Community Mental Health Journal
Volume3, Number2, Summer,1967
THE CUSTODIAL HOSPITAL AS A COMMUNITY RESOURCE FOR PSYCHIATRIC TREATMENT PETER WEISS, PH.D.*
Custodial practices in mental hospitals are usually regarded as anfitherapeutic and inimical to treatment objectives. This conclusion arises from the failure to distinguish between custodial organization and custodial goals. It is the existence of the latter that subverts the treatment effort. This paper describes the use of a custodial hospital setting for psychiatric treatment purposes and suggests that elaborate intramural therapy routines may not be necessary to the rehabilitation of patients.
In a recent study (Weiss, Archer, & Pincus, 1965), it was illustrated that the discharge of patients from a custodial mental hospital did not depend on an internal revision of the custodial organization of the hospital. Success in releasing patients depended rather on changes in public policy regarding the use of the hospital for custodial purposes, changes in the administrative practice of the hospital itself and in the assignment of treatable cases to the institution, i.e., acute first admissions. That is, the release of patients did not require elaborate intramural therapy programs but rather involved intensive psychiatric and social work support for early discharge. The findings of this study suggest that the essential differences between treatment and custodial hospitals is found in the presence or absence of procedures for releasing patients. In order to understand this proposition, one must distinguish between custodial organization and custodial goals. The former refers to caretaking practices (found in all hospitals) and the latter to the encapsula-
tion of the patient within the institution and the prevention of his release. The length of time a patient spends in the hospital depends largely on the latter, both in terms of staff expectations and in terms of the patient's own adjustment to the realities of this goal. It is the goal of custody and the absence of contravening procedures for release that is crucial. Whether the wards are locked may be irrelevant. It is well known, for example, that most mental hospitals have a residual chronic population that may have complete freedom of movement within the institution and may even be essential to its maintenance as "key workers." Chronicity in mental hospitals depends heavily on the orientation of the patient to the outcome and not to the style of his confinement. It is necessary to note here that the goals of organizations are only imperfectly achieved. This stems from the difficulty in aligning organizational activity with institutional aims. This is particularly true of mental hospitals where the aims are very general and allow for a variety of goal-
*Dr. Weiss, a psychologist,is Pro~ectDirector, County Mental Hospital Project, Wisconsin Ps~(chiatric Institute, University of Wisconsin, lwadisou, Wis. This investigation was supported by a grant trom the National Institute of Mental Health, MH 1182, Study of County Mental Hospitals in Wisconsin. 171
172
THE COMMUNITYMENTALHEALTHJOURNAL
related activities. Effective custody, for example, can be achieved by a variety of devices ranging from manacles to milieu therapy, and the organizational systems they reflect may be equally varied. Moreover, staff outlook is apt to be defined in terms of staff activity and not in terms of institutional goals, and in some cases it may be very difficult to assess the relevance of such activities in light of those goals. Thus, staff perspective on goal changes is not necessarily prohibitive, since those changes may not interfere with existing hospital routines. The possibility being raised here is that the organization of a custodial hospital may be relatively unaffected by the establishment of release pro. cedures. Caretaking practices do not specify a time limit. Provision for the removal of deceased patients is noninterfering with existing routines. Likewise, provision for the removal of living patients may also be noninterfering. Thus, the need for organizational change may not be what current sociological thought might predict (Belknap, 1956) in changing hospital goals. The quality of custodial care may be such as to allow for appropriate psychiatric intervention from outside the hospital. It may be passive and therefore intrinsically receptive to this intervention and not in competition with it. It may provide services that are essential to patient welfare, such as competent nursing and medical supervision. The use of such hospital services may be part of a treatment strategy and is not inevitably a sign of failure at treatment in the community. Disabilities associated with psychic collapse need to be treated and authoritative control may need to be imposed. This can be achieved in any good hospital, psychiatric or otherwise (Moil, 1963). PSYCHIATRICTREATMENT The hospital in this study is one of 34 county.operated institutions in Wisconsin, which traditionally have been ~back wards" to the two state hospitals. Under this arrangement state hospital treatment failures, seniles, mental defectives, and other chronic invalids are cared for in county institu.
tions. This amounts to a partial decentralization of public mental institutions in the state, a situation that has existed since the mid-nineteenth century. The hospital in this study is a 225-bed facility, similar in size and function to other county hospitals. The majority of its patients are chronic either in terms of their disorder or in terms of their social circumstances. The custodial regime is benign. The wards are clean and not crowded, and the patients are generally docile and quiet. The hospital is located in an urban area, which makes it somewhat atypical and similar to only three or four other county institutions in the state. The significance of its location lies in the availability of psychiatric services, but in terms of the traditional custodial perspective of these institutions, this is not an inevitable source of improvement. Its location merely allows for its more varied use. The development of psychiatric services for patients who normally would use, or be sent to, the distant state hospital involved the joint efforts of the county probate udge, the county clinic psychiatrist and the local hospital superintendent. The major aim of the arrangement to be described was to prevent the legal commitment of people referred to the county court. The surplus effects of this amount to the existence of a local psychiatric treatment program. This does not represent the establishment of a mental health center in terms of the 1964 federal regulations nor is it the product of state planning. It is a locally inspired and locally conceived arrangement based on local need that was locally perceived. At the time of this writing the program has not been officially recognized by the state as a viable treatment plan according to the statutes, although it is regarded with a good deal of official interest and unofficial approval. The county courts in Wisconsin are a major source of referral to the state hospitals. By law, a person in need of hospitalization and whose condition is not chronic may be sent to the state hospital in the district. Commitment to a county hospital is permissible only in cases of chronic mental illness, mental infirmity (senility), in.
