h e w o rk e r i n q u i r e d a b o u t a l t e r n a t i v e p l a n s he m ig h t h a v e . He h ad t h o u g h t t h e r e c o u ld b e no o t h e r . The w o rk e r e x p l a i n e d t h e h o s p i t a l p r o c e ­ d u r e s a b o u t l e a v e e m p h a s iz in g t h a t t h e r e w ould be a . m u tu a l a g r e e m e n t o f t h e h o s p i t a l an d h i m s e l f a b o u t a p l a n f o r o u t s i d e l i v i n g t h a t w o uld a f f o r d him t h e b e s t o p p o r t u n i t y f o r a d j u s t m e n t . D r. S . d i s c u s s e d f r e e l y t h e i m p l i c a t i o n s o f b e i n g p a r o l e d t o M rs. S . , h i s i n a b i l i t y t o t r u s t h e r ju d g m e n t, a n d h i s d i s l i k e o f h a v in g t o a s k h e r p e r m i s s i o n t o do w h at he w a n t­ ed. He saw t h e p l a n o f h a v i n g M rs. S . s i g n him o u t as "fo rced r e c o n c ilia tio n " . He p l a n n e d t o d i s c u s s w i t h M rs. S . t h e i d e a o f h i s l i v i n g by h i m s e l f , an d w o rk in g to w a r d h i s m a r r i a g e fro m t h e o u t s i d e r a t h e r t h a n b e i n g p lu n g e d i n t o i t . He e n u m e r a te d a num ber o f h i s f r i e n d s who a d v i s e d him a g a i n s t g o in g b ac k t o h e r . D u r i n g t h i s i n t e r v i e w , t h e w o r k e r h e l p e d D r. S . e x p r e s s some o f h i s f e e l i n g s a b o u t h i m s e l f a s a p r o f e s s io n a l p erso n b ein g a p a t i e n t . By t h e t i m e o f t h e n e x t i n t e r v i e w , D r. S . had w o rk ­ ed a day i n O c c u p a t i o n a l T h e ra p y t y p i n g an d l i k e d t h e f e e l i n g o f u s e f u l n e s s i t g av e him . D r. S. t o l d o f t h e d i s c u s s i o n w i t h M rs. S . o f h i s p l a n f o r l i v i n g by him­ s e l f , an d h e r r e a c t i o n o f b eco m in g u p s e t , c r y i n g and m aking u n j u s t a c c u s a t i o n s . T h i s was p a i n f u l f o r him b e c a u s e he h a t e d t o h u r t a n y o n e . He e x p r e s s e d a g r e a t d e a l o f r e s e n t m e n t to w a r d M rs. S . f o r h i s commitment by h e r , t h e way i t was d o n e , w i t h no n o t i c e a t a l l . He f e l t i f s h e s i g n e d him o u t he w ould b e a s f a r away from r e t u r n i n g t o t h e h o s p i t a l a s s h e w ou ld be from th e te le p h o n e . He r e l a t e d t h i s t o h i s n o t w a n tin g t o r e tu r n to th e h o s p ita l a g a in . B e fo r e t h e n e x t i n t e r v i e w , D r. S . had b e e n a s s i g n ­ ed t o work i n t h e Com m issary d o in g g e n e r a l w a re h o u se l a b o r and d e l i v e r i n g fo o d and m e d ic a l s u p p l i e s a r o u n d t h e h o s p i t a l g r o u n d s . He f e l t good a b o u t t h e w ork, commented t h a t t h e e x e r c i s e was good f o r him and b e s t o f a l l , he f e l t u s e f u l . He saw t h i s a s b e i n g d i f f e r ­ e n t fro m h i s p r e v i o u s i n e r t i a an d c o m fo r t i n s t a y i n g on t h e w ard a l l d a y . He t a l k e d i n g r e a t e r d e t a i l o f t h e p r e v i o u s w e e k ’ s i n c i d e n t w i t h M rs. S . , o f h i s f e e l i n g s i c k an d u n a b l e t o e a t a s a r e s u l t o f M rs. S . ’ s o u tb u rst. A p r o f e s s i o n a l f r i e n d h ad o f f e r e d t o s i g n him o u t an d h av e him l i v e i n h i s home. He f e l t t h i s p l a n was n o t good b e c a u s e he w ould f e e l t o o o b l i g a t e d to p a r t i c i p a t e in t h e i r s o c ia l l i f e . W ith t h e s h o r t ­

