The Therapeutic Community Inpatient Ward: Does it Really Work? Anthony Lehman and Barry Ritzier
I
N the “therapeutic community” approach to inpatient treatment,‘.2 patients are viewed as socially, as well as psychologically, disabled, and the “therapeutic milieu” is designed to teach more effective social skills and provide a better emotional basis for work functioning. This treatment approach differs significantly from the medically oriented treatment programs aimed primarily at the elimination or alteration of “symptoms.” The present study covers the testing of three hypotheses. (1) The social-therapeutic structure of a community-oriented psychiatric ward when compared with a medical model ward provides an atmosphere with greater involvement, increased patient autonomy, and more practical treatment orientation. (2) The communityoriented program is more satisfactory to its members (patients and staff) than a medical model program is to its members. (3) Treatment is more effective on a community-oriented ward. MATERIALS AND METHODS
Setting Member satisfaction and ward atmosphere were measured by administering Real and Ideal forms 01 the Community Oriented Program Environment Scale3.‘1 to patients and staff on two wards: ( I ) a psychiatric ward with a therapeutic community approach to treatment (Ward A) and (2) a more traditional medically oriented psychiatric ward (Ward B). Both wards are inpatient units at a university hospital that serves the metropolitan and suburban populations of Rochester, New York and the surrounding counties. In terms of physical facilities, staffing, and patient assignment, the two psychiatric wards are essentially identical. Each unit serves a maximum of 22 male and female patients who are admitted randomly to the wards according to bed supply and demand. The average number of patients on each ward at a given time is 21. The admission rate on Ward A is approximately 384 patients per year with an average tenure of 21 days: while on Ward B, the admission rate is 454 patients per year with an average tenure of I8 days. On both psychiatric wards, the staff and patients are divided into two teams with each staff primarily responsible for the care of the patients on their team. Staff-patient team meetings. generally devoted to group issues and dynamics, are held three times weekly on Ward A and twice weekly on Ward B. The staff members on each team hold planning sessions approximately three times per week. In addition to these team meetings both wards have daily nursing reports and weekly general staff meetings. The community-oriented ward (Ward A) also has daily morning patient--staff community meetings at which ward issues and community policies are discussed, as well as another weekly community meeting, a weekly staff group dynamics workshop, and a monthly patient alumni meeting. There are no meetings comparable to these on the medically oriented ward (Ward B). The chief administrator on each ward was asked to submit a statement of treatment philosophy for his own unit. Because these add a valuable dimension to the ward descriptions, they are quoted below.
From the University of Rochesler Medical School, Rochester. N. Y. Anthony Lehman, M.D.: Honors Fellow. University of Rochester Medical School; Barry Ritzier. Ph.D.: Assistani Professor, Department of Psychiatry, Univrrsiry of Rochester Medical Center. Reprint requests should be addressed to Dr. Barry Ritzier. Department of Psychiatry. University o/ Rochester Medical Center. 300 Crittenden Boulevard, Rochester. N. Y. 14642. c 1976 by Grune &Stratton, Inc. Comprehensrve Psychiatry, Vol. 17, No 6 (November/December).
1976
755
756
LEHMAN
Table 1. Characteristics
of Staff Members
AND
RITZLER
Surveyed Ward
Staff Position(#I
A
(1) MDs (2) Nurses
B
6
6
15
15
8
8
4
4 1
(3)
Nursing assistants
(4)
Specialized therapists (activities, physical, etc
(51
Social worker
1
(6)
Psychologist
1
1
(7)
Other
2
2
)
Mean age (years)
26.4 (20-41)
Male:female ratio
17:20
16:21
Mean tenure (months)
16.3 (l-60)
36.0 (3-258)
28.3 (22-60)
Neither of the administrators was aware of the hypotheses nor intent of the study at the time the descriptions were written. “(Ward A) is a therapeutic community in statu nascendi, where Ward A (therapeutic community). we attempt to utilize in a therapeutic way the interactions between patients and patients and patients and staff. To this end, frequent meetings are held on the floor and patients and staff are strongly encouraged to take an active role in helping each other. This assignment of responsibility, along with our attempts to minimize infantilization, dependence on staff and regression, probably are the features which most distinguish (Ward A) from the other inpatient floors. As much as possible, we also attempt to give patients a role in the development of community policies and organization.” “The therapeutic approach and philosophy of (Ward B) is Ward B (medically oriented treatment). essentially eclectic; a variety of modalities is utilized. Pharmocotherapy is perhaps stressed a bit more on this floor than elsewhere in the department, although certainly family therapy, group therapy, insight oriented approaches and behavior modification all constitute significant components of our therapeutic armamentarium.”
