DEAR

Exhibit 6

(SUGGESTED LETTER TO PATIENT)

It has been determined that you no longer require the level of care which we are licensed to provide. Because of the demand for this type of care we must request that you, your relatives, and your physician make other arrangements for your continued care.

The primary responsibility for locating a facility which can provide appropriate care rests with you and your relatives. We will be glad to assist you, as will your Public Aid caseworker, although every effort should first be made by your own family. These arrangements should be made so that your move may be completed within the next seven days.

If you have any questions, do not hesitate to contact me.

Yours truly,

Administrator.

cc: To all known relatives, recipient's physician, County Department of Public Aid (Cook County, Nursing Home Service).

ITEM 2. TECHNIQUES AND FACTORS REVERSING THE TREND OF POPULATION GROWTH IN ILLINOIS STATE HOSPITALS1

(By Conrad Sommer, M.D., Springfield, and Jack Weinberg, M.D., Chicago, Ill.) In January, 1941, a study of the rate of increase of resident population in the nine Illinois state hospitals was made by Dr. Charles F. Read of Elgin, for the purpose of charting a proper policy for the future, to determine what steps were needed and could be taken to stem the tide of the increasing numbers of chronically ill and long-time institutionalized patients. Consideration was given both to the financial costs and to the human values of many thousands of patients spending five, ten or as high as forty years of adult life in state mental hospitals. The question as to whether so much long-time institutionalization was good psychiatric practice was also raised.

As a result of this survey a policy was adopted by the Illinois state mental hospitals that a distinct effort should be made using as many approved procedures of a psychiatric, medical and social work nature as possible to halt the ever-increasing numbers of patients with chronic mental illnesses retained in the hospitals for these long periods of time. In addition to a more liberal policy of release and return to the community it was also felt that the too frequent and too easy recourse to commitment should be prevented by more careful pre-commitment study and greater efforts to adjust the somewhat mentally ill patient in the community. This paper is a report on the policy adopted, the techniques used, the results secured and on other factors contributing to these effects, including the changed social and economic conditions and the larger role now placed by psychiatric treatment in the community by neuropsychiatrists and general practitioners.

POLICY

Convinced by the experiences of other states that a more liberal policy of the release of patients would have important psychiatric, humanitarian and fiscal values, the superintendents of the nine mental hospitals in consultation with the central control authorities adopted a policy that the state's resources should no longer be thrown into the building of additional wards and the provision of new beds but, rather, in the direction of an enlarged extra-mural mental hygiene and supervisory service, a liberal release program, longer and more careful supervision after release, and the establishment of mental hygiene facilities for the community adjustment of patients who would otherwise 1 Read at the ninety-ninth annual meeting of The American Psychiatric Association, Detroit, Michigan, May 10-13, 1943.

2 Read, Charles F. A. study of possibilities of fewer institutionalized mental patients during the next 4 years. The Ill. Psychiat. J., II: 1, 7.

be committed. In substance, the content of a resolution on this subject passed by the superintendents of the Illinois state hospitals in May, 1941, on the completion of Dr. Read's survey was as follows:

"Whereas in the past fifty years the population of the State of Illinois has doubled, its mental hospital population has octuplied, rising from 3,850 to 31,500. From 1927 to 1937 the average increase of resident population was 700 and from 1937 to 1941 the average resident population increased 900 patients per year.

Believing that there are at present enough public bed facilities for the mentally ill in Illinois, we propose to freeze the level of resident patient population where it stood at the beginning of this biennium, June 30, 1940, namely at 30,782, and to make unnecessary the future provision of any large number of additional beds by a more active institutional treatment program, and by an enlarged extra-mural program. The future building program should only be of such amount as to be in proportion to the increase in the general population of the state. (This goal was some 700 patients less than the number present in the hospitals at the time of the survey.)"

The present report describes the effort to carry out the mandate of this resolution during the 18 months beginning July 1, 1941.

In embarking on this program it became necessary to keep careful, comparative monthly reports on the progress or lack of progress of the undertaking. The statistical office prepared tables and graphs on the admissions, therapeutic paroles, direct discharges, discharges from parole, returns from parole, deaths, transfers, deportations and other factors influencing the changes in the resident hospital population. A friendly rivalry developed between the staffs of the nine hospitals as such comparative box scores were placed before them each month. The setting of a specific resident population goal seemed to act as a special incentive to carry out this program. However, the moratorium on building since the beginning of the war caused this at first optional program to become an absolutely necessary program. Otherwise intolerable over-crowding would quickly have resulted.

