Community Mental Health Journal Volume 3, Number 2, Summer, 1967
TERRITORIAL EVALUATION OF MENTAL HEALTH SERVICES WILLIAM G. SMITH, M.D., ~ D NORRIS HANSELL, M.D.*
The current phase of rapid growth in mental health services requires an increased emphasis on the systematic estimation of effectiveness. Serious evaluation requires the specification of goals in measurable categories and the setting up of a data-gatherlng and processing capacity. The argument is advanced that epidemiologic rates describing a variety of types of social disability need to be monitored in order to have a truly territorial description of mental health casualties. Summaries of casualty flow rates in relation to the deployment of resources can lead to useful estimates of productivity, or return-on-effort. The evaluation process has scientific, clinical, and managerial aspects.
At the present time treatment facilities for mental health problems are rapidly expanding throughout the United States. The Mental Health Study Act of 1955, the establishment of the National Institute of Mental Health, and the Community Mental Health Act of 1963 reflect a national interest in mental health with substantial increases in research, manpower training, and services. Much of this increased volume of activity is innovative and exploratory. Such times of rapid and enthusiastic growth are open to the hazard that the worth of a program may be assessed more on the basis of the fervor of the participants than on demonstration of accomplishment. A special emphasis on systematic and continuous evaluation is required if genuine progress is to be made.
While almost no one would take exception to the principle of evaluative research, large-scale action programs do not have an enviable record in carrying through programs of evaluation. There are a variety of reasons for this. Ambitious territorial programs operate without benefit of a carefully controlled laboratory environment. It is difficult to control or even identify all the crucial variables involved. Large-scale un. dertakings typically have multiple and often vaguely defined goals. Even in face of these difficulties, a first approximation to valid knowledge demands that evaluative research be viewed as an essential part of the program. This paper describes the assumptions and goals of a large community mental health center where evaluation is given a high priority.
*Dr. Smith, a psychiatrist, is Assistant Zone Director for Research and Evaluation Services, and Dr. Hansell, a psychiatrist, is the Zone Director for the H. Douglas Singer Zone Center, Illinois Department of Mental Health, Rockford, Ill. 61103. Copies of the core record-keepin$ forms that serve as the data source for the studies described in this paper may be obtained from the authors.
119
120
THE COMMUNITY MENTAL HEALTH JOURNAL THEMES AND EMPHASES
The H. Douglas Singer Zone Center of the Illinois Department of Mental Health is an inpatient, outpatient, and consultative service agency for an area of 10,000 square miles in Northern Illinois. The target population for the Center's services are those who have a high risk of chronic institutionalization associated with mental illness or mental retardation. This group was chosen for special emphasis because it currently contains the most serious and most costly mental disorders in our society. Operationally, the Center has selected the goals of reducing the average duration of hospitalization per capita per year for mental illness and retardation and of maximizing the community functioning of seriously disturbed persons within the 10 counties and 650,000 people which comprise the Zone. There is a delineation of responsibility that includes all citizens within the territory who have seriously reduced social competence and mental illness or retardation. This categorical and territorial definition of the problem orients the Center toward a public health model in the distribution of services, and hence a number of public policy and managerial themes receive emphasis. 1. There is an emphasis on describing the level of community casualties in terms of occurrence in the total population-at-risk rather than in terms of the patients who first come for services or who are receiving services at any particular point in time. The concept of doing the greatest good for the greatest number within the limits of available resources becomes a key notion in the system. 2. There is a corollary emphasis on return-on-effort and on estimates of effectiveness. The central decision-related comparison focuses on output per unit input, or productivity. For example, how many hospitalized patients can be returned to effective citizenship in the community per 100 hours of professional effort? A premium is placed on information that will allow the allocation of resources in a more effective way. Less weight is placed on process (what happened in a particular group therapy ses-
sion) and more weight is attached to outcome (how successful a social adjustment did the patient make after experiencing specified services). 3. Finally, the theme of prevention, or more precise intervention, receives particular attention. This takes the form of early, short-term, crisis-oriented management of problems. Priority is placed on alternatives to institutionalization or the more precise use of institutionalization and/or an active effort to keep the patient linked with his family and resident in the community. Noninstitutional methods for managing mental illness and disability are stressed because of the humanitarian and public costs associated with institutional desocialization. There is emphasis on the identification of high-risk markers, i.e., antecedent events or crises in people's lives that are likely to be associated with later mental breakdown, reduced social competence, and the need for hospitalization. When such a risk marker is identified, various interventional programs can be designed and tested for effectiveness in reducing the rate of institutionalization or hospitalization among high-risk persons in the population. PROGRAMDESCRIPTION
