Community Mental Health Journal Volume 2, Number 1, Spring, 1966
PROGRAM
DEVELOPMENTS
The Day Care Center: A New Dimension of Treatment in a M e n t a l H y g i e n e Clinic
The introduction of a treatment modality which emphasizes the principles of the therapeutic community has had a profound effect on the traditional practices and future perspectives of mental hygiene clinics of which a day treatment center is an integral part. The therapeutic milieu concept employed in these clinics is a logical step in the progression of treatment methods. Its advancement may be compared with an earlier development--the establishment of the outpatient clinic as an independent entity, serving the community, rather than the hospital. The Veterans Administration Mental Hygiene Clinics may be regarded as typical of this design. These clinics are required by law to limit th~.;r services to veterans and their families. Hence, there are restrictions with respect to the community as a whole. Nevertheless, the fact that veterans are integrated into the community validates the concept of the Veterans Administration Clinic as a community focused agency. At this stage of growth in the national network of 60 or so V.A. Mental Hygiene Clinics, after six years of development, 25 have Day Treatment Centers coordinated with their total programs, and are considered as one modality in the spectrum of therapy. The observation has been made of the growing tendency to set up independent therapeutic milieu institutions as ends in themselves with no coherence to hospital or clinic. One may speculate that such criticism reflects the concern, that without linkage to traditional models of psychiatric practice,
a loss will be incurred in providing a disciplined and appropriate service to the patient. Dr. Joshua Bierer, during a panel discussion at the Third World Congress of Psychiatry in Montreal in 1961, also expressed concern about those proponents in social psychiatry which, "could put the mental hospitals largely out of business with a type of comprehensive day hospital." Perhaps there is a legitimate need for both types of institutions, i.e., one that is integrated into the hospital or clinic, and the so-called independent entity. In the long run, it is rather the needs of patients and the acceptance by the public of community mental health concepts that are the final determinants. The Brooklyn V.A. Mental Hygiene Clinic views its day care operation as an integral part of its organization structure and treatment program. It is considered as another modality to be prescribed in a manner that is consistent with patients' requirements and therapeutic perspectives. The interdisciplinary team is the counterpart of those functioning in the other sections of the clinic. However, there are obvious differences in the manner of carrying out professional responsibilities characterized by the staff's pervasive involvement with patients and with each other in the open milieu. The Day Treatment Center in Brooklyn is regarded as a pilot program for centers of similar pattern in the Veterans Administration. The Center stemmed from the long felt and long observed needs of the typical and large group of veterans attending the 79
80
THE COMMUNITYMENTALHEALTH JOURNAL
Mental Hygiene Clinic, who were not re- contributing to this group effort, is an sponsive to traditional and conventional important therapeutic factor. The physical setting, geographically adj aclinical treatment procedures, usually individual or group psychotherapy. These are cent to the Mental Hygiene Clinic, consists the so-called "dispensary," type patients; of what in a home would be considered a the chronic ambulatory schizophrenics, so- living room, a workshop (with occupational matically fixed, unemployed, or marginally and manual arts, therapeutic equipment and employed, and with vague or nonexistent materials), a recreation area with billiard family ties. An equally significant and table, shuffle board, and table tennis, major group for whom provision needed to library, music room, dining room, and be made was the trial visit or aftercare kitchen, all furnished in an informal home category, the acutely ill in a fair degree of like manner, dissimilar from an instituremission, for whom an experience in a tional atmosphere. There are prints, colorful therapeutic milieu was seen as a condition- wall hangings, travel posters, periodicals, ing one in helping to bridge the transition musical instruments, radios, a phonograph, between hospital and community living. a television set, and a coffee and snack bar. Still a third group are those patients in- Housekeeping and food preparation are, for curring overt symptoms, whose hospitaliza- the most part, handled by patient committion might be forestalled by exposure to the tees through the patient government organization with the assistance of staff and therapeutic community. What is the rationale of day center volunteers. The staff offices with open doors, semitherapy? The difficulties of most of the partitioned, are strategically located in the patients may be characterized by the triad of emotional shifting, ideational distortion center or hub of the area, situated with a and behavior bizarreness in various degrees ready accessibility to patients. There are and combinations. They have had years of also rooms for individual interviews and conventional, intensive and extensive treat- group discussions where patients and relament, from regularly spaced individual or tives may be seen in a more formal and group psychotherapy sessions, to infre- confidential setting as requirements dictate. quent, dispensary type of therapy, with Yet, experience has proven that best results drugs as the main support. For many, every are achieved by stressing the informal, and new hospitalization means a new scar and frequently a casual (though