CHAPTER III

MENTAL HOSPITAL AS A FORMAL ORGANISATION

Chapter outline

1. Organisational theory: characteristics of formal organisations.

Goals, organisational requirements, functions, structural features.

2. Mental hospital as a formal organisation.

a) Application of the theoretical framework from (1).' .

b) concept of social management ,of patients -attendants and social management. Classification scheme based on therapeutic' and administration-maintenance functions.

c) A brief description of hospitals A and B based on (a). .

3. Organisational structures of Hospitals A & B.

Application of the therapeutic and admini­stration-maintenance functions classification scheme to Hospital A and Hospital B. Personnel, departments, etc. based on (b) of (2).

tiU

CHAPTER III

MENTAL HOSPITAL AS A FORMAL ORGANISATION

ORGANISATIONAL THEORY : CHARACTERISTICS OF FORV~ ORGANISATIONS

One of the older and simpler definitions of an

61

-organisation was by J.D.~ooney who defined it as the form of

every human association for the attainment of a common

purpose (Meoney, J.D., 1939). Most of the social SCientists . who have tried to formUlate definitions for organisations

.. '6 ..

have, indicated the significance of purposes or goals for the •

analysis of organisations. What distiniuishes one formal

organisation from another is the goal and therefore, "the •

primacy of orientati~n t~. the· attainment C!f a specific goal" .-:'- .

is the defining characteristic·of an organisation and there-•

fore, it has implications for the organisation's internal

and external relationships (Parsons T., 1961). When the .. '

interactions between members of the organisation are pre-

scribed in advance and enforced by people within or outside

the organisation, then it is called a formal organisation.

By this definition, industrial firms, governmental agenCies,

hospitals, colleges and schools are all formal organisations.

The goals of formal organisations are determined by

the belief systems and values of the persons who establiSh

62

the organisation and also, sometimes, by the teChnologyl

available in that society regarding ways and means of

achieving the goals. A clear distinction, however, has to

be made between business organisations and service organisa-. tions (Blau P. and Scott W.R., 1963). Business organisation

like all industrial organisations are profit making collecti­

vities ~iCh have an output in the form of a product or

service which can be sold. On the other hand, most of the

SChools, colleges and hospitals are service organisations

since the services they produce or r~nder are not generally

sold, at a profit. Service organisations are generally formal

organisations which cater to the developmental needs or

health needs of human beings, and their goals are shaped by •

the ideas and beliefs which that particular society has as . ' .' regards what is desirable for human growth and development.

The goals of an organisation may change in the course

of its history corresponding to the 'changes in its environ­

ment. The, reasons for change of goals are varied; for • example, at some point of time in its existence the original

goals for which it was started may be fulfilled and it faces

the situation of either terminating itself or to continue •

eXisting by adopting new goals. Or, it may happen that the

original goals lose their relevance, in course of time, as

r'egards social needs and change becomes necessary. In some

1. The word "technology" is used in this report to mean knowledge and techniques which human beings use to

·obtain certain objectives.

organisations the goals are so unattainable that in course of

time it becomes necessary to bring the goals down to more

realistic levels. The reverse may be the case ldth some

other organisation; higher goals and newer perspectives will

be feasible in the wake of new resources and new technologies . '

in contrast to the time when the original goals were set.

Goals or objectives of an organisation are abstractions

and the process of goal-attainment consists of various con-•

crete functions or patterned activities within the organiza­

tion which are to be performed by the participants of the •

organisation; with or without the help of non-human materials

like tools, 'instruments, lands and buildings. It is apparent •

that goals can be pursued only through the mobilisation of

human and non-human resources. ~he establishment and alloca-

.tion of functions and relationships and the distribution of

resourceS gives rise to what is oalled the formal structure

of the organisation. For conceptual convenience, the organi­

sational st~cture.may be considered as the framework of an

edifice consisting of many parts and units, and sub-parts and

sub-units. Roles. are the smalleet sub-units of an organisa­

tion. Social roles are associated with the different social

positions which are again parts of the'social structure. To

be more precise, each social position has a set of roles

associated with it (Olsen, M.E., 1968). One important

component of social role is expeotations. There are certain

expectations about every role, which prescribe and proscribe

actions and attitudes for the persons who enact the role.

Some of these expectations are cultural, meaning tney are

related to the culture of the people who formed the organi­

sation and are therefore, social norms pertaining to that

particular role. The role-.enactors are the participants or

functionaries of the'organisationl who are expected to follow

certain norms of behaviour prescribed for those particular

roles delineated in the organisational structure.

In,order that social organisations may survive, remain

stable and achieve their goals, certain conditions have to be

fulfilled. In other words, there are certain organisational

requireme~ts which are: 1) pattern maintenance by the parti­

cipants of the organisation,2) adaptation of the organisa­

tion to its social environment, 3) integration of the various • parts of the organisation (Bales R.F., 1949).

Pattern maintenance: Every social organisation has to ••

develop mechanisms and processes by which the cultural

patterns and values are incorporated by the participants • •

Organisational goals are different from,the personal motives

of role-enactors. Some of the personal motives of partici­

pants are desire for remuneration, ~~~~smaDe«atj«nX~

desire for using knowledge and skills and desire for sharing

the prestige of the organisation. Conflicts between private

1. The words "role-enactors", "participants", "members" and "functionaries" are used synonymously in this chapter unless stated otherwise in specific contexts.

65

objectives and the goals of the organisation are disruptive

as far as the organisation is concerned. Therefore, it is

imperative that inducements, coercion or force have to be

used in order that the members may identify adequately with

the organisation and work for its goals. Inducements turn

out to be a better mechanism than coercion or force in the

long run. The purpose of inducements is to help the members

to internalise the goals of the organisation. The greater

the number of individual needs satisfied within the organisa­

tion and the higher the perceived prestige of the organisa­

tion, the stronger will be the identification of the parti­

cipants with the organisation (March T.G. and Simon R.A.,

1958). The individual needs and personal motives mentioned

before are more or less the same except for the difference

that the needs pertain also to the here and now aspect of

the participant's existence in the organisation, the faci­

lities and amenities provided for role enactment, the psycho­

logical needs of recognition, encouragement and appreciation

and to the opportunities for creativity in role enactment.

The organisation develops processes to prevent distraction

and deviation from the organisational goals. These processes

are concerned with the establishment of and maintenance of

social norms and rules and mechanisms of control, provision

of inducements of different kinds for need fUlfilment and

creation of adUlt socialisation patterns.

66

Adaptation of the organisation to the social environment:

It has been mentioned before that one of the ways by Which

the organisation adapts to the environment is through modi­

fication of its goals as and when required according to the

changes in the environment. Another means of adaptation is

through maintenance of links with the environment. One

important. link is related to the procurement of resources.

The resources needed are, physical facilities, equipment,

materials, buildings, technology and human services. The

availability of financial resources is an important conSi­

deration which is partially determined by the goals. Business

organisations are able to sell their products, the proceeds

of which are sufficient for the procurement of resources.