PETER WEISS ebriates, drug addicts, and chronic invalids. Acute first-admission cases are sent to the state institutions. In the present county, the probate judge has been reluctant to use the statutory commitment procedure to send patients to the state hospital, both for reasons of the stigma associated with such commitments and the social difficulties associated with the legal deprivation of liberty. The rehabilitation problems created by the removal of the patient to the distant state hospital may not have been apparent, but the sociolegal position taken has the same effect. Candidates for hospitalization, coming before the court, are sent to County Hospital, either as voluntary admissions or under a court order for observation, which is good for 30 days and may be twice renewed. It is during this observation period that psychiatric intervention is made and discharge planning begins. There is admittedly very little by way of intramural treatment, and the psyehiatrie effort is directed toward the earliest possible release of the patient. There is nothing particularly unusual about this aim in modern hospital psychiatry, but the time needed to release a patient has been governed, in part, by the extent of intramural services. In one state hospital in Wisconsin, for example, the customary practice of elaborate intake procedures, i.e., giving the patient a thorough "workup," may require a waiting period of three weeks to a month before treatment recommendations are made. This may be the partial result of staff limitations, but it also may be a reflection of the intramural orientation of the hospital, given in the very faet of maintaining its own treatment staff. In County Hospital, new admissions are evaluated within three days and release can be arranged immediately. Here the hospital has no treatment staff of its own, with these services being provided by the psychiatrist from the county clinic, the social worker from the court, and the county judge, who maintains continuing interest in patients under court order and is, in a sense, the incarnation of community pressure for discharge. The result of this arrangement is an average length of stay for all patients, vol-
173
untary and involuntary, of three weeks (numerical reference based on data for a nine-month period; N=222) as compared to the state hospital where it is at least two months.
DOCTOR-PATIENT RELATIONSHIP Psychiatric treatment in this case addresses itself to the severe limitations of custodial hospital resources and to the immediate social and psychological situation of the patient, including the temporal boundaries created by the court. It recognizes the need for symptom relief as well as the severe social consequences of confinement. The acute disturbance requires medical and psychological support. It also requires a context that will define the relevance of such treatment in terms of the patient's early return to the community. That is, the treatment given does not occur in an expectational vacuum but rather the patient is told that he will be released in a short period provided he follows medical orders. His release is easily arranged at the request of the psychiatrist, and psychological support is continued at the county clinic. The patient is rehabilitated outside of the hospital, which remains as a resource for renewed treatment in case of a relapse. The psychiatrist takes direct charge of the case from the start and maintains that contact during confinement and for posthospital care. Continuity of treatment is thus assured, and two crucial issues are revealed: (a) compliance with medical orders is based on a contract between the doctor and the patient and not on an abstract treatment principle, and (b) the same doctor has seen the patient in all phases of the disorder, thus reducing the possibility of medical excitement over a relapse. Obedience to medical orders in the case of severe illness is important, to say the least. It may not be what we think it is, but in terms of the patient's need for authoritative support as well as the physician's need to be effective, which in psychiatry is a rare reward for effort, it would seem to be a minimum requirement for medical responsibility (Ort, Ford, & Liske, 1954). This has amounted to a serious problem in large hos-
174
THE COMMUNITYMENTALHEALTHJOURNAL
pitals, where psychiatric activity is a shared endeavor, where different specialists may be involved in carrying out the treatment plan and where disposition of the patient is often a committee decision. In such cases the patient is confronted with the rationale of treatment rather than with the rationality of his physician. In the case of a bone fracture, this rationale may be readily understood by the patient, but in the case of mental illness it is often not even understood by the hospital staff. The ambiguities of mental hospital treatment often raise doubts about suitability in the mind of the patient, and his focus is on the treatment person rather than on abstract treatment principle. This underlies the meaning of the oft-cited need for establishing rapport with the patient, and it needs to be restated that it is not the hospital that establishes this rapport with the patient. In County Hospital, the patient is diagnosed and treated by one person, who follows his course on the ward, arranges for his release, and continues posthospital treatment at the county clinic. This is similar to the situation where the patient has his own physician in attendance and in charge of his hospital care. The sensibility of this approach to the problem Of mental illness has been demonstrated in the use of general hospitals for psychiatric patients, including the use of medical wards (Moll, 1963). The issue of compliance with the doctor's orders is thus reduced to contractual arrangement between two people, and the margin of ambiguity in the patient's expectations of treatment, at least as far as release is concerned, is appreciably reduced. The patient is led to believe that if he does as the doctor directs him to do, he will get out. He is not faced with the unendurable expectation that it is entirely up to him (the patient), which usually elevates the rehabilitation problem to the status of a grand mystery. Putting aside the whole question of the efficacy of psychiatric treatment as we know it, there is a hoary truth to be regained in the charismatic relationship of doctors to people who are very ill. It is the laying on of medical hands to someone who needs
them that is crucial to effective treatment. There are times when a man cannot endure by himself, despite cultural prescriptions about independence, and one of them is when he is ill. Further, putting aside the whole question of the reality of mental disorder as an illness, mental patients are cast in the sick role and tend to expect of doctors what sick people in general expect--expert assistance. Once this condition is met, then even a mental patient is manageable, and the necessity of confinement, which arose from the fact that he was not manageable, is reduced. If the patient's estimation of the seriousness of his condition is a confounding characteristic of his symptom picture, then a contractual relationship with a doctor is a basic requirement for self-control in this regard. It allows the patient to derive information about his condition from someone who is responsible rather than to founder in the morass of uncertainties that are embedded in the signs and symbols of confinement to a mental hospital. This is what one might expect from all that has been reported in the literature on the significance of the therapeutic relationship to behavioral change vis-'t-vis the specific technique that is used. It is the quality of the relationship between doctor and patient that accounts for the latter's improvement (Barrett-Leonard, 1958; Fiedler, 1950). Continuous care by one psychiatrist at County Hospital also allows for the patient's acceptance of aftercare. One of the major difficulties in the posthospital maintenance of psychotic patients is a continuance of the medication regime established while the patient was in the hospital. It is not clear why many patients fail to continue their prescription after discharge (even when provided), but it may be that the absence of continued psychiatric support alters the meaning of the treatment experience. However, patients released from County Hospital remain under the care of their psychiatrist and see him regularly at the local clinic. In this case the problem of following a prescription seems to be minimized, and it is reported that virtually all of the patients thus treated have experienced no difficulty
