DOCUMENT RESUME

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TITLE MENTAL HEALTH MANPOWER AND THE PSYCHIATRIC TECHNICIAN. INSTITUTION CALIFORNIA SOCIETY OF PSYCHIATRIC TECHNICIANS, SACRAMENTO.; NATIONAL ASSOCIATION OF PSYCHIATRIC TECHNOLCGY, SACRAMENTO, CALIF. PUB LATE 68 NOTE 43P. AVAILABLE FECM NATIONAL ASSOCIATION OF PSYCHIATRIC TECHNOLOGY, 1127 I1TH STREET, SACRAMENTO, CALIFORNIA 9581 4($2.00)

LDRS PRICE EDRS PRICE ME-0.25 HC-$2.25 DESCRIPTORS *CCNFEEENCE REPCRTS, CURRICULUM DESIGN, LEGAL PROBLEMS, *MENTAL HEALTH, *PARAMEDICAL OCCUPATIONS, PROGRAMING, PSYCHIATRIC HOSPITALS ILENIIFIERS CALIFCRNIA, *PSYCHIATRIC TECHNICIAN

ABSTRACT DYNAMIC CHANGES ARE TAKING PLACE I.1HE FIELD OF MENTAL HEALTH CARE WHICH HAVE A GREAT EFFECT ON THOSE PEOPLE WHO PROVIDE THE PRIMARY SERVICES OF PATIENT CARE, REHABILITATION,AND TRAINING, IN RECOGNITION OF THESE CHANGES, THE NATIONALASSOCIATION OF PSYCHIATRIC TECHNOLOGY SELECTED "MENTAL HEALTHMANPOWER AND THE PSYCHIATRIC TECHNICIAN" AS THE THEME IOR ITS ANNUAL CONVENTIONIN 1967. THIS REPORT PRESENTS SIX ARTICLES WHICH REPRESENT A SELECTED DIGEST OF THE PROCEEDINGS FFCM THE FRESNO CONVENTION. THESEARE "MENTAL HEALTE: THE DYNAMICS OF REVOLUTION," "MENTAL HEALTHMANPOWER IN TRANSITION," A SYMPCSIUM ON FEDERAL AND STATEREGULATIONS OF NURSING SFEVICES, "LEGAL ASPECTS OF UTILIZATION OF PSYCHIATRIC TECHNICIANS IN MENT;1L HEALTH SERVICES," "PRIVATE PSYCHIATRIC HOSPITALS," AND "PROGRAMMING FOR THE FUTURE." A CURRICULUM REPORT IS APPENDED. (BC) - : :: :i/' :,: _y :. :77: ':: : :. : : :: : :

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CALIFORNIA SOCIETY OF PSYCHIATRIC TECHNICIANS Non-profit organizations devoted to improved professionalism and recognition as a means toward better behavioral care treatment and training of the mentally and emotionally incapacitated.

OFFICERS NATIONAL ASSOCIATION OF PSYCHIATRIC TECHNOLOGY

PRESIDENT Zeryl Dryden (California) PAST PRESIDENT FIRST VICE PRESIDENT Franklin F. Fiedler (California) Ted Low (Colorado) SECOND VICE PRESIDENT THIRD VICE PRESIDENT Elsie Ferguson (Arkansas) Rose A. Douglas (Massachusetts) SECRETARY-TREASURER Bette A. Outlaw (California)

FIXED TRAINING STANDARDS EXPANDED ADVANCEMENT THROUGHOUT THE NATION OPPORTUNITY FEELING OF DIGNITY IN PRIDE IN CONTRIBUTION TOWARD EMPLOYMENT MENTAL HEALTH PROFESSIONAL GROWTH

OFFICERS CALIFORNIA SOCIETY OF PSYCHIATRIC TECHNICIANS PRESIDENT Don Wise PAST PRESIDENT FIRST VICE PRESIDENT Earl C. Wilkerson Warren Malone SECOND VICE PRESIDENT SECRETARY-TREASURER William E. Outlaw Laretta Thomson REGIONAL DIRECTORS CALIFORNIA SOCIETY OF PSYCHIATRIC TECHNICIANS

William V. Kalinauskas Virginia Ledford Wood H. Smith George L. Waggoner Frances Belongy Ophelia Williams H. D. Whitfield Frank R. Favela Helen Johnson Roy M. Goucher Isaac J. Claybrooks Frar, ces Watts De lois Higinboti: John 0. Calderon W, B. Hoxk c.) U.S. DEPARTMENT OF HEALTH, EDUCATION & WELFARE r) OFFICE OF EDUCATION 10 THIS DOCUMENT HAS BEEN REPRODUCED EXACTLY AS RECEIVED FROM THE re\ PERSON OR ORGANI/ATION ORIGINATING IT,POINTS OF VIEW OR OPINIONS STATED DO NOT NECESSARILY REPRESENT OFFICIAL OFFICE OE EDUCATION

POSITION OR POLICY, E3 Contents Page No.

PREFACE William Grimm

MENTAL HEALTH IN CALIFORNIA: THE DYNAMICS OF REVOLUTIGN Dr. James T. Shelton "The changing character of our hospitals, complicated financing of the new programs in communities, and the place to be found there by the psychiatric technician."

MENTAL HEALTH MANPOWER IN TRANSITION 7 Dr. James A. Peal "Innovations in the use of treatment personnel in community mental health programs."

SYMPOSIUM: 14 Interpreting federal and state regulations which affect staffing standards for nursing services in state and local facilities. Howard Worley Ralph Zeledon

LEGAL ASPECTS OF UTILIZATION OF PSYCHIATRIC TECHNICIANS IN MENTAL HEALTH SERVICES 21 Attorney Robert Thorn "A review of the legal implications of transition from state to community and federal programs."

PRIVATE PSYCHIATRIC HOSPITALS 24 Arthur Jost "Will new staffing approaches and modification of roles help to close the manpower gap?'

PROGRAMMING FOR THE FUTURE 29 Senator Nicholas Petris "A probing insight into changing mental health patterns and requirements for the coming decade."

APPENDIX I: 36 All that glitters may not be gold.

