Relatives must be told that schizophrenia is not purely the result of environmental factors-that there are hereditary factors and almost certainly a biochemical imbalance. Such information reduces their fears that by their actions they will drive other relatives, especially their children, crazy. It also makes them more willing to cooperate with the patient’s treatment, In some instances, assertiveness training may help the relative set limits on the schizophrenic’s behavior and deal more effectively with professionals. Of course, some relatives are already too assertive; professionals should tactfully work with them to lessen their assertiveness or to channel it into activities such as advocacy for better services for their schizophrenic relative. There is a need for adequate treatment and rehabilitative services for the patient so relatives will have help in caring for him. Without these services the family may have all they can do to simply cope with the patient, much less treat and rehabilitate him. A whole
range of facilities with all degrees of structure are needed for that large proportion of patients who need out-of-home placement. Otherwise the schizophrenic may be unwilling and the parents too guilt-ridden to effect the separation. One type of schizophrenic patient who probably needs a highly structured program with intense supervision, at times even restriction, is the patient with an alcohol or drug problem or both. Other patients need a less structured, highly nurturing environment. All patients need mental health professionals able to determine who should have what kind of placement. Many families can manage their schizophrenic relatives well at home if they have access to periodic respite care so that they can take a vacation from the hard work of managing a schizophrenic. Such vacations are also helpful for the siblings, who frequently are neglected in the midst of the family’s preoccupation with taking care of the patient.#{149}
A Social Interaction Program for Chronic Psychiatric Patients Living in a Community Residence HARVEY J. LIEBERMAN, PH.D. Director, Bayview Manor Project ARNOLD WINSTON, M.D. Director South Beach Psychiatric Center Staten Island, New York FRANCIS A psychiatric tion program charged from
MAROLLA,
improved on measures of socialization, men improved more than women, and residents over 65 years of age improved the least. Residents in the experimental group did not improve much more than those in the control group. Costs for the experimental group, including room and board, were $16.59 a day per resident. Costs for the control group were $15.61 a day per resident.
PH.D.
center in Brooklyn provided a socializain a community residence for adults disstate hospitals and made a study of the
program’s outcome. Residents on two floors of the home, the experimental group, received an enriched treatment program; those on the other four floors, the control group, received a minimum of therapeutic intervention. A comparison of residents’ ratings on assessment scales made early in the program and after seven months of operation showed that residents on all floors
Dr.
Liebermans
address
is
Bayview
Manor,
2255
Cropsey
Avenue,
Brooklyn, New York 11214. Dr. Winston also is a clinical associate professor at the Downstate Medical Center of the State University of New York in Brooklyn. Dr. Marolla, formerly director of research and evaluation at South Beach Psychiatric Center, is deceased.
806
HOSPITAL
& COMMUNITY
PSYCHIATRY
#{149}When the South Beach Psychiatric Center opened a geographic mental health center in Brooklyn in 1972, it assumed responsibility for a catchment area that contained a private residence housing approximately 230 regressed chronic mental patients who had been discharged from state hospitals. While the center had limited resources, it wanted to meet two specific goals: to reverse the negative effects of institutionalization on the residents and to convert the home into a low-cost, long-term therapeutic alternative to inpatient care for chronic patients. Before a program to meet those two objectives could be established, the parameters that formally and informally govern the home’s institutional functioning had to be considered. In return for a statewide fixed rate for publicly funded residents (few are privately funded),
the management of the six-story home is responsible for the provision of all meals and housekeeping services. The home’s 15 staff members assist residents with hygiene, recreation, and medication. The staff members have no formal psychiatric training. The population of the home is usually divided fairly equally between men and women. While each floor houses both men and women, members of the same sex occupy the bedrooms, most of which accommodate two people. Because the home is relatively unsupervised, residents must be able to exercise self-control. They must also be continent, ambulatory, and able to clothe and feed themselves. Symptomatology that does not grossly interfere with living conditions of other residents is accepted. A breakdown of the primary psychiatric diagnoses of the residents taken from hospital records showed