Psychiatric patients' perceptions of their individual treatment program in an in-patient treatment facility with an established therapeutic milieu

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Authors Sweeney, Linda June, 1947-

Publisher The University of Arizona.

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Link to Item http://hdl.handle.net/10150/554830 PSYCHIATRIC PATIENTS’ PERCEPTIONS OF THEIR INDIVIDUAL TREATMENT'PROGRAM IN AN IN-PATIENT TREATMENT FACILITY WITH AN ESTABLISHED THERAPEUTIC.

MILIEU

by-

Linda Jill Sweeney

A Thesis Submitted to the Faculty of the

COLLEGE OF NURSING

In Partial Fulfillment of the Requirements For the Degree of 1 MASTER OF SCIENCE

In the Graduate College i .

THE UNIVERSITY OF ARIZONA

1 9 7 4 STATEMENT BY AUTHOR

This thesis has been submitted in partial fulfill­ ment of requirements for an advanced degree at The University of Arizona and is deposited in the University Library to be made available to borrowers under rules of the Library. ,

Brief quotations from this thesis are allowable without special permission, provided that accurate acknowl­ edgment of source is made. Requests for permission for extended quotation from or reproduction of this manuscript in whole or in part may be granted by the head of the major department or the Dean of the Graduate College when in his judgment the proposed use of the material is in the inter- ests of scholarship. In.. all other instances, however, permission must be obtained from the author.

SJGNED:

APPROVAL BY THESIS DIRECTOR

This thesis has been approved on the date shown below;

ftARLYS A. MOECKLY Assistant Professor of Nursing ACKNOWLEDGMENTS

The author wishes to express her grateful! apprecia­ tion to each of the members of her thesis committee, as they have made a significant contribution to the development of this study by their constructive recommendations and their understanding and supportive attitudes„ The committee members are Marlys Moeckly, thesis chairman; Dr. Margarita Kay; and Helen Navin. Dr. Janelle Krueger has also been a valuable resource person. All are faculty of the College of Nursing at The University of Arizona.

Many members of the staff in the Department of

Psychiatry at the Arizona Medical Center, The University of

Arizona, deserve special thanks for cooperating with the study and for allowing it to be conducted. The author is especially grateful to the patients who agreed to partici­ pate in the study.

The author expresses her deepest appreciation to her husband, Steve, for his encouragement and unfailing co­ operation during this past year and to her son, Nathan, for enduring some periods of maternal deprivation during the progress of this study. - TABLE OF, CONTENTS

Page LIST OF TABLES ...... , ...... vii LIST OF ILLUSTRATIONS ...... xii

ABSTRACT ...... xiii

CHAPTER

I. INTRODUCTION ...... 1

Statement of the Problem ...... 7 Significance of the Problem ...... 7 Conceptual Framework ...... 10 II. REVIEW OF THE LITERATURE 18

III. DESIGN OF STUDY ...... 30

Population Selection .... 30 Method of Data Collection ...... 31 Method of Data Analysis . . , , . , . . . . . 33

IV, RESEARCH FINDINGS AND INTERPRETATION OF DATA ...... 34

Characteristics of the Population ..... 36 Analysis of Findings 43 Specific Components of Treatment Program . . 45 Most Helpful Components of Treatment Program . . « . . . . @ . . . . . @ , . . 52 • Least Helpful Components of Treatment Pr og r am . @ . , . « , . , . . . . . , , * 61 Most Helpful Single Event During This Hospitalization ...... , . » „ . 71 Most Helpful Person (s) During This Hospitalization 72 Gains from This Hospitalization ...... 84 Suggestions for Improving the Care n ■ 7 Ejas*t ... . . , ...... 89 Summary of Findings „ . , ...... 95 V TABLE OF CONTENTS— Continued

Page V. . SUMMARY OF THE STUDY ...... 101

Review of Findings ...... 103 Conclusions and Recommendations ...... 105 APPENDIX A. SUMMARY OF MILIEU THERAPY ...... 112 APPENDIX B. SUMMARY OF MILIEU THERAPY AS IT IS USED AT THE ARIZONA MEDICAL CENTER . . 114

APPENDIX C. LETTER OF PERMISSION ...... 117

APPENDIX D. INITIATING THE DISCHARGE INTERVIEW . . . 118

APPENDIX E. STRUCTURED DISCHARGE INTERVIEW ..... 119

APPENDIX F. QUESTION #2: SPECIFIC COMPONENTS ■ OF TREATMENT PROGRAM ...... 121

APPENDIX G. QUESTION #2: SPECIFIC COMPONENTS OF TREATMENT PROGRAM CATEGORIZED . . . 123

APPENDIX H. QUESTION #3: MOST HELPFUL COMPONENTS OF TREATMENT PROGRAM 126 APPENDIX I. QUESTION #3: MOST HELPFUL COMPONENTS OF TREATMENT PROGRAM CATEGORIZED ...... 127 APPENDIX J, QUESTION #4: LEAST HELPFUL COMPONENTS OF TREATMENT PROGRAM 129 APPENDIX K. QUESTION #4: LEAST HELPFUL COMPONENTS OF TREATMENT PROGRAM CATEGORIZED . . . „ „ . . . . . 131 APPENDIX L, QUESTION #5: MOST HELPFUL SINGLE EVENT DURING THIS HOSPITALIZATION 133 APPENDIX M. QUESTION #5; MOST HELPFUL SINGLE EVENT DURING THIS HOSPITALIZATION CATEGORIZED . . , „ . , . . . . . , . . 135

APPENDIX N. QUESTION #6: MOST HELPFUL PERSON (S) DURING THIS HOSPITALIZATION . . . , . 137 vi TABLE OF CONTENTS— Continued

Page APPENDIX 0. QUESTION #6: MOST HELPFUL PERSON(S) DURING THIS HOSPITALIZATION CATEGORIZED ...... 139 APPENDIX P. QUESTION #7: GAINS FROM THIS HOSPITALIZATION ...... 141

APPENDIX Q. QUESTION #7: GAINS FROM THIS HOSPITALIZATION CATEGORIZED ...... 143

APPENDIX R. QUESTION #8: SUGGESTIONS FOR IMPROVING THE CARE ON 7 EAST . . . . . 146

APPENDIX S. QUESTION #8: SUGGESTIONS FOR IMPROVING THE CARE ON 7 EAST CATEGORIZED ...... 148 v SELECTED BIBLIOGRAPHY ...... 150 LIST OF TABLES

Table Page

1. Length of Hospitalization of Patients ..... 35

2. Age of Patients . . . , 37

3. Marital Status of Patients ...... 38 4. Religious Affiliation of Patients ...... 38 5. Highest Level,of Educational Attainment A of Patients ...... 39 6. Occupation of Patients ...... 40 7. Occupation of Patient's Spouse ...... 41 8. Previous Psychiatric Treatment of P atiencs » . .. «...... 42 9. Question #2: Total Number of Treatment Components Mentioned by Each Patient . . . . . 46

10. Question #2: Number of Treatment Components Mentioned by Each Patient Within the Category of Recreation- Physical . . . . „ . „ „ „ „ ...... 48

11. Question #2: Number of Treatment Components Mentioned by Each Patient Within the Category of Recreation- iVI e n t a 1...... 49

12. Question #2: Number of Treatment Components Mentioned by Each Patient Within the Category of Verbal Interaction „ „ 49

13. Question #2: Number of Treatment Components Mentioned by Each Patient Within the Category of Creature Comforts . . . 50 14. Question, #2: Number of Treatment Components Mentioned by Each Patient Within the Category of Staff Supervision . . . 51

vii viii LIST OF TABLES— Continued Table Page 15. Question #2: Number of Treatment Components Mentioned by Each Patient Within the Category of Diagnostic and Medical Services 52 16. Question #2: Specific Components of Treatment Program, Statistical Comparison of the Six Categories ...... 53

17. Question #3: Total Number of Most Helpful Treatment Components Mentioned by Each Patient ...... 54

18. Question #3: Number of Most Helpful Treatment Components Mentioned by Each Patient Within the Category of Recreation-Physical ...... 56 19. Question #3: Number of Most Helpful Treatment Components Mentioned by Each Patient Within the Category of Recreation-Mental ...... , ... . » 57 20. Question #3: Number of Most Helpful Treatment Components Mentioned by Each Patient Within the Category of Verbal Interaction @ . . « . . . . « # . . .- ...... * $ .. 57

21. Question #3: Number of Most Helpful Treatment Components Mentioned by Each Patient Within the Category of Creature Comforts ...... 58 22. Question #3: Number of Most Helpful Treatment Components Mentioned by Each Patient Within the Category of Staff Supervision ...... 59

23. Question #3: Number of Most Helpful Treatment Components Mentioned by Each Patient Within the Category of Diagnostic and Medical Services ...... „ 60

24. Question #3: Most Helpful Treatment Components, Statistical Comparison of the Six Categories . . .. . , ...... 60 i

ix LIST OF TABLES— Continued Table Page

. 25. Question #4: Total Number of Least Helpful Treatment Components Mentioned by Each Patient ...... 62

26. Question #4: Number of Least Helpful Treatment Components Mentioned by Each Patient Within the Category of Recreation-Physical ...... 63

27. Question #4: Number of Least Helpful Treatment Components Mentioned by Each Patient Within the Category of Recreation-Mental . . . . . , ...... , . . ' 64 28. Question #4: Number of Least Helpful Treatment Components Mentioned by Each Patient Within the Category of Verbal Interaction . . . , . , . . . . 65

29. Question #4: Number of Least Helpful Treatment Components Mentioned by Each Patient Within the Category of Creature Comforts ...... „ , „ , ...... 66

30. Question #4: Number of Least Helpful Treatment Components Mentioned, by Each Patient Within the Category of Staff Supervision ...... 66 ^ . • 31. Question #4: Number of Least Helpful Treatment Components Mentioned by Each Patient Within the Category of Diagnostic and Medical Services ...... 67

32. Question #4: Least Helpful Treatment . ^ Components,Statistical Comparison of• the Six Categories ...... 68

33. Comparison of Statistical Data Regarding Tabulation of Components from Questions #2, #3, and #4 ...... 70 34. Question #5: Most Helpful Single Event During This Hospitalization, Statistical Comparison of the Six Categories , , „ .... „ 73 X LIST OF TABLES— Continued

Table Page

35. Question #6: Total Number of Persons Mentioned by Each Patient ...... 74

36. Question #6: Number of Persons Mentioned by Each Patient Within the Category of Psychiatrists and Psychologists ...... 76 37. Question #6: Number of Persons Mentioned by Each Patient Within the Category of Residents, Psychology Interns, and Medical Students ...... ■ . . . . . 77 38. Question #6: Number of Persons Mentioned by Each Patient Within the Category of Registered' Nurses and Licensed Practical Nurses ...... i . ... , 78

39. Question #6: Number of Persons Mentioned by Each Patient Within the Category of Psychiatric Technicians . . . . . , . .,. . 78

40. Question #6: Number of Persons Mentioned by Each Patient Within the Category of Social Workers ...... 79

41. Question #6: Number of Persons Mentioned by Each Patient Within the Category of Occupational Therapists arid Occupational Therapist Interns ...... 80 42. Question #6: Number of Persons Mentioned by Each Patient Within the Category of Other Patients ...... 81 43. Question #6: Most Helpful Person(s).During This Hospitalization, Statistical Comparison of the Seven Categories . . . 82

44. Question #7: Total Number of Gains from This Hospitalization Mentioned by Each 85 45. Question #7 :• Number of Gains Mentioned, ■ by Each Patient Within the Category of Feelings About Self ...... „ , 86 xi LIST OF TABLES— Continued

Table Page 46. Question #7: Number of Gains Mentioned by Each Patient Within the Category of Feelings in Relation to O t h e r s ...... 87 47. Question #7: Number of Gains Mentioned by Each Patient Within the Category of Physical Well-Being ...... 87 48. Question #7: Gains from This Hospitalization, Statistical Comparison of the Three Categories ...... 88 49. Question #8: Total Number of Suggestions for Improving the Care on 7 East Mentioned by Each Pat i e n t ...... 89

50. Question #8: Number of Suggestions Mentioned by Each Patient Within the Category of Recreation-Physical 91

51. Question #8: Number of Suggestions Mentioned by Each Patient Within the Category of Recreation-Mental ...... 92 52. Question #8; Number of Suggestions Mentioned by Each Patient Within the Category of Verbal Interaction , , , . „ , , 92 53. Question #8: Number of Suggestions Mentioned by Each Patient Within the Category of Creature Comforts ...... „ . 93

54. Question #8: Number of Suggestions Mentioned by Each Patient Within the Category of Staff Supervision 94

55. Question #8: Number of Suggestions Mentioned by Each Patient Within the Category of Diagnostic and Medical S erv ices . . « ...... 94 56. Question #8: Suggestions for Improving the Care on 7 East, Statistical ' Comparison of the Six Categories.„ ...... 96 LIST OF ILLUSTRATIONS

Figure Page 1. Function and Process of Perception 16 ABSTRACT

This study was designed to provide information con­

cerning psychiatric patients' perceptions of their individual

treatment program in an in-patient treatment facility with

an established therapeutic milieu. The responses of 24 patients aged 16 to 69 years to an 8-item questionnaire, developed and administered by the investigator, constituted the data collected.

The 24 patients identified 57 components as part of their treatment programs. Patients with more education mentioned more treatment components than those with less education. Talking with staff members was considered the most helpful treatment component by the most patients, and medication was the most frequently mentioned least helpful treatment component.

Six categories were used to organize the data: recreation-physical, recreation-mental, verbal interaction, creature comforts, staff supervision, and diagnostic and medical services. More of the identified treatment compo­ nents were categorized under verbal interaction than any other category. The second most mentioned category was recreation-physical.

As patients listed the most helpful persons during their hospitalization, 3 6 students and staff members and xiii four other patients were identified. Two psychiatric tech­ nicians, a registered nurse, and an occupational therapist were mentioned most often. Patients tended to see persons of their same sex and close to their age as particularly helpful. CHAPTER I

INTRODUCTION

Many practitioners who have worked with psychiatric patients have long felt that the environment in which psychiatric treatment is conducted can influence the outcome of the patient's therapy; that is, the environment itself can be an instrument of treatment. Such a feeling eventu­ ally developed into an assumption that forms the basis for the treatment philosophy of milieu, milieu therapy, thera­ peutic milieu, or therapeutic community, terms widely used in the psychiatric and mental health literature of the last two decades. In reviewing the literature, the researcher has noted that some authors make no distinction, between these four.terms while other authors do define them differ­ ently. For the purposes of this paper, no distinction shall be made between these four terms; they shall be considered interchangeable unless.otherwise specified in a particular usage or reference.

Milieu therapy, as a treatment modality, has been criticized for its lack of clear definitions, methods, objectives, and scientific basis (Lewis et al. 1971, p.

203). It seems to be a nebulous entity that is somehow difficult to pin down. Attempts must be made to pin it 2 down and to define it, however, in order to better evaluate it.

The literature contains a variety of definitions of milieu therapy, since most authors who discuss it to any extent also feel the need to define it. One of the shorter definitions refers to milieu therapy as "any program using the environment or aspects of it for therapeutic purposes" (Kraft 1966, p. 543). Most definitions of milieu therapy are more de­ tailed .

Milieu therapy is an increasingly popular approach to the treatment of psychiatric patients and a model of general application. It places emphasis on social and group interactions, on the sharing of responsibility and decision-making, on the freeing of communication on both vertical and horizontal planes and on dealing with the realities of the here-and-now (Lewis et al. 1971, p. 206).

From another point of view

. . . milieu therapy can be defined as the means of organizing a community treatment environment so that every human interaction and every treatment technique can be systematically utilized to further the patients' aims of controlling symptomatic behaviors and learning appropriate psychosocial .skills (Abroms 1969, p. 557).

One final definition of milieu therapy states: Milieu1 therapy may be described as a careful structuring of the social and physical environment of a psychiatric treatment program so that every interaction and activity is therapeutic for the patient. Open communication between staff members and patients is encouraged. These interactions often take place in the context of group activities, group therapy discussions, community meetings,. family therapy sessions, and individual ; relationship's with the staff (Visher and O'Sullivan 1970, p. 451) .

The above definitions describe and define milieu therapy from several viewpoints. They are included to give the reader a feel for the varied perceptions in the litera­ ture of what milieu therapy is. As one reads the literature

and/or works with patients in varied milieu settings,

however, it is also possible to get a feel for common perceptions of what milieu therapy is.

Whether milieu therapy is regarded as a specific

form of treatment, a collection of management techniques, or a general treatment philosophy, and even though it is utilized somewhat differently in each treatment setting,

there are some common features in all milieu therapy programs. White (1972,. pp. 45-46) has summarized the rationale, values, axioms, strategy, and tactics generally used by milieu therapists (Appendix A). Although the reader may find milieu therapy practiced in a way that does not exactly fit into White's framework, it is included in

this study as the most comprehensive and yet concise

summary of milieu therapy that the researcher located in

the literature. White's summary describes the common per­ ceptions of milieu therapy.

