VY" .7 1 vv. v :w—v—vv— 'fifvvv mmmmm surf—“oars AND FOST - HOSPML masmm: A PEN? STUBY Tina: for flu Daqree of M; A. RECHEEAN STATEBNIVERSITY ’ ~ Keith Lyon ' ’ - 13923 _ In A hill) i $21“ 53- '. ‘9 I. .7 n ? versi tv 1. I; w -. ,. c .. fig—.fl-H~ ' ' ABSTRACT ENVIRONMENTAL SUPPORTS AND POST-HOSPITAL ADJUSTMENT: A PILOT STUDY BY Keith Lyon Studies done in the area of community and hospital adjust- ment have found several specific variables that appear to be re- lated to the adjustment an individual will make both in an in— stitution and in the community. They may be formal or infor- mal, positive or negative, but the relationship between an in- dividual's environment and his mental health is clearly shown. The present study is designed to provide information on the spe- cific environmental support variables at work in producing im- proved post-hospital behavior and to assist in the development of a questionnaire and measurement scale which will be useful in further study in this area. In particular, factors relat- ing to the immediate, day-to-day life of the ex-patient, (e.g. amount and quality of contact with relatives and friends; em- ployment experiences), rather than hospital related activities --such as outpatient therapy--were examined. Three hypotheses guided our inquiry. They were (1) that the extent of environmental support given an individual after his stay in the hospital will be positively related to good relative adjustment after three months; (2) evidence of an ade- quate pre-hospitalized adjustment (e.g. marriage) will corre- late positively with relative adjustment and absolute adjust- ment at three months; and (3) adult socioeconomic class will Keith Lyon be positively correlated with both measures of adjustment. Measures of adjustment were based on a self-administered symptom checklist using (1) absolute symptomatology at three months and (2) the difference in symptomatology comparing scores on the checklist administered on the ward with those at three months. Environmental supports were measured by an Environmental Support Questionnaire developed for the study and scored blindly on 13 criteria by two raters. Interrater reliabilities ranged from .62 to 1.00. Subjects were approached initially while hospitalized and were given the Symptom Checklist. After discharge they were interviewed by phone monthly for three months. At these contacts, they were given the Environmental Questionnaire. Three months after discharge they were mailed a second Symptom Checklist and the Activity Checklist. In terms of the original hypotheses, no individual items were found to relate significantly to improvement over three months. Also, social class differences were not found in the data. This could be due to the preponderance of lower-middle SES individuals in the inpatient unit and in the sample. Evi- dence was found of the relationship between an adequate pre- hospitalization adjustment and measures of pathology after hos- pitalization. A cluster analysis was performed and a stable home life (marriage, high home living involvement, older age, and many home activities) was linked with low three months symptomato- logy (p<(.Ol) and improved symptom change to three months Keith Lyon Q><.10). The presence of benign visitors (high visitor in- volvement, little pressure from visitors, and a positive per- ception of visitors) was also related to low three months symp- tomatology (p<:.05). These two clusters were independent (r = -.06). The study has provided an initial trial for a measure of a series of environmental support variables that may be useful in the rehabilitation of the ex-patient. The ease with which these variables divide into clusters would imply that the con- cept of "environmental support" is not unitary. In addition, the presence of two clusters related to symptomatology is sug- gested, though these results must be viewed as tentative given the state of development of the environmental support instru- ment and the small sample size. /%/¢1w/( 3/5”; /%?Z:%W flQ§Zyxcxf' ENVIRONMENTAL SUPPORTS AND POST-HOSPITAL ADJUSTMENT: A PILOT STUDY By ‘_\ 9*” Keith Lyon A THESIS Submitted to Michigan State University in partial fulfillment of the requirements for the degree of MASTER OF ARTS Department of Psychology 1973 f :fi ACKNOWLEDGEMENTS I would like to express my appreciation to Dr. Robert Zucker for his guidance and encouragement as chairman of my thesis committee. I would also like to thank Dr. Jack Hunter for his advice and direction in terms of the data analysis and Dr. Arthur Seagull and Dr. Albert Rabin for their parti- cipation as members of my thesis committee. A special note of thanks goes to the staff of the St. Lawrence Community Mental Health Center Inpatient Unit, under the direction of Miss Rita Carbuhn, without whose interest, advice, and, most importantly, tolerance, the project could not have been completed. I would also like to thank Dr. Gustav Lo and Dr. Jose Llinas who allowed me to approach their patients in my search for volunteer subjects. Finally, I would like to express my appreciation to those individuals who allowed me to enter their lives for the course of the study. ii TABLE OF CONTENTS CHAPTER I II III INTRODUCTION REVIEW OF LITERATURE PAGE Environmental Factors Related to Continua- tion or Discontinuation of Psychopathology in the Community. Institutional Forces in Psychopathology. Post-hospitalization Adjustment. STATEMENT OF THE PROBLEM. HYPOTHESES. METHOD INSTITUTION SUBJECTS INSTRUMENTS PROCEDURE RESULTS CORRELATIONS WITH OUTCOME MEASURES CLUSTER ANALYSIS PROCEDURE INTERCORRELATIONS AMONG CLUSTERS CLUSTERS X OUTCOME VARIABLES iii 3 5 11 12 15 15 15 17 21 24 24 30 30 34 TABLE OF CONTENTS (Cont'd) CHAPTER PAGE IV DISCUSSION 36 BASIC HYPOTHESES 36 PREDICTION OF OUTCOME 37 Symptom Change 37 3 Month Symptomatology 33 Activity Level 39 V SUMMARY AND CONCLUSIONS 41 LIST OF REFERENCES 43 APPENDICES 45 A. SYMPTOM CHECKLIST 45 B. ENVIRONMENTAL SUPPORT VARIABLES ' 50 C. CHARACTERISTICS OF THE SAMPLE POPULATION 53 D. ENVIRONMENTAL SUPPORT QUESTIONNAIRE 55 E. MEAN VALUES OF THE SYMPTOM BHECKLIST ITEMS AT DISCHARGE 53 F. ACTIVITY CHECKLIST 55 G. MANN WHITNEY U VALUES FOR PATIENTS WITH 5 GREATEST INCREASES IN SYMPTOMATOLOGY VS. 5 GREATEST DECREASES 69 H. INTERCORRELATIONS AMONG SOCIAL SUPPORT VARIABLES AND BACKGROUND FACTORS 70 iv 1A. 2A. 3A. LIST OF TABLES PAGE RESEARCH ON COMMUNITY AND HOSPITAL ADJUSTMENT 10 STUDY PROCEDURES AND TIMING OF MEASUREMENTS 21 VARIABLES UTILIZED IN THE STUDY 23 INTERRATER RELIABILITY OF ENVIRONMENTAL SUP- PORT VARIABLES 27 CORRELATIONS OF ENVIRONMENTAL SUPPORT VARI- ABLES AND BACKGROUND FACTORS WITH POST- HOSPITALIZATION ADJUSTMENT 23 INTERCORRELATIONS AMONG OUTCOME VARIABLES 29 INTERCORRELATIONS AMONG ENVIRONMENTAL SUPPORT CLUSTERS 33 CORRELATIONS OF CLUSTERS WITH INDIVIDUAL OUTCOME VARIABLES 35 MEAN VALUES OF THE SYMPTOM CHECKLIST ITEMS AT DISCHARGE 63 MANN WHITNEY U VALUES FOR PATIENTS WITH 5 GREATEST INCREASES IN SYMPTOMATOLOGY VS. 5 GREATEST DECREASES 59 INTERCORRELATIONS AMONG SOCIAL SUPPORT VARIABLES AND BACKGROUND FACTORS 7o LIST OF FIGURES FIGURE PAGE 1. INDIVIDUAL ITEMS IN ENVIRONMENTAL SUPPORT CLUSTERS 32 vi CHAPTER I INTRODUCTION Most research in mental illness can be placed in one of two broad categories. Much work has been done to reach an understanding of the origins of specific problems and of psy- chopathology in general. Though these efforts are made from many different theoretical camps and may include methodology ranging from case histories to community surveys, they all ha- ve one factor in common--the accent on origin rather than con- tinuation of disorder. Any mention of the continuation of symptoms is handled in a "more Of the same" approach--more of the same unresolved conflicts, pressures, or schedules of rein- forcement depending on the theoritical framework utilized. The second category includes studies that follow the indi- vidual during or after a treatment program. Here, the major emphasis is on the comparison of treatment effectiveness, and data is gathered with this goal in mind. Variability of other factors is either defended against by randomization or matching or ignored. Thus, the results obtained differentiate between programs at the expense of any other factors that may relate to adjustment. Andthis makes it very difficult to generate a broad theory about the forces present in the post-hospitaliza- tion environment and their effect on the former patient. It is with this difficulty in mind that the present study was designed. Unlike work in the first category, we will be focusing exclusively on a post-hospitalization population, but our study will not be accenting hospital related activities either. We will be examining influences present in the indi- vidual's own non-institutionalized environment and relating them with his ability to adjust upon his return home, with the proposition that environmental supports in the form of peer group and family contact will be crucial in an individual's success or failure