TECHNIQUES

The equivalent time of four additional psychiatrists and eleven psychiatric social workers was added to the staffs of the several hospitals to carry out the new program. In addition other members of the medical and social worker staffs devoted more time and effort in seeking out releasable patients, preparing them for discharge, and assisting with their subsequent supervision. Since the large majority of the patients at the Elgin, Chicago, Kankakee and Manteno State Hospitals were committed from Chicago and Cook County, a new clinic, the Chicago Community Clinic, was established to supervise the patients released from these four hospitals to Cook County. The number of one-day monthly clinics for the supervision of newly released patients throughout the state was increased from 12 to 22. Thus a more careful coverage of the state by the clinics brought the extended extra-mural service closer to many communities and permitted the release of larger numbers of patients requiring careful supervision.

A diagnostic and consultative service to patients about to be committed was established in the full time Chicago Community Clinic and the 22 one-day per month clinics. Judges, physicians, social workers and relatives use this precommitment service and are given prescriptions for the vocational, social and home adjustment of patients for whom the pre-commitment study reveals that institutionalization is not required. The members of the clinic gave information to the community as to what the state hospital can and cannot do for the different types of personality maladjustment.

Considerable, perhaps excessive, publicity was given to the fact that the Пlinois state hospitals would now become much more liberal in the release of mental patients. The fantastic figure of "7,000 mental patients" was once blazoned in the press as the number of persons immediately to be released. Among the beneficial results of this otherwise dubious publicity was the fact that a number of relatives who had quite forgotten their patients hastened to the hospitals to object to their release. Some who came to object remained to give consideration to the possibility of again caring for their somewhat mentally ill relative at home. Social agencies and local public officials, at first concerned about the possibility of dangerous mental patients being released into

the community, became converted and began to assist in finding more community resources for the mentally convalescent patient. The State Bureau of Vocational Rehabilitation was found willing to include in its program for the physically handicapped those released mental patients for whom our psychiatrists prescribed vocational retraining.

The Old Age Assistance service of the state co-operated by granting financial aid to hundreds of persons beyond the age of 65 suffering from senile and arteriosclerotic psychoses. Although the state hospitals found 2,000 elderly patients in these categories who could safely be released, the difficulties of finding satisfactory places of residency in the community and of appointing conservators to safeguard the interests of the patient and to make possible the payment of Old Age Assistance funds, considerably slowed the transfer of these patients to Old Age Assistance rolls.

There was found buried in the statutes a legal device whereby mental patients could be boarded out in private homes at state expense not to exceed the per capita cost of the patient in the hospital from which he was released. A program of family care for patients too young or otherwise ineligible to receive Old Age Assistance benefits was devised. During this 18 months' period, 340 patients were removed from the state hospitals and placed with families other than their own. The majority of this group became self-supporting or were supported by relatives, a minor fraction was supported by Old Age Assistance and relief grants, while only a negligible number were supported by state hospital funds. In some instances, although the patient did not live with his own family, several of his relatives contributed so that his support outside of the community was possible. Because of the many legal, fiscal and medical procedures about which the social workers needed to have special knowledge, a social service manual on the family care of mental patients was developed.

As the ward physician reviewed his patients one by one to discover those who could properly be released, we were often chagrined at the discovery of patients whose release would have been feasible many years earlier. Several patients were found to have large estates which made possible their release, support and supervision in the community. Forgotten relatives were communicated with, and enlisted in the effort to get suitable patients out into the communities.

More staff meetings were held to discuss the possibility of release of borderline cases, and to prescribe the kind of community care needed. A form was devised and distributed among the physicians entitled, "Physician's Release Recommendations," to be used at the staff meeting deciding whether or not the patient could be released, and subsequently by the physician and social worker supervising the patient after release to the community. The data included the patient's present mental status, his present physical status, the presence of any somatic disease requiring medical attention, the patient's general strength and ability to sustain himself and to work, the patient's public health status excluding the presence of tuberculosis or of enteric disease carrier states; recommendation as to the kind and amount of supervision required; a statement as to the patient's employment possibilities, advice as to with whom in the community the patient would adjust best; advice as to recreation; the need for a conservator; special warnings regarding the patient's behavior, and a final overall statement about release couched in the following language:

Check one of the following:

Patient should be released;

Patient could be released;

Patient should not be released because: he is (check one) homicidal, suicidal, sex problem, recurrent community problem, other;

However, we did not in all instances rigidly adhere to the rather elaborate arrangement of staff meetings and pre-parole investigations of the home set-up to safeguard the procedure of releasing and supervising cases. The several superintendents of the hospitals continued to exercise their right of what one of them aptly dubbed "the extemporaneous release of patients"; that is, the superintendent, upon having interviewed the patient and a responsible member of his family, effects an immediate discharge of the patient without recourse to some of the more formal procedures mentioned.

