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University Microfilms International 300 N. ZEEB RD.. ANN ARBOR, Ml 48106 8207163

Chung, Douglas Kuei-Nan

A PILOT STUDY OF A VOLUNTEER INTERVENTION MODEL IN HELPING CHRONICALLY MENTALLY-DISABLED PATIENTS ADJUST TO COMMUNITY PLACEMENT

The Ohio Stale University PH.D. 1981

University Microfilms International300 N. Zeeb Road, Ann Arbor, MI 48106

Copyright 1982 by Chung, Douglas Kuei-Nan All Rights Reserved A PILOT STUDY OF A VOLUNTEER INTERVENTION MODEL IN HELPING

CHRONICALLY MENTALLY-DISABLED PATIENTS

ADJUST TO COMMUNITY PLACEMENT

DISSERTATION

Presented in Partial Fulfillment of the Requirements for

the Degree Doctor of Philosophy in the Graduate School

of The Ohio State University

By

Douglas K. N. Chung, B.A., M.S.W., M.A.

******

The Ohio State University

1981

Reading Committee: Approved by

Joseph J. Parnicky

John Behling v Adv/i ser / Robert Ryan College of Social W

The researcher has received valuable assistance from a large number

of individuals. The list of persons is far too long to be included

here; however, grateful acknowledgment is expressed to all who made

this research possible.

Special thanks are extended to Dee Roth, Joe Wiant, and Carla

Davis of the Division of Mental Health for the support and encouragement

in every phase of the study. This research is a part of the project,

"Effect of Patient Advocacy on the Community Adjustment of Aftercare

Patients," funded by the Ohio Division of Mental Health. Without the

funding, this research could not have, been completed. Also, special

thanks are extended to Professors John Behling, Joseph Parnicky and

Robert Ryan of the College of Social Work at the Ohio State University

for their guidance throughout the study.

To Kenton Gearhart, Margie Shaw, Tom Q uilter, Ellen Colom Deacon,

Gwen Longthom, Sylvia Shuman, Theo Grudzien, Frank Hamilton, and all

staff members of the Mental Health Association and PAVE participants

for their encouragement, help and cooperation as part of the team which made up the PAVE program. Grateful acknowledgment is expressed

to Andrew Juhas and Ellen Chung for th e ir help in each step of the

study.

Finally, to faculty members in the College of Social Work for

their encouragement and assistance.

Douglas K.N. Chung

Columbus, Ohio September 1981 ii VITA

January 16, 1943 ...... Born — Yun-Lin, Taiwan

1966 ...... B.A., Soochow University, T aipei, Taiwan

1967 - ....1971 ...... Superintendent, Christian Children's Fund, In c., Taiwan

1973 ...... M.S.W., West Virginia University, Morgantown West, Virginia

1973 - 1974 ...... Researcher, Institute of Community Development and Training in the Republic of China, Taiwan

1974 - .....1978...... Lecturer, Department of Sociology, Fu-Jen University, Taipei, Taiwan

1980 ...... M.A., Ohio State University, Columbus, Ohio

1980 - 1981...... Research Director, Mental Health Association of Franklin County

FIELDS OF STUDY

Major Field: Social Work

Studies in Social Functioning. Professors Joseph Parnicky and Samuel Dixon

Studies in Social Work Practice. Professors Richard Medhurst and Jim Billups

Studies in Social Policy. Professors Nolan Rindfleisch and Milton Rosner

Studies in Social Work Research. Professors John Behling and Rocco D1Angelo

iii TABLE OF CONTENTS

fia e

ACKNOWLEDGMENTS . . ' i 1

VITA...... i i i

LIST OF TABLES...... vii

LIST OF FIGURES...... ix

Chapter

I. INTRODUCTION...... 1

Statement of the Problem ...... 1 Historical Background ...... 4 The Period Before 1850 ...... 4 The Period Between 1850 to 1900 ...... 4 The Period Between 1900 to 1930 ...... 5 The Period Between 1930 to 1980 ...... 7 Problems of Deinstitutionalization ...... 10 Community R esistance ...... 10 Inadequate Community Support System ...... 11 Lack of Service Coordination in the Community . . . . 11 Financial Issues ...... 12 Legal Issu e s...... 12 Lack o f Evaluation and Follow-Up S tu d ies ...... 13 Related Studies ...... 14 Volunteer Intervention ...... 14 Group Approach...... 21 Measure of Success...... 24 Impressions from L iterature Review ...... 29 Purpose of Study ...... 30 Major Areas of Inquiry ...... 31 Major Hypothesis ...... 32 Minor Hypotheses ...... 34

NOTES FOR CHAPTER I ...... 36

II. SETTING AND METHODOLOGY...... 44

S e ttin g...... 44 Volunteer Intervention Model ...... 45 Research Design...... 48 General Characteristics of the Study Population ...... 49 Sampling Frame and P r o c e d u r e ...... 50 iv TABLE OF CONTENTS (C ontinued)

Controlled Variables ...... 52 Indicators of Effectiveness ...... 53 Instrument PARS Scale ...... 54 Instrument Client's Evaluation Sheet ...... 56

NOTES FOR CHAPTER I I ...... 59

III. POPULATION CHARACTERISTICS...... 61

Size of the Study Population ...... 61 Demographic C haracteristics ...... 62 Clinical Characteristics ...... 65 "'Background Homogeneities...... 65 Pretest of Adjustment and Functioning Characteristics .’ . 68 Summary ...... 70

IV. FINDINGS AND CONCLUSIONS...... 71

Major Hypothesis Analysis ...... 71 Effectiveness of Volunteer/Client Relationship ...... 71 Effectiveness of Group Approach ...... 77 The C lien t's Community Adjustment and Personal Characteristics ...... 83 The C lien t’s Community Adjustment and Volunteer Relationship ...... 90 The Client's Community Adjustment and Significant Other Relationship ...... 93 Client Comparisons of Interpersonal Relationships with the Significant Other and the Volunteer ...... 98 The Client's Community Adjustment and Volunteer F a c to r s ...... 101 The C lien t's Community Adjustment and Group Activities Participation ...... 107 The C lien t’s Community Adjustment and Volunteer's Attendance in Group Activities...... m Client Feedback ...... 114 Summary ...... 119

V. IMPLICATIONS...... 125

Volunteer Intervention and Community Adjustment ...... 125 Is Volunteer Intervention Effective? ...... 125 Duration of Intervention ...... 126 Volunteer Intervention and Readmission ...... 1.26 Volunteer Intervention and Employment ...... 128 Volunteer - Patient Relationship ...... 129 v TABLE OF CONTENTS (C ontinued)

Page

The Client's Community Adjustment and Personal Characteristics ...... 131

The Client's Community Adjustment and Volunteer ...... 134 Importance of Significant Other ...... 135 The C lien t's Community Adjustment and Vounteer Characteristics ...... 137 The C lien t's Community Adjustment and Group Activities Participation ...... 138 The Client's Community Adjustment and Volunteer's Attendance...... 139 Program Management and Environments ...... 141 The Research Contributions ...... 143 The Research Limitations ...... 146 Summary...... 147

NOTES FOR CHAPTER V...... 149

GLOSSARY...... 150

APPENDIXES

A. Client's Explanation of PAVE Study ...... 154 B. Referral Form...... 156 C. Agreement to Talk to a PAVE R ep resen tativ e ...... 158 D. Consent to Participate in the PAVE Study ...... 160 E. Request for Volunteer...... 162 F. Client Information Sheet ...... 164 G. Demographic and Clinical Information ...... 166 H. Cover Letters for P retest and Posttest PARS Scale. .... 168 I. Data Collection Instrument PARS Scale ...... 171 J. Internal Consistency Reliabilities for PARS Factor Scores Significant Correlations Between Self and Other Ratings of Adjustment and Functioning ...... 174 K. Pre- and Post-Treatment PARS Scores ...... 175 L. Data Collection Instrument Evaluation Sheet ...... 178 M. Helping Contract ...... 185 N. Analysis of Variance for Measuring Factors and Community A djustm ent ...... 150

BIBLIOGRAPHY...... 151

vi LIST OF TABLES

T able Page

1 Demographic C haracteristics of the Study Population .... 63

2 Clinical Characteristics of the Study Population ...... 66

3 Background Homogeneities Between Experimental and Control Groups ...... ' ...... 67

4 P retest PARS Scores of Experimental and Control Groups. . . 69

5 Posttest PARS Scores of Experimental and Control Groups . . 72

6 Pretest and Posttest Adjustment Means for Experimental and Control Groups ...... 74

7 Analysis of Covariance: House Activity by Sample Group Belonging with Sex, Number of Siblings and Types of R esidence ...... 75

8 Other Adjustment Indicators for Experimental and Control Groups ...... 76

9 Posttest PARS Scores of Group Activity Participants and Non-Participants ...... 78

10 Pretest and Posttest Adjustment Means for Group Activity Participants and Non-Participants ...... 79

11 Other Adjustment Indicators for Group Activity Participants and Non-Participants ...... 80

12 Analysis of Variance for the Clients' Community Adjustment and Adjustment-related Factors ...... 88

13 Correlation Coefficients Between the Clients' Community Adjustment and Interpersonal Relationship with Volunteer. . . ; ...... 92

14 Correlation Coefficients Between the Clients' Community Adjustment and Interpersonal Relationship with Significant ...... 97

15 Client Comparison of Interpersonal Relationships with the Volunteer and the Significant O ther...... 100

vi i LIST OF TABLES (Continued)

Table Page

16 Analysis of Variance for the Clients' Community Adjustment and Volunteer Age Groups ...... 103

17 The C lients' Community Adjustment and Volunteer Sex ...... 1°4

18 Analysis of Variance for the Clients' Community Adjustment and Volunteer Educational Groups ...... 106

19 Analysis of Variance for the Clients' Community Adjustment and Volunteer Motivation Groups ...... 108

20 Analysis of Variance for Experimental Subjects' Adjustments and Frequency of Group Activity Participants ...... HO

21 Participants and Volunteers' Attendance in PAVE M eetin g s...... 1*2

22 Analysis of Variance for the Participants' Adjustment and Frequency of Volunteer Attendance in Group A ctivity ...... 113

23 Problems Encountered and Services U tilization ...... 117

24 Community Adjustment Scores of CMHC Utilizers and N o n - u tiliz e rs ...... 1'0

v i i i LIST OF FIGURES

Fi gure Page

1. Sampling Procedure ...... 51

ix CHAPTER I

INTRODUCTION

Statement of the Problem

For more than one hundred years chronically mentally disabled per­ sons in the United States were increasingly put into and/or treated in large institutions for a part or most of their lives. Now, the trend is being reversed. Deinstitutionalization has been influenced by several factors: Political and social change in the United States, the development of psychotropic agents, an increase of local community services and facilities, changes in welfare services and medical in­ surance, and new legislation of patient rights protection. These factors are reducing the census of state hospitals drastically. Some states have even closed, or considered closing, a few or most of th eir state hospitals. Many positive and negative opinions in regard to deinstitutionalization have been expressed.

Advocates of deinstitutionalization emphasize that there may be a better chance for the mentally-ill person to recover in a normal community setting. However, others are concerned that the quality of life for mentally-ill persons in the community may be worse than it was in the hospitalJ

Bertram Brown, the Director of the National Institute of Mental

Health defined three essential components of d e in stitu tio n aliza­ tion: (1) the prevention of inappropriate mental hospital admissions through the provision of community alternatives for treatment;

(2) the release to the community of all institutional patients who

have been given adequate preparation for such a change; and (3) the establishment and maintenance of community support systems for non­

institutionalized persons receiving mental health services in the 2 community. If this definition were followed, d ein stitu tio n alizatio n would certainly be a desirable goal or an ideal. However, in re a lity , the community has not yet established adequate alternative treatment models and support systems. Many serious problems in d e in stitu ­ tionalization therefore result from simply discharging mentally-ill patients into the community without carefully designed programs, as discussed below.

For chronically mentally-disabled persons to benefit from dein­ stitutionalization, they must have ongoing access to supportive services and reh ab ilitatio n in the community. Placement in the community often does not meet the needs of discharged, chronically mentally-disabled persons due to such facts as: (1) there is a lack of service coordina- O tion among the agencies involved in the local community; (2) there 4 are inadequate community support systems, such as lack of peer support networks and friendship for emotional support, aggressive outreach services for employment, social a c tiv itie s and access to necessary rehabilitative services; (3) there is community discrimination and 5 stigmatism by neighborhoods, landlords, and potential employers;

(4) there are financial difficulties in sponsoring deinstitutionalized C J services; (5) there is patient rights provision but lack of an adequate p atient rights advocacy program; and (6) there is an inadequate o procedure of individual tran sitio n from the hospital to the community.

The President's Commission on Mental Health observes that "many

chronically mentally disabled persons enter, re-enter, or remain in

state hospitals when they could be treated in the community, . . .the

plight of many of those discharged is utterly miserable, due largely q to inadequate planning and follow-up care." As Smith points out,

"After being discharged, they may often find themselves without a job, without a car, with little money, and perhaps with few or no friends.

As a result they may end up spending most of their time at home or in their immediate neighborhood."^

Recidivism is probably the major symptom of the failure to the deinstitutionalization movement. The national recidivism rate is 11 12 estimated to range from 40 percent up to 57 percent. According to statistics from the Ohio Department of Mental Health and Mental 13 Retardation 75 percent of admissions were formerly hospitalized.

Compared to the national recidivism rate, Ohio ranks high. Talbott's study (1974) indicates that 84 percent of the readmissions examined could have been prevented i f there were improvements in existing out- 14 p atien t services and new or augmented services and f a c ilitie s .

Merely changing the location of care does not insure achieving the goals of deinstitutionalization. Therefore a study..of how to establish a supportive community system to meet the client's needs becomes very important. This study intended to test whether the establishment of volunteer intervention for chronically mentally disabled persons

(recidivists) is an effective approach as a part of a community support system. H istorical Background

From an historical perspective, each social problem has its roots

deeply established within its economic, political and cultural back­

ground. The issues of deinstitutionalization in the field of mental

health today have been sig n ific a n tly influenced by h isto ric a l origins.

It is important to trace the origins and trends for further under­

standing of the problem.

The Period Before 1850: The majority of the mentally-ill were

confined e ith e r in poorhouses, j a i l s , or in one of the small number of

state mental hospitals. If the mentally"ill were kept at home they were

often hidden and excluded from the lif e of the f a m ily .^ Deutsch has

pointed out that "the tendency of the mentally ill in America was

stimulated by contemporary affairs in Great.,Britain (and Europe), which was still the 'mother country1 as far as social influences were

concerned."^ Deutsch has labeled the general treatment of the

dependent insane in early America as the pauper system.

He observes that: "the general treatment of the dependent insane

during this period . . .Sick poor, old poor, able-bodied poor, infant poor, insane and feeble-minded--all were grouped together under the

same stigm atizing lab el, "paupers," and all were treated in very much

the same manner. 1,17 The popular view both in Europe and in the United

States was that infestation of evil spirits was the cause of insanity.

The Period Between 1850 and 1900: This period can be described as the institutional or state hospital movement. Deutsch has in­ dicated that this originated in the public health movement which was

engaged in an altruistic effort to save the lives and health of the factory workers. However, "in order to p ro tect the factory owner

and the man of wealth from contagions and in fectio n s, i t was necessary

to produce different conditions among their employees. This was 19 simply self-preservation." The capitalists joined the altruistic

effort to improve the public health for their own benefits. In time,

conflicts developed between these differing views and the debated

question became: "Why should the mentally ill survive?"

The Group for the Advancement of Psychiatry reports: "Dorothea

Dix, spearheaded a reform movement based on the humanitarian and

therapeutic concerns that characterized 'moral treatment.' She

founded and enlarged more than 30 state institutions. . . . Thus, she was responsible for a dramatic shift in the main locus of treat­ ment from communities to sta te h o sp itals. . . . In less than 50 years most of the state hospitals became enormous, poorly-financed, barracks-like settings that encouraged regression rather than 19 recovery. . . ." Hurd reports that: "In 1850, the insane population in state institutions was given at 15,610. During 1860 to 1890, 108 state hospitals (asylums) and 33 private hospitals (asylums) were ?n established. In 1890 the insane population had increased to 106,485."

The Period Between 1900 and 1930. Deutsch states: "at the beginning of the 20th century in general, those schools (of psychiatry) fell into two major methods of approach—the neurological and the psychological. 'Insanity is a brain disease' was the dogmatic state­ ment in the neurological approach which dominated American Psychiatry 21 at the beginning of the 20th century." Aligned with the neurological approach was the eugenics perspec­

tive. This perspective was a popular view in the early part of the

20th century. The eugenics perspective emphasized that mental illness

was transmitted through heredity. Begab has observed that this view

was further buttressed by sociological theories current at the time.

Most prominent was the concept of Social Darwinism advanced by Herbert

Spencer. According to this theory, society was subject to the same

principles of natural selection as plants and animals and, thus, 22 only the fittest would survive. Under the influence of this view,

society placed controls on mentally-ill persons and mentally-retarded

persons which legally prohibited marriages, and at times forced

sterilization. Others advocated restrictive marriage laws at the time.

"In 1915, 12 states had passed compulsory s te riliz a tio n laws and most

others soon embarked on a program of indefinite detention for those 23 persons considered to be social risks and a menace to society."

Another important influence in the early 20th century was

led by Freud's psychoanalytic theory. This theory assumed that once

the basic cause or underlying malady had been diagnosed from a patient's

symptoms, treatment procedures could be prescribed. "These new

psychobiological and psychoanalytic theories began to restore optimism about the possibility of preventing mental illness. These hopes en­ couraged the development of child guidance and other community clinics, but had little effect on state hospitals where the care remained mostly custodial 25 Clifford W. Beers (1876-1943) was a former psychotic mental patient who fought a lifelong battle against mental illness in both his family and himself. His autobiography, A Mind That Found Itself

(1908), exposed his hospital experiences, sufferings, and needs. The enormous influence of his autobiography led a national health move­ ment to reform the status of the mental patient and to promote social treatm ent. He convinced the American people (especially the rich and the e lite s ) th at mental patients were unjustly treated , prevention of mental illness was feasible, and support for reforms would be forth­ coming. He founded the National Committee for Mental Hygiene (pre­ decessor of the National Mental Health Association), the American

Foundation for Mental Hygiene, and the International Committe for

Mental Hygiene. Eventually, he had aroused the national and in te r­ national conscience to act on behalf of the mentally ill.

Beers' impact has been realized: preventive medicine and public health have indicated in their stand on medical education that the prevention of mental illness is, indeed, feasible. Beers' movement to reform the status of the mental patient and his social treatment had heralded the beginning of the present-day client advocacy programs.

The Period Between 1930 and 1980. The Great Depression and the

New Deal led to more governmental responsibility by providing public 25 assistance for psychiatric patients. The return of mentally- impaired military personnel along with the psychiatric trained military physicians after World War II necessitated the post-war development of veteran hospitals as well as psychiatric units in community general 27 hospitals. The establishment of the Joint Commission on Mental Illness and Health recommended the return of mentally-ill persons to the community as soon as possible. In 1963, President Kennedy sent a message to Congress, 11. . .a new approach to mental illn ess

(replacing) the cold mercy of custodial isolation, . . .by the open 28 warmth of community concern and capability. . ." which intended to limit the functions of state hospitals and emphasize community services. These factors have been identified as forces forming the movement toward community treatment.

This deinstitutionalization movement was backed by new technology, new psychotropic agencts, and new psychological theories. The Social

Learning Theory promised that mental health can be learned. "Man is a mechanical mirror of his environment and his behavior is the essence of his personality. Behavior is explained by environmental shaping and does not include reliance on concepts like drives or inner states for 29 its explanation." The Symbolic Interaction Theory posed th at per­ sonality is generated through interaction and consists of "self-othef" systems. "Thus, the interactionist approach was inclined to view deviancy as an outgrowth of interpersonal processes and was concerned 30 primarily with effects on the individual and his associates." The

Conflict Theory was applied in the 1960's antiwar movement, and en­ couraged advocates to organize mentally-ill persons into cohesive political groups to fight for their own rights. Mental health-related professionals began to realize that there were many alternatives for the treatment of mental illness and no single approach or profession could solve the problem. Professionals from different fields began to accept 9 each other and work together toward a comprehensive community mental health model recently.

The deinstitutionalization reform movement is based on humanitarian 31 concerns and backed by sc ie n tific methodologies. Hersch states th at,

"the movement is also the expression of a philosophy rooted in an era of social and political reform which strongly emphasized peoples' self- determination and their right to control the forces that affect 32 them." This movement, as Bachrach points out, called for very basic and fundamental changes in patterns of life deeply embedded in the

American culture. Thus, d ein stitu tio n alizatio n has "become the focus of an emotional debate," which was characterized by polarized attitudes and 33 resistance to compromise. The problems or issues involved in de­ institutionalization were therefore not simply lack of adequate financial support and aftercare. In 1964, Edwalds wrote:

Primary functions demanded of the state mental hospital have included (A) public safety and the removal from society of individuals exhibiting certain kinds of socially disruptive behavior; (B) custodial care for persons who, by reason of mental disorder, cannot care for themselves or be cared for elsewhere. . . . Treatment and re­ habilitation of the-mentally ill has always been, a t best, a secondary function of the state mental hospital. For many years, it was not considered part of the function of the state hospital at all. Today, treatment and reh ab ilitatio n are usually officially regarded as the primary functions of the state mental hospital; leading to a remarkable amount of self-deception and confusion on the part of society and the personnel working in these hospitals.34

Edwalds' above statement along with studies into the nature of institutionalization by Jarcho and Rutman p indicate that these custodial functions of mental institutions were rooted in the social 10 history of this country. From a functionalist point of view, as

Bachrach in terp rets, "mental hospitals must not and cannot be eliminated until alternatives for the functions of asylum and custodial care have 37 been provided." Fowlkes explains the issues in in stitu tio n alizatio n as "a form of in terest co n flict in which in stitu tio n alized aspects of the mental hospital were functional for some societal groups (hospital adm inistrators and s ta ff, patients' fam ilies, vested economic in te rests), 38 but dysfunctional for others (patients)." Thus, the role of the state psychiatric hospital is still a controversial issue.

Problems of Deinstitutionalization

The literature concerning the problems of the deinstitutionaliza­ tion movement can be summarized as follows:

1. Community resistan ce: Sources of community resistance come from various levels: families as well as groups. Doll says that "the return of patients to their families may cause serious crises in the lives of those families who are now responsible for the care and re- 39 habilitation of the relatives who are released from mental hospitals."

Kirk and Therrien report that "former patients are not welcomed back into their communities with open arms; instead, they are often con­ fronted by formal and informal attempts to exclude them from the com­ munity by using city ordinances, zoning codes, and police arrests.

Lack of adequate housing in the community for hospitalized patients is a frequent experience among state hospital dischargees. The community often rejects mental patients as undesirable residents. Rothman reports that "there are resistant citizens who do not want a group 41 home or halfway house on th eir stre e t." 2. Inadequate community support systems: Both informal and formal community support systems are inadequate. As Mechanic points out, "successful functioning depends on material assistance and 4? emotional support which we receive from our fellows." "Such sup­ ports are frequently unavailable to mental patients residing in the community, often as the resu lt of the very special psychological and interactional difficulties that characterize them. Without well- organized and aggressive community support services. . .patients are often lost in the community and eventually end up in difficulty.

Bachrach points out: "Accessibility is a problem in community support systems. These systems are needed to assist noninstitutionalized patients in those areas of life where friendly intervention and a helping-hand are frequently needed by, for example; the development of friendship networks, seeking out of employment opportunities, and organization of leisure and social activities. Often, support systems are needed to assist patients in areas related to treatment by setting up appointments and transportation to therapy sessions."44

3. Lack of services coordination in community: Smith and Smith suggest that "one reason for failure in deinstitutionalization is a 45 lack of preparation and coordination between the agencies involved."

Community-based mental health services do not have coordinated or centralized management, therefore, services tend to be fragmented and communication between the agencies and the "patient" becomes muddled. The trend of specialization in each profession leads to more fragmented services which creates more problems for the individual client. Consequently, community services have become less accessible 12 to mental patients; particularly to those ex-patients having a lower motivational ability to go through the bureaucratic processes for services. At the same time more complex problems may ex ist for the individual c lie n t in the complex society. Horshall and Friedman quote one former p a tie n t's observation: "Sometimes i t seems as if the mental health care system has become so complex that one needs a college 46 degree just to be a patient."

4. Financial issues: Rothman, in his discussion of the con­ flict between institutional care and community care, argues that "the heads and the direct beneficiaries of institutions (whether employees or building contractors) have dominated the budgets in order to pre- 47 vent the growth of community service alternatives." In addition, there are many indirect, hidden costs of community mental health services, which are hard to estimate. It makes budget-conscious legislators hesitant to authorize a budget for a network of com­ munity mental health services at the agency level. The individual ex-patient, as mentioned by Smith, finds himself "without a job, 48 without a car, with l i t t l e money."

5. Legal issues: Recently, the legal rights of mentally-ill patients have been c la rifie d . These include: the right to tre a t­ ment, the right to notice immediately upon involuntary detention, and the right to hearings; the right to communicate freely with 49 others; and the right to personal privileges. It is the author's general observation that, although many rights are identified with mentally-ill patients, many hospitalized patients do not know the rights they possess. This indicates that both the internal and ex­ ternal advocacy system in the hospital do not function well. A new external advocacy system may help to protect the rights of the patients. Under the provision of client rights, the legal issues involved with mentally-ill patients become extremely complex.

6. Lack of evaluation and follow-up studies: The literature by 50 51 52 Glenn, Goertzel, and Bachrach, recommends that it is necessary to have ongoing evaluation studies in order to provide the feedback necessary for planning and implementing modifications in programs al- 53 ready in process. Bachrach states that, "Although there are many follow-up studies of mental patients after their release into the community, th eir resu lts are largely inconclusive in any broad sense.

For the most part, these studies have very limited replicability and 54 generalizability."

We especially need a series of experimental studies to test the effectiveness of community mental health supportive systems, services coordination and community acceptance. Without these studies, it will be difficult for our society to make rational decisions regarding future community mental health planning and deinstitutionalization programming. 14

Related Studies

Of the various approaches that have been developed to help chron­ ically mentally-disabled patients adjust to community placement, this section concentrates on the literature which is concerned with the methods and measures of individual volunteer and group intervention.

Volunteer Intervention: A volunteer relates on a caring, per­ sonal level with the client and thus cushions the client from the overwhelming depersonalization of our complex, bureaucratic society in which individuals are judged by their productiveness, their con­ formity to dominant values, and their similarity to the majority.

In 1976, Camilla Weber states, volunteers ". . .help to avoid the communication gap between the professional in the organization and the client who may be from a different racial, ethnic, economic, or ed- 55 ucational background." Weber adds, ". . .contribute sensitivity, 56 perspective, and judgement in dealing with and planning for change."

In 1976, Feinstein and Cavanaugh in itia ted an organization of volunteer paraprofessionals in the Case Aide Program in a state mental 57 hospital to help the patients "make it out and stay there." The concern and support of the Case Aides "gave the patients a sense of CO being special, of counting, of being hopeful." Feinstein and

Cavanaugh attempted to accomplish three goals through the concerned, 59 supportive volunteers. The first goal was to help resocialize a mental patient to become a useful citizen capable of making a life with dignity and pride. The patient must overcome three handicaps in order to be resocialized and to build satisfying relationships: 1) The damage of the illn ess must be undone. The patient needs to tru s t and 15 to be trusted again. 2) The patient must adjust to a world that has been changing and growing while the patient had been standing s t i l l ; marking time. 3) The patient must overcome the effects of living in a structured, bureaucratic institution in order to live a self-directed, individualized lif e in the community. The second goal of the Case Aid

Program was to provide community residents an opportunity to learn new skills and to make a meaningful contribution to the community through helping to resocialize mental patients. Feinstein and Cavanaugh believe

"what is needed is people-to-people contact, especially to prevent fin breakdowns, hospitalizations, and readmissions." Volunteers can offer valuable, equal and shared peer relationships. The third goal was to bridge the gap between the mental health service delivery systems and the communities which they serve. The public was educated to be more informed volunteers and more helpful neighbors through person-to- person involvement with the daily problems of the discharged mentally- i 11 persons. In addition, the Case Aide Program included a volunteer- patient group. The group had three purposes: 1) to enable patients to relearn the rudiments of social interaction so that they could develop or transplant social networks, regardless of where they lived; 2) to dilute the intensity of the individual relationship so that more re­ gressed patients might benefit, and 3) to provide a good vehicle to fil prepare patients for one-to-one relationships. Of the patients who participated in the group, 19 percent were discharged and half of them found employment within the period of one year. Overall, 50 percent of the patients who had Case Aides were discharged, although recidivism 16 was not measured. Feinstein and Cavanaugh believe th at th e ir program could be improved to be larger and more comprehensive, but th at the personal caring and support of the volunteers were paramount to patient dignity and confidence. The volunteer can be an important part of the patient's support system as the patient attempts to ad­ just to community living. This study sought to determine how im­ portant and effective the support of the volunteer can be.

