SUMMARY AND RECOMMENDATIONS
The hospitals have been working with low per capitas, small staffs, particularly professional and semi-professional staffs, overcrowding and inadequate equipment. Their splendid efforts and achievements in spite of these handicaps are deeply appreciated.
The statements in this report are made as a pointing out of needs, not in any way as a criticism of accomplishments of the hospitals under existing conditions.
Problems in Virginia which seem to deserve careful consideration and suggested aids to a solution are as follows:
1. The Great Volume of Admissions, the Increasing Ratio of Hospitalized Mentally Diseased and Mentally Defective Patients to Total Population of the State and the Heavy Expense of Their Care
There have been over 9,000 admissions of mental patients to Virginia State hospitals in the past four years.
Increase in ratio of patients to population has been from 69.7 hospitalized patients per 100,000 population in 1880 to 297.0 per 100,000 in 1930, over four times as large a proportion.
The cost in 1933 was $1,462,339.99. This was in spite of compulsory cuts in budgets, refusal of admission to many white and colored mental defectives and colored insane because of lack of space and funds, and dangerous overcrowding and low per capita allowances for patients under care.
Recommendation: That measures be adopted to keep down need for hospitalization as suggested in the following sections.
2. Present Unsatisfactory Procedure for Securing Admission
The overwhelming majority of admissions are still of the old type of court commitment of patients as insane or feebleminded.
This is costly. Expenses amount to many thousands of dollars a year.
It is distressing to patients and their relatives and friends.
It gives to mental disease and mental defect added publicity and suggestion of criminality.
It makes for delays in getting patients into hospitals and for jail stay while waiting for commission proceedings to be completed.
It apparently tends to get into the hospitals too many aged patients of whom the community wants to rid itself and too few patients who might recover under treatment.
It is unnecessary. There are other states which get on well
— page 119 —without so much court procedure. Rights of patients are protected by habeas corpus provisions.
It is likely to prolong need for hospital care because of its injurious effect on patients.
The Virginia law penalizes the voluntary patient coming without court commitment who wants treatment and if he could get it without too distressing experience first, might have good hope of recovery.
He must pay transportation to the hospital. The committed patient can have it free.
He must pay board in case of a mental defective, and in case of a mentally diseased person must pay unless especially exempted by the hospital board, and even then free care is limited to two months. Committed patients pay nothing for care and treatment, except that committed inebriates or drug addicts, if they have property, are liable to a charge.
He may not be received if his admission would deprive a committed patient of care, even though the committed patient may need care less than he does.
This militates against patients' coming to mental hospitals for early treatment and for delay until the case may be incurable. There are other states which handle voluntary admissions satisfactorily without Virginia's discriminations.
The Virginia law also greatly restricts admission on physicians' certificates as well as voluntary admissions.
The certificates of two physicians must show urgent need of immediate custody and treatment.
The period for which hospital care can be given by virtue of the certificates is limited to ten days.
The persons petitioning for emergency admission of a patient must within five days have him committed by court, if insane, or have him removed from the hospital.
Various other states find restrictions of this type unnecessary and consider that they are thoroughly undesirable, that they make for needless expense by favoring court proceedings and strengthen the idea of the hospitals as places of last resort to which patients are sent for restraint, instead of as curative institutions to which patients come for treatment in the hopeful stages of disease.
Recommendation: That admission laws be revised. That present discrimination against voluntary admissions and physicians' certificate admissions be abolished.
That examining clinical and outpatient social service work be provided for each State hospital to advise patients from the surrounding area regarding admission to any State hospital and to help with plans for patients who with some aid can get on outside.
— page 120 —3. The Extensive Practice of Using Jails for Confining Mental Patients During Examination and Pending Admission Into Hospitals and Use of Almshouses for Mental Defectives
Jail stay is costly for the State at the time and is also likely to seriously damage patients and their prospects of speedy cure or improvement after they reach the hospitals. Different other states have condemned the practice and abolished it entirely or almost entirely. In Virginia it is partly a result of overcrowding of the Central State Hospital and the State Colony, but use of jails exists also to a large extent in cases of patients where lack of room in the State hospitals is not the excuse. In the year 1932–33 there were here over 1,000 admissions of mental patients as such to jails and over 11,000 patient days' board in jail was paid for them.
