REFERRALS TO A

PRISON PSYCHIATRIC CLINIC

Carl Henry Welch

 

 

 

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.. REFERRALS TO A
PRISON PSYCHIATRIC CLINIC

By
Carl Henry Welch

A PROJECT REPORT

Submitted to the School of Social Work,
Michigan State University, in partial
fulfillment of the requirements
fOr the degree of

MASTER OF SOCIAL WORK

December V 1960

/‘<’i‘/fl/(

Chairman, Research Committee

 

Approved:

 

    

 

 

Director 0 School

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ACKNOWLEDGMENTS

To all those who contributed to this research project,
I extend my deep gratitude. Encouragement came my way from
several staff members of the Psychiatric Clinic of the State
Prison of Southern Michigan at Jackson, Michigan. Mr. Alfred
Ball, Director of Psychiatric Social Services, and Dr. Edward
Steininger, Chief Psychologist, helped to stimulate interest
in beginning this particular undertaking. Dr. Herbert Thomas,
Director, kindly granted permission to use the Clinic’s rec-
ords. Mr. Kenneth Davis, Staff Social worker, gave invaluable
help at several points.

Tb my research committee, I wish to express my very sin-
cere appreciation. Dr. Max Bruck, Chairman, gave considerable
time and made a significant contribution to the project.

Mr. Arnold Gurin's pertinent suggestions at certain stages
were extremely helpful.

For placing the proper records at my disposal and for

other clerical help, I owe many thanks to ”Mac" and ”Doug."

Finally, to Gladys, my wife, appreciation is due for con-
stant encouragement and for her many hours devoted to typing

the preliminary drafts.

ii

TIBLE OF CONTENTS

PAGE

‘0 KN OWLEDGMNT S O O O 0 O O O O I O O O O O O O O O 1 1

LI 8 T OF TABLES O O O O O O O O O O O O O C O O O O 1'
CHAPTER

I O IN TRODUC TION O O O O O O I O O I O O O O O 1

Nature of the Study 1

Comparisons with Previous Studies 2

The Setting 5

Definitions of Terms Used 7

Procedure 9

II. REVIEW OF LITERATURE . . . . . . . . . . . 12

Introduction 12

The Readings 12

1. Treatment in a Prison Setting 13

2. Community Psychiatric Clinics 17

3. Prison Psych atric Clinics 23

III. PRESENTATION AND ANALYSIS OF DATA . . . . . 30

Referral Sources 30

Reason for Referrals 39

Disposition of Referrals hh

Referrals and Diagnoses 51

IV. CONCLUSIONS AND RECOMMENDATIONS . . . . . 58

‘PPEN DH 0 O O O I O O O C C O O O O O O O O C O 0 6h

BIBLIOGRAPH! O O O O O O O O O I O O O O O O O O O C v

111

LIST OF TABLES

TABLE PAGE

1. Comparison of Referral Sources, 1958 - 1956 . . . 32
2. Referrals and Re-Referrals by Sources, 1958 . . . 33
3. Referrals and Re—Referrals by Sources, 1956 . . . an

t. Referral Sources and Reason fer Referrals,
1958eeeeeeeeeeeeeeeeeeeeee 36

5. Referral Sources and Reason fer Referrals,
1956eeeeeeeeeeeeeeeeeeeeee 37

6. Referral Sources and status of Referrals,
1958eeeeeeeeeeeeeeeeeeeeee ‘06

7. Referral Sources and Status of Referrals,
1956 O I O O I O O O O O O O I O O C O O O O I 0 w

8. Referral Sources and Type of Further Contact,
1958 . O O O I O O O O O O O O O O O O O O O O O O “7

9. Referral Sources and Type of Further Contact,
19 56 O O O I O O O O O O O O O O O Q O O O O O O “7

10. Referral Sources and Type of Treatment, 1958 . . 58

11. Referral Sources and Type of Treatment, 1956 #8

O
O

12. Reasons for Referrals and Status of Referrals,
19 58 O O O O O O O O O O O O O O O O O O O O O 0 so

13. Sources of Referrals and the Diagnosis, 1958 . . 52
1t. Reasons for Referrals and the Diagnosis, 1956 . . 5h
15. Dis sition of Referrals and the Diagnosis,

195 eeeeeeeeeeeeeeeeeeeeee 56

iv

CHAPTER I

INTRODUCTION

Nature of the Study

A psychiatric clinic in a penal institution, like a
psychiatric clinic in any setting, is dependent for its
patients upon some kind of referral procedure. The patient
cases or is brought to the clinic because somebody has re-
ferred him. The question, therefore, as to‘ggg refers and
‘ghz_assumes a high degree of importance. The extent to
which the referral sources understand the purpose of the
clinic goes a long way toward determining whether or not the

resources of the clinic are being used to the best advantage.

The setting of this study is the Psychiatric Clinic at
the State Prison of Southern Michigan, the specific concern
being the referral sources. The object of the study is to
find out how well the function of the clinic is understood
by those who refer the patients.

It would be very difficult for the psychiatric clinic
to prescribe exactly the type of patient or the type of prob-
lem it prefers because psychiatric services extend over a
wide range of personal situations. But the clinic has found

through experience that its efforts are more required and

- 2

more fruitful in certain cases than in others. Hence, be-
cause ef limitations of time and resources, it has become
necessary to turn down certain requests for services which
may appear to be out of place, ill-timed, or of lesser import-

8110's

It is assumed that the continued relationship with the
clinic provides an Opportunity for the referral sources to
become more aware of what circumstances and needs of an in-
mate warrant a referral of’that individual. It is then
hypothesised that these referral sources are coming to have
a better perception of the clinic's function and that this
increased understanding is being reflected in.more apprOpri-

ate referrals.

Four different aspects of the referral process will be
examined: the referral sources, the referral reasons, the
disposition of the referrals by the clinic, and the clinic's
psychiatric diagnostic classification of the patients

referred.

Comparisons with Previous Studies

To a great extent, this study will involve comparisons
with the study made by Mr. Kenneth R. Davis in 1956. The
purpose of the present researcher, however, is somewhat dif-

ferent. Whereas, Mr. Davis' study was chiefly of an

- 3

exploratory nature dealing with the referral and intake pro-

cedure, this is a study focused upon a specific aspect of the
referral process, the perception of the clinic's function by

the referral sources. A brief explanation of the 1956 study

as well as a similar study in l95h is in order.

The year following the establishment of the clinic in
1953. a student doing his field work at the clinic conducted
an exploratory study of the referral and intake procedure of
the clinic, taking his data from the clinic files for the
period of October through December, 195k. One of his recom—
mendations was that the referral sources should belhelped

"to formulate more definite reasons for referral."

Two years later, another graduate student whose field
work was at the clinic made a study of the referral and in-
take procedure, taking his data frgm the files for the period
of October through December, 1956. The 1956 study was
initiated with the intention of comparing the referral and
intake procedure at that time with that shown in the l95t

 

lJohn Eldon Davis, 'An Exploratory Study of Referrals and

Intake Procedure within the Psychiatric Clinic at State
Prison of Southern Michigan" (unpublished Master's Research
Project Report, Department of Social werk, Michigan State
University, 1955), pp. #2, t3.

2Kenneth R. Davis, ”An Exploratory Study of Referral and
Intake Procedure within the Psychiatric Clinic at State
Prison of Southern Michigan" (ubpublished Master's Research
Project Report, Department of Social Work, Michigan State

University, 1957)-

-1.

study. However, the researcher of 1956 found that because

of certain changes he could make only a partial comparison
with the l95h study. He did find, however, certain "dis-
tinguishable differences” in the intake and referral procedure
of 1956 as compared with 195k. The sources of referral seemed
to have a somewhat different conception of the clinic's func-
tions. For example, the majority of referrals in l95h were
for ”acting out” behavior while the 1956 study showed the
majority of referrals to be for psychiatric evaluation and
treatment. This discovery indicates that the referral sources
were coming into a somewhat truer conception of the clinic's

function.

The second major purpose of the 1956 study was to deter-
mine the effect which the newly created Reception-Diagnostic
Center had produced upon the clinic's referral and intake
procedure. This center, known as the 'R-DC,” is housed with-
in the prison but serves the entire program of the Michigan
Department of Corrections. Here men newly sentenced remain
for an orientation period of 30 to #5 days, during which time
social histories are taken, inoculations given, and psycho-
logical tests are administered prior to classification for
transfer to one of the several state penal institutions.