A multidisciplinary mental health team based at Longview State

Hospital in Cincinnati, Ohio, studied the problem of high recidivism in one of the state's psychiatric institutions in 1968, and again in 1971.

In order to prevent rehospitalization, the team initiated an aftercare program a t the hospital using volunteers. Volunteer therapists were trained and supervised in work as advocates and therapists for former mental patients in the community. Their tasks included: checking that patients kept appointments and took medications as prescribed; evalua­ ting patients for decompensation (critical signs such as lack of sleep, failure to eat, refusal to take required medication); lending environ­ mental assistance such as helping patients to look for housing and jobs; and giving supportive counseling. Reporting on this, Katkin, Zimmerman, and Rosenblatt state:

At the end of one year, recidivism rates in the treatment group were sig n ifican tly lower than in the control group. Four of the 36 women in the treatment group (11%) had to be rehospitalized, compared with 12 in the control group (34%). The resu lts were significant a t the .05 level. The 11% recidivism rate for the treatment group was particularly low when compared to national recidivism rates, which average 40 to 50 percent. The majority of recidivists in both groups had returned by the fourth month. The finding suggests th at patients need special attention from outpatient treatment programs during th eir f i r s t four months a fter release from the h o sp ita l.62

These team researchers interpret the results as indicating that

"the successful volunteers were aware of patients' problems and crises and could help them before rehospitalization was required. The un­ successful volunteers seemed less sensitive to their patients

/TO (encountered problems)."

There were only five volunteers in th is program. They were middle-class housewives ranging in age from 35 to 55. They were recruited from the Mental Health A ssociation's volunteer training program and taught by the team's psychiatrist and social worker about interview techniques, critical signs of decompensation, and the side- effects of medication. There were 36 chronic, schizophrenic women under the volunteer therapists' treatment and another 36 women out­ patients with similar diagnoses as control group.

The weaknesses of the Cincinnati Study were: 1) The sampling method was not available in the lite ra tu re . 2) A small sample size. 3) Only women outpatients participated in the program.

4) The volunteers whose patients had lower recidivism rates were successful because they recognized the higher number of severe life crises of their patients without considering any other factors. The

Cincinnati study pointed out that volunteer intervention might be an alternative in preventing rehospitalization.

Donna Aguliera states that "crisis intervention can be an effective therapy modality with chronic psychiatric patients in the community."6^ 18

Aguliera defines a person in crisis as: "One who faces a problem that

he cannot readily solve by using the coping mechanisms th at have worked

for him before." She thinks that crisis intervention--an inexpensive,

short-term therapy that focuses on solving a particular problem—can

offer the immediate help that a person in crisis needs in order to re­

establish equilibrium. She notes:

The minimum therapeutic goal of crisis intervention is the psychological resolution of the individual's immediate crisis and restoration at least to the level of functioning that existed before the crisis. A max­ imum goal is improvement in function above the precrisis level. It is important to learn from the patient or from his family what event precipitated the return to psychotic behavior and also to determine whether the patient is taking his medication as prescribed. . .several techniques which can be used in c ris is and to express his feelings openly, exploring coping mechanisms used in the past and those that could be used in the present, finding individuals who can support him, and planning with the patient ways to reduce the likelihood of future crisis.66

The volunteer may serve as a feedback channel between the d is­

charged patient and his primary therapist during the ex-patient's

crisis period and help to solve the problem. Agulier's point of view

implied that providing the patient with an opportunity to express his

feelings and to learn various coping mechanisms may be helpful for th eir

successful community adjustment.

Samuel Grob expresses that "work is a necessary element in

fi7 assimilation of ex-mental patients into normal community life."

Based on his review of studies he reports that:

Many of the vocational difficulties of former patients resulted not from a lack of public or employer accep­ tance, vocational skills aptitude, or intelligence per se, but from the ex-patients difficulties in inter­ personal relations. Other factors that compound 19

employment problems included ex-patients' phobic attitude toward work in general, fear of failure, unrealistic job interviews, projection of self­ rejection to authority figures and oversensitivity to disappointment or inadequacy.

Anthony's review of studies in 1972 shows 30 to 50 percent of patients

were employed in six months a fte r release; 20 to 30 percent in 12 69 months, and 25 percent at three to five years. Patients are regarded

as handicapped by the public and potential employers. At the same time,

patients themselves do not feel that they can obtain better jobs or

positions. It may not be realistic to expect high employment among

those ex-patients. However, the volunteer may help the client to

overcome the d iffic u ltie s arising from interpersonal relations and

develop an adequate attitude toward the work.

Hudson states th at, "the patient must be viewed not as an isolated

individual but as a member of a family, a community, and a system."7^

He reports that there needs to be a new social system--

one that will give its members a feeling of identity and as active

a role as their potentialities allow. He indicates that such an

ideology could be found in the extended psychosocial kinship system

proposed by Patti son. According to Patti son, the system consists of

the nuclear family, blood relation relatives by marriage, friends,

neighbors, and associates from church, work, or recreational activi­

ties.71 Individuals in this system provide affective support,

emotional involvement, personal interest, and psychological support.

The system itself provides instrumental support in the form of food,

clothes, and substance in living and working. Budson reviewed the

literature on the effectiveness of community care for mentally-ill 20 persons and found that, "psychological kinship system was a common 72 element in the successful community program." In Budson's statement, the psychological kinship system referred to the social network.

Mitchell and Trickett state that, "the concepts of social net­ works and social support systems have recently become increasingly 73 popular foci of inquiry for both researchers and practitioners."

Theorists from a variety of fields, in sociology, psychology, and social work (Caplan,^ Erickson,^ Garrison and Herfel,^ Weiss,^ 78 79 Cohen, and Tolsdorf ), have suggested the importance of social support for individual well-being. Speck indicates that "the goals of all network intervention were to stimulate, to reflect, and to focus the potential within the network to solve one another's prob- 80 lems." He defines "an individual's social network as the sum of those human relationships that have had a significant effect on 81 his life." A member of a person's social network may represent either/both an affective resource, with an emotional support, or an instrumental resource, with housing, medical care, and food. Thus, a network might include a spouse, other relatives, friends, clergy, 82 and a doctor.

Speck explains that "the social network approach was based on the assumption that the solution to a variety of human dilemmas lies 83 within the collective resources of the individual network."

Garrison and Howe report that, "social network intervention seems particularly well-suited for use with elderly clients, since they often experience complex medicopsychologic problems, which benefit from a coordinated multiple personal effort to meet both affective 84 and instrumental needs." Froland, Brodsky, Olson, and Stewart's study indicate that "the mutuality of exchange (with reciprocity) 85 was a central feature of social support." "Family members and friends may continue to provide support to the chronic client as long as reasonable reciprocity existed, however, lack of reciprocity may cause feelings of burden." They conclude that, "if the ideology of community-based mental health care is to be successfully imple­ mented, there is a clear need to form a partnership between the 87 client's networks of support and providers of formal treatment."

The volunteer may help the client in such daily-living skills as shopping, budgeting and job-seeking-instrumental support, and provide emotional-affective support and become a part of the client's social network and treatment team.

Group Approach: Silverman in his monograph, "Mutual Help Groups:

A Guide for Mental Health Workers" emphasizes the modality of the mutual help group as a powerful and constructive means for people 88 to help themselves and each other. He stated:

This modality is especially effective during periods of critical transition when people must seek a new role definition for themselves in their social net­ work. Through mutual help indivdiuals learn a set of behaviors appropriate to their new role and in­ crease both self-reliance and the ability to take charge of their own lives. Mutual help further en­ ables them to maintain connectedness to their world as they build new links and networks. Mutual help groups represent an opportunity to find new solutions to problems, to enlist new helpers, to utilize the life experience of their members. . . . By facilitating and enhancing these networks it may be possible to prevent or alleviate psychological stress andRimprove the quality of lif e in any community. Silverman describes two mutual help groups in the mental health field: Schizophrenics Anonymous and Recovery, Inc. Schizophrenics

Anonymous (S.A.) is an organization for individuals who have been diagnosed as schizophrenic. "At S.A. meetings, members talk about th eir individual problems and what they can do to help each other. .

They focus on what it means to be sick. . . . Individual learns to become aware of symptoms and how to deal with them, to understand th at he is not exempt from all resp o n sib ilities because he is sick. . .

Recovery, Inc. is an organization devoted to preventing chron- icity in former mental patients. The group members attend regular weekly meetings to learn a self-help approach that stresses symptoms as distressing but not dangerous, and self-approval for efforts made to overcome the shame and self-condemnation for having been a mental 91 patient and that no case is hopeless.

Silverman’s monograph does not describe the outcomes of these mutual help groups. Their effectiveness and accountability are, therefore, unknown. However, group psychotherapy for psychiatric 92 patients, as stated by Yalom, and group process, as reported by 93 Buchanan, are beneficial to the chronically ill. Buchanan states that, "groups for the chronically ill provide a mutual support base among members who have common problems and experiences. This s o li­ darity provides an accepting background for free expression of feelings. Members can also observe the progress, behavioral changes, and success of the other participants, and they are often motivated to try new solutions to their own problems through imitating others." Buchanan conducted group therapy for 15 chronic physically-ill patients during weekly meetings. Each meeting was held for one, to one and one-half hours. The basic philosophy of his two-phase model was that the meetings were an integrated part of the treatment for that particular disease. He used a modified intake interview to ex­ plain the nature of the group in order to reduce the patient's anxiety and provide the patient the appropriate expectations from the meetings. These interviews were supportive and they emphasized the benefit of the acquisition of knowledge. The information of the interviews also helped the group leader to understand the background of the patient and his strengths and weaknesses. The leader was able to use this information in order to support individuals in group dynamics. There were ten meetings. Buchanan reported the outcome of the two-phase group: "It does not solve all of the patients' problems.

It does, however, make dealing with emotional issues an acceptable part of their disorder, and it does provide chronically-ill patients and their 95 families with an entry to assistance those problems."

Buchanan's study, along with Silverman's monograph, implies that the group approach can be a powerful and constructive means in terms of providing opportunities for mutual help and socialization among the mental patients. Through the group approach, they can identify success­ ful roles, express their emotions, increase their social contacts, help to solve their own problems and; therefore, help to have a better adjustment and a successful community life. 24

Measures of Success

A major problem of evaluating d ein stitu tio n alizatio n programs is establishing an effective measure for the success of patients in adapt­ ing to community placement. The most publicized measure of success is the rate of readmission.

Rosenblatt and Mayer's review of studies on readmission of patients to mental hospitals uncovers only one variable that con­ sistently predicted the rehospitalization of mental patients: the 96 number of previous admissions. Their study finds that: "the more often patients have been admitted to a mental hospital, the 97 more likely they are to return in the future."

The studies they considered ranged in sample size from 46 to 403 and in the length of follow-up time from three months to one year.

The following variables have been controlled: age, sex, eth n icity , social class or education, marital status, diagnosis or degree of go illness, and at tendance at afercare clinics. One limitation of th eir review is that the studies were pulled from d ifferen t agencies, each set of data may represent a different set of definitions or criteria representative of each agency. In addition, policies of re­ admissions may likewise differ with setting. Rosenblatt and Mayer were unable to identify any particular factors in social processes which contribute to patient readmission rates. 25 99 100 The studies of Suroill and Mittleman, Freeman and Simons,

and Maisel,101 reveal that the longer patients remain in the hospital, the more likely they are to return. Rosenblatt and Mayer indicate

that "patients, especially those who resided in modern-day hospitals, respond strongly to humanitarian aspects of their milieu that have 102 relatively little to do with psychiatric interventions per se."

In fact, they conclude: "For many patients, the hospital, when com­ pared with their home environment, holds greater promise of fulfilling 103 their needs." Munley and Hyes followed up an earlier investigation

in which demographic and clinical ch aracteristics of psychiatric patients were used to predict readmission within three months of d is­ charge. Of the 202 initial samples, 186 (92.1%) had been discharged

in the first year of study and 16 (7.9%) remained hospitalized. Of the 186 discharged patients, 177 had completed the initial three- month follow-up period; 67 (39%) were readmitted. Of the 177 patients,

175 completed the one-year follow-up. Of the 175 patients, 107

(61.1%) were readm itted.104

They report:

In the initial study, stepwise multiple regression analysis identified six variables as optimal set of predictors for readmission within 3 months of d is­ charge: type of discharge, number of prior psychia­ tric hospitalizations, race, suicide attempt within 1 month of admission, subjective report of depression upon admission, and occupational level (R=.452). In the present study the same sample was followed up at 1 year after discharge, and demographic and clinical variables were used to predict readmission within 1 year of discharge. Stepwise multiple regression analysis identified three variables as the optimal set of predictors for readmission within 1 year of discharge: past history of suicidal behavior, 26

subjective report of depression upon admission, and number of prior psychiatric hospitalizationsJ05

Munley and Hyer's study has a suitable size of sample and length of study (one year). This study controls 21 demographic and clinical variables to predict readmission at three-month and one-year follow- up periods.

In 1972, Anthony and his collaborators also reviewed the lite ra tu re and reported that "in the first six months after discharge, the re­ admission rate was 30 percent to 60 percent; after one year it was 40 percent to 50 percent; and after three to five years, it was 65 percent to 75 percent."1^ These figures were thought by the Group for the

Advancement of Psychiatry, "to be reliab le 'baserate data' which measure the efficiency of specific rehabilitation programs.1,107

Wilier and Miller report that:

Community adjustment of former psychiatric patients has been found to re la te highly to the likelihood of rehospitalization and community tenure. The present study examined the a b ility of a community adjustment scale and various other patient characteristics to predict rehospitalization. Multiple regression analysis using rehospitalization as the dependent variable identified thirteen items including twelve from'the community adjustment scale, which combined to provide a highly accurate prediction. The brief scale (13 items) which is now being cross-validated is potentially a useful tool for clinical evaluation -,no and planning of follow-up services to former patients.

The thirteen items of self-assessment include: most friendly with others, angry and broke things, hospitalized in previous year, not written or seen family, attempted or thought suicide, most people not cooperative, trouble with the law, moody, not in control of feel­ ings, did not look for a job, not satisfied with self, many headaches, 27 1 HQ repeatedly did senseless things, had difficulty talking to others.

Miller and Wilier's study finds that "social factors, as measured

by a community adjustment scale in combination with the number of prior

admissions and whether the patient had been hospitalized during the

previous year, produced an extremely accurate prediction of re­

hospital ization.

Smith and Smith suggest th at, "using both recidivism and adjust­

ment as dependent variables will provide the researchers with a clear

picture of the patient's adaptation.They state that, "a pa­

tient's staying out of the hospital did not necessarily imply that he 112 or she had made or can make a successful return to the community.1

Furthermore, recidivism statistics could be manipulated by individuals 113 representing institutional, political, or fiscal forces."

Overall, these studies indicate that recidivism is one of the

most pressing problems being encountered by hospital psychiatric pro­

grams in this country. The percentage of persons being admitted to

psychiatric hospitals who previously had been hospitalized is increas- 114 ing. Although the number of prior psychiatric hospitalizations is

consistently found as a predictor of the rehospitalization among those

several studies, recidivism statistics can be manipulated. Staying out of the hospital does not necessarily imply th at one has made or can make

a successful return to the community, as argued. The rec id iv ists,

therefore, are particularly in need of a community support system.

Project PAVE (Patient Advocacy through Volunteers Efforts) is designed

to respond to th is need. 28

For the research purpose in this study regarding recidivism, it 115 is more adequate, as argued by Miller and Wilier, to use social factors measured by the community adjustment (PARS) scale, in com­ bination with the demographic and clinical factors to predict re- hospitalization as well as to assess the effectiveness of the experimental program. The Personal Adjustment and Role Skills (PARS)

Scale is an outcome evaluation approach developed by Ellsworth using the criteria of changes in behavioral adjustment occurring during the 116 period of intervention. The PARS Scale is a rating by significant others for patients treated in psychiatric hospitals, and a rating of those clients seen in community clinics regarding their behavior changes and role skills development. Usually, clients are regarded as the best source for measuring internal states such as felt distress. Some studies show that conclusions based on client ratings agree with conclusions reached from relatives.^ The use of same raters for both pre- and post-treatment ratings tends to control the potential human bias. The

PARS Scale has been well accepted as an instrument in measuring pro­ gram effectivness in the mental health field.

A major weakness in using significant others in the PARS Scale is the potential for incomplete and hence unusable information if they fail to complete the "pre-" and/or "post ratings." It is better to obtain data both from the clients and their significant others so that both perspectives are explored. Besides the readmission, measures of the success of community placement should include indicators; such as, number of services u tiliz e d , length of employment and community residence, as well as, personal adjustment. 29

Impressions from Literature Review

In summary, the available literature on volunteer and group inter­ vention helping chronically mentally-disabled patients, leads to the following impressions:

1. The present community support systems for chronically mentally- disabled patients are inadequate.

2. Chronically mentally-disabled patients need assistance in order to increase their instrumental and affective resources for problem-solving, and their adjustment to community placement during periods of critical transition.

3. The group approach is a powerful and constructive means in helping chronically mentally-disabled patients during periods of critical transition from the hospital to the community when they seek new role definitions.

4. Any mechanisms which help the patient to identify a new role definition and increase his instrumental and affective resources for problem-solving in the periods of transition are beneficial.

The literature on community adjustment of chronically mentally- disabled patients can be summarized indicating that these patients, under the present community mental health care system, have an inadequate community support system. Anxieties and difficulties arise in their daily lives as new roles are assumed, a high ratio of patients return to the hospital.

Volunteer intervention stressing the one-to-one interpersonal relationship, and a group approach; which provides a supportive system and role models for these patients, may be able to improve a p a tie n t's 30

adjustment and help him to adjust to community life. A volunteer in­

dividual intervention along with a group approach as part of a com­ munity supportive system in deinstitutionalization have not, up to

this point, been tested seriously. This pilot study took a step in i.

this direction.

Purpose of Study

The main purposes of th is study were:

1. To evaluate the effectiveness of both a volunteer individual

intervention and a group approach in terms of accessing community

services and providing friendship and role models. These interventions were expected to reduce the recidivism rate by enhancing community adjustment through the assistance of a volunteer friend and self-

help group process. At the end of the sixth month of the patient- volunteer match, the experimental group was pared with the control group of clients without volunteers and group intervention.

2. To explore and compare the patient's perception of his re­ lationship with the volunteer with that of his significant other at the end of six months of volunteer intervention. If the interpersonal relationship between the clien t and the volunteer was equal to or

b etter than the interpersonal relationship between the clien t and his significant other, then it would indicate that the volunteer pro­ vided an important social support. 31

Major Areas of Inquiry

Major areas of inquiry were:

1. Identification of the comparative degrees of community adjust­ ment between the experimental and control groups according to the PARS

(Personal Adjustment and Role Skills) Scale as rated by each client's significant other. These dimensions of community adjustment include:

Interpersonal Involvement, Anxiety, Depression, Confusion, Household

Management, Relations with Children, and Employment (a description of the PARS Scale is provided in Chapter II, also see Appendix I). Besides the PARS Scale, the Client's Evaluation Sheet (see Chapter II and

Appendix L) was used to determine the effectiveness of volunteer and group intervention by identifying statistically the following indicators of community adjustment: length of time in employment, length of com­ munity residence, number of rehospitalizations, number of services u tiliz e d in the community, number of service u tiliz a tio n helpers, number of problems, and relations with significant others and volunteers.

2. Examination of the impact of the one-to-one volunteer relation­ ship,and group meetings on the client's community adjustment, as measured by the PARS Scale and the Client's Evaluation Sheet.

3. Exploration of the relation between the client's community adjustment and the client's personal characteristics, such as: age, sex, race, education, marital status, number of siblings, diagnosis, number of previous hospitalizations, and length of current hospitalizations (intervening variables). 32

4. Examination of the volunteer/client interpersonal relationships as a helpful peer support system measured by the Client's Evaluation

Sheet (described in Chapter II).

5. Exploration of the relation between the c lie n t's community adjustment and the personal characteristics of the volunteer, such as; age, sex, education, and motivation (intervening variables).

Major Hypothesis

The major hypothesis is: There is a significant relationship between volunteer intervention and the successful community adjustment of chronically mentally-disabled clients. There are two approaches in the volunteer intervention model: the one-to-one volunteer relationship and the group activity. Each approach was considered as an independent variable in order to measure its affect on the subject's community adjustment through the PARS Scale and other adjustment indicators.

The major assumption of the experimental program is th at d is­ charged chronically mentally-disabled are going to suffer anxieties 118 due to difficulties in dealing with their re-entry into the community.

They are in a period of critical transition and seeking new role definitions. These anxieties and difficulties can cause maladjustment and may lead to high recidivism. Therefore, a planned program of volunteer relationship along with group activities was provided to discharged chronically mentally-disabled patients to resolve their pro­ blems and reduce their anxieties during the critical period following discharge. Better personal adjustment, growth and lower recidivism was 33

expected among the volunteer-matched patients, as compared with those

who did not receive volunteer intervention.

The rationale for using volunteers was that their primarily

altruistic natures (versus financial for paid workers) suggest higher 119 level of affective commitment to their clients. The others were

"The outreach, involvement, and caring effo rts needed in working with

the neglected, the rejected and the powerless, require a mobilization of 120 the efforts of a widespread network of local volunteers." Thus,

volunteer intervention can increase the client's instrumental and

affective resources for problem-solving, for making a successful a

djustment to society, and for avoiding rehospitalization.

The volunteer intervention included the volunteer-client relation­

ship and group activities. The volunteers had the dual roles of

being a supportive friend to the clients and being an advocate to

assist the clients in assessing community services. The interpersonal

relationships between the volunteer and the c lie n t, which were close,

frequent, face-to-face and accompanied by commitment and warmth, had

problem-solving functions such as job seeking, appointment setting,

transportation provision, client rights advocacy, and access to agency-

based services. The group meetings were designed to serve as a vehicle

for viewing role models, obtaining mutual help, emotional support,

socialization, and self-advocacy. Through the volunteer-client re­

lationship, and the group activities, chronically mentally-disabled clients can be motivated to help themselves in gaining more access to

community services thus enhancing overall adaptation to a non-

institutional lifestyle and preventing their return to the hospital. 34

Minor Hypotheses

1. There is a significant relationship between the client's com­ munity adjustment and the client's personal characteristics of age,

sex, race, education, marital status, number of children, number of

siblings, diagnosis, number of previous hospitalizations, and length of current hospitalization.

2. There is a significant relationship between the c lie n t's com­ munity adjustment and the client's perceptions of his relationship with his volunteer.

3. There is a significant relationship between the c lie n t's community adjustment and the client's perception of his relationship with his significant other.

4. There is a significant relationship between the client/volunteer interpersonal relationship and the client/significant other interpersonal relationship.

5. There is a significant relationship between the c lie n t's corn- community adjustment and the volunteer's personal characteristics.

6. There is a significant relationship between the c lie n t's community adjustment and the frequency of the client's participa­ tion in group a c tiv itie s .

7. There is a significant relationship between the c lie n t's community adjustment and the frequency of the volunteer's attendance in group meetings. By reviewing the chronically mentally-disabled patients related literature and observing the mental health services, the problems encountered by these patients are defined. The major hypothesis of providing a volunteer intervention model to solve the patient's encountered problems and lead to a successful community life is assumed. By gathering data from the experimental study, the major hypothesis and minor hypotheses are tested. NOTES FOR CHAPTER I

1. Group for the Advancement o f Psychiatry, The Chronic Mental Patient in the Community. The Mental Health Materials Center, Inc., New York, Vol. X, No. 102, 1978, pp. 290-295.

2. Leona L. Bachrach, Deinstitutionalization; An Analytical Review and Sociological Perspective, U. S. Department of Health, Edu­ cation and Welfare, NIMH, 1976, p. 1.

3. I b id ., p. 12.

4. I b id ., p. 13.

5. I b id ., p. 13.

6. Ib id ., p. 14.

7. Ib id ., p. 15.

8. Report to the Congress by the Comptroller General of the United States--Summary of a Report—"Returning the Mentally Disabled to the Community: Government Needs To Do More," General Accounting Office; 1977, p. 6.

9. I b id ., p. 1.

10. Christopher J. Smith, "Recidivism and Community Adjustment Among Former Mental P atients," Social Science and Medicine, Vol. 12, Pergamon Press, 1978, p. 18.

11. W. W. Anthony and G. F. Buell, "Psychiatric Aftercare Clinic Effectiveness as a Function of Patient Demographic C haracteristics," Journal of Consulting and Clinical Psychology, 41 August, 1972, pp. 116- 119. Also see Steven Katkin, Virginia Zimmerman, Jonathan Rosenthal, "Using Volunteer Therapists to Reduce Hospital Readmissions," Hospital and Community Psychiatry, 26, 3 (March, 1975), p. 152.

12. Aaron Rosenblatt and John E. Mayer, "The Recidivism of Mental Patients: A Review of Past Studies," The American Journal of Ortho­ psychiatry, 44, 5 (October, 1974), pp. 637-706.

13. Division of Management Services, Bureau of Statistics, "State of Ohio Monthly S ta tis tic a l Summary Report," 30 E. Broad S t., 12th Floor, Columbus, Ohio, Report No. 3, Vol. XXXI, No. X, A pril, 1980, p. 2.

14. John A. Talbott, "Stopping the Revolving Door—A Study of Readmissions to a State Hospital," Psychiatric Quarterly, 48, 1974, pp. 159-168. 36 15. Emil Kraepelin, One Hundred Years of Psychiatry, Philosoph­ ical Library, New York, 1962, p. 297-299.

16. Albert Deutsch, The Mentally 111 in America: > History of Their Care and Treatment From Colonial Times, Columbia University Press, New York, 1949, p. 99.

17. Ib id ., p. 116.

18. I b id ., p. v i i .

19. Michael J. Begab, e d . , The Mentally Retarded and Society: A Social Service Perspective, University Park Press, Baltimore, 1975, p. 6.

20. Henry M. Hurd, ed., The In stitu tio n a l Care of the Insane in the United States and Canada, The Johns Hopkins Press, Baltimore, MD, 1916, p. 60.

21. See citatio n 16, p. 484.

22. See citatio n 15, pp. 297-299.

23. Ibid.

24. See citatio n 16, p. 299.

25. Norman Dain, Clifford W. Beers: Advocate for the Insane, University of Pittsburgh Press, 1980. The Book's Jacket.

26. I. D. Rutman, "Position Paper: Adequate Residential and Community Based Programs for the Mentally Disabled For Submission to the White House Conference on Handicapped Individuals," Philadelphia, PA: Horizon House Institute for Research and Development, February, 1976.

27. Ibid.

28. Ib id ., pp. 299-303.

29. James K. W hittaker, Social Treatment, Aldine Publishing Company, Chicago, 1974, p. 75.

30. S. P. and Denzin, Spitzer, N. K. , The Mental Patient: Studies in the Sociology of Deviance, McGraw-Hill Book Company, New York, 1968, p. 7.

31. See citatio n 16, p. 307.

32. C. Hersch, Social History, Mental Health, and Community Con­ tro l," American Psychologist, 27:749-754, August, 1972. 38

33. Leona L. Bachrach, Deinstitutionalization: An Analytical Review and Sociological Perspective, U. S. Department of Health, Education and Welfare, NIHH, 1976, p. 2.

34. R. M. Edwalds, "Functions of the State Mental Hospital as a Social Institution," Mental Hygiene, 48, October, 1964, pp. 666-671.

35. S. Jarcho, "The Fate of British Traditions in the United States as Shown in Medical Education and in the Care of the Mentally 111, 1750-1850," Bulletin of the New York Academy of Medicine, 52: 419-444, March-April, 1976.

36. See c ita tio n 25.

37. See citatio n 32, p. 19.

38. M. R. Fowlkes, "Business as Usual at the State Mental Hospital," Psychiatry, 38:55-64, February, 1975.

39. W. Doll, "Family Coping With the Mentally 111: An Unantici­ pated Problem of Deinstitutionalization," Hospital and Community Psy­ chiatry, 38:209-217, August, 1975.

40. S. A. Kirk and M. E. Therrien, "Community Mental Health Myths and the Fate of Former Hospitalized Patients," Psychiatry, 38:209-217, August, 1975.