Assessment of Ward Atmosphere Moo$~ has developed two very similar scales for assessing psychiatric treatment environments: the Ward Atmosphere Scale,3 designed for inpatient programs, and the Community-Oriented Program Environment Scale4 for transitional community-oriented treatment programs. The Community Oriented Program Environment Scale (COPES) was adapted from the Ward Atmosphere Scale (WAS), and the two scales are directly parallel, having the same categories for comparison. Since the wording of the COPES is designed specifically for community-oriented programs, it was used in this study. The test-retest reliability and profile stability of the WAS and COPES are substantial and have been discussed thoroughly elsewhere.S Subjects were asked to complete form C (real) and form I (ideal) of COPES in order to assess their perceptions of the existing programs and conceptions about ideal programs. Each of these forms consists of 102 statements about treatment environments that are rated as true or false by the subjects. The items are divided into ten subscales that represent various dimensions of treatment environments. Three of these subscales were designed to measure relationship dimensions-involvement, spontaneity, anger, and aggression. Four other subscales described various aspects of the treatment program-support, practical orientation, and personal problem orientation. The remaining four relate to administrative structure-patient autonomy, order and organization, clarity and staff control. Detailed definitions of the ten scales can be found in MOOS.~ Member satisfaction was measured by the reciprocal of the mean difference between real and ideal scores for each scale of the COPES. Since the difference between real and ideal scores is an inverse measure of satisfaction (i.e., the greater the satisfaction, the smaller the difference), the reciprocal measure was used so that a larger score represents greater satisfaction. To compare treatment effectiveness of the psychiatric wards, readmission rates and discharges against medical advice were tallied for a l-year period constituting the first year of operation of the community-oriented program. Hospital record summaries provided by the medical records department made such a tally possible.3
COMMUNITY
INPATIENT
757
WARD
Subjects The subjects in the study include staff members and patientson the wards previously described. Subjects completed the questionnaires privately and returned them anonymously. Approximately IO% 20% of the patients were not asked to participate because of the severity of their illnesses. e.g.. active psychosis, aphasia, or delirium. Hence, the results reported for the patients consists mostly of the views and perceptions of the less disturbed patients. The response rates for both staff groups are high, but those for the patient groups are lower and more variable between the wards, with Ward A showing the largest patient response. These rates were comparable to those of previous studies with the WAS, which have reported rates of 70% 85% for staff and 45% 75% for patients. Table I summarizes the job-related characteristics of the statf members participating
in the survey. R ESU LTS
Perceived
Ward A tmosphere (Real Ratings i
The real scores on the Community Oriented Program Environment Scale (COPES) were analyzed by a two-way (wards x categories), repeated measures analysis of variance,6 with COPES categories as the repeated measure. The results of the analysis revealed significant main effects for wards (p < .05) and significant interaction effects for ward x categories (p < .Ol). The differences between Wards A and B are further delineated by the results of the individual comparisons of the ward x categories interaction scores. Ward A rated significantly higher (p < .05) than Ward B on categories involvement, autonomy, practical orientation, and anger and aggression. Likewise, Ward A rated significantly lower than Ward B on the category order and organization. The only variations from the A # B trend were on categories clarity, support, spontaneity, and staff control, where there were no differences between wards. Satisfaction Scores Satisfaction scores were analyzed by a three-way (wards x status x categories), repeated measures analysis of variance with categories as the repeated variable. The results of the analysis revealed significant main effects for ward (p < .OOl) and categories (p < ,001) and significant interaction terms for wards x categories (p < .OOl). The main effect for status (patients versus staff) was not significant. Table 2 summarizes the satisfaction scores for wards by categories. Treatment Efectiveness Readmission rates and frequency of discharges against medical advice were checked for 385 patients on the community-oriented ward and 443 patients on the medical model ward. Table 3 presents a summary of readmission rates for all patients combined and four major diagnostic categories. Inspection of the table reveals a significantly higher overall readmission rate for the community-oriented ward (x’ = 4.70, df = 1). Further inspection of the table reveals a large difference in readmission rates for neurotic patients with the rate for the communityoriented ward twice as high as the rate for the medical model ward (x’ = 4.02, df = 1). There were no differences between the psychiatric wards for overall frequency of discharges against medical advice (7% for the community-oriented ward and 5% for the medical model ward). The frequencies for diagnostic categories showed
758
LEHMAN
Table2.