One more quotation is brought to the reader's attention to further facilitate his understanding of milieu;

An effective milieu should be able to provide for the patient who is unaware of his emotionsvor unable to express them constructively, and for the patient who is unable to control emotions and is easily overcome by them. It should be able to provide controls for the impulsive patient, flexi­ bility for the constricted patient, confrontation for the patient with character pathology, and support for the patient in affective turmoil. The distrustful patient must be helped to feel secure, but the overly dependent patient must be firmly and rapidly mobilized. The patient who needs insight must receive appropriate interpretations, while the patient who conforms his behavior to the expectations of others must be nourished toward self-definition (Lewis and Selzer 1972, p. 298).

The above quotation describes what the researcher

views as the ideal milieu situation for psychiatric

patients. Within this milieu some very stiff requirements

are posed in order to meet the individual needs of each

patient. Common problems and needs, which may be positively

influenced by the milieu, characterize these patients. For example, when patients seek admission to a

psychiatric in-patient treatment facility, it is usually

because they are having difficulty in coping with daily

living situations, especially in regard to their relation­

ships with other people. They frequently have difficulty in communicating their thoughts and feelings to others and

in perceiving situations in a realistic and undistorted manner. Interpersonal relationships have often deteriorated,

. and these patients feel rejected and alone. The researcher

believes that the purpose of milieu therapy is to utilize

the total environment to provide daily living situations for

these, patients so that they can gain a better understanding of how they relate to other people and of how they cope with stress situations. In milieu therapy they are encouraged and given the opportunity to practice and to learn more helpful methods of communicating and of coping.

The researcher views milieu therapy mainly as a general treatment philosophy which is flexible enough to incorporate a variety of treatment techniques. Selection of individual techniques is based on the identified needs of each individual patient as well as on the skills and orientations of treatment personnel. The treatment setting also influences the practice of milieu and is one of the reasons that milieu therapy varies from one setting to another.

In this context milieu is not viewed as competing with individual treatment techniques, but as something larger than a single technique. For example, even though milieu places an emphasis on group interactions and activi­ ties, this does not negate the possibility of including individual psychotherapy sessions for selected patients within the total milieu therapy program. Perhaps it is this degree of flexibility that has helped to popularize milieu therapy.

Where did milieu therapy come from? Milieu therapy is viewed as an outgrowth of the nineteenth century concept of moral treatment (Lewis et al. 1971, p. 203) . The more recent historical development of milieu therapy dates from 1950. At that time the fact that ward setting (milieu) had a profound influence on patient behavior was increasingly recognized, and the determinants of psychopathology were viewed as not entirely within the individual. Attempts were made to enhance the psychiatric ward setting in order to make it more beneficial to patients. The term "milieu therapy" was coined and generally defined as the modifica­ tion of the patient environment in order to facilitate better patterns of interaction (Ellsworth et al. 1971, p.

428).

The early 1950's brought an increased emphasis on the patient's responsibility in managing his own affairs.

In The Therapeutic Community, published in 1953, Maxwell

Jones presented the idea of a therapeutic community in which there would be decreased patient passivity and dependency. He also stressed the team concept in treatment planning.

These ideas expanded the roles of both patients and non­ professional staff as treatment agents. In 195 6 new psychotropic medications were introduced which further facilitated the adoption of the whole concept of milieu therapy which has become increasingly popular through the years. Concern has recently developed, however, regarding the effectiveness of milieu, therapy concepts and practices

(Ellsworth et al. 1971, pp. 428-429). This concern leads then into the purpose of the present study. Statement of the Problem

The two questions posed are as follows:

1. What components of milieu therapy do psychiatric

patients, receiving care in an in-patient treatment facility with an established therapeutic milieu,

identify as treatment in their individual treatment program?

2. Which components of milieu therapy do these

psychiatric patients perceive as most helpful and as least helpful in their individual treatment program?

Significance of the Problem Milieu therapy has become a widely accepted treat­ ment philosophy for in-patient psychiatric treatment facilities in the United States. The wide acceptance of milieu therapy has been acclaimed and questioned and often taken for granted. Much has been writeen about the varying characteristics of different milieu treatment programs for psychiatric care; little research has been done, however, to relate program dimensions to treatment effectiveness, that is, the extent to which certain program elements correlate with successful psychiatric treatment (Ellsworth et al.

1971, p. 427). Visher and O'Sullivan (1970, p. 451) have also commented that research into the effectiveness of milieu techniques is lacking. 8 The time has come to stop assuming that milieu pro­ grams are effective and to assess if and what particular components of milieu therapy are beneficial to patients.

Some research has been done to assess the merits and short­ comings of milieu therapy, but many questions remain totally or partially unanswered. These questions may be looked at from the patient's and/or the treatment team's point of view.

Health professionals spend much time planning care for individuals as well as for groups of patients. We establish treatment goals and then work with patients to reach those goals, sometimes successfully and sometimes not.

To what extent, however, do we take into consideration the patient's perception of the treatment program that we have planned for him? How often does a patient fail to cooperate with his planned treatment because he perceives the treat­ ment as not beneficial? How can we help patients to co­ operate more fully with their treatment program? Does a patient's perception of his treatment program affect his treatment outcome?

The researcher believes that a logical beginning toward answering the above questions is to look first at the ability of psychiatric patients to identify components of milieu therapy, as treatment, in their individual treatment program. A second consideration is which components of their milieu therapy program do they percieve as most 9 helpful and as least helpful. The purpose of this study is to look at these aspects of patients' perceptions„

For example, if patients upon discharge are able to identify several components of the milieu therapy program as significant in their care, then knowledge of how often these individual elements are mentioned is helpful for continued planning of the milieu. Such information provides at least some justification for maintaining frequently mentioned components and for emphasizing or deleting compo­ nents that are mentioned infrequently or not at all. Conversely, if patients mention little more re­ garding their treatment programs than the regular visits made to them by their psychiatrist, this information can also facilitate planning of the milieu. This kind of in­ formation emphasizes the need for both staff members and patients to be oriented to the philosophy, purposes, and methods of the milieu therapy program in that particular facility. As patients are further oriented to the purposes of various ward activities and situations, they are perhaps more apt to cooperate with their total treatment program.

A well informed treatment team is needed to orient patients to the treatment program soon after admission and to con­ tinue the orientation, as needed, throughout the patient's stay. 10 Conceptual Framework

As milieu therapy has been utilized in patient care settings, observations have been made and several research studies have been conducted which have led to the develop­ ment of a body of knowledge about milieu therapy. For many years, however, there was a lack of theoretical integration of this body of knowledge. This identified lack was part of the impetus for Gumming and Gumming1s writing of Ego and

Milieu in which they formulated a conceptual framework around the development and function of the ego in relation to its environment (Gumming and Gumming 19 62, pp. vii, 57).

Gumming and Gumming began by studying the concept of ego as it has been formulated by various authors. They looked for segments of common meaning in each formulation and then developed one general concept of the relationship of the ego to the milieu (Gumming and Gumming 1962, p. 32).

Central themes of this concept are ego organization, ego sets, ego elements, and ego ability.

An ego set is a unit of ego organization as well as an organization of ego elements (ego elements -> ego sets -> ego organization) (Gumming and Gumming 1962, pp. 32, 34).

More specifically, an ego set is "an internal representation of a constellation or sequence of events experienced as part of an environment with a specific affective tone" (Gumming ' and Gumming 1962, p. 32). For example, the organization of various fragments of interactions, thoughts, and sensations 11 might lead to a .group of ego sets that together, correspond to a person's relationship with his aunt. This group of ego sets might then be generalized to a person's other relation­ ships with older women. In this way, general role learning occurs, and new role demands are able to be met as the ego sets are reorganized. An inadequate variety of ego sets or poorly differentiated ego sets lead to poor ego organization and imperfect socialization. (Gumming and Gumming 1962, pp.

33-35) for "organized patterns of these sets of internalized role elements are constantly used in dealing with the milieu" (p. 33).

The concepts of response to change and adaptation may be added to the above basic framework. Change is a normal occurrence in every day living, but the quality or magnitude of the change is important to consider. ". . „ it seems probable that the ego must have a certain minimum variety of elements and a certain minimum generality of organization in order not to experience change as a crisis" p. 3 6). Also there must be a minimum degree of stability in the environment in which the individual is acting, but what exactly constitutes minimum is not yet definable.

. . . however, we can suggest that if the ego is indeed a complex of interconnected systems that are themselves systems of elements, then there cannot be any change in any egotized object or relation­ ship or patterned event without disequilibrium of the system and some "ego sensation." This dis- equilibration should apply both to losses of cathected objects and additions of new objects— as in either case there must be some ego 12 reorganization— and this in turn requires some differentiation of sets so that there can be a rearticulation in a new organization (Gumming and Gumming 1962,p . 36). Ego organization, to function effectively, depends upon a certain degree of constancy in the environment which provides repeated feedback to the ego sets involved. A certain amount of familiar objects, role constellations, and ideas must be present in the environment for smooth functioning (p. 37). Most individuals can withstand most shifts in ego organization with little difficulty. Some compensation occurs as the elements of the ego are being de-differentiated and re-organized. This allows the ego to be in a constant state of mild movement, but also in a state of equilibrium

(p. 38). Ego growth may also, occur as new ego sets are developed. The more ego sets that are developed and the greater the number of general ego organizations, the less vulnerable the ego will be to disruption (pp. 38-39).

Not all ego sets are used at.the same time, and not all ego sets are of the same level of usefulness. Some are concerned with taking action, and some are concerned with interpretation of mental input. The ego sets are considered relatively permanent aspects of ego organization, but they vary in strength or hierarchical arrangement according to the way in which they are learned, including the cultural 13 values surrounding their acquisition (Gumming and Gumming 1962, p. 42).

One final term that is important to this conceptual framework is ego ability, "the capacity to find the sets or organizations to deal with any particular environmental problem and to hierarchize them appropriately to the prob­ lem" (p. 43). Another term that is close to ego ability is ego strength, "the general capacity of the ego— that is, the number and variety of sets, the generality and complexity of their organization, and the ability to hierarchize, select, and act out of appropriate organizations" (p. 43). The state of an individual's ego organization is partly avail­ able to him through awareness of his feeling and affective state and through his self concept (p. 43).

A number of theories of ego organization, such as

Erik Eriksen's (cited by Gumming and Gumming 1962, p. 46), are based on the idea that periodic disequilibrium occurs between a developing child and his environment which is followed by resolution and re-equilibrium.at a higher level of ego organization. As the normal child grows and develops, periodic biological changes occur that require a readaptation between the child and his environment. As the child reaches and resolves these periods of developmental crises, his ego is enhanced by increasing the number and variety of ego sets and the complexity and generality of the ego organization. As the ego is reorganized to meet new 14 environmental demands, and harmony is restored, the appro­ priateness of the ego organization is reinforced (Gumming and Gumming 1962,p . 46).

Conversely, a child who fails to resolve a develop­ mental crisis has difficulty in progressing to and resolving future crises because he has too few or too undifferentiaded ego sets and an inadequate level of ego organization. Other life crises such as retirement, bereavement, and disaster lead to similar patterns of crisis resolution or non- resolution with similar consequences of ego organization or disorganization (pp. 46-52). Ego growth is then "a series of disequilibriums and subsequent re-equilibriums between the person and the environment" (p. 56).

Since ego growth is desirable, it seems reasonable to try to induce ego growth by presenting an individual with a series of graded crises situations under, conditions that maximize his chance of resolving them. . In other words, crisis resolution may be viewed as a therapeutic tool that can be scientifically controlled in order to facilitate ego growth by increasing the number and variety of ego sets and ego organization (p. 56).

To summarize, a conceptual framework has been formulated which describes ego development and function in relation to the ego's environment. Therapeutic milieu is defined by Gumming and Gumming (19£2) as "the scientific manipulation of the environment aimed at producing changes 15 in the personality of the patient" (p. 57). In the thera­ peutic milieu, therapeutic community, milieu, or milieu therapy, controlled crisis situations are introduced to allow practice of crisis resolution which, in turn, promotes ego growth to the extent that crisis resolution is success­ ful. The extent to which scientific manipulation of the environment can produce changes in the personality of the patient will be influenced by the patient's awareness of himself in relation to the environment. "This process of acquiring and maintaining awareness of self and environment is called perception"(Knutson 19 65, p. 147). Rogers (1971) explains perception this way:

It is the perception of the environment which con­ stitutes the environment, regardless as to how this relates to some "real" reality which we may philo­ sophically postulate. The infant may be picked up by a friendly, affectionate person. .If his percep­ tion of the situation is that this is a strange and frightening experience, it is this perception, not the "reality" or the "stimulus" which will regulate his behavior. To be sure, the relationship with the environment is a transactional one, and if his con­ tinuing experience contradicts his initial percep­ tion, then in time his perception will change. But the effective reality which influences behavior is at all times the perceived reality. We can operate theoretically from this base without having to re­ solve the difficult question of what "really con­ stitutes reality" (p. 19 6) .

The process of perception is quite complex as it is influenced by many factors (see Figure 1). The process begins when the perceiving individual scans the environment and receives sensory data from the environment via his The perceiving individual Receives sensory Sensory data Which may be from his special data from reach his given off vantage point environment sense organs concurrently influenced by: by means of: by means of: by many sources:

Genetically based tenden- Seeing Sight wave particles cies to organize sensations Hearing Sound wave particles

The quality of his Tasting Chemical particles Speaker sensory equipment Smelling Chemical particles

Sizzling Neural traces of experience Touching Pressures < steak Values i Feeling Pressures, Tensions, Wants Heat Vibrations Concerns Cold Fears Pain Hopes . Tension Assumptions Movement Expectations . 1

Figure 1. Function and Process of Perception — From Knutson (1965, p. 167) 17 sense organs. The act of scanning involves identification of or perception of things, and as Bruner (1957) states,

"perception involves an act of categorization" (p. 123). In order to perceive something, you must have a way to cate­ gorize it or to identify it, that is, a name or a label to apply in order for perception to occur.

As perceptions are made by an individual, they influence his actions. "Man tends to act in terms of what he knows, expects, or hopes that action to yield; how man behaves with respect to any situation tends to be in accord with how he perceives or defines that situation" (Knutson

1965, p. 159). Translated in terms of the present study, how a patient behaves with respect to the milieu therapy ward environment tends to be in accord with how he perceives or defines that situation.

The purpose of this study is to look at how psy­ chiatric patients, receiving care in an in-patient treatment facility with an established therapeutic milieu, identify and perceive components of milieu therapy in their indi­ vidual treatment program. Patients' perceptions will be determined through the use of language in a structured interview, for "language is the means of communicating perceptual and symbolic information" (Houston 1971, p. 268). CHAPTER II

REVIEW OF THE LITERATURE

Several research studies have been done regarding the merits and shortcomings of milieu therapy as well as how patients perceive the treatment they receive. Studies related to these two general topics are summarized below, beginning with milieu therapy.

Gauthier et al. (1972, pp. SS145-SS148) conducted a comparative study with 64 chronic schizophrenic female patients to evaluate the effects of milieu, group psycho­ therapy, and occupational therapy on patient behavior.

Three rating scales were used to assess the patients.

According to these scales, two of the factors, milieu and occupational therapy, did not significantly affect the patient's psychiatric condition. The third factor, group psychotherapy, did significantly reduce the patients' degree of anxiety without modifying mental state or patient behavior.

Models for milieu therapy vary, but they all include active participation of the patients in decision-making and often in group situations. Reid (1970) conducted a study to examine the functioning of elected patient leaders in a task-oriented group setting in a mental hospital, in order

18 19 to focus on the interrelated functioning of the leader and the group. He specifically looked at the character of the participation that occurred and on the impact that different types of leaders had on a patient group. The Bales and Borgatta Scale for measuring and describing group members1 participation in meetings was modified and adapted for use in this study. The sample consisted of 17 leaders and their groups with each leader having at least three meetings with his group. Different kinds of leaders did emerge with a different impact on their respective groups as measured by verbal activity. In these task-oriented group situations studied, information gathering tended to exceed opinion sharing which in turn was greater than decision-making activity. Total activity of the leader and group tended to equalize in varying situations; that is, in a group where the leader was inactive, the group tended to compensate by increasing activity. These findings suggest that effective leadership in task-oriented groups seems partly dependent on the leader's ability to express his own feelings and to encourage and accept expression of feelings of group members.

This finding varies from usual assumptions about task-. oriented groups which emphasize a focus on facts, and per­ haps opinions, but not feelings (Reid 1970, pp. 268-276).

