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The principles of convalescent care for psychiatric patients—as demonstrated in a special group on leave from state mental hospitals

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THE PRINCIPLES OF CONVALESCENT CARE FOR PSYCHIATRIC PATIENTS— AS DEMONSTRATED IN A SPECIAL GROUP ON LEAVE FROM STATE MENTAL HOSPITALS

t

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

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

by Chauncey A . Alexander May 1950

UMI Number: EP66317

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.

UMI Dissertation Publishing

UMI EP66317 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 Arhnr, Ml 48106 -1346

T h is thesis} w r it t e n u n d e r the d ire c tio n o f the candidate’s F a c u lt y

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

by a l l its m embers, has been presented to and accepted by the F a c u lt y o f the G ra d u a te S ch o o l o f S o c ia l W o r k in p a r t i a l f u lf il m e n t o f the re­ quirem ents f o r the degree o f

MASTER OF SOCIAL WORK

Dean

D a ti

T h e s is o f. ...P.HAUNCET.A

*. AI^E^NDER

F a c u lty C o m m itte e

ase Chairm an

TABLE OF CONTENTS *

CHAPTER I.

PAGE

INTRODUCTION

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

1

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

2

The problem

Statement of the problem

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

2

Importance of the study

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

3

The setting for the study

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

4

Definition of terms Plan of study

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

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

Kinds of data collected

II.

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

7 11 14

Source of d a t e ..................

15

Selection of c a s e s .......................

16

Outline of chapters

20

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

THE PHILOSOPHY AND PRINCIPLES OF CONVALESCENT CARE

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

21

Convalescent care— integral phase of the • total treatment process Summary

........

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

21 31

Emerging principles of convalescent care in California

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

32

The initiation of a community-centered service, 1939-1943

36

Convalescent care— experimentation and consolidation, 1943-1946

45

iv CHAPTER

PAGE Convalescent care— an essential service, 1946-1943

. . ........

52

Convalescent care— an integrated and differentiated service, 1943-1950 Summary III.

...

..........

...

53

. . . . . . . . .

63

PRESENTATION OF D A T A ...................

66

Characteristics of exclusive leave patients

........

. . . . . .

..........

66

Observable factors influential at point of l e a v e ...........................

71

Patientfs leave activity in relation to the Bureau of Social Work

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

74

Observable factors indicative of leave a d j u s t m e n t .........................

77

IV. CONSISTENCY OF EXCLUSIVE LEAVE ACTIVITIES AND CONVALESCENT *CARE PRINCIPLES

..........

31

Are exclusive leave patients an appropriate group for convalescent care service

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

. . .

Convalescent care principles in relation to patients1 activities at the point of l e a v e ........................... Convalescent care principles in relation to patients1 leave activity with

34

32

V

CHAPTER

PAGE Bureau of Social Work

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

$9

Convalescent care principles in relation to leave adjustment activities V.

SUMMARY AND CONCLUSIONS

..........

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

93 97

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

103

A P P E N D I X ...............................

109

L IS T OF TABLES

TABLE I.

PAGE Distribution of Exclusive Leave Patients by Age G r o u p s .............................

II.

Distribution of Exclusive Leave Patients by Number of Children

III.

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

68

Distribution of Exclusive Leave Patients by Grade L e v e l s ...........................

IV.

67

68

Distribution of Exclusive Leave Patients by Periods of State Residence

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

70

V. Distribution of Exclusive Leave Patients by Type of Psychiatric Diagnosis VI.

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

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

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

112

115

Patient’s Leave Activity in Relation to Bureau of Social Work

XII.

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

Observable Factors Influential at Point of Leave

XI.

110

Compilation of Characteristics of Exclusive Leave Patients

X.

78

Characterististics of Exclusive Leave Patients

IX.

76

Distribution of Exclusive Leave Patients by Time Period Since Last C o n t a c t ........

VIII.

71

Requests of Exclusive Leave Patients at Point of Leave

VII.

.........



Compilation of Patient’s Leave Activity in

116

vii TABLE

PAGE Relation to the Bureau of Social Work

XIII•

. . ♦

124

Observable Factors Indicative of Leave Adjustment

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

125

CHAPTER I

INTRODUCTION Mental illness is America’s number one public health problem*

Reliable estimates indicate that over one-half of

the hospital beds in the United States are occupied by mental patients*

It is predicted that one out of every

eighteen persons ($,334>OQO Americans) \tfill spend some part of his life in a mental hospital. Today, 97*7 per cent of all mental patients are in public hospitals; 34*2 per cent in state hospitals*^

This

fact reveals that care of the mentally ill is seen by the community as a charge upon the state governmental system. In the United States, a philosophy regarding the treatment of the mentally ill is emerging which may be termed the. concept of the tttotal treatment process.11 Having as its basic goal the maximum functioning of the individual in the community, the total treatment process now encompasses a wide range of services available in a great variety of forms and degrees of development* Community education and preventive services are in their infancy, treatment and hospitalization facilities are "Mental Health In America,M Southern California Society for Mental Hygiene, Los Angeles, (mimeographed), February, 1950, p. 1.

2 taking on the beginning stability of early adulthood, while convalescence and social readjustment are shaking off the upheavals of adolescence. Underlying this philosophy, and evident in the fluctuations of the mental health movement, is the deepening democratic awareness of the community’s responsibility for its sick members* I.

THE PROBLEM

Statement of the problem*

A vital aspect of the

total treatment process for the mentally ill occurs when hospitalization eventuates in re-entrance to the community. The problem of readjustment precipitated by this change requires the judicious use of all available re­ sources*

Most immediate of these are individual resources

(relatives, friends, employers) or society-directed re­ sources (social agencies, family care and work placements, etc.) that will accept responsibility for some part in the patient’s readjustment. Responsibility for offering and supervising the program for readjustment has been delegated by the community to trained social workers*

This program is historically

designated as aftercare or parole; is presently referred to Ni

as convalescent care; and in California is officially termed extramural care.

This program, like all other phases in treatment of the mentally ill, has had a stormy and uneven development, pushed and pulled by the pressures and sentiments of the times*

Although becoming an integral part of the total

treatment process, the program still has its own distinct story of growth and change in which it can be seen to be moving toward a clearer definition of its own boundaries and effectiveness. Part of this inquiry will examine the program of convalescent care in California in order to arrive at a formulation of the principles under which it operates.

A

special group of psychiatric patients who are bridging the gap between hospitalization and an independent life are examined for demonstration of these principles. In the examination this study proposes to answer these questions:

l$hat are the characteristics of this

special group of patients and their activities within the convalescent care program?

In what way is the activity of

this group consistent with the defined principles of convalescent care? Importance of the study.

A segment of the convales­

cent care program has been selected that is particularly challenging to the theory and practices of community readjustment of the mentally ill.

In our highly industrialized and competitive society the personal and group relationships of masses of people are often subjected to extreme strains and pressures.

As a

result, the efforts of an individual*— particularly one who is seriously disadvantaged— to achieve or maintain a responsible role may be temporarily blocked or even completely frustrated* The fact of hospitalization for a mental illness, with its stigma rooted in superstition and ignorance, often severs whatever personal or group ties a sick person might have had.

It frequently happens also that the associates of

a mentally ill individual were themselves significant factors in the pathogenic process and continue to act as obstacles to readjustment. A group of patients exists whose status sharply highlights the above problem of readjustment.

Such are

patients whose recovery permits them to leave the state mental hospitals, but who do not have the usual community ties.

Selection of such a group isolates a special problem

for a program of convalescent care. II.

THE SETTING FOE THE STUDY

In the State of California, the State Department of Mental Hygiene has historically been vested by the community with 11jurisdiction over the execution of the laws relating

5 to the care, custody, and treatment of the insane, alleged insane or mentally ill persons, feeble-minded persons, epileptics, idiots and other incompetent persons, . . .2 The Bureau of Social Work i3 a part of the State Department of Mental Hygiene, with its Administrative Office located in Sacramento, and headed by the Supervisor of Extra-Mural Care.

There are two Regional Offices located in

Los Angeles and San Francisco with branch offices respon­ sible to the regional offices.

In the Southern Area there

are sub-regional offices in Santa Barbara and San Diego. The official manual states that: The Bureau of Social Work (hereafter referred to as ,fBureauw ) is responsible for all Social Services to hospital-patients under the jurisdiction of the State Department of Mental Hygiene except those given by resident workers. Resident Workers are those who work in the hospital with the patients and their families, and who act as liaison between the hospital and the Bureau. These workers are on hospital payroll, and are responsible to the Medical Superintendent. Co-ordina­ tion of the resident program and the Bureau program is provided by the Casework Supervisors of the Bureau. The Bureau workers are those who work out of the Regional and Sub-Regional Offices, and are on the pay­ roll of the Bureau. Their.first regular contact with patients and families in Los Angeles County, is at the point of commitment when they .are responsible for helping the family with the problems arising out of the hospitalization of the patient and for obtaining a social history from them. In other counties, social ^ Welfare and Institutions Code X and Laws Relating to Social Welfare« State of California, Printing Division TDocuments Section), Sacramento, California, 1947, Part 5, Section 7500, p. 271*

6

histories are not routinely taken, but are secured by Bureau workers when requested by the medical staff. While patients are in the hospital, the Bureau workers are called upon when the doctor or resident social worker, in consultation with the doctor, has any special request requiring contact in the community. This includes request for evaluating the home situation to which a patient would return on leave-of-absence, for working out work leave placement or plans for Family Care placement. When patients escape from the hospital, the Bureau worker may be called upon to give assistance in the return of the patient. When patients go on indefinite leave of absences to a responsible person or agency, to work leave or to Family Care, they automatically become the responsibil­ ity of the Bureau for supervision and case work service. The Bureau workers are also responsible for facili­ tating return of patients to the hospital when neces­ sary, and have responsibility for getting to the hospi­ tal the information on which decision for discharge or other change of plan can be made. In some instances, where there are no responsible relatives or friends to assume supervision of the patient on leave-of-absence, the patient is released to the Bureau of Social Work. The work is co-ordinated with the hospital program and there is close contact and frequent consultation with the resident worker and the medical staff. The Regional and Sub-Regional offices are responsible for working with the community in relation to community problems which may arise due to the presence of our patients in the community. The workers give service to former patients in relation to change of status or referral to other community agencies. They are also called upon to give advice and referral service to individuals who seek help regarding emotional and social problems, or information about the Department of Mental Hygiene, commitment procedure, or psychiatric resources.3

^ Manual of the Los Angeles Regional Office, Bureau of Social Work, Department of Mental Hygiene, State of California,, (unpublished, unpaged).

7 As can be seen, the Bureau of Social Work has varying responsibilities for different phases of the total treatment process for the mentally ill.

These may include:

informa­

tional and community education functions, initial historytaking upon commitment, pre-leave investigations or services to relatives during a patient’s hospitalization, and the major activity— supervision during leave of absence. III. The Bureau.

DEFINITION OF TERMS

The Bureau refers to the Bureau of

Social Work, Los Angeles Office, Department of Mental Hygiene, State of California. The hospitals.

The hospitals refers to the three

mental hospitals in the Southern Region— Camarillo, Norwalk, and Patton. Commitment.

Commitment is the legal process by which

persons judged to be mentally ill or mentally deficient and/or in need of care and treatment are admitted to the State Hospitals.

Commitment is through the Superior Court

or through the local Health Officer. Definite Leave-of-Absence.

The release of a hospi­

talized patient for a definite or stated period of time. Indefinite Leave-of-Absence.

The release of a

6 patient from the hospital to a responsible person or agency, for an indefinite period, usually a year.

Approval of the

Medical Staff is necessary, and the hospital continues responsibility for the patient through the Bureau of Social Work until the patient is discharged or needs to be returned to the hospital.< Leave of Absence Agreement.

The form signed by a

responsible person or agency to whom the patient is being released for an indefinite period.

Signing this form is an

assumption of responsibility for welfare of the patient, and for return of the patient to the hospital if necessary. Discharge.

The legal termination of hospitalization

either at the time that the patient leaves the hospital or at the end' of an" indefinite Leave-of-Absence. Escape.

The official status of a patient absent

from a*State' Hospital without approval of the Medical Staff. This status also applies to patients on Leave-of-Absence whose whereabouts are unknown and who may be a potential danger to themselves or others. Work Leave Placement.

A therapeutic work plan in a

protected environment for patients who are not yet ready to adjust in the competitive living outside an institution. The patient works for his room, board, and a small salary,

usually in a sanitarium, hospital or private home.

Both

the employer and the patient are supervised by the Bureau. Family Care.

A therapeutic program for custodial

care of patients who do not require hospital medical care and can benefit from a more personal relationship and a homelike atmosphere.

These homes are licensed by the State

Department of Mental Hygiene for from one to six patients, on recommendation of the Bureau of Social Work.

The care­

taker is paid for services by the State Department of Mental Hygiene or other state sources, the patient, his family, or other private support; or some combination of these.

Both

the caretaker and the patient are supervised by the Bureau.^ Convalescent Care.

That phase of the total treatment

process for the mentally ill which is devoted to bridging the gap between hospitalization and an independent, selfresponsible life.

The term convalescent care is employed as

the modern designation for this program, because it is used in the definitive publications of the Group for the Advance­ ment of Psychiatry and is most adequately descriptive of the treatment aspect.

Aftercare is the historically accurate

term for this program, but does not capture the present

k The foregoing definitions were quoted verbatim from the Manual, ibid. the writer.

The following definitions were devised by

10 conception of an on-going treatment process.

Extramural

care is the legally and administratively accurate term for the program in the State of California, but is reflective of the hospital-centered conception of treatment of mentally ill. Exclusive leave responsibility#

A special term

devised by the writer for the purpose of distinguishing the special group of leave patients that are utilized in this study.

As previously indicated in the definitions and the

setting, the Bureau of Social Work, Los Angeles Office, has as its major function the supervisory responsibility for patients on leave from state mental hospitals.

This

responsibility, as a general rule, encompasses the res­ ponsibility also taken by individuals (family, friends, employers) or society-directed resources (family care homes, work placements, social agencies).

This latter responsi­

bility taken by individuals for themselves or a group is formalized through signing a leave-of-absence agreement. However, that group of patients examined in this study, defined officially as those who have "no responsible rela­ tives or friends to assume supervision of the patient on leave of absence,"5 are those in which the Bureau assumes

5 Ibid

11 exclusive leave responsibility, and for whom no other individual or community resource has assumed any responsi­ bility.

This does not relieve the hospitals from their

legal responsibility for the patients on leave, since the Bureau of Social Work is acting as the extension or repre­ sentative in the community at present* IV.

PLAN OF STUDY

In order to determine in what way the leave activi­ ties of exclusive leave patients are consistent with the principle of the agency, it was necessary to formulate the present philosophy of convalescent care and to define its principles as operative within the Department of Mental Hygiene. However, in an area of service whose development has been so recent and which is in the process of definition and expansion, a special problem exists.

That problem is

one of viewing this group of patients in terms of an emerging and partly undifferentiated service.

Viewed at

any point of operation the service is in process of change. This requires giving consideration to the trends and influences which have shaped that operation and are determ­ ining its future direction. Part of this problem is due to the recent geometrical growth of the mental health movement in all its facets and

12 with its stress on community responsibility for the treat­ ment of the mentally ill. Then too, with convalescent care a community readjust­ ment program, another influence has been that of the social work profession.

In execution its development has paral­

leled the development of the speciality of psychiatric social work.

In this respect the present status of the

social work profession, with its increasing self examination of its area of competence, adds both complication and insight. For these reasons examination of the literature provided a perspective for understanding the present conception of convalescent care as part of a total treatment process for the mentally ill. In California the convalescent care program has developed as a social work program functioning within certain medical limits.

Here the problem of growth and

change is immediately evident.

The pioneering aspects of

the program; the pressure of need in an expanding popula­ tion; the definition and differentiation of social work practice create a kaleidoscopic picture affecting the program of which it is part. It was therefore necessary to determine the emerging and established principles of convalescent care within the Bureau of Social Work.

Such a determination required a

13 review of all available written material concerning the policies and discussions of practices which delineates the present conditions and direction of the convalescent care program.

The Departmentfs Circular Letters, Minutes of

Superintendent’s Conferences, official publications and reports were reviewed in order tq document the definition of these principles. The next major step was to examine specifically the group of exclusive leave patients and their experiences within the program.

For this purpose the entire group

(a total of twenty-eight) who were on indefinite leave of absence on January 7, 1950, and continued in this status through March 7, 1950, were examined.

