205
VOLUNTEER CASE AIDES IN THE U.S.A.
(Jeanne Lewington is a Voluntary Services Organiser at a psychiatric hospital, England) by LEWINGTON JEANNE SUMMARY
awarded a 1973 Winston Churchill Fellowship to the U.S.A. and look at the way volunteers are used, particularly in the field of mental health. She studied projects at State and Private Mental Hospitals and Community Health Centres. She was particularly impressed with the contribution of Volunteer Case Aides in one to one work with psychiatric patients and describes this principle in some detail. On her return Mrs. Lewington approached the King’s Fund London and has been given a grant to finance the establishment of a two year Volunteer Case Aide Programme based at St. Crispin Hospital, Northampton, England, evaluation of which will take place during 1975.
MRS. visit
Jeanne Lewington
was
INTRODUCTION
indebted to the Winston Churchill Memorial Trust for the opportunity to spend two months during 1973 visiting the United States of America and seeing something of the way volunteers work there, particularly in the field of Mental Health. The trust was established in 1965 as a unique form of National Memorial to Sir Winston Churchill. It enables men and women who might otherwise not have the chance, to travel abroad, widen their knowledge in their own field of activity, learn how people live and work in different parts of the world, and as a result of the experience they gain they are able, hopefully, to contribute something different to their profession, community and country. Every year the Council chooses a number of categories which reflect a broad/cross section of life in the country, the arts, social and public service, industry, nature, sport and adventure. So far there are 689 Churchill Fellows in 99 different categories (545 men and 144 women), and they have travelled to almost every country in the world. I was appointed Voluntary Services Organiser to the St. Crispin group of hospitals, Northampton, in January 1970, and my responsibilities cover voluntary services in an 800 bedded psychiatric hospital built back in 1876, a brand new hospital for the care of the mentally subnormal housing 500 patients, and three Day Hospitals in the community. We are just starting in the Health and Social Services to appreciate the contribution which can be made by volunteers. My own type of appointment is relatively new (6) and one finds feelings of professionals rather mixed regarding the use of volunteers. Such feelings have to be respected, brought out into the open and worked through before a voluntary help scheme can be introduced with any hope of success. In my own hospitals I use the help of adult and youth volunteers in work with long stay and geriatric (or perhaps I should say psycho-geriatric) patients, and in this area I developed a procedure whereby senior schoolchildren from local schools became involved in visiting and befriending elderly people in hospital. This has expanded during the last three years so that eight schools participate with over one hundred senior schoolchildren coming along every week to visit and befriend long stay patients (4). I also enlist the help of more mature youth volunteers in work I
am
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206 with young patients in our psychiatric hospital. Young patients are a minority group in the setting of a large mental hospital but have special needs, particularly to step outside ward boundaries to meet and discuss with other young patients and young people from the community. Volunteers provide a link with the outside world for these patients in hospital and thus become a stepping stone for patients to return to the community (5). What volunteers have to offer in both these projects and in others seems unique. In the United States volunteer programmes have been in operation for many years, organized by Directors of Voluntary Service, and from what I had heard professionals and volunteers worked alongside each other as colleagues. I wanted to study their ways of preparing, supporting and using volunteers and to try to understand how this working together came about because I felt sure it did not just
&dquo;happen&dquo;.
With American experience I hesitate about generalisations because moving from State to another in America is rather like moving from one country to another. But what I did find in most places I visited was greater acceptance of the volunteer role by mental health professionals than in this country. However, resistances we seem to be working through here now had to be worked through originally in America. At least most professionals I talked with intimated this. Indeed, sometimes I had the feeling that the elaborate training programmes and carefully structured supervision I was to witness in the U.S.A. were as much to protect the feelings of the professional as for the volunteer. I visited Massachusetts, New York, Illinois, Georgia, Virginia and Washington D.C., and saw many fascinating volunteer programmes. In General Hospitals I saw groups of Auxiliaries, rather like our own League of Friends, and in most places I visited it was customary for middle class married women to give some time in voluntary work at the local hospital. In various cities I visited there were many worthwhile voluntary projects carried out by &dquo;Senior Citizens&dquo;, one notable one being the Foster Grandmother and Foster Grandfather idea. Senior Citizens were trained by professionals, to become foster grannies or foster grandpas to children in hospitals, residential homes for disturbed children, physically handicapped children, mentally handicapped children and children with special problems living away from home. Professionals spoke highly of the benefits of a one to one relationhsip in this kind of work and pointed out that these elderly people had the time available to give. From the senior citizens’ point of view there was a clear indication that they still had something worthwhile to contribute. I also saw many voluntary schemes aimed at assisting the elderly, and one which I found very refreshing was that set up by the Community Council of Greater New York. During the last thirteen years 56,000 older New Yorkers, who otherwise would have been trapped in hot apartments in New York City throughout the summer months, without the means or hope of relief from discomfort and isolation, were sent on summer camping vacations in the country. But the technique I became most interested in was the use of specially trained volunteers as Case Aides in work with psychiatric patients in State Mental Hospitals, Private Mental Hospitals and Community Mental Health Centres, and for the purposes of this paper is a concept which I should like to discuss more fully. THE CASE AIDE A Case Aide is a rather special kind of volunteer who is selected for this work by the Director of Voluntary Service. Such a person is rather special because she is a volunteer who wants to commit herself to a particular patient and work towards one
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207
specified goals, is willing to undertake a training programme and receive regular supervision from a professional. In other words, this is undertaking more of a personal commitment than many volunteers would wish, valuable though their help may be. The Case Aide enters a period of training designed to give the volunteer a mental health background which increases understanding and reduces anxiety about working with psychiatric patients. She is given a framework of reference into which she can fit what she is doing. The Case Aide is then introduced to her patient and they continue meeting for a period of one year for an average of three to four hours a week. The doctor, or treatment team, responsible for the patient request the help of a Case Aide, and with the request goes a realistic plan to be aimed for, e.g. with one patient who has been institutionalised over a long period of time the goal might simply be to talk more with people, move cut of the ward, visit the hospital shop; in another case more ambitiously working with a patient towards a move from hospital to a community home. It is most important that the goals which are set are realistic ones. The Case Aide receives backup support from the professionals clinically responsible for the patient, but primary supervision is provided in a group setting which is led by a skilled professional specifically designated to this task. Meetings between the Case Aides and this professional normally take place fortnightly and last for approximately one and a half hours. This is the opportunity for the volunteers to discuss what has been happening in their relationship with a patient and also provides an opportunity to bring up anything which is bothering them. This kind of group provides a good certain
deal of mutual support for Case Aides from their peers in addition to support from the professional leader. I studied various excellent schemes in different parts of the States but should like to concentrate on two areas where I was able to spend time talking with the various professionals and volunteers involved in such work, in addition to attending group supervision meetings. One was in the setting of a community Mental Health Centre and the other in a State Psychiatric Hospital.
