The effects of a milieu therapy program were observed in 80 male psychiatric-medically infirm patients assigned to open, semi-closed, and closed wards. Ratings by nursing aides indicated that the functioning of the men in the closed and semi-closed wards improved significantly over 3 mo., whereas the functioning of those in the open wards remained the same. It was concluded that the milieu therapy program had been most beneficial for the patients who had been very regressed and socially deprived.
Robert A. Steer, EdD,2 and William P. Boger, MD
Although milieu therapy has been successful in promoting the resocialization of neuropsychiatric and geriatric patients (Cumming & Cumming, 1962; Gottesman, 1965; Heap, Boblitt, Moore, & Hord, 1970; Sanders, Smith, & Weinman, 1967), its efficacy with elderly patients who are psychiatric-medically infirm (PMI) is still being investigated (Paul, 1969; Watson & Fulton, 1968). The difficulties encountered in using the milieu treatment approach with PMI patients are usually attributable to the concepts that (I) their physical limitations override their psychiatric and social needs and (2) the salvage expectancies are poor. The providing of continuous medical surveillance favors the impression that PMI patients will require chronic care and efforts directed toward therapy of psychiatric problems are either unnecessary or minimally productive. Such conclusions are the antitheses of milieu therapy, which encourages patients to participate in instrumental or group activities, even though they have physical disabilities (Abroms, 1969). The purpose of the present study was to ascertain whether or not a simple treatment program of "movement and supervised activity" would improve the over-all functioning of elderly PMI 1. VA Hospital, Coa+esville, PA. The opinions expressed here are the authors' and do not necessarily reflect those of the Veterans Administration. The authors wish to express their appreciation to the following staff who helped with data collection and provided clinical support—Josephine Brovey, Irvin Draper, Bessie Farrow, Ruth Gehman, Lydia Griffy, Margaret Hicks, Florence Jackson, Earl Leapheart, Dorothy Roberts, and James Trace. 2. Present address: West Philadelphia Community Mental Health Consortium, PO 8076, Philadelphia 19101.
patients residing in open, semi-closed, and closed wards. The study was also initiated at a time when an administrative transfer of a group of patients from one building to another presented the opportunity for testing the effects of a physical "milieu change" upon elderly PMI individuals. Selecting the Patients An administrative transfer of 20 male patients from the open ward of a PMI building at a Veterans Administration hospital to a physically different ward in another building defined one study group. The clinical staff of the PMI building selected the "best" patients for transfer, specifically, those needing the least supervision on the new ward. From those patients remaining in the PMI building, which originally housed 140 patients, 20 patients were selected from each of the open, semi-closed, and closed wards. The 60 individuals selected from these three wards matched those of the transfer group in terms of age, diagnoses, and length of institutionalization. The mean ages of the transfer (Group A), open (Group B), semi-closed (Group C), and closed (Group D) patients were 63.6 [SD = I 1.6), 63.7 [SD = 12.2), 63.8 [SD = 11.6) and 63.9 [SD = 11.9) years, respectively. All patients carried a primary psychiatric diagnosis of schizophrenia, but represented a wide distribution of medical diagnosis ranging from diabetes (modal) to carcinoma (least frequent). The men were ambulatory, and their lengths of current
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Milieu Therapy with Psychiatric-Medically Infirm Patients
hospitalization ranged from 6 to 43 years, with a median of 18 years for each of the four groups. Assignment to open, semi-closed, and closed wards reflected the clinical staff's perception of how much supervision each patient needed at the beginning of the study and, respectively, defined a ranking of the patients in terms of increasing manifest psychopathology. The transfer and open-ward patients were permitted to leave their wards at anytime during the day, whereas semi-closed ward patients were only permitted to leave their wards in the afternoon.