For procedures used

in selection of the group see the following section, page 16.

For the kinds of data collected, see Chapter III,

page 66. Finally, the experiences of the special group of exclusive leave patients were then related to, or compared with, the philosophy and principles of convalescent care operative in the Bureau of Social Work in order to determine if their activity was consistent with the purpose of the total program. The following quotations from an article on the problem in this type of research by Helen Witmer seems to support this approach:

14 . . . It follows, then, that a major task in research in Social Work is to collect the current concepts and principles and to make their theoretical background and relationships clear. Such research would no sooner be under way than a multitude of questions would come to light that could form the basis for many smaller and more detailed investigations. . . . What I do mean is that in the present state of the profession those who undertake research must be prepared to give more attention to formulating their problems and discovering out of what they arise than do workers in other professions.^ This study does not propose to evaluate the program of convalescent care in the Bureau of Social Work, or to judge its effectiveness for this group of exclusive leave patients.

Such a study would involve a different approach

with considerations of number of personnel, quality of practice, etc.

In some sense this study might form the

basis for such further studies, giving clues as to priori­ ties, areas for investigation, etc.

It does propose to

focus on the experiences of a group of patients in such a way as to reveal in what way that group’s activities are

'

consistent with the purpose of the program. Kinds of data collected.

In order to ascertain the

general characteristics of this group of patients and the kinds of experiences in which they were involved the 6 Helen Leland Witmer, ’’Basic Conceptions in Social Work Besearch,” Mental Hygiene.. Vol. XXXIII, No. 1, January, 1949,~p* 111#

15 twenty-eight case records were examined to determine: 1*

The general characteristics of the individuals

making up the group of exclusive leave patients and charac­ teristics of their hospitalization* 2.

The observable factors at the point of leaving

the hospital which seem to be influential in their plan of leave* 3*

The patients’ leave activity in relation to the

Bureau of Social Work. 4.

The environmental activities and conditions

observable in the group after at least three months on leave of absence. Source of data*

The Bureau of Social Work, Los

Angeles Office, maintains a centralized file of all patients on indefinite leave of absence from the three state mental hospitals and the one state hospital for mental defectives located in Southern California.

The individual card,

alphabetically indexed by patient’s name, lists a minimum of facts necessary to distinguish individual cases.

It

was this card file that was used to locate the special group of patients who qualified for this study* After the group for study was ascertained, the individual case records on file in the bureau office were examined and appropriate data recorded*

16 ’ Selection of cases.

Every card in the indexed file,

a total of 3,363, was examined on January 7, 1950.

All

patients whose cards stated that they were on Leave to the Bureau of Social Work were listed as to name, date of leave, and assigned social worker.

In many instances this listing

was carried in the name of the hospital social worker.

A

total of ninety-six individual eases was noted* It became evident that there were a large number of these cases so listed that still did not qualify for inclusion in the group of exclusive leave responsibility patients defined for this study.

These included cases in

which the social worker signed the leave form as temporary fulfillment of the release procedure so that patients might be taken to families, family care homes, sanitarium place­ ments, etc., where other persons would subsequently sign the leave form.

The following groups did not qualify and

were excluded from the basic group for study: 1*

Patients on leave from Pacific Colony*

Since

this group of patients was made up of mental defectives and children with severe adjustment problems, it was evident that the circumstances of their commitments and their leaves would involve factors other than those of the adult mental patients.

Many would also be disqualified

because they were in boarding homes and industrial place-

17 ments.

Twenty-four (24) cases were thus eliminated, 2*

Patients on work leave placements.

This group

did not qualify for selection since the sanitariums have either a direct or implied supervisory responsibility for patients placed with them.

It was evident through examina­

tion of several case records that hospital social workers may have signed the leave forms temporarily until another could be signed by the sanitarium manager.

In some instan­

ces it seemed indicated that it was thought desirable for social workers to maintain complete responsibility.

But

the point was not clearcut and the reason for the placement seemed to be to obtain a closer and more continuous super­ vision than the bureau alone could offer.

A total of

fourteen (14) cases were eliminated. 3.

Patients on leave in family care homes.

group was comparable to the one above in that their place­ ment in family care homes was indicative of the degree or type of supervision which the hospitals felt was desirable for them.

Again, some investigation of case records

revealed that the signing of the leave form by the hospital social worker was a matter of convenience or expediency and did not involve the hospitalfs desire for a special single responsibility from the bureau. category were eliminated.

Fifteen (15) cases in this

This

13 4**

Patients on leave to relatives or friends.

Similar to the two groups above were several cases which were signed out by social workers but in which the patients had gone to live with friends or relatives as part of the leave plan.

This group appeared to take some leave res­

ponsibility so that they were not believed to qualify. Four (4) cases were eliminated, 5*

Children on leave.

Children’s cases which were

under the supervision of the hospital social worker did not qualify. 6*

Two (2) cases were eliminated, Leave cases carried in other regional offices.

Two (2) cases were listed as on leave to the Bureau of Social Work, although one was carried by the San Francisco office and the other by the San Diego office, 7,

Patient on leave to self.

One (1) patient was

released from a northern hospital, signed his own leave form, and went to live with a friend, thus being disquali­ fied. Patients discharged or returned to the hospital during present study period.

Since the concept of the

study required some evaluation of the aftercare period, involving the patient’s use of the Bureau and his present situation, it was necessary to set up a three month period

19 for this group in order to guarantee a minimum period of evaluation*

The patients who were in the process of dis­

charge, discharged, or returned to the hospital were not considered appropriate for this study.

A total of six (6)

patients were necessarily eliminated. A total of twenty-eight cases out of the ninety-six first listed were thus strictly qualified under the defini­ tion of the patient group for whom the Bureau of Social Work has exclusive leave responsibility. Each of these cases was examined and data obtained pertaining to four major areas of information thought pertinent to an analysis of convalescent care.

The follow­

ing four areas were examined and appropriate data compiled: 1. patients:

Characteristics of exclusive leave responsibility Sex, ethnic group, age, education, military

service, religion, occupation, marital status, number of children, state residence, period of hospitalization (dates of commitment and leave, previous commitments or leaves) and diagnosis. 2.

Observable factors influential at point of leave:

Initiation of leave, mental condition, bureau pre-leave help, personal leave help, finances at leaving, leave plan. 3*

Patient1s leave activity in relation to Bureau of

20

Social Work:

Time on leave, activity at leave, activity

during leave.

km ment:

Observable factors indicative of leave adjust­

Last contact, employment, education, social activi­

ties, emotional adjustment. Outline of chapters.

Chapter II presents a review

and analysis of the trends and influence which have contri­ buted to the present philosophy of convalescent care for the mentally ill in the United States.

It then examines

and documents in greater detail the trends and forces which have shaped the present principles of convalescent care for the mentally ill in California. Chapter III presents the findings of the examination of the special group under study— patients who were the exclusive leave responsibility of the Bureau of Social Work. .Chapter IV is devoted to relating the findings of this group to the present principles of convalescent care within the bureau and within the concept of the total treatment process. Chapter V presents a summary of the significant findings, conclusions to be drawn from those findings, implications of the conclusions and areas for future study.

CHAPTER I I

THE PHILOSOPHY AND PRINCIPLES OF CONVALESCENT CARE I.

CONVALESCENT C A R E -

INTEGRAL PHASE OF THE TOTAL TREATMENT PROCESS The story of aftercare— the convalescent care of the mentally ill in America— is yet to be told*

And in the

telling a parallel chapter productive of deep insights will be added to the chronicle of social welfare and medi­ cine in,this country— new revelations of man’s increasing responsibility for man. Inquiry into the history of our social welfare institutions and practices readily reveals the basic influence of the political, economic and social movements of successive periods.

The field of mental health sensi­

tively reflects the fluctuating temper of our citizens at various periods, while even a cursory examination of the specialized program of convalescent care readily demon­ strates the emerging philosophy of community responsibility for individual members. It is significant that the aftercare program in America, seventy years after its beginnings in Europe, was introduced coincidentally with the final clash of the rival systems of state and county care of the mentally ill.

It

22

is no accident that aftercare began at this time when the establishment of state care ,fundoubtedly marked one of the great milestones in the history of the treatment of mental illness in the United States, !tl

For aftercare was con­

ceived, born and raised in the growing belief in community responsibility for the mentally ill. Its initiation in institutions came with the great reform movements of the first decade of the Twentieth Century, formed the soil for nurturing an important part of the social work profession, and marked the beginnings of the collaboration between social workers and psychiatrists. When World War I focused attention on the treatment of nervous and mental diseases, it also motivated the sweeping mental hygiene movement of the 1920s*

The public

became sharply aware of the existence of mental hospitals and humane treatment of the mentally ill was demanded. Part of this demand was for the release of recovered patients from the hospitals and it was soon evident that effecting their social readjustment required special skills. A sweeping cognizance of the need for new develop­ ments in federal and state hospitals treating mental disease, and in mental hygiene departments and clinics, led to a growing demand for psychiatrists, schooled in the study and treatment of mental disorders and for social workers trained in psychiatric knowledge to meet and handle the social problem of the patient

^ Albert Deutsch, The Mentally 111 in America, (New Xork: The Columbia University Press, 1949), p. 271*

23 mentally ill*2 The social readjustment need of the mentally ill— reflected in the aftercare programs— formed the base of development of psychiatric social work.

As indicated by

French: It is well to emphasize these two main channels of psychiatric social work; which are closely related and yet distinct. One concerns the steady progress of social work with the hospitals and clinics for treatment and prevention of mental disease, the other the permea­ tion by psychiatry and mental hygiene of other fields.3 The poverty of integrated material on aftercare programs makes it necessary to obtain some clues to its major trends through the better recorded history of psy­ chiatric social work. With the economic depression of 1929 and the follow­ ing years of crisis, the state mental hospitals suffered the axe of'economy.

Although in one way it was possible to

recruit better personnel to the hospitals, it was difficult under the budgetary limitations that were imposed to provide programs that would raise the quality of care.

This

particularly applied to any programs which were not consi­ dered essential to an ”institutional-centered” custodial

2 Leona M. Hambrecht, !,Beyond a Decade,” The NewsLetter of the AAFSW. Vol. X, No. 2, Autumn, 1940, p. 7» 3 Lois Meredith French, Psychiatric Social Work, (New York: The Commonwealth Fund, 1940), p . -5*

24 program.

Aftercare, except' in a few states with indepen­

dent programs, became a matter of the interest of individual superintendents or a device for meeting clerical and opera­ tional needs. The following quotations from a review of psychiatric social work by Leona M. Hambrecht are indicative of this period: New needs, those concerned with unemployment and ”our starving millions in the midst of plenty” eclipsed the earlier focus on mental hygiene. . . . State and other public hospitals and clinics, although fortunate in having been maintained by the stable support of public funds under careful adminis­ tration, were likewise handicapped in securing substan­ tial allotments for new programs.4 ^ Affecting professional development of aftercare service was the exodus of the r e l a t i v e ^ small number of trained workers to other more lucrative or appreciated fields. It was these public welfare programs which were presently responsible for the series of shifts and realignments of personnel, which took place throughout the country, for the new services promptly attracted not only the young and inexperienced, but many seasoned people from the staffs of private casework agencies; and among the latter, no small number of psychiatric social workers in hospitals and clinics, who, like the rest, saw opportunity in the supervisory and consultant responsibilities which so quickly became available. • . . Psychiatric programs under public auspices such as state hospital clinics or social service departments proved equally unprepared for competition.5

Hambrecht, op. cit., pp. 8-9*

25 In these same public welfare programs were the elements of community interest and responsibility which were eventually to affect the problems of the mentally ill. For out of these reform and reconstruction movements came progressive government administrations more sensitive to the social needs of communities.

Publications such as

Deutsch's Mentally 111 in America, a rash of exposes, and increasing emphasis on environmental and social factors in mental illness contributed to the interest. At the same time, the field of psychiatry was devel­ oping new techniques of treatment, such as shock therapies, while dynamic psychology was in the ascendancy.

All of

these factors contributed to emphasis on social readjustment of the mentally ill.

Programs began springing up in state

hospitals, each having its own particular emphasis or direction.

In some it was family care, in others vocational

placement, in others a generalized movement of patients out of hospitals. It is important to indicate another trend which greatly influenced the integration of convalescent care (aftercare) as part of, or as an extension of, the hospital treatment process.

This was the professional and lay

interest in treatment and prevention which began to gain

5 Winifred W. Arrington, "Some Vocational Aspects of Psychiatric Social Work,” The News-Letter of the AAPSW, Vol. X, No. 3, Winter 1940-if1, p. 1.

26

ground about 1940.

The psychiatric social workers who were

working in convalescent phases of state hospital care began to become part of the initiation of treatment through the special function of history-taking or work in out-patient clinics. The result was the flourishing of convalescent care in the United States, moving toward a clearer definition of service and setting up the framework for future integration into a total treatment process.

Examination of literature

suggests that the characteristic of this period— the early 1940s— was that of a proving stage.

Most descriptions of

this service were devoted to demonstrations that it was a necessary and beneficial adjunct to hospital programs and that it was linked to the treatment process* When all is said and done, family care cannot but be considered as a success when judged from the angle of human values, and we certainly feel that this program has a definite place in the treatment of the mentally ill.® It was during this period, when convalescent care was being defined as an individual service, that what seemed to be two basic trends in the functioning of the program developed.

The following quotations give a clear indication

of this functional consideration.

6 Maysie T. Osborne, MThe Use of Family Care as a Treatment Procedure with the-.Mentally 111,” Mental Hygiene« July, 1943, p. 423.

27 The Psychiatric Social Worker is the long arm of the hospital physician reaching far into the community to protect and guide the patient until he is inured to fending for himself.7 I believe that the integration of the family care function into the state«ho3pital program marks the end of the pioneer era in this field and the beginning of an era in which sound professional development can take root. It is the point where social case work is able to separate from the psychiatric function and begin to exist in its own right.° In the first statement of Dr. Hamilton appeared the conception of the social worker as ”handmaiden of the physician,11 performing some part of the physicians function.

From this view, convalescent care was seen as an

extension of the function of medical treatment rather than a differentiated function of social readjustment. Miss DeWittfs statement presents the point of view that convalescent care, as a social work program within a state mental hospital system, has an individual and distinct function of its own.

It is concerned with aiding social and

community readjustment of the patient within medical limits set by the hospital.

This differentiation contributes to a

more realistic and purposeful integration of service.

In

7 Samuel W. Hamilton, M. D., ”The Mental Hospital in the Program of Mental Health,” Mental Hygiene. Vol. XXVII, No. 3, July, 1932, p. 411. - ............. ^ Henrietta B. DeWitt, "Family Care as the Focus for Social Case Work in a State Mental Hospital,” Mental Hygiene. Vol. XXVIII, No. 4, October, 1944, p. 603."

2a both of these conceptions can be seen the historical influences based on the degree to which the community accepts and has a part in providing services to the mentally ill# World War II again brought concern with psychiatric problems.

The public was bombarded through mass media with

material on psychiatry, dramatized through its application in the armed forces.

Practical considerations of manpower

even helped to open some community doors to the mentally ill.

As White indicates, ,fBecause of the war, employers and

communities are ready and eager to participate in the re­ habilitation of recovering patients. fT9 Meanwhile, however, the state mental hospitals and programs were suffering manpower and financial shortages arising out of a total war effort.

In a sense the public

was getting an accelerated education from psychiatric programs for the armed forces, while the home-front programs for the mentally ill were trying their best to hold their own. With the psychiatric emphasis on the returning veteran and direction of popular attention to psychiatric problems, communities began to examine their own facilities

9 Ruth Romig White, "The Social Services in the State Hospital of Illinois," Mental Hygiene, Vol. XXVII, No. 4, October, 1943, p. 572.

29 and found them wanting.

Almost immediately, attacks began

to center on state hospitals; so much so, that the National Committee of Mental Hygiene was forced to release the following statement in July, 1946; Mental Hospitals are again under fire. By convicting institutions in a few supposedly leading states, the handling of the mentally ill in the whole country, if not the whole world is impeached. The current attacks, however, differ in a significant way from the exposes of recent decades. *They are an attack on a system, rather than on the administration of a specific insti­ tution. Mental hospitals have never outgrown the age in which social problems were handled in a palliative (custodial) manner, and as if they existed apart from other social problems. . . . The handling of the men­ tally ill is ward centered, instead of being focused on the whole community. . . .10 These exposls, fact-findings, and professional moves in the direction of greater community responsibility in serving the mentally ill, which are still in motion, have meant the crystallizing of the convalescent care program as a necessary and distinctive part of state mental hospital programs.