3

a g e o f room s p a c e a t home an d l a c k o f p r i v a c y , he t h o u g h t he w o uld p r e f e r t o l i v e t h e r e i f he c o u l d n ’t l i v e by h i m s e l f . W orker c l a r i f i e d f o c u s o f i n t e r ­ v ie w s a s t o w here he was g o i n g t o l i v e an d who w ould s i g n him o u t . Upon t h e d i s c u s s i o n o f how many t r o u b l e s w ere on t h e o u t s i d e f o r him b e f o r e h o s p i t a l ­ i z a t i o n — o v e r w o rk , l a c k o f s l e e p , m a r i t a l d i f f i c u l ­ t i e s , D r. S . w a n te d t o know w h at he s h o u ld a v o i d m o s t. The w o rk e r i n t r o d u c e d t h e s e r v i c e s o f t h e B u re a u o f S o c i a l Work a s a r e s o u r c e f o r h e l p i f he had d i f f i ­ c u l t i e s on t h e o u t s i d e . D u rin g t h e n e x t i n t e r v i e w , D r. S . t a l k e d a t some l e n g t h a b o u t t h e h o s p i t a l j o b , t e l l i n g o f many n e g a ­ t i v e f e e l i n g s a b o u t t h e r e v e r s a l o f t h e r o l e he had i n t h e h o s p i t a l . A lth o u g h he f e l t " i n s u b o r d i n a t e " i n t h e h o s p i t a l a s com pared w i t h h i s f o r m e r p r o f e s ­ s i o n a l s t a t u s on t h e o u t s i d e , he f e l t t h i s h ad n o t h in d e re d th e h e lp f u ln e s s o f th e h o s p i t a l . He showed some p o s i t i v e r e a c t i o n t o h a v in g g ro u n d p a r o l e an d l i k e d b e i n g away fro m t h e w ard a l l d a y . I n t h i s i n ­ t e r v i e w t h e w o rk e r i n t r o d u c e d t h e p o s s i b i l i t y o f h i s l e a v i n g i n f o u r o r f i v e w eeks ( a s c o n f e r e n c e w i t h w ard p h y s i c i a n d i s c l o s e d ) . D r. S . was r e c o n s i d e r i n g t h e o f f e r o f h i s p r o f e s s i o n a l f r i e n d b e c a u s e he t h o u g h t M rs. S . w ould a p p r o v e o f i t . D r. S . b r o u g h t i n w h at he t h o u g h t was a n a d d e d h e l p t o p a t i e n t s i n t h e h o s p i t a l — a s s o c i a t i o n w i t h o t h e r p a t i e n t s who w ere a t s i m i l a r l e v e l s o f r e c o v e r y , and d i s c u s s i o n o f m u tu a l e x p e r i e n c e s . He fo u n d c e r t a i n s i m i l a r i t i e s i n e a c h when t h e y w ere f i r s t a d m i t t e d t o t h e h o s p i t a l . They d i d n ’t c a r e w h ere t h e y w e r e ; t h e n t h e r e came a p o i n t when t h e y c a r e d an d when t h e y d i d n ’t w an t t o h ave a n y t h i n g t o do w i t h " d e t e r i o r a t e d ” p a t i e n t s f o r f e a r o f t a k i n g on t h e i r c h a r a c t e r i s t i c s . I n t h e f o l l o w i n g i n t e r v i e w , D r. S . was f e e l i n g q u i t e d e s p o n d e n t b e c a u s e o f M rs. S . ’ s a t t i t u d e t o ­ w ard h i s l e a v e p l a n s . When he b r o u g h t up h i s l i v i n g w i t h t h e p r o f e s s i o n a l f r i e n d , sh e f l e w i n t o a r a g e . He g av e v e n t t o some o f h i s f e e l i n g a b o u t M rs. S . , h e r f i e n d i s h d e s i r e t o p o s s e s s him an d h e r d i s l i k e o f h is frie n d s. He w a n te d t o h av e p e a c e a s h e l e f t an d saw h i m s e l f a s b e i n g f o r c e d i n t o t h e f a m i l y s i t ­ u a t i o n b e c a u s e he c o u l d n ’t s t a n d t h e p a i n f u l n e s s o f h u r tin g anyone. At t h e n e x t t o t h e l a s t i n t e r v i e w , t h e w ard p h y ­ s i c i a n had t o l d him he w o u ld be b r o u g h t t o S t a f f w i t h -

