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STATEMENT OF PURPOSE

has a membership of approximately 300 psychiatrists, most of whom are organized in the form of a number of working committees.

These committees direct their efforts toward the study of various aspects of psychiatry and the application of this knowledge to the fields of mental health and human relations.

THE GROUP FOR THE ADVANCEMENT OF PSYCHIATRY

Collaboration with specialists in other disciplines has been and is one of GAP's working principles. Since the formation of GAP in 1946 its members have worked closely with such other specialists as anthropologists, biologists, economists, statisti­ cians, educators, lawyers, nurses, psychologists, sociologisLs, social workers, and experts in mass communication, philosophy, and semantics. GAP envisages a continuing program of work according to the following aims: 1. To collect and appraise significant data in the fields of psychiatry, mental health, and human relations 2. To reevaluate old concepts and to develop and test new ones 3. To apply the knowledge thus obtained for the promotion of mental health and good human relations.

GAP is an independent group, and its reports represent. the compo site findings and opinions of its members only, guided by its many consultants.

THE POSITIVE ASPECTS OF LONG TERM HOSPITALIZATION IN THE PUBLIC SECTOR FOR CHRONIC PSYCHIATRIC PATIENTS was V

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ȝϠC‫ھڞ׳‬Ɍ ‫ ھ‬ȷϡH ؆ ‫ ھ‬Ƹh Ӣ̰؇Ù‫ ڗ ˃ھ‬Ú‫ ھ‬ƑѦe ‫¡׆‬Ϣ‫ׇ‬؈ղ=‫ھ‬ Ȟ ѧԮ‫ھ‬ǎ ‫ھ‬ŝΪ̱ԈEÛ‫ ھ‬ǩ̲ {؉‫پ‬ҋ ϣ ‫ ھ‬ǠӣoĞ‫ھ‬ ΃u‫ ̳ ھٍׯ‬Α¨ Ü‫ ھ‬ʼnϤH‫˾ھ‬ճ‫׈‬Ҽ ‫ ھ‬ɨ ˿+‫ھ‬ ʴº̴ ӏϥ‫ھڟ‬Ǵ ‫ ھ‬Ǐ Ϋ Ϧ4L‫ ھ‬ŷХӤԉմ>َÝ‫̵_ ھ‬؊؋‫ھ‬ ^յѨԯ‫ ھ‬ǪĈ‫] ھ‬٫>άϧ‫@¯׉‬԰ ‫ ھ‬-Ц ԊնԱ‫̶ ھ ؼ‬،‫ھ ؍‬ ɍշ‫״‬DҌ؎‫ھ‬Ş ‫ ھ‬Ⱦү֭‫ؽ‬ո= ‫ ھ‬ƒ ̷֮έ‫ ; ھ‬Þ‫ ھ‬ɩ [ĉ‫ھ‬ ȟAѩ ‫ ھ‬ǫ ‫ ھ‬ȸչպ Ϩ‫ڠ‬ß‫ ھ‬ƹͷ ̸°à‫˄ھ‬ϩ‫ژ‬,‫ھ‬ ƱѪ̹! ؏‫ھ‬ʍ ‫ ھ‬ɿß‫׊‬ҍϪĴĵ ‫ ھ‬ѫҎӐ̺ή~ӥ֯6 ̻(‫ ھ‬ʎ̼ ‫ھ‬ şӑяϫί‫ ھ‬ǵ ‫ ھ‬ʵϬ̽ԋջ á‫ ھ‬35 ;ЧؐӦШ‫ ھڡ‬ӧ ؑ&‫ ھ‬Ɏ̾‫ھ سز‬ Ƞռ7 ‫ ھ‬ʶV‫ ھ‬ʷ‫̿׌׋‬٬ؒؓ ‫ ھ‬ɪv‫ ھڍ‬Ƕ̀‫ٿ‬ϭ %‫ ھ‬Ɠս Բ ‫ھ‬

̪дӆաղ ȩ ղ ſ Խ ̫ϤĔP ϲ ղ Ŏʎϳʫ Ρ˧͙̬ ղ ǖ Ԉԉ ղ ŏͱʏ΢Ӈґ̭ӈ Ēϴղ թ¡ ղ Ȍ ʬ_әԪղ>̮RՄ̯ӉԊ6ղ ŝT'ϝTԋÖղ ȥ̰՘óղ ū'Ϟ̱еղ ôղ >̲ӊϵʐж×ղ G #ѺзØղ Ȁʑõղ Ƽ̴̳ղ *϶ʭӋjϷĎνÞƀӌUeVӟÙղ ȁͲΣϟXY`ϐҒͳΤʒÚղ Ȃʓ<ղ ƜӍʔղ Ş ղ ƁtΥ˃pÛղ հ˄ՔղɄѻӎξ0ղ Ǯ ɇ ղ ŵӚ̵˨\ӏk˅οղƂѼӐӞ&Φˆʮ.ղ ƽ ԌղĢи͚bϠaԍ ղ Őʕ άɊղ őʹʖ r̶ ղģղ;ղ ăċʞϣѽй̷8ղ ŒϡaՅ̿ϢWк˩Üղ ǵ͵mѾղ ƮѿԎ̸ғͶղ ȖʗԟԠˇл ղ ȗ мղ ձըӑʘнˈΧԏˉҀ ղ œʙϥή͇ ղ

cґΰԴ٠‫ھڣ‬ʸ ‫ ] ھ‬αϰԵؕրѭ (‫ھ‬Ȣ͈Ԏ͉ҒΒ͊M‫ ھ‬Ç ̀ ‫ھ‬ ɬŋցԶıęҵ‫ ھ‬ǷϱӪĶΓ‫ؖ͋˭ˬھ)׏‬ѮғԷѓ֦ٓԸè‫ ھ‬ƺ ƙ ‫ھ‬ ʞ єϲ‫ ھא‬ʑϳϴ ϵ'‫ؗ͌˱ ھ‬ѯ Թ ‫ؾ‬ւ?é‫ ھ‬ƻ ƚ ‫ھ‬

