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AN ASSESS MEMT OF THE COMMUNTTY ADIUS Tm" fl 7
SF PARTICIPANTS m THE MOADON SHALOM==A
REHABIUFATEON CLUB FOR EX - MENTAL PAWS
3N fERUSALEM, ISRAEL

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AN'ASSESSMENT OF THE COMMUNITY ADJUSTMENT 0F PARTICII PANTS
IN THE MOADON SHALOM--A REHABILITATION CLUB FOR
EX-MENTAL PATIENTS IN JERUSALEM, ISRAEL

presented by

Jay Twig Lazier

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Services and Educational
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ABSTRACT

AN ASSESSMENT OF THE COMMUNITY ADJUSTMENT OF PARTICIPANTS
IN THE MOADON SHALOM--A REHABILITATION CLUB FOR Ex-MENTAL
PATIENTS IN JERUSALEM, ISRAEL
by

Jay Twig Lazier

The purpose of this study was to assess the community
adjustment of participants in the Moadon Shalom, a rehabil-
itation club for ex-mental patients in Jerusalem, Israel.
The criteria for community adjustment in this thesis were:
(a) maintenance of the ex-mental patient in the community
(community tenure) and (b) adequate adjustment in essential
living tasks (living arrangements, household duties, work,
self-care, social activities and recreational activities).
Community tenure was defined as the percentage of hospital-
ization time saved since being referred to the Moadon, and
was measured by comparing time spent in the community after
referral to the Moadon with a comparable baseline period
before referral. Community adjustment was defined as the
quantity and quality of social interaction in the above-
mentioned living tasks and was measured by the Social Inter-

action Questionnaire developed by Spivak ('67).

Jay Twig Lazier

The Social Interaction Questionnaire was constructed
from a mapping sentence based on facet theory and contains
a measure of present functioning, functioning at one's best
period since the age of twenty, and a comparison between
these two periods. Social interaction scores were thus
based on the discrepancy between present functioning and
functioning during one's best period since the age of
twenty.

A first step in the execution of this study was to
define the population being evaluated (the 150 active mem-
bers of the Moadon Shalom). Since population parameters
were available from a census study of the Jerusalem ex-

1, it was possible to define the

mental patient population
Moadon population by comparing it with the census popula-
tion (1,531 people who were released at least once from a
mental institution between 1963 and 1968) on the demo-
graphic variables being considered. Results of this compar-

ison indicated that the Meadon was not working with a cross-

section of the ex-mental patient population, but rather with

 

1This study is related to a larger study of the Jerusalem

ex-mental patient population under the direction of Dr.
Mark Spivak, Israel Institute of Applied Social Research,
Jerusalem, Israel.

Jay Twig Lazier

a chronic population characterized by an inability to
adjust to life in the community and by poor rehabilitation
potential.

The results relating to community tenure demonstrated
that the great majority of Moadon participants saved a sig-
nificant amount of hospitalization time after participating
in the Moadon. Further analysis indicated that those who
saved hospitalization time could not be differentiated from
those who lost hospitalization time in terms of those
variables related to chronicity. Support is thus provided
for the hypothesis that increased community tenure was
related to participation in the Moadon, rather than to
greater rehabilitation potential on the part of those who
saved hospitalization time. Although those saving and
losing hospitalization time could not be differentiated in
terms of attendance and contact (outreach), it was found
that gainers with high attendance and high contact ratings
were more chronic than gainers with low attendance and low
contact ratings. These results led to the conclusion that
the Moadon was attaining its goal of successfully working
with those clients at the negative end of the continuum in

terms of chronicity and rehabilitation potential.

I!

Jay Twig Lazier

The results relating to the other aspects of com-
munity adjustment indicated that: (a) vocational function-
ing on the part of the great majority of Moadon members
improved after participation in the Moadon; (b) a relation-
ship existed between attendance and quantity of social
interaction, with high attenders being more actively in-
volved in the community; (c) a relationship existed between
attendance and quality of social interaction, with high
attenders expressing more positive feelings about the
quality of their life in the community. It was concluded
that participation in the Moadon was related both to in-
creased community tenure and improved community adjustment.

The study was also seen as making a contribution to
the field of psychiatric rehabilitation because of its con-
sideration of the following issues: (a) determining the
applicability of a treatment program for a particular seg-
ment of the ex-mental patient population, (b) using a
period of time before referral as a baseline from which to
measure community tenure, and (c) assessing the quality of

life as well as maintenance in the community.

AN ASSESSMENT OF THE COMMUNITY ADJUSTMENT OF PARTICIPANTS
IN THE MOADON SHALOM-9A REHABILITATION CLUB FOR EX-MENTAL
PATIENTS IN JERUSALEM, ISRAEL

BY

Jay Twig Lazier

A THESIS

Submitted to
Michigan State University
in partial fulfillment of the requirements
for the degree of

DOCTOR OF PHILOSOPHY
Department of Counseling, Personnel Services
and Educational Psychology

College of Education

1972

G) ACKNOWLEDGMENTS

My appreciation and thanks are extended to the
many peOple who have helped me with this project and
throughout my doctoral studies. Dr. John E. Jordan, my
major advisor, has been a constant source of support to
me, and his concern for and interest in my deveIOpment
have been instrumental in motivating me to complete the
doctoral program. Dr. Richard Johnson has also been most
supportive, and is appreciated for his willingness to
listen, and his ability to provide objective and meaning-
ful feedback to new ideas both in the classroom and in
individual discussion. Dr. Frank Bruno, in his relation-
ships with my sister, my wife and myself, has shown
himself to be a person who really cares about his students,
and as a result, has helped make our graduate careers
more human and meaningful experiences.

Special thanks are extended to Dr. Mark Spivak
of the Israel Institute of Applied Social Research who
has devoted much time and energy to the direction of my
thesis; and who, by establishing the Moadon Shalom, has
provided a much needed service to the people of Israel.

Other members of the IIASR staff who have helped with this

ii

project and to whom I am most grateful are Zvi Fein, Tamar
Biran, Elana Lev, Diane Kelman and Shmaya. Thanks are also
in order for the Social and Rehabilitation Service of the
Department of Health, Education and Welfare which provided
the initial funding for the Moadon Shalom and which has
financed my graduate studies.

I would also like to thank my parents who have
given me much love and support and who have taught me the
value of a good education: my mother deserves special
recognition for her efforts in typing this thesis.

My wife Nancy cannot be thanked enough for all of
the help and encouragement she has given to me. I am
grateful for her critical reading of my term papers and
thesis, typing of endless rough drafts, and most of all
for her faith in me at times when I had little faith in
myself.

Finally, I would like to acknowledge my little
son Benji and my grandma who really didn't help me with

my thesis but whom I love very much.

iii

TABLE OF CONTENTS

Page
ACKNOWLEDGMENTS. . . . . . . . . . . . . ii
LIST OF TABLES . . . . . . . . . . . . . vii
LIST OF FIGURES. . . . . . . . . . . . . xiv

LIST OF APPENDICES. . . . . . . . . . . . xv

Chapter
I. INTRODUCTION . . . . . . . . . . . 1
Need . . . . . . . . . . . . . 14
Purpose . . . . . . . . . . . . 16

II. REVIEW OF THE LITERATURE . . . . . . . 20

Treatment in a Mental Hospital Setting. . 20
Reasons for Shorter Periods of Hospi-

talization . . . . . . . . . 22

Reasons for High Readmission Rates . . 23

Gains in the Hospital Are Not

Necessarily Generalizable . . . 24
Negative Effects of Hospitalization. 25
Problems of Post-Hospital Adjustment 27
Demographic Variables Associated

with Rehospitalization Rates . . 30

Post-Hospital Treatment as an Effective
Means of Preventing Rehospitalization . 31

Studies Demonstrating the Success of
Post-Hospital Programs 33

iv

Chapter Page

Outpatient vs. Hospital Treatment. 34

Drug Treatment Programs . . . 34

Outpatient vs. No Treatment . . 36

sumaryo 0 O O O O O O O O 0 37

III. DESCRIPTION OF TREATMENT PROGRAM. . . . 38
IV. DESIGN OF STUDY . . . . . . . . . 48
Dependent and Independent Variables . 48
Instrumentation . . . . . . . . 54

Sample . . . . . . . . . . . 59
Procedure . . . . . . . . . 61
Experimental Design. . . . . . . 72
Hypotheses. . . . . . . . . 78

Analysis Procedures. . . . . . . 81

Summary. . . . . . . . . . . 84

V. DESCRIPTION OF THE MOADON (REHABILITATION
CLUB) POPULATION . . . . o . . . 87

VI. RESULTS AND ANALYSIS. . . . . . . . 105
Community Tenure. . . . . . . . 106

H2a--Number of Moadon Members Saving

Hospitalization Time. . 106
H2b--Amount of Hospitalization Time
Savedo . . . . . 108

H2c--Relationship Between Community
Tenure and Rehabilitation

Potential . . . . . . . llO
H3 --Relationship Between Attendance
and Community Tenure. . . llS

H4 --Relationship Between Contact
(Outreach) and Community Tenure 120

Chapter Page
Community Adjustment. . . . . . . . 121
Quantity of Social Interaction . . . 123
H5--Vocational Functioning. . . . 123
H6--Re1ationship Between Attendance
and Community Involvement . . 126
Quality of Social Interaction. . . . 130
H7--Relationship Between Attendance
and Quality of Life in the
Community . . . . . . . 130
Summary and Conclusions. . . . . . . 131
Treatment in the Moadon as Compared to

Treatment in a Hospital Setting . . 134
The Moadon in Relation to Other Com-

munity Based Programs . . 136
Contributions of the Study to the Field
of Psychiatric Rehabilitation. . 137

Future Research Stimulated by the Study 138

Relationship Between Specific Aspects

of the Moadon and Community Adjust-

ment . . . . . . . . 139
Relationship Between Community

Tenure and Community Adjustment . 139
Measurement of Community Adjustment. 140
Need for Longitudinal Research . . 142

REFERENCES . . . . . . . . . 143

APPENDICES. . . . . . . . . . . . . . . 154

vi

Table

5.1

5.2

5.3

5.4

5.5

5.6

5.7

5.8

5.9.

5.10

LIST OF TABLES

Summary of hospitalization trends for
psychiatric patients

The Moadon
in terms

The Moadon
in terms

The Moadon
in terms

The Moadon
in terms

and Census populations compared
of total number of admissions.

and Census populations compared
of total time in hospital . .

and Census populations compared
of length of admissions. .

and Census populations compared
of age at first admissions. .

The Moadon and Census populations compared
in terms of diagnosis . . . . . .

Comparison of readmission rates in the
Moadon, Census population and the liter-

ature O O O O I O O O I O O 0

Comparison of the Moadon and Census popula-

tions in terms of time between admissions.

Comparison of the Moadon and Census popula-
_'tions in terms of the percentage of'
patients not requiring readmissions. .

Percentage of Moadon clients remaining in

the community for less than six months who,

after their preceding admission, had re-
mained in the community for more than six
months . . . . . .

Percentage of males and females in the hos-
pital at time of the census study in
relationship to the prOportion of males
and females in the total mental patient
p0pulation . . . . . . . . . .

vii

Page

21

89

9O

92

94

95

96

97

99

100

Table

5.11

5.12

6.1

6.2

6.3

6.4

6.5

6.6

6.7

6.8

6.9

The Moadon

in terms of sex . . . . . .

The Moadon

in terms of country of birth. .

Number and

and Census populations compared

and Census populations compared

percentage of active clients sav-

ing and losing hospitalization time . .

Comparison of active clients saving
ing hospitalization time in terms
time in the hospital . . . .

Comparison of active clients saving
ing hospitalization time in terms
at first admission . . . . .

Comparison of active clients saving
ing hospitalization time in terms
number of admissions . . . .

Comparison of active clients saving
ing hospitalization time in terms
length of first hospitalization.

Comparison of active clients saving
ing hospitalization time in terms
length of second hospitalization

Comparison of active clients saving
ing hospitalization time in terms
diagnosis . . . . . . . .

Comparison of active clients saving
ing hospitalization time in terms
work at referral. . . . . .

Comparison of active clients saving
ing hospitalization time in terms

viii

and los-
of total

and los-
of age

and los-
of

and los-
of

and 103-
of

and los-
of

and los-
of

and los-
of sex.

Page

100

101

107

111

112

112

112

112

112

112

113

Table

6.10

6.11

6.12

6.13

6.14

6.15

6.16

6.17

6.18

6.19

6.20

Comparison of active clients saving and los-
ing hospitalization time in terms of
living arrangements. . . . . . . .

Comparison of active clients saving and los-
ing hospitalization time in terms of
.marital Status . . . . . . . . .

Comparison of active clients saving and los-
ing hospitalization time in terms of
attendance. . . . . . . . . . .

Comparison of gainers with high attendance
and low attendance in terms of number of
admissions. . . . . . . . . . .

Comparison of gainers with high attendance
and low attendance in terms of total time
in hospital . . . . . . . . . .

Comparison of gainers with high attendance.
and low attendance in terms of age at
first admission . . . . . . . . .

Comparison of gainers with high attendance
and low attendance in terms of living
arrangements . . . . . . . . . .

Comparison of gainers with high attendance
and low attendance in terms of marital
Status 0 O C O O O O O O O O 0

Comparison of gainers with high attendance
and low attendance in terms of sex. . .

Comparison of gainers with high attendance
and low attendance in terms of situation

at referral . . . . . . . . .

Comparison of gainers with high attendance
and low attendance in terms of diagnosis.

ix

Page

113

113

116

116

116

116

117

11}

117

117

Table

6.21

6.22

6.23

6.24

6.25

6.26

6.27

6.28

6.29

6.30

A.1

Comparison of gainers with high attendance
and low attendance in terms of length of
first admission . . .

Comparison of gainers with high attendance
and low attendance in terms of length of
.second admission. . . . . . . . .

Comparison of gainers with high attendance
and low attendance in terms of length of
third admission . . . .

Comparison of gainers with high attendance
and low attendance in terms of work at
referral . . .

Comparison of clients saving and losing hos-
pitalization time in terms of contact.

Gainers with low attendance and gainers with
high attendance compared in terms of con-
tact. O O O O I O O 0

clients before and
in the Moadon . . .

Work status of Moadon
after participation

Work status of Moadon clients before and
after participation in the Moadon (for
high attenders) . . . . . . .

Relationship between attendance and quan-
tity of social interaction . . . .

Relationship between attendance and quality
of life in the community .

A comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of total number of
admissions. . . . . . . . . .

Page

117

117

118

120

121

124

125

129

131

163

Table Page

A.2 A comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of total time in
hospital. . . . . . . . . . . . 163

A.3 A comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of age at first
admissiOn . . . . . . . . . . . 163

A.4 A comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of diagnosis. . . 163

A.5 A comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of situation at
referral. . . . . . . . . . . . 164

A.6 A comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of sex. . . . . 164

A.7 A comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of living
arrangements . . . . . . . . . . 164

A.8 A comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of work at
referral. . . . . . . . . . . . 164

A.9 A comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of marital status . 165

A.10 A comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of length of first
admission .‘ . . . . . . . . . . 165

xi

Table

A.11

A.12

A.13

A.14

A.15

A.16

A.17

A.18

A.19

comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of length of
second admission . . . . . . .

comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of length of
third admission. . . . . . . .

comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of length of
fourth admission . . . . . . .

comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of length of
fifth admission. . . . . . . .

comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of length of
sixth admission. . . . . . . .

comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of age . . .

comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of community
tenure . . . . . . . . . .

comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of attendance.

comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of length be-
tween first and second admission . .

xii

Page

165

165

166

166

166

166

167

167

167

Table Page

A.20 A comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of length be-
tween second and third admission. . . . 167

A.21 A comparison of participants and non-
participants on the Social Interaction
'Questionnaire in terms of length be-
tween third and fourth admission. . . . 168

A.22 A comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of length be-
tween fourth and fifth admission. . . . 168

A.23 A comparison of participants and non-
participants on the Social Interaction
Questionnaire in terms of length be-
tween fifth and Sixth admission . . . . 168

xiii

Figure
1,1
4.1

4.2

4.3

LIST OF FIGURES

Lifespace of psychiatric rehabilitation. .
Mapping sentence for social interaction. .

Schematic presentation of facetized content
for each living task (Facet C) . . . .

Diagram of work necessary to execute study.

xiv

Page
. 1
. 55
. 57

62

LIST OF APPENDICES

Appendix
A Scoring scales for quantity and quality
of social interaction. . . . . .
B .Social interaction questionnaire.
C A comparison of questionnaire participants
and non-participants on relevant demo-
graphic variables . . . . . . .

XV

Page

155

158

163

CHAPTER I

INTRODUCTION

This thesis is concerned with assessing the commu-
nity adjustment of participants in the Moadon Shalom, a re-
habilitation club for ex-mental patients in Jerusalem,
Israel. Before pursuing this issue, an adequate definition
of psychiatric rehabilitation must be developed; for there
is still lacking a clear understanding as to what the proc-
ess of pschiatric rehabilitation actually represents
(Siedenfeld, '57; Schwartz and Schwartz, '64). A problem
with a number of previously developed definitions has been
their lack of specificity. Greenblatt ('59), for example,
conceptualizes psychiatric rehabilitation as a life-space
containing the following aspects: (a) psychological,

(b) vocational, (c) social-recreational, (d) family,

(e) community and (f) educational.

 

 

Psychological
Vocational Rehabilitat ion \ Family
lifespace .
Social-recreational =u4/// Educational
Community

Figure lJ. Lifespace of psychiatric rehabilitation

Although useful in pointing out areas where intervention
might be desirable, this conceptualization is too vague to
be used as a basis for an evaluation study, Since specific
criteria for success are not defined. Other definitions
that can be criticized for the same reasons are as follows:
(a) "assisting the client to realize to the fullest pos-
sible extent those potentialities that are his"(Siedenfeld,
'57). (b) "to assist the patient in transition from a
protective hospital environment to independent community
living by changing the social identity of the individual
from that of a patient to a functioning citizen.” (Tanaka,
'65). (c) "assisting the patient to achieve an optimal
social role (in the family, on the job and in the community
generally), within his capacities and potentialities”
(Williams, '53). (d) "restoration of the handicapped to
the fullest physical, mental, social, vocational and eco-
nomic usefulness of which they are capable. (Whitehouse
National Council on Rehabilitation, '51). (e) ”reintegra-
tion of the individual into the community on the most effi-
cient and useful level of adjustment possible" (Carmichael,
'59). (f) "the restoration to useful activity of indivi-
duals who have been wounded so as to suffer from physical
or emotional disability, such restoration including treat-
ment of the disability and training to fit the individual
for occupation in industry" (Simon, '59).

When concerned with measuring the effects of a

rehabilitation program, it is not enough to set such

nebulous goals, for there is a need for tangible and in-
controvertible facts that will tell us when we have reached,
or at least reasonably approximated, the aims of such a
program (Siedenfeld, '57). In short, specific criteria must
be established for evaluating the rehabilitation process.
Given different theoretical approaches, these criteria may
differ, and in this paper they have been developed from the
approach to psychiatric rehabilitation discussed below.
Traditionally, treatment of the mentally 111 has
been based entirely on the classical medical model that
emphasized disease, diagnosis, and therapeutic procedure
(Wessen, '65). In treatment settings based on the medical
model, the patient was considered to be a unique individual,
separated from the social world, and the rehabilitating
agent was concerned with assessing his traits and determining
an appropriate treatment (Bloom, '65). Such an approach may
be effective in treating a disease but not in reversing the
course of disability (Nagi, '65). Disability can be defined
as a pattern of behavior that evolves in a situation of long
term or continued impairments that are associated with func-
tional limitations. An illness or sickness on the other
hand, while indicating the presence of pathology, may not
involve limitations in the performance of normal role and
daily activities (Nagi, '65). The major goal in treating
an illness is to eliminate the underlying pathology. How-
ever, when dealing with a disability, the objective is to

reverse the course of the disability and to restore one

to his optimal level of functioning (the general goal of
rehabilitation given this conceptualization of mental ill-
ness).

The definition developed by the professional serv-
ices branch of NIMH is a step toward Operationalizing this
general approach to psychiatric rehabilitation:

First, whatever the etiology of mental disorders,

they manifest themselves prominently by psycholog-

ical decrements which may affect the social behav—
ior and interactions of the individual in adverse
ways and have adverse socio-psychological effects
on those around him. Hence, psychiatric rehabili-
tation should be concerned especially with optimal
restoration of social roles and social functioning
within the social systems significant for the
patient such as family; or various associations

and participation in the general life of the com-

munity.

The focus of this definition is on the restoration
of social roles and functioning in areas relevant to the
individual and is thus consistent with Nagi's conceptuali-
zation of reversing the course of disability. What is lack-
ing in the NIMH definition are the specific areas in which
social functioning takes place, for unless they are known,
it is difficult to determine the extent to which rehabilita-
tion programs or techniques have been successful. By con-
structing a mapping sentence, and thus bringing into focus
the various components of social interaction, Spivak ('69)
was able to delineate the major areas in which social func-
tioning takes place and listed them under the general head-

ing of "living tasks.” They are as follows:

1. living arrangements

2. household duties

3. work

4. Self Care: (a) personal appearance and care,

(b) taking of medication and (c) therapeutic
visits

5. .social activities

6. recreational activities

In developing meaningful rehabilitation goals from
the above framework, a primary objective would be mainte-
nance of the ex-patient in the community. On a more quali-
tative level, rehabilitation goals could be conceptualized
as adequate adjustment in the above-mentioned areas of
social functioning, for as was just mentioned, the focus of
the NIMH definition is on the quality of social functioning
in all significant aspects of one's life.