Reliability of index.—In a pilot experience with the Ward Adjustment Index, an aide, head nurse, and physician were asked to rate independently, 15 patients who had been picked at random from the three wards in the PMI building. The agreement between raters was very high with a reliability coefficient between these raters' total scores of .97 (Winer, 1962). The magnitude of this coefficient was reassuring and indicated the Index was applicable when used by persons without extensive medical training. Ratings by Aides The nursing aides described each of their assigned patients the week before the administrative transfer occurred and then rated the
April 1975
Implementing the Milieu Approach The components of the milieu therapy program were implemented by a "total push" approach (Gilligan, 1965). A total push is defined here as a concerted and simultaneous effort by all ward personnel to (I) improve the patients' interpersonal relationships, (2) help the patients renew their interests in activities about the ward and hospital, and (3) encourage all patients to appreciate the daily aspects of everyday life. To achieve the three aforementioned goals, the staff began meeting in small planning groups drawn from all services represented in the PMI building and started discussing possible therapeutic interventions I mo. before the scheduled transfer of patients. After the components described below had been chosen, it was further decided to commence the entire milieu approach throughout all wards at once rather than gradually introduce individual components one at a time. The milieu therapy program was instituted in the open, semi-closed, and closed wards of the PMI building the day after the 20 transferred patients had been moved to their new location. The very nature of the groups under discussion precluded the use of any but the simplest tasks to motivate and involve them in activities. The lowest denominator of the entire effort was "more attention" over and above daily requirements. The major thrust was to introduce new stimuli into the pattern of daily life. The transfer of patients was accomplished in a single day. The remaining patients were assigned to at least one of the following types of group activities: (I) remotivation therapy, (2) personal hygiene instruction, (3) bibliotherapy, (4) occupational therapy, and (5) psychotherapy. In addition, every patient was encouraged to perform some type of minimal task about the ward, such as helping aides fold towels, feeding birds, making beds, decorating the ward, etc. The staff urged the patients to make simple decisions. Patient discussions, so-called councils, were started on all three wards. Volunteers from the community were enlisted to help in scheduling daytripe
139
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Evaluating Change in Functioning A Ward Adjustment Index was developed to measure the over-all functioning of the PMI patients who by definition were limited in their abilities to perform socially, mentally, and physically. The Index was designed to measure easily observable features of daily activity, to require minimal time for recording, and to suit the background and training of nursing aides. The aides were asked to use a three-point rating scale to describe how frequently during the month each of their assigned patients had been: (I) bothering other patients, (2) sitting idly about the ward, (3) talking with other patients, (4) helping staff with their duties, (5) maintaining his personal appearance, (6) destroying property, (7) persisting in instrumental activities, (8) displaying mental confusion, (9) bathing and dressing himself, and (10) comprehending the staff's requests. Each of the 10 items was positively scored for absence of pathology and summed to reflect over-all functioning or "adjustment." The total scores could, therefore, range from 10 to 30 with a score of 10 indicating least adjustment and a score of 30 representing most adjustment.
same patients again at monthly intervals for 3 mo. After the ratings were completed each month, the Indices were collected; past ratings were not available for reference or comparison v/hen subsequent ratings were done. The cooperation of the aides was obtained by telling them that the Ward Adjustment Index was being tried as a new type of progress note.