ƔʀŐɏȍȚ‫ھڲڱ‬ĪŎ‫ھ‬ƕʁ˩Ǜʝɫ̍IлнĠÄÀâзиŠȎ ‫ ھ‬

˪˫ҏ Ӿ ́Ԍ‫̎ ھ‬ˡã‫ ھ‬ˢ͂=‫ھ‬dُ֥ԳϮä‫ ھ‬ʏ̓ վ‫ھ‬šӨِտå‫ ھ‬Ɩ̈́ө ̈æ‫ھ‬ Ɨ‫ھ‬ѬͅҐ‫ְ׍‬w՛Ĕ >(‫ھ‬ ȡ͆ԍϯؔ‫ ھ‬ʐĊ‫ ھ‬ƘgّْЯ Ӓ ‫ ھ‬A ¸x‫׎‬y‫ڢ‬ç‫ ھ‬/͇‫ش‬F ‫ھ‬

ʂɐ‫ڹ‬ķĸ˒ ӫǙ‫ھ‬ī‫ ھں‬ǸŢ‫ڻ‬Ƽȏƛţ‫ב‬ħ‫ھ‬ ɭփ ԏ͍Ժ‫ھ ھ‬Y϶® ±сxҔԻê‫ ھ‬ƜѰ qiѕ ë‫ ھ‬ȗȄċì‫ھ‬ Ɲѱ͎ҕ‫¡ג‬s©´ Լ‫ھ‬ ŹϷ·ٔ‫ھڤ‬ȣW‫ ھ‬вϸыϹC΄͏‫׷٭‬í‫ ھ‬ǹ ‫¶ؘٮ‬քԽM‫ ھ‬Ϻ‫ھ ڙ‬ Ǭϻօ"іϼ‫׵͐˅ھ‬jԾ%‫ ھ‬ȹ ‫ھؙ‬Ť їЩӬϽ‫ھ ؚ‬ƞ͑ Ұй‫ھ‬ ѲBԐ͒²‫ ھ‬Ɵ ‫ھ‬3Ͼ΅‫·؛‬Ͽ‫؜͓˲ھ ד‬ѳҖԿјٕĭՀî‫ھ‬ƽ ƠW‫ھ‬ ǺЀ "‫ ھڥ‬ǻ ‫̏ ھ‬þֆ‫ ה‬O‫؝͔ڵڎ ھ‬ѴҗՁ ‫ ؿ‬Ղï‫ ھ‬Ճ Δ ‫ھ‬

\ևɑٝģфхӓˆǤоġ‫ھ‬ʃɮ‫ ھ‬IJŇӷˇǐʟɯł̒˜ʄŊťȺ‫ھ‬bǚȻŦˈг2‫ڼ‬Åʹ‫ھ‬ Ǟ‫͕ו‬ՄΕҘ‫ ھ؞‬Ęǡ ‫ ھ‬Z͖‫ז‬ՅЁ‫ ھ ؟‬. Ђ‫ھڦڀ‬ơ ͗FЃð‫ھ‬0β ‫ھ‬ ѵ͵Ҷ‫ـֱח‬ì‫ؠ‬ֈՆ‫ھ‬ ʥΆЄ®ٖ‫ځفھ‬ӭ ‫ ھ‬ƾ։DՇñ‫ ھ‬ɰ ‫ױ‬ю ӆý‫ ھ‬ˣ͘ ‫ھ‬ Ȥ 7 ‫ ھ‬Ǒ ‫ھ‬ɒ͙Ζҽò‫ ھ‬ƢѶ ‫ٷ قء‬ٟ‫ھ‬Ǽҙ Ӯ ‫ ھ‬ɓ͚$$‫ھ‬ ʠ ‫ ھ͛ك‬ʡ֊љЅ‫ װ ˉھ'آט‬k?Ηy ‫ ھ‬ƣ͜;ҚпŃ‫ھ‬ źІ#¶¨͝ԑ‫ھ‬ǽ ‫ʺ ھ‬Θѷ͞дч՜Ї‫ ھ י‬ɱ‫ھ‬Ι‫©֋́ ھڏ‬Ҿ ‫ ھ‬ɲ ‫ ھ‬ c¸ЈֲѸЉ ‫ھ‬Ż ‫ ھ‬ʻѹ͟ՈэЪ γČ‫ٯ ھ‬Κ‫֌أ‬Չ ‫ ھ‬ŧª9‫ھ ڬ‬ ˤ͠Ԓқҿ‫ ھ‬ƿ ‫֍˥ ھ‬:ӅpՊó‫ ھ‬ƤѺ͡‫ך‬Ӕ֎ٗ٘Њ‫ڂؤ‬ҜӯӰ|+‫ ˦ ھ‬

ƥ2ɔɕȐˊˋǢĚǣě‫ھ‬ʅɳ‫ھ‬ĥļǒʉȔƦŨȼ‫ھ‬ǓӱӲˠƧũˌȑ2ɴ‫ھ‬ ǀͺ δ‫ ھ‬ʢQ‫ ھ‬Ǿ͢‫ڐ‬Ӏҝ?‫إ‬ô‫ ھ‬ƨ ұIҲΟͣњ֏œ‫ ھ‬ȕӳ ĕҞ‫ھ‬ Ʃ ͤҟ"¢Ћ#‫ھ ֐ئ‬ ƪlª֧ӕ‫ ھ‬ɵͥεЫӴ‫ھ‬³֑ )‫ ھ‬-֒‫ص‬ٙ õ‫ ھ‬ɖͦ´‫ھ ا‬ ǿЌ«·Ѝ£ٛĢ‫ ھ‬ʒͧ‫כ‬ζЎ‫ ھ ب‬ʣ֓рńӁ‫ڃ‬ҠȀ ‫ ھ‬ɗη ‫ھ‬ ƫͨ‫ڧ ֔ל‬Ջ‫ ھ‬b֕Έ8 ֖̕ӸėŁҳӵ‫ڭ‬K‫ ھ‬-‫ מם‬Џ‫ة‬θm ‫ ھ‬ɘ4,‫ھ‬ ʼҡιՌА‫ ھڨ‬ȿ ‫˳ھ‬Б‫ן‬ӈԓͩՍ ‫ ھ‬ǁВՎ‫ڄ‬Г‫ ھ נ‬Ƭ֗Ӗ֘‫ھ‬