PETER WEISS in taking medication. Acceptance of psychiatric treatment seems to prevail for the duration of the agreement between the patient and his doctor at least where matters of symptom control are concerned. It is important to mention that this psychiatric treatment is directed toward the patient's social problems and the reduction of anxiety generated by social failure. It does not, and because of staff limitations, could not, involve a serious psychological confrontation with the patient. Fortunately, social restoration of the patient has its surplus effect on the symptom picture, and the psychiatrist who renders such treatment is doing nothing more than is generally done for a malady in medical practice, i.e., restoring sufficient integrity to the system to allow that system to heal itself. The physician conspires, as it were, with nature to achieve restitution. Given the present state of knowledge in psychiatry, this achievement can only be roughly approximated, but we now know enough about the social requirements of psychological integrity at least to alter the circumstances of mental illness with some success. The key to that success, in terms of our limited definition--a reduction in the need for confinement to a hospital--lies in the patient's expectation for survival, and this depends on his definition of the psychiatric situation. Even a madman relies on social reality for definitional cues, and supportive psychiatry can do much to amplify them through the mediating situation of the patient's dependence on his doctor. Because the psychiatrist who sees the patient during his hospital stay is the same one who gives posthospital treatment, a relapse may not be alarming. The margin of tolerance for the recurrent psychosis is much greater than is usually the case where the physician has not treated the acute stage of the illness. The customary practice of public mental hospitals is to provide their own treatment staff and for the community to provide its own. Aftercare is often rendered, if at all, by a psychiatrist who has never seen the patient in the acute stage of disorder. Thus, when the patient collapses, the significance of the episode in the con-
175
text of the entire course of the illness is not apparent. In the case of patients in the present study, relapse is more easily understood in terms of the patient's needs and less in terms of those of his doctor. Rehospitalization in County Hospital tends to be a controlled phenomenon and may be for as little as 24 hours. The provision of continuous care and the administrative simplicity of the hospitalization process at County Hospital reduce some of the hazards of confinement. This locates the hospital as a resource in a community treatment effort as opposed to its traditional role as depository for treatment failures. As reported earlier (Weiss, Archer, & Pincus, 1965), it is to be noted that community acceptance is essential to the success of a rapid treatment program, i.e., the early discharge of patients. But this is not the same thing as widespread community acceptance. It may he in this case that this plan for early and appropriate psychiatric treatment is not well known outside of a few public agencies. Community acceptance may require only a few important agencies, as in this case the county clinic, health department, welfare department, and court. Especially the court! A broader referral base may be needed for wider usage of the treatment services, but the majority of the candidates for public mental hospital serv. ices in the county are now being treated. STAFF MORALE Much has been said about the necessity of trained personnel in psychiatric treatment programs; so much, in fact, that it is often felt that the mere existence of these people will ensure a visible and relevant treatment program. There are, nevertheless, limiting considerations. Staff enthusiasm, regardless of training and availability, is crucial to successful treatment. This enthusiasm varies with a number of factors, one of which is the degree of autonomy accorded to the mental health worker in the conduct of his work. Another is the degree of centralization of authority in the institution (Aiken & Hage, 1966). According to this formulation, both are indices of the degree of control one has over his work ex-
176
THE COMMUNITYMENTALHEALTHJOURNAL
perience. The greater this control, the higher the staff morale. In so far as professional services are concerned, the state mental hospital is highly centralized in the authority of the superintendent and the clinical director, and work roles are highly controlled. These features tend to vary as one moves up or down in the organization. In County Hospital, the superintendent leaves all clinical decisions to the psychiatrist who is doing the work (decentralization of authority). In addition to this, that treatment person does not have to share his treatment role with any other service (autonomy). His relations with nursing service are not competitive. Nursing is, in fact, not another service. There are a day nurse and a night nurse and several aides. It is not the usual situation whereby a hospital service entrenches itself in the face of a frequent turnover of psychiatric personnel. The tendency of the nursing staff to interfere with the medical routine because of competing definitions of the patient's behavior is minimal, because the hospital superintendent who supports the arrangement is in direct authority and because there is no effort to make the nursing staff do anything more than provide good nursing care, i.e., no ward therapy, etc. The psychiatrist does not attempt to define the nursing role for the nurse but rather attempts to define it for the patient. Thus, he maintains his control of the patient directly, with the help of the nursing staff and not in spite of it. As suggested above, a high degree of psychiatric control tends to minimize the debilitating effects of the custodial routine. On the other hand, the degree of psychiatric interference with that routine is small, and few demands for more than kindness are placed on the nursing staff. Thus, even on the acute ward, the staff has a good deal of autonomy and control of task performance. No attempt is made to introduce obscure and complex therapeutic meanings to their jobs, and staff training is put on the most acceptable terms. Staff im. provement concentrates on improving standards of nursing care, and this does not require organizational changes, i.e., in this case, status changes.