Fig. I presents the mean adjustment scores of the four wards before and during the 3 mo. of treatment. The rapid accelerations in the adjustment curves of Groups C and D indicate that their mean levels of adjustment increased over time. The slope of the curve plotted for Group D shows that its patients showed the most response to treatment. Effectiveness of Milieu Approach The pattern of results suggests that the total push milieu program was partially successful in bringing about changes in PMI patients. The patients in the semi-closed and closed wards responded quickly to the milieu approach, but the approaches employed had no effect on patients already enjoying the privileges of "open housing." The conclusion seems obvious that those patients judged to be most regressed responded to the therapeutic program, whereas the patients who were least regressed and accordingly allowed more nominal movement within the hospital showed no change in response to the program employed. The lack of change in the functioning of Group A was surprising because Lentz and Paul (1971) have reported that administrative transfers of chronic patients may lead to brief decrements in behavioral functioning. The consistency shown by Group A and Group B patients may
Ratings Indicate Positive Change in Two Groups
30
A two-way analysis of variance design with months of treatment (T) considered as nested in wards (W) was used to test for changes in adjustment over time.3 The mean errors attributable to both the main effect of T and the interaction of W X T were added and assumed to be equally distributed over the simple effects for the nested factor, Ts-in-W (Marascuilo & Levin, 1970). Consequently, the alpha level for each of the T-in-W contrasts was set at .01/4 or .0025. There was no significant main effect for ward membership (W). The patients treated in the new facility in an entirely different physical location (Group A), and those who remained on the open ward (Group B), revealed no changes in their levels of adjustment over the 3 mo. The patients treated in the semi-closed (Group C) and closed (Group D) wards did show changes in their levels of adjustment over the 3 mo. (both p < .001).
25
20
O" 15 WARDS D
10
0
1
2
O
O
3
MONTHS 3. The analysis of variance table is available upon request from the senior author.
Fig. I. Mean adjustment scores of four wards for 3 mo.
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away from the hospital. The wards were repainted and decorated to produce a physical "change" in the environment. A Sunshine Club was formed to give recognition to those patients who were judged by the staff as showing more conversation and pleasantry in the open and semi-closed wards. Patients were awarded distinctive badges when simple duties or assignments had been carried out in a better fashion than previously. In summary, the PMI building's patients who were socially crippled by long institutionalization because of physical and mental defects were exposed to a variety of new circumstances— changes in environment, more personal attention, and new activities. Since most of the PMI patients had been previously on acute wards, they were not being exposed to new treatment modalities, but reintroduced to previous experiences. No attempt was made to change any of the activities engaged in by the transferred patients (Group A) after they had moved. The new facility was open, had been recently decorated, and definitely represented a more pleasant environment than the ward from whence the patients came. The personnel charged with the care of this newly transferred group were not instructed to adopt any specific attitudes toward these patients.
Summary
A total push program of milieu therapy was implemented in the open, semi-closed, and closed wards of a building housing 140 elderly psychiatric-medically infirm patients. Matched samples of 20 men were drawn from each of three wards, and another matched sample of 20 men was transferred from an open ward to a new physical location prior to the total push. All four groups were rated on a Ward Adjustment Index before and at monthly intervals for 3 mo. after treatment. A two-way analysis of variance
of the patients' total adjustment scores indicated that the men in the closed wards improved over the 3 mo., whereas men physically transferred from one open ward to another and those continuing on an open ward remained the same. The conclusion was drawn that a milieu treatment program produced the greatest change in those patients who were most regressed and most socially deprived. References Abroms, S. M. Defining milieu therapy. Archives of G e n e r a l Psychiatry,
1969, 2 1 , 533-560.
Cumming, J., & Cumming, E. Ego and milieu. Atherton, New York, 1962. Gilligan, J. Review of the literature. In M. Greenblatt, M. H. Soloman, A. S. Evans, & G. W. Brooks (Eds.), Drug
and
social
therapy
in
chronic
schizophrenia.
Charles C Thomas, Springfield, IL, 1965. Gottesman, L. E. Resocialization of the geriatric mental patient. American Journal of Public Health, 1965, 55, 1964-1970. Heap, R. F., Boblitt, W. L. Moore, C. H., & Hord, J. E. Behavior-milieu therapy with chronic neuropsychiatric patients. Journal of Abnormal Psychology, 1970, 76, 349-354. Lentz, R. J., & Paul, G. L. "Routine" vs. "therapeutic" transfer of chronic mental patients. Archives of General Psychiatry, 1971, 25, 187-191.