after hospitalization. As no instrument designed to tap this area of the ex—patient's life currently exists, one had to be developed for the study, making this re- search a pilot study for the new instrument. REVIEW OF THE LITERATURE. Environmental Factors Related to Continuation or Dis- continuation of Psychopathology in the Community. There is little evidence in the recent literature of attempts to ex- amine directly the forces active in continuing pathological behavior. But some work has been done, such as the Midtown Study (Langner and Michael, 1963) which examined mental ill- ness in a community setting through a survey technique. Speci- fically, they were looking at social class differences in the duration of pathology. What they found was quite different response styles between classes, with the lower classes uti- 1izing much less adaptive ways of dealing with problems. Thus, the ability of the response to allieviate the stress (as in the middle class compulsive response to job oriented worries) and avoid hospitalization (a common result of a lower class acting out response) will determine the psychopathology's duration. Leff, Roach and Bunney (1970) found unfavorable life events prior to hospitalization in the depressive patients they studi- ed. This was true for both the acute and endogenous depressives. While at first glance this may seem unrelated to the maintenan- ce of symptoms, it must be remembered that most individuals in- volved in short-term hospitalization return to essentially the same environment they experienced previously. In such a situa- tion, high stress levels could "maintain" a chronic picture of periodic hospitalizations. Sometimes at lower stress levels the mere suggestion of help can produce a marked change. Kellner and Scheffield (1971) found that, with patients in both anxious, depressed and psy- chophysiological categories, improvement was noted during a waiting period before treatment. This effect was greater than the effect of subsequent brief therapy, and was felt to be due to the "impact of the clinic" or the response to the "symbols of competent care." Dohrenwend and Dohrenwend (1969) approach the question of the role of social factors in the maintenance of mental ill- ness directly. In discussing the relationship between stress- ful events and psychological symptoms (p. 129), they note that whether the symptom disappears or is maintained after the stress is allieviated depends upon the presence or absence of secondary gain. In other words, if the rewards for the symp- tom produced in response to the stress are sufficiently great (e.g. compensation payments, removal of responsibility, etc.) the symptom will be maintained by these rewards after the ori— ginal need for it is removed. Social classes differ in the number of adequate resources present to cope with stressful situations. Lower class hus- bands and wives provide little mutual support (Rainwater, 1965) and a lower class individual is less likely to be involved in voluntary organizations (Cohen and Hodges, 1963). As a group, they are less able to purchase adequate medical care (Langer, 1966) and are dealt with less favorably by social agencies (Dohrenwend, 1961). The above class differences, when combined with the higher level of symptomatology present in the lower class (Hollingshead and Redlich, 1968, Dohrenwend and Dohrenwend, 1969), and the other evidence presented in this section, provide strong sup- port for the Dohrenwends' hypothesis that the absence of ade- quate resources with which to cope with stressful situations is a factor in the continuation of symptomatology. Thus, the studies cited seem to point to two general con- ditions which may lead to the continuation of symptomatology. First, the stress level that produced the original response may continue unabated with no hope for the pt. of relief in sight. And, second, the symptom may be reinforced by the so- cial milieu to such an extent that it is not relinquished once the stress is removed. Either condition seems to relate di- rectly to the environmental support picture in the individual's environment. Institutional Forces in Psychopathology. In a hospital setting, and using a participant-observer role, Goffman (1961) has noted the institutional pressures to force the patient in- to a "sick" role. Deviations from this expected behavior are firmly dealt with because they are threatening to the whole system. The forces are so intense that an entire subculture develops among the patients in an attempt to salvage some au- tonomy. Stillman, (1971) in a study of the relationship between social interaction and health--sickness of patients in the Exit Unit of a Veterans Administration hospital, focuses on the pa- tient rather than the staff environment. He reported a positive correlation between staff and patient evaluation of mental health status and peer group popularity. While this leaves the question of causality unanswered, it seems clear that there is strong social support for "well" behavior among the patients on the ward. Thus, we find a paradox in which the institutional structure pressures patients into a "sick" role, while the peer group supports "well" behavior. Post-hospitalization Adjustment. Several factors in the post-hospitalization environment have been correlated with com- munity adjustment by prior studies. Though these dealt prima- rily with the chronic, institutionalized patient they are sug- gestive of forces more generally present in persons following hospitalization. Specifically, Kardiner and Spiegel (1947) examined soldiers suffering from war neuroses and found that the neurosis seemed to be prolonged by the presence of direct disability compensation, (p. 392). This factor was made more intense by the role of the therapist in making the decision relating to compensation eligibility. Silverstein (1968) points to the need for agency aftercare facilities such as medication monitoring, day treatment centers, coUnseling, and psychotherapy. He feels that services of this sort were neededby 9 out of 10 of the patients who left the 18 state hospitals of Pennsylvania during his study. Further support for the need for aftercare facilities was suggested by the fact that 44.3% of the patients who returned to the hos- pital did not utilize any of the available assistance. Unfortunately, data was gathered only on those who failed. This study, along with the others presented in this section, makes the need for post-hospitalized help and support for suc- cessful readjustment clear. Lucas (1959) found that group support in the form of an ongoing therapy group was beneficial in increasing the self- confidence of the former patient. This was felt to be of spe- cial importance to the person labeled schizophrenic who must struggle with his oversensitivity and feelings of lack of be- longing. Life stress has already been mentioned as a factor affect- ing mental health status (Dohrenwend and Dohrenwend, 1969) in the community. The difference between momentary symptoms and more chronic problems was felt to depend in part on the avail- ability of stress alleviating community resources and also on the secondary gain afforded the symptom in the social setting. This point is supported by Silverstein's finding that 35% of all his subjects who failed in the community did so because of an inability to cope with stressful situations. The guided autonomy and social supports of a live-in "Lodge" situation was found to be more successful in preventing rehos- pitalization than completely independent attempts at community readjustment (Fairweather, Sanders, Cressler, and Maynard, 1969). Here, peer interaction was felt to be most beneficial in sta- bilizing the former patient. Table 1 summarizes the studies done in the area of commu- nity and hospital adjustment. It presents the specific variables found to be related to adjustment by each researcher and the date of publication of each study. It can be seen that several different types of environmental support have been link- ed to the adjustment an individual will make both in an insti- tution and in the community. They may be formal or informal, positive or negative, but the relationship between an indivi- dual's environment and his mental health is clearly shown. The abOve research tends to support the theoretical model advocated by Caplan (1964). He assumes that in order to avoid mental disorder a continual source of "supplies" is needed by the individual. These supplies can be grouped into three ge- neral areas: physical, psychosocial and sociocultural and a lack in any one area can be very detrimental. Physical sup- plies include food, shelter, sensory stimulation and other things necessary for bodily health and development. Psycho- social supplies relate to the "stimulation of a person's cog- nitive and affective development through personal interaction with significant others..." (p. 32). And sociocultural sup- plies are those influences exerted by the culture and the so- cial structure in terms of enhancing or blocking challenge or opportunity as well as in the degree of stability present in the society. These three groupings are, of course, interrelated, and it is felt that a lack in any area of supplies would greatly affect the individuals'ability to cope with a crisis situation. Cap- lan's use of the term "supplies" parallels what we mean by en- vironmental supports, but the present study is not intended as an all inclusive assessment in this area, but instead narrows down on those supply aspects that were felt to be most salient to the patient's immediate post-hospital adaption. 