In a study of milieu therapy Visher and O'Sullivan

(1970) made regular observations of a milieu treatment program on a psychiatric ward for a period of two weeks to establish baseline data. They then suspended all planned group and activity programs on the ward for two weeks and continued to make regular observations to determine if and what kinds of changes would occur in patient behavior during the experimental period. This was followed by a final observation period of two weeks after the milieu therapy program had been restored. The researchers had hypothesized that during the two week experimental period, psychotic symptoms would increase and patient socialization would decrease. The patients, however, did not withdraw or de­ compensate during the experimental period; they assumed responsibility and leadership in planning their own activi­ ties, and they initiated an increased number of contacts with staff members. The researchers did not comment about whether they thought this could be due to the "Hawthorn effect" (Visher and O'Sullivan 1970, pp. 451-456). In another study Pardes et al. (1972) sought to further identify that small group of patients who seem not to benefit from an intensive milieu treatment program. The behavior of these patients steadily deteriorates as they regress to a level far more primitive than their status on admission. The researchers revi. wed the admissions of 107 patients and evaluated their status as "improved," "funda­ mentally unchanged," and "worse." Five patients fell into the last category, and they had all been transferred to a more custodial and authoritarian treatment setting due to 21 unmanageable regressive behavior. Following transfer, these patients generally reversed their regression and were soon discharged. Sources of data included the memories of the researchers,individual interviews with staff, and hospital records. Several common characteristics were identified in the patients and their treatment situations. Methods for improving management of such patients were identified. The researchers hinted at difficulty in carrying out all of these suggestions in a milieu therapy setting, and that once these patients were identified, it might be best to transfer them to a more custodially oriented and authoritarian treat­ ment setting (Pardes et al. 1972, pp. 29-48). Melbin (1969) conducted a study to learn about the behavior of mental hospital ward attendants or psychiatric aides with, mental patients. Four trained observers gathered information about these personnel in a survey at two hospitals— a small private mental hospital and a large state hospital. The small hospital also served as a teaching unit for a nearby medical school; the larger hospital had a negligible psychiatric-teaching affiliation. Observations were made and recorded over a period of two years regarding the conduct of these personnel in the presence of patients at randomized times and places. As the conduct of personnel was being recorded, notes were also made on what patients were doing. These patient behaviors were classified as unusual (bizarre disturbances) or common disturbances (not considered bizarre). As behaviors were classified and frequencies were tallied, a pattern in the timing of disturbances in the small private hospital was discovered. Patients in this hospital were far more likely to show an unusual disturbance on weekdays than they were on evenings and weekends. Disturbances occurred on evenings.and week­ ends, but during these periods such upsets were very likely to be normal in form and thus classified as nonbizarre.

Patients in the large state hospital did not display selectivity in the timing of their disturbances. The re­ searcher accounted for this difference by the weekday presence in the small private hospital of clinical trainees who are receptive to the revelation of symptoms and react with interest and tolerance. This finding provides evidence that the immediate environment or milieu does influence behavior; it supports the need to plan and utilize the en­ vironment for therapeutic purposes (Melbin 1969, pp. 650-

665) .

The remaining studies involve both milieu therapy and patients1 perceptions'of their treatment program. The focus of a study by Ellsworth et al. (1971, pp. 427-441) was the identification of particular components of milieu therapy that correlate with successful psychiatric treat­ ment. The researchers examined efficiency (high patient turnover) and effectiveness (low rate of return to the hospital) as their measure of successful treatment. The tools used to identify milieu characteristics were a Patient

Perception of Ward Scale questionnaire completed by 1141 / patients and a Staff Perception of Ward Scale questionnaire

completed by 479 nursing staff. There were no milieu

characteristics that differentiated overall successful and unsuccessful programs. A few tendencies regarding milieu

characteristics were pointed out, but the findings seemed

inconclusive. The researchers suggest further study in this area using other perception scales and other measures of program success.

Keniston, Boltax, and Almond (1971, pp. 107-118)

conducted a study of intensive milieu therapy in which they

looked for and compared relationships among a variety of

treatment outcome measures for 65 patients--staff ratings of improvement, changes of behavior over the course of hospitalization, attitudinal change, self-reported improve­ ment on follow-up, interviewer-rated improvement, and various objective indices of functioning after hospitaliza­ tion. The researchers came to two major conclusions. First,

improvement and good functioning of a patient have many dimensions; some are subjective, some are objectively related to rated behavior, some are concerned with values, and others are concerned with quality of participation in the social structure of the treatment program. Second, a factor to remember in evaluating treatment systems is that a patient may be affected or changed in one area but not in 24 others. The study results support the use of multiple criteria of patient improvement, mental health, and thera­ peutic effectiveness rather than reliance on a single dimension of improvement due to the low correlations between various treatment outcome variables.

In a study conducted on a ward in a neuropsychiatric hospital. Gross, Curtin, and Moore (1970) evaluated the extent that four variables were part of the milieu therapy environment as judged by both staff members and patients on the ward. The four variables were: (1) congruence— "agree­ ment between feelings, attitudes, intentions of staff and their behavior toward patients"; (2) empathy— "staff under­ standing of patients' behavior and feelings"; (3) level of regard--"positive or negative feelings toward patients"; and (4) unconditional regard— "regard constancy, i.e., invariance of staff regard for patients irrespective of patient behavior" (p. 514). The Barrett-Leonard Relation­ ship Inventory was modified for use in this study with a sample of 13 staff members and 31 patients. Results of the study showed that the milieu therapy climate as a composite was judged favorably by both patients and staff with staff ratings being higher on all four variables than those of patients. A major difference between staff judgment of themselves and patient judgment of staff appeared on one variable— unconditional regard. Improvement may therefore be needed with respect to this particular characteristic 25 of the milieu therapy environment on the ward (Gross et al=

1970, pp. 541-545) . Almond, Keniston, and Boltax (1968, pp. 545-561) reported the first part of a complex study that they con­ ducted regarding the value system on a milieu therapy unit.

They explored, defined, and measured the shared beliefs and values of patients and staff. The study was conducted on a 24-bed psychiatric in-patient unit within a general city hospital that is part of an academic medical center.

Following anthropological and case studies of the unit and its inhabitants, a questionnaire was developed to measure the ward's primary therapeutic values. Patients completed the questionnaire four times on the following schedule: within 48 hours of admission, one week after admission, one month after admission, and prior to discharge. Complete data were collected from 52 patients. Fifteen staff members were also asked to complete the questionnaire. The ward values were found to be very intercorrelated; they could be defined by one factor, "Social Openness and Ward Involve­ ment." Items defining this factor stress belief in valua­ tion of patient membership in the hospital community, open­ ness of communication,, acceptance of responsibility, and confrontation with problems.

In a second report on the study by Almond,

Keniston, and Boltax (19.69, pp. 339-351) , changes in patient values were studied in relation to the therapeutic value system of staff members and of the ward culture as a whole. Both questionnaires and case studies revealed that the vast majority of patients change toward the prescribed value

system of the ward community. These changes continued

through the time of discharge from the ward. The re­

searchers concluded that the process of milieu therapy is

based on acceptance and utilization of ward values which

emphasize social openness and ward involvement as valued

aspects of the patient role. Regression to a dependent,

dehumanized patient role is thereby discouraged. Staff members serve as models to patients as acceptance and

utilization of the described ward values are encouraged.

A study regarding patients' posthospital evaluations

of psychiatric nursing treatment received on a 26-bed, coed, psychiatric ward which used milieu therapy was done by

Chastko et al. (1971, pp. 333-338) . Several staff members conducted telephone interviews based on a nine-item ques­

tionnaire concerning how the patient felt he was doing out

of the hospital and how he now felt about various aspects

of his hospital treatment program. Two of the questionnaire

items dealt with the patients' evaluations of nursing care and their reasons for viewing it as helpful or not helpful.

Data were collected from 47 patients with the time period between discharge and follow-up ranging from 6 to 15 months. Nine nursing staff members rated the 47 patients on a ten- point scale regarding how much each patient had benefitted 27 from the nursing care aspect of his ward treatment. The reported results focused on the evaluation of psychiatric nursing treatment. Most patients valued highly the psy­ chiatric nurse's role as a therapeutic agent. Her helpful­ ness was most commonly related to her supportiveness, avail­ ability, confrontation, and insight. The patients' views of nurses' helpfulness and the nurses' own ratings of how helpful they saw themselves revealed high agreement between the two groups.

In a study by Zaslove, Ungerleider, and Fuller

(1966, pp. 568-576) at a university teaching hospital using milieu therapy, the helpfulness of psychiatric hospitaliza­ tion was examined from the viewpoints of physicians (psy­ chiatric residents), nurses, and patients. During the week prior to his discharge each patient was asked, "What has helped you the most during your hospital stay?" The patient's physician (a psychiatric resident) and the head nurse on the unit were also individually asked, "What do you feel has helped this patient most during his hospital stay?"

Data were collected on 93 patients over a three month time period. Treatment modalities judged most helpful by physicians, nurses, and patients included individual psycho­ therapy (with physicians), milieu, drugs, and EST„ Ques­ tionnaire data were classified under milieu whenever refer­ ences were made to the hospital environment, other patients, non-medical hospital, staff, or to any of the psychological therapies (excluding individual psychotherapy) such as large and small group therapies in which non-medical personnel

participate. Thirty^two percent of the patients chose the

relationship with their physician as most helpful, while 45

percent did not mention their doctors at all as being of help to them. Sixty-one percent chose milieu as having been most helpful. The psychological therapies were chosen by 93 percent of the patients as most helpful, while physicians selected these therapies in 50 percent of the cases.

General agreement occurred between nurses and patients regarding what had been most helpful; physicians tended to disagree with both groups.

In a second report of the study by Zaslove, Unger-

leider, and Fuller (19 68, pp. 482-486) the focus was placed on the importance of the psychiatric nurse from the view­ point of physicians, patients, and nurses. The. study

results revealed that psychiatric residents do not identify nurses as helpful to psychiatric patients. Of all available treatment agents mentioned by the psychiatric residents, nurses were viewed as the least helpful. Nurses identified

the psychiatric residents as quite helpful to psychiatric patients. Nurses and psychiatric residents were regarded by

the patients as being equally helpful to them.

These studies focus on the general topic of milieu

therapy in psychiatric patient care and attempt to assess various aspects of milieu therapy. Several of the studies 29 also include patients' perceptions of their milieu therapy programs. What components of milieu therapy are beneficial to patients? What is the impact of milieu therapy on patient behavior? Is milieu therapy beneficial for all patients? How do patients perceive and evaluate their psychiatric treatment? The results of these studies begin to answer these questions, but much more definitive re­ search needs to be done on various aspects of milieu therapy to complete the answers. CHAPTER III

DESIGN OF STUDY

This study was designed to answer the following two

questions: (1) What components of milieu therapy do psy­

chiatric patients, receiving care in an in-patient treatment

facility with an established therapeutic milieu, identify as

treatment in their individual treatment program? (2) Which

components of milieu therapy do these psychiatric patients perceive as most helpful and as least helpful in their indi­ vidual treatment program?

This chapter explains how the researcher conducted this study in order to answer the above two questions. The population selection procedure, method of -data collection including a brief description of the instrument used, and

the method of data analysis are described.

Population Selection

Patients who were discharged from the psychiatric in-patient unit at the Arizona Medical Center during the period of data collection comprised the population for this study. (See Appendix B for SUMMARY OF MILIEU THERAPY AS IT

IS USED AT THE ARIZONA MEDICAL CENTER.) Twenty-four patients, who agreed to participate in the study and who met the criteria listed below, were included in the population. 31 Criteria for sample selection for this study

included that the patients were:

1. Discharged from the milieu therapy program on the

psychiatric in-patient unit at the Arizona Medical

Center.

2. Willing to give permission to participate in the study. 3. Physically and mentally able to respond to questions

in a structured interview.

There were no restrictions as to age, sex, or previous psy­ chiatric treatment.

Method of Data Collection

The researcher submitted a copy of the intent and design of the study, to the Head of the Department of Psy­

chiatry and to the Associate Director of the Department of

Psychiatry in Nursing at the Arizona Medical Center. Sub­

sequently an ad hoc committee was selected to scrutinize the research proposal and to ultimately grant permission to

conduct the study on 7 East, the in-patient psychiatric unit (Appendix C). Other personnel were given a brief oral

explanation of the intent and design of the study.

When a patient was found to meet the criteria for

inclusion in the study population, the researcher explained

the purpose and methods of the study to the patient

(Appendix D), and the patient was asked if he would be 32 willing to participate. Patients consenting to participate were then interviewed.

One instrument, a questionnaire, was developed by the researcher for the purpose of data collection. After the first draft of the questionnaire was completed, the questionnaire was administered to and discussed with two patients on the in-patient psychiatric unit at the Arizona Medical Center. As a result of that trial use, most of the questions were reworded and shortened.

The final draft of the questionnaire consisted of biolgraphical. information and 8 indirect style questions

(Appendix E). The biographical Information included age, sex, marital status, race, religion, education, occupation, spouse's occupation, and previous psychiatric treatment.

This kind of information was sought in order to obtain a baseline of data about each patient for the purpose of com­ parison. The 8 indirect style questions were designed to encourage patients to talk about their psychiatric hospi­ talization and to share their perceptions of their individ­ ual treatment program.

The questionnaire was administered by the re­ searcher to each patient in the form of a structure inter­ view within 72 hours before the patient's anticipated dis­ charge from the in-patient psychiatric unit at the Arizona

Medical Center. The purpose of the interview was to collect data regarding the patient's- perception of the psychiatric • \

33 treatment he had received on an in-patient psychiatric unit using milieu therapy.

Method of Data Analysis

As the researcher conducted each interview, the patient's verbal comments were summarized in writing on the

interview form. At the close of the interview, the written

summaries were shown to the patient, and the information was directly validated by him. If a patient was dissatisfied with the wording of a summary, the wording was changed accordingly.

Each questionnaire was identified with a number.

Patient names were not used at any time in the recordings

of the study in order to maintain the individual’s privacy. •

The data from the questionnaires were categorized, tabu­

lated, coded, and analyzed by the researcher with the assistance of computer analysis. CHAPTER IV

RESEARCH FINDINGS AND INTERPRETATION OF DATA

The purpose of this chapter is to present and dis­ cuss the data collected by means of the questionnaire and to relate the data to the original statement of the problem.

The two questions posed are as follows: (1) What components of milieu therapy do psychiatric patients, receiving care in an in-patient treatment facility with an established therapeutic milieu, identify as treatment in their indi­ vidual treatment program? (2) Which components of milieu therapy do these psychiatric patients perceive as most helpful and as least helpful in their individual treatment program? . The period of da,tq collection extended from January

1, 1974 to March 1, 1974. During that time period 24 indi­ viduals, who met the criteria for population selection, were interviewed within 72 hours before anticipated discharge from the in-patient psychiatric unit at the Arizona Medical Center.

The presentation of data in Table 1 shows the length of hospitalization for each of the 24 patients„ The range for length of hospitalization was 5 to 126 days, mean was

32.79 days, mode was 15 days, median was 18 days, and 34 35 Table 1. Length of Hospitalization of Patients

Number of Percent of Cumulative Days Patients Patients Percent of Patients

5 1 4.2 4.2

11 2 8.3 12.5 13 1 4.2 16.7

15 3 12.5 29.2 16 2 8.3 37.5

17 2 8.3 45.8

18 2 8.3 54.2

19 1 4.2 58.3

22 1 4.2 62.5

31 1 4.2 66.7

36 1 4.2 70.8 37 1 4.2 75,0

50 1 4.2 79.2

59 1 4.2 83.3

71 1 4.2 87.5 74 1 4.2 91.7

75 1 4.2 95.8

126 _1 4.2 100.0

Total 24 100.0 100.0 36 standard deviation was 29.13 days. Sixteen of the patients were hospitalized for one month or less. As the patients were admitted to the hospital, their admission status was classified as voluntary or involuntary.

Sixteen patients of the population were admitted to the hospital voluntarily, and 8 patients were admitted involuntarily.

Characteristics of the Population

The biographical information sought for the purpose of this study included age, sex, marital status, race, religion, education, occupation, spouse's occupation, and previous psychiatric treatment.

Data regarding age of the patients are presented in

Table 2. The patients ranged in age from 16 to 69 years. Fifty percent of them were 22 years of age and younger.

> Mean age was 34.21 years, mode was 20 years, median was 24 years, and standard deviation was 17,97 years.

The population was evenly split according to sex—

12 males and 12 females.

The marital status of each patient was categorized as married, divorced, separated, single (never married), or widowed. Twelve of the patients had never been married.

Seven of the patients were married at the time of the Study which suggests a problem in establishing and/or maintaining close interpersonal relationships. Also, the low incidence 37

Table 2. Age of Patients

Years Number of Patients

16 to 20 8

21 to 30 5

31 to 40 2

41 to 50 . 3 51 to 60 3. 61 to 69 3 Total . 24

of marriage may be explained by the generally young age of

the population. A summary of the data is presented in

Table 3,

Of the. 24 patients in the population, 20 were Anglo-

American and 4 were Mexican-American.

The religious affiliation of each patient was

categorized as Protestant, Jewish, Catholic, or no

preference. Nineteen of the patients stated a religious

preference. A summary of the data is presented in Table 4.

The highest level of education attainment for each

patient was categorized as elementary school (through grade

8), high school (grades 9, 10, 11, and 12), high school

graduate, college (years 1, 2, 3, and 4), college graduate. 38

Table 3. Marital Status of Patients

Marital Status Number of Patients

Married 7 Divorced 1 Separated 2 Single (Never Married) 12

Widowed _2

Total 24

Tdble 4, Religious Affiliation of Patients

Religious Affiliation Number of Patients

Protestant 9

Jewish 2 Catholic 8

No Preference _5

' Total 24 or graduate school. Two patients had some graduate school, but no other patients' had obtained a college degree. The two patients with a maximum education attainment of eighth grade were both female and aged 49 and 6 7. years respectively.

The average education level for males and females was the same. High school graduate was the mean educational attain­ ment and also the mode. The data a:re presented in Table 5.

