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MENTAL HEALTH MANPOWER AND THE PSYCHIATRICTECHNICIAN.CALIFORNIA SOCIETY OF PSYCHIATRIC TECHNICIANS,SACRAMENTO.; NATIONAL ASSOCIATION OF PSYCHIATRICTECHNOLCGY, SACRAMENTO, CALIF.68

43P.NATIONAL ASSOCIATION OF PSYCHIATRIC TECHNOLOGY, 1127I1TH STREET, SACRAMENTO, CALIFORNIA 9581 4 ($2.00)

EDRS PRICE ME-0.25 HC-$2.25*CCNFEEENCE REPCRTS, CURRICULUM DESIGN, LEGALPROBLEMS, *MENTAL HEALTH, *PARAMEDICAL OCCUPATIONS,PROGRAMING, PSYCHIATRIC HOSPITALSCALIFCRNIA, *PSYCHIATRIC TECHNICIAN

DYNAMIC CHANGES ARE TAKING PLACE I. 1HE FIELD OFMENTAL HEALTH CARE WHICH HAVE A GREAT EFFECT ON THOSE PEOPLE WHOPROVIDE THE PRIMARY SERVICES OF PATIENT CARE, REHABILITATION, ANDTRAINING, IN RECOGNITION OF THESE CHANGES, THE NATIONAL ASSOCIATIONOF PSYCHIATRIC TECHNOLOGY SELECTED "MENTAL HEALTH MANPOWER AND THEPSYCHIATRIC TECHNICIAN" AS THE THEME IOR ITS ANNUAL CONVENTION IN1967. THIS REPORT PRESENTS SIX ARTICLES WHICH REPRESENT A SELECTEDDIGEST OF THE PROCEEDINGS FFCM THE FRESNO CONVENTION. THESE ARE"MENTAL HEALTE: THE DYNAMICS OF REVOLUTION," "MENTAL HEALTH MANPOWERIN TRANSITION," A SYMPCSIUM ON FEDERAL AND STATE REGULATIONS OFNURSING SFEVICES, "LEGAL ASPECTS OF UTILIZATION OF PSYCHIATRICTECHNICIANS IN MENT;1L HEALTH SERVICES," "PRIVATE PSYCHIATRICHOSPITALS," AND "PROGRAMMING FOR THE FUTURE." A CURRICULUM REPORT ISAPPENDED. (BC)

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NATIONAL ASSOCIATION OF PSYCHIATRIC TECHNOLOGY

CALIFORNIA SOCIETY OF PSYCHIATRIC TECHNICIANS

Non-profit organizations devoted to improved professionalism and recognition as a means toward betterbehavioral care treatment and training of the mentally and emotionally incapacitated.

OFFICERSNATIONAL ASSOCIATION OF PSYCHIATRIC TECHNOLOGY

PAST PRESIDENT

Franklin F. Fiedler (California)SECOND VICE PRESIDENTElsie Ferguson (Arkansas)

PRESIDENTZeryl Dryden (California)

SECRETARY-TREASURER

Bette A. Outlaw (California)

FIRST VICE PRESIDENTTed Low (Colorado)THIRD VICE PRESIDENT

Rose A. Douglas (Massachusetts)

FIXED TRAINING STANDARDSTHROUGHOUT THE NATION

FEELING OF DIGNITY INEMPLOYMENT

EXPANDED ADVANCEMENT

OPPORTUNITY

PROFESSIONAL GROWTH

PRIDE IN CONTRIBUTION TOWARD

MENTAL HEALTH

OFFICERS


PRESIDENTDon Wise

PAST PRESIDENTEarl C. Wilkerson

SECOND VICE PRESIDENTWilliam E. Outlaw

FIRST VICE PRESIDENT

Warren Malone

SECRETARY-TREASURER

Laretta Thomson

REGIONAL DIRECTORS


William V. KalinauskasWood H. SmithFrances BelongyH. D. WhitfieldHelen JohnsonIsaac J. ClaybrooksDe lois Higinboti:W, B. Hoxk

Virginia LedfordGeorge L. WaggonerOphelia WilliamsFrank R. FavelaRoy M. GoucherFrar, ces WattsJohn 0. Calderon

c.)U.S. DEPARTMENT OF HEALTH, EDUCATION & WELFARE

OFFICE OF EDUCATIONr)10 THIS DOCUMENT HAS BEEN REPRODUCED EXACTLY AS RECEIVED FROM THE

re\ PERSON OR ORGANI/ATION ORIGINATING IT, POINTS OF VIEW OR OPINIONS

STATED DO NOT NECESSARILY REPRESENT OFFICIAL OFFICE OE EDUCATION

POSITION OR POLICY,

E3 Contents

PREFACEWilliam Grimm

Page No.

MENTAL HEALTH IN CALIFORNIA: THE DYNAMICS OF REVOLUTIGNDr. James T. Shelton

"The changing character of our hospitals, complicated financingof the new programs in communities, and the place to befound there by the psychiatric technician."

MENTAL HEALTH MANPOWER IN TRANSITIONDr. James A. Peal

"Innovations in the use of treatment personnel in communitymental health programs."

SYMPOSIUM:Interpreting federal and state regulations which affect staffingstandards for nursing services in state and local facilities.

Howard WorleyRalph Zeledon

LEGAL ASPECTS OF UTILIZATION OF PSYCHIATRIC TECHNICIANSIN MENTAL HEALTH SERVICES

Attorney Robert Thorn"A review of the legal implications of transition from state tocommunity and federal programs."

PRIVATE PSYCHIATRIC HOSPITALSArthur Jost

"Will new staffing approaches and modification of roles helpto close the manpower gap?'

PROGRAMMING FOR THE FUTURESenator Nicholas Petris

"A probing insight into changing mental health patterns andrequirements for the coming decade."

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APPENDIX I: 36All that glitters may not be gold.

APPENDIX II:THE CURRICULUM REPORT

Anabele Miller

37

Preface

The entire field of mental hygieneacross the nation is in a state of rapidchange.

Many trends which here in the late1960's are transforming the field of men-tal health care and treatment into adynamic new enterprise will have a mark-ed effect on the people who perform theprimary functions and provide the prim-ary services of patient care, rehabilitationand training.

It was in recognition of this era ofchange, this historic time of revolution,that the National Association of Psy-chiatric Technology selected the theme,"Mental Health Manpower and the Psy-chiatric Technician", as the keynote ofits annual convention at Fresno, Calif-ornia, in October of 1967.

Since it is the psychiatric technicianwho is most intimately involved in theday-to-day response to patient needs, itis he who will be most directly affectedby changes and modifications in the sys-tems of mental health care which ultim-ately will evolve.

As a pivotal figure within the profes-sional mental health treatment team, hewill play a key role in the changing char-acter of the large state hospital as thetrend toward decentralization continues.He will occupy a critical role in the dev-elopment and growth of community-based programs. He must play a centralrole in the redefinition of treatmentfunctions and personnel. He must makehis voice heard in the formulation ofpublic funding patterns and other politi-cal decisions which will impact upon the

future of these community-based pro-grams.

Most important of all, the psychiatrictechnician (or his counterpart profession-al under other title) must continue toperform as a responsible leader in theshaping of visionary solutions to the veryserious manpower problems now facingthe mental health professions through-out America.

In California and in other progressivestates today, there is every indicationthat these problems and issues andchanges are but a beginning that themental health revolution will continueto accelerate for many more years yetto come.

In many ways, evidences of this greattransition are today most pronouncedin the dynamic state of California. Butthey are likely to be but previews of thesame evolutionary processes which otherstates will encounter within the next fewyears.

For that reason, the California Societyof Psychiatric Technicians and the Nat-ional Association of Psychiatric Technol-ogy have joined in the publication ofthis selected digest of the transactionsof our provocative Fresno conventionof 1967 in the hope that others whoyet must face the problems and oppor-tunities of this great revolution mightin some small measure benefit from theinsights of some of California's front-line mental health authorities.

William GrimmExecutive Dirmtor

Mental Health in California:The Dynamics of Revolution

by Dr. James T. Shelton

Dr. Shelton obtained his A.B. fromPomona College and his M.D. from theUniversity of Southern California, doinghis psychiatric residency at Langley-Por-ter Neuro-Psychiatric Institute in SanFrancisco. Shelton was clinical instructorin psychiatry at the University of Calif-ornia, San Francisco Medical Center, andhas been Superintendent and MedicalDirector at Porterville State Hospital,Porterville, California for the past 14years.

His credentials include: Diplomat ofthe American Board of Psychiatry andNeurology; accreditation by the Ameri-can Medical Association as a Mental Hos-pital Administrator; and fellow of theAmerican Psychiatric Association and theAmerican Association on Mental Defic-iency.

Shelton received the Golden RuleAward of the California Council forRetarded Children in 1961.

I believe it's customary that whenyour group meets throughout the variousareas in California that the state hospitalclosest to the meeting area conventionsite handles the program arrangementsand welcomes the various delegates. Al-though we at Porterville are some milesfrom Fresno, we feel this is our bailiwick,so we are very pleased to have you meethere.

As I reviewed the program "MentalHealth Manpower and the PsychiatricTechnician" and noted the various speakers that you are going to be listening toover the next three days, I concludedthat a great deal of thoughtful planninghas certainly gone into the programs thisyear because the theme of your conven-tion recognizes trends we see in mental

1

hygiene which are coming at an increas-ingly rapid rate.

Change, of course, always creates anx-iety, and when change comes too rapidly,then anxiety reaches such a height as toalmost result in panic. Recognition isgiven, at least in the selection of yourspeakers, to one of the primary trendsthat is occurring in our field of mentalhygiene that is, the trend to communitymental health service, rather than thisservice being centered almost exclusivelyin the State Hospitals.

The second trend that is tacitly ad-mitted by your program is that of thechanging character of the hospitals. Ofcourse this would obviously follow withincreasing the mental-health programm-ing in the community: It almost goeswithout saying that the hospital is goingto have to change its character, its pro-grams, perhaps even its fuhction, in orderto keep up with this move toward thecommunity.

A third thing the program tacitly re-cognizes is the point financing of mentalhealth programs. As short as twenty yearsago in 1947, the primary financing oftreatment services for the mentally illand mentally retarded was by states. Thestates, for the most part, picked up al-most 100% of. the tab, and, because ofits funding, maintained control of theprograms it financed. Very little wasbeing done in county, city, local com-munities, and extremely little was doneby the federal government. But it is quiteobvious that the trend. is shifting towardfinancing by state, federal and "local""local" being counties and cities. We haveseen a combined funding by federal, stateand local agencies such as we have inwelfare programs. Currently, our mentalhealth programs are being funded bythese three sources.

The fourth trend, which obviouslymust follow because of the first threetrends, is that the worker in the field ofmental health must change his role tokeep pace with other changes in the field.No longer can he act and do and performas he has acted and done and performedin the last twenty years.

In your program I want to commendyou because I see you realistically eval-uating the present and looking to thefuture rather than, as some organizationsin this field, emphasizing the past par-ticularly the past nine and one-halfmonths. This period has been, as we allknow, one of turmoil, recriminations,and what I think is most unfortunate, aa great deal of misinformation. I thinkthe most disturbing factor has been themisinformation about the cutbacks, andthe impact that this has had upon ourtreatment programs.

We have been hollering about the cut-backs during the last nine and a halfmonths, yet it was after the first sixmonths of the year before any cutbacksoccurred. And, we heard very little em-phasis being placed upon the freeze,which really had the greatest impact onour treatment programs. Although Itried, I couldn't convince anybody thatthe freeze was the thing to focus on toget that lifted. We could probably takethe cutbacks in stride, as we are doing.

The other piece of misinformationthat I think has been the worst thing - Iagain read an organization's statement(it wasn't this one) about how horriblethe conditions were at Stockton. I look-ed at this, read it over, and I said, "Thiscannot be the result of anything that hashappened since the last nine and a halfmonths, because nothing was involvedduring the last nine and a half months toaffect the amount of money to feedpatients. That has always been adequate.In fact, the department has always turn-ed back money for feeding. While we'venever had any lack of money to feedpatients or to buy food, this was playedup in a maudlin way to make people be-lieve that this had something to do with

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the present administration. I think thisis wrong.

I'm not denying that there might be aproblem in this area. But the point I wantto make is that we've had problems eversince we've had a Department of MentalHygiene. We should be very careful aboutascribing the causes of those problems tothe present administration. It may not allbe. Some may be, but not all. And Ithink it is very important to very care-fully delineate that which is our own re-sponsibility and in our own bailiwick tocorrect within our own resourcesrather than sitting back and blaming it allon something or somebody, or lack ofmoney, or lack of personnel.

You see the same kind of thing inpsychiatry with the parents who cometo you with disturbed kids. The kidshave all kinds of behavior problems, butnormal kids have behavior problems too.Before you can honestly and factuallydetermine what really is abnormal, youhave got to know what the normal prob-lems are so you will not be confused andsay it's all due to a particular condition.I think there is a good analogy here.We've got to sift out what our normalproblems are, and not blame them allupon the present situation.

Sometimes, I think the time we spendon complaints, petitions and other move-ments might be much better spent onmore constructive endeavors and on pa-tient care. Now, we are living with thepresent situation, and it hasn't beensomething that any of us has liked.We've all lost something the hospitalsfor the mentally ill much more than thehospitals for the mentally retarded. Thereis no question about that, but we areliving with it. There were lots of direpredictions about the cutbacks. For ex-ample, I sincerely thought that the pop-ulation for the mentally ill would in-crease because of the decrease in person-nel. But the facts do not bear this out.The facts are that the population is stillcontinuing to decrease. We cannot ignorethese facts they're the facts of life. Idon't think myself or anyone in the De-

partment or the Administration likes tohold the line based upon a level of carewhich is not adequate and which has lotsof holes in it, particularly in terms ofnot considering admission factors ade-quately. Yet, we put up a battle andfought it. Instead of sitting back, sulkingand crying in our beards, we shouldendeavor to move ahead with what wehave. I, for one, hope -- and I think wehave many indications for this hopethat we will go ahead next year eventhough this year has been one of holdingthe line and, in some cases, of actuallyretrenching.