To briefly review, Nagi's conceptualization of re-
versing the course of disability was used as a general frame-
work for the development of rehabilitation goals. This
framework was elaborated upon by the NIMH definition which
focused upon the restoration of social roles and function-
ing in significant social systems, and became more clearly
defined through Spivak's development of the areas in which
social functioning takes place. Specifically, the rehabili-
tation goals to be used in this thesis are maintenance of
the ex-mental patient in the community and adequate adjust-
ment in the above-mentioned living tasks. This obviously
is not the only operational definition of psychiatric re-

habilitation that could be developed, but it does provide

concrete goals and therefore serves as a basis for the
evaluation of rehabilitation programs.

Given this conception of rehabilitation goals, past
and existing programs can be evaluated as to how effective
they have been in rehabilitating the mentally ill. The
mental hospital has until recently been the major instru-
ment of rehabilitation for the mentally ill, but despite
government funding, innovative treatment programs and in—
creased theoretical SOphistication, few inroads have been
made in the rehabilitation of the mentally ill in hospital
settings (Vitale and Steinbach, '65). Evidence of this
fact can be seen in studies of the mentally ill which indi-
cate that while time spent in mental hospitals is decreasing,
readmission rates are on the rise (Ratliff, '64; Brown,
Parkes and Wing, '59; Miller and Dawson, '68).

An explanation for this phenomenon can be attributed
to a conceptual framework that does not take into account
all of the rehabilitation needs of the mental patient. By
examining the philosophy and structure of hospital based
programs, such deficiencies can be observed. In general,
hospital based treatment programs have emphasized the medi-
cal model of mental illness described earlier. High re-
hospitalization rates, however, demonstrate the failure of
many hospital programs to meet even the minimal requirement
of successful rehabilitation developed in this paper--

maintenance of the ex-patient in the community. One reason

for this failure can be attributed to the medical model's
lack of emphasis on the functional limitations that accom-
pany mental illness (Pasamanick et a1, '67; Vitale and
Steinback, '65). Thus, although meeting the criteria of a
disability, mental illness has not been treated as such by
hospital programs based on the medical model.

The social structure of the mental hospital also
contributed to its lack of success in rehabilitating the
mentally ill. According to Hunt ('58), ”much of the unneces-
sary crippling of the mentally ill must be laid at the door
of the state mental hospital both from the standpoint of how
it functions internally and how it is used by the society
it serves." Ullman ('67) concurs with Hunt and states that
"during the last 100 years, with a very few exceptions the
psychiatric hospital is more likely to have been a manufactor
of chronic insanity than to have been a milieu likely to
improve chances of acceptable extra hospital adjustment."

The specific aspects of the hospital culture that made it
incompatible with the goals of rehabilitation have been suc-
cinctly presented by Goffman ('61). He sees the mental
hospital as having the characteristics of a special class of
social organization that can be called a "total institution."
In a "total institution" all aspects of life are conducted in
the same place under the same authority in the immediate
company of many others and according to a fixed and unusually

tight schedule. The sharp cleavage that exists between life

inside and outside the institution leads to a radical shift
in a person's moral career and self-image, for the patient
begins to absorb much of the inpatient culture that sur-
rounds him and learns to derive satisfaction from it.
Specifically the role of the patient in the mental hospital
differs from that of an ordinary person in several respects:
(a) Patient is separated from ordinary relationships.

(b) Needs of patient are provided for by the institution.
(c) Loss of personal responsibility develops because the
total institution is incompatible with family and community
living.

In summary, becoming a mental patient leads to a
radical shift in social position in a generally degrading
and handicapping direction and tends to increase rather
than alleviate the disability. (Felix, '58). Thus, it can
be seen that the hospital social structure and the model
under which it was operated are incompatible with the re-
habilitation goals stated in this paper.

The apparent incompatibility between hospital struc-
ture and rehabilitation goals did not go unnoticed by mental
health professionals; and just as many hospitals evolved
from custodial care institutions to ones that provided
individualized treatment (Wessen, '65; Mechanik and Nathan,
'65), other more prOgressive institutions developed pro-
grams that took into account the functional limitations of
the patient as well, thus moving into the framework of a

rehabilitation model. These experiments and reforms in

the mental hospital have been described by terms such as
"milieu therapy" or "therapeutic community." Some of the
characteristics of such programs are as follows: (a) Status
distinction among staff and patients is minimized.

(b) Unit is designed so that interest in the ”real world"
outside the hospital is maximized while still protecting
the patients from morbid pressures of their social environ-
ments. (c) Special roles are designed for patients that
allow them to take on increasingly meaningful responsibi-
bilities. (d) While retaining the therapeutic ideology of
medicine, the traditional trappings and symbols of the
hospital care model are systematically minimized.

Although helping to improve vastly psychiatric
services within mental institutions, this conceptual model
of rehabilitation was also found to be lacking, especially
for the chronic patient. Sanders, Smith and Weinman ('67)
in a comprehensive evaluation of a ”therapeutic community"
within a hospital setting reached the following conclusion:

The findings of the present study make it evident

that although hospital based socio-environmental

programs effect a remission of symptoms and are
valuable in preparing chronic patients for com-
munity life, these programs are not in themselves
sufficient to insure the patient an adequate com-
munity adjustment. Despite successful efforts of
hospital based treatment, the chronic patients'
residual limitations, inflexibility and adapta-
bility can only be surmounted by continued guidance
and assistance in adjusting to actual community
life situations...A community based rehabilitation
service is needed both to help patients with every
day living problems and to assist them directly in

attaining greater individuation and self-sufficiency
in the community.

10

Given the above data, it becomes apparent that
reversing the course of a disability within a hospital set-
ting is a difficult task and that the focus of rehabilita-
tion services must shift to the community.

The question can now be posed as to whether the
services provided by community based programs are compatible
with the rehabilitation goals stated earlier. This is an
extremely difficult question to answer,for out-patient
services are characterized by a diversified system of care
with each treatment center establishing its own criteria
for selection, treatment, and success (Schwartz and Schwartz,
'66).

To simplify matters, this thesis will focus on one
particular type of post-hospital program--the ex-mental
patient club. Although the numerous clubs that have been
established differ from one another in some respects, they
do have a common philosophy and structure. Landy and Singer
('61) state a number of basic elements in the structure of
clubs for ex-mental patients: (a) Clubs are characterized
by persisting but loosely formed relationships built upon
interdependent needs of members. (b) The ethic of equality
of rights and privileges with regard to anonymity and com-
monness of similar experiences leads to a leveling of social
status in the organization. (c) The club is a place where
the mental patient is accepted without question as to medi-

cal antecedents, dependency, etc. (d) The club is a

11

place where the patient can talk about his hospital expe-
rience and symptoms. (e) The club is a place where the ex—
patient can find and give support to others. (f) Club
members Share a sense of responsibility for one another.

In summary, ”the club for ex-mental patients serves
as a bridge between the hospital and the community--a way
of facilitating the patients' re-entry in the community in
the areas of family life, work, accomodation, social and
recreational activities” (Spivak, '69).

Theoretically speaking, the philos0phy of ex-mental
patient clubs appears to be consistent with the rehabilita-
tion goals stated earlier. However, there are still a
number of mental health professionals who see dangers in
this and other types of post-hospital programs. Specifi-
cally:

l. Aftercare is thought to foster over-dependency
on the part of the ex-patient (Schwartz et a1” '64).

2. Aftercare leads to psychiatric hypochondriasis---
overconcern with emotional reactions, family adjustment, etc.
(Schwartz et al., '64).

3. Aftercare programs may reinforce the stigma of
being in a mental hospital and encourage a person to think
of himself as being sick (Schwartz et al., '64).

4. Decline in training and use of inadequately
trained subprofessionals to work in programs (Wallerstein,
'68).

5. Community services can be as dangerous a source

12

of institutionalism as the hospital itself (Wing, '63).

6. Mass disillusionment if current enthusiasm over-
sells itself andfails to reach high expectations (Wallerstein,
'68).

7. UInadequate program evaluation in projects geared
more to the demonstration grant mold, with the unfortunate
discarding of the wide open opportunity (and the concomitant
important obligation) to test and evaluate innovations, so
that out of the crucible of experience more productive
methods may be delineated and better theory may be evolved"
(Wallerstein, '68).

Although all of the above criticisms focus on the
limitations of post-hospital treatment programs, they ap-
proach the problem from different perspectives and thus
must be examined independently. overdependence, psychi-
atric hypochondriasis, stigmatization and institutionalism
can all be considered possible dangers of post-hospital
treatment programs, but they are not necessarily inherent
in these programs. Schwartz and Schwartz ('64), in re-
sponse to the problems that they and others have raised,
state that the organizational structure of the post-hospital
program is the key to the prevention of some of these
dangers. In particular, they point to the flexibility of
organizational response (built in mechanisms to respond
to changing needs) and the focusing on patients' needs
(continual scrutiny and evaluation of program to determine

whether individualized needs are being met) as means of

13

preventing overdependency, institutionalism, etc. A lack

of sensitivity on the part of administrators and an inflex-
ible organizational structure might thus lead to the valida-
tion of the above-mentioned criticisms, but as was pointed
out, although representing potential dangers, they are not
inherent characteristics of post-hospital treatment pro-
grams.

The danger of inadequately trained subprofessionals
must be considered in the context in which it was written.
Wallerstein's article was concerned with the challenge of
community mental health to psychoanalysis, and did not
objectively assess the role played by subprofessionals.
Recent studies (Magoon and Golann, '66; Carkhuff and Truax,
'65) have shown them to be playing important and effective
roles in community mental health, as well as other related
programs, thus putting into question the validity of Waller-
stein's claim.

As far as disillusionment is concerned, this is a
danger of any innovation that is enthusiastically accepted.
At this point in time, it is already quite apparent that
the community mental health movement is not a panacea to
the mental health problems of society; but rather than ex-
periencing mass disillusionment, mental health professionals
as well as community leaders appear to be confronting and
not avoiding problems that have arisen.

‘Finally, the problem of inadequate program evalua-

tion represents more of a need than a danger, and can be

l4

resolved by an improvement in the quality of evaluation
studies of mental health programs. Hopefully, the present
study will be a step in this direction.

In summary, what can be derived from the above dis-
cussion is that despite the theoretical consistency of many
mental health programs with the rehabilitation goals de-
veloped in this paper, there are still many factors that
can interfere with the implementation of these goals. It
is thus imperative that these dangers be taken into account

by mental health administrators.

Need

 

In the previous section, Optimal rehabilitation
goals were developed and the incompatibility of hospital
treatment with those goals was demonstrated. It was also
shown that community treatment in the form of ex-mental
clubs was consistent with the goals of rehabilitation as
defined in this thesis, but there still was doubt among
some professionals as to the effectiveness of this and
other types of aftercare programs. Initial evaluation
studies have shown community based treatment programs to be
successful (Weinman et al., '70, Guy et al., '69; Vitale
and Steinbach, '65; Sheldon, '64; Sheldon and Jones, '67;
Beard et al., '63) thus eliminating some of the above—
mentioned doubts; but as Wallerstein points out, there is

a great need for more detailed and better controlled studies.

Michaux et al. ('69) and Friedman, Von Mering and Hinko ('66)

15

point this out in the following statements:

1. If the proliferating community mental health
services are not to become a muddle in which we
lose our sense of therapeutic direction, we
must therefore evaluate-~and without delay--
the comparative effectiveness of the various
new treatment modalities and their differen-
tial suitability for various types of patients
'(Michaux et a1. '69).

2. Consequently, newer approaches of intramural
and extramural program assessment must empha-
size follow-up evaluation and deal more with
the linked problems of extension of community
tenure and reduction of rehospitalization.
There is also a need for more comprehensive
and controlled studies on the qualitative
nature of the former patients' posthospital
functioning as an indicator of program accom-
pégohment. (Friedman, Von Mering, and Hinko,
l
The above points to the major failure of most evalu-
ation studies until now -- the emphasis on readmission rates
as a dependent variable without considering quality of life
in the community. According to Pasamanick et a1. ('67),
the fact that a person is Saved hospitalization time does
not validate the effectiveness of a program, especially
when one-third of the males in their study couldn't hold
jobs and one-third of the females couldn't perform basic
household activities. Therefore, although home patients may
be better off than hospitalized patients, this may not be
sufficient success.
Vitale and Steinbach ('65) also point to the plight
of the ex-mental patient in the community. In general, they
found them "grossly dependent and maintaining marginal, non-

productive social adjustment as shown by the median patient

16

who lives alone, does not work, but still manages to stay
out of the hospital."

The above arguments point to the inadequacy of re—
admission rates as a sole dependent variable in evaluation
studies of community based rehabilitation programs. Al-
though the prevention of rehospitalization is a goal worth
striving for, its value must be questioned unless rehabili-
tation programs can also be shown to be effective in improv-
ing one's level of functioning within his community.

In summary, a need exists for evaluation studies
that will examine both of these variables, and in particu-
lar the specific rehabilitation goals stated earlier in the

paper.

Purpose

The purpose of this paper is to assess the com-
munity adjustment of participants in the Moadon Shalom in
terms of the rehabilitation goals developed in this paper.
The instruments of evaluation in this study will be a census
study of the Jerusalem mental patient population and a question-
naire based on facet theory (Gattman, ' 58 and '71; Jordan, '71),
the focus of which is on social interaction in major living tasks
(basis of optimal rehabilitation goalsO . Before such an evalua—
tion can be attempted, the major characteristics of the popula-
tion to be evaluated must be known. llpreliminary objective
of this study will thus be to compare the Moadon population

with the general population of mental patients in the

17

Jerusalem area with regard to the following characteristics:
(a) sex, (b) country of birth, (c) length between admissions,
(d) number of admissions, (e) diagnosis, (f) age at first
admission, (g) total time in hospitals, (h) length of admis-
sions. Once this information has been obtained, the evalua-
tion of the program can begin.

AS stated earlier, a primary measure of community
adjustment is time spent in the community. A major goal
would thus be to determine whether time in the community in-
creases as a result of participation in Moadon Shalom. This
variable will be measured by comparing Moadon members to
themselves, or in other words, determining whether they are
staying in the community longer after having participated
in the Moadon program than they did before they entered the
program.

At this point, the relationship between the follow-
ing aspects of the Moadon program and community tenure can
be determined: (a) attendance (participation in specific
Moadon activities), (b) work, (c) contact ("reaching out”;to
new clients).

If it can be ascertained that increased community
tenure is associated with participation in the Moadon, the
next logical step would be to compare the clients on the
qualitative variables mentioned earlier. The major hypo-
thesis of this comparison would be that the wider a person's

social interaction network, the less likely he will return

18

to the hospital after release. In other words, to the
extent to which a person is functioning adequately on the
living tasks mentioned earlier, the less likely are his
chances of being rehospitalized.

Two specific questions emanate from this hypothesis:

1. In general, are those clients staying in the
community longer high social functioners as well? This
question focuses on an issue raised earlier -- are community
based treatment programs only successful in maintaining ex-
patients in the community or are they also successful in
improving the quality of life in the community? The possi-
bility also exists that even in cases where readmission
rates are not altered, ex-patient clubs might still be effec-
tive in making their community tenure more meaningful.

2. How are the above-mentioned aspects of the Moadon
program (attendance and contact) related to adjustment in
the living tasks mentioned in the questionnaire?

In general, participation in the Moadon should have most
effect in the areas of self-care, social activities, recrea-
tional activities, work and household duties, whereas the
impact of the Moadon on living arrangements will be less un-
less there was direct intervention with the family.

In summary, this analysis should present a compre-
hensive picture of the relationship between participation
in the Moadon and success on the above-mentioned variables.

What remains to be resolved are the specific criteria of

19

success, given the rehabilitation goals mentioned earlier.
If, for example, we are talking about a population of
chronic schizophrenics from low socio—economic backgrounds,
our criteria will differ greatly than if concerned with a
population of non-clients who have higher socio—economic
status. .

In general, the Moadon has had a policy of
accepting chronic patients (hospitalized frequently and
for long periods of time) and who are considered poor
rehabilitation risks by most public agencies. Results of
the census study will thus verify or disconfirm the extent
to which the Moadon has effectively carried out this policy.
If confirmed, this fact will have to be reflected in the
statistical analysis since when working with clients who
have demonstrated little rehabilitation potential, even
minimal gains must be considered significant. The specifics
of this matter will be considered in the methodology
section, but it should be noted that this is a problem of

great import with regard to the purpose of the study.

CHAPTER II

REVIEW OF THE LITERATURE

In the previous section, rehabilitation goals were
develOped, and it was hypothesized that only treatment with-
in a community setting would be sufficient to attain these
objectives. The purpose of this section is to examine these
generalizations in more depth through a review of the litera-
ture, and specifically:

1. To demonstrate the failure of mental hospitals in

rehabilitating the mentally ill in light of the
goals developed earlier, and to expand upon the

reasons for failure.

2. To discuss the implications of this failure for
future rehabilitation programs.

3. To examine initial data demonstrating the effec-
tiveness of post-hospital treatment programs.

Treatment in a Mental Hospital Setting

 

Historically, the mental hospital has assumed respon—
sibility for treating the emotionally distrubed (Miller and
Dawson, '68), but it is only within the past two decades that
attempts have been made to assess the effect of the hospital
experience on the mental patient. Recent literature in this
area reveals a significant trend--shorter stays in the hospi-
tal, but higher readmission rates. Table 2.1 demonstrates the
existence of this trend, not only in the United States, but in

other countries as well.

20

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22

Although the population size, length of hospitali-
zation and percentage of readmissions differed from study
to study, the trend of shorter hospitalizations and higher
readmission rates is apparent; and it can be seen that the
career pattern of the mental patient has changed from one
of long stay chronicity to intermittent patienthood (Fried-
man, Von Mering, and Hinko, '66). Given the rehabilitation
goals developed in this paper, this trend demonstrates the
general ineffectiveness of hospital based treatment programs
in rehabilitating the mentally ill. The reasons for this
failure can be best understood by discussing the reasons why
mental patients are now being released more quickly than in
the past and why? at the same time, readmission rates are on

the increase.

Reasons for Shorter Periods of Hospitalization

One explanation for shorter periods of hospitaliza-
tion is change in administrative policy (Brown, Parkes and
Wing, '61). An example of such a change is the need to
release people to the community before it is therapeutically
advisable when there is pressure for bed space (Linn, '64;
Odegard, '61).

A second and perhaps more significant reason for
the early release of mental patients is the increasing
emphasis placed on community treatment. Hogarty('68),

Stotsky ('67), Titmus ('65), Carhill ('67) and Greenblatt

23
('68) found that the existence of aftercare programs (i.e.,
increased community care) accounted for differing release
rates among mental hospitals. Freeman ('68) confirms this
hypothesis and states that the total accomplishment of the
last twenty years has been the transfer of the mental ill-
ness problem from the hospital to the community. He also
points out that the mental hospital should be looked at
merely as a way station, and that intensive treatment and
rehabilitation efforts must take place in the community and
not the hospital.

A final explanation for early release from mental
institutions is the increasing use of tranquilizers and
other types of chemotherapy in the treatment of mental ill-
ness. Hartman and Myer ('69), Stotsky ('67), Brown, Parkes
and Wing ('61) and Moon and Patton ('65) all account for
the decreasing number of long term patients in mental hospi-
tals for this reason.

In examining the above reasons for shorter hospitali-
zations, it is apparent that none of them are related to the
increased effectiveness of hospital programs in improving

the social functioning of ex-mental patients in the community.

Reasons for High Readmission Rates
High readmission rates, on the other hand, are
directly related to the effectiveness of hospital programs,
and demonstrate their failure to prepare patients adequately

for life in the community. In general, explanations for

24

this phenomenon can be attributed to the following:
1. Gains in the hospital are not necessarily
generalizable to the community.
2. Negative effects of hospitalization
3._ Problems of post-hospital adjustment
4. Demographic characteristics related to high

readmission rates.

Gains in the Hospital Are Net Necessarily Generalizable

In many instances, despite good hospital adjustment
and the lessening of the problems for which the patient was
admitted, release from the hospital leads to many diffi-
culties and eventually rehospitalization (Doehne, Sandifer,
Phillips and Waters, '65). More specifically, "the return
of functioning within the hospital is no guarantee that the
patient will function following discharge; amelioration of
symptoms in one setting does not mean that symptoms may not
recur in another. Somehow, the gains made within the hospi—
tal must be consolidated and extended in the post-discharge
phase of treatment" (Astrachan and Detre, '68).

There is general agreement in the literature that a
wide variety of social services in the community must be
established in order to maintain the gains made in the
hospital and to help ex-patients deal with additional prob-
lems that they will face in the community (Doehne et al.,
'65; Astrachan and Detre, '68; Miller and Schwartz, '65).

An approach suggested by Fairweather ('64) is to teach role

25
behavior within the hospital that is consistent with com-
munity living. As a mechanism to bridge the gap between
the hospital and community, Fairweather recommends the
establishing of reference groups within the hospital and
returning them as units to the community. By creating such
groups, similar patient behavior is required both within
and outside the hospital, thus filling the needed gap be-
tween the hospital and community. The conclusion that can
be drawn from the literature, however, is that most hospital
experiences do not adequately prepare patients to live out-
side the hospital environment, thus leading to high readmis-

sion rates.