41. David 0. Rothman, "Can D einstitutionalization Succeed?" New York University Education Q uarterly, 1979, pp. 16-22.

42. D. Mechanic, "Alternatives to Mental Hospital Treatment: A Sociological Perspective," Presented at Conference on Wisconsin, Madi­ son, Wisconsin, October, 1975. Also see Notes for Chapter One, citation 2 .

43. D. Mechanic, "Social Factors Affecting Psychotic Behavior," Center for Medical Sociology and Health Services Research, Research and Analytic Report Services N. D., no. 9, 1975, Madison, Wisconsin: Uni­ versity of Wisconsin.

44. Leona L. Bachrach, "A Conceptual Approach to Deinstitutional­ ization," Hospitals and Community Psychiatry, Vol. 29, No. 9, September, 1978, pp. 573-577.

45. Christopher J. Smith and Carolyn A. Smith, "Evaluating Out­ come Measures for Deinstitutionalization Programs," Social Work Research and A bstracts, 1979, p. 23.

46. J. Friedman and D. H oshall, "Evaluation From a Former P atien t's Point of View," Evaluation, 2:3-9, 1975. 39

47. See c ita tio n 25.

48. See c ita tio n 10.

49. "Client Rights," Ohio Department of Mental Health, July, 1980. Also see Leona L. Bachrach, Deinstitutionalization: An. Analytical Review and Sociological Perspective, L). S. Department of Health, Education, and Welfare, NUMH, 1976, p. 15.

50. T. D. Glenn, "Community Programs for Chronic Patients—Admin­ istrative Financing," Psychiatric Analysis, 5:174-177, May, 1975.

51. V. Goertzel, "Program Evaluation," in Community Survival for Long-Term Patients, H. R. Lamb, ed., San Francisco, Calif., Jossey-Bass Publishers, 1976.

52. See c ita tio n 2, p. 15.

53. Ibid.

54. Leona L. Bachrach, "A Note on Some Recent Studies of Released Mental Hospital Patients in the Cotmiunity," American Journal of Psy­ c h ia try , 133:73-75, January, 1976.

55. Camilla Jelm Weber, "Volunteer Utilization in Extension of Family Planning Services," Thesis, The Ohio State University, 1976, p. 21.

56. Ib id ., p. 21.

57. Barbara Feinstein and Catherine Cavanaugh, The New Volunteerism, Cambridge, Mass., Schenkman Publishing Co., 1976, p. T.

58. I b i d ., p. 4.

59. Ib id ., pp. 4-6.

60. Ibid. , p. 7.

61. I b id ., p. 8.

62. Steven Katkin, Virginia Zimmerman, J. Rosenbllatt, and M. Ginsburg, "Using Volunteer Therapists to Reduce Hospital Readmissions," Hospital and Community Psychiatry, Vol. 26, No. 3, March, 1975, p. 151-153.

63. Ibid. 40

64. "Special Report: The Chronic Psychiatric Patient in the Community--High1ights from a Conference in Boston," Hospital and Community Psychiatry, Vol. 28, No. 4, April 1977, p. 285-286.

65. Ib id ., p. 285.

66. Ibid.

67. Ib id ., p. 286.

68. Ibid.

69. W. A. Anthony, "Efficacy of Psychiatric Rehabilitation," Psychological B ulletin 78, 1972, pp. 667-656.

70. See citation 63, p. 284-285.

71. I b i d ., p. 285.

72. Ibid.

73. R. E. Mitchell and E. J. T ric k e tt, "Social Networks as Medi­ ators of Social Support: An Analysis of the Effects and Determinants of Social Networks," Community Mental Health Journal, 1980, 16 (1) 1, p. 27.

74. G. Caplan, Support Systems and Community Mental H ealth, Behavior Publications, New York, 1974.

75. Gerald D. Erickson, "The Concept of Personal Network in Clinical P ractice," Family Process, 1975, 14, 487-498.

76. John Garrison and Sandra Werfel , "A Network Approach to Clinical Social Work," Clinical Social Work Jo u rn a l, 1977, 5 (2), pp. 108-116.

77. Robert S. Weiss, "The Provisions of Social Relationships," in Zick Rubin (e d .), Doing Unto O thers, Englewood C liffs, N .J.: P ren tice-H all, 1974.

78. Carl I. Cohen and Jay Sokolovsky, "Schizophrenia and Social Networks: Ex-Patients in the Inner City, Schizophrenia Bulletin, 1978, 4 (4), pp. 545-560.

79. Christopher Tolsdorf, "Social Networks, Support, and Coping: An Exploratory Study," Family Process, 1976, 15 (4), p. 407-417,

80. Ross V. Speck and Carolyn L. Attneave, "Social Network Intervention," in C lifford L. Sager and Helen S. Kaplan (eds.) Progress in Group and Family Therapy, New York: Brunner/Mazel, 1972, p. 419. 41

81. Ross B. Speck and Carolyn L. Attneave, Family Networks, Pantheon, New York, 1973. Also see c ita tio n 79, p. 109.

82. John E. Garrison and Jo-Ann Howe, "Community Intervention with the Elderly: A Social Network Approach," Journal o f the American Geriatrics Society, Vol. XXIV, No. 7, 1976, p. 330.

83. See c ita tio n 79. Also see c ita tio n 75, p. 109.

84. See c ita tio n 81, p. 333.

85. Charles Froland and Jerry Brodsky, and Madeline Olson and Linda Stewart, "Social Support and Social Adjustment: Implications for Mental Health P rofessionals," Community Mental Health Journal, 15 (2), 1979, p. 92.

86. Ibid.

87. Ib id ., p. 93.

88. Phyllis R. Silverman, "Mutual Help Groups: A Guide for Mental Health Workers," National Institutes of Mental Health, DHEW Publication No. (ADM) 78-646, 1978, p. 56.

89. Ib id ., p. 56.

90. I b id ., p. 31.

91. Ibid., p. 32.

92. ID Yalom, The Theory and Practice of Group Psychotherapy, New York, Basic Books, 1970. '

93. DC Buchanan, "Grouptherapy for Chronic Physically 111 Patients," Ps.ychomatics, Vol. 19, No. 7, July 1978, pp. 429-431.

94. Ib id ., p. 429.

95. Ib id ., p. 431.

96. John E. Mayer and Aaron Rosenblatt, "The recidivism of Mental Patients: A Review of Past Studies," American Journal of Ortho­ psychiatry, 44 (5), October 1974, p. 697.

97. Ibid.

98. Ib id ., p. 700.

99. P. Burvill and M. Mittleman, "A Follow-up Study of Chronic Mental Hospital P atien ts," Social P s y c h ia tris t, 1971, 6:167-171. 42

100. H. Freeman and 0. Simmons, The Mental P atien t Comes Home, John Wiley, New York, 1963.

101. R. Maisel, The Mental Patient and His Family: A Study of the Success of Ex-Mental Patients in the Community, Doctoral D isserta- tion, Yale University, New Haven, Connecticut, 1964.

102. See c ita tio n 61, p. 703-704.

103. Ibid.

104. Leon A. Hyer and Patrick H. Munley, "Demographic and Clinical Characteristics as Predictors of Readmission: A One-Year Follow-Up," Journal of Clinical Psychology, Vol. 34, No. 4, October, 1978, p. 833.

105. Ibid.

106. W. A. Anthony, e t. al., "Efficacy of Psychiatric Rehabilita­ tion," Psychological Bulletin, 78, 1972, pp. 447-456.

107. See c ita tio n 1, p. 312.

108. Gary H. Miller and Barry Wilier, "A Brief Scale for Predict­ ing Rehospitalization of Former Psychiatric Patients," Canadian Psy­ c h ia tric Association Jo u rn a l, Vol. 22, 1977, p. 80.

.109. Ib id ., p. 79.

110. Gary H. Miller and Barry Wilier, "Predictors of Return to a Psychiatric Hospital," Journal of Consulting and Clinical Psychology, 44:398-900, 1976.

111. Christopher J. Smith and Carolyn A. Smith, "Evaluating Out­ come Measures for Deinstitutionalization Programs," Social Work Research and A b stracts, 1979, p. 29.

112. Ibid.

113.William Doll and P hyllis Solomon, "The V arieties of Recidivism: The Case Against the Use o f Recidivism Rates as a Measure of Program Effectiveness," American Journal of Orthopsychiatry, 49, April, 1979, pp. 230-238. Also see Ibid.

114. See c ita tio n 104, p. 77.

115. See c ita tio n 102.

116. Robert B. Ellsworth, "PARS Scale Measuring Personal Adjustment and Role Skills," Institute for Program Evaluation, 124 Chapin, Ann Arbor, Michigan 1979, p. 1. 43

117. Robert B. Ellsworth, K. C. Finnell, and C. Leuthold, "Com­ munity Treatment for Young Psychiatric Patients: A Case Study in Program Evaluation," Evaluation and the Health Professions, 1978, No. 1, pp. 66-80. Also see Ibid.

118. See c ita tio n 10.

119. Eva Schindler-Rainman and Ronald Lip p itt, The Volunteer Community, Virginia: NTL Learning Resources Corporation, 1975, p. 34.

120. Ibid., p. 35. CHAPTER II

SETTING AND METHODOLOGY

Setting

The setting for this study was Project PAVE (Patient Advocacy through Volunteer Efforts). This project was initiated by the Ohio

Mental Health Association and implemented by the Mental Health Associa­ tion of Franklin County. The project was financially sponsored by the

Battelle Memorial Institute Foundation from January 1980 to December

1980. In October 1980, the project was sponsored by d ifferen t grant agencies. The ACTION Agency provided the key grant for the program activities and staff which included a Project Director and one part- time Prograiji Assistant. This study was supported by a research grant provided by the Ohio Division of Mental Health. The grant enabled the researcher to serve as a full-time Research Director. In October

1980, the CETA organization provided one full-time secretary and one part-tim e secretary. These two secretaries le f t the program the middle of April 1981, due to budget cuts. One VISTA volunteer worker joined the program in January 1981, and transferred to another pro­ gram in May 1981. The Program Assistant quit the job on February 1,

1981 and this position was never filled. The project involved two student interns. One served in Fall Quarter 1980. Another served in

Winter and Spring Quarters.

44 45

In September 1980, six offices were provided by the Central Ohio

Psychiatric Hospital (COPH) to Project PAVE to facilitate the services.

A conference room in COPH was also available for volunteer training.

Physically located in COPH, financially sponsored by different grant agencies and administratively responsible to the Mental Health Asso­ ciation of Franklin County were the ch aracteristics of the project.

Project PAVE saw its e lf as an external advocacy program for mentally-disabled patients in COPH to facilitate their returning to the community. In order to achieve its goals, the project implemented the following Volunteer Intervention Model as a strategy to help the clients have a successful community placement.

Volunteer Intervention Model

There were two approaches in the Volunteer Intervention Model: the client-volunteer relationship and the group activity. The first approach was the one-to-one volunteer relationship. Based on the prob­ lem understanding from problem statement, a volunteer who was trained to apply behavioral principles and techniques served as a linkage between the discharged chronically mentally-disabled person and his successful transition from the hospital to the community. The volunteer played two important roles in fulfilling his linkage func­ tion. The volunteer served as both a supportive friend and a community-based advocate to the patient.

A supportive friend as defined by PAVE was a person who was willing to make a commitment to help a mentally-disabled person adjust to daily life after hospitalization. This person was someone 46 who cared and from time-to-time assisted the client to reassume a new role in the community (provided the affective resources).

The purpose of the volunteer as described in the PAVE volunteer Job

Description was:

To establish a linkage with a chronically mentally disabled person in one of Ohio's State Hospitals for the purpose of facilitating the patient's re­ entry into the community upon discharge; and to continue the linkage as a supportive friend and a community based advocate to ensure that the patient receives the necessary mental health services and has access to other necessary support systems. The volunteer will help the patient access the net­ work of formal community supports and services as well as the informal social and supportive systems.

The specific duties of the volunteer were:

To assist your friend's re-entry into the community in a variety of ways; to be a supportive friend to a mentally disabled person; to be an advocate and ~ assist your friend in accessing community services.

The time requirement for each volunteer was four to six hours per week and/or 20 hours per month to perform the job and duties with a six- 3 month commitment. The volunteer was responsible to the program d irecto r. The program required the volunteer to p articip ate in 30

hours of training and attendance at in-service seminars. The training content consisted of ten modules, each three hours in length. They

included:

1) an orientation and introduction to PAVE and the Mental Health Delivery System in Ohio; 2) mental health/mental illness--modes of treatment, degrees of illness, psychotropic medications; 3) primary service people and community resoures; 4) communications s k ills; 5) art of listening; 6) mini-assertiveness training; 7) the hospital environment; 8) the beginning relationship; 9) advocacy s k ills and know-how; and 10).entitlem ents and social welfare programs. 47

The training program aimed to ensure th at volunteers were equipped with the skills necessary to perform successfully their volunteer responsi- 5 b ilitie s .

The selection of the volunteer was based on a Volunteer Rating

Scale used by the program coordinator during a screening interview for volunteer applicants. This rating scale included the following personality characteristics: maturity, stability, self-direction, perception (non-judgemental), accurate empathy, not primarily working on own problems in relations with others, willing to learn, a "doer," strong se lf-id e n tity , a b ility to communicate, basic concern for people, £ and responsibility.

The other considerations of volunteer selection by the program coordinator were qualifications of the volunteer such as: "resident of the community with access to transportation; ability to relate as a friend (persistence, patience, willingness to respect confidentiality and to maintain the relationship); willingness to learn about problem areas for the mentally disabled; a belief in friendship and advocacy for mentally-disabled persons."7 The second approach in the Volunteer Intervention Model was group activity. The group activity (PAVE Meeting) aimed to provide a social vehicle for role models, mutual help, emotional support, socialization, and self-advocacy. It provided opportunities for the patients' educa­ tion ( i . e . , movie, lecture, discussion) and personal growth (self- advocacy). The group was a vehicle for the patients and volunteers 48 to develop into a cohesive social and political group to protect their

rig h ts; and to improve th eir well-being (group advocacy network).

Meetings were held in the evening biweekly and the program lasted two hours. These approaches were aimed at increasing the collective in­ strumental and affective resources for the client's problem-solving and community adjustment.

Research Design

This study used an experimental, pretest-posttest control group Q design as defined by Campbell and Stanley to test whether there is a significant relationship between volunteer intervention and the successful community adjustment of chronically mentally-disabled clients. The focus was on comparing the experimental group and the control group by using the PARS Scale community adjustment and other community adjustment indicators as measured by the Client's

Evaluation Sheet. After clients were referred to PAVE and their in­ formed consent was obtained (forms attached in Appendix A - E), the c lien ts were randomly assigned to the experimental and the control groups. In order to protect the client's identity, a procedure of in­ formed consent was established. Project PAVE was explained by the primary therapist according to Client's Explanation of PAVE Study

(Appendix A). If the clien t agreed to participate in the study, a

Referral Form (Appendix B) was sent to Project PAVE along with a signed

Agreement to talk to a PAVE representative (Appendix C). An intake was arranged by the PAVE staff to gain the client's consent to participate

(Appendix D) and c la rify any questions. All information gathered was 49 transferred into unidentified data for satistical analysis under the researcher's control. The mailing envelopes did not have the

agency's name or address. The volunteers, were assigned to the clients in the experimental group based on sex, age, and race con­ siderations. Group meetings were provided to the experimental group members for a six-month period while members of the control group were not. Based on the individual preference, the PAVE staff informally introduced the volunteer to the client. Then, the staff formally matched them i f they were mutually accepted.

The PARS VI Community Adjustment Scale was used both as a pretest and posttest questionnaire. It was initially mailed prior to volunteer intervention to significant others designated by the client and asked for their assessment of the client's level of functioning and community adjustment. The posttest was given at the end of the six- month program period and again u tilized the PARS Scale but also added the Client Evaluation Sheet (see section of instruments).

After the posttest, Client Evaluation Sheet was used to measure the client's perception of his relationship with the volunteer (ex­ perimental group) and with the significant other (experimental and control groups) and other adjustment indicators by a personal interview.

The responses of the experimental and control groups were statistically analyzed and compared.

General Characteristics of the Study Population

It was a central assumption of this study that volunteer inter­ vention functions well in a target population which is readmitted 50 for or has long-term residents (at least six months) in the state psychiatric hospital. Since review of the literature indicated that discharged chronically mentally-disabled are likely to suffer anxieties 9 in dealing with their re-entry into the community volunteer inter­ vention would potentially benefit the psychiatric recidivist and the long-term hospitalized patient. As noted in Chapter I,

Talbott finds th at 84 percent of readmissions could have been pre­ vented with improved service access.10 Project PAVE theorized that the c lie n t's community adjustment is improved by volunteer and group approaches (pp. 45-48). The client criteria in this study were therefore:

1. Classified as recidivist (one who had previous psychiatric hospitalization at least more than one week) or the current episode being of at least six months d u ra tio n ..

2. Age between 18 to 65 years.

3. Primary diagnosis not alcohol or drug related.

4. Physically able to take care of oneself.

5. Referred for post-hospitalization care based on primary therapists' judgement and plan that the patient will be discharged within two months.

6. Willing to participate in the study (informed consent).

Sampling Frame and Procedure

This study assumed the discharging psychiatric patients as its universe aggregation. Its population included all psychiatric recidivists residing in the state mental hospitals (see Figure 1).

Its study population was patients on the referral list (N = 60) which were referred by the primary therapist of the Central Ohio 51

UNIVERSE discharging psychiatric patients

POPULATION all psychiatric recid­ iv ists in sta te mental hospitals

patients on referral STUDY l i s t 1 POPULATION I

SAMPLING patients willing FRAME to participate

I I RANDOM ASSIGNMENT I I

XG 01 X 02 CG 03 04

XG = experimental group CG = control group X = six months intervention 0 = observation or measurement 01&03 = pretest 02&04 = p osttest

F ig u re !. SAMPLING PROCEDURE Psychiatric Hospital according to pre-set client criteria. The

sampling frame (the actual list of sampling units) consisted of those

willing to (N = 55) take part in the study. Using a random table, the

researcher then assigned patients randomly to the experimental and the

control groups.

Controlled Variables

As mentioned in Chapter I, many factors influence the outcome of

deinstitutionalization. The length of stay in a psychiatric hospital

and the number of previous psychiatric hospitalizations have had a

significant relationship with readmission. In addition to these, this

study also controlled: age, sex, race, religion preference, number

of siblings, education, marital status, number of children, previous occupation, diagnosis, and type of community residence after discharge.

They were viewed as potential confounding variables.

The volunteer intervention model as a designed program strategy

had two approaches, as mentioned previously: the one-to-one volunteer

and c lie n t relationship and the group a c tiv itie s . They were both con­

sidered as elements of the independent variable (intervention). The vol­

unteer's personal characteristics, such as sex, age, education, and

reason for being a volunteer were examined as potential intervening

variables and as a part of the minor hypothesis.

The dependent variables included community adjustment as measured

by the PARS Scale, and length of employment, length of community

residence, number of rehospitalizations, services utilized in the com­

munity, number of service helpers, number of problems, and sum of the interpersonal relationships as measured by the Client's Evaluation

Sheet. The decision to use multiple types of dependent variables was based on the previous review of lite ra tu re and program assumptions.

These included: 1) recidivism alone may not be a comprehensive measure 12 of recuperation in the community; 2) the rehabilitation of chronic mental patients is aimed at two independent goals and hence requires multiple measures: a) successful community tenure, with the prevention of symptomatic relapse and of rehospitalization, and b) assumption of an adequate social role, with an appropriate instrumental performance in the community (vocational adjustment, including homemaking and social 13 and interpersonal adjustment).

Indicators of Effectiveness

The following variables served as indicators of effectiveness of volunteer intervention:

1) The degree of community adjustment functioning of the experi­ mental group compared with the control group, as measured by the PARS

Scale.

2) The length of employment of the experimental group compared with the control group as measured by the Client's Evaluation Sheet.

3) The length of community residence of the experimental group com­ pared with the control group as measured by the Client's Evaluation Sheet.

4) Number of hospitalizations of the experimental group compared with the control group, as measured by the Client's Evaluation Sheet.

5) The number of services used by the experimental group com­ pared with the control group as measured by the Client's Evaluation

Sheet. 54

6) The number of service helpers of the experimental group com­

pared with the control group as measured by the Client's Evaluation

Sheet.

7) The number of problems expressed by the experimental group

compared with the control group, as measured by the C lien t's Evalua­

tion Sheet.

8) The quality of interpersonal relationship perceived by the

client with the volunteer and the significant other as measured by

the Client's Evaluation Sheet. The quality of interpersonal relation­

ship with the volunteer served as an indicator of the added interpersonal relationship compared to the client/significant other

relationship.

Since the significant other was selected by the client as a per­

son who knows him best, and at the same time, whom the clien t feels most close to, the interpersonal relationship between the c lie n t and

his significant other was an important social relation to the client.

Therefore, if the interpersonal relationship between the c lie n t and

his volunteer was found to be equal or even better than the inter­

personal relationship between the client and his significant other,

then it would be safe to conclude that the volunteer provided a

significant interpersonal relationship with the client.

Instrument: PARS Scale

The PARS VI was the sixth version of the Personal Adjustment and

Role Skills Scale (see Appendix I) which was used to te s t the major

hypothesis and some minor hypothesis. The PARS Scale measured the 55

adjustment and role functioning of adult clients, as perceived by a

significant other (spouse, parent, close relative, or friend), in

mental health service evaluation. The Scale designed by Robert E. 14 Ellsworth for measuring the community adjustment of both psychiatric

clinical clients and hospital patients, was developed for use as a mail-

out questionnaire.

The areas measured by the Scale include: a) Interpersonal

Relations, b) Alienation, c) Anxiety, d) Confusion, e) Alcohol-Drug

Use, f) Household A ctivity, g) Child Relations, and h) Work. It

includes 31 items th at can be used for both men and women. The PARS

Scale has its lim itations discussed in Chapter I. One of the weakness

of the PARS Scale is the measure of perception of significant other

rather than the subject self-report. This weakness has been criticized

I C I C by King, Muraco and Vezner, and Weissman. Other major weakness in

using significant other in the PARS Scale is the potential for incom­

plete and hence unusable information. However, the PARS Scale is suited

to this research endeavor for following reasons. First, it has been

designed and administered as an instrument in measuring program effec­

tiveness in the psychiatric clinics and hospitals concerning community

adjustment.^ The PARS VI Scale is currently adopted by the North

Central Community Mental Health Center, Columbus, Ohio for program

evaluation. Second, the PARS Scale has been revised five times, th ere­

fore, it has well-tested internal consistency reliabilities (Coefficient

Alpha in the range of .83 to .92 as seen in Appendix J - Internal Con- 18 sistency Reliabilities for PARS Factors Scores) and validity. The

v alid ity of the PARS Scale has been estimated in two ways. PARS ratings 56 by relatives have been found to correlate with reworded self-rated PARS 19 20 21 for hospitalized patients by Ellsworth, Fontana, and Laferrierre.

A recent estimate of PARS Scale validity was made by comparing PARS ratings by significant others with self-ratings on the Profile of 22 Adaptation to Life (PAL). The correlations between PAL self-ratings and PARS ratings by others offer substantial evidence for the validity of the PARS Scale (as seen in Appendix J - Significant Correlations

Between Self and Other Ratings of Adjustment and Functioning).

Another estimate of PARS Scale validity is score sensitivity to change in pretest and posttest for people receiving mental health services. As can be seen in Appendix K - Pre- and Post-Treatment PARS

Scores, the t value tests found the pre-treatment and three-month follow-up significant changes in most of the symptomatic and personal adjustment areas. The reliability and validity of PARS Scale are also 23 recognized by King, Muraco and Vezner.

Instrument: Client'.s Evaluation Sheet The Evaluation Sheet (Appendix L) included 28 items. It included one item to measure recidivism. The sub-items included length and number of rehospitalizations during the six-month researh period.

Four items measured employment, i . e . , 1) length of employment;

2), income from employment; 3) who helped to get the employment; and

4) the reason for being unemployed. Two items measured the services utilization within the community. These included: 1) types of services used and 2) who helped to obtain those services. One item measured the kinds of problems encountered in the community. Seven items 57 measured the interpersonal relationships. These were: 1) general re­ lationship with the significant other and/or volunteer; 2) interper­ sonal relationships with the significant other and/or volunteer;

3) the person who was asked to aid the client; 4) amount of time spent with the volunteer; 5) the most important help from the volunteer; 6) termination of the relationship with the volunteer; and 7) whether staff had been helpful. The area of interpersonal relationship had ten sub-items with a four point scale. They were 24 derived and modified from the PARS Scale (Personal Adjustment and

Role Skills) and PAL Scale25 (Profile of Adaptation to Life). Total scores of these sub-items were used to measure the outcome of the interpersonal relationship. The first four items were basic informa­ tion. Six items measured group activity and the newsletter's help­ fulness. The last item asked for comments about the program.

These evaluative items assessed the program from the client's point of view. The Evaluation Sheet was used to test the major hypothesis and minor hypotheses.

Most of the items on the Evaluation Sheet were simple, single­ dimension questions. Therefore, the issue of reliability and validity were not crucial except the measurement of interpersonal relationship.

The Evaluation Sheet as a pilot survey instrument, had been pretested and revised before application. Thus, its strength in face validity comes from the use of personal interview and subject-self-report on internal states of interpersonal relations. 58

The program design focused on a comparison between the control

group and the experimental group by using some adjustment indicators (in

addition to the PARS Scale) including length of employment, length of

community residence, number of rehospitalizations, number of services

utilized, total number of helpers, total number of problems, sum of

relations with significant other, and sum of relations with volunteer.

These indicators were measured by the Client Evaluation Sheet, which was administered in the personal interview with the participants at the end

of the program.

The three indicators: number of services utilized, total number

of helpers, and total number of problems served as controlled variables

to identify any volunteer's significant impact on the experimental group for service access and problem-solving. The major hypothesis assumed th at the provision of volunteer relationship along with group activities may help the clients to resolve their problems and reduce their anxieties, leading, therefore,' to better personal adjustment. NOTES FOR CHAPTER II

1. “Volunteer Job Description," Mental Health Association of Frank­ lin County, 250 East Town S tre e t, Columbus, Ohio.

2. Ibid.

3. Ibid.

4. “Pave Training: A Summary," Mental Health Association of Frank­ lin County, 250 East Town S tre e t, Columbus, Ohio.

5. Ibid.

6. “Volunteer Rating Scale," Mental Health Association of Franklin County, 250 East Town S tre e t, Columbus, Ohio.

7. See c ita tio n 1.

8. Donald T. Campbell and Julian C. Stanley, Experimental and Quasi - Experimental Design for Research, Rand McNally and Company, Chicago, 1963.

9. Christopher J. Smith, "Recidivism and Community Adjustment Among Former Mental P atien ts," Social Science and Medicine, Vol. 12, Pergamon Press, 1978, p. 18.

TO. John E. Mayer and Aaron Rosenblatt, "The Recidivism of Mental Patients: A Review of Past Studies," American Journal of Ortho­ psychiatry, 44 (5), October 1974, p. 697.

11. John A. T albott, "Stopping the Revolving Door—A Study of Re­ admissions to a State Hospital," Psychiatric Quarterly, 48, 1974, pp. 159-168.

12. Christopher Smith, "Recidivism and Community Adjustment Among Former Mental P atien ts," Social Science and Medicine, Vol. 12, 1978, p. 18.

T3. H. Freeman and 0. Simmons, The Mental Patient Comes Home, John Wiley and Sons, New York, 1963.

14. Robert B. Ellsworth, "PARS Scale Measuring Personal Adjustment and Role S k ills ," 1979, I n s titu te for Program Evaluation, 124 Chapin, Ann Arbor, Michigan. 59 60

15. James A. King, William A. Muraco, Karl 0. Vezaer, Transitional Services: The Community Adjustment Experience, The Ohio Department of Mental Health, Columbus, Ohio 1981, p. 87.

16. Myrna M. Weissman, "The Assessment of Social Adjustment," Archives of General Psychiatry, 32, pp. 357-365, 1975.

17. Robert B. Ellsworth, "PARS Scale Manual," 1975, Institute for Program Evaluation, Ann Arbor, Michigan, p. 5.

18. See citatio n 14.

19. Robert B. Ellsworth, "Consumer Feedback in Measuring the Effectiveness of Mental Health Programs. In Guttentag and Struening (eds.) Handbook of Evaluation Research, (Vol. 2) Beverly Hills, CA: Sage Publications, 1975.

20. A. F. Fontana and B. N. Dowds, "Assessing Treatment Out­ come: I Adjustment in the Community," J Nervous and Mental Disease, 1975, 161, pp. 221-230.

21. L. LaFerriere, The Validity of a Self-report Instrument for Evaluating Mental Health Treatment Outcomes. Unpublished d is­ sertation, Ann Arbor, University of Michigan.