CONCORD AREA COMPREHENSIVE MENTAL HEALTH CENTRE I spent two weeks at the Concord Area Comprehensive Mental Health Centre, which is a consortium of three agencies, Emerson Hospital, the Walden Guidance Association and the Mental Health Association of Central Middlesex. They provide inpatient and outpatient care, education and consultation to a ten town area in Massachusetts, comprising Region III, Area II of the Massachusetts Department of Mental Health. These towns are varied and individual, historically, culturally and economically. About half are primarily suburban-commuter and serve Boston and the others tend to be more rural in atmosphere. In 1960 the population of the area was 58,991. In 1970 the census was 89,820. In most of the towns the nuclear family predominates and the extended family is not common. As indicated, the Centre is basically a partnership of agencies which are responsible for an Out-Patient Clinic, Day Treatment Centre, the thirty bedded ward of Emerson Hospital called Wheeler III, and nursery schools for disturbed and retarded children. I was greatly assisted in my study of the use of volunteers as Case Aides by Mrs. Laurel Hayler who directed the work. In her programme Case Aides worked with adult patients, providing support, help with socialisation and current functioning. brothers and sisters to disturbed Adult and some High School volunteers served as children who needed stimulation, adult attention, role models, or other kinds of
big
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208
therapeutic help. She was confident that such a project can become a solid, smoothfunctioning part of a Centre if sufficient attention is given to building around both
the needs of the Health Care agency and the volunteer. She considered that Aides could meet patient needs in a special way because of their enthusiasm, their knowledge of the community, the flexibility of having no structured professional role and their general orientation towards health and strength and the special status of being unpaid. In a paper she presented at a Conference on Current Developments in Case Aide programmes in Hospitals and Community Centres sponsored by the Massachusetts Association for Mental Health she talked about staff attitudes towards such a venture. She felt that the biggest initial and continuing job in this kind of programme was to encourage staff support. She said that initially everyone gave some support to the introduction of Case Aides but there was hidden resistance in many staff members at the commencement of the project. &dquo;Negative feelings could be seen in patronising attitudes, ignoring the volunteers, or by requesting them to provide magic in impossible situations. It was necessary to move slowly&dquo;. BOSTON STATE HOSPITAL Looking at Case Aide work in the Community Mental Health Centre setting logically took me on to study such schemes in the State Psychiatric Hospitals where they originated. I was particularly interested in the programme at Boston State Hospital because this was set up in 1963 and has served as a model for similar programmes, not only in Massachusetts, but throughout the U.S.A. I spent some time with Mrs. Anne Evans who had been involved in the project right from the start, and it was fascinating to discover that she had also to work through initial resistances very similar to those I would envisage happening in this country. Her actual expression to me was &dquo;at the beginning it was like walking on eggs&dquo;. However, a grant was made available to her in 1963 to set up the project &dquo;to demonstrate the theory that intelligent and highly motivated community volunteers, under the supervision of professionals, could help chronically ill patients&dquo; (3). The Boston State Hospital Volunteer Case Aide programme was designed to extend the more traditional use of volunteers in a mental hospital setting. It was the aim of the programme that while engaging in &dquo;friendship therapy&dquo; the volunteer must view himself (or herself) as a person who had both an interest in, as well as an awareness of, the patient’s capacities and limitations. Mrs. Evans started in a small way with a pilot project on two or three wards where psychiatric nurses were sympathetic to the scheme. Since then over 700 volunteers have donated a minimum of four hours a week for at least one year in one to one relationships with the mentally ill. Getting on for 1000 patients were seen on an individual basis by Case Aide Volunteers there , about one third of the volunteer population having worked with more than one patient. Statistics in 1972 showed that of the patients currently being seen 77% were in-patients, 23% were living outside of the hospital in their own families, nursing homes, co-operative apartments or family care facilities. The ages of the patients concerned were over 65: 6%, adolescent age range : 10%, ages 25-65 : 84%. 60% of the patients were considered to be &dquo;chronically ill&dquo;, having been continuously hospitalized for an average period of five years. 15% were also mentally handicapped. Of the remaining 40% of the patient population 5% had never been hospitalized (referrals being made by the out-patient department) and 35% had been hospitalized anywhere from three weeks to one year. At the time approximately 12% of the current total in-patient census at Boston State Hospital were being seen in a continuing relationship by Case Aide Volunteers. Downloaded from isp.sagepub.com at Purdue University on May 19, 2015
209 out that many of the initial aims had been achieved, for example the community for resources both to help move the patient from the drawing upon hospital and helping him integrate into the community; strengthening the flow of communication between the hospital and community; supplementing the severe manpower shortage in the field of mental health in a creative manner by extending the therapeutic services that trained and experienced, but scarce, professionals can offer; helping prevent further chronicity of long-stay patients; and assisting in the rehabilitation of patients so they eventually may be discharged in to the community. Anne Evans emphasised that her Case Aides represented a wide range of ages and social backgrounds, from College Students to Senior Citizens, but most were between 30 and 60. A proportion were from varying professions outside the hospital service, but the majority were housewives, many of whom had a college education, although she did tell me about an interesting experiment when thirteen Catholic Seminarians were introduced into the programme who worked sensitively in the rehabilitation of various patients from the back wards of the hospitals (2). The hospital found that volunteers such as these could not only adapt themselves to the institutional setting but also could bring a fresh and creative point of view to the institution’s rehabilitative facility. The volunteer intervened with mentally ill patients, in a way which was partly therapeutic, partly educational and partly supportive resulting in a surprisingly high degree of patient improvement. THE CASE AIDES THEMSELVES I was interested to discern the sort of person who became a Case Aide and it soon became apparent that an important source of recruitment was from mature married women in their thirties or early forties, possessing a family of two or three children, who had mostly attained school age. I also found that five out of six used the Case Aide programmes as a useful experience and a testing ground, prior to going on to further training for social work. I spoke on voluntary services at Boston College to Social Work students there and in discussion with members of the faculty afterwards they told me that in the current year there had been 700 applications for the 100 places available and, further, that every single place in the course could have been filled by mature students such as these anxious either to reenter or to embark on work in the social services. Most Case Aides saw their patients at least once a week, normally for a period of two to three hours, and also time was allotted on a fortnightly basis for group supervision which lasted one and a half hours. From what I could deduce the Case Aides worked conscientiously with their patients in all kinds of ways, but particularly striving after goals set down by the therapist who was always clinically responsible for the patient. Sometimes the Case Aides I spoke with were keen to continue beyond the stipulated one year, as it seemed obvious to them that many of their cases were the kind who would need some kind of support and a helping hand indefinitely. Nevertheless, the formal commitment was for one year always, and supervisors and other professionals were at pains to assure Case Aides that, providing there was proper termination, they should not feel badly about moving on as another Case Aide could be assigned if necessary. However, some Case Aides did carry on longer with patients, perhaps shouldering a further case to widen their experience, thus in time carrying a case load. I attended many group supervision meetings and talked with Case Aides individually, sometimes with their families, as well as with their supervisors, and I was fortunate to be allowed to sit in at one of the regular meetings of Case Aide leaders with Anne Evans at Boston State Hospital. These were Case Aides who had
