Community Mental Health Journal Volume 2, Number 2, Summer, 1966



The high rate of return to the mental hospital constitutes a major public health problem for which our present posthospital services seem inadequate. This research indicates most ex-state mental hospital patients occupy family role positions which are not central and decisive, and have a high degree of financial and social dependency. Given these facts, what would be needed to prevent their return to a state mental hospital? A new system of meeting the social needs of ex-patients must be developed. Suggestions made imply a radical change in professional services--both in kind and degree. In short, the ex-patient seems to require more than "out-patient" services.

Today in the United States greater numbers of persons are being released from state mental hospitals than ever before. In California, for example, 85% of all admitted patients are released from the mental hospital after a stay of six months or less. However, many released patients will return to the mental hospital again and again. The rehospitalization rate is steadily increasing and now constitutes a significant public health problem. In general, little is known about ex-state mental patients as a group. Hollingshead and Redlich's (1958) study of social class and mental illness points out that many state mental patients come from the lower socioeconomic class. Isabel McCaffrey and Elaine Cumming find many ex-patients on public welfare rolls. Helen Ellis (1962) finds most ex-patients either unemployed or unemployable. Simmons and Freeman (1963) report that the ex-patient's role performance in both affective and instrumental areas are important to their community adjustment. John and Elaine Cure-

*Dorothy Miller, a psychiatric social worker, is a research specialist for the California Department of Mental Hygiene, 3330 Gear,] Blvd., San Francisco. 124


ruing (1962) examined the ego-damaged and "socially inadequate" ex-patient in relation to his community adjustment. The research findings presented here are a further attempt to describe the ex-patient group and to examine some of the social problems inherent in each family role position. METHOD The research reported here is based on a representative sample of 965 patients released on leave

of absence from California Department of Mental Hygiene facilities (1963). These patients were followed for a 12 month period and approximately 40% were rehospitalized during that 12 month period. Another five year follow-up study found that approximately three-fourths of the released patients were rehospitalized at least once. This staggering rate of return to the mental hospital constitutes a major area for concern to all who work with the posthospital mental patient. To examine some of the social problems facing the expatient, this research categorized the expatients by age (21-64), sex, and living arrangements into five major family role positions; i.e., those of spouse, adult-child, relative, isolate and institutional care (such as family care homes, nursing homes, etc.) Table 1 shows the distribution of these classifications among the ex-patient population. Each family role position has a different rate of rehospitalization which is also shown in the table. Those in the spouse role have the lowest return rate, while those in the dependent roles of adultchild and institutional settings have the highest return rate. Using these research findings, it is possible to build a picture which describes expatients in each family role position. TABLE I DISTRIBUTION OF RELEASEDMENTAL PATIENTS A M O N G FAMILY ROLE POSITIONS AND OF THOSE RETURNED TO THE STATE HOSPITAL OVER A TWELVE MONTH PERIOD

Positions Unknown

Husbands Wives Sons Daughters Male Relatives Female Relatives Male Isolates Female Isolates Family Care and Private Institut. Total

Total No. %

Return No. %





102 304 70 54 33 60 98 50

10 32 7 6 3 6 10 6

25 90 38 17 11 31 47 23

25 30 54 31 33 52 48 38

143 965

15 99%

75 387

53 40%


The largest single group of ex-patients are wives. A m o n g the younger wives, 80% return to households with younger children, while 45% of the older wives have minor children in their homes. Most of these wives have never worked outside their home, have less than a high school education, and reside in lower class neighborhoods. Many face varying degrees of marital conflict. They are most likely to be returned to the hospital by their husbands because of poor household management or because of severe marital conflict. Once these wives undergo a return to the mental hospital they are likely to become "revolving door patients." After a series of readmissions, many of them are divorced by their husbands and undergo a change of family role position. Often they are then faced with even greater responsibility for the total care of a home and minor children. In a year's time, 30% of the wives have been rehospitalized. Ex-patients who are husbands face serious employment problems, as well as problems of marital conflict, alcoholism, and financial difficulty. Prior to their admission to the mental hospital about 85% of these ex-patients were employed--after their release from the hospital less than 50% find employment. Frequently they find work at a lower or more marginal skill level than they had held before admission. Many have wives who work outside the home, and often these husbands hang around the house all day and do not assume the head of the household role which is generally assigned to a husband in our society. There seems to be evidence that ex-husbands who have been divorced in the course of their patient careers are likely to become chronic mental patients, while those who are able to stay in their marriage and find support for their dependency, however tenuous, have the lowest rate of rehospitalization. Adult sons and daughters constitute a special problem group, in that two-thirds of them never left their parental homes and more than half have never worked or assumed an independent status. Another