CONCLUSION It may be argued that the conditions of a custodial hospital environment may be dangerous to the patient (Barton, 1959; Smith, 1955; Wing, 1962). The patient is apt to develop symptoms of institutional neurosis and lose interest in life outside the hospital, i.e., lose interest in his own recovery. An aspect of the problem that is often overlooked is that the vulnerability of the patient to hospital conditions is only partly determined by his psychologcal disorder. It is also a function of his expectation that he will not recover. It is in the absence of evidence to the contrary that the coercive features of life in a total institution take their telling effect. But the bad influence of dosed ward life is not inevitable, and a patient who expects to be in the hospital a short time and who is led to this expectation by his psychiatrist, who intends to release him, is not likely to suffer greatly from institutional side effects. The severity of mental disorder is partly dependent on how sick the patient thinks he is, i.e., dependent partly on what has been referred to as "phrenophobia" (Raimy, 1963). Interventions that reduce the severity of phrenophobia provide the patient with much needed support. This may well be the reason for the success of emergency treatment in military psychiatry (Glass, 1953) and in the moral treatment of the nineteenth century (Bockoven, 1963). Patients recover from symptomatic attacks in part because they expect to, and this expectation is partly controlled by the way they are doctored. The sick role is not the sickness, and in psychiatry we are finding out what has been well known in other branches of medicine for some time, e.g., surgery, where recovery involves the earliest possible re-establishment of autonomous behavior. Nevertheless, this expectation of recovery on the part of the patient is not sufficient, however necessary it may be. Acute psychosis is what the term implies--a transient phenomenon. In time, it subsides, and the patient reverts usually to his former state of mind. The process of psychiatric labeling has obvious dangers in such a
PETER WEISS
situation (Menninger, 1942), and if psychiatry can treat the acute phase of the illness for what it is, an emergent symptomatic outbreak, the sick role can be minimized. Restoration then involves social rehabilitation outside, not inside, the hospital. REFERENCES AIKEN, M., & HATE, G. Organizational alienation: a comparative analysis. Amer. sociol. Rev., 1966, 31, 497-507. BARRETT-LEONARD,G. T. Dimensions of the client's experience of his therapist associated with personality change. Unpublished doctoral dissertation, Univer. of Chicago, 1958. BARTON, R. Institutional neurosis. Bristol, England: John Wright& Sons, 1959. BELKt'~AP,I. Human problems of a state mental hos. pital. New York: McGraw-Hill, 1956. BOCKOVEN,J. S. Moral treatment in American psychiatry. New York: Springer, 1963.
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FEIDLER, F. E. A comparison of therapeutic relationships in psychoanalytic, non-directive and Adlerian therapy. J. consult. Psychol., 1950, 14, 436-445. GLASS, A. J. Psychiatry in the Korean campaign. U.S. Armed Forces med. J., 1953, 4, 1563-1583. MENr~INCER,W. C. Functions of a psychiatric hospital. Bull. Menninger Clin., 1942, 6, 109-114. MOLL~ A. E. Evaluation of psychiatry in a general hospital and the community. Comprehensive Psychiat., 1963, 4, 394-408. ORT, R. S., FORD, AMASAB., & LISKE, R. E. The doctor-patient relationship as described by physicians and medical students. J. Hlth & hum. Behav., 1964, 5, 25-34. RAIMY, V. C. How strong is a conviction? ]. Ark. reed. Soc., 1963, 60, 181-187. SMITrr, DOROTHYE. The logic of custodial organization. Psychiat., 1965, 28, 311-323. WExSS, P., ARCHES R., & PI~cus, A. Discharging patients from a custodial institution. Community/ ment. Hlth ]., 1965, 1, 346-352. WINe, J. K. Institutionalism in mental hospitals. Brit. ]. soc. ella. Psychol., 1962, 1, 38-51.