22. See citatio n 14.

23. See citatio n 15.

24. See c ita tio n 17.

25. Robert B. Ellsworth, "PAL (Profile of Adaptation to Life)," 1976, In stitu te for Program Evaluation, Ann Arbor, Michigan. CHAPTER III

POPULATION CHARACTERISTICS

This chapter reports characteristics of the sample, for both

intervening and dependent variables. It also describes any initial

differences between the clients in the experimental group and control

group. Nine demographic variables, three clinical variables and PARS

pretest scores were used to define the characteristics of the study

population, as well as the state of their adjustment and functioning

(PARS Scale) before the intervention. These variables were chosen to

test the initial background homogeneities between the experimental and

control groups. The variables included: age, sex, race, religion,

number of siblings, education, marital status, number of children,

previous occupation, diagnosis, number of previous psychiatric

hospitalizations and length of current hospitalization.

Chi-square and " t" -te s t were used to determine if any significant

differences existed between the experimental and control groups among

these variables.

Size of the Study Population

Due to a lack of volunteer availability, the hospital only referred a total of 60 subjects to Project PAVE. Five referred patients refused

to participate in the study. The rest of the 55 subjects were

randomly assigned to the control (28 subjects) and the experimental

(27 subjects) groups. Among these 55 subjects: two subjects (one 61 62 in each group) moved out of the area after the pretest; one subject

(experimental group) quit before the posttest; one significant other

(control group) was hospitalized and was, therefore, unable to rate the subject in the posttest; one significant other (control group) refused to rate the subject; and six subjects (three in each group) participated in the study, but were never discharged during the program period.

Thus, the study population was limited to those 44 qualified subjects

(22 subjects in each group).

Demographic C haracteristics

Table 1 presents a demographic profile of the study population.

The data presented were generated from the client's past and present hospital records, as well as, the first interview. The data indicate th at the sample population consisted primarily of adults ranging from

19 to 58 years, with the mean age being 34. The sample population was composed to 47.7% males and 52.3% females and was characteristized in racial composition as 7.0.5% white, 25.0% black, and 4.5% other. The religious preferences of the sample population were 34.1% Catholics,

50.0% Protestants, 2.3% Jewish, 2.3% other and 11.4% of the samples indicated no preference. There were 86.6% of the sample population who had siblings, with the mean number of siblings being 3.8.

In respect to education, 40.9% of the sample population did not complete high school education, 25.0% completed high school education,

31.8% had some college education and 2.3% completed their college education. The marital status of the sample population at the time of 63 Table 1

Demographic C haracteristics of the Study Population

Experimental GR Control GR Total GR Dimensions Number % Number % Number %

AGE 19 to 25 7 31.6 5 22.5 n 27.1 26 to 35 4 18.0 5 22.5 9 20.4 36 to 45 7 31.6 10 45.3 17 38.6 46 to 58 4 18.0 2 9.0 6 13.7

SEX Males 7 31.8 14 63.6 21 47.7 Females 15 68.2 8 36.4 23 52.3

RACE White 16 72.7 15 68.2 31 70.5 Black 6 27.3 5 22.7 11 25.0 Other 0 0.0 2 9.1 2 4.5

RELIGIOUS PREFERENCE Catholic 5 22.7 10 45.5 15 34.1 Protestant 13 59.1 9 40.9 22 50.0 Jewish 0 0.0 1 4.5 1 2.3 None 3 13.6 2 9.1 5 11.4 Other 1 4.5 0 0.0 1 2.3

NUMBER OF SIBLINGS 0 2 9.1 4 18.2 6 13.6 1 to 2 10 45.4 8 36.4 18 40.9 3 to 4 5 22.7 1 4.5 6 13.6 5 to 6 5 22.7 3 13.6 8 18.1 Above 6 0 0.0 6 27.2 6 13.6

EDUCATION Not Complete H.S. 10 45.5 8 36.4 18 40.9 H.S. Graduate 5 22.7 6 27.3 11 25.0 Some College 7 31.8 7 31.8 14 31.8 College Graduate 0 0.0 1 4.5 1 2.3 64 Table 1 Cont'd

Experimental GR Control GR Total GR Dimensions Number % Number % Number %

MARITAL STATUS Married 1 4.5 1 4.5 2 4.5 Divorced 627.3 4 18.2 10 22.7 Wi dowed 0 0.0 4 18.2 4 9.1 Separated 2 9.1 0 0.0 2 4.5 Never Married 13 59.1 13 59.1 26 59.1

NUMBER OF CHILDREN 0 12 54.5 15 68.2 27 61.4 1 2 9.1 2 9.1 4 9.1 2 4 18.2 2 9.1 6 13.6 3 3 13.6 2 9.1 5 11.4 5 1 4.5 1 4.5 2 4.5

PREVIOUS OCCUPATION Unskilled Laborer 313.6 5 22.7 8 18.2 Clerk 4 18.2 2 9.1 6 13.6. •• Nurses' aide 2 9.1 1 4.5 3 6.8 Secretary 3 13.6 2 9.1 5 11.4 Waitress 2 9.1 0 0.0 2 4.5 Student 0 0.0 1 4.5 1 2.3 None 2 9.1 4 18.2 6 13.6 Other 6 27.3 7 31.8 13 29.5

the in itia l interview were: 4.5% of the sample were married, 22.7% were divorced, 4.5% were separated and 59.1% were never married. 38.6% of the sample population had children, with a mean number of 2.4 children. In terms of previous occupation, all the participants were unskilled and non-professional. 65

Clinical Characteristics

Table 2 presents a clinical profile of the study population.

The data presented in Table 2 are generated from the c lie n ts ' past and present hospital records. The clinical profile includes three fac to rs.

In respect to diagnosis, the majority of participants in this study (79.5%) were diagnosed as schizophrenia-related, 13.6% had other psychoses, 4.5% were personality disorders, and 2.3% were diagnosed as other. The number of previous psychiatric hospitaliza­ tions among the sample population ranged from 0 to 12 with the mean being 4.2. The length of current hospitalization ranged from 1 to

99 weeks, with a mean of 12.2 weeks.

Background Homogeneities

Table 3 presents background homogeneities between the experi­ mental and control groups. As can be seen, there were only two significant differences (statistically) between the groups in terms of their background characteristics. The first signficant dif­ ference was sex distribution. The experimental group had more females (15) while the control group had more males (14) a t the .03 level. Using the Pearson Correlation, a further statistical examina­ tion of the relationship between the sex of the participants and their

PARS Scale pretest scores was performed. The sex factor had a significant positive correlation with one of the adjustment sub- scales-House Activity. Females scored higher than males in House

Activity at a significant level (p = .01). This finding indicates 66 Table 2

Clinical Characteristics of the Study Population

Experimental GR Control GR Total GR Dimensions Number % Number % Number %

Diagnosis

Schizophrenia 11 50.0 10 45.4 21 47.7 Schi zaphreni a Paranoid 0 0.0 5 22.7 5 11.4 Schizo-Affective 4 18.2 4 18.2 8 18.2 Schizophrenia- Residual 1 4.5 0 0.0 1 2.3 Other Psychosis 4 18.2 2 9.1 6 13.6 Personality Disorder 2 9.1 0 0.0 2 4.5 Other 0 0.0 1 4.5 1 2.3

imber of Hospitalizations

0 0 0.0 1* 4.5 1 2.3 1 2 9.1 2 9.1 4 9.1 2 7 31.8 4 18.2 11 25.0 3 3 13.6 5 22.7 8 18.2 4 1 4.5 3 13.6 4 9.1 5 3 13.6 1 4.5 4 9.1 6 2 9.1 1 4.5 3 6.8 7 2 9.1 1 4.5 3 6.8 8 to 12 2 9.1 4 18.2 6 13.6

ingth of Current H ospitalizati on (Weeks)

1 to 2 4 18.2 7 31.8 11 25.0 3 to 4 3 13.6 3 13.6 6 13.6 5 to 8 7 31.8 5 22.7 12 27.2 9 to 12 2 9.1 2 9.1 4 9.2 13 to 99 6 27.2 5 22.7 11 25.0

*The only non-recidivist subject in this study is due to the fact that this subject was a long term hospitalized patient and was referred by the primary therapist for volunteer match. Table 3

Background Homogeneities Between Experimental and Control Groups

Factors Exper. Group Control Group Jomputa- r tion t value Age: X 34.36 (N=22) 34.32 (N=22) U.U1 sd 11.78 9.55

Number of children: % 2.40 (N=10) 2.43 (N=7) 0.04 sd 1.17 1.39

Number of siblings: X 2.85 (N=20) 4.77 (N=18) 2.29* sd 1.56 3.24

Number of previous hospital­ ization: X 3.95 (N=22) 4.47 (N=21) 0.62 sd 2.38 3.11

Length of current h o sp ital­ ization: 51 12.91 (N=22) 11.55 (N=22) ' 0.25 sd 12.23 14.69 Chi Square Sex: Male 31.8% (N=7) 63.6% (N=14) 4.46* Female 68.2% (N=15) 36.4% (N=8)

Race: White 72.7% (N=16) 68.2% (N=15) 1.08 Non-White 27.3% (N=6) 31.8% (N=7)

Education: Not complete H.S. 45.5% (N=10) 36.4% (N=8) 0.98 H.S. graduate 22.7% (N=5) 27.3% (N=6) Post H.S. 31.8% (N=7) 36.4% (N=8)

Religious Preference: Catholic 27.8% (N=5) 52.6% (N=10) 2.36 Protestant 72.2% (N-13) 47.4% (N=9)

Marital Status: Once married 40.9% (N=9) 40.9% (N=9) 0.00 Never married 59.1% (N=13) 59.1% (N=13)

Previous Occupation: White co lla r 40.9% (N=9) 22.7% (N=5) 1.94 Blue collar 22.7% (N=5) 22.7% (N=5) Other 36.4% (N=8) 54.6% (N=12)

Diagnosis: Schizophrenia related 72.7% (N=16) 86.4% (N=19) 1.26 Non-schizophrenia related 27.3% (N=6) 13.6% (N=3)

* p < .05 that the sex factor should be controlled whenever the participants'

House Activity is analyzed. Another significant difference is the

number of siblings. The experimental group had a lower mean number

of siblings than the control group (p = .03). A further statistical

examination of the relationship between the number of siblings and

the participants' PARS Scale pretest scores was performed using the

Pearson Correlation. The number of siblings has a significant

positive correlation with one of the Adjustment Dimensions-Child

Relations (p = .01).

The experimental and control groups are similar in terms of

background items obtained except in sex and number of siblings.

Pretest Adjustment and Functioning Characteristics

The pretest assessments of subjects adjustments and functioning

provided by significant others were examined to check any significant differences between the participants in the control group and the experimental group. Eight areas of adjustment and functioning were

scored by the PARS Scale: Alienation, Depression, Anxiety, Confusion,

Alcohol-Drug Use, Close Relations, House Activity, Child Relations and

Employment. The f i r s t four areas were scored negatively which indicated

the higher scores, the poorer adjustment. Table 3 summarizes the PARS

Scale areas of adjustment and functioning between the participants of the control group and the experimental group. The "t" test values

indicated that there were no statistically significant difference

between these two groups. The control group had slightly higher ratings on Close Relations and Child Relations. The experimental group had 69

Table 4

P re te s t PARS Scores of Control Group and Experimental Group

P re te st Mean Scores Subscales Exper. G Control G "t" te s t 2-Tail (N = 22) (N = 22) prob.

Alientation-DepressionC-) 9.1 9.2 0.09 .92

Anxiety (-) 7.7 6.3 1.58 .12

Confusion (-) 9.2 7-7 1.53 .13

Alcohol-Drug-Use (-) 4.7 3.9 1.14 .26

Close Relations 10.5 11.3 0.94 .35

House A ctiv ity 8.4 7.9 0.51 .61

Child Relations 9.3 10.1 0.16 .87

Employment 7.5 7.0 0.28 .81

(-) The higher scores, the poorer adjustment in these subscales

NOTE: The number of House Activity is 21 for both groups. The number of Child Relations is 6 fo r experimental group and 8 for control group. The number of Employment is 2 for experimental group and 2 for control group. The subjects who didn't stay with children or had no employment were excluded from the analysis of the last two subscales.«

slightly higher ratings in Anxiety, Confusion, Alcohol-Drug Lise, House

A ctivity and Employment. Both groups had almost the same ratings on

A1ienation-Depression. In those four PARS subscales: Alienation-

Depression, Anxiety, Confusion and Alcohol-Drug Use, the higher scores

indicated the poorer adjustment in this study. It can be concluded that 70 there were no significant differences between the participants in the control group and the experimental group on PARS scores of adjustment and role functioning.

Summary

Nine demographic factors and three clinical factors of the 44 participants in th is study were examined in this chapter. Eight subscales of adjustment and functioning were also obtained and analyzed in the pretest. Based on the analyses performed, no signif­ icant difference existed between the experimental and control groups in regard to the selected measures except in the areas of sex and number of siblings. The random assignment used in this study, therefore, can be confirmed. Since there were significant relationships between Sex and House A ctivity, and between Number of Siblings and Child Relations, these two intervening variables were held constant in related data analyses reported in the subsequent discussion of findings. CHAPTER IV

FINDINGS AND CONCLUSIONS

Major Hypothesis Analysis

The major hypothesis is: there is a significant relationship be­ tween volunteer intervention and the successful community adjustment of chronically mentally-disabled clients. There were two approaches in the volunteer intervention model: the one-to-one volunteer relation­ ship and the group activity. Each approach was considered as an in­ dependent variable in order to measure its affect on the subject's community adjustment through the PARS Scale and other adjustment indicators. The "t"-test and analysis of covariance (if there were any significant differences) were applied to each approach. This chapter reports these findings according to the order of major and minor hypotheses testing.

Effectiveness of Volunteer/Client Relationship

Posttest - First, the PARS Scale areas of adjustment and function­ ing th at differen tiated the experimental group and the control group were examined, as seen in Table 5. The experimental group clients had poorer ratings on Close Relations, Alienation-Depression, Confusion,

House Activity, and Relation to Children than the control group.

Employment, however, was higher in the experimental group. None of the "t"-test mean differences were statistically significant. Thus,

71 72 Table 5

Posttest PARS Scores of Experimental and Control Groups

Exper. G. Control G. 2-Tail Subscales (N = 22) (N = 22) "t"-value Prob.

A1 ienation- Depression (-) 9. 7 8. 2 1.46 .15

Anxiety (-) 7.0 7.0 0.06 .95

Confusion (-) 9.5 8.0 1.65 .11

Alcohol-Drug Use (-) 4.5 4.5 0.06 .95

Close Relations 11.0 11.9 0.90 .37

House A ctivity 8.8 9.0 0.17 .87

Child Relations 11.0 13.1 0.91 .38

Employment 7.3 5.0 1.29 .24

(-) The higher scores, the poorer adjustment in these subscales.

NOTE: The number of Child Relations is 5 for experimental group and 7 for control group. The number for Employment is 6 for experimental group and 2 for control group. The subjects who didn't stay with children or had no employment were excluded from the analysis of the last two subscales.

* p < .05

there was no significant difference between the control group and the experimental group in regard to th eir p o sttest PARS Scale scores.

Pre- Posttest Changes - This study examined whether or not there were any differences in the kinds of pre- posttest changes that took place between the experimental group and the control group. This 73 was examined by the independent " t" -te s t between pretest and posttest mean scores within each group and the correlated " t" -te s t between pre­ te s t and posttest scores between the two groups. As can be seen in

Table 6, the only significant change in the pre- and posttest adjustment occurred in the area of House Activity in the control group (.02 level).

An Anova-analysis of covariance for comparing the experimental group and the control group in regard to the House Activity in the posttest PARS

Scale was performed with covariates and their joint effects as well as their interactions with the interventive variable (group belonging) were associated with the House A ctivity scores. As can be seen in Table 7, the sex covariate had a significant relationship (F = 5.43, p = .02) with House Activity. The number of siblings was also significantly related to House Activity also (F = 5.43, p = .02). Those participants with a higher number of siblings were perceived by significant others as having better house management skills than those who had fewer siblings.

Type of residence in the community also had a significant relationship

(F = 3.98, P = .05) with House Activity. The participants who lived in their own apartments/rooms were rated higher in House Activity than those living with their families or in group homes. These findings led to the conclusion that the control group with more males, a larger number of siblings, and more participants who stayed at their own apartments/rooms with th eir fam ilies were obliged to master house management s k ills a fte r they returned to the community. 74

Table 6

Pretest and Posttest Adjustment Means for Experimental and Control Groups

Experimental Group Control Group Subscales (N=22) (N=22) Pre Post t value Pre Post t value

Alienation-Depression (-) 9.1 9.7 0.92 9.2 8.2 1.31

Anxiety (-) 7.7 7.0 1.07 6.3 7.0 1.30

Confusion (-) 9.2 9.5 0.49 7.7 8.0 0.61

Alcohol-Drug Use (-) 4.7 4.5 1.74 3.9 4.5 1.30

Close Relations 10.5 11.0 0.66 11.3 11.9 0.95

House A ctivity 8.4 8.7 0.31 7.9 9.1 2.36*

Child Relations 10.4 11.0 0.47 11.0 12.7 0.93

Employment 7.5 8.5 1.00 8.00 6.00 —

(-) The higher scores, the poorer adjustment in these subscal es.

NOTE: The number of House A ctivity is 21 for both groups due to the missing data. The number of Child Relations is 5 for experi­ mental group and 6 for control group. The number for Employment is 2 for experimental group and 1 for control group. The subjects who d id n 't stay with children or had no employment were excluded from the analysis of the la s t two subscales.

*P < .05. 75 Table 7

Analysis of Covariance House A ctivity by Sample Group with Sex, Number of Siblings and Type of Residence

Significance Source of Variation SS DF MS F Level

Covariates 177.47 3 59.16 6.33 0.001 **

Sex 50.79 1 50.79 5.43 0.025*

No. of Siblings 50.73 50.73 5.43 0.025*

Type of Residence 37.21 1 37.21 3.98 0.053*

Main Effects 1.05 1 1.05 0.11 0.740

Sample Group 1.05 1 1.05 0.11 0.740

Explained 179.85 4 44.96 4.81 0.003**

Residual 345.76 37 9.34

Total 525.62 41 12.82

*p < .05 **p < .01

Other Adjustment Indicators - As can be seen in Table 8, there is

no sig n ifican t difference between the experimental group and control

group in regard to th eir community adjustment indicators obtained via

the Client-Evaluation Sheet (see Appendix L). The data trends appeared

to favor the experimental group. The problems encountered and the

services utilized by the clients after their discharge from the hospital were presented in the section of c lie n t feedback and Table 23. 76 Table 8

Other Adjustment Indicators for Experimental and Control Groups

Exper. Control Indicators Group Group 2-ta il (N=22) (N=22) "t" value Prob.

Length of Employment (weeks) 4.3 1.8 1.31 .19

Length of Community Residence (weeks) 14.3 13.8 0.25 .80

Number of Rehospitalizations 0.4 0.4 0.23 .82

Number of Services Utilizated 2.9 2.1 1.54 .13

Total Number of Helpers 1.4 1.3 0.52 .61

Total Number of Problems 1.6 1.3 0.71 .48

Sum of Relations with Significant Others 24.9 26.2 0.57 .57

Sum of Relations with Volunteers 27.0 — — —

NOTE: The mean is based on the calculation of subjects' self- report experiences during the program period according to Client Evaluation Sheet which may range from 0 to whatever the real number. Sums of Relations with significant others and volunteers are calcu­ lated from Interpersonal Relations subscale in Client Evaluation Sheet which is presented in Table 15. Effectiveness of Group Approach

This section examines the impact of the group activities (PAVE

Meetings) on the subject's community adjustment. There were 18 sub­ jects out of 22 (86.4%) who participated in the group activity.

According to participants' self-report, 7 participated rarely, 4 participated sometimes, 5 participated often, and 2 participated always.

PARS Posttest - The f i r s t PARS Scale scores were examined for the group activity participants and the group activity non-participants

(as seen in Table 9). Although the data favored the group participants in the areas of Alienation-Depression, Anxiety, Confusion, Alcohol-Drug

Use, and Employment there were no significant statistical differences between the PAVE Meeting participants and non-participants in regard to their PARS posttest subscale scores.

Pretest and Posttest Changes - The second examination consisted of the pretest and p o sttest changes of PARS Scale scores between the group activity participants and non-participants. As can be seen in Table 10, the group ac tiv ity participants did show slig h tly more improvement than the non-participants in the areas of Close Relations, Anxiety, Alcohol-

Drug Use and Employment at n o n -statistical difference level.

Other Adjustment Indicators - In regard to community adjustment indicators obtained via the Client Evaluation Sheet, this section examined significant differences between the group a c tiv ity participants and non-participants. As seen in Table 11, one significant difference is noted between these two groups. The group a c tiv ity participants 78 Table 9

Posttest PARS Scores of Group Activity Participants and Non-Participants

Acti vi ty Non- 2-Tail Subscales Participants Participants "t"-value Prob. (N = 18) (N = 26)

A1ienation- Depression (-) 8.3 9.8 1.46 0.15

Anxiety (-) 6.8 7.2 0.47 0.64

Confusion (-) 8.3 9.3 1.08 0.29

Alcohol-Drug Use (-) 4.3 4.7 0.43 0.67

Close Relations 11.3 11.6 0.27 0.78

House A ctivity 8.8 8.9 0.12 0.90

Child Relations 9.3 13.2 1.56 0.15

Employment 7.8 5.8 1.28 0.29

(-) The higher scores, the poorer adjustment in these subscales.

NOTE: The number of Child Relations is 3 for group participants and 9 for non-participants. The number for Employment is 4 for both groups. The subjects who did not stay with children or had no employment were excluded from the analysis of the la s t two subscales. Of 26 non-participants, 4 came from experimental group.

had a greater number of services utilized than the non-participants

(.05 level). Besides, the group activity participants had overall

higher ratings than non-participants in all the items except Number

of Rehospitalization. 79

Table 10

Pretest and Posttest Adjustment Means for Group Activity Participants and Non-Participants

Activity Participants Non-Participants Subscales (N=18) (N=26) Pre Post t value Pre Post t value

A!ienation-Depression (-) 9-4 9.8 0.65 8.3 9.0 1.01

Anxiety (-) 7.6 7.2 0.63 6.6 6.9 0.54

Confusion (-) 9.3 9.4 0.14 7.9 8.3 1.01

Alcohol-Drug Use (-) 4.9 4.7 1.37 3.9 4.4 1.08

Close Relations 10.3 11.3 1.4 11.3 11.6 0.38

House A ctivity 7.8 8.6 1.02 8.4 9.1 1.20

Child Relations 10.3 9.3 1.00 10.9 12.9 1.44

Employment 6.0 7.0 — 8.5 8.0 0.35

(-). The higher scores, the poorer adjustment in these subscales.

NOTE: The number for Child Relations is 3 for group participants and 8 for non-participants. The number for Employment is 1 for group participants and 2 for non-participants. The subjects who did not stay with children or had no employment were excluded from the analysis of the last two subscales. 80

Table 11

Other Adjustment Indicators for Group Activity Participants and Non-Participants

Group A ctivity Indicators Participants Non-Part. 2-Tail (N=18) (N=26) "t" value Prob.

Length of Employment (weeks) 4.2 2.3 0.95 .34

Length of Community Residence (weeks) 14.6 13.7 0.42 .67

Number of Rehospitalizations 0.4 0.4 0.49 .63

Number of Services Utilized 3.1 2.1 1.95 .05*

Total Number of Helpers 1.5 1.2 1.02 .31

Total Number of Problems 1.6 1.3 0.68 .50

Sum of Relations with Significant Others 25.7 25.4 0.14 .89

Sum of Relations with Volunteers 26.6 29.0 0.60 .55

NOTE: The mean is based on the calculation of subjects' self- report experiences during the program period according to Client Evaluation Sheet which may range from 0 to whatever the real number. Sums of Relations with significant others and Volunteers are calcu­ lated from Interpersonal Relations subscale in Client Evaluation Sheet which is presented in Table 15.

*P < .05. 81

The question arises as to whether the number of services utilized by the client, the greater number of helpers, and the more problems, when defined, can serve as indicators of better adjustment. One-way analysis of variance was performed comparing the PARS Scale and Client Evaluation

Sheet's ratings of c lie n t community adjustment with each v a ria b le 's subgroups. Testing outcomes can be seen in Appendix N (p. 190).

In terms of Number of Services utilized, there were five significant relationships between Number of Services Utilized and the areas of

Anxiety, Confusion, Close Relations, House Activity (PARS) and Total

Number of Helpers (Evaluation Sheet). The subgroup of higher services utilizers (five to seven services utilized) had a lower Anxiety and

Confusion ratings than the subgroup of lower service utilizers (one service utilized) at a .05 significant level. The group with a greater number of services utilized (five to seven) had a better performance in

Close Relations and House Activity than both groups of participants with one and none service utilized (.05 level). All seven subgroups service utilizers (range from one to seven services utilized) had a greater number of helpers than the group of non-service utilizers (.05 level).

Thus, there were significant relationships between number of services utilized and the PARS Scales of Confusion, Anxiety, Close Relations,

House Activity and Number of Helpers (Evaluation Sheet).

Regarding the Number of Helpers, the F statistic indicated four significant relations between Number of Helpers and the areas of

Alienation-Depression, Close Relations (PARS), Length of Employment and Number of Services Utilized (Evaluation Sheet). The subgroup with two helpers had a lower degree of Alienation-Depression than the 82 subgroup with only one helper (.05 level). The subgroup with two helpers had a higher rating in Close Relations than the subgroup with only one helper (.05 level). The subgroup with three helpers had a longer employment than the subgroups with one and none helper

(.05 level). Both subgroups with one and two helpers had greater number of services utilized than the subgroup with no helper (.05 level). The subgroup with two helpers had a greater number of ser­ vices utilized than the subgroup with only one helper. Thus, there were significant relationships between number of helpers and the areas of Alienation-Depression, Close Relations (PARS), and Length of

Employment and Number of Services Utilized (Evaluation Sheet).

In respect to Number of Problems, the F statistic indicated only one significant relationship with Length of Employment (Evaluation

Sheet). However, the number of subgroups involved was so small that the finding cannot be accepted. Thus, there was no significant re­ lationship between Number of Problems and clien t community adjustment.

In summary, the major hypothesis was not accepted although there was a significant relationship between the participation of group activity and number of services utilized. The group activity partic­ ipants had a greater number of services utilized than non-participants

(.05 level). However, there were no overall significant relationships between each approach and the su b ject's successful community adjustment. 83 The C lien t's Community Adjustment

and Personal C haracteristics

The first minor hypothesis is: there is a significant relation- •! V ship between the c lie n t's community adjustment and the c lie n t's per­ sonal and clinical c h a racteristics. A one-way analysis of variance is carried out to define any significant relationships. The selected personal characteristics have been discussed in Chapter III and presented in Table 1 and Table 2; the main purpose here is to indicate the results of the analysis.

Age and Community Adjustment

A one-way analysis of variance was performed examining any s ig n if i­ cant differences between age subgroups in terms of th e ir PARS Scale ratings of community adjustment. From this set of analysis and Table

12, there were no sig n ifican t differences in any area of community adjustment.

Sex and Community Adjustment

The " t" -te s t was performed and examined for any sig n ifican t d if­ ferences between males (21) and females (23) in ratings of th eir community adjustments by significant others. From this set of analysis and Table 12, there were two significant differences between the males and the females as measured by PARS Scale. Male participants had poorer adjustment (.05 level) than the female participants in the area of Anxiety. Male participants also had better adjustment (.05 level) than the female participants in the area of House Activity. The factors of sex, the number of siblings, and the type of community 84 residence were covariates of House Activity, as indicated in Table 7.

Thus, the sex of the clients appears to be an important adjustment factor in the areas of Anxiety and House Activity, but not for the overall adjustment.

Race and Community Adjustment

From this set of analysis and Table 12, there was one significant difference in the racial area shown in the subscale of Alcohol-Drug

Use (measured by PARS). The F statistic indicates that the white participants were less involved in Alcohol-Drug Use than the black participants at a statistically significant level (p < .05).

Religion and Community Adjustment

There was no significant difference (Table 12) in any areas of community adjustment in regard to d iffe re n t religious groups.

Education and Community Adjustment

From this set of analysis and Table 12, there was no significant difference shown in any area of community adjustment. Although the educational subgroups tended to have differences in the role skill areas of House Activity (at .06) and Child Relations (at .07), they did not meet the criteria.

