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By Doctorandus in Psychology, University of the Netherlands, 1975 at the October, 1987 Massachusetts Institute of Technology, Si

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By Doctorandus in Psychology, University of the Netherlands, 1975 at the October, 1987 Massachusetts Institute of Technology, Si VIRTUAL INSTITUTIONS: COMMUNITY RELATIONS AND HOSPITAL RECIDIVISM IN THE LIFE OF THE MENTAL PATIENT. by HENDRIK CORNELIS WAGENAAR Doctorandus in Psychology, University of Amsterdam, The Netherlands, 1975 SUBMITTED TO THE DEPARTMENT OF URBAN STUDIES AND PLANNING IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF DOCTOR OF PHILOSOPHY at the MASSACHUSETTS INSTITUTE OF TECHNOLOGY October, 1987 Q Massachusetts Institute of Technology, 1987 Signature of Author ............ onenofUrban Studies October, 1987 Certified by............. Martin Rein, Professor Thesis Supervisor Accepted by, '.- t Langley Keyes, Professor Chairman Ph.D. Committee 1 R&C VIRTUAL INSTITUTIONS: COMMUNITY RELATIONS AND HOSPITAL RECIDIVISM IN THE LIFE OF THE MENTAL PATIENT. by HENDRIK CORNELIS WAGENAAR Submitted to the Department of Urban Studies and Planning on October 1987, in partial fulfillment of the requirements for the degree of Doctor of Philosophy. ABSTRACT The transformations, since WW II, of the system of mental health care in the U.S.A., have been described as a movement from exclusion to inclusion. One of the most important changes, the expansion, through patient's rights litigation, of the mental patient's constitutional rights, has had the effect of making traditional exclusionary forms of care in the large state mental hospital ethically unacceptable. The result has been a form of inadvertent inclusion of the mental patient in the community. Because of altered commitment procedures and reduced lengths of stay, the mental patient now spends most of his time in the community. In this -service context, high rates of readmission to public mental hospitals developed into a major public problem. High readmission rates are seen as the result of a mismatch between available services and the chronicity of the patient's disorder. The subject of this thesis is the social situation of the formerly hospitalized mental patient in the community. With the use of qualitative research methods the patient's relations to the principal domains of community life -- marriage, family, work, and housing -- are analyzed. The patient's life in the community is described as perennially disordered. His relations to these recognized institutions of community life are characterized by unresolvable tension and discontinuity. This puts him at considerable risk for rehospitalization. Due to his persistent lack of resources, he becomes exceedingly vulnerable to adversity. Relatively small problems turn into major, acute crises, from which only such services of last resort as the police, the emergency room, or the mental hospital offer relief. In this way the patient's social and economic environment in the current system of inclusionary care contributes to the "chronicity" of his disorder. Thesis Supervisor: Martin Rein, Professor, Massachusetts Instttute of Technology. i "First, we must see that the discreteness of entity in which the disorder exists is questionable.......In so far as the patient's symptomatic behavior is an integral part of his interpersonal situation, the server would have to import this whole situation into the hospital in order to observe the patient's difficulty and to treat it. Instead of there being a relatively benign and passive environment and an isolated point of trouble, the figure and ground of usual service conceptions merge into one, the patient's interpersonal environment being inseparable from the trouble he is experiencing." Erving Goffman, Asylums. ii CONTENTS PART I FROM EXCLUSION TO INCLUSION: THE MENTAL PATIENT'S RETURN TO THE COMMUNITY. 1 Chapter 1 Exclusion, Inclusion, and the Problem of Readmissions to Public Mental Hospitals. 2 1.1 Cases 2 1.2 The Transition from Exclusion to Inclusion in Psychiatric Service Delivery 7 1.3 Chronic Mental Illness and the Rising Readmission Rate 22 1.4 Chronic Mental Illness and the Problem Of Contextuality: the Realist Conception of Chronic Mental Illness 29 1.5 Subject of the Study 38 1.6 Description of the Study 43 Chapter 2 The Patients. 54 PART II GETTING OUT: THE SOCIAL SITUATION OF THE MENTAL PATIENT IN THE COMMUNITY. 80 Chapter 3 Marriage and Family. 81 3.1 Marriage 81 3.2 Family 87 Chapter 4 Housing 109 Chapter 5 Work 129 5.1 Introduction: Contradictions and Complexities in the Career of the Mental Patient 129 5.2 Getting In: Jobs and Job Satisfaction 131 5.3 Getting Out: the Occupational Mobility of the Formerly Hospitalized Mental Patient 139 5.4 Work as Resource and Liability 153 Chapter 6 The Social and Financial Rewards of Work. 158 6.1 Income and Expenditures 158 6.2 The Social and Personal Benefits of Work 180 iii PART III GETTING IN: THE MENTAL HOSPITAL IN THE LIFE OF THE FORMERLY HOSPITALIZED MENTAL PATIENT 197 Chapter 7 Trouble. 