It has meant that the convalescent care program

is rooted in the total hospital program by virtue of community demand and responsibility for service. The mental health of all persons in the community is a community problem in which citizens bear the full responsibility for the adequacy of resources and meet the needs.11

1® "Attacks on Mental Hospitals," editorial in Mental Hygiene, Vol. XXX, No. 3, July, 1946, p. 353.

30 Or, as the Group for the Advancement of Psychiatry has formulated it: The committee considers that the treatment of the mentally ill is primarily a community responsibility, and that the hospital is a treatment facility of the community, rather than its dump-pile for the disposal of human wreckage* The goal of treatment is seen as return to community living, with the fullest utiliza­ tion of all medical resources for the personal, social and vocational rehabilitation of the patient*12 Concurrent with the community trend of demanding and supporting a total treatment program, with convalescent care as one integrated phase, the hospitals themselves have become involved in the movement of integration of community services for mental health* The modern state hospital is striving to become a dynamic facility integrated with the total community health program* No longer can treatment seem to begin and end in the hospital,13 These facilities can and must cooperate with schools, churches, courts, private practice, and family members in a program for developing individual potentialities to the highest level of adjustment, maturity, and useful living,14

11 Marian McBee, ”The Responsibility of the Citizen in Bridging the Gap Between Mental Hospitals and Community,” Mental Hygiene, Vol. XXIII, No. 3, July, 1949, p. 385. 12 "The Psychiatric Social Worker in the Psychiatric Hospital,” Group for the Advancement of Psychiatry, Topeka, Kansas, Report No. 2, January, 1948, p. 1* 13 Henrietta B* DeWitt, ”The Function of the Social Worker in the Total Treatment Program in a State Mental Hospital,” American Journal of Psychiatry, Vol. 105, No. 4, October, 1948, p. .

31 The community demand for establishment of new resources for prevention and treatment and more appropriate use of existing facilities has resulted in this two-way process.

This process is accomplishing a coordination and

integration of services to the mentally ill that is called the total treatment process# This kind of integration of services into a continuum or whole, the understanding of the social needs in relation to the medical needs, has required a consistent attempt to better define the different phases of treatment, to delin­ eate the appropriate functions of each profession engaged with the patient. "Each group should also be fully aware of the area of its own responsibility in order to be free to develop its particular skills in the interests of the total setting,"15 is the way that Henrietta B. DeWitt has stated it.

It is this effort to define and to professionalize

services to the patient which is characteristic of presentday practice. Summary.

Convalescent care, although still in the

14 Frank F. Tallman, M. D., "A State Program of Mental Health," Mental Hygiene. .Vol. XXXII, No. 2, April, 1943, p. 275. — ^

DeWitt, op. cit.

32 process of definition and development, is an essential part of an integrated service for the mentally ill. Its development occurs in direct relation to the degree of responsibility the community takes for the problem of its mentally ill members.

The increasing interest and

demand of the community is bringing convalescent care together with prevention, early treatment and hospitaliza­ tion in a unity of purpose that will give a totality of service to community members. This combination of services, each differentiated in function, yet integrated in purpose is the total treatment process. II.

EMERGING PRINCIPLES

OF CONVALESCENT CARE IN CALIFORNIA The purpose of this section of Chapter II Is to establish the principles of convalescent care in California. Since these principles have not been classified, and since they are in transition, it was deemed necessary to describe and document their origin and degree of metamorphosis. The early program for the maintenance of the mentally ill in California is probably most succinctly described as f,institutional-centered.M

Institutions posited in rural

sites maintained a protective distance from sensitive communities; while the quiet routine of farm work was

33 advocated for the relief of mental pressures of insanity. Treatment consisted of restraint of the violent and the ordered living of institutional custody. Fortunately, California had avoided the chaos of the county poor house system by establishing state institutions under medical supervision.

let years of isolation had

created a series of autonomous units, only loosely tied together by a State Lunacy Commission. As a result of the national movement for governmental efficiency after the first World War, these isolated insti­ tutions were gathered into the administrative fold of a State Department of Institutions in 1921 along with those for delinquents and criminals.

This step did not greatly

alter the control or autonomy of the mental institutions and it was in this soil that convalescent care had its origin— in the image of the individual hospital super­ intendent— as an "institutional-centered” program. This pattern of authority was defined as recently as 1937 in the first published Rules and Regulations of the Department of Institutions, and indicated some responsibil­ ity to a central administrative body, via appointive powers. 6. Director of Institutions, as head of the Depart­ ment of Institutions, has general control and management of all institutions and agencies within the Department of Institutions and is the appointing power of the Superintendent or head of each institution or agency. 7.

Superintendent . . . authorized head of such

34 institution. He shall have general supervision and control of buildings and property in his institution and the care, custody, treatment and education of inmates thereof,1° That the post-war mental hygiene movement, as well as the practical problems of returning patients to the community, continuously focused attention to the problem of after-care is illustrated in a Circular Letter which comments that: Plans for unifying the extramural work of this Department have been under discussion for almost twenty years, A plan of coordinated placement and parole work was first suggested in 1929. Two years later a similar proposal was made by Dr. Fredrick HI Allen after he had conducted the Mental Hygiene Survey for the State of California. This Department first accepted the plan of unification for its social work activities in 1939 when the Legislature appropriated a lump sum to the budget of the Department for the employment of additional social workers,17 Another clue to the leyel of the convalescent care program during this period is given by the fact that although a psychiatric social worker classification was set up by the State Civil Service Commission in 1933, there was little use made of it by the mental institutions.

1^ Rules and Regulations Relating to Management. Conduct. and -Personnel -of Institutions under Jurisdiction of Department: and Licensing and Conduct of -Private Institutions. Department of-Institutions, State-of-Calif­ ornia, effective August 14, 1937, P* 2* 17 *»Plan of Organization for Bureau of Social Work in the Department,” Circular Letter No. 1296, Department .of Mental Hygiene,.State of California, March 1, 1946, p. 1,

35 A hospital superintendent, working within the limitations of a "depression” program in which his competence was judged by the amount of money he returned to the State Treasury each biennium, could ill afford the "luxury” of a flourishing patient follow-up program*

The convalescent

care program is well characterized in the two following quotations: Duties tended to conform to the prevailing idea that treatment was purely an institutional matter. Social workers did errand work related to release of patients ffon parole ;!f and were the community eyes and ears of hospitals apprehensive lest maladjusted patients bring down community wrath on their heads. Prior to 1939 the Department’s mental institutions had employed for several years untrained social workers, many of only high school education.. . . • At the end of 193$ there were eight of these workers in the seven hospitals for the mentally ill, responsible for almost 3,000 leave patients.18 The narrow institutional approach to a practical situation prior to 1937 is demonstrated by the only written rules which related to the release of patients from the institutions. 16. Outfitting released inmates— Every inmate dis­ charged or paroled from an institution within the Department shall, upon his leaving the institution, be furnished with clothing suitable to the season and may, at the discretion of the Superintendent be fur­ nished with transportation to his home or nearest relative and a sum of money not in excess of $25.00. 1^ Lawrence Kolb, M. D . , Acting Director, ,?Social Work Program of the Department of Mental Hygiene,fi (Letter to National Institute of Mental Health), April 25, 1949, p. 1*

36 Transportation costs outside the State of California shall first be approved by the Director* 17• Security for Return of Paroled Inmate— Before any patient is paroled from an institution for the insane or home for the feeble-minded, the person to whom he is paroled must sign such statement or give such security as may be necessary to cover the cost of returning the patient to the institution if it should become necessary to return the patient from his parole *19 Thus, aftercare in California was sired by a new and diffuse mental hygiene movement and continued its gestation in a high degree of local administrative autonomy and a custodial program.

It was a loose set of clerical and

personal activities, uncoordinated and ill defined, which fulfilled some of the operational needs of an institutional centered program* The legally defined responsibility of the institution consisted of guaranteeing patients adequate attire and the means to reach their homes, and provided the basis for a formal procedure at leaving that would relieve low-budgeted hospitals of the expense of a patient1s return. The initiation of a community-centered service, 1939-1943*

A radical change to this whole approach came

with the appointment of Dr* Aaron J. Rosanoff as the Director of Institutions in the beginning of 1939*

■*■9 Rules and Regulations, op* cit*, p* 9*

37 Following in the wake of a depression period and the stormy political struggles of the 1930s, Dr. Rosanoff*s appointment and program was the expression of a state administration more responsive to the will of the people and the needs of the communities. The rapid population growth of California was creating unprecedented problems in housing the mentally ill and financing their care.

A more sensitive public, new

psychiatric treatment techniques and strengthened psychia­ tric, medical, and psychiatric social work professions added to the impetus for a convalescent care program. Dr. Rosanoff adopted a practical and immediate approach— that of dealing with the tremendous overcrowding in the most economical fashion.

He believed that many

patients, nearly 65 per cent, in mental hospitals were sufficiently recovered to be released, and questioned the legality of retaining them in mental hospitals.

His famous

letter to the community of April 27, 1940, outlined his views: It should be borne in mind that not all patients having a mental disorder are subject to legal commit­ ment to a mental-hospital on an allegation of insanity. . . . A legal adjudication of ^insanity” leading to commitment to a mental hospital is authorized by our statutes only in those cases- in which the mental disorder is of such nature and degree as to render the patient a menace to health, person or property.20

3* Dr. Rosanoff literally made the state mental hospital program public property for he distributed his letter to everyone possible and invited applications for release of patients* Dr. Rosanoff sold his program to the State Legis­ lature on the basis of saving money, by guaranteeing to return large numbers of patients to normal living.

He

proposed to relieve the overcrowding and pressure on state hospitals and avoid the need to construct additional building.

Although linked with the concept of a treatment

program in the hospitals, his program was essentially one of convalescent care and he turned to social service to accomplish this mission. Along with a $100,000 appropriation went the under­ standing that by June 30, 1941, the end of the biennium, the extramural patient load would be increased from 3,000 to 5,000.

The positions of Supervisor of Extramural Care

and of fourteen social workers were established and, significantly, were placed on the Department budget rather than that of the hospitals.

Dr. Rosanoff recognized that

the impact of this type of program on traditional institu-

^ Aaron J. Rosanoff, M. D., ,fLetter: To All Patients in State Hospitals, their Relatives and Friends, State-Hospital Employees and Officers, Judges of the Superior Courts of the Various Counties, and Other Whom it may Concern,” April 27, 1940, p. 1-2.

39 tional procedure would inevitably evoke resistance.'

He

believed that by independent administration of the staff responsible for carrying out the program he could guarantee its success* In November, 1939, a Supervisor of Extramural Care was appointed, and by March, 1940, all social work classi­ fications had been filled. under way!

The "total push" program was

Widespread publicity, personal visits by

Dr. Rosanoff to the hospitals, inauguration of family care and work plans stimulated the program and resulted in great responsibility being placed on social workers.

The social

work staffs of the hospitals, through varying enthusiasm of the individual superintendent, were given pioneering responsibilities within the hospitals. The significance of this development for the program of convalescent care was clearly demonstrated in the figures for June 30, 1941, (the deadline of the agreement with the State Legislature) showing 5,161 patients on leave— double the number on leave three years earlier.

The following

figures are also important: Almost 25 per cent more patients were being dis­ charged from leave. There were almost four-fifths as many patients going on leave as were being admitted to the hospitals. The rate of return from leave remained about the same. The significance of these figures was great. They established that there were many patients ready for extramural care. They proved that a social service

40 program with institutional cooperation and sustain these leaves. They showed for the first time in the department’s annual rate of population increase was

could expedite a method whereby . history the checked.21

The effect of this kind of a "total push" program on the hospitals is extremely important for it influenced the development of the present conception of the total treatment process.

The study quoted below reveals that effect, which

was also apparent in the California hospitals. A liberal policy of release forces the mental hospi­ tal to enlarge its therapeutic program . . . when large numbers of patients are released from the institution the occupational and recreational therapy programs and other elements in the total push program of necessity must be accelerated to recruit from among idle patients new working patients to replace those working patients who have gone home• 22 This points to the tremendous problem and opposition that is concomitant with upsetting an institutional system that operates on a substantial proportion of patient-labor. At any rate, this new development brought with it a series of special problems as reflected in the official Circular Letters of the department.

As early as November 1,

^940, Circular Letter No. 1 of Extramural C a r e 23 indicated 21

Kolb, op. cit., p. 2.

^ Conrad Sommer, M. D. and Jack Weinberg, M. D., "Techniques and Factors Reversing the Trend of Population Growth in Illinois State Hospitals,” (unpublished paper), p. 11.

^ "Unemployment Assistance for Paroled Patients," Circular Letter No. 1, Extramural Care, State Department of Institutions, State of California, November 1, 1940.

41 that the question of employability of parolees by the State Relief Administration was to be solved in conference.

On

May 5, 1941, a Circular Letter^4 requested notification of the State Department of Industrial Welfare if patients discharged from Industrial Parole were being retained at the same wages. The effect of this program, as suggested above, was demonstrated in the policy ruling on October 2, 1941, making it "permissible to transfer freely among mental hospi­ tals."^

This new orientation and awareness of the com­

munity resulted in a procedure that was to enable patients to be in hospitals nearest their relatives, a treatment consideration formerly disregarded.

Shortly afterward a

policy was established enabling mass transfers between hospitals. Most indicative of this new orientation and emphasis of the department on return of patients to the community was the procedure set forth for "Paroling Patients Against the Will of the Guardian."

^4 "Discharge of Patients from Industrial Parole," Circular Letter No. 267, May 16, 1941• 25 "Guests or Emergency Transfers," Circular Letter No. 337, October 2, 1941*

26 "Suggested Form of Paroling Patients Against the Will of the Guardian," Circular Letter No. 367, November 19, 1941.

42 Meeting legislative expectations by the success of his program, Dr.* Rosanoff obtained support for his requests for the 1941-43 biennium.

This included plans for a separate

departmental agency--*a Division of Extramural Care.

The

concept of such a division was to guarantee development of the convalescent care program and continued release of patients from hospitals.

The following quotation describes

Dr. Rosanoff1s conception: This division was conceived as having full autonomy under an Acting Medical Superintendent of Extramural Care with authority to go into the hospitals and select patients for leave. These patients would be transferred to the division’s rolls and carried by the social work staff in regional offices under social work supervision. The patients would be assigned to social workers by hospitals as much as possible, but in remote districts patients of several hospitals might be carried by the same worker. The division would promote supplementary social services, such as initial social histories; social treatment work in communities with relatives or hospitalized patients; and pre-leave planning. The existing program of placing patients in supervised jobs would be continued; but in addition extensive use of family care would be attempted. Hospital doctors would conduct outpatient clinics in the division’s offices. The concept of a division with such authority and autonomy was an effort to establish a program stronger than any hospital. However, an important feature of the plan was that all the social worker positions, intramural and extramural, be placed in hospital budgets to abolish the existing dual staff system. Functional control of the extramural social workers would be granted the division, but not administrative control* The need for qualified personnel was taken care of in the establishment in 1941 of the three psychiatric social worker classifications, the minimum requirement for the lowest grade being one year of graduate social work training.

43 The division plan was approved by the Legislature and became effective September 13, 1941. It carried a biennium budget of over $500,000. More than $300,000 of this was for family care, which was regarded as an important device for helping more patients get out of the hospitals* 7 The convalescent care program, with its emphasis on the needs of patients, continued to move forward.

This

movement is reflected in the order of January 13, 1942,2^ which established twenty-five dollars in a patient fund for the incidental needs of each patient while on leave in family care placement*

Further recognition was demonstrated

by a survey of needs for stenographic help for extramural service on January 19, 1 9 4 2 * ^

The program was reaching

some definition as revealed by the establishment of social workers as separate from members of the clerical force in application of the Skeleton Crew L a w . 30 That this program consistently moved against the inertia of an "institution-centered" psychology, was a reality evidenced by such incidents as occurred in the Superintendents1 Conference of June, 1942*

The possibility

27 Kolb, op. cit., p. 3* 2^ "Incidental Needs of Family Care Patients," Circular Letter No* 403, January 13, 1942. 29 "Stenographic Help for Extramural Service," Circular Letter No. 409, January 19, 1942. 30 "Social Workers and the Skeleton Crew Law,” Circular Letter No. 412, January 20, 1942*

44 of holding patients longer before discharge or leave, or even putting them on the payroll at fifteen dollars per week, was advanced as a means of relieving the increasing shortage of personnel in the early war years.31 Although the Division was established by the appoint­ ment of Dr. Thomas'W. Hagerty on September 13, 1942, as Acting Medical Director, it did not materialize as planned, and the convalescent care program was considerably retarded* A number of factors contributed to the slackened pace* First was the entrance of the United States into World War II which drew public attention in another direction and left the program on its own.