COPES Satisfaction
AND RITZLER
Scores: Wards x COPES Categories Ward
A
B
Community
Category
Medical
Individual Comparisons
Model
Involvement
0.419’
0.196
A>
Support
0.556
0.459
No difference
Spontaneity
0.474
0.362
A>B
Autonomy
0.578
0.301
A>
0.419
0.282
B>A
0.730
0.700
No difference
2.127
0.529
A>B
B
B
Practical orientation Personal problem orientation Anger and aggression Order and 0.556
0.562
No difference
Clarity
0.340
0.281
A>
Staff control
1.163
0.787
A>
B
Ward totals
0.559
0.381
A>
B
organization
B
*Satisfaction scores were obtained by calculating the reciprocal of the mean difference between real and ideal scores.
one significant difference, however. Character disorder patients left against medical advice significantly more often on the community-oriented ward (13% AMA discharge rate on the community ward versus 5% on the medical model ward, x2 = 4.37, df = 1, p < .05). There were no differences for the other diagnostic categories. DISCUSSION
Perceived
Ward A tmosphere
Members of a community-oriented inpatient ward perceived more involvement among members, greater opportunity for autonomy, more emphasis on a practical orientation to treatment, and a greater expression of anger and aggression than was perceived by members of the medical model ward. In contrast, members of the medical model ward perceived more order and organization in their ward atmosphere. These results suggest that an inpatient treatment program that stresses a community orientation sacrifices the appearance of a smooth-running, orderly environment in pursuit of increased human contact, enhanced self-expression, and a more practical, everyday life orientation. This is consistent with the rationale behind a community “therapeutic milieu” orientation that states that one of the drawbacks of a medically oriented psychiatric inpatient Table 3. Readmission
Rates for Wards by Diagnostic Categories
Communny
Medical
Model
X2 Results
Diagnosis
Ward
All patients
26%
19%
p < 0.05
Neurotics
33%
16%
p < 0.05
Psychotics
29%
23%
NS
Character disorder
26%
20%
NS
Other
16%
15%
NS
NS. not significant.
Ward
COMMUNITY
INPATIENT
WARD
759
ward is that too much emphasis is placed on keeping the patients “in line” and Instead, the community-oriented prohibiting so-called “inappropriate behavior.” approach takes a more positive route in encouraging social involvement, selfexpression, and responsible action. A second important finding of this study is that there was no difference between patients and staff members in their perceptions of ward atmosphere. This lends credibility to the assumption that the results of the COPES scale represent a generally agreed upon statement as to what it is like to experience life on a psychiatric inpatient ward. There is a popular tendency to believe that patients and staff members perceive events differently because of their different role functions. but the results of the present study do not support this hypothesis. Satisfaction Scores The satisfaction scores for ward x categories clearly support the hypothesis that there will be greater member satisfaction on community-oriented psychiatric wards than on traditionally medically oriented settings. For nearly every COPES category, the community-oriented ward reported significantly more satisfaction than the medical model ward. While evidence of member satisfaction does not necessarily herald a successful (i.e., curative) treatment program, there is logic in assuming that a sense of satisfaction is a welcome product as well as useful catalyst for work toward further progress in successful treatment programs. Perhaps the most convincing result is that in no instance (i.e., for no COPES scoring category) was the medical model ward more satisfied than the communityoriented ward. Such pervasive lower satisfaction is certainly suggestive of lower morale and confidence in the treatment program. A possible alternate interpretation of the data is that elements of ward atmosphere measured by the COPES scale are unimportant in a treatment program aimed at symptom reduction and that the wrong questions have been asked to gauge satisfaction. The results of ongoing outcome studies on the two psychiatric wards should help to determine if member satisfaction on the COPES categories is related to successful treatment. As a word of caution it should be noted that the results of this study are only as valid and comprehensive as the questions asked in the COPES questionnaire. While this procedure has established credibility,l there are undoubtedly areas of ward atmosphere that are untapped by the 102 questions in the test booklet. In addition, it bears repeating that the most severely disturbed patients were not able to participate in the study. It is conceivable that the perceived atmosphere and the degree of satisfaction for these patients might provide a somewhat different pattern of results. The higher overall readmission rate for the community-oriented ward suggests that this inpatient treatment approach was not very effectivein preventing serious reoccurrence of symptoms following discharge. In a large follow-up study in Great Britain. Freeman and Simmons’ presented evidence that demonstrated that high readmission rates do not necessarily mean that treatment has failed. Freeman and Simmons argued that patients who leave the hospital to become actively involved in potentially rewarding life situations (e.g., work, marriage, friendship) are more likely to encounter recurring increases in stress and may require more frequent rehospitalization than patients who withdraw to sheltered, marginally rewarding situations upon discharge. Indeed, the high involvement, autonomy-encouraging