Table 5. Highest Level of Educational Attainment of Patients

Educational Attainment Number of Patients

Elementary School (through grade 8) 2

High School (grades 9/ 10, 11, 12) 7

High School Graduate 8

College (years 1, 2, 3, 4) 5

College Graduate 0

Graduate School 2 Total 24 40

The presentation of data in Table 6 shows the categorization of each patient's occupation as professional, business personnel, skilled laborer, unskilled laborer, student, or housewife. None of the patients were cate­ gorized as business personnel. Twelve of the patients were skilled or unskilled laborers. Six of the patients called themselves students. Of the 24 patients, only 3 considered themselves still employed which suggests that psychiatric patients requiring hospitalization have difficulty in maintaining a job. The other 21 patients were housewives, students, retired, or Out-of-work.

Table 6. Occupation of Patients

Occupation Number of Patients

Professional 2

Business Personnel 0

Skilled Laborer 6

Unskilled Laborer 6

Student 6 Housewife _4

Total 24 41

The presentation of data in Table 7 shows the .categorization of occupation for each patient's spouse. The

same categories are used here as were used in Table 6 with

one addition. "Does not apply" was added for those

patients who do not have a spouse— who are single, divorced,

or widowed. No spouses were categorized as students or

housewives. Seven of the spouses were employed at the time

Of the patient's hospitalization, and 2 were not employed at that time,

Table 7. Occupation of Patient’s Spouse

Spouse's Occupation Number of Patients

Does Not Apply 15 Professional 3

Business Personnel 4

Skilled Laborer 1 Unskilled Laborer 1

Student 0 Housewife _0

Total 24 42 Previous psychiatric treatment was another variable examined for each patient. Categories used were in-patient, out-patient, in-patient and out-patient, and none. Eight of the patients had had no previous psychiatric treatment while 2 patients had had both in-patient and out-patient treat­ ment. Twelve of the patients had had previous in-patient psychiatric treatment which suggests a pattern of repeat hospitalizations. The data are summarized in Table 8.

Table 8. Previous Psychiatric Treatment of Patients

Previous Psychiatric Treatment Number of Patients

In-Patient 10

Out-Patient 4

In-Patient and Out-Patient 2

None _8 Total 24

In summary, the population of 24 patients for this study ranged in age from 16 to 69 years. The patients tended to be young in that 12 of them were 22 years of age and younger. Twelve of the patients were male and 12 were female. Seven of the patients were married at the time of the study, and 12 of the patients had never been married. 43

Five of the patients stated no religious preference, while

9 were Protestant, .8 were Catholic, and 2 were Jewish.

Fifteen of the patients had attained at least a high school education, and 2 were college graduates. Six of the patients considered thems,elves students at the time of the study. Twelve of the patients were skilled or unskilled laborers, and 2 were considered professionals. Only 3 patients considered themselves employed at the time of the study. Of the 9 patients who had spouses, 3 of the spouses were professionals, 4 were business personnel, and 2 were laborers. Eight of the patients had had no previous psychiatric .treatment, and 12 of the patients had had previous in-patient psychiatric treatment.

Analysis of Findings

The analysis of the data is of a descriptive nattire which coincides with the basic purpose Of this study, to determine and describe psychiatric patients’ perceptions of their individual treatment program. The data analysis will follow the sequence of questions on the questionnaire

(Appendix El „

The first of a series of 8 non-directive questions asked, "What happened to you that you came to the hospital?"

The question was designed to encourage the patient to begin talking about his hospitalization and was not viewed as directly applicable to the study questions. There was a 44 wide variance in the patients' ability to recall precipitat­ ing circumstances related to their hospitalization. Each patient's response was, therefore, ranked on a scale of 1 to

5, 1 representing no recall, 3 representing partial recall, and 5 representing total recall. The grading of recall ability was based on the extent that the patient's descrip­ tion of his perceptions coincided with the admission note on the chart.

Of the 24 patients in the sample, 6 patients were totally unable (or unwilling) to tell the researcher any­ thing about the precipitating circumstances that led to their hospitalization. Six other patients were graded as total recall in that they related the precipitating circumstances in detail, and what they related coincided with the admis­ sion note on their chart. The remaining 12 patients showed partial ability to recall— 3 were given a grade of 2, 3 were given a grade of 3, and 6 were given a grade of 4„ Twelve of the patients were able and willing to recall all or most of the precipitating circumstances that led to their hospitalization„ To at least some of the patients, this may have been a threatening or uncomfortable question to which they were not totally willing to respond, even if capable of remembering and sharing the information.

,As the researcher collected the data for this study, she was impressed by the number of times the word suicide was mentioned by patients or in admission notes on charts in the description of precipitating circumstances that led to hospitalization. Suicidal ideation only was involved in 5 of the patient situations, suicidal ideation plus suicide attempt was involved in 5 other situations, and no mention of suicide was made in the remaining 14 patient situations.

Specific Components of Treatment Program Item number 2 of the questionnaire reads, "Tell me about your treatment program here," It is not stated as a question, but it was designed to encourage the patients to talk about their individual treatment program and to deter­ mine what kinds of components they viewed as treatment. A simple tabulation was done to determine how many different treatment components each patient mentioned, Table 9 presents a summary of the results. ■ The range of number of treatment components mentioned by each patient was 2 to 15 components. The mean was 8.71, the mode was 11, the median was 9.50, and the standard deviation was 3.46. Thus, there was much variation in the ability of patients to identify treatment components; some mentioned many components, and some identified only a few components„ There was a small tendency for patients with higher levels of education to identify a larger number of treatment components than those with lower levels of education. Length of hospitalization and the experience of previous psychiatric treatment did 46 Table 9. Question #2: Total Number of Treatment Components Mentioned by Each Patient

Number of Components Number of Patients

2 to 3 2

4 to 5 4 6 to 7 2

8 to 9 .4 10 to 11 7

12 to 13 3 14 to 15 2 Total 24

not show a distinguishable influence on the number of

components that individuals mentioned.

A comprehensive list was then made of all the

treatment components mentioned by 1 or more patients in the population. Frequency counts were tabulated for those

treatment components mentioned by more than 1 patient. See

Appendix F for the comprehensive listing of treatment

components, The most frequently mentioned treatment

.components are as follows: occupation therapy’—-22 times,

talking with staff members— 20 times, group therapy— ;17

times, psychodrama’— 16 times, medication— 12 times, and 47 group outings as spectator or observer (hockey game, movie, etc.)— 11 times. A total of 57 different treatment components was mentioned by the 24 patients.

Another way of looking at the data is to categorize the specific treatment components into groups of components. Six categories were selected for this purpose: recreation- physical, recreation-mental, verbal interaction, creature comforts, staff supervision, and diagnostic and medical services. Appendix G consists of the 57 specific treatment components separated into the 6 categories.

The individual categories of treatment components will now be analyzed 1 at a time in order to scrutinize the data'more closely. The first category is recreation- physical which refers to treatment components that provide both diversion and active participation for patients. The presentation of data in Table 10 shows the number of treat­ ment components that each patient mentioned within the category of recreation-physical. The range of number of components mentioned was 0 to 6. Most patients identified

1 to 4 components. One might expect young males to favor this category, but in reality, this trend was only slight.

Generally both males and females who were old and young favored and disfavored components in this category.

The second category is recreationtmental which refers to treatment components that provide a mainly mental type of diversion, for patients, with little physical 48

Table 10. Question #2: Number of Treatment Components Mentioned by Each Patient Within the Category of Recreation-Physical

Number of Components Number of Patients

0 1

1 to 2 10 3 to 4 10 5 to 6 3 Total 24

activity. The presentation of data in Table 11 shows the number of treatment components that each patient mentioned within the category of recreation-mental. The range of number of components mentioned was 0 to 3» Fewer components were identified in this category than in recreation-physical. No trends appeared on the basis of sex, age, education, etc„

The third category is verbal interaction which refers to verbal communication between patients, families, and staff members, The presentation of data in Table 12 shows the number of treatment components that each patient mentioned within the category of verbal interaction. The range of number of components was 0 to 6. This category had about equal appeal to the various age groups, There was 49

Table 11. Question #2: Number of Treatment Components Mentioned by Each Patient Within the Category of Recreation-Mental

Number of Components Number of Patients

0 10 1 5

2 6

3 _3 . Total 24

Table 12, Question #2: Number of Treatment Components Mentioned by Each Patient Within the Category of Verbal Interaction

Number of Components Number of Patients

0 1

1 to 2 8 3 to 4 . 12

5 to 6 _3

Total 24 50

a small tendency for patients with lower levels of education to mention fewer components in this category than those with higher levels of education. Males tended to mention more components in this category than did females, even though the average educational level for males and females was the same in this population.

The fourth category is creature comforts which refers to meeting of physical needs such as food, sleep, safety, quiet, and other aspects of physical comfort. The presentation of data in Table 13 Shows the number of treat­ ment components that each patient mentioned within the category of creature comforts. The range of number of components was 0 to 4. Most patients mentioned 0 or 1 component in this category. There were no distinguishable trends based on biographical categories.

Table 13. Question #2: Number of Treatment Components Mentioned by Each Patient Within the Category of Creature Comforts

Number of Components Number of Patients

0 14 1 7

2 to 4 _2 Total 24 51 The fifth category is staff supervision which refers to rules, regulations, schedules, and other aspects of observation and regulation of patients by staff members.

The presentation of data in Table 14 shows the number of treatment components that each patient mentioned within the category of staff supervision. The range of number of components was 0 to 4. Most patients mentioned 0 or 1 component in this category. No other trends in manner of response were apparent.

Table 14. Question #2: Number of Treatment Components Mentioned by Each Patient Within the Category of Staff Supervision

Number of Components Number of Patients

0 14

1 8

2 to 4 2 Total 24

The sixth category is diagnostic and medical services which includes medical treatments such as medica­ tion and diagnostic services such as psychological testing.

The presentation of data in Table 15 shows the number of treatment components that each patient mentioned within the category of diagnostic and medical services. The range of 52 Table 15. Question #2: Number of Treatment Components Mentioned by Each Patient Within the Category of Diagnostic and Medical Services

Number of Components Number of Patients

0 10 1 12

2 to 3 _2 Total 24

number of components was 0 to 3. As was true of the previous 2 categories, most patients mentioned 0 or 1 component in this category. There were no distinguishable trends based on biographical categories.

The presentation of data in Table 16 shows a

statistical comparison of the 6 categories used to group the data from question number 2. As can be seen by looking at the means, more treatment program components were cate­ gorized under verbal interaction than any other category. The second most popular category was recreation-physical.

If the 2 recreation categories were grouped together, they would become the most popular single category.

Most Helpful Components of Treatment Program

,Item number 3 on the questionnaire reads, "What has been most helpful to you?" The purpose of this question was 53

Table 16. Question #2: Specific Components of Treatment Program, Statistical Comparison of the Six Categories

Number of Standard Different Devia­ Components Category Range Mean Mode Median tion „ .Mentioned

Recreation-

Physical 0 to 6 2.67 1 . 2.67 1.66 9 Recreation- Mental 0 to 3 1.08 0 .90 1.10 11 Verbal Interaction 0 to 6 3.00 3 3.00 1.53 13

Creature Comforts 0 to 4 .67 0 . 36 1.05 10

Staff Supervision 0 to 4 .58 0 .36 .93 9

■Diagnostic and Medical Services 0 to 3 ,71 1 .67 .75 5

Total 57 54 to encourage patients to share their perceptions of what specific components of their treatment program they found most helpful. A simple tabulation was done to determine how many different treatment components each patient identified as most helpful. Table 17 presents a summary of the results. The range of number of treatment components mentioned by each patient was 0 to 7 components. . The mean was 3.75, the mode was 3, the median was 3.33, and the standard deviation was 2.05. There was much variation in the ability of patients to identify most helpful treat­ ment components. No distinguishable trends appeared on the basis of sex, age, or education as the data were fairly evenly distributed among the different categories.

Table 17. Question #3: Total Number of Most Helpful Treatment Components Mentioned, by Each Patient

Number of Components , Number of Patients

0 to 1 2 2 to 3 11

4 to 5 6

6 to 7 _5

Total 24 55 A comprehensive list was then made of all the most helpful treatment components mentioned by one or more patients in the sample. Frequency counts were tabulated for those most helpful treatment components mentioned by more than 1 patient. See Appendix H for the comprehensive listing of most helpful components of treatment program.

The most frequently mentioned treatment components that were considered most helpful are as follows: talking with staff members— 16 times, occupational therapy— 12 times, and psychodrama--9 times. A total of 31 different treatment components was mentioned as most helpful by the 24 patients.

Another way of looking at the data is to categorize the specific treatment components into groups of components as was done for the data from question number 2, The same

6 categories were again selected: recreation-physical, recreation-r-mental, verbal interaction, creature comforts, staff supervision, and diagnostic and -medical services,

Appendix I consists of the 31 most helpful components of treatment program separated into the 6 categories.

The individual categories of most helpful components of treatment program will how be analyzed 1 at a time in order to scrutinize the data more closely. The first category is recreation-physical, and the presentation of data in Table 18 shows the number of most helpful components of treatment program that each patient mentioned within this category. The range of number of components mentioned was 56

Table 18. Question #3; Number of Most Helpful Treatment Components Mentioned by Each Patient Within the Category of Recreation-Physical

Number of Components Number of Patients

0 8 1 11 2 to 3 _5

Total 24

0 to 3. Most patients identified 0 or 1 component in this category. No other trends in manner of response were apparent. The second category is recreation-mental, and the presentation of data in Table 19 shows the number of most helpful components of treatment program that each patient mentioned within this category. The range of number of components mentioned was 0 to 3. Most patients identified

0 or 1 component in this category. Fewer components were identified in this category than in recreation-physical.

No trends appeared on the basis of biographical categories.

The third category is verbal interaction, and the presentation of data in Table 20 shows the number of most helpful components of treatment program that each patient mentioned within this category. The range of number of 57 Table 19. Question #3: Number of Most Helpful Treatment Components Mentioned by Each Patient Within the Category of Recreation-Mental

Number of Components. Number of Patients

0 16

1 6 2 to 3 _2 Total 24

Table 20. Question #3: Number of Most Helpful Treatment Components Mentioned by Each Patient Within the Category of Verbal Interaction

Number of Components Number of Patients

0 4

1 to 2 14

3 to 4 6

Total 24 58 components -mentioned was 0 to 4. There was a small tendency for patients with lower levels of education to mention fewer components in this category than those with higher levels of education. Males tended to mention more components in this category than females. The fourth category is creature comforts, and the presentation of data in Table 21 shows the number of most helpful components of treatment program that each patient mentioned within this category. The range of number of components mentioned was 0 to 2. Only 1 patient mentioned more than 1 component in this category. There were no dis­ tinguishable trends based on biographical categories.

Table 21. Question #3: Number of Most Helpful Treatment Components Mentioned by Each Patient Within the. Category of Creature Comforts

Number of Components Number of Patients

0 18

1 to 2 6 Total 24 59 The fifth category is staff supervision, and the presentation of data in Table 22 shows the number of most helpful components of treatment program that each patient mentioned within this category. The range of number of components mentioned was 0 to 1. Most patients mentioned no components in this category. No trends in response based on biographical data were apparent.

Table 22. Question #3: Number of Most Helpful Treatment Components Mentioned by Each Patient Within the Category of Staff Supervision

Number of Components Number of Patients

0 21

1 _3 Total 24

The sixth category is diagnostic and medical services, and the presentation of data in Table 23 shows the number of most helpful components of treatment program that each patient mentioned within this category. The . range of number of components was 0 to 2. Only 1 patient mentioned more than 1 component in this category.

The presentation of data in Table 24 shows a statistical comparison of the 6 categories used to group 60 Table 23, Question #3; Number of Most Helpful Treatment Components Mentioned by Each Patient Within the Category of Diagnostic and Medical Services

Number of Components Number of Patients

0 19

1 to 2 5 Total 24

Table 24, Question #3: Most Helpful Treatment Components, Statistical Comparison of the Six Categories

Number of Standard Different Devia­ Components Category Range Mean Mode Median tion Mentioned

Recreation- Physical 0 to 3 .92 1 . 86 ,83 6 Recreation- Mental 0 to 3 .46 0 .25 .78 6

Verbal Interaction 0 to 4 1.71 2 1.75 . 1.12 9 v

Creature Comforts 0 to 2 .29 0 .17 .55 5

Staff Supervision 0 to 1 .13 0 .07 .34 3

Diagnostic and Medical Services 0 to 2 .25 0 .13 .53 _2

Total 31 61 the data from question number 3„ As can be seen by looking at the means, more most helpful components of treatment program were categorized under verbal interaction than any other category. The second most mentioned category was recreation-physical. If the 2 recreation categories were grouped together, they would still be in second place behind verbal interaction. See Table 16 in order to compare these data with, the similar data from question number 2.

Least Helpful Components of Treatment Program

Item number 4 on the questionnaire reads, "What has been least helpful to you?" The purpose of this question was to encourage patients to share their perceptions of what specific components of their treatment program they found least helpful. A simple tabulation was done to determine how many different components each patient identified as least helpful. Table 25 presents a summary of the results.

