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Transcript of CHAPTER III MENTAL HOSPITAL AS A FORMAL...
CHAPTER III
MENTAL HOSPITAL AS A FORMAL ORGANISATION
Chapter outline
1. Organisational theory: characteristics of formal organisations.
Goals, organisational requirements, functions, structural features.
2. Mental hospital as a formal organisation.
a) Application of the theoretical framework from (1).' .
b) concept of social management ,of patients -attendants and social management. Classification scheme based on therapeutic' and administration-maintenance functions.
c) A brief description of hospitals A and B based on (a). .
3. Organisational structures of Hospitals A & B.
Application of the therapeutic and administration-maintenance functions classification scheme to Hospital A and Hospital B. Personnel, departments, etc. based on (b) of (2).
tiU
CHAPTER III
MENTAL HOSPITAL AS A FORMAL ORGANISATION
ORGANISATIONAL THEORY : CHARACTERISTICS OF FORV~ ORGANISATIONS
One of the older and simpler definitions of an
61
-organisation was by J.D.~ooney who defined it as the form of
every human association for the attainment of a common
purpose (Meoney, J.D., 1939). Most of the social SCientists . who have tried to formUlate definitions for organisations
.. '6 ..
have, indicated the significance of purposes or goals for the •
analysis of organisations. What distiniuishes one formal
organisation from another is the goal and therefore, "the •
primacy of orientati~n t~. the· attainment C!f a specific goal" .-:'- .
is the defining characteristic·of an organisation and there-•
fore, it has implications for the organisation's internal
and external relationships (Parsons T., 1961). When the .. '
interactions between members of the organisation are pre-
scribed in advance and enforced by people within or outside
the organisation, then it is called a formal organisation.
By this definition, industrial firms, governmental agenCies,
hospitals, colleges and schools are all formal organisations.
The goals of formal organisations are determined by
the belief systems and values of the persons who establiSh
62
the organisation and also, sometimes, by the teChnologyl
available in that society regarding ways and means of
achieving the goals. A clear distinction, however, has to
be made between business organisations and service organisa-. tions (Blau P. and Scott W.R., 1963). Business organisation
like all industrial organisations are profit making collecti
vities ~iCh have an output in the form of a product or
service which can be sold. On the other hand, most of the
SChools, colleges and hospitals are service organisations
since the services they produce or r~nder are not generally
sold, at a profit. Service organisations are generally formal
organisations which cater to the developmental needs or
health needs of human beings, and their goals are shaped by •
the ideas and beliefs which that particular society has as . ' .' regards what is desirable for human growth and development.
The goals of an organisation may change in the course
of its history corresponding to the 'changes in its environ
ment. The, reasons for change of goals are varied; for • example, at some point of time in its existence the original
goals for which it was started may be fulfilled and it faces
the situation of either terminating itself or to continue •
eXisting by adopting new goals. Or, it may happen that the
original goals lose their relevance, in course of time, as
r'egards social needs and change becomes necessary. In some
1. The word "technology" is used in this report to mean knowledge and techniques which human beings use to
·obtain certain objectives.
organisations the goals are so unattainable that in course of
time it becomes necessary to bring the goals down to more
realistic levels. The reverse may be the case ldth some
other organisation; higher goals and newer perspectives will
be feasible in the wake of new resources and new technologies . '
in contrast to the time when the original goals were set.
Goals or objectives of an organisation are abstractions
and the process of goal-attainment consists of various con-•
crete functions or patterned activities within the organiza
tion which are to be performed by the participants of the •
organisation; with or without the help of non-human materials
like tools, 'instruments, lands and buildings. It is apparent •
that goals can be pursued only through the mobilisation of
human and non-human resources. ~he establishment and alloca-
.tion of functions and relationships and the distribution of
resourceS gives rise to what is oalled the formal structure
of the organisation. For conceptual convenience, the organi
sational st~cture.may be considered as the framework of an
edifice consisting of many parts and units, and sub-parts and
sub-units. Roles. are the smalleet sub-units of an organisa
tion. Social roles are associated with the different social
positions which are again parts of the'social structure. To
be more precise, each social position has a set of roles
associated with it (Olsen, M.E., 1968). One important
component of social role is expeotations. There are certain
expectations about every role, which prescribe and proscribe
actions and attitudes for the persons who enact the role.
Some of these expectations are cultural, meaning tney are
related to the culture of the people who formed the organi
sation and are therefore, social norms pertaining to that
particular role. The role-.enactors are the participants or
functionaries of the'organisationl who are expected to follow
certain norms of behaviour prescribed for those particular
roles delineated in the organisational structure.
In,order that social organisations may survive, remain
stable and achieve their goals, certain conditions have to be
fulfilled. In other words, there are certain organisational
requireme~ts which are: 1) pattern maintenance by the parti
cipants of the organisation,2) adaptation of the organisa
tion to its social environment, 3) integration of the various • parts of the organisation (Bales R.F., 1949).
Pattern maintenance: Every social organisation has to ••
develop mechanisms and processes by which the cultural
patterns and values are incorporated by the participants • •
Organisational goals are different from,the personal motives
of role-enactors. Some of the personal motives of partici
pants are desire for remuneration, ~~~~smaDe«atj«nX~
desire for using knowledge and skills and desire for sharing
the prestige of the organisation. Conflicts between private
1. The words "role-enactors", "participants", "members" and "functionaries" are used synonymously in this chapter unless stated otherwise in specific contexts.
65
objectives and the goals of the organisation are disruptive
as far as the organisation is concerned. Therefore, it is
imperative that inducements, coercion or force have to be
used in order that the members may identify adequately with
the organisation and work for its goals. Inducements turn
out to be a better mechanism than coercion or force in the
long run. The purpose of inducements is to help the members
to internalise the goals of the organisation. The greater
the number of individual needs satisfied within the organisa
tion and the higher the perceived prestige of the organisa
tion, the stronger will be the identification of the parti
cipants with the organisation (March T.G. and Simon R.A.,
1958). The individual needs and personal motives mentioned
before are more or less the same except for the difference
that the needs pertain also to the here and now aspect of
the participant's existence in the organisation, the faci
lities and amenities provided for role enactment, the psycho
logical needs of recognition, encouragement and appreciation
and to the opportunities for creativity in role enactment.
The organisation develops processes to prevent distraction
and deviation from the organisational goals. These processes
are concerned with the establishment of and maintenance of
social norms and rules and mechanisms of control, provision
of inducements of different kinds for need fUlfilment and
creation of adUlt socialisation patterns.
66
Adaptation of the organisation to the social environment:
It has been mentioned before that one of the ways by Which
the organisation adapts to the environment is through modi
fication of its goals as and when required according to the
changes in the environment. Another means of adaptation is
through maintenance of links with the environment. One
important. link is related to the procurement of resources.
The resources needed are, physical facilities, equipment,
materials, buildings, technology and human services. The
availability of financial resources is an important conSi
deration which is partially determined by the goals. Business
organisations are able to sell their products, the proceeds
of which are sufficient for the procurement of resources.