10 TABLE 1 RESEARCH ON COMMUNITY AND HOSPITAL ADJUSTMENT STUDY DATE VARIABLES AFFECTING ADJUSTMENT COMMUNITY Lagner and Michael 1963 Ability of response to allieviate stress. Dohrenwend and Dohrenwend 1969 Secondary gain; Coping resources. Leff, Roach and Bunney 1970 Unfavorable life events. Kellner and Sheffield 1971 The promise of help (screening interview). INSTITUTIONAL Goffman 1961 Institutional pressures into the "sick" role. Stillman 1971 Patient peer group support of "well" role. POST-HOSPITALIZED Kardiner and Spiegel 1947 Direct disability compensation (secondary gain). Lucas 1959 Ongoing therapy group. Silverstein 1968 Agency aftercare facilities. Fairweather, Sanders, Cressler and Maynard 1969 Guided autonomy (live-in facilities). 11 STATEMENT OF THE PROBLEM. AS has been noted above, a number of investigators have pointed to environmental supports (including compensation), both formal and informal, as the deciding factors in success- ful community adjustment. The present study is designed as a pilot to develop an instrument capable of measuring the amount of social support present in the ex-patient's environment and also to provide information on the specific environmental sup- port variables at work in producing improved post-hospital be- havior. In particular, factors relating to the immediate, day- to-day life of the ex-patient, rather than hospital related activities such as outpatient therapy were examined, focusing primarily on Caplan's psychosocial supplies with a secondary emphasis on physical supplies. Our outcome measure of symptomatology is compared to three sets of variables: Pre-Hospitalization Adjustment, Post-Hos- pitalization Adjustment, and Social Class. 12 HYPOTHESES. The following operational definitions are used in the pri- mary hypotheses: (A) RELATIVE ADJUSTMENT is defined Operation- ally as the patient's score on a symptom checklist (Appendix A) (Michaux, William, Katz, Martin, Kurland, Albert, and Gan— sereit, Kathleen, 1969) self administered on the ward, sub- tracted from his score on the same checklist filled out 3 months after discharge. (B) ABSOLUTE ADJUSTMENT is the pa- tient's score on the symptom checklist at three months. (C) ENVIRONMENTAL SUPPORTS are operationally defined by the 13 ra- ting scales listed in Appendix B. These items will be further described in "Method". The hypotheses for the study are as follows: 1. The extent of environmental support given an individual after his stay in the hospital will be positively related to good relative adjustment after three months. In other words, if an individual has had a great deal of contact with help Since he left the hospital, his condition will have a greater tendency to improve than will that of another subject with less contact. Support for this hypothesis comes from the studies on post— hospitalization treatment programs. These programs were found to be quite important in the adjustment of the individuals stu- died, and, as has been mentioned previously, aftercare treat- ment seems to be a formalized, structured case of what we mean by environmental support. 13 This hypothesis also grows out of the literature on stress and mental illness cited previously. For a large number of people in contact with the former patient will make it much more likely that he will be able to find the help he needs when faced with a crisis. Also, meaningful participation in a social network is, it- self, rewarding. Its absence, and the accompanying feeling of alienation from those around one can precipitate a neurosis (Maddi, 1967). This would seem especially traumatic to the individual who has just experienced the close, intense rela- tionships present in a closed institution such as a hospital (Goffman, 1961). 2. Evidence of an adequate pre-hospitalized adjustment (e.g. marriage) will correlate positively with both measures of ad- justment after discharge. Individuals with adequate interper- sonal relationships prior to admittance will be less impaired on an absolute scale. They should also show less deteriora- tion over the course of the study (i.e. a situational crisis in a better functioning person has a better prognosis). Support for the absolute difference is grounded in the work previously done relating good vs. poor pre-morbid adjustment to symptomatology (Zigler and Phillips, 1960). The longitu- dinal prediction was based on the belief that individuals who enter the hospital from a functioning social network will re- turn to essentially the same milieu after a short-term absence. The effect of this environment, as expressed in Hypothesis 1, will be to aid in the ex-patient's readjustment. These 14 individuals also will have more resources within themselves and will be more likeable. 3. Adult socioeconomic status will be positively correlated with both measures of adjustment. Higher SES individuals will be less impaired on an absolute sense and will also Show a de- crease in symptomatology after their return to the community. The greater incidence and the more serious nature of dis- orders in the lower classes is well documented (Hollingshead and Redlich, 1958; Dohrenwend and Dohrenwend, 1969). This should lead to an absolute difference in impairment. Also, differences in the resources available to the different clas- ses with which to alleviate stress would suggest a less ade- quate post-hospitalization adjustment in the lower class. Fi- nally, the lower SES patient is less likely to find sympathe- tic, understanding individuals in his immediate environment (Hollingshead and Redlich, 1958). CHAPTER II METHOD INSTITUTION. The Inpatient Unit at the St. Lawrence Community Mental Health Center provides several services to its coverage area. It is designed to deal with acute, Short term mental upsets which can not be handled on an outpatient basis, but which do not require extended absences from the community. To prevent "acute" from becoming chronic, the maximum stay for Community Mental Health patients without private physicians in attend- ance~ is 30 days. This limitation leads directly to the second major func- tion of the unit. Patients who show no signs of improvement as a result of their stay, or have a history of prior hospi- talizations, are referred for committment to state institu- tions directly from the Inpatient Unit. Thus, the unit is ac- tively involved with a population precariously balanced be- tween community life and institutionalization. SUBJECTS. Forty three individuals entering the Inpatient Unit at the St. Lawrence Community Mental Health Center, without organic damage or drug addiction nor under committment orders to an- other institution were included in the sample. All patients who qualified were approached, and participation in the study 15 16 was voluntary. Though no data was kept on the number of re- fusals within the total population contacted, approximately 60-70% of those approached agreed to participate in the study. No general trends were discernible among those refusing. Per- mission was also obtained from private physicians where they were involved. Demographic data and formal diagnoses for the- se individuals are presented in Appendix C. Of the original 43, two refused to complete the final eva- luation after responding reluctantly to each of the phone con- tacts. Three others were rehospitalized during the three months follow-up period. These subjects for whom data would be either incomplete or contaminated by institutionalization were remo- ved from the sample. A review of the incomplete date Obtain- ed from these individuals revealed no discernable trends ex- cept that the two who refused to cooperate were women. Social supports among those who were rehospitalized were within the lower-middle range. 