She
pointed
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210 been with the project for many years and had been trained to lead groups themselves. One of these leaders talked with me about the dynamics of the supervision opportunity. Volunteers could live with a difficult situation, he thought, if there was a possibility to air it in a group. Building trust could be very slow between a Case Aide and the patient-and it might be difficult for a volunteer to take continous rejection, but his group can support him in this. IMPRESSIONS FROM A GROUP SUPERVISION MEETING This was a group supervision meeting I attended at which some five Case Aides were present and the professional leader Mrs. R. Robinson who was a Senior Psychiatric Social worker specially designated to this role for the past year. The meeting was made as informal as possible, with Case Aides and leader sitting round in a circle in comfortable chairs. These are just some glimpses and impressions of the one and a half hour meeting :CASE AIDE Married woman (39) with two teenage children had spent two years in college, been a medical secretary,participated in group work, prison voluntary work and voluntary work in hospitals. She had only recentdly been assigned to the case. Case Miss X, a young crippled woman of 32 with multiple phobias, who felt unable to leave the house. She presented many physical symptoms which her doctor stated were mainly of emotional origin. The doctor who requested the help of a Case Aide had in his notes for her intimated &dquo;This is an isolated, narcissistic, lady who acts much like a girl in her early teens. There are also disturbing angry feelings between her and her parents ...&dquo; Goals Support and encouragement to get out of the house and a relationship in which she can learn how her own behaviour pushes people away. Case Aide : &dquo;I have seen my girl once. She is 32 and is in a wheelchair. Apparently up until two years ago she was doing fairly well and had a job and her outlook on life was quite good. Two years ago she went downhill and has been at home since with physical symptoms which they tell me are symptomatic. She has accepted her physical problems before but those which have come on recently have frightened her. She can’t find anyone to give her a satisfactory explanation as to why she feels how she does. This was my first visit and I had to fight my own feelings. Until I got there I felt this might be depressing for me, but it wasn’t, and I was glad. We spent the first session getting acquainted, but she went through a whole list of symptoms. I let this go on for a while because I was new, then I tried to get her mind on to something she was interested in, which turned out to be Tom Jones. She told me about the time she had seen him in person. She has no friends and misses this. There is a possibility if she joins his Fan Club she could have pen pals. I encouraged this. There was this fun story she told me about the policeman pushing her right through the crowd, past everyone, right up to where he would be arriving, and I said people would be interested to hear about this. She and I will be able to talk about this and we can work at it together&dquo;. Other Case Aide : &dquo;Does she work now-does she live alone&dquo;? Case Aide : &dquo;She lives with her mother and father. The family situation is not good. The mother has had emotional problems for many years and has been in and out of mental hospitals. The father is over protective. I didn’t get this from her but from the social worker involved. Father had encouraged her to quit her job : her working life was one and a half years and she told me it was the happiest time of her life&dquo; Leader : &dquo;Is one of the goals to get her back to work?&dquo; Case Aide : &dquo;No, this would be unrealistic. To get her to go out at all is my goal at this stage, and this is what I shall begin to aim at on my second visit. I am seeing Downloaded from isp.sagepub.com at Purdue University on May 19, 2015
211 her
again tomorrow&dquo;. A psychiatrist I talked with commented that Case Aides tended to work on the healthy aspects of the patient, not the pathology. They did not look at everything with a professional psychiatric focussed vision and could often see just simple things in people’s lives and families going wrong where a professional would look more for symptoms. CASE AIDE Married woman (31) with three small children. She was one of the exceptions who did not have a college education but was still intent on a career in social work. She was thus an extremely busy person because she was involved with her own family, her studies, a part-time job as a waitress to help finance her studies because these are expensive in the States, and several hours a week she devoted to to her Case Aide work. She had been with her case for several months. Case Mrs. Y, a woman of 62 who was formerly a patient on a psychiatric ward, at which time she was referred to the Case Aide. The person who requested the help of a Case Aide in this instance was the professional on the ward, a nurse, who was in charge of their After-Care Programme. The Case Aide started work with Mrs. Y during the latter part of her stay on the ward and then been involved in helping her make the move from the hospitals to a Nursing Home which had been arranged by the After-Care team. At the present time Mrs. Y. was not responding well to her new environment which did not appear to be a particularly happy one. Goals To befriend Mrs. Y during the latter part of her stay on the psychiatric ward and then to help her make the transition from hospital to the nursing home-also to stimulate her interest in the outside community. Case Aide : &dquo;When we are alone, the occasional times we can be alone in the Nursing Home, she tells me more. But she has to share this narrow room with another woman who is 80-it’s very depressing-and she covers up. Someone being there all the time irritates her and I think this is only natural. She says to me that they have got to the point where they can read each other’s thoughts. It’s such a terribly depressing room too, it’s so tiny and narrow and there they are the two of them ! I like to see progress and I just cannot see any further progress occurring while she’s still there. The others in that Nursing Home seem so mad and she is such a sane person really&dquo;. Leader: &dquo;Last time we met you were going to take her to your own home weren’t
you&dquo; Case Aide : &dquo;Yes, but she hasn’t been yet. The first time she had a growth on her face and when I went to get her it was sore. The next week the doctor had given her anti-biotics and she was put on them for a week so couldn’t come. The next time she had a bad cold, and it was a bad cold. I hope she will come with me today when I go to visit her. I really believe she may have had legitimate reasons for not coming before, and I think basically she would like to come. I was discussing it with my husband and children-her visiting us I mean- and we agreed she might be a little bit shy about coming. It’s difhcult for her to come into a home where nearly everyone else is a stranger to her. I go and visit her in the nursing home and it can be an awkward time. I talk about my week, but then she has been confined most of her week. If she would come and visit we would keep her over-night and I’d take her back the next day.But I’ll let you krow what happens&dquo;. Leader : &dquo;I may be well off base, but I think if she could accept another placement the whole picture would change considerably. She wouldn’t look at anything else when she went there because her brother lived near, but you’ve said before she doesn’t go and visit him much now anyway&dquo;. Case Aide : &dquo;Yes, that’s true, but when I’ve attempted to discuss this she has felt Downloaded from isp.sagepub.com at Purdue University on May 19, 2015
