PATIENTS' COMMENTS ON PSYCHIATRIC I N P A T I E N T T R E A T M E N T EXPERIENCES: P A T I E N T - T H E R A P I S T RELATIONSHIPS AND T H E I R I M P L I C A T I O N S FOR T R E A T M E N T O U T C O M E Hart Soo Lee, M.D.
Only few researchers pay systematic attention to what patients may have to say about their treatment experience during psychiatric hospitalization. This study not only delineates the various therapeutic aspects of an open psychiatric inpatient unit based on the patients' comments, but also attempts to correlate the data with the objective outcome of treatment rated clinically by the therapists and independently by the author. Positive patient-therapist relationship has been found to be the most significant factor correlated closely with the treatment outcome. The correlation may support the relevance of the patients' comments regarding subjectively perceived therapeutic benefits vs. objective actual benefits. During the recent two decades, people's increasing awareness and sophistication regarding various mental illnesses have created a series of new trends on the American psychiatric scene. One of the trends is that psychiatric patients have become more critical of what they are getting as consumers of health care. They voice their positions more collectively than ever before. In line with these trends various authors made attempts to evaluate the general nature and efficacy of various psychiatric treatment modalities either in outpatient or inpatient settings by using patients' reports. Some of the earliest work 1-3 in this area provided scales whereby patients' attitudes toward mental hospitals could be studied in conjunction with the attitudes of nonpatient subjects. Later in 1963, Gynther et al. 4 compared attitudes of patients of markedly different educational and socioeconomic levels toward treatment, psychiatrists, and hospitals and Dr. Han Soo Lee is Staff Psychiatrist at Long Island Jewish-Hillside Medical Center and Assistant Professor in Clinical Psychiatry at the State University of New York, Stony Brook. Reprint requests should be addressed to Dr. Lee at Inpatient Services, Hillside Division Long lstand Jewish-Hillside Medical Center, Glen Oaks, N.Y. 11004. T h e author wishes to thank Dolores Millan, B.A., of the Research Department ot the Long Island Jewish-Hillside Medical Center, for her assistance in compiling and evaluating the statistical data. PSYCHIATRIC QUARTERLY.VOL 51(1) 1979 0033-2720/79/1300-0039500.95
39
40 PSYCHIATRIC QUARTERLY
found no significant differences between them. That study also concluded that readmissions have more favorable attitudes than first admissions. Jones et al. a, by using questionnaires, developed a method of arriving at a consensus on a variety of specific dimensions of attitudes toward hospital and psychiatric treatment. They suspected that patients' attitudes on those dimensions will differ to a considerable extent from hospital to hospital, according to the particular orientation of a given hospital. Klett et al. ~, using a restricted randomized sampling procedure on 190 patients from eight wards in a State hospital, proved consistent difference in Ward Evaluation Scale scores between the patients on the more adequate wards and the patients on the less adequate wards. The significance of their finding is the consistent correlation between the staff-designated adequacy of the wards and the evaluation of such wards by the patients. Various time points of data collection were adopted by different authors such as beginning or end of treatment or a post-discharge time point. Allen and Barton 7 studied patients' attitudinal shift from admission to discharge follow-up in four main categories of concern, that is, relationship, treatment, physical environment, and disposition. Eisenthal and Lazare 8 evaluated a "customer approach" in conducting the initial psychiatric interview in a walk-in clinic setting and found that the patients' perception of the clinician's utilization of the customer approach correlated positively with measure of outcome. Some of the later work in this area revealed the increasing interest in the question, "What benefits hospitalized psychiatric patients?" and in how the patients' evaluation of the treatment experience correlate with or contrast to the staff's evaluation. Zaslove et al. 9, using open-ended questionnaires, asked both patients and psychiatrist what had been most helpful to the patients during their hospitalization. Of the patients, 93 percent chose the psychological therapies, while physicians elected those therapies as most helpful in only 50 percent of the cases. Nurses and patients tended to agree about what had helped, while physicians tended to disagree with both groups. Kotin et al. TM compared the function of the nurses and the doctors and found that talking with the doctors was not considered more helpful than with the nurses or attendants because there was not enough time with the doctors. They state that the relation between psychiatric patients' opinion of their treatment and hospital experiences, and treatment efficacy remains in doubt. Gotdstein et al. 11, in a systematic study involving over 300 psychiatric patients and their residents, drew the conclusion that the high rank order correlation of item means for patients and residents indicated that despite the differences in absolute ratings, the two groups were in substantial agreement regarding the relative benefit derived from the various items of treatment. Recent studies by Leonard 12 and Dowds et al. lz similarly contrasted patients' and therapists' perception of the helpfulness of specific treatment modalities. Different inpatient settings with varying orientation would place different emphasis on various specific treatment modalities and this will eventually be reflected in the patients' evaluation of such modalities. With this point in mind, the current study not only tries to delineate the helpful
41 H. S. LEE
aspects of an open psychiatric unit through the comments given by the patients but also to correlate their comments with the objective outcome of treatment rated clinically by their therapists and independently by the author. Hopefully, the latter attempt may increase the relevance of the patients' comments regarding perceived therapeutic benefits to actual benefits. SUBJECTS T h e sample comprised 36 males and 40 females, a total of randomly selected 76 inpatients, who were treated in an open psychiatric unit of Long Island Jewish-Hillside Medical Center, Glen Oaks, N.Y., and were discharged between September 1975 and December 1976. T h e patients' ages ranged between 14 and 61 years; there were eight teenagers (14-19), 39 patients in their twenties, 14 in their thirties, 10 in their forties, three in their fifties, and two in their sixties; thus the majority of them were younger than 40 years of age with a peak of 39 patients in their twenties. During the 15-month period, the unit received a total of 198 admissions, from which the following groups of patients were excluded from the study: those who were unmanageable in the open-unit setting and subsequently required a transfer to closed units, those who were discharged following a 3-day letter, and AWOLs. T h e diagnostic make-up of these 76 patients on admission was: 59 psychotic patients including 44 schizophrenic patients, 17 nonpsychotic patients including various personality disorders, severe neuroses, and adjustment reactions of adolescence. T h e average length of hospital stay for this group of patients was 69 days.