The system by which local officials receive from State funds committal fees and per diem allowances for persons held in jail and especially high allowances for mental patients puts a premium on getting patients into jail and on delay in getting them out.
Use of almshouses for mental defectives is costly to the locality and injures prospects for trainable patients, so that they are likely later to need longer hospitalization. It is due to insufficient colony space, lack of any State training schools for the mentally deficient and inadequacy of other provisions for the mentally subnormal.
Recommendation: That State hospitals have more space available for new admissions and also for patients generally so that usually patients too acutely disturbed or otherwise urgently in need of care to be detained temporarily in their own homes can be accepted as emergency admissions. Ways of getting space will be recommended later.
That each State hospital be equipped to serve when necessary as an emergency receiving centre for patients from its vicinity going to another State hospital.
That local communities be encouraged to arrange with general hospitals that the hospitals shall adequately equip themselves for this purpose and give needed temporary detention and examination of mental patients.
That each jailer be required to immediately notify the jail statistics office of the State Department of Public Welfare when a mental patient is placed in jail.
That the department at once notify the hospital social worker or probation and parole worker nearest the jail of the fact and the worker be made responsible for following up the case.
That each physician serving on a commission or certifying a patient for a State hospital be required to immediately inform the department of his findings.
That when a superintendent has room for a patient, but is unable to send for him promptly, and unless other arrangements are made, the patient will be held in jail, the local
— page 121 —communities be encouraged to have the patient brought in by relatives or friends in suitable cases, or, if this is not practicable, to have him brought by a probation or parole officer, or by a sheriff or sergeant, if necessary, with, however, a woman accompanying women patients.
That local communities be urged to make funds available for telephoning or telegraphing to State hospitals regarding emergency cases.
That the State hospitals or local communities or both have more facilities for bringing in emergency patients quickly.
That mental patients held in jail more than a few days because of lack of space in State hospitals be transferred when practicable to the State Farm for Defective Misdemeanants or State Farm for Women. That such transfer, however, for patients needing hospitalization be used only as a last resort when otherwise jail care would be unavoidable.
4. Delays in Getting Patients Into State Hospitals and Expense to the State Resulting from Present Practice Regarding Conveyance to Hospitals
Virginia provides for conveying patients to the State hospitals at the expense of the hospitals and not of the local community which latter is the custom in many other states. Hospitals here commonly send their own workers to get patients, a system which has merits, if it does not cause delay. If relatives or friends bring patients in they do so at their own expense. If local officials convey patients it is at local cost unless they wait to get an express authorization from the hospital to bring them with transportation fees paid by the hospital. The State Criminal Fund pays for jail board but not for telephones nor for speedy transportation to avoid jail stay. Once the patient is placed in jail, his relatives are thereby separated from him and are less likely to bring him to the hospital after admission is authorized. For colored patients and for the colony one institution serves the entire State. It takes time for communications other than by telephone and for hospitals to send for patients. The present system makes it a financial advantage to relatives, friends and the local community to let the patient stay in jail till sent for by the hospital after the superintendent has received the papers and arranged as to where the patient is to be picked up. So far as mere distance to be covered in conveying patients is concerned, it should be possible to get them in quickly.
In addition to proposals affecting conveyance already made under preceding Section 3, the following suggestion is offered:
Recommendation: That possible desirability be considered of charging transportation to local communities, not the State, where relatives or friends do not take care of it.
— page 122 —5. Need of Space in Hospitals for Reception of Patients, Overcrowding, Waiting Lists and Unfortunate Results.
Hospitals, especially the Central State, the Eastern State, and the State Colony, are not only unprepared for future needs, they are already greatly overcrowded. They cannot properly classify present patients and avoid harmful contacts as between recoverable patients and discouraging, hopeless inmates, or between violent epileptics or insane and timid, trainable feebleminded. This, however, is tied up also with lack of staff. The Central State Hospital and the State Colony cannot take care of current admissions. Recognized mental patients in urgent need of proper institutional care have to stay not merely for very temporary detention, but for longer periods in jails, industrial schools, other penal and correctional institutions and almshouses, or else they remain outside in the community laying up trouble for the future through the aggravation of their own condition and through the unfortunate progeny they bring into the world. This means great expense in caring for mental patients as delinquents or dependents instead of in ways that are more helpful to them and to the community and in caring for illegitimate and neglected children. Virginia, according to latest available statistics, has far less provision than the average state for institutional care of the feebleminded. The State has no institutional space at all for feebleminded colored males. These are causing an immense amount of trouble in the community and are filling the industrial school, the jails and the penitentiary.
