(navigation image)
Home American Libraries | Canadian Libraries | Universal Library | Community Texts | Project Gutenberg | Biodiversity Heritage Library | Children's Library | Additional Collections
Search: Advanced Search
Anonymous User (login or join us)
Upload
See other formats

Full text of "North Carolina journal of mental health [serial]"

HEALTH SCIENCES LIBRARY 

OF THE 

UNIVERSITY OF NORTH CAROLINA 




Digitized by the Internet Arcliive 

in 2011 witli funding from 

North Carolina History of Health Digital Collection, an LSTA-funded NC ECHO digitization grant project 



http://www.archive.org/details/northcarolinajou41970curt 



NORTH CAROLINA JOURNAL OF 
MENTAL HEALTH 

Published by 
The State Department of Mental Health 
in conjunction with the 
N. C. Neuropsychiatric Association 

EDITOR-IN-CHIEF 
Eugene A. Hargrove, M.D. 

ASSOCIATE EDITORS 

Nicholas E. Stratas, M.D. 

Assadullah Meymandi-Nejad, M.D. 

SENIOR EDITORIAL CONSULTANT 
Bernard Glueck, M.D. 

CONTRIBUTING EDITORS 
Granville Tolley, M.D. Sam O. Cornwell, M.D., Ph.D. 

Gilbert Gottlieb, Ph.D. Harvey L. Smith, Ph.D. 

Philip G. Nelson, M.D. Norbert L. Kelly, Ph.D. 

EDITORIAL ADVISORY BOARD 

George Ham, M.D. Halbert B. Robinson, Ph.D. 

C. Wilson Anderson, Ph.D. Ewald W. Busse, M.D. 

John A. Fowler, M.D. Mark A. Griffin, M.D. 

John A. Ewing, M.D. Martha C. Davis, M.S. 

Richard C. Proctor, M.D. N. P. Zarzar, M.D. 

Richard A. Goodling, Ph.D. Jacob Koomen, Jr., M.D. 

PRODUCTION EDITOR EDITORIAL ASSISTANT 

George H. Adams jaccjueline M. Ransdell 

N. C. NEUROPSYCHIATRIC ASSOCIATION 
EXECUTIVE COUNCIL 

President Richard Proctor, M.D. 

President elect Thomas Curtis, M.D. 

Vice President Robert Harper, M.D. 

Secretary Charles Neville, M.D. 

Treasurer James McMillan, M.D. 

Delegate Hans Lowenbach, M.D. 

Alternate Charles Vernon, M.D. 

Past President Charles Vernon, M.D. 

Past President Paul G. Donner, M.D. 

INFORMATION COMMITTEE 

Eugene Hargro\e, M.D. \V. Samuel Pearson, M.D. 

N. E. Stratas, M.D. Thomas Curtis, M.D. 

Robert Rollins, M.D. H. F. Adickes, Jr., M.D. 
William Hollister, M.D. • William Fowlkes, M.D. 

Robert Rollins, M.D. N. P. Zarzar, M.D. 

John Giragos, M.D. N. E. Stratas, M.D. 

William Shaip, M.D. Charles Vernon, M.D. 



NORTH CAROLINA JOURNAL OF 
MENTAL HEALTH 



Volume 4 Number 1 

1970 



CONTENTS 



ARTICLES 



Duke University Center for the Study of Aging 

Daniel T. Peak 8 

Marriage and Senior Citizens 

William F. Eastman 17 

Selecting a Patient for Boarding Home Placement 
JoAnne Seagroves, Charles L. Auman and 
Jesse N. McNiel 27 

Sex in Old Age 

Eric PfeifiFer 34 

Negro Aged in North Carolina 

Jacquelyne Johnson Jackson 43 

Follow-up Study 

Information and Counseling Service for Older Persons 

Grace H. Polansky 53 

Evaluation of Treatment Outcomes in the Elderly 

Jesse N. McNiel, H. S. Wang and W. J. Eichman 57 

Organic Brain Syndromes 

H. Shan Wang 64 

Editorial 3 



NORTH CAROLINA JOURNAL OF MENTAL HEALTH 

is published quarterly, Spring, Summer, Fall and Winter. 

It is a scientific journal directed to the professional disciplines en- 
gaged in care, treatment, and rehabilitation of mentally ill and re- 
tarded patients as well as to those engaged in professional research and 
preventive work in the field. 

This journal is intended to be inclusive rather than exclusive and is 
not meant to be regarded as simply a house organ of the North Caro- 
lina State Department of Mental Health. 

It is hoped that the journal will reflect the broad-based philosophy of 
psychiatry current and will draw on areas reflecting the total spectrum 
of psychiatric and neurologic thought, program and research. 

Subscription may be obtained by writing the Editorial Offices, North 
Carolina Department of Mental Health, P. 0. Box 9494, Raleigh, North 
Carolina 27603. 

(Notice to contributors — see inner back cover) 



EDITORIAL 



The Aged: 

A Deprived Minority 



Minority groups will always exist in any sizable group of 
human beings, but how these minority groups are defined and 
recognized is rather complicated. Minority groups can be 
distinquished by such factors as their expressed beliefs and 
resulting behavior, their physical appearance, their character- 
istic clothes, eating habits, religious expressions, sexual be- 
havior, or fixed and recognizable patterns of handling such 
human experiences as insecurity, fear, grief, aggression, etc. 
At certain points in the history of a nation minority groups are 
more easily recognized and are seen as more deviant than at 
other points in time. Minority groups often become less visible 
as they gradually alter their patterns or they effect a change in 
the majority so that it becomes increasingly difficult to dis- 
tinguish the so-called majority from a minority. 

The Myth of Equal Opportunity 

Is it possible for any minority group to have total and true 
equal opportunities with a majority group? Equal opportunity 
is highly unlikely as long as the minority group volitionally or 
by external force maintains social expectations and behavior 
that are different from the majority. The minority will be de- 
prived of opportunities for certain avenues of expressing and 
achieving satisfaction and rewards. This paradoxically is even 



4 N.C. JOURNAL OF MENTAL HEALTH 

true of what might be called the affluent minority group. 
Further, there are many minority groups who elect to bypass 
the so-called opportunities offered by the majority in order to 
maintain their value system. Minority groups can exist in a 
larger society when they are relatively content with the ad- 
vantages offered by their own group and the range of oppor- 
tunities open to them. 

Deprivation and Suicide 

As I have already indicated, it is apparent that some mi- 
nority groups are the creation of the larger mass of society, and 
that membership in the minority may not be welcome but is 
enforced. It is my belief that in many respects the elderly re- 
tired person or couple is a member of a deprived minority 
group. Approximately one-third of all people over the age of 
65 are classified as living in poverty. The majority in order to 
preserve its current economic balance forces many persons 
into retirement and provides inadequate opportunities for 
maintaining their financial security. Further, the elderly per- 
son forced into retirement may at the time of his retirement 
appear to have an adequate income, but within a few years 
with rising cost and inflation, his fixed dollar return as a re- 
tirement benefit gradually but surely brings down his stand- 
ards of living. The elderly retired person is often cut off from 
sharing many of the advantages of the employed adult and 
because of this lack of financial resources is denied many 
opportunities for activities which will express his interests 
and needs. It is my belief that the sharp rise in the incidence 
of suicide after the age of 65 in the white male in the United 
States is not primarily attributable to a decline in physical 
health but rather is a clear expression of the numerous losses 
he has suffered. 

Misdirected Aggression 

Violence and verbal hostility are types of excessive aggres- 
sions which are currently of considerable concern to society 
as a whole. It is somewhat surprising to me that aged persons 
have not been more vocal in their expressions of discontent 
and hostility. But there is another side of this problem and 
this relates to what transpires when individuals who belong to 
a minority group are moving through the transition of expan- 
sion of their opportunities and their relative dissolution of the 



E. BUSSE 5 

minority into the majority. As the expanded opportunities are 
made available to them, there will be those who belong to the 
minority group who do not have the capacity to take advantage 
of such opportunities, while there are within the minority group 
those who have such capabilities and successfully utilize the 
new opportunities. It will be unlikely that the person who does 
not have the qualifications to utilize the opportunities will 
readily recognize his defects but rather in order to preserve 
his own self-esteem will accuse the majority including those 
people who have passed from the minority into the majority 
of discriminating against him and preventing him from attain- 
ing the success that he believes is possible. At this point his 
aggression will emerge if the opportunity presents itself in 
forms of violence and hostility expressed towards his definition 
of the "establishment," and if such outward expressions are 
not possible, it is likely that the hostility would be turned 
inward resulting in an increase in suicide. If this assumption 
has any validity, one can then predict that as some members 
of minority gain new opportunities and some fail, and if at the 
same time society restricts the outward expression of agres- 
sion, there will be a sharp rise in suicides. I believe that this 
is already evident by the current peak of non-white suicides 
at the approximate age of 25. 

Survival of a Minority 

By definition a minority group is different from the mass. 
Hence the continuing survival of a minority group is not only 
related to the strength of the minority but also to the permis- 
siveness of the majority. A majority can only effectively utilize 
the assets of a minority when they have an appreciation of the 
value system of the minority and understand the processes 
by which the values are maintained. This ability requires a 
type of mature thinking minimally or completely devoid of the 
influences of prejudices or bias. 

Prejudice and the Elderly 

Social and health problems in primitive societies are often 
complicated by the influences of folklore, myth, and super- 
stition. In so-called affluent societies equally serious compli- 
cations exist in the form of unverbalized individual prejudices 
and group biases. These complications are often difficult to 
recognize, as they are not sufficiently distinct in structure and 



6 N.C. JOURNAL OF MENTAL HEALTH 

origin to be identified and placed in the category of a myth 
or superstition. Prejudices affect thought and behavior and 
are usually manifested by lack of sustained interest, mis- 
interpretation of facts, and inappropriate reactions, such as 
overconcern or disinterest in real or imaginary threats. The 
abode of prejudice is largely in the unconscious mind; hence, 
its existence is substantially hidden from the individual or the 
group. The conscious recognition that a prejudice is present is 
usually a fleeting, transitory experience. Prejudices can be 
acquired throughout life, but the mechanisms that facilitate 
their development are primarily rooted in childhood fears 
and thinking. Consequently, a prejudice carries the intense 
emotionality of childhood, but this feeling is attached to the 
covering adult-like thought and behavior. Therefore, the prej- 
udiced adult holds to his convictions with intense feelings 
resisting reality and logic. The prejudiced adult must first 
recognize that the excessive feelings which accompany his 
attitude or conviction are unreasonable and he then must be 
willing to unlearn by actual personal experience the faulty 
learning and replace it by a rational approach. Fortunately, 
prejudice can be reduced or eliminated by proper education 
of the young or new adult learners. It should be recognized 
that many adults cannot tolerate the anxiety that results from 
the recognition of a defect within their thinking and behavior; 
that is, the recognition of a prejudice and the expenditure of 
effort that is required to unlearn and relearn a process. Many 
adults see the resolution of a prejudice as a partial destruction 
of their self-competence and self-image and therefore cannot 
tolerate admitting the existence of such a defect. 

The preceding oversimplified description of origin and im- 
pact of prejudice explains a major determinant in many of our 
current social problems, but it may not be recognized as a 
serious influence affecting the status and role of elderly 
citizens in our society. It has been repeatedly stated that we 
are a youth-oriented society. This, in effect, means we place 
greater value on youth than on the mature adult or elderly 
person. Moreover, many young and middle-aged adults hold 
the false belief that all "old" people are weak, sick, or not very 
intelligent. They fail to recognize that compulsory retirement 
based upon economic pressures pushes many people into re- 
tirement who are quite capable of continuing to function 
effectively. Since death is inevitable and death usually results 
from disease, it is true that as a person passes through the 
years he acquires more evidence of disease. But it is improper 



E. BUSSE 7 

to think of the majority of persons over the age of 60 as 
physically debilitated persons incapable of contributing to 
society. 

Bolstering this false information is the prejudice that re- 
sults from unresolved fear of disability and pain acquired in 
early childhood. Unfortunately, there is a wide variation in 
how adults manifest the prejudice that is rooted in such fears, 
but simple avoidance is not uncommon. This means that 
many knowledgeable people who are attempting to educate 
our citizens, particularly those in positions of responsibility, 
are frequently frustrated by the sudden realization that an 
authority is blocked in his capacity to properly appreciate the 
problems of the elderly and to plan for them because of his 
own unresolved conflicts. 



Summary 

To summarize, it is my belief that the aged person in the 
United States, particularly the so-called retired person or 
couple, is in effect a member of a deprived minority group. 
The elderly retired share few of the advantages held by the 
majority, and prejudice results in attitudes and policies that 
restrict opportunities to achieve personal satisfactions while 
making contributions to the entire society. 

Ewald W. Busse, M.D. 
Center for the Study of 
Aging and Human Development 
Duke University 
Durham, N. C. 



Duke University Center 
for the Study of Aging 



Daniel T. Peak, M.D. 

The face of our society is changing; we are aging. Each year 
the elderly occupy a higher proportion of our population and it 
is obvious that the present crop of neonates will have an even 
better chance of surviving the proverbial "three score and ten". 
Changes bring inevitable problems, the solution of which leads 
to progress. However, change without problem-solving leads to 
a compounding of existing problems and a generally disrupted 
and poorly functioning system. This latter has been the state of 
affairs in regard to agencies providing services to the elderly 
and provided an impetus for the development of more efficient 
agencies concerned with their problems. In the past fifteen years 
a number of centers for studies in aging have been developed. 
One of the first was established at Duke University in 1957 and 
is now known as The Duke University Center for the Study of 
Aging and Human Development. The center originally was pri- 
marily devoted to research and training; however, it became 
apparent that outlets were needed for the accumulation of knowl- 
edge gained from this research and it was necessary to begin 
to provide practical application; namely, to improve the lot of 
the elderly person in the community. The next logical step was 
to design an agency, set up especially to provide contact and 
needed services. About five years ago plans were begun to form 



D. PEAK 9 

such an agency at Duke University. Considerable effort was 
put into these early preparations. The direction was provided 
mainly from findings which were accumulating as a result of the 
Duke Longitudinal Study of elderly community residents which 
began in 1954. 

It is quite apparent that all service agencies must work on a 
priority system. This is true especially in regard to age, with the 
result that the older person falls to the bottom of the list. At 
times one can sight no other reason than being classified as to 
chronological age. A usual outcome for handling "dead wood" 
on long waiting lists is to pass them on to "other agencies" where 
they can "be better accommodated". A good, hard look indi- 
cated that no agency existed which focused primarily on the 
problems of the elderly. The nature of the often non-verbalized 
needs appeared to call for a central agency where people with 
knowledge and experience in dealing with such problems could 
provide the specific types of interventions needed. It became 
very apparent that there was a dire need for family counseling 
where the nucleus of the problem involved an elderly person. 
It is true that agencies such as the Family Service agencies have 
been dealing with such problems, but oftentimes while an 
adequate plan is formulated, the lack of personnel, or strained 
client lists, reduce the possibility of carrying out such well laid 
plans. A specific agency to provide services and continuity of 
treatment for the elderly was needed to handle the diverse and 
multiple problems which the elderly present. It was envisioned 
that such an agency could, on the one hand, assume full re- 
sponsibility for an elderly client, or could work in a supportative 
or consultative capacity with existing agencies where weak links 
in the continuity of care exist. 

It was also apparent that there was a great need for training of 
individuals already working with the elderly and for people 
interested in doing so. Techniques of counseling older persons 
and family members, the isolation and proper handling of prob- 
lems, the ability to formulate realistic plans, and direct contact 
experience in working with older people were viewed as training 
needs for such persons. Since many of the aged are disabled in 
a number of ways, especially involving physical ambulation, 
travel difficulties exist. Emphasis on home health care programs 
is therefore indicated. It was also envisioned that certain mid- 
career people might be utilized to work with the elderly if a 
proper training experience could be provided for them. 



10 N.C. JOURNAL OF MENTAL HEALTH 

Since the elderly present multiple problems, it was apparent 
that a multi-disciplinary group would be needed to carry on such 
training activities. Such a training center was conceptualized as 
an on-going agency whereby many types of training experiences 
could be provided for diverse groups of people. The techniques 
of crisis intervention were found to be applicable since many 
times a slowly simmering familial situation threatened to erupt 
and immediate help was needed. It was therefore apparent that 
a certain fluidity was essential in order to handle pressing prob- 
lems as well as long standing ones. 

A proposal for an Information and Counseling Service for 
Older Persons at Duke University was submitted to the Ad- 
ministration on Aging. A grant was provided and the agency 
began operation in the spring of 1967. As it currently exists, the 
ICSOP is a part of the Duke University Center for the Study of 
Aging and Human Development and is included within the De- 
partment of Psychiatry. It is currently housed in the medical 
center proper but will shortly be moving to a new building, 
physically separated from the main center which will house a 
new rehabilitation facility. In addition, two community exten- 
sions of the service are planned. One, already in operation, is 
located at a centrally located church and operates in conjunction 
with the local senior citizens center program. The other will be 
housed in an apartment building for older persons which is being 
constructed and is scheduled for occupancy in the fall of 1969. 
The positioning of these outreaches is an attempt to reach the 
older person who is unable to travel freely to the central offices. 

Methods of Operation of ICSOP 

Referrals are received from a great variety of sources. These 
include the Duke University clinics, community physicians, the 
clients themselves, the Department of Public Welfare, public 
health nurses, relatives, friends, and others. The secretary-recep- 
tionist is often the first person to handle the referral. An appoint- 
ment is set up for an intake interview at which time all pertinent 
information is recorded and a clear outline of the problems and 
total situation is made. The information is recorded on a standard 
intake form which was developed so as to make actuarial data 
easily available. The nature of the problems are discussed in 
some detail. Occasionally, appropriate solutions or information 
is given during this initial interview which will be sufficient to 
satisfy the needs, and the case may be closed. In most cases, this 



D. PEAK 11 

initial interview is conducted by the social worker member of 
the team; however, it may be done by any team member. All 
cases are discussed in a weekly case planning conference with all 
team members present. The staff includes psychiatrists, social 
workers, nurses, physical therapists, occupational therapists, 
chaplains, secretary-receptionist and psychologists. In addition, 
consultants in the field of sociology and dietetics are available. 
A plan of intervention is prepared for each client. Due to the 
multiplicity of problems the plan usually includes active partici- 
pation of a number of team members. A particular note is made of 
agencies and persons already involved with the client so that 
duplication of services does not occur. If such an agency is 
already engaged, our intervention is that of consultant, if they 
so choose. The plan often involves home visits bv one or more 
team members. Most frequently, this involves nursing service, 
social work, psychiatric, physical therapy, and/or chaplain serv- 
ices. Such team mobility has allowed the older person to remain 
in his home setting with much benefit. 

Counseling services of various types are given. These include 
family counseling, co-joint therapy, individual counseling and 
psychotherapy. At times, environmental manipulation is neces- 
sary to provide a placement in a nursing or rest home or mental 
hospital. Treatment is necessary if gross mental problems are 
present or local environmental supports are inadequate to main- 
tain the individual in the community. We are also in a position 
to help in the rehabilitation of the older person who is returned 
to the community from such settings. 

All continuing cases are reviewed periodically as needed, 
particularly if the staff members involved feel that other aids are 
necessary. We are particularly concerned with the areas in an 
older person's life which are being neglected, such as proper use 
of leisure time, providing adequate external stimulation, and 
proper mobilization, particularly in home bound individuals. 

There is a great deal of overlapping of services provided by 
specific members of the group. For example, a nurse, physical 
therapist, or occupational therapist may provide a good deal of 
counseling while providing a specific treatment. Also, advice on 
physical activity may be provided by the social worker. Such 
fluidity in staff efforts is sometimes difficult to develop but is 
necessary to provide the most efficient service to the client. A 
fair amount of effort must be devoted to the development of this 
fluidity between team members. If the focus remains on the 



12 N.C. JOURNAL OF MENTAL HEALTH 

client and the needs to be met, the person to provide them be- 
comes of secondary importance. Such team effort has developed, 
however, not without efforts from all members to achieve this 
end. 

Facts and Figures 

Since inception, the ICSOP has handled a total of 193 cases. 
Most frequently this involves an elderly woman in the order of 2 
to 1 over elderly men. About 75% of these are Caucasian and the 
greatest number are in the 60-year-old age group. The most fre- 
quent referral is from physicians. This is probably tme since we 
are located in a medical center. However, as knowledge of our 
service disseminated, more referrals came from community phy- 
sicians and other community sources. The referring person next in 
order was the client himself. This occurred particularly when 
satisfied clients had been helped and spread the information to 
others. In most cases, the person was living with his spouse. 
Next in order were those living by themselves. An important 
pattern noted involved the necessity of the older person to en- 
gage another in the help-seeking role. This, as noted above, was 
either the person's physician, member of the family, or public 
services worker such as welfare caseworker, public health nurse, 
etc. This emphasizes the importance of case finding. The elderly 
clients seen in ICSOP represent all educational levels. However, 
the greatest number come with 8 years or less of formal schooling. 
In almost 100% of the cases a religious affiliation is apparent. 
As has been pointed out recently, about }i of the elderly popula- 
tion constitutes the so called "poverty group" and this is reflected 
in our clientele since most of them report an income below 
$2,000 annually. It was apparent, however, that in spite of this 
low annual income, good budgeting and fiiigality allowed many 
of these older persons to manage fairly well under very adverse 
circumstances. It was also noted that about only 50% of those 
eligible were receiving Medicare benefits. 

Often, many members of the family were involved in a com- 
plex interaction. It was apparent that other family members, in 
most cases the children, were having more difficulties than the 
elderly person themselves, while the elderly person was also 
suffering. The involvement and interest of the family revealed a 
definite desire for help in rectifying the situation. In most cases, 
rather than wanting to "dump a burden", the family members 
were genuinely interested in providing the best possible environ- 



D. PEAK 13 

mental conditions for their elderly relative. Many of these people 
were willing to go through great personal and financial sacrifices 
in order to help. However, what was necessary was an analysis 
of the total situation and direction in providing what would 
ultimately be best for the older person. Occasionally, this in- 
volved a temporary rearrangement of the living situation and 
family interactions with supportative counseling of family mem- 
bers, while formulating a long-range plan. As noted above, 
crisis intervention is sometimes necessary and immediate meas- 
ures must often be taken. However, our experience showed that 
what at first glance appeared to be a crisis could be handled 
with much of the anxiety reduced, once the family knew that 
someone was able and willing to help them. 

Since one of our aims was to reach the cloistered groups in 
the community, it has been gratifying to see that a survey of 
intakes over the last four months has revealed evidences that 
this is occurring. The clients, in general, are becoming younger 
and we are seeing an increasing number of black persons. Also 
the number of men seen is increasing. The current group tends 
to be of a lower socioeconomic level and more are receiving pub- 
lic aid. It appears that these trends are most likely related to the 
increasing knowledge of our agency to other community agencies 
and also to the community residents themselves. 

The Nature of the Problems Presented by Older Persons 

We isolated the problem or problems presented by our older 
clients into the following categories: 

1 ) Housing 

2 ) Finances 

3) Counseling on: 

a ) Family problems 

b ) Marital problems 

c ) Emotional problems 

d ) Legal aid or advice 

4) Health 

5 ) Welfare Department aids 

6) Physical therapy 

7) Institutional placement 

8 ) Various services such as employment, vocational 
training, homemaker service, food preparation 
and delivery, transportation, general information, 
Golden Age Clubs, recreation, etc. 



14 N.C. JOURNAL OF MENTAL HEALTH 

Analysis of the first 173 cases revealed the need for the follow- 
ing types of services at intake with the percentages : 

1 ) Counseling on personal emotional problems 61% 

2 ) Financial problems 40% 

3 ) Institutional placement 28% 

4 ) Family counseling 26% 

5) Medical treatment 23% 

6 ) Services 16% 

7 ) Marital problems 10% 

It is also common knowledge that older persons suffer in 
multiple problem areas. While most of our clients did, in fact, 
suffer to some degree in most of the above areas, we were inter- 
ested in recording only the major problem areas where it was 
judged that some intervention was necessary. 

The following shows the frequencies of multiple problems: 

Number of Cases Number of Problems Percentage 

173 1 100% 

114 2 66% 

68 - 3 39% 

31 4 17% 

14 5 8% 

It is important to point out that these findings are very much 
related to the type of setting. In this case, the university medical 
center setting very much influences the nature and number of 
problems that older persons bring to such an agency. It is 
directly related to the availability of other services. This is re- 
flected in regard to the needs for medical treatment which ap- 
peared in only 23% of the clients. The availability of medical 
services in the center eliminates this as a major presenting 
problem. In fact, many of the referrals came from the medical 
clinics where other problem areas were discovered. Also, in our 
operations medical problems that are of major importance were 
referred back to the clinics. 

It may appear somewhat surprising that 61% presented with 
a need for counseling on emotional problems. In most cases these 
were not self-referrals but were referred by other agencies or 
persons, most often the client's medical physician. However, 
since the ICSOP is contained within the department of psy- 
chiatry at Duke, this biases such referrals. However, it is now 
common knowledge that surveys of older community residents 



D. PEAK 15 

reveal a high percentage of diagnosable mental problems which 
should be receiving treatment. However, due to favorable condi- 
tions these persons are often able to function in their particular 
protective setting. 

The second most frequent presenting problem, namely, fi- 
nances is also not surprising. We are fully aware that the so- 
called "poverty group" in the United States contains many of 
the over-65 group. It must be kept in mind, however, that these 
figures represent problems and not demographic statistics. It was 
quite revealing to see how often the older person was able to 
stretch a very meager budget to meet his needs. 

The need for family counseling appears to be under represen- 
ted by these figures since oftentimes this was not presented as 
a major problem. In most cases of personal emotional problems, 
the need for institutional placements, and most other problems, 
family counseling was needed. In fact, oftentimes the resolution 
of the older person's problems was accomplished mainly by work- 
ing through family members and not directly with the client. 
Family involvement is almost a universal necessity in our ex- 
perience. 

In order to assess the agreement and focus on major problem 
areas we compared the severity of the presenting problems as 
seen by the client and the interviewer. Such a comparison is 
important since it facilitates intervention if there is agreement 
on where efforts should be focused. After the initial intake inter- 
view, the interviewer assessed and recorded the degree of 
severity as seen by the client and by himself This is a rough 
estimate based on the judgment of the interviewer, but in most 
cases agreements or disagreements in severity were not difficult 
to judge. Of the total group rated, there was agreement in 64% 
of the cases. In 19%, the client saw their problems as more severe 
than the interviewer, and in 16% the interviewer saw the prob- 
lem more severe than the client. This shows that about % of the 
cases were in good agreement. The major areas of disagreement 
appeared in problems related to financing, health, and a need for 
counseling services. The client was seen as overly concerned 
about financial and health matters while the interviewer saw a 
greater need for counseling on emotional and/or family problems. 
The most feasible interpretation of these discrepancies seems to 
be that the client was concerned mostly with relief of his immedi- 
ate discomforts while the interviewer was concerned more with 
underlying problems which appeared to be aggravating these 
immediate ills and was focusing more on a program of inter- 



16 N.C. JOURNAL OF MENTAL HEALTH 

vention which would reduce the urgency of these needs. This 
appeared to be the case since financial and medical aid was 
already available to most of these individuals. 

Summary and Conclusions 

In its eighteen months of operations the Information and Coun- 
seling Service for Older Persons of Duke University has demon- 
strated that agencies which provide specific services to aging 
clients are needed and can function as an integral part of any 
community program. However, it is necessary to have a clear 
idea of the services that are provided in a particular area and 
how such an agency can fit into the total structure. Such an 
agency must have a clear idea of what its goals will be and what 
types of services it may be able to provide. 

In setting up such agencies it is necessaiy to have the avail- 
ability of a number of trained professionals. Most important are 
social workers, nurses, physical therapists, physicians and psy- 
chiatrists. The availability of others such as occupational thera- 
pists, chaplains, psychologists, recreational therapists, dietitians 
are a definite boon if they are available. However, such persons 
are often difficult to find. In most cases the critical needs for 
medical treatment and financial help are being met to some de- 
gree. This leaves problems involving overall planning within the 
family structure and a definite need for counseling services for 
clients and family members. In many cases families are able to 
solve what seems to be insurmountable problems involving an 
older person, with a minimum of information giving and pro- 
fessional counseling. Depending on the point of intervention, 
such services can have a preventive function, provide direct aid 
and treatment, or serve a rehabilitative function. 

In our experience we have found that it takes a considerable 
time for knowledge of such a new agency to infiltrate to all 
areas of the community. Also, it is necessary to have an active 
liaison person for the securing and dispensation of services. This 
may be a family member, public service worker, etc. The most 
pressing need is for the institution of a clear plan of action and 
the counseling of involved parties. In many cases direct services 
are provided but there is no one available with which to work 
out feelings or to clarify a frustrating situation. Such agencies 
must be ready to provide such services with the proper personnel. 
Fluidity within the agency is important and the responsibility 
to spawn trained workers must be accepted so as to provide per- 
sons to fill existing needs. 



17 



Marriage 

and 

Senior Citizens 



William F. Eastman, Ed.D. 

Assistant Professor of Marriage Counseling, 

Marriage Counselor, Student Health Service 

Universitij of North Carolina 

Chapel Hill, N. C. 

Although marriage is a topic of frequent discussion, it is seldom 
that the marriages of senior citizens are considered. Yet in a na- 
tion that focuses predominantly on youth, the proportion of our 
often overlooked senior citizens, aged 65 and over, continues to 
increase faster than our total population. Senior citizens number 
19 million, or nearly ten percent of our population. Estimates 
are that by the turn of the century this group will number 30 
million.^ While the life expectancy in the United States is now 67 
years for a man and 73 years for a woman,^ the South Atlantic 
area has a below-average proportion of aging due to its large pro- 
portion of nonwhites with their shorter life expectancy .^ 

Before examining some values and vulnerabilities of marriage 
among senior citizens, it seems appropriate to explore further: 
Who are our senior citizens? What is their life like? What are 
their needs — now and in the future? 

As our total national population grows younger, our older 
population is growing older. One-half of all senior citizens are 
now 72.7 years or older. Also, there is an increasing proportion 
of younger aging. Earlier retirements will broaden the age span 
of the senior citizens,^ so that the unique needs of the younger- 
older, middle-older, and older-older groups, spanning ages 65 
to 112, will be identified more sharply.^ 

Senior citizens are remaining more active and vigorous as a 
result of medical, nutritional and psychological supports, and 



18 N.C. JOURNAL OF MENTAL HEALTH 

this will be particularly true as advances are made against some 
of the physical, psychological and social complications as well 
as the diseases which adversely affect senior citizens.^ Physical 
problems are expected among senior citizens who spend two and 
one-half times as many days in hospitals as those under 65 and 
comprise one-third of the hospital population.^ Although in the 
early 1960's 81 percent of senior citizens had one or more chronic 
conditions, which is about twice the proportion found in the 
general population, only one-half contended with interference to 
major activities due to their condition, and less than 16 percent 
experienced severe restrictions in their usual activities.^ 

The educational level of senior citizens is increasing.^ At the 
same time, there will be less opportunity for continued employ- 
ment in certain fields as automation expands and advances are 
made into areas requiring new skills. Many of them want and/or 
need to continue working. Approximately 27 percent of older 
men and less than ten percent of older women are either em- 
ployed full or part-time or are actively seeking employment. ^^ 

Independence is highly valued by senior citizens who conse- 
quently seek institutional care for physical and/or emotional 
reasons as a last resort. Only one in twenty-five lives in an 
institution, and 70 percent of all senior citizens who are not in 
institutions live with their spouse or in a household with their 
children.^ ^ Two-thirds of the men but only one-third of the 
women live in families with their own spouse. Nearly one-third 
of the women but only one-sixth of the men live alone or with 
non-relatives. More than one-half of all older women, 55 percent, 
are widows. ^^ 

There are 35,000 marriages per year involving persons over age 
65, and, in one-third of these, both partners are over 65.^^ 

Negroes are under-represented in our total senior citizen popu- 
lation. While Negroes comprise 10.5 percent of our total popula- 
tion,^^ they constitute less than eight percent of our total senior 
citizen population. ^^ Also, although among whites, senior citizens 
constitute nearly ten percent of the population, among Negroes 
senior citizens comprise only six percent of the population.^® 

The income level of senior citizens, not surprisingly, is dras- 
tically lower than for younger persons. In 1963, over three- 
fourths of the 4.3 million "unrelated individual senior citizens" 
had an annual income of $2,000 or less. In the same year, there 
were 6.8 million families headed by a person aged 65 and over 



W. EASTMAN 19 

among our total of 47.4 million families. The median family in- 
come of these senior citizen families was $3,352 in 1963 or $3,300 
less than for younger families. The great majority of these older 
families had only two persons and the median income for these 
couples was even less, or under $3,000. Only one-third of senior 
citizen families had incomes of $5,000 or more and only one-tenth 
had incomes of $10,000 or more.^^ In the last six years the median 
income for younger families has increased by $2,000, while in- 
creasing only $750 for older families. ^^ Earnings, the largest single 
source, represent one-third of senior citizens' income. Ninety per- 
cent are either receiving, or are eligible to receive. Social Se- 
curity benefits under OASDI. These benefits account for 30 per- 
cent of the aggregate income of all senior citizens. ^^ The average 
national monthly payment to senior citizens with a median age 
of 76 is only $52.30.^0 It is apparent that most senior citizen 
families experience significant economic insecurity. 

In summary, senior citizens are increasing in numbers and 
proportion, are more active, live with chronic illnesses, will in- 
creasingly be better educated, will be increasingly mobile, are 
poor, and among them more women than men live alone or with 
non-relatives. 

Attention will now be focused on some adaptations normally 
required of senior citizens. In a society that esteems youth, as- 
sertiveness, strength, attractiveness, agileness, a facile memory, 
and productivity, senior citizens are accorded lessened venera- 
tion and security. They feel "left out" and "put on the shelf." 
Often, feeling ignored in the present, they refer to more meaning- 
ful experiences from their past. As physical processes slow down 
and energy is lessened or is spent more quickly for smaller re- 
turns, they experience fatigue more readily. Having discharged 
responsibilities in the past, they prefer freedom from numerous 
current commitments. Many verbalize considerable dissatisfac- 
tion with their lives as an expression of their loneliness and as a 
consequence of having little that seems worthwhile to do. In 
order to maintain their self-respect, physical complaints may be 
offered to excuse shortcomings. As befits their experience, wis- 
dom and accomplishments, many are justly proud. The senior 
citizen realizes that he has lost his magic, for he is no longer 
sought out as before. In situations where civic clubs, fraternal 
organizations and church groups exclude them from responsi- 
bilities for which youth is preferred, the senior citizen's sense of 
dignity restrains him from competing for responsibility and 



20 N.C. JOURNAL OF MENTAL HEALTH 

honors. For the economically insecure, welfare carries an un- 
favorable taint among many, basically because it is unfortunately 
equated with dependence and charity and, also, because it can- 
not provide those who are cold and hurt and ill-protected the 
minimum necessary financial base by which they can live with 
dignity. In a society that tends to do for them or to them rather 
than with them, they deeply desire to remain self-directing. They 
want autonomy, and individuals sometime relate down rather 
than across to them. Many are capable of learning and changing 
and remaining vital and creative as long as life lasts. They have 
much to offer themselves and their community. Their wisdom 
of experience, maturity of judgment, stability of emotions, and 
capacity to teach are assets that can well compensate for the 
speed and endurance of by-gone years. 

Perhaps few people, anywhere, at any time, have been called 
upon to make as many adjustments as have our older Americans. 
Thrust upon them have been developments such as the informa- 
tion explosion, the recurrent tragedy of armed conflict, industrial- 
ization, wholesale alterations of family life, the sexual rennais- 
sance, the various protests, racism, and the changes in national 
unitedness. With all these and more they have coped, often with 
grace, effectiveness and magnificence. In fact, the positive qual- 
ity of our national life is, in significant measure, attributable to 
their efforts. 

Each new experience for senior citizens carries additional fear 
which can prompt resistance to change. After all, having lived 
longer, they are asked to give up more of the known. 

Even their marital relationship is not immune from the neces- 
sity of change in most instances. At the time in their cycle when 
personal contribution and public recognition are lessening, at a 
time in our national history when security and sereneness are 
difficult for anyone to achieve, when their circle of friends and 
family continues to be visited by death, with the accompanying 
feelings of isolation and insecurities, when life generally tends 
to become more restricted, at such a time, the senior citizen turns 
expectantly toward the vital human relationship of life — his mar- 
riage. Yet, here too, life requires him to cope with changes. At a 
point when his self-esteem is consistently questioned, he must 
adapt successfully to changes in his most important relationship 
in order to maintain his sense of worth and satisfaction. 

At this point, thoughts regarding senior citizen marriage will 
be limited to the sexual adjustment. This is not a choice of chance. 



W. EASTMAN 21 

As is SO often the case, regardless of age, the sexual adjustment 
can mirror the entire relationship. Problems with sex can be the 
result of dissatisfactions related to such factors as dependency, 
support, control, and hostility. Conversely, understanding a per- 
son well in one adjustment, provides valid ideas regarding his 
feelings, attitudes, and behaviors in other aspects of his life. 

The best prediction of satisfactory sex adjustment among senior 
citizens is a normally active and satisfactoiy sex adjustment at 
earlier ages. Sex activity and interest patterns extend into old. 
age in much the same form as in their earlier years .^^ 

Among senior citizens, an active sex life is the rule. Masters 
and Johnson learned that while there is a decline with age in the 
responsiveness to sexual stimuli, this interest continues into ad- 
vanced old age.22 

Men experience a steady decline in the frequency of sex ac- 
tivity and there is no age at which activity abruptly lessens. 
Kinsey reported that no other single factor affected the frequency 
of sexual outlet as much as age.^^ Research conclusions on this 
point are similar. Kinsey found that only five percent of men were 
not having intercourse at age 70. A study at Duke University 
indicated that over one-half of senior citizens were sexually active 
and that not until age 75 was there a significant decrease in the 
number of men having coitus. Sexology Magazine's survey study 
found 70 percent of husbands having regular coitus .2"* 

Among women, sexual capacity has been found to remain 
more or less constant from its peak in the twenties into the fifties 
and sixties .2^ Masters and Johnson found that, as expected, older 
women evidenced significant sexual capacity and effective sexual 
performance, although the intensity of the physiologic reaction 
and the rapidity and duration of the anatomic response to sexual 
stimulation were reduced with advancing years .^^ Kinsey re- 
ported finding little evidence of any aging in the sexual capaci- 
ties of the woman until late in her life.^'^ 

In light of this continued interest and capacity it is unfortunate 
that our society often is less than thoughtful or accepting regard- 
ing the sexual interests and needs of senior citizens. Due to their 
own unresolved issues, some younger persons cannot tolerate 
comfortably the fact that older persons have sexual wishes and 
drives. The dating of senior citizens often is viewed humorously. 
Sexual misadventures among senior citizens can bring down upon 
them scorn or ostracism, thereby increasing their already felt 



22 N.C. JOURNAL OF MENTAL HEALTH 

threat of interpersonal failure. As indicated, research data informs 
us that we can recognize as normal and desireable their interest 
in the opposite sex.^^ 

Illness and physical infirmities place special stress upon the 
senior citizen's sexual adjustment as it does with other adjust- 
ments. Chronic, more than acute, conditions are prevalent in this 
phase of life. However, there is less physical sexual disability 
among the chronically ill than has generally been assumed.^^ 

As an indication of the limited disability stemming from 
chronic illness, a study of cerebrovascular accident patients, 
(under age 60 ), showed that for 60 percent their libido was un- 
changed or increased. The fact that sexual experience was de- 
creased much more than libido points toward the importance of 
physiological and social factors involved in the sexual behavior 
of the patients .30 

Many males and their wives worry excessively about the hus- 
band's sexual response to prostatectomy. One study concluded 
that 70 percent of men who were potent prior to surgery were 
also potent following surgery .^i 

Diabetes results in an erectile impotence in men which is two 
to five times higher, at all ages, than in the general population.^^ 
Thus, it seems appropriate that male impotency should prompt 
an examination to rule out diabetes. 

For the woman, there is no evidence that a hysterectomy, by 
itself, should cause any decrease in sexual desire, pleasure or the 
ability to participate in sex. Any such changes are usually related 
to the psychological effects of genital surgery. Drellich has cited 
two reasons for this unrealistic fear. One apprehension is that 
any subtractive surgery will reduce the limited quantity of energy 
and strength in the body. The second reason for the fear is that 
some believe that the uterus is the major source of strength. Con- 
sequently, they feel that its loss will produce dramatic weakness 
and impairment. Conversely, some women are relieved via sur- 
gery from fear of pregnancy, and thus post-operatively experience 
greater relaxation, more spontaneity and increased sexual satis- 
faction. ^s 

In this brief treatment of a few chronic conditions which can 
affect the sexual adjustment, the point is this : if adequate adjust- 
ments can be made, this re-establishment of sexual satisfaction 
can have deep significance for the individuals involved. At a 
time when they are burdened with the limitations and frustra- 



W. EASTMAN 23 

tions of chronicity, they can still actively find expression of their 
wish to give and receive pleasure and love. They have the sense 
of their body providing pleasure and the feeling of mastery 
through their physical functioning. The husband can experience 
renewed feelings of masculinity. The wife will find confirmation 
that, despite her condition, in the eyes of her husband and her- 
self, she is whole and desired. Such acceptance and success can 
touch all of life, since that which is experienced in any one ad- 
justment in marriage can affect the person in other adjustments. 
The higher one's self-esteem and the more positive one's outlook 
on life, the healthier, more productive, more creative, more en- 
joyable that person is to himself and others. 

Certainly, many senior citizen couples grow old gracefully to- 
gether. However, with increased awareness of their world as they 
feel and see it, perhaps communities can extend themselves, their 
agencies, and services to them in a more effective, and humanly 
dignifying manner. 

In recognizing the needs and wishes of senior citizens, more 
appropriate individual, conjoint or group counseling services can 
be offered these couples. Supportive help can sustain or rebuild 
their ego strengths when this is necessary. The chronically 
anxious, dependent person with the poorly developed ego can be 
sustained by therapeutic contact. The individual with the well- 
developed ego who suffers a temporary ego weakening or break- 
down can be returned to his prior level of functioning through 
relationship with a skilled professional person. 

Prevention is always preferred when it can eliminate the need 
for rehabilitation. Perhaps exceeding professional counseling in 
potential is the contribution that could be made in most com- 
munities by a senior citizens' coordinating council that could 
work with and for senior citizens. Any group of senior citizens 
will represent a great diversity of need, inclination and capacity. 
It is predictable that activities, programs and services for them 
are currently limited. Conceivably, most communities could use 
an enabling service that would coordinate, plan and develop 
programs with the senior citizens. Under salaried, professional 
leadership, the responsibilities could include the following: 

1. To coordinate more effectively the existing activities and 
services; 

2. To assist the senior citizens in developing plans by which 
the interests, resources and needs of the senior citizens and 



24 N.C. JOURNAL OF MENTAL HEALTH 

the community could be more creatively related; 
3. To sensitize the community to the needs and wishes of the 
senior citizens. 

The primary task of this coordinating person or council would 
be not to deliver services, but rather, to function as a catalyst, 
guide and source of information and referral. Rather than impos- 
ing programs, the emphasis would be on enabling the senior 
citizens to plan and develop the activities and services that they 
deem important to themselves and to provide a vehicle for their 
increased participation in the life of their community. 

In response to the needs of senior citizens. Congress passed 
the Older Americans Act of 1965 which established an Admin- 
istration on Aging within the U. S. Department of Health, Educa- 
tion, and Welfare. The Administration on Aging serves as the 
central coordinating federal agency for programs related to senior 
citizens. 

An appropriate community goal is to enable senior citizens to 
live as fully, constructively, creatively, and serviceably as they 
desire and are able. By increased satisfaction in their relationship 
to their community, the married individual senior citizens will 
bring more self-esteem to their marriages. As a more sustained 
and vital contact is created with their home community, perhaps 
less will be required of the marriage, which, when relieved of 
some tension, can remain more flexible and rewarding, and thus 
more nearly approach its unique function of providing fulfillment 
to spouse and self in the midst of the continuing changes of the 
senior citizen years. 



BIBLIOGRAPHY 

Administration on Aging, Guide to Community Action, 
Washington, D.C.: Department of Health, Education, and 
Welfare, 1967, p. 25. 

Wolff, K., Geriatric Psychiatry, Charles C. Thomas, Spring- 
field, Illinois, 1963, p. 4. 

U. S. Bureau of the Census, Statistical Abstract of the United 
States: 1967, (88th edition) Washington, D.C., 1967, pp. 
10, 25, 27. 



W. EASTMAN 25 

4. The United Presbyterian Church in the U.S.A., The Church 

and the Aging, The United Presbyterian Church in the 
U.S.A., 1967, pp. 22-24. 

5. The National Council on the Aging, Centers for Older 

People, Washington, D.C.: The National Council on the 
Aging, 1962, p. 12. 

6. Birren, J., et al, "Summary & Interpretations", in Human 

Aging: A Biological ir Behavioral Study, ed. James Birren, 
et al., Washington, D.C.: U.S. Department of Health, Edu- 
cation, and Welfare, 1963, pp. 315-316. 

7. Wolff, loc. cit., p. 4. 

8. Administration on Aging, op. cit., p. 26. 

9. U.S. Bureau of the Census, op. cit., p. 114. 

10. Administration on Aging, op. cit., p. 25. 

11. Shanes, E., "Living Arrangements of Old People in the 

United States", in Social and Psychological Aspects of 
Aging, ed. Clark Tibbitts and Wilma Donahue, Columbia 
University Press, New York, 1962, pp. 459-463. 

12. Administration on Aging, loc. cit. 

13. Rubin, I., "Marital Sex Behavior: New Insights and Find- 

ings," Medical Times, 1964, 3, pp. 228-237. 

14. U.S. Bureau of the Census, op. cit., p. 29. 

15. Ibid, p. 10. 

16. Ibid., p. 27. 

17. The United Presbyterian Church in the U.S.A., op. cit., p. 25. 

18. Kreps, J., "Higher Incomes for Older Americans", in Older 

Americans: Social Participants, ed. Rosamonde R. Boyd, 
Converse College, Spartanburg, S. C. 1968, 65-68. 

19. Administration Aging, op. cit., pp. 25-26. 

20. The United Presbyterian Church in the U.S.A., op. cit., p. 26. 

21. The National Council on the Aging, op. cit., p. 16. 



26 N.C. JOURNAL OF MENTAL HEALTH 

22. Rubin, I., "Sex and the Aging Man and Woman," unpub- 

lished paper, pp. 1-17. 

23. Kinsey, A. C, Pomeroy, W. B., and Martin, C. E., Sexual 

Behavior in the Human Male, Philadelphia: Saunders, 
Philadelphia, 1948, p. 218. 

24. Rubin, "Marital Sex Behavior: New Insights and Findings," 

loc. cit. 

25. Ihid. 

26. Rubin, "Sex and the Aging Man and Woman," loc. cit. 

27. Kinsey, A. C, et al., Sexual Behavior in the Human Female, 

Saunders, Philadelphia, 1953, p. 353. 

28. The National Council on Aging, op. cit., p. 16. 

29. Ford A. B., and Orfiere, A. P., "Sexual Behavior and the 

Chronically 111 Patient", Medical Aspects of Human Sex- 
uality, 1967, 2, p. 51. 

30. Ihid, p. 27. 

31. Ihid. 

32. Ihid, p. 28. 

33. Drellich, M. C, "Sex After Hysterectomy," Medical Aspects 

of Human Sexuality, 1967, 3, 62-64. 



27 



Selecting a Patient for 
Boarding Home Placement 

JoAnne Seagroves, M.S.W., Charles L. Auman, M.S.W., 
Jesse N. McNiel, M.D. 

Central Unit, John Umstead Hospital, Biitner, N. C. 

As chief social worker on Central Unit at John Umstead 
Hospital, I have been involved in arranging boarding home 
placements of more than one hundred patients during the past 
three years. Most of these patients had been hospitalized for 
several years and would have probably spent the remainder of 
their lives in the hospital if no action had been initiated by the 
hospital to place them. 

In arranging boarding home placements, I have found the 
work very complicated and tedious, but extremely interesting 
as I have gained a better understanding of all the problems in- 
volved. The following information is related to the procedures 
used and some of the problems which had to be dealt with in 
order to accomplish the goal of placing patients. 

Evaluation of the Patient's Potential to Live 
Outside the Hospital 

In considering a patient as a candidate for placement outside 
the hospital, it is necessary to determine if his mental and phys- 
ical condition is good enough to adjust to another type of living 
situation. The diagnosis of his mental illness is not as important 
as a clear picture of his daily behavior. This includes the pa- 
tient's attitude, his ability to get along with staff and other pa- 
tients, his willingness to take care of his personal needs, and his 
flexibility. Sometimes a patient appears fairly stabilized in all 
these areas as long as his daily routine is not disturbed. When 
something unexpected happens and the patient becomes dis- 
turbed, it is important to know how he behaves under strain. 
If he is unable to tolerate frustration or change, one could not 
expect him to move successfully into a boarding home situation 
for any length of time. The move would be too disturbing. 

On Central Unit we hold a review conference twice a week 
for the purpose of evaluating a patient's progress and his potential 
for adjusting outside the hopsital. The team approach is used 
and the staff consists of the patient's physician, nurse, attendants 



28 N.C. JOURNAL OF MENTAL HEALTH 

and social worker, as well as other therapists who are familiar 
with the patient. 

It is not unusual for one team member to have an impression 
of the patient which is quite different from another team member. 
This is explained both by the nature of contact a staff member 
has with the patient as well as the personality differences of staff 
members and how the patient reacts. Sometimes we find that 
a patient seems to be well-adjusted at first glance but then learn 
that he has not entered into enough activities or been exposed to 
enough new situations to enable the staff to evaluate him properly. 

At the review conferences the staff reaches a decision as to the 
patient's readiness to leave the hospital and they decide on a 
plan which will best prepare the patient for leaving. This in- 
cludes increased activities on the ward, occupational therapy, in- 
dustrial therapy, and recreational therapy. It also includes special 
trips to the community with an attendant to shop for clothing 
and eating meals away from the hospital. 

At this point, the social worker becomes active in the specific 
service, known as release planning, to plan and carry out the 
goal of placing the patient outside the hopsital. This consists of 
working with the patient's relatives, the welfare department, staff, 
and patient. 

Contact with Relatives 

I think the greatest problem in this service has been the efforts 
exerted to establish contact with the chronic patient's relatives. 
As I mentioned previously, the majority of patients with whom 
I worked had been in the hospital for several years. Most of the 
relatives had quit visiting the patient, except on holidays. Many 
of them had not had any contact with the staff members for 
years. The records show evidence that little effort had been made 
in past years to involve relatives in the patient's hospitalization. I 
found that it was necessary to bring them back into the picture 
once our staff felt the patient was able to live outside the hospital. 

There was reluctance and, occasionally refusal, on the part of 
relatives to be involved in plans for the patient to leave the 
hospital. One relative informed me that he was told by the pa- 
tient's physician several years ago that the patient would never 
be able to leave the hospital. He could not understand why we 
now felt the patient could leave. Another relative referred to a 
physician who advised him, several years ago, not to visit the 
patient. My contacting relatives revived in many of them the 



J. SEAGROVES, C. AUMAN AND J. McNIEL 29 

long buried feelings of hopelessness, frustration, anger, and fear 
of the patient. 

On the other hand, most of the patients still held on to an 
unspoken hope that a family member might someday take them 
home. When I approached a patient about leaving the hospital, 
in most cases, he would state his preference to stay in the hosp- 
ital or to return to live with the relative. In order to help the 
patient accept a plan to go live in a boarding home, it was very 
important to have the relative's cooperation in letting the patient 
know that he could not return to his original home and to help 
him accept the idea of a boarding home. 

If Interest could be stimulated to the extent that relatives re- 
established a relationship with the patient, it was very gratifying 
to see the sudden improvement in the patient. 

I worked with one chronic patient who seldom had visits from 
her family although they lived only a few miles away. When I 
contacted the relatives to help us plan for the patient's placement 
in a boarding home (they had already stated previously that the 
patient could not possibly live with any of the family) they came 
to visit her mostly out of curiosity. Then they began making reg- 
ular visits and bringing the patient clothing and presents. They 
later became very much interested in plans for her to go to a 
boarding home. The patient is looking forward to moving to a 
boarding home where she will be closer to her relatives. Pre- 
viously, she had been very reluctant to leave the hospital where 
she felt secure. 

Another reason why it is important to involve the relatives is 
that they must go to the local welfare department of the county 
where the patient is a resident to apply for help in arranging a 
boarding home placement for the patient. This is the welfare de- 
partment's requirement if the whereabouts of relatives are known. 
Sometimes relatives were acceptable to a plan for the patient to 
live in a boarding home; however, they disliked the idea of 
having to apply at the welfare department because of the stigma 
attached to this. In most cases, though, they needed financial 
assistance to help pay the costs of a boarding home and they 
needed assistance in locating a vacancy. 

It frequently took several weeks to get relatives to make appli- 
cation at the welfare department, but this was a first step. At 
the same time, it was my responsibility to provide the welfare 
department with a summary of the patient's hospitalization (con- 
sisting of the same information obtained in the review conference ) 



30 N.C. JOURNAL OF MENTAL HEALTH 

as well as a statement of the patient's willingness to go to the 
boarding home and what type of home we felt would be most 
suitable. 

From then until placement was completed, I communicated 
with both relatives and the welfare department as to what prog- 
ress was being made in locating a home for the patient, when he 
could move, who would take him, and various other problems. 
We sometimes had a delay because a vacancy could not be lo- 
cated and during this time I continued to talk with the patient 
about his feelings about leaving and what progress was being 
made in locating a home for him. As Dr. Kurt Wolff states, "To 
be uprooted by leaving their country, city or home, is one of the 
most important stresses for elderly people ... I have observed 
that this resistance to every kind of change is one of the greatest 
obstacles in having geriatric patients leave the hospital and 
always calls for special skill and effort." (1) 

Preparing Patient to Leave 

In helping the patient prepare to leave the hospital, I found 
that the most crucial aspect of the planning was after arrange- 
ments had been definitely made for the patient to go to a speci- 
fied boarding home at a definite time. At this point, almost every 
patient reacted the most strongly. If given complete freedom of 
choice in the matter, I feel sure that most patients would cling 
to the hospital rather than agree to separate from it at this 
particular point. The patients varied in their capacity to express 
these feelings about leaving, but one way or the other, the feelings 
were expressed. My role was to help the patient to cope with his 
feelings about leaving and to have some understanding about 
where he was going. 

According to the patient's needs, I tried to prepare him in 
every way for the move. 

Theodore Rosen describes the elderly person's admission to a 
boarding home as a process which has a beginning, middle and 
end. He points out the dual problem involved which is the pa- 
tient's having to separate from the hospital and the need to ad- 
just to the boarding home. (2 ) This sometimes meant taking the 
patient beforehand to visit the boarding home before final plans 
were completed for the move. I found that the relative's partici- 
pation in preparation of the patient made the move much easier. 
Without it, the patient felt no reassurance that he would be cared 



J. SEAGROVES, C. AUMAN AND J. McNIEL 31 

for outside the hospital. He could not blindly trust the boarding 
home operator whom he did not know. 