I wrote a letter for our PortervilleState Hospital Parent Group and our em-ployees to cover just some of the thingsI am mentioning, and I was extremelysurprised to receive a letter from ourGovernor who apparently had seen acopy. 1 had said, in essence, "Let's quitbickering and complaining and do withwhat we've got to the best of our ability."The Governor wrote that this attitudewas sincerely appreciated by him. Hesaid, "It certainly was good to read thevoice of reason in all the sound and fury,and I hope others will follow your ex-ample." The letter was signed, "Sincerely,Ronald Reagan." Now, Ronald Reaganis our Chief Executive; he is our Govern-.or. And as I tell new employees at thehospitals, "Even though we, as civil ser-vants, owe a certain amount of respectto him as Chief Executive, we don't haveto agree with him, but we don't have toknock him. He is doing what he thinkshas to be done at this point in time. Wemay disagree, but he's made the decision.If someone disagrees so strongly that hecan't accept it without being negativeand vicious at times, then I think it ishis responsibility to get out of the sys-tem. I'm not saying that you should dothis before you fight for what you be-lieve in. But once the decision is made,you should accept it and look to thefuture doing what you can with whatyou have rather than crying over spilledmilk.

You know, we've come an awful long3

way in the Department of Mental Hy-giene since 1947, twenty years ago. Hereit is 1967.1 mentioned 1947 because thiswas the time of Governor Warren, FrankTallman the time when headlines werefilled with references to the "snakepit."

The interesting thing, though, is thedifference in programming in 1947 fromthat in 1967. Now we have thousands ofadditional new employees. Salaries haveskyrocketed still not high enough inmy opinion but certainly an improve-ment over 1947. Then, a psychiatric tech-nician got $40 a month plus live-in, hada set of keys thrown at him, and he wentto work with the mentally ill and men-tally retarded without any training. We'vecome an awful long way since then, so Ithink that rather than crying in ourbeards we ought to just reflect on howfar we have come and try to work withwhat we have Despite the freeze andcutbacks with which we do not agree,we have something this year that we havenever had before in mental hygienegreater flexibility in the use of staffingbudget. Most of you don't have too manydealings directly with the operating bud-gets of the hospitals, but I can tell youas hospital superintendent of many years,I have never seen the flexibility that wehave this year in spending dollars fortreatment personnel.

While this flexibility is limited to theclassifications of physicians, social work-ers, psychologists and psychiatric tech-nicians, it is a marked'improvement overthe time when such did not exist. We canconvert vacant positions to other posi-tions that we are able to fill on a dollarfor dollar basis. At Porterville we've hadphysician positions and psychologist pos-itions vacant for nearly two years. Weare taking money for these positions andplan to create some 30 new psychiatrictechnician positions this fiscal year. Weare giving first choice to trained psychi-atric technicians from the hospitals forthe mentally ill who may be faced withlay-off. These are psychiatric technicianswho are already fully accredited so wedon't have to put them through an in-

tensive training program other than anorientation to the hospital. Our patientstherefore, benefit from this flexibility inthe utilization of staff funds because weare permitted to use dollars whichnormally would not be available to us. Ithink this flexibility is something on thepositive side of the ledger of whichpeople need to be made aware.

One other thing I think a lot of peopleare not aware of is the fact that the Gov-ernor ordered all of his State Depart-ments in California to reduce this years'budget by eight per cent EXCEPT theDepartment of Mental Hygiene. WhileI'm not rolling in the aisles with pleasureover features of the present programs,these desirable things should be recog-nized along with the less encouragingfactors.

I have read the Governor's letter tothe Director of Mental Hygiene concern-ing budget proposals for the next year.Economy is mentioned, but therc, is alsoinstruction to give full consideration tonew programs and to augmentation ofcurrent programs if they are found justi-fiable. We have submitted some six pro-grams from Porterville for budget aug-mentation in the amount of some threeor four million dollars of additionalfunds. We're not going to get that much,but if we get five hundred thousand,that's better than nothing. I might addthat most of those budget augmentationsexcept those for research, call for addi-tional personnel additional psychiatrictechnicians.

So where are we going, and what isgoing to be the role of the psychiatrictechnician? Well, you're going to hearspeakers who will give you some of theirideas of where they think the psychiatrictechnician is going and perhaps what therole of the psychiatric technician will be.You will undoubtedly receive a great dealof information about the movement tothe local community mental health pro-grams, one of which is the Lanterman-Petris-Short Act, Senate Bill 677, whichis known also as the "California MentalHealth Act of 1967." This will profound-

fly affect the hospitals for the mentallybut will have less affect on hospitals

for the mentally retarded and Atascaderosince patients in these facilities were ex-cluded from the bill.

You are undoubtedly going to hearabout the impact of the Federal Govern-ment, Medicare and Medic Aid.You're go-ing to hear about the Department's em-phasis on cost reporting. You've alreadybeen involved with that in some of yourward surveys. All of this is done in aneffort to get more federal dollars. Thisis the whole purpose of some of the dis-cussions that are going on about Medi-care and Medi-Cal.

In an effort to get more dollars so thatmore services can be provided, and this isthe avowed intent of these programs,we're going to have to contend with pro-blems of federal law which set forth cer-tain definitions for certain kinds of peo-ple that are necessary. We're wrestlingwith this. I think it was important thatthe Fairview situation with the conver-sions of psychiatric technician to regis-tered nurses was subsequently called to ahalt, and then looked at very thoroughly,because there may be other compromisesor other approaches. It is not impossibleto change federal regulations by broad-ening their definition. These are thethings that should be looked into, Ithink, by a group such as yours. Thereseems to be no reason at all why federalregulations involving Medi-Cal and Medic-Aid, which is a federal program for thestates, could not be written so that wherementally ill and mentally retarded areinvolved, the psychiatric technician couldbe on the same plane, if you will, withthe registered nurse. After all, adminis-trative regulations can be and should bechanged periodically to meet our needs.

I think we're going to see a decreasein the number of 24-hour hospital careprograms. We've seen that in, today'sShort-Doyle programs. I think, of course,that this is best proven by the decreasein the populations in hospitals for thementally ill, except that we're seeing achange in the population to the more

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profoundly sick, whether they be the"back-wards patients" or the severely re-tarded, or the geriatrics cases. We're moreand more going to have to care for thatkind of case in the state hospitals as thecommunities begin to provide care forthe easier-to-care-for patients.

This means that the role of the tech-nicians and the personnel in the hospitalswill gradually change, You're going tohave to become more skillful. We aretalking now in the Department aboutconsidering multi-purpose facilities, sothat state hospitals could care for boththe mentally ill and the mentally retard-ed and all kinds of mental disorders. Youalready see the movement toward thiswith DeWitt State Hospital. They havemore retarded there now than mentallyill, and of course there is the mentally re-tarded unit at Patton, the unit at Agnews,and now the unit starting at Camarillo.Then, the plan (I think it is being done atthe present time) is to transfer somementally disordered sex offenders fromAtascadero to Napa. That's probably justthe start of hospitals becoming multi-purpose facilities in caring for all kindsof problems. This is going to change therole of the hospital and the role of theworker in the hospital. Undoubtedly thehospital will become a back-up service tothe community. Hopefully the hospitalwill become, and I think it a proper role,a training center where people can comein and really learn how to care for thementally disordered. The people whoreally know how to care for them, wehave found, are in the hospitals. I happento be active in community mental healthprograms through service on the TulareCounty Mental Health Advisory Boardfor the Short -Do le program. It's aston-ishing sometimes how the professionalworkers in the community are unawareof the difficult problems which are sec-ond nature to us in the hospitals. So wehave a double role to play here in thetraining C. the professional who does thework in the community. There's a psy-chiatric technician who has done a mar-velous job at Tulare County Hospital in

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the psychiatric unit. He's had some ex-perience in state mental hospital work. Iwas talking to him and he said he thoughtthis was the most valuable part of hisexperience and training. Here is a psychi-atric technician who is working in thecommunity in one of these Short-Doyleprograms and there are many others be-sides him, of course. There is a growinguse of the psychiatric technician. I in-clude the psychiatric technician as a"professional" even though he is some-times referred to by some as a "sub-pro-fessional". I still like to conceptualizethe psychiatric technician as a profes-sional with talents equal to the registerednurse.

This doesn't mean that they don'thave separate functions to perform. Inmy opinion, the registered nurse hasmuch more experience and training andknowledge concerning the medically illpatient, such as an expanding hydro-cephalic. This isn't to say that the psy-chiatric technician can't learn these ele-ments, and is beginning to do so. On theother hand, I see no reason to use a reg-istered nurse on a ward which is betterrun by a psychiatric technician out onthe campus where you are dealing morewith educational - habilitational prob-lems. We use them on our co-ed ward.

I do think that there may be a trenuin the future toward some kind of anamalgamation of these fields registerednursing, if you want to call it that, andpsychiatric technology. Perhaps the com-bination would have some other namewhich is yet to be devised.

I think, however, we make a mistakein spending time fighting between our-selves on this rather than trying to pulltogether and recognizing that we bothhave a job to perform. If you don't feelthat your particular hospital has an ap-preciation of the need for both groups,then I think that CSPT has a role to playin convincing the hospital administra-tions, and anybody else concerned, thatthere is every need for both kinds ofprofessional workers in the hospital.

I hope this morning that I have given

you, besides a cordial welcome, some-what of an overview of the situation asI see it. I think I have been able toreasonably well keep within my time.

According to my watch, it's two min-utes after ten, and that's just about thetime hat your program calls for coffee.Thank you very much.

PLEDGE OF THE

PSYCHIATRIC TECHNICIAN

Having developed an awareness of thedignity encompassed in the field of psychi-atric technology and of my responsibilitybecause of specialized training in thetherapeutic techniques utilized in the pro-motion of mental health,

I pledge myself:

To uphold the integrity and human dignityof those entrusted in my care and protectthem against humiliation, insult or injurywithout regard to race, color or creed.

To inspire hope and confidence, givingassistance with understanding and friend-liness, in finding realistic acid meaningful

To continue my development of professionalcompetence, complementing scientificstudy, improvement of therapeutic tech-niques and maintaining high standards ofleadership in the field of PsychiatricTechnology.

Mental Health ManpowerIn Transition

by Dr. James A. Peal

Dr. Peal is Director of the FresnoCounty Department of Mental HealthServices. Well known as a pioneer in psy-chiatric services and in local programs,Dr. Peal has practiced in many Californiahospitals including Napa and AgnewsState Hospitals as staff psychiatrist, theMedical Facility at Vacaville as Chiefof Psychiatric Services, and StocktonState Hospital as Associate Superintend-ent. He recently returned from Michigan,where, as Assistant Director of the De-partment of Mental Health, he organizeda manpower utilization and developmentprogram for that state. Licensed in Mary-land, Connecticut, Michigan and Calif-ornia, Peal is also a Fellow of the Ameri-can Psychiatric Association.

On December 31, 1965, there were28,400 patients in the hospitals for thementally ill and 12,920 patients in thehospitals for the mentally retarded. Dec-ember 31, 1966, there were 24,057 pat-ients in the hospitals for the mentally illand 13,340 patients in the hospitals forthe mentally retarded. These patients hadalready been extruded from their com-munity through the existing commitmentpractices. They have been hospitalized,institutionalized and many have seentheir fellow members returned to thecommunity; some for a better life, somefor a worse life, and some for an exist-ence similar to what they had before theycame to the hospital. I wonder if thesepatients think. "Am I included in thecommunity program or is this for thosewho are yet to come here? Am I a partof the number that is to be written off?"The experience of being excluded is notnew for the patient who has been in thestate hospital on the back ward for

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twenty years because he has scen newprograms come and go. He has seen pat-ients selected for the new programs whoseprognosis and expectation has been thathe would recover. He has always justmissed being picked for this or that. Hehas seem his fellow patient come, gettreated, and go in fairly large numbers,for the Department of Mental Hygieneover the past few years has accomplisheda reduction of over 10,000 patientsthrough the advent of Medi-Cal and new-er techniques in psychiatric treatment.It is to the patient who now sits on theback ward and those yet to come whoseillnesses may not respond to the treat-ment now possible in the community,it is to these people that we dedicateourselves in this consideration of mentalhealth manpower and the psychiatrictechnician .

Any comprehensive mental health pro-gram, whether local as in the presentShort-Doyle programs or state as in thestate hospitals, must include in all of itsingredients treatment programs designedto meet needs of all patients not a sel-ected few. If it does not do this, then itis a mental health program that is direct-ed toward part of the community andnot all of it. People who develop mentalillness should retain their membership inthe local home community regardless ofany temporary sojourn to a state hospitalor other treatment facility, and that com-munity should accept this person back,offering him what rehabilitation serviceshe needs and, more important, offeringhim a warm and friendly welcome home.

This organization and this institute isthus dedicated to the patients that weserve. Manpower is the means of provid-ing the hope, happiness, and health topatients by bringing appropri to psychi-atric skills to him in an atmosphere of

care. acceptance and understanding. Men-tal health manpower development andutilization, including staffing, trainingand funding, must be centered in meet-ing the needs of the patients we serve.

Today morale may be at its lowestebb. This is the first time in many yearsthe mental health budget has been cutinstead of increased.The very existenceof the system that trained and nurturedus is in question. 'We may find ourselvesembittered and angry, bewildered andperplexed, hopeless and despairing.

You have seen your numbers shrink,your training programs reduced and allbut eliminated, and demands placed uponyou increased by your shortage in num-bers. Your very worth to the systemwhich nurtured you is being questioned.By virtue of the cut back, the institu-tion you worked in, namely, the statehospital has been declared a thing of thepast by some, to be replaced by the newcommunity mental health Short-Doyleprograms.