The range of the number of treatment components mentioned by each patient was 0 to 7. The mean was 2.04, the mode was 2, the median was 1.67, and the standard deviation was 1.83. There was some variation in the ability of patients to identify least helpful treatment components, but less than the variation in the ability of patients to identify most helpful treatment components. There was a small tendency for males to identify more least helpful treatment components than females. Patients with a lower level of 62

Table 25, Question #4: Total Number of Least Helpful Treatment Components Mentioned by Each Patient

Number of Components Number of Patients

0 5 1 to 2 12 3 to 4 5

5 to 7 2 Total 24

education tended to identify few least helpful treatment components. A comprehensive list was then made of all the least helpful treatment components mentioned by one or more patients £n the sample„ Frequency counts were tabulated for the least helpful treatment components mentioned by more than one patient. See Appendix J for the comprehensive listing of least helpful components of treatment program.

The most frequently mentioned treatment components that were considered least helpful are as follows: medication—

4 times, psychodrama— 3 times, group therapy— 3 times, and creative movement— 3 times. A total of 37 different treat­ ment components was mentioned as least helpful by the 24 patients. 63 Another way of looking at the data is to categorize the specific treatment components into groups of components as was done for the data from questions number 2 and 3.

The same 6 categories were again selected: recreation- physical, recreation-mental, verbal interaction, creature comforts, staff supervision, and diagnostic and medical services. Appendix K consists of the 37 least helpful components of treatment program separated into the 6 cate­ gories.

The individual categories of least helpful components of treatment program will now be analyzed 1 at a time in order to scrutinize the data more closely. The first category is recreation-physical, and the presentation of data in Table 26 shows the number of least helpful components of treatment program that each patient mentioned within this category. The range of number of components is 0 to 1, No trends in responses based on biographical data were apparent.

Table 26, Question #4: Number of Least Helpful Treatment Components Mentioned by Each Patient Within the Category of Recreation-Physical .

Number of Components Number of Patients

0 19

1 _5

Total 24 The second category is recreation-mental, and the presentation of data in Table 27 shows the number of least helpful components of treatment program that each patient mentioned within this category. • The range of number of components mentioned was 0 to 1. Only 1 patient, the youngest male in the population, mentioned a component in this category.

Table 27. Question #4: Number of Least Helpful Treatment Components Mentioned by Each Patient Within the Category of Recreation-Mental

Number of Components .Number of Patients

O' 23 1

— ■ Total 24

The third category- is verbal interaction, and the presentation of data in Table 28 shows the number of least helpful components of treatment program that each patient mentioned within this category. The range of number of components mentioned was 0 to 4. This category had about equal appeal to the various age groups and levels of education background represented in the sample. The main 65

Table 28. Question #4: Number of Least Helpful Treatment Components Mentioned by Each Patient Within the . Category of Verbal Interaction

Number of Components Number of Patients

O' 14 1 to 2 8

3 to 4 2 Total 24

distinguishable trend is that males mentioned more components in this category than did females.

The fourth category is creature comforts, and the presentation of data in Table 2 9 shows the number of least helpful components of treatment program that each patient mentioned within this category. The range of number of components mentioned was 0 to 2. Most patients mentioned no component in this category. No other trends in response were distinguishable. The fifth category is staff supervision, and the presentation of data in Table 30 shows the number of least helpful components of treatment program that each patient mentioned within this category. The range of number of components is 0 to 3. Most patients mentioned 0 or 1 66 Table 29. Question #4: Number of Least Helpful Treatment Components Mentioned by Each Patient Within the Category of Creature Comforts

Number of Components Number of Patients

0 21 . 1 to 2 3

Total 24

Table 30. Question #4: Number of Least Helpful Treatment Components Mentioned by Each Patient Within the Category of Staff'Supervision

Number of Components Number of Patients

0 14

1 7 2 to 3 3 Total 24 67 component in this category. There were no distinguishable trends based on biographical categories„

The fifth category is diagnostic and medical services, and the presentation of data in Table 31 shows the number of least helpful components of treatment program that each patient mentioned within this category. The range of number of components is 0 to 2. Only 1 patient mentioned more than 1 component in this category. No other trends in response were apparent.

Table 31. Question #4: Number of Least Helpful Treatment Components Mentioned by Each Patient Within the Category of Diagnostic and Medical Services

Number of Components Number of Patients

0 19

1 to 2 5

Total 24

The presentation of data in Table 32 shows a statistical comparison of the 6 categories used to group the data from question number 4, As can be seen by looking at the means, more,least helpful components of treatment pro­ gram were categorized under verbal interaction than any other category. The second most mentioned category was 68 Table 32. Question #4: Least Helpful Treatment Components, Statistical Comparison of the Six Categories

Number of Standard Different Devia­ Components Category Range Mean Mode Median tion Mentioned

Recreation- Physical 0 to 1 .21 0 ,13 .42 3

Recreation- Mental 0 to 1 .04 0 .02 .20 1 Verbal Interaction 0 to 4 .75 0 .36 1.11 13

Creature Comforts 0 to 2 .21 0 .07 .59 5

Staff Supervision 0 to 3 .58 0 .36 .83 12

Diagnostic and Medical Services 0 to 2 .25 0 .13 .53 _3 Total 37 - 6.9 staff supervision. See Tables 16 and 24 in order to compare these data with the similar data from questions 2 and 3.

The presentation of data in Table 33 shows a comparison of statistical data regarding tabulation of components from questions 2 (all components), 3 (most helpful components), and 4 (least helpful components).

Patients generally mentioned more most helpful than least helpful components. A larger number of different least helpful than most helpful components were mentioned, but they were usually mentioned by only 1 patient. There was a small tendency for patients having a higher level of educa­ tion to mention_ more treatment components than those patients having a 'lower level of education which suggests that educational level influences patients' perceptions of or ability to communicate their perceptions of what is treatment, There was also a small tendency for patients having a lower level of education to identify few least helpful treatment components and for males to identify more least helpful components than females„

Several trends are also apparent in how the patient responses fell into the 6 categories for questions 2, 3, and 4 of the questionnaire. Verbal interaction was the most popular category for all 3 questions which suggests that verbal interaction in a variety of forms played an integral part in the general treatment program. This finding certainly coincides with the philosophy of milieu therapy. 70 Table 33. Comparison of Statistical Data Regarding Tabula­ tion of Components from Questions #2, #3, and #4

Number of Standard Different Devia­ Components Question Range Mean Mode Median tion Mentioned

#2— All Components 2 to 15 8.71 11 9.50 3.46 57 # 3--Most Helpful 0 to 7 3.75 3 3.33 2.05 31 #4— Least Helpful 0 to 7 2.04 2 1.67 1.83 37

Recreation-physical was the second most mentioned category for all 3 questions which points to the balance of work and play that is needed in treatment planning.

When biographical data were screened in relation to the 6 categories used for patient responses, several findings became apparent. A slight trend existed for young males to favor treatment components in the recreation- physical category. There was a small trend for patients with a lower education to mention less components in the verbal interaction category than did the patients with a higher education in questions 2 and 3, Males mentioned more components in the verbal interaction category than did females in responding to questions 2, 3, and 4, Other 71 biographical influences that may have been operating remained indistinguishable in this small population of 24 patients.

Most Helpful Single Event During This Hospitalization

Item number 5 on the questionnaire reads, "What

single incident seemed to be a turning point for you, that

is, the most helpful single event during your hospitaliza­ tion?" The purpose of this question was to further pin­

point what patients perceive as most helpful in their treat­ ment program. Fifteen patients were able to identify a most helpful single event, and 9 patients were unable to identify

such an event» A listing by questionnaire number is avail­

able in Appendix L of those who were able and unable to

identify a most helpful single event. A list of the most

helpful single events and on which questionnaire each one

appeared is also available in Appendix L. Two events were mentioned by more than one person: leaving the hospital to

go home (discharge)--2 times and first time in seclusion

room— 2 times. Thirteen different most helpful single

events were mentioned.

Another way of looking at the data is to categorize

the single events into groups of events as was done for the

data from previous questions (2, 3, and 4). The same 6

categories were again selected: recreation-physical, recreation-mental, verbal interaction, creature comforts, 72 staff supervision, and diagnostic and medical services.

Appendix M consists of the 13 single events separated into the 6 categories.

The individual categories of most helpful single event during this hospitalization will not be analyzed 1 at a time as was done with the data from questions 2, 3, and 4.

The data from question 5 are less complex and will thus be summarized more concisely. The presentation of data in Table 34 shows a statistical comparison of the 6 categories used to group the data from question 5. No most helpful single event fell into the first 2 categories. Seven of the events related to staff supervision, and 6 events related to verbal interaction, so these were the 2 most mentioned categories. See Tables 16, 24, and 32 in order to compare these data with the similar data from questions 2,3, and 4.

No distinguishable trends in patient response were apparent based on biographical categories.

Most Helpful Person(s) During This Hospitalization

Questionnaire item number 6 reads, "Who seemed to be the most helpful person (s) during your hospitalization?" Staff involvement in patient care from many of the health disciplines is a part of the milieu philosophy. Thus, the purpose of the above question was to learn about patients’ perceptions of the people they were in contact with during Table 34, Question #5: Most Helpful Single Event During This Hospitalization, Statistical Comparison of the Six Categories

Number of Standard Different Devia­ Components Category Range Mean Mode Median tion Mentioned

Recreation- Physical 0.0 0.0 0 0.0 0.0 0 Recreation- Mental 0,0 0.0 0 0.0 0.0 0

Verbal Interaction 0 to 1 .25 0 .17 .44 6 Creature Comforts 0 to 1 ,04 0 .02 ,20 1

Staff Supervision 0 to 1 .29 0 .21 .46 5

Diagnostic and Medical Services 0 to 1 .04 0 .02 .20 1

Total 13 74 their hospitalization— staff members from various health disciplines and other patients.

In analyzing the data for question number 6, a simple tabulation was done to determine how many different persons each patient mentioned. Table 35 presents a summary of the tabulation. The range of number of persons mentioned by each patient was 0 to 10. The mean was 4.33, the mode was 5, the median was 4.5, and the standard deviation was

2.78. There was much variation in the ability of patients to identify the most helpful person (s) including 2 patients, one young male and one young female, who were unable to single out anyone as most helpful.

Table 35. Question #6: Total Number' of Persons Mentioned by Each Patient

Number of Persons Number of Patients

0 2

1 to 2 6

3 to 4 4 '

5 to 6 8

7 to 8 2

9 to 10 _2 Total - 24... 75 Males showed a small tendency to name more persons than females. Level of education showed no pattern in number of persons named. One might speculate that those who were admitted involuntarily might name fewer people, but no such pattern developed. The 2 people who named no one had been admitted voluntarily. Length of hospitalization also revealed no distinguishable pattern in patient response.

A comprehensive list was then made of.all the per­ sons mentioned by 1 or more patients in the sample. Fre­ quency counts were tabulated for those persons mentioned by more than 1 patient. See Appendix N for the comprehen­ sive listing of persons, according to. title. The most frequently mentioned persons are as follows: psychiatric technician A— 9 times, psychiatric technician B— 8 times, registered nurse A — -1 times, and occupational therapist A—

6 times. Forty different persons were mentioned by the 24 patients.

Another way of looking at the data is to categorize the specific persons into groups of persons. Seven cate­ gories were selected for this purpose: psychiatrists and psychologists; residents, psychology interns, and medical students; registered.nurses and licensed practical nurses; psychiatric technicians; social workers; occupational therapists and occupational therapist interns; and other patients„ Appendix 0 consists of the 40 persons by title separated into the 7 categories„ 76 The individual categories of persons will now be

analyzed 1 at a time in order to scrutinize the data more

closely. The first category is psychiatrists and psycholo­

gists. The presentation of data in Table 36 shows the number of persons that each patient mentioned within this category. The range of number of persons mentioned is 0 to

2. Fifteen patients mentioned no one in this category.

No trends in response based on biographical data were

apparent.

Table 36. Question #6: Number of Persons Mentioned by Each Patient Within the Category of Psychiatrists and Psychologists

Number of Persons Number of Patients

o 15

1 8 2 1

Total 24

The second category is residents, psychology interns,

and medical students. The presentation of data in Table 37

shows the number of persons that each patient mentioned

within this category. The range of number of.persons mentioned is 0 to 3, Twelve patients mentioned no one in 77 Table 37. Question #6: Number of Persons Mentioned by Each Patient Within the Category of Residents, Psychology Interns, and Medical Students'

Number of Persons Number of Patients

0 12 1 8

2 3

3 _1 ‘Total 24

this category. No trends in response based on biographical data were apparent. The third category is registered nurses and licenses practical nurses. The presentation of data: in

Table 38 shows the number of persons that each patient mentioned within the category. The range, of number of persons is 0 to 4. Ten patients mentioned no one in this category. Females mentioned people in this category of all females more often than did males.

The fourth category is psychiatric technicians. The presentation of data in Table 39 shows the number of persons that each patient mentioned within this category„ The range of persons is 0 to 3. Nine patients mentioned no one in 78 Table 38. Question #6: Number of Persons Mentioned by Each Patient Within the Category of Registered Nurses and Licensed Practical Nurses

Number of Persons Number of Patients

0 10

1 7

2 2

3 4

4 _1 Total 24

T^ble 39 e Question #6; Number of Persons. Mentioned by Each Patient Within the Category of Psychiatric Technicians

Number of Persons Number of Patients

0 9

1 6

3 _3 Total 24 79 this category. There was a marked trend for young male patients to frequently identify persons from this category of mostly young male staff members. Six of the 9 patients who identified 2 or 3 persons in this category were young males. The fifth category is social workers. The presenta­ tion of data in Table 4 0 shows the number of persons that each patient mentioned within this category. The range of number of persons is 0 to 1. Sixteen patients mentioned no one in this category. No trends were apparent on the basis of biographical categories.

Table 40. Question #6: Number of Persons Mentioned by Each Patient Within the Category of Social Workers

Number of Persons Number of Patients

0 16

1 8

Total 24

The sixth category is occupational therapists and occupational therapist interns. The presentation of data in Table 41 shows the number of persons that each patient mentioned within this category. The range of number of persons is 0 to 2, Seventeen patients mentioned no one in 80 Table 41. Question #6: Number of Persons Mentioned by Each Patient Within the Category of Occupational Therapists and Occupational Therapist Interns

Number.of Persons Number of Patients

0 17

1 3 2 _4

Total 24

this category. No trends in response based on biographical data were apparent. The seventh category is other patients. The presentation of data in Table 42 shows the number of persons that each patient mentioned in this category. The range of number of persons is 0 to 2, Only 3 patients identified other patients as particularly helpful during their hospitalization, <

The presentation of data in Table 43 shows a statistical comparison of the 7 categories used to group the data from question number 6. As can be seen by looking at the means, more most helpful persons were categorized under 2 categories than any of the others— registered nurses and licensed practical nurses and psychiatric technicians, Six psychiatric technicians were mentioned 81

Table 42. Question #6: Number of Persons Mentioned by Each Patient Within the Category of Other Patients

Number of Persons Number of Patients

0 21

1 2

2 _JL Total 24 Table 43. Question #6: Most Helpful Person(s) During This Hospitalization, Statistical Comparison of the Seven Categories ,/

Number of Different Standard Persons Category Range Mean Mode Median Deviation Mentioned

Psychiatrists & Psychologists 0to 2 .42 0 .30 .58 6

Residents, Psychology Interns, & Medical Students 0 to 3 .71 0 .50 ' .86 8

Registered Nurses and Licensed Practical Nurses 0 to 4 1.13 0 .79 1.26 12

Psychiatric Technicians ^0 to 3 1.13 0 1.00 1.08 6

Social Workers 0 to 1 .33 0 .25 .48 2 Occupational Therapists & Occupational Therapist Interns 0 to 2 .46 0 .21 . 78 2

Other Patients 0 to 2 .17 0 .07 .48 _4

' Total 40 83 as often as a group as the 12 registered nurses and licensed

practical nurses. Residents, psychology interns, and medical students were the next most frequently mentioned group.

The researcher notes with interest that persons in the two most popular categories, registered nurses and

licensed practical nurses and psychiatric technicians, tend

to have more hours of direct contact with in-patients than do persons in the other categories. This quantity of patient contact may thus be a major influence on patients'

identifying persons in these categories as most helpful.

Sex differences in categories chosen is also of interest. Female patients mentioned persons in the category of registered nurses and licensed practical nurses, an all

female category, more frequently than did males. Likewise,

there was a marked trend for young male patients to fre­ quently identify persons in the category of psychiatric technicians, a mostly young male category, as most helpful.

This pattern suggests that patients in an in-patient psychiatric setting may tend to seek help from and feel

closer to persons of the same sex and even of a similar age.

The data from question 6 certainly support the milieu philosophy of utilizing staff members from the various • - health disciplines. The data also suggest the need for

utilizing both male and female staff members and of various

ages. 84 Gains from This Hospitalization Questionnaire item number 7 reads, "What have you gained from this hospitalization?" This question is less directly related to the main questions posed in this study

than most of the other questionnaire items, but it was added as another way of looking at patients' perceptions of their individual treatment program. A simple tabulation was done to determine how .many different gains each patient identified. Table 44 presents a summary of the tabulation.

