The Practice of Psychiatry in General Hospitals [Reprint 2020 ed.] 9780520346000

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The Practice of Psychiatry in General Hospitals

The Practice of Psychiatry in General Hospitals

A . E. BENNETT, M . D . Associate Clinical Professor of Psychiatry, University of California, School of Medicine, San Francisco; Chief of Psychiatry, Herrick Memorial Hospital, Berkeley. EUGENE A. H A R G R O V E , M.D. Assistant Professor of Psychiatry, University of North Carolina, School of Medicine, Chapel Hill. BERNICE ENGLE, M.A. Research Associate, Department of Psychiatry, University of California, School of Medicine, and The Langley Porter Clinic, San Francisco. with contributing authors

UNIVERSITY OF CALIFORNIA PRESS Berkeley and Los Angeles • 1956

University of California Press •

Berkeley and Los Angeles, California

Cambridge University Press

•

London, England

Copyright, 1956, by The Regents of the University of California Library of Congress Catalog Card Number: 56-8472 Printed in the United States of America

Mental disease is a medical problem and every general hospital should set aside ten percent of beds for psychiatric cases. This does more to overcome prejudice and fears about mental illness than does any other method of public education. FRANK F . T A L L M A N ,

M.D.

The establishment of psychiatric facilities in general hospitals eliminates the medieval idea that general hospitals cannot care temporarily for mentally ill patients. Every general hospital has at all times a large number of psychiatric patients, the nature of whose difficulties is not recognized. We do not need more beds in state hospitals. If we had facilities in general hospitals for early treatment of psychiatric disorders, thousands of patients would not be sent to state institutions. The people should be alerted to this fact and insist that the community hospitals provide these facilities. Psychiatric wards in general hospitals are one of the best health investments society can make. WILLIAM

B . TERHUNE,

M.D.

Foreword Daniel Blain, M.D. Medical Director of the American Psychiatric Association; Associate Clinical Professor of Psychiatry, Georgetown University, School of Medicine

A few properly planned and equipped rooms should be available in every general hospital for patients who need psychiatric care. This need, in every community, is too obvious to be argued: mental illness should be treated on a par with all medical and surgical conditions. Patients who need psychiatric care should be able to get it promptly from psychiatrically trained physicians in hospitals equipped to provide immediate treatment, with facilities for treating other types of illness close at hand. So far specialists in mental illnesses have been unable to reduce the number of patients requiring psychiatric care to less than half the number of all hospital beds in the United States; nor have they been able to staff adequately the large mental hospitals placed in localities far from medical centers. Neither have psychiatrists been able to handle the entire load adequately. Consequently the burden of care and treatment of this type of case must be shared between the specialized mental hospitals and the general hospitals in the smaller localities. T h e burden must be shared by both psychiatrists, as specialists in the field, and other members of the medical profession, who are often able to handle many of the problems which occur in the earlier stages. Some provision must also be made in community hospitals to care for those temporary psychiatric complications which so often arise in toxic and debilitative conditions in various medical and surgical entities. T h e establishment of psychiatric sections in general hospitals, the expansion of outpatient clinics, and an increase in the treatment facilities of large mental hospitals constitute the three great hopes for meeting the needs of one of the largest categories of sick individuals in the country. In recognition of this fact, the Department

FOREWORD

of Medicine and Surgery of the Veterans' Administration adopted, in 1946, the policy that all general hospitals under its jurisdiction should make from twenty to thirty per cent of their beds available for the treatment of psychotic, psychoneurotic, and neurological cases. All general hospitals should be prepared to meet this need in order to serve their communities. The psychiatric section, to achieve its best result, must be designed for psychiatric treatment in all its phases, including specific physical, clinical, and psychological approaches—not as a ward in which to house a disturbed patient until transfer is arranged. The attention and interest of both the public and the medical profession should be aroused by the work of Dr. Bennett and his associates. Much credit is due them.

Introduction Karl M . B o w m a n , M . D . Professor of Psychiatry, University of California, School of Medicine, San Francisco; Medical Superintendent, T h e Langley Porter Clinic; Past President, American Psychiatric Association

In the beginning, all sickness was regarded as punishment by an angry God. It was gradually recognized that physical sickness had ordinary physical causes, but the lingering superstition about mental sickness led to the confinement of persons suffering from mental disorders in prisons—even to their torture or execution. Three hundred years ago the patient with hysterical anesthesia would have been looked upon as possessed by evil spirits and would have been burned at the stake. Such ideas changed slowly, and it was not until the early nineteenth century, following the work of Chiarugi in Italy, Pinel in France, and Tuke in England, that the mentally sick were removed from prisons and dungeons and given humanitarian care. Many persons considered Pinel insane, since they felt that no sane person could suggest such a preposterous and ill-advised idea. The new institutions for the mentally sick in Great Britain and the United States were called asylums or retreats: the term hospital was rejected because it was felt that it would disgrace respectable persons who were suffering from mental disorders to send them to institutions labeled hospitals, since only paupers went there. For over a century the lunatic asylum was literally a place of refuge for the mentally sick and for those who took care of them. Psychiatry was thus isolated from the rest of medicine, to the detriment of both psychiatry and medicine. It is true that a few general hospitals have always had wards for the mentally sick: Bellevue Hospital in New York City, one of the oldest hospitals in this country, is one of these. Only within the last fifty years in the United States, however, have we seen the return of psychiatry to the rest of medicine, and the mentally sick no longer entirely isolated in asylums well out in the country, far away

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INTRODUCTION

from general hospitals, medical schools, and other medical organizations. Recently psychiatric hospitals have been built side by side with general hospitals. In a number of states the state itself has erected a small psychiatric hospital to operate in conjunction with a general hospital and medical school: early examples were the Michigan State Psychopathic Hospital and the Boston Psychopathic Hospital. Private psychiatric pavilions have been built as a part of general hospitals: for example, the Phipps Psychiatric Institute in connection with the Johns Hopkins Hospital. With this has come the demand to abandon the terms asylum and retreat, because of the stigma of these names, and to use the word hospital instead. However, with a few notable exceptions, general hospitals have only recently begun to accept mental patients. General hospitals have traditionally excluded certain groups of patients; principally those suffering from highly contagious diseases, so-called venereal diseases, alcoholism, drug addiction, and mental disorders. In recent years these prejudices have gradually decreased, and the general hospital has tended to become a general hospital in fact as well as in name. The American Hospital Association recently recommended allocating three per cent of hospital beds for alcoholics. So-called venereal cases would generally be admitted at the present time, but this is not necessary, since most of them can be quite satisfactorily treated as outpatients with the newer antibiotic drugs. The general isolation procedures for contagious diseases are slowly disappearing. Even persons with leprosy (Hansen's disease) are now at times accepted in the general hospital. Gradually, too, psychiatric wards are becoming an integral part of the modern general hospital, although many examples of the old division still persist. Tripler Hospital, a governmental hospital of the armed forces, in Hawaii, one of the most beautiful and modern of general hospitals, has its psychiatric ward more than an eighth of a mile from the main hospital building. Even university regents sometimes protest against including a psychiatric pavilion in a general medical center on a university campus. In setting up the modern psychiatric unit we find in many places the same old prejudices, in a newer guise. Neurotic or psychosomatic patients are accepted but persons with more serious types of mental disorder are rejected. I know of no other branch

INTRODUCTION

of medicine in which only the mild cases are admitted to the general hospital and the more severe and serious are refused admission. What would be said of a surgical pavilion that took only the simplest surgical cases, or an obstetrical ward that took only simple and uncomplicated cases of childbirth? T h e psychiatric ward or pavilion of the general hospital should take all types of mental cases, just as the surgical pavilion accepts all types of surgical cases. Obviously the psychiatric ward of a general hospital has many advantages for a mentally sick patient. Good consultation services from all other fields of medicine are available at a moment's notice if only a corridor or door separates the medical from the psychiatric ward. Conversely, medical, surgical, obstetric, and pediatric cases can receive more accurate diagnosis and better care if psychiatric advice is as readily available as any other consultation. All patients can use the same laboratory, X-ray, electroencephalographic, and surgical facilities without need for costly duplication. Finally, a psychiatric section within the general hospital makes not only the public but also medical and nursing students, and even doctors, think of psychiatry as simply one of the various fields of medicine. Teaching in psychiatry can be on a par with teaching in other specialties and thus make for an all-around preparation. The specialized mental hospital will always be with us and will have its place, and we will always have specialized hospitals for the treatment of cancer, tuberculosis, and many other conditions. However, this specialization should never exclude the possibility that the general hospital will also have facilities for treating such conditions.

Preface The outstanding failure of medicine has been in meeting the challenge of mental illness. The triumphs of modern medicine have been in the fields of internal medicine and surgery. In general, errors in medical practice have largely been due to ignoring the psychiatric approach to the patient's problems. Ignorance and prejudice continue to dominate our thinking and to prevent our facing the extreme prevalence of mental illness. The seriousness and wide extent of mental illness make it of concern to everyone. Yet only a few persons, in comparison to the magnitude of the task, have really come to grips with the nation's most important medical problem—chronic mental illness. In past generations the mentally ill have been put away in asylums. T h e concept of mental illness which resulted in such treatment still persists; therefore the attempts to modernize state institutions and make them into real hospitals have only partly succeeded. The great need is for complete integration of psychiatry within general medicine. Such integration can be accomplished only by getting general hospitals to accept their responsibility for treating mental illness without discrimination. Men prominent in the practice and teaching of internal medicine were recently interrogated about their referral of patients to psychiatrists and their opinion of the effectiveness of such treatment. In their replies, these specialists almost unanimously agreed upon the great need for better integration of psychiatry into medicine. In part they attributed the present failure to the lack of psychiatric facilities in general hospitals, and stated that future advances in psychiatric medicine will depend upon improving the quality of psychiatric education in medical schools. They enlarged this statement to mean a closer working relationship between psychiatry and all the specialties of medicine in training interns, residents, and nurses, thereby providing complete medical care of both psyche and soma of all patients early in their illnesses.

PREFACE

Along with improved medical education must go a sound educational program based on community problems: programs for teaching health; research; knowledge of good mental hygiene principles; directions on how and where to obtain scientific help for people in emotional distress. Neglect of public education encourages the spread of cultism. A t present far too many people go to cultists or quacks or are attracted by pseudoreligious promises. Organizations like the National Association for Mental Health must take a greater interest in the problems of integration of psychiatry within general hospitals. The revision of obsolete commitment laws and the removal of all possible stigmas from the admission of the involuntary patient are basic. Recommendations by the American Hospital Association, by the President's Commission on the Health Needs of the Nation, by the American Psychiatric Association, and by many interested agencies, should receive serious and careful consideration. In the past quarter of a century my associates and I have done considerable pioneer work in developing four psychiatric departments within three general hospitals. As a result of the work and the experience thus gained, we began a general survey of the status of psychiatry within the general hospital field. This extensive survey, incorporated into a scientific exhibit and displayed at three national medical and two national hospital meetings, attracted much attention and brought inquiries from an increasingly large number of persons—psychiatrists, hospital administrators, and others. In order to answer queries and to provide at least partial information, we have prepared this book, based on the material that was collected for the exhibit. This material was obtained by querying all registered hospitals classified as general by the American Medical Association and described by the American Hospital Association. Detailed questionnaires were sent to those United States and Canadian hospitals thought to have a psychiatric unit, and a short questionnaire was sent to all other general hospitals with more than 75 beds. A separate questionnaire was sent to medical schools. W e found, in the United States, 329 general hospitals with psychiatric beds, of which 279 had at least a 15-bed unit; of their 163,000 beds a total of 23,000 were for psychiatric patients. The other 50 hospitals offered beds merely for detention or temporary

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PREFACE

custody. In Canada, 21 general hospitals had such units, with 509 psychiatric beds in the total of 12,000 beds. Of the 950 United States general hospitals without psychiatric beds that gave information—although more than 300 occasionally accepted a psychiatric patient in an emergency or for diagnosis and very occasionally treated mild cases, and 400 reported some kind of mental hygiene clinic or psychiatric consultation—at least half offered no psychiatric service of any sort and never admitted a known psychiatric patient. Similar information came from 60 Canadian general hospitals. This means that although mental patients occupy more than half of all hospital beds in the United States and Canada, general hospitals accommodate less than 1 per cent of them. More than a third of the 73 four-year medical schools in the country do not have access, for teaching medical students, to a complete psychiatric unit in a general hospital. The information and the many comments obtained from more than 1500 respondents, then, plus the experience we have had in setting up and conducting psychiatric units in several general hospitals, form the basis of this book, which aims to consider the main problems connected with installing and operating a psychiatric department within a general hospital. It is our belief that, as the advantages of the psychiatric unit are better understood, patients will gradually be admitted to general hospitals for treatment of acute mental illness to the same extent as for other acute medical illnesses, disorders, and accidents; that modern medicine will eventually accept its responsibility to treat the entire person. Thus, our book is, in part, devoted to advocating the use of general hospital psychiatry. W e have been fortunate to have the help of many associates, colleagues, and other friends interested in the general problem. Several have contributed chapters or parts of chapters, and others have aided in the preparation of certain sections. Those contributors who have written separate chapters or sections are listed in the table of contents and at the head of the appropriate section. In addition to these, various colleagues and other friends have aided in the preparation of the book by suggesting additions and revisions. Special help was given to us by the following persons: Howard O. Brower, staff assistant, and associates, Council of Medical Service, American Medical Association; Lewis Carpenter, Ph.D. and Chris-

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PREFACE

tine Miller, Ph.D., clinical psychologists; Helen Byron of T h e Langley Porter Clinic; L. G . McKeever, M.D.; Frederick R . Ford, M.D.; June T . Eaton, R . N . ; and Helen Jordan, R . N . , O . T . R . Generous and interested help came, also, from several medical students and secretaries: of the latter, Dorothy K . Clark was particularly helpful. W e also wish to acknowledge with thanks the help of the various individuals and organizations that assisted us in gathering material for the survey. These were: Dr. Daniel Blain, Medical Director, American Psychiatric Association; Dr. Paul B. Magnuson, Chief Medical Director, Veterans' Administration; Mr. C. C. Limburg, National Institute of Mental Health, United States Public Health Service; Dr. Harvey J . Tompkins, Chief, Psychiatry and Neurology Division, Veterans' Administration; Dr. J. T . Boone, Medical Director ( 1 9 5 2 ) , Veterans' Administration; Dr. W . B. Terhune, Committee on Cooperation with L a y Groups, American Psychiatric Association; American Hospital Association; National Association for Mental Health; T h e National Committee for Mental Hygiene, Canada; United States Public Health Service; and the mental hygiene departments of the various states and Canadian provinces. W e are also grateful for the editorial assistance received from John Gildersleeve of the University of California Press. W e realize that our book, as a forerunner, has many shortcomings and gaps, but we hope that its publication may serve to stimulate others to enlarge, improve, and advance the scope of investigation and accomplishment in general hospital psychiatry. With greater and more concerted effort than in the past, the general medical and hospital administrative professions should be able, within the next decade, to meet the challenge of providing psychiatric care in the general hospital. A.E.B.

Contents Foreword, by Daniel Blain

vii

Introduction, by Karl M. Bowman

ix

Preface 1

2

xiii

Staffing the Psychiatric Unit

i

The Nursing Staff

2

Occupational Therapy

8

Clinical Psychology

13

Social Service

18

Training Programs

24

Physician's Training Nursing Education, by Marion Kalkman .

24 .

28

3

Administration, by A. E. Maffly and Agnes Watty Boyle

40

4

Architecture, by Allston G. Gutter sen

57

5

The Problem of Psychiatric Referral

77

6

Medicolegal Aspects of Psychiatric T r e a t m e n t . . . .

90

7

8

The Psychiatrist's Viewpoint, by Douglas M. Kelley

92

The Legal Viewpoint, by Thomas Hadfield

.

113

Voluntary Health Insurance and Nervous and Mental Disease

124

The Day Hospital, by D. Eiven Cameron

134

.

9

Special Treatments

151

Drug Therapy

151

Alcoholism

153

Geriatrics

159

Group Psychotherapy, by Donald A. Shaskan .

.