studied and regression to a lower level of existence and disciplined) approach to patients through adjustment. The day center attempts to a pervasive involvement of staff, and by offer these patients all day exposure to using the equipment, materials, furnishings, multiple therapeutic influences of the milieu activities, and programs as devices of theras well as to the community which reaches apy. The interaction of patients, staff and into the day center through a volunteer volunteers is therefore in the open and program and community activities. In observable. The staff consists of a clinical team, analgeneral, the therapy serves a twofold purogous to its counterparts in the Mental pose: (a) to keep the chronic schizophrenic on a level of living, feeling and functioning, Hygiene Clinic, with some modifications. bearable to himself and acceptable to others, A psychiatrist with the overall responsibility for the medical program, clinical and (b) to prevent possibly acute flare-ups, psychologist, and clinical social worker. In leading to hospitalization. addition there are an occupational-recreaThe day center offers the patients a tional therapist, a vocational counseling steady environment of purposeful relations, psychologist offering part-time services, a battleground for continuous struggle with and student trainees in social work and their engulfing anxiety, loneliness, insecu- psychology. There are nine regularly scherity and self-consciousness. The self-realiza- duled volunteers and a varied number of tion of patients that they themselves are groups of community and service organiza-
PRO(RAM DEVELOPMENTS tions contributing specialized or "friendly visitor" services integrated in the total program. There are approximately 100 patients on the register, of whom from 50 to 60 attend for an 8-hour clay (a registered patient is one who visits the Center and uses its facilities at least three times per week). All patients are medically referred, from the treatment teams in the Mental Hygiene Clinic or by the V.A. psychiatric hospitals in the metropolitan area. Their acceptance as Day Center members is contingent upon their adjustment, interest, and motivation, determined during a 30-day trim period. Attendance and participation are permissive and group meetings are open ended. Activities, programs, and treatment plans are worked out for each patient, with individualized application by the staff, of degrees of permissiveness, directiveness, and structure dependent upon psychodynamic considerations. From the patient's point of view the atmosphere may appear casual and informal. There is, however, a disciplined regard for each patient, which is exemplified by the planning which occurs in frequent staff meetings and the periodic reviews of patient experience and progress. Experience has shown that it is necessary to be opportunistic with regard to exploiting this psychotherapeutic method. In our early experience we designated group therapy sessions in the program. When it was discovered that "therapy" was an emotionally laden, threatening description for many of our patients--since they simply would not attend these sessions--the technique was revised. "Group therapy" became the "Music Appreciation Club," the "Spanish Language Class," "Veteran-Staff Business Meeting," and other groups that were seemingly activity centered, but in actuality were opportunities for interpersonal discussions and interactions on a realistic level. There are many other activities and program dements that are what they seem to be: e.g., the vocational counseling program, the monetary-incentive unit (a kind of sheltered workshop experience), casework concerned with environmental prob-
81
lems and family adjustment, counseling or home economics, recreational and sports activities, music instruction, arts and crafts, publication of a newspaper and many other activities available in the course of a day. The patient's reactions, interactions with staff and others, are all grist for the mill of problem solution. There is sometimes professional concern expressed that our patients will become overly dependent, that we are substituting artifices for the realities of everyday living. Time and again, observations reveal that the schizophrenic patient lacks the will or motivation to organize his life. The contrived provision of activities by others is necessary to furnish the stimulus that will enable the patient to obtain the necessary start in the process that results in helping himself. A staff functioning in the therapeutic milieu needs to be sensitive to the shifting requirements of the group and to be helpful in protecting against severe consequences of patient failure, frustration, and incapacity through immobility. On the other hand, staff members need to recognize the point at which the patient appears competent in his ability to achieve some degree of autonomy and dissociation. In brief, the staff must be part of the patient's group, and also represent the outside world. Finally, in a recently completed study involving sociometric choice patterns of 49 schizophrenic patients attending the Day Center, it was found that, when compared to their hospitalized counterparts, those in the outpatient setting showed a significantly greater capacity to use a milieu that provided opportunities for adaptive and supportive experiences in social interaction. JOSEPH A. WINN, M.D. AND WALTER LESSER, M.S.W. ~ * Dr. Winn, a psychiatrist, is Chief, Psychiatry and Neurology Service, Veterans Administration Outpatient Clinic, Brooklyn, New York. He is also Associate Clinical Professor of Neurology, New York Medical College. Mr. Lesser, a psychiatric social worker, is Assistant Chief, Social Work Service, VA Outpatient Clinic, Mental Hyg. Serv., Boston, Mass. He is also an assistant in Psychiatry at the Tufts Medical School, Boston.