Volume3, Number2, Summer,1967
THE CUSTODIAL HOSPITAL AS A COMMUNITY RESOURCE FOR PSYCHIATRIC TREATMENT PETER WEISS, PH.D.*
Custodial practices in mental hospitals are usually regarded as anfitherapeutic and inimical to treatment objectives. This conclusion arises from the failure to distinguish between custodial organization and custodial goals. It is the existence of the latter that subverts the treatment effort. This paper describes the use of a custodial hospital setting for psychiatric treatment purposes and suggests that elaborate intramural therapy routines may not be necessary to the rehabilitation of patients.
In a recent study (Weiss, Archer, & Pincus, 1965), it was illustrated that the discharge of patients from a custodial mental hospital did not depend on an internal revision of the custodial organization of the hospital. Success in releasing patients depended rather on changes in public policy regarding the use of the hospital for custodial purposes, changes in the administrative practice of the hospital itself and in the assignment of treatable cases to the institution, i.e., acute first admissions. That is, the release of patients did not require elaborate intramural therapy programs but rather involved intensive psychiatric and social work support for early discharge. The findings of this study suggest that the essential differences between treatment and custodial hospitals is found in the presence or absence of procedures for releasing patients. In order to understand this proposition, one must distinguish between custodial organization and custodial goals. The former refers to caretaking practices (found in all hospitals) and the latter to the encapsula-
tion of the patient within the institution and the prevention of his release. The length of time a patient spends in the hospital depends largely on the latter, both in terms of staff expectations and in terms of the patient's own adjustment to the realities of this goal. It is the goal of custody and the absence of contravening procedures for release that is crucial. Whether the wards are locked may be irrelevant. It is well known, for example, that most mental hospitals have a residual chronic population that may have complete freedom of movement within the institution and may even be essential to its maintenance as "key workers." Chronicity in mental hospitals depends heavily on the orientation of the patient to the outcome and not to the style of his confinement. It is necessary to note here that the goals of organizations are only imperfectly achieved. This stems from the difficulty in aligning organizational activity with institutional aims. This is particularly true of mental hospitals where the aims are very general and allow for a variety of goal-
*Dr. Weiss, a psychologist,is Pro~ectDirector, County Mental Hospital Project, Wisconsin Ps~(chiatric Institute, University of Wisconsin, lwadisou, Wis. This investigation was supported by a grant trom the National Institute of Mental Health, MH 1182, Study of County Mental Hospitals in Wisconsin. 171
172
THE COMMUNITYMENTALHEALTHJOURNAL
related activities. Effective custody, for example, can be achieved by a variety of devices ranging from manacles to milieu therapy, and the organizational systems they reflect may be equally varied. Moreover, staff outlook is apt to be defined in terms of staff activity and not in terms of institutional goals, and in some cases it may be very difficult to assess the relevance of such activities in light of those goals. Thus, staff perspective on goal changes is not necessarily prohibitive, since those changes may not interfere with existing hospital routines. The possibility being raised here is that the organization of a custodial hospital may be relatively unaffected by the establishment of release pro. cedures. Caretaking practices do not specify a time limit. Provision for the removal of deceased patients is noninterfering with existing routines. Likewise, provision for the removal of living patients may also be noninterfering. Thus, the need for organizational change may not be what current sociological thought might predict (Belknap, 1956) in changing hospital goals. The quality of custodial care may be such as to allow for appropriate psychiatric intervention from outside the hospital. It may be passive and therefore intrinsically receptive to this intervention and not in competition with it. It may provide services that are essential to patient welfare, such as competent nursing and medical supervision. The use of such hospital services may be part of a treatment strategy and is not inevitably a sign of failure at treatment in the community. Disabilities associated with psychic collapse need to be treated and authoritative control may need to be imposed. This can be achieved in any good hospital, psychiatric or otherwise (Moil, 1963). PSYCHIATRICTREATMENT The hospital in this study is one of 34 county.operated institutions in Wisconsin, which traditionally have been ~back wards" to the two state hospitals. Under this arrangement state hospital treatment failures, seniles, mental defectives, and other chronic invalids are cared for in county institu.
tions. This amounts to a partial decentralization of public mental institutions in the state, a situation that has existed since the mid-nineteenth century. The hospital in this study is a 225-bed facility, similar in size and function to other county hospitals. The majority of its patients are chronic either in terms of their disorder or in terms of their social circumstances. The custodial regime is benign. The wards are clean and not crowded, and the patients are generally docile and quiet. The hospital is located in an urban area, which makes it somewhat atypical and similar to only three or four other county institutions in the state. The significance of its location lies in the availability of psychiatric services, but in terms of the traditional custodial perspective of these institutions, this is not an inevitable source of improvement. Its location merely allows for its more varied use. The development of psychiatric services for patients who normally would use, or be sent to, the distant state hospital involved the joint efforts of the county probate udge, the county clinic psychiatrist and the local hospital superintendent. The major aim of the arrangement to be described was to prevent the legal commitment of people referred to the county court. The surplus effects of this amount to the existence of a local psychiatric treatment program. This does not represent the establishment of a mental health center in terms of the 1964 federal regulations nor is it the product of state planning. It is a locally inspired and locally conceived arrangement based on local need that was locally perceived. At the time of this writing the program has not been officially recognized by the state as a viable treatment plan according to the statutes, although it is regarded with a good deal of official interest and unofficial approval. The county courts in Wisconsin are a major source of referral to the state hospitals. By law, a person in need of hospitalization and whose condition is not chronic may be sent to the state hospital in the district. Commitment to a county hospital is permissible only in cases of chronic mental illness, mental infirmity (senility), in.