165

1 o Needs, Recommendations, and Suggestions for the Future

170

Index

178

CHAPTER 1

Staffing the Psychiatric Unit

Adequate and comfortable physical facilities are of course important, but they are secondary to a well-trained, qualified staff of psychiatrists, residents, interns, psychiatric nurses, occupational and recreational therapists, aides, and orderlies. A modern efficient department should also include psychologists and psychiatric social workers, at least on a part-time basis. A well-trained, closely knit, and cooperative staff can often compensate for a cramped, poorly arranged physical plant. The unavailability of competent personnel is a major obstacle in the way of efficient operation of psychiatric departments. Indeed, a considerable number of psychiatric units that are physically ready are unable to function because of lack of personnel, and a good many other units are attempting to operate with woefully inadequate staffs. In part this shortage of personnel is due to the requirements of the armed forces, in part to the fact that many units do not offer training programs. Three or four attending psychiatrists, aided by a competent staff, can handle a 30-bed unit and yet have half-days available for office practice. On the other hand, a unit of this size can accommodate the needs of ten to twelve psychiatrists. The chief psychiatrist should be certified in neurology and psychiatry, and attending psychiatrists should be certified or in the process of fulfilling the requirements for board certification. Since the general hospital practice of psychiatry is somewhat different from the institutional type of practice, staff psychiatrists should have had some experience in general hospitals. T w o psychiatric residents and an intern assist the psychiatrists and should be on 24-hour duty for continuous care of patients. Every good psychiatric department should give psychiatric training to student nurses, from among whom staff nurses may later be recruited. A 30-bed unit should have a supervisory nurse, seven trained nurses, and seven student nurses. The department should

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STAFFING THE PSYCHIATRIC UNIT

also have a program for training aides and orderlies; four of each are required. An occupational-recreational therapist if possible, at least a part-time clinical psychologist, and a part-time psychiatric social worker, round out the staff. ADEQUATE 25-30 BED PSYCHIATRIC UNIT Physical Facilities A wing or section with semiprivate rooms Day, dining, occupational-recreational rooms (sexes mixed) Two soundproof and airconditioned seclusion rooms Combined open-closed unit with daytime patient service Minimum Personnel (40-Hour Week) for 24-Hour Service i psychiatric nurse supervisor i instructor 7 graduate psychiatric nurses 7 senior student nurses 4 aides 4 orderlies 1 occupational-recreational therapist 2 psychiatric residents i intern i clinical psychologist 1 i psychiatric social worker / m a 7 b e P a r t " t l m e

THE NURSING STAFF Obtaining experienced psychiatric nurses is usually the biggest problem. However, directors of schools of nursing can usually recommend intelligent nurses interested in organizing and setting up nursing schedules for a new department. Such nurses can be sent to successfully operating psychiatric units where they can obtain practical experience in psychiatric nursing. After a head nurse, or supervisor, has been obtained, the individual hospital unit can usually train additional staff members more easily than it can get them elsewhere. Inservice training programs in established psychiatric units should be able to train nurses, aides, and orderlies both for replacing and adding workers in their own units and for staffing new ones. The adequate 25- to 30-bed unit can function well with such minimum nursing personnel as the following: a psychiatric-nurse supervisor in charge, and for each 8-hour shift, one graduate psy-

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chiatric nurse, an assistant nurse or two senior student nurses, and two aides, preferably a man and a woman. Additional personnel is necessary to fill in during the regular employees' free time, vacation periods, and sick leave. Married nurses with previous training are often available for supplementary duty. In cities, college students, particularly premedical and medical students, are an excellent source of aides. Total full-time nursing personnel would then be i psychiatric nurse supervisor, i instructor, 7 graduate psychiatric nurses, 7 senior student nurses, 4 aides, and 4 orderlies. Each would work a 40-hour week. The size of the staff will also be influenced by the selection of patients admitted to the department and upon the types of therapy administered. For example: admission of schizophrenic patients for whom insulin therapy is the preferred treatment would make a larger number of professional nurses necessary; admission of patients with severe neuroses requires that more of a psychiatrist's time be spent in the hospital in psychotherapy. The chief psychiatric nurse should have independent authority to develop all rules and regulations of her department. This freedom to develop procedures which most benefit the patients stimulates the chief nurse's initiative. Advice from the psychiatric staff and conferences with other hospital and nursing administrative personnel will aid her to establish regulations based on nursing needs and at the same time avoid misunderstanding and tension between the nursing staff and other professional workers. One of the chief nurse's major responsibilities is the training of an auxiliary staff of assistants, an important duty during the present shortage of personnel. Important also is the establishment of a good esprit de corps among all psychiatric professional staff workers. Nurses must learn how to approach the psychiatric patient, how to display genuine friendliness, and how to help the patient begin to handle his problems. More than any other therapists, the chief nurse and her assistants create the atmosphere and feeling for the whole department and determine the proper setting in which all therapy proceeds. Another of the head nurse's responsibilities is to maintain high standards of nursing care. This means, among other things, the abolition of restraint methods, both physical and chemical, except seclusion, hydrotherapy, or sedative pack therapy—and these are

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but temporary symptomatic measures, prescribed by the physician until the immediate tense situation has passed. One important function of the nursing personnel is the admission of patients, which includes making out the necessary admission records, checking the patient's belongings, explaining visiting rules and other policies of the psychiatric unit to relatives. Women nurses succeed especially well in the initial care of suspicious, fearful men patients who will not at first trust the male aide or even the physician. For this reason, most psychiatric departments use women to supplement male aides. Close attention to the prevention of accidents is also important since their incidence is higher among emotionally disturbed or hyperactive patients than on nonpsychiatric wards. The nurse should be alert to observe in patients incipient tendencies toward tension, panics, impulsive behavior, marked confusion, or other destructive reactions. B y instituting early protective measures, one may often prevent accidents. Accidents must be carefully described in the patients' charts and reported to the hospital administrator; all are potential medicolegal problems. It is important at a depressed patient's admission to search carefully for hidden drugs, razor blades, and other means of suicide. All depressed psychiatric patients are potentially suicidal, but psychiatric nurses and aides must know which patients are the greatest suicidal risks and watch them unobtrusively; rounds at frequent irregular intervals and personal inspection of each patient are helpful. The nurse should know the whereabouts of these patients and report any sudden physical change or unusual behavior. They should not be permitted, except under strict observation, to use objects with which they might conceivably cut or hang themselves. Patients also may attempt self-mutilation by knocking or throwing themselves against walls, furniture, or radiators. Secreting instruments to aid in escape and slipping out of exit doors are ever-present dangers against which the staff must be alert. Charts are especially important in the psychiatric department because they serve as the psychiatrist's guide, assist diagnosis, and help maintain consistency in nursing care. The nurse should chart the patient's changes of mood, attitudes, and appearance, and record his various reactions to the day's activities. Revealing conversations, any slight defects of memory, mistaken ideas, gross errors of judg-

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ment, fears, and unusual or bizarre behavior are important. Chart notes should cover details of how the patient eats, sleeps, works, plays, and adjusts himself to ward activities. A daily conference period spent in review of patients' charts is extremely helpful to all personnel and is also useful in teaching and training programs. From a complete chart it is often possible to gain a general impression of the patient's diagnostic reaction type. Behavior charts in which the patient's reactions are indicated on a graph tend to produce superficial and stereotyped observations by the nursing personnel, and for this reason are being discarded in many hospitals. Despite the fact that many psychiatrists ignore the nurse's role in psychotherapy and that much controversy about it exists, all nurses in psychiatric wards do psychotherapy of one kind or another, if only by the atmosphere they create and maintain by their day-long contacts with patients. As the demands on psychiatrists' time increase, they can spend less and less time upon wards, and must delegate more responsibility to nurses. This they must do by careful instruction and conference, rather than by inattention or dispute. A recent questionnaire circulated by a special committee of the Group for the Advancement of Psychiatry to mental hospital and nursing administrators showed a 90 per cent approval of the psychiatric nurse's participation in psychotherapy. In any case, the controversy is out-of-date; as Sleeper has pointed out, it is simply fatuous, in the present scarcity of professional assistants, to argue that nurses should not share in psychotherapy. Certain nurses can be trained to take excellent psychiatric histories and to obtain other detailed information; these relationships help establish rapport and make the nurse from the start an aid in psychotherapy, thereby saving the psychiatrist's time and shortening the treatment program. The nurse should also participate more widely in group psychotherapy, as she is trained to do on many British mental wards. Her day-by-day familiarity with the patient makes her a key figure to him and she is in probably a better position than either the clinical psychologist or the social worker to aid in psychiatric therapy. In many departments, too, psychiatric nurses and aides assist the occupational therapist and carry on the work in her absence. Such supervised participation of the psychiatric nurse

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contributes greatly to all treatment procedures and increases her emotional satisfactions in a healthy nurse-patient relationship. Another important role of the psychiatric nurse is that of research, especially in fields related to improvement of psychiatric nursing methods. Investigation of such problems as greater control of the patient's environment, the effect upon him of personnel and of other patients, nondirective counseling, therapeutic grouping of patients, and new technics of stimulating rapport have been suggested as suitable topics for research. Preliminary studies, such as those by Caudill, Tudor, and Bullard, have already pointed the way to better treatment of many types of chronic patients too often labeled as hopeless, unresponsive, or assaultive by the nurse or aide who is unaware of the interpersonal relations in psychiatric-ward living. As psychiatric supervisors and nurses assume these greater professional responsibilities they must be released from onerous routine duties of bedside nursing. Aides and other auxiliaries perform most of these duties. The proper discharge of patients is almost as important as is their mode of admission. Outstanding are these precautions: No patient should be discharged without the permission of the business office and the physician's written order; if he is removed without such a dismissal order, a signed release must be obtained from a responsible relative. If the patient is discharged against medical advice, he may be apprehensive or create a scene, or the indiscreet behavior of relatives may increase his emotional instability. The nurse should reassure both the patient and his relatives, and attempt to modify any abnormal attitudes. Such precautions are necessary both to protect the patient's best interests and to maintain good relations between the patient and his family and the hospital. If the patient is discharged as recovered the nurse acts as a warm friend in encouraging him, and arranges for his follow-up visits, according to the physician's instructions. Patients dismissed for transferral to another institution should be reassured and told they are being transferred for further treatment. The nurse should encourage the patient's cooperation with the suggestion that he will eventually recover. Every discharged patient or his responsible representative should sign a receipt for clothing, cash, and other

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valuables kept during hospitalization and returned t o him at his dismissal. In summary, it is clear that the psychiatric nurse has a highly interesting role if she realizes her potentialities. H e r education and specialized training enable her to develop exceptional skills in dealing with patients. As she develops her capacity f o r leadership and teaching she gains more competence in w a r d management. T h e mental stimulation which leads to professional g r o w t h is always present in a well-run psychiatric department of a general hospital, w h e r e selection of acute cases allows a high percentage of recoveries. T h e profession becomes a real challenge. T h e psychiatric nurse can indeed become the complement of t h e psychiatrist. REFERENCES Bennett, A. E. and June T . Eaton. T h e role of the psychiatric nurse in the newer therapies, Am. J. Psychiat., 108:167-170, 1951. Bennett, A. E. and Avis P. Purdy. Psychiatric Nursing Technic. Philadelphia: F. A. Davis Co., 1940. Bennett, A. E. and Bernice Engle. Psychiatric nursing and occupational therapy, in Progress in Neurology and Psychiatry. N e w York: Grune & Stratton, 1945— Bullard, D. M. Problems of clinical administration, Bull. Menninger Clin., 16:193-201, 1952. Caudill, W . et al. Social structure and interaction processes on psychiatric ward, Am. J. Orthopsychiat., 22:314-334, 1952. Davis, J. E. Clinical Applications of Recreational Therapy. Springfield, 111.: C. C. Thomas, 1952. Group for the Advancement of Psychiatry. Committee on Psychiatric Nursing. The Psychiatric Nurse in the Mental Hospital. (Report no. 22) Topeka, Kan.: 1952. Hall, Bernard H . et al. Psychiatric Aide Education. N e w York: Grune & Stratton, 1952. Ingram, M. E. Principles of Nursing. Philadelphia: Saunders, 1949. Kalkman, Marion. Introduction to Psychiatric Nursing. N e w York: McGraw-Hill, 1950. W h a t the psychiatric nurse should be educated to do, Psychiat. Quart. Supp., 26:93-102, 1952. Mayden, P. M. W h a t shall psychiatric patients read? Am. J. Nursing, 52:192-193, 1952.

Montag, M. L. The Education of Nursing Technicians. N e w York: Putnam, 1951. Sleeper, F. H . Present trends in psychiatric nursing, Am. J. Psychiat., 109:203-207, 1952.

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Tudor, G. E. Sociopsychiatric nursing approach to problem of mutual withdrawal on mental hospital ward, Psychiatry, 15:193-217, 1952.

OCCUPATIONAL THERAPY Psychiatric occupational therapy has slowly evolved from two types of activity. For years, long-term patients in large hospitals, especially in mental hospitals, have done a good share of the work that keeps the institution going, and other patients have learned crafts, often merely as a way to put in time. Orthopedic patients, too, have been taught various crafts as a sugar-coated means of giving them useful exercise. From these sources psychiatric occupational therapy has gradually marked out a field and developed a professional training. It has become an adjunctive form of psychiatric treatment which uses constructive activity to make the patient more accessible to therapy. There are twenty-eight accredited schools of occupational therapy in this country and two awaiting accreditation (1955). These are approved by the Council of Medical Education and Hospitals of the American Medical Association. The graduate from one of these schools receives a certificate as a registered occupational therapist. The training and certification are somewhat parallel to those of a registered nurse, and some persons obtain certification in both fields. Ideally, the function of occupational therapy is rééducation. Psychiatric occupational therapy helps the patient learn to do things, to get a feeling of accomplishment, to participate with others in various activities, to feel himself a part of the community. All this must be done without giving the patient the idea that he must always be busy, that he has to produce successful pieces of work, or that he has to join any particular group. The patient's real needs at the time may be for other things than compliance, productivity, or participation, and these needs must be considered by the psychiatrist and the therapist. After the diagnosis and evaluation of the patient have been made, an activity program is medically prescribed. The therapist must be able to anticipate and recognize changes in the patient and readjust the program accordingly. Large mental hospitals can usually afford to have sizeable quarters and an adequate staff of registered psychiatric occupational

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therapists, aides, students, and volunteer workers. The smaller hospitals and the psychiatric unit of a general hospital must get along with more limited space and staff. Space is usually at a premium, but a number of plans can be worked out to make the best use of what is available. A booklet, At Your Fingertips, published by the Colorado Occupational Therapy Association, offers a good guide for the small department. A plan recommended by West and Clark for the mediumsized unit calls for floor space of about 47 by 18 feet. This plan allows room for a workroom, an office, and storage cabinets. The space should be easily accessible and with good daylight exposures, and should, if possible, have access to porches and sundecks. Equipment can be fairly modest to begin with. A lathe, a jigsaw, perhaps a circular saw for men, and a table loom for women are usually considered to be basic; smaller pieces can be added as funds permit. A few tables should be available for weaving and braiding, leatherwork, block-printing, fly-tying, sewing, and art work. Bench work may include light carpentry, work with plastics, metalwork, and the painting and finishing of articles. Storage cabinets should provide for at least three months' supplies. There must be a sink with both hot and cold water, and gas and electric outlets. Funds should be provided to buy new materials as they are needed. One psychiatric occupational therapist can direct the work of 25 to 30 patients in a daily morning or afternoon session of about two hours. The therapist should have the assistance of at least one aide, one or two nurses, and some volunteer workers. Because occupational therapy is usually combined with recreational and educational therapy, all psychiatric personnel in the unit should give some help to the occupational therapist. Volunteer workers can be especially valuable. A number of the larger mental hospitals organize corps of these workers, and use them most successfully. The workers must be carefully chosen and then given a short orientation and training course. The occupational therapist can often train a competent nonprofessional person to select and instruct these workers and assist in supervising their work. This person can herself be a volunteer who is willing to give a fairly large amount of time, on a permanent basis. The help of skilled craftsmen and artists can often be obtained for short periods.

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The local mental hygiene society is often an important source of volunteer workers. Work with mental patients can be more stimulating and enlightening to society members than any number of lectures about psychiatry. Invariably, some volunteers become extremely interested in the work, and capably interpret the problems of mental illness to the community. Patients should choose their own projects and work at their own speed, especially in the beginning, since the patient's eventual reeducation is the aim. Deeply depressed patients may often show the first sign of interest in a toy to be made for a child or grandchild. Patients often take the finished article home, but satisfaction should come from some aspect of the work itself rather than from mere productivity. Most departments disapprove of work done for sale or at the hospital's order, believing it unwise even indirectly to exploit the patient's activity. A problem at present with acutely ill depressed patients accepted for short-term treatment is the confusion accompanying electroshock therapy during the early course of treatment. The patient needs to be kept occupied and yet he can do only a limited number of things, especially in the small space of the ordinary hospital unit. No work that requires following a pattern or directions or remembering instructions, however simple, is suitable for the confused patient. Preparation of Red Cross or other hospital supplies, such as basting towels or making binders out of old linen, is usually possible. Women can do their own laundry, but not the ironing. Men in this phase of treatment can play dominoes, checkers, or simple card games, read at least the daily newspaper headlines, and sit around and talk. Jigsaw puzzles, shuffleboard, and television pass the time for others. Listening to the radio and watching television keeps the patient in contact with the outside world. Patients usually develop interest in sports, especially baseball or football games, and in political events. During fund-raising campaigns for such purposes as aid to the blind or to children with cerebral palsy, some patients will ask to send in a donation. For patients able to concentrate fairly well on various activities, Swedish weaving offers interesting creative work. Ceramic articles can be made from various kinds of clay, some of which do not have

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to be fired. Ash trays and other small articles can be made of metal and plastics. Leather can be worked up into key chains, coin purses, or belts in the ordinary small shop. Anagrams and crossword puzzles attract some patients. Simple instruction in sketching and other art work often interests the patient without promising to make a Grandma Moses or a Rousseau out of him. T o y making is usually popular, because most people like to give presents to children. Practicable articles are stuffed dolls and animals; yarn dogs or cats made on a frame, with so little sewing involved that most men are willing to make them; cardboard toys; and simple toys made from wood. If one article turns out successfully, then the other patients want to make it too. A craft that many patients enjoy is the making of plaster figures for toys and decorations. They are made in inexpensive molds, and the figures may then be hand colored or tinted in numerous ways. Such art work allows the maximum self-expression to the minimum of skill or talent. The psychiatric occupational therapist ought also to participate in choice of ward furnishings and decoration. The use of color and of attractive, comfortable furniture helps to compensate considerably for the restrictions of a closed ward, to make the patient's stay pleasant, and to make him more agreeable to various kinds of therapy. Good food is important. Therapists should insist that the food be better and that there be more of it than in the rest of the hospital—that it always be the best possible. Letters written by patients always mention good food, new and attractive dishes and ways of serving them. Mixing of the sexes at meals and in group work helps greatly to promote sociability and to make the ward more homelike. Birthdays and holidays provide occasions for parties, with simple refreshments. At birthday parties the guest of honor is encouraged to cut the cake and help serve the guests. Most units carry out occupational therapy in the morning and recreation in the afternoon, but the dividing line between the two is often narrow. Games like shuffleboard, ping-pong, cards, checkers, dominoes, Chinese checkers, and chess arouse interest. Any game that fairly large numbers can play together is a useful adjunct to therapy. Volunteer workers are especially useful in arranging trips and