212 there is no alternative. ’This is where I am and this is where I’m going to have to stay until I die&dquo;. Leader : &dquo;Perhaps you might say ’You don’t have to stay here’ when she raises being unhappy there, pick up on her cues, feel around a bit?&dquo; CaseAide : &dquo;Yes, I could research with her new possibilities-this would be a more constructive use of the time we spend together. Then if we could just get her to start visiting with us at home as well I feel this would make her feel less hopeless about being stuck there somehow&dquo;. A Nursing Home in this context is more akin to what we think of as a Residential Home. However, in the U.S.A. different Nursing Homes provide different levels of care and in this one residents would be people needing maximum nursing attention. CASE AIDE Young man in his early thirties, prematurely grey. He had been crippled in a former accident at work and moved around with difficulty, using a stick. Probably as a result of his own misfortune he had been under pressure himself at times and in need of help. He now wanted, in his turn, to be of help to somebody else. Case A 19 year old adolescent living with his sister, slightly older. His mother, with whom he had a close relationship, died last year. Possible complication of an incestuous relationship between brother and sister. An aunt who lived not very far away was only slightly in the picture and did not want to become too involved. Goals To provide a sympathetic male figure in the picture, to bring fresh interests into the life style of the boy and be a caring person. The therapeutic team asking for the assistance of a Case Aide in this instance consisted of a psychiatrist and the key nurse on the ward most closely involved with him when he was an in-patient, and from whom he still received some support. The Case Aide had been with the case between two to three months. Case Aide : &dquo;I don’t have a great deal more to report this week. We are still endeavouring to set up a meeting with the aunt but there has been another postponement. As you know he is getting out and about a good deal more now. When I saw him last week he said he was much happier with his job again, and we are looking into the possibility that he might take up further training so he can move up into something more interesting eventually. He is keen on this. I haven’t seen him yet this week because I am feeling somewhat under pressure myself at the moment and, in fact, when I leave here I am going up to the ward for a couple of days. But I’m not dropping the case if this is alright with you. I think I am doing some good-I really feel I am beginning to get through to him&dquo;. Leader : &dquo;Does he know you were on the same ward once yourself and you are to go in for a few days again now?&dquo; Case Aide : &dquo;He didn’t know I was in before and I don’t think he knows about my going back in&dquo;. Leader : &dquo;What do you plan to do about that?&dquo; Case Aide : &dquo;I am seeing him Wednesday and will tell him then&dquo;. Leader : &dquo;If it’s understood you will tell him yourself then his key nurse won’t do so. I think it’s important for him to hear it from you&dquo;. Case Aide : &dquo;I agree with you: it’s very important he hears it from me and I’m arranging it will be this way&dquo;. Leader : &dquo;Do you plan to try and keep to these meetings too ?&dquo; Case Aide : &dquo;Yes, I do&dquo;. Leader: &dquo;That’s good&dquo;. Downloaded from isp.sagepub.com at Purdue University on May 19, 2015
213 Professionals I met who were concerned in Case Aide projects did not necessarily exclude people who might have had problems themselves. However, under these circumstances, they had to be particularly careful in the selection process. But they did feel that sometimes such a person might be even more sensitive to the needs of others. CONCLUSION
I was deeply impressed by the various Case Aide programmes I witnessed in the U.S.A. and the way they were able to utilise community volunteers in work with psychiatric patients on a one-to-one basis with backup support and supervision from professionals. It was good to witness the great measure of cooperation between, and respect for the work of the other, by volunteer and professional, who seemed to work together as colleagues. Obviously there were different methods of approach, but overall there was an acceptance of the value of the voluntary contribution. Of course there has been time in the U.S.A. to give the principle respectability. When Mrs. Anne Evans was setting up her Case Aide model in Boston State Hospital in 1963, in Great Britain the first Voluntary Services Organiser was appointed as a three year experimental project at Fulbourn Hospital, Cambridge, supported by the Nuffield Provincial Hospitals Trust (1). During the ensuing years it would seem that Voluntary Service Organisers have become an accepted part of the hospital scene, so perhaps we may envisage the same for Case Aides within future years. I came away from the States with warm memories of their kindness and hospitality. It was refreshing to hear professionals working out how they could expect the community to help them in their work, which was with the community after all. I came back with many questions of course. For example, some may say that volunteers are used in the U.S.A. in such interesting projects as Case Aide because of the shortage of trained staff and the vast numbers of people wanting help. But is not that the case here too? Again, it was not just in the crowded clinics of Manhattan that I visited where such volunteers were welcomed with open arms, but also in institutions like the Georgia Mental Health Institute where the ratio of staff to
patients
use
was
extremely high.
Of course my main question was-What can we most usefully here? My belief is that this could be the Case Aide principle.
bring
back and
ACKNOWLEDGMENTS
I thank the Winston Churchill Memorial Trust whose generosity made the visit possible, my own Hospital Management Committee who allowed me to take up the opportunity, and Dr. M. A. T. Waters, Consultant Psychiatrist, who first told me about Case Aide volunteers in America. My warm thanks go also to all those in the U.S.A. who gave me so freely and willingly of their time and made the experience such a memorable one. REF RENCES REFERENCES
Clark, D. H. and King, E. M. C. "Voluntary Workers in a Psychiatric Hospital". The Lancet, May 14, 1966. pp. 1088 1090. 2 Evans, Anne and Goldberg, Margaret, "Catholic Seminarians in a Secular Institution". Mental Hygiene (1970) Vol. 54, No.4. (U.S.A.) 3 Genineau, V. A. and Evans, Anne. "Volunteer Case Aides Rehabilitate Chronic Patients". Hospital and American Psychiatric Association (March 1970 (U.S.A.) Psychiatry—a journal of the 4 Lear, T. E. and Lewington, "Who is Educating Whom?" A Study of the Mutual Influence of School. teachers, Youth Volunteers, Psychiatric Nurses and Patients in a Mental Hospital Project. British Journal of Phsychiatry (1972 120, No. 556, 293 - 300. 5 Lear, T. E. and Lewington, Jeanne. "Young People in Mental Hospitals". British Journal of Psychiatry (1974) 1
Community
124 No. 210 - 211. 6 Rocha, Jan. "Organisers of
Jeanne.
Voluntary Services
in
Hospitals".
a
King’s
Fund Report
(1968) (London).
FOOTNOTE Since Mrs. Lewington’s return from the U.S.A. the King’s Fund have generously awarded a two year research in this country, based at St. Crispin Hospital, grant to enable her to establish a Volunteer Case Aide Northampton. Work on this project has now started and evaluation will take place during 1975.
grogramme
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VOLUNTEER CASE AIDES IN THE U.S.A.