This paper does not cover in more than a suggestive way the description of how the H. Douglas Singer Zone Center plans to achieve the goals and emphases listed above. However, a few points can be mentioned. A substantial portion of staff time is spent in community linking activities. These community activities include: linking a patient and his family, linking different agencies, discussing policy with other agencies, working with citizens' groups to increase funding for mental health services, motivating administrative authorities to accept responsibility for interagency and territorial planning. Particular patients who are at risk of becoming detached from their families or from friendship networks are linked to substitute families, to agencies, to jobs and job skills through the activities of a person called a "mental health rehabilitation expediter." The expediter focuses the activities of many agencies, professionals, and
WILLIAMG. SMITHAND NOI~IS HANSELL
resources within the community onto the particular problems of a specific person with reduced social competence and mental illness or retardation. In addition to the mental health rehabilitation expediter, other new forms of mental health cadre are being developed to carry out the Zone goals, for instance, the "mental health program worker." The program worker is a general purpose, inpatient milieu staff person who has a professional training intermediate in depth between the psychiatrist, social worker, and psychologist on the one hand and the aide and custodial staff on the other. Other technologic features of the H. Douglas Singer Zone Center include transitional services before and after incare through such devices as "spinoff groups" and "pipehne groups." These are group therapy methods in which a group of patients is set up during an inpatient hospitalization and taught how to operate as a crisis-support and counseling system to its members over a period of years, with minimal professional intervention. Interruption of long-term use of state hospitals is stressed through brief, intense inpatient care, associated with home care and noninstitutional support by the same staff involved in the incare phase of management. TERRITORIALDESCRIPTION OF CASUALTYRATES
In line with the themes outlined above, it is necessary to make summary descriptions of the population living within the territory. Epidemiologic methods have particular prominence in such a system (Reid, 1960). Rates in which the numerator is some kind of "case" or event and the denominator is some population-at-risk are common methods for describing the composition of mental health casualties or changes in casualty rates. In order to construct meaningful indices, it is necessary to define precisely what constitutes a case, what are the kinds of cases, and what kinds of events reflect changes in the population that are relevant to the goals of the Singer Zone Center. The territorial case register is a device used to record centrally all mental health
121
treatment contacts with members of a population defined on the basis of residence within a given geographic area (Gorwitz, Bahn, Chandler, & Martin, 1963; Miles & Gardner, 1966). Whether a person went to agency A or practitioner B, whether he received treatment last year or this, whether in the public or private sector, a case register records each event centrally and by person. Matters of confidenti~/lity and restricted access to this information, or reporting only in summarized and anonymous ways, become important issues. The case register provides a method for describing unduplicared counts of mental health casualties, their distribution in various segments of the population, the longitudinal course of various disorders, as well as the patterns of care and the effectiveness of different modes of intervention. Casualty flow rates at two points in time or comparisons of portions of the territory with differing resource patterns at the same time provide alternative methods for assessing the effectiveness of a network of mental health services. Such investigations involve the collection of data on flow rates for a given group of agencies that service the people who live in a particular territory. As with case registers, it is important to document concomitantly increases or decreases in the general population due to births, deaths, and migration. Another example of the description of mental disorders in a community is the "territorial polygraph." This is a multiple line graph that simultaneously depicts a number of parameters that have relevance to mental health, plotted at monthly or quarterly intervals. Examples of relevant rates might include the following: homicides, predatory crimes, imprisonments, infant maltreatments, first admissions and readmissions to mental hospitals, admissions to schools for the retarded, persons on the roles of welfare agencies, unemployment, marriage failures, school dropouts, etc. Some of these rates describe casualties, while others describe high-risk groups often associated with mental breakdown and reduced social competence. Most of these categories involve a general social appraisal,
122
THE COMMUNITYMENTALHEALTHJOURNAL