If you don't quite understand whatthese things are, it may be because theyaren't very often clearly defined. Natur-ally you wonder where you fit in thisnew scheme of things, or if you fit at all.Does your profession have anything tooffer now to the patients in communityprograms in this new order of things?I come to you today out of the exper-ience closely identified with the statehospital. For I, too, received my psychi-atric training in a state hospital andworked in various state hospitals, bothon the wards and in the administration.I have participated in the third psychiat-ric revolution in which the newer modal-ity of psychiatric treatment, namely, som-atic treatment, drugs, group therapy andthe therapeutic community system ofpatient management have changed ourhospitals from custodial facilities intopsychiatric treatment centers.

I now find as director of a communityprogram that there is a greater need andchallenge here at the community level totranslate these programs into hope andhelp for those patients at the end of the

line because communities have not beenaccustomed to accepting and keepingtheir sick people. They traditionally havesent them on to state hospitals. It is,therefore, my purpose today to first de-fine what community mental health ser-vices mean to the patients, and then toexamine with you some of these newcommunity health centers, local pro-grams, and Short-Doyle programs, andthe new vocabulaiy they are bringingonto the scene.

Second, I will spell out the ingredientsof these new community programs interms that are familiar to you and thatare similar to state hospital operation. Iwant to examine your present skills asthey now exist to see how they fit intothis program. Then we will examine thedifferent ingredients in the local pro-grams where your technology and skill asit now exists may not fit, and identifyneeded appropriate changes (additionsand deletions) in your training to makeyour skills useful. We need to definesome of the more immediate problems incourses of action that your organizationmust consider if it is to become a part ofthe community program, and finally toreview the current political and legislativehappenings to see what they hold for thepresent and for the future.

Community health services are thosemental health services which exist in thecommunity. The community is definedas a political subdivision or geographicalsubdivision which has a local governingboard. The mental health services in thecommunity are usually considered asdirect treatment services, or those ser-vices given to patients, and indirectservices which include consultation ser-vices given to helping agencies in thecommunity.

For example, the local or county wel-fare department provides social servicesincluding room, board and clothing forall people who are indigent in the com-munity. Consultation services to the wel-fare department enabling welfare work-ers to provide these services for the men-tally handicapped is a very profitable

8

thing for the patients. It gets for yourpatient an adequate place to live, clothesto wear and food to eat, and providesother social services that keep him in thecommunity. If the Welfare Departmentor its staff gets too nervous about him,these resources in the community maydry up; and he becomes a person withouta home and, therefore, hospitalization issought to solve his problem. The welfareworker can become a friend to the pat-ient,a helper in the program.

By the same token consultation ser-vices to the Public Health Departmentcan provide visiting nursing services.Visiting nurses and public health nursesare a major resource in keeping sickpeople at home. They help the patient.with problems in medication; they givethe patient a friend, someone who under-stands them, and someone who knowsthe neighborhood and is able to help thepatient make maximum use of the re-sources there.

Consultation with law enforcement isa very useful program for it serves thesame purpose as consultations withWelfare. The more the police and lawenforcement officers understand aboutthe problems of the mentally ill, themore skills they have in being able tomanage them as policemen. Thus thepatient has a better chance of having lawenforcement available to assist himrather than having law enforcement de-signed only to incarcerate him. In gen-eral, by having a network of consulta-tion and education services to these var-ious helping agencies in the community,both public and private, one is able toenlist many services for patients that heotherwise would not get. The manpowerinvolved in (Trying out these consulta-tions programs usually comes from pro-fessional people, i.e., psychiatrists, socialworkers, and psychologists. However, thepsychiatric technician with his under-standing of the nature of mental illness,his knowledge of sick people and how toget along with them may be a very help-ful person in this overall consultationprogram. An additional advantage for

9

the psychiatric technician is his member-ship in the community. As a lay memberof the community he probably has moreacceptance by the grass roots of theseagencies than do the professionals. Justimagine, if a psychiatric technician werea member of the reserve police force,how much effective education he couldgive to his fellow policemen. This maybe as effective as a lecture that the psy-chiatrist would give on the nature ofschizophrenia or how you manage a per-son who is about to kill himself. How-ever, these duties in community programsare not usually, at the present time, as-signed to psychiatric technicians. Thedirect services program provides directtreatment to patients. It includes in-patient, day care and outpatient services.

Most local programs have a smallinpatient service, (small compared to thesize of the state hospitals)with from 5 to90 beds servicing a county of 100,000 toover a million people. It is obvious thatwith this small number of beds thatlong-term inpatient hospitalization isnot an integral part of the local program.An effective program treats acute dis-turbances in a few days. Patients whootherwise would require 90 or 120 daysin a state hospital are more efficientlytreated in a community program byusing not only the inpatient service butthe day care service and outpatientservices all combined and coordinated ina treatment design to meet the patient'sneeds.

The practice of psychiatry in thecommunity program presents manychallenges and many stressful momentsto the institutional trained psychiatristand other professionals. Most communi-ty programs have a walk-in clinic. This isa place where anyone who is disturbedcan come himself or be brought and beseen by members of the professionalstaff. One physician has termed this"instant psychiatry". That is, the patientis seen, and in 15 or 20 minutes adiagnostic evaluation is made and atreatment program is developed whichhas to solve the immediate problem of

where this patient has to live in order tobe effectively treated. Generally if themanifestations of the illness do not makethe patient a danger to himself or others,even though he may be quite disturbed,he will be given adequate dosages oftranquilizing drugs immediately andassigned to the day hospital or to theoutpatient clinic and not be hospitalized.

It might be well to follow a disturbedpatient through the various elements ofthis program so that you see how theywork. A patient is found by the policehaving turned on the gas and closed offthe windows in a bona fide suicide at-tempt. The patient is brought to thehospital on an emergency 72-hour com-mitment. The patient is examined eitherthe same day or the following day by thechief of the inpatient service who is apsychiatrist, and a diagnosis and treat-ment plan is made that day. The treat-ment plan is started that day on theinpatient service. By the time the 72-hour commitment is up the patient maynot be ready to leave the hospital so heis encouraged to sign a voluntary ad-mission. He stays on the inpatient serviceuntil the acute manifestation of the de-pression has subsided and then becausethe patient is not ready to resume hisfull life at home he may be placed inthe partial hospitalization or day careprogram.

The dzy care program consists of aseries of highly organized, scheduled ac-tivities including occupational therapy,recreational, and group therapy that takeup the patient's day. It is identical to thesame daily program the patient has whilean inpatient. The only difference is thatthe patient sleeps at home and not in thehospital. The patient is given his meals,medication and rail bilitation program inday care. When the illness has subsidedand the patient begins to think of whathe or she does next, he will be referredto vocational rehabilitation or returnedto his home, school or job, as discussedall during the patient's hospitalization.The patient's plans for discharge aremade almost immediately after coming

10

to the program. After the experience inday care when the patient has more con-fidence in himself, he may be referred tovocational rehabilitation and/or may besent back to his job in the community.The average length of stay on the in-patient service is 6 days for most ill-nesses. However, the average length ofstay in day care may be 2 to 3 months,depending upon the degree of the illness.The patient may be discharged from daycare and not come back at all or he maygo from day care to outpatient situationfor either drugs, group therapy, or in-dividual therapy. In any case he is a freeagent usually back working on his own.

Now you may say, "What about thepatient who is chronically ill and whohas had three and four episodes of ill-ness?" These patients are provided for inessentially the same way. The acute man-ifestations of the disturbance are man-aged on an inpatient basis until the pat-ient is able to manage himself at home.He then may be treated in day carewhich is the same treatment being con-tinued but he is now able to live at homeinstead of the hospital, and he may befollowed on an outpatient basis. We re-cognize that for this group of patients,identity with our center may be a life-time one because their illness will comeand go as they meet various stresses with-in the community. So we have to planfor these patients a long-term programof treatment with the goal of helpingthem to maintain as high a level of func-tioning as possible. The most, meaningfulgoal though that one has to have forthese patients is to enable them to livehappily in the community and enjoytheir lives.

Toward this end many volunteer or-ganizations in the community help thepatient to have fun. As an example, Icite the Senior Citizens. However, not allof the patient's life in the community ishappiness and joy. Many patients findjust as much desolation and loneliness inthe third rate hotel rooms and in theflop houses or the nondescript boardinghomes as they would on the wards of the

state hospital. In fact, you have had theexperience of having patients refuse toleave the hospital. They have found moremeaningful relationship in the state hos-pital community and, therefore, a moremeaningful life. You have given themmore acceptance and understanding therethan they could find in the cold un,friendly community. What they need athome in their community is a familiarface, people who understand what theyare experiencing, people who under-stand what being ill is like, who care andare there to help them through their ex-perience. Psychiatric technicians are thesekind of people and have done this kindof service in the hospital, and, in someplaces, are now doing it in the com-munity.

Social welfare workers , physicians,and psychiatrists are also these kinds ofpeople, but are not as involved in thestresses and strain of the daily living asthe public health nurse, the mentalhealth nurse and the psychiatric tech-nician.

I would like to describe the functionsof the inpatient, outpatient and day careprograms and the required duties.

The inpatient service is similar to theadmission and acute treatment wards inthe state hospital. The main job isintensive psychiatric treatment. Thenursing care is provided by psychiatricnurses assisted by licensed vocationalnurses and attendants, and psychiatrictechnicians in a few cases. The presentbasic training of the psychiatric tech-nician along with the Range B trainingwould be adequate for this program. Thefollowing differences are important.

1. The hospital stay is short.2. The patient is a free agent and is

regarded as such.3. The major emphasis is on rapid

effective treatment and early re-tum home.

Outpatient L.;rvice includes home visit-ing and emergency care.These services are new to the psychi-atric technician except in some fewplaces. The technician's knowledge and

11

ward experience with the acute andchronicaThi ill is a good background. Themanagement of patients in these servicesis different. Home visiting is new to psy-chiatry. The technician is expected to beable to do things for patients by doingthings with the patients. The goal of carehere is to enable the patient to use thecommunity and its resources as a full fled-ged citizen. Mentally ill people have notbeen so regarded o- treated by the pub-lic or by the professionals caring forthem. This requires the technician andall professionals to examine his own basicconvictions. Are these poor mentally illpeople as good as I am? Do they have theright to be my neighbor?

Emergency service is just what it says:care for people in crisis. The crisis maybe determined by the patient or his care-taker. It usually comes when patientssucceed in getting others nervous aboutthem.

Day care programs are familiar to statehospitals and those technicians who havehad this unique experience in state hos-pitals. Those technicians who have beenpart of the special Hospital ImprovementProgram project involving rehabilitationwould be at home in the communityprograms, for many of the Hospital Im-provement Program grants have preparedthe people in them for the kind ofpractice that is carried out in the com-munity: The Mendocino Pkograms TheStockton State Hospital Program TheCamarillo Program The Group LeaderProgram Range B.

Local programs are authorized to bereimbursed for halfway houses and otherappropriate protected living programs.

What can psychiatric technology do tomeet the challenges of community pro-grams? What are some of the problems itshould consider?

1. Psychiatric technology can re-main as it began and is now, an ancillarynursing service, providing basically nurs-ing care. Whether he is an assistant nurseor a junior nurse is not important. Thetechnology now is defined within thecontext of nursing and as such will be

viewed as a branch or sub-branch.2. Psychiatric technology can take

a hard look at what community pro-grams are and what they will need, andadd to its skills those which would makeit provide some unique service in theprogram not now provided. These skillsare in social service areas: knowledge ofcommunity agencies, occupational ther-apy, skills in use of crafts, public healthaid, vocational rehabilitation. The psy-chiatric technician then becomes a gen-eralist in community care, able to bringmore skills to the patients. The degree oftraining in these areas would be less thanthat of the professional at the collegelevel. Outpatients may not need theseservices from that professional.

3. These are some problems:1. The psychiatric technician pro-

fession is basically state hospital nursingcare-oriented as to training and salary.

2. Inpatient services in communityprograms are in county or private hospi-tals provided under service contracts.These county and/or private hospitalshave never used psychiatric technicians.

3. There is no such position in coun-ty civil service structure.

4. Local mental health directorslook at cost of manpower related toskills produced. Six thousand dollars ayear buys a technician, nurse or mentalhealth rehabilitation worker with A.B.degree. Who is more effective in doingthe job? Program directors may not beaware of skills technicians have.

5. Opportunity for vertical promo-tion in community programs is limited.Technician supervisors, A.S.N.S. etc.,are not used as such because there arenot the large living units as in state hos-pitals. Supervisory positions in nursingare filled by psychiatric nurses, with orwithout degrees. Horizontal promotionsbased on responsibility for managementof a program is more lilr.ely. Tvie7e is notmuch of an established formai personnelorganization in county government spec-ifically for mental health programs.

6. Problems related to legislation:Community programs are funded by re-

12

imbursement. The service must be creat-ed and produced before it can be collect-ed for, There is no advance capital tostart new programs except from countyfunds. For example, Fresno County hasapproximately 600 former Stockton StateHospital patients here. We have designedand planned a program of continuedcare for them. In order to carry this pro-gram out we need to hire some people.There is a statutory provision for 100%reimbursement. The people would have tobe hired out of this budget, the servicesrendered and then collected for. If thereare no funds to hire them, the servicesare not rendered, therefore, cannot becollected for. It's the same problem facedby a broke mechanic who wants to starta garage or a broke cook who wants toopen a restaurant.

