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Family care program: A descriptive study of the family care program at the Neuropsychiatric Hospital, Veterans Administration Center, Los Angeles

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Family care program: A descriptive study of the family care program at the Neuropsychiatric Hospital, Veterans Administration Center, Los Angeles

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Content PmiLY CARE PROGRAM: A DESCRIPTIVE STUDY OP THE FAMILY CARE PROGRAM AT THE NEUROPSYCHIATRIC HOSPITAL \ VETERANS ADMINISTRATION CENTER LOS ANGELES A Thesis Presented to the Faculty of the School of Social Work University of Southern California In Partial Fulfillment of the Requirements for the Degree Master of Social Work by John J. Appleby, Jack G. Larsen, John Robert Muegge, Curtis Hawley Stevens June 1955 UMI Number: EP66541 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. Disisertaîfen P^blibteng UMI EP66541 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 LLC. 789 .East Eisenhower Parkway P.O. Box 1346 Ann Arbor, Ml 48106-1346 9^^ ê u i- 'SS This thesisj written under the direction of the candidate's Faculty Committee and approved by a ll its members, has been presented to and accepted by the Faculty of the School of Social W o rk in partial fulfilm ent of the requirements for the degree of MASTER OF SOCIAL WORK Dean Date.» 147/, JOm J . APPL2BY, JACK G. IAR8EN, Faculty Committee .. Chairman TABLE OF CONTENTS i ! Page I LIST OF TABLES..................................... v| Chapter | I. INTRODUCTION..................... .......... 1 The Setting Research Design II. STATISTICAL FINDINGS....................... 101 ! Disposition Compared with Adjustment and | Movement j Age Compared with Disposition, Adjustment, j and Movement j Education Compared with Disposition, ! Adjustment, and Movement I Diagnosis Compared with Disposition, Adjustment, and Movement Hospital Experience Compared with Disposition, Adjustment, and Movement Family Care Experience Compared with Disposition Family Care Homes Compared with Disposition, Adjustment, and Movement Summary III. PATIENTS RECEIVING MHB DISCHARGE ...... 24 Hospital Adjustment Family Care Adjustment Summary IV. PATIENTS RETURNED TO THE HOSPITAL 33 i Hospital Adjustment Family Care Adjustment Social Worker*s Prognosis Attitude Toward Sponsor iv Chapter Page Attitude of Family Worker’s Evaluation of the Home Summary V. PATIENTS STILL IN FAMILY CARE................ 44 Summary VI. SUMMARY AND CONCLUSIONS..................... 53 BIBLIOGRAPHÏ.......... 58 APPENDIXES I. Tables..................................... 6l II. Schedule . ............................... 64 LIST OF TABLES Table Page 1. Disposition Compared with Adjustment and Movement . . . . . . . . . 13 2. Diagnosis Compared with Disposition, Adjustment and Movement................. . l6. 3. Hospital Experience Compared with Disposition, Adjustment and Movement .... 17 4. Family Care Experience Compared with i Disposition........................ 19 5. Family Care Homes Compared with Disposition, Adjustment and Movement ..... 21 6. Age at Placement Compared with Disposition, Adjustment and Movement .......... 60 7. Education Compared with Disposition, Adjustment and Movement .......... 6l CHAPTER I I i INTRODUCTION . i i The Family Care Program, at the Neuropsychiatrie Hospital, Veterans Administration Center, Los Angeles 25, California, is the placement of carefully selected patients in private homes. , There has not been a study made of this Family Care j I Program to date and, since it has passed the experimental j I stage of development, a study at this time seems vital. j i I Care for mental patients in family care homes has been drawing considerable interest as a promising vehicle for moving improved patients out of neuropsychiatrie hospitals. This interest is increasing because patients benefit from this treatment and also because of the dilemma being pre- icipitated by overcrowding in all neuropsychiatrie hospitals. ! !A study of this program at this time should prove valuable to the hospital and also of Interest to other neuropsy chiatrie hospitals across the nation that may wish to ini tiate or improve family care programs. ^Neuropsychiatrie Hospital, Veterans Administration Center, Los Angeles 25, California, will be hereafter referred to in the text as the hospital. 2 It is the purpose of this study to evaluate and describe the Family Care Program as it has been in opera tion at the hospital. This study is limited to an objective review of the program and does not attempt to make compari- > i :80ns with other similar programs in other hospitals. In i : I doing this, a close look has been taken at the patients and the family care homes; that is, what factors involved in placement of patients in homes have resulted in success and what factors have caused patients to be returned to the ' I hospital. It is also the purpose to draw theoretical con- | jelusions, based upon this study, in order to facilitate the : irefinement and expansion of placement of neuropsychiatrie patients in family care homes in the future. The early care of the mentally ill in homes other than their own began in the village of Gheel, Belgium during the sixth century.^ It was not until l882 in America that two mentally ill patients were placed in homes ' 2 other than their own in the state of Massachusetts. By I the early 1930*s this method of caring for the mentally ill was seen as a continuation of hospital treatment and its ^Horatio M. Pollock, Family Care of Mental Patients (Utica, N.y. : State Hospital Press, 1936), ppTlL13-l^. ^Horatio M. Pollock, "Brief History of Family Care of Mental Patients in America," The American Journal of Psychiatry (Nov. 19^5), P* 351. 3 use has been steadily increasing up to the present. How ever, there is by no means general acceptance of family care i ^ 'programs. In 1947 there were only six states which had I ; ’ • % 'over one hundred patients in family care homes. By the lend of 1952 only three hundred and five patients had been placed in homes other than their own from all Veterans Administration Neuropsychiatrie Hospitals in the United 2 States. Family care programs for mental patients have not I I Igained as wide acceptance as the foster care programs for | I f Ithe placement of children. There are many reasons for this I I ' ' ! jdifference in public acceptance of these programs. His- | i ; I Î itorically, society has felt a great moral obligation to care for the dependent child by placement in an atmosphere which resembled a home to some degree, whereas the care of the mentally ill adult has been directed toward the protec tion of the community from the person by institutionalize- , jtion. The factors that cause child dependency, such as jparent death, have been easily understood and accepted by society. The causal factors of mental illnesses have not i been understood, thus causing great fear and suspicion ^J. Mayone Stycos, "Family Care; A Neglected Area iOf Research," Psychiatry (August, 1951), p. 302. 2 i Proceedings of Institute on Foster Home Care i(North Little Rock VA Hospital, 1953), P* 4. 4 toward the person who acts In a peculiar manner. A small boy caught urinating in the street is sent home to his mother, but an adult would be institutionalized for the same behavio# regardless of the motivation for this act. The great child care movements during the nineteenth century were directed toward mass foster home placement. At the same tim% many great buildings were erected for the custo dial care of the mentally ill in order to protect society. During the last ten years, the knowledge and interest about mental illness has increased and the emphasis is now placed on returning the patient to the community rather than on custodial care. The family care programs for mental patients have borrowed much from the foster care programs for children. As with children, the homes must be carefully selected to meet the individual needs of the particular patient. Many of the same basic psychological factors are seen in both I programs. They provide security and supervision in a warm 'accepting atmosphere on an individualized basis. Ego- i identification and development toward emotional maturity is offered to the child as well as the mentally ill patient whose illness is in such remission as to permit continued growth. Finally, the motivation for families* participa tion in these programs has some basic similarities, such as the desire to help someone in a less fortunate position 5 although the monetary factor appears to play a greater part in motivating families to care for mental patients* Community acceptance of the mental patient in a j I ' I I family care home is not on a par:, with the acceptance of | I ! jthe child foster care programs. The fear and stigma | attached to mental illness is slowly being overcome through public education programs; however, it appears that our social thinking as a nation has a long way to go in this area. I The Setting i ! ! Many hospitalized patients could be returned to the ! I community if it were not for the fact that they either do not have a family or their family for some reason is not able to accept them. The main emphasis of the hospital is directed toward intensive treatment, rehabilitation, and the eventual return of the patient to some type of coramuni- ! ;ty life. The Family Care Program is used in carrying out this philosophy. It was first inaugurated at the hospital 'in 1950 when the pilot phase was started. It was not until 1953 that it became actively operative. The program is open to improved patients who are considered capable of living on the outside, but who have no place to go. Inter ested patients must, however, be deemed potentially 6 qualified for successful functioning in a family care home by the hospital staff before placement is considered. Also the patient must be able to pay the entire cost of his board and care which averages about $100.00 per month. I The sponsor is a family that takes a patient into its home and, undervsupervision of the family care social caseworker, assumes responsibility for his welfare. Most of the sponsors have taken the initiative in contacting the hospital for participation in this program. Patients leave the hospital in a number of ways. I Some go directly to the Domiciliary Home, some are com- jpletely discharged, MHB, a large number go on Trial Visit. iThis latter affords an opportunity for the patient to test the gains made in the hospital in the more stressful com munity situation with the help of the social worker. Family Care is one form of Trial Visit in which the patient is placed in a home other than his own. It is the respon- jsibility of the family care social worker, a member of the I hospital social service staff, to help in the selection of !a patient for placement in a family care home; to select an appropriate home for this particular patient; to complete I licensing arrangements with the State Department of Mental Hygiene for the home; to help the patient sustain and advance the improvement made while in the hospital; to help the sponsor accept the patient; and to make reports of the patient*s adjustment and evaluation of the home and sponsor for the medical staff Research Design | This study was undertaken by four social work stu- ; dents at the hospital. They are Mr. J. Appleby, Mr. J. Larsen, Mr. J. Muegge, and Mr. C. Stevens. It is a descrip tive study utilizing the social service records, the clini cal records, the claims files, the correspondence files of I Î I the patients in the program, and the records'kept on the : I I ifamily care homes where these patients were placed. The i I administrative aspects of this study were handled by the j group’s faculty thesis instructor. Dr. Maurice B. Hamovitch. The other members of the committee included Miss Josephine Di Paola, Miss Dorthea M. Lane, Head Social Worker, and Mr. Robert Emerson, Family Care Social Worker. The study involves the patients who participated in I the Family Care Program of the hospital between January 1, 1953 and August 31, 1954. The beginning date of the period was the time the program shifted from the experimental stage of development to an accepted phase of treatment offered by the hospital. The latter date used for the cut-off date for the study was selected so that all patients still in ^"Veterans Administration Social Service Manual," (Undated Mimeographed Pamphlet), Section E, b, 1. 