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although the remainder, who are feebleminded and epileptic, also come under the supervision of the Department of Mental Diseases. Of these 17,000 there are 1,675 patients out on trial visit at the present time. These patients are automatically discharged at the end of the year, if it has not been necessary to return them to the hospital previous to that time. On the other hand we also have a system of renewal of visits. Many patients who, at the end of the year, for some reason or other are not making satisfactory progress and have not made a full recovery, but who may soon require hospitalization again, have their visits renewed for another year. This renewal of visit does away with the necessity, oftentimes, of recommitment. The doors of the hospital thus stand open without any further formality of commitment and, at the same time, there is the saving to the counties of the expense of commitment, should necessity require their readmission to the institution from which they came. About two-fifths of all patients out on trial have their visits renewed.
We have, in connection with all of our hospital districts, clinics which are established in all the larger cities and towns within a convenient distance from the hospital. Monthly clinics are conducted by the superintendent, or some member of the hospital staff. At these clinics patients, who are out on visit, report and are examined and are given such advice as is indicated at the time. These clinics are also out-patient clinics and serve an additional purpose of offering the service of psychiatrists to the general public free of charge and, in this way, a certain number of patients are supervised without hospital commitment. At some of these clinics as many as 40 or 50 patients may present themselves in a day. Most of these are patients on visit, but a small number are new patients. These clinics are the link between the hospital and the community, and it is through them that contact is had with patients on visit, and without them the control and supervision of patients on visit would be far less effective.
Back of this whole system of trial visit is social service, without which, the system could not be carried on with its present effectiveness. The Department of Mental Diseases has a social service director, who supervises and coordinates the activities of the various social service workers at the hospitals, each hospital having one or more social service workers. These workers are especially
trained in psychiatry, most of them having had the benefit of a course such as is given at Smith College, Simmons College, and other schools. Our quota calls for about 50 psychiatric social service workers. They are of assistance to us not only in the after-care of the patients, but many, being residents of the hospitals, assist in getting the histories, in making contacts with families, in investigating their homes, and obtaining additional information concerning the environment or background of the patient which otherwise could not be obtained. The hospital staff thus obtains a more complete picture of that patient's environment and when the question comes up in placing the patient on visit, full information as to the advisability of such action is available. One hospital, the year after the establishment of the social service department, discharged 116 patients, on recommendations of the social service workers who had previously investigated the homes of these patients. The social service worker attends the staff conferences, becomes familiar with the patient and his psychosis, has an opportunity to follow the patient on the ward, and in this way develops an interest in the patient and a knowledge of the problems involved in any particular case, so that, when the time comes to release the patient, the social service worker is fitted not only to prepare the family and home for the patient, but to continue supervision of that patient when he is placed on trial visit.
The social service workers have regular conferences. The director has a weekly conference to which all workers come and bring their problems. In addition there is a monthly conference, devoted to lectures on psychiatry, mental hygiene, or some other allied subject. We feel that the social service workers have assisted us a great deal in opening the doors of the hospitals. They are interested in their problems, optimistic in their outlook, and helpful in effectively placing patients on visit.
In comparison with other states it would appear that our recovery rate is rather low. Undoubtedly, we actually do have as many recoveries as do other states. Patients who leave the hospitals on trial visit may return in another attack before the expiration of the visit, thus we do not get the benefit of a statistical recovery. Most of our hospitals base their recoveries more on a psychiatric recovery than on a social recovery. Before discharge all patients are brought before the staff and the cases are carefully
discussed and very few patients are discharged outright. Patients may recover within the period of their visit, but if there is a possibility that they may have another attack, or if the family desires to have the visit renewed, their trial visits may be renewed and are renewed again and again; thus the patient is never reported as having recovered.
Of course the social service workers cannot follow every patient. They do however, establish contacts with the local agencies in the town or city, or wherever the patient may happen to be, and in this way they keep in touch with some of the patients. On the whole, we feel that it is a very desirable thing to get patients into their natural home environment as soon as possible and we feel that it is good treatment to do so. The public has confidence in the hospital and appreciates the interest of the hospital in the welfare of the mentally ill in its locality, whether it be in preventive psychiatry or in the problems of readjustment.