7. Senate Bill 677* in its presentform presents some problems. It providesfor a more expensive system of care loc-ally than counties presently have. Thefinancing is by reimbursement with nocapital for expanding or starting program.It eliminates the present commitmentsystem before the alternative programcan be developed. It also identifies men-tally ill people in state hospitals as dan-gerous. This sanctions, by law, the fearsand apprehensions the public has hadabout the mentally ill. The only men-tally ill who can be involuntarily com-mitted are those who have been certifiedas dangerous or those who are so disabledthey need conservators. All others can govoluntarily to the state hospital; but whowould voluntarily go to a place that hasbeen explicitly designated for dangerouspeople? Would this be a safe place fortreatment? The state hospital remainsa major resource in mental health pro-grams. The Department of Mental Hy-giene is committed to providing an ex-cellent level of care there and is inte-grating the two programs. Communityprograms cannot carry the treatmentload alone. This language of the law com-promises the effective integration of statehospital and community program by de-claring the state hospital as the place for

dangerous people involuntarily commit-ted and then encouraging all othersvoluntarily to go there. State hospitalshave increased their voluntary admissionrates, opened their wards, developedtherapeutic community programs, and insome cases integrated their programswith the community. At the same timethey have treated people who haddangerous behavior because of mentalillness at no great risk to the safety ofeither community. This has beenpossible because the focus was not onthe 2atient's dangerous and possiblypermanent behavior, but rather on thepatient's treatable and therefore tempo-rary illness.

The SB677 implies that once mentallyill and dangerous always mentally ill anddangerous, and this is perplexing to boththe patient and the staff and makes forsuspicion and distrust of each other.

"I'm voluntary and safe.""He's involuntary and dangerous.""So if you're so safe why didn't theykeep you in your local program? Whydid you volunteer to come here?"Likewise in the local program the same

questions arise among the "three-dayer",the "fourteen-dayer", and the volunteers.Voluntary commitment which shouldarise from self-awareness and self-seekingof help may well become submission tothe tyranny of the system which growsfrom fear. "If you don't go voluntarilyfor the treatment I think you shouldhave, I'll have you declared dangerousand put away until you are proven safe."

In summary:1. We must dedicate our thinking to-day to the patients of the state hospi-tal community who are left behind, aswell as to those in the non-hospitalcommunity who are here with us.2. The discussion of the communityprogram is our message to them that

they still belong to the community ofmankind and, therefore, retain mem-bership in their own. They are in ourthoughts, our plans, our hopes, andour ambitions.3. The psychiatric technician remainsa major resource in mental health.There are some challenges. The profes-sion has to meet these challenges to re-main a viable resource in the commun-ity program.4. There are some immediate organiza-tional and legislative challenges to bemet if this manpower resource is goingto be made available to communityprograms.

a) The education of lay and pro-fessional leaders in local programson the availability of this resource.b) The integration of supplementaryeducation and skill into the profes-sion necessary for the full utiliza-tion of the technician by the patientin the community.

Senate Bill 677: This organization as oneof the professional organiz ations ofpeople who care for the mentally illshould join with other professional or-ganizations to study this bill and makerecommendations for revisions.

We who have dedicated our profession-al lives to the care and treatment of thementally ill should not concern ourselvessolely with the mechanics of financingprograms. Experts will do that. Norshould we concern ourselves with theesoteric philosophical preoccupations oflaw. Other experts will do that. Norshould we concern ourselves with thesame basic question that the authors ofthe bill themselves are sincerelyconcerned with, namely, "How can thisbill be made so that it will be effective inbringing services to the mentally ill witha minimum of delay, despondency, anddespair and a maximum of health andhope?"

* Lanterman-Petris-Short Act (Mental Health Act of 1967) provides for changes inthe commitment system for mentally ill to prevent inappropriate and indefinitecommitments. Other portions of the Act encourage the development of localservices and foster a greater integration of state hospitals and local programs.

13

SYMPOSIUM: INTERPRETING FEDERAL AND STATE REGULATIONS

WHICH AFFECT STAFFING STANDARDS FOR NURSING

SERVICES IN STATE AND LOCAL FACILITIES.

MODERATOR: Leland F. ErbacherMEMBERS:

Howard A. Worley

Ralph Zeledon

Moderator Erbacher is employed bythe Training and Research Division, Per-sonnel Office, of the Department ofMental Hygiene of California.

INTRODUCTIONS TO SYMPOSIUM

by Howard A. Worley

Mr. Worley, a graduate of StanfordUniversity and its School of Business,is Chief of the Bureau of Licensing andCertification for the California Depart-ment of Public Health. He has been withthe Department since 1949. His Bureauis responsible for the licensing of morethan 1900 health facilities and for theircertification for participation in the stateand federal medical care programs.

The title for the subject matter beingconsideied today suggests that the Staterequirements for licensure of health facil-ities and the Federal requirements forparticipation in the medical care pro-grams are in need of interpretation.

These requirements indeed do needinterpretation or at the very leastexplanation. Words can mean differentthings to different people and regul,tions must be set down in words.

By way of background, let me describebriefly how licensure requirements forhealth facilities are established. As youknow, both the State Department ofPublic Health and the State Departmentof Mental Hygiene have responsibilitiesfor health facility licensing programs.The Department of Public Health licenses

14

hospitals, nursing homes, establishmentsfor handicapped persons, certain clinics,home health agencies, and clinical labora-tories; and by formal agreement with theState Department of Mental Hygiene,and subject to Department of MentalHygiene requirements, the Health Depart-ment licenses and inspects alcoholismhospitals, long term facilities for thementally ill and day care centers for thementally retarded.

The Department of Mental Hygiene hassole licensing responsibility for psychiat-ric hospitals, day treatment hospitals,children's treatment centers for the emo-tionally disturbed, family homes formentally ill, resident schools for thementally retarded and nurseries for thementally retarded.

There is a Hospital Advisory Board,appointed by the Governor, which ad-vises the State Department of PublicHealth regarding reasonable rules andregulations for the hospitals and nursinghomes licensed by the State Depart-ment of Public Health. This Board holdsthree to four public meetings each yearto consider proposals for changes in therequirements for the licensure program.The Recommendations of the AdvisoryBoard must be adopted by the StateBoard of Public Health, in public hearing,before filing with the Secretary of Stateas part of the California AdministrativeCode.

In practice, proposals which are con-sidered by the Hospital Advisory Boardare discussed with the professional organ-izations concerned: the California Hospi-tal Association, the California Associationof Nursing Homes, and the CaliforniaMedical Association. Each of these organ-izations has a consultant to the Depart-ment on matters regarding the licensureprogram. Additionally, special areas of

interest are discussed with the respectiveprofessional associations, particularly theCalifornia Nurses' Association regardingnursing services and the California Coun-cil, American Institute of Architectsregarding construction requirements. Dis-cussions are also held with the Associa-tion of Medical Records Librarians, As-sociation of Hospital Pharmacists, Physi-cal Therapy Association and others re-garding specific problem areas.

The State Department of Mental Hy-giene employs similar procedures fordeveloping licensure requirements forhealth facilities under its jurisdiction,except that no provision is made bylaw for an advisory board. Special com-mittees serve this function on an inform-al basis.

Each of the classifications of facilitieslicensed by the two Departments havediffering staffing requirements for nurs-ing and other personnel. It would be con-fusing not only to you but to myself ifI attempted to recite these requirementsin detail. However, I would like to men-tion a few basic requirements and con-fuse you only with the specific require-ments for nursing homes and long termfacilities.

All facilities are required to have suf-ficient qualified personnel to providecare to patients in the institution bothday and night. The actual number ofnursing personnel which must be em-ployed involves a judgement factor andcan vary with the number of patientsbeing cared for, the specific needs ofthose patients, t!,-, qualifications of thenursing personnel employed, and thelayout or arrangement of the physicalplant.

Hospitals licensed by the Depart-ment of Public Health and psychiatrichospitals licensed by the Department ofMental Hygiene require a registerednurse on duty at all times, with additionalqualification by education, training andexperience for the director of nurses orsupervisor in larger institutions.

Public health nursing homes of 10 orfewer beds must have at least one nurse

15

who is a registered nurse, a licensed voca-tional nurse or a person who is quali-fied by training and experience to super-vise the nursing care in the institution.The adequacy of this training and experi-ence is determined by the Department.Nursing homes of 11 to 25 beds musthave a registered nurse, a liters red voca-tional nurse, or a nurse graduated from aschool of nursing who the Departmentdetermines has sufficient training andexperience to assume the responsibilityof supervision of nursing care.

Nursing homes of more than 25 bedsmust have a registered nurse on duty dur-ing the day shift responsible for supervi-sion of nursing care. Additionally, nurs-ing homes of 60 to 99 beds must haveeither a registered nurse or a licensedvocational nurse on duty during theremainder of the day and night. Nursinghomes of 100 or more beds must have aregistered nurse on duty at all times.

Mental Hygiene long-term facilitieshave similar yet different requirements.The facility of 25 or less beds must havea registered nurse, a graduate nurse, alicensed vocational nurse with two yearsexperience subsequent to licensure, or acertified psychiatric technician withtwo years experience subsequent tocertification to be responsible forsupervision of nursing services during theday shift. Facilities of 26 or more bedsmust provide a registered nurse, duringthe day shift responsible for supervisionof nursing services. Facilities of 100 ormore beds must have a registered nurse, agraduate nurse, a licensed vocationalnurse, or a certified psychiatric tech-nician on duty at all times. Facilities of200 or more beds must have a directorof nursing services who is a registerednurse qualified by education, training,and experience in nursing administration.

At this point I can anticipate a ques-tion running through your minds. Whydo the Public Health requirements ex-clude mention of certified psychiatrictechnicians?

Two other state agencies now becomeinvolved - the Board of Nursing Educa-

lion and Nurse Registration and theOffice of the Attorney General. section2728 of the Business and ProfessionsCode - part of the Nursing Practice Act -

states:

"If adequate medical and nursingsupervision by a professional nurse ornurses is provided, nursing service maybe given by attendants in institutionsunder the jurisdiction of or subject tovisitation by the State Department ofPublic Health, the State Departmentof Mental Hygiene or the Departmentof Corrections.

"The Director of Mental Hygieneshall determine what shall constituteadequate medical and nursing super-vision in any institution under thejurisdiction of the State Department ofMental Hygiene."

The same Act defines a professionalnurse as one licensed as a registered nursein California.

The Board of Nursing Education andNurse Registration has interpreted this tomean that in facilities licensed by theState Department of Public Health,nursing services may be given by otherthan a registered nurse only if super-vision by a registered nurse is provided.This produces an apparent conflict fornursing homes of less than 26 bedswhich are not required to provide aregistered nurse supervisor. The Boardof Nursing Education and Nurse Regis-tration together with the Calif orniaNurses' Association has requested thatthe regulations be amended to require aregistered nurse supervisor regardless ofsize of the nursing home. Such a proposalwas reviewed by the Hospital AdvisoryBoard in September and was referred tothe Health Department staff for furtherstudy.

The present requirements wereadopted in 1959 following extensive dis-cussion by the Hospital Advisory Board.The question of the certified psychiatrictechnician was not considered at thattime. That the certified psychiatrictechnician should be considered as the

16

equivalent of the Licensed VocationalNurse has been posed since. Such equiv-alency has, however, not been specificallyproposed as an amendment to existingrequirements. I can only point out thatthe education and experience require-ments for certification are different thanrequired for the licensed vocationalnurse, and that the psychiatric techni-cian who meets the education and expe-rience requirements may qualify to takethe examination for licensure as a voca-tional nurse but only until next year,unless the law is extended.

If I may digress for a moment. Al-though there is no specific mention ofthe duties of the nursing supervisor inregulations or requirements, she is ex-pected to perform certain functions inthe nursing home. A high level of train-ing and experience is necessary to per-form these functions adequately. Let memention a few of her duties:

1. Developing and maintaining nurs-ing manuals.

2. Writing and updating job descrip-tions for nursing personnel.

3. Recruiting and selecting nursingpersonnel.

4. Assigning and supervising all nurs-ing personnel.

5. Participating in patient care plan-ning and job analysis.

6. Coordinating the various patientcare services.

7. Planning and conducting in-ser-vice programs.

8. Determining the assignment ofpatients in the facility.

9. Delegating the responsibility forcarrying out the patient's nursing careplan and reviewing the plan with theperson to whom the duty was delegated.

10. Making daily rounds, visiting eachpatient, reviewing clinical records, medi-cation cards, and staff assignments.

The basic statutory requirements fornursing services in extended care facili-ties for participation in the FederalMedicare program are that at least oneregistered nurse be employed full timein the facility and be responsible for the

nursing service, that a registered nurseor licensed vocational nurse be on dutyat all times to be in charge of nursingactivities, and that sufficient nursing per-sonnel be on duty at all times to meetthe total needs of patients.

Nursing personnel for determining ade-quacy in numbers includes registerednurses, licensed vocational nurses, aidesand orderlies.

In addition, the facility must meet theState's licensing standards whether sub-ject to licensure or exempt. State licen-sure requirements exceed Medicare condi-tions of participation for nursing servicesin one area only, in that nursing homes of100 or more beds are required to have aregistered nurse on duty at all times.

For the State Medi-Cal program - atthe present time the only requirementfor participation as a nursing home isthat the facility be licensed by the StateDepartment of Public Health or theState Department of Mental Hygiene orbe exempt from licensure. Further re-quirements, to be effective January 1,1968, are essentially the same as forMedicare for nursing services, or, pro-vided the State Department of PublicHealth determines by November 30,1968 that the facility shows reasonableexpectation of meeting this and otherstandards, by January 1, 1969.

The requirements for Medicare and forMedi-Cal for hospitals owned and oper-ated by the state are the same as for non-state hospitals. However, a problemappears to arise. Hospitals accredited bythe Joint Commission on Accreditationof Hospitals by Federal law meet the con-ditions of participation for hospitals ifthey have an acceptable utilization re-view mechanism, and in the case of psy-chiatric hospitals meet certain other con-ditions regarding medical records andsocial services. All of the State Hospitals,exer;pt those operated by the Depart-ment of Corrections, are certified to par-ticipate in both programs for hospitalservices.

17

The hospitals operated by the StateDepartment of Mental Hygiene are cur-rently certified as psychiatric hospitals.The provisions of the Federal MedicareProgram permit the psychiatric hospitalto have a "distinct part" and be certifiedeither as a general hospital for medical-surgical services or as an extended carefacility providing skilled nursing services,if the distinct part meets the conditionsof participation. If so certifies', the dis-tinct part is also eligible under the Medi-Cal program.