On the other hand, service organisations have only their

services to offer. Those who need these services may not

be in a pOSition to pay for them. Sometimes, service

organisations have a few material products to sell - products

made by the patients, inmates, etc. The sale proceeds of

service organisations from suCh products are too meagre to

provide for adequate resources to meet the needs of the

service agency and hence these services are financed by

larger organisations like the government of the country

which gets financial resources through taxations. or by

trusts, foundations or voluntary contributions by individual

Provision of financial resources by a larger

ion may lead to certain obLigations and restraints

67

being put on the organisation by the supporting agency. For

example, a hospital supported by the government is account­

able to the goyernment in many areas, and the government

exerts its authority in various ways. One of the ways is

through policy decisions which are of various types ranging

from the decision to set up the hospital at one end, to the

decision to close it at the other end. Between these two

ends of policy decisions there are other types of policy

decisions on matters relating to the quality or standard of

service, scales of operat~on, relationships with the reci­

pients of service, the processes of pattern maintenance

discussed before, and the appropriate utilisation of resources. ,

If an organisation is financially supported by a government

which is politically of the democ~atic type, the former

organisation's accountability to the government has another

aspect which is its indirect accountability to the electorate

which exerts its pressure through the legislative bodies. . . A distinction between business organisations and

service organisations is not limited to the pattern of their

financing. Consideration of some of the other differences

between the two types of organisation is relevant in this

context. In service organisationa, the participants provide

the service in such a" way that there is contact between the :-

participant and the recipient of the service. In other words,

68

in 'some'aspects of role enactment. the role-enactor and the

service-recipient become,role-partners. For example, the

teacher and the student, ~d the doctor and the patient are

role-partners. It is evident in this context, that the

student and the patient, both become 'indirect "members", in

a special sensel , of the school in one case and of the

hospital in the other. Perceiving the service-recipients

as indirect members of the organisation has very important

implications as regards the structure of the organisation.

One outcome is that the interactions between the functionaries •

and service-recipients become an important part of the

organisational structure. Besides the links that an organisa­

tion has with the supporting organisation, there can be other

links with the outside community or the public at large which

is the source of service-recipients, as well as functionaries

for the organisation. The prestige of the organisation to

some extent depends upon the image it projects to the public • •

at large. If a large number of people of the public consider

that the organisation's goals are important societal goals *

and that the organisat!on is functioniDg, on behalf of the

society, the organisation ~dll be getting ,support from the

public in different ways and links between the two will t ... ."

evol v e easily • .. , On the other hand, if only a few people among

-the public at large consider the organisation's goals

1. This special meaning does not apply to the word "functionary" or "role-enactors".

69

important, then it will be fdifficult to build connections.

In such circumstances, the organisation may undertake as its

secondary goal, support and cooperation. from the public and

work for it through different processes.

Integration of the various parts of the organisation is

another requiremen t for the growth, survival and stability

of the organisation. Social integration is a process in

which the component parts of an organisation become coordi­

nated and united so as to give unity to the organisation as

a whole (Olsen, 1968). There are two sociological theories .

about social integration. One is the theory of normative

integration and the other of functional integration. The

first theory relates to the organisational unity based on

the internalisation of COmmon values by the members of the .. . organisation. The theory of functional integration assumes

the division and distribution of labour; the functionsl

within the organisation are specified, some of.which become

specialised activities. The specialised activities are·

assigned to those individualS who through adult socialisation

have acquired necessary knowledge and techniques to perform

them. Since a formal organisation has many specialised

functions which are performed by different functionaries,

. there have to be ties of interdependence among these

functionaries. As far as the organisational objectives are

1. The word "functions" is used in this chapter to mean "required activities".

70

concerned, no functionary is self-sufficient and he cannot

function without a larger perspective of the whole organisa­

tion. The implication at the practical levels is that

processes have to be devised to coordinate the various

activities and to create collaborative interdependence among

the different participants. Professionalism is the result.

of specialisation of activities. The Wider the specialisa­

tion, the larger will be the number of , professionals in the

organisation. There will all the more be the need for co­

ordination among the professionals.

Though both normative and functional integration occur

in all social organisations it appears that there is more of

functional integration in formal organisations because they

have been deliberately established for some definite purposes.

• • The organisation becomes socially integrated as comple­

mentary relationship; among spec ~lised and inter-dependent

sub-parts are established and maintained through unified co­

ordination (Olsen, 1968). This kind of integration does not

occur automatically. It requires the establishment of rules

and procedures to deCide the extent of specialisation, to

establish, maintain and guide relationships and to mark out

channels of communication.

All the organisational aspects which have been dis­

cussed in this chapter can be summarised in a list of compo­

nents of organisational structure as follows:

71

1) Sub-groups of various types

2) Roles of various types within the organisation as a group and within the sub-groups.

3) Regulative norms governing relationships and roles.

4) Cultural values (Johnson li.N., 1960) •

• Based on the discussion of organisational requirements,

one can broadly divide the organisational functions into two

categories, those pertaining to professional activities and

those pertaining to administration. It is not a neat cate­

gorisation because professional functions and administrative

functions have some common elements. Further., professionals

have some administrative functions and administration itself

may be considered as a profession. It is, however, possible

to make a distinction between the two aspects of organisa­

tional life, professionalism and administration. Administra­

tion can be considered as a survival requirement which must

be fUlfilled by all formal organisations. It is basic to

the process of organising because it deals with problems of

maintenance, coordination or in other words, management of

human and material resources. Administrative activities

range from determination of function and policies and execu­

tive leadership to routine operations such as keeping

records and accounts and carrying on maintenance services of

the premises. Administration is only indirectly connected •

with goal attainment except when organisational maintenance

and survival itself is perceived as a goal.

72

Professionalism can be considered as an operational

requirement directly connected with goal attainment. Some

aspects of operational requirement are common to all formal

organisations while the rest are determined by the goals of

the specific organisation at particular times (Olsen, 1968).

Weber's theoretical model of bureaucracy is used by

sociologists for analysis of formal organisations. This

model has inco%porated many of the organisational concepts

which have been presented in this chapter. According to this

model the characteristics of a bureaucracy are:(l) Activities

are distributed among the various social positions implying a

division of labour and specialisation. Specialisation fos~ers

expertness among the staff (role-enactors) directly and also

indirectly by enabling the organisation to hire the staff on

the basis of their profeSSional or technical qualifications.

(2) Each social position has clearly defined duties and respon­

sibilities. (3) The offices (social positions) are arranged in

hierarchies related to authOrity. (4) All activities are guidEd

by formally prescribed rules and procedures. (5) All decisions

are made on the basis of technical knowledge and governed by

rules and regulations and not by personal considerations.

(6) Relationships.among role-enactors are impersonal and

limited to role ob~iga:ions. (7) RecrUitments to social posi­

tions are determin~d by criteria of merit. (8) All activities

. are recorded in documents which are preserved. (9) Role­

enactors are judged SOlely on the quality of their performance.

73

(10) Role-enactors are paid salaries (WeberM., 1946). Most

formal organisations have structures which present many of

the characteristics of the Weberian model of bureaucracy,

As the organisation grows in years and size, its structure

will have many sub-parts with specialised activities and

extensive interactions among sub-parts and the result will

be pressure for coordination. Furthermore, there will be

multiple hierarchies and different levels of authority. Such.

formal organisations are referred to as complex organisations.

their compLexity depending both upon the diversity and inter­

dependence of the sub-parts.

THEYiliNTAL HOsPITAL AS A FORMAL ORGANISATION

Mental hospitaGare formal organisations because they

have been estabLished to render services to the mentally ilL

and to the public at large and they have formally instituted

pattern of interaction. Most of the mental hospitals are

service organisations, although there may be a few private

mental hospitals in some countries which make a profit.

"In the 18th century mad men were locked up in mad

houses; in the 19th century lunatics were sent to asylums;

and in the 20th century the mentally ill receive treatment

in hospitals" .(Jones K .• , 1965). This statement indicates ,"-,', . .t'

the changes in goals and values associated with mental

hospitals through'the decades. One of the ways by which the

mentally ill are admitted to mental hospitals is through

legal commitment. The fact of legal commitment has some

important implications as regards the goal of mental hospitals

in contrast to the goals of other types of hospitals. The

law invests the mental hospital with a custodial role which

places on the hospital the responsibility of protecting the

outside community from real or potential violence of insane

persons. As a result, social control of the mentally ill

becomes a function of the hospital. In some of the western

countries the nature of commitment laws has changed making it

possible for other functions to gain prominence. For instance,

the Mental Health Act of 1959 of Great Britain has eliminated

legal commitment altogether and stresses, instead, the treat­

ment goals. Apart from the progressive developments in a

few countries, treatment of the mentally ill in general has

not progressed at the same pace as that of the physically ill

for various reasons. There are many gaps in the knowledge

of mental health and mental illness. Psychiatry has not

developed a unified theory about the causation of mental dis­

orders. For this reason, psychiatry has remained "the

Cinderella of medicine" for many years. I1oreover, earlier

psychiatric practice and study was confined to mental hospi­

tals \1hich were isolated from the main streams of social and

scientific life of the times. At one time psychiatrists

were considered in terms of mystics, priests and miracle

workers not only by the public but also by general medical

practitioners (Deutsch, 1936). The gaps in knowledge about

75

mental illness have been filled with incorrect ideas and

superstitions as far as the general lay public is concerned.