On the other hand, service organisations have only their
services to offer. Those who need these services may not
be in a pOSition to pay for them. Sometimes, service
organisations have a few material products to sell - products
made by the patients, inmates, etc. The sale proceeds of
service organisations from suCh products are too meagre to
provide for adequate resources to meet the needs of the
service agency and hence these services are financed by
larger organisations like the government of the country
which gets financial resources through taxations. or by
trusts, foundations or voluntary contributions by individual
Provision of financial resources by a larger
ion may lead to certain obLigations and restraints
67
being put on the organisation by the supporting agency. For
example, a hospital supported by the government is account
able to the goyernment in many areas, and the government
exerts its authority in various ways. One of the ways is
through policy decisions which are of various types ranging
from the decision to set up the hospital at one end, to the
decision to close it at the other end. Between these two
ends of policy decisions there are other types of policy
decisions on matters relating to the quality or standard of
service, scales of operat~on, relationships with the reci
pients of service, the processes of pattern maintenance
discussed before, and the appropriate utilisation of resources. ,
If an organisation is financially supported by a government
which is politically of the democ~atic type, the former
organisation's accountability to the government has another
aspect which is its indirect accountability to the electorate
which exerts its pressure through the legislative bodies. . . A distinction between business organisations and
service organisations is not limited to the pattern of their
financing. Consideration of some of the other differences
between the two types of organisation is relevant in this
context. In service organisationa, the participants provide
the service in such a" way that there is contact between the :-
participant and the recipient of the service. In other words,
68
in 'some'aspects of role enactment. the role-enactor and the
service-recipient become,role-partners. For example, the
teacher and the student, ~d the doctor and the patient are
role-partners. It is evident in this context, that the
student and the patient, both become 'indirect "members", in
a special sensel , of the school in one case and of the
hospital in the other. Perceiving the service-recipients
as indirect members of the organisation has very important
implications as regards the structure of the organisation.
One outcome is that the interactions between the functionaries •
and service-recipients become an important part of the
organisational structure. Besides the links that an organisa
tion has with the supporting organisation, there can be other
links with the outside community or the public at large which
is the source of service-recipients, as well as functionaries
for the organisation. The prestige of the organisation to
some extent depends upon the image it projects to the public • •
at large. If a large number of people of the public consider
that the organisation's goals are important societal goals *
and that the organisat!on is functioniDg, on behalf of the
society, the organisation ~dll be getting ,support from the
public in different ways and links between the two will t ... ."
evol v e easily • .. , On the other hand, if only a few people among
-the public at large consider the organisation's goals
1. This special meaning does not apply to the word "functionary" or "role-enactors".
69
important, then it will be fdifficult to build connections.
In such circumstances, the organisation may undertake as its
secondary goal, support and cooperation. from the public and
work for it through different processes.
Integration of the various parts of the organisation is
another requiremen t for the growth, survival and stability
of the organisation. Social integration is a process in
which the component parts of an organisation become coordi
nated and united so as to give unity to the organisation as
a whole (Olsen, 1968). There are two sociological theories .
about social integration. One is the theory of normative
integration and the other of functional integration. The
first theory relates to the organisational unity based on
the internalisation of COmmon values by the members of the .. . organisation. The theory of functional integration assumes
the division and distribution of labour; the functionsl
within the organisation are specified, some of.which become
specialised activities. The specialised activities are·
assigned to those individualS who through adult socialisation
have acquired necessary knowledge and techniques to perform
them. Since a formal organisation has many specialised
functions which are performed by different functionaries,
. there have to be ties of interdependence among these
functionaries. As far as the organisational objectives are
1. The word "functions" is used in this chapter to mean "required activities".
70
concerned, no functionary is self-sufficient and he cannot
function without a larger perspective of the whole organisa
tion. The implication at the practical levels is that
processes have to be devised to coordinate the various
activities and to create collaborative interdependence among
the different participants. Professionalism is the result.
of specialisation of activities. The Wider the specialisa
tion, the larger will be the number of , professionals in the
organisation. There will all the more be the need for co
ordination among the professionals.
Though both normative and functional integration occur
in all social organisations it appears that there is more of
functional integration in formal organisations because they
have been deliberately established for some definite purposes.
• • The organisation becomes socially integrated as comple
mentary relationship; among spec ~lised and inter-dependent
sub-parts are established and maintained through unified co
ordination (Olsen, 1968). This kind of integration does not
occur automatically. It requires the establishment of rules
and procedures to deCide the extent of specialisation, to
establish, maintain and guide relationships and to mark out
channels of communication.
All the organisational aspects which have been dis
cussed in this chapter can be summarised in a list of compo
nents of organisational structure as follows:
71
1) Sub-groups of various types
2) Roles of various types within the organisation as a group and within the sub-groups.
3) Regulative norms governing relationships and roles.
4) Cultural values (Johnson li.N., 1960) •
• Based on the discussion of organisational requirements,
one can broadly divide the organisational functions into two
categories, those pertaining to professional activities and
those pertaining to administration. It is not a neat cate
gorisation because professional functions and administrative
functions have some common elements. Further., professionals
have some administrative functions and administration itself
may be considered as a profession. It is, however, possible
to make a distinction between the two aspects of organisa
tional life, professionalism and administration. Administra
tion can be considered as a survival requirement which must
be fUlfilled by all formal organisations. It is basic to
the process of organising because it deals with problems of
maintenance, coordination or in other words, management of
human and material resources. Administrative activities
range from determination of function and policies and execu
tive leadership to routine operations such as keeping
records and accounts and carrying on maintenance services of
the premises. Administration is only indirectly connected •
with goal attainment except when organisational maintenance
and survival itself is perceived as a goal.
72
Professionalism can be considered as an operational
requirement directly connected with goal attainment. Some
aspects of operational requirement are common to all formal
organisations while the rest are determined by the goals of
the specific organisation at particular times (Olsen, 1968).
Weber's theoretical model of bureaucracy is used by
sociologists for analysis of formal organisations. This
model has inco%porated many of the organisational concepts
which have been presented in this chapter. According to this
model the characteristics of a bureaucracy are:(l) Activities
are distributed among the various social positions implying a
division of labour and specialisation. Specialisation fos~ers
expertness among the staff (role-enactors) directly and also
indirectly by enabling the organisation to hire the staff on
the basis of their profeSSional or technical qualifications.
(2) Each social position has clearly defined duties and respon
sibilities. (3) The offices (social positions) are arranged in
hierarchies related to authOrity. (4) All activities are guidEd
by formally prescribed rules and procedures. (5) All decisions
are made on the basis of technical knowledge and governed by
rules and regulations and not by personal considerations.
(6) Relationships.among role-enactors are impersonal and
limited to role ob~iga:ions. (7) RecrUitments to social posi
tions are determin~d by criteria of merit. (8) All activities
. are recorded in documents which are preserved. (9) Role
enactors are judged SOlely on the quality of their performance.
73
(10) Role-enactors are paid salaries (WeberM., 1946). Most
formal organisations have structures which present many of
the characteristics of the Weberian model of bureaucracy,
As the organisation grows in years and size, its structure
will have many sub-parts with specialised activities and
extensive interactions among sub-parts and the result will
be pressure for coordination. Furthermore, there will be
multiple hierarchies and different levels of authority. Such.
formal organisations are referred to as complex organisations.
their compLexity depending both upon the diversity and inter
dependence of the sub-parts.
THEYiliNTAL HOsPITAL AS A FORMAL ORGANISATION
Mental hospitaGare formal organisations because they
have been estabLished to render services to the mentally ilL
and to the public at large and they have formally instituted
pattern of interaction. Most of the mental hospitals are
service organisations, although there may be a few private
mental hospitals in some countries which make a profit.