Problems seem to be growing worse because of the apparently higher birth rate of the mentally defective and mentally unstable than of the normal population.
Following are suggestions as to increasing space provision. They are in addition to recommendations for releasing beds through strengthening curative and parole work and for reducing hospitalization needs through preventive service which will be found in Sections 6, 7, 8 and 9.
Recommendation: That additional bed space in regular hospital buildings be provided as rapidly as practicable.
That boarding care in family homes under adequate supervision be utilized for suitable patients.
That simple farm colony care on property of the institution be developed.
That outside colony care in rented properties be tried for some of the trainable mental defectives being prepared for parole.
6. The Need of More Adequate Treatment and Training to Effect as Much Cure or Improvement as Possible to Get Patients Out
Great numbers of patients say in the hospitals for long periods or for life, leaving no room for new admissions. Custodial care for many years is more expensive than intensive treatment or thorough training for a shorter period to fit the patients for outside life. Virginia
— page 123 —hospitals, as already indicated, need bed space for prompt admission to early treatment of patients in the curable stage. They also need both space and equipment of buildings for suitable grouping of inmates to prevent injurious contacts and to make possible such aids, as for example, sufficient indoor as well as outdoor recreation for patients. They greatly need the staff and facilities which are required even more than space, to make proper classification practicable, and are required in addition and especially to give effective treatment and training after the patients are classified. While exact, up-to-date comparisons are not available because of cuts now irregularly in progress in different states, latest statistics obtainable from the U. S. Census for the entire country show Virginia as having ratios of professional, semi-professional and total staffs to patients and per capita expenditures for patients much lower than the average in the United States. Staffs need facilities, too. For example, the nurses need nurses' homes where they can get quiet and rest in their free hours to keep them fit for their nerve-wracking task of constant care of mental patients.
Moreover, Virginia does not yet have free psychopathic hospital provision or more than a beginning of free psychopathic pavilion provision. Such provision serves purposes of receiving centre work for some patients, of careful diagnosis and special study of cases, of intensive treatment and speedy cure of patients with incipient or mild mental illness, who would not go to a hospital or hospital division of the protracted care type, of specialized training of psychiatric staffs, as well as of general mental hygiene educational and research service, which will be taken up in Section 9. It can likewise make possible separate service for children.
Virginia also lacks training schools for the feebleminded. It has only custodial care and some training for white and colored patients. But most of the other states have training schools and have had them for years. Training school care leading to self support and socialized conduct is less expensive than the life-long burden to the community of the mentally deficient patient in or out of an institution who cannot earn an honest living and keep out of trouble—the type who are now filling our eleemosynary and correctional and penal institutions.
Recommendation: That, as soon as practicable, staff, facilities of every kind, and per capita allowances for the State hospitals be increased.
That psychopathic pavilion work at these hospitals and the included teaching service for medical students and others be further developed.
That in addition some psychopathic hospital or pavilion service outside the State hospitals and associated with the State medical schools be encouraged to reach and educate the medical profession and others regarding patients with incipient or mild mental disease.
That psychopathic pavilions for children be set up.
That training schools for feebleminded, white and colored, boys and girls, be established.
— page 124 —7. The Need of More Sterilization.
Virginia has between 3,000 and 4,000 illegitimate children born each year. These are believed to be largely though not wholly children of anti-social feebleminded or emotionally unstable parents. There are in addition large numbers of legitimate children of such parents born to lives of misery. The birth rate of the total population has been greatly decreasing but not the illegitimate birth rate. The proportion of illegitimate births is markedly increased. Health and welfare services keep more immoral feebleminded or mentally diseased parents from being sterilized by disease and also keep more illegitimate children and children of feebleminded or mentally ill parents alive now than formerly. Illegitimate children with their handicaps of social stigma and lack of a father's care and both legitimate and illegitimate children of delinquent feebleminded and mentally diseased parents with their difficulties of poor inheritance and home training contribute heavily to burdens of dependency and delinquency and health problems.
