THE NON-MENTAIH DEFECTIVE PATIENT IN

A STATE INSTITUTION FOR MENTAL DEFECTIVES

by
BYRON HOSMER

 

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THE LON-MEMTALLY DEFECTIVE PATIENT
IN A STATE INSTITUTION FOR MENTAL DEFECTIVES

A study of factors contributing to commitment and an
examination of social work activities leading to discharge.

by

Byron Hosmer

A PROJECT REPORT

Submitted to the School of Social Work
Michigan State University
in Partial Fulfillment of the
Requirements for the Degree
of

I‘lASTER OF SOCIAL WORK

June 1960

Approved: @ K m

Chairman, Research Committee

 
   

of School

 

 

ACKNOWLEDGEMENTS

I wish to gratefully acknowledge the willingness with which the
facilities of the Lapeer State Home and Training School were made
accessible for the completion of this research. The leadership of the
late Doctor A. T. Rehn, medical superintendent, in promoting the wel-
fare of the mentally defective patient made possible the ready review
of existing professional practice. He succeeded in establishing a
stimulating climate of professional advancement and deveIOpment that
has been of great personal benefit to me.

I further wish to express my appreciation to my faculty research
committee, Mrs. Lucille Barber and Mr. Arnold Gurin who contributed

to the structure of the project design and guided the formulation of

the report.

ii

TABLE OF CONTENTS

ACKNOWIaEmEI'ENTS .0O0.00.0.0.0...0..O...OOOOOOOOOOOOOOOOOOCCOO

Chapter
I. INTRODUCTIOI; .0OOOOOOOOOOOOOOOOOOOCOOOOOOOOOOOOOOOOO

II. THE LITERATURE AND CURRENT OPINION .................
III. METHODS AND PROCEDURES .............................
IV. PRESENTATION OF DATA ...............................
V. SUMMARY AND IMPLICATIONS ...........................

APPEIGDIX .OOOOOOOOOOOOOOOIOOOOOOO0.00.00.00.00.00000000COOOOOO

BIBLIOGRAPHY 0.0.0.000...COOOOOOOOOOOOOOOOCOOOOOOOOOOOOOOOOOO.

iii

CHAPTER I

INTRODUCTION

This paper concerns itself with that group of patients who have
been duly adjudicated, committed and admitted to a State Home and
Training School, but upon admission are found to be not mentally
defective. Through personal knowledge of the institution and its
workings, it is apparent to the writer that these non-defective
patients are a source of some problems and are demanding an undue
amount of professional staff time. There is the further complication
of the state statute which states, “The medical superintendent shall
discharge...a patient committed to an institution as insane, feeble-
minded or epileptic and who in the Opinion of the medical superin-
tendent is not insane, feeble-minded nor epileptic at the time of ad-
mission to the institution."1 Such discharges are not always feasible
and frequently demand considerable effort to effect at all. As a
result, time that should be spent with appropriately placed mental
defectives is being spent with inapprOpriately placed non-mental

defectives.

 

lMichigan, Act 151, W (1923) as last amended by
3.610.235. W (1945). Section 25.

l

To study this problem, it was decided to take the admissions for
one calendar year and to screen from them the patients who were ini-
tially diagnosed not mentally defective. The statistical division of
the Department of Mental Health did this screening and from the admis-
sions of 1956, thirty cases were identified as not mentally defective.
They furnished information regarding name, number, sex, admission date,
age on admission, urban or rural environment, record of community mis-
conduct and intelligence quotient. With the study group thus identified,
all additional information was obtained directly from the case records
of the Lapeer State Home and Training School, by use of appropriate
schedules.

The problem actually presents two facets: the identification of
the group of non-defectives and their similar characteristics; the
practice of the social service department in working with this group
of patients. An elaboration of the former aspect of this problem will
hopefully lead to a keener awareness that a substantial number of
patients are inadequately or inappropriately diagnosed and are thus
caused to reside in a setting that is not intended for their care and
treatment. Accepting the fact then that such patients do exist in the
present institution population and probably will continue to be ad-
mitted, it becomes necessary to learn in what manner their discharge
can be best effected. Inasmuch as all discharge planning is the
responsibility of the social service department, it is the intent of
this study to learn what methods have been most successful in effecting

the discharge of these patients.

The Lapeer State Home and Training School is "a hospital, home
and training school for the humane, scientific, educational and
economical treatment of feeble-minded persons."2 It serves a specific
geographic area of the state, consisting of the following counties:
Alcona, Alpena, Antrim, Arenac, Bay, Benzie, Charlevoix, Chehoygan,
Clare, Crawford, Emmet, Genesee, Gladwin, Grand Traverse, Gratiot,
Huron, Isabella, Iosco, Kalkaska, Leelanau, Livingston, Macomb,
Manistee, Mecosta, Midland, Missaukee, Montmorency, Oakland, Ogemaw,
Osceola, Oscoda, Otsego, Presque Isle, Roscommon, Saginaw, St. Clair,
Sanilac, Shiawassee, Tuscola, Wayne, and Hexford. Appropriate patients
for this institution are those who have been adjudicated feeble-minded
by the probate court and who are consequently committed for care and
treatment.

The Lapeer State Home and Training School is one of the largest
institutions of its kind in the world. Its patient population varies
from.about 3500 to 4000. All types of mental defectives are cared for.
There is no age limit and no lower limit on intelligence or ability.
The upper limit of intelligence is, in practice, generally based on
the results of psychological tests. Thus patients are generally'conp
sidered defective and appropriate for care if they test below seventy
on a standard scale of intelligence. The borderline defective range
of from seventy to eighty is not generally considered to describe a

mentally defective person and such a patient is not considered to be

 

2Ibid., Section 1.

appropriately placed in the Lapeer State Home and Training School.

Generally, all patients below the age of seven are assigned to
the nursery. The program consists of routine nursing care for the
youngest. As the children grow and develop, they are taught as much
self-care as possible. Such training is carried on by the attendant
personnel within the building.

Patients within the age group of five to eighteen and who possess
intellectual capacity for education or training are enrolled in a school
program. Two programs, generally comparable to type A and type B
classes in the community, serve the educable child and the trainable
child. The range of intelligence quotients is roughly from fifty to
seventy for educables and thirtysfive to fifty for trainables.

The patient in an educable program may progress to about the fifth
or sixth grade level of academic skill. In his later years of school-
ing, emphasis is placed upon practical application of his knowledge so
that he will be as well prepared as possible to take a productive place
in society.

Following school, the educable patient is placed in a work
training program. This consists of a regular job assignment on the
grounds where he works under close supervision. This is not true
vocational training. The primary focus is to develop good work habits
rather than specific Job skills. It is heped that the patient will
learn to accept responsibility for his Job and to become amenable to
supervision. ‘When patients are successful in this area of training,

they may become available for what is known as day work. This means

that they can go into the community and receive payment for a half day
or a day‘s work. The opportunity for broader contacts, wider range of
work skills and varying kinds of supervision is thus afforded them.

A recent addition to the work training program is that of full
time day work. In this program, presently limited to male patients,
the patient resides at the institution but works a full work week in
one of the community's places of business. If a patient is successful
on this program for one year, he is generally considered ready for a
work placement in which he would also reside outside of the institution.

Trainable level patients (LQ. thirty-five to fifty) will probably
become institutional workers, following their school program. They
will receive regular job assignments on the grounds and will usually
work a regular work week. While some of these patients may do occa-
sional day work, they are not generally considered to be candidates for
work placement and discharge as independent citizens. Regular‘work is
considered to give them a meaningful occupation of their time and.to
impart a sense of personal accomplishment.

A.major portion of the institution's facilities is devoted to the
care of the patient who is severely retarded. This group generally
tests below thirty-five on an intelligence test. The general focus
for this group of patients is to offer custodial care. Insofar as
possible this group is taught self-care and organized recreational
activities are provided for them.

At the time this study began, the social service department con-

sisted of three units, two on the institution grounds and one in

downtown Detroit. One of the Lapeer units was the group responsible
for all family care activities. The program of family care is one in
which patients are placed in licensed boarding homes in various rural
and small urban communities.3 The range of patients selected is quite
wide, but the majority fall below the educable level. The exception
to this is the occasional patient who is placed in a boarding home to at-
tend a public school in the community. At the beginning of this study
the family care unit consisted of a supervisor and four workers. It
must be noted that this unit makes considerable use of practical
nurses to make routine supervisional calls and transport patients for
medical check-ups, et cotera. Home finding, annual evaluations for
licensing and resolution of problems are handled by trained social
workers.

