Alternative to Mental
I.
Conceptual Model, Treatment Program,
Leonard I.
Stein, MD, Mary Ann Test, PhD
Gen
Psychiatry 37:392-397, 1980)
to the
who suffered from
illness were hospital¬
for a lifetime. There have since
years and
been continuous efforts to reduce the hospital stay and
increase treatment in the community. These efforts have
included the improvement of inpatient treatment to facili¬
tate early discharge,' shortening of the hospital stay,2-7 the
substitution of day hospital treatment,8 the use of halfway
houses for transitional living and continued treatment,"
and the development of community psychosocial rehabili¬
tation centers that utilize a rehabilitation model.10
The most radical form of community treatment involves
attempts to develop a community-treatment alternative to
the mental hospital. Three studies that randomly assigned
patients from a sample in which the families accepted
home treatment demonstrated that it is possible to treat
patients at home rather than in the hospital."11 In all three
studies, the home-treatment condition involved a relatively
minimal therapeutic input. In the Pasamanick et al12
project, this consisted of visits by public health nurses to
early 1950s, patients
Prior
chronically disabling psychiatric
ized for
often
Accepted
Treatment
and Clinical Evaluation
\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
publication Sept 19, 1979.
Department of Psychiatry, University of Wisconsin Medical
School (Dr Stein), and the School of Social Work and the Institute for
Research on Poverty (Dr Test), University of Wisconsin, Madison.
Reprint requests to Department of Psychiatry, University of Wisconsin
Medical Center, 600 Highland Ave, Madison, WI 53792 (Dr Stein).
for
From the
Downloaded From: http://archpsyc.jamanetwork.com/ on 07/07/2012
patients' homes weekly or less often to provide drugs and
supportive therapy. In the Langsley and Kaplan" study,
the home treatment was family-crisis therapy that was
aimed at teaching the patient ways of handling crises
without hospitalization. In the Rittenhouse" project, the
home treatment consisted of family-unit therapy as devel¬
oped by Satir." All three studies found that at least 77% of
the experimental (E) patients could be kept out of the
hospital continuously as long as the home treatment was in
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.
The present study extended the quest for alternatives to
mental hospital treatment for patients who suffer from
chronically disabling psychiatric illness. First, we dealt
with an unselected rather than a limited sample of patients
who came to a state mental hospital for admission. Second,
placed a major emphasis on improving psychosocial
functioning by assertively working with patients who were
living primarily independently rather than in parental
homes or sheltered settings.
The first section of the report describes a conceptual
model, which is based on patients' needs, for the develop¬
ment of community-based treatment programs for the
chronically disabled psychiatric patient. The second section
reports the results of a controlled experiment that com¬
pared 14 months of a treatment program entitled "Train¬
ing in Community Living" (TCL) with short-term hospital¬
ization plus aftercare and describes a follow-up after the
we
discontinuation of TCL.
CONCEPTUAL MODEL
We contend that current community treatments do not
effectively address certain factors that are required by
patients. The absence of one or more of these factors leads
to a tenuous community adjustment that keeps patients on
the brink of rehospitalization. These requirements, which
are
derived from our clinical
are as follows:
ture,21
experience and the litera¬
1. Material
resources such as food, shelter, clothing, and medical
Community-treatment programs must assume responsibility
for helping the patient acquire these resources.
2. Coping skills to meet the demands of community life. These
are skills we take for granted, such as using public transportation,
preparing simple but nutritious meals, and budgeting money.
Learning these skills should take place in vivo, where the patient
will be needing and using them.
care.
3. Motivation to persevere and remain involved with life. Our
patients experience stress, and their motivation to remain in the
community is easily eroded. A readily available system of support
to help the patient solve real-life problems, feel that he is not
alone, and feel that others are concerned is crucial.
4. Freedom from pathologically dependent relationships. We
define a pathologically dependent relationship as one that inhibits
personal growth, reenforees maladaptive behavior, and generates
feelings of panic when its loss is threatened. Many have had a
lifelong pathological dependence on families or institutions. Hos¬
pitalization can deepen this, and on discharge the patient is often
returned to a highly conflictual family situation that leads to the
revolving-door syndrome. To break that cycle and dependency,
community programs must provide sufficient support to keep the
patient involved in community life and to encourage growth
toward greater autonomy.
