PactAlternative to Mental Hospital Treatment

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    Alternative to MentalHospital TreatmentI. Conceptual Model, TreatmentProgram,andClinicalEvaluation

    Leonard I. Stein,MD,Mary AnnTest, PhD

    \s=b\A conceptual model for the development of community-based treatment programs for the chronically disabledpsychiat-ricpatient wasdeveloped, and the results of a controlled studyandfollow-up arereported.A community-treatment program thatwas basedontheconceptual model wascompared with conven-tional treatment(ie, progressive short-termhospitalization plusaftercare). The results have shown that use of the communityprogram for 14 months greatly reducedthe need tohospitalizepatientsand enhanced the community tenureandadjustment ofthe experimental patients. When thespecial programming wasdiscontinued,many of the gains that were attaineddeteriorated,and use of the hospital rose sharply. The results suggest thatcommunity programming should be comprehensive and on-going.

    (Arch Gen Psychiatry37:392-397,1980)

    Prior to the early 1950s, patients who suffered fromchronicallydisabling psychiatric illness were hospitalized foryears and often for a lifetime. There have sincebeen continuous efforts to reduce the hospital stay andincrease treatment in thecommunity. These efforts haveincluded theimprovement ofinpatienttreatment to facilitateearlydischarge,' shortening ofthehospitalstay,2-7thesubstitutionofdayhospitaltreatment,8the useofhalfwayhouses for transitional living and continued treatment,"and the developmentofcommunity psychosocial rehabilitation centers thatutilize a rehabilitation model.10

    Themostradicalformofcommunity treatment involvesattempts todevelop a community-treatmentalternative tothementalhospital.Three studies thatrandomlyassignedpatients from a sample in which the families acceptedhome treatment demonstrated thatit ispossible totreatpatientsathome ratherthan inthehospital."11 In allthreestudies,thehome-treatmentcondition involvedarelativelyminimal therapeutic input. In the Pasamanick et al12project, thisconsisted ofvisits by public health nurses to

    patients'homesweekly or less often to provide drugsandsupportive therapy. In the Langsley andKaplan" study,the home treatment was family-crisis therapy that wasaimed at teaching the patient ways of handling criseswithout hospitalization. In the Rittenhouse" project, thehome treatmentconsisted offamily-unittherapyas developedby Satir." Allthreestudiesfound that atleast77%ofthe experimental (E) patients could be kept out of thehospitalcontinuouslyas longasthehometreatment wasineffect.

    Threecontrolledstudies expanded thegenerality ofthealternative tomental-hospitalresearch topatientswhodidnot have a stable home situation by demonstrating thepossibility of treatment in anonfamilial, residential setting. Irvin D. Rutman, PhD, (unpublished data, October

    1971)divertedarandomsample ofnonassaultive or

    suicidalnew admissions to Philadelphia State Hospital to a halfway-house-type setting where all patients who met thestudy-admission criteria weretreated in a token-economymilieu. Mosher et al15" reported on young, first-breakschizophrenics at aresidentialsetting that had a permissive, unstructured milieu that was staffed primarily byparaprofessionals who"guided"clientsthrough theirpsychoses, usually without medications. Only two of 30patients over an average stay of 167 days had to betransferred toinpatient care. Polak and Kirby17 admittedpatients in Denver to "crisis homes" run by privatefamilieswhoprovidedsupportandshelter forpatients forseveral days to several weeks and who were aided bymentalhealthworkerswhoprovidedoutreachservices and

    consultation. Ten of the first 40 patients could not be sotreated, but this percentage declined over time eventhoughthesample was totallyunselected.

    Three controlled studies compared day treatment with24-hourin-hospital careforpatientswhosoughtadmissionto an in-hospital setting.1S-2" The Wilder et al2" studyrejected a thirdof thepatients randomly assigned to theday-treatment condition, whereas the other two studiesonly sampled from thosepatients "for whom both treatments were judged equally feasible." Thus, the day-treatment studies excluded a ratherlarge andundefinedgroup who were judged a priori to be "too ill" for theday-treatment setting. Of those treated, all but approximately 20% were kept out ofthe hospital completely.

    Accepted forpublication Sept 19, 1979.From the Department of Psychiatry, University of Wisconsin Medical

    School (Dr Stein), and the School of Social Work and the Institute forResearch on Poverty(Dr Test),University of Wisconsin, Madison.