"In the 18th century mad men were locked up in mad
houses; in the 19th century lunatics were sent to asylums;
and in the 20th century the mentally ill receive treatment
in hospitals" .(Jones K .• , 1965). This statement indicates ,"-,', . .t'
the changes in goals and values associated with mental
hospitals through'the decades. One of the ways by which the
mentally ill are admitted to mental hospitals is through
legal commitment. The fact of legal commitment has some
important implications as regards the goal of mental hospitals
in contrast to the goals of other types of hospitals. The
law invests the mental hospital with a custodial role which
places on the hospital the responsibility of protecting the
outside community from real or potential violence of insane
persons. As a result, social control of the mentally ill
becomes a function of the hospital. In some of the western
countries the nature of commitment laws has changed making it
possible for other functions to gain prominence. For instance,
the Mental Health Act of 1959 of Great Britain has eliminated
legal commitment altogether and stresses, instead, the treat
ment goals. Apart from the progressive developments in a
few countries, treatment of the mentally ill in general has
not progressed at the same pace as that of the physically ill
for various reasons. There are many gaps in the knowledge
of mental health and mental illness. Psychiatry has not
developed a unified theory about the causation of mental dis
orders. For this reason, psychiatry has remained "the
Cinderella of medicine" for many years. I1oreover, earlier
psychiatric practice and study was confined to mental hospi
tals \1hich were isolated from the main streams of social and
scientific life of the times. At one time psychiatrists
were considered in terms of mystics, priests and miracle
workers not only by the public but also by general medical
practitioners (Deutsch, 1936). The gaps in knowledge about
75
mental illness have been filled with incorrect ideas and
superstitions as far as the general lay public is concerned.
As a result of misinformation and ignorance, mental illness
has always had a social stigma attached to it. Since legal
commitment has been associated With admission to mental
hospitals, the custodial role of the hospital has been
stressed more than its other role. Realistically, the custo
dial role is easier than treatment when treatment technology
is inadequate. The harsh treatment that was often meted out
to the mentally ill was not always the result of wilful
cruelty. Very often it was the result of ignorance; people
did not know any better method. From the sociological per-
spective, prestige of agencies forthe care and treatment of
the mentally ill has been decidedly low, just as the pre
stige of psychiatrists has been comparatively lower than
that of other medical specialists. It is evident from these
factors, that goal setting of mental hospitals has been
influenced by the belief systems and cultural values prevalent
in the society.
Parsons in a sociological assessment of mental hospi
tals delineates the goal of the hospital as "coping with the
consequences for the individual patient and for patients as
a social group, of the condition of mental illness". This
abstract goal can be expanded further to signify concrete
separate goals: 1) Protection of the community from the . .' • dangerous actions of the mentally ill, regardless of whether
•
76
they are predictable or unpredictable, 2) Protection and care
of the mentally ill, as they may not be able to take care of
themselves. They have to be protected from behaviour Which
is harmful to their own selves. Additionally, there is the
goal of life maintenance and this goal is realised by meeting
the patient's basic needs, 3) Therapeutic-rehabilitative
goals which provide for measures which help to improve the
patient's social functioning, disturbance in which has
brought him initially to the hospital (Parsons, 1957). One
hundred and thirty-five years ago a committee appointed by
the Connecticut state Medical Society of U.S.A. to explore
the possibility of starting a "lunatic asylum" had included
three additional goals: -1) to give comfort and sympathy to
the incurable patients, 2) to provide an economical means
of maintaining the insane at public expense, 3) to serve as
a valuable school of instruction to doctors (Deutsch, 1937).
These goals are still relevant in spite of the passage of
time. There are always _some patients who cannot be cured
and for them treatment measures are not of any avail; what'
they need is alleviatory measures. There are many chronic
patients for whom the currently available medical technology •
is inadequate and for those patients the hospital becomes
an asylum. This committee was very much ahead of the times,
as regards the goal of training of doctors. This is a goal ,.
of mental hospitals of current times.
77
The sets of goals mentioned above exclude the organisa
t ional needs of survival. Further, the hos pi tal can also
serve as a venue for research so that.tne horizons of know-I
ledge .about mental illness may be expanded. Taking all these
factors into consideration, seven goals can be listed. They
are given below:
I) Pro:t·ection of the community from the violent behaviour of patients.
2) Protection and care of patients so that they may be treated.
3) Therapy and rehabilitation of patients.
4) Permanent care and protection of the chronically ill patients.
5) Training of treatment related professionals.
6) Research to advance knowledge.
7) Organisational maintenance and survival.'
One can trace the growth and d evelopmen t of these
goals historically which this researcher will be doing in
another chapter. The important point in this context is
the fact that mental hospitals vary in the weightage they
give to each of the~se goalS. Within the same hospital
these goals may probably be perceived differently by diffe
rent functionaries. The administrative staff are likely to
give greater importance to goals of custody, protection and
care of patients and organisational maintenance. The profe
ssional staff may give more primacy to therapeutic goals.
The degree of importance that one gives to each of these
78
i~ very much upon one's own experience of treat
edge about mental disorders and beliefs.
of the mental hospitals are governmental institu-
~e financially supported by the State. Therefore,
a pa~ or tne administration is through policy decisions made
outside the hospital. The hospital administrator within the
organisations has to find a balance among three conditions
before determining certain lines of action: 1) professional
norms and standards based on the technology of the treatment
of the mentally ill, 2) public values as regards what is
desirable or undesirable for the mentally ill, 3) economic
efficiency. it follows that there are different kinds of
pres aures impinging on the hospital from internal and exter
nal social forces which shape its process of adaptation.
The activities of the organisation fall mainly within
two cadres of function.s - prof essional and administrative.
Different disciplines have contributed kno~lledge towards the
treatment of the mentally ill and there are many professionals
working in the mental hospital •. There is no one single cause
for mental disorders; there is a multiplicity of causes. As
there is an interplay of social, biological and psychological
factors in the causation as well as in treatment plans, the
team or multidisciplinary approach becomes useful. The
professionals in the mental hospital, therefore, include
psychiatrists, physicians,. psychologists, social workers,
nurses, occupational therapists, phySiotherapists and music
79
therapists. There are para-profeSsionals like medical techni
ciansl • The administrative unit consists of administrator,
business manager, accountant, office assistants, physical
plant maintenance staff, store-keeper, and food service staff.
The researcher has purposely omitted the employee group of
attendants who are the subjects of this study. They cannot
be obviously included among the professional groups, nor are
they being inclUded among the administrative staff in this
report by this researcher because their work has many aspects
outside the maintenance functions. This problem will be
taken up later in this section of the chapter.
The Weberian model of bureaucracy does fit mental
hospitals in some aspects. The major aspects are: (1) .There
is functional division of labour in the allocation of treat-
ment functions to the treatment related profeSSional staff
and management and maintenance functions to the administra
tive staff. (2) Staff pOSitions and functions are defined
specifically and recruitments are made according to merit
and competence. (3) There are multiple hierarchies related
to each profession. (4) All activities are governed by rules
.of procedures and regulations.
1. Some sociologists do not acknowledge psychology, social work, nurSing, occupational therapy, physiotherapy and music therapy as professions. According to their sociological analysis these are "semi-professions" and medial technicians semi-skilled workers.
80
There is, however, an important difference. Profe
ssional activities do not in every area conform to the
impersonal and universalistic aspects of staff-client rela
tionships prescribed by the Weberian model. Relationship
itself is considered as a medium of treatment for mental
patients and consequently purposeful relationships between
professionals and patients are necessary requisites for treat
ment. Since the level and intensity of relationship is to be
determined by the socio-emotional needs of each patient,
particularism has to be acknowledged as an aspect of this
relationship. However, the nature of particularism and
affectivity is to be guided by professional knowledge and
cannot be of the same level or degree which marks primary
relationships as in a family. Moreover, the treatment rela
tionship being a consciously established. relationship has
aspects of detachment as well as anvolvement, objectivity
as well as empathy, permissiveness as well as firmness and
consistency as well as change and therefore, it.is distinctly
different from other types of particularistic and affective
relationships.