As a result of misinformation and ignorance, mental illness

has always had a social stigma attached to it. Since legal

commitment has been associated With admission to mental

hospitals, the custodial role of the hospital has been

stressed more than its other role. Realistically, the custo­

dial role is easier than treatment when treatment technology

is inadequate. The harsh treatment that was often meted out

to the mentally ill was not always the result of wilful

cruelty. Very often it was the result of ignorance; people

did not know any better method. From the sociological per-

spective, prestige of agencies forthe care and treatment of

the mentally ill has been decidedly low, just as the pre­

stige of psychiatrists has been comparatively lower than

that of other medical specialists. It is evident from these

factors, that goal setting of mental hospitals has been

influenced by the belief systems and cultural values prevalent

in the society.

Parsons in a sociological assessment of mental hospi­

tals delineates the goal of the hospital as "coping with the

consequences for the individual patient and for patients as

a social group, of the condition of mental illness". This

abstract goal can be expanded further to signify concrete

separate goals: 1) Protection of the community from the . .' • dangerous actions of the mentally ill, regardless of whether

•

76

they are predictable or unpredictable, 2) Protection and care

of the mentally ill, as they may not be able to take care of

themselves. They have to be protected from behaviour Which

is harmful to their own selves. Additionally, there is the

goal of life maintenance and this goal is realised by meeting

the patient's basic needs, 3) Therapeutic-rehabilitative

goals which provide for measures which help to improve the

patient's social functioning, disturbance in which has

brought him initially to the hospital (Parsons, 1957). One

hundred and thirty-five years ago a committee appointed by

the Connecticut state Medical Society of U.S.A. to explore

the possibility of starting a "lunatic asylum" had included

three additional goals: -1) to give comfort and sympathy to

the incurable patients, 2) to provide an economical means

of maintaining the insane at public expense, 3) to serve as

a valuable school of instruction to doctors (Deutsch, 1937).

These goals are still relevant in spite of the passage of

time. There are always _some patients who cannot be cured

and for them treatment measures are not of any avail; what'

they need is alleviatory measures. There are many chronic

patients for whom the currently available medical technology •

is inadequate and for those patients the hospital becomes

an asylum. This committee was very much ahead of the times,

as regards the goal of training of doctors. This is a goal ,.

of mental hospitals of current times.

77

The sets of goals mentioned above exclude the organisa­

t ional needs of survival. Further, the hos pi tal can also

serve as a venue for research so that.tne horizons of know-I

ledge .about mental illness may be expanded. Taking all these

factors into consideration, seven goals can be listed. They

are given below:

I) Pro:t·ection of the community from the violent behaviour of patients.

2) Protection and care of patients so that they may be treated.

3) Therapy and rehabilitation of patients.

4) Permanent care and protection of the chronically ill patients.

5) Training of treatment related professionals.

6) Research to advance knowledge.

7) Organisational maintenance and survival.'

One can trace the growth and d evelopmen t of these

goals historically which this researcher will be doing in

another chapter. The important point in this context is

the fact that mental hospitals vary in the weightage they

give to each of the~se goalS. Within the same hospital

these goals may probably be perceived differently by diffe­

rent functionaries. The administrative staff are likely to

give greater importance to goals of custody, protection and

care of patients and organisational maintenance. The profe­

ssional staff may give more primacy to therapeutic goals.

The degree of importance that one gives to each of these

78

i~ very much upon one's own experience of treat­

edge about mental disorders and beliefs.

of the mental hospitals are governmental institu-

~e financially supported by the State. Therefore,

a pa~ or tne administration is through policy decisions made

outside the hospital. The hospital administrator within the

organisations has to find a balance among three conditions

before determining certain lines of action: 1) professional

norms and standards based on the technology of the treatment

of the mentally ill, 2) public values as regards what is

desirable or undesirable for the mentally ill, 3) economic

efficiency. it follows that there are different kinds of

pres aures impinging on the hospital from internal and exter­

nal social forces which shape its process of adaptation.

The activities of the organisation fall mainly within

two cadres of function.s - prof essional and administrative.

Different disciplines have contributed kno~lledge towards the

treatment of the mentally ill and there are many professionals

working in the mental hospital •. There is no one single cause

for mental disorders; there is a multiplicity of causes. As

there is an interplay of social, biological and psychological

factors in the causation as well as in treatment plans, the

team or multidisciplinary approach becomes useful. The

professionals in the mental hospital, therefore, include

psychiatrists, physicians,. psychologists, social workers,

nurses, occupational therapists, phySiotherapists and music

79

therapists. There are para-profeSsionals like medical techni­

ciansl • The administrative unit consists of administrator,

business manager, accountant, office assistants, physical

plant maintenance staff, store-keeper, and food service staff.

The researcher has purposely omitted the employee group of

attendants who are the subjects of this study. They cannot

be obviously included among the professional groups, nor are

they being inclUded among the administrative staff in this

report by this researcher because their work has many aspects

outside the maintenance functions. This problem will be

taken up later in this section of the chapter.

The Weberian model of bureaucracy does fit mental

hospitals in some aspects. The major aspects are: (1) .There

is functional division of labour in the allocation of treat-

ment functions to the treatment related profeSSional staff

and management and maintenance functions to the administra­

tive staff. (2) Staff pOSitions and functions are defined

specifically and recruitments are made according to merit

and competence. (3) There are multiple hierarchies related

to each profession. (4) All activities are governed by rules

.of procedures and regulations.

1. Some sociologists do not acknowledge psychology, social work, nurSing, occupational therapy, physiotherapy and music therapy as professions. According to their socio­logical analysis these are "semi-professions" and medial technicians semi-skilled workers.

80

There is, however, an important difference. Profe­

ssional activities do not in every area conform to the

impersonal and universalistic aspects of staff-client rela­

tionships prescribed by the Weberian model. Relationship

itself is considered as a medium of treatment for mental

patients and consequently purposeful relationships between

professionals and patients are necessary requisites for treat­

ment. Since the level and intensity of relationship is to be

determined by the socio-emotional needs of each patient,

particularism has to be acknowledged as an aspect of this

relationship. However, the nature of particularism and

affectivity is to be guided by professional knowledge and

cannot be of the same level or degree which marks primary

relationships as in a family. Moreover, the treatment rela­

tionship being a consciously established. relationship has

aspects of detachment as well as anvolvement, objectivity

as well as empathy, permissiveness as well as firmness and

consistency as well as change and therefore, it.is distinctly

different from other types of particularistic and affective

relationships.

