Questions keep coming up in the groups. "My patient wants to double date. What should I do?" We had one funny incident with a charming girl, a good case-aide, whose patient, a lady, told her that her son would not allowed her to see her husband. For 20 years, supposedly, her son had not allowed her to see her husband, who had just had, supposedly, his second coronary up in New Hampshire. The case-aide was all set to take this patient in a car to New Hampshire to see her husband.

Before she could go, it came to my attention--fortunately, because first, we don't even know if there is a husband; second, we don't know if he is in New Hampshire, and if she crosses a state line, she can say. "Out! Bve!" Third suppose that there is a husband and he's had his second corpary and he hasn't seen his wife in 20 years and she's been in a mental hospital and looks all disheveled. When she walks in he's going to have his third coronary, and that'll be fatal.

Jealousy

Sometimes the case-aide worker becomes possessive of his patient and resents any "interference" by the hospital--sometimes appropriately. Quite correctly at times students feel that the system helps perpetuate an illness and impedes the patient's discharge.

Three years ago, people would go out and comment on how horrible the hospitals were; now they come out and say. "I thought it would be worse." I don't know whether the hospitals have changed that much or whether the case-aides have gotten feedback--they'd been told how horrible the hospitals are and see that they aren't so bad.

Three years ago they'd come out ready to teach the hospitals how to run things. Now they are a little more worried about whether they can handle it. Fortunately, they also bring lots of energy and imagination. They are not musclebound with knowledge, and as a result they bring iniative; they do things with the children, for example, that are perfectly marvelous and that the professional staff is too old, and too tired, and too beaten down by the system, even to try. Similarly, with the adults, case-aides can invest in an individual in a situation where normally one doctor, with 300 patients, gets to see them once every Gow-knows-when. This is not the doctor's fault, he is overburdened and just can't.

What the patients have done is to alienate the world. They've withdrawn from it and they've force dit not to want them around, either. The case-aide must mediate between the patient and the community and get them to accept each other more, without doing fancy intra-psychic work--which only the patient can really do. In therapy you don't cure patients. You open doors and try to let the patient go through if he wants.

Getting Out

Of those case-aides who have come back for two, three, or four years, many have been able to get their patients out of the hospital. It involves meeting their families, getting them an apartment, going out and getting them a job, or getting them to get a job, telling them they look lousy, they're not going to get a job without a necktie on, dragging them around in a car to these jobs--supporting them at all points. It isn't just on a once-a-week basis that you get these people out of the hospital.

Nobody leaves as a result of case-aide work. They leave as a result of getting some help in leaving. They might not have gotten this without case-aide simply because they're lost in a mob of 300 people. The patient has to get himself to the point of leaying, but frequently he cannot do this on his own. At least five out of the about 25 adult patients who have been seen by case-aide workers in the past three years have gone to halfway houses, or gotten out and gotten jobs. This is usually the result of two or three, not one, year's work.

If the case-aide is not coming back, this is made clear. It is unfortunate, as is any break in a relationship, or a friendship. It is guilt-inducing, but the realities are that Harvard students go off places come sommertime. Those that have stayed have tended to get involved in the summer program, and have gone out to see their patients--usually without supervision. They don't just sit on the ward and talk to patients. If the weather's nice they take them out. If they have cars, they might take them to Harvard Square or something. They do all kinds of things that are perfectly marvelous to reintroduce the patients to the community.

They have a lack of fear about doing things with the patients that the staff doesn't have the time or the inclination to do. A girl runs up a hill with a little boy and he loves it and he's laughing--I don't have the energy to do it. Students get down on the floor and play with the kids.

In the course of case-aide work, a certain amount of judgment is called for. The exercise of this judgment prevents the exercise of pure rebellion by the case-aide against a system that has become top-heavy, monolithic, under-financed and therefore incapable of dealing with the problems that are involved in getting patients out. The new Commissioner of Mental Health, Dr. Greenblatt, is and has been very supportive of case-aide work. He really is moving this group, attempting to get patients out into the community and to get community people to work with the patients, to get them placed, and so forth. The case-aide program has been anticipating these efforts for several years.

I'M A BIT of a martinet in this regard: You do make a contract with your patient, and you have a sem-i professional relationship, insofar as you have a commitment. I also very much believe in activism--in getting the case-aide and patient to talk to the doctors, in discussing getting medication lowered if the patient thinks it's too high; in relating to the ward personnel, the nurses and attendants, and trying to learn from them even if one does not take everything they say at face value.

Rivalries