(Jeanne Lewington is a Voluntary Services Organiser at a psychiatric hospital, England) by LEWINGTON JEANNE SUMMARY
awarded a 1973 Winston Churchill Fellowship to the U.S.A. and look at the way volunteers are used, particularly in the field of mental health. She studied projects at State and Private Mental Hospitals and Community Health Centres. She was particularly impressed with the contribution of Volunteer Case Aides in one to one work with psychiatric patients and describes this principle in some detail. On her return Mrs. Lewington approached the King’s Fund London and has been given a grant to finance the establishment of a two year Volunteer Case Aide Programme based at St. Crispin Hospital, Northampton, England, evaluation of which will take place during 1975.
MRS. visit
Jeanne Lewington
was
INTRODUCTION
indebted to the Winston Churchill Memorial Trust for the opportunity to spend two months during 1973 visiting the United States of America and seeing something of the way volunteers work there, particularly in the field of Mental Health. The trust was established in 1965 as a unique form of National Memorial to Sir Winston Churchill. It enables men and women who might otherwise not have the chance, to travel abroad, widen their knowledge in their own field of activity, learn how people live and work in different parts of the world, and as a result of the experience they gain they are able, hopefully, to contribute something different to their profession, community and country. Every year the Council chooses a number of categories which reflect a broad/cross section of life in the country, the arts, social and public service, industry, nature, sport and adventure. So far there are 689 Churchill Fellows in 99 different categories (545 men and 144 women), and they have travelled to almost every country in the world. I was appointed Voluntary Services Organiser to the St. Crispin group of hospitals, Northampton, in January 1970, and my responsibilities cover voluntary services in an 800 bedded psychiatric hospital built back in 1876, a brand new hospital for the care of the mentally subnormal housing 500 patients, and three Day Hospitals in the community. We are just starting in the Health and Social Services to appreciate the contribution which can be made by volunteers. My own type of appointment is relatively new (6) and one finds feelings of professionals rather mixed regarding the use of volunteers. Such feelings have to be respected, brought out into the open and worked through before a voluntary help scheme can be introduced with any hope of success. In my own hospitals I use the help of adult and youth volunteers in work with long stay and geriatric (or perhaps I should say psycho-geriatric) patients, and in this area I developed a procedure whereby senior schoolchildren from local schools became involved in visiting and befriending elderly people in hospital. This has expanded during the last three years so that eight schools participate with over one hundred senior schoolchildren coming along every week to visit and befriend long stay patients (4). I also enlist the help of more mature youth volunteers in work I
am
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206 with young patients in our psychiatric hospital. Young patients are a minority group in the setting of a large mental hospital but have special needs, particularly to step outside ward boundaries to meet and discuss with other young patients and young people from the community. Volunteers provide a link with the outside world for these patients in hospital and thus become a stepping stone for patients to return to the community (5). What volunteers have to offer in both these projects and in others seems unique. In the United States volunteer programmes have been in operation for many years, organized by Directors of Voluntary Service, and from what I had heard professionals and volunteers worked alongside each other as colleagues. I wanted to study their ways of preparing, supporting and using volunteers and to try to understand how this working together came about because I felt sure it did not just
&dquo;happen&dquo;.
With American experience I hesitate about generalisations because moving from State to another in America is rather like moving from one country to another. But what I did find in most places I visited was greater acceptance of the volunteer role by mental health professionals than in this country. However, resistances we seem to be working through here now had to be worked through originally in America. At least most professionals I talked with intimated this. Indeed, sometimes I had the feeling that the elaborate training programmes and carefully structured supervision I was to witness in the U.S.A. were as much to protect the feelings of the professional as for the volunteer. I visited Massachusetts, New York, Illinois, Georgia, Virginia and Washington D.C., and saw many fascinating volunteer programmes. In General Hospitals I saw groups of Auxiliaries, rather like our own League of Friends, and in most places I visited it was customary for middle class married women to give some time in voluntary work at the local hospital. In various cities I visited there were many worthwhile voluntary projects carried out by &dquo;Senior Citizens&dquo;, one notable one being the Foster Grandmother and Foster Grandfather idea. Senior Citizens were trained by professionals, to become foster grannies or foster grandpas to children in hospitals, residential homes for disturbed children, physically handicapped children, mentally handicapped children and children with special problems living away from home. Professionals spoke highly of the benefits of a one to one relationhsip in this kind of work and pointed out that these elderly people had the time available to give. From the senior citizens’ point of view there was a clear indication that they still had something worthwhile to contribute. I also saw many voluntary schemes aimed at assisting the elderly, and one which I found very refreshing was that set up by the Community Council of Greater New York. During the last thirteen years 56,000 older New Yorkers, who otherwise would have been trapped in hot apartments in New York City throughout the summer months, without the means or hope of relief from discomfort and isolation, were sent on summer camping vacations in the country. But the technique I became most interested in was the use of specially trained volunteers as Case Aides in work with psychiatric patients in State Mental Hospitals, Private Mental Hospitals and Community Mental Health Centres, and for the purposes of this paper is a concept which I should like to discuss more fully. THE CASE AIDE A Case Aide is a rather special kind of volunteer who is selected for this work by the Director of Voluntary Service. Such a person is rather special because she is a volunteer who wants to commit herself to a particular patient and work towards one
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207
specified goals, is willing to undertake a training programme and receive regular supervision from a professional. In other words, this is undertaking more of a personal commitment than many volunteers would wish, valuable though their help may be. The Case Aide enters a period of training designed to give the volunteer a mental health background which increases understanding and reduces anxiety about working with psychiatric patients. She is given a framework of reference into which she can fit what she is doing. The Case Aide is then introduced to her patient and they continue meeting for a period of one year for an average of three to four hours a week. The doctor, or treatment team, responsible for the patient request the help of a Case Aide, and with the request goes a realistic plan to be aimed for, e.g. with one patient who has been institutionalised over a long period of time the goal might simply be to talk more with people, move cut of the ward, visit the hospital shop; in another case more ambitiously working with a patient towards a move from hospital to a community home. It is most important that the goals which are set are realistic ones. The Case Aide receives backup support from the professionals clinically responsible for the patient, but primary supervision is provided in a group setting which is led by a skilled professional specifically designated to this task. Meetings between the Case Aides and this professional normally take place fortnightly and last for approximately one and a half hours. This is the opportunity for the volunteers to discuss what has been happening in their relationship with a patient and also provides an opportunity to bring up anything which is bothering them. This kind of group provides a good certain
deal of mutual support for Case Aides from their peers in addition to support from the professional leader. I studied various excellent schemes in different parts of the States but should like to concentrate on two areas where I was able to spend time talking with the various professionals and volunteers involved in such work, in addition to attending group supervision meetings. One was in the setting of a community Mental Health Centre and the other in a State Psychiatric Hospital.