17 INSTRUMENTS. The study may be conceptualized as a comparison of measure- ment made at three points along a time dimension: Long-Term Life History Variables vs. In-Hospital Variables vs. Post- Hospitalization Variables. Life history variables include facts relating to the so- cial experiences of the patient prior to hospitalization. In- formation on employment, marital status, age, sex, education and number of previous hospitalizations was gathered. Socio- economic status was also determined from the history data. The in-hospital variable consisted of the results of the symptom checklist (Appendix A, Michaux, Katz, Kurland, and Gansereit, 1969), administered on the ward as explained in "Procedures." The third group of variables constitutes the major focus of the study, the post-hospitalization environment in which the patient finds himself. We examined the social, work, and therapeutic encounters of the former patient after his release and his role within each. As part of the examination of role we obtained a measure of the locus of motivation for the indi- vidual patient. In particular, we focused on such aspects as the living ar- rangements experienced by the former patient in the community as well as the interaction patterns present in the living unit, whatever it may be. For, here is found the potential for the most intense support or alienation experienced by the indivi- dual. Questions have been devised to tap the many aspects of 18 the home environment--including task, entertainment, and gene- ral interactional factors. For each factor, data on motiva- tion and enjoyment was coIbcted (see Appendix D). But family "support" to the exclusion of all others can be at least as damaging as no support at all. It is with this in mind that our questions also focus on phone or personal con- tacts outside the home. Thus, contact outside the home is seen as a crucial variable in adjustment, bofi1for its own sake and in terms of determining the effect of family interaction pat- terns. Another area of major concern in the adjustment process is that of employment. The number of weeks spent on a job has been shown to be of little utility in a study of chronic men- tal patients (Fairweather, et. al., 1969), largely because of the difficulty in securing jobs. The measure was effective for those involved in the treatment program including joint op- eration of a small business, but for those individuals in the control group the rate of employment was well below a statis- tically useful level. Even though the population we are concerned with is compos- ed Of acute, short-term cases, it was felt that the above find- ings, combined with the short time span of the study, would in- validate employment records as a measure of adjustment. For, given the realities of the job market today, employment during the three months after discharge would seem to relate more close- ly to such factors as pre—hospitalization status on the job, the employer's personal reaction to mental upsets, and company l9 policy. But, even though we can not depend on employment to meas- ure a wellness-illness dimension, it does give an indication of the number and quality of social contacts experienced by the subject. For those not working, questions about the ex- tent of job hunting and the involvement of significant others in the process tap a very important source of environmental support. At the same time, the locus of motivation can be discovered in this crucial, practical area of the subject's life. Agency and therapist contact was included in the study in the belief that it will prove helpful to the client as an ad- ditional social contact. And medication levels are also im- portant because Of the effect drugs can have on the symptoms recorded as well as on the personality and motivation of the client. The Environmental Support Questionnaire (Appendix D), used to measure the subject's post-hospitalization environment, was scored on 13 criteria described in Appendix B by four raters. Scoring was done on 5 point scales, and the scores of the two raters who correlated best with each other were pooled for further analysis. Adjustment was measured in two ways: (1) on an absolute scale using Katz's Symptom Checklist (see Appendix A, Michaux, et. al., 1969) after three months in the community, and (2) on a relative basis, comparing scores on the Symptom Checklist administered in the hospital and at 3 months after discharge 20 (i.e. a measure of symptomatology change). This instrument was self-administered. 21 PROCEDURE. TABLE 2 STUDY PROCEDURES AND TIMING OF MEASUREMENTS In Hospital Post-Discharge Termination TIME Off Step A Discharge plus 90 days 30, 60 and 90 days ACTIVITY Interview Phone Interview Mail Questionnaire Background Environmental Symptom Checklist Questionnaire Support Questionnaire Activity checklist FORMS Release Form Symptom Checklist Demographic and history data were gathered upon arrival on the Inpatient Unit. Each patient was contacted and permission obtained when the staff removed him from Step A (the initial, restricted category). It was felt that at this point acute, presenting symptoms would have subsided, but the patient would not yet begin anticipating release. Both of these conditions could have greatly affected the Symptom Checklist administer- ed on the ward. Upon release, subjects were approached monthly for the next three months. Contact was by phone, directly to the for- mer patient. At three months, a questionnaire was mailed to the individual in addition to the phone contact.‘ 22 As outlined in Table 2, subjects were given the back- ground interview mentioned above and the Symptom Checklist (Michaux, et. al., 1969) (Appendix A) when they were removed from Step A. (See Appendix E for mean symptom values in the sample). At monthly intervals, the Environmental Support Questionnaire (Appendix D) was administered by phone, with direct contact if no phone was available. At three months, a questionnaire combining the Symptom Checklist and an acti- vity checklist (Michaux, et. al., 1969) (Appendix F) was mail- ed to the subject. This was timed to arrive just prior to the final phone contact. The Environmental Support Variables (Appendix B) have been designed to measure the frequency, duration and the dyna- mics involved in social contacts after release. It was felt that these contacts would be crucial to the success of a for- mer patient. AS three months is too short a time to obtain good recid- ivism data (Fairweather, 1967), the primary instrument for measuring post-hospitalization status was the Symptom Check- list. Scores from the final evaluation were compared with those obtained on the ward before discharge to determine each patient's status. Table 3 presents the variables utilized in the study. The two outcome variables were correlated with the variables indicated, focusing on each of three points in time; pre-hos- pitalization, discharge, and post-discharge. Each of these variables is correlated with each other variable as well in the final analysis. 23 TABLE 3 VARIABLES UTILIZED IN THE STUDY DEPENDENT INDEPENDENT VARIABLES VARIABLES (_l_) (_2_) (3) (A) Post—hospital Pre-Hospital Symptomatic Environmental Adjustment at & Demographic Status at Support After Three Months History Discharge Discharge (B) In vs. Post- Socioeconomic Symptom Environmental Hospital Status Checklist on Support Adjustment Ward Variables Change Score Marital and Family Statu Activity checklist Education COMPARISONS (1) vs. (5) (_1_) vs. (E) (1) vs. (3) (I) vs. (3) (2) vs. (5) (_2_) vs. (13) (3) vs. (3) (3) vs. (A) (3) vs. (E) CHAPTER III RESULTS CORRELATIONS WITH OUTCOME MEASURES. Interrater reliability correlations for Environmental Support Variables are presented in Table 4. For each item, a Pearson Product-Moment Correlation (r) was computed compa— ring each of four raters' scores with those of each other rater. Raters had been trained using the descriptions of the scale items given in Appendix B; monitoring of their scoring on the first 20 questionnaires revealed no real discrepancies between their ratings and those of the researcher on each item. The scores of the two raters with the best overall pattern of correlations were selected for further analysis and pooled. Reliability coefficients are all adequate, with the possible exception of Employment Pressure and Visitor Pressure. Correlations of each of the environmental support and background variables used in the study are presented in Table 5. In this table (as well as in all the succeeding ones) the number of significant relationships is greater than 5 per cent of the total number examined--i.e., the correlations we dis- cuss here and in the following sections are by the large not random. Missing data for any individual subject was handled by substituting the mean across all subjects for that particu- lar item. 24 25 As can be seen in the table, high Discharge Symptomato- logy and subject's negative Perception of Visitors were signi- ficantly correlated at the .01 level with high Three Month Symptomatology. At the .05 level, more Pressure from Visitors correlated significantly with 3 month symptomatology level. There were also trends (p.