8, family care homes had been in placement for at least three , months. The universe, or total number who have been in the i program to the present time, is 48 patients. Of this num- g ber there were 4l patients who participated in this program; ! • I ! during the period under study. Since one of the patients | was a female veteran who was in a family care home only five days, it was decided to exclude her from the study, j leaving a sample of 40 male patients as the total study ! group. I I Each student examined all available records and I iextracted pertinent information for 10 cases. This in- i i i j eluded the 17 family care sponsors* records that were used i jin this study. | One schedule with three parts was prepared to guide the student group in the extraction of information from the case records. A copy of the schedule may be found in the ; appendix. Part I includes identifying data, diagnosis at I I I time of placement in the program, length of stay in the i I , I hospital, doctor * 8 prognosis, social worker * s evaluation of the patient as a candidate, and reason for choosing the i home. Part II covers the home and provides identifying data, locale and type of home, its previous use in the pro-| gram, the social worker*s evaluation of it, and the spon sor's motivation for participation in the program. Part i I III covers the period of the patient's stay in the home 9 including such material as how he adapted, why he returned ito the hospital or did not return. I Two scales were used in the schedule to evaluate I the patient's adjustment and movement. The family care : worker's evaluation was Interpreted in terms of the scale by the student group members and each interpretation was checked by another member of the group. The professional judgment of the individual members proved to be consistent. Each student ran a pilot study on one case to test ■the construction and use of the schedule and scales. The ! I . I I work and responsibility for the total project was divided { I I equally among the four students. Each student had an equal| ! i Î Î part in the collecting, analyzing, and presenting of the data. The following chapters present the statistical data, a description of those patients discharged, those ; returned, and those still in the home as of the final date ; I of this study, as well as a chapter of conclusions. The appendix includes a copy of the schedule, some statistical tables; a bibliography is also included. CHAPTER II I STATISTICAL FINDINGS I ' I A statistical presentation of the more objective material is presented here in order to provide a framework for the understanding of the program. Of the 40 patients included in this study, 10 have been discharged with raaxi- " 1 mum hospital benefit (MHB), 10 have been returned to the ! hospital, and 20 are still in family care homes. Tabula- ' tion has been made of various factors in relation to dis position, adjustment, and movement. The factors considered ^ objective enough to be tabulated were: age, education, clinical diagnosis, hospital experience such as number and 'length of hospitalizations, family care experience, and the homes used. It was found that race, religion, and occupa- Ition were not meaningful in this study. Race was not tabu- ! lated because only three of the veterans were listed as races other than white. Religion was not tabulated because 1 of the difficulty in determining the degree of participa tion. Occupation was not tabulated because the information available was too general and diverse. In considering ^MHB will be used throughout to denote maximum hospital benefits. 11 marital status as a factor, it was found that only two of the 40 patients were married and four others had some imarital experience, giving the group considerable homoge- Ineity. ! As was mentioned in the introduction, a scale was used to evaluate adjustment and movement. Adjustment is graded according to good, marginal, and poor. The evalua tion was based on such factors as recreational, vocational, avocational interests, and the general social adjustment in I the home and community as reported by the family care j ! ! I worker's quarterly reports. Movement was graded according ! i to improved, stable, and regressed. The evaluation was ! : / ! based totally on the family care worker's quarterly reports as interpreted by the group. As used in this study, im proved indicates that the patient has shown positive move ment since placement. Stable indicates that there has been : no significant change in the patient's clinical appearance land regressed indicates that his level of functioning was I 'not as high as shown in the hospital. Disposition Compared with Adjustment and Movement Of the 40 patients included in this study, one half were still in family care homes, one quarter had been re turned to the hospital, and one quarter had been discharged I MHB. Only one of the patients discharged made a poor 12 adjustment and none were rated as Improved on the movement scale. On the basis of this statistical information it might be predicted that the majority of the patients will ; eventually be discharged as only three patients have shown poor adjustment and none have regressed. This is discussed further in Chapter V. These three groups are shown and compared with adjustment and movement in Table 1. ^ Age Compared with Disposition, Adjustment, and Movement The age of the patients is at the time of placement! The span of the patients in this program ranges from 21 to j 78 years. It is noteworthy that in contrast to the family | care programs in many other hospitals, 30 of the 40 pa tients are under 50 years of age, and 22 of these are under 40 years of age. Most of the patients placed in family care programs have been in the older age brackets.^ In addition to the fact that this program is focusing on the treatment of a younger group of patients, it is significant' that age does not seem to be a limiting factor in disposi- tion, adjustment, or movement. Table 6 showing age at time of placement as compared to disposition, adjustment, and movement is placed in the appendix. ^George Kent, "Home Instead of Hospital," Survey Graphic. Vol. 37 (1948), pp. 315-317. 13 •o (D 1 C Q 0 > C Q lT \ 0 Lf^ 0 K © bO B ■ -P a © m Q > A § S A CO c\j m 'C O w (D 0 $ A > > -P o O C O m: S A 1 © s > c v j CO 0 ^ A 0 < M A E H W a E H - CQ u p 0 CO A 0\ CO 0 1 —1 rH A P M 4a c A W 0 ) 1 A P Q E H s ÎH C C J ■ = t - CO A 0 ^ H -p c d C A A E h Is C Q S A 3 b O A • 0 s < a j T3 0 CO VO 0 b - P L , 0 A s 0 o o s A o « J 0 0 0 0 A + 4 1 —1 1 —1 CM Eh 0 H A CO O © A P4 CO C 0 cd H 0 •0 -PA 0 A •H © cd bO Td-P Ü >s A ( h © a a a © C d C A A 0 A A Pj © A S PL (d 0 A 3 0 A © © -P © S P A A <p A 0 A © P A A A « C O 14 Education Compared with Disposition, Adjustment, and Movement j I The veterans placed in the family care program Irepresented a variety of educational backgrounds covering ^grade school through college. Although eight of the patient's educational backgrounds are unknown, it was felt that knowledge of this would not significantly alter the findings. As can be seen from Table 7 in the appendix, .education does not seem to have an effect on disposition, Iadjustment, or movement. I Î Diagnosis Compared with Disposition, Adjustment, and Movement All of the patients placed in family care homes had been diagnosed as one of three psychoses, namely: Schizo- t jphrenia. Manic-depressive, or "Organic Brain Pathology." IThere were 36 patients who were diagnosed as schizophrenic at time of placement, one manic-depressive, and three with organic brain pathology. The general diagnosis of schizo phrenia and the various classifications of types did not bring forth any significant differentiation when compared to disposition, adjustment, and movement. As there was only one patient diagnosed as manic-depressive, no significant conclusions could be drawn. This patient was still in the 15 family care home. All three of those patients diagnosed as' having organic brain pathology were discharged. None of these patients had made a poor adjustment or had regressed ; i as can be seen from Table 2. | Hospital Experience Compared with | Disposition, Adjustment, and Movement There were 28 patients who had one or less previous hospitalization. Of this group eight had been discharged, I six returned, and l4 were still in the home. There appears| I I I to be no significant difference between this group of 28 | I patients and the 12 patients who had two or more hospitali-| zations when they are compared as to disposition, adjust- i ment, and movement. This can be seen in Table 3* Only eight of the patients included in this study : had previous hospitalizations of two years or more. As can be seen in Table 3, there is no significant difference in i disposition, adjustment, or movement in this group and I those 32 patients with one year or less of previous hospi tal experience. There is considerable variation in the length of time these 40 patients have been in this hospital as is shown in Table 3* The range is less than one year to over 20 years. There are no significant differences in disposi tion, adjustment, and movement in relation to the length of l6 Q > V3 , 0 9 I < a ; k I r - 4 •s w 1 <M M g I ^ A I M I If . C S S t o c i3 § •rt a o A to •rt A e g *§ E - i « 9 •H I A L f \ t r \ KN CM 8i P K\ CM rH I—I KN rH rH rH 8 2 O $ A a t EH vO K\ CM CM CO ITS lA CM CM CM fA A CM O A A CM lA tA A CM lA CM A A O CM O rA O A A tA A A A A A O ' -O lA LA A g 6 L 1 tJ • r l •H Q > < r J 4» « CM O O O CM A A A O O tA tA I 0 (0 1 o o A I TABLE 3 HOSPITAL EXPERIENCE COMPARED WITH DISPOSITION, ADJUSTMENT AND MOVEMENT Disposition Adjustment Movement Type of Experience M H B Returns in Rome Good Marginal Poor Improved Stable Regressed No. Total 10 10 20 13 I4 13 22 13 5 Previous Hospital Admissions None I4 5 3 6 7 2 5 7 4 3 I 14 3 3 8 4 6 4 9 3 2 2 5 I I 3 I 3 I 4 I 0 3 4 I I 2 I I I I 3 0 4 2 0 I I 0 I I I I 0 5 or more I 0 I 0 0 0 I 0 I 0 Years Total 10 10 20 13 14 13 22 13 5 Length of Previous Hospitalization None 12 4 2 6 7 I 4 7 3 2 0- I 20 5 6 ? 