that 78 per cent of the residents had been diagnosed schizophrenic, 12 per cent had a diagnosis of affective or involutional psychosis, 5 per cent were diagnosed as having an organic brain syndrome, and 5 per cent had either a nonpsychotic diagnosis or no psychiatric history. The impression conveyed by the home’s milieu suggested that, regardless of the residents’ socialization and psychiatric status upon admission, they would all soon adapt to a norm of social avoidance. Many inpatient and outpatient projects have been successful in reversing the consequences of institutionalized social avoidance, thereby enhancing the functioning of the patients. The main characteristic of those programs, however, has been control over every aspect of the treatment environment.1’ In contrast, in community residences (designated in New York State as homes for adults’ ) only certain gross behavioral standards may be officially supported; any treatment program must be voluntary, and any alteration of the environment must take into account the potential opposition of those residents who have no interest in treatment. A close inspection of effective socialization projects indicates that they tend to be either social-psychological or behavioral in orientation. They stress social interaction, use consistent rewards to create norms for healthy social interactions, choose reinforcers according to the Premack principle, and encourage residents to ‘ ‘
‘
‘A. E. Kazdin and R. R. Bootzin, “The Token Economy: An Examination of Issues,” in Advances in Behavior Therapy, Vol. 4, R. D. Rubin, J. P. Brady, and J, D. Henderson, editors, Academic Press, New York City, 1973, pp. 159-176. 2 R. Sanders, R. Smith, and B. Weinman, Chronic Psychoses and Recovery, Jossey-Bass, San Francisco, 1967. ‘C. W. Fairweather, Social Psychology in Treating Mental Illness: An Experimental Approach, Wiley, New York City, 1964. R. S. Long, Remotivation: Fact or Artifact, American Psychiatric Association, Hospital & Community Psychiatry Service supplementary mailing, Washington, D.C., June 1962. ‘T. Ayllon and N. Azrin, The Token Economy: A Motivational System for Therapy and Rehabilitation, Prentice-Hall, Englewood Cliffs, New Jersey, 1968. #{149} Ibid.
focus on external rather than on internal events. The programs have a clear-cut organizational structure to monitor and to ensure the promotion of those factors. Using those treatment principles, we designed a program and a study to determine whether, and under what circumstances, the community-residence norm of social avoidance could be altered to produce an improvement in the socialization level and psychiatric status of the residents. When the study began, 180 of the 230 residents of the home were registered as outpatients with the South Beach Psychiatric Center. They were chronically ill, and their stays in state mental hospitals ranged from ten to 40 years. Not all patients remained in the program from its beginning to the time of our first analysis seven months later; thus usable protocols, taken at two points in time, were available for 125 residents on one measure and for 145 residents on three other measures. The mean age of all rated residents was 60.2 years, and the mean educational level was ten years. The program staff consisted of four female clinical staff members-one psychiatric nurse and three paraprofessionals-and a male psychiatrist who worked part time. The clinical staff held regular weekly coffee socialization groups that had about 20 members each. All 230 residents were invited to join one of the coffee groups. They could also join an occupational therapy group that met three times a week. Residents of the third and fifth floors of the home were chosen at random to receive an enriched program of additional activities on two half-days per week. The goal of the enriched program was to increase the number and quality of social interactions and thereby improve the over-all social and psychiatric functioning of residents. The activities included personal grooming, sewing, and development of practical skills. There were also community meetings. The activity groups met once a week; community meetings were held twice a week. Residents had the opportunity to participate in 32 half-day activity sessions. Staff kept a record of participation for residents of the two floors that were offered the enriched program. Some of the lowest-functioning residents who could not tolerate too much social stimulation attended one remotivation group each week. Some residents received individual counseling, as needed. MEASURING
THE
PROGRAM’S
EFFECT
At the beginning of the study the four clinical staff members and the director of the program rated residents on a 30-item discrete scale version of the Nurses Observation Scale for Inpatient Evaluation (NOSIE30). Two months later, after initial stabilization of the home’s residents in the program, staff rated them on three other scales that were created for the socioenvironmental rehabilitation program for chronic patients
ual,
National Institute of Mental Health, 2nd revision, Rockville, Maryland,
VOLUME
29 NUMBER
12 DECEMBER
ECDEU
Assessment
Man-
1970.