PETER WEISS ebriates, drug addicts, and chronic invalids. Acute first-admission cases are sent to the state institutions. In the present county, the probate judge has been reluctant to use the statutory commitment procedure to send patients to the state hospital, both for reasons of the stigma associated with such commitments and the social difficulties associated with the legal deprivation of liberty. The rehabilitation problems created by the removal of the patient to the distant state hospital may not have been apparent, but the sociolegal position taken has the same effect. Candidates for hospitalization, coming before the court, are sent to County Hospital, either as voluntary admissions or under a court order for observation, which is good for 30 days and may be twice renewed. It is during this observation period that psychiatric intervention is made and discharge planning begins. There is admittedly very little by way of intramural treatment, and the psyehiatrie effort is directed toward the earliest possible release of the patient. There is nothing particularly unusual about this aim in modern hospital psychiatry, but the time needed to release a patient has been governed, in part, by the extent of intramural services. In one state hospital in Wisconsin, for example, the customary practice of elaborate intake procedures, i.e., giving the patient a thorough "workup," may require a waiting period of three weeks to a month before treatment recommendations are made. This may be the partial result of staff limitations, but it also may be a reflection of the intramural orientation of the hospital, given in the very faet of maintaining its own treatment staff. In County Hospital, new admissions are evaluated within three days and release can be arranged immediately. Here the hospital has no treatment staff of its own, with these services being provided by the psychiatrist from the county clinic, the social worker from the court, and the county judge, who maintains continuing interest in patients under court order and is, in a sense, the incarnation of community pressure for discharge. The result of this arrangement is an average length of stay for all patients, vol-
173
untary and involuntary, of three weeks (numerical reference based on data for a nine-month period; N=222) as compared to the state hospital where it is at least two months.
DOCTOR-PATIENT RELATIONSHIP Psychiatric treatment in this case addresses itself to the severe limitations of custodial hospital resources and to the immediate social and psychological situation of the patient, including the temporal boundaries created by the court. It recognizes the need for symptom relief as well as the severe social consequences of confinement. The acute disturbance requires medical and psychological support. It also requires a context that will define the relevance of such treatment in terms of the patient's early return to the community. That is, the treatment given does not occur in an expectational vacuum but rather the patient is told that he will be released in a short period provided he follows medical orders. His release is easily arranged at the request of the psychiatrist, and psychological support is continued at the county clinic. The patient is rehabilitated outside of the hospital, which remains as a resource for renewed treatment in case of a relapse. The psychiatrist takes direct charge of the case from the start and maintains that contact during confinement and for posthospital care. Continuity of treatment is thus assured, and two crucial issues are revealed: (a) compliance with medical orders is based on a contract between the doctor and the patient and not on an abstract treatment principle, and (b) the same doctor has seen the patient in all phases of the disorder, thus reducing the possibility of medical excitement over a relapse. Obedience to medical orders in the case of severe illness is important, to say the least. It may not be what we think it is, but in terms of the patient's need for authoritative support as well as the physician's need to be effective, which in psychiatry is a rare reward for effort, it would seem to be a minimum requirement for medical responsibility (Ort, Ford, & Liske, 1954). This has amounted to a serious problem in large hos-
174
THE COMMUNITYMENTALHEALTHJOURNAL
pitals, where psychiatric activity is a shared endeavor, where different specialists may be involved in carrying out the treatment plan and where disposition of the patient is often a committee decision. In such cases the patient is confronted with the rationale of treatment rather than with the rationality of his physician. In the case of a bone fracture, this rationale may be readily understood by the patient, but in the case of mental illness it is often not even understood by the hospital staff. The ambiguities of mental hospital treatment often raise doubts about suitability in the mind of the patient, and his focus is on the treatment person rather than on abstract treatment principle. This underlies the meaning of the oft-cited need for establishing rapport with the patient, and it needs to be restated that it is not the hospital that establishes this rapport with the patient. In County Hospital, the patient is diagnosed and treated by one person, who follows his course on the ward, arranges for his release, and continues posthospital treatment at the county clinic. This is similar to the situation where the patient has his own physician in attendance and in charge of his hospital care. The sensibility of this approach to the problem Of mental illness has been demonstrated in the use of general hospitals for psychiatric patients, including the use of medical wards (Moll, 1963). The issue of compliance with the doctor's orders is thus reduced to contractual arrangement between two people, and the margin of ambiguity in the patient's expectations of treatment, at least as far as release is concerned, is appreciably reduced. The patient is led to believe that if he does as the doctor directs him to do, he will get out. He is not faced with the unendurable expectation that it is entirely up to him (the patient), which usually elevates the rehabilitation problem to the status of a grand mystery. Putting aside the whole question of the efficacy of psychiatric treatment as we know it, there is a hoary truth to be regained in the charismatic relationship of doctors to people who are very ill. It is the laying on of medical hands to someone who needs
them that is crucial to effective treatment. There are times when a man cannot endure by himself, despite cultural prescriptions about independence, and one of them is when he is ill. Further, putting aside the whole question of the reality of mental disorder as an illness, mental patients are cast in the sick role and tend to expect of doctors what sick people in general expect--expert assistance. Once this condition is met, then even a mental patient is manageable, and the necessity of confinement, which arose from the fact that he was not manageable, is reduced. If the patient's estimation of the seriousness of his condition is a confounding characteristic of his symptom picture, then a contractual relationship with a doctor is a basic requirement for self-control in this regard. It allows the patient to derive information about his condition from someone who is responsible rather than to founder in the morass of uncertainties that are embedded in the signs and symbols of confinement to a mental hospital. This is what one might expect from all that has been reported in the literature on the significance of the therapeutic relationship to behavioral change vis-'t-vis the specific technique that is used. It is the quality of the relationship between doctor and patient that accounts for the latter's improvement (Barrett-Leonard, 1958; Fiedler, 1950). Continuous care by one psychiatrist at County Hospital also allows for the patient's acceptance of aftercare. One of the major difficulties in the posthospital maintenance of psychotic patients is a continuance of the medication regime established while the patient was in the hospital. It is not clear why many patients fail to continue their prescription after discharge (even when provided), but it may be that the absence of continued psychiatric support alters the meaning of the treatment experience. However, patients released from County Hospital remain under the care of their psychiatrist and see him regularly at the local clinic. In this case the problem of following a prescription seems to be minimized, and it is reported that virtually all of the patients thus treated have experienced no difficulty