It is impossible for the State to confine in institutions during the years of reproductive life all the over 48,000 persons estimated to make up the socially inadequate mentally deficient of the State. Sterilization for a considerable number of the worst patients who have to be at large seems essential to keep down future hospitalization needs. Yet last year the State only sterilized about 250 persons altogether. This is not believed to nearly equal the number of seriously mentally handicapped children born in the same year to delinquent defective parents in miserable homes where there is no proper care or training.
Sterilization appears needed in many cases to safeguard future generations. It seems needed also for protection of the socially inadequate mentally subnormal and otherwise mentally abnormal parents themselves. When they are trying to get on in the outside world they often break down physically and nervously from inability to cope with family responsibilities.
Sterilization is not being carried out now for feebleminded prisoners and there are not even facilities for identifying them in the case of prisoners in jail or inmates of the State Farm for Defective Misdemeanants or State Farm for Women. The feebleminded are identified but not sterilized in the case of convicts in the State penitentiary. Sterilization is obtained only in rare instances for industrial school inmates, although they are examined and numbers of them are known to be mentally defective with serious anti-social tendencies. Moreover, sterilization is not effected for inmates of the division for white criminal insane at Southwestern State Hospital. State and local welfare agencies are carrying heavy burdens of support of children of feebleminded parents who are or have been in penal or correctional institutions.
Besides obstacles to sterilization in lack of space and facilities in the hospitals there is another obstacle in some instances in lack of cooperation of sheriffs. The law requires that the parents be served notice before the petition for the sterilization of a minor goes to the board. Sheriffs sometimes will not take the trouble to serve these notices.
— page 125 —Recommendation: That space, staff service and other facilities be increased for sterilization through State hospital systems of patients clearly eligible under the present law.
That measures be adopted to secure identification of feebleminded and mentally diseased prisoners in jails, the State Farm for Defective Misdemeanants and the State Farm for Women, and to obtain sterilization as needed for such persons and also for mentally handicapped inmates of the industrial schools and the penitentiary.
That means be found of preventing present delays in sterilization of minors due to difficulties in getting sheriffs to serve notices.
8. The Need of Parole Service
Trained, well qualified field social workers to help get and keep mental patients out satisfactorily are reported in other states an invaluable aid in releasing beds, a benefit to patients, and a means of great saving to the hospitals. Virginia hospitals have as yet no field parole service of their own. The law requires local superintendents of public welfare to help with parole work for hospital patients, but many counties do not have welfare superintendents and the counties that have them overload them with other tasks.
Parole problems have complications here because of distances in the State, because the Central State Hospital, the State Colony and the Division for the Criminal Insane of Southwestern State Hospital serve the entire State, also one hospital for white insane may have to take patients from the territory of another on account of crowding. The commission appointed by the General Assembly to study Virginia's probation and parole needs is proposing for the courts and penal and correctional institutions a combined probation-parole staff of forty qualified workers throughout the State, and is suggesting that this staff could serve the State hospitals in addition.
Recommendation: That as soon as possible each State hospital be provided with at least one trained psychiatric social service field worker attached to the hospital who can combine parole service with the aid in reception service and care of outpatients proposed in Section 2, and can get histories to facilitate the more adequate treatment recommended in Section 6.
That the social worker attached to each hospital serve all the hospitals in matters requiring visits in the vicinity of the hospital where she has her headquarters.
That because of the need for this joint service the psychiatric social workers of the hospitals be centrally financed and organized.
That since one social worker attached to each hospital would be inadequate for the work, but may be all that can be obtained at present, the requirement of parole service from local superintendents of public welfare be retained in addition.
That the hospitals have aid also in outside case work for pa-
— page 126 —tients from the combined probation-parole staff proposed for the State.
9. The Urgent Necessity of More Preventive Service in and Outside teh State Hospital System
It is evident that unless preventive work is enlarged and strengthened the problems of meeting hospital admission needs and also the problems of care of mentally handicapped dependents and delinquents will become impossible ones.