ƭĬņāĹĺ̖ӽшӗˍǥǔ‫ھ‬ʆɶ‫ڽ ھ‬ŀij‫ڳ‬ňȖˎůȽ‫ ھ‬ȁǕŪɀ˔Ȃ‫ ھ‬ʽӼŅȥӘ˧ȒƮșʾ‫ھ‬ ٜÁ ‫ڮ‬:‫ھ ھ‬dֳҴ ֙N‫ ھ‬ə ә‫ٰͪڑ‬ӂzzö‫̔ ھ‬ĝ˨Ң‫ت‬čJ‫ ھ‬Ưѻͫң‫ִס‬Д‫ע‬µ֚ ‫ھ‬ `ͬ‫ھکף‬XՏՐ‫ ھ‬żĎ‫ ھ‬Žh­ٚ‫֛` ھ÷ج ثٱ‬C«Ή‫څ‬ȃ ЬN‫ ھ‬ʓjď‫ھ‬ XӶ nՑ‫ھ‬ž{ҤћЭ½ø‫ٲ ھ‬Λ‫֜ح‬Ւ ‫ھ‬ū‫פ‬ҥ‫ھ گ‬ ǖ»ќ| Е‫ھ‬/ ‫ ھ‬ưͭьЖ‫ھ ڪ‬Ȧ Ė*‫ ھ‬ſB‫ ڒ‬З ‫ ھ‬0κ ‫ھ‬ ɚИ ¬ < ‫ھ ˏھ‬Ǘͮº֨ O‫ھ‬ʇՓ‫ل‬ĦѼͯP‫ھ‬ɷЙΊ‫ײ‬U‫ھ‬ ȧ֝³}ֵ ‫˕ھ‬R‫ھ‬ǘՔѝӚ F ù‫ھ‬ɸК‫§֞̂ھړ‬Ӄ ‫ ھ‬Ō ‫ھ ̃ھ‬ ˴ ‫˵ ھ‬nӻ¹Л‫ھץ‬ɛМՕՖҦ՗ў}‫צ‬ú‫ ھ‬ː ֶНӇl&‫ ھ‬ȰͰ՘µ ‫ھ‬ Ȩ֟‫خ‬5‫ھ‬ҧÈӛm‫ھͱمק‬ʿŒ‫ن‬ҨͲ û‫ھ‬ˑ‫ٳ‬Μ‫֠د‬ՙ)‫ ھ‬Ŭ‫ר‬ҩ‫ھ ڰ‬ ǭО֡‫ש‬џП‫ ھ‬ǟ ‫˶ھ‬Ҫ<²֢՚ü‫ھ‬ZЮ Р‫ھ‬ɜСͳλ ‫ ھ‬ɹȩ ‫ھ‬ ȪoΝӄ‫ھ‬ŭV‫ ھ‬3֣ к֩‫ת‬μL‫ ھ‬ʔҫ‫ذٴ‬΋‫ ھ ¦ٵ‬ʕʹĐ‫ھ‬

$ʁɅɆȊ Ǜǜ‫ݓ‬ʂĬ‫ ݓݎ‬ʖʬNJdzɤˍҢ̜Ņŋ‫ ݓ‬ʗʽ˾ƈǴȋŕˠʺ ‫ݓ‬ ʾÜϜ‫ب‬LI½‫ݓ‬ǨԨ ΑӶí‫ ݓ‬ϝ‫ݓܟ‬ǵ̟‫ܖ‬Ϟիb‫ݓ‬Ɖ‫ ד‬լn ‫ݓ‬sѬ̠ң‫ض‬Vϟ‫הڊط‬խ‫ݓ‬ Ƽ ‫ ݓ‬ȱծҤїѭۖ‫ݓ‬pԍθ‫ظ‬ҥΒѮî‫ ݓ‬Ɗѯ ÌԎ0կϠÖ‫ܗ‬Ҧ ԩΓ ‫ ˧ݓ‬j‫ݓ‬ ˨ҧÂԏ ‫˰ݓ‬l‫ ݓ‬ՉՊ 1R̡‫ع‬ι4‫ ݓ‬ɥϡÞ‫غ ˿ݓ‬+9‫ ݓ‬Ļ̒ ‫ݓ‬ Ƞ‫܁‬Ԑ ‫ ݓ ˩ݓڋ‬ƋÅԪм²̢հō‫ ݓ‬ɦϢ‫ݓܠ‬Ƕ ‫ܘ‬ϣձ ‫ ݓ‬ƌ‫ו‬ղ¶ ‫ݓ‬ ˱ « ̣Ւ‫ ݓ‬Ƿ ‫ݓ‬ǸϤΔ݅ճΕ Ռĭ ۗ4‫ݓ‬ʘѰ¥ ̤κн.‫ة‬£M Ħ‫ݓ‬ʙ̥ ‫ݓ‬ ҨΖ£̦Íλ‫ ݓ‬ǩ ‫ ݓ‬ɇÃ1‫ػ‬ҩԫԬï‫ ݓ‬Տ‫^ڌז‬ÃմĮ‫ ݓ‬Ɉ ‫ڎڍ‬į‫ݓ‬ ǹD‫ؼ‬ÐҪ‫ ݓڏ‬ŵ!‫ ݓ‬ʚ Η,ħ‫ ݓ‬ɧϥ‫ݓܡ‬ʭ ΘLϦ.ԭϧ`‫ ݓ‬ɨ ̀İ‫ݓ‬

