Effects of Community Follow-up on Post-hospital Adjustment of Psychiatric Patients

S. A. Purvis, M.P.S.* R. W. Miskimins, Ph.D.

ABSTRACT: Comprehensive community follow-up programs may be considered essential in increasing the community adjustment of former psychiatric pa- tients. Even intermittent hospitalization perpetuates dependency and hinders full rehabili- tation in the community. Research findings are presented which indicate that subjects re- ceiving post-hospital follow-up in the community show reduced hospital contact and re- cidivism and increased vocational success and satisfaction. Follow-up which offers moder- ate support and is distinct from the hospital, i.e., community-based, fosters the most inde- pendence and adjustment in its participants.

With considerable evidence that psychiatric hospitaliza- tion alone does not insure post-hospital community adjustment, many as- sume that improved hospital treatment programs are the answer to the psy- chiatric patient's successful community functioning. Although institution- alization has demonstrated value in cases of crisis and severe disorientation where a change in the total environment is essential, there is reason to ques- tion its effectiveness in realizing the final goal of therapeutic treatment, that of reestablishing the person within the community. The alternative advo- cated here involves the utilization of the community itself in effecting rehabilitation. The theoretical framework for this research focuses on three main points. The first is that psychiatric hospitalization alone cannot insure an ex-patient's community adjustment. Secondly, even the presently popular alternative of brief, intermittent hospitalization appears to be inadequate in that it also often fosters the institutional orientation of dependency, main- taining the "patient" identity, thus encouraging return to the hospital. Finally, it is proposed that the appropriate alternative in effecting community ad- justment is a structured, community-based "follow-up" program which af- fords the patient support and counseling, but does so independent from the hospital setting.

The proposition that psychiatric hospitalization alone cannot foster re- habilitation in the community is suggested by a large number of researches considering hospital treatment and later community adjustment. For ex- ample, Forsythe and Fairweather (~96~) found little relation between within- hospital measures, such as ward behavior, and community adjustment, and

* Mrs. Purvis is Assistant Director, Group Follow-up Services, Men- tal Health and Manpower Project, Fort Logan Mental Health Center, Denver, Colorado. Dr. Miskimins is Research Coordinator for the same project. This research was supported in part by the U.S. Department of Labor, OMPER, Grant Number 82-06-66-62.

374 Community Mental Health Journal, Vol. 6 (5), 1970

S. A. Purvis and R. W. Miskimins 375

Gaviria, Lund, Micek, & Berry (i967) determined that no demographic or hospital data at the Fort Logan Mental Health Center had any predictive value regarding future rehospitalization. Williams and Walker (196I) found that a patient's chances of rehospitalization were unrelated to his condition at discharge, while Koegler and Brill (1967) concluded that, after one year in the community, "waiting list" subjects were as successful as those who received hospital treatment.

As indicated by the statement of Beard, Pitt, Fisher, & Goertzel (~963) who dealt with hospital program evaluation, "rehospitalization... is a rec- ognized indicator of unfavorable community adjustment"; and for this rea- son, increasing hospital readmission rates further indicate the need for new alternatives in psychiatrictreatment. In a discussion of "intermittent pa- tienthood" Friedman, Von Mering, & Hinks (x966) point out that the high discharge rates of modern treatment methods are accompanied by equally high readmission rates reaching up to 64%. Reflecting this phenomena, Moon and Patton (~965) have reported that readmissions in ~96o-63 have increased by ~2% from ~948-55 .

A final indication of the need for an active post-hospital follow-up pro- gram is the high record of vocational failure incurred by ex-psychiatric pa- tients. Miskimins, Cole, and Oetting (~968) found that even for those pa- tients participating in special vocational rehabilitation programs, less than 50% are employed at a later date. Since vocational adjustment is regarded as one of the few reliable correlates of community adjustment, increased post-hospital vocational adjustment should be commensurate with increased community adjustment.