Marital Status and Community Adjustment

From this set of analysis and Table 12, there were three signif­ icant differences in the areas of Confusion, Alcohol-Drug Use and Length of Community Residence associated with marital status. On each of these areas, the F statistic varied at the .05 level. In the PARS subscale of Alcohol-Drug Use, the group of divorced participants had a better 85 rating than the group of separated participants (p < .05). In the

PARS Subscale of Confusion and Length of Community Residence, the F computation also indicated that the group of widowed participants had better ratings than the group of separated participants (p < .05).

The validity of the above findings may be questioned because of the small number in the categories of the separated (n = 2) and the widowed (n = 4). Thus, marital status is not considered to be an important factor in community adjustment.

Number of Children and Community Adjustment

From this set of analyses and Table 12, there was a significant difference in the area of total number of problems between the group of participants who had three children and the groups of participants who had two children. The group participants who had three children had a larger number of problems (2.8) after they returned to the community, as compared to the group of participants who had two children (1.0), and those who had five children (0). This occurred at a significant level of difference (p < .05). However, because of the small number of participants in these three groups, it is hard to accept this finding.

Number of Siblings and Community Adjustment

From this set of analyses and Table 12, there was a significant difference in the area of Confusion (PARS) between the group of p a rtic ­ ipants who had more than six siblings and the group of participants who had no siblings. The group of participants who had more than six siblings had less Confusion (PARS) than the group of participants who had no siblings (p = .02). 86

Previous Occupations and Community Adjustment

From this set of analysis and Table 12, there was no significant differences shown in any of the areas of community adjustment and different previous occupations. Thus, the participants' previous occupation is not an important factor in community adjustment.

Diagnosis and Community Adjustment

According to this set of analyses and Table 12, there were two sig n ifican t differences in the areas of length of employment and total number of helpers. The F statistic indicates that the group of participants with the diagnosis of Personality Disorder had a greater number of helpers- than the other four groups of participants with diagnosis as Schizophrenia Chronic Undifferentiated Type (CUT),

Schizophrenia Paranoid, Schizo-Affective, and other Psychoses (.05 level). The F statistic also indicates that the group of participants with Other Psychosis had a longer employment than those above four groups of participants (.05). The validity of these findings were questionable because of the small numbers in the groups of Personality

Disorder and Other Psychosis. Thus, it is hard to recommend this factor as important to community adjustment in this study.

Number of Psychiatric Hospitalizations and Community Adjustment

From this set of analyses and Table 12, the F statistic indicates that the group of participants with 7 to 12 prior psychiatric hospitalizations had a better performance (lower scores) in Anxiety 87 adjustment than the group of participants with three to four prior psychiatric hospitalizations (p < .05).

Length of Current Hospitalization and Community Adjustment

There were no significant differences (Table 12) in any of the areas of community adjustment in regard to different lengths of cur­ rent hospitalization groups. Thus, length of current hospitalization was not a significant factor of community adjustment in this sample.

Types of Residence and Community Adjustment

After having been discharged from the hospital, half of the partic- pants (50%) stayed in group homes, one-third of the participants (31.8%) stayed in th e ir own apartments or rooms, and one-fifth of the p a rtic ­ ipants (18.2%) stayed with th e ir fam ilies. The one-way analysis of variance was performed, comparing any significant differences among these various types of community residences.

Test outcomes can be seen in Table 12. There was one significant difference shown in the area of Alienation-Depression. The group of participants who stayed with their families had a better adjustment in the area of Alienation-Depression than the group of participants who stayed in group homes at a statistically significant level of dif­ ference (p < .05). Thus, the factor of type of community residence is significantly associated with client community adjustment in the area of Alienation-Depression. 88

Table 12 Analysis of Variance for the Clients' Community Adjustment and Adjustment-related Factors (N a 44)

Factors' F Ratio

Areas of a> Sex Sex (“t" value) Race Religion Education ofNumber Children Marital Status Siblings Number ofNumber Previous Current Current Hosp. Residence Occupations Prior Hosp. Length of Type Type of Number ofNumber

Adjustment [Diagnosis Alienation- Depression {-) 1.00 0.30 1.05 1.39 0.31 1.76 0.14 1.01 0.64 0.89 1.16 0.37 3.41* Anxiety (-) 1.98 2.11* 0.07 1.71 0.20 1.19 0.75 2.41 1.12 1.58 4.70 0.39 0.61 Confusion (-) 1.76 0.45 2.64 0.01 0.73 3.13* 0.45 3.05* 0.50 1.29 1.62 0.11 2.33 Alcohol-Orug Use (-) 1.13 0.24 4.44* 0.36 0.70 2.27* 0.48 1.15 1.16 0.78 0.23 0.58 0.93 Close Relations 1.53 0.40 0.06 0.85 0.31 1.58 0.36 0.70 0.60 1.17 0.97 0.67 0.26 House A ctivity 1.13 2.53* 0.36 2,. 55 0.14 0.48 1.00 2.46 1.02 0.55 0.23 0.23 2.39 Child Relations 2.97 0.29 0.29 3.45 3.55 1.07 1.97 0.67 0.25 0.81 0.59 0.62 3.23 Employment 0.05 0.58 3.37 0.71 0.46 0.04 1.45 0.38 1.25 0.38 0.37 1.27 0.27 Length of Employment 0.63 0.26 0.32 1.25 0.71 0.39 0.45 0.87 1.16 3.83* 4.60* 0.31 0.89 Length of Com. Residence 0.15 1.19 0.27 0.38 0.10 2.45* 0.19 1.02' 0.66 2.01 1.09 2.36 1.91 Number of Rehospital. 0.82 0.97 0.22 1.88 0.78 0.50 0.40 0.14 1.81 1.27 1.37 1.05 0.21 Number of Service Util. 0.64 1.28 0.50 0.96 0.54 0.35 0.53 0.98 0.47 1.34 0.62 0.19 1.42 Total number of helpers 0.42 1.48 0.62 0.86 0.73 1.21 0.45 1.29 0.55 3.92* 0.45 0.38 1.52 Total number of problems 0.18 1.33 0.32 0.42 0.64 1.36 3.51* 2.14 0.56 1.28 1.29 1.01 0.64 Sum of Rel. with Sig. oth 0.81 0.26 0.31 1.33 0.08 0.42 0.68 1.32 1.15 1.09 1.20 0.19 2.27 Sum of Rel. with Volunt. 0.24 1.85 0.33 2.06 0.61 0.22 0.96 1.19 2.33 0.96 0.44 1.31 0.03

(-) The higher scores, the poorer adjustment in these subscales.

NOTE: The number for Child Relations is 12. The number for Employment is 3. The subjects who d id n 't stay with children or had no employment were excluded from the analysis in that subscales. The number for Sum of Relations with volunteer is 22. *P < .05 **p < .01 89

In summary, the first minor hypothesis was partially accepted since there were eight variables which had significant relationships with key areas of community adjustment. These significant rela tio n ­ ships can be summarized as follows:

1. The factor of sex was associated with Anxiety and House Activity

(PARS).

2. Race factor was associated with Alcohol-Drug Use (PARS).

3. The factor of marital status was associated with Confusion,

Alcohol-Drug Use and Length of Community Residence.

4. The factor of number of children was associated with the number of problems.

5. The factor of number of siblings was associated with Confusion.

6. Diagnosis factor had significant associations with length of employment and number of helpers.

7. The factor of number of previous psychiatric hospitalization had significant associations with Anxiety.

8. The factor of types of residence was associated with

A1ienation-Depression.

However, the validity of findings in the factors of marital status, number of children and diagnosis were questionable due to the small number of samples. The C lien t's Community Adjustment

and Volunteer Relationship

The second minor hypothesis is: there is a signficiant relation­ ship between the c lie n t's community adjustment and the c lie n t's per­ ceptions of his relationship with his volunteer. Pearson Correlation was carried out to examine any sig n ifican t relationships. The data were generated by the Client's Evaluation Sheet through the personal interview with the client at the end of the program.

Table 13 shows significant correlations between the client's interpersonal relations with volunteers and other community adjustment indicators measured by the Client Evaluation Sheet. From the angle of interpersonal relations between the c lie n t with the volunteer and clien t community adjustment the most significant correlations were the items of "Sum of Relations with Volunteer," the item of "Volunteer has been

Helpful" and the item of "Volunteer has Respected You." All of these three items had three positive sigificant correlations (.05 level) with the factors of Number of Services, Number of Helpers and Sum of Rela­ tions with Significant Other. It indicated that the better relations the client perceived with his volunteer, the greater number of services utilized, the greater number of helpers and better relations with significant other that the clien t had.

It also indicated that the more the volunteer had been helpful, and the more the volunteer had respected the client, the greater the number of services utilized, the greater number of helpers, and the better the relationship with his significant other, and visa versa. 91 The item of "Agreed with Volunteer" had two positive significant

correlations (.05 level) with the factors of Number of Services Utilized

and Number of Helpers. It indicated that the more the client had agreed

with his volunteer, the greater the number of services utilized and

the greater number of helpers the client had, and visa versa.

The item of "Felt Close to Volunteer" had three positive signifi­

cant correlations (.05 level) with the factors of Length of Employ­

ment, Number of Problems and Sum of Relations with Significant Other.

These correlations indicate th at three relationships between c lie n t and

volunteer existed. They are: The closer the client felt to the

volunteer, the longer his employment. The closer the c lie n t f e lt to

the volunteer, the greater the number of problems that were defined by

the client. The closer the client felt to the volunteer, the better the

relationship with his significant other.

The item of "Talked With Volunteer" had one significant correlation

(.05 level) with the factor of Number of Services. This correlation

indicates th at the more the clien t had communicated with his volunteer,

the greater the number of services that were utilized by the client.

The data also indicate that the more the client respected his

volunteer, the better the relation with the significant other.

There was a significant correlation between the item of "Relationship with Volunteer" and the factor of Length of Employment (p = .02).

There were no significant correlations between the re st of the

items and the seven factors of community adjustment (Client Evaluation

Sheet). Table 13 Correlation Coefficients Between the Clients' Community Adjustment and Interpersonal Relationship with Volunteer (N - 22)

length of Number of Total Total • Total Sum of Conanuni ty Rehospital­ Length Number of Number of Number of Relations Residence ization Employment Services Helpers Problems with Sig. Other

Relation with 0.20 -0.02 0.3B 0.26 0.19 0.23 0.07 Volunteer p=0.1B p=0.46 *p=0.03 p=0.12 p=0.18 p=0.14 p=0.36

Talked with 0.22 -0.04 0.19 0.40 0.27 0.28 0.25 Volunteer p-0.15 p=0.34 p=0.18 *p=0.03 p=0.10 p=0.09 p=0.12

Enjoyed witli 0.03 -0.16 0.28 -0.06 0.06 0.20 0.01 Volunteer p=0.44 p=0.23 p=0.09 p=0.39 p=0.38 p=o.ia p=0.48

Uiscussed with 0.07 -0.32 0.24 0.29 0.31 0.13 0.32 Volunteer p=0.37 p=0.06 p=0.13 p=0.09 p=0.07 p=0.28 p=0.06

Felt Close to 0.03 -0.03 0.37 0.22 0.21 0.35 0.35 Volunteer p-0.44 p=0.43 *p=0.04 p=0.15 p=0.16 *p=0.05 *p=0.05

Solving Problem -0.05 -0.17 0.22 0.31 0.33 0.11 0.31 with Volunteer p=0.40 p=0.21 p=0.15 p=0.08 p=0.06 p=0.30 p=0.07

Agreed with 0.20 0.15 0.20 0.53 0.45 0.27 0.24 Volunteer p-0.09 p=0.25 p=0.09 **p=0.005 **p=0.01 p=0.10 p=0.13

VolunLeer 0.10 -0.05 0.19 0.36 0.35 0.02 0.49 Respected You p=0.32 p=0.39 p=0.19 *p=0.04 *p=0.05 p=0.44 **p=o.oi

You Respected 0.10 -0.29 0.20 0.26 0.11 -0.18 0.45 Volunteer p=0.32 p=0.09 p=0.18 p=0.11 p=0.31 p=0.20 **p=0.01

Volunteer iias 0.21 -0.02 0.13 0.45 0.40 0.11 0.40 been Helpful p=0.17 p=0.45 p=0.26 **p=0.01 *p=0.03 p=0.03 *p=0.03

Been Helpful 0.26 -0.05 0.22 0.22 0.30 -0.00 0.12 to Volunteer p=0.U p=0.39 p-tl.15 p=0.15 p=0.08 p=0.48 p=0.29

Son of Relations 0.17 -0.14 0.33 0.42 0.40 0.19 0.40 with Volunteer l»=0.21 p-0.25 p=0.06 *p=0.02 *p=0.03 p=0.19 *p=0.03

*p < .05 ** p < .01 93

When analyzing factors of community adjustment (Client Evaluation

Shee) the most sig n ifican t correlations occurred in the areas of Number

of Services Utilized, and Sum of Relations with Significant Others.

These two factors had five significant correlations (.05 level) with items of client's interpersonal relationship with his volunteer

(Table 14). The factor of Number of Helpers also had four significant correlations (.05 level) with items of.Interpersonal Relationship with the Volunteer.

Thus, the second minor hypothesis was p a rtia lly accepted.

The C lien t's Community Adjustment

and Significant Other Relationship

The third minor hypothesis is: there is a significant relation­

ship between .the c lie n t's community adjustment and the c lie n t's perception of his relationship with his significant other. The data analysis here are based on 44 subjects.

When analyzing the interpersonal relationship (perceived by the clien t) between the c lie n t and his significant other; the most sig n if­ icant correlations between interpersonal relationship with s ig n ifi­ cant other and client community adjustment (rated by the significant other) was the item of "You have Respected Significant Other." This item had five significant correlations (.05 level) with the PARS

Scales of Anxiety, Confusion, Alcohol-Drug Use, House Activity, and

Child Relations. The correlations in the areas of Anxiety, Confusion, and Alcohol-Drug Use, and indicates that the more symptoms the client had developed (which was perceived by the sig n ifican t other) the more the client had respected his significant other (client's perception), and visa versa. These three correlations also revealed th at there was a relationship of dependency and expectation between the c lie n t and his significant other. The correlations in the areas of House

Activity and Child Relations indicate that the more the client had respected his significant other, the better performance the client had in the areas of House Activity and Child Relations and visa versa. The item of "Agreed with Significant Other" had four sig n if­ icant correlations (.05 level) among eight areas of PARS Scale.

These significant correlations included two negative significant correlations in the areas of Anxiety and Confusion, and two positive correlations in the areas of House Activity and Child Relations. The two negative significant correlations in the areas of Anxiety and Con­ fusion, indicate that the more symptoms the client had developed, the more the client agreed with his significant other and visa versa. The two positive correlations in the areas of House Activity and Child

Relations also indicate that the more the client agreed with his significant other, the better adjustment the client had in the areas of House Activity and Child Relations, and visa versa.

In addition, the item of "Significant Other has Respected You" had three significant correlations at the .05 level within the areas of Confusion, House Activity, and Child Relations (PARS). Both items of "Solving Problems with Significant Other" and "Sum of Relations with Significant Other" had three significant correlations (.05 level) with the areas of Anxiety, House Activity, and Child Relations. The item of "Discuss with Significant Other" had three significant cor­ relations (.05 level) with the PARS Subscale of Anxiety, Close Relations and House A ctivity. The item of "Significant Other has been Helpful" also had three significant correlations (.05 level) with the PARS

Subscales of Anxiety, Confusion, and Child Relations. It indicated that the more symptoms the client demonstrated in the areas of Anxiety and Confusion, the more helpful the significant other had been. It also indicated that the more the significant other had been helpful, the better adjustment the client had with the children.

The item of "You have been Helpful to Significant Other" had two significant correlations (.05 level) with the PARS Scales of Alienation-

Depression and Child Relations. This correlation indicates that the more the client had been helpful to the significant other, the better adjustment the client had with the children. However, it needs further study to explore the significant correlation between client's

Alienation-Depression and "You have been Helpful to Significant Other."

The item of "Enjoyed with Significant Other" had two positive significant correlations (.05 level) with the PARS Scale of Alcohol-Drug

Use and Child Relations. The correlation between Alcohol-Drug Use and

"Enjoyed with Significant Other" indicates that the more the client enjoyed his time with his significant other, the more the client re­ leased his Alcohol-Drug Use background to his significant other. The second correlation between Child Relations and "Enjoyed with S ig n ifi­ cant Other" indicates the more the client enjoyed his time with his significant other, the better the adjustment with the children. 96

Both items of "Relations with Significant Other" and "Talk with

Significant Other" had a significant correlation (.05 level) with the area of Child Relations. The two correlations indicate that the better the relationship perceived by the client with his significant other, and the more he talked with his significant other (perceived by the client), the better the adjustment the client had with children (perceived by the significant other). There was no signifi­ cant correlation between the area of Employment and items of inter­ personal relationship with significant other.

From the angle of PARS areas, the most significant correlations between interpersonal relationships with sig n ifican t other and c lie n t community adjustment were positive correlations in the PARS Scales of

Child Relations, House Activity (Role skills), negative correlations in the PARS Scales of Anxiety and Confusion (adjustment).

Based on the analysis of those significant statistical correla­ tions mentioned above, there were sig n ifican t correlationships between the client's community adjustment and client's interpersonal relation­ ship with his significant other, although not at an overall level.

All of the following seven items: "You have Respected Significant

Other," "Agreed with Significant Other," "Significant Other had

Respected You," "Significant Other had been Helpful," "Solving Problems with Significant Other," "Discussed with Significant Other" and "Sum of Relations with Significant Other" had significant correlations with both client's symptom areas and role skills.

In other words, the clients were highly dependent on and associ­ ated with significant others while clients had symptoms of anxiety and Table 14 Correlation Coefficients Between the Clients' Community Adjustment and Interpersonal Relationship with Significant Other (N = 44)

Alienation- Anxiety Confusion Alcohol- Close House Child Depression (-) (-)(-) Drug Use (-) Relations Activity Relations Employmer

Relations with 0.15 0.22 0.14 -0.15 0.13 0.17 0.57 0.48 Sig. Other p=0.15 p=0.01 p=0.16 p=0.16 p=0.49 p=0.13 *p=0.02 p=0.11

Talked with 0.05 -0.03 -0.01 -0.11 -0.04 0.04 0.54 -0.09 Sig. Other p=0.36 p=0.41 p=0.45 p=0.23 p=0.38 p=0.38 *p=0.03 p=0.41

Enjoy with 0.08 0.01 -0.15 -0.24 0.07 0.04 0.52 0.48 Sig. Other p=0.28 p=0.45 p-0.16 *p=0.05 p=0.30 p=0.39 p=0.04 p=0.11

Discussed with 0.18 0.29 0.19 -0.17 0.26 0.37 0.36 0.05 Sig. Otfter p=0.11 *p=0.02 p=0.10 p=0.13 *p=0.04 **p=0.006 p=0.12 p=0.44

Felt Close 0.09 0.07 -0.02 -0.28 0.11 0.17 0.42 0.36 To Sig. Other p=0.26 p=0.31 p=0.42 *p=0.03 p=0.23 p=0.13 p=0.08 p=0.18

Solving Problem 0.15 0.25 0.19 -0.16 0.11 0.24 0.56 -0. !4 with Sig. Other p=0.15 *p=0.04 p=0.10 p=0.14 p=0.23 *p=0.05 *p=0.02 p=0.36

Agreed with 0.19 0.29 0.26 -0.04 0.23 0.31 0.53 0.17 Sig. Other p=0.10 *p=0.02 *p=0.04 p=0.38 p=0.06 *p=0.02 *p=0.03 p=0.34

Sig. Other 0.00 0.17 0.24 -0.08 0.12 0.37 0.59 -0.06 Respected You p=0.49 p=0.12 *p=0.05 p=0.30 p=0.21 **p=0.006 *p=0.02 p=0.43

You Respected 0.23 0.32 0.31 -0.29 0.05 0.39 0.61 0.32 Sign Other p=0.06 *p=0.01 **p=0.01 *p=0.02 p=0.30 **p=0.005 **p=0.01 p=0.21

Sig. Other Has 0.13 0.26 0.25 -0.17 0.06 0.13 0.48 -0.42 been Helpful P=0.19 *p=0.04 *p=0.04 p=0.12 p=0.34 p=0.19 *p=0.05 p=0.14

Been Helpful 0.26 0.21 0.18 -0.08 0.05 0.04 0.64 0.08 to Sig. Other *p=0.04 p=0.07 p=0.11 p=0.28 p=0.37 p=0.38 **p=0.01 p=0.42

Sum of Relations 0.18 0.25 0.19 -0.22 0.14 0.28 0.66 0.10 with Sig. Other p-0.10 *p=0.05 p=0.10 p=0.06 p=0.16 *p=0.03 **p=0.009 p=0.40 (-) The higher scores, the poorer adjustment in those subjects. NOTE: The number for Child Relations is 12. The number for Employment is 8. The subjects who did not stay with children or have no employment were excluded from the analysis in that subscale. p < .05 .01 98 confusion rather than alienation-depression. Also, while clients were rated by the significance others with high scores in the areas of House

Activity and Child Relations, they gave a higher rating on interpersonal relationships with significant other.

The lack of overall sig n ifican t correlations between the area of

Close Relations and interpersonal relations was due to the different perceptions of interpersonal relationship between the c lie n t and his significant other. That was while the client rated a higher interper­ sonal relationship with his significant other, the significant other did not rate the client's Close Relations highly. There was only a significant correlation between the item of "Discussed with Significant

Other" and the PARS Scale of "Close Relationship." The significant correlation indicated a consistency between the perceptions of sig n if­ icant others and the client regarding their relations.

Thus, the third minor hypothesis was partially accepted.

Client Comparisons of Interpersonal Relationships

with the Significant Other and the Volunteer

The fourth minor hypothesis in this research is: there is a significant relationship between the client and volunteer interper­ sonal relationship and the client/significant other interpersonal relationship. The independent "t"-test was carried out to examine the Hypothesis. The data were generated by the Client's Evaluation

Sheet through the personal interview with the clients at the end of the program. 99

In order to determine the significant relationship, the inter­ personal relationship between the clients and their significant others, as well as, the interpersonal relationship between the clients and their volunteers in the experimental group were measured and compared. Since the significant other was selected by the client as a person who both knows him best and is closest to him, the interpersonal relationship between the client and his significant other was classified, by the client, as an important social relationship. Therefore, if the in terpersonal relationship between the clien t and his volunteer was found to be equal, or even better than the interpersonal relationship between the client and his significant other; then, it is safe to conclude that the volunteer provided an important interpersonal relationship with the client even though a statistically significant level was not represented.

The independent " t" -te s t between the clien t ratings of the in te r­ personal relations with his significant other and the interpersonal relations with his volunteer was performed, examining any significant differences between these two relationships. As can be seen in Table

15, there was only a sig n ifican t difference (.05 level) between "Vol­ unteer has Respected You" and "Significant Other has Respected You."

The 22 participants in the experimental group, perceived that their volunteers respected them more than their significant others did

(p < .05).

Overall, the average ratings for the relations with volunteers were higher than the relations with significant others, except that one item "Felt Close to Volunteer or Significant Other" was rated 100

Table 15

Client Comparison of Interpersonal Relationships with the Volunteer and the Significant Other (N=22)

Items of 2-Tail Relations Volunteer Sig. Other "t" value Prob.

Relationship with Volunteer or Sig. Other 3.3 3.1 0.68 .50

Talked with Volunteer or Sig. Other 2.5 2.1 1.05 .30

Enjoyed with Volunteer Sig. Other 2.7 2.5 0.46 .65

Discussed with Volunteer or Sig. Other 2.2 2.0 0.70 .49

Felt close to Volunteer or Sig. Other 2.7 2.7 0.00 1.00

Solving problem with Volunteer or Sig. Other 2.1 1.8 0.88 .38

Agreed with Volunteer or Sig. Other 2.3 2.2 0.44 .66

Volunteer or Sig. Other respected you 3.6 3.1 2.34 .02*

You respected Volunteer or Sig. Other 3.5 3.1 1.90 .07

Volunteer or Sig. Other has been helpful 3.0 2.7 1.58 .12

Been helpful to Volunteer or Sig. Other 2.0 2.2 0.50 .62

Sum of relations with Volunteer or Sig. Other 27.0 24.9 1.22 .23

*P < .05. 101

statistically the same and one item ("Being Helpful to Volunteer or

Significant Other"), was rated higher for the significant other.

Therefore, the volunteers provided an important interpersonal relation­

ship to the clients. However, the minor hypothesis was not accepted,

since only one significant difference was found out of 12 items, in

favor of the volunteers over the significant others.

Client's Community Adjustment

and Volunteer Factors

The fifth minor hypothesis in this research is that there is a

significant relationship between the volunteer's personal character­

istics and the ratings of the client's community adjustment. The volunteer's personal characteristics, such as; age, sex, education, and motivation to be a volunteer were selected as intervening variables.

Such analyses were carried out by the one-way analysis of variance and the Chi-square for examining any significant difference between these four variables and the ratings of the client's community adjust­ ment.

Client's Community Adjustment and Volunteer Age

The question examined here was whether the age of the volunteer was related to his effectiveness in helping the client. The ages of the 22 volunteers ranged from 26 to 66 years old with the mean being

41. They were older than their clien ts whose mean age was 34.

The ages of the volunteers were classified into three groups for analysis. These three groups were: 1) 26 to 35 (N = 7), 2) 36 to 45 102

(n = 8), 3) 46 to 66 (N = 7). A one-way analysis of variance was performed comparing the ratings of client community adjustment among the three volunteer age groups. From this set of analyses, there was no significant difference with respect to these three groups, as can be seen in Table 16.

Client's Community Adjustment and Volunteers1 Sex

The traditional question of whether or not females are more effec­ tive human service providers than males was examined here. Among those

22 volunteers, there were five (5) males (22.7%) and 17 females (77.3%).

A "t"-test was performed examining any significant differences between the male and female volunteers in the area of community adjustment. As can be seen in Table 17, there was no significant difference between the male and female volunteers in clients' community adjustment.

Client's Community Adjustment and Volunteers' Education

The issue here was whether those volunteers with high levels or those with low levels of education were associated with better client community adjustment. Among the 22 volunteers, there was one

(1) volunteer (4.5%) who did not complete high school education, six

(6) (27.3%) who completed th eir high school education, six (6) (23.7%) who had some college education, and nine (40.9%) who were college graduates. Compared to their matched clients, whose education levels consisted of 10 (45.4%) who did not complete high school education, 103

Table 16 A nalysis o f Variance fo r th e C lie n ts ' Community Adjustment and Volunteer Age Groups (N=22)

Subscales F Ratio F Prob.

Alienation-Depression (-) 0.12 .88 Anxiety (-) 0.19 .82 Confusion (-) 0.81 .45 Alcohol-Drug Use (-) 0.71 .50 Close Relations 0.94 .40 House Activity 0.003 .99 Child Relations 0.10 .90 Employment 1.23 .40 Length of Employment 0.83 .45 Length of Community Residence 1.17 .33 Number of Rehospitalizations 0.34 .72 Number of Services Utilized 0.86 .53 Total Number of Helpers 0.56 .57 Total Number of Problems 0.98 .39 Sum of Relations with Significant Others 0.11 .89 Sum of Relations with Volunteer 0.29 .74

(-) The higher scores, the poorer adjustment in these subscales.

NOTE: The number for Child Relations is 5. The number for Employment is 6. The subjects who didn't stay with children or had no employment were excluded from the analysis of these two subscales. The means for other community adjustment indicators are based on the calculation of subjects self-report experiences during the program period according to Client Evaluation Sheet which may range from 0 to whatever the real number. Sums of Relations with significant others and volunteers are calculated from Interpersonal Relations subscales in Client Evaluation Sheet which is presented in Table 15. 104 Table 17 The C lients' Community Adjustment and Volunteer Sex

Male Female 2-Tail Subscales (N=5) (N=17) "t" value Prob.

Alienation-Depression (-) 12.2 9.7 1.59 .12 Anxiety (-) 7.8 8.0 0.19 .85 Confusion (-) 10.8 10.3 0.26 .79 Alcohol-Drug Use (-) 9.2 10.8 1.23 .20 Close Relations 12.6 10.5 1.15 .26 House Activity 9.0 8.7 0.16 .87 Child Relations 12.0 10.7 0.33 .76 Employment 7.5 7.2 0.11 .91 Length of Employment 7.0 3.5 0.86 .34 Length of Community Residence 14.0 14.5 0.13 .89 Number of Rehospitalizations 0.0 0.53 1.45 .16 Number of Services Utilized 3.0 2.9 0.12 .91 Total Number of Helpers 1.6 1.4 0.45 .65 Total Number of Problems 1.4 1.7 0.32 .76 Sum of Relations with Significant Others 27.4 24.2 0.82 .42 Sum of Relations with Volunteer 26.2 27.2 0.29 .77

(-) The higher scores, the poorer adjustment in these subscales.