a court appraisal, or a determination by professionals who are not formally part of the mental health professions. Each category is expressed as a rate in which the numerator is a count of cases or events and the denominator is some territorially defined population-at-risk. None of these categories describes anything that very many people would precisely term mental disorder, but taken as a group, the polygraph may be said to "monitor the extrusion routes" from society. A conjoint comment is made upon the effectiveness of mental health services in a whole community. They may indirectly comment on the product delivered by the community mental health treatment apparatus. Certainly each rate is sensitive to many factors, including administrative fiat, and it would be improper to attach meaning to changes in particular categories in an uncritical way. The indices certainly should not be taken seriously as the object being treated but may be considered as statistical approximations to the product as seen from a conventional social distance. What is probably of genuine significance in such a monitoring system is the abrupt covariance of several of these indicators at the same time. Such marked fluctuation, when correlated with major social events, may provide leads to important factors influencing the mental health "climate" of the community, much as the stock market indices reflect major economic and social upheavals in our society. PRODUCTIVITYESTIMATES The development of methods to evaluate return-on-effort includes an emphasis on output and productivity and on the specification of output in objective terms. In addition, there is the requirement of developing a more complete and accurate statement of the cost of various programs and a more complete record of the kinds of activities carried on by staff persons. Such cost-accounting techniques are related to the economic concept of productivity, which is output divided by input. Measures of productivity are just beginning to enter the health and welfare sector, but they need to come in to focus new resources into those activities
that the evidence suggests are most effective. Measures of productivity make a contribution to scientific knowledge, furnish information for the efficient allocation of resources, and help tie the definition of professional competence among the staff to the mission of the Zone Center. For instance, if the management goals of the Zone effort can be defined in operational terms, more precise recognition can be given to the staff for accomplishing difficult goals or goals more congruent with the overall aims of the Zone Center. At a first level of approximation this recognition might be accomplished by assigning weights to various levels of a patient's social competence. A gross Social Competence Scale might include the following categories and weights: 100 points Institutionalized, poor adjustment (patient is "out of contact," or requires special nursing care) 80 points Institutionalized, good adjustment 40 points In the community but requiring professional and financial assistance 15 points In the community, requiring professional guidance only 0 points In the community, not requiring pro. fessional help Thus, a patient who on initial contact had to be institutionalized and required intensive nursing care but was later able to be returned to the community on public assistance, followed by aftercare visits, would have a positive credit of 60 ( 1 0 0 - 4 0 ) change units; an outpatient who required only psychotherapy and later could get on without it would accumulate a positive credit of 15 change units; an outpatient who had to be hospitalized would represent 65 negative change units. By algebraically summing social competence change units over all patients within a group and dividing by the number of man hours invested, an index of effectiveness can be calculated. Similar scales representing the patient's subjective satisfaction or the degree of the family's satisfaction with the patient's performance can be derived. In this scheme, emphasis is placed on the level of reduced social competence associated with mental disorder rather than on the particular quality of the symptoms in-
WILLIAMG. SMITHAND NORMS HANSELL volved. Considerable effort is going into the refinement of social-competence estimates, which will include functioning on the job, family and community relations, and satisfaction which the patient and his family report regarding his adjustment. It is assumed that in evaluating a public health model in the area of mental health the success of management should be based on whether a more acceptable level of social adjustment is achieved by the patient in his community. Unless real improvements in social competence are achieved, community tolerance for the mentally ill and reductions in the average length of institutionalization are unhkely to be sustained. SERVICE PATTERNCOMPARISONS The chief purpose of gathering territorial casualty rates, descriptive monitoring indices, and return.on-effort data is to test the effectiveness of several types of service patterns in reducing chronicity associated with serious mental disorder. To make such tests, it is often necessary to take advantage of cir. cumstances in nature in order to establish controls. For example, in the start-up phase of the H. Douglas Singer Zone Center's operation, it was only possible to provide significant services to about one-third of the total Zone territory. The remainder of the territory continued to be served by the preexisting state hospital system. Such a situation allows an opportunity to determine whether the Zone emphasis on noninstitutional management can achieve better resuits than the existing system of care. Two cohorts, one from the area serviced by the Zone Center and the other from the remainder of the territory, can be followed for a period of five years. It may then be possible to determine whether the mix of brief intensive incare, job training, and community linking efforts will significantly alter the outcome. The changed outcome should be indicated by lowered lengths of hospital stay and raised levels of social competence in seriously disturbed persons. In addition to determining effectiveness, it should also be possible to compare return. on-effort achieved by resources deployed into each of several differing caregiving systems.