'When this study was begun, the second unit at Lapeer was re-
sponsible for all social services rendered to patients and their

families, except those whose residence had been in'thne County and

 

3For detailed information regarding this program see the
following:

E. Beryl Bishop, “Family Care--The Institution,” W
We LVII, (October, 1954” P0 308-

E. Beryl Bishop, ”Family Care: The Patients,” Amgnigan_lgnzngl_gfi
We LXI, (Jam-3179 19.57), P- 583.

E. Beryl Bishop, and Ethelbert Thomas, Jr., tFamily Care As A Source

of Comnity Education. " MW. 111.
(July. 1956). p. 239.

Etholbert Thomas. Jr.. 'Tamily Care." W
W. LI. (January. 1956). p- 615.

the southern edges of Oakland and.Macomb Counties. This unit also was
responsible for all placements outside the institution on what was
technically known as convalescent status. The two placement programs
consisted of home placement, in which a patient is placed with rela-
tives, and work placement, in which a working patient is placed outside
the institution on an employment basis. This unit was staffed by a
supervisor and three workers, and employed both graduates and under-
graduates.

The wayne, southern Oakland and southern Macomb county area was
the responsibility of the Lapeer Consultation Center, a social work
office in downtown Detroit. This unit carried essentially the same
responsibilities for their area as did the Lapeer unit for the re-
mainder of the geographical area served by the institution. They
traveled to Lapeer regularly for patient interviews and contacted
families from the Detroit area both in the office and in the families'
homes. They did not carry any family care cases. The office was
staffed by a director and four workers and, like the Lapeer unit,
utilized both graduates and undergraduates.

_ In the ensuing years covered by this study, certain administrative
changes have taken place in the structure of the social service
department. What was originally the family care unit assumed responp
sibility for the entire placement program. Thus family care, home
placement and work placement for all cases outside the greater‘wayne
County area came under the jurisdiction of the unit which came to be

known as the placement unit.

All patients on the grounds, including those from the greater
wayne County area, became the responsibility of the Lapeer unit,
which became known as the inservice unit. All social services for
resident patients and their families became the responsibility of the
unit.

The Lapeer Consultation Center changed its name and function.

It became known as the Detroit Consultation Center and began moving
in the direction of becoming a social work field office for all
Department of Mental Health hospitals and training schools. Their
relationship with Iapeer patients then became one of supervising all
placements in the greater wayne County area. Again, this excluded
family care patients.

Staff composition has changed somewhat in the years covered by
this study. There have been additional personnel in all units, and a
greater proportion of graduate workers than previously.

As stated previously. social service is responsible for all dis-
charge planning. Patients who have been successful on either home or
work placement are usually discharged by the medical superintendent
acting upon the recommendation of the social worker. The staff,
acting for the superintendent, may recommend.that a resident patient
be discharged. Such cases are then referred to the social service
department for discharge planning. When plans that are not detrimental
to the best interests of the patient and the community are'worked out,
the social.worker will recommend discharge. The actual discharge is

then made by the superintendent.

It is the purpose of this study, then, to seek out the identifying
characteristics of this grouptof inappropriately placed patients and
to determine why they came to be placed in an institution for mental
defectives. The second phase of the study is to determine which of
the original group were discharged and to endeavor to find the factors
which led to discharge in some instances but not in others. The

hypotheses that the social worker contributed to effective discharge
will be tested.

CHAPTER II

THE LITERATURE AND CURRENT OPINION

The possibility that non-mentally defective patients are committed
to and reside in institutions for the mentally defective has apparently
received little thought, if the quantity of published material is to
be considered as an indicator. However, a study was recently done and
reported upon by Garfield and Afflecku regarding the individuals in
one such state institution who were discharged as not mentally de-
fective. Their interest centered in the problem of incorrect diagnosis
and factors that contribute to such problems in diagnosis. Their
findings demonstrated an overemphasis upon the intelligence quotient
and a lack of consideration of the emotional and environmental factors
which might influence the subjects ability to score well on intel-
ligence tests. They found a high percentage of cases who had been pre-
viously institutionalized. There was also a significant number of
cases involving antisocial behavior, inadequate home situations or

emotional disturbances. They indicate that such factors prompted

 

“Sol L. Garfield and D. C.Aff1eck, "A Study of Individuals
Committed to a State Home for the Retarded'Who were Later Released as

Not Mentally Defective." WWW March.
1960, LXIV.

lO

11

community attention and commitment to the state home followed because
of a lack of more apprOpriate facility and/or inadequate diagnosis.

The area of diagnosis is a distinct problem area in the field of
mental deficiency. The diagnosis must depend largely upon the
definition and there does not seem to be unanimity of opinion here. In
1957. the American Association on Mental Deficiency published the fol-

lowing definition:

Mental retardation refers to that group of conditions
which is characterized by: (1) inadequate social adjust-
ment; (2) reduced learning capacity; (3) slow rate of
maturation; present singly or in combination, due to a
degree of intellectual functioning which is below the
average range, and is usually present from birth or early
age.

Mental retardation is a generic term incorporating
all that has been meant in the past by such terms as
mental deficiency, feeblg-mindedness, idiocy, imbecility,
and moronity, et cetera.

This definition does not relate itself specifically to etiology.
It lacks diagnostic quality and is a functional approach.

Jervis differs from this slightly when he states:

Mental deficiency is a condition of arrested or

retarded mental develOpment which occurs before

adolescence and ariseg from genetic cause or is induced

by disease or injury.
While function is certainly a condition of the above definition, the

reason for the impairment of function is here taken into consideration.

 

5Committee on Nomenclature, Wm, 14th ed. American
Association on Mental Deficiency, 1957, p. 9.

6George A. Jervis, "The Mental Deficiencies,"

W
of Psychiatry, ed. Silvano Arieti (New York, Basic Books, Inc., 1959),
volume II, p. 1289.

12

Such a differentiation would seem to exclude those persons who function
at a retarded level, but do so because of environmental deprivation,
emotional disturbance or psychosis. These would not be considered
mentally defective, then.

Noyes7 crosses the lines in considering etiological factors,
accepting causes acting prior to birth, causes acting at birth and
causes acting after birth. In this latter group he includes retard-
ation in intellectual development due to emotional factors without
organic defect.

In 1959, the American Association on Mental Deficiency published a
restatement of their definition:

Mental retardation refers to subaverage general

intellectual functioning which originates during the

developmental period and is associated with impairment

in one or more of the following: (1) maguration,

(2) learning, and (3) social adJustment.

Here again, there is no differentiation made between mental
retardation and mental deficiency. Little emphasis is placed on
etiology.

The Group for Advancement of Psychiatry recently stated their

definition as follows:

 

7mm Noyes. WW (Philadelphia.
'W. B. Saunders Co., 1953). pp. 298-317.

8Rick Haber, "A.Manual on Terminology and Classification in
Mental Retardation" (A monograph supplement to the American_£gnznal
212W Septo. 1959). LXIV. p. 3.

13

Mental retardation is a chronic condition present
from birth or early childhood and characterized by im-
paired intellectual functioning as measured by standard-
ized tests. It manifests itself in impaired adaptation
to the daily demands of the individual's own social
environment. Commonly these patients show a slow rate of
maturation, physical and/or psycholOgical, together with
impaired learning capacity.9

With regard to consideration of etiology in this definition,

they state:

It would be preferable to classify mental retardation
on the basis of etiology, but present knowledge makes this
difficult. Therefore, classification is largely dependent
on the use of symptomatology and the severity of the de-
ficiency as the major criteria. Evaluation of mental
retardation must include organic, psychological and social
factors which are closely interwoven in this as in any other
condition affecting the individual and his adaptation to the
environment.

The diagnostic process is by no means complete with
a mere determination of “mental retardation.” An
adequate diagnosis is concerned with the implications
of the specific symptomatology, an understanding of
etiology, a realistic prognosis and a comprehensive
program of care, treatment and training. Diagnostic
study and the subsequent treatment of the mentally
retarded not only requires collaboration between the
psychiatrist and pediatrician, but often calls for the
help of many other medical specialists because of the
frequent coexistence of multiple handicaps. The role of
other professions such as education, nursiBg, psychology,
and social work cannot be overemphasized.

In some publications, a marked distinction is made between mental
retardation and mental deficiency. The definitive use of these two

terms can be most meaningful. world Health Organization utilizes such
a distinction:

 

   
 
   

9.

‘. ~ 00‘ e; . on ‘c :.QA' 3: ' t '0‘- M Li...“
A Report Formulated by the Committee on Mental Retardation (New York:
Group for the Advancement of Psychiatry, 1959), p. 7.