The study disclosed that most of the referrals from the R-DC
required extensive services in the areas of psychiatric

evaluations and treatments, leading the 1956 researcher to

.-5
conclude that the clinic's referral and intake procedure had

been modified thereby.

The present study was decided upon after it was ascer-
tained that the two-year period following the 1956 study was
a sufficiently long period to make possible certain comparis-
ons. By taking the data from the files for the period of
October through December, 1958, and making direct comparisons
with the 1956 study, it was thought that some trends might be
pointed up that would help the clinic staff to understand
better how its function is coming to be interpreted by the

referral sources.

The Setting

The Psychiatric Clinic at the State Prison of Southern
Muchigan serves a community of some 5,000 inmates. The pris-
on walls enclose an area of fifty-seven acres inside of which
live approximately 3.500 inmates under conditions of maximum
security. Outside the walls in the trusty division may be
found something like 1,500 inmates who live under conditions
of medium.and minimum security. The clinic is housed within
the fifth (or top) tier of cell block No. 6. The ward has
seventy beds and is usually utilised to full capacity. The
four lower tiers of this block accomodate around 300 exdward
patients, medical patients, and other inmates who need

special care. All these men require frequent contacts with

the clinic for treatment and general supervision.

Although housed within the prison, the Psychiatric
Clinic is not by administrative structure a part of the
prison. The director is responsible solgy to the.Michigan
Department of Corrections. At the same time, the clinic ex-
ists wholly to answer needs that arise from the inmate
population. Though administratively separate, the clinic is
engaged in a program that functionally ties in with the gener-
al operation of the prison. The lines of communication are
kept open between the clinic and the proper prison officials.
The director of the clinic may confer directly with the warden
on.matters of top-level concern. Communicationlis further
enhanced through direct personal contact by certain clinic
staff members, respectively assigned to coordinate clinic
services with those of the other departments of the prison.

In 1958, at the time covered by this present study,
there were thirteen civilian employees of the clinic. Of
the three psychiatrists, one was the director who served
only part-time, one a resident on full-time status and one a
consultant on part-time. Two of the three psychologists
were employed full-time, the third one being a part-time
consultant. Three full-time social workers were on the
staff, one being the director of psychiatric social services.
In addition, there were two nurse supervisors, an electro-

encephalogram technician, and a secretary to the director,

- 7

all full-time. Twenty-seven inmates were employed by the
clinic; of this number, fifteen were nurses while four served
on the office clerical force. Most of the remaining inmate

positions were filled by one individual each.

Definitions of Terms Used

Custody is that part of the administrative structure of
the prison which is responsible for the safekeeping of the
inmates and for the enforcement of the prison rules. The
Reception-Diagnostic Center is a separate unit housed within
the prison whose duties cluster around the inmates' orienta-
tion and initial classification. glgggification means the
classification committee which, as a part of the classifica-
tion division of the prison, is responsible for the process-
ing, reclassifying and reassigning of all inmates. The
counselogs function as a part of the classification division,
one of their chief responsibilities being to help the in-
mates with their own personal problems. Sglf-referrals are
those in which the inmate, himself, makes a direct request
for the service by writing a note to the clinic.

A case of Re-referral is that in which the inmate re-
ferred has upon some previous occasion been a patient of the
clinic. An In-patient is one who lives on the ward. An
‘Qgtgpetient is one who is a recipient of the clinic's ser-

vices, but does not live on the ward. By Diaposition is

- 8

meant the determination of whether or not a case referred to
the clinic is to be closed with the initial interview or kept

open for some kind of further services.

‘Eglchotic disorder; ”are characterised by a varying de-
gree of personality disintegration and failure to test and
evaluate correctly external reality in various spheres. In
addition, individuals with such disorders fail in their abil-
ity to relate themselves effectively to other people or to
their own work,"1 .ggggonalitydisorders “are characterised
by deve10pmental defects or pathological trends in the per-
sonality structure, with tunimal subjective anxiety, and
little or no sense of distress. In most instances, the dis-
order is manifested by a lifelong pattern of action of be-
havior, rather than by mental or emotional symptoms.'2 The
chief characteristic of a Psychoneurotic disorder 'is
'anxiety' which may be directly felt and eXpressed or which
may be unconsciously and automatically controlled by the
utilisation of various psychological defense mechanisms
(depression, conversion, displacement, etc.)." £2929.

Disorder "is a basic mental condition characteristic of

 

lDiagnostic and Statistical Manual - mental Disorders,

erican Psychiatric Risociation Mental Hospital-gervice
(Washington: 1952), p. 2b.

21bid., p. 3a.
31bid., p. 31.

-9

diffuse impairment of brain tissue function from any cause.

It may be mild, moderate, or severe...."1 Mental Deficiency
“is primarily a defect of intelligence existing since birth,
withoutzduonstrated organic brain disease or known prenatal

Procedure

The system by which data was collected for this study
followed very closely the plan used by the 1956 researcher.
It was thought that using the same schedule would facilitate
comparing the findings of the two studies. The only change
in the schedule was adding an item in regard to out-patient
group treatment, which type of treatment had not yet been
initiated in 1956. '

The first step was to examine the file cards listing the
innate numbers and dates of referral. All patients have a
folder starting with their first contact with the clinic.
Having thus obtained thetgnumbers of the patients referred for
the period of October through December, 1958, the next step
was to examine the individual folders. There were found to
be 228 referrals for the period. Certain of these referrals

 

laid. ’ p. 1‘.
21bid., p. 23.

- 10

not being usable, the plan of elimination followed that of
the 1956 study.

Re—referrals were included only if the patients were
not already in an actiVe relationship with the clinic. Some
patients were in an ongoing process of evaluation or treat-
ment at the beginning of October. Referrals of such patients
were not included in the study, regardless of when the re-
ferral might have occurred during the period. There were
seventeen such referrals. Also eliminated were twelve
referrals in which, for some reason or other, the patient
did not appear at the clinic for interview. Not included,
also, were nine referrals which were only reports on pre-
vious contacts. Also in some of the clinic folders examined
the data was incomplete, in others the contact had been
through correspondence, and in a few other cases there were
duplications. This miscellaneous group amounted to twenty-
three. The total number of referrals eliminated was
sixty-one. This left 167 referrals which were Judged to be
appropriate fer the study.

It was intended for this study to make comparisons with
the 1956 study in order to bring to light any changes and
trends that may have occurred in two years. In great part,
it has been possible to follow this plan. However, by in-
cluding psychiatric diagnostic classification, the present
study was able to go into an area not sufficiently open for

- 11

the other study. The findings here were limited as far as
the search for changes in the two-year period was concerned,
but it was thought that an examination of this phase of the
referral process might contribute to the purposes of the

study.

CHAPTER II

REVIEW OF LITERATURE

Introduction

The literature abounds with material on psychiatric
clinics. It seems that practically every phase of clinical
operation has been more or less adequately dealt with, but
for one exception - the prison psychiatric clinic. Perhaps
one reason for this is that it has been only in comparatively
recent times that the change in penal philosophy has gotten
under way. To look upon the offender as an individual who
is in need of rehabilitation rather than of punishment re-
quires an approach which society, as yet, is altogether
too unwilling to accept. Hence we find that, by and large,
the prison psychiatric clinic has not as yet achieved the
place of importance in penology which it deserves.

The Readings

The readings divided themselves into three general
types: first, those discussing the general problem of treat-
ment in a total prison setting; second, those which are
concerned with psychiatric clinics in general; and third,
those having to do specifically with psychiatric clinics in

prisons.

- 12

- 13

1. Treatment in a prison setting

Reckless observes that it has been over 500 years since
the beginning of prison reform.1 Not much progress was per-
ceptible for a very long time. Though having been at the
task much longer, it has been far more difficult for correct-
ions than for family service and child welfare to inaugurate
programs of treatment. The writer, however, senses encourage-
ment. “As correctional institutions get personnel who are
skilled in group therapy methods and begin trying out certain
projects on a limited scale a grass roots experience will be
built up and the possibilities and limitations of the tech-
nique will be understood.'2

Judge Westover sees the post-prison environment as being
responsible for the lack of success in the rehabilitation of
offenders.3 The released individual faces a hostile, indiffer-
ent and cold world where he is denied employment. The result
is the undoing of whatever rehabilitation was begun or accomp
plished by the treatment facilities of the prison. Society
should becoms concerned and provide the opportunities needed
for earning a livelihood.