123
EVALUATIONOF PREVENTIVEEFFORT At the Singer Zone Center an attempt is being made to identify antecedent high-risk markers associated with later serious mental breakdown or long-term hospitalization. Information on a number of characteristics that are impressionistically linked with high risk of institutionalization is gathered on all patients admitted to outcare, incare, transitional, or home-care services of the Zone Center. These characteristics include such events as recent unemployment, residence in a culturally or economically deprived area, previous hospitalization for mental illness, recent in-migration from a substantially different cultural background, social isolation, etc. Persons with such markers are all considered to be in a state of crisis, with increased psychological stress, threats to the self-identity, and a reduced availability of problem-solving mechanisms. The design of high-risk studies involves two phases: (a) establishing in a systematic way whether or not a suspected high-risk indicator does in fact result in a higher incidence of hospitalization than would be expected in the general population; and (b) testing whether or not an interventional program directed toward such individuals does reduce the incidence. After it has been shown that a particular risk marker frequently occurs prior to the onset of serious disturbance, the next phase of the project would require that a sample of persons with such a potential risk marker, but who are not in treatment, be identified in the community. This can be done through a canvass of various agencies that deal with persons in particular difficulties. For instance, the recently unemployed might be identified through the state employment or workmen's compensation agencies or a survey of persons in deprived circumstances through the Office of Economic Opportunity and the Bureau of the Census. Once such a sample is identified, patient records at the Zone Center and in the case register can reveal whether this group experiences a significantly higher rate of hospitalization and length of stay than the general population. When an indicator proves to be a valid risk marker, a next step would involve de-
124
THE COMMUNITYMENTAL HEALTH JOURNAL
FIGURE 1 DESIGNOFANEXPERIMENTIN PREVENTIO~
High-Risk Group
Special lnterventional Program
No Interventloa Program
A
B
stated as follows: Group B (high-risk without intervention) will have the highest rate of residential care and length of stay, followed, in order, by Group A (high-risk with intervention) and Group C (no risk), which will have the lowest rates. A series of such experiments may well add significant theoretic knowledge regarding the causes and management of mental illness and provide valuable leads for preventive programs. REFERENCES
signing a program of preventive intervention. The design of such an experiment is outlined in Figure 1. A first hypothesis would be that Groups A and B (high-risk groups) will have a higher rate of residential care and length of stay than Group C (riskfree group). A second hypothesis might be
GORWlTZ, K., BAHN, A. K., CHANDLER,C. A., & MARTIN,W. A. Planned uses of a statewide psychiatric register for aiding mental health in t h e the community. Amer. J. Orthopsychiat., 1963, 33, 494-500. MILES, H. C., & GARDNER,E. A. A psychiatric c a s e register. Arch. gen. Psychiat., 1966, 14, 571-580. REID, D. D. Epidemiological methods in the study of mental disorders, Public Health Papers No. 2. Geneva, Switzerland: WHO, 1960.