Other problems which arose from the anticipation of leaving 
the hospital included everything from the patient's feeling that 
he was no longer wanted by the hospital staff to his feeling that 
he could not measure up to the expectations which he believed 
would be imposed upon him in a boarding home. Unfortunately, 
our patients hear of the experiences which other patients had in 
boarding homes and usually these are the unsuccessful place- 
ments. Our patients have heard only from those who left the 
hospital and had to return because of failure to adjust. 

It is primarily through the patient's relationship to the social 
worker that he is encouraged to express his feelings, whatever 
they are, about leaving the hospital. 

Of equal importance is the attendant's role in preparing the 
patient. The attendant already has a close relationship with the 
patient and he is the key person who can keep the social worker 
informed of the patient's reaction to leaving. I found it was worth- 
while to take the attendants on trips to visit the boarding homes, 
not only for their own information but also because they were 
then able to help the patient feel more comfortable about leaving. 
The patient was able to detect the attendant's feelings about the 
boarding home and as time passed, I noticed that certain attend- 
ants always reported the patient's willingness to move to a board- 
ing home while certain others seldom felt a patient was accepting 
the plan. It appeared that the attendant's influence was greater 
than any of the rest of the staff in determining the patient's 
attitude. The social worker can play an important part in helping 
the attendants understand the problems related to boarding 
homes, and to accept what they have to offer. 

Evaluation of Rest Homes 

As we consider a patient as a candidate for a boarding home, 
it is important to consider how the hospital differs from the rest 
home and how this might affect the patient. Although he does 
not benefit from active psychiatric treatment, we must give equal 
consideration to the therapeutic milieu within the psychiatric 
hospital as opposed to that of a boarding home. One sometimes 
overlooks the fact that our entire staff has been exposed through 
specialized training and experience to all types of behavior prob- 
lems and we deal with this every day whereas the boarding home 



32 N.C. JOURNAL OF MENTAL HEALTH 

is operated by a person with no training in this area. Our hospital 
is provided with various techniques and staff including trained 
attendants, nurses, physicians, regulation of medications, and 
the use of seclusion rooms when needed. The boarding home does 
not have these facilities or persons at their disposal. They are not 
set up to deal with patients who become uncontrollable or be- 
yond the boarding home operator's ability to reason with them. 
Local physicians do not always know what to suggest. While 
we might feel that a patient does not need or respond to psycho- 
therapy, we must consider how much attention he requires on 
the ward because of unexpected outbursts of behavior or agita- 
tion or confusion to the extent he cannot control his behavior. 
The attendants are the best source of information concerning this. 
They handle numerous problems of behavior which are never 
reported to the rest of the staff. If a patient should spend several 
restless nights in the hospital, no one becomes alarmed. Possibly, 
a sleeping pill is ordered. In a boarding home, this same problem 
could precipitate the need for returning the patient to the hos- 
pital. 

Secondly, it is necessary to understand as much as possible 
about the boarding home itself if we are considering this as a 
resource for the patient. Boarding homes are owned by private 
individuals who are required to meet standards established by 
the welfare department in order to be licensed. These standards 
are primarily related to the physical structure of the boarding 
home itself including sanitary and safety features. Since the 
homes are privately owned and operated, the owner is free to 
pick and choose which patients he feels will best fit into his home. 
Regardless of the hospital's feelings as to what patients the board- 
ing home should be able to handle, the final decision is up to 
the owner. One can expect that much depends on a particular 
owner's knowledge and attitude toward a patient from a psychi- 
atric hospital. This varies greatly among boarding homes but I 
have found the communities which can provide medical, psychi- 
atric counseling, and casework services to the boarding home 
operator make her much more receptive to taking our patients. 
If help is forthcoming, when needed, the operator does not feel 
so threatened when a problem arises. 

One last observation regarding the boarding home is the 
simple fact that it is located in the community side by side with 
private homes. The boarding home must prove acceptable to the 
community and this makes it necessary for the patient's conduct 
to be normal enough that others do not become disturbed and 



J. SEAGROVES, C. AUMAN AND J. McNIEL 33 

upset. Consideration must be given to the overall group and 
little allowance can be made for individual behavior problems 
which cannot be tolerated by the group. 

In contrast, our hospital does not pick and choose our pa- 
tients. We do the best we can to keep things running smoothly, 
but all of us are aware of the multitude of problems that do arise 
among patients which sometimes become trying for a large staff 
who can share the problem. We must consider what it would be 
like for one boarding home operator to have this responsibility 
around the clock. 

In conclusion, I do not think there is any magic formula for 
arranging successful rest home placements. There are many 
factors involved and the more information we have about our 
patients and the boarding homes, the better we are prepared to 
make sound judgments. All down the line, the quality of services 
provided by our staff in preparing the patient to leave the 
hospital, the efficiency of the boarding home operator and serv- 
ices available within the community to give assistance, and the 
prevailing attitudes and willingness to help the patient with his 
problems, reflect the degree of success we have in placing our 
patients in boarding homes. 

Mr. E. V. Cowdry gives interesting information describing 
the various services available in the community for the aged. This 
includes counseling services, descriptions of nursing homes, 
boarding homes, activity centers, state and federal programs. (3) 

As the hospital and community join hands in providing services 
for the elderly, we should be able to help him better according 
to his individual needs. 



REFERENCES 

1. Wolff, Kurt, M.D.: The Biolog^ical, Sociological, and Psycho- 

logical Aspects of Aging: Charles C. Thomas Publisher, 
Pages 77, 78; Springfield, Illinois 1959. 

2. Leeds, Morton and Shore, Herbert: Geriatric Institutional 

Management; G. P. Putnam Sons, New York, 1964. 

3. Cowdy, E. V., Editor: The Care Of The Geriatric Patient; 

Pages 497-527, The C. V. Mosby Company, 1963. 



34 



Sex In Old Age 



Eric Pfeiffer, M.D. 

Department of Psychiatry 

and 

Center for the Study of Aging and Human Development 

Duke University 

Durham, N. C. ' ^ 



Most readers of this journal are no doubt impressed with the 
important role which sex plays in the lives of adults and ado- 
lescents. They are probably also convinced that sexual behavior, 
in its overt or covert forms, has significance in children as well. 
Is it not amazing, then, that behavior which occupies so prom- 
inent a place throughout the early and middle portion of the life 
cycle should suddenly disappear almost altogether in late life? 
For it is a fact, is it not, that sex is of no consequence to the aged 
— that sexual interest and sexual activity cease to exist with the 
onset of old age or, at least, that they should cease to exist? And 
is it not true that aged persons who claim that they still have an 
active sex life are either morally perverse or are engaged in 
wish-fulfilling prevarications and/or self-deceptions? These are 
facts, are they not? 

Unequivocally, no. The ideas expressed above are the prevail- 
ing negative stereotypes of sexual behavior in old age. For sex 
in old age is a taboo subject. The paucity of factual knowledge 
in this area helps to maintain the taboo. The existence of the 
taboo, at the same time, constitutes a serious impediment to 
objective, in-depth investigations. The taboo is manifested in 
several ways: Aged subjects are often reluctant to participate 
in studies which are clearly labeled sexual in nature. When they 
do participate, usually only limited data of a socially acceptable 
nature can be obtained. Not infrequently, younger relatives ob- 
ject to participation of their older family members in such stud- 



E. PFEIFFER 35 

ies. There is also the contention frequently voiced by laymen, but 
at times by physicians and behavioral scientists as well, that 
sexual matters are essentially private and personal and therefore 
should not be studied medically. Lastly, investigators must them- 
selves overcome a degree of culturally determined hesitancy and 
embarrassment before they can comfortably inquire into the sex 
life of their seniors. 

The root causes of a taboo are generally hard to find. It is 
often said that the taboo against sex in old age is merely a hang- 
over from a Victorian Age. But why does it persist? A number of 
possible contributing factors come to mind. Basically, our society 
still holds that sex should be engaged in primarily for procreative, 
only secondarily for recreative, purposes. Of course, in old age 
the illusion that sexual activity may result in offspring can no 
longer be maintained and sex in old age is therefore unaccept- 
able. It is also possible that the taboo is related, in part, to the 
more generalized incest taboo. Children of all ages experience a 
great deal of anxiety from observing or imagining their parents 
engaged in sexual activity. Since the aged constitute the parent 
generation of the regnant group, some of the avoidance of looking 
at sex in old age may be accounted for on this basis. Lastly, the 
fiction of an asexual old age might be maintained in a culture 
from fear of competition with a still powerful group of aged 
persons. The public and private reactions to the recent marriages 
of persons like Supreme Court Justice William Douglas, Senator 
Strom Thurmond, and Aristotle Onassis, give credence to this 
view. These are all prominent older men who married attractive 
young women. Thus, despite their age, they constitute a real 
threat in competition for sexual objects with the younger genera- 
tion. 

It is only in the last two and a half decades that sexual behavior 
in old age has been systematically investigated. Three series of 
studies will be reviewed and evaluated in this paper: the findings 
of Kinsey and his associates (1,2); those of Masters and Johnson, 
as summarized in their book Human Sexual Response (3); and 
the findings of a group of Duke University investigators, one of 
whom is the present author (4-7 ). 

At the outset it must be stated that there are substantial dif- 
ferences in sexual behavior at any given age, including old age, 
between men and women. This point will be documented for 
sexual behavior in old age further on in the paper. For the mo- 
ment, however, it should be stated that there are at least two 



36 N.C. JOURNAL OF MENTAL HEALTH 

implications of this observation; one, an implication for research, 
the other for clinical practice. First, data in regard to any given 
aspect of sexual behavior should be examined separately for men 
and for women. Second, the sometimes unequal or unmatched 
sexuality of men and women can lead to sexual conflict for some 
individuals. 

Kinsey studied the sexual histories of 14,084 men. Included in 
this huge group were only 106 men over age 60, only 18 of whom 
were over 70. It is therefore not an exaggeration to say that the 
aged were under-represented in Kinsey 's sample. For this reason 
some of the statements which Kinsey makes must be viewed 
somewhat cautiously since they were, in a number of instances, 
based on extrapolations from data on younger age groups. In 
addition, many of the analyses in his book do not include the 
aged at all (Ref. 1, Table 60 thru 66, Figs. 53 thru 88). Kinsey 
nevertheless reached a number of interesting conclusions which 
he felt were justified on the basis on his data. One of these was 
that men were sexually most active in late adolescence (ages 
16 thai 20) and that their activity then gradually declined and 
that the "rate at which males slow up in these last decades does 
not exceed the rate at which they have been slowing up and 
dropping out in the previous age group" (page 235). This should 
be contrasted, however, with the fact that he then goes on to 
present on the succeeding page data on the rapid increase in the 
proportion of subjects who are impotent. His figures indicate that 
this rises from 20 percent at age 60 to 75 percent at age 80. 
Kinsey also noted that married men, when compared with either 
single men or with men who had been previously married, had 
frequencies of sexual activity which were only slightly higher 
than those of their non-married counterparts. 

Masters and Johnson devoted a considerably greater portion of 
their book to geriatric sexual responses than did Kinsey (3). They 
reported findings in two categories: a. sexual anatomy and physi- 
ology in old age; b. sexual behavior in old age. They reported 
that men past age 60 were slower to be aroused sexually, slower 
to develop erection, slower to effect intromission, and slower to 
achieve ejaculation. Accompanying physiological signs of sexual 
excitement, such as sexual blush and increased muscle tone, were 
also less pronounced than in younger subjects. The findings were 
similar for women. Degree of physiological response to sexual 
stimulation, as indicated by breast engorgement, nipple erection, 
sex blush over the breasts, increased muscle tone, clitoral and 



E. PFEIFFER 37 

labial engorgement, were diminished in women over age 60. 
However, capacity to reach orgasm was not diminished, especial- 
ly among those women who had had regular sexual stimulation. 

Masters and Johnson also interviewed 133 men above age 60, 
52 of whom were above age 70. They presented their conclusions 
somewhat categorically and without giving the reader the actual 
data upon which these conclusions are based. They state that 
"there is no question of the fact that the human male's sexual re- 
sponsiveness wanes as he ages." Great emphasis is placed by them 
on the role of monotony in sexual activity in determining declin- 
ing sexual activity. Why monotony should be more important in 
advanced age than earlier in life is not explained. Vincent has re- 
cently pointed out that monotony of sexual expression is at least 
as significant a problem in young marriages (8). Masters and 
Johnson also concluded that men who had had a high sexual 
"output" during their younger years were likely to continue to be 
sexually active in old age. This is in congruence with the findings 
of Newman and Nichols who earlier reported a positive correla- 
tion between strong sexual feelings in youth and continued 
sexual interest in old age (9). Masters and Johnson also inter- 
viewed 54 women above age 60, 17 of whom were about 70. 
They felt that they were justified in concluding from the inter- 
view data that capacity for sexual intercourse with orgasmic re- 
sponse was not lacking in these older women. They do not ad- 
dress themselves, however, to the actual incidence of continuing 
sexual interest or the activity in these women. They agree with 
Kinsey that a sizeable portion of the post-menopausal sex drive 
in women is related to the sexual habits established in earlier 
years. The chapter, however, contains no information on the 
effect of age, marital status, health status, and especially no data 
on the availability or the sexual capacity of sexual partners in 
these women. 

They also asked about masturbation in this age group and 
concluded, rather cavalierly, it seems, that "masturbation repre- 
sents no significant problem for the older-age group of women." 
They go on to state that "there is no reason why the milestone of 
the menopause should be expected to blunt the human female's 
sexual capacity, performance, or drive." While the statements 
may be true from a physiological standpoint, they underestimate 
the significance of the actual psychosocial conditions which exist 
for many aged women. Thus satisfaction of sexual needs through 
coital activity is no longer readily available for many aged women 



38 N.C. JOURNAL OF MENTAL HEALTH 

and considerable conflict may attach to the practice of mastur- 
bation. The authors further state that "there is no time hmit 
drawn by the advancing years to female sexuality." This again 
ignores the fact that the majority of aged women will spend a 
considerable portion of their old age without an available sexual 
partner and thus the statement again addresses itself only to the 
physiological but not to the social and psychological realities in- 
volved. Despite these criticisms, however, there can be no doubt 
that Masters and Johnson have ventured into an area of study 
which has long been closed to scientific investigation and they 
have thus made a monumental contribution to the further under- 
standing of human sexual behavior. 

At the Duke University Center for the Study of Aging and 
Human Development a longitudinal, interdisciplinary study of 
older individuals has been carried out since 1954 and is still in 
progress. As part of the study which seeks to elicit somatic, 
psychological, and social changes associated with old age, data 
on past and present sexual behavior were also obtained. Subjects 
of the study were seen repeatedly at approximately 3-year inter- 
vals. This technique made possible the observation of changes 
occurring within individual subjects over time, not merely 
changes in groups of subjects, as is the case in cross -sectional 
studies. Information was obtained in regard to degree of enjoy- 
ment of sexual intercourse and intensity of sexual feelings, both 
at the present time and in younger years. Also sought was in- 
formation on the present frequency of intercourse in those sub- 
jects who were still sexually active and on the reasons for and 
age of cessation of coital activity in those subjects who were no 
longer sexually active. 

Initially, 254 subjects, ranging in age from 60 to 94 years, and 
roughly equally divided between men and women, were studied. 
At subsequent examinations this number gradually dwindled as 
subjects died, became seriously disabled, and a few failed to con- 
tinue in the study for a number of personal and situational rea- 
sons. Included in the study panel were 31 intact couples who 
provided the investigators with a unique opportunity to cross- 
validate the information provided by each of the two marriage 
partners. This was important methodologically because the re- 
liability and validity of data on sexual behavior obtained by inter- 
view techniques has at times been questioned. 

The results of these studies have been presented in a number 
of related articles and papers (4-7 ). Only a brief summary of them 



E. PFEIFFER 39 

can be presented here. From the longitudinal data the following 
major statements can be made. First, that sexual interest and 
coital activity in persons beyond age 60 are by no means rare. 
Second, patterns of sexual interest and coital activity differs sub- 
stantially for men and for women of the same age. 

About 80% of the men whose health, intellectual status, and 
social functioning was not significantly impaired, reported con- 
tinuing sexual interest at the start of the study. Ten years later 
the proportion of those still sexually interested had not declined 
significantly. In contrast, however, in this same group of men 
70% were still regularly sexually active at the start of the study 
but 10 years later this proportion had dropped to only 25%. Thus 
there was among these men a growing discrepancy with ad- 
vancing age between the proportion of those still sexually inter- 
ested and those still sexually active. 

Among women whose health, psychological, and social status 
were good only about a third reported continuing sexual interest, 
and this proportion did not change significantly over the next 10 
years. Only about a fifth of these same healthy women reported 
they were still having sexual intercourse regularly. Again, this 
proportion did not decline significantly over the next ten years. 
But significantly fewer women than men were still sexually inter- 
ested or coitally active. This was a somewhat surprising finding 
which obviously calls for an explanation. 

The present author has suggested three possible explanations 
for this phenomenon. First, women may always have had lower 
levels of sexual interest than men in their younger years as well 
as in old age. Kinsey's data (1,2 ) as well as our own (5 ) lends some 
support to this notion; but whether this difference exists as a 
result of a cultural or a biological double-standard cannot be 
said at this time. Second, there is reason to believe that the clearly 
demarcated menopause in women, signally the end of reproduc- 
tive capacity, may have a negative influence on sexual interest 
and activity in at least some women. A new longitudinal study 
just begun at Duke University of persons between ages 45 and 
70 may shed some light on this supposition. Third, decline of 
sexual interest and activity in women may have occurred before 
their entry into the study (that is, before age 60). Our data indi- 
cate that the medium age of cessation of intercourse occurred 
nearly a decade earlier in women (about age 60) than in men 
(about age 68 ) (4 ). Quite interestingly, the overwhelming majority 
of women attributed responsibility for the cessation of sexual 



40 N.C. JOURNAL OF MENTAL HEALTH 

intercourse in the marriage to their husbands; the men in general 
agreed, holding themselves responsible. 

A number of other important findings also emerged from the 
study. Among these were the following: 

(1 ). As Kinsey had found for the younger ages, we found that 
in old age, too, married men did not differ markedly from non- 
married men in degree of reported sexual interest and activity. 
On the other hand, married women did differ substantially from 
non-married women; only a very few of the latter reported any 
sexual activity, and only 20% reported any sexual interest. 

(2). While our cross-sectional data indicated a gradual de- 
cline in sexual interest and activity with increasing age, our 
longitudinal data revealed that some 20 to 25% of the men, but 
only a few percent of the women, actually showed patterns of 
rising sexual interest and activity with advancing age. Further- 
more, rising patterns were more frequent among non-married 
than among married men. 

(3 ). Among the group of intact couples included in the study 
panel there was a very high level of agreement between husbands 
and wives in regard to reported frequency of sexual intercourse 
and reasons for stopping coital activity. 

It must be admitted that the Duke longitudinal data on sexual 
behavior in old age are far from complete. Additional informa- 
tion is obviously needed to answer some of the following ques- 
tions: What sexual conflicts and problems do the married and 
the non-married aged experience? What are their sexual fantasies, 
dreams, and concerns? How important is masturbation as a 
sexual outlet for those aged who no longer have a capable sexual 
partner available to them, and what conflicts does it arouse? 
To whom do the aged turn for help with their sexual or marital 
problems? Full and satisfying answers to these and other ques- 
tions are not currently available and more comprehensive studies 
are needed. ^^ - . ' 

In the meantime, what are the implications for clinical prac- 
tice of the above mentioned areas of ignorance and of knowledge? 
The practitioner — whether he be a psychiatrist, internist, general 
or family physician, social worker or welfare agent — must be 
aware and accepting of the fact that many aged continue to have 
or to desire an active sex life. Further, he must be able to con- 



E. PFEIFFER 41 

vey this acceptance to his patient or chent. But he must also be 
aware that not all in the larger society share this view of the 
legitimacy of the aged person's sexual strivings. He must there- 
fore seek to educate and to temper prejudices where he can. 
Elsewhere in this issue Busse addresses himself to the problem 
of the aged as an underprivileged minority, defining a minority 
group as one denied opportunity solely on the basis of member- 
ship within that group. It is no exaggeration to say that the aged 
are sexually underprivileged. Their sexual overtures, aspirations, 
and performances are often ridiculed. Elderly widows and wid- 
owers interested in dating or in re-marrying are often placed 
under severe pressure to give up their aims by their "friends" 
or relatives; they are told "not to make fools of themselves." 
Aged couples living with their children or other relatives often 
are afforded no real privacy, even though their other needs may 
be well provided for. Many state hospitals, nursing homes, and 
homes for the aged practice segregation of the sexes or else permit 
men and women, even husbands and wives, to spend time with 
each other only in public dayrooms or under "supervision." But 
the aged themselves and those interested in the welfare of the 
aged are becoming increasingly interested not only in the dura- 
tion of survival but in the quality of survival as well. An open- 
ness about sexual matters, availability of counsel for sexual prob- 
lems, and living arrangements which permit sexual expression, to 
the extent that the aged individual is still interested in and 
capable of, would not appear to be too outrageous a series of 
demands on behalf of the aged. 

That is not to say that the practitioner should exhort all of his 
aged patients or clients to vigorous sexual activity. Sexual needs 
vary tremendously from individual to individual, and past in- 
tensity of sexual desire and activity are probably the best pre- 
dictors of sexual interest and activity in old age. Then, too, the 
gift of longevity has been distributed unequally between the 
sexes. As a result a very sizeable portion of women will spend a 
major portion of their old age in widowhood, without a sexual 
partner. To exhort them to an active sexual life when none is 
available, would be cruel advice indeed. In short, what is needed 
is for the practitioner to give concerned, equanimous attention 
to the aged person's individual sexual needs, past preferences, 
and current limitations and opportunities. In so doing he will 
significantly enhance the quality of survival for many persons in 
old age. 



42 N.C. JOURNAL OF MENTAL HEALTH 

REFERENCES 

1. Kinsey, A. C, Pomeroy, W. B., and Martin, C. R.: Sexual 

Behavior in the Human Male (Philadelphia: Saunders, 
1948). 

2. Kinsey, A. C, Pomeroy, W. B., Martin, C. R., and Gebhard, 

P.H.: Sexual Behavior in the Human Female (Phila- 
delphia: Saunders, 1953). 

3. Masters, W. H., and Johnson, V. E.: Human Sexual Response 

(Boston: Little, Brown & Co., 1966). 

4. PfeifFer, E., Verwoerdt, A., and Wang, H. -S.: Sexual Be- 

havior in Aged Men and Women. I. Observations on 254 
Community Volunteers. Arch. Gen. Psychiat. 19: 753-758, 
1968. 

5. Pfeiffer, E., Verwoerdt, A., Wang, H. -S: The Natural History 

of Sexual Behavior in a Biologically Advantaged Group 
of Aged Individuals. Read at Annual Meeting of the 
Gerontological Society, Denver, Colorado, Oct. 21-Nov. 
2, 1968. J. Gerontology, in press. 

6. Verwoerdt, A., Pfeiffer, E., and Wang, H. -S.: Sexual Behav- 

ior in Senescence: I. Changes in Sexual Activity and Inter- 
est of Aging Men and Women. J. Geriatric Psychiat., in 
press. 

7. Verwoerdt, A., Pfeiffer, E., and Wang, H. -S.: Sexual Be- 

havior in Senescence. II. Patterns of Sexual Activity and 
Interest. Geriatrics, 24: 137-154, 1969. 

8. Vincent, C. E. Sex and the Young Married, Medical Aspects 

of Human Sexuality, 3: 13-23, 1969. 

9. Newman, G., and Nichols, G. R.: Sexual Activities and Atti- 

tudes in Older Persons. J.A.M.A. 173: 33-35, 1960. 



43 



Negro Aged 

In North Ceirolinai 



Jacquelyne Johnson Jackson, Ph.D. 

Medical Sociologist, Department of Psychiatry 

Duke University Medical Center 

Durham, North Carolina 



Generally, since "few valid generalizations beyond the objec- 
tive socio-economic statuses of aged Negroes are" presently pos- 
sible (due largely to extremely limited data and to relative fre- 
quent divergences among findings therein ),^ a comprehensive or 
succinct overview of all relevant geriatric and gerontological 
aspects of aging and aged Negro Americans — including those re- 
siding in North Carolina— is, while extremely desirable and much 
needed, not yet possible. 

Among those limited data, however, are some useful in pro- 
viding some information and speculation about some aged Ne- 
groes in North Carolina, which, in some way, no doubt, may be 
related to their mental health. 

In 1965, Smith observed that nonwhite admission rates to North 
Carolina state mental institutions tended to be negatively related 
to rurality and poverty; somewhat positively related to in-migra- 
tion, youth problems, suicide, and working women; and highly 
and positively correlated with economic problems (especially 
those of underemployed males, welfare rates for children, the 
disabled, and the aged ); and the proportion of aged in a given 
population. Additionally, he noted that diagnoses of chronic 
brain syndromes were correlated highest with the proportion of 
the population 65-1- years of age, with areas losing population 
through out-migration, and with deprivation and rurality .^ 

Using, then. Smith's observations as a point of departure, this 
paper has two primary purposes. 



44 N.C. JOURNAL OF MENTAL HEALTH 

Its first purpose is that of providing some highly Hmited demo- 
graphic data about aged Negroes in North CaroHna (culled from 
available 1960 U. S. Bureau of Census data) and some commen- 
tary about certain empirical findings from studies utilizing Ne- 
gro aged in North Carolina as their subjects. 

Its second purpose is that of providing some speculation about 
the present and future mental health needs o( some aged Negroes 
in North Carolina, and some suggestions for local community 
mental health centers in North Carolina which may be or may 
become involved in providing needed services for such persons. 

Limited Data and Findings 

Selected census data. In 1960 ,3 the proportion of persons 65 + 
years of age in North Carolina's nonwhite population (i.e., 5.4 
percent) was less than the corresponding total national percent 
of 9.1, the Negro national percent of 6.2, and the state's white 
percent of 7.1. 

Over 80 percent of these nonwhite, aged North Carolinians 
were natives of the state; about 42 percent were between the 
ages of 65 and 69 years; about 41 percent of the Negro males and 
46 percent of the Negro females were in urban areas; and about 
15 percent of the males and 19 percent of the females were classi- 
fied as unrelated individuals in households; and only 0.02 per- 
cent were living in group quarters, including institutions. 

The average household size declined from rural farm to rural 
nonfarm to urban areas, where, e.g., the average number of mem- 
bers in husband-wife families, with the head between 65 and 74 
years of age, was 4.51, 3.95, and 3.31 respectively. 

Some of these nonwhite, aged North Carolinians were em- 
ployed (about 41 and 22 percent each of males 65-69 years of 
age and of males 70+ years of age, and 20 and 8 percent re- 
spectively of their female counterparts ). The model male occupa- 
tion (30.4 percent ) was that of farming, while most of the females 
(58.2 percent) were private household workers. 

Some were without any income: true for seven percent of 
males, 65-74 years of age, 11 percent of males, 75+ years of age, 
and 32 and 26 percent of females 65-74 and of females 75+ years 
of age. Their median income for 1959 ranged from $543 (females, 
75+ years of age) to $840 (males, 65-74 years of age). 



J. JACKSON 45 



Table 1 below provides some information about Negro aged 
in the nation and in the South, while Table 2 below contains 
further demographic characteristics of North Carolinian older 
Negroes. 

Table 1. Some demographic characteristics of Negroes, 65+ years 
of age, in the United States and the South, 1965 





CHARACTERISTIC 


United States 




South 


% of Negroes 65+ years in the tota' 










Negro population: 




6.1 




7.3 


% male 




5.8 




6.6 


% female 




6.4 




7.9 


% nonfarm 




6.2 




- 


% farm 




5.6 




° 


Median school years completed: 


(65 + 


years of age) 


(55 + 


years of age) 


Both sexes 




5.1 




" 


male 




4.6 




4.5 


female 




5.6 




5.8 


Marital status: 










% male — single 




4.3 




3.4 


married, with 










spouse 




59.5 




62.3 


widowed 




23.7 




24.6 


% female — single 




3.6 




3.9 


married, with 










spouse 




22.2 




25.1 


widowed 




66.5 




64.9 



% 65+ years of age in total Negro 
population as family heads: 
% all families 
% families with female 

heads 
% husband-wife 
% female head 
% subfamilies 
% husband (65+ years of age) - 
wife families with 1964 in- 
come under $2,500 
% with 1964 income under $1,500: 
families head 65+ years 
unrelated individuals, 65 + 
years 



11.5 

11.1 
10.7 
12.6 

2.8 



51.2 



30.5 



82.8 



14.9 

13.4 
13.1 
19.7 



- = not given. 

Source: U. S. Bureau of the Census. Current Population Reports, Series 
P-20, No. 155, "Negro Population; March, 1965," U. S. Government Print- 
ing Office, Washington, D. C, 1966. 



46 N.C. JOURNAL OF MENTAL HEALTH 

Table 2. Some demographic characteristics of Negroes," 65+ 
years of age, in North CaroHna, 1960 



CHARACTERISTIC North Carolina 



% males 65-69 years of age in 65+ population 43.1 

% females 65-69 years of age in 65+ population 41.2 

% Negro males in urban areas 40.8 

% Negro females in urban areas 45.9 

% males as unrelated individuals in households 14.9 

% females as unrelated individuals in households 18.6 

% males 65-69 years of age employed 41.2 

% females 65-69 years of age employed 20.0 

% males 70+ years of age employed 21.9 

% females 70+ years of age employed ^ 8.3 

% males 65-74 years of age without income . 6.9 

% males 75+ years of age without income - 11.3 

% females 65-74 years of age without income 32.5 

% females 75+ years of age without income 26.5 

Median 1959 income, males 65-74 years of age $840 

Median 1959 income, males 75+ years of age $645 

Median 1959 incomes, females 65-74 years of age $575 

Median 1959 incomes, females 75+ years of age $543 



Source: U. S. Bureau of the Census. U. S. Census of Population: 1960. 
Detailed Characteristics. North Carolina. Final Report PC(1)-35D. U. S. 
Government Printing Office, Washington, D. D., 1962. 

"Most of the data, unless otherwise specified, were actually for nonwhites, 
the vast majority of whom were Negroes. 

No doubt, the 1970 federal census will indicate some increase 
in the proportion of aged Negroes in North Carolina, and in the 
proportion residing within urban areas, and, probably, some de- 
crease in the proportion employed and some increase in the pro- 
portion unemployed within the labor force. Most of them will 
still have incomes placing them at (or, more likely, below) the 
poverty level. 

A March, 1969, working paper prepared for the United States 
Senate's Special Committee on Aging has indicated clearly 
in the words of its chairman, the Honorable Harrison A. Williams, 
Jr., that 

The economic problems of old age are not 
only unsolved for today's elderly, but they will 



J. JACKSON 47 

not be solved for the elderly of the future— to- 
day's workers— unless this Nation takes posi- 
tive, comprehensive actions going far beyond 
those of recent years .^ 

Even more clear, perhaps, is the immediate need — now — to help 
increase incomes not only for Negro, but also for many white 
aged and aging persons in North Carolina, for, irrespective of 
whether mental health status is or is not related to one's socio- 
economic status, the latter is most definitely related to the types 
of treatment and care one receives when in need of such (the 
direction and strength of such a relationship being too familiar 
to reiterate here). 

Increasing medical and other health-care provisions will prob- 
ably prolong the life of some who otherwise would have died, 
among Negro aged, suggesting that, coupled with other factors, 
the percent of those in group quarters, or at least in need of group 
quarters, will probably increase, unless, of course, community 
mental health centers and other agencies providing mental health 
services play a significantly larger role in reducing the social 
conditions which lead toward increased institutionalization and 
in increasing the use of meaningful out patient services, where 
necessary, for this population. 

Essentially, then, one tie-up with Smith's observations is that 
the nonwhite admission rates of Negro aged to the state mental 
institutions is likely to increase significantly within the next 
decade, inasmuch as there will be some decline in their rurality, 
some in-migration increase in urban and more out-migration in 
rural areas ("Soul City," North Carolina, notwithstanding), more 
unemployment and underemployment, disability, aged, suicides, 
et cetera, unless, again, some positive steps are taken to reduce 
such a likely trend. It could also be argued, of course, that the 
increase may well occur, not with higher admission rates to state 
mental institutions, but to various nursing and rest homes. 

If so, then it suggests that the state of North Carolina might 
well begin now to increase the numbers, types, and distributions 
of nursing and rest homes which will both admit and serve 
humanely Negro aged. That suggestion, in turn, means that the 
funds necessary for such tender, loving care must be forthcoming, 
and forthcoming in at least two ways (which brings us right back 
to income ): 1 ) through increased retirement benefits for Negroes 
near, at, or in retirement at the present time; and 2) increased 
lifetime earnings and increased fringe benefits related to retire- 
ment income for Negroes not yet near, at, or in retirement. 



48 N.C. JOURNAL OF MENTAL HEALTH 

Commentary about selected empirical findings. Unfortunately 
for the purpose at hand, at least, none of the gerontological stud- 
ies a ) restricted to North Carolinians and b ) including — in whole 
or part — Negro aged subjects, which were available to me, em- 
ployed random sampling nor utilized institutionalized subjects.^ 
Consequently, of course, none of their findings can be extended 
justifiably to the population of white and/or Negro aged North 
Carolinians. 

Neverthelsss, it is my feeling (my feminine intuition, if you 
please, but based largely upon certain theoretical and experi- 
ential factors ) that a replication — based upon representative sam- 
pling — of certain of these studies would produce further con- 
firmation of their findings and/or conclusions,^ whereas others 
would fall outside this pattern. 

Essentially, it is the latter such studies which I wish to com- 
ment upon herein. Since raw data never "speak for themselves," 
but are always — and inevitably — "spoken for," these "data spokes- 
men" tend, I think, to be influenced unduly by particularistic 
values toward Negroes which they, themselves, bring to the re- 
search process at the very outset. Thus, they fail too often to con- 
sider possible alternatives in data interpretation. Hence, e.g., 
Negro aged are often stereotyped as being extremely religious 
and as having weak family ties.^ 

As I have pointed out elsewhere, "at the present time, data are 
too sparse to generalize about the relationships of religious ac- 
tivity and attitudes, old age, and race."^ A recent pilot study, 
based upon 32 aged Negro subjects, all but one of whom resided 
in Durham, has suggested that parent-adult child relationships 
among Negro aged, as among other aged, may vary considerably 
by such factors as the sex and social class of the parent and each 
of his offspring. These subjects tended to express a preference 
for what Rosenmayr and Kockeis have termed "family relations 
based on an intimacy but at a distance." Help from children to 
parents among these and similar aged is probably a function of 
such factors as local residence, the extent of the parental need 
and the child's capacity to respond to that need, and the parental- 
child aflfectional relationships.^ 

Thus, such a study suggests, inter alia, the need for consider- 
ably more data about family and other relationships which have 
a definite impact upon mental health. Most of these studies, in- 



J. JACKSON 49 

eluding the ones in which I, myself, have engaged, concentrate 
to little or not at all on the larger social environment in which 
these subjects and other Negro aged reside, thereby, perhaps, 
failing to help provide mental health professionals with addi- 
tional information about causal nexuses between the social en- 
vironment (not just the family, but the neighborhood, the public 
and private social agencies, employment practices, etc. ) and these 
individuals. 

What, then, about mental health needs which may already be 
present and which are likely to develop within the future? What 
about community mental health centers? 

Present and Future Mental Health Needs 



As a "modern Job," I think that the present and future mental 
health needs of some aged Negroes in North Carolina is and will 
be very much interrelated with both basic social problems and 
with individualistic problems, which will necessitate greater and 
more adequate preventive planning. 

For example, as employment opportunities for older Negroes 
decrease, their income problems and their leisure-time problems 
will probably increase. If such problems are not coped with in 
ways satisfactory to the recipients, it is very likely that mental 
illness may well increase among them, for they will be more 
vulnerable. 

Another supposition: it may be that the increasing trend to- 
-ward housing segregation by age may have some effect on cer- 
tain Negro aged females especially, because they will be at a 
greater distance from their kith and kin, without sufficient sub- 
stitutes therefor. 

Other suppositions are, without doubt, possible, but without 
listing additional ones now, what can be said about community 
mental health centers and Negro aged? 

In the first place, it is my impressionistic judgment that mental 
health centers in North Carolina tend— and considering their 
funding and other structural components, perhaps rightly so — to 
be highly cautious in trying to effect meaningful change in some 
of the social conditions within given areas which tend to help 
reduce adequate mental health. Thus, there is a serious need for 
more identification of the basic types of social conditions which 



50 N.C. JOURNAL OF MENTAL HEALTH 

lead to mental illness (i.e., for those illnesses largely precipitated 
by outside factors ) or at least to those types of conditions which 
do not permit the individual to function adequately within his 
environment. Once such identifications (many of which are, quite 
truthfully, already available) are made, then it is incumbent 
upon community mental health centers not to apply bandages 
to cover the wounds, but to help remove the wounds! 

This means, e.g., that, in North Carolina, more active inter- 
vention by community mental health and other agencies in areas 
of critical social concerns must take place. Apparently, too many 
day care centers within the state are yet too much concerned 
about the racial identity of the clients whom they will and will 
not service, or yield only to token desegregation. Too few psy- 
chiatrists and others speak up "loud and clear" about such prob- 
lems, as did too few North Carolinians generally about the recent 
events which indicated that some state workers were receiving 
wages below the minimum wage scale — a fact which some persons 
may interpret as unrelated, e.g., to Negro aged, but which is 
quite related inasmuch as, again, we are back to income! Income 
affects, in various ways, adjustment in old age. 

Community mental health centers could well assist communi- 
ties in planning more facilities and services needed for older 
persons (with a first task in North Carolina probably being 
helping to reduce the frictions apparently existing among such 
agencies, and in helping to promote overall coordination) and 
should provide such impetuses. For example, could certain older 
persons be trained to help provide supportive services for chronic 
alcoholics— about which too little is apparently now done— and 
help to reduce their alcoholic bouts on the weekends especially? 
Could community mental health centers do much to identify the 
"gatekeepers" between community members and resources, and 
provide them further with the necessary training and skills to 
perform such tasks more adequately? 

One such instance in which some attempt is being made in 
the latter direction is that of the Durham County Community 
Mental Health Center, presently in the process of trying to deter- 
mine what types of training programs might be useful for min- 
isters within the area, inasmuch as a number of them seem to be 
"gatekeepers" for the aged and for other persons with problems. 

In short, then, community mental health centers, it seems to 
me, might assist further in helping to deal with such problems 



J. JACKSON 51 

as those of poverty — including employment and sufficient income, 
racism, youth problems, and suicides. A resolution of these types 
of problems would help to improve considerably the conditions 
and mental health statuses of Negro, and of other, aged within 
North Carolina. 

SUMMARY 

This paper about Negro aged in North Carolina was concerned 
chiefly with providing some limited demographic data about 
such persons; with pointing out the need for further studies about 
them, with especial emphasis upon factors affecting their mental 
health statuses; and with suggesting that community mental 
health centers throughout the state might well — in fact, should— 
play significant roles in helping to reduce the types of social 
conditions which tend to affect adversely the mental health 
statuses of Negro, and of other, aged. 



FOOTNOTES 

^J. J. Jackson: "Social gerontology and the Negro: a review. 
The Gerontologist, 7:168-178, 1967. 

^Harvey L. Smith (Executive Director): A comprehensive men- 
tal health plan for North Carolina, Areal Reviews, Appendix I. 
North Carolina Mental Health Planning Staff, August, 1965. 

3U. S. Bureau of the Census. U. S. Census of Population: 1960. 
Detailed Characteristics. North Carolina. Final Report PC 
(1)-35D. U. S. Government Printing Office, Washington, D. C, 
1962. 

^Harrison A. Williams, Jr.: Preface to Economics of aging: 
toward a full share in abundance. A working paper prepared by a 
task force for the Special Committee on Aging, United States 
Senate, 91st Congress, 1st Session. U. S. Government Printing 
Office, Washington, D. C, March, 1969. 

^The specific studies were a) C. Eisdorfer: "Rorschach per- 
formance and intellectual functioning in the aged." /. Geront., 
18:358-363, 1963; b) G. L. Maddox: "Self-assessment of health 
status."/. Geront., 17:180-185, 1962; c) E. W. Busse, F. C. Jeffers, 
and W. D. Obrist: Factors in age awareness. Proceedings of the 



52 N.C. JOURNAL OF MENTAL HEALTH 

Fourth Congress Intl. Association of Gerontology (Merano, 1957). 
Fidenza, Mattioli, Italy, 1958; d) D. Heyman and F. Jeffers: 
"Study of the relative influence of race and socioeconomic status 
upon the activities and attitudes of a southern aged population." 
/. Geront., 19: 225-229, 1964: e) F. Jeffers, C. Eisdorfer, and E. W. 
Busse: "Measurement of age identification: a methodologic note." 
/. Geront., 17:437-439, 1962; f ) V. Stone: Personal adjustment in 
aging in relation to community environment, a study of persons 
sixty years and over in Carrboro and Chapel Hill, North Carolina. 
Unpubl. Ph.D. dissertation. Univ. of North Carolina, Chapel Hill, 
1959; g) V. Stone: "Personal adjustment in aging in relation to 
community environment." In: F. C. Jeffers (ed. ), Proceedings of 
Seminars, 1959-1961. Duke Univ. Council on Gerontology, Duke 
Univ., Durham, N. C, 1962, pp. 61-74; h) J. A. Antenor: An ex- 
ploratory study of the relation of the adjustment of 100 aged 
Negro men in Durham, North Carolina with their education, 
health, and work status. Unpubl. M. A. thesis. North Carolina 
College at Durham, Durham, N. C, 1961; i) M. L. Hamlett: 
An exploratory study of the socio-economic and psychological 
problems of adjustment of 100 aged and retired Negro women in 
Durham, North Carolina during 1959. Unpubl. M. A. thesis. 
North Carolina College at Durham, Durham, N. C, 1959; j) 
J. Himes and M. Hamlett: "The assessment of adjustment of 
aged Negro women in a southern city." Phylon, 23:139-147, 1962; 
k) C. E. King and W. H. Howell: "Role characteristics of flexible 
and inflexible retired persons." Sociol. ir soc. Res., 49:153-165, 
1965; and, finally, 1 ) several of my own studies utilizing Negro 
aged North Carolinians as subjects. 

^Among the examples here are a ), b ), and e ) in the immediately 
preceding footnote. 

'^See Jackson, op. cit., for a more detailed discussion of these 
points. 

»Ibid., p. 172. 

^See J. J. Jackson: "Negro aged parents and adult children: 
their affective relationships." Accepted for forthcoming publica- 
tion in Varia; and J. J. Jackson: "Sex and social class variations in 
Negro older parent-adult child relationships." Paper presented 
at the 21st Annual Meeting of the Gerontological Society, Denver, 
Colorado, 1 November 1968. 



53 



Follow-Up Study 



Information and Counseling 
Service for Old Persons 



Grace H. Polansky, M.S.W. 



The Information and Counseling Service for Older Persons at 
Duke Medical Center planned a follow-up study of all persons 
seen so that there could be an evaluation of the effectiveness of 
the agency's services. This was to be done at least 6 months 
after the initial interview unless circumstances made such an 
approach inadvisable in an individual case. The procedure in 
most instances has been to have a telephone interview using a 
questionnaire. This was done by a caseworker responsible for 
the study unless a staff member carrying the case preferred to 
do it. Many people live at quite a distance from Durham and they 
were written to with the request to telephone collect, with an 
explanation of our interest at that time. We have modified this 
procedure on some later cases and have called people directly 
without an introductory letter. Persons still being seen at the 
time of follow-up may have the questions incorporated in a 
treatment interview. We are reporting on 40 out of the 82 clients 
seen in the first year. 

We have assessed, rated and compared the following items: 

1 ) Problems at intake which were recalled by the client at 
follow-up. 

2 ) Problems originally identified by the client which the inter- 
viewer had to remind the client of. 

3 ) Client's perception of current general health as related to 
recollection of health at intake. 

4 ) Client's impression of effect on problems of being seen at 
Information and Counseling Service for Older Persons. 



54 N.C. JOURNAL OF MENTAL HEALTH 

5) Steps taken to remedy problems during or after ICSOP 
contact. 

6) Recommendations the client recalls being made by ICSOP 
staff, and 

7) New current problems. 

The clients rated severity of problem now and compared it 
with severity at intake. The interviewer compared current se- 
verity with severity at intake. New current problems are rated 
by client as to severity. Ratings of change in severity are: 

1. Clearly worse 

2. Worse 

3. The same 

4. Slightly improved 

5. Improved « 

In addition, we secured current data on such items as income, 
living arrangements, employment status, social and recreational 
activity, and use of community health and welfare resources, 
which can be compared with these items at intake. 

Frequently, the total number of problems is larger than the 
number of cases because of the multi-problem pattern in aging 
clients. These cases averaged 2.2 problems each. It was not pos- 
sible to get data on every item in some cases. Problems spon- 
taneously recalled by the client and compared for severity at 
intake showed: 

' ( improved 42 

slightly improved 10 

the same 13 

,' worse 7 

clearly worse 3 

Current severity was: 

mild 35 
moderate 15 
marked 14 
no longer applicable be- 
cause of improvement 14 

Problems the interviewer had to remind the client of were: 

, ' improved 6 

slightly improved 2 









G. POLANSKY 


the same 






5 


worse 






2 


rity was: 








mild 

moderate 
marked 
no longer 
cause of i 


applicable be- 
mprovement 


6 
2 
1 

3 



55 



The severity of problems recalled is currently at the 1.4 level 
of rating with mild rated as 1, moderate as 2, marked as 3. The 
rating of problems the client was reminded of was 1.1. Percep- 
tion of current general health was : 

improved 20 

the same 14 

worse 4 

These were all as rated by the client. 

The interviewer's impression of severity of problems recalled 
was: 

improved 38 

slightly improved 13 

the same , 16 

worse 6 

clearly worse 2 

Problems the client had to be reminded of were rated by the 
interviewer as: 

improved 6 

slightly improved 3 

worse 2 

Both client and interviewer found 4.1 average change in problems 
recalled: 4. is the slightly improved rating. In problems the 
client had to be reminded of, the client found 3.8 change and 
the interviewer 4.2 change. This data supports the effectiveness 
of ICSOP intervention assessment ratings by the clients, which 
would seem more likely to be conventional responses. Twenty- 
nine positive, negative, and 9 indefinite responses were ob- 
tained. It is recognized that in spite of interviewing precautions 
these may tend to be conventional responses. 



56 N.C. JOURNAL OF MENTAL HEALTH 

Steps taken to remedy problems during or after being seen 
at Information and Counseling Service for Older Persons av- 
eraged 2.5: 

Change in attitudes or feelings 23 

Medication 20 

Contact with other professionals or helping agencies 19 

Changes in pattern of daily living 18 

Environmental changes 17 

Other 2 

Recommendations clients recalled being made by ICSOP staff 
averaged 1.7: 

Medication 15 

Contact with other professionals or helping agencies 15 

Changes in pattern of daily living 13 

Environmental changes 11 

Other 4 

New current problems had developed for some clients who 
rated them: 

Mild 3 

Moderate 4 

Marked 3 

Future studies will examine which type of problems and what 
severity have been more amenable to positive change. More 
vigorous attempts to complete follow-up are planned. For in- 
stance, though the client has died, a relative will be interviewed, 
and lack of response by a client to an approach will not be 
assumed to be unwillingness. In a few instances in the past it 
has been thought inappropriate or non-therapeutic to contact a 
particular individual and this may well hold in the future. We 
have contacted 57 clients and 40 have responded at this time. 
It has been our impression that some who did not complete the 
follow-up had weathered a crisis quickly and others had a psychi- 
atric condition making it unlikely that they would contact us 
again. There may be others in the group with negative feelings 
they did not feel comfortable in expressing. 

In summarizing those who replied, we find that 29 express 
positive feeling and 9 are not sure whether it helped them to be 
seen at Information and Counseling Service; 60 problems have 
shown improvement, 18 are the same, and 12 are worse. Overall 
change averages a slightly improved rating. 



57 



Evaluation of Treatment 
Outcomes In the Elderly 



Jesse N. McNiel, M.D.^, H. S. Wang, M.D.", and 
W. /. Eichman, Ph.D.'''' 

The 1960's have been a period of innovation and rapid ex- 
pansion in the area of mental health. Programs for the aged have 
included transfer of large numbers of patients from state mental 
hospitals into the community, more active treatment programs, 
and alteration in milieu. Increasing numbers of older citizens 
have resulted in Medicare and, more recently, its extension Title 
16. Both increasing need and increasing opportunity press for 
careful evaluation of projected plans. 

The goal of this paper is to outline some types of evaluative 
scales and describe a limited study of treatment outcomes in 
older patients at John Umstead Hospital. The list of scales avail- 
able in psychiatry is extremely long, but scales useful for evalua- 
tion of the older patient may be difficult to locate. For instance, 
the U. S. Department of Health, Education, and Welfare (1) 
published a Handbook of Psychiatric Rating Scales (1950-1964) 
containing 19 highly respected scales; and while some have 
selective value for the elderly, not one of them was designed 
specifically for the older patient. Until recently the individual 
seeking to evaluate an older patient group usually used a scale 
designed for use elsewhere or made up his own. The literature is 
full of scales used for one study and most often not standardized. 
Geriatric measuring tools may be divided into five categories: 
1. ) those that deal heavily with functional symptoms such as 
depression, paranoia, anxiety, etc.; 2.) those that emphasize the 
patient's behavior and his ability to take care of himself; 3. ) 
those that emphasize organic brain syndromes; 4.) those that 
emphasize physical condition; and 5. ) mixtures of these. 



°Dr. McNiel is a fellow in geropsychiatiy at Duke University; 

°Dr. Wang is assistant professor of psychiatry at Duke University, and 
Dr. Eichman is associate professor of psychology at the University of 
North Carolina, and Director of Research, John Umstead Hospital. 



58 N.C. JOURNAL OF MENTAL HEALTH 

Mental Status Questionnaire 

This scale was introduced by Kahn, Goldfarb, Pollock, and 
Peck in 1960 (2) and is frequently called the "Goldfarb Scale." 
It consists of 10 simple questions such as "where are you", 
"where were you born," "what day is this," etc. It is easy to give 
and measure organicity in a fairly rough fashion. It is very useful 
for patients with chronic brain syndromes of late life. It has been 
used in a number of studies and can be used clinically for part 
of the mental status exam. A professional examiner is not required 
but the person should be familiar with the test. 

Isaac -Walkey (3) 

This test, like the Mental Status Questionnaire, measures 
organicity. It uses questions similar to the Goldfarb scale but 
adds a block stacking problem and asks the patient to remember 
pairs of items. The examiner names pairs of items, tells the patient 
one item of the pair, then asks him to name the other. The test 
is more sensitive than the Goldfarb and slightly longer. A pro- 
fessional is not required, though in most cases would be pre- 
ferred. 

Mental Status Schedule 

The mental status schedule (4) was reported on by Spitzer, 
Fleiss, Endicott, and Jacob in 1967. It is probably the most 
extensive scale available for the geriatric patient. It has been 
highly standardized and is a mixed test. It includes behavior, 
functional symptoms and organicity. The style is observation of 
the part of the examiner and a series of questions designed to 
bring forth information. In general, a capable professional having 
some experience with the test is desired. This scale is especially 
helpful since it has a special geriatric supplement in addition 
to extensive items correlating with mental patients generally. The 
disadvantage of the scale is its length. However, where time 
permits, it may be well worth the trouble. 

Stockton 

The Stockton Geriatric Rating Scale (5) was reported by 
Bernard Meer and Janet Baker in 1965. It emphasizes behavior 
and is filled out by the person taking care of the patient. There 
are 33 items that can be further broken down into 4 clusters — 
physical disability, apathy, communication failure, and socially 



J. McNIEL, H. WANG AND W. EICHMAN 59 

irritating behavior. This scale has been thoroughly standardized 
and has been used considerably among institutional patients. 
Aspects such as measurement of practical ward behavior prob- 
lems, high interrater reliability, and simplicity make it a favorite. 
Meer and Baker also felt this scale could be used as a clinical 
guide in the treatment of the older patient. 

Lowenthal Scales 

Lowenthal (6 ) in 1964 reported on extensive studies of public 
hospital admissions. Her book, Lives In Distress, forms a basic 
reference in this area and can serve as a reference for smiliar 
work. For this reason the combination social and physical self- 
maintenance scale may be particularly valuable. It is relatively 
short and does not require professional people and is composed 
of 18 items all dealing with the patient's actual behavior in his 
pre-hospital environment. Each item contains a series of descrip- 
tive statements, ranging from those describing a "normal person" 
to those describing a person entirely dependent on the assistance 
of others for the provision of basic needs. A number of correla- 
tions to other information have been made with this scale. 

Brief Psychiatric Rating Scale (7) 

This scale is mentioned because it is a good brief psychiatric 
rating scale for general use. Its use is for acutely ill patients with 
functional symptoms, primarily schizophrenia and affective dis- 
orders. Unfortunately, a great number of older patients do not 
present primarily as functional diagnostic types. This scale does 
require a trained professional, preferrably a psychiatrist. 

Classification of Nursing Care Needs 

In reality, the classification of patients according to nursing 
care need is not a scale, but it may prove useful in patient sur- 
veys. The Veterans Administration (8) in -1964 authorized a 
circular for guidance to nursing home bed units. It divides pa- 
tients into categories as to degree of intensity of illness, diagnostic 
type and type of care required. It places patients into medical, 
spinal cord injury, surgical, and psychiatric divisions. Of course, 
it requires highly professional personnel to rate patients. 

The following study will illustrate an approach to the use of 
some of the scales. In an effort to get a more systematic picture 
of treatment outcomes in the older patient, it was determined to 



60 N.C. JOURNAL OF MENTAL HEALTH 



follow patients on the Durham Unit of John Umstead Hospital 
who were age 55 or older and had not been admitted for the 
past 5 years. They were tested weekly for four weeks and monthly 
thereafter. Three scales were used: 1) Brief Psychiatric Rating 
Scale done by a psychiatrist, 2) Goldfarb Scale done by a psy- 
chiatrist, and 3 ) Stockton Geriatric Rating done by the attendant 
staff in association with a research attendant. The Brief Psychi- 
atric Rating Scale was chosen because of the shorter time period 
required though it represented a compromise. The Goldfarb 
Scale was chosen because of its simplicity and reliability for 
organicity and the Stockton was felt to be the best behavioral 
scale available and also easiest to use. 