PROGRAM
DEVELOPMENTS
The Day Care Center: A New Dimension of Treatment in a M e n t a l H y g i e n e Clinic
The introduction of a treatment modality which emphasizes the principles of the therapeutic community has had a profound effect on the traditional practices and future perspectives of mental hygiene clinics of which a day treatment center is an integral part. The therapeutic milieu concept employed in these clinics is a logical step in the progression of treatment methods. Its advancement may be compared with an earlier development--the establishment of the outpatient clinic as an independent entity, serving the community, rather than the hospital. The Veterans Administration Mental Hygiene Clinics may be regarded as typical of this design. These clinics are required by law to limit th~.;r services to veterans and their families. Hence, there are restrictions with respect to the community as a whole. Nevertheless, the fact that veterans are integrated into the community validates the concept of the Veterans Administration Clinic as a community focused agency. At this stage of growth in the national network of 60 or so V.A. Mental Hygiene Clinics, after six years of development, 25 have Day Treatment Centers coordinated with their total programs, and are considered as one modality in the spectrum of therapy. The observation has been made of the growing tendency to set up independent therapeutic milieu institutions as ends in themselves with no coherence to hospital or clinic. One may speculate that such criticism reflects the concern, that without linkage to traditional models of psychiatric practice,
a loss will be incurred in providing a disciplined and appropriate service to the patient. Dr. Joshua Bierer, during a panel discussion at the Third World Congress of Psychiatry in Montreal in 1961, also expressed concern about those proponents in social psychiatry which, "could put the mental hospitals largely out of business with a type of comprehensive day hospital." Perhaps there is a legitimate need for both types of institutions, i.e., one that is integrated into the hospital or clinic, and the so-called independent entity. In the long run, it is rather the needs of patients and the acceptance by the public of community mental health concepts that are the final determinants. The Brooklyn V.A. Mental Hygiene Clinic views its day care operation as an integral part of its organization structure and treatment program. It is considered as another modality to be prescribed in a manner that is consistent with patients' requirements and therapeutic perspectives. The interdisciplinary team is the counterpart of those functioning in the other sections of the clinic. However, there are obvious differences in the manner of carrying out professional responsibilities characterized by the staff's pervasive involvement with patients and with each other in the open milieu. The Day Treatment Center in Brooklyn is regarded as a pilot program for centers of similar pattern in the Veterans Administration. The Center stemmed from the long felt and long observed needs of the typical and large group of veterans attending the 79
80
THE COMMUNITYMENTALHEALTH JOURNAL
Mental Hygiene Clinic, who were not re- contributing to this group effort, is an sponsive to traditional and conventional important therapeutic factor. The physical setting, geographically adj aclinical treatment procedures, usually individual or group psychotherapy. These are cent to the Mental Hygiene Clinic, consists the so-called "dispensary," type patients; of what in a home would be considered a the chronic ambulatory schizophrenics, so- living room, a workshop (with occupational matically fixed, unemployed, or marginally and manual arts, therapeutic equipment and employed, and with vague or nonexistent materials), a recreation area with billiard family ties. An equally significant and table, shuffle board, and table tennis, major group for whom provision needed to library, music room, dining room, and be made was the trial visit or aftercare kitchen, all furnished in an informal home category, the acutely ill in a fair degree of like manner, dissimilar from an instituremission, for whom an experience in a tional atmosphere. There are prints, colorful therapeutic milieu was seen as a condition- wall hangings, travel posters, periodicals, ing one in helping to bridge the transition musical instruments, radios, a phonograph, between hospital and community living. a television set, and a coffee and snack bar. Still a third group are those patients in- Housekeeping and food preparation are, for curring overt symptoms, whose hospitaliza- the most part, handled by patient committion might be forestalled by exposure to the tees through the patient government organization with the assistance of staff and therapeutic community. What is the rationale of day center volunteers. The staff offices with open doors, semitherapy? The difficulties of most of the partitioned, are strategically located in the patients may be characterized by the triad of emotional shifting, ideational distortion center or hub of the area, situated with a and behavior bizarreness in various degrees ready accessibility to patients. There are and combinations. They have had years of also rooms for individual interviews and conventional, intensive and extensive treat- group discussions where patients and relament, from regularly spaced individual or tives may be seen in a more formal and group psychotherapy sessions, to infre- confidential setting as requirements dictate. quent, dispensary type of therapy, with Yet, experience has proven that best results drugs as the main support. For many, every are achieved by stressing the informal, and new hospitalization means a new scar and frequently a casual (though studied and regression to a