5 9 6 12 5 3 2 - 3 6 I I 4 I 4 I 3 3 0 4- 5 0 0 0 0 0 0 0 0 0 0 6-10 0 0 0 0 0 0 0 0 0 0 11-15 I 0 0 1 0 0 I 0 I 0 16-19 0 0 0 0 0 0 0 0 0 0 20 or more ■ I G I 0 0 0 I 0 I 0 Years Total 10 10 20 13 I4 13 22 13 5 Length of Current Hospitalization 0- I 7 2 3 2 ■ 3 2 2 4 2 I 2 - 3 10 4 3 3 2 4 4 5 4 I 4- 5 5 2 I 2 2 2 I 3 2 0 6-10 13 2 2 9 5 4 4 8 3 2 II-I5 I 0 0 I 0 I 0 I 0 0 16-19 I 0 I 0 0 0 I 0 0 I 20 or more 3 0 0 3 I I I I 2 0 18 time these patients have remained in this hospital. It is generally believed that patients remaining in a mental hos pital over a year have a more difficult adjustment to make ; 1 I when returning to their communities. This, however, is not| i ' I i borne out here. ! i I Family Care Experience Compared with Disposition ! The length of time spent in the family care homes by the patients who have been discharged ranged from one month to over 21 months. This is discussed further in i Chapter III. It is significant that eight out of the 10 I patients were in family care homes six months or more as i can be seen in Table 4. In contrast to those patients who I i were discharged, eight out of the 10 patients who were ,returned to the hospital were in family care homes six imonths or less. Seven out of the 10 returned patients were I I in family care homes three months or less. This is shown in Table 4 and is discussed further in Chapter IV. All of the patients who are still in family care : homes have been in placement more than three months. Of these 20 patients, 17 have been in placement more than six : months. On the basis of length of time in family care, it might be supposed that all 17 of the patients remaining in a home over six months would be discharged. This is not true as there are many other factors which effect the 19 TABLE 4 FAMILY CARE EXPERIENCE COMPARED WITH DISPOSITION Time in Home Total MHB Returns Still in Home Total 40 10 10 20 1-3 months 8 1 7 0 3- 6 months 5 1 1 3 6- 9 months 12 3 1 8 9-12 months 9 1 0 8 12 or more 6 4 1 1 20 'eventual disposition of these patients and are further dis cussed in Chapter V, The number of patients still in family care homes and the length of time is shown in Table ;4. Family Care Homes Compared with Disposition, Adjustment, and Movement Table 5 shows considerable variation in the number of patients who have been placed in each home* Five of the 1 117 homes have had one patient, five have had two, six have i I had three, and one home has had seven patients. There is i also great variation in the disposition, adjustment, and movement of the patients placed in each home. This is sig- ;nifleant in the fact that it demonstrates the need to match, on an individual basis, each patient with each home. The home is a good example of the importance of : matching the patient*s emotional needs to the emotional and personality structure of the family in which he is placed. ■ This home, which consisted of a middle-aged couple who had no children, cared for two patients. One patient was re- ,turned to the hospital and one was discharged MHB, remain- Iing in the home following his discharge. The patient who was returned to the hospital did not adjust well because his particular needs were not met by the great deal of 'attention which he was receiving. He wanted to be left 21 lA î I i P G4 s B Q 8 B ii § 1 • t S < D (0 to I 3) M I a rH ® fl -p •H G Q 3 h T? *d < r s o o C ÎJ § • r l s a n A < p W to *§ % ® § ® f£ w ^ *d f l 3 ® M ^ o A A LA I I I I r-4 I i-l I I r-t < î «<-« I rH | | | JA r - t If-t # PA # # M M (M I lf-4 ltAr-i I r-l C V J CVIr-1 IC Ü IA C V } IC V I I r-l O j M r4 (M I r-i rH CVl K\ rH I I I K\ I iH ^ iH IrH IrHCVll I I hA & lrHr-4<\JrH r~t (A iHiH IGjrAI l(M I ICVJrH i ; I r-l | | | O rH I I I lA I I C\J I rACM I W <W fArH rH CVl O I I I IfAlrHrHrHlrHrH lrHlrHI O OJrHcHCJrHOJl I I I lfH| I I | I rH ^ t A iH rH C V l r -C M •-* K> »H f A K> C V J C V l l A N> C V l n O S < t { p Q O Q j j q i x , e j { r j H i - a W P f ^ ^ O |X « C3 r o E h 22 alone. The patient who succeeded in this home was extremely happy with all the attention he received. He was described ; i I ■as a benign old gentleman who made a good adjustment from j ; ' I I the ver% beginning. I I I The most frequently used home studied by the group I was the home. The sponsor was a 56 year old white I widow who lived alone in a rural frame house. Because of its location the home was found to be suitable for the more chronic and regressed patients. Also this woman's attitude itoward the patients seemed especially adaptable for the ! ! I 1patients whose prognosis was uncertain. Mrs. ”e" was not a j I j Iparticularly warm person nor was she domineering. Instead, | I ! I She gave the patients a free rein and only supervised their i activities when it was necessary. There were seven patients Iplaced in this home from the entire group of 40 patients studied. Besides the one patient who was discharged MHB and who remained in the home, there were three who had to return ! ; ito the hospital and three who are still in the home. I I All but one of the homes was located within a 50 ; |mile radius of the hospital. Some of the homes were urban ! j ^and some were rural. Similar variations existed in the ! Ifamlly composition of the sponsors such as widowed persons and couples with other family members still in the home. iThe only factor which seemed consistent was the sponsors* motivation for participation in the family care program. 23 This was given as a need to supplement their present income. In addition to this monetary motivation, the majority of the sponsors liked people and wanted to help mental patients- j I (recover. • i ; I Summary ! A careful analysis of the charts and tables estab lishes the fact that there is no "magic formula" for the selection of patients for the family care program based on jobjective statistical information. No factor or group of i i I |factors such as age, education, diagnosis, hospital experi- ; lence, family care experience, or particular homes used could be used as criteria for either good or poor candidates or sponsors for the family care program. This chapter has given the reader a "bird*s-eyeview" of the study. The following three chapters describe those patients who have been discharged; those returned to the hospital; and those who were still in family care homes as :of August 31, 1954. CHAPTER III PATIENTS RECEIVING MHB DISCHARGE The emphasis In the family care program of this hospital is considered a continuation of hospital treatment, under the supervision of the family care social worker and the ultimate goal for the patient is to free himself from I ■ I I dependency on the hospital. As was pointed out earlier in j I the study, the social worker's role is to help the patient I i i ; sustain and advance the improvement made while in the hos- i pital and to make reports of the patient's adjustment.^ It is on the basis of the family care social worker's quarterly reports and recommendations that the patient's disposition is decided upon by the medical staff. Ten of the patients placed during the period I studied were ultimately discharged MHB. The length of time I I in foster care prior to discharge for this group of ten patients ranged from one month to twenty-one months. The mean for this group was 10.7 months. The patient who was only in family care one month made a marginal adjustment in the foster home, but was discharged upon resolution of his ^Supra, p. 6. 25 marital problem and reconciliation with his wife. Two of the four patients in foster homes for a length of time greater than twelve months had their trial visits in the j I 'homes disrupted by a return to the hospital for short ! i j iperiods of a little over a month each. Following their i : - I return to the homes, they began a new trial visit period. i This explains why one patient was in family care as long as I twenty-one months. The reason the other two patients were in family care longer than the limitation of one year was [ I I ! an administrative delay caused by the legal establishment | ; I I of guardianship. ! I Hospital Adjustment I I ' An analysis of the patients in this group revealed that nine of them have made what was considered a good hos pital adjustment prior to placement. Also it was felt by : the medical staff that nothing further could be gained by keeping these patients in the hospital setting. The prog- 1 jnosis of these patients by the doctors was generally consi- idered guarded but with a qualifying statement such as, "patient seems stabilized and it is felt he is ready to leave the hospital." An exception to what was considered a good hospital adjustment prior to placement in this group was a very regressed and mute catatonic patient. His placement was 26 'considered an experiment. He was placed in a very warm home where the sponsor had demonstrated previously a skill in iworking with mute patients. Although he needed a great deal ^ I I of supervision, he made a fairly good adjustment from the | ' I : very beginning. Except for reservations in the latter I experimental placement, the social worker's prognosis and evaluation of this group prior to placement was positive. i Family Care Adjustment I I , j I It normally would be expected that this group would! ! have made a good adjustment in the home and the community. I I However, according to the adjustment rating of these ten | ! ' patients by the study group it was felt that while six were rated good, three of the group could be only rated ,marginal in interpersonal relationships and one was rated , poor. A typical patient in this group who made a good jadjustment was a thirty-seven year old single veteran. ! Mr. Lint grew up in a home with four siblings. His older brother took over the duties of the I father who died when the patient was still an infant. He served two years in the Army Air Corps; the last ! two months of his service was spent in an Army hos pital under psychiatric examination. The patient was committed involuntarily to this hospital with a diagnosis of schizophrenic reaction, hebrephrenic type, a year after his discharge from the service. 27 Six and one half years later Mr. Lint was placed in a foster home. His diagnosis at the time of placement was schizophrenic reaction, paranoid type, treated, partial remission, impaired judgment. He was considered legally incompetent. He was referred because he had shown marked improvement during the year and one half prior to placement and had made an excellent ward adjustment. The family was unable to assume responsibility for him. His brothers were rejecting and the mother was in a rest home. How ever, they were willing for him to leave the hospital and enter family care. Both the doctor and the social worker felt that the patient was stabilized and that he had the capacity for establishing good relationships and for adjustment in community living. The patient was placed in the home of a middle- aged white couple whose two children were married and living away from the home. Both the sponsor and her husband had previous experience working with mental patients as aides in a mental hospital and possessed a good understanding of the mentally ill. Mr. Lint liked both the sponsor and her husband on whom he was especially dependent. He received considerable supervision and protection in the home and on the job. The only areas of maladjustment or complaint were that he easily became lost in the neighborhood and developed a panic; also that he was quite suggestible and would easily be imposed upon if not supervised. The patient liked picnics and car rides and he made trips to various points of interest that were arranged for him. He was parti cularly interested in work around the house including gardening. Mr. Lint made a remarkably good adjustment from the very beginning. He settled down in the home almost at once and was soon working as a general handyman in the shipping room of a factory whfere the sponsor's husband worked. He started at $26.00 per week and was raised shortly, to $41.00 per week. His adjustment remained good until June 1953, when he abruptly refused to go to work. It became evi dent that he felt under considerable pressure on the job, became quite anxious, fearing that he might not be able to perform satisfactorily. He was unable to sleep at night and began drinking excessively. 