At the present time it is unclear re-garding the eligibility of hospitals for thementally retarded to participate either inMedicare or Medi-Cal other than for adistinct part certified either as a generalhospital or as an extended care facility.

The Departments of Public Health,Mental Hygiene, and Social Welfare andthe Office of Health Care Services areworking together closely to attempt tosolve the problems both of eligibility ofthe hospitals and eligibility of patients.We hope that a satisfactory solution canbe arrived at which will be acceptableto the Federal agencies concerned.

In closing I would like to leave a fewstatistics with you.

In 1956 the Health Department li-censed less than 1,000 facilities with acapacity of 57,000 beds. Today, includingthe mental health facilities, the Depart-ment licenses more than 2,000 facilitieswith 150,000 beds. The bulk of thisspectacular increase has been in nursinghomes, which added approximately 600facilities and 50,000 beds during the11-year period.

While we don't have complete informa-tion on nurse staffing, some samplinginformation on nursing homes is ofinterest. Surveys of nursing homes in1961, 1964, and 1966 indicate that nurs-ing personnel employed have kept pacewith the increase in number of beds.

The table below shows the trend instaffing nursing homes.

Estimated Number of Nursing Service Personnel (Full timeequivalent) in Nursing Homes

Year RN Graduates INN Other Total Beds

(March 31)

1961 700 260 480 5,400 6,840 18,778

1964 1,390 360 920 8,800 11,470 36,351

1966 2,100 100 1,400 15,600 19,200 61,736

(Sept. 30)

1967 2,500 100 1,600 18,600 22,800 61,229

by Ralph Zeledon

Mr. Zeledon, Coordinator for Medi-Care for the California Department ofMental Hygiene, is a graduate of theuniversity of Southern California. Mr.Zeledon was awarded a Master of SocialWork degree from the School of SocialWork of Los Angeles, and is a memberof the Academy of Certified Social Work-ers. He was formerly associated with theEconomic Opportunities Council.

Perhaps the best way to approach thissubject is to give you a brief descriptionf my job; then the history of the

Department of Mental Hygiene in regardto the Medicare - Medi-Cal programs;and finally bring you up to date wherethings now stand and present goals andcomplications.

riefly, the Coordinator of MedicareServices coordinates the Department'sprogram for securing benefits which areavailable under the Federal and StateMedicare laws and regulations; analyzesand evaluates Medicare legislation, rulesand regulations to determine benefitsavailable to mentally ill and mentallyretarded patients and types of servicesrequired for participation in the Medicare

18

program; and proposes departmental pol-icies and procedures for securing benefitsfor, and providing services to patients.

Medicare is a nationwide program ofmedical insurance for persons age 65 andover. It is related to he Social SecurityBenefits Program and is an insurance pro-gram which limits benefits to a 90-dayspell of illness or hospitalization. Medi-Cal or Medicaid as it is known nationallyis a Federal encouragement for states tolaunch their own programs in which theFederal Government will pay 50% of thecost. It is available for all four categoriesof public assistance and any medicallyindigent who can meet the criteria of awelfare category other than income. Aregular medical hospital can bill foreligible Medi-Cal beneficiaries in anyage group. However, with the psychiatrichospital there is what is known as apsychiatric exclusion which limits pay-ments to persons age 65 and over.

Medicare or Title XVIII pays almost100% of the cost for prescribed periodswhen the patient is eligible. Medi-Cal orTitle XIX is paid out of the Health CareFund and then reimbursed 50% federally.Therefore, half the cost is Federal andhalf is State. But the Department ofMental Hygiene does not keep any of

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these payments as it operates on anallocated budget. Medicare payments areforwarded back to the Health Care Fund.Therefore, this program within the De-partment of Mental Hygiene representsa shifting of cost from the State to theFederal Government. The money doesnot go back to the hospital to raise thelevel of care. There are some minor bene-fits to the hospital in meeting Federal re-quirements.

To receive Medicare payments, a hospi-tal must be approved as a vendor of serv-ices by the Social Security Administra-tion. The Social Security Administrationdoes not have the staff within each stateto survey hospitals and ascertain whichhospitals meet the Federal requirementsand, which do not. Therefore, each statedesignates a state agency to act in thismanner in behalf of the Social SecurityAdministration. The Federal Governmenthas spelled out the specific requirementsin the booklet entitled "Conditions ofParticipation for Hospitals". One of therequirements which must be met is con-dition Number V for the Nursing Depart-ment. It reads as follows "The hospitalhas an organized nursing department. Alicensed registered professional nurse ison duty at all times and professionalnursing service is available for all patientsat all times." If a facility or part of afacility is to be considered an extendedcare facility, it must meet the followingrequirement: "The extended care facilityprovides 24-hour nursing service whichis sufficient to meet the nursing needs ofall patients. There is at least one regis-tered professional nurse employed fulltime and responsible for the total nursingservice. There is a registered professionalnurse or licensed practical nurse who isa graduate of a state-approved school ofpractical nursing in charge of nursing ac-tivities during each tour of duty." How-ever, if a hospital is accredited by theJoint Commission on Accreditation ofHospitals, it is pre; wed to meet all ofthe requirements with the exception ofUtilization Review. This is a criticallyimportant distinction.

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In 1956, the Department of MentalHygiene requested that all 14 State hospi-tals and the 2 neuropsychiatric institutesbe approved as psychiatric facilities. Allwere approved on the basis of being ac-credited.

In California Department of MentalHygiene hospitals, there are approximate-ly 13,000 mentally retarded patients. Ofthese, approximately 177 are age 65 andover and qualify for Medi-Cal benefits.If these hospitals were classified as medi-cal instead of psychiatric, the psychiatricexclusion for patients under age 65 wouldnot apply. There are approximately7,000 patients between the ages of 18and 65 who could meet the criteria ofthe Aid-to-the-Disabled program. Thepotential revenue here is for between$2.5 and $3 million per month of which50% would be paid for by the FederalGovernment.

Therefore, the Department of MentalHygiene asked for a change in classifi-cation for hospitals for the 'nentally re-tarded from psychiatric to medical hospi-tal. This request was made in August1966. The Social Security Administrationis admittedly apprehensive about chang-mo. the classification of the hospitals forthe mentally retarded. The entire TitleXIX program has cost far more than ex-pected. Perhaps this is why the SocialSecurity Administration has never madea decision on this matter.

When the Department of Mental Hy-giene requested reclassification of thementally retarded hospitals, a differenceof opinion developed between the De-partment of Public Health and the De-partment of Mental Hygiene. PublicHealth felt that the hospitals do notreally meet the requirements for a medi-cal hospital and that they would have tobe surveyed to determine the conformitywith the Federal requirements. Whateverportions did not conform would be des-ignated as extended care facilities orsimply not included in the program. TheDepartment of Mental Hygiene main-tained that accreditation was sufficientand the hospitals did not have to be sur-

veyed. The impasse was not in the bestinterest of the State. Therefore, in aneffort to resolve the differences, the De-partment of Public Health agreed to sur-vey one hospital to determine how farapart the two Departments were intheir thinking but to take no action onthe survey without Department ofMental Hygiene approval. This was doneat Fairview State Hospital on July 25-26,1967.

The findings of that survey were thatunder one classification or another everybed in the hospital could be approved if10 registered nurses and 10 LVNs wereadded to the staff. The Department ofMental Hygiene asked the State Depart-ment of Public Health to survey the restof the hospitals for the mentally retardedand present their findings to Dr. JamesLowry, Director of Mental Hygiene, forhis consideration.

Suddenly, a barrage of telephone callswere received at the Department of Men-tal Hygiene Headquarters protesting theassignment of the additional staff. Dr.Lowry stated that there would be nochanges until he could see the total rec-ommendation. The surveys were com-pleted and the findings presented onSeptember 20. At that time, the adminis-trative staff at the Department of MentalHygiene recommended to Dr. Lowry thatthe Department hold its ground and COl-itinue to seek approval of the hospitals onthe basis of their being accredited.

We are still in the midst of negotia-tions. The hospitals may be approved bythe Social Security Administration onthe basis of accreditation. If so, there willbe no need to alter present staffing pat-terns to qualify. If not, I cannot foretellthe outcome.

It behooves us to look at the realitieswhich will have to be considered in mak-ing a decision. To decide not to partici-pate in the Medi-Cal program will mean

the State's forfeiting between $12 and$25 million per year of Federal money.This is where the matter stands now.

In concluding, I would like to com-ment on the effect I believe these Federalprograms will have on the psychiatrictechnicians. The decreasing mentallyill population is fact, not prophecy. Thequestion is to wl extent will it decrease.I think there is lithe doubt but that wewill see a similar de-population movementof the mentally retarded. This poses twoquestions:

1) What direction is the mentalhealth movement taking in California?

2) How do we enable staff occu-pationally to fit in with the new direc-tion? It seems to me that the futuredirection of mental health treatment inCalifornia is spelled out in the Lanter-man-Petris-Short Act.

Every effort will be made to providetreatment on a local level so as to avoidstate hospitalization. The local commun-ity then is where there should be jobopenings for people with psychiatricexperience. I would like to quote from(Division 5, Part 1, Chapter 1, Section5008(c) the Lanterman-Petris-Short Actin describing these local facilities:

"Intensive treatment shall be providedby properly qualified professionals andcarried out in facilities qualifying forreimbursement under the California Med-ical Assistance program or under TitleXVIII of the Federal Social SecurityAct and regulations thereunder."

Therefore, the question of Federalrequirements will be faced in the com-munity as well as possibly within theState hospitals. I wonder about thepossibility of psychiatric technicianspressing for an LVN equivalency ratingor some arrangement which would en-able them to move into the positionswhich will be created by these localfacilities.

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Legal Aspects Of UtilizationOf Psychiatric Technicians

In Mental Health Servicesby Robert Thorn, J. D.

Thorn, an outstanding authority onforensic psychiatry who practices in SanDiego, California, is that county's Chair-man of the Mental Health AdvisoryBoard, a member of the Governor's Ad-visory Committee on Mental Health, Pres-ident and Board member of the VistaHill Psychiatric Foundation, and hasserved on the Medical - Legal Institutefaculty of the Western and the CaliforniaHospital Associations. He has also con-ducted legal seminars for the NationalAssociation of Private PsychiatricHospitals.

In our modern society we frequentlyhear cries of loss of identity or lack ofidentification. From the standpoint ofprofessional identification in the legalsense, the psychiatric technician mightbe classified as the all-time loser. Whilethe "Psychiatric Technician Law" hasbeen part of the California Codes since1959, little has been gained under thisstatute toward legal identity as a trueprofessional in the healing arts. This maybe primarily due to the fact that the"Psychiatric Technician Law" is a cert-ification act as distinguished from alicensing act.

The distinction between the two basictypes of legislative recognition, i.e., thoseof certification vs licensing, is primarilythis: Under the certification act, as in thecase of the psychiatric technician, anyindividual, regardless of training or ex-perience may hold himself out to be apsychiatric technician and engage in suchpractices as are customarily performedby psychiatric technicians so long as hedoes not use the term "Certified Psychi-atric Technician".

In the case of licensing, as in the pro-fessi s ns of law and medicine, not only isone prohibited from using the term "law-

21

yer" or "physician", but one is also pro-hibited from engaging in the practice oflaw or medicine without a valid Statelicense. Historically, professional recog-nition has come from licensing and fromadditional standards of competency developed by an association of those engagedin the profession such as those beingdeveloped by your association. The latterwithout the former, however, has alwaysbeen legally ineffective. The psychiatrictechnician in California therefore remainsat most a civil service classification with-out true legal identification.

One thing that can be said about thelaws of the State of California and theadministrative rules promulgated undersuch laws is that they are consistent inthe non-recognition of the psychiatrictechnician. A two-months intensive studyof such laws, rules and regulations of thisState discloses that in no single instanceoutside of the "Psychiatric TechnicianLaw" is a psychiatric technician recog-nized as even existing.

All portions of the California Admin-istrative Code relating to professionalstandards for all types of medical insti-tutions° from the nursing home or sani-tarium to the general hospital, fail to setforth a single mention of the psychiatrictechnician, while at the same time recog-nizing the professional status of theLicensed Vocational Nurse. It is paxcul-arly upsetting to find that in the admin-istration rules for staffing under theShort -Doyle Act, the categories dropfrom the registered nurse to attendants.Until the implementation of titles 18 and19 of the Social Security Act, betterknown as Medicare and our Medi-cal programs, little or no problemswere encountered from the hospitals'standpoint in staffing standards as theywere primarily free to prescribe their

own rules within the somewhat vaguestandard set forth by the Joint Commis-sion on Accreditation of the A. M. A. andA. H. A.

Under the Nursing Practice Act, theDirectors of the Departments of MentalHygiene and Public Health were givencarte blanche authority to determineproper nursing staffing procedures instate hospitals. While currently FederalGovernment is accepting accreditation bythe Joint Commission as satisfactoryproof of proper staffing for Medicare andMedi-Cal, there appears to be a great fearon the part of the hospital administratorthat the Federal Government will in thenear future impose greater and muchmore stringent staffing requirements.

While, as mentioned, California is con-sistent in its non-identification of thepsychiatric technician, the Federal Gov-ernment follows a great path of incon-sistency in this regard with its variousprograms.

In its 64-page book of rules for condi-tions for participating hospitals underMedicare, the psychiatric technician ismentioned only once and this is in regardto the authorization to give medicationsunder the direct supervision of a regis-tered professional nurse in a general hos-pital. It is somewhat discouraging to findthat while these rules prescribe specialstaffing procedures for psychiatric hospi-tals requiring utilization of milieu ther-ap3 and the team approach to treatment,no reference is made to the psychiatrictechnician.