Negative Effects of_Hospitalization

 

A number of theorists see the mental hospital expe-
rience itself as being a major cause of chronicity (Erikson,
'58; Scheflen, '65; Cumming and Cumming, '65; Fairweather,
'64; Greenblatt, '70). Scheflen ('65) sees a number of
negative behavioral patterns that result from hospitaliza-
tion. Some of these include claustrophobia, overdependency,
rationalization, self-recrimination and internalized and
externalized hostility. Sommer and Osmond ('61) also dis-
cuss the symptoms of institutional care: (a) deindividua-
tion -- reduced capacity for thought and action; (b) dis-
culturation —- acquiring institutional values and attitudes;

(c) psychological or physiological damage that persists after

26
leaving the institution; (d) estrangement -- changes in
extra-hospital world during hospitalization; (e) isolation --
being forgotten by friends and family; (f) stimulus depri-
vation -- becoming accustomed to a life whose tempagreatly
differs from that outside the hospital. Cumming and Cumming
('65) discuss two other problems related to institutional
care: (a) the stigma associated with hospitalization and
(b) the loss of social competence in institutionalized
settings.

Finally, Erikson ('58) emphasizes the danger of
hospitalization by stating that "the medical conditions
which it is currently believed provide the optimal clinical
setting for treatment may at the same time be social condi-
tions which put a stamp of permanence on the illness. The
danger that the patient will find himself a permanent form
of activity in keeping with his momentary patienthood, while
trying to engineer access to the medical patient role which
psychiatry advocates for him, cannot be overlooked when
psychiatrists consider their high readmission rates and
their constant struggle with chronicity." Erikson goes on
to say that the time has come for mental health professionals
to produce a therapeutic environment which relies less on
medical analogies and places emphasis on "re-education rather
than therapy, on development and training rather than on re-
integration of ego processes, and on the therapeutic com-

munity with its roots in outside society rather than on the

27

hospital with its specialized culture."

Problems of Post—hospital Adjustment

 

A third approach to understanding high readmission
rates is to look outside the hospital, and in particular
at the problems that the ex-patient faces upon returning to

the community.

Family Setting

The family setting to which the ex-patient returns
is a significant factor in preventing or causing rehospitali-
zation. Results of a number of studies (Davis, Freeman and
Simmons, '58; Dinitz et al., '61; Freeman and Simmons, '63;
Schooler et al., '67; Michaux et al., '69) demonstrate that
return to a conjugal setting leads to higher social perform-
ance and prevents rehospitalization. In such settings,
expectations of instrumental performance is higher,thus
leaving little room for deviancy. In parental settings, on
the other hand, there is usually little expectation of
instrumental performance and the ex-patient often assumes
the role of a child (Davis, Freeman, and Simmons '58; Kohn
and Clausen, '56). Even if the ex-patient doesn't return
to the hospital, "return of the patient to the parental
family...may well occasion regression from rather than move-
ment toward better functioning and eliminates any gains of

other hospital experiences." (Freeman and Simmons, '58).

28

Dinitz et al., ('61) confirmed this hypothesis and found that
low functioning patients successful in remaining in the com-
munity were in some respects more similar to rehospitalized
patients than to the moderate or high level functioners. In
cases where families don't exist, surrogate families are
often formed that provide the functional equivalents of
mothers and wives, and in which patterns can be found simi-
lar to those in actual families (Freeman and Simmons, '58).
In summary, the family setting to which a person returns,
surrogate or real, has been shown to have an impact both on
rehospitalization rates and level of patient functioning

within the community.

Community Adjustment Problems

Problems related to general community adjustment
have also been shown to affect rehospitalization rates.
Specifically, loneliness and social isolation are seen as
major reasons for high readmission rates (Raskin and Dyson,
'68; Miller and Schwartz, '65; Dudgeon, '64). Ex-patients
with a history of rehospitalization have also been shown to
have a poorer level of social adjustment within the commu-
nity than those who had no relapses (Bockoven et al., '56).
According to Miller and Schwartz ('65), chronic patients
who are constantly released and readmitted share the follow-
ing characteristics: (a) Their community careers are likely

to be carried out in a marginal or tangential role position.

29
(b) They have severe interpersonal difficulties and lack
material and emotional support in the community. In general,
there seems to be a consensus that the lack of social support
within the community to deal with some of the above-mentioned
problems is_a primary cause of readmission to mental institu-
tions (Brown et al., '64; Lamb, '68; Dudgeon, '64; Miller and
Schwartz, '65). "These shuttlebus cases seem to require
extensive psychiatric and social services in the community
if in the Opinion of the professional social worker, they
are going to be able to solve their problem in such a way as
to remain in the community after their next release from the

mental hospital" (Miller and Schwartz, '65).

Employment Problems

A strong relationship has also been shown to exist
between employment and the ability to maintain oneself in
the community. It has been shown that employed ex-patients
remain longer in the community (Linn, '64; Lorei, '64; Brown,
Corstairs and Topping, '58; Vitale and Steinbach, '65), and
also that readmission rates for the unemployed are higher
than for those employed (Dudgeon, '64).

Although there is no disagreement that the employed
have lower rehospitalization rates than the unemployed, a
strong possibility exists that it is the factors associated
with the ability to obtain employment rather than the con-

dition of unemployment itself that causes rehospitalization.

3O

Demographic Variables Associated with Reshospitalization Rates

Attempts have also been made to Show the relationship
between high readmission rates and a number of demographic
variables (i.e., diagnosis, age, etc.), but with only moder-
ate success. (Linn, '64; Taraka, '65) Two variables that
have been shown to have a Significant relationship with high
readmission rates are the length and frequency of previous
hospitalizations. Linn ('64) found that the higher the num-
ber of hospitalizations, the greater the chances are of
being readmitted in less than one year. Freeman and Simmons
('58) on the other hand found that the key variable in pre-
dicting length of time in the community is length of hospie
talization. More specifically, the Shorter the hospitaliza-
tion, the greater the success in remaining in the community.
Spivak and Kelman ('71) also found lengthy stays in the
hospital to be predictive of high readmission rates. In
studies conducted by Lorei ('64), Pishkin and Bradshaw ('66)
and Robins ('55) both the length and frequency of hospital
care were found to be related to outcome.

Another variable found to be related to high hospital
readmission rates was age of first psychiatric contact.
Rosen et al., ('68) found that both the age at first psychi-
atric contact and scores of a social competence scale were
predictive of readmission rates. However, the prognostic
value of the social competence scale was based entirely upon

its relationship with age of first psychiatric contact, thus

31

emphasizing its value as a predictor of readmission rates.
Michaux et al., ('69) carried out a comprehensive
study of those factors that separated successful vs. unsuc-
cessful (readmission to hospital) community adjustment among
mental patients. Using a community adjustmentment scale,
they found that social measures discriminate best between
successful and readmitted patients. Among the background
variables the authors found that number of prior hospitali-
zations, years hospitalized before last admission and
diagnosis (schiZOphrenia) were the best predictors of re-

hospitalization.

Post-Hospital Treatment as an Effective Means of
Preventing Rehospitalization

In reviewing the literature, it becomes apparent that
the: mental hospital has not been successful in rehabilitating
the mental patient, for despite shorter periods of hospitaliza-
tion, ex-mental patients are being rehospitalized more fre-
quently and in greater numbers. This is not to say that treat-
ment programs within mental institutions are not effective in
alleviating symptoms, but rather that they do not adequately
prepare the mental patient for life outside of the institu-
tion. The reasons for this failure have been elaborated
upon, but the question remains as to how to meet the rehabili-
tation needs of the mental patient.

A great majority of mental health professionals have

concluded that the solution to the rehabilitation of the

32

mentally ill lies in the development of adequate after-care
programs. The 1960's has seen the birth of the community
health movement and the establishment of numerous after-
care facilities, including day hospitals, mental health
clinics, halfway houses and community based vocational pro-
grams. The following section will focus on the rationale
for after-care programs, and in addition, the effectiveness
of such programs in preventing rehospitalization.

Much of the literature dealing with aftercare serv-
ices describes the need for such programs, and many mental
health professionals feel that increased post-hospital serv-
ices will facilitate post-hospital adjustment, and in the
long run, will prevent rehospitalization (Freedman, Von
Mering and Hinko, '66; Carhill, '67; Miller, '66; Miller and
Schwartz, '65; Lamb, '68; Freeman, '68; Doehne et al., '65).

Becker, Murphy and Greenblatt ('65) describe the
entire range of post-hospital services that can be provided
for the ex-mental patient. The day hospital, for example,
is seen by many as an effective rehabilitation agent, for
the patient avoids the stigma of hospitalization and is
treated within his own community (Becker, Murphy and Green-
blatt, '65; Winn and Lesser, '66; Jones, '63; Vitale and
Steinbach, '65; Zwerling and Wilder, '62; Winn and Lesser,
'66). Kramer ('62) concludes that "...Day Hospital is poten-
tially the major psychiatric facility of the future. His-
torical and current trends lend a degree of likelihood to

the prediction that the Day Hospital will in fact develop

33

as an alternative to the full time mental hospital."

The night hospital, on the other hand, is used by
patients able to work, but not able to remain at home, and
those patients who find themselves in a crisis situation
that requires temporary intervention (Mechanick and Nathan,
'65; Becker et al., '65).

A third type of facility is the halfway house which
provides sheltered living for those expected to have diffi-
culty reintegrating in the community. Wechsler ('61) has
surveyed existing halfway houses and their services.

The ex-patient club is seen as another service that
can help prevent rehospitalization. Although differing in
orientation, most of these clubs have been established to
meet the social needs of ex-patients and to teach them gradu-
ally how to function independently within their own community
(Friedman, '61; Lerner, '60; Palmer, '58; Wechsler, '61;
Spivak, '67; Tanaka, '65).

Finally, a number of mental health professionals have
advocated the establishment of comprehensive mental health
centers that will meet all of the needs of the ex-patient
(Wing, '63; Miller, '60; Patterson, '65).

o - I-uoe. ; o: o- . - . o '0 —-o o a ' o: in.

Although descriptive material about aftercare-serv-
ices is in abundance, there is a paucity of literature
demonstrating the effectiveness of after-care treatment. The

few studies that do exist can be divided into three categories:

34
1. Studies comparing outpatient vs. hospital treat-
ment.

2. Studies concerned with drug therapy as an after-

care service.

3. ‘Studies comparing outpatient treatment vs. no

treatment after release.

Outpatient vs. Hospital Treatment

 

Weinman et al., ('70) compared the effectiveness of
a community based treatment program with a hospital based
social treatment program and a traditional hospital program.
Results of this study are as follows: (a) A significantly’
greater number of patients were returned to the community
from community based treatment programs than from the hospi-
tal based social treatment program. (b) The readmission rate
of control (traditional hospital program) patients is signi-
ficantly greater than that of experimental patients.

The investigators concluded that one reason for the
success of the community based program was the fact that it
helped patients make meaningful and productive contact with
neighborhood social, recreational, religious,and health

facilities.

Drug Treatment Programs

 

Pasamanick, Scarpitti, and Dinitz ('67) compared
three groups of patients: (a) drug group kept at home with

psychiatric care; (b) placebo group (placebo substituted for

35

actual drugs); (c) hospital control group -- treatment in
accordance with customary hospital procedure. Subjects were
randomly assigned to the three groups. Results of the study
are as follows: (a) 77% of drug treatment subjects remained
at home after thirty months followup. (b) 34% of placebo
group remained at home after followup period. (c) 54% of
released hospital patients did not require additional hospi-
talization during the followup period.

The authors concluded that hospitalization is not
necessary in many instances since those at home fared as
well as those in the hospital. However, they also mention
that the fact that a person is saved hospitalization does
not validate the effectiveness of the program, especially
when one-third of the males couldn't hold jobs and oneéthird
of the females couldn't perform basic household activities.
The results, therefore, are more of an indictment of hospi-
talization than a tribute to home treatment.

Guy, Gross, Hogarty and Dennis ('69) compared the
effectiveness of two community based treatment centers.
Results of the study are as follows: (a) Day hospital
treatment (drugs plus milieu) was more effective for schizo-
phrenic patients than outpatient treatment (drugs alone).
(b) There was no significant difference between the number
of hospitalizations, but patients treated with drugs plus
milieu required shorter hospitalizations.

The existing data demonstrated that although drugs

are helpful in maintaining an ex-patient in the community,

36

their therapeutic value is enhanced when patients are receiv-

ing social treatment as well (Astrachan and Detre,"68; Kris,

'59).

Outpatient vs. No Treatment

A number of studies have demonstrated the effective-
ness of post-hospital services when compared to a non—treat-
ment control group (Orlinsky and Elia, '64; Saenger, '70;
Beard, Fisher and Goertzal, '63; Sheldon, '64; Sheldon and
Jones, '67). Sheldon ('64) found that psychiatric aftercare
is associated with a significantly lower readmission rate
(17.7%) than no care (47%). In a followup study of the same
population, Sheldon and Jones ('67) found that the same
effect (lower rehospitalization rate) holds over three years,
but is diminished somewhat. More specifically, it was found
that the longer the period spent outside the hospital, the
shorter the rehospitalization and the fewer the readmissions.
It was also found that poor outcome was associated with (a)
a diagnosis of schiZOphrenia and (b) many readmissions.

Vitale and Steinbach ('65) in comparing treatment in
a mental hygiene clinic and day center with traditional
hospital treatment, found that both community based groups
were found to be less dependent than currently hospitalized
chronic patients exhibiting similar demographic character-
istics.

The Beard et al., ('63), Sheldon ('67) and Sheldon

and Jones ('67) studies also contain other valuable

37

information relating to the predictors of success in aftercare
programs. Beard et al. found that those subjects who remain
in the community had a higher degree of initial attendance in
the treatment program than those patients who were rehospi-
talized. Sheldon ('64), Sheldon and Jones ('67) and Tanaka
('65) also found that good attendance leads to lower readmis-
sion rates. They concluded that attention should be paid

to ensure continuing and regular supervision of cases, as
well as the extension of aftercare to a higher proportion of

cases 0

Summary

The above review of the literature has demonstrated
the failure of mental hospitals to rehabilitate the mentally
ill given the rehabilitation goals developed in this paper;
and in addition, has examined initial data demonstrating the
success of post-hospital programs. A case has thus been
made for more exhaustive studies of post-hospital treatment
programs, and the evaluation of the Moadon Shalom program

will be one step towards the implementation of this goal.

CHAPTER III
DESCRIPTION OF TREATMENT PROGRAM

The major independent variable in this study is

participation in the treatment program at Moadon Shalom.

The purpose of this chapter will thus be as follows: (a)

to describe the theoretical: and operational aspects of the
Moadon program, and (b) to justify the Moadon as an appropri-
ate treatment program to be studied.

The treatment program at Moadon Shalom is a social-
psychological approach to mental illness that takes into
account personality system variables, social system variables
and their reciprocal impact on one another. The model of
personality used is that of Cameron and Magaret (151), a
social theory with behavioral interpretation that emphasizes
social interaction processes. More specifically, SohiZOphrenia
is conceptualized as evolving from and comprising a dynamic
interaction of disorganization and desocialization. .Qig-

organization is defined as a disruption of a unified reaction

 

or system of reactions,aand its replacement by behavior that
is fragmentary, haphazard and chaotic. Desocialization, on
the other hand, is defined as a reduction in social articu-
lation of behavior which results from the partial or complete
detatchment of an individual from the activities of the social

community.

38

39

The rehabilitation club (Moadon Shalom) is strudnired
so as to provide an environment that should counteract desocial-
izing and disorganizing influences. Within this framework,
there are a series of constructs that mediate the interaction
of personality and organization variables and which, when
operative, counteract the conditions of desocialization and
disorganization. They are as follows:

1. Interactional control mechanisms -- interpersonal
relationships between staff and patients that :counteract
desocialization: (a) social support (b) permissiveness of
the expression of deviant tendencies (c) denial of recipro-
city for deviant expectations (d) conditional manipulation;
of rewards.

A dichotomous relationship can be seen between the
first two and last two control mechanisms, but this does not
imply a contradiction. Instead, it indicates support or non—
rejection of deviant behavior, while at the same time pointing
out that one's behavior is not optimal and should be changed.

2. Social structural control mechanisms -- hypothesized
to counteract disoragnization and derived from special insti-
tutionalized roles and mechanisms: (a) dimension of integrae'
tion -- establishing a stable environment whose structure of
expectations is integrated, and in which influences upon the
patient are supportive and compatible. (b) adaptive dimension --
social conformity demands in club that approximate demands of

the community (c) instrumental role performance -- initially

40

using simple tasks in the building of success contingencies,
rather than the complex requirements of adult-status roles.
(d) affective-expressive dimension —- permissiveness of social
structure for the expression of emotional excitement which
in turn is countered by the manner of interaction with the
patient (e) social role adequaCy -- binding the patient
into various inStrumental and status role structures in his
group and other aspects of the club, including interrelation-
ships among patients, patients and staff, and work program.
Given the interactional and social structural control
mechanisms, the general goal of the club can be stated as
follows: ”The goal towards which our rehabilitation club
strives in its attempt to counteract desocialization and
disorganization is to help the patient develop those general-
ized resistance resources which can be applied to meet the
demands placed on him by his inner and outer environment"
(Spivak, '69). The concept of resistance resources was
developed by Antonovsky ('69) and includes the following:
(a) adaptability -- flexibility and readiness to adapt to
new situations (b) profound ties to immediate others --
the greater the extent interpersonal ties exist, the more
one will be able to deal with demands, and (c) ties between
the individual and the community.
All programs of the rehabilitation club are based on
the theoretical constructs outlined above, the operative

aspect of which is the quality and quantity of social inter-

41

action a person has within his community. On a.more descriptive
level, the rehabilitation club has been described (Spivak,
'67) as follows:

The Day Program of the Rehabilitation Club
is viewed as a basic departure from the sheltered,
rehabilitation workshop programs which are being'
increasingly utilized and adopted for the rehabilita-
tion of the psychiatric patient. The Day Program
is organized specifically to meet the needs of the
severely disabled group of ex- patients. It is the
problem of WW
designed to help him that occupies a great deal of
our effort at the Rehabilitation Club. Handling
at intake, the daytime environment, and a reaching
out program are specifically designed to facilitate
the patient's involvement in the rehabilitation
environment. A rehabilitation setting must be suc-
cessful in getting the patient initially involved
if the rehabilitation effort is to be realized. In
general, the patients who are sought for service at
the Rehabilitation Club will be those not regarded
as having sufficient potential for existing vocational
training programs, and thus neither reach nor are
referred to agencies, or have been rejected by more
orthodox rehabilitation programs.

Thus, one of the primary functions of a
Rehabilitation Club is to reach out to such patients,
and to involve them in a real environment where they
have the opportunity to form interpersonal relation-
ships which are not unduly influenced by their
pathology, by avoidance or over reaCtion of others.
The patient becomes a part of the group environment,
where he can receive social gratification and Where
he can respond to influences designed to help him
re-organize his life, not only in terms of simple
everyday routines and habits, but also in terms of
his identification with an environment in which the
performance of productive work has a high value.

The Rehabilitation Club operates with a set
of standards sufficiently different from the Community
at large, so that the patient is able to achieve
membership in a social environment not otherwise c
available to him. Demands upon the member are not
as high or as persistantly maintained as they are
in the community, not are certain deviances as severe-
ly sanctioned. In a nonclinical atmosphere, staff,

42

volunteers and members attempt to provide a family-
like milieu, in which the new member can become in-
volved in positive, interpersonal relationships.
Patients are helped to learn new roles, to assume
previous roles, leading to the establishment of
interpersonal relationship through which reality
testing occurs, and the patient's motivations, desires
and value for life and work are increased.

The basic orientation of the Club program can
be summarized as follows:

The activities program is generated by concepts
that the ex-mental hospital patient is disabled in the
use of social tools either as a resu1t of his illness,'
hospitalization, or as a result of a total life experience.
Since many of the men and women are unable to obtain
employment or to resume family roles immediately
following their hospitalization, the program endeavours
to enable such individuals to re-develOp their former
skills, capacities and tolerance for work, as well as
increase their motivation for employment and confidence
that a job can be handled successfully. The program
is designed to counteract the tremendous discouragement
that results when one is unable to secure a job or hold
it.

The first objective is to attract into the club
during the day men and women who are making only a marginal
adjustment in the community, or who, while still patients
in the mental hosiptal, are facing imminent release.
Initially involvement is on a passive level, sitting,
reading, talking and eating. Members at this stage are
for the most part unemployed and tend to be socially
isolated. Even though they are attracted into the
program for various reasons, their initial passivity
occurs in an atmosphere in which many productive
activities are occurring.

As the new passive, withdrawn member finds
himself in this busy environment he becomes slowly ine
volved in the basic motivation provided by the setting.
The activities provided by the program include menu
planning, codking, serving food and washing dishes,
sweeping floors, painting rooms, running errands,
addressing and sealing envelopes, typing membership
mailings. All these activities require the learning
of regularity and the develOpment of routine work

43

habits. In addition, a broad range of social and rec-
reational activities have been undertaken in which

the interestssof the patient can find expression: classes
in game playing, music appreciation, arts and crafts

are offered. Efforts are also made to expand the members'
social participation in various community activities ‘
where they will form relationships with other healthy
people.

