SOCIALIZATION OF THE EX-MENTAL PATIENT *
by Louis BEEKOWITZ * *
Executive
Director,
The Educational
Alliance
A B R A H A M LURIE E D . D . * *
Director
of Social Service, Hillside Hospital,
New York
has often been overlooked by mental
hospitals has been a continuation of the
therapeutic community concept after
discharge. It is now assumed that if it
is important to know about patients and
their time involvements within the hos­
pital structure, then we must also in­
tervene actively in helping the patient
utilize his time after discharge. Dr.
Greenblatt, has described a very active
program which deals with this very
problem at the Massachusetts Mental
Health Center.
Growing Interest in Post-Hospital
Socialization Programming
T
HERE has been a great deal of at­
tention paid recently to the concept
of the therapeutic community as it has
evolved within a mental hospital. This
idea was first described by Bockhovn as
a moral approach to patient care. More
recently, this concept has received a
great impetus because of the book, The
Mental Hospital, by Drs. Stanton and
Schwartz. Essentially, it involves the
utilization of existing hospital structure
and of all interpersonal relationships
and contacts which the patient has in
an institution; the interaction of these
relationships and the hospital structure;
and the development of a therapeutic
formulation in terms of these relation­
ships and interaction. The total time
the patient spends in an institution is
utilized in some therapeutic manner to
help him overcome his emotional prob­
lems.
1
3
2
Hillside Hospital, a psychiatric treat­
ment residence for 180 patients under
the New York Federation of Jewish
Philanthropies, has been trying to work
with community social agencies to de­
velop jointly a therapeutic milieu and
therapeutic attitude which would be
helpful to patients after discharge.
As part of the mobilization of com­
munity agencies, a socialization pro­
gram for discharged psychiatric pa­
tients was jointly developed with the
Educational Alliance, a Federationsupported Jewish community center
serving some 6,000 individuals of all
ages. This joint project has made avail­
able to ex-patients leisure-time facili4
Despite this recent emphasis, what
* Presented at the Annual Meeting of the
National Conference of Jewish Communal Serv­
ice, Los Angeles, June 3, 1964.
** Principal investigators of a demonstration
project: Social Rehabilitation of Discharged
Psychiatric Patients, supported by a grant of
NIMH
of U.S. Public
Health
Service
# MH101A-2.
i j . S. Bockhovn, "Moral Treatment in
American Psychiatry," J. Nervous and Mental
Disease, Vol. 124, No. 2 (1956), pp. 167-194;
No. 3 (1956), pp 292-331.
s Greenblatt, "Beyond the Therapeutic Community," Journal of the Hillside Hospital,
July-October, 1963, pp. 167-194.
* Lurie and Pinsky, "Collaboration between
Psychiatric Hospital and Community Agencies," in Greenblatt, ed., Mental Patients in
Transition, Thomas, Springfield, 111., 1961,
pp. 163-174.
2 Alfred H . Stanton and Morris S. Schwartz,
The Mental Hospital, Basic Books, New York,
1954.
[186]
I
j
j
j
i
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Journal of Jewish Communal Service
ties which will provide social experi­
ences useful to rehabilitate the ex-mental
patient. Until recently reports have in­
dicated that former mental patients have
hesitated to join such activities. "When
they did participate, they often tended
to segregate themselves into ex-patient
clubs or into ex-patient center groups.
In such groups, the ex-mental patients
tended to continue their excessively de­
pendent behavior. In and of itself en­
couragement of dependent behavior
does not have a deleterious effect. How­
ever, the encouragement of such be­
havior without proper professional
guidance can lead to a perpetuation of
symptomatology which in the long run
can be self-defeating to the patients.
In this joint project, the aim was to
develop new clinical service areas in
social rehabilitation and to evaluate the
effectiveness of the community center
in the improvement of the social func­
tioning of discharged mental patients.
