Maryland. Legislature, Joint Com- mittee Report to Study State Mental Hospitals. 1949 REPORT OF THE Joint Senate and House Committee ON THE of Maryland March 1949 REPORT OF THE Joint Senate and House Committee to Study the State Mental Hospitals State of Maryland March, 1949 Committee Senators Delegates P. G. Stromberg, Chairman Henry H. Balch Clarence E. Tyler, Vice-Chairman C. Ray Barnes George W. Della Myron L. Bloom Daniel Ellison Robert B. Kimble T. Raymond Burch Jacob R. Ramsburg John Grason Turnbull Jerome Robinson Consultants G. Wilson Shaffer, Ph.D. Paul V. Lemkau, M.D. Executive Secretary Elwyn A. Mauck LETTER OF TRANSMITTAL March 9, 1949. To The Governor of the State of Maryland To The Members of the General Assembly: There is submitted, herewith, the Report of the Joint Senate and House Committee to Study the State Mental Hospitals. This Committee was appointed by the President of the Senate and the Speaker of the House on January 26, 1949, at the invitation of the Governor, to investigate Maryland’s five mental institutions. The Committee devoted much time and effort to ascertaining the facts by inspection of the institutions and receipt of expert testi- mony. Sub-committees visited all five of the institutions, at which employees and officials were interviewed and facilities inspected. It heard witnesses from Maryland and from outside of the State where it believed such witnesses could contribute to the solution of the Committee’s problems. Much time and consideration were given to study of all feasible suggestions presented to the Com- mittee or initiated by its members. The Committee is reporting its findings and its recommenda- tions herewith. The members reached unanimous agreement on all points. The Report presents not only the recommendations but also the factual material and the reasoning followed by the Committee. The Committee is recommending a plan which will provide a firm basis for sound structure and procedures in Maryland’s men- tal hygiene system. The framework outlined herein should con- stitute the basis of a permanent organization. However, the Com- mittee wishes to emphasize that the plan is not self-executing. It will operate satisfactorily only if the organization is staffed with competent personnel. Also, the Committee wishes to empha- size that the solutions recommended herein must be made the subject of constant study and revision. The work of the Com- mittee has been completed, but the problem is continuing and ever-changing. The public must remain alert to its responsibili- ties and obligations in order that the New Mental Health Pro- gram will not be allowed to lapse. Only by such vigilance will the work of the Committee be of lasting value. Respectfully submitted, P. G. Strom berg. Chairman Henry H. Balch George W. Della Daniel Ellison Robert B. Kimble John Grason Turnbull Clarence E. Tyler, Vice-chairman C. Ray Barnes Myron L. Bloom T. Raymond Burch Jacob R. Ramsburg Jerome Robinson TABLE OF CONTENTS SUMMARY OF RECOMMENDATIONS Chapter Part I. Committee Findings 1. Buildings, Grounds, and Other Equipment 2. Food, Kitchens, and Dining Facilities 3. Medical and Psychiatric Facilities and Treatment 4. Custodial Care, Parole, and Discharge of Patients Part II. The New Mental Health Program Chapter 5. Reorganization of the Administrative Structure 6. Revitalization of the Personnel Program 7. Capital Improvement and Expansion 8. Development of Therapeutic and Custodial Services 9. Mental Health Clinics and Preventive Psychiatry 10. Financing the New Mental Health Program Appendices A. Springfield State Hospital B. Spring Grove State Hospital C. Crownsville State Hospital D. Eastern Shore State Hospital E. Rosewood State Training School F. Analysis of Statistical Reports from the Hospitals and Rosewood G. The State Department of Mental Hygiene FOREWORD The Committee has approached its task with the aim of con- trolling the increase in the population of the State Mental Hos- pitals. It believes that this can be done by preventive efforts, by intensive treatment, and by proper after-care. This approach does not neglect the proper care of patients now in hospitals; indeed, more intensive treatment through additional personnel and facilities is herein recommended. By restoring earning power to patients, by more rapidly alleviating their condition in order that they can return to a normal existence, by early out- patient treatment procedures to prevent change of a patient’s status in his community because of his affliction, and by shorten- ing hospital stay where admissions are necessary, it believes that the State’s citizens will be more economically and more satis- factorily served and that the mental health of the State will be preserved most effectively. 5 MAJOR RECOMMENDATIONS The Committee Unanimously Recommends: (1) The Board of Mental Hygiene should be abolished and its powers and functions transferred to the Department of Mental Hygiene responsible directly to the Governor. (2) The Boards of Managers of the five mental hospitals should be abolished. (3) A Board of Review of nine members, consisting of two ex-officio members from the General Assembly and seven members appointed by the Governor, should be established to visit the mental hospitals, make whatever other investigations it deems necessary, and report annually to the General Assembly, the Governor and the Commissioner of Mental Hygiene. (4) There should be established an Advisory Board consisting of the officers who now constitute the advisory members of the Board of Mental Hygiene. (5) The Commissioner of Mental Hygiene should be appointed by and responsible directly to the Governor. He should be selected from a list of names recommended by the Advisory Board. (6) The Commissioner should have complete power and re- sponsibility for administration and operation of the five State mental hospitals. (7) The Commissioner and the hospital superintendents should be trained psychiatrists experienced in administration. (8) To enable him to execute his duties successfully, the Com- missioner should have the assistance of expert professional and administrative personnel at the State level. A Division of Budget and Administration and a Division of Psychiatric Training and Education should be established by statute. (9) Superintendents of the five State mental hospitals should be appointed by and fully responsible to the Commissioner. (10) The Commissioner, superintendents and professional per- sonnel in the central office should be appointed outside the merit system but should be removable only for cause. (11) Review, re-evaluation and reclassification of positions in the hospitals, in accordance with the program initiated by the Standard Salary Board, should be adopted. (12) Adjustment and increases in compensation, based on re- classification of positions and studies of competitive wage and salary rates, should be adopted. (13) A gross wage and salary plan should be adopted to re- place the present plan of salary plus maintenance. (14) Further thought and planning should be directed to the problem of hours of work in all of Maryland’s institutions, look- ing toward the ultimate adoption of the forty-hour work week. 6 (15) Immediate action should be taken to improve the em- ployees’ living accommodations by providing, for example: (a) More space; (b) Housing removed from patients’ quarters; (c) Reception rooms; (d) Telephone service. (16) There should be further development of the employee and patient services, such as libraries, free transportation to and from the grounds, and canteens at which employees and patients could buy many items they need or desire. (17) Studies of the Standard Salary Board and the Depart- ment of State Employment and Registration should be under- taken with the view of establishing new procedures or reorgani- zation for better solution of personnel problems. (18) Provision should be made at all institutions for: (a) Patients’ bed space; (b) Day room space; (c) Occupational therapy space, all in accordance with standards established by the U. S. Public Health Service. All buildings should be pro- vided with suitable ventilation facilities. (19) Crownsville should be manned by color personnel as rapidly as feasible. In the other hospitals, the possibility for the use of colored personnel in some classifications should be con- sidered. (20) All the criminal insane should be committed to one hos- pital. (21) Proper classification and segregation is urged as the necessary first step of the institutional program for the treat- ment and rehabilitation of patients. (22) The proposed psychopathic unit at the University Hos- pital should be planned to accommodate 150 patients in order that it can adequately meet the needs for undergraduate and graduate psychiatric education. Further consideration should be given to the service functions of this unit in order that it may eventually provide an acute treatment service for new admissions to the State hospital system. (23) The psychopathic unit should contain a ward for the treatment of emotionally disturbed children. (24) Long range planning requires the development of a re- ception center at the Spring Grove State Hospital. (25) Preventive and out-patient psychiatric services conducted by the State Department of Health should be expanded through- out the State as rapidly as possible. (26) The financial responsibility of each political sub-division for each of its patients should be increased from |125 to $300 per year. (27) Central control of preparation and service of food should be established in the office of the Commissioner of Mental Hygiene and executed by a dietitian in each hospital. 7 PART I. COMMITTEE FINDINGS CHAPTER 1 Buildings, Grounds, and Other Equipment In external appearance, Maryland's five State mental institutions at Springfield, Spring Grove, Rosewood, Crownsville and Eastern Shore vary from onty adequate to most attractive. Spring Grove may be described as closest to presenting the appearance of a prison, but Eastern Shore, on the other hand, might well be mistaken for a fairly luxurious private institution. Even Spring Grove, how- ever, could be compared favorably with many a poorly planned college campus, since its buildings represent variety in architec- ture and lack of harmony in appearance and arrangement one with the other. All of the institutions are located in relatively open country. All except Eastern Shore are built on Maryland’s undulating hills, thus providing a most attractive setting for the institutions. East- ern Shore is most fortunately located along the banks of the beautiful Choptank River. The grounds at all the institutions are tastefully landscaped with an abundance of trees and shrubbery. At some of the institutions plentiful vines cover the buildings. Trees, shrubbery and lawns are well maintained. Building exteriors are attractive at all of the institutions. The stark lines of some buildings at Spring Grove are softened during most of the year by vines covering the massive grey stone. The Eastern Shore buildings are most attractive because of the two types of surfaces resulting from adoption of the Tudor style of architecture. The lower floors reveal a red brick exterior and the upper floors a grey masonry surface. With the exception of Spring Grove, all of the institutions have had their buildings arranged and spaced with due consideration to aesthetic taste as well as to practical considerations. The Springfield buildings are widely separated into several groups or units, thus creating the impression of expansiveness and roominess that belies the conditions within their walls. The interiors of the buildings offer stark contrasts to the ex- teriors. The interiors of buildings of some institutions are in relatively good repair, but at others much needs to be done to make the buildings more comfortable and attractive to their occu- pants, The floors of many buildings have deteriorated to the extent that they should be replaced immediately. Broken and loose boards in the floor are a constant hazard to the occupants as well as unsightly to everyone.. The usual reply to questions by Committee members was that funds for repair or replacement of the floors had been requested, but the items invariably were deleted before the appropriation measures became law. 8 The interiors of many of patients’ buildings need paint and minor repairs. In some instances there is evidence of damage of recent origin, but in others the need for repair is a matter of long standing. The Committee observed considerable activity in paint- ing of interiors and resurfacing of floors which is improving the appearance of the wards immeasurably. Leaky pipes, exposed wires, inadequate fire escapes, and poor ventilation are in evidence in many wards. Most day rooms of patients have a plentiful supply of natural light. In only a few did the Committee observe that lighting is most inadequate. Windows at the end of these long hall-like rooms are inadequate to give sufficient natural light at any time. Most day rooms, however, have adequate natural light supplied by win- dows on two or three sides. The extent of furnishings provided patients varies greatly among the institutions and among the various wards of any one institu- tion. For obvious reasons, there can be little or no furnishings provided in the wards for disturbed patients, but in some of the institutions there appears to be no attempt to provide furnishings in wards where the patients could be fully trusted not to injure themselves or others. The Committee’s investigations reveal that attempts by professional personnel to secure minor furnishings to remove the drabness of such wards have been resisted by admin- istrative personnel who believe in “economical” operation of the institution. Draperies, curtains, scatter rugs and occasional tables would do much to brighten these wards. Some volunteer groups and individuals have contributed immeasurably in this manner. For example, the Committee examined the splendidly furnished ward which is under sponsorship of a volunteer women’s group at Sykesville. This ward for senile women at Springfield provides a rocking chair for every patient in the ward, as well as radios, pianos, tables and other items of comfort. The patients give every appearance of happiness and contentment. Most of the institu- tions provide no facilities in which patients can keep their personal belongings, but Eastern Shore supplies a locker for every patient who can make use of one. The attendants keep possession of the keys and open the lockers on the request of the patients. Bedside tables also are furnished at Eastern Shore but less frequently at the other institutions. Housing facilities for employees are adequate for some but obviously inadequate for others at most of the institutions. In some institutions they are quartered on the top floor of buildings occu- pied by patients. Their rooms are not insulated and become unbearably hot during the summer months. The quarters for social service workers at Spring Grove were inspected by members of the Committee. They observed that these employees have no 9 telephone service and no reception rooms in which to entertain guests. The occupants expressed dissatisfaction in regard to these items. An important component in the operation of each of the institu- tions is the farm which is an integral part of it. However, the Committee did not have sufficient time available to inspect the farms. In the course of its investigations, it heard no major criticisms directed against the farm operations. It ascertained that, during the past year, the farms produced food valued at $450,000. This provides an important element in the patients’ and employees’ diets. The Committee received testimony that the milk supply is unsafe at several of the institutions, but it received assurances that pasteurization plants have been authorized and are being installed in the very near future. It heard some criti- cisms in regard to individual dairy animals in one herd, but it believes its function does not extend to investigation of these specific points. Proposals were advanced several years ago to abandon the farms at all the mental institutions, but the Com- mittee has no reason to believe that any such action is desirable. The evidence is ample that the value of the food and the thera- peutic value of farm work for many of the patients makes abandon- ment of the farms undesirable and impracticable. The Committee inspected recreation buildings and facilities and questioned responsible officials regarding the extent of their use. In some institutions, athletic fields are of value to the patients only to the extent that they are spectators at neighborhood ball games. An exception to this generalization is Rosewood, where competitive athletics flourish. Auditoriums and recreation halls exist at some of the institutions. These are used for movies and dances for the patients. Also, plays frequently are presented. In some instances, neighborhood plays are produced at the institu- tions, and patients are permitted to attend the dress rehearsal. At Rosewood, the patients, themselves, present plays on various occasions in these recreation buildings. In summary, the Committee concludes that the institutions have been established at desirable locations, and the grounds are main- tained in a very satisfactory manner. It also concludes, however, that the interiors have been allowed to deteriorate to the extent that considerable repair and renovation work now is absolutely essential. Programs of improvement are discussed in Chapter 7. 