 

1Walter C. Reckless, ”Significant Trends in the Treatment of
Crime and Delinquency,“ Federal Probation, Vol. XIII (Mhrch,
19‘9) . pp. 6.8e

guide, pe 8e

3Barry C. Westover, ”Is Prison Rehabilitation Successful?”
zederal Probation, vol. 22 (March, 1958), pp. 3-6.

The question as to the extent to which inmates are ac-
tually reformed is quite in place. Vold points out that
there is general agreement that the desired end of imprison-
ment is reformation.1 But, as to the methods of bringing
this reformation about, there is considerable controversy
among penal authorities. The psychological and psychiatric
services deal with deep-seated mental disturbances as they
relate to misconduct. Treatment is patterned on that of a
mental hospital and the recidivism is high. The other type
of service is education and vocational training. Weld goes
on to say, "The mere increasing of facilties and manpower to
do better and more completely what we are now doing will not
help much unless there is developed a comprehensive and
deeply searching program of rgscarch as the springboard for
new techniques of treatment.“ Vold concludes his article
by stressing that what is needed is more skilled research
workers, the support of‘whom will be provided in the budgets.
This can be attained only by selling top-level responsible
administration on the idea.

Hegel sees penal institutions as expected to perform a
dual service for the protection of society, namely, the

 

1George B. Weld, "Does the Prison Reform?“ Prisons in
Transformation ed. Thorsten Sellin The AmerIcan Icademy
BIFaEIIEIEEI‘Efid Social Science (Philadelphia: 1951),

pps “2-50e
21bid., p. 50.

- 15

l
custody and reformation of the offender. The warden is

prone to feel that his success is largely measured by the
fact there are no escapes and riots. What is too often for-
gotten is the fact that the services of caseworkers help to
dispel anxiety and, hence, prevent trouble. Inmates need
help around current reality problems. The emphasis should
be on short-term treatment so that more inmates can get help.
Institutional maladjustment or a violation of the rules
creates anxiety that often stimulates the individual to seek
help. Sometimes by helping to clear up an inmate's worry
about his family, a caseworker gives a big assist both to
custody and to treatment.

Th; uniqueness of prison society is pointed up by
Miller. The inmates carry their hostile attitudes and anti-
social behavior into prison. They are unable to form inter-
personal relationships or mutual trust and faith. The inmate
is the result of a previous life experience of rejection. He
is suspicious and finds it difficult to accept humanitarian-
isn. A hierarchy of “pecking order" develops. To a great

extent, the inmates make and enforce their own decrees,

 

1William G. Hegel, ”Custody and Treatment - Twin Aims of the
Prison Social WOrker,‘ Casework Papersa 1221, Family Service
Association of America ew or : , pp. 91-10 .

”Paul R. Miller ' ”The Prison cw..- American Journal of
{alchiatry, We . llk, January, 195 , pp. - .

- l6

exercising a great measure of control through fear and fines.
Control falls into the hands of the most manipulative, preda-
tory inmates. The prison code, which is enforced by positive
and negative sanctions evolved by the inmates themselves, is

outside the regular, institutional rules. Acting to prevent

resocialisation the prison code is a deterrent to treatment.

But custodial officials oftentimes use the code to their ad-

vantage, for if special privileges are granted to the strong-
est he helps maintain order and, thus, gives an assist to

custody.

McCorkle and Kern also show how very difficult is re-
socialization of prison inmates,1 The inmate social system
becomes most useful to those who have become most independent
of society's values. Those whose self-evaluations are de-
pendent on the values of the non-criminal society have the
hardest time adjusting to a social system whose major values
are based upon the rejection of that society. Aggressive
inmates exercise control through threats and rewards. Cus-
tody uses the inmate power structure as an aid in prison
administration. Humanitarianisl is not especially appreci-
ated by the inmate because his system of adaptation creates

within him a need to protest. In his role of the martyred

 

1Lloyd W. McCorkle and Richard Kern, "Resocialization Within
Prison Walls,” Prisons in Transformation, ed. Thorsten Sellin,

The American Academy of Political and §Scial Science
(Philadelphia: 195 ), pp. 88-98.

- l7

victim, he needs some place upon which to turn the hostility
generated by his failure in human relations. He gains abso-
lution from the sense of guilt by thinking of society's
offense against him.

2. Community psychiatric clinics

 

Bradbury made a study based upon fifty random intake
records taken from the periods of August, 1958 through
January, 191.9 and of August, 1950 through January, 1951.
The study was concerned with intake trends and effbrts cf
the clinic staff to interpret its function to the referral
sources. The areas examined were: reasons for referral,
source of referral, presenting problem, tentative diagnosis
and disposition of the case. The majority had been referred
by other sources within the hospital. It was found that
there was an increase in the number of psychotic patients
and a decrease in neurotic patients. The greatest decrease,
however, was in patients with somatic disorders. There was
an increase in diagnostic evaluation and short-term treat-
ment. The study showed that the clinic's interpretative
activities had succeeded in the hospital but had had little
effect in the community at large.

 

1Ruth 8. Bradbury yi ”Intake Trends and Interpretation in a
c,

Psychiatric Clin '(Strong.Memorial Hosp tal Rochester,

N. Y.), Smith Colle e Studies in Social Work, Vol. 1111
(July, 3315. p. 157

- 18

The matter of long waiting lists and inability of‘a
clinic to respond adequately to crisis situations received
the attention of Coleman and Zwerling.1 ”Soon after the
clinic is established a familiar pattern asserts itself: the
overwhelming demands for service quickly gluts up the lines
which feed into the clinic from the community." The sooner
the individual's trouble is gotten to the better. Hence the
need for early diagnosis and treatment. What is urgently
needed is the ability of a clinic to offer a wide variety of

immediate out-patient services.

Cooper notes that social workers lean tozard the demo-
cratic philosophy of first come first served. But intake
workers must be alert lest they be manipulated. In the
selecting of urgent cases look for the answers to certain
questions. Is the client facing a.new life crisis occasioned
by environmental stress? Is he going through some develop-
mental physical and emotional change? Are there new'symptoms?
Are there sudden and sharp regressions? Do the defenses ap-
pear to be shifting? Is the psychopathology spreading? Are
there in the environment available peeple to lend support
and help? A final question would be, is the individual

 

IDonald M. Coleman and Israel Zwerling, “The Psychiatric
Emergency Clinic, A Flexible Way of.Meeting Community Mental
Health Needs,” American Journal of Psychiatgz, Vol. 15
(May. 1959). p. .

2Shirley COOper, "Emergencies in a Psychiatric Clinic,” 80515;
Casework, Vol. XLI (March, 1960), pp. 13h-139e

- l9

liable to do harm to himself or others? The intake worker
should get enough of the problem to weigh the urgency of the
referral. He should be in a position to estimate the degree
of "the push of anxiety” or the "pull of depression." The
degree of reliability of the referral source should be con-
sidered. In essence, Cooper seems to say: when in doubt,

give the appointment.

An experiment with acutely disturbed patients in an
open ward is reported by Young.1 The setting was a thirty-
bed psychiatric ward in a community hospital. Previously
the inmates were kept in single locked rooms because of the
anxiety of the staff as to possible violence, escapes and
suicides. Out of the experiment, which‘was considered a suc-
cess, certain principles evolved:

‘1; keep span the lines of communication so that

mutual understanding can be maintained among

all the staff members and patients;

‘3‘ help patients use their strengths by working
with the healthy parts of the personality;

foster group living by helping patients as-
cept res nsibility and become a part of the
group; g ve each person one vote;

It”

‘5‘ at group meetings examine feelings;

 

1Calvin L. Teung, "A Therapeutic Community with an Open Door
in a Psychiatric Receiving Service!“ A.M.A. Archives of

Neurology and Psfchiatgz, vol. 81 January EFFEuEE July,
9 PP. "' °

- 20

.2; by this group process, those patients admitted
are examined and evaluated by the staff and a
treatment plan set up for each.

