NEW YORK STATE AFTERCARE CLINICS IN NEW YORK CITY*

DONALD M. CARMICHAEL, M.D.

Director, Ajtertare Ciinics, New York State Department of Menial Hygiene, Brookhn

a view to providing improved aftercare services for its institu- WITH tions’ convalescent patients living in New York City, the New York State Department of Mental Hygiene, in 1954, established full-time com- munity aftercare clinics. Prior to this time, throughout the country, after- care was merely an afterthought, such services being, with a few exceptions, inadequate or nonexistent. In New York State each of the state hospitals and schools conducted its own aftercare program on a part-time basis once a week or less, and outside of New York City this is still the practice.

It has been gratifying-especially for those of us who worked in the field in preceding years-to see, over the past five years, the awakening of interest in and strengthening of psychiatric follow-up services. For years about one third of all patients leaving mental hospitals on convalescent status had to return for further care. However, a number of intensive treatment projects in aftercare have reduced such returns to 10-20 per 100 convalescent place- ments as contrasted with country-wide rates of 30-50. At present, readmis- sions to mental hospitals form 30 per cent of total admissions. In New York State alone, during the last fiscal year, these two groups totaled almost 13,000. Here, then, is a sizable identified group of patients presenting an im- mediate challenge for prevention and surely warranting every effort to main- tain as many as possible of them in the community.

Psychiatric aftercare programs in the United States are quite varied, most of them using psychiatric social workers, public health nurses, or welfare workers, psychiatrists being available only for consultation as needed. The New York City program is medically oriented, its basic treatment unit a t present being 350 patients under the care of one psychiatrist, assisted by six psychiatric social workers and one senior worker.

There are a t the present time in New York City over 8,000 mentally ill and mentally defective patients on convalescent care from state institutions. Aftercare services for them are provided through five community clinics, one in each of the city’s five boroughs. Over half of the 8,000 patients are schizophrenics, about 400 are mental defectives, some 700 are children and adolescents, and 400 are old people over 65. The clinics are open five days plus one evening or a Saturday each week.

The whole program is administered by a director and administrative staff, with an assistant director in charge of each clinic except the one on Staten

Presented at the 1960 Annual Meeting.

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Island, which is a branch of the Manhattan clinic. Each of the four larger clinics has a social work staff under a supervising social worker. On the basis of our experience, the desirable ratio of psychiatrists and social workers to patients would be 1 to 250 and 1 to 50, respectively. Each clinic has a psy- chiatric nurse, who is responsible, under a psychiatrist’s direction, for pa- tients-almost half of the total on the clinic rolls-on maintenance doses of tranquilizing drugs. The Brooklyn clinic has a full-time vocational counselor and an intensive day therapy center (day hospital). The Manhattan clinic has a smaller day center serving both the research unit and regular clinic pa- tients.

The services of the aftercare clinics are complemented by those of other community agencies, especially with regard to vocational and social rehabili- tation. Among these agencies are the State Division of Vocational Rehabili- tation, State Employment Service, sheltered workshops, social clubs for ex- patients, and local mental health societies.

The clinics’ social service departments do all field work necessary regard- ing inpatients on request from the institutions. This consists mainly of pre- convalescent home evaluations and histories. Because of the shortage of trained, experienced social workers, we have been unable to achieve our goal of a preconvalescent home evaluation for every patient before he leaves the institution. This is related to the often inadequate preparation of the family for the return of the patient to the home and our frequent failure to work closely with them during convalescence.

There has always been a high incidence of relapse among our patients shortly after their release from the hospital. During this early period at home, the relationships between patient and family are tenuous and vulnerable to disruption, so that relatively minor irritations may precipitate a family crisis with subsequent impulsive and often unnecessary rehospitalization. This is particularly likely to occur on weekends, holidays, and a t night, with little or no consideration given to calling clinic or hospital except to arrange for the return. This points up the importance of having assistance immediately available to patients and their relatives in a psychiatric setting as well as in general medical practice. The advantage of prompt meeting of emergency needs has been shown in the 24-hour emergency psychiatric service with ambulance in Amsterdam, and others such as Jacobi Hospital in New York City, Maudsley Hospital in London, and the Home Treatment Service in Mattapan, Massachusetts. Of special value is “on-the-spot” aid given a t the patient’s home. For our New York City aftercare clinics we have tentative plans for a telephone answering service, with a psychiatrist or perhaps a sen- ior social worker on call and arrangementcwith a psychiatric inpatient serv- ice (general or mental hospital) to provide- emergency overnight or weekend bed care, followed as soon as possible by a visit to the aftercare clinic, pref-