T H E R A P E U T I C SETTING T h e unit is a 22-bed open therapeutic community operated by a multidisciplinary team, which consists of two full-time staff psychiatrists, one half-time clinical psychologist, three social workers, several nurses divided into three shifts per day, and two activity therapists. T h e patients experienced the following five aspects of treatment within a nonauthoritarian ambience. 1. Individual Psychotherapy. Every patient had individual psychotherapy either by a psychologist or a social worker one to three times per week u n d e r the supervision of the unit psychiatrists. 2. Activities Therapies. All patients were given weekly A.T. group and individual counseling. Additional daily A.T. of 3-4 houra duration were given in a separate A.T. building away from the unit. 3. Small-Group Psychotherapies. T h r o u g h o u t the hospitalization every patient participated in a therapy group attended by seven or eight patients.
42 PSYCHIATRIC QUARTERLY
The therapist who conducted the group therapy also treated the same patients individually, except one or two whose individual treatment was given by another psychotherapist of the unit. Usually there was a nurse cotherapist for each group session. 4. Psychotropics. 87% of the patients were given varying doses of major and minor tranquilizers, tricyclic antidepressants, MAO inhibitors, and lithium at some point during the hospitalization. 5. The Unit Milieu. This includes the unit living in general, twice-aweek community meetings, weekly patient-government meetings and functions, other unit activities, and ongoing interaction with fellow patients and staff. PROCEDURE
A. Patients' Comments All 76 patients were interviewed on their admission and discharge by the author who also followed them throughout their entire hospitalization. The data presented under Patients' Comments were collected from the interview on discharge. An average interview lasted for approximately 45 minutes per patient. When the patient acknowledged that by having been in the hospital he or she had been helped, the interviewer then asked several main questions covering the following five steps of study.
The First Step. This step dealt with the question, "What was the most helpful of the following five aspects of the hospital experience as far as he or she was concerned: (1) individual psychotherapy, (2) activities therapy, (3) small-group psychotherapies, (4) medication if he was on any psychotropics, and (5) the unit milieu." The patients were also asked to rank the five items in the order of helpfulness pertaining to their own experience. Second Step. The patient was then asked to concentrate on the firstranked aspect and describe in what ways that particular aspect of treatment was so helpful to him. Third Step. He was asked which one of the two groups of people in the unit, namely his fellow patients or the staff, gave him more help than the other and which persons in particular and why. Fourth Step. What did they feel about the duration of their hospitalization. Was it too long, too short, or adequate, and how much more or less of time did they want and for what reasons. Fifth Step. Any complaints or suggestions they might have for the treating staff or the unit program itself?.
43 H. S. LEE
B. The Treatment Outcome Ratings T h e therapist and the a u t h o r i n d e p e n d e n t l y rated the t r e a t m e n t outcome into one o f the following five categories based on the clinical conditions o f the patient at the time o f discharge c o m p a r e d with the baseline condition o n admission: (1) worse, (2) little change, (3) symptomatic imp r o v e m e n t only, (4) some personality reintegration as well as symptomatic i m p r o v e m e n t , and (5) significant positive personality change. T h e o u t c o m e ratings were correlated with the data collected u n d e r A in o r d e r to answer the following questions: 1. Is t h e r e any t r e a t m e n t o u t c o m e d i f f e r e n c e between the patients who r a n k e d individual p s y c h o t h e r a p y as the most helpful modality and the patients who r a n k e d o t h e r t r e a t m e n t modalities as the most helpful? 2. Some patients felt that the fellow patients h e l p e d t h e m m o r e than the staff did, others felt the patients and the staff were equally helpful, and the third g r o u p o f patients felt that the staff h e l p e d t h e m m o r e than the patients did. Is t h e r e any o u t c o m e d i f f e r e n c e a m o n g the three groups o f patients? 3. Is t h e r e any o u t c o m e d i f f e r e n c e between patients who stated that the length o f hospitalization was too short, too long o r adequate?