Problems 

Problems were encountered early with the Brief Psychiatric 
Rating Scale since most patients were not acutely ill but had 
an illness which was organic in nature with chronic behavioral 
problems. Little change was recorded in the scale, and because 
of its brevity no clear separation of degree on the organic items 
was possible. The Stockton was more difficult to use than antici- 
pated because without a special ward maintained by the same 
personnel, multiple attendant raters were the rule. This is a 
problem anytime the natural history of patients is desired, since 
the holding of patients on a single ward changes the natural 
milieu. There were fairly significant differences in the scoring 
of a patient by one attendant on a closed ward versus an open 
ward, or simply between two attendants. While maintaining the 
same patient environment and ward staff would have helped 
considerably with rating constancy, the attitude of the attendant 
and his opportunity to observe the patient are important factors. 
For instance, a more maternal attendant might bathe a patient 
and rate him as not being able to bathe himself while another 
attendant would encourage the patient to bathe himself and 
rate him as able to bathe himself. The open wards with pri- 
vate rooms and low staff-patient ratio made complete observation 
of patient behavior difficult. A specialized geriatric ward would 
be most ideal for patient study. The Goldfarb Scale was gen- 
erally good, but a few patients seemed in relatively good con- 
tact, yet could not give the date accurately or tell the name of the 
hospital, etc. 

Results 

For analysis, patients were separated into two groups: those 
patients remaining in the hospital at the end of the eight month 



J. McNIEL, H. WANG AND W. EICHMAN 61 

study, and those that had been discharged. The "discharge" 
group totaled 8 and the "not discharged" group totaled 18. An 
analysis of variance was run with these two groups using pre 
and past observations (first measure and last measure obtained). 
There were no significant differences on the Brief Psychiatric 
Rating Scale. With the Goldfarb Scale the "discharge" group 
(mean score = 1.31 ) was significantly lower than the "Not Dis- 
charge" group (mean score = 6.50). This has a probability of 
0.005. There was no significant difference for either group in 
regard to change over time. With the Stockton the "discharge" 
group (mean score-15.35) was significantly lower though the 
"not discharged" group at the 0.01 level. Both groups combined 
show significant improvement at the 0.05 level during hospitaliza- 
tion (first measure = 27.63, last measure = 22.73). 





Correlations Among Measures 


N 


Correlation 


Prohahilitij 








Co 


efficient 
r 




a) 


Age X Goldfarb 


22 




.53 


.02 


b) 


Age X Brief Psychiatric 


22 




.17 


" 


c) 


Age X Stockton 


17 




.48 


.05 


d) 


Goldfarb x Brief Psychiatric 


24 




.45 


.05 


e) 


Goldfarb x Stockton 


17 




.43 


- 


f) 


Psychiatric x Stockton 


17 




.33 


- 



lyiscussion 

The observation that the Goldfarb scale was the best predictor 
of outcome is in line with other studies emphasizing the negative 
aspects of organicity to recovery (9). The simplicity of the scale 
does not reduce its usefulness; on the other hand it was not 
possible to measure change in a significant manner with it. The 
Stockton does seem quite capable of measuring changes as well 
as correlating with prognosis. The difficulty with variability 
between raters must be attributed primarily to the movement 
of patients from one ward to another since Meer and Baker (5) 
achieved good reliability on a specialized geriatric ward. The 
Brief Psychiatric Rating Scale proved to be of almost no value. 
This may not be surprising since Clausen (10) after reviewing 
psychiatric examinations in the elderly, noted, "psychiatric evalu- 
ations based on intensive examination were no more predictive 
of social functioning in day to day life than were a number of 
cognitive and psychological measures or a simple measure of 
environmental loss." It would seem that a behavioral or organic 
type scale is most useful. Whenever possible some controlled 



62 N.C. JOURNAL OF MENTAL HEALTH 

ward situation without frequent patient moves is desirable. All 
these scales indicated very little change in patients over time. 
While this could mean the scales did not measure the type of 
change that was occurring in the patients, it is more likely that 
the discharge prognosis was predetermined at the time of ad- 
mission — those patients with functional illness or mild organic 
brain syndromes would leave while those who were sicker would 
remain. Less sick individuals may be returned to their own 
homes or to community custodial facilities. Sicker patients have 
no alternative placement except the hospital. Further studies 
should include the role of the outside environment as well as 
the hospital treatment. 

Summary 

A significant number of good scales for evaluating the geriatric 
patient have become available in the last few years. They are 
capable of indicating prognosis, measuring changes, and of fol- 
lowing patients clinically. It is suggested that greater use of these 
scales should be made for systematic evaluation of the elderly 
at every level. 



REFERENCES 

1) Handbook of Psychiatric Rating Scale (1950-1964) Public 

Health Service Publication No. 1495. Supt. of Documents, 
U. S. Govt. Printing Office, Washington, D. C. 20402 - 
Price .45. 

2) Kahn, R. L.; Goldfarb, A. I.; Pollock, M; and Peck, A., Brief 

Objective Measures For The Determination of Mental 
Status In The Aged; Am. J. of Psychiatry, Pg. 326-28, 1960. 

3) Isaacs, B. & Walkey, F. A.: Measurement of Mental Impair- 

ment In Geriatric Practice; Gerontologia Clinica, 6: pg. 
114-123, 1964. 

4) Spitzer, Robert L.; Fleiss, Joseph L; Endicott, Jean; and 

Cohen, Jacob; Arch Gen. Psychiatry, Vol. 16, pg. 479-493, 
Apr. 1967. 



J. McNIEL, H. WANG AND W. EICHMAN 63 

5) Meer, Bernard and Baker, Janes A.; The Stockton Geriatric 

Rating Scale, J. of Gerotology, pg. 392-403, 1965. 

6) Lowenthal, Marjorie Fiske; Lives In Distress, Basic Books, 

Inc., N. Y., 1964, pg. 266. (Scales available only by personal 
communication with Dr. Lowenthal). 

7) Overall, J. E. and Gorham, D. R., The Brief Psychiatric 

Rating Scale, Psycho Rep. 10, 799-812, 1962. 

8) Circular 10-64-170, Classification of Patients According to 

Their Nursing Care Needs. Veterans Administration, Dept. 
of Medicine and Surgery, Washington, D. C. 20420. 

9) Locke, Ben Z., Hospitalization History of Patients with 

Mental Disease of the Sensorium. J. of Gerotology, Vol. 17, 
pg. 381-84; 1962. 

10) Clausen, John A. Conceptual and Methodologic Issues in the 
Assessment of Mental Health in the Aged. pg. 151-60. 
Chapter from Psychiatric Research Report 23, 1968, Aging 
In Modern Society, edited by Simon, Alexander and Ep- 
stein, Leon J., American Psychiatric Association. 



64 



Organic Brain Syndromes 

The Role of Cerebral Oxygen Metabolism 

H. Shan Wang, M.B. 

Assistant Professor of Psychiatry 

Duke University Medical Center 

Durham, N. C. 

The diagnostic approach currently prevaiHng in psychiatry is 
based on a classification of psychiatric disorders according to 
their etiology. Patients who show evidence of diffuse brain dis- 
order (usually characterized by an impairment of intellectual 
function and judgment, loss of memory, disorientation, and emo- 
tional instability ) are usually given the diagnosis of "organic brain 
syndrome" regardless of any concurrent behavioral disturbance 
or psychotic symptoms (1), 

The prevalence of organic brain syndromes in aged persons 
is well recognized. Of all the individuals over 64 years of age 
who are patients in public and private psychiatric institutions in 
the United States, about one half are diagnosed as having such 
a disorder (2, 3). Among persons who are past 64 when they are 
admitted for the first time to a psychiatric institution, three out 
of every four are given this diagnosis (2, 3 ). "Organic brain syn- 
drome" is the diagnosis made on about 40% of all elderly patients 
discharged from the psychiatric services of general hospitals or 
from psychiatric outpatient facilities (3, 4 ). Such syndromes are 
also quite common among aged residents in homes providing 
nursing or personal care. In 1964, a survey of such homes dis- 
closed that about 30% of the geriatric residents were suffering 
from neuropsychiatric conditions attributable to senility; about 
36% had vascular lesions affecting the central nervous system— 
a condition in which organic brain syndromes are almost in- 
variably present (5 ). Based on data from psychiatric hospitals and 
those from nursing and personal care homes, it is estimated that 
the rate of organic brain syndromes requiring institutional care 
is at least 2,300 per 100,000 elderly population (6). 

Even elderly persons who are in good health and are leading 
normal and active lives in the community are not all spared from 
such brain disorder. At the Duke University Center for the Study 
of Aging and Human Development, a longitudinal study on a 
group of community volunteers past the age of 60 showed some 



H. WANG 65 

evidences of brain impairment (psychiatric, psychological, neuro- 
logical, or electroencephalographic ) in about one third of the 
subjects. 

Classification of Organic Brain Syndromes 

Organic brain syndromes are further subclassified according to 
the underlying causative pathological processes— the two most 
common being cerebral atherosclerosis and the cerebral degen- 
erative disease such as senile dementia. Brain syndromes that 
are temporary and reversible are considered acute; those that 
are permanent and irreversible, as chronic (1). 

Clinical differentiation of the various types of organic brain 
syndromes is extremely difficult, if not impossible. This difficulty 
is due largely to a lack of effective and practical methods for 
routine evaluation of the brain and for the detection of various 
causative factors. Furthermore, most organic brain syndromes 
come to clinical attention at such a late stage that secondary 
changes or complications have already developed in most cases. 

Among the many changes that commonly occur in the senile 
brain, some are chiefly attributable to chronological age, while 
others clearly result from pathological processes, either within 
the brain or elsewhere in the body. The common feature of all 
insults to the brain, whatever the cause, is a loss of neurones and 
a decline in neuronal functioning. Both these changes result in a 
reduction of metabolic activity within the brain tissue involved. 

Metabolism of the Brain 

The normal brain has a respiratory quotient of about 1. There 
is no significant arterio-venous difference in any energy-rich 
substrate except oxygen and glucose, and the relationship be- 
tween the cerebral uptake of oxygen and that of glucose is almost 
stoichiometrical. These facts lend support to the theory that 
the brain derives its energy for normal functioning almost ex- 
clusively from the aerobic oxidation of glucose, the metabolic 
products of which are water and carbon dioxide (7). 

The stores of oxygen and glucose in the brain are extremely 
small (8). It is estimated that the blood withm the brain at any 
one time contains a total of 5 ml. of oxygen, while not more than 
2 ml. are dissolved in the brain substance. The total stores of 
glycogen and glucose within the brain have been estimated as 
being equivalent to approximately 2 gm. of glucose. At a normal 
rate of utilization, the stores of oxygen in the brain would last 



66 N.C. JOURNAL OF MENTAL HEALTH 

about ten seconds, and those of glucose would be depleted 
within two hours. The functional and structural integrity of the 
brain thus depends on a sufficient and uninterrupted supply of 
oxygen and glucose from the blood, and also on the proficiency 
of the brain tissue in utilizing these two nutrients. Because the 
store of glucose in the brain is so much greater than that of 
oxygen, and because the analytic method of determining the 
amount of glucose in the blood is not specific (it includes re- 
ducing substances other than glucose), the cerebral metabolic 
rate of oxygen (the cerebral oxygen consumption) is, as a rule, 
the more sensitive and reliable indicator of cerebral metabolic 
activity. In order to calculate cerebral oxygen consumption, it 
is necessary to measure both cerebral oxygen uptake and cerebral 
blood flow. The various methods used for making these measure- 
ments are well described elsewhere (7, 9). 

The brain has a very high rate of oxygen metabolism. In normal 
young adults, each 100 gm. of brain tissue takes up, on the av- 
erage, about 3.5 ml. of oxygen per minute. For an average 
adult brain weighing 1,400 gm., the total oxygen uptake is esti- 
mated to be approximately 50 ml. per minute. The amount of 
oxygen consumed by the brain (which accounts for only 2% of 
the body weight ) is almost 20% of the body's total oxygen con- 
sumption (7). The rate of blood flow to the brain is also high, 
being estimated at 50 to 55 ml. per 100 gm. of brain tissue per 
minute — about 15% of the cardiac output for a normal young 
adult (10). 

Under normal conditions, cerebral oxygen consumption is, 
within limits, independent of the cerebral blood flow; the cere- 
bral blood flow, in turn, is regulated largely by the local meta- 
bolic needs of the brain tissue, particularly the carbon dioxide 
tension in the arterial blood. With normal brain and normal 
cerebral vascular system, both cerebral oxygen consumption and 
cerebral blood flow remain quite constant under a great variety 
of physiological and pathological conditions ( 7, 8, 10). The 
unique compensatory mechanism responsible for this remarkable 
stability can be illustrated by two formulas: 

Cerebral Oxygen consumption = cerebral blood flow x cerebral 

oxygen uptake 

Cerebral blood flow = 

blood-pressure gradient (or mean arterial blood pressure ) 

cerebral vascular resistance 



H. WANG 67 

Since a change in blood pressure is normally accompanied by 
a proportional change in cerebral vascular resistance in the same 
direction (and vice versa ), the cerebral blood flow normally re- 
mains constant. A reduction of cerebral blood flow ensues when 
the decrease in cerebral vascular resistance lags behind that 
in arterial blood pressure, or when the increase in arterial blood 
pressure lags behind that in cerebral vascular resistance. The 
former condition might occur in the presence of a sudden decline 
in mean arterial blood pressure to 60 mm. Hg or less; the latter, 
in the presence of severe polycythemia or a marked increase in 
intracranial pressure. When the cerebral blood flow is dimin- 
ished, the healthy brain will normally compensate by taking up 
more oxygen from the blood per unit of time, thus widening the 
arterio-venous oxygen difference. When the autoregulstory mech- 
anism of the cerebral vascular system is intact, anemia or 
hypoxemia is accompanied by an increase in the cerebral blood 
flow. These two compensatory mechanisms — increase of oxygen 
uptake and increase of blood flow— serve to keep constant the 
amount of oxygen available to the brain tissue, so that the normal 
function of the brain can be maintained. 

Effect of Aging on Cerebral Metabolism and Blood Flow 

In old age, both cerebral blood flow and cerebral oxygen con- 
sumption tend to decrease (7, 8, 10). These reductions are not 
the result of chronological age per se, but rather of certain 
pathological processes frequently associated with advanced age. 
Dastur and his associates (11) have showed that both cerebral 
blood flow and cerebral oxygen consumption are about the 
same in old persons having excellent health as in healthy young 
adults. A study using the 133-xenon inhalation method (12, 13) 
showed that the mean cortical blood flow of the left parietal 
region was significantly lower in a group of elderly community 
volunteers than in healthy young adults; there was, however, 
considerable overlapping between the two groups. In the elderly 
subjects, the blood flow ranged from 33 to 72 ml. per 100 gm. 
per minute; in the young adults, the range was 57 to 92 ml. (13). 

The factor that is perhaps most often responsible for a reduc- 
tion in cerebral blood flow is cerebral atherosclerosis, which 
leads to an increase in cerebral vascular resistance and an im- 
pairment of the autoregulatory mechanism. To maintain a normal 
blood supply to the brain in the presence of advanced cerebral 
atherosclerosis, a relatively high blood pressure or a well- 
developed collateral circulation, or both are indispensable. In 



68 N.C. JOURNAL OF MENTAL HEALTH 



patients with cerebral atherosclerosis, the cerebral hemodynamics 
may be seriously affected by even a small drop in the systematic 
blood pressure. Because the autoregulatory mechanism is im- 
paired, the ability of the cerebral vascular system to compensate 
for hypoxemia and anemia is also markedly reduced. 

Causes and Effects of Decreased Cerebral Oxygen Consumption 

An inadequate supply oi oxygen to the brain (cerebral hypoxia ) 
may therefore result from (1 ) insufficient blood supply (ischemic 
hypoxia), (2) lack of oxygen-carrying elements in the blood 
(anemic hypoxia ), or (3 ) lack of oxygen in the blood (hypoxic 
hypoxia). Any type of cerebral hypoxia may lead to depression 
of the cerebral metabolic activity, which may manifest itself as 
an impairment of the high cortical functions (cloudiness of con- 
sciousness, disorientation, cognitive deficits, etc. ). In such a case 
the oxygen consumption is reduced (Table 1). Cerebral oxygen 
consumption can also be reduced by conditions that decrease 
the supply of glucose to the brain (essential hypoglycemia or 
insulin coma, for example ) or that impair the utilization of glu- 
cose by the brain (diabetes mellitus ). 

The condition most commonly responsible for reducing cere- 
bral oxygen consumption, however, is impairment of the brain 
tissue. Degenerative changes of varying degrees are expected 
to develop sooner or later in all senile brains. In addition, old 
age is commonly associated with many metabolic and electrolytic 
disturbances which originate outside the brain but eventually 
involve the brain. Any impairment of the brain, whether struc- 
tural or functional, also reduces the metabolic activity and hence 
the cerebral oxygen consumption. Such an impairment also in- 
creases the brain's vulnerability to ischemic hypoxia because it 
diminishes the ability of the brain to compensate for an in- 
adequate blood supply by extracting more oxygen from the 
blood. 

The correlation between intellectual deterioration in old per- 
sons and a decline in cerebral oxygen consumption or cerebral 
blood flow was first demonstrated by Freyhan and his co-workers 
(15) and has been repeatedly confirmed in patients with various 
neuropsychiatric disorders ( 16, 17, 18 ) as well as in community 
volunteers (12). Since the reduction in cerebral oxygen consump- 
tion or cerebral blood flow is usually accompanied by a slowing 
of the dominant frequency in electroencephalograms (19, 20), 
this measure is useful in evaluating the status of the brain and in 



H. WANG 69 



following the course of elderly patients suspected of having or- 
ganic brain syndromes. 

Therapy 

Unfortunately, none of the degenerative diseases of the brain 
are amenable to therapy, and there is little that can be done for 
most patients v^ith cerebrovascular insufficiency. The therapeutic 
value of various vasodilators or anticoagulants in this condition 
is still questionable. In certain cases where the blood supply 
to the brain is being compromised by a localized lesion in the 
extracranial carotid system, surgical procedures such as endar- 
terectomy may be effective. 

Cerebral hypoxia of the anemic or hypoxic type is more amen- 
able to therapy; the early recognition of such condition is ex- 
tremely important. In most elderly patients, drugs that are known 
to depress the brain function, such as barbiturates, should be 
avoided, and drugs that may lower the blood pressure, such as 
phenothiazines, should be used with extreme caution. Special 
attention should be given to old persons who are exposed to 
situations that may decrease the oxygen content of blood — 
anesthesia, for example, as well as certain operations, medica- 
tions, and posture (21, 22, 23). 

Summary 

Brain syndromes are prevalent in old age. Although they can 
result from a great variety of pathological processes that arise 
either originally from the brain or from elsewhere in the body, 
the common feature in all these disorders can be viewed as a 
disturbance of the cerebral oxygen metabolism — its supply or 
utilization. The present paper reviews the mechanisms that help 
to maintain the cerebral oxygen metabolism and those factors 
commonly associated with old age that tend to disturb it. The 
early recognition, correction and prevention of the causative or 
contributory factors to cerebral hypoxia or the reduction of cere- 
bral oxygen consumption is emphasized. 

REFERENCES 

1. A. P. A. Committee on Nomenclature and Statistics. Diag- 
nostic and Statistical Manual of Mental Disorders (2nd 
ed. ). Washington, D. C: American Psychiatric Association, 
1968. 



70 N.C. JOURNAL OF MENTAL HEALTH 

2. U. S. Public Health Service, National Institute of Mental 

Health. Patients in Mental Institutions, 1966, Part II, State 
and County Hospitals (PHS Publication No. 1818). Wash- 
ington, D. C: U. S. Government Printing Office, 1968. 

3. U. S. Public Health Service, National Institute of Mental 

Health. Patients in Mental Institutions, 1966, Part III, Pri- 
vate Mental Hospitals and General Hospitals with Psychi- 
atric Service (PHS Publication No. 1818). Washington, 
D. C: U. S. Government Printing Office, 1968. 

4. U. S. Public Health Service, National Institute of Mental 

Health. Outpatient Psychiatric Clinics, Special Statistical 
Report, Old Adult Patients, 1964, State and Total United 
States (PHS Publication No. 1553). Washington, D. C.: 
U. S. Government Printing Office, 1967. 

5. U. S. Public Health Service, National Center for Health 

Statistics. Prevalence of Chronic Conditions and Impair- 
ments among Residents of Nursing and Personal Care 
Homes— United States, May-June, 1964 (PHS Publication 
No. 1000, Series 12, No. 8). Washington, D. C.: U. S. 
Government Printing Office, 1967. 

6. Wang, H. S.: Organic brain syndromes. Int. Psychiat. Clin., 

1969 (in press ). 

7. Sokoloff, L.: Metabolism of the central nervous system in 
( vivo. In Field, J. (Ed.), Handbook of Physiology, Section 

I, Neurophysiology, Vol. III. Washington, D. C: American 
Physiological Society, 1960. 

8. Kety, S. S.: Circulation and metabolism of the human brain 

in health and disease. Amer. J. Med., 8:205-217, 1950. 

9. Harper, A. M.: Measurement of cerebral blood flow in man. 

Scot. Med. J., 12:349-360, 1967. 

10. Fazekas, J. F., Kleh, J., and Finnerty, F. A.: Influence of age 

and vascular disease on cerebral hemodynamics and 
metabolism. Amer. J. Med., 18:477-485, 1955. 

11. Dastur, D. K., Lane, M. H., Hansen, D. B., Kety, S. S., Perlin, 

S., Butler, R., and Sokoloff, L.: Effects of aging on cerebral 
circulation and metabolism in man. In Birren, J. E., Butler, 
R. N., Greenhouse, S. W., Sokoloff, L., and Yarrow, M. 
(Eds.): Human Aging: A Biological and Behavioral Study 



H. WANG 71 

(PHS Publication No. 986). Washington, D. C: U. S. 
Government Printing Office, 1963. 

12. Wang H. S., Obrist, W. D., and Busse, E. W.: Neurophysio- 

logical correlates of the intellectual function of community 
elderly persons. Presented at the American Psychiatric 
Association Annual Meeting, Bal Harbour, Florida, 1969. 

13. Obrist, W. D., Thompson, Jr., H. K., King, C. H., and Wang, 

H. S.: Determination of regional cerebral blood flow by 
inhalation by 133-xenon. Circ. Res. 20: 124-135, 1967. 

14. Scheinberg, P., and Jayne, H. S.: Factors influencing cerebral 

blood flow and metabolism, a review. Circulation, 5:225- 
236, 1952. 

15. Freyhan, F. A., Woodford, R. B., and Kety, S. S.: Cerebral 

blood flow and metabolism in psychoses of senility. J. 
Nerv. Ment. Dis., 113:449-456, 1951. 

16. Lassen, N. A., Munck, O., and Tottey, E. R.: Mental function 

and cerebral oxygen consumption in organic dementia. 
Arch. Nerol. Psychiat., 77:126-133, 1957. 

17. Hedlund, S., Kohler, V., Nylin, G., Olsson, R., and Regn- 

strom, O.: Cerebral blood circulation in dementia. Acta 
Psychiat. Scand., 40:77-106, 1964. 

18. Klee, A.: The relationship between clinical evaluation of 

mental deterioration, psychological test results and the 
cerebral metabolic rate of oxygen. Acta Neurol. Scand. 
40:337-345, 1964. 

19. Ingvar, D. H., Baldy-Moulinier, M., Sulg, I., and Horman, 

S. : Regional cerebral blood flow related to EEC. Acta 
Neurol. Scand., Suppl. 14:179-182, 1965. 

20. Obrist, W. D., Sokoloff, L., Lassen, N. A., Lane, M. H., But- 

ler, R. N., and Feinberg, I.: Relation of EEC to cerebral 
blood flow and metabolism in old age. Electroenceph. 
Clin. Neurophysiol., 15:610-619, 1963. 

21. Payne, J. P., and Conway, C. M.: Hypoxemia after surgery 

and anesthesia. Postgrad. Med. J., 42:341-350, 1966. 

22. Ward, R. J., Tolas, A. C, Benveniste, R. J., Hansen, J. M. 

and Bonica, J. J.: Effect on posture on normal arterial 
blood gas tensions in the aged. Geriatrics, 21 (2): 139-143, 
1966. 



Notice to Contributors 

Manuscripts and editorial comments should be addressed to 
the Editor-in-Chief, N. C. Department of Mental Health, P. 0. 
Box 9494, Raleigh, N. C. 27603. 

Contributors need not be psychiatrists, neurologists or 
M.D.'s but should be involved in some aspects of program, 
whether clinical, educational, or research, pertinent to mental 
health or mental illness. 

Manuscripts offered for publication should be submitted in 
the original, typed on bond paper and double spaced with 70 
characters per line. Footnotes, bibliographical references, quo- 
tations, etc., should also be double spaced and the use of foot- 
notes minimized. 

References to books and journals should be numbered con- 
secutively in a bibliography at the end in the order in which 
they appear in the manuscript. References should be limited 
to those used by the author in the preparation of the article 
and kept to a minimum. 

The author's privilege of correcting galley proofs may apply 
only to printer's errors. 

Tabular material, drawings and charts should be submitted 
on separate sheets, clearly marked as to where they are to 
appear in the text. 



NORTH CAROLINA JOURNAL OF 
MENTAL HEALTH 

Published by 
The State Department of Mental Health 



EDITOR-IN-CHIEF 
Eugene A. Hargrove, M.D. 

ASSOCIATE EDITOR 
Nicholas E. Stratas, M.D. 

SENIOR EDITORIAL CONSULTANT 
Bernard Glueck, M.D. 



CONTRIBUTING EDITORS 
Granville Tolley, M.D. Sam 0. Cornwell, M.D., Ph.D. 

Gilbert Gottlieb, Ph.D. Harvey L. Smith, Ph.D. 

Philip G. Nelson, M.D. Norbert L. Kelly, Ph.D. ■ 



EDITORIAL ADVISORY BOARD 

George Ham, M.D. Halbert B. Robinson, Ph.D. 

C. Wilson Anderson, Ph.D. Ewald W. Busse, M.D. 

John A. Fowler, M.D. Mark A. Griffin, M.D. 

John A. Ewing, M.D. Martha C. Davis, M.S. 

Richard C. Proctor, M.D. N. P. Zarzar, M.D. 

Richard A. Goodling, Ph.D. Jacob Koomen, Jr., M.D. 



Produced by 

Division of Information and Public Relations 

Benjamin G. Runkle, Director 

Jacqueline M. Ransdell 

Lillian W. Pike 

Sally R. Cameron 



NORTH CAROLINA JOURNAL OF 
MENTAL HEALTH 



Volume 4 Number 2 



1970 



CONTENTS 



ARTICLES 



Management Information and the Administration 
of Community Mental Health Centers 

Harold D. Holder and Robert J. Gregory , 5 

Classical Conversion Reaction— A Case of 
Spinal Cord Tumor 

James D. Mallory, Jr., and Carroll 

D. Patterson 16 

Medicaid and Mental Health 

Donald S. Leventhal and H. Melvyn Gilley 19 

Client Characteristics: The Cumberland 
County Mental Health Center 

Robert J. Gregory and Marianne Ingram 22 

The Effects of Alcohol on Brain Function 

William P. Wilson 30 

Editorial 3 

Announcement 47 



NORTH CAROLINA JOURNAL OF MENTAL HEALTH 

is published quarterly, Spring, Summer, Fall and Winter. 

It is a scientific journal directed to the professional disciplines en- 
gaged in care, treatment, and rehabilitation of mentally ill and re- 
tarded patients as well as to those engaged in professional research 
and preventive work in the field. 

This journal is intended to be inclusive rather than exclusive and is 
not meant to be regarded as simply a house organ of the North Carolina 
State Department of Mental Health. 

It is hoped that the journal will reflect the broad-based philosophy of 
psychiatry current and will draw on areas reflecting the total spectrum 
of psychiatric and neurologic thought, program and research. 

Subscription may be obtained by writing the Editorial Offices, North 
Carolina Department of Mental Health, P. 0. Box 26327, Raleigh, North 
Carolina 27611. 

(Notice to contributors— see inner back cover) 



EDITORIAL 



Reorganization of state government- 
threat or challenge? 



There is at present a study commission looking into reorgani- 
zation of state government in North Carolina. An eventual 
outcome of this study may be inclusion of the Department 
of Mental Health with some other departments into a Depart- 
ment of Human Resources. At the present time the Depart- 
ments of Corrections, Juvenile Corrections, Public Health, 
Mental Health, and Social Services deal to some extent with 
the same group of clients. No doubt some of our programs 
overlap and some areas receive very limited services. 

Combination of these several departments into one agency 
may allow the state to focus more clearly on the question, 
"What level of services should state government provide or 
guarantee to individual citizens?" A Department of Human 
Resources may be able to define levels of state support with 
regard to: 

Environment 
Health 
Education 
Deviance 



This editorial isn't a campaign for a comprehensive cradle 
to grave welfare state, but rather support for a reorganization 
that permits the citizens and their elected representatives to 
choose what level of services the state will guarantee and 
also the possible benefits and consequences of the choices 
made. 



N. C. JOURNAL OF MENTAL HEALTH 



The advantages to Mental Health of such a reorganization 
seem to be: 

1 ) The mental health focus can shift further from treatment 
of endstage disease and those extruded from the social 
system to prevention of disability and attainment of 
maximum individual potential. 

2 ) Mental health concepts can be more easily incorporated 

into programs now assigned to other agencies. 

3 ) Over-all planning and priorities should be more compre- 

hensive. 

4) Mental Health can benefit from know-how and systems 
of delivery now present in other agencies. 

5) Deviance can be handled in a planned and comprehen- 
sive way. 

The major benefit for all departments should be the focus 
on clients and services, rather than the territorial concerns of 
competing agencies. Expected economics may not occur on 
an over-all basis. There will probably be some savings from 
elimination of duplication of programs. However, a clearer 
view of the consequences of failure to provide environment, 
health, and education services that allow maximum utilization 
of human resources may result in greater public commitment 
and actually in greater expenditure of funds — but with a higher 
degree of public understanding and involvement. Better man- 
agement also is expensive— it takes skilled managers, staff, and 
information systems. 

Those looking to reorganization of state government for 
economy may be disappointed, but others may be cheered by 
more efficient use of funds, better management, more involve- 
ment and commitment by citizens, and greater realization of 
individual potential by all citizens. 

R. L. Rollins, Jr., M. D. 
Superintendent 
Dorothea Dix Hospital 
Raleigh, North Carolina 



Editor's Note: This editorial was submitted for publication prior to 
approval of the reorganization referendum in the November general 
election. 



MANAGEMENT INFORMATION AND THE 

ADMINISTRATION OF COMMUNITY MENTAL 

HEALTH CENTERS 



Harold D. Holder, Ph.D. 

Director, Systems Analysis and Program Evaluation 
North Carolina Department of Mental Health 

Robert J. Gregory, Ph.D.* 

Director, The Institute of Human Ecology 



The effective management of community mental health 
services is concerned with the proper utilization of fixed and 
limited resources rather than providing all necessary or pos- 
sible services. Resources are simply not that available. Pro- 
gramming decisions operate within an environment of con- 
straint in which concern is with identifying possible alterna- 
tives (programs and services ) and selection of that set or 
combination of activities most likely to achieve the goals of 
the organization with available resources. 

Management decisions require information about potenti- 
ally meaningful alternatives, costs, or losses, and returns or 
payoffs even though such notions appear not in mental health 
but in business nomenclature. This does not, however, make 
such concepts and their implications for mental health man- 
agement less relevant. It is logical to consider any participant 
in a community mental health organization a decision-maker 
if his tasks involve choice, i.e., if he has freedom in behavior. 
This is true whether we consider a center director, a social 
worker, a staff psychiatrist or physician, a community liaison 
person or a clinical aide. 

In the field of mental health, we have too long ignored the 
need for a systematic attack on the problems of obtaining 
management information. The process of collecting, organiz- 
ing, analyzing, and disseminating information as a basis for 
decision has been historically left to personal, private, and 
informal means. The purpose of this article is to underscore 
the need for information in direct support of administration 

^Formerly Research Scientist, Cumberland County Mental Health Center 



6 N. C. JOURNAL OF MENTAL HEALTH 



and describe how one staff began to come to grips with the 
problem. 



Information and Administration 
Data and Management Utility 

Mountains of data are now available to community mental 
health workers, but an examination of this data reveals simul- 
taneously a concern with an extensive range of problems re- 
flected in scattered and free-ranging research and a fairly 
narrow concern in data collected regularly. Laboratories and 
field investigations have produced an overwhelming set of 
figures and research observations, while at the same time 
extensive statistical services on state, regional, and national 
levels in public mental health collect epidemiological data 
concerned with the incidents of institutional admissions, types 
and numbers of diagnoses, the profile of related socio-econo- 
mic characteristics, length of treatment, types of treatment, 
and so forth. 

Thousands of pages of reports and program summaries are 
produced to benefit supervisors, advisory and legislative 
groups, and review committees. Such data may possess his- 
torical and thus predictive value but rarely supports specific 
future decisions. Special studies conducted at community 
sites and reported in the research literature have general value 
and provide important insights but do not deal with the uni- 
queness of each community program. Sensitivity to the un- 
certainties of administering community programs has been 
rare. Efforts at planning and evaluation, both essential tasks 
in mental health management, would directly benefit from a 
change in emphasis. 

Formal public organizations providing service to the com- 
munity, including mental health groups, have a long tradition 
of operationally separating research efforts from management 
by distinguishing between "pure" and "applied" research. This 
dichotomy is often based on the belief that some inquiries 
are not based on concern for solution of a particular problem, 
but rather concern for inquiry alone. However, two identical 
research projects may differ only because of some charac- 
teristic of the investigator (s ). On closer examination, such 
distinctions between pure and applied research are less useful. 
A more useful continuum is to consider the relative utility 
of the investigation according to the needs and values of the 
individual or groups conducting the research and the indivi- 
dual or organization sponsoring the inquiry. All research "ap- 



H. HOLDER and R. GREGORY 



plies" to the problem (s ) of the investigator and the organiza- 
tion of which he is a part. 



Information Systems 

Modern administrative strategy, best exemplified by the 
nation's most successful industrial corporations, has demon- 
strated by the development of robust decision-making tools 
the usefulness of research in support of management. Why 
then should mental health not purposefully use research to 
collect information as a direct part of management rather than 
an adjunct to it? The interrelatedness of effective management 
of social organizations and an understanding of them has been 
often pointed out (Freeman and Sherwood, 1965; Marris and 
Rein, 1967, pp. 159-160; Jackson, 1967 ). Could community 
mental health programs not develop a management informa- 
tion system based, not on special studies, even though they 
would be essential in initial development and later modifica- 
tion, but on a purposeful, goal-directed effort to collect and 
disseminate relevant information? Dissemination refers here 
not to publication in a widely distributed journal but to the 
vital process of putting in the hands of each decision-maker 
information essential to his tasks. The import of this has often 
been underscored for business and industry (Clough, 1963; 
Shuchman, 1963; Wilson and Wilson, 1965) and for mental 
health in planning and evaluation (Phillips, 1967; Mercer, 
et al., 1964; Kramer, 1966; Smith and Hansell, 1967; Kiresuk 
and Sherman, 1968 ). Gumming (1968), in herstudy of health, 
education, legal and welfare agencies in Syracuse, found that 
as the size and complexity of the network of agencies grew, 
traditional and consensual techniques of coordinating gave 
way to more rational planning. One symptom of growth, then, 
is the development of administrative and management meth- 
ods which are more efficient. 

Such a management information system could be derived 
through staff cognizance of the decisions which both the or- 
ganization and the participating individuals must make and the 
uncertainties related to these decisions. Paramount are ques- 
tions of planning (the establishment of goals ), identifying steps 
to be followed in reaching goals; evaluation or control to 
compare performance against predetermined standards judged 
necessary to reach goals; staffing to use personnel as effec- 
tively as possible within the organization; program design to 
identify alternative activities in which the organization should 
and/or could become involved to meet community needs; and 
case assistance to identify what is necessary to aid an indivi- 
dual in returning to an acceptable level of social competence. 



N. C. JOURNAL OF MENTAL HEALTH 



Indentification of such decisions is tlie basis of a systematic 
and directed effort to create a management information system 
which could provide quantified information (statistics ) and/or 
non-quantified information (summary statements) to staff. In 
short, this is a formalized effort to identify and meet the in- 
formation needs of the community organization. The collection 
of information is in the primary service of the community- 
based enterprise and is of secondary service to others. In 
small organizations, this system may not be complex or ex- 
tensive. Staff members themselves may be responsible for 
organization and maintenance and complex and highly tech- 
nical methods may not be necessary and quite possibly not 
be useful. In other words, "information system" refers not to 
the mechanics of how information is collected and dissemi- 
nated (this can assume as many forms as there are organiza- 
tions ) but to the process itself. 

Categories of Information 

In the search for information for a community mental health 
program, relevant and reliable information in three categories 
should be available to managers in a community mental health 
program: (1 ) external — information about the environment out- 
side the program; (2 ) internal — information about the program, 
its subparts and internal relationships; and (3 ) interactional- 
information about the exchanges which occur between the 
program and its environment. 

External information includes knowledge of the population 
to be served, community profiles and needs, available re- 
sources to support and complement mental health efforts, 
unique mental health problems, formal groups such as legis- 
lative bodies, advisory boards, and pressure or special interest 
organizations, and informal groups such as the community 
power structure, neighborhood subcultures, or family constel- 
lations which impinge on or have the potential to affect the 
organization. Levy, etal., (1968 ) suggests one approach to this 
category for program evaluation. 

Internal information involves an understanding of the public 
relationships (formal and legal ) which compose the organiza- 
tion as well as the private relationships (informal and inter- 
personal ) on which social intercourse is based. How does 
information flow in the organization? What are the sources of 
noise and misunderstanding? How are resources, whether 
materials, time, facilities, patients, or peronnel utilized? Carzo 
and Yanouzas (1967) outline some important concepts and 
analysis tools for understanding formal organizations. 



H. HOLDER and R. GREGORY 



Interactional information has to do with the relationships 
between the mental health organization and its environment— 
the linkages between mental health in a community and other 
public and private agencies and the changes which occur in 
the community due to the existence of a mental health organi- 
zation, as well as a result of its efforts and activities. A paper 
by Halpert (1967 ) suggests several alternative models in un- 
derstanding these inter-linkages between agencies. 



Patient Flow in a Community 
Mental Health Center 

Manager Uncertainty 

As a demonstration of using research to assist administra- 
tive problem-solving in a community mental health center and 
as a first step in developing a staff-related information system, 
this paper will describe an effort to document the paths and 
rate of flow for outpatients treated by the Cumberland County 
Mental Health Center, Fayetteville, North Carolina. A primary 
administrative concern at Cumberland has been in understand- 
ing the internal operating nature of this patient-relating aspect 
(inpatient facilities have only recently been developed ) of the 
center and its relationship to other community agencies. With 
such knowledge the staff felt it would be able to make appro- 
priate organizational changes. Prior information about the out- 
patient program was limited to an organizational chart showing 
the paths along which patients should proceed from admission 
to termination and the descriptions of treatment and observed 
response obtained in individual patient files. At least three 
bits of information necessary to understand the changes oc- 
curring in this particular part of the total organization were 
missing. 

First, no objective knowledge was available about the paths 
most frequently used by patients and the type of individuals 
proceeding along one pathway as opposed to available alter- 
nates. Second, while suspicions abounded, nothing was known 
of the pathways not shown on the formal organizational chart 
but clearly existing since patients were able to traverse them. 
These exceptions are the non-public or informal structure 
of the organization in contrast to the public-codified and 
formal. The operating structure of the organization was actual- 
ly a combination or integration of both. Third, the rate of flow 
for patients through particular pathways was lost except for 
personal impressions that some "took longer than others." 
Little was known of the work load at various contact points 



10 N. C. JOURNAL OF MENTAL HEALTH 



and meaningful organizational adjustments were very difficult 
to make. 

There existed seven points or steps along which people 
were to proceed in flowing through the outpatient program: 

(1 ) Referral— the official notification of the Mental 
Health Center through telephone, letter, personal visit, or 
intercession by a representative of some other agency of the 
need for an appointment for a "client"; 

(2) Intake— the initial interview with a client to take a 
social history, usually conducted by a social worker; 

(3 ) Intake Staff Conference — a group meeting with several 
variant forms-, county school liaison teachers present cases 
to members of the mental health center for possible further 
work by the staff, or members of the center staff who have 
conducted intake interviews present their findings to senior 
staff members for a group formulation of future action, or 
members of the city school staff present cases to senior mem- 
bers of the mental health center for further planning; 

(4 ) Evaluations — psychiatric or psychological examination 
to provide an understanding of an individual's psychological 
dynamics. (In rare cases, neurological or physical ); 

(5) Interpretives — conferences held with clients and/or 
parents or other relatives of clients and/or members of agen- 
cies who have an interest in a given client to discuss findings 
of evaluations or intake interviews and to plan treatment pro- 
grams; 

(6 ) Treatment— therapeutic regimes including drug ther- 
apy, individual psychotherapy, group therapy or involvement 
in special classes in school, etc.; 

(7 ) Termination— formal end of a client's case, often after 
a failure to show up for further services. 

The linkages between the seven steps in the center are 
called "tracks" such that movement from a physician (a source 
of referral ) to an intake interview constitutes a track. Primary 
questions for this investigation were the nature of tracks exis- 
ting in the patient-treatment subsystem and the frequency or 
probability with which each was used. 

Only terminated cases were used since theirs was a com- 
plete trek. I n total 805 cases from July 1, 1967, to July 1, 1968, 
were analyzed. The individual patient records were used to 
capture three types of data-. (1 ) social-demographic charac- 
teristics, (2 ) the tracks entered or used in proceeding from 



H. HOLDER and R. GREGORY 11 



referral to termination, and (3 ) tiie number of days in each 
track. 



Findings and Conclusions 

The specific data resulting from this study has limited in- 
terest as it mirrors the uniqueness of this particular program 
and its community. A detailed summary of the data is omitted. 
However, Figure 1 shows the tracks making up the outpatient 
program and the number of cases in each track and provides 
some comprehension of the diffuse pattern of patient move- 
ment. 

Some of the insights gained by the staff in understanding 
the nature of their outpatient clinic can be summarized. First, 
the need for better control of information about patients was 
made evident. As a result, a patient-tracking system was estab- 
lished. Each patient is now described on a 3 x 5 card, and 
the cards filed in appropriate categories as progress takes 
place. The patient-tracking system readily provides both visual 
data (thickness of card-deck ) and quantitative data about the 
numbers and characteristics of patients in any particular (or 
all ) tracks. 

Second, the major tracks used by patients have been iden- 
tified. The major thrust of patient-flow was not always along 
the anticipated paths. In some cases a patient may skip the 
next sequential step. The hypothesized six tracks between the 
seven points were often bypassed. For example, the referral- 
to-intake track contained 574 cases; intake-to-intake staff, 388; 
intake-staff-to-evaluation, 288; evaluation-to-interpretive, 106; 
interpretive-to-treatment, 88, and treatment-to-termination, 
544. Interpretive was not one of the major steps utilized in 
the sub-system; more than eighty per cent of the patients 
flowed around interpretive. Treatment, the hypothesized 
"heart" of the outpatient program, was bypassed by a quarter 
of the cases. This suggests a character of the outpatient clinic 
other than diagnosis and treatment. 

Third, the direction of patient flow in the clinic is primarily 
forward (referral toward termination ), but some right-to-left 
movement existed, meaning that a patient might move back 
to pick up a step missed or to repeat a step. 

Fourth, the center staff realized this program to be most 
complex. For example, there are forty-two potential tracks (all 
combinations of steps). While Figure 1 shows twenty opera- 
tional tracks (those serving more than one per cent of the 
patient population ), there were thirty possible tracks (at least 



12 N. C. JOURNAL OF MENTAL HEALTH 



one patient moved along it). The possible sequence in which 
tracks may be used reveals even more complexity. 

Fifth, some potential problems became evident to the staff. 
While the large number of referrals from the city and county 
schools (some thirty-eight per cent of the total referrals) is 
related to the staff's school consultation program, the small 
numbers of cases referred from the police department, two, 
local clergy, seven, and public health nurses, two, prompted 
a re-examination of center relationship with these individuals 
and organizations. Specific speculation: "While these agencies 
and individuals likely come in contact with many people having 
severe problems, why are they not referring such cases to the 
mental health center?" The amount of time spent in the vari- 
ous tracks provided additional insight. Time spent in the 
referral-to-intake track ranged from an average of two weeks 
for vocational rehabilitation referrals to approximately one day 
for those agencies having most direct control of their wards, 
that is, public schools and courts. 

In general, the movement of cases from the referral source 
is to placement in some step in the outpatient program of the 
center. Rare, almost nonexistent, is the movement of the 
patient back to the referral source prior to termination. The 
center staff has begun to question whether cases should be 
wholly the responsibility of the center or whether more involve- 
ment with referral sources should occur. While the intake 
interview has been designed as the major contact and case 
information gathering device for the center, at least three 
other tracks exist around it. 

( Summary 

While this particular study was, as with most research, 
stimulated by questions and uncertainty, it was designed to 
assist the managers of the outpatient clinic in more clearly 
understanding strengths and weaknesses and providing a 
sounder basis for maintaining or changing existing relation- 
ships. This study was chosen to illustrate the need for and 
value of relating investigation to management considerations 
rather than to curiosity or personal interest. Information is 
essential to management and, therefore, data alone has little 
or no utility outside a relationship to administration. Many 
types of research data may be neither helpful nor useful. 

Through this investigation, management needs have been 
made public to all the staff rather than left to be fulfilled by 
impression and personal observation. Consequently, manage- 
ment decisions can be more explicit and shareable. For the 
Cumberland County Mental Health Center, this project was an 



H. HOLDER and R. GREGORY 13 



essential step toward the continuous use of research investi- 
gation to directly assist center administration and provide 
the basis for a management information system. 

This article has had the purpose of directing attention 
toward the need to systematically collect, analyze and dis- 
seminate data concerning the external, internal, and interac- 
tional nature of public mental health organizations providing 
services in a community. Such research need not suffer from 
less validity or reliability than other investigations. It should 
certainly not be any less scientific. The major differences 
between supporting an information system for a mental health 
organization and conducting field or experimental research 
relating to the community programs is in the emphasis on 
administration of the organization. Investigation is not viewed 
as a series of unrelated or related projects but a part of a 
purposeful system with utility for staff members. 

The communities served by mental health programs and the 
organizations providing these programs are complex and dyna- 
mic. Mental health cannot hope to understand and effectively 
manage without continuous insights into the nature and in- 
teractions of both. 



14 



N. C. JOURNAL OF MENTAL HEALTH 



O 



0) 

X 
75 



oc E 



a. 
o 







-■ 






2o5 




S^ 










q: en 






^^ 






H. HOLDER and R. GREGORY 15 



REFERENCES 

Carzo, R., and Yanouzas, J. N. Formal organization. Illinois: 
Richard D. Irwin, Inc., and The Dorsey Press, 1967. 

Clough, D. J. Concepts in management science. Englewood 
Cliffs, N. J.: Prentice-Hail, Inc., 1963. 

Gumming, E. Systems of social regulation. New York: Atherton 
Press, 1968. 

Freeman, H. E., and Sherwood, C. C. Research in large scale 
intervention programs. Journal of Social Issues, 1965, 21, 
11-28. 

Halpert, H. P. Models for the application of systems analysis 
to the delivery of mental health services. Paper presented 
to 45th annual meeting, American Orthopsychiatric Associ- 
ation, Chicago, 1967. 

Jackson, J. Some issues in evaluating programs. Hospital and 
Community Psychiatry, 1967, 18, 161-168. 

Kiresuk, T. J., and Sherman, R. E. Goal attainment scaling: a 
a general method for evaluating comprehensive community 
mental health programs. Community Mental Health Journal, 

1968, 4, 443-453. 

Kramer, M. Mental health statistics of the future. Eugenics 
Quarterly, 1966, 13, 186-204. 

Levy, L., Herzog, A. N., Slotkin, E. J. The evaluation of state- 
wide mental health programs: a systems approach. Com- 
munity Mental Health Journal, 1968, 4, 340-349. 

Marris, P., and Rein, M. Dilemmas of social reform: proverty 
and community action in the United States. New York: 
Atherton Press, 1967. 

Mercer, J. R., Dingman, H. P., and Tarjan, G. Involvement, 
feedback, and mutuality. American Journal of Psychiatry, 
1964, 121, 228-237. 

Phillips, L. The competence criterion for mental health pro- 
grams. Community Mental Journal, 1967, 3, 73-76. 

Suchman, A. (ed. ) Scientific decision making in business. 

New York: Holt, Rinehart, and Winston, Inc., 1963. 

Smith, W. G., and Hansell, N. Territorial evaluation of mental 
health services. Community Mental Health Journal, 1967, 
3, 119-124. 

Wilson, I. G., and Wilson, M. E. Information, computers, and 
system design. New York: John Wiley and Sons, Inc., 1965. 



16 



CLASSICAL CONVERSION REACTION- 

A CASE OF SPINAL CORD TUMOR 



James D. Mallorv, Jr., M.D.* Carroll D. Patterson, M.D. 

Assistant Professor of Psychiatry Resident in Psychiatry 

Duke University Duke University 



This case demonstrates the dynamics of a classical con- 
version reaction. The symptom was of sudden onset and in- 
volved the voluntary neuro-muscular system.' The acute epi- 
sode was heralded by a "previous period of mounting emo- 
tional tension."- It occurred in the setting of current conflicts 
concerning self-esteem, economic success, sexual adequacy, 
and family relationships.'''^ The patient prominently used the 
mechanisms of denial and repression, demonstrating little 
anxiety. His general attitude, in fact, was that of "satisfied 
indifference." On some occasions, however, he described his 
symptoms in quite dramatic terms and made equally dramatic 
efforts to move his paralyzed legs.'^ His illness afforded sec- 
ondary gain in job and family difficulties.-* His past history 
revealed chronic maladaptation especially in the roles of hus- 
band and father.-' However, this case presented a significant 
diagnostic problem because the patient had a spinal cord 
tumor to which he was reacting in the above mentioned 
fashion. 

The patient, Mr. A., is a 58 year old male meat market 
worker in a large food store chain. His illness apparently began 
in 1965 when he became very fearful of being replaced in 
his managerial position by a younger man. At this time, he 
took a three months sick leave because of nervousness. When 
he returned to work he was demoted with a significant cut 
in salary. Mr. A. disclaimed any irritation or frustration over 
this but smilingly maintained it was all for the best and "they" 
had his best interest at heart, in that they gave him a less 
responsible job so he would not get so tense. 

His continued to work in his lowered position until June 
1966. While at work he fell against some crates striking his 
chest. He began to complain bitterly, but many trips to various 
doctors uncovered no cause for his pain. Mr. A. stated he was 
finally told by a chest consultant, "It's all in your head." He 

*Presently Medical Director, Atlanta Counseling Service 



J. MALLORY and C. PATTERSON 17 



was considered depressed at this time, referred to a psychia- 
trist and received four electric shock treatments. He then 
signed out of the hospital against medical advice, continued 
to complain of pain and remained at home. 

One week later, the day before the onset of his leg symp- 
toms, his boss telephoned asking him to go to a hockey game 
with the admonition not to try to back out. Mr. A. attended 
the game and awoke next morning with a paralyzed left leg. 
Three days later Mr. A. was referred to our hospital for psy- 
chiatric evaluation. When interviewed for possible admission 
he seemed quite unconcerned and said while smiling, "It 
worries my wife to death." He was described as exhibiting 
typical "la belle indifference." His dramatic attempts to walk 
were interpreted as astasiaabasia. 

Mr. A. was admitted to the Psychiatry Service four days 
later, now stating he could not walk at all. Nevertheless, he 
appeared jovial and quite talkative. He had a carefree, super- 
ficial air, disclaiming any worries. He described his mood as 
"very good." Although there was no weakness in his upper 
extremities, he was unable to lift his leg from the floor with 
his hands to the wheelchair footrest. He pleasantly asked the 
examining physician to do this for him. 

Mr. A.'s past history revealed chronic gastrointestinal 
complaints and a stormy home situation which he completely 
denied. His first marriage ended in divorce, his parents dis- 
owned him when he married his second wife because of reli- 
gious differences, his wife had threatened to leave him, and 
his sexual relations were hampered by premature ejaculation. 
Mr. A.'s daughter left home at age 15, three years prior to 
hospitalization, because of his constant bickering. During the 
time of his illness her own marriage was in trouble, and Mr. 
A.'s attempts to get her to come home were successful. 

Physical examination revealed mild spasm of his thigh 
adductors and unsustained ankle clonus. There was no sensory 
loss, and rectal tone was good. The remainder of the exam 
was unremarkable. Nursing notes stated Mr. A. was constantly 
laughing about his condition and would not try to help himself. 
He frequently said, "I wish I weren't so much trouble to you." 

His wife and daughter visited him, and he suddenly ap- 
peared incapacitated with pain. After they left he resumed his 
more smilling, indifferent attitude. 

Mr. A. was presented at a diagnostic conference. There 
was general agreement that the patient presented a classical 
case of conversion reaction. Two days later Mr. A. began to 
be incontinent of feces and urine. When asked how he was 



18 N. C. JOURNAL OF MENTAL HEALTH 



feeling while sitting in his excrement, he pleasantly replied, 
"I'm fine doctor, how are you." 

Neurological consultation was obtained, and a physical 
exam now revealed sensory loss to T-7, flaccid paralysis, dis- 
tended bladder and no rectal tone. After myelogram he under- 
went surgery. A spinal cord tumor was found. Skull and chest 
x-rays were normal. 

In summary, a patient is presented who had been in con- 
siderable conflict at home and at work. In this setting he 
suddenly developed paralysis of his legs. His reaction was 
strikingly devoid of anxiety. The illness afforded him a golden 
bridge to cross over from loss of self esteem in his work to 
possible medical retirement, and it brought his wife and 
daughter back to him in a new relationship. Thus, the secon- 
dary gain, the "solution" of his conflicts through the sudden 
appearance of his illness, and his indifferent attitude pre- 
sented a textbook picture of conversion reaction. However, 
the basis for his inability to walk was a spinal cord tumor. 
This case graphically demonstrates the dangers of the false 
dichotomy, "Is it organic or psychological." 

BIBLIOGRAPHY 

^Gregory, I.: Psychiatry, Biological and Social, p. 415, Phila- 
delphia and London: W. B. Saunders Co., 1961. 

2 Mayer-Gross, W., Slater, E., and Roth, M.: Clinical Psy- 
chiatry, p. 137, Baltimore: The Williams and Wilkins, Co., 
1963. 

3Arieti, S.: American Handbook of Psychiatry. Vol. I, pp. 
277-285, New York: Basic Books, Inc., 1959. 

^Noyes, A. and Kolb, L.: Modern Clinical Psychiatry, pp. 

430-439, Philadelphia and London: W. B. Saunders Co., 1964. 



19 



MEDICAID AND MENTAL HEALTH 



Donald S. Leventhal, Ph.D. H. Melvyn Gilley, Ph.D. 

Duke University Medical Center Appalachian State University 



Title XIX of Public Law 89-97 has great relevance for agen- 
cies concerned with mental health in North Carolina. Though 
Title XVIII of this law, popularly known as Medicare, has re- 
ceived greater publicity, TITLE XIX (Medicaid ) is of equal social 
significance. Basically Title XIX provides federal funds to the 
states, on an approximately 75/25 federal-state matching 
basis, in order that the medically indigent may receive high 
quality and comprehensive medical care. 