This project has been so structured
that ex-patients are purposefully moved
through a series of four phases of prog­
ressively broader social experiences. In
the first phase they are prepared for
this program while they are still in the
hospital. The patients enter the second
phase after discharge, participating
only in ex-patient groups. In the third
phase, they are encouraged to move into
groups composed in part of ex-patients
and in part of members of a community
center who have had no psychiatric
treatment. Finally, the ex-patients be­
come involved in community center
activities on the same basis as other
community center members.
The patients are referred to the pro­
gram by the hospital team at Hillside.
All adult patients, above the age of 17,
who are believed able to benefit from a
planned community center experience,
are eligible. Approximately 60 percent
of the patients referred have hospital di­
agnoses of schizophrenia; the remainder
have been diagnosed as affective dis­
orders or character neuroses. The aver­
age period of hospitalization is seven
months to one year. Our project popu­
lation to date has included 221 people
over 17 years of age, about 113 of whom
are currently active in the different
phases, 28 in Phase I, 25 in Phase II, 35
in Phase III and 25 in Phase IV. Ten
have successfully completed Phase I V
and the balance have dropped out of the
project at various points along the way.
About 75 percent of these men and
women have been Jewish, the great ma­
jority
middle-class
(Hollingshead's
Class I I I ) with completion of one year
of college.
5
Preparing Hospital and
Agency for Project
Because of the nature of this problem,
a very intensive orientation program
had to be instituted within the hospital.
It was difficult often to have hospital
staff recognize the importance of de­
veloping socialization programs after
discharge. There was a natural ten­
dency for the hospital, which emphasizes
psychotherapy, milieu therapy and
drug therapy, to feel that after dis­
charge the primary readjustment factor
is a continuation of psychotherapeutic
relationships. Considerable effort was
required to raise the socialization after­
care project in status.
Whenever a new program is in­
troduced in a social agency, a certain
amount of preparation and "tooling
u p " is necessary for a favorable recep­
tion and potentially successful opera­
tion. A survey was made by a research
class of graduate students in a cooperat­
ing school of social work. This indi­
cated that the rank and file staff of the
community center, The Educational Al­
liance, was only average among a variety
of community centers tested with regard
to favorable attitudes towards receiving
» Hollingshead, Two Factor Index of Social
Position, New Haven, 1957, 10 pp.
S O C I A L I Z A T I O N O F THE EX-MENTAL
discharged psychiatric patients, al­
though the administrative leadership
was more positively disposed than most.
Accordingly, an orientation program
was undertaken with the clerical, main­
tenance, receptionist and professional
staff, including graduate students and
such specialists as the art teachers, who
would be likely to participate in the
project.
The project director and the Alli­
ance's associate director carried the
major responsibility for this orienta­
tion of Alliance personnel before the
ex-patients started to arrive. Realistic
projections as to the behavior to be ex­
pected and the problems likely to arise
were given. For those staff most di­
rectly involved, this continued after the
patients arrived, in the form of individ­
ual supervision and group seminars on
the problems actually encountered and
the methods of service utilized.
A similar process was undertaken
with the Alliance's board. A t a meet­
ing of the board program committee the
idea of the project was first launched,
with a joint presentation by the hospi­
tal's social service director and the pros­
pective project field director and the top
administrative staff of the Alliance.
Subsequently, the program committee
as part of its report to the board as a
whole invited the participation of a
board committee from Hillside Hospital
and its medical director. Many of the
Alliance trustees were still fearful, but
felt this service would be a "mitzvah"
when reassured that the program could
be adequately administered at the center.
A joint board committee of the two in­
stitutions was then set up with service
from representatives of the two profes­
sional staffs to keep abreast of major de­
velopments in the project. It is of in­
terest to note that while the center board
as a whole evinced great pride in the
project, several members remained fear­
ful that the presence of the hospital's
PATIENT
discharged patients might, through
their very presence in the center or
through bizarre or dangerous behavior,
drive away substantial numbers of the
center membership.