RESULTS--A
First Step Results (What was the most helpful of the 5 aspects of Inpatient Treatment Table 1 shows how the patients r a n k e d the five aspects o f t r e a t m e n t as the most helpful, the second most helpful, the third most helpful and so on. As shown in the 2nd c o l u m n o f the Table, 41 o f 76 patients r a n k e d indiTable 1 76 Patients' Ranking of Five Treatment Modatities Treatment Most 2nd Most Modality Helpful Helpful I
II III IV V Total
3rd Most 4th Most Helpful Helpful
Least Overall Helpful Total Rank
41 8 8 9 10
23 11 18 18 6
4
4
4
76
t
20 27 15 10
29 15 6 22
8 8 18 28
76 76 66 76
4 2 3 5
76
76
76
76
76
66
Note: I. Individual Psychotherapy; II. Activities Therapy; III. Small Group Psychotherapy ; IV. Medication (only 66 patients were on medication) ; V. Unit milieu.
44 PSYCHIATRIC QUARTERLY
vidual psychotherapy (I) to be the most helpful, eight patients ranked the activities therapies (II), eight patients the small-group therapy (III), nine patients the medication (IV), and ten patients the unit milieu (V), respectively, to be the most helpful. Regarding the medication, 10 of 76 patients did not receive any psychotropics. The overall ranking of the five items, as shown in the last column, is that individual psychotherapy has been the most helpful, the unit milieu least helpful, and in between the two, came the three other aspects, namely, group psychotherapy, medication and activities therapy in that order of helpfulness.
Second Step Results (in what ways the patient perceived the different aspects of treatment as the most helpful) 1. The Unit Milieu. Those who stated that the unit milieu was the most helpful felt that the milieu disallowed individual isolation, challenged their tenuous reality testing, and enabled them to dispetl their paranoid stance. Initial positive interaction with one or two other patients in the community often contributed to later development of feelings of belonging to the entire milieu and subsequent lessening of distorted defensiveness. 2. Activities Therapy. Task-oriented groups, although often lacked one-to-one relationship, enabled the patients to relate themselves to tangible external objects. A few patients said, "In A.T., I get intensely concentrated in what I do. I think of nothing else while working. I stop ruminating over depressive things. Not thinking about your own problem does not mean that you are doing nothing. You are getting out of yourself." A sustained sense of accomplishment in A.T. has been reported to be the impetus in promoting therapeutic effort in their interaction with peers and A.T. therapists. 3. Medication. Most patients in this group reported the medications taking effect and that medication prevented them from recurrent symptoms. Many reported the subsidence of specific delusions and being able to think more clearly. Less fragmentation in thinking and speaking were experienced. 4. Small-Group Psychotherapies. Their responses could be summarized in the following composite quotations: "Group therapy was helpful because it gave me needed feedback from the people who were getting to know me. I saw my problems through other people's problems and felt the value of empathy. Materials dealt with in group therapy often facilitated and stimulated my individual therapy. I had a chance to help others in return, which enhanced my self-esteem. When the people in the group accepted me as I am, I felt strong and felt a sense of belonging."
45 H. S. LEE
5. Individual Psychotherapy. Patients who r a n k e d the individual p s y c h o t h e r a p y as the most helpful (N = 41) ( G r o u p A), invariably gave positive remarks about their therapist and t r e a t m e n t relationship and very few o f them (4/41) m a d e negative remarks c o n c u r r e n t l y about their therapists (p < 0.001). By contrast, the patients who favored o t h e r treatm e n t modalities (N = 35) ( G r o u p B), gave only few (4/35) positive remarks and many (20/35) negative remarks about their t h e r a p y relationship (p < 0.001). It was one o f the most impressive findings o f this study that there was outstanding prevalence in the patients' description o f their individual t r e a t m e n t experience. It seemed that without describing the relationship with their therapists, it was virtually impossible f o r t h e m to explain how the total inpatient t r e a t m e n t h e l p e d them. Many patients used the p h r a s e "very g o o d " in o r d e r to describe the relationship and a d d e d the following characterizations: It was a congenial relationship where my therapist showed me respect and saw me as a person. I, too, saw my therapist in that way; the relationship was an open, trusting one and I was honest because I had faith in her; the freedom that was created by the therapy relationship allowed me to hide nothing; the way she spoke to me encouraged compassion and mutual respect. She was more human than a technical professional; I felt I wanted to know more about my therapist personally as therapy progressed; there was an air of nonjudgemental receptiveness in the relationship. T h e therapist's quality as a p r o f e s s i o n a l as well as a p e r s o n was described:
My therapist understood me correctly and answered many questions; she cared for me, was supportive of my action, let me trust her, reassured when I felt hopeless; listened to me; was firm, but warm, tried to reach out; was concerned, devoted, tolerant; direct; encouraged me to do things I was afraid to, tuned into what I was feeling, was interested in my problems, was receptive; professionally skillful; valued my opinion and took time with me; she was after all an honest human being. Many patients r e p o r t e d that it was their first useful e x p e r i e n c e as an individual patient while previous psychotherapies did not result in so m u c h o f a change. Many felt unable to explain clearly how individual psychot h e r a p y h e l p e d except in seeing the g o o d results as essentially related to the t h e r a p y relationship. In contrast, the patients who r a n k e d o t h e r than the individual t h e r a p y as the most helpful, had to say the following negatives: My therapist did not understand me, did not support me; the relationship was not good, there was no relationship. The relationship was so-so; she was intelligent but icy cold; technical and impersonal; at times I felt I was abused by my therapist; she was too objective and only cared to get information from me.