28 and became abusive and argumentative. He was returned to the hospital 7/23/53 against his wishes. It was felt that he was pushed too far and was expected to perform above his capacities and that removal from the situation for a short period would alleviate his anxiety. The patient soon regained equilibrium and was returned to the same home where he again made a good adjustment. The study group rated this patient's adjustment *'good" and his movement "improved." He was discharged 12/11/54 after twenty-one months in family care and remained in the home. Although this patient's adjustment and progress in the family care program was typical of this group, his case is unique in that he had to be brought back to the hospital i i ifor a short period following a psychotic episode. There ! ! ■ ! jwas only one other patient who had a similar development in | i j ithis group and he was placed also in the "d" home. The j sponsor and her husband were too eager in their desire to see the patients fully rehabilitated* Mr. "d" found part- time jobs for them but soon the jobs developed into full time. The added work pressures caused great anxiety in ! these patients and brought on a psychotic break which (necessitated their return to the hospital. ; There were three patients in this group who were Igiven a marginal rating. The patient who was only in family care one month was one of these. One month was hardly enough time to make a valid evaluation of his adjustment. He seemed to adjust well but there were periods of irrita bility and because of these moods and his failure to take an 29 active interest in recreational community activities the ,group hesitated to rate his adjustment as good. His move ment was rated stable. The second member of this group of tlu'ee with a marginal adjustment rating did show positive movement but due to his senile state and poor physical condition he needed constant supervision. He had no recreational, voca tional or avocational interests. This patient was in family care twelve months when he was discharged. Since he I had no living relatives and was quite happy in the home in {which he was placed he remained in the home after his dis- I charge. A marginal adjustment rating was given to a third patient although he, too, showed movement while in family care. This patient showed some improvement in the first ninety day period, securing a part time job in a garage and; service station. However, he participated in no other ^ {activities out of the home and was not receptive to super- * vision from the sponsor. He used very poor judgment in the ; 'handling of money and when he was declared competent, receiving his own benefit checks, he spent money foolishly. After he was in this home eight months he left and moved into a hotel near the hospital. Subsequently, he was placed 'on TV in his own custody and was discharged MHB four months later. 30 The following is a brief history of the patient who was given a poor adjustment rating, but who received MHB discharge from this hospital. There may be some question for classifying him as belonging in this group considering other factors in this case. Mr. Sun Lin is a twenty-eight year old, single, Chinese veteran who served in the Navy three years. He has two brothers living in the United States. His father and two other brothers are still living in China. The patient spent the last six months of his military service in Naval Neuropsychiatrie Hospitals and was transferred directly to this hos pital. His diagnosis was schizophrenic reaction, chronic undifferential type. The precipitating stress for his illness was unknown. Because of response to therapy during the last year the patient was considered suitable for main tenance in a foster home and was placed after seven years of hospital care. Mr. Sun Lin's placement was considered with some misgiving because he was a very regressed, catatonic patient. The plan was to find a permanent home since his brothers were rejecting of him and disinterested in his welfare. Mr. Sun Lin was placed in the home of a Negro family which was located near Chinatown. This home had been used previously for another Chinese patient and the home was found to be extremely warm and attentive to patients. The sponsor was especially skillful in handling mute patients and possessed a sincere desire in helping people. The patient had no objection in being placed in a Negro home and expressed a desire to live in the home on the initial visit and refused to look at any others. He needed and received a great deal of supervision, for he was quite untidy and very careless about his personal appearance. Other than some social drinking the patient made a poor community adjust ment. At least he did not have any recreational, vocational or avocational interests. 31 According to the family care social worker's report the patient improved from month to month and became more and more aware of his surroundings. However two months prior to his scheduled discharge date the patient eloped from the home. It was learned that he had gone to San Francisco, had been picked up by the police, and been admitted to another mental hospital. For administrative reasons the I patient was given a discharge from this hospital. The group rated the above patient's movement as improved for his attitude underwent a remarkable improve ment the eight months he was in the family care home. Also his adjustment improved as the months went by and he began I to relate extremely well to the foster family and with j those with whom he drank socially in Chinatown. If he had I not eloped, this patient's adjustment rating undoubtedly would have been good. His elopement shortly before dis charge and his request to enter another hospital apparently indicated that he had not gained sufficient strength to . accept the fact that he would be free of his dependence on the hospital. I Summary ' In analyzing this group of patients who have been ! discharged, one is struck by the fact that this is not a unique group of patients. These ten patients have been hospitalized in fourteen other mental hospitals and in all ' the group spent forty-three years in hospital care. They 32 represented a variety of severe mental illnesses. Seven of the group had a diagnosis of schizophrenia; three suffered | jfrom organic brain pathology. It is evident that all types | {of mental disease can benefit from family care placement, lit is true that nine of the group made a good hospital : adjustment prior to placement but this does not differen tiate the group from those who did not succeed in family 'care. Although these patients were very sick the irapor- I I I tant fact remains that in order to make a successful place-| I I j ment, the foster family must be understanding of the needs | I I ! of the patient placed in their home. They must be able to j : . ! accept patients on the levels at which they are capable of { functioning. Furthermore, care needs to be taken that the patient is not extremely over- or underplaced. That is, he needs to be placed in a home that approximates his i I standard of living. Therefore, the selection of a home is ■ I based primarily upon the individual needs of the patient and one which offers good therapeutic possibilities. : CHAPTER IV I I I PATIENTS RETURNED TO THE HOSPITAL I : ! Ten of the patients placed in Family Care homes needed to be returned to the hospital because of failure to adjust satisfactorily to the community living situation. Eight of the ten returned within three months of their placement and both of the men who stayed in homes longer , I I : gave definite indications of inability to adjust during the j ! ' I ; first three months. One regressed immediately after he was I placed but then gradually improved enough to warrant an i extension of the placement provided additional help could be given him. He was given electroshock therapy on an out- .patient basis and this sustained him sufficiently to enable ; ! him to stay in the home for nine months before he regressed' I so severely that his return was necessitated. The other ' ’was also very regressed from the start but the family care {worker felt that perhaps a change of homes might enable him to make a better interpersonal adjustment. He moved after three months in one home and was able to stay in his second .home for nine months before he became so sick that he had to return to the hospital. After two months in the hospi tal placement was again attempted in a third home and this 34 : time the patient stayed only eighteen days before he began acting out in an antisocial manner and had to be taken back to the hospital. Except for the two cases in which special effort Î i was made, the range of time spent in the home by these : patients who were not able to adjust was from twenty days to three months, six days. This supports the findings of previous studies which have indicated that the first three month period is the most critical in Trial Visits.^ It can I be concluded that, unless special effort is made, the ! I patients who cannot make good use of the program will ireturn within three months. This does not mean that j special effort is not warranted in individual cases for some patients have made a marginal adjustment at first but with help have improved to the point of making a very satisfactory adjustment. It does establish that unless the patient gives definite indication of improvement in this i I period, he is unlikely to derive continued benefit from I i placement. Hospital Adjustment Each of the ten patients had made an adjustment to ^Jimmie D. Barr, et al., "The Short-Term Trial Visit" (unpublished Master*s thesis. School of Social Work, U.S.C., 1954). 35 the hospital environment termed "good" before being placed in a home. It is the policy of the Family Care Program to limit consideration of candidates to those who have made a good adjustment in the protective, accepting, well struc tured hospital environment because it is felt that only these patients can benefit from a program designed as a continuation of hospital care in a somewhat more stressful situation. An adjustment rating of "good" does not neces sarily indicate that the patient is able to function well jin an environment less structured and accepting than the | {hospital but implies only that the patient is achieving an | {adequate social and clinical adjustment in the light of his | emotional disability. For example: one patient was making •a "good" hospital adjustment but the doctor's prognosis stated: "Guarded. He has done well on passes and seems stabilized and cooperative. He is severely incapacitated." A prediction of success or failure in a Family Care home cannot, therefore, be based solely on an evaluation of Ithe patient's hospital adjustment. A good adjustment and some degree of stability are vital as a basis for considera- ;tion of candidates but do not indicate a good or stable , adjustment in the home. Family Care Adjustment Nine of the ten patients made a poor adjustment in ' 36 , the community living situation. The exception was the patient previously mentioned who was able to make a marginal adjustment over a period of a year with the help of the , social worker who tried him in three different homes. Five! of the patients regressed after placement, including the I one mentioned above. The others remained stable but the level of their functioning was not sufficient to permit them to stay in the homes. An example is given of one patient who remained stable. I Mr. Able is a single, 32 year old veteran of j World War II. The picture of his family composi- j ■ * tion is very incomplete but it is known that his I mother recently married his stepfather and that he j has several siblings and half-siblings. The status of his natural father is unknown. His military I service lasted only four months and he was dis charged as unable to adjust because of his "child ish manner." Following his discharge were a number of short periods of hospitalization in various V.A. and state NP hospitals, all precipi tated by his odd, childish behavior. He was committed here in 194? for similar behavior and was diagnosed as: Schizophrenic reaction, simple type, chronic. His diagnosis remained essentially the same at time of placement in 1953 except that his acute symptoms were in partial remission. He is totally disabled and incompetent. He was referred because the medical staff felt that he had gained as much as he could from hos pitalization. He was seen as having little poten tial for rehabilitation but the doctor felt he would do well in a protective environment and might maintain himself indefinitely in a Family Care home. The social worker felt he could adjust to a warm atmosphere offering him much supervision and firmness but felt that the sponsors would need much help in understanding and accepting the patient. 