The Alliance specialists' reactions
have been particularly noteworthy. In
order to be "helpful" to the ex-patients,
one specialist at first alienated a number
by indicating there were a lot of
" K o o k s " in his activity area and these
ex-patients should feel at home! Sub­
sequently, his own fear better tempered,
he became extremely warm and sincerely
accepting of the ex-patients. Toward
the latter part of the project, especially
in Phase IV, when the specialist be­
comes the key Alliance staff member to
the ex-patient, most specialists with the
aid of supervision and consultation have
performed well, shown appropriate in­
terest and provided the supports neces­
sary for the ex-patients in their group.
On the whole, the specialists have been
particularly enthusiastic about being
part of this program.
The "normal" clientele with whom
the ex-patients have been "integrating"
have generally not indicated any aware­
ness of special difference from the indi­
vidual ex-patient. In one instance, a
group whose members have been part of
the young adult program for some time,
a number of whom live in a residence
sponsored by a treatment agency, "rec­
ognized" the character of one of the expatient groups. But the vast majority
of the regular members have not been
aware of the nature of any differences
with the ex-patients as individuals and
have accepted them as they would any
other individuals. No attempt has been
made to orient the "normal" clientele
as such, although workers will answer
direct questions truthfully and matterof-factly.
The nature of the "normal" clientele
would also bear some closer examination,
particularly because of their acceptance
[188]
Journal of Jewish Communal Service
jection rather than a reality situation
often prove sufficient to tide over the
crises.
and/or toleration of the hospital ex-pa­
tients. The center program for younger
adults tends to be built largely around
special interest activities such as art,
drama, music, dance, sculpture, ceramics
and the like, with some social groups
particularly for the 18- to 22-year-olds,
and for the single group between 26 and
50. Virtually all the groups are co-ed,
informal, relaxed, yet mostly task-ori­
ented with the focus on developing or
furthering skills in a friendly, congenial
atmosphere. These groups generally are
open, with intake controlled by the
agency so that members are accustomed
to having newcomers enter their groups.
They have also become tolerant of a wide
variety of behavior since many people
who are especially drawn to the arts may
be deviant in behavior or appearance.
Since the Hillside and Alliance clientele
are mostly Jewish and middle-class in
at least their cultural aspirations, there
tends to be little, if any, overt or even
subtle rejection. Some ex-Hillsiders are
friendly and outgoing and others are
quieter and more withdrawn, but this is
not too different from the balance of the
population.
Communication and Articulation
Between the Two Institutions
The project is held together by its key
staff who attempt to coordinate the serv­
ices of the two institutions as they bear
on the aims of the project. The key
staff includes as principal investigators
the director of social services at Hillside
and the executive director of the Alli­
ance. Also involved are the associate
director and a key staff member in the
younger adults program at the Alliance.
Two former hospital group workers, one
the project field director, are the fulltime staff members. Also on the coordi­
nating group are the hospital's director
of group work services and two parttime researchers, one on the staff of the
center and one originally on the hospi­
tal staff. The project action staff are all
housed in the center but have regular
contacts with the hospital.
This pairing of staff from the two
institutions at various levels makes it
possible for close articulation of needs
and understanding at the different levels
of function. Also participating periodi­
cally in project development and super­
vision are the hospital's medical direc­
tor, clinical director, after-care director
and administrator. All of these people
need to feel their stake and their de­
partment's stake in the success of the
project since they play important roles
in referrals, preparation, data provision,
the socialization process after discharge
and the analysis of the data.
We have noted that the ex-patient
often needs more individual attention
than the ordinary member, particularly
in the earlier phases, and some even in
Phase IV. However, towards the latter
part of the project, the ex-patient
mainly needs reassurance that a staff
member is available if needed. Crises
occurring in the ex-patients' personal
lives may flow over into their attitudes
towards others in the center program
and while most do get help from after­
care therapists, they will tend to project
the problem in fantasy (although not
necessarily acting it out as such) into
the group situation. In the more ad­
vanced stages of the project an oppor­
tunity to discharge some feeling, to get
the worker's attention, and to see the
problem in the group as largely a pro­
The major day-to-day articulation is
done through the social workers of the
two institutions—almost all of whom are
group workers. Using their authority
and their persuasive powers they affect
the processes going on within their sepa­
rate institutions. Besides setting up and
modifying the original structure to make
[189]
S O C I A L I Z A T I O N O F T H E EX-MENTAL
PATIENT
mal population. "We learn to walk be­
fore we learn to run.