Visher reports on an expermment in shortening the amount
of time in psychotherapy.1 In the 1950-1953 period each
staff'nember of this clinic served 61.1 patients per year,
averaging thirty-six hours per patient. In 19519-1955. with
the emphasis on psychiatric diagnosis and group therapy, 121
patients were served with an average of twenty-four hours per
treated case. The staff must be educated as to the possibil-
ities of short-term treatment. In this case, the staff saw
some patients who had been successfully treated in five to
ten interviews. There was quite an administrative problem,
however, in finding the most likely patients. The criteria
of selection was: first, readiness for change; second, the
nature of the presenting problem; third, environmental,sta~
bility; and fourth, the reaction of the patient to the intake
interview. .

Brief psychotherapy, the writer points out, is not 'a
desperate expedient adopted by an.overburdengd clinic staff
to dispose of as many patients as possible." It is treat-

ment of choice where the goal is to return to former

 

1John S. Fisher, “Brief Psychotherapy in a Mental Health
Clinici' American Joggnal of Psych atgz, Vol. 13 (April: 1959),

pp. 33 ~352-
21bid., p. 3&1.

- 21

functioning, not to arrive at normal expectation. To say it
another way, the ”goal of treatment is to relieve anxiety
and to teach more effective ways of ceping with problems
which have temporarily overwhelmed the individual.'1 "From
the standpoint of a mental hygiene clinic itself, brief
psychotherapy, when available, is a potent weapon of the
clinic staff in the attempt to meet the therapeutic needs

of a diverse papulation.'

To what type of patient should group psychotherapy be
extended? Leopard sees group therapy operating on many lev-
els and as being a method of treatment which could be
recommended for many types of patients. It has been found
effective for borderline and ambulatory schizophrenics. For
some patients who are socially deprived and isolated, the
group fulfills their need for belonging and establishing bet.
ter social relationships. With other patients the transfer-
ence in individual therapy is too intense and anxiety
producing, and the group offers an opportunity for the re-
lease of tensions and the reduction of guilt feelings. Some
patients are better able in this group to express hostile

feelings than in the one-to-one relation. Homosexuals may

 

11bid., p. 342.

21mm, p. 31.2.

3Harold Leopard, "Selection of Patients for Group Psycho-
therapyi' American Journal of Psychotherapy, Vol. 11

(July, 9575, pp. 553-557.

- 22

begin to be able to establish better interpersonal relation-
ships.

Leopard goes on then and gives some criteria for deter-
mining who should be in a group. The individual must be a
person who (1) has full reality contact (2) can be reached
emotionally in an interpersonal relationship (3) is suffici-
ently flexible to increase or decrease group tensions, and
(A) may at times act as a catalyst for another member of the
group. The individual who should not be in the group is he
who (1) because of constant irrational productions cannot be
reached by the other members (2) over a protracted period so
monopolizes the group that all interaction is blocked (3)
cannot cope with anxiety provoking unconscious productions -
his own or those of others and, therefore, becomes a burden
to the group, and (h) by his destructive impulse-ridden and

anti-social behavior elicits fears in the other members of

the group.

Leopard concludes by saying it is a mistake to use
"diagnostic label and pathologic ramifications of the person-
ality' as the only consideration. It is necessary to study
the variables of the personality structure and also the group
structure or, in other words, the "psycho-dynamics of the_
patient and the psychologic impact of the group."

Can group therapy and individual therapy be combined

into one treatment program? Lipschuts advocates this as a

- 23

definite method of therapy and, when so used, the two types
must be equated not one used to supplement the other.1 Nor
should this method be confused with the circumstances in
which individual therapy is used to get the patient ready for
group therapy or vice versa. In certain situations the com-
bin337B3§ much to offer. To some patients the expression of
hostility toward the therapist in the group would mean the
breakdown of the entire defense system, hence the need for
the individual session. With other patients the transference
in individual therapy is too strong. In the individual ses-
sions the therapist becomes aware of current conflicts thus
knowing what to look for in the group. The combined method
offers the opportunity for the modification of transference
and counter-transference. It provides a.flexible way of

handling a greater variety of problems.

3. Prison psychiatric services

 

That psychiatry as practiced in prison is different frog
that in other settings is pointed up by Powelson and Bendix.
The prevailing view is that the purpose of the prison sentence

 

lDonalan. Lipschuts, "Combined Group and Individual Psycho-
therapy,” American Journal of Psychotherapy, vol. ll
(April, 1957), pp. 535:3kh.

2Herve Powelson and Reinhard Bendix "Psychiatry in Prison,"
Psych atrz, Vol 1t (1951), pp. 73-83.

- 2g

is to punish the offender and protect society by putting the
offender in safe keeping. It is necessary for the psychi-
atrist to come to an adjustment or compromise with this
prevailing viewpoint. In prison the inmate is subjected to
the final authority of the guard. The moral depravity of the
prisoner being assumed there is a moral gulf between the pris-
oner and the guard. On the other hand, the psychiatrist
recognises that criminal tendencies exist in everybody -
guards and officials as well as prisoners. There are times
when the guard may be wrong. In regard to the motivation of
the prisoner, custodial officials see him as wanting above
all things to get out of the prison, be the means foal or
fair.' The psychiatrist sees the inmate as afraid of the out-
side world and adjusting all too well to the Jungle. A
psychiatrist with an authoritarian tendency fits better into
a prison system. If he is otherwise he is ineffective.

Speaking from his experience as staff psychiatnst in a
medium security psychiatric ward of a Federal prison hospital,
Graft maintains that inmates respond favorably to humane
treatment.1 "The climate of the ward changed despite a resi~
due of chronically ill patients. The unitwwon.the softball
league championship. The year before they were not permitted

 

1Norman Graft ”Experiences in a Prison Hospital," Bulletin
Menninger Clinic, Vol. 20 (March, 1956), pp. 85-91”.

- 25

t3 use a full-size bat because it was considered a lethal
weapon. The unit became cheaper to operate because of the de-
crease in breakage."1 The officers in charge got the spirit
and cooperated in improving the ward. Graft is convinced that
'a schism between the goals of custody and therapy is not in-
evitable if the attempt is made to educate custodial personnel
to the value of an active therapeutic milieu in terms of
greater Job satisfaction for them.'2 "An effective thera-
peutic program in a prison hospital...cannot succeed without
the cooperation of the administrative echelons of custody

and therapy at higher levels."3 Tb succeed the program
necessitates an in-service training program for the custodial

officers.

Tb what extent does a prisoner feel free to discuss with
the therapist any phase of his career? MacCormick stresses
the fact that a prisoner has as much right to a.oonfidential
relationship with his therapist as with his attorney or
clergyman.“ Group settings should foster freedom of expres-

sion unhindered by a fear that any new knowledge will be added

 

1Ibid., p. 90.

21bid., p. 91.
3Ibid., p. 91

‘Austin MacCormick, "A Griminologist Looks at Privile e,”

American Journal of Psychiatrz,vol. 115 (June, 1959 ,
ppe " e

- 26

to the inmates' records. ”Unless they can be sure that. what-
ever they reveal in therapy will not be reported to the
institution administration or parole board the effectiveness
of the psychotherapy will be disastrously impaired.1

Based upon an experiment in a California state hospital,
Rood concludes that more effective therapy for certain non-
psychotics can be provided in a non-prison setting.2 Group
therapy of sexual psychopaths was conducted by psychiatrists,
psychologists and social workers. The hospital is a better
setting for psychotherapy than a penal institution because of
the spirit of acceptance of the entire staff as against the
punitive philosophy of the prison. Absent is the cold war
which exists in a prison setting and, hence, the atmosphere

is more relaxed.

The Psychiatric Clinic of the State Prison of Southern
Michigan is mentioned in an article describing the work of
the Michigan Department of Corrections.3 The purpose of the
clinic is described as being primarily that of providing

diagnostic and short-term treatment services.

 

1Ibid., p. 1070.