10 CHAPTER 2 Food, Kitchens, and Dining Facilities As has been stated in Chapter 1, a large portion of the food eaten by patients and employees is produced on the farms operated by the mental institutions. This food includes vegetables, milk, beef and pork products. All other food consumed at the institu- tions is purchased through the Department of Budget and Pro- curement or, by special dispensation, through appropriate hospital officials. Some hospitals exercise great ingenuity and initiative in securing fruits and vegetables in season from the community and in purchasing meat “on the hoof”, thereby securing higher quality products at lower prices than would otherwise be possible. The Committee noted that only at Spring Grove does there seem to be no purchase of fresh fruits and milk to supply adequately the needs of patients. Staff officials testified to the Committee members that milk is served only on doctors’ prescriptions and that they seldom or never see fresh fruit served to patients in their wards. Planning of diets and food purchasing are grossly deficient in all but one institution. For example, at Spring Grove, it was found that a menu had been placed on the wall of the kitchen and had never been changed in the memory of the kitchen personnel. This provides an identical weekly menu throughout the year; stew appears on this menu four times weekly. In contrast, at Spring- field, where the only dietitian in any mental institution in Mary- land is on duty, the Committee was impressed with the planning of food administration. The Committee examined menus of all the institutions and was not dissatisfied as to the regard paid to the inclusion of milk, fresh fruit, etc. in the diets except in one institu- tion. The Committee heard testimony that dietary allowances are too low. The Committee visited the kitchens in all five of the institutions and discovered wide variation among them in the amount and quality of cooking equipment. Some kitchens have been reno- vated fairly recently, and they contain modern and glistening equip- ment. They appear to be adequate in every respect. On the other hand, some of the kitchens inspected are old, the equipment is worn out or outmoded, and the cooks are severely handicapped in what they can prepare because of the lack of facilities. In some of these kitchens, equipment that has been abandoned for years still occupies space that could be used to better advantage. The Committee observed food in storage and in process of prepa- ration in most of the institutions. Some of the institutions, notably Rosewood, have plentiful supplies of food which are being pro- tected under scientifically controlled conditions. In other institu- tions, the reserves appear to be rather limited. The Committee fully realizes, however, that these differencs may merely be the 11 result of varied delivery schedules rather than lack of planning at any specified institution. The Committee observed the dire need for additional kitchen help at all institutions. The institutions are attempting to solve this problem by using patient help. The value of patient help appears to be questionable except for a few specific duties. For example, one instance was cited in which a patient was intrusted with a large quantity of food which he proceeded to ruin completely, thereby causing not only wastage of the food but expenditure of considerable time to “clean up the mess”. On the other hand, the patient help at Rosewood appear to be very proficient in their tasks. Meals are served to employees at all the institutions under rela- tively pleasant conditions. Several institutions use the cafeteria style of service in the employee dining rooms. At Rosewood, the employees are provided with music while they eat. The Committee was told that dining facilities at Spring Grove had been most unsatisfactory, but that they were in process of being remedied at the present time. Committee members inspected the cafeteria at Spring Grove, and both general appearance and food appeared to be entirely satisfactory. In most of the institutions the employees’ dining rooms are located very near to the kitchens, thus permitting the food to be served while hot. The dining rooms for patients sometimes are close to the kitchens, but in some of the institutions they are too far from the place Avhere the food is prepared. Numerous difficulties have arisen as a result of these inadequate arrangements. Although the Com- mittee was reassured that the food is placed in large containers and therefore remains relatively hot, there appears to be some question whether this is possible under the circumstances. Where 600 people are served in one dining room, there naturally arises con- siderable difficulty in serving the food hot. The patients’ dining rooms could be improved in almost all in- stances. They present drab and dilapidated appearances with no visible attempt being made to provide a more pleasant environ- ment in which the patients might eat. The need for sanitary facilities is much in evidence in many of the kitchens visited. One doctor at Spring Grove commented that the patients observed preparing the food probably had not washed their hands in weeks. Facilities at which employees and patients in the kitchens could wash their hands seem to be lacking at all the institutions. In other sanitary aspects, the kitchens seem entirely adequate. The Committee observed that the cooking utensils are clean at all five institutions. At Rosewood the cooking utensils appear to be immaculate. The Committee members were very much satisfied and pleased witli this aspect of kitchen operations. Since the State Department of Health is responsible for inspec- tion of the mental institutions in regard to sanitary problems, Dr. 12 R. H. Riley was requested to testify before the Committee in regard to this phase of his activities. He stated that systematic inspec- tions have been made of the institutions since 1946. Twenty-five such inspections have been made since that date. He stated that these inspections disclosed a wide variety of unsatisfactory condi- tions including defective garbage disposal methods, inadequate methods of handling food, inadequate and unsuitable diets, im- proper sterilization of cooking utensils, the presence of rats, mice, and verminous insects, and a variety of other difficulties. Dr, Riley reported that he had made an inspection of all five institutions in preparation for his appearance before the Committee, and he noted that much had been done to correct many of the unsatisfactory con- ditions. This activity, however, had been restricted to those things which could be done without large capital expenditures or sub- stantial increase in personnel. Plans for improving these conditions are described in Chapter 8. CHAPTER 3 Medical and Psychiatric Facilities and Treatment Very early in its consideration of the problem, the Committee became aware of the acute shortage of technical staff at all of the institutions. The extent of these shortages is indicated in the appendix to this report. Psychiatrists, psychologists, medical doctors, registered nurses, dentists, social workers, and other per- sonnel are needed in all phases of treatment of patients. It is obvious to the Committee that these shortages severely hamper the work of the mental institutions. Reasons for the personnel shortages of this type are not too difficult to ascertain. There exists a nation-wide shortage in the field of trained psychiatrists and psychiatric nurses. Other doc- tors, psychologists and psychiatric social workers, as well as dieti- tians, are far from plentiful at the present time. The mental institutions of all states are experiencing grave difficulty in filling these important positions. Regarding the salaries of doctors, the Committee is of the opinion that they are not unduly low. It bases this assertion on the testimony of numerous professional persons who have stated their beliefs to the Committee to this effect. Also, the living ac- commodations provided doctors usually are quite satisfactory, where such are available. Many of the doctors live in individual houses on the grounds furnished them by the State. Housing of some professional personnel, as the psychiatric social workers men- tioned above, is inadequate as stated. The Committee received testimony to the effect that the greatest incentive that could be offered professional personnel to induce them to come to the mental institutions is the opportunity for ad- vanced training. Maryland is in a particularly fortunate position 13 in this matter, since Baltimore already is recognized nationally as a center of psychiatric training. Eastern Shore probably would remain too “isolated” to take advantage of this relationship, but the remaining four institutions should be able to develop programs of cooperation which would enable them to secure the services of psychiatrists in training. In substantiation of this belief, it is ob- served that Spring Grove, because it is most accessible from Balti- more, now has the most complete psychiatric staff of the four State mental hospitals. Only a small proportion of the doctors there, however, plan to stay beyond the necessary training period. The Committee observed the lack of infirmaries for patients and employees at some of the institutions. In some instances, there are no such facilities, and, in others, the facilities are crowded into inadequate space. The Committee also noted that laboratory facili- ties are found in some of the institutions, but apparently rather poorly developed in others. Surgical facilities seem to be quite adequate in some institutions, and Committee members were told that the operating rooms contain equipment that is the envy of some city hospitals. However, the hospitals tend to avoid major surgery despite the fact that they have all the needed equipment. This is a result of lack of experienced personnel necessary in the performance of the operations. Major surgery cases are usually taken to general hospitals. Hydrotherapy tubs are standard equipment in all of the institu- tions (except Rosewood) for the treatment of patients. However, they are not used and are insufficient in number. The explanation again is lack of trained personnel necessary to observe the patients while under such treatment. The appendix to this report indicates the extent to which continuous tub facilities are available. The Committee is not in a position to pass judgment on the appropriate use of insulin and electric shock treatment, but it did receive testimony to the effect that these treatments are in use in some of the hospitals. In regard to the insulin shock treatment, Spring Grove pioneered its development in the United States. Some of the institutions using insulin shock state they do not attempt to use deep shock because of lack of trained personnel. The ingenuity and initiative of one doctor came to the attention of the Committee when it was observed that he secured from the families of four women patients sufficient funds to hire a registered part-time nurse in order to enable him to administer insulin shock treatment. This has resulted in great improvement and probable recovery of at least two of the four patients. The Committee observed the great need for additional occupa- tional therapy and physiotherapy treatment. Only two of the hos- pitals have physiotherapists on their staffs, and several have no occupational therapy activity at the present time. Others attempt to provide occupational therapy without trained personnel. Very successful occupational therapy was observed by the Committee at 14 the Eastern Shore State Hospital. The women patients were ob- served sewing, and they appeared to be very contented and pro- ficient in their work. The trained occupational therapist in charge stated that some of the women have become so proficient that they are conducting a small business by selling their sewing products on the outside which supplies them with spending money. She is responsible also for the male occupational therapy work, but she deplored the fact that there is no trained therapist for this phase of the activity. The need for therapeutic treatment through recreational and religious activities also was observed by members of the Committee. As stated above, some playing fields were observed at the institu- tions, but they are of minimum use to the patients. Patients usually are only spectators at games played on these recreational fields and at entertainments in the recreation halls. An exception to this generalization is the Rosewood Training School where athletics and dramatics form part of the patients’ activities. Some of the other institutions conduct periodic dances and movies for the patients. Under discussion at the present time is a plan to permit the patients to use bowling alleys at Springfield now re- served for the employees only. Also of high therapeutic value in the opinion of witnesses ap- pearing before the Committee is religious activity. Most of the institutions provide religious services for their patients but in- dividual counseling is practically non-existent. The services are conducted on a part-time basis by ministers in the vicinity for which they usually are paid a small fee. CHAPTER 4 Custodial Care, Parole, and Discharge op Patients The five institutions reveal a very wide degree of patient care. At Spring Grove, in many of the wards, the patients do not have their hair combed and they present a dirty and slovenly appear- ance. In some wards the patients have their hair neatly combed. Much more nakedness was observed at Spring Grove than else- where. The attendant of the disturbed women’s ward stated merely that she placed dresses on the patients in the morning, but within a few moments some would have theirs stripped off. Ap- parently, no attempt was made to dress them again during the day. By evening, she stated, some of the patients might be wearing three dresses. Questioning at the other institutions revealed that a much more serious attempt is made to keep the patients clothed at all times. The Committee inspected the bedrooms in selected wards at all the institutions. In practically all instances, beds are crowded close together. They occupy much less than the 60 square feet 15 per patient as recommended by the U. S. Public Health Service. In some instances, more than two beds occupy the space that should be given to one. In only a few wards does the amount of space approach the United States standards. The variations in sanitation in the patients’ dormitories was shocking to the Committee members. In Spring Grove, in the wards visited, the floors reek with the smell of urine which had impregnated the floors. The blankets on the beds which had been made up for that evening’s occupancy had traces of human feces clearly obvious on some. The mattresses also were urine soaked, and the Committee members were told that there appeared to be no solution since patients removed the rubber coverings whenever they were placed on mattresses. The smell of urine is as strong in the wards of new buildings as in the old at Spring Grove. By way of contrast, Springfield contains no odor except a slight one in the disturbed wards. The floors of the bedrooms are as old and dilapidated but did not contain the odors found as Spring Grove. It was explained that the mattresses are maintained in an odor- less condition by the process of removing every mattress the mo- ment it becomes soiled. The mattress then is emptied of the straw which it contains and the ticking is laundered. The problem at Rosewood, obviously, is somewhat different in character, but there it is possible to use rubber coverings for protection of mattresses. Day room facilities usually are comparable to bedrooms, in mat- ters of sanitation. In other words, the Committee discovered that, if the bedrooms were clean, in all probability the dayrooms were also. The dayrooms of Spring Grove are as odorous as the bed- rooms. In addition, the temperatures are maintained at such a high level as to make the temperature, plus the odor, plus the sights, nauseating to the uninitiated. Some wards are as cheerful and as comfortable as possible under the circumstances. All, how- ever, show evidence of overcrowding, but some are clean and the patients appear to be relatively contented. It was obvious to the Committee and testimony was received from psychiatrists that too much restraint is used in the institu- tions. Exception to this generalization is Eastern Shore, where officials make no use whatever of strait jackets. In the other insti- tutions, there was considerable evidence of use of strait jackets and