NOTE: The number for Child Relations is 5. The number for Employment is 6. The subjects who didn't stay with children or had no employment were excluded from the analysis of these two subscales. The means for other community adjustment indicators' are based on the calculation of subjects' self-report experiences during the program period according to Client Evaluation Sheet which may range from 0 to whatever the real number. Sums of Relations with significant others and volunteers are calculated from Interpersonal Relations subscales in Client Evaluation Sheet which is presented in Table 15. 105

five (22.8%) who completed high school education, seven (31.8%) who

had some college education, and none who were college graduates, the

volunteers had a higher education.

A one-way analysis of variance was performed comparing the clien t

community adjustment among these three volunteer groups (one volunteer

who did not complete high school was combined into high-school category).

From this set of analyses and Table 18 findings indicate that no

sig n ifican t difference between those three groups was found.

Client Community Adjustment and Volunteers1 Motivation

A question arises as to whether those volunteers motivated

by self-interest or those interested in helping others were more effective. During the volunteer application process, the volunteer was asked the open-ended question, "Why did you join Project PAVE?"

in addition to questions about personal characteristics. According to the answers provided, the researcher classified them into three categories. The first group consisted of the persons who basically were looking for self-growth, such as; "to learn knowledge and s k ills

in mental health"; "to know more about mental illness and how to work with them"; "to learn more about the problems encountered by hospit­ alized people"; etc. Six (27%) were classified in this group. The

second group consisted of the persons who basically wanted to help,

such as; "I enjoy working with people in the mental health institution";

"want to help hospitalized people"; etc. Thirteen (60%) were c la s s i­ fied in this group. The third group consisted of the persons who had 106

Table 18 Analysis o f Variance fo r the C lie n ts ' Community Adjustment and Volunteer Educational Groups (N=22)

Subscales F Ratio F Prob.

Alienation-Depression (-) 0.62 .54 Anxiety (-) 0.01 .98 Confusion (-) 0.96 .39 Alcohol-Drug Use (-) 0.86 .43 Close Relations 2.10 .14 House A ctivity 0.11 .89 Child Relations 4.12 .13 Employment 0.33 .59 Length of Employment 1.29 .30 Length of Community Residence 0.64 .53 Number of Rehospitalizations 0.68 .57 Number of Services Utilized 0.002 .99 Total Number of Helpers 0.08 .91 Total Number of Problems 1.23 .32 Sum of Relations with Significant Others 1.61 .22 Sum of Relations with Volunteer 1.34 .28

(-) The higher scores, the poorer adjustment in these subscales.

NOTE: The number for Child Relations is 5. The number for Employment is 6. The subjects who didn't stay with children or had no employment were excluded from the analysis of these two subscales. The means for other community adjustment indicators are based on the calculation of subjects' self-report experiences during the program period according to Client Evaluation Sheet which may range from 0 to whatever the real number. Sums of Relations with significant others and volunteers are calculated from Interpersonal Relations subscales in Client Evaluation Sheet which is presented in Table 15. 107 multiple answers such as; "I want to learn more about mental health and how I can be of help to them"; "I want to learn more about mental illn e ss and how to help people with mental illn ess. . .to get employ­ ment in some mental health area." Three (14%) were classified in this group. Therefore, basically the volunteers (74%) wanted to help the mental patients. Even when the primary motivation was learning or gaining experiences for employment, the motivation of helping people was associated.

A one-way analysis of variance was performed, comparing the clien t community adjustment among the three volunteer groups. As can be seen in Table 19, there was a significant difference in this set of analyses.

The group of volunteers with multi-answers had clients with a greater number of rehospitalizations than the group of volunteers with motiva­ tion of help other (.05 level). This finding was not accepted due to the small number of samples.

The C lien t's Community Adjustment and

Group Activities Participation

The sixth minor hypothesis in this research is that there is a significant relationship between the client's community adjustment and the frequency of the client's participation in group activities.

A one-way analysis of variance was performed comparing the d if­ ferences of frequency of group activity participation and the client's community adjustment, as can be seen in Table 20. Twenty-two subjects of the experimental group in this study were classified into three groups according to their frequencies of group participation for 108

Table 19 A nalysis o f Variance fo r the C lie n ts ' Community Adjustment and Volunteer Motivation Groups (N=22)

Subscales F Ratio F Prob.

Alienation-Depression (-) 0.27 .74 Anxiety (-) 1.55 .23 Confusion (-) 0.29 .74 Alcohol-Drug Use (-) 0.71 .50 Close Relations 0.23 .79 House A ctivity 3.03 .07 Child Relations 0.45 .68 Employment 2.33 .20 Length of Employment 0.25 .77 Length of Community Residence 0.71 .50 Number of Rehospitalizations 3.44 .05* Number of Services Utilized 1.47 .25 Total Number of Helpers • 1.38 .27 Total Number of Problems 1.77 .19 Sum of Relations with Significant Others 0.43 .65 Sum of Relations with Volunteer 0.37 .69

(-) The higher scores, the poorer adjustment in these subscales.

NOTE: The number for Child Relations is 5. The number for Employment is 6. The subjects who didn't stay with children or had no employment were excluded from the analysis of these two subscales. The means for other community adjustment indicators are based on the calculation of subjects' self-report experiences during the program period according to Client Evaluation Sheet which may range from 0 to whatever the real number. Sums of Relations with significant others and volunteers are calculated from Interpersonal Relations subscales in Client Evaluation Sheet which is presented in Table 15.

*P < .05. 109 analysis. These three groups were: 1) non-group a c tiv ity participants

(4), 2) low frequency participants (11) included seven "rarely" partic­ ipants and four "sometimes" participants, and 3) high frequency partic­ ipants (7) including five "often" participants and two "always" participants.

From this set of analysis, there were four PARS Scales (Anxiety,

Confusion, Close Relations, and Employment) had significant differences with respect to the subgroups of participation frequency. The group of

"high frequency participants" had a better adjustment in both subscales

Anxiety (.05 level) and Confusion (.01 level) than the group of "low frequency participants." The group of "high frequency participants" had a better adjustment in the area of Close Relations than the group of "low frequency participants" (.01 level). Both groups of "high and low frequency participants" had a better performance in the area of

Employment than the group of "non-participants" (.03 level).

Thus, the sixth minor hypothesis was partially accepted. Among the areas examined, there were four subscales (Anxiety, Confusion,

Close Relations, and Employment) that had significant relationships with the frequency of the client’s participation in group activities.

As can be seen in Table 21, the c lie n t's participation in the group a c tiv itie s was presented. During the program period, the average number of participants in the PAVE meetings was eight with the participation rate being 36.6%. 110

Table 20 Analysis of Variance for Experimental Subjects' Adjustments and Frequency of Group Activity Participation (N=22)

Subscales 1I F Ratio F Prob.

Alienation-Depression (-) 2.31 .12 Anxiety (-) 4.43 .02* Confusion (-) 8.88 .001** Alcohol-Drug Use (1) 0.82 .45 Close Relations 6.22 .008** House Activity 1.48 .25 Child Relations 0.10 .76 Employment 13.87 .03* Length of Employment 0.91 .42 Length of Community Residence 2.53 .90 Number of Rehospitalizations 0.13 .87 Number of Services Utilized 1.01 .38 Total Number of Helpers 0.83 .45 Total Number of Problems 1.03 .37 Sum of Relations with Significant Others 0.02 .97 Sum of Relations with Volunteer 0.48 .62

(-) The higher scores, the poorer adjustment in these subscales.

NOTE: The number for Child Relations is 5. The number for Employment is 6. The subjects who didn't stay with children or had no employment were excluded from the analysis of these two subscales. The means for other community adjustment indicators are based on the calculation of subjects' self-report experiences during the program period according to Client Evaluation Sheet which may range from 0 to whatever the real number. Sums of Relations with significant others and volunteers are calculated from Interpersonal Relations subscales in Client Evaluation Sheet which is presented in Table 15.

*P < .05, **P <.01. The C lien t's Community Adjustment and

Volunteer's Attendance in Group Activities

The seventh minor hypothesis in this research is that there is a sig n ifican t relationship between the c lie n t's community adjustment and the frequency of the volunteer's attendance in the group activities.

The volunteers' participation in the PAVE meetings is presented in Table 22. A one-way analysis of variance was performed comparing the differences of frequency of the volunteer's attendance in the group activity and the 18 group activity participants' adjustment. From this set of analyses, two sig n ifican t differences were found as can be seen in Table 22. The group of participants who were "always" attended by their volunteers had a better adjustment in the area of Anxiety (PARS) than the group of participants who were "sometimes" attended by their volunteers, at the .03 level of significance. Both groups of participants who were "always" and "often" attended by their volun­ teers showed a better adjustment in the area of Confusion (.01 level).

This statistic counters the level of confusion by the group of partic­ ipants who were "sometimes" attended by their volunteers.

Thus, the seventh minor hypothesis was partially accepted. Among the areas examined, there were two areas of adjustment—Anxiety and

Confusion—that had a significant relationship with the frequency of the volunteer's attendance in the group activities. Table 21

Participants' and Volunteers' Attendance in PAVE Meetings

Date 1980 1981

10/8 10/27 11/17 11/24 12/22 1/14 1/26 2/18 2/25 3/3 3/23 Attendance Average

Participants 10 9 13 11 8 '4 5 12 11 2 3 8

Volunteer 5 10 3 5 5 3 - 1 1 2 4 3.5

Sources: ACTION-Sponsor Quarterly Program Report, Jan. 10, 1981; April 10, 1981, by Ellen Colom Deacon, Mental Health Association of Franklin County, 250 E. Town S treet, Columbus, Ohio 43215 113 Table 22 Analysis of Variance for the Participants' Adjustment and Frequency of Volunteer Attendance in Group Activity (N=18)

Subscales F Ratio F Prob.

Alienation-Depression (-) 0.35 .79 Anxiety (-) 3.90 .03* Confusion (-) 4.82 .01** Alcohol-Drug Use (-) 0.45 .72 Close Relations 0.68 .57 House A ctivity 2.68 .07 Child Relations —— Employment 0.25 . 66 Length of Employment 0.23 .86 Length of Community Residence 0.99 .43 Number of Rehospitalizations 2.10 .15 Number of Services Utilized 0.51 .69 Total Number of Helpers 0.77 .53 Total Number of Problems 0.72 .55 Sum of Relations with Significant Others 1.47 .26 Sum of Relations with Volunteer 0.32 .80

(-) The higher scores, the poorer adjustment in these subscales.

NOTE: The number for Child Relations is 3. The number for Employment is 4. The subjects who didn't stay with children or had no employment were excluded from the analysis of these two subscales. The means for other community adjustment indicators are based on the calculation of subjects' self-report experiences during the program period according to Client Evaluation Sheet which may range from 0 to whatever the real number. Sums of Relations with significant others and volunteers are calculated from Interpersonal Relations subscales in Client Evaluation Sheet which is presented in Table 15.

*P < .05, **P < .01. Client Feedback

The final phase of data analysis in this research was the presenta­ tion of the c lie n ts' feedback on the program operation. I t included the clients' opinions about the amount of time spent with the volunteer, most important help received from the volunteer, termination of their relationship, further comment, and an examination of relations between the service utilization of a Community Mental Health Center (CMHC) and the client's community adjustment.

Time Enough

In response to personal interview, 75 percent (16) of the 21 clients (oneirefused to give a response) in the experimental group responded favorably to the time spent with the volunteer. The times ranged from one and one-half to four hours per week. The other twenty- five percent (5) responded that the time spent with the volunteer was not sufficient. However, the dissatisfied clients indicated they wish to spend only one and one-half to three hours per week with their volunteers.

A "t"-test was performed, examining any significant differences between the above-mentioned two groups in regard to th e ir community adjustment. Although the data tended to favor the group members who responded favorably to the time spent with the volunteer in most of the areas examined, only one significant difference was found.

Those who responded favorably to the time spent with their volunteers had a better adjustment in the subscale of Confusion (PARS) than those 115 dissatisfied clients (.01 level). Thus, the importance of the length of time: the volunteer spent with the client in helping the clients' community adjustment is open for further testin g .

The PAVE program required the volunteer to commit four to six hours per week and/or 20 hours per month. According to the data col­ lected, 86.4% (19) of the volunteers did not meet the time requirement.

Most Important Help from the Volunteer

All of the 22 participants in the experimental group were asked

"What is the most important help th at you received from your volunteer friend?" The answers were classified into two categories as affective resources or instrumental resources. Eighteen participants (81.8%) answered that the most important help was affective; such as, being a friend, listener, and source of support when frustrated. Four partic­ ipants (18.2%) answered th at the most important help was instrumental; such as, clothes, finding an apartment, finding a job, etc. This finding indicates that the volunteer impact was more on motivational and affective levels rather than instrumental or direct service levels.

However, no sig n ifican t differences were found between the most im­ portant help offered to the client and the clients' community adjustment.

Earlier Termination

At the end of the program, all 22 participants were asked whether or not the relationship with the volunteer was terminated during the program. Eight participants (36.4%) responded that their relationship had been terminated; th at is, they did not see each other any more, nor did they contact each other for any apparent reason during the 116 program period. In regard to the termination of the participants three answered that the volunteers terminated, and four answered that they d id n 't know why the volunteers d id n 't see them anymore. One p a rtic ­ ipant indicated that he had terminated.

Problems Encountered and Services Utilization

As can be seen in Table 23, the problems encountered by the

(N = 44) after their discharge from the hospital were basically the same for both the experimental and control groups. About two-thirds of the clients utilized the CMHC services, and one-third utilized BVR and

SSI services. The data were self-evident (as can be seen in Table 23) and was not discussed in detail.

Further examination of who helped the clients utilize the service, found th at of 21 service u tiliz e rs (47.7%) who were helped by th eir therapeutic agency; one (3%) was helped by a friend; one (3%) was helped by the significant other; three (6.8%) were helped by themselves;

14 (31.8%) did not utilize any service, and four (9.1%) did not answer this question. None of the participants mentioned that the volunteer helped them to utilize the services.

CMHC U tilization and Community Adjustment

The fact that about one-third of 44 clients (31.8%) did not contact and u tiliz e a Community Mental Health Center (CMHC) a fter they were discharged from the hospital, leads to the concern of examining the relationship between CMHC u tiliz a tio n and the c lie n ts' community ad­ justment. The testing outcomes, as shown in Table 24, indicate that the clients who utilized a CMHC, had better ratings among eight out 117 Table 23

Problems Encountered and Services U tilization

Experimental G Control G Total G Dimensions Number % Number % Number % (N = 22) (N = 22) (N = 44)

Problems Encountered

Housing 5 22.7 1 4.5 6 13.6

Transportation 1 4.5 3 13.6 4 9.1

Lack of friendship 3 13.6 1 4.5 4 9.1

Job hunting 6 27.3 6 27.3 12 27.3

Other problems 10 45.5 11 50.0 21 47.7

Services Utilized

CMHC 15 68.2 15 68.2 30 68.2

Rehab, service (BVR) 8 36.4 4 22.7 13 . 29.5

Food stamp 3 13.6 2 9.1 5 11.4

Employment 2 9.1 2 9.1 4 9.1

Housing 1 4.5 1 4.5 2 4.5

Medi care 5 22.7 2 9.1 7 15.9

Medicaid 6 27.3 3 13.6 9 20.5

S.S.I. 6 27.3 9 40.9 15 34.1

Welfare 0 0.0 1 4.5 1 2.3

Transportation 3 13.6 0 0.0 3 6.8

Other 13 59.1 5 22.7 18 40.9 118

Table 24

Community Adjustment Scores of CMHC Utilizers and N on-utiliziers

CMHC CMHC Subscales U tilizers Non-Util. 2-Tail (N=30) (N=14) "t" value Prob.

Alienation-Depression (-) 8.1 10.7 2.58 .01** Anxiety (-) 6.4 8.3 2.65 .01** Confusion (-) 7.8 10.9 3.31 .002** Alcohol-Drug Use (-) 4.2 5.2 1.23 .23 Close Relations 12.5 9.2 3.49 .001** House A ctivity 9.8 6.9 2.70 .01** Child Relations 12.6 11.5 0.44 .66 Employment 6.0 8.0 1.22 .26 Length of Employment 2.2 4.9 1.34 .18 Length of Community Residence 15.5 11.1 2.23 .03* Number of Rehospitalizations 0.4 0.4 0.29 .77 Number of Services Utilized 3.3 0.8 5.95 .00** Total Number of Helpers 1.6 0.8 3.23 .00** Total Number of Problems 1.7 1.0 1.66 .10 Sum of Relations with Significant Others 26.4 23.9 1.02 .32 Sum of Relations with Volunteer 28.3 24.4 1.18 .25

(-) The higher scores, the poorer adjustment in these subscales.

NOTE: The number for Child Relations is 12. The number for Employment is 8. The subjects who didn't stay with children or had no employment were excluded from the analysis o f these two subscales. The means for other community adjustment indicators are based on the cal­ culation of subjects' self-report experiences during the program period according to Client Evaluation Sheet which may range from 0 to whatever the real number. Sums of Relations with significant others and volunteers are calculated from Interpersonal Relations subscales in Client Evaluation Sheet which is presented in Table 15.

*P < .05, **P < .01. 119

16 community adjustment factors than the non-CMHC utilizers at a

significant level (.05). These significant differences included

Alientation-Depression, Anxiety, Confusion, Close Relations, House

Activity, Length of Community Residence, Number of Services Utilized,

and Number of Helpers. The CMHC utilizers had overall better per­

formance except in the area of Employment. Therefore, the variable

of CMHC utilization did have a significant relationship with the

clients' community adjustment.

There were six clien ts (three from each group) who were never

released during the study period. The informal conversation by the

researcher regarding why they were never discharged indicated that they did not intend to be discharged. They were either afraid of the

stressful lif e in the community, or sa tisfie d with the lif e in the

h o sp ital.

Summary

The major hypothesis was not accepted. Overall, there was no

significant relationship between each approach of volunteer inter­

vention and the successful community adjustment of the clients.

However, there was a significant relationship between the group activ­

ity participation and number of services utilized. The group activity

participants had a greater number of services utilized than the non­

participants (.05 level). Further testing, did find that the number

of services utilized had significant relationships with areas of

Anxiety, Confusion, Close Relations, House Activity (PARS) and Number

of Helpers. 120

The findings of minor hypotheses testing can be summarized as accepted, doubtful and not accepted by the following:

Accepted Hypotheses

1. There were fiv e factors which had significant relationships associated with major areas of the client's community adjustment

(PARS): Sex, race, number of siblings, number of previous hospitaliza­ tions and type of residence.

2. There were eight items of the client's perceptions of his relationship with his volunteer which had significant correlations with factors of the client's community adjustment measured by the

Evaluation Sheet. These items included: "Sum of Relations with

Volunteers," "Volunteer has Respected You," "Volunteer has been

Helpful," "You Felt Close to Volunteer," "You Agreed with Volunteer,"

"You Talked with Volunteer," "You Respected Volunteer, "Relationship with Volunteer."

3. There were 12 items of the client's perceptions of his relationship with his significant other which had significant cor­ relations with major areas of the client's community adjustment

(PARS). These 12 items included all items (see Table 14) in the

Interpersonal Relationship Scale measured by the Evaluation Sheet.

4. The clients perceived that their volunteers respected them more than their significant other did.

5. The volunteers provided an important interpersonal relation­ ship with the clients since ten out of 12 items of interpersonal 121 relationship with the volunteer were rated by the clients as better and stronger than the interpersonal relationship with the significant other.

6. There were four sig n ifican t relationships between the frequency of the client's group activities participation and the client's community adjustment (four PARS Scales: Anxiety, Confusion,

Close Relations, and Employment).

7. There were two sig n ifican t relationships between the fre ­ quency of the volunteer's attendance in the group activities and the c lie n t's community adjustment (two PARS Scales: Anxiety and

Confusion).

Doubtful Findings

There were three factors which because of the small sample size had doubtful significant relationships associated with major areas of the c lie n t's community adjustment.

These factors were marital statu s, number of children and diagnosis.

Rejected Hypotheses

There were five factors which did not have significant rela tio n ­ ship associated with the client's community adjustment. These factors included age, religious preference, education, previous occupation and length of current hospitalization. There was no overall significant relationship between the client's personal characteristics and the client's community adjustment. 122

2. There were four items of the client's perceptions of his relationships with his volunteer which did not have significant cor­ relatio n with facto rs of the c lie n t's community adjustment measured by the Evaluation Sheet. These items included: "Enjoyed with

Volunteer," "Discussed with Volunteer," "Solving Problem with

Volunteer," and "Been Helpful to Volunteer." There was no overall significant relationship between the client's perceptions of his relatio n sh ip with his volunteer and the c lie n t's community adjustment.

3. There were no overall significant relationships between the client's perception of his relationship with his significant other and the c lie n t's community adjustment.

4. There were no overall sig n ific a n t relatio n sh ip s between the client and volunteer interpersonal relations and the client and significant other interpersonal relations.

5. There were no significant relationships between the volunteer's personal c h a ra c te ristic s and the c lie n t's community adjustment.

6. There were no overall significant relationships between the frequency of the client's group activity participation and the c li e n t's community adjustment.

7. There were no overall significant relationships between the frequency of the volunteer's attendance in the group activities and the c lie n t's community adjustment.

The amount of time that the client expected the volunteer to spend with him ranged from one and one-half hours to four hours per week. Thus, four hours per week can be an acceptable point for vounteers to follow. Most of the clients (81.8%) considered that the most important help received from their volunteers was that of emotional support. More than one-third of clients (36.4%) had their relationships terminated with th e ir volunteers during the program. Roughly, one- third (31.8%) of the participants (both in the experimental and control groups) did not utilize the community mental health center services while the variable of CMHC utilization was found having eight significant relationships with the client's community adjustment. CHAPTER V

IMPLICATIONS

This study evaluated the effectiveness of the volunteer inter­ vention of Project PAVE through the testing of major and minor

hypotheses. Although the major hypothesis was not accepted, other findings of this study provided certain levels of understanding about the applicability of the volunteer in this area of mental health.

Based on the analysis in Chapter IV, the implications of the findings are discussed below.

Volunteer Intervention and Community Adjustment

Is Volunteer Intervention Effective?

A rejection of the major hypothesis, in this study would lead one to question the effectiveness of volunteer intervention.

In the first part of the discussion, the focus will be centered on identifying whether the lack of significant relationships between the volunteer intervention and the client's community adjustment really means that the volunteer's intervention is not an effective approach

in helping the chronically mentally-disabled person to have a success­ ful community placement. The conclusion summarized in Chapter IV may

be interpreted as the absence of significant impact, overall, from the program which may come from such sources as lack of high p a rtic ­

ipation rate in group activity, lack of adequate time (not enough),

124 125 efforts (too little in providing instrumental resources), and inadequate termination of client from the volunteer. Besides, there was a sig n ifican t change of program operation and performance from the original design due to budget cuts at national/state levels; and certain volunteer responsibilities, especially the advocate role, were not fully carried out.

The major issues are the volunteer recruitment, training and management. Since only a small number of volunteers were available for

Project PAVE, there was really no basis for volunteer selection.

Although there were ten modules of volunteer training, the ongoing inservice volunteer supervision was really weak and short which in­ fluenced the performance of volunteer intervention. On the other hand, it may suggest that volunteer intervention was unable to make signif­ icant impact on client's community adjustment either due to chronic nature of disease or volunteer's competence of intervention.

It is recommended that the major hypothesis be kept open for further testing because of the following facts: the clients who had a high frequency of participation in group activities did have a better adjustment in certain areas than those low frequency p articip an ts; there was a sig n ifican t relationship between the group activity participation and number of services utilized. Duration of Intervention

The second concern is whether the six-month volunteer intervention was long enough to make a significant impact on the client's community adjustment. Ellworth's study (1978) indicated that with three-month's intervention, both clinic clients and hospital patients had significant changes in all the areas of the PARS Scale except the area of employ­ ment.1 However, the intervention was carried out by professional s ta ff. Whether six-month's intervention is long enough to make significant changes by the volunteer is still kept open for further test­ ing. One of the weaknesses in this research is that the intervention occurred while the client was still in the hospital and was counted six months from the match of the volunteers and the c lie n t. However, these clients were discharged at different dates. This resulted in various lengths of community residence among the clients. Since the discharge date is unpredictable, it is better to start the study right after the discharge. In this way, the clients will receive the same duration of intervention in community placement.

Volunteer Intervention and Readmission

One of the goals of volunteer intervention was to prevent re­ admission. There were no significant differences in number of rehosp­ ita liz a tio n s between the experimental and control groups. The re­ admission rate was 31.8% in both groups. When compared to Anthony's

Report, noted in Chapter I: ". . .in the first six months after 2 discharge, the readmission rate was 30 percent to 50 percent"; then, the rate in this study was relatively low for the same period. 127

But when compared to the Cincinnati Study (Chapter I) which indicated 3 a recidivism rate of 11 percent at the end of one year, then the rate in this study was obviously higher within a shorter duration.

The volunteer tasks in the Cincinnati study included: checking that the patients kept appointments and took medications as prescribed; evaluating critical mental health signs; lending evironmental assist­ ance; and giving supportive counseling (as mentioned in Chapter I).

However, the focus of the PAVE program was more on volunteer/client re­ lations. The intended team approach of psychiatrist, therapists, and volunteer was beyond the control of Project PAVE. There was no com­ munication and coordination. In terms of program design, the program did not provide the volunteer for team coordination. Therefore, the volunteer had difficulty in helping his client to keep appointments and take medication, as prescribed. The difficulties arose because the volunteers were not provided the necessary information by the team.

For example, about one-third of the clients did not keep any clinical appointments and medication with CMHC. Obviously, there was a gap between the volunteer job description and what the volunteer did undertake. The client's perception of the volunteer task in this study was that of providing emotional support. None of the clients mentioned that the volunteer helped them to utilize the community services. 128

Volunteer Intervention and Employment

As noted in Chapter I, Grob expressed that "work is a necessary element in the assimilation of ex-mental patients into normal comr 4 munity." Based on his research, he commented th at "many of the vocational difficulties of former patients resulted. . .from the ex­ patients' difficulties in interpersonal relations and other factors, such as, a phobic a ttitu d e toward work, fear of fa ilu re , u n realistic job interviews, projection of self-rejection to authority figures, and over sensitivity to disappointment or inadequacy." In this study, 29 c lie n ts indicated th at they were not employed during the program period.

Of these 29 clients, 18 (62.1%) indicated that they did not try to look for a job at all. Nine (31.0%) indicated that they looked forward to work, but couldn't find the means, and two (6.9%) indicated th at they rarely looked forward to work.

Thus, a t least two-thirds of the unemployed clien ts did not have the motivation to look for a job. Compared to Anthony's study (1972), which showed th at 30 percent to 50 percent of the patients were employed six months a fte r release, the employment rate in th is study (34.1% within six months) was about the same.

The lack of significant differences between the experimental and control groups, and between the group participants and non­ participants regarding to employment, indicated that volunteer in te r­ vention did not have significant impact on the c lie n t's employment.

The findings were that an important issue does exist; that is, "how to motivate and help the c lie n t to gain employment." Volunteer - Patient Relationship

The collected data indicated that the PAVE volunteers played more of a friendship role than an advocate role, through providing more affective resources as opposed to instrumental resources. If compared to the Cincinnati study/ the tasks involving PAVE volunteers were too limited. The Cincinnati volunteer therapists were trained and super­ vised in work as advocates and therapists. Their tasks included: checking that patients kept appointments and took medications as pre­ scribed; evaluating patients for decompensation; lending environmental assistance; such as, helping patients to look for housing and jobs; and giving supportive counseling. Since there were significant dif­ ferences between the CMHC service u tiliz e rs and n o n -utilizers in the key areas of the client's community adjustment, it is important to help all clients contact and utilize the CMHC services. The volunteers emphasis on providing the instrumental resources; such as, helping clients keep contact with CMHC, looking for job, housing, etc., appears, therefore, to be very important. This issue can be resolved by revising the volunteer job description, providing volunteer skill training, and applying the helping contract (see Appendix M). The helping contract can be made in the first meeting among the volunteer and the client, and the client's therapist. The volunteer defines the friendship role as sharing and supporting the client's feelings, and the advocate role as helping to plan and obtain necessary services and medical treatment and appointments. The client may express his expecta tions and specific needs and promise his willingness to share any prob­ lems or negative feelings which may cause rehospitalization. In this 130 way, both the volunteer and the c lie n t work together as a team in solving the problem (instrumental level), rather than, only talking about feelings or companionship (affective level).