2Reginald J. Rood, "The Ron-psychotic Offenders and the State
Hospital,” American Journal of Psychiatry, Vbl. 115
(DOGOIbOr, . ppe " 0

3Gus Harrison, ”Michigan Corrections Department,” American
Journal of Correction, Vol. 20 (July-August, 1958;, pp. 5-7,

- 27

The most complete study concerning prison psychiatric
facilities is that of Dr. Wills, which was completed in July,
1951..1 Note is first made of’a survey conducted in 1927 by
the National Crime Commission through its Sub-committee on
the Medical Aspects of Crime. This earlier study covered
Federal as well as state penal and correctional institutions.
It included Juvenile institutions, farms, and criminal courts
and Jails. The responses to the survey showed nineteen full-
time and twenty-four part-time psychiatrists active in this
field. But twenty-four states and thirty-four prisons had
none. Federal prisons reported three full-time and one
part-time psychiatrists.

In Dr. Wille's study, questionnaires were sent to the
315 state and federal prisons and correctional institutions
listed by the American Prison Association. Of this total
number, 167 were prisons or reformatories for adult or young-
adult offenders. The responses from these latter sources

totaled 121 or seventy-two per cent.

Of the 150 state prisons and reformatories, 10A report-
ed showing eighty of these institutions as having psychiatric
services. Nineteen had a full-time psychiatrist, twenty-
eight had the regular part-time services of a psychiatrist,

 

1Warren 3. Wills, “Psychiatric Facilities in Prisons and
Correctional Institutions in the United States,” The American
Journal of Psychiatgz, Vbl. llh (December, 1957), pp. $31-$37

- 28

and thirty-six had consultation services only. Ten states
had no psychiatric services at all for their correctional
institutions. Thirteen others made use of only occasional

psychiatric consultation.

The eighty state institutions with psychiatric services
employed thirty-one full-time psychiatrists, thirty-four
part-time psychiatrists, and fortybtwo psychiatric consult-
ants. Pederal institutions showed twelve full-time and five
part-time psychiatrists with nine consultants. The grand
total of psychiatrists, including consultants, for federal
and state institutions was one hundred and thirtybthree.

There is a great variation among the different states.
One state had a seventy-five bed ward but no services of a
psychiatrist. The patients were examined once per year by a
state hospital psychiatrist. Some states were making use of
regional mental out-patient clinics for psychiatric evalu-
ation. Other states were deve10ping central psychiatric

services.

Six prisons, including the State Prison of Southern
Michigan, were using psychiatric residents through arrange-
ments with medical schools. Forty-seven institutions had
psychiatric wards within the prison hospital, but only ten
had more than twenty-five beds. Eleven of these wards had no

trained civilian nurses. Nineteen had either trained civilian

- 29

nurses or nurse supervisors and ten had only civilians on the

nursing staff.

In seventeen institutions, the staffs of the psychiatric
services carried on individual psychotherapy while twenty-
eight others provided only for group psychotherapy. In other
institutions only emergencies were attended to by the meager
psychiatric staff. Thirty-one institutions had psychiatric
reference libraries and twenty-eight had diagnostic files.
There were eight institutions with electroencephalographic

laboratories.

Eighty-five psychologists and ninety-eight social
workers were employed in state institutions. In federal
prisons, there were five psychologists and sixty-six.social
workers. In thirty-four cases regular use was made of the

teamwork type of clinical approach.'

Dr. Ville concludes his article by saying that ”Despite
,the increasing recognition that many repetitive offenders are
mentally ill and that criminal behavior stems from unconscious
conflicts very few criminals actually receive thorough
psychiatric study or treatment.'1

.4

1Ville, 0p. cit., p. #87.

CHAPTER III

PRESENTATION AND minus 0! pm
Referral Sources
The 195‘ study found self-referrals heading the list,
foliosed ty referrals free custody. the sees the sources

though in reverse order ranked first and second in the 195‘
'Me ‘

this present study shows a considerable shifting of rel-
ative positions in the rankings of the referral sources. That
the eeunselors acved free aidway to the top piece can partly
be “count“ for by the fast that by the time of the 1958
period self-referrals could he only re-referrals. in iaaete
without previous contact with the clinic had to he referred
by some person in official capacity. If he desired soae
clinic service he could discuss the setter with seas official.
usually his counselor, who sight deea it appropriate to grant
his request to he referred, or the counselor. hiaself. eight
handle the problea. This change in procedure apparently has
helped to eliainate some needless self-referrals.

classification. which ranked neat to the last in the 1956
period studied, attained second place in the 1958 period. The
increase in referrals free classification can be largely

-30

~31

accounted for by the fact that the referrals free the Recepo
tion-Diagnostic center reach the clinic through the classifi-
cation consittee. It was found to be difficult to select out
the referrals from n-oc since the origin of the referral was
not always stated on the referral sheet. Hence B-Dc was net
included as a referral source. As the inaatcs pass from 3-06
to classification those the former recommends to the clinic
are not always referred immediately.

Two other referral sources which had increased their pro-o“
portions of the referrals were the parole board and warden.-
Exaaining Tables 2 and 3 we see that what probably contributed
to this increase was that both referral sources were asking
greater use of the clinic for psychiatric evaluations.

The three referral sources that showed decreases were.
self. custody . and the hospital. The drop in self-referrals.
as already noted, was due to a change in the clinic's policy.
nany inastee had cone to annoy going to the clinic on the
slightest excuse bccause of the friendly eteosphcre there.
Others who had never been to the clinic wanted to satisfy
their curiosity. Hence controls had to be set up for self-
referrals. There were to be no new self-referrals. is for e
re-refcrral. an innate could send a note to the clinic asking
for an interview or a service. He eight or night not be
accepted, depcnding on the clinic's decision based upon prior
knowledge of that innate.

2
3
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- 33

 

 

 

 

 

 

 

 

 

 

 

 

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- 35

Host of custody's personal involvement with innates is
in the case of acting-cut behavior._ in innate who has been a
patient is the clinic is not to receive eevei-e discipline
without the consent of the clinic. If this written permission
has not already been entered in the inmate's folder in the
aain record office. the officer's first impulse may be to send
the offending innate to the clinic. fable 2 shows most of
custody's referrals to be re-refcrrals. hes preceding fable
1 it is to be seen that there has been a very great my in
referrals froa custody. It is quite evident that what has
happened is that custodial officials instead of incdiately
referring an acting-out insets to the clinic are casing to
find that they themselves can often handle the situation.
Sonatiacs all that is needed is firuess and understanding.

Referrals free the hospital also showed a very consider—
able decrease. h-ea 'i'abie t and table 5 it is seen that the
hospital was taking care of a nuaber of cases of bisarrc be-
hevicr and eacticnal upset which it foraerly would probably
have referred to the clinic.-

a referral source froa which there were no referrals in
this study was 'Othcr Institutions“. It is known that the
other correctional institutions were still referring a few
cases but during this three-cont]: period there Just happened
to be no referrals from this source. It can be seen frca
i'ablc ll that cost of these patients were transferred free
other institutions for iii-patient care. The great reduction

6
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~30

in such referrals was apparently due to the fact that the in-
patient capacity of the clinic was now having tc be almost
wholly utilised for chronic patients of the local prison.

An explanation would help to clarify the mean for the
clinic's inability to respond to the need for custodial care
of psychotic patients. The state facilities for the care of
the mentally ill offenders are becoming very crowded. When
it was no longer possible to move some of the iii-patients tc
other institutions. the in-peticnt group tended to becoac col-
, posed of a high proportion of chronios who need longer care.
Hence admissions to the ward had to be carefully .........

is for the 'nisccllanaous' listmng the chief referral
sources were the work supervisors and the chaplains who also
were represented in the 195‘ study. There were not enough
referrals here to Justify trying to make comparisons.

It is quite apparent that in the intervening period be-
tween the two studies there was a considerable shift in the
relative preportion of referrals among the various sources.

In most respects the changes were greater than in the period
between the 195k and 1956 studies. For instance, the 195“
study showed sixty-eight per cent of the referrals coming from
the three sources of custody, self, and the hospital. the
195‘ study found fifty-seven per cent casing free the same
three sources. But this researcher found these sources as-

counting for only thirty per cent of the referrals.

a 39
to coaplete this picture of the reversal in referral sear-
hes the present study found sixty-three per cent of the refer»
rels seeing free the counselors, classification. the parole
board and the women. The 195‘ study revealed that only twen-
ty per cent case fros these sources. the use em showed '
that these sourees accounted for fifteen per seat efthe refer-
rals. with none at all reported free classificatim.