    Reprint requests to Department ofPsychiatry,University of WisconsinMedicalCenter,600 HighlandAve,Madison, WI 53792(D rStein).

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    Thepresentstudyextendedthequest for alternatives tomental hospital treatment for patients who suffer fromchronically disabling psychiatric illness. First, we dealtwithanunselectedratherthan alimitedsampleofpatientswhocameto a statementalhospital foradmission.Second,we placed a major emphasis on improving psychosocialfunctioningbyassertivelyworkingwithpatientswhowereliving primarily independently rather than in parentalhomes orshelteredsettings.

    The first section of the report describes a conceptualmodel,which is based on patients' needs, forthe development of community-based treatment programs for thechronicallydisabledpsychiatricpatient.Thesecondsectionreports the results of a controlled experiment that compared 14 months of a treatment program entitled "TraininginCommunityLiving"(TCL)with short-termhospitalization plus aftercareanddescribes a follow-up afterthediscontinuation ofTCL.

    CONCEPTUALMODEL

    Wecontend thatcurrentcommunity treatments do noteffectively address certain factors that are required bypatients.Theabsenceof one or more of thesefactorsleadstoa tenuous

    community adjustment that

    keepspatientson

    the brinkof rehospitalization. These requirements, whichare derived from our clinical experience and the literature,21 areas follows:

    1. Material resourcessuchasfood,shelter,clothing,andmedicalcare. Community-treatmentprograms must assumeresponsibilityforhelpingthe patient acquire these resources.

    2. Copingskills to meetthedemandsof communitylife.Theseareskillswetakeforgranted,such asusing publictransportation,preparing simple but nutritious meals, and budgeting money.Learningtheseskillsshouldtake place in vivo,wherethe patientwill be needing and usingthem.

    3. Motivation to persevere and remain involved with life. Ourpatientsexperiencestress,and theirmotivation toremainin thecommunityis easilyeroded.A readilyavailablesystemofsupportto help the patient solve real-life problems, feel that he is notalone,and feel thatothers areconcerned i s crucial.4. Freedom from pathologically dependent relationships. Wedefinea pathologicallydependentrelationshipas one that inhibitspersonalgrowth,reenforeesmaladaptivebehavior,andgeneratesfeelings of panic when its loss is threatened. Many have had alifelongpathologicaldependence on families orinstitutions. Hospitalizationcan deepenthis,andon dischargethepatientis oftenreturned toa highlyconflictualfamily situation thatleads to therevolving-doorsyndrome. To break that cycle and dependency,communityprograms must provide sufficientsupportto keepthepatient involved in community life and to encourage growthtowardgreater autonomy.

    5. Support and education of community members who areinvolved with patients. An important factor that influencespatient behaviors and thus community tenure are the ways inwhichcommunity members (family, law enforcement personnel,agency people, landlords, etc) relate to patients. Communityprograms must provide support and education to help thesecommunitymembers torelatein a manner thatis both beneficialforthe patientand acceptable tothem.

    6. A supportive system thatassertively helps the patient withthe previous fiverequirements. Chronically disabledpatients arefrequently passive,interpersonallyanxious,andprone todevelopsevere psychiatric symptomatology. Such characteristics oftenleadthesepatients to fail tokeepappointmentsand to"dropout"oftreatment,particularlywhen they are becoming more symptomatic. Hence,theprogram must be assertive,involvepatientsintheirtreatment,andbe prepared to"go to"thepatient to preventdropout. It must also actively insure continuity of care amongtreatmentagencies ratherthan assumethat a patientwill successfully negotiate theoften difficult pathways from one agency toanotheron his own.

    METHODS

    Theexperiment was designed to study theeffects on patientfunctioning during a 14-month intensive community-treatmentprogram and to evaluate patient functioning afterward whenpatients were transferred to traditionalcommunity programs.Toaccomplish this, the TCL model was rigorously evaluated bycomparingit with a control (C) group that received progressivein-hospital treatment plus community aftercare. Subjects wereassigned to the TCL approach for 14 months, after which theyreceived no further

    input from the -unit staff. The latter few

    monthsof the 14-month period was used togradually wean thepatients and to integrate them into existing programs that inessence werethe same programs that treatedthe C group.