These indices of deficiencies in traditional treatment, high readmission, and vocational failure rates, plus the unpredictable effect of psychiatric hos- pitalization on community adjustment, have influenced many in the mental health area to advocate the alternative of brief but frequent hospitalization

a s the means of sustaining the patient in the community. This approach to treatment, one where the patient returns only briefly to the hospital or clinic for support in crisis situations, is what Friedman (~966) has termed "inter- mittent patienthood" and what Beard et al. (~963) have presented to be a treatment philosophy for "furthering recovery" through offering "trial visits" to the community. This alternative, although potentially reducing total time spent in hospitals, nevertheless faces the inherent disadvantages of institutionalization. Mendel and Green (~967) state that "hospitals are inappropriately u sed . . . " and for "patients who are discharged, the major problems are those of undoing the effects of chronic alienation and hospitali- zation . . . . " These authors caution mental health professionals against "con- sidering hospitalization as the only alternative . . . . " Ruesch, Brodsky, & Fisher (~964) provide a similar warning in stating that hospitalization in any form encourages psychological invalidism, dependency, and social iso- lation, and that it should be used only when absolutely unavoidable.

376 Community Mental Health Journal

In view of the rehabilitative shortcomings associated with psychiatric hospitalization, one is directed to the alternative of community treatment. After conducting a community-based "aftercare" program for discharged mental patients, Kasser and Cohen (1966) concluded that the prevention of rehospitalization and a "graduated degree of adjustment" to the community can be the result of a structured follow-up program. Beard et al. (1963) com- pared released psychiatric patients served by the community rehabilitation program of the Fountain House in New York to those not receiving this structured follow-up--results indicated that after 9 months in the commu- nity, only 28% were rehospitalized and 32% were employed for fhose in the program as compared with 46% ad 23% in the control group. Other re- searches report recidivism rates of 15%, 20%, and I4% for groups receiv- ing aftercare, contrasted to the 39%, 3t/~ and 36~o figures of those receiv- ing no aftercare (Free & Dodd, 196I; Hornstra & McPartland, I963; and Greenblatt, Moore, Albert, & Solomon, I963) Mendel and Rapport (I963) in a study of community follow-up for psychiatric patients, concluded that their resulting return rate of 3oC~o was comparatively quite low. In sum- mary, these studies indicate that community aftercare programs tend to in- crease post-hospital community adjustment and minimize the need for re- hospitalization.

Belief in the rehabilitative potential of community follow-up for psy- chiatric patients led the Mental Health and Manpower Project, a comprehen- sive study regarding vocational adjustment of psychiatric patients, at the Fort Logan Mental Health Center, Denver, Colorado, to establish such a post- hospital follow-up program. The present research was undertaken to deter- mine the effectiveness of a vocationally-oriented follow-up program upon hospital recidivism and vocational adjustment. The study has unique con- tribution in that it not only compares follow-up to no follow-up, but also compares types and degrees of aftercare. The three follow-up possibilities were Group, Individual, and Control (no follow-up) and the three degrees of participation in follow-up (Group and Individual) were classified as Active, Moderate, and None. The following hypotheses define those questions con- sidered relevant for this follow-up study:

I. An active, interventive community follow-up program will reduce hos- pital contact and recidivism.

A. A comparison of Group, Individual, and Control follow-up condi- tions will demonstrate that Group and Individual subjects have less hospital contact and recidivism.

B. Active participants in Group follow-up will demonstrate the least hospital contact and recidivism when compared with the Group Mod- erate and Non-participants.

C. Active participants in Individual follow-up will demonstrate the least hospital contact and recidivism when compared to the Individ- ual Moderate and Non-participants.

S. A. Purvis and R. W. Miskimins 377

II. A communi ty follow-up program will increase post-hospital vocational

success and job satisfaction. A. A comparison of Group, Individual, and Control follow-up condi-

tions will demonstrate that Group and Individual subjects have

greater vocational success and job satisfaction. B. Active participants in Group follow-up will d~monstrate the great-

est vocational success and job satisfaction when compared with the

Group Moderate and Non-participants. C. Active participants in Individual follow-up will demonstrate the

greatest vocational success and job satisfaction when compared

with the Individual Moderate and Non-participants.