1978
807
at Philadelphia State Hospital in the late fifties: the Social Interaction Rating Scale (SIRS), the Social Participation Scale (SPS), and the Psychiatric Status Scale (P55).8 Seven months after the initial NOSIE-30 rating was made, staff took ratings on all four scales. Staff obtained nine scores for each resident on the NOSIE-30 by grouping certain items of the schedule into six content factors and three aggregates. Three of the content factors are positive; they are listed as social competence, social interest, and personal neatness. The other three content factors are negative; they are listed as irritability, manifest psychosis, and retardation (psychomotor). The algebraic sum of the positive factor and the negative factor scores is the total score. The other three scales are each made up of five oneor two-sentence descriptions of functioning on a vertical scale. The SIRS descriptions cover social functioning, the P55 covers levels of psychiatric impairment, and the SPS set describes “levels of mutuality of relationship in group or in individual “ The number of times that residents on the third and fifth floors attended the enriched social interaction program ranged from none to 31. Men and women over 65 years of age on both floors tended to participate less in activities than residents in other age groups. In two instances the two-tailed t tests on the differences between cell means were significant. Women between 55 and 65 years of age on the third floor and men between 30 and 54 years of age on the fifth floor attended the enriched program more frequently than women on the third floor who were over 65. The main data of the study, however, consist of a comparison of the patients’ scores on each of the four rating scales made early in the program and after it had been in effect for seven months. The t tests done on the comparisons of data from before and after showed statistically significant improvement for all the residents on the SF5, SIRS, and PSS scales. There were no significant changes on the NOSIE-30 total score. More detailed analyses were made in order to determine the source of those global results. We grouped the individual items on the NOSIE-30 into the nine score categories. The second rating scores on the NOSIE-30 and the second rating scores on the three other scales, adjusted by regression methods, are the dependent variables. There are three independent variables of interest: the age of the patient, the sex of the patient, and the floor on which the patient resides. Patients on floors other than the third and the fifth were grouped as controls. An analysis of covariance was made on each set of second rating scores, with the first rating as the covariate. The Scheff#{233}test’#{176} was used to evaluate the differences among the different levels within an independent variable when the variable was found to be significantly related to an adjusted dependent variable. #{149} Sanders, Smith, and Weinman, #{149} Ibid. H. Scheff#{233}, The Analysis of 1959.
808
HOSPITAL
op. cit. Variance,
Wiley,
& COMMUNITY
New
York
PSYCHIATRY
City,
Table 1 summarizes the significant results found in the analysis of covariance of the second rating score for the 12 measures, where each measure was adjusted for the first rating taken on the scale. Each of the three NOSIE-30 factor categories by content is listed in the table under the appropriate aggregate category of either positive or negative factor score. The independent variables are sex, age (30 to 54 years, 55 to 65 years, and over 65 years), and floor (third, fifth, other). Whenever we found significant effects or interactions, we applied Scheff#{233}tests on all possible combinations in order to pinpoint the components of the interactions. NOSIE-30 total score. We found no statistically significant results on this measure, which is the algebraic sum of the subjects’ positive and negative factor scores. NOSIE-30 positive factor score. The three independent variables of age, sex, and floor of residence interacted significantly on the positive factor. The Scheff#{233} tests on the interaction’s component means offered no meaningful pattern of simple effects. NOSIE-SO negative factor score. There was no significant relationship among the three independent vanables on this factor adjusted for the first rating. As can be seen in Table 1, the analyses of the NOSIE subscales of social interest and personal neatness yielded statistically significant interactions, while no significant interactions appeared on the subscales of social competence, irritability, and manifest psychosis. Scheff#{233}tests on the component means of the significant interactions did not produce an interpretable pattern of simple effects. On the subscale of retardation, the main effect of age and the double interactions of age by floor of residence and age by sex were statistically significant. A Scheff#{233} analysis of those effects revealed that men and women in the 30- to 54-year age range showed less retardation than members of their sex over 65. Analysis of the age by floor interaction yielded no meaningful results. TABLE and floor
1 (F)
Statistically significant effects on 12 dependent variables
Dependent
variable
adjusted
for first
of sex
(S),
age
(A),
Main
rating
effect
Interactions
-
-
NOSIE-30 Total
score
Positive
factor
score
-
S,A,F
Social
competence
F
-
Social
interest neatness
S
S,A,F
-
A,F;
-
-
Personal Negative
factor
score
Retardation
A
A,F;
Irritability
-
-
-
-
SPS
S
S,A,F
SIRS
-
S,A,F
PSS
-
S,A,F
Manifest
Other
psychosis
scales
S,A,F A,S