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escorting patients to movies, museums, zoos, and other sight-seeing spots. They also supply the needed personnel to assist with dances, picnics, and walks. The small psychiatric department is apt to neglect educational therapy. It is true that most patients in the acute-treatment units do not remain long enough to receive much educational direction, but an alert therapist can, in the six weeks or so of the patient's stay, explore briefly various promising fields for interest and stimulation. An introduction to stamp collecting, for example, may start the patient on a project that will continue long after he has left the hospital. For some patients the collecting of fragile glass or thin china objects absorbs a considerable amount of hostility. Photography has many ramifications. Finishing of new unpainted furniture or refinishing of old pieces is a practical craft, easily learned. One patient, while under treatment, became interested in collecting books, maps, and articles on the early history of the development of railroads in a Middle Western state; after leaving the hospital she was able to get a part-time job as a curator of an industrial museum. A patient may become interested in new subjects through university or adult education classes. In the outpatient or office interviews following his hospital discharge, he can be encouraged to develop his new interests. Outstanding work in educational therapy has been done in the Menninger Foundation and the Institute of Living. Here the therapists make a great effort to broaden the patient's interests. Patients are encouraged to join classes that include subjects ranging from leatherwork to astronomy; they read drama or poetry, discuss socioeconomic topics, see documentary movies, take courses in public speaking. Arrangements are made to let patients read advance copies of new books, see movies not yet distributed generally, or begin correspondence courses that can be finished at home. In this way the patient returns to his milieu not only abreast of the times, but, in some respects, ahead of them. As hospital administrators come to see the advantages of a good psychiatric occupational therapy division and the part it plays in hastening the patient's recovery and return to more normal living, they become more willing to give it adequate space and equipment. Eventually, psychiatric occupational therapy should be correlated,

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and in part combined, with physical and occupational therapy for general patients. REFERENCES

Colorado Occupational Therapy Association. At Your Fingertips [Rev.] Denver: 1952. Dunton, W. R. and S. Licht, eds. Occupational Therapy. Springfield, 111.: C. C. Thomas, 1950. Fidler, G. S. and J. W. Fidler. Psychiatric Occupational Therapy. New York: Macmillan, 1954. Reider, Norman. Psychotherapy based on psychoanalytic principles, in James L. McGary and Daniel E. Sheer, Six Approaches to Psychotherapy. New York: Dryden Press, 1955. Ridgway, E. R. Volunteer program at Delaware State Hospital, Am. J. Occup. Therapy, 5:205, 1951. Silver Hill Foundation. Avocational Therapy. New Canaan, Conn.: The Foundation, 1951. Stetson, E. R. Role played by volunteers in the mental hospital, Am. J. Occup. Therapy, 5:203, 1951. West, W . and A. W. Clark. Planning the complete occupational therapy service, Hospitals, 25:85, 1951.

CLINICAL PSYCHOLOGY Research, diagnosis, and psychotherapy have been designated as the areas of the clinical psychologist's activity. In large departments a full-time clinical psychologist usually operates in all these areas; he administers intelligence, diagnostic, and prognostic tests, takes part in therapy under medical supervision, and he undertakes research projects either independently or in collaboration with the medical staff. Many small departments, however, employ a part-time psychologist whose only duty is to administer diagnostic tests. Even narrowly diagnostic tests may have some therapeutic effects; at least, the psychologist's awareness of possible therapeutic factors helps make all testing a part of the treatment program. Even when the psychologist functions in such a limited capacity, his addition to the staff is most valuable. Since clinical psychology draws its body of knowledge from psychology, anthropology, personality theory, psychiatry, and psychoanalysis, it has a wide field of application. T h e clinical psy-

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chologist, of all scientists, has, by his use of psychometric tests, acquired the best understanding of the individual's intellectual functioning, including concept formation and memory. The various projective approaches and interview material permit analysis of structural and dynamic aspects of personality. From the patient's style of expression, inferences can be drawn about such interrelationships of personality variables as role and self concepts, and discrepancies between them and the ways in which others perceive the patient. The inferences frequently elucidate important personal and social problems. Psychologic-test stimuli constitute a kind of standard situation in which the varying reactions of different patients may be observed. Then, too, the ambiguity of the stimuli and the instructions provoke responses which are of necessity more characteristic of the patient's personal modes of response than are his conventional responses to conventional situations. Although many patients are understandably reluctant to reveal their peculiar and disturbing thoughts, and are able to some extent to conceal them in an interview, in the unfamiliar, unstructured situation of telling what an inkblot looks like on the Rorschach they may unknowingly demonstrate a characteristic mode of thinking. The psychologist must be aware of the degree of anxiety created by the test situation and the kind of material requested. Information is more easily elicited if rapport is quickly and easily established. In some instances the psychologic interviews begin the process of desensitization. They allow the patient early chances for abreaction, and he may even begin to see some of the causal relationships in his difficulties. The high degree of clinical acumen needed to interpret diagnostic psychological tests in borderline psychotic states, and the contribution a balanced battery of tests can make toward a complete inventory of ego functioning in the patient, have been pointed out by Knight. In his words, they "combine the advantages of support from a visible and interested professional listener, as in the face to face psychiatric interview, and the diagnostically significant unstructured situation of the couch-free-association interview." Most psychiatrists believe the Rorschach and the Thematic Apperception Test ( T A T ) , as used by the psychologist, to be the most useful projective tests; useful nonprojective tests are the

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Wechsler-Bellevue Intelligence Test, the Goldstein Scheerer Blocks, the Minnesota Multiphasic Personality Inventory, and the Bender Gestalt. The Rorschach is the best single test. It usually confirms clinical impressions of psychodynamics and diagnosis, and often yields new information on personality structure and the interrelation of defenses that help direct psychotherapy and predict its outcome. In the hands of an experienced psychologist, Rorschach studies are extremely valuable in showing, for example, the patient's emotional reactions, suicidal or homosexual trends, amount of anxiety, sexual adjustment. In general, the test enables the psychologist to evaluate personality structure and dynamics. Rorschach analysis can also show the presence of intellectual deterioration, although not the exact extent. It is particularly valuable in borderline cases in which the organic factors are not clear after clinical diagnosis. The T A T can be used to obtain early knowledge of the dynamics of the patient's difficulties. During psychotherapy it is often used when the patient finds obstacles to free associations or has poverty or superficiality of associations; when he resists expressing his thoughts, or objects to interpretations of them; or when he is so depressed as to speak little. If the procedure is also directly therapeutic, the psychologist may interpret selected material to the patient or comment on those interpretations hit upon by the patient. Nonprojective tests are useful in research but have less direct value as aids to diagnosis and prognosis. Harrower has outlined the use of clinical psychology in the practice of medicine. She assumes that some day clinical psychologists will routinely work "in general hospitals to aid in the understanding of the personality problems of all patients," and explains the various tools by which psychologists "can make an important contribution at the present time." Psychologic diagnostic procedures do not as a rule substitute for careful psychiatric clinical evaluation, although they do contribute essential information to the total psychodynamic picture and point the way toward significant aspects of the patient's problem. In general the clinical psychologist is not equipped to make an accurate complete psychiatric diagnosis, and therefore should work in conjunction with the psychiatrist. C. P. Oberndorf, a psychiatrist with long experience in psycho-

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therapy, has indicated the difficulty in placing the nonmedically trained person in the scheme of therapy, pointing out that "the unity and continuous interaction of mind and body is incontrovertible and hence the necessity for familiarity with both for the maximum effectiveness in diagnosing and treating illness is apparent." There are, however, some differences of opinion as to the role the clinical psychologist can assume in the scheme of therapy in general hospital psychiatric departments. Most department heads feel that any therapy by psychologists should be carried out under the direction of a psychiatrist, but a few believe that clinical psychologists who have had specialized training as psychotherapists can conduct therapy independently. Some large psychiatric clinics give clinical psychologists special training in psychotherapy or psychoanalysis, but in such clinics they always function under supervision. Under conditions that provide adequate psychiatric safeguards, the clinical psychologist can also conduct group psychotherapy advantageously. Experience has shown that it can be used successfully in psychiatric departments and clinics to supplement individual psychotherapy. Although it may not produce changes in the basic personality structure, it helps the patient to attain more acceptable social adjustments. From his study of the social reference of psychiatric disorders, the psychologist is increasingly able to estimate how the patient relates himself to others, how well he perceives the relevant factors in social situations and is able to act upon them, and how his behavior affects other people. A recent estimate is that 30 per cent of the psychologists in the American Psychological Association have as one of their fields of special interest some phase of the practice of psychotherapy. This raises the question of whether the practice of psychotherapy is to be an integral part of the psychologist's profession, how adequate training is to be obtained, and at what level, predoctoral or postdoctoral. The American Psychological Association has taken steps to raise standards for clinical psychologists by requiring that they have Ph.D. degrees, with intensive training in both academic psychology and clinical work in diagnostic testing and psychotherapy. This requirement is now established for the position of clinical psycholo-

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gist in V A and other federal hospitals and clinics. Some states already have the requirement, and others—California, for example —are attempting to include the requirement in a licensure law. The clinical psychologist can be of great value in conducting both independent and collaborative research. Recently the selection of subjects and the methodology of research in psychiatry have been seriously criticized; the lack of control studies is a particular objection. The proper use of statistical methods and the construction of an experimental design by a competent research psychologist can be of invaluable assistance to the psychiatrist. The Group for the Advancement of Psychiatry has listed several fruitful topics for both independent and joint research, among them the development and refinement of diagnostic devices for detecting various types of maladjustment and abnormality and the classification of syndromes of maladjustment. Recent research has concerned the psychodynamics of personality structure; the nature of the psychotherapeutic process; the structure and functioning of the ego; and the interrelationships between the various psychopathologies and the so-called psychosomatic illnesses, for example, studies in ulcers, hypertension, and asthma. A number of extremely valuable studies have concerned aging and geriatrics, including the involutional psychoses. In the larger clinics much research is now oriented toward clinical problems, and the various problems that arise in the interactions of staff and patients on the psychiatric ward. The clinical psychologist may also be helpful in discussing with patients the possibilities of change in occupation or in suggesting appropriate avocations. In the larger department this counseling can be much expanded. Only occasionally does he assist in the selection of personnel for the unit. Clinical psychology, then, with its high standards of education and training, is the richest of the so-called social sciences and by far the most directly useful to the psychiatrist. Other workers from the social sciences—for example, sociologists—are sometimes employed, but their value is doubtful unless the above mentioned standards of training and psychiatric safeguards are most carefully observed.

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REFERENCES

Beck, S. J. The psychologist in the clinic setting, Am. J. Orthopsy chiat., 18:492-522, 1948.

Group for the Advancement of Psychiatry. Committee on Clinical Psychology. The Relation of Clinical Psychology to Psychiatry. (Report no. 10) Topeka, Kan.: 1949. Harris, Robert E. Psychodiagnostic testing in psychiatry and psychosomatic medicine, in Molly Harrower, ed., Recent Advances in Diagnostic Psychological Testing. Springfield, 111.: C. C. Thomas, 1950. Chap. II. Harrower, Molly. Appraising Personality. New York: Norton, 1952. Knight, Robert P. Borderline states, Bull. Menninger Clin., 17:1-12, January 1953. Menninger, Karl A., D. Rappaport, and R. Schaffer. The new role of psychological testing in psychiatry, Am. J. Psychiat., 103:47376, 1947.

Menninger, W. C. Psychiatry: Its Evolution and. Present Status. Ithaca, N. Y.: Cornell Univ. Press, 1948. Oberndorf, C. P. A History of Psychoanalysis in America. New York: Grune & Stratton, 1953. Watson, Robert I. The Clinical Method in Psychology. New York: Harper, 1951. Wikler, Abraham. Fundamentals of scientific research in psychiatry, Neuropsychiat.,

2:87-98, 1952.

Yacorzynaki, G. K. Medical Psychology. New York: Ronald Press, 1951.

SOCIAL SERVICE Social service is an important function in every psychiatric department of a general hospital and the social worker is an integral part of the psychiatric team. There is little correlation between the size of the psychiatric department and the use or role of the psychiatric social worker, because psychiatric social work in the general hospital is largely an unexplored area and the possible benefits have not yet become widely known. Several small departments of 20 to 30 beds have a full time psychiatric social worker; some departments of 60 to 100 beds have no more; several general hospitals with only psychiatric outpatient departments employ psychiatric social workers. Because the social worker attached to the general hospital psychi-

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atric unit usually works alone she must be experienced enough to work independently of social work supervision, although consultation with the psychiatrist is of course essential. Although the worker's primary concern is with the relatives and their difficulties, the information she obtains about the patient is often of great value in determining the course of therapy. She obtains a full social history from a reliable relative—an excellent background of the relatives' attitudes and conduct toward the patient, the family and home atmosphere, and the general situation in which the patient's illness has evolved. She should, therefore, participate not only in study of the patient's problem but also in planning the psychiatric treatment, so that the whole process is one continuum in which all therapists contribute to the understanding and treatment of the patient. If hospital admission is decided upon, the relatives will need a clear, simple interpretation of the patient's disorder and what it is hoped that treatment will accomplish. Careful working out of the relatives' main conflicts will help to ease the family situation and indirectly to benefit the patient. If treatment cannot be immediate, the social worker maintains a liaison relationship, meantime helping the patient and his family to complete arrangements for hospital admission or clinic treament. Mutual discussion between psychiatric social worker and family regarding the patient's main problems and course of treatment serves to ease the worry of relatives about their responsibilities and share in the disordered personal relationships. Often it is possible to call attention to community resources of aid to the family in improving their social and perhaps educational adjustment, so that the patient after treatment can return to a better environment than his former one. The social worker may discuss with family members such matters as finances, jobs, living arrangements, school or camp placement of children. The social worker has an excellent chance to do good follow-up work. Follow-up contacts by a qualified social worker serve to prevent many relapses and thereby save the patient and his family the cost of futher intensive treatment periods, with possible hospitalization. Through therapeutic work with the relatives, the social worker is able to continue a good relationship with both patient and family. The social worker can give the patient upon his dis-

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charge from treatment direct help upon certain of his adjustments, and, if necessary, discuss with him his needs for further consultation in either outpatient treatment or office appointments. All follow-up contacts by the social worker should be carefully recorded. These records become invaluable as a basis of research into the thesis that certain treatment procedures are more practical than others, or that one technic is superior to another. Most important, only such carefully validated material as this will finally show beyond controversy or doubt the value of immediate treatment of acute mental illnesses in a general hospital setting. Besides discussing and interpreting psychiatric treatment to patients and relatives and direct therapeutic work with them, the psychiatric social worker is very well equipped to receive new patients, especially in the larger outpatient clinics. According to a study of a group of adult psychiatric clinics in New York City, patients were more discriminately selected and broken appointments were fewer in those clinics using psychiatric social workers for intake work. Although the suggestion is controversial, some departments have found that the experienced psychiatric social worker can take excellent patient histories. This function is not exercised if the chief psychiatrist feels, as many do, that taking the complete psychiatric history is an essential part of the resident physician's education. In some departments the social worker is trained to do supervised insight or supportive therapy with the patient. Whether the social worker participates directly in psychotherapy depends both on his training and competency and on the attitude of the chief psychiatrist. In many cases adult patients with psychiatric problems can be helped by casework. This is especially true of patients whose difficulties relate directly to current life problems. Nor is the severity of the illness in itself a contraindication to casework therapy, since certain schizophrenic patients "with situational anxiety often respond to it very well." Of course sound psychiatric evaluation is necessary for proper assignment of such cases. In the larger clinics and psychiatric sections throughout the country the medical student, intern, and resident receive orientation instruction in the social service field. This instruction can best be given by clinical psychologists and psychiatric social workers, whose special training best fits them to deal with the many social

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and interpersonal aspects of psychiatric disorders in hospital and clinic treatment. Problems of acculturation, of social contrasts like those between urban and rural communities, of differing attitudes and customs at varying socioeconomic levels, and of family and community life should be discussed. Social work students can also be trained in departments maintaining an experienced worker and can benefit from field experience with private patients; this is an almost unexplored field within the general hospital. As a group, social workers need to take time from the pressure of daily work to survey their scope of usefulness. They have done far too little research. It is significant that in a list of research projects being conducted in forty-one medical schools there were almost no studies in psychiatric nursing or psychiatric social work. Initiation of worthwhile research programs will greatly increase the usefulness and prestige of social service. If social workers do not accept responsibility to explore carefully by scientific research methods the varied aspects of psychiatric treatment, they will soon find the service invaded by other members of the social sciences with mimimum understanding of psychiatry's real function as a branch of medicine. The psychiatric social worker has a definite challenge to explore more fully the pioneer field of private psychiatric practice. He can, if he will, do much to obtain full public approval and acceptance of early psychiatric treatment. There is one final problem—that of providing adequate compensation. Should the hospital pay for the service, should attending psychiatrists contribute jointly, or should patients pay a separate fee for psychiatric social service? Perhaps the most practical arrangement is for the hospital to take on the service, with the idea of ultimately making it self-supporting. The support could come from the attending psychiatrists who utilize the material collected by the social worker in follow-up interviews to aid them in therapy and in their research studies, and from fees collected from the patients, to whom the worker's therapeutic interviews are a part of their continuing treatment. A need exists for pilot studies, possibly under the supervision of a university social service department, in this field.

