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GETTING DOWN TO CASES Published by T H E HOGG FOUNDATION The University of Texas February, 1951 G E T T I N G D O W N T O C A S E S — F O R A N I M P R O V E D M E N T A L H O S P I T A L P R O G R A M I N T E X A S Dur ing the last three decades four or five surveys have been made of mental hospital conditions in Texas. Some of the survey recommendations have been put into practice but our state system is still in need of much improvement. T h e follow-ing list of policy recommendations is a bringing-up-to-date of the various studies. T h i s outline was prepared originally for discussion by the Texas Citizens Committee on Mental Health which met in the Capitol Monday evening, November 13, 1950. Several changes were made in the list of recommendations as a result of the Citizens Committee discussion. T h e following outline should prove useful to local mental health societies, mental health committees of the Junior Cham-ber of Commerce, study groups in women's organizations and in other groups which are interested in the improvement of mental health conditions in Texas. [ 3 ] I . What Should Be the Objectives of an Improved State Hospital Program in Texas? 1. Humane and friendly care of each patient is the first objective. ( N o t until every attendant, every hospital employee, every staff member helps to create an atmosphere of encouragement and personal interest in each patient w i l l Texas be able to look with pride upon its State Hospitals. T h e outstanding work of a few attendants which has resulted in the improvement and discharge of a number of their patients suggests what strides could be made i f this attitude and skil l characterized the work of a l l hospital personnel.) 2. Every patient's treatment should be under expert psy-chiatric supervision whether he is a newly-admitted patient or a long-standing case. 3. Every patient should receive the benefit of the various individual and group therapies now available. I n other words, an all-out program of rehabilitation should be planned by the staflF for each patient and his progress noted periodically. 4. Out-patient services should be established so as to treat cases early and without the necessity of admitting al l of them to the hospitals. 5. T h e State Hospital Board and StaflF should co-operate with al l community and state organizations in develop-ing a still broader program of prevention. ( T h e most economical way to care for a case of mental illness is to prevent it. Not until the hospital stafifs [ 5 ] themselves take leadership in this direction w i l l a l l the available resources in the community see the need of co-operating.) 6. T h e State Hospital Board and staff should set aside funds and provide personnel to conduct research whose goal w i l l be the continuous improvement of knowledge about the prevention and treatment of mental illness. I I . Specific Proposals Directed Toward Achieving the Above Objectives CONCERNING T H E STATE BOARD I T S E L F : 1 . T h e Citizens Committee recommends that the State Board serve exclusively as a policy-forming group. A s the official and responsible body representing the people of the State, the Board should outline a broad and progressive program of improvement; it should set goals and general standards. 2. T h e Board should not become administrative. W h o m to employ on the staff, whom to admit as patients, and how to operate a particular institution should be the administrative responsibility of the Central Staff and of the institutional staffs. ( I f the State Board enters this field of decision making, it w i l l be subject to al l types of political pressure.) 3. T h e State Board should set general standards for per-sonnel and performance, and support its executive director in maintaining these standards. 4. T h e State Board should provide in the budget for research, even i f the beginning is a small one. ( T h e [ 6 } i best qualified young psychiatrists w i l l not take state hospital jobs unless there is the professional stimulation which comes from research activities. T h e same is true of the other professional workers.) I n fact, the State Hospital program should stress three activities constantly: the care of the patient, the training of per-sonnel, the carrying on of research studies. 5. T h e State Board should encourage the Central Staff to take steps immediately to make some of the insti-tutions (and eventually a l l ) accredited training centers in psychiatry, clinical psychology, psychiatric social work, psychiatric nursing, occupational therapy, and the other professional fields. 6. T h e State Board or the Central Staff should establish advisory groups from the different professional associa-tions in the State. These experts in psychiatry, clinical psychology, psychiatric case work, occupational therapy, recreational therapy, physical therapy, psychiatric nurs-ing, chaplaincy work, dietetics, accounting, hospital construction, and other fields should be encouraged to study and make recommendations concerning policy matters, but should have no part in administrative decisions. 7. T h e State Board should provide for consultants of national authority to visit the institutions from time to time, conduct training programs, make surveys or render whatever other assistance is needed. 8. T h e State Board and Central Stafif should study con-tinuously the hospital and mental health surveys which have already been made. 9. T h e State Board should request the Governor to ap-point an independent commission of outstanding citi-[ 7 ] zens who would employ experts to make long-time studies of the care of the mentally i l l , of the prevention of mental illnesses and of the promotion of mental health. Such a Commission should study the relation of the State Hospitals to the work of the State Depart-ment of Health, the State Department of Welfare , the Youth Development Commission, and other State agencies dealing with mental health. CONCERNING T H E EXECUTIVE DIRECTOR: 1 . A n executive director should not be selected until standards for the position have been clearly determined by the State Board with the aid of professional advisory committees. 