The basic services to be provided under Title XIX are not 
new and include: 1 ) inpatient hospital services; 2 ) outpatient 
hospital services; 3) other laboratory and x-ray services; 4) 
skilled nursing home services for persons aged 21 and older, 
and 5 ) physician services. These basic services are now avail- 
able to the indigent of North Carolina. However, by July 1 of 
1975 the scope of services offered and eligibility for services 
must be greatly increased by the states. Additional services 
to be offered under Title XIX which have mental health signi- 
ficance may include 1 ) medical care of any other type of 
remedial care recognized under the state law furnished by 
licensed practitioners within the scope of their practice as 
defined by state law; 2 ) home health care services; 3 ) physical 
therapy and related services; 4) other diagnostic, screening, 
preventive, and rehabilitative services, and 5 ) any other medi- 
cal care and any other type of remedial care recognized under 
state law, specified by the Secretary of Health, Education, and 
Welfare. The intent of these additional services, as stated 
in Public Law 89-97, is very clear: to enable eligible individ- 
uals ". . .to attain or retain independence or self care." 

Those individuals who will receive medical assistance under 
Title XIX will be, by and large, the underprivileged, the under- 
employed, and the undereducated of a citizenry living in the 
urban slum or in rural isolation. The mental health needs of 
such individuals are far greater than those of the more af- 
fluent and effectively functioning segments of our society in 

^A version of this paper was presented to the Office of Comprehensive 
Health Planning, Department of Administration, State of North Carolina. 
The content of this paper represents the official position on Medicaid 
of the North Carolina Psychological Association. 



20 N. C. JOURNAL OF MENTAL HEALTH 



North Carolina. It has been demonstrated many times that the 
segment of our population below the poverty line makes a 
contribution to the case registers of our state institutions for 
the mentally retarded and emotionally disturbed far out of 
proportion to their representation in the population at large. 

Such over-representation among the ranks of the socially 
disabled is clearly associated with such other signs of social 
disability as broken families (well in excess of 40% amongst 
nonwhites in certain counties), illegitimacy (sometimes ap- 
proaching 30% amongst nonwhites ), school dropouts, alcohol- 
ism, and frequent changes of place of residence. 

We believe that such pervasive social disorganization does 
require mental health involvement of the traditional inpatient 
and outpatient sort. However, mental health efforts must be 
aimed at what we believe to be one of the basic sources of 
affliction in the generally impoverished segment of our soci- 
ety; the familial and social alienation and isolation of such 
individuals must be countered, ameliorated, and eliminated 
in order for a mental health program geared to such indivi- 
duals to be effective in any sense of the word. The family 
must be the focal point for mental health involvement under 
Title XIX. 

In short, mental health and social adaptation for the poor 
must of necessity be directed toward dealing with the social 
roots of emotional disturbance in such groups of people. To 
be sure, the poor are oftentimes in need of the traditional 
psychotherapeutic services of mental health agencies (state 
hospitals, mental health clinics, social work agencies ). In fact, 
comprehensive implementation of the provisions of Title XIX 
will make such treatment available to the poor for the first 
time. The fact clearly remains, however, that individual psy- 
chotherapy will not meet the needs of such people. Innovative, 
socially cognizant, and family-oriented approaches to mental 
health for the poor and socially disabled are clearly needed. 
Such approaches might have their bases in various kinds of 
agencies including mental health clinics, family service 
agencies, and university-affiliated psychological service cen- 
ters. The efforts of such agencies would be devoted to working 
directly with the families of the poor in meeting their mental 
health needs. Specific forms of service might include: 1 ) 
comprehensive home health care including public health nurse 
visitation and social work services in the home; 2 ) direct group 
work with entire families, and 3 ) therapeutic tutoring of school 
children in the home. 

Other innovative approaches to the mental health needs 
of the poor would include such primary preventive efforts as: 



D. LEVENTHAL and H. M. GILLEY 21 



1 ) casework with mothers of illegitimate children on a far 
wider scale than is currently the case; 2 ) therapeutic nursery 
schools for preschool children from disorganized families who 
exhibit early signs or precursors of emotional disturbance, 
and 3) meaningful vocational training programs or mental 
health liason with industry groups capable of providing such 
training. 

One may correctly wonder if the vendor-payment system of 
reimbursement utilized in Title XIX (wherein a patient obtains 
services from a provider who is then reimbursed ) would legiti- 
mately permit more than the orthodox types of mental health 
services. We think it can. A vendor could well be, in all legiti- 
macy, a family service agency, a mental health clinic, a psy- 
chological service center, or the aftercare clinic of a state 
hospital. Reimbursement to the agency for some of the inno- 
vative services described above could therefore be funded 
through the vendor-payment system of TITLE XIX and at the 
same time a high degree of comprehensive and forceful im- 
pact would be attained. 

From cursory inspection, it might appear that such a com- 
prehensive and innovative program of mental health for the 
recipients of medical assistance under Title XIX would be too 
costly. In point of fact, it is highly likely that the dollar and 
cents total for primary prevention of disability will never equal 
that spent for the more unobtrusive but ultimately more costly 
treatment and rehabilitative efforts that currently go on in our 
mental hospitals, institutions for the retarded, and mental 
health clinics. The very real salvaging of human resources 
through programs for primary prevention must also be con- 
sidered in the cost accounting comparison. 

The health needs of the poor are inextricably tied to their 
economic, social and psychological problems. A single agency 
approach cannot meet any of these needs adequately. Inter- 
agency coordination is mandatory for an effective Title XIX 
program. 



22 



CLIENT CHARACTERISTICS: THE CUMBERLAND 
COUNTY MENTAL HEALTH CENTER 



Robert J. Gregory, Ph.D. 

Director, The Institute of Human Ecology 

Marianne Ingram 

Cumberland County Mental Health Center 



Introduction 

Comprehensive community mental health centers are rapid- 
ly gaining ground on the traditional hold of state mental 
hospitals in North Carolina. 

Nationally, the predicted growth in comprehensive com- 
munity centers is great. Mines (1968 ), The Washington Editor 
of the World Book Science Service, stated that, "By 1970 there 
will be 500, and this number is expected to double and double 
again in the ensuing 10 years until by 1980 there may be as 
many as 2,000."' In North Carolina, nine centers are fully 
operational as of January, 1970, with five others on the verge. 
In two years, there are scheduled to be thirty-four centers. 
Ultimately, each of the thirty-seven mental health areas of the 
state will possess a center with five components, including 
inpatient, outpatient, emergency, day care, and consultation 
services. 

Given this development, it is important to examine the 
characteristics of the clientele served. Numerous questions 
must be raised to determine whether the dreams of compre- 
hensive community care first promulgated by John F. Kennedy 
in 1963 are being realized. For example, are black people 
being treated in numbers proportional to the overall popula- 
tion? Also, are younger and older people being treated in pro- 
portional ratios? What are the chief agencies referring clients 
to the centers? Are some community agencies referring only 
certain types of clients, i.e., discrimination by age or race? 

Methods and Procedures 

Data was collected and tabulated from the admission re- 
cords in 1968 for the Cumberland County Mental Health 



R. GREGORY and M. INGRAM 23 



Center. Table I presents data concerning the major sources 
of referral by age categories. Table II presents data concerning 
the major sources of referral by sex and race. Tables III and 
IV summarize the preceding tables and present census in- 
formation^ permitting comparisons. Each of these four tables 
raises questions, but also provides answers to some of the 
already stated questions. 



Results 

It is obvious that black people are being admitted to the 
center in more than proportional numbers. It is also evident 
that school age people are being admitted far more frequently 
than older people. The chief agencies listed that refer clients 
to the center are the schools, physicians, the courts. Voca- 
tional Rehabilitation; self referrals. Social Services, and vari- 
ous other agencies. 

It is further evident that certain types of clients are referred 
by the agencies, so much so that a new series of questions 
can be developed relating to why such disparities exist. 

In Table I, the following questions arise: 

1. The schools refer school children in great numbers. The 
schools also referred at least 4 individuals over age 21. Who 
are these 4? Could they be teachers or parents? 

2. There are few children referred from agencies other 
than the schools because liaison teachers are always called 
in when school children are involved at the center. Neverthe- 
less, Social Services and other agencies managed to refer 
some children without the school's involvement. Why did this 
happen? 

3. Why are there so few cases from Public Health and 
clergymen, especially when the previous director of the center 
made numerous appeals to church groups and clergymen? 

4. Why are so few children seen prior to age 5? 

5. The Cumberland County Coordinating Council on Older 
Adults has been promoting better treatment of older citizens 
in recent months. It is likely that more older people were seen 
in 1969, and that more older people will be seen in 1970. 
The influence of an agency in the community could be mea- 
sured by changes in admission statistics for other agencies 
through a chronological study. 

In Table II, some representative questions that might be 
raised include: 



24 N. C. JOURNAL OF MENTAL HEALTH 



1. Less than proportional numbers of blacks are referred 
by physicians, self-referrals, parents and relatives, and clergy- 
men. Indeed, no black people were referred through the clergy. 
Does this indicate discrimination, lack of knowledge about the 
center, or lack of appropriate treatment with consequent 
avoidance? 

2. On the other hand, less than proportional numbers of 
whites are referred by other agencies. Again, why is this 
happening? 

3. Females are more likely to be referred than males by 
physicians. Social Services, Dorothea Dix Hospital and self- 
referral. Why does this happen? 

4. It is "legitimate" to go to the center upon referral from 
another agency, and this makes the category of self referral 
qualitatively different from other categories. It appears signi- 
ficant that white females and then white males are able to 
enter the center, but that blacks are highly unlikely to refer 
themselves. Further investigation of perceptions about the 
center are warranted. 

In Tables III and IV, additional questions could be raised. 
They are not, in the interest of brevity. A graph, Graph I, has 
been drawn to illustrate the data concerning age categories 
more clearly. 

Implications 

The value of data such as presented above is two-fold. The 
chief use of the information should rest upon the center di- 
rector and governing bodies (Mental Health Authority, State 
Department of Mental Health, Mental Health Association, Ad- 
visory Board, and County Commissioners are some) to plan 
and implement more equitable services to all members of the 
community. The data can be used to raise and answer ques- 
tions concerning what is happening. 

Secondly, the people in the community should have access 
to such data. This can be done for publicity reasons, but more 
likely, if "community mental health" is to succeed, more in- 
volvement is necessary. Members of the community, conse- 
quently, can be involved only when there is a clear and con- 
stant output of reliable information about the center and its 
appointed role. This type of data is useful in that regard. 



R. GREGORY and M. INGRAM 



25 



< 



O 
CO 



o 



o 

o 

c 
o 



(A 

Q. 



IT) 
US 



in (^ 



IX) IT) 






1X5 O 

CNJ (V) 



^ un 

CNJ CNJ 



CO o 

■-I CNJ 



a; ^ 



^ r^ 



X) o 



Lor^CNiromusoO'^'XicTiixioO'-HCNjxJoo 



ro r-^ (Ti r^ 



ID .-H "^ l£> 



r^ (X> -— I 



>* CNJ .-H .-H 



oot-H^cnx) cnx)'-iCNj ud 



to --I '^ .-I CNJ CNJ 

CNJ ^ ro •-• 



1^ •=d- 00 

CNJ 



00 o 
00 



ID LDiX)iX>CNI COLDOOCNJCNjr^r-H 



r^ .-H 00 o~i ro 



00 O CNJ .-H ID 
00 >— I 



■-I r^ v£) -^ 
r-^ en 



'^t CNJ 00 

en 



CNJ CNJ LD ID 00 CNJ LD 



00 



.—I I— I 00 -—I 



.— I ^ 00 LD 



"^ o S . 2 
^ i2 t 3 

2 Q 



1/5 ro dj Q 

+-• m <U r- 



03 





3 


u 




a: 




O 

o 


> 


to 


li 


ra 


T3 


CA) 


3 


c 


'o 


C 




o 


o 


ro 


ra 


o 


■-(_. 


V) 








rtj 


>> 


>^ 


o 


(D 


CJ 


^ 


,*ti 


o 


^ 


o 


Q. 


O 


CO 


1- 


> 



cu 



^ f ^ ■-= u 



5^2 

3 <D O _ 

Q- Q Q C/5 



TO 

1 1 

i; Jlli 

2^ -^ -o >, ^ ^ o 

CA)CLLi_0003|— 



26 N. C. JOURNAL OF MENTAL HEALTH 



o 





o 


LLl 




_I 


(U 


CD 

< 


o 






o 

CO 



o •= 

t/5 0) 



E 


^ — 


3 
o 


iH E 


o 


U- 






■D 




0) 




-t-" 




+-> 




E 




T3 
< 


i5^ 




ro TO 



^ CD 



un t^ 00 



•^LnuDoO'^incritx)ooooc\jLnoo 



c\j c\j c\j ro 



r^ r^ o <^ 00 CM 
en r-i --( CM 



in c\j 



CM en '-f CD 

■-H 00 



oo <^ r^ 

IX) CO CM 



'^ c» 00 
00 r^.^ 



^USOOCMP^'^OOlDUDUDOOCM'-H 
>— < >— • ^ ■— I o 

00 



tooi^cniocMi^LncMix) 
^ CM CM en 

00 






o o 



O O) C 

■^ E o - 

ro -*-' +j ro 

■:^ ^ 3 •■^ 

~ Q. _ Q. 

X) (u ro (£) 

ro Q > o 

x: LU X 

q:- -£.^ 

_ ro a; Q 

ro OJ p 

<- X t 



ro 



^ o 



>> >- 



Q. CU 0) 
.t^ 0) > ^ 

D- O Q ^ I— 



CI 0) 

_o x: 

0) o 



ro 



>^ T3 

O .— 

C > 
CD 



3 <D O (U 
Q- Q Q CO 



&0 >i C 

<5 w E < — 5 

"^ "a >, , , o ifl 

ro c — +-'+-' c o 

Q- Li_ O O O 3 H 



R. GREGORY and M. INGRAM 



27 



TABLE III 

Statistical Comparison by Age of Cases Admitted to the Cumberland 
County Mental Health Center in 1968 with Census Data 



Age Categories 


Center Statistics 




Census Statistics 




Population Totals 


Per Cent 


Per Cent 


0-4 


12 


1.1 


11.8 


5-9 


204 


19.5 


11.0 


10-14 


231 


22.0 


10.0 


15-19 


139 


13.3 


10.6 


20-24 


85 


8.1 


11.7 


25-29 


75 


7.2 


10.6 


30-34 


57 


5.4 


9.1 


35-39 


46 


4.4 


6.3 


40-44 


49 


4.7 


4.9 


45-49 


40 


3.8 


3.9 


50-54 


36 


3.4 


3.0 


54-59 


37 


3.5 


2.2 


60-64 


12 


1.1 


1.6 


65-69 


12 


1.1 


1.3 


70-74 


2 


0.2 


0.9 


75-79 


4 


0.4 


0.6 


80-84 





0.0 


0.4 


85 + 





0.0 


0.2 


Unknown 


7 


0.7 


0.2 


Total 


1048 


100.0 


100.0 




TABLE IV 







Summary by Race and Sex of Cases Admitted to the Cumberland County 
Mental Health Center in 1968 with Comparative Census Data 

A. Center Admissions by Race and Sex in 1968* 

White Black 

Male 396 180 

Female 301 158 

Total 697 338 



B. Center Admissions by Race and Sex in Per Cents 

White Black 

Male 38% 17% 

Female 29% 15% 

Total 67% 32% 

C. County Population by Race and Sex in Per Cents 

White Blagk 

Male 42% 12% 

Female 33% 12% 

Total 75% 24% 



Total 
576 
459 

1,035* 

Total 

55% 
44% 
99% 

Total 
54% 
45% 
99% 



*There were 13 cases with only partial information available, and they 
are omitted from this table. 



28 



N. C. JOURNAL OF MENTAL HEALTH 



Q. 

< 

(3 



T3 s: 








Ego 




T3 VO 




< m 




i-H 




<n 




0) c 




U) .— 




to J_ 




O <U 




-t-J 




t; £= 




O 0} 




^o 




<u 




bo-c 




<±i 






TO 
+-> 
TO 


W) "to 


Q 


cr 


</) 


0) 0) 


(/) 

r 


<1> ^ 


n> 


Q.4^ 


C) 


"~^ C 








»- X3 




S c 




2-(c 




fen 




O 0) 




o-o 




_ 1= 




ro rj 




.yo 




+-> 




(/) <u 




■^ -c 




TO -^ 




.-^ P 






iN33tl3d 



R. GREGORY and M. INGRAM 29 



Notes 

The author acknowledges valuable assistance in preparation of the 
tables from Mrs. Brenda Dillard. A further indebtedness is due to Mrs. 
Millie Donavant for typing and proofreading. 

Dr. Gregory, Director of The Institute of Human Ecology at 720 St. 
Mary's Street, Raleigh, N. C, was formerly Research Scientist at the 
Cumberland County Mental Health Center in Fayetteville, N. C. Mrs. 
Marianne Ingram was formerly a volunteer worker at the Cumberland 
County Mental Health Center. 



REFERENCES 

^Hines, William, "Area Mental Health Centers Vital Weapon 
in Battle," Fayetteville Observer, December 3, 1968, p. 7A. 

2The percent distribution for the Cumberland County Popu- 
lation for July 1, 1968 was supplied by Therese H. Ramsey of 
the Division of State Planning, North Carolina Department of 
Administration, Raleigh, N. C. 



30 



THE EFFECTS OF ALCOHOL ON BRAIN FUNCTION 

A review of its Psychological and Physiological Effects 



William P. Wilson, M.D. 

Professor of Psychiatry 
Duke University Medical Center 



"The services rendered by intoxicating substances in the 
struggle for happiness and in warding off misery rank so highly 
as a benefit that both individuals and races have given them 
an established position within their libido economy. It is not 
merely the immediate gain in pleasure which one owes to 
them, but also a measure of the independence of the outer 
world which is so sorely craved ... We are aware that it is 
just this property which constitutes the danger and injurious- 
ness of intoxicating substances. "i 

The acceptance of Freud's point of view leads us to ask 
the question, how does alcohol act to create this independence 
of the outer world so desired by mankind? In what v«/ays does 
it alter brain function and what psychological changes occur 
when brain function is altered? 

Alcohol is a central nervous depressant.^ The effects of 
alcohol are well known in our society and are part of our 
folklore. The potential depression which on rare occasions can 
occur with this substance is illustrated by the stories of res- 
piratory arrest in some acutely intoxicated persons. Such 
events are an exception yet all of us are aware that significant 
changes in mental function can result even when small 
amounts of alcohol are ingested. They occur within a remark- 
ably short time. Behavioral changes occur, especially in group 
situations. We also know there is considerable individual varia- 
tion in susceptibility to alcohol. Finally, it is quite clear that 
physiological tolerance to alcohol can develop with chronic 
heavy ingestion and that if this ingestion is suddenly de- 
creased or stopped, symptoms occur which will "dramatically" 
demonstrate the dependence that the organism has developed. 

Much has been written concerning the effects of alcohol 
on brain function, yet this information is not readily available 
in a meaningful form to persons interested in the problem of 
alcoholism. Little attention is paid to the subject in textbooks 



W. WILSON 31 



of psychiatry and pharmacology or in the medical curriculum. 
This neglect exists in spite of the fact that its use and abuse 
contributes to accidents, delinquency and crime, family in- 
stability, and results in complicating diseases such as cir- 
rhosis of the liver, epilepsy and delirium tremens. As well, the 
economic burden imposed on the individual and society is 
incalculable. Cancer, stroke, and heart disease are now in the 
spotlight, but are minor problems compared to alcoholism. 
Alcoholism should be considered one of the major public 
health problems of our time.^ 

In a recent article, Mayfield-* has viewed alcoholism as an 
illness, recognizing that precedents have been set which have 
taken chronic alcoholism out of the courts and jails where it is 
considered moral terpetude and put it in the hospitals where 
the patient is to be treated and "cured" of his "disease." Be- 
cause of this change, medicine has been challenged to con- 
duct research which can be used to provide more adequate 
treatment. Such treatment will hopefully result in a dramatic 
decrease in the incidence of secondary effects of the alcohol- 
ism, and as has happened with veneral disease and polio- 
myelitis, another public health problem will be controlled. 
After receiving this charge, we are forced to ask the question 
where do we start? What do we do? 

A logical way to begin is to determine the state of our knowl- 
edge. It is the purpose of this essay to attempt to make such 
a determination regarding the effects of alcohol on brain func- 
tion. 

The workings of the brain are revealed in three dimensions. 
The first, a functional one, is manifest by behavior, intelligence 
and emotion. The second, a physiological dimension, is re- 
flected in electrical activity and the third, or metabolic can 
be ascertained by observing the chemical processes. This 
review is limited to functional and physiological dimensions 
and is an attempt to determine whether physiological altera- 
tions might explain the functional alterations that occur. 

Psychological Functioning 

Interest in the effect of alcohol on psychological function- 
ing has unfortunately not been great for there is a r-elative 
dearth of studies on the psychological effects of this sub- 
stance. Nevertheless, Jellinek^ was able to critically review the 
subject in 1940, and Carpenter* brought this up to date with 
an excellent summary in 1962. Both reviewed the knowledge 
available and made an effort to categorize their findings under 
major areas of psychological function. 



32 N. C. JOURNAL OF MENTAL HEALTH 



In a review of the psychopharmological properties of any 
drug, it is necessary that we consider doses used, routes of 
administration, and the experimental situation. Any reviewer 
is then forced to attempt to determine at what blood levels 
the effects of the drug are produced, as well as the design 
of the experiments before he can attempt to correlate the vari- 
ous studies. For a detailed summary of some of the problems 
encountered, one is referred to the excellent discussion of 
Jellinek.^ It is important, however, that we briefly consider 
a few fundamental facts about alcohol ingestion in experi- 
mental situations. Most investigators have preferrentially used 
the oral route for producing significant blood levels; unfortun- 
ately, different concentrations of alcohol and water are ab- 
sorbed at different rates. These influence blood levels often 
to a significant degree. Habituation to large doses of alcohol 
also influences absorption so that there is more rapid and 
greater absorption by heavy drinkers than by abstainers, par- 
ticularly in the first hour after ingestion. Intravenous injection 
of alcohol results in initially high levels which decrease at a 
rate similar to those produced by oral ingestion. Metabolic 
rates are essentially the same for both habituated and control 
subjects. Alcohol is rather equally distributed in all tissues. 
The ratio of plasma to tissue concentrations for all tissue 
except fat, ranges from .730 to .810. About 90% of a dose of 
alcohol is metabolized in 6 hours and only negligible amounts 
will be found in the blood after 8 hours.'^ 

A social experimental situation influences test results rather 
markedly. The best data reflecting this effect is found in the 
report of Talland^ who noted differences in single perfor- 
mances when these were compared to group performances 
on the same test. Group periformances were significantly 
poorer. 

What symptoms and signs are noted when a person drinks? 
Jetter, whose work is summarized in Jellinek and McFarland's 
review,^ delineated the following clinical evidences of intoxica- 
tion in 1000 patients and correlated the appearance of the 
symptoms with blood alcohol levels. At 0.05% alcohol in the 
blood, 80% will have a flushed face, 11 to 18% will have speech 
changes, and 6 to 8% will have gait disturbances. At blood 
levels of 0.20% , 80% or more will have gait and speech distur- 
bances and 90% will have an odor of alcohol on their breath. 
At 0.35% blood concentrations, 80% will have dilated pupils 
and flushed face and more than 90% will have the other three 
symptoms. Thus, clinical evidence of intoxication is quickly 
evident in a large number of persons even at low blood alcohol 
levels; and at levels legally considered as intoxicating, clinical 
signs are almost always apparent. The data is significant for 



W. WILSON 33 



it stands in contrast to data obtained using psychological tests 
which for the most part have been presented to subjects whose 
blood alcohol levels are often well below the levels necessary 
for clinical recognition of intoxication.'''^ Their impairment by 
these lower doses is more consistently observable. 

Alcohol depresses synaptic activity^ in the brain and re- 
sults in a dysfunction that for the most part seems to origi- 
nate in higher centers. i"' ''-^ How does this manifest itself 
clinically. Numerous studies of reflex activity have demon- 
strated that although reflex mediated phenomena are slowed 
by alcohol, there is no evidence that this is determined at 
a spinal or nerve-muscle level. The best evidence to support 
this contention is the study of Malamud, Lindemann, and 
Jasper^o which demonstrated a change that was thought to 
be centrally determined. 

Such a central depression can manifest itself in a variety 
of tests that are dependent on central mechanisms. One ex- 
cellent example is, of course, the often quoted experiment 
which demonstrates a marked increase in typing errors with 
only a minimal change in speed. Other tests using pinboards, 
bead stringing, sewing, and target shooting have demonstrated 
a consistent impairment in ability even with small does of 
alcohol.^ Reaction time which can play a role in the complex 
behaviors just described is almost always lengthened, even 
though a number of authors have reported an initial shorten- 
ing. Jellinek and McFarland criticize the experimental design 
of most of these reports by pointing out the failure to allow 
for practice effects in the initial part of the experiment. Im- 
provement with practice gives rise to what appears as an 
initial stimulant effect. How do these changes in complex 
function and in reaction time influence the public health? 
Perhaps their most profound effects are manifest in auto driv- 
ing where a marked decrement in ability is observed. In a study 
by Coheni2 involving bus drivers, it was concluded that there 
was no safe blood alcohol level below which it was certain 
that no impairment in judgement would occur. In a similar 
study using a driver trainer, it was observed that drivers tended 
to move toward the center of the road and to over steer. ^^ 
Another experiment has demonstrated that reaction distance 
for braking is increased from 16 to 22 feet at 30 miles/hour 
after doses of whiskey ranging from 1 to 5 oz.^i 

There is evidence that even in subjects habituated to alco- 
hol, a change in reaction time can be observed in practical 
tests. 5 

Goldbergi4 has reviewed the literature relative to the in- 
fluence of alcohol on cerebellar function and observed this 



34 N. C. JOURNAL OF MENTAL HEALTH 



function using two commonly clinical tests. In both instances 
he instrumented his experiments to furnish objective evidence 
of involvement. His results, as have the results of others, 
demonstrated a definite involvement of cerebellar function 
even at low blood levels of alcohol. 

In the foregoing, it is clear that perception of sensory clues 
are a necessary part of the tests and thus it is possible that 
the motor involvement might result from depression on the 
sensory side of the reflex arc. What evidence is there then 
that the somato-sensory, visual, and auditory systems are 
involved. Simple tests of two point discrimination reveal a 
marked change in the ability to recognize two points in a 
variety of cutaneous areas. Sensitiveness to touch is also said 
to be altered. Visual acuity is decreased by alcohol and there 
is a decrease in perceptual functions with a marked increase 
in the number of errors obtained when reading a variety of 
stimuli presented tachistoscopically. Color naming is also 
impaired with small doses of alcohol. It also appears from 
the data available that color perception is more markedly 
impaired than recognition of symbols.*^ In contrast to these 
findings are the recent observations of Mayfield^^ that demon- 
strate an increase in color responses in the Holtzman Inkblot 
test. Although one can relate this to change in affectivity, his 
group of normal subjects did not show any objective or sub- 
jective evidence of affective change. Certainly one is left with 
the niggling suspicion that a change in color "awareness" had 
occurred. The significance of his findings has no ready inter- 
pretation at the moment. Considerable criticism of the investi- 
gations of the effect of alcohol on various sensory phenomena 
has been leveled by Carpenter^ who has reviewed the 18 ex- 
periments performed. He criticizes the lack of breadth (16 
of them involve the visual system) and the relative lack of 
sophistication of the experimental designs. 

In spite of the widespread availability of tests of intellectual 
functioning and their relative sophistication, there are few 
"in depth" studies. Most studies as indicated by Jellinek^ have 
involved subtests of intelligence which cannot be correlated 
with ease into a meaningful whole. Yet, in Jellinek's and in 
Carpenter's^ review, the tests of subtraction, block design, 
drawing, verbal fluency, memory span and calculation were 
all impaired to some degree. These findings would therefore 
indicate that alcohol influences general intelligence to a signi- 
ficant degree when blood levels were between O.lOand 0.15% . 
It is interesting that the study of Cattel|i^ which was criticized 
by Jellinek for faulty statistical treatment of the data has not 
been repeated. This set of experiments did demonstrate a 
decrease in general intelligence, even though it was small. 



W. WILSON 35 



The effect of alcohol on the function of memory is deserving 
of a more detailed consideration. All of the authors mentioned 
by Jellinek reported an impairment of function. In all instances 
nonsense syllables, digit series, digit symbols and four letter 
words exposed backwards were remembered less well after 
varying doses of alcohol. It was clear, too, that the memoriza- 
tion of complex passages of the Odyssey was also impaired. 
Thus it seems that immediate memory is affected. Data is not 
available for the function of remote memory. 

Studies of emotion, will, and attention have for the most 
part been uninspired until recently.-' ^^^ '" Unfortunately, little 
effect of alcohol on attention has been demonstrated in habi- 
tuated subjects; however, these have been studied and rather 
interesting results obtained. Mayfieldi^ has studied the effects 
of alcohol on emotion. He used the Clyde Mood Scale^o to 
determine the subjective effects of a dose of intravenous alco- 
hol producing mild intoxication in a group of abstinent or 
occasional drinkers, a group of chronic alcoholics, and a third 
group of depressed male patients. The subjects were matched 
for age, race and socio-economic status. The psychological 
measure he used has five subscales and measures depression, 
clear-thinking, subjective energy, jitteriness and friendliness. 
Aggressiveness is also determined. His results are impressive 
in that alcohol did not appreciably alter emotional tension in 
either the control or alcoholic group. The depressed patient, 
however, was markedly benefited and was significantly less 
depressed after alcohol infusion. Unfortunately, the measures 
used by Mayfield test only one dimension of affect, i.e., af- 
fective tension. No data is available concerning the effect of 
this substance on subjective affective reactivity. This latter 
dimension is often altered by alcohol in social situations. 

Physiological Functioning 

This brief overview of the alterations of psychological func- 
tion occurring with alcoholism must now be correlated with 
physiological function. Although it is clear that psychological 
functions are poorly studied, the effects of alcohol on brain 
function have been even more meagerly studied. Perhaps 
the observation of Carpenter^ concerning the dearth of investi- 
gations of sensory function is even more pertinent here, for 
it may be that the study of physiological phenomena are in 
the territory of the specialist who is too busy with this one 
interest to bother with alcohol experiments. On the other hand, 
the specialist in alcohol problems is also too busy with his 
own interests, usually clinical, to bother to learn and use the 
techniques of the physiologist. 



36 N. C. JOURNAL OF MENTAL HEALTH 



The electrical activity of the brain is a summation of the 
physiological events occurring in the neurones as they transmit, 
receive and process information. In most instances, we are 
interested in what goes on in the dendrites of the cells, for 
it is at this level that information processing goes on.^i Thus, 
alterations of dendritic functioning may play the most impor- 
tant role in functional activity of the brain. Most measure- 
ments of the electrical activity of the brain are gross. In man, 
we have been, until recently, handicapped by our inability 
to record directly from the brain. In animals, we are more 
fortunate; nevertheless, the difficulties encountered in obtain- 
ing satisfactory recordings have discouraged all but a few. 
The specialists who have the capability have been more in- 
terested in the fundamental neurophysiology of the brain than 
in drugs and as a result, most of the information available to 
us has been derived from recordings obtained extracranially 
using the electroencephalogram. 

The EEG is a measurement of the dendritic activity in the 
cells of the cortical mantle. The activity observed is in all like- 
lihood regulated by the reticular activating system. Both the 
activity of the cortex and the reticular system can be altered 
by specific afferent (sensory ) input. Alterations in function of 
the cortex or of the reticular system or both, can be observed 
in the EEG. Physiological changes in the function of the cells 
of the cortical mantle result in two types of response. The 
first occurs as a decrease in function which generally results 
in slowing of the resting electrical activity. The second is 
hyperexcitability which results in the occurrence of epileptic 
activity. It is therefore apparent that the electroencephalogram 
can tell us much even though we recognize its shortcomings 
in that it is at best a gross measure of physiological activity. 
The effect of alcohol on the electrical activity of the brain as 
a whole has been evidenced in the EEG literature, where a 
total of 34 references are available in the most recent biblio- 
graphy compiled in 1965.22 In general, these articles have 
demonstrated that with small doses of alcohol little change is 
observed in the basic EEG frequencies. With increasing doses, 
however, there is a shift to the slower frequencies. The most 
critical study is that of Horsey and Akert^^ who recorded the 
cortical electrical rhythms, the rhythms in the caudate nu- 
cleus, and in the medial and ventral nuclei of the thalamus 
of the cat. The subcortical recordings were obtained in two 
groups of 7 animals each. Cortical recordings were obtained 
from 17 unrestrained animals, 8 restrained and 22 immobi- 
lized and artifically respirated animals. At blood levels below 
0.05%, very slight changes in EEG activity were observed. 



W. WILSON 37 



Slight slowing did occur; however, this was thought to be 
related to drowsiness. At blood levels of 0.10%, the animal 
became drowsy and slow activity at 1-3/ second was seen. 
At 0.20% , the sleep rhythms were slowed and slow waves at 
1-3/ second became more frequent. Above 0.25% there was a 
progressive increase in the slow activity and a progressive 
decrease in the voltage of all frequencies. Subcortical rhythms 
were similarly affected. Similar findings are observed in 
man.'--*-'' There is a better correlation of EEG change with 
clinical evidence of intoxication than with blood alcohol 
levels. Patients who are habituated to alcohol have relatively 
normal EEG patterns even when steadily consuming 30 oz. 
of whiskey per day.-'' 

Sleep is affected by alcohol in that the rapid eye move- 
ments decrease in frequency and duration.-'-- ■'■'■ No comments 
are made about changes in other aspects of sleep. 

Rapid withdrawal from chronic intoxication with large doses 
of alcohol can result in abnormal EEGs. Wilker, et al.'^^ in 
their classic experiments observed slowing and/or transient 
epileptic discharges in their three patients who were inten- 
sively studied during a period of controlled drinking with care- 
ful observations and control of food and vitamin intake. A num- 
ber of clinical studies have demonstrated similar changes in 
patients with delirium tremens and withdrawal seizures.-^^'- ^^^-^^ 
EEGs in patients who were chronic alcoholics studied dur- 
ing a period of abstinence were most often normal.-^'-^2-44 

These observations on the gross electrical activity of the 
brain may be summarized as indicating that there is a de- 
pressant effect of the alcohol on the regulating mechanisms 
of the brain and that during withdrawal after prolonged imbiba- 
tion, this depressant effect is replaced by hyperexcitability. 
This is manifest by the spikes and sharp activity that occurs. 
The origin of the slowing that occurs with acute intoxication 
has been interpreted in two ways. Kalant^^ has indicated that 
the primary site of action of alcohol is in the reticular system. 
His interpretation is based primarily on the micro- and semi- 
microelectrode studies of Gaspers who observed a decrease 
in unit activity in the reticular system of rats when alcohol 
was administered in varied doses. This depression was associ- 
ated with increased synchronization of cortical rhythms (slow- 
ing). Di Perri, et al.^*' have, however, taken a different point 
of view and believe that their studies indicate a primary de- 
pression of cortical function. Brown on the other hand, in a 
recent abstract, has observed that hippocampal activity is 
shifted in the direction of alert wakeful behavior whereas 
"other structures" not named are shifted toward depression 



38 N. C. JOURNAL OF MENTAL HEALTH 



or sleep. These conclusions drawn from three different neuro- 
physiological experiments do little to explain the origin of the 
electroencephalographic slowing occurring with acute intoxi- 
cation. Unfortunately, neither the studies of Di Perri, et al. 
or of Brown are available in final form and one is unable to 
determine how adequately their data supports their con- 
clusions. That alcohol could produce slowing by either a pri- 
mary cortical or subcortical action is quite clear for there are 
drugs that can do either.^*^ We must, however, attempt to make 
our correlations. Since the most convincing evidence is that 
of Di Pierri, et al.,^^ we can begin by asking what areas of 
psychological function would most likely be disturbed by a 
primary cortical depression. The work of Magoun, Jasper and 
others"*^ has demonstrated that the reticular activating system 
regulated consciousness by regulating information input. On 
the other hand, the cortex may be considered the level at 
which information processing occurs. It would appear then 
that the behavioral and psychological data support the con- 
tention that the cortex is most involved for in contrast to 
barbiturates which have a profound primary effect on the 
reticular activating system and primarily result in drowsiness 
or sleep, alcohol produces drowsiness only at high blood levels. 
Thus, it appears that information input is not as altered as 
information processing. Behavioral changes occurring 
should be related to the cortical depression. 

A number of investigations have been conducted on the 
effects of alcohol on specific afferent transmission. At the 
receptor level, we have evidence that changes occur, for in 
the visual system, both Goldberg^^ and Weiss^^ have observed 
that it is necessary to increase the intensity of the light in 
order to produce a fusion of the flicker at the critical frequency. 
Weiss and his colleagues interpreted their findings as indi- 
cating a differential suppression of inhibitory influences in 
the retina although they felt that both the excitatory and inhibi- 
tory components were depressed. They did not speculate as to 
whether this was centrally determined. The previously de- 
scribed work of Di Perri, et al.^e was directed toward deter- 
mining the effects of alcohol on transmission in the auditory, 
visual, and somato-sensory systems where a progressive de- 
cline in the voltage of the cortical and thalamic relay evoked 
potentials were observed in the visual and somato-sensory 
systems. Little change was noted in the auditory evoked re- 
sponses. A preliminary report by these authors'^ does furnish 
some evidence that cortical function may be primarily in- 
volved, for the changes in evoked responses involve all com- 
ponents. Both primary and secondary components are de- 
pressed. Such a change could be caused by depression of 
the synaptic activity of the cortex and thus all inputs to the 



W. WILSON 39 



cortical cells both specific and nonspecific fail to produce a 
response. On the other hand, it is also possible that the inputs 
are reduced as well and that there is a diffuse reduction of 
synaptic activity in the brain at a cortical and subcortical level. 
The data is not congruous with primary depression of the 
reticular system for one would expect to see an increase in 
the secondary response. The observations of Gross, et al.'^'^ 
support the notion that the cortex is depressed or that there 
is diffuse depression of the brain for they observed in man a 
reduction in both the primary and secondary components of 
the auditory evoked response by alcohol. Such interesting 
findings certainly need to be pursued particularly from the 
standpoint of more detailed explorations of the various sys- 
tems. Perceptual studies are also a must, particularly in the 
auditory system, for to date the best study to demonstrate 
deterioration of auditory function is that of Talland^ who used, 
auditory, visual and combined audiovisual signals to deter- 
mine changes in attention following the administration of alco- 
hol. Such findings although testing another parameter of 
mental function, do not correlate with the findings of Di Perri.^e 

Changes in spinal cord and spinal synaptic activity have 
not been studied. Observations on descending reticular in- 
fluences are not available. Only the reports of Malamud, et 
al."^ and Lolli, et al.-'* furnish any iniformation concerning 
peripheral nervous function. The results of Malamud demon- 
strated a central effect on chronaxie. Lolli reported a decrease 
in muscle tension. These findings in themselves tell us little 
about the neurophysiological mechanisms accounting for the 
changes observed. 

Intellectual Functioning 

To complete our review, we must look at the neurophysio- 
logical correlates of intellectual functions. Intelligence is so 
complex that it is difficult to outline its neuroanatomical and 
physiological mechanisms. Emotion, on the other hand, has 
been extensively investigated, particularly in relation to the 
limbic system. Finally, memory has been considered and 
some knowledge is available to us. Because little is known 
concerning intelligence, it would be best to begin our inquiry 
with emotion. 

Gellhorn^'^ has offered the m.ost attractive neurophysiologic 
construct of emotion and has pointed out that emotions in- 
volve two systems. In his recent synopsis of his concepts, he 
presents his concept of the neurophysiology of emotion and 
advances the hypothesis that tonic affects have their origin 



40 N. C. JOURNAL OF MENTAL HEALTH 



in the hypothalamus. He cites experimental work which dem- 
onstrated the effect of selective lesions in the hypothalamus. 
These lesions produced opposite states of excitation of in- 
hibition. The balance between these two systems is, in his 
mind, the determinant of the tonic affective state at a given 
moment. The hypothesis is far more complex, however, for 
these excitatory and inhibitory systems serve as fine but dif- 
fuse modulators of the tonic action of the hypothalamus. For 
example, he implicates the activating system of Magoun and 
the inhibitory system originally described by Verzeano, et al. 
and further investigated by Gellhorn and by Buchwald, et al. 
More specific is the influence of the cortex, for evidences 
presented by Gellhorn that suggest that the paleocortex (lim- 
bic system ) exerts an inhibiting influence on hypothalamic 
activity, whereas the neocortex exerts an excitatory influence. 
Finally, to complete his synthesis, the bulbar reticular system 
exercises an inhibitory influence centrifugally and an excita- 
tory influence on higher centers. (See Gellhorn for references ). 
Attemping to integrate our knowledge concerning the effects 
of alcohol into Gellhorn's conceptualizations, we find that we 
know little that can be useful to us. Certainly the clinical ob- 
servations of Mayfield and Allen on emotion would suggest that 
if the effect of alcohol is cortical, it probably influences the 
excitatory systems, i. e. frontal cortex, and if its action is 
predominantly subcortical, it is depressing reticular activity. i^ 
We have only the psychophysiological data of Coopersmith-^^ 
that suggests that affective reactivity is increased by alcohol 
ingestion. He observed heightened GSR responses to word 
association tests with a comparison of responses to words of 
low and high affective significance. 

Let us now return to the subject of memory which has re- 
ceived considerable attention in the last decade. The observa- 
tions of Thompson and McConnell'^''^ and their notions concern- 
ing R.N. A. did much to stimulate further research in the 
physiology of memory. New work then followed in the life 
long efforts of Lashley^^ who had made a concerted effort to 
determine the anatomical systems that mediated the "trace." 
Although he felt that he had learned little concerning where 
the memory trace could be found and what it was, he did lay 
the ground work for more recent investigations. His observa- 
tions demonstrated that the motor cortex was not necessarily 
for memory formation. In contrast, the sensory cortex could 
not be removed without decreasing memory function. Sub- 
cortical lesions in the specific afferent systems did not serious- 
ly interfere with learning and memory. Since Lashley's time, 
a number of important contributions have been made. Notable 
among these are the observations of Scoville and Milner "^s, 57 
who have indicated that the hippocampus is necessary for 



W. WILSON 41 



the retention of new experiences. The work of Penfield^*^ is 
complimentary to theirs and suggests that the temporal cortex 
is also involved in the memory mechanisms. Finally, our knowl- 
edge of disease also tends to incriminate the mamillary bodies 
in the memory mechanism. ^'^ The reticular system regulates 
consciousness, and without it learning, of course, cannot take 
place. 

The logical question to ask is whether investigations have 
been conducted which would help us explain the consistent 
memory difficulties demonstrated in subjects who had re- 
ceived alcohol. It is clear that there is a dearth of information. 
Only the observations of Brown^*^ are available to us and they 
tell us little. The effects of alcohol could, therefore, be due 
to effects of inputs, information processing, consciousness, 
or on the memory mechanisms in the hippocampus and tem- 
poral cortex. Let us hope that subsequent investigations will 
attempt to elucidate the effect of alcohol on these important 
physiological functions. 

Conclusion 

In conclusion, it is clear that our knowledge of the neuro- 
physiology of mental function seriously limits our understand- 
ing of the effects of alcohol on the brain. Yet there is a dearth 
of knowledge concerning the effects of alcohol on mental 
functioning. One cannot help but be appalled at our abysmal 
ignorance. Certainly one should be humbled too by the enor- 
mity of the task that seemingly lies ahead of us. 

To end this review on a more optimistic note, I would like 
to say that man has one way of dealing with seemingly enor- 
mous problems. To illustrate this, I should like to quote Dante 
Gabriel Rossetti,ii ^^q once wrote: 

"My doctor's issued this decree 

That too much wine is killing me. 

And furthermore, his ban he hurls 

Against my touching naked girls. 

How then? 

Must I no longer share good wine or beauties. 

Dark and fair? 

Doctor, goodbye, my sails unfurled, 

I'm off to try another world." 



42 N. C. JOURNAL OF MENTAL HEALTH 



BIBLIOGRAPHY 

ipreud, S. Civilization, War, and Death. Psychoanalytical 
Epitomes, Hogarth Press, 1939. 

^Hildebrant, H. Ueber die Beiinfliessung der Willenskraft 
durch den Alkohol. Quelle and Meyer, Leipzig, 1910. 

^Hilleboe, H. E. and Larimore, G. W. Preventitive Medicine. 
W. B. Saunders, Philadelphia, 965. 

^Mayfield, D. G. Alcoholism Viewed as an Illness. South. 
Med. J. 60:736-740, 1967. 

^Jellinek, E. M. and McFarland, R. A. Aanalysis of Psycho- 
logical Experiments on the Effects of Alcohol. Quart. J. Stud, 
of Alcohol. 1:272-371, 1940-41. 

•^Carpenter, J. A. Effects of Alcohol on Some Psychological 
Processes. Quart. J. Stud, of Alcohol. 23:274-314, 1962. 

^Himwich, H. E. Alcohol and Brain Physiology. In Alcohol- 
ism, George N. Thompson, ed., C. C. Thomas, Springfield, 
Illinois, 1956, pp. 291-408. 



^Talland, G. A. Effects of Alcohol on Performance in Con- 
tinuous Attention Tasks. Psychosom. Med. 28:596-604, 1966. 

^Larrabee, M. G., Ramos, J. G. and Bulbring, E. Do Anes- 
thetics Depress Nerve Cells by Depressing Oxygen Consump- 
tion? Fed. Proc, 9-75, 1950. 

lOMalamud, W., Lindemann, E. and Jasper, H. H. Effects of 
Alcohol on the Chronaxie of the Motor System. Arch. Neurol, 
and Psychiat. 29:790-807, 1929. 

iiLaurence, D. R. Clinical Pharmacology, Little, Brown and 
Co., Boston, 1966, pp. 283, 295. 

i^Cohen, J. et al. The Risk of Driving under the Influence 
of Alcohol. Brit. Med. J. 1:1438, 1958. 

i^^Drew, G. C. et al. Effect of Small Doses of Alcohol on a 
Skill Resembling Driving. Brit. Med. J. 2:993, 1958. 

i^Goldberg, L. Quantitative Studies on Alcohol Tolerance 
in Man. Acta. Physiol. Scand., vol. 5, supp. 16, 1:128, 1943. 

i^Mayfield, D. G., Personal communication. 

i^Cattell, R. B. The Effects of Alcohol and Caffeine on In- 
telligent and Associative Performance. Brit. J. Med. Psychol. 
10:20-33, 1930. 



W. WILSON 43 



i^Fleetwood, M. F. Biochemical Experimental Investigations 
of Emotions and Chronic Alcoholism. In Etiology of Chronic 
Alcoholism, Oskar Diethelm, ed., C. C. Thomas, Springfield, 
Illinois, 1955, pp. 43-109. 

'^Gantt, W. Horsley. Acute Effect of Alcohol on Autonomic 
(sexual, secretory, cardiac) and Somatic Responses. In Alco- 
holism, H. E. Himwich, ed., pub. No. 47 of the AAAS, Washing- 
ton, 1957, pp. 73-89. 

i^Mayfield, D. G. and Allen, D. Alcohol and Affect: A Psy- 
chopharmacological Study. Am. J. Psych. 123:1346-1351, 
1967. 

20Clyde, D. J. Construction and Validation of an Emotional 
Association Test, unpublished PhD Thesis, Pennsylvania State 
College, 1950. 

-•Stevens, C. F. Neurophysiology: A Primer. John Wiley, 
New York, 1966. 

22Bickford, R. G., Jacobsen, J. L. and Langworthy, D. A 
KWIC Index of EEC Literature. Elsevier, New York, 1965. 

23Horsey, W. J. and Akert, K. The Influence of Ethyl Alcohol 
on the Spontaneous Electrical Activity of the Cerebral Cortex 
and Subcortical Structures of the Cat. Quart. J. Stud. Alcohol. 
14:363-377. 

2^Davis, P. A., Gibbs, F. A., Davis, H., Jetter, W. W. and 
Trowbridge, L. S. The Effects of Alcohol Upon the Electroen- 
cephalogram. Quart. J. Stud. Alcohol. 1:626-637, 1941. 

^^Docter, R. F., Naitoh, P. and Smith, J. E. Electroenceph- 
alographic Changes and Vigilance Behaviour during Experi- 
mentally Induced Intoxication with Alcoholic Subjects. Psy- 
chosom. Med. 28:605-615, 1966. 

26Engel, G. L. and Rosenbaum, M. Delirium III. Electroen- 
cephalographic Changes Associated with Acute Alcohol Intoxi- 
cation. Arch. Neurol, and Psychiat. 53:44-50, 1945. 

27Engel, G. L., Webb, J. P. and Ferris, E. B. Quantitative 
EEG Studies of Anoxia in Humans: Comparison with Acute 
Alcohol Intoxication and Hypoglycemia. J. Clin. Invest. 24:691- 
697, 1945. 

28Holmgren, G. and Martens, S. Electroencephalographic 
Changes in Man Correlates with Blood Alcohol Concentration 
and Some Other Conditions Following Standardized Ingestion 
of Alcohol. Quart. J. Stud. Alcohol. 16:411-424, 1955. 

29Lolli, G., Nencini, R. and Misiti, R. Effects of Two Alco- 
holic Beverages on the Electroencephalographic and Electro- 



44 N. C. JOURNAL OF MENTAL HEALTH 



myographic Tracings of Healthy Men. Quart. J. Stud. Alcohol. 
25:451-458, 1964. 

30Weiss, A. D., Victor, M., Mendelsohn, J. H. and La Dou, 
J. Experimentally Induced Chronic Intoxication and Withdrawal 
in Alcoholics. 7. Electroencephalographic Findings. Quart, J. 
Stud. Alcohol, supp. 2, 1964, pp. 96-99. 

•^iWikler, A., Pescor, F. T., Fraser, H. F. and Isbell, H. 
Electroencephalographic Changes Associated with Chronic 
Alcoholic Intoxication and the Alcohol Abstinence Syndrome. 
Am. J. Psychiat. 113:106-114, 1956. 

^2Gresham, S. C, Webb, W. B. and Williams, R. L. Alcohol 
and Caffeine's Effect on Inferred Visual Dreaming. Science. 
140:1226-1227, 1963. 

33Yules, R. B., Freeman, D. X. and Chandler, K. A. The 
Effect of Ethyl Alcohol on Man's Electroencephalographic 
Sleep Cycle. Electroenceph. and Clin. Neurophysiol. 20:109- 
111, 1966. 

■•^^Bennett, A. E., Doi, L. T. and Mowery, G. L. The Value of 
Electroencephalography in Alcoholism. J. Nerv. Ment. Dis. 
124:27-32, 1956. 

35Dyken, M., Grant, P. and White, P. Evaluation of Electro- 
encephalographic Changes Associated with Chronic Alcohol- 
ism. Dis. Nerv. Syst. 22:284-286, 1961. 

3*^Faure, J. and Bannel, F. Sur I'Electroencephalogramme 
de 12 Alcooliques. Ann. Med. Leg. 31:82-84, 1951. 

•^^Greenblatt, M., Levin, S., Cori, F. D. The EEG Associated 
with Chronic Alcoholism, Alcoholic Psychosis and Alcoholic 
Convulsions. Arch. Neurol. Psychiat. 52:290-295, 1944. 

•'^Neveu, P., Derquet, E. and L'Hermit, M. Delire Aigu 
Alcoolique h Debut Convulsif Traite par Hibernation. Controle 
Electroencephalographique. Ann. Med. Psychol. 2:732-737, 
1954. 

39Rodin, E. A., Frohman, C. E., and Gottlieb, J. S. Effect 
of Acute Alcohol Intoxication on Epileptic Patients: A Clinical 
Experimental Study. A.M.A. Arch. Neurol. 4:103-106, 1961. 

-i^Shagass, C. and Jones, A. L. A Neurophysiological 
Study of Psychiatric Patients with Alcoholism. Quart. J. Stud. 
Alcohol. 18:171-182, 1957. 

4iVan Reeth, P. C. and Souris, M. L'Electroencephalo- 
gramme dans la Psychose de Korsakow, d'Origine Alcoolique. 
Acta. Neurol. Psychiat., Belg., 60:302-311, 1960. 



W. WILSON 45 



42Funkhauser, J. B., Nagler, B. and Waike, N. D. The Electro- 
encephalogram of Chronic Alcoholism. South. Med. J. 46:423- 
428, 1956. 

43Little, S. C. and McAvoy, M. EEG Studies in Alcoholism. 
Quart. J. Stud. Alcohol. 13:9-15, 1952. 

^^Green, R. L. The Electroencephalogram in Alcoholism, 
Toxic Psychoses, and Infection. In Applications of Electroen- 
cephalography in Psychiatry, W. P. Wilson, ed., Duke Univer- 
sity Press, Durham, N. C, 1965. 

**^Kalant, H. Some Recent Physiological and Biochemical 
Investigations in Alcoholism. Quart, J. Stud. Alcohol. 23:52-93, 
1962. 

^6Di Perri, R., Dravid, A., Schweigerdt, H., and Himwich, 
H. E. Effects of Alcohol on Evoked Potentials of Various Parts 
of the CNS of Cat. Quart. J. Stud. Alcohol. 28:742, 1967. 

^^Brown, B. B. and Shryne, J. E. Cat Personality Character- 
istics and Neurophysiologic Correlates as Animal Model for 
Psychiatric Research. Effect of Alcohol, Fed. Proc. 24:328, 
1965. 

^*^Bradley, P. B. Central Action of Certain Drugs in Rela- 
tion to the Reticular Formation of the Brain. In Reticular For- 
mation of Brain, H. H. Jasper, et al., eds., Little, Brown, 
Boston, 1958. 

49Magoun, H. W. Neurophysiology. In Field, J., ed.. Hand- 
book of Physiology, Section I, Neurophysiol. American Phy- 
siological Society, 1960. 

soWeiss, A. D., Victor, M., Mendelsohn, J. H. and La Dou, 
J. Critical Elicer Fusion Studies. Quart. J. Stud. Alcohol, supp. 
2:87-95, 1964. 

^^Dravid, A. R., Di Perri, R., Morillo, A. and Himwich, H. E. 
Alcohol and Evoked Potentials in the Cat. Nature. 200:1328- 
1329, 1963. 

52Gross, M. M., Begleiter, H., Tobin, M., and Kessin, B. 
Changes in Auditory Evoked Response Induced by Alcohol. 
J. Nerv. Ment. Dis. 143:152-156, 1966. 

^•'Gellhorn, E. A Prolegomena to a Theory of Emotion. Per- 
spect. in Biol. Med. 4:403-436, 1961. 

^^Coopersmith, S. The Effects of Alcohol on Reactions to 
Affective Stimuli. Quart. J. Stud. Alcohol. 25:459-475, 1964. 

^^Thompson, R. and McConnell, J. V. Classical Conditioning 
in the Planarian, Dugesia dorotocephela. J. Comp. Physiol. 