37 The patient's parents were disinterested but would prefer that he remain in the hospital. They live in Texas and had not boon in contact with the ; patient. The patient expressed himself as wanting I to try Family Care and was satisfied with the home | when he visited it before placement. | ! The home is described as a rural, modern one ! large enough for four patients. The sponsor, a ! widow in her fifties is described as warm, a good mother figure who is over solicitous but good for regressed patients. Her motivation for taking patients is both financial and a desire for company. The patient was anxious to leave the hospital but his adjustment in the home was very poor. He was extremely dependent, childish and demanding; was very restless and unable to follow the most basic rules of courtesy. He resented the sponsor when she directed him and his only interest was in playing with toy planes with a neighbor's child. I His return to the hospital came when he felt unable | to get along with his sponsor because she chided j him for not closing a door. This illustrates the difference between a good hospital and a good home adjustment. The patient was actually little different in the home but his behavior was of a sort that is most difficult for the community to ^ accept. His sponsor was very accepting but was unable to keep from chiding him on occasion when his demands, child ishness and inability to follow basic rules overwhelmed her. Acting-out in an antisocial manner was the cause for return to the hospital of three patients. Such behavior as .the killing of a pet rabbit, minor thefts, the setting of small fires and the destruction of property inevitably 38 frighten and anger a community even if a sponsor feels capable of controlling it. In such cases,return to the hospital is accomplished for the protection of the patient, the sponsor, the community and the program. Regression to a less socially acceptable, less nature level of functioning caused the return of three patients. Two became withdrawn and asocial to the point that they could derive little from the home environment. The third, illustrated above, became childish, petulant and 1 . ^demanding. It was felt that prolonging the stay in the ihome could have little therapeutic benefit but could lead Î ito further regression. i In three cases, the sponsor * s inability to meet the needs of the patient seems to have been the prime factor in the patient's failure. In one cas^ the sponsor argued with the patient about his delusions; in another, the patient and the woman of the home were not able to establish a {relationship and in the third the patient found the rela- I :tionship too warm and preferred to return to the more impersonal hospital atmosphere. An evaluation indicates that neither the homes nor the patients can be described as poor for the program. The patients might have been able to utilize the program through another placement and the sponsors have been able to help other patients but in these instances the matching of sponsor and patient was 39: not correct. In one case, it seems that the placement was actually I contrary to the patient's wishes though he expressed eager-, i j iness to participate after much preparation. Shortly after | i I I placement» he eloped and entered another V.A. Neuropsychiat-| ric hospital voluntarily. It can be speculated that he felt rejected by this hospital but unable to express this feeling except by acting upon it. Regression and acting-out in an antisocial manner | ! I brought six of the ten patients back to the hospital. j I Improper matching of patient and sponsor led to three fail-i i I Iures and poor choice of candidate to one. From this it is | ! I ' . I .concluded that the Family Care social worker has an impor- ! tant role, along with the psychiatrist and other members of the clinical team, in choosing candidates who can succeed and in matching candidate and sponsor. It is interesting to note with what degree of accuracy failure can be pre dicted by the worker at the time of placement. ! ; Social Worker's Prognosis The Family Care social worker's prognosis was recorded in each case at the time of placement. This prog nosis was based in part upon intangibles resulting from interviews with the patient but to a greater extent upon such factors as: motivation to Utilize the program. 40 behavior in the hospital and on previous Trial Visits and passes and ability of the sponsor to accept regressed behavior. Lack of good motivation was noted in four cases. This included one in which the patient was eager to go to I . ; ! the home but could give little real consideration to what this would mean. In two instances the patient was described 1 as apathetic and indifferent or lacking in initiative and , in one the patient was resistant to leaving the hospital but seemed eager to go after much help was given him in I I Ithis area. In four cases,the patients* behavior history I ■ i iled the worker to have question about their ability to ! j i I succeed. One had a history of sexual acting-out, one j 'intellectualized to a high degree and two were very limited in their behavior of any type. In two cases the worker felt that all tangible signs were good. This evaluation led the worker to the following prognosis for the ten patients. Five were seen as having I only a dubious chance for success.. One was given only a {very poor chance. Two were judged as having a fair chance and two were thought to have a good chance of making a successful adjustment in the homes. In six out of the ten cases^ the worker's prognosis proved valid and in only two was the prognosis entirely wrong. This brings great emphasis to the importance of the social worker's evaluation of the candidate. His 41 professional judgment based on experiential awareness of : important factors combine with his casework training to ^ i enable him to predict with great accuracy. The same is j I true in matching patient and sponsor for in only three | I I I cases was improper matching an important factor in the | failure of a patient to adjust. I Attitude Toward Sponsor The patient * s attitude toward his sponsor was noted| I at time of placement. Four definitely liked their sponsors| ! and one liked his sponsor but not his sponsor's wife. ! I j I Five showed immediate indication of problems in this area, i i i I ! i ' Attitude of Family Family consent to placement of a patient in a home other than his own is required before Family Care can be considered. A review of family attitudes shows that three were totally disinterested in any planning, six favored the 'plan and one resisted strongly and would have preferred ' that the patient stay in the hospital indefinitely. Worker's Evaluation of the Home Eight homes were used for the group of patients who I returned to the hospital. All of the homes except one are 42 described as warm and accepting. The exception is a home since dropped from use in the program for failure to follow ^ the rules established by the hospital regarding refund of i I money paid for care when a patient is returned to the hos- Ipital. All of the sponsors showed considerable ability to 'accept the patients placed in their homes, many of whom were very sick and behaving in a manner which would be try ing at best. It was felt that if the sponsor had a role in the return of the patient it was due to poor matching not poor sponsors. I Half of the homes are in urban or semi-urban areas land half are in rural ones. Locale is not seen as impor tant in itself but is important to the extent that it meets the needs and desires of the patient. Summary A study of the ten cases in which return to the ! hospital terminated utilization of the program has led to ' certain conclusions relevant to the program as a whole. The first three month period is critical in that in this time patients who are not able to benefit from the , program give discernible evidence of maladjustment which is sufficient to warrant their return to the hospital. If further study of this confirms it, much time and effort can 43 be saved as well as considerable unhappiness and trauma for sponsor and patient. I The Family Care social worker can utilize his pro- ifessional judgment and experience in evaluating certain i ! ; I tangible factors such as motivation and previous behavior ; ! ■ I {to make predictions with considerable accuracy concerning ' the patient's ability to utilize the program. Combined with the finding that there is no set formula based upon statistical information for choosing a successful candidate I this confirms the importance of individualization which is I I I j a basic principle of social casework. | ; The Family Care worker becomes experientially aware| I of many factors which have a bearing on his choice of ; icandidates. He has found, for example, that patients who have had lobotomies do not make good candidates. This has been borne out (beyond the limits of this study) by the ' : failure of six out of seven patients so treated to adjust. 