(Continued from page 229) While extrapyramidal symptoms were not infre-

although the study did not substantiate their optimistic quent, they were no more severe on the high-dose
expectations for the high-dosage ‘#{176} regimens. Staff reported one patient who was confused,
In our treatment setting, high-potency neuroleptics possibly secondary to medication. The one case of seri-
were used routinely in doses of 60 to 100 mg. daily; the ous toxicity was a 30-year-old man who had been
dosage was increased when psychotic symptoms were treated for more than ten years with neuroleptics. He
uncontrolled. We studied the outcome of high-dosage developed agranulocytosis after receiving chlorproma-
patients treated over a three-year period, from July zine, 3900 mg., and fluphenazine decanoate, 100 mg.
1973 to June 1976; their hospital treatment included a He recovered without incident.
course of neuroleptic therapy above an arbitrarily cho- We were unable to confirm any remarkable benefits
sen cutoff of 100 mg. daily of a high-potency neurolep- from high-dose neuroleptic treatment. The results are
tic-fluphenazine, haloperidol, trifluoperazine, or no better than those that one might expect from con-
thiothixene-or 2000 mg. of chlorpromazine. ventional chemotherapy. The doses we used are some-
Treatment was determined by residents under super- what higher than those reported by McClelland and by
vision of a staff psychiatrist and included chemother- Prien, but considerably lower than those used by Rifkin
apy; individual, group, and family therapy on a crisis- or reported in the world literature. No study has shown
oriented model; and milieu and recreational therapy. that patients do less well on high-dose treatment than
Referrals were from the community; the patients were on standard-dose regimens. Davis has suggested that
generally acutely psychotic. The average stay was about aggressive chemotherapy in the acute situation may
three weeks. hasten remission of symptoms and thus lower cumula-
Discharge summaries for all patients seen on the tive exposure to neuroleptics and risk of tardive dyski-
service during the three years were used to identify 11

schizophrenic patients who had been treated with high- The dose range from 100 to 500 mg. daily of high-
dose chemotherapy. The patients’ medical records were potency neuroleptics may yet be a fruitful area for
examined to ascertain diagnosis, drug treatment, out- controlled studies. I suspect that the doses reported
come, and disposition. In some instances, patients were here are not rare in today’s treatment settings. Con-
included when they were receiving combinations whose trolled evaluation of outcome is greatly needed. Nei-
total, in equivalents, was clearly above the cutoff (for then drug-induced extrapyramidal symptoms nor other
example, fluphenazine, 70 mg. per day, with fluphena- major toxicity appears to be an impediment to the
zine decanoate, 150 mg. per week). All doses reported design of such studies, although the literature and this
were oral. Additional medications were used as needed. clinical report would suggest that any optimism should
Response to treatment was recorded as improved, ques- be cautious.
tionably improved, or unimproved. J M. Davis, “Overview:
11 Maintenance Therapy in Psychiatry: I.
A total of 681 patients were treated with neuroleptics Schizophrenia,” AmericanJournal ofPsychiatry, Vol. 132, December
during the period. Of those, 31, or 4.5 per cent, were 1975, pp. 1237-1245.
treated during 35 admissions with 42 courses of high-
dose therapy. The therapy ranged from five days to six
weeks, although in nearly every instance there was a A LOOK AT THE PROFESSIONALIZATION
period before or after when patients received the same OF THE MENTAL HEALTH VOLUNTEER
drug at lower doses. Some patients had more than one
course of treatment during an admission. Carl Fellner, M.D.
After 12 of the courses patients were seen as im- Mary Holscher, MEd.
proved, after five they were seen as questionably im-
proved, and after 25 they were rated as unimproved. UVolunteer work-an important part of health care
Drugs used included haloperidol, 100 to 350 mg. ; flu- delivery systems-is especially important in mental
phenazine, 100 to 180 mg. ; chlorpromazine, 2000 to health. While volunteers in the general medical field
4000 mg. ; thiothixene, 100 to 225 mg. ; and tn- may do rather peripheral work in well-circumscribed
fluoperazine, 100 to 120 mg. Because of the uncon- areas that are not essential for the provision of medical
trolled nature of patient selection, drug assignment, services, those in mental health have moved into more
and evaluation, no statistical manipulations of the data central positions and often participate in almost all
were deemed appropriate, and comparisons between phases of care. In addition, volunteers have helped
the groups or drugs cannot be made. On discharge, 13 establish and staff independent lay services such as
admissions were seen as improved, six as questionably crisis intervention centers, rap centers, and suicide pre-
improved, and 16 as unimproved. Seven of the un- vention centers.
improved patients were discharged to the state hospital There are, of course, many reasons for the greater
for further treatment.
Dr. Fellner is professor of psychiatry and behavioral sciences at the
University of Washington, at Harborview Medical Center, 325 9th
10 H. A. McClelland et al., “Very High Dose Fluphenazine Deca- Avenue, Seattle, Washington 98104. Ms. Holscher, a Ph.D. can-
noate: A Controlled Trial in Chronic Schizophrenia,” Archives of didate, is on the faculty of the graduate psychology program at
General Psychiatry, Vol. 33, December 1976, pp. 1435-1439. Antioch College West in Seattle.