46 



N. C. JOURNAL OF MENTAL HEALTH 



Psychol. 48:65-68, 1955. 

^^Lashley, K. S. In Search of the Engram. Soc. of Exp. 
Biol. Symposium No. 4. Physiological Mechanisms in Animal 
Behaviour, pp. 478-505, 1950. 

s^Scoville, W. and Milner, B. Loss of Recent Memory after 
Bilateral Hippocampal Lesions. J. Neruol. Neurosurg. and 
Psychiat. 20:11-19, 1957. 

sspenfield, W. The Permanent Record of the Stream of Con- 
sciousness. Acta. Psychol. 11:47-69, 1955. 

^^Talland, George A. Deranged Memory, Academic Press, 
New York, 1965. 



ANNOUNCEMENT 47 



ANNOUNCEMENT 



Master's Degree Training Programs in Biostatistics With 
Application to Mental Health 



The Biostatistics Department of the University of North 
Carolina School of Public Health is now accepting applications 
for September 1971 admission to Master's degree training 
programs in mental health statistics. These programs train 
biostatisticians at the Master's degree level and prepare them 
to apply the statistial training to fields such as mental health, 
community psychiatry, psychiatric disorders, mental retarda- 
tion, and psychiatric research. 

There are three Master's degrees available: (l)M.P.H. (Mas- 
ter of Public Health ), (2)M.S.P.H. (Masterof Science in Pub- 
lic Health ), and (3) M.S. (Master of Science in Biostatistics ). 
The M.P.H. is an applied statistics degree and requires no 
background in calculus. The M.S.P.H. and M.S. degrees re- 
quire calculus background and include work in applied and 
theoretical statistics. Other components of the training are 
epidemiology, public health, and mental health statistics. 

NIMH fellowships, plus dependency allowances where appli- 
cable are available to qualified applicants. For more informa- 
tion write to: 

Donna R. Brogan, Ph.D. 
University of North Carolina 
School of Public Health 
Department of Biostatistics 
Chapel Hill, North Carolina 27514 



Notice to Contributors 

Manuscripts and editorial comments should be addressed 
to the Editor-in-Chief, N. C. Department of Mental Health, 
P. 0. Box 26327, Raleigh, N. C. 27611. 

Contributors need not be psychiatrists, neurologists or 
M.D.'s but should be involved in some aspects of program, 
whether clinical, educational, or research, pertinent to mental 
health or mental illness. 

Manuscripts offered for publication should be submitted 
in triplicate, with the original typed on bond paper, and 
double spaced with 70 characters per line. Footnotes, biblio- 
graphical references, quotations, etc., should also be double 
spaced and the use of footnotes minimized. 

References to books and journals should be numbered con- 
secutively in a bibliography at the end in the order in which 
they appear in the manuscript. References should be limited 
to those used by the author in the preparation of the article 
and kept to a minimum. 

The author's privilege of correcting galley proofs may apply 
only to printer's errors. 

Tabular material, drawings and charts should be submitted 
on separate sheets, clearly marked as to where they are to 
appear in the text. 



NORTH CAROLINA JOURNAL OF 
MENTAL HEALTH 

Published by 
The State Department of Mental Health 



EDITOR-IN-CHIEF 

Eugene A. Hargrove, M.D. 

ASSOCIATE EDITOR 
Nicholas E. Stratas, M.D. 

SENIOR EDITORIAL CONSULTANT 
Bernard Glueck, M.D. 



CONTRIBUTING EDITORS 
Granville Tolley, M.D. Sam 0. Cornwell, M.D., Ph.D. 

Gilbert Gottlieb, Ph.D. Harvey L Smith, Ph.D. 

Philip G. Nelson, M.D. Norbert L. Kelly, Ph.D. 



EDITORIAL ADVISORY BOARD 

George Ham, M.D. Halbert B. Robinson, Ph.D. 

C. Wilson Anderson, Ph.D. Ewald W. Busse, M.D. 

John A. Fowler, M.D. Mark A. Griffin, M.D. 

John A. Ewing, M.D. Martha C. Davis, M.S. 

Richard C. Proctor, M.D. N. P. Zarzar, M.D. 

Richard A. Goodling, Ph.D. Jacob Koomen, Jr., M.D. 



Produced by 

Division of Information and Public Relations 

Benjamin G. Runkle, Director 

Jacqueline M. Ransdell 

Lillian W. Pike 

Sally R. Cameron 



NORTH CAROLINA JOURNAL OF 
MENTAL HEALTH 



Volume 4 Number 3 

1970 
CONTENTS 
ARTICLES 



The Role of Law Enforcement in the 
Helping System 

Morton Bard 3 

A Psychoactive Drug Dispensing System for 
Community IVIental Health Clinics in North Carolina 

Edward F. Doehne 16 

Perceptions of Mental Illness Among Leaders in 
Two Rural North Carolina Communities 

W. Kenneth Bentz, J. Wilbert 

Edgerton and William G. Hollister 19 

The Hypothetical Community, A Template For 
Planning Mental Retardation Programs 

Donald J. Stedman 26 



History of the Department of Psychiatry at Duke 
University, Part I - Department Without 
Portfolio, 1930-1940 

James F. Gifford, Jr., and Eric Pfeiffer 30 

Research Abstracts 43 

Announcement 45 



NORTH CAROLINA JOURNAL OF MENTAL HEALTH 

is published quarterly, Spring, Summer, Fall and Winter. 

It is a scientific journal directed to the professional disciplines en- 
gaged in care, treatment, and rehabilitation of mentally ill and re- 
tarded patients as well as to those engaged in professional research and 
preventive work in the field. 

This journal is intended to be inclusive rather than exclusive and is 
not meant to be regarded as simply a house organ of the North Caro- 
lina State Department of Mental Health. 

It is hoped that the journal will reflect the broad-based philosophy of 
psychiatry current and will draw on areas reflecting the total spectrum 
of psychiatric and neurologic thought, program and research. 

Subscription may be obtained by writing the Editorial Offices, North 
Carolina Department of Mental Health. P. 0. Box 26327, Raleigh, North 
Carolina 27611. 



(Notice to contributors— see inner back cover) 



THE ROLE OF LAW ENFORCEMENT 
IN THE HELPING SYSTEM^ 

Morton Bard, Ph. D. 

Professor and Director, The Psychological Center 
The City College of The City University of New York 

It is one of the ironies of social existence that the greatest 
progress often occurs at times of greatest social unrest. Indeed, 
it is the threat of violence that is frequently the most powerful 
force to promote change in the institutions of society. History 
attests to the fact that the most dramatic technological ad- 
vances in science and industry have occurred during periods 
when our nation was imperiled by war. There is little question 
that when "under the gun" we are able to marshal our re- 
sources, we can reappraise our priorities, and we can alter our 
institutions to enhance our survival as a social order. 

Today, threats of violence are legion— not so much from 
without but from within our society. And the crucial question 
is: Are we prepared to undertake critical appraisal of our 
institutions and alter them to insure survival? If the past is 
prologue, we will; the signs are already evident that the neces- 
sary changes are taking place, even if haltingly. 

Two institutions are currently in the forefront of social reap- 
praisal: law enforcement and academe. It is hardly accidental 
that these two should be paired at this time in history. Both 
play critical roles with respect to the internal harmony of 
society: one primarily by thought, the other primarily by action; 
the one given to change; the other committed to the status 
quo. Unfortunately, both have failed to adapt to rapidly chang- 
ing conditions. The simplistic notion of the police as a re- 
pressive force in the defense of property is no more viable 
today than is the naive notion that the university is a medieval 
cloister given to abstract thought far removed from the reali- 
ties of everyday life. As a consequence of adhering to out- 
moded functional concepts, both institutions find themselves 
increasingly remote from those they serve and decreasingly 
effective in fulfilling their primary missions. 

Perhaps the key issue for both of these institutions lies in 
their failure to acknowledge present-day realities. Much of the 
university's prime function is regarded as irrelevant today. 
There seems to be less and less tolerance for abstract re- 



*Presentation at dedication of Cumberland County Mental Health Center. 



N.C. JOURNAL OF MENTAL HEALTH 



search exercises which do not contribute to the world of real 
people. A similar charge of irrelevance is directed at law en- 
forcement. There is increasingly less tolerance for police be- 
havior patterned after the Hollywood-reinforced stereotype of 
the tight-lipped, gun-slinging frontier marshall. 

There was a time when the myth of academic intellectual 
purity excluded practical application of knowledge in much 
the same way that law enforcement tended to reject all func- 
tions but those based upon force. But each institution has 
had to confront its own myths. The university did so initially 
by incorporating elements of the practical in science and 
technology, creating schools of engineering and agriculture; 
later, medical colleges, schools of social work and schools of 
education were added to the array of interests which could be 
said to serve the community without compromising the uni- 
versity's mission to extend the horizons of knowledge. The 
university accepted its responsibility in the preparation of 
society's professional helpers. Interestingly, save for rare ex- 
ceptions, the university ignored the education of one of the 
most direct helpers in society. . .the police. It is the thesis 
of this paper that our present national crisis makes it im- 
perative that law enforcement be acknowledged as a partici- 
pating profession in the helping system. To do so will mark 
our maturation toward progress and responsibility. There is no 
better barometer of the state of any society than the state of 
its law enforcement. 

Recent changes in the helping system have created a parti- 
cularly favorable climate for embracing the police as appro- 
priate participants. Increasing population density, growing 
economic inequities and ever greater complexity and aliena- 
tion have caused helping institutions to examine some of their 
myths. Selectivity in the delivery of services, organizational 
inadequacies and other givens of the "helping game" have 
suddenly become irrelevant (that word again ). Agencies with 
long traditions of helping in particular ways have found their 
hallowed methods under attack. The pressure for change has 
grown increasingly insistent. . .the call for revolution, more 
strident. It is a never ceasing source of wonder that this kind 
of social unrest succeeds in bringing about the adaptive 
changes which, in the end, make for a better society. 



Law Enforcement and Order Maintenance 

The goals of the university, law enforcement, and the help- 
ing system can be said to converge at the issue of relevance. 



M. BARD 



When one examines the point of convergence, one is struck 
by how naturally congenial they are. One is prompted to ex- 
claim, "Why, of course — how simple! Why wasn't it seen be- 
fore?" It is suggested here that, like certain distant planets, 
their communality could not be seen until all conditions were 
in harmony. Ironically enough, it is at this time of social 
disharmony that conditions seem best for the incorporation 
of the police as full participating professional members of 
the helping system. 

At this point, it must be emphasized strongly that there is 
no intention here to minimize the primary peace-keeping fun- 
tion of the police. The police officer's first responsibilities 
are to enforce the law and to maintain order. This is a "given" 
in every known society. But there is ample evidence-' •■• '^- "■ '-• 
that in the United States between 80% and 90% of a police- 
man's daily activity in rural, suburban, and urban areas in- 
volves maintenance of order as distinct from law enforcement. 
Wilson pointed out that: 

The vast majority of police actions taken in response to 
citizen calls involve either providing a service (getting a 
cat out of a tree or taking a person to the hospital ) or 
managing real or alleged conditions of disorder (quarrel- 
ing families, public drunks, bothersome teen-agers, noisy 
cars, tavern fights). Only a small fraction of these calls 
involve law enforcement such as checking on a prowler, 
catching a burglar in the act or preventing a street 
robbery.i=5 (p.l30) 

Wilson's distinction between order maintenance and law en- 
forcement is a crucial one. 

The difference between order maintenance and law en- 
forcement is not simply the difference between "little 
stuff" and "real crime." The distinction is fundamental 
to the police role, for the two functions involve quite 
dissimilar police actions and judgments. Order mainten- 
ance arises out of a dispute among citizens who accuse 
each other of being at fault; law enforcement arises out 
of the victimization of an innocent party by a person 
whose guilt must be proved. . . .Because an arrest can- 
not be made in most disorderly cases, the officer is ex- 
pected to handle the situation by other means and on 
the spot, but the law gives him no guidance on how he 
is to do this; indeed, the law often denies him the right 
to do anything at all other than make an arrest. . . .Alone, 
unsupervised, with no policies to guide him and little 
sympathy from onlookers to support him, the officer must 
"administer justice" at the curbstone. ^^ (p. 131. ) 

The helping system has virtually ignored the implications of 



N.C. JOURNAL OF MENTAL HEALTH 



that aspect of the policeman's function which Wilson calls 
maintenance of order. This is made particularly striking by 
the fact that the police in every community have been func- 
tioning as social and mental health agencies by virtue of their 
order maintenance function. Instantly available 24 hours of 
each day (unlike other helpers, who operate between the hours 
of 9 and 5 and not on weekends), they come when called 
(eliminating the frustrating delays of waiting lists and return 
visits) and they do something (unlike the typical verbal ab- 
stractions of the usual "planned intervention" ). 

The "something" policemen "do," however, is the central- 
ly crucial issue. The police establishment is not geared to re- 
cognizing the validity of order maintenance as "real" police 
work. Like the rest of society, the institution recognizes and 
rewards the quick draw on Main Street as the prototype of 
police excellence. It is loathe to acknowledge service func- 
tions, one suspects, because compassion and helping might 
in some way tarnish the masculine mvstique of law enforce- 
ment. However, this institutional insensitivity to the "order 
maintenance" function of police work has been costly indeed. 
Recently, the FBI reported that 22% of policemen killed in the 
line of duty nationally were slain while intervening in distur- 
bances such as family disputes.'* Estimates of time lost be- 
cause of injuries sustained in the line of duty indicate that 
about 40% occur in the same way. 

It is therefore more than curious that there has been so 
little interest by society in the policeman's helping role. In- 
deed, this is particularly striking when one compares society's 
investment in the helper most like him . . . the physician. There 
are no other two professionals in the helping system whose 
identities and responsibilities approximate each other so 
much. The physician is an authority with the power of life 
and death in situations which involve physical disorder. The 
policeman, on the other hand, is an authority with the power 
of life and death in situations of social disorder. And yet, the 
average physician receives a mimimum of 11,000 hours of 
training to prepare him for his role; the average policeman 
receives less than 200 hours of training to prepare him for 
his.5 (p.83) 

There are undoubtedly many factors which contribute to 
the disparity in training. But in view of the escalation of social 
disorder, it is highly questionable that society can continue 
to ignore the extensive ramifications of the range of functions 
subsumed under the rubric of law enforcement. Perhaps the 
time has come for the kind of creative collaboration between 
law enforcement and the academic-professional communities 



M. BARD 



which would maximize the potentials of the police as acknowl- 
edged members of the helping professions. 

Experimental Program 

For almost two years now an experimental program has been 
in operation which may serve as a model for demonstrating 
the potentials inherent in police-helping system collaboration. 
The program has shown that the mutual distrust of both in- 
stitutions can be minimized while they cooperate to serve the 
community more effectively. What is more, the collaboration 
permitted each agency to remain faithful to its own primary 
mission. For the police . . . enhancement of its law enforcement 
and order maintenance mission; for the university . . . the edu- 
cation of helping professionals (in this instance, clinical psy- 
chologists ), research, and community service. Impetus for the 
program was derived from a number of sources: increasing 
crime rates, increasing violence and aggression, worsening 
police-community relations, and increasing social and pro- 
fessional pressure for innovation in preventive mental health. 

The President's Commission on Law Enforcement and Ad- 
ministration of Justice commented on a phenomenon well 
known to every policeman: 

A great majority of the situations in which policemen 
intervene are not, or are not interpreted by the police to 
be, criminal situations in that they call for an arrest. . . . 
A common kind of situation. . .is the matrimonial dis- 
pute, which police experts estimate consumes as much 
time as any other kind of situation. i=^ (p. 134) 

The program to be described was designed to deal with this 
social reality. Crime statistics indicate that between 35% and 
50% of all homicide victims in the United States are related 
to their killers and that in fewer than 20% of the cases are 
homicide victims and perpetrator complete strangers. It is 
apparent from these startling figures that family crisis inter- 
vention offered unlimited experimental and preventive pros- 
pects. 

The psychological helping professions have become in- 
creasingly disenchanted with traditional methods of diagnosis 
and treatment. Not only are their methods found wanting in 
themselves, but they seem to have lessening social impact 
as the demand for psychological services quickly outdistances 
manpower resources. Prevention appears to offer the greatest 
promise of relief. The project in police family crisis interven- 
tion embodies principles of at least three distinct tracks of 
mental health theory and research: 1 ) the training of the front- 



N.C. JOURNAL OF MENTAL HEALTH 



line mental health workers; 2 ) the role of the family in deter- 
mining disordered behavior; and 3) preventive crisis interven- 
tion. 

As Reiff and Riessman^ and Riochi" have demonstrated, 
indigenous mental health aides can effectively extend the 
social impact of the highly trained professional. There appears 
little question that intelligent laymen can be trained to render 
effective mental health services under supervision. In such 
an approach, the highly trained supervisor does little direct 
service but instead influences the functioning of those he 
supervises, thus extending the effects of his education and 
experience. We proposed the selection and training of a group 
of policemen to serve in the capacity of indigenous mental 
health personnel in the course of their regular police duties. 
This was based on the supported contention that policemen 
were already engaged in quasi-mental health roles and that 
specific training would simply enhance their effectiveness in 
doing what they were already doing. 

And so, a program was conceived which embodied crime 
prevention and preventive mental health principles — but, more 
important perhaps, afforded a research framework within the 
psychological and social matrix of a living community. . .an 
opportunity to explore a variety of hypotheses regarding the 
natural history of aggression. Most important, perhaps, was 
the design of a model for the utilization of policemen as 
primary crisis intervention agents*. i 

Briefly, eighteen police officers were selected from among 
45 volunteers. Because the community surrounding the cam- 
pus (west Harlem ) is largely black, the design called for the 
selection of nine white and nine black patrolmen who were 
to be paired interracially. No effort was made to induce parti- 
cipation except for the proffer of three college credits. Selec- 
tion was based upon evidence of motivation and aptitude for 
family crisis intervention and a minimum of three years' ex- 
perience as partrolmen to insure sufficient skill in police work. 

For the entire month following selection, the men were re- 
leased from all duties to engage in an intensive training 
program which included lectures, workshops, field trips and 
a unique opportunity to "learn by doing." Three Family Crisis 
Laboratory Demonstrations involved the enactment of speci- 
ally written plays by professional actors in which the patrol- 
men intervened in pairs. The value of the experience was to 

*This project was supported in part by the Office of Law Enforcement 
Assistance, U. S. Department of Justice, Grant No. 157; the New York 
City Police Department and The City College, The City University of 
New York. 



BARD 



enable the men to see how different interventions could pro- 
duce different outcomes. All the practice interventions were 
subjected to extensive critique and reviewed by all members 
of the unit. The intensive training also included human rela- 
tions workshops which helped sensitize the men to their own 
values and attitudes about disrupted families. 

After the month of intensive training, the Family Crisis Inter- 
vention Unit began its current operational phase. For a two- 
year period, one radio car is designated for use by the Unit 
and is dispatched on all complaints which can be predeter- 
mined as involving "family disturbance." A special duty chart 
permits twenty-four-hour-a-day coverage by men of the Unit 
in a circumscribed experimental area of about 85,000 people. 

The men have continued their training by appearing on 
campus in groups of six for discussions with a professional 
group leader each week. In addition, each man has an indivi- 
dual consultation with an advanced graduate student in clini- 
cal psychology who uses the experience to enhance his won 
training as a mental health consultant. 

Finally, the project will undergo evaluation to determine if, 
indeed, the method reduces the number of homicides, suicides 
and assaults in the demonstration area. Comparable data is 
being collected in a neighboring precinct which does not have 
the services of a specially trained unit. 

Since being operational, the Family Crisis Unit has engaged 
in more than 1,400 interventions with more than 900 different 
families. In addition, the men of the Unit have performed all 
routine police duties on a par with the men of their command. 
However, despite the high hazard work involved in family 
crisis intervention, there has been only a single minor injury 
sustained by one member of the Unit. During the same period, 
three partrolmen not trained in family crisis intervention have 
sustained injury in domestic disturbances. 

While conclusions based upon the method described will 
have to await final evaluation, preliminary findings are begin- 
ning to serve as a basis for speculation. For example, the 
remarkable absence of injury to a group of officers exposed 
in the extreme to dangerous and highly volatile aggressive 
situations strongly suggests the importance of the role played 
by the victim in the exacerbation of violence. Recently Sarbin 
characterized danger as connoting a relationship, pointing out 
that assaultive or violent behavior which leads to the designa- 
tion dangerous "can be understood as the predictable outcome 
of certain antecedent and concurrent conditions. . .among 



10 N.C. JOURNAL OF MENTAL HEALTH 



these conditions are degradation procedures which transform 
a man's social identity. "^^ (p. 286 ) 

Sarbin develops the notion that social identity is formed out 
of role-relationships and that individuals who do not meet 
minimal social expectations may be classified as "brutes" or 
as "non-persons," or, to put it another way, are deprived of 
their social identity. By the nature of his work, a policeman 
is always ready to classify conduct as potentially dangerous. 
The officer's negative valuation of the other person in the 
power relationship may entail degrading behavior toward those 
he classifies as "non-persons." Indeed, the officer may even 
engage in premature power display, thus further provoking the 
untrusted "non-person" to behave as the expected "wild 
beast." In this connection, the conclusion may iDe drawn that 
the dangerous person may, in large measure, then be the out- 
come of the very institutions we have created to control him. 
In a Mertonian sense, the self-fulfilled prophecy. 

It may be that the officers engaged in our project, through 
their sensitivity training, have avoided premature power dis- 
plays and have eschewed classifying people as "non-persons" 
and hence have avoided potentiating clanger and violence 
directed at them. Perhaps an illustration will clarify the con- 
cept as it occurred in our "laboratory" for the study of aggres- 
sion. After repeated family difficulty, yet always reluctant to 
summon the police, in desperation a black family requested 
assistance. Two members of our unit responded, took appro- 
priate action, and started to leave the apartment. The white 
patrolman went out the door and his black partner was about 
to follow when the lady of the house asked him to stay a 
moment. She described previous difficulties and spoke of her 
reluctance to summon aid before — because of her fear of the 
kind of treatment she might receive. "Finally," she said, "we 
called for help and the first one through the door was your 
partner. I looked at that white man and said to myself, "Now 
we've had it!" "But," she said, looking squarely at the officer, 
"I want you to know how much it meant to us that he and 
you treated us as a family and treated my husband like a 
man." This illustrates how the men of the unit may avoid 
making negative valuations which transform individuals to the 
status of non-persons and so do not also engage in premature 
power displays which provoke danger and violence. Indeed, 
the Family Crisis Intervention Unit's performance in this re- 
gard has been acknowledged in the recent Report of the 
National Advisory Commission on Civil Disorders. Taking note 
of domestic disputes as precursors to violence, the report 
included the project as a recommendation.^ (p 318-319) 



M. BARD 11 



Implications of Project 

This project has many implications; space permits touching 
upon only a few. If there is a single most significant element 
in our approach, it is that we have managed to avoid role 
identity confusion in our officers. Throughout the project, 
every effort was made to avoid giving the men the notion 
that they were functioning in any way other than as police 
officers. Their professional identities were respected and pre- 
served and, indeed, constantly reinforced. The members of the 
unit never lost sight of their primary objective: restoring and 
maintaining the peace. Our view, and theirs, was that their 
insight and training served to enhance their performance as 
policemen. 

This aspect of the experience has been paramount, perhaps 
because it highlighted one of the greatest pitfalls in mental 
health community consultation. IVlost community consultants 
succeed in confusing the role identity of their consultees. 
Undoubtedly, many of you have witnessed the consequences 
of this. . . most notably in the field of education. Well-meaning 
consultation programs in the schools almost universally suc- 
ceed in confusing the classroom teacher. Before very long, 
the teacher is not quite sure about whether she is a teacher 
or whether she is a psychotherapist. It may be that pride and 
omniscience endow many consultants with a subtle form of 
proselytizing enthusiasm which only serves to confuse the 
consultee. Awareness of the problems of role identity con- 
fusion must be regarded as a keystone in the mental health 
consultation process. 

The validity of the concept of utilizing as mental health 
resources those individuals already in the psychological front- 
lines needs no further emphasis here. What should be under- 
scored, however, is the importance of identifying those in 
society who are in this front line role. Mental health personnel 
typically move in safe social sub-systems. The most popular 
is the educational sub-system; working through that institution 
is usually justified by the claim that the child is father to 
the man and as such represents the best of all preventive 
possibilities. While this may be true in part, it may not be 
the real reason for investing so much effort in the schools. 
A more subtle reason may be that the educational sub-system 
is more familiar, more comfortable, and hence safer for the 
mental health professional. The school establishment is well 
travelled ground and requires little re-orientation. Not so in 
other sub-systems. The police establishment, for example, is 
a sub-system as remote from the world of mental health pro- 



12 N.C. JOURNAL OF MENTAL HEALTH 



fessionals as it is possible to be. And, as such, it is regarded 
as uncomfortable and, in a way, unsafe. There are many sub- 
systems which offer unusual and creative opportunities for 
extending preventive mental health principles. They exist, 
however, outside of the safety of the schools and of the 
hospitals and the like; they exist in abundance elsewhere in 
the community. They represent the real challenge in preventive 
mental health, but it remains for us to search them out and 
use them effectively. 

Research Possibilities 

Aside from service potentials and fulfilling the objectives 
of prevention, such approaches open a wide range of research 
possibilities. The world of people as seen through the eyes 
of those in unfamiliar sub-systems can only enlarge and add 
dimension to our knowledge of human behavior. For example, 
in our police family crisis intervention program, we expect 
to learn a great deal about the social psychology of aggression 
—not in the context of the scientifically pure experimental 
laboratory, but in the pulsating, real-life laboratory that every 
community represents. We already have some preliminary 
data with interesting implications in tracing the epidemiology 
of the family fight. We should be able to trace hourly, daily 
and even seasonal trends in the frequency of family fights 
requiring police intervention. We already have some basis for 
questioning the commonly held conviction that Friday night 
(pay day) is the time of greatest incidence. Our preliminary 
data indicate that there is indeed a peaking on Friday night 
but that it maintains the same level on Saturday night, and, 
even more surprisingly, all day Sunday and into Sunday night. 
Also, interestingly, there is a precipitous drop in incidence 
on Monday and Tuesday, with a slight building from then to 
the first peak on Friday. This all may be more suggestive of 
increasing tension as the dreaded weekend of togetherness 
approaches, while the dramatic drop on Monday perhaps is 
related to the opportunity for "getting away" from one's "loved 
ones." 

Typical of the kinds of clinical hypotheses to be tested is a 
study now being prepared which will involve a representative 
sample of children from among the families served by the 
unit. For a long time there has been endless debate regarding, 
and laboratory experimentation on, stimulus threshold in ag- 
gression. We now have the opportunity to identify and study 
young children actually raised in an atmosphere of violence 
and aggression in order to understand the effects of such 
early experiences on subsequent development and the quality 



M. BARD 13 



of aggression. 

We also have an opportunity to discover whether there is a 
"homicide signal" emitted by the person who ultimately kills, 
just as the suicide repeatedly cries for help. Do frequent and 
repeated requests for police intervention in family fights pre- 
sage a fatal outcome? Do individuals know that they will kill 
and ask, in this way, to be stopped? From the statistics on 
homicide and intimacy, there is a suggestion that such may 
be the case. 

Or, what role does alcohol play in murderous and assaultive 
behavior within the family? Are there certain styles of family 
interaction which are characteristic? Can we develop an as- 
sault or homicide index? These are only a few of the questions 
to which we hope to find answers. 

The family crisis project with the New York City Police 
Department is The Psychological Center's first venture into 
serving the mental health needs of the community by collab- 
orating with existing community institutions. Others are in 
the planning or funding stages. For example, we are currently 
awaiting funding for a project proposal prepared jointly by 
The Center and the New York City Fire Department. This two- 
stage project will attempt to understand and modify a very 
recent and particularly destructive kind of urban behavior- 
harassment of fire fighters and the increasing rate of false 
alarms of fire. 

If The Psychological Center does its job properly, however, 
it should terminate its collaboration, leaving the cooperating 
institution with capacities and insights it did not have before. 
An exciting spin-off of the police family project is the promise 
it holds for a new structuring of police organizations. Typically, 
police departments follow the specialist model. Individual 
police officers are assigned to highly specialized tasks, e.g. 
traffic control, emergency services, community relations, 
youth detail, etc. The officer so assigned performs his special- 
ized function to the exclusion of generalized law enforcement. 
But, unfortunately, that approach has had results with which 
specialists in other fields are only too familiar— psychiatrists, 
for example. The specialist officer is quickly regarded by his 
fellows as no longer a "real cop" and, following a fundamental 
biological principle, he is rejected as a foreign body. What is 
more, the public also views the behavior of the police specialist 
as not being typical of the police in general. 

Our project suggests the viability of the generalist-specialist 
model of police patrol. It would entail utilizing the special 
talents and interests of each patrolman, while at the same 



14 N.C. JOURNAL OF MENTAL HEALTH 



time having each perform over-all patrol duties. The unit 
operating as family crisis intervention specialists patrol as 
do all other members of their command but are available 
within their precinct area whenever a family disturbance oc- 
curs. The same approach might be taken in relation to youth 
disorders, alcoholics, attempted suicides, or psychotics. It is 
too much to expect that every policeman should have special- 
ized capacities in relation to the enormous range of human 
problems. It does make sense, however, to assume that a 
patrolman with special proclivities in managing a psychotic 
may not be so well suited to managing a group of unruly 
adolescents. . .or vice versa. What is more, the public is ex- 
posed to police whose behavior is consistent with special 
capacity and special training, thus vastly improving their im- 
pressions of the police. If the public attitude toward police 
is to improve, it won't be because of highly-touted community 
relations gimmickery, but because policemen are handling 
their order-maintenance functions with skill, understanding 
and compassion. If professionalism is to occur in law enforce- 
ment, it will be necessary to modify outmoded organizational 
structures which are no longer relevant in today's complex 
society. 

These remarks have seemed to focus on the issue of rele- 
vance. It is perhaps one of the most fortunate characteristics 
of the current scene that so many of our institutions are 
questioning organizational structural forms which have clearly 
become irrelevant. In the last analysis, relevancy is probably 
the benchmark of adaptation. If we are to change and continue 
to grow, we must constantly question the relevancy of what 
we do. In these comments, the measure has been taken of 
the helping system, of the academic-professional community, 
and of law enforcement. These three social institutions share 
more in common at this time in history than could ever have 
been thought possible even a short time ago. Perhaps we 
can take solace in these troublesome times in the thought 
that our national crisis may produce the kind of synthesis 
from among the three that is bound to make for a better 
society. 



REFERENCES 

^Bard, M. and Berkowitz, B. Training police as specialists 
in family crisis intervention; a community psychology action 
program. Community Mental Health Journal 3, 1967, 315-317. 



BARD 15 



^Cumming, Elaine, Cumming, Ian and Edel, Laura. Police- 
man as philosopher, guide and friend. Social Problems 17, 
1965, 276-286. 

^Epstein, Charlotte. Intergroup Relations for Police Officers. 

Baltimore, Md.: Williams and Wilkins Company, 1962. 

^FBI Law Enforcement Bulletin, January 1963, p. 27. 

^Lipset, S.M. Why cops hate liberals and vice versa. Atlantic 
Monthly, March, 1969, 76-83. 

^McCann, R., director, Chicago Police Department Training 
Division. Personal communication. 

^McCloskey, C.C. Jr., executive director. Division of Police 
Administration Services, Office for Local Government, State 
of N.Y. Pers. comm. 

sReiff, R. and Riessman, F. The Indigenous Non-Profes- 
sional: A Strategy of Change in Community Action and Com- 
munity Mental Health Programs. U. S. Dept. of Health Educa- 
tion and Welfare, Report No. 3, November, 1964. 

^Report of the National Advisory Commission on Civil Dis- 
orders. Bantam Books, 1968. 

lORioch, M. et al. National Institute of Mental Health pilot 
study in training mental health counselors. American Journal 
of Orthopsychiatry 33, 1963, 678-689. 

^^Sarbin, T. The dangerous individual: an outcome of social 
identity transformations. Bristish Journal of Criminology, July 
1967,285-295. 

i^Wilson, J. Q. Varieties of Police Behavior. Cambridge: 
Harvard University Press, 1968. 

^^Wilson, J. Q. What makes a better policeman. Atlantic 
Monthly, March, 1969, 129-135. 



16 



A PSYCHOACTIVE DRUG DISPENSING SYSTEM 

FOR COMMUNITY MENTAL HEALTH CLINICS IN 

NORTH CAROLINA 



Edward F. Doehne, M.D. 

Assistant Professor of Psychiatry 
University of North Carolina at Chapel Hill 



For a considerable number of patients seen in psychiatric 
outpatient clinics, the ability to be maintained outside of a 
hospital setting rests with tiieir taking psychotropic medica- 
tions. A primary consideration in maintaining patients on these 
medications is the cost. Some clinics in other states give the 
medications free of charge. In North Carolina the well-to-do 
are usually not seen in community mental health clinics and 
can easily afford the medications. Patients receiving welfare 
funds have to pay a small initial sum to the druggist, but 
their prescription fees are largely paid by the Department of 
Welfare. Welfare programs have an additional category of 
"medically indigent" patients who do not need financial as- 
sistance in managing their usual expenses, but when con- 
fronted by large medical bills are considered indigent. It is 
for these patients that I am describing the following method 
of obtaining psychiatric medications. 

On coming to the psychiatric clinic the patient who is having 
difficulty paying for his medication is first sent to the Welfare 
Department for certification of medical indigency. This certi- 
fication is completed in duplicate with one copy retained by 
the Welfare Department and another returned to the clinic. 
This certification enables the clinic to sell the patient medica- 
tions at cost. Each clinic in North Carolina is able to purchase 
medications from their regional state hospital or from drug 
companies at costs below that paid by the neighborhood drug 
store. (This refers to psychiatric medications only. ) 

In setting up a medication dispensing system the clinic 
first determines which are the commonly used medications 
in their area. A list of about ten different psychotropic drugs 
will probably be a large enough inventory to cover most pa- 
tients. These would include: Thorazine, Stelazine, Mellaril, 



E. DOEHNE 17 



injectable Prolixin, Elavil, Trofanil, Librium, and Valium. The 
next step for the clinic is to negotiate with the local group 
of druggists in the town in which the clinic is located to 
determine if a druggist will for a minimal fee per prescription, 
keep a stock of clinic-supplied psychiatric medications in their 
drugstore and fill the prescriptions of medically indigent pa- 
tients. In most communities it is probably not feasible to use 
more than one drugstore. Ideally it would be close to the 
clinic. In this agreement the clinic agrees to (1 ) purchase and 
supply the necessary medications, (2) collect all fees for 
medications prior to the patient's coming to the drugstore, 
(3 ) at the end of the specified time, for example each month, 
pay the druggist a set fee, i.e. a dollar or a dollar and half for 
each prescription he fills. The druggist agrees to (1 ) keep in 
a separate stock the medications mentioned above, (2 ) notify 
the clinic when new medications should be ordered, (3) fill 
the prescriptions of the patients, (4) bill the clinic once a 
month for the services rendered. His records would include 
the prescription given him by the patient and a list of those 
filled during the month. This system has an advantage of (1 ) 
not making a lot of paper work for the druggist, (2 ) not having 
the clinic in the business of dispensing medications. 

When a patient has been certified medically indigent, he 
gives the prescription to the nurse in the clinic. From a price 
list obtained from the state hospital, she figures the cost of 
the medication on the prescription and charges the patient, 
giving him a receipt for the charge. The nurse then fills out 
a slip with the number and amount of medication on it and 
gives this to the patient. The patient then takes the doctor's 
prescription and the slip to the druggist. The druggist recog- 
nizes from the slip that this is a medically indigent clinic 
patient but handles the prescription just as he would any 
other, thus avoiding any patient embarrassment. In the clinic 
the nurse has made a record in a permanent card file of the 
patients type of medication and amount purchased including 
the date and fee paid. This card file provides a fairly simple 
review of patients on medication and a periodic review of this 
card file serves as a clue to which patients are taking their 
medications. 

After the initial purchase of drugs, this system has the 
advantage of paying for itself. That is, each month drug fees 
will pay for more medication for the next month. The patients 
are able to get their needed medication, paying a considerably 
smaller amount than they would in the drugstore. The system 
can serve patients treated by their family physician as well 
as the clinic. 



N.C. JOURNAL OF MENTAL HEALTH 



SUMMARY 

Goal: To provide "medically indigent" clinic patients with 
medications at a reasonable cost, dispensed by a pharmacist. 

Operations: 

State Hospital 

Provides bulk amounts of medication "at cost" to mental 
health clinic 

Welfare Department 

Evaluates patients for certification of medical indigency 

Clinic 

Determines which medications used in their area 
Works out agreement with local drugstore 
Buys medications from State Hospital 
Stocks medications in drugstore 
Signals medically indigent patients to drugstore 
Pays druggist fee per prescription basis 
Records and bills each patient for drug purchase according 
to State Hospital price list 

Drugstore 

Stocks clinic medications in separate area 
Fills medically indigent prescription 
Bills clinic one time a month for service 
Notifies clinic when stock replenishing needed 

Patient 

Obtains certification of medical indigency 
Returns to clinic when out of medication 
Pays clinic for medication 
Obtains medication at drugstore 



19 



PERCEPTIONS OF MENTAL ILLNESS 
AMONG LEADERS IN TWO RURAL 
NORTH CAROLINA COMMUNITIES 



W. Kenneth Bentz, Ph.D. 

J. Wilbert Edgerton, Ph.D. 

William G. Hollister, M.D., FAPHA 

Department of Psychiatry, School of Medicine 
University of North Carolina at Chapel Hill 



The Community Psychiatry section of the Department of 
Psychiatry at the University of North Carolina is currently 
engaged in a five year project designed to find new, additional 
ways to meet the mental health and mental illness needs in 
rural areas and to develop new patterns for the 1600 rural 
counties in the United States. Two rural North Carolina coun- 
ties are participating in the program aspects of the project 
while a rural county in Virginia which borders on the project 
counties is serving as a control county. 

In any community it is important to work in close coopera- 
tion with and the approval of the leadership structure includ- 
ing county commissioners, the health, education, welfare, and 
law enforcement leaders as well as the local medical and 
ministerial association in carrying out a mental health pro- 
gram. 

This is especially true for a rural community where the 
leaders are well known and are highly influential in shaping 
the attitudes and values of the community at large. Leaders 
by virtue of their positions, exert a tremendous influence on 
social norms, and should thus be considered as playing an 
important part in the process of attitude formation and change. 
The general public tends to follow social standards established 
and articulated by the community's leaders. Thus leaders, 
through their innovations and examples, can and do influence 
the attitudes of the general public toward mental illness as 
well as other social problems. In view of this it was felt that 
the program's ultimate success or failure will be largely de- 
pendent upon the climate of opinion in the community, thus 

The research reported in this paper was supported by Grant No. 
IVIH 02351 from the National Institute of Mental Health. 



20 N.C. JOURNAL OF MENTAL HEALTH 



it appeared desirable to study the perceptions of mental ill- 
ness held by the leaders in the project communities. The 
purpose of this paper is to report the results of this research. 



Method 

A total of 418 community leaders in the two predominantly 
rural counties participated in the study. One positional ap- 
proach which equates the holding of formal positions or of- 
ifices with leadership was the primary criterion for determining 
the leader sample. Nevertheless, a number of questionnaires 
were sent to persons designated as informal leaders by com- 
munity informants. Leaders from all the major areas of com- 
munity life are represented in the sample including: Politics 
(60 ), economics (38 ), education (51 ), religion (34), social- 
recreational areas (160 ), medicine (24 ), and other (51 ) which 
included persons such as law enforcement officials, rescue 
squad leaders, storekeepers, etc. 

The sample can be described as follows: It is a highly rural 
stable population consisting of 83 per cent whites and 17 
per cent Negroes. Fifty-seven per cent of the sample is male. 
The age composition is 20 through 69 years with all age 
groups represented. The leaders are highly stable in terms of 
spatial mobility: 70 per cent having lived in their respective 
communities more than 20 years, and better than half have 
not moved in the past ten years. Most of the respondents are 
married (86 per cent), and a smaller number are widowed, 
divorced, or single. For the most part, the respondents have 
been reared and have spent most of their lives on a rural 
farm or in a small town (88 per cent ). They are well educated, 
especially when compared with the general educational level 
of the community; 47 per cent are college graduates, and 
and another 38 per cent have at least completed high school. 
Reflecting this educational background, most of the leaders 
are professional people (66 per cent). Consistent too are the 
income levels of the leaders: 41 per cent have annual total 
family incomes of $10,000 or more. Only 16 per cent make 
less than $5,000 annually. In terms of an index of socio- 
economic status based on education, occupation, and income 
the leader group is strikingly different from the average citizen 
in these rural communities. 

The leaders were requested to read and answer a series of 
questions pertaining to four case abstracts which were de- 
signed to investigate the ability to recognize and/or a willing- 
ness to label the behavior of the person described in the 
abstract as mental illness. The abstracts were developed and 



W. BENTZ, J. EDGERTON AND W. HOLLISTER 21 



used by Shirley Star in a nationwide survey about mental ill- 
ness for the National Opinion Research Center in 1950. ' 

The case abstracts used in the present study are as follows: 

Simple Schizophrenic 

First of all, there is this young woman in her twenties . . . 
let's call her Betty Smith. She has never had a job, and she 
doesn't seem to want to go and look for one. She is a very 
quiet girl, she doesn't talk much to anyone— even her own 
family — and she acts like she is afraid of people, especially 
young men her own age. She won't go out with anyone and 
whenever someone comes to visit her family, she stays in her 
own room until they leave. She just stays by herself and day- 
dreams all the time and shows no interest in anything or 
anybody. 

Alcoholic 

Now about Bill Williams. He never seems to be able to hold 
a job very long because he drinks so much. Whenever he has 
money in his pocket he goes on a spree; he stays out till all 
hours drinking and never seems to care about what happens 
to his wife and children. Sometimes he feels very bad about 
the way he treats his family; he begs his wife to forgive him 
and promises to stop drinking, but he always goes off again. 

Depressed Neurotic 

Here's another kind of man; we call him George Brown. He 
has a good job and is doing pretty well at it. Most of the time 
he gets along all right with people, but he is always very 
touchy and he always loses his temper quickly, if things 
aren't going his way, or if people find fault with him. He 
worries a lot about little things, and he seems to be moody 
and unhappy all the time. Everything is going along all right 
for him, but he can't sleep nights, brooding about the past, 
and worrying about things that might go wrong. 

Acting-Out Child 

Now, the last person I'd like to describle is a twelve year 
old boy— Bobby Grey. He's bright enough and in good health, 
and he comes from a comfortable home. But his father and 
mother have found out that he's been telling lies for a long 
time now. He's been stealing things from stores, and talking 
money from his mother's purse, and he has been playing 



22 N.C. JOURNAL OF MENTAL HEALTH 



truant, staying away from school whenever he can. His parents 
are every upset about the way he acts but he pays no attention 
to them. 

After reading each case abstract the leader was to indicate 
if he thought anything was wrong with the person described, 
and also asked if he had ever known anyone who acted like 
this person. If he agreed that something was wrong, he was 
asked whether the person should or should not be regarded 
as mentally ill, and whether he thought the illness was serious 
or not. Finally, he was asked where or to whom he would 
refer the person for help. 

Results 

The data in Table I show that, with the exception of the 
simple schizophrenic, a majority of the leaders indicated they 
knew someone who acted like the persons described in the 
abstracts. The finding that almost nine of every ten leaders 
knew someone who was thought of as an alcoholic while only 
slightly more than one of three leaders were familiar with the 
shy, withdrawn woman is not surprising in view of the relatively 
high incidence of "alcoholism" in these rural communities. 
With regard to knowing persons described as a depressed 
neurotic and a young boy with behavior problems, better than 
one-half of the leaders were acquainted with a person who 
fit these descriptions. 

The fact that leaders felt the behavior of the persons de- 
scribed in the abstracts was not normal is well illustrated 
in their responses to the question "Is something wrong with 
this person?" An overwhelming number of the leaders answer- 
ed in the affirmative in the cases of the schizophrenic (89 
per cent), alcoholic (90 per cent), and the acting-out child 
(82 per cent). In the case of the middle-aged depression, 
three-fourths of the leaders indicated that they felt something 
was wrong. 

Although there is an extremely high degree of consensus 
among leaders that the aboved described behaviors are prob- 
lematic, not all of them agreed that the behavior is sympto- 
matic of mental illness. In the cases of the simple schizoph- 
renic and the alcoholic, about three-fourths of the leaders 
labeled them as mentally ill. The depressed neurotic and the 
acting-out child were described as mentally ill by slightly 
better than one-half of the rural community leaders. 

Of those leaders who identified the case abstracts as mental 
illness, six of ten felt that the alcoholic had a serious problem. 
This is about twice as many who thought the depressed middle- 



W. BENTZ, J. EDGERTON AND W. HOLLISTER 23 



aged neurotic to be seriously ill. An equal number of leaders, 
44 per cent, perceived the simple schizophrenic and the 
acting-out child to have an illness of a serious nature. 

The leaders are evenly split with regard to their attitudes 
about an eventual cure for both the alcoholic and the acting- 
out child. On the other hand, two of three leaders are optimis- 
tic about a cure for the schizophrenic and alcoholic. These 
results suggest that the attitudes of defeatism or pessimism 
about an eventual cure for mental illness are in the process 
of diminishing. 

The places or persons to which the mentally ill person would 
be referred for help are of particular interest, especially in 
view of findings in other studies. Unlike these studies which 
have suggested that the general public have strong negative 
feelings toward mental hospitals and psychiatrists, and toward 
the people who seek help from these resources, this study 
provides little or no evidence of negative attitudes toward 
these resources. Quite the contrary, as the data in Table III 
indicate, there appears to be an attitude of acceptance of 
medical and psychiatric resources by community leaders. In 
response to the open-ended question of where the respondent 
would send the person described in the case abstract for help, 
the resource mentioned most often was a hospital (26.5 per 
cent), followed closely by a psychiatrist (21.9 per cent). Al- 
together then, medically related resources were mentioned 
about 67 per cent of the time as the most preferred helping 
source. It seems apparent that these leaders perceive the 
persons described in the case studies as medically "sick" 
and they assign the responsibility for their care and treatment 
to psychiatrists, physicians, and medical institutions. 

One surprising result was the small number of leaders who 
said they would utilize the services of ministers to help these 
sick people. This finding is in stark contrast to that of Gurin, 
Veroff, and Feld who reported that 42 per cent of their respon- 
dents would turn to a minister for help with their problems.^ 

Summary 

This paper reports the results of a recent study of the per- 
ceptions of mental illness held by a group of leaders in two 
rural North Carolina communities. Four case abstracts which 
describe the behavior of a simple schizophrenic, and alcoholic, 
a depressed neurotic and a disturbed child were utilized. Al- 
most all of the leaders perceived that something was wrong 
with the persons described in the abstracts. With regard to 
the identification of mental illness, the simple schizophrenic 



24 



N.C. JOURNAL OF MENTAL HEALTH 



and alcoholic were most readily recognized. A little more than 
half indicated that the depressed neurotic and the disturbed 
child were psychiatrically ill. Of the leaders who identified 
the vignettes as mental illness, there was mixed reactions 
as to the seriousness of the problem. A majority of the leaders 
were quite optimistic about the possibility of a cure for the 
illness. The leaders seemed to be quite familiar with helping 
resources for mental illness. Psychiatrically and medically 
related resources were mentioned most frequently. 

TABLE I 

Distribution of Leaders' Positive Responses to Questions 

About the Case Abstracts, in Per Cent 

N= 418 



Knew Someone 
Felt Something Wrong 
Identified as Mental Illness 
Described as Serious 
Optimistic about a Cure 



Simple 
Schizo- 
phrenic 


Alcoholic 


Depressed 
Neurotic 


Acting 

Out 

Child 


37.1 


86.6 


57.2 


50.5 


88.8 


89.9 


75.3 


81.6 


75.6 


73.4 


57.9 


55.9 


44.7 


62.0 


30.1 


44.5 


65.8 


64.4 


50.0 


50.0 



TABLE II 

Help Resources to Which Leaders 
Would Refer the Person Described 
in the Case Abstract, In Per Cent 





Simple 






Acting- 






Schizo 




Depressed 


Out 




Help Resource 


phrenia 


Alcoholic 


Neurotic 


Child 


Total 


Mental/General Hospital 


28.1 


37.9 


19.6 


17.6 


26.5 


Psychiatrist 


28.7 


10.7 


28.3 


21.1 


21.9 


Physician 


26.0 


il.6 


27.9 


10.9 


19.0 


Minister 


6.6 


7.3 


14.1 


6.0 


8.3 


Family/Friends 


2.4 


0.6 


0.7 


8.1 


2.8 


Alcoholic Anonymous 





26.9 


— 


— 


7.3 


Reform School 





— 


— 


10.2 


2.4 


Counselor/Psychologist 


3.9 


2.4 


4.7 


23.2 


8.2 


Other* 


4.2 


2.6 


4.7 


2.9 


3.6 



Total Number of Responses** 331 



335 



276 



284 1226 



*Other includes social worker, nurse, teacher, self-help, lawyer, etc. 

*" Respondents could give as many help resources for each case abstract 

as they wished. 



W. BENTZ, J. EDGERTON AND W. HOLLISTER 25 



Footnotes 

^Star, Shirley A., "The National Opinion Research Center 
Study," Psychiatry, The Press, and The Public, American Psy- 
chiatric Association, Washington. 

^Gurin, G., Veroff, J., and Feld, S., Americans View Their 
Mental Health. New York: Basic Books, 1960. 



26 



THE HYPOTHETICAL COMMUNITY, 

A TEMPLATE FOR PLANNING MENTAL 

RETARDATION PROGRAMS 

Donald J. Stedman, Ph.D. 

Associate Professor of Psychology and Associate Director, 

the John F. Kennedy Center for Research on Education 

and Human Development, George Peabody College. 

Over the last several years many local, county, state and 
national level planners and program developers have found 
the "hypothetical community" (August, 1963 ) of value in esti- 
mating the incidence of mental retardation in their geographic 
and population areas. This version of the hypothetical com- 
munity was developed for the President's Panel on Mental 
Retardation appointed by President Kennedy in 1961. 

Using a very conservative estimate of 3% as the incidence 
of mental retardation, a table was developed that indicated 
the distribution of persons of all ages and all degrees of 
mental retardation that would be found in the average Ameri- 
can community with a population of 100,000. 

The services needed by these persons were estimated, 
based on the figures yielded in the table of incidence. 

Planners have found this extremely useful in presentations 
of need in certain geographic areas but have been increasingly 
frustrated by the considerable underestimate yielded by the 
conservative 3% incidence. 

Using the technical definition of mental retardation,* one 
now finds different incidence percentages useful in planning 
as a function of different geographic-population areas. 

Therefore, a revised version of the "hypothetical commu- 
nity" has been generated that is based on 1965 census figures. 
The new template yields four different tables based on esti- 
mated incidences of 2%, 3%, 5%, and 7%. 

The 2% incidence is roughly described as suburbia; the 3% 
incidence is still a useful, "across-the-board" figure as with 
the earlier version; the 5% incidence could be seen as a useful 



*Subnormal intellectual function from birth or early age accompanied 
by an impairment of learning, social and/or adaptive functions. 



D. STEDMAN 27 



rural figure; and the 7% incidence is a conservative estimate 
of psychometrically defined mental retardation in the high 
density inner city population areas. 

The four age groups selected (preschool, school-aged, young 
adults, and adults 25 and over) are based on practical group- 
ings of ages found important in developing programs for the 
mentally retarded. School is the major contingent factor. 

The categories of severity of mental retardation are mild, 
moderate and severe. The percentages for severity levels indi- 
cated on the table are based on an extrapolation from the 
normal distribution of intelligence, coupled with the IQ equi- 
valence of the labels, mild, moderate and severe mental retar- 
dation. 

The revised "hypothetical community" tables should provide 
a next step toward more precision in estimating the incidence 
of mental retardation, as it is currently defined, for use by 
planners, program developers, and other individuals seeking 
to develop services for the mentally retarded. 

Using one of these tables, for example Table 4, one can 
describe a few of the major services that would be needed 
in order to solve the program crisis generated by the mental 
retardation population estimated: 

Diagnostic and counseling services for all of the 7,000 
mentally retarded and their families. 

Welfare, social and educational services to enrich the 
learning opportunities of the 624 mildly retarded pre- 
school children, many of whom live in slums or in other- 
wise depressed circumstances. 

Public health nursing and homemaker services to assist 
in caring for the 99 moderately and 25 severely retarded 
infants and young children in this population. 

About 93 special education classes for the 1,683 mildly 
retarded school-aged children who, with specialized train- 
ing, could become self-sufficient adult citizens. 

About 27 special educational classes for the 268 moder- 
ate or trainable mentally retarded children who, with the 
appropriate training, could become productive workers 
in supervised or sheltered work settings. 

A day care, recreational center for the 66 severly re- 
tarded children of school age who would be unable to 
profit from formal school placement. 

Vocational counseling, job training and placement services 
for the 389 retarded young adults who can contribute 



28 N.C. JOURNAL OF MENTAL HEALTH 



to their own and the community's welfare if given an 
opportunity to work in a supervised environment. 

Specialized job training for the 3,145 mildly retarded 
adults over 25 who can take a productive place in our 
nation's economy. 

Activity centers for the 563 retarded adults who may 
never take their full places as workers in the community 
but who are no less important from the social and human- 
itarian point of view. 

Residential centers to meet the needs of those 138 re- 
tarded with problems requiring supervision, care and 
training so comprehensive as to require a 24-hour effort. 

All in all, 7,000 or more individuals (boys and girls, men 
and women) of all degrees of mental retardation are found 
in this high density group. It is extremely important that early 
identification programs, special education, counseling, voca- 
tional training and job placement, and guardianship programs 
be devised to meet the crises - health, educational, and social - 
that can be generated by the collision between the develop- 
mentally retarded and the increased complexity of the Ameri- 
can community. 



D. STEDMAN 



29 



Hypothetical Community 

(Revised 1969) 

Average incidence of mental retardation based on 1965 
census figures in four populations: 100,000 people. 





Est. 