5. Support and education of community members who are
involved with patients. An important factor that influences
patient behaviors and thus community tenure are the ways in
which community members (family, law enforcement personnel,
agency people, landlords, etc) relate to patients. Community
programs must provide support and education to help these
community members to relate in a manner that is both beneficial
for the patient and acceptable to them.
6. A supportive system that assertively helps the patient with
the previous five requirements. Chronically disabled patients are
frequently passive, interpersonally anxious, and prone to develop
severe psychiatric symptomatology. Such characteristics often
lead these patients to fail to keep appointments and to "drop out"
of treatment, particularly when they are becoming more sympto¬
matic. Hence, the program must be assertive, involve patients in
their treatment, and be prepared to "go to" the patient to prevent
dropout. It must also actively insure continuity of care among
treatment agencies rather than assume that a patient will success¬
fully negotiate the often difficult pathways from one agency to
another
on
his
own.
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METHODS
The experiment was designed to study the effects on patient
functioning during a 14-month intensive community-treatment
program and to evaluate patient functioning afterward when
patients were transferred to traditional community programs. To
accomplish this, the TCL model was rigorously evaluated by
comparing it with a control (C) group that received progressive
in-hospital treatment plus community aftercare. Subjects were
assigned to the TCL approach for 14 months, after which they
received no further input from the -unit staff. The latter few
months of the 14-month period was used to gradually wean the
patients and to integrate them into existing programs that in
essence were
the
same
programs that treated the C group.
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
The subjects were
staff. Control subjects were treated in the hospital for as long as
necessary and then were linked with appropriate community
agencies. Experimental subjects did not enter the hospital (except
in rare instances), but instead received the TCL approach for 14
months before integration into existing community programs.
Assessment data on all patients were gathered at the baseline
(time of admission) and every four months for 28 months through
face-to-face interviews by a research staff that operated inde¬
pendently of both clinical teams. Data on E subjects who were
hospitalized are reported. No patients were excluded on the basis
of severity of symptomatology or for any reason other than failure
to meet the three specified admission criteria.
Experimental
Treatment
The implementation of the TCL program has been described in
detail.22 In brief, the program was implemented by a retrained
mental-hospital ward staff who were transplanted to the commu¬
nity.23 Staff coverage was available 24 hours a day, seven days a
week. Patient programs were individually tailored and were based
primarily on an assessment of the patient's coping-skill deficits
and requirements for community living. Most treatment took
place in vivo: in patients' homes, neighborhoods, and places of
work. More specifically, staff members on-the-scene in patients'
homes and neighborhoods taught and assisted them in daily living
activities such as laundry upkeep, shopping, cooking, restaurant
use, grooming, budgeting, and use of transportation. In addition,
patients were given sustained and intensive assistance in finding
a job or sheltered workshop, and the staff then continued daily
contact with patients and their supervisors or employers to help
with on-the-job problem solving. Patients were aided in the
constructive use of leisure and the development of effective social
skills by the staff, who prodded and supported their involvement
in recreation and social activities. Their effort was directed
toward taking advantage of patients' strengths rather than
focusing on their pathology. Providing support to patients,
patients' families, and community members was a key function of
the staff. The program was "assertive"; if a patient did not show
up for work, a staff member immediately went to the patient's
home to help with any problem that was interfering. Each
patient's medical status was carefully monitored and treated.
Medication was routinely used for schizophrenic and manic-
were fully completed
partially completed.
interviews
were
The patients were immediately screened by a member of the
hospital's treatment unit that served patients from Dane County,
Wisconsin. They were usually (although not necessarily) admitted
for progressive treatment that was aimed at preparation for
return to the community. The Dane County Unit served as a
stringent control since it had a high clinical staff-to-patient ratio
(1:1) and offered a wide variety of services: inpatient care, partial
hospitalization, and outpatient follow-up. The patients in the unit
had a median length of stay of 17 days and made liberal use of
Madison, Wis.
least once, for a readmission rate of 58% in the first year
compared with 6% of the E patients.