198 7.1 Introduction 198 7.2 The Notion of Trouble 199 7.3 Personal Trouble 203 7.4 Interpersonal Trouble: the Family Context 211 7.5 Interpersonal Trouble: the Institutional Context 223 Chapter 8 The Readmission as Routine. 237 8.1 Introduction 237 8.2 Hospital Preference and Entrance Management 238 8.3 Symptom Management and Readmission 245 PART IV CONCLUSION 263 Chapter 9 Conclusion: Resources, Risk, and the Mental Hospital 264 9.1 Introduction 264 9.2 Commitment and the Well-Ordered Life 266 9.3 Risk and Vulnerability 276 9.4 The Disordered Life and Services of Last Resort 283 9.5 Mental Disorder in an Inclusionary System of Care 291 Appendix 297 iv ACKNOWLEDGEMENTS Writing and completing a dissertation amounts to a succession of firsts. For most of us it is the first time that we, reluctantly, find ourselves committed to our ideas as they have become the foundation of the undeniable, day-to-day reality of a large research project. Transforming data into insight is the first experience with the art of, in my case qualitative, data analysis. Writing the thesis implies, after a prolonged diet of ten-page term papers, the sustainment of an argument over several hundred pages. All these tasks so far, formulating a question, collecting and analyzing data, reporting one's insights, are nothing more or less than the search for a style of research and writing that best suits one's temperament and sensibility. And above all, a dissertation involves the first exposure to the humbling, but ultimately rewarding experience of confronting long-held, comfortable prejudices to the unrelenting persuasive force of empirical data. I am forever grateful to the members of my dissertation committee, Martin Rein, Dan Lewis, Robert Weiss, and Sheldon White, who helped me chart this formidable obstacle course of firsts. Quite simply, without their continuing support and friendship this study would not have been. In addition, many people have offered their time and assistance in helping to bring this study to a successful end. First and foremost, I thank the seventeen people whose life stories have formed the basis of this study. The openness and patience with which they explained to me what it is like to cope with mental disorder and its social and personal consequences was truly gratifying. Similarly I thank the families and friends of the patients whom I interviewed. Their's was not a simple situation and I can only hope that I have done justice to it in this study. Finally I'd like to thank the treatment coordinators in the mental hospital and the therapists, clinical workers, and other professionals in the various community facilities who, despite their overwhelming workload gave me generous amounts of their time to answer my questions about their clients. The insights that each, from their own perspective, gave me in the functioning of the contemporary mental health system have been invaluable. I thank Tom Lombardo of Madden Mental Health Center and Janet Bremer of Chicago Read Mental Health Center for skillfully mediating my relations with the hospital organization. Gertrue Chase and June Harris from Medical Records at Chicago Read and Pamela Tomlin from Medical Records at Madden helped me locate subjects for my study and finding my way in the hospital records. v Many people have read parts of the manuscript. Susan Reed, Helen Rosenberg, Stephanie Riger, Zev Kalifon, Bruce Johnson, and Arthur Lurigio of the Northwestern Mental Health Policy Project helped me transform my first incoherent ideas into a feasible research project. Francoise Carre, Sarah Kuhn, Wim Overmeer, Christy Baxter, Andrew Lang, and Brenda Nielsen of the Dissertation Writing Group at MIT not only graciously pointed out the defects in my writing, but in addition alleviated the loneliness of dissertation writing. Charlotte Schwartz and Merton Kahne carefully read parts of the manuscript and with their thoughtful and incisive commentary helped me find a language in which to express my thoughts about chronic mental illness. The Whitaker Health Sciences Fund has made this study possible with their generous support. Finally, my greatest debt is to my wife Mariolein, whose unfaltering support carried this work from inception to completion. vi PART I: FROM EXCLUSION TO INCLUSION: THE MENTAL PATIENT'S RETURN TO THE COMMUNITY 1 1. EXCLUSION, INCLUSION AND THE PROBLEM OF READMISSIONS TO PUBLIC MENTAL HOSPITALS. 1.1 Cases. Let's edge into the complex subject of readmissions to public mental hospitals by considering some concrete examples. Early in March of 1986, Jack, a single, white man, calls up the C-South unit of Chicago Read Mental Health Center, and asks if they have space to admit him. Jack looks much older than his 32 years. His hair and clothes are disheveled, he walks in a stoop, and he squints severely. He suffers from diabetes; recently the disease has begun to affect his eyesight which has deteriorated rapidly to the point that he is now legally blind. Jack knows C-South, and its staff and patients, well. Since Christmas 1985, he has been admitted there three times, each time for only a few days.
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