By way of suasary it can be said that cosparison with the
195‘ study elem; use a few refereneea to the 19:» study shows
that considerable chances were taking place sees; the referral
scurees. Purtherscre, these changes especially in sese cases I
were of a type that sesaed to indicate that the referral sour-
ees were using to have sosewhat of a better met-standing ef
the clinic's purpose and lisitaticas.

Reasons for Referrals

In trying to categorise the reasons for referral as given
by the referral searees it was found neeessary to resort to a
seasure of interpretation. while in the great merit: of
cases the reason was explicitly stated. in acne instances it
was not clear exactly why the referral had been cede and it
was soaetises necessary to exaaine the dictated interview in
order to arrive at a decision as to what category to ascribe

the reason for referral.

.150

For exasple, in this study the category of “emotional
disturbancc' is used also to include certain types of behavior
that the two previous researchersaost probably classified as
"nervous' and 'inability to adjust‘. In a few cases soae self-
referrals specifically stated 'I as nervous0 and other refer-
rals indicated an inability of the inmate to adJust to a prison
routine. a further reading of these records see-ed to Justify
the inclusion in the sectional disturbance category. I

Regardless of any change which this study made in slin-
inating the categories, the fact reeains that referrals for
“nervousness' and 'inability to adjust' had declined very
appreciably free the number reported in Table 5 for the 1956
period. '

As has Just been noted. it is difficult in certain in-
stances to differentiate along the stated reasons for the ref-
errals. It is still were difficult to detersine the actual
reason! which lies behind the referral. For exasple, an insets
say be acting strangely‘or anti-socially. He is referred to
the clinic. One referral source sight state that the patimt
is emotionally upset, while another night siaply request pay-s

chiatric evaluation.

Also. it should be numbered that although different
referral sources say give identical or sisilar reasons for the
referral, it can by no scans be assused that they all seen the
ease thing. Hhat is seant by psychiatric evaluation, for

«#1

exasple, depends upon.the referral source and the purpose be.
hind the referral. The parole board wants an.evaluation.of
an.inmate in.regard to his possible return to society. atlase-
ification asks for evaluation.so as to better understand how .
to get the innate into the proper prison progras, as regards
such things as Job, education, and cell block, to which to
assign his. Then the counselor may suggest evaluation with
possible therapy in view. To the clinde psychiatric evaluau
tion is very flexible and is guided by the specific circuse
stances surrounding the referral. ' All

With these explanations the data in Tables h and 5'still
can be seen to give considerable interaction about reasons for
referral. here sources are giving psychiatric evaluation.snd
treatment as the purpose of the referrals. To sisplify a ref-
errel by stating that the patient was 'esotionally disturbed'
or 'asting queerly' is not practiced.by the referral sources
'nearly so such as it once was. However, it should be pointed
out that though the referral source gives psychiatrtc evalua~
ties or treatsent es the reason for referring, there oftentises
is an accospanying description of behavior.' As for priority,
essrgeney referrals. each as acute situational episodes, get
innediate attention. l‘ '

The drastic reduction in.the nusber of referrals for non-
clinic inquiry oan‘be accounted for by the restricticns placed

upon self-referrals as heretofore sectioned. New referrals

a. #27

from self can no longer be made. Ben-referrals from self are.
carefully scrutinised before being accepted. Thsclinic pre-
fers not to expend its resources of time and effort on requests
and inquiries the answers to which clearly fall within the.

function of other departments of the prison.

It is to be noted that with a few exceptions the changes
between 1956 and 1958 in referral reasons are rather eodest.
The general tendency is for the referral sources to continue
giving the same reasons for their referrals. But there is
perceptible a small overall shift in the direction of referral
sources giving psychiatric evaluation and treatsent as the

reasons for their referrals.

fable ‘5 shows what proportion of the total nuaher of re-
ferrals is represented by each referral reason. Roughly, out
of every ten referrals. six were for psychiatric evaluatim.

two were for treatment, and one was for sectional disturbance.

Comparing the individual sources with the general average
percentage. for each reason the extent of some, deviations is'
noticeable. The parole board is high on psychiatric evaluation
and low on treataent with none foreeotienal disturbance. ‘
The warden is high on psychiatric evaluation, low on sectional
disturbance, with none for treatment. Classification is high
on treatment and low on emotional disturbance. Self is low
on psychiatric evaluation and high on treatment. Custody is
low on psychiatric evaluation and extremely high on emotional

-t)

disturbance and bisarre behavior with none for treateent. fhe
hospital is high on psychiatric evaluation. The source varying
the least free the general average is the counselors.

that we see here is that easrgensy referrals tend to cone
free these sources closest to the innate in his everyday life.
ne-referrals tree custody arechisfly for sectional disturbance
and bisarre behavior. the oomselors and the hospital whe are
a little farther resevu free the inaates than custodial offi-
cers are fairly well represented in the essrgency referrals.

Referrals that result free a fair degree of deliberation
and planning tend to eeee free sources with when the innate
has enly very rare contact. that referrals for psychiatric
evaluation ran high for the parole board and warden reflect
the feet that these twe sources used the clinic's psychiatric
appraisal of an innate who is being considered for parole or
is cosing up for discharge.

is for treatasnt classification ranked very high. This
we would expect when resubering that classification gets the
insets at the beginning of his confine-eat and sees his in
possible need of a treataent progres.

‘i‘he counselors who sade a sederate nusber of referrals
of an easrgency sectional nature also attained an average
rating in referrals for psychiatric evaluation and treatsent.
i'his rather balanced type of referrals free this source reflects
the diversity of insets probleas with which the counselors deal.

Disposition of Referrals

After the initial interview the referral can be classi~
fied as either a closed or en open ease. the clinic's deoio
lion whether to terminate or continue a case depends upon the
purpose of the referral, the patient's needs and trim capaci-
ties and the resources of the clinic. I: in its disposition
of the case further contact seems necessary or advisable the
services offered are usually either in the area of further

evaluations or of treatesnt.

The appropriateness of a referral is not necessarily
based upon the fact as to whether or not the referral was kept
as an open case or closed with one contact. If the iseediatc
problem concerned treat-ant and it was decided to take the
patient into treatment, undoubtedly this referral could be
considered quite appropriate. But if the patient was not
taken into treat-ant and the case was tersinsted in one cen-
tact the referral night still be considered quite in place if
through it the referral source or the patient received sees
newer they sought.

is already esphesised psychiatric evaluation is a general
tern that covers a broad area. It would be difficult to set
the boundaries to the diagnostic services in the clinic. lab:
patients through one contact receive the requested service.
however, it is cost reasonable to scenes that it would be
aeeng the one contact referrals that the less appropriate ref-
errals would be found.

-t5

Proceeding upon this assumption and. coaparing Tables 5
and 6 we say be set by an mediate surprise to find that the
proportion of single contact referrals was greater in the
1958 period ethane than in the i956 period. rhe expienetiea .
is found when we loch at the in-paticnt situation. 00er
Tables 10' and ll we see the very iaaenae drop in the in-pat-
ient adaiesicns to the ward. This has been referred to'and
explained earlier. I. f *

Although'the clinic perceives its function to include
in-patient care and treataent. it is moving in the direction
of expanding its out-patient treataent propel. Gasparia‘
tables 10 and ii there is shown to be a considerable imreese
in these services. this the clinic has 5.... able to do by '
accepting wore patients into out-patient group therapy. at
the ease ties the outcpatient progra- of individual therapy
continues. Although all inc-patients are considered ee being
in treataent. there are any chrcnics on the ward for whoa
the clinic can provide little more than custodial care. coa-
sidering the entire treatment prograa, the time considers
itself to be com; acre actual treatment than in the 1956 per-
iod. Il'he referral sources are doing their part by referring
new prospects to be received into therapy as the treatment
load and resources of the clinic permit.