46 PSYCHIATRIC QUARTERLY
"Fable 2 Who Helped More-Staff or Other Patients Who Helped More Staff Other Patients Equally
Individual Other Modalities Psychotherapy Most Helpful(B) Most Helpful (A) 28(68%) 4 (10%) 9 (22%) 41 X2 = 6.5830
14(40%) 9 (26%) 12 (34%) 35
Total
42(55%) 13(17%) 21(28%) 76
p(O.05
Third Step Results: (Who helped more, staff or other patients?) Forty-two (55%) of 76 patients felt that the staff helped them more, 13 patients (17%) felt that their fellow patients helped them more than the staff did, and 21 patients (28%) stated that they were equally helpful. As shown in Table 2, if these responses are tabulated against the results of the First step, namely, the ranking difference (Table 1), it shows that those who favored individual psychotherapy tend to say the staff helped them more (p < .o5). There was no statistically significant difference between the psychotic and nonpsychotic patient groups in answering the question who helped more, staff or patients. Regarding the specific names of people who were recognized as the most helpful, it was noteworthy that although the majority of patients recognized their individual therapist as the most helpful staff person, there were quite a few patients who constantly named specific nursing staff. Two particular nursing staff were cited by almost every patient. Such staff's personalities were characterized by warmth, maturity with empathy, and consistently caring attitude. Similarly, the common characteristics of patients who were recognized by their peers as more helpful, were moderate to great verbal activity and a considerable degree of ability to commiserate. They also had more than average personal encounters with the patient who gave the rating. Psychotic as well as nonpsychotic patients seemed to be equally influential to their fellow patients.
Fourth Step Results: (Duration of hospitalization) Twenty-four patients (32%) felt it was too short by 5 weeks. Some of the reasons for feeling that the duration of hospital stay was too short were:
47 H. S. LEE
t want to continue the treatment as it has been going well; I do not want to leave the supportive milieu as of now; I am not prepared to leave, t was given a short notice; I want to feel well more steadily for a little while longer because I feel my improvement is still tenuous. I still have lots of problems to solve; I'm frightened to go home now. My outside job is not quite ready. I have no substantial plan. O n the o t h e r h a n d , 12 patients (16%) felt that it was too long by an a v e r a g e 2.8 weeks. T h e y said, " I ' m only waiting for a transfer; I a m anxious to start outside t r e a t m e n t ; b e i n g in the hospital m e a n s I a m still sick but I a m better now; I d o n ' t want to wait. I f I stayed longer, I would get depressed again. I a m j u s t b o r e d . " Forty patients (52%) felt it was adequate.
Fifth Step Results." Patients' c o m m e n t s a n d suggestions were largely a b o u t the unit structure a n d the staff. (Incidentally, m a n y patients took the o p p o r t u n i t y to praise the s t a f f a n d the hospital r a t h e r than to criticize e v e n w h e n they were asked to o f f e r their complaints.)
Complaints About the Staff. " T h e s t a f f should use m o r e plain words. H a r d a n d o b s c u r e technical t e r m s do not h e l p us; staff should show m o r e o f their own p h i l o s o p h y a n d p e r s o n in addition to their psychologizing expertise; staff expect us to tolerate very d i s t u r b e d patients too o f t e n a n d b e y o n d o u r ability. T h e y should not f o r g e t that we are patients; at times the team's c o m m u n i c a t i o n was wacky. We know that you have factions too, but have it only to s o m e extent. You n e e d m o r e talk a m o n g yourselves; I was Table 3 Ranking of Treatment Modalities and Treatment Outcome Number of Patients
I
II
III
IV
Individual Therapy most HeIpful(A)
41
0
1 (0.02)
22 17 (0.536) (0.414)
Other Modalities Most Helpful (B)
35
1 (0.02)
7 (0.02)
I9 8 (0.542) (0.22)
X2 = 11.5235
V
(0.02)
p~.001
Note: I. Worse; II. Little change; III. Symptomatic improvement; IV. Some personality reintegration as well as symptomatic improvement; V. Significant positive personality change.
48 PSYCHIATRIC QUARTERLY
moved from one group to the other without sufficient explanation given by the staff. The staff should include the patients when they make major policy changes; staff should not overlook the brighter side of their patients; they should not spend so much time in their offices but come out and interact more with the patients."
Complaints About the Unit Structure. There were a number of criticisms about "too many meetings," rigidity of unit regulations, curfews at night, overcrowded dining room, too many unstructured free hours, too frequent blood testings, too rigid rules about PCs (the physical contacts) among patients and poorly made discharge plans. Several patients felt that the waiting period for status change was too long. Individual therapy time should be further increased generally. Geriatric patients should have a separate program, for very often they feel out of place. Duration of hospitalization should be individualized according to the patients' clinical needs. RESULTS--B
Outcome of Treatment Five classes of treatment outcome based on clinical condition on admission and discharge were used in rating. As the intraclass rating correlations between the therapists and the independent rater (author's) ranged from 0.4581 (p < 0.5) to 0.7108 (p < 0.1), only the data that were based on the author's outcome rating are being presented here.