The one-to-one relationship mentioned in the preceding

paragraph is a major feature in psychotherapy which has been

one of the earliest methods of psychiatric treatment. It was

based on this method that the concept of therapeutic hour was

developed. Group psychotherapy was a later development in

psychiatric treatment. Both these methods imply the use of

, 81

specific t.echniques by.professionally trained therapists. . '

The number'o~. trained therapists always lags behind the ,I 10'

increasing"need of large nUmbers of mental patients in hospi-

tals. - Psychiatry did not have for a long time techniques , ..

which could be used in institutional settings. Though chemo-

therapy and physical methods like electro-convulsive treatment

and insulin shock therapy are also part of psychiatric treat­

ment, these also require the services of psychiatrists or psy-

sicians. Moreover, it has been noted in western countries,

especially in U.S.A., that a large majority of psychiatrists

go into private practice thus perpetuating the situation

of shortage of professionals in mental hospitals. Concurrently,

the search for newer and practical methods of treatment has

been going on. One answer to this search is the knowledge

that social interactions between the patient and staff

and other patients can be effectively used as a therapeutic

medium for bringing ab out changes in the patient's behaviour.

The patient is in the hospital by reason of his disturbed beha­

viour which usually manifests itself in interpersonal relation­

ships. Therefore, one way of helping the patient is to use the

interpersonal relationships in the hospital as an opportunity

for bringing about change. This fact is further corroborated

by the observations of researchers and treatment experts indi­

cating the significance of the whole social situation of the

patient in the hospital. Stanton and Schwartz, Bettelheim,

Belknap, Sullivan and others have pointed out the relevance

of developing specifications for the twenty-four hour social

82

situation'of,the -institutionalised mental patient. From " ., 4 _, . ~ .. , this frame of reference; the treatment of the' hospitalised • ~.. a

·mentai. pa"tient m~ be perceived as occUring along. two channels . , .

of experience,o the clinical and social. In other words, the . ",

treatment ,consists' of two types of management: 1) clinical •

management, 2) social management (Greenblatt & others, 1955) •• •

Clinical management will include all those processes speci­

fically designated as professional activities performed by

professionals or medical technicians. Medical and psychia­

tric treatment, nurs~ng_activities, social case work, group

workland personality tests 2 will all be components of

clinical management. Clinical management is of two diffe­

rent types: 1) psychiatrically oriented clinical management,

2) medically oriented clinical management. All the profe­

ssional activities carried out by the different professionals

with reference to the mental illness of patients fall within

the first category. On the other hand, various physiological

tests and procedures can be considered as medically oriented

clinical management. Here the term "medicat' is used in a

narrow sense referring to the treatment of the physiological

conditions of the patient. This differentiation is based on

the body-mind dichotomy, an assumption which is true only

partially. BeSides, those who fall within the first category .-may perform purely medical activities.' For instance, psychia-

trists, physicians and nurses may be using medical procedures

1. Social case work and social group work are social work methods.

2. Personality tests are used by the clinical psychologist • •

83

for solely somatic (phySical or bodily) effects on patients.

But this categorisation is used for the convenience of con­

ceptualisation and for differentiating the treatment activi-

ties of professionals from those of non-professionals. All

interactions that take place between staff and patients,

outside clinical management, interactions related to patients'

needs of food, sleep and rest, personal cleanliness and for

companionShip and conta'ct with others, will be social manage­

ment. Obviously, attendants have the greatest involvement

in social management. This categorisation of treatment into

three groups of activities is in keeping with the operational

definition of treatment developed in the second chapter.

Social management has two important goals: 1) protecting the • • •

patients' opportunities for improvement by means of clinical

management and providing other opportunities outside the

clinical processes, 2) to release the abilities of both staff

and patients to understand and reduce to a minimum the mental

disorder and its effects and to promote better social fun­

ctioning in patients (Stanton & Schwartz,'1954).

Clinical management provides some opportunities for

improvement. These opportunities. can be protected only by

preventing some probable events like suicide, escape from

the hospital, interference with physical he~lth and self­

injuries. Besides, opportunities for personal grooming,

contact with others and recreation have to be provided.

According to this frame of reference, some elements of the

84

custodial procedures become a part of social management.

To some patients who are afraid of their own impulses, lock­

ing of doors may be reassuring that they are being taken

care of against their own impulses. Some others may need

the repeated verbal assurance from the staff that the locking

of doors is not a mode of punishment but a measure of safety

and security for patients themselves.

The second goal of social management does not lend

itself for easy definition. D.ifferent kinds of efforts at

• different levels have to be tried. But certain general

principles can be stated. Efforts should be made to allay

patients' fears and anxiety. The level of tension should be

as low as possible and patients should be comf~rtable. The

staff can use ordinary types of interpersonal support like·

encouragement, warmth, advice, suggestion, information, .' ..

direction and explanation. "

Social treatment from· the frame of reference of the

two goalS would mean:,(l) patients' behaviour should be under­

stood not only by the professionals but by the non-profe­

ssional staff also who have specified and patterned contacts

with the patients. It does not mean that the non-pfofe­

ssionals should have deep theoretical knowledge about the

patient's pathology, but they should have sufficient informa­

tion about mental illness, symptoms, and treatment to remove

superstitions and misconceptions and to facilitate acceptance

of patients. (2) Staff should have the right kind of attitude

85

An appropriate attitude will mean, kindness, sympathy, hope­

fulness, sense of realism and respect for patients. (3) A

combination of adequate knowledge and the appropriate atti­

tude will facilitate therapeutic handling of patients in the

various situations. Patients may show excessive anger, fear,

grief, bate or apathy_ These emotional expressions have to .. be handled in a way which is therapeutic. A patient's violent . "

behaviour may be an expression of anger, fear, hate or dis­

appointment. If· the' patient's'violence is met with violence . I:

.. ". .at ••..

or other types of punitive reactions on the part of the staff,

it will only help,t~ increase the underlying anger, fear,

hate or disaPPOintment, and thus prevent therapeutic processes.

It is natural that the patient's behaviour provokes negative

emotions in the staff and what is required is not denial of

emotions but their control in the level of awareness. Develop­

ment of knowledge of the self is a vital element in the train­

ing of people for social management o~ .the mentally ill so

that they may have a controlled emotional involvement with . patients. ,(4) Patients and staff have potentialities for

therapeutic interactions. For example, a patient's love of

music may be used therapeutically for him and other patients.

Similarly, the staff may have talents and abilities that can

be put to effective use in social management. For example,

an attendant's enthusiasm and skill in gardening can be

utilised in stimulating some of the apathetic patients for

activity.

86

Clinical management of patients is more precise and

specific. On the other hand, social management is diffuse,

touching many routine and non-routine activities of daily

living. The diffuseness is an advantage, nevertheless. The

therapeutic skill lies "in making creative use of these

aspects of living for changes in patients' behaviour.

The advantage of social management as a treatment

strategy is that no~-professional staff also can be usefully

involved in it. Of all the non-professional staff the atten­

dants have the most contact with patients. The attendant is

the staff member with whom the patient interacts at the

closest proximity and also continually. Attendants are the

largest')occupational group and therefore, quantitatively the

essential manpower in the hospital is located in their ranks

and their .interactions ,dth the patient cover a wide range

of activities.

The ~ental hospital as an organisation is occupied with

the functions of receiving, classifying, diagnosing, treating,

maintaining and discharging the patients. These patient­

related functions can further be broken into the following

operations:

1) Receiving all persons who are brought to the

hospital for admission. They will be of 3 cate­

gories: voluntary patients, committed patients

and those sent for observation and for later

commitment if diagnosis demands it.

2) Examining these persons and securing as much

information from them or about them.

3) Maintaining official records and correspondence.

4) Observing the admitted person's behaviour.

5) Diagnosing and planning for clinical treatment.

6) Providing the different modes of treatment

according to plan.

7) Maintaining clinical files.

8) Keeping accounts, 'billing and transacting money

matters.

9) Providing security for patients, staff and the

public.

10) Preparing patients' food and laundering their

clothes.

11) Lighting, plumbing and sanitary arrangement.

12) Housekeeping tasks for order, cleanliness and

comfort.

87

13) Seeing to the patient's personal care: food, cloth­

ing, sleeping, arrangements and care of the body.

14) Observing the patienteFnmder treatment, also super­

vision of patients engaged in work or recreational

activi ties.