SYSTEM OF THE NEW YORK STATE HOSPITALS*
BY HORATIO M. POLLOCK, Ph. D.,
DIRECTOR, STATISTICAL BUREAU, DEPARTMENT OF MENTAL HYGIENE
The present parole system of the New York State hospitals is an outgrowth from an old custom of permitting patients to leave the hospital temporarily to visit friends or to go out on trial for indefinite periods. The custom for many years was not authorized by law but had the sanction of usage. Chapter 446 of the Laws of 1874, the general Insanity Law which preceded the State Care Act of 1890, provided that "no insane person confined in any county poorhouse, or county asylum shall be discharged therefrom without an order from a county judge or a judge of a Supreme Court." This law did not apply to the counties of Kings and New York. In these two counties the superior professional standing of the asylum physicians was recognized and they were authorized to discharge patients. In the State lunatic asylums the board of managers was given authority to discharge patients on the certificate of the superintendent. The certificate, however, had to state that the patient had completely recovered, or that he was incurable or that he was harmless.
The superintendents of up-State institutions for the insane were then as now law-abiding citizens but they disliked to bother county or supreme court judges or boards of managers about the discharge of patients and some of these physicians were hesitant about making out the required certificates. They found an easier way. They discovered that although the law restricted discharges it said nothing about paroles. Whereupon the superintendents proceeded to parole patients and sometimes forgot all about discharging them. Thus the parole system, that we extol today, developed in part through the evasion of an obnoxious law.
The matter ran along without change until after the passage of the State Care Act in 1890. The new Commissioners in Lunacy were not satisfied with the law relating to the discharge of patients and recommended its amendment, but not being immediately successful in securing legislative action, they issued an order on November 18, 1890, that no insane patient while in the custody of an institution be allowed to go on parole who in the judgment of the medical superintendent is homicidal, suicidal, destructive or dangerous either to himself or others, and that no parole be granted for a greater period than 30 days inclusive of the date thereof.
* Read at Quarterly Conference at Brooklyn State Hospital, December 16, 1926.
One of the reasons given for limiting the period of parole to 30 days was that the possibility might arise of patients being reconfined when not insane by reason of recovery during the parole period. Six years later, a law authorizing a superintendent of an asylum for the insane to parole patients for a period not to exceed 30 days was passed and became Chapter 545 of the Laws of 1896. For several years thereafter everybody concerned seemed satisfied with the law; but in the Commission's report for the year ended September 30, 1907, we find the following argument for a longer parole period:
"It is a patent fact to those who have had much to do with committing insane patients to State hospitals that a paroled patient manages to exercise self-control and to appear and actually do well for about two months after his discharge on trial from the hospital. At the end of the 30-day period during which he is paroled, the influence of the institution is still in control; and he often feels so sure of himself and so safe that he refuses to report in person or apply by letter to have his parole extended for an additional period of 30 days, as provided by the law. Often before another month has elapsed, however, he breaks down again and recommitment becomes necessary. Appreciating this fact, and with a view to preventing the patient from the discouragement of such a breakdown, and to protect his friends from the uncertainty and perplexity attending a recommitment, such a patient is often held very wisely in an institution for an additional month to cover the epoch at which the second break might occur."
Although this argument in the light of later experience does not seem entirely convincing, it had the desired effect. Chapter 261 of the Laws of 1908 extended the time limit for paroles from 30 days to 6 months.
At the Quarterly Conference held at the Central Islip State Hospital, October 18, 1916, Dr. Marcus B. Heyman presented a paper on the extension of the parole period and recommended that the time limit be fixed at one year instead of six months. The recommendation received the support of the Commission and the Conference and the desired change was made by Chapter 335 of the Laws of 1917.
In the meantime the attitude of the institution authorities, the courts, the Legislature and the general public with reference to paroles and discharges had greatly changed. Patients were no longer considered as belonging to the criminal class, and admission to a hospital for the insane was no longer regarded as a life