Marascuilo, L. A., & Levin, J. R. Appropriate post hoc comparisons for interaction and nested hypotheses in analysis of variance designs: The elimination of Type IV errors. American Educational Research Journal, 1970, 7, 397-421. Paul, G. L. Chronic mental patient: Current status-future directions. Psychological Bulletin, 1969, 71, 81-94. Sanders, R., Smith, R. S., & Weinman, W. S. Chronic psychosis and recovery. Jossey-Bass, San Francisco, 1967. Watson, G. G., & Fulton, J. R. Treatment potential of the psychiatric-medically infirm: II. Psychiatric symptomatoloy. Journal of Gerontology, 1968, 23, 226-230. Winer, B. J. Statistical principles in experimental design. McGraw-Hill, New York, 1962.
CONFERENCE O N SUCCESSFUL TREATMENT OF THE ELDERLY MENTALLY ILL May 22-24, 1975, at Duke University Eric Pfeiffer, MD, Conference Chairman This national conference is designed for practitioners working with older patients, including psychiatrists, internists, family practitioners, nurses, social workers, psychologists, and pastoral counselors. It is sponsored by the Older Americans Resources and Services Program of the Center for the Study of Aging and Human Development, with support from Wyeth Laboratories, and is part of the series of activities commemorating the 20th Anniversary of the Center. Registration is limited to 250 persons. For further details and registration materials: Dorothy Heyman Duke University Medical Center, Box 3003 Durham, N.C. 27710
April 1975
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be attributable to their having been already engaged in more instrumental and group activities than the semi-closed ward patients prior to this study. For example, 14 individuals in Group A and 16 persons in Group B had been in occupational therapy before and remained in such therapy after the study's inception. The physical relocation and scheduling of additional activities may not have represented a significantly perceptible alteration in their living patterns, at least not enough to produce change as measurable by the Ward Adjustment Index. A 3-mo. exposure to the milieu program may have been too short a time for assessment of the effects produced by complete environmental change. Another reason for the apparent lack of change in the transfer (Group A) and open-ward (Group B) patients may have been the unsuitability of the Ward Adjustment Index to measure the level of functioning shown by patients in these groups. An example of the lack of sensitivity of the Index is the fact that all of these patients were initially able to dress and bathe themselves; and hence no improvement could be measured by this item in the Ward Adjustment Index.
Robert A. Steer, EdD,2 and William P. Boger, MD
Although milieu therapy has been successful in promoting the resocialization of neuropsychiatric and geriatric patients (Cumming & Cumming, 1962; Gottesman, 1965; Heap, Boblitt, Moore, & Hord, 1970; Sanders, Smith, & Weinman, 1967), its efficacy with elderly patients who are psychiatric-medically infirm (PMI) is still being investigated (Paul, 1969; Watson & Fulton, 1968). The difficulties encountered in using the milieu treatment approach with PMI patients are usually attributable to the concepts that (I) their physical limitations override their psychiatric and social needs and (2) the salvage expectancies are poor. The providing of continuous medical surveillance favors the impression that PMI patients will require chronic care and efforts directed toward therapy of psychiatric problems are either unnecessary or minimally productive. Such conclusions are the antitheses of milieu therapy, which encourages patients to participate in instrumental or group activities, even though they have physical disabilities (Abroms, 1969). The purpose of the present study was to ascertain whether or not a simple treatment program of "movement and supervised activity" would improve the over-all functioning of elderly PMI 1. VA Hospital, Coa+esville, PA. The opinions expressed here are the authors' and do not necessarily reflect those of the Veterans Administration. The authors wish to express their appreciation to the following staff who helped with data collection and provided clinical support—Josephine Brovey, Irvin Draper, Bessie Farrow, Ruth Gehman, Lydia Griffy, Margaret Hicks, Florence Jackson, Earl Leapheart, Dorothy Roberts, and James Trace. 2. Present address: West Philadelphia Community Mental Health Consortium, PO 8076, Philadelphia 19101.