APPENDIX II: 37 THE CURRICULUM REPORT Anabele Miller Preface

The entire field of mental hygienefuture of these community-based pro- across the nation is in a state of rapid grams. change. Most important of all, the psychiatric Many trends which here in the latetechnician (or his counterpart profession- 1960's are transforming the field of men-al under other title) must continue to tal health care and treatment into aperform as a responsible leader in the dynamic new enterprise will have a mark-shaping of visionary solutions to the very ed effect on the people who perform theserious manpower problems now facing primary functions and provide the prim-the mental health professions through- ary services of patient care, rehabilitationout America. and training. In California and in other progressive It was in recognition of this era ofstates today, there is every indication change, this historic time of revolution,that these problems and issues and that the National Association of Psy-changes are but a beginning that the chiatric Technology selected the theme,mental health revolution will continue "Mental Health Manpower and the Psy-to accelerate for many more years yet chiatric Technician", as the keynote ofto come. its annual convention at Fresno, Calif- In many ways, evidences of this great ornia, in October of 1967. transition are today most pronounced Since it is the psychiatric technicianin the dynamic state of California. But who is most intimately involved in thethey are likely to be but previews of the day-to-day response to patient needs, itsame evolutionary processes which other is he who will be most directly affectedstates will encounter within the next few by changes and modifications in the sys-years. tems of mental health care which ultim- For that reason, the California Society ately will evolve. of Psychiatric Technicians and the Nat- As a pivotal figure within the profes-ional Association of Psychiatric Technol- sional mental health treatment team, heogy have joined in the publication of will play a key role in the changing char-this selected digest of the transactions acter of the large state hospital as theof our provocative Fresno convention trend toward decentralization continues.of 1967 in the hope that others who He will occupy a critical role in the dev-yet must face the problems and oppor- elopment and growth of community-tunities of this great revolution might based programs. He must play a centralin some small measure benefit from the role in the redefinition of treatmentinsights of some of California's front- functions and personnel. He must makeline mental health authorities. his voice heard in the formulation of public funding patterns and other politi- William Grimm cal decisions which will impact upon the Executive Dirmtor Mental Health in California: The Dynamics of Revolution by Dr. James T. Shelton hygiene which are coming at an increas- ingly rapid rate. Dr. Shelton obtained his A.B. from Change, of course, always creates anx- Pomona College and his M.D. from the iety, and when change comes too rapidly, University of Southern California, doing then anxiety reaches such a height as to his psychiatric residency at Langley-Por- almost result in panic. Recognition is ter Neuro-Psychiatric Institute in San given, at least in the selection of your Francisco. Shelton was clinical instructor speakers, to one of the primary trends in psychiatry at the University of Calif-that is occurring in our field of mental ornia, San Francisco Medical Center, and hygiene that is, the trend to community has been Superintendent and Medicalmental health service, rather than this Director at Porterville State Hospital, service being centered almost exclusively Porterville,California for the past 14 in the State Hospitals. years. The second trend that is tacitly ad- His credentials include: Diplomat ofmitted by your program is that of the the American Board of Psychiatry andchanging character of the hospitals. Of Neurology; accreditation by the Ameri- course this would obviously follow with can Medical Association as a Mental Hos- increasing the mental-health programm- pital Administrator; and fellow of the ing in the community: It almost goes American Psychiatric Association and the without saying that the hospital is going American Association on Mental Defic- to have to change its character, its pro- iency. grams, perhaps even its fuhction, in order Sheltonreceivedthe Golden Ruleto keep up with this move toward the Award of theCalifornia Council for community. Retarded Children in 1961. A third thing the program tacitly re- cognizes is the point financing of mental Ibelieveit's customary that when health programs. As short as twenty years your group meets throughout the variousago in 1947, the primary financing of areas in California that the state hospital treatment services for the mentally ill closest to the meeting area convention and mentally retarded was by states. The site handles the program arrangementsstates, for the most part, picked up al- and welcomes the various delegates. Al- most 100% of. the tab, and, because of though we at Porterville are some milesits funding, maintained control of the from Fresno, we feel this is our bailiwick, programs itfinanced. Very little was so we are very pleased to have you meet being done in county, city, local com- here. munities, and extremely little was done As I reviewed the program "Mental by the federal government. But it is quite Health Manpower and the Psychiatric obvious that the trend. is shifting toward Technician" and noted the various speak financing by state, federal and "local" ers that you are going to be listening to "local" being counties and cities. We have over the next three days, I concluded seen a combined funding by federal, state that a great deal of thoughtful planning and local agencies such as we have in has certainly gone into the programs this welfare programs. Currently, our mental year because the theme of your conven- health programs are being funded by tion recognizes trends we see in mental these threesources. 1 The fourth trend, which obviously the present administration. I think this must follow because of the first three is wrong. trends, is that the worker in the field of I'm not denying that there might bea mental health must change his roleto problem in this area. But the point Iwant keep pace with other changes in the field. to make is that we've had problemsever No longer can he act and do and perform since we've hada Department of Mental as he has acted and done and performed Hygiene. We should bevery careful about in the last twenty years. ascribing the causes of those problemsto In your program I want to commend the present administration. Itmay not all you because I see you realistically eval- be. Some may be, but not all. AndI uating the present and lookingto the think it is very importantto very care- future rather than, assome organizations fully delineate that which isour own re- in this field, emphasizing the past par- sponsibility and inour own bailiwick to ticularly the past nine and one-half correct within our ownresources months. This period has been,as we all rather than sitting back andblaming it all know, one of turmoil, recriminations, on something or somebody, or lack of and what I think is most unfortunate,a money, or lack of personnel. a great deal of misinformation. I think You see thesame kind of thing in the most disturbing factor has been the psychiatry with the parents whocome misinformation about the cutbacks,and to you with disturbed kids. The kids the impact that this has hadupon our have all kinds of behavior treatment programs. problems, but normal kids have behaviorproblems too. We have been hollering aboutthe cut- Before youcan honestly and factually backs during the last nineand a half months, yet it determine what really isabnormal, you was after the first six have got to know what thenormal prob- months of theyear before any cutbacks lems are soyou will not be confused and occurred. And,we heard very little em- say it's all due to a particular condition. phasis being placedupon the freeze, I think there isa good analogy here. which really had the greatest impact on We've got to sift out whatour normal our treatment programs. AlthoughI problems are, and notblame them all tried, I couldn't convinceanybody that upon the present situation. the freezewas the thing to focus onto Sometimes, I think the time get that lifted. We could we spend probably take on complaints, petitions and othermove- the cutbacks in stride,as we are doing. ments might be much better The other piece of spent on misinformation more constructive endeavors andon pa- that I think has beenthe worst thing-I tient care. Now,we are living with the again readan organization's statement present situation, and it hasn't (it wasn't this one) been about how horrible something thatany of ushas liked. the conditionswere at Stockton. I look- We've all lost something ed at this, read it the hospitals over, and I said, "This for the mentally ill muchmore than the cannot be the result of anythingthat has hospitals for the mentally happened since the retarded. There last nine anda half is no question aboutthat, butwe are months, because nothingwas involved living with it. Therewere lots of dire during the last nine anda half months to predictions about the affect the amount cutbacks. Forex- of money to feed ample, I sincerely thoughtthat thepop- patients. That has alwaysbeen adequate. ulation for the mentallyill would in- In fact, the departmenthas always turn- crease because of the decrease in ed back person- money for feeding. While we've nel. But the facts donot bear this out. never had any lack ofmoney to feed The factsare that the population is still patients or to buy food,this was played continuing to decrease. Wecannot ignore up in a maudlin way to make peoplebe- these facts lieve that this had they're the facts of life.I something to do with don't think myselfor anyone in the De- 2 partment or the Administration likes toway in the Department of Mental Hy- hold the line based upona level of care giene since 1947, twenty years ago. Here which is not adequate and which has lotsit is 1967.1 mentioned 1947 because this of holes in it, particularly in terms ofwas the time of Governor Warren, Frank not considering admission factors ade- Tallman the time when headlines were quately. Yet, we put up a battle and filled with references to the "snakepit." fought it. Instead of sitting back, sulking The interesting thing, though, is the and crying in our beards,we should difference in programming in 1947 from endeavor to move ahead with whatwe that in 1967. Nowwe have thousands of have. I, for one, hope-- and I think we additional new employees. Salaries have have many indications for this hope skyrocketed still not high enough in that we will go ahead nextyear even my opinion but certainlyan improve- though this year has beenone of holding ment over 1947. Then, a psychiatric tech- the line and, in somecases, of actually nician got $40 a month plus live-in, had retrenching. a set of keys thrown at him, and he went I wrote a letter forour Portervilleto work with the mentally ill andmen- State Hospital Parent Group andour em- tally retarded withoutany training. We've ployees to cover justsome of the things come an awful long way since then,so I I am mentioning, and Iwas extremely think that rather than cryingin our surprised to receivea letter from ourbeards we ought to just reflecton how Governor who apparently hadseen afar we havecome and try to work with copy. 1 had said, in essence, "Let's quitwhat we have Despite the freezeand bickering and complaining and do with cutbacks with whichwe do not agree, what we've got to the best ofour ability." we have something this year thatwe have The Governor wrote that this attitudenever had before in mental hygiene was sincerely appreciated by him. He greater flexibility in theuse of staffing said, "It certainlywas good to read thebudget. Most ofyou don't have too many voice of reason in all the sound and fury, dealings directly with theoperating bud- and I hope others will followyour ex- gets of the hospitals, but Ican tell you ample." The letterwas signed, "Sincerely, as hospital superintendent ofmany years, Ronald Reagan." Now, Ronald Reagan I havenever seen the flexibility thatwe is our Chief Executive; he isour Govern-.have thisyear in spending dollars for or. And as I tell new employees at thetreatment personnel. hospitals, "Even thoughwe, as civil ser- While this flexibility islimited to the vants, owe a certain amount ofrespectclassifications of physicians,social work- to him as Chief Executive,we don't have ers, psychologists and psychiatric tech- to agree with him, butwe don't have tonicians, it isa marked'improvementover knock him. He is doing whathe thinksthe time when such didnot exist. We can has to be done at this pointin time. We convert vacant positionsto other posi- may disagree, but he's made the decision. tions thatwe are able to fill on a dollar If someone disagreesso strongly that hefor dollar basis. AtPorterville we've had can't accept it without beingnegative physician positions andpsychologistpos- and vicious at times, then Ithink it isitions vacant for nearlytwo years. We his responsibility toget out of the sys-are taking money for these positionsand tem. I'm not saying thatyou should doplan to createsome 30 new psychiatric this before you fight forwhat you be-technician positions this fiscalyear. We lieve in. Butonce the decision is made,are giving first choice to trained psychi- you should accept it and look to theatric technicians from thehospitals for future doing whatyou can with whatthe mentally ill whomay be faced with you have rather than crying over spilledlay-off. Theseare psychiatric technicians milk. who are already fullyaccredited sowe You know, we'vecome an awful longdon't have to put themthrough an in- 3 tensive training program other than an fly affect the hospitals for the mentally orientation to the hospital. Our patients but will have less affect on hospitals therefore, benefit from this flexibility in for the mentally retarded and Atascadero the utilization of staff funds because we since patients in these facilities were ex- arepermittedtousedollars which cluded from the bill. normally would not be available tous. I You are undoubtedly going to hear think this flexibility is somethingon the about the impact of the Federal Govern- positive side of the ledger of which ment, Medicare and Medic Aid.You're go- people need to be made aware. ing to hear about the Department'sem- One other thing I think a lot of people phasis on cost reporting. You've already are not aware of is the fact that the Gov- been involved with that in some of your ernor ordered all of his State Depart- ward surveys. All of this is done inan ments in California to reduce this years' effort to get more federal dollars. This budget by eight per centEXCEPT the is the whole purpose of some of the dis- Department of Mental Hygiene. While cussions that are going on about Medi- I'm not rolling in the aisles with pleasure care and Medi-Cal. over features of the present programs, In an effort to get more dollarsso that these desirable things should be recog- more services can be provided, and this is nized along with the less encouraging the avowed intent of theseprograms, factors. we're going to have to contend withpro- I have read the Governor's letter to blems of federal law which set forthcer- the Director of Mental Hygieneconcern- tain definitions for certain kinds ofpeo- ing budget proposals for the next year. ple that are necessary. We're wrestling Economy is mentioned, but therc, is also with this. I think it was important that instruction to give full consideration to the Fairview situation with theconver- new programs and to augmentation of sions of psychiatric technician to regis- current programs if they are found justi- tered nurses was subsequently called toa fiable. We have submitted some sixpro- halt, and then looked atvery thoroughly, grams from Porterville for budget aug- because there may be other compromises mentation in the amount of some three or other approaches. It is not impossible or four million dollars of additional to change federal regulations by broad- funds. We're not going to get that much, ening their definition. Theseare the but if we get five hundred thousand, things that should be looked into, I that's better than nothing. I might add think, by a group suchas yours. There that most of those budget augmentations seems to be no reason at all why federal except those for research, call for addi- regulations involving Medi-Cal and Medic- tional personnel additional psychiatric Aid, which is a federalprogram for the technicians. states, could not be written so that where So where are we going, and what is mentally ill and mentally retardedare going to be the role of the psychiatric involved, the psychiatric technician could technician? Well, you're going to hear be on the same plane, if you will, with speakers who will give you some of their the registered nurse. After all, adminis- ideas of where they think the psychiatric trative regulations can be and should be technician is going and perhaps what the changed periodically to meetour needs. role of the psychiatric technician will be. I think we're going tosee a decrease You will undoubtedly receivea great deal in the number of 24-hour hospitalcare of information about the movement toprograms. We've seen that in, today's the local community mental healthpro- Short-Doyle programs. I think, ofcourse, grams, one of which is the Lanterman- that this is best proven by the decrease Petris-Short Act, Senate Bill 677, which in the populations in hospitals for the is known also as the "California Mental mentally ill, except that we're seeinga Health Act of 1967." This will profound- change in the population to themore 4 profoundly sick, whether they be thethe psychiatric unit. He's had some ex- "back-wards patients" or the severely re- perience in state mental hospital work. I tarded, or the geriatrics cases. We're morewas talking to him and he said he thought and more going to have to care for thatthis was the most valuable part of his kind of case in the state hospitals as the experience and training. Here is a psychi- communities begin to provide care foratric technician who is working in the the easier-to-care-for patients. community in one of these Short-Doyle This means that the role of the tech-programs and there are many others be- nicians and the personnel in the hospitalssides him, of course. There is a growing will gradually change, You're going touse of the psychiatric technician. I in- have to become more skillful. We areclude the psychiatric technician as a talking now in the Department about"professional" even though he is some- considering multi-purpose facilities, sotimes referred to by some as a "sub-pro- that state hospitals could care for both fessional".I still like to conceptualize the mentally ill and the mentally retard-the psychiatric technician as a profes- ed and all kinds of mental disorders. Yousional with talents equal to the registered already see the movement toward thisnurse. with DeWitt State Hospital. They have This doesn't mean that they don't more retarded there now than mentallyhave separate functions to perform. In ill, and of course there is the mentallyre- my opinion, the registered nurse has tarded unit at Patton, the unit at Agnews, much more experience and training and and now the unit starting at Camarillo.knowledge concerning the medically ill Then, the plan (I think it is being done atpatient, such as an expanding hydro- the present time) is to transfersome cephalic. This isn't to say that thepsy- mentally disordered sex offenders fromchiatric technician can't learn these ele- Atascadero to Napa. That's probably just ments, and is beginning to do so. On the the start of hospitals becoming multi- other hand, I see noreason to use a reg- purpose facilities in caring for all kindsistered nurse on a ward which is better of problems. This is going to change therun by a psychiatric technician out on role of the hospital and the role of thethe campus whereyou are dealing more worker in the hospital. Undoubtedly thewith educational-habilitational prob- hospital will becomea back-up service to lems. We use themon our co-ed ward. the community. Hopefully the hospital I do think that theremay be a trenu will become, and I think ita proper role,in the future towardsome kind of an a training center where people can come amalgamation of these fieldsregistered in and really learn how tocare for thenursing, if you want to call it that, and mentally disordered. The people who psychiatric technology. Perhaps thecom- really know how tocare for them, webination would have some othername have found,are in the hospitals. I happen which is yet to be devised. to be active in community mental health I think, however,we make a mistake programs through service on the Tularein spending time fighting betweenour- County Mental Health Advisory Boardselves on this rather than trying to pull for the Short -Do leprogram. It's aston-together and recognizing thatwe both ishing sometimes how theprofessional have a job to perform. If you don't feel workers in the communityare unaware that your particular hospital hasan ap- of the difficult problems whichare sec- preciation of the need for bothgroups, ond nature to us in the hospitals. Sowe then I think that CSPT hasa role to play have a double role to play here inthein convincing the hospital administra- training C. the professional whodoes the tions, and anybody else concerned, that work in the community. There'sa psy- there is every need for both kinds of chiatric technician who has donea mar- professional workers in the hospital. velous job at Tulare County Hospitalin I hope this morning that I have given 5 you, besides a cordial welcome, some-According to my watch, it's two min- what of an overview of the situation asutes after ten, and that's just about the I see it.I think I have been able totime hat your program calls for coffee. reasonably well keep within my time.Thank you very much.

PLEDGE OF THE PSYCHIATRIC TECHNICIAN

Having developed anawareness of the dignity encompassed in the field of psychi- atric technology and of my responsibility becauseofspecializedtraininginthe therapeutic techniques utilized in the pro- motion of mental health, I pledge myself: To uphold the integrity and human dignity of those entrusted in my care and protect them against humiliation, insult or injury without regardtorace,color or creed. To inspire hope and confidence, giving assistance with understanding and friend- liness, in finding realistic acid meaningful