15) Determining when the patient is ready for discharge

or that he requires further treatment.

16) Arranging for discharge. (Belknap, 1956).

This listing is sketchy and lacking in precision as

there is a wide variation as regards the depth and content

88

of each operation. But the list can be used for a rough

assessment of attendants' involvement in the social situation

of patients. All these 16 operations or sets of operations

are patient-related out of which 10 can be considered as

patient-contact activities meaning activities involving

direct contact with patients. Attendants have some kind of

involvement in nine of these activities.

Though the medical examination of patients is conducted

by the doctor there is always an attendant standing by to

provide security to the examining doctor and to help the

patient to respond to the doctor's inquiries appropriately.

Some patients show resistance to the medical examination and

to the hospital's rule that .they should change into hospital

clothes. It requires tact and skill on the part of the

attendant to persuade the patient to comply with the doctor's

instructions and hospital's rules. Since attendants have the

most contact with patients, they are able to observe patients

and to help the doctors with their observed data for making .

a diagnosis. They shoulder the main responsibility for

providing security for the patients, doctors and the public.

It is their job to see that the patients do not run away and

they lock up the patients every night. The keys of the ward

are carried around and kept by the attendants. The key is

an important external symbol to the patient, the symbol of

his helplessness and the power of the attendant.

89

The attendant in the ward is responsible for some of

the housekeeping. tasks of that ward. He performs all the

tasks connected with the patient's physical care.- Attendants

serve food and have to be watchful to·see that patients eat

adequately., They have to feed the patient who does not eat • and bathe the patient who does not bathe. All aspec~of per-

sonal cleanliness are part of their job. Since mental illness

does affect:the patient's capacity or readiness for self-care

activities, physical care becomes an important responsibility •

• '. Just as it is important to observe the patient for .

diagnost,ic purposes , it is equally necessary to follow up

the patient's progress in treatment. by observing his behaviour.

It is a time-worn. practice of mental hospitals to get the

patients 'engaged in some work of the hospital. This mayor

may not be part of occupational therapy. It 'is generally •

the attendants who supervise patients in their work and in . . some situations they may assist the patients by working with

~ 9 ...

them. They pass on to the doctor information,about .patients' •

general behaviour 'and work performance. Doctors use this

informatton in making decisions as regards patients' mental

condition and fitness ~or discharge •

. From this brief description of the attendant's involve­

ment in the total social situation of/the hospitalised

90

men tal patient, it is quite evid ent that their inv c1.v amen t

is substantial in a quantitative perspective. One of the

objectives of this research project is to investigate about

this involvement in both the quantitative and qualitative

aspects.

Using the model of cl;nical-social management of the • patient, a classificatory,scheme for the functionaries may

be developed. The classification is illustrated in a chart

on the next page.

Therapeutic functions are those functions which involve

interactions wit~ patients - interactions which are covered

under clinical or social managements. There are three types

of functionaries who perform these functions: 1) Professionals;

2) Technicians, 3) Non-professionals.

Professionals: This category will include all those treatment

oriented personnel who occupy specific social positions

because of their special skills ~ich they have acquired

after professional training.1 Their involvement is in psychia-•

trically oriented cl~ical managemEnt of patients.

Technicians:

These functionaries are of a lesser status than the

professionals, though they also have special skillS which

they have acquire'd after training. . . They have contacts with • •

patients but these contacts are not continual and are less + ... • ....

CHART 1

MENTAL HOSPITAL STAFF

~ o

Therapeutic Functions (clinical and social ianagement of yatients) I I I

Psychiatrically oriented clini­cal management.

Professionals

psychiatrists Physicians Nurses Psychologists Social workers Occupational­therapists

Medically Social oriented manage­clinical ment management

Non- profe­Technicians sSionals

e.

Physiothe- Attendants. rapists Dentists Radiologists Pharmacists Medical-technicians

o Administrat on-maintenance Functions

Executive Organisation functions. maintenance­

oriented functions.

Superin­tendent. Deputy SUperin­tendent.

Business­Manager .Accountant Office­Assistants

Building and Equipment staff Store­keepers.

I I

Patient oriented maintenance functions.

Training &:

Research.

Food service Librarian staff Housekeeping staff Laundry staff

92

frequent. Their work is concerned with the biological E\Vstem

o£ human beings and they handle body-products, and tissues

and use tools or machines for their work. Their work as

mentioned before is for the medically oriented clinical •

management of patients. I ,

Non-professional therapeutic functions:

Attendants are the functionaries who perform the kind

of non-professional therapeutic functions. The inclusion of

attendants among therapeutic functionaries is based on the

concept of Social management discussed before and the related

discussion about attendants' invo~veJDent in the social situa-

tion of patients. The division of therapeutic functions into

clinical and SOCial management ie a conceptual frame work and

not a part of the functional claesification adopted by the

hospitals. According to the claesification Which is in use,

attendants will be included amo~ the patient oriented main­

tenance personnel in the same category as cooks, laundrymen

and linen keepers. CookS, laund~ymen and linen keepers per­

form tasks which are directly cOllnected with the patient

care, but they do not come into Qirect personal contact with

patients. Attendants are contact points between patients

and the staff like cooks and la~drymen and hence they have

been referred to as patient cont~ct personnel, earlier in

this chapter. Attendants' location at the first level

contact with patients has 1mplic~tions as regards patients'

93

opportunities for improvement. The cook may be preparing

good food in the kitchen, but if it is served to the patients

by the attendant in a disrespectful manner, it will provoke

negative reactions in the patients. Though psychiatrists are

patient contact staff, for certain activities like the

observation of patients' behaviour for prolonged periods,

they have to rely on attendants who serve as a link between

the professional and the patient for the fulfilment of a

clinical function. It is evident, therefore, that attendants'

functions are different from those of patient oriented main­

tenance personnel. In later chapters of this report the

researcher will examine the different aspects of the contact

between attendants and patients in order to determine the

real and potential content of attendants' contribution to

the social management of patients Which is a part of thera­

peutic management.

4dministration-maintenance functionsl :

These functions are different from the therapeutic

functions because the functionaries generally do not have

any direct contact with patients. Hence their work is neither

clinical management nor social management (There are a few

exceptions which will be mentioned later).

1. In "administration-maintenance" administration means the management of staff and financial resources and mainte­nance means, keeping the patients, building, equipments and the grounds in good condition. Since these two functi6ns are so inter-related and overlapping, the compound word is used.

The executive division consists of the superintendent who is

th~ chief administrator. He is assisted by deputy superin­

tendents and sometimes by other kinds of assi~tants. This

division has the highest authority in the hospital as regards

deciSion making, directing and controlling functions.

Organisation maintenance oriented division:

This is the second division of the area of functions

covered by the administration-maintenance functions. The

main sub-part is the business section which handles money

transactions of different types. Budgeting, purchasing,

salary payments, accounting and related operations are

handled by this sub-part. In some hospitals, this division

is headed by the bUSiness manager who is likely to have had

training in bUSiness administration.

A second sub-part of this division deals with the

upkeep of buildings, eqUipments and grounds.

Patient oriented maintenance functions:

This is the third division within administration­

maintenance. Protection and care of patients is one of the

organisational goals of the hospital and patient care in

essenee is connected with the fulfilment of the baSic needs

of which the need for food is the most urgent. Food service,

therefore, is a vital service. This third functional divi­

sion deals with the services connected with food, clothing,

95

sleep and rest and related items. KitChen services, laundry

and housekeeping are included in this division.

Training and research:

Any hospital vThich' grows aftd expands will have train­

ing programmes of two types for developing its own staff and

students in the healing professio~s. There will be in-,

serVice programmes for the staff and programmes of training

for students who come to "the hospital from different profe­

ssional schools. This form of adult socialisation is very

valuable to help the staff or potential staff to identify

Some of the teaching and training staff may have only

these educational functions and may not strictly belong to

the therapeutic functionaries of the hospital although they

are professionals by their traini~g. Similarly, some staff

whose main function is therapeutic may have a secondary

function of teaching. This situatinn may apply to research

as well.