patients residing in open, semi-closed, and closed wards. The study was also initiated at a time when an administrative transfer of a group of patients from one building to another presented the opportunity for testing the effects of a physical "milieu change" upon elderly PMI individuals. Selecting the Patients An administrative transfer of 20 male patients from the open ward of a PMI building at a Veterans Administration hospital to a physically different ward in another building defined one study group. The clinical staff of the PMI building selected the "best" patients for transfer, specifically, those needing the least supervision on the new ward. From those patients remaining in the PMI building, which originally housed 140 patients, 20 patients were selected from each of the open, semi-closed, and closed wards. The 60 individuals selected from these three wards matched those of the transfer group in terms of age, diagnoses, and length of institutionalization. The mean ages of the transfer (Group A), open (Group B), semi-closed (Group C), and closed (Group D) patients were 63.6 [SD = I 1.6), 63.7 [SD = 12.2), 63.8 [SD = 11.6) and 63.9 [SD = 11.9) years, respectively. All patients carried a primary psychiatric diagnosis of schizophrenia, but represented a wide distribution of medical diagnosis ranging from diabetes (modal) to carcinoma (least frequent). The men were ambulatory, and their lengths of current
138
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Milieu Therapy with Psychiatric-Medically Infirm Patients
hospitalization ranged from 6 to 43 years, with a median of 18 years for each of the four groups. Assignment to open, semi-closed, and closed wards reflected the clinical staff's perception of how much supervision each patient needed at the beginning of the study and, respectively, defined a ranking of the patients in terms of increasing manifest psychopathology. The transfer and open-ward patients were permitted to leave their wards at anytime during the day, whereas semi-closed ward patients were only permitted to leave their wards in the afternoon.
Reliability of index.—In a pilot experience with the Ward Adjustment Index, an aide, head nurse, and physician were asked to rate independently, 15 patients who had been picked at random from the three wards in the PMI building. The agreement between raters was very high with a reliability coefficient between these raters' total scores of .97 (Winer, 1962). The magnitude of this coefficient was reassuring and indicated the Index was applicable when used by persons without extensive medical training. Ratings by Aides The nursing aides described each of their assigned patients the week before the administrative transfer occurred and then rated the
April 1975
Implementing the Milieu Approach The components of the milieu therapy program were implemented by a "total push" approach (Gilligan, 1965). A total push is defined here as a concerted and simultaneous effort by all ward personnel to (I) improve the patients' interpersonal relationships, (2) help the patients renew their interests in activities about the ward and hospital, and (3) encourage all patients to appreciate the daily aspects of everyday life. To achieve the three aforementioned goals, the staff began meeting in small planning groups drawn from all services represented in the PMI building and started discussing possible therapeutic interventions I mo. before the scheduled transfer of patients. After the components described below had been chosen, it was further decided to commence the entire milieu approach throughout all wards at once rather than gradually introduce individual components one at a time. The milieu therapy program was instituted in the open, semi-closed, and closed wards of the PMI building the day after the 20 transferred patients had been moved to their new location. The very nature of the groups under discussion precluded the use of any but the simplest tasks to motivate and involve them in activities. The lowest denominator of the entire effort was "more attention" over and above daily requirements. The major thrust was to introduce new stimuli into the pattern of daily life. The transfer of patients was accomplished in a single day. The remaining patients were assigned to at least one of the following types of group activities: (I) remotivation therapy, (2) personal hygiene instruction, (3) bibliotherapy, (4) occupational therapy, and (5) psychotherapy. In addition, every patient was encouraged to perform some type of minimal task about the ward, such as helping aides fold towels, feeding birds, making beds, decorating the ward, etc. The staff urged the patients to make simple decisions. Patient discussions, so-called councils, were started on all three wards. Volunteers from the community were enlisted to help in scheduling daytripe
139
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Evaluating Change in Functioning A Ward Adjustment Index was developed to measure the over-all functioning of the PMI patients who by definition were limited in their abilities to perform socially, mentally, and physically. The Index was designed to measure easily observable features of daily activity, to require minimal time for recording, and to suit the background and training of nursing aides. The aides were asked to use a three-point rating scale to describe how frequently during the month each of their assigned patients had been: (I) bothering other patients, (2) sitting idly about the ward, (3) talking with other patients, (4) helping staff with their duties, (5) maintaining his personal appearance, (6) destroying property, (7) persisting in instrumental activities, (8) displaying mental confusion, (9) bathing and dressing himself, and (10) comprehending the staff's requests. Each of the 10 items was positively scored for absence of pathology and summed to reflect over-all functioning or "adjustment." The total scores could, therefore, range from 10 to 30 with a score of 10 indicating least adjustment and a score of 30 representing most adjustment.