The one-to-one relationship mentioned in the preceding
paragraph is a major feature in psychotherapy which has been
one of the earliest methods of psychiatric treatment. It was
based on this method that the concept of therapeutic hour was
developed. Group psychotherapy was a later development in
psychiatric treatment. Both these methods imply the use of
, 81
specific t.echniques by.professionally trained therapists. . '
The number'o~. trained therapists always lags behind the ,I 10'
increasing"need of large nUmbers of mental patients in hospi-
tals. - Psychiatry did not have for a long time techniques , ..
which could be used in institutional settings. Though chemo-
therapy and physical methods like electro-convulsive treatment
and insulin shock therapy are also part of psychiatric treat
ment, these also require the services of psychiatrists or psy-
sicians. Moreover, it has been noted in western countries,
especially in U.S.A., that a large majority of psychiatrists
go into private practice thus perpetuating the situation
of shortage of professionals in mental hospitals. Concurrently,
the search for newer and practical methods of treatment has
been going on. One answer to this search is the knowledge
that social interactions between the patient and staff
and other patients can be effectively used as a therapeutic
medium for bringing ab out changes in the patient's behaviour.
The patient is in the hospital by reason of his disturbed beha
viour which usually manifests itself in interpersonal relation
ships. Therefore, one way of helping the patient is to use the
interpersonal relationships in the hospital as an opportunity
for bringing about change. This fact is further corroborated
by the observations of researchers and treatment experts indi
cating the significance of the whole social situation of the
patient in the hospital. Stanton and Schwartz, Bettelheim,
Belknap, Sullivan and others have pointed out the relevance
of developing specifications for the twenty-four hour social
82
situation'of,the -institutionalised mental patient. From " ., 4 _, . ~ .. , this frame of reference; the treatment of the' hospitalised • ~.. a
·mentai. pa"tient m~ be perceived as occUring along. two channels . , .
of experience,o the clinical and social. In other words, the . ",
treatment ,consists' of two types of management: 1) clinical •
management, 2) social management (Greenblatt & others, 1955) •• •
Clinical management will include all those processes speci
fically designated as professional activities performed by
professionals or medical technicians. Medical and psychia
tric treatment, nurs~ng_activities, social case work, group
workland personality tests 2 will all be components of
clinical management. Clinical management is of two diffe
rent types: 1) psychiatrically oriented clinical management,
2) medically oriented clinical management. All the profe
ssional activities carried out by the different professionals
with reference to the mental illness of patients fall within
the first category. On the other hand, various physiological
tests and procedures can be considered as medically oriented
clinical management. Here the term "medicat' is used in a
narrow sense referring to the treatment of the physiological
conditions of the patient. This differentiation is based on
the body-mind dichotomy, an assumption which is true only
partially. BeSides, those who fall within the first category .-may perform purely medical activities.' For instance, psychia-
trists, physicians and nurses may be using medical procedures
1. Social case work and social group work are social work methods.
2. Personality tests are used by the clinical psychologist • •
83
for solely somatic (phySical or bodily) effects on patients.
But this categorisation is used for the convenience of con
ceptualisation and for differentiating the treatment activi-
ties of professionals from those of non-professionals. All
interactions that take place between staff and patients,
outside clinical management, interactions related to patients'
needs of food, sleep and rest, personal cleanliness and for
companionShip and conta'ct with others, will be social manage
ment. Obviously, attendants have the greatest involvement
in social management. This categorisation of treatment into
three groups of activities is in keeping with the operational
definition of treatment developed in the second chapter.
Social management has two important goals: 1) protecting the • • •
patients' opportunities for improvement by means of clinical
management and providing other opportunities outside the
clinical processes, 2) to release the abilities of both staff
and patients to understand and reduce to a minimum the mental
disorder and its effects and to promote better social fun
ctioning in patients (Stanton & Schwartz,'1954).
Clinical management provides some opportunities for
improvement. These opportunities. can be protected only by
preventing some probable events like suicide, escape from
the hospital, interference with physical he~lth and self
injuries. Besides, opportunities for personal grooming,
contact with others and recreation have to be provided.
According to this frame of reference, some elements of the
84
custodial procedures become a part of social management.
To some patients who are afraid of their own impulses, lock
ing of doors may be reassuring that they are being taken
care of against their own impulses. Some others may need
the repeated verbal assurance from the staff that the locking
of doors is not a mode of punishment but a measure of safety
and security for patients themselves.
The second goal of social management does not lend
itself for easy definition. D.ifferent kinds of efforts at
• different levels have to be tried. But certain general
principles can be stated. Efforts should be made to allay
patients' fears and anxiety. The level of tension should be
as low as possible and patients should be comf~rtable. The
staff can use ordinary types of interpersonal support like·
encouragement, warmth, advice, suggestion, information, .' ..
direction and explanation. "
Social treatment from· the frame of reference of the
two goalS would mean:,(l) patients' behaviour should be under
stood not only by the professionals but by the non-profe
ssional staff also who have specified and patterned contacts
with the patients. It does not mean that the non-pfofe
ssionals should have deep theoretical knowledge about the
patient's pathology, but they should have sufficient informa
tion about mental illness, symptoms, and treatment to remove
superstitions and misconceptions and to facilitate acceptance
of patients. (2) Staff should have the right kind of attitude
85
An appropriate attitude will mean, kindness, sympathy, hope
fulness, sense of realism and respect for patients. (3) A
combination of adequate knowledge and the appropriate atti
tude will facilitate therapeutic handling of patients in the
various situations. Patients may show excessive anger, fear,
grief, bate or apathy_ These emotional expressions have to .. be handled in a way which is therapeutic. A patient's violent . "
behaviour may be an expression of anger, fear, hate or dis
appointment. If· the' patient's'violence is met with violence . I:
.. ". .at ••..
or other types of punitive reactions on the part of the staff,
it will only help,t~ increase the underlying anger, fear,
hate or disaPPOintment, and thus prevent therapeutic processes.
It is natural that the patient's behaviour provokes negative
emotions in the staff and what is required is not denial of
emotions but their control in the level of awareness. Develop
ment of knowledge of the self is a vital element in the train
ing of people for social management o~ .the mentally ill so
that they may have a controlled emotional involvement with . patients. ,(4) Patients and staff have potentialities for
therapeutic interactions. For example, a patient's love of
music may be used therapeutically for him and other patients.
Similarly, the staff may have talents and abilities that can
be put to effective use in social management. For example,
an attendant's enthusiasm and skill in gardening can be
utilised in stimulating some of the apathetic patients for
activity.
86
Clinical management of patients is more precise and
specific. On the other hand, social management is diffuse,
touching many routine and non-routine activities of daily
living. The diffuseness is an advantage, nevertheless. The
therapeutic skill lies "in making creative use of these
aspects of living for changes in patients' behaviour.
The advantage of social management as a treatment
strategy is that no~-professional staff also can be usefully
involved in it. Of all the non-professional staff the atten
dants have the most contact with patients. The attendant is
the staff member with whom the patient interacts at the
closest proximity and also continually. Attendants are the
largest')occupational group and therefore, quantitatively the
essential manpower in the hospital is located in their ranks
and their .interactions ,dth the patient cover a wide range
of activities.
The ~ental hospital as an organisation is occupied with
the functions of receiving, classifying, diagnosing, treating,
maintaining and discharging the patients. These patient
related functions can further be broken into the following
operations:
1) Receiving all persons who are brought to the
hospital for admission. They will be of 3 cate
gories: voluntary patients, committed patients
and those sent for observation and for later
commitment if diagnosis demands it.
2) Examining these persons and securing as much
information from them or about them.
3) Maintaining official records and correspondence.
4) Observing the admitted person's behaviour.
5) Diagnosing and planning for clinical treatment.
6) Providing the different modes of treatment
according to plan.
7) Maintaining clinical files.
8) Keeping accounts, 'billing and transacting money
matters.
9) Providing security for patients, staff and the
public.
10) Preparing patients' food and laundering their
clothes.
11) Lighting, plumbing and sanitary arrangement.
12) Housekeeping tasks for order, cleanliness and
comfort.
87
13) Seeing to the patient's personal care: food, cloth
ing, sleeping, arrangements and care of the body.
14) Observing the patienteFnmder treatment, also super
vision of patients engaged in work or recreational
activi ties.