The highest governmental authorityfor the interpretation of these rules asapplied in the State of California haspublicly stated that while the licensedvocational nurse can be recognized in thestaffing pattern, of a hospital, the psy-chiatric technician, whether certified ornot, cannot receive such recognition asthey are "not licensed personnel". Theidentical procedures and applications areutilized in Medi-Cal as well as in the Medi-care program. Conversely, in the federallysp nsored Home Health Program, reim-bursement may be obtained f u r perform-

22

ante of services by psychiatric technic-ians. Again under the Community Men-tal Health Centers Act, the NationalInstitute of Mental Health recognizes theutilization of the psychiatric technicianand will reimburse a hospital for servicesperformed by the psychiatric technicianunder its federal staffing grant.

With the growing support of programsin the non-governmental psychiatric hos-pital and mental Hcalth Center by boththe State and Federal Governments, thereobviously is a need for the increased util-ization of the psychiatric technician insuch facilities.

During the last year, many adminis-trators and directors of nurses in suchhospitals, have expressed concern aboutthe use of psychiatric technicians for per-forming nursing services in relation toliability for malpractice. We have pointedout to such individuals that if a negligentact is performed by an employee of thehospital whether it be a psychiatric tech-nician, a licensed vocational nurse, orregistered nurse, the liability is identical.In the absence of the negligent act bysuch employee, the hospital faces liabilityonly if the employee is required to per-form a service for which he has not beentrained. In other words, we see no haz-ard whatsoever in the utilization of thepsychiatric technician within the limitsof his training.

I am sure that most of you here todayare saying, "Well, we recognize our lackof identity under both State and Federallaw, but what can we do about it?" Whatconstructive steps can be taken to gainprofessional recognition in the eyes ofboth the State and Federal Government.I would suggest consideration of the fol-lowing measure.

First would be an appeal to the Sec-retary of Health, Education, and Welfareto establish and recognize the psychiatrictechnician as an integral part of the treat-ment team in milieu therapy, whether itbe in a psychiatric hospital or in a generalhospital providing psychiatric care. Therecent amendments to th,, Social SecurityAct give the Secretary a great deal of

discretion in setting forth the rules andregulations applicable to the Medicareand Medi-Cal programs and he fully haswithin his power the right to give suchre -tognition. Should the Secretary be non-responsive to such an appeal, we wouldsuggest that a Joint Resolution of theCongress be sought, expressing congres-sional opinion that the psychiatric tech-nician be recognized in a professionalstatus under all of the various federalprograms for the treatment of the men-tally ill and mentally retarded.

Finally, and perhaps the most import-ant, you should consider proposing aproper licensing statute defining thescope of the practice of the psychiatrictechnician and prohibiting practice ofpsychiatric technology except by thosepersons meeting proper standards of ed-ucation and experience.

I think that the average citizen inCalifornia might be somewhat astonishedto find out that someone who is entrust -

ed with the great responsibility of directcare to the mentally ill performs thisservice as an unlicensed individual, whileno-one can cut your hair, or press yourpants in this State without being licensed,We would question whether such pro-posed licensing legislation should be sub-servient to the Nursing Practice Act.The services rendered by the psychiatric

23

technician seem to be by nature muchbroader in their scope than normal nurs-ing practices, particularly in the applica-tion of other social sciences.

As many of you are aware, the legis-lature amended the"Psychiatric Technic-ian' Law" so as to plate the psychiatrictechnician in a direct line of communica-tion with the physician as distinguishedfrom the former requirement that he besubordinate to a registered nurse. This,at the request of the Department of Men-tal Hygiene, was unfortunately vetoed bythe Governor. We do feel, however, thatin the coming year with proper explana-tion to the administration, such legisla-tion might be successful.

In a recent meeting sponsored by theCalifornia Hospital Association, a leadinghospital administrator stated that the reg-istered nurse has reduced her role to thatof an injection giver and that others wereperforming her previous service of directpatient care. If others like the psychiatrictechnician are in fact performing suchservice, why should they not be licensed,recognized and identified?

SEE APPENDIX I:ALL THAT GLITTERS MAY NOT BEGOLD

Private Psychiatric Hospitals

by Arthur Jost

Arthur Jost, Administrator of King'sView Hospital, Reed ley, California, isPresident of the California Hospitals As-sociation and Chariman of the CaliforniaCommittee of the National Associationof Private Psychiatric Hospitals. He haslong been lauded as a leading authorityin planning and development of psychi-atric facilities throughout the country.

The California Hospital Associationhas historically been related to generalhospitals. Today, the administrators arebeing urged by the A.H.A. as well as bythe C.H.A. to establish community com-prehensive centers which would includecare of the mentally ill. Some of us whohave for many years been active in theC.H.A. are quite concerned with theHealth Care Fields movement into theproblems of the mentally ill and men-tally retarded.

First, I want to go a little bit into mybackground so that you can appreciatesome of my perspectives regarding per-sonnel. About 20 years ago, after servingfor 3 years in a state hospital both inpersonnel work and ward work, I wastransferred to the headquarters of theMennonite Hospital in Pennsylvania.

Through a great deal of survey andsearch work the Mennonite Church,which has operated many hospitals, nurs-ing homes, and old people's homes,felt that it should move into the areaof providing instit,-.''ons for the mentallyill. We had one mci institution locatedin the Crimea in Russia. Many of ourpeople lived there, and one of the brightspots in their history was the establish-ment of a 100-bed, non-sectarian generalhospital. This heritage, plus experienceduring World War II in civilian public

24

service, prompted the church to moveinto a mental health program. At thattime, 1946, it projected three small psy-chiatric hospitals: one near Hagerstown,Maryland, OM in Newton, Kansas, andone in Reedley, California. I assisted inthe establishment of a 40-bed hospitalnear Hagerstown which is considered tobe a comprehensive mental health center.I then assisted in the establishment ofPrairie View Hospital in Kansas. One ofthe very significant things this hospital isdoing is working through a state hospitalin the impl3mentation of a large mentalcare research program. We also estab-lished King's View Hospital in 1951 andtoday this hospital is a 55-bed facility.We also moved into the Day Care pro-gram in Elkhart, Indiana. Today we areoperating a rather large program therewith placement homes right in the com-munity. There, some patients from outof town can now stay overnight.

Our most recent completed project isat Bakersfield. On the invitation of theMemorial Hogpital Board in Bakersfield,our Board of Directors duplicated King'sView Hospital there and it has been inoperation for one year. This 25-bed hos-pital will be expanded to 50 beds.

The real motivations for this dynamicprogram in the United States in 1946were diverse. One was to provide care forour members. This element today con-stitutes only about 2 per cent of our pa-tient load. We made it nonprofit andwere able to establish a reasonable fee.Then, the church, through its colleges,church programs and publications, be-came interested in learning what it couldabout the potentials in the field. We feltthat the hospital itself could be sort of alaboratory where we would build experi-ence that could help us progress. Therewas also another motivation which came

out of our public service experience. Thiswas to utilize the large resources of per-sonnel which we discovered to be avail-able. Thousands of young people haveworked in these institutions. It is veryheartening to see how many of theseyoungsters, having completed a year ortwo, have gone into the various profes-sions. We have today a large number ofpsychiatric social workers in our church,a few psychiatrists, some nurses, andmany psychiatric technicians who havegone into these fields professionally be-cause of the experiences they had in ourinstitutions. I might add here, parenthet-ically, that back in about 1950 or 1951,I also assisted in opening certain otherservices at Mendocino, Camarillo, Atasca-dero, and a few other State Hospitalswhere some of our students and youngpersonnel, were working alongside thepsychiatric technicians.

At Kings View Hospital we have ex-panded to operation of out-patient clinicsin Hanford and Visalia. At King's ViewHospital we are widening our sphere ofactivities. First of all, we are interested indirect care to in-patients. Up to 1955 wewere pretty well satisfied that our pro-gram would be an in-patient service pro-gram. But later, with development ofmany of the drugs, we broadened ourvista and became involved in non-directservices in (communities. So today we areinterested in both, and the in-directservices are being advanced in Visaliaand Hanford. We are also very muchinterested in regional planning. In fact,we are very much involved in it. I believeregional planning is rapidly coming intoits own in the psychiatric field. Justrecently there was federal legislationwhich has been implemented in Cali-fornia and other states. This will providethe means of giving more attention topsychiatric facilities and planning. Weare now exploring possibilities in Visaliato provide in-patient services for acutelydisturbed patients. In Bakersfield, wewill also be involved in regional planningwith Kern View Hospital.

At King's View Hospital we now have25

an arrangement with Fresno StateCollege to train clinical psychiatrists inlimited fields with limited scope. Oncewe have the University closer we willproceed further into this field. We hopeto be working shortly with Fresno StateCollege in psychiatric social workertraining. We are not now training

psychiatric technicians.Talking just a moment now about

training for the future: All of our centers,King's View Hospital, Kern View Hospi-tal, and other private psychiatric hospi-tals throughout the country will need toget much more actively involved in train-ing programs. The National Institute cen-tral office, which has been instrumentalin assisting us in obtaining Federal Grantscontinually emphasizes that we mustlook forward to future training programs.As we develop this further in the valley,we hope to be more involved in trainingpsychiatric social workers, nurses, publichealth nurses, and eventually psychiatrictechnicians.

I recall a number of years ago whenhe was Director of the Department ofMental Health Dr. Cohan said thatCalifornia would have the first trainingprogram for psychiatric technicians inthe country. So I am justly proud ofthese service units that we establishedthroughout the state mental health pro-grams, extensions which evolved out ofCamarillo and other state hospitals. Whenthis program got underway, a programthat many of our young people estab-lished, the results included the 300 hoursof training which facilitated installationof the direct-training program. Aboutthat time, some 10 years ago, I receiveda telephone call from someone in yourassociation who wanted to discuss thepossibility of setting up a section in theprivate psychiatric health field for train-ing psychiatric technicians. But, unfortu-nately, we never got beyond the discus-sion stage. We have since witnessed inCalifornia an active program of trainingfor psychiatric technicians. Unfortunate-ly, this trend has not permeated the non-profit, private sector. We can now look

at such possibilities more realistically.I am going to shift here and ask ques-

tions about the future of the mentalhealth field and mental health programsin general. We must know: Where will theaction be? Many of you have been inter-ested in the Mental Health Act of 1967.I understand by way of the grapevine andthrough communication channels of theprivate psychiatric hospitals that there isa great deal of interest nationally inCalifornia's action during this last year.Under terms of this bill, which changescommitment procedures in Californiaapproximately one year from today, wewill no longer see large numbers of peo-ple being committed to state institutions.We will see further implementationwhereby local communities will need tocontract with state hospitals if they wishto continue to make services available bystate institutions. Even though financingis not spelled out too clearly, we mustask ourselves what happens when largeamounts of money leave the county inorder to provide services to county resi-dents in state institutions. How will thiswork? How will the governing body ofthe county react to this, and how longcan it go on? How active will state hos-pitals be? How rapidly will we move intothese programs in the local community?

Assemblyman Frank Lanterman, asyou know, is one of the chief authors ofthe bill. What Mr. Lanterman wanted toachieve was a change in the commitmentlaws. He simply wanted to reduce com-mitments. In visiting with him the otherday he pointed out to me again how sin-cerely he wants to see this done in Calif-ornia so that other states can follow ourexample. I think we must understandthat even though the bill doesn't includeall the methods of implementation, andeven though there will be regulationsthat are not going to suit many of us,the central kernel with which we canfind no argument is the one of treatingpsychiatric patients by moving them intocommunity treatment centers. I believewe are going to see from Mr. Lantermanand others a very heavy emphasis on

26

compliance with this bill.I think it is very easy to see the im-

plications of this Act. No longer will wecommit patients to the state institutionsthrough judicial procedure. Local treat-ment will be much more profitable andit will become, for local and county of-ficials and other people in the commun-ity, a more palatable system.

We want to go much further than sim-ply offering jobs or, if you are a psy-chiatrist, simply practicing psychiatry. Weneed a much more comprehensive pro-gram. Where will the patients be in 5years? And where will the technicians ofthe future be trained? I am very closely as-sociated with Reedley Junior College. Weknow that colleges today are seeking ad-ditional programs to assist the commun-ity. It does seem that very soon we shouldbe able to get junior colleges to supple-ment training programs which are goingon in state institutions today. It doesn'tmean that we need to replace state hos-pital, training programs, but we need tosupplement them. We need to have sim-ilar programs right in the community. Alot of youngsters who are not going to auniversity or a 4-year college would goto a junior college if they could findsomething there to challenge them andlead to a good job serving the commun-ity when they finished. I think this couldbe made into a very practical programfor either a four-year or two-year college.Having been quite close to this for overtwo years, and having discussed this typeof program with Reedley Junior Collegeofficials, I believe we could move aheadin this area. Another question is: Howdo psychiatric technicians relate to theR. N. or the medical personnel. Mr.Thorn's paper touched on this in a verypositive and very constructive way today.I was involved in a CNA study and thepresentation of the urgency act to keepthe certification program going for thepsychiatric technician. For me this wasa very excellent experience. I becamefurther acquainted with the needs of thepsychiatric technician and gained a newappreciati n for them. I appeared before

a hearing in Stockton on behalf of theP.T.'s at one point. But what we have inMr. Thorn's paper would go even further.

At this point I would like to go intosome of the problems we are having insmall, private psychiatric hospitals. Inour program we have about 120 employ-ees, and you can well understand thatmany of them are psychiatric aideswe don't use the term psychiatric tech-nician. We do have a classification andsalary structure for psychiatric technic-ians written into our personnel programsand policies, but we have never hired one.We didn't understand the need for them.

At Carmel about three months ago weparticipated in a meeting of the Californ-ia Committee of the National Associa-tion of Private Psychiatric Hospitals, andfinally realized how many hospitals util-ized the psychiatric technician. One hos-pital administrator spoke of his doubtsabout using P.T.s in private hospitals. Indefense of the psychiatric techniciansthere were three or four hospital admin-istrators who lauded the extra back-ground and training as well as the com-petence of the P.T.s they had hired. Icould see from the conversation thatthere were many ideas on how the P.T.can be used in psychiatric hospitals andcan be used in community centers. Wehave one on our staff at King's Viewbut he is working in our two-county hos-pital in Hanford, assisting with workwhich perhaps some social workers orpublic health nurse could do. But thisman does it very well. All our personnel,our social workers, psychiatrists and psy-chologists have agreed that he does amighty fine job. He's got their blessing.