Social Participation Scale. The analysis of covaniance produced a statistically significant main effect of sex and a significant triple interaction of age by floor by sex. For the main effect, it was found that men participated to a greater degree than did women. A Scheff#{233}analysis of the triple interaction produced no meaningful configuration of effects. Social interaction Rating Scale. The age by floor by sex triple interaction was statistically significant for this scale. Data for the SIRS triple interaction were very similar to the SPS triple interaction. The Scheff#{233}analysis produced no interpretable results. Psychiatric Status Scale. The age by floor by sex triple interaction was again significant. The Scheff#{233}analysis showed no consistent pattern of simple effects. Because erratic medication patterns can markedly influence the effects of environmental manipulations and psychological interventions, we investigated the medication patterns for residents on the experimental and control floors. We found no statistically significant differences between floors in the prescription patterns of various types of medication. EXPLAINING
THE
FINDINGS
This study demonstrates that patients with severe and chronic psychiatric disabilities can respond positively to a well-designed treatment program. Residents on all floors showed global improvement on three of the four assessment scales. Residents on floors receiving the enniched program, however, did not improve much more than those on the other floors. Perhaps that outcome was a result of contamination, since all the residents interacted freely except when those in the experimental group were participating in the enriched program. There are other important results of the study that relate to the type of patient that responds to such a program. Men improved more than women, and those residents over 65 years of age improved the least. The men were all functioning poorly and had more symptomatology than did the women at the beginning of the study. Even if one allows for those initial differences, however, the men still improved more than the women. One possible explanation for the program’s differing effects on men and on women is that all the therapists were women. It is likely that women therapists may stimulate men patients more than they stimulate women patients. It is also possible that while both sexes may have been stimulated equally by the women therapists, they were stimulated in different directions. The men may have regarded the stimulation as attractive, and the women may have developed negative, competitive, jealous, or homosexual reactions toward the therapists that might have interfered with treatment. There is another explanation that may account for the superior performance of men in this study. The norms for resident behaviors were initially set at a level that was slightly above the median level for the over-all resident population. Since women, in general, were functioning somewhat above the median level to begin
with, they were under relatively little pressure to improve their functioning. Sanders, Smith, and Weinman found, in working with a younger age group, that a mixing of the sexes produces more agitation than when the sexes are kept separate. Our study took place in a co-educational setting. Patients who improved on the retardation subscale did so by becoming more active and socially involved without a corresponding increase in agitation. Sanders, Smith, and Weinman also found that men did better than women in terms of socialization although the women had a higher initial socialization level.” That corresponds to our findings and would indicate that a different program is needed for women functioning at a higher socialization level. The fact that the more elderly population improved the least seems to relate to their attending treatment sessions less frequently. They often did not want to be bothered, or said that they were retired.” The older patients also had spent longer periods of time in institutions, which might account for their general lack of responsiveness. Also, elderly residents tended to attempt to disguise disability due to cerebral dysfunction. They seemed to cope with organicity by engaging only in the most routine behaviors that they knew they could perform effectively. Because contact with the social interaction program required residents to slightly alter their behavior patterns, older residents might have seen the program as threatening rather than attractive. The over-65 age group needs a more specialized program or a more active approach to get them to attend the treatment sessions. “
ANALYZING
THE
COST
A cost analysis of the program indicates that highquality care can be offered at a fraction of the cost of inpatient treatment. In 1976 public funds, which support almost all the adult home residents, allotted each resident $386 per month for bed and board and an average of $30 per month as a personal allowance. The basic maintenance cost is $13.69 a day per resident. Treatment costs for the control group were $1.92 a day per resident, while treatment costs for the enriched program amounted to $2.90 a day per resident. Included in the treatment cost figures are staff salaries and benefits, psychotropic medication expenses, activity supply costs, and administrative expenses. Excluded from the cost calculations are treatment costs for nonpsychiatric illnesses that are financed by Medicaid. Maintenance costs of $13.69 a day per resident and costs of $2.90 for the enriched program yield a total cost of $16.59 a day per resident. That cost is far below inpatient or day hospital costs. It would seem that this program offers an economical method of housing and treating chronically ill patients in a humane and therapeutic atmosphere.U “Sanders,
VOLUME
Smith,
and
29 NUMBER
Weinman,
op. cit.