VOLUME3ONUMBER4 APRIL 1979 233

participation and more central use of volunteers in the cent, “I like to work with people, it ‘fits’ me” ; and 13
mental health field, not the least of which is a shortage per cent, “utilitarian.”
of funds to hire sufficient staff. But more significant is Although agencies may desire a highly skilled volun-
the belief among many leaders in the field that the teer who is willing to take on increasingly responsible
volunteer’s general life experiences and personal ma- and central duties without an increase in status, author-
tunity are qualities that can be as valuable as profes- ity, or pay, our investigation indicates that the more
sional training and knowledge of the field. Yet it skilled volunteers become, the more likely they are to
seemed to us that the more training, supervision, and seek credentials that will enable them to take on a
experience the volunteer receives, the less likely he is to professional role and earn a professional salary.
continue to work without pay and be content with It is interesting to note, however, that although the
volunteer status. Once a volunteer has gained con- respondents had lost their enthusiasm for doing volun-
fidence in his knowledge and skills, he may begin to teen work, they still appreciated volunteers. They de-
move toward a paid professional role. scnibed volunteers as more sincere, humane, enthusias-
In order to test that theory and determine what influ- tic, and selfless than professionals. They believed that
ence volunteerism has on career choice, we investigated the volunteer has something to give that should be
the background of students in, recent graduates of, and recognized and valued as a significant contribution to
applicants to a graduate psychology program at Antioch the mental health field.
College West in Seattle. The program emphasized din- The respondents showed some change in attitude
ical psychology. Applications were considered from toward professionals; it generally was the feeling that
the community as well as from the student body. the professional role was demystified as the respondents
We distributed questionnaires to 40 current students, had more exposure to it. In some cases, the change went
15 applicants, and ten recent graduates to find out how beyond demystification to disillusionment. Never-
they got involved in the mental health field, how much, theless, most respondents identified a select few profes-
if any, experience they had had as a volunteer, and sionals whom they saw as embodying the values and
what, if any, intervening steps they had taken between skills they had expected to be more widespread.
doing volunteer work and applying for professional It seems likely that former volunteers who are critical
training. We asked those who had started out as volun- of professionals in general see themselves as different
teers how their attitudes toward volunteers and toward from other professionals who entered the field for more
professionals had changed since they chose to become traditional, less altruistic career motives. They seem to
professionals. feel they have, through their life experiences, paid their
We received 45 responses. From them we randomly dues in a way that other professionals have not. The
selected ten graduates and current students to inter- question of whether the professionalization of the vol-
view extensively so the information on the question- unteer mental health worker is to be looked at as a gain
naires could be verified. The typical respondent was a or a loss to the delivery of services remains unanswered.
white woman between the ages of 30 and 40. One-third
of the respondents were men ; most were also between
30 and 40. A SURVEY OF THE IMPACT
About 87 per cent of the 45 respondents did volun- OF A PATIENTS’ RIGHTS LAW
teer work at some point before entering graduate train- ON STATE FACILITIES IN INDIANA
ing in the mental health field. Of those, about 47 per
cent went directly from volunteer work to paid employ- Marlene Swan, M.S., O.T.R.
ment as a paraprofessional, and then to graduate Dennis Dipert, MS., R.P. T.
school. Twenty-three per cent left volunteer work to go
to graduate school. Thirteen per cent went from volun- #{149}Amidthe patients’ rights and advocacy movements of
teen work to undergraduate education in human serv- the past decade, the Indiana state legislature enacted
ices, psychology, or a related field, Then to paraprofes- Public Law 158. The law, which went into effect in
sional employment and graduate school. Another 4 per 1973, identifies the specific rights of patients at the
cent followed the latter route but skipped paraprofes- state’s 12 psychiatric hospitals and 20 community men-
sional work. tal health centers. It stipulates fines and possible prison
The remaining 13 per cent of our sample either had sentences for anyone found guilty of intentionally abus-
received undergraduate degrees in the field before be- ing, mistreating, or neglecting the mentally ill in a
coming volunteers or had no volunteer experience be- psychiatric facility.
fore entering the field. Many respondents said they
were involved in personal therapy, workshops, or non- Ms. Swan is director of occupational therapy at Larue D. Carter
degree training programs in the field before applying Memorial Hospital and at the time of the study was chairman of the
for graduate school. patient-advocate committee there. Mr. Dipert is assistant professor
and director of the physical therapy program of the division of allied
In response to a question about what attracted them
health sciences at the Indiana University School of Medicine in
to the mental health field, 31 per cent checked the Indianapolis. Ms. Swan’s address at the hospital is 1315 West 10th
statement “a need to serve, to contribute to others”; 24 Street, Indianapolis, Indiana 46202.
per cent checked “my own personal growth”; 31 per (Continued on page 237)

234 HOSPITAL & COMMUNITY PSYCHIATRY