Employment Status.-The E subjects spent significantly
less time unemployed and significantly more time in
sheltered employment than did the C subjects (Table 2).
There was no significant difference between the groups in
the percentage of time spent in competitive employment
situations; however, the E subjects earned significantly
more income through competitive employment than did
the C subjects (Table 3).
Assessment Instruments
The baseline measures were as follows: (1) the Demographic
Data Form was used to collect standard demographic data on life
situation and economic variables; (2) the Short Clinical Rating
Scale24 measured symptomatology; (3) the Community Adjust¬
ment Form measured the patient's living situation, time spent in
institutions, employment record, leisure time activities, social
relationships, quality of environment, and subjective satisfaction
with life; and (4) the Rosenburg Self-Esteem Scale2' was a
self-report measure of self-esteem. Measures taken at the subse¬
quent four-month intervals were the Short Clinical Rating Form,
the Community Adjustment Form, and the Rosenburg Self-
Leisure Time
Table 1.—Mean Percentage of Data-Collection Periods
Within-Treatment
Phase,
Living
Situa¬
tion
Institutional
Living Situations*
Posttreatment Phase,
mo
24
20
16
28
E
C
E
C
E
C
E
C
E
C
E
C
E
C
<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-
of leisure time activities showed
that measured "contact with trusted friends" showed that
E subjects had significantly more contact (P < .05) than
did C subjects at the 12-month period. In addition, on a
scale that measured "social groups belonged to and
attended in the last month," E subjects scored significantly
higher than did C subjects at the 4-, 8-, and 12-month
periods. There was no significant difference between the
The results reported here are those of 65 E and 65 C
subjects. In the tables and discussion that follow, groups of
less than 65 are the result of missing data in cases where it
was impossible to obtain the scheduled follow-up interview
for reasons of patient nonavailability or lack of coopera¬
tion. Through assertive data collection, 80.8% of all possible
vised
measure
significant differences, nor did several of the scales
derived to measure social relationships. However, one scale
no
RESULTS
Super-
Activities, Social Relationships, and Quality of
Environment—A
Esteem Scale.
Penal
additional 6.9%
The results of the first year of the study have been
reported20 and reflect the within-treatment phase of the
experiment. A summary of those results follows.
Living Situations.—Throughout the first year, E subjects
spent very little time in psychiatric institutions compared
with C subjects (Table 1). This did not lead to a greater use
by E subjects of medical or penal institutions or of
supervised living situations in the community. In fact, the
E group spent significantly more time than the C group in
independent living situations in the community. Of the 58
C patients who were hospitalized, 34 were readmitted at
Control Treatment
Psychiatrio
an
Within-Treatment Results
depressive patients.
aftercare services available in
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
t
93.36
20.99
.;.
t
*E indicates the experimental group; C, the control group.
tThe difference between the E and C groups is significant
ÎThe difference between the E and C groups is significant
§The difference between the E and C groups is significant
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i
82.09
§
i
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
E
<n=
60)
(n=
61)
SD
33.76
36.48
SD
26.68
38.33
SD
39.56
42.49
Sheltered
employ¬
C
<n=
61)
t
C
E
(n=
57)
(n=
59)
(n=
58)
56.76
43.31
25.94
37.08
t 57.03 31.15 Î 56.91
1.10
22.20
t
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
*E indicates the experimental group; C, the control group.
fThe difference between the E and C groups is significant at
ÎThe
difference between the E and C groups is
§The difference between the E and C groups is
significant
significant
Table 3.—Mean Amounts of
Within-Treatment Phase,
(n=
56)
E
(n=
59)
2.00
t
C
(n=
59)
C
(n=
57)
at
at
Competitive
t
<
<
<
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
t
mo
24
C
41.34
Phase,
E
(n=
60)
42.93
Situations*
20
16
E
36.23
5.06
Employment
Posttreatment
t 61.74 22.97 t 53.97 30.31
37.04
in Various
mo
12
E
Spent
28
C
E
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
t
.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.
quality of environment (meals, quality of living
Table 4.—Significant Differences Between
Experimental (E) and Control (C) Groups on Items
From the Short Clinical Rating Scale*
situation, etc).