ƍʃɉȟˮȖȗˢˣNjnj‫ݓ‬ʄɩ‫ݓ‬ʛʿ ƎǺшŖ ʮ́‫ݓ‬Ų=éȯȘì‫ݓ‬ƏʅɊӵ̝‫݌‬ņˤ‫ݏ‬șˡ̂‫ݓ‬ xÆѱյ‫ ݓ‬ŗ ‫ ݓ ۮ_ ΀ ̧ˎݓ‬ɪϨ‫̃ ݓܢ‬/Î,Ĩ‫ ݓ =̓= ݓ‬ƐѲ ҫ‫ؽ‬Êϩ‫חڐؾ‬ն‫ݓ‬ ȡ/ѳշ‫ݓ‬Ƒk‫ ݓ‬ɫΙ‫ډ‬N̨Ѵa‫ ݓ‬q‫ט‬3ۘ‫י‬ո5‫ ݓ‬ՍèŊ̩‫ڑ‬ń ‫ݓ‬ ŘԮо‫·̪ܯ‬μϪ‫ ݓؿ‬ʯ‫ך‬ј̫‫ڒܣ‬ӷҬ ‫ ݓ‬ȳÄ‫ݓړ‬řչљп-ϫØ6‫ ݓ‬ƒDՈҭ¡ł‫ݓ‬ Ȣ‫כ‬ѵպ‫ݓ‬y ‫ݓ‬ˀΚѶ‫̬ܤ‬Fð‫ݓ‬ȴ ‫܂‬Ү‫ܙڔ‬ӫ°ԯϬ6‫ݓ ܴ? ݓ‬ sѷ̭‫¯ٲ‬ϭ‫ݓڕ‬Ր ‫˲ݓ‬үá©ѸҰ‫לږ‬ջñ‫ ݓ‬Ȳ ‫ݓژ̮ڗ‬ƓұÚß ‫ ݓ‬ɋÄ ‫ݓ‬

ƔʆɌɍȌ vv‫ݓ‬ʇ‫ۿ‬Ő‫ݓ‬ʜˁ̄ƽ԰ҲȍŚ ʰ̅‫ݓ‬śɬǀ‫ݓ‬ȵŜ˳‫ݓ‬ ȶ0Ô ռ‫ ݓ‬ǻ ‫^ם ݓ‬Ջҳ ‫}ݓ‬Ҵ‫ۯ‬۰‫ـ܃΁ڙ‬њѹ ‫ ݓ ̯~ݓ‬ƕ ̰ҵY‫ز‬Ϯ‫ ښف‬ս‫ݓ‬ Ǎ Ӭ×[̱‫ ݓ‬ʝ:‫ ݓ‬ŶϯվϰνϱӸò‫ݓ‬ŝSտ‫ݓ‬ŞX΂ ‫ ݓ ق‬ɎҶΛѺ ‫ݓ‬ ʞ ‫ك‬ӹ‫ݓ‬ǝļ‫ ݓ‬ǁ ϲ݆ۙ ŷрԱQ‫מ‬րۚó‫ ݓ‬ɏ̲‫ݓ ڜڛ‬ ȣ‫ן‬ѻR‫ ݓ‬ǂ‫נ‬ցւϳԲ ܵ ‫ ݓ‬Ǽ ‫ٳ‬۱¡‫لئ‬ξ ‫ ݓ‬Ɩ‫ס‬փ ‫ݓ‬ ϴܶՓ‫܄ע‬Ï‫ ݓ‬ȷ;‫ ݓ‬ǽ( Գс + ‫ ݓ‬ƗѼ ÊтԴ‫ݓ‬Ǿ Եô‫ ݓ‬ɭ Ƙ"‫ݓ‬ ƙ̳‫ٴ‬Զ‫ݓ‬ʟl‫̴' ݓ‬PՔ‫ۛڝ§܅س‬8‫ @ ݓ‬SSϵ̵‫ףت‬ԑO]õ‫ ݓ‬ɐҷք¸ ‫ݓ‬ ş ‫ݓ‬ȸÅÝOØ‫ ݓ‬ɑΜǪ̶‫ܷٶٵ‬ö‫ ݓ‬ǫZ϶̷ۜ‫ݓ‬ѓő Ν+b‫ ݓ‬ɮ ‫ݓ‬ ǿ‫ مݐݓ‬ηօ‫ݓ‬ƚm‫ݓ‬ɒ‫פ‬ο Oֆ÷‫ ثץˏݓ‬Ӻ̸ ‫̹& ݓ‬և‫ݓ ڞ‬ ı‫ݓ‬â‫צݓ‬ֈ̺‫ ݓڟ‬A ‫ݓ‬ʱ̻‫حج‬Ϸ‫خ‬Æ‫ ݓ ٸٷ‬ʲBѽҸՕ‫نק‬I ‫ ݓ‬ɓπ ‫ݓ‬ ̘Ŀ̔ҹ- ҺCՖ‫ ݓ‬% ‫̖ݓ‬ϸ ‫݇۝‬ρ ȹΞŁܳԒ։ћåɂ‫֊ר‬6‫ݓ ܸ& ݓ‬

ƛʈɔɕ‫ه‬щːǞ݊‫ ݓ‬ʉɯ‫˂ݓ‬ʊƜŇŠȺ‫ݓ‬Ȏ˃˄˥ǎ˅‫ݓ‬ ʳ‫@ݓ ˴ݓܹש‬ϹT¹һ֋ќϺÐø‫ݓ‬ˑ‫دת‬ϻӻ̼ù‫ ڠ¾̽?ݓ‬ú‫ݓ‬ƝѾ ¨Ñ‫ذ‬ϼ‫ݓ֌׫ڡو‬ ȏ U‫ݓ‬š‫ ݓ‬ŢԓKϽ1c‫ ݓ‬ɰϾ‫ٹؠ̆ݓܥ‬+ ‫ ݓ‬ɱ ‫ ̇ݓ‬k‫ݓ‬ ˵ҼԷԸҽ̾Q‫ ݓ ݓ‬Ͽ̿ÒG‫ ڢ‬ЀЁû‫׭۞ڣ׬> ݓ‬¹ü‫ݓ ڥڤ̀' ݓ‬ ʠ ‫ݓ«܆‬Ȥ‫ ݓ‬ǟҾ֍Ӽý‫~ ݓ‬ѿҿԔ́G ԕVҀӀ ‫} ݓ‬BIJ‫ݓ‬ ȀЂ¸Xܺ‫ݓ‬Ľȫ ‫ݓ‬ǬC ҁþ‫ ݓ‬ȁ ѝ҂Ԗ*֎G‫ ݓ‬ʡ͂‫ى‬ӽÿ‫ ݓ‬ãȚț ‫ݓ‬ ‫ ׮‬J‫ي‬ӭβ‫ݓ‬ǭ ً֏ЃܻĀ‫ ݓ‬Ȼ‫ݓڦׯ‬ţ֐ў ‫ڧ‬c‫ ݓ‬ƞ̓ ъ‫ݓ‬ ЄÏÒà‫ ݓ‬ʋ‫ݓ‬۲_Ѕ֑΃Іٌџd‫ ݓ‬ʢ҃Ӯ ԗË҄Ӂ ‫ ݓ‬ʣ̈́ij‫ݓ‬