PETER WEISS in taking medication. Acceptance of psychiatric treatment seems to prevail for the duration of the agreement between the patient and his doctor at least where matters of symptom control are concerned. It is important to mention that this psychiatric treatment is directed toward the patient's social problems and the reduction of anxiety generated by social failure. It does not, and because of staff limitations, could not, involve a serious psychological confrontation with the patient. Fortunately, social restoration of the patient has its surplus effect on the symptom picture, and the psychiatrist who renders such treatment is doing nothing more than is generally done for a malady in medical practice, i.e., restoring sufficient integrity to the system to allow that system to heal itself. The physician conspires, as it were, with nature to achieve restitution. Given the present state of knowledge in psychiatry, this achievement can only be roughly approximated, but we now know enough about the social requirements of psychological integrity at least to alter the circumstances of mental illness with some success. The key to that success, in terms of our limited definition--a reduction in the need for confinement to a hospital--lies in the patient's expectation for survival, and this depends on his definition of the psychiatric situation. Even a madman relies on social reality for definitional cues, and supportive psychiatry can do much to amplify them through the mediating situation of the patient's dependence on his doctor. Because the psychiatrist who sees the patient during his hospital stay is the same one who gives posthospital treatment, a relapse may not be alarming. The margin of tolerance for the recurrent psychosis is much greater than is usually the case where the physician has not treated the acute stage of the illness. The customary practice of public mental hospitals is to provide their own treatment staff and for the community to provide its own. Aftercare is often rendered, if at all, by a psychiatrist who has never seen the patient in the acute stage of disorder. Thus, when the patient collapses, the significance of the episode in the con-
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text of the entire course of the illness is not apparent. In the case of patients in the present study, relapse is more easily understood in terms of the patient's needs and less in terms of those of his doctor. Rehospitalization in County Hospital tends to be a controlled phenomenon and may be for as little as 24 hours. The provision of continuous care and the administrative simplicity of the hospitalization process at County Hospital reduce some of the hazards of confinement. This locates the hospital as a resource in a community treatment effort as opposed to its traditional role as depository for treatment failures. As reported earlier (Weiss, Archer, & Pincus, 1965), it is to be noted that community acceptance is essential to the success of a rapid treatment program, i.e., the early discharge of patients. But this is not the same thing as widespread community acceptance. It may he in this case that this plan for early and appropriate psychiatric treatment is not well known outside of a few public agencies. Community acceptance may require only a few important agencies, as in this case the county clinic, health department, welfare department, and court. Especially the court! A broader referral base may be needed for wider usage of the treatment services, but the majority of the candidates for public mental hospital serv. ices in the county are now being treated. STAFF MORALE Much has been said about the necessity of trained personnel in psychiatric treatment programs; so much, in fact, that it is often felt that the mere existence of these people will ensure a visible and relevant treatment program. There are, nevertheless, limiting considerations. Staff enthusiasm, regardless of training and availability, is crucial to successful treatment. This enthusiasm varies with a number of factors, one of which is the degree of autonomy accorded to the mental health worker in the conduct of his work. Another is the degree of centralization of authority in the institution (Aiken & Hage, 1966). According to this formulation, both are indices of the degree of control one has over his work ex-
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perience. The greater this control, the higher the staff morale. In so far as professional services are concerned, the state mental hospital is highly centralized in the authority of the superintendent and the clinical director, and work roles are highly controlled. These features tend to vary as one moves up or down in the organization. In County Hospital, the superintendent leaves all clinical decisions to the psychiatrist who is doing the work (decentralization of authority). In addition to this, that treatment person does not have to share his treatment role with any other service (autonomy). His relations with nursing service are not competitive. Nursing is, in fact, not another service. There are a day nurse and a night nurse and several aides. It is not the usual situation whereby a hospital service entrenches itself in the face of a frequent turnover of psychiatric personnel. The tendency of the nursing staff to interfere with the medical routine because of competing definitions of the patient's behavior is minimal, because the hospital superintendent who supports the arrangement is in direct authority and because there is no effort to make the nursing staff do anything more than provide good nursing care, i.e., no ward therapy, etc. The psychiatrist does not attempt to define the nursing role for the nurse but rather attempts to define it for the patient. Thus, he maintains his control of the patient directly, with the help of the nursing staff and not in spite of it. As suggested above, a high degree of psychiatric control tends to minimize the debilitating effects of the custodial routine. On the other hand, the degree of psychiatric interference with that routine is small, and few demands for more than kindness are placed on the nursing staff. Thus, even on the acute ward, the staff has a good deal of autonomy and control of task performance. No attempt is made to introduce obscure and complex therapeutic meanings to their jobs, and staff training is put on the most acceptable terms. Staff im. provement concentrates on improving standards of nursing care, and this does not require organizational changes, i.e., in this case, status changes.