STAFFING THE PSYCHIATRIC UNIT REFERENCES Group for the Advancement of Psychiatry. Committee on Psychiatric Social Work. Psychiatric Social Work in the Psychiatric Clinic. (Report no. 16) Topeka, Kan.: 1950. Group for the Advancement of Psychiatry. The Psychiatric Social Worker in the Psychiatric Hospital. (Report no. 2) Topeka, Kan.: 1948. Inwood, Eugene R. Therapeutic interviewing of hospital relatives, Am. J. Psychiat., 109:455-458, 1952. Rhode, Charl. Psychiatric social work in the adult mental hygiene clinic, in Education for Psychiatric Social Work: Proceedings of Dartmouth Conference. N e w York: American Assoc. of Psychiatric Social Workers, 1950.

CHAPTER 2

Training Programs PHYSICIANS' TRAINING The head of a large, reputable clinic recently estimated that 50 per cent of patients coming to his clinic "had no organic disease whatsoever; their troubles were entirely disorders of the mind." In an additional 2 5 per cent he found that the mental complication rather than the somewhat insignificant organic trouble was the real reason for seeking medical aid. Many experienced physicians agree with these estimates. Such a situation makes the general hospital the ideal place in which to teach psychiatry. Here the staff of interns, residents, and nurses can see psychiatry in its proper perspective as they come to understand the role of emotions in causing or contributing to many illnesses besides the obviously psychoneurotic or psychotic disorders. On each service psychiatric orientation and education are necessary. For example, interns, residents, and nurses on the obstetrical service, working with the psychiatric staff, become more sensitive to emotional forces in normal pregnant women and more competent in handling them. They learn to recognize minor emotional problems occurring in some pre- and postpartum women or the graver warning signs of major mental breakdowns in others. The house staff on the surgical and medical wards become familiar with toxic-delirium states. Even more important, they learn to recognize the early signs of an incipient deliroid state and to take the necessary prophylactic measures. The interns and residents on the orthopedic service learn to understand that the patient whose bones are knit but who is still unable to walk is suffering from an emotional problem. On the surgical or gynecologic wards they learn about patients whose personality disorders and emotional problems lead them to seek unnecessary surgical procedures. On the other hand, the residents in psychiatry are in constant touch with other medical activities. They are not in a walled-off medical atmosphere. Their own diagnostic acumen is thereby

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sharpened. The intern staff, of course, come to know more about psychoneurotic and psychotic disorders while rotating through the psychiatric service. They learn how somatic complaints may mask a serious emotional problem, and become familiar with special psychiatric technics. In turn, their fears and prejudices about emotional problems are dissipated. The psychiatric training program in a general hospital leads to a better integration of medicine and psychiatry. The specific program itself has two objectives: ( i ) to provide a rounded, wellsupervised course of training for residents in psychiatry; (2) to provide a program of instruction in basic psychiatric principles for interns and residents in other medical specialties. Training Psychiatric Residents Chart conferences.—These are conducted every morning, before ward rounds, by the staff psychiatrists; all psychiatric residents and interns on the service are expected to attend. The patients and their reactions of the past twenty-four hours are discussed. Particular note is taken of the new patients and their history; this provides a good opportunity to discuss the collecting, recording, and analysis of historical data, psychiatric diagnoses, and the prescription of a therapeutic program. Of special interest to the intern are discussions of the symptoms which led the family doctor to refer a patient for psychiatric care. It is often possible to describe briefly common psychiatric problems found in general practice. Ward rounds.—Rounds follow the morning conferences. Every patient is interviewed and new patients are examined in detail. This procedure gives the house staff some understanding of both the interviewing process and the mental-status examination, and thereby leads to recognition of the various reaction types. Psychotherapy and its adjuncts.—Under supervision the psychiatric residents assume actual case management of about five patients for a given period of time. This includes taking histories and making complete physical and psychiatric examinations of these patients. Analysis of the historical data then suggests a therapeutic program which the resident carries out. Throughout a year's time the resident physician gives and becomes familiar with such somatic therapies as electroconvulsive treatments, insulin coma,

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and subshock insulin. As he does intensive therapy on his hospital patients and outpatients, under supervision, he becomes familiar with technics of psychotherapy and problems of transference and resistance. Clinics.—The residents and interns, under staff supervision, attend the part-pay outpatient psychiatric clinic. Here they evaluate, treat, and dispose of cases assigned to them. They are expected to follow a selected number of patients for prolonged therapy, to do some goal-limited psychotherapy, and to make only diagnostic evaluation on other patients. The psychiatric staff also attends the other outpatient clinics that are part of every general hospital. The liaison between the various clinics provides further study and training in psychosomatic problems and is a most valuable means for integrating psychiatry into medicine and for teaching psychiatry as one medical specialty among others. Seminars.—Seminars are held daily by the teaching staff for the residents and interns in psychiatry. In these seminars clinical case material is so presented that psychopathology, dynamics, and therapy are stressed. Once each week a conference, attended by the entire house staff, is devoted to basic psychopathology. Research.—Once a month, the residents, along with the teaching and nursing staff, attend a research conference. Each resident is encouraged to carry out some clinical psychiatric research problem designed to develop his knowledge of the procedures in psychiatric research. A journal club brings familiarity with current psychiatric literature. Because of the close association of the other medical disciplines in a general hospital, psychosomatic problems are often chosen for investigation. Typical subjects are: psychiatric treatment in the general hospital; emotional factors in nonspecific uveitis; diagnosis and treatment of barbiturate intoxication in a general hospital; a study of emotional factors in the pregnant woman. Teaching.—The senior resident is responsible for outlining a basic twenty-lecture course in psychiatry and teaching it to student nurses. Emergency service.—The emergency department of a general hospital has many psychiatric emergencies. These are covered by the psychiatric residents before the consulting psychiatrist is called in, a procedure allowing the resident to make the preliminary psychiatric evaluation and to initiate emergency treatment on his own.

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Since many persons who have attempted suicide are brought to the hospital, the resident gets particularly good experience in differentiating causes of coma and in observing various emotional patterns which lead to suicidal attempts. Consultations.—The psychiatric staff is frequently called into consultation by other services. Residents and interns participate in these consultations, which not only bring them in touch with other specialties but allow all the house staff to see the ubiquity of emotional factors in illness. T o illustrate: A 50-year-old man was admitted to the medical service for vague abdominal complaints. In the course of a series of X-ray examinations he became "uncooperative" to ordinary medical and nursing care. A psychiatric consultation demonstrated the man's agitation, nihilistic delusions, bizarre somatic delusions, and marked depressive mood, with mild ideas of persecution. Here the house staff saw how somatic complaints were the presenting symptoms that only thinly veiled serious emotional disturbance. Frequently, too, the psychiatric staff consults on patients whose behavior is bizarre following head injuries, and the resident learns to distinguish between hysterical reactions and those which have a physical origin. Training Other Residents and Interns The general hospital with a psychiatric unit and staff can also most effectively plan a program of instruction in basic psychiatric principles for interns and residents in other medical specialities. The ward rounds, consultations, and clinics provide actual experience with emotional disorders. In such a setting little didactic teaching is necessary, although if the training program allows time, some didactic work in the form of seminars and case presentations can be used. Here again the access to live material makes this a most practical course. It is suggested that interns spend at least four to eight weeks in the psychiatric section. Interns and residents in other specialties accompany the psychiatrists on their visits to patients on general floors. A t this time the importance of emotions in precipitating or contributing to illnesses is pointed out. The staff also learn the psychiatric and emotional aspects of physical disorders; for example, they learn about the

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common problem of delirium—how to recognize its early manifestations and h o w to initiate proper prophylactic therapy. T h e interns rotating through the psychiatric service attend the daily seminars; the residents in other medical specialties attend a w e e k l y seminar devoted to basic principles of psychopathology. Emphasis in these seminars is put on the psychiatric aspects of illness and the common emotional problems met with in general medical practice. F o r example, in one hospital, f o u r w e e k l y seminars w e r e held on each of the following twelve topics: common neurologic problems; bases of human behavior; problems of psychosis in general practice; problems of neurosis in general practice; doctorpatient relations; personality development; psychology of women; influence of emotions on body physiology; emotional problems of children; place of psychiatry in general medicine; psychotherapy in medical practice; psychiatry as related to other fields; sexual deviation and forsenic psychiatry were covered in t w o seminars each. W h i l e attending clinics, interns and residents in other medical specialties see many outpatients with emotional factors in their illness. A s a result of their training on the psychiatric section and in seminars they often learn to recognize and deal competently with many of the emotional reactions and their physical manifestations. T o o , psychiatric residents attending these clinics are in a good position to point out many psychiatric aspects of illness to their colleagues in other specialties. A s a case in point, a y o u n g woman patient complaining of chest pain was seen in an outpatient clinic b y several interns w h o had not y e t been in the psychiatric service. Various measures were prescribed f o r the patient's pain, including use of a stronger, tighter brassiere. Eventually an intern w h o had rotated through the psychiatric department recognized the patient's anxiety reaction with its concomitants of palpitation, shortness of breath, and chest pain, and was able to institute proper therapy. REFERENCES Cameron, D. Ewen. The American Psychiatric Association and medical education, Am. J. Psychiat., 109:704-706, 1953. Hawley, Paul R . New Discoveries in Medicine. N e w York: Columbia University Press, 1950. Psychiatry and Medical Education. Washington, D. C.: American Psychiatric Association, 1952. Witmer, Helen, ed. Teaching Psychotherapeutic Medicine. N e w York: Commonwealth Fund, 1947.

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NURSING EDUCATION Marion E. Kalkman, R.N. Assistant Professor of Psychiatric Nursing, University of California, School of Medicine, San Francisco

The psychiatric unit of a general hospital offers excellent opportunities for teaching psychiatric nursing. As a part of the total hospital set-up and one of the essential departments or services of the hospital, the psychiatric unit does not have the disadvantages of seeming remote and different—qualities that are commonly ascribed to institutions which care for psychiatric patients exclusively. The fact that the psychiatric unit is regarded as an integral part of the total treatment facilities of a modern hospital is extremely helpful in the education of medical personnel who are getting their first introduction to psychiatry and psychiatric patients. It gives the students a kind of emotional security to receive this instruction in the same setting as that in which they receive training in other medical specialities. Patients admitted to the psychiatric unit of a general hospital for treatment are usually acute cases who are likely to respond to treatment rapidly or whose illness is such that they require only a short period of hospitalization. No such unit, with its limited bedspace, can afford to carry patients requiring long-term therapy. Consequently, though psychiatric treatment in general is notoriously long and time-consuming, the patients admitted to psychiatric units of general hospitals offer the student nurse the best opportunity to see change and improvement in the short space of time that she is assigned to the service. This selection of patients also helps to overcome the false impression, common among the uninitiated, that psychiatric disorders carry a poor prognosis. The best way to overcome this misapprehension is to give the student the opportunity to see patients get well and go home. Patients on the psychiatric unit often have a combination of mental and physical symptoms, or they may be patients who were originally admitted to some other service of the hospital for a physiThis is a revision of an article which originally appeared in Nursing September 1953.

Outlook,

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cal complaint and later transferred to the psychiatric service. This gives the student the opportunity to move from the known to the unknown, for by the time the student has reached the psychiatric service she is already familiar with many medical and surgical conditions and feels fairly competent to deal with these aspects of the patients' difficulties. This makes for an easy and natural introduction to psychiatric nursing. Several types of psychiatric nursing education programs are well-suited to the psychiatric unit of a general hospital. They may be grouped for convenience under three headings: ( i ) a basic program for student nurses, (2) an inservice staff program, and (3) an outservice program for other departments of the hospital. The Student Nurse Program Student nurses from the school of nursing associated with the general hospital may be assigned to the psychiatric unit as an integral part of their clinical nursing experience. Also, affiliate student nurses from other schools of nursing may be accepted for psychiatric nursing experience. Most psychiatric nursing educators feel that twelve weeks is the desirable length of time for a basic or introductory psychiatric nursing program. Not only must considerable psychiatric information be given the uninitiated student if she is to have any understanding of psychiatric patients and their conditions, but she needs time to assimilate this information, to acquire the rudiments of a psychiatric point of view, and, even more important, to make the necessary emotional adjustments in her own personality. In some university schools of nursing, courses in clinical psychiatry, abnormal psychology, and other related courses are offered before the student is assigned to the psychiatric service; psychological aspects of treatment have also been integrated into other clinical areas such as pediatrics, obstetrics, and psychosomatic medicine. In these schools the period of student experience on the psychiatric service may be shortened to two months. For the three-year nursing school program, however, in which the student does not have a psychiatrically oriented program, three months' experience on the psychiatric service is recommended. The introduction of a student-nurse program into a psychiatric unit carries with it certain responsibilities. Students must have oppor-

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tunities to learn from experience and must be taught and supervised by qualified personnel. They should have access to charts, case histories, library facilities; they should be able to attend some of the staff conferences, ward rounds, clinics, and lectures; their assignments should include different types of patients. Although students may contribute a great deal to the amount of nursing care given to the patient, they should not be depended upon to carry the load of patient care nor should they be required to perform routine activities beyond the point of learning. That is, they should not be used to relieve the regular personnel of monotonous ward duties. It is usually desirable not to have student nurses work after the evening activities have been completed and the patients go to bed, since learning opportunities are then minimal. Even more important than the provision for learning by experience is the presence of adequately prepared personnel. Students learn psychiatric nursing more quickly and effectively if they can observe it being practiced by competent psychiatric nurses, aides, and attendants. A qualified staff that works well together as a team is a necessity before students can be introduced to the unit. The psychiatric nurse who is responsible for the student program should be chosen carefully. If the psychiatric unit is a small one consisting of one 12 to 16 bed ward and if there will be only a few students (not more than eight), the psychiatric nurse supervisor may also function as the instructor. This, however, takes an experienced supervisor who is able to see that neither the patients nor the students suffer from lack of attention. Even an experienced supervisor faces the ever-present possibility that a ward class or a student interview may be interrupted or even cancelled because of some unforeseen situation arising on the ward. A generally more satisfactory plan is to take a few more students and have a qualified psychiatric nursing instructor responsible for the student program. One instructor can give adequate instruction to fifteen or twenty students. With more than twenty students, additional instructors should be employed. Even when an instructor is responsible for the student program, the ward supervisor and head nurse play an important role in the student educational program. The instructor is responsible for the student records, attendance, contacts with the nursing-school office, and the student health service. She must also outline the curriculum,

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arrange for lectures, teach the classes in psychiatric nursing, assign students to wards, classes, and other educational activities, check experience records and evaluation reports, and hold individual conferences with students. But the nurse who observes most closely the students' contacts with patients is the head nurse on the ward, and it is consequently important for her to be interested in students, and willing and able to teach. Though her teaching is often very informal and is imparted in small discussion groups or on-the-spot supervision, it is nevertheless extremely valuable to the student and cannot be delegated to the instructor, for no one can know the details of the patients' care as does the head nurse. A hostile head nurse or one unable to communicate her skills to a student nurse can seriously hamper an educational program. Good staff nurses are also important to an educational program since they can demonstrate to the student nurse good psychiatric nursing in action and also help the student in her first contacts with patients. Students should always be supervised by a graduate nurse and not be assigned to work under a psychiatric aide or attendant, though the student may learn much from observing skilled aides. In some psychiatric units, students are assigned to work with designated staff nurses for a few days before working with patients independently. It is difficult to estimate the number of students that can be accommodated on a psychiatric service. This depends on the variety of conditions demonstrated by the patients, the variety of treatments available and the number of special departments within the service —occupational therapy, physical therapy, outpatient service, somatic therapy, neurosurgery and so on. A 30-bed unit consisting of only one ward with the same type of patients and therapy could accommodate far fewer students than a 30-bed unit of three 10-bed wards, with patients of varied psychiatric conditions receiving different kinds of therapy. It is important that there be sufficient permanent members of the staff to maintain a therapeutic ward milieu and give the patients a sense of security and continuity of nursing care. Certain advantages of introducing a student-nurse program into a psychiatric unit more than compensate for the expenditure of money for the instructor's salary and for the time spent by the staff in teaching. Among the most important is the effect such a program

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has on the patients and the permanent staff. Every member of the staff, from the chief of service to the kitchen maid, responds to the interest, lively curiosity, and youthful enthusiasm with which students approach this new and fascinating experience. Suddenly, work which a nurse may have been doing for years in a competent but routine fashion becomes fresh and interesting as she attempts to present it to young students. Their questions make her constantly reevaluate material which otherwise would remain undisturbed in the back files of her mind. N e w ideas, new ways of doing things are tried: current articles in professional magazines are read by the staff more frequently to find material for the students. A teaching program makes for greater mental flexibility in the staff. Students are important to the patients too. T h e y often find students easier to talk to and prefer to engage in social activities with them rather than with the more psychiatrically sophisticated staff, with whom they are always more or less on guard. Students change fairly frequently, which means new faces and new personalities. From student nurses the patients can often get extra attention that the busy ward personnel are not always able to give them, and they often feel freer to make requests of the students than of the staff. Patients may become very much interested in the student program; often they like to tell an instructor about a particular student who they feel is doing a good job or whom they particularly like. In planning the educational program for the undergraduate students one should neither include too much in the curriculum nor stress the most infrequent or most pathological aspects of psychiatry. The majority of students will be going into fields of nursing other than psychiatry, and need particularly to learn to recognize the more common forms of mental disorders, and to gain skills in psychological nursing which they can apply to any patient, whatever his diagnosis. T o be sure, if one has planned a good basic program, a student who has completed the program should have acquired enough skills in psychiatric nursing to be employed as a staff nurse in a psychiatric facility. She should understand, however, that to continue psychiatric work in a professional capacity she will need either inservice training or an advanced psychiatric nursing course, or both. T h e programs offered under the auspices of the United