Another factor

was the necessity to give direction of the Division to two hospital superintendents, each of whom could not give up other heavy assignments to give it close attention.

No

social work supervisors had been provided for by the legislature to guarantee the proper fulfillment of case assignments or advance the professional level of the workers.

The demise of Dr. Rosanoff as Director in July,

1942, was a crushing blow and the end of one era of con­ valescent care in California. At this point it is important to summarize the

31 Minutes of Superintendents’ Conference, Department of Institutions, State of California, San Francisco, June 3-9, 1942.

45 activities and developments of this period of 1939 to 1943: 1.

Removal of administrative and budgetary res­

ponsibility for convalescent care from the hospitals to the department• 2.

Introduction of social work personnel with pre­

liminary differentiation from clerical staff* 3.

Development of new patient policies which created

needs for a social work service. 4.

Initiation of policies recognizing community

problems• 5*

Spontaneous use of a community education program

as preliminary to recognition of community responsibility. Convalescent care--experimentation and consolidation. 1943-1946.

The period of 1943 to 1946 could be character­

ized as a holding and consolidating era for the convalescent care program in the Department of Institutions.

However,

several basic principles were developed which were of great value in later periods.

Some of the advances were sustained

in spite of the loss of Dr. Rosanoff*s leadership. One of these advances was the geographical division of the state for the purposes of convalescent care.32

This

represented a step away from the follow-up work with

32 "Geographical Distribution of State for Purposes of Extramural Care,” Minutes of Superintendents* Conference, Department of Institutions, State of California, Sacramento, November 12, 13 and 14, 1942, p. 6.

46 patients on the basis of the hospital to which they had been committed and a step toward centralizing and coordinating the convalescent program. Another was the cooperative experiment of Patton and Camarillo State Hospitals in centralized social work admin­ istration in the Los Angeles area which had as its objective the measurement of the effectiveness of such a system in time for recommendations to the 1945 legislature.

Many of

the original ideas of the planned Division of Extramural Care were introduced, such as centering extramural work in Los Angeles, hospital social workers and clerical staff, and copies or transcripts of hospital records. clinics were also conducted there.

Outpatient

Essential differences

were: a. Cases were referred, rather than transferred, by the hospitals, and so remained on the hospital rolls; b. Cases were; assigned primarily by geographical districts, a concept not fully established in the earlier plan; and, c. There was no social work supervisor in charge of the office. Such supervision as could be was provided by Mr. QJathan] Sloate [Supervisor of Extramural Care] from Sacramento.33 Convalescent care received much validation in Calif­ ornia by this experiment and the stage was set with approval

33 Kolb, 0£. cit., p. 4* (Words in brackets are author’s own for purpose of clarification.)

47 of its attempt by the superintendents on July 13, 1943, with "the understanding that such a program will be worked out carefully and gradually with a view to determining whether it would be applicable for the State as a whole.!f34

How­

ever, even this modest experimental attempt threatened the vested view of an institutional-centered program.

Only one

month later opposition to the plan for a "centralized extra­ mural care program" was expressed on the basis that the hospital loses contact with its patients and the physicianpatient relationship is destroyed.35 Significant of the problem of this period, with its partial retreat from the community, was the reaction to the request by a reporter representing the San Francisco Chronicle newspaper.

He asked whether the Director of the

Department stood by the views outlined by Dr. Rosanoff in his famous letter to the community on the liberalization of the parole system.

When the decision about the answer was

left to the hospital superintendents they did not support the letter on the basis that "it only stirred up the paranoid patients and relatives, did not effect the release of patients who would not have been otherwise released; that

34 Minutes of Southern Superintendents1 Conference, Los Angeles, July 13, 1943* 35 Minutes of Southern Superintendents1 Conference, Los Angeles, August 17, 1943*

43 no good resulted from it.f|36 Nevertheless, there was a crystallization of several recommendations during this period that were important to the future of convalescent care.

First was the report of

the Camarillo-Patton experiment,37 in which a 25 per cent increase in unit work output was reported.

Major contribu­

tions are the elimination of duplicated travel and greater efficiency and understanding on the part of the workers because of having patients’ records available.

The report

appealed for an organic tieup with the hospitals by express­ ing a belief that keeping cases on hospital rolls would stimulate more interest in extramural work among hospital doctors, as well as finding that no hospital-patient relationship suffered.

A new concept was brought forward

at that time in conjunction with the recommendation to expedite the provision of supervision for the social workers.

It was incorporated in the suggestion that a

centralized program would be the basis for inservice and student training of social workers. Ihe recommendation for the establishment of a Deputy Medical Director position in the department was a

------- w Minutes of General Superintendents1 Conference, Los Angeles, October 14-15, 1943* 37 Minutes of Conference of Superintendents, Board of Trustees, and Medical Advisory Board, San Francisco, July 26 and 27, 1944#

49 thrust to further professionalize the program and to provide the central administrative coordinating authority that a community-centered program required.

This recommendation

was to link, curiously enough, with the same recommendation from another side of the community responsibility emphasis. During this period, toward the latter part of the war, the public was becoming intensely aware of the need for psychiatric treatment and prevention services.

Precipi­

tated by a letter from the League of Women Voters to the Department and subsequently referred to the Governor, a Committee on Prevention of Mental Illness was set up by the Governor to outline a prevention program for the state. On November 10, 1944, the committee recommended consolidation of the Department of Institutions into a Department of Mental Hygiene (transferring the juvenile corrections program and adult penal institutions to a Department of Corrections); the establishment of a Medical Deputy Director position; the establishment of four out­ patient clinics; and a research and training center in Los Angeles.38 A third major influence was the report made by Dr. Samuel W. Hamilton, Mental Hospital Adviser of the United States Public Health Service, who had just completed

38 Minutes of Northern Superintendents’ Conference, November 1G, 1944*

50 a survey of hospital construction for the Department*39 Total emphasis of this report was the need for a closer connection with the community and its related resources by the hospitals. Appointment of Dr. Lawrence Kolb as Deputy Medical Director in 1945 provided the professional administrative authority for two important phases of the total treatment process; early treatment in outpatient clinics; and a community-centered convalescent care program. Most of the activities of this period were on the recommendation level and did little to affect the immediate operations of the convalescent program.

This is illus­

trated by the topic on the Superintendents* Conference agenda of November 10, 1944, entitled "Use of Social Workers in Transporting Property of Small Value*"

The superintendents

agreed with one another that there were not sufficient attendants available to take over this duty * ^ The Supervisor of Extramural Care summed up the reality of these years, as reported in the minutes of the Superintendents1 Conference of September 12, 1945; when he "called attention to the fact that the Extramural Care

39 Minutes of Conference of Superintendents, Board of Trustee, and Medical Advisory Board, San Francisco, July 26-27, 1944, p. 5# ^ Minutes of Northern Superintendents1 Conference, Sacramento, November 10, 1944, p* 4*

51 Division had been waiting a long time to get started on a definite program.ff^This opportunity was provided by Dr. Kolb's appoint­ ment.

Upon the base of the Camarillo-Patton experiment and

recommendations of the Supervisor of Extramural Care, details were worked out for a centralized social work organization, although too late to take them to the 1945 legislature.

The basis for this program was a compromise

between hospital control and complete independence.

Dis­

cussed in superintendents conferences in the North and the South, modifications were made between social services emanating from the hospitals and a unified social service division emanating from the central office in Sacramento. The plan established social work supervisors and the direction of personnel in the Bureau of Social Work. This period of 1943 to. 1946 completed „another distinct phase in the development of the convalescent care program in which the following facts may be noted: 1.

Establishment of centralized medical administra­

tion and authority for the program of convalescent care. 2.

Convalescent care was sustained at a single level

during that period while the need was increasing. 3.

A step toward a differentiation of convalescent

^ Minutes of General Superintendents1 Conference, Los Angeles, September 12-13, 1945, P* 2d.

52 care through geographical division, etc. 4.

Increased attempts at definition of the service

through experimentation. 5.

Influence on convalescent care of the moves to

establish other phases of the total treatment process, such as early treatment services. 6.

Professional recommendations to increase links

with the community. 7.

Recommendations for professionalizing service

through supervision, student training, etc. Convalescent care— an essential service, 1946-194#. The establishment of the Bureau of Social Work signalized the formal recognition of the essential role of the con­ valescent care program in the treatment of the mentally ill in California.

Its original formulation is outlined in two

Circular Letters of March 1, 1946, and May 2 4 , 1946.

The

Circular Letter of March 1, 1946, states: In order to further increase the efficiency of the Department’s social work program by providing uniformly high standards of case work procedure and to improve the service to patients, I am requesting that the social work program operate on a .Department-wide rather than a hospital-wide basis. Social workers will continue in the same working relationship with the hospitals as at present but will be responsible to the Bureau of Social Work through the Supervisor of Extramural Care. Under this arrangement all social work and related clerical personnel would be appointed, evaluated, and discharged or suspended by the Bureau. This would include the workers at the hospitals as well as those in the field, as it is felt that this would better contribute to a

53 closer coordination of the work. This would in no way disturb the doctor-social work relationships that now exist as those are considered essential to the function­ ing of a successful social work program. The present hospital-social worker relationship will continue except that supervision of the social workers will come from the case work supervisors, who will, of course, work closely with the hospital personnel and be sensitive to the hospital’s needs.42 This program became effective March 15, 1946.

After

some operation it was necessary to issue a clarifying letter about the policies and procedures.

This Circular Letter of

May 24, 1946, set forth important clarification of pre­ viously stated procedures and for the first time indicated a philosophy of treatment. An effort will be made to offer more complete social work service than has been possible in the past. To offer this complete service, it is desirable for the social workers to establish a relationship with the patient’s family and friends as soon as possible follow­ ing commitment. In taking initial social histories an opportunity is offered not only to gather much needed information for the hospital’s records but also to begin to prepare the family for the care and treatment the patient will receive at the hospital and following his release on leave. This points to a program of social treatment carried on by the social workers with interested friends and relatives in the community paralleling the treatment offered the patient at the hospital, and will be in conjunction with that treat­ ment .43 Further reference was made to the necessity for selectivity of cases, liaison with the medical staff,

^ ’’Plan of Organization for Bureau of Social Work in the Department," Circular Letter No. 1296, March 1, 1946. ^ "Policies and Procedures Involving the Bureau of Social Work," Circular Letter No. 1332, May 24, 1946.

54 methods of referral of cases, and established that patients on leave of absence would not be transferred to the Bureau, but remain on the records of the hospitals.

Hospital social

workers were expected to conform to hospital policy and routine.

nThe Bureau of Social Work will provide the

immediate social work supervision in accordance with the placement plan as approved by the hospital staff.tf44 With the tremendous wartime publicity of psychiatry and mental health problems arose a flourishing public interest in treatment.

This community awareness and

developing active interest infiltrated the Department, bringing with it the kind of community demand and responsi­ bility which could only serve to reinforce a convalescent care program.

The General Superintendents* Conference in

Los Angeles on September 30 and October 1, 1946, gives vivid testimony to this fact. "I think the Department of Mental Hygiene is going to be missing its calling if it fails to take responsibility for the mental health of the community,**^5 stated Dr. Edwin E. McNiel, a member of the recently activated Medical Advisory Board. That this recognition of the growing public interest

V* Ibid. *5 Minutes of General Superintendents' Conference, Los Angeles, September 30 and October 1, 1946, p. 5«

55 and the Department’s responsibility was clear is seen in the triple emphasis of Dr* Kolb, the Medical Deputy Director* First was the need to provide an adequate and pro­ fessional program through trained personnel.

"Dr. Kolb,

however, emphasized the fact that plans have been made for an intensive treatment and research building at all of the hospitals.

Aside from the construction, the rest of the

hospital program really comes down to a program for per­ sonnel."^ Second was expansion of treatment services, and third (a renewed conception) was the responsibility for a community education program.

Dr. Kolb stated:

The extramural care program also envisions the establishment of more clinics. The federal public health mental hygiene assistance program provides for giving to the states for mental hygiene activity, money on a matching basis, and through this program we can carry on eompaigns of education in mental health, we can assist and enlarge the established mental hygiene societies throughout the state, and we can establish additional mental health clinics.^7 The effect of the reorganization of the social work program, with supportive emphasis on clinic treatment services and community education was to produce "another very intensive increase in the number of patients on leave of absences.”^

^

IbidT, p. 8.

47 Ibid.. p. 9.

56 This linkage of the convalescent care program with early and hospital treatment— the responsibility to the community— was finally documented in a Circular Letter on November 29, 1946*

The essential contribution of this

document was to define within the total treatment process, the social work responsibility, the integration of con­ valescent care, and the responsibility to the community. The reorganization aimed to offer a more complete service to the communities from the time of the patient’s admission to the hospital to the time of his final discharge; to eliminate duplication of effort; and to stimulate the professional development of the social workers through more effective casework super­ vision. 49 . Reaction to this orientation was not slow in coming and the long-smoldering symptoms of the institutionalcentered interests broke out in full force in the General Superintendents’ Conference on February 17, 1947*

Most of

the meeting was devoted to violent attacks on the social work program, projecting arguments that the patients were getting away from the control of the hospital, with allu­ sions to the importance of the superintendent’s authority# Clearly the main factor in preventing any retro­ gression of program at this time was the administrative authority and orientation of the Medical Deputy Director.

48 Ibid.. p. 13. 49 tTProgram of the Bureau of Social Work,” Circular Letter No. 1395, November 29, 1946.

57 The 1947 Legislature made three important changes that advanced the convalescent care program: . . . it transferred all extramural workers to the Bureau of Social Work; it increased the number of extramural social worker positions Uo forty-two; and it provided for six extramural social work supervisors* Control of intramural staff was returned to the indivi­ dual hospitals.50 The 194$ Budgetary Session increased the social work staff to fifty-two.

The result is best indicated in the

following summation: There has been steady growth in the leave population. It stood at 6,£06 at the end of February, 1949* The number of patients going on leave has increased (1,000 more in 194$ than in 1946)• Discharges from leave were up 50% for the fiscal year ending June 30, 194$, over the figure for the preceding year. The rate of net leaves (total leaves granted less returns from leave) has been increasing. If the rate of hospital admissions in 194$ had remained what it was in 1946, the leave activity would have led to an actual reduction in hospi­ tal population. Contacts with patients on leave and their families have increased greatly. . . . Coverage now involves not only routine leave contacts, but social history taking; special and pre-leave investigations; the development and use of work leave and family care resources; preventive mental hygiene work through con­ ferences and talks; and consultation and referral ser­ vices on non-Departmental community cases of mental illness.51 During this period of March, 1946, to the end of 194$, the following activities influencing convalescent care

50 Minutes of General Superintendents1 Conference, Sacramento, February 17-1$, 1947, p. 1$* 51 Lawrence Kolb. M. D., Letter to National Institute of Mental Health, April 2$, 1949, p. 7.

53 are significant to the development of its present principles: 1.

Increasing responsibility of Department to

community, as indicated by activation of Medical Advisory Boards, etc. 2.

Increasing recognition of community education as

an appropriated function of the Department. 3#

Recognition of need for rapid expansion of

hospital treatment. 4.

Increasing authority of Deputy Medical Director.

5.

Increasing emphasis on treatment services,

particularly outpatient and hospital. 6.

Increased differentiation of convalescent care

as social work program, rather than medical program. 7*

Developments in services to patients which moved

in the direction of making treatment an integrated process; namely, social histories, pre-leaves, etc. £.

Sudden expansion of social \tfork staff.

9.

Establishment of social work supervisors.

Convalescent care— an integrated and differentiated service, 1943-1950*

In the fact of the geometrical popu­

lation growth in California this small advance could not be expected to meet themass nature mentally ill for the

state.

of the problem of the

The rate of admissions in the

59 hospitals held the overcrowding rate at 25 per cent to 30 per cent with Southern California especially burdened. In the urban centers small struggling psychiatric clinics, both state and voluntary financed, had waiting lists months long, while in rural areas such clinics were simply non­ existent#

And the temper of the public had been steadily

heated by a constant flow of material on psychiatric problems# The spark that unleashed this frustration came from the succinct legislative program of the Southern California Society for Mental Hygiene in December, 194&*

Starting with

a kQS Angeles Daily News editorial, the Society’s program initiated statewide attention to the problem of state mental hospitals and coincided with the concentration on psychia­ tric problems that was extant in the mass media. As a result public attention and demand spread like a prairie fire, and a Conference on Mental Health was called by the Governor to be held in Sacramento on March 3 and 4, 1949*

Over eight hundred professional and lay people

met in this conference to formulate a future program of mental health for the state.