760
LEHMAN
AND
RITZLER
environment of a community-oriented ward is likely to persuade patients to seek more active and independent situations when they leave the hospital, thereby placing themselves at higher risk for readmission. Palmer and McGuireB have suggested that effective psychiatric wards provide patients with beneficial treatment experiences, thereby increasing the likelihood that they will return to the same setting when problems recur following discharge; correspondingly, the results that show neurotic patients returning more frequently after discharge from a community-oriented psychiatric ward perhaps can be attributed to the higher overall satisfaction reported by patients and staff on this ward. Neurotic patients tend to be dependent, lacking in confidence, and in need of support and encouragement. Consequently, they are likely to be more inclined to return to a high-involvement, supportive treatment setting when symptoms recur after discharge. On the other hand, we do not want to give the impression that we feel such results are particularly desirable for a treatment program. We think it behooves the advocates of a community-oriented approach to attend to the uncomfortably high readmission rates, especially for neurotics, observed in this study. Not all patient types showed higher readmission rates following hospitalization on a community-oriented ward, suggesting that the community approach has differential effects on different types of patients. The higher AMA discharge rate for character disorder patients also implies that patients’ diagnostic characteristics interact with inpatient treatment approach. It appears that the more open, free-wheeling atmosphere of the community-oriented ward may not be a good match for the impulsive, acting-out individual with sociopathic tendencies. Perhaps a patient must possess a certain base level of social cooperation and concern for the community-oriented treatment to be effective. Again, a community-oriented program might seek to modify the approach to better integrate the character disorder patient into the treatment atmosphere. In answer to the original question, “Does the therapeutic community inpatient ward really work?” the present study appears to provide a qualified “yes.” The community treatment approach resulted in a perceived ward atmosphere that provided more involvement, autonomy, and practical orientation than the perceived atmosphere on a traditional medically oriented ward. More importantly, patients and staff alike appear to be more satisfied with most aspects of a community-oriented program. On the other hand, higher readmission rates and more AMA discharges for character disorder patients indicate the need for modification in the community-oriented technique. SUMMARY
This study compared ward atmosphere, member satisfaction, and treatment effectiveness on community-oriented and medical model psychiatric inpatient wards. The method used for comparison was the Community Oriented Program Environment Scale (COPES) developed by Moos. The results showed that the community-oriented ward has greater patient autonomy, interpersonal involvement, and practical orientation than the medical model ward, whereas the medical model ward shows more order and organization. These results suggest that a community orientation sacrifices the appearance of an orderly ward for increased
COMMUNITY
INPATIENT
761
WARD
patient activity and involvement. In addition, the members of the communityoriented ward showed significantly greater satisfaction than the members of the medical model ward, suggesting that the community approach is more effective at creating a helpful level of morale and confidence in the treatment approach. A check of hospital records revealed that neurotics treated on the communityoriented ward were readmitted twice as frequently as neurotics on the medical model ward. Also, character disorder patients left the hospital against medical advice more frequently on the community-oriented ward. ACKNOWLEDGMENT The authors wish to thank Mrs. ArleneTitus assistanceon this work.
and her staRat
the Strong
Memorial
Hospital
for their
programs.
J Abnorm
Psycho1 79:9
REFERENCES I. Mechanic
D: Sociological issues in mental health, in: Public Expectations and Health Care. New York, Wiley-lnterscience, 1972 2. Nagi SZ: Some conceptual issues in disability and rehabilitation, in Susman M (ed): Sociology and Rehabilitation. Washington, American Sociological Association, 1966 3. Moos RH, Houts PS: Assessment of the social atmospheres of psychiatric wards. J Abnorm Psycho1 73:595604, 1968 4. Moos R: Assessment of the psychosocial environments of community-oriented psychiatric
treatment 1912
IX.