The people we pick to work in ourhospitals are housewives people whohave raised a family and have knownsomething about human relationships.They are warm and like people. We haveabout 78 of these, none of whom hashad formal training. This puts a tremen-dous load on our supervisory personnel.They have to train them to work withpsychiatric patients. I don't think this isright. I think these people should have

training when they come to us or atleast there should be a parallel traininggoing on and a certificate or licenseshould be issued when they have beentrained. I have felt this for a long time,having had experience with recruitmentand staffing of a private hospital. Thepeople who do this supervisory work andtraining are another problem. Findingpsychiatric nurses who are qualified to-day is like finding a needle in a haystack.In Bakersfield today we have a psychiat-ric nurse who is a good trainer and agood supervisor. So we have one. But insome of our other hospitals, we havepicked up R. N.'s who have had little, ifany, psychiatric training to be t;:e train-ers and the supervisors. You can see whata tremendous burden this puts on thepsychiatric social workers, psychiatristsand other people who are really trainedin the psychiatric profession. There isstill this great lack of qualified trainedmanpower. I would suggest that some-how we get together that somehow wefind a way that PT's can work into theprivate sector. We are going to be movinginto community health centers very rapid-ly. I suggest that in five years communitymental health centers, general hospitalsand private hospitals are going to move along way toward shorter treatment per-iods. Patients will leave the hospital forthe community but they will still needour personnel outside of the hospital orin the clinic. Some of us are rushing tothe NIMH training program to prepareourselves for this new frontier in staffing.

We want people in our program whocan, when they come to us, show us theircredentials so that we can employ themas supervisors and administrators in ourhospitals knowing they have been train-ed. I am certainly not down-grading thestaff we have. I think they are doing amagnificent job. As I said at the outset,in the last 20 years we have seen a thou-sand of these young people make a con-tribution, and at the same time they havebeen helped to achieve greater humanunderstanding and have been guided intothe mental health program. This is great,

27

but if we expect nurses who are RN's,doctors who are M.D.'s and L.V.N.'swith licenses to perform as licensed pro-fessionals, PT's, too, should have licens-ing. On the other hand, we should not

28

expect a great "Amen!" from all theseother professions. They should certainlysay "Amen!" to new frontiers, new dia-logues, and new approaches because theyare coming.

Programming For The Future

Senator Petris, a Stanford Law Schoolgraduate, represents A lemeda County andhas been a member of the Legislaturesince 1958. He co-authored the MentalHealth Act of 1967, developed while hewas Chairman of a Senate Committeewith jurisdiction over the Mental Hygieneand Social Welfare Departments. Knownfor his legislation of social significance,he is also a member of the Public HealthCommittee.

As an official member of the officialfamily of the state of California, repre-senting the legislative branch, I extend ahearty and warm welcome to all our vis-itors from out of state.

Before I discuss the subject which hasbeen assigned to me, I want to make twoor three personal comments. One is, Iwant to congratulate your association onyour choice of a representative in Sacra-mento, Mr. Bill Grimm. He didn't knowI was going to say this, and it would beeasier to say if he weren't here, but he'sdone an outstanding job, and of courseyou who are active in your associationknow about it, but I think this wordshould b e transmitted to all of yourmembers here and at home. The task ofrepresenting an organization of this kindis a state-wide job and an extremely dif-ficult one. Any of you who have dealtwith any of us know that every singleone of us is egotistical. That makes itdifficult right off the bat. If we weren't,we wouldn't offer ourselves for publicoffice. Of course we go into it becausewe are concerned about the problems ofpeople, and we are hoping to offer thebest solutions we know to take care ofthese problems. But we also go in becauseof the attention we get. We like to be in-cluded in the center of the spotlight fromtime to time. Basically, however, any pol-itician who offers himself for public of-

fice has a deep liking for people. If wedidn't, we wouldn't be in politics. Thereare those who say that politicians lovemankind and hate people, but that's nottrue. Anyway, all of these things put to-gether make the job of the legislative ad-vocate a very difficult one. And it's ex-tremely tough to try to get in to see allof these people who have importantthings to do about legislation. There are120 of us and more than 500 legislativeadvocates. When you take all of us andcount all the number of persons that tryto see us and combine them with all ofour visitors from home, you find that aa really effective legislative advocate hasto be very nimble, he has to have a goodpersonality, he has to know his subjectmatter, and most of all, he has to enjoythe confidence and respect and friend-ship of the members of the legislature.And I'm here to tell you that Bill Grimmis worthy in the highest degree. I thinkyou should be very proud of the work hedoes for your group.

Secondly, I should let you take a peekwith me, inasmuch as the subject thathas been assigned to me is taking a look,at programming of the mental health pic-ture for the future. But I can't talk aboutthe future without talking a little bitabout the past. Although I haven't beenactive in coming to your meetings ormeeting with you as individuals, I wantyou to know that I've learned a lot aboutyou and the things you are doing fromBill Grimm. I've also learned a lot aboutwhat you are doing, not as members ofthis organization, but as employees ofour great state. You are working in anarea which is one of the most difficult ofall. I've gained a tremendous amount ofadmiration and affection for you as in-dividuals by looking at your reports, byconferring with doctors with whom youwork, and some of the people in the De-

29

partment of Mental Hygiene, and lastly,by checking the budget each year. It wasmy duty for about four years, as chair-man of the subcommittee of Ways andMeans which had jurisdiction over mentalhygiene, to see what the budget provis-ions were going to be after the Governorsubmitted it to the legislature for the en-suing year. I've always been amazed thatthe State of California has been able torecruit as many persons in your field aswe have through the years without pay-ing much higher salaries, and withoutoffering a lot of other fringe benefits thatare available with other types of employ-ment outside of state service. I alwayscame to the conclusion that there mustbe a tremendous missionary zeal com-parable with the clergy, our great teach-ers, and others to whom society has notyet demonstrated sufficient gratitude orsufficient understanding of the import-ance of the work they are doing as wellas the extreme sensitivity and complexityof their jobs. If it is any comfort to you,I want you to know that I personallybave that view, and I knew many other!yen hers of the legislature do too. Thepronlems, unfortunately, are that everytime the budget session does come up,everyone is scrambling for that tax dollar,and it's very difficult to make the alloca-tions that you want to make. I also wantyou to know that I personally, becauseof this knowledge, continue to admireyou individually and as a group, and willcontinue to do every thing I can for you.I have had many fights in the past onthis to see that the salaries and thestructure of compensation of our peoplewho are working as psychiatric technic-ians in our state hospitals are continuallyupgraded. I feel sorry that it's not a lotbetter today than it is, but we haven'tforgotten, although sometimes it seemsthat we have. It's just that other thingsget in the way, and appear a little morecharming by virtue of the fact that theyare in even worse shape. We get back totrying to pick through, and go from yearto year with improvement in as manyprograms as we can.

30

Many people have heard some thingsabout the Mental Health Act of 1967.It's a kind of milestone. We don't knowexactly how it's going to work out. We4tre to some extent taking a chance onCongressional provisions, but in lookingahead, I wanted to make three or fourpoints extremely clear which I think willlink directly to your profession and yourwork.

Number one, I hope you don't feelthat this bill was designed to dismantlestate hospitals or close them and send allthe technicians and other people workingin the hospitals off to the wilds some-where or to another area where they havenot been trained to work. I know thatAssemblyman Lanterman, who was prin-cipal author of the bill and introduced itin the Assembly, shares my view thatwe're not going to stand by and watchpsychiatric technicians as a body disinte-grate because we are trying to de-empha-size this enormous centralization of carefor the mentally ill that we've had formany many years. I know that there is amajor defect in the code now by virtueof the fact that psychiatric techniciansare unique to the state hospitals. Thereare very few of you operating outsidethe state hospitals. You get all of yourtraining in state service, and the varioussections of the code which define whatthe psychiatric technician is limits it tostate hospitals.

It seems to me that the state will notbe meeting its responsibilities if we de-cide to decentralize to such an extentthat a large number of psychiatric tech-nicians have to follow a patient fromstate hospital centers to the local com-munity without providing equal provis-ions in the code safeguarding the tech-nicians' interests. I, for one, intend to seeto it that this is done; I hope in thiscoming session. We must transfer the def-inition from state hospitals alone and ex-pand. it to include the same definition inall local mental health facilities whetherthey be public or private. I pledge to youthat I am very much interested in that,and will work to get a bill through this

coming year. I have talked about it. toBill Grimm. We have at least another yearto go almost another year before theLanterman Petris Short bill is actuallyput into operation. I would hope thatyou can devote some of your time, athome in your local chapters, to assistwith legislative recommendations thatwill make our transition smoother, andbeneficial for both patient and the peoplewho take care of the patients. Youpeople, in my judgement, will really formthe backbone of our entire state mentalhospital system.

So, when we look at the future, wesee, number one, a continued decentral-ization of care of mentally ill away fromthe large hospital centers to more andm i re treatment in the community. Thistrend was started with the original Short-Doyle Act of 1957. That measure pro-vided for many improvements for thecare of the mentally ill. We have managedto keep a lot of people close to homewhere they were able to visit with theirfamilies. And in many situations it hasbeen clearly documented that the effecton the morale of the patient is such thathe actually snaps back to normal a lotfaster than he does far away where hefeels that no one cares about him. Hesimply, in many cases, lost his will tolive.

The first signs of looking into the fut-ure is the continuation of this develop-ment fre,'I the past. That is more andmore decentralization to the extent thatwe can do it and still improve the serviceto the patient.

Along with that will be a change inthe law so that the psychiatric technicianand others who will be transferred tofollow the patient as it were, will alsomaintain at, as an absolute minimum,the status they now enjoy, and we hopewill be improved.

My prediction is that the status of thepsychiatric technician will be upgradedrather than kept at the same level ordown-graded even though people tell younow that they are going to )try for sal-aries in a lower category of pay and

31

lower category of medical hierarchy.There are two reasons why I tell youthis. Not just because I'm a politicianwho is trying to please you, and I haven'teven checked the roster to see how manyof you live in my district. I say this fortwo reasons: number one, as the decen-tralization process is accelerated andmore and more people are cared for loc-ally, county after county will have tomake provisions for some kind of hospi-tals or clinics whern there is more thanout-patient care. The patient will stayovernight, or for a few nights or for afew weeks. And more and more privatefacilities will be established. The pressureon local private facilities and public fac-ilities from the families who are clamor-ing to see that their patients are caredfor at home will rise in direct proportionto the number of patients that are takencare of at home, for better standards oftraining and pay for the people who helpthose who need the help. It is as simpleas that.

The second reason of course is thatthose of us in Sacramento who are con-cerned about these programs are not go-ing to abandon the people who havebeen so brave in helping us take care ofthe mentally ill. We are going to do ourbest to see to it, together with pressuresfrom people at home, that some positiveand constructive steps are taken in thecurrent session. The key is working to-gether toward this goal.

The third thing I see in developmentin the next few years is a continuation ofthe use of state hospitals. I know you'vebeen told by many that they would beclosed, particularly since the Administra-tion first announced all those enormouscuts, which I opposed very strongly. Restassured we do not intend by this bill, theMental Health Act of 1967, to close upthe state hospitals. There are differentkinds of patients, as you all know betterthan I do. We intend to emphasize, andcontinue emphasizing, local treatment forthose who are amenable to local treat-ment. But there are also many manyother patients who simply will not be

able to respond and will have to go tostate hospitals. People get the wrong im-pression, that because we want to keepas many of those patients at home as wecan, we're going to automatically closeup the hospitals. What is going to happento those other severely ill and chronicpatients who have been there for years?Are they just going to be tossed outsomewhere? Of course not. As a matterof fact, one of the reasons that we feelwe can help all the patients is that if wekeep the newer milder cases active intheir own community with local help,state hospitals to concentrate on thosewho need help the most.

There is another thing that I wouldlike to predict for the future in connec-tion with the role of the state hospitals;they will have changing functions. They

will remain as important training centersfor medical personnel who will be need-ed in the local communities. We intendto change the definition of the psychiat-ric technician to include those personswho work in local county hospitals andother local, public and private facilitiesThese individuals must be trained. Whereare they going to get their training? Wecan't start with brand new facilities inall of the counties who don't have theexperience that you have had and whichthe doctors have had on staffs of ourstate hospitals. Training for all these localfacilities must come from our large train-ing centers which will be the state hospi-tals. Unfortunately, many of you will bepulled away from the bedside work thatyou are doing now. Many of you will becalled on to train other psychiatric tech.nicians even to a greater extent than youare doing today. This I think may not berealized immediately at the coming ses-sion, but it will definitely be part of thetrend in the next few years.

Then we have the final predictionwhich I would like to make before givingyou some of the details about this MentalHealth Act. My final prediction is (andit's not one based on medical knowledgebecause I'm not a doctor) but it seems to

1.

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me fairly obvious from the figures wehave been receiving consistently for sev-eral years, that the need for hospitalswill continue simply because more of ourpeople are cracking under the strain ofan advanced technology that we have inour society they are cracking under thestrain of the rat race the enormousamount of worry we seem to be doing,both public and private, about privateaffairs and public affairs which are be-coming more difficult and complex. Wehave wars overseas too many of ouryoung men are being killed down tocity problems even though it may bejust wrestling over a city ordinance.

