GOALS OF THE HOSPITAL The goals of Riverside Hospital are best described by Marcus D. Kogel, M. D., then commissioner of hospitals, in his annual report of the New York City Department of Hospitals for 1952: "The primary aim of the school-hospital is to have the patients understand and accept patterns of normal social living and behavior. Effort is made to create within the patients the ability to establish meaningful interpersonal relationships and to develop mature and realistic goals. The patients must learn that immediate gratification is not possible in the world, and they must be taught that work, responsibility, constructive endeavors, and the giving of oneself are ultimately more rewarding than easily acquired but short-lasting gratifications." INTRODUCTION TO THE PROBLEM After the hospital's opening, two severe shortcomings were recognized. These were the absence of realistic vocational training facilities and the lack of a well-defined work program. These were adequately demonstrated by followup surveys of patients. It was soon learned that it is a far cry from identifying a person's aptitudes and skills to enabling him actually to do a day's work. It was agreed that a program would have to be developed that would provide an opportunity for hospitalized persons to start learning such basic things as getting to work on time; going to work every day; accepting direction from a superior; controlling impulsive tendencies to walk off a job the moment it became slightly uncomfortable, and finally, learning of just what the world of work consisted. In other words, they had to relearn in their young adulthood the harsh realities of adjustment to routine. It was further realized that the best situation would be the presence of a true vocational training facility and enough work around the hospital to keep a large proportion of the patient population actually and purposefully occupied. However, the board of education's school had been initially set up basically as an academic facility, and equipment was not available to facilitate a change. In addition, Riverside is a comparatively small hospital, situated on a small island in the East River, and, thus, there were geographic and physical limitations. These obstacles, though real enough, were still no excuse for inaction. The only thing to do was to take what was on hand and do the best that could be done with it. STUDY AND OBSERVATION In studying the type of patient at Riverside, certain almost universal patterns manifested themselves. As a group, patients came from psychologically impoverished and economically uncertain homes. There was a lack of a consistent authority figure; there were unorganized habits of living, absence of the basic guidance methods common to the average family constellation; and, finally, the lack of opportunity to relate to any meaningful figure in any positive way. In the way of employment, few patients indeed presented anything that even approached consistent job histories. Job histories were disorganized both from the points of view of time spent on given jobs and of similarity of jobs held. This pattern showed, both in a general way and in comparison with job records of normal teen-agers from similar geographic locations and comparable socioeconomic levels. In addition to irregular job patterns, there were many patients who had never worked at all. In addition, the patients in general were not of a type whose needs could be filled in a classical psychotherapeutic relationship. That is, they were too young. too impulsive, and-most important-too unaware of specific problems, to be handled adequately with prolonged interview therapy. They seemed to respond best to short-term goals--in fact, ambitious, longterm planning was often very threatening. They needed the kind of experience that would impress upon them the fact that they were able to do things; that they were reasonably adequate; that they were not total failures whose only recourse lay in the fantasy that escape by way of narcotics provided. From the therapist's viewpoint, something was needed that would crystallize reality thinking within the patient population; that would succeed in impressing these patients with the very inadequacies that had led them to use drugs; and finally, something that could indicate to them in a very objective manner that they were not ready for discharge. That is, something was needed that would succeed in creating a measure of constructive self-concern. It followed logically that all these needs could be filled only through creating a cross section of life-reproducing the very situations in the hospital that had been most troublesome to the patient while in the community. Naturally, it was impossible to attempt establishing family units; but the treatment personnel-psychiatrists, psychologists, psychiatric social workers, and counselors-were adequately filling the roles of symbolic parental figures. On the other hand, it was not impossible to establish a vocational training program, patterned along industrial lines, that would be very real and very meaningful. It was reasoned that such a program could provide opportunity for these people to explore the world of work constructively; expose themselves to the sort of situations that they had had difficulty handling in the community; test their skills and aptitudes; develop work tolerance and habits; and experience Interpersonal relationships of a satisfying nature, oriented to the world of work. Such a program could provide a therapeutic measure that was less verbal than psychotherapy and more action laden. It would have potentials for more immediate gratifications than a long-term adjustment program and would create opportunities to crystallize problems that patients could bring to the counseling interviews, therefore developing greater degrees of self-motivation. A vocational program could pinpoint their technical shortcomings and their needs for further training and thus make the hospital school, and education in general, a more