Conparing from Table 6 the individual referral sources
with the general average for further contact it is noted that

~46

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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classification and custody are high and the parole board low.
Otherwise, there is little deviation among the various sources.
That the referrals from classification tend toiget further
contact would be expected since Table 8 shows these referrals
running strongly toward treatment. This is because these are
costly newly-received inaates whoa a-pc has recouended for
treataent. That the parole board's referrals tend to be closed
with a single contact is due to the fact that these referrals
are chiefly for psychiatric evaluation as shown by Tabled.

There was a clearcut division aaong the referral sources
in regard to the type of further contact given to the patient
referred. Banking high in treatment were self. hospital.
classification and counselor, while ranking high in evaluation
were the parole board, custody and the warden.

Comparison of individual referral sources with those of
the 1956 period in regard to single and further contacts is
difficult because in large part Table 6 and Table 7 are too
different to coapare.

Reasons for referrals ease to carry strong iaplications
as to disposition as shown in Table 1:. Referrals for psych-
iatric evaluation tend strongly (3 to l) to be closed with
one contact. Referrals for troataent and emotional disturbance
tend (2 to 1) toward being accorded further contact. Referrals
for bizarre behavior are very likely (5 to l) to be kept open

for further contact. These correlations suggest considerable

-50

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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.. 51
knowledge of the clinic's function on the part of the referral

.m.‘ e

Referrals and Diagnoses

The psychiatric diagnostic classification used by the
clinic follows the noaenclature cf the manual prepared by the
iserieah Psychiatric Aeeoeieties.1 In this study only the

general classificatim are used.

The psychiatric diagnosis lay be aade inediately follow-
ing the interview. Sonatiaee the staff seaber say want sore
tiae to wake his decision. If he feels he needs help, he
seeks consultation and if necessary brings the case to staff
seating. than the diagnosis is arrived at. entry is wade in
the patient's folder which is kept in the record office. at
the tics of the 1956 period studied this data was not in a
sufficient state of completion to be usable, hence in this
area there can be no coapariscns with that study.

free Table 13 it can be seen that personality disorder
and psychotic disorder doainate the distribution. Only a few
of those disposed as psychotic disorders are currently in a
state of psychosis. hany of than are scattered aacng the
general population. Sosa are considered potentially dangerous.

 

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-53

but as has been clarified before in this report there is not
nearly enough roca for thee all on the ward.

Escept for personality disorder all the categories are
represented in such greater proportion than. they occupy aaong
the general prison population.

There is very little in the psychiatric diagnostic class-
ifiostion that helps to establish whether or not the refeml
was appropriate to the clinic's function. Any innate,- whatever
his psychiatric diagnosis . say at any tiac have the type of
problea for which he should be referred to the clinic. m the
other hand even asny classed under psychotic disorders say go
for long periods of ties with no special need to contact the
clinic.

Pros Table l) we can deter-sine whether along the various
referral sources there are any aarsed deviations froa the
general average in each diagnostic category. For personality
_ disorder the parole board and the hospital are high and the
warden low. For psychotic disorder the warden is high and the
hospital low. For brain disorder the counselors and self are
high. classificatim low and the parole board none. For sental
deficiency the counselors and the warden are high and the hosp-
ital none. Psycho-neurotic disorder was high for custody and
the hospital with the only other source being the counselors.

From Table it we can find the referral reasons for each

diagnostic category. were there any asrhed deviations froa

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~ 55
the general average? For personality disorder treatment and
emotional disturbance are high and bizarre behavior loll. For
psychotic disorder, bizarre behavior and non-clinic inquiry
are high. Gases of brain disorder were referred only for
psychiatric evaluation and treatment. For mental deficiency
non-clinic inquiry is high. with bizarre behavior none. For
psycho-neurotic disorder emotional disturbance was high, with

bizarre behavior none.

From Table 15 we can find the disposition for each ding-
nostic category. From Table 6 we saw that two out of five
referrals were kept open for further contact. Here there any
pronounced deviations? Personality disorder and brain disor-
der were low. Peychotic disorder and psychoaneurotic disorder
were high.

or those receiving further contact about what proportion
in each diagnostic category was placed into trestlent as
against further evaluation? Pereonality disorder comes first
with two out of three. The other categories divide about
equally between evaluation and treatment as the type of further
contact. in interesting observation is that the preportion
getting treatment is with the exception of brain disorder al-
aost exactly one-fourth of the total number in that diagnostic

0‘30“" e

is for the type of treatment peraonality disorder and
psycho-neurotic disorder run strongly toward out-patient

~56

 

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- 57
treat-at. la aeeerd with what would be expected, psychotie

diserder aad aeatal deficiency run decidedly toward ia-
petieat treatsent.

CHAPTER“

CONCLUSIONS AND BRGOMIDL‘I'IOUE

The writer was interested to find out if the "an...
of the Psychiatric Clinic of the State Prison of Southern
liehigaa night he used to better advantage. The approach
that was chosen for this particular study was that of essa-
ining the referrals. since the clinic vast work with patients
when soaebcdy else decides to and to it.

Although it turns down a few requests without seeing the
patient, for the seat part the clinic grants the referred pat-
ient an interview. In deter-icing what patients are to elaiw
the clinic's tine, the referral sources assuse a place of vit-
al iaportance to the clinic's prograa.

Ii’he basic assusption of this study was that through the
continued relationship with the clinic. the referral sources
were provided with an opportunity to beccae acre aware of the
particular needs of an innate which warranted a referral to
the clinic. The hypothesis was that the referral sources are,
in fact, analog to have a better perception of the clinic's
function, which increased understanding is being reflected in

sore appropriate referrals.

A problea that was i-ediately set was that of deciding

what was an appropriate referral. The clinic has never set up

-58

- 59
any standard by which the referrals can be measured as to
suitability. It was believed, however, that an eminaticn
of sole of the factors of the referral process eight throw
light upon the question of the referral sourcee' understanding
of the clinic's function. in iaportant-part of the study was
that of waking comparisons with a study of referrals which was
sade two years previously .to see if changes had occurred in
regard to referrals and if so to try to deteramne whether or.
not these changes indicated that the referral sources m.
waking nore apprOpriate referrals than for-erly.

The comparison with the 1956 study showed considerable
change among the referral sources inregard to. the number of
patients referred fro: each source. 0f the seven different
sources referring during the period. four greatly increased -
the number of their referrals while three had quite a consid-
arable decrease. While in acne eases the reasons for these
changes are rather apparent, in other cases the rescue are

not clear.

The sources which had increased their referrals were the
counselors. classification, the parole board and the warden.
In the case of classification cost of the referrals had been
mended by the Reception-Diagnostic Genter and in the case
of the parole board, by the board's psychiatrist. the sources
whose referrals had decreased were self, custody. and the
hospital. On the whole those sources with increases had

- 60
personal whose training better equipped thee to make proper
referrals than did those sources with decreases. It could be
inferred that this observation. supports the hypothesis, but
on this point the findings offer little help.

Turning to the sources with decreasein‘referrals, we
find in two cases soaething quite concrete m pertinent“ to '
this study. The great reduction in self referrals reflects
a policy inaugurated by the clinic to out down on the nit-her
of referrals of an unsuitable nature which were coring fro-
the inaates theaselves. here the hypothesis is supported

since self-referrals are core appropriate than formerly.

Practically all the referrals froa custody are due to
situational episodes and “any related an... infringeaent
of prison rules. is a rule the clinic prefers not to beccae 1
involved in these situations. though it will not refuse the
referral. The reduced nuaber of referrals of this nature in-
dicates that custodial officials are cosine to recognise that
the resolution of this type of a problem falls to thee. Here
we see definite support for the hypothesis.

As for the reasons which the referral sources give for
the referral there was a decided change. . Referral sources in
1958 tended such acre strongly than in 1956 to state the reason
for the referral as being either psychiatric evaluation or
treatment. But here caution should be exercised in interpreting
the findings. The trend away from I'eactionul disturbance' or

~61

‘birarre behavior' as the referral reason may be sore apparent
than real because a referral for psychiatric evaluation lay
actually stea froa soae sort of sectional upset or free strange
behavior. it any rate. referrals for sectional probleas way
in certain cases be quite in place. Hence here the findings

‘1'. 1m1t‘.1” e

Ii'here is one instance where the findings in regard to
referrals and reasons eake s definite contribution. the great
reduction in referrals for non-clinic inquiry supports the
hypothesis. *

we sight be inclined with acne Justification to feel that
one test of the appropriateness of a referral is the disposi-t
tion accorded it by the clinic. Referrals which after the
initial interview were kept open for further services could
in cost cases safely be called appropriate referrals. It
aust not be overlooked, however, that quite often one contact
is all that is necessary for the purpose of the referral. But
the fact reaains that the less appropriate referrals tend to
be closed after the one contact. The slight increase in aces
eases kept open for further evaluation lends acne support to
the hypothesis.