15) Determining when the patient is ready for discharge
or that he requires further treatment.
16) Arranging for discharge. (Belknap, 1956).
This listing is sketchy and lacking in precision as
there is a wide variation as regards the depth and content
88
of each operation. But the list can be used for a rough
assessment of attendants' involvement in the social situation
of patients. All these 16 operations or sets of operations
are patient-related out of which 10 can be considered as
patient-contact activities meaning activities involving
direct contact with patients. Attendants have some kind of
involvement in nine of these activities.
Though the medical examination of patients is conducted
by the doctor there is always an attendant standing by to
provide security to the examining doctor and to help the
patient to respond to the doctor's inquiries appropriately.
Some patients show resistance to the medical examination and
to the hospital's rule that .they should change into hospital
clothes. It requires tact and skill on the part of the
attendant to persuade the patient to comply with the doctor's
instructions and hospital's rules. Since attendants have the
most contact with patients, they are able to observe patients
and to help the doctors with their observed data for making .
a diagnosis. They shoulder the main responsibility for
providing security for the patients, doctors and the public.
It is their job to see that the patients do not run away and
they lock up the patients every night. The keys of the ward
are carried around and kept by the attendants. The key is
an important external symbol to the patient, the symbol of
his helplessness and the power of the attendant.
89
The attendant in the ward is responsible for some of
the housekeeping. tasks of that ward. He performs all the
tasks connected with the patient's physical care.- Attendants
serve food and have to be watchful to·see that patients eat
adequately., They have to feed the patient who does not eat • and bathe the patient who does not bathe. All aspec~of per-
sonal cleanliness are part of their job. Since mental illness
does affect:the patient's capacity or readiness for self-care
activities, physical care becomes an important responsibility •
• '. Just as it is important to observe the patient for .
diagnost,ic purposes , it is equally necessary to follow up
the patient's progress in treatment. by observing his behaviour.
It is a time-worn. practice of mental hospitals to get the
patients 'engaged in some work of the hospital. This mayor
may not be part of occupational therapy. It 'is generally •
the attendants who supervise patients in their work and in . . some situations they may assist the patients by working with
~ 9 ...
them. They pass on to the doctor information,about .patients' •
general behaviour 'and work performance. Doctors use this
informatton in making decisions as regards patients' mental
condition and fitness ~or discharge •
. From this brief description of the attendant's involve
ment in the total social situation of/the hospitalised
90
men tal patient, it is quite evid ent that their inv c1.v amen t
is substantial in a quantitative perspective. One of the
objectives of this research project is to investigate about
this involvement in both the quantitative and qualitative
aspects.
Using the model of cl;nical-social management of the • patient, a classificatory,scheme for the functionaries may
be developed. The classification is illustrated in a chart
on the next page.
Therapeutic functions are those functions which involve
interactions wit~ patients - interactions which are covered
under clinical or social managements. There are three types
of functionaries who perform these functions: 1) Professionals;
2) Technicians, 3) Non-professionals.
Professionals: This category will include all those treatment
oriented personnel who occupy specific social positions
because of their special skills ~ich they have acquired
after professional training.1 Their involvement is in psychia-•
trically oriented cl~ical managemEnt of patients.
Technicians:
These functionaries are of a lesser status than the
professionals, though they also have special skillS which
they have acquire'd after training. . . They have contacts with • •
patients but these contacts are not continual and are less + ... • ....
CHART 1
MENTAL HOSPITAL STAFF
~ o
Therapeutic Functions (clinical and social ianagement of yatients) I I I
Psychiatrically oriented clinical management.
Professionals
psychiatrists Physicians Nurses Psychologists Social workers Occupationaltherapists
Medically Social oriented manageclinical ment management
Non- profeTechnicians sSionals
e.
Physiothe- Attendants. rapists Dentists Radiologists Pharmacists Medical-technicians
o Administrat on-maintenance Functions
Executive Organisation functions. maintenance
oriented functions.
Superintendent. Deputy SUperintendent.
BusinessManager .Accountant OfficeAssistants
Building and Equipment staff Storekeepers.
I I
Patient oriented maintenance functions.
Training &:
Research.
Food service Librarian staff Housekeeping staff Laundry staff
92
frequent. Their work is concerned with the biological E\Vstem
o£ human beings and they handle body-products, and tissues
and use tools or machines for their work. Their work as
mentioned before is for the medically oriented clinical •
management of patients. I ,
Non-professional therapeutic functions:
Attendants are the functionaries who perform the kind
of non-professional therapeutic functions. The inclusion of
attendants among therapeutic functionaries is based on the
concept of Social management discussed before and the related
discussion about attendants' invo~veJDent in the social situa-
tion of patients. The division of therapeutic functions into
clinical and SOCial management ie a conceptual frame work and
not a part of the functional claesification adopted by the
hospitals. According to the claesification Which is in use,
attendants will be included amo~ the patient oriented main
tenance personnel in the same category as cooks, laundrymen
and linen keepers. CookS, laund~ymen and linen keepers per
form tasks which are directly cOllnected with the patient
care, but they do not come into Qirect personal contact with
patients. Attendants are contact points between patients
and the staff like cooks and la~drymen and hence they have
been referred to as patient cont~ct personnel, earlier in
this chapter. Attendants' location at the first level
contact with patients has 1mplic~tions as regards patients'
93
opportunities for improvement. The cook may be preparing
good food in the kitchen, but if it is served to the patients
by the attendant in a disrespectful manner, it will provoke
negative reactions in the patients. Though psychiatrists are
patient contact staff, for certain activities like the
observation of patients' behaviour for prolonged periods,
they have to rely on attendants who serve as a link between
the professional and the patient for the fulfilment of a
clinical function. It is evident, therefore, that attendants'
functions are different from those of patient oriented main
tenance personnel. In later chapters of this report the
researcher will examine the different aspects of the contact
between attendants and patients in order to determine the
real and potential content of attendants' contribution to
the social management of patients Which is a part of thera
peutic management.
4dministration-maintenance functionsl :
These functions are different from the therapeutic
functions because the functionaries generally do not have
any direct contact with patients. Hence their work is neither
clinical management nor social management (There are a few
exceptions which will be mentioned later).
1. In "administration-maintenance" administration means the management of staff and financial resources and maintenance means, keeping the patients, building, equipments and the grounds in good condition. Since these two functi6ns are so inter-related and overlapping, the compound word is used.
The executive division consists of the superintendent who is
th~ chief administrator. He is assisted by deputy superin
tendents and sometimes by other kinds of assi~tants. This
division has the highest authority in the hospital as regards
deciSion making, directing and controlling functions.
Organisation maintenance oriented division:
This is the second division of the area of functions
covered by the administration-maintenance functions. The
main sub-part is the business section which handles money
transactions of different types. Budgeting, purchasing,
salary payments, accounting and related operations are
handled by this sub-part. In some hospitals, this division
is headed by the bUSiness manager who is likely to have had
training in bUSiness administration.
A second sub-part of this division deals with the
upkeep of buildings, eqUipments and grounds.
Patient oriented maintenance functions:
This is the third division within administration
maintenance. Protection and care of patients is one of the
organisational goals of the hospital and patient care in
essenee is connected with the fulfilment of the baSic needs
of which the need for food is the most urgent. Food service,
therefore, is a vital service. This third functional divi
sion deals with the services connected with food, clothing,
95
sleep and rest and related items. KitChen services, laundry
and housekeeping are included in this division.
Training and research:
Any hospital vThich' grows aftd expands will have train
ing programmes of two types for developing its own staff and
students in the healing professio~s. There will be in-,
serVice programmes for the staff and programmes of training
for students who come to "the hospital from different profe
ssional schools. This form of adult socialisation is very
valuable to help the staff or potential staff to identify
Some of the teaching and training staff may have only
these educational functions and may not strictly belong to
the therapeutic functionaries of the hospital although they
are professionals by their traini~g. Similarly, some staff
whose main function is therapeutic may have a secondary
function of teaching. This situatinn may apply to research
as well.