locked chairs to restrain a number of the patients. The Com- mittee is satisfied that, in a limited number of cases, such restraint is absolutely essential, as, for example, where a patient would be inclined to gouge his own eyes if given the opportunity. On the other hand, the Committee took cognizance of heresay to the effect that some attendants use restraint as a method of punishment un- beknown to the physicians in charge. The locked chairs are both attacked as inhuman treatment and defended as a more humane method of protecting patients. On the one hand, it was pointed out that the patients are required to remain in the chairs for long 16 periods of time, at least until they have soiled their clothing. Also, it was pointed out that the chairs are a hazard to the occupants, since they can be turned over. On the other hand, it was asserted that a chair permits the patient to be in company with his fellow patients, and therefore it is superior to solitary confinement. Authorities at Springfield assured the Committee that persons in locked chairs are taken to the toilets at least five times a day and, therefore, there is no necessity for soiling on the part of such patients. The locked chair is a protection both for the patient occupying it and for the fellow patients, according to the defenders of this method. The Committee came to the conclusion that the essential difficulty once more is lack of attendants which requires the use of too many locked chairs and strait jackets. However, it recognizes that there may well be occasion, depending on the type of patient, for the use of locked chairs, and, in a very limited number of cases, for the use of restraint in strait jackets. The Committee came to the conclusion that toilet facilities are, for the most part, quite inadequate. They appear to be insufficient in number in practically all wards. Also, toilets are entirely ex- posed, thus affording no privacy. In some instances, the Com- mittee recognizes that patients cannot be permitted out of sight of the attendants for any period of time whatever, but it appears obvious that, in many instances, walls between the toilets would be entirely feasible. It agrees that doors on such partitions prob- ably would be inadvisable. The social service program requires major development at all of the institutions with the exception of Springfield. The latter in- stitution has developed this phase of mental health work to the extent that it has attained nation wide reputation for the quality of work performed. The success of the program is demonstrated by the fact that, in the fourteen years the director has been at the mental hospital, 800 patients have been placed in family care. One hundred eighty three of these patients are, at the present moment, in the hospital, some only temporarily. Of the remaining 617 who are not in the hospital as of January 1, 160 are presently in family care and 457 have been discharged as fully adjusted to the com- munity. Since patients are placed in foster homes only if other curative plans cannot be made for them, this group of 800 repre- sents persons who would have been committed permanently to the hospital if they had not been treated in this wray. However, the director reports that, at the present time, she still has insuffici- ent staff and insufficient funds for boarding care to place the num- ber of patients actually referred to this program. The Committee believes that money spent in the expansion of this program will result in eventual savings since more patients will be returned to the community. If sufficient medical personnel were available, the rate of patient parole and discharge could be materially increased. In addition, 17 the Committee was assured by authorities that there are hun- dreds of persons who could be placed in boarding home care if funds were available. These cases, in all probability, could be cured at a more rapid rate if this step were taken. At least one of the hospitals indicates that it has a discharge rate for patients higher than that of the national average. This, however, does not neces- sarily indicate it is as high as it should be. The Committee is convinced that the discharge rate can be raised even higher. PART IT. THE NEW MENTAL HEALTH PROGRAM CHAPTER 5 Reorganization of the Administrative Structure Because of the findings of the Committee as described in Part I of this report, it is convinced that fundamental reorganization of the Department of Mental Hygiene is essential in order to raise it to satisfactory levels of service. It is strikingly evident to the Committee that all institutions are not equally deficient in all respects or equally proficient in others. The fact that one or more hospitals are definitely sub-standard in numerous respects indi- cates to the Committee the need for strengthening central re- sponsibility and control. Consequently it is proposing a plan in which the lines of authority and responsibility are clearly defined and there can be no question as to where credit or blame for con- ditions in all the hospitals should rest. The Committee recommends the abolition of the Board of Men- tal Hygiene. It can observe no useful function performed by this Board which might not be performed better by an improved ad- ministrative structure as outlined below. Certain members of the Board have proved to be very helpful in the operations of the De- partment, and nothing in this recommendation is intended to re- flect on the capacity, contribution or sincerity of any member of the Board. This Committee earnestly desires to retain all of the advantages to the Department that have accrued from the services of Board members, but in addition it wishes to remove all ele- ments that lead to diffusion of responsibility. The Committee proposes that the advisory members to the Board be re constituted as the Mental Hygiene Advisory Board. The members of the Board should be available to advise and con- sult with the Commissioner collectively or individually on matters of technical significance. It would be anticipated that the Com- missioner would call upon the Board members frequently for such advice. As provided under the present law, these Board mem- bers are leading specialists in the State. The Board also would perform a collective function whenever there was a vacancy or 18 impending vacancy in the office of Commissioner. In such instances the Board would be expected to canvass the field in order to dis- cover the best person available for the post. A list of highly quali- fied persons would be submitted to the Governor with the recom- mendation that he choose one person from the list. It is con- ceivable under unusual circumstances that the Advisory Board could discover only a single person with the required qualifica- tions, but under normal circumstances it would be expected to submit at least three names. The Committee does not believe that the Advisory Board should be required by law to submit more than one name. The Committee recommends also the establishment of a Mental Hygiene Board of Review, This Board would consist of nine mem- bers including the President of the State Senate and the Speaker of the House of Delegates serving as ex-officio members. The ex- officio members should be permitted to designate persons to serve in their stead. All other members would be appointed by the Governor for six-year, overlapping terms. Of these, two should be psychiatrists, one should be a medical doctor, not a specialist in psychiatry, one a psychologist, one an educator and two should be persons selected at the discretion of the Governor. This Board as well as the Advisory Board would receive no pay for its services, but it might be allowed per diem expenses when actually in the service of the State. The Governor should designate one of the Board members to serve as Chairman. The Board would have primary responsibility for visiting the five mental institu- tions periodically and reporting its findings annually to the Gov- ernor, the General Assembly and the Mental Hygiene Commis- sioner. Based on its own experience, the Committee is convinced that a single board inspecting all institutions can perform a serv- ice much superior to that performed by any body responsible for only a single institution. The comparative observations that can be obtained are absolutely essential for a genuine understanding of hospital operations and insight into the quality of adminis- tration. Consequently, this Committee is recommending the abolition of the Boards of Managers of the five institutions. The Committee is convinced that these individual boards serve no function not better carried out by the central authority herein proposed. Under the reorganized structure as recommended by this Com- mittee, the Commissioner of Mental Hygiene would be clearly and solely responsible to the Governor for efficient operation of the mental institutions. He would be appointed for an indefinite term outside of the merit system, but he should be protected against political vicissitudes by a provision which prohibits his removal from office except for cause. After thorough investigation of the problem, the Committee concluded that the Commissioner should 19 be a person trained in psychiatry. Although it recognizes the need for administrative ability in the top position, the evidence is overwhelming that training in psychiatry also is essential. Lead- ing psychiatrists and business administrators of mental hygiene departments of other states were unanimous on this point. A re- view of the laws of all the states indicated that a majority con- tain this provision. The Committee fully recognizes the difficulty of discovering a person possessing these combined qualifications, but it believes that such people are available and that the recom- mendation therefore is sound. The requirement in the recommen- dation that the Commissioner be experienced in administration is stated in sufficiently broad language to permit the appointment of a person whose administrative experience might not be neces- sarily in a mental hospital or a mental hygiene department. The Committee recommends that two major divisions be created in the Department of Mental Hygiene. It suggests that these be called ‘‘The Division of Psychiatric Education and Training” and “The Division of Administration and Finance”. At the present time, the law does not provide for organizational structure in the Department of Mental Hygiene, and one apparent result is the inadequate development of structure and personnel to exercise supervision necessary to ensure adequate service in the hospitals. Recognition of the need for these functions at the State level by specifying the divisions in the statute would tend to emphasize the necessity for adequate staff and organization. The Division of Psychiatric Education and Training would be functionally responsible for the technical services performed in the hospitals. It would contain such units and technical staff as might be found necessary to advise and consult with personnel in the hospitals on professional matters. It should contain psy- chiatrists and psychologists to advise on technical problems with- in their respective fields. A registered nurse with psychiatric training and experience should be included to advise on this phase of the program. A food supervisor would have over all functional jurisdiction over the dietitians in the respective hospitals. These technical and professional officials should be appointed without regard to the merit system but should be removable only for cause. In the Division of Administration and Finance, the personnel officer would be one of the most important officials at least during the next few years. The Committee has received unanimous testi- mony to the effect that the State Department of Employment and Registration has been of no material benefit in the recruitment of hospital personnel. Such personnel as has been secured has been the result of the activities of the hospital staffs. The superin- tendents have advertised in journals, written to training schools and even sent recruiting agents into neighboring states to secure attendant personnel. The Committee is convinced that this is not 20 an appropriate function of the hospitals. It rightfully belongs in the personnel office. The Committee has received considerable evidence of friction between the Standard Salary Board and the office of Employment and Registration in regard to classification of positions. The Com- mittee has insufficient evidence to resolve the issue, and conse- quently it is recommending that further study be given to the problem in order that an adequate job of classification may be performed for the hospitals. Because of this weakness in the State merit system machinery, as well as the re-organization of the De- partment of Mental Hygiene, the personnel officers in the Depart- ment of Mental Hyigiene will have burdensome and important functions during the first several years of their existence. The Committee believes that the Division of Administration and Finance should be responsible also for management of the farms at the five institutions. The farm supervisor would serve as liaison officer between the farm expert in the Department of Budget and Procurement and the persons in charge of farming operations in the respective institutions. Another unit in the Divi- sion would be responsible for the budget and accounting opera- tions of the Department. The Committee secured evidence that contacts with the Department of Budget and Procurement were frequently unsatisfactory because of lack of knowledge by the superintendents regarding financial procedures. A procurement unit would serve as point of contact with the Department of Budget and Procurement in regard to all matters of food, supplies and equipment for the hospitals and the central office. This technique of control over the hospitals should in no way interfere with their right to procure fruits, vegetables and other local produce where it is obviously to the advantage of the State and the hospitals to have them do so. The Committee be- lieves very strongly that much needs to be done to raise the standard of diet in the hospitals. It believes the first essentials are an effective procurement system and scientifically planned diets under the guidance of the food supervisor discussed above. An engineering and maintenance unit would provide functional guidance and advice on matters of repair, renovation, maintenance and planning of patient and employee buildings. This unit would serve as liaison with the Department of Public Improvements and the Department of Health in all matters in which they have juris- diction at the mental institutions. The superintendents also should be trained psychiatrists ex- perienced in administration. They should be appointed by the Commissioner without regard to the merit system, but they should be protected from arbitrary removal by the provision that they could be removed only for cause. The Committee is convinced that their existing responsibilities to the Governor, the Commis- sioner of Mental Hygiene and to their respective Boards of Man- 21 agers has led only to confusion and avoidance of genuine respon- sibility. Under the proposed plan, the superintendents would be fully responsible to the Commissioner only for all operations in their respective institutions. They, in turn, would appoint all personnel within their institutions. This personnel would be ap- pointed under provisions of the merit system. This Committee does not believe it to be within its function to outline the organizational structure in the various hospitals. It wishes to emphasize, however, that all such personnel would have direct line responsibility leading up to the superintendent, although many would have functional responsibilities to the pro- fessional staff and technicians in the central office. One such officer would be the personnel officer to be established at least in the larger institutions. His primary function would be that of hand- ling all personnel problems for his superintendent, but for con- tacts with the Department of Employment and Registration and for technical advice, he would secure the assistance of the per- sonnel officer in the Department of Mental Hygiene. Similar or- ganization should be established in such areas as dietetics, re- habilitation, business administration, etc. PROPOSED ORGANIZATION OF THE DEPARTMENT OF MENTAL HYGIENE COMMISSIONER OF MENTAL HYGIENE MENTAL HYGIENE ADVISORY BOARD MENTAL HYGIENE BOARD OF REVIEW CHIEF, DIVISION OF PSYCHIATRIC TRAINING AND EDUCATION CHIEF, DIVISION OF ADMINISTRATION AND FINANCE Functions Include: Psychiatric Services Nursing RehabllItatlon Social Work Food Supervision Functions Include: Personnel and Public Relations Budget and Accounting Procurement Farm Management Engineering and Maintenance Superintendent Crownsvllle State Mental Hospital Superintendent Springfield State Mental Hospital Superintendent Spring Grove State Mental Hospital Superintendent Eastern Shore State Mental Hospital Superintendent Rosewood State Training School 22 CHAPTER 