TERRITORIAL EVALUATION OF MENTAL HEALTH SERVICES WILLIAM G. SMITH, M.D., ~ D NORRIS HANSELL, M.D.*
The current phase of rapid growth in mental health services requires an increased emphasis on the systematic estimation of effectiveness. Serious evaluation requires the specification of goals in measurable categories and the setting up of a data-gatherlng and processing capacity. The argument is advanced that epidemiologic rates describing a variety of types of social disability need to be monitored in order to have a truly territorial description of mental health casualties. Summaries of casualty flow rates in relation to the deployment of resources can lead to useful estimates of productivity, or return-on-effort. The evaluation process has scientific, clinical, and managerial aspects.
At the present time treatment facilities for mental health problems are rapidly expanding throughout the United States. The Mental Health Study Act of 1955, the establishment of the National Institute of Mental Health, and the Community Mental Health Act of 1963 reflect a national interest in mental health with substantial increases in research, manpower training, and services. Much of this increased volume of activity is innovative and exploratory. Such times of rapid and enthusiastic growth are open to the hazard that the worth of a program may be assessed more on the basis of the fervor of the participants than on demonstration of accomplishment. A special emphasis on systematic and continuous evaluation is required if genuine progress is to be made.
While almost no one would take exception to the principle of evaluative research, large-scale action programs do not have an enviable record in carrying through programs of evaluation. There are a variety of reasons for this. Ambitious territorial programs operate without benefit of a carefully controlled laboratory environment. It is difficult to control or even identify all the crucial variables involved. Large-scale un. dertakings typically have multiple and often vaguely defined goals. Even in face of these difficulties, a first approximation to valid knowledge demands that evaluative research be viewed as an essential part of the program. This paper describes the assumptions and goals of a large community mental health center where evaluation is given a high priority.
*Dr. Smith, a psychiatrist, is Assistant Zone Director for Research and Evaluation Services, and Dr. Hansell, a psychiatrist, is the Zone Director for the H. Douglas Singer Zone Center, Illinois Department of Mental Health, Rockford, Ill. 61103. Copies of the core record-keepin$ forms that serve as the data source for the studies described in this paper may be obtained from the authors.
119
120
THE COMMUNITY MENTAL HEALTH JOURNAL THEMES AND EMPHASES
The H. Douglas Singer Zone Center of the Illinois Department of Mental Health is an inpatient, outpatient, and consultative service agency for an area of 10,000 square miles in Northern Illinois. The target population for the Center's services are those who have a high risk of chronic institutionalization associated with mental illness or mental retardation. This group was chosen for special emphasis because it currently contains the most serious and most costly mental disorders in our society. Operationally, the Center has selected the goals of reducing the average duration of hospitalization per capita per year for mental illness and retardation and of maximizing the community functioning of seriously disturbed persons within the 10 counties and 650,000 people which comprise the Zone. There is a delineation of responsibility that includes all citizens within the territory who have seriously reduced social competence and mental illness or retardation. This categorical and territorial definition of the problem orients the Center toward a public health model in the distribution of services, and hence a number of public policy and managerial themes receive emphasis. 1. There is an emphasis on describing the level of community casualties in terms of occurrence in the total population-at-risk rather than in terms of the patients who first come for services or who are receiving services at any particular point in time. The concept of doing the greatest good for the greatest number within the limits of available resources becomes a key notion in the system. 2. There is a corollary emphasis on return-on-effort and on estimates of effectiveness. The central decision-related comparison focuses on output per unit input, or productivity. For example, how many hospitalized patients can be returned to effective citizenship in the community per 100 hours of professional effort? A premium is placed on information that will allow the allocation of resources in a more effective way. Less weight is placed on process (what happened in a particular group therapy ses-
sion) and more weight is attached to outcome (how successful a social adjustment did the patient make after experiencing specified services). 3. Finally, the theme of prevention, or more precise intervention, receives particular attention. This takes the form of early, short-term, crisis-oriented management of problems. Priority is placed on alternatives to institutionalization or the more precise use of institutionalization and/or an active effort to keep the patient linked with his family and resident in the community. Noninstitutional methods for managing mental illness and disability are stressed because of the humanitarian and public costs associated with institutional desocialization. There is emphasis on the identification of high-risk markers, i.e., antecedent events or crises in people's lives that are likely to be associated with later mental breakdown, reduced social competence, and the need for hospitalization. When such a risk marker is identified, various interventional programs can be designed and tested for effectiveness in reducing the rate of institutionalization or hospitalization among high-risk persons in the population. PROGRAMDESCRIPTION