    SubjectsAll subjectssoughtadmission toMendotaMental Health Insti

    tute for inpatient care and met the following three criteria: (1)were residents in Dane County, Wisconsin (Madison and thesurroundingarea), (2) were aged 18 to 62 years,and (3)had anydiagnosisother than severe organic brain syndrome orprimaryalcoholism.

    Seventy-three percent were either single, separated, ordivorced; 55% were men; the mean age was approximately 31years;andpatients hadaccumulated a mean of 14.5 months inpsychiatricinstitutionsspread overa mean of fivehospitalizations

    per subjectbefore the current admission.

    Twenty percent came

    directly from another institution, and 14% came from shelteredliving situations. Only 17% had spent no time in a hospital. Thepatientshad awide rangeof diagnoses, andapproximately 50%wereschizophrenic.The E and C groupsdid not differsignificantly on demographiccharacteristics or on any of themajor measurement instruments given at the time of admission, with theexceptionof the measureof self-esteem.

    ExperimentalDesignThe subjects were randomly assigned by the admission office

    staff. Control subjects were treatedin thehospital for as long asnecessary and then were linked with appropriate communityagencies.Experimentalsubjectsdid not enterthehospital(exceptin rare instances), but instead received theTCL approach for 14months before integration into existing community programs.Assessment data

    on all patients

    were

    gathered at

    the baseline(time ofadmission)and every fourmonths for28 monthsthroughface-to-face interviews by a research staff that operated independentlyof both clinical teams. Data on E subjects who werehospitalized are reported.No patients wereexcluded onthe basisofseverityofsymptomatology orforanyreasonotherthan failureto meetthe three specifiedadmission criteria.

    Experimental TreatmentTheimplementation ofthe TCL programhas beendescribedin

    detail.22 In brief, the program was implemented by a retrainedmental-hospitalward staffwho weretransplanted tothe community.23 Staffcoverage wasavailable 24 hours a day, seven days aweek.Patientprograms wereindividually tailoredand werebasedprimarily on an assessment of the patient's coping-skill deficitsand requirements for community living. Most treatment took

    place in vivo: in patients' homes, neighborhoods, and places ofwork. More specifically, staff members on-the-scene in patients'homesandneighborhoodstaughtand assistedthemindailylivingactivities such aslaundry upkeep, shopping, cooking, restaurantuse,grooming, budgeting, and use oftransportation. Inaddition,patients weregivensustainedandintensive assistancein findingajob or sheltered workshop, and the staff then continued dailycontact withpatients and their supervisors or employers to helpwith on-the-job problem solving. Patients were aided in theconstructiveuse of leisureandthe development ofeffectivesocialskillsby the staff,whoprodded and supported their involvementin recreation and social activities. Their effort was directedtoward taking advantage of patients' strengths rather thanfocusing on their pathology. Providing support to patients,patients'families,andcommunitymembers wasakey functionofthestaff. The program was"assertive"; if a patientdid not show

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    up forwork, a staffmember immediately went to the patient'shome to help with any problem that was interfering. Eachpatient's medical status was carefully monitored and treated.Medication was routinely used for schizophrenic and manic-depressivepatients.

    Control Treatment

    The patients were immediately screened by a member ofthehospital'streatment unit thatservedpatients fromDaneCounty,Wisconsin. They were usually(althoughnot necessarily) admittedfor progressive treatment that was aimed at preparation forreturn to the community. The Dane County Unit served as astringentcontrolsinceithada highclinical staff-to-patientratio(1:1)andoffered awidevarietyof services:inpatientcare,partialhospitalization,andoutpatientfollow-up.Thepatients in the unithad amedian lengthofstayof 17 days andmade liberal use ofaftercareservicesavailablein Madison, Wis.

    Assessment Instruments

    The baseline measures were as follows: (1) the DemographicData Form wasused tocollectstandarddemographicdata on lifesituation and economic variables; (2) the Short Clinical RatingScale24 measured symptomatology; (3) the Community AdjustmentFormmeasuredthepatient'slivingsituation,timespentininstitutions, employment record, leisure time activities, social

    relationships, qualityof

    environment,and

    subjectivesatisfaction

    with life; and (4) the Rosenburg Self-Esteem Scale2' was aself-report measure of self-esteem. Measurestaken at the subsequent four-month intervals were the ShortClinicalRatingForm,the Community Adjustment Form, and the Rosenburg Self-EsteemScale.