Also of great value, are the deepened
knowledge of institutional articulation,
and the methods used to achieve it in
this project could well be adapted to
close cooperation between any two so­
cial agencies or institutions. Particularly
is this necessary when the attempt is
made to provide a smooth and effective
transition of clientele from one type of
institution to the other. The way in
which information is shared and prob­
lems are resolved may make all the dif­
ference in the development of viable and
successful transitional services. The in­
terested "outsider" may have fresh in­
sight into one institution's internal prob­
lems, particularly those which affect the
project, and these may have carry-over
value to non-project areas as well.
the service viable and to help the patient
make the transition from inpatient
status in the hospital to integration into
the community center as a full member,
they have brought to bear influences
and thinking on any or all of the prin­
cipals in the project at any point when
it was necessary. At one point, the flow
of discharged patients into the project
was too slow and too delayed. At an­
other point, ex-patients felt unable to
move ahead into the regular center
groups. A t still another point, the cen­
ter's program did not offer enough of
program opportunity during the sum­
mer months. The institutions had to
modify procedure, change certain pat­
terns of operating, alter policies, expand
budgets and utilize man-power differ­
ently in order for the project to be
more effective. The project pointed up
flaws, problems and limitations in some
of the existing patterns of service. The
remedies developed proved useful for
both institutions beyond the realm of the
project itself. For example, the center
for the first time has now extended its
special activity program for adults
through the summer months; and
throughout the year the specialists and
group workers have been brought more
closely together than ever before. The
hospital modified its after-care program
and its way of looking at the importance
of socialization experiences in the reha­
bilitation process. Both institutions have
gotten to know each other better and
the status of the group worker in the
rehabilitation process has been consider­
ably enhanced.
Another useful concept that emerges
from the project is a methodology for
working with people with weaker egos
on shorter range rehabilitation efforts.
This is the appropriate combination of
"pressure" and support. The "pres­
sure" comes in the form of expectations
which are set for the individual, i.e.,
that within a certain period of time, he
is "expected" to move into the next
phase. If these expectations are suffi­
ciently flexible to allow some leeway but
sufficiently firm to be felt, they can
strengthen motivation. But along with
"expectations" must go appropriate
and useful supports. Sympathy for the
difficulties involved and the new learn­
ing needed, the suggestions as to how
this or that difficulty can be dealt with
and how the situation might be tested in
reality must also be provided as needed.
For while expectations properly admin­
istered raise aspirations and hope, the
weakened ego may need some sensitive
and skillful help in its efforts to achieve.
Some Implications of the Project Resulting
from Its Findings To-date
The methodology developed appears to
be very viable and useful. The concept
of a phased program with graded steps
has proven valuable and may well point
a generalized way to controlled integra­
tion of handicapped groups into a nor­
One effect of this project has been to
bring closer together the hospital and
the various community centers within
[190]
Journal of Jewish Communal Service
the idea of developing such programs.
They have pointed out that many of
their activities are primarily geared to
a middle-class aspiring group. The par­
ticipation of ex-mental patients is seen
as devaluing the center programs from
the point of view of the groups whom
they hope to serve. One of the most
significant findings in our project has
been that the Educational Alliance has
been able to develop and sustain a pro­
gram for the larger community which
can also meet the needs of an ex-mental
patient group. Far from defeating the
primary purpose of the Jewish commu­
nity center to deal with and to develop
an activity program for Jewish young
people these programs for ex-mental pa­
tients seem to have had a most salutary
effect in enriching the program for
" n o r m a l " people.
the community. This has expanded the
horizon of the therapeutic milieu in that
the hospital has, in fact, become a part
of the patient's community. The project
has contributed to eliminating the false
dichotomy that exists between the hos­
pital and the community. It has sensi­
tized the hospital personnel to the aware­
ness that the hospital is part of the
community. The integration for the expatient into the community becomes an
easier task.