lower level of existence and disciplined) approach to patients through adjustment. The day center attempts to a pervasive involvement of staff, and by offer these patients all day exposure to using the equipment, materials, furnishings, multiple therapeutic influences of the milieu activities, and programs as devices of theras well as to the community which reaches apy. The interaction of patients, staff and into the day center through a volunteer volunteers is therefore in the open and program and community activities. In observable. The staff consists of a clinical team, analgeneral, the therapy serves a twofold purogous to its counterparts in the Mental pose: (a) to keep the chronic schizophrenic on a level of living, feeling and functioning, Hygiene Clinic, with some modifications. bearable to himself and acceptable to others, A psychiatrist with the overall responsibility for the medical program, clinical and (b) to prevent possibly acute flare-ups, psychologist, and clinical social worker. In leading to hospitalization. addition there are an occupational-recreaThe day center offers the patients a tional therapist, a vocational counseling steady environment of purposeful relations, psychologist offering part-time services, a battleground for continuous struggle with and student trainees in social work and their engulfing anxiety, loneliness, insecu- psychology. There are nine regularly scherity and self-consciousness. The self-realiza- duled volunteers and a varied number of tion of patients that they themselves are groups of community and service organiza-
PRO(RAM DEVELOPMENTS tions contributing specialized or "friendly visitor" services integrated in the total program. There are approximately 100 patients on the register, of whom from 50 to 60 attend for an 8-hour clay (a registered patient is one who visits the Center and uses its facilities at least three times per week). All patients are medically referred, from the treatment teams in the Mental Hygiene Clinic or by the V.A. psychiatric hospitals in the metropolitan area. Their acceptance as Day Center members is contingent upon their adjustment, interest, and motivation, determined during a 30-day trim period. Attendance and participation are permissive and group meetings are open ended. Activities, programs, and treatment plans are worked out for each patient, with individualized application by the staff, of degrees of permissiveness, directiveness, and structure dependent upon psychodynamic considerations. From the patient's point of view the atmosphere may appear casual and informal. There is, however, a disciplined regard for each patient, which is exemplified by the planning which occurs in frequent staff meetings and the periodic reviews of patient experience and progress. Experience has shown that it is necessary to be opportunistic with regard to exploiting this psychotherapeutic method. In our early experience we designated group therapy sessions in the program. When it was discovered that "therapy" was an emotionally laden, threatening description for many of our patients--since they simply would not attend these sessions--the technique was revised. "Group therapy" became the "Music Appreciation Club," the "Spanish Language Class," "Veteran-Staff Business Meeting," and other groups that were seemingly activity centered, but in actuality were opportunities for interpersonal discussions and interactions on a realistic level. There are many other activities and program dements that are what they seem to be: e.g., the vocational counseling program, the monetary-incentive unit (a kind of sheltered workshop experience), casework concerned with environmental prob-
81
lems and family adjustment, counseling or home economics, recreational and sports activities, music instruction, arts and crafts, publication of a newspaper and many other activities available in the course of a day. The patient's reactions, interactions with staff and others, are all grist for the mill of problem solution. There is sometimes professional concern expressed that our patients will become overly dependent, that we are substituting artifices for the realities of everyday living. Time and again, observations reveal that the schizophrenic patient lacks the will or motivation to organize his life. The contrived provision of activities by others is necessary to furnish the stimulus that will enable the patient to obtain the necessary start in the process that results in helping himself. A staff functioning in the therapeutic milieu needs to be sensitive to the shifting requirements of the group and to be helpful in protecting against severe consequences of patient failure, frustration, and incapacity through immobility. On the other hand, staff members need to recognize the point at which the patient appears competent in his ability to achieve some degree of autonomy and dissociation. In brief, the staff must be part of the patient's group, and also represent the outside world. Finally, in a recently completed study involving sociometric choice patterns of 49 schizophrenic patients attending the Day Center, it was found that, when compared to their hospitalized counterparts, those in the outpatient setting showed a significantly greater capacity to use a milieu that provided opportunities for adaptive and supportive experiences in social interaction. JOSEPH A. WINN, M.D. AND WALTER LESSER, M.S.W. ~ * Dr. Winn, a psychiatrist, is Chief, Psychiatry and Neurology Service, Veterans Administration Outpatient Clinic, Brooklyn, New York. He is also Associate Clinical Professor of Neurology, New York Medical College. Mr. Lesser, a psychiatric social worker, is Assistant Chief, Social Work Service, VA Outpatient Clinic, Mental Hyg. Serv., Boston, Mass. He is also an assistant in Psychiatry at the Tufts Medical School, Boston.