$

i n a week* I n h i s d e s i r e t o k e e p p e a c e and a v o i d u p s e t , he had d e c i d e d on a p l a n o f ftt r i a l r e c o n c i l ­ i a t i o n ” w i t h h i s f a m i l y . He r e c o g n i z e d t h a t even th o u g h t h e p l a n was e s s e n t i a l l y t h e same a t f i r s t , he saw now so much b e t t e r w hat he was g e t t i n g i n t o and w h a t d i f f i c u l t i e s t h e r e w ere f o r him i n i t * He a l r e a d y had t a k e n s t e p s t o h av e Mrs* S . i n c l u d e d w i t h h i s f r i e n d s an d w anted t o t r y t o w ork i t o u t . A lth o u g h he was g o i n g t o l i v e w i t h h i s f a m i l y , h e tfw ould n o t g i v e i n ” t o M rs. S . on t h e m a t t e r o f s i g n i n g o u t and w a n te d h i s p r o f e s s i o n a l f r i e n d t o do t h i s f o r him . The w o rk e r d i s c u s s e d w i t h him some o f t h e S t a f f p r o c e d u r e an d some o f h i s f e e l i n g s a b o u t g o in g t o S t a f f . On t h e d a y o f t h e l a s t i n t e r v i e w , D r. S . had b e e n t o S t a f f and was g r a n t e d a l e a v e o f a b s e n c e w i t h t h e p l a n he h ad made o f w h ere he w ould l i v e an d who w ould s i g n him o u t a p p ro v e d by t h e S t a f f . He was o b ­ v i o u s l y p l e a s e d a b o u t t h e outcom e o f S t a f f , had many q u e s t i o n s a b o u t h i s l e a v e an d h i s s t a t u s when on l e a v e . The w o rk e r a g a i n t a l k e d more s p e c i f i c a l l y a b o u t t h e B u re a u o f S o c i a l Work. D r. S . commented t h a t he f e l t h e was l e a v i n g a t t h e r i g h t tim e i n s p i t e o f w h at he had s a i d so many t i m e s b e f o r e , sp o k e i n t e r m s o f a c h a n g e o c c u r r i n g i n him a b o u t f o u r o r f i v e w eeks ag o when he had b eg u n t o f e e l d i f f e r e n t l y — more i n t e r e s t e d i n p e o p l e g e n e r a l l y , and i n w hat h a p p e n e d t o him . He r e l a t e d t h e c h a n g e t o t h e Com­ m i s s a r y j o b , g o in g home f o r a two d a y w eekend and t h e i n t e r v i e w s a n d w o n d e re d w h ic h o f t h e t h r e e c a u s e d t h e c h a n g e . The w o rk e r i n d i c a t e d t h e d i f f i c u l t y o f s i n g l i n g o u t any one t h i n g , i n d i c a t e d he had u s e d f o r h i m s e l f w hat t h e r e was t h a t h e l p e d him , t h a t he h i m s e l f had a m a jo r p a r t i n a c c o m p l i s h i n g t h e c h a n g e . D r. S . was o v e r j o y e d a t g o in g t o t h e o u t s i d e . He th a n k e d t h e w o r k e r warmly f o r h e r h e l p an d s a i d t h a t he w ould m is s t h e i n t e r v i e w s . M rs . Sycam ore M rs. S . was s e e n w ee k ly by t h e s o c i a l w o rk e r f o r s i x w e e k s . The i n t e r v i e w s w i t h h e r r e v e a l e d h e r d e t e r m ined s t r u g g l e t o c o n t r o l D r. S . She t o l d o f h e r r e a c tio n s to h is p la n s f o r le a v in g t h a t d id n o t i n ­ c lu d e h e r . T h e r e w ere i n d i c a t i o n s t h a t sh e r e c o g ­ n i z e d su c h a c t i v i t y was n o t good f o r D r. S . , b u t s h e

hO was n o t a b l e t o u s e t h i s kno w led ge t o p r e v e n t v i o l e n t r e a c t i o n s . M rs. S. was n o t a b l e t o u s e t h e s e r v i c e s o f th e s o c i a l w o rk er c o n s t r u c t i v e l y . The v a l u e - i n t h e s e c o n t a c t s o f t h e w o rk e r w i t h M rs. S . was i n t h e c l a r i f i c a t i o n , f o r t h e h o s p i t a l an d B u re a u o f S o c i a l Work, o f t h e r e a l i t y s i t u a t i o n i n t h e S . home. The c o n t e n t o f t h e i n t e r v i e w s w i t h D r . Sycam ore i n d i ­ c a t e d i n h i s own w o rd s t h a t he became b e t t e r a b l e t o u s e t h e h o sp ita l.

The l a s t tw o i n t e r v i e w s d i s c l o s e d t h e c h a n g e s i n

him d u r i n g t h i s t i m e .