ƟʌɖɗȐ˒ٍǏǐ‫ݓ‬ʍɲ‫˓ݓ‬ȂǑʻ Ōʤǒ˦˔ȑƠ‫ ݓ‬ơŴʴы‫ݓ‬ ʎ‫ٺ‬ӯ֒ͅς‫ ݓװ‬Ÿ ‫ ݓ‬ȼ Ѡ҅۟ю‫ױء‬Ԙf‫ ݓ‬Ź ‫ڨ‬۳‫ ڪک͆ݓ{ ݓ ֓آ‬

źIÕÁ͇Wσ‫ ݓ‬Ż͈֔ ԙЇَ ‫ ݓ‬#͉՗΄ُӂτK ‫ ݓ‬ŒʼnͶ3‫ە‬j‫ݓ‬ ˕҆‫ײ‬Q͊‫ݓګ‬Ǔ ‫ݓ‬Ƣ ‫ٻ‬۴Ӄ‫ ݓ ڬ‬ƣ҇͋ËуԹ‫ ݓ‬ȃӄ ¯ā‫ ݓ‬ɳ ƾ ‫ݓ‬ ʵ‫̙ݓ֕ݑ۠ ׳‬äӅĪ Ƥӆ҈‫֖״ڭ‬5‫֗׶ڮܦ׵˖ݓ‬Ĵ‫ ݓ‬ɘυ‫ݓ‬

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!@õܵ Ƞ ܵ ȖęζB٘‫ ܵ ڠ‬Ȯ՜ΎҞ0ö ‫ָ׻‬àҟٙŅܵ ȯ՝µ ܵ ʱO‫ܵܕ‬ʲ ܵǓؕҠ՞ÜӺT ܵ Ě 'ܵ ǔË Έ«ѕăņܵ ȲìԢmܵ ɐηٚ‫ڡ‬θ‫ܵؖ‬ȗ‫ؗ‬B՟ٛ‫ ܵ ÷ֺֹ׼‬v!ٜ‫܁‬ՠ ܵ ͛‫ڕ‬ٝ ܵ Ȉ‫ֲك‬8Ĩ‫ܵڼ‬. ܵ ~‫¾ېؘ‬Kͦιٕ ܵ ǂ̎à‫ ڽ‬ՇֻěÇ ܵ ɥ7 ܵ ʽ‫ ڢ‬աáκ‫ܵܖ‬ȡ̏ՈՉּբٞYܵɡЪ܏ҡգі‫׶ھ‬դŇܵ ɄĴ ܵ ȶֽЫԣܵ ܵ Ȣ̐եβԤλĜňܵ/ҢFՊμ‫¿ڤڣ‬ZܵɁíî ܵ Vbď½ĚA Ě >sü ­þ Ì Ě ,ÍÎĚ -ìu í Ě ®y¨ Ě T ċ îĚ ?c ý(àzáÁ¯ÿ Ě \âë »d Ě De Ā Ě

ǕO‫ۀڿ‬νĝܵ ȣÓ‫ؙ‬ٟΉ@ͧξPÉ[ܵ˙Ą‫׽‬οӼ Zܵ Ʌ̑զ٠ ܵ

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$‫ڦ‬Ëܵˮ ܵ ɓҫΒ‫ܬ‬ŏܵ˯ׄ‫ׅ‬ΓͩŐҬ·ј¾ ܵ xĉկհ ܵ ɨ ‫۔‬Qҭ²¿ܵȊ ܵ ɔҮձΔϏղ ܵ ʠѵүF̕¸Юԧ؄ѶҰ̖'ܵ ʡ̗ ܵ ȋ ‫ؚ‬âܵƲ ܵ ɕ‫׆‬ăՍұĨƊȹğ őܵ ș": øؒ‫׸‬ğ#'ܵ ʃ ̈ ܵ À?ҲM0Հ·ܵʿmܵ ɖ‫؛ەׇ‬ҳ Œܵ Ǚѷϐ‫۾‬ĴܵǚѸ̘٨ϑ&ܵ ¹ ܵ ϒ؅X ܵ ܵ ɩ2³о̙"H̚Ăϓ ܵ ~ ‫؜‬ΕϔճܵǛҴĭ‫ ܵ ܩ‬ʄ ˽ ܵ Ⱥ‫׈‬ѹմܵƳ ܵ ƮԌ̛͵ɗͶ‫׹‬γœܵ ǜDյ³ҵնշ̜‫ڧ‬ҶŔܵʘÐ ‫ܵ׉‬ ɢ<Ĕܵ ɪ ّՄ‫ ܵ_܃׊‬Ѻҷã ΖЯ ؆ѻҸ aܵʢ̝ ܵ ˀҹΗùϕ‫ܵܘ‬Ț ܵ ɫ ‫؝‬É Iӯոdܵ -ϖչ۬ϗ‫؞‬ŕܵǝ‫ܵ ׌ ׋‬ ϘXϙ‫ܵ؟‬ƴ ܵ ɬ̞պҺջ(ܵ ˁ‫׍‬İ‫ڨ‬ѼѐӵÇ ΘŖܵ .ÕͷÎƋܵ Ƶӿ<ܵɭ ‫ک‬į‫ږ‬٩Ċúŗܵ ʅ>‫ؠ׎˾ܵ܄‬Ԁƌܵ Ɋq˿*ܵ -̟ۭCΙܵɮϚռΚΛԍ ܵ ȩĈۖĪįĐս^ܵ˚ϛ‫ܵ ܐ‬ JiñĖĚ< Ě ò| ó Ě Pėj}¼ Ě Q Ě^!Ě