The range of number of gains from this hospitalization is

0 to 5. The mean is 2.50, the mode is 2, the median is

2.36, and the standard deviation is 1,56. There was a small tendency for patients with long hospitalizations to identify several gains. For example, the three patients who identified 5 gains were hospitalized 126, 50, and 74 days respectively. Long hospitalizations suggest that these patients had more complex problems and the need to make more gains than patients with short hospitalizations. No biographical trends were distinguishable except that males identified a few more gains than did females.

A comprehensive list was then made of all the gains from this hospitalization mentioned by 1 or more patients . ' ■ • in the population. Frequency counts were tabulated for those gains mentioned by more than 1 patient. See Appendix P for the comprehensive listing of gains from this hospitalization. The most frequently mentioned gains are 85 Table 44. Question #7: Total Number of Gains from This Hospitalization Mentioned by Each Patient

Number of Gains Number of Patients

0 3 1 3 2 7 3 4

4 4

5 _3 Total 24

as follows: no longer feel so depressed— 5 times and better able to communicate with other people— 3 times. Forty- seven different gains from this hospitalization were mentioned by the 2 4 patients.

Another way of looking at the data is to categorize the specific gains from this hospitalization into groups of gains. Three categories were selected for this purpose: feelings about self, feelings in relation to others, and physical well-being, Appendix Q consists of the 47 gains separated into the 3 categories.

The individual categories of gains from this hospitalization will now be analyzed 1 at a time in order to scrutinize the data more closely. The first category is 8 6 feelings about self. The presentation of data in Table 45 shows the number of gains that each patient mentioned within this category. The range of number of gains mentioned is 0 to 4. Only 5 patients did not identify a gain in this category.

Table 45. Question #7: Number of Gains Mentioned by Each Patient Within the Category of Feelings About Self

Number of Gains Number of Patients

0 5 1 to 2 13

3 to 4 _6

Total 24

The second category is feelings in relation to others. The presentation of data in Table 46 shows the number of gains from this hospitalization that each patient mentioned within this category. The range of number of gains mentioned is 0 to 3. Sixteen patients identified no gains in this category. The third category is physical well-being. The presentation of data in Table 47 shows the number of gains from this hospitalization that each patient mentioned within 87 Table 46. Question #7: Number of Gains Mentioned by Each Patient Within the Category of Feelings in Relation to Others

Number of Gains Number of. Patients

0 16 1 5 2 to 3 3 Total 24

Table 47. Question #7: Number of Gains Mentioned by Each Patient Within the Category of Physical Well- Being

Number of Gains Number of Patients

0 18

1 2

2 to 3 _4 Total 24 88 this category. The range of number of gains mentioned is 0 to 3. Eighteen patients identified no gains in this category.

The presentation of data in Table 48 shows a statistical comparison of the 3 categories used to group the data from question number 7. As can be seen by looking at the means, most of the gains from this hospitalization were categorized under feelings about self. The other 2 categories shared about equal importance. The same basic trends were present in all 3 categories of the data. People with longer hospitalizations tended to mention more gains than people with shorter hospitalizations, and males tended to mention more gains than did females.

Table 48, Question #7: Gains from This Hospitalization, Statistical Comparison of the Three Categories

Number of Different Standard Gains Category Range Mean Mode Median Deviation Mentioned

Feelings about Self 0 to 4 1,54 1 1,28 1,25 28 Feelings in Relation to Others 0 to 3 ,50 0 ,25 ,83 9

Physical Well-Being 0 to' 3 .46 0 ,17 ,88 10

Total 47

\ 89 Suggestions for Improving the Care on 7 East Questionnaire item number 8 reads, "What sugges­ tions do you have for improving the care on 7 East?" This question provided 1 last opportunity for learning how the patients perceived their treatment program and how they thought their treatment could have been improved. A simple tabulation was done to determine how many different sugges­ tions each patient made. Table 49 presents a summary of the tabulation. The range of number of suggestions is 0 to 5, the mean is 1.29, the mode is 0, the median is 1.25, and the standard deviation is 1.30. Nine patients identified no suggestions for improving the care on 7 East. Most of the remaining patients identified 1 or 2 suggestions. No other trends in the data are distinguishable.

Tqble 49, Question #85 Total Number of Suggestions for Improving the Care on 7 East Mentioned by Each Patient

Number of Suggestions Number of Patients

0 9

1 4

2 8

2 to 5 _3 Total 24 90 A comprehensive list was then made of all the

suggestions for improving the care on 7 East mentioned by

1 or more patients in the population. Frequency counts

were tabulated for those suggestions mentioned by more than

1 patient. See Appendix R for the comprehensive listing of suggestions„ The only suggestions that were mentioned by more than 1 patient were not enough games to play on the

unit and more group outings. Both of these suggestions were

made by 2 patients. Twenty-nine different suggestions were

made by the 24 patients. One suggestion, need a pool table, has already been filled as the in-patient unit

received a pool table midway through the study. Another way of looking at these data is to cate­

gorize the specific suggestions for improving the care on

7 East into groups of suggestions. Six categories were

selected for. this purpose; recrea,t±onpphysical, recreation- mental, verbal interaction, creature comforts, staff super­

vision, and diagnostic and medical.services.. Appendix S

consists of the 2 9 suggestions separated into the 6 cate­

gories . The individual categories of suggestions for

improving the care on 7 East will now be analyzed 1 at a

time in order to scrutinize the data more closely. The

first category is recreation-physical. The presentation of data in Table 50 shows the number of suggestions that each patient mentioned within this category. The range of number 91 Table 50. Question #8: Number of Suggestions Mentioned by Each Patient Within the Category of Recreation- Physical

Number of Suggestions Number of Patients

0 16

1 7

2 ’ Total 24

of suggestions mentioned is 0 to 2. Sixteen patients made. no suggestions in this category.

The second category is recreation-mental. The presentation of data in Table 51 shows the number of suggestions that each patient mentioned within this cate­ gory, The range of number of suggestions mentioned is 0 to 3. Eighteen patients made no suggestions in this category. The third category is verbal interaction. The presentation of data in Table 52 shows the number of sugges­ tions that each patient mentioned within this category. The range of numbers of suggestions mentioned is 0 to 1.

Twenty-two patients made no suggestions in this category.

The fourth category is creature comforts. The presentation of data in Table 53 shows the number of 92 Table 51. Question #8: Number of Suggestions Mentioned by Each Patient Within the Category of Recreation- Mental

Number of Suggestions Number of Patients

0 18 1 4

2 to 3 _2 Total 24

Table 52, Question #8: Number of Suggestions Mentioned by Each Patient Within the Category of Verbal Interaction

Number of Suggestions Number of Patients

0 22 1 2

Total 24 93 Table 53. Question #8: Number of Suggestions Mentioned by Each Patient Within the Category of Creature Comforts

Number of Suggestions Number of Patients

0 21

1 2

2 J L '

Total 24

suggestions that each patient mentioned within this category.

The range of numbers of suggestions mentioned is 0 to 2. Twenty-one patients made no suggestions in this category.

The fifth category is staff supervision. The presentation, of data in Table 54 shows the number of • suggestions that each patient mentioned within this cate­ gory. The range of numbers of suggestions mentioned is

0 to 2„ Seventeen patients made no suggestions in this category. The sixth category is diagnostic and medical services. The presentation of data.in Table 55 shows the number of suggestions that- each patient mentioned within this category. The range of numbers of suggestions mentioned is 0 to 1, Twenty-two patients made no sugges­ tions in this category. 94 Table 54. Question #8: Number of Suggestions Mentioned by Each Patient Within the Category of Staff Supervision

Number of Suggestions Number of Patients

0 17 1 5

2 2 Total 24

Table 55, Question #8: Number of Suggestions Mentioned by Each Patient Within the Category of Diagnostic and Medical Services

Number of Suggestions Number of Patients

0 22

•1 _2 Total 24 95 The presentation of data in Table 56 shows a statistical comparison of the 6 categories used to group the data from question number 8„ As can be seen by looking at the means, the suggestions occurred most frequently in 3 categories, recreation-physical, recreation-mental, and staff supervision, Most of the suggestions were made by only 1 patient, and no single category contains a large majority of the suggestions„

Summary of Findings

Twenty-four individuals, 12 males and 12 females, between the ages of 16 and 69 years, and hospitalized from

5 to 126 days, comprised the population for this study.

Sixteen of these patients came to the hospital voluntarily, and 8 came involuntarily. Twelve of the patients had had previous in-patient psychiatric treatment. Suicidal idea­ tion only was involved in 5 patient admissions to the hospital and suicidal ideation plus suicide attempt was involved in 5 other patient admissions.

As the patients discussed their individual treatment program, they identified 57 different treatment components„

The most frequently mentioned treatment components are as follows: occupational therapy--22 times, talking with staff members— 20 times, group therapy-— 17 times, psychodrama— 16 times, medication— 12 times, and group outings as spectator or observer (hockey game, movie, etc.1— -11 times. More of 96 Table 56. Question #8: Suggestions for Improving the Care on 7 East, Statistical Comparison of the Six Categories

Number of Different Standard Sugges­ Devia­ tions Category Range Mean Mode Median tion Mentioned

Recreation- Physical 0to 2 .38 0 .25 .58 8 Recreation- Mental 0 to 2 .38 0 .17 .77 7

Verbal Interaction 0 to 1 .08 0 .05 .28 2

Creature Comforts 0 to 2 .17 0 .07 .48 4

Staff Supervision 0 to 2 .38 0 .21 .65 9 Diagnostic and Medical Services 0 to 1 .08 0 .05 .28 2 Total 29 97 the identified treatment components were categorized under verbal interaction than any other category„ The second most mentioned category was recreation-physical. If the 2 recreation categories were grouped together, they would become the most mentioned single category,

Thirty-one different treatment components were identified as most helpful by the 24 patients. The most frequently mentioned treatment components that were con­ sidered most helpful are as follows: talking with staff members— 16 times, occupational therapy— 12 times, and psychodrama— 9 times. More most helpful components of treatment program were categorized under verbal interaction than any other category. The second most mentioned category was recreation-physical. If the 2 recreation categories were grouped together, they would still be in second place behind verbal interaction.

A total of 37 different treatment components was identified as least helpful by the 24 patients. The most frequently mentioned treatment components that were con­ sidered least helpful are as follows: medication— 4 times, psychodrama— 3 times, group therapy— 3 times, and creative movement— 3 times. More least helpful components of treat­ ment program were categorized under verbal interaction than any other category. The second most mentioned category was . ■ ) staff supervision. . " 98 When patients were asked to identify the most help­ ful single event during their hospitalization, 15 patients of the 24 were able to do so. Two events were mentioned by more than 1 person: leaving the hospital to go home (discharge)--2 times and first time in seclusion room— 2 times. Thirteen different most helpful single events were mentioned. Seven of the events related to staff supervi­ sion, and 6 events related to verbal interaction.

Staff involvement in patient care from many of the health disciplines is a part of the milieu philosophy. It is, therefore, of interest to note that as patients identified the most helpful persons during their hospitali­ zation, the persons they named represented the various health disciplines. The most frequently mentioned persons are as follows: psychiatric technician A--9 times, psychiatric technician B— 8 times, registered nurse A— 7 times, and occupational therapist A--6 times. Forty different persons were mentioned by the 24 patients— 36 students and staff members and 4 other patients.

The 2 4 patients identified 47 different gains from this hospitalization. The most frequently mentioned gains are as follows: no longer feel so depressed— 5 times, and better able to communicate with other people— 3 times.

Most of the gains from this hospitalization were cate­ gorized under feelings about self. The other two 99 categories, feelings in relation to others and physical

well-being, shared lesser and about equal importance.

In discussing their individual treatment programs,

the patients identified 29 different suggestions for

improving the care on 7 East. Only 2 suggestions were made by more than 1 person, more games to play on the unit and more group outings. Both of these suggestions were made by

2 patients. The suggestions occurred most frequently in 3 categories, recreation-physical, recreation-mental, and

staff supervision. When the data from this study were scrutinized

according to biographical categories, several trends became

distinguishable. There was a small tendency for patients with a higher education to mention more components in their

total treatment program than patients with a lower level of education. Patients with a lower educational background

tended to identify few least helpful treatment components,

To almost every question in the questionnaire males in

general identified more of what was requested than did

females. The average educational attainment of both males and females, however, was the same. Males, as a group, mentioned more components in the verbal interaction category

of almost every question than did females. Patients tended

to identify persons of their same sex and somewhat close to

their age as particularly helpful to them, A more detailed 100 description of biographical trends is presented throughout Chapter IV.

The purpose of this chapter has been to present and analyze the data collected via the 24 structured inter­ views. The patient responses have been listed, tabulated,

and analyzed in order to determine how psychiatric patients, receiving care in an in-patient treatment facility with an

established therapeutic milieu, identify and perceive components of milieu therapy in their individual treatment program. CHAPTER V

SUMMARY OF THE STUDY

The main impetus for this study resulted from the researcher's interest in milieu therapy, a widely accepted

treatment philosophy for in-patient psychiatric treatment

facilities in the United States. Little research has been

done regarding milieu therapy and the effectiveness of its

various components. The purpose of this study was to pro­

vide a beginning assessment of what particular components

of milieu therapy are beneficial to patients and to conduct

the assessment from the patient's point of view. In ac­

complishing this purpose, the researcher looked first at the

ability of psychiatric patients to identify components of milieu therapy, as treatment, in their individual treatment

program. A second consideration was which components of their milieu therapy program did they perceive as most help­ ful and as least helpful.

As observations have been made and research has been

conducted regarding milieu therapy, a body of knowledge

about milieu therapy has been developed. There was a lack

of theoretical integration of this body of knowledge until

Gumming and Gumming (1962), in Ego and Milieu, formulated a

conceptual framework around the development and function of

101 102 the ego in relation to its environment. Manipulation of the environment in milieu therapy is influenced by the patient's perception of himself in relation to the environment. How a patient behaves with respect to the milieu therapy ward environment tends to be in accord with how he perceives or defines that situation. This study provides an opportunity to look at patient perceptions as they relate to the following two questions: (1) What components of milieu therapy do psychiatric patients, receiving care in an in­ patient treatment facility with an established therapeutic milieu, identify as treatment in their individual treatment program? (2) Which components of milieu therapy do these psychiatric patients perceive as most helpful and as least helpful in their individual treatment program?

A questionnaire was developed by the researcher, for the purpose of data collection, which consisted of bio­ graphical information and 8 indirect style questions.

Patients who were discharged from the psychiatric in-patient unit at the Arizona Medical Center during the two-month period of data collection comprised the population for this study. The questionnaire was administered by the researcher to each patient in the form of a structured interview within

72 hours before the patient's anticipated discharge. The written summary of the interview was shown to the patient, and the information was directly validated by him. The purpose of the interview was to collect data regarding the 103 patient's perception of the psychiatric treatment he had re­ ceived on an in-patient psychiatric unit using milieu therapy.

Interviews were conducted with 24 individuals who met the criteria for population selection. The data were categorized, tabulated, coded, and analyzed. The main difficulty was in finding discrete categories that were descriptive of and applicable to the data. Presentation of data included comprehensive lists of patient responses

(Appendices F, H, J, L, N, P, R), categorized lists of patient responses (Appendices G, I, K, M , O , Q, S), and tables of statistical data regarding frequency tabulation for each question and categorization of each question.

Review of Findings

Fifty-seven different treatment components were identified by the 24 patients as a part of their individual treatment program. The more traditional aspects of psy­ chiatric treatment were mentioned, such as group therapy and medication, as well as less traditional aspects of treatment, such as talking with other patients.and avail­ ability of telephone. A variety of specific components of the patient environment was identified as treatment, there­ fore, and not simply as a means to fill in time.

Thirty-one different treatment components were identified as most helpful and 37 components as least help­ ful. The most helpful treatment components were categorized 104 under verbal interaction and recreation-physical. The least helpful treatment components were categorized under verbal interaction and staff supervision. The latter 2 categories

were.also the most mentioned for the identified most helpful

single events.

From the above findings it would seem that the

patients generally perceived verbal interaction as very

important in their treatment program. A somewhat related category is staff supervision in that the examples given in „patient responses frequently involved some verbal inter­

action. Recreational activities involving physical exercise were also perceived by many of the patients as a definite

and helpful part of their individual treatment program.

Further examination of the data shows the following

pieces of information. Psychiatric technicians led the list

of most helpful persons during this hospitalization. Four

other patients and 3 6 students and staff members repre­

senting a variety of health disciplines were identified as

most helpful by the patients. Identified gains from this

hospitalization related most frequently to feelings about

self. Several suggestions were made for improving the care

on 7 East, but only 2 suggestions were repeated.

When biographical categories were applied, to the

data from this study, several additional findings became apparent. For example, patients with a higher level of

education tended to identify more treatment components than 105 did patients with a lower level of education. To almost

every question in the questionnaire, males generally

identified more of what was requested than did females.

Patients tended to identify persons of their same sex and somewhat close to their age as particularly helpful to them. The purpose of this study, the research methodology, and the research findings have been briefly summarized. A more detailed description of these 3 topics are related in

separate and previous chapters.