To continue my development of professional competence, complementing scientific study,improvement of therapeutic tech- niques and maintaining high standards of leadershipinthefieldof Psychiatric Technology. Mental HealthManpower In Transition by Dr. James A. Peal twenty years because he has scen new programs come and go. He has seen pat- Dr. Peal is Director of the Fresno ients selected for the new programs whose County Department of Mental Healthprognosis and expectation has been that Services. Well known as a pioneer in psy-he would recover. He has always just chiatric services and in local programs,missed being picked for this or that. He Dr. Peal has practiced in many California has seem his fellow patient come, get hospitals including Napa and Agnewstreated, and go in fairly large numbers, State Hospitals as staff psychiatrist, thefor the Department of Mental Hygiene Medical Facility atVacaville as Chiefover the past few years has accomplished of Psychiatric Services, and Stocktona reductionof over 10,000 patients State Hospital as Associate Superintend-through the advent of Medi-Cal andnew- ent. He recently returned from Michigan, er techniques in psychiatric treatment. where, as Assistant Director of the De-It is to the patient who now sitson the partment of Mental Health, he organizedback ward and those yet to come whose a manpower utilization and developmentillnesses may not respond to the treat- program for that state. Licensed in Mary-ment now possible in the community, land, Connecticut, Michigan and Calif-it is to these people that we dedicate ornia, Peal is also a Fellow of the Ameri-ourselves in this consideration of mental can Psychiatric Association. health manpower and the psychiatric technician. On December 31, 1965, there were Any comprehensive mental healthpro- 28,400 patients in the hospitals for thegram, whether local as in the present mentally ill and 12,920 patients in theShort-Doyle programs or stateas in the hospitals for the mentally retarded. Dec-state hospitals, must include in all of its ember 31, 1966, therewere 24,057 pat-ingredients treatment programs designed ients in the hospitals for the mentally illto meet needs of all patients not a sel- and 13,340 patients in the hospitals forected few. If it does not do this, then it the mentally retarded. These patients hadis a mental health program that is direct- already been extruded from theircom-ed toward part of the community and munity through the existing commitmentnot all of it. People who develop mental practices. They have been hospitalized,illness should retain their membership in institutionalized andmany have seenthe local home community regardless of their fellow members returned to theany temporary sojourn to a state hospital community; some fora better life, someor other treatment facility, and that com- for a worse life, andsome for an exist-munity should accept thisperson back, ence similar to what they had before theyoffering him what rehabilitation services came to the hospital. I wonder if thesehe needs and, more important, offering patients think. "Am I included in thehim a warm and friendly welcome home. community programor is this for those This organization and this institute is who are yet to come here? Am Ia partthus dedicated to the patients thatwe of the number that is to be written off?"serve. Manpower is the means of provid- The experience of being excluded is noting the hope, happiness, and healthto new for the patient who has been in thepatients by bringing appropri to psychi- state hospital on the back ward foratric skills to him inan atmosphere of 7 care. acceptance and understanding. Men- line because communities have not been tal health manpower development and accustomed to accepting and keeping utilization, including staffing,training their sick people. They traditionally have and funding, must be centered in meet- sent them on to state hospitals. It is, ing the needs of the patients we serve. therefore, my purpose today to first de- Today morale may be at its lowest fine what community mental health ser- ebb. This is the first time in many years vices mean to the patients, and then to the mental health budget has been cut examine with you some of these new instead of increased.The very existence community health centers, local pro- of the system that trained and nurtured grams, and Short-Doyle programs, and us is in question. 'We may find ourselves the new vocabulaiy they are bringing embittered and angry, bewildered and onto the scene. perplexed, hopeless and despairing. Second, I will spell out the ingredients You have seen your numbers shrink, of these new community programs in your training programs reduced and all terms that are familiar to you and that but eliminated, and demands placed upon are similar to state hospital operation. I you increased by your shortage in num- want to examine your present skills as bers. Your very worth to the system they now exist to see how they fit into which nurtured you is being questioned. this program. Then we will examine the By virtue of the cut back, the institu- different ingredients in the local pro- tion you worked in, namely, the state grams where your technology and skill as hospital has been declared a thing of the it now exists may not fit, and identify past by some, to be replaced by the new needed appropriate changes (additions community mental health Short-Doyle and deletions) in your training to make programs. your skills useful. We need to define If you don't quite understand what some of the more immediate problems in these things are, it may be because they courses of action that your organization aren't very often clearly defined. Natur- must consider if it is to become a part of ally you wonder where you fit in this the community program, and finally to new scheme of things, or if you fit at all. review the current political and legislative Does your profession have anything to happenings to see what they hold for the offer now to the patients in community present and for the future. programs in this new order of things? Community health services are those I come to you today out of the exper- mental health services which exist in the ience closely identified with the state community. The community is defined hospital. For I, too, received my psychi- as a political subdivision or geographical atric training in a state hospitaland subdivision which has a local governing worked in various state hospitals, both board. The mental health services in the on the wards and in the administration. communityare usually consideredas I have participated in the third psychiat- direct treatment services, or those ser- ric revolution in which the newer modal- vicesgiventopatients, and indirect ity of psychiatric treatment, namely, som- services which include consultation ser- atic treatment, drugs, group therapy and vices given to helping agencies in the the therapeutic community system of community. patient management have changed our For example, the local or county wel- hospitals from custodial facilities into fare department provides social services psychiatric treatment centers. including room, board and clothing for I now find as director of a community all people who are indigent in the com- program that there is a greater need and munity. Consultation services to the wel- challenge here at the community level to fare department enabling welfare work- translate these programs into hope and ers to provide these services for the men- help for those patients at the end of the tally handicapped is a very profitable 8 thing for the patients. It gets foryour the psychiatric technician is his member- patient an adequate place to live, clothes ship in the community. As a lay member to wear and food to eat, and provides of the community he probably has more other social services that keep him in the acceptance by the grass roots of these community. If the Welfare Department agencies than do the professionals. Just or its staff gets too nervous about him, imagine, if a psychiatric technician were these resources in the communitymay a member of the reserve police force, dry up; and he becomes a person without how much effective education he could a home and, therefore, hospitalization is give to his fellow policemen. This may sought to solve his problem. The welfare be as effective as a lecture that the psy- worker can become a friend to the pat- chiatrist would give on the nature of ient,a helper in the program. schizophrenia or how you manage a per- By the same token consultationser- son who is about to kill himself. How- vices to the Public Health Department ever, these duties in community programs can providevisitingnursingservices. are not usually, at the present time, as- Visiting nurses and public health nurses signed to psychiatric technicians. The are a major resource in keeping sick direct services program provides direct people at home. They help the patient treatment to patients.It includes in- .with problems in medication; they give patient, day care and outpatient services. the patient a friend,someone who under- Most localprograms have a small stands them, andsomeone who knows inpatient service, (small compared to the the neighborhood and is ableto help the size of the state hospitals)with from 5 to patient make maximumuse of the re- 90 beds servicing a county of 100,000to sources there. over a million people. It is obvious that Consultation with law enforcement is with this small number of beds that a very useful program for it serves the long-terminpatienthospitalization is same purposeasconsultationswith not an integral part of the localprogram. Welfare. The more the policeand law An effective program treats acute dis- enforcement officers understandabout turbances in a few days. Patients who the problems of the mentallyill, the otherwise would require 90 or 120 days more skills they have in being able to in a state hospital aremore efficiently manage them as policemen. Thus the treated in a communityprogram by patient has a better chance of havinglaw using not only the inpatient service but enforcement availabletoassisthim the day careserviceand outpatient rather than having law enforcement de- services all combined and coordinated in signed only to incarcerate him. Ingen- a treatment design to meet the patient's eral, by havinga network of consulta- needs. tion and education services to thesevar- The practiceof psychiatry in the ious helping agencies in the community, communityprogrampresentsmany both public and private,one is able to challenges and many stressful moments enlist many services for patients that he to the institutional trained psychiatrist otherwise would not get. Themanpower and other professionals. Most communi- involved in (Trying out these consulta- ty programs have a walk-in clinic. This is tions programs usuallycomes from pro- a place where anyone who is disturbed fessional people, i.e., psychiatrists, social can come himself or be brought and be workers, and psychologists. However, the seen by members of the professional psychiatric technician with his under- staff. One physician has termed this standing of the nature of mental illness, "instant psychiatry". That is, the patient his knowledge of sick people and howto isseen, and in15 or 20 minutes a get along with them may bea very help- diagnosticevaluationis made and a ful person in this overall consultation treatment program is developed which program. An additional advantage for has to solve the immediate problem of 9 where this patient has to live in order toto the program. After the experience in be effectively treated.Generally if theday care when the patient has more con- manifestations of the illness do not makefidence in himself, he may be referred to the patient a danger to himself or others,vocational rehabilitation and/or may be even though he may be quite disturbed,sent back to his job in the community. he will be given adequate dosages ofThe average length of stay on the in- tranquilizingdrugsimmediatelyand patient serviceis 6 days for most ill- assigned to the day hospital or to the nesses. However, the average lengthof outpatient clinic and not be hospitalized. stay in day care may be 2 to 3 months, It might be well to follow a disturbed depending upon the degree of the illness. patient through the various elements ofThe patient may be discharged from day this program so that you see how they care and not come back at all or he may work. A patient is found by the police go from day care to outpatient situation having turned on the gas and closed offfor either drugs, group therapy, or in- the windows in a bona fide suicide at- dividual therapy. In any case he is a free tempt. The patient is brought to the agent usually back working on his own. hospital on an emergency 72-hour com- Now you may say, "What about the mitment. The patient is examined either patient who is chronically ill and who the same day or the following day by thehas had three and four episodes of ill- chief of the inpatient service who is aness?" These patients are provided for in psychiatrist, and a diagnosis and treat-essentially the same way. The acute man- ment plan is made that day. The treat-ifestations of the disturbance are man- ment plan is started that day on theaged on an inpatient basis until the pat- inpatient service. By the time the 72-ient is able to manage himself at home. hour commitment is up the patient mayHe then may be treated in day care not be ready to leave the hospital so hewhich is the same treatment being con- is encouraged to sign a voluntary ad-tinued but he is now able to live at home mission. He stays on the inpatient serviceinstead of the hospital, and he may be until the acute manifestation of the de-followed on an outpatient basis. We re- pression has subsided and then becausecognize that for this group of patients, the patient is not ready to resume hisidentity with our center may be a life- full life at home he may be placed in time one because their illness will come the partial hospitalization orday care and go as they meet various stresses with- program. in the community. So we have to plan The dzy care programconsists of afor these patients a long-term program series of highly organized, scheduled ac- of treatment with the goal of helping tivities including occupational therapy, them to maintain as high a level of func- recreational, and group therapy that take tioning as possible. The most, meaningful up the patient's day. It is identical to thegoal though that one has to have for same daily program the patient has whilethese patients is to enable them to live an inpatient. The only difference is that happily in the community and enjoy the patient sleeps at home and not in thetheir lives. hospital. The patient is given his meals, Toward this end many volunteer or- medication and rail bilitation program in ganizations in the community help the day care. When the illness has subsidedpatient to have fun. As an example, I and the patient begins to think of whatcite the Senior Citizens. However, not all he or she does next, he will be referredof the patient's life in the community is to vocational rehabilitation or returnedhappiness and joy. Many patients find to his home, school or job, as discussedjust as much desolation and loneliness in all during the patient's hospitalization.the third rate hotel rooms and in the The patient's plans for discharge areflop houses or the nondescript boarding made almost immediately after cominghomes as they would on the wards of the 10 state hospital. In fact, you have had the ward experience with the acute and experience of having patients refuse to chronicaThi ill is a good background. The leave the hospital. They have found more management of patients in these services meaningful relationship in the state hos- is different. Home visiting isnew to psy- pital community and, therefore, a more chiatry. The technician is expected to be meaningful life. You have given them able to do things for patients by doing more acceptance and understanding there things with the patients. The goal ofcare than they could find in the cold un, here is to enable the patient touse the friendly community. What they need at community and its resourcesas a full fled- home in their community is a familiarged citizen. Mentally ill people have not face, people who understand what theybeen so regardedo- treated by the pub- areexperiencing, people who under-lic or by the professionals caring for stand what being ill is like, who care and them. This requires the technician and are there to help them through their ex- all professionals to examine hisown basic perience. Psychiatric techniciansare these convictions. Are thesepoor mentally ill kind of people and have done this kind people as good as I am? Do they have the of service in the hospital, and, insome right to be my neighbor? places, are now doing it in thecom- Emergency service is just what itsays: munity. care for people in crisis. The crisismay Socialwelfare workers,physicians,be determined by the patientor his care- and psychiatrists are also these kinds oftaker. It usuallycomes when patients people, but are not as involved in the succeed in getting othersnervous about stresses and strain of the daily living as them. the publichealth nurse, the mental Day care programs are familiar tostate health nurse and the psychiatric tech-hospitals and those technicians who have nician. had this unique experience instate hos- I would like to describe the functions pitals. Those technicians who have been of the inpatient, outpatient andday care part of the special Hospital Improvement programs and the required duties. Program project involving rehabilitation The inpatient service is similarto thewould be at home in the community admission and acute treatment wardsin programs, for many of the Hospital Im- thestatehospital. The main jobis provement Program grants have prepared intensivepsychiatrictreatment.The the people in them for the kind of nursing care is provided by psychiatric practice that is carried out in thecom- nurses assisted by licensed vocational munity: The Mendocino Pkograms The nurses and attendants, and psychiatric Stockton State Hospital Program The technicians in a fewcases. The present Camarillo Program The Group Leader basic training of the psychiatric tech- ProgramRange B. nician along with the RangeB training Local programs are authorizedto be would be adequate for thisprogram. The reimbursed for halfway houses and other following differencesare important. appropriate protected livingprograms. 1. The hospital stay is short. What can psychiatric technology do to 2. The patient isa free agent and ismeet the challenges of community pro- regarded as such. grams? What are some of the problems it 3. The major emphasis ison rapid should consider? effective treatment and earlyre- 1. Psychiatrictechnology canre- tum home. main as it began and isnow, an ancillary Outpatient L.;rvice includes home visit- nursing service, providing basicallynurs- ing and emergency care. ing care. Whether he isan assistant nurse These services arenew to the psychi-or a junior nurse is not important. The atrictechnician except insome few technology now is defined within the places. The technician's knowledge andcontext of nursing and as such will be 11 viewed as a branch or sub-branch. imbursement. The service must be creat- 2. Psychiatric technology can take ed and produced before it can be collect- a hard look at what community pro-ed for, There is no advance capital to grams are and what they will need, and start new programs except from county add to its skills those which would makefunds. For example, Fresno County has it provide some unique service in the approximately 600 former Stockton State program not now provided. These skills Hospital patients here. We have designed are in social service areas: knowledge of and planned a program of continued community agencies, occupational ther- care for them. In order to carry this pro- apy, skills in use of crafts, public health gram out we need to hire some people. aid, vocational rehabilitation. The psy- There is a statutory provision for 100% chiatric technician then becomes a gen- reimbursement. The people would have to eralist in community care, able to bring be hired out of this budget, the services more skills to the patients. The degree of rendered and then collected for. If there training in these areas would be less than are no funds to hire them, the services that of the professional at the college are not rendered, therefore, cannot be level. Outpatients may not need these collected for. It's the same problem faced services from that professional. by a broke mechanic who wants to start 3. These are some problems: a garage or a broke cook who wants to 1. The psychiatric technician pro- open a restaurant. fession is basically state hospital nursing 7. Senate Bill 677* in its present care-oriented as to training and salary. form presents some problems. It provides 2. Inpatient services in communityfor a more expensive system of care loc- programs are in county or private hospi- ally than counties presently have. The tals provided under service contracts.financing is by reimbursement with no These county and/or private hospitals capital for expanding or starting program. have never used psychiatric technicians. It eliminates the present commitment 3. There is no such position in coun- system before the alternative program ty civil service structure. can be developed. It also identifies men- 4. Local mental health directorstally ill people in state hospitals as dan- look at cost of manpower related to gerous. This sanctions, by law, the fears skills produced. Six thousand dollars aand apprehensions the public has had year buys a technician, nurse or mentalabout the mentally ill. The onlymen- health rehabilitation worker with A.B.tally ill who can be involuntarilycom- degree. Who is more effective in doing mitted are those who have been certified the job? Program directors may not be as dangerous or those who are so disabled aware of skills technicians have. they need conservators. All otherscan go 5. Opportunity for vertical promo- voluntarily to the state hospital; but who tion in community programs is limited. would voluntarily go toa place that has Techniciansupervisors, A.S.N.S.etc., been explicitly designated for dangerous are not used as such because there arepeople? Would this bea safe place for not the large living units as in state hos-treatment? The state hospital remains pitals. Supervisory positions in nursinga major resource in mental health pro- are filled by psychiatric nurses, with orgrams. The Department of Mental Hy- without degrees. Horizontal promotionsgiene is committed to providingan ex- based on responsibility for managementcellent level of care there and is inte- of a program is more lilr.ely. Tvie7e is notgrating the two programs. Community much of an established formai personnelprograms cannot carry the treatment organization in county government spec-load alone. This language of the lawcom- ifically for mental health programs. promises the effective integration of state 6. Problems related to legislation:hospital and communityprogram by de- Community programs are funded by re-claring the state hospitalas the place for 12 dangerous people involuntarily commit- they still belong to the community of ted and then encouraging allothers mankind and, therefore, retain mem- voluntarily to go there. State hospitals bership in their own. They are in our have increased their voluntary admission thoughts, our plans, our hopes, and rates,openedtheir wards, developed our ambitions. therapeutic community programs, and in 3. The psychiatric technician remains some cases integrated their programs a major resource in mental health. with the community. At the same time There are some challenges. The profes- they havetreatedpeople who had sion has to meet these challenges to re- dangerous behavior because of mental main a viable resource in the commun- illness at no great risk to the safety of ity program. eithercommunity.Thishasbeen 4. There are some immediate organiza- possible because the focus was not on tional and legislative challenges to be the2atient's dangerous and possibly met if this manpower resource is going permanent behavior, but rather on the to be made available to community patient's treatable and therefore tempo- programs. rary illness. a) The education of lay and pro- The SB677 implies that once mentally fessional leaders in localprograms ill and dangerous always mentally ill and on the availability of this resource. dangerous, and this is perplexing to both b) The integration of supplementary the patient and the staff and makes for education and skill into the profes- suspicion and distrust of each other. sion necessary for the full utiliza- "I'm voluntary and safe." tion of the technician by the patient "He's involuntary and dangerous." in the community. "So if you're so safe why didn't theySenate Bill 677: This organizationas one keep you in your local program? Whyof the professional organiz ations of did you volunteer to come here?" people who care for the mentally ill Likewise in the localprogram the sameshould join with other professionalor- questions arise among the "three-dayer",ganizations to study this bill and make the "fourteen-dayer", and the volunteers. recommendations for revisions. Voluntary commitment which should We who have dedicated our profession- arise from self-awareness and self-seekingal lives to the care and treatment of the of help may well become submissionto mentally ill should not concern ourselves the tyranny of the system whichgrows solely with the mechanics of financing from fear. "Ifyou don't go voluntarilyprograms.Experts will do that. Nor for the treatment I thinkyou shouldshould we concern ourselves with the have, I'll haveyou declared dangerousesoteric philosophical preoccupations of and put away untilyou are proven safe."law. Other experts will do that. Nor should we concern ourselves with the In summary: same basic question that the authors of 1. We must dedicate our thinking to-the billthemselvesaresincerely day to the patients of the state hospi-concerned with, namely, "Howcan this tal community whoare left behind, as bill be made so that it will be effective in well as to those in the non-hospitalbringing services to the mentally ill with community who are here withus. a minimum of delay, despondency, and 2. The discussion of the communitydespair and a maximum of health and program is our message to them thathope?" * Lanterman-Petris-Short Act (Mental Health Act of 1967) provides for changes in the commitment system for mentally ill to prevent inappropriate and indefinite commitments. Other portions of the Act encourage the development of local services and foster a greater integration of state hospitals and local programs. 13 SYMPOSIUM: INTERPRETING FEDERAL AND STATE REGULATIONS WHICH AFFECT STAFFING STANDARDS FOR NURSING SERVICES IN STATE AND LOCAL FACILITIES.