5. Sidman J. Moos R: On the relation between psychiatric ward atmosphere and helping behavior. J Clin Psycho1 29:74 78. 1973 6. Winer BJ: Statistical Principles in Experimental Design. New York, McGraw-Hill, 1962 7. Freeman H, Simmons 0: The Mental Patient Comes Home. New York, Wiley, 1963 8. Palmer J, McGuire F: The use of unobtrusive measures in mental health research. J Clin Consult Psycho1 40:431 436, 1973
I
N the “therapeutic community” approach to inpatient treatment,‘.2 patients are viewed as socially, as well as psychologically, disabled, and the “therapeutic milieu” is designed to teach more effective social skills and provide a better emotional basis for work functioning. This treatment approach differs significantly from the medically oriented treatment programs aimed primarily at the elimination or alteration of “symptoms.” The present study covers the testing of three hypotheses. (1) The social-therapeutic structure of a community-oriented psychiatric ward when compared with a medical model ward provides an atmosphere with greater involvement, increased patient autonomy, and more practical treatment orientation. (2) The communityoriented program is more satisfactory to its members (patients and staff) than a medical model program is to its members. (3) Treatment is more effective on a community-oriented ward. MATERIALS AND METHODS
Setting Member satisfaction and ward atmosphere were measured by administering Real and Ideal forms 01 the Community Oriented Program Environment Scale3.‘1 to patients and staff on two wards: ( I ) a psychiatric ward with a therapeutic community approach to treatment (Ward A) and (2) a more traditional medically oriented psychiatric ward (Ward B). Both wards are inpatient units at a university hospital that serves the metropolitan and suburban populations of Rochester, New York and the surrounding counties. In terms of physical facilities, staffing, and patient assignment, the two psychiatric wards are essentially identical. Each unit serves a maximum of 22 male and female patients who are admitted randomly to the wards according to bed supply and demand. The average number of patients on each ward at a given time is 21. The admission rate on Ward A is approximately 384 patients per year with an average tenure of 21 days: while on Ward B, the admission rate is 454 patients per year with an average tenure of I8 days. On both psychiatric wards, the staff and patients are divided into two teams with each staff primarily responsible for the care of the patients on their team. Staff-patient team meetings. generally devoted to group issues and dynamics, are held three times weekly on Ward A and twice weekly on Ward B. The staff members on each team hold planning sessions approximately three times per week. In addition to these team meetings both wards have daily nursing reports and weekly general staff meetings. The community-oriented ward (Ward A) also has daily morning patient--staff community meetings at which ward issues and community policies are discussed, as well as another weekly community meeting, a weekly staff group dynamics workshop, and a monthly patient alumni meeting. There are no meetings comparable to these on the medically oriented ward (Ward B). The chief administrator on each ward was asked to submit a statement of treatment philosophy for his own unit. Because these add a valuable dimension to the ward descriptions, they are quoted below.
From the University of Rochesler Medical School, Rochester. N. Y. Anthony Lehman, M.D.: Honors Fellow. University of Rochester Medical School; Barry Ritzier. Ph.D.: Assistani Professor, Department of Psychiatry, Univrrsiry of Rochester Medical Center. Reprint requests should be addressed to Dr. Barry Ritzier. Department of Psychiatry. University o/ Rochester Medical Center. 300 Crittenden Boulevard, Rochester. N. Y. 14642. c 1976 by Grune &Stratton, Inc. Comprehensrve Psychiatry, Vol. 17, No 6 (November/December).
1976
755
756
LEHMAN
Table 1. Characteristics
of Staff Members
AND
RITZLER
Surveyed Ward
Staff Position(#I
A
(1) MDs (2) Nurses
B
6
6
15
15
8
8
4
4 1
(3)
Nursing assistants
(4)
Specialized therapists (activities, physical, etc
(51
Social worker
1
(6)
Psychologist
1
1
(7)
Other
2
2
)
Mean age (years)
26.4 (20-41)
Male:female ratio
17:20
16:21
Mean tenure (months)
16.3 (l-60)
36.0 (3-258)
28.3 (22-60)
Neither of the administrators was aware of the hypotheses nor intent of the study at the time the descriptions were written. “(Ward A) is a therapeutic community in statu nascendi, where Ward A (therapeutic community). we attempt to utilize in a therapeutic way the interactions between patients and patients and patients and staff. To this end, frequent meetings are held on the floor and patients and staff are strongly encouraged to take an active role in helping each other. This assignment of responsibility, along with our attempts to minimize infantilization, dependence on staff and regression, probably are the features which most distinguish (Ward A) from the other inpatient floors. As much as possible, we also attempt to give patients a role in the development of community policies and organization.” “The therapeutic approach and philosophy of (Ward B) is Ward B (medically oriented treatment). essentially eclectic; a variety of modalities is utilized. Pharmocotherapy is perhaps stressed a bit more on this floor than elsewhere in the department, although certainly family therapy, group therapy, insight oriented approaches and behavior modification all constitute significant components of our therapeutic armamentarium.”