2. Those standards should take into account: T h e director's proven ability in the field of medical administration. T h e director's proven ability to lead and work with a team of professional staflf members. T h e director's training and experience in dealing with problems of the mentally i l l , the tubercular and special education of children. Preferably, he should be a Diplomate of the American Board of Neurology and Psychiatry. T h e director's ability to plan programs and interpret those programs to the Legislature and to citizens' groups. T h e salary for this position should be set at a high bracket in order to attract the best person available anywhere in the nation. A systematic search should be initiated immediately to find such a person. [ 8 } CONCERNING T H E POSITION OF MEDICAL DIRECTOR: 1 . T h i s position should not be filled until the Board has outlined the qualifications needed and the functions of the medical director. 2. T h e job specification for this position should take into account: T h e division of responsibility between the medical director and the executive director. T h e general relationship of the medical director to the superintendents and clinical directors of the various institutions. T h e psychiatric training and experience of the medical director. H e should be a Diplomate of the American Board of Neurology and Psychology. Equal important attention should be given to the proven ability of the candidate to work as a team member along with the various professions which are now contributing to the treatment of patients and to the prevention of mental illness. ( A narrowly trained expert with no experience in teamwork w i l l be in-adequate to improve the entire treatment atmosphere and methods of our hospitals.) CONCERNING T H E R E L A T I O N OF T H E CENTRAL O F F I C E TO T H E LOCAL INSTITUTIONS: 1 . T h e Board should define this general relationship and vigilantly keep the relationship clear and co-operative. 2. T h e Central Staff should engage in overall planning but should leave responsibility and freedom for devel-opment of the program of treatment to the local insti-tutions. T h e responsibility of the local superintendent [ 9 } toward his own staff and patients should be clearly defined. Also, his responsibility for in-service training and the upgrading of a treatment program should be definite. A n organizational manual might wel l be pre-pared providing it is used as a working guide which can be revised. CONCERNING T H E UPGRADING OF PERSONNEL: 1. Each patient w i l l not receive humane and ski l l ful treatment until modern personnel methods are used to secure the best possible attendants (psychiatric aides) , nurses, doctors and therapists of a l l types. Modern methods of screening personnel should be used. Care should be given to their proper orientation to hospital work. I f new workers are welcomed by co-workers with a friendly, helpful attitude, they are more likely to show similar attitudes toward patients. T h e lack of consideration of some employees toward patients may reflect their own personal and job insecurity. 2. H i g h personnel standards cannot be maintained until an intensive program of in-service training is established for al l types of staff members. Tra ining facilities in the State should be called upon and each hospital clinical director should establish continuous training programs for his personnel. ( T h e physicians and nurses now on the staffs should be enabled through paid leaves of absence to add to their general training the necessary special preparation in psychiatric work. T h i s additional training should be secured at accredited in-stitutions. Other personnel should also go away for special training or a high quality in-service training program provided in the hospitals.) [ 1 0 } 3. H i g h personnel standards cannot be maintained i f there is any personal favoritism or political interference concerning appointments, promotions and other matters of personnel merit. A positive program of personnel upgrading and promotion should be developed as further assurance against such interference. 4. H i g h personnel standards cannot be maintained unless the public and the Board work for higher salaries. ( T h e last session of the Legislature gave only slight increases, not commensurate with the need. Most of the increased appropriation was for new buildings.) 5. Staff members from the various professional groups should be encouraged to affiliate with their state and national professional organizations, and be encouraged to attend training conferences and to keep in touch with the latest publications in their field. CONCERNING T H E PREVENTION OF M E N T A L ILLNESS AND T H E REHABILITATION OF T H E M E N T A L L Y I I I : 1. Each institution should have an out-patient service available to the surrounding area. Its diagnostic and treatment team should be of the highest trained per-sonnel. T h e clinics should be located and operated in such a way as to encourage citizens to come early for diagnosis and treatment. 2. Commitment procedures in the case of hospitalization should be studied and improved. I f new legislation is needed, the Central Staff should explain what would constitute a more enlightened policy and encourage citizens' groups to secure the necessary legislation. 3. Detention in jails should be abolished and commitment procedures developed which w i l l make such detention unnecessary and impossible. [ 1 1 ] 4. Quick admission to the hospital should be made pos-sible in order that treatment can begin immediately. 5. Newly-admitted patients should be admitted to a special section of the hospital where their needs can be studied quickly and early treatment administered. Only i f such intensive treatment fails to bring results should they be transferred to the wards for more prolonged treatment and care. 6. T h e rehabilitation of each patient should be studied by an inter-professional team on the hospital staff. T h e recommendations of this team should be clearly re-corded, provision made for carrying out of the recom-mendations, and for periodic checkup on the progress of the patient. ( T h e case history records on the patients are inadequate at present.) 