MODERATOR:Leland F. Erbacher hospitals, nursing homes, establishments MEMBERS: for handicapped persons, certain clinics, home health agencies, and clinical labora- Howard A. Worley tories; and by formal agreement with the Ralph Zeledon State Department of Mental Hygiene, and subject to Department of Mental Moderator Erbacher is employed by Hygiene requirements, the Health Depart- the Training and Research Division, Per- ment licenses and inspects alcoholism sonnel Office, of the Department of hospitals, long term facilities for the Mental Hygiene of California. mentally ill and day care centers for the mentally retarded. The Department of Mental Hygiene has INTRODUCTIONS TO SYMPOSIUM sole licensing responsibility for psychiat- richospitals, day treatment hospitals, by Howard A. Worley children's treatment centers for theemo- tionally disturbed, family homes for Mr.Worley, a graduate of Stanford mentally ill, University and its School of Business, resident schools for the is Chief of the Bureau of Licensing and mentally retarded and nurseries for the Certification for the California Depart- mentally retarded. ment of Public Health. He has been with There is a Hospital Advisory Board, the Department since 1949. His Bureau appointed by the Governor, which ad- is responsible for the licensing of more vises the State Department of Public than 1900 health facilities and for their Health regarding reasonable rules and certification for participation in the state regulations for the hospitals and nursing and federal medical care programs. homes licensed by the State Depart- ment of Public Health. This Board holds The title for the subject matter being three to four public meetings eachyear consideied today suggests that the State to consider proposals for changes in the requirements for licensure of health facil- requirements for the licensureprogram. ities and the Federal requirements for The Recommendations of the Advisory participation in the medical care pro- Board must be adopted by the State grams are in need of interpretation. Board of Public Health, in public hearing, These requirements indeed do need before filing with the Secretary of State interpretation or at the very least as part of the California Administrative explanation. Words can mean different Code. things to different people and regul, In practice, proposals whichare con- tions must be set down in words. sidered by the Hospital Advisory Board By way of background, let me describe are discussed with the professional organ- briefly how licensure requirements for izations concerned: the California Hospi- health facilities are established. Asyou tal Association, the California Association know, both the State Department of of Nursing Homes, and the California Public Health and the State Department Medical Association. Each of theseorgan- of Mental Hygiene have responsibilities izations has a consultant to the Depart- for health facility licensing programs. ment on matters regarding the licensure The Department of Public Health licenses program. Additionally, special areas of 14 interest are discussed with the respective who is a registered nurse, a licensed voca- professional associations, particularly the tional nurse or a person who is quali- California Nurses' Association regarding fied by training and experience to super- nursing services and the California Coun- vise the nursing care in the institution. cil, American Institute of Architects The adequacy of this training and experi- regarding construction requirements. Dis- ence is determined by the Department. cussions are also held with the Associa- Nursing homes of 11 to 25 beds must tion of Medical Records Librarians, As- have a registered nurse, a liters red voca- sociation of Hospital Pharmacists, Physi- tional nurse, or a nurse graduated from a cal Therapy Association and others re- school of nursing who the Department garding specific problem areas. determines has sufficient training and The State Department of Mental Hy- experience to assume the responsibility giene employs similar procedures for of supervision of nursing care. developing licensure requirements for Nursing homes of more than 25 beds health facilities under its jurisdiction, must have a registered nurse on duty dur- except that no provision is made by ing the day shift responsible for supervi- law for an advisory board. Special com- sion of nursing care. Additionally, nurs- mittees serve this function on an inform- ing homes of 60 to 99 beds must have al basis. either a registered nurse or a licensed Each of the classifications of facilities vocational nurse on duty during the licensed by the two Departments have remainder of the day and night. Nursing differing staffing requirements for nurs- homes of 100 or more beds must have a ing and other personnel. It would be con- registered nurse on duty at all times. fusing not only to you but to myself if Mental Hygiene long-term facilities I attempted to recite these requirements have similar yet different requirements. in detail. However, I would like to men- The facility of 25 or less beds must have tion a few basic requirements and con- a registered nurse, a graduate nurse, a fuse you only with the specific require- licensed vocational nurse with twoyears ments for nursing homes and long term experience subsequent to licensure,or a facilities. certified psychiatric technician with All facilities are required to have suf- two years experience subsequent to ficient qualified personnel to provide certification to be responsible for care to patients in the institution both supervision of nursing services during the day and night. The actual number of day shift. Facilities of 26or more beds nursing personnel which must be em- must provide a registered nurse, during ployed involves a judgement factor and the day shift responsible for supervision can vary with the number of patients of nursing services. Facilities of 100or being cared for, the specific needs of more beds must have a registered nurse, a those patients, t!,-, qualifications of the graduatenurse,a licensed vocational nursing personnel employed, and the nurse, or a certified psychiatric tech- layout or arrangement of the physical nician on duty at all times. Facilities of plant. 200 or more beds must have a director Hospitals licensed by the Depart- of nursing services who isa registered ment of Public Health and psychiatric nurse qualified by education, training, hospitals licensed by the Department of and experience in nursing administration. Mental Hygiene require a registered At this point I can anticipatea ques- nurse on duty at all times, with additional tion running through your minds. Why qualification by education, training and do the Public Health requirementsex- experience for the director of nursesor clude mention of certified psychiatric supervisor in larger institutions. technicians? Public health nursing homes of 10 or Two other state agenciesnow become fewer beds must have at least one nurse involved-the Board of Nursing Educa- 15 lion and Nurse Registration and theequivalent of the Licensed Vocational Office of the Attorney General. section Nurse has been posed since. Such equiv- 2728 of the Business and Professions alency has, however, not been specifically Code- partof the Nursing Practice Act- proposed as an amendment to existing states: requirements. I can only point out that "If adequate medical and nursing the education and experience require- supervision by a professional nurse or ments for certification are different than nurses is provided, nursing service may required for the licensed vocational be given by attendants in institutions nurse, and that the psychiatric techni- under the jurisdiction of or subject to cian who meets the education and expe- visitation by the State Department of rience requirements may qualify to take Public Health, the State Department the examination for licensure as a voca- of Mental Hygiene or the Department tional nurse but only until next year, of Corrections. unless the law is extended. If I may digress for a moment. Al- "The Director of Mental Hygiene though there is no specific mention of shall determine what shall constitute the duties of the nursing supervisor in adequate medical and nursing super- regulations or requirements, she is ex- visionin any institution under the pected to perform certain functions in jurisdiction of the State Department of the nursing home. A high level of train- Mental Hygiene." ing and experience is necessary to per- The same Act defines a professional form these functions adequately. Let me nurse as one licensed as a registered nurse mention a few of her duties: in California. 1. Developing and maintaining nurs- The Board of Nursing Education and ing manuals. Nurse Registration has interpreted this to 2. Writing and updating job descrip- mean that in facilities licensed by the tions for nursing personnel. State Department of Public Health, 3. Recruiting and selecting nursing nursing services may be given by other personnel. than a registered nurse only if super- 4. Assigning and supervising all nurs- vision by a registered nurse is provided. ing personnel. This produces an apparent conflict for 5. Participating in patient care plan- nursing homes of less than 26 beds ning and job analysis. which are not required to providea 6. Coordinating the various patient registered nurse supervisor. The Board care services. of Nursing Education and Nurse Regis- 7. Planning and conducting in-ser- tration together with the Calif ornia vice programs. Nurses' Association has requested that 8. Determining the assignment of the regulations be amended to requirea patients in the facility. registered nurse supervisor regardless of 9. Delegating the responsibility for size of the nursing home. Such a proposal carrying out the patient's nursing care was reviewed by the Hospital Advisory plan and reviewing the plan with the Board in September and was referred to person to whom the duty was delegated. the Health Department staff for further 10. Making daily rounds, visiting each study. patient, reviewing clinical records, medi- The present requirements were cation cards, and staff assignments. adopted in 1959 following extensive dis- The basic statutory requirements for cussion by the Hospital Advisory Board. nursing services in extended care facili- The question of the certified psychiatric ties for participation in the Federal technician was not considered at that Medicare program are that at leastone time. That the certified psychiatricregistered nurse be employed full time technician should be considered as the in the facility and be responsible for the 16 nursing service, thata registered nurse The hospitals operated by the State or licensed vocational nurse be on dutyDepartment of Mental Hygieneare cur- at all times to be in charge of nursing rently certifiedas psychiatric hospitals. activities, and that sufficient nursingper- The provisions of the Federal Medicare sonnel be on duty at all times to meet Program permit the psychiatric hospital the total needs of patients. to have a "distinct part" and be certified Nursing personnel for determining ade- either as a general hospital formedical- quacy in numbers includes registered surgical servicesor as an extended care nurses, licensed vocational nurses, aides facility providing skilled nursing services, and orderlies. if the distinct part meets theconditions In addition, the facility must meet the of participation. Ifso certifies', the dis- State's licensing standards whether sub- tinct part is also eligible underthe Medi- ject to licensureor exempt. State licen- Cal program. sure requirements exceed Medicare condi- At the present time it is unclearre- tions of participation for nursing services garding the eligibility of hospitalsfor the in one area only, in that nursing homes of mentally retarded to participate eitherin 100 or more bedsare required to have a Medicare or Medi-Cal other thanfor a registered nurseon duty at all times. distinct part certified eitheras a general For the State Medi-Calprogram - at hospital or asan extended care facility. the present timethe only requirement The Departments of Public Health, for participationas a nursing home is Mental Hygiene, and SocialWelfare and that the facility be licensed by the Statethe Office of Health CareServices are Department of Public Healthor the working together closelyto attempt to State Department of Mental Hygieneor solve the problems both ofeligibility of be exempt from licensure. Furtherre- the hospitals and eligibility ofpatients. quirements, to be effective January 1,We hope thata satisfactory solution can 1968, are essentially thesame as forbe arrived at which will beacceptable Medicare for nursing services,or, pro- to the Federal agencies concerned. vided the State Department of Public In closing I would liketo leave a few Health determines by November 30, statistics with you. 1968 that the facility shows reasonable In 1956 the Health Departmentli- expectation of meeting this and othercensed less than 1,000 facilitieswith a standards, by January 1, 1969. capacity of 57,000 beds. Today,including The requirements for Medicare and for the mental health facilities,the Depart- Medi-Cal for hospitals owned andoper- ment licenses more than 2,000 facilities ated by the stateare the same as for non- with 150,000 beds. The bulkof this state hospitals. However,a problem spectacular increase has beenin nursing appears to arise. Hospitals accredited byhomes, which addedapproximately 600 the Joint Commissionon Accreditationfacilities and 50,000 bedsduring the of Hospitals by Federal lawmeet the con- 11-year period. ditions of participation for hospitalsif While we don't have complete informa- they have an acceptable utilizationre- tion onnurse staffing, some sampling view mechanism, and in thecase of psy-informationon nursing homes is of chiatric hospitals meet certain othercon- interest. Surveys of nursinghomes in ditions regarding medical recordsand 1961, 1964, and 1966 indicatethat nurs- social services. All of the State Hospitals,ing personnel employedhave kept pace exer;pt those operated by the Depart-with the increase in numberof beds. ment of Corrections, are certified topar- The table below shows the trend in ticipate in bothprograms for hospitalstaffing nursing homes. services.