Assessment of Ward Atmosphere Moo$~ has developed two very similar scales for assessing psychiatric treatment environments: the Ward Atmosphere Scale,3 designed for inpatient programs, and the Community-Oriented Program Environment Scale4 for transitional community-oriented treatment programs. The Community Oriented Program Environment Scale (COPES) was adapted from the Ward Atmosphere Scale (WAS), and the two scales are directly parallel, having the same categories for comparison. Since the wording of the COPES is designed specifically for community-oriented programs, it was used in this study. The test-retest reliability and profile stability of the WAS and COPES are substantial and have been discussed thoroughly elsewhere.S Subjects were asked to complete form C (real) and form I (ideal) of COPES in order to assess their perceptions of the existing programs and conceptions about ideal programs. Each of these forms consists of 102 statements about treatment environments that are rated as true or false by the subjects. The items are divided into ten subscales that represent various dimensions of treatment environments. Three of these subscales were designed to measure relationship dimensions-involvement, spontaneity, anger, and aggression. Four other subscales described various aspects of the treatment program-support, practical orientation, and personal problem orientation. The remaining four relate to administrative structure-patient autonomy, order and organization, clarity and staff control. Detailed definitions of the ten scales can be found in MOOS.~ Member satisfaction was measured by the reciprocal of the mean difference between real and ideal scores for each scale of the COPES. Since the difference between real and ideal scores is an inverse measure of satisfaction (i.e., the greater the satisfaction, the smaller the difference), the reciprocal measure was used so that a larger score represents greater satisfaction. To compare treatment effectiveness of the psychiatric wards, readmission rates and discharges against medical advice were tallied for a l-year period constituting the first year of operation of the community-oriented program. Hospital record summaries provided by the medical records department made such a tally possible.3
COMMUNITY
INPATIENT
757
WARD
Subjects The subjects in the study include staff members and patientson the wards previously described. Subjects completed the questionnaires privately and returned them anonymously. Approximately IO% 20% of the patients were not asked to participate because of the severity of their illnesses. e.g.. active psychosis, aphasia, or delirium. Hence, the results reported for the patients consists mostly of the views and perceptions of the less disturbed patients. The response rates for both staff groups are high, but those for the patient groups are lower and more variable between the wards, with Ward A showing the largest patient response. These rates were comparable to those of previous studies with the WAS, which have reported rates of 70% 85% for staff and 45% 75% for patients. Table I summarizes the job-related characteristics of the statf members participating
in the survey. R ESU LTS
Perceived
Ward A tmosphere (Real Ratings i
The real scores on the Community Oriented Program Environment Scale (COPES) were analyzed by a two-way (wards x categories), repeated measures analysis of variance,6 with COPES categories as the repeated measure. The results of the analysis revealed significant main effects for wards (p < .05) and significant interaction effects for ward x categories (p < .Ol). The differences between Wards A and B are further delineated by the results of the individual comparisons of the ward x categories interaction scores. Ward A rated significantly higher (p < .05) than Ward B on categories involvement, autonomy, practical orientation, and anger and aggression. Likewise, Ward A rated significantly lower than Ward B on the category order and organization. The only variations from the A # B trend were on categories clarity, support, spontaneity, and staff control, where there were no differences between wards. Satisfaction Scores Satisfaction scores were analyzed by a three-way (wards x status x categories), repeated measures analysis of variance with categories as the repeated variable. The results of the analysis revealed significant main effects for ward (p < .OOl) and categories (p < ,001) and significant interaction terms for wards x categories (p < .OOl). The main effect for status (patients versus staff) was not significant. Table 2 summarizes the satisfaction scores for wards by categories. Treatment Efectiveness Readmission rates and frequency of discharges against medical advice were checked for 385 patients on the community-oriented ward and 443 patients on the medical model ward. Table 3 presents a summary of readmission rates for all patients combined and four major diagnostic categories. Inspection of the table reveals a significantly higher overall readmission rate for the community-oriented ward (x’ = 4.70, df = 1). Further inspection of the table reveals a large difference in readmission rates for neurotic patients with the rate for the communityoriented ward twice as high as the rate for the medical model ward (x’ = 4.02, df = 1). There were no differences between the psychiatric wards for overall frequency of discharges against medical advice (7% for the community-oriented ward and 5% for the medical model ward). The frequencies for diagnostic categories showed
758
LEHMAN
Table2.