12 DECEMBER
1978
809
range of facilities with all degrees of structure are needed for that large proportion of patients who need out-of-home placement. Otherwise the schizophrenic may be unwilling and the parents too guilt-ridden to effect the separation. One type of schizophrenic patient who probably needs a highly structured program with intense supervision, at times even restriction, is the patient with an alcohol or drug problem or both. Other patients need a less structured, highly nurturing environment. All patients need mental health professionals able to determine who should have what kind of placement. Many families can manage their schizophrenic relatives well at home if they have access to periodic respite care so that they can take a vacation from the hard work of managing a schizophrenic. Such vacations are also helpful for the siblings, who frequently are neglected in the midst of the family’s preoccupation with taking care of the patient.#{149}
A Social Interaction Program for Chronic Psychiatric Patients Living in a Community Residence HARVEY J. LIEBERMAN, PH.D. Director, Bayview Manor Project ARNOLD WINSTON, M.D. Director South Beach Psychiatric Center Staten Island, New York FRANCIS A psychiatric tion program charged from
MAROLLA,
improved on measures of socialization, men improved more than women, and residents over 65 years of age improved the least. Residents in the experimental group did not improve much more than those in the control group. Costs for the experimental group, including room and board, were $16.59 a day per resident. Costs for the control group were $15.61 a day per resident.
PH.D.
center in Brooklyn provided a socializain a community residence for adults disstate hospitals and made a study of the
program’s outcome. Residents on two floors of the home, the experimental group, received an enriched treatment program; those on the other four floors, the control group, received a minimum of therapeutic intervention. A comparison of residents’ ratings on assessment scales made early in the program and after seven months of operation showed that residents on all floors
Dr.
Liebermans
address
is
Bayview
Manor,
2255
Cropsey
Avenue,
Brooklyn, New York 11214. Dr. Winston also is a clinical associate professor at the Downstate Medical Center of the State University of New York in Brooklyn. Dr. Marolla, formerly director of research and evaluation at South Beach Psychiatric Center, is deceased.
806
HOSPITAL
& COMMUNITY
PSYCHIATRY
#{149}When the South Beach Psychiatric Center opened a geographic mental health center in Brooklyn in 1972, it assumed responsibility for a catchment area that contained a private residence housing approximately 230 regressed chronic mental patients who had been discharged from state hospitals. While the center had limited resources, it wanted to meet two specific goals: to reverse the negative effects of institutionalization on the residents and to convert the home into a low-cost, long-term therapeutic alternative to inpatient care for chronic patients. Before a program to meet those two objectives could be established, the parameters that formally and informally govern the home’s institutional functioning had to be considered. In return for a statewide fixed rate for publicly funded residents (few are privately funded),
the management of the six-story home is responsible for the provision of all meals and housekeeping services. The home’s 15 staff members assist residents with hygiene, recreation, and medication. The staff members have no formal psychiatric training. The population of the home is usually divided fairly equally between men and women. While each floor houses both men and women, members of the same sex occupy the bedrooms, most of which accommodate two people. Because the home is relatively unsupervised, residents must be able to exercise self-control. They must also be continent, ambulatory, and able to clothe and feed themselves. Symptomatology that does not grossly interfere with living conditions of other residents is accepted. A breakdown of the primary psychiatric diagnoses of the residents taken from hospital records showed that 78 per cent of the residents had been diagnosed schizophrenic, 12 per cent had a diagnosis of affective or involutional psychosis, 5 per cent were diagnosed as having an organic brain syndrome, and 5 per cent had either a nonpsychotic diagnosis or no psychiatric history. The impression conveyed by the home’s milieu suggested that, regardless of the residents’ socialization and psychiatric status upon admission, they would all soon adapt to a norm of social avoidance. Many inpatient and outpatient