17 Estimated Number of Nursing Service Personnel (Full time equivalent) in Nursing Homes

Year RN Graduates INN Other Total Beds

(March 31)

1961 700 260 480 5,400 6,840 18,778

1964 1,390 360 920 8,800 11,470 36,351

1966 2,100 100 1,400 15,600 19,200 61,736 (Sept. 30)

1967 2,500 100 1,600 18,600 22,800 61,229

by Ralph Zeledon program; and proposes departmental pol- icies and procedures for securing benefits Mr. Zeledon, Coordinator for Medi- for, and providing services to patients. Care for the California Department of Medicare is a nationwide program of Mental Hygiene,is a graduate of the medical insurance for persons age 65 and university of Southern California. Mr. over. It is related to he Social Security Zeledon was awarded a Master of Social Benefits Program and is an insurance pro- Work degree from the School of Social gram which limits benefits to a 90-day Work of Los Angeles, and is a member spell of illness or hospitalization. Medi- of the Academy of Certified Social Work- Cal or Medicaid as it is known nationally ers. He was formerly associated with the is a Federal encouragement for states to Economic Opportunities Council. launch their own programs in which the Federal Government will pay 50% of the Perhaps the best way to approach this cost. It is available for all four categories subject is to give you a brief description of public assistance and any medically f my job;then the history of the indigent who can meet the criteria of a Department of Mental Hygiene in regard welfare category other than income. A to the Medicare-Medi-Cal programs; regularmedical hospital canbillfor and finally bring you up to date where eligibleMedi-Calbeneficiaries in any things now stand and present goals and age group. However, with the psychiatric complications. hospital there is what is known as a riefly, the Coordinator of Medicare psychiatric exclusion which limitspay- Services coordinates the Department's ments to persons age 65 and over. program for securing benefits which are Medicare or Title XVIII pays almost available under the Federal and State 100% of the cost for prescribed periods Medicare laws and regulations; analyzes when the patient is eligible. Medi-Cal or and evaluates Medicare legislation, rules Title XIX is paid out of the Health Care and regulations to determine benefits Fund and then reimbursed 50% federally. available to mentally ill and mentally Therefore, half the cost is Federal and retarded patients and types of services half isState. But the Department of required for participation in the Medicare Mental Hygiene does not keepany of 18 these paymentsasit operateson an In 1956, the Department of Mental allocated budget. Medicarepayments are Hygiene requested that all 14 Statehospi- forwarded back to the Health CareFund. tals and the 2 neuropsychiatric institutes Therefore, thisprogram within the De-be approvedas psychiatric facilities. All partment of Mental Hygienerepresentswere approved on the basis of being ac- a shifting of cost from the State to the credited. Federal Government. Themoney does In California Department of Mental not go back to the hospitalto raise the Hygiene hospitals, thereare approximate- level of care. Thereare some minor bene- ly 13,000 mentally retardedpatients. Of fits to the hospital in meeting Federalre- these, approximately 177are age 65 and quirements. over and qualify for Medi-Cal benefits. To receive Medicarepayments, a hospi- If these hospitalswere classified as medi- tal must be approvedas a vendor of serv- cal instead of psychiatric, the psychiatric ices by the Social Security Administra- exclusion for patients underage 65 would tion. The Social Security Administration not apply. Thereare approximately does not have the staff within eachstate 7,000 patients between theages of 18 to survey hospitals and ascertain whichand 65 who could meet thecriteria of hospitals meet the Federalrequirements the Aid-to-the-Disabledprogram. The and, which do not. Therefore, eachstate potential revenue here is forbetween designates a stateagency to act in this $2.5 and $3 millionper month of which manner in behalf of the Social Security 50% would be paid for by the Federal Administration. The Federal Government Government. has spelled out the specificrequirements Therefore, the Department ofMental in the booklet entitled "Conditionsof Hygiene asked fora change in classifi- Participation for Hospitals". One ofthe cation for hospitals for the 'nentallyre- requirements which must bemet is con- tarded from psychiatric to medicalhospi- rt dition Number V for the NursingDepart- tal. This requestwas made in August ment. It reads as follows "Thehospital 1966. The Social Security Administration has an organized nursing department.A is admittedly apprehensive aboutchang- licensed registered professionalnurse is mo. the classification of the hospitals for on duty at all times and professionalthe mentally retarded. Theentire Title nursing service is available for all patients XIX program has cost farmore than ex- at all times." If a facilityor part of apected. Perhaps this is why theSocial facility is to be consideredan extended Security Administration hasnever made care facility, it must meet the following a decision on this matter. requirement: "The extendedcare facility When the Department of MentalHy- provides 24-hour nursing servicewhich giene requested reclassificationof the is sufficient to meet the nursingneeds ofmentally retarded hospitals,a difference all patients. There is at leastone regis- of opinion developed betweenthe De- tered professional nurse employed fullpartment of Public Health and theDe- time and responsible for the totalnursing partment of Mental Hygiene. Public service. There is a registered professional Health felt that the hospitalsdo not nurse or licensed practical nurse who is really meet the requirementsfor a medi- a graduate of a state-approved school ofcal hospital and that they wouldhave to practical nursing in charge of nursingac- be surveyed to determine theconformity tivities during each tour of duty." How- with the Federal requirements.Whatever ever, if a hospital is accredited by theportions did not conform wouldbe des- Joint Commissionon Accreditation ofignated as extendedcare facilities or Hospitals, it ispre; wed to meet all ofsimply not included in theprogram. The the requirements with the exceptionof Department of Mental Hygienemain- Utilization Review. Thisis a critically tained that accreditationwas sufficient important distinction. and the hospitals didnot have to be sur- 19 veyed. The impasse was not in the best the State's forfeiting between $12 and interest of the State. Therefore, in an $25 million per year of Federal money. effort to resolve the differences, the De- This is where the matter stands now. partment of Public Health agreed to sur- In concluding, I would like to com- vey one hospital to determine how far ment on the effect I believe these Federal apart the two Departments were in programs will have on the psychiatric their thinking but to take no action on technicians. The decreasing mentally thesurveywithoutDepartmentof ill population is fact, not prophecy. The Mental Hygiene approval. This was done question is to wl extent will it decrease. at Fairview State Hospital on July 25-26, I think there is lithe doubt but that we 1967. will see a similar de-population movement The findings of that survey were that of the mentally retarded. This poses two under one classification or another every questions: bed in the hospital could be approved if 1) What directionisthe mental 10 registered nurses and 10 LVNs were health movement taking in California? added to the staff. The Department of 2) How do we enable staff occu- Mental Hygiene asked the State Depart- pationally to fit in with the new direc- ment of Public Health to survey the rest tion? It seems to me that the future of the hospitals for the mentally retarded direction of mental health treatment in and present their findings to Dr. James California is spelled out in the Lanter- Lowry, Director of Mental Hygiene, for man-Petris-Short Act. his consideration. Every effort will be made to provide Suddenly, a barrage of telephone calls treatment on a local level so as to avoid were received at the Department of Men- state hospitalization. The local commun- tal Hygiene Headquarters protesting the ity then is where there should be job assignment of the additional staff. Dr. openings forpeople with psychiatric Lowry stated that there would be no experience. I would like to quote from changes until he could see the total rec- (Division 5, Part 1, Chapter 1, Section ommendation. The surveys were com- 5008(c) the Lanterman-Petris-Short Act pleted and the findings presented on in describing these local facilities: September 20. At that time, the adminis- "Intensive treatment shall be provided trative staff at the Department of Mental by properly qualified professionals and Hygiene recommended to Dr. Lowry that carried out infacilities qualifying for the Department hold its ground and COl- reimbursement under the California Med- itinue to seek approval of the hospitals on ical Assistance program or under Title the basis of their being accredited. XVIII of the Federal Social Security We are still in the midst of negotia- Act and regulations thereunder." tions. The hospitals may be approved by Therefore, the question of Federal the Social Security Administration on requirements will be faced in the com- the basis of accreditation. If so, there will munity as well as possibly within the be no need to alter present staffing pat- Statehospitals.Iwonder about the terns to qualify. If not, I cannot foretell possibilityof psychiatrictechnicians the outcome. pressing for an LVN equivalency rating It behooves us to look at the realities or some arrangement which would en- which will have to be considered in mak- able them to move into the positions ing a decision. To decide not to partici- which will be created by these local pate in the Medi-Cal program will mean facilities.