10
mos PF- 9'10-

 
 
   
  

   
 
  
 

    
  

     
 

  

 
 

   

         
    
    

114

To standardize the terminology, the term 'mental
retardation' has been used in this report to refer
only to those whose educational and social performance
is markedly lower than would be expected from what is
known of their intellectual abilities. When terms are
needed to describe conditions in which the mental
capacities themselves are diminished as a result of
pathological causes, as opposed to environmental causes
which may lead to mental retardation, 'mental defect' and
'mental defective' are used. (Those who suffer {fem
mental defect may, of course, also be retarded.)

A similar position is taken by Masland, Sarason and Gladwin:

The diagnosis of mental deficiency clearly requires
the presence of central nervous system pathology. 'With-
in this group, however, there is tremendous variation in
degree and site of pathology, and, of great practical im-
portance, in the degree to which normal intellectual and
social develOpment are possible. For purposes of this
report we shall use the term mental deficiency or mental
defect to refer to those individuals who have demonstrable
central nervous system pathology of a kind and to a degree
which probably rules out normal social and intellectual
functioning. This, of course, involves in young children
the prediction of status at maturity, which in some cases
it is difficult to do. It should also be explicitly stated
that although the diagnosis of mental deficiency implies
irreversibility of the condition, it clearly does not rule
out that in the future we will learn how to prevent
entirely certain types of mental deficiency or bypass the
drastic effects by early detection (e.g., galactosemia,
phenylketonuria).

we feel it is important to differentiate between
mental deficiency and mental retardation. Mentally
retarded individuals...presumably do not have any central
nervous system pathology...

From the standpoint of etiology, diagnostic clarity,
prognosis, social implications, educational orientation,
and research planning, it can only be a source of cone
fusion if mentally defective and mentally re ed indi-
viduals are not differentiated from each other.

 

11'The world Health Organization, The Menta S bno 1 Child
(The world Health Organization Technical Report Series, l95u5, LXXV.

12Richard Masland, Seymour Sarason and Thomas Gladwin, Mgntal
Subnormality, (New York, Basic Books, Inc., 1958), pp. 151-153.

l5

Clarity of definition gives focus to all services for the pro-
spective client. It first defines who is to be the appropriate patient
and then dictates what type of program is to be offered the patient.
Two patients may function at the same apparent level, but one may be
mentally defective and the other mentally retarded, using these terms
as defined above. The defective person functions as he does because
of intellectual impairment and organically reduced capacity. The
retarded person may function at a lower level because of emotional
disturbance and/or environmental deprivation. To treat these two
patients alike is to ignore the factors which caused the retardation
in the second case. To allow this patient to utilize his full capacity,
there must be attention given to relief of his emotional disturbance
or improvement of his environment. Failure to make a diagnostic dis-
tinction between deficiency and retardation clouds the treatment plan
and reduces the possibility of hopeful prognosis in cases of retard-
ation.

To move away from inaccurate diagnosis and categorization of such
patients and to insure that all deviant children receive the full
benefit of available services, the Group for Advancement of Psychiatry
made the following statement:

It is our conviction that there is need to so re-

structure our psychiatric services that all therapeutic

skills beneficial to children will be made available to

the psychiatrically deviant child regardless of the

specific category into which he may have been classified.

Such a concept calls for the development of Psychiatric

Centers for Children with diversified programs including in-
patient, day hospital, and out-patient services.

The Psychiatric Center for Children's first respon-
sibility would be that of comprehensive differential
diagnosis followed by the development of a treatment plan
based on the concept that the patient is first a child and
only secondarily afflicted with an abnormality. This
approach would eliminate overemphasis on diagnostic terms
which in the past have determined administrative decisions
concerning institutionalization or other disposition. At
the present time, contacts between the family and state
institutions for the retarded are directed toward the
family's predetermined desire to "place the child."

A Psychiatric Center for Children would instead first
offer diagnosis and then the development of an appropriate
plan for constructive treatment, training and care as
individually indicated. The center should draw on other
community resources in its planning and should in turn be
an integral part of community services for children.

...aggressive antisocial children who do not present
primary symptoms of mental retardation, neurosis or
psychosis should not be admitted to a Psychiatric Center
for Children or present-day hospitals for retarded,
neurotic or psychotic children. 'Wherever these children
are cared for, there should be psychiatric services
available for consultation work and individual therapy.13

It is obvious then that distinction must be made between the de-
fective and the retarded. Cuttslu'writes on the differentiation between
pseudo-mental defectives with emotional disorders and mental defectives
with emotional disturbances. He suggests that complete clinical eval-
uation is necessary for accurate diagnosis. He would include observ-
ation of behavior, objective test results, drawing tests, projective
personality tests and case history material.

There are those in practice today who would accept in the state

 

13Group for the Advancement of Psychiatry, Basic Considerations in
Mental Retardation: A Prelimina Re rt, A Report Formulated by the
Committee on mental Retardation (New York: Group for the Advancement of
Psychiatry, 1959), pp. 16-17.

14R. C. Cutts, "Differentiation between Pseudo-Mental Defectives
with Emotional Disorders and Mental Defectives with Emotional Dis-
turbances," (American Journal on Mental Deficiency, 1957), LXI,
Pp. 761-772-

homes and training schools all patients who function as mental defectives.
This would include patients with severe emotional disturbances, autistic
children, childhood schiZOphrenics, and children from deprived environ-
ment. However, it would seem only reasonable that the treatment indi-
cated should be based on accurate diagnosis. It would not appear that
the treatment of the true defective would be identical to the treatment
of a patient who functioned at a retarded level because of one of the
above-noted reasons. If, then, the state institutions were to accept
this type of child as an appropriate patient, it would be necessary to
adept a psychiatrically oriented treatment program for their care. Such
programs do not now exist in Michigan and present staff ratios preclude
their immediate adOption.

Inappropriate patients will probably continue to be referred to

0
cf ..-
a; 4 ‘

d

(D

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zones and trainin

f)

3 schools. The professional workers in the field
are not in agreement as to what mental deficiency (or mental retardation,
or feeble-mindedness) really is. The law that created the state
institutions does not define the appropriate pOpulation nor has the
Department of Mental Health clarified the issue. The Lapeer State Home
and Training School, by their lack of written policy and their varying
recommendations, have not demonstrated clarity with regard to who their
appropriate patient is, either.

Until some clarity is forthcoming in the field itself, agencies
outside the field must be expected to continue to occasionally refer

an inappropriate patient.

CHAPTER III

EETHCDS AND PROCEDURES amass

When the general area of this study was defined, it was decided to
take one group of nonadefective patients and follow their progress over
a period of time. t was felt that such a study would give a more dy-
namic view of the problem than to perhaps take the entire non-defective
population and study them in any given moment of time. The question
then was to find suitable criteria for choosing the population to study.
It was felt that the group should not be taken from admissions of many
years previous, because of the recent improvements in diagnostic and
classification skills. Also, services available to patients should
approximate what is presently existent.

On the other hand, it would be equally undesirable to pick a group
of so recent admission that there would be no time elapsed in which to
discern movement. It was then tentatively decided to see if the
admissions for one calendar year would provide a sufficient number for
study. The year chosen was 1956.

In April, 1958, assistance was obtained from the Statistical
Division of the Department of Mental Health. From the resident pOpula~
tion of the institution at the end of the year, all patients diagnosed
not mentally defective were screened by means of an IBM machine. To

18

this list was added all patients discharged during the year who were
diagnosed not mentally defective. It was necessary also to screen all
patients on placement in 1956 who shared this diagnosis. These lists
were then compiled and the following information printed by the machine:
number, name, sex, environment, history of community misconduct, date of
admission, intelligence quotient, and diagnosis. This list was then re-
viewed and those patients who were shown as being admitted during the
calendar year 1956 were chosen for the study. This was a group of
thirty.

All additional information was then obtained directly from the
patients' case records at the institution. A schedule was prepared to
classify pertinent information regarding each patient.15 The purpose
was to gain as much identifying information about each patient as
possible.

It was felt that this group of patients would present many common
identifying characteristics and would have had many similar life
eXperiences. It might have been predicted that the group would be pri-
marily composed of adolescent and young adult males who came from an
urban environment. It was anticipated that they would have been known
to various social agencies, probably have had contact with a juvenile
court and may have been in residence in other institutional settings.
Prediction would be that intelligence testing prior to admission to

Lapeer would range from sixty to eighty or from the defective range

 

l539e Appendix A.

through the borderline defective range and that not all patients would
have received such tests. It was expected that all psychological tests
at Lapeer would range from seventy through one hundred or from the
borderline defective range through the normal range.16 It could also

be anticipated that a victim of cerebral palsy might be identified in
this group of non-defectives because there is no appropriate state
residential facility expressly for the care of this type of patient and
they are not infrequently given residence at Lapeer. In summary, it

was expected that the group of non-defective patients would be identified
as those who had not made an adequate social adjustment and on the basis
of this and an inability to score well on an intelligence test, had been
committed as mentally'defective.