Socialization involves the development
of social skills for the purposes of en­
hancing social integration. In the case
of the ex-mental patient, often such so­
cial skills have been completely undevel­
oped. It, therefore, becomes necessary
not to develop resocialization programs
but socialization programs. This entails
the development of such programs in the
many geographic areas in which the pa­
tients find themselves after they leave
the hospital. The most logical agencies
for such programs would seem to be
community centers. Community center
activities, however, particularly the Jew­
ish community centers, emphasize pri­
marily middle-class values. These values
stress cultural identification and aspira­
tions for achieving higher goals. In
many situations, the problem in dealing
with the ex-mental patient is to help
him achieve realistic goals which are
more consonant with an ability impaired
as a result of emotional difficulties. It
becomes necessary to develop within
community centers activity programs
which will enable the ex-mental patient
to develop social skills and to utilize
them in social functioning in such a way
that they will not try to attain goals
which are far beyond their reach. It is
equally true that some pressure in the
form of realistic expectations can be an
important therapeutic dynamic.
One needs also to remember that in
many of the community centers it is
conceivable that individuals who seek
such programs may in reality have less
integrated personalities than many of
the ex-mental patients. The ex-patients
have had the re-educational experience
of psychotherapy. Some individuals al­
though without psychiatric experience
are often motivated to seek out commu­
nity center programs for resocialization
to work out their personal problems.
Socializing with ex-mental patients is
to many, who are not familiar with it,
a frightening notion. In reality the ill­
ness of a community and certainly the
illness of many individuals within the
community can be seen to some extent
by some of the incidents which have
occurred recently and which have re­
ceived national publicity. "We are re­
ferring to what may well be not only an
apathy to helping one's neighbor but,
perhaps even more significant, an atti­
tude which approximates pathology.
This is an attitude of aloofness and iso­
lation which enables or permits members
of the community to be destroyed or
In general, our experience has been
that the community centers have not,
at least until recently, been receptive to
[191]
SOCIALIZATION O F THE EX-MENTAL
coaxed to destruction by other members.
This was evident in the incident in which
a killer stalked a woman for more than
half an hour in the sound and sight of
many neighbors in New York City none
of whom for one reason or another called
the police. It was also evident in Albany,
New York where an individual was
urged to jump to his death from a
four-story building by a group stand­
ing on the sidewalk only to be saved by
his nephew, a seven-year-old boy.
It is obvious that not all those who
are ill are confined to hospitals and cer­
tainly not all those who had been hos­
pitalized are necessarily the sickest
members of a community. The values of
planned socialization experiences are not
only for ex-mental patients, but for
those who have not had psychiatric
treatment.
Another area of resistance which is
important for us in helping community
centers work through feelings about
dealing with hospitalized patients, is the
fear that many of these patients will
require rehospitalization. Unfortunately,
we have been led to believe that rehospi­
talization is equated with failure in the
treatment of the ex-mental patient.
PATIENT
has contributed in some measure to help­
ing ex-patients integrate themselves into
the community, enhance their social
skills, participate more actively in a
socialization program, and improve their
level of functioning.
Also, Hillside Hospital serves a fairly
homogeneous patient population. We
have an opportunity to measure the
effects of developing socialization pro­
grams for such a group. For example,
70 to 75 percent of the patients at the
hospital are Jewish. Does this have an
effect on resocialization or on developing
after-care programs for such a group!
Most studies have shown that religion
of patients or of the parents does not
seem to effect the performance of the exmental patient. Langner and Michael
have found that, "religious heterogene­
ity of the parents shows virtually no
association with mental health. Persons
with parents of the same religion were
similar in mental health to persons
whose parents were of different reli­
gions." Freeman and Simmons, in The
Mental
Patient
Comes Home,
says
"There is some trend for Catholics to
perform at lower levels than the two
other religious groups, but the relation­
ship is not statistically significant for
either sex.''