20 Legal Aspects Of Utilization Of Psychiatric Technicians In Mental Health Services by Robert Thorn, J. D. Thorn, an outstanding authorityon yer" or "physician", butone is also pro- forensic psychiatry who practices in San hibited from engaging in thepractice of Diego, California, is that county's Chair- law or medicine withouta valid State man of the Mental Health Advisory license. Historically, professionalrecog- Board, a member of the Governor's Ad- nition has come from licensing and from visory Committee on Mental Health, Pres- additional standards ofcompetency dev ident and Board member of the Vista eloped by an association of those engaged Hill Psychiatric Foundation, and has in the profession suchas those being served on the Medical - Legal Institute developed byyour association. The latter faculty of the Western and the California without the former, however, has Hospital Associations. He has also always con- been legally ineffective. Thepsychiatric ducted legal seminars for the National technician in California thereforeremains Association of Private Psychiatric at most a civil service classification with- Hospitals. out true legal identification. One thing thatcan be said about the In our modern societywe frequently laws of the State of California andthe hear cries of loss of identityor lack of administrative rules promulgated under identification. From the standpoint of such laws is that they professional identification in the legal are consistent in the non-recognition of thepsychiatric sense, the psychiatric technician might technician. A two-months intensive be classified as the all-time loser. While study of such laws, rules and regulationsof this the "Psychiatric Technician Law" has State discloses that inno single instance been part of the California Codes since outside of the "Psychiatric 1959, little has been gained under this Technician Law" is a psychiatric technicianrecog- statute toward legal identityas a true nized as even existing. professional in the healing arts. Thismay All portions of the CaliforniaAdmin- be primarily due to the fact that the istrative Code relating "Psychiatric Technician Law" isa cert- to professional ification actas distinguished from a standards for all types of medicalinsti- licensing act. tutions° from the nursing homeor sani- tarium to the general hospital, fail The distinction between the to set two basic forth a single mention of thepsychiatric types of legislative recognition, i.e., those technician, while at the of certification same time recog- vs licensing, is primarily nizing the professionalstatus of the this: Under the certification act,as in the case of the psychiatric technician, any Licensed Vocational Nurse. It ispaxcul- arly upsetting to find that inthe admin- individual, regardless of trainingor ex- istration rules for staffing under perience may hold himself out the to be a Short -Doyle Act, the categoriesdrop psychiatric technician andengage in such from the registerednurse to attendants. practices as are customarily performed Until the implementation of titles18 and by psychiatric techniciansso long as he 19 of the Social Security Act, better does not use the term "Certified Psychi- known asMedicare and our Medi- atric Technician". cal programs, little or no problems In the case of licensing,as in the pro- were encountered from the hospitals' fessi s ns of law and medicine, not only is standpoint in staffing standardsas they one prohibited from using the term "law- were primarily free to prescribe their 21 own rules within the somewhat vagueante of services by psychiatric technic- standard set forth by the Joint Commis-ians. Again under the Community Men- sion on Accreditation of the A. M. A. andtal Health Centers Act, the National A. H. A. Institute of Mental Health recognizes the Under the Nursing Practice Act, theutilization of the psychiatric technician Directors of the Departments of Mentaland will reimburse a hospital for services Hygiene and Public Health were givenperformed by the psychiatric technician carte blanche authority to determineunder its federal staffing grant. proper nursing staffing procedures in With the growing support of programs state hospitals. While currently Federalin the non-governmental psychiatric hos- Government is accepting accreditation bypital and mental Hcalth Center by both the Joint Commission as satisfactorythe State and Federal Governments, there proof of proper staffing for Medicare andobviously is a need for the increased util- Medi-Cal, there appears to bea great fearization of the psychiatric technician in on the part of the hospital administratorsuch facilities. that the Federal Government will in the During the last year, many adminis- near future impose greater and muchtrators and directors of nurses in such more stringent staffing requirements. hospitals, have expressed concern about While, as mentioned, California iscon-the use of psychiatric technicians for per- sistent initsnon-identification of theforming nursing services in relation to psychiatric technician, the Federal Gov-liability for malpractice. We have pointed ernment follows a great path of incon-out to such individuals that if a negligent sistency in this regard with its variousact is performed by an employee of the programs. hospital whether it be a psychiatric tech- In its 64-page book of rules for condi-nician, a licensed vocational nurse, or tions for participating hospitals underregistered nurse, the liability is identical. Medicare, the psychiatric technician isIn the absence of the negligent act by mentioned only once and this is in regardsuch employee, the hospital faces liability to the authorization to give medicationsonly if the employee is required to per- under the direct supervision of a regis-form a service for which he has not been tered professional nurse in a general hos-trained. In other words, we see no haz- pital. It is somewhat discouraging to findard whatsoever in the utilization of the that while these rules prescribe specialpsychiatric technician within the limits staffing procedures for psychiatric hospi-of his training. tals requiring utilization of milieu ther- I am sure that most of you here today ap3 and the team approach to treatment,are saying, "Well, we recognize our lack no reference is made to the psychiatricof identity under both State and Federal technician. law, but what can we do about it?" What The highest governmental authorityconstructive steps can be taken to gain for the interpretation of these rulesasprofessional recognition in the eyes of applied in the State of California hasboth the State and Federal Government. publicly stated that while the licensedI would suggest consideration of the fol- vocational nurse can be recognized in thelowing measure. staffing pattern, of a hospital, the psy- First would be an appeal to the Sec- chiatric technician, whether certified orretary of Health, Education, and Welfare not, cannot receive such recognition asto establish and recognize the psychiatric they are "not licensed personnel". Thetechnician as an integral part of the treat- identical procedures and applications arement team in milieu therapy, whether it utilized in Medi-Cal as wellas in the Medi-be in a psychiatric hospital or in a general care program. Conversely, in the federallyhospital providing psychiatric care. The sp nsored Home Health Program, reim-recent amendments to th,, Social Security bursement may be obtained f ur perform-Act give the Secretary a great deal of 22 discretion in setting forth the rules and technician seem to be by nature much regulations applicable to the Medicare broader in their scope than normal nurs- and Medi-Calprograms and he fully has ing practices, particularly in the applica- within his power the right to give such tion of other social sciences. re -tognition. Should the Secretary be non- As many of you are aware, the legis- responsive to such an appeal,we would lature amended the"Psychiatric Technic- suggest that a Joint Resolution of the ian' Law" so as to plate the psychiatric Congress be sought, expressingcongres- technician in a direct line of communica- sional opinion that the psychiatric tech- tion with the physician as distinguished nician be recognized ina professional from the former requirement that he be status under all of the various federal subordinate to a registered nurse. This, programs for the treatment of the men- at the request of the Department of Men- tally ill and mentally retarded. tal Hygiene, was unfortunately vetoed by Finally, and perhaps the most import- the Governor. We do feel, however, that ant, you should consider proposing a in the coming year with proper explana- proper licensing statute defining the tion to the administration, such legisla- scope of the practice of the psychiatric tion might be successful. technician and prohibiting practice of In a recent meeting sponsored by the psychiatric technology except by those California Hospital Association, a leading persons meeting proper standards of ed- ucation and experience. hospital administrator stated that thereg- istered nurse has reduced her role to that I think that the average citizen in of an injection giver and that otherswere California might be somewhat astonished performing her previous service of direct to find out that someone who is entrust- patient care. If others like the psychiatric ed with the great responsibility of direct technician are in fact performing such care to the mentally ill performs this service, why should they not be licensed, service as an unlicensed individual, while recognized and identified? no-one can cut your hair, or press your pants in this State without being licensed, We would question whether suchpro- posed licensing legislation should be sub- SEE APPENDIX I: servient to the Nursing Practice Act. ALL THAT GLITTERS MAY NOT BE The services rendered by the psychiatric GOLD

23 Private Psychiatric Hospitals by Arthur Jost service, prompted the church to move into a mental health program. At that Arthur Jost, Administrator of King'stime, 1946, it projected three small psy- View Hospital, Reed ley,California,is chiatric hospitals: one near Hagerstown, President of the California Hospitals As-Maryland, OM in Newton, Kansas, and sociation and Chariman of the Californiaone in Reedley, California. I assisted in Committee of the National Associationthe establishment of a 40-bed hospital of Private Psychiatric Hospitals. He hasnear Hagerstown which is considered to long been lauded as a leading authority be a comprehensive mental health center. in planning and development of psychi-I then assisted in the establishment of atric facilities throughout the country. Prairie View Hospital in Kansas. One of the very significant things this hospital is The California Hospital Associationdoing is working througha state hospital has historically been related to generalin the impl3mentation ofa large mental hospitals. Today, the administrators arecare research program. We also estab- being urged by the A.H.A. as well as bylished King's View Hospital in 1951 and the C.H.A. to establish community com-today this hospital isa 55-bed facility. prehensive centers which would includeWe also moved into the Day Carepro- care of the mentally ill. Some of us whogram in Elkhart, Indiana. Today we are have for many years been active in theoperating a rather large program there C.H.A. are quite concerned with thewith placement homes right in thecom- Health Care Fields movement into themunity. There, some patients fromout problems of the mentally ill andmen-of town can now stay overnight. tally retarded. Our most recent completed project is First, I want to goa little bit into myat Bakersfield. On the invitation of the background so thatyou can appreciateMemorial Hogpital Board in Bakersfield, some of my perspectives regarding per-our Board of Directors duplicated King's sonnel. About 20 yearsago, after servingView Hospital there and it has been in for 3 years ina state hospital both inoperation for oneyear. This 25-bed hos- personnel work and ward work, Iwaspital will be expanded to 50 beds. transferred to the headquarters of the The real motivations for this dynamic Mennonite Hospital in Pennsylvania. program in the United States in 1946 Through a great deal ofsurvey andwere diverse. One was to provide care for search work the Mennonite Church,our members. This element todaycon- which has operatedmany hospitals, nurs-stitutes only about 2per cent of our pa- ing homes, and old people's homes,tient load. We made it nonprofit and felt that it shouldmove into the areawere able to establish a reasonable fee. of providing instit,-.''ons for the mentallyThen, the church, through its colleges, ill. We had one mci institution locatedchurch programs and publications, be- in the Crimea in Russia. Many ofourcame interested in learning what it could people lived there, andone of the brightabout the potentials in the field. We felt spots in their history was the establish-that the hospital itself could besort of a ment of a 100-bed, non-sectarian generallaboratory wherewe would build experi- hospital. This heritage, plus experienceence that could help us progress. There during World War II in civilian publicwas also another motivation which came 24 out of our public service experience. This an arrangement with FresnoState was to utilize the large resources of per-College to train clinical psychiatrists in sonnel which we discovered to be avail-limited fields with limited scope. Once able. Thousands of young people havewe have the University closer we will worked in these institutions. It is veryproceed further into this field. We hope heartening to see how many of theseto be working shortly with Fresno State youngsters, having completed a year orCollege inpsychiatricsocialworker two, have gone into the various profes- training. We are not now training sions. We have today a large number ofpsychiatric technicians. psychiatric social workers inour church, Talking just a momentnow about a few psychiatrists, some nurses, and training for the future: All ofour centers, many psychiatric technicians who have King's View Hospital, Kern View Hospi- gone into these fields professionally be- tal, and other private psychiatric hospi- cause of the experiences they had in ourtals throughout the country will need to institutions. I might add here, parenthet- get much more actively involved in train- ically, that back in about 1950or 1951, ing programs. The National Institutecen- I also assisted in opening certain othertral office, which has been instrumental services at Mendocino, Camarillo, Atasca- in assisting us in obtaining Federal Grants dero, and a few other State Hospitalscontinually emphasizes thatwe must where some of our students andyounglook forward to future trainingprograms. personnel, were working alongside the As we develop this further in the valley, psychiatric technicians. we hope to be more involved in training At Kings View Hospitalwe have ex- psychiatric social workers,nurses, public panded to operation of out-patient clinics health nurses, and eventually psychiatric in Hanford and Visalia. At King's View technicians. Hospital we are wideningour sphere of I recall a number of years ago when activities. First of all,we are interested in he was Director of the Department of direct care to in-patients. Upto 1955 we Mental HealthDr. Cohan saidthat were pretty well satisfied that our pro-California would have the first training gram would be an in-patient service pro- program for psychiatric technicians in gram. But later, with development ofthe country. So I am justly proud of many of the drugs, we broadened ourthese service units thatwe established vista and became involved in non-directthroughout the state mental healthpro- services in (communities. So todaywe are grams, extensions which evolved out of interestedin both, and the in-direct Camarillo and other state hospitals. When services are being advanced in Visaliathis program got underway,a program and Hanford. Weare also very muchthat many of ouryoung people estab- interested in regional planning. In fact, lished, the results included the 300 hours we are very much involved in it. I believe of training which facilitated installation regional planning is rapidly coming into of the direct-trainingprogram. About its own in the psychiatric field. Justthat time, some 10 yearsago, I received recentlythere was federal legislationa telephone call from someone in your which has been implemented in Cali-association who wanted to discuss the fornia and other states. This will provide possibility of setting upa section in the the means of givingmore attention to private psychiatric health field for train- psychiatric facilities and planning. We ing psychiatric technicians. But, unfortu- are now exploring possibilities in Visalia nately, we never got beyond the discus- to provide in-patient services for acutely sion stage. We have since witnessed in disturbed patients. In Bakersfield,we California an active program of training will also be involved in regional planningfor psychiatric technicians. Unfortunate- with Kern View Hospital. ly, this trend has not permeated thenon- At King's View Hospitalwe now have profit, private sector. Wecan now look 25 at such possibilities more realistically. compliance with this bill. I am going to shift here and ask ques- I think it is very easy to see the im- tions about the future of the mental plications of this Act. No longer will we health field and mental health programs commit patients to the state institutions in general. We must know: Where will the through judicial procedure. Local treat- action be? Many of you have been inter- ment will be much more profitable and ested in the Mental Health Act of 1967. it will become, for local and county of- I understand by way of the grapevine and ficials and other people in the commun- through communication channels of the ity, a more palatable system. private psychiatric hospitals that there is We want to go much further than sim- a great deal of interest nationally in ply offering jobs or, if you are a psy- California's action during this last year. chiatrist, simply practicing psychiatry. We Under terms of this bill, which changes need a much more comprehensive pro- commitment proceduresinCalifornia gram. Where will the patients be in 5 approximately one year from today, we years? And where will the technicians of will no longer see large numbers of peo- the future be trained? I am very closely as- ple being committed to state institutions. sociated with Reedley Junior College. We We will see further implementation know that colleges today are seeking ad- whereby local communities will need to ditional programs to assist the commun- contract with state hospitals if they wish ity. It does seem that very soon we should to continue to make services available by be able to get junior colleges to supple- state institutions. Even though financing ment training programs which are going is not spelled out too clearly, we must on in state institutions today. It doesn't ask ourselves what happens when large mean that we need to replace state hos- amounts of money leave the county in pital, training programs, but we need to order to provide services to county resi- supplement them. We need to have sim- dents in state institutions. How will this ilar programs right in the community. A work? How will the governing body of lot of youngsters who are not going to a the county react to this, and how long university or a 4-year college would go can it go on? How active will state hos- to a junior college if they could find pitals be? How rapidly will we move into something there to challenge them and these programs in the local community? lead to a good job serving thecommun- Assemblyman Frank Lanterman, as ity when they finished. I think this could you know, is one of the chief authors of be made into a very practical program the bill. What Mr. Lanterman wanted to for either a four-year or two-year college. achieve was a change in the commitment Having been quite close to this forover laws. He simply wanted to reduce com- two years, and having discussed this type mitments. In visiting with him the other of program with Reedley Junior College day he pointed out to me again how sin- officials, I believe we couldmove ahead cerely he wants to see this done in Calif- in this area. Another question is: How ornia so that other states can followour do psychiatric technicians relate to the example. I think we must understandR. N. or the medical personnel. Mr. that even though the bill doesn't include Thorn's paper touchedon this in a very all the methods of implementation, and positive and very constructive way today. even though there will be regulations I was involved ina CNA study and the that are not going to suit many ofus, presentation of the urgency act to keep the central kernel with whichwe can the certification program going for the find no argument is the one of treating psychiatric technician. Forme this was psychiatric patients by moving them into a very excellent experience. I became community treatment centers. I believe further acquainted with the needs of the we are going to see from Mr. Lanterman psychiatric technician and gaineda new and others a very heavy emphasison appreciati n for them. I appeared before 26 a hearing in Stockton on behalf of thetraining when they come to us or at P.T.'s at one point. But what we have inleast there should be a parallel training Mr. Thorn's paper would go even further.going on and a certificate or license At this point I would like to go intoshould be issued when they have been some of the problems we are having intrained. I have felt this for a long time, small, private psychiatric hospitals. Inhaving had experience with recruitment our program we have about 120 employ-and staffing of a private hospital. The ees, and you can well understand thatpeople who do this supervisory work and many of them are psychiatric aides training are another problem. Finding we don't use the term psychiatric tech-psychiatric nurses who are qualified to- nician. We do have a classification andday is like finding a needle in a haystack. salary structure for psychiatric technic-In Bakersfield today we have a psychiat- ians written into our personnel programsric nurse who is a good trainer anda and policies, but we have never hired one.good supervisor. Sowe have one. But in We didn't understand the need for them.some of our other hospitals, we have At Carmel about three months ago wepicked up R. N.'s who have had little, if participated in a meeting of the Californ-any, psychiatric training to be t;:e train- ia Committee of the National Associa-ers and the supervisors. You can see what tion of Private Psychiatric Hospitals, anda tremendous burden this puts on the finally realized how many hospitals util-psychiatric social workers, psychiatrists ized the psychiatric technician. One hos-and other people whoare really trained pital administrator spoke of his doubtsin the psychiatric profession. There is about using P.T.s in private hospitals. Instill this great lack of qualified trained defense of the psychiatric techniciansmanpower. I would suggest that some- there were three or four hospital admin-how we get togetherthat somehow we istrators who lauded the extra back-find a way that PT'scan work into the ground and training as well as the com-private sector. We are going to be moving petence of the P.T.s they had hired. Iinto community health centersvery rapid- could see from the conversation thatly. I suggest that in fiveyears community there were many ideas on how the P.T.mental health centers, general hospitals can be used in psychiatric hospitals andand private hospitalsare going to move a can be used in community centers. Welong way toward shorter treatmentper- have one on our staff at King's Viewiods. Patients will leave the hospital for but he is working in our two-county hos-the community but they will still need pital in Hanford, assisting with workour personnel outside of the hospital or which perhaps some social workersorin the clinic. Some ofus are rushing to public health nurse could do. But thisthe NIMH trainingprogram to prepare man does it very well. All our personnel,ourselves for this new frontier in staffing. our social workers, psychiatrists and psy- We want people in ourprogram who chologists have agreed that he doesacan, when they come to us, show us their mighty fine job. He's got their blessing.credentials so thatwe can employ them The people we pick to work inouras supervisors and administrators inour hospitals are housewives people whohospitals knowing they have beentrain- have raiseda family and have knowned. I am certainly not down-grading the something about human relationships.staff we have. I think theyare doing a They are warm and like people. We havemagnificent job. As I said at theoutset, about 78 of these, none of whom hasin the last 20years we have seen a thou- had formal training. This putsa tremen-sand of theseyoung people make a con- dous load on our supervisory personnel.tribution, and at thesame time they have They have to train them to work withbeen helped to achieve greater human psychiatric patients. I don't think this isunderstanding and have been guided into right. I think these people should havethe mental healthprogram. This is great, 27 but if we expect nurses whoare RN's, expect a great "Amen!" from all these doctors who are M.D.'s and L.V.N.'s other professions. They should certainly with licenses to performas licensed pro- say "Amen!" to new frontiers, new dia- fessionals, PT's, too, should have licens- logues, and new approaches because they ing. On the other hand,we should not are coming.