Because many potential members of the Club are
too withdrawn or unmotivated to initially become full
participants in the rehabilitation services of the Club,
we have organized visiting teams of staff and members
to reach out to such ”home bound" individuals.

Finally, as members take up employment or
continue in their present employment, the vocational
counsellor, together with other staff seeks to extend
relationships developed in the Club into the work
situation and conversely bring new and important issues
aroused at work into the therapeutic environment of the
Club.

Now that both the theoretical and operational bases
of the Moadon program haVe been described, its role as the
major independent variable in this thesis can be justified.
Specifically, the Moadon is an appropriate treatment program
to be evaluated because of its compatibility with both the
general goals of psychiatric rehabilitation1 and those

2
develOped in this thesis.

 

1"assisting the patient in transition from a protective hospital
environment to independent community living by changing the

social identity of the individual from that of a patient to a
functioning citizen", (Tanaka, '65); ”reintegration of the
individual into the community on the most efficient and useful
level of adjustment possible”, (Carmichael, '59); "assisting

the patient to achieve anT optimal social role in the family,

or on the job and in the community generally, with his capacities
and potentialities, (Williams, '53). .

2Maintenance of the ex-mental patient in the community, and
adequate adjustment in major living tasks -- living arrangements,
household duties, work, self care, social activities and
recreational activities.

44

As can be seen from the general definitions of
rehabilitation stated above, the basic goal of any post-
psychiatric rehabilitation program is to belp a person adapt
to life outside of the hospital. The Moadon program fits within
this general framework, for its major concern is to teach the
social Skills necessary to adapt to community living (including
those social skills that facilitate vocational adjustment.) In
addition, the Moaddn is not only geographically located within
a community setting, but has made every effort possible to
integrate itself into the community at large. A great deal of
staff time is thus spent contacting civic leaders, employers,
family of clients, and others who play significant roles in
the process of community adjustment for ex—mental patients.
Contacts with family members, for example, are useful in providing
support for efforts to help the client adjust to life within
the family setting, and in providing feedback as to the problems
being experienced at home. Contacts with employers are also
beneficial, in that they make them aware of a possible resource
for employers, amd more important, give the employer a place to
turn in the event that a client is having difficulty on the
job, thus giving him an alternative to firing the client.

The Moadon's involvement in the community differentiates
it from hospital based programs, and is the key to its potential
success. Specifically, helping to link the ex-patient to
various community resources is especially important for one

who has been living in a relatively dependent state in an

45

institution where his needs are met and where little initiative
is required. Furthermore, a program that strives to make itself
an integral part of the community and that encourages staff
involvement with community leaders, potential employers, and
family members, should facilitate the task of community adjust—
ment for the ex-patient.

The choice of the Moadon treatment program as the
major independent variable in this thesis can also be justified
on the basis of its theoretical framework. The central point
regarding the theoretical constructs of the Moadon is that
emphasis is placed on treating the individual within the social
system in which he lives. The above stated rehabilitation goals
are compatible with this approach for they are concerned with
helping the ex-mental patient learn the social skills necessary
to maintain himself within the community. Specifically, helping
an individual to attain adequate adjustment in his living
situation, work, and social activities, requires involvement
in relevant community organizations, as well as individual
treatment (or support), thus justifying a treatment approach
that emphasizes personality system variables, social system
variables and their impact on one another.

The specific aspects of the theoretical structure are
designed to help the ex-patient develOp the resistance resources
necessary to meet demands within the community. For example,
the staff-client relationship as defined by the interactional

control mechanisms provides both the support the ex-patient

46

needs to work out his problems (social support, permissiveness
of the expression of deviant tendencies, etc.) and the require-
ments of reality that he will be facing once on his own in the
community. (achieved by mechanisms 3 and 4 -- denial of recipro-
city for deviant expectations, and conditional manipulation
of rewards.)

The social structural control mechanisms are designed
to gradually help the client to adapt to organizational
structures similar to those found in the community. For
example, within the club itself, social conformity demands are
placed on the client just as they will be in the community
(adaptive dimension). In addition, within the various
activities of the club, the individual must learn the appropriate
roles necessary to function in his group, with other patients,,
with staff, and in a work setting. However, demands are placed
on the client gradually, and in the early stages of the program
more permissivity is acceptable than in community institutions.
Also, simple requirements are placed upon the client before

attempting to teach him complex adult-status roles.

In summary, the Moadon is essentially attempting to
prepare its clients for independent functioning within the
community, but in an environment in which they are not confronted
with all of society's demands at once. Instead, he is given
an opportunity to learn them gradually with the support of the
staff. Such a program appears to be directed toward the goals

of maintaining the ex-patient in the community (by structuring

. "fl

47
the program so as to provide support during crises, tolerance
during regressions, and allowing the client to meet society's
expectations in gradual steps rather than confronting him
with them all at once) as well as helping him adjust to the
major living tasks within the community (by providing services
such as helping to find adequate living arrangements, linking
members to social facilities within the community, assisting
in job placement, and teaching skills in the area of self care,
household duties and interpersonal relations) thus demonstrating
its compatibility with the rehabilitation goals adopted in
this paper.

In terms of its compatibility with both the general goals
of rehabilitation and the operational definition of rehabilitation
developed in this paper, the Moadon appears to be an appropriate
program to evaluate in terms of its effectiveness in rehabilitating
ex-mental patients. In addition, such an evaluation should
demonstrate whether this apparent semantic compatibility is
also indicative of the behavior change that should accompany
participation in a program of this nature.

In summary, this chapter has focused on the following:
(a) describing the theoretical constructs of the Moadon's
treatment program, (b) describing the operational aspects of the
Moadon program, and (c) justifying the Moadon as an appropriate

treatment program to be evaluated.

CHAPTER IV

DESIGN OF STUDY

The purpose of this chapter is to describe the design
of the Study. Specifically, the following will be discussed:

1. Dependent and Independent Variables

2. Instrumentation

3. Sample

4. Procedure

5. Experimental Design

6. Hypotheses

7. Analysis Procedures

Dependent and Independent Variables

 

Dependent Variables

In describing the dependent variables of this study,
discussion must focus on what represents successful outcome
in a post-psychiatric rehabilitation program. Given the
goals of this paper, any definition of success must include
both a measure of community tenure and community adjustment:

1. Community Tenure -- Community tenure can be

 

48

49

evaluated in a number of ways. One possible approach would
be to consider only the amount of time Spent in the commu-
nity after referral to the Moadon. This definition is not
adequate, for symptoms of mental disorders often reoccur,
and without information relating to time Spent in the commu-
nity before referral, it is only possible to assess the
length of time Spent in the community, and not whether there
has been an increase or decrease of time spent in the commu-
nity. For the purpose of this study, it is important to
consider the amount of time in the community both before and
after referral to the Moadon, Since we are interested in
learning whether the Moadon is effective in increasing com-
munity tenure. The definition of community tenure adopted
for this study is thus the percentage of hogpitalization

time saved since being referred to the Moadon. If, for

 

example, twenty months had passed from time of referral to
March '71 (cut-off date for evaluation study -- records are
still being kept) and the client was hospitalized for two
months out of the twenty, this figure was compared with the
client's hospitalization during the twenty months previous
to his referral to the Moadon. Assuming that he was

hospitalized for ten of the twenty months, his percentage

50

of hospitalization saved would be 80%.

_ Time hospitalized after referral l 2
Time hospitalized before referral '16

2. Community Adjustment -- For the purpose of this

 

paper, community adjustment was defined as the quantity and
quality of social interaction in the major living tasks in
which social functioning takes place. These living tasks

as delineated by Spivak ('69) are as follows: (a) living
arrangements, (b) household duties, (c) work, (d) self-care
(appearance, medication, therapeutic visits),(e) social
activities, and (f) recreational activities. The tool used
to assess the level of functioning in these living tasks

was the Social Interaction Questionnaire which will be dis-
cussed in depth in this chapter. Although present level of
functioning would provide one indicator of community adjust-
ment, a more meaningful measure would be to compare one's
present level of functioning (after or during participation
in the Moadon) with his functioning during a different period
of time. The Social Interaction Questionnaire provides such
a comparison, for it assesses present functioning and function-
ing at one's best period since the age of twenty. The opera-
tional definition for the two aspects of community adjustment

being considered (quantity and quality of social interaction)

51

is as follows: The higher the present level of functioning,
and the smaller the discrepancy between present and past
levels of functioning, the higher the level of community
adjustment.. More specifically, a subject would receive the
highest possible score if his level of functioning after
participation in the Moadon was better than during his best
period since the age of twenty. The next highest score
would be assigned to a subject whose level of functioning
had not changed since his best period (no discrepancy) and
who was functioning on a high level during both periods. A
lower score would be assigned to a subject for whom there
was no discrepancy but who was functioning on a low level
during both periods; and the lowest score would be assigned
to a subject whose level of functioning is lower at preSent
than it was during his best period (high discrepancy). One
score was assigned for each living task, and these scores
were combined to form two global scores--one for the quan-

tity and the other for the quality of social interaction.1

Indgpendent Variables
Of primary importance in any study is the selection

of the independent or treatment variables. The major

 

1The rationale for scoring is discussed in depth in Appendix
A. _

52

independent variable in this study is participation in the
treatment program at Moadon Shalom. For the purposes of
this study, participation in the treatment program was de-
fined according to two criteria:

1. Outreach -- total number of contacts concerning
the client. More specifically, outreach is defined as staff
effort to involve the ex-patient in the Moadon program,
including contacts with a member himself, social workers,
psychiatrists, psychologists, employment bureau, place of
employment, landlord and family. Low outreach was con-
sidered to be 1-10 contacts, medium outreach 11-30 contacts
and high outreach 31+ contacts.

2. Attendance -- total number of times that a

 

client participated in the Moadon from time of referral.
Low attendance was considered to be 50 attendances or less,
and more than 50 attendances was considered to be high
attendance. It Should be noted that the criteria for
developing the ranges for high and low attendance, and
high, medium, and low contact, were arrived at by polling
veteran staff members and arriving at a consensus among
them as to appropriate cut-off points.

In addition to the major independent variables

stated above, a number of demographic variables that have

53

been shown to correlate with rehabilitation success in the
literature are also being treated as independent variables.
A list of these variables and the references in which their
relationship with rehabilitation success has been demonstra-

ted is as follows:

1. Total number of admissions (Bockoven, et al.,

 

'56; Miller and Schwartz, '65; Linn, '64; Lore, '64; Pishkin
and Bradshaw, '66; Robbins, '55).

2. Diagnosis (Michaux et al., '69).

 

3. Total time in hospitals (Michaux et al., '69).

4. Length of admissions (Freeman and Simmons, '63;

 

Lore, '64; Pishkin and Bradshaw, '66; Robins, '65).

5. Age at first admission (Rosen et al., '68).

 

6. Length between admissions -- not discussed in

 

literature, but is hypothesized to correlate with rehabili-
tation success.

7. Employment status (Linn, '64, Lorei, '67; Brown,

 

Corstairs and Topping, '58; Vitale and Steinback, '65;
Dudgeon, '64).

8. Living situation (Raskin and Dyson, '68; Miller
and Schwartz, '65; Dudgeon, '64).

9. Marital status (Davis, Freeman and Simmons, '58;

 

Dinitz et al., '61; Freeman and Simmons, '63; Schooler et

al., '67; Michaux et al., '69).

54

Instrumentation

 

Three sources of information were used in the evalu-
ation of the Moadon program:

1. .Social Interaction Questionnaire -- Because the

 

'rehabilitation club is bound to specific theoretical con-
structs, the task of assessing outcome is much easier. As
mentioned earlier, the operational aspect of these con-
structs is the quality of social interaction a person has
within the community. To help with the development of a
questionnaire designed to measure social interaction, facet

theory (Guttman, '58 and '70; Jordan, '71) was used to
construct a mapping sentence upon which the questionnaire
is based. The focus of this social interaction mapping
sentence is on living tasks, and we are interested in
knowing how the patient (or ex-patient) interacts with
others for the purpose of happiness, support (financial),
and obligations. In addition, the mapping sentence is
constructed so as to give us information as to the
patient's present state, a past state (the best state
since the age of twenty), and a comparison between these
two states.

The construction of the questionnaire (Spivak, '67)
was guided by a facet design which makes it possible to

construct items by a systematic a priori method instead of

55

MAPPING SENTENCE FOR SOCIAL INTERACTION

 

 

 

 

B
CondItion (Social—Relations )
1 involvement in
I 1. state of , ’ , ,
The E2. change in_) ex-patlent (x)'s (2. llklng of )
$2 2
Living Tasks Referrent
(1. living arrangements )
(2. homemaking activities )
(3. work >
(4. self care ) Eé' 8:8:rs )
a. a earance rovides '
E Eb- mggication )) p (3. self and others )
( (c. therapeutic visits)) (4‘ nelther )
(5. social & recreational ')
( activities )
E E
Referrent

ActIon

 

 

(l. s31f_

)
with the fulfillment of (1' giving to ) (2- others )
(2. receiving from ) (3. self and others)

)

(4. neither

 

 

E. H
PUEBQSE TIme
(1. happiness ) (1. best state sInce age 20) high .
(2. support ) at (2. present time )____ I 909131 .
(3. obligations) (3. general ) 16w Interactlo

Mark Spivak, Ph.D.
The Israel Institute of
Applied Social Research
1967
Figure 4.1 Mapping sentence for social interaction

56

intuition or by use of "judges." Thus, by combining each
element of each facet of the mapping sentence, one with the
other, it would be possible to have 2x3x5 etc. number of
variables and hence that number of questions. However, in
constructing the questionnaire, only those questions making
both semantic and psychological sense were employed, while
trying to use as wide a range as possible of these combina-
tions.

A facet-by-facet examination of the mapping sentence
will. demonstrate how the questionnaire was developed from
it (Figure 4.2).

2. Census Study_-- The census study was undertaken

 

in order to define the nature and characteristics of the
Jerusalem mental patient population. The definition of popu-
1ation parameters enabled the interrelationship among various
variables to be studied (i.e., ethnic origin with length of
hospitalizations, sex with number of hospitalizations, etc.),
provided information regarding services required by various
segments of the mental patient population, and in addition,
provided the baseline data necessary to define the nature of
the Moadon population.

Information for the census was collected on 1,531

57

ZOmHm<mZOO A<UHUOAozmzozmzm

self to others

others to self
others
self

E
E

f s
l r
e 9
sh

t
00
t

O
S t S
r r
efEf
hlhl
t e t e
0805

 

mZOHH<OHAmO Hmommbm

r

{I

_

ZOmHm<wzoo

.t S
l r
e e
S.h

t
0 O
t

O
S t s
r r
e.t e.I
.h.l.n.1
t e t
080

I
L__ se

mmmszd<m

_

AU Doommv xmmu wow>HA Loom now
ucmucoo oonwumomm mo coHumucomoud owumEosom N.d onowwh

self to others
1f

L__se

others to self

others

 

mZOHH<OHAmO

ZOmHm<mZOo A<ZOHH<AmmMOO A<UHHW4<Z<

.I S .t 8
1r if
86 ee
S.h S.n

t t
00 00
t t

O O
S t S S_t S
r r r r
efef efef
.n.1.h.l .h.l.h.l
Cete tete
O S O S O S O S
CL CL

 

Hmommam mmmszm<$

 

swam

Am m a memo<mv

_ __ _ mezmmmmmmm

mHHB ZOHHU<

.t S .t S .r S
.1 r .1 r .l r
e e e e e e
S.h S.h S.h

t t t
O o O 0 O O
t t t

O O O
S t S S t S S t S
r r r r r r
8.x e,t e,t e e.t e.t
.h.l.h.l .h_l.h .h.l.h.l
tete tet tete
O S O S O S O O S O S

I:
“’1:

-|

 

mone<oHomo eeoamem mmmszm<m Au emo<mv
HI _ ._mmoam:m mom

 

Hzmmmma Am +mo<mv mzHe e<
1:2:tllhmlamu<av oneHozoo

 

Mm<H UZH>HA

58

patients discharged to the Jerusalem area at least once in

a five and one-half year period from hospitals in the
Jerusalem area. It should be noted that this includes
patients who were first hospitalized prior to the five year
period and discharged during the five year period, but does
not include patients who were admitted and discharged before
this period. The names of patients discharged during that
period were collected from the five main hospitals in the

Jerusalem area, as well as from a half-way hostel. Further
information was gathered from the central index of the
Ministry of Health, and additional data was synthesized by
the research staff such as time between hospitalizations
and total time hospitalized. In summary, when one or more
discharges occurred during the period of time covered by
the census study ('63-‘68), it was possible to collect a
fairly complete history for the 1,531 patients included
in the study.

3. Moadon Records -— In addition to the above
sources of data, records kept by the Moadon provided a
final source of information. Specifically, data were
gathered from: (a) attendance sheets--daily record of,
client attendance in all Moadon activities; (b) communica-

tion sheets--a detailed record of staff contacts including

59

object of contact, reason for contact, amount of the con-

tact, and who initiated the contact.

Sample

The sample for this study was obtained from two
sources: (a) the census study of the Jerusalem ex-mental
patient population and (b) the client population at Moadon
Shalom.

The census study was described in the discussion on

instrumentation, and the census_population itself comprised

 

the 1,531 Jerusalem area residents who were discharged once
from a Jerusalem mental hospital between 1963 and 1968. The
major function of the census population in this Study was to
provide population parameters with which the Moadon popula-
tion could be compared. Specifically, by using these popu-
1ation parameters as a baseline measure, it was possible to
describe the Moadon population in terms of these variables,
and as a result, define that segment of the ex-mental patient
population that is being treated at the Moadon. The Specific

population that was compared to the census was the 150 active

 

_pgrticipants in the Moadon program. Active participants were
those judged by staff members as pe0p1e who have either

actually participated in Moadon activities and/or for whom

60

sufficient effort had been made to involve them in the pro-
gram. More specifically, participants were rated active or
inactive by a concensus reached among the four staff members
who had worked at the Moadon since its inception. It should
be noted that clients were considered to be active even when
efforts were unsuccessful in drawing them into the program.
Therefore, in evaluating the success of the Moadon program
in increasing community tenure, the data will be biased
against the Moadon, for some of the clients being considered
were those who never participated in Moadon activities but
who were considered active on the basis of the outreach ex-
tended to them.

In administering the questionnaire to Moadon clients,

 

attempts were made to involve both active and inactive
clients. The results of these efforts were disappointing,

for it was only possible to administer the questionnaire to

70 of the 150 active clients and 7 of the 53 inactive clients.
The reasons for this lack of success will be discussed in
depth in the section on Procedure, but can be summarized
briefly as follows: (a) Inability to locate subjects who
were no longer participating in the Moadon or who had never
participated in the Moadon program; (b) Lack of interviewers--

although beginning with approximately 35 interviewers, most

61

had terminated their work before interviewing was begun
with Moadon clients (the initial interviews were carried
out with subjects in the census population as part of the
overall research project). (c) Complexity of the question-
naire -- some of the more chronic clients were not able to
relate to many of the questions asked in the questionnaire.
In summary, those who actually comprised the sample
of this study are as follows: (a) the 1,531 subjects in
the census study of the Jerusalem ex-mental patient popula-
tion, (b) the 150 active participants in the Moadon Shalom
program, and (c) the 77 clients in the Moadon to whom the

social interaction questionnaire was administered.

Procedure

 

Figure 4.3 represents an overview of the work neces-
sary to execute the entire study of the Jerusalem ex-mental
patient population, of which this thesis is a part. The
following outline is an expanded form of Figure 4.3:

15. Organization of demographic and other relevant data.
The demographic data was obtained from the files of the
Ministry of Health in Jerusalem. These data were coded,
transcribed to Fortran sheets and punched on computer cards.

A. Coding of other information related to Moadon

program

62

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time 15 Organizing TB Preliminary 10 Review
of Demo- Work on Ques- -_'of
graphic Data tionnaire Literature
2212: 11'}. I .110.
Training Contacting Determining
Interviewers Patients . Interview
Procedures
‘ \ IIIA 1L IIIB
Interviewing Hypothesis
A ‘_ Development

 

 

 

 

 

 

 

 

 

Ila 1112

Data Determining

Preparation Statistical
Tests

 

 

 

 

.\/
V

Data
Analysis

 

 

 

 

Figure 4.3 -- Diagram of work necessary
to execute Study

_I_B_.

63

Attendance Sheets -- Client attendance in
all activities has been kept Since the in-
ception of the Moadon. This information
was coded in the same manner as the demo-
graphic data described above.

Staff contact sheets -- Records of all
staff contacts at the Moadon have also
been kept [i.e., object of contact, type
of contact (phone, letter, etc.), length
of contact and reason for contact], and
this information, as the above, was coded,
transcribed onto Fortran Sheets, and

punched on computer cards.

Preliminary Work on Questionnaire

A. Subjects for questionnaire

1.

Names and addresses -= Records of the
Ministry of Health, individual hospitals,
and the Moadon were used to obtain the most
recent address of project participants.
Letter preparation -- A letter explaining
the purpose of the project, and asking for
participant c00peration, was written.

Permission from hospitals -- Meetings were

64

arranged with the administrators and pro-
fessional staff of Talbiye Hospital in order
to obtain their permission to interview
patients, who at one time were hospitalized
in that institution.

B. Preparation of questionnaire

1. Practice trials of the questionnaire were
administered; problems in the questionnaire
and answer sheet were noted.

2. The questionnaire and answer sheets were
thoroughly reviewed and written up in their
final form.

C. Preparation of the instruction book -- An instruc-
tion book was prepared for interviewer
orientation which discussed in depth the question-
naire, the purpose of the project and how to
contact and interview ex-patients.