one-third have returned to their parental homes after an unsuccessful marriage or a disappointing independent living experience. The average age of these adult children is 42.7 years, which indicates that their parents upon whom they are dependent, are aged persons facing social problems of their own. This group has the highest rate of rehospitalization. Ex-patients in the "relative" position tend to reside with their adult children. Only a few are either employed or self-supporting. Male relatives seem less likely to be rehospitalized than are female relatives. Often these ex-patients are in poor physical health, and many seem to become "aged Cinderellas" in someone else's chimney corner.

The "isolates," i.e., those ex-patients who live outside a family group, face many serious social problems without the role support from a family. Only about one-half are employed, and those are generally working in a marginal or transient job. Some drift into skid rows or jails. Female isolates are very likely to be rehospitalized when they are without work or a source of financial support. Male isolates seem to find other deviant pathways in the social structure and are likely to be rehospitalized only when they get into difficulty in the community and are picked up by the police and identified as an ex-mental patient. Those ex-patients who are in family care homes and private institutions remain quasi-patients. Often they seem to trade one rocking chair for another. In fact, workers report that one of the major adjustments required for these patients is to give up the hospital social and recreational activities for the less formalized routine of a foster home. The rate of rehospitalization is greatest for this group of ex-patients. PREVENTION OF REHOSPITALIZATION

The ex-mental patient is studied in relation to these role problems. It has been found that patients are frequently rehospitalized for "role failures" without showing overt psychiatric symptoms. For example, in about one-third of the cases of return,

reasons given by the patient and the returning agent dealt with social rather than "psychiatric" problems. Josephine Bates (1963), in a study of returnees to a Washington State Hospital, found that "social stress" was given as a reason for return in 33% of the cases studied, while ditficulty in the community was given in another 15% of the cases. What, then, could be done to prevent these patients from returning to a mental hospital? It seems obvious that each group of these ex-patients require a wide range of social services to support them during the transitional period from the ward into the world. They also require direction and training in role playing if they are to be able to function in a more satisfactory way in the community. What services are presently available to offer both support and re-orientation to the ex-mental patient as he comes home? A number of states offer some type of specific aftercare service; other states use existing health and welfare agencies for ex-patients; while some states have no aftercare programs for the released mental patient. The California Department of Mental Hygiene, Bureau of Social Work, provides an example of a specific program geared to helping the ex-state mental patient adjust in the community. In California, patients who are released from mental hospitals on leave of absence are assigned to a psychiatric social worker located in each district. The worker may interview the patient in the Bureau of Social Work office or visit the ex-patient's home. After assessing the ex-patient's social and psychiatric condition, the worker may offer direct casework services or a series of referrals to other agencies for vocational training, employment, medical care, or marital counseling, etc. The Bureau of Social Work also supervises family care homes. Given that the ex-mental patients, in various family role positions, face a range of social problems, what kind of services would be required to afford an alternative to rehospitalization? (At this point it must be noted that the conflicts, problems, and


alternatives found for the ex-mental patient would also apply to the not-yet, but aboutto-be mental patient. The problem of returns to the mental hospital cannot be separated from the problems of admission to the mental hospital. The ex.patient may have only more difficulty due to his changed self-definition, the effects of stigma (1963) and to the depletion of hope which may accompany a series of rehospitalizations.) To offer alternatives to a return to the mental hospital, certain assumptions about how change occurs in human behavior must be made. This report suggests the need for a role-learning model to aid the ex-patient resume a civilian career. However, the techniques of teaching and the conditions for learning are not simple. We know mental patients do learn they learn rules, norms, and limits on their hospital wards very rapidly. The Cummings' (1962) have discussed many techniques for using the therapeutic milieu to rebuild damaged egos. Theodore Sarbin, the social psychologist, has suggested the learning theory model for use with ex-mental patients. It is recognized that great skill is necessary to develop the setting, the opportunities, and the ex-patient's motivation for learning. But, let us imaginatively construct a setting, expand the professional skills, and offer to the ex-patient an opportunity to obtain help in staying out of the mental hospital. The study of the social problems of exmental patients reveal the need for realistic financial support, employment, and opportunities for emotional support and interaction with others--all around the central focus of becoming more adequate in role performance. The ex-patient must have more than psychotherapy; he must have a place to stay, someone to care for him, money enough to live on--a chance to both work and love. SUGGESTED ALTERNATIVE SERVICES