<:.10), with high Living Involve- ment, increased age, positive Perception of Home Responsi- bilities and being male related to low Three Month Symptom- atology. Less pressure for home responsibilities, being married, and being older were related at the .05 level to higher acti- vity level at three months. High Symptom Change during the three months follow-up period was found to correlate with high Discharge Symptom— atology (.01 level), a positive Perception of Employment (.10 level) and a greater number of previous hospitalizations (.10 level). This meant that being discharged with a large number of symptoms, enjoying one'S job, and having been hospitalized previously were linked to remission of symptoms over three months. Table 6 presents the intercorrelations among the three outcome variables. Those who improved over the three month follow-up period had fewer symptoms at three months and were engaged in more activities. Low three month symptomatology and low three month activity levels were directly correlated as well. All correlations between outcome variables were Sig- nificant at the .01 level. 26 An analysis was performed comparing the five indivi- duals with the highest positive symptom change with the five exhibiting the greatest negative symptom change (over three months) on sixteen dependent variables. Mann-Whitney U's were computed and none were found to be significant. Results are presented in Appendix G. 27 TABLE 4 INTERRATER RELIABILITY OF ENVIRONMENTAL SUPPORT VARIABLES (Calculated on 38 Subjects) Environmental Support Variables Interrater Reliability Residenthl Living Involvement' Residential Living Pressure Employment Involvement Employment Pressure Employment Perception Responsibility Involvement Responsibility Pressure Responsibility Perception Visitor Involvement Visitor Pressure Visitor Perception Professional Involvement Medication Involvement .91 1.00 .83 .66 .83 .89 .80 .83 .83 .62 .84 .91 1.00 28 TABLE 5 CORRELATION OF ENVIRONMENTAL SUPPORT VARIABLES AND BACKGROUND FACTORS WITH POST-HOSPITALIZATION ADJUSTMENT MEASURES AT 3 MONTHS (N 38) Post-Hospital Adestment Measures. Independent Variables Symptom Amount of Amount of Change to Symptom— Activity 3 Months atology at at 3 Months 3 Months Residential Living Involvement .11 -.30x .22 Residential Living Pressure .00 .00 .00 Employment Involvement -.01 .06 -.02 Employment Pressure .26 -.ll .07 Employment Perception .31x -.20 .23 Responsibility Involvemenr -.05 -.05 .24 Responsibility Pressure .02 .26 -.37* Responsibility Perception -.06 -.29x .22 Visitor Involvement .12 .04 .06 Visitor Pressure -.17 .39* -.11 Visitor Perception .24 -.42** .23 Professional Involvement -.05 .20 -.07 Medication Involvement -.18 .14 -.08 Discharge Symptoms .47** .42** -.17 Marital Status .22 -.26 .37* Socioeconomic Status .06 .04 .11 Age (in years) .13 -.31x .33* Sex (M=l; F=2) -.23 .27x -.15 Years Education -.15 .11 -.16 NO. Previous Hospitali- zations .31x -.06 .20 x p<.10 * p_(.05 ** p( .01 29 TABLE 6 INTERCORRELATIONS AMONG OUTCOME VARIABLES (E = 33) 3 Month 3 Month Sympt. Chg. Symptoms Acitivity To 3 Months 3 Month Symptoms - - 3 Month Activity -.55 - - Symptom Change TO Three Months -.58 .43 — Note: All p's< .01 3O CLUSTER ANALYSIS PROCEDURE. The above analysis--and a rough cluster analysis gene- rated by hand using squared correlations as a measure of the variance accounted for by each relationship between items-— suggested the possibility of clusters being present in the data. To investigate this further, a formal cluster analysis was performed using PACKAGE, a system of computer routines de- signed in part to generate a cluster analysis on correlational data (Hunter and Cohen, 1969). The effectiveness of this pro- gram in forming clusters was demonstrated in a comparison with clusters formed by hand. In the example cited, the same clus- ters were produced with a time saving of 75% (Hunter, 1972, p. 11). This program generates a matrix of similarity coeffi- cients which are then ordered from the highest absolute cor- relation on down to the least correlated item in the matrix. Using the ordered matrix and item content as guides, preli- minary clusters were formed and these were run as a "multiple groups analysis." This run formed groups of each cluster by summation and correlated them with each other as well as with each original item. Cluster descriptions can be found in Fig- ure 1. INTERCORRELATIONS AMONG CLUSTERS. Table 7 presents the intercorrelations among the clusters. Stable Home Life correlated with Home Responsibilities and Out- come at the .01 level and with low Professional and Medicine 31 Involvement at the .05 level. Home Responsibility also was negatively related to Dis- charge Symptomatology (.05 level), and Pro & Med Involvement correlated negatively with Employment (.05 level). 32 Stable Home Life - High Residential Involvement, Home Acti- vities, Marriage, Age. Home Responsibilities - Home Responsibility Involvement, Positive Perception of Responsibilities, Lack of Pressure on Responsibilities. Pro & Med Involvement - Professional Involvement, Medication. Employment - Employment Involvement, Positive Percep- tion of Employment, Lack of Employment Pressure. Visitors - Visitor Involvement, Positive Perception of Visitors, Lack of Visitor Pressure. Low Social Class - Low SES, Little Education, Many Previous Hospitalizations. Outcome - Symptom Change to 3 Months, Few 3 Month Symptoms, Many 3 Month Activities. FIGURE 1. INDIVIDUAL ITEMS IN ENVIRONMENTAL SUPPORT CLUSTERS. 33 TABLE 7 INTERCORRELATIONS AMONG ENVIRONMENTAL SUPPORT CLUSTERS. HOME HOME P RO & LIFE RESPONS.MED :EH- PLOY- VISI- DISCH OUT- MENT TORS SES SYMP. COME ** p< .01 HOME LIFE - HOME RESPON- SIBILITIES .46** - PROFESSIONAL & MEDICATION '.38* ".02 - VISITORS P.06 -.01 .07 .08 - SES .22 .23 “.18 ‘.02 -.13 - DISCHARGE SYMPTOMATOLOGYT.24 -.35* .02 .05 -.09 .15 - OUTCOME .54** .22 -.18 .04 .31 .18 -.05 - * p < .05 34 CLUSTERS X OUTCOME VARIABLES. The correlations of clusters with individual outcome measures is presented in Table 8. Only Home Life was found to be significantly related to Symptom Change to Three Months, (.10 level). The Home Life cluster was also related to low symptomat- ology at three months (.01 level), as was the Visitor cluster (.05 1eVel). The three month activity measure was related to both Home Life (.01 level) and Home Responsibility (.05 level). 35 TABLE 8 CORRELATIONS OF CLUSTERS WITH INDIVIDUAL OUTCOME VARIABLES Clusters Improved Symptom Low 3 3 Month Low Dis- Change To Three Month Activity charge Months Symptomato- Symptomato- logy 109! Home Life .27x .47** .61** .24 Home Respon— sibility -.05 .25 .35* .35* Professional & Medication -.14 -.22 -.09 7.02 Employment .02 .02 .06 —.05 Visitors .24 .35* .18 .09 SES .21 .05 .18 -.15 X p_<.10 * p (1.05 ** p < .01 CHAPTER IV DISCUSSION BASIC HYPOTHESES. In terms of the original hypotheses on environmental support, only the individual's perception of employment, that is, whether he liked his job situation, was related to im- provement over three months. As will be discussed in more detail later, the three month time limit could have been too short to obtain good data on the change in symptomatology. The correlation of the stable home life cluster, espe- cially age and marital status items, with each of the outcome measures as well as with the outcome cluster lends strong sup- port to the hypothesis relating adequate pre-hospitalization adjustment with measures of pathology after hospitalization. That is, individuals who had been able to make an at least overtly adequate response to others--prior to hospitalization --i.e. getting married and functioning as an adult within a family unit-~showed fewer symptoms and were more active at the end of the follow-up period. Social class differences did not appear on the data. This is probably due to the preponderance of lower-middle and lower class individuals included in the study. Research has sug- gested that a large proportion of upper class individuals u- tilize private treatment facilities or enter public facilities 36 37 under the care of a private physician. Our sample of patients for whom the community mental health center had primary re- sponsibility reflected that trend. PREDICTION OF OUTCOME. Symptom Change. Only one independent variable was sig- nificantly correlated with Symptom Change to Three Months, high Discharge Symptomatology. (Table 5). Thus, we find a situation in which those with the most symptoms on discharge had the greatest tendency toward improvement. This finding could relate to the different types of symptoms represented in the Checklist. Certain symptoms (e.g. feeling blue, feeling you were not functioning as well as you could, nervousness and shakiness under pressure, etc.) do not necessarily prevent discharge. Thus, an individual would be released from the unit with a great many symptoms--or strong scores on a moderate amount of symptoms--providing the symp- toms involved were not considered serious. These data Show that, when that's true, these symptoms have a tendency to drop out or reduce their pressure on the individual. So, this finding must be considered a descrip- tion of a discharge decision based on an analysis of impair- ment to which our measuring instrument was insensitive. The fact that these highly symptomatic individuals do Show improvement after discharge would serve to support the concept of a drive for health inherent in the individual and independent of environmental factors. 