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erably on the next clinic day. Merely an opportunity to talk on the phone with a staff person can be helpful, as long as service-clinic, day hospital, or inpatient-will be promptly forthcoming. Any one of these, if available a t the time of a family crisis, whether major or minor, will aid in lessening new- old tensions, strengthening and sustaining family ties, and often maintaining the patient in the home for a longer time than would otherwise be possible.

Orientation meetings for newly released patients and their relatives are held every Friday afternoon in our clinics. I n the group meeting an experi- enced social worker explains the clinic services; and later each patient, with his relatives, meets privately with his own social worker, and psychiatrist too, if indicated. Through this means, all patients are seen a t least within a week of leaving the hospital, and usually by this time we have a card for each, giving immediately pertinent data. The patient’s entire hospital record is sent to the clinic within a period of one to three weeks.

For most posthospitalized patients the regular coordinated services of psychiatrist’s interviews with casework of the social worker are sufficient. So far as possible, the social worker sees his patient twice within four to six weeks before the first interview with the psychiatrist, a t which time a tenta- tive treatment plan is made. Interviews with psychiatrist and social worker are closely scheduled in the early months of convalescence, with unit con- ferences held regularly to note the patient’s status and modify the treatment plan as needed. The treatment program includes individual, supportive, and group psychotherapy; social casework; chemotherapy; electroconvulsive therapy; and rehabilitative measures, both vocational and social. The period of convalescence is usually about nine months, during which time a patient may be interviewed 6 to 20 or more times by members of the clinic staff.

Though individual psychotherapy is extensively used in the usual com- munity mental health clinic, relatively few patients in aftercare clinics re- quire this, whereas supportive and group psychotherapy are often indicated. Social casework is probably more important in aftercare because of the seri- ous socioeconomic dislocations of patients and their families. For a sub- stantial number of patients occasional brief interviews with the psychiatrist have therapeutic value in addition to permitting a check of the status of pa- tients receiving maintenance tranquilizing drug therapy. Although a pa- tient’s appointment may be two months away, he is assured that he may call on the clinic for assistance a t any time. These patients, many of whom may need such maintenance therapy for a period of years, could-and should-be treated in community outpatient clinics and by general practitioners after discharge from aftercare.

With permanent community aftercare clinics it has been possible to obtain more cooperation and coordination with local public and private health and

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welfare agencies. Rehabilitation of the mentally ill has gained recognition and importance in the past five or six years. Though vocational rehabilita- tion services for the physically disabled are plentiful, little is available as yet for our mentally disabled. The situation is improving as we in the mental health field and those in the vocational rehabilitation field better understand our roles. However, concern and anxiety are still present on both sides, with resistance to acknowledging the other discipline’s status and recognizing the need to modify our preconceptions. There has been steady improvement in the coordination of our staffs efforts with those of the State Division of Vocational Rehabilitation, which has assigned a vocational counselor to each of our clinics and to the state hospitals once a week. The special placement counselors of the State Employment Service give our referred patients good service, and we have good working relations with the Altro Workship, Insti- tute for Crippled and Disabled, and the Brooklyn Bureau for Social Service. Through our own vocational counselor we have become increasingly aware of a widespread tendency among mental health personnel, including ourselves, to do things for our patients rather than help them to do for themselves. A good patient (showing improvement) is not necessarily ready for a job in the competitive labor market. Determination of job readiness must precede re- ferral for placement.

For several years the Brooklyn Society for Mental Health has supplied our day center with volunteers for service in different areas and has also taken some of the patients into its office to gain clerical experience. Recently the Manhattan Society for Mental Health has also offered to place patients in its clerical department and to work with us and other agencies on a research project. Through the Musicians’ Emergency Fund there is a Music Re- habilitation Center for which our patient referrals are eligible.