28 Programming For The Future

Senator Petris, a Stanford Law School fice has a deep liking for people.If we graduate, represents A lemeda County and didn't, we wouldn't be in politics. There has been a member of the Legislature are those who saythat politicians love since 1958. He co-authored the Mental mankind and hate people, but that's not Health Act of 1967, developed while he true. Anyway, all of these things put to- was Chairman of a Senate Committee gether make the job of the legislative ad- with jurisdiction over the Mental Hygiene vocate a very difficult one. And it's ex- and Social Welfare Departments. Known tremely tough to try to get in to see all for his legislation of social significance, of these people who have important he is also a member of the Public Health things to do about legislation. There are Committee. 120 of us and more than 500 legislative advocates. When you take all of us and As an official member of the official count all the number of persons that try family of the state of California, repre- to see us and combine them with all of senting the legislative branch, I extend a our visitors from home, youfind that a hearty and warm welcome to all our vis- a really effective legislativeadvocate has itors from out of state. to be very nimble, he has to have a good Before I discuss the subject which has personality, he has to know his subject been assigned to me, I want to make two matter, and most of all, he has to enjoy or three personal comments. One is, I the confidence and respect and friend- want to congratulate your association on ship of the members of the legislature. your choice of a representative in Sacra- And I'm here to tell you that Bill Grimm mento, Mr. Bill Grimm. He didn't know is worthy in the highest degree. I think I was going to say this, and it would be you should be very proud ofthe work he easier to say if he weren't here, but he's does for your group. done an outstanding job, and of course Secondly, I should let you take a peek you who are active in your association with me, inasmuch as the subject that know about it, but I think this word has been assigned to me is taking a look, should b e transmitted to all of your at programming of the mental health pic- members here and at home. The task of ture for the future. But I can't talk about representing an organization of this kind the future without talking a little bit is a state-wide job and an extremely dif- about the past. Although I haven't been ficult one. Any of you who have dealt active in coming to your meetings or with any of us know that every single meeting with you as individuals, I want one of us is egotistical. That makes it you to know that I've learned a lot about difficult right off the bat. Ifwe weren't, you and the things you are doing from we wouldn't offer ourselves for public Bill Grimm. I've also learned a lot about office. Of course we go into it because what you are doing, not as members of we are concerned about the problems of this organization, but as employees of people, and we are hoping to offer the our great state. You are working in an best solutions we know to take care of area which is one of the most difficult of these problems. But we also go in because all. I've gained a tremendous amount of of the attention we get. We like to be in- admiration and affection for you as in- cluded in the center of the spotlight from dividuals by looking at your reports, by time to time. Basically, however, any pol- conferring with doctors with whom you itician who offers himself for public of- work, and some of the people in the De- 29 partment of Mental Hygiene, and lastly, Many people have heard some things by checking the budget each year. It was about the Mental Health Act of 1967. my duty for about four years, as chair- It's a kind of milestone. We don't know man of the subcommittee of Ways and exactly how it's going to work out. We Means which had jurisdiction over mental 4tre to some extent taking a chance on hygiene, to see what the budget provis- Congressional provisions, but in looking ions were going to be after the Governor ahead, I wanted to make three or four submitted it to the legislature for the en- points extremely clear which I think will suing year. I've always been amazed that link directly to your profession and your the State of California has been able to work. recruit as many persons in your fieldas Number one, I hope you don't feel we have through the years without pay- that this bill was designed to dismantle ing much higher salaries, and without state hospitals or close them and send all offering a lot of other fringe benefits that the technicians and other people working are available with other types of employ- in the hospitals off to the wilds some- ment outside of state service. I always where or to another area where they have came to the conclusion that there must not been trained to work. I know that be a tremendous missionary zealcom- Assemblyman Lanterman, who was prin- parable with the clergy,our great teach- cipal author of the bill and introduced it ers, and others to whom society has not in the Assembly, shares my view that yet demonstrated sufficient gratitudeor we're not going to stand by and watch sufficient understanding of the import- psychiatric technicians as a body disinte- ance of the work they are doing as well grate because we are trying to de-empha- as the extreme sensitivity and complexity size this enormous centralization of care of their jobs. If it isany comfort to you,for the mentally ill that we've had for I want you to know that I personally many many years. I know that there is a bave that view, and I knewmany other major defect in the code now by virtue !yen hers of the legislature do too. The of the fact that psychiatric technicians pronlems, unfortunately,are that every are unique to the state hospitals. There time the budget session doescome up, are very few of you operating outside everyone is scrambling for that tax dollar, the state hospitals. You get all ofyour and it's very difficult to make the alloca- training in state service, and the various tions that you want to make. I alsowant sections of the code which define what you to know that I personally, because the psychiatric technician is limits it to of this knowledge, continueto admire state hospitals. you individually and as a group, and will It seems to me that the state will not continue to do every thing Ican for you. be meeting its responsibilities ifwe de- I have had many fights in thepast on cide to decentralize to such an extent this to see that the salaries and the that a large number of psychiatric tech- structure of compensation ofour people nicians have to follow a patient from who are workingas psychiatric technic- state hospital centers to the local com- ians in our state hospitalsare continually munity without providing equal provis- upgraded. I feelsorry that it's not a lot ions in the code safeguarding the tech- better today than it is, butwe haven't nicians' interests. I, for one, intend tosee forgotten, although sometimes itseems to it that this is done; I hope in this that we have. It's just that other things coming session. We must transfer the def- get in the way, and appeara little more inition from state hospitals alone andex- charming by virtue of the fact that they pand. it to include the same definition in are in even worse shape. We get back to all local mental health facilities whether trying to pick through, andgo from year they be public or private. I pledge to you to year with improvement inas many that I am very much interested in that, programs as we can. and will work to get a bill through this 30 coming year. I have talked about it. to lower category of medical hierarchy. Bill Grimm. We have at least anotheryear There are tworeasons why I tell you to goalmost another yearbefore the this. Not just because I'ma politician LantermanPetrisShort bill is actually who is trying to pleaseyou, and I haven't put into operation. I would hope that even checked the roster to see howmany you can devote some of your time, at of you live inmy district. I say this for home in your local chapters,to assist two reasons: numberone, as the decen- with legislative recommendations that tralization process is acceleratedand will make our transition smoother, and more and more people are cared for loc- beneficial for both patient and the people ally, county aftercounty will have to who take care of the patients.You make provisions forsome kind of hospi- people, in my judgement, will reallyform tals or clinics whern thereis more than the backbone ofour entire state mental out-patient care. The patientwill stay hospital system. overnight, or fora few nights or for a So, when we look at the future,we few weeks. Andmore and more private see, number one, a continued decentral- facilities will be established. Thepressure ization of care of mentally illaway from on local private facilities and public fac- the large hospital centersto more and ilities from the families whoare clamor- m i re treatment in the community. This ing to see that their patientsare cared trend was started with the originalShort- for at home will rise in directproportion Doyle Act of 1957. Thatmeasure pro- to the number of patients thatare taken vided formany improvements for the care of at home, for better standards of care of the mentally ill. We have managed training andpay for the people who help to keep a lot of people closeto home those who need the help.It is as simple where theywere able to visit with their as that. families. And inmany situations it has The secondreason of course is that been clearly documented that theeffect those ofus in Sacramento who arecon- on the morale of the patient is such that cerned about theseprograms are not go- he actuallysnaps back to normal a lot ing to abandon thepeople who have faster than he does faraway where he been so brave in helpingus take care of feels thatno one cares about him. He the mentally ill. Weare going to do our simply, in manycases, lost his will to best to see to it, together withpressures live. from people at home, thatsome positive The first signs of lookinginto the fut- and constructivesteps are taken in the ure is the continuation of this develop- current session. The key is workingto- ment fre,'I the past. That ismore and gether toward this goal. more decentralization to the extent that The third thing Isee in development we can do it and still improve the service in the next fewyears is a continuation of to the patient. the use of state hospitals.I know you've Along with that will bea change in been told bymany that they would be the law so that the psychiatrictechnician closed, particularly sincethe Administra- and others who will be transferredto tion first announced all thoseenormous follow the patientas it were, will also cuts, which I opposedvery strongly. Rest maintain at, asan absolute minimum, assured we do not intend bythis bill, the the status theynow enjoy, and we hope Mental Health Act of 1967,to close up will be improved. the state hospitals. Thereare different My prediction is that thestatus of the kinds of patients,as you all know better psychiatric technician will beupgraded than I do. We intendto emphasize, and rather than kept at thesame level or continue emphasizing, localtreatment for down-gradedeven though people tell you those whoare amenable to local treat- now that they are going to )try for sal- ment. But thereare also many many aries in a lower category ofpay andother patients who simplywill not be 31 P

,

able to respond and will have to go to me fairly obviousfrom the figures we state hospitals. People get the wrong im- have been receiving consistently for sev- pression, that because we want to keep eral years, that the need for hospitals as many of those patients at home as we will continue simply because more of our can, we're going to automatically close people are cracking under the strain of up the hospitals. What is going to happen an advanced technology that we have in to those other severely ill and chronic our societythey are cracking under the patients who have been there for years? strain of the rat race the enormous Are they just going to be tossed out amount of worry we seem to be doing, somewhere? Of course not. As a matter both public and private, about private of fact, one of the reasons that we feel affairs and public affairs which are be- we can help all the patients is that if we coming more difficult and complex. We keep the newer milder cases active in have wars overseas too many of our their own community with local help, young men are being killed down to state hospitals to concentrate on those city problems even though it may be who need help the most. just wrestling over a city ordinance. There is another thing that I would We hear that the need for mental like to predict for the future in connec- health services is lessening. This is one tion with the role of the state hospitals; of the misleading statements that has they will have changing functions. They been made frequently with respect to the will remain as important training centers cuts in the field of the Mental Hygiene for medical personnel who will be need- Department and the staff. I challenged ed in the local communities. We intend the Administration time and time again, to change the definition of the psychiat- publicly, in press conferences, on the air, ric technician to include those persons and elsewhere, to take part in panel (1:4s- who work in local county hospitals and eussions with the Director of Mental Hy- other local, public and private facilities giene on this one point. I thought it was These individuals must be trained. Where a cruel and misleading approach to say are they going to get their training? We that because of the population in the can't start with brand new facilities in state hospitals the population is now all of the counties who don't have the lower than it was on any given day last experience that you have had and which year or two years ago that there is no the doctors have had on staffs of our longer any need for additional personnel state hospitals. Training for all these local or that the personnel can be reduced in facilities must come from our large train- direct proportion to that reduction in ing centers which will be the state hospi- population. The actual total number of tals. Unfortunately, many of you will be patients treated in our state hospitals is pulled away from the bedside work that still growing each year bysome 12-13 you are doing now. Many of you will be thousand. In fact, the first six months called on to train other psychiatric tech. of this year, the increasewas very sharp nicians even to a greater extent than you over last year a lot more than were are doing today. This I think may not be actually predicted which means we realized immediately at the coming ses- will actually need more personnel, rather sion, but it will definitely be part of the than less, and I hopewe discover that officially at the proper level ofour state trend in the next few years. government in time to reverse the present Then we have the final prediction trend of cutting back. People don't real, which I would like to make before giving ize that even though theremay be, and you some of the details about this Mental there is, a smaller total number ofpa- Health Act. My final prediction is (and tients in the hospitals here today, that it's not one based on medical knowledge thousands more are being treated. We have because I'm not a doctor) but it seems to been able to reduce drasticallyover the 32