CONCORD AREA COMPREHENSIVE MENTAL HEALTH CENTRE I spent two weeks at the Concord Area Comprehensive Mental Health Centre, which is a consortium of three agencies, Emerson Hospital, the Walden Guidance Association and the Mental Health Association of Central Middlesex. They provide inpatient and outpatient care, education and consultation to a ten town area in Massachusetts, comprising Region III, Area II of the Massachusetts Department of Mental Health. These towns are varied and individual, historically, culturally and economically. About half are primarily suburban-commuter and serve Boston and the others tend to be more rural in atmosphere. In 1960 the population of the area was 58,991. In 1970 the census was 89,820. In most of the towns the nuclear family predominates and the extended family is not common. As indicated, the Centre is basically a partnership of agencies which are responsible for an Out-Patient Clinic, Day Treatment Centre, the thirty bedded ward of Emerson Hospital called Wheeler III, and nursery schools for disturbed and retarded children. I was greatly assisted in my study of the use of volunteers as Case Aides by Mrs. Laurel Hayler who directed the work. In her programme Case Aides worked with adult patients, providing support, help with socialisation and current functioning. brothers and sisters to disturbed Adult and some High School volunteers served as children who needed stimulation, adult attention, role models, or other kinds of
big
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208
therapeutic help. She was confident that such a project can become a solid, smoothfunctioning part of a Centre if sufficient attention is given to building around both
the needs of the Health Care agency and the volunteer. She considered that Aides could meet patient needs in a special way because of their enthusiasm, their knowledge of the community, the flexibility of having no structured professional role and their general orientation towards health and strength and the special status of being unpaid. In a paper she presented at a Conference on Current Developments in Case Aide programmes in Hospitals and Community Centres sponsored by the Massachusetts Association for Mental Health she talked about staff attitudes towards such a venture. She felt that the biggest initial and continuing job in this kind of programme was to encourage staff support. She said that initially everyone gave some support to the introduction of Case Aides but there was hidden resistance in many staff members at the commencement of the project. &dquo;Negative feelings could be seen in patronising attitudes, ignoring the volunteers, or by requesting them to provide magic in impossible situations. It was necessary to move slowly&dquo;. BOSTON STATE HOSPITAL Looking at Case Aide work in the Community Mental Health Centre setting logically took me on to study such schemes in the State Psychiatric Hospitals where they originated. I was particularly interested in the programme at Boston State Hospital because this was set up in 1963 and has served as a model for similar programmes, not only in Massachusetts, but throughout the U.S.A. I spent some time with Mrs. Anne Evans who had been involved in the project right from the start, and it was fascinating to discover that she had also to work through initial resistances very similar to those I would envisage happening in this country. Her actual expression to me was &dquo;at the beginning it was like walking on eggs&dquo;. However, a grant was made available to her in 1963 to set up the project &dquo;to demonstrate the theory that intelligent and highly motivated community volunteers, under the supervision of professionals, could help chronically ill patients&dquo; (3). The Boston State Hospital Volunteer Case Aide programme was designed to extend the more traditional use of volunteers in a mental hospital setting. It was the aim of the programme that while engaging in &dquo;friendship therapy&dquo; the volunteer must view himself (or herself) as a person who had both an interest in, as well as an awareness of, the patient’s capacities and limitations. Mrs. Evans started in a small way with a pilot project on two or three wards where psychiatric nurses were sympathetic to the scheme. Since then over 700 volunteers have donated a minimum of four hours a week for at least one year in one to one relationships with the mentally ill. Getting on for 1000 patients were seen on an individual basis by Case Aide Volunteers there , about one third of the volunteer population having worked with more than one patient. Statistics in 1972 showed that of the patients currently being seen 77% were in-patients, 23% were living outside of the hospital in their own families, nursing homes, co-operative apartments or family care facilities. The ages of the patients concerned were over 65: 6%, adolescent age range : 10%, ages 25-65 : 84%. 60% of the patients were considered to be &dquo;chronically ill&dquo;, having been continuously hospitalized for an average period of five years. 15% were also mentally handicapped. Of the remaining 40% of the patient population 5% had never been hospitalized (referrals being made by the out-patient department) and 35% had been hospitalized anywhere from three weeks to one year. At the time approximately 12% of the current total in-patient census at Boston State Hospital were being seen in a continuing relationship by Case Aide Volunteers. Downloaded from isp.sagepub.com at Purdue University on May 19, 2015
209 out that many of the initial aims had been achieved, for example the community for resources both to help move the patient from the drawing upon hospital and helping him integrate into the community; strengthening the flow of communication between the hospital and community; supplementing the severe manpower shortage in the field of mental health in a creative manner by extending the therapeutic services that trained and experienced, but scarce, professionals can offer; helping prevent further chronicity of long-stay patients; and assisting in the rehabilitation of patients so they eventually may be discharged in to the community. Anne Evans emphasised that her Case Aides represented a wide range of ages and social backgrounds, from College Students to Senior Citizens, but most were between 30 and 60. A proportion were from varying professions outside the hospital service, but the majority were housewives, many of whom had a college education, although she did tell me about an interesting experiment when thirteen Catholic Seminarians were introduced into the programme who worked sensitively in the rehabilitation of various patients from the back wards of the hospitals (2). The hospital found that volunteers such as these could not only adapt themselves to the institutional setting but also could bring a fresh and creative point of view to the institution’s rehabilitative facility. The volunteer intervened with mentally ill patients, in a way which was partly therapeutic, partly educational and partly supportive resulting in a surprisingly high degree of patient improvement. THE CASE AIDES THEMSELVES I was interested to discern the sort of person who became a Case Aide and it soon became apparent that an important source of recruitment was from mature married women in their thirties or early forties, possessing a family of two or three children, who had mostly attained school age. I also found that five out of six used the Case Aide programmes as a useful experience and a testing ground, prior to going on to further training for social work. I spoke on voluntary services at Boston College to Social Work students there and in discussion with members of the faculty afterwards they told me that in the current year there had been 700 applications for the 100 places available and, further, that every single place in the course could have been filled by mature students such as these anxious either to reenter or to embark on work in the social services. Most Case Aides saw their patients at least once a week, normally for a period of two to three hours, and also time was allotted on a fortnightly basis for group supervision which lasted one and a half hours. From what I could deduce the Case Aides worked conscientiously with their patients in all kinds of ways, but particularly striving after goals set down by the therapist who was always clinically responsible for the patient. Sometimes the Case Aides I spoke with were keen to continue beyond the stipulated one year, as it seemed obvious to them that many of their cases were the kind who would need some kind of support and a helping hand indefinitely. Nevertheless, the formal commitment was for one year always, and supervisors and other professionals were at pains to assure Case Aides that, providing there was proper termination, they should not feel badly about moving on as another Case Aide could be assigned if necessary. However, some Case Aides did carry on longer with patients, perhaps shouldering a further case to widen their experience, thus in time carrying a case load. I attended many group supervision meetings and talked with Case Aides individually, sometimes with their families, as well as with their supervisors, and I was fortunate to be allowed to sit in at one of the regular meetings of Case Aide leaders with Anne Evans at Boston State Hospital. These were Case Aides who had