The classification of the ~ospital staff into thera
peutic personnel and administration-maintenance personnel .. ~ 040'
" is not strictly precise because ot many overlapping functions.
The therapeutic personnel carry some administrative duties,
as well. The chief administrator is also a psychiatrist by
96
profession and 1'1i thin his social position there is a combina-. tion of administrative and therapeutic functions. The organi-
• sat ion maintenance oriented division does handle some of the
patient related activities also such as handling of, .
.'1) .official documents like commitment papers from the court
and reception orders, 2) dealing with patients' accounts.
If one feature of administration is the process of
getting the work done by people, this process goes on in all
parts of the hospital. Directing, supervising and controlling
are administrative activities used by many functionaries .. , regardless of whether they are therapeutic staff or admini
stration-maintenance staff, in relation to other staff who
are under their authority. The doctor in the ward, head-..
nurSe and staff nurse do carry on some administrative duties
along with their therapeutic work. Even the attendant who
occupies a very low position in the ward hierarchy has been
sometimes referred as the ward administrator although the
d~signation is by default (Barton W.E., 1962).
The mental hospital ,is a complex organisation by the
nature of the complicated role-relationships within the
organisation. A simple illustration would be to have a chart
to connect the goals of the hospital with related functions.
The graphic pattern will be a confusing labyrinth of
connecting lines.
CHART - z Personnel
A. Therapeutic Functions
1. PrOfessionals
2. Tecl:micians
Goals
1. Custody of patients
• Care of patients
Therapy
97
3. Non-professional . 4. Long-term care of j.n-
therapeutic etaff" 'attendants) curable patients.
B. Administration-maintenance functiOns.
1. Executive
2. Or~anisation maintenance oriented staff •
• 3. Patient oriented main-
tenance staff. .
4. Training & research staff.
Organisation maintenance.
Teaching.
7. Research.
This chart shows the involvement of the attendants in
the process of goal attainment. They have some common fun
ctions with the patient oriented maintenance staff of the
third division in B. Theoretically they belong to this diVi
sion. They are associated with .the five goals, custody, care,
therapy and the continuing care of chronic patients and
. organisation maintenance.
After hav'ing discussed the characteristics of formal
organisations in general and about mental hospitals in parti
cular, it is necessary to examine the two hospitals, the
settings for this study, with reference to the theoretical
frame work.
98
Mental Hospitals A and B:
Hospital A and Hospital B were both "mad houses" at
the time of their origin. Hospital A began in 1799 as an
institution under the administration of East India Company
for "accommodating persons of unsound mind". It came under
the provincial government in 1871 and at that time it was
called "the lunatic asylum" and in 1922 the name changed to
"the government mental hospital". ,Hospital A is the only
mental hospital in the State which has a population of over
four crores.
Hospital B was started in 1901. The foundation stone
which was laid in 1895 is still visible near one of the wards.
The cost of construction was about 4 lakhs of rupees out of '. which one lakh was donated. The hospital is still called by
the name of the person whose family had donated the amount
towards its construction. Hospital B is one of the four
mental hospitals in the State with a population of over five
crores. •
Hospitals A and B are state institutions and the
expenses are met by public exche~ers. The annual outlay of
Hospital A is about ~ 4,700,000 and that of Hospital B
~ 4,200,000. Using the list of goals of mental hospital
presented earlier, it can be said that both hospitals A & B
share the objectives of custody, care and therapy. These
goals have been the original goals indicated in the Indian
99
LunacY- Act of ~9~2 \ The Law wi~~ be discussed for fUrther
details in the next chapter). Hospital A seems to have an
additional goal, that of training people in the medical and
allied professions, like medicine, nursing, clinical psycho
logy, social work and occupational therapy. Though Hospital
B also offers some aspects of training facilities for occupa
tional therapy and psychiatric social work, the hospital is
not recognised as a teaching mental hospital. The only
training programme that Hospital B has is for its overseers.
The remote location of the hospital far away from the profe
ssional schools of the city D is a factor which reduces the
hospital's potentiality as a training facility for mental
health professionals. On the other hand, Hospital A is
within the municipal limits of city C and is easily accessible
to the students and staff of professional schools. Students
of medicine, nursing, social work, psychology and occupational
therapy come to this hospital to learn about mental illness,
its treatment and the specific techni~es their respective
disciplines have developed in the treatment programmes for
the mentally ill. Hospital A conducts refresher courses in
psychiatry for the general practitioners twice a year. Train
ing programmes and the trainees themselves serve as links
between the hospital and the. outside community. The superin
tendent and two other senior psychiatrists of Hospital A are
professors of psychiatry in the three local medical colleges.
When the University of city C in which Hospital A is located
100
started the postgraduate diploma course in psychological
medicine (DPM) , the hospital got involved in this programme
by ,organising lectures and clinical conferences and thereby
assumed a higher status in the educational system. As a
res~t of these on-going links with outside organisations,
the hospital has been the venue for conferences and seminars
on topics related to the field of mental health. Far frem
being isolated and cut off from the rest of the community,
Hospital A maintains continuous and close contacts with the
outSide community. Hospital B lacks these advantageous con
tacts being phySically and culturally removed from the life
of the city D.
Research does not seem to be a prominent goal in these
two hospitals though it is carried out on a small scale.
The custodial role is important for both the hospitals,
because a majority of the patients are court committed cases.
But the external symbols of the custodial role are less evi
dent in Hospital A. Hospital B has high walls (about 10 ft.
high) all around and a big, heavy and imposing gate. Hospital
A has high walls on the three Sides and a very low wall (4 ft.
'high) in front and a very inconspicuous gets. Hospital B has
only two open wards - one in the male section and the other
in the female section. Hospital A has only three closed wardS,
housing the criminally insane, the newly admitted patients and
the epileptic patients. All the rest are open wards in the
101
sense that the doors of the wards are not locked during the
day, which gives better freedom of movement to patients. The
voluntary patients of Hospital A are allowed to spend the
day out with their families on week-ends depending upon their
level of improvement.
The two hospitals are under the director of health
services of the respective States and under the Ministry of
Health. Most of the major policy decisions regarding the
hospital are made outside the hospital by the ~linister or
Director of Health. Some of the policy decisions made this
way outside the walls of the hospital serve to reinforce or
change the goals of the hospital. The Indian Lunach Act of
1912 (ILA) though outdated in the light of the new develop
ments in psychiatry, is still an important factor influencing
the hospital's[goals and programmes.
The Hospitals A & B are run by funds drawn from the
public exchequer though a few patients in both the hospitals
pay for their stay. and treatment. Voluntary contributions
are not entirely absent but theY are usually for specific
purposes. A few additional attendants are employed by a
• charitable organisation to give individual care to the child
patients of Hospital A. The canteen of Hospital A which
caters to both patients and staff of the hospital has been
started through donations from interested citizens of the
community. Both hospitals A and B have received gifts in
102
the form of T.V.sets, radios, typewriters, sewing machines,
etc. for the patients' use.
ORGANISATIONAL STRUCTURES OF HOSPITAL A AND HOSPITAL B
In this part of the chapter, the sub-groups and roles
within the hospitals will be described and discussed. The
mental hospital comprises many kinds of medical functions
and also complex functions of administration - accounting,
housekeeping, food management, purchasing, laundry and
others. It incorporates within its structure some aspects . . of the prison, the healing place, hotel and the business
organisation and therefore, the structure turns out to be
rather complex.