positive, meaningful experience. Finally, it could provide a reasonable index as to the patient's vocational readiness for discharge. CRITERION FOR EVALUATION Since there are no two patients at the hospital in the same state of therapeutic progress or degree of initial pathology, it was impossible to set up limits arbitrarily to indicate successful or unsuccessful participation in the program. A very loose sliding scale was adapted, one that was completely clinical as opposed to statistical. Depending on the degree of disturbance of the patient upon referral to the rehabilitation counselor, the purpose of the referral and the level of vocational adjustment existing at the time of referral, the patient's progress and the program's value to the patient was evaluated according to: 1. Attendance at the assigned job. 2. Degree of vocational insight demonstrated in terms of job identification, levels of aspiration, etc. 3. His progress within the program as indicated in weekly reports. 4. Progress in the counseling relationship from the time of assignment. 5. Overall adjustment progress as evaluated by the patient's therapist. 6. Ultimately, and probably most important, the patient's vocational adjustment following discharge. Though this criterion and method of analyzing results will not yield any neat statistical package, it is felt that functional conclusions certainly can be drawn and that they may possibly indicate specific variables that will respond to more formal statistical treatment. SCOPE AND PARTICIPANTS With the recognition of the need and the theoretical determinants established, the need to set the limits within which such a program would operate, and to select the personnel who would be directly responsible for carrying it out, followed. It was understood that this was to be a combined training and therapeutic measure and, as such, nothing that even approached exploitation of the patient would be countenanced. Since the patients dealt with were somewhat disturbed, adequate supervision had to be provided for protection of the patient and hospital property, and of course, instructional purposes. In view of the fact that Riverside is a hospital and the school on the reservation is academically oriented, it was not anticipated that finished tradesmen would be produced, merely people who were better adjusted to the world of work and their own vocational needs. The project was named the "In-Hospital Vocational Training Program.” Since it was considered to be an integral part of the general rehabilitation proc ess at Riverside, all treatment personnel were involved, but it was of primary necessity to name coordinating and supervising individuals. In addition, it became necessary to use the skills of various nonprofessional workers at the hospital. To implement the plans of the supervising team, the cooperation of the various nonprofessional divisions was solicited and received. This meant that for the first time carpenters, electricians, plumbers, pipefitters, dietitians, bakers, cooks, porters, storekeepers, stock clerks, and general clerical workers were to be very meaningful factors in the overall therapeutic procedure at Riverside Hospital. DEVELOPMENTAL PROCEDURE The first concrete step in getting the project underway was to meet with members of the various service departments so that the aims, design, and neds that the program was expected to meet could be discussed. This was done under the direction of the senior psychiatrist and the rehabili tation counselor. An attempt was made to: 1. Insure common understanding of the scope, style, and aims of the program. 2. Get the practical work of defining jobs, job specifications, and limits carried forward to the working stage. 3. Lay the stage for actual job assignments. In terms of scope, style, and aims, the needs of the project were describedas they were outlined in the theoretical discussion. In addition to providing an opportunity for all who would be concerned with the program to identify with each other, the overall aims were set. Essentially, they are an attempt to be instructional, not authoritarian; tolerant but not protective; and consistent but not rigid. Further, there was an attempt to emulate industrial conditions as far as possible. But, "Don't 'fire' anyone, merely explain what would happen to the offender in the industrial world." The response of the service workers was at first rather cautious and something less than spontaneous; but when they were told about the total situation and their specific roles in it, there was a marked change. They became animated and responsive to the whole idea. The next major area to be covered was the developing of an operational procedure; the developing of a workable and efficient report form; and the identifying and describing of the various jobs that could be done by the patients around the hospital. OPERATIONAL PROCEDURE An outline of the best functioning and most efficient operational procedure developed to date follows: 1. Referrals to the rehabilitation counselor for assignment in the program are accepted only from the caseworker treating a particular patient. This operation insures adequate lines of communication and determination of responsibility. 2. Each referral is accompanied by a well-defined objective, i. e., vocational exploration, development of work tolerance, improvement of habits, etc. 3. Actual assignment to the program is made only by the rehabilitation counselor. 4. There is preassignment counseling by the rehabilitation counselor, to bring the purpose of the anticipated activity into sharp focus in the patient's mind. 5. Preassignment consultation is held between the rehabilitation counselor and the nurse coordinator to insure complete understanding of the prescription ordered and the purpose of the patient's referral. 6. Actual assignment is handled by the nurse coordinator-who reports the ultimate program objective for the individual patient to the actual supervising person, and in addition informs the hospital school of the patient's changed program. 