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States Public Health Service in many of the country's leading universities are especially good. Many psychiatric nurses give credit to their basic psychiatric nursing program for inducing them to become psychiatric nurses. Psychiatric hospitals that have a nursing educational program have less difficulty in getting and keeping an adequate staff of graduate nurses than other institutions, not only because many former students apply for positions after graduation, but also because other graduate nurses like to work in the progressive, stimulating atmosphere that pervades a teaching institution. One final problem in any student-nurse program is the provision of adequate housing facilities and a good housemother for affiliate student nurses. Such a housemother should be aware both of the problems the student has as a growing adolescent girl, with her possible attendant homesickness and loneliness, and of the problems related to her psychiatric experience. The student is often emotionally shaken by some of the problems which she encounters in her contacts with patients. The subject matter of her lectures and classes in psychiatric theory and her growing awareness of her own emotions and personal conflicts often create considerable anxiety. An understanding housemother can herself do much to help the student with these difficulties, and she should also be able to recognize when a student needs professional help from a psychiatrist. A psychiatrist who is interested in students and their problems should be available to such students as need his help. Perhaps only one or two students in each group would require psychiatric help but they might benefit greatly from an interview or two with a psychiatrist. Inservice Education Program

Rarely can an institution completely staff its wards with experienced psychiatric personnel. It is necessary for most units to employ nurses and aides with varying degrees of psychiatric knowledge and skill —including some individuals without any previous psychiatric experience—and it is therefore imperative to have some type of inservice educational program. Inservice training can be given in many ways, depending upon the administrative organization of a given unit and the particular problems of the staff. Sometimes it is a matter

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of giving the staff a good background in psychiatric theory, or filling in gaps in previous experiences, or getting a staff to accept newer and more modern techniques; sometimes it is none of these but rather a matter of teaching the staff some principles of supervision and administration and helping them to learn to work together more effectively. In the psychiatric unit of a general hospital, the problem of the nurse or aide who has had no previous experience in psychiatry is a common one. Often individuals who have been employed in some other service of the hospital are transferred to the psychiatric unit. Such persons need careful and comprehensive orientation to both ward and patients, given them by the head nurse (or her assistant, if she has one) before they are given a working knowledge of psychiatry and psychiatric nursing. If a student program is already established, it may be possible to work the new staff nurse or aide into some of the student classes, such as the lectures in psychiatry, demonstrations in hydrotherapy, attendance at staff conferences, and ward rounds. Sometimes it is possible for the new staff nurse to attend the classes in psychiatric nursing which the instructor gives the students, but it is usually better to arrange for separate instruction in psychiatric nursing for staff nurses and for aides, because their ward duties and problems with patients differ, and instruction given by the ward supervisor rather than by the instructor is often more useful to them. In the absence of a student educational program, the supervisor of the unit is usually made responsible for the entire program and for arranging the necessary classes and instruction. Another important aspect of the inservice training of the inexperienced staff member is rotation through all the services and departments related to the psychiatric unit before he is given a permanent assignment. In order to function most effectively, the new employee needs to get an over-all picture of the treatment facilities. Periodic discussions with his supervisor about his potentialities, progress, and short-comings based on evaluation of his work by the supervisors on each of the wards or departments during the critical learning period often make the difference between a competent employee and a failure. The second group of nursing personnel who need an inservice educational program are those staff members with varying degrees

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of psychiatric experience. This group is most often neglected in the total educational program. Student nurses are on the service primarily for education; the new employees must have instructions to function safely and effectively; but for nursing personnel who have worked for some time either in their present staff position or on the staff of some other institution, an educational program has often not been regarded as necessary. This group constitutes the backbone of the nursing service. They have close and prolonged contacts with patients. Student nurses, residents, and interns come and go, but they remain. It is they who create the psychological environment, the milieu, in which the patients live. They carry out the instructions of the psychiatrists and maintain the policies of the administration; yet, generally, little or no attention is given to what they know of psychiatry or what their attitudes are, until the rigid ideas of a nurse or the superstitious beliefs of an aide succeed in frustrating the psychiatrist's efforts in treating a patient. Unless an educational program is provided in which such problems can be discussed with staff nurses and aides, it will be impossible to provide effective therapy for patients. The purpose of such a program is not so much to impart psychiatric information—though keeping abreast of modern psychiatric developments should not be neglected—as it is to modify untherapeutic attitudes, to acquaint the staff with the rationale of psychiatric treatment used in the unit, to pool the experience gained in other institutions, and to agree on what could be used profitably in theirs. Didactic or formal methods should not be used in teaching staff personnel. Such methods are often misinterpreted as attempts of the instructor to make the personnel appear stupid or inferior. Informal discussion groups led by the ward psychiatrist or the ward supervisor are much more satisfactory. Problems of dealing with individual patients, ward problems, questions about existing orders, or suggestions regarding new or needed orders may be discussed profitably. Such discussion allows an exchange of information about patients and helps develop new ideas about how to deal with a nursing problem. It also serves as an outlet for pent-up feelings of irritation and frustration which the staff have accumulated, and gives them a feeling of being supported by the psychiatrist and the supervisor. Ward conferences which all the ward personnel can attend are very valuable for the permanent staff. At these conferences, the

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patients, ward problems, and problems of interpersonal relationships among staff may be discussed. Staff members should also be encouraged to attend staff conferences and special lectures whenever possible. Head nurses, instructors, and supervisors also need some type of inservice educational program. It is difficult to make specific suggestions regarding this group because much depends on the number of nurses on the supervisory staff and their psychiatric background. If the unit has, for example, only one head nurse and one instructor, further educational growth may come from meetings with the supervisory staff of other departments. The psychiatric supervisors in nursing, social service, occupational therapy, and clinical psychology, may participate in the psychiatric unit's journal club, and should be encouraged to attend nursing-school faculty meetings, meetings of head nurses of the general hospital, meetings of professional nursing organizations, and psychiatric institutes and meetings. If the staff consists of several head nurses and supervisors, head-nurse seminars should be organized. Members of the group should plan their own programs, which may include single sessions of speakers on special subjects or a planned course of study of some aspects of psychiatric nursing; the systematic review of current psychiatric articles and books is a program well suited to such a group. Discussions on problems of supervision on a psychiatric unit—problems which are somewhat different from those in general nursing supervision—and discussions on the teaching aspects of psychiatric nursing are always helpful. Outservice Educational Program The psychiatric unit has a definite responsibility to the nursing services of other departments of the hospital: it should not only set the standards of psychological nursing care in the hospital, but it should also be a source of information and assistance when psychological problems in nursing care arise on other services. It can do an important educational job in helping to overcome the fear and misunderstanding that most nurses unfamiliar with psychiatric nursing have about psychiatric disorders. When a psychiatric unit is first opened in a general hospital, the most common reaction is to give it a wide berth, as though it

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harbored patients with some peculiarly virulent contagious disease. A little later, it becomes a wonderful place to which one can temporarily send patients who suddenly become psychotic during hospitalization. Soon the nursing staff may discover that difficult, neurotic patients or troublesome patients with personality disorders can often be permanently transferred to the psychiatric unit where "the nurses are better equipped to handle such cases." This referral of all psychiatric nursing problems, flattering as this may be to the psychiatric unit, is neither practical—because of the limited number of beds available on the psychiatric service—nor is it a healthy state of affairs for the rest of the hospital nursing service. Therefore some educational plan for the general hospital nurse needs to be evolved. The student nurse is often an excellent psychiatric missionary to the older, more experienced graduate nurse who has had no psychiatric training. The student who has completed her psychiatric service writes more observant notes on the clinical charts when she returns to other clinical services. She is likely to note signs of depression, suicidal trends, evidences of hallucinations, delusions, and other psychopathological symptoms, as well as to comment on the patient's reactions to medications and treatments, and thus bring psychological observation to the attention of the graduate nursing and medical staff. Many head nurses, pleased with the improved clinical notes and the increased sensitivity to the patient's emotional needs, encourage the students. Some, however, unaware of the significance of the students' psychological observations or conscious of their own lack of knowledge in psychiatry, may ridicule the student, so that she is discouraged from putting into practice what she has learned during her psychiatric experience. If the student is to integrate what she has learned on the psychiatric service into her general nursing care, it is important that the nurses in the general hospital have some understanding of psychiatric nursing or at least some sympathy with the psychiatric point of view. The National League of Nursing Education has for a long time recommended that a special psychiatric nurse be employed on the nursing faculty of every school of nursing to assist the other clinical services with the psychological problems that arise on their services, or to point out psychological aspects of nursing care that are being overlooked. Another practical method is to have the instructor or the supervisor of the psychiatric unit talk to the general staff nurses

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periodically at their meetings. Generally those aspects of psychiatric nursing which the general staff nurse encounters in her patients prove more interesting and helpful than discussions on purely psychiatric conditions. There is an awakening interest among nurses in the so-called psychosomatic illnesses. The psychiatric nurse could be of great assistance to her colleagues in nursing regarding the care of these patients. Films such as Emotional Health, produced by McGraw-Hill Films, The Feeling of Rejection, The Feeling of Hostility, Overdependency, produced by the National Film Board of Canada, can often be used to good advantage, particularly if an opportunity is given for discussion afterward. A film made specifically for affiliated psychiatric nursing students, A Nurse's Day ivith the Mentally III, by A. E. Bennett, E. A. Hargrove, and June Eaton, is available from Psychological Cinema Register, State College, Pennsylvania. In some psychiatric units it might be possible to work out opportunities for direct observation and experience for those graduate nurses without previous psychiatric training. Perhaps an orientation period of a week, or a twelve-week period of instruction and experience similar to that given the undergraduate student nurse might be developed. This latter course should carry academic credit if possible. The psychiatric unit can often utilize special events such as the opening of a new ward, a tea in honor of a new instructor, the demonstration of new equipment, or a special lecture or conference to break down the barriers between psychiatrically oriented and nonpsychiatrically oriented nurses. Any of the nursing education programs that have been discussed here could be instituted in a well-organized psychiatric unit of a general hospital without too much difficulty. These programs, however, do not exhaust the educational opportunities of such a unit. Many problems in psychiatric nursing urgently need to be investigated. Nurses must be found who are willing to advance the skills of psychiatric nursing, as well as nurses who are eager to do some research in the field. It does not take a large number of patients to make a good teaching and research laboratory. But it does take a nurse with imagination and creative ability to see the educational potentialities in such a unit and to develop them.

TRAINING PROGRAMS REFERENCES

Babcock, Charlotte G. Emotional needs of nursing students, Am. J. Nursing, 49:166-169, 1949. Barrett, Mary V. An inservice educational program for nurses, Am. J. Nursing, 51:388-391, 1951. Barton, Walter E. The nurse as an active member of the psychiatric team, Am. J. Nursing, 50:714-715, 1950. Beck, Sister M. Berenice. Is more education necessary? Am. J. Nursing, 51:207-208, 1951. Bixler, Elizabeth S. Psychiatric nursing in the basic curriculum, Ment. Hyg., 32:89-101, 1948. Cameron, D. Ewen. General Psychotherapy. New York: Grune & Stratton, 1950. Chapter 12, Nursing Psychotherapy, pp. 207-288. Ellis, Albert and Earl W. Fuller. The personal problems of senior nursing students, Am. J. Psychiat., 106:212-215, 1949. Haigh, Gerald. Staff conferences make a difference, Mod. Hosp., 69:74-75, October 1947. Kalkman, Marion E. Psychiatric principles applied to general nursing care, in National League of Nursing Education. Annual Report, 1948. New York: [1949], pp. 146-152. The psychiatric affiliation, Am. J. Nursing, 47:399, 1947. What the psychiatric nurse should be educated to do, Psych. Quart. Supp., 26:93-102, 1952. Mereness, Dorothy. Meeting the students' emotional needs, Am. J. Nursing, 52:336-338, 1952. Preparation of the nurse for the psychiatric team, Am. J. Nursing, 51:320-322, 1951. Naes, Estelle B. Clinical courses for graduate nurses, Am. J. Nursing, 52:338-399, 1952. Reiter, Mary. Educating adolescents to become nurses, Am. J. Nursing, 47:117-120, 1947. Stevens, Leonard F. and Pauline L. Bombard. A training program for psychiatric aides, Am. J. Nursing, 52:472-476, 1952. U. S. Public Health Service. Training and Research Opportunities under the National Mental Health Act. (P.H.S. pub. no. 22) [Rev.] Washington, D. C., Govt. Printing Office, 1954. Wallace, Grace. Joint planning for the psychiatric affiliation, Am. J. Nursing, 51:409-410, 1951.

CHAPTER 3

Administration A. E. Maffly, F.A.C.H.A. Administrator of Herrick Memorial Hospital, Berkeley; Lecturer in Hospital Administration, University of California and Columbia University; President, Western Hospital Association

Agnes Watty Boyle Assistant Administrator, Herrick Memorial Hospital

The fast-growing power of medicine to prevent or reduce suffering and to increase well-being and longevity has made the general hospital a tremendously important health center in the community. This responsible position makes it necessary for the hospital to develop strong leadership and to provide health services for all classes and groups in its locality. Quite as much as governmental institutions and organizations, private general hospitals and voluntary health insurance plans have a social obligation to provide care, treatment, and protection of mental patients, who, too often at present, are shunted off to state mental institutions or even to jails. Private mental hospitals, in most areas, are too few and scattered and too costly to care for more than a limited number of acutely ill mental patients. What deters hospital boards of trustees and administrators from providing facilities for mental patients along with the traditional medical, surgical, and obstetrical services? Some administrators state that a psychiatric unit is relatively expensive to install and maintain. A Kentucky administrator calls the psychiatric unit the most expensive department in his hospital. Another official says that the unit produces problems in public relations because the community does not recognize or appreciate the role of psychiatric service; the police and other community agencies often regard the unit as a catch-all for difficult cases, from drunkenness to family quarrels. It is not unusual for staff members to complain about lack of beds for medical and surgical patients, and blame

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the psychiatric unit for the shortage. A n occasional patient may object that noise from psychiatric patients disturbs him. Again, administrators say that psychiatrists demand too much special attention: surgeons have often had the reputation of dictating all affairs in their department, now psychiatrists require equally stringent conditions and rules. Some psychiatrists feel on the defensive; because all general hospitals do not have psychiatric units they continually feel the need to justify to both hospital and public the values of psychiatric service. This means that the psychiatric unit does not settle down into its proportionate place in the total administrative picture, according to certain critics. Administrators also hear complaints from residents and interns that psychiatric teaching is less definite, concrete, and practical than is instruction on other services. In contrast, other persons, both physicians and lay officials, urge the inclusion of mental patients in general hospitals without realizing the extent of the task. N o t only is it a considerable job to create a psychiatric department, but to manage and maintain it requires constant work. Experience has shown that a unit is not feasible or financially practical with fewer than 15 beds. Almost the same number of personnel can care for 20 as for 10 patients. Other costs of care and maintenance do not differ greatly. For example, the initial outlay varies little for small or medium-sized units. It costs about the same to equip suitable quarters for the mentally ill whether the unit accommodates 10 or 20 patients: yet in the latter case the income is double. One still has to install safety windows; set up a self-contained unit with nurses' station, dayroom, and recreational facilities, and maintain a closed section with locked doors to facilitate careful supervision of acutely ill psychotic patients. It is always wise to study the local situation carefully. Trained observers estimate that the ordinary community of seventy-five to a hundred thousand population can easily support a 2 5-bed psychiatric unit in a general hospital. Yet as late as 1948 the San Francisco Bay Area, with about a million inhabitants, had no psychiatric unit in a private, nonprofit general hospital. Indeed, no hospital in the whole state of California had then such a unit except for a university teaching hospital and the various governmental institutions that are

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forced to admit patients for temporary care, pending admission to state mental hospitals. In presenting plans for a psychiatric unit the chief psychiatrist should outline full details of the service. Staff members, nurses, and other personnel should have full opportunity to raise questions and objections both before the decision to equip a unit is made and before the unit is opened. In discussion meetings it can be pointed out that 15 to 25 per cent of the patients in any hospital are partially or totally disabled because of emotional or personality disorders. The fact that the fundamental psychiatric aspect is ignored and goes untreated serves to increase the demands for medical and surgical beds without ever going to the core of the patient's problem and effecting permanent recovery. Staff members can be shown by competent medical authorities that operation of a psychiatric department raises the standards of all medical care by providing accurate diagnosis and suitable treatment for psychologically motivated disorders. A t the same time, the equipment of the general hospital is available, without costly duplication, to give mental patients adequate medical and surgical care. Denning's research project showed that the presence of a psychiatric unit permits more rapid diagnosis and treatment of patients on general floors, thereby reducing the general patient's stay by an estimated three days. The hospital administrator thus sees that all departments benefit by the inclusion of psychiatric service. It is explained that only patients with acute early mental disorders are admitted, as a rule, in order to conserve the supply of beds. These patients are selected according to prognosis—the evaluation that they can be socially rehabilitated in a relatively short period. Chronic or custodial patients are not accepted, just as tuberculous, arthritic, or other chronically disabled patients who need long term care are not admitted to the medical wards. Experience in psychiatric departments has shown that the following types of patients can be admitted and treated with good success: those with psychosomatic disorders or severe psychoneuroses that result in serious disablement; affective disorders, including depressive or elated reactions; early schizophrenic disorders that respond to one or another form of shock therapy; organic psychotic reactions due to brain disease or toxic deliria; and a miscellaneous group that includes childhood behavior problems, psychomotor