Structure of Hospital A:
The Hospital has a patient capacity of 1800 and has
14 sections which are listed below:
Sections
A
B~
C
D
E
Fl
I F2 ttl G2
for
" " "
"
"
Newly admitted patients
TJj patients
Leprosy patients
GriminaJ.s
Epileptics
Chronic and aged patients and patients who do not fall under the above categories.
Special l'lard
Femal patients' section
Medical ward - patients who suffer from physical ailments.
Outpatient department
Day hospital.
103
Tue female section is divided into five sub-sectio~s
catering to the following types of patients: (1) Newly
admitted patients, (2) Epileptic and T.B.patients, (3) Crimi
nally insane, (4) Child patients, (5) Chronic and aged
patients. Each section has one or more wards upto a maxilllum
of four ,.ards.
me division of the hospital into different sectio~S
is not b~sed on any scientific classification of patients.
It represents a pattern for the institutional management of
patients in terms of age, sex, economic status, behaviour
patterns, physical illnesses, legal status, etc. (Belknap,
1956). 1he classification s,eems to fUlfU some requirements
of treatlllent and care and the custodial. functions of the
hospital. Section D, housing the criminally insane is a
closed section with high walls surrounding it and with an
imposing gets which is always kept closed. The staff stru
cture of Hospital A may be examined with reference to the
therapeutic personnel and administration-maintenance per-
sonnel.
"
1 O~
Professionals Technicians
Physicians 25 Physiotherapist 1
Psychiatrists 5 Dentist 1
Nurses 104 Radiographer 1
Psychologists 3 Pharmacist 3
Social workers 25 Medical technicians 5
o c cupa tional therapists 1
Of the five psychiatrists, one is the superintendent
who is also occupying the top position in the administration
maintenance part of the structure. He practices psychiatry
while two other doctors, the deputy superintendent and the
residential medical officer (HMO) have very little profe
sSional activity as they form a part of the executive division
and are involved mainly in administrative functions. In the
medical cadre, there is a hierarchy followed by the consul
tantsand the medical officers. The two consultants share
with the superintendent some administrative duties under the
unit system. The superintendent and the consultants are
given two fixed days of the week as regards responsibi~ity
for consultation and certain types of clinical administration
like dealing with admission and discharge decisions.
The superintendent and th e consul tan ts ar e also heads
of the psychiatric departments of three general hospi~ls in
•
105
the city which have medical colleges attached to them. Con
sequently they are professors of psychiatry in those medical
colleges. This link helps to raise the prestige of the
hospital in the eyes of the public.
The nurses' group is comparatively a large professional
group and forming a hierarchy in itself - matron, assistant
matrons, head nurse and staff nurses. The matron's position
is occupied by a man in this hospital, WhiCh is not very
common. There are other male nurses also but the practice of
recruiting men for nursing has been stopped till 1958. Male
nurses work only in male wards, but female nurses work in all
wards except in the ward for the criminally insane.
From among the total of 104, 21 are psychiatric nurses,
in the sense that.they had one year's training in psychiatric
nursing in the Indian Institute of Nental Health, Bangalorel •
The diploma in psychiatric nursing (DPN) is a status symbol
among nurses; beSides, it entitles them to a higher pay.
Promotions are not based on additional qualifications but on
seniority of service in the government. It is here that the
Weberian model does not fit. The-matron of this hospital does
not have DPN qualification; but the assistant matron has the
qualification.
1. which is currently known as the National Institute of Mental Health and Neuro Sciences.
106
Every section has a head nurse, and every ward, one or
more staff nurses. The matron and assistant matron are
occupied with administrative responsibilities and have very
few therapeutic functions.
The hospital has three psychologists, one for the out
patient department and two for the rest of the.hospital.
The hospital has 25 social workers which is compara
tively a large number. They are of three different cadres.
Nine of them have post-graduate degrees or diplomas in social
work. Fourteen had undergone a two-year programme in psychia
tric social work organised by the Red Cross Society for which .
the requirement was that the candidates should have passed
the pre-University examination. The two remaining ones were
college graduates without any social work qualification, who
were recruited on the government's special programme for
employment of university graduates.
There is only one occupational therapist though there
are three occupational therapy programmes going on in the
hospital - book-binding, carpentry and envelope making.
Envelopes are made on a large scale in response to orders
from other organisations; this activity is part of industrial
therapy which has been started as a form of sheltered work
shop for the occupational rehabilitation of mental patients.
The industrial therapy team consists of a doctor, a nurse
(who is the assistant matron), a social worker and the
occupational therapist.
107
The non-professional therapeutic personnel are the
attendants who are 345 in number. There are only two levels
in the hierarchy. Class I attendants and Class II attendants.
The first category of attendants are also called senior atten
dants who have supervisory responsibilities over the other
attendants of the same ward. Associated with this position
is the exemption from might duty.
Male attendants have two levels of direct authority.
As regards hours of work,schedule of work and assignment of
duties and wards they come under the overseers who keep the
roster for marking attendance, leave of absence, etc. But in
the ward they are under the direct supervision and authority
of nurses. There was a time when overseers were assigned to
wards and attendants were accountable only to the overseers.
After the hospital adopted the policy of gradually abolishing
the post of overseers new recruitment to this job stopped.
The hospital at present has only 3 overseers. The female
attendants have only one level of authority, the one repre
sented by the nursing hierarchy. They are under the direct
supervision of nurses in the ward.
The diviSion of the hospital into various sub-units
like clinics and departments is the outcome of the develop
mental phases related to the specialisation of the therapeutic
functions. The different sub-units are given below:
Epilepsy clinic
Mental deficiency clinic
Neurology clinic
N euro -surgery clinic
Neuroses clinic
Child Guidance clinic
X-ray department
Dental clinic
Physiotherapy
Medical photography
Psychology department
Social work department
Occupational therapy department.
Administration-maintenance personnel
108
The executive division of this category consists of
the Superintendent, the deputy sUperintendent, and the
residential medical officer. As an executive, the superin
tendent has a schedule of regular weekly visits to the diffe
rent sections of the hospital so that every section is visited
once a week. patients, premises and methods of treatment are
the objects of the visit. The RMO also accompanies the
superintendent for visits. In addition to the scheduled
visits, there are also surprise visits by the superintendent
and his assistants.
llU
near the hospital kitchen, a second office which he occupies
for a few hours regularly every day for the supervision of
delivery of groceries and other food stuffs like meat, fish,
fruits and v;egetables. Another important fe-ature of food
management is that the kitchen team is headed by a head-nurse
who is assisted by staff nurses and cooks. The kitchen
itself is spacious and well-equipped with modern facilities
like gas,stoves and electrically operated grinding machines.
These are features which have an important impact on one
aspect of patient care, namely, the preparation and serving
of food, and the attendants, the subject of this study, are
involved in this aspect.
~atient oriented maintenance personnel:
The functions in this division are those related to
food service, tailoring, laundry, sanitational hygiene, etc.
The personnel ~lho come under this division are:
But le.r s
Cooks
Dhobies
Barbers
2
26
4 .
8
Sanitary workers 135 (Sweepers)
Training and research:
As already mentioned, Hospital A has different types of
training programmes in the·form of conferences, lectures. The
111
hospital serves as a fi~ld of practice experience for students
of nursing, psychology and social work 'tho come to the hospital
from their professional schools in the city to learn about
mental illness and about treatment strategies. Realising the
importance of att endants' work 'I'li th patients, Hespi tal A had
tried programmes of in-service training for the attendants.
The division of training and research does not have functiona
ries exclusively for these functions. The professionals of
the therapemtic personnel category undertake responsibilities
of teaching and training in addition to their treatment tasks.
The importance of rules and procedures was discussed
in the first part of this chapter in relation to the organisa
tional reqlirements of pattern maintenance, and social integra
tion. AS regards the staff of Hospital A, rules governing
their professional behaviour are laid do,m in a book called
"The JI'lental Hospital Code" published by the State Government.