same patients again at monthly intervals for 3 mo. After the ratings were completed each month, the Indices were collected; past ratings were not available for reference or comparison v/hen subsequent ratings were done. The cooperation of the aides was obtained by telling them that the Ward Adjustment Index was being tried as a new type of progress note.
Fig. I presents the mean adjustment scores of the four wards before and during the 3 mo. of treatment. The rapid accelerations in the adjustment curves of Groups C and D indicate that their mean levels of adjustment increased over time. The slope of the curve plotted for Group D shows that its patients showed the most response to treatment. Effectiveness of Milieu Approach The pattern of results suggests that the total push milieu program was partially successful in bringing about changes in PMI patients. The patients in the semi-closed and closed wards responded quickly to the milieu approach, but the approaches employed had no effect on patients already enjoying the privileges of "open housing." The conclusion seems obvious that those patients judged to be most regressed responded to the therapeutic program, whereas the patients who were least regressed and accordingly allowed more nominal movement within the hospital showed no change in response to the program employed. The lack of change in the functioning of Group A was surprising because Lentz and Paul (1971) have reported that administrative transfers of chronic patients may lead to brief decrements in behavioral functioning. The consistency shown by Group A and Group B patients may
Ratings Indicate Positive Change in Two Groups
30
A two-way analysis of variance design with months of treatment (T) considered as nested in wards (W) was used to test for changes in adjustment over time.3 The mean errors attributable to both the main effect of T and the interaction of W X T were added and assumed to be equally distributed over the simple effects for the nested factor, Ts-in-W (Marascuilo & Levin, 1970). Consequently, the alpha level for each of the T-in-W contrasts was set at .01/4 or .0025. There was no significant main effect for ward membership (W). The patients treated in the new facility in an entirely different physical location (Group A), and those who remained on the open ward (Group B), revealed no changes in their levels of adjustment over the 3 mo. The patients treated in the semi-closed (Group C) and closed (Group D) wards did show changes in their levels of adjustment over the 3 mo. (both p < .001).
25
20
O" 15 WARDS D
10
0
1
2
O
O
3
MONTHS 3. The analysis of variance table is available upon request from the senior author.
Fig. I. Mean adjustment scores of four wards for 3 mo.
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away from the hospital. The wards were repainted and decorated to produce a physical "change" in the environment. A Sunshine Club was formed to give recognition to those patients who were judged by the staff as showing more conversation and pleasantry in the open and semi-closed wards. Patients were awarded distinctive badges when simple duties or assignments had been carried out in a better fashion than previously. In summary, the PMI building's patients who were socially crippled by long institutionalization because of physical and mental defects were exposed to a variety of new circumstances— changes in environment, more personal attention, and new activities. Since most of the PMI patients had been previously on acute wards, they were not being exposed to new treatment modalities, but reintroduced to previous experiences. No attempt was made to change any of the activities engaged in by the transferred patients (Group A) after they had moved. The new facility was open, had been recently decorated, and definitely represented a more pleasant environment than the ward from whence the patients came. The personnel charged with the care of this newly transferred group were not instructed to adopt any specific attitudes toward these patients.