If any single point stands out

in the findings and recommendations of this conference it was the conception of developing a total integration and coordination of all services in the mental health field. A significant development out of this conference

60 was the appointment of a Continuing Committee of twenty-one members appointed by Governor Earl Warren on March 25, 1949, to ,fcarry forward the recommendations of the Conference.,f52 Meanwhile, the resignation of the Director of the Department of Mental Hygiene had taken place.

A special

Advisory Committee to the Governor had investigated and recommended the appointment of Dr. Frank F. Tallman as Director of the Department. On September 15, 1949, the appointment of Dr. Tallman brought to the Department a psychiatrist whose experience and orientation was that of providing the maximum in a community-centered program of treatment, training, research and community education. During the period of 194$ to 1950 the convalescent care program had continued to give the same coverage of service, but with increasing attention to the professional level of services.

Professional committees and staff

conferences explored the possibilities for selectivity of cases for appropriate casework and therapy services; and attempted to work out procedures that would guarantee the maximum of coverage and service.

Under Dr. Tallman1s

leadership this program was greatly intensified. Two other significant developments have contributed

52 Report of the Continuing Committee on Mental Health, December 16, 1949, p. !•

61 to the movement toward a community-centered program.

First

was the Progress Report of the Governor’s Continuing Com­ mittee on Mental Health, which was completed on December 16, 1949*

This report detailed a program that would give the

State Department of Mental Hygiene responsibility for leadership in the state in stimulating and coordinating mental health services and providing treatment services at every point of need in conjunction with existing or proposed local community services* Second was the announcement ,of the coordination of the social work program, which would provide the basis for accomplishing a total integration of convalescent care within the entire range of services provided by the depart­ ment : The Department announces the coordination of the social work programs in operation in the state hospi­ tals, clinics and extramural care activities. This administrative change has been made to ensure a higher level of integration in our total program. 53 To implement a npatient-centeredfT program, Dr. Tallman requested and obtained a budget increase of approx­ imately $4,000,000.

The perspective for the convalescent

care program was an almost 100 per cent expansion of personnel whose activities would be geared to the expanded treatment services in the hospitals and clinics.

The

53 "Coordination of Social Work Program,” Circular Letter No. 1912, February 1, 1950.

62 groundwork was laid for another period of expansion and development of convalescent care* Focusing on the developments related to convalescent care during the period of December, 194& to April, 1950, reveals the following influential activities: 1*

Steady expansion of community need outstripping

available services* 2.

Radical increase in community interest and

responsibility in the Department program. 3*

Community formulation of concept of total inte­

gration and coordination of mental health services with the Department given leadership responsibility* 4.

Increased professionalization of convalescent

care service. 5*

Return to departmental administrative direction

by professional psychiatrist. 6.

Rationalization of operational procedures.

7.

Administrative approval of principle of total

integration of social work program and coordination of convalescent care with all other services of the department. 8.

Prospects for expansion of service through

raising quality and quantity of personnel; and for expansion of community education and prevention services.

63 Ill.

SUMMARY

The present philosophy of convalescent care.

The

result of the review of the trends in convalescent care in the United States and of the program in California is to establish the conception of the "total treatment process" as the guiding and emerging philosophy for the provision of services to the mentally ill.

Underlying this conception is

the demonstrated fact that this conception has developed as a result of a steadily advancing responsibility of the community, or our American society, to understand and establish services for the care of the mentally ill. As presently conceived, the total treatment process is an integrated program, each phase to be skillfully interlocked with the succeeding phase in such a way as to provide a flexible network of services sensitive to the mental health needs of the community. As presently conceived, such a program desirably might begin with a general education and preventive service to the community at large.

At the point that individuals

were finding difficulty in their adjustments, they would find early treatment information and referral service available.

Following this would be the actual early treat­

ment services of psychiatric clinics. For those who cannot meet their difficulties on this

64 level would follow the actual hospitalization and all that goes into that phase of the process*

Each succeeding step

has in it a series of special needs and activities and in each step would be the problem of maintaining community contact for each individual*

This becomes especially true

as the patient moves through specific treatment activities in a hospital* The provision of the latest treatment would move the person toward medical recovery, which initiates the need for planning of community readjustment, the pre-leaves, etc* Holding with the patient through this transfer process, and moving through the convalescent care part of the process means facilitating the use of community and individual resources, with the goal of ending the treatment connection*

Even after this severance, would come the

responsibility for using the patients* experiences in consultation and planning for more'effective integration and sensitivity to need. The totality of this concept gives important clues to present practices toward facilitating and sustaining the treatment process. The principles of convalescent care in California* Examination of the trends in convalescent care in California points up the movement that is in the principles under which it operates.

They are emerging out of the realities and the

65 need that is necessary to meet the problems of mental ill­ ness in a pioneer state.

From the examination and evalua­

tion of the trends the following principles are evident: 1*

The convalescent care program provides patient

supervision under direct medical responsibility and limits. 2.

The convalescent care program is in movement to

operate as a department-wide service. 3.

The convalescent care program is in movement

toward integration with other phases of the treatment process.

k*

The convalescent care program is in movement

toward a differentiation of its professional service from others in the Department. 5.

The convalescent care program is in movement

toward providing a professional social work service within certain operational and administrative limits. 6.

The convalescent care program serves as an

increasing link with, and facilitates use of, the resources of the community. 7*

The convalescent care program has developed on

the basis of the degree to which the community assumes responsibility for the treatment of the mentally ill.

CHAPTER I I I

PRESENTATION OF DATA The case records of the twenty-eight "exclusive leave11 patients were examined for significant data relative to their personal and hospitalization characteristics and in three areas of the leave process:

observable factors

influential in plan of leave, patient*s leave activities in relation to the Bureau of Social Work, and observable factors indicative of leave adjustment*

In instances where

information was not complete in the records, individual social workers assigned to each case were interviewed* This chapter includes a description of the patients and the significant factors indicative of their activity in the convalescent process. I.

CHARACTERISTICS OF EXCLUSIVE LEAVE PATIENTS

The following compilations give an important picture of the exclusive leave patients and is grouped into charac­ teristics of their person and characteristics of their hospitalization.

It answers the question, **Who are these

patients who upon leaving state mental hospitals are placed under the exclusive supervision of the Bureau of Social Work? w

Sex*

This group is almost totally male, with only

two females, who represent 7 per cent of the twenty-eight patients* Ethnic group*

Predominantly Protestant in religious

belief, with eighteen in this category, the group also contained nine (32 per cent) who were Catholic.

None of

Jewish faith were represented, although there was one person who was of Christian Science belief* Age groups* the age of thirty.

Over 75 per cent of the group was over With 53 per cent over the age of forty,

over half of the group falls in the middle age bracket* The following table indicates the age distribution: TABLE I DISTRIBUTION OF EXCLUSIVE LEAVE PATIENTS BY AGE GROUPS

Age of patient Under 21 to 31 to 41 to 51 to 61 to

21 30 40 50 60 70

Number of patients 1 6 6 11 2 2

Marita]/ status: This group can be readily character------ 7------ized as unattached, for only five of the group were listed as married*

One-third of the group had never been married,

6a while exactly half of them were separated or divorced* Number of children*

Over half of the group (57 per

cent) had no children, while another quarter of them had one child.

The distribution is listed: TABLE. II

DISTRIBUTION OF EXCLUSIVE LEAVE PATIENTS BY NUMBER.OF CHILDREN

Number of children

Group total

None One Two Three Four Five

Education*

Percentage

16 7 1 2 1 1

57 25 3.5 7 3.5 3.5

Of the group. 30 per cent had less than

a grammar school education, while 56 per cent. had not completed high school, and 96 per cent had not completed college.

Following are the grouped totals: TABLE III DISTRIBUTION OF EXCLUSIVE LEAVE PATIENTS BY GRADE LEVELS

Grade level

Number of patients

7th grade or less Grammar to 11th grade High school to 3 yrs of college Completed college

£ 7 11 1

Percentage 30 26 40 4

69 Occupation.

There was a great deal of discrepancy

between the patients1 statement of occupation and the type of work they were performing prior to commitment*

This

discrepancy was also demonstrated at the point of leaving the hospital when their stated occupation would differ from their original statement, or differ with the type of work they were seeking upon leaving*

In ascertaining the

occupational classification of each patient, the type of work in which they had demonstrated skill as evidenced in their work history, was utilized.

There did not seem to

be any special grouping of occupational classifications, with vocations ranging from kitchen workers to public relations specialist., Sixty per cent of the group was unskilled as indi­ cated by the following breakdown:

unskilled— 17; semi­

skilled— 7; skilled— 4* Residence.

The vast majority of the group, 61 per

cent, technically qualified as residents of the State of California with at least three years residence.

Sixty-five

per cent of the group had resided in California for ten years or more, while six (21 per cent) had resided here their entire lives.

Following is the distribution:

70 TABLE I V

DISTRIBUTION OF EXCLUSIVE LEAVE PATIENTS BY PERIODS OF STATE RESIDENCE

Residence period

Number of patients

Less than 3 years (Non-residents) Since 1940 Since 1930 Since 1920 Life Unknown

Military service.

5

(14, 16, 17 mos*, 2 and 3 years)

4 4 8 6 1

Eight (28

per cent) had some

type of military service in World War II and two in World War I* Period of hospitalization*

The length of hospital­

ization for this group ranged from one and one-half months to twenty-nine months♦

Fifty-seven per cent were in

hospitals less than six months, while 81 per cent were there under a year.

During hospitalization three had

escapes and four had leaves, with one having both* Diagnosis*

Less than half (46 per cent) of the

group had the diagnosis of alcoholism, with only 17 per cent diagnosed as alcoholic without psychosis.^ Following is the distribution by diagnosis:

71 TABLE V DISTRIBUTION OF EXCLUSIVE LEAVE PATIENTS BY TYPE OF PSYCHIATRIC DIAGNOSIS

Diagnosis

Number of patients

Alcoholic Psychosis Alcoholism without Psychosis Schizophrenia Manic-depressive Psychosis Organic— Psychosis with Syphilitic MeningoEncephalitis, Traumatic and drug addiction Psychoses Primary Behavior Disorders Involutional Melancholia Undifferentiated Psychosis

II.

a 5 4 4

3 2 1 1

OBSERVABLE FACTORS

INFLUENTIAL AT POINT OF LEAVE The following data examines the factors that appeared to be operative at the point of leave— the beginning of the convalescent period.

It is designed to give some insight

into the situation with which exclusive leave patients embark upon their period of readjustment to the community. Initiation of leave.

Although in some instances it

was difficult to determine on what basis the leave was initiated, there.was enough information in the records to make the following general differentiation: At least three-quarters of the patients were responsible for initiating their own leaves, while five of

72 them (1$ per cent) evidenced that the leave involved some mutual activity with the physician.

In one instance the

leave was precipitated mutually by the patient and his brother, and in another it appeared the doctor had assumed responsibility for precipitating the leave* Mental condition*

In attempting to judge the mental

condition of the exclusive leave patients it was necessary to make arbitrary judgments on the basis of the recording of pre-leave notes, opinions at staff conferences, and the leave note.

All of those who left without any questioning

of their mental condition or with specific references to good recovery were noted as "mental condition— Good*"

If

there was any question about it, the case was noted as "Fair."

In no instance were any noted as "Poor*" In the total group nineteen (over two-thirds) were

noted as in "Good" mental condition. listed as "Fair."

The remaining were

One was listed as "Excellent."

Bureau pre-leave help.

In four out of the twenty-

eight cases there was some pre-leave help or planning.

In

one of this group there was extensive planning involved in the temporary transfer of a paraplegic boy to a hospital. Two of the four involved the Bureau of Social Work staff in clearances to verify possible employment for the patient.

In one instance lodging was arranged*

73 It was impossible to determine just how much the patients put into the pre-leave planning on their own, although certain of the group give some clues*

In one

instance a patient obtained a few days leave from the hospital to look for work, returned with a job, was seen at staff conference and released* Personal leave help*

Forty per cent of the group

had no personal community ties available to assist them in leaving*

Of this number, four out of the eleven had

relatives in other states or foreign countries* There was as high a percentage that had relatives available to help but who were unwilling to assist them* Of this number, three out of the eleven were the wives of patients while the rest were blood relatives* One-fifth (21 per cent) had friends or relatives who could assist them and did.

Four out of the six were helped

by friends* Finances at leaving*

Exactly half of the group had

some money at the point of leaving, in amounts varying from $11.00 to $331.36.

Of the number having some money, eight

out of fourteen had amounts below $65*00, most of them below $35.00*

Three out of the fourteen had $100.00;

$200*00; and $331*36, respectively.

Another three had

finances that were simply listed as 11adequate.T!

74 One-third of the total group of patients had no money at all.

Out of this group of nine, three received

small amounts from the patients1 fund, but no planning was involved* There were five cases in which the amounts could not be determined from the records* Of the entire group there were only six who had enough means that it could be considered that they could finance themselves for a period of two weeks* Leave plan*

Over one-half (57 per cent) of the

group were released from the hospitals on the basis that they were going to "seek employment.” Five out of the twenty-eight (1$ per cent) had definite employment to which they could return, while four others of the group "hoped” to return to former employment. One person left under a combination training and employment plan, one simply to live with friends, and a third temporarily transferred to a general hospital* In four of the total group, housing was listed as part of their immediate need* III.

PATIENTS’ LEAVE ACTIVITY IN RELATION TO THE BUREAU OF SOCIAL WORK

Examination of the leave activities of the exclusive leave patients in relation to the Bureau provides direct

75 insight into its consistency with convalescent care princi­ ples#

Incidentally, it gives some insight into what this

group of patients considers to be the function of the Bureau, as well as some idea of the kinds of problems which they face#

It was necessary to examine the length of time that

these patients had been on leave at the time of the study in order to know what opportunity they would have had for readjustment activity.

All were guaranteed at least three

months on leave through the arbitrary selection of this period for the duration of the study# The activity on leave is analyzed in two parts: first, at the point of leaving, and, secondly, during the entire leave period* Time on leave*

With the minimum leave period of

three months guaranteed, 42 per cent of the total group (12 persons) were on leave for six months or less at the March 7, 1950, deadline#

It should be remembered that six

other patients were eliminated from this study on the basis of their discharge or return to the hospitals during this period# Only four were included in the period of from six to twelve months, with three of them falling into the eleventh month# Another 42 per cent of the group had been on leave twelve months or more at the deadline, with two out of the

76 twelve over a year and a half Activity at leave*

Three-quarters of the group did

not have any activity in connection with the Bureau at the point of leaving*

In the instance of seven patients that

made some request of the Bureau, their requests are as follows: TABLE VI REQUESTS OF EXCLUSIVE LEAVE PATIENTS AT POINT.OF LEAVE

Type of request

Number of requests Patients: D

G

1 1 1

1

Financial assistance Referral for employment Loan Fund information Lodging Personal relationship problems Referral to V* D* clinic

M

R

1

1

1 1

U

1 1

V

w

1

1 1

1

1

The major need indicated was that of employment in which five out of the seven were asking help*

The next two

needs indicated were financial assistance and help with some problem of personal relationships* Activity during leave♦

Ten (one-third) of the group

did not use the Bureau in any way; only two out of the ten patients having as much as one contact* Three (11 per cent) of the twenty-eight patients

77 maintained a regular reporting contact with the Bureau during their leave, with no indication in the record of any attempt to use the Bureau worker in a special way* One-fifth (22 per cent) of the patients used the Bureau intensively over a special period of time, usually for three months, for help with a special crisis or problem* Two situations involved matters of litigation and two of them were attempts to obtain discharges in which the out­ patient clinic was the focus.

One situation involved a

patient in jail and another one in the hospital* Nine members of the group utilized the Bureau at one time or another in short-term contacts with environ­ mental adjustment problems, such as employment and housing# Table XII in the appendix, Compilation of Patient’s Leave Activity in Relation to the Bureau of Social Work,” is an additional revelation of the sporadic nature of the patient’s activities in relation to the Bureau. IV.