ܲȌ$љϜվϝܵɯϞ‫ܙ‬Â‫ ܵ ء‬v3í‫ڪ‬Ӱó‫׏‬ęϟ`ܵ ɰ5ƍܵ Ȼ̠Վ ٪ܵțƎܵ ɱC À‫آ‬Əܵ ԎܳՏһ‫ۺڗ‬ҼëԨܴƐܵ ɋ‫ܵ ܚ‬ ȼ‫א‬ѽKܵȍ ܵ ʆ̡ĠºҽտÓ`ܵ / ĩѾҾրњ‫ ګ‬ց ܵ Ǽ ǻ ܵ Ƚċ٫Ϡ؇ѿܵ} ܵ ʇČ٬Ҁ؈ҿW‫ ˰ ܵ ܭ‬UҁӀLћ‫ی‬ĊN(ܵǽ Ǟ ܵ ɘİ͸‫ܵۮ‬Ǿ ܵ ʙ‫ أ͜ܮ‬Laܵ džϡԩ ͹‫ژ‬δ­eܵ ɲΜ ܵ wϢƥ±S¸ܵəoܵ ¡ͺϣîԪ̢ ܵ ʈϤ‫ۯܵ܅‬Ɲƀ‫ؤ‬ԁŘܵ ʉpܵ̀ ܵ ʊ ‫إ‬Ր̣ւܵ ܵʣ̤ۗԏ ܵ ʴ!‫!ۂ٭‬փ\ܵ ¢‫ٯٮ‬+ܵ ɳ͝Q۰ӁքܵȎ ܵ ʤ8ģԆÚօٰbܵ č£ֆ‫ב‬ԂаƁܵ˩ ܵ ǟ҂̥‫ئ‬Gϥƞ‫ܵڙ‬ƶ ܵ ӂùΝͻ‫ا‬Ïۘќ҃Æ‫ٱ‬řܵ LJÁ½є‫ب‬µŚܵ ɴ̦‫ٳٲ‬Ƒܵ ˂Â‫ܛ‬óĖۙġܵ ʥ‫ג‬ԫ ¤´Ý ܵ ɚĎ‫ܵٴ‬Ʒû?ϦԐ;‫ ܵ ٵ‬Ǡ̧ԑ×п ܵ ǿ̨۱ӃΞܵʋoܵ ʵ̩Ց¯‫ͤۻ‬ïϧśܵ ǡ҄Ϩ‫ܵܪۿ‬ǢA ‫ٶ‬ϩ ܵ ɵΟnܵ ˱¥ð‫ڬ‬Ϫ‫ܵة‬ʶϫӄͼ҅cܵ ʷ‫҆ͽד‬ÖäԃŜܵ .ε ܵ Ȫ̪Q‫۽‬Ϭ‫ܵܜ‬ɣ ܵ ܵ ʸ= Ւ ԇkܵ y ԬԭϭѝϮܵ ¡‫ت‬EdܵɶΠ ܵ /+ ȀďևͥåΡܵ Đ‫ܵ ڛښ‬zӅֈΊӱ։֊4Vӆ ܵʚÌӇ‫ܵה‬ ɛϯ‫ڭٷ‬ϰ‫ܵث‬ȫ ܵʹۚ΢ĵƒܵ ǣAӈ΋͞ўO ܵ ȳ Ԯ ܵ Ȝϱ‫ו‬ěÊÃܵȓơ ܵ ۛѓŝܵ ʦÒӉï͟6бԯ؉҇ ̫ ܵ ʧ̬ ܵ ; qĊ Ě

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Statement of Purpose

X

COMMITTEE ACKNOWLEDGMENTS Dana L FrartS\.,·orth, Belmont, Mas�.

Stephen Flec.k 1 \'ew Haven, Conn.

Jerome Frank, Baltimore, Md. Ed,"·ard 0. Harpr.r. Cleveland, Ohio !v1;:trg-,:1rct rvr. Lawrenc .:c, Pomona, N.Y. Harold l. Lief, Philaudphia.. Pa. Judd Marmor, Ins Angele,, Calif Karl A. i\·lenningcr, Topeka, Kans.

Le\-vis L. Robbins1 Glen Oaks, N.Y. Mabd Ross. Sun City, Ari.o.

Franci!-i A. Sleeper, Cape .Elizabeth, Maine l.JFE CO'.'JSUf.TANT

".\1rs. Ethd L. Gin�burg, N<',,,. York, N.Y. llOt\RD OF DIRECTORS Officers President

Henn· H. Work 1700 Eighteenth Street, N. W. Wa.'fhingr.on, r>.C. 20009

Douald W. Hammersley :vialkah Tolpin Nocman \Villiam C. Offcnkrantz Ronald M. Wintrob Past Presid.e111s "William C. Menninger Jack R. F.walc Walter E. Barron 'Sol W. Gin,burg Dana L. FarnS\'vOrd 1 ,,.Marion E. K<"nwonhy l lenry \�'. Brosit1 Leo H. Bancmcic1· Roben S. Garber Herbert C. Modlin John Donnelly George Tarjan Judd Mannor Jnhn C. Nemi; .th Jack A. Wolford Robcrr W Gibson

1946-51 1951-53 1953-55 1955-57 I 957-,!i9 1959-61 1961-6S 1963-65 1965-67 1%7-69 1969-7 l 1971-73 1973-75 1975-77 1977-79 1979-8 I

In the preparation of this report, the Committee wishes co acknowledge the ass_istance of David Soskis who since its completion has g one on inactive status as a contnbutmg member. We also wish to express our appreciation for the contributions in the fo rnlation "'.' of this document of our two Ginsburg Fellows, Jeffrey Berland and James Ellison.

David A. Acll�r. Chairman

PUBLICATIONS llOARO Robert VI/. Gibson Sht>pparrl and Enoch Prau Hospital Tov,.-son, Md. 21204 SecrP.t.ary Allilo Ueigel 30 Camino E,panole Tucson, Ari,_ 85716

Trramrn i\·Iir.hael R. Zale� Edgewood Drive Greenwich� Conn. 06830 lmmedtate Past President. 1981-82 •Jack Weiubcrg, 1981-82

Chai1man :\1errill T. Eamn Nebraska Psychiatric Instirute h02 South 45th Street Omaha, "'Jc:b. 68106 C. Knight Aldrich Robert Arnstein Carl P. MahnquiH Perry Ottcnherg Alexander S. Rogawski Cortmllanl

John C. !\.'emiah F,x-0/ftdo R.obert W. Gibson Henry H. \.Vork

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6

The Positive Aspects of Long Tenn Hospitalization

indicate that the move to community-based treaunent of chronic psychiatric patients has gone too far, too quickly, with too little planning and preparation. The case is not as clear as has been stated that the elimination of hospitals providing longterm treaunent, which are primarily state and county hospitals, is either a wise or beneficial decision. This is not to ignore the abuses that have occurred within the state hospital system or to call for a return to previous transgressions. Nor is it to say that the deinstitutionalization movement has been without benefit But to decide from these considerations that all longterm hos­ pitalization is bad and should be eliminated would leave a certain proportion of our chronic mental patients without the locus of care for them to obtain needed, appropriate, and adequate treatment The social struggle of how best to deal with a chronic psychiatric population that "refuses to go away" would be made more, rather than less, difficult by dismantling the longterm public hospital system.