This paper does not cover in more than a suggestive way the description of how the H. Douglas Singer Zone Center plans to achieve the goals and emphases listed above. However, a few points can be mentioned. A substantial portion of staff time is spent in community linking activities. These community activities include: linking a patient and his family, linking different agencies, discussing policy with other agencies, working with citizens' groups to increase funding for mental health services, motivating administrative authorities to accept responsibility for interagency and territorial planning. Particular patients who are at risk of becoming detached from their families or from friendship networks are linked to substitute families, to agencies, to jobs and job skills through the activities of a person called a "mental health rehabilitation expediter." The expediter focuses the activities of many agencies, professionals, and
WILLIAMG. SMITHAND NOI~IS HANSELL
resources within the community onto the particular problems of a specific person with reduced social competence and mental illness or retardation. In addition to the mental health rehabilitation expediter, other new forms of mental health cadre are being developed to carry out the Zone goals, for instance, the "mental health program worker." The program worker is a general purpose, inpatient milieu staff person who has a professional training intermediate in depth between the psychiatrist, social worker, and psychologist on the one hand and the aide and custodial staff on the other. Other technologic features of the H. Douglas Singer Zone Center include transitional services before and after incare through such devices as "spinoff groups" and "pipehne groups." These are group therapy methods in which a group of patients is set up during an inpatient hospitalization and taught how to operate as a crisis-support and counseling system to its members over a period of years, with minimal professional intervention. Interruption of long-term use of state hospitals is stressed through brief, intense inpatient care, associated with home care and noninstitutional support by the same staff involved in the incare phase of management. TERRITORIALDESCRIPTION OF CASUALTYRATES
In line with the themes outlined above, it is necessary to make summary descriptions of the population living within the territory. Epidemiologic methods have particular prominence in such a system (Reid, 1960). Rates in which the numerator is some kind of "case" or event and the denominator is some population-at-risk are common methods for describing the composition of mental health casualties or changes in casualty rates. In order to construct meaningful indices, it is necessary to define precisely what constitutes a case, what are the kinds of cases, and what kinds of events reflect changes in the population that are relevant to the goals of the Singer Zone Center. The territorial case register is a device used to record centrally all mental health
121
treatment contacts with members of a population defined on the basis of residence within a given geographic area (Gorwitz, Bahn, Chandler, & Martin, 1963; Miles & Gardner, 1966). Whether a person went to agency A or practitioner B, whether he received treatment last year or this, whether in the public or private sector, a case register records each event centrally and by person. Matters of confidenti~/lity and restricted access to this information, or reporting only in summarized and anonymous ways, become important issues. The case register provides a method for describing unduplicared counts of mental health casualties, their distribution in various segments of the population, the longitudinal course of various disorders, as well as the patterns of care and the effectiveness of different modes of intervention. Casualty flow rates at two points in time or comparisons of portions of the territory with differing resource patterns at the same time provide alternative methods for assessing the effectiveness of a network of mental health services. Such investigations involve the collection of data on flow rates for a given group of agencies that service the people who live in a particular territory. As with case registers, it is important to document concomitantly increases or decreases in the general population due to births, deaths, and migration. Another example of the description of mental disorders in a community is the "territorial polygraph." This is a multiple line graph that simultaneously depicts a number of parameters that have relevance to mental health, plotted at monthly or quarterly intervals. Examples of relevant rates might include the following: homicides, predatory crimes, imprisonments, infant maltreatments, first admissions and readmissions to mental hospitals, admissions to schools for the retarded, persons on the roles of welfare agencies, unemployment, marriage failures, school dropouts, etc. Some of these rates describe casualties, while others describe high-risk groups often associated with mental breakdown and reduced social competence. Most of these categories involve a general social appraisal,
122
THE COMMUNITYMENTALHEALTHJOURNAL