OBSERVABLE FACTORS

INDICATIVE OF LEAVE ADJUSTMENT An attempt was made to gather data on which some evaluation could be obtained as to how members of the exclusive leave group were adjusting to their environment# Personal interviews were held with all social workers who had some recent contact with patients, since specific

78 activities of the patients was considered the best criteria of their adjustment*

The last contacts with the Bureau were

recorded to obtain and validate any judgments. There were only five patients on which this informa­ tion was available, so attention was given also to the elapsed time of contact with the Bureau for the entire group. Last contact*

There were five of the group of

twenty-eight patients with whom the social workers had had recent enough contact to reveal the circumstances of their environmental adjustment. With the remaining twenty-three there had been no contact within three months*

In a group of seven patients

contacted within three and four months, three had been on leave only four months. Following is the distribution of the remaining twenty-three patients according to the number of elapsed months: TABLE VII DISTRIBUTION OF EXCLUSIVE LEAVE PATIENTS BY TIME PERIOD SINCE LAST CONTACT

Months since contact:

3 4 5 6 7 a 9 10 11 12 13 14 15 16 17

Number of patients:

4 3

3 2 2 1

2

3

1

1

1

79 Special note*

One patient in the group of five on

which information was available was a special case in which the patient was temporarily in a hospital and required intensive casework by the social worker.

This patient was

engaged in a vocational training program, was making a good emotional adjustment, and was fairly adaptable to the social activities available in his limited situation. Following is a summary of the adjustments of the four remaining patients: 1.

Employment activity:

Two of the four were

successfully engaged in steady employment while the other two, although employed, had been working intermittently. 2.

Educational activity;

One of the men steadily

employed was engaged in a special training course. 3*

Social activity:

Two of the four who were

steadily employed were represented as moving in a social circle of friends, both outgoing in personality.

One had

been diagnosed as "alcoholic" and the other "manicdepressive psychosis." The other two patients were described as moving in a more restricted circle of acquaintances and activities; one by virtue of a fairly close-knit family circle; the other by virtue of his inability to establish long-standing stable relationships* 4.

Emotional adjustment:

The personality adjustment

so of these four patients was indicated to be on fairly adaptable level*

In three of the four there were some

reservations by the social workers which were based on the long-standing personality structure of the individual* These patients were described as "dependent" and "immature•"

CHAPTER IV

CONSISTENCY OF EXCLUSIVE LEAVE ACTIVITIES AND CONVALESCENT CARE PRINCIPLES This chapter is devoted to relating the activities of exclusive leave patients (Chapter III) to the convales­ cent care principles outlined in Chapter II, in order to determine in what way they are in conformity with each other* The characteristics of the exclusive leave group will be examined in the light of their appropriateness as state mental hospital patients and subsequent candidates for convalescent care* The activities at the point of leave will be expected to reveal some indication of the need of this group for convalescent care service as well as whether there are evidences of convalescent care principles operating at that point* The patients’ leave activities are the most likely area for revealing in what ways the principles are opera­ tive.

The leave adjustment is another indication of the

appropriateness of this group for convalescent care service*

82 I.

ARE EXCLUSIVE LEAVE PATIENTS AN APPROPRIATE GROUP POR CONVALESCENT CARE SERVICE? Examination of the hospitalization characteristics

of this group reveals that they present a range of medical and psychiatric disorders for which hospitalization would not be questioned.

If a sizeable section of this group

were diagnosed as alcoholic, hospitalization and subsequent leave under this plan might be questioned, even though they may be legally committed, since the present methods of treatment for alcoholism are controversial. However, the fact that only 17 per cent of the group were diagnosed "alcoholic without psychosis," and the rest of the group represented a sampling of usual functional and organic disorders, automatically qualified them for proper attention within the hospital and conse­ quently for services in a convalescent care program. The period of hospitalization of exclusive leave patients ranged from one and one-half months to twentynine months, indicating a wide variability of use and response to the medical and psychiatric treatment.

With

57 per cent in the hospital less than six months and 81 per cent under a year, it would be indicated that their response to treatment is within the present desired medical practice of attempting to effect some degree of recovery within the

S3 period of one year*

If the data had indicated that a

proportionate number of this group had remained hospitalized an excessively long or particularly short time there would be some basis for questioning their response or need for treatment* The state residence status of the group threw additional weight in the direction of their appropriateness in this setting*

The fact that Si per cent qualify as

state residents and 65 per cent have resided in the state for ten years or more, clearly places with the state and this community the legal and moral responsibility for their care and treatment* Some question might be raised about ten of the group on the basis of their military service and whether they might not appropriately be using the services of the Veterans Administration Hospital*

Since information on

the eligibility of these ten patients for Veterans Adminis­ tration care was not available in the case records, three possibilities are posed:

clearance with Veterans Adminis­

tration had been accomplished and recorded elsewhere, clearance was in process, or clearance had been overlooked* Under any circumstances, the state hospitals were taking immediate responsibility for their care* Since the state hospitals do not have other limita­ tions on receiving service, such as distinctions of sex or

$4 religion, etc., no questions could be raised as to the groupfs appropriateness in terms of personal characteristics. The personal characteristics of this group, the age, sex, occupational skills, etc., certainly indicated that special consideration would have to be given in any program planning.

The age (53 per cent over forty years old) and

the predominant lack of skill (60 per cent unskilled) creates special considerations for convalescent care that might appropriately require future study.

In general, it

might be said that the fact of the clustering of the group’s characteristics in certain areas indicates some need in relation to Principle 3 (integration of convalescent care services with the hospitalization phase of the treatment process)» In summary it can be said that the characteristics of the exclusive leave patients reveal that they are appropriately the concern of the state mental hospitals and may qualify for convalescent care. II.

CONVALESCENT CARE PRINCIPLES IN RELATION TO PATIENTS’ ACTIVITIES AT THE POINT OF LEAVE

In examination of the activities of exclusive leave patients in relation to the convalescent care principles, the area at which they enter the convalescent care program (the point of leaving the hospital), was deemed significant.

It is around this point of contact of two phases of the total treatment process, the ending of hospitalization and the beginning of convalescent care, that valuable clues might be obtained*

It would be expected that the nature of

a service in progress toward integration with another ser­ vice would evidence variable and limited expression of principles* Initiation of leave*

The fact that three-fourths of

the patients initiated their own leaves might be considered of some significance in their future relationship to the total treatment process* That 16 per cent of the group had their leaves initiated in conjunction with the medical staff, and one entirely by a doctor, is indication that the conception of the total treatment process (the need for movement from one phase to another) is operative to some degree within the hospital setting* Mental condition*

The mental condition of patients

at the point of leave is a single major determinant for their release.

The fact that two-thirds of the group were

released in nGoodft mental condition, and approximately one-third as wFair,tt seems in accordance with the use of the Bureau for supervision (Principle 1). If a sizeable group of the patients had been listed

£6 as having an ,!Excellenttf or "Poor” mental condition the consistency with the supervision principle would be open to question.

In the one case listed as "Excellent” this

might be true. Bureau pre-leave help.

The number of patients

(four out of twenty-eight) who received some pre-leave help indicates that the movement toward integration with other phases of the treatment process (Principle 3) is in operation to some degree* The extensive pre-leave planning in one case, the employment verification in two cases, and the lodging arrangement in one, is consistent with the facilitation of use of community resources (Principle 6).

The extensive

planning and preparatory activity with one patient is consistent with the provision and differentiation of pro­ fessional social work servive (Principles 4 and 5)* For the majority of exclusive leave patients (twenty-four out of twenty-eight) their activities around pre-leave help from the Bureau were not consistent with the convalescent care principles, although the data indi­ cated their need. Personal help*

That one-fifth of the group of

patients received some personal assistance from friends or relatives, yet were not placed on leave to them, is evidence

37 of the conformity with the principle (Principle 1) of supervision within medical limits* The fact that 40 per cent of the group had relatives available to help who were unwilling is not evidence as to the consistency of the activities of this group with the principles of convalescent care, but more of a verification of their need or qualification for its use* Again, the 40 per cent of the group that had no personal ties may be indicative of certain needs, such as their use of community resources (Principle 6).

However,

the data here is not applicable to the question of consis­ tency of practice with principle. Finances at leaving*

With this special group of

patients, it would be expected that their financial status at the point of leaving the hospital would be a critical factor for their initial leave adjustment.

The fact that

only six out of the total group had enough finances to sustain'themselves for a month’s period is demonstrable of their qualification for use of the services of convalescent care.

One-third of the group having no finances at all

lends weight to this point* With three of the group of twenty-eight receiving small amounts from the patient’s fund as the result of hospital referral, this activity coincides with the

aa principles of integration with, and differentiation from, another service (Principles 3 and 4)•

From the fact that

the amount and use of funds was not related to the patient’s leave plan, it is evident that this activity was not consis­ tent with the principle (Principle 5) of providing a pro­ fessional social work service* Leave plan*

Upon their re-entrance into the com­

munity the exclusive leave group demonstrated exceedingly tenuous plans of readjustment*

With over half the group

released on the basis of "looking” for employment, and four others "hoping" to return to employment, it is evident that their plan was such as to qualify them for services of the convalescent care program. Two of the five patients who had definite employment had that employment verified, which indicated that their activities were in concordance with the integration and differentiation principles (Principles 3 and 4)* These principles were outstandingly demonstrated in the single situation of the patient transfer to a general hospital, as was the provision of a professional service (Principle £)♦ Summary *

Examination of the observable factors

influential at the point of leave reveals that they are indicative of the need of the group for various types of

89 help*

Their need for employment, for some type of financial

assistance and planning, etc., indicates that they are appropriate candidates for convalescent care service*

The

fact that they have some potential personal resources (relatives who are apparently unwilling to help them) also indicates some possibility of utilizing convalescent care help* The evidence for a small section of this group of patients points to Principles 3 through 6 as being operative at some level in their pre-leave plans.

The principle of

integration with other phases of the treatment process (Principle 3) and the differentiation of service (Principle 4) were the most coordinate with the activities of the group and appeared to be to some degree interdependent. III.

CONVALESCENT CARE PRINCIPLES IN RELATION TO

PATIENTS* LEAVE ACTIVITY WITH BUREAU OF SOCIAL WORK It is the patients* activities in connection with the Bureau, during the actual period of leave, which should give the clearest indication of the relationship of the group to convalescent care principles* Time on leave*

Examination of the time period

during which this group was on leave is not to determine a parallel with convalescent principles, but simply indicates

90 whether the period is adequate of proper evaluation of activities•

The minimum period of three months established

in the selection of the group gives this guarantee of minimum coverage of activities* The fact that 42 per cent of the patients on leave fell into the three to six month time period, and another 42 per cent in the period of over one year on leave, gives evidence of a broad distribution.

However, since the bulk

of the patients are grouped at both ends of the range of time, a special factor influencing the distribution may be indicated* With 42 per cent of the group on leave over one year without contact there might be some indication of inconsistency with the principle of providing supervision within medical limits (Principle 1), since a year’s leave is usually considered appropriate for consideration of discharge.

This may, however, be indigenous to the activi­

ties of this special group. Activity at leave.

That three-fourths of this group

did not demonstrate activity at the point of leaving in spite of the previous indication of their needs for employ­ ment and other help points to several facts.

It seems

indicated that the general activity of the group at the beginning of leave is not consistent with the two convales-

91 cent principles that might be expected to be operative at this time, those of integration with the hospital service and facilitating the use of community resources (Principles 3 and 6)• The group of seven patients that had some activity at leave revealed that it was coordinate with the prin­ ciples of differentiation of social work service, its integration with the hospital, and its link with the community* Examination of the services indicates that the services requested (employment, financial assistance, personal relationship problems, etc*) are consistent with the usual professional service of social work (Principle 5)* The two major requests received from six out of seven patients for financial assistance and employment throws some light on the need for a facilitating and integrative service between the community and the hospital*

The nature

of the problems presented indicates some consistency with the principle (Principle 7) of convalescent care functioning to the degree that the community takes responsibility for its mentally ill* Activity during leave♦

With the exclusive leave

group, which in many ways represents a group least apt to receive special attention in a new and developing program,

92 the activity on leave is quite revealing.

The irregular

nature of the use of the convalescent care program may be some substantiation of the conception that the convalescent care principles are in various stages of application. For one section of the exclusive leave patients— two-fifths of the group of tiventy-eight— the principles were not seen to be in evidence even to the most established principle of providing supervision under medical limits (Principle 1).

It was this group where two out of eleven

had as much as one contact* Eleven per cent of the group demonstrated by their irregular supervision contact with the Bureau that there was a consistency with the first principle.

For the rest

of the group that had contacts there was a sporadic adherence to this principle. The one-fifth of the group that used the program intensively for special periods indicated clearly that the principle of providing a differentiated service was operative.

For two-thirds of these patients the matters

involved activity consistent with the principle (Principle 5) for provision of a professional social work service and was particularly demonstrated in one case.

The additional

one-third, in their attempts to obtain discharges in the outpatient clinic, was involved in matters related to a differentiation of service (Principle k) and integration

93 with the hospital (Principle 3)* The short-term activities of eight of the exclusive leave group show them to be consistent with the differentia­ tion of service and facilitating use of community resources (Principles 4 and 6). Summary.

It was determined by the distribution of

the time periods of patients on leave that their activities would be susceptible to consideration. Examination of those activities at the beginning of leave disclosed that for most of the patients there was not a demonstration of the convalescent care principles.

There

were activities by a small section of patients which were indicative of convalescent care principles being operative. The activity during leave did show a consistency with convalescent care principles and suggests the variable level of development of the various principles.

The group’s

use of the Bureau in different ways (for supervision reporting contacts, for help with intensive problems, and for short-term service) is substantiation of this variation and partialization of service. IV.

CONVALESCENT CARE PRINCIPLES

IN RELATION TO LEAVE ADJUSTMENT ACTIVITIES An evaluation of the patients’ leave adjustment activities was undertaken in order to determine if the total

94 adjustment qualified them for convalescent care and revealed a consistency with the convalescent care principles.

A

compilation of the dates of last contact with the Bureau was made to establish the validity of this evaluation, and revealed that the limited number of patients in recent contact would not give an accurate total evaluation of the group.

Some observations can be made on the data regarding

last contacts with the patient which are indicative of their activities in relation to the Bureau. Last contact.

Since only five of the group of

twenty-eight patients (18 per cent) were seen recently enough to obtain proper evaluation of their leave adjust­ ment, there was not enough sampling to reveal the general level of the group.

It might be assumed that since most of

the patients had not returned to the Bureau or been called to their attention, and were not known to be in trouble, that they were making enough of an adjustment to remain in the community.

However, there was information in two of

the cases that made their adjustment open to question. From the fact that over two-thirds of the group (68 per cent) had not been seen within the regulatory three month period it seemed evident that the activities of most of the group were not consistent with the most established principle of being supervised within medical limits

95 (Principle 1).

The group as a whole did not eventuate in

using the convalescent care program as a continual link with the community, and as a group they tend to separate themselves from it. Leave adjustment.

The five patients of the exclusive

leave group on which adequate information about leave adjustment could be obtained were not considered numerically sufficient to draw valid generalizations for the entire group.

Pour of these five patients who were engaged in

usual community activities were evenly split as to the mode of that activity. Two of the group were successfully engaged in the employment, education, social or emotional aspects of their surroundings.

For these two, the success of their adjust­

ments would open to question their present appropriateness as convalescent care patients. The other two patients, with a more limited or inter­ mittent adjustment record, would indicate that their leave might be considered consistent with the need for convales­ cent care help. Summary.

From the information on the date of last

contact it would seem that the activities of the group were not in conformity with the principle of being supervised. The limitations thus placed on the knowledge of the leave

96 adjustment made it impossible to consider whether the group was appropriate to the continued service of the convalescent care program*

CHAPTER V

SUMMARY AND CONCLUSIONS Summary♦

The purpose of this study was to consider

in what way the activities of,a special group of patients, the exclusive leave patients, were consistent with the established conception and principles of convalescent care* Chapter II revealed that there was a developing conception about the convalescent care service to the mentally ill that viewed it as one of a series of services including outpatient treatment, hospitalization, and community education.

It was seen as an integral and inter­

acting phase operating in conjunction with the other phases in a continuum of activity termed "the total treatment process."

It was found that this process was in the period

of differentiation of its own function, while at the same time accomplishing an integration of itself with the other functions within the total treatment process* It was also found that this development was taking place in the convalescent care program in California.

In

examination of the program and its evolution as part of a total treatment process, seven principles were shown to be in effect.