6 Revitalization op the Personnel Program The Committee early in its deliberations became convinced that the matter of personnel constitutes the most pressing of all prob- lems at the mental institutions. The poor services in almost all respects are attributable to insufficient employees to perform the work adequately. The Committee received testimony to the effect that especially during the war period the quality of personnel ob- tainable reached a very low standard but that this has been a problem of decreasing significance since the end of the war. All the evidence regarding present brutality and drunkeness by em- ployees appeared to the Committee to be quite inconclusive. If true, it may well be a significant symptom of low morale among the employees resulting from the unpleasant working conditions. The Committee is recommending numerous changes in personnel matters to alleviate the worst features of the present personnel problems. It is hopeful that adoption of the recommendations will constitute a very significant stride forward in the solution of the problem. It is convinced that the method of compensation under which employees receive salary plus maintenance if desired and available is an antiquated system. Consequently, it is recommend- ing that a gross salary scale be adopted. The value of living accom- modations and laundry service, if elected by the employee, should be deducted from the employee's pay. Cafeteria service for em- ployees should be provided approximately at cost but on a commer- cial basis under which the employee selects his food and pays for what he chooses. This method of compensation has been recom- mended by the Standard Salary Board after expert study and meets with the full approval of this Committee. Reclassification of positions and the establishment of new salary scales also are sorely needed in the mental hospitals. As discussed in the preceding chapter, the services of the Department of Em- ployment and Registration have been wholly inadequate in per- forming this function. A re-evaluation of positions in the mental hospitals recently has been concluded under sponsorship of the Standard Salary Board. It has resulted in recommendation for re-classification of many of the positions. New pay scales are set up based on the new job descriptions and on a study of comparable wage scales in the competitive field. The Standard Salary Board has recommended the results of the survey which would represent an average increase of 14.26% over present pay scales. This Committee is fully convinced of the desirability and need for the wage and salary adjustments, that have resulted in the in- crease in pay scales. The specific evaluations and classification of positions are administrative matters outside the province of this Committee. Review of the techniques employed convinced the Com- 23 mittee, however, that acceptable procedures have been followed in respect to most positions. It believes, however, that more study should be given to the classification of some of the top technical positions. Positions such as clinical director, clinical pathologist, psychiatrist, physician and clinical psychologist apparently are rated at too low a level. The psychologists should have Doctor of Philosophy rather than Master of Arts degrees. In regard to the other positions listed, there should be consultation with profes- sional men in the respective fields before the classifications and descriptions finally are adopted. Another condition which causes vacancies in mental hospital positions at the attendant level is the long work week. Most attendants work forty-eight hours per week, while many work sixty hours. Overtime usually is compensated at straight time rates. The reaction of employees to the many hours of work varies with the individuals. Some are very desirous of shorter hours of work, but others are anxious to secure the additional compensa- tion provided by overtime. As a matter of fact, some are fearful that better working conditions would increase the staff to such an extent that they would lose the opportunity of securing overtime pay. The Committee believes it is not in a position to resolve the difficulty inasmuch as this is a problem affecting all custodial and penal institutions operated by the State of Maryland. Conse- quently, the problem must be studied in regard to its effect on all institutions. The Committee believes, however, that the shorter work week is an ideal toward which the State must strive. It recommends, therefore, that studies be undertaken in order to ascertain the possibilities eventually of achieving the forty-hour work week for institutional employees. Solution of the employee shortage problem also lies in improved living conditions for attendants and other employees. The Com- mittee is convinced that satisfied employees cannot be secured un- less they are given comfortable living quarters. They cannot be crowded three or four or even up to eight in a room with the reasonable expectation that they will be satisfied under such circumstances. Furthermore, they must be moved out of attic rooms which are insufferably hot during the summer months. The welfare of the workers requires that they be removed entirely from patient quarters to an adequate distance to enable them to relax and forget about their work during off hours. The Committee inspected the quarters of social workers at Spring Grove as reported above. These cottages are attractive but they do not contain the essentials of comfortable living for those who occupy them. It is understood by the Committee that these changes are in the plans of reconstruction at the present time. Many items of apparent minor significance loom large in em- ployee morale and satisfaction in respect to his job. One of these is the services of a canteen at which employees and patients can 24 secure tobacco, ice cream, confectionery, beverages, food, reading matter and other minor items. The lack of such a canteen has caused much dissatisfaction to be expressed to the Committee. The Committee has received recommendations on the other extreme that complete commissaries comparable to those in army camps be established within hospital grounds. The Committee, however, believes that a canteen as described above with financial operations independent of the remainder of the institution w’ould fill ade- quately the needs of employees. Psychiatrists testifying before the Committee were emphatic in their belief that such a canteen has great therapeutic value for mental patients. Another item of significance in the employee problem revolves about the relative isolation and lack of transportation facilities to and from the institutions. Most of the institutions are located a considerable distance from public transportation facilities. The result is that many employees feel confined to the institution almost to the extent as are the patients. Some of the institutions have in- augurated transportation schedules to and from the villages near which they are located. This Committee believes that such trans- portation furnished on a free basis is an important element in the recruitment and morale of employees. The transportation need be furnished only to and from the nearby village and points of public transportation. This is especially important in this period of high prices for automobiles which place them at prohibitive levels for many workers. The Committee believes that the hospitals imme- diately should expand their transportation facilities to the point found necessary to meet the needs of their employees. Members of the Committee observed no rooms for reading or general relaxation for employees in any of the institutions. It believes there is a definite need for such places in which employees can congregate and relax beyond the reach of patients. Such places probably should be supplied with recreational books and magazines for employees’ use. Investigation should be made of the need and desire for more extensive library facilities requiring the services at least of a part-time librarian. If such were de- veloped, they could be utilized in all probability by many of the patients. The Committee believes that the employment of a Negro staff at Crownsville should be developed as rapidly as feasible. In view of the dire shortage of personnel, it appears to be wholly unreasonable virtually to exclude colored personnel from a colored institution as apparently has been done. Experience in other states and private institutions appears to be conclusive that the difficulties of colored and white personnel working cooperatively usually are quickly resolved and necessary adjustments can be made. Fur- thermore, the Committee believes that personnel staffs should initiate studies to ascertain the feasibility of employing colored personnel to some extent in the other four institutions. 25 The Committee is convinced that employee training at all levels is sorely needed both to improve the quality of services and to attract personnel. At the top level, it strongly endorses the de- velopment of the proposed psychopathic unit of the University of Maryland Hospital. It has consulted with University officials and others and is thoroughly convinced of the great need for this unit as a teaching center to provide training in psychiatry for medical students, to provide post-graduate training in psychiatry for doctors, psychiatric training for graduate nurses and psychiatric training for social workers. It believes that a unit accommodating approximately 70 beds should be regarded only as the bare minimum and that consideration should be given for immediate expansion to approximately double this size. This expanded unit should include a ward for children suffering from emotional disturbances. Coupled with its training facilities, the psychopathic unit should engage in fundamental research in the field of psychiatry. It is generally agreed that the field of research is largely unexplored in the Mary- land hospitals at the present time. The Committee believes that, perhaps in cooperation with the Medical School of Howard University, Crownsville may be de- veloped into a training and research center for Negro physicians and psychiatrists, social workers, nurses and other classes of per- sonnel. This would provide adequately trained persons at all levels to man the hospital itself and, eventually, would also represent a contribution beyond the limits of Crownsville. CHAPTER 7 Capital Improvement and Expansion The Committee, in its surveys of the five mental institutions, immediately realized that all are badly crowded. In many wards the beds of patients are crowded so closely together that it is almost impossible to walk between them. In other instances, beds are placed in hallways and at other locations where normally the space should be used for other purposes. In only a few wards did the Committee observe beds spaced sufficiently far apart to provide what appeared to be necessary comfort for the patients. Personnel at the hospitals testified to the effect that beds placed so closely together were dangerous to the patients because some might become violent at night and injure others before they could be stopped. The day rooms are similarly crowded. Inadequate space is pro- vided for occupational therapy rooms, for infirmaries, for employee quarters and rooms for other purposes. Consequently, the Com- mittee became convinced that the overcrowding ought to be relieved both for the better treatment of curable patients and for greater comfort of those who would be destined to spend the remainder of 26 their lives in the institutions. This cannot be accomplished with- out the expansion of facilities. The Committee has received testimony and information from a variety of sources in regard to the feasibility of additional space being made available for the mental patients’ treatment and cus- tody. It has studied the report and heard witnesses in regard to the study conducted by the Department of Public Improvements. This study was completed in consultation with Dr. Riley H. Guthrie, Mental Hospital Adviser of U. S. Public Health Service. Dr. Preston and superintendents of the hospitals also were consulted in the course of the study. The study is based on the assumption that certain minimum space requirements are needed for patients at any mental institu- tion. These have been established by the U. S. Public Health Service. They include 60 square feet of dormitory space per patient, 50 square feet of dayroom space per person using such facilities, and 10 square feet of space per patient for all patients in the hospital for occupational therapy. Somewhat more space is re- quired in the case of Rosewood because of the different type of service performed at that institution. The study constitutes a demonstration of how the additional space can be achieved by conversion of existing space to patient use and by the building of additional facilities. In the conversion program, it is anticipated that all employees will be moved out of patient buildings and placed in their own group of buildings or off the grounds as the result of adoption of the gross salary recom- mendations. The study is based on the assumption that approxi- mately 50% of the employees will choose to live within the hos- pital grounds. Attic rooms now occupied by employees, but found unsuitable as living quarters, will not be used as living space for patients. In some instances, large sections of buildings have been closed because they have deteriorated to such an extent that major repairs are necessary. Such sections will be renovated under the space utilization plan. The employees who choose to remain living on the grounds would be provided for as follows: physicians and other key personnel with families would be provided cottages in which they could live a normal family life. Other married per- sonnel would be provided small apartments of the living-room, bedroom, kitchenette and bath type, and single employees would be provided with single rooms. Where feasible the new facilities would be located in an “employees’ village”. It is contemplated that additional space can be recovered for patient use through providing a central storehouse in each institution. It is expected that central- ization of storehouses will release much available space in patients’ buildings, as well as leading to a more economical and efficient method of supply control. Also, storehouse buildings can be con- structed more economically than patients’ space. Basement and 27 attic space converted for patient use will not be used for dormitory space but rather for dayroom or occupational therapy. A few statistics will show the present overcrowding and the solutions proposed by the survey. At Springfield, the survey reports approximately 3,050 patients at the present time. Based on 60 square feet per patient, there is room at Springfield for approxi- mately 2,150 patients. However, under the plans proposed, 210 additional beds can be provided by better space utilization and 600 beds must be provided by new construction. Spring Grove, with 2.353 patients, has space for 1,693 but 280 additional beds could be provided by better utilization, and the survey recommends con- struction to accommodate an additional 380 beds. Crownsville has 1,783 patients and bed space for 1,266 patients. Consequently, the survey recommends that 97 additional beds be secured from better utilization of space and 360 from the construction of new buildings. Eastern Shore, with a patient population of 486 is reported to have space for 345. Therefore, the survey recommends that 100 addi- tional beds be provided by better space utilization and 70 as a result of new construction. Finally, it reports that Rosewood, with a population of 1,237, has space sufficient for 935. It recommends, therefore, that 212 additional beds be provided as a result of space utilization and 280 by new construction. In summary, the 8,881 patients now have bed space which should be occupied by only 6,389 patients, if the recommended standard of 60 square feet per patient is accepted. Similar analyses are made in regard to the require- ments for day room space and occupational therapy. It is observed in the study that, of the 8,881 patients, approximately 1,140 are bedridden, making a load of 7,741 patients to use the day room space. The U. S. Public Health Service recommends 40 to 50 square feet per patient and, consequently, the present amount of space should accommodate only from 3,584 to 4,488 patients. On the basis of 10 square feet per patient for occupational therapy, the present 8,881 patients are using the space that ought to be accom- modating only 4,102. The construction program contemplated would not quite provide for the present population, but it would approximate this standard. If the attempts at better utilization of existing space were aban- doned, the new facilities at present costs would amount to $31,- 044,000. The study recognizes that there may be increases or de- creases in the patient population of the hospitals which are not provided for in the study.. The Committee does not attempt to pass judgment on the tech- nical and engineering aspects of the report. However, it does endorse the standards established by the U. S. Public Health Service and utilized as the basis of the report’s calculations. It believes the standards as set are reasonable and should constitute the goals of the State in its mental health program. 