CONCLUSION It may be argued that the conditions of a custodial hospital environment may be dangerous to the patient (Barton, 1959; Smith, 1955; Wing, 1962). The patient is apt to develop symptoms of institutional neurosis and lose interest in life outside the hospital, i.e., lose interest in his own recovery. An aspect of the problem that is often overlooked is that the vulnerability of the patient to hospital conditions is only partly determined by his psychologcal disorder. It is also a function of his expectation that he will not recover. It is in the absence of evidence to the contrary that the coercive features of life in a total institution take their telling effect. But the bad influence of dosed ward life is not inevitable, and a patient who expects to be in the hospital a short time and who is led to this expectation by his psychiatrist, who intends to release him, is not likely to suffer greatly from institutional side effects. The severity of mental disorder is partly dependent on how sick the patient thinks he is, i.e., dependent partly on what has been referred to as "phrenophobia" (Raimy, 1963). Interventions that reduce the severity of phrenophobia provide the patient with much needed support. This may well be the reason for the success of emergency treatment in military psychiatry (Glass, 1953) and in the moral treatment of the nineteenth century (Bockoven, 1963). Patients recover from symptomatic attacks in part because they expect to, and this expectation is partly controlled by the way they are doctored. The sick role is not the sickness, and in psychiatry we are finding out what has been well known in other branches of medicine for some time, e.g., surgery, where recovery involves the earliest possible re-establishment of autonomous behavior. Nevertheless, this expectation of recovery on the part of the patient is not sufficient, however necessary it may be. Acute psychosis is what the term implies--a transient phenomenon. In time, it subsides, and the patient reverts usually to his former state of mind. The process of psychiatric labeling has obvious dangers in such a
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situation (Menninger, 1942), and if psychiatry can treat the acute phase of the illness for what it is, an emergent symptomatic outbreak, the sick role can be minimized. Restoration then involves social rehabilitation outside, not inside, the hospital. REFERENCES AIKEN, M., & HATE, G. Organizational alienation: a comparative analysis. Amer. sociol. Rev., 1966, 31, 497-507. BARRETT-LEONARD,G. T. Dimensions of the client's experience of his therapist associated with personality change. Unpublished doctoral dissertation, Univer. of Chicago, 1958. BARTON, R. Institutional neurosis. Bristol, England: John Wright& Sons, 1959. BELKt'~AP,I. Human problems of a state mental hos. pital. New York: McGraw-Hill, 1956. BOCKOVEN,J. S. Moral treatment in American psychiatry. New York: Springer, 1963.
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FEIDLER, F. E. A comparison of therapeutic relationships in psychoanalytic, non-directive and Adlerian therapy. J. consult. Psychol., 1950, 14, 436-445. GLASS, A. J. Psychiatry in the Korean campaign. U.S. Armed Forces med. J., 1953, 4, 1563-1583. MENr~INCER,W. C. Functions of a psychiatric hospital. Bull. Menninger Clin., 1942, 6, 109-114. MOLL~ A. E. Evaluation of psychiatry in a general hospital and the community. Comprehensive Psychiat., 1963, 4, 394-408. ORT, R. S., FORD, AMASAB., & LISKE, R. E. The doctor-patient relationship as described by physicians and medical students. J. Hlth & hum. Behav., 1964, 5, 25-34. RAIMY, V. C. How strong is a conviction? ]. Ark. reed. Soc., 1963, 60, 181-187. SMITrr, DOROTHYE. The logic of custodial organization. Psychiat., 1965, 28, 311-323. WExSS, P., ARCHES R., & PI~cus, A. Discharging patients from a custodial institution. Community/ ment. Hlth ]., 1965, 1, 346-352. WINe, J. K. Institutionalism in mental hospitals. Brit. ]. soc. ella. Psychol., 1962, 1, 38-51.
