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I.
Leonard I.
Gen
to the
Accepted
Treatment
\s=b\ A conceptual model for the development of communitybased treatment programs for the chronically disabled psychiatric patient was developed, and the results of a controlled study
and follow-up are reported. A community-treatment program that
was based on the conceptual model was compared with conventional treatment (ie, progressive short-term hospitalization plus
aftercare). The results have shown that use of the community
program for 14 months greatly reduced the need to hospitalize
patients and enhanced the community tenure and adjustment of
the experimental patients. When the special programming was
discontinued, many of the gains that were attained deteriorated,
and use of the hospital rose sharply. The results suggest that
community programming should be comprehensive and on-
going.
(Arch
Hospital
From the
effect.
Three controlled studies expanded the generality of the
alternative to mental-hospital research to patients who did
not have a stable home situation by demonstrating the
possibility of treatment in a nonfamilial, residential set
ting. Irvin D. Rutman, PhD, (unpublished data, October
1971) diverted a random sample of nonassaultive or suicidal
new admissions to Philadelphia State Hospital to a half
way-house-type setting where all patients who met the
study-admission criteria were treated in a token-economy
milieu. Mosher et al15" reported on young, first-break
schizophrenics at a residential setting that had a permis
sive, unstructured milieu that was staffed primarily by
paraprofessionals who "guided" clients through their psy
choses, usually without medications. Only two of 30
patients over an average stay of 167 days had to be
transferred to inpatient care. Polak and Kirby17 admitted
patients in Denver to "crisis homes" run by private
families who provided support and shelter for patients for
several days to several weeks and who were aided by
mental health workers who provided outreach services and
consultation. Ten of the first 40 patients could not be so
treated, but this percentage declined over time even
though the sample was totally unselected.
Three controlled studies compared day treatment with
24-hour in-hospital care for patients who sought admission
to an in-hospital setting.1S-2" The Wilder et al2" study
rejected a third of the patients randomly assigned to the
day-treatment condition, whereas the other two studies
only sampled from those patients "for whom both treat
ments were judged equally feasible." Thus, the daytreatment studies excluded a rather large and undefined
group who were judged a priori to be "too ill" for the
day-treatment setting. Of those treated, all but approxi
mately 20% were kept out of the hospital completely.
discontinuation of TCL.
CONCEPTUAL MODEL
ture,21
1. Material
on
his
own.
METHODS
the
same
Subjects
subjects sought admission to Mendota Mental Health Insti
tute for inpatient care and met the following three criteria: (1)
were residents in Dane County, Wisconsin (Madison and the
surrounding area), (2) were aged 18 to 62 years, and (3) had any
diagnosis other than severe organic brain syndrome or primary
All
alcoholism.
single, separated, or
was approximately 31
years; and patients had accumulated a mean of 14.5 months in
psychiatric institutions spread over a mean of five hospitalizations
per subject before the current admission. Twenty percent came
directly from another institution, and 14% came from sheltered
living situations. Only 17% had spent no time in a hospital. The
patients had a wide range of diagnoses, and approximately 50%
were schizophrenic. The E and C groups did not differ significant
ly on demographic characteristics or on any of the major measure
ment instruments given at the time of admission, with the
exception of the measure of self-esteem.
Seventy-three percent
divorced; 55%
were
were
men; the
either
mean
age
Experimental Design
randomly assigned by the admission office
Experimental
Treatment
interviews
were
Madison, Wis.
Assessment Instruments
Leisure Time
Phase,
Living
Situa
tion
Institutional
Living Situations*
Posttreatment Phase,
mo
24
20
16
28
<n=
62)
(n=
(n=
62)
(n=
60)
(n=
<n=
59)
<n=
57)
(n=
59)
(n=
57)
(n=
(n=
56)
(n=
57)
(n=
54)
(n=
55)
11.63
22.88
4.71
16.61
13.13
26.56
3.34
13.94
14.91
27.52
6.45
19.52
15.37
7.18
28.62
21.20
12.46
25.47
60)
62)
59)
9.56 11.32
23.85 24.33
1.59
5.35
t 21.20
20.62
1.38
3.99
0.97
4.89
1.12
3.19
0.12
0.44
0.54
1.85
0.78
3.83
0.81
2.17
0.87
3.92
1.29
4.23
0.25
1.04
1.44
6.66
0.24
0.84
0.61
2.50
0.48
1.46
0.39
SD
X
SD
4.42
15.39
3.53
10.65
5.14
19.96
5.27
15.45
3.47
14.37
6.06
21.24
4.30
20.18
3.38
14.68
5.10
20.91
3.21
14.54
5.23
20.56
3.71
15.23
2.62
14.07
5.20
19.68
19.58
30.45
11.80
28.57
20.02
31.56
12.65
29.78
16.78
31.04
12.66
28.51
16.91
29.46
13.06
14.10
31.02
Total
SD
Noninstitutionaj
Total
in Various
X
SD
Medical
dent
Spent
mo
12
Indepen-
vised
measure
RESULTS
Super-
EnvironmentA
Esteem Scale.
Penal
additional 6.9%
Control Treatment
Psychiatrio
an
Within-Treatment Results
depressive patients.
and
17.44
28.14
8.96
23.39
6.37
22.39
12.02
24.69
8.95
26.38
86.99
34.22
70.54
37.02
32.50
82.56
28.14
91.04
23.39
at
at
at
<
<
.001.