28 The Committee has received and considered recommendations that additional sites be acquired by the State for mental patients. One recommendation embraces the acquisition of an hotel and of hospital facilities, the latter at present operated by a county. The Committee is in no position to consider the merits of the pro- posal, but it has taken the necessary action to submit the proposal to appropriate administrative officials. One objective earnestly sought by the Committee is better classi- fication and segregation of patients by type. It believes this can be accomplished when more space is available. It believes and strongly recommends that the criminal insane, irrespective of color, should be placed in one institution because of the additional protection required. As in the Maryland penal institutions, there may be separation on the basis of sex and race, but there appears to be no necessity for more than one institution for all the criminal insane of the State. Also, the Committee strongly believes that the Rosewood State Training School should be devoted to the purpose implied in the title. In other words, all untrainables should be segregated in the institution. The untrainables then would be clearly separated from the children who are capable of sufficient training and educa- tion to permit their discharge back into the community. The Committee received testimony from psychiatrists that classifi- cation and segregation into wards on the basis of social behavior patterns is the logical basis in mental hospitals. The Committee is not passing judgment on the technical problems involved, but it is recommending that adequate space must be provided to make available the facilities for segregation necessary to improve the therapeutic and custodial care given to patients. CHAPTER 8 Development op Therapeutic and Custodial Services The Committee’s observations at the five hospitals force the con- clusion on it that lack of adequate therapeutic and custodial service is primarily the result of personnel shortages. As already indi- cated some of the professional personnel with which the Committee came in contact impressed the Committee members favorably. The attendants and other workers also are frequently interested in their duties and are sincere in their attempts to provide the neces- sary comfort for the patients. The Committee received ample testimony to the effect that the hospitals were past the low point reached in the war when no competent personnel in the attendant class could be secured under any conditions. There is need for more infirmary facilities for both employees and patients. Some institutions contain no infirmaries for em- ployees, and in other instances they are inadequate and crowded. 29 The present building plans as developed by the Department of Public Improvements provide for infirmary facilities which, it is hoped, will be adequate to fill this need for both patients and em- ployees at all institutions. Drugs and medical supplies are ade- quate at some hospitals. Well equipped laboratories were observed by the Committee members. The surgical facilities in some institu- tions are excellent and the pride of the institution. The Committee is not in a position to pass judgment on tech- nical problems involving the use of shock treatment. The Maryland institutions appear to be adequately equipped with the necessary drugs and equipment to administer the most advanced type of shock therapy needed in the treatment and cure of mental cases. The primary deficiency is the deficiency resulting from lack of trained personnel. The Committee believes that the adoption of its recommendations as contained in this report will solve to a large extent the personnel problems thus permitting more wide- spread use of treatment in which Spring Grove has pioneered and which other hospitals are using. A similar need for personnel was evident in all institutions to provide physiotherapy treatment. Occupational therapy is being utilized to a very limited extent. It is generally recognized that this is one of the most important types of therapy that can be employed. The Committee was very favorably impressed with the work under way at the Eastern Shore State Hospital in occupational therapy for women patients. The Committee believes strongly that occupational therapy work should be extended to all the other institutions as soon as personnel con- ditions permit. Lobotomy operations are performed on some of the patients, but apparently the operations are performed in city hospitals rather than at the institutions. Psychotherapy requires much time and attention devoted to the individual patient. Conse- quently it, too, can be practiced only to a very limited degree be- cause of insufficient personnel to do the work. The therapeutic value of such items as recreation and canteen facilities at which patients can purchase small items already has been discussed in this report. A very important aspect of therapeutic treatment is religious activity. The institutions provide religious services at the present time, but the Committee believes that this type of service should be greatly expanded. It discussed the problem from numerous angles, and it recognizes that there are dangers in placing religious personnel on the State payroll. It believes the theory of separation of church and state is sound and would not wish to do violence to this principle. On the other hand, the Committee recognizes that a person in the ministry would not necessarily be able to minister to the religious needs of mental patients. Consequently volunteer assistants might be wholly inadequate to serve the purposes of 30 mental institutions. The Committee believes that cooperative ar- rangements should be made with the faiths and denominations of the community in order to provide trained persons who will come to the institutions not only to conduct services but also to give individual counseling to mental patients. Furthermore, the Com- mittee believes that as soon as possible there should be rooms set aside as chapels in which religious services may be conducted. This type of facility would not only serve an important need for the patients but would be of great value in restoring many of them back to normal health. In regard to the custody of patients, the Committee recommends that additional steps be taken to add to their comfort and pleas- ures in so far as possible. Despite the evidence of satisfaction on the part of the patients, the Committee believes that more should be done for their comfort and welfare. As has already been indi- cated, more space should be provided and furnishings should be placed in the wards to add to their attractiveness. Attempts should be made to decorate the rooms in as bright and cheerful manner as possible. Scatter rugs, flowers, radios, simple games and simi- lar items for recreation and adornment should be provided wher- ever conditions of the patients permit. The Committee believes that food is a very important element in patient satisfaction with his environment, and psychiatrists agree that the serving of foods is an element in the recovery of patients. In other words, table manners are important in restoring a person to normal attitudes and complete recovery for discharge to the outside world. The Committee recommends improvement in the method of serv- ing the food. Although the large dining room for men at Spring- field was quiet and orderly, the Committee believes it would be much more attractive if divided into several units of smaller size. The Committee believes further that cafeteria facilities should be installed for all patients except those who cannot feed themselves. Plans for the installation of cafeteria service are under way at several institutions. Furthermore the Committee believes that the food should be served in a manner which permits its separation by type. The divided trays used in the army would be much superior to the single bowl into which all food is placed at most of the institutions today. Eastern Shore is exceptional, because there most food for patients is served in divided trays. The Committee is advised by the Department of Budget and Procurement that these divided trays are available for a very low price for use in the institutions. The Committee strongly recommends their adop- tion. 31 CHAPTER 9 Mental Health Clinics and Preventive Psychiatry The Committee believes that great opportunity exists and part of the solution of its problem are to be found in the prevention and early treatment of mental disturbances. Consequently, it is recommending very highly the inauguration of programs that will keep persons out of the mental institutions by the prevention of the disease. Just as preventive medicine has flourished in many other aspects of the medical field, it is believed that preventive psychiatry is merely “scratching the surface” at the present time. Reference already has been made to the psychopathic units pro- posed as part of the University of Maryland hospital. The Com- mittee believes that the training of all medical students in the University in regard to the basic elements of psychiatry will be of tremendous benefit to the State. In this way, many general prac- titioners will have sufficient knowledge of psychiatry to cure cases before they reach advanced stages or to refer such patients im- mediately to appropriate clinics. The training of psychiatrists at the University of Maryland medical school should result in a greater number in the State serving either in a public or private capacity, thereby reducing the number of persons who must be committed to an institution. Psychiatric social workers also would play their parts in the preventive field. The Committee is so favorably impressed with the possibility of preventive psychiatry that it believes there should be immediate development of reception facilities at which the best talent avail- able might be used to effect a high degree of cure in early stages of mental disease. It believes in principle that the most effective type of treatment for mental disease is achievable in a genera! hospital at which facilities and personnel are available for all medical aspects of the problem. Consequently, the Committee has been very favorably inclined to the proposition of establishing an admission and treatment center at the University of Maryland hospital. Such a center of three hundred or four hundred beds, the Committee believes, could serve practically the entire State and effect a much higher rate of cure than is possible in the crowded mental institutions. From both the humanitarian and economic points of view, such a program is considered important in the State mental health program. Patients found to be incurable or those requiring long periods of treatment would, of course, be channeled to the institutions. However, the Committee recognizes the fact that such a center might “swamp” University facilities and seriously impair its ability to train personnel in psychiatric work. Therefore, this Committee is recommending a unit of one hun- dred fifty bed capacity, including a ward for children, which will fulfill the following functions: (a) Training of medical stu- 32 dents of the University medical school; (b) the training of State mental hospital personnel; (c) service to the community in the admission and treatment of acutely ill patients. Another phase of the program recommended by the Committee is the establishment of community mental hygiene clinics. At the present time, there is one in operation in College Park, Maryland, established by the U. S. Public Health Service. In addition, county clinics associated with the county health departments have been established in eight of Maryland’s counties. These are operat- ing under the Maryland Department of Health but with Federal funds exclusively. Beginning in the fiscal year 1050-1951, these clinics must be supported in part by State funds. The Federal government will then contribute two dollars to such clinics to every one dollar contributed by the State. This Committee is con- vinced that the activity aided by the Federal government is essen- tial for the mental health program of the State and everything should be done to develop this facility as rapidly as possible. Therefore, it believes that staffs immediately should be recruited for this purpose. At least a token appropriation is being re- quested for the year 1949-1950 in order to enable the State to further its recruitment program and to provide assurance that Maryland plans to develop this phase of the mental health pro- gram. The Committee recommends that such appropriation be granted. These out-patient psychiatric clinics would serve both adults and children. They would not only provide preventive treatment to keep persons out of the mental institutions, but early diagnosis might well assist in proper psychiatric treatment after admission in the hospitals. Furthermore, the clinics would be used for appropriate treatment of mental patients after discharge where such treatment might prove necessary. At the present time Baltimore City is served primarily by Phipps Clinic, the Harriet Lane Home, the Mental Hygiene Society Clinic at University Hospital, and the Veterans’ Administration clinic. The county clinics are now found in Allegany, Baltimore, Carroll, Cecil, Charles, Washington, and two in Anne Arundel County. In addition to these part-time clinics, a full-time clinic is maintained in Montgomery County. Remaining counties should receive comparable services. The Committee recommends the expansion of clinical services to embrace all counties of the State as well as Baltimore City, 33 CHAPTER 10 Financing the New Mental Health Program The Committee is fully aware that the new mental program as outlined in this report will be costly to the State. However, it is convinced that the money will be well spent in several respects. The program as outlined in the preceding chapters should offer the solution to most of the problems that have hampered effective service in the field of mental hygiene. The Committee wishes to conclude its report with some observations regarding the cost of the program and the distribution of the burden involved in such costs. The recommendations embraced in this report in regard to salaries would result in increased appropriations of approximately one-half million dollars per year. This figure is the result of in- creasing the salary of many employees because of reclassification upward of their responsibilities and as a result of the competitive comparison made with private industry. The present payroll appropriation is $3,750,504. Under the plan recommended by the Standard Salary Board the payroll cost would be |5,333,341. This represents an increase of $1,572,837 over that requested in the 1950 budget. However, it is estimated that deductions from payroll for charges against employees for maintenance which is now provided gratis would recover for the state the sum of $1,027,500. Thus, the net additional funds needed for the fiscal year 1950 would be $545,337 for employee salaries and wages. This represents an average increase in pay of 14.26%. The Committee believes that this increase is justified and is hopeful that it will have an im- portant effect in increasing the personnel employed at the institu- tions. The capital improvement program of the Department of Public Improvements as outlined above would require the expendi- ture of funds in 1950 as follows: Springfield $6,265,556; Spring Grove $3,079,244; Crownsville $5,400,400; Eastern Shore $1,125,- 200; Rosewood $4,356,825; or a grand total $20,227,225. Appropria- tions for 1951 are planned as follows: Springfield $850,150; Spring Grove $2,350,450; and Rosewood $701,750; making a total of $3,912,350. The gross expenditures estimated for the two years thus is computed at $24,139,575. Proposed expenditures for the psychopathic unit of the Univer- sity of Maryland hospital would under present plans of a seventy bed building involve the expenditure of $2,200,000. Of this sum $1,035,000 already is available from past action of the General Assembly and from Federal matching funds. If the bed capacity of the unit were to be doubled, it would cost approximately an additional million dollars. For a 300 bed unit, the cost would be 34 approximately five million dollars. These figures represent capital outlays only. Obviously there would be additional expenditures involved in operating the enlarged unit. The Mental Hygiene Division of the Maryland Department of Health is operating on a very small budget at the present time. During 1948, it had a budget of approximately $47,000. All of these funds were supplied through the U. S. Public Health Service, under the National Mental Health Act. It is expected that Mary- land