The chronic care system for psychiatric patients is a system in transition. Local communities as well as the private sector have taken on some of the responsibility and burden of care for this population. Nonetheless, while it may be theoretically possible for most of the chronic care system to take place within com­ munities, in reality, satisfactory alternatives for most patients with chronic mental illness have not been provided. There is little evidence that better alternatives in the community will ever become a reality.

There have been a number of definitions of the chronic mental patient. 15• 41• 42• 45 Peele (personal communication) has defined the chronic mental patient as a "person who needs psychiatric services indefinitely to attain and preserve the maxi­ mum possible independence from a substantially disabling mental illness." In this report we shall focus our attention on those patients, with a diagnosis ofpsychosis, with severe disability in social and vocational role functioning, and with a duration of illness of at lease two years. While some will argue with the

Introduction

7

breadth or narrowness of the definition, most can agree chat there is a hard core of such chronic patients that are not appropriate for most community-based programs. Kraft et al 43 estimated their number at J percent of hospitalized patients. In Switzerland, where social supports for the mentally ill are im­ pressive, Bleuler 44 estimated that at least 10 percent of schizo­ phrenics should remain permanently hospitalized.

Several clinical examples of chronic patients who need and/or could benefit from longterm hospitalization may better illustrate the population of concern: •

•

•

•

•

A 38-year-old single man has a 20-year history of 25 psychiatric hospitalizations (more than 13 years ofhospital stay) for recurrent psychotic decompensations in a malig­ nant chronic psychotic process. A pattern of leaving his sheltered residence, inappropriately spending his social security allotment, se!f:neglect, erratic attendance at his day program and medication clinic remains unmodifiable.

A 27-year-old single man with repeated hospitalizations for assaultive behavior based on a chronic paranoid de­ lusional system remains unresponsive to current medi­ cations.

A 25-year-old single woman with a I 0-year history of persistent unremitting psychosis, unresponsive to current treatment interventions, is repeatedly sexually abused when living outside a structured environment in the community.

She refuses to attend any structured day or evening pro­ gram, and manages escape from a locked skilled nursing home.

A 40-year-old chronically psychotic man with a long history of alcohol abuse, deinstitutionalized after 15 years of hospitalization and relative sobriety, has many readmis­ sions for serious alcohol abuse and psychotic decompen­ sations. He refuses all attempts at alcohol treatment.

A 65-year-old woman diagnosed as chronic, undifferenti-

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10

The Positive Aspects of Long Tenn Hospitalizatwn

hospital can provide containment for the out-of-control, protec­ tion for the unprotected, and support and nurturance for the unwanted.

For the chronic mental patient, longterm hospitalization can provide a stable environment in which the level of stimulation can be regulated. Those aspects of structure which the facility may use to compensate for disorganization include many of the services which are conventionally called custodial. Awakening and sleep limes are determined, baths can be given, meals prepared, clothes bought, and exercises organized. Cues for appropriate behaviors can also be provided by staff, in the form of reminders to make one's be<l, come to meals, take one's medications, and attend to one's attire. Thus patients who are insufficiently able to order their lives to meet their basic needs are able to benefit from the care which others can directly provide in meeting those needs within a normalizing struccure.

Such structuring requires an adequate number of trained staff.

Gunderson identifies the function of containment as sustaining the "physical well-being of patients and removing the unac­ cepted burdens of self control" (pp. 328-9). The chronically mentally ill are frequently troubled by disabling degrees of disorganized thinking, even when properly medicated. Their perceptual and associative apparatus may be so distorted and poorly functioning that they are unable to process even the simplest of everyday tasks and respond in a self-protective or socially appropriate fa.�hion.

There a.re also patients who need special types of structure to help control unpredictable, sometimes violent, impulses. The assaultive patient, the self-destructive patient, the patient who touches impulsively or exposes himself, are often unable to control their own behavior sufficiently to avoid social distur­ bance, public outrage, or legal action. The patient whose be­ havior is so extreme, needs support, and containment and protection from his/her own social inappropriateness. The self­ destructive patient needs external help to shield him from his own harsh self-treatment Self-destructive behavior may not be

Positive Aspects of Longtenn Hospitalization

11

eliminated within the time constraints of a.cute psychiatric hos­ pital treatment. Suicidal feelings and ideation may be chronic problems for some patients. While many of these people can manage in the community or at levels of care less intensive than a hospital, for some, only easy and rapid access to protective caretakers will suffice. For these unfortunate people the degree of containment can mean the difference between wholeness and mutilation, life and death.

Structure can also help the chronic psychotic patient learn new patterns for adaptive living. Because the ability to appreciate means-ends relationships deteriorates in chronic mental illness, the repetition of new, more adaptive behaviors can result in enhanced learning and ability to function. Because of the limited ability of certain patients to retain learned behavior, therapeutic contacts on a monthly, weekly, or even daily basis may not suffice for rehabilitation. Continual monitoring and structuring of ex­ pected behavior can be a benefit of hospitalization which lower level of care facilities cannot easily match.

Structure, containment, and support are the products of those services which the hospital can provide to either compensate for the patient's disorganization or to help the patient organize his thoughts and impulses at a higher level of functioning. Theo­ reticallv such structure could and should be provided within smalle; units within the community (i.e., in sheltered living situations). In reality, however, the longterm hospital remains the only place outside the penal system that provides such structure.