.05.
<
.01.
6.98
t 25.85
17.47
21.31
6.64
20.99
7.82
10.74
21.58
X
SD
20.49
X
SD
85.20
26.06
63.41
X
SD
93.02
17.50
t 74.15
31.02
21.31
93.36
20.99
.;.
82.09
1.31
20.00
31.74
8.51
23.97
12.27
26.90
11.20
28.69
11.78
27.46
6.37
21.07
19.55
36.42
6.86
23.59
25.49
5.21
21.17
67.73
38.49
80.29
35.56
68.64
39.38
81.83
35.58
60.43
42.95
80.49
36.01
70.16
40.77
82.13 68.99
33.92 40.88
80.00
31.74
91.49
23.97
80.42
30.45
88.20
28.57
79.98
31.56
87.35
29.78
83.22
31.04
87.34
28.51
83.09
34.51
Table 2.Mean
Percentages
Within-Treatment
of Data-Collection Periods
Phase,
Unemploy
ment
ment
Competi
tive em
ployment
<n=
60)
(n=
61)
SD
33.76
36.48
SD
26.68
38.33
SD
39.56
42.49
Sheltered
employ
<n=
61)
(n=
57)
(n=
59)
(n=
58)
56.76
43.31
25.94
37.08
1.10
22.20
8.24
42.14
42.69
13.53
22.50
37.69
33.20
36.03
54.53
46.27
9.79
22.39
38.64
44.03
43.07
47.30
45.86
The
significant
significant
(n=
56)
(n=
59)
2.00
(n=
59)
(n=
57)
at
at
Competitive
<
<
<
44.71
43.11
40.21
0.95
5.16
14.91
34.10
51.86
44.24
42.02
45.31
53.94
47.43
44.36
mo
24
41.34
Phase,
(n=
60)
42.93
Situations*
20
16
36.23
5.06
Employment
Posttreatment
in Various
mo
12
E
Spent
28
C
(n=
57)
(n=
54)
(n=
56)
32.63
43.41
51.29
46.17
37.06
44.14
54.77
15.64
1.28
48.40
0.29
1.91
35.01
9.63
7.65
23.84
1.78
1.79
42.80
44.51
51.73
47.91
47.43
46.50
55.29
47.36
43.45
48.20
.001.
.01.
.05.
Income
(Dollars)
Earned
During Data-Collection
Posttreatment
mo
12
Phase,
20
16
Periods*
mo
24
28
C
C
C
C
C
C
E
E
CE
E
E
E
E
Dollars (n=61) (n=59) (n=61)
(n=54)
(n=59) (n=57) ( =59) ( =56) (n=58) ( =55)
(n=59) (n=55) (n=54) (n=52)
X
610.00 308.80
872.30 t 436.00
759.80f 418.90 825.00 535.00 834.00 t 398.00 734.00 367.00 875.00 t 359.70
SD
696.80
1,053.40 622.80 1,260.00
834.00 1,063.50
711.60 1,085.00 955.00 1,209.00
738.00 1,236.00 690.00 1,395.00
*E indicates the experimental group; C, the control group.
fThe difference between the E and C groups is significant at
groups
on
<
.05.
situation, etc).
Follow-up Results
The following summarizes the data from the latter half
of the experiment, the period in which E subjects were no
longer being treated by the TCL program but instead had
traditional community programming available.
Living Situation.The most striking change was in use of
Posttreatment
Within-Treatment
Phase,
Phase,
mo
12
Items
Depressed
.01
mood
Suicidal
trends
.001
Anxiety
or
.001
.01
.05
.01
.01
16
20
mo
24
28
.02
fear
of
anger
Social with
drawal
Motor agita
tion
Motor retarda
tion
Paranoid be
havior
Hallucinations
Thought dis
order
Expression
.001
.01
Hyperactivity
or
.02t
.001
.01
.05
elation
Physical com
plaints
Global illness
.05t
.05
.001
.01
*The numbers are the values of the significant differences between the
groups. For all but two of the cases of significant differences, the C
subjects were more symptomatic than the E subjects.
tlndicates that the E subjects were more symptomatic than the C
subjects.
psychiatrie hospitals.
hospital,
as
patients.
Implementation Problems
This treatment model has several barriers to wide
implementation. The major one is financing; even though
this model is economically feasible in terms of total costs
and benefits (for details see the second article in this series
by Weisbrod et al, pp 400-405), the kinds of services it
provides are largely not reimbursable by third-party
payers. Modes of treatment that are reimbursable have a
profound influence on shaping the types of services pro
vided. As Mechanic" pointed out, it is relatively easy to
determine what one must pay for a day in the hospital, but
it is much more difficult to determine how to pay for a total
pattern of services that includes medical care and social
supports. One possible solution is payment on a capitation
basis, but if new funding mechanisms are not developed,
TCL-type programs will not be widely implemented.
Another barrier lies in the difficulties inherent in dissem
inating programs that require social technologies that
require considerable coordinating ability and that fall
outside of the usual organizational patterns of the medical
sector.31
Role of the
Program
With such limitations in mind, the within-treatment
results indicated that the TCL program was an effective
alternative to mental hospital treatment for the large
majority of subjects. Specifically, with minimal use of the
The
Hospital
ment, but
one
Finally,
or
longer.
we
chronic
we are
able to prevent
or
once
it has
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