This identifying material was readily available from the case
record and was consistent from case to case. Some of the information
was contained on the face sheet. However, it was also necessary to
review the psychological test results, the social history and the copy
of the court commitment papers. The running progress notes were also
read and yielded information regarding staff recommendations, insti-
tutional program and adjustment, and date and type of discharge.
Material from Schedule A, then, gave identifying information, pre-
institutional maladjustment, institutional adjustment and time of

discharge.

 

(
1)Nomenclature in common use at Lapeer for the ranges of intel-

ligence in question are "defective, borderline defective, dull normal,
and normal.”

21

Another schedule was then prepared to classify data regarding
social service activity with each patient.17 This material was taken
solely from the running progress notes. The only'exception to this was
a check of the correSpondence which revealed some social service
activity which was pertinent to the study.

The patients' records at the Lapeer State Home and Training School
are not kept for research purposes. They are kept only for care and
treatment purposes and as such are lacking in some of the details that
might be useful. The social history in most instances does not give
extensive psycho-social history and frequently bears greater resemblance
to a medical history. These histories are not compiled from a series of
interviews with patient and/or family, but primary information is gained
from a multiopage personal and family history form that the family is
asked to complete. Additional information is obtained by sending letters
of inquiry to doctors, hospitals, schools, and social agencies who have
known the case. The primary purpose of the history material is to
assist in diagnosis, classification, and planning.

The psychological testing program is intended to assist in
diagnosis and in program planning for the patient.

The running progress notes are written by doctors and social
workers, primarily; occasionally, notes from attendant personnel and
nursing staff are included. The doctors include all hospitalizations
in these notes, with diagnosis, treatment and response. Nursing and

attendant personnel would enter notes usually only in cases of serious

 

17See Appendix B.

misbehavior in the building or on the grounds. limitations of social
service staff time and demands of large case loads preclude extensive
recording by the caseworkers. It is generally acknowledged that only
vital material is dictated; that is, such material that must be known
to continue any given process with a patient. Also, recording would
seem to vary somewhat between the three social service units. It
appears to be the general impression that the placement unit and the
Detroit Consultation Center do more regular recording than does the in-
service unit.

This area of recording presents an unavoidable weakness in the
reliability of any study involving the social service department.
Through the writer's personal knowledge of the function of this depart-
ment, it is apparent that only a portion of the number of interviews
actually held are ever noted in the patients' folders. However, there
is at present no better way to determine the activity of the social
service department in the cases of this study than through the dictation

found in the patients' folders.

CHAPTER IV

PRESENTATION AND ANALYSIS OF DATA

 

To begin the evaluation of the material gathered, the general
identifying information will be examined. Material from Schedule A
will be considered to determine the common characteristics of the study
group and to see if the results are as predicted in Chapter III.

The general ratio of male-female patients within the institution
is approximately one to one. However, the impression gained from the
staff by the writer was that the non-mentally defective group would be
predominantly male. This impression was borne out by the study, as the
group consists of twenty-three males and seven females. The signifi-
cance of this fact is not immediately clear but may be accounted for
by the hypotheses that the male in community difficulty is more apt to
be handled authoritatively than is the female.

The admission ages of this group show a much narrower range than
is common in the institutional general population. Admissions may
occur as early as one month or six weeks of age and a large number of
children under school age are admitted. The range extends upward with
no theoretical or actual limit. However, this group of patients '
admission ages falls within a rather circumscribed range. This is shown

23

2a

in Table l. The actual range is from nine through twentybfive, the
mean being approximately sixteen years, six months. Two-thirds of
this group fall within the age range served by junior high and high
schools. Here, then, is a group of adolescents who have a full-time
community program established for them, but who apparently are unable
to use it. It might also be concluded that this group was not identi-
fiable as mentally retarded at an early age and even may have enjoyed
some degree of success in the early school years. The six patients
who were twenty and above are above the age anticipated for this group
of patients, but even with their inclusion, the age range for the

patients of this study is strikingly narrow.

Table 1
Age of Noanentally Defective Patients Upon Admission

Number of
___Aaa_ Bailouts.

Total ................... 30

5, under 10 ...................
10, under 15 ...................
15, under 20 ...................

20, under 25 eeeeeeeeeeeeeeeeeee

r4 tn 5: ~o ya

25’ under 30 eeeeeeeeeeeeeeeeeee

The study groups' environmental distribution of eighty percent
ubran and twenty percent rural is not dissimilar to the average popu-

lation distribution and so is not a significant factor. Distribution

25

by county of commitment follows approximately the same distribution as
the general pOpulation with nearly half coming from wayne County, and
the remainder coming in diminishing numbers from the more northerly
counties.

It was anticipated that patients of this group were probably
known to social agencies prior to commitment to Lapeer. This was pre-
dictable on the basis of the fact that they were probably not first
recognized as being mentally defective but rather came to the attention
of agencies because of inadequate social adjustment. It would be
expected that social agencies offering protective services, or
psychiatrically oriented diagnostic services would have been utilized.
Also, antisocial behavior would precipitate contact with the juvenile
court. These predictions were borne out in the study. Thirteen, or
slightly less than half the cases, show a history of contact with social
agencies. Nine of these had a history of public misconduct, ranging
from truancy and juvenile delinquency through the commissions of mis-
demeanors and felonies. Of this group of nine, seven were males. All
fell within the age range of fourteen through seventeen.

In an effort, no doubt, to ascertain the cause of the lack of
adequate social adjustment, seven patients had been examined in various
psychiatric facilities, such as Neuro-Peychiatric Institute and Child
Guidance Clinics. One patient had been examined in three such
facilities.

Inadequate enyironment is indicated in three cases, for the pro-

tective services offered by children's agencies were utilized.

26

As anticipated, two cerebral palsied children were identified in
the group and they had been known to the Detroit OrthOpedic Clinic.
Their presence in Lapeer, even though they are not mentally defective,
is generally accepted because of the lack of another specialized
facility for their residential care.

It was felt that many of the non-defective patients received at
Lapeer had been in residence in some other institutional setting prior
to admission. This is borne out by the fact that two-thirds of the
group in this study had histories of previous institutionalization.
This includes four patients who were in boarding or foster home care.

The type of institution previously used gives strong indication
of the problem that precipitated removal from the community. Public
misconduct heads the list with six of the group having been in Boys'
Vbcational School just prior to commitment. Four of these boys, plus
six others from the study group, had a record of being in a Juvenile
Detention Home. The basic problem and the one most long standing in
these cases would seem to be one of inadequate social adjustment.

Three facilities more nearly akin to Lapeer were utilized:
Traverse City State Hospital, Caro State Hospital for Epileptics and
Whyne County Training School. These institutions are designed to
handle specific diagnostic entities and transfers of inappropriate
patients to other mental health facilities is not uncommon. However,
such transfers may not always be based on an accurate admission
diagnosis, but may be precipitated after some length of time. The

factors precipitating transfer may not be dissimilar to the communities

N
\7

reasons for original commitment. That is, that the person in question
does not fit into the existing programs, has received maximum benefit
of the program, or has become troublesome and antisocial. Transfers
and commitments upon such basis are not determined by diagnosis and
prognosis, but by desire for removal of such a person. If diagnosis,
prognosis and genuine desire to work for the best interests of the
patient were motivating forces, it would be reasonable to assume that
commitments and transfers would be made immediately upon diagnosis and
that the receiving facility would be appropriate. In one case, a
patient had been in Traverse City State Hospital for one year seven
months before he was re-adjudicated and committed to Lapeer. Another
was in Caro State Hospital for Epileptics for seven years eight months
before coming to Lapeer. This patient's seizures had long since been
controlled, tot he was a distinct behavior problem. Two patients

came to Lapeer from wayne County Training School. One had been in
residence for seven years and one for sixteen years six months. The
Training School felt both of these patients to be too severely handi-
capped to gain further from their program. However, all of these
patients were inappropriately placed at Lapeer, as they each were
diagnosed not mentally defective. It would seem, then, that not only
are some commitments from the community based on inadequate diagnosis
and secondary motivations, but the same is true of some of the
exchanges of patients with existing mental health facilities. It has
become the general impression at Lapeer that the community and its
agencies feel that if an appropriate facility does not exist, the

patient or citizen should be accepted at Lapeer, regardless of whether

28

or not he is diagnosably mentally defective.