projects have been successful in reversing the consequences of institutionalized social avoidance, thereby enhancing the functioning of the patients. The main characteristic of those programs, however, has been control over every aspect of the treatment environment.1’ In contrast, in community residences (designated in New York State as homes for adults’ ) only certain gross behavioral standards may be officially supported; any treatment program must be voluntary, and any alteration of the environment must take into account the potential opposition of those residents who have no interest in treatment. A close inspection of effective socialization projects indicates that they tend to be either social-psychological or behavioral in orientation. They stress social interaction, use consistent rewards to create norms for healthy social interactions, choose reinforcers according to the Premack principle, and encourage residents to ‘ ‘
‘
‘A. E. Kazdin and R. R. Bootzin, “The Token Economy: An Examination of Issues,” in Advances in Behavior Therapy, Vol. 4, R. D. Rubin, J. P. Brady, and J, D. Henderson, editors, Academic Press, New York City, 1973, pp. 159-176. 2 R. Sanders, R. Smith, and B. Weinman, Chronic Psychoses and Recovery, Jossey-Bass, San Francisco, 1967. ‘C. W. Fairweather, Social Psychology in Treating Mental Illness: An Experimental Approach, Wiley, New York City, 1964. R. S. Long, Remotivation: Fact or Artifact, American Psychiatric Association, Hospital & Community Psychiatry Service supplementary mailing, Washington, D.C., June 1962. ‘T. Ayllon and N. Azrin, The Token Economy: A Motivational System for Therapy and Rehabilitation, Prentice-Hall, Englewood Cliffs, New Jersey, 1968. #{149} Ibid.
focus on external rather than on internal events. The programs have a clear-cut organizational structure to monitor and to ensure the promotion of those factors. Using those treatment principles, we designed a program and a study to determine whether, and under what circumstances, the community-residence norm of social avoidance could be altered to produce an improvement in the socialization level and psychiatric status of the residents. When the study began, 180 of the 230 residents of the home were registered as outpatients with the South Beach Psychiatric Center. They were chronically ill, and their stays in state mental hospitals ranged from ten to 40 years. Not all patients remained in the program from its beginning to the time of our first analysis seven months later; thus usable protocols, taken at two points in time, were available for 125 residents on one measure and for 145 residents on three other measures. The mean age of all rated residents was 60.2 years, and the mean educational level was ten years. The program staff consisted of four female clinical staff members-one psychiatric nurse and three paraprofessionals-and a male psychiatrist who worked part time. The clinical staff held regular weekly coffee socialization groups that had about 20 members each. All 230 residents were invited to join one of the coffee groups. They could also join an occupational therapy group that met three times a week. Residents of the third and fifth floors of the home were chosen at random to receive an enriched program of additional activities on two half-days per week. The goal of the enriched program was to increase the number and quality of social interactions and thereby improve the over-all social and psychiatric functioning of residents. The activities included personal grooming, sewing, and development of practical skills. There were also community meetings. The activity groups met once a week; community meetings were held twice a week. Residents had the opportunity to participate in 32 half-day activity sessions. Staff kept a record of participation for residents of the two floors that were offered the enriched program. Some of the lowest-functioning residents who could not tolerate too much social stimulation attended one remotivation group each week. Some residents received individual counseling, as needed. MEASURING
THE
PROGRAM’S
EFFECT
At the beginning of the study the four clinical staff members and the director of the program rated residents on a 30-item discrete scale version of the Nurses Observation Scale for Inpatient Evaluation (NOSIE30). Two months later, after initial stabilization of the home’s residents in the program, staff rated them on three other scales that were created for the socioenvironmental rehabilitation program for chronic patients
ual,
National Institute of Mental Health, 2nd revision, Rockville, Maryland,
VOLUME
29 NUMBER
12 DECEMBER
ECDEU
Assessment
Man-
1970.