Recidivism specifically required a return to a more intensive care status

such as day care or 24-hour care from outpatient or discharge status. Hospital

contact involved maintaining a rather close and consistent relationship (day

care or 24-hour care) to the psychiatric hospital during the time period of

the s t u d y - - t h u s including both recidivists and those who, a l though taking

a job, remained in intensive treatment. Vocational success in Hypothesis II

was defined to be durability in work or training (over 3 months) . Vocational

satisfaction refers to the degree to which vocational needs were being met

on the job as measured by the Minnesota Importance Questionnaire (Dawis,

England, & Lofquist, 2964), a scale constructed by the Minnesota Industrial

Relations Center.

METHOD The sample consisted of 252 psychiatric patients in the latter phases

of treatment at the Fort Logan Mental Health Center. These subjects were included in the Mental Health and Manpower Project follow-up program upon initiation of employment or training. Characteristic elements of post-hospital Group and Individual follow-up in- cluded the following: support, crisis intervention, vocational counseling, and counseling for community and personal adjustment. Upon referral the patient was randomly assigned to one of the three follow-up modes. Group follow-up consisted of participation in a com- munity-based, weekly group meeting conducted by two vocational rehabilitation coun- selors. Individual follow-up involved a one-to-one counseling contact on a regular basis made by the vocational rehabilitation counselor from the patient's therapeutic "team" at the hospital. Control, or no follow-up, consisted solely of the periodic issuance of MHM Project research forms. The three follow-up modes may have been contaminated by the aftercare practices of the hospital teams. One may assume that this contaminating factor affected all of the groups, but most particularly ControI~to practice "no follow-up" for a group of patients at the Fort Logan Mental Health Center is virtually impossible. Thus, any effects upon the results of this study would have to be in the direction of minimizing rather than increasing, predicted differences.

In order to more thoroughly investigate the effects of aftercare, individuals in the major follow-up modes were assigned to subgroups according to their degree of participation in the follow-up mode. Group subdivisions were determined by group attendance. Active group participants (GAP) were persons who had attended five or more meetings; moder- ate participants (GMP) attended one to four meetings; and non-participants (GNP) had at- tended no meetings. The Individual mode subdivisions---labeled IAP for active participants, IMP for moderate participants, and INP for non-participants--were determined by coun- selors' ratings.

Data for the vocational success inquiry was provided by the Mental Health and Man-

378 Community Mental Health Journal

power Project (MHM). Vocational satisfaction and success measures were taken for each person as part of routine patient follow-up. The data on hospitalization and recidivism were compiled for each subject from hospital records. Prior to studying recidivism it was necessary to be certain that the follow-up modes were similar in the total number of days the subjects spent out of intensive hospital care in the period under study. An analysis of variance to determine the average "days out" of each of the main groupings, group, in- dividual, and control resulted in a nonsignificant difference (F ~ 1.2o) among the means-- 265.07, 293.63, and 272.57. A further analysis of variance on the means of the seven par- ticipation subgroupings, 288.~6, 256.83, 224.46, 312.58, 269.22 ' 292.9i , and 272.57, illus- trated that no difference (F = ~.6o) existed among the subgroups.

RESULTS

While findings for the Group follow-up mode supported

Hypothesis IA, this was not true for the Individual follow-up mode. The ma-

jor fol low-up modalities, Group, Individual, and Control, were found to dif-

fer significantly (p - - < .o5) in the extent of their contact with the hospital.