Indications are that four patients came from inadequate home
situations in that they had been placed in boarding homes. This be—
speaks physical deprivation at an early age and concommitant with this
is the possibility of emotional neglect. Either of these factors may
lead to arrested maturation and lack of full deve10pment of intellectual
potential. One patient was placed in boarding care following three
months evaluation and treatment in Mauro-Psychiatric Institute for such
emotional disturbance and lack of development. Another patient had
been in boarding care for a five-year period, and this represents the
longest foster care for any of this group.

One other patient came to Lapeer after apparently exhausting the
program of another state facility. This patient attended Michigan
School for the Deaf over a four years five months period and was
committed when they felt he could no longer benefit from their program
because of his mental deficiency.

As noted in Chapter I, all patients coming to Iapeer are committed
by the probate court in the county of residence. Such proceedings are
begun by the filing of a petition. The petitioner may be a relative,
guardian, peace officer, or any other interested person whom the judge
of probate might deem suitable.18 In some instances, it is apparent
that the petitioner acted upon the suggestion or recommendation of

another. It was attempted to identify this second party also,

 

lamchigan. mun. man: (1923) as last amended by M.
W (1945). Section 11.

29

whenever possible.

It might be assumed that in instances where the petitioner is
not a relative, the subject to be committed has gotten beyond the
jurisdiction of his family. This could indicate that the family has
abdicated its rights through neglect, as might be expected in the cases
where the patient has been placed in boarding care. It could also
indicate that the subject of the petition has come under the jurisdiction
of a community authority through antisocial acts of his own.

In tabulating the petitioners for this group, it appears that one-
half of the group were committed on petitions filed by someone other
than the family. It might be noted, too, that of the family
petitioners, one acted on the recommendation of a child guidance clinic
and one under pressure from the court. Thirteen admissions were at the
instigation of police officers, social workers, or superintendents of
other residential facilities. The remaining two cases are those whose
record was not available. This is a substantial number, then, that
apparently were no longer under the jurisdiction of their family, but
had, through their behavior, come to the attention of community
authorities.

The psychological test results for this group of patients are of
great importance. Results of intelligence testing probably represent
the most objectives and most frequently used means of determining mental
defectiveness. Thus, anyone who fails to make an adequate social,
educational or economic adjustment, may be tested at some point to

determine if mental deficiency is the cause of his lack of adjustment.

30

If the subject is unable to score well on such a test, it is usually
concluded that he is mentally defective and in need of institution-
alization. On the basis of this, it might be predicted that the
individuals in this study group had psychological evaluations prior to
commitment and that they had scored within the defective range.

The patients' records were reviewed to determine what tests had
been conducted prior to admission and within what range the patients
scored. 0f the twenty-eight records available, there is no indication
of precommitment testing having been done in eight cases. In the
remaining twenty cases, intelligence quotients ranged from fiftyaeight
to eighty-eight. The mean was sixtyseight. Nine of the patients
tested above the defective range: eight within the borderline defective
range and one in the dull normal range. It appears, then, that in
eight cases no objective measurement was used to determine if the
commitment to Lapeer was apprOpriate. In those cases where tests were
used, the indications were that in nine cases commitment to Lapeer was
contraindicated because the patient tested above the appropriate range.
The reasoning behind the commitment of this latter group is difficult
to determine with certainty. It may be that community agencies and the
community at large do not know what type of patients Iapeer is equipped,
by law and by program, to serve. It may also be that these patients
needed to be removed from Open society, needed some type of institu-
tionalization and no more appropriate facility could be found.

Results of intelligence testing at Lapeer are very significant
factors in classification and planning. Inasmuch as this entire group

was originally classified as not mentally defective, it was predicted

31

that the entire group would test above the defective range. This was
borne out by the study. The actual range of intelligence quotients
attained at Lapeer was from seventy through ninety-four. Twelve patients
tested in the borderline defective range, thirteen within the dull
normal range and the remaining five within the normal range. The mean
test score was slightly over eighty-five.

Table 2 presents pre-commitment test results and the results of
tests at Lapeer soon after admission.

TABLE 2

INTELLIGENCE TESTS OF NON-MENTALLX DEFECTIVE PATIENTS

Eaticni W—C Mnem—
East LA. 1.9 Test .91.. L9
1 we: 16-2 63 33.1. 16—7 87
2 we: 15-: 66 we: 15.10 79
3 SB—L 9-0 69
we: 18-1 70 SB—L 23-9 78
L: 313.1. 10-2 66 wan 23-1 78
5 SB u-8 6n SB—L 2 5-2 81
SB 5-3 75
55 8-5 7n
we: 15.10 6n WB.II 19-7 85
7 we: 1L6 7o SB-L :u-1o 81
8 7 5-4 76 SB-L 12-11 88
9 * ? ? ? ? 7 79
10 513.1. L11 7: SB—L 11+-o 93

*Record not available--Patient transferred to other institution.

Key: ‘WB—I--;Wechsler-Bellvue, form I.
WB-II-o;wechsler-Bellvue, form II.
SB—--Stanford-Binet.
SB—L—--Stanford-Binet, form L.
WAIS---Wechsler Adult Intelligence Scale.
WISC—--wechsler Intelligence Scale for Children.
CAP--Chronological Age.
IQ---Intelligence Quotient.

mm

13
14

15

l7

l8
19
20
21
22

30

-C ' t

1251 ._Q‘A_
NONE

WISC 15-1
NB- 1 15—0
SB—L ll-ll
NONE

Chicago 8-6
Non-Verbal
NONE

'1’ ?

WE— I 16-5
NONE

NONE

SB—L 12-8
SB-L 12-?
NONE

? '3

WISC ll-lO
SB—L 12-0
NONE

NONE

WB—l 13-8
WISC ?

32

t
1.9

65

70

71

72

‘70
88

65
58

Test _§_A_ LQ
313.1 11+~1 73
WISC 15—2 67
WAIS 16-1 78
W-B—I 15-8 82
WAIS 17-3 83
set 15— 5 87
wax: 16-4 70
WAIS 18-10 78
SB—L 15—8 93
w:sc 13-1 P 82
SB—L 23-8 80
WAIS 2 5.9 81
1413.: 16-4 94
WB-II 16-8 77
WB-II 16—11 88
38-1. 9-3 70
we: 15.10 80"
w:sc 15.11 61*"
WISC 13-8 77
SB—L 23-8 9n
? a 8 5
mac 12-9 7h
1413.1 22-2 72
WISC 15—5 93
WISC 13-11 83
m1 17-0 75

 

*Record not available--Patient transferred to other institution.

**Estimated
* “‘Invalid

This group's psychological tests represent five standard tests
of intelligence: Stanford-Binet, wechsler-Bellvue, forms one and two,
wechsler Intelligence Scale for Children and the Wechsler Adult In-
telligence Scale. It is also noted that one deaf patient was tested
prior to commitment on the Chicago Non-Verbal test. A careful analysis
of the type of test given does not show it to be a significant factor
in determining variations from one test to another. Of the seventeen
cases where the type of test given before commitment is known, eight
were some form of the Stanford-Binet and nine were some form of the
‘Wechsler. Following admission, nine of these seventeen were tested on
the same general type of test as was given prior to commitment. Five
who had received some form of the Stanford-Binet before commitment,
were evaluated at Lapeer on some form of the wechsler. Three who had
been tested on wechsler scales received Stanford-Binets following ad-
mission. It does not appear, then, that variations between types of
tests could account for the consistent upward variation in test results.
Actually, in practice an intelligence quotient is probably usually
accepted at face value, whether it comes from a Stanford-Binet or from
a wechsler test and regardless of what the correlation between these
two tests might be.

Regardless of the types of tests administered, there is an
appreciable increase in intelligence quotient scores from the pre-
commitment tests to the tests done at Lapeer. The twenty patients
who were tested prior to admission gained from four to twenty-four

intelligence quotient points when tested at Lapeer. The mean gain was

k.)

lh.95 points. Several theories might be advanced as to the reason for
this increase, but no 3 ingle theory would seem to apply to all the cases.

Guertin's19 hypothesis of slow mental maturation would seemingly

xplain sor e of the cases, but in others, the pre-ccmmitment test and

the new admission test were given very close together. The mean time
lapse in months between the two tests was slightly over seventy months.
However, eight of the cases were retested in less than one year and
five of these in less than six months. The increase in these eight
cases, then, could probably not be attributed to late mental maturation.
However, five cases showed a time lapse of one to five years, two cases
of more than five but less than ten, and two others of more than ten
but less than fifteen. One patient showed a lapse of twenty years,
six months between tests. In these ten cases, slow mental m'turation
night account for incr ase in intelligence quotient.

