A Wilcoxon matched-pains, signed-ranks test (8) comparing the frequency of assaults during the baseline and implementation periods failed to achieve significance at the .05 level (T=30, N= 19). However, additional Wilcoxon tests performed to evaluate the significance of differ ences between the baseline period and six three-month periods after implementation of the program all achieved significance at levels that exceeded .025 . By the last three month period in the study, a 92 per cent decrease in aggressive behaviors was evident, with only four intol erable acts committed. During the course of the study, three of the 19 patients were trans ferred to a medium-security ward that was also operated according to social learning principles and that had a seclusion policy identical to that on the maximum-security ward. No intolerable acts were committed
Paul and Lentz (5), another fruitful area of study would be the effect of administrative policymaking on day to-day clinical practice.
5.
References 6. 1. Soloff PH, Gutheil TG, Wexler DB: Sc elusion and restraint in 1985: a review and update. Hospital and Community Psychi
atry36:652—657, 1985 2. Carmel H, Hunter M: Compliance with training in managing assaultive behavior and injuries from inpatient violence. Hos pital and Community Psychiatry 41:558— 560, 1990 3. Monroe C, Van Rybroek Gj, Maier Gj: Decompressing aggressive inpatients: breaking the aggression cycle to enhance positive outcome. Behavioral Sciences and
Law 6:543—557, 1988 4. Beck NC, Menditto AA, Angelone E, et al: Decreasing the frequency of aggressive behavior in chronically mentally ill for ensic patients. Poster presented at the 24th
7.
8.
9.
annual convention of the Association for the Advancement of Behavior Therapy, San Francisco, Nov 1—4,1990 Paul GL, Lentz Rj: Psychosocial Treat ment of Chronic Mental Patients: Milieu Versus Social Learning Programs. Cam bridge, Mass, Harvard University Press, 1977 Paul GL (ed): Observational Assessment Instrumentation for Service and Research: The Time Sample Behavioral Checklist. Assessment in Residential Treatment Set tings, Part 2. Champaign, Ill, Research Press, 1987 Paul GL (ed): Observational Assessment Instrumentation for Service and Research: The Staff-Resident Interaction Chrono graph. Assessment in Residential Treat ment Settings, Part 3. Champaign, Ill, Research Press, 1988 Ferguson GA: Statistical Analysis in Psy chology and Education. New York, Mc Graw-Hill, 1966 Paul GL: Behavior modification research: design and tactics, in Behavior Therapy: Appraisal and Status. Edited by Franks CM. New York, McGraw-Hill, 1969
by any of these patients after their transfer.
Quality of Life of Seriously Mentally Ill Persons in Mississippi
Discussion Strictly speaking, the lack of matched groups of appropriate con trol subjects makes it impossible to draw cause-effect conclusions re garding the relationship between ob served decreases in intolerable behav ion and the introduction ofthe social learning treatment program (9). In particular, it is not possible to rule out the chance that the passage of time was responsible for the de creases in aggressive behavior that were noted. Nevertheless, the steady and eventually dramatic decrease in these behaviors oven time, when coupled with the findings ofthe cane fully controlled study conducted by Paul and Lentz (5), provides highly suggestive evidence that a compre hensive social learning approach can be ofvalue in dealing with the serious problems of aggressive behavior in chronic mentally ill forensic patients. Further research is needed on the effects ofthe time variable, as well as on the interaction between seclusion procedures and other aspects of psy chosocial treatment environments. In light of the paradoxical effect of the two-hour time limit on seclusion imposed by the Illinois Department ofMental Health during the study by
measure in studies of many clinical populations, including the seriously mentally ill population ( 1). Lehman and associates (2,3) have previously studied quality of life in seriously mentally ill populations living in board-and-care facilities in Los An ge!es and in community residences in Maryland. We recently extended this work into a different population, seriously mentally ill persons living with their families in Mississippi (4). In this study we report on sub jec tive rather than objective quality of life. An assessment of objective quality oflife is, for example, a mea sure of an individual's monthly in
752
July 1991
come. An assessment of subjective quality oflife measures how satisfied the individual is with that income. Past studies have found that seriously mentally ill persons have relatively
Greer Sullivan, M.D.,
M.S.P.H. Kenneth B. Wells, M.D., M.P.H. Barbara Leake, Ph.D.
high
Qualityof life hasbecomea relevant
Vol. 42
No. 7
subjective
ratings
ofthe
quality
oflife(2,3).
Since the population that we studied, seriously mentally ill pa tients in Mississippi, represents an extreme in poverty in the United States (5), and since studies of objec tive quality oflife have found Missis sippi's living conditions, education, and
state
and
local
government
health and welfare services to be sub standard (6), we wanted to know whether and to what extent these extreme conditions are reflected in subjective quality-of-life ratings. Methods Study design. The study was a cross sectional survey ofseniously mentally ill persons living in the community. Hospital and Community Psychiatry
Table 1 Mean quality-of-life patients
ratings1
by samples
ofseriously
mentally
ill patients
and a national
sample
and subsamples
of non-mentally-ill
sample4TotalLow non mentally-ill Seriously
mentally
socio
ill samplesNational
economic sub subsampleBlack
sampleMississippi Los
Angeles2Maryland3Domain(N= 106)Livingsituation5.2
101)
(N=278)(N=66)(N=
1,297)(N=
122)(N=
4,5*5.15.3—45*Social 4.8*5.255*55*55*Health5.3 life5.2 4.6*5.35.34.8*47*Finances4.0
3.945*4.8*4•4*49*Lifeingeneral5.3 4.45.25.45.14.8* I Rated
on a scale
ranging
from
I, indicating
extreme
dissatisfaction,
to 7, indicating
extreme
satisfaction
@: Lehman (2) , Lehman,
@
Possidente,
and
Hawker
(3)
Andrews and Withey (8) * p
Paul and Lentz (5), another fruitful area of study would be the effect of administrative policymaking on day to-day clinical practice.