'The worker's application of his experience and professional j training to the evaluation of candidates and to supportive , therapy for those placed is, perhaps, the most important single, dynamic factor of the program. CHAPTER V I PATIENTS STILL IN FAMILY CARE Twenty of the forty patients studied are still active in the family care program. These are divided into five groups according to their rating on both the movement and adjustment scales. In Group I are the seven patients who have made a i I favorable adjustment on both scales. In Group II are the I six who show improvement on the movement scale but have made a marginal adjustment. In Group III are four who ’ have remained stable and marginal on their respective scales. In Group IV is the one improved on the movement scale but has shown poor adjustment. In Group V are the I two who show stabilization on the movement scale but have ! made a poor adjustment. It seems noteworthy that none of I the patients show regression on the movement scale. The ; significant factors around the types of adjustment the ; patients in these five groups are making will be examined. All seven patients in Group I were making a good ward adjustment and their condition was considered clinic- . ally stabilized before placement. Length of hospitaliza- ! tion ranged from eight months to twenty-three years and 45 therefore does not seem to be of prognostic value. There also is a wide variation in length of placement, three months to twelve months. All adjusted quickly to the ! family care home, making a noticeable improvement the first few weeks, then stabilizing and usually regressing slightly before again progressing. In all seven cases the family care worker predicted that the patient would probably adjust to family care. A total of four homes were used for these patients. All have had previous use in the program and i ■ ! I are considered good homes by the family care worker. A j I typical example of a patient in this group is Mr. Batten. I I I : Mr. Batten is a single, 36 year old man. Bis | I mother, a brother and a twin sister are living, ! but have had very little contact with the patient since his hospitalization. Be was in military > service nearly four years, beginning in 1941. Be was first committed to a mental hospital in 1946 and transferred to this hospital in 1948. Be has a total hospital experience of more than seven years and has been in the family care home eleven months. Bis diagnosis at the time of placement was schizophrenic reaction, paranoid type. Be was referred for family care placement I because his family was unwilling to take the respon sibility for his care and it was felt that he could function in the community with proper supervision. The family care worker thought he should fit into a home setting and would adjust well with minimal supervision. Placement was made in the rural home of a middle aged widow. She is described as a good mother figure and has shown much basic warmth and understanding. The patient has become very friendly with her and as was expected has required little supervision. Be also has become popular with the neighbors and takes pleasure in helping them— particularly with painting. 46 The family care worker summarizes his progress as follows: At the end of the first reporting period he had made a "remarkably good adjustment I with no particular supervision. In the second period he showed no change, happy but made no effort I to find work. The third period he is reported to have made "an outstanding social adjustment but I still needs considerable direction in any work he : does." At the end of the fourth period he was recommended for discharge. In Group II are the six patients who have improved on the movement scale, but have made only a marginal adjust ment. They were also making a good ward adjustment and were considered to be stabilized in the hospital. Again there is a great variance in length of hospitalization, under two years to over fourteen, and also in time in family care placement, three months to one year. One patient in this group was placed twice. The first placement lasted about two months but the patient had to be returned because of a temper outburst. He was returned to the same home after four months of hospitalization and since that time has shown satisfactory adjustment. The family care social worker was optimistic before placement, feeling all of these patients would adjust with proper supervision. This group also seemed to have made marked improvement the first few weeks of placement before leveling off or regressing. These six patients were placed in six different homes. Five have had previous use in the program. All were evaluated favorably by the family care 47 worker. An example of this group is Mr. Clarkson. Mr. Clarkson is a single, 29 year old man. He served in the army for two years. His first hos pitalization was in 1945 immediately following army discharge. He was treated for nine months and released on Trial Visit in custody of his mother but returned one week later because of abusive behavior. He had more than six years of continuous hospitalization before placement. He has been in the family care home seven months. He was referred for care because his mother was unwilling to accept him into her home. Also, because he was an illegitimate birth the stepfather has no interest in him. His mother permitted family care placement only after being guaranteed that the hospital was taking full responsibility for him. The family care social worker*s evaluation for placement was as follows: "because he relates remarkably well and responds very rapidly to a kindly and understanding approach, I believe that he will adjust very well to family care." He was placed in a home in a small rural community. The sponsors are a young couple (34) with two teenaged sons. The husband is a truck driver and his wife a practical nurse. It offers a friendly and relaxed atmosphere and the patient immediately related very well. He spends most of his time working around the yard, but needs and accepts close supervision. This is considered one of the best homes in the program, because of the sponsor*s ability to be friendly and relaxed but yet able to set realistic limits. There are three patients placed here at present. During the first period of adjustment the patient did well; however, he remained limited in his activities. In the second period there was no marked change, however he seemed to be getting along better with people and is much more settled. It is expected that he will need to remain in a highly protected environment the rest of his life. 48 In Group III are the four patients who have shown no movement and are making only a marginal adjustment. !They also were considered stable and making a good ward adjustment before placement. Their length of hospitaliza tion was from six years to twenty-one years and the length of family care placement varied from six months to eleven months. The family care worker was not overly optimistic about any of these patients, feeling that close and careful : supervision would be necessary to maintain their level of I ‘hospital adjustment. It is necessary for the worker to I ! make additional visits and for the sponsor to be unusually understanding, tolerant and accepting to enable these patients to remain outside the hospital. Only a slight regression in their adjustment would necessitate their return. A good illustration of this type of patient is Mr. Usher. Mr. Usher is a single, 32 year old man. The whereabouts of his family is unknown and have never been contacted. He was admitted to this hospital voluntarily directly from the Navy in October 1946, making a total of more than seven years of hospi talization before family care placement. He has been in placement nearly six months. His diagnosis at the time of placement was schizophrenic reaction, catatonic type. He was referred because it was thought that he could benefit from community liv ing. The family care worker felt that the patient might adjust to a closely supervised home with a warm accepting atmosphere. Placement is with a sixty-four year old widow in a rural setting. 49 The home has had previous use in the program and is considered satisfactory. The patient seems happy with the sponsor but is extremely shy and needs constant supervision. He is very regressed, speaks ' very incoherently and continually "gets into mis- I chief." He has been in the home nearly seven ; months. ' i j At the end of the first three months the patient was cheerful and essentially no change. During the second period he remained essentially the same, but began doing small tasks for the sponsor. The third period the patient became hostile toward the sponsor and struck her but calmed down immediately. The fourth period "the patient remains unchanged. The one patient in Group IV showed improvement on !the movement scale, but was making a poor adjustment. He I lalso was considered to have gained MHB and with community j jliving might improve. The family care worker was quite (skeptical of his ability to adjust in a family care home. It is given as an illustration because it represents a possible poor family care prospect. Mr. Talbot is a single, 4l year old man. He has no known family. He served in the army more than two years before being transferred directly to this hospital in 1945, where he had been hospitalized continually until family care placement. He has been in the family care home nearly nine months. His diagnosis at time of placement was schizophrenic reaction, paranoid type, treated and in partial remission. The referral was made because the patient had no family, but might benefit from supervision out side the hospital. The family care worker felt that he would make a,fair adjustment with consider able supervision. He seems to have benefited a good deal from family care, but his ability to remain out of the hospital seems remote. 50 The patient was placed in the rural home of an elderly retired couple. Incidentally, this was the first home used in the family care program; however, ! Mr. Talbot is only the second patient placed here. I The first remained in the home a number of months. The home is described as having a warm, accepting and encouraging atmosphere. The patient has related I slightly to the sponsor, but is extremely apathetic. I He needs considerable protection and supervision though he is not a problem. During the first reporting period the patient improved, but very slowly. He worked in the garden, but is generally disinterested in his sur roundings. In the second period he still showed improvement, talked a bit. He might be hearing voices, but see,s improved otherwise. It is feared that he is nearing a stage of open hostility and proper precautions are being taken. i The two patients in Group V are the ones who re- ;raained stable on the movement scale but show poor adjust- i ment. These patients also were considered stabilized in the hospital. They both have had over fifteen years of continual hospitalization and have been in their respective foster homes for more than eight months. They are very similar in all objective factors. The family care worker 1 doubted their ability to adjust because of their apathetic •behavior. They will most likely have to be returned to the ^hospital. One is being given as an example. Mr. McLish is a single, 56 year old man. He served in the army four years, from 1919 to 1923. His only known relative is a niece who is unable to take responsibility for him. He was hospitalized for twelve years in another state before being transferred here where he remained three years before being placed in a family care home. His diagnosis at time of placement was schizophrenic 51 reaction, catatonic type. He was referred for family care because he "has potential for adjustment in an accepting, supervised I family situation." The family care worker felt that I the patient would have difficulty in adjusting I because of his inability to communicate. He is placed in a rural home of a middle aged widow. This is the most used home in the program (five previous placements) and is considered one of the best. The patient has remained very seclusive and needs a great deal of supervision and prodding. He has no apparent interests— his only activity is a daily walk to the store. During the first reporting period there was no improvement. The second period also showed no improvement but still the patient remained stable but may have to be returned to the hospital if weight loss from not eating continues. Summary In analyzing the twenty patients still in the fam ily care homes, the thirteen In Groups I and II appear to be successful placements. It is noted that these have all the characteristics of those discussed in Chapter III who have received MHB and subsequent discharge. The success of the four patients in Group III is questionable. These will probably continue in