This book delineates functions of different occupational
groups and supervisory procedures. From the point of view of
social management, the code book has the following types of
instructions:
1) Steps and precautions as regards the custodial care
and protection of patients.
2) Requirements as regards quality and gquantity of
food and clothing.
112
3) Guidelines of specific areas in social management,
particularly with reference to attendants'
functions.
Some concepts related to the appropriate attitudes and
controlled emotional involvement discussed earlier in this
chapter are spelt out in the form of concrete prescriptions
and prohibitions. For illustration, one rule is, "They
(attendants) shall under all circumstances treat the patients
under their control kindly ... When abused or threatened,
they must not retaliate but must try to calm the individual
patient by some harmless concession or kind words" (Section
XIII, Article 220, p.lll).
Just as a family is not meant to be a society (Parsons
T, 1955) the mental hospital as a social organisation cannot
remain isola ted from the larger community. Hospital A has
its links with the community and these have already been
mentioned. There is an additional link in the form of an
advisory committee which was constituted by the State Govern
ment in 1964. This body of influential non-officials has
been taking an active interest in the affairs of the hospital.
The advisory committee has been instrumental in expediting
the construction of new buildings and. in improving other
phYSical facilities. The hospital's well-equipped kitchen
and steam laundry are the results of the committee's involve
ment.
113
structure of Hospital B
Hospital B has provision for 1850 patients and like
Hospital A, it has two major divisions segregating male and
female patients. Each of these divisions is further divided
into 15 wards as listed below:
Ward 1 for chronic mental patients
Ward 2 for epileptic patients
Ward 3 observation ward
Ward 4 for chronic and "dirty" patients
Ward 5 for criminally insane patients
Ward 6 for chronic patients
Ward 7 for leprosy patients
Ward 8 ) for weak patients (those who are 9 ~ physically debilitated).
10
Ward 11 for TB patients
Ward 12 for the physically ill patients
Ward 13 for patients undergoing electro-convulsive therapy
Ward 14 for patients undergoing insulin shock therapy
Ward 15 Open ward.
Hospital B does not have any children I s ward nor does
it have any special wards for patients who can afford to pay
a higher rate of hospital fees.
Therapeutic personnel of Hospital B
Professionals
Psychiatrist
Physicians
Nurses
Psychologist
Social worker
o ccupa tional therapists
1
13
46
1
1
4
Technicians
Pharmacist
Compounder
Lab.Technicians
Lab.assistants
1
1
2
2
IIi
There is only one psychiatrist in Hospital B and he is
the superintendent. The nearest civil hospital has recently
started a psychiatric out-patient department where he conducts
the clinic a few days of the week. Out of 13 physicians, 4
are graduates of Indian medicine and one a licentists in
medicine.
Matron,assistant matrons, ward sisters and staff
nurses constitute the hierarchy of nurses. About 8 have the
post-graduate diploma (DPN). Some wards like Ward 12 (for
mental patients who are also physically ill) have two nurses
or more, with the resUlt that some wards do not have nurses
exclusively for their nursing needs. Since most of the wards
are situated in separate buildings, it is rather inconvenient
for one nurse to look after the patients of more than one
ward. As a result, nurse-patient contacts become less fre
quent and the situation referred to earlier arises where the
115
the attendant becomes the "ward administrator". Though the
hospital has 4 positions for social workers, only one is
filled, inspite of the fact that there are two professional
schools of social work in the city D. The physical and
cultural isolation of the hospital is one of the main reasons
for this state of affairs.
Non-professional therapeutic personnel:
There are 286 attendants in three levels - havildars,
senior attendants and attendants. The function of a havild?r
is supervisory; he is in charge of two or more wards. Havil
dars and senior attendants are exempted from night duty as
in Hospital A. Higher to the attendant is the overSeer Who
is a functionary among the organisation maintenance oriented
personnel, in the administration-maintenance category. Over
Seers are assigned to wards also (unlike in Hospital A) in a
supervisory capacity. The chief among overseers is the
supervisor who directs the administrative activities regard
ing attendants' schedule of work and maintenance of their
records of attendance, leave of absence, etc. Attendants
are subject to two levels of authority in the ward, authority
of the overseer and that of the nurSe. Attendants' dealings
with patients come under the supervision of nurses and all
the other aspects related to punctuality and regularity at
work, compulsory wearing of uniforms and similar rules and
also cleanliness of premises come under the supervision of
overseers.
116
There are three female overseers in the section for
female patients. These three overseers are under the direction
of the matron who is a woman in this hospital, and not under
the male supervisor.
Administration-maintenance
The executive division includes the superintendent and
the R.lIi.0. (Residential Medical Officer). Both the superin
tendent and the HMO perform therapeutic functions as well.
The organisation maintenance oriented personnel
Senior administrative officer
Junior. administrative officer
Steward
Assistant steward
Accountant
Office assistants
Overseers
Driver
Peon
1
1
1
1
I
11
22
2
2
The Senior administrative officer's position is similar
to that of the lay secretary in Hospital A, but of lower
status. The steward is in charge of purchase of food items.
There is also a committee consisting of the ffi~O, the matron,
chief overseer and others for supervising the delivery of
groceries and other food stuffs.
,
,
117
Building and equipment personnel are very few in
Hospital B. There are three carpenters and four weavers in
this sub-division.
Patient oriented maintenance personnel
Kitchen supervisor
Linen-keeper
Tailors
Cooks
Barbers
Sweepers
lraining and research
1
1
5
29
8
2~
Apart from the field work programme in the hospitai
for social work students and occupational therapy students
who come to the hospital for practical experience, from their
professional schools in the city, there is no training pro
grammes for professional students.
Till about two decades ago, medical undergraduates, medical graduates specialising andLin psychiatry used to come to the hospital for practical
experience. This practice has stopped after the local
medical college hospitals developed psychiatric services • •
Hospital B conducts a series of lectures on psychiatry for
the benefit of overseers and also conducts an examination.
OVerseers have to pass this examination in order to get
annual increments of salary.
118 • Hospital B hasc,a "~lental Hospital Manual" correspond-
ing to the "Mental Hospital Code" of Hospital A. There is
only one copy for the whole hospital which itself is a typed
copy with a few pages missing. This copy is almost like an
ancient relic and not easily accessible to students or
researchers.
Though a comparison of the two hospitals A and B is
not an objective of this study, some differences between the
two are too obvious to be missed. Hospital A has more profe
ssionals than Hospital B. There are marked differences in
the number" of doctors, nurses an~ social workers. The spe
cialised clinics and services operating within the structure
of Hospital A are absent in Hospital B. The reasons are
associated with certain factors which were mentioned before.
The annual budget of Hospital A exceeds that of Hospital B
by about Rs.4,OOO.OO. Some of the advantages that Hospital A
has over Hospital B are due to its status as a teaching
hospital. Being a teaching hospital it emphasises the treat
ment goal which is indicated by the larger number of treat-·
ment personnel and specialised treatment services. The
custodial role seems to be an important feature of Hospital B
which finds expression in its high walls, imposing gate and
locked wards. The "open door policy" which implies the use
of unlocked wards has been a progressive step in the treat
ment of the mentally ill (Jones, K & Sidebotham R, 1962).
1'19
Hospital A seems to have caught this idea and is practising
it by keeping many of its wards open. One of the main draw
backs of Hospital B is its phYSical and cultural isolation.
Service giving professionals as well as organisations should
have role visibility so that the public may acknowledge the
role and give support. IVhen the role is invisible there will
be no public image or if at all there is an image, it will be
a distorted one. I'lhat is required is a permeability between
the hospital and the community. Hospital A has developed
this permeability by means of its social and cultural links
with the community, whereas Hospital B is lacking in this.