will receive no more than $41,000 in the coming fiscal year from the Federal government. For reasons stated above, the Men- tal Hygiene Division of the State Health Department requested the sum of $27,000 in the State budget in order to aid the State pro- gram on a matching basis with Federal funds. This item was deleted from the budget. If the program is expanded to include all counties, the appropriations by the State will be increased ma- terially. The Committee believes that full advantage should be taken of available Federal funds in the future in all phases of the mental health program. The Committee has been informed that there is the possibility the Hill-Burton Act will be amended, which will have the effect of making available to Maryland additional Federal funds to expand its mental hospital facilities. The Committee be- lieves the State of Maryland should take advantage of funds avail- able in the establishment of community clinics on the basis of the two dollar of Federal funds to one dollar of State funds. At the present time counties and Baltimore City are required to contribute to the support of their residents who are patients in the mental hospitals to the extent of $125 each per year. The counties and Baltimore, in turn, are authorized to collect from the families of patients for the cost of such patients in the institutions. Re- cently, the Board of Mental Hygiene established such cost at fifty dollars per month per patient and authorized the local units to collect this amount. In case of inability of the families to pay any or the full fifty dollars per month, the county welfare depart- ments adjust the obligations of the families accordingly. Of the funds so received, the county first reimburses itself to the extent of the $125 paid to the State and thereafter turns over any addi- tional funds on each specific patient to the State government. Testi- mony received by the Committee, however, reveals that a number of counties make no attempt whatever to collect from the families of patients. They bear the full burden of the $125 per patient out of general tax funds. The State Department of Mental Hygiene, in the belief that additional funds could be secured from the families of patients, established a small unit for this purpose. It has succeeded in collecting approximately $150,000 per year from such families. This fund is used for the boarding-out care pro- gram. 35 The Committee ascertained that the $125 per year contribution from political sub-divisions was established many years ago (1912) when that figure paid one-half of the cost of the patient to the State. The cost per patient now is about $750 per year. Because of the need of increased funds to meet the State’s new mental hygiene program, the Committee believes that contributions from political sub-divisions should be increased to a flat rate of $300 per year. By adoption of this increased figure under the same condi- tions as the $125 figure has been handled, the State will recover an increase of $1,650,000.00. The Committee urges that every effort be made to have the counties use positive methods for collecting this sum. It also recommends that the Commissioner use the unit already established in his department to collect from families able to pay the full amount of the cost. In such cases the counties or Baltimore City should, as in the past, be reimbursed for whatever amount they might have paid on each patient. This recommendation for recovery of money for the State hos- pitals is one which should be readily acceptable in the face of the tremendous demands made on the State for more services and greater capital outlay. APPENDIX A Springfield State Hospital A. Physical Plant. The physical plant at Springfield is located in Carroll County near Sykesville. The buildings are in from fair to mostly good condition. Moderate repairs to a few such as floors, etc., in the disturbed men’s buildings would place them all in good condition. All buildings are crowded. Patient population was 3,050; with capacity on basis of 60 square feet per patient, 2,162. Tempera- tures were very satisfactory. All buildings and equipment were found to be in exceptionally clean condition. Odors were almost non-existent, except for very slight ones in the disturbed men’s day room. Additional space is necessary to relieve the overcrowded condition and to permit proper segregation, as well as separate employee quarters. B. Personnel. Personnel was found to be inadequate but doing a good job with the numbers compared to the need. There seemed to be a general feeling of cooperation among the employees, resulting in good morale, and a respect and praise for the administration. They pointed with pride to the new employee apartments soon to be completed and occupied and felt provision should be made to permit all employees to live in buildings separate from patient buildings. 36 They have 4S3 employees at present with 647 needed to enable the institution to function at top efficiency. It is felt that with adjustment in pay to recognize living out, additional employees will be attracted from surrounding community. C. Food. Springfield has the only dietitian in the State mental hospitals, and much credit is given that fact for the condition and quality of the food served. The kitchens were found spotless and food observed being served patients looked appetizing, as well as suffi- cient in quantity. Rulk method of serving, however, is never too satisfactory and it is felt steam tables, enabling serving in cafeteria style would be a great improvement. D. Condition of Patients. Patients generally were found in good condition in relation to what would be expected in an institution such as this. Their clothing was clean, and about as to be expected, although better fitting, etc,, in connection with better segregation seems desirable. Restraint is held to a minimum. Locked chairs was the only method used and then only where safety of patient and fellow- patients was involved. For instance, in the disturbed women’s ward, only five patients were in chairs, and it is felt that treat- ment was indicated and humanitarian. A degree of discipline above expectation was observed. E. Special Therapies. Use of shock treatments is limited because of insufficient per- sonnel. More should and will be used when personnel is obtained. Continuous tubs exist but are not used. Occupational therapy is used, but not to extent it could or should be with sufficient per- sonnel and segregation. Social service is one of hospital’s most important phases of operation. It not only reduces the population of the hospital, thereby permitting others to enter, but removes them from confines of the hospital, yet continues to follow and supervise them. It also awakens the community to the work of the institution and makes it a part of the community rather than isolated. Additional per- sonnel should be employed in this activity. It would seem very desirable to extend this service to all of the institutions. 37 APPENDIX B Spring Grove State Hospital A. Physical Plant. 1. Spring Grove State Hospital is located in beautiful rolling country near Catonsville, Baltimore County, Maryland. Although its older buildings have an institutional outside appearance, gen- erally it presents a pretty picture to the eye. The main buildings blend fairly well with each other, but the white cottages for the personnel do not fit in esthetically with them, although these latter appear to be fairly useful functionally. The interiors of the institutional buildings are in large part forbidding, unattractive, unsafe, dirty and odorous. In certain buildings the stench was so great as to make several members of the Legislative Committee actually nauseated. In the older build- ings the lighting conditions are such that patients live, even on bright sunny days, in a state of semi-dusk and gloom at all times. Little effort appears to have been made to brighten the surround- ings, although some painting has recently been done. The farm apparently is productive in season, and the produce is fed to the staff and patients. A playing field is laid out and in existence on the property, but the Committee was informed that the staff and patients make little or no use of the field, chiefly because there has been no organized recreation for the staff, and there has always been insufficient attendants to permit its use by the patients. 2. Excessive crowding was observed throughout. In some wards there is not sufficient room for anyone to walk between beds, and patients must crawl over the ends in order to get in or out of bed. The so-called “day rooms” are in fact mere corrals where patients are herded during the daylight hours and are dark, unattractive, uninviting and generally odorous. 3. Throughout the wards the temperature is so great as to be oppressive. It was stated that this was made necessary by the fact that some patients will not wear clothing, and it is, of course, essential that they be kept warn. Lack of proper ventilation was noticeable. 4. Generally speaking the plant was reasonably clean. In the disturbed wards there was some uncleanliness as stated, the smell from crowded human bodies was everywhere, and nauseating stench of urine and fecal matter permeated all the disturbed wards and some in which there were no disturbed patients. In the old buildings the floors have become so soaked with matter that it would be impossible to remove the odor without removing the entire floors and gutting the buildings. 38 B. Personnel. 1. Surprisingly, considering the physical surroundings ,the morale in the lower levels seemed to be good. There was evident in some quarters a real feeling of friendship on the part of the patients toward attendants and doctors. As to morale between top level and lower levels, it appeared to be reasonably good, although the Committee got the impression that many of the doctors, nurses, and attendants were dissatisfied with what might be termed a negative point of view on the part of the top echelon toward requests by personnel for improvements for themselves and for the patients. 2. Dissatisfaction was general with regard to living quarters. Many attendants are quartered in the same buildings as the patients, as are some of the medical staff with their families. For these people, there is no escape from the institution unless they physically leave the grounds, as the noises and odors are ever present and noticeable. As to the personnel not quartered in the buildings with patients, their living accommodations, although clean and new, are meager and cramped. For example, in cottages in which young women are quartered, there is no living room, no kitchen, and no telephone service. For these young ladies to enter- tain their guests or relatives there is impossible. 3. The need for personnel in all categories is so patent and obvious that it hardly needs comment. Attendants, nurses, ther- apists, dietitians, doctors and all other classes of staff are severely under manned. There is no dietitian in the hospital. Until recently there was no superintendent of nurses. 4. It is but fair to state that the personnel with whom the Committee came in contact appeared to be exceptionally well trained, competent and intelligent. The Clinical Director and other doctors obviously are men of fine competence, interested in their work and in the patients. The Superintendent of Nurses made an exceptionally fine impression upon the Committee. The turn- over, however, in the medical staff has been high. It was stated that one reason, at least, for this turnover, is that under the present regulations of the American Psychiatric Association only two years’ training at Spring Grove can be considered toward the completed training of a psychiatrist; the third year must be taken elsewhere. C. Food. Spring Grove has no dietitian. The only menu available to the Committee was one posted years ago in the kitchen, which provides an identical menu week after week, month after month, year after year. Fresh vegetables are served when available from the farm 39 during the summer. It was stated that fresh fruit is almost un- heard of. The only patients who receive milk at any time are those who are put on a special diet by a member of the medical stalf. Each building has its own kitchen. 2. The kitchens were found to be reasonably clean, in charge of a “cook” who prepared the meals with patient help. One of the “cooks” stated that because of lack of proper assistance he was practically forced to serve stew frequently to the point of monot- ony, as it was the only item which could be prepared in the time, with the help and with the equipment available. 3. When served, the food is completely unattractive and un- appetizing. What happens to it between its raw state and its serving to the patients is terrible to contemplate. The coffee served on the day the Committee made its inspection was so unattractive to the nostril that no member of the Committee dared taste it. 4. There seems to be no reason why good raw material should be ruined in preparation. Competent supervision of kitchens and “cooks”, with competent personnel should eliminate this difficulty. D. Conditioyi of the Patients. 1. The clothing of the patients was generally as unattractive as their physical surroundings. Little effort seemed to be made to enable the patients to try to make themselves attractive. This was not wholly the case throughout the hospital as in one or two wards the women seemed to be making some effort to keep them- selves neat. Generally, however, the clothing was dirty, ragged, patched, and rough. A check was made and there appeared to be some clothing reserve but not by any means a plentiful reserve. Parenthetically it was stated that male attendants are issued only two pairs of white trousers. Hence when one pair was in the laundry an attendant would possess only the pair lie wore. The clothing of attendants is subject to being soiled or torn by patients. Many patients tear their clothes off or have them torn off by other patients and spend their day in a state of complete nudity. Bedding was worn and patched, although the beds were neatly made and there appeared to be ample supplies of bedding. In the disturbed and “soilers” wards, the blankets were filthy with a prevalent odor of urine and evidence of fetal matter plainly to be seen. 2. One or two instances of strait-jackets were observed which were stated to be necessary because the patients would harm them- selves and others. There are some isolation rooms which are dark and dirty. The most frequent type of restraint was the “locked chairs”. A number of patients were observed in these chairs. This is the only method in view of the lack of detention rooms, by which 40 many patients can be restrained with existing facilities. They have occasionally been used, without authority, by attendants for punitive purposes. Restraint in locked chairs has to be used at times in order that patients could be safe while the only available attendant was required to leave the) ward. 3. Segregation can be used only to a limited degree. The criminal insane are kept separate from the non-criminal insane, but the only other basis of segregation seems to be that of sex. The Committee could get no satisfactory information as to whether or not there was any systematic method of segregation according to age or type of mental deficiency. E. Special Therapies. 1. Although there is some occupational therapy, there seems to be no planned system or routine to administer it. Patients do work on the farm in the summer time, and some of them assist in various tasks around the hospital, but occupational therapy seems to be actually haphazard. 2. Electric shock treatments are given several times each week and could be given more often to more patients, thus increasing the chance of returning patients to society if equipment were avail- able. At the present time it is not. 3. At the time the Committee visited the hospital there were eight patients receiving insulin shock treatments. It was stated by one of the members of the psychiatric staff that there were hundreds in the hospital who might benefit from such treatment if personnel were available to take care of them. 4. The use of tubs has been abandoned because of lack of per- sonnel to attend to patients while in the tubs. All seem to agree that tub therapy is desirable and helps the patients, but lack of personnel prevents its use. 5. Treatment of patients who are physically sick is apparently adequate. There is an infirmary for sick patients and an equipped operating room, laboratory and other facilities. It was stated that occasionally there is some difficulty in obtaining medicines necessary for proper treatment of physical disabilities. 