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states, epileptic equivalents, and selected alcoholic or other drug addictions. About three-fourths of the patients admitted to inpatient services undergo such physiologic treatments as shock therapies, lobotomy, and other medical therapies, in addition to psychotherapy and the "total push" treatment of a psychiatric ward. Results of treatment in an adequate department show that 80 per cent of all patients recover fully or to such degree that the individual can lead a normal business or professional and social life. Of these, some 25 to 30 per cent recover socially but require further specialized treatment for symptoms and for social rehabilitation. Some 5 to 10 per cent do not improve and eventually become chronically disabled or have problems of such severity that they require long-term treatment or custodial care. These patients must then be committed to state hospitals, since few are able to afford private mental hospital care. Financial considerations to the patient.—General hospital administrators must be prepared to answer the contention that psychiatric care is too expensive for the average family. True, psychiatric care in the general hospital is expensive, but not disproportionately so. In many psychiatric departments the average patient remains four to six weeks. Compared to the period required for an appendectomy or an uncomplicated obstetrical case, this time may seem unduly long. Modern medical and surgical treatment and hospital care have shortened hospitalization from months to weeks or even days. Psychiatric advances have similarly reduced duration of treatment, and can be expected to accomplish much more as therapy improves in this relatively new field of medicine. An added difficulty is the lack of adequate health insurance protection. By far the most popular method of amortizing hospital expenses in the more common medical and surgical cases is hospital insurance, either on a service or indemnity basis. In the ordinary hospital about 75 per cent of all patients have some type of insurance. At present this service is denied to psychiatric patients in many states, and the only plans to cover mental illness are provided by private commercial insurance companies. Psychiatric illness is as much a disease as is pneumonia, and can be as accurately diagnosed and in most cases as effectively treated. As an illness or disabling disorder, mental disease should be and eventually must be covered

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b y the various hospital insurance plans. This coverage will remove what is perhaps the final barrier to greater utilization of psychiatric departments in general hospitals. Most hospitals establish a flat rate f o r room and care of psychiatric patients that compares closely with the rate f o r similar accommodations for other patients. Laboratory fees, shock treatments, administration of insulin and other special medications are extra, just as are ancillary services to medical and surgical patients. Because most patients are hospitalized f o r at least a month, it is common to ask for an advance payment of $100 to $150 whenever possible. T h e fact that the hospital bill alone in these admissions can reach or exceed $500 exerts great economic pressure to get the patient out of hospital as soon as possible. In part this can be accomplished b y wider use of outpatient therapy similar to the day hospital plan discussed b y Doctor Cameron in chapter 8. This method of treatment markedly reduces hospital costs and frees the beds f o r a larger annual turnover of patients. Many patients who must be treated at first on the closed ward become so cooperative that they can be sent home and returned for outpatient treatment as indicated. When this is not possible, and the economic burden proves too heavy f o r the family to bear, psychiatrists should recommend transfer of the patient to a state hospital, on a voluntary basis whenever possible. Many families insist upon private care rather than state hospital care, then find they cannot aiford to continue treatment. Denning's research study showed great savings to the community from a psychiatric unit in the general hospital. H e found that such treatment reduced or eliminated bills f o r unnecessary surgery, laboratory tests, and prolonged observation; prevented much chronic psychiatric illness, with its resulting dependency and welfare problems; eliminated carrying on administrative and dispositional measures by mail; eliminated transportation expense to distant hospitals; reduced distress of patient and family upon his removal from home; and minimized his readjustment to the community upon his return, since his social and economic status was less threatened. Hospital costs of operation.—One psychiatric unit, during its first five-year period, starting with 10 beds and increasing to 30 beds, found that fees paid b y patients comfortably support the costs of operating the unit. This department, in a general hospital of about

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200 beds, gradually assumed its share of the remodeling and operating costs, and now compares favorably with other self-supporting medical departments. Recent figures computed under the Government Reimbursable Cost Formula for a hospital of this size in the same area, including the psychiatric department, amounted to $31.44 per patient per day. The usual patient in this hospital pays $25.00 a day. Psychiatric patients offer greater collection problems than do other patients, because they stay longer and their bills are therefore higher, they are not usually covered by hospital insurance plans, and their illnesses do not as a rule constitute compensable injuries. For these reasons it is best to insist on an initial advance and to arrange for as large advance payments as possible throughout the patient's stay. Bills should not be allowed to run for a long period after the patient's discharge. Prompt and careful collection methods keep losses on psychiatric patients to a minimum—in many hospitals, smaller than on patients in other departments who do not have insurance coverage. Denning finds that psychiatric units have proved to be selfsustaining, and that most show a profit. Census is uniform, with consequent increased annual revenue, and psychiatric units have as a rule the highest percentage of occupancy of any service. Mental patients are mistakenly assumed to be indigent; in 1947 half of all persons admitted to state hospitals were listed as "marginal" or "comfortable" in economic status. Administrators often object to the risk of malpractice and other liability suits connected with operating a psychiatric department. On the average, the malpractice and liability insurance rates compare favorably with rates on the same number of patients in other medical departments, and the general hospital can obtain more adequate, reasonable insurance coverage than the private mental sanitarium. T o be sure, this problem may become more serious in the future, unless the courts reverse their present trends of holding hospitals responsible for accidents. The American Psychiatric Association is now carefully studying this problem. Chapter 6 contains a discussion of ways in which to protect patients and guard against accidents. The inclusion of a unit, and the more complete service thus provided, also aids fund raising. Some citizens become interested in

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the work of the psychiatric department and wish to contribute toward its support. Mental hygiene societies increase public understanding of the service. Inclusion of a unit has often been an advantage in applying for Hill-Burton funds. The act specifies that five types of hospital facilities shall be financed for construction: general hospital beds, psychiatric beds, chronic beds, tuberculosis beds, and health centers. It sets a standard of one psychiatric bed for every 220 persons in a community, which means that a need for approximately 300,000 new beds for mental patients is recognized. The physical facilities for a psychiatric unit in a general hospital are discussed fully by Guttersen in chapter 4. Here it suffices to say that many hospitals already have a secluded wing or section that without too much difficulty can be converted into a closed unit. Often a group of rooms elsewhere can be adapted to serve as a small convalescent ward. Rooms inside the closed unit, with the obvious exception of seclusion rooms, resemble those in the rest of the hospital. T h e y need to be comfortably furnished, with attractive designs and colors. Extra space is needed for dayrooms, dining, occupational therapy, and recreation. The main distinctive feature of the psychiatric department is that most of the patients are ambulant, and as a rule are confined to their beds for only a small part of waking hours. Provisions must therefore be made for the comfort of the ambulatory patient. Several economies are possible in a department. A small diet kitchen can be arranged in which ward attendants fill trays from a heated food cart and serve them to patients in the community dining room. Men and women eat together at small tables. Excellent food, appetizingly served, is important, and helps greatly in promoting real sociability. The dining room may well double between meals as the recreational and even the occupational therapy room, although the latter needs special stationary equipment, and supplies are more easily stored and distributed in a separate shop. Heavy equipment can be placed in one room, lighter equipment in another. Adequate lavatory and toilet facilities for both patients and personnel and bath and light-laundry facilities for patients can be provided in a relatively small, centralized space. These features are fully discussed in chapter 4, as are examination, treatment, and con-

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sulfation rooms. A sitting room where convalescent patients may see visitors can well be situated in the open part of the unit. Personnel.—Since chapter i discusses adequate staffing of the unit it is necessary to comment on only a few aspects here. Administrators must understand that auxiliary personnel such as aides and orderlies require special training and orientation and therefore cannot be rotated through the hospital, as those in other departments may be. Psychiatric nurses and their assistants can help convince other nurses of the advantages of psychiatric treatment. Nursing supervisors of all departments are encouraged to visit the psychiatric department and to observe the progress of treatment. The occupational and recreational therapist, even with limited equipment, is able to arouse the patients' interest and attention. The therapist also enlists help of nurses, students, and attendants in creating and sustaining new interests. There is considerable evidence that occupational therapy can profitably be combined with physical therapy, and a pool of therapists maintained to serve in rehabilitation of other hospital patients besides psychiatric ones. Medical disabilities caused by arthritides, poliomyelitis, and industrial accidents are an example. The increasing high degree of specialization among therapists, however, makes this application difficult. In the same way, medical social workers have a training different from that of psychiatric social workers. The psychiatric department can be the most efficient department in the hospital in obtaining maximum utilization of personnel, because as a rule its percentage of occupancy is always uniform and at or near capacity. Transfer of personnel is handled as in other hospital departments. Legal requirements.—The general hospital instituting a psychiatric department must meet several legal requirements. The unit must comply with all laws covering general hospitals as such, and in several states the hospital must obtain a special license to cover the psychiatric unit. As admission to the psychiatric department of a general hospital is on a voluntary basis, it is essential that the patient's family stand back of the physician in keeping the patient in the hospital for the optimum treatment period. This is most important, since very few

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hospitals allow mental patients to have visitors during their earlyperiod of hospitalization and treatment. If the family accepts these stipulations and cooperates with the physician and hospital, treatment can proceed in an orderly way, and much benefit can usually be obtained. However, the patient and his family always have the right to withdraw the patient from the hospital. When treatment is unsuccessful or terminated for financial reasons and it becomes necessary for the patient to enter a state institution, the hospital should in every way facilitate the patient's transfer. Here several reforms are badly needed, particularly in methods of easy transfer, that will establish a good working relationship between committing court boards, state hospitals, and general hospital psychiatric departments. From time to time interested groups have drawn up model commitment laws. Present state laws, in their effort to safeguard the individual's rights and prevent improper commitment, so restrict commitment procedures as to work real harm and injury to the mentally ill patient and seriously to delay his admission and treatment in a state hospital. Bowman has cited the case of a California man who was depressed and had delusions that persons were trying to kill him. Following the necessary routine his wife swore out a warrant and the sheriff arrested and took the patient to the county jail where he was to await court hearing. That night he hanged himself in the jail. His legal rights were well preserved, but the patient was not. Civil rights are very important, but not more so than health and life. It should be possible for a patient to be transferred to a state institution upon competent psychiatric certification. This process would eliminate arrest by policeman or sheriff, confinement in jail with common criminals, court hearing before judge and jury, other routines of criminal trials, and the stigma of insanity. Many suicides would thus be prevented. No such procedure is required for transferring a tuberculous patient to a state sanitarium where he may stay for a long period. One trouble is that most state commitment laws are obsolete and go back to a time when psychiatric diagnosis and treatment were inadequate and custodial confinement amounted to imprisonment. Hence the laws that rigidly protect individual rights to freedom. These archaic laws do much to hamper the efficient treatment

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of patients within the psychiatric department of general hospitals. Quick, easy transfer of the patient from one type of institution to the other would facilitate the continuity of treatment, save the patient and his family much suffering and disgrace, and improve standards of medical care. Under present conditions the family may unduly sacrifice their savings in order to keep the patient at home or in some private institution, rather than undergo the stigma of the patient's arrest and commitment. If the patient has improved under treatment but long-term care is indicated, the benefits of earlier treatment are lost and the patient deteriorates during the long waiting period in jail or in a county hospital until a hearing is held. Guttmacher and Weihofen, in Psychiatry and the Law, fully discuss this problem of proper transfer and commitments, as does Davidson in Forsenic Psychiatry. Overholser's The Psychiatrist and the Law recommends several forms of emergency commitment procedures and informal arrangement. Some states, like Maryland, admit the patient to a mental hospital on certificate of two physicians and detain him until he demands his release, when steps for a formal court hearing may be taken. Massachusetts, under an arrangement for temporary care, authorizes a ten-day admission to a mental hospital on the unsworn statement of a single physician or police officer or health officer. The ten-day period allows time for a decision as to disposition and formal commitment, if necessary. About half of the patients admitted to Massachusetts mental hospitals enter on this certification. Overholser vouches for the fact that these temporary observation periods were always reasonably indicated, and is convinced that "railroading" is an extremely rare occurrence. Representatives of many welfare agencies in 1952 participated in drafting a model act governing hospitalization of the mentally ill. The act aims to protect adequately the rights of the some 300,000 citizens who are admitted yearly to governmental mental hospitals, and at the same time to provide good hospitalization and medical care. Specifically, the draft act clarifies basic criteria for identifying individuals in need of hospitalization and for deciding upon emergency or temporary admissions. It permits a health or police officer to recommend commitment of a person likely to injure himself or others, with a report to be made by the head of the admitting hospital. The act allows the mental hospital to designate competent

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examiners for certificating admission of patients within a fifteen-day period. It explains the types of information that may be disclosed about a patient's confidential medical record. In short, the act amply provides for voluntary hospitalization; for admissions by medical certification, court order, and emergency or temporary procedures; for care of patients and possible transfer; and for release or discharge. The Utah commitment law, modeled on this draft act, has proved efficient and workable, according to Branch. Experience so far, however, suggests two important revisions: provision for legally authorized medical personnel to handle nondangerous but uncooperative, stubborn patients, and a regularly constituted medical authority to review state hospital admissions and investigate complaints. Rules and regulations.—The following policies, rules, and regulations were prepared by the administrative staff of a general hospital with the cooperation of the medical advisory board, the medical staff, nursing personnel, and the business office. They have been followed, with minor modifications, for some years. They may be useful to the administrator who is establishing a psychiatric unit. RULES A N D REGULATIONS FOR THE NEUROPSYCHIATRY DEPARTMENT Purpose of the Department T o provide complete neuropsychiatrie service for the diagnosis and treatment of acute emotional illness, early mental disorders and organic brain diseases. Direct Admission All new admissions must be from a qualified psychiatric specialist on the Active, Associate, or Courtesy staff. Only psychiatrists who are accredited by the American Board of Psychiatry and Neurology can attain active staff membership. Transfer Admissions from Other Departments All transfers to the Neuropsychiatrie Department must be made after psychiatric consultation with a staff member of the hospital. There must not be any emergency transfer of troublesome patients by interns. A qualified resident in psychiatry may, in emergency, make such a transfer, after consultation with his psychiatric chief by telephone, when emergency direct consultation is impossible.

ADMINISTRATION Financial A r r a n g e m e n t s for Admission

Since all admissions will be through psychiatric consultation, the admitting office will assume no responsibility. The admitting psychiatrist will call the head nurse of the department, describing the nature of the patient's problem; the nurse, in turn, will notify the admitting office and indicate how the patient is to be admitted. The business office shall insist upon financial responsibility being assumed by a responsible relative, and hospitalization cost shall be paid weekly in advance. Under exceptional circumstances, when recommended by the psychiatrist in charge, a patient may assume his own financial obligation. It is suggested that he pay for one month in advance unless the attending psychiatrist accepts responsibility for the account. Types of Patients To Be Admitted

The criterion for admission shall be recoverability. Cases with good prognosis under treatment shall have priority. N o chronic or custodial patients are accepted, except for diagnosis, and within one week, if found to be chronic or incurable, they will be transferred. Alcoholics and drug addicts are not accepted unless the patient voluntarily comes for treatment of his addiction: no emergency alcoholics who are not critically ill or coming in for curative therapy. Specific desirable types: 1. Psychoneurotic and psychosomatic disorders. 2. Affective disorders—depressed or elated. 3. Early schizophrenic reactions that are acceptable for either form of shock therapy. Selected schizophrenics for lobotomy. 4. Organic psychiatric reactions, vascular, neoplastic, traumatic, or infections that can be treated successfully. 5. Miscellaneous—childhood behavior problems, psychopathic states, epileptic equivalents, or other borderline conditions needing diagnostic or therapeutic service. Treatment M a n a g e m e n t in the Department

Criteria of ward rules—the greatest comfort, protection, and speediest recovery of the patient. Visiting.—Absolutely no visiting shall be permitted on the ward during active treatment except in cases of critical illness. The only other exception shall be upon direct order of the psychiatrist in charge, where he feels it will be to the best interest of the patient to receive visits from cooperative relatives. Such visits shall be off the ward. No telephone privileges.—If the attending doctor grants such a request, a telephone other than those on the ward shall be used. Smoking regulations.—Patients will not carry matches and cigarettesPatients will be permitted to smoke once each hour if they so desire. Rest hour periods.—Observed by all. Directed by nurse. Bedtime routine.