The classification of the ~ospital staff into thera­

peutic personnel and administration-maintenance personnel .. ~ 040'

" is not strictly precise because ot many overlapping functions.

The therapeutic personnel carry some administrative duties,

as well. The chief administrator is also a psychiatrist by

96

profession and 1'1i thin his social position there is a combina-. tion of administrative and therapeutic functions. The organi-

• sat ion maintenance oriented division does handle some of the

patient related activities also such as handling of, .

.'1) .official documents like commitment papers from the court

and reception orders, 2) dealing with patients' accounts.

If one feature of administration is the process of

getting the work done by people, this process goes on in all

parts of the hospital. Directing, supervising and controlling

are administrative activities used by many functionaries .. , regardless of whether they are therapeutic staff or admini­

stration-maintenance staff, in relation to other staff who

are under their authority. The doctor in the ward, head-..

nurSe and staff nurse do carry on some administrative duties

along with their therapeutic work. Even the attendant who

occupies a very low position in the ward hierarchy has been

sometimes referred as the ward administrator although the

d~signation is by default (Barton W.E., 1962).

The mental hospital ,is a complex organisation by the

nature of the complicated role-relationships within the

organisation. A simple illustration would be to have a chart

to connect the goals of the hospital with related functions.

The graphic pattern will be a confusing labyrinth of

connecting lines.

CHART - z Personnel

A. Therapeutic Functions

1. PrOfessionals

2. Tecl:micians

Goals

1. Custody of patients

• Care of patients

Therapy

97

3. Non-professional . 4. Long-term care of j.n-

therapeutic etaff" 'attendants) curable patients.

B. Administration-maintenance functiOns.

1. Executive

2. Or~anisation maintenance oriented staff •

• 3. Patient oriented main-

tenance staff. .

4. Training & research staff.

Organisation main­tenance.

Teaching.

7. Research.

This chart shows the involvement of the attendants in

the process of goal attainment. They have some common fun­

ctions with the patient oriented maintenance staff of the

third division in B. Theoretically they belong to this diVi­

sion. They are associated with .the five goals, custody, care,

therapy and the continuing care of chronic patients and

. organisation maintenance.

After hav'ing discussed the characteristics of formal

organisations in general and about mental hospitals in parti­

cular, it is necessary to examine the two hospitals, the

settings for this study, with reference to the theoretical

frame work.

98

Mental Hospitals A and B:

Hospital A and Hospital B were both "mad houses" at

the time of their origin. Hospital A began in 1799 as an

institution under the administration of East India Company

for "accommodating persons of unsound mind". It came under

the provincial government in 1871 and at that time it was

called "the lunatic asylum" and in 1922 the name changed to

"the government mental hospital". ,Hospital A is the only

mental hospital in the State which has a population of over

four crores.

Hospital B was started in 1901. The foundation stone

which was laid in 1895 is still visible near one of the wards.

The cost of construction was about 4 lakhs of rupees out of '. which one lakh was donated. The hospital is still called by

the name of the person whose family had donated the amount

towards its construction. Hospital B is one of the four

mental hospitals in the State with a population of over five

crores. •

Hospitals A and B are state institutions and the

expenses are met by public exche~ers. The annual outlay of

Hospital A is about ~ 4,700,000 and that of Hospital B

~ 4,200,000. Using the list of goals of mental hospital

presented earlier, it can be said that both hospitals A & B

share the objectives of custody, care and therapy. These

goals have been the original goals indicated in the Indian

99

LunacY- Act of ~9~2 \ The Law wi~~ be discussed for fUrther

details in the next chapter). Hospital A seems to have an

additional goal, that of training people in the medical and

allied professions, like medicine, nursing, clinical psycho­

logy, social work and occupational therapy. Though Hospital

B also offers some aspects of training facilities for occupa­

tional therapy and psychiatric social work, the hospital is

not recognised as a teaching mental hospital. The only

training programme that Hospital B has is for its overseers.

The remote location of the hospital far away from the profe­

ssional schools of the city D is a factor which reduces the

hospital's potentiality as a training facility for mental

health professionals. On the other hand, Hospital A is

within the municipal limits of city C and is easily accessible

to the students and staff of professional schools. Students

of medicine, nursing, social work, psychology and occupational

therapy come to this hospital to learn about mental illness,

its treatment and the specific techni~es their respective

disciplines have developed in the treatment programmes for

the mentally ill. Hospital A conducts refresher courses in

psychiatry for the general practitioners twice a year. Train­

ing programmes and the trainees themselves serve as links

between the hospital and the. outside community. The superin­

tendent and two other senior psychiatrists of Hospital A are

professors of psychiatry in the three local medical colleges.

When the University of city C in which Hospital A is located

100

started the postgraduate diploma course in psychological

medicine (DPM) , the hospital got involved in this programme

by ,organising lectures and clinical conferences and thereby

assumed a higher status in the educational system. As a

res~t of these on-going links with outside organisations,

the hospital has been the venue for conferences and seminars

on topics related to the field of mental health. Far frem

being isolated and cut off from the rest of the community,

Hospital A maintains continuous and close contacts with the

outSide community. Hospital B lacks these advantageous con­

tacts being phySically and culturally removed from the life

of the city D.

Research does not seem to be a prominent goal in these

two hospitals though it is carried out on a small scale.

The custodial role is important for both the hospitals,

because a majority of the patients are court committed cases.

But the external symbols of the custodial role are less evi­

dent in Hospital A. Hospital B has high walls (about 10 ft.

high) all around and a big, heavy and imposing gate. Hospital

A has high walls on the three Sides and a very low wall (4 ft.

'high) in front and a very inconspicuous gets. Hospital B has

only two open wards - one in the male section and the other

in the female section. Hospital A has only three closed wardS,

housing the criminally insane, the newly admitted patients and

the epileptic patients. All the rest are open wards in the

101

sense that the doors of the wards are not locked during the

day, which gives better freedom of movement to patients. The

voluntary patients of Hospital A are allowed to spend the

day out with their families on week-ends depending upon their

level of improvement.

The two hospitals are under the director of health

services of the respective States and under the Ministry of

Health. Most of the major policy decisions regarding the

hospital are made outside the hospital by the ~linister or

Director of Health. Some of the policy decisions made this

way outside the walls of the hospital serve to reinforce or

change the goals of the hospital. The Indian Lunach Act of

1912 (ILA) though outdated in the light of the new develop­

ments in psychiatry, is still an important factor influencing

the hospital's[goals and programmes.

The Hospitals A & B are run by funds drawn from the

public exchequer though a few patients in both the hospitals

pay for their stay. and treatment. Voluntary contributions

are not entirely absent but theY are usually for specific

purposes. A few additional attendants are employed by a

• charitable organisation to give individual care to the child

patients of Hospital A. The canteen of Hospital A which

caters to both patients and staff of the hospital has been

started through donations from interested citizens of the

community. Both hospitals A and B have received gifts in

102

the form of T.V.sets, radios, typewriters, sewing machines,

etc. for the patients' use.

ORGANISATIONAL STRUCTURES OF HOSPITAL A AND HOSPITAL B

In this part of the chapter, the sub-groups and roles

within the hospitals will be described and discussed. The

mental hospital comprises many kinds of medical functions

and also complex functions of administration - accounting,

housekeeping, food management, purchasing, laundry and

others. It incorporates within its structure some aspects . . of the prison, the healing place, hotel and the business

organisation and therefore, the structure turns out to be

rather complex.