As reported by Talbott (noted in Chapter I) "84% of the readmis­ sions examined could have been prevented i f there were improvements in existing out-patient services and new or augmented services and Q facilities." The volunteer was used as a linkage with chronically, mentally-disabled persons in order to facilitate the client's success­ ful re-en try into the community upon his discharge. This linkage was designed to aid in the prevention of the 84 percent readmission of former clients by: 1) involving the staff, client, the client's signifi­ cant other, and related community agencies in the discharge plan and and follow-up services; and 2) educating and discussing in group meetings, the patient's medication program between the patient and his family and particularly, the significant other. The finding of the volunteer's weakness in providing the instrumental resources in this study seemed to support the perspective of Talbott.

Based on T a lb o tt's Report and the Cincinnati Study, th is researcher will define the volunteer's roles and tasks. The following tasks are recommended as guidelines for the volunteer in the mental health field :

1) To discuss needs, problems, hopes, and ways to solve problems or make achievements.

2) To provide friendship and emotional support by sharing happiness and b ittern e ss.

3) To help to keep c lin ic appointments with a community mental health center. 131 4) To remind the c lie n t to take medications, as prescribed.

5) To help the client look for housing and jobs.

6) To help the client access the necessary and helpful community services.

7) To bridge communication among the client, the therapeutic staff (agency), family (particularly the significant other), and related community agencies.

The C lien t's Community Adjustment

and Personal C haracteristics

As noted in Chapter I, many studies have searched (and some found)

predicators of rehospitalization and indicators of community adjustment.

In this study, eight out of the 13 of the client's personal and

clin ical ch aracteristics examined had significant relationships in

certain subscales of community adjustment. Age, education, religion,

previous occupations, and length of current hospitalization have no relationship with community adjustment.

Male clients showed higher PARS Scores than the female clients

in Anxiety and House Activity. The individual and societal role expectations for the males have apparently caused more pressures and anxieties among the males who were trying to adapt to a new way of

life (community liv in g ). In addition, the males who lived in th eir own apartments were obliged to develop and improve th e ir s k ills in housekeeping and house management. This is a new finding because no

significant relationship between the factor of sex and community ad­ justment exists in any literature review.

The white participants were less involved with Alcohol-Drug Use

.than the black participants. If compared to the Munley and Hyes' Study wherein, "the race variable is a predictor of readmission within 3 132 g months of discharge," this study did not confirm their finding regard­

less of the size of the samples.

The factors of marital status and the number of children are

not accepted as significant factors of community adjustment, due to

the small sizes of the subgroups. These factors are, therefore, kept

open for further examination.

Those participants with more than six siblings showed less Con­

fusion than those with no siblings. Although this is only one area

of adjustment, it is hypothesized that the existence of several sibl­

ings, prepared the clients to develop new relationships to accept

support and criticism from others. However, no general conclusions

can be drawn from th is isolated indicator. The relationship of the

number of siblings and the client's community adjustment is, therefore,

kept open for further study.

Those with more than seven prior psychiatric hospitalizations had

less Anxiety (PARS) than those with three to four hospitalizations.

When compared to Rosenblatt and Mayer's review of studies, in the area of "one variable (the number of previous admission) consistently predicting the rehospitalization of mental patients,"^0 this study did not confirm their finding. On the other hand, this study finds that the more often that a patient has been admitted to a mental hospital, the more lik e ly he is to have less anxiety in the community.

Rosenblatt and Mayer's study had also concluded that "... modern day hospitals offered a wide range of amenities: palatable food; pleasant living quarters and surroundings; sports, recreation, and entertainment; opportunities to interact and socialize with members of the hospital community, etc. For many patients, the hospital, when compared with their home environment, holds greater promise of ful­ filling their needs.This study seems to agree with their con­ clusion. About one-tenth (six out of 55) of the participants were never discharged during the program period. Informal conversations with these clients by the researcher suggest that either they were afraid of the stressful life in the community or satisfied with the life of the hospital and, therefore, did not intend to be discharged. In such cases, the volunteer services either should not include them as service targets, or the services should create a favorable social environment to induce the client's motivation of living in the community. This study also suggests a policy issue including the role and function of the mental hospital in providing a permanent residence service for patients who wish to remain in the hospital setting.

The participants who stayed with families had a better adjust­ ment in the area of Alienation-Depression (PARS) than those in group homes. This was due to the family as a primary group, which provides both a close relationship and acceptance of the client. Virginia 12 Satir uses the family as a therapeutic unit and considers the family dynamics as forces for growth and indicators of the power of in te r­ actional transitions.

In summary there were no striking predictors of adjustment. How­ ever, it was found that sex, race, number of siblings, and type of residence are factors which have significant relationships with certain 134 areas of adjustment. Further studies applying improved research design and method are required in which adequate clien t sample sizes are provided in each of the subgroups of characteristics, particularly those factors which had significant differences but were not accepted due to

small numbers.

The C lien t's Community Adjustment

and Volunteer

The third minor hypothesis of testing found several significant correlations between the client's interpersonal relations with his

volunteer and other community adjustment indicators. Rather than

overall community adjustment indicators, these indicators include:

length of employment, number of services, number of helpers, number of

problems, and the sum of relations with his significant other. Testing

the fourth minor hypothesis indicated that the interpersonal relation­

ship between the c lie n t and his volunteer was stronger than the

interpersonal relationship betwen the client and his significant other

at a non-statistically significant level. The experimental group

participants felt that the volunteers respected them more than their

significant others.

However, the rejected major hypothesis indicates that there was

no sig n ifican t relationship between the volunteer/client relationship

and client community adjustment. Therefore, the effectiveness of

volunteer/client relationship still requires further study. 135

Importance of Significant Other

The sig n ifican t correlations between the c lie n t's community ad­

justment and the client's perception of his relationship with his

significant other, indicates the importance of the significant other's

role in the client's support system.

The Significant correlation between the client's adjustment in

Close Relations (PARS) and "Discusses Problems with Significant Other"

indicates that the client's significant other may be an important

alternative to help the client to define and solve problems.

The positive sig n ifican t correlation between the area of Alienation

Depression and the item of "Has been Helpful to Significant Other" may

have various in terp retatio n s. However, such an interpretation is

difficult since there is only one significant correlation in 12 items.

Again, fu rther study is needed to explore the meaning and significant

correlations between c lie n t's A1ienation-Depression and c lie n t's

interpersonal relationship with his significant other.

The positive significant correlations between the area of Anxiety

and the items of "Discussed Problems with Significant Other," "Solving

Problems with Significant Other," "Agreed with Significant Other,"

Yyou Respected Significant Other," "Significant Other has been Helpful,"

and "Sum of Relations with Significant Other" indicate that when the

c lie n t's anxiety symptoms increased, the interaction between the client and his significant other and the dependency on his significant other increased. A second indicator shows that when there was a better

relationship between the client and his significant other, the signif­

icant other became more sensitive to the client's anxiety symptoms. 136

The client's adjustment symptom of Anxiety is, therefore, significantly correlated to the interpersonal relationship with his significant other.

Another interpretation is that anxiety is a motivating force for new coping skills; such as, collective problem-solving. Also, anxiety may be considered as a symptom of the client's discomfort with his significant other and, therefore, he encounters problems with those positive significant correlations which are listed above.

The positive sig n ifican t correlations between the area of Con­ fusion and the items of "Agreed with Significant Other"; "Significant

Other has Respected You"; "You have Respected Significant Other"; and

Ssignificant Other has been Helpful" suggest the client's reciprocal

(dependent) relationship with his Significant other. Therefore, the significant other may be an important figure in the client's support system.

The negative sig n ifican t correlations between the area of Alcohol-

Drug Use and the items of "Enjoyed Being with Significant Other"; "Felt

Close to Significant Other"; and "You have Respected Significant Other"; indicate that the closer the relations perceived by the client with his significant other in these three areas, the more the significant other become aware of the c lie n t's involvement in Alcohol-Drug Use, and visa versa. Therefore, the significant other plays an important role in providing the client with an enjoyable companion and a close relation­ ship. Also by gaining the client's respect, the significant other might share information with the client of his involvement in Alcohol-

Drug Use. In other words, the significant o th er's affective reactions 137 toward the client had gained the client's trust and, therefore, the information of the client's involvement in Alcohol-Drug Use was shared.

The positive sig n ifican t correlations between the area of House

A ctivity and the items of "Discussed Problems with Significant Other";

"Solving Problems with Significant Other"; "Agreed with Significant

Other"; "Significant Other has Respected You"; "You have Respected

Significant Other"; and "Sum of Relations with Significant Other" indicate that the client's role skill in House Activity is correlated significantly with the interpersonal relationship with the client's significant other. The high, overall significant correlations between the area of Child Relations and the items of interpersonal relations with significant other indicates the consistency of both the client and the significant other's perceptions on interpersonal relations.

These implications lead to the conclusion that the client's significant other is an important support system for the client's successful community adjustment. An important issue exists, pertaining to the development of a team consisting of the client's significant other to work with the client, the volunteer, the staff, and related agencies. All of these people will be used to help the client to have a successful community lif e .

The C lien t's Community Adjustment

and Volunteer Characteristics

Overall, the volunteer's characteristics did not have a significant relationship with the client's community adjustment. 138

In the program operation, the random assignment of volunteers was

pre-empted by the attempt to match clients to volunteers with similar

characteristics and interests. Using peers is a logical approach in

the formation of a friendship. However, this study was not designed

to measure thk effectiveness of volunteer s with characteristics similar

to the clients. Future studies are urged to consider the effect of ipersonal sim ila ritie s between the volunteer and the c lie n t. Another

approach is to stratify the sample to include ample representatives of

the subgroups of each characteristic.

The problem in making operable either of these approaches, is the

small number of persons w illing to volunteer. Many people are not willing to commit their free time to volunteering. In this study,

women volunteers greatly outnumbered the men (17:5) because more women

knew about project PAVE due to the volunteer recruitment being conducted

in organizations consisting primarily of church groups and those women who cared more about helping others or had more free time.

The C lien t's Community Adjustment

and Group Activities Participation

The sixth minor hypothesis when tested showed four significant re­ lationships in terms of community adjustment. The four relationships were between those high frequency group a c tiv itie s participants and those with low frequency group activities participants. Those high freqeuency group activities participants had better adjustment in the areas of Anxiety, Confusion, Close Relations, and Employment. The relationships may indicate that those high frequency group activities participants have a better adjustment in the areas of Anxiety, Con­ fusion, and Close Relations, therefore, they can participate intensely.

On the other hand, the relationships also imply th at the group activities have the function of reducing the client's Anxiety and

Confusion symptoms and improving the client's interpersonal relation­

ship. Since there were no striking significant differences among the areas thett were examined between the high frequency group a c tiv itie s participants and the low frequency group activities participants, it

is difficult to make a concrete conclusion. The low participation rates among the experimental group participants and volunteers in the group a c tiv itie s indicate th at group a c tiv itie s were not well designed and run. At this point, it is suggested that further studies may attempt to isolate the group approach with a standard process; such as, a single

intervention to test this minor hypothesis.

The C lien t's Community Adjustment

and Volunteer's Attendance

Overall, the frequency of the volunteer's attendance with the c lie n t in the group a c tiv itie s did not have any sig n ifican t relatio n ­ ships with the client's community adjustment. However, the group of participants who were "always" attended by their volunteers had a better adjustment in the PARS area of Anxiety than the group of participants who were "sometimes" attended by their volunteers at the

.03 level of significance. Besides, both the groups of participants who were "always" and "often" attended by their volunteers had a better ad­ justment in the area of Confusion (PARS) than those participants who 140 were "sometimes" attended by their volunteers at the .01 level of significance. The former indicates that the frequency of the vol­ unteer's attendance with the client in the group activities has a significant relationship with the client's Anxiety and Confusion symptoms.

The group approach may be potentially beneficial in helping chron­ ically mentally-disabled persons to have a successful community life because of the following facts:

1. The group a c tiv ity participants had a greater number of services utilized than the non-participants (.05 level) (Table 11).

2. The group activity participants had better ratings than non­ participants in most of subscales examined at a n o n -statistical level

(Table 9, 10, and 11).

3. There are four significant differences in the PARS Subscales of Anxiety, Confusion, Close Relations, and Employment with respect to the subgroups of group participation frequency. The groups of

"higher frequency participants" have better adjustment in these four mentioned areas than the groups of "low frequency or non-participants"

(.05 level) (Table 20).

4. There are two significant differences in the PARS Subscales of Anxiety and Confusion with respect to the subgroups of participants who were accompanied by the volunteers in group a c tiv itie s . According to the PARS subscales of Anxiety and Confusion (.05 level) (Table 22) the groups of participants who were accompanied by the volunteers with

"greater frequency" had a better adjustment than the groups of partic­ ipants who were accompanied by th e ir volunteers with "lesser frequency." 141

Therefore, an important issue arises by "integrating the client, the client's significant other, and the volunteer in creating a group approach toward an effective community support system.

Program Management and Environments

The program began with and proceeded on the basis of a program design. This study based on data analysis and the above discussion, defined th at the absence of significant impact from the program had come from such sources as: lack of adequate input from the volunteer, both in time (not enough) and in e ffo rt, too l i t t l e help in providing instrumenting resources, and lack of adequate termination and lack of high participation rate in group activity. The task team consisted of one Project Director, and one Project Assistant sponsored by ACTION, one Research Director sponsored by the Ohio Division of Mental Health, two CETA workers. One VISTA volunteer (joined in January 1981) and students (one each quarter) from Columbus Technical Institute and the

Ohio State University.

The program output was influenced by the organizational, internal factors which include goal settin g , sta ff supervision, and coordination, volunteer management, and an uncertainty of agency sponsorship. For example, one-third of all volunteers had terminated their relationship with their clients during the program period without adequate notice to the client and the agency. However, the external environmental factors also had an important influence on the program operation and performance. For example, the grant program suffered a shock from 142 budget cuts at national/state level. Two CETA workers were told, first in February, that th e ir program with Project PAVE would be cut to 12 months instead of the original 18 month agreement of stay. Later in

March, they were told th at th e ir program in Project PAVE would be terminated on April 15, 1981. Therefore, they were forced to look for job alternatives. The research grant contract was cancelled in

December 1980, but the termination was rescinded later. The difficulty of volunteer recruitment from the community was far beyond the original estimation. The shortage of suitable housing for patients ready for discharge had caused the delay of discharge from the hospital.

There were many other p o ssib ilitie s which might have led to the absence of significant impact from volunteer intervention. For example, another possibility might have consisted of the volunteer's difficulty in helping those chronically mentally-disabled persons to adjust to community placement. The implication, in this case, will be that more professionals or full-time para-professionals are needed rather than volunteers to assume these tasks.

The following recommendations are suggested for future program development:

1. To write a specific volunteer job description and provide comprehensive training and management, which will enable the volunteer to fulfill his responsibilities within his ability and availability.

2. To involve more staff, volunteers, and clients in the participation of program planning, execution and evaluation on the agency level. 143

3. To define the sponsorship of the program for funding and social sanction.

4. To define and establish both the volunteer model as part of a community support system, and a task team in the community mental health system.

The Research Contributions

The research findings in this study may add the following con­ trib u tio n s to the knowledge of d e in stitu tio n alizatio n and the social work profession.

1. The findings of sig n ifican t relationships between the c lie n t's community adjustment and the frequency of participation in group activities, as mentioned indicate that the group approach may be potentailly beneficial in helping chronically mentally-disabled persons to have a successful community life .

2. There were significant correlations between the c lie n t's interpersonal relationship with his significant other and the PARS

Scales of community adjustment. There were also significant correla­ tions between the client's interpersonal relationship with the volunteer and other community adjustment indicators. These findings imply that the volunteer, and the significant other have different areas of association with client's community adjustment. Yet, both of them are important to the client as community support systems.

3. This study also revealed a serious problem in the present community mental health follow-up system; that is, one-third of the 144

clients discharged from the psychiatric hospital did not utilize (or contact) the Community Mental Health Center's service. This had

significant relationships with c lie n t community adjustment. The method(s) of how to improve the present follow-up system in order

to assure that the client take his medication, if needed, and continues

to attend his medical appointments to prevent unnecessary readmissions,

is an important issue for the policy makers, service professionals, con­

sumers, and the public to consider.

4. This study found five client demographic and clinical factors which had significant relationships with certain areas of community adjustment. These factors include sex, race, number of siblings, number of previous hospitalizations and type of residence. These may serve as reference for further studies.

5. This study pointed out one important issue in deinstitu­ tionalization; that is, about one-tenth of the clients had preferred to stay in the hospital, or lacked the motivation to live in the com­ munity. This study suggests that policy makers, service providers, and the public may not realize that some clients in psychiatric hospitals should not be d ein stitu tio n alized into the community, despite clien t willingness. If all clients were to be deinstitutionalized, an im­ portant question would arise as to what methods would be needed to motivate those clients to live in the community and provide them with a more favorable environment in which to stay. If these methods are not defined, then the psychiatric hospital would have a definite function in 145

providing long-term residence for clients requiring long-term stay.

It implies that deinstitutionalization may misguide the people.

Reinstitutionalization may be another alternative for some people.

6 . This study did not accept the major hypothesis. There was

no sig n ifican t relationship between the one-to-one volunteer and client relationship and the client's community adjustment. There were no overall sig n ifican t relationships between group intervention

and the client's community adjustment. The only significance was

found between the group a c tiv ity participants and non-participants

in regard to number of services utilized. The group activity

participants had a greater number of services utilized than the non- participants (.05 level).

Although there were four significant relationships between the frequency of the client's group activities participation and the client's community adjustment, no overall significant relationships existed. Data did not support the effectiveness of the volunteer intervention. This could be due to program contingencies (such as budgetary cuts, nature of volunteer training and supervision, and the limited period of intervention) along with aspects of the research design (such as adequacy of definitions and measures of adjustment). 146

This study is a pilot study of a volunteer model using a one-to one volunteer/client relationship and group approach for community support systems in the field of mental health. Therefore, it can serve as baseline data for comparisons, as well as, for program improvement.

Research Limitations

This study was limited to testing the effectiveness of volunteer intervention as an approach in helping to reintegrate chronic psychi­ atric hospital recidivists into successful living. An extensive variety of factors may influence the outcome of community life. The study had the following limitations:

1. Only a small number of volunteers were available for Project

PAVE. Therefore, the size of the sample studied was limited to a rela tiv e ly small one (N = 44).

2. In order to protect human rights, the program was limited to clients who volunteered to participate in the study. The question remains are the clients who are willing to participate more-adjusted because they are willing to participate? If so, there is a potential for experimental bias.

3. Referred clien ts were based on the primary th e ra p is t's judge­ ment. This may have caused a selection bias in the sampling.

4. The volunteers were assigned to the c lien ts based on sex, age, race considerations and mutual acceptance, rather than randomly assigned to the clients. These considerations in assigning client to 147 volunteer were assumed to f a c ilita te a better volunteer service.

This factor might also cause an experimental bias.

5. This researcher's p o st-test data were based on six months' intervention after the assignment of volunteers to the clients. Since each client was discharged at different times within the six-month test period, the post-test data reflected the various periods of times that each client was spending in the community. The six-month pro­ gram period obviously is a short time in which to measure changes in some variables, such as, employment related to community placement.

These issues were due to the inadequate design of research.

6 . Project PAVE, within which this study was conducted, experi­ enced cuts in budget during the period of the research. The budget cuts influenced the program performance.

7. The Evaluation Sheet which was designed by the researcher for this particular program, was not tested for validity and reliability. It had some confounding items.

Summary

This chapter discusses the implications of findings.and con­ cludes that while neither individual nor group approaches as applied in this study produced lower rates of rehospitalization, further research is needed. Program contingencies, such as, cutbacks in budget, the extent and nature of volunteer training and the limited period of intervention along with research design limitations may have influenced the results obtained. The continued high incidence of rehospitalizations of discharged mental patients continues to be problematic and underscores the need for exploring further how best to utilize resources such as volunteers may provide. The research accomplished herein suggests questions needing further exploration, conditions that need to be considered with regard to research design,

selection, training, and supervision of volunteers. NOTES FOR CHAPTER V

1. Robert B. Ellsworth, "The Comparative Effectiveness of Community Clinic and Psychiatric Hospital Treatment," Journal of Community Psychology, 6 (1978), p. 105.

2. W. A. Anthony, et al., "Efficacy of Psychiatric Rehabilita­ tion," Psychological B u lletin , 78, 1972, pp. 447-456.

3 . Steven Katkin, Virginia Zimmerman, J. Rosenblatt, and M. Ginsburg, "Using Volunteer Therapists to Reduce Hospital Re­ admissions," Hospital and Community Psychiatry, Vol. 26, No. 3, March 1975, pp. 151-153.

4 . "Special Report: The Chronic Psychiatric Patient in the Community-High!ights from a Conference in Boston," Hospital and Community Psychiatry, Volume 28, No. 4, April 1977, pp. 285-286.

5. Ib id ., p. 286.

6 . See citation 2.

7. Steven Katkin, Virginia Zimmerman, J. Rosenblatt, and M. Ginsburg, "Using Volunteer Therapists to Reduce Hospital Re­ admissions," Hospital and Community Psychiatry, Volume 26, No. 3, March 1975, p. 151.

8. John A. Talbott, "Stopping the Revolving Door - A Study of Readmissions to a State Hospital," Psychiatric Quarterly, 48, pp. 159-168.

9. Leon A. Hyer and Patrick H. Munley, "Demographic and Clinical C haracteristics as Predictors of Readmission: A One-Year Follow-up," Journal of Clinical Psychology, Volume 34, No. 4, October 1978, p. 833.

10. John E. Mayer and Aaron Rosenblatt, "The Recidivism of Mental Patients: A Review of Past Studies," American Journal of Ortho­ psychiatry, 44 (5), October 1974, p. 697.

11. Ibid, pp. 704-705.

1:2. Virginia Satir, Conjoint Family Therapy, Science and Bevior Books, Inc., Palo Alto, California, 196/, p. ix.

149 GLOSSARY

Advocacy. The term is defined in this study as speaking on behalf of a

person or issue being involved in actions which have high personal costs-

fin a n c ia l, emotional, and personal risk s. Advocacy comes in many v arie­

ties, such as legal service, patient rights, and legislative advocacies.

PAVE emphasizes the service advocacy for chronically mentally disabled

persons.

Internal Advocacy. The term is defined in this study as the

advocacy program funded by a governmental or public resource and/or

tax dollars. It means that the advocacy program is supported by

the system, such as the Client Advocates at state hospitalsJ

External Advocacy. The term is defined in this study as the advo­

cacy program funded by the Private sector (supported externally). 2 PAVE is an external advocacy program.

Chronically mentally disabled person. The term is defined in this study

as those individuals between the ages of eighteen and sixty-five who are on the rolls of the Central Ohio Psychiatric Hospital and have been

hospitalized in any psychiatric hospital once previously (at least

one week) or the current episode being of at least six-months duration."^

Community support system. "A network of caring and responsible people

committed to assisting a vulnerable population to meet their needs and

develop their potentials without being unnecessarily isolated or

excluded from the community" as defined by NIMH guidelines for the

Community Support Program. 1(-n 151

Control group. The control group in this study serves as a comparison group to test the volunteer advocacy effect on the experimental group.

This refers to those patients who are not assigned to a volunteer advo­ cate.

Experimental group. The experimental group in this study refers to those individuals provided with advocacy services to test whether such inter­ vention has an effect on the group's community adjustment.

PAVE (Patient Advocacy through Volunteer E ffo rts). PAVE is defined as an external advocacy program to enable chronically mentally disabled persons to have a successful community life. It is sponsored by the Mental Health

Association of Franklin County.

Significant other. A person who knows the study subject best, and at the same time, the subject feels most close to. I t is assumed th at the sig­ nificant other is the key person to provide the subject with both affec­ tive and instrumental resources in his or her social network. The sig­ nificant other in this study is selected by the subject for the purpose of assessing the subject's community adjustment in both experimental and control groups.

Social network. The term is defined in this study as the network of social relations. "The individual's social network is defined as the sum of those human relationships that have a lasting impact on his or her life." A member of a person's social network may represent either an affective resource, i.e., a source for psychosocial supplies, or an in­ strumental resource, i.e., a source for such things as money, housing, and employment. Thus a network may include a spouse, other re la tiv e s, friends, or an employer. Subject. Any one of 44 chronically mentally disabled persons referred by the Central Ohio Psychiatric Hospital to PAVE, and participating in this study.

Volunteer. A person who is willing to commit himself to be a friend and advocate of a matched chronically mentally disabled patient within a six month period to help the patient to have a successful community ad­ justment. I t is assumed th at the volunteer will help his/h er matched friend to increase the collective affective and instrumental resources for problem-solving and well-being. The volunteer in this stydy is defined as the person recruited, trained and supervised by PAVE.

1. "PAVE Training Manual," Mental Health Association of Franklin County, 250 East Town Street, Columbus, Ohio, p. 193.

2. Ibid.

3. "Client Criteria for Project PAVE," Mental Health Association of Franklin County, 250 East Town S tre e t, Columbus, Ohio . APPENDIX A

Client's Explanation of PAVE Study

153 PROJECT PAVE Helping Hand

C U S H T 'S EXPLANATION OF PAVE STUDY

Project PAVE (Patient Advocacy through Volunteer Efforts) is a program of the Mental Health Association of Franklin County.

PAVE is a study to deternine what happens to hospitalized patient3 during the first year following discharge.

Zf you agree to participate in PAVE, a staff person will ask you for some information such as where do you plan to live after discharge, how long and how many tines have you been in the hospital, and what are seme of your interests and hobbies. You will be asked to sign a "Selease of Indorsation" fora so that we can look at your records to find out the dates of your hospitalization (s) and other statistical indorsation.

Once you leave the hospital, a PAVE staff person will contact you ones avery 2 months to ask hew you are doing. This will generally be done by telephone and will take just a few ainutes of your tine.

After you have been discharged for one year, the study will end. APPENDIX B

Referral Form

155 156

HELPING HAND

REFSRHRL FORM

Data ______

Nana o£ Parson Referred; Phone;

Age Blrthdata Sax

Special Needs/Inforaation:

Expected Data o£ Discharge ______

Plans for Placement ______

Special Medication Maintenance

Other Special Needs

Mama of Person Making Referral:

Agency;

Telephone:______Return to: Project p a v s c/o COPH 1360 W. 3road Street Columbus, CH 43223 276-7233 or COPH Ext. 2333 APPENDIX C

Agreement To Talk To A PAVE Representative

157 AGREEMENT TO TALK TO A PAVE REPRESENTATIVE

I voluntarily agree to meet with a representative of Project PAVE for the purpose of finding out more about Project PAVE and how I might participate in the program. This agreement does not mean that I now agree to participate but only that X will meet with a representative from Project PAVE.

PATIENT______DATE Signature

PATIENT Print Full Name

WITNESS ______DATE Signature APPENDIX D

Consent To Participate In The PAVE Study

159 160

CONSENT TO PARTICIPATE IN THE PAVE STUDY

I voluntarily agree to participate in the PAVE Study and to have a representative of the Mental Health Association and Project PAVE contact the following named person for the purpose of obtaining limited Information necessary for the PAVE

Study. I further agree that the following named person will provide the requested

information to Project PAVE at least twice within a year. 1 hereby grant Central Ohio

Psychiatric Hospital permission to release my medical file for the purpose of the Study.

Information on Important Other: (Please Print)

Name: ______

Address: (street) ______

(town) ______(zlo)______

Telephone: ______

Relationship: ______

This consent may be revoked by me at any time, and if not specifically revoked earlier, this consent expires at the end of a year from today.

PATIENT DATE SIGNATURE

PAT1ENT ______PRINT FULL NAME

WITNESS DATE SIGNATURE

An "Important Other" is the person who is fam ilar with you and the one you feel close to. She/he may be your parent, spouse, relative or friend.

P-3 & k APPENDIX E

Request For Volunteer

161 162

Request For Volunteer

I understand that a volunteer from the Mental Health Association's Project PAVE

Is willing to be my friend and advocate to assist me in making a successful community adjustment. I realize that she/he is willing to help me to try to solve any problem which I may have, but some problems may not be easily resolved.

I may share my feelings and discuss important issues with my volunteer friend so that we may work together to solve problems and be friends.

I, ______, hereby ask the Mental Health Association's

Project PAVE, to assign a volunteer to assist me on a six-month period. I am .. w illin g to work with her/him fo r my own b e n e fits .