Table 4 Who Helped More and Outcome Number of Patients
Ia
Staff)Pts. (C)
42
1 (0.023)
Staff ~Pts. (D)
34
0
X2 = 4.5080
IIa
IIIa
IVa
Va
1 24 15 1 ( 0 . 0 2 3 ) (0.571) (0.357)(0.023) 7 (0.205)
17 10 (0.500) (0.294)
0
p
Only few researchers pay systematic attention to what patients may have to say about their treatment experience during psychiatric hospitalization. This study not only delineates the various therapeutic aspects of an open psychiatric inpatient unit based on the patients' comments, but also attempts to correlate the data with the objective outcome of treatment rated clinically by the therapists and independently by the author. Positive patient-therapist relationship has been found to be the most significant factor correlated closely with the treatment outcome. The correlation may support the relevance of the patients' comments regarding subjectively perceived therapeutic benefits vs. objective actual benefits. During the recent two decades, people's increasing awareness and sophistication regarding various mental illnesses have created a series of new trends on the American psychiatric scene. One of the trends is that psychiatric patients have become more critical of what they are getting as consumers of health care. They voice their positions more collectively than ever before. In line with these trends various authors made attempts to evaluate the general nature and efficacy of various psychiatric treatment modalities either in outpatient or inpatient settings by using patients' reports. Some of the earliest work 1-3 in this area provided scales whereby patients' attitudes toward mental hospitals could be studied in conjunction with the attitudes of nonpatient subjects. Later in 1963, Gynther et al. 4 compared attitudes of patients of markedly different educational and socioeconomic levels toward treatment, psychiatrists, and hospitals and Dr. Han Soo Lee is Staff Psychiatrist at Long Island Jewish-Hillside Medical Center and Assistant Professor in Clinical Psychiatry at the State University of New York, Stony Brook. Reprint requests should be addressed to Dr. Lee at Inpatient Services, Hillside Division Long lstand Jewish-Hillside Medical Center, Glen Oaks, N.Y. 11004. T h e author wishes to thank Dolores Millan, B.A., of the Research Department ot the Long Island Jewish-Hillside Medical Center, for her assistance in compiling and evaluating the statistical data. PSYCHIATRIC QUARTERLY.VOL 51(1) 1979 0033-2720/79/1300-0039500.95
39
40 PSYCHIATRIC QUARTERLY
found no significant differences between them. That study also concluded that readmissions have more favorable attitudes than first admissions. Jones et al. a, by using questionnaires, developed a method of arriving at a consensus on a variety of specific dimensions of attitudes toward hospital and psychiatric treatment. They suspected that patients' attitudes on those dimensions will differ to a considerable extent from hospital to hospital, according to the particular orientation of a given hospital. Klett et al. ~, using a restricted randomized sampling procedure on 190 patients from eight wards in a State hospital, proved consistent difference in Ward Evaluation Scale scores between the patients on the more adequate wards and the patients on the less adequate wards. The significance of their finding is the consistent correlation between the staff-designated adequacy of the wards and the evaluation of such wards by the patients. Various time points of data collection were adopted by different authors such as beginning or end of treatment or a post-discharge time point. Allen and Barton 7 studied patients' attitudinal shift from admission to discharge follow-up in four main categories of concern, that is, relationship, treatment, physical environment, and disposition. Eisenthal and Lazare 8 evaluated a "customer approach" in conducting the initial psychiatric interview in a walk-in clinic setting and found that the patients' perception of the clinician's utilization of the customer approach correlated positively with measure of outcome. Some of the later work in this area revealed the increasing interest in the question, "What benefits hospitalized psychiatric patients?" and in how the patients' evaluation of the treatment experience correlate with or contrast to the staff's evaluation. Zaslove et al. 9, using open-ended questionnaires, asked both patients and psychiatrist what had been most helpful to the patients during their hospitalization. Of the patients, 93 percent chose the psychological therapies, while physicians elected those therapies as most helpful in only 50 percent of the cases. Nurses and patients tended to agree about what had helped, while physicians tended to disagree with both groups. Kotin et al. TM compared the function of the nurses and the doctors and found that talking with the doctors was not considered more helpful than with the nurses or attendants because there was not enough time with the doctors. They state that the relation between psychiatric patients' opinion of their treatment and hospital experiences, and treatment efficacy remains in doubt. Gotdstein et al. 11, in a systematic study involving over 300 psychiatric patients and their residents, drew the conclusion that the high rank order correlation of item means for patients and residents indicated that despite the differences in absolute ratings, the two groups were in substantial agreement regarding the relative benefit derived from the various items of treatment. Recent studies by Leonard 12 and Dowds et al. lz similarly contrasted patients' and therapists' perception of the helpfulness of specific treatment modalities. Different inpatient settings with varying orientation would place different emphasis on various specific treatment modalities and this will eventually be reflected in the patients' evaluation of such modalities. With this point in mind, the current study not only tries to delineate the helpful
41 H. S. LEE
aspects of an open psychiatric unit through the comments given by the patients but also to correlate their comments with the objective outcome of treatment rated clinically by their therapists and independently by the author. Hopefully, the latter attempt may increase the relevance of the patients' comments regarding perceived therapeutic benefits to actual benefits. SUBJECTS T h e sample comprised 36 males and 40 females, a total of randomly selected 76 inpatients, who were treated in an open psychiatric unit of Long Island Jewish-Hillside Medical Center, Glen Oaks, N.Y., and were discharged between September 1975 and December 1976. T h e patients' ages ranged between 14 and 61 years; there were eight teenagers (14-19), 39 patients in their twenties, 14 in their thirties, 10 in their forties, three in their fifties, and two in their sixties; thus the majority of them were younger than 40 years of age with a peak of 39 patients in their twenties. During the 15-month period, the unit received a total of 198 admissions, from which the following groups of patients were excluded from the study: those who were unmanageable in the open-unit setting and subsequently required a transfer to closed units, those who were discharged following a 3-day letter, and AWOLs. T h e diagnostic make-up of these 76 patients on admission was: 59 psychotic patients including 44 schizophrenic patients, 17 nonpsychotic patients including various personality disorders, severe neuroses, and adjustment reactions of adolescence. T h e average length of hospital stay for this group of patients was 69 days.