From t h i s c o n t e n t and h i s p e r f o rm a n c e

i n t h e h o s p i t a l , i t c o u ld b e c o n s i d e r e d t h a t h i s c o n t a c t s w i t h t h e s o c i a l w o rk e r h e l p e d him i n h i s b e t t e r u s e o f t h e h o s p i ­ ta l.

U s in g t h e s o c i a l w o rk e r seem ed t o be a means o f h i s

w o rk in g o u t h i s own l e a v e p l a n s .

W ith t h e w o r k e r ’ s h e l p , he

u s e d h i s own f e e l i n g s and r e a c t i o n s t o f o r m u l a t e t h e p l a n he w a n te d .

P e r h a p s h i s f e e l i n g t h a t he h a d p l a y e d a p a r t i n t h e

m o ld in g o f t h e s e p l a n s w i l l make h i s a d j u s t m e n t i n t h e l i v i n g s itu a tio n e a sie r.

CHAPTER IV WARD INVOLVEMENT AND VALIDITY OF THE PLAN OF WARD OFFICE HOURS WARD INVOLVEMENT The P h y s i c i a n .

The w e e k ly c o n f e r e n c e s o f t h e s o c i a l

s e r v i c e s u p e r v i s o r , an d s o c i a l w o rk e r w i t h t h e w ard p h y s i c i a n w e re an i n t e g r a l p a r t o f t h e p r o f e s s i o n a l p e r f o r m a n c e o f t h e s o c i a l w o rk e r on t h e w a r d .

The p r i n c i p a l c o n t e n t o f a l l f i r s t

i n t e r v i e w s w i t h p a t i e n t s was d i s c u s s e d . w ere r e f e r r e d t o t h e p h y s i c i a n .

S o m a tic c o m p l a i n t s

C o n s i d e r a t i o n w as g iv e n t o

t h e p a t i e n t s who i n d i c a t e d a d e s i r e t o u s e t h e s o c i a l w o r k e r fs s e r v i c e s t o g e t h e r w i t h some e v a l u a t i o n o f t h e i r a b i l i t y t o b e h elp ed .

Where p a t i e n t s w ere b e i n g s e e n w e e k ly , t h e w o rk e r

s h a r e d h e r i m p r e s s i o n o f a p a t i e n t ' s movement i n t h e ca sew o rk in te rv ie w s.

T h i s was t a k e n i n t o c o n s i d e r a t i o n by t h e w ard

p h y s ic ia n to d e te rm in e a p a t i e n t 's r e a d in e s s to le a v e th e hos­ p i t a l o r a b i l i t y t o move t o an open w a r d .

What h o s p i t a l s e r ­

v i c e s c o u l d c o n t r i b u t e t h e m o st t o t h e p r o g r e s s o f p a r t i c u l a r p a t i e n t s w ere a l s o d i s c u s s e d t o g e t h e r w i t h a g r e e m e n t on a p l a n f o r t h e s o c i a l w o rk e r an d p h y s i c i a n t o h e l p b r i n g a b o u t t h e u t i l i z a t i o n of th e se s e rv ic e s .

I n r e a l i t y , t h e w o rk in g t o ­

g e t h e r w i t h a p a r t i c u l a r g ro u p o f p a t i e n t s p r o v i d e d a means f o r t h e i n t e g r a t i o n o f s o c i a l s e r v i c e w i t h w ard m e d ic a l s e r ­ v ic e .

42 The A t t e n d a n t .

A lth o u g h i t was n o t f u l l y f o r e s e e n a t

t h e i n i t i a t i o n o f t h e p r o j e c t , t h e c h a rg e a t t e n d a n t on t h e w ard became an i m p o r t a n t l i n k b e tw e e n t h e s o c i a l w o r k e r an d th e p a t i e n t s .

As new p a t i e n t s came on t h e w a rd , t h e c h a r g e

a t t e n d a n t t o l d them o f t h e w e e k ly a v a i l a b i l i t y o f t h e s o c i a l w o rk e r and g av e some i n t e r p r e t a t i o n o f h e r f u n c t i o n and t h e a r e a s w h ere s h e m ig h t be h e l p f u l . When t h e s o c i a l w o r k e r was w o rk in g w i t h o n e p a t i e n t who was g e t t i n g r e a d y t o l e a v e t h e h o s p i t a l , t h e c h a r g e a t t e n ­ d a n t was a b l e t o h e l p .