Summary
A total push program of milieu therapy was implemented in the open, semi-closed, and closed wards of a building housing 140 elderly psychiatric-medically infirm patients. Matched samples of 20 men were drawn from each of three wards, and another matched sample of 20 men was transferred from an open ward to a new physical location prior to the total push. All four groups were rated on a Ward Adjustment Index before and at monthly intervals for 3 mo. after treatment. A two-way analysis of variance
of the patients' total adjustment scores indicated that the men in the closed wards improved over the 3 mo., whereas men physically transferred from one open ward to another and those continuing on an open ward remained the same. The conclusion was drawn that a milieu treatment program produced the greatest change in those patients who were most regressed and most socially deprived. References Abroms, S. M. Defining milieu therapy. Archives of G e n e r a l Psychiatry,
1969, 2 1 , 533-560.
Cumming, J., & Cumming, E. Ego and milieu. Atherton, New York, 1962. Gilligan, J. Review of the literature. In M. Greenblatt, M. H. Soloman, A. S. Evans, & G. W. Brooks (Eds.), Drug
and
social
therapy
in
chronic
schizophrenia.
Charles C Thomas, Springfield, IL, 1965. Gottesman, L. E. Resocialization of the geriatric mental patient. American Journal of Public Health, 1965, 55, 1964-1970. Heap, R. F., Boblitt, W. L. Moore, C. H., & Hord, J. E. Behavior-milieu therapy with chronic neuropsychiatric patients. Journal of Abnormal Psychology, 1970, 76, 349-354. Lentz, R. J., & Paul, G. L. "Routine" vs. "therapeutic" transfer of chronic mental patients. Archives of General Psychiatry, 1971, 25, 187-191.
Marascuilo, L. A., & Levin, J. R. Appropriate post hoc comparisons for interaction and nested hypotheses in analysis of variance designs: The elimination of Type IV errors. American Educational Research Journal, 1970, 7, 397-421. Paul, G. L. Chronic mental patient: Current status-future directions. Psychological Bulletin, 1969, 71, 81-94. Sanders, R., Smith, R. S., & Weinman, W. S. Chronic psychosis and recovery. Jossey-Bass, San Francisco, 1967. Watson, G. G., & Fulton, J. R. Treatment potential of the psychiatric-medically infirm: II. Psychiatric symptomatoloy. Journal of Gerontology, 1968, 23, 226-230. Winer, B. J. Statistical principles in experimental design. McGraw-Hill, New York, 1962.
CONFERENCE O N SUCCESSFUL TREATMENT OF THE ELDERLY MENTALLY ILL May 22-24, 1975, at Duke University Eric Pfeiffer, MD, Conference Chairman This national conference is designed for practitioners working with older patients, including psychiatrists, internists, family practitioners, nurses, social workers, psychologists, and pastoral counselors. It is sponsored by the Older Americans Resources and Services Program of the Center for the Study of Aging and Human Development, with support from Wyeth Laboratories, and is part of the series of activities commemorating the 20th Anniversary of the Center. Registration is limited to 250 persons. For further details and registration materials: Dorothy Heyman Duke University Medical Center, Box 3003 Durham, N.C. 27710
April 1975
141
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be attributable to their having been already engaged in more instrumental and group activities than the semi-closed ward patients prior to this study. For example, 14 individuals in Group A and 16 persons in Group B had been in occupational therapy before and remained in such therapy after the study's inception. The physical relocation and scheduling of additional activities may not have represented a significantly perceptible alteration in their living patterns, at least not enough to produce change as measurable by the Ward Adjustment Index. A 3-mo. exposure to the milieu program may have been too short a time for assessment of the effects produced by complete environmental change. Another reason for the apparent lack of change in the transfer (Group A) and open-ward (Group B) patients may have been the unsuitability of the Ward Adjustment Index to measure the level of functioning shown by patients in these groups. An example of the lack of sensitivity of the Index is the fact that all of these patients were initially able to dress and bathe themselves; and hence no improvement could be measured by this item in the Ward Adjustment Index.