placement only with continued close supervision of the family care worker. The three patients in Groups IV and V are remaining in placement only by special effort of the family care worker and the patient»s sponsors. It would appear at this point that 52 these are unsuccessful placements. There are no apparent differences In the patients or the homes of the five groups. Length of hospitalization and length of placement vary greatly in all groups as do diagnosis and age. It is noted, however, that all of these; patients have been in placement past the critical three month period discussed in Chapter IV. The referrals and the patients* attitudes toward placement are also much the same in each group. It is further noted that the patients in all five groups were stabilized and adjusting well at ! I the hospital before placement. j The ten homes which are being used for these twenty• patients were all evaluated as "good" homes, with emphasis on the sponsor's ability for acceptance and understanding of the patient and his behavior. A successful family care placement seems to be predictable only from the evaluation before placement by the family care worker of both the patient and the home in which he is placed. It would, therefore, seem that the suc cess of a placement lies in the worker's ability to eval uate the patient's needs and place him in the home where these needs will be most closely met. CHAPTER VI SUMMARY AND CONCLUSIONS The preceding chapters have evaluated and described the Family Care Program at the Neuropsychiatrie Hospital, Veterans Administration Center, Los Angeles 25, California during its "infancy" phase of development. The 40 patients and 17 family care homes studied were Involved In the pro gram between January 1, 1953 and August 31, 1954, a period of 20 months. All of the patients and sponsors have been studied on an individual basis. The purpose of this study is to aid in determining the factors that enter into a successful or unsuccessful adjustment by a patient upon returning to community life. By a close examination of these factors, criteria may be set up and followed in order to help a greater number of i patients make a successful adjustment in future placements. As has been previously stated, there is no "magic formula" brought out by this study that can be used to predict the outcome of a particular placement. There are, however, several general statements that can be made concerning the factors involved in placing a patient In a family care home. 54 It is important to know the patient well from a clinical and social standpoint so that the family care social worker can match the patient to a home that will best meet his needs. This knowledge of the patient and sponsor combined with the professional competence and judg ment of the family care worker is the most significant single finding of this study concerning the placement of a patientJ The family care worker's evaluation In each case was not based on mere intuitive hope but on a thorough ■study of the patient's clinical picture, adjustment on the Iward, and attitude as well as knowledge of the proposed I sponsor. As has been stated throughout this thesis, it has been the family care worker's ability to match a particular ’ patient with a particular home that has usually resulted in the patient being discharged. There are, of course, many other factors that enter into the eventual outcome of the placement which are on an ’ individual basis. It is seen by comparing the results i described in Chapter III and Chapter IV, that the first three months of the placement is the crucial period. It is during this period that the patient is subjected to his first experience outside of the protected institutional environment. Again, it is the family care worker's know ledge of the patient and his skill in the professional caseworker's role that determines the amount of support 55 needed by the patient and sponsor. Some patients needed considerable support during this period while others wanted ' to be left alone and test their strengths. During this 'period the patient starts to make some adjustment to his j ' i : new environment and some movement either toward an improved| : or regressed clinical picture. A patient may regress | slightly at first due to the increased emotional strain but ! ! by the end of the three month period the findings of this | study indicate that the eventual outcome of the placement i can be predicted, barring unforeseen events. There are, j j j : of course, exceptions to this. j The factors that were found to have no significance| .were age, education, clinical diagnosis, hospital experi- • ence, and length of hospitalization. These factors were evaluated in an attempt to find out if they played a major role in determining the outcome of family care placements. I The group of 40 patients in this study had considerable variation when compared in relation to these factors and a ! 'similar variation in the eventual disposition. For example, there were 36 of the 40 patients diagnosed as schizophrenic. Seven of these were discharged, 10 returned to the hospital, and 19 are still in homes. These same 36 ' schizophrenic patients had considerable variation in age, education, hospital experience, and length of hospitaliza tion. This again points to the importance of the knowledge 56 about the patient as an individual and the sponsor by the family care worker and the use of his skill in placing the patient in a particular home. As this study was done during the early develop- ! mental phase of the family care program, the student group advises that a yearly follow-up study be done in order to further refine the program. The methods for doing this have been worked out in this study; however, there is room for improvement. A more comprehensive analysis of the sponsors could be made, especially in the area of their (motivations for participation other than monetary gain. ITo accomplish this would require more complete records on I their backgrounds than were available to this group. During the study the student group often asked about the patient who had no funds to use in order to par ticipate in this program, especially in relation to the high cost of hospital care and the ever-increasing need for I I beds. As no satisfactory answer was found, they decided I that further study in this area would prove valuable. A factor which is thought by the student group to be of some significance in the patient's eventual outcome in the family care program, is the length of time of a patient's stable adjustment on the ward before placement. Future studies in this area should consider this factor as having some possible significance. BI B L I O G R A P H Y BIBLIOGRAPHY Books Alexander, Franz, and Ross, Helen, Dynamic Psychiatry. Chicago: The University of Chicago Press, 1952. Crutcher, Hester B. Foster Home Care for Mental Patients. New York: The CommonwealthFund, 1944. Deutsch, Albert. The Mentally 111 in America. New York: Columbia University Press, 1949. j Pollock, Horatio M. Family Care of Mental Patients, i Utica, New York: State Hospital Press, 193b. I Report i ; Proceedings of Institute on Foster Home Care. North Little ■ Rock Veterans Administration Hospital, 1953. Articles Aptkar, Herbert. "Three Aspects of the Role of the Worker in Home Finding," Child Welfare League of America Bulletin, January 1944. De Witt, H. B. "Family Care as Focus for Social Casework in State Hospitals," Mental Hygiene, October 1944, pp. 602-31. Hutchinson, Dorothy. "Parent-Child Relationship as a Factor in Child Placement," The Family, April 1943. Kent, G. "Home Instead of Hospital," Survey Graphic, June 1948, p. 315. Malcts, L. "Family Care-Method of Rehabilitation," Mental Hygiene, October 1942, pp. 594-95. 59 Pollock, Horatio M. "Brief History of Family Care of Mental Patients in America," The-American Journal of Psychiatry, November 1945, pp. 351-01. (Stevenson, 0. S. "Development of Extramural Psychiatry in United States,V American Journal of Psychiatry, April 1944, pp. 147-50. Istycos, J. M. "Family Care," Psychiatry, August 1951, pp. 301-06.. Unpublished Material Barr, Jimmie D., et al. "The Short-Term Trial Visit: A Comparison of the New.Short Term Trial Visit Program of a Veterans Administration Neuropsychiatrie Hospital with the Former Long Term Program." Unpublished Master's Thesis, School of Social Work, University of Southern California, Los Angeles, 195%. "Veterans Administration Social Service Manual." Pamphlet, Brentwood Neuropsychiatrie Hospital, Los Angeles, undated. (Mimeographed.) APPENDIX I TABLES so I 8 OS GO I I k o o p 4 -p fl H i •p 1 CQ bO s s k •o <4 *d o o CÎ3 •H «9 A, « 2 S "3 E4 if ^ o © * ITV O t<N iH rH O O KN KN m o O p4 8i rcv iH a r c \ r4 $ ( d •g e - 4 sO ^ NO C V l HI iH r o v c v i ON I LfN H O C V J C V I o ' G f \0 i f \ m o o o ( V I m H C V I o o rH O K\ CVJ CVI H iH r-4 rH S' CO C O % A 4 I I =8 a i • d < D m ta S I iH I *d I I d o o Ph d r4 ® si .0 d -P •H ta %0 S k *o -cJ^ <4 TJ o o o c d t Eh § •rt I S M 62 m KN ^ iH CM m CM fC\ ^ iH H CM O CM O ' 4 - O 00 H o d ■ë EH lA CM C D CM K\ K\ r4 H O UN O o\ lA O 00 sO O lA S' Æ w TJ O 05 0 3 tA ® r4 f-4 5 APPENDIX II SCHEDULE SCHEDULE PART I Code No.____________ Completed _by_________ Date Completed^ A. Identifying Data 1. Date of birth: Month _____ Date_________Year____ 2. Race: W N M 0 3. Religion:__________________________________________ 4. Education: Circle highest grade completed— a. 1 2 3 4 5 6 7 8 b. 9 10 11 12 c. College 1234 d. Graduate 5678 5. Marital status: a. Married____ b. Single c. Divorced____ d. Separated e. Widowed___ 6. Family Composition: a. Relationship to b. Age c. Status patient 7. Usual Occupation: V. 8. Military Service (dates): m B. Previous Hospital Experience: 1. Dates of Hospitalization 2. Hospital 3* Diagnosis Prom To (C. Current Hospitalization: 1. Date of Admission: Month Day Year _ 2. Type of Admission: a. voluntary b. Committed^ 3. Precipitating Stress________ 4 • Diagno si s__________________________________________ iD. Placement Data: I 1. Date of Placement: Month Day Year___ I 2. Age (years) at time of placement______________ j 3. Diagnosis at time of placement________________ 4. Competency: a. Legally competent^ b. Inc ompetent 5. Disability_________________ ^ 6. Amount of Compensation $______ 7. Reason for Referral a. Family attitudes b. Patient's attitudes and preparation^ 8. Objectives of placement ___________ 9. Doctor's Prognosis____________________ _ 10. Social Workers Evaluation PART II A. Identifying Data (home) Family Composition 1. Man Age_____ 2. Race: W N M 0 Religion____ Education^ Occupation Woman Age 3. Sponsor M or W Race: W N M 0 Religion____ Education__ Occupation 4. Others in the Home: Age Relationship to Marital Level of _________Sponsor_______Status Education Occupation 5. Amount of income $_ 6, Source of income per 7. Locale and Type of Home 8. Previous use of home in the program 9. Social worker's evaluation of the home 10, Sponsor's motivation for participation 11. Sleeping arrangements (describe briefly) 61 PART III A. Adjustment Summary: 1. Patient's attitude toward his sponsor 2. Patient's feelings at time of placement 3. Amount of supervision needed by patient 4. Areas of maladjustment or complaint 5. Patient's adjustment in the community as to a. Recreational interests__________________ b. Vocational interests c. Avocational interests 6. Summary of social worker's reports 7. Adjustment Rating: Improved Stable Regressed Good Marginal Poor I 8. Whereabouts of patient as of December 31, 195^ ‘ • « W s J t y o, S o u t h a . n C a N t o r n l . Ui»rmrf