S in c e t h e p a t i e n t h ad no f r i e n d s o r

r e l a t i v e s o u t s i d e t h e h o s p i t a l w i t h whom he c o u ld v i s i t o r l i v e , t h e s o c i a l w o rk e r a n d w ard p h y s i c i a n f e l t t h a t t h e e x ­ p e r i e n c e o f l i v i n g on an o pen w a rd w ould be h e l p f u l t o him a s a p re p a ra to ry ste p to liv in g o u ts id e th e h o s p ita l.

The p a ­

t i e n t r e s i s t e d t h e i d e a o f t r a n s f e r b e c a u s e he f e l t more s e ­ c u r e on t h e w ard w here he h ad l i v e d f o r t h e p e r i o d o f h i s h o sp ita liz a tio n .

He was aw a re t h a t r e s i d e n c e on a n o p en w ard

was n o t a lw a y s a n e c e s s a r y c o n d i t i o n f o r l e a v i n g t h e h o s p i t a l . I n a d i s c u s s i o n w i t h t h e c h a r g e a t t e n d a n t , who was aw a re o f t h e p a t i e n t s r e s i s t a n c e , t h e s o c i a l w o rk e r e x p l a i n e d t h e r e a s o n s f o r t h e open w ard t r a n s f e r .

The c h a r g e a t t e n d a n t

t h e n h e l p e d t h e p a t i e n t who was a b l e t o a c c e p t t h e move t o an o p en w a rd .

43 The P a t i e n t s .

As t h e p a t i e n t s on t h e w ard became a c ­

q u a in te d w ith th e s o c i a l w o rk er, t h e i r g e n e r a l f e e l i n g to n e to w a r d h e r became f r i e n d l y and i n t e r e s t e d .

E ach week a t l e a s t

one p a t i e n t who had b e e n s e e n p r e v i o u s l y w a n te d t o t e l l some­ t h i n g t h a t had h a p p e n e d , u s u a l l y i n r e l a t i o n t o t h e c o n t e n t o f t h e i n t e r v i e w o f t h e p r e v i o u s w eek. I t i s p r o b a b l e t h a t t h e s o c i a l w o r k e r ’ s g o in g r e g u l a r ­ l y t o t h e w ard had m eaning f o r t h o s e who d i d n o t u s e h e r f o r in d iv id u a l c o n s u lta tio n .

The s o c i a l w o rk e r came on t h e w ard

to w a r d t h e end o f t h e l u n c h h o u r a s some o f t h e p a t i e n t s w ere g r o u p e d t o r e t u r n t o t h e i r d e t a i l j o b s o f f t h e w a rd .

Many o f

t h e p a t i e n t s who had n o t a v a i l e d t h e m s e l v e s o f t h e s e r v i c e s o f t h e s o c i a l w o rk e r re m a rk e d tfh e r e Ts t h e s o c i a l w o r k e r 11 o r m et h e r w i t h a g r e e t i n g .

Betw een i n t e r v i e w s on t h e w a rd , i f

t h e a t t e n d a n t was n o t a v a i l a b l e t o f i n d a p a t i e n t h a v in g an ap p o in tm e n t, s e v e r a l p a t i e n t s v o lu n te e r e d t o h e lp .

The g e n ­

e r a l i m p r e s s i o n was t h a t t h e s o c i a l w o rk e r had become p a r t o f t h e w ard f a m i l y — a n o t h e r h e l p i n g p e r s o n . VALIDITY OF THE PLAN OF WARD OFFICE HOURS To d e t e r m i n e t h e v a l i d i t y o f t h e p l a n o f s o c i a l s e r ­ v i c e o f f i c e h o u r s on t h e w ard w ould seem t o depend upon two fa c to rs:

f i r s t , t h e num ber o f p e o p l e who w ere h e l p e d ; s e ­

c o n d l y , w h e t h e r o r n o t t h i s a l lo w e d f o r t h e a p p r o p r i a t e u s e

kk o f t h e s o c i a l w o r k e r w i t h h e r p a r t i c u l a r com petence* O f t h e t o t a l num ber o f 30 p a t i e n t s i n c l u d e d i n t h i s s t u d y , from t h e f i n d i n g s , i t w e re h e l p e d i n some way.

can be s a i d t h a t 20 p a t i e n t s

(S ee T a b le I ) .

On t h e b a s i s o f t h e c a s e m a t e r i a l , * p o s i t i v e ch an ge o r r e s u l t s o f t h e w o r k e r f s a c t i v i t y c o u ld be a s c e r t a i n e d o n ly by t h e d e v e lo p m e n t, p r o g r e s s an d chan ge i n t h e p a t i e n t s i n t e r m s o f a p p e a r a n c e , p e r f o r m a n c e , c o n t e n t o f i n t e r v i e w s and r e l a t i o n ­ sh ip w ith o th e r s .