38 In addition to the above, trends were discovered link- ing positive Employment Perception and a greater number of Previous Hospitalizations to high Symptom Change. It is felt that these relationships are measurement artifacts as the Previous Hospitalizations item is very heavily skewed (over 1/2 the sample had no previous hospitalizations) and data on Employment Perception could be gathered only from those who were currently working--about 1/2 the sample. This essenti- ally based the correlation on the mean score because of so much missing data. 3 Month Symptomatology. The poSitive correlation of 3 Month Symptomatology with Discharge Symptomatology (Table 5), essentially a pre-post test situation, was expected. Thus, while changes in symptomatology did occur over 3 months, one of the best predictors of final level of symptoms remained our measure of pathology at discharge. This relationship, when combined with that relating Discharge Symptomatology and Symptom Change, implies that much of the change in scores is due to the phenomenon Of discharge decision making mentioned previously. The correlation with 3 month Symptomatology of a positive Perception of Visitors and little Visitor Pressure led to the creation of a Visitors cluster, adding the amount of Visitor Involvement. This entire unit seems to suggest a benign con- tact, positively perceived, that relates to lower post-hospi- talization symptomatology. The fact that no significant 39 relationship was found with reduction of symptoms implies that the cause-effect nature of this relationship is not clear. It could be that the effect is a long term one, not revealed in so short a time, or it could be that the relationship is merely correlational. Another cluster was formed utilizing the variables of Living Involvement and higher Age as a base. These items were placed with Marital Status and Home Activities, forming a picture of a stable, or at least intact, home life which was related to low symptomatology and a lot of activity at three months. Thus, two general groupings of environmental suppOrt variables were discovered which were related to 3 Month Symp- tomatology (Table 8) and yet are independent of each other (r = -.06) (Table 7). Both a stable home life and the pre- sence of friends and neighbors in the former patient's en- vironment can effectively influence the level of disturbance in the patient. The trend for women to have more symptoms than men may be explained in terms of each sex's role within the culture. It is much more acceptable for a woman to admit weakness and ask for help than it is for a man (for example, women typi- cally score higher on anxiety and neuroticism scales than do men). To the extent that the Checklist was interpreted as an admission of weakness, men would be less inclined to admit their symptoms than women. Activitnyevel. Being married and of older age both 40 relate to more activity at three months. Marriage apparently Opens up the individual to new responsibilities and involve- ment with others, but it must be remembered that only those willing to become active would get married. Thus, no causa- tion direction can be implied. It is felt that Older age is related to activity level through its correlation with marri- age as well as its relationship to maturity. From the original Activity Checklist, activities relating to the house and household chores (shopping, training of other household members, budgeting, etc.) were gathered into a Ho- me Activities index. It is an indication of the strong rela- tionship between a stable home life and activity level that this subscale, Home Activities, was included in the Home Life cluster during the statistical analysis. Pressure from others in the area of home responsibilities shows a negative relationship to activity level. Thus, those individuals who receive more pressure to perform at home are less active generally. The effect seems to be interactional, an hypothesis supported by the fact that the strongest posi- tive correlation between Pressure for Home Responsibilities and activity level is with Home Activities. In other words, while pressure to perform at home may be detrimental to the individual, it must be kept in mind that those individuals not functioning well in the first place tend to call forth the greatest amount of pressure. CHAPTER V SUMMARY AND CONCLUSIONS The contribution of the present study to the field of mental health procedures lies mainly in its providing an ini- tial trial for a measure of a series of environmental support variables that may prove useful in the rehabilitation of the ex-patient. More work needs to be done, but the feasability of measuring environmental supports by means of a question- naire has been established. In addition, the ease with which these variables divide into clusters would imply that the concept of environmental support is not unitary. Though the results are only tentative given the state of development of the environmental support instrument and the small sample size, two general clusters were discovered which tentatively were related to a more benign post-hospital ad— justment. The first of these clusters, and the more powerful, is that of a stable home life. It was found that an intact kin- ship network does have a strong relationship to patient con- dition. The only qualification that must be added is that the individual must be in a "parent" rather than a "child" position in the system. The other cluster involves the presence of benign visitors, 41 42 either friends or relatives. These individuals must exert a minimum of pressure on the patient to be really effective. Thus, this study suggests that either one of the above groupings in the patient's external environment indicates a more positive prognosis than might otherwise be the case. Both clusters were found to be significantly related to the level of symptomatology at three months. But in the section of the study dealing with actual change in symptomatology, only the results in terms of a stable home life appear, and then only as a trend. This suggests a direction of movement-- for this variable--which might have been stonger had there been a longer follow-up period. It has long been assumed that family and friends can be very helpful in the rehabilitation of the hospitalized mental patient. It was the aim of this study to help devise ways to examine this assumption systematically and begin to clari- fy the conditions under which improvement could be expected. We feel that this has been done on a limited basis, and that further research should involve both a larger, more represen- tative sample of patients and a more extensive follow-up pe- riod to allow the trends to become clearer. LIST OF REFERENCES LIST OF REFERENCES Caplan, Gerald, Principles of Preventive Psychiatry, New York, Basic Books, Inc., 1964? Cohen, A. K. and Hodges, H. M. Jr., Characteristics of the Lower-Blue-Collar Class, Social Problems, 10, 1963, 303- 334. Dohrenwend, B. P., The Social Psychological Nature of Stress: a Framework for Casual Inquiry. Journal g£.Abnormal and Social Psychology, 62, 1961, 294-302. Dohrenwend, B. P. and Dohrenwend, B. 8., Social Status and Psychological Disorder, New York, John WiIey & Sons, Inc., I969. Fairweather, George W., Social Psychology in Treating Mental Illness: An ExperimentaI Approach, New York, John Wiley & Sons, Inc., 1964. ., Methods for Experimental Social Inter- vention, New York, JOhn Wiley 5 Sons, Inc., 1967. ., Sanders, David H., Cressler, David L., Maynard Hugo, Community Life for the Mentally Ill, Chicago, Aldine Publishing Co., 1969. Goffman, Erving, Asylums, New York, Doubleday & Co., Inc., 1961. Greenblatt, Milton, Levinson, Daniel, Klerman, Gerald, (Ed.), Mental Patients in Transition, Springfield 111., Charles C. THomas, I96I. Hollingshead, A. B., and Redlich F. C., Social Class and Men- tal Illness, New York, John Wiley & Sons, Inc., 1958. Hunter, John E., Methods of Reordering the Correlational Matrix to Facilitate Visual Inspection and Preliminary Cluster Analysis, Unpublished Manuscript, 1972. Hunter, John E., and Cohen, Stanley M., Package: A System of Computer Routines for the Analysis of Correlational Data, Educational and Psychological Measurement, 29, 1969, 697- 700. Kardiner, Abram and Spiegel, Herbert, War Stress and Neurotic Illness, New York, Paul B. Hoeber, 1947. 