In addition to measures already proposed in preceding sections there are others in successful use in various states. These include:
Clinical psychiatric, psychological and social service work by the hospitals and by other agencies for patients who have never been inmates or applicants for admission and also for discharged patients to provide prompt, suitable treatment as required.
Mental examinations of school children, psychiatric service for pupils needing it, special classes, developing of better understanding of children's problems by all teachers, visiting teacher service, vocational guidance and vocational training to reach and aid children at a time when aid can be effective.
A comprehensive program of community supervision of mental patients, to supplement the services of the hospitals, clinics, and educational system, and to aid pre-school children as well as older persons.
Educational work in mental hygiene for doctors, nurses, teachers, social workers, court workers, ministers, employers, parents and others.
Research in relation to prevention and cure of mental difficulties.
Virginia has some out-patient consultant service by State hospitals, has a State Mental Hygiene Clinic, and some local clinic service, and also clinical work at the State penitentiary—all invaluable as far as it goes, but small in comparison with the need.
For school children there is routine mental testing, which is helpful, but there is little specialized clinical psychological or psychiatric service available and little special class provision. There are some supervising teachers, but not yet as many as one to a county. There are no visiting teachers as such. The vocational guidance and training supplied in the school system are for the children in the higher grades, not for the mental defectives, who greatly need such service. The superintendent of public instruction has plans under way to include in teacher training more work to develop understanding of children's difficulties and needs and also to increase the number of supervising teachers so that there will be at least one of each race for each county.
A general community supervision program for mental defectives by the State Department of Public Welfare is provided by law, but it is inoperative because appropriation and staff have not been supplied. The department boards a few feebleminded children out of a small
— page 127 —fund for that purpose and gives some consultant and advisory service to mentally handicapped patients as well as others not only through its State Mental Hygiene Bureau, but also through other bureaus. The department's Children's Bureau cares for mentally deficient and other children committed by the courts as delinquents. But all the work is limited by lack of facilities and so far it reaches as a rule only those already damaged by a long history of dependency, neglect, delinquency or emotional disturbance.
In mental hygiene education the State hospitals, the State Mental Hygiene Bureau, the Governor's Advisory Board on Mental Hygiene and the psychiatrist serving at the State penitentiary, the various out-patient clinics, the medical schools and the medical societies are all doing helpful work, but this is only a beginning of meeting the needs.
In the research field needs are recognized, but staff and funds are not available for the work.
In relation to mental disease and mental defect the situation in Virginia is still what it was years ago in relation to tuberculosis. Large sums are spent from public and private funds to care for persons in the last stages when it is too late for much help, but comparatively little is expended for the preventive service that might save the situation.
Recommendation: That each State hospital have as soon as practicable extensive out-patient clinical service, not only for applicants for admission to hospitals and for paroled patients, but for others as well.
That the clinical work of the State Mental hygiene Bureau be enlarged.
That traveling clinical service be provided from the State hospitals and Mental Hygiene Bureau.
That increase of local clinic work be promoted.
That more facilities be provided for examination and treatment of inmates of correctional and penal institutions, of persons coming before the juvenile and adult courts, of preschool and school children and other persons needing it.
That all possible cooperation and support be given in the matter of development of an adequate school program not only for mental testing of pupils, but also for special class work, special training of all teachers in relation to mental hygiene and the needs of mentally handicapped children, visiting teacher and supervising teacher service, vocational guidance and vocational training for mentally deficient children.
That as soon as practicable funds and staff be secured and general community supervision service for the feebleminded be put into effect.
That the educational work of the State hospitals and Mental Hygiene Bureau be extended and increase of similar educational work by other agencies be promoted.
That research service by the State hospitals and other agencies be developed.
— page 128 —HOW RECOMMENDATIONS MAY BE FINANCED
Present and Future Savings.—If we grant that what has been recommended is desirable, we have still the question of where the money is to come from to pay for it. The following points seem worth considering:
(a) Changes in hospital admission, temporary detention and conveyance to hospitals should not be financially impracticable. Saving in commission expenses and jail fees should exceed costs at local hospitals or State hospitals of unavoidable temporary detention of patients and costs of telephones or telegrams to hospitals regarding emergency admissions. More conveyance of patients to the hospitals by relatives or friends without expense to the State or locality, should offset freer practice of bringing in patients one by one and promptly when they do have to be conveyed by State workers or local officials. Promoting both conveyance by relatives or friends when appropriate and prompt conveyance by State or local officers when their service is necessary should help cut down jail stay.