    RESULTS

    The results reported here are those of 65 E and 65 Csubjects. Inthe tablesanddiscussion thatfollow,groupsoflessthan65are theresultofmissingdataincaseswhereitwas impossible toobtainthescheduled follow-up interviewfor reasons ofpatient nonavailability orlackof cooperation.Throughassertivedatacollection,80.8%ofallpossible

    interviews were fully completed and an additional 6.9%werepartiallycompleted.

    Within-Treatment Results

    The results of the first year of the study have beenreported20 and reflect the within-treatment phase of theexperiment. Asummary ofthose resultsfollows.

    Living Situations.Throughoutthe first year, E subjects

    spent very littletimein psychiatric institutionscomparedwithC subjects(Table 1).This did notleadto agreateruseby E subjects of medical or penal institutions or ofsupervisedlivingsituationsin thecommunity. Infact,theE groupspentsignificantly moretimethanthe C groupinindependentlivingsituationsin the community.Ofthe 58C patients who were hospitalized, 34 were readmitted atleast once, for areadmission rateof 58% inthe first yearcompared with 6%of the Epatients.

    Employment Status.-The E subjects spent significantlyless time unemployed and significantly more time inshelteredemployment thandid the C subjects (Table 2).Therewas nosignificantdifference between the groupsinthe percentageoftime spent incompetitive employmentsituations;however, the E subjects earned significantlymore income through competitive employment than didthe C subjects (Table 3).

    Leisure TimeActivities,SocialRelationships,andQualityofEnvironmentA measureof leisure time activitiesshowedno significant differences, nor did several of the scalesderivedto measuresocialrelationships.However, onescalethatmeasured"contactwithtrusted friends"showed thatE subjects had significantly more contact (P < .05) thandid C subjects at the 12-month period. In addition, on ascale that measured "social groups belonged to andattendedinthelastmonth,"Esubjectsscoredsignificantlyhigher than did C subjects at the 4-, 8-, and 12-monthperiods. There was no significant difference between the

    Table1.Mean Percentage of Data-Collection PeriodsSpentin VariousLiving Situations*

    Within-Treatment Phase, mo PosttreatmentPhase, mo

    12 16 20 24 28

    LivingSitua

    tion

    E

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    Table 2.Mean Percentages of Data-Collection PeriodsSpent in Various Employment Situations*

    Within-Treatment Phase, mo Posttreatment Phase, mo

    12 16 20 24 28

    E

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    psychiatriehospitals. In each data-collection period aftercessationof the program there was agradual but definiteincreasein hospital use bythe E group.Thetimespentinhospital at the 28-month period was double that of the12-month period, whereas use of the hospital by the Cgroup from the 8-month data-collection period onwardremainedquite stable.

    Employment Status.The timespentinshelteredemployment was quite constant while E patients were in the

    program (22% to 26% of their employment time). Thispercentagebegan to declinestrikingly aftercessation,andby 28 monthsithaddropped tolessthan 8%.There was analmost equal increase in unemployment andcompetitiveemployment. Unlike theirothergains,theadvantagetheEsubjectsshowed in money earned in competitive employment did not deteriorate after cessation of the TCLprogram.

    LeisureTimeActivities,Social Relationships, andQualityofEnvironment.There continued to be no significant difference between the groups on leisure time activities and

    quality ofenvironment.However,thegreater contact withtrusted friends shown by the E group at 12 monthsdisappeared postcessation.Duringthe entireperiod,the Egroupmaintained theirsignificantlyhigherattendanceatsocial groups.SatisfactionWith LifeandSelf-esteem.Thegreatersatisfactionwith lifeexpressedbythe E subjects at 12monthsdisappeared. The lack ofdifferencebetweenthe groups inself-esteemcontinuedunchangedfrom 4 months totheendofthe experiment at 28 months.Symptomatology.Thestrikingdifference in symptoma

    tology thatfavoredthe E groupwhilethey were involvedwithTCL disappeared veryrapidly.

    Medication.AfterTCL,therecontinued tobe nodifferencebetweenthegroupsinmedicationsprescribed;however,thedifferencein compliance thatfavored the E groupat 8 and 12months disappeared.