But this is an area where the findings need sows inter-
pretation. Along the referrals in 195‘ a greater proportion
get further contact than did the referrals in 1958. The con-

parison between the two periods , however, is thrown askew by

- 62

the fact that the in-patisnt adsissicnsin 1956 so greatly
exceeded those of 1958. Considering the cot-patient treat-
sent pregraa which the clinic had cone to eaphasise, acre
patients rare in sctnal treataent in 1950 than. in 1956.
Since patients taken.intc treatasnt usually represent appro~
priete referrals. the change here fro-.1956 supports the
hypothesis.

The psychiatric diagnostic classification.ehcved five
general categories covering the patients referred for the
period. Personality disorder followed by psychotic disorder
predoainated. The other three categories were brain disorder.
aental deficiency and.psyehc¢nenrctie disorder. the diagnos-
tic hue-inhuman here memes” that cost of these peuehte
were either pathological or borderline. But this does not
help as in.interpreting the appropriateness of the referrale,'
since the need of a patient for the services of the clinic
depends neither upon the nature nor the extent of his psyche»
pathology.

To scenarise, we can say that considerable changes were
found to have occurred in.certain.areas of the referral p39-
eeea. While froa scat of these changes fee conclusions
bearing directly upon the writer's hypothesis could be dress,
there did eserge froa the findings in.a few instances sons
facts that indicated scae support for the hypothesis.

\\

-63

is a way by which the referral process sight be isprov-
ed, the writer would suggest first, that the clinic attespt
to communicate to the referral sources what it considers to
he unquestionably inapprOpriete referrals. and, second. that
the clinic attespt to get acre inforaaticn about the behavior
of the patients which proapted the referrals.

As an area for further research the writer feels that a
study of the out-patient group treat-ens progras would
cos-end itself. '

1.

3.

k.

5.

7.

8.

REFERRALS TU PSYCHIATRIC CLINIC
October 1, 1958 - December 31, 1958

 

 

 

 

Number New Referral Rs-Referral
Referral Date Referred by
Stated Reason for Referral

 

 

Date of Initial Contact With Whom

Single Contact____ Further Contacts (within 3 nonths[____
With Whoa

(s) Types of Contacts: 3. Scheduled 0p R;______

1. Evaluation 5. Unscheduled 0p Rr____

2. In-Patient Rx____ 5. Op Group Rx

Length of Time Between Referral and First Contact

Did Psychiatric Clinic Contact Referral Source
If yes, was it:
(a) Within two weeks after Completion
of Services
(b).More than two weeks after Completion

of Services

Diagnosis

APPENDIX - 6h

BIBLIOGMPII

Articles

Coleaan, Donald R. and Zwerling, Israel, The Psychiatric
East-gens: Clinic. A Flexible way of fleeting Community
Rental Health Needs ' inerican Jamal of Pslohiatg,
Vol. 115 (by. 19595. . .

Cooper. Shirley. 'Raergensies in a Psychiatrie Clinic,' 29-
ial Caseworh. .Vol. m (Harsh, 19“). Pp. 1310—139. w

Graft, Korean, 'Rxperiences in a Prison Ros itsl.‘ Bulletin
Mar clinic, Vol. 20 (harsh, 1956 . pp. 83-"'91'.""'"

Harrison on 'hichigan Corrections Depart-cut ' iaericen
Joui'msl 8: Correction, Vol. 20 (July-Au‘us't. 17387“.
Ppe . - e '

Leopard, Harold, 'Seleotion of Patients for My Pashcthero
:33; inerioan Journal+ cf Bayohctheran. Vol. ll (July,
9 PP0 535:;37-

Lipschuts, Donald R. , 'Conhined Group and Individual Psycho-

therapy . ' Anariean Journal of Patchotherafl, Vol. ll
(Apr‘l. 1 ' pp. 0

thorkel. Lloyd w. and torn. Richard, 'Besooialisstion Within
Prison Walla,‘I Prisons in Transformation, ed. Thorsten
Sellin, The Aner can any 0 o and Social
Science (Philadelphia: 1951). PP. 08-98. ‘

 

Modernist, Austin, “A Crininolcgist Looks at Privile .'
American Journal of Pew, Vol. 115 (June. 959).
PP. 1533'15750 a

Miller, Paul 3., 'The Prim Code,‘l American Journal of Pa ..
ehiatrl, Vol. 11‘», January, 1958," "p"p'".""5!FZ$ES'.""""""1

Hagelhflillias 0., 'Custody and Treatmt - Twin lies of the

icon Sonia lvlorker,‘ll Casework Papers 19 . really
Sauce Association of 1m:- ca" "I'l'ew" ' Tori! fin), PP- 91-

Pcwelson, heresy and Bendix, Reinhard 'Psyehiatry in Prison.‘
Pszohiatg, Vol. lb (1951), pp. ‘53 6.

Reckless. Halter 0.. 'Signifiont Trends in the treat-cut of
Criae and Delinquency“ Federal Probation. Vol. XIII
(mu. 19w. pp. 6-6.

Rood, Reginald J. , 'The Hon-psychotic Offenders and the State

Hospital,‘I inerican Journal of Pslchiatgl, Vol. 115
(M.b.r. , DP. "’ e

Visher, John 8., 'Brief Psychotherapy in a Rental Health
Cliniefl Aaerican Journal of Ps szshiatn, Vol. 13 (April:
1959’s pp. ,31’3‘20

Void, George 3., “Does the Prison Betas-av Prisons in Trans-
fornaticn, ed. Thorsten Sellin The issr'fcan‘me' sy' ' of
es and Social Science (Philadelphia: 1951), pp.

“2‘50e
westover,nsrry 'Ie Prison Rehabilitation Successful?”l
new Probation on, Vol. “march, 1953), pp. 3-6.

 

Hills, warren 3., “Psychiatric Facilities in Prisons and
Correctional Institutions in the United States,“ Lhe

inericsn Journal of Psychiatry, Vol. ll“ (Decanter.
. pp. - 0

Young, Calvin J... '5. Therapeutic Conunity with an Open Door
in a Psychiatric Receiving Servioez' i.h.i. Archives of

leurolo and Pa chiat , Vol. ll at .
I939}: PP. 353*!‘5-

vi

 

Studies and Reports

Bradbury, Ruth 3.. “Intake Trends and.Intarpretation.in.a
Psychiatric Clinic,’ (Strong Meaorial Hospital, Roch-

ester, N.I.), Smith Colle e Studies in Social Work,
Vol. XXII. (JuIiT‘IQEIT7'gf'1277 I
The Connittee on Nomenclature and Statistics of the American

Psychiatric Association. Die stic and Statistical lane
. ual - Mental Disorders, Amer§can Psychiatric Iieooiation
We (Washington: 1952). PM 943.

 

Unpublished laterisl

Currie Robert I... 'in haploratory Investigation of Personal
Standards, Social Service Practices, and Current Trends
within.tha Psychiatric Clinics in.8elacted United Statee
Adult hale Prisons' (unpublished masters Research Proc-
Jeot Report. Departsent of Social work, hichigan State
“1",.1t’. 19”) e

Davis Jon Eldon. 'in hploratory Study of Referrals and
Intake Procedure within the Psychiatric Clinic at State
Prison of Southern hichigan' (unpublished Heaters Ra-
seareh Project Report. Departaent of Social Work, nich-
ignn.8tate‘university, 1955), pp. #2~#3.

Davis, Kenneth 3., ‘in Exploratory Study of Referral and In-
take Procedure within the Psychiatric Clinic at State
Prison of Southern hiohigan' (unpublished heaters Re-
search ProJect Report, Depart-mt of: Social work, Rich-
igan State University, 1957).

'11

 

JUL 26 1981*

 

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