COPES Satisfaction
AND RITZLER
Scores: Wards x COPES Categories Ward
A
B
Community
Category
Medical
Individual Comparisons
Model
Involvement
0.419’
0.196
A>
Support
0.556
0.459
No difference
Spontaneity
0.474
0.362
A>B
Autonomy
0.578
0.301
A>
0.419
0.282
B>A
0.730
0.700
No difference
2.127
0.529
A>B
B
B
Practical orientation Personal problem orientation Anger and aggression Order and 0.556
0.562
No difference
Clarity
0.340
0.281
A>
Staff control
1.163
0.787
A>
B
Ward totals
0.559
0.381
A>
B
organization
B
*Satisfaction scores were obtained by calculating the reciprocal of the mean difference between real and ideal scores.
one significant difference, however. Character disorder patients left against medical advice significantly more often on the community-oriented ward (13% AMA discharge rate on the community ward versus 5% on the medical model ward, x2 = 4.37, df = 1, p < .05). There were no differences for the other diagnostic categories. DISCUSSION
Perceived
Ward A tmosphere
Members of a community-oriented inpatient ward perceived more involvement among members, greater opportunity for autonomy, more emphasis on a practical orientation to treatment, and a greater expression of anger and aggression than was perceived by members of the medical model ward. In contrast, members of the medical model ward perceived more order and organization in their ward atmosphere. These results suggest that an inpatient treatment program that stresses a community orientation sacrifices the appearance of a smooth-running, orderly environment in pursuit of increased human contact, enhanced self-expression, and a more practical, everyday life orientation. This is consistent with the rationale behind a community “therapeutic milieu” orientation that states that one of the drawbacks of a medically oriented psychiatric inpatient Table 3. Readmission
Rates for Wards by Diagnostic Categories
Communny
Medical
Model
X2 Results
Diagnosis
Ward
All patients
26%
19%
p < 0.05
Neurotics
33%
16%
p < 0.05
Psychotics
29%
23%
NS
Character disorder
26%
20%
NS
Other
16%
15%
NS
NS. not significant.
Ward
COMMUNITY
INPATIENT
WARD
759
ward is that too much emphasis is placed on keeping the patients “in line” and Instead, the community-oriented prohibiting so-called “inappropriate behavior.” approach takes a more positive route in encouraging social involvement, selfexpression, and responsible action. A second important finding of this study is that there was no difference between patients and staff members in their perceptions of ward atmosphere. This lends credibility to the assumption that the results of the COPES scale represent a generally agreed upon statement as to what it is like to experience life on a psychiatric inpatient ward. There is a popular tendency to believe that patients and staff members perceive events differently because of their different role functions. but the results of the present study do not support this hypothesis. Satisfaction Scores The satisfaction scores for ward x categories clearly support the hypothesis that there will be greater member satisfaction on community-oriented psychiatric wards than on traditionally medically oriented settings. For nearly every COPES category, the community-oriented ward reported significantly more satisfaction than the medical model ward. While evidence of member satisfaction does not necessarily herald a successful (i.e., curative) treatment program, there is logic in assuming that a sense of satisfaction is a welcome product as well as useful catalyst for work toward further progress in successful treatment programs. Perhaps the most convincing result is that in no instance (i.e., for no COPES scoring category) was the medical model ward more satisfied than the communityoriented ward. Such pervasive lower satisfaction is certainly suggestive of lower morale and confidence in the treatment program. A possible alternate interpretation of the data is that elements of ward atmosphere measured by the COPES scale are unimportant in a treatment program aimed at symptom reduction and that the wrong questions have been asked to gauge satisfaction. The results of ongoing outcome studies on the two psychiatric wards should help to determine if member satisfaction on the COPES categories is related to successful treatment. As a word of caution it should be noted that the results of this study are only as valid and comprehensive as the questions asked in the COPES questionnaire. While this procedure has established credibility,l there are undoubtedly areas of ward atmosphere that are untapped by the 102 questions in the test booklet. In addition, it bears repeating that the most severely disturbed patients were not able to participate in the study. It is conceivable that the perceived atmosphere and the degree of satisfaction for these patients might provide a somewhat different pattern of results. The higher overall readmission rate for the community-oriented ward suggests that this inpatient treatment approach was not very effectivein preventing serious reoccurrence of symptoms following discharge. In a large follow-up study in Great Britain. Freeman and Simmons’ presented evidence that demonstrated that high readmission rates do not necessarily mean that treatment has failed. Freeman and Simmons argued that patients who leave the hospital to become actively involved in potentially rewarding life situations (e.g., work, marriage, friendship) are more likely to encounter recurring increases in stress and may require more frequent rehospitalization than patients who withdraw to sheltered, marginally rewarding situations upon discharge. Indeed, the high involvement, autonomy-encouraging