T h e re was no a p p a r e n t ch a n g e i n any o f t h e

s i x p a t i e n t s i n t h e g ro u p w h ere r e l a t i o n t o r e a l i t y was p o o r . I t can be s a i d t h a t a l l o f t h e p a t i e n t s w i t h whom h o s p i t a l r e g u l a t i o n s an d p r o c e d u r e s w ere c o n s i d e r e d w ere h e l p e d i n v a r y in g d e g r e e s , p ro b a b ly a c c o rd in g to t h e i r n e e d .

Of th e f i v e

p a t i e n t s w i t h whom p ro b le m s o u t s i d e t h e h o s p i t a l w ere c o n s i d ­ e r e d , two l e f t t h e h o s p i t a l s h o r t l y a f t e r t h e f i r s t i n t e r v i e w . S i n c e a t l e a s t one s u b s e q u e n t i n t e r v i e w had b e e n p l a n n e d , i t was n o t p o s s i b l e t o e v a l u a t e t h e h e l p f u l n e s s o f t h e s o c i a l w o rk er.

I n c l u d i n g t h e two p a t i e n t s who w ere a s s i s t e d i n p l a n ­

n i n g to w a r d l e a v i n g t h e h o s p i t a l and t h e o n e p a t i e n t who was h e lp e d in u sin g th e h o s p i t a l c o n s tr u c tiv e ly , i t i s t h e r e f o r e p o s s i b l e t o assum e t h a t 2 0 o f t h e 3 0 p a t i e n t s w ere h e l p e d by t h e c o n t a c t t h e y had w i t h t h e s o c i a l w o r k e r . A l l b u t one o f t h e 30 p a t i e n t s b r o u g h t t o t h e s o c i a l w o rk e r w h at r i g h t f u l l y b e l o n g e d i n h e r a r e a o f f u n c t i o n .

Even

45

TABLE

I

AREAS OF SOCIAL SERVICE TO PATIENTS ON A LOCKED WARD AT NORWALK STATE HOSPITAL FOR THE PERIOD 1 1 - 2 2 - 4 9 TO 1 - 3 1 - 5 0

H elp by S o c i a l W orker i n R e l a t i o n t o P ro b le m s o f P a t i e n t s

Number S een

Number H elp e d

30

20

P o in t o f c o n ta c t f o r p u rp o se fu l i n t e r r a c t i o n d i f f i c u l t to e s­ ta b lis h because o f p a t i e n t s 1 poor r e l a t i o n to r e a l i t y

6

0

A tte m p ts t o p o i n t up r e a l i t y f a c ­ t o r s w ith p a t i e n t s u n ab le to ac ce p t t h e i r need f o r h o s p i t a l­ iz a tio n

2

0

C o n s id e ra tio n o f h o s p it a l re g u la ­ t i o n s an d p r o c e d u r e s a s th e y a ffe c te d th e p a t i e n t s ’ d a ily l i v i n g i n and l e a v i n g t h e h o s ­ p ita l

14

14

C o n s i d e r a t i o n o f p r o b le m s o u t s i d e th e h o s p ita l

5

3

Help i n c o n s t r u c t i v e u s e o f h o s ­ p ita liz a tio n

1

1

A s s i s t a n c e i n p l a n n i n g to w a rd le a v in g th e h o s p ita l

2

2

TOTAL

46 t h e p a t i e n t s who had p o o r r e l a t i o n t o r e a l i t y had p ro b le m s w i t h w h ich t h e s o c i a l w o rk e r m ig h t h av e h e l p e d h a d t h e y b ee n in b e t t e r re m issio n .

In d ic a tio n o f th e in t e r e s t in th e s e r ­

v i c e a v a i l a b l e was g a u g e d by t h e p a t i e n t s 1 r e s p o n s e t o m aking w e e k ly a p p o i n t m e n t s w i t h t h e a t t e n d a n t . The number o f p a t i e n t s h e l p e d on t h e w ard d u r i n g t h i s p e r i o d o f t i m e , t h e a p p r o p r i a t e u s e o f t h e s o c i a l w o r k e r an d th e g e n e ra l response to h er a v a i l a b i l i t y — a l l in d ic a te d th a t s e r v i c e b e i n g made a v a i l a b l e i n t h i s way was v a l i d .