Grace Arthur Spoke to this point when she stated:

...some adolescents pror.our ced incorrigible before their

arrival at (the State school), responded prcnmtlr and

continuously to healthy living conditions, courteous

treatment, efficient teaching and a good recreational

program. For the first time in their lives they found

themselves likin’ sczo<- 41 cooperating in a constructive

‘program. ‘Nith thter. Nor in bits, imprO'ei physical.con—

ditions ani lnCLM'a ed rate of learnir 5, some of the Pinet

s began to increase and continuei until they

cached a level cf ...(dull normal)... These individuals
are not regs: ded as "cured," but as having made an

as stment that permitted a mo e ne az'ly'accurate measure-
eat cf their mental capacity.

1\

 

19W. H. Cue ertin, "Differential Characteristics of the Pseudo-
feeble-minded,” Amezjgau JQHIDEJ gfi r'gnia] Qgrjgiangn, 195011V5 13p, 39h-398

“U race Arthur, "Some Factors Contributing to Errors in the Diagnosis
of r eble—niniedncss," American Journal of liental Def'ciency, LIV, 1950,

501:
pp. ;5- 01.

b)
\ 11

However, it is somewhat questionable if this theory applies to the in-
creased test results in these cases. In general, new admissions are
tested within the first month of residency at the institution. It is
doubtful if any marked degree of improved life adjustment is attained
this soon. The effect of the more or less benign environment is
probably operatiwc, but it is difficult to prove to what degree, if,
indeed, it is at all.

One factor which might be significantly Operative in improved
tsst results is that of the increased ability of the psychological
examiners at Lapeer to obtain the Optinum results from a subject who
finctions at an apparently lower level than do most patients tested
in community facilities. Their experience with retarded persons might
contribute to a more easily established rapport with these patients

and therefore enable them to get a more accurate appraisal of their

true potential.

 

Usually within the first month following admission, cases are
presented at a staff meeting for diagnosis, classification and planning.
The social history, medical nistory and results of physical and
psychological examinations done at Lapeer are used in these staff
meetings. At such a staff meeting, the thirty cases of this study
were all diagnosed not mentally defective. It is the intended purpose
of the remainder of this paper to determine what happened to this study
group following the above-mentioned diagnosis.

To accomplish this, case records were studied to determine

\J
L\

activities up to December 31, 1959. This allowed a minimum of three
years movement for each case and it was felt that in this length of
time, appreciable n vement could be seen. Particular focus is upon the
fact that some of the group have been discharged, while a substantial
number have not. It is intended that some of the determining factors
that lead to discharge will be identified. Also, the role of the social
worker in relation to this group of not mentally defective patients

will be examined.

For purposes of this study, it is assum d that any patient at
Lapeer who is diagnosed not mentally defective is, therefore, an
inappropriate patient for that facility. This is, of course, in accord
with the law, but should also be accepted from a clinical and ad-
ministrative standpoint. On this premise, then, a value is placed
upon a plan that will lead to the discharge of such a patient. It has
been the practice of the staff at Lapeer to endeavor to accomplish all
discharges in a manner that will not be detrimental to the patient,
his family or the community. Planning for such a discharge becomes
the responsibility of the social service department almost exclusively.
The role of the social worker, then, is very important in relation to
this group of patients.

A review of these patients' records as of December 31, 1959,
immediately divided the group into two distinct classes: those who
were still patients at the institution and those who had been dis-
charged. These two groupings will be examined separately and compared

.
vvw

with each other to endeavor to identify the factors that brought

successful discharge.

’7'?
/4

Of the thirty cases, eleven were still patients. Nineteen had been
discharged. Two of the nineteen had been transferred to other institu-
tions: one to Pontiac State Hospital as a psychotic and one to Fort
Custer State Home, another state institution for mental defectives.
This means that after over three years had elapsed, more than one-third
of the group was still in residence at Lapeer. It might be noted that
one of the patients discharged did not go to the community or to an
appropriate setting, but simply to another state home for defectives.

In identifying factors which would lead to discharge, the first
to be considered would be the recommendation of classification staff.
It might be assumed that with a diagnosis of not mentally defective
there would be a recommendation of discharge. However, the study
indicates that in only twelve cases was such a recommendation forth-
coming and in the remaining sixteen cases, some type of program for care
or training at Lapeer was planned. It might then be predicted that
where staff recommended discharge, such a plan was followed. This was
not always the case. Three cases of the twelve are still in residence.
Where a residential program was originally'recommended, half of the
group of sixteen have been discharged.

In subsequent staff meetings in the ensuing three years, ive more
cases were recommended for discharge an were released. Also, three
patients still in residence had the original recommendation of dis-
charge repeated, but release was not effected. In summary, it would
appear that staff recommendations of discharge are not essential to

discharge and cannot always be followed through when they are made.

38

There seems to be little relationship between staff recommendation and
predictability of successful discharge.

It was felt that institutional adjustment might have some bearing
on whether or not a patient would be discharged. However, it could
hardly be predicted whether good adjustment would lead to discharge or
maladjustment would bring more staff attention and ultimately discharge.
When the resident and discharged groups' records were examined for
notations of misbehavior and lack of general adjustment, four of the
eleven residents showed such aberrations as did seven of the seventeen
discharged patients. Such misbehavior consisted of escapes and
attempted escapes and so-called "disturbed episodes." It would not
seem, therefore, that institutional adjustment is a significant factor
Operating either for or against discharge.

Pre-commitment record of adjustment was examined to see if there
was a correlation between contact with agencies, other institutions, a
record of public misconduct and successful discharge planning. It was
felt that if a patient had been known to agencies, had resided in other
institutions and had a record of misconduct, it might be more difficult
to return him to the community than to discharge a patient who did not
have such a record. Examination of the data reveals that fortyhseven
percent of the discharged patients and fifty-five percent of the
resident patients had been known to other agencies. Regarding previous
institutionalizations, seventy-six percent of the discharged patients
had been in some residential facility as compared to sixtybfour percent

for the resident group. These figures indicate that a history of

39

previous agency contact or institutionalization does not mean that it
will be more difficult to return the patient to the community. This is
reinforced by the fact that of the discharged patients, forty-seven
percent had a history of public misconduct, while in the group of
resident patients, only nine percent of the group had such a history.
The area of pre-commitment adjustment, then, does not offer a signifi-
cant degree of predictability as to what kind of patient is discharged.

It seemed that it might be predicted that if the family had
jurisdiction of their child and were interested enough to commit him to
Lapeer, this interest would also permit them to take the patient back
home if such a plan were in the best interests of the patient. Perhaps,
then, a patient would have a better chance of discharge if his family
had petitioned for commitment. This theory is not supported by the
study, however, for seven such cases were found in the resident pOpu-
lation and eight such in the discharged group.

Admission ages were checked in the two groups and only a slight
variation was found. The mean age of admission of the resident group
was approximately fifteen and eight-tenths years, and the range was
from nine years to twenty-four years. This compares to an admission
age of about seventeen and two—tenths years and a range of from eleven
years to twentyhfive years for the discharged group. It is not felt
that this slight increase in range and mean age could be a significant
factor in detenmining successful discharge.

There is also a slightly higher mean intelligence quotient for the

discharged group. They ranged from seventy=three to ninety-four and

#0

had a mean of eighty-two and six-tenths. The resident group ranged from
seventy to ninety-three and had a mean score of seventy-nine and three-
tenths. The difference of three and three-tenths intelligence quotient
points can hardly be considered to be a significant determinant of
discharge.

It was decided to examine the group of discharged patients by them-
selves and to identify the significant factors surrounding their dis-
charge. There was a wide variation in the length of time in residence
for the group. The range was from twentyatwo days to 1,156 days. The
mean was #60 days. This represents a considerable eXpenditure of time
and money and would seem to be an unjustifiably long time in which to
effect a discharge. This is especially true when considered in the
light of an admission diagnosis that indicated the patient was in-
appropriately placed from the beginning.