1. last few years, the total amount of time county officials seized uponsome eccen- which an individual patient spends in the tricity some little form of senility or hospital. That doesn'tmean the service something along that line but certainly drops. The service to each patientgoes not a person who was psychotic under up, and it doesn't mean there are less the law and belonged ina state hospital. patients, because as the figures have in- We also found that therewas a sharp de- dicated, there are thousands and thous- cline in their desire to live. This happened ands more patients eachyear than we many times, 80 percent of these people have ever had before. Whenyou combine died the firstyear after coming into the all these things and put them together, state hospital under those conditions. We I don't see how peoplecan say that they wanted to eliminate that. see the hospitals are going to be folded Once we got into the possibility of up either because of the Governor and changing the commitment procedure, his cutbacks or because of the Lanter- then of course we became involved in man-Petris-Short bill. what happened to these people at home, What does the Mental Health Act of and we had to lay outa program designed 1967 provide that might giveus a little to offer the maximum amount of service. hint toward the future? Well, Mr. Lan- That is basically whatwe do with the terman started on this problem in 1955, Lanterman-Petris-Short bill. We havea before I ever went to the Legislature. He pre-petition screening to avoidunneces- and I were both concerned about the sary involuntary detention. The whole commitment process the thing that thrust of the bill reallygoes to the com- happens beforeyou people ever see the mitment process. We try to reduce the patient. We found thatwe have an an- proportion of those whoare committed cient commitment procedure in this state involuntarily and increase thepercentage which has resulted insome terrible injus- of those who seek attention voluntarily, tices with the result thatover the years This is a program whichwas tried in other thousands upon thousandso f persons states with this emphasis, and it worked have been transferred to state hospitals beautifully, andwe hope that it will work who didn't belong there. I'msure many as well here. Some of our hospitalsare of you are aware of this. It happened doing it already,as a matter of fact. We that many persons, particularlyan older have a comprehensive evaluationof a age group the senior citizens category patient which is necessary to determine who had no relative to look after themthe nature of his problems and thebest or whose relatives and friends turned solutions, locally with the screeningcom- their backs on them, became the victims mittee. We want to tie the involuntary of a combination of indifference, apathy, detention and treatment througha cert- and downright hostilityon the part of ification procedure andnot just through private citizens and the budget conscious- a court hearing which takes only a mat- ness of public officials. We found thatter of four and one-half minutes inmost many, many counties who simply did not parts of the state. When peoplecome want to pick up the tab for takingcare into court, bewildered after three days of some of these senior citizens locally, of intensive observation, inmany cases felt they would take the least expensive before they know what has happened, way out and simply dump them into thethe judge has banged his gavel and said, state hospitals because of the fact that "This person is going to such and sucha the state pickedup 100% of the tab andhospital," and that's the end of it the local county doesn't have topay any- We allow a maximum of 14 days forin- thing. We found in thecourse of our voluntary treatment, andno extension of research, that some 3,000 to 3,500 senior that unless there is another screeningpro- citizens were being wrongfully dumped cess and full and ample opportunity for into state hospitalsevery year. But thea hearing before the patient is movedon 33 to the next step. The right to a court right to have reasonable access to tele- hearing, when it is requested, is made phones, both to make and receive con- during the first 14 day period. We havefidential calls, and we had a lot of static additional periods of 90 days of invol- on this too; the right to access to letter untary commitment for the benefit of writing materials, including envelopes and persons who are proved in court to be stamps, and the right to receive and mail dangerous to others. In this area we left unopened correspondence; the right to out the point of being "dangerous to refuse shock treatment; and the right to themselves". This is an area of great con- refuse a lobotomy. The denial of these troversy, but the experts themselves arerights, if it has to do with treatment and divided on the question, and after serious is in the interest of the patient, can be consultation with many experts and con- made by the appropriate person on the sideration of the problem, we decided to medical staff. However, an evaluation omit, not to include, the area "dangerous must be made, and indication must be to themselves" because we were con- made in writing in the file as to why the vinced by the majority of the experts particular right has been taken away both that this was really the best thing for the for the purpose of reviewing and for rec- patient and that it would reduce the in- tifying, if need be, in case the patient cidence of suicide. We have two options wasn't helped and we need to find out available to judges. Whether they refer why the policy of the bill was not carried people to state hospitals or a local facil- out. ity, to an alcoholic clinic, alcoholic treat- There are several other provisions in ment facility, and so forth. Now, youthe bill, and many of them are simply see the major emphasis is, number one,repeating present law, but those are the away from relying on automatically send- basic parts. I just thought I would des- ing people far away from their homes to cribe them to you, partially to give you a massive institution, and continuilig the a picture of what to expect in the next previously established policy of 1957, of few years. In closing, once again I want more care at home. Number two, a great to say that I, as a member of the Legis- deal more concern about what happens lature, am very grateful to each and every to the individual as a person in the com- one of you for the services of you per- mitment process, and after he gets in the sonally and as a group, performing the hospital. Number three, a much greatertasks you are doing and have done variety of choices for courts and local through the years. Speaking of transfer- judges as to what can be done, and a ring other people and going other places, much greater regulation about what if we lost you psychiatric technicians,we should be done by direction from the might just as well close up these hospi- state than we've ever had before. Then, tals because we can't do any good with- after the patient gets to the hospital, he's out you. There are more of us who know going to have many more rights than he that than you probably know or under- had before the right to wear his ownstand. There are many of us whoare clothing instead of some type hospitalconcerned about the problem thatwe garment; the right to keep his own per- haven't been able to move ahead with sonal possessions, including his toiletyou as fast as we would like. This new articles, and the right to spend a certainlaw as it goes into effect in July, 1968, amount of his own money for canteenmay need changes that we do not know. expenses and small personal items; theWe would greatly appreciate your help right to have access to individual storage and recommendations before it goes into space, (Some of you who think we areeffect because we have a full and regular crowded now may laugh at that, but we session. We deliberately establisheda lead all know that this has to be worked out.);time of a full year for all persons whoare the right to see visitors each day; thedirectly concerned to study it thoroughly 34 and giveus recommendations for im- changed toone that doesn't mention provements in the law, refining itso we your training, your experience, oryour can improve services and also upgrade background. I thinkas a counter measure training and standards andcompensation it would be wise to have legislationand and everything thatgoes with the needto have you work hard for it, which to have the best possible personnelcon- creates official recognitionin the form tinue to serveus. of licensing if thatappears necessary and With that I will thankyou for extend- it may well be the best form of your ing me the honor of addressingyou, and own classification rather than being class- hope youcan go back to your respective ified as LVN'sor anything else. I would hospitals refreshed and withnew ideas heartily opposeany effort, and I Ichow and new determination. Iwish each and some people have interpreted it thisway, every one of you the best ofsuccess in to state that if youare moved into a every area of this field. county setting you are automaticallygo- I thankyou very much. ing to be classifiedas LVN and that's the end of it. I thinkyou should fight for yourown classification which is un- ique, to get official recognitionat the local level as wellas the national level. Question by Executive Director: The LVN's, and I have nothingagainst them and don't It has been suggested in mean to be critical of some quarters them, are simply not trainedand do not that the best method of transferringfrom have the backgroundto do your work. the state hospital to the communitypro- I would urgeyou to band together and grams would be for us to become some- make that one of thing other than psychiatrictechnicians; your most urgent pro- grams for 1968. I would be in to give up the role and become LVN'sor your cor- something else. Couldwe have your ner and I will do everything Ican to see comment on this, Senator? that your classification is officiallyre- cognized thatway, and if you need lic- SENATOR PETRIES: I personally wouldbe ensing in that category, then let'sgo after opposed to havingyour classification licensing. I wishyou the best of luck.

35 APPENDIX I

ALL THAT GLITTERS MAY NOT BE GOLD Californians have always taken great pride in "pioneering". The cries of

-1P "Eureka" brought strong-hearted indiv- iduals from all over the world to Calif- ornia a century ago. Such persons were quick to find uut however, that all that glittered on the ground of the Golden State was not gold. The 1967 Legislature has pioneered in the field' of mental health with the adoption of the Lanterman-Petris-Short Act. The motivation behind this Legisla- tion was definitely good. The legislation was directed primarily at the practice of indefinite court commitments to State Hospitals which definitely had been ab- used in some counties. The Act, however, goes far beyond these problems and will revolutionize the treatment of the ment- allyill in this State. Unfortunately the philosophy contained in the Bill that only those individuals who have threat- ened or attempted injury on the person of another need more than 14 days in- voluntary treatment is not a medically accepted fact. Unless amended by the State Legislature, this "noble experi- ment" will be put into effect during the current year. Regardless of the outcome, it will have a dramatic effect upon all non-governmental psychiatric hospitals. The question still remains whether either the mentally ill and the profession of psychiatry can live with the Act. What is even nriore important, is whether or not society can live with it. Robert Thorn, President r Vista Hills Psychiatric Foundation 5 January 68 36

0 APPENDIX II

Curriculum Report by Anabele Miller

The areaof psychiatric technician this category of worker so that hecan training is one that has received consid- make the most useful contribution to the erable attention in the last ten years. care of patients and families in commun- Providing adequate care for patients in ity mental health facilities. psychiatric hospitals, schools for the men- With this in mind a committee has tally retarded and other mental health been working during the past several facilitiesisa problem that has been months to develop an effective training brought sharply into focus by the 1962 program for psychiatric technicians. The Report of the Joint Commission on committee has suggested the following MentalIllness and Health. framework for the development of such Statistics indicate that most of the a program. 24-hour-a-day care of patients in psychi- The purpose of the program is to train atric hospitals is given by a group of a generalized psychiatric technician prac- workers variously designated as psychi- titioner who can function therapeutically atric technicians, aides, attendants and with patients and families in the hospital, nursing assistants. Up to the present time, the home and the community. they have constituted approximately 80 The primary difficulty with college- percent of the nursing personnel in psy- based programs is their lack of relevance chiatric institutions. Of all the people to problems confronted on the job. The concerned with the treatment and care difficulty with in-service training is the of the psychiatric patient, the psychiatric low level of cogoitive areas of learning technician has the most continuous and that give a broadei base of understanding constant interaction with him. The tech- to the mental health worker. nician has the opportunity to develop This training program is also an open- close relationships with patients and for ended course of study and practice that observing _their behavior in a variety of will permit the psychiatric technician to situaticr(f,: augment his academic achievement,if The question has been raised as to the able and motivated, with a further car- most effective and efficient way to train eer in the mental health field.

37 OUTLINE OF RECOMMENDED ASSOCIATE IN ARTS PSYCHIATRIC TECHNICIAN DEGREE ELECTIVES STUDY PROGRAM Anatomy & Physiology Semester Pharmacology First Semester CreditsAnthropology Learning Theory Clinical Work Experience 4 Sociology of Mental Health and Seminar 3 Social Psychology Art Group & interpersonal 2 Aging Music Process Lab Psychology 3 Community Organization & Sociology 3 Social Case Work Physical Education 1/2 Special Studies Honors Sociology of the Family 151/2 Introduction to Data Processing Second Semester Clinical Work Experience 4 and Seminar 3 Group & I Nterpersona I 2 Process Lab Growth & Development 3 Health & Education 2 Elective 2-3 Physical Education 1/2 161/2 -17% Third Semester Clinical Work Experience 2-4 and Seminar 2 Group Process Lab 2 Abnormal Psychology 3 Elective 3 English Composition 3 Physical Education 1/2 151/2_171/2

Fourth Semester Clinical Work Experience 2-4 and Seminar 2 Group Process Lab 2 Elective 4-6 American Hist. & Govt. 3 Physical Education 1/2

131/2 -171/2

38 THE NATIONAL ASSOCIATION OF PSYCHIATRIC TECHNOLOGY

and

THE CALIFORNIA SOCIETY OF PSYCH!ATRIC TECHNICIANS are dedicated to the demonstrated competence of psychiatric technicians in the areas of behavioral care, treatment and training. We feel that curriculum and stand- ards must be developed for the entire profession, adaptationsmust be periodically reviewed and modified to the changing focusof the mental hygiene field, and through these changed accents, the skills, treatment and training of the psychiatric technician must be enhanced and the technician himself challenged.

We need your assistance. In order topress for increased recognition, to work for professional development and recognition, improved working conditions andhigher salaries, to establish high standards ofour profession through legislative action and to develop a uniform curriculum nation-wide, we must have financing.

The status of the psychiatric technician has consistently been improving, and itcan be greatly accelerated through your cooperation and support. wwwwwwwwwwwwwwwww Please send me a membership application in THE NATIONAL ASSOCIATION OF PSYCHIATRIC TECHNOLOGY, 1127 11th Street, Sacramento, California 95814.

Name Last 1stInitial 2nd Initial

Address Phone

City State Zip

Please direct me to the state psychiatric technicians association in my state. 0 I would like information on helping to form a state psychiatric technicians association 0