Satisfaction With Life and Self-esteem.—The E subjects
were significantly more satisfied with their life situations
than were the C subjects at 12 months. The E group showed
significantly higher self-esteem than the C group at
baseline (P < .05). The two groups may actually represent
different populations on this variable, but they did not
differ significantly on any other variable at baseline. Since
this measure was taken a few days after the patient's
admission to the study, the lower self-esteem in the C
group may be related to the fact that almost all C patients
initially hospitalized while almost all E patients were
kept in the community. Subsequently, both t tests and
analyses of covariance of self-esteem scores of all the
subsequent data-collection periods showed no significant
were
differences between the E and C groups.
Symptomatology.—The E subjects showed less symptoma¬
tology postbaseline than did the C subjects, and by 12
months they showed better functioning on seven of the 13
scales (Table 4).
Medication and Compliance.-No significant difference
was found between the groups on the numbers of persons
with prescribed psychotropic medications. The only signif¬
icant differences on compliance were at the 8- and 12month periods for antipsychotic medication, with the E
group being more compliant than the C group.
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
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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.
In each data-collection period after
cessation of the program there was a gradual but definite
increase in hospital use by the E group. The time spent in
hospital at the 28-month period was double that of the
12-month period, whereas use of the hospital by the C
group from the 8-month data-collection period onward
remained quite stable.
Employment Status.—The time spent in sheltered employ¬
ment was quite constant while E patients were in the
program (22% to 26% of their employment time). This
percentage began to decline strikingly after cessation, and
by 28 months it had dropped to less than 8%. There was an
almost equal increase in unemployment and competitive
employment. Unlike their other gains, the advantage the E
subjects showed in money earned in competitive employ¬
ment did not deteriorate after cessation of the TCL
program.
Leisure Time Activities, Social
Relationships, and Quality of
Environment.—There continued to be no significant differ¬
ence between the groups on leisure time activities and
quality of environment. However, the greater contact with
trusted friends shown by the E group at 12 months
disappeared postcessation. During the entire period, the E
group maintained their significantly higher attendance at
social groups.
Satisfaction With Life and Self-esteem.—The greater satis¬
faction with life expressed by the E subjects at 12 months
disappeared. The lack of difference between the groups in
self-esteem continued unchanged from 4 months to the end
of the experiment at 28 months.
Symptomatology.—The striking difference in symptoma¬
tology that favored the E group while they were involved
with TCL disappeared very rapidly.
Medication.—After TCL, there continued to be no differ¬
ence between the groups in medications prescribed; howev¬
er, the difference in compliance that favored the E group
at 8 and 12 months disappeared.
COMMENT
There are several factors that may influence any general
conclusions from these findings. The study was conducted
in a nonindustrial, progressive community that was recep¬
tive to this type of study. Our therapeutic interventions
and our outcome measures involved values. These values
were summarized by Cumming27: (1) it is better to be
outside a hospital rather than inside; (2) it is better to work
productively than to be dependent on others; (3) it is
important to be effectively interdependent; and (4) it is a
good thing for people to be happy.
It should be clear that our diagnoses were based on
clinical judgment rather than on research diagnostic crite¬
ria. We carefully trained our raters to measure symptoma¬
tology, but once the study was initiated, further reliability
estimates were not made. Although there was no signifi¬
cant difference in medications prescribed, patients in the
E group reported significantly greater compliance in the 8and 12-month collection periods than did the C patients.
We can not partial out how much of the gains made by the
E subjects was secondary to the success of the TCL
program in gaining medication compliance as compared
with its psychosocial interventions.
it was possible to treat in the community an
unselected group of patients who applied for admission to a
state mental hospital. While most of the C subjects were
admitted to the hospital and many were subsequently
readmitted, almost all of the E patients had a sustained
community tenure for the year. Most important, the data
indicated that their sustained community living was not
gained at the expense of their quality of life, level of
adjustment, self-esteem, or personal satisfaction with life.