She
pointed
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210 been with the project for many years and had been trained to lead groups themselves. One of these leaders talked with me about the dynamics of the supervision opportunity. Volunteers could live with a difficult situation, he thought, if there was a possibility to air it in a group. Building trust could be very slow between a Case Aide and the patient-and it might be difficult for a volunteer to take continous rejection, but his group can support him in this. IMPRESSIONS FROM A GROUP SUPERVISION MEETING This was a group supervision meeting I attended at which some five Case Aides were present and the professional leader Mrs. R. Robinson who was a Senior Psychiatric Social worker specially designated to this role for the past year. The meeting was made as informal as possible, with Case Aides and leader sitting round in a circle in comfortable chairs. These are just some glimpses and impressions of the one and a half hour meeting :CASE AIDE Married woman (39) with two teenage children had spent two years in college, been a medical secretary,participated in group work, prison voluntary work and voluntary work in hospitals. She had only recentdly been assigned to the case. Case Miss X, a young crippled woman of 32 with multiple phobias, who felt unable to leave the house. She presented many physical symptoms which her doctor stated were mainly of emotional origin. The doctor who requested the help of a Case Aide had in his notes for her intimated &dquo;This is an isolated, narcissistic, lady who acts much like a girl in her early teens. There are also disturbing angry feelings between her and her parents ...&dquo; Goals Support and encouragement to get out of the house and a relationship in which she can learn how her own behaviour pushes people away. Case Aide : &dquo;I have seen my girl once. She is 32 and is in a wheelchair. Apparently up until two years ago she was doing fairly well and had a job and her outlook on life was quite good. Two years ago she went downhill and has been at home since with physical symptoms which they tell me are symptomatic. She has accepted her physical problems before but those which have come on recently have frightened her. She can’t find anyone to give her a satisfactory explanation as to why she feels how she does. This was my first visit and I had to fight my own feelings. Until I got there I felt this might be depressing for me, but it wasn’t, and I was glad. We spent the first session getting acquainted, but she went through a whole list of symptoms. I let this go on for a while because I was new, then I tried to get her mind on to something she was interested in, which turned out to be Tom Jones. She told me about the time she had seen him in person. She has no friends and misses this. There is a possibility if she joins his Fan Club she could have pen pals. I encouraged this. There was this fun story she told me about the policeman pushing her right through the crowd, past everyone, right up to where he would be arriving, and I said people would be interested to hear about this. She and I will be able to talk about this and we can work at it together&dquo;. Other Case Aide : &dquo;Does she work now-does she live alone&dquo;? Case Aide : &dquo;She lives with her mother and father. The family situation is not good. The mother has had emotional problems for many years and has been in and out of mental hospitals. The father is over protective. I didn’t get this from her but from the social worker involved. Father had encouraged her to quit her job : her working life was one and a half years and she told me it was the happiest time of her life&dquo; Leader : &dquo;Is one of the goals to get her back to work?&dquo; Case Aide : &dquo;No, this would be unrealistic. To get her to go out at all is my goal at this stage, and this is what I shall begin to aim at on my second visit. I am seeing Downloaded from isp.sagepub.com at Purdue University on May 19, 2015
211 her
again tomorrow&dquo;. A psychiatrist I talked with commented that Case Aides tended to work on the healthy aspects of the patient, not the pathology. They did not look at everything with a professional psychiatric focussed vision and could often see just simple things in people’s lives and families going wrong where a professional would look more for symptoms. CASE AIDE Married woman (31) with three small children. She was one of the exceptions who did not have a college education but was still intent on a career in social work. She was thus an extremely busy person because she was involved with her own family, her studies, a part-time job as a waitress to help finance her studies because these are expensive in the States, and several hours a week she devoted to to her Case Aide work. She had been with her case for several months. Case Mrs. Y, a woman of 62 who was formerly a patient on a psychiatric ward, at which time she was referred to the Case Aide. The person who requested the help of a Case Aide in this instance was the professional on the ward, a nurse, who was in charge of their After-Care Programme. The Case Aide started work with Mrs. Y during the latter part of her stay on the ward and then been involved in helping her make the move from the hospitals to a Nursing Home which had been arranged by the After-Care team. At the present time Mrs. Y. was not responding well to her new environment which did not appear to be a particularly happy one. Goals To befriend Mrs. Y during the latter part of her stay on the psychiatric ward and then to help her make the transition from hospital to the nursing home-also to stimulate her interest in the outside community. Case Aide : &dquo;When we are alone, the occasional times we can be alone in the Nursing Home, she tells me more. But she has to share this narrow room with another woman who is 80-it’s very depressing-and she covers up. Someone being there all the time irritates her and I think this is only natural. She says to me that they have got to the point where they can read each other’s thoughts. It’s such a terribly depressing room too, it’s so tiny and narrow and there they are the two of them ! I like to see progress and I just cannot see any further progress occurring while she’s still there. The others in that Nursing Home seem so mad and she is such a sane person really&dquo;. Leader: &dquo;Last time we met you were going to take her to your own home weren’t
you&dquo; Case Aide : &dquo;Yes, but she hasn’t been yet. The first time she had a growth on her face and when I went to get her it was sore. The next week the doctor had given her anti-biotics and she was put on them for a week so couldn’t come. The next time she had a bad cold, and it was a bad cold. I hope she will come with me today when I go to visit her. I really believe she may have had legitimate reasons for not coming before, and I think basically she would like to come. I was discussing it with my husband and children-her visiting us I mean- and we agreed she might be a little bit shy about coming. It’s difhcult for her to come into a home where nearly everyone else is a stranger to her. I go and visit her in the nursing home and it can be an awkward time. I talk about my week, but then she has been confined most of her week. If she would come and visit we would keep her over-night and I’d take her back the next day.But I’ll let you krow what happens&dquo;. Leader : &dquo;I may be well off base, but I think if she could accept another placement the whole picture would change considerably. She wouldn’t look at anything else when she went there because her brother lived near, but you’ve said before she doesn’t go and visit him much now anyway&dquo;. Case Aide : &dquo;Yes, that’s true, but when I’ve attempted to discuss this she has felt Downloaded from isp.sagepub.com at Purdue University on May 19, 2015