Structure of Hospital A:

The Hospital has a patient capacity of 1800 and has

14 sections which are listed below:

Sections

A

B~

C

D

E

Fl

I F2 ttl G2

for

" " "

"

"

Newly admitted patients

TJj patients

Leprosy patients

GriminaJ.s

Epileptics

Chronic and aged patients and patients who do not fall under the above categories.

Special l'lard

Femal patients' section

Medical ward - patients who suffer from physical ailments.

Outpatient department

Day hospital.

103

Tue female section is divided into five sub-sectio~s

catering to the following types of patients: (1) Newly

admitted patients, (2) Epileptic and T.B.patients, (3) Crimi­

nally insane, (4) Child patients, (5) Chronic and aged

patients. Each section has one or more wards upto a maxilllum

of four ,.ards.

me division of the hospital into different sectio~S

is not b~sed on any scientific classification of patients.

It represents a pattern for the institutional management of

patients in terms of age, sex, economic status, behaviour

patterns, physical illnesses, legal status, etc. (Belknap,

1956). 1he classification s,eems to fUlfU some requirements

of treatlllent and care and the custodial. functions of the

hospital. Section D, housing the criminally insane is a

closed section with high walls surrounding it and with an

imposing gets which is always kept closed. The staff stru­

cture of Hospital A may be examined with reference to the

therapeutic personnel and administration-maintenance per-

sonnel.

"

1 O~

Professionals Technicians

Physicians 25 Physiotherapist 1

Psychiatrists 5 Dentist 1

Nurses 104 Radiographer 1

Psychologists 3 Pharmacist 3

Social workers 25 Medical technicians 5

o c cupa tional therapists 1

Of the five psychiatrists, one is the superintendent

who is also occupying the top position in the administration­

maintenance part of the structure. He practices psychiatry

while two other doctors, the deputy superintendent and the

residential medical officer (HMO) have very little profe­

sSional activity as they form a part of the executive division

and are involved mainly in administrative functions. In the

medical cadre, there is a hierarchy followed by the consul­

tantsand the medical officers. The two consultants share

with the superintendent some administrative duties under the

unit system. The superintendent and the consultants are

given two fixed days of the week as regards responsibi~ity

for consultation and certain types of clinical administration

like dealing with admission and discharge decisions.

The superintendent and th e consul tan ts ar e also heads

of the psychiatric departments of three general hospi~ls in

•

105

the city which have medical colleges attached to them. Con­

sequently they are professors of psychiatry in those medical

colleges. This link helps to raise the prestige of the

hospital in the eyes of the public.

The nurses' group is comparatively a large professional

group and forming a hierarchy in itself - matron, assistant

matrons, head nurse and staff nurses. The matron's position

is occupied by a man in this hospital, WhiCh is not very

common. There are other male nurses also but the practice of

recruiting men for nursing has been stopped till 1958. Male

nurses work only in male wards, but female nurses work in all

wards except in the ward for the criminally insane.

From among the total of 104, 21 are psychiatric nurses,

in the sense that.they had one year's training in psychiatric

nursing in the Indian Institute of Nental Health, Bangalorel •

The diploma in psychiatric nursing (DPN) is a status symbol

among nurses; beSides, it entitles them to a higher pay.

Promotions are not based on additional qualifications but on

seniority of service in the government. It is here that the

Weberian model does not fit. The-matron of this hospital does

not have DPN qualification; but the assistant matron has the

qualification.

1. which is currently known as the National Institute of Mental Health and Neuro Sciences.

106

Every section has a head nurse, and every ward, one or

more staff nurses. The matron and assistant matron are

occupied with administrative responsibilities and have very

few therapeutic functions.

The hospital has three psychologists, one for the out­

patient department and two for the rest of the.hospital.

The hospital has 25 social workers which is compara­

tively a large number. They are of three different cadres.

Nine of them have post-graduate degrees or diplomas in social

work. Fourteen had undergone a two-year programme in psychia­

tric social work organised by the Red Cross Society for which .

the requirement was that the candidates should have passed

the pre-University examination. The two remaining ones were

college graduates without any social work qualification, who

were recruited on the government's special programme for

employment of university graduates.

There is only one occupational therapist though there

are three occupational therapy programmes going on in the

hospital - book-binding, carpentry and envelope making.

Envelopes are made on a large scale in response to orders

from other organisations; this activity is part of industrial

therapy which has been started as a form of sheltered work­

shop for the occupational rehabilitation of mental patients.

The industrial therapy team consists of a doctor, a nurse

(who is the assistant matron), a social worker and the

occupational therapist.

107

The non-professional therapeutic personnel are the

attendants who are 345 in number. There are only two levels

in the hierarchy. Class I attendants and Class II attendants.

The first category of attendants are also called senior atten­

dants who have supervisory responsibilities over the other

attendants of the same ward. Associated with this position

is the exemption from might duty.

Male attendants have two levels of direct authority.

As regards hours of work,schedule of work and assignment of

duties and wards they come under the overseers who keep the

roster for marking attendance, leave of absence, etc. But in

the ward they are under the direct supervision and authority

of nurses. There was a time when overseers were assigned to

wards and attendants were accountable only to the overseers.

After the hospital adopted the policy of gradually abolishing

the post of overseers new recruitment to this job stopped.

The hospital at present has only 3 overseers. The female

attendants have only one level of authority, the one repre­

sented by the nursing hierarchy. They are under the direct

supervision of nurses in the ward.

The diviSion of the hospital into various sub-units

like clinics and departments is the outcome of the develop­

mental phases related to the specialisation of the therapeutic

functions. The different sub-units are given below:

Epilepsy clinic

Mental deficiency clinic

Neurology clinic

N euro -surgery clinic

Neuroses clinic

Child Guidance clinic

X-ray department

Dental clinic

Physiotherapy

Medical photography

Psychology department

Social work department

Occupational therapy department.

Administration-maintenance personnel

108

The executive division of this category consists of

the Superintendent, the deputy sUperintendent, and the

residential medical officer. As an executive, the superin­

tendent has a schedule of regular weekly visits to the diffe­

rent sections of the hospital so that every section is visited

once a week. patients, premises and methods of treatment are

the objects of the visit. The RMO also accompanies the

superintendent for visits. In addition to the scheduled

visits, there are also surprise visits by the superintendent

and his assistants.

llU

near the hospital kitchen, a second office which he occupies

for a few hours regularly every day for the supervision of

delivery of groceries and other food stuffs like meat, fish,

fruits and v;egetables. Another important fe-ature of food

management is that the kitchen team is headed by a head-nurse

who is assisted by staff nurses and cooks. The kitchen

itself is spacious and well-equipped with modern facilities

like gas,stoves and electrically operated grinding machines.

These are features which have an important impact on one

aspect of patient care, namely, the preparation and serving

of food, and the attendants, the subject of this study, are

involved in this aspect.

~atient oriented maintenance personnel:

The functions in this division are those related to

food service, tailoring, laundry, sanitational hygiene, etc.

The personnel ~lho come under this division are:

But le.r s

Cooks

Dhobies

Barbers

2

26

4 .

8

Sanitary workers 135 (Sweepers)

Training and research:

As already mentioned, Hospital A has different types of

training programmes in the·form of conferences, lectures. The

111

hospital serves as a fi~ld of practice experience for students

of nursing, psychology and social work 'tho come to the hospital

from their professional schools in the city to learn about

mental illness and about treatment strategies. Realising the

importance of att endants' work 'I'li th patients, Hespi tal A had

tried programmes of in-service training for the attendants.

The division of training and research does not have functiona­

ries exclusively for these functions. The professionals of

the therapemtic personnel category undertake responsibilities

of teaching and training in addition to their treatment tasks.

The importance of rules and procedures was discussed

in the first part of this chapter in relation to the organisa­

tional reqlirements of pattern maintenance, and social integra­

tion. AS regards the staff of Hospital A, rules governing

their professional behaviour are laid do,m in a book called

"The JI'lental Hospital Code" published by the State Government.