ADMINISTRATION Suicidal and escape precautions.—Fully explained to nursing staff. Excitement states.—No restraints will ever be permitted. Seclusion quarters and appropriate symptomatic treatment shall be sole method employed. Consultation by head nurse, attending psychiatrist, or qualified resident shall be held before instituting such measures. Treatment permit.—A signed permit to hold patient for treatment shall be obtained at admitting office. A special permit signed by patient or responsible relatives shall be obtained by the resident or attending doctor in all cases needing shock treatment. Care of patient's valuables.—Jewelry, money, watches, rings, etc., shall be put in safe keeping and a record kept by the head nurse. Occupational and recreational therapy.—To be developed within the psychiatric treatment program. Special therapy.—The attending physician must be solely responsible for special therapies. Resident physicians may not give shock therapy except under direct supervision of the attending chief. Preliminary curarization to shock therapy is required to prevent traumatic complications. Ambulating outpatients.—Although outpatient shock therapy is not encouraged, selected patients may be treated for justifiable reasons. The attending physician must be solely responsible for such treatment and some responsible relative or friend must be instructed as to its hazards and accept responsibility for delivery of patient from home to hospital and back home. Psychiatric case records.—Administrators m a y also be interested in the w a y in which psychiatric case records are handled. Because they are necessarily detailed and comprehensive, these records are difficult to keep up to date. Mechanical means f o r dictation b y residents and transcription of patients' records allow them to be transcribed in the medical record department and placed immediately in the patients' charts upon the floors. Suitable record forms have been devised and are attached to the case records, as follows: ( i ) insulin shock therapy record; ( 2 ) electroshock therapy record; ( 3 ) antabuse release f o r m ; (4) antabuse card which patient carries; (5) common-sense principles f o r the abnormal drinker; (6) summary of patient's record; (7) psychiatric card ( f o r cross-filing and statistical purposes); (8) clothing sheet; (9) psychiatric admission record; ( 1 0 ) weight and therapy chart. M a n y medical record librarians have difficulty in coding the psychiatric patient's diagnoses. T o relieve this situation it is urged that the Diagnostic and Statistical Manual of Mental Disorders, October, 1952, as approved b y the American Psychiatric Associa-

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tion, be adopted by attending and resident staffs in recording diagnoses of psychiatric-ward patients. The medical record librarian can then more easily identify and code the standard diagnoses, terms, and statistics, as recommended in the section on disease of the psychobiologic unit in Standard Nomenclature of Disease and Operation. Such standardization also greatly benefits physicians because it permits statistical studies and comparisons, along with estimates of successful and unsuccessful methods of treatment. Administrative responsibilities for psychiatric training and education.—Since education and training of professional hospital personnel is second in importance only to treatment of the hospital patient, hospital administrators must do everything possible to help develop and improve standards of training. It is here that the psychiatric department greatly influences the general hospital's teaching program. First of all, the hospital does not have to affiliate with another institution in order to obtain adequate psychiatric training of house staff and student nurses. Training proceeds within the hospital walls. Psychiatrists, psychiatric residents and nurses can also contribute greatly to the thorough training of other student personnel, such as social workers, aides, attendants. Benefits of these teaching programs quickly appear. Members of other departments become increasingly aware of psychiatric signs and symptoms among patients who have been admitted ostensibly for other disorders. Psychiatric disease becomes no stigma, and a scientific attitude toward treatment and cure arises. A teaching program should be fully approved by the Council on Medical Education and Hospitals of the American Medical Association, for rotation of intern training. Residency training programs in various specialties should be approved by the AMA and the respective specialty boards. When the available number of interns allows, they should be rotated to the psychiatric service as part of their basic training. Both psychiatric residents and rotating interns should work under the supervision of staff psychiatrists. In our hospital, an outline of the intern and residency training program, together with the list of all seminars, including psychiatric seminars, is printed annually in our house staff manual. Notices of coming psychiatric seminars are also printed monthly in the medical staff bulletin. Staff physicians and other hospital personnel are in-

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vited to these seminars, which thus serve a wide educational function. Seminars for a single month may include such topics as bases of human behavior; common neurologic problems; problems of psychosis in general practice. The general hospital should encourage research in various fields of medical endeavor. In our hospital each clinical department has its specific projects; for example, the department of medicine is carrying on a detailed investigation of cholesterol and obesity. The psychiatric unit has contributed comparative studies on the use of curare and curarizing agents, antabuse in alcoholism, carbon dioxide therapy and psychotherapy, and new drugs in psychoses and epilepsy. Resident physicians are encouraged to participate in these research projects. Community health education.—Hospital administrators and psychiatric staff should participate actively in local and state mental health and mental hygiene societies: we provide space in our hospital for the local mental health society's office and circulating library. Administrative and professional personnel should also participate in radio and television programs, and join state and regional organizations and committees that help spread mental hygiene principles. These are excellent means whereby to educate the public in matters of mental health. The psychiatric department and the hospital can protect the mental patient and control his environment only so long as he remains in the hospital. When he leaves, the burden shifts to the community, and it is here that the aid of various community agencies, and their interrelation with the hospital, greatly benefit the patient and his family. Value to hospital administrative interns and residents.—Administrative interns and residents who study at a complete general hospital before taking further academic training or before taking an administrative post at a hospital have the opportunity of observing the influences of a psychiatric department in the hospital. They may be encouraged to give papers and reports at professional meetings; some of them may base their material on the psychiatric department. The attending psychiatrists, psychiatric residents, and interns also have opportunities to educate these future hospital administrators. Lectures about the department may be held at the hospital for students taking courses in public health and hospital

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administration in nearby universities. These lectures can be given by the chief of the department. If administrators maintain good relations with the press, reporters and staff writers will often be glad to write helpful educational articles, and their understanding and sympathy can be of practical use in emergencies. For example, a prominent citizen, a patient in our department, had attempted suicide before his admission. Appeal to the city editor not to publish details of the attempt resulted in withholding the story, and facilitated the patient's return to his community upon his recovery. In summary, we believe that despite the many problems which opening and operating a department bring, the advantages are many. T h e presence of the unit broadens the concepts of the entire hospital, as every department becomes aware of psychiatric aspects of illness. T h e psychiatric department helps the general hospital to fulfill part of its obligation of protecting health and curing illness in the community. Every administrator of a general hospital should consider seriously the possibility of establishing a psychiatric unit within his hospital. Until general hospitals accept psychiatric medicine as an integral part of total patient care, we cannot hope to change the attitudes toward state hospitalization or standards of care. W h e n this is accomplished, the incidence of chronic mental cases should be greatly reduced and better care given all mental patients, whether in private or governmental institutions. REFERENCES Bennett, A. E. Psychiatry is good business in the general hospital, Mod. Hosp., 67:43-45, January 1947. Bowman, Karl M. Presidential address to the American Psychiatric Association, Am. J. Fsychiat., 103:1-17, 1946. Boyle, A. W., J. C. Heidenreich and R. T. McHugh. It's time for general hospitals to open the door to mental patients, Mod. Hosp., 78:66, April 1952. Bradley, Frank R. Psychiatric service in the general hospital; 3-year report, Hospitals, 21:45-47, January 1947. Branch, C. H. Utah's experience with national draft act for hospitalization of mentally ill, Am. J. Fsychiat., 109:336-343, 1952. Brill, N. Q. Psychiatric patients belong in a general hospital, Mod. Hosp., 68:56-57, January 1947. Commission on Hospital Care. Hospital Care in the United States. New York: The Commonwealth Fund, 1947.

j6 Davidson, Henry A. Forensic

Psychiatry.

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N e w York: Ronald Press,

Denning, Reuben H. Should the administrator organize a psychiatric unit in a general hospital? Hosp. Admin. Rev., 6:32-38, September 1953. Deutsch, Albert. The Shame of the States. N e w York: Harcourt, 1948. Ebaugh, F. G . and Charles A . Rymer. Psychiatric facilities within the general hospital, Mod. Hosp., 55:71, August 1940. Freeman, Lucy. It's Your Hospital and Your Life. (Public Affairs Pamphlet no. 187) N e w York: Public Affairs Committee, 1952. Guttmacher, Manfred S. and Henry Weihofen. Psychiatry and the Law. N e w York: Norton, 1952. Hamilton, S. W . What psychiatric service should general hospitals have? Hosp. Management, 66:29-31, December 1948; 67:72-78, January 1949. Harris, Titus H. and H. Ford. The management of psychiatric patients in a general hospital, Texas State J. Med., 33:636-640, 1938. Haun, Paul. Psychiatric Sections in General Hospitals. N e w York: Dodge Corporation, 1950. Hospital Council of Greater N e w York. The Master Plan for Hospitals and Related Facilities for New York City. [New York: 1947] Keyes, B. L., R. S. Bookhammer, and A . J . Kaplan. Psychiatry in the general hospital, Am. J. Psychiat., 105:90-95, 1948. Menninger, Karl M. The future of psychiatric care in hospitals, Mod. Hosp., 64:43-45, May 1945. Overholser, Winfred. The Psychiatrist and the Law. N e w York: Harcourt Brace, 1953. Roberts, C. A., A . F. Gough, and W . F. Mennie. Psychiatric services in general hospitals in Canada, Canad. M.A.J., 68:578-582, 1953. U. S. Public Health Service. A Draft Act Governing Hospitalization of the Mentally III. (P.H.S. pub. no. 5 1 ) : Washington, D. C., Govt. Printing Office, 1952.

CHAPTER 4

Architecture Allston G. Guttersen, A.I.A. Architect, American Psychiatric Association; Formerly Hospital Architect, Division of Hospital Facilities, United States Public Health Service

The comparatively rapid growth, in recent years, of psychiatric service in general hospitals and the changing attitudes toward nervous and mental patients are responsible for the development of psychiatric nursing units which are much simpler than those in use only a few years ago. Facilities for a large percentage of mental patients, except for day-living and recreational areas, are becoming more like those of medical nursing units of the general hospital. In at least one hospital, 75 per cent of the patients who were received, without screening, during a three-year period, were treated entirely on open medical nursing units, and the remaining 25 per cent were in the locked section, or units, only part of the time. A complete psychiatric service will provide for the reception and diagnosis of all types of patients and for the treatment of patients of favorable prognosis on a short-term basis. Facilities will be provided in both the inpatient and outpatient areas of the hospital. Inpatient services may include living and treatment facilities in a locked section for patients having periods of confusion and excitement, and an open, or unlocked, section for convalescing and dayor night-care patients. Provision may also be made for short-term treatment on medical, surgical, or other nursing units, without transfer to the psychiatric facility, of those patients exhibiting psychiatric conditions in the course of their treatment for another illness. Outpatient services will provide for follow-up care of patients who have been on intensive treatment and for early care of those who may continue to live and work in the community. It may also provide a child-guidance clinic. Many psychiatric services in general hospitals will not include all of these services, and the classifications of patients whom they will accept for treatment will vary. It is only after a careful survey

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of community needs and an evaluation of the diagnostic and treatment services which the particular general hospital can support that the number of beds and the types of services to be rendered can be determined. In the following discussion of planning, reference is continuously made to general hospitals. There is a large amount of information on current practices and standards for all elements of the general hospital, and these elements, their location, arrangement, equipping, and detailing have been generally accepted by all professions engaged in their planning and operations. The psychiatric service should be well integrated into the general hospital and may satisfactorily adopt many of its accepted elements and details. The Program When the number of beds and types of mental health services to be offered have been determined by the hospital board, a program should be developed. This program should state the patient classifications, by behavior characteristics, for which treatment is to be given, the number of patients in each classification, and the facilities, areas, equipment, and personnel each group will require in the treatment program. It should clearly state the requirements of each department, each service, and each activity in terms of desirable arrangement, major items of equipment, and personnel to be employed. T o o much importance cannot be placed on this preparatory work, as the architect cannot satisfactorily design and specify areas, traffic patterns, equipment, and materials unless he has a complete understanding of the requirements of each of the activities and their interrelation. After the program is complete, the architect will translate the information into preliminary sketches. During this period there will be much discussion of the program and the sketches. Changes may be made in both in order more nearly to satisfy the total requirements. After approval of the preliminary sketches, the architect can proceed with the preparation of working drawings and specifications. Inpatient Facilities In the design of psychiatric nursing units for general hospitals, two major divisions are recommended: (a) an open section for con-

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valescing and day patients and (b) a locked, or closed, section for patients having periods of confusion or excitement. Both divisions will need living and recreation rooms for daytime activities, though in other respects the open unit may be similar to medical nursing units. The locked section should have separate bedroom and livingroom areas for the segregation of patients of different behavior characteristics; provision should be made, whenever possible, for at least three classifications: quiet, depressed, and disturbed. In the large service, separate nursing units may be provided for each classification. In the small service, which must have both open and locked sections in a single twenty-five bed unit, it may be possible to provide only two separate areas in the locked section. The arrangement should be flexible in order that full use of all facilities may be made at all times, as patient behavior and classifications change during the treatment program. The recommended maximum size of nursing units for the closed section is twenty-five beds. The open section may have nursing units up to forty beds. The percentage of the total number of patients in each classification varies greatly in different localities and with the services rendered by the hospital; for the purpose of discussion they are here assumed to be: ( i ) convalescing patients, 30 to 40 per cent; (2) day patients, 5 to 10 per cent; (3) quiet patients, 30 to 40 per cent; (4) depressed patients, 20 to 25 per cent; (5) disturbed patients, 5 to 10 per cent. Facilities of the Nursing Units Facilities within the nursing unit may be divided into ( 1 ) patient accommodations and (2) treatment facilities. It is desirable to separate treatment facilities from patient accommodations in order to provide an appropriate environment in the patient area, as patients who are engaged in recreational or occupational therapy, or who are relaxing, should not be distracted by patients receiving special medical treatment. Comfortable and attractive surroundings in the patient area will encourage informal group discussions, occupational activities, reading, social activities with participation of families, and so on. Facilities of the patient area include: bedrooms, living rooms with closets for occupational and recreational therapy equipment,

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toilet rooms, bath and shower rooms, a patient's laundry for women patients of the locked section, a pantry, a dining room or space, and a nurses' station. Facilities of the treatment area of the small service include: psychiatrist's office and interview room, medical-examination room, psychologist's office, and a visitors' room. A room for continuousflow-bath and pack treatments may also be included though neither treatment is used as much as formerly and opinions vary as to the need for such a room in the small unit. In the larger service the additional facilities which are required may serve more than one nursing unit. There should be at least one interview room, for use by psychiatrists, psychologists, and psychiatric social workers, for each ten patients. Receiving and special-treatment bedrooms, insulintreatment suites, and a staff conference room are also desirable. Facilities in the nursing units which should be convenient to both the patient area and the treatment area are: utility room, linen closet, supply closet, janitor's closet, stretcher closet, patients' clothes room, and attendants' toilet.

Bedrooms Two-bed rooms may be used in the open section for the convalescing patients, and some may be specified for quiet patients of the closed section, though approximately 60 per cent of the beds of the closed section should be in single rooms. Single rooms are required for disturbed patients; single and four-bed rooms are desirable for depressed patients. In general, two-bed rooms are unsatisfactory on the psychiatric service, except for convalescing patients. One-bed rooms, two-bed rooms, and four-bed rooms for the open section should be similar to those for medical and surgical nursing units, except that cubicle curtains should not be used. Bedrooms for the closed section should be designed in accordance with the principles of psychiatric safety. There should be no projections of structure, piping, or sharp corners on which an excited patient may injure himself. A simple room, every part of which can be seen at a glance, is desirable. Eighty square feet per bed in two-bed and four-bed rooms and one hundred square feet in single rooms is the minimum desirable size. Approximately 10 per cent of the bedrooms for quiet patients should have a private bath

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with tub, as these will be required in the treatment of some patients. There should be clothes closets in all bedrooms of the open section and in those for the quiet patients of the closed section. They are desirable in rooms for depressed and disturbed patients, though the closet doors should open into the corridor rather than the room and the nurse should retain the key.

Living Rooms Living rooms should be comfortable and attractively furnished for informal activities, such as reading, group discussion, and writing, and comfortable chairs should be provided for those who wish to relax. There should be at least two, one small and one large, for each nursing unit, except that where there is to be more than one classification of patients in a single nursing unit, there should be a living room for each classification. This will provide the necessary flexibility for use by patients of different sex, behavior, age, activity, and so on. The larger living room should have large closets for storage of occupational and recreational therapy equipment. Living-room area of from forty to fifty square feet per patient is recommended for nursing units.

Nurses' Station T h e nurses' station for open sections can be as specified for medical or surgical nursing units. Nurses' stations in the closed section should be enclosed and so situated as to provide good observation of corridors and living rooms. They are usually enclosed with glass to provide unobstructed observation, a design that has the added advantage of giving those patients who are reassured if they are able to see a nurse a view of one at all times. It should be remembered, however, that privacy for the nursing staff is required in the medicalpreparation area and in the area for such activities as record-making, conferences, and telephone conversations. An ideal arrangement for a nurses' station would include a charting-counter area, glazed and projecting into the corridor and so situated that the nurses can observe the activities in the day room, a separate small medicalpreparation area, and an adjacent interview room for use by the

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staff only. The nurses' toilet should be nearby. It is also desirable to provide a single or a four-bed room adjacent to the nurses' station for patients who need continuous observation. Glass used for enclosing the nurses' station and for observation panels should be heat tempered. Toilet and Bathroom Units

Toilet and bathroom facilities for the open section and for quiet, cooperative patients can be as specified for medical and surgical nursing units. Toilet and bathroom facilities for the closed section should be designed in accordance with the principles of psychiatric safety. Water-closet and lavatory rooms should be so arranged as to facilitate observation while still affording the patient as much privacy as is possible with safety. Toilet spaces for the disturbed- and depressed-patients' area should be larger than those for less-confused or less-excited patients. Water-closet stalls should be of sturdy construction, with doors that swing out and have no provision for locking. The tops of the doors should be approximately four feet six inches from the floor and the bottoms approximately eighteen inches from the floor. Water closets should be of the flush-valve type, and water-closet seats should be reinforced. Lavatories in the disturbed- and depressed-patients' area may be of the institutional type, preferably those having concealed supplies and trap, though they may have exposed trap and keyed supplies. The faucets should be sturdy. Mirrors should be of heattempered glass. Shelves, soap containers, and other fixtures should be built into the tile walls. Outlets for electric shavers should be provided. Shower stalls for the closed section should be approximately three feet wide by five feet long. Institutional-type shower heads are recommended and it is desirable to place these in the entrance lintel to the shower stall. The controls should be placed outside the shower stall. The lintel over the entrance should extend to the ceiling. Dressing areas should be provided.