We hear that the need for mentalhealth services is lessening. This is oneof the misleading statements that hasbeen made frequently with respect to thecuts in the field of the Mental HygieneDepartment and the staff. I challengedthe Administration time and time again,publicly, in press conferences, on the air,and elsewhere, to take part in panel (1:4s-eussions with the Director of Mental Hy-giene on this one point. I thought it wasa cruel and misleading approach to saythat because of the population in thestate hospitals the population is nowlower than it was on any given day lastyear or two years ago that there is nolonger any need for additional personnelor that the personnel can be reduced indirect proportion to that reduction inpopulation. The actual total number ofpatients treated in our state hospitals isstill growing each year by some 12-13thousand. In fact, the first six monthsof this year, the increase was very sharpover last year a lot more than wereactually predicted which means wewill actually need more personnel, ratherthan less, and I hope we discover thatofficially at the proper level of our stategovernment in time to reverse the presenttrend of cutting back. People don't real,ize that even though there may be, andthere is, a smaller total number of pa-tients in the hospitals here today, thatthousands more are being treated. We havebeen able to reduce drastically over the

P

,

last few years, the total amount of timewhich an individual patient spends in thehospital. That doesn't mean the servicedrops. The service to each patient goesup, and it doesn't mean there are lesspatients, because as the figures have in-dicated, there are thousands and thous-ands more patients each year than wehave ever had before. When you combineall these things and put them together,I don't see how people can say that theysee the hospitals are going to be foldedup either because of the Governor andhis cutbacks or because of the Lanter-man-Petris-Short bill.

What does the Mental Health Act of1967 provide that might give us a littlehint toward the future? Well, Mr. Lan-terman started on this problem in 1955,before I ever went to the Legislature. Heand I were both concerned about thecommitment process the thing thathappens before you people ever see thepatient. We found that we have an an-cient commitment procedure in this statewhich has resulted in some terrible injus-tices with the result that over the yearsthousands upon thousands o f personshave been transferred to state hospitalswho didn't belong there. I'm sure manyof you are aware of this. It happenedthat many persons, particularly an olderage group the senior citizens categorywho had no relative to look after themor whose relatives and friends turnedtheir backs on them, became the victimsof a combination of indifference, apathy,and downright hostility on the part ofprivate citizens and the budget conscious-ness of public officials. We found thatmany, many counties who simply did notwant to pick up the tab for taking careof some of these senior citizens locally,felt they would take the least expensiveway out and simply dump them into thestate hospitals because of the fact thatthe state picked up 100% of the tab andthe local county doesn't have to pay any-thing. We found in the course of ourresearch, that some 3,000 to 3,500 seniorcitizens were being wrongfully dumpedinto state hospitals every year. But the

county officials seized upon some eccen-tricity some little form of senility orsomething along that line but certainlynot a person who was psychotic underthe law and belonged in a state hospital.We also found that there was a sharp de-cline in their desire to live. This happenedmany times, 80 percent of these peopledied the first year after coming into thestate hospital under those conditions. Wewanted to eliminate that.

Once we got into the possibility ofchanging the commitment procedure,then of course we became involved inwhat happened to these people at home,and we had to lay out a program designedto offer the maximum amount of service.That is basically what we do with theLanterman-Petris-Short bill. We have apre-petition screening to avoid unneces-sary involuntary detention. The wholethrust of the bill really goes to the com-mitment process. We try to reduce theproportion of those who are committedinvoluntarily and increase the percentageof those who seek attention voluntarily,This is a program which was tried in otherstates with this emphasis, and it workedbeautifully, and we hope that it will workas well here. Some of our hospitals aredoing it already, as a matter of fact. Wehave a comprehensive evaluation of apatient which is necessary to determinethe nature of his problems and the bestsolutions, locally with the screening com-mittee. We want to tie the involuntarydetention and treatment through a cert-ification procedure and not just througha court hearing which takes only a mat-ter of four and one-half minutes in mostparts of the state. When people comeinto court, bewildered after three daysof intensive observation, in many casesbefore they know what has happened,the judge has banged his gavel and said,"This person is going to such and such ahospital," and that's the end of itWe allow a maximum of 14 days for in-voluntary treatment, and no extension ofthat unless there is another screening pro-cess and full and ample opportunity fora hearing before the patient is moved on

33

to the next step. The right to a courthearing, when it is requested, is madeduring the first 14 day period. We haveadditional periods of 90 days of invol-untary commitment for the benefit ofpersons who are proved in court to bedangerous to others. In this area we leftout the point of being "dangerous tothemselves". This is an area of great con-troversy, but the experts themselves aredivided on the question, and after seriousconsultation with many experts and con-sideration of the problem, we decided toomit, not to include, the area "dangerousto themselves" because we were con-vinced by the majority of the expertsthat this was really the best thing for thepatient and that it would reduce the in-cidence of suicide. We have two optionsavailable to judges. Whether they referpeople to state hospitals or a local facil-ity, to an alcoholic clinic, alcoholic treat-ment facility, and so forth. Now, yousee the major emphasis is, number one,away from relying on automatically send-ing people far away from their homes toa massive institution, and continuilig thepreviously established policy of 1957, ofmore care at home. Number two, a greatdeal more concern about what happensto the individual as a person in the com-mitment process, and after he gets in thehospital. Number three, a much greatervariety of choices for courts and localjudges as to what can be done, and amuch greater regulation about whatshould be done by direction from thestate than we've ever had before. Then,after the patient gets to the hospital, he'sgoing to have many more rights than hehad before the right to wear his ownclothing instead of some type hospitalgarment; the right to keep his own per-sonal possessions, including his toiletarticles, and the right to spend a certainamount of his own money for canteenexpenses and small personal items; theright to have access to individual storagespace, (Some of you who think we arecrowded now may laugh at that, but weall know that this has to be worked out.);the right to see visitors each day; the

34

right to have reasonable access to tele-phones, both to make and receive con-fidential calls, and we had a lot of staticon this too; the right to access to letterwriting materials, including envelopes andstamps, and the right to receive and mailunopened correspondence; the right torefuse shock treatment; and the right torefuse a lobotomy. The denial of theserights, if it has to do with treatment andis in the interest of the patient, can bemade by the appropriate person on themedical staff. However, an evaluationmust be made, and indication must bemade in writing in the file as to why theparticular right has been taken away bothfor the purpose of reviewing and for rec-tifying, if need be, in case the patientwasn't helped and we need to find outwhy the policy of the bill was not carriedout.

There are several other provisions inthe bill, and many of them are simplyrepeating present law, but those are thebasic parts. I just thought I would des-cribe them to you, partially to give youa picture of what to expect in the nextfew years. In closing, once again I wantto say that I, as a member of the Legis-lature, am very grateful to each and everyone of you for the services of you per-sonally and as a group, performing thetasks you are doing and have donethrough the years. Speaking of transfer-ring other people and going other places,if we lost you psychiatric technicians, wemight just as well close up these hospi-tals because we can't do any good with-out you. There are more of us who knowthat than you probably know or under-stand. There are many of us who areconcerned about the problem that wehaven't been able to move ahead withyou as fast as we would like. This newlaw as it goes into effect in July, 1968,may need changes that we do not know.We would greatly appreciate your helpand recommendations before it goes intoeffect because we have a full and regularsession. We deliberately established a leadtime of a full year for all persons who aredirectly concerned to study it thoroughly

and give us recommendations for im-provements in the law, refining it so wecan improve services and also upgradetraining and standards and compensationand everything that goes with the needto have the best possible personnel con-tinue to serve us.

With that I will thank you for extend-ing me the honor of addressing you, andhope you can go back to your respectivehospitals refreshed and with new ideasand new determination. I wish each andevery one of you the best of success inevery area of this field.

I thank you very much.

Question by Executive Director:

It has been suggested in some quartersthat the best method of transferring fromthe state hospital to the community pro-grams would be for us to become some-thing other than psychiatric technicians;to give up the role and become LVN's orsomething else. Could we have yourcomment on this, Senator?

SENATOR PETRIES: I personally would beopposed to having your classification

35

changed to one that doesn't mentionyour training, your experience, or yourbackground. I think as a counter measureit would be wise to have legislation andto have you work hard for it, whichcreates official recognition in the formof licensing if that appears necessary andit may well be the best form of yourown classification rather than being class-ified as LVN's or anything else. I wouldheartily oppose any effort, and I Ichowsome people have interpreted it this way,to state that if you are moved into acounty setting you are automatically go-ing to be classified as LVN and that'sthe end of it. I think you should fightfor your own classification which is un-ique, to get official recognition at thelocal level as well as the national level.The LVN's, and I have nothing againstthem and don't mean to be critical ofthem, are simply not trained and do nothave the background to do your work.I would urge you to band together andmake that one of your most urgent pro-grams for 1968. I would be in your cor-ner and I will do everything I can to seethat your classification is officially re-cognized that way, and if you need lic-ensing in that category, then let's go afterlicensing. I wish you the best of luck.

-1P

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APPENDIX I

ALL THAT GLITTERSMAY NOT BE GOLD

Californians have always taken greatpride in "pioneering". The cries of"Eureka" brought strong-hearted indiv-iduals from all over the world to Calif-ornia a century ago. Such persons werequick to find uut however, that all thatglittered on the ground of the GoldenState was not gold.

The 1967 Legislature has pioneeredin the field' of mental health with theadoption of the Lanterman-Petris-ShortAct. The motivation behind this Legisla-tion was definitely good. The legislationwas directed primarily at the practice ofindefinite court commitments to StateHospitals which definitely had been ab-used in some counties. The Act, however,goes far beyond these problems and willrevolutionize the treatment of the ment-ally ill in this State. Unfortunately thephilosophy contained in the Bill thatonly those individuals who have threat-ened or attempted injury on the personof another need more than 14 days in-voluntary treatment is not a medicallyaccepted fact. Unless amended by theState Legislature, this "noble experi-ment" will be put into effect during thecurrent year. Regardless of the outcome,it will have a dramatic effect upon allnon-governmental psychiatric hospitals.

The question still remains whethereither the mentally ill and the professionof psychiatry can live with the Act. Whatis even nriore important, is whether ornot society can live with it.

Robert Thorn, PresidentVista Hills Psychiatric Foundation

5 January 6836

APPENDIX II

Curriculum Report by Anabele Miller

The area of psychiatric techniciantraining is one that has received consid-erable attention in the last ten years.Providing adequate care for patients inpsychiatric hospitals, schools for the men-tally retarded and other mental healthfacilities is a problem that has beenbrought sharply into focus by the 1962Report of the Joint Commission onMental Illness and Health.

Statistics indicate that most of the24-hour-a-day care of patients in psychi-atric hospitals is given by a group ofworkers variously designated as psychi-atric technicians, aides, attendants andnursing assistants. Up to the present time,they have constituted approximately 80percent of the nursing personnel in psy-chiatric institutions. Of all the peopleconcerned with the treatment and careof the psychiatric patient, the psychiatrictechnician has the most continuous andconstant interaction with him. The tech-nician has the opportunity to developclose relationships with patients and forobserving _their behavior in a variety ofsituaticr(f,:

The question has been raised as to themost effective and efficient way to train

this category of worker so that he canmake the most useful contribution to thecare of patients and families in commun-ity mental health facilities.

With this in mind a committee hasbeen working during the past severalmonths to develop an effective trainingprogram for psychiatric technicians. Thecommittee has suggested the followingframework for the development of sucha program.

The purpose of the program is to traina generalized psychiatric technician prac-titioner who can function therapeuticallywith patients and families in the hospital,the home and the community.

The primary difficulty with college-based programs is their lack of relevanceto problems confronted on the job. Thedifficulty with in-service training is thelow level of cogoitive areas of learningthat give a broadei base of understandingto the mental health worker.

This training program is also an open-ended course of study and practice thatwill permit the psychiatric technician toaugment his academic achievement, ifable and motivated, with a further car-eer in the mental health field.

37

OUTLINE OF RECOMMENDEDPSYCHIATRIC TECHNICIAN

STUDY PROGRAM

ASSOCIATE IN ARTSDEGREE ELECTIVES

Anatomy & PhysiologySemester Pharmacology

First Semester Credits Anthropology

Clinical Work Experienceand Seminar

Group & interpersonalProcess Lab

432

Learning TheorySociology of Mental HealthSocial PsychologyAging

ArtMusic

Psychology 3 Community Organization &SociologyPhysical Education

31/2

Social Case WorkSpecial Studies HonorsSociology of the Family

151/2 Introduction to Data Processing

Second Semester

Clinical Work Experience 4and Seminar 3

Group & I Nterpersona I 2Process Lab

Growth & Development 3Health & Education 2Elective 2-3Physical Education 1/2

161/2 -17%

Third Semester

Clinical Work Experience 2-4and Seminar 2

Group Process Lab 2Abnormal Psychology 3Elective 3English Composition 3Physical Education 1/2

151/2_171/2

Fourth Semester

Clinical Work Experience 2-4and Seminar 2

Group Process Lab 2Elective 4-6American Hist. & Govt. 3Physical Education 1/2

131/2 -171/2

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THE NATIONAL ASSOCIATION OF PSYCHIATRIC TECHNOLOGY

and

THE CALIFORNIA SOCIETY OF PSYCH!ATRIC TECHNICIANS

are dedicated to the demonstrated competence of psychiatric technicians in theareas of behavioral care, treatment and training. We feel that curriculum and stand-ards must be developed for the entire profession, adaptations must be periodicallyreviewed and modified to the changing focus of the mental hygiene field, andthrough these changed accents, the skills, treatment and training of the psychiatrictechnician must be enhanced and the technician himself challenged.

We need your assistance. In order to press for increased recognition, to work forprofessional development and recognition, improved working conditions and highersalaries, to establish high standards of our profession through legislative action andto develop a uniform curriculum nation-wide, we must have financing.

The status of the psychiatric technician has consistently been improving, and it canbe greatly accelerated through your cooperation and support.wwwwwwwwwwwwwwwwwPlease send me a membership application in THE NATIONAL ASSOCIATION OFPSYCHIATRIC TECHNOLOGY, 1127 11th Street, Sacramento, California 95814.

NameLast 1st Initial 2nd Initial

Address Phone

City State Zip

Please direct me to the state psychiatrictechnicians association in my state.

I would like information on helping to forma state psychiatric technicians association

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california society of psychiatric technicians, … · california society of psychiatric...

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