    COMMENT

    Thereare severalfactors thatmayinfluenceany generalconclusions fromthese findings. Thestudy was conductedin a nonindustrial,progressivecommunity that was receptive to this type of study. Our therapeutic interventionsand our outcome measures involved values. These valueswere summarized by Cumming27: (1) it is better to beoutside ahospitalratherthaninside;(2)itis better toworkproductively than to be dependent on others; (3) it isimportant tobeeffectively interdependent;and (4)it is agoodthing forpeople to be happy.It should be clear that our diagnoses were based on

    clinicaljudgmentratherthan on researchdiagnosticcriteria.Wecarefullytrained our raters to measure symptomatology,but oncethestudywas initiated, furtherreliabilityestimates were not made.Although there was no significantdifference in medications prescribed, patients in theEgroupreportedsignificantlygreatercompliancein the 8-and 12-month collection periods than did the C patients.Wecan notpartial outhowmuchofthegainsmadeby theE subjects was secondary to the success of the TCLprogram in gaining medication compliance as comparedwithi ts psychosocial interventions.

    Effects of the TCL ProgramWith such limitations in mind, the within-treatment

    results indicated that theTCL program was an effectivealternative to mental hospital treatment for the largemajority ofsubjects. Specifically, withminimal use ofthe

    hospital, it was possible to treat in the community anunselected groupofpatientswhoapplied foradmission to astate mental hospital. While most ofthe C subjects wereadmitted to the hospital and many were subsequentlyreadmitted, almost allof the E patients had a sustainedcommunity tenure forthe year. Most important,thedataindicated that their sustained communityliving was notgained at the expense of their quality of life, level ofadjustment,self-esteem, or personalsatisfaction with life.

    Instead, relative to C patients, the E patients showedenhanced functioning in several significant areas andmaintained less subjective distress andgreater satisfaction with theirlivesin the 14 months ofTCL treatment.

    However, our follow-up results indicated that whenpatients were weaned from the TCL program to moretraditional community programming, many of the previously noted differences betweenthe groups disappearedand use of the hospital began to increase. Other studieshavesimilarlyfound thatwhenintensive treatmentceasespatients regress and their use of the hospital sharplyincreases.2"-"'

    Several interrelatedconclusionscan bedrawn.The firstis that traditional community programming for thesepatients is either insufficient, inappropriate, or both. Thesecond is that when community programming is inadequate,the hospitalis forced to serve as theprimary locusoftreatment forthepatientratherthanbeingused forthemore appropriate specializedroleit is capable ofperforming.Third,the resultssuggest that for a large numberofchronically disabled psychiatric patients treatment mustbe an ongoing rather than a time-limited endeavor. Ourstudysuggeststo us thatthisongoingtreatment programmust be organized so thatit can provide aflexiblesystemofdelivery thatgivesthepatientonly whathe needswhenhe needsit andwhere he needs it. This involved carefulassessment ofpatient needs, close monitoring ofpatientfunctioning, assertive intervention, and working closelywithandprovidingsupport to communitymembersaswellas

    patients. Implementation ProblemsThis treatment model has several barriers to wide

    implementation. Themajor one is financing; even thoughthis model iseconomically feasible in terms of total costsandbenefits(fordetailssee thesecond articlein thisseriesby Weisbrod et al, pp 400-405), the kinds of services itprovides are largely not reimbursable by third-partypayers. Modesof treatment that are reimbursable have aprofound influence on shaping the types of services provided. As Mechanic" pointed out, it is relatively easy todetermine whatone mustpay for a day in the hospital,butitismuch moredifficult to determinehow to pay for atotalpattern of services that includes medical care and social

    supports.One possiblesolution is payment onacapitationbasis, butif new funding mechanisms are not developed,TCL-type programs will not be widely implemented.Anotherbarrierliesin the difficultiesinherentin disseminating programs that require social technologies thatrequire considerable coordinating ability and that falloutside oftheusualorganizationalpatterns ofthe medicalsector.31

    Role of the HospitalThestudyhas helped usdefine our own views of what a

    hospital's role can optimally be. Although hospitalizationmay have undesirable effects on patients, there may begreaterpatientharm andcertainlygreaterburden to the

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