With the exception of the two who were transferred to other
Department of Mental Health facilities, all the discharged patients
were rated, at the time of discharge, according to their capabilities
as follows: not capable of self-support; capable of partial self-
support; capable of self-support. This represents an estimation of
immediate potential capabilities rather than appraisal of an existing
employment situation. of the seventeen, one was capable of only
partial self-support, four were not capable of self-support at all,
while the remaining twelve were discharged as being capable of self-
support. This does not mean, however, that they were discharged to be

entirely independent. Actually, only two of the group were discharged

41

under such conditions. One patient escaped not long after admission

and staff discharged him as capable of self-support. The other case

was one in which community employment had been found for the patient and
after demonstrating his success on the job, he, too, was discharged as
being capable of self-support.

The remaining fifteen discharged patients went with some member of
their family at the time of discharge. From this fact, it might be
concluded that an interested family, willing to assume responsibility
for a patient, is a significant factor in effecting discharge, even
though the patient is not mentally defective and probably capable of
self-support. In seven of these discharges, the family was assuming
responsibility at the time of release when they had not been responsible
at the time of admission, in that they were not the petitioners for
commitment.

To begin to determine the role of the social worker in effecting
discharge, the program from which the patient was discharged was noted.
0f the nineteen discharged, two went to other state facilities, and one
‘was discharged from escape, as previously noted. Nine patients were
discharged directly from institutional residence. The remaining seven
were discharged while in a program for which the social service depart-
ment is responsible. Four of these were on a placement program in the
community: three in home placement with relatives and one in work
placement. Three patients were discharged while on visit with relatives.
In less than half of the discharges, then, were the patients involved

in a distinctly social service supervised program.

It was then decided to review all the available case records of
this study group to determine the amount of contact each patient had
with a social worker. Particular attention was given to the number of
interviews held, both with the patient and with others regarding the
patient, and to the frequency of these interviews. In some instances,
correSpondence of an especially significant nature was counted as an
interview. An example of this would be a letter to a family or the
court of commitment in which assistance with plans for discharge of a
patient was requested.

To aid in the determination of factors leading to discharge, it
was decided to consider the study group in three parts: the group who
were discharged; the group in actual residence within the institution;
and the two who were involved in one of the placement programs. Of
those discharged, on ' seventeen of the nineteen cases could be used,
because of the absence of the folders of the two who were transferred
to other facilities. The two patients on placement included one on
family care and one on home placement.

In tabulating the interviews, it was assumed that each patient was
interviewed on the day of admission. While this interview is not
recorded in any of the records, the assumption is in harmony with the
admission policy of the social service department. It was not assumed
that any other interviews were held and only those recorded in the
patient's record were counted.

It might be predicted that the discharged patients were seen by

their social worker more times and with greater frequency than were the

243

patients who have not been discharged. The study indicates that the
resident patient's mean number of interviews was four. They ranged from
one to seven interviews. Of the two patients on a placement program,
one had twelve interviews and the other had twentyetwo interviews, for

a mean of seventeen. The patients who were discharged showed a range

of interviews from two to twenty-seven. The mean number of interviews
was slightly over nine.

The increased number of interviews for the two patients on a place-
ment program needs some consideration to place them in the proper
perspective with relation to either of the other two groups. One patieni
is one of the two cerebral palsied patients found in the study. Within
five months of the time of his admission, he was returned to the care
of his family on home placement. However, it is assumed that when the
family can no longer care for him he will need to be returned to the
institution, as there is no other appropriate state residential
facility for his care. The other placement patient is on family care
and attending public school. In similar cases in the past, such patients
have been maintained on family'care until the completion of high school,
at which time they can be discharged as capable of self£support. This
patient went on family care within one month of the time of admission.
These two cases,then,represent situations where considerable social
service activity is entailed, but in which the focus of the activity
is not on discharge planning. It then becomes difficult to compare the
activities devoted to these patients with either of the other two groups

without skewing the conclusions and clouding the facts.

an

The significant fact of the number of social service interviews is
that the discharged group show more thar twice as many contacts as do
the resident group.

It was felt that the frequency of contacts with the social worker
might be significantly different between the resident group and the dis-
charged group. The two patients on placement showed a mean time lapse
between interviews of two and five-tenths months. The resident patients,
on the mean, had one interview every five and seven-tenths months. The
discharged patients had a mean time lapse of one and eight—tenths months.
The mean time lapse between interviews,then, was over three times as
great for the resident patients as for the discharged group.

The activity of the social worker seems to be a highly significant
factor in the discharge of these not mentally defective patients.
However, it is not clear as to why these patients were chosen 1y the
social worker for this increased activity. Direct staff referrals for
discharge planning does not account for all of these, but for some of
them. However, of the resident patients who have been referred by
staff for discharge, there is an increase of only one additional inter-
view over the mean number for the remainder of the resident group and
the frequency of interviews is slightly lower. It does not appear that
siaff referral is the answer as to the increased social service activity.

With case loads varying from 350 to over 1200, it is conceivable
that chance plays a role in determining what patients are seen more

frequently by social workers.

T‘-

Fron the data available in this study, it is not possible to
iderxtify the factors that cause increased social work activity, but it
can only he stated that the discharged patients show a significant in-
crease in number and frequency of contacts with the social worker.

To get some indication as to the specific function of the social
worker, each recorded interview was identified in one of the six
categories suggested by Berknan.21 These categories were: (1) inter-
pietations of te patients illness, treatment, and surrounding problems,
(2) assistance with proolems of farnily xelationsi ips, (3) supportive
treatment, (h) psychotherap', (5) help with concrete problems,

(6) interpretation to and liaison with other agencies. It was anti-
cipated that the majority of the interviews would fit within the first
two classifications, a limited number within the category of supportive
treatment and none within the category of psychotherapy.

The validity of the evaluation of the interviews for such classi-
fication purposes is questionable,as it was done by the writer with no
comparison again net the classification of the sa me interviews by a group
of social workers. ProbabLy for this reason, a large percentage of the
interviews are seen as not falling into any one class but into combinations
of from two to three categories.

As classified, the results indicate that the largest percentage of

interviews crossed the lines of any distinct classification and contained

 

21Tessie D. Berkman, ”Practice of Social'workers in Psychiatric

hospitals and Clinics," WW
Mars. New York. 1953.

elements of up to three different types. This group represented about
thirty-five percent of the total.

The next largest category consisted of thirty-one percent of the
total and was identified as being interpretation of illness, treatment
and surrounding problems.

Help with concrete problems and interpretation to and liaison with
other agencies were nearly equal categories, the percentages being
eleven and ten, respectively.

As expected, no series of interviews that could be identified as
psychotherapy was noted. Only ten percent of the interviews came under
the heading of supportive treatment.

Help with problems of family relationships accounted for the
remaining three percent.

Perhaps the most significant thing presented by this classification
is that only ten percent of the interviews were devoted to supportive

treatment and no practice of psychotherapy is noted at all.

CHAPTER V

SUI'II CARY AND B-TLICATIOI‘SS

Through the writer's personal knowledge of the Lapeer State Home
and Training School, it was apparent that a number of patients who were
not mentally defective were being admitted each year. While there were
general impressions among staff members as to who these patients were
and how they had come to be committed, no effort had been made to gather
objective data regarding this group and their management. Because of
the acute shortage of Space for the care of appropriate patients, it
seemed to the writer that a study of the inappropriate patient was in
order. If means could be found to discharge the patients who were not
mentally defective and to prevent commitment of this type of patient in
the future, the institution could utilize its Space and staff for the
originally intended purpose.

The study proposal was to take all patients who were admitted
during one calendar year that were diagnosed not mentally defective
and ascertain their identifying characteristics and determine what
happened to them following their admission. Thirty such cases, admitted
during 1956, comprised the study group.

All information was gathered from the Statistical Division of the

Department of mental Health and from the case records at the Lapeer

u?

h8

State Home and Training School.

The group consisted of twenty-three males and seven females who
ranged in age from nine through twenty-five. The age range was signi-
ficantly narrow and the majority of the cases were adolescents at the
time of their admission.

A high percentage of the patients demonstrated an inadequate social
adjustment prior to admission. Nearly half had been known to social
agencies, and nearly one—third had a history of public misconduct. Ten
percent of the group had required the protective services of a children's
agency. Twenty-three percent of the patients were also known to
psychiatrically oriented agencies.

This group of inappropriately placed patients had a high instance
of previous institutionalizations. Two-thirds of the group had been in
residential care prior to coming to Lapeer. Twenty percent had been
in Boys' Vocational School and thirty-three percent had been in juvenile
detention homes. Thirteen percent came to lapeer from other psychiatric
facilities. These figures indicate that this group of patients had
presented problems of a social or psychiatric nature before entering
Lapeer and that a careful diagnosis of the basic problem was either not
done or was so difficult and complex that the proper treatment plan
was not clear and an inappropriate referral resulted. It is also
possible that referring agencies are not clear as to what constitutes
an appropriate patient for Lapeer.