Total Care: Comprehensiveness of Services

The hospital providing longterm care can offer a comprehensive system of services: psychiatric, medical and dental, aftercare planning and support that may not be readily available in the community, especially for the chronic mental patient. 39 In the best of our model community programs, coordination of neces­ sary services may exist. However, most chronic mental patients

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The Positive Aspects of Long Term Hospitalization

14

because of distress or deterioration in functioning. Others may return because of a lack of available alternatives, such as the absence or unavailability of family and support groups, or a lack of adequate minimal community resources. For still others who return, the reasons seem to relate to not wanting to leave the asylum in the first place. A large number of patients who benefit from longterm hospitalization would voluntarily choose to re­ main hospitalized if they could. 53• 58 These patients perhaps accurately assess their impaired capacity to adapt in the com­ munity and choose to remain within the safe and supportive confines of the hospital. The needs of this group of patients should be respected and longterm care made available in a safe, caring asylum. For some chronic patients, the public hospital is the location which is "least restrictive" among the patient's options. 8• 1 57 9---

Clarification of Diagnostic Problems and Evaluation of Treatment Response Acute psychiatric hospitalization has as its goal the rapid evalu­ ation and treatment of individuals so they may be returned to the community for continued treatment. Short-term psychiatric hospitalization however is often inadequate to undertake inten­ sive innovative treatments in seriously ill chronic psychiatric patients. 39, 58• 59 Longterm hospitalization, beyond six months, allows for diagnostic and therapeutic evaluation through twenty­ four-hour-a-day observation, drug-free, and intensive psycho­ logical and biological workup by a skilled professional staff.

Removing people from their environmental stressors gives a new perspective to individual strengths and deficits, permitting care­ ful and multidisciplinary obsen,ation of response to various treatments. 39 It may also partially obscure the natural course of the disorder.

Longterm psychiatric hospitalization allows for more success­ ful pharmacologic treatment, monitoring of blood levels and

Positive Aspects of Longterm Hospitalization

15

side-effects, switching if necessary to new drugs which may best be initiated in an inpatient facility. Such hospitalization may allow for the undertaking ofintensive psychodynamic treatment.

Longterm hospitalization may even begin the process of skills training and community reorientation for chronic psychotic patients within specialized behavioral and rehabilitative wards. 39 One of the major problems faced by psychiatric hospitals providing longterm care has been their isolation (physical and otherwise) from medical centers and their professional and technologic resources.

Research As long as an understanding of both the etiologies and the effective and appropriate treatment methodologies for chronic psychiatric disorders remain inadequate, there will be the need for locations to carry out continuing investigations. The long­ term public sector hospital can and should serve as a place to continue work in the understanding of the phenomenology of disease, the close monitoring of disease course, the development of new treatments, and the application of new treatment meth­ odologies. 60 Such research belongs with the population of interest and should be carried on within such hospitals. The traditional isolation of public hospitals from medical centers must be corrected. It should be clear, however, that no patient should be kept in a hospital for extended periods of time solely for research purposes. Finally, safeguards need to be instituted to protect patients' rights as well as to ensure informed consent.

20

The Positive Aspects of Long Term Hospitalization

community certainly remains unproven. In part, the cost of caring for a patient in the community will be dependent on the amount of services the patient needs.

The question remains unresolved as to where that money should be spent. Perhaps the more basic question is how can the severely ill chronic mental patient best be served. It is clear that society has some difficult and perhaps impossible choices, but it must choose. Development of community mental health facilities is beneficial when it widens the diversity of treatment options for chronic mental patients, not when it closes options. Realistically, it does not seem possible that all of the functions of a longterm public hospital can be replaced by any combination of even adequately financed community services. Attempts are likely to prove more costly, and not necessarily less institutional. Test and Stein demonstrate that the cost of treating chronic mental patients is very high if adequate care is to be given. 78 Hospitals providing longterm care are a necessary part of a comprehensive treatment system. 58 • 60 One cannot, however, be satisfied with the current public mental hospitals' inability to carry out the overabundance of functions assigned to them with inadequate staffing levels, overbureaucratization, and antiquated, isolated physical plants.

Lack of adequate planning, oversimplification, denial of needs, as well as the diverse range of necessary services all remind us that the movement to close longterm public hospitals and deinstitutionalize their clientele has fallen far short of its goals. s. 14, 11-19, 21, ss, 6s. 64, 74, 76, 79, s1 Test and Stein 78 have demonstrated that modest gains can be achieved through direct, intense, in situ intervention with chronic patients. These gains can only be sustained as long as treatment continues. Such model programs are too small in number, and probably too expensive to suffice as a solution. In addition, what works in such programs may not be generalizable for large scale application. 47 The community mental health center movement has been unable to replace the state hospital system. Among the reasons include inadequate funding, as well as the political developments

Discussion

21

that withdrew support before the deficiencies of the original plan and the conceptual errors could be corrected. In addition, state governments, in part, used the movement as a means of closing costly state institutions. Attempts to coordinate care through a system of case managers seems largely to have added an addi­ tional and ineffective layer of bureaucracy. 82 Particularly, given the financial realities 6� one sees little evidence that the private sector is willing to adequately assume the burden for the func­ tions of longterm hospital care for chronic psychotic patients except in model programs. Plans for the operation of all services through contractual arrangements with the private sector, while having some merit, remain theoretical. Given how little the private sector has done, it does not seem likely that they will provide adequate facilities of last resort. One must hope the notorious case of the nursing home industry is not such an ex.ample. This is not to say that the private sector has no role to play, especially in the psychodynamic treatment of such patients and their families. As stated before, however, this is the subject of another report.

Rachlin et al 54 have emphasized that it is the severely ill and the chronically ill who are most in need of the services provided by the public hospital. The public hospital, past and present, functions within a service delivery system providing care to some patients that no other segment has yet accepted with adequate responsibility-" the referral oflast resort that accepts the patient for care or treatment based only on his needs" 85 (p. 39).

We have described the functions of the public hospital provid­ ing longterm care, both in what it really does and what it should be doing. The most salient criticism of the state hospital system is that "it has not worked in the past." An effective public sector hospital system providing longterm care is a necessary part ofthe system of psychiatric services for severely disabled mental pa­ tients. While such hospitals can provide such services, whether they will remains an unanswered question hinging largely on financial considerations.

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