The Canadian Journal of Psychiatry

Part I gives a description of the unit system type of hospital organization and the other changes that were brought about at the same time. The conditions leading to the adoption of this plan were also discussed. The second section describes some of the effects of this plan in terms of hospital population movement. By necessity, the historical approach was employed although the weaknesses inherent in this approach are well known. In spite of insufficient data there are indications that the plan is producing favourable results. Results suggest that in-patient population is decreasing in spite of increased admissions, the difference being accounted for by more extensive use of hospital approved homes and of probations. Discharge rate has also increased since the inauguration of the unit system but data on re-admissions must be gathered before this situation can be properly evaluated. Also, patients who are to be discharged within a year will be discharged earlier than under the previous system. The third section deals with the advantages and disadvantages of the unit system, gathered from a series of interviews with many members of staff. A discussion of changed roles and functions of the various professions brings the paper to a close.

At this point it is important to consider the difficulties encountered in this type of study. Basic to any mental health scheme is a formal statement of objectives. It is important to know if a programme is aimed at returning patients to the community as soon as possible or restructuring personality according to some ideal, treating symptoms or curing a disease, providing custodial care or striving to reduce mental illness in the community. Are programme planners to accept present techniques and concepts or strive for progress and improvement? Is a programme to be service oriented or research oriented or both? Many of these goals are implied in projects but the point to be made is that these objectives need to be explicitly stated. Once this is done it is then necessary to state and develop objective criteria to indicate to what extent these objectives are being attained. Discharge and re-admission rates can reflect either patient status or hospital policy. What are the criteria for judging improvement after therapy? Rating scales, questionnaires and mental tests are a few attempts in this direction. Certainly more attention is needed to develop sensitive measures of change in these areas. Closely related to this matter is a lack of information in hospital records on which to base these estimates. Relevant information is not consistently obtained or recorded. To remedy this situation various departments need to contribute, on an equal basis, their recommendations concerning information to be collected. Then, as mentioned in the May 1961 issue of Mental Hospitals, the data could profitably be handled by an automatic data processing system so that uniform and necessary information is readily available for large numbers of patients.

Therefore, if evaluations of mental health programmes are to rise above the descriptive and subjective level, a critical review of objective criteria to measure progress or regression, and methods of collecting and recording patient data is warranted.

This paper is intended to be suggestive rather than conclusive. It is premature in the sense that one year of operation does not lend itself to a thorough investigation. The preliminary examination, like an initial intake interview, does, however, suggest answers to several general questions. In five years an exhaustive survey of this unit system will be undertaken and answers to many specific questions will be attempted.

This paper presents a subjective evaluation of the unit system approach to hospital organization. Advantages and disadvantages were gathered through interviews with staff members at all levels. Advantages generated improvements in many aspects of patient care and treatment, relationships between staff and relatives of patients, and the quality of work of the staff members both as groups and as individuals. Disadvantages were noted in duplication of services, role of the unit director, increased variability in clinical judgments and some areas of patient care. Some suggestions were made to eliminate these disadvantages.

Also discussed were changes in the professional roles and functions of the psychiatrists, psychologists, social workers, occupational therapists, nurses and attendants. All interviewees reported expanded roles and increased functions and felt that the unit system represented an improvement.

The paper closed with a consideration of the difficulties encountered in this type of study and the questions that must be answered before an accurate evaluation can be achieved.

During the course of high dosage chlorpromazine treatment, the following complications were observed in a group of 43 chronic schizophrenic patients.

1. Epileptic seizures in 23% of the patients related to a high daily and total dosage, but unrelated to blood pressure changes, to liver tests or other side effects.

2. Pyramidal tract lesion in 13% of the patients occurring again at a high daily dosage and receding after discontinuation of the treatment.

3. 75% of the group manifested mild to severe forms of Parkinsonism; neither of the 2 lobotomized patients was thus affected.

4. Vasoconstriction of the retinal vessels and increased blood pressure was found in several cases at the height of the treatment.

5. Leukopenia and erysipelas were encountered; the former more frequently than the latter. Both were related to a high daily dosage.

It is long established that teaching and treatment get along well together. It is also definite that the treatment of emotional disturbances, severe enough to warrant hospitalization, is best accomplished on a ward basis. The ward becomes for everyone concerned staff and patients a new environment that can be therapeutic for the patient and a learning experience for the staff.

On the ward, even if each patient has his own doctor, he is also treated by multiple therapists, each member of the staff, in his role, being therapeutic or the contrary. Groups have always existed, structured or not, in hospitals. Modern psychiatrists have not invented groups: they have used them for diagnosis, therapeutic and teaching purposes.

The service has for its primary function to observe, understand, communicate, interpret behaviour of all those who interact on the ward be they doctors, nurses or patients. This situation, as far as the teaching programme is concerned, has the main advantage of reducing the subjective distance between normal and pathological behaviour. As far as the treatment programme is concerned, this situation multiplies the emotional experience of personal relationships that can be corrective of past difficulties in this field.

Insight as we know is hard to gain, strong defence mechanisms are at play, patterns of behaviour are entrenched, resistances operate against interpretation and insight, both for the patient and the student. In a person to person relationship, interpretation is often crude, if we may say, too verbal, leaving too little way out for the individual self pride. Group techniques have the immense advantage of eliciting repetitive patterns of behaviour worthy of interpretation, of relying mostly on non-verbal interpretations prior and preparatory to verbal ones, of allowing time, possible escape and limited acting-out in the way of increased motor activity to help patient and student digest his new experience in dealing with others and profiting of same.

Oftentimes, we came to realize that if, in the past, ward therapy had dwindled in its efficiency, the reason was that it was not prolonged enough, the staff was not integrated enough, a single personality (chief of service mostly) was influential in maintaining the group, while interchangeability of roles, equal participation in the group (each in his—or her specific function), maintenance of a core of stable personnel, reliance on all patients rather than on a very verbal one, were factors of success.

We have presented a case of double personality with the death of the imaginary partner. The differential diagnosis and psychodynamics have been briefly discussed to emphasize the role of the hysterical mechanisms in the genesis of such a syndrome. Attention has also been called to the relation between such cases and Erikson's cases of “acute identity diffusion.”

An attempt has been made to clarify the psychiatric problems of families who come to an outpatient clinic for retarded children. The families may be reacting to the presence of a retarded child; marital conflicts may already exist; neurotic and psychotic problems may be present within the individual parent; the families may regard themselves as outcasts from the community. Individual counselling, marital counselling, individual psychotherapy, group psychotherapy and case work are the techniques which have been used with these families. It is felt that with the retarded child as with the other mentally ill, the individual cannot be regarded in isolation but as part of a family with dynamic relationship existing between all members. The psychiatrist is urged to recognize his counter-transference feelings in dealing with “incurable” children, and those parents who superficially appear to distrust psychiatric intervention.