Fountain House, a well-known social club for former mental hospital pa- tients, provides an excellent social rehabilitation facility for many of our pa- tients as well as others. Although there are still obstacles, we are gradually having our discharged patients accepted for follow-up of maintenance tran- quilizer therapy in municipal psychiatric clinics a t both Bellevue and Kings County hospitals.

For over three years we have been operating a day therapy center (day hospital) as an intensive treatment unit for cases selected from the 2600 pa- tients of the Brooklyn Aftercare Clinic. It has a capacity for 50 patients and a staff of two psychiatrists, one senior social worker, two occupational therapists, two nurses, five attendants, and a part-time vocational coun- selor. The chief role of the day center is intervention in the early stages of convalescence in order to stabilize and sustain the gains patients bring with them from the hospital. I t also serves to avert hospitalization for many of

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those showing signs of relapse. The only unsuitable cases for the center are an occasional overly aggressive acting-out psychopath, some mental defec- tives (IQ below 70), and most adolescents under 16.

The program for treatment and rehabilitation is planned to meet each pa- tient’s individual needs. Among the modalities and services available are the following: individual and supportive psychotherapy, group psychotherapy, ECT and pharmacotherapy, social casework, vocationally oriented occupa- tional therapy, vocational counseling, and social rehabilitation for patients and their families.

During our three years’ experience in the operation of the day therapy center we have learned 1) that with such a center many quite sick, relapsing patients can be treated successfully in the community without hospitaliza- tion; 2) that the rehabilitation potential of chronic schizophrenics has been greatly underestimated; 3 ) that the center serves as a safeguard to success in community integration for a wide variety of convalescent patients; and 4) that this is an extremely flexible and valuable facility and has a place in mental health programs, whether of psychiatric hospitals or clinics.

The success of any aftercare program in helping patients to bridge the gap between mental hospital and community is as much dependent on the ade- quacy of the hospital treatment and rehabilitation program as it is on that of the clinic program itself. In the over five years since our New York City pro- gram began, there have been extensive changes in mental hospital practices, such as the use of tranquilizing drugs, introduction of the “open” hospital program, increase in voluntary admissions, and in many cases a shorter period of hospitalization. The decrease in inpatient census in New York State has been about 5000 in the past five years, while the increase in pa- tients on convalescence has been about 7000. As a measure of the activity each month in New York City aftercare, there are over 800 opened and 800 closed cases, the clinic census of 8000+ being about half of the state’s total. New cases are received in the clinics a t the rate of 9,300+ per year, an in- crease of almost 1000 over the previous year. It is apparent that many of these patients, after a shorter hospital stay, require more medication and more intensive aftercare services. The demands on the state hospitals are also greater because of the highest admission rate during the past three years in their entire history. However, the activity programs of the hospitals and, even more, the hospitals’ rehabilitative potential, have not caught up with the demand. Though the aftercare program is expanding, it is overstretched under present demands, and the psychiatric rehabilitation facilities of the community are woefully insufficient. It is of interest to note that statistics for the state’s last fiscal year show that the rehospitalization rate for patients in the New York City aftercare clinics compares very favorably with that of the aftercare services conducted by the hospitals themselves.

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Although there are signs of improvement, our society still attaches a stigma to mental illness, and communities are loath to accept responsibility for posthospitalized patients. Since the size qua non for patients in aftercare is to become reidentified with the community, it is essential that aftercare clinics be so identified, whether operated by the mental hospital itself or in- dependently, but coordinated with it. It is of paramount importance to keep to a minimum the separation, both literal and figurative, of our patients from the community. The longer a patient is hospitalized and consequently separated from his place in society, the greater the difficulty in regaining a role as a contributing member of the community, whether a t home, in school, or on the job.

It is our role as a state-operated aftercare clinic to work actively with our patients (and their relatives) in the clinic itself, to facilitate their active par- ticipation in essential complementary services of public and private com- munity agencies, as well as individuals. Our goal is to aid each patient to identify himself with his home community while gradually withdrawing the clinic from activity on the patient’s behalf, but a t the same time communi- cating our continuing interest and availability if need should arise.

There are still serious gaps in the presently available aftercare services, the most important being the need for more active involvement of the patients’ families, services of general practitioners of medicine, and public education to overcome the stigma still attached to mental illness.