Conclusions and Recommendations

This study was designed to produce descriptive data

about how psychiatric patients, receiving care in an in­

patient treatment facility with an established therapeutic milieu, perceive their individual treatment program. The

basic goal of the study was met in that much descriptive

data were generated. Collectively the 24 patients, who

participated in the study, were able to identify numerous

and varied components of their treatment program. Taken

individually, however, the patients showed much variance in

their ability to identify components in their individual treatment program. Some identified up to 15 varied compo­

nents, and some identified only 2 components. Those

patients who identified.only a few components present a

narrower picture of the individual patient's perception of

what constitutes treatment. 106 What factors influence a patient's ability to per­ ceive and to share his perceptions of what constitutes treatment in an in-patient milieu treatment setting? The findings from this study provide a beginning toward answer­ ing this question. The higher the level of the patient's educational attainment, the more apt he was to identify many and varied treatment components. Even though the average educational attainment for males and females was the same, males identified more treatment components, more helpful persons, and more gains from this hospitalization than did females. Thus, education and sex are possible influences on patients' perceptions of their treatment program. More research needs to be done to further confirm and pinpoint influencing factors.

Several limiting factors and variables have in­ fluenced the progress and results of this study. A larger sample size would have increased the reliability of the findings. Since the sample size was small, only a few trends based on differences in sex, age, educational back­ ground, and other biographical data were distinguishable.

A larger sample size would amplify or disconfirm and hope­ fully add to the study findings.

Many patients in the population had had previous

: in-patient psychiatric treatment which may have influenced the perceptions of their most recent hospitalization. The

24 patients did not receive a standard orientation to the 107 in-patient unit and to the milieu therapy philosophy. They were oriented by a variety of staff members who conducted the orientation in their own way. The study findings are

descriptive of the milieu treatment program at the Arizona Medical Center, but since milieu treatment programs vary

greatly depending on the setting, the researcher is unsure

about the extent that these study findings may generalize

to other milieu programs. •-

Use of a control group would have strengthened the

impact of the study findings. For example, one patient

group could have been given a standard and specially planned orientation to the unit and to the treatment philosophy,

and a second patient group could have been given no special

orientation to the unit and to the treatment philosophy.

Although the researcher recognizes and acknowledges

, some limitations regarding the design of and findings from

.this research study, she wishes also to point out and

emphasize some important implications that these research

findings have for planning and improving psychiatric

patient care.

Prior to the introduction and use of milieu therapy

in the 1950's, psychiatric treatment and care was based

mainly on the medical model with the physician or psychi­

atrist as the main planner and director of psychiatric care

! and with emphasis oh medical treatment measures such as lobotomy, electroconvulsive therapy, and medications as they 108 became available. , With the advent and increasing use of

milieu therapy in in-patient treatment settings, the focus

has gradually shifted from the traditional medical model to a team approach where staff members from several of the health professions work, plan, and-make decisions together regarding patient care.

As the practice of milieu therapy varies greatly from one setting to another, the continued influence of the

medical model also varies greatly in different settings.

Since this study was conducted on an in-patient psychiatric

unit in a medical center and teaching hospital, it is not

surprising that aspects of the medical model continue to

pervade the practice of milieu therapy in this setting. The

researcher was therefore impressed by the fact that patients

identified a wide variety of staff members as particularly

helpful to them rather than only their psychiatrist and/or

psychiatric resident. Such a response conveys acceptance

of persons representing a variety of the health professions as being helpful and influential in the delivery of care in

a psychiatric setting.

Psychiatric technicians, registered nurses, and

licensed practical nurses have an 8 hour a day, continuous

contact with psychiatric patients in in-patient settings.

These were the staff members who were most frequently mentioned as most helpful by psychiatric patients. This

finding supports the important role that people from these 109 health disciplines play in the providing of treatment and

care for psychiatric patients. Therefore, these staff

members need to be involved in the planning as well as the

delivery of psychiatric patient care along with other members of the treatment team. As the patients in this study identified what components of their environment that they considered as

treatments, their responses as a group included a wide

variety of treatment components, including many items that

are not considered by the researcher as medical treatments

or part of the traditional medical model. Since much of

health care delivery is based on the medical model, it has

been the researcher's experience that patients often enter psychiatric treatment with a medical model orientation. They want to have something done to them to make them well, or they want to be given medication and then sit back and

let it take effect. The findings from this study, however,

convey acceptance of a wide variety of treatment approaches

for psychiatric problems. As patients recognize a larger variety of treatment components as helpful to them, they may become more involved in and less resistant to cooperating with their plan of treatment. The whole process of therapy

then becomes less mystical and more realistic to the patients.

The researcher does not wish to imply that medical kinds of treatment do not make an important contribution to 110 psychiatric care; they do contribute much. However, a

variety of other treatment approaches, including many compo­

nents of milieu therapy, deserve acknowledgment as supple­

ments to, and sometimes replacements for, medical treatment measures.

This study shows that patients perceive different

areas of the milieu treatment program as treatment. There­

fore, if the treatment team believes that it is helpful for patients to be able to identify various aspects of their

treatment program as treatment, they must continue to work

toward orienting patients throughout their hospital stay.

Each patient's orientation needs to be individualized

according to his level of understanding upon admission.

Hopefully, the data from this study will help staff members to better understand how psychiatric patients may

perceive their treatment program and thus facilitate orienta­

tion procedures. The findings from this study may serve as a basis

for future studies on patients1 perceptions and milieu

therapy. In order to gain further knowledge in these areas,

the researcher recommends a number of additional studies;

1. A replication of this study using a larger sample.

2. A comparative study of two or more milieu treatment

programs.

3. A study of a milieu treatment program that incor­ porates use of a control group. A study that looks for a relationship between a patient's ability to identify components of his treatment program and his ability to respond to therapeutic intervention. APPENDIX A

SUMMARY OF MILIEU THERAPY

1. The milieu rationale: a. Dysfunction is a result of faulty learning„ b. Distress is a consequence of dysfunction or mis­ perception of the environment. c„ Social re-learning can correct both dysfunction and distress. d. A group of people with common concerns is a potent social teaching device. e .■ Continued dysfunction can be extinguished through lack of reward. f. Individual commitment to group values creates leverage for group action.

2. The milieu values:

a. Dependency is bad. b . Disorders are not medical. . c. Opennes is (very) good. d. Responsibility for oneself is good. e. Responsibility for one's fellow is better. f. Responsibility for the group 4 s much better. 3. The milieu axioms:

a. All interactions have therapeutic value. b. A healthy environment discourages pathology. c. Social problem-solving is a remedial experience. d. The staff is the environment. e. The patients are the environment, f. Staff's usefulness is in not disclosing their use­ fulness.

4. The milieu strategy:

a. Replicate a 'normal' living situation. b. Educate.(indoctrinate) patient (and staff) to milieu values. c. Eliminate staff hierarchy. d. Eliminate medical (magical) staff identification.

112 113 e. Create intimacy and trust: communalism with staff. f. Make patients.responsible. The milieu tactics: a. The group accepts (admits) the patient. b. The patient is initiated into the group. c. Morning meetings review each day's experiences. d. Teams of patients and staff plan treatment programs. e. Staff resolve problems in sensitivity groups. f . Administrative decisions are made by entire milieu community (White 1972, pp. 45-46). APPENDIX B

SUMMARY OF MILIEU THERAPY AS IT IS USED AT THE ARIZONA MEDICAL CENTER

The following is an excerpt from the "Arizona

Medical Center Psychiatric Unit Information Booklet":

TYPES OF TREATMENT PROGRAMS AT UNIVERSITY HOSPITAL THAT YOU MIGHT BECOME INVOLVED IN DURING YOUR HOSPITALIZATION ARE: 1- Individual Psychotherapy— Your primary therapist and other staff will meet with you one or more times weekly with the purpose being to help you determine the prob­ lems that led to your hospitalization and to help you deal with them.

2. Group Therapy--This is held three times weekly for appropriate patients. The guiding principle for the group is that a sharing of feelings, ideas, and expe­ riences in an atmosphere of respect and understanding enhances self-respect and helps the person to live with others. 3. Psychodrama-— is a somewhat different way of looking at ourselves and others. It frequently helps us solve difficult problems and also feel more comfortable within ourselves. It uses spontaneous role playing and does not rely upon any prepared script. With assistance of staff members, patients act out personal situations of the past, present, or potential future.

4. Family Therapy— Family members need to be involved in the treatment of some patients if the treatment is to be successful. The purpose of this therapy is to increase understanding among the individual members of the family of their needs and expectations and to improve communica­ tion among the family members.

5. Activity ProgramT-There is an activity program on the ward in which all patients are expected to participate. The emphasis of many activities is on the importance of group interchange and interaction. Activities on the ward might include the following: Music Hour, 114 115 Creative Movement, Happy Hour, and Handicrafts Group. Off ward activities include occupational therapy, physical therapy, and participation in Tucson's cultural and recreational facilities. Occupational therapy offers you the chance to explore working in various crafts media such as leather, clay, and wood; while physical therapy provides you with an opportunity for exercise and the development of relaxation tech­ niques.

6. Therapeutic Community— The relationships you develop here are considered to be important ones for you. We believe patients and staff can be mutually helpful to one another,- and that what you might learn by living in this community can be applied to your living situation outside the hospital. We, by being a therapeutic community, want to provide a place in which you can try out new ways of looking at and working on the problems which brought you to the hospital.

Item 6, Therapeutic Community, is listed as one of 6 types of treatment programs used on the in-patient psy­

chiatric unit at the Arizona Medical Center. In actual practice observed by the researcher, the concept of thera­

peutic community (milieu, milieu therapy, or therapeutic milieu) serves as a general treatment philosophy which in­

corporates the other 5 types of treatment programs that are

listed. The following is a statement of the "Philosophy of

Nursing in Psychiatry" from the Nursing Department at the

Arizona Medical Center.

The philosophy of nursing in psychiatry is complementary to the philosophy and objectives of The University of Arizona Medical Center

Nursing's primary goal in psychiatry is to establish and maintain a therapeutic milieu which is directed towards the re-entry of patients into the greater community. 116 We respect each patient as an individual with a unique family and cultural background and value orientation which must be taken into account in any comprehensive treatment plan. Lines of communication between members of the staff should be kept as open as possible regarding any aspect of patient care or the functioning of the therapeutic community.

In any comprehensive treatment setting we will recognize the interdependence of the various hospital departments. We will be aware of and receptive to new treatment modalities. APPENDIX C

LETTER OF PERMISSION

December 19, 1973 MEMORANDUM

TO: Linda Sweeney, R.N.

FROM: Martin R. Levy, Ph.D., Chairman Ad Hoc Committee

SUBJECT: Research Proposal

The opinion of the committee members indicates that your proposed study to be carried out on 7E does not infringe upon human rights and is carefully designed to safeguard confidentiality.

While a few members had some questions about the research design, we feel that this is definitely not our province but rather that of the College of Nursing. I mention this only in case you would like to pursue criticisms with the committee members from the Department of Psychiatry,

MRL/jc cc: Alan !„ Levenson, M.D,

117 APPENDIX D

INITIATING THE DISCHARGE INTERVIEW

After evaluation of the patient by the criteria for inclusion in the study, the method of data collection was explained to the patient as follows:

(Patient's name), my name is Linda Sweeney, and I am a nurse in the graduate program in the College of Nursing at

The University of Arizona. I am interested in talking with patients, like you, near the time of their discharge re­ garding their perceptions of the treatment or therapy that they have received during their hospitalization.

After I have followed this procedure with several patients, I will come to some conclusions based on the in­ formation that I have gathered. My conclusions will be shared with other people in an effort to improve the general

f ■ ■ treatment or therapy program that we use on this unit.

You are under no obligation to participate in this study with me. If you do consent to participate, but later wish to withdraw from the study, you may do so at any time.

Do you have any questions that I can answer for you? (At this time any questions regarding the study were answered.

Upon verbal consent to enter the study, the interview was begun.)

118 APPENDIX E

STRUCTURED DISCHARGE INTERVIEW

Subject No. ______Date of Interview ______Time of Interview ■ Date of Discharge from 7 East ___ __ Time of Discharge from 7 East ______Length of Hospitalization ______Diagnosis ______Type of Admission______

Biographical Information:

Age - Sex — Marital Status - Race - Religion - Education - Occupation: Type - Still employed - How long - If not, when terminated - Spouse's Occupation:, Type - Still employed - How long - If not, when, terminated - Previous Psychiatric Treatment: Type - How long - When terminated - Where -

Patient's Perception of Treatment Received:

1. What happened to you that you came to the hospital

2. Tell me about your treatment program here.

3. What has been most helpful to you? What has been least helpful to you?

What single incident seemed to be a turning point for you, that is, the most helpful single event during your hospitalization?

Who seemed to be the most helpful person(s) during your hospitalization?

What have you gained from this hospitalization?

What suggestions do you have for improving the care on 7 East? APPENDIX F

QUESTION #2: SPECIFIC COMPONENTS OF . TREATMENT PROGRAM

Total Times Specific Treatment Components Mentioned and Mentioned ______Questionnaire Numbers 22 Occupational Therapy - 2, 3, 5, 6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 20 Talking with staff members - 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 19, 20, 21, 22, 23, 25 17 Group Therapy - 2, 3, 5, 6, 8, 10, 11, 12, 13, 14, 16, 18, 19, 20, 21, 22, 23 16 Psychodrama - 2, 3, 5, 6, 7, 8, 10, 11, 12, 13, 14, 15, 16, 17, 18, 22 12 Medication - 3, 4, 5, 6, 7, 8, 10, 13, 16, 18, 19, 24 11 Group outings as spectator or observer (hockey game, movie, etc.) - 5, 10, 11, 12, 18, 19, 20, 21, 22, 23, 25 9 Creative movement - 3, 7, 10, 11, 12, 15, 17, 24, 25 8 Physical Therapy - 2, 3, 8, 12, 21, 22, 24, 25 8 Ping pong - 2, 3, 8, 12, 18, 19, 21, 25 8 Talking with other patients - 2, 8, 12, 13, 14, 19, 22, 23 7 Walks - 2, 11, 12, 16, 21, 22, 23 4 Good food - 6, 10, 12, 22 4 Group outside activities (kickball, baseball, etc.) - 18, 21, 22, 23 4 Pool - 18, 19, 21, 25 3 Seclusion - 2, 12, 16 3 General peaceful ward environment - 8, 18, 25 2 Family Therapy -2,12 2 Individual daily schedule to plan one's time - 3, 7 2, Playing cards - 5, 6 2 Watching television - 6, 10 2 Behavior modification point system--reward of certain behaviors - 8, 16 2 Psychological testing - 10, 15 2 Availability of telephone - 10, 16

121 122 Total Times Specific Treatment Components Mentioned and Mentioned Questionnaire Numbers

2 Talking with one particular staff member - 15, 17 2 Having a housekeeping or ward responsibility - 19, 21 2 Listening to records on the unit - 19, 22 2 Culture Group or Hour - 20, 21 2 Music appreciation - 23, 25 1 Chess - 2 1 • Communication between staff and family members - 2 1 Close observation by staff members -3 1 Prescribed time for getting up in the morning . — 3 1 Prescribed time for going to bed at night - 3 1 Having door to my room open at night - 4 1 Not talking with a real psychiatrist - 4 1 Staff members' tough attitude with me - 5 1 Cribbage - 5 1 Willingness of staff members to listen - 5 1 Staff members not wanting to be referred "to as staff - 5 1 Writing letters to people outside hospital - 8 1 Clean linen - 10 1 Availability of coffee - 10 1 Blood test - 10 1 Availability of social worker - 11 1 Physical examination on admission - 12 1 Able to sleep well - 12 1 Being petitioned into the hospital - 14 1 Individual crafts, like embroidering - 16 1 Visitation of family members - 16 1 Books and magazines available on ward - 19 1 Eating together with other patients - 20 1 Therapeutic community feeling of orderliness and routine - 20 - 1 Having a private room-^no roommate - 20 1 Patients selecting outside group activities

- 21 1 Chance to get out of home and work environment; to break cycle of work all the time - 23 1 ECT - 24 1 Cooking and baking on the unit - 25 APPENDIX G

QUESTION #2: SPECIFIC COMPONENTS OF TREATMENT PROGRAM CATEGORIZED

Total Times Specific Treatment Components Mentioned and Mentioned Questionnaire Numbers

1. Recreation-Physical

22 Occupational Therapy - 2, 3, 5,6, 8, 9, 10, 11, 12, 13, 14, 15, 16, 17, 18, 19, 20, 21, 22, 23, 24, 25 9 Creative movement - 3, 7, 10, 11, 12, 15, 17, 24, 25 8 Physical Therapy - 2, 3, 8, 12, 21, 22, 24, 25 8 Ping pong - 2, 3, 8, 12, 18, 19, 21, 25 7 Walks - 2, 11, 12, 16, 21, 22, 23 4 ■ Group outside activities (kickball, baseball, etc.) - 18, 21, 22, 23 4 Pool - 18, 19, 21, 25 1 Individual crafts, like embroidering - 16 . 1 Cooking and baking on the unit - 25

2. Recreation-Mental

11 - Group outings as spectator or observer (hockey game, movie, etc.) -- 5, 10, 11, 12, 18, 19, 20, 21, 22, 23, 25 2 Playing cards - 5, 6 2 Watching television 6, 10 2 Listening to records on the unit - 19, 22 2 Culture Hour - 20, 21 2 Music appreciation - 23, 25 1 Chess - 2 1 Cribbage - 5 1 Writing letters to people outside hospital - 8 1 Books and magazines available on ward - 19 1 Patients selecting outside group activities - 21