Signature _

Name P rinted

Date ______

Witness ___

P-4 APPENDIX F

Client Information Sheet

163 164

Case Nunber: Client Information Sheet

Name: Phone:

Address:

Name of Significant Other: Relationship:

Address: ______

Phone:

In case of emergency, contact:

Relationship to Client: _____ Phone:

Address:

Medication and Dosage:

Community Mental Health Agency R eferral: ______

Phone: Contact Person:

Hospital Personnel: Primary Therapist Doctor

Name of Volunteer Matched: ______Date:

Address: ______Phone:

Type of community residence expected on discharge:

a. on own (apt. room, house) _ _ d. nursing home b. with others (family, friends) e. other (identify) c. halfway house; group home problems/needs1 short term goal long term goal modaIi ty

Dace referred APPENDIX G

Demographic And C linical Information

165 166

Demographic and Clinic Information

Case Number: •

Age: ______Date of Birth: ______Sex:

Race: ______White ______Black ______Other (Specify) ______

Education (highest grade completed): ______

Any Vocational .Training: Re I ia ion: ______

Marital Status: ___ Married ___ Divorced' ___ Single Widowed Separated

Number of Children: Numberof Siblings: brother(s) sister(s

Previous Occupation: ______

Diagnosis: ______

Number of Prior Psychiatric Hospitalizations: ______

Length of Current H o sp italizatio n : _ _ _ _ _ Months _ _ _ _ _ Weeks

Admission Oate: Reason: ______

Discharged Date: Plans to rejoin family: • Yes No

Type of community residence a f te r discharge:

a. on own (apt. room, house) d. nursing home b. with others (family, friends) e. other (identify) ______c. halfway house: group home

Date entering community residence: ~ Length of community residence: months weeks Special Interests/Hobbies: ______

Life Goal (What You Intend To Oo) A fter Discharge:

Date terminated/referral ______Reason:

Follow-up date ______Reason:

P-6B APPENDIX H

Cover Letters for Pretest and Posttest PARS Scale

167 163

mental health association CF R3ANKUN CCUNTY C/0 C.O.P.H. P roject PAVE/Helping Hand 1960 VI. Broad.St. Columbus, Oh. 43223

______joined our PAVE study seme months ago. You were kina enougn to fill out a questionnaire regarding his/her adjustment at that time. We appreciate your helping us in this way.

Now at the end of the study, we would like to ask you to rata his/her adjustment one more time. As before, this information will be kept confidential by our staff. This information is very important to our study and , therefore, helps us to improve our senvicas.

Please complete all the questions and return the form to us in the self-addressed, stamped envelope provided.

Thank you very much for your assistance. Your cooperation is Important in our effort to provide the best possible service to our clients. If you have any question, please don't hesitata to call us at 276-7233.

Sincptrnl >/.

Douglas K.N. Chung, MSJC-IA Program Evaluation and Research D irector Project PAVE/Helping Hana

233 cost Tcwn Sheer. Cclumcus. Chic 4221 £ • Teiecncne( 614)228-1244 IStecrenVcnHeycaPtesaenr • Kemon P. GectnctT, Executive Director TnSr mental health association CF FRANKLIN COUNTY C/0 C.O.P.H. Project PAVE 1960 W.Broad St. Columbus, Oh. 43223

Permission has been given by ______for us Co contact you regarding his/her current adjustment and behavior. It has been•indicated that you were someone who knows this person well and will be'able to answer the following questions.

The information you provide will help us better understand this person and is essential in helping us develop a better program. When answering the following questions, please answer in terms of how he or she is doing NOW. We are interested in the present condition, not what happened six months or a year ago.

It is important Chat we receive this information quickly. Please complete the questionnaire a s’soon as possible and return it to us in the enclosed envelope. Peel free to call us at 276-7233 if you have any questions.

Your co-operation is deeply appreciated.

S incerely,

£11en P. Colom Douglas Chung Project PAVE Oirector Principal Sesearcher

Enc.

250 East Town Sireet. Columbus, Ohio 43215 • Telephone (614)228-4344 J, Stephen Vcn HeyOe. Resident • Kenton P. Gearhart, Executive Clrector . APPENDIX I

Data Collection Instrument-PARS Scale

170 PERSONAL ADJUSftENT AID ROLE SKILLS A. Please describe the person's Adjustment during the past month by answering each question below. (PARS SCALE) B. Hark your answer to each question by making a \ / i n I / 1 ' the box under your answer choice, like th is: ------V' I

Name of Person Being Rated DURIHC PAST HOHTH. HAS HE/SHE . . . 1 2 T 4 The person named above has given us permission to contact you for IPlease onauea each queatcoii) Rarely Some­ Often Almost information about his or her adjustment and behavior. The information times Always you provide wilt be used only to plan and evaluate services and will 1. Shorn consideration be kept s tric tly confidential by the agency staff. far you. □ □ 1 11 1 It is Important that the staff receive this information quickly. 2. Cooperated (gone along) with Please complete the questionnaire and return it to us as soon as things asked of him/her. possible. Your cooperation is deeply appreciated. U3 □ 1 11 -1 3. Shown in terest In what you say. □ □ 1 !1 ! four Name 4. Shown affection toward Today's Date: ______< you. □ □ 1 1 U Hunth Day Year Please Answer the following Background Questions: 1 1 Answer choices I A. Your relationship to the person you are rating. (Check one answer) DURING PAST HONTII, HAS HE/SHE . . . l 2 3 4 (1 ) Spouse (Please aitswe* each question) Never Rarely Some­ Often (2 ) Parent times 3] Other relative (sister, aunt, etc.) i4) Friend 5. Said people don't care about him/her. □ □ □ 1 1 B. Current marital status of person you are rating. (Hark one) (1) Never married 6. Said people tre a t him/ ( 2 _____ Currently separated, divorced, or widowed her unfairly. □ □ □ 1 1 (3 )_____ Currently married and'living with spouse 7i Said people try to push C. How much education does th is person have? (Hark one) him/her around: □ □ □ 1 i (1 )_____ Did not complete high school (2 ) High school graduate 8. Said life wasn't worth (3 ) Some college living. □ □ □ (4 ) College graduate .u 0. Sex of person you are rating. (Check one) 1 1 (1 ) Hale Answer choices 1 (2 ) Female DURING PAST HONTII. I1AS HE/SIIE . . . 1 2 3 4 I PI ease unawe* each question! Almost Some­ Often E. Age of person you are rating ______Almost Never' times Always 9. Been nervous. □ □ □ COPYRIGHT 1979 by IPEV I n t'l. Rei»oduction by any psoces* without □ peAmiiiion viotatu copy/light Cows. 10. Acted restless and tense. □ □ □ IPEV Int'l. (Institute for Proyram Evaluation) □ Box 46S4, Roanoke. VA 24015 II. Had difficulty sleeping. Phone (703) 309-7511 □ □ □ □ 1 1 Answer choices I DURING PAST HONTH, IMS IIE/SIIE ... 1 —D2------31------4‘*p H 23. Are there usually children in the hose} (Hark one) (Please anitotx each question) Never Rarely No (If you narked “Ho*, skip to question 28) Saner Often Ves ( I f you narked “Ves*, answer questions 24-27) times 12. Just sa t and ______Answer choices ______I stared. CURING PAST HOHTH, HAS HE/SHE' ~ 1 2 3 4 1 1□ □ □ (Please ansueA each question) Almost Some- Often Alnost 13. Forgotten to do Never tines Always important things. 1 1□ □ □ 24. Spent tine with the children. 14. Been In a daze, or □ □ □ □ confused. 1 1□ □ □ 25. Shown affection toward the children. 15. Seemed to be off in □ □ □ m another world. 1 1□ □ □ 26. I II II II I r 1 27. Been consistent In reacting to the children. Answer choices i □ □ □ □ DURING PAST HONTII, HAS IIE/SIIE . ,. . 1 2 3 4 (PteOiC anitot* each question) Never Rarely Some­ Often times l&U, Z,-Z>1 16. Been drinking alcohol or using drugs to excess. □ □ □ □ 28. Been employed outside the hone la s t aionth? (Hark one) Unemployed ( I f unemployed, do not answer questions 29-31) 17. Become drunk on alcohol Employed part tine la s t month or high on drugs. □ □ □ □ Employed fu ll time la s t month 18. Had a drinking or drug NOTE: i f employed part or fu ll tin e , answer questions 29-31. problem that upset family. □ □ □ □ 29. About how nuch take home pay did he/she earn fron working last no.7 Please . . . Vo not -Include money (son pension ok wel(aae) 1 1 1)_____ Earned l i t t l e or no money from working la s t nonth Answer choices , | DURING PAST HONTII. HAS IIE/SIIE . . . 1 2 3 4 (Please anauiee each question! Alnost Some­ Often Almost Never times Always 2)______Earned less than' 1100 per week 13) Between $100 and 1200 per week 19. Dune chores aiuund 4)_____ Over )200 per week from working house. □ □ □ □ 30. From working, did he/she eam an adequate amount of uoney la s t mo.7 20. Oone household Hark one) cleaning. 1) Earned l i t t l e o r no money by working la s t month □ □ □ a 2| _____ Earned enough to take care of personal needs 21. Prepared meals for the 3 )_____ Earned enough to p a rtially support a family family. 4 )_____ Not Earned employed enough la to s tadequately month support a family a □ □ □ ’ Rarely looked forward to work 22. Done laundry, ironing, 31. Did he/she’ Semetlaes look forward looked to forward going to to work work each day7 (Hark one) or mending. □ □ □ □ Usually looked forward to work

(Sua 29-31 Thanh you {ok completing tin qutationnaiae. Voiui help is vt*y such appreciated. Please chtck back to make suae you have not stepped any questions. (

APPENDIX J

Internal Consistency Reliabilities For PARS Factor Scores

S ignificant C orrelations Between S elf and Other Ratings of Adjustment

and Functioning

■173 174

INTERNAL CONSISTENCY RELIABILITIES FOR PARS FACTOR SCORES

' CN *-395 Cases)

Coefficient PARS Factor Aloha

A. Close Relations .35 B. AHenation-Cepression. .85 C. Anxiety .34 D. Ccnfusi on .86 E. Alcohol-Orug Use .91 F. House-Activity .92 G. Child Relations .88 H. Employnient .83

SIGNIFICANT CORRELATIONS BETWEEN SELF ANO OTHER RATINGS OF ADJUSTMENT ANO FUNCTIONING

(N - 40 Males and 105 Females)

PARS Ratings by Significant Others

(1) (2) (3)"..... (4) (5) T s T " (7) (3) PAL Self- Close Alien Anxiety Conf Alcohol House Child Work Ratinas Sex Relat Oeo Oruq Act. Relat

A. Negative M Emotions F .20* -.34**

S. Well M -.25* -.45** .47** Being F -.31** -.22**

C. Income M -.36** ’ -.58** -.26* .35* Mgm F -.20* -.24** -.20* .23*

0. Physical M .31* -.37* Symptoms F .28** .33** .25** -.37**

E. Alcohol M .52** Orug Use F .48**

F. Close M .55** -.30* -.34* -.52** .77** .39* Relations F -.28*

G. Child M .59** -.42** -.39** .71** .86** Relations F -.28** -.23* -. 27* -.29**

*p .05 level of confidence for appropriate degrees of freedom

**p .01 level of confidence for appropriate degrees of freedom

Sources: Rob.ert B. Ellsworth, "PARS Scale Measuring Personal Adjust-?. ment and Role S kills" 1979, In s titu te for Program Evaluation, 124 Chapin, Ann Arbor, Michigan 48103. APPENDIX K

Pre and Post Treatment PARS Scores

175 176

PRE AND POST TREATMENT PARS SCORES

MALE PARS SCORES (N * 83) FEMALE PARS SCORES (N =■ 129) Pre Post r t Pre Post r t

(A) Close 10.2 11.6 .55 3.77** 11.7 12.0 .48 1.08 Relations (B) Alienation 9.6 7.4 .63 6.65** 10.0 7.9 .41 6.18** Qepressl on (C) Anxiety 8.9 - 6.3. . .36 3.28** 8.4 6.2 .48 9.81**

(D) Confusion 10.3 8.1 .SO 5.58** 9.4 7.4 .42 6.10** to O

(E) Alcohol- • 4.3 .65 2.67** 4.1 3.7 .49 2.74** Orug Use (F) House < 6.9 7.7 .42 2.38* 10.9 11.5 .45 1.35 A ctivity (G) Child 10.5 11.3 .62 1.63 12.3 12.2 .53 .21 Relations (H) Employment 6.S 7.8 .69 3.45** 7.4 7.8 . 57 1.27

*p .05 level **p .01 level

Sources: Robert B-Ellsworth, "PARS Scale Measuring Personal Adjustment iSa « • 2 « 5 10' for Program Evaluation, 124 Chapin Ann Arbor, Michigan 48103 APPENDIX L

Data Collection Instrument-Evaluation Sheet

177 178

EuahuakZan SkzzX (Intetvtew SaizauZz]

You. kauz paxtZaZpatzd Zn t h e PxojZ&t PAVE Study ion a tvkiZi. Hauit we wouZd Zikz you. to g iv e cu yoan. spZnZom to hzip ua to Zm- p tc v e qua. pnajzct itudy. The Zn&onmatZan you. pnauZdz wZLZ be u aed only to plan and e v a lu a te izw Z a u and vuJJL be feept atugtdy

’ Today'& data ______Coae Vumoet tonai Hay / e a t

?. Va you. kauz a vohmtiZA. Land aottqnzd by tkz aazncy!

7) .Va (don't an&wen. questions with *)

2 1 • Yzi P tzu z qZuz k ii/n zx n a m e ______

2. Pdeoae gZuz tk z name and .iziatZon a{ youn. important otkzx whom you. LLutzd when you. zZyned tkz c o n c e n t j \onm to pankZ&Zpatz Zn tk z akudu.

Vame

PiiaXZan /| ______Spa cue

21 ______P a te n t

31 ______Qtkzx PzhatZuz ( S i a t e t , Aunt, e t a .)

A) ______fxZznd

3. A te you. ZZuZng Mitk kZm/hzx? ______Yu ______Ha

4. la he/a he atddd the one you. j'eed moat adaae to? ______/ea Vo

5. h ave vou. been te h a a p tta d tz e d dunZna tk z h u tz Zj . m cntha?

J) ______Vo

2) ______/ e a . Plzxiz qZuz tk z dunatZon, r.vjm ______To _____ flionXjt cjjj moYiZjx

3) Tota d ______weeaa

4) Vumoet oj tdmea tehoa aZtaiZz zd ■■ ______179

o . Have you been employed outcide the home a t anything during tkz l o t iiu monthi?

7) unemployed (jump to amuien question 9)

2) _ _ _ _ _ employed pant time. P leue indicate dotation.

3) employed {a ll time. Pleaiz indicate dotation.

4) Total weeki ______, {nom ______To ______montn aay manat aay

7. About how muck do {did] you earn {aam wanking? {Pleaoe do not include money {nom Pen&ion on. Uel{ane .)

71 Ecrtnzd l i t t l e on. no money {nom wanking

21 canned l e a than $100 pen week 3) Between $100 and $Z00 pen ween

4 1 Oven $200 pen week {nom wanking

3. Who helped you get the job? 1} ' - Selif S) Relative 2) Impantant a then 3) Fniend 31 ______UoZunteen {niend 7) ______Therapeutic agencu 4) ______PAl/E agency/ikn{{ 3) ______t'-tken______

9. {Only {on unemployed ) Vid you look {ontwatd to 'wank?

11 Hat a t a ll.

2] ______Panzly lacked {onward to wonk.

3] ______Looked {onswand to wand, but couldn’t {ind meant. Please explain neaoam {on each annwen.

10. A{ten yaun dicchange {nom the hospital, what tupec o{ coimunity ienvicec have you u tilize d?

a.) Community Mental Health 3-1 Medicaid Centen b > —. Pehabiltation Senvice (5WJJ U _ ___ S .S .i. c) rood Stamp i\ __ ___ Wel{ane

___ 4 — ___ Employment Senvice yi _ Ttampontction to Agency

e] __ ___ Houiing _ PekAenol \fnvice

— Medicate i] Othen (name i t 1 Total rwmaen typee o{ ienvicec uced. -continued- 11. Who helped you. utilize the iznvicz ?

/] _____ Selh 51_____ Relative

21____ Important other 6 1 Friend 31 Volunteer hriend 7) Therapeutic agency

41____ PAVE agency/Atahh 2) Othen______

Total number o

1) Hou si n g 2) Transportation 3) Lack oh hAjjendiiUp

4 )_____ Vihhitulty in applying {aa community services (Food stamps, SSI. handicap services, legal services 1

51 J ob hunting

6) • Vihhicultu in getting appointment mith physician/therapist

71 _ _ _ Failure to take medicine regularly

5) ; Othen ______

Total number oh problems encountered ______13. When you. run into a problem the h i n t person luhom you go to hor help i i

11 iVo one can help

21____ ImpoAtant other

3 1 Volunteer hniend

4 ) ______PAVE a g e n c y /ita h h

5) Relative

6) ____ Friend 71 Therapeutic agency

3 ) Othen______

- continued- 181

14. Yawi reiatianship Mith youn. important other :i s 4- JT Most 2 3 More Most Uncomtorta. biz IMcom^ontohiz Com/ortahiz Com6or£anZz ComfantaJbZz

15. z you and th is person _*■ raneZy sometimes o&ten aJbutys a) Seen abiz to taih it tiinouqk when ansiaus? □ I i l_J f a ) Spent en/oyahiz times together? 1_____ 1 l_l | 1 cl Viseussed important matterts? I_1 O LJ d) Fzit dose to took other? 1_____ I n n r e) Spent timz In soiving pro bizms? □ i i i i £]' Agreed about sociai Laativitizs S intends? □ n 3) Yawi important other I ( i i has treated you. mith 1 .1 1_____ I respect. You. have treatedyour hi importantother Mith □ □ respeet. i] Yowl important a then. 'not b een heipiuZ ta r~i n i i □ You? I) You hawz been hzZp(ui to youn important O □ □ other? I OtOJ. *16. Youn reZatianship Mith youn. uaZuntzzr intend it: jr Host 2 3 More .‘■lost UncomiartahZz□ Uncomjortabiz □ ComiartahZz □ CcmiartabZz Com^ortadLz *17. Vwung the pant month, have you. and t u t person .

al Seen abZz.to taih i t- I------T through, men anurous- i I □

fa) Spent enjoyabiz times , - — ■■ together? I_____ [ □ -continued- 77 cl Discussed important mattens? □ □ □ □ d) Felt close ta each athen? □ □ □ □ el Spent time in saZving problems? □ □ □ □ 41 Agreed about social tzZivities and intends? □ □ n □ 3) Youn volunteer has treated you. with □ □ □ □ nespeat. h) 'You. have treated youn □ □ □ L _ 1 nespeat. i\Youn Volunteer has been helpiuZ to you? □ □ □ □ /I You. have been heZpiuZ ta youn VoZunteen? □ □ □ □

* •1 8 . Has the amount o& time you've spent mith youn volunteer intend, been enough.? 7) Ves 2) lia [how much time needed hns./w k.)

* -1 9 . What is the most impontant kelp that you. received {nom youn volunteer intend? 7) kjieattoe nesaunces

2) Instrumental nesaunces t<*2£7. Zi you. one terminating youn relationship with youn volunteer intend, what one the neasons? 1) I tenminated

2) My volunteer intend tenminated

3) I don’t know why

X- 21. Has the PAVE st&H been heLpiuL to you in youn nziationsiUp?

1) _Yes

2) Ha

•continued- *22. Wave you even paxticipatzd in PAVE meeting*?

1 )____ Yu

2) Ho

*23. I({ y u , how c£ten -os yoat voluntzex able to accompany you. to the PAVE meeting ?

1 )_____ Hevex

2) PaxeJLy [once/two month*]

3) Sometimu [once a. month]

41 QAten [biweekly with exception)

5) Aiwait* [attend evexy meeting)

*24. Wow afaten do you. paxticipatz in PAVE meeting*?

II Paxzlii [onczltwa m oniful

2) Sometimu [once a month)

3) Of,ten (biweekly with, exception)

41 Aim uz [attend evexy meeting)

*25. Have you xzad the PAVE neiaizttzi?

1 ) _____ Yu

2 ) _____ Ho

*25. Hoi the PAVE newilettct been hzip&ui to you?

I]_ __ Yu

21_____ Ho

*27. Have you even. wxitten any axtiatz {on the PAVE nemlzttzx?

1) Yu

21 Ho

23. Have you anu iuggution* ox comments about P.iajeat PAVE that might heJLp 04 impxavz the pxogxam 1

Sianatuxe 06 intzxviewex Vatz ♦

APPENDIX M

HELPING CONTRACT

184 185

Helping Contract

Douglas Chung MSW, MA

I. What is Contract?

Contract is a term defined to indicate a mutual agreement between 2 or more partners. It is assumed through the contract making, all the partners involved in a task of problem-solving or goal achieve­ ment will have a better understanding about the role played, there­ fore, lead to a better performance. Socialization is a kind of conscious or unconscious social contract. Laws; so c ia l, moral and societal critiques as part of social contract, are key tools of social control. The helpful contract application in human service, therefore, should include responsibilities, expectations among both parts in term of achieving the common goal.

II. Levels of Contract - 3 levels

1. Legal: by signing documents. 2. Oral: by orally mutual agreement. 3. Non-Verbal; certain behaviors expected by people. Some cul­ tural or social customs in various societies. a. Conscious: People know it, i.e., lady first, table manner. b. Unconscious: If one violates this contract, people become unhappy or angry without knowing or reasoning why.

III . Key elements in making helping contract.

1. Person: both sides - volunteer and client.

2. Issue: common goal to be achieved. i.e., to successfully settle down in the community.

3. Time:- Whenever both sides are ready, (emotionally as well as psychologically) Physically not tired.

4. Location: quiet, private where both sides can concentrate on discussion to: - define common goal, and - mechanisms or methods to achieve the goals

5. Mutual agreement: not tell the client to . . . but discuss with him about his situations, needs and how can two work together to solve the potential problems and achieve the goal. 186

6. Contract rebuilding: in case of contract failure, the volunteer should rebuild the contract with the c lie n t as soon as possible. Define the cause of failure and make a new contract to prevent further failure. You may re­ modi fy the contract from time to time according to the situation encountered.

7. Contract termination: from the beginning the contract should state for how long the contract will last.

IV. How to do the verbal helping contract (recommended format)

A. Reduce c lie n t's anxieties T. Receive him in the hospital. 2. Introduce myself. a. My name, job, and my in te rests. b. I am the one who's going to help you in the coming six months. c. Glad to make friends with you. 3. Get acquainted with your client (friend). Let client intro­ duce himself by his terms through conversation. a. Who am I? b. What are my interests, issues or things bothered (prob­ lems), and expectations? c. Why I want to participate in the study?

B. Show appreciation for working together 1. Glad to see you are a friend of mine and happy to see you are going back home...... 2. Like you to have a successful experience of reunion with the family and community. 3. Like you to work out something from daily life.

C. Contract During the f i r s t few months of your returning home and community you may feel uncomfortable from the people and environment you will live with. So, it is important that you understand these f i r s t couple of months—because i f YOU DON'T, YOU WILL LIKELY BECOME FRUSTRATED AND MAY LEAVE HOME AND THEN YOU ARE BACK IN THE HOSPITAL. Most of the Discharged Chronically Mentally dis­ abled patients that stay over the first six months at home do not need any hospitalization unless for a very special reason.

1. You may have the following problems: a. Difficult to answer questions from your friends and relatives in terms of your conditions (either the hos­ pitalization or your plans for the future). b. Some people's words or questions may make you feel bad or frustrated. "How long has your stay in the hospital been this time?" "It's difficult to find a job!" 187

c. Difficult to stand the attitudes of your friends or family members who treat you as a "psychiatric patient" or "mentally ill patient." d. Hesitate to tell your problems or ask questions which you may have. e. Difficult to find a suitable friend to share your bitterness and happiness. f. East less or sleep less than the normal conditions. g. Don't know where to go, or difficult to find transpor­ tation for shopping, medical appointment, clinical visit or applying for any needed services.

2. I t is a normal condition to have problems when people are discharged from the hospital and return back home. a. People usually have a difficult time to readjust to their own home environments after a long period of hospitalization, although people are used to their own home environment. b. It is a reality that some people have incorrect percep­ tions about the mental illness. c. It is also a reality that we as human beings and the environments we lived in are not perfect. Certain responsibilities we can't avoid, such as housekeeping and child caring. d. But there are certain things (ways) th at we can work together to solve the problem you may encounter. e. You will feel fine when we work together to solve your problems.

Don't give up because you have these feelings or prob­ lems—all the chronically mentally disabled patients have them—expect to be nervous and fru strated — i f you weren't, you'd feel sick. About 60% of the chronically mentally disabled patients were rehospitalized during the first six months after their discharge. They expect too much. Those who recognize the problems and try to overcome i t find these feelings and problems largely disappear. You will notice many people like you suffer­ ing the same thing, yet living the life with apparent ease—having no difficulty. They are just like you. They had certain limitations and experienced the same difficulties you will. You will become just as compe­ te n t and ju s t as much at ease—i f you give yourself the chance.

3. I will be glad to help you. Please don't hesitate to tell me any problem which you may have.

Give yourself a chance to adjust to these things. If you are having some difficulties which your family cannot help you with, I want you to contact me. I commit myself to help you i f I can to have a successful lif e in your community. 188

So, I'd like to sort of make a contract with you—If you are having difficulties which may lead you to be frustrated, isolated, I want you to contact me immediately. I don't mean that I can solve every problem, but I will try. For example, i t is possible for me to help you contact and apply for any community service for you. However, i t costs nothing to talk and probably I may help. O.K.? (Wait for the client to promise orally.)

4. Reassure the contract. a. Ask for questions at this point. b. Try to respond to the anxiety of feelings which may be present. c. Tell him/her what is the next step. d. Tell him/her how he/she can reach you: —your address, telephone number (both day and night tim e). e. Tell him/her when and how you two will contact again. f. Be sure he/she knows your name and your telephone number or the way to reach you. g. Make this firm again that he/she will not suffer anxie­ ties, frustrations and isolation without telling you."

V. Contract as key strategy.

The key strategy of volunteer service to help the client to have a successful community adjustment is to help the client to recognize the coming anxieties and frustrations and help him/her to overcome it accordingly. Therefore, it is important for the volunteer to understand the client's needs and potential frustrations before and during the service. The effective service will depend on the accurate analysis of the client's adjustment problems and conjointed efforts to solve these potential problems by the client and the vol­ unteer. The conjointed effort is mainly due to the nature of help­ ing relationship—a human touched friendship and advocacy. The helping contract serves as an important linkage between the c lie n t's adjusting problems and the conjointed efforts for successful adjust­ ment. APPENDIX N

ANALYSIS OF VARIANCE FOR MEASURING FACTORS AND COMMUNITY ADJUSTMENT

189 190

Analysis of Variance for Measuring Factors and Community Adjustment

Factors' F number of number of number of Ratio services helpers problems F F F F F F Areas of Adjustment Ratio Prob. Ratio Prob. Ratio Prob.

Alienation-Depression (-) 1.68 .17 3.14 .02* 0.42 .83

Anxiety (-) 3.36 .01** 2.29 .07 1.37 .26

Confusion (-) 3.91 .009** 1.74 .15 0.91 .48

Alcohol-Drug Use (-) 1.98 .11 0.59 .67 0.28 .92

Close Relations 2.64 .04* 5.36 .001** 1.65 .17

House Activity 2.58 .05* 2.42 .06 1.31 .28

Child Relations 0.75 .55 0.54 .60 0.84 .54

Employment 0.71 .53 0.03 .96 2.49 .24

Length of Employment 2.97 .03 2.71 .04* 3.78 .007**

Length of Community Residence 1.34 .27 1.17 .34 0.57 .72

Number of Rehospitalizations 2.27 .07 0.19 .94 1.00 .43

Number of Services Utilized — — 11.11 .00** 3.02 .02

Total Number of Helpers 13.36 .00 —— 1.95 .11

Total Number of Problems 1.75 .15 1.21 .32 — —

Sum of Relations with Significant Others 1.16 .33 1.52 .22 1.55 .19

Sum of Relations with Volunteer 2.46 .06 1.13 .35 1.55 .19

(-) The higher scores, the poorer adjustment in these subscales. NOTE: The number of Child Relations is 12. The number of Employment is 8 . The subjects who d id n 't stay with children or had no employment where ex­ cluded from the analysis in that subscales. * P .05 ** P .01 BIBLIOGRAPHY

Anthony, W. A. "Efficacy of Psychiatric Rehabilitation." Psychological Bulletin 78, 1972, pp. 447-456.

______. and Buell, G. P. "Psychiatric Aftercare Clinic Effectiveness as a Function of Patient Demographic C haracteristics." Journal of Consulting and Clinical Psychology 41, August, 1972, pp. 116-119.

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