Abstract (if available)

Abstract There has not been a study made of the Family Care Program at the Neuropsychiatric Hospital (Veterans Administration Center, Los Angeles 25, California) to date and, since it has passed the experimental stage of development, a study at this time seems vital. Care for mental patients in family care homes has been drawing considerable interest as a promising vehicle for moving improved patients out of neuropsychiatric hospitals. This interest is increasing because patients benefit from this treatment and also because of the dilemma being precipitated by overcrowding in all neuropsychiatric hospitals. A study of this program at this time should prove valuable to the hospital and also of Interest to other neuropsychiatric hospitals across the nation that may wish to initiate or improve family care programs.

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Creator Appleby, John J. (author), Larsen, Jack G. (author), Muegge, John Robert (author), Stevens, Curtis Hawley (author)

Core Title Family care program: A descriptive study of the family care program at the Neuropsychiatric Hospital, Veterans Administration Center, Los Angeles

School School of Social Work

Degree Master of Social Work

Degree Program Social Work

Publisher University of Southern California (original), University of Southern California. Libraries (digital)

Tag Health and Environmental Sciences,OAI-PMH Harvest,Social Sciences

Place Name California (states), Los Angeles (city or populated place), Los Angeles (counties), USA (countries)

Format application/pdf (imt), iv, 67 leaves : ill. ; 29 cm. (aacr2)

Language English

Contributor Digitized by ProQuest (provenance)

Advisor Hamovitch, Marion B. (committee chair), Di Paola, Josephine (committee member), Medhurst, Pieland (committee member)

Permanent Link (DOI) https://doi.org/10.25549/usctheses-m39

Unique identifier UC11314956

Identifier EP66541.pdf (filename),usctheses-m40 (legacy collection record id),usctheses-c39-215821 (legacy record id),usctheses-m39 (legacy record id)

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Document Type Thesis

Format application/pdf (imt),iv, 67 leaves : ill. ; 29 cm. (aacr2)

Rights Appleby, John J.; Larsen, Jack G.; Muegge, John Robert; Stevens, Curtis Hawley

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Access Conditions The author retains rights to his/her dissertation, thesis or other graduate work according to U.S. copyright law. Electronic access is being provided by the USC Libraries in agreement with the au...

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