To meet these needs, perhaps a centralized agency in the patient's community could be developed, offering a range of


social services accompanied by a role learning situation. For example, an "aftercare supermarket" and adult education center could be assembled, with disability, welfare, vocational, medical, employment, psychiatric, educational, and homemaking services--all under one roof, with trained personnel as "clerks" and teachers who will freely offer various types of "merchandise" and training programs from which the expatient may select. The ex-patient would come to this supermarket and school directly from the mental hospital to shop for the goods and services he will need to keep him in the community. The services would be immediately available to him without red tape, delays, appointments, etc. This would be an around-the-clock establishment with an accompanying "motel" for those ex-patients traveling from one living arrangement to another. Further, this aftercare supermarket must offer "delivery services" to those who are unable to move to the store. The ex-patient is not likely to have either a car or a driver's license and he may also be without funds, family or friends to chauffeur him about to keep a range of referral appointments. Some will be too angry, too frightened, too unaware to come into the store, and the professionals will need to go out to the ex-patient and his family. In conjunction with the supermarket, there must be an "ambulance service" available on a 24 hour basis. Too often ex-patients undergo crisis periods after offce hours. Suppose police, fire and hospi. tals operated from nine to five. . . . ? Yet, families and ex-patients often must call upon these protective services, since the professional psychiatric shop is closed for the day. Most ex-patients get into difficulty during the evening and week-ends when family interaction is most intensive. If crisis services could be available, many problems which now cause the patient's return to the mental hospital could possibly be solved within the family and the community. Inherent in this approach is the widest use of the ex-patients themselves. Each has skills on some level and, with imagination



and support, can solve many problems for and paper offering to too few, too little, too himself and can be of considerable help late. to others. All of the departments within It would seem that with such an array of the supermarket must be manned, insofar services, many ex-patients could be mainas possible, by patients themselves. For tained and helped to satisfactorily adjust example, for wives who need to gain house- to a civilian status without having to hold skills, a community cooking school undergo again and again, a return to a and kitchen operated by patients can be state mental hospital. used. For patients with poor personal appearance and hygiene, charm and beauty REFERENCES shops can be developed, operated by the BATES, JOSEPHINE. Returnee study--1962. Fort patients. For men who have never worked Steilacoom, Washington: Mental Health Research Institute. Unpublished manuscript, 1963. or who are "skidding" in the labor market, a series of realistic sheltered workshops CUMMINr J. & CUMMINr ELAINE.Ego and milieu. New York: Atherton Press, 1962. can be established and run with patient ELLIS, HELEN. The social and economic effectivehelp. ness of patients on convalescent leave from New Opportunities in such a setting are unMexico State Hospital. Mimeographed paper, 1962. limited. People gain in ego strength by establishing status in the eyes of others. The GOFFMAN,E. Stigma. Inglewood Cliffs, New Jersey: Prentice-Hall, 1963. ex.patient can gain immeasureably by HOLLINGSHEAD, A. B., & REDLICH, F. C. Social being useful, busy and needed. class and mental illness, New York: John Wiley & Sons, 1958. A structured program would offer many challenges and opportunities for other so- 9McCAFFREY, ISABEL, & CUMMING, ELAINE. Posthospital patients on public welfare rolls. Mimeocially inadequate groups in our society. graphed paper. For example, if such a supermarket is good MILLE~, DOROTHY.From the ward into the world. for the socially inept ex-mental patient, San Francisco: Cal. Dept. of Mental Hyg., Bur. of Soc. Wk. Mimeographed report, 1963. why wouldn't it also be good for the aged, DOROTHY. Five year follow-up study of the retarded, the public welfare client, the MILLER, leave of absence patients: a progress report, physically disabled, etc. ? Such a re-organi. NIMH 1269-1. San Francisco: Social Research zation of existing social services and auxilLaboratory. Mimeographed paper, 1963. liary personal services calls for the highest SARBIN, T. hnplications of role theory for the posthospital mental patient. Paper given at the Buextension of generic professional skill in reau of Social Work Training Session, Oakland, order to assume the direction and impleCalifornia, 1963. mentation of such a program. We are now SIMMONS, O. & FREEMAN,H. The mental patient comes home, New York: John Wiley &Sons, 1963. spending a great deal of time, money, skill,

Alternatives to mental patient rehospitalization.

The high rate of return to the mental hospital constitutes a major public health problem for which our present posthospital services seem inadequate. ...
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