It can be seen in Table i that subjects in the Group follow-up mode had the

least hospital contact, 35%, while the Individual and Control modes had high-

er, similar contact percentages, 56% and 54%, respectively. A similar pat- tern in the major modalities was found in the hospital recidivism results

(Table 2). Subjects in Group follow-up returned less to an intensive care

status, only 20%, compared to those in Individual and Control follow-up who

both returned at a 34% rate. Hypothesis IB was confirmed to the extent that Active participants in the

Group follow-up mode tended (p = < . io) to have less hospital contact

(25%) than those who participated moderately (60%) or not at all (38%)

(Table I) . The Active participants in Group follow-up also showed less hospital re-

cidivism, I 6 % , than the moderate or non-participants who showed 33% and

23 %, respectively (Table 2).

TABLE i Proportions of patients requiring intensive care contact with the hospital--recidivists and persons continuing intensive care at time of placement--according to follow-up conditions

Contact No contac! Total Sample group f % [ % f %

Group 19 35 35 6~ 54 zoo Active 7 25 21 75 a8 l o~ Moderate 6 6o 4 4 ~ lo ~ oo None 6 38 -Io 62 16 too

Individual 27 56 2 r 44 48 Loo Active 12 71 5 29 17 ioo Moderate 6 43 8 57 -14 ~oo None 9 53 8 47 17 too

Control 27 54 23 46 50 ioo TOTAL 73 79 152

S. A. Purvis and R, W. Miskimins 379

T A B L E 2

Proportions of patients who returned to an intensive hospital care status according to follow-up conditions--recidivists

Recidivists Non-recidivists Total Sample group f % f % f %

Group 9 20 35 80 44 zoo Active 4 i6 2z 84 25 zoo

Moderate 2 33 4 67 6 loo

None 3 23 zo 77 z3 zoo Individual zz 34 2I_ 66 32 loo

Active 7 58 5 42 12 loo Moderate z zz 8 89 9 zoo

None 3 27 8 73 zz 1oo Control z2 34 23 66 35 zoo TOTAL 32 79 zzz

T A B L E 3

Proportions of patients succeeding or failing vocationally according to follow-up conditions

Failure Success Total Sample group Group

Active Moderate None

Individual

Active Moderate None

Control TOTAL

f % f % f 21 40 3I 60 52

zz 41 16 59 27

4 44 5 56 9 6 37 Io 63 16

I8 38 29 62 47 6 35 ix 65 I7

5 36 9 64 z4 7 44 9 56 z6

23 46 27 54 5 ~ 62 87 149

% "100

ZOO

1 0 0

ZOO

ZOO

ZOO

1 0 0

I 0 0

I O O

T A B L E 4

Proportions of patients reporting satisfaction from their work or training according to follow-up conditions

Dissatisfied Satisfied Total Sample group f % f % f %

Group Io 37 z 7 63 27 loo Active 7 39 zz 6z 18 ioo Moderate 2 50 2 50 4 ioo None z 20 4 80 5 zoo

Individual 20 62 z2 38 32 loo

Active 7 47 8 53 z5 zoo Moderate 5 62 3 38 8 zoo None 8 89 I zz 9 zoo

Control z3 54 i z 46 24 zoo

TOTAL 43 4 ~ 83

380 Community Mental Health Journal

The hospital contact and recidivism findings for the Active participants in Individual follow-up did not support Hypothesis IC predictions. Active Individual participants registered a 72~o hospital contact rate while moderate and non-participants showed 43% and 53%, respectively (Table 2). The Active Individual participants' recidivism rate, 58%, was higher ( p - -

.20) than that of the moderate participants, 2~%, and the non-partici- pants, 27% (Table 2). These Active Individual participants also differed sig- nificantly (p = K .o25) in their rate of return to the hospital, 58%, from the Active Group participants, i6%, and the Control group, 34% (Table 2).

The vocational adjustment findings for the major follow-up modes were consistent with Hypothesis IIA predictions. The Group and Individual fol- low-up modalities showed greater vocational success than the Control mode, 6o% and 62% compared to 54%, though statistical significance was not reached (Table 3). The three major follow-up modes tended to differ (p -- ~ .~o) in degree of vocational satisfaction. The Group mode showed 63% need satisfaction while Individual provided 38% and Control 46% (Table 4).