7. A daily tour of inspection is made by the nurse coordinator to insure smooth functioning of the program. 8. Attendance sheets are submitted daily by each supervisor to the nurse coordinator, who, in turn submits a weekly overall report to the rehabilitation counselor. 9. The weekly progress reports submitted to the rehabilitation counselor are interpreted to the patient during the weekly progress interview that is held with each patient in the program. This provides the patient with an opportunity to comment on his feeling, progress and difficulties in relation to an actual work situation. 10. There are semimonthly conferences of the supervising psychiatrist, rehabilitation counselor, nurse coordinator and school representative. These conferences have the overall purpose of providing an opportunity for an exchange of information and for a current evaluation of the program. 11. There are monthly conferences of all these individuals and the medical superintendent. Monthly statistical reports are submitted to the medical superintendent at these conferences, and the general effect of the program in terms of hospital functioning is discussed. 12. Informal conferences are held as required by any members of the supervising team. The report form (p. 206) has proved to work exceedingly well. It is sufficiently direct and unencumbered by technical terminology to be readily understood by the nonprofessional persons for whose use it was designed. FINDING SUITABLE JOBS Crucial to the program's success, was the locating of suitable and sufficiently varied jobs which could be offered to the patients. Each job was chosen according to the following criterion. Each job must have an industrial application or analog. This would insure "face" validity and patient acceptance, and in addition provide the opportunity for structuring counseling interviews with an industrial and community-centered orientation. Each job must be sufficiently simple to insure a modicum of success and positive conditioning toward the world of work; yet sufficiently complex to provide a measure of challenge and insure a feeling of achievement with continued application. The job problem was initially approached through a survey of all hospital service and maintenance divisions with an eye both to individual jobs and available personnel for adequate supervision and training. Following this survey, the planning conference mentioned was held with the service division heads. The results of this survey were discussed here, and these people were requested to present to the rehabilitation counselor lists of job descriptions and of persons available to provide supervision. Following is one job description and a list of additional job titles that are now being used for rehabilitation: I. Maintenance division: 1. Carpenter's assistant. 1. Maintain and repair doors. 2. Repair broken sash. 3. Maintain tools. 4. Help with carpenter work in shop. Gain facility in the use of various hand and machine wood working tools. 6. Help in maintenance and erection of carpenter work in hospital. I. Maintenance division-Continued 2. Boilerroom assistant. 3. Electrician's assistant. 4. Plumber's assistant. II. Storekeeper division: 1. Storehouse assistant. III. Dietary division: 1. Butcher's helper. 2. Counterman. 3. Stockroom (dietary). 4. Cook's helper. 5. Baker's helper. 6. Dishwasher. 7. Busboy. 8. Vegetable man. IV. Housekeeping division: 1. Porter. 2. Maid, wards. 3. Sewing-room helper. 4. Cleaning supply distributor. 6. Gardener's helper. 7. Garbage assistant. SUMMARY AND CONCLUSIONS Whatever the general therapeutic approach to treating narcotic addicts at Riverside Hospital may be—and the procedure has been to study cross sections of it first-there is a large group of addicts whose outstanding needs are for experience with work situations. They need to learn good work habits, tolerance, skill, and adequacy in the interpersonal relations of employment; and their probable benefit from psychotherapy attempts is small. For these patients, a simple vocational experience was necessary to adapt them for living; and an attempt was made to establish a program that would fill this need. The nonprofessional staff made vital contributions to the program. Its members were cooperative about requests for assistance and participation-once their importance as persons in worthwhile jobs that were tools for helping others was impressed upon them. Although the size of the population included in the program and the time elapsed since its inception do not warrant any definite conclusions, certain trends and patterns of performance did manifest themselves: The program seems to be functioning as (a) a fairly reliable tool to test out the sincerity and reality functioning of statements, aspirations and intentions verbalized in interview sessions; (b) an additional diagnostic tool for aptitude and interest determinations; (c) a catalytic agent for the crystallization and recognitions of problem areas in the world of work; (d) an area where the patient can perceive growth and development rather easily, thus making his hospital stay a more meaningful one; and (e) an instrument for emphasizing to the entire treatment staff, the existence and extent of the vocational needs of the patients. EXHIBIT No. 29 ANNUAL REPORT FOR 1952 RIVERSIDE HOSPITAL This first annual report from Riverside Hospital would be without significance unless the events leading up to the reopening of this facility were made the basic part of the report. Drug addiction has been a serious social, cultural, and medical problem for about 100 years, and since the passage of the Harrison Narcotic Act in 1914 addiction to narcotics has also been a law-enforcement problem of major importance. Although statistics from the United States Public Health Hospital at Lexington, Ky., show that 20 percent of their adult addicts began the use or narcotic drugs in adolescence, nevertheless there had never been an epidemic of drug addiction |