Instead, relative to C patients, the E patients showed
enhanced functioning in several significant areas and
maintained less subjective distress and greater satisfac¬
tion with their lives in the 14 months of TCL treatment.
However, our follow-up results indicated that when
patients were weaned from the TCL program to more
traditional community programming, many of the pre¬
viously noted differences between the groups disappeared
and use of the hospital began to increase. Other studies
have similarly found that when intensive treatment ceases
patients regress and their use of the hospital sharply
increases.2"-"'
Several interrelated conclusions can be drawn. The first
is that traditional community programming for these
patients is either insufficient, inappropriate, or both. The
second is that when community programming is inade¬
quate, the hospital is forced to serve as the primary locus
of treatment for the patient rather than being used for the
more appropriate specialized role it is capable of perform¬
ing. Third, the results suggest that for a large number of
chronically disabled psychiatric patients treatment must
be an ongoing rather than a time-limited endeavor. Our
study suggests to us that this ongoing treatment program
must be organized so that it can provide a flexible system
of delivery that gives the patient only what he needs when
he needs it and where he needs it. This involved careful
assessment of patient needs, close monitoring of patient
functioning, assertive intervention, and working closely
with and providing support to community members as well
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
Effects of the TCL
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
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The
Hospital
study has helped us define our own views of what a
hospital's role can optimally be. Although hospitalization
may have undesirable effects on patients, there may be
greater patient harm and certainly greater burden to the
community if use of the hospital is denied on "principle"
without providing adequate community programming in
its place. The more comprehensive the community pro¬
gram, the less need there is to use the hospital. With a
program such as TCL available, we believe that the hospi¬
tal need be used only for the following cases:
1. For protection of the individual or others when the patient is
imminently suicidal or homicidal. Care must be taken to not
hospitalize patients who use self-destructive behavior as a means
of getting help. This presents a very burdensome clinical judg¬
that can be learned and made if the clinician is
willing to do so. In our experience, if the patient is provided with
the support he needs, the danger is minimal.
2. For patients whose psychiatric illness is complicated by
significant medical problems that require the special diagnostic
and treatment facilities only available in a hospital.
3. For patients whose psychosis is so severe that they require
the structure and good nursing care that only a hospital can
provide. The goal here is to medicate the patient and interrupt the
psychotic process as quickly as possible. We have used the hospital
for this purpose with patients in the midst of a very manic episode
or a highly disruptive schizophrenic episode when we were unable
to insure that the patient was being adequately medicated. The
length of hospitalization in these cases was rarely over two weeks
and often a matter of days.
ment, but
one
Psychosis per se was not necessarily an indication to
hospitalize the patient. We were able to successfully treat
many patients who were acutely psychotic without use of
the hospital. Furthermore, the TCL program, which limited
hospital use, did not increase the burden to families or to
the community (for details see the third article in this
series by Test and Stein, pp 409-412). Given adequate
community programming, we envisage use of the psychiat¬
ric hospital only in the specific instances just described.
There is one obvious qualifier: we do not know what the
TCL program would provide or encounter over a period of
five years
Finally,
or
longer.
we
chronic
believe that until
we are
able to prevent
or
psychiatric disease we should change our
treatment strategy from preparing patients for communi¬
ty life to maintaining patients in community life. A
fruitful area for research would be to identify what
Holzman32 referred to as "pathotrophic factors" (that is,
cure
those that feed and nurture the disorder
once
it has
developed) as well as to identify those factors that we call
'normatrophic" (that is, those that lead toward stabiliza¬
tion and normalization of functioning). Treatment pro¬
grams constructed to help the chronically disabled psy¬
chiatric patient to modify or avoid pathotrophic factors
and to acquire normatrophic factors would be very useful
to this long-neglected group of people.
This investigation was supported in part by grant 05-R 000009 from the
National Institute of Mental Health.
The research staff. Rick Bowman, MA, Carl Schwanz, BS, Suzanne Senn,
BA, and Gene Jackson, MSW, provided skillful and diligent assistance.
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