Hypothesis IIB could not be accepted on the basis that the Non-partici- pants within the Group mode showed higher vocational success, 63%, and satisfaction, 8o%, than did the Active participants who had 59% vocational success and 62~o vocational satisfaction or the Moderate participants who had 56% vocational success and 50% satisfaction (Tables 3 and 4).

Hypothesis IIC was given minimal support in that the Active partici- pants in the Individual follow-up mode showed only a slight advantage in vocational success, 65%, compared to 64% and 56% (Table 3), yet these Active participants demonstrated (p -- ( . i o ) greater vocational need satis- faction, 53%, than did the Moderate participants at 38% and particularly the Non-participants at 52% (Table 4).

DISCUSSION The results strongly support the thesis that hospitaliza~

tion alone is insufficient in achieving community adjustment for former psychiatric patients. Follow-up is better than no follow-up, and a community- based follow-up program is most efficient. This latter point is reinforced by the findings that the Group follow-up program greatly reduced the need for hospital contact and yet maintained the higher vocational adjustment level reached by both follow-up modalities. The very community-oriented phi- losophy of the Group follow-up program coupled with its physical autonomy from the hospital appears to have broken the hospital tie while affording sufficient support and guidance. Perhaps because the counselors in Indi- vidual follow-up were hospital team members and because there existed this direct channel to the hospital, the patients in Individual follow-up were re- turned more readily in time of crisis to hospital care. Eliminating identifica-

S. A. Purvis and R. W. Miskimins 381

tion with and reliance upon the hospital appears to have the positive result of reducing hospital contact while maintaining vocational adjustment.

The "participation" results also recommend community-based follow-up. Although the active participants in the Individual follow-up program achieved high vocational success, active participants in the Group program achieved high vocational adjustment and high general community adjust- ment. The inverted findings that the active group participants (GAP) and the moderate individual participants (IMP) returned to the hospital least, ~6~o and ~ o , while the moderate group participants (GMP) and the active in- dividual participants (IAP) returned the most, 33% and 58%, further il- lustrate this point. The latter groups are similar in that they include persons most identified with the hospital. The IAP are actively involved both with their team counselors and with intensive hospital care. While the IAP ex- perience no need to disturb their "hospital habit," the GMP do and must reject the community group in favor of hospitalization. Both are unwilling and unable to accept a substitute for the established dependency pattern. What then is the critical variable for the other groups? With support and guidance the GAP and the IMP are able successfully to take the gamble of coping with the reality of the community. The GNP and INP in emphasizing self-reliance and risk-taking and reducing the "support" aspect (evidenced by their non-participation) do fairly well; however, they do fail more in the community than those who accept some guidance (supported by the findings of Orlinsky and D'Elia, ~964). Perhaps the optimum situation for community adjustment, then, involves a person who is independent enough to accept some risk (i.e., the separation from the hospital) combined with moderate support. A group in the community or minimum counselor contact repre- sent this type of moderate support combined with "risk." However, the com- munity group is recommended here in part because of its economical nature but primarily because of its potential for accustoming the ex-patient to ful- filling his needs in the community. Close team contact, i.e., with the coun- selors, may be too tempting in time of crisis. Kraft, Binner, and Dickey, (2968) have emphasized that chronic patients haven't a need to attain their satisfactions outside the hospital. Not only must there be comprehensive follow-up programs, but also follow-up which encourages using the commu- nity as the primary resource, rather than the hospital.

In summary, it appears that a comprehensive, community-oriented fol- low-up program is useful for increasing the community adjustment of for- mer psychiatric patients. Reviews of current research literature reveal that hospitalization alone does not insure maximum community rehabilitation and that the alternative of intermittent hospitalization appears also to pro- duce dependency problems. The literature suggests that community-based groups are an effective alternative to institutionalization. The present study lends further support to this approach to treatment, demonstrating the utility of community-based follow-up for minimizing hosptial contact and maxi- mizing general community adjustment.

382 Community Mental Health Journal

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