19, Review of Literature
A. Reading and categorizing of relevant literature
B. Writing a review of the literature

llé;_ Training of Interviewers
A. Recruiting interviewers

1. Ads were placed in local papers and on the

65

bulletin board at the University for inter-
viewers with appropriate qualifications
(psychology and social work students and/or
professionals in those fields).

2. Prospective candidates were interviewed and
those .suitable for the study were invited
to the orientation session.

B. Instruction and practice trials of interviews

1. Two preliminary orientation sessions were
held in which information in the instruction
book was presented.

2. Interviewers were instructed to review
thoroughly the questionnaire and to admin-
ister two practice questionnaires at home.

3. Interviewers met in small groups with re-
search coordinator at which time problems
with the questionnaire were brought up and
answer sheets were reviewed. Interviewers
were also given an opportunity to role
play in order that their competence could
be evaluated.

TIE, Contacting Patients

A. Letters were sent to prospective interviewees

IIC.

IIIA.

IIIB.

IVA.

IVB.

VA.

66

informing them that an interviewer would soon come
to their home and asking for their c00peration.

B. Returned letters were noted, and attempts were
made to locate new addresses by checking hospitals
and/or Moadon files.

Interviewing Procedure

A. Weekly appointments were made with interviewers
to discuss problems and to return answer sheets.

B. Returned answer sheets were checked for accuracy.

Interviewing Patients
Hypothesis Development
Data Preparation

A. Answer sheets were checked a second time.

B. Answer sheets were sent for punching.

C. Punched cards were received.

D. Cards were submitted to computer and marginals
received.

Determining Statistical Tests to be Run

Data Analysis

A. Cards again submitted to computer with instruc-
tions as to which tests should be run.

B. Return of data

67

It should be noted that the above outline and de-
scription of procedure does not contain a discussion of the
numerous problems that were experienced in the execution of
this study. A discussion of these difficulties will indi-
cate the types of problems that can arise in a study of
this nature and should be useful for those carrying out
similar projects.

A basic problem in this Study and one for which solu-
tions are not readily available is that of sampling. A
general goal of the project was to administer the question-
naire to the 1,531 people who comprised the population of
the census study.

Two major obstacles had to be overcome in this area,
one of which was successfully resolved, and the other which
prevented the execution of the study as originally planned."
Since the Ministry of Health has records on every person who
has been hospitalized in the State of Israel, defining the
mental patient population in Jerusalem and its demographic
characteristics (i.e., sex, number and length of hospitaliza-
tion, etc.) presented little difficulty. However, in attempt-
ing to interview this population, problems began to arise.

In order to begin the study, permission had to be sought from

the hospitals in which the patients were hospitalized.

68

The administrator of the largest hospital (635 out of the
1,531 were hospitalized there) was approached, and his per-
mission was sought to carry out the interviews. Although
agreeing with the general goals of the study a year pre-
viously, he felt that he could not give his final approval
until he consulted his professional staff. Many of the
staff psychiatrists at first opposed the project on the
following grounds: (a) The interview might stir up dormant
problems in the ex-patients. (b) Such an interview was an
infringement upon the privacy of the individual, especially
those whose hospitalization had been kept a secret from
their family. (c) Since the interview was not of thera-
peutic value for the individual subjects, it was unethical
to ask them to participate in an experiment of this nature.
In order to allay their fears, a meeting was arranged
between the project director and the hospital staff. At this
meeting, the questionnaire and purpose of the Study were
reviewed in detail and the value of the study for ex-mental
patient population as a whole was emphasized. At the end of
the meeting, an agreement was reached, and the hospital staff
was given the option to eliminate those patients for whom
they thought an interview would be damaging. By the time the

approved patient list was returned, more than a month and a

69

half had passed and much valuable time had been lost. Un-
fortunately, problems with the hospital administration did
not stop at this point. Upon receipt of the letter asking
for participation in the project, approximately ten ex-
patients Contacted the hospital and stated their refusal to
be interviewed. This response caused additional antagonism
towards the project on the part of the hospital administra-
tion, and pressure was brought to bear on the research team
to discontinue the project. Again, it was necessary to re-
assure the hospital staff that it was only a small minority
of patients who responded negatively to the project, and
this was not sufficient justification to terminate it. After
a week or so of negotiations, approval to proceed was ob-
tained, but again valuable time had been lost.

A second and more serious problem was the inability
to locate many of the subjects who were to be interviewed.
As mentioned earlier, addresses were obtained from the
records of the Ministry of Health, and those that were un-
clear or unavailable were obtained from the hospital records.
Of the 600 interviews that were attempted, approximately 30
subjects indicated that they did not want to participate in
the experiment, 87 were carried out successfully, and the

others could not be located. In many instances, the addresses

70

listed were non-existent and in others the subject had changed
his residence. When the latter occurred, neighbors were
asked as to the whereabouts of the subjects and, although in
some cases it was possible to locate them in this manner, in
most cases little help was given. Although other resources
were available to track down subjects (i.e., tax records,
voting records, etc.), budgetary limitations made it impos-
sible to proceed further. Instead, all efforts were focused
on the more easily accessible population at Moadon Shalom.
From this experience, it was concluded that unless hospital
records are extremely accurate and up to date, an extremely
large budget is needed to locate subjects successfully in a
project of this scope. Given the present situation, the
only solution to this problem appears to be a full-time
staff with the sole responsibility of tracing subjects; but
this again requires the monetary allocations mentioned above.
Another major difficulty in this Study was that of
maintaining interviewer motivation. Approximately 50 poten-
tial interviewers participated in the first orientation
session. By the end of the second session, about 10 had
already been eliminated because of an inability to master
the questionnaire or because of their decision not to parti-

cipate due to the low salary or pressure of school work.

71

The greatest number of interviewers dropped out after their
first few interviews. Many found the actual interview expe-
rience with ex-mental patients to be too traumatic, others
found it difficult to work with such a lengthy question-
naire and other interviewers were frustrated by the fact
that they were spending most of their time tracking down
clients rather than interviewing. Although individual meet-
ings were held with the interviewers in a very supportive
atmosphere, only about 15 interviewers became totally com-
mitted to the project and became adept at administering the
questionnaire. Solutions to this problem are also not
readily available, for in a situation where a small salary
is not compensated for by a rewarding experience, it is
extremely difficult to maintain interviewer motivation.

A final problem that was alluded to earlier was the
complexity of the questionnaire itself. Many questions,
especially the more abstract ones and those dealing with
comparisons of past and present stateg confused many of
the subjects. Other questions raised problems that many
of the subjects had given little or no thought to in the
past, thus causing additional difficulties. The high per-
centage of "no response" or "inability to respond” scores

substantiated this generalization. In addition to problems

72

of complexity, some interviewers felt that the questionnaire
was too lengthy for many subjects. Specifically, it was felt
that for chronic and regressed subjects, it was extremely
difficult to concentrate on the questions for a long period
of time.’ Even after the interview was divided into two
sessions (1-1% hours each), many interviewers felt that they
often lost contact with the subject and had to struggle to

maintain the subject's interest.

Experimental Design

 

The experimental design in this study was developed
for both the specific goals of the project and as a general
approach in rehabilitation research. The traditional ap-
proach in determining the effect of specific treatments is
to make inferences about population parameters from sample
information. Such an approach typically involves the com-
parison of two or more groups, therefore suggesting the use
of a control group. In experiments of this nature, the
major objective is to eliminate any systematic differences
between the treatment and control groups except what is
specifically described as treatment. The use of random
sampling and assignment helps to achieve this goal and in-

ferences can then be made about the population from which

73

samples were drawn.

This approach presents some major problems in the
evaluation of psychiatric rehabilitation programs. First
of all, taking a random sample from a Specific client popu-
lation and randomly assigning the subjects to experimental
and control groups does not assure the representativeness of
the two groups in terms of the population of psychiatric
patients or ex-mental patients, since referrals to psychi-
atric rehabilitation programs are not made on a random basis.
It is thus difficult to ascertain what kind of population we
can make inferences about. Since a basic assumption of
random selection is being violated (every individual in a
population has an equal chance of being selected), inferences
cannot be made about the general population of ex-mental
patients, but only about the population from which the sample
was drawn (i.e., population of a particular rehabilitation
center), thus limiting the external validity of the study.
Practically speaking, if a particular treatment is found to
be effective within a given group, its further use is limited

unless the client population is adequately defined.
Adopting an alternative approach of matched groups

(matching on a number of variables related to the dependent

variable) does not insure comparable groups because of the

74

difficulty in identifying all of the relevant variables in
psychiatric programs. This assumption has been substantia-
ted by researchers (Linn, '64; Tanaka, '65) who have had
only moderate success in isolating variables that are re-
lated to community adjustment.

The use of research designs that depend on the use
of inferential statistics can thus be seen to have serious
limitations in studies designed to assess the effectiveness
of psychiatric rehabilitation programs. What appears to be
needed is a new kind of research design that eliminates the
above limitations, and that is appropriate for the evalua-
tion of rehabilitation techniques.

Evaluation of most rehabilitation programs falls into
the framework of a field study. Specifically, rather than
being artificial situations created in a laboratory type
setting, they are real situations in which certain phenomena
of interest are found. Within this framework, two general
types of studies can be designed:

l. Exploratory Studies -- concerned with discovering
and analyzing relationship between variables, rather than

predicting relationships.

2. Hypothesis testing -- detailed measures are taken

of the independent variable, and exact predictions are made

75

on the basis of the theoretical model upon which the program
is based.

For the purpose of studies concerned with evaluating
the effectiveness of rehabilitation programs, the latter
alternative is most appropriate, and was used as the general
framework of this study. Specifically, we are talking about
a theoretically oriented research project in which the experi-
mentor manipulates an independent variable in a real social
setting in order to test some hypothesis.

The major disadvantage of field studies is that they
prevent the use of experimental designs based on inferential
statistics because of the difficulty in creating control
groups and selectively applying treatments. The research
design used in the present study resolves this problem by
defining the sample (Moadon) population in terms of the popu-
lation parameters obtained from the census study, thus
eliminating the need to control for demographic variables
hypothesized to correlate with criterion measures.
Specifically, records from the census study provided the
necessary information to define the parameters of the ex-
mental patient population of Jerusalem. By analyzing these
records and in some cases synthesizing information, it was

possible to define the ex-mental patient population in

76

terms of sex, age at first admission, length of admissions,
total time in hospital, length of time between admissions,
diagnosis, ethnic background, number of admissions, and
situation at referral.

These population parameters were then used as
"baseline" measures in the description of the Moadon popu-
lation. For example, if 10% of the Jerusalem mental patient
population had more than three hospitalizations as compared
to 80% of the Moadon population, it would be clear that in
terms of chronicity, the Moadon falls at the high end of
the continuum. In summary, instead of randomly selecting
control groups out ofainon-member sample or matching on a
number of a priori variables (that are hypothesized to re—
late to rehabilitation success), it was possible to define
the Moadon population by comparing it to almost all (85%)
Jerusalem ex-mental patients discharged from a Jerusalem
hospital within a five year period.

This approach provides an answer to the basic ques-
tion as to the type of clients being treated. Specifically,
it was possible to determine whether the Moadon is treating
a cross section of the population (thus allowing generaliza-
tions to the entire population of ex-mental patients) or

just a segment of it (in which case generalizations are

77

made only to mental patients with Similar characteristics).
Once this goal had been attained, the baseline measure
approach was used as a basis for the evaluation of program
effectiveness. This problem could be approached in a number
of ways{

1. Comparing members to themselves -- If, for example,
a client had been in the community two months out of thirty
months before coming to the Moadon, this time period can
serve as a baseline measure when attempting to determine the
effect of participating in the Moadon on community tenure.

2. Comparing the Moadon with the census population --
For example, in the census, if 80% of the subjects with five
hospitalizations are rehospitalized within a year, the
Moadon clients with Similar characteristics can be evaluated
in contrast to this.

For the purposes of this study, alternative No. 1 was
adopted. That is, the period of hospitalization prior to
referral to the Moadon was used as a baseline which was com-
pared to the length of hospitalization after referral. We
are, therefore, talking about a before-after design (the
baseline period prior to referral to the Moadon being
considered the "before” period and a similar time period

from date of referral being considered the "after" period)

78

with the clients serving as their own control group.

The results of such comparisons permit statements
to be made about the effectiveness of a treatment for the
Moadon population. This is the same goal that is attained
through the use of inferential Statistics with one basic
difference -- with the use of the research design outlined
above, we can also define the population that is being
evaluated, thus eliminating problems of generalizability.

In summary, the availability of population parameters
provides the researcher with the information necessary to
define the population with which he is working, and with
baseline measures to serve as a basis for program evaluation.
Thus, the need for random selection and assignment is elimi-
nated, since we can now specify the population for which a

particular treatment is effective or ineffective.

Hypotheses
Comparison of Moadon and Census POpulation
If the Moadon population is representative of that
segment of the ex-mental patient population characterized
by its chronicity, then:
filg -- The Moadon population will have a greater number of

admissions than the Census population.

Hle

'33
I—"
I'h

F:
H
5‘

79

The Moadon population will have spent a longer total
time in mental institutions than the Census popula-
tion.

The Moadon population will have lengthier admissions
than the Census population.

The Moadon population will have been first admitted
to a mental institution at an earlier age than the
Census population.

The Moadon population will.have more diagnoses of
schizophrenia than the Census population.

The Moadon population will have Spent less time in
the community between admissions than the Census popu-
lation.

The Moadon population will have a higher percentage
of males than the Census population.

There will be no difference in the ethnic distribu-

tion of the Moadon and Census populations.

Communigy Tenure

If the Moadon Shalom program is successful in in-

creasing community tenure, then:

HZa -- The number of Moadon members saving hospitalization

time will exceed the number of Moadon members losing

8O

hospitalization time after participation in the
Moadon.
H22 -- Hospitalization time saved will exceed hospitaliza-
tion time lost after participation in Moadon Shalom.
Hgg_-- Moadon members saving hospitalization time will not
differ from Moadon members losing hospitalization

time on relevant demographic variables.

Attendance in Moadon

H3_-- If attendance in the Moadon Shalom program is respon-
sible for community tenure, then Moadon members with
high attendance will save more hospitalization time

than Moadon members with low attendance.

Contact

H4 -- If amount of contact in the Mbadon is responsible
for community tenure, then Moadon members with high
contact ratings will save more hospitalization time

than those members with low contact ratings.

 

Employment
H5 -- If the Moadon program is successful in preparing its

clients for work roles, then the number of employed

81

clients (competitive and sheltered) will be greater
after participation in the Moadon than before parti-

cipation in the Moadon.

Community Involvement4(Quantity of Social Interaction)

‘Hé -- If attendance in the Moadon Shalom is responsible
for increased community involvement, then Moadon
members with high attendance will have higher per-
fonmance ratings than those clients with low

attendance.

anlity of Social Interaction

H7 -- If attendance in the Moadon is responsible for improv-
ing quality of life in the community, then members
with high attendance will. have higher ratings on
those items dealing with this variable than members

with low attendance.

Analysis Procedures

 

Non-parametric statistics were used to analyze the
data in this study because two of the basic conditions for
the use of parametric statistics could not be met. Speci-
fically, the variables of interest were not normally distri-

buted among the population, Since Moadon members were

82

chosen on the basis of their chronicity and maladaptive
behavior patterns. Secondly, random sampling was not used
since Meadon members served as the sample population. A
final reason for the use of non-parametric statistics was
that much of the data analyzed was measured on nominal and
ordinal scales.

The specific tests used in this thesis were as follows:

1. McNemar test for the Significance of changes in
related samples (corrected for continuity). This test was
used to analyze changes in vocational Status in Moadon mem-

bers after participation in the Moadon Shalom.

x2 = (1A - DI - 1)2 With df = 1
A + D

 

>
w

 

 

 

 

 

2. Wilcoxon matched pairs signed ranks test. 'This
test is applicable when subjects serve as their own control
groups and when differences observed for various matched
pairs can be ranked. Specifically, Wilcoxon's matched pairs
signed ranks test employs both the magnitude and the direc—
tion of the differences by ranking the absolute values of
the differences and attaching to the ranks the signs of the
original differences. This test was used to determine

whether time in the community was greater for Moadon members

83

after they participated in the Moadon program as compared
to before their participation.

n n+1
Z = min(T(+),T(-) - 4

\/;,.1 [n(n+1)(2n+l)- gin-3141)]

 

3. Chi square test for independent samples -- This
test is used when the researcher is interested in seeing
whether two groups differ in terms of the relative frequency
with which group members fall in several categories. Most
of the hypotheses being tested in this thesis lent them-
selves to this type of analysis and the chi square test was
used frequently throughout the study. The two basic forms
of the chi square test used were as follows:

a. For 2x2 contingency tables

 

 

 

 

 

 

c D x2 = N(|-AD - BC] 4})2 df = 1

 

(A+B) (C+D) (A+C) (B+D)
This formula is applied to 2x2 contingency tables Since
it concludes a correction for continuity, therefore improv-

ing the approximation of the distribution of the computed

 

x2 by the x2 distribution.
b. For other contingency tables the following
. . . . . 2
formula was used: x2 =£é (013 " Elli
Eij

Oij--observed scores Eij-~expected scores under Ho

84

Summary

In describing the design of the Study, it has become
apparent that this thesis is concerned with a number of new
issues in the evaluation of psychiatric rehabilitation pro-
grams; for although most studies concerned with assessing
the effectiveness of such programs have dealt with maintain-
ing the ex-mental patient in the community (Weinman et al.,
'70; Sheldon, '64; Sheldon and Jones, '67; Tanaka, '65),
they have not related to the following:

1. Determining the applicability of agprogram for a

particular segment of the ex-mental patient population --

 

From the description of the treatment program in Chapter 111,
it was apparent that the Moadon Shalom is primarily interested
in providing services for chronic, schizophrenic ex-patients
in the Jerusalem mental patient population. By comparing

the Moadon population to the Census population, it was possible
to determine whether in fact the Moadon was treating a chronic
population, therefore allowing generalizations regarding the
success or lack of success of the treatment program to be

made to this particular segment of the ex-mental patient
population. In most studies where the definition of the
treated population in terms of population parameters cannot

be achieved, it is only possible to determine the success

85

of a program in general terms and not whether it is applic-
able for a particular type of client.

2. Using a period of time before referral as a base-

 

line from which to measure community tenure. This procedure

 

introduces a new concept in the evaluation of rehabilitation
efforts and one which provides a more accurate assessment

of success or failure in the program. Given the operational
definition of community tenure that was developed in this
chapter (percentage of hospitalization time saved since
being referred to the Moadon), it is possible to measure
client success in terms of his past psychiatric history, as
opposed to measuring success only in terms of length of time
in the community after referral. For example, a high gainer
according to this definition may be a client who has spent
less time outside of the hospital than another client, but
in terms of his past hospital record has made a substantial
gain. On the other hand, another client with relatively
more months in the community may be considered a low gainer
because he spent little time in the hospital before referral
to the Moadon. Such an evaluation procedure thus provides

a more realistic picture of a client's success or failure

in the program, and also provides an opportunity to recog-

nize improvement in chronic patients that would be ignored

86

using other evaluation procedures.

3. Assessing the quality of life as well as mainten-

 

ance in the community. The focus of most rehabilitation

 

evaluation studies has been on assessing success in terms

of community tenure (Weinman et al., '70; Sheldon, '64;
Sheldon and Jones, '67; Guy, Gross, Hogarty and Dennis, '69).
The need also to evaluate the quality of life in the com-
munity is now being given more emphasis (Friedman, Von
Mering and Hinko, '66; Vitale and Steinback, '65; Pasamanick
et al., '67) and through the use of the social interaction
questionnaire, it is now possible to evaluate community
adjustment in terms other than community tenure.

In summary, the present chapter has fulfilled two
primary functions: (a) describing the design of the study
and (b) pointing out the new issues in the evaluation of
psychiatric rehabilitation programs that are emphasized in

this thesis.

CHAPTER V

DESCRIPTION OF THE MOADON(REHABILITATION CLUB)POPULATION

When evaluating the effectiveness of a treatment program,
results are more meaningful when the population being treated
can be defined. The availability of population parameters
from the Census Study of the Jerusalem ex-mental patient
population made it possible to compare the Moadon population
with the general ex-mental patient population on a number of
demographic variables. This information was invaluable, for
it provided an opportunity to determine the type of clients
being treated at the Moadon, as well as giving an indication
of their rehabilitation potential. If, for example, the
treated clients had spent little time in the hospital and had
few rehospitalizations, criteria for success would differ
greatly than if the clients were more chronic. Since the
Moadon's policy was to recruit chronic patients unacceptable
to traditional rehabilitation programs, it was hypothesized
(hypotheses la-h) that the Moadon population would fall at
the lower end of the continuum in terms of those variables
related to chronicity and poor rehabilitation potential.
Specifically, it was hypothesized that there would be differ-

ences between the Moadon and the Census populations on

87

88

variables a-g, and no difference on variable h. The hypotheses
being tested and the analysis of the data related to these
hypotheses are as follows:

If the Moadon population is representative of that
segment of the ex-mental patient population characterized by
its chronicity, then:

ng--The Moadon population will have a greater number
of admissions than the Census population.