This book delineates functions of different occupational

groups and supervisory procedures. From the point of view of

social management, the code book has the following types of

instructions:

1) Steps and precautions as regards the custodial care

and protection of patients.

2) Requirements as regards quality and gquantity of

food and clothing.

112

3) Guidelines of specific areas in social management,

particularly with reference to attendants'

functions.

Some concepts related to the appropriate attitudes and

controlled emotional involvement discussed earlier in this

chapter are spelt out in the form of concrete prescriptions

and prohibitions. For illustration, one rule is, "They

(attendants) shall under all circumstances treat the patients

under their control kindly ... When abused or threatened,

they must not retaliate but must try to calm the individual

patient by some harmless concession or kind words" (Section

XIII, Article 220, p.lll).

Just as a family is not meant to be a society (Parsons

T, 1955) the mental hospital as a social organisation cannot

remain isola ted from the larger community. Hospital A has

its links with the community and these have already been

mentioned. There is an additional link in the form of an

advisory committee which was constituted by the State Govern­

ment in 1964. This body of influential non-officials has

been taking an active interest in the affairs of the hospital.

The advisory committee has been instrumental in expediting

the construction of new buildings and. in improving other

phYSical facilities. The hospital's well-equipped kitchen

and steam laundry are the results of the committee's involve­

ment.

113

structure of Hospital B

Hospital B has provision for 1850 patients and like

Hospital A, it has two major divisions segregating male and

female patients. Each of these divisions is further divided

into 15 wards as listed below:

Ward 1 for chronic mental patients

Ward 2 for epileptic patients

Ward 3 observation ward

Ward 4 for chronic and "dirty" patients

Ward 5 for criminally insane patients

Ward 6 for chronic patients

Ward 7 for leprosy patients

Ward 8 ) for weak patients (those who are 9 ~ physically debilitated).

10

Ward 11 for TB patients

Ward 12 for the physically ill patients

Ward 13 for patients undergoing electro-convulsive therapy

Ward 14 for patients undergoing insulin shock therapy

Ward 15 Open ward.

Hospital B does not have any children I s ward nor does

it have any special wards for patients who can afford to pay

a higher rate of hospital fees.

Therapeutic personnel of Hospital B

Professionals

Psychiatrist

Physicians

Nurses

Psychologist

Social worker

o ccupa tional therapists

1

13

46

1

1

4

Technicians

Pharmacist

Compounder

Lab.Technicians

Lab.assistants

1

1

2

2

IIi

There is only one psychiatrist in Hospital B and he is

the superintendent. The nearest civil hospital has recently

started a psychiatric out-patient department where he conducts

the clinic a few days of the week. Out of 13 physicians, 4

are graduates of Indian medicine and one a licentists in

medicine.

Matron,assistant matrons, ward sisters and staff

nurses constitute the hierarchy of nurses. About 8 have the

post-graduate diploma (DPN). Some wards like Ward 12 (for

mental patients who are also physically ill) have two nurses

or more, with the resUlt that some wards do not have nurses

exclusively for their nursing needs. Since most of the wards

are situated in separate buildings, it is rather inconvenient

for one nurse to look after the patients of more than one

ward. As a result, nurse-patient contacts become less fre­

quent and the situation referred to earlier arises where the

115

the attendant becomes the "ward administrator". Though the

hospital has 4 positions for social workers, only one is

filled, inspite of the fact that there are two professional

schools of social work in the city D. The physical and

cultural isolation of the hospital is one of the main reasons

for this state of affairs.

Non-professional therapeutic personnel:

There are 286 attendants in three levels - havildars,

senior attendants and attendants. The function of a havild?r

is supervisory; he is in charge of two or more wards. Havil­

dars and senior attendants are exempted from night duty as

in Hospital A. Higher to the attendant is the overSeer Who

is a functionary among the organisation maintenance oriented

personnel, in the administration-maintenance category. Over­

Seers are assigned to wards also (unlike in Hospital A) in a

supervisory capacity. The chief among overseers is the

supervisor who directs the administrative activities regard­

ing attendants' schedule of work and maintenance of their

records of attendance, leave of absence, etc. Attendants

are subject to two levels of authority in the ward, authority

of the overseer and that of the nurSe. Attendants' dealings

with patients come under the supervision of nurses and all

the other aspects related to punctuality and regularity at

work, compulsory wearing of uniforms and similar rules and

also cleanliness of premises come under the supervision of

overseers.

116

There are three female overseers in the section for

female patients. These three overseers are under the direction

of the matron who is a woman in this hospital, and not under

the male supervisor.

Administration-maintenance

The executive division includes the superintendent and

the R.lIi.0. (Residential Medical Officer). Both the superin­

tendent and the HMO perform therapeutic functions as well.

The organisation maintenance oriented personnel

Senior administrative officer

Junior. administrative officer

Steward

Assistant steward

Accountant

Office assistants

Overseers

Driver

Peon

1

1

1

1

I

11

22

2

2

The Senior administrative officer's position is similar

to that of the lay secretary in Hospital A, but of lower

status. The steward is in charge of purchase of food items.

There is also a committee consisting of the ffi~O, the matron,

chief overseer and others for supervising the delivery of

groceries and other food stuffs.

,

,

117

Building and equipment personnel are very few in

Hospital B. There are three carpenters and four weavers in

this sub-division.

Patient oriented maintenance personnel

Kitchen supervisor

Linen-keeper

Tailors

Cooks

Barbers

Sweepers

lraining and research

1

1

5

29

8

2~

Apart from the field work programme in the hospitai

for social work students and occupational therapy students

who come to the hospital for practical experience, from their

professional schools in the city, there is no training pro­

grammes for professional students.

Till about two decades ago, medical undergraduates, medical graduates specialising andLin psychiatry used to come to the hospital for practical

experience. This practice has stopped after the local

medical college hospitals developed psychiatric services • •

Hospital B conducts a series of lectures on psychiatry for

the benefit of overseers and also conducts an examination.

OVerseers have to pass this examination in order to get

annual increments of salary.

118 • Hospital B hasc,a "~lental Hospital Manual" correspond-

ing to the "Mental Hospital Code" of Hospital A. There is

only one copy for the whole hospital which itself is a typed

copy with a few pages missing. This copy is almost like an

ancient relic and not easily accessible to students or

researchers.

Though a comparison of the two hospitals A and B is

not an objective of this study, some differences between the

two are too obvious to be missed. Hospital A has more profe­

ssionals than Hospital B. There are marked differences in

the number" of doctors, nurses an~ social workers. The spe­

cialised clinics and services operating within the structure

of Hospital A are absent in Hospital B. The reasons are

associated with certain factors which were mentioned before.

The annual budget of Hospital A exceeds that of Hospital B

by about Rs.4,OOO.OO. Some of the advantages that Hospital A

has over Hospital B are due to its status as a teaching

hospital. Being a teaching hospital it emphasises the treat­

ment goal which is indicated by the larger number of treat-·

ment personnel and specialised treatment services. The

custodial role seems to be an important feature of Hospital B

which finds expression in its high walls, imposing gate and

locked wards. The "open door policy" which implies the use

of unlocked wards has been a progressive step in the treat­

ment of the mentally ill (Jones, K & Sidebotham R, 1962).

1'19

Hospital A seems to have caught this idea and is practising

it by keeping many of its wards open. One of the main draw­

backs of Hospital B is its phYSical and cultural isolation.

Service giving professionals as well as organisations should

have role visibility so that the public may acknowledge the

role and give support. IVhen the role is invisible there will

be no public image or if at all there is an image, it will be

a distorted one. I'lhat is required is a permeability between

the hospital and the community. Hospital A has developed

this permeability by means of its social and cultural links

with the community, whereas Hospital B is lacking in this.