a court appraisal, or a determination by professionals who are not formally part of the mental health professions. Each category is expressed as a rate in which the numerator is a count of cases or events and the denominator is some territorially defined population-at-risk. None of these categories describes anything that very many people would precisely term mental disorder, but taken as a group, the polygraph may be said to "monitor the extrusion routes" from society. A conjoint comment is made upon the effectiveness of mental health services in a whole community. They may indirectly comment on the product delivered by the community mental health treatment apparatus. Certainly each rate is sensitive to many factors, including administrative fiat, and it would be improper to attach meaning to changes in particular categories in an uncritical way. The indices certainly should not be taken seriously as the object being treated but may be considered as statistical approximations to the product as seen from a conventional social distance. What is probably of genuine significance in such a monitoring system is the abrupt covariance of several of these indicators at the same time. Such marked fluctuation, when correlated with major social events, may provide leads to important factors influencing the mental health "climate" of the community, much as the stock market indices reflect major economic and social upheavals in our society. PRODUCTIVITYESTIMATES The development of methods to evaluate return-on-effort includes an emphasis on output and productivity and on the specification of output in objective terms. In addition, there is the requirement of developing a more complete and accurate statement of the cost of various programs and a more complete record of the kinds of activities carried on by staff persons. Such cost-accounting techniques are related to the economic concept of productivity, which is output divided by input. Measures of productivity are just beginning to enter the health and welfare sector, but they need to come in to focus new resources into those activities
that the evidence suggests are most effective. Measures of productivity make a contribution to scientific knowledge, furnish information for the efficient allocation of resources, and help tie the definition of professional competence among the staff to the mission of the Zone Center. For instance, if the management goals of the Zone effort can be defined in operational terms, more precise recognition can be given to the staff for accomplishing difficult goals or goals more congruent with the overall aims of the Zone Center. At a first level of approximation this recognition might be accomplished by assigning weights to various levels of a patient's social competence. A gross Social Competence Scale might include the following categories and weights: 100 points Institutionalized, poor adjustment (patient is "out of contact," or requires special nursing care) 80 points Institutionalized, good adjustment 40 points In the community but requiring professional and financial assistance 15 points In the community, requiring professional guidance only 0 points In the community, not requiring pro. fessional help Thus, a patient who on initial contact had to be institutionalized and required intensive nursing care but was later able to be returned to the community on public assistance, followed by aftercare visits, would have a positive credit of 60 ( 1 0 0 - 4 0 ) change units; an outpatient who required only psychotherapy and later could get on without it would accumulate a positive credit of 15 change units; an outpatient who had to be hospitalized would represent 65 negative change units. By algebraically summing social competence change units over all patients within a group and dividing by the number of man hours invested, an index of effectiveness can be calculated. Similar scales representing the patient's subjective satisfaction or the degree of the family's satisfaction with the patient's performance can be derived. In this scheme, emphasis is placed on the level of reduced social competence associated with mental disorder rather than on the particular quality of the symptoms in-
WILLIAMG. SMITHAND NORMS HANSELL volved. Considerable effort is going into the refinement of social-competence estimates, which will include functioning on the job, family and community relations, and satisfaction which the patient and his family report regarding his adjustment. It is assumed that in evaluating a public health model in the area of mental health the success of management should be based on whether a more acceptable level of social adjustment is achieved by the patient in his community. Unless real improvements in social competence are achieved, community tolerance for the mentally ill and reductions in the average length of institutionalization are unhkely to be sustained. SERVICE PATTERNCOMPARISONS The chief purpose of gathering territorial casualty rates, descriptive monitoring indices, and return.on-effort data is to test the effectiveness of several types of service patterns in reducing chronicity associated with serious mental disorder. To make such tests, it is often necessary to take advantage of cir. cumstances in nature in order to establish controls. For example, in the start-up phase of the H. Douglas Singer Zone Center's operation, it was only possible to provide significant services to about one-third of the total Zone territory. The remainder of the territory continued to be served by the preexisting state hospital system. Such a situation allows an opportunity to determine whether the Zone emphasis on noninstitutional management can achieve better resuits than the existing system of care. Two cohorts, one from the area serviced by the Zone Center and the other from the remainder of the territory, can be followed for a period of five years. It may then be possible to determine whether the mix of brief intensive incare, job training, and community linking efforts will significantly alter the outcome. The changed outcome should be indicated by lowered lengths of hospital stay and raised levels of social competence in seriously disturbed persons. In addition to determining effectiveness, it should also be possible to compare return. on-effort achieved by resources deployed into each of several differing caregiving systems.