760
LEHMAN
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environment of a community-oriented ward is likely to persuade patients to seek more active and independent situations when they leave the hospital, thereby placing themselves at higher risk for readmission. Palmer and McGuireB have suggested that effective psychiatric wards provide patients with beneficial treatment experiences, thereby increasing the likelihood that they will return to the same setting when problems recur following discharge; correspondingly, the results that show neurotic patients returning more frequently after discharge from a community-oriented psychiatric ward perhaps can be attributed to the higher overall satisfaction reported by patients and staff on this ward. Neurotic patients tend to be dependent, lacking in confidence, and in need of support and encouragement. Consequently, they are likely to be more inclined to return to a high-involvement, supportive treatment setting when symptoms recur after discharge. On the other hand, we do not want to give the impression that we feel such results are particularly desirable for a treatment program. We think it behooves the advocates of a community-oriented approach to attend to the uncomfortably high readmission rates, especially for neurotics, observed in this study. Not all patient types showed higher readmission rates following hospitalization on a community-oriented ward, suggesting that the community approach has differential effects on different types of patients. The higher AMA discharge rate for character disorder patients also implies that patients’ diagnostic characteristics interact with inpatient treatment approach. It appears that the more open, free-wheeling atmosphere of the community-oriented ward may not be a good match for the impulsive, acting-out individual with sociopathic tendencies. Perhaps a patient must possess a certain base level of social cooperation and concern for the community-oriented treatment to be effective. Again, a community-oriented program might seek to modify the approach to better integrate the character disorder patient into the treatment atmosphere. In answer to the original question, “Does the therapeutic community inpatient ward really work?” the present study appears to provide a qualified “yes.” The community treatment approach resulted in a perceived ward atmosphere that provided more involvement, autonomy, and practical orientation than the perceived atmosphere on a traditional medically oriented ward. More importantly, patients and staff alike appear to be more satisfied with most aspects of a community-oriented program. On the other hand, higher readmission rates and more AMA discharges for character disorder patients indicate the need for modification in the community-oriented technique. SUMMARY
This study compared ward atmosphere, member satisfaction, and treatment effectiveness on community-oriented and medical model psychiatric inpatient wards. The method used for comparison was the Community Oriented Program Environment Scale (COPES) developed by Moos. The results showed that the community-oriented ward has greater patient autonomy, interpersonal involvement, and practical orientation than the medical model ward, whereas the medical model ward shows more order and organization. These results suggest that a community orientation sacrifices the appearance of an orderly ward for increased
COMMUNITY
INPATIENT
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patient activity and involvement. In addition, the members of the communityoriented ward showed significantly greater satisfaction than the members of the medical model ward, suggesting that the community approach is more effective at creating a helpful level of morale and confidence in the treatment approach. A check of hospital records revealed that neurotics treated on the communityoriented ward were readmitted twice as frequently as neurotics on the medical model ward. Also, character disorder patients left the hospital against medical advice more frequently on the community-oriented ward. ACKNOWLEDGMENT The authors wish to thank Mrs. ArleneTitus assistanceon this work.
and her staRat
the Strong
Memorial
Hospital
for their
programs.
J Abnorm
Psycho1 79:9
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D: Sociological issues in mental health, in: Public Expectations and Health Care. New York, Wiley-lnterscience, 1972 2. Nagi SZ: Some conceptual issues in disability and rehabilitation, in Susman M (ed): Sociology and Rehabilitation. Washington, American Sociological Association, 1966 3. Moos RH, Houts PS: Assessment of the social atmospheres of psychiatric wards. J Abnorm Psycho1 73:595604, 1968 4. Moos R: Assessment of the psychosocial environments of community-oriented psychiatric
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5. Sidman J. Moos R: On the relation between psychiatric ward atmosphere and helping behavior. J Clin Psycho1 29:74 78. 1973 6. Winer BJ: Statistical Principles in Experimental Design. New York, McGraw-Hill, 1962 7. Freeman H, Simmons 0: The Mental Patient Comes Home. New York, Wiley, 1963 8. Palmer J, McGuire F: The use of unobtrusive measures in mental health research. J Clin Consult Psycho1 40:431 436, 1973