1978
807
at Philadelphia State Hospital in the late fifties: the Social Interaction Rating Scale (SIRS), the Social Participation Scale (SPS), and the Psychiatric Status Scale (P55).8 Seven months after the initial NOSIE-30 rating was made, staff took ratings on all four scales. Staff obtained nine scores for each resident on the NOSIE-30 by grouping certain items of the schedule into six content factors and three aggregates. Three of the content factors are positive; they are listed as social competence, social interest, and personal neatness. The other three content factors are negative; they are listed as irritability, manifest psychosis, and retardation (psychomotor). The algebraic sum of the positive factor and the negative factor scores is the total score. The other three scales are each made up of five oneor two-sentence descriptions of functioning on a vertical scale. The SIRS descriptions cover social functioning, the P55 covers levels of psychiatric impairment, and the SPS set describes “levels of mutuality of relationship in group or in individual “ The number of times that residents on the third and fifth floors attended the enriched social interaction program ranged from none to 31. Men and women over 65 years of age on both floors tended to participate less in activities than residents in other age groups. In two instances the two-tailed t tests on the differences between cell means were significant. Women between 55 and 65 years of age on the third floor and men between 30 and 54 years of age on the fifth floor attended the enriched program more frequently than women on the third floor who were over 65. The main data of the study, however, consist of a comparison of the patients’ scores on each of the four rating scales made early in the program and after it had been in effect for seven months. The t tests done on the comparisons of data from before and after showed statistically significant improvement for all the residents on the SF5, SIRS, and PSS scales. There were no significant changes on the NOSIE-30 total score. More detailed analyses were made in order to determine the source of those global results. We grouped the individual items on the NOSIE-30 into the nine score categories. The second rating scores on the NOSIE-30 and the second rating scores on the three other scales, adjusted by regression methods, are the dependent variables. There are three independent variables of interest: the age of the patient, the sex of the patient, and the floor on which the patient resides. Patients on floors other than the third and the fifth were grouped as controls. An analysis of covariance was made on each set of second rating scores, with the first rating as the covariate. The Scheff#{233}test’#{176} was used to evaluate the differences among the different levels within an independent variable when the variable was found to be significantly related to an adjusted dependent variable. #{149} Sanders, Smith, and Weinman, #{149} Ibid. H. Scheff#{233}, The Analysis of 1959.
808
HOSPITAL
op. cit. Variance,
Wiley,
& COMMUNITY
New
York
PSYCHIATRY
City,
Table 1 summarizes the significant results found in the analysis of covariance of the second rating score for the 12 measures, where each measure was adjusted for the first rating taken on the scale. Each of the three NOSIE-30 factor categories by content is listed in the table under the appropriate aggregate category of either positive or negative factor score. The independent variables are sex, age (30 to 54 years, 55 to 65 years, and over 65 years), and floor (third, fifth, other). Whenever we found significant effects or interactions, we applied Scheff#{233}tests on all possible combinations in order to pinpoint the components of the interactions. NOSIE-30 total score. We found no statistically significant results on this measure, which is the algebraic sum of the subjects’ positive and negative factor scores. NOSIE-30 positive factor score. The three independent variables of age, sex, and floor of residence interacted significantly on the positive factor. The Scheff#{233} tests on the interaction’s component means offered no meaningful pattern of simple effects. NOSIE-SO negative factor score. There was no significant relationship among the three independent vanables on this factor adjusted for the first rating. As can be seen in Table 1, the analyses of the NOSIE subscales of social interest and personal neatness yielded statistically significant interactions, while no significant interactions appeared on the subscales of social competence, irritability, and manifest psychosis. Scheff#{233}tests on the component means of the significant interactions did not produce an interpretable pattern of simple effects. On the subscale of retardation, the main effect of age and the double interactions of age by floor of residence and age by sex were statistically significant. A Scheff#{233} analysis of those effects revealed that men and women in the 30- to 54-year age range showed less retardation than members of their sex over 65. Analysis of the age by floor interaction yielded no meaningful results. TABLE and floor
1 (F)
Statistically significant effects on 12 dependent variables
Dependent
variable
adjusted
for first
of sex
(S),
age
(A),
Main
rating
effect
Interactions
-
-
NOSIE-30 Total
score
Positive
factor
score
-
S,A,F
Social
competence
F
-
Social
interest neatness
S
S,A,F
-
A,F;
-
-
Personal Negative
factor
score
Retardation
A
A,F;
Irritability
-
-
-
-
SPS
S
S,A,F
SIRS
-
S,A,F
PSS
-
S,A,F
Manifest
Other
psychosis
scales
S,A,F A,S