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Food Service Both the open and closed nursing units should have a service pantry and small dining room. In the small nursing unit treating all classifications of patients, one dining room is sufficient. In the large service having several nursing units, a central dining room or rooms may be used for all patients of the open units and some patients of the closed units. In the small service, plates may be made up from hot-food carts in the pantry and placed on the table for each patient. In the larger, central dining area, a cafeteria service may be desirable. Provision should be made in the pantry for tray service to the rooms of those patients who are unable to go to the dining room. Patients7 Laundry Women patients will require a facility for the handwashing of personal garments. A small room in the nursing unit, near the dayactivity areas, should be equipped with laundry tubs, drying cabinets, and ironing boards. Recreation Facilities Areas for outdoor exercise and relaxation should be provided. These are preferably located on the grounds of the hospital, but where this cannot be accomplished, roof areas may be developed. Roof areas should be enclosed by walls or sturdy fences. The hospital having a large psychiatric service will need a gymnasium containing standard gymnasium equipment, such as dumbbells, flying rings, and parallel bars, and with provision made for games like handball, ping-pong, and shuffle board. Occupational Therapy Facilities In the large psychiatric service of the large general hospital, there should be a central occupational therapy department to provide a diversity of programs to meet the needs of the individual patient. Part of the lighter occupations, such as sewing, typing, and painting, will be supervised in the living rooms of the nursing units. Those occupations requiring more or heavier equipment will be

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conducted in the central department. These may include woodcarving, modelmaking, block printing, painting, weaving, typing, leatherwork, and so on. In a service with only one nursing unit, a separate room should be provided for the heavier and noisier activities. Patients' Clothes Locker Room Patients of the psychiatric service need many clothes. T h e y stay in the hospital longer than patients of the other services, and recreational and occupational therapy, requiring a variety of clothing, is a large part of their treatment program. Therefore, a clotheslocker room, for those articles which cannot be kept in the closets of the patients' bedrooms, should be located near the entrance to each nursing unit. In addition to lockers for each patient, there should be luggage space and a table with equipment for the marking of all clothes and personal articles. Receiving and Special-Treatment Bedrooms Some new, quiet patients may have difficulty in adjusting to the hospital atmosphere; other patients may be in need of special treatment or observation which may be better conducted out of the patients' living area. For this reason, one or two bedrooms with private bath are advisable in the treatment area. T h e y will be used in administering many treatments requiring isolation, such as fever, narcosis, and electroshock treatments. If one of these rooms is large enough to accommodate four or more beds, it may be used for insulin treatment. This is best administered in the patient's bedroom, but since it requires constant and careful nursing for approximately a four-hour period, it can be given there only if sufficient nursing personnel is available. For this reason some hospitals provide a special large treatment room. If this is done, a small utility room for preparation and a room for difficult recoveries should be included nearby. Continuous-Flow-Bath and Pack-Treatment Rooms If hydrotherapy is to be included in the treatment given in the psychiatric section the small unit will need at least two tubs. Since

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continuous-flow-bath treatments cannot be scheduled, there must be two separate tub rooms, one for men, one for women. Tubs should be placed a minimum of three feet six inches from the wall. When there is more than one tub in a room, the tubs should be placed a minimum of eight feet on center. In the large service which has several tubs, some single-tub rooms, for use by noisy patients, should be provided. Pack treatment may be given on movable or fixed tables. Tables should be a minimum of eight feet on center and three feet six inches from the wall. In the small unit, pack treatment may be given in the tub room, on a wheeled treatment stretcher with wheel locks, or in a single-bed room. Linen and blanket closets, a laundry tub, and a blanket warmer should be included in the continuous-flow-bath and pack-treatment area. Where stimulative salt-rub treatments are given, a hydrotherapy shower is also required. Continuous-flow-bath and packtreatment rooms should be adjacent to disturbed patients' bedroom areas, but also accessible to patients of other classifications. Water closets and dressing rooms should always be provided. Other Rooms

Examination and treatment rooms, interview rooms, utility rooms, the floor pantry, the flower room, linen and supply closets, the stretcher closet, and janitor's closets may be as specified for medical and surgical nursing units, except that the principles of psychiatric safety must be observed as to locks, door swings, window protection, and so on, in the closed section. If linen chutes are provided, they should be in a room off the corridor. N o rooms, not even the stretcher closet, should be left open; all should have doors which swing into the corridor, and can be locked from the outside only. Entrance Halls

Main-stair or elevator lobbies should be convenient to the nursing unit, but not in it, and should be accessible from patient areas only through locked doors. Stair halls should be completely enclosed and the doors to them should be capable of being locked. Stair

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walls, or balusters, should be continuous from stair to stair and not stop at the handrail. All possible security and safety measures should be observed in entrance and stair lobbies, but they should be unobtrusive. The area should be attractive and reassuring, as first impressions of the inpatient units may be formed at this point. Visitors' Rooms Visitors' rooms should be adjacent to the nursing unit, but outside it. The rooms should be attractive, comfortably furnished, and arranged to provide privacy for at least two or three groups of patients and visitors. Arrangement of Facilities in a Small Unit The larger psychiatric services, with several nursing units, each one designed for a particular patient classification, can be comparatively simple in arrangement: patient living areas can be easily separated from treatment areas. It is the small service of from twenty to twenty-five beds that must have facilities for several patient classifications that is difficult to design. In planning the layout of the small service, it must be remembered that the staff, upon entering the nursing unit, should be able to go to the area of treatment facilities without entering the patient areas. If the entrance is near the center, as in Tee or Cross-form plans, this is simple, as from this central point one may go to any separate patient area or to the treatment area. Nurses' stations near the converging corridors may provide supervision of each corridor and still be near the treatment area. Such a layout can be very flexible in operation, as each wing may be operated separately for a special group or treatment program or all wings may be operated together. In the Straight-line plan, double corridors may be used to advantage in providing access to separate patient areas or the treatment area. In small units, where disturbed-patients' living-room and bedroom areas are completely separated from other patient areas, as is desirable, a nurses' substation will be required, so that no patient will be left unobserved except for very short periods. All diagnostic and treatment facilities of the general hospital

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will be available, without change, for use by the psychiatric service. If an electroencephalograph is added to these facilities in the small hospital, it may best be placed in the laboratory suite or in the same room with the basal-metabolism equipment. In the large hospital, it may be desirable to locate the electroencephalograph adjacent to the neurological nursing unit, in order to reduce, as much as possible, anxiety or excitement which a patient may develop in travel to the examining room. Outpatient Facilities The outpatient facilities for nervous and mental patients in the small service will be located with the other outpatient facilities. In the larger service, there may be a separate area or floor for the service. The number of offices and interview rooms is determined by the size of the psychiatric team and the allocation of their time. The recommended team is composed of one psychiatrist, one psychologist, two or three psychiatric social workers, and at least two secretaries. The average time of each patient interview is estimated as one hour, and it is recommended that the team average twenty patient interviews per week, the remaining time being taken with administrative work. Few hospitals are able to have either this team ratio or hold to twenty hours per week on interview, so that the medical staff must be consulted about the number of rooms necessary. Interview rooms should be constructed so that there is complete privacy. The rooms should be comfortable and large enough for two easy chairs and a desk for psychological testing. A conference room, large enough for family or staff interview or consultation, should be available. Materials and Finishes In the open section, materials and finishes can be as specified for medical and surgical nursing units. In the locked section, maximum security and safety should be provided in an unobtrusive manner. Care should be taken to avoid such things as projections of structure, sharp corners, and exposed

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piping, and no design should be accepted which could encourage attempts at hiding, suicide, or escape. Simplicity of room arrangement and details is desired. Walls, ceilings, and floors.—In the open section and in bedrooms for quiet and depressed patients wall construction and finishes can be as specified for medical and surgical patients. Painted plaster or washable wall coverings are preferred. Ceilings should be of acoustical material except in rooms exposed to moisture, where they should be of nonabsorbent material. Floors for patient areas can be of the same materials used in other patient rooms. Any type of resilient floor material which is reasonably resistive to indentation is probably the most satisfactory. In rooms exposed to moisture, floors should be of nonslip tile. In the closed section where rooms may sometimes be locked, any local fire regulations governing the construction of locked rooms should be followed. All structural members should be of noncombustible material. A two-hour fire-resistive rating is desirable. The use of combustible material for finishes should be severely limited. Materials which have low smoke- orflame-producingcharacteristics should be used. The construction of bedrooms for seriously disturbed patients presents a special problem. Julian Smariga of the United States Public Health Service says, "The consensus of authorities on acoustics is that an average transmission loss of forty-five decibels is desirable to produce satisfactory results for walls between patient rooms." Hospital bedroom walls are usually constructed of four-inch hollow masonry block plastered on both sides, and this does not always achieve the desired reduction. It is obvious that rooms for disturbed patients require an even greater reduction, because of the transmission of noise when walls and floors are pounded. To reduce the transmission of noise caused by impact into rooms or corridors where it would be objectionable, double-wall construction may be used. A four-inch hollow-block wall completely separated from a wall constructed of metal studding and metal lath may be used. The block construction should be on the disturbed-patient side in order to reduce breakage of plaster surfaces. Where rooms for disturbed patients are adjacent, two completely separated walls of hollow block may be used. Floors for disturbed-patients' bedrooms also may need special

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consideration. In new construction, the structural slab may be depressed and a second concrete slab poured over a one-inch thickness of wood or glass fibre, cork board, or similar cushion. The floors should be finished with a nonabsorbent, easily cleaned material. It is difficult for even the most active patient to pound on the ceiling, so that a suspended ceiling having blanket insulation may be sufficient to reduce noise transmission. Most installations do not include rooms constructed in accordance with the above recommendations, largely because such rooms are seldom necessary, as modern treatment programs can effectively and rapidly decrease the degree and length of disturbance. The psychiatric staff should be consulted about the need for rooms of this kind, as it is they who are most familiar with the type of patients who may be treated and the treatment program. Windows.—When detention screens are used at window openings, any type of sash or glass may be used. The screen should be mounted flush with the wall surfaces at window head, jambs, and sill to eliminate projections on which a patient may be injured. The best installation will provide for operation of the sash by a removable crank without opening the screen. When detention screens are not used, sturdy windows, operated by a removable crank, are recommended. These should be of such design that they cannot open far enough to permit exit and yet can provide sufficient ventilation. Heat-tempered glass should be used to reduce breakage. No window should swing into a room. Since light may be too stimulating to some patients, it should be possible to darken the room easily. Shutters or Venetian blinds should be installed between the detention screen and the sash. Enough space should be allowed between the screen and blinds or sash for movement of the screen under stress. Doors.—In the open section, doors can be as specified for medical and surgical nursing units. In the closed section, all doors to patients' bedrooms should have vision panels. Doors for quiet and depressed patients may be similar in construction to those in the open section. For disturbed patients, doors should be of sturdy design to resist damage and prevent noise transmission. Special doors, having insulated wood panels set into solid-wood frames, are available, as are metal-clad solid-core doors.

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Solid-wood doors are probably the most satisfactory from the point of view of appearance and utility, and where disturbed-patients' rooms are reached from subcorridors, are satisfactory for noise resistance. Doors to patients' bedrooms should be three feet ten inches wide. View panels in patients' bedroom doors should be of heattempered glass and approximately eight inches wide by twelve inches long. They should be approximately four feet six inches from the floor to facilitate observation. Shutters should be installed over the view panels on the corridor side. Doors to the bedrooms may swing in or out. Although it is true that a patient may barricade a door which swings into a room, the opinion of many is that there is better control of the patient with the in-swinging door. There is danger of injury to patients or personnel or of damage to structure or equipment from an outswinging door which may be thrown open too quickly. Outswinging doors are more difficult to secure adequately, and where there are a number of rooms along a corridor, diminish ease of observation of the corridor from a nurses' station. Doors to bathrooms, closets, and the patients' laundry room should swing out and be capable of being locked from the outside only. The doors of the patients' laundry, the utility room, and the pantry, and all entrance and corridor doors should have view panels. Doors to interview, examination, and conference rooms can be as specified for medical and surgical nursing units, except for locks. It should be possible to lock these doors from both sides by keyoperated dead bolts. Heating.—In the open section, heating may be as specified for the medical and surgical patients. In the closed section, radiant panel heating from floors, walls, or ceilings may be used. In disturbed-patients' bedrooms, radiant heating in the floor is desirable. Air conditioning in the disturbed-patients' area is recommended, both for patients' comfort and in order that windows may be closed to prevent noise transmission to streets or adjacent patient areas. If radiators are used for heating, they should be recessed into the walls and covered with metal grilles placed flush with wall surfaces. A cove at the interior corners of the jambs, head, and sill of the recess will facilitate cleaning.

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Electrical.—In the open section and for quiet and depressed patients, lighting, convenience outlets, nurses' call, and so forth, can be as specified for medical and surgical nursing units. In the disturbed-patients' area, recessed lighting fixtures with heat-tempered glass covers are recommended. Outlets for floor or desk lamps should be placed seven feet six inches from the floor. Night lights should have heat-tempered glass covers. Nurses' call systems especially designed for disturbed-patients' areas are being manufactured. Plumbing.—For plumbing fixtures, see section on Toilet and Bathroom Units (p. 62). Hardware.—In the open section, hardware can be as specified for medical and surgical nursing units. In the closed section, doors should have hospital-type hinges and roller latches. Single-seated hospital arm pulls, turned down, may be used in the quiet- and depressed-patients' area. In the disturbed-patients' area, these pulls may be used on the corridor side of the patient's room and flush cup pulls on the room side. Locks should be dead-bolt, operated by key only, and it should be possible to lock the patients' rooms, bathrooms, and storage closets from the outside only. Interview offices, examination, conference, and treatment rooms should be capable of being locked from both sides, and by key only. It is recommended to key all locks in the closed section, except that to the drug cabinet, to one key. Entrance and exit doors to the unit should be on a separate key. Costs The costs per bed of building and equipping psychiatric sections in general hospitals will vary with the requirements of each particular project. They can compare favorably with the cost of the other nursing units of the general hospital. Open or unlocked psychiatric nursing units may be similar to the medical nursing units except for furnishings. Closed sections will, in general, have fewer beds per total floor area of nursing units than the usual medical nursing units because of the added requirements for living rooms, interview offices, etc. Estimates of costs cannot be drawn from cost-per-bed averages. The requirements of each project and local construction costs are

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so variable that per-bed costs m a y be double f o r one hospital w h a t they are f o r another. It is only after preliminary sketches, based .on a c a r e f u l l y prepared list of requirements, have been drawn, that costs per cubic or square f o o t can be estimated with any degree of accuracy. REFERENCES American Psychiatric Association. Design for Therapy. An Investigation into . . . Mental Hospital Design, Construction and Equipment. Washington, D. C.: T h e Association, 1952. American Psychiatric Association. Standards for Psychiatric Hospitals and Clinics. Washington, D. C.: T h e Association, 1952. Blain, Daniel, and Pat Vosburgh. Recreational Trends in North American Mental Institutions. Washington, D. C.: American Psychiatric Association, 1950. Butler, Charles, and Addison Erdman. Hospital Flanning. N e w York: Dodge Corporation, 1946. Ebaugh, Franklin G . Care of the Psychiatric Patient in General Hospitals. Chicago: American Hospital Association, 1940. Haun, Paul. Psychiatric Sections in General Hospitals. N e w York: Dodge Corporation, 1950. McEachern, Malcolm T . Hospital Organization and Management. Chicago: Physician's Record Co., 1946. Mental hospitals (Building types study 166), Architectural Record, 108:123-256, 1950. Mental hospitals [continued] (Building types study 204), Architectural Record, 1 1 4 : 1 8 1 - 2 1 2 , 1953. N e w and revised elements of the general hospital, Architectural Record, 1 1 1 : 1 8 2 - 1 9 3 , 1952. Psychiatric service [A three year report of services in the Barnes Hospital of the Washington University Clinics in St. Louis], Hospitals, 21:45-61, January 1947. Rosenfield, Isadore. Hospitals: Integrated Design. N e w York: Reinhold, 1951. West, Wilma L . and Alonzo W . Clark. Planning the complete occupational therapy service, Hospitals, 25:85-94, October 1951. Williams, Harold D. General hospital provision f o r psychiatrics indicated, Hospital Management, 73:51-54, January 1952.

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PLANS T h e following plans are not presented as a solution to any particular project. Every project has its own particular requirements and these must be clearly stated by the hospital staff in order that the architect may clearly understand the problem before preparing sketches. A plan, its materials and equipment, must be an expression of the needs of patients and staff if a satisfactory project is to result. T h e purpose here is only to show facilities, and their relationship to each other, which are designed in accordance with generally accepted medical procedures and practices. T h e y may be used as guide material for discussions, or for programming and planning a project. T h e statements regarding area requirements of each facility, their arrangement and relationship to each other, and the equipment, are intended to apply to an average small service. Additional design information for larger psychiatric services has been developed by the Public Health Service, Division of Hospital Facilities, Technical Services Branch, through whose courtesy the plans given here are reproduced.

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