T H E R A P E U T I C SETTING T h e unit is a 22-bed open therapeutic community operated by a multidisciplinary team, which consists of two full-time staff psychiatrists, one half-time clinical psychologist, three social workers, several nurses divided into three shifts per day, and two activity therapists. T h e patients experienced the following five aspects of treatment within a nonauthoritarian ambience. 1. Individual Psychotherapy. Every patient had individual psychotherapy either by a psychologist or a social worker one to three times per week u n d e r the supervision of the unit psychiatrists. 2. Activities Therapies. All patients were given weekly A.T. group and individual counseling. Additional daily A.T. of 3-4 houra duration were given in a separate A.T. building away from the unit. 3. Small-Group Psychotherapies. T h r o u g h o u t the hospitalization every patient participated in a therapy group attended by seven or eight patients.
42 PSYCHIATRIC QUARTERLY
The therapist who conducted the group therapy also treated the same patients individually, except one or two whose individual treatment was given by another psychotherapist of the unit. Usually there was a nurse cotherapist for each group session. 4. Psychotropics. 87% of the patients were given varying doses of major and minor tranquilizers, tricyclic antidepressants, MAO inhibitors, and lithium at some point during the hospitalization. 5. The Unit Milieu. This includes the unit living in general, twice-aweek community meetings, weekly patient-government meetings and functions, other unit activities, and ongoing interaction with fellow patients and staff. PROCEDURE
A. Patients' Comments All 76 patients were interviewed on their admission and discharge by the author who also followed them throughout their entire hospitalization. The data presented under Patients' Comments were collected from the interview on discharge. An average interview lasted for approximately 45 minutes per patient. When the patient acknowledged that by having been in the hospital he or she had been helped, the interviewer then asked several main questions covering the following five steps of study.
The First Step. This step dealt with the question, "What was the most helpful of the following five aspects of the hospital experience as far as he or she was concerned: (1) individual psychotherapy, (2) activities therapy, (3) small-group psychotherapies, (4) medication if he was on any psychotropics, and (5) the unit milieu." The patients were also asked to rank the five items in the order of helpfulness pertaining to their own experience. Second Step. The patient was then asked to concentrate on the firstranked aspect and describe in what ways that particular aspect of treatment was so helpful to him. Third Step. He was asked which one of the two groups of people in the unit, namely his fellow patients or the staff, gave him more help than the other and which persons in particular and why. Fourth Step. What did they feel about the duration of their hospitalization. Was it too long, too short, or adequate, and how much more or less of time did they want and for what reasons. Fifth Step. Any complaints or suggestions they might have for the treating staff or the unit program itself?.
43 H. S. LEE
B. The Treatment Outcome Ratings T h e therapist and the a u t h o r i n d e p e n d e n t l y rated the t r e a t m e n t outcome into one o f the following five categories based on the clinical conditions o f the patient at the time o f discharge c o m p a r e d with the baseline condition o n admission: (1) worse, (2) little change, (3) symptomatic imp r o v e m e n t only, (4) some personality reintegration as well as symptomatic i m p r o v e m e n t , and (5) significant positive personality change. T h e o u t c o m e ratings were correlated with the data collected u n d e r A in o r d e r to answer the following questions: 1. Is t h e r e any t r e a t m e n t o u t c o m e d i f f e r e n c e between the patients who r a n k e d individual p s y c h o t h e r a p y as the most helpful modality and the patients who r a n k e d o t h e r t r e a t m e n t modalities as the most helpful? 2. Some patients felt that the fellow patients h e l p e d t h e m m o r e than the staff did, others felt the patients and the staff were equally helpful, and the third g r o u p o f patients felt that the staff h e l p e d t h e m m o r e than the patients did. Is t h e r e any o u t c o m e d i f f e r e n c e a m o n g the three groups o f patients? 3. Is t h e r e any o u t c o m e d i f f e r e n c e between patients who stated that the length o f hospitalization was too short, too long o r adequate?
RESULTS--A
First Step Results (What was the most helpful of the 5 aspects of Inpatient Treatment Table 1 shows how the patients r a n k e d the five aspects o f t r e a t m e n t as the most helpful, the second most helpful, the third most helpful and so on. As shown in the 2nd c o l u m n o f the Table, 41 o f 76 patients r a n k e d indiTable 1 76 Patients' Ranking of Five Treatment Modatities Treatment Most 2nd Most Modality Helpful Helpful I
II III IV V Total
3rd Most 4th Most Helpful Helpful
Least Overall Helpful Total Rank
41 8 8 9 10
23 11 18 18 6
4
4
4
76
t
20 27 15 10
29 15 6 22
8 8 18 28
76 76 66 76
4 2 3 5
76
76
76
76
76
66
Note: I. Individual Psychotherapy; II. Activities Therapy; III. Small Group Psychotherapy ; IV. Medication (only 66 patients were on medication) ; V. Unit milieu.