123
EVALUATIONOF PREVENTIVEEFFORT At the Singer Zone Center an attempt is being made to identify antecedent high-risk markers associated with later serious mental breakdown or long-term hospitalization. Information on a number of characteristics that are impressionistically linked with high risk of institutionalization is gathered on all patients admitted to outcare, incare, transitional, or home-care services of the Zone Center. These characteristics include such events as recent unemployment, residence in a culturally or economically deprived area, previous hospitalization for mental illness, recent in-migration from a substantially different cultural background, social isolation, etc. Persons with such markers are all considered to be in a state of crisis, with increased psychological stress, threats to the self-identity, and a reduced availability of problem-solving mechanisms. The design of high-risk studies involves two phases: (a) establishing in a systematic way whether or not a suspected high-risk indicator does in fact result in a higher incidence of hospitalization than would be expected in the general population; and (b) testing whether or not an interventional program directed toward such individuals does reduce the incidence. After it has been shown that a particular risk marker frequently occurs prior to the onset of serious disturbance, the next phase of the project would require that a sample of persons with such a potential risk marker, but who are not in treatment, be identified in the community. This can be done through a canvass of various agencies that deal with persons in particular difficulties. For instance, the recently unemployed might be identified through the state employment or workmen's compensation agencies or a survey of persons in deprived circumstances through the Office of Economic Opportunity and the Bureau of the Census. Once such a sample is identified, patient records at the Zone Center and in the case register can reveal whether this group experiences a significantly higher rate of hospitalization and length of stay than the general population. When an indicator proves to be a valid risk marker, a next step would involve de-
124
THE COMMUNITYMENTAL HEALTH JOURNAL
FIGURE 1 DESIGNOFANEXPERIMENTIN PREVENTIO~
High-Risk Group
Special lnterventional Program
No Interventloa Program
A
B
stated as follows: Group B (high-risk without intervention) will have the highest rate of residential care and length of stay, followed, in order, by Group A (high-risk with intervention) and Group C (no risk), which will have the lowest rates. A series of such experiments may well add significant theoretic knowledge regarding the causes and management of mental illness and provide valuable leads for preventive programs. REFERENCES
signing a program of preventive intervention. The design of such an experiment is outlined in Figure 1. A first hypothesis would be that Groups A and B (high-risk groups) will have a higher rate of residential care and length of stay than Group C (riskfree group). A second hypothesis might be
GORWlTZ, K., BAHN, A. K., CHANDLER,C. A., & MARTIN,W. A. Planned uses of a statewide psychiatric register for aiding mental health in t h e the community. Amer. J. Orthopsychiat., 1963, 33, 494-500. MILES, H. C., & GARDNER,E. A. A psychiatric c a s e register. Arch. gen. Psychiat., 1966, 14, 571-580. REID, D. D. Epidemiological methods in the study of mental disorders, Public Health Papers No. 2. Geneva, Switzerland: WHO, 1960.