To further explore the extent to which these patients had con-

stituted a community problem, a tabulation of petitioners for commitment

.5.-
\O

was made. This showed that in only half the cases was a family member
the petitioner. This suggests that in fifty percent of the commitments,
an authority figure in the community was acting in lieu of the parents.
It might then be assumed that the parents had abdicated their rights or
that the patient's antisocial behavior had placed him in under the
jurisdiction of a community authority.

In summation, then, a significant percentage of patients demon-
strated an inadequate social adjustment as indicated by contacts with
social agencies, and residency in other institutional settings.

The significance of psychological testing in the determination of
mental deficiency is great. It might be assumed, then, that before a
patient is committed to a state institution for mental defectives, he
would receive a psychological test and that he would test within the
defective range. Examination of the data reveals that in eight cases,
no such testing was done. In nine cases, the pre-commitment test
indicated that the patient functioned above the level of what is con-
sidered appropriate for Lapeer. In the remaining cases, the tests
were within the mental defective range. It would seem that commitments
are made without objective testing in some cases, and in some instances
are made when the test results contraindicate such planning. An
appreciable difference is noted between test results obtained in the
community and those at Lapeer. The entire study group tested above the
defective range and scored from seventy through ninetyefour, following
their admission. The increase ranged from four through twentyefour

points and the mean gain was 13.95. No single theory could account for

this universal increase. Slow mental maturation would apply in some
cases and improved general life adjustment might account for the increase
in others. The varying ahality of the examiners to gain rapport with
the patients might also be considered.

Of the thirty non-mentally defective cases admitted in 1956, eleven
were still in residence at the conclusion of this study on December 31,
1959. Of those discharged, two had been transferred to another state
institution. A clear policy for diSposition of these cases was not in
evidence, as recommendations for discharge were not always followed and
a substantial number were discharged when some type of residential pro-
gram had been recommended. There was lit le relationship between staff
recommendations and predictability of successful discharge.

An effort was made to determine wia factors did contribute to
discharge. To do this, the resident group and the discharged group
were compared. Institutional adjustment and pre—commitment adjustment
did not offer areas of predictability, as significant instances of poor
adjustment were found in both the resident group and the discharged
group.

There was no significant di ference in either age or measured
intelligence of the two subgroups.

In examining social work activity with the two groups, a signifi-
cant difference is noted. he resident group had less than half as many
contacts with the social worker and these contacts came with less than
one-third the frequency of those of the discharged group. Increased
social work w uld seem to contribute significantly to successful dis-

charge.

\J

- o
The major role of the social worker seemed to he in the area of

.L

interpretation, both so patients and to ha.il es 0. Only ten percent of
the activities could be identified as supportive treatment and no
psychotherapg'was practiced.

Of the discharged group, length of residency ranged from twenty-
two days to -,l§6 days. At the time of discharge, slightly over

seventy percent were considered to be capable of self-support. However,

about eighty-eight percent were discharged to the care of an interested

f"“ :1.

.u y member.

The most significant factors, t.cn, that lead to discharge of the
not mentally defective patient are those of consistent social work
practice and an interested family to accept the patient.

This st'dy suggests several implications for current practice.

Community agencies could legin to adapt their policies so that
they could serve more effectively the client wh tests in the border-
line defective and dull norna l ranges. In this, they could follow the

lead of the pub olic schools in the metrOpolitan areas where they have

expanded their services to meet the needs of this group. Indications

fr

I‘L‘

quently are that many agencies see institutionalization as the most
anpzo»iiate answer whenever mental deficiency is suggested. If such
practice exists, it is apparent that a large segment of the population
that might test between seventy ar d ninety are going to find no

services available to them.

53

is 5 especially true of psyclia 'ic

-L‘« ”4-.

services, where the patient is "too brig ht" for a state home and training

school and ”too defective" for in-laticnt or out-patient psychiatric

O
SQTVICC‘S o

rd

It...
’

Inasmuch as nore than one—fourth of th cases of this grout received

$

V W

no pre—ccnmftnent ,sycnovogics 1 testing, it might be recommended that
all pros; ems tive patients be tested to prevent inappropriate commitments.
It is also mi rificant that in no case was the staff at lapeer consulted
prior to commitment as to whether they felt they could serve the pro.
patient. Als o, oft see who we re tested, such a larger n'mber
scored shove the range of Lapeer's apprOpriate patients that it seems

obvious chat the comgzunitv is not

93

.r are of the real purpose of the

The whole method of court commitment could he heli up to serious

question. IV'such procedures, it 18 possible for pa mti to to be com-
mitte ed to a state ins tution without ever havin been seen by anyone
wi h special knowledge or diagnostic skills in the area of mental illness
or mental deficiency. When a con it sent is made, it is necessary that
the patient be dmitted, whetmh he is an anpropriate patient or not.

ven if the patient iso obviously not mentally defective, he must he
admitted. Refusal of admission is contenp t of court. 1 as a patient is
admiston, it is very difficult to return him to the community. Use of

2’)
ne voluntary admission procedure, “ which is already provided for in
the law, would make it ne(essary for the medical superintendent of the

institution to approve of all applications for ads is raion. This would

eliminate the forced admission of inappropriate patients.

 

an, Act ' , Nu),ig acts (1923), as last wended by Act9
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EIE-LIOG RAPE

:‘EQQ‘.’(\
Jervis, George A. “The Hen tal Deficiencies," m n- _ ,~
r c,3. i 7 ed. Silzar o Arieti, Ne: York, Basic Books,
Inc 0 , 1959 , Volume 11,8: .

Kanner, Leo,
Child Care Publication, l9k9

 

Lax-mesa Lawson G. We, 1561-: York,
Coliqbia University Press, 19,2

\'

Ensland, xichar l, an---on, Seymour, and Gladwin, Thomas, m - "

:1 ‘ I: . r, 1:813" J- ror?:’ RSELC BOOK‘:S , Illc . , 1958 .
‘CJ es, Alfred, WM“ " ' ° "A r, Euladelphia, 1:. ".

Saunders -o., 1953-

Per-man, Helen Harris, §Q3131_Qg§gggzk, Chicago, I'niversity of
Silicago Press, 195?.

Rose, Arnold K., V *" ’ V ' ‘, New York,
w.‘w; Norton and Company, Inc., 1955.

n

Arthur, orace, "Pseudo-feeble-mindedness," ' ' ' ‘

"hard Ezjojgngy, 19b7, LII, pp. 37-11%“-

"so

 

me Factors Confributing to Errors in the Diagnosis
of Feeole-mindedness, " h ‘ “ N * ,
1950, 11V, pp. L95—501.
Benton, Arthur L., "The Concept of Pseudo-f eeble-mindedness,"
WW 19 6. LXXV.
3(9'3880

Berkman, Tessie D., "Practice of Social'workers in Psychiatric
HOSpitals and Clinics," w ~' ’ ' v ’ 'c

W225. 1953.
57

Cutts, R. A., "D'fferentiation BetwLen Pseudo—Eental Defectives
with Emotional Disorders and Mental Defectives with Emotional
Disturbances," Afiezican Journal 0:1 IHent l Defi iency, 195?,
III, pr. 731-772.

carfield, 301 L. and Affleck, D. C., "A‘ stud" of Individuals Committed
to a State Home for the Retaried Who were Later Released as Hot
Men tally Defective,' " ‘° ' V e ' ' ‘
March, l9o0, LXI‘J, pp. 9 uG— 915.

3

Guertin, W} 3., "Di ferential Characteristics of the Pseudo-

feetle—minded " WM. 1950.
5% pp. 39“,..333,

‘Willians, Ruth, "Casework With Defective Delinquentsg" AufiIiQQQ
J ‘ 1 “I 9 o .0 .7, 1956, U1, pp. bl’j-Ulf},

An;eri can Ass cociation of I'ental Deficiency, §Laiifiiigal_fianual.

A Report Prepared by the Committee on Nomenclature, 1957.

Group for the Advancement of Psychiatry, ' ' ' '
V “ , ' ' ' ' r . A report formulated
by the committee on mental retardation, flew York: Group for
the Advancement of Psychiatry, 1959

Heber, Rick, "A Manual on Terminology and Classification in Mental
Retardation," A monograph supplement to the American_lgnznal
MW Sept. 19 9.1513! .

'World Health Organization, The, ‘ ’ ° ‘ ° ,
The world Health Organization Technical Report Series,
1954, LXXV.

W

Michigan. Ml. W (1923). as last amended by M
W (1945).