Hlb--The Moadon population will have spent a longer
total time in mental insitutions than the Census population.

ng--The Moadon population will have lengthier admissions
than the Census population.

ngf-The Moadon population will have been first admitted
to a mental institution at an earlier age than the Census
population.

ngf-The Moadon population will have more diagnoses of
schizophrenia than the Census population.

Riff-The Moadon population will have spent less time
in the community between admissions than the Census population.

ngf-The Moadon population will have a higher percentage
of males than the Census population.

th--There will be no difference in the ethnic distri-

bution of the Moadon and Census populations.

89

HQEf-Number of admissions -- A significant difference at the
.001 level (x2=24.9) was found between the Moadon and Census
population with regard to total number of admissions. Table
5.1 indicated that 16% of the Moadon population as compared
with 35% of the Census population have had only one admission,
whereas 41% of the Moadon as compared to 21% of the Census
population have had more than five admissions. Since
chronicity is defined in terms of this variable (Miller and
Schwartz, '65; Bockoven et al., '56), the above results lend

support to the hypothesis.

 

 

 

 

 

 

 

 

 

 

Table 5.1 -- The Moadon and Census populations compared
in terms of total number of admissions
l admission 2-4 admissions 5+ admissions
16% 44% 41%
Moadon 22 6O 55 T 137
35% 44% 21%
Census 528 681 32 1529
550 741 375 666
x=24.9 df=2 p (.001

Hlb--Tota1 time in hospitals -- It was hypothesized that

 

Moadon members will have spent a greater amount of time in
mental instutitions than subjects in the Census population.
Results (Table 5.2) indicate that:

l. 62% of the Census population as compared to 26% of
the Moadon members have spent less than one year in the

hospital.

90

2. 38% of the Census population and 74% of the Moadon
population have been hospitalized for two years or more.
A significant difference between the two populations was
found at the .001 level (x2=48.2), thus providing further
support for‘the hypothesis.

Table 5.2 -- The Moadon and Census populations compared
in terms of total time in hospital

 

 

 

 

 

 

 

 

-2 years +2 years Total
26% 74%
Moadon 39 96 135
62% 38%
Census 931 566 1497
970 662 1632
x2=48.2 df=1 p (.001

H1c--Leng§h of admissions -- The trend of short hospitalizations

 

discussed in the review of the literature (Brown, Parkes and
Wing, '59; Odegard, '61; Ratcliff, '64; Miller and Dawson, '68;
Herjanic, Hales and Stewart, '69; Friedman, Von Mering and
Hinko, '66) was also evident in the Census population in which
the majority of patients were released within three months

of being hospitalized Eor all six admissions). Specifically,
Table 5.3 shows that 68% of the Census population was released
within the first three months on first admission, 69% on the
second admission, 56% on the third admission, 58% on the

fourth admission, 59% on the fifth admission and 59% on the

91

sixth admission. In the Moadon population, however, the
percentage of those patients being released within three months
was lower, (33% on the first admission; 46% on the second
admission; 40% on the third admission; 44% on the fourth admis-
sion; 45% On the fifth admission; 42% on the sixth admission),
the implications of which will now be discussed.

As can be seen in Table 5.3, Moadon members have lengthier
hospitalizations than subjects in the Census Study, thus
providing one more indication of greater chronicity in the
Moadon population. However, Chi square tests were found to
be significant on only the first four admissions. This
apparent inconsistency can be accounted for by the fact that
as admissions increase, the difference between the Moadon and
Census populations decreases. For example, when talking
about the length of the fifth admission, only those subjects
hospitalized five times or more are considered, thus eliminating
much of the non-chronic patients. It should also be noted that
no trend exists toward longer or shorter hospitalizations
with successive admission in either the Moadon or Census pop-
ulation, thus indicating that hospital release policies remain

unchanged, even when treating chronic patients.

92

Table 5.3 -- The Moadon and Census pOpulations compared in
terms of length of admissions

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-3_months 4112 12+
33% 43% 24%
Moadon 44 56 31 131 lst admission
68% 26% 6%
Census 986 392 81 1459
1030 448 112 1590
X2=78.3 df=2 p (.001
-3 months 4-12 12+
46% 26% 28%
Moadon 52 29 31 112 2nd admission
69% 20% 11%
Census 562 164 85 811
614 193 116 923
x2=24.5 df=2 p<.001
-3 months 4-12 12+
40% 40% 21%
Moado 38 37 20 95 3rd admission
56% 26% 18%
Census 376 173 118 667
414 210 138 762
X2=9.26 df=2 p<.Ol
-3 months 4-12 12+
44% 38% 18%
Moadon 29 25 12 66 4th admission
58% 24% 18%
Census 264 109 79 452
293 134 91 518

 

 

 

 

 

X2=6.25 df=2 p<.05

Table 5.3 (Cont'd.)

_4

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-3 months 4-12 12+
45% 24% 31%
Moadon 25 13 17 55 5th admission
59% 24% 17%
Census 186 74 54 314
211 87 71 369
x2=5.23 df=2 p<NS
-3 months 4-12 12+
42% 39% 19%
Moadon 15 14 7 36 6th admission
59% 22% 19%
Census 124 47 39 210
139 61 46 246
x2=5.71 df=2 p(NS

Hld--Age at first admission -- Age at first psychiatric

 

contact has been Shown to be predictive of readmission

rates (Rosen, '68), thus demonstrating its relevance in

the description of a chronic population. Table 5.4 indicates
that 39% of the Moadon population was first admitted to

a mental hospital before the age of 22 as compared to only
23% in the Census study, while 77% in the Census as compared
to 61% in the Moadon population were admitted after the age
of 22.

A Chi square test was found to be significant at

the .001 level (EL15.5), further demonstrating the chronicity

94

of the Moadon population.

Table 5.4 -- The Moadon and Census pOpulations compared
in terms of age at first admission

 

 

 

 

 

 

 

Less than More than
22 years old 22 years old
39% 61%
Moadon .52 82 134
23% 77%
Census 350 1164 1514
x2=15.5 df=l p-<.001

Hle--Diagnosis -- Table 5.5 indicates that 75% of the Moadon

 

population as compared to 53% of the Census population had
been diagnosed as shcizophrenic. A Chi square test was found
to be significant at the JMH.level (x2=14.94) thus revealing
another difference between the two populations, and

helping to substantiate the hypothesis that the Moadon is
treating a population comprised mainly of chronic schizophrenic

clients.

Table 5.5 -- The Moadon and Census populations compared
in terms of diagnosis

 

 

 

 

Schizophrenia Affective disorders Other
75% 8% 17%
Moadon 104 11 33 148
53% 19% 28%
Census 688 253 331 1272
, 792 264 364 1420

 

 

 

 

 

x2=l4.94 df=2 p (.01

95

Hlf—- Length between admissions -- Data from other studies
(Ratcliff, '64; Miller and Dawson, '68; Herjanic, Hales,

and Stewart, '68; Friedman, VOn Mering and Hinko, '61;
Fairweather and Simon, '60 and '63; Miller, '65; Rayxie

and Denber, '61) indicate short community tenure after
release from mental institutions. Readmission rates in both
the Census and Moadon populations are consistent with the
findings in the literature (Table 5.6), thus demonstrating
that the trend of a high percentage of readmissions within a
short time of release is an international phenomenon.

Table 5.6 -- Comparison of readmission rates in the Moadon
opulation, Census population and the literature

 

 

 

Percentage of MOadon Census LIferature

readmissions 32% 27% 33%

within six months (Friedman,gVon Merigg,
Hinko, '61

Percentage of 39% 39% 40%

readmissions (Miller and Dawson,

within one year '68)

 

 

 

 

Although no differences were found between the Moadon
and Census populations with regard to length between admissions
for those patients who were eventually rehospitalized (Table
5.7), a consistent difference can be seen in the number of
patients not being readmitted after each release (Table 5.8).
For example, 16% of the Moadon population were not readmitted

after their first hospitalization as compared to 35% of the

Census population.

This trend continues through the sixth

admission where 68% of the Moadon and 80% of the Census

population did not have a sixth admission.

It was originally

hypothesized that Moadon clients would be rehospitalized

sooner than the Census Study population.

This hypothesis

is not supported by the data (Table 5.8) since the length

of community tenure is similar for both populations.

However,

a significantly higher proportion of the Census population

remained in the community permanently after each successive

admission, thus indicating that the percentage of patients

requiring readmission is a better indicator of commmunity

adjustment difficulties for a given population than the

length of time between admissions.

Table 5.7 -- Comparison of the Moadon and Census populations

 

 

 

 

 

 

 

 

in terms of time between admissions

 

 

 

 

 

 

-3 months 4-12 12+
29% 29% 42%
Moadon 33 34 45 112
28% 39% 33%
Census 278 370 305 963
311 354 410 1075
-3 months 4-12 12+
39% 38% 23%
Moadon 36 28 21 85
32% 45% 23%
Census 219 240 199 658
"255 jfi_268 220 743,

 

 

 

 

 

lst and 2nd
x2= .42
df=2

p (not 5 ignificant

2nd and 3rd

x2=3.04
df=2
p (not Significant

97

Table 5.7 (Cont'd.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

-3 months 4-12 12+
45% 34% 24%
‘Moadon 32 22 12 66 3rd and 4th
' 36% 35% 29% X2=2.85
Census 166 159 115 440 df=2
e— 198 181 127 506 p«(not Significant
-3 months 4-12 12+
45% 34% 21%
Moadon 26 20 8 54 4th and 5th
40% 40% 20% x2=l.81
Census 122 122 65 309 df=2
148 142 73 363 p(not Significant
-3 months 4-12 12+
40% 50% 10%
Meadon 14 18 4 36 5th and 6th
37% 43% 20% x2=.30
Census 77 87 40 204 df=2
9]- 105 44 240 p < not significant

Table 5.8 -- Comparison of the Moadon and Census populations
in terms of the percentage of patients not
requiring readmissions

 

 

 

No 2nd No 3rd No 4th No 5th No 6th
Admission Admission Admission Admission Admission
16% 32% 47% 58% 68%
'Moadon 22 43 65 79 93
35% 56% 71% 79% 80%
Census 530 853 1071 1209 1212

 

 

 

 

 

 

 

98

In addition, the increasing percentage of people
that return to the hospital within one year (67% after the
first admission - 80% after the fifth admission in the Census
study; and 58% after the first admission - 90% after the
fifth admiSsion in the Moadon population) points to the increas-
ingly difficult task of remaining in the community as the
number of hospitalizations increase. Although these data
do not indicate the source of difficulty in the community
adjustment of the ex-mental patient, they do lead to one
obvious conclusion -- effective intervention in the community
is needed, and the earlier this intervention occurs, the
greater is the chance of preventing further rehospitalizations.
The need for early intervention is supported by another set
of data as well -- the percentage of clients remaining out
of the hospital for more than six months after one admission
who remained out of the hospital for less than six months
after the following admission (only considering those clients
readmitted). Specifically, the results (Table 5.9) show that
the majority of those patients who stayed out of the hospital
six months or more after one admission, remained in the

community six months or less after their next admission.

99

Table 5.9 -- Percentage of Moadon clients remaining in
the community for less than six months who,
after their preceding admission, had remained
in the community for more than six months

 

Percentage of Moadon clients remaining in the
community for six months or more after their

 

first admission, who remained in the community 51%
for less than Six months after their second

admission

+6 after second admission 78%

-6 after third admission

 

+6 after third admission 65%
-6 after fourth admission

Analysis of data concerning the fifth and sixth admissions
could not be made because of the samll number of clients
hospitalized for six months or more (i.e., for fifth admission
N=12). However, for the data that were sufficient, if can be
concluded that since community tenure decreases from one
admission to the next, early intervention in the community

is of great importance.

ng -- Sex -- It was hypothesized that there would be a higher

 

percentage of males in the Moadon population than in the

Census population, based on the assumption that it was relatively
easier for a woman to resume her role in the community than

a man. The Census Study (data on present status and sex --

Table 5.10) shows that 59% of the Census population hospital-

ized at the time of the study were male, while only 51% of

100

the total population was male. In addition, Halevy's study
of Israel's mental institutions shows 53% male and 47% female
as compared to 51% male and 49% female in the discharged
population, thus indicating that men in general have difficulties
in community adaptation. This difficulty in community adapt-
ation among males was found to be even more prevelant in the
Moadon population in which 68% of the population are male
and 32% female. A significant difference (2414.3) was found
at the.001 level between the Moadon and Census population
on this characteristic (Table 5.11), providing additional
support for the hypothesis.

Table 5.10 -- Percentage of makes and females in the

hospital at time of the census study in

relationship to the proportion of males
and females in the total mental patient

 

 

 

 

 

,population

Male Female
lijospital 59% 41%
Percentage of
Total Population 51% 49%

 

Table 5.11 -- The Moadon and Census populations
‘compared in terms of sex

 

 

 

 

 

 

 

Male Female g_
68% 32%
Moadon 102 48 150
51% 49%
Census 771 742 1513
873 790 1663

 

 

x2=14.3 df=2 p (.001

101

H1h--Country of birth -- Table 5.12 reveals a similarity in
ethnic distribution between the Moadon and Census populations.
No differences were expected on this variable since chronicity

is not considered to be common to any particular ethnic group.

The one difference that did appear is on the native born

population where 39% of the Moadon and 29% of the Census

population were born in Israel, thus reflecting the fact that

the Moadon's rehabilitation program is geared to a younger

population.

Table 5.12 -- Moadon and Census populations compared in

terms of country of birth

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Westérn Eastern CentraI'ISouthern *EngIISh
Europe Europe Europe Europe Speaking Countries
3% 13% 6% 1% 1%
Moadon 4 19 9 2 2
2% 16% 7% 2% 3%
Census 23 208 90 28 37
oufh North Middle No
America Africa East Israel Information Total
17? T67, I97. 397.
Moadon 2 24 28 57 3 150
1% 20% 21% 29%
Census 10 255 27 373 O 1294
Summary

The above comparison has demonstrated that the Moadon

population differs from the general mental patient population

on a number of demographic variables that are hypothesized to

102

relate to chronicity. Specifically:

1. First admissions to a mental institution occurred
at a younger age among Moadon members.

2. Moadon members have had more readmissions than the
Census population.

3. Total time spent in mental institutions was greater
among Moadon members.

4. Moadon members were hospitalized longer during
their first four admissions.

(The lack of significance on the fifth and sixth
admissions was attributed to the fact that two relatively
homogeneous populations, both having a high number of
admissions,were being compared).

5. There was a higher percentage of male members in
the Moadon population.

6. More Moadon members were diagnosed as being schiz-
ophrenic.

7. Fewer Moadon than Census subjects remained perman-
ently in the community after each successive admission.

Similarities between the two populations were found
on the following variables:

1. Ethnic distribution

2. Length of time between hospitalizations for those

who were eventually rehospitalized.

103

It can be seen from the above comparisons that the
Moadon is not working with a cross-section of the mental
patient population, but rather a chronic population that is
characterized by an inability to adjust to life outside of
a hospital. On a continuum ranging from good-poOr rehabili-
tation potential, Moadon clients would be ranked at the lower
end of the scale, and the expectations for their rehabilitation
success would not be great. This conclusion is based on the
hospitalization history of the MOadon population in comparison
with that of the general ex-patient population, and is substan-
tiated by an additional fact: the high percentage of Moadon
clients whose community tenure decreased from one discharge
to the next. Since a basic criteria for successful rehabilita-
tion in this thesis and in general is increase in community
tenure, it is apparent that Moadon clients demonstrate poor
rehabilitation potential, both in terms of their own background
and in comparison with the general ex-patient population. In
addition, the value of the preceding comparisons is twofold:
1. Given the nature of the Moadon population, a basis
is provided for the development of realistic expectations
for success in the Moadon program. Specifically, since the
Moadon population is characterized by a higher number of

readmissions, lengthy hospitalizations and other characteristics

104

related to chronicity, expectations for success cannot
be similar to those for less chronic patients. Rather,
gains by a particular member must be viewed in the light of
his past hospitalization history, if a realistic picture
of his success is to be obtained.

2. By describing the Moadon population in terms of
a number of demographic variables related to chronicity,
the group to which treatment effects can be attributed has

been defined.

CHAPTER VI

RESULTS AND ANALYSIS

The purpose of this chapter is to present the
data emanating from the research hypotheses stated in
Chapter IV. The data is divided into the following
three areas:

1. Data relating to community tenure

2. Data relating to community involvement

(quantity of social interaction)

3. Data relating to quality of life in the

community.

To determine whether Moadon clients increased their
community tenure after being referred to the Moadon was of
primary importance in this study. It was thus hypothesized
that if the Moadon was successful in attaining its goals,
more Moadon members would save rather than lose hOSpitaliza-
tion time (H3a), and that the amount of hospitalization time
saved would exceed that of hospitalization time lost (H3b).
In addition, it was important to explore the possibility

that hospitalization time gained by Moadon members was

105

106

related to their greater rehabilitation potential (as
defined by more healthy ratings in terms of those demo-
graphic variables related to chronicity) rather than to
their participation in the Moadon program (H3c).

Hypotheses 4 and 5 wamaalso concerned with identi-
fying those factors related to successful rehabilitation.
Since a major goal of the study was to determine the
effectiveness of the Moadon in rehabilitating ex-mental
patients, it was hypothesized that participation in the
Moadon (as defined by the amount of attendance and contact)
would be related to rehabilitation success. Hopefully, in
addition to increasing community tenure, participation in
the Moadon was also seen as playing an important role in
the community adjustment of its clients. It was thus
hypothesized that participation in the Moadon would be
related to improvement in work status (H6), increased com—
munity involvement (H7), and improved quality of life in
the community (H8).

The data and its analysis are as follows:

Community Tenure

 

H2a -- If the Moadon program is successful in in

creasing community tenure, then the number of Moadon members

107

saving hOSpitalization time will exceed the number of Moadon
members losing hospitalization time after participation in
the Moadon.

Data relating to the number of active clients saving
and losing hospitalization time and the percentage of the
time saved or lost are represented by Table 6.1.

Table 6.1 -- Number and percentage of active clients
saving and losing hospitalization time

 

 

 

 

 

 

N N %

G 1-24% 9
A
I 25-49% 11
N 72 73%
E 50-74% 14
R
S 75-100% 38
L 1-24% 6
O
S 25-49% 7
E 20
R 50-74% 3
S

75-100% 4 27%
Neither saving
or losing time 6
In community for
entire period 35
In hospital for
entire period 17

 

 

 

 

The data reveal that among those clients who were
neither hospitalized for the entire period or in the community

for the entire period, 73% saved hospitalization time. With

108

regard to the percentage of hospitalization time saved, it
should be restated that these figures are based on the for-

mula developed in Chapter IV:

_ Time hospitalized after referral
Time hospitalized before referral

 

As was emphasized in the discussion relating to the
development of this formula, using the amount of time hos-
pitalized before referral as a baseline measure and com-
paring it with the amount of time hospitalized after refer-
ral, provides a more meaningful measure of community tenure
than merely counting the number of months in the community
since discharge. ‘What is especially revealing about these
data is that 38 out of 72 (53%) clients who saved hospitaliza-
tion time increased their community tenure by more than 75%.

_ng_-- If the Moadon is successful in increasing com-
munity tenure, then hospitalization time saved will exceed
hospitalization time lost after participation in Moadon
Shalom.

Time gained -- 523 months
Time lost -- 72 months
Total time gained -- 451 months
These data are also based on the comparison of baseline

information with the amount of time hospitalized after

109

referral to the Moadon. For example, if one was hospitalized
for Six months of the 18 months that he participated in the
Moadon and 12 out of the 18 months prior to being referred to
the Moadon, a gain of six months was recorded. To examine this
hypothesis more closely, baseline and post-treatment data were
compared using the Wilcoxon matched-pairs test. After correct-
ing for tied observations, a z score of 5.75 was obtained, which
is significant at the .001 level. The conclusion can thus be
reached that participation in the Moadon is related to an in-

crease in community tenure among program participants.

Summary

The following can be summarized from the data emanating
from hypotheses Hla and Hlb:

1. Considerably more hospitalization time was gained
than lost by active participants.

2. Considerably more clients saved hospitalization time
than lost hospitalization time.

3. Among those who saved hospitalization time, more
than one half of the clients increased their community tenure
by more than 75%.

Although these data are only gross indicators of pro-

gram success, they do demonstrate that a great majority of

110

active Moadon participants saved a significant amount of hos-
pitalization time after participating in the Moadon. The
question still remains as to what conclusions can be drawn

from these data. As was pointed out in the comparison of the
Moadon and Census populations, Moadon clients were shown to
have poor rehabilitation potential in terms of their own back-
ground and in comparison with the general ex-patient popula-
tion. 0n the basis of this data, it can be concluded safely
that the increase in community tenure was above and beyond the
expectations that would be held for a population of this nature.

Egg -- If the Moadon program is successful in increas-
ing community tenure, then Moadon members saving hospitalization
time will not differ from Moadon members losing hospitalization
time on relevant demographic variables.

The above hypothesis is based on the assumption that
successful community tenure (percentage of hospital time saved)
is a function of participation and/or program effectiveness
rather than pre-existing differences between successful and
unsuccessful clients on the demographic variables being con-
sidered. Results (Tables 6.2-6.10) indicate that there are no
significant differences between the groups on any of the demo-
graphic variables, thus demonstrating that less chronic patients
are not necessarily those who are successful. The question must

now be asked as to whether these findings are unique to the

111

Moadon population or whether they are also substantiated in
the literature.