Incidence - 


2% (Suburbia) 






1 


Pre-school 
Under age 6 


School-age 
Age 6-19 


Young Adults 
Age 20-24 


Adults 
Age 25 and over 


Total 
All Ages 


Mildly 

Moderate . . . 
Severe 


179 

28 

7 


480 
77 
19 


111 
18 

4 




899 
143 

35 


1,669 

266 

65 


TOTAL 


214 


576 


133 




1,077 


2,000 




Est 


. Incidence 


- 3% (Overall) 








II 


Pre-school 
Under age 6 


School-age 
Age 6-19 


Young Adults 
Age 20-24 


Age 


Adults 
25 and over 


Total 
All Ages 


Mildly 

Moderate . . . 
Severe 


267 
43 
10 


722 

115 

28 


167 

27 

6 




1,347 
215 

53 


2,503 

400 

97 


TOTAL 


320 


865 


200 




1,615 


3,000 




Est. Incidence 


- 5% (Rural) 








III 


Pre-school 
Under age 6 


School-age 
Age 6-19 


Young Adults 
Age 20-24 


Age 


Adults 
25 and over 


Total 
All Ages 


Mildly 

Moderate . . . 
Severe 


446 
71 
17 


1,202 

192 

47 


279 
44 
10 




2,246 

358 

88 


4,173 
665 
162 


TOTAL 


534 


1,441 


333 




2,692 


5,000 




Est. 


ncidence - 


7% (Inner City) 






IV 


Pre-school 
Under age 6 


School-age Young Adults 
Age 6-19 Age 20-24 


Adults 
Age 25 and over 


Total 
All Ages 


Mildly 

Moderate . . . 
Severe 


624 
99 
25 


1,683 

268 

66 


389 
62 
15 




3,145 
501 

123 


5,841 
930 
229 


TOTAL 


748 


2,017 


466 




3,769 


7,000 



Conversion Ratios 



IQ Distribution 


Category 


% 


Mildly.... 


. 83.43 


Moderate 


..13.30 


Severe . . 


.. 3.27 


TOTAL 


100.00 



1965 Census - Age Group/Percentage Population 



Category Under 6 6-19 


20-24 


25 and over TOTAL 


% 10.68 28.82 


6.66 


53.85 100.00 



30 

HISTORY OF THE DEPARTMENT OF PSYCHIATRY 
AT DUKE UNIVERSITY 

Parti 
Department Without Portfolio, 1930-1940 



James F. Giftord, Jr., S.T.M. Eric Pfeiffer, M.D. 

Foundation Fellow in History Assistant Professor of Psychiatry 
Duke University Duke University 

Introduction 

The number of medical school and hospital departments of 
psychiatry is still increasing radpidly,i as is the number of 
community mental health centers which closely resemble 
departments of psychiatry. For this reason it may be useful 
to review in some detail the history of one modern department 
of psychiatry: to examine the problems of growth and expan- 
sion, of funds and of space, of curriculum, of personnel, and 
of ideas, as well as of influences from outside the field of 
psychiatry. It is hoped that such a report may prove useful 
to others now engaged in the building of new departments 
of psychiatry and also constitute a contribution to the history 
of American psychiatry generally. 

The history of the Department of Psychiatry at Duke is of 
general significance because it illustrates processes and 
problems faced by developing departments elsewhere. Not 
only did other departments face similar internal struggles but 
they were subject to some of the same external influences 
which helped shape the department at Duke; in particular: 
the Depression, the Second World War, arid the current era 
of post-war prosperity. In fact, the history of psychiatry at 
Duke seems to fall naturally into three distinct phases parellel- 
ing these external, largely economic, determinants. 

From 1930 to 1940 neither funds nor space were available 
for the establishment of a separate department. Nevertheless 
the roots of a department were laid down and psychiatry was 
introduced into the curriculum. At the same time certain mem- 
bers of the medical school faculty worked with state officials 
and the Rockefeller Foundation to educate the public to the 
need for psychiatric education and services. At the end of 



J. GIFFORD AND E. PFEIFFER 31 



the decade the Department was formally created, in part as an 
outgrowth of Duke's involvement in mental health problems 
at the state level. The initial theoretical orientation at Duke 
was essentially Meyerian, an influence which would be further 
developed during the next phase, with the selection of a de- 
partment chairman from the Hopkins faculty. 

The second phase ran from 1940 to 1953. During this time 
the Department expanded its teaching of medical students, 
developed an inpatient service, opened outpatient facilities, 
equipped and staffed an EEG laboratory, mounted a residency 
program, and ventured into the area of child psychiatry. The 
demands of the Second World War, however, showed the 
forward movement of the Department, and many new begin- 
nings had to be made after the war. 

The third phase includes the years from 1953 to the present, 
a period of relative national prosperity. The Department, now 
on a par with other major departments in the Medical Center, 
not only enlarged its role in the education of medical students 
and the care of patients, but also grew to national prominence 
as a major research and training center. The first national 
Center for the Study of Aging was created at Duke under the 
leadership of the chairman of the Department. Many research 
publications have issued from its faculty, and no fewer than 
five former faculty members have gone on to build new de- 
partments of psychiatry in other medical centers. 

The present paper will deal primarily with the first of these 
three phases, covering the years from 1930 to 1940. 

Methodology 

The methods used in gathering the background material for 
this study were standard historical methods. They included 
the examination of official and personal correspondence, 
newspaper articles, medical school catalogs, minutes of uni- 
versity and medical school boards and committees, depart- 
mental and interdepartmental memoranda, and interviews with 
persons involved in the development and growth of the depart- 
ment. The work represents the collaborative efforts of a psy- 
chiatrist and a graduate student of history and was fostered 
by the concurrent development at Duke University of a Medical 
Historian Training Program*, developed jointly by the Medical 
School and the University Department of History, and sup- 
ported by the Josiah Macy, Jr. Foundation. 

*This program leads to the awarding of the M.D. and the Ph.D. in history 
after six or more years of integrated study in medicine and history. 



32 N.C. JOURNAL OF MENTAL HEALTH 

Department Without Portfolio 

Uncertain Beginnings 

Duke Hospital opened its doors to patients on July 21, 1930; 
the School of Medicine received its first students on October 1, 
1930. The gifts of James B. Duke had provided a four million 
dollar plant with what then seemed unlimited space.^'^* But 
the annual income which the school and the hospital received 
from Duke University was not sufficient to provide staff for all 
departments. In fact, if it had not been for an eleventh hour 
grant of $300,000 from the John D. Rockefeller-financed 
General Education Board, the preclinical years of the medical 
school could not have been offered at all in the beginning and 
the school would have opened by taking in students in their 
junior year after they had the first two years of medical school 
training elsewhere. As it was, the school admitted 30 students 
to its freshmen class and 18 students with advanced standing 
to the third year class. 

Psychiatry was among the disciplines for which no adequate 
provision could be made in the beginning. Efforts made by 
the Dean of the School of Medicine, Dr. Wilburt C. Davison, 
to secure funds from private foundations for the support of a 
psychiatry department in advance of the opening of the 
medical school, were unsuccessful. With their own resources 
decreased by the depression, these foundations were unwilling 
to assume responsibility for any part of the operating budget 
of the school or hospital, nor could capital be spared by the 
foundations to create endowments for such departments.^ In 
North Carolina personal income declined by one fourth be- 
tween 1929 and 1931.^ At the Duke Hospital during 1930 
three fifths of all care given was on a charity basis; by 1932 
this amount had risen to four fifths.^ Thus patient revenues 
could not provide an operating budget for additional depart- 
ments. 

The original curriculum of the Duke University School of 
Medicine had made some provision for the teaching of psy- 
chiatry. The curriculum was built on the quarter system. 
Normally a student would be enrolled for three quarters each 
year, but it was possible by attending school in the summer to 
complete four quarters per year and thus finish the entire 
curriculum in three years. Under this plan the 9th quarter, 
normally the third quarter of the junior year, was devoted 
primarily to "the specialities." In this quarter "approximately 
two weeks" were to be used to acquaint students with neurol- 
ogy, psychiatry, and urology.^ Without funds for a psychiatric 



J. GIFFORD AND E. PFEIFFER 33 



staff, however, even this minimal block of time in psychiatry 
could not be provided. Instead, during the first year of opera- 
tion instruction in neurology, psychiatry, and mental hygiene 
was provided for junior students by occasional visiting lec- 
turers and trips to state mental hospitals. Thus in May of 
1931 Dr. J. W. Beckman came from Washington University 
in St. Louis to give clinics and ward rounds in neurology and 
psychiatry. Once a week for one quarter, students also visited 
the state hospital in Raleigh where Dr. Albert Anderson pro- 
vided patients for case study. When these same students were 
seniors they were asked about the adequacy of their instruc- 
tion in psychiatry, and seven replied that they had been in- 
terested in the subject but none was confident that they had 
acquired sufficient knowledge of the principles of psycho- 
therapy to apply them to their own patients.^ The dean, stu- 
dents, and faculty alike were concerned with the adequacy of 
instruction in psychiatry and it was clear to everyone in the 
medical center that there was, to say the least, considerable 
room for improvement. 

Pressure for irnprovement also came from practicing mem- 
bers of the medical profession within the region. They saw 
the need for better diagnosis of patients with psychiatric prob- 
lems and for treatment which went beyond the provision of 
custodial care. The opening of the Duke School of Medicine 
had been heralded as the beginning of the end of the shortage 
of doctors in the Carolinas, and no speciality was in shorter 
supply than psychiatry. The state mental hospital in Raleigh 
was chronically short of staff, and its superintendent. Dr. 
Albert Anderson, who was cooperating with Duke by providing 
patients for study by Duke students, appeared before the 
University Trustees to plead for the establishment of a depart- 
ment of psychiatry.^ The Seaboard Medical Association, which 
was comprised of physicians from the eastern part of Virginia 
and North Carolina, petitioned the medical school to establish 
a chair in psychiatry and "a ward for the reception of mental 
cases for observation, diagnosis, and contemporary treat- 
ment. "i*' The most that Duke could do at that time, however, 
was to employ one of the two occasional visiting lecturers on 
a regular, two-day-a-week basis. This was Dr. Ernest M. Poate 
of Southern Pines, North Carolina, who was both a practicing 
psychiatrist and an attorney. Poate was extremely enthusiastic 
and hoped to be able to provide an "adequate psychiatric 
service" without the expense of "a psychopathic ward" in the 
hospital. He felt that adequate admission examinations would 
reveal "a considerable number of neuroses and psycho-neuro- 
ses in the wards of the Hospital "which could be used to 
instruct students as to the psychic conflicts and stresses 



34 N.C. JOURNAL OF MENTAL HEALTH 



which are present in every patient, though his disease may be 
primarily physicaL" He hoped that a psychiatric section in the 
outpatient clinic would be able to treat all but the most severe 
of mental disorders, and he expected no lack of patients, 
since there were few practitioners "willing to bother with 
mental cases of any sort." He also envisioned an association 
with the Durham City Schools which, he hoped, would provide 
both a community counselling service competent to distin- 
guish between "intelligence defects and psychopathies" while 
giving medical students opportunities to study developmental 
defects and "problem children." He felt that a similar connec- 
tion with courts might be established to yield additional and 
varied cases. None of these measures, he felt, would require 
substantial funds! Yet all would provide service to the public. 
By having clinical clerks on these varied services and by 
giving a basic lecture course Poate believed Duke could pro- 
vide sounder psychiatric instruction than most other medical 
schools, and without substantial financial outlay. '• As far as 
can be determined from the record, none of the community 
efforts were ever implemented, at least not during that decade. 
Clearly, Poate was a visionary, an early dreamer about com- 
munity psychiatry. 

Psychiatry Becomes a Division in the Department of Medicine 

Poate's appointment and the enthusiasm which his teaching 
generated among the students reinforced Dean Davison's con- 
viction that a full-time psychiatrist should be added to the 
staff. Dr. Frederick M. Hanes, the Professor of Medicine, who 
had a strong interest in neurology, supported Davison in his 
efforts. In September 1933 Dr. Raymond Crispell came to 
Durham. He was a native of Kinston, New York. He had in- 
terned at Bellevue, taken a psychiatric residency at the West- 
chester Division of the New York Hospital, and had had post- 
graduate training in neurology and psychiatry at the University 
of Utrecht and at John Hopkins, under Adolph Meyer. He of- 
fered his lecturing services free to Duke University, as an 
experiment to see if he could teach psychiatry in a medical 
school. In October 1933, he was invited to become Acting 
Assistant Professor of Psychiatry, initially without salary but 
with the hope that after June 1934 he could be paid $4,000 
annually.'- At the time of his appointment Neuropsychiatry 
was created as a separate Division in the Department of 
Medicine, achieving status as a permanent division of the 
department when funds became available in March of 1934, 
some three months earlier than had been anticipated. 

Crispell concentrated his attention more on the medical 
curriculum and on psychiatric services within the medical 



J. GIFFORD AND E. PFEIFFER 35 



center and less on service to and through public agencies than 
had Poate. Third year students were given an introductory 
series of lectures and clinics in which the close relationships 
of psychiatry to neurology and internal medicine were em- 
phasized. Topics covered in this course, according to the 
catalog, included theories of personality development, the 
principal schools of psychopathology, normal and abnormal 
"mental mechanisms," intelligence and intelligence testing, 
mental deficiency, mental hygiene, and methods of psychiatric 
examination and treatment. 

In the senior year a "more clinical and practical course" 
was given (one lecture per week ) in which the major psychoses 
were examined; clinical demonstrations provided experience 
"in handling such psychiatric problems as occur on wards 
and in the public dispensary of the hospital."''^ More severe 
cases were studied during clinics at state institutions (four 
visits per year), and elective work at these institutions was 
offered to students with special interest in psychiatry. Begin- 
ning in October 1934 a lecture-clinic (eleven sessions of two 
hours each ) was added for second year students.'^ Crispell 
described this as "a course in Psychobiology and Psychopath- 
ology such as in being given in all the big medical schools."'"' 
It was to serve "as a bridge between academic and clinical 
psychological work and as an introduction to Neuropsychiatry." 
In addition, Crispell required his students to apply their psy- 
chiatric training "for purposes of better self-understanding" 
by asking them to write "on their own selves a psychiatric or 
personality make-up examination.""' In so doing he followed 
his teacher, Adolph Meyer, who had initiated the practice.'' 

The teaching program in psychiatry, as outlined above, was 
to remain essentially unchanged for the remainder of the 
decade. It was intended "to give the student a worthy con- 
ception of the individual as a whole, the psychobiological unit, 
that may be applied in practice. "'*5 In other words, teaching 
in psychiatry under Crispell was based primarily on Meyerian 
concepts and had a practical, common-sense quality. Crispell 
was also concerned that with the rapid advances in the basic 
sciences, medicine was becoming increasingly mechanistic 
and was in danger of turning out "technicians instead of phy- 
sicians." He felt psychiatry could make a useful contribution 
to medical education by keeping students focused on the 
whole personality rather than on diseased organs or organ 
systems.'^ 

Limitations of the program, however, were obvious. First 
year students received no training in psychiatry. In the second 
year the clinical material available for demonstrating symp- 



36 N.C. JOURNAL OF MENTAL HEALTH 



toms and methods of examination was inadequate. And, four 
sessions per year at one of the state hospitals were insufficient 
for acquainting junior and senior students with the major psy- 
choses and for integrating knowledge about them with the 
study of general medicine. No psychiatric ward rounds could 
be held at Duke Hospital because there was no psychiatric 
ward, nor could the students learn to work as team members 
with psychiatrists, psychologists and psychiatric social work- 
ers. Most serious perhaps, was the fact the students developed 
no ongoing personal experience under supervision in dealing 
with psychiatric patients. The 70 hours of required work in 
psychiatry fell well below the average of U.S. medical schools. 
Even in the South only 7 of 21 four-year schools had fewer 
required hours than did Duke.i^-^" 



Concurrent Developments at the State Level 

Crispell knew from the start that his position involved far 
more than teaching. Psychiatrists were scarce m North Caro- 
lina. By the end of 1934 the state had only 28 physicians work- 
ing in psychiatry, and 17 of these were on the staffs of the 
three state hospitals (Raleigh, Goldsboro, and Morganton ). 
Seven others were employed in the state's four private psy- 
chiatric institutions (Appalachian Hall in Asheville, Broadoaks 
Sanitarium in Morganton, Highland Hospital in Asheville, and 
Pinebluff Sanitarium in Pinebluff ). Only three were in private 
practice. -1 Crispell was the only one engaged in teaching. Even 
he could not escape a staggering patient load of some 600 
to 660 per year,i'^ many of whom he saw on a continuing basis. 
Lack of a proper referral system complicated his work; almost 
half of his patients were persons with physical (mostly neu- 
rological ) rather than psychiatric problems.-- At the same time 
many patients sent to the hospital for supposedly physical 
problems were suffering primarily from psychiatric distur- 
bances. Even such psychiatric patients as might have re- 
covered in a few weeks had to be turned away because Duke 
Hospital, occupied to capacity by 1934, had no space for 
treating them. At the state hospitals, which were short of both 
space and staff, little more than custodial care could be 
provided. The State Hospital at Raleigh had five doctors for 
over 2,000 patients and one observer reported that some 
wards were so full "that a bicycle could be driven across the 
beds without upsetting."^'^ 

In 1934 Dean Davison, Dr. Hanes, and Dr. Crispell drafted 
a resolution for presentation to the 1935 North Carolina Gen- 
eral Assembly requesting that a survey of the State's mental 



J. GIFFORD AND E. PFEIFFER 37 



health needs be made, and at the same time petitioned the 
Rockefeller Foundation for funds to support the study. The 
General Assembly adopted the resolution on March 20, 1935,24 
and authorized the Governor to appoint a Commission for the 
Study of the Care of the Insane and Mental Defectives to find 
ways and means of improving the care offered in the state 
hospitals, to increase discharge rates, and to eliminate waiting 
lists at the hospitals. This commission, chaired by Hanes, 
directed by Dr. Lloyd Thompson of Yale University, and sup- 
ported by funds from the Rockefeller Foundation, submitted 
A Study of Mental Health in North Carolina to Governor J. C. B. 
Ehringhaus in December, 1936. This report was a scathing 
indictment of North Carolina's care of the mentally ill. Per 
capita expenditure for patients was low and the patient-doctor 
ratio extremely high. Thus at one hospital patients were allot- 
ted 17e per day for food and $1.10 per day for their total 
care. And while the American Psychiatric Association recom- 
mended one physician for each 150 hospital patients and 
one nurse for every eight, in North Carolina the patient-to- 
doctor ratio was 528 to 1, the patient-to-nurse 17 to 1. The 
Commission concluded that under such conditions it was 
"humanly impossible for the patients to obtain the proper 
care." Because of the Depression, the General Assembly had 
made cuts in the per capita allowance for patients and had 
cut off all funds for improvements and expansion. This re- 
presented a saving on paper, but the result was to make the 
yearly appropriation for maintenance of the hospitals "in large 
part a net loss to the taxpayers," since no effort could be made 
to restore patients to community life. They remained in custo- 
dial care, constituting a drain on the budget. Expenditures 
aimed at returning patients to active and productive lives 
would be required.-'^ 

Hanes, Davison, and Crispell all worked to secure enact- 
ment of the Commission's recommendations. As president of 
the newly-formed North Carolina Neuropsychiatric Association, 
Crispell worked to find ways and means of implementing 
the recommendations by soliciting suggestions from the 
State's psychiatrists. North Carolina was not willing, however, 
to support new programs on behalf of the mentally ill, and 
the Commission's report became only a substitute for action.^e 
Two things, however, had been accomplished. The needs of 
the State in the field of mental health had been set down 
as a basis for future action, and the Rockefeller Foundation 
had invested funds toward the goal of improving mental health 
in North Carolina. 

Among the problems which the Governor's Commission 
considered was that of improving "the standards of psychiatric 



38 N.C. JOURNAL OF MENTAL HEALTH 



efficiency of the entire medical profession of North Carolina." 
Because Duke had the only four-year medical course in the 
State, the Commission recommended that Duke establish a 
department of psychiatry, ranking equally with other depart- 
ments, to provide undergraduate and post-graduate training 
in psychiatry on a level equal to that in the best medical 
schools in the country, with a psychiatric hospital of at least 
50 beds adjacent to the main hospital and a completely staffed 
outpatient clinic. Such a training center would provide spe- 
cialists for private practice, clinic work, and hospital positions 
in the state. -^ Before Duke could consider staffing such a 
facility, however, it would have to solve problems of funds 
and of space. 

Movement Towards Department Status 

By April of 1938 it was clear that North Carolina would do 
nothing to implement the recommendations of the Governor's 
Commission. Hoping to capitalize on the Rockefeller Founda- 
tion interest in improving mental health care in North Carolina, 
Davison approached Dr. Alan Gregg, the Foundation's Director 
for Medical Sciences, for funds for a full department of psy- 
chiatry at Duke. Through such a department some of the 
objectives of the Foundation in underwriting the work of the 
Governor's Commission might be realized. Davison pledged 
that Duke would build and equip a psychiatric ward and would 
appropriate $5,000 annually to the department of psychiatry 
if the Rockefeller Foundation would grant $25,000 annually 
for seven years. This new department, Davison suggested, 
would provide badly needed facilities for psychiatric diagnosis, 
facilities for proper referral of patients to hospitals, and facili- 
ties for rehabilitation of patients, which would help relieve 
the custodial care problem of the state hospitals. In addition 
it might help educate North Carolinians in mental health af- 
fairs and provide a statewide diagnostic service by holding 
monthly clinics in major cities throughout North Carolina. 

The Foundation was interested. Within a month of the ori- 
ginal proposal Hanes reported that "if and when we can come 
to them with the physical space completed or assured," the 
Foundation would cooperate with Duke to secure an adequate 
operating budget.-^ 

At almost the same time space came unexpectedly from 
another source. Dr. Robert S. Carroll, Medical Director and 
owner of Highland Hospital, a private mental hospital in Ashe- 
ville. North Carolina, proposed to the Duke University Trustees 
that he donate his entire hospital, complete with equipment 



J. GIFFORD AND E. PFEIFFER 39 



and 450 acres of land, to Duke University in fee simple. The 
hospital was to be utilized by the Chair of Psychiatry of the 
University's medical department, although Carroll was to re- 
main as medical director for five years. --^ Davison and Hanes 
both appeared before the Trustees to urge acceptance of the 
proposal, and on February 2, 1939, the Board advised Carroll 
that they favored acceptance of the gift, subject to a comple- 
tion of an audit and title search.''*' 

By April 1939 Duke University and the Duke Endowment 
committed funds for the addition of a new wing to the hospital 
to provide increased facilities for private and semi-private 
patients. As a part of the reallocation of space accompanying 
this construction, a part of the third floor of the hospital was 
committed to use as a psychiatric ward. Once this commitment 
was made, Gregg pledged himself to placing the Duke proposal 
"at the top of the list" for grants to be awarded in 1940.''i 
In cooperation with Gregg, Davison and Hanes began to search 
for a professor to head the new department of psychiatry. Dr. 
Adolph Meyer of Johns Hopkins, Dr. E. G. Gildea, then at 
Yale, Dr. Stanley Cobb of Harvard, and Dr. R. A. Lambert of 
the Rockefeller Foundation, among others, were asked to sug- 
gest and evaluate candidates for the post."'- From a list of 
fifteen men Dr. Richard S. Lyman of the Johns Hopkins Medi- 
cal School was chosen-^'' and approved by the Executive Com- 
mittee of the Duke Trustees in June, 1939, on condition that 
the Rockefeller Foundation approve the grant proposal.^-* The 
Rockefeller Foundation, anxious to implement at least some of 
the recommendations of the Governor's Commission, approved 
the Duke plans in January, 1940.''5 when approval''*^ of the 
grant was announced, Lyman's appointment was made official. 
The dedication of the Department of Neuropsychiatry in Nov- 
ember, 1940, brought the first decade and first phase in the 
history of the Duke University Medical School to a close. The 
school was now "well-rounded and well-balanced, containing 
under one roof the laboratories needed for scientific investiga- 
tion and the wards for the care of patients" of all types.'^^ 

Summary 

Between 1930 and 1940 psychiatry at Duke grew from a 
discipline, the teaching of which depended on occasional 
guest lecturers, into a separate division within the Department 
of Medicine, and finally into an independent Department. 
Originally students were taught psychiatry only in the junior 
year; later the teaching program was expanded to include 
teaching in the sophomore, junior, and senior year. For most 
of this decade the work in psychiatry rested on the shoulders 



40 N.C. JOURNAL OF MENTAL HEALTH 



of one man, although many on the faculty were concerned 
about the subject. Initially psychiatry was taught by lecture 
material alone; later demonstrations of psychopathology in 
medical, surgical, pediatric, and obstetrical patients, as well 
as in psychiatric patients, were included. Towards the end of 
the decade solid progress had been made towards the develop- 
ment of a psychiatric ward and a psychiatric outpatient clinic 
at Duke Hospital. The initial theoretical orientation in psy- 
chiatry at Duke was essentially Meyerian, an influence which 
would be further developed with the choice of a department 
chairman from the Johns Hopkins faculty. 

Editor's Note: The second and third parts of this paper will appear in 
future issues of the Journal. 



REFERENCES 

^Medical Education in the United States. J.A.M.A. 206: 
1987-2112, 1968. 

2Earl W. Porter, Trinity and Duke, 1892-1924, Durham, N.C: 
Duke University Press, 1964. 

^Indenture of James B. Duke Establishing the Duke Endow- 
ment, with Provisions of the Will and a Trust of Mr. Duke 
Supplementing the same (n.p., n.d. ) 1-17. Hereinafter cited 
as "Indenture." 

^Letters, W. C. Davison to E. L. Bishop, March 26, 1930; 
W. C. Davison to S. Paton, May 9, 1930; W. C. Davison to 
M. Churchill, May 7, 1930; M. Churchill to W. C. Davison, 
November 24, 1930; November 29, 1930; May 5, 1931, Davi- 
son Papers. 

^Hugh T. Lefler, History of North Carolina, New York: Lewis 
Historical Publishing Co., 1956, II, 772. 

^The Duke Endowment Hospital Section, Application for 
Assistance, Duke University Hospital, 1930, 3; 1931, 3. 

^Bulletin of Duke University: The School of Medicine, Vol. 
II, No. 1, January 1930, 29. 

^Letters, W. C. Davison to F. Ebaugh, July 9, 1931; F. 
Ebaugh to W. C. Davison, August 13, 1932, Davison Papers. 

^Minutes of the Board of Trustees of Trinity College and 
Duke University, with Minutes of the Executive Committee, 
June 6, 1932. Hereinafter cited as "Duke University Minutes." 

i^Letter, Seaboard Medical Association to W. C. Davison, 
December 5, 1931, Davison Papers. 



J. GIFFORD AND E. PFEIFFER 41 



iiLetter, E. M. Poate to H. L. Amoss, June 11, 1932, Davison 
Papers. 

i^Minutes of the Executive Committee of the Duke Univer- 
sity School of Medicine and Hospital, January 10, 1934, Jan- 
uary 31, 1934. 

I'^Bulletin of Duke University: The School of Medicine, VI, 

No. 1, January, 1934, 35-36. 

i^A Study of Mental Health in North Carolina, Report to the 
North Carolina Legislature o^ the Governor's Commission, ap- 
pointed to study the care of the insane and mental defectives. 
Ann Arbor, IVlichigan, 1937, 313-317. Hereinafter cited as 
"Governor's Commission." 

i5Raymond S. Crispell, Report on the First Year of a Full- 
Time Division of Neuropsychiatry, Southern Medicine and 
Surgery, 97, 1-4, 1935. 

i*^Bulletin of Duke University: The School of Medicine, VII, 
No. 1, January, 1935, 37-38. 

i^Raymond S. Crispell, The Place of Neuropsychiatry in 
Modern Education and Practice. Southern Medicine and Sur- 
gery 100:579-584, 1938. 

isRaymond S. Crispell, Extramural and Neuropsychiatry in 
a General Hospital, Southern Medicine and Surgery, 102: 
105-110, 1940. 

i^F. G. Ebaugh and R. A. Noble, Psychiatry in Medical Edu- 
cation, New York: National Committee for Mental Hygiene, 
1933. 

20Governor's Commission, 315. 

21R. L. Garrard et al, A History of the North Carolina Neu- 
ropsychiatric Association and North Carolina District Branch 
of the American Psychiatric Association. North Carolina J. 
Ment. Health 3: 16-17, 1968. 

22|nterview with Raymond S. Crispell, by Clark Cahow, Octo- 
ber 16, 1966. 

23Minutes of the Meetings of the Governor's Commission, 
December 10, 1935. Files, State Department of Mental Health, 
Raleigh, North Carolina. 

24Garrard, 17. 

25Governor's Commission, xii-xvi, 167-82, 226, 357, 368. 

26Clark R. Cahow, The History of the North Carolina Mental 



42 N.C. JOURNAL OF MENTAL HEALTH 



Hospitals, 1848-1960. Unpublished Ph.D. dissertation, Depart- 
ment of History, Duke University, 70-72. 

27Governor's Commission, vi. 

28Letter W. C. Davison to A. Gregg, April 22, 1938; Memo- 
randum, F. M. Hanes to W. C. Davison, May 16, 1938, Davison 
Papers. 

29Memorandum written on the personal stationery of Dr. 
Robert S. Carroll and dated April 7, 1939, Davison papers. 

=^oDuke University Minutes, December 10, 1938, February 
1, 1939, March 1, 1939. 

^^\N. C. Davison, The First Twenty Years, Durham, N. C: 
Duke University Press, 1952, 8. 

=52Letters, W. C. Davison to Adolph Meyer, July 27, 1939; 
Edwin F. Gildea to Davison, June 20, 1939; Stanley Cobb to 
W. C. Davison, February 7, 1939; Robert A. Lambert to W. C. 
Davison, January 23, 1939, Davison Papers. 

=53Memorandum, F. M. Hanes to the Executive Committee 
of the Duke University Medical School and Hospital, May 30, 
1939, Davison Papers. 

34Duke University Minutes, June 28, 1939. 

s^The Rockefeller Foundation Annual Report for 1940, New 

York, 1940, 144-45. 

36Letter, N. S. Thompson to W. P. Few, January 23, 1940, 
Flowers Papers. 

3^F. M. Hanes, Dedication of the Department of Neuropsy- 
chiatry, Duke University School of Medicine, November 29, 
1940; typescript contained among Davison Papers. 

The Davison, Few, and Flowers Papers are housed in the 
Manuscript Department, Perkins Library, Duke University. 



43 



ABSTRACTS 

Dental Pathology In A Psychiatric 
Population 



Ian Wilson, M.B., D.P.M. Lacoe Alltop, B.S., B.A. 

Research Psychiatrist Biostatistician 

N.C. Department of Mental Health 



Sam Simmons, B.S. 

Dental Student 
University of North Carolina at Chapel Hill 



The dental records of a sample of 1,966 patients at 
Dorothea Dix Hospital were reviewed to determine the inci- 
dence of dental caries and missing teeth in this population. 
The data was analyzed with the population broken down by 
sex, race, age and psychiatric diagnosis. When matched by 
sex, race and age with the general population of North Caro- 
lina, the psychiatric population showed a highly significant 
increased incidence of both dental caries and missing teeth. 
Within the study population, age was the most significant 
factor in determining the incidence of dental pathology. This 
was understandable and has been well defined as an impor- 
tant variable in other populations. 

Examination of the raw data showed an apparent association 
between diagnosis and incidence of pathology. Analysis of 
variance showed this association to be produced spuriously 
by an age-diagnosis interaction with age being the important 
determinant of the frequency of both dental pathology and 
psychiatric diagnosis, e.g. the diagnosis of Chronic Brain 
Syndrome was confined by and large to the older age groups 
whereas Personality Disorder diagnoses were generally limited 
to younger subjects. 

Rationale are provided for undertaking the study and the 
discussion provides a number of theoretical considerations to 
explain the extremely high incidence of dental pathology in 
the mental hospital subjects. 



44 N.C. JOURNAL OF MENTAL HEALTH 

Ketimipramine (Dignil) versus Imipramine 
Hydrochloride (Tofranil) in the Treat- 
ment of Depression 



Ian C. Wilson, M.B., D.P.M.; S. J. Cefalu, M.D.; A. M. Rabon, M.D.; 
W. J. Buffaloe, M.D.; L B. Alltop, B.S., BA 

Division of Research 
N. C. Department of IVlental Health 

T. K. McClane, M.D. 

Department of Psychiatry 
University of North Carolina at Chapel Hill 

Fifty consecutive, male and female, primary depressions 
aged less than 60 yrs. were randomly assigned to receive 
either ketimipramine or imipramine hydrochloride in dosages 
of 50 mg t.i.d. A double blind procedure was used. Behavioral 
ratings were performed three times weekly on an observer 
rating scale, the Hamilton Scale, and on a subjective rating 
scale, the Self-rating Depressive scale. Side-effects were re- 
corded thrice weekly and appropriate laboratory tests were 
performed regularly. 

The results showed both drugs to be highly efficacious 
anti-depressant medications with significant improvement 
(analysis of variance) occurring early in treatment followed 
by continuous steady improvement throughout the study 
period of four weeks. Statistical comparison of the results 
between drugs at each rating session (t-tests ) showed no 
significant differences on scores on: the total Hamilton scale; 
Self-rating Depressive scale; or the Hamilton sub-scales. Dur- 
ing the study period no behavioral or physiological complica- 
tions occurred of sufficient intensity to require discontinuation 
of either drug. 

This study showed ketimipramine to be an efficacious anti- 
depressant comparing favorably with imipramine hydrochlo- 
ride as regards therapeutic efficacy and incidence of side- 
effects. 



ANNOUNCEMENT 45 



ANNOUNCEMENT 

Master's Degree Training Programs in Biostatistics 
With Application to Mental Health 

The Biostatistics Department of the University of North Caro- 
lina School of Public Health is now accepting applications 
for September 1971 admission to Master's degree training 
programs in mental health statistics. These programs train 
biostatisticians at the Master's degree level and prepare them 
to apply the statistical training to fields such as mental health, 
community psychiatry, psychiatric disorders, mental retarda- 
tion, and psychiatric research. 

There are three Master's degrees available: (l)M.P.H. (Master 
of Public Health ), (2)M.S.P.H. (Master of Science in Public 
Health), and (3) M.S. (Masterof Science in Biostatistics ). The 
M.P.H. is an applied statistics degree and requires no back- 
ground in calculus. The M.S.P.H. and M.S. degrees require 
calculus background and include work in applied and theoreti- 
cal statistics. Other components of the training are epidemio- 
logy, public health, and mental health statistics. 

NIMH fellowships, plus dependency allowances where appli- 
cable, are available to qualified applicants. For more informa- 
tion write to: 

Donna R. Brogan, Ph.D. 
University of North Carolina 
School of Public Health 
Department of Biostatistics 
Chapel Hill, North Carolina 27514 



I 



NOTICE TO CONTRIBUTORS 

IV-'U scripts and editorial comments should be addressed to 
11 Editor-in-Chief, N.C. Department of Mentai *iealth, P. 0. 
Box 26327, Raleigh, N. C. 27611. 

Contributors need not be psychiatrists, neurologists or M.D.'s 
but should be involved in some aspects of program, whether 
clinical, educational, or research, pertinent to mental health 
or mental illness. 

Manuscripts offered for publication should be submitted in 
triplicate, with the original typed on bond paper, and doubled 
spaced with 70 characters per line. Footnotes, bibliographical 
references, quotations, etc., should also be double spaced 
and the use of footnotes minimized. 

References to books and journals should be numbered con- 
secutively in a bibliography at the end in the order in which 
they appear in the manuscript. References should be limited 
to those used by the author in the preparation of the article 
and kept to a minimum. 

The author's privilege of correcting galley proofs may apply 
only to printer's errors. 



Tabular material, drawings and charts should be submitted 
on separate sheets, clearly marked as to where they are to 
appear in the text. 



NORTH CAROLINA JOURNAL OF 
MENTAL HEALTH 

Published by 
The State Department of Mental Health 



EDITOR-IN-CHIEF 
Eugene A. Hargrove, M.D. 

ASSOCIATE EDITOR 
Nicholas E. Stratas, M.D. 

SENIOR EDITORIAL CONSULTANT 
Bernard Glueck, M.D. 



CONTRIBUTING EDITORS 
Granville Tolley, M.D. Sam 0. Cornwell, M.D., Ph. D. 

Gilbert Gottlieb, Ph.D. Harvey L. Smith, Ph.D. 

Philip G. Nelson, M.D. Norbert L Kelly, Ph.D. 



EDITORIAL ADVISORY BOARD 



George Ham, M.D. 
C. Wilson Anderson, Ph.D. 
John A. Fowler, M.D. 
John A. Ewing, M.D. 
Richard C. Proctor, M.D. 
Richard A. Goodling, Ph.D. 



Halbert B. Robinson, Ph.D. 
Ewald W. Busse, M.D. 
Mark A. Griffin, M.D. 
Martha C. Davis, M.S. 
N. P. Zarzar, M.D. 
Jacob Koomen, Jr., M.D. 



Produced by 

Division of Information and Public Relations 

Benjamin G. Runkle, Director 

Jacqueline M. Ransdell 

Lillian W. Pike 

Sally R. Cameron 



NORTH CAROLINA JOURNAL OF 
MENTAL HEALTH 



Volume4 Number4 

1970 
CONTENTS 
ARTICLES 



The Argument 

Gilbert Gottlieb 3 

Re-Ed As a Temporary System 

Anne K. Parrish 8 

Interagency Collaboration in Services 
to People 

George H. Adams and Harold A. Benson 13 

Epilepsy: Review of Clinical Findings, 
Prognosis and Treatment 

Herman B. Shubert 18 

A Psychiatric Social Worker in a 
Community Hospital 

George M. Johnson 35 

Difference in Population Served by Private and 
Public Mental Health Services in a Rural 
Community 

Philip G. Nelson, Lacoe B. Alltop, and 

Dorothy Lemley 41 

Use of the Marathon in Sensitivity Training 
of a Ministers Group 

R. W. Whitener 61 

News Note 67 



NORTH CAROLINA JOURNAL OF MENTAL HEALTH 

is published quarterly, Spring, Summer, Fall and Winter. 

It is a scientific journal directed to the professional disciplines en- 
gaged in care, treatment, and rehabilitation of mentally ill and retarded 
patients as well as to those engaged in professional research and 
preventive work in the field. 

This journal is intended to be inclusive rather than exclusive and is 
not meant to be regarded as simply a house organ of the North Carolina 
State Department of Mental Health. 

It is hoped that the journal will reflect the broad-based philosophy of 
psychiatry current and will draw on areas reflecting the total spectrum 
of psychiatric and neurologic thought, program and research. 

Subscription may be obtained by writing the Editorial Offices, North 
Carolina Department of Mental Health, P. 0. Box 26327, Raleigh, North 
Carolina 27611. 

(Notice to contributors — see inner back cover) 



THE ARGUMENT 



Gilbert Gottlieb, Ph.D. 

Research Division 
C. Department of iVlental Health 



The big, airy room had no ceiling. It was nonetheless filled 
with smoke from cigars, pipes, and cigarettes. Seated around 
the room, in overstuffed chairs, four men and a woman were 
in the midst of a discussion. The intense facial expressions of 
the participants and the occasional sharpness of vocal tone, 
seemed to indicate that the discussion had been underway 
for some time and it was of extreme interest and importance 
to each of the participants. 

Someone said in outraged tone: "It is ridiculous!" 

The speaker, an old white-bearded gentleman with heavy 
black-framed glasses, was wearing a slightly baggy tweed suit 
with vest. His starched white collar glistened in spite of the 
dim illumination of the room. He spoke English with a rather 
heavy German accent. 

"That's nonetheless what he is doing, or, at least, what he 
purports to do." The unaccented answer came from a slightly- 
built younger man who was wearing rimless glasses. He wore 
a closely-clipped, dark mustache and his clothing was of 
American vintage. He was the youngest of the group. 

The woman spoke slightly accented tones: "Yes, I remember 
my own astonishment upon first hearing of it— I have met him 
— he is a sincere person. We should remember he has not 
had medical training." The woman wore a business suit and 
presented herself with a certain frankness and openness. She 
was obviously at home with the men. 

The thick-set man spoke, with his pincez-nez balanced 
precariously on the bridge of his nose: "How does he point 
out obvious 'compensations'?" H is speech was heavily-accented 
and his mustache somewhat unkempt. 

"And the birth trauma?" wondered the fourth man, also a 
European according to his dress and speech. 

White-beard persisted, "It is ridiculous to assume that the 
analysis will ever come to an end — it amounts to nothing more 
than continual free-association. No building, no interpreting — 



N. C. JOURNAL OF MENTAL HEALTH 



he will soon grow weary or be tarred-and-feathered." He turned 
to the younger man as he spoke the last part of his sentence. 
"You still do that in America, don't you?" he said with obvious 
amusement. 

The younger man smiled slightly, "Yes, and we also learn 
to swim perfectly on land without ever going in the water, 
while I have heard that, formerly, Europeans used to throw 
themselves into the deepest regions of ocean without any of 
the basic preliminaries usually performed with safety closer 
to shore." 

"Now, now," chided the woman, "defense mechanisms or 
security operations will get us nowhere." As she said 'defense 
mechanisms' she looked at the older man and as she used the 
term 'security operations' she glanced at the younger man. 

They all laughed and exchanged mutually knowing nods. 

The younger man continued, "He attempts to become part 
of the person — an alter-ego, as he puts it." 

"Why does he not become an alter-id or an alter-superego?" 
queried white-beard, obviously pleased with his remark. 

The woman said, "He emphasizes the present life situation." 

"And cares nothing of childhood?" said the three older 
men, almost in unison. Their tone was one of astonishment. 

"Only as it is represented in the present, according to the 
patient's own remarks," shrugged the younger man. He in- 
haled deeply from his cigarette and exhaled, "His stress 
appears to me to be in the interpersonal sphere, insofar as 
he stresses anything besides the relevance of the client's 
feelings." He paused and added in an almost inaudible whis- 
per, "His growth principle reflects the modern trend ... in 
America, at least." 

"What is this 'growth principle' that you are so shy about 
it?" asked the thick-set one taking his pincez-nez in hand. 
"Before you answer I would like to say that I believe he is on 
the right track, as you call it, emphasizing the individual and 
the ego over the id." As he slurred the word 'id' he smirked 
at white-beard. 

"The basic tendency of the organism is forward," began the 
youngest of the men, "it . . ." 

"The ultimate driving force," interrupted the woman, "is 
the person's unrelenting efforts to come to grips with himself, 
a wish to grow and to leave nothing untouched that prevents 
growth." 



G. GOTTLIEB 



"It is this principle, I believe," continued the younger man, 
"that explains why people come to us in the first place and it 
explains also why they leave us . . . whether their leave-taking 
is to our happiness or dismay." 

The woman continued, "The achievement of individuation, 
relative autonomy, self-direction or what you might call self- 
actualization . . . this is what lies behind it all. It is quite an 
event to watch this happen toward the end of a successful . . ." 

"How literary!" commented white-beard with a slight smile. 

The thick-set one was seemingly preoccupied with an 
examination of his pincez-nez. 

"This appears to be a direct reversal of my fundamental 
tenet," said the other man morosely. 

After a long pause, during which each of the three older 
men fussed with their smoking equipment, white-beard said 
cautiously: "And the one in Switzerland . . . what does he say 
to this?" 

The woman and the younger man exchanged glances. She 
answered, quite gently, "It resembles something like that 
which he has been maintaining for some time now." 

"Though its a little mixed-up in his theology," appended 
the younger man. 

Everyone was looking at white-beard now. 

The old man took his black-framed glasses in his right 
hand and began searching his vest pockets for a match to 
re-light what was left of his cigar. He gave up the search 
abruptly and moved to the glassless window, where he stood 
staring out into the void, his back to the rest of the group. 

After several minutes the woman rose from her chair and 
moved concernedly to the side of white-beard. She found him 
with a faint smile on his face. He turned and, still smiling, 
he said to her in a low tone: 

"Can you imagine him, the one in Zurich, saying that I 
viewed the brain solely as an appendage to the genital glands." 
He threw his head back and laughed. 

The old man's laughter alleviated the tenseness of the dis- 
cussion somewhat — the other men shifted in their chairs and 
chuckled lightly. 

The woman returned to her chair and, after sitting down, 



N. C. JOURNAL OF MENTAL HEALTH 



said, "Getting back to our original discussion ... uh ... it is 
interesting to note that tine transference is minimal in . . ." 

"How does he deal with it?" interrupted white-beard. 

"The particular therapist attitude is maintained . . . that is, 
he accepts and tries to understand," the woman answered. 
"The maintenance of this attitude, it is believed, gives the 
patient very little evidence upon which to base the transfer- 
ence ... or parataxic distortion (she looked at the younger 
man ). You see, he is adamant about not displaying a usual 
social attitude, that is, he is not a judge, he doesn't evaluate 
. . . eventually the impression is conveyed to the patient that he 
is worthy enough to make judgments or analyze his own be- 
havior, if that's what he wants to do, and also that he is best 
qualified to make these decisions and . . ." 

"The reflection of this attitude of worth or esteen for the 
other on the part of the therapist is indispensable," added the 
younger man. "It provides the necessary climate for mutual 
collaboration ... I have been concerned about one aspect 
only, that is, is this attitude enough for the most effective 
therapeutic advance? I have carefully observed the cultural 
attitude, you might call it, of people who come to seek help. 
They are for the most part anticipating an expert-client rela- 
tionship of varying magnitude . . . that is, of varying degrees of 
expertness on the part of the therapist. Now, the ingredients 
or that which goes into making up their conception of 'expert' 
can be roughly approximated by the statement 'He is an 
expert in interpersonal relations, he is exquisitely sensitive 
to the needs of other people, he knows more about people 
than anyone, in a short while he will know much about me and 
then I will be helped by this relationship.' " 

They were all listening intently now, the young man paused 
to scrutinize them individually as if to get some confirmation 
that they followed him thus far. 

White-beard said, "Yes, yes, and . . ." 

The young man continued, "And they are right, I mean in 
their expectancy of help, but the form that this socalled 'help' 
will take, how exactly meaningful information will be arrived 
at is usually a fuzzy issue. Some persons expect prescriptions, 
after all, if one is a doctor one issues prescriptions. On the 
other hand, if a 'prescription' is prematurely offered, the 
patient becomes annoyed, 'resists', you might say. This annoy- 
ance may take the form of doubting the expertness of the 
expert . . . the doctor has really been clumsy in this instance." 
The young man arose abruptly from his chair and began pac- 



G. GOTTLIEB 



ing up and down in front of it. 

He continued, "For many years, while I was practicing 
privately, I wished that I had two offices, one adjoining the 
other, so, that at certain critical times in the interview situa- 
tion I might beat a hasty retreat into the room that was empty. 
For example, once a patient of mine of long standing opened 
the hour by announcing that he had just met the most won- 
derful girl and they were planning to be married in the very 
near future. I replied with a vague 'Oh!' and promptly excused 
myself from the room, eventually spending ten minutes at the 
water cooler in my anteroom. Upon my return the patient 
told me he had reconsidered the matter of marriage and 
thought that he had better wait a while. We then turned our 
attention to other matters and the subject of marriage was 
broached no more for that hour." The young man sat down. 

A pause ensued. 

Finally, white-beard said, "My friend, you are sometimes a 
bit obscure. I would like to comment upon your earlier re- 
marks concerning the encountering of resistance — my sugges- 
tion is that the analysis of the resistance would be helpful." 

The two other older men nodded their agreement. The 
woman made no move. The younger man lit another cigarette. 

The woman spoke, "The development of responsibility is 
facilitated by the person's recognition that other people, or 
at least one other person, believes in his capabilities." 

"A-ha!", exclaimed white-beard, "it is now clear to me that 
we have two self-actualizers in our midst. And you think you 
stand alone. On this point I believe we can all agree." The two 
other older men nodded emphatically. 

"It is a matter of how this might best be achieved," said 
white-beard, "it appears to me the best . . ." 

"Yes," said the thick-set one interrupting, "I believe we all 
agree and I would like to explain my position . . ." 

"Now let me enumerate . . ." said one. 

"I want to make one thing clear . . ." said the other. 

And The Argument continued. 



Note: The foregoing was written in 1953, at which time the author was 
studying the often bewildering array of approaches to psycho- 
therapy. 



RE-ED AS A TEMPORARY SYSTEM: 

Reflections on the Process as 

it IVIoves from Separation and 

Entry to Termination and Re-entry 



Anne K. Parrish, A.C.S.W. 

Wright School 



Re-ED is a temporary system.* Two conceptsthatare inherent 
in temporary systems are separation and entry, or to elaborate 
—separation and entry, termination and re-entry. Potentially 
traumatic, they are part of the therapeutic warp and weft of 
the process of re-education as it is perceived in Project Re-ED. 
To become the master of these formidable events that confront 
us all of our lives is a strong ego building experience for a 
child, particularly one who has known few successes for him- 
self or with others. 

Project Re-ED, a project for the re-education for emotionally 
disturbed children, came into being in 1960 as a pilot project, 
co-sponsored by the National Institute of Mental Health, and 
the Departments of Mental Health in North Carolina and 
Tennessee. The purpose was to demonstrate the effectiveness 
of an innovative social institution in response to three major 
problem areas which are: 

I. The urgent need for more services 
and facilities for troubled children 
and families, and to develop new 

' sources of manpower 

II. To extend the effectiveness of 
highly trained mental health and 
education personnel, and 

III. To find new patterns of opera- 
tion to insure the fullest and most 
effective utilization of all resources. 

Re-ED meets these three needs by tapping the manpower 
resource of teachers, emphasizing careful selection, provid- 
ing condensed highly specific functional training, backstop- 
ping their day by day activities with a strong supervisory staff. 



'Paper presented on Panel at the American Orthopsychiatric Association 
meetings: 1969, New York, N. Y. 



A. PARRISH 



and a dependable system of consultation by top-level profes- 
sional personnel. 

The model is that of education, hence the concept of cure 
is not applicable in the short term Re-ED setting. The em- 
phasis "is on health rather than on illness, on teaching rather 
than on fundamental personality reorganization, on the 
present and the future rather than on the past, and most 
particularly on the functional adequacy of the total social 
system of which the child is but one part." 

For the child himself we see our task as helping him learn 
new and more rewarding ways of looking at himself and his 
world, and to learning habits that lead to more effective 
functioning. To quote Nick Hobbs: "We assume that life is 
more healing than we are; that our intervention is indeed 
temporary; that our major goal is to get a therapeutic alliance 
established with the child, the family, the public school and 
the community so that the whole system has a significant 
margin of probable success over probable failure." 

North Carolina's Re-ED Center is Wright School in Durham, 
North Carolina. Children are referred from all over the state. 
From the beginning it is firmly established that this is a family 
affair. Problems within the family have been looked at with 
openness. The focus is on problem solving, and parents and 
child are perceived as "responsible collaborators." This is a 
motivating factor for both, who often for the first time admit to 
shared responsibility. It is emphasized that the period of time 
will be four months. 

By the time a child is admitted, firm linkages have been 
established by the Liaison Teacher between Wright School 
and his community, not only with the family but with his prin- 
cipal, his teacher, the agency who will be working with his 
parents, and significant others who may need to be involved. 

All of these factors make separation less traumatic. Even so 
it hurts. For many children this is a new experience. For others 
it resonates with too many separations. Reactions vary. The 
hysteria of a school phobic child, tearfulness, quiet observa- 
tion, compulsive talking, indifference, or hostility are just a 
few of the initial responses. But whatever the response, the 
members of the group he is entering are quick to identify the 
newcomer's uneasiness and make attempts to help him feel 
more comfortable and to know that he has a place in the 
group. Later this may be challenged as his behavior needs 
confronting by the group, but everyone knows this is a rough 
time and so for now there is empathy and support. There, too. 



10 N.C. JOURNAL OF MENTAL HEALTH 



for him is his teacher-counselor team — caring, consistent 
adults. Experienced in working with children who are basically 
disinclined to trust, the teacher in this early phase must 
respond almost entirely to messages transmitted through 
behavior rather than to words of face value. 

That first evening the newcomer finds further confirmation 
of his place in the group at the unit meeting. Again efforts are 
made to help him feel "part of." He learns from the others that 
the unit meeting is the central opportunity to talk about prob- 
lems with self, within the unit, at Wright School, in public 
school, or home and community. The atmosphere is one in 
which the ability to talk about problems is encouraged and 
supported. A high value is placed on honesty and authenticity. 
Very few newcomers participate initially; however, they ob- 
serve how other children within the group express concerns 
and receive supportive encouragement from group members 
and the teacher-counselor. Perhaps the most important mes- 
sage the youngster receives now is that he is not alone in what 
he feels in problems with himself and others. 

During the next few days and weeks he learns the basic 
structure of Wright School in terms of routine, expectations, 
and consequences. The best indicator of beginning change is 
his behavior. Even though his words may say " I hate this place" 
or "Do I have to stay here four months," his behavior is no 
longer that of an observer. Expression of gripes, goals, prob- 
lem areas, new successes in the classroom, learning to walk 
the monkey bridge on the obstacle course, making a contribu- 
tion in the rocket project, all find him involved. 

Expectations begin to be tested. This may run the gamut 
from aggressive acting out to tentative passive-aggressive 
technique with a very dependent child. Having learned that 
limits and expectations hold and therefore are predictable, 
the child tests them in increasingly creative and sophisticated 
ways, depending on his sense of power within himself. What- 
ever they may be, they are important for him and for the 
teacher-counselors who adjust their handling techniques to 
the individuality of each child and to his changing needs. 

Gradually, as he learns to trust, he shares more of his inner 
self, of his hurts, his wants and his needs with the group and 
with the team. Reflected back to him is validation that his 
concerns are important, that his group will listen to him and 
give him feedback, that indeed he is important. 

There are always children in the group in various stages of 
the Re-ED process; steps forward — for example, assuming 



A. PARRISH 11 



more responsibility for oneself — have been demonstrated 
for him by others in the group. He has gone through the separa- 
tion process with more than one child and found himself the 
first time angry and hurt, not quite understanding why, until 
talking it over with the group helps a few things fall into place. 
Yes, he was angry with Jim for leaving; angry at Wright School 
for making him leave, and hurt and scary somewhere down 
deep inside because he knows that one day before too long 
he too will have to go. But there are now group members who 
are new and looking to him for direction as he looked to others 
some weeks ago. Likely next time around he will be helping 
them examine their feelings about a member leaving. 

Throughout this process the child has returned home each 
weekend to keep him and his family in touch with each other 
and to changes. 

Weekend diaries completed by parents and returned to us 
both re-enforce and responsible collaborative aspect and give 
us valuable feedback. We have been in close reciprocal com- 
munication with the community, the agency working with 
parents, the public school, and relevant others. Monthly school 
visits have been made by the child and a report sent back to us 
by the teacher. Progress conferences have been held with 
parents, Re-ED staff, child, and public school personnel from 
time to time, providing additional opportunities to work on 
authentic interpersonal relationships. Each sign of improve- 
ment in any part of the system is perceived and acknowledged, 
and increases motivation on everyone's part for continued 
progress. 

Toward the fourth month of a child's stay his attention 
begins to shift to the proximity rather than the remoteness of 
the discharge date. Varied reactions can be expected "What 
if I run away, would I have to stay longer?" "Nobody can help 
me learn except Mr. Anderson," "I don't think I've worked on 
my problems long enough" or "I hate you. If you really cared 
about me you wouldn't make me go home." Often we see a 
return to old outgrown behaviors, or see new adopted ones. 

The teacher-counselors move with the child into this final and 
critical stage as his individual needs indicate. In spite of 
major efforts to make the transition a smooth one, they know 
that Wright School has become a very important place for him. 
He has learned to trust and has known success here. He has 
not only learned that he is cared for, he has learned to care. 