43 44 Katz, Martin and Lyerly, Samuel, Methods for Measuring Ad- justment and Social Behavior in the Community: I Ra- tionale, Description, Discriminative validity, and Scale Development, Psychological Reports, 13, 1963, 503-535. Kellner, R. and Sheffield, B. F., The Relief of Distress Fol- lowing Attendance at a Clinic, British Journal 9: Psy- chiatry, 118 (Feb.), 1971, 195-198. Langer, E., Medicine for the Poor: a New Deal in Denver, Langner, Thomas and Michael, Stanley, Life Stress and Mental Health, London, The Free Press of GIencoe-Collier Mac- Millian Ltd., 1963. Leff, Melitta, Roach, John, and Bunney, William, Environmental Factors Preceeding the Onset of Severe Depressions, Psy- Lucas, Leon, The Detroit Group, Detroit, United Community Ser- vices Of MetropolitaI Detroit, 1959. Maddi, S., The Existential Neurosis, Journal g£_Abnormal Psy- chology, 72 (4), 1967, 3H—325. Michaux, William, Katz, Martin, Kurland, Albert, and Gansereit, Kathleen, The First Year Out: Mental Patients After Hos- pitalization, BaItimore, Jofins HopEins Press, I969. Rainwater, L., Famil Design: Marital Sexuality, Family Size, and Contraception, Chicago, Aldine Publishing Co., Inc., I965. Silverstein, Max., Psychiatric Aftercare, Philadelphia, Univ. of Penn. Press, 1968. Stewart, A., Selkirk, S. A., and Sydiaha, D., Patterns of Ad- justment of Discharged Psychiatric Patients as Measured by Mailed Questionnaires, Community Mental Health Journal, 5 (4), 1969, 314-319. Stillman, Stephen, Mental Illness and Peer Group Popularity, Journal gf Clinical Psychology, 27 (2), 1971, 202-203. Zigler, Edward and Phillips, Leslie, Social Effectiveness and Symptomatic Behaviors, Journal g£_Abnormal and Social Psychology, 61 (2), 1960, 231-238. APPENDICES APPENDIX A SYMPTOM CHECKLIST SYMPTOM CHECKLIST The items listed below are complaints that you may or may not have had ig_the past few weeks. Each item can be responded to in four ways. Please check the one which best describes your own experience. An example is given below: A. Feeling Thirsty l 2 3 4 Have not Bothers Bothers Bothers me had this me a me quite almost all complaint little a bit the time If you often feel thirsty, you should check number 3, "Bothers me quite a bit." Today or during the past few weeks 1 2 3 4 Have not Bothers Bothers Bothers me had this me a me quite almost all complaint little a bit the time 1. Headaches 2. Pains in the heart or chest 3. Heart pounding or racing 4. Trouble getting your breath 5. Constipation 6. Nausea, vomiting or upset stomach 7. Loose bowel movements 45 46 Today or during the past few weeks 1 2 3 4 Have not Bothers Bothers Bothers me had this me a me quite almost all complaint little a bit the time 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. 21. Twitching of the face or body Faintness or dizziness Hot or cold spells Itching Frequent urination Pains in the lower part of your back Difficulty in swallowing Skin eruptions or rashes Soreness of your muscles Nervousness and shakiness under pressure Difficulty in falling asleep or staying asleep Sudden fright for no apparent reason Bad dreams Blaming yourself for things you did or failed to do 22. 23. 24. 25. 26. 27. 28. 29. 30. 31. 32. 47 Today or during_the past few weeks 1 Have not had this complaint Feeling gene- rally worried or fretful Feeling blue Being easily moved to tears A need to do things very slowly in order to be sure you were doing them right Feeling like you have to do the same thing over and over again, like touching, counting, hand- washing, etc. Unusual fears Thoughts or im- pulses which you don't like keep pushing themselves into your mind Your "feelings" being easily hurt Feeling that people were watching or talking about you Preferring to be alone Feeling lonely 2 Bothers me a little 3 Bothers me quite a bit 4 Bothers me almost all the time 33. 34. 35. 36. 37. 38. 39. 40. 41. 48 Today or during the past few weeks 1 Have not had this complaint Feeling like you have to ask others what you should do People being unsympathetic with your need for help Feeling easily annoyed or irritated Severe temper outbursts Feeling critical of others Frequently took medicine to make you feel better Difficulty in speaking when you were exCited Feeling you were not functioning as well as you could, feeling blocked or unable to get things done Having an impulse to commit a violent or destructive act, for example, desire to set a fire, stab, beat or kill some- one, mutiliate an animal, etc. 2 Bothers me a little 3 Bothers me quite a bit 4 Bothers me almost all the time 42. 43. 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. 55. 49 Today or during the past few weeks Have not 1 had this complaint Blurring of vision Feeling thirsty Pains in arms or legs Loss of strength Dry mouth Pain in belly Feeling hungry Getting tired easily Feeling sleepy much of the time Keyed up and jittery Having no interest in things Having trouble keeping your mind on what you were doing Loss of appetite Having strange sexual ideas 2 Bothers me a little 3 Bothers me quite a bit 4 Bothers me almost all the time APPENDIX B ENVIRONMENTAL SUPPORT VARIABLES ENVIRONMENTAL SUPPORT VARIABLES LIVING INVOLVEMENT. Judgement of Healthiness or Responsibi- lity in the living situation. (e.g. 5 = meals and other interaction with family daily, 1 = living alone). LIVING PRESSURE. Amount of pressure from others to maintain or change living involvement. (e.g. 5 = constant sugges- tion or push to change, become more active, 1 = no men- tion of dissatisfaction). EMPLOYMENT INVOLVEMENT. Independent judgement of healthiness, responsibility and involvement in employment. (e.g. 5 = good attendance record at a full time job, 1 = no employ- ment). EMPLOYMENT PRESSURE. Amount of pressure from others to main- tain or change employment involvement. (e.g. 5 = constant push from others to find job, or stay on present one, 1 = no mention of others dissatisfaction). EMPLOYMENT PERCEPTION. Subject's global negative to positive perception of his employment situation (Involvement and Pressure combined). (e.g. 5 = very happy about all as- pects, l = totally displeased. RESPONSIBILITY INVOLVEMENT. Independent judgement of healthi- ness, responsibility, and involvement in home responsi- bilities. (e.g. 5 = performs more than normative amount of tasks, 1 = no involvement in household tasks). 50 51 RESPONSIBILITY PRESSURE. Amount of pressure from others to maintain or change home responsibility involvement. (e.g. 5 = constant push from others, 1 = no mention of encou- ragement or pressure--self-motivated). RESPONSIBILITY PERCEPTION. Subject's global negative to po- sitive perception of his home responsibility situation (Involvement and Pressure combined). (e.g. 5 = very hap- py about all aspects, 1 = totally displeased). VISITOR INVOLVEMENT. Independent judgement of healthiness, responsibility, and involvement in visits from others and trips outside the house (contact with the larger world). (e.g. 5 = many contacts by several people, much activity with others, 1 = no contacts outside the home). VISITOR PRESSURE. Amount of pressure from others to maintain or change involvement with visitors and visits. (e.g. 5 = most contacts, suggestions from others, invitations, etc., 1 = no contacts from others with suggestions). VISITOR PERCEPTION. Subject's global negative to positive perception of his relationships with others outside the immediate family (Involvement and Pressure combined). (e.g. 5 = very happy about all aspects, 1 = totally dis- pleased). PROFESSIONAL INVOLVEMENT. Contact on a structured basis with a mental health professional or agency program designed as therapeutic (individual therapy, groups, day centers, etc.). (e.g. 5 - contact 2 x per week or more,l = no con- tact). 52 MEDICATION. The presence or absence of prescribed medica- tion. (e.g. 2 = yes, 1 = no). APPENDIX C CHARACTERISTICS OF THE SAMPLE POPULATION CHARACTERISTICS AGE 34 28 35 42 22 48 25 48 58 29 23 35 47 25 52 36 50 25 67 31 45 22 56 24 47 39 24 23 46 23 46 SEX MARITAL YEARS STATUS EDUCAT. HOSPIT. F M 7 F Div. 12 F M 12 F Div. 12 M S 3 yr. F Div. 9 F Div. 7 F M 12 F M 12 M Div. 8 F S 9 M S 2 yr. F M 9 F M 12 M Sep. 8 F S 3 yr. F Div. 12 F Div. 12 M M 2 yr. F Sep. 9 F M 12 F S 3 yr. F M 7 F S 2 yr. F M 12 M Div. 12 F M 12 M M 11 F S BA F M 1 yr. F 8 BA F Div. 12 F M 12 M M BA 53 PREV. coll. coll. coll. l-‘OHI—‘OOOJSWONhH OOOH 5 coll.0 7 l coll.0 1 coll.0 NH)" O coll. OOOOOO OF THE SAMPLE POPULATION. FORMAL DIAGNOSIS Chronic Schiz. Anxiety Neurosis Acute Schiz. Hysterical Perso- nality Schiz. Chronic Schiz. Chronic Schiz. Inad. Pers. Neurosis Alcoholic Schiz. Schiz. Inad. Pers. Schiz. Chronic Schiz. Paranoid Schiz. Inad. Pers. and Alcoholism Depression Acute Schiz. Depression Inad. Pers. and Alcoholism Inad. Pers. and Depr. and Hyst. Depression Adj. react. to Adulthood Acute PsychOtic episode Anxiety Neurosis Depression Alcoholism and passive agg. pers. Schiz. Depressive react. Depression Depression Passive agg. pers. Depression PT. 35 36 37 38 AGE 34 29 28 SEX "11'11'11'11 MARITAL YEARS STATUS EDUCAT. HOSPIT. M Wid. M Sep. 54 PREV. 1 yr.coll. 1 12 12 12 0 0 0 FORMAL DIAGNOSIS Hysterical Neurotic. Depression Neurosis Inad. Pers. APPENDIX D ENVIRONMENTAL SUPPORT QUESTIONNAIRE ENVIRONMENTAL SUPPORT QUESTIONNAIRE Hello, this is . I spoke with you last about a month ago at St. Lawrence when you agreed to help us in our follow-up of how things are going for you these days. (RESISTANCE) Perhaps I should explain that any information given by you will be considered strictly confidential. We hope to be better able to help future patients at St. Law- rence by talking with former patients after their return home.... (REFUSAL) CONTACT IN PERSON. Mr. , you de- cided not to participate in our study after first agreeing to it. I was wondering if you could tell me what changed your mind? A) How have things been going in general? Would you say very well, pretty well, fair, or poorly? 