(b) Increase in hospital beds should reduce the number of mentally subnormal and mentally abnormal persons now going in such large numbers at State expense to corrective and penal institutions. It should aid in keeping down future hospital population through getting patients under care earlier and having room to classify them better, thus increasing the number of those who can be paroled early and of those who can be permanently cured, and also through making more sterilization practicable. Sterilization should reduce institutional needs not only in the next generation, but immediately. Free of possibilities of illegitimate parenthood or parental responsibilities of any kind some persons can get on outside who break down when they struggle with bearing or rearing or supporting children. Some supplementing of hospital beds without capital expenditures could be effected by family care in boarding homes, or colony care in rented properties. Supplementing with small capital expenditure, can be effected by simple colony care on institutional property
(c) More treatment and training in the State hospitals should be economy through bringing about more cures or improvement to the point of being able to get on in the outside world for mentally diseased and feebleminded inmates.
(d) Hospital field social service workers hould pay for themselves in getting and keeping out of the hospitals patients who with their help can get on outside, and in reducing stay of mental patients in jail. The general probation and parole workers giving service also to hospitals should likewise pay for themselves. This, provided means can be found of keeping the jails from being filled up anyhow under the
— page 129 —operation of the fee system and keeping the hospitals from increasing pressure of new admissions because of lack of preventive service.
(e) A strong program of preventive work in and outside the hospitals seems an essential economy measure to keep down mounting hospitalization needs.
At the same time it seems necessary that the State squarely face the fact that for institutions and for outside service for mental disease and defect, as for tuberculosis, money must be spent. False economy now merely means more public expenditure later, to say nothing of untold cost in private economic loss and in human misery.
No cutting down of hospital admissions for years can be hoped. Too many are outside at present in all sorts of unsuitable situations, needing proper care and not getting it, dealt with merely as dependents requiring relief, or delinquents who should have restraint or punishment.
Gifts and Endowments.—For services for which State funds are not immediately obtainable, several possibilities offer hope.
One is securing of gifts or endowments. The University of Virginia has recently had a substantial donation for its mental hygiene work. The great new Payne-Whitney Clinic in New York City with psychopathic hospital as well as clinic service associated with New York Hospital and Cornell University was made possible through generous benefactions.
Long Term Program.—Another possibility is setting up a long term program. Dr. V. C. Branham, deputy commissioner of the Department of Correction of the State of New York and former medical director of the New York State Committe on Mental Hygiene, has published a program for that State of immediate objectives realizable within two or three years and more remote objectives to be approached over ten or twenty years. There seems no reason the same thing could not be done in Virginia.
The following would appear immediate objectives:
- Changing admission laws.
- Setting up a field staff.
- Regulating jail detention.
- Promoting receiving beds for mental patients in general hospitals.
- Reserving receiving beds in State hospitals.
- Changing conveyance procedure.
- Using some boarding in family homes in connection with State hospitals.
- Arranging between penal and corrective institutions and the State hospitals for more sterilization in urgent cases of delinquent defectives and mentally diseased.
— page 130 —The following would seem objectives for attainment as rapidly as funds permit:
- More beds in State hospitals.
- Colony care for mental defectives in rented properties.
- More adequate treatment and training in State hospitals.
- More sterilization.
- Stronger preventive service of all kinds.
Regarding the whole matter of effectively dealing with problems of hospital admission and hospitalization needs, the important question appears to be not so much "Can the State afford to deal with them?" as "Can it afford not to?" Is not a laissez-faire attitude simply saying, "After us the deluge?" With the illegitimacy situation, the crime situation, and the increase in demand for hospitalization, the State is letting difficulties pile up at a rate that calls for serious thought. Yet a constructive policy, undertaken as promptly as possible, would seem to offer a hopeful way out of those difficulties and a better prospect for a mentally capable and healthy and socially useful citizenry.