It was found quite profitable to extend cooperation to the association of former alcoholic patients called Alcoholics Anonymous. A close-working relation

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ship developed between those of our state hospitals in the vicinity of Chicago in which there is a strong and co-operative group of Alcoholics Anonymous. Selected members of this group spent many hours in our hospitals working with undeteriorated and not very psychotic alcoholic patients. The favorable results of this technique, especially at the Manteno State Hospital, have been described by McMahan.3

Other techniques may be mentioned which, however, were used too little or too late in this program to play more than a negligible role in contributing to the results. However, it is intended to make greater use of these techniques which include: group psychotherapy, an adaptation of Abraham Low's Recovery Association technique, and the treatment with hyperpyrexia and arsenicals of patients not yet psychotic, who are discovered to have positive spinal fluid complement fixation reactions. Fifteen hundred such patients have been discovered by the venereal disease clinics in Illinois; 600 patients are admitted annually to the state hospitals suffering from paresis; 3,000 beds are at present occupied in these hospitals by patients suffering from paresis. It is obvious that the pre-psychotic treatment of impending paresis or cerebral vascular syphilis is an important part of any program designed to restrict the increase of institutional population.

RESULTS

In interpreting results, one is immediately confronted by the fact that many factors other than the specific procedures already described, played an important role in reversing the trend of the population level in the Illinois state hospitals. First let us consider the actual variation in resident population in the hospitals during the four years preceding and during the 18 months of the program being reported. A precise examination of Graph 1 reveals that the actual reversal of the population trend began in April, 1941, and continued after July of that year. During the spring of 1941, our medical and social service staffs, aware of what was in the air, spontaneously liberalized their release policy. The decline stopped in 1942, and became a hilly plateau. On January 1, 1943, the resident population of the Illinois mental hospitals was 30,951 or almost 600 less than the peak reached in March, 1941 (31,548), and approximately the same as it had been in November, 1940. Whereas in this 26-month period there was no net rise in population, the average increase in patients for equal segments of time in previous years had ranged 1760 to 1950. This is a sharp change in trend.

McMahan, H. G. The psychotherapeutic approach of chronic alcoholism in conjunction with the alcoholics anonymous program. The Ill. Psychiat. J., II: 2, 15.

Babor of Adeissfu

Next let us consider the variations in admissions prior to and during the 18 months of this study. Graph 2 shows the important role played by the change in the rate of all admissions to the hospitals. That social and economic factors of the type described by Neil Dayton played an important role, perhaps more important than the techniques described in reversing the trend in institutional population by lessening admissions is evident from the fact that admissions did not rise in 1939 (the first year in 15 without a rise); that the admissions declined slightly in 1940 and in the first quarter of 1941; and declined sharply in the last 9 months of 1941 and again levelled off during 1942. It will be a worth while endeavor, but beyond the scope of this paper to analyze the role played by this reversal of the usually rising admission rate. However, in 1942, the junior author showed that the number of patients given shock treatment and other psychiatric treatment in general hospitals had increased rapidly from 1935 to 1940. The number of psychiatric patients treated in general hospitals in Cook County in the latter year being three times those treated in 1935. The variations of all discharges (direct and from parole and family care) prior to and during the period of study are considered in Graph 3.

Comparing the absolute number of discharges during the 18 months under consideration with a similar period, we find all discharges (direct and from parole) during 18 months beginning July 1939 to be 9,645; for 18 months beginning July 1941, 10,066. There was an absolute increase of 421 discharges during the new program. The results of the more liberal release program did not include an increase in re-admissions or a return to the hospital of patients on trial in the community. The re-admissions were as follows: re-admissions in 18 months beginning July 1, 1939, 4,168; in 18 months beginning July 1, 1941, 3,923.

GRAPH 2.-Admissions to the major state hospitals, by months: 1925-1942.