44 PSYCHIATRIC QUARTERLY
vidual psychotherapy (I) to be the most helpful, eight patients ranked the activities therapies (II), eight patients the small-group therapy (III), nine patients the medication (IV), and ten patients the unit milieu (V), respectively, to be the most helpful. Regarding the medication, 10 of 76 patients did not receive any psychotropics. The overall ranking of the five items, as shown in the last column, is that individual psychotherapy has been the most helpful, the unit milieu least helpful, and in between the two, came the three other aspects, namely, group psychotherapy, medication and activities therapy in that order of helpfulness.
Second Step Results (in what ways the patient perceived the different aspects of treatment as the most helpful) 1. The Unit Milieu. Those who stated that the unit milieu was the most helpful felt that the milieu disallowed individual isolation, challenged their tenuous reality testing, and enabled them to dispetl their paranoid stance. Initial positive interaction with one or two other patients in the community often contributed to later development of feelings of belonging to the entire milieu and subsequent lessening of distorted defensiveness. 2. Activities Therapy. Task-oriented groups, although often lacked one-to-one relationship, enabled the patients to relate themselves to tangible external objects. A few patients said, "In A.T., I get intensely concentrated in what I do. I think of nothing else while working. I stop ruminating over depressive things. Not thinking about your own problem does not mean that you are doing nothing. You are getting out of yourself." A sustained sense of accomplishment in A.T. has been reported to be the impetus in promoting therapeutic effort in their interaction with peers and A.T. therapists. 3. Medication. Most patients in this group reported the medications taking effect and that medication prevented them from recurrent symptoms. Many reported the subsidence of specific delusions and being able to think more clearly. Less fragmentation in thinking and speaking were experienced. 4. Small-Group Psychotherapies. Their responses could be summarized in the following composite quotations: "Group therapy was helpful because it gave me needed feedback from the people who were getting to know me. I saw my problems through other people's problems and felt the value of empathy. Materials dealt with in group therapy often facilitated and stimulated my individual therapy. I had a chance to help others in return, which enhanced my self-esteem. When the people in the group accepted me as I am, I felt strong and felt a sense of belonging."
45 H. S. LEE
5. Individual Psychotherapy. Patients who r a n k e d the individual p s y c h o t h e r a p y as the most helpful (N = 41) ( G r o u p A), invariably gave positive remarks about their therapist and t r e a t m e n t relationship and very few o f them (4/41) m a d e negative remarks c o n c u r r e n t l y about their therapists (p < 0.001). By contrast, the patients who favored o t h e r treatm e n t modalities (N = 35) ( G r o u p B), gave only few (4/35) positive remarks and many (20/35) negative remarks about their t h e r a p y relationship (p < 0.001). It was one o f the most impressive findings o f this study that there was outstanding prevalence in the patients' description o f their individual t r e a t m e n t experience. It seemed that without describing the relationship with their therapists, it was virtually impossible f o r t h e m to explain how the total inpatient t r e a t m e n t h e l p e d them. Many patients used the p h r a s e "very g o o d " in o r d e r to describe the relationship and a d d e d the following characterizations: It was a congenial relationship where my therapist showed me respect and saw me as a person. I, too, saw my therapist in that way; the relationship was an open, trusting one and I was honest because I had faith in her; the freedom that was created by the therapy relationship allowed me to hide nothing; the way she spoke to me encouraged compassion and mutual respect. She was more human than a technical professional; I felt I wanted to know more about my therapist personally as therapy progressed; there was an air of nonjudgemental receptiveness in the relationship. T h e therapist's quality as a p r o f e s s i o n a l as well as a p e r s o n was described:
My therapist understood me correctly and answered many questions; she cared for me, was supportive of my action, let me trust her, reassured when I felt hopeless; listened to me; was firm, but warm, tried to reach out; was concerned, devoted, tolerant; direct; encouraged me to do things I was afraid to, tuned into what I was feeling, was interested in my problems, was receptive; professionally skillful; valued my opinion and took time with me; she was after all an honest human being. Many patients r e p o r t e d that it was their first useful e x p e r i e n c e as an individual patient while previous psychotherapies did not result in so m u c h o f a change. Many felt unable to explain clearly how individual psychot h e r a p y h e l p e d except in seeing the g o o d results as essentially related to the t h e r a p y relationship. In contrast, the patients who r a n k e d o t h e r than the individual t h e r a p y as the most helpful, had to say the following negatives: My therapist did not understand me, did not support me; the relationship was not good, there was no relationship. The relationship was so-so; she was intelligent but icy cold; technical and impersonal; at times I felt I was abused by my therapist; she was too objective and only cared to get information from me.