212 there is no alternative. ’This is where I am and this is where I’m going to have to stay until I die&dquo;. Leader : &dquo;Perhaps you might say ’You don’t have to stay here’ when she raises being unhappy there, pick up on her cues, feel around a bit?&dquo; CaseAide : &dquo;Yes, I could research with her new possibilities-this would be a more constructive use of the time we spend together. Then if we could just get her to start visiting with us at home as well I feel this would make her feel less hopeless about being stuck there somehow&dquo;. A Nursing Home in this context is more akin to what we think of as a Residential Home. However, in the U.S.A. different Nursing Homes provide different levels of care and in this one residents would be people needing maximum nursing attention. CASE AIDE Young man in his early thirties, prematurely grey. He had been crippled in a former accident at work and moved around with difficulty, using a stick. Probably as a result of his own misfortune he had been under pressure himself at times and in need of help. He now wanted, in his turn, to be of help to somebody else. Case A 19 year old adolescent living with his sister, slightly older. His mother, with whom he had a close relationship, died last year. Possible complication of an incestuous relationship between brother and sister. An aunt who lived not very far away was only slightly in the picture and did not want to become too involved. Goals To provide a sympathetic male figure in the picture, to bring fresh interests into the life style of the boy and be a caring person. The therapeutic team asking for the assistance of a Case Aide in this instance consisted of a psychiatrist and the key nurse on the ward most closely involved with him when he was an in-patient, and from whom he still received some support. The Case Aide had been with the case between two to three months. Case Aide : &dquo;I don’t have a great deal more to report this week. We are still endeavouring to set up a meeting with the aunt but there has been another postponement. As you know he is getting out and about a good deal more now. When I saw him last week he said he was much happier with his job again, and we are looking into the possibility that he might take up further training so he can move up into something more interesting eventually. He is keen on this. I haven’t seen him yet this week because I am feeling somewhat under pressure myself at the moment and, in fact, when I leave here I am going up to the ward for a couple of days. But I’m not dropping the case if this is alright with you. I think I am doing some good-I really feel I am beginning to get through to him&dquo;. Leader : &dquo;Does he know you were on the same ward once yourself and you are to go in for a few days again now?&dquo; Case Aide : &dquo;He didn’t know I was in before and I don’t think he knows about my going back in&dquo;. Leader : &dquo;What do you plan to do about that?&dquo; Case Aide : &dquo;I am seeing him Wednesday and will tell him then&dquo;. Leader : &dquo;If it’s understood you will tell him yourself then his key nurse won’t do so. I think it’s important for him to hear it from you&dquo;. Case Aide : &dquo;I agree with you: it’s very important he hears it from me and I’m arranging it will be this way&dquo;. Leader : &dquo;Do you plan to try and keep to these meetings too ?&dquo; Case Aide : &dquo;Yes, I do&dquo;. Leader: &dquo;That’s good&dquo;. Downloaded from isp.sagepub.com at Purdue University on May 19, 2015
213 Professionals I met who were concerned in Case Aide projects did not necessarily exclude people who might have had problems themselves. However, under these circumstances, they had to be particularly careful in the selection process. But they did feel that sometimes such a person might be even more sensitive to the needs of others. CONCLUSION
I was deeply impressed by the various Case Aide programmes I witnessed in the U.S.A. and the way they were able to utilise community volunteers in work with psychiatric patients on a one-to-one basis with backup support and supervision from professionals. It was good to witness the great measure of cooperation between, and respect for the work of the other, by volunteer and professional, who seemed to work together as colleagues. Obviously there were different methods of approach, but overall there was an acceptance of the value of the voluntary contribution. Of course there has been time in the U.S.A. to give the principle respectability. When Mrs. Anne Evans was setting up her Case Aide model in Boston State Hospital in 1963, in Great Britain the first Voluntary Services Organiser was appointed as a three year experimental project at Fulbourn Hospital, Cambridge, supported by the Nuffield Provincial Hospitals Trust (1). During the ensuing years it would seem that Voluntary Service Organisers have become an accepted part of the hospital scene, so perhaps we may envisage the same for Case Aides within future years. I came away from the States with warm memories of their kindness and hospitality. It was refreshing to hear professionals working out how they could expect the community to help them in their work, which was with the community after all. I came back with many questions of course. For example, some may say that volunteers are used in the U.S.A. in such interesting projects as Case Aide because of the shortage of trained staff and the vast numbers of people wanting help. But is not that the case here too? Again, it was not just in the crowded clinics of Manhattan that I visited where such volunteers were welcomed with open arms, but also in institutions like the Georgia Mental Health Institute where the ratio of staff to
patients
use
was
extremely high.
Of course my main question was-What can we most usefully here? My belief is that this could be the Case Aide principle.
bring
back and
ACKNOWLEDGMENTS
I thank the Winston Churchill Memorial Trust whose generosity made the visit possible, my own Hospital Management Committee who allowed me to take up the opportunity, and Dr. M. A. T. Waters, Consultant Psychiatrist, who first told me about Case Aide volunteers in America. My warm thanks go also to all those in the U.S.A. who gave me so freely and willingly of their time and made the experience such a memorable one. REF RENCES REFERENCES
Clark, D. H. and King, E. M. C. "Voluntary Workers in a Psychiatric Hospital". The Lancet, May 14, 1966. pp. 1088 1090. 2 Evans, Anne and Goldberg, Margaret, "Catholic Seminarians in a Secular Institution". Mental Hygiene (1970) Vol. 54, No.4. (U.S.A.) 3 Genineau, V. A. and Evans, Anne. "Volunteer Case Aides Rehabilitate Chronic Patients". Hospital and American Psychiatric Association (March 1970 (U.S.A.) Psychiatry—a journal of the 4 Lear, T. E. and Lewington, "Who is Educating Whom?" A Study of the Mutual Influence of School. teachers, Youth Volunteers, Psychiatric Nurses and Patients in a Mental Hospital Project. British Journal of Phsychiatry (1972 120, No. 556, 293 - 300. 5 Lear, T. E. and Lewington, Jeanne. "Young People in Mental Hospitals". British Journal of Psychiatry (1974) 1
Community
124 No. 210 - 211. 6 Rocha, Jan. "Organisers of
Jeanne.
Voluntary Services
in
Hospitals".
a
King’s
Fund Report
(1968) (London).
FOOTNOTE Since Mrs. Lewington’s return from the U.S.A. the King’s Fund have generously awarded a two year research in this country, based at St. Crispin Hospital, grant to enable her to establish a Volunteer Case Aide Northampton. Work on this project has now started and evaluation will take place during 1975.
grogramme
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