Analysis of this question leads to the conclusion that
the demographic variables being considered do in fact differ-
entiate between successful and unsuccessful community adjust-
ment (in most studies success and failure are defined in terms
of frequency of hospitalization). Various studies have shown
that total time in hospitals (Michaux et a1. '69), age at
first admission (Rosen et a1. '68), number of admissions
(Bockoven et a1. '56; Miller and Schwartz, '65; Linn, '64;
Lorei, '64; Pishkin and Bradshaw, '66 and Robbins, '55), length
of admissions (Freeman and Simmons, '63; Lorei, '64; Pishkin
and Bradshaw, '66; Robbins, '65) and diagnosis (Michaux et a1.
'69) are all related to community tenure. Results of the
present study contradict those found in the literature, thus
providing further proof that successful participants in the
Moadon program are not those who are less chronic.

Table 6.2 -- Comparison of active clients saving

and losing hospital time in terms of
total time in the hospital

    
    
 
 

   
   
  

    

2

   

-2

   

ears +
37
ll
48

ears
34
15
49

      
    
 

71
26
97

  
 

Loss

112

Table 6.3 -- Comparison of active clients saving and
losing hospitalization time in terms of

  
 
   
    
  

     
   
   

  
  
   

    
 
 

-22 22+ x2=. 19
30 41 71 df=l
Loss 9 17 26 p < NS

39 58 97

Table 6.4 -- Comparison of active clients saving and
losing hospitalization time in terms of

 
 
   
    
  

    
    
  
 

  
  
 
  

  

  
 

1-2 3+ x2=3o50
27 44 71 df=l

1 66 97
Table 6.5 -- Comparison of active clients saving and

losing hospitalization time in terms of
1 ion

   
   
    

     
    
   
 

      
 
   

    
 
 

 

months 6 months + x2=.09
42 28 7O df=1
14 12 26 p (NS

6

Table 6.6 -- Comparison of active clients saving and
losing hospitalization time in terms of
tio
-6 months 6 months + x =.27
43 16 59 df=l
l7 8 25
NS
60 24 84 p <

Table 6.7 -- Comparison of active clients saving and
losing hospitalization time in terms of
dia nosis

 

   
  
   

  
    

   
     

     
 

 

Schiz. Other X2=,39
Gain 54 17 71 df=1
22 4 26 p<NS

   

76

Table 6.8 -- Comparison of active clients saving and
losing hospitalization time in terms of

 
   

  
    
    

   
   
  

  
 
 

     
   
 

Work No Work* x2=,33
Gain 20 51 71 df=1
Loss 4 21 p<NS

 

25
2 9
*includes sheltered employment

113

Table 6.9 -- Comparison of active clients saving and
losing hospitalization time in terms of Sex
=.O9

 

!

 

 

 

Male Female x
CEin 36 36 _fi 72 df=1
Loss 14 12 26 p (NS
50 48 98

 

 

 

 

Table 6.10 -7 Comparison of active clients saving and
losing hospitalization time in terms

 
   
    
 
 

     
    
   

   
   
      

      
    

With Others Alone x2=.01
Gain 36 36 72 df=1
Loss 14 12 26 p (NS

     

50 48 98

Table 6.11 -- Comparison of active clients saving and
losing hospitalization time in terms

    

       
   
   

 

    
  
  

  
 

   
  

 

Married Other x7-=. 18
8 72 df=1
Loss 2 23 25 p (NS

10 87 97

The above data also show no significant differences
between successful and non-successful clients in terms of
marital status. In the literature, however, marital status
is shown to be related to rehabilitation success with married
ex-patients functioning on a higher level than unmarried ex-
patients (Davis, Freeman and Simmons, '58; Dinitz et a1. '61,
Freeman and Simmons, '63 and Schooler et a1. '67). Data in
this study again contradict the literature and show that success-
ful and non-successful participants in the Moadon cannot be
differentiated in terms of this variable.

It would also be logical to assume that those who lived

with others would remain in the community longer than those who

114

lived alone because of the greater potential for support and
interaction in this type of setting. This assumption is sup-
ported in the literature by articles linking high readmission
rates with loneliness and social isolation (Raskin and Dyson,
'68; Miller and Schwartz, '65; Dudgeon, '64). The data in

this study (Table 6.10) Show that there was no significant
difference between successful and unsuccessful clients in terms
of this variable, thus eliminating living situation as a factor
related to success in the Moadon program.

Sex is another variable that has not been mentioned. It
has been shown to be a poor predictor of community tenure in
the literature (Linn, '64; Tanaka, '65) and also did not dis—
criminate between successful and unsuccessful clients in this
study.

A final variable that would be expected to discriminate
between successful and unsuccessful clients is work status at
referral. It would seem likely that these clients who were
successfully employed would have a better chance of remaining
in the community than those without employment. This assump-
tion is supported in the literature (Linn, '64; Lorei, '64;
Brown, Corstairs and Topping, '58; Vitale and Steinbach, '65)
where it is found that employed ex—mental patients do in fact

remain in the community longer. However, it can be seen from

115

Table 6.8 that work at referral is not related to the community
tenure of Moadon clients.

The purpose of the above analysis was to demonstrate
that increased community tenure was not related to a greater
rehabilitation potential as defined by demographic variables
related to community tenure. Since there were no differences
between successful and unsuccessful clients on these variables,
it can be concluded that successful Moadon clients were not
merely those who had a greater potential to succeed.

H; -- If attendance in the Moadon Shalom is responsible
for community tenure, then Moadon members with high attendance
will save more hospitalization time than Moadon members with
low attendance.

Hypothesis 4 examines the relationship between atten-
dance and success in the Moadon program. The findings (Table
6.12)indicate that there is not a significant relationship
between these two variables. The question thus arises as to
the value of attendance in the Moadon, Since apparently those
clients with low attendance are as successful as those with
high attendance. To investigate this issue further, the
successful high and low attenders were compared on a number
of demographic variables related to chronicity. Results of

these comparisons are contained in Tables 6.13-6.22.

116

Table 6.12 -- Comparison of active clients saving and losing

 

 

 

 

 

 

hogpital‘zation tile in terms of attend nce
Percentage of Hi (50+) Lo(O-50) x =1,42
hospitalization df=1
time saved Gain 40 32 72 A p<NS
* Loss 18 8 26
58 40 98

 

 

 

 

*Loss includes those who neither saved or lost hospitaliza-
tion time.

Table 6.13 -- Comparison of gainers with high attendance and
low attendance in terms of number of admissions

 

 

 

 

1-2 admissions 3+ admissions
*1 A B
11 28 39 x2=2.67
*2 c D df=1
l6 16 32 p (NS
27 44 71

 

 

 

 

*1 = Gainers with high attendance
*2 = Gainers with low attendance

Table 6.14 -- Comparison of gainers with high attendance and
low attendance in terms of total time in hospital

 

 

 

 

-1 year 1 year+ x2=6,10
1 13 26 39 df=1
2 21 ll 32 p (.01
34 37 71

 

 

 

 

Table 6.15 -- Comparison of gainers with high attendance
and low attendance in terms of age at first

  
   
     
  

 
     

  
  
    
 

   
  

   
  

-22 22+ x2=.0001
17 22 39 df=1
13 19 32 p < NS

30 41 71

Table 6.16 -- Comparison of gainers with high attendance
and low attendance in terms of living
arran ements ,
Alone With Others x2=.06
24 16 df=1
21 ll p< NS
5 27

    

117

Table 6.17 -- Comparison ofgainers with
and low

Married

2

6

8

 
   
    
  

   
 
 

Not Married
38
26
64

   

Table 6.18 4- Comparison of gainers with

  
 
 
    
    
   

    
    
  

Female
l6
16
32

Male
24
16
40

 
  
  

 

 
 
    
     

high attendance

  
  

tal sgatus
X =3.l6
40 df=1
32 p (.10

72

high attendance

 
   

x2=.37
o ”df=1
32 p (NS

  

72

 

 

 

 

 

 

 

Table 6.19 -- Comparison of gainers with high attendance and
1am,attendancehin-termslof_situation at Zreferral
In Out X =. 0
l 20 20 4O df=1
2 16 16 32 p (NS
34 34 72
Table 6.20 -- Comparison of gainers with high attendance

  
 
  
  

    
    
  

Others
7

 
  
  

Schiz.
32

22 .10
54 17

6.21 -- Comparison of gainers with
‘ and lOw attendance in terms

Table

  
   
    
  

   
    

6 months+
20
23 9
41 29
6.22 -- Comparison of gainers with
and low attendance in terms
second admission

6 months+
ll

5
l6

-6 months
18

  
   
 

NH

Table

   
    

 
 
 
 

-6 months
22
21

 

nosisz

 
   

   

X =1.05
39 df=1
32 p<NS

  

      

71

high attendance
of length of

 

   

x2=3.34
38 df=1
32 p<.10

  

   

70

high attendance
of length of

  
   
  
  

 
   

X2=.83
33 df=1
26 p<NS

  

  

59

118

Table 6.23 -- Comparison of gainers with high attendance
and low attendance in terms of length of

 
   
    
 
   

   
      

  
 

     

     

   
 

       

-6 months 6 months+ x2=3.63
1 23 5 28 df=1
2 . 8 8 16 p (.10
31 13 44

Table 6.24 -- Comparison of gainers with high attendance
' and low attendance in terms of work at

   
   
    

      
    
   
 

  
  

     
  

Work No Work x2=4.01
7 33 40 df=1
13 18 31 p (.05

    

20 51 71

On the demographic variables being considered, there
were significant relationships between total time of hospital
and attendance (p'<.05), work at referral and attendance
(p‘<.05), length of length of first admission and attendance
(P‘<-10)1, length of third admission and attendance (p«<.lO).
and marital status and attendance (p‘<.10). Specifically,
successful high attenders have spent more time in mental insti-
tutions than successful low attenders, have had lengthier first
and third admissions than low attenders, were less frequently

employed than low attenders, and were less frequently married

 

1Although under ordinary circumstances, relationships at the .10
level are not considered significant, they are seen as being
relevant in this context for the following reason. The popula-
tion which is being considered has already been defined as being
highly chronic in comparison with the general mental patient
population. We are, therefore, analyzing data from a homogeneous
population with a narrow range on most variables. When working
with such a population, relationships significant at the .10
level have greater meaning than when talking about a more hetero-
geneous population, thus justifying their includsion in the dis-
cussion of significant results.

119

than low attenders.

Although significant relationships were not found on
all of the above variables, a definite trend can be seen: that
high attenders appear to be the more chronic members of a popu-
lation already defined as being chronic. A significant rela-
tionship can thus be seen between attendance on the part of
the more chronic segment of the Moadon population and success,
whereas success on the part of the low attenders can be attri-
buted to factors such as better employment records and less
time spent in hospitals. In general, what appears to be oper-
ating is a self-selection process in which the less chronic
clients do not choose to participate in the Moadon program as
much as the more chronic clients. Another possibility is that
the less chronic patients simply do not need as much treatment
as their more chronic counterparts in order to increase their
community tenure.

Finally, the possibility exists that a greater staff
effort is being extended to the more chronic members of the
Moadon, a theory that will be examined in Hypothesis 4. In
any case, it is apparent that given any of the above explana-
nations, the Moadon is attaining its goal of successfully
working with those clients at the negative end of the continuum

in terms of chronicity and rehabilitation potential.

responsible

120

H3 -- If amount of contact in the Moadon program is

for community tenure, then Moadon members with

high contact ratings will save more hospitalization time than

those members with low contact ratings.

ference netween amount of contact and success in the Moadon

program.

previously stated results regarding the type of client that
is being treated intensively in the Moadon.

strates that a significant relationship exists between

Further analysis, however, lends support to the

attendance (among successful clients) and contact.

cally, high attenders have a significantly higher contact
rating than low attenders, thus indicating that not only do

chronic clients participate more, but there is also more

Table 6.25 indicates there is not a Significant dif-

Table 6.26 demon-

Specifi-

direct intervention on the part of the staff to involve them

in the‘

program and to aid them in other aspects of community

adjustment.

 

 

 

 

Table 6.25 -- Comparison of clients saving and
losing hospital time in terms of
contact
1-10 contacts 10-30 30+
Gain 24 l9 19 62
Loss 12 3 12 37
36 22 31 99

 

 

 

 

 

x2=5.5
df=2
p'<NS

121

Table 6.26 -- Gainers with low attendance and gainers
with high attendance compared in terms
of contact

 

 

 

 

1-10 contacts 10-30 30+
Gain-- 17 5 3 25 x2=13,47
low attend. df=2
Gain-- ' 87 14 15 37 p <301
high attend.
25 l9 18 62

 

 

 

 

From the data relating to contact and attendance, it
is apparent that in the Moadon program the more chronic clients
are receiving more treatment in comparison to the "healthier"
clients. This points to a major difference between the Moadon
and many mental institutions; for in most mental hospitals
less effort is expended for the chronic patients sitting in
the back wards, and greater effort is given to Short term

patients with greater rehabilitation potential.

CommunityiAdjustment

 

The criteria for successful rehabilitation defined in
Chapter I include both maintenance of the ex-patient in the
community and community adjustment as measured by the quantity
and quality of social interaction. The preceding discussion
focused on the relationship between participation in the

Moadon and community tenure, and the purpose of this section

122

will be to present the data concerning community adjustment.

As was pointed out in the discussion of Procedure (Chapter IV),
the Social Interaction Questionnaire could be administered only
to 69 of the_150 active clients. The question thus arises as
to whether this group is a representative sample of the active
Moadon population.

In order to determine if the same is representative, the
participating and non-participating clients were compared on
the following variables: total number of admissions, total
time in hospital, age at first admission, diagnosis, in-out of
hospital at referral, sex, living arrangements, work at referral,
marital status, length of first admission, length of second
admission, length of third admission, length of fourth admis-
sion, length of fifth admission, length of sixth admission,
age, community tenure, attendance, length between first and
second admissions, length between second and third admissions,
length between third and fourth admissions, length between
fourth and fifth admissions, length between fifth and sixth
admissions. Results of these comparisons (Appendix C) indi-
cate that the only difference between the two groups was in
attendance. An explanation for this finding is that the
social interaction questionnaire was administered to those

clients who were easily accessible, or in other words, those

123

clients who frequently attended the Moadon program. What

is important, however, is that on the background variables being
considered and particularly those related to chronicity,

there is no difference between the two groups. It can, therefore,
be concluded that the population being evaluated in terms of
community adjustment is a representative sample of the

active Moadon population, thus allowing generalizations to

be made to the entire active population.

,Quantity of Social Interaction --the performance of living

 

tasks related to community adjustment (living arrangements,
work, household duties, Self-care and social).
Vocational Functioning

Of particular importance in the evaluation of a
rehabilitation program is the determination of whether a
relationship exists between program participation and change
in vocational functioning. The following hypothesis is
concerned with this issue.
Héf-If the Moadon program is successful in preparing its
clients for work roles, the number of employed clients
(competitive and sheltered) will be greater after participation

in the Moadon than before participation in the Moadon.

Table 6.27 indicates that the number of clients

employed in either competitive or sheltered settings

124

increased significantly after participating in the Moadon,

thus supporting the hypothesis.

Table 6.27 -- Work status of Moadon clients before
and after participation in the Moadon

 

 

 

 

After
Work No Work
_,No Work 36 50 86
Before Work 36 5 41
72 55 ’ 127

 

 

 

 

p&<.001

An additional analysis comparing successful high and

low attenders was attempted, but not successfully carried

out, because there was only information on 15 of the 32 low

attenders. For the high attenders, however, there were data

on 37 out of 40 clients.

are as follows:

Situation at time
of referral

 

No work

Irregular work
Sheltered employment
No work

No work

Competitive employment
No work

The data relating to high attenders

Situation after
pgrticipation

 

No work

Irregular work
Sheltered employment
Sheltered employment
Vocational training
Competitive employment
Competitive employment

lz

Col l—'
\lCDLnl—‘UJI—‘NN

 

125

Final Results

 

Number competitively employed = 13
Number employed in sheltered settings = 14
Number unemployed (including irregular work) = 9
Number in training = 1
Table 6.28 -- Work status of Moadon clients before and

after participation in the Moadon (for
high attenders)

 

 

 

 

 

 

After
No Work Work
Work 0 6 x2=19
Before No Work 9 21 df=1
9 27 p(.001

 

Vocational rehabilitation is usually considered to
be the last stage of the rehabilitation process. The fact
that 61% of the active population was involved in some type
of work activity after participation as compared to only
31% before referral is indicative of the progress being made
by many of the Moadon clients. It is also interesting to
observe that among the high attenders who increased their
community tenure, a significant proportion of them were
employed in either a sheltered or competitive setting after

participating in the Moadon (Table 6.28).thus demonstrating

126

the relationship between participation in the Moadon and
improved vocational functioning.

Performance of Other Living Tasks

 

Originally, the intent of this section had been twofold:

(a) to see whether those clients who increased their community
tenure were high functioners on the various living tasks;
and (b) to see whether there was a relationship between
attendance in the Moadon program and performance of the living
tasks. Since only eight clients who lost hospitalization
time completed the questionnaire, a comparison of those
clients who increased and decreased their community tenure
was not feasible. It was possible, however, to analyze the
relationship between attendance and level of functioning of
the living tasks.
‘HQ --If attendance in the Moadon Shalom is responsible for
increased community involvement, then Moadon members with
high attendance will have higher performance ratings than
those clients with low attendance.

As was described in the discussion of dependent
variables, the procedure used for determining the level of
functioning for an individual was to compare his present level
of functioning with a baseline defined as his best period of

functioning since the age of twenty. A scoring scale (Appendix A)

 

127

was then developed that took into consideration present
and past levels of functioning, as well as the discrepancy
between the two periods.

The specific living tasks evaluated in the data to
be presented are as follows: household duties, personal
grooming, entertainment, visiting outside of the home, and
entertaining at home. (The specific items used in this analysis
are found in Appendix B). Work, another of the living tasks
evaluated, was considered independently in the previous
section. The living tasks not being considered, but which

were included in the mapping sentence (Figure 4.1) are as
follows: living arrangements and self care (medication and
therapeutic visits). In general, we were concerned about
those living tasks which might be affected by participation in

the Moadon. Although suitable living arrangements are important
in one' 5 community adjustment, attendance in the moadon was not
seen as being instrumental in determining the type or quality of
living arrangements , and thus not included in the evaluation .

arrangements, and was thus not included in the evaluation.
The same is true of therapeutic visits since contact with a
social worker, psychiatrist, or psychologist not on the
Moadon staff is independent of participation in the Moadon
program. Other reasons for eliminating items were lack of
response and lack of item discrimination. On the medication

question, for example, only about 20% of the respondants were

128

taking medication during their period of best functioning
as compared with approximately 80% at present. It was thus
difficult to determine whether clients are more responsible
about their medication now as compared to then, since
there was no opportunity for comparison for the majority of
clients.

Before presenting the data relating to the hypothesis,
one more basic question should be answered -- that is,
whether one's best period Since the age of twenty was really
a good period, or whether it was difficult for the subjects
to differentiate between good and bad periods in their lives.
The answer to this question is found in a questionnaire item
asking subjects the extent to which they were happy during
this period -- 11 were happy to a very great extent, 20 to
a great extent, and 9 to a small extent. None of the subjects
indicated that they were unhappy during this period, thus
providing evidence that the subjects were in fact comparing
their present functioning with a period in which all of them
were happy in varying degrees.

The data relating to Hypothesis 6enxefound in Table 6.29.

129

Table 6.29 -- Relationship between attendance and
quantity of social interaction

 

 

 

 

 

 

 

 

 

High (18+) Medium (14-18), Low (-l4)
High Attendance 7 17 10 34
Low Attendance 1 4 ll 16
8 21 21 50
x2=7 .10 df=2 p (.05

The results of these data indicate there was a
realtionship between attendance in the Moadon and one's
level of functioning on the living tasks. Specifically,
high attendance was found to be related to increased community
involvement among Moadon members, irrespective of the amount
of hospitalization time saved or lost.

These results become more meaningful when they are
analyzed in light of the chronicity of the Moadon population.
After numerous hospitalizations and success with shorter
periods in the community, one would expect Moadon members to
be living a marginal existence in the community (Miller and
Schwartz, '65; Bockoven et al., '56) therefore leading to a
large discrepancy between past and present functioning.

The fact that more than half of the clients indicated they
were functioning on the same level of even a higher level

than they did during their best period, is thus an unexpected

 

Rationale for scoring scale can be found in AppendixA .

130

finding and provides further support for the effectiveness
of the Moadon program.

Quality of Social Interaction

Hl--If attendance in the Moadon is responsible for improving
quality of life in the community, then members with high
attendance will have higher ratings on those items dealing
with this variable than members with low attendance. '

When referring to the quality of social interaction,
we were concerned with facet G (purpose) in the mapping
sentence (Figure 4.1) -- how the person interacts for the
purpose of happiness, support, and obligations. AS in the
measurement of the quantity of social interaction, a client's
present level of functioning was compared with his best period
of functioning since the age of twenty and a scale was
develOped that took into consideration present and past level
of functioning and the discrepancy between the two periods.

The living tasks included in this evaluation were
household duties, grooming and entertainment. The other living
tasks were eliminated for the following reasons: (a) living
arrangements, self-care (therapeutic visits) -- not relevant

for the reasons described in the previous section, (b) work,

 

An explanation for the scoring scale can be found in Appendix A.