7. I n the plan of therapy, special attention should be given to the staff members, particularly the attendants (psy-chiatric aides) who come into daily contact with the patient. T h e supervision of their work should be in the hands of persons competently trained psychiatrically and in related fields of therapy. 8. I n the plan of therapy, stress should be placed on securing information about the patient's home and community and help prepare them for the patient's return. T h e patient's recovery w i l l be speeded i f he knows that the social service department is showing the same friendly regard for his relation at home as it does for his rehabilitation while in the hospital. 9. I n order to insure intensive quick treatment of the new patient, one or more special institutions should be es-tablished in addition to the development of out-patient work and intensive treatment centers in each hospital. [ 1 2 ] ( T h e Board has approved the construction of one such hospital. W o r k on this project should be started at once, but, even more important, steps should be taken to secure and further train a high quality diagnostic and therapy team for such an institution which w i l l save taxpayers money by making early rehabilitation possible in a high percentage of cases.) CONCERNING T H E CARE OF T H E Y O U N G PATIENT: 1. I n addition to providing the best possible early treat-ment for al l new patients and especially for young patients, provisions should be made for the continued education of the young patient. ( A t present there is no provision in the mental hospitals for a young patient to continue any type of schooling.) 2. T h e social service department should keep in touch with the schools and community agencies which have known the patient and work out with them a plan for his rehabilitation when he leaves the hospital. T h i s policy which applies to al l patients should be followed with particular care in the case of young patients. CONCERNING T H E T R E A T M E N T OF OLDER PATIENTS: 1. T h e Central Staff should plan facilities in the State which can receive from other institutions the more chronic cases which fa i l to respond to the best possible treatment methods. Among these cases w i l l be many known as "senile." Their cure should never be regarded as hopeless. Their rehabilitation and return to the community should never be abandoned, but during months of care in a public institution they can better be 1 : 13 } provided for in buildings and surroundings more re-sembling community l ife than a hospital. T h e cost w i l l be less and a chance for normal l iving better. But these community institutions should be carefully supervised by competent staff members and emphasis continued upon rehabilitation of the patient. 2. T h e social service department should give special at-tention to the return of the aged patient to his own home. Co-operation should be developed with com-munity agencies which can assist the patient in this adjustment. CONCERNING T H E T R E A T M E N T OF SPECIAL PATIENTS, S U C H AS ALCOHOLICS: 1 . Any special type of case requiring special methods of treatment should be given attention by expert con-sultants and a program developed by the Central Staff. A survey of the problems of alcoholism and other special types of cases is needed. 2. Advisory committees could be secured which would work with the Central Staff and with the Board in developing the best possible program for these cases of special need. CONCERNING T H E T R E A T M E N T OF T H E CRIMINALLY INSANE: 1. T h e present confusion as to who is responsible for the care of the criminally insane, the State Hospital System or the Prison Board, should be clarified by new legislation. 2. Special provisions should be made for this type of case with emphasis on rehabilitation, research and special-ized treatment. [ 1 4 ] CONCERNING T H E COST OF CARING FOR PATIENTS: 1. T h e Central Staff should take the initiative in outlining a broad program of fee payment with appropriate recommendations for revising the system so that fam-ilies able to pay can be required to pay for the cost of patient care. ( W h i l e such a system has been authorized by the Legislature, it has never been put into effect fully. T h e amount of fees charged and collected from relatives of patients is grossly inadequate.) 2. T h e quality of the treatment should not depend on the ability to pay, however. A l l patients should be entitled to the same care. 3. T h e present careful system of accounting and of collection should be developed still more. CONCERNING T H E LOCATION OF N E W BUILDINGS: 1. H i g h quality professional services are difficult to main-tain at points distant from professional schools and other hospitals. 2. Consequently, new buildings and institutions should be located close enough to the professional schools in the State to assure that the State institutions w i l l be used as training centers. 3. Such location is particularly important for a l l active treatment hospitals. CONCERNING T H E HOSPITALS AS TRAINING C E N T E R S : 1. H i g h quality staff members cannot be secured in large numbers until the hospitals qualify as training and research centers. [ 1 5 } Trainees coming to the hospitals from the different professions add a great stimulus to the quality of work carried on by the resident staff. Trainees should be welcomed from al l of the related fields of human adjustment work. Close relation should be maintained with al l of the professional groups and standard setting agencies among the different professions. [ 1 6 } 

Getting Down to Cases

https://repositories.lib.utexas.edu/bitstream/2152/72755/2/1951-Getting%20Down%20to%20Cases.pdf

Getting Down to Cases

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