Expressed fantasies about staying longer are met realistic- 
ally and firmly, but gently. Fearful, angry and sad feelings are 



12 N.C. JOURNAL OF MENTAL HEALTH 



accepted, but expectations remain. He is encouraged to talk 
over tiiese feelings with the group and individually with the 
team, to begin to talk realistically about what he anticipates, 
the good and the bad. 

He will probably be reminded by the group how he helped 
Ted or Bob or Sam look at their ambivalent feelings— the pull 
to go as well as the pull to stay. Mirrored back to him are his 
new found strengths in responsibility for himself and his own 
behavior. 

During his last week his back home teacher will come and 
spend a day at Wright School, observing and talking with staff. 
On this day, too, his parents will come for the final conference. 
At some point during the day, relevant staff, parents, child and 
teacher will all meet together. We have found this conference, 
with the people who have been the major actors in this process, 
to be a most rewarding human relations experience. It seems 
to reaffirm for all that growth has begun and will continue. 

Thus termination occurs and re-entry follows, but a stronger 
child is re-entering a stronger, more caring and responsive 
system, and experience has proved that there is a significant 
margin of probable success over probable failure. 



13 



INTERAGENCY COLLABORATION IN SERVICES 

TO PEOPLE 



Harold A. Benson, Jr., ACSW 

Assistant Commissioner 

George H. Adams 

Assistant to Eastern Regional Commissioner 
North Carolina Department of Mental Health 



Mental Health and Family Service have long shared many 
common concerns.* As we consider these, it occurs that many 
possibilities exist whereby our two agencies might each 
strengthen the other toward the goal of providing more com- 
plete and more effective services for troubled people who 
come to us for help. But at this stage in our developing rela- 
tionship, we are certainly not prepared, nor do we believe 
anyone is to offer any specific blueprint or glib panaceas as to 
how such collaborative efforts may be implemented. 

We would like to raise some pertinent questions regarding 
interagency collaboration, and to only suggest some possible 
directions in which answers to these questions might be found, 
in order that this might stimulate our thinking. It is one thing 
to say that interagency collaboration is a good thing, but we 
must follow that with the hard question, how specifically can 
we, namely Family Service and Mental Health, collaborate 
in services to meet the needs of people? 

We might want to look realistically at each agency and ask, 
what can one agency do better than the other? 

Who are we serving? Are they the same people? Does it 
make any difference if there is overlapping of services between 
our two agencies? We need to remind ourselves constantly 
that the major focus in both our agencies is on services to 
people. When we get side-tracked from that mission by terri- 
torial hangups, the needs of the patient take a back seat and 
are neglected. 

Is it possible to blend or converge our lines of respon- 
sibility? 



*Paper Presented At The Second Annual Family Service, Mental Health 
Conference, Greensboro, North Carolina, March 1970. 



14 N.C. JOURNAL OF MENTAL HEALTH 



How are we going to solve the ever present communica- 
tions problem, so that appropriate cases get to the appropriate 
agency? We all must recognize the extreme importance of a 
free flowing exchange of information between agencies. Carry- 
ing this a step further, we might consider the possibility of 
an interagency record keeping system, which would enhance 
the free flow of information. 



Agency Identification 

Before agencies can collaborate, perhaps they each need to 
have a clear identity and understanding of their purpose. How 
did each agency come into existence? To serve what kinds of 
needs? Under what legal or societal sanctions must each 
operate? Certain covert assumptions in reference to one's 
mission must be made very clear to all concerned, both to staff 
and to patients. All too often, we refer patients to another 
agency or what that agency's name means to the patient. 
When Mrs. John Doe picks up the phone book to call for help 
with a problem, how does she decide which agency to call? 
Does she decide on the basis of what she really knows about 
the helping agencies — Family Service and Mental Health in 
this case? Or does she rely on intuitive feelings, perhaps 
choosing the agency with the least threat implied in the name? 
Or does she act on misinformation regarding agency function? 

A determined effort must be made to delineate the similari- 
ties, differences, and overlapping functions with clarification 
of areas of function, competency and effectiveness taking 
place in the process. It might be helpful here to have a brief 
look at the comparative aspects of the mental health clinic 
and the Family Service Agency. 

The Family Service Agency, on the one hand, is a social 
work agency The social worker is concerned primarily with 
social adjustment and family relationships; in short, with 
problems in social functioning and not nnedical diagnosis. The 
social worker classifies social problems in terms of inter- 
personal relationships, personality adjustment, disabilities, 
physical complaints, economic problems, education and voca- 
tional problems, employment and housing. This adds up to a 
concern with the total environment in which people live and 
function, and this places Family Service very much in the 
mainstream of growing national concern with this vital 
problem. 

The mental health clinic, on the other hand, has traditionally 
been a psychiatric clinic concerned with emotional and mental 
illness. An interdisciplinary team approach is employed in the 



H. BENSON and G. ADAMS 15 



diagnosis and treatment of patients, in which there is a mu- 
tually supportive relationship among the various disciplines. 
This has resulted over time in the blurring of traditional lines 
of competency, and has led us to see the need for developing 
a "mental health generalist" career line, which will officially 
recognize the lowering of territorial barriers among the psy- 
chiatric disciplines. The orientation of the treatment team is 
different from that of Family Service, however, in that they 
classify psychiatric problems in terms of organic brain syn- 
dromes, psychotic reactions, personality disorders, including 
both psychotic, neurotic and sociopathic mechanisms; and 
finally, transient situational reactions, including adjustment 
problems of later life. 

This orientation will always be very important in the mental 
health clinic. But it is changing and broadening. Mental health 
has opened its doors and its eyes and through its developing 
relationships with other agencies, such as Family Service, 
has become more aware of the need for a total community 
approach, if you will an environmental approach, in the de- 
livery of services to people. So it seems to us that more than 
either agency realizes we have been moving closer together 
in the way we view our mission. 



Staffing Patterns 

In the matter of staffing patterns, are there sufficient and 
feasible ways for staff functions and roles to become more 
interlocking, thus enabling us to provide continuity of care 
from a family-focused approach? How can we go about setting 
up mechanisms for sharing and utilizing each other's exper- 
tise? Family Service agencies, for example, have had extensive 
experience in day care programs. Can we work together in a 
joint effort in the further development of day-care services in 
communities throughout the state, an area in which mental 
health programs are vitally interested? It seems to me that 
Family Service, in turn, should be able to look to the mental 
health center for backup psychiatric consultation and support 
in providing services for mentally sick patients whom they 
may now be referring. How can we jointly utilize the staffs 
in the development of homemaker services and other care- 
taker groups, another area of Family Service experience and 
expertise. 

Another opportunity which presents itself for possible joint 
staff utilization is that of child adoptions. Family Service, of 
course, handles a number of adoption cases every year. At the 
same time, we know that a fairly high percentage of adopted 



16 N.C. JOURNAL OF MENTAL HEALTH 



children are referred to mental health clinics for treatment. 
Could we work together in the joint development of a pre- 
adoption program which might ensure better, happier lives 
for many of these children? How can we pool our creative 
know-how in developing new approaches to reaching the lower 
socio-economic group, where so many problems exist that 
need the kind of help that we can, and want to offer? 

Some means for organizational blending suggest them- 
selves. What is the possibility, for example, of establishing 
joint or interlocking governing or advisory boards for our two 
operations? There is already some precedent for this, since in 
some places there have already been established joint staff 
meetings and individual conferences, as well as case-centered 
consultation conferences. 



Shared Funding 

Is there a possibility of shared funding? In that regard, we 
would urge Family Services agencies to become more knowl- 
edgeable of Federal and state legislation and programs. What 
are the inclinations of Family Service in response to govern- 
mental funding? There are many benefits, of course, which 
come with such funding, but they are also accompanied by 
governmental regulations and guidelines, which go along with 
receiving tax funds. These alternatives must be faced and 
certain policy decisions made in the full light of their impli- 
cations for the agency. 

What segments of the Family Service programs and facili- 
ties, as well as the mental health programs and facilities, can 
be offered and utilized? Several possibilities come to mind. 
First, could the use of homemaker service be considered in 
the after-care of recovering mental patients who have returned 
to the community? Could they provide assistance to families of 
severely retarded or disturbed children while awaiting their 
placement in an appropriate residential facility or the develop- 
ment of community programs? What about assistance to the 
family of the geriatric patient? 

What different types of therapy are used in both the Family 
Service Agency and the mental health center? What mechan- 
isms might we develop, whereby we can learn from one 
another and share our experience in the use of these various 
therapies. Consultation must be approached with the full 
recognition that it is a two-way street. Both agencies teach and 
both learn. On this basis, can both the mental health clinic 
and Family Service offer agency consultations, as well as case 



H. BENSON and G. ADAMS 17 



consultations, and would each be willing to engage in this 
activity? 

In the matter of training, can interagency, inservice training 
programs be a feasible channel for collaboration? Staff mem- 
bers with similar types of job assignments may very well par- 
ticipate jointly in an in-service training program, which would 
enhance skills and techniques in all. What would be the pos- 
sibility of utilizing senior staff from a number of community 
agencies to develop a community-centered training program 
to serve the entire community? How much can we do in the 
training of volunteers? Both our agencies utilize volunteers. Do 
our agencies train them about the services and functions of 
other agencies, or do we just inform them about our own? It 
must be remembered that volunteers are, perhaps, a major 
vehicle in interpreting our agencies' roles and functions to the 
community at large. It is important that they be fully knowl- 
edgeable in order to correctly convey the message to the 
people. 

Basic to interagency collaboration, no matter what the 
nature of the agencies, is the need to develop and foster good 
will, understanding and respect for each other. This respect 
must encompass the dignity of agencies and persons who 
staff the agencies. Agency leadership should examine, study 
and understand the alternatives in services, before estab- 
lishing policies as to what services to provide. Choices and 
decisions are to be expected and should be respected. An 
agency's choice to provide a given cluster of services may not 
always be exactly complementary to the other agency's serv- 
ices, but the decision should be respected and understand- 
ings reached, making it possible for all to coexist in as much 
harmony as possible. 



18 



EPILEPSY: REVIEW OF CLINICAL FINDINGS, 
PROGNOSIS AND TREATMENT 



Herman B. Shubert 

Coordinator, 

Pyschological Services 

Division of Special Education 

North Carolina Department of Public Instruction 



Epileptic seizures are the manifestation of a paroxysmal 
discharge characterized by a recurrent, abrupt, brief disorder 
of cerebral function. Although unconsciousness and convul- 
sions are often present, they are not essential for the diagnosis 
of an epileptic attack (Elliott, 1964; Brain, 1964). 

Epilepsies are commonly separated into two groups, sympto- 
matic and idiopathic, the former indicating the presence of 
organic disease of the brain and the latter term implying an 
absence of organicity. However, some writers feel that such a 
division is artificial (Brain, 1964; Elliott, 1964; Dekaban, 
1959 ). Seizures occurring in organic disease may not be solely 
due to that disease but may occur due to the factor of pre- 
disposition (hereditary) or emotional trauma. Idiopathic epi- 
lepsy may imply no structural lesion is present but improved 
diagnostic and pathologic techniques revealed small lesions 
or scars in cases which were formerly thought to be idiopathic. 

Electroencephalography has been largely responsible for 
identifying differences between epileptic seizures. Different 
seizures are associated with abnormal electrical rhythms 
recorded from the surface of the head (EEG ) and differ in their 
characteristics and localization (Brain, 1964). Because of this 
there are two general classes of seizures. The first are those 
accompanied by a paroxysmal bilateral (both sides of the 
brain ), symmetrically synchronous generalized EEG discharge, 
which appears to originate from a deep midline pacemaker 
(within the recesses of the brain ). The second are those asso- 
ciated with a recordable electrical discharge taken from a 
localized area of the scalp but which may or may not spread 
to the rest of the brain. The first group corresponds to 
idiopathic grand mal and petit mal and the second group to a 
heterogeneous collection of seizures referred to as focal, local 
or partial epilepsy which are usually associated with structural 
lesions at or near the site of the focal discharge though the 



H. SHUBERT 19 



lesion may not necessarily be a progressive or enlarging one. 
Seizures which clinically resemble grand mal may often result 
from a generalized discharge which started focally, and 
since symptoms which accompany the focal discharge may be 
inconspicuous, electroencephalographic data is often de- 
pended on to distinguish between idiopathic and symptoma- 
tic seizures (Elliott, 1964). 



Classification 

Because little is known about the etiologic factors of 
epilepsy no classification on this basis can be made at present. 
However, classification has been made on the clinical features 
of seizures. On this basis two classifications seem to be typical 
of those found in the literature. Other neurologic authorities, 
namely Brain (1964), make no general classification but dis- 
tinguish seizures on the basis of clinical features and associ- 
ated structural pathology and electro-physiological patterns 
of the brain. Of the two types of general classifications, the 
first classified seizures for the purpose of clinical investiga- 
tion and their management, and the other one the basis of 
clinical features and correlated electrophysiological data. The 
first general classification has the following categories 
(Dekaban, 1959): 

A. Recurrent attacks associated 
demonstrable organic brain lesions: 

1. Attacks with progressive cere- 
bral lesions 

2. Attacks with stationary cere- 
bral lesions 

B. Recurrent attacks not asso- 
ciated with demonstrable organic 
brain lesions: 

1. Idiopathic epilepsy 

2. Febrile convulsions 

C. Transient attacks occurring 
during an acute illness affecting 
the central nervous system or in a 
generalized disturbance of metabol- 
ism. 

The second classified attacks in the 
following manner (Elliott, 1964): 
A. Generalized Epilepsies 

1. Generalized convulsions 
a. Generalized from the 
(grand mal ) 



20 N.C. JOURNAL OF MENTAL HEALTH 



b. Generalized, but with 
focal onset 
2. Petit Mai 

a. Simple "absence" 

b. Myoclonic petit mal 
B. Local, Partial, or Focal Epi- 
lepsies 

1. Jacksonian motor seizures 

(Psychomotor seizures ) 

2. Jacksonian sensory seiz- 
ures 

3. Akinetic seizures (includ- 
ing "drop attacks" ) 

4. Temporal lobe epilepsy 

5. Antonomic seizures (vis- 
ceral epilepsy ) 

6. Atypical 

a. Tonic attacks ~ 

b. Hypsarrhythmia 

The first method appears to be concerned generally with 
the traditional symptomatic versus idiopathic classification 
and is more a treatment model than a research one. The 
second model considers massive discharge as opposed to 
initially focal discharge as per electro-physiologic correlates. 
Though both generalized and focal seizures are recurrent 
types, this distinction is more directed toward being a research 
model. Both models include data on all different varieties of 
seizures, but with increasing refinement of electrophysiologi- 
cal diagnostic techniques it may be too cumbersome to con- 
tinually classify recurrent seizures as idiopathic with no 
demonstrable brain damage. Before discussing the different 
varieties of eiplepsy and subsequently looking at treatment, 
we shall look at some general findings about epilepsy. 



General Findings 

Seizures occur irrespective of race and sex (Elliott, 1964; 
Richardson, et al., 1965 ). Figures in the United States, Britain 
and Europe show that about five persons in every thousand 
are affected by epilepsy (Elliott, 1964; WHO (World Health 
Organization), 1957). The incidence of eipleptic seizures is 
highest during the first four years of life, particularly in the 
first two years; declines around the middle years of adulthood; 
and rises after sixty years of age (Elliott, 1964; Colver and 
Kerridge, 1965). First born are twice as likely to develop 
symptoms than subsequently born children. Generally, the 
later the age of onset, after 25 years, the greater the likeli- 



H. SHUBERT 21 



hood of some structural pathology (Elliott, 1964). 

Etiology 

Some authorities have found that a hypothetical model of 
etiology is useful in trying to help clarify the rather vague in- 
formation about the history and causes of recurrent seizures. 
Elliott (1964 ) constructed a continuum of sufferers of attacks 
with the idiopathic epileptics without clinical evidence of dis- 
ease at one end and those without seizures but show traumatic 
disease and lesions at the other. Midway between the two are 
those who are free of seizures until the appearance of a brain 
lesion or systematic intoxication. The general feeling is that 
some people tend to convulse more easily than others in the 
absence of any significant clinical disease. 

On the basis of statistically significant data, it was found 
that there may be some association between a tendency to 
convulse and some hereditary aspects. The rate of seizures is 
about five times greater for those with a family history of 
epilepsy than the rate in the general population; and if one of 
the pair of identical twins has eiplepsy, the other is more 
likely to be epileptic, but this is not true for non-identical 
twins (Lennox, 1947). Of 55 patients studied with seizures, 
it was found that 95% of their parents had abnormal EEGs, 
while in seizure-free adults abnormal EEGs were found in 
16% of their parents. 

In other studies, a child with one epileptic parent has about 
29 out of 30 chances of being normal, and if he has no 
seizure by age 40, the chances of being seizure-free are 39 
out of 40. If two epileptics marry or one has no seizures but a 
significantly abnormal EEC, the likelihood of their having an 
epileptic child is increased. However, such likelihood is con- 
siderably less than in diabetics for example where hereditary 
incidence is better than 25% (Elliott, 1964 ). Elliott points this 
out to be a rather interesting fact on the perspective of sig- 
nificance of heredity in epilepsy in light of what he calls an 
"unjustified" stigma against those who would not marry an 
eipleptic but who would unhesitatingly marry into a diabetic 
family. 

Diseases and intoxications which may cause seizures can 
be any condition which affects the ganglion cells of the cere- 
bral hemispheres either structurally or through metabolic 
means. They are congenital, traumatic, infective, degenerative, 
and neoplastic diseases, and innate and acquired metabolic 
disorders. Other seizure inducing conditions may arise from 
outside the brain such as hypoglycemia, anoxia, uremia. 



22 N.C. JOURNAL OF MENTAL HEALTH 



hepatic failure and eclampsia. 

The site of the damage may have an effect on whether 
seizures occur. For example, damage to the sensory-motor 
cortex and temporal lobe will more likely produce seizures 
than will damage to the frontal and parieto-occipital lobes. In 
addition, affected white matter brain areas do not ordinarily 
cause seizures where affected gray matter areas do. Cerebro- 
vascular disease is not a common cause of epilepsy. When 
such attacks do occur in association with this disease, it is 
probably due to tissue death and hemorrhage of limited cere- 
bral areas and not the immediate result of the disease (Elliott, 
1964 ). 

Violent and prolonged convulsion in infancy can cause brain 
damage as the result of anoxia; so the epileptic infant who 
suddenly has a large number of convulsions may suffer focal 
damage and consequently a persistent tendency to epilepsy 
after this episode. There is not evidence however that con- 
vulsions result in brain damage other than through anoxia 
or by falling down during a seizure and injuring the brain. 
Where anoxia is not present in infants or adults, the frequency, 
rate or severity of seizures does not directly result in organi- 
city. On the other hand, others have speculated that seizures 
are the result of some cerebral damage, except in the case of a 
transient attack occurring in reaction to acute illness affecting 
the central nervous system, but with no observable structural 
damage (Dekaban, 1959). In general, for example, otherwise 
normal infants (from ages 6 months to 4 years) who have 
febril convulsions have excellent prognosis regarding persist- 
ence of seizures in later life than do children with congenital 
defects or obvious brain damage. If seizures occur with low 
fever, family history of seizures, evidence of brain damage 
and abnormal EEGs, there is a 50% chance of epilepsy (Living- 
ston, 1947, Dekaban, 1959, Nelhaus, 1963). 



Precipitating Factors 

Aside from acquired or inherited conditions resulting in 
seizures, there are other factors which govern why any par- 
ticular attack comes on at a particular moment in time. Three 
categories for this are offered by Elliott (1964): 

1. Seizures precipitated by bio- 
chemical changes, i.e., which can 
promote conditions favorable for an 
attack, such as hypoglycemia, an- 
oxia, hypocalcemia, hyperventila- 
tion, water intoxication, sudden with- 



H. SHUBERT 23 



drawal of barbiturates or alcohol, 
and extreme fatigue from sleep de- 
privation. 

2. Emotional upsets or trauma 
precipitating attacks via psychophy- 
siological mechanisms. 

3. Attacks caused by sensory 
stimuli having an idiosyncratic effect 
for the individual. In fact, some epi- 
leptics knowing what can cause them 
to have a seizure, may induce an 
attack for secondary gain. Attacks 
can be set off by reading, watching 
television, flickering lights, alter- 
nating shadow and sunlight as may 
be found while riding, and sunlight 
reflected off water. Auditory stimuli 
may be sudden loud noises, music, 
the sound of bells, and vigorous laby- 
rinthine stimulation. There is also 
rubbing the skin at a particular site, 
voluntary movement, voluntary devia- 
tion of the eyes (very rare) and by 
special types of intellectual exer- 
cise such as mental arithmetic. 

Appropriate to mention here is that there are ways of 
voluntarily aborting attacks by mental concentration, and by 
tightening some binding or ligature around the wrist of the 
affected side, i.e., the side where the coming attack may be 
felt, as in the case of a Jacksonian seizure. 

There is contrary information to causing an attack by 
sensory stimuli in that there is a frequent occurrence of grand 
mal seizures and EEG discharges during sleep. Generally, 
attacks are more apt to occur while the person is daydreaming 
than when he is closely attentive and interested in something. 
As yet there is no information as to whether an attack at any 
particular moment is due to certain sequences of biochemical 
occurrences or if it is the result of only a single cause. 



Clinical Feature of Seizures 

Petit Mal 

This attack usually seen in children is commonly called the 
absence attack because of a momentary break in stream of 
thought and activity, and unconsciousness is so brief that it 



24 N.C. JOURNAL OF MENTAL HEALTH 



is hardly noticed. It lasts for a few seconds and the victim is 
unaware to the extent that when it is over he resumes activities 
or a conversation where it was left off. The attacks may occur 
many times during the day. There is no change in facial color; 
one stares forward, to one side, or upward and the eyelids 
may flicker. 

Myoclonic Petit ma! resembles the absence attack except 
there is a pronounced sudden myclonic jerking of the ex- 
tremities or trunk. It is rare for the person to drop or fall 
suddenly. 

EEGs show paroxysmal symmetrical spike and wave com- 
plexes both during and between petit mal seizures. The cere- 
bral symmetry of the discharge indicates dysfunction from a 
deep midline pacemaker. Petit mal often clears up after 
puberty but in some cases it gives way to less frequent but 
more generalized convulsions. Both types are seen, however, 
in the same child. (Elliott, 1959; Brain, 1964). 

Grand Mal 

This is a generalized seizure in which tonic and clonic 
spasms are symmetrical in onset and they are accompanied by 
diffuse symmetrical synchronous discharges originating in 
the deep midline center of the brain. This convulsion differs in 
no way from a generalized seizure caused by a focal lesion 
discharge except in its EEC characteristics and that it is 
generalized from the onset. (Elliott, 1964 ). - 

Grand Mal, without or with apparent brain damage, is 
usually proceeded by an aura lasting no longer than a second 
or two, the most common one starting from the epigastrium 
and passing up into the throat and head. Such an experience 
is diifferent from anything else and does not resemble symp- 
toms of gastrointestinal disease or upset. The aura is a sudden 
sense of "rushing in the head" suggesting the presence of a 
focal discharge in the cortex as for example an abnormal 
sensation or movement in the face or limb when the sensory- 
motor cortex is involved. Since the focal origin may be in a 
variety of areas in the brain there may be a corresponding 
variety of auras such as a complex mental state, irrelevant 
emotion or fear, hallucination in smell, taste, vision, or hear- 
ing or some abnormal feeling in some part of the body. The 
aura may be an inability to speak or the attack may start with 
a movement of a part of the body. The convulsion does not 
usually start with a loud cry and unconsciousness is almost 
immediate after the aura or at the beginning of the seizure. 



H. SHUBERT 25 



The patient falls to the ground in which most of the serious 
injuries occur, and the tonic spasm of the muscles on both 
sides of the body start. Usually the head and eyes are turned 
and the mouth is drawn to one side. The upper limbs are 
rigid at the shoulder and the other joints flexed; the lower 
limbs are extended with the feet inverted. Breathing may stop 
during this tonic phase because of respiratory muscle spasm, 
but this phase lasts only several seconds. The tonic phase 
gives way to the clonic phase of sharp, short, interrupted 
jerks and during this the tongue may be bitten, foaming at the 
mouth because of pressure on salivary ducts, and incontinence 
of urine may occur, but usually not feces. Cyarrosis occurs 
during the tonic phase but disappears quickly when respira- 
tion starts again. In severe convulsions small cutaneous 
hemorrhages may occur. Near the end of the clonic phase the 
interval of jerks or muscular contractions becomes longer 
until they finally stop. The patient remains unconscious any- 
where from a few minutes to half an hour, and recovering 
consciousness, may often sleep for several hours. Headache 
may be common after the attack (Brain, 1964; Elliott, 1964; 
Dekaban, 1959). 

Unlike petit mal, grand mal may also be a symptom of 
cerebral lesion, rather than idiopathic, situated in any lobe 
but most often in one frontal or temporal lobe. Again, in such 
cases, it is supposed that the discharge of the lesion in the 
affected lobe spreads to the central mechanism that causes 
the loss of consciousness and the generalized convulsion. 



Focal Seizures 

The most important types of focal or partial seizures are 
Jacksonian and temporal lobe seizures. Ordinarily the frontal 
and occipital lobes have high seizure thresholds, and it is 
uncommon for them to be the sight of focal seizures. However, 
focal seizures do spread to produce generalized convulsion 
and unconsciousness. 

Jacksonian Seizures 

This seizure, described by Hughlings Jackson, originates in 
the precentral or controlateral motor cortex and begins with 
clonic movements of a small part of the opposite side (contra- 
lateral to the cortical side ) of the body, the thumb, index finger, 
angle of the mouth or big toe. The spread is systematic to 
adjacent muscle groups showing the cortical movement of the 
seizure across controlling cortical areas. As the convulsion 
becomes more severe, the initial movement becomes more 



26 N.C. JOURNAL OF MENTAL HEALTH 



violent and spreads inwardly in the limb involving flexor 
muscles. It then spreads outwardly to the other limb on the 
same side, to the face, and finally encompasses both sides 
of the body when consciousness is finally lost. The attack is 
usually followed by transitory weakness of the involved muscles 
which may last from a few hours to two days. This weakness 
is known as Todd's paralysis. EEG recordings often show a 
focal discharge. It is thought that the weakness is due to an 
"inhibitory mechanism" rather than to local neuronal exhaus- 
tion (Brain, 1964; Elliott, 1964). 

Focal Sensory Seizures (Jacksonian Sensory Attacks ) 

This term is used to describe the aura of sensory halluci- 
nations which are involved in the sense modality. One of the 
most common is a feeling of numbness or tingling "pins and 
needles" experience which spreads in a similar manner to the 
motor convulsion in a Jacksonian attack. The attack usually 
originates in the opposite parietal lobe around the postcentral 
gyrus and may develop into a generalized convulsion. The 
tingling aura last several seconds distinguishing it from similar 
sensations of migraine or other symptoms which last much 
longer (Brain, 1964). 

Akinetic Seizures 

These are rare attacks where the patient falls to the ground 
with warning and with great enough force to seriously injure 
himself (broken bones, etc. ). The fall is due to loss of con- 
sciousness and if nothing serious happens in the fall, the 
patient is usually able to get up again at once. These are known 
as "drop attacks" (Brain, 1964 ). 

Temporal Lobe Epilepsy 

This term pertains to a group of epilepsies having a dis- 
charging lesion in or near one temporal lobe. The most con- 
spicuous feature is a disturbance in the content of conscious- 
ness (not unconsciousness) which may take the form of 
hallucinations, especially of smell or taste (usually acrid ), a 
remembered visual scene or musical tune, disturbance of seen 
objects or the patient's body, or perceptual illusions; deja vu, 
that is, feeling that what is happening happened before to 
you; vivid revival of past memories; fear, depression, turmoil. 
The motor accompaniments are usually varied. The patient 
looks dazed, does not respond adequately or at all when 
spoken to. The aura usually begins with the taste or smell 
hallucinations and leads to automatic chewing, tasting and 



H. SHUBERT 27 



lip smacking and is known as uncinate attacks. (Brain, 1964 ) 

Temporal lobe epilepsy also known as psychomotor, or 
psychparetic seizures, usually affects adults more than chil- 
dren. Some last several minutes but are usually very brief. 
The psychomotor seizure manifests itself in a series of highly 
organized coordinated acts which are bizarre, out of place or 
context and serve no useful purpose, and are done in an 
unconscious manner. Sometimes temporal lobe attacks are in 
the form of a brief mental or emotional experience such as the 
affect of misery, happiness, anger, or unreality. In cursive 
epilepsy the person may run about and may at times have a 
generalized attack. But brief laughing spells (out of context 
and without awareness) may be the entire attack in gelastic 
epilepsy. As with all temporal lobe attacks the seizure may in 
some cases become generalized. Due to the aberrant nature 
of behavior, such victims may commit criminal acts but this 
does not mean that all the acts such a person commits that 
are criminal are due to the periodic attacks. Such individual 
acts must be assessed carefully since criminal activity is 
generally no more common to these epileptics than to non- 
epileptics (Elliott, 1964). 

Autonomic Seizures (Diencephalic Epilepsy ) 

These are quite rare and are usually due to a tumor in the 
thalamus or hypothalamus of the autonomic nervous system. 
Various combinations of the following symptoms occur with or 
without consciousness: dilation of the pupils, flushing of the 
face and neck, sudden profuse sweating (sometimes on one 
side of the body ), piloerection and goose pimples, bradycardia, 
sudden rise or fall of blood pressure, alterations in respiratory 
rhythm, hiccups, yawning, sudden fever or chill, abdominal 
pain and discomfort or a desire to suddenly defecate. The 
attacks may be accompanied by fear or apprehension or some 
form of anxiety. They are brief, episodic and the patient is 
usually normal between attacks distinguishing them from 
anxiety states (Brain, 1964; Elliott, 1964). 

Atypical Epilepsies 

Tonic Seizures 

Attacks are brief in which extremities and trunk become 
rigid, and there may be an associated loss of consciousness 
but not followed by clonic movements. The head is extended, 
the arms thrown out in front extended at the elbows and 
internally rotated, and the fingers somewhat flexed. The lower 



28 N.C. JOURNAL OF MENTAL HEALTH 



limbs are extended. The attacks usually are the result of 
organic disease of the brain producing temporary dicerebra- 
tion, but they are occasionally idiopathic (Brain, 1964). 

Hypsarrhythmia 

This is an EEG abnormality found in infants and shown by 
high, sharp, irregularly occurring spikes in all tapped areas 
interspersed with many high voltage (high for EEG ) slow waves. 
It is associated with infantile spasms, that is, frequent sudden 
jerks of the eyes, neck, limbs and trunk. A mental defect is 
usually present and there may be associated disease and 
metabolic disorders including PKU and hypoglycemia (Elliott, 
1964). 

Epilepsia Partialis Continua 

This is a rare form of focal convulsion with persistent 
clonic movements confined to a limited part of the body such 
as thumb flexion or flexion of one or more digits. The move- 
ments continue for long periods, for days and sometimes 
months without stopping. They are usually the result of a focal 
lesion involving the area of the motor cortex opposite to the 
somatic attack (Brain, 1964). 



Associated Effects of Seizures 

Postepileptic Automatism 

This term is used to describe the behavior of a patient who 
carries out a series of more or less complex acts without 
being conscious of them at the time and without being able 
to recall them. The acts may be bizarre, violent, abusive, and 
unlike his usual self, such as the cultured spinster may use 
indecent language, or the devoted father who wanders from 
home, or the good soldier who goes AWOL. The attacks may 
last minutes, hours, or several days and may be difficult to 
distinguish from hysterical fugue states or malingering. They 
are not difficult when a seizure has preceded them, but the 
attack may be so slight as to go unnoticed. It is difficult to say 
to what extent the automatism is the result of epileptic dis- 
charge or the extent to which it is maladjustive behavior of 
the lower centers of the nervous system temporarily out of 
control, by the seizure, from normal functioning. This seizure 
is mostly seen in temporal lobe epilepsy but sometimes fol- 
lows grand mal or petit mal (Elliott, 1964). 



H. SHUBERT 29 



Status Epilepticus 

This is consistent attacks without an intervening period of 
consciousness. If the convulsions cannot be arrested, the coma 
deepens and ovrexia or hvoerovrexia develops until death 
occurs. Status epilepticus is a rare occurrence and may be 
precipitated by sudden withdrawal or anticonvulsant drugs, 
especially the barbiturates (Brain, 1964). 



Prognosis 

True petit mal is a childhood disease and tends to clear up 
as the brain matures at puberty or shortly afterward (Currier, 
et.al., 1963). Occasionally it may give way to generalized 
convulsions. Febrile convulsions ordinarily have excellent 
prognosis especially in the absence of overt brain damage. 
Grand mal prognosis is often difficult to make early in a 
patient's history. Some suffer one or two attacks a year and 
may be followed by complete remission for several years at a 
time. Others have several seizures a month and may have to 
live carefully circumscribed lives, but in these cases the seizure 
frequencies diminish greatly in later life. In one study of 246 
cases (Walker, 1957 ), one-third were free of seizures 5 to 10 
years after traumatic injury and less than half of them received 
treatment. 

Recovery in epilepsy means cessation of attacks but even 
if this is achieved and the patient remains free from attacks 
without treatment, there is a slight risk that they may reoccur 
in the future. To achieve recovery one must eliminate attacks 
by treatment long enough for the patient to lose the epileptic 
habit. Thorough treatment is essential and must be continued 
for at least three years after attacks have stopped and in some 
cases a mild dose of anticonvulsants should be given in- 
definitely. The sooner the treatment can be done, the better 
the prognosis and it is best for those who begin to have attacks 
after 20 years of age. Patients with a family history of epilepsy 
often respond better to recovery treatment than those without 
any hereditary signs. Those with frequent severe attacks are 
least likely to be completely cured and marked mental deteri- 
oration and severe cerebral damage have a poorer prognosis. 
Patients with epilepsy and deterioration requiring institutiona- 
lization have four times the death rate than that of the general 
population. Few such patients ever become free from attacks. 
About 30 percent of non-institutional epileptics remain free 
from seizures indefinitely (Brain, 1964). 

Generally epileptics have a shorter life than the normal 



30 N.C. JOURNAL OF MENTAL HEALTH 



population. Aside from running the same risk of disease as 
others, they have to face risks as a result of seizures such as 
status epilepticus, suffocation from rolling on their face dur- 
ing seizures, fatal falls, road accidents, drowning, and other 
potential fatal situations exposed to during an attack (Elliott, 
1964). 



Treatment 

Generally the life of epileptics should be as normal as 
possible except in situations where there is obvious danger in 
case of a seizure such as working at heights or the likelihood 
of working in areas that may precipitate an attack as may be 
the case with certain cases of idiopathic epilepsy. However, 
each case should be judged separately and family, personal, 
social and medical history are necessary for adequate evalua- 
tion of what any epileptic is capable of doing. 

Anticonvulsant medication is most times required. Positive 
health habits are also essential and this requires a compromise 
between fussy rigid interference and careless neglect. Exercise 
in the open air, adequate rest, and appropriate recreation are 
more beneficial than a sheltered existence surrounded by 
imposing restrictions. Diet restriction are not necessary, but 
alcoholic drinks may be taken in small quantities only on 
occasion. Large amounts of fluid, including beer, should not be 
allowed since hydration will precipitate an attack. Chronic 
alcoholic epileptics pose a difficult management problem 
since sudden withdrawal of alcohol can cause an attack 
(Brain, 1964). 

Anticonvulsant medication is most commonly used for pre- 
vention of attacks but in some cases of known lesions surgical 
excision has been done successfully especially in cases of 
temporal lobe epilepsy. The continuous use of anticonvulsants 
has no ill effects if the dosage is correct and there are not 
idiosyncratic reactions. Since continuous usage may be a 
burden to the patient, many authorities feel that medication 
may be stopped for patients who are relatively free from attacks 
such as one attack per year (Elliott, 1964). 

Phenobarbitone, Dilantin, Mysoline, and Mesantoin are most 
effective for grand mal. They can be used alone or in combina- 
tions; if used alone the full therapeutic dose should be used. 
Psychomotor attacks are best treated by Dilantin. Petit mal 
responds to Tridione, Paradione, Milontin and Zarontin, the 
last being most effective. Generally, children tolerate relatively 
large doses of anticonvulsant medication. The aim of drug 
therapy is to maintain an effective serum level of each agent. 



H. SHUBERT 31 



It takes several days of treatment to reach such a level and it 
is customary to prescribe medication three times a day. Since 
twice a prescription may be sufficient, it may be given this way 
for more convenience to the patient who may forget a midday 
dose for any reason (Brain, 1964; Elliott, 1964; Zimmerman, 
1956). 

Again it is essential to point out, especially in the case of 
epileptic children, that activities should not be limited but 
rather the seizure threshold of the child should be raised 
through medication, and the child should be treated normally. 
It is important for those in contact with children to know that 
they are not fundamentally different from others (Chamberlain, 
1957; Kram, 1963; World Health Organization, 1957). 

The explosiveness of grand mal, the social stigma of epilep- 
tics with the ensuing frustration and feelings of being different 
from others often create frustration and embarrassment that 
on most occasions is more harmful psychologically than the 
illness is physically. Because of the secondary psychological 
effects, group therapy for both epileptic children and their 
parents proved to be beneficial as they learned a clearer 
conception of the problem of epilepsy. Parents who share 
their problems and obtain a better perspective about epilepsy 
and vent their frustrations and hidden feelings are able to 
allay their fears and misconceptions about epilepsy (Baus, 
et.al., 1958; Hughes and Jabbour, 1958; Kamin, et.al., 1958; 
Kidder, et.al., 1963; Livingston, 1957). 



Psychological Findings 

It is generally accepted today that epileptics do not have a 
particular personality profile. Where there is no intellectual 
impairment, epileptics as a group have essentially normal 
personality characteristics. Patients with periodic seizures 
may develop secondary neurotic symptoms as a result of 
frustration, a sense of being different and inability to live a 
normal social and professional life (Elliott, 1964; Kram, 1963 ). 

A careful study using the Rorschach to determine person- 
ality differences between epileptics with grand mal and non- 
epileptics failed to confirm such differences which have been 
alledged to occur in clinical sessions without experimental 
control (Shaw and Cruickshank, 1957 ). This study also reported 
the Rorschach as not useful in differential diagnosis of epi- 
lepsy. Differential findings for epileptics indicate that temporal 
lobe epileptics show high aggression and low neuroticism 
scores when compared to petit mal patients on a four point 



32 N.C. JOURNAL OF MENTAL HEALTH 



examiner scale (Nuffield, 1961 ). This result is open to ques- 
tion, however, in light of possible variability or scores in 
qualitative judgments on the scale. 

The general trend of information on intelligence of epileptics 
is that there are no differences between them and the general 
population, although the mean for institutionalized epileptics 
is below the general average (Kram, 1963). Unless epilepsy 
was a symptom of general brain damage affecting intellectual 
functioning, there seems to be no evidence between epileptics 
and normals or between grand mal and petit mal groups 
(Keith, et.al., 1955). However, contrary information has been 
noted in that a comparison of epileptics from both residential 
and regular schools with non-epileptics from regular schools 
showed lower scores on the Stanford-Binet Form L and poorer 
visual motor performance for epileptics (Halstead, 1957 ). In 
a study by Shaw and Cruickshank (1956) which matched 
idiopathic epileptics with a group of non-convulsive children 
on the basis of age, sex and intelligence, they found no dif- 
ference between the groups on dexterity performance as 
indicated by the Bender-Gestalt. Epileptics did have more 
difficulty, however, in spacing the figures on the paper, making 
them the proper size, and in placing them on the paper. They 
concluded that these difficulties were not due to mispercep- 
tion of the figures but possibly showed inability to organize 
their thought processes orderly. 



Education 

Most findings support the idea that the epileptic child is no 
different from the normal child except during a seizure (Kram, 
1963 ). Provided that adequate medical attention is given, most 
epileptic children can go to regular schools. The school in 
most cases rather than medical personnel should decide 
where a child should be placed for his education depending 
upon intellectual ability. The school should be informed of 
the child's condition and the teacher should be aware of the 
various forms of seizures. By and large, teachers have no 
difficulty in taking care of the convulsion. During this time 
attention should be directed toward ways of preventing the 
child from hurting himself in a fall. There may be some activity 
restriction where there is danger of head injury such as foot- 
ball or climbing (Risner and Schade, 1961; The Epilepsy 
Foundation, 1965). In school, epileptic children have a full 
range of academic achievement as do normal children, and 
placement should be made on the basis of achievement 
potential (Himmler and Raphael, 1945). 



H. SHUBERT 33 



Perhaps the single most important emphasis for the school 
teacher is to stress the potential for epileptics the same as 
would be done for non-epileptic children and to minimize 
the differences between them and others. The epileptic child's 
academic and social adjustment can be greatly improved by 
the teacher's acceptance of the problem. An objective and 
accepting teacher attitude can lead to understanding and 
acceptance by the class (Sands, 1956). 



Bibliography 

Baus, G. J., Letson, L., and Russell, E. "Group sessions for 
parents of children with epilepsy" J. Pediat. 1958, 52,3, 
270-273. 

Brain, Lord. Clinical Neurology. London: Oxford University 
Press, 1964. 

Chamberlain, H. "Some aspects of the evaluation and manage- 
ment of convulsive disorders in childhood," North Caro- 
lina Med. J. 1957, 18, 10, 453-458. 

Colver, T. and Kerridge, D.F. "Birth order in epileptic children," 
J. Neurol. Neurosurg. Psychiat. 25, 59-62, 1965. 

Currier, R. D., Kovi, K. A., and Saidman, L. J. "Prognosis of 
'pure' petit mal: a follow-up study," Neurol. 13, 959, 
1963. 

Dekaban, Anatole. Neurology of Infancy. Baltimore: The Wil- 
liams and Wilkins Company, 1959, 235-253. 

Eisner, V. and Schade, G. H. "Epilepsy in the classroom" The 
Elem. Sch. J. 1961, 61, 7, 384-387. 

Elliott, Frank A. Clinical Neurology. Philadelphia: W. B. Saun- 
ders Company, 1964, 132-159. 

The Epilepsy Foundation. Series A: Children With Epilepsy. 

Washington: The Epilepsy Foundation, 1965. 

Halstead, H. "Abilities and behavior of epileptic children." 
J. Ment. Sci. 1957, 103, 430, 28-47. 

Himmler, L. E. and Raphael, T. "A follow-up of 93 college 
students with Epilepsy" Amer. J. Psychiat. 1945, 101, 
760-763. 

Hughes, J. G. and Jabbour, J. T. "The treatment of the epilep- 
tic child" J. Pediat. 1958, 53, 1, 66-68. 

Kamin, S. H., Llewellyn, C. J., and Sledge, W. L. "Group dynam- 



34 N.C. JOURNAL OF MENTAL HEALTH 



ics in treatment of epilepsy" J. Pediat. 1958, 53, 410-412. 

Keith, H. IVl., Ewart, J. D., Green, M. W., and Gage, R. P. "Men- 
tal status of children with convulsive disorders" Neurol- 
ogy, 1955, 5, 6, 419-425. 

Kidder, T., Angle, J. S. and Dennerll, R. D. "Group counseling 
aids epileptics" J. Rehabil. 1963, 29, 4, 23-24. 

Kram, C. "Epilepsy in children and youth." In W. M. Cruick- 
shank (Ed. ) Psychology of Exceptional Children and 
Youth. Englewood Cliffs, N. J., Prentice-Hall, 1963, 
369-393. 

Lennox, W. G. "Sixty-six twin pairs affected by seizures". 
Res. Pub. Assn. Res. Nerv. Ment. Dis. 26, 11, 1947. 

Lennox, W. G. "The genetics of epilepsy" Amer. J. Psychiat. 
103, 457, 1947. 

Livingston, S., Bridge, E. M., and Kajdi, L. "Febrile convul- 
sions: a study with special reference to heredity and 
prognosis," J. Pediat. 31, 509, 1947. 

Livingston, S. "The social management of the epileptic child 
and his parents" J. Pediat. 1957, 51, 2, 137-145. 

Nelhaus, Gerhard. "Convulsions in Childhood" Chicago Medi- 
cine. 66, 14, 591-597, 1963. 

Nuffield, E. J. "Neuro-physiology and behavior disorders in 
epileptic children" J. Ment. Sci. 1961, 107, 438-457. 

Richardson, W. P., Higgins, A. C, and Ames, R. G. The handi- 
capped children of Alamance County, North Carolina: a 
medical and sociological study. Wilmington, Delaware: 
the Nemours Foundation, 1965. 

Sands, H. "Epilepsy" In M.E. Frampton and E. P. Gall (eds. ) 
Special Education for the Exceptional. Vol. Ill, 204-214. 

Shaw, M. C. and Cruickshank, W. M. "The use of the Bender- 
Gestalt test with epileptic children" J. Clin. Psychol. 
1956, 12, 2, 192-193. 

Shaw, M. C. and Cruickshank, W. M. "The Rorschach perform- 
ance of epileptic children: J. Consult. Psychol. 1957, 21, 
5, 422-424. 

World Health Organization. Juvenile Epilepsy Report of a study 

group. Geneva: WHO, 1957, Tech. Rpt. Ser. No. 130. 

Zimmerman, F. "Explosive behavior anomalies in children on 
an epileptic basis" New York State J. of Med. 1956, 56, 
2537-2543. 



35 



A PSYCHIATRIC SOCIAL WORKER IN A 
COMMUNITY HOSPITAL 



George M. Johnson, ACSW 

Wilson County Mental Health Clinic 



in all medical practices there are patients whose com- 
plaints are not in keeping with the physical findings, many of 
which are minor. Such individuals are often hospitalized by 
the physician who, in order to adequately evaluate the com- 
plaints, performs extensive diagnostic evaluations with per- 
haps temporary improvement in symptoms. Yet, since the 
home environment remains the same, a cycle is formed with 
resultant multiple hospital admissions. There has been in- 
creasing recognition of the role emotional or functional factors 
contribute to the illnesses of such patients. Frequently over- 
worked private practitioners are being expected to treat the 
emotional as well as the physical aspects of the patient's 
illnesses. 

The members of the Department of Internal Medicine, Wilson 
Memorial Hospital, Wilson, North Carolina, in the absence of 
available psychiatric consultants, requested the services of a 
Psychiatric Social Worker (PSW ) from the Mental Health 
Clinic on a trial basis. The provision of services by a PSW was 
approved as a part of the responsibility of the clinic by repre- 
sentatives of the medical staff, the Mental Health Clinic and 
the State Department of Mental Health. This paper is a report 
of the project and covers 2 years experience (Aug.-67-Aug.-69 ) 
in providing mental health social work consultation to patients 
for private physicians in a general hospital. 

The Mental Health Clinic has a full time psychologist, psy- 
chiatric social worker, receptionist, nurse, and a secretary; 
also five part-time psychiatrists, three psychologists, and a 
physician. It is governed by an advisory board and the admin- 
istrative board of the Wilson Memorial Hospital whose assistant 
manager is administrative director of the Clinic. 

The hospital, opened in 1964 with 254 beds, serves Wilson 
County (Pop. 57,716) and 5 nearby counties, one of which, 
Greene, shares in the services and financial support of the 
Clinic. 

To obtain the services of the PSW, the referring physician 



36 N.C. JOURNAL OF MENTAL HEALTH 



wrote an order on the chart, instructing the ward secretary 
to contact the Mental Health Clinic, giving the name and 
room number of the patient. By arrangement the Hospital 
provided an office on the respective floors for the patient's 
interview with the PSW. Among the many topics discussed 
during the 60-90 minute interviews were early home environ- 
ment, health, education, employment, marriage, financial 
status and emotional involvement — past and present. Some 
patients had been nervous and unable to sleep. Others were 
irritable and sensitive. In many cases patients were reared in 
an environment of alcoholism, infidelity, poverty, and other 
situations that did not contribute to emotional adjustment or 
development of adult maturity. Some were eager for help, 
others ignored or stubbornly resisted it. The PSW learned that 
a positive approach — honesty with warmth and understanding 
— was effective in allaying suspicion and doubt. The hospital 
setting was conducive to a patient's giving of himself so that 
his problem might be resolved in such a way as to help the 
patient help himself. Generally most patients soon said they 
felt better, their manner and tone of voice reflecting their 
feelings. 

During the 2 year period 74 patients were seen in Wilson 
Memorial Hospital. The total admissions to the Clinic during 
that time were 618. The total number of interviews in the 
Clinic by the PSW was 1,089 and included follow-ups on 
patients from the hospital to whom appointments were given. 
Of the 74 patients seen in the hospital, 27 were males with 
an average age of 39.26 and 47 females with an average age 
of 37.4. 

The referring physician promptly received a social history 
from the PSW, and subsequently the Mental Health Clinic 
received a copy of the discharge summary from the referring 
doctor. There were no formal conferences between physicians 
and the PSW, with the exception of brief meetings on the 
ward. Other members of the hospital staff became interested 
in the services provided and contributed greatly to patients' 
acceptance of the service and adjustment to the hosptial 
routine. 

Characteristic of general hospital admissions, there were 
frequently 3 and sometimes 4 to 5 discharge diagnoses listed 
in the medical records of the 74 patients. An example, (1 ) 
fever undetermined cause, (2 ) anxiety depressive reaction, 
(3 ) headache due to muscular contraction, (4 ) anemia, mild. 
Thus from the many different discharge diagnoses, some 
duplicated, the chart below will indicate the 4 main categories 



G. JOHNSON 37 



into which each patient seen was classified. 

No. Per Cent 

A. Primary Physical diagnosis 22 30 

B. Primary Emotional illness or 

diagnosis with physical symptoms 22 30 

C. Primary Emotional illness mani- 
fested by anxiety or depression 
and no secondary or tertiary 

organic diagnosis 22 30 

D. Primary Emotional (Anxiety or 
Depressive ) with secondary or 

tertiary physical diagnosis 8 10 



74 100% 

Even though in category A the patient was admitted pri- 
marily due to a physical symptom there were frequently latent 
emotional problems, that influenced the necessity of hospitali- 
zation. Many patients were aware of but were unwilling to 
accept the emotional involvement as a contributing cause to 
their illness. Some readily admitted being nervous, others 
denied it. In some instances it was difficult to establish good 
rapport before the patient left the hospital. The Psychiatrist 
in the Mental Health Clinic subsequently saw 16% of the 
patients seen in the hospital, the referral having been approved 
by the physician. The remainder were given an additional 
opportunity to visit the Clinic and talk with the PSW; however, 
only four patients chose to do so. It was surmised that of the 
patients seen in an earlier stage of emotional illness many 
responded more quickly and made a fairly satisfactory adjust- 
ment to their environment. 

To many patients the word Psychiatry was synonymous 
with mental illness or a state mental institution. They usually 
said, "I'm not crazy. My mind is alright. I am just nervous." 
Several illustrative case reports are here presented. 

One 22 year old female patient, 
stenographer with a previous hos- 
pitalization, presented with somatic 
complaints and cried as she talked. 
Being an only child, she was pro- 
tected by her wealthy parents. The 
physical findings were negative. She 
confided that she feared she had a 
brain tumor and for the past 12 
months had remained at home, 
tired, listless, and discouraged. Dur- 



38 N.C. JOURNAL OF MENTAL HEALTH 



ing the second interview she said, 
"Do you mean to tell me I'm not 
sick?" A few days later, follwoing 
her discharge from the hospital, she 
resumed her work and within a rea- 
sonable length of time made a sat- 
isfactory adjustment in the home, 
community, and on the job. 

A 12 year old female, who was 
pleasant and outgoing, supposedly 
did not have good use of her lower 
limbs, especially when she had 
exams at school or was assigned 
chores she didn't wish to do. She was 
favored by her solicitous parents 
and 4 siblings. Her physical condi- 
tion was good. The onset of her 
complaints, following being frigh- 
tened 4 years earlier during a thun- 
der storm, gradually became worse 
and resulted in her mother's caring 
for her like an infant at times. The 
patient observed instead of partici- 
pating in school activities. She be- 
came interested in boys and had 
asked her mother if she, the patient, 
could ever have any children. After 
discharge and on her second visit to 
the Clinic she smiled and said, "I can 
play some now and my knees are 
getting better." With the coopera- 
tion of her parents she became more 
concerned about her peer group and 
less interested in her "handicapped" 
condition and has returned to full 
time school activity without interrup- 
tion. 

In an attempt to obtain some follow-up on the effects of 
the interviews the PSW sent a questionnaire to the 74 
patients; only 24 were returned and of these, 5 persons did 
not check an answer. In the unchecked group 2 relatives, 
writing for the patient, indicated they were ill physically and 
unable to respond. Among the group responding several wrote 
complimentary and encouraging notes. Responses to the 
question "To what extent was this visit by the Social worker 



Number 


Per Cent 














3 


13 


16 


67 


5 


20 



9 


38 


6 


25 


2 


8 


1 


4 








4 


17 


2 


8 



G. JOHNSON 39 



helpful to you?" were as follows: 

Degree 

None 

Slightly 

Moderately 

Greatly 

Unchecked 

In a like manner 24 patients checked the following state- 
ments: 

Number Per Cent 

It helped me get things off my chest 

I looked at my problems more realistically 

It gave me sound information 

It clarified some questions 

It was of no value to me 

(Incorrectly checked ) 

(No check) 

24 100% 

A follow-up questionnaire on each patient was also sent to 
the 5 physicians specializing in Internal Medicine, who re- 
ferred the 74 patients. The question "To what degree was the 
Social Work Consultant useful in the diagnosis in this 
patient's complaints?" was answered as follows: 

Degree 

None 
Slightly 
Moderately 
Greatly 

74 100% 

The physicians also answered the question, "To what extent 
was the visit by the PSW helpful in the treatment of the 
patient?" Their results are here compiled. 

Degree 

None 
Slightly 
Moderately 
Greatly 

74 100% 

The results suggested that the combined efforts of the 
physician, the psychiatrist, and the PSW working in the same 



umber 


Per Cent 


3 


4 


7 


9 


45 


61 


19 


26 



Number 


Per Cent 








4 


6 


18 


24 


52 


70 



40 N.C. JOURNAL OF MENTAL HEALTH 



setting can accomplish more in less time with encouraging 
results. 

As time passed the distance of five miles to the hospital 
seemed less far and within the not too distant future, perhaps 
in 14 months, it is anticipated that a new facility, a compre- 
hensive Mental Health Center, will become a part of the 
Wilson Memorial Hospital. At that time we will be in a better 
position to render greater psychiatric service to patients from 
Greene and Wilson Counties. 



SUMMARY 

1. A report is presented of a project in which a Psychiatric 
Social Worker assisted private practitioners in the care of 
their patients in a community general hospital. 

2. Of those patients responding to a follow-up questionnaire, 
80% indicated that the consultation with the PSW was 
moderately or greatly helpful. 

3. Results of a questionnaire to the referring physicians 
indicated that 94% responded that the consultations were 
greatly or moderately helpful and 6% slightly helpful. 

4. In this time of progressing medical manpower shortage 
and increasing recognition of the importance of appro- 
priate treatment for the emotional illness in patients seen 
by practicing physicians in general hospitals, it is deter- 
mined that a Psychiatric Social Worker, as a member of 
the health team, can provide a significant contribution in 
improving patient care. 