41 APPENDIX C Crownsville State Hospital A. Physical Plant. (1) Crownsville State Hospital is located at Crownsville, in Anne Arundel County, Maryland, There is a large acreage suitable for expansion and development of needed facilities and buildings. The buildings are well located and present a nice exterior appear- ance. The interiors of the buildings are clean and neat. The walls are cleanly painted and kept clean. The floors are scrubbed and kept free from filth. There is very little unpleasant odor or stench. The rooms are fairly well lighted. Decorations appropriate wher- ever desirable and feasible make for a pleasant atmosphere under the circumstances. (2) There is patient overcrowding to the extent of approximately seven hundred (700) patients. In some instances, two children occupy one bed (from necessity). In other instances, because of lack of room, mattresses without beds are set out for patients. Because of lack of space, epileptics are not segregated, although the staff desires such separation. (3) The buildings seem to be well heated. Temperatures, at time of visit, were neither excessive nor too low.. (4) The buildings generally, outside and inside, were clean. The rooms and beds were clean and neat. Due to lack of space and from an administrative point of view, the criminal insane make for a problem and should be removed from this institution. The infirmary and laboratory were nicely maintained and seemed to be of good order. B. Personnel. (1) The general quality of personnel was fair. The attendant group, of necessity, was not of a high level of intelligence. The turnover in this group has been rather large. However, there is a faithful, loyal and conscientious core of this personnel around which an effective staff can be built. The Superintendent was keenly interested in the welfare and treatment of his patients. He was making every attempt, in spite of severe handicaps, to introduce and make use of the best tech- niques and facilities for therapy of his patients. His staff was loyal and conscientious and deeply devoted to their patients1 welfare. (2) Dissatisfaction was expressed with regard to living quarters and accommodations for personnel. Personnel deemed salaries in- 42 adequate. Some of the better personnel also expressed desire for an improved training program which would include not only train- ing as a practical nurse in general medical bedside technique but also special training in psychiatric approach to handling of pa- tients. (3) The morale of personnel was good. However, morale could be improved thru better living quarters, higher salaries, library facilities, and recreational facilities. (4) Attitude towards living quarters on part of personnel was one of dissatisfaction. (5) The ratio of nurse to patients is: one (1) to twenty-three (23) during day; one (1) to sixty-five (65) at night. The nursing group and attendants on duty are far below the number allowed in the budget because additional personnel could not be procured. C. Food. (1) No dietitian is on duty at this hospital. There is a chef and an assistant. The food is purchased thru the buyer at the hospital. The chef prepares a menu for each week and submits it to the administrative assistant (Miss Wolfe) at the hospital, who, in turn, consults with the physicians as to sufficiency of diet, etc. (2) The kitchen is very large, clean and appears to have all needed facilities. (3) The food appears to be palatable. There are a nice variety and several courses. The food is good and the type that anyone could sit down to eat. It was noted that food was carried to dis- tant parts of the institution on rubber wheeled carriages specially constructed to keep food warm and to protect it from handling while en route. D. Condition of Patients (1) The clothing of patients as observed was neat and clean generally. Some disturbed patients were not as neatly dressed as others. Some violent patients tore off clothes and were observed nude. (2) Very little, if any, restraint was noted. In fact, this institu- tion is remarkably free from restraint. No locked chairs or strait- jackets were observed on this visit. (3) It was the general impression that the patients and the at- tendants and staff got along well. Patients were generally cheerful and displayed friendliness and confidence towards staff and at- tendants. An item worthy of special mention was the type of isolation room used. The door of each isolation room had a window-type square opening through which patient could be observed by at- tendants at all times. 43 E. Special Therapies. (1) There were no occupational therapy or facilities observed. An impression was obtained that there is no personnel to handle such a program. Some patients do work on farm and assist in various tasks about the hospital. (2) No insulin shock treatment is given because registered nurses are required in attendance and there is a lack of this per- sonnel. (3) Electric shock treatment is used but not as extensively as the staff would desire. (4) There are three hydrotherapy tubs but they are not in use because of lack of personnel. (5) Treatment of patients who are physically sick is provided in an infirmary and an adequate operating room. However, there is insufficient staff for proper care of these patients. The labora- tory is an exceptionally well equipped one and is used extensively. The Superintendent desires to purchase and install equipment for electroencephalography but it has been denied. The X-ray technician makes photographs of each patient ad- mitted with proper identifying information. This type of record has proved of great administrative value. APPENDIX D Eastern Shore State Hospital A. Physical Plant. 1. The physical plant consisting of eight buildings has an ex- cellent appearance and is of brick construction and Tudor archi- tecture. The outside appearance is enhanced by a beautiful set- ting, with a green lawn on the banks of the Choptank River. All buildings need minor revisions and seven need major repairs and renovations, i.e. fire escapes and mechanical ventilation. The in- terior appearance is not as attractive as the exterior. 2. The buildings are overcrowded throughout. At the time of our visit, there were 487 persons, and the bed capacity at the hospital should not be over 315. 3. The temperature in the buildings was comfortable, and upon inquiry we learned that none of the patients suffered from colds. 4. The general cleanliness of the plant was evident. With addi- tional help it could be made spotless. 5. Odors were reduced to a minimum. 6. It is reported that there are not enough toilets, and it is recommended that some plan be devised whereby at least partial privacy may be obtained. The infirmary is well run but too small, and a special building is recommended. 44 B. Personnel. 1. The general quality of the personnel is mediocre. 2. A member of the medical staff appears to be extremely eccentric. 3. The woman in charge of occupational therapy deserves special praise because of her very fine and brave spirit as was evidenced by her accomplishments. 4. The general morale of the personnel may be defined as good. 5. Attendants were living in the third story parts of the build- ing, and upon questioning, indicated that they preferred to live out. 6. There are 112 employees, 51 of whom are living in Cambridge. It was suggested that the employees be increased by 65. There are one registered nurse and one graduate nurse. There is no occu- pational therapist. There are one physician in charge, who was absent, one medical doctor and one psychiatrist, a woman. 7. It is recommended that additional registered and graduate nurses be added to the staff. C. Food. 1. The food was very good. The control pattern of administra- tion was loose but apparently effective by a stewardess without previous training but with many years of experience. 2. The condition of the kitchen was fair. 3. Condition of food when served—good. 4. It is noted that the fine appearance of the kitchen was de- tracted from by the untidy appearance of patients who acted as kitchen police and it is therefore recommended that cooks or maids be entrusted with the preparation and handling of the food. It was noted that the patients get milk three times a day. D. Condition of Patients—Untidy. 1. The clothes were sufficient but drab and unattractive looking. 2. Restraint was used very little, except for patients who might do injury to themselves or other patients, and one who was a sexual pervert. The attitude of the officials towards restraint was that it should be used as little as possible. 3. There are in the hospital six continuous tubs which have not been used for a long time. There is no occupational therapy for the men and no clinical director, and there is no resident dentist. The occupational therapy for women is under the supervision of a very efficient and competent woman. 4. The general needs of the patients are a. Space b. Attention c. Occupational therapy for the men and more occupational therapy for the women. 45 d. It is suggested that chaplain’s service should be en- couraged. At times there have been as many as eight alcoholics among the patients: at present—two. APPENDIX E Rosewood Training School A, Physical Plant. The location of Rosewood Training School is in a very beauti- ful rolling countryside and the buildings, improvements, land- scaping, etc. all make for a rather pleasant setting for such an institution. Rosewood is established for treatment, schooling and housing of mentally deficient children between the ages of 6 and 16. The problems are therefore the training of sub-normal minds of youngsters with a low level of mentality, many of whom are also handicapped by physical deficiencies and some whose future ap- pears to be hopeless. There are now 1,240 patients in quarters that should house about 900. There is, therefore, considerable over- crowding, although not as bad as other institutions visited. Several outstanding needs are indoor space for play and recrea- tion, more space for schooling facilities and school shop for voca- tional training, etc. The kitchen is very good and has excellent equipment. There is no space for use as a chapel or place for religious worship and it is apparent that such provisions are a most important part of this and all other institutions. Some of the buildings need fireproofing and fire escapes to eliminate existing fire hazards. Most of the buildings appeared to be in good repair. More employee housing is necessary as many em- ployees are now housed in buildings with patients. The hospital, or medical section, seemed well equipped and efficiently operated, although limited by lack of properly trained personnel. A train- ing class, or school, is being conducted, but facilities and lack of instructors restrict number able to attend these classes. Addi- tional special personnel trained in the care of children must be provided. Of course, it is impossible to make detailed recommenda- tion regarding buildings and space based on a short visit but these are suggestions worthy of study and necessary corrections. B. Personnel. Our sub-committee was very favorably impressed with apparent effort being made by the Superintendent, his Administrative Assis- tant, the Clinical Director, and others of the personnel of this institution. They all seem most interested in their work and anxious to do a good job and to effect just as many cures and release or parole as many patients as rapidly as possible, although 46 the Superintendent said he preferred to keep patients usually until 20 years or more of age because they were then so much better trained. Social service or parole work should be developed here. Like all other mental institutions there is a shortage of personnel, especially nurses and attendants, although not as serious as the other mental institutions. There are only four nurses while nine are allowed in budget and more needed. Most employees have to live in the institution as the location in the country does not pro- vide living accommodations in the nearby vicinity. This creates a further housing problem which should be corrected. C. Food. The food and its preparation seemed to be good and according to menus are varied daily. There is no dietitian, the menus sup- posedly being approved by the medical staff. There should be a dietitian for an institution of this size, especially with the type of patients necessary to feed. The food seems well prepared in the excellent kitchen, which was very clean, but the service is difficult as all food after preparation must be carried in cans by push carts around the grounds to the different buildings, and is thereby cooled and apparently not so palatable when finally served. Food is served in undivided plates or bowls and therefore also not too palatable. The dining rooms are in each separate building and are rather unattractive. Considerable food is raised on the institu- tion’s farm, but the larger percentage has to be purchased. All patients are given about a quart of milk per day, except, of course, those not able to consume that much. D. Condition of Patients. Clothing, bedding, etc., appeared to be adequate, and to our ob- servation all patients seemed to be well cared for. Finally, it appears very definite that the situation at Rosewood would be greatly helped as to housing, treatments, schooling, and in general if only children up to sixteen years of age, or perhaps to twenty, are admitted or retained there.. Over half of the pa- tients now in the school are over 21 years of age and they range all the way to 70 years. It seems many of these older people who apparently will be permanent residents should be transferred to more appropriate institutions, thus providing more space for those of the 6 to 16 age who need the facilities and training Rosewood is set up to provide. 47 APPENDIX F Analysis of Statistical Reports from the Hospitals and Rosewood General: Maryland has 415 per 100,000 of her citizens in psy- chiatric hospitals (exclusive of the feebleminded). The rate of hos- pitalization is compared with that of other states in the table below: Hospitalization Rates, Various States an d U nited States Md. Conn. N.H. R.I. Va. Del. U. S. Rate hospitalization per 100,000 population . 415 539 581 502 382 586 399 The relative low rate in Maryland as compared to other states is probably due to the fact that only emergency cases are able to find beds in the crowded hospitals and thus there are in the com- munity a number of persons who would be in hospitals if there were room. In 1936 it is known that in the Eastern Health Dis- trict of Baltimore there were about 25% of the known psychotics now in hospital. This is not necessarily bad practice, but it is not scientific reasons but crowding of hospitals that makes it prevail in Maryland. The following tables and statements have been selected and com- piled from a statistical form sent by the Joint Legislative Com- mittee to the superintendent of each hospital. Many of the figures refer to a specific day in February, 1949, and are to be regarded as a one-day picture so far as “on duty” columns are concerned. In general, it is believed that the data are not overly biased by this consideration. I. Capacity and Overcrowding : Capacity, Number of Patients, Empty Beds and Percent Overcroicding in Maryland Psychiatric Hospitals Capacity* No. Patients % Overcrowding Empty Beds Springfield 2,162 3,032 40.2% f 0 Spring Grove... 1,647 2,358 49.2% 0 Crownsville .... 1,100 1,777 61.5% 0 Eastern Shore. .. 345 490 42.0% 19 Rosewood 897 1,232 37.4% 43 * Figured on basis of 60 square feet per patient. t Formula: Patients—Capacity x 100% Overcrowding Capacity. 48 II. Organization : Administrative organization varies from hospital to hospital. Spring Grove has 8 subordinates reporting directly to the superin- tendent (only one of these is medical, the clinical director), Spring- field 4, the Eastern Shore 3, while Rosewood and Crownsville have but 2, a clinical director and an administrative assistant. The functional division appears about the same in each hospital, though Spring Grove appears overly elaborate particularly on the adminis- trative side. In only one hospital does the superintendent of nurses report directly to the superintendent, the Eastern Shore Hospital. From this review, and in the light of recommendations made in the body of the report, it would appear wise to make the internal organization of each hospital the same in so far as the varying geographical and size factors allow. This organization should correspond to that set forth for the office of the Commis- sioner, There is no uniformity whatever in the various dietary and other forms submitted by the superintendents as a part of the statistical reports requested. III. Fiscal Organization : Organization varies in the hospitals. Purchasing and general finance are the same department at the Eastern Shore Hospital which is small; in each of the others, these are separate depart- ments. The departments cannot be directly compared since func- tions are differently assigned. The combined cost of these depart- ments and the purchases they supervise are given in the table below: Cost of Fiscal and Purchasing Departments and Percent Administrative Cost of Purchasing Budgeted for Fiscal and % Costs, Purchasing Administration Departments Purchases Purchases Springfield |27,0d4 1856,602 3.1% Spring Grove 26,027 765,150 3.3% Crownsville 16,087 663,735 2.4% Eastern Shore . .. . 