6
Recidivist rates are often quoted to
show a failure of treatment. This, how­
ever may not be a valid way of assessing
efficacy of treatment. Rehospitalization
at appropriate times might indeed be a
most therapeutic intervention in terms
of alleviating emotional distress. Avoid­
ing hospitalization at all costs can be a
detrimental step. This is important be­
cause success or lack of success in terms
of follow-up performance by our exmental patients cannot and should not
be judged in terms of rehospitalization.
What we do need to measure is the rate
of progress of social functioning of the
ex-mental patient as he goes about his
business after leaving the hospital. The
project which we have developed jointly
with the Educational Alliance, we think,
7
These findings would tend to indicate
that religion or faith of patients, or
their parents, is not a crucial variable in
establishing the effectiveness of treat­
ment or of follow-up programs. On the
other hand, it would be decidedly un­
wise to disregard the feelings that could
easily be engendered were the absence
of a friendly and accepting group not
available to patients who leave a mental
hospital. It is in the attempt to develop
a therapeutic atmosphere after discharge
o Langner and Michael, Life Stress and Men­
tal Health, Free Press, Glencoe, 1963, p. 238.
7 Freeman and Simmons, The Mental Patient
Comes Home, Wiley and Sons, New York, 1963,
p. 127.
[192]
Journal of Jewish Communal Service
that while the discharged patient may
take additional time to work with, he
is usually responsive to and appreciative
of the attention given and of the efforts
expended in his behalf, a reward not
always forthcoming to the hard-pressed
social work professional.
that the Educational Alliance, a federa­
tion institution, and Hillside Hospital,
a federation hospital, have joined to­
gether. The basic ethnic and class simi­
larity of the center and hospital popula­
tion, the warmth and friendliness and
sense of belonging imparted, and the
belief that helping each other is a good
value, that people care, whether an out­
growth of Jewish, American, social work
or humanistic values—all of this tends
to make the person who is unsure of
himself feel at home in the Jewish com­
munity center. It is from such programs
that it will be possible for us to develop
subsequent research proposals. It is
from such projects that we can learn
more about how each of us works and
how each of us can help the other in
developing programs for the ex-mental
patient.
Conclusion
While the project has another year to
run, and the research findings are not
all in, the first two years and nine
months of operation have been reward­
ing and valuable. A pattern of opera­
tion has been evolved which successfully
moves significant numbers of patients
from a pre-discharge status at the hos­
pital to full membership in the commu­
nity center within a limited time period.
Both the hospital and the community
center have been able to modify ap­
proaches not only without any detri­
mental effects to their total operations
but actually by enhancing their regular
services. A significant number of expatients have found the strength to
cross the barriers they have anticipated,
and which have proven mostly internal
rather than external in this project, and
the normal center population has largely
not found the presence of these ex-pa­
tients disturbing in any notable way.
With the large number of first and
second hospitalizations now facing our
nation, with the age of initial hospital­
ization getting younger nationally, with
the change in treatment patterns result­
ing from chemo-therapy and more en­
lightened attitudes and more experimen­
tation, the need to meet the challenge to
social agencies of all sorts and especially
community centers, to play some greater
role in the reintegration of the mentally
ill into our society's social institutions
becomes a great moral imperative. The
project has demonstrated that the pres­
ence of a significant number of dis­
charged patients, most of them not com­
pletely "cured," has not only not dis­
turbed the normal population but ac­
tually enhanced the existing programs
in many ways. This should be encour­
aging to other community centers. It
might also serve as a source of reassur­
ance to other community social agencies
We will still be testing our methodol­
ogy further and we will wish to learn
what we can about specific methodolog­
ical aspects, as well as about the char­
acteristics of the ex-patients which seem
to be significant in their ultimate social­
ization in the center. We will also be
testing a socialization rating instrument
which we have developed for the project,
and we will be encouraging other com­
munity centers to test the findings of
the project in their own settings.
[193]