These principles, listed below, were shown to

be in various stages of formulation and development: 1*

The convalescent care program provides patient

9$ supervision under direct medical responsibility and limits*

2m

The convalescent care program is in movement to

operate as a Department-wide service* 3*

The convalescent care program is in movement

toward integration with other phases of the treatment process*

k*

The convalescent care program is a movement

toward a differentiation of its professional service from others in the Department* 5*

The convalescent care program is in movement

toward providing a professional social work service within certain operational and. administrative limits* 6*

The convalescent care program serves as an

increasing link with, and facilitates use of, the resources of the community* 7*

The convalescent care program has developed on

the basis of the degree to which the community assumes responsibility for the treatment of the mentally ill* Chapter III revealed the characteristics, the problems and activities of a special group of leave patients, those who are the exclusive leave responsibility of the Bureau of Social Work.

Compilation of the personal

and hospitalization characteristics revealed that this was a predominantly unattached male group, over thirty years of age, occupationally unskilled and state residents.

Their

99 periods of hospitalization, type of illness and mental condition were all found to be compatible with utilization of convalescent care* Generally, the group was found to be without help or plans at the point of leaving the hospital, although a small percentage had used financial help, help from rela­ tives and Bureau services* Their activity at leave and during leave revealed a quite variable relationship to the Bureau in supervision, short-term and intensive contacts, although a high propor­ tion did not use it at all*

There was not enough data

available to draw adequate conclusions about their leave adjustment* Chapter IV indicated that their hospitalization and need at point of entering the community were such as to make the group appropriate for convalescent care*

For

limited proportions of the group of exclusive leave patients, their activities at various points in the program revealed a consistency with certain of the established principles of convalescent care*

Principle 1 of providing supervision;

Principle 3 of integration with other phases of the process; and Principle 1+ of the movement toward differentiation of the service, were particularly in evidence. For the greater proportion of the patient group at any one point, their activities were not demonstrative of

100 consistency with convalescent care principles* Adequate evidence was not available for consideration of the patients’ present leave adjustment* Conclusions*

For the exclusive leave group of

patients it is evident that there are needs and character­ istics which make it an appropriate group for use of the convalescent care program*

It would appear that for the

exclusive leave group of patients the principles are in effect to a limited degree* This study, since it was exploratory, revealed a wide range of problems in a convalescent care program that is in process of growth and change toward fulfilling the conception of the total treatment process.

The variation

in principle and practice opened up a number of areas for study and in some sense gives an overall view that assists in establishing priorities of investigation* Innumerable other factors would be involved or * f introduced in consideration of any one of the problems revealed, such as financing, quantity and quality of personnel, level of community resources, and of casework practice*

It is considered enough simply to indicate broad

areas where fruitful investigation might be conducted*

An

allied study is indicated which could investigate the activities of the agency (hospitals and Bureau) in relation

101 to convalescent care principles* The level of age and occupational skill, combined with the period of hospitalization indicates a problem of rehabilitation services of significance for patients re­ entering the community.

Investigation of the realistic

problems in pre-leave planning of finances, employment and lodging, as related to community readjustment, would be a valuable contribution, as would some examination of the personal relationship problems demonstrated in the potential resources of relatives for these patients* The problems in asking for and receiving help from the Bureau immediately upon leave is indicated as important. The investigation of the factors involved in the varied use of the Bureau by patients on leave would be exceedingly valuable, and would be a contribution to deepening the understanding and use of the present seven principles of the convalescent care program. This exploratory study has revealed repeatedly that the convalescent care program is in a dynamic process of development.

It is seen to be in fluctuation and movement,

both from the standpoint of its internal practices and its external relationships to other phases of the treatment process. Capturing some perspective on such a dynamic program, with its complex activities and various stages of develop­

102 ment, provides the most challenging of tasks for investi­ gator and practitioner alike* It is hoped that this study will open the way for further investigation and clarification of various aspects of the convalescent care program as a phase of the total treatment process#

BIBLIOGRAPHY

A*

BOOKS

Crutcher, Hester B., Foster Home Care for Mental Patients* New York: The Commonwealth Fund, 1944. 199 pp. Deutsch, Albert, The Mentally 111 in America* Columbia University Press, 1949* 555 pp.

New York:

French, Lois Meredith, Psychiatric Social Work* The Commonwealth Fund, 1940* 344 pp*

New York:

Jaffary, Stuart K., The Mentally 111 and Public Provision for their Care in Illinois* Chicago: University of Chicago Press, 1942* 207 pp* Rennie, Thomas A. C., and Luther E* Woodward, Mental Health in Modern Society* New York: The Commonwealth Fund, T 94 BT 424 pp* B*

PERIODICALS

Arrington, Winifred W., "Some Vocational Aspects of Psychia­ tric Social Work,” The News-Letter of the AAPSW, X, No* 3 (Winter, 1940-41 J T T ^ l 5* "Attacks on Mental Hospitals," Editorial in Mental Hygiene* XXX, No. 3 (July, 1946), 353-54. Bateman, J* Fremont, and H. Warren Dunham, "The State Mental Hospital as a Specialized Community Experience," The American Journal of Psychiatry, CV, No. 6 (December, I 9 W ; - ™ 4 4 5 ^ -------- ------Bellsmith, Ethel B., "The Mentally 111 Patient," The NewsLetter of the AAPSW, XI, No. 1 (July, 19411, 3-3• Bigelow, Newton, "Opening the Doors of the Mental Hospital to the Public," Mental Hygiene, XXXIII, No* 3 (July, 1949), 366-75* Crutcher, Hester, "The Function of the Psychiatric Social Worker in a Mental Hospital," The News-Letter of the AAPSW, XII, No. 1 (Summer, 194277 3^11.

105 DeWitt, Henrietta B., ”Family Care as the Focus for Social Case Work in a State Mental Hospital,” Mental Hygiene, XXVIII, No. 4 (October, 1944, 602-31. , tfThe Function of the Social Worker in the Total Treatment Program in a State Mental Hospital,” The American Journal of Psychiatry, CV, No* 4 (October, 19'W), ^9^302T;------- ------Hambrecht, Leona M., ”Beyond A Decade.” The News-Letter of the AAPSW, X, No. 2 (Autumn, 1940;, 7-12. Hamilton, Samuel W., ”The Mental Hospital in the Program of Mental Health,” Mental Hygiene, XXVII, No. 3 (July, 1943), 403-11. Maletz, Leo, ”Family Care— A Method of Rehabilitation.” Mental Hygiene, XXVI, No. 4 (October, 1942), 594-o05. McBee, Marian, ”The Responsibility of the Citizen in Bridging the Gap Between Mental Hospitals and Com­ munity,” Mental Hygiene, XXXIII, No. 3 (July, 1949). 376-85. Osborne, Maysie T., ”The Use of Family Care as a Treatment Procedure with the Mentally 111,” Mental Hygiene, XXVII, No. 3 (July, 1943), 412-23. Rennie, Thomas A. C., Temple Burling, and Luther Woodward, ”Vocational Rehabilitation of the Psychiatrically Disabled,” Mental Hygiene, XXXIII, No. 2 (April, 1949).

200- 8 .

Tallman, Frank F., ”A State Program of Mental Health,” Mental Hygiene, XXXII, No. 2 (April, 1948), 271-78.

^

White, Ruth Romig, ”The Social Service in the State Hospitals of Illinois,” Mental Hygiene, XXVII, No. 4 (October, 1943), 354-73. Witmer, Helen Leland, ”Basic Conceptions in Social Work Research,” Mental Hygiene, XXXII, No. 1 (January, 1949), 108-14. C.

OTHER SOURCES

Circular Letters, Department of Mental Hygiene, State of California:

106 "Unemployment Assistance for Paroled Patients," Circular Letter No. 1, Extramural Care, November 1, 1940* "Discharge of Patients from Industrial Parole," Circular Letter No, 267, May 16, 1941# "Guests or Emergency Transfers," Circular Letter No. 337* October 2, 1941# "Mass Transfers," Circular Letter No, 342, October 10, 1941# "Paroling Patients Against the Will of the Guardian," Circular Letter No, 367, November 19, 1941# "Incidental Needs of Family Care Patients," Circular Letter No. 403, January 13, 1942# "Stenographic Help for Extramural Service," Circular Letter No. 409, January 19, 1942* "Social Workers and the Skeleton Crew Law," Circular Letter No. 412, January 20, 1942* "Publicity Regarding Boarding Home Program," Circular Letter No. 555, July 7, 1942. "Plan of Organization for Bureau of Social Work in the Department," Circular Letter No. 1296, March 1, 1946* "Policies and Procedures Involving the Bureau of Social Work," Circular Letter No. 1332, May 24, 1946. "Program of the Bureau of Social Work," Circular Letter No. 1395, November 29, 1946. "Coordination of Social Work Program," Circular Letter No. 1912, February 1, 1950. Minutes of Superintendents1 Conferences, State Department of :Mental Hygiene, State of~“California: Superintendents’ Conference, San Francisco, June $-9, 1942. Superintendents’ Conference, Sacramento, November 12, 13 and 14, 1942. Southern Superintendents’ Conference, Los Angeles, July 13, 1943#

107 Southern Superintendents1 Conference, Los Angeles, August 17, 1943• General Superintendents* Conference, Sacramento, October 1415, 1943* Conference of Superintendents, Board of Trustees, and Medical Advisory Board, San Francisco, July 26-27, 1944. Northern Superintendents’ Conference, Sacramento, November 10, 1944. General Superintendents’ Conference, Los Angeles, September 12-13, 1945. General Superintendents’ Conference, Los Angeles, September 30 and October 1, 1946. General Superintendents’ Conference, Sacramento, February 17-16, 1947. Final Report, The Governor’s Conference on Mental Health, Sacramento, March 3-4, 1949* 99 pp. Kolb, Lawrence, M. D., ’’Social Work Program of the Department of Mental Hygiene,” Letter to National Institute of Mental Health, April 25, 1949. Manual of the Los Angeles Regional Office, Bureau of Social Wor k, Department of Mental Hygiene, State of California, (unpublished)• ’’Mental Health In America,” Southern California Society for Mental Hygiene, Los Angeles, February, .1950. 2 pp. . (mimeographed)• Report of the Continuing Committee on Mental Health, Governor’s Conference on Mental~Health, December 16, 1949. 23 pp. (Mimeographed). Rosanoff, Aaron, M. D., ”Letter: To All Patients in State Hospitals, Their Relatives and Friends, State-Hospital Employees and Officers, Judges of the Superior Courts of the Various Counties, and Others Whom it may Concern,” Department of Institutions, State of California, April 27, 1940. The Langley Porter Clinic-Dedicatory Ceremony, February 13, 1943, Department of Institutions, State of California

103 ,fThe Psychiatric Social Worker in the Psychiatric Hospital,” Group for the Advancement of Psychiatry, Topeka, Kansas, Report No* 2, January, 1943. 14 pp* Sommer, Conrad, and Jack Weinberg, techniques and Factors Reversing the Trend of Population Growth in Illinois State Hospitals*” Unpublished paper distributed in the State Department of Institutions* Welfare and Institutions Code and Laws Relating to Social Welfare,“"State of California. Printing Division, Sacramento, California, 1947*

APPENDIX

110 TABLE VIII CHARACTERISTISTICS OF EXCLUSIVE LEAVE PATIENTS

Ethnic Case Sex group Age Education

Military service Religion

A

M

W

36

High school

None

Protestant

B

M

W

43

Army

Protestant

C

M

W

27

College 1 yr. High school

Army

Protestant

D,

M

W

49

High.school

Protestant

E

M

W

50

None

World War I None

Catholic

F

M

W

35

None

None

Protestant

Occupation Restaurant worker Clerktypist Cabinet maker Kitchen worker Bath attendant Laborer

Marital status

State Date of Date of Children residence commitment leave

Single

None

Life

5/48

11/48

Single

None

1923

12/48

3/49

Single

None

16 mos.

1/49

9/49

Divorced

1

1943

12/48

3/49

Separated

None

1922

5/49

10/49

Married

5

1942

6/47

9/49

Diagnosis Alcoholic Psychosis Alcoholism

Previous Previous commitment leaves 1939

Escape

None

None

Dementia Praecox- None Catatonic Alcoholic 1943 Psychosis None Psychosis-drugs Traumatic Psychosis

None

Escapes (two) None None 7/47 8/47 12/47

escape l/48 escape 4/48 10/48

None

Catholic

.49 High school

None

Protestant

College 4 yrs. High school 2 yrs.

None

Catholic

None

Protestant

25

3th grade

None

Catholic

W

55

3th grade

None

Protestant

W

21

G

M

W

47

R.

M

N.

I

M

W

63

J

F

W

25

K

M

W

L

M

M

M

5th grade

F

w

25

0

M

w

44

Jollege 3 yrs. ligh sc’ 2 yrs.

None

Married

Restaurant worker Domestic Produce worker Odd Jobs, painter

4

1923

4/47

9/49

Separated

None

1939

11/48

2/49 '

Divorced

3

1925

7/48

12/48

Divorced

1

17 mos.

3/47

10/48

Divorced

None

1933

12/48

4/4/49

Married

1

1944

11/47

2/24/49

Alcoholic Psychosis Alcoholic with­ out Psychosis Involutional Melancholia Dementia PraecoxCatatonic Alcoholic without Psychosis Alcoholic Psychosis (Chronic Deterioration) Primary behavior disorder-simple maladjustment Manic Depressive

Catholic

Machine operator

Married

1

1946

9/15/49

12/5/49

Protestant

Clerical

Divorced

None

Life

9/5/49

12/1/49

Protestant

Lather

Separated

None

1924

6/18/49

10/19/49 Alcoholic Psychosis

3 yrs. N-

Restaurant operator Houseman

8/48

escape 5/49 6/48 8/48 None

None

None

None

1943

9/47

None

7/48 escape None

None

None

None

1945

1945

None

1943 (2)

None

Ill TABLE V I I I

(c o n tin u e d )

CHARACTERISTISTIC S OF EXCLUSIVE LEAVE PATIENTS

Ethnic Case Sex group Age Education

Military service Religion Protestant

M

W

68

6th grade

None

Q

M

W

41

R

M

W

34

College 3 yrs. 7th grade

Navy 4 yrs. Army

s

M

W

40

None None

Protestant

Occupation

»Marital status

Tailor

Divorced

Protestant Office clerk Protestant Culinary

Catholic

State Date of Date of Children residence commitment leave_____ Diagnosis 1924

9/4/48

12/17/48

Single

None

1911

11/13/47

8/5/46

Separated

1

1930

2/10/48

2/23/49

Divorced

3

Life

6 / 1/49

7/21/49

Laborer

Married

None

1924

9 / 25/48

9/10/49 ' 12/6/49

Public relations

Alcoholic Psychosis-Acute Hallucinosis Dementia PraecoxCatatonic Psychosis with SyphiliticMeningoEncephalitis Manic Depressive Circular Type

Previous Previous commitment leaves 1929

None

None

None

None

None

None

None

None

4 / 15/49

T

M

N

41

High school business college 4th grade

U

M

W

23

3th grade

None

Protestant

Writer

Single

None

1946

8 / 14/48

V

M

N

34

high school

Army

Protestant

Landscaping

Separated

None

1939

10 / 15/48

4/28/49

Alcoholic without None Psychosis

w

M

W

32

None

Army

None

Separated

1

Life

6 /1 7 / 4 9

12/7/49

X

M

W

41

None

Christian Science

Single

None

1939

7/9/48

4/30/49

Alcoholic without None Psychosis Dementia Praecox- None Paranoid

Y

M

W

46

High school business college 4th grade

Truck driver Cook

None

Protestant

Cook

Single

None

1903

10/20/48

1/25/49

Z

M

w

17

None

Catholic

Student

Single

None

Life

11/2/48

11/3/49

AA

M

w

49

High school x yr • 5th grade

WW I ^

Protestant

Laborer

Divorced

2

14 mos.

8/1/49

9/14/49

BB

M

w

26

College

None

Protestant

Radio

Single

None

1943

6/6/47

1/5/49

i

Alcoholic Psychosis Manic Depressive

Alcoholic Psychosis Primary behavior disorder Undifferentiated Psychosis Manic Depressive Circular Type

None

(1 mo.) 1/16/49 to 6/18/49 1/29/49 to 4 /8/49 None None

None

None

None

None

1943 (2 yrs.) 1940 (6 wks.)

None None

112 TABLE IX COMPILATION OF CHARACTERISTICS OF EXCLUSIVE LEAVE PATIENTS

SEX



26 males 2 females (7$)

ETHNIC GROUP

RELIGION

AGE GROUPS

OCCUPATION

..........