9,577 197,970 4.8% Rosewood 21,276 537,554 3.9% IV. Data Relating to Food and its Service; Because of differences in classification between the hospitals, it is impossible to compare directly the personnel practices regarding food administration in the various hospitals exactly. In the fol- lowing table a comparison has been made, but it is very rough. 49 For example, dietitians’ aides are classed with dietitians for one hospital, though it is questionable if these are meant to be pro- fessional personnel. Dietitians on Duty, Allowed in Budget; Patients per Dietitian, Kitchen Personnel and Kitchen Personnel per Patient Dietitians Kitchen Pts. per Allowed Pts. per Helpers, Each Dietitians in Budget, Dietitian Cooks, Kitchen on Duty 1948 Budgeted etc. Personnel Springfield ... 1 3 1,010 35 86 Spring Grove . 0 9 246 31 76 Crownsville .. . 0 3 590 21(?) 85 Eastern Shore 0 1 490 8 61 Rosewood .... 0 3 410 20 62 Total 1 19 550 115 74 While much of the variation shown in this table is due to differ- ences in size of hospitals it is apparent that planning varies widely in the various institutions. The vacancies in positions of dietitians are especially serious. Shortages in other positions are also severe but cannot be presented in tabular form. V. Occupational Therapy: Occupational Therapists on Duty, Allowing in Budget, and Patients per Budgeted Therapist O.T, workers O.T. workers Pts. per budgeted on duty budgeted therapist Springfield 1 18 168 Spring Grove .... 8 12 188 Crownsville 3 11 161 Eastern Shore... 2 4 120 Rosewood 1(?) 17(?) • • • The ideals of the hospitals as regards occupational therapy coverage appear about the same throughout the system. Eosewood, because of the pecularities of its problems, cannot be compared with the mental hospitals in respect to occupational therapy. The inability to fill allowed jobs is obvious. The data are not to be considered exactly comparable since some hospitals include shop people in the Occupational Therapy group, others do not. In one instance, recreational workers might be counted into the Occupa- tional Therapy group, but this has not been done. 50 While the numbers of patients being treated in Occupational Therapy departments cannot be directly compared and are conse- quently not presented, it is apparent that active, professionally supervised Occupational Therapy reaches less than 5% of patients in the Maryland hospitals at the present time. Space Devoted to Occupational Therapy and Sq. Ft. per Patient for Occupational Therapy Space devoted to Sq. Ft. per 0. T. exclusively Patient Springfield 7,520 2.4 Spring Grove 13,100 5.5 Crownsville Eastern Shore 2,780 5.7 Kosewood At Crownsville there are no Occupational Therapy areas except in the school for the feebleminded. The standard accepted for Occupational Therapy space is 10 sq. ft. per patient. VI. Physical Therapy: Continuous Tubs Available and in Use. Physiotherapist on Duty and Allowed in 1948 Budget. Patients per Physiotherapist Alloiced. Number Number Pts. per Continuous Continuous P. T. P. T. P. T. Tubs in Tubs Personnel Personnel Personnel Use Available on Duty Allowed Allowed Springfield . .. . 0 4 2 2 1,516 Spring Grove . . 0 6 1 8 188 Crownsville .. . 0 3 0 0 • . • Eastern Shore 0 (3 0 1 490 Rosewood . , 0 6 206 Recreational Aides, appearing in the budgets of only Rosewood and Spring Grove, are counted as physical therapists. The jobs cannot be filled due to administrative difficulties within the work- ings of the merit system. Apparently Crownsville has been allowed no physiotherapy personnel whatever; it is not known whether it has been requested. Continuous tubs are present in all the hospi- tals; they appear to be used nowhere, at least if they are used at all, it is very rarely. Some hospitals make use of wet sheet packs, diathermy treatments, etc., but use of these treatment procedures is far from uniform. 51 VII. Family Care Practice and Parole : Patients in Family Care; Patients on Parole and Total Patients Outside Hospital Expressed as % of All Patients No. Pts. in % of Hosp. Pop. on No. Pts. % of Hosp. Pop. Total % Family Family on on Outside Care Care Parole Parole Hospital Springfield ... . 158 5.2 419 13.8 19. Spring Grove.. , 87 3.6 807 13.0 16.6 Crownsville. ... . 6 0.5 307 17.3 17.8 Eastern Shore. 46 2.5 46 9.4 11.9 Kosewood 73 6. 6. Family care is practiced at all of the mental hospitals, but at Crownsville there is no money provided for payment of board, etc. in foster homes. This type of care has been a special project at Springfield for some years which accounts for that hospital’s good showing; the work was later starting in the other hospitals. Family care is considered of doubtful value in relation to Rose- wood by the superintendent, though it has been widely used in New York State for these patients. The percentage of patients on parole shows a considerable variation between the hospitals, the reasons for which are not immediately apparent. The same stand- ards cannot be applied to the other hospitals. VIII. Medical Personnel: The figures below are taken from the Guthrie Report. They check reasonably closely with those given the Joint Legislative Committee and were used to avoid new calculations. Number of Assistant Physicians and Physician /Patient Ratio Assistant Physicians Physician/Patient Ratio Springfield 13 228 Spring Grove . .. 11 206 Crown sville 10 164 Eastern Shore .. 2 240 Rosewood . . . Md. Average ... 36 201 XL S. Average. .. 1,398 313 Maryland stands higher in regard to supply of physicians in state hospitals than the U. S. average. This is largely due to the fact that Baltimore is an outstanding psychiatric teaching center in the United States. This is the only category in which Maryland 52 approaches accepted personnel standards in its hospitals, and this only when the patients are considered all to be chronic. For active treatment, the physician/patient ratio should be definitely under one physician to 100 patients; on admission services a figure of one to thirty is suggested by the American Psychiatric Association. IX. Nursing Personnel: Nurses on Duty, Positions Allowed 1948 Budget and Alloived Nurse/Patient Ratio Nurses on Allowed in Nnrse/Patient Duty 1948 Budget Ratio Allowed Springfield .... 4 11 (18)* 285 Spring Grove ... 11 214 Crownsville ... . . . .. 1 3 590 Eastern Shore . . ... . 2 6 82 Rosewood .. . . 4 9 137 Md. Total. . .... 16 40 326 * Reported increased through shifting unexpended budget funds for 1949. The American Psychiatric Association standard is one nurse for each 40 patients. Nationally, public psychiatric hospitals sup- ply 1 nurse for each 176 patients. The unevenness of distribution of allowances for nursing services to patients in the various hos- pitals is obvious. It is not known whether this reflects a varia- tion of ideals in the various hospitals or not. X. Psychological Personnel : Psychologists on Duty, Psychologists budgeted for. and Patients Allowed in 1948 Budget Springfield .... Psychologists on Duty 2 Psychologists allowed 1948 2 Patients Per Psychologist allowed 1,516 Spring Grove . . 3* 3(?) 785 Crownsville . .. 1 1 1,777 Eastern Shore . 1 2 245 Rosewood 1 2 616 Md 8 10 714 * Two are students. Psychologists are reasonably available to Maryland mental hos- pitals, as shown by the fact that 8 to 10 allowed positions are filled. There are no standards generally accepted on what the 53 ratio of patients to psychologist should be. The Veterans Ad- ministration uses a rather idealistic standard, 1 psychologist to 300 chronic patients, one to each 50 patients available to apply these standards to Maryland hospitals. The unevenness of distri- bution of psychological service in the various hospitals is, however, obvious. XI. Psychiatric Social Work Unfortunately, no numerical data were collected by the Joint Legislative Committee on the number of psychiatric social workers in the various hospitals. It is known, however, that the distribu- tion is uneven, the extent of psychiatric social work service in each of the hospitals may be gauged fairly accurately from the number of patients in family care, though this is by no means the only service this personnel renders. The psychiatric social service program at Springfield is outstand- ing not only as a service, but as a teaching center. It is the one area of outstanding scientific leadership in the Maryland State hospital system. XII. Attendant Personnel and Practical Nurses: Attendants on Duty, attendants allowed in Budget 1948, % Jobs Filled, allowed patient/attendant ratio and % attendants who are Practical Nurses. % Attend. 1948 Pts. per who are Attend. Attend. % of Jobs Attend. Practical on Duty Allowed Filled Allowed Nurses Springfield ... 317 408 77% 7.4 17% Spring Grove. 179 317 56% 7.4 23% Crownsville .. 114 206 55% 8.6 22.8% Eastern Shore 58 66 88% 7.4 0% Rosewood .... 148 164 90% 7.5 13.2% The number of patients per attendant is much larger in actual practice than is represented in the figures in the 4th column of the table above, since these must be covered at all times in the 24 hours. With a three shift, 8 hours a day, the factors by which these figures must be multiplied would be at least three, even though one shift was smaller during the night hours, since week-ends and holidays must be figured in. The standard of the American Phychiatric Association is one attendant to 6 or 8 patients at all times; Mary- land hospitals allow hardly a third of this service to its patients. Except for Crownsville, where allowances are very low, the hos- pitals are about equal in allowed attendant distribution. The percent of attendants trained as practical nurses varies markedly between the hospitals and is not high in any. XIII. Practices as Regards Restraint: Patients in Locked Chairs, in Jackets and in Seclusion by Numbers and Percent of all Patients Pts. in Pts. in Locked Pts. in Seclusion Total in Chairs Jackets Room Restraint Springfield 41 1.3% 16 0.5% 8 0.3% 65 2.1% Spring Grove... 32 1.4 7 0.3 34 1.4 73 3.1 Crownsville .... 0 0 4* 0.2 27 1.5 31 1.7 Eastern Shore..' 0 0 0 0 7 .7 7 .7 Rosewood 0 0 13f 1 1 0.1 14 1.1 * Cuffs and ankle cuffs t The design of restraint clothing is different at Rosewood because of the special problems presented there. Variations in the use of restraint in the hospitals are rather marked. It does not correlate exactly with the number of attend- ants available, though there may be a tendency observed in this direction. Summary of Statistical Comparison of the Hospitals: Comparison of statistics available primarily from special forms filled out at the request of the Joint Legislative Committee by the superintendents of the hospitals indicates that there is little uni- formity among the hospitals in either ability to achieve goals set or in the setting of goals. For the most part, the allowed budgets would not bring standards very high, even if all positions were filled. APPENDIX G The State Department of Mental Hygiene The State Department of Mental Hygiene is created under Article 59 of the Annotated Code, Section 15, which establishes a Board of Mental Hygiene with supervision over all institutions, public, corporate or private in which insane persons are detained. The board consists in part of the Commissioner of Mental Hygiene, who serves as chairman of the board, and six appointed members. At least three of the members must be from the City of Baltimore, at least three must be physicians, graduated from an accredited medical college and with five years experience, two of the phy- sicians must have had at least five years experience in the treat- ment of the insane, and at least one of the members must be a woman. All are appointed'by the Governor with the advice and consent of the Senate for six year terms. The Commissioner of Mental Hygiene must be a qualified physician with at least five 55 years experience in the treatment of mental diseases. He retains his office as long as he faithfully and efficiently discharges the duties thereof, but he may be removed by the Governor for cause after an opportunity for a hearing. In addition to the appointed members, the Board of Mental Hygiene consists of five advisory members. These include the Professor of Psychiatry at the University of Maryland, the Pro- fessor of Psychiatry at the Johns Hopkins School of Medicine, the Director of the School of Hygiene of the Johns Hopkins University, the Director of the State Department of Public Welfare, and the Supervisor of Special Education of the State Department of Edu- cation. Any vacancy in the office of Commissioner must be filled by appointment by the Governor of the man designated and nomi- nated by a majority of the Board’s members. The Department of Mental Hygiene consists of a small office performing a limited number of functions in the State mental health program. It performs an admissions function for two of the hospitals, namely, Springfield and Spring Grove. The remain- ing hospitals perform their own admissions activities. Admissions to Springfield and Spring Grove are divided on a geographic divi- sion of the State, but Baltimore City and Baltimore County pa- tients are allocated to either institution on a basis of available beds at the time of commitment. Practically all of this admis- sions work is based on telephone calls rather than personal visits or correspondence through the mails. Two full-time and two part- time officials are assigned to the task of receiving these calls and making the decisions necessary. All four apparently are experi- enced in mental hospital operations. Two sets of card files, one on admissions and the other on rejections, are kept of all telephone calls on this subject. The Commissioner’s office also is responsible for problems of deportation and receipt of patients to and from other states. The Commissioner’s secretary devotes a large part of her time to the mechanics of this operation. The standard of one year’s residence in Maryland usually is used as the basis of determining eligibility of a patient to enter the Maryland institutions. Most of the nego- tiations are made with the District of Columbia. The problem of contact with Baltimore City and the counties of Maryland constitutes another important function of the Commis- sioner’s office. Questions of county residence of the patients must be determined in order to ascertain the liability of the counties for the patients’ care. Contacts with the county welfare department are essential to ascertain the ability of the patient’s family to bear part or all of the expense involved in the patient’s care. The de- partment determines periodically the approximate cost for caring for each patient in the Maryland mental institutions. The latest estimation was $600 per year, but present costs are considerably above this figure. Counties must be notified of the death of pa- 56 tients or their discharge from the hospitals in order that the counties be relieved of further responsibility and that the counties may seek reimbursement from the estate if funds are available. The department maintains records including monthly reports from all the mental institutions. These reports indicate the num- ber of admissions, discharges and paroles in each. The reports also indicate the number of patients placed in seclusion or restraint, the number of accidents, injuries and suicides and comparable informa- tion. An admission card and a discharge card are prepared and maintained for every patient in a Maryland public mental institu- tion. Patients who are discharged or who have died have their cards placed in inactive files. Similar cards are used for paroled patients. A statistical card is used which identifies the patient only by number and records many items of statistical value. It is planned that this information may some day be used in a punch card operation. Reports from Spring Grove and Springfield are received daily, both by telephone and by written report. The Board of Mental Hygiene meets monthly and advises the Commissioner on problems and policies. Usually it tends to ap- prove his ideas and assists him in carrying them into effect. On occasion, however, there will be opposition and a compromise solu- tion may be reached. The Commissioner formerly visited all institutions but is no longer able to do so. He now has an inspector who performs this function. He visits them only occasionally and sees only a few of the wards on such visits. He serves also as a court officer in sanity cases. Frequently he will request one or two of the medical mem- bers of the board to accompany him in such hearings. The hear- ings require a considerable amount of the Commissioner’s time. w co ° g go < 95 O < PQ S EH a W w > go PS w o Eh SS O M 95 PS M W PS Op CP D CO CO • ~1 EH S3 Q W W gw M w w Eh O 53 S3 M M PS PS w cp CP CO w EH eh 95 S5 w w PH S Eh W £ S S W CO ° g Q O PS o o W W M o o Q £c PS < w o < CQ Eh 95 W S PS O H co CO M O O EH a w o c 95 c w c H 2 95 P M C PS C W P OF THE w co ° s s s C 95 o < CQ JE S3 O O S3 M M £h CO O « w p CP ss co 53 M EH a w W PS go w W CO Eh :s a M OS PS W W EH a. co O < CO W 170 95 o O M W CO W M M > g co EH 2 W o w S w W W Eh M a > M CO (X JS w S a. o 1=) cs co o W CO ° g Q O PS <