Social Participation Scale. The analysis of covaniance produced a statistically significant main effect of sex and a significant triple interaction of age by floor by sex. For the main effect, it was found that men participated to a greater degree than did women. A Scheff#{233}analysis of the triple interaction produced no meaningful configuration of effects. Social interaction Rating Scale. The age by floor by sex triple interaction was statistically significant for this scale. Data for the SIRS triple interaction were very similar to the SPS triple interaction. The Scheff#{233}analysis produced no interpretable results. Psychiatric Status Scale. The age by floor by sex triple interaction was again significant. The Scheff#{233}analysis showed no consistent pattern of simple effects. Because erratic medication patterns can markedly influence the effects of environmental manipulations and psychological interventions, we investigated the medication patterns for residents on the experimental and control floors. We found no statistically significant differences between floors in the prescription patterns of various types of medication. EXPLAINING
THE
FINDINGS
This study demonstrates that patients with severe and chronic psychiatric disabilities can respond positively to a well-designed treatment program. Residents on all floors showed global improvement on three of the four assessment scales. Residents on floors receiving the enniched program, however, did not improve much more than those on the other floors. Perhaps that outcome was a result of contamination, since all the residents interacted freely except when those in the experimental group were participating in the enriched program. There are other important results of the study that relate to the type of patient that responds to such a program. Men improved more than women, and those residents over 65 years of age improved the least. The men were all functioning poorly and had more symptomatology than did the women at the beginning of the study. Even if one allows for those initial differences, however, the men still improved more than the women. One possible explanation for the program’s differing effects on men and on women is that all the therapists were women. It is likely that women therapists may stimulate men patients more than they stimulate women patients. It is also possible that while both sexes may have been stimulated equally by the women therapists, they were stimulated in different directions. The men may have regarded the stimulation as attractive, and the women may have developed negative, competitive, jealous, or homosexual reactions toward the therapists that might have interfered with treatment. There is another explanation that may account for the superior performance of men in this study. The norms for resident behaviors were initially set at a level that was slightly above the median level for the over-all resident population. Since women, in general, were functioning somewhat above the median level to begin
with, they were under relatively little pressure to improve their functioning. Sanders, Smith, and Weinman found, in working with a younger age group, that a mixing of the sexes produces more agitation than when the sexes are kept separate. Our study took place in a co-educational setting. Patients who improved on the retardation subscale did so by becoming more active and socially involved without a corresponding increase in agitation. Sanders, Smith, and Weinman also found that men did better than women in terms of socialization although the women had a higher initial socialization level.” That corresponds to our findings and would indicate that a different program is needed for women functioning at a higher socialization level. The fact that the more elderly population improved the least seems to relate to their attending treatment sessions less frequently. They often did not want to be bothered, or said that they were retired.” The older patients also had spent longer periods of time in institutions, which might account for their general lack of responsiveness. Also, elderly residents tended to attempt to disguise disability due to cerebral dysfunction. They seemed to cope with organicity by engaging only in the most routine behaviors that they knew they could perform effectively. Because contact with the social interaction program required residents to slightly alter their behavior patterns, older residents might have seen the program as threatening rather than attractive. The over-65 age group needs a more specialized program or a more active approach to get them to attend the treatment sessions. “
ANALYZING
THE
COST
A cost analysis of the program indicates that highquality care can be offered at a fraction of the cost of inpatient treatment. In 1976 public funds, which support almost all the adult home residents, allotted each resident $386 per month for bed and board and an average of $30 per month as a personal allowance. The basic maintenance cost is $13.69 a day per resident. Treatment costs for the control group were $1.92 a day per resident, while treatment costs for the enriched program amounted to $2.90 a day per resident. Included in the treatment cost figures are staff salaries and benefits, psychotropic medication expenses, activity supply costs, and administrative expenses. Excluded from the cost calculations are treatment costs for nonpsychiatric illnesses that are financed by Medicaid. Maintenance costs of $13.69 a day per resident and costs of $2.90 for the enriched program yield a total cost of $16.59 a day per resident. That cost is far below inpatient or day hospital costs. It would seem that this program offers an economical method of housing and treating chronically ill patients in a humane and therapeutic atmosphere.U “Sanders,
VOLUME
Smith,
and
29 NUMBER
Weinman,
op. cit.
12 DECEMBER
1978
809