55 B) 56 I'd like to ask you a few more questions now about what's been happening for you. I. First, where are you now living? What type of house is this? A. Who else is living there? (names-to l, O-to II) Name Relationship to you? Age How often do_you see them II. Are A. Do you share meals with the other household members? How often/week? you currently employed? (Yes-to A, No-to B) Where are you employed? What do you do? 1. How did you find this job? Who helped? 2. Do you find your co-workers friendly? Which ones? In what ways? (to III) 57 B. Have you worked at all in the last four weeks? (Yes-to 1, No-to C) 1. What happened? C. Has anyone suggested that you find a job? (No-to III) 1. Who? 2. Has anyone offered to help you look for work? a. How have they helped? b. How do you feel about this? III What regular duties or responsibilities do you have at home these days? (#-toA, None-to B) A. What are they? Anything else? Anything else? 1. Was this your own idea, or has anyone encou- raged you to do these tasks? Who? How? 58 2. Do you enjoy them or not? What do you enjgy about them? What not? B. Are there any areas at home in which you help out periodically? 1. Was this your own idea, or has anyone encou- raged you to do these tasks? Task Who encouraged How encouraged How do you feel about this? 2. DO you enjoy them or not? What do you enjoy about them? What not? C. What kinds of things do you do around the house? What kindscf things? With whom do you do them? 59 IV. Who has visited you or called you on the phone in the last week? (#-to A, O-to V) A. How Often was each person in contact with you? B. What did you talk about? What else? What else? C. Did you suggest doing anything together? Did you do it? How was it? D. Did they suggest doing anything together? Did you do it? How was it? V. In the past week, where have you gone outside the home? (#-to A, O-to B1 With whom? 60 A. Was this your own idea, or did someone else suggest it? Where Who suggested it Did you enjoy it or not? What did you enjoy about it? What not? B. In the past month, where have you gone outside the home? With whom? 1. Was this your own idea, or did some else suggest it? Where? Who suggested it? Did you enjoy it or not? What did you enjoy about it? What not? 61 VI. What have you done for entertainment in the past month? (0-to C) Entertainment Where did you go for this? Who did you go with? What else? What else? A. Were you invited out at any time in the past month when you decided not to go? Entertainment Where? Who invited you? Why didn't you go? VII.Have you had any contact with a Clinic, agency, or office during the past month? (Example of needed: St. Lawrence outpatient unit) (Yes-to A, No-to VIII) A. How Often? B. What kind of treatment are you getting? 62 VIII Have you had any contact with any therapist during the past month? (Yes-to A, No-to IX) A. How often? B. What do you do there? IX. Are you currently taking any medication? How often? A. Who prescribed this? B. Was any prescribed by the doctor when you left the hospital? C. Have you seen anyone recently about this? Is there anything that you would like to add to what you have already told me? Do you have any questions? Thank you very much for your time. I'll be in touch with you again next month. When would be a good time of day to call? APPENDIX E MEAN VALUES OF THE SYMPTOM CHECKLIST ITEMS AT DISCHARGE TABLE 1 A MEAN VALUES OF THE SYMPTOM CHECKLIST ITEMS AT DISCHARGE (Scale of l - 4) Headaches Pains in heart or chest Heart pounding or racing Trouble gettingyour breath Constipation Nausea, vomiting or upset stomach Loose bowel movements Twitching of face or body Fainting or dizziness Hot or cold spells Itching Frequent urination Pains in lower part of body Difficulty in swallowing Skin eruptions or rashes Soreness of your muscles Nervousness or shakiness under pressure Difficulty in falling or staying asleep Sudden fright for no apparent reason Bad dreams Blaming self for things you did or failed to do Feeling generally worried or fretful 63 2.00 1.45 1.76 1.69 1.57 1.69 1.52 1.43 1.67 1.69 1.68 1.57 2.21 1.45 1.43 1.62 2.67 2.38 1.90 1.70 2.55 2.55 64 Feeling blue Being easily moved to tears Need to do things slowly Feeling you have to do the same thing over and over again Unusual fears Feelings being easily hurt Feeling others were watching or talking about you Preferring to be alone Feeling lonely Feeling you have to ask others what you should do People being unsympathetic with your need for help Feeling easily annoyed or irritated Severe temper outbursts Feeling critical of others Frequently take medication to make you feel better Difficulty in speaking when you were excited 2.24 2.29 2.00 1.57 1.81 2.43 1.69 2.07 2.45 2.00 1.50 2.07 1.57 1.64 1.95 2.02 Feeling you were not functioning as well as you could Having an impulse to commit a violent act. Blurring of vision Feeling thirsty Pains in arms or legs Loss of strength Dry mouth Pain in belly Feeling hungry Getting tired easily Feeling sleepy much of the time 2.45 1.40 1.76 2.00 1.55 2.00 2.24 1.55 2.10 2.12 2.05 65 Keyed up and jittery Having no interest in things Having trouble keeping your mind on what you were doing Loss of appetite Having strange sexual ideas 2.60 1.88 2.17 1.50 1.40 APPENDIX F ACTIVITY CHECKLIST ACTIVITY CHECKLIST The statements below describe some of the things that you might be doing around the house. Each statement can be completed in five ways. Please check the one which best de- scribes your own activities. An example is given below. Example: I watch TV. Never Rarely Sometimes Often Always If you watch the TV several times a day, you should check "Often." l. I help with household chores. ____Always ____Often ____Sometimes ____Rarely ____Never 2. I dress and take care of myself. ____Always ____Often ____Sometimes ____Rarely ____Never 3. I help with the household budgeting. ____Always ____Often ____Sometimes ____Rarely ____Never 4. I remember to do important things on time. ____Always ____Often ____Sometimes ____Rarely ___yNever 5. I get along with household members. ____A1ways ____Often ____Sometimes ____Rare1y ___yNever 6. I get along with neighbors. Always Often Sometimes Rarely Never 66 7. 8. 9. 10. ll. 12. 13. 14. 15. 16. 17. 18. 19. 67 I help with household shopping. Always Often Sometimes Rarely Never I help in the care and training of other household members. Always ____Often ____Sometimes ____Rarely I help support the household. Always ____Often Sometimes ____Rarely I work in and around the house. Always ____Often Sometimes ____Rarely I work in the garden or yard. Always ____Often ____Sometimes ____Rarely I shop for groceries. Always ____Often Sometimes ____Rarely I visit my friends. Always ____Often Sometimes ____Rarely I visit my relatives. Always ____Often Sometimes ____Rarely I entertain friends at home Always ____Often ____Sometimes ____Rare1y I go to parties and other social activities. Always ____Often Sometimes ____Rarely I go to church. Always ____Often ____Sometimes ____Rarely I take up hobbies. Always ____Often Sometimes ____Rarely I work on some hobby. Always Often Sometimes Rarely Never Never Never Never Never Never Never Never Never Never Never Never 20. 21. 22. 23. 24. 25. 26. 27. 28. 29. 68 I listen to the radio. Always ____Often ____Sometimes ____Rarely I watch television Always ____Often ____Sometimes ____Rare1y I go to the movies. Always ____Often ____Sometimes ____Rarely I write letters. Always ____Often ____Sometimes ____Rarely I attend lectures, theatre. Always ____Often ____Sometimes ____Rarely I attend club, lodge, or other meetings. Always ___yOften ____Sometimes ____Rarely I take part in community or church work. Always ____Often ____Sometimes ____Rarely I bowl or play other sports. Always ____Often ____Sometimes ____Rarely I play cards or other table games. Always ____Often ____Sometimes ____Rarely I read. Always Often Sometimes Rarely 30. I take rides. Always Often Sometimes Rarely Never Never Never Never Never Never Never Never Never Never Never APPENDIX G MANN WHITNEY U VALUES FOR PATIENTS WITH 5 GREATEST INCREASES IN SYMPTOMATOLOGY VS. 5 GREATEST DECREASES TABLE 2 A MANN WHITNEY U VALUES FOR PATIENTS WITH 5 GREATEST INCREASES IN SYMPTOMATOLOGY VS. 5 GREATEST DECREASES VARIABLE U Living Involvement 12.5 Employment Involvement 8.0 Employment Pressure 11.0 Employment Perception 7.5 Responsibility Involvement 9.5 Responsibility Pressure 12.0 Responsibility Perception 6.5 Visitor Involvement 11.0 Visitor Pressure 6.5 Visitor Perception 8.5 Professional Involvement 8.5 Medicine Involvement 6.5 Socioeconomic Status 11.5 Age 6.0 Marital Status 10.0 Sex 10.0 Note: None of the above comparisons are significant. 69 APPENDIX H INTERCORRELATIONS AMONG SOCIAL SUPPORT VARIABLES AND BACKGROUND FACTORS 70 I mH.I 8. 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