5.
References 6. 1. Soloff PH, Gutheil TG, Wexler DB: Sc elusion and restraint in 1985: a review and update. Hospital and Community Psychi
atry36:652—657, 1985 2. Carmel H, Hunter M: Compliance with training in managing assaultive behavior and injuries from inpatient violence. Hos pital and Community Psychiatry 41:558— 560, 1990 3. Monroe C, Van Rybroek Gj, Maier Gj: Decompressing aggressive inpatients: breaking the aggression cycle to enhance positive outcome. Behavioral Sciences and
Law 6:543—557, 1988 4. Beck NC, Menditto AA, Angelone E, et al: Decreasing the frequency of aggressive behavior in chronically mentally ill for ensic patients. Poster presented at the 24th
7.
8.
9.
annual convention of the Association for the Advancement of Behavior Therapy, San Francisco, Nov 1—4,1990 Paul GL, Lentz Rj: Psychosocial Treat ment of Chronic Mental Patients: Milieu Versus Social Learning Programs. Cam bridge, Mass, Harvard University Press, 1977 Paul GL (ed): Observational Assessment Instrumentation for Service and Research: The Time Sample Behavioral Checklist. Assessment in Residential Treatment Set tings, Part 2. Champaign, Ill, Research Press, 1987 Paul GL (ed): Observational Assessment Instrumentation for Service and Research: The Staff-Resident Interaction Chrono graph. Assessment in Residential Treat ment Settings, Part 3. Champaign, Ill, Research Press, 1988 Ferguson GA: Statistical Analysis in Psy chology and Education. New York, Mc Graw-Hill, 1966 Paul GL: Behavior modification research: design and tactics, in Behavior Therapy: Appraisal and Status. Edited by Franks CM. New York, McGraw-Hill, 1969
by any of these patients after their transfer.
Quality of Life of Seriously Mentally Ill Persons in Mississippi
Discussion Strictly speaking, the lack of matched groups of appropriate con trol subjects makes it impossible to draw cause-effect conclusions re garding the relationship between ob served decreases in intolerable behav ion and the introduction ofthe social learning treatment program (9). In particular, it is not possible to rule out the chance that the passage of time was responsible for the de creases in aggressive behavior that were noted. Nevertheless, the steady and eventually dramatic decrease in these behaviors oven time, when coupled with the findings ofthe cane fully controlled study conducted by Paul and Lentz (5), provides highly suggestive evidence that a compre hensive social learning approach can be ofvalue in dealing with the serious problems of aggressive behavior in chronic mentally ill forensic patients. Further research is needed on the effects ofthe time variable, as well as on the interaction between seclusion procedures and other aspects of psy chosocial treatment environments. In light of the paradoxical effect of the two-hour time limit on seclusion imposed by the Illinois Department ofMental Health during the study by
measure in studies of many clinical populations, including the seriously mentally ill population ( 1). Lehman and associates (2,3) have previously studied quality of life in seriously mentally ill populations living in board-and-care facilities in Los An ge!es and in community residences in Maryland. We recently extended this work into a different population, seriously mentally ill persons living with their families in Mississippi (4). In this study we report on sub jec tive rather than objective quality of life. An assessment of objective quality oflife is, for example, a mea sure of an individual's monthly in
752
July 1991
come. An assessment of subjective quality oflife measures how satisfied the individual is with that income. Past studies have found that seriously mentally ill persons have relatively
Greer Sullivan, M.D.,
M.S.P.H. Kenneth B. Wells, M.D., M.P.H. Barbara Leake, Ph.D.
high
Qualityof life hasbecomea relevant
Vol. 42
No. 7
subjective
ratings
ofthe
quality
oflife(2,3).
Since the population that we studied, seriously mentally ill pa tients in Mississippi, represents an extreme in poverty in the United States (5), and since studies of objec tive quality oflife have found Missis sippi's living conditions, education, and
state
and
local
government
health and welfare services to be sub standard (6), we wanted to know whether and to what extent these extreme conditions are reflected in subjective quality-of-life ratings. Methods Study design. The study was a cross sectional survey ofseniously mentally ill persons living in the community. Hospital and Community Psychiatry
Table 1 Mean quality-of-life patients
ratings1
by samples
ofseriously
mentally
ill patients
and a national
sample
and subsamples
of non-mentally-ill
sample4TotalLow non mentally-ill Seriously
mentally
socio
ill samplesNational
economic sub subsampleBlack
sampleMississippi Los
Angeles2Maryland3Domain(N= 106)Livingsituation5.2
101)
(N=278)(N=66)(N=
1,297)(N=
122)(N=
4,5*5.15.3—45*Social 4.8*5.255*55*55*Health5.3 life5.2 4.6*5.35.34.8*47*Finances4.0
3.945*4.8*4•4*49*Lifeingeneral5.3 4.45.25.45.14.8* I Rated
on a scale
ranging
from
I, indicating
extreme
dissatisfaction,
to 7, indicating
extreme
satisfaction
@: Lehman (2) , Lehman,
@
Possidente,
and
Hawker
(3)
Andrews and Withey (8) * p