46 PSYCHIATRIC QUARTERLY
"Fable 2 Who Helped More-Staff or Other Patients Who Helped More Staff Other Patients Equally
Individual Other Modalities Psychotherapy Most Helpful(B) Most Helpful (A) 28(68%) 4 (10%) 9 (22%) 41 X2 = 6.5830
14(40%) 9 (26%) 12 (34%) 35
Total
42(55%) 13(17%) 21(28%) 76
p(O.05
Third Step Results: (Who helped more, staff or other patients?) Forty-two (55%) of 76 patients felt that the staff helped them more, 13 patients (17%) felt that their fellow patients helped them more than the staff did, and 21 patients (28%) stated that they were equally helpful. As shown in Table 2, if these responses are tabulated against the results of the First step, namely, the ranking difference (Table 1), it shows that those who favored individual psychotherapy tend to say the staff helped them more (p < .o5). There was no statistically significant difference between the psychotic and nonpsychotic patient groups in answering the question who helped more, staff or patients. Regarding the specific names of people who were recognized as the most helpful, it was noteworthy that although the majority of patients recognized their individual therapist as the most helpful staff person, there were quite a few patients who constantly named specific nursing staff. Two particular nursing staff were cited by almost every patient. Such staff's personalities were characterized by warmth, maturity with empathy, and consistently caring attitude. Similarly, the common characteristics of patients who were recognized by their peers as more helpful, were moderate to great verbal activity and a considerable degree of ability to commiserate. They also had more than average personal encounters with the patient who gave the rating. Psychotic as well as nonpsychotic patients seemed to be equally influential to their fellow patients.
Fourth Step Results: (Duration of hospitalization) Twenty-four patients (32%) felt it was too short by 5 weeks. Some of the reasons for feeling that the duration of hospital stay was too short were:
47 H. S. LEE
t want to continue the treatment as it has been going well; I do not want to leave the supportive milieu as of now; I am not prepared to leave, t was given a short notice; I want to feel well more steadily for a little while longer because I feel my improvement is still tenuous. I still have lots of problems to solve; I'm frightened to go home now. My outside job is not quite ready. I have no substantial plan. O n the o t h e r h a n d , 12 patients (16%) felt that it was too long by an a v e r a g e 2.8 weeks. T h e y said, " I ' m only waiting for a transfer; I a m anxious to start outside t r e a t m e n t ; b e i n g in the hospital m e a n s I a m still sick but I a m better now; I d o n ' t want to wait. I f I stayed longer, I would get depressed again. I a m j u s t b o r e d . " Forty patients (52%) felt it was adequate.
Fifth Step Results." Patients' c o m m e n t s a n d suggestions were largely a b o u t the unit structure a n d the staff. (Incidentally, m a n y patients took the o p p o r t u n i t y to praise the s t a f f a n d the hospital r a t h e r than to criticize e v e n w h e n they were asked to o f f e r their complaints.)
Complaints About the Staff. " T h e s t a f f should use m o r e plain words. H a r d a n d o b s c u r e technical t e r m s do not h e l p us; staff should show m o r e o f their own p h i l o s o p h y a n d p e r s o n in addition to their psychologizing expertise; staff expect us to tolerate very d i s t u r b e d patients too o f t e n a n d b e y o n d o u r ability. T h e y should not f o r g e t that we are patients; at times the team's c o m m u n i c a t i o n was wacky. We know that you have factions too, but have it only to s o m e extent. You n e e d m o r e talk a m o n g yourselves; I was Table 3 Ranking of Treatment Modalities and Treatment Outcome Number of Patients
I
II
III
IV
Individual Therapy most HeIpful(A)
41
0
1 (0.02)
22 17 (0.536) (0.414)
Other Modalities Most Helpful (B)
35
1 (0.02)
7 (0.02)
I9 8 (0.542) (0.22)
X2 = 11.5235
V
(0.02)
p~.001
Note: I. Worse; II. Little change; III. Symptomatic improvement; IV. Some personality reintegration as well as symptomatic improvement; V. Significant positive personality change.
48 PSYCHIATRIC QUARTERLY
moved from one group to the other without sufficient explanation given by the staff. The staff should include the patients when they make major policy changes; staff should not overlook the brighter side of their patients; they should not spend so much time in their offices but come out and interact more with the patients."
Complaints About the Unit Structure. There were a number of criticisms about "too many meetings," rigidity of unit regulations, curfews at night, overcrowded dining room, too many unstructured free hours, too frequent blood testings, too rigid rules about PCs (the physical contacts) among patients and poorly made discharge plans. Several patients felt that the waiting period for status change was too long. Individual therapy time should be further increased generally. Geriatric patients should have a separate program, for very often they feel out of place. Duration of hospitalization should be individualized according to the patients' clinical needs. RESULTS--B
Outcome of Treatment Five classes of treatment outcome based on clinical condition on admission and discharge were used in rating. As the intraclass rating correlations between the therapists and the independent rater (author's) ranged from 0.4581 (p < 0.5) to 0.7108 (p < 0.1), only the data that were based on the author's outcome rating are being presented here.
Table 4 Who Helped More and Outcome Number of Patients
Ia
Staff)Pts. (C)
42
1 (0.023)
Staff ~Pts. (D)
34
0
X2 = 4.5080
IIa
IIIa
IVa
Va
1 24 15 1 ( 0 . 0 2 3 ) (0.571) (0.357)(0.023) 7 (0.205)
17 10 (0.500) (0.294)
0
p