T h e r e w ere

many i n d i c a t i o n s t h a t t h e s o c i a l w o r k e r ’ s w o rk in g t o g e t h e r w i t h t h e w ard p h y s i c i a n an d w ard c h a r g e a t t e n d a n t a l l o w e d f o r t h e i n t e g r a t i o n o f s o c i a l s e r v i c e a s p a r t o f t h e w a r d te a m i n t e r ­ e s t e d i n a n d w o rk in g to w a r d t h e r e t u r n o f t h e p a t i e n t s t o t h e com m unity.

CHAPTER

V

SUMMARY AND CONCLUSIONS T h i s s t u d y i n d i c a t e d t h e many w ays t h a t s o c i a l s e r v i c e can b e u t i l i z e d on a l o c k e d w ard i n a s t a t e m e n ta l h o s p i t a l when p a t i e n t s h av e r e f e r r e d t h e m s e l v e s o r a r e r e f e r r e d by t h e w ard p h y s i c i a n .

The s t u d y i n d i c a t e d t h e k i n d s o f p a t i e n t s

n e e d i n g an d w a n tin g t o u s e t h e s e r v i c e t o g e t h e r w i t h some e v a l u a t i o n o f w h ere t h e s e r v i c e was h e l p f u l .

T h is e v a lu a tio n

has been concerned w ith th e p a t i e n t s ’ r e s u l t a n t a c t i v i t y . I t was s i g n i f i c a n t t h a t 20 o f t h e 30 p a t i e n t s who w ere s e e n by t h e s o c i a l w o r k e r made u s e o f t h e s e r v i c e o f f e r e d . A lth o u g h t h e p r i n c i p a l c o n t e n t o f t h e i n t e r v i e w s was t h e b a s i s f o r t h e d i v i s i o n . o f t h e s e p a t i e n t s i n t o g r o u p s , i t s h o u ld be p o i n t e d o u t t h a t t h e aim o f t h e s o c i a l w o r k e r was t o h e l p t h e p a t i e n t w i t h h i s p ro b le m i n o r d e r t h a t he m ig h t make c o n s t r u c ­ t i v e use o f th e h o s p i t a l i z a t i o n . A p o s i t i v e n e e d p o i n t e d up i n t h e i n t e r v i e w s was c o n ­ c e r n a b o u t h o s p i t a l r e g u l a t i o n s an d p r o c e d u r e s .

A d m iss io n t o

a s t a t e m e n ta l h o s p i t a l c o n f r o n ts th e p a t i e n t w ith a d a i l y l i f e p la n n e d d i f f e r e n t l y f r o m w h a t he e x p e r i e n c e d on t h e o u t s i d e . I t seems v a l i d t h a t he s h o u ld know w hat he can e x p e c t fro m t h e h o s p i t a l an d w h at t h e h o s p i t a l e x p e c t s o f him .

S in c e t h e new

a p p r o a c h t o t r e a t m e n t c o n s i d e r s t h e p a t i e n t a s an i n d i v i d u a l i n r e l a t i o n t o h i s e n v i r o n m e n t, i t w ould seem a p p r o p r i a t e f o r

a s o c i a l w o rk e r t o s e e t h e p a t i e n t upon a d m i s s i o n f o r t h e p u rp o se o f c o n s id e r in g th e e n v iro n m e n ta l a s p e c t s o f h o s p i t a l ­ iz a tio n * T h i s s t u d y a l s o p o i n t e d up t h e v a l u e o f t h e i n t e g r a t i o n o f s o c i a l s e r v i c e w i t h w ard m e d ic a l s e r v i c e a n d t h e s e r v i c e o f t h e ward a t t e n d a n t p e r s o n n e l .

The w e e k ly c o n f e r e n c e s w i t h t h e

w ard p h y s i c i a n w ere an i n t e g r a l p a r t o f t h e s o c i a l s e r v i c e p e r f o r m a n c e on t h e w a rd .

S in c e t h e w ard p h y s i c i a n was n o t

aw a re o f t h e s o c i a l w o r k e r ’ s a c t i v i t y w i t h a p a t i e n t u n t i l a f ­ t e r t h e i n t e r v i e w , i t i s p o s s i b l e t h a t more p u r p o s e f u l u s e o f t h e s o c i a l w o rk e r c o u ld h a v e b e e n made by some s c r e e n i n g p r o ­ c e s s by t h e p h y s i c i a n p r i o r t o t h e i n t e r v i e w .

I t seems e s s e n ­

t i a l t h a t w ard a t t e n d a n t p e r s o n n e l u n d e r s t a n d t h e f u n c t i o n o f t h e s o c i a l w o rk e r an d know w hat t h e S o c i a l S e r v i c e D e p a rtm e n t ca n d o .