Authors Note: I am indebted to Clifford B. Reifler, M.D., Asso- 
ciate Professor of Psychiatry, University of North Carolina 
Medical School, Chapel Hill, N.C, who worked closely with me 
in the preparation of the report. I am also indebted to John L. 
McCain, Internal Medicine, Wilson Memorial Hospital, Wilson, 
N. C, who made most helpful suggestions in finalizing this 
report. 



41 



DIFFERENCE IN POPULATION SERVED BY 

PRIVATE AND PUBLIC MENTAL HEALTH 

SERVICE IN A RURAL COMMUNITY 



Philip G. Nelson, M.D. 

Greenville 

Lacoe B. Alltop, M.S.P.H. 

Biostatistician 
N.C. Department of Mental Health 

Dorothy Lemley, M.A. 

Assistant Director 
Coastal Plain Mental Health Center 



introduction 

The question has often arisen as to whether the public 
mental health clinic might not be in competition with the 
private psychiatric practitioner. Some years ago in the Pitt 
County Commissioners Meeting the thought was expressed 
that perhaps the private psychiatrists were reducing the patient 
load of the public clinic. Thus not only did some feel that the 
private practice of psychiatry might be hurt by the public 
clinic, but in at least one situation, the idea arose that the 
private practitioner might be treating patients who one would 
expect to find in the public clinic patient load. We thought 
that the facts might be worth pursuing in the rural community 
of Greenville, North Carolina during the period of 1966-1967. 

Our study grew out of the Tri-County Psychiatric Case Study. 
In July 1964 the Tri-County Psychiatric Case Study began 
collecting data on mental patients in three counties. Orange, 
Durham and Wake. Basically, this study was a demonstration 
project, funded by the National Institute of Mental Health, 
which was able to plot the patterns of utilizations of mental 
health services by patients in these three counties. As patients 
moved in and out of the various mental health services such as 
state mental hospitals, general hospitals with psychiatric 
services, mental health clinics, child guidance clinics, vet- 
erans hospital, private psychiatrist and psychologist, and etc., 
information was collected and tabulated. The mechanism 
established by this method permits an investigator to study 



42 N.C. JOURNAL OF MENTAL HEALTH 



populations without a patient being counted more tiian once 
and in only one population group. 

In 1965, both of the Directors of the private and public 
mental health services were contacted regarding their partici- 
pation in this study. Both agreed. 

It was decided to use the same source documents, and the 
same methodology of handling the data as was used in Tri- 
County Psychiatric Case Study. Collection of data on patients 
served in both of these services began in the latter part of 
1965 and continued until about the middle of 1968. Later it 
was agreed that the data collected during the two calendar 
years, 1966 and 1967, were the most representative of the 
services rendered. 

The purpose of this study was to determine if these two 
services served only one population in need of mental health 
service or were there two different populations existing in this 
rural community. Also, a description of the population (s ) 
utilizing these services was desired. 

Methodology 

Information on patients was collected and periodically 
forwarded to the Division of Statistics where the data were 
punched in the cards and stored. After all the data had been 
collected, the cards were matched to identify those patients 
who had received service in both services, and also, those 
patients admitted more than once to either of these services. 

Some of the patients had utilized both services for at least 
one visit. If a patient had been admitted to either of these 
services then referred to the other one, he or she was identi- 
fied with the population to which he or she was referred. 
Therefore, a patient was either identified in the private popu- 
lation group or public, not both. Also, if a patient had been 
terminated then readmitted, he was still only counted once— 
his or her first admission. 

There are 810 patients in the private population group and 
474 in public thus giving a total of 1,284 patients in all. 



Analysis 

There are three methods of analysis used in this study. The 
frequency distribution indicates the number and the per- 
centage distribution reveals percentage in each cell for both 
of the services. The statistical test— Chi-square— was used to 



p. NELSON, L. ALLTOP, and D. LEMLEY 43 



determine if there was any relationship between the type of 
mental health service and the specific factor. The level of 
significance was set at the 95 percent level. 

(a ) Age Group. 

Both populations were divided into nine age groups as 
shown in Table no. 1. The population under 18 years of age 
made up one-third (33.3 percent) of the public population 
whereas for the private only 13.7 fell in these two groups. The 
older population was more apt to go to private service than to 
public. The Chi-square was 109.49 which is significant thus 
indicating there was a relationship between age and type of 
service. 

(See Table 1, Page 48) 

(b) Marital Status. 

The two groups, single and married, accounted for nearly 90 
percent of these two populations as noted in Table no. 2. The 
highest percentage group for the public service was the single 
group and for the private the married. It was only in the married 
group that the private service had the highest percentage, but 
we must keep in mind that the private served nearly 70 percent 
more patients than the public. Here again the Chi-square 
(23.30) was significant and indicates a relationship between 
marital status and type of service. 

(See Table 2, Page 49) 

(c ) Environment. 

Using the same definition for rural-farm, rural-non farm, and 
urban as the U. S. Census, Table no. 3 gives a breakdown of 
environment in which the patient resides. The Chi-square 
(17.02) again was significant. The analyses indicate that 
patients from the rural areas are more apt to go to the private 
service and the urban population to public. Nearly a third of 
the patients seen in the private sen/ice came from rural as 
compared to about one-fifth of the public. 

(See Table 3, Page 50) 

(d ) Employment Status. 

As might be expected, the highest percentage of patients 
seeking service in private service were employed whereas in 
public it was the unemployed. This is shown in Table no. 4. 



44 N.C. JOURNAL OF MENTAL HEALTH 



Also, housewives made up approximately one-fourth of private 
population but only about one-seventh of public. The Chi- 
square of 114.21 was significant thus, again, indicating a high 
degree of relationship between employment status and type 
of service. 

(See Table 4, Page 51) 

(e ) Occupation. 

In coding information regarding housewife, pre-school child, 
or student, the occupation of the head of the household was 
noted. If a person was retired, the occupation which he was 
most closely identified with was recorded. Again, using the 
definition as defined by U. S. Census, the occupation for these 
populations are given in Table no. 5. Approximately one-fourth 
of the patients seen in public service came from a family 
where the head of the household did not have an occupation. 
It is suspected that in this group many may not have wanted 
to state their occupation, in addition, probably some of those 
with unknown occupations were included. Numberwise, the 
private service had nearly four times as many professional as 
the public. Also, the biggest difference came in the farmers 
who were more apt to go to private than public sen/ice (7 
versus 119). The Chi-square of 137.38 was significant. Thus 
again, indicating a relationship between the occupation of 
the household and the type of service. 

(See Table 5, Page 52) 

(f ) Education Level. 

Table no. 6 shows the educational level of these two popula- 
tions. This table, no doubt, is closely related to the finding in 
Table no. 1, which deals with age groups. Similar to Table no. 
1, those patients in lower educational levels are more apt to 
be seen in public services and those in higher levels, in the 
private services. The chi-square of 191.70 was significant. 

(See Table 6, Page 53) 

(g) Prior Outpatient Service. 

The prior outpatient status of patients was either "no previ- 
ous outpatient service", at "this clinic", or "another outpatient 
service." If a patient had previous service at this clinic and 
also at another outpatient service, he or she would be counted 
with the "other" group. Table no. 7 reveals that approximately 



p. NELSON, L. ALLTOP, and D. LEMLEY 45 



two-thirds of the patients had never had previous outpatient 
care. Approximately one-sixth of the patients in both services 
had received care at another outpatient service. The Chi- 
square of 51.95 was significant. 

(See Table 7, Page 54) 

(h ) Prior Inpatient Service. 

A little higher percentage of the patients had never had 
previous inpatient service for a mental condition than those 
for prior outpatient service (75.5 versus 66.7 percent). As 
shown in Table no. 8, both services render after-care service 
with about one-fifth of the public population and one-eighth 
of private falling into this category. Here again, the Chi- 
square of 22.28 was significant. 

(See Table 8, Page 55) 

(i ) Source of Referral. 

In both the public and private mental health services, the 
major source of referrals were private physicians as revealed 
in Table no. 9. The kecond major source in both of these serv- 
ices was self referrals. Less than 2 percent of the total popula- 
tion was referred from psychiatric inpatient facility. It would 
appear that during the time of this study not many aftercare 
patients were referred to either of these services. As might be 
expected, social and welfare agencies were more apt to refer 
patients to public service rather than the private. The Chi- 
square of 196.42 was significant. This, again, indicates a rela- 
tionship between the source of referral and type of service. 

(See Table 9, Page 56) 

(j ) Treatment. 

1. Therapy A includes individual, educational, family and 
the combination of these therapies. IVIany of the patients 
didn't receive any of this type of therapy as shown in Table 
no. 10. Of the three therapies, individual therapy was more 
apt to be the one selected. The Chi-square of 12.86 was 
significant. 

(See Table 10, Page 57) 

2. Therapy B includes such therapies as group, chemo, 
somatic, and the combination of these three groups. Slightly 
over 20 percent of the population received any of these three 



46 N.C. JOURNAL OF MENTAL HEALTH 

therapies as shown in Table no. 11. 

(See Table 11, Page 58) 

(k) Number of Interviews. 

At least one half of the patients had over two interviews as 
noted in Table no. 12. The median number of interviews in 
public service was 2.7 and slightly lower in private -2.6. There 
were five patients in public service and 8 in private who had 
50 or more interviews. 

(See Table 12, Page 59) 

(1 ) Disposition. 

Looking at Table no. 13, the biggest discrepancies occurred 
between the two services regarding disposition of the patients. 
Approximately one-third of the patients withdrew from both 
services because of illness, moved, and etc. but they did notify 
the clinic or private psychiatrist that they were not returning. 
In the second category, approximately 36.7 percent of the 
public and 5.6 percent from private service without notifying 
psychiatrist of their intentions. The private service terminated 
15.3 percent of their population without further referrals 
whereas only 2.1 for service. Where additional care was needed 
and not available, 22.3 percent of private patients fell into 
this category whereas only 4.6 of the public patients. The 
public service referred a higher percentage (4.0 ) of their popu- 
lation to public mental health services than private which only 
sent 0.4 percent. 

The Chi-square of 325.10 indicates a significant relationship 
between the type of service and disposition of patients. 

(See Table 13, Page 60) 

Summary 

In the rural community of Greenville, North Carolina, during 
the period 1966-67 the private and public mental health 
service administered to two populations. The patients served 
by the private mental health service were older with a higher 
education level. Also, the private service treated more of 
rural population whereas the public mental health service 
was more apt to see a greater proportion of the urban popula- 
tion. The private served a greater proportion of full time em- 
ployed, retired, and housewives whereas the public sen/ice 
dealt with students and the unemployed. 



p. NELSON, L. ALLTOP, and D. LEMLEY 47 



Even though private physicians referred patients to both 
services, the private service received the greatest number and 
proportion of these referrals. Self, family, and friends re- 
ferrals were more apt to go to the public service. Referrals made 
by private psychiatrist to public mental health service made 
up the fourth highest group for the public service. 

As might be expected the professionals, farm owners, or 
managers, and private proprietors along with their dependents 
were more apt to be served by private service whereas the 
craftsmen, laborers, and those without a job classification 
were more likely to go to public mental health clinics. 

Patients who had previously been hospitalized for mental 
illness or had previous outpatient care were more apt to go to 
public mental health clinics. The major proportion of the 
private service patients had not received mental health service 
prior to their admission. 

The disposition of these populations were significantly 
different. Many of the patients at public mental health clinics 
terminated treatment without notifying the clinic. Public 
health clinics referred more to public mental hospitals 
whereas the private service referred many of their inpatients 
to other than a public mental hospital. 

Patients going to the private service were more apt to 
receive individual or group therapy than at the public mental 
health service. 



48 



N.C. JOURNAL OF MENTAL HEALTH 





"D 


"D 


H 




■V 


-D 


H 


CO 


' 






— ?_ 


c 







-^ 


c 





(D 








<' 


a; 


r-t- 




<' 


CT 


i-i- 

0) 











(D 


0" 






0) 


0' 




H 








1— ' 


1— » 


1— ' 








1—' 











O 










00 


4^ 


[V> 


r-h 








o 










1 — ' 


■^ 


00 










b 


b 


b 







4^ 


4^ 




c 
Q) 3 








hO 


1— ' 






I—* 


I—" 


A 


=J D- 






en 


00 


ro 




4^=* 


1—' 


en 


1 — i 


Q. CD 






00 


b 


I—' 




00 


M 


en 


4^ 

1— ' 


H 

^K 






00 


<Xi 


00 




CT) 


4^ 


1—' 

I—" 


f. 


^ -D 






4^ 


^ 


b 




00 


cn 


4^ 


1—' 

1 — ' 


(_ r-(- :d 






-1^ 


00 






1 — ' 
I—* 


^ 


I— » 
en 


00 


tage 
al He 
Greei 
uly 1 






4^ 


b 


4^ 




--J 


M 





ro 





3 


















Distributior 
alth Servic* 
iville, NortI 
, 1965-Jun( 




5i ^ 
S II 

Z2 

^ o 

Tl ^ 


I—" 
1— ' 

1—' 


00 
b 

1—' 


1—' 


4^ 


13 
CD 


(D 

13 
r+ 


1—' 


4^ 


00 
4^ 

rv> 


Age Group 
21-24 25-34 


H 

CD 

z 




4^ 


•X) 


cr> 


00 


OfQ 


en 


■vj 


00 


(D _) lU — 




A ^ 


(Ji 


b 


So 


a> 


00 





4^ 


00 oW ^ 

QJ v^ _„ 


—^ 


b 

I—' 


















- -! ^ T) 




1—' 
CD 

Id 


1 — ' 
(JI 


I—" 

00 
I—" 




I—" 

1 — ' 


■^ 
M 


00 

00 


00 
en 

4^ 


atients 
Selecte 
olina 
1967 




















-P^ 


Q- CO 






I—" 


1 — ' 


t— ' 








I—" 


en 


(JQ < 




- 


I—" 





1—' 




(D 


4:^ 


4^ 






(ji 


H- ' 


b 




00 


00 


1—' 


en 
en 


CD CD 
CD^ 

=>■ 






en 


4^ 


en 




4^ 


t— ' 


CJ> 


en 


1^ 






b 


b 


k) 




00 


UD 


-vj 


CT) 























y <■ 

CD 
(-1- 




















?s 


03 






N) 


1—' 


ro 




N) 




00 








bo 


b 

1 — ' 


en 
1— > 




00 


UD 




c: 








b 


^ 


k) 




•-vj 


00 


en 







p. NELSON, L. ALLTOP, and D. LEMLEY 



49 



CM 

d 



■o 

O) - 

<D ^ 

(/) ro 

iT) CO 

-4-' 

c — 

<D TO 

._ -t-J 

-t-" ■ — 

M— 

o >, 

.9 oJ 



.E CT) 



ro o 
O c\J 

O =3 



ao CD 

c 

CU TO 
? 0) 

J;; -^ 
ro 03 

s- > 

XI CL 

E 

3 



+^ -— CT> 



-^^ C3 3 



CL 



en 

"to 

I -E 

°^ TO 



^D 



r^ 



CD 




ao 

c 






in 


CO 






•^ 


CD 

4-' 


00 


o 


CNJ 


1- 


r—i 


^_ 




o 





■*-• 


CD 


o 


-t-l 


cu 


O 


(/) 


1- 



v£i 



CT) 



in 



cu 

CD 

c 
d) 
o 

cu 
Q_ 



C\J 



en 



<N 



CvJ 



r^ 



CD 



o 

00 
CO 



•K 


V 


Q 




CO 


CL 


CO 


^-^ 


CNJ 


+-> 




C 


II 


CD 




O 


X 


H^ 




'c 




QD 



C/) 



50 



N.C. JOURNAL OF MENTAL HEALTH 



CO 

2 II 

r-h i-i 

'-' b 

A * 



<X) 



00 



(D 

o 

CD 

I-+ 
O) 
OQ 
CD 



IV> 



y:z 



— ^ 
3 



Z3 
< 

O 

Z3 

3 

(D 

=3 





^3 




^^ 




0) ^ 




=! QJ 




Q- 3 




_„ Q. 




Tl 




C TJ 


(_ 


O" CD 


c O 


^'2 


i_i CD 


- =5 


CD 0) 


< 


Z5 OQ 


1 — ' — 


'-^- CD ^ 


^ :;r 


a) ^ 


(y)P 


~2 ^ 


Z^ 


CD ::+ ™ 


c o 


0) Z. 2 


=5 ;=+ 


^? o 


CD =r 


IT C 




r-t- 


00 o c/5 5' " 


O CD 


CD 3 


-^ 


-^ 


, o 


< o 


1 — ' i_ 


if Rati 
ice, b 


ID 5' 




^ CD 




m2- 




Z5 (/5 




< 




o fD 




^ ^ 




3 fi> 




m CL 



p. NELSON, L. ALLTOP, and D. LEMLEY 



51 





•a 








c 








ro 








0) 








+-< 








ro 








> 








'v_ 


c/T 






Q- 


13 






c 


TO 








C/) 






"O 








(U 


-1-' 






> 


c 






^- 


<u 






0) 
CO 


E 








>% 


r-~ 




to 


o 


J5 ID 

.E CJ1 




-t-' 

c 


Q. 




QJ 


E 


o^ 




+-' 


UJ 


^_ 




TO 




TO O 


^ 


Q- 


^oro 


. 


M— 




SZ (U 


o 
Z 


o 

c 


O 


O =5 


« 


o 


■^ 


^5 


S3 


13 


cu 


• — 1 — 1 
> 




JD C/) 




(/5 


•*— ^ 


c - 




Q 


TO 
0) 


cu " — 

9^ >^ 




03 


X 

TO 


CD =5 




-I-' 


-t-> 






c 


c 






<v 


CD 






o 


^ 















Q_ 


o 






■o 


5 






c 


=3 






TO 


Q_ 






^- 








0) 








^ 








E 








3 







CO 

■+-I 

c 
cu 
E 
_o 

Q. 

E 

UJ 



o $ 

X 



S a; o 

"O CL o 

E CO 



CO 



(D 

■o 

(U 
Z) CL 



+j (U 
TO E 



_ cu 
■5 E 



00 


o 


CO 




.—1 


CD 


00 


(^ 


in 


CNJ 




Lfi 


CD 

I— 1 


CNJ 


00 


00 


O 




<J] 


CO 


r^ 


UD 


<X) 


O 




<D 


"vf 


•=:t 


C\J 




CNJ 




C\J 


I— 1 


C\J 


o 


in 


in 




CO 


VD 


CO 


lO 


^ 


o 




l< 


d 


iri 


CO 


I— 1 


C\J 




C\J 


CO 


C\J 


^ 


CO 


I— 1 




1 — 1 


UD 


^ 


1— 1 




T— 1 


OX) 

TO 


1 — 1 


CD 


r— 1 


I— 1 


C\J 


cn 


cu 


CO 


U3 


CO 


r^ 


r— 1 


LO 


CO 


CO 


r^ 


t— 1 


r-l 




cu 

CL 


1 — 1 


CNJ 




o 


I — 1 


en 




CO 


CO 


CO 


CO 


.— 1 


r— 1 




c\j 


CNJ 


CNJ 


00 


in 


CO 




•^ 


O) 


CvJ 


r^ 


00 


cn 




cr> 


r^ 


CD 


CO 




C\J 




C\J 


I— 1 


CO 


-st- 


^ 


o 




q 


q 


o 


00 


r^ 


I— 1 




CD 


CD 


CD 


CN 


^ 


00 




o 


o 


O 


.— 1 








I— 1 


r-l 


.— 1 




o 


-t-j 






o 




^^ 


■^ 


TO 




^— 


'"" 


TO 


TO 
-t-J 


J2 


> 




TO 
-I-' 


JD 


> 


o 


3 


'^_ 




o 


Z2 


'i_ 


1- 


Q_ 


Q_ 




1- 


Q_ 


CL 



.— 1 


V 


CNJ 


Q_ 


^ 




t— 1 




1—1 




II 


TO 


O 


c^) 


M— 


X 


'c 




.op 




In 



O — - 

■t-> — 

o 
cu 
(f) 



52 



N.C. JOURNAL OF MENTAL HEALTH 



CO 

n> 
o 

r-h 

:::;■ ~ o 



CD 


c 
o' 


H 
o 

r-t- 




T) 
CD 


c 
a; 

0' 


H 



O 
O 

b 


1— > 
O 

o 
b 


o 
o 

b 




00 

1— ' 

o 


4^ 
4^ 


1 — ' 

N) 
00 
4^ 


00 

b 


00 

bo 


1—' 

00 

b 




CJI 


1—' 
1—' 
00 


1— ' 
00 


1 — ' 

00 

b 


00 

b 


I—" 

00 




1 — ' 

4:^ 
cn 


00 
00 


1— ' 
00 
4^ 


1—' 


1— ' 

CJI 


CD 
00 




1— ' 
1 — ' 

CD 


^ 


I—" 
0^ 


b 


cn 


00 
00 


CD 

O 
CD 

13 
i-i- 

era 

CD 


00 






I—' 



4^ 


b 


-1^ 

4^ 




00 


I—" 
CD 


(Si 






00 
b 






00 


1— > 

1—' 
1 — ' 




1 — > 
C71 

b 


1 — ' 
o 
b 




cn 


4^ 


1—* 
CO 

cn 


1—' 
1—' 

cn 


1—' 

p 

1—' 


b 




CD 
00 


4^ 
00 


I—" 

4^ 

1 — ' 


1—' 
b 


I—" 


1—' 
b 




00 




1— ' 
1—' 
4^ 


4^ 



3 








D" 




CD 








CD 

:3 










c 


HD 











O" 


CD 




_— h 






0' 



CD 

=3 
r-t- 




-n 


( 




CD 


era 

CD 




CO 


c 


CD 


13 




-^ 






r-h 




3 


^ 


CD 
CD 


Q) 







CD 


I—" 








-^ 




3 


X 


<y5' 




(/) 




< 


CD 
0) 
i-i- 

ZT 


i-t- 




0) 


I—* 
CD 

cn 
(ji 


p 


cr 

c 




13 


2 


(f) 


0' 


CD 


OfQ 


c 








=3 


z 




3 

CD 




^ 


0^ 





CO 


00 



CD 


"D 


cn 







Q) 




CD 






CD 


I—" 




a- 


cd' 






VD 

cn 


5' 

0) 






c 
■a 


3 

I-+ 

(/) 

C/) 
CD 

5 




CO 






i-h 


CD 




Q) 






0' 


Q. 




CD 






rj 







(f> 






(/5 






^ 








<' 




0) ^ 








CD 




^ ? 








0) 
Q. 




? ^"° 












IT Z. 












5. c < 













p. NELSON, L. ALLTOP, and D, LEMLEY 



53 



CO 

d 

z 

X3 



> 

_j 
■o 

C c 

<u o 

CO ■-4-' 

ro >, o ^ 

Q_ ^ i- ^ 
TOO 

o ^t^ ^ 
■■^ a^S^ 



a; 



iS -!± CD 3 
o ^ 

0) O 

1- -a 

£ 

3 



O 

c 

c 
Z) 



o o 

(U ^ 
Q. O 
COCO 

<u 

-t-" — 

ro o 

=5 o 

-o -c 






X 



o 



en 



o 

I- 



o 

4-' 
O 

CD 
CO 



UD 






ID 



iJD 



00 



OyQ 

c 
a; 
o 

u_ 

<v 
a. 



CN 



CD 



00 



o 



O 


V 


r-. 


Q. 


r—t 


^_^ 


(Tl 




■1— 1 




11 


TO 


O 


C<l 


■4— 


X 


'c 




QD 



CO 



54 



N.C. JOURNAL OF MENTAL HEALTH 



Table No. 7 

Number and Percentage Distribution of Patients Served in 

Private and Public Mental Health Service, by 

Prior Outpatient Service 

Greenville, North Carolina 

July 1, 1965-June 30, 1967 



Prior Outpatient Service 



Sector 


Total 


None 


This 
Clinic 


Other 


Unknown 


Total 


1284 


857 


109 


206 


112 


Public 


474 


254 


70 


71 


79 


Private 


810 


603 


39 


135 


33 


Percentage 


Total 


100.0 


66.7 


8.5 


16.0 


8.7 


Public 


100.0 


53.6 


14.8 


15.0 


16.6 


Private 


100.0 


74.4 


4.8 


16.7 


4.1 



X2 = 51.95* 
Significant (P < .01 ) 



p. NELSON, L. ALLTOP, and D. LEMLEY 55 



Table No. 8 

Number and Percentage Distribution of Patients served 

in Private and Public Mental Health Service, by Prior 

In-patient Service, Greenville, North Carolina, 

July 1, 1965-June 30, 1967 







Prior 


n-patient S 


ervice 


Section 


Total 


None 


Yes 


Unk. 


Total 


1284 


970 


199 


115 


Public 


474 


295 


95 


84 


Private 


810 


675 


104 


31 


Percentage 


Total 


100.0 


75.5 


15.5 


9.0 


Public 


100.0 


62.3 


20.0 


17.7 


Private 


100.0 


83.3 


12.9 


3.8 



X2 = 22.28* 
^Significant (p<.01 ) 



56 



N.C. JOURNAL OF MENTAL HEALTH 





c 


o 


C/3 


o 


tn 


-0 


O 


TJ 


O 


■V 


T) 


-n 


C/5 


H 






o 




O 


o 


o 


<fl 










Ul 


a> 


fD 


o 






17 
fD 


3- 
O 


c 
</> 

03 


o 


O 

3- 
O 


fD 


<' 

Oi 
fD 


fD 

o 


< 

0) 
fD 


5" 

XI 


3 




cu 






3 






3 


3 




fD 


■0 


-0 


-V 


Qi 


-n 
















Q. 
O 


Q. 


fD 

3 


Q. 


3- 
■< 


o 


>< 


-n 


5' 

3 
















01 


fD 


CD 


o| 






cu 


Q. 
















3 


ET 


O 

fD 


O 


a)' 

3 






o 


















5" 


(D 






























U) 


> 

TO 
O 






Ol 










to 


ro 


z 

c 
3 
cr 

fD 




w 


ID 


cn 


H-i 


00 


1—^ 


hO 






Ul 


K) 


ID 


o 


CO 


' 


Ol 


ID 


^ 


00 


Ul 


cn 


to 


s^ 


ID 


^ 


00 


O 


Ul 


-Pi 


































* 






























"□ 


TO . 
















*» 










^ 


o 


fD 


1. ^ 


ro 


^ 


Ol 


H^ 


ro 


i-" 


►-' 


^ 


O 


■p' 


^ 


~~J 


Ol 


o 


n 

fD 


O II 


-vj 


00 


Ko 


b 


■^ 


Ko 


■~J 


bo 


^ 


4^ 


bo 


b 


b 


b 


3 


a> 
































3 I-" 
































r+ ID 
































^ CTi 
































T3 j^ 






























Z 


A "^ 
















H-» 












■P> 


C 

3 


1— t 


ro 


w 




00 




1 — 1 


-P^ 




(Ji 


t— > 


Ul 


CD 


^ 


b 


o 


o 


-p^ 


0^ 


t\o 


CTi 


o 


00 

00 


00 


O 


■t^ 


00 


00 
ro 


-Pi 

o 


fD 

■D 
fD 




N5 


-P» 


Ul 


>-• 


O^ 


i-- 


ro 




o 


o 


00 


i-- 


p 


o 


O 

fD 

3 




b 


N) 


l—L 


00 


bo 


00 


b 


fo 


cn 


cn 


b 


fo 


■~j 


b 
































































Z 


















-Pi 










!_• 


00 


C 

3 




ro 


^ 


■P^ 








t— ' 


cn 








00 


o 






CJl 


ID 


00 


^ 


00 


ID 


hO 


cn 

CJl 


cn 


^ 


ID 


^ 


^ 


o 
o 


cr 

fD 

-a 

fD 




00 


ID 


Ol 


o 


o 


i-" 


I-" 


;-J 


p 


o 


H-- 


-Pi 


00 


P 


O 

fD 

3 




j_. 


00 


00 


b 


i:» 


^ 


Ul 


Ol 


^ 


b 


^ 


cn 


Ko 


o 







































c: 









3 




CO 


3 


Q- 




o 


"D 


CD 




o 




CD 




0) 


0) 


rs 






r-t- 


Q. 




o 


(D 






<_ -+- 




TI 




E :o 


=3 


CD 




vc fD 


Q. 


O 




-+i 




CD 




1—1 O 


Tl 


13 




ID- 


c 
a; 


(-+ 

CfQ 
CD 




(1. CD 


o' 




CT 


^ 


O 
CD 


(B 


§1 

CD 5. 


r-l- 


cr 


z 

o 


^p 




c 


CO 


X 


o 




Nort 
, 196 


CD 
0) 


o 




ZT 


— h 




o 


CO 

(D 


(-1- 




aj 


< 


cd' 




o_ 


o' 


3 




^' 


CD 


C/) 




Z3 


"* 






O) 


cr 


CD 

< 

CD 

Q. 





p. NELSON, L. ALLTOP, and D. LEMLEY 



57 



-o 








<u 








> 








CD 
CO 


>^ 


TO 




X2 


C 




(/) 


oT 


"o 






o 


TO 




0) 


> 


o 




TO 


a3 


^ 




D- 


c/) 


-t— 1 


r-v 


"o 


-1— 1 


o 

2 




c 

o 

o -^ 


TO 
CU 

X 


_ar 


1 — 1 

d" 

CO 


1- 3 





> 




X2 


03 


c 


(V 


O Z 


4—' 

c 


0) 


c 


•^ -t-" 


cu 


0) 


13 


Q) Q 


CD 


un 


TabI 

tage 


o 


< 


en 


Iq 


>. 


1 — 1 


13 


Q. 


^ 


c 


CL 


TO 


1 — 1 


CD 
O 


T3 


(X) 


>> 


^ 


c 


SI 


~~ 


CD 


TO 


H 


13 


Q- 




4_/ 


' 




0) 


C 




C 
TO 


-t-i 
TO 
> 








'i_ 


-t-j 




^- 


CL 


TO 




O) 




O) 





-Q c 

E- 

13 



■D 

C 
TO 



5e 

T3 TO 






CO 



CN 



00 



0) 
DO 
TO 
+-' 

c 

0) 

o 

^- 
(O 
CL 



00 



CO 





q 




V 




Q. 


-K 


— ■ 


UD 


+-> 


00 


C 


CNJ 


TO 
O 


I— 1 






V*— 


II 


"c 




OD 






X 


cn 



58 



N.C. JOURNAL OF MENTAL HEALTH 



-D 


T3 


H 




-0 


"D 


H 


CO 


-^ 


C 


O 




-^ 


c 


O 


0) 




CT 


<-t- 
0) 




<' 


CT 


r-t- 


o 

1-1- 

o 




o' 






f? 


o" 




t— ' 


1—' 


1 — ' 








K- ' 


—1 


o 


o 


O 






4^ 


hO 


o 


o 
b 


o 
b 


O 

b 




00 

o 


4^ 


00 
4^ 


r-t- 


^ 


00 


^ 




o^ 


CO 


CD 


-z. 


(J) 


o 


^ 




1— ' 


00 


CD 


o 


00 


4^ 


bo 




00 


1—' 


CD 


13 
CD 

£7) 


(Jl 


M 


4i> 




4^ 


I—* 


CJl 


o 

c 
■o 


^ 


CJi 


Ol 


Tl 

CD 


cn 


tV) 


00 








-^ 
















O 
















(t> 
















3 
















i-h 
















Q) 
















OQ 








o 


t— ' 


1—' 


1— ' 


CD 


1—' 




1— ' 


IT 


-1^ 


CJI 


CJI 




N) 


^ 


CD 


CD 


bo 


00 


k) 




O 


en 


Ol 


3 
o 

C/5 
O 


o 


o 


o 




CO 


O 


CO 


3 


4^ 


b 


k) 










i-i- 

o' 
CD 

o5 


N) 
00 


1—' 
1— ' 


k) 




00 


Ol 


00 


IT C 
CD "D 

Q. 
O 


p 


o 


o 










if 










o 


t— ' 


1— ' 


b 


k) 


1— ' 
























l-t- 
















o- 
















Q. 



■D 
DO 





T) 


:z 






-T 


c 








3 






(-(- 


D- 






CD 


CD 






O) 








13 


Q) 




H 


Q. 


:3 




3- 




Q. 




CD 


T) 






-^ 


c 


"D 




t_ ^ 


O" 


CD 




c: "^ 


o' 


O 

CD 




DO 

1— ' - 


^ 


i-t- 




KO CD 


CD 

i-t- 


OQ 

CD 


0) 


CT) CD 
21. 


X 


o 


CD 


c ^^ 


CD 


1-1- 


z 


zs a; 




cf 


o 


CD " 


CO o 


- 


O i^ 


CD 


13 




i—t- 


^. 


O 




<D O 


o 






CTi 0) 


CD 


"D 




■^ -! 


"* 


QJ 




O 


cr 


cd" 




5' 




3 




Q) 


—1 


r-1- 






CD 


(/) 






0} 


C/) 






r-h 


CD 






3 


5 






CD 


CD 






rs 


crL 





p. NELSON, L. ALLTOP, and D. LEMLEY 



59 



CM 






.Eh- 

o 

cu c 

(/, i 

-1-1 TO 

■■*^ - p ,^ 

"3 <1> m "^ 

CD-I-' 

S ^ o Q 
9 ^ -S 00 



Z5 ±: _ 0) 

O JD 03 (1) C 



"^ -•- ^ l' 

Q TO 0) ^ 

Q) C s^ ^ 

Ofl CU MJ " 

TO ^ ^ - 
-1-1 «^ - 1 — I 

S.y ^>^ 

cu Z3 > ""^ 
Q-CL ^ 

■D X3 C 
C C — 
TO TO 

(D ^ 
JD TO 

11 





-(-> 




C 




(U 




o 




^_ 




cu 


<u 


Q_ 


-t-J 




TO 




> 




'i_ 




Q_ 


^- 




CU 




-Q 




E 




Z3 




Z 




-t-j 




c 




cu 




o 




&_ 




cu 


O 


CL 


!q 




3 




CL 


&- 




cu 




.Q 




E 




=3 




2 




-t-j 




c 




cu 




o 




^- 




(U 




Ql 


"to 




-t-" 




o 




1- 






^_ 




cu 




JD 




E 




3 




z 


M— 




o 


(/5 




<: 


q3 


cu 


E 


cu 


3 


+-> 


Z 


c 



o cr> .— 1 <— 1 in 00 


<X) 00 t^ Ln o 


<D oS -vt CD CX) uri 

O C\J I— 1 T— 1 ,— 1 


■=t ro .-H o --H 



O C\J "^t CNJ CTi 00 00 
>— I "=^ -— I 00 ID C\J .— I 

00 C\J <— I ,— I r-l 



,— I '^ '^t 00 
CO <— I 



o 
d 






^c^Ln';t'^(r)CNjooi£) 
rot^crJododcNJ-^^dd 

C\J I— I 1— I 1 1 !— I 



CNj'^or-^ooO'^roLn 
00 IX) >=^ 00 lO c\j 



q ^ CO 
CD r^ Lfi 
o c\J ^ 



-— loddro'-'^.-Hd'— i 



"^c\jiX)(X)cj>LncD'— loot^ro 
ooiDcji'^tO'— ir^Ln.— I .-H 

C\J CO t— I r-l >— I C\J ,— I 



c\j 00 "^ 



CJ> CJ) (J) CT) 

00 --^ C\J CO ^ 

lO cfi CD d CD 

c\j CO ^ 



60 



N.C. JOURNAL OF MENTAL HEALTH 



-JJ 


> 


"D 


O 


o 


"D 


5 > 


H 


^ 


^ 


H 









(D 


^"" 


-^ 


r-h 


r-t- 


c 


O Q. 


CD 











3 




«^ 


ZT 


3- 


Q- 


'-^ Q. 


-^ 


i-h 


(-h 


I-t- 




C/)' 


-z. 


o 

I-t- 


r-t- 


CD 


CD 


o' 

CD 

3 


cr 


3 


3- 
Q. 


ZT 
Q- 


QJ 




-a 



3 
a- 

(D 


5' 

13' 
OQ 


(0 

H 




Tl 

CO 


3 


3' 


(D 

f 


CD 






C/) 

r-t-' 

o' 

3 




— s 


CO 


p 




i-t- 
0) 


^S 


3 














3 




3 

i-i- 
o" 

13 

cn 


o' 

0)' 

13 


b 


CO 

(D 

o' 

CD 


o 

C/) 

■o 

r-h 
0) 


(D 

13 
CD 
CD 
Q. 
CD 
Q. 

cr 

c 

1-1- 


i-t-' 

3- 


c 

r-1- 

CD 
—♦1 
CD 


5' 
0' 



r-h 

r-h 
— h 

cd' 

Q. 


5' 
0' 



i-t- 

— h 

cd' 

Q. 


1 — ' 


2 




id Percentage Distribut 
by Disposition, Gr< 








I—" 






N> 


1—' 


ro 


4^ 


N> 


3 




lUl — • 

CD 
Z3 =3 

^•0 


N) 


(JI 


00 


o 


CT) 


N) 


O 


00 


1— ' 


00 


00 




O 


(Ji 


^ 


o 


1 — ' 


N) 


00 


4^ 


(D 


00 


4==- 


D" 
CD 




























H 


^ — h 




























1— t- 


^ T3 


























Q) 


2^ 
























"D 




fD 














h- ' 


I—" 


1—' 


00 


1 — ' 



CD 






1 — ' 


-1^ 


ro 


^ 


-P' 


1 — ' 


(S\ 





;-J 


00 






CD 

13 




(Ji 


bo 


UD 


bo 


bo 


^ 


bo 


4^ 


1 — ' 


-vj 


b 




Q^ 
























I-t- 




Q) CD 

— (D 
=i Q. 
Q) 
























Z 




3 


















1—' 


I—" 


4^ 


C 




t_ 




K) 




00 




1 — ' 


ro 


H-» 


^ 


^ 


^ 


3 




C T3 


(J) 


OJ 


00 


00 


-vj 


l£» 


ro 





4^ 


N) 


4^ 
1— ' 


D" 
CD 

TJ 

CD 


c 
cr 

0' 


rivate and 
ly 1, 1965- 


















00 


00 







*- Tl 


I—" 


-P^ 


1 — ' 


-^ 


1— ' 


-P^ 


4^ 


ro 


cn 


cr> 










C r^ 


Kj 


Id 


^ 


b 


Ol 


b 


b 

1 — ' 


1 — ' 
1— ' 


^ 


00 


b 
00 


CD 

i-h 

:z 




iblic IVienta 
ne 30, 196 


1 — ' 


00 


hO 


CT> 


Ol 




00 


IV) 


4^ 


CTi 


1 — ' 


3 




^ — 


4^ 


K) 


<x> 


^ 


-f^ 


00 


1— ' 


4^ 


CJl 


1—' 





cr 

CD 


Tl 

<' 

Q) 
i-i- 


X 
CD 
0) 

=r 
CO 














ro 


1 — ' 




00 


I—" 



"0 

CD 


CD 


CD 


(— ' 


-1^ 


00 


00 


en 


o 


N) 


(Ji 


C71 


M 






CD 

3 







'<T> 


b 


CT> 


OJ 


^ 


4^ 


'OJ 


OJ 


b 


iv> 


b 




0) 
























I-t- 







_. w 



61 



USE OF THE MARATHON IN SENSITIVITY 
TRAINING OF A MINISTERS GROUP 



R. W. Whitener, M.D. 

Greensboro 



Various efforts have been made in the sensitivity training of 
ministers. Usually these have consisted of workshops lasting 
from three days to a week or two. This paper will report on the 
use of a marathon session to initiate sensitivity training fol- 
lowed by one and a half hour weekly sessions for twenty 
sessions. 



Organization of the group 

This group experience grew out of a community psychiatry 
effort in the community mental health center. For the previous 
year a group of ministers had met every two weeks for an hour 
to discuss problems ministers had in their daily contacts 
with parishioners in the area of mental health. The group had 
been originated because of a request by a minister to the 
director of the mental health center, and group attendance 
had been open to members of the city Ministerial Fellowship. 
However, there were several dissatisfactions voiced as well 
as a large turnover of individuals participating. These dis- 
satisfactions included: lack of intensity of group experience, 
lack of continuity both in terms of infrequent meetings and 
turnover of participants, lack of a firm "contract" that was 
accepted by all group members. As a result, it was decided to 
form a sensitivity group to consist of a marathon and follow-up 
sessions with a specific fee and the specific goal of under- 
standing oneself and group dynamics. 

Thus there was a certain self selection process (in the 
author's view) in formation of the sensitivity group which 
eliminated two extremes: those who were anxious enough to 
want an intensive group experience initially, became dissatis- 
fied with the prior group and dropped out; those who wanted 
a didactic, distant, perhaps case study experience who were 
quite hesitant about any searching into their own reactions. 

In formation of the sensitivity group we avoided a major 
pitfall by proposing a specific contract at the outset. It had 
been discovered that the lack of a specific contract caused 



62 N.C. JOURNAL OF MENTAL HEALTH 



the group to struggle for months to arrive at a contract. It is 
postulated that the leader should be more definite in propos- 
ing his side of contract initially to avoid this hazard. The group 
was informed that we would begin with a nine hour marathon 
on a holiday followed by weekly one and a half hour sessions 
for twenty sessions. Despite the initial enthusiastic reception 
to the idea two months prior to beginning the group, only four 
members of the final six came from the larger group, two 
members being recruited by word of mouth and were strangers 
to the author. After the fifth weekly session following the 
marathon a female social worker was added to the group. 



The Marathon 

It was postulated that for this group to make a shift from 
the less intensive relationship of the prior year to a more 
intensive group experience some device would be required. 
The nine hour marathon was settled upon as a technique which 
should accomplish this. The members of the group essentially 
knew each other, were familiar with each others' roles, had 
previously established some specific attitudes and methods 
of communicating. It was felt that an intensive group experi- 
ence would be necessary to alter these previously established 
modes of superficial communication so that a deeper level 
of honesty could be obtained. Individuals came into the office 
in pairs, were shown around the office, made various jokes 
about their preconceptions of a psychiatrist's office. We then 
settled in the group room which is described briefly as a room 
large enough for the participants, used frequently for group 
therapy, but which has the disadvantage of two chairs that 
are distinct from the rest. One of these chairs is obviously 
the "leader's chair"; however, after the first break at lunch 
time the leader deliberately sat elsewhere, and as the mara- 
thon progressed all but one individual moved seats at least 
one time. Much of the changing of chairs during the marathon 
seemed to be related to an interpretation early in the day that 
those to the right of the author were supportive of him, those 
to the left being more willing to attack. This tended to sensitize 
the group to their relative positions regarding the author and 
each other. 



Major conflicts 

The conflicts relating to authority, masculinity, identifica- 
tion with the deity, and homosexuality were most prominently 
uncovered. As background material was revealed in the mara- 



R. WHITENER 63 



thon and later, it became apparent that a majority perceived 
the father as being weak or absent, not close at all. There 
was either early death or distance through being strict and 
authoritarian, with limited emotional interaction between 
father and son. The mother was understandably somewhat 
overprotective and often dominating, much closer to the son. 
The transference feelings toward the author seemed to polarize 
in excessive attack and hositlity toward the perceived distant, 
rejecting male and the excessive flattering, appreciation, and 
defense of the authority figure. Several relationships within 
the group were established in the marathon and continued 
pretty much throughout the follow-up sessions. One group 
member was the rebellious son who attacked both the author 
and the group for "not going anywhere"; one member usually 
filled the shoes of the father figure because of being slightly 
older than the rest of the group. Because of a more compulsive 
character structure one member functioned pretty much as 
the conscience of the group, backing up his stand with quota- 
tions both from the Bible and other literature. One member 
quickly proclaimed himself the sickest, with the most open 
acknowledgement of anxiety, and seemed to look for the 
experience to provide him with psychotherapy. Another mem- 
ber deliberately used the marathon to abreact to the death of 
his father when he was 14 years old, planning to do so before 
the marathon began. Although this was perceived as thera- 
peutic for him, he did not seem to look toward the entire 
experience as a substitute for psychotherapy as much as the 
former. The above examples illustrate the kinds of individual 
dynamics revealed in any group as well as the individual's 
attempts to work through his conflict. 



Conflicts regarding masculinity 

Because of the all male aspect of the group the initial feel- 
ings about closeness aroused discussion of homosexuality. 
The author was admitted to several "in jokes" regarding clerical 
robes, but the tendency in the marathon was to drop the 
subject or deal with it intellectually. In early follow-up sessions 
there developed considerable competitiveness, mild threats 
of leaving the group, and oblique attacks at the author through 
criticizing the establishment. There were strong feelings 
among younger ministers that the role they were cast in was 
degrading. There was intellectual involvement in the concepts 
of castration anxiety. Again, the selection of the "leader's 
chair" which was also identified as the "hot seat" allowed 
various ones at different sessions to hold the center of atten- 
tion and exhibit feelings. Nonverbal methods of exhibitionism 



64 N.C. JOURNAL OF MENTAL HEALTH 



were observed and commented on in terms of posture. After 
the fifth session a woman social worker was introduced into 
the group. There was some hostility expressed at the arbitrary 
introduction of a new member to the group, but the hostility 
was directed at a scapegoat who continued to be unwilling to 
express anger about it. With the one woman in the group 
homosexual thoughts and feelings were suppressed, and after 
two sessions the author mentioned this. From this point on 
discussion of sexual conflicts alternated between hetero- 
sexual and homosexual. Closely related to the homosexual 
conflicts were the conflicts over the male authority, both the 
desire to please and to attack. In the seventh session the 
author particularly rejected one member and the group joined 
in attacking this member. He was sick physically at the next 
session time, and the group was depressed for two sessions. 

It took several more sessions for the group to give up their 
feelings of the author's omnipotence. This was considerably 
helped by a movie on television where the group therapist was 
killed by a psychotic member. Several of the group members 
had seen the move and discussed it prior to a group meeting. 
With this shift in relationship to authority at about the fifteenth 
session there was greater ability to handle ambivalent feeling. 



Termination 

At about the sixteenth session the group began to deal with 
the prospect of termination. There were scattered absences 
because of illness (both group member and family member of 
group member ). There was both hopefulness about the progress 
some members had made in their own emotional growth as 
well as hopelessness over the accepted scapegoat of the 
group who continued to maintain this position by attacking 
the group and attacking the leader. The author helped steer 
the group to discussion of death and afterlife during the last 
session or so. Most of the need for afterlife was evident in the 
desire for continuation of this group or a similar group. In the 
intellectual discussion of theology it was apparent that some 
members had grave doubts about a life after death, a surprise 
to the author. 



Sensitivity group vs. group therapy 

Some of the differences between group therapy and the 
sensitivity group, as perceived by the author, should be pointed 
out. Initially, there is a difference in contract. The therapy 
group has the goal of personality change or symptom allevia- 



R. WHITENER 65 



tion in an individual who sees himself as disturbed. The 
leader has the role of modifying anxiety if it becomes too 
intense or promoting anxiety to overcome resistance. He is 
familiar with the individual's personal problems and dynamics 
and will occasionally protect one individual from another 
when a sensitive area is approached. 

The sensitivity group begins with a contract that empha- 
sizes self awareness, awareness of group dynamics, aware- 
ness of how one is perceived by others. The individual does 
not see himself as "sick" seeking a "cure". The experience 
may be therapeutic for him in some degree, but this is not 
the main objective. The leader has an obligation to emphasize 
the "here and now" aspect of understanding of group behavior 
through experiencing it; teaching the members to become 
more observant of themselves and others. Although the past is 
inevitably brought up, the emphasis is on the present. The 
contract is not between therapist and patient but between 
a leader and a group to define its own goals, pursue them, and 
evaluate the groups' progress in doing so. 



Summary and Conclusions 

An intensive group experience for ministers was planned 
using a marathon session followed by weekly one and a half 
hour sessions. It was concluded that the marathon was useful 
in establishing intimacy, formulating the contract, and initiat- 
ing the working through of some conflicts as well as identify- 
ing others for later handling. The marathon facilitated a 
change toward more intimate relationships among group 
members who had existing superficial relationships. Follow-up 
sessions were considered valuable, some group members 
stating that they got more out of the less intense weekly 
sessions than they did from the marathon. It was generally 
agreed by the author and group members that 20 sessions in 
follow-up were more than needed, and it is the author's 
suggestion that follow-up be limited to ten sessions. Some 
follow-up to any marathon is desirable to look objectively 
at what transpired. The number of ten follow-up sessions is 
suggested as a compromise between the views that 20 ses- 
sions extended the life of the group too long for probably 
unconsicious narcissistic needs of the author and the view 
of some that the initial follow-up sessions were of more value 
than the marathon alone. It is my conclusion that the marathon 
was essential in establishing this kind of group sensitivity 
training. A group of people who have prior relationships with 
each other must have an intensive group experience to alter 
these prior relationships. Without this intensive experience 



66 N.C. JOURNAL OF MENTAL HEALTH 



the members of the group would tend to deal with each other 
with all the former masks, defenses, etc. Obviously, a three 
day or longer work shop would accomplish the same objective. 
However, the use of the marathon with follow-up may be more 
economical of time for a community group. Specific conflicts 
of the clergy brought most to light in this group were homo- 
sexual conflicts, conflicts toward authority, identification with 
the deity, and conflicts over expression of hostility. Because of 
the need to resolve these conflicts in those doing a great deal 
of individual counseling and group interaction, it is recom- 
mended that community mental health workers further test 
out the use of the marathon and follow-up sessions (about 10 ) 
with this community population. 



67 



NEWS NOTE 
Group-Oriented Organization Enters Second Year 



Interest in and work with group phenomena derives from 
many disciplies. Opportunities for communication concerning 
work with groups does not often bridge across discipline or 
special interest group boundaries. During the last calendar 
year, however, a new organization hoping to provide such 
bridging has come into existence in this State. That organiza- 
tion is the North Carolina Group Behavior Society. Its purposes 
are: (1 ) to promote education in group behavior principles 
and practice; (2) to conduct scientific meetings providing a 
forum for exchange of ideas, theories, studies, research, and 
experience in group behavior; (3 ) to encourage and promote 
the writing and publication of studies and research in group 
behavior; and (4) to promote the establishment of training 
programs in group behavior and the use of group behavior 
techniques in a greater number of facilities. 

Membership in the organization is open to professionals 
working in mental health or a mental health-related field in 
North Carolina. Currently, the membership list includes repre- 
sentatives from the disciplines of psychology, psychiatry, 
social work, nursing, the ministry, counseling, vocational 
rehabilitation, sociology and education. Members are em- 
ployed in private practice, in medical schools, in university 
departments of psychology, education, sociology, and in state 
hospitals, schools, mental health clinics and correctional in- 
stitutions. Mental health-related professionals interested in 
affiliating with or learning more about the organization are 
invited to address inquiries to the membership chairman. Dr. 
Fred Thompson, 3924 Browning Place, Raleigh, North Caro- 
lina 27609. 

The NCGBS is very much an organization in the process of 
development. The society had its origins in an October 1969 
meeting in Greensboro of mental health professionals in- 
terested in discussing the formation of a regional affiliate of 
the American Group Psychotherapy Association. The initial 
discussions concluded that the membership restrictions of 
AGPA represented constraints that did not reflect the state of 
"good work" in North Carolina. A committee consisting of Tom 
Dunn (Ministerial Chaplaincy ), Bob Whitener (Psychiatry ) and 
Tom Long (Psychology) was formed and instructed to draft a 



68 N.C. JOURNAL OF MENTAL HEALTH 



constitution for a North Carolina Group Therapy Society. The 
committee's constitution draft was presented to a second 
organizational meeting on January 18, 1970. Approximately 45 
interested mental health professionals attended that meeting, 
constituted themselves as a committee of the whole, rewrote 
the consitution to its present form, renamed the organization 
the North Carolina Group Behavior Society and elected a slate 
of officers. Those elected were: President — Bob Whitener 
(Psychiatry ); President-Elect — Terry Miller (Psychology ); Sec- 
retary — Henrietta Franklin (Social Work); Treasurer— Tom 
Dunn (Ministerial Chaplaincy); and Member-at-Large— Phil 
Nelson (Psychiatry — later replaced by Fred Thompson, Psy- 
chiatry ). 

A third organizational meeting was held in Raleigh on May 2 
and 3. That meeting was organized around the types of work 
settings of the membership and directed toward assessing 
needs for group work and training in the state (universities, 
clinics, institutions, industry). Dr. Martin Lakin addressed the 
meeting on the ethics of work with groups. The third organiza- 
tional meeting assigned the organization a task of surveying 
the field of work with groups in the state, felt needs for further 
training in different aspects of group work and of resource 
people that might be called on for short and long term training 
endeavors. More than two hundred mental health professionals 
responded to the survey. 

The North Carolina survey provided a basis for planning for 
the Fall Meeting of the NCGBS. That meeting was held in 
Greensboro on October 16 through October 18, 1970. The 
meeting focused on approaches to work with groups. Both 
panel and workshop meetings were held. The basic panel 
consisted of Jack Pixley (PsychoanalyticGroup Psychotherapy ), 
Bruce Norton (Inpatient and Mileau Group Work ), Tom Elmore 
(Group Counseling ), John Woodmansee (Encounter Groups ), 
and Jack Preiss (T-Groups ). The panel was chaired by Penny 
Smith. Workshops focused on Principles of Group Process and 
Group Development, Group Research, Encounter Groups, Rela- 
tionships between Individual and Group Dynamics, Group 
Counseling and Sensory Awareness and Non-Verbal Group 
Techniques. Workshop leaders included Helen Corter, Graham 
Gibbard, Tom Curtis, Jack Pixley, John Woodmansee, Peggy 
Utley, Marvin Loper, Tom Elmore, and Mimi Rouse. 

Planning for mail-ballot elections and for a spring meeting 
are currently underway. The president-elect of the organiza- 
tion has general program and education responsibilities. The 
immediate past president has a general responsibility for the 
development of continuing education programs. It is the 



NEWS NOTE 69 



general hope of the organization that it can be of assistance in 
helping to bring into being training programs to meet the 
needs of professionals already working in the field. 



i 



I 



Notice to Contributors 

Manuscripts and editorial comments should be addressed 
to the Editor-in-Chief, N. C. Department of Mental Health, 
P. 0. Box 26327, Raleigh, N. C. 27611. 

Contributors need not be psychiatrists, neurologists or 
M.D.'s but should be involved in some aspects of program, 
whether clinical, educational, or research, pertinent to mental 
health or mental illness. 

Manuscripts offered for publication should be submitted 
in triplicate, with the original typed on bond paper, and 
double spaced with 70 characters per line. Footnotes, biblio- 
graphical references, quotations, etc., should also be double 
spaced and the use of footnotes minimized. 

References to books and journals should be numbered con- 
secutively in a bibliography at the end in the order in which 
they appear in the manuscript. References should be limited 
to those used by the author in the preparation of the article 
and kept to a minimum. 

The author's privilege of correcting galley proofs may apply 
only to printer's errors. 

Tabular material, drawings and charts should be submitted 
on separate sheets, clearly marked as to where they are to 
appear in the text. 



I 




^BilB 


r 




^^^Bi 


1 




^B 


1