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As long as the psychiatric social worker, for instance, was limited, as unfortunately they are in many institutions, to a mere gathering of social history materials on the patient's family, no particular problem arose. But as soon as plans were made for this social worker to become concerned with the patient, and to make a direct contribution to the rehabilitation program on the wards, then there was an immediate conflict between the traditional "line" of authority from superintendent to ward physician to charge nurse, to attendant on the one hand, and the activities of the psychiatric social worker on the other hand. The same, of course, was found with the clinical psychologists as soon as they moved on from a restricted routine testing program to active therapy with the patient.

While no comparable study has as yet been published, my observations in many institutions for the mentally retarded have borne out that we are facing the same problems in these institutions.

Another indication of this power structure which in turn governs the way in which the communication system is set up within the institution is found in the way in which the institutions set up their case conferences. Typically staff conferences are held in the administration building and not in the wards where the patient lives and where the attendants have their twenty-four hour a day contact with them. Hence even in those more progressive institutions where the charge nurse or perhaps even the attendant is permitted to sit in on the case conference, the setting of the conference in the administration building, the seat of all wisdom, affects adversely meaningful participation by the attendants' staff.

Again a good number of institutions have made efforts to set up communications (through memoranda, circulars, staff meetings, etc.) in order to involve the personnel charged with the daily care of the patient. Yet if one takes a close look, one discovers that this communication is often but a one way street: the vital observations which the attendant makes (or should be able to make if properly guided) are all but lost in the ponderous hierarchical system of most large institutions.

I am well aware that there are available in print many staff training manuals which put great emphasis on the concept of team work within the institution. The point I am making (and I might say here that I am also basing this observation on my own fifteen years of institutional experience) is that the reality of the traditional power structure interferes with the new theoretical concept of team work.

This leads to a subsidiary problem. I have implied in my remarks that we should strive in our institutional planning to secure for the staff concerned with the daily care of the patient (first of all the attendant) a more meaningful participation in the basic purpose of the institution, in our case physical restoration, therapy, education and training. Obviously in order to achieve this, we need an attendant who is better prepared for his job, and this implies also a more adequate compensation. At this point in my discussion, I am usually challenged by some institutional administrator who claims that this would result in "over training" our attendant. "Whom would we then have available on the wards willing to do the dirty work?" is a common reaction. Several things need to be said here. First of all, it is obviously illogical to say that because we need a great deal of clean-up operations with the untidy crib cases, we should not have a different type of personnel in the wards or cottages where we have high-grade retardates. Secondly, and of equal importance, the point has been made by some people that a move to introduce more highly skilled personnel might well result in more effective training even among the most severely retarded to the point of their achieving some degree of tidiness and thus of requiring less care. In any case there is definite need for controlled studies to test out this supposition.

In line with the suggestion that we have a greater diversification of personnel, I should mention here that in at least one state a move is definitely under way to employ for specific closely supervised menial ward duties, rehabilitated former patients as special employees under civil service regulations. To be sure this can only be undertaken in a state with a quality of supervisory personnel that would provide guarantee against abuse of this situation. But in its dual purpose of solving the problem of finding appropriate ward service for the crib cases and of securing simple jobs for the mentally retarded, capable of assuming such responsibilities, this plan merits most careful study and a systematic testing out.

In all these efforts we are faced in most states with the problem of conveying to the civil service authorities the new concepts in care and training of the mentally retarded which have developed during the past few years and which should lead to such definite shift in our patterns of institutional work. Here is a job in which parent organizations can make a particular contribution, both in their own capacity and by enlisting the sympathetic aid of civic and professional groups in the community.