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

........

. .

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

Caucasian Negro Other

25 3 0

(11$)

Protestant Catholic Jewish Christian Science Under 21 to 31 to 41 to 51 to 61 to

21 30 40 50 60 70

1 6 6 11 2 2

Unskilled Semi-skilled Skilled

Id 9 0 1

75$ over age of 30 53$ over age of 40

17 7 4

Sixty per cent of the group are unskilled. There was evident discrepancy between reported occupations and the actual work which had been performed* EDUCATION

............... 7th grade or less d - 30$ Grammar to 3 yrs* of high school 7 - 26$ High school to 3 yrs. of college 11 - 40$ Completed college 1 - 4$ 56 $ 96$

not completed high school not completed college

113 TABLE I X

(c o n tin u e d )

COMPILATION OF CHARACTERISTICS OF EXCLUSIVE LEAVE PATIENTS

MARITAL STATUS

....

Single Married Separated Divorced

9 - 32% 5 - 1&% 6 - 22% 8 — 28%

One-third single 50% separated or divorced None One Two Three Four Five

RESIDENCE

Unknown 1 Non-residents 5 14 mos., 16 raos., 17 mos., 2 yrs., 3 yrs. Since 1940 4 Since 1930 4 Since 1920 8 Born residents 6

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

16 7 1 2 1 1

- 57% - 25% - 3*5% - 7 % - 3*5% - 3*5%

NUMBER OF CHILDREN . . .

81% are residents PERIOD OF HOSPITALIZATION

Range from l| mos. to 29 mos.

57% under 6 mos. 81% under 1 yr. During hospitalization 4 had escapes and 5 had leaves DIAGNOSIS

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

Alcoholic Psychosis Alcoholic Schizophrenic Manic-depressive Organic-PSME and Traumatic Involutional

114 TABLE IX (continued) COMPILATION OF CHARACTERISTICS OF EXCLUSIVE LEAVE PATIENTS

DIAGNOSIS (continued)

.. . Drugs • • . Primary Behavior Disorders Undifferentiated Psychosis

1 2 1

46% are alcoholics 17% alcoholics without psychosis MILITARY SERVICE

. . . . 8 World War II 2 World War I No clearance on V. A., eligibility

NOTE: The foregoing compilations give important information on the patients under study and serve to indicate the relationship of this group to the problem of aftercare for mental hospital patients.

TABLE X OBSERVABLE FACTORS INFLUENTIAL AT POINT OF LEAVE

. Personal preInitiation Mental ■ condition leave help Case of leave A

Patient

Good

B

Patient

Good

C

Good

D

Patient and brother Patient

E

Patient

Fair

F

Patient

Fair

G

Patient

Fair

H

Patient

Fair

I

Patient

J

Finances at leaving

None Father and brother un­ willing Foster par­ Unknown ents in East

Leave plans

Bureau pre­ leave help

Seek employment

None

Return to former employment, attend trade school on GI Bill, electrician Seek.employment,, live with brother

None

None - $10 patient.fund

GI Aero School and part-time work

None

None

Siblings in Los Angeles will help None, mother in Columbia, S. A. None

Unknown

$35

Seek, employment

None

None

Seek employment

None

None - $5 patient fund 165

Seek employment

None

Seek employment

None

Fair

Wife, unwilling Wife, unwilling Wife gone; cousin, unwilling None

Patient

Good

None

K

Patient

Good

0

Patient

Good

P

Patient

Fair

None, friends patient unwilling None, friends None

Q

Patient

Good

R

Patient

S

Patient

Sister, unwilling Good Two sisters, unwilling Excellent None

T

Patient

Good

U

Good

V

Patient k Doctor Patient

w

Patient

Good

X

Doctor

Good

Y

Patient

Good

Z

Patient k Doctor Patient k Doctor Patient k Doctor

Fair

AA BB

Good

Good

Good Good

Unknown - money Seek employment in account None Escape changed to leave, seek work Hopes return to $16 former job A, „ A former job

None

$331.36

Hopes return to former job Seek employment

None

Seek employment

None

Seek employment and housing Definite job

None

Return to former job Seek employment; lodging at YMCA Return to former job

None

$50, OAA due Adequate finances $30 None

Sister, not $12 interested Sister, $11 unwilling Parents East ,Unknown separated from wife Mother, can­ None not help Parents in $54 Jugoslavia Father in None Oklahoma Parents, Available rejecting None Unknown Parents in Unknown Iowa; friends

Seek employment, disability ins. Live with friends Hopes return to former job Transfer to LAGH: treatment plan Return to definite employme nfc Seek employment

None None

None

None

Lodging Employment clearance None None None Casework Help Employment clearance None

H* M vn

TABLE XI PATIENT’S LEAVE ACTIVITY IN RELATION TO BUREAU OF SOCIAL WORK

Case Leave date A

11/24/4&

Activity at leave None

B

3/2/49

None

C

10/29/49

None

Activity during leave 3/24/49^ To contact patient 3/2&/49T To contact patient 4/49 Worker’s attempt to il/49 Worker’s attempt to 3/49L 4 / 6/491

contact contact (No Activity)

To contact patient Patient reporting 5/49 Patient reporting 9/15/49L To contact patient 9/27/491 Patient reporting 11/491 Patient reporting l/ 50 T Patient reporting (Supervision Activity) 11/5, 11/15, 11/29/49 - Patient reporting 12/13/491 Friend reporting; patient in jail 12/16/491 With patient in jail; reporting 12/27/491 Patient’s brother and City Defender 1/3/501 Patient and City Defender 1/6/501 Patient and City Defender I/25 / 5OI Patient’s brother 2/21/501 Patient’s brother and City Defender 2/23/501 Probation Officer 2/2&/50T Patient’s brother 3/1/501 Patient reporting 3/2/501 Patient reporting (Intensive Activity)

TABLE X I (c o n tin u e d ) PATIENT'S LEAVE ACTIVITY IN RELATION TO BUREAU OF SOCIAL WORK

Case Leave date

D

9/22/49

Activity at leave

9/23/49 - $10 assistance, OSES referral, Loan Fund information

E

0

3/7/49

None

9/23/49

None'

9/6/49

9/7/491 - $5 assistance

H

2/25/49

None

Activity during leave 10/26/49L To locate patient 10/31/491 Patient; Public Assistance, housing, Psych, care, pension claim. 11/31/491 Patient; employment referral 11/25/49L Patient; V. A. adjudication (Short-term Activity) 3/22/491 Patient; financial assistance, employment referral 3/2$/491 Patient reporting 5/25/491 To locate patient (Short-term Activity) 10/15/49L To locate patient 11/15/49L To locate patient I/ 12 / 5 OT. From BPA, aiding wife and children, patient asking aid (None) 9/15/49T Patient1s lawyer 9/19/49T Patient’s lawyer 11/15/49T Patient’s lawyer 11/15/491 Patient reporting 11/21/49T Patient’s lawyer 12/16/491 Patient requesting discharge 12/24/49T Patient; medical insurance 12/30/49T Patient; laid off work (Short-term Activity) 4/491 Patient reporting 5/491 Patient reporting 6/49, $/49, 8 / 4 9 T - Patient reporting

TABLE XI (continued) PATIENT'S LEAVE ACTIVITY IN RELATION TO BUREAU OF SOCIAL WORK

Activity at leave

H (continued)

12/2/48

Activity during leave S/19/49I 12/19/49

None

3/491* 1 0 /l0 / 4 9 1

7/23/48 escape

None

10/ 14/48 leave

9 / 15 / 4 ST 9 / 27 / 4 ST

10/9/4SI 1 0 /1 9 / 4 ST 10/27/ifSL 1 0 / 29 / 4 ST 12/S/4SL 1/21/491 4/11/491 1 /1 1 / 5 0 1 2/6/5OT.

K

4/4/49

None

5 / 4 /4 9 I

Patient; changes in employment Worker attempting to contact patient (Supervision Activity) Patient requesting money from hospital account To hospital requesting patientfs money (Short-term Activity) Friend; clinic date set Friend; patient will not attend clinic Patient; evaluative and supportive Friend; patient has left To contact patient Friend reporting To contact patient To contact patient To contact patient To contact patient; returned BPA; patient married; another son in Alabama; agencies indicate patient disturbed (Intensive Activity) Friend reporting; no contact since (No Activity)

911

Case Leave date

TABLE X I (c o n tin u e d ) PATIENT’ S LEAVE ACTIVITY IN RELATION TO BUREAU OF SOCIAL WORK

Case Leave date

Activity at leave

2/24/49

None

M

12/5/49

N

12/1/49

12/6/491 w Referrals for lodging, CSES special section, trouble with motherin-law None

0

10/19/49

None

12/17/43

None

Activity during leave 3/491 Patient reporting 4/491 Patient; release of funds 3/6/491 Friend reporting 3/27/49T Med. Soc. Wkr., patient in LAGH (Short-term Activity) 12/24/491 Patient; financial aid, referred to BPA 2/16/50T Friend; patient in jail (Short-term Activity) None 11/491 11/49L 1/19/49T 3 / 11 A 9

8/18/491 1/10/50T

1/16/501

1/ 3 1 / 5 0 T

(No Activity) Patient; money from hospital To hospital (Short-term Activity) To BPA and landlady to verify patient’s status Visit to contact patient Patient; in LAGH 4 mos* BPA seeking patient At BPA and home to contact patient BPA; patient’s whereabouts un­ known; condition bad; return authorized to Sheriff (No Activity)

TABLE XI (continued) PATIENT'S LEAVE ACTIVITY IN RELATION TO BUREAU OF SOCIAL WORK

Case Leave date Q

8/5/48

Activity at leave None

R

2/23/49

2/24/491 - Referrals to CSES, VD clinic

S

7/21/49

None

9/10/49

None

Activity during leave Patient requesting discharge; to handle own money; clinic appoint­ ment arranged Package for patient 9/6/L8 9/10/48T Patient's sister reporting 9/23/481 With patient to clarify OP clinic and psychiatric care 10/5/481 Patient1s sister reporting 10/9/481 Patient; OP clinic l/18/491 Patient; supportive Sister; patient leaving town 3/7/49T 5/18/49L Detective's report on patient San Diego worker to investigate 6/49L 8/24/49T Sister; patient not good II/IO/49 I Patient's sister reporting 1/50T Patient's sister reporting (Intensive Activity) Report from patient 3/4/49L To contact patient 4/6/49L (No Activity) Worker attempted to contact 10/7/49 11/16/49L To contact patient Worker contacted patient, 3/1/501 reporting (No Activity) Worker attempted to contact 11/7/49 11/25/49L To contact patient (No Activity)

8/20/481

TABLE XI (continued) PATIENT'S LEAVE ACTIVITY IN RELATION TO BUREAU OF SOCIAL WORK

Case Leave date U

12/6/49

V

4/28/49

W

12/7/49

X

4/30/49

Activity at leave

Activity during leave

12/12/49T Patient reporting job 12/13/491 Patient; referral to vocational rehabilitation 1/16/501 Patient; lost job 2/14/501 Patient; broke; worker interceded with landlady 2/16/501 San Francisco Wkr.; financial assistance; referral to Travelers Aid 2/20/501 To discuss work leave placement 2/27/501 Placement in private sanitarium; money for transportation 3/10/50T Patient reporting (intensive Activity) Patient; asking help to get 4/28/491 - Patient 4/29/49T money owed him; no help asking help to get Patient; in trouble with landlady clothes from landlady; 7/7/491 clearance on employment11 /23/49^ To locate patient (Short-term Activity) None 12/9/491 - Patient requesting funds and job; carfare given and aid obtained from BPA at VSC (No Activity) Patient; help on lawsuit; employ­ None 5/4/491 ment; medical care; none 5/10/491 Patient; help with medical records and employment; none

12/6/491'- Lodging arranged and supportive interview

121

TABLE XI (continued) PATIENT*S LEAVE ACTIVITY IN RELATION TO BUREAU OE SOCIAL WORK

Case Leave date

Activity at leave

X (continued)

Activity during leave 5/16/491 6/7/491 9/2/49T IO/2 B/ 49 L 1/5/501

Y

1/25/49

None

2/14/491 3/7/49I 6/7/491 6/10/49L 6/17/491 2/23/50

Z

11/3/49

None

12/4/491 12/9/49T 12/16/49T 12/19/491 1/4/50T 1/9/501 1/11/50T 1/27/50T 1/30/50T

Patient; employment and lawsuit; referral to CSES Patient giving up on employment through Bureau office; attorney dropped case To locate patient To locate patient Patient^s former employer; patient gone (Intensive Activity) Patient reporting With landlady; patient well Patient; disability insurance Disability insurance Patient reporting Worker called at home, patient not there, works regularly (Short-term Activity) Clarification with hospital LAGH, plans for patient LAGH, Bureau responsibility LAGH worker contacted Patient*s parents, plans Parents, problem of son and plans for care LAGH Wkr., parents* plans LAGH Wkr., patient ready to leave LAGH, patient to stay until home found

TABLE X I (c o n tin u e d ) PATIENT»S LEAVE ACTIVITY IN RELATION TO BUREAU OF SOCIAL WORK

Case Leave date

Activity at leave

Activity during leave 1/31/50T

Z (continued)

2/3/50T 2/&/50T 2/10/50T 2/14/501 2/23/50T 2/24/50T 2/27/50T 3/1/50T 3/3/50T 3/6/50T AA

9/14/49

None

BB

1/5/49

None

Crippled Childrens Society, regarding home Vocational Rehabilitation, training Hospital Dr*, plans for patient Appointment call Patient, Dr*, Soc. Wkr*, and 0. T* progress report Patient’s mother, plans; Camarillo, plans; conference with Dr*, plans LAGH, plans Patient’s mother, plans; Camarillo, clearance Patient’s father; LAGH plans LAGH; patient’s father, plans; conference, family care plans Camarillo, medical clearance (Intensive Activity)

None (No Activity) Patient; money; referral to Vocational Rehabilitation 4/4/491 Patient reporting S/26/491 Patient, to continue leave 1/20/50L Telegram to contact patient 2/20/50L To contact patient 2/15/50L To contact patient _______ . _________ ISupervision Activity) 1/19/49

TABLE X I I

COMPILATION OF PATIENT'S LEAVE ACTIVITY IN RELATION TO THE BUREAU OF SOCIAL WORK

Case

ABCD EFGH U K L MNOP QRST UVWX YZ AA BB

Supervision contacts with patients: Services requested by patients:

Collateral contacts initiated by:

1 26

56 Number of interviews Financial aid discharge requests Employment Housing Claims Individuals Agencies

Worker’s attempt to Letters contact patients..':* Telephone Field calls Collateral contacts initiated by Agency worker with:* Individuals

2 1 1 1 1 I 1 1 1 1 1 2 1 1

14

1 1

1

1 1

11 2

5 2

1

* 2 3 1

1

5 3

4 2 3

2

2

2

1

1

1

1

2 1

1 2 2

1.

512 1 1 6 2

12 1 12 1 2 1

2

31

1

111

4

1 1

2

2

1

1

1 2 1

12

1 14 26

*These categories are not pertinent to this study but were included in compilations.

TABLE X I I I

OBSERVABLE FACTORS INDICATIVE OF LEAVE ADJUSTMENT

Last Case contact1Employment Education A B

1/50

C

3/2/50

D E F G H I J K L M N 0 P Q R S

11/49 3/49

Social activity

Emotional adjustment

11/48

Working steadily

Attending radio television school

Inter­ mittent

Moves in circle of friends; lives at . . gym; ”black sheep” Close relations to family; ”black sheep;” moves in~family circle only

Fairly good; immature

Active in business and community life; lives with two older children

Good insight

Immature; dependent goodnatured

9 /4 9 12/49

8 /4 9 3/49 10/48

4 /4 9 4 /4 9 12/49 12/49

11/49 8 /4 9

1/49 3 /4 9 3/50

Working None steadily; $100 w k .; promotions

TABLE XIII (continued) OBSERVABLE FACTORS INDICATIVE OF LEAVE ADJUSTMENT

Last Case contact Employment Education T U

9/49 3/50

V W X Y

Z

7/49 12/49 6/49 11/49 3/50

AA BB

9/49 7/49

Working and living in sanitarium; handyman

Vocational training program

Social activity

Emotional adjustment

Outgo ing; so ciable moves on own

Good; dependent

Hospitalized; moving into boarding home;

Good adjustment to all except parents