S in c e a t t e n d a n t s a r e w i t h t h e p a t i e n t s more t h a n any

o th e r h o s p ita l p e rso n n e l, th e y a re in a p o s itio n to a s s i s t in r e f e r r i n g th e p a t i e n t f o r h e lp . I n a d d i t i o n t o e m p h a s is on t h e u s e a n d n e e d o f c o n c r e t e s e r v i c e s , t h i s s t u d y a l s o p o i n t e d up ways t h a t p a t i e n t s can be h e l p e d t h r o u g h a c o n t i n u o u s ca sew o rk r e l a t i o n s h i p u n t i l t h e y a re a b le to le a v e th e h o s p it a l.

F u r th e r stu d y and p u b lic a t io n

o f t h e s o c i a l w o r k e r ’ s c o n t r i b u t i o n t o t h e o v e r a l l c a r e and t r e a t m e n t o f t h e p a t i e n t w ould be h e l p f u l i n a t t a i n i n g b e t t e r in t e g r a t i o n o f s o c i a l s e r v ic e w ith o th e r c l i n i c a l s e r v ic e s in

49 th e h o s p ita l s e ttin g * E v e r y t h i n g m ust b e d o ne t o h e l p t h e p a t i e n t r e t u r n t o t h e community*

A c o n s t r u c t i v e h o s p i t a l e x p e rie n c e n o t o n ly

h a s t e n s r e c o v e r y b u t s t r e n g t h e n s t h e p a t i e n t t o assum e h i s r o l e in th e o u ts id e w o rld .

W ith s t a t e m e n ta l h o s p i t a l s t o ­

day f a c e d w i t h an o f t e n o v e rw h e lm in g h o s p i t a l p o p u l a t i o n , t h e w o rk in g t o g e t h e r o f t h e p r o f e s s i o n a l d i s c i p l i n e s on t h e S t a f f becom es a n e c e s s i t y .

C asew ork s e r v i c e s o f a m e a n i n g f u l and

c o n s t r u c t i v e n a t u r e make a v a l i d c o n t r i b u t i o n t o t h e o v e r a l l tre a tm e n t o f th e p a t ie n t .

BIBLIOGRAPHY

BIBLIOGRAPHY A.

BOOKS

D e u ts c h , A l b e r t , The M e n t a l l y 111 i n A m e ric a . D o u b le d a y , D oran and Company, I n c . , 1 9 3 3 . F r e n c h , L o i s M e r e d i t h , P s y c h i a t r i c S o c i a l Work. The Commonwealth F und, 1940* 293 PP*

New Y o rk : 496 p p . New Y ork :

S t e r n , E d i t h M ., M e n ta l I l l n e s s : A G u id e f o r t h e F a m i l y . New Y o rk: The Commonwealth Fund, 1945* 93 p p . W ard, Mary J a n e , The Snake P i t . 1 9 4 6 . 273 p p .

New Y ork:

P e t e r s , F r i t z , The W orld N ext D o o r. a n d Company, 1949* 3 6 2 p p .

Random H ouse,

New Y ork:

R i c h a r d s o n , Henry B ., P a t i e n t s Have F a m i l i e s . Commonwealth F u n d , 1945* 3C>7 p p . B.

F a rra r S tra u s New Y o rk :

The

PERIODICAL LITERATURE

D a r r a g h , H elen A ., ”The R o le o f S o c i a l S e r v i c e w i t h F a m i l i e s o f M e n ta l H o s p i t a l P a t i e n t s , ” S m ith C o l l e g e S t u d i e s i n So­ c i a l W ork. 1 3 : 1 3 7 - 3 3 , S e p te m b e r , 1 9 42 . D e W itt, H e n r i e t t a B . , f,The F u n c t i o n o f t h e S o c i a l W orker i n T o t a l T r e a tm e n t P ro g ra m i n a S t a t e M e n ta l H o s p i t a l , ” A m eri­ c a n J o u r n a l o f P s y c h i a t r y . 1 0 5 :2 9 3 - 3 0 4 , O c t o b e r , 1 9 4 3 . B atem an, J . F rem o nt and Dunham, H. W a rren , ”The S t a t e M e n ta l H o s p i t a l a s a S p e c i a l i z e d Community E x p e r i e n c e , ” A m erican J o u r n a l o f P s y c h i a t r y . 1 0 5 :4 4 5 - 4 3 , D ecem ber, 1 9 4 3 . C.

PARTS OF SERIES

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52 D.

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u n iv e r sity or Southern C alifornia Liorar.