131

visiting -- insufficient N. (c) self-care (medication) --
poor item discrimination.
The data relating to Hypothesis 7 are found in Table 6.30.

Table 6.30 -- Relationship between attendance and
yquality of life in the community

 

 

 

 

 

8+ -8
High Low
High Attendance l8 _ 10 28
Low Attendance 3 ll 14
21 21 42
x2=5.25 df=1 p (.05

Although limited by the small N and the exclusion
of some relevant living tasks, the data still present a
clear relationship between attendance in the program and
quality of social interaction. In summary, attendance in the
Moadon has been Shown to be an important factor in improving
the quantity and quality of social interaction, both of
which were basic criteria of successful rehabilitation as

defined in this paper.

Summary and Conclusions
Now that the results have been presented, the value
of the Moadon Shalom as a post-psychiatric treatment program

can be evaluated. Essentially, we are asking whether the

132

Moadon meets the criteria of a good rehabilitation program.
According to the National Institute of Mental Health definition
(Chapter 1, p.4), psychiatric rehabilitation should be
concerned with the restoration of social roles and social
functions within significant social systems for the individual
(i.e. family, job, participation in the general life of

the community). Operationally defined, the criteria for
successful rehabilitation develOped in this paper were

as follows: (a) maintenance of the ex-patient in the community
(b) adjustment to life in the community -- the extent to
which an individual performs relevant living tasks (quantity
of social interaction) and his involvement in these living
tasks (quality of social interaction). The Moadon has been
Shown to be effective in meeting both of these criteria.
Specifically, after participating in the Moadon, a significant
percentage of the Moadon population (73%) increased their
community tenure and the amount of hospitalization time saved
was far greater than hospitalization time lost. Given the
chronicity and poor rehabilitation potential of the Moadon
population, this gain demonstrates a strong relationship
between participation in the Moadon and the maintenance of

chronic ex-patients in the community. In investigating this

133

issue further, it was found that attendance in the Moadon,

and reaching out (Contact) were especially important for

more chronic members of the Moadon, thus demonstrating the
particular success of the Moadon in helping its low functioning
members.

Participation in the Moadon was also found to be
related to the level of perfomance on relevant living tasks
(work, grooming, household duties, recreational activities,
visiting and entertaining at home) and the quality of life
in the community. Specifically, the more one attended the
Moadon, the more likely he was to beélhigh functioner on
the living tasks being considered and the higher was his
quality of interaction on these living tasks (as defined by
facet G -- interaction for the purposes of happiness,
obligation, and support). Although the data related to
community adjustment were limited, the existing results do
demonstrate the Moadon's effectiveness in helping marginal
members of society become more involved in the community.

It should be emphasized, however, that the improvement in
functioning being referred to is relative to the prior level

of functioning of the individual client, and that participation
in the Moadon does not lead to complete personality or

behavior change. However, even when viewed in its proper

134

perspective, the Moadon has been shown to be an important
factor in the community adjustment of its clients.

At this point, the implications of the above results
and other general issues related to the study can be
considered. Specifically, the following will be discussed:
(a) treatment in the Moadon as compared to treatment in a
hospital setting (b) the Moadon in relation to other community
based programs (c) contributions of the study to the field
of psychiatric rehabilitation (d) future research stimulated

by the study.

Treatment in the Moadon as compared to treatment in a hospital

setting

It was pointed out in Chapter I that hospital treatment
often creates a "shuttlebus effect" (short stays in the hospital
and high readmission rates), a trend that has been corroborated
by most demograhpic studies (Ratcliff, '64; Miller and Dawson,
'68; Herjanic, Hales and Stewart, '69; Friedman, Von Mering,
and Hinko, '66). The medical model orientation of most
hospital programs (i.e. treating mental disorders as a
sickness and not as a disability) and other factors associated
with institutionalization were seen as a major cause of
mental hospitals' failure to combat this trend (Erikson, '58;

Schefler, '65; Cumming and Cumming, '65; Fairweather, '64;

135

Greenblatt, '70). The Moadon program on the other hand was
designed to treat the functional limitations associated
with mental disorders rather than the disorder itself; and
it was shown that participation in the Moadon led to the break-
ing of the shuttlebus effect and an increase in community
tenure. On the other hand, it can be said that not all
hospital programs are based on the medical model and that some
of them have programs with similar orientations to that of
the Moadon. Hospital programs such as these, however, have
also been Shown to be ineffective in helping patients adjust
to life in the community after release, the major reason
being that they cannot help clients with every day living
problems once they are in the community (Sanders et al., '67).
It should be emphasized that this is not a condemnation of
hospital treatment, for hospital programs might be effective
in treating a patient within a hospital setting. However,
without community based support upon release, gains in
the hospital do not generalize to the community (Doehne,
Sandifer, Phillips and Waters, '65), thus justifying com-
munity based programs as either a substitute or supplement
for hospital treatment.

The above discussion has pointed to two factors

necessary for successful rehabilitation of chronic mental

136

patients: (a) treating mental disorders as disabilities
and emphasizing the functional limitations of the disability

(b) treatment within the community.

The Moadon in relation to other community based programs 1
A second issue to be considered is the relationship
between the Moadon and other community based programs.
Although treadnent' within the community was shown to be a
crucial element in the Moadon program, the Moadon's success
does not provide across the board support for all community
based programs. As was mentioned above, other factors
such as the nature of the treatment program, is also an
important factor in determining the effectiveness of the
program. However, even if other community based programs had
similar treatment programs, their success still would not be
assured, for the present study was concerned with only the
chronic segment of the ex-mental patient population and not
the ex-mental patient population as a whole. Therefore, it
is difficult to determine whether a treatment program effective
for this type of population would also be effective for other
segments of the ex-patient population. Finally, because most
other programs do not base their criteria for success on a
comparison of prior and present functioning, program

comparison is not possible. In summary, two basic points have

137

been made: (a) although a program such as the Moadon has
been shown to be effective in treating chronic, desocialized
clients, there is still a question as to whether a program
of this nature would also be effective for other segments

of the ex-mental patient population (b) a comparison of the
Moadon and other community based programs is not possible

unless assessment techniques are similar.

Contributions of the study to the field of psychiatric
gghabilitation

 

 

Much emphasis haskxxmiplaced in this chapter on
the effectiveness of the Moadon's treatment program. However,
in addition to increased knowledge about the treatment of
chronic ex-mental patients, the present study has made a
number of other contributions to the field of psychiatric
rehabilitation:

1. In the area of assessment, client success was
measured by using past history as a baseline rather than in
terms of present functioning alone. Such an evaluation procedure
is especially effective for chronic clients, for it provides
an opportunity to recognize improvement that might otherwise
be ignored using other evaluation procedures. In addition,
such an evaluation procedure provides an alternate approach
to control groups in settings where they cannot be easily

obtained.

138

2. In Chapter I, a need was expressed for program
evaluation that focused not only on maintenance in the
community, but also on the quality of life in the com-
munity (Fasamanick et al., '67; Friedman, Von Mering, and
Hinko, '66).

In the present study, an operational definition of
psychiatric rehabilitation was developed that included
both of these criteria, and through the use of the evaluation
techniques just mentioned, it was possible to measure both
the cOmmunity tenure and community adjustment of the
treated clients.

3. In most studies, where the treatment population
is not specifically defined, it is only possible to determine
the success of a program in general and not whether it is
applicable for a particular type of subject. In the present
study, it was possible to determine the type of client for
whom the treatment program was effective, thus helping to

define the population to which generalizations could be made.

Future research stimulated by the study
Future research stimulated by this study falls

into two categories: (a) research stimulated by the findings

139

of this study (b) research needed because of the failure
of the study to deal with certain important issues.
1. Relationship between specific aspects of the

Moadon and community adjustment -- Although information

 

about specific Moadon programs is available, it has not
yet been analyzed, thus only allowing for statements of
success regarding the general program. Future research
in the Moadon and other programs as well should include
an evaluation of the various components of their programs
in addition to a general evaluation. It is certain that
all of the activities are not equally effective and if the
less effective ones could be eliminated, the quality of
the Moadon program would improve as a result.

2. Relationship between community tenure and

community adjustment -- The lack of sufficient information

 

on the questionnaire also made it impossible to study the
relationship between community tenure and community
adjustment. Although participation in the Moadon was

found to be related to both of these components of community
adjustment, the analysis cannot be considered complete
unless it can be determined whether those who have saved

hospitalization time are also those who have increased their

 

140

community involvement. Hopefully, future research in this
area will include an evaluation of the interrelationship

between these two components of community adjustment.

 

3. Measurement of community adjustment -- Another
question of a more theoretical nature is how best to
measure community adjustment. The questionnaire used in this
study, although being comprehensive, was too complex for
the Moadon population, thus leading to many unanswered
questions and much missing information. Future research
in this area would be improved if an instrument could be
devised that was compatible with the ability level of the
subjects being evaluated and that still obtained all the
essential information.

A related issue that has not yet been treated is
the validity and reliability of the questionnaire. With
regard to validity, a pre-test of the questionnaire was
administered to 15 clients who had participated in the
Moadon since its inception and who were well' known to all
of the staff members. The subjects' responses on the
questionnaire were then compared to the behavior and feelings
of the clients as they were perceived by the staff. In
general, there was agreement between responses on questionnaire

items and staff perceptions, thus providing a gross measure

 

141

of concurrent validity. The use of facet theory to construct
the social interaction questionnaire gives the questionnaire
content validity by definition since all relevant variables
related to social interaction were included.

With regard to reliability, insufficient responses
on many items was a major reason why the questionnaire's
reliability could not be adequately ascertained. There was
however some data that demonstrated the internal consistancy
of the questionnaire. On the comparison questions (comparing
present period with best period since age 20), one of the
possible responses was no difference between the two periods.
In such instances it was possible to check similar questions
relating to present and past periods in order to see whether
the subject was consistent in his responses. It was found
in the great majority of the cases that when a subject
responded "no difference" on the comparison questions, there
was in fact no difference between his responses to questions
relating to past and present functioning.

Despite the above evidence relating to the reliability
and validity of the questionnaire, future research would be
improved if the validity and reliability of the measuring

instruments would be ascertained more thoroughly.

142

4. Need for longitudinal research -- Finally we come

 

to the question of the permanence of the gains made by

Moadon clients. The present study was not longitudinal in
nature, and measured community adjustment while most of

its members were either still actively involved in the program
or had only recently become less active. The question

thus remains as to whether these short term gains will continue
after an extended period of time. Evidence in the literature
indicates that gains begin to diminish three years after
treatment and that readmission rates again begin to rise.

Since the Moadon has a policy of keeping its doors open

to its former clients, the possibility exists that treatment
effects can be maintained over a long period of time.

However, without considering the nature of the treatment
program, future research in this area would be of most value

if it were longitudinal in nature, thus including an evaluation

of long-term as well as short-term effects of participation.

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143

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APPENDICES

154

155

APPENDIX A

SCORING SCALES FOR QUANTITY AND QUALITY OF SOCIAL INTERACTION

l. Scoring scale for quantity of social interaction --
i.e., household duties, grooming, entertainment, visit-
ing outside of home (with friends or family), spending
Sabbath and holidays with family (at home or elsewhere).

1 point--negative change (i.e., high functioning
during best period--1ow functioning at
present)

2 points--1ow 1eve1--no change

3 points--high leve1--no change

4 points--positive change

a. Scoring scale for work:

1 point--negative change (i.e., no work -
no change)

2 points--low 1eve1--no change (i.e.,

sheltered workshop)

3 points--high level--no change (i.e.,
competitive employment) and no
employment-~sheltered workshop

4 points-~positive change (i.e., no employ-

ment--competitive employment or

 

156

sheltered employment--competitive
employment).

Subjects with total scores for the six areas of 18
points and above were rated as high level functioners,
those with 14-18 points as average functioners, and those
with less than 14 points as low level functioners.

Rationale for scoring: To receive a score of 18 points
or more, one would have to be functioning higher now than
he did during his best period, or at least be functioning
on the same level that he did during his best period since
the age of 20 (low discrepancy--high level of functioning).
Average functioners would be those who have improved their
functioning in some areas and regressed in other areas, or
who have low discrepancy scores, but have been functioning
on a low level in some areas and on a high level in other
areas. Low functioners are those who have either maintained
a low level of functioning or who have regressed in function-

ing since their best period.

2. Scoring scale for quality of social interaction --
i.e., household duties, grooming and entertainment.
1 point--negative change (lower functioning now

than during best period).

 

157

2 points--1ow leve1--no discrepancy (i.e., when
response was 7--no discrepancy between now
and best period--responses to questions
concerning best and present period were
referred to--if answers indicated low
level functioning, the subject received
two points).

2.5 points (for those living tasks that were com-
prised of only two comparisons). If one
response indicated better functioning now
and the other indicated better functioning
during his ”best” period, 2.5 points were
assigned.

3 points--high level--no discrepancy (same procedure
as described under 2 points).

4 points--positive change (functioning better now
than during best period since age 20).

Subjects with total scores of 8 points and above were
rated as high level functioners and subjects with total
scores of 8 points and below were rated as low level
functioners. Rationale for scoring: To receive a score of
8 points, a subject must be functioning on a high level in

at least two of the areas being evaluated.

 

158
APPENDIX B

SOCIAL INTERACTION QUESTIONNAIREl

1. Quantity of Social Interaction
Possible responses
(a) To a very great extent
(b) To a great extent
(c) To a small extent
(d) Not at all
A. Household Duties
Present:
1. To what extent do you go shopping?
2. To what extent do you take part in cleaning the
house?
3. To what extent do you go about getting a repair-
man when something goes wrong?
4. To what extent do you attend to your laundry--
clothes, linen, etc.?
Best period since age 20:
1. To what extent did you go shopping then?
2. To what extent did you take part in cleaning

the house?

 

1Only those items that were analyzed for the study

 

159

3. To what extent did you go about getting a repair-
man when something went wrong?
4. To what extent did you attend to your laundry--
clothes, linen, etc.?
B. Entertainment
Present: How often do you do the following?
1. Go to the cinema?

2. Go to concerts, theater?

 

3. Go to lectures or talks?

4. Go out walking or to a cafe?

Best period since age 20: How often did you do the

following:

1. Go to the cinema?

2. Go to a concert, theater?

3. Go to a lecture or talk?

4. Go to a cafe or out walking?

C. Self-care -- grooming

Present:

1. To what extent do you yourself take care of
your personal grooming?

2. To what extent do you receive help from members
of the family in your personal grooming?

3. To what extent do you have help from friends in

160

your personal grooming?

Best period since age 20:

1. To what extent did you yourself take care of
your personal grooming?

2.' To what extent did you receive help from members
of the family in your personal grooming?

3. To what extent did you receive help from friends
in your personal grooming?

Visiting outside home

Present:

1. How often do you visit relatives?

2. Approximately how often do you visit friends?

Best period since age 20:

1. Approximately how often did you visit relatives?

2. Approximately how often did you visit friends?

Entertaining at home

Present:

1. To what extent do you usually spend holidays
with relatives and family at home?

2. To what extent do you usually spent Friday night
(Shabbat) with relatives and family at home?

Best period since age 20:

1. To what extent did you spend holidays with

 

161

relatives and family at home?
2. To what extent did you spend Friday night

(Shabbat) with relatives and family at home?

11. Quality of Social Interaction

Possible responses

(a) Very much more

(b) Much more

(c) More

(d) Less

(e) Much less

(f) Very much less

(g) No difference

Household Duties

Considering what you do in the house now as compared

with then (best period since age 20) -—

1. Does it give you pleasure now as compared with
then?

2. To what extent does it give others pleasure now
as compared with then?

3. To what extent do you feel you should do these
things now as compared with then?

Grooming

When you think about your personal appearance as

162

compared with then --

1. To what extent are you happy with your appearance
now as compared with then?

2. To what extent do you think others who are
important to you are happy with your appearance
now as compared with then?

Entertainment

When you think about your entertainment activities

now as compared to then, to what extent do you --

1.

Go out specifically for that activity as com-
pared to the past?

Go out because you like being with other people
as compared to the past?

Go out because other people invite you as com-
pared to the past?

Go out because you have nothing else to do as

compared to the past?

163

APPENDIX C

A COMPARISON OF QUESTIONNAIRE PARTICIPANTS AND NON-PARTICI-
PANTS ON RELEVANT DEMOGRAPHIC VARIABLES

Table A.1 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of total number of admissions

 

 

 

 

 

 

 

 

Participants 9 30‘ 24 63_
Non-participants 13 30 31 74

, 22 60 ’ 55 137
x2=.727 df=2 p (NS

Table A.2 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of total time in hospital

 

 

 

 

 

 

 

 

Participants 28 34 62
Non-particlpants 32 41 73

6O 75 135
x2=.0003 df=1 p <Ns

Table A.3 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of age at first admission

 

 

 

 

 

 

 

 

Participants 22 40 62
Non-particlpants 30 43 73

52 83 . 135
x2= . 2403 df=1 p < NS

Table A.4 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of diagnosis

 

 

 

 

 

 

 

Participants 48 4 11 63
Non-participants 56 7 12 75
104 l 11 23 138

 

x2= .418 df=2 p 013

 

l

64

Table A.5 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of in-out of hospital at referral

 

 

 

 

 

 

 

Participants 32 37 69
Non-participants 37 44 81

69 81 81
x2=.0062' df=2 p<Ns

Table A.6 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of sex

 

 

 

 

 

 

 

Participants 45 24 69
Non-participants 57 '24 81

102 48 AA 150 _ -
x2=.490 df=2 p <Ns

Table A.7 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of living arrangements

 

 

 

 

 

 

 

 

With Someone ‘Without
Else Someone Else
Participants 30 7 37
Non-participants 31 13 44
61 20 81 ___
x2=.71 df=1 p (NS

Table A.8 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of work at re

ferral

 

 

 

 

 

 

 

Participants 20 48 68
Nonsparticipants 28 52 80

48 100 148
x2-.18 df=1 p (NS

 

165

Table A.9 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of marital status

 

 

 

 

 

 

 

 

Participants 6 62 68
Non-particlpants 15 65 8O

21 127 148
X2=l.76 df=1 p (NS

Table A.10 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of length of first admission

 

 

 

 

 

 

 

 

Partiglpants 20 28 14 62
Non-participants 24 28 20 72

44 56 34 134
X2=.64 df=2 p (NS

Table A.11 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire

 

 

 

 

 

 

 

 

in terms of length of second admission
Participants 27 10 15 52
Non-participants 25 19 16 60
> 52 29 31 112

x2=2 .44 df=2 p (NS

Table A.12 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of length of third admission

 

t

 

 

 

 

 

 

Participants 17 11 8 36
Non-participants 21 10 12 49
1 38 27 20 85

 

x2=.181

df=2

P

'(NS

 

166

Table A.13 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire

in terms of fourth admission

 

 

 

 

 

 

 

 

Participants 15 10 3 28
Non-partiCipants 14 15 9 38

29 25 12 66
X2=2.98 . df p<Ns

Table A.14 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of fifth admission

 

 

 

 

 

 

 

 

Particlpants 9 5 10 24
Non-particlpants l6 8 7 31

25 13 17 55
x2=2.412 df p (NS

 

Table A.15 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of sixth admission

 

 

 

 

 

 

 

 

Participants 4 9 3 l6
Non-participants ll 5 4 26

15 y 14 7 36
x2=4.233 df=2 p< NS

Table A.16 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of age

 

 

 

 

 

 

 

 

Participants 9 14 46 69
Non-participants 9 18 51 78

18 32 97 147
x2=1. 65 df=2 p (NS

167

Table A.17 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of communi yltenure

 

 

 

 

 

 

 

 

Participants 31 9 40
Non-participants 41 17 58

72 _ 26 . 98
x2=.26 df=1 p< NS

Table A.18 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of attendance'

 

 

 

 

low high attendance
Participants 19 50 69
an:particlpants 42 39 81
61 , 89 150

 

 

 

 

 

x2=9.01 df=1 p < .01

Table A.19 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of length between first and second

 

 

 

 

 

 

 

 

admission
Participants 17 12 24 53
Non-participants 16 22 24 60
33 34 ‘j 48 113
x2=2.52 df=2 p (NS

Table A.20 -- A comparison of participants and non-partici-
pants on the Social Interaction Questionnaire
in terms of length between second and third

 

 

 

 

 

 

 

 

admission
Participants 19 8 14 41
Non-participants 17 20 15 52
36 28 29 93
x2=4.435 df=2 p (NS

168

Table A.21 -- A comparison of participants and non-partici-

pants on the Social Interaction Questionnaire
in terms of length between third and fourth

 

 

 

 

 

 

 

 

admission
Participants 14 10 8 32
Non-participants 18 12 10 40 __
32 , 22 18 . 72
x2=.007 df=2 p (NS
Table A.22 -- A comparison 0f participants and non-partici-

pants on the Social Interaction Questionnaire
in terms of length between fourth and fifth

 

 

 

 

 

 

 

 

admission
Participants 11 9 5 25
Non-participants 15 ll 7 33
26 A 20 12 58
x2=.005 df=2 p (NS

Table A.23 -- A comparison of participants and non-partici-

pants on the Social Interaction Questionnaire
in terms of length between fifth and sixth

 

 

 

 

 

 

 

admission
Participants 6 8 7 21
Non-partigipants 8 10 4 22
14 18 11 43
x2=l.932 df=2

 

p<NS

 

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