123 124 Total Times Specific Treatment Components Mentioned and Mentioned Questionnaire Numbers 3. Verbal Interaction

2 0 Talking with staff members - 2, 3, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 16, 17, 18, 20, 21, 22, 23, 25 17 Group Therapy - 2, 3, 5, 6, 7, 8, 10, 11, 12, 13, 14, 16, 18, 19, 20, 21, 22, 23 16 Psychodrama - 2, 3, 5, 6, 7, 8, 10, 11, 12, 13, 14,.15, 16, 17, 18, 22 8 Talking with other patients - 2,8, 12, 13, 14, 19, 22, 23 2 Family Therapy - 2, 12 2 Talking with one particular staff member - 15, 17 1 Communication between staff and family members

1 Not talking with a real psychiatrist - 4 1 Staff members1 tough attitude with me - 5 1 Willingness of staff members to listen - 5 1 Staff members not wanting to be referred to as staff - 5 1 Availability of social worker - 11 1 Visitation of family members - 16

4. Creature Comforts

4 Good food - 6, 10, 12, 22 3 . General peaceful ward environment - 8, 18, 25 2 Availability of telephone - 10,16 1 Clean linen - 10 1 Availability of coffee - 10 1 Able to sleep well - 12 1 Eating together with other patients' - 20 1 , Therapeutic community feeling of orderliness and routine -20 1 Having a private room— no roommate - 20 1 Chance to get out of home and work environment; to break cycle of work all the time - 23

5. Staff Supervision

3 Seclusion - 2, 12, 16 2 Individual daily schedule to plan one's time - 3, 7 2 . Behavior modification point system - 8, 16 125 Total Times Specific Treatment Components Mentioned and Mentioned Questionnaire Numbers 2 Having a housekeeping or ward responsibility - 19, 21 1 Close observation by staff - 3 1 Prescribed time for getting up in the morning

— 3 1 Prescribed time for going to bed at night - 3 1 Having door to my room open at night - 4 1 Being petitioned into the hospital - 14

6. Diagnostic and Medical Services

12 Medication - 3, 4, 5, 6, 7, 8, 10, 13, 16, 18, 19, 24 2 Psychological testing - 10, 15 1 Blood test - 10 1 Physical examination on admission - 12 1 ECT - 24 APPENDIX H

QUESTION #3: MOST HELPFUL COMPONENTS OF TREATMENT PROGRAM

Total Times Specific Treatment Components Mentioned and Mentioned _____ Questionnaire Numbers

16 Talking with staff members - 2, 3, 5, 6,7, 9, 12, 13, 14, 16, 17, 18, 20, 22, 23, 25 12 Occupational Therapy - 2, 3, 5, 6,9, 14, 15, 18, 21, 22, 23, 25 9 Psychodrama - 3, 6, 11, 12, 14, 15, 16, 17, 18 7 Group Therapy - 8, 12, 13, 14, 18, 19, 22 6 Group outings as spectator or observer (hockey game, movie, etc.) - 5, 10, 18, 19, 21, 22 5 Medications -3,6, 7,8, 24 4 Talking with other patients - 13, 19, 22, 23 3 Walks - 2, 16, 22 3 General peaceful ward environment - 8, 18, 25 3 Physical Therapy - 8, 22, 25 2 Creative movement - 11, 12 1 Individual daily schedule to plan one's time - 3 ' 1 Staff members' tough attitude with me - 5 1 Playing cards - 5 1 Cribbage - 5 1 Willingness of staff members to listen - 5 1 Behavior modification point system - 8 1 Ping pong - 8 1 Writing letters to people outside hospital - 8 1 Group outside activities (kickball, baseball, etc.) - 18 1 Availability of social worker - 11 1 . Family Therapy - 12 1 Seclusion - 12 1 Good food - 12 1 Talking with one particular staff member - 15 1 Listening to records on the unit -19 1 Therapeutic community feeling of orderliness arid routine - 20 1 Having a private room— no roommate - 20 1 Chance to get out of home and work environment; to break cycle of work all the time - 23 1 ECT - 24 1 Music appreciation -25

126 APPENDIX I

QUESTION #3: MOST HELPFUL COMPONENTS OF TREATMENT PROGRAM CATEGORIZED

Total Times Specific Treatment Components Mentioned and Mentioned ______Questionnaire Numbers 1.’ Recreation-Physical

12 Occupational Therapy - 2, 3, 5, 6, 9, 14, 15, 18, 21, 22, 23, 25 3 Physical Therapy - 8, 22, 25 3 Walks - 2, 16, 22 2 Creative movement - 11, 12 1 Ping pong - 8 1 Group outside activities (kickball, baseball, etc.) - 19

2. Recreation-Mental

6 Group outings as spectator or observer (hockey game, movie, etc.) - 5, 10, 18, 19, 21, 22 1 Playing cards - 5 1 Cribbage - 5 1 Writing letters to people outside hospital - 9 1 Listening to records on the unit - 19 1 Music appreciation - 25

3. Verbal Interaction -

16 Talking with staff members - 2, 3, 5, 6, 7, 9, 12, 13, 14, 16, 17, 18, 20, 22, 23, 25 9 Psychodrama - 3, 6, 11, 12, 14, 15, 16, 17, 18 7 Group Therapy - 8, 12, 13, 14, 18, 19, 22 4 Talking with other patients -13, 19, 22, 23 1 Staff members' tough attitude with me - 5 1 Willingness of staff members to listen - 5 1 Availability of social worker - 11 1 Family Therapy - 12 1 Talking with one particular staff member - 15

127 128 Total Times Specific Treatment Components Mentioned and Mentioned ______Questionnaire Numbers ______4. Creature Comforts

3 General peaceful ward environment - 8, 18, 25 1 Good food - 12 1 Therapeutic community feeling of orderliness and routine - 20 1 Having a private room— no roommate - 20 1 Chance to get out of home and work environment to break cycle of work all the time - 23

5. Staff Supervision

1 Individual daily schedule fo plan one's time - 3 1 Behavior modification point system - 8 1 Seclusion - 1 2

Diagnostic and Medical Services

5 Medications - 3, 6, 7, 8, 24 1 ECT - 24 APPENDIX J

QUESTION #4: LEAST HELPFUL COMPONENTS OF TREATMENT PROGRAM

Total Times Specific Treatment Components Mentioned and Mentioned Questionnaire Numbers

4 Medication - 5, 16, 18, 19 3 Psychodrama -2,7,8 3 Group Therapy -2,16,21 3 Creative movement - 15, 17, 25« 2 Seclusion Room - 2, 12 2 Crazy talk from other patients -8/12 2 Not being able to go outside for activities - 15, 16 1 Constant bombardment by so many different people (patients and staff), especially early in the hospitalization - 2 1 Mixed messages to family members by various staff members - 2 1 . Getting up so early (7:30 a.m.) - 3 1 Going to bed so late (10:00 p.m.) - 3 1 Having the door to my room open at night - 4 1 Not talking with a real psychiatrist - 4 1 Staff members not wanting to be referred to as staff - 5 1 Individual daily schedule - 7 1 Noise on the unit - 8 1 People playing ping pong at night when I*m trying to sleep - 8 1 Psychological testing - 10 1 Blood test - 10 1 Extended length of hospital stay - 10 1 Switch in doctors— worked with two psychi­ atrists and two psychiatric residents - 11 1 Lack of written explanation of ward rules ,v schedule, etc. (verbal explanation not enought) - 11 ■ 1 Lack of scheduled activities on weekends (boring) - 11 1 Found hospital page system annoying (intercom located by telephone) - 11 1 Staying in room during day; wasted much time because bored - 12 129 130 Questionnaire Numbers 21 hospital - 14 etc.) - 21 not not communicating more with nursing staff— not aware of this expectation meof as a patient - 20 - ______Dad Dad getting angry me at - 12 Specific Treatment Components Mentioned and Time Time here goes so slow - 16 Restricted visitation of members family - 16 Fact that father petitioned me into the Restricted use of telephone - 16 Behavior modification point system - 16 Occupational Therapy - 19 Being excluded from culture group because of Culture hour - 21 Talking with one particular staff member - 23 Group outside activities baseball, (kickball, Not using more initiative to talk with staff

I— I I— 1 I— I I— 1 I— i I— I I— I I— I I— I I— I I— I Mentioned Total Times APPENDIX K

QUESTION #4: LEAST HELPFUL COMPONENTS OF TREATMENT PROGRAM CATEGORIZED

Total Times Specific Treatment Components Mentioned and Mentioned ______Questionnaire Numbers______1. Recreation-Physical

3 Creative movement - 15, 17, 25 1 Occupational Therapy - 19 1 Group outside activities (kickball, baseball, etc.) - 21

2. Recreation-Mental

1 Culture hour - 21

3. Verbal Interaction

3 Psychodrama -2,7,8 3 Group Therapy - 2, 16, 21 2 Crazy talk from other patients -8,12 1 Being excluded from culture group because of not communicating more with nursing staff— not aware of this expectation of me as a patient - 20 1 Restricted visitation of family members - 16 1 Constant bombardment by so many different people (patients and staff), especially early in the hospitalization - 2 1 Mixed messages to family members by various staff members - 2 1 Not talking with a real psychiatrist - 4 1 Staff members not wanting to be referred to as staff - 5 1 Staying in room during day; wasted much time because bored - 12 1 Dad getting angry at me - 12 1 Not using more initiative to talk with staff

— 21 1 Talking with one particular staff member - 23

131 132 Total Times Specific Treatment Components Mentioned and Mentioned - Questionnaire Numbers

4. Creature Comforts

1 Noise on unit - 8 1 People playing ping pong at night when I am trying to sleep - 8 1 Found hospital page system annoying (intercom located by telephone) - 11 1 Time here goes slow - 16 1 Restricted use of telephone - 16

5. Staff Supervision

.2 Seclusion Room -2,12 2 Not being able to go outside for activities - 15, 16 1 Getting up so early (7:30 a.m.) - 3 1 Going to bed so late (10:00 p.m.) - 3 1 Having door to my room open at night - 4 1 Individual daily schedule - 7 1 Extended length of hospital stay - 10 1 Switch in doctors--worked with 2 psychiatrists and 2 psychiatric residents - 11 1 Lack of written explanation of ward rules, schedule, etc. (verbal explanation not enough) - 11 1 Lack of scheduled activities on weekends (boring) - 1 1 1 Fact that father petitioned me into the hospital - 14 1 Behavior modification point system - 16

6. Diagnostic and Medical Services

4 Medication - 5, 16, 18, 19 1 Psychological testing - 10 1 Blood test - 10 APPENDIX L

QUESTION #5: MOST HELPFUL SINGLE EVENT DURING THIS HOSPITALIZATION

Ability to identify the most helpful single event:

Total Response and Questionnaire Numbers

15 Yes 2, 3, 5, 6, 8, 9, ll, 12, 13, 15, 16, 17, 18, 23, 25 9 No 4, .7, 10, 14, 19 20, 21, 22, 24

Total Times Description of Event and on Mentioned Which Questionnaire

Leaving the hospital to go home (discharge) - 6, 13 2 First time in seclusion room - 12, 16 1 Suicide attempt in hospital in October - 2 1 The point in time when I started getting tired and sleepy; that meant I was slowing down ' and starting to get better - 3 The night session I had with a particular- registered nurse when she forced me to eat — 5 1 Point in time when medicine finally took effect - 8 1 Social worker talking with me about financial matters - 9 1 Two weeks after admission when I was told to apply myself or I would be sent to Arizona State Hospital for at least six months. Thought choice already made, but then realized the decision was mine - 11 1 A discussion I had with a particular staff member Wednesday night - 15 1 Being allowed to go back to school one week before discharge - 17 1 Going home on a pass last Tuesday - 18 1 One particular session with psychiatric resi­ dent and medical student when they asked me to discuss what creates animosity in me and how I handle it - 23

133 134 Total Times Description of Event and on Mentioned. Which Questionnaire

Second day here when I accepted reality of being a patient after being scolded for interfering with another patient's treat­ ment - 25 APPENDIX M

QUESTION #5: MOST HELPFUL SINGLE EVENT DURING THIS HOSPITALIZATION CATEGORIZED

Total Times Description of Event and on Mentioned - Which Questionnaire 1, Recreation-Physical

2, Recreation-Mental

3„ Verbal Interaction

1 The night session I had with a particular registered nurse when she forced me to eat - 5 1 Social worker talking with me about financial matters - 9 1 Two weeks after admission when I was told to apply myself or I would be sent to Arizona • State Hospital for at least six months. Thought choice was already made, but then realized the decision was mine - 11 1 A discussion I had with a particular staff member'Wednesday night - 15 1 One particular session with psychiatric resident and medical student when they asked me to discuss what creates animosity in me and how I handle it - 23 1 Second day here when I accepted reality of being a patient after being scolded for interfering with another patient's treat­ ment - 25

4. Creature Comforts

1 The. point in time when I started getting tired and sleepy; that meant I was slowing down and starting to get better - 3

135 136 Description of Event and on Which Questionnaire 6, 6, 13 effect - effect - 8 before discharge - 17 Suicide Suicide attempt in hospital October in - 2 Being allowed back to to school one week Point in whentime medicine finally took First time in seclusion room - 12, 16 2 2 Leaving the hospital go to home - (discharge) 1 CN i—I r—( 1 Going home on pass a last Tuesday - 18 Mentioned 5. 5. Staff Supervision 6. 6. Diagnostic Medicaland Services Total Times APPENDIX N

QUESTION #6: MOST HELPFUL PERSON(S) . DURING THIS HOSPITALIZATION

Total Times Mentioned Title and Questionnaire Numbers

9 Psychiatric Technician - 5,8, 13, 14, 15, 18, 19, 22, 25 8 Psychiatric Technician - 5, 8, 12, 14, 15, 19, .21, 23 7 Registered Nurse - 4, 5, 6, 12, 13, 16, 25 6 Occupational Therapist Intern - 8, 14, 15, 16, 23, 25 5 Psychiatric Resident - 2, 3, 8, 14, 23 5 Social Worker -3,6, 8, 9, 11 5 Occupational Therapist - 3, 14, 15, 23, 25 4 Psychiatric Technician - 3, 13, 19, 21 3 Registered Nurse - 2, 6, 23 3 Licensed Practical Nurse - 3, 17, 25 3 Psychiatric Resident - 12, 20, 23 3 Social Worker - 12, 14, 15 3 Psychiatrist - 15, 18, 24 3 Medical Student - 18, 20, 23 2 Registered Nurse - 2, 25 2 Registered Nurse -2,3 2 Psychiatric Technician - 3, 25 .2 Psychiatric Technician - 3, 17 2 Psychiatric Technician -5,6 2 Psychiatrist -8,25 2 Registered Nurse - 12, 16 2 Psychology Intern - 13, 24 2 Registered Nurse - 16, 17 2 Registered Nurse - 17, 19 2 Psychologist - 23, 25 1 Psychiatrist - - 2 1 Psychiatrist - 6 1 Family Practice Resident - 6 1 Registered Nurse - 11 1 Medical Student - 12 1 Psychologist - 12 1 Registered Nurse - 1 2 1 Another Patient - 12 1 Another Patient - 13

137 138

Total Times Mentioned. ,______Title and Questionnaire Numbers 1 Psychiatric Resident - 18 1 Registered Nurse - 18 1 Another Patient— 22 1 Another Patient - 22 1 Neurology Resident - 25 1 Registered Nurse - 16 APPENDIX O

QUESTION #6: MOST HELPFUL PERSON(S) DURING THIS HOSPITALIZATION CATEGORIZED

Total Times . Mentioned ______Person and Questionnaire Numbers 1. Psychiatrists and Psychologists

3 A - 15, 18, 24 2 B - 8, 25 2 C - 23, 25 1 D - 2 1 E - 6 1 F - 12

Residents, Psychology Interns, and Medical Students 5 A — 2, 3, 8, 14, 23 3 B - 12, 20, 23 3 C - 18, 20, 24 2 D - 13, 24 1 E — 18 1 F - 6 1 G - 25 1 H 12

Registered Nurses and Licensed

7 A — 4, 5, 6, 12, 13, 3 B - 2, 6, 23 3 C - 3, 17, 25 2 D - 17, 19 2 E - 16, 17 2 F - 2, 25 2 G - 2, 3 2 H - 12, 16 1 I - 11 1 J - 12 1 K - 16 1 L -. 18

139 140

Total Times Mentioned Person and Questionnaire Numbers' 4„ Psychiatric Technicians

9 A - 5, 8, 13, 14, 15, 18, 19, 22, 8 B — 5, 8, 12, 14, 15, 19, 21, 23 4 C - 3, 13, 19, 21 2 D - 3, 25 2 E - 3, 17 2 F - 5, 6

5. Social Workers

5 A — 3, 6, 8, 9, 11 3 B - 12, 14, 15

6. Occupational Therapists and Occupational Therapist Interns

6 A - 8 , 14, 15, 16, 23, 25 5 B - 3, 14, 15, 23, 25

7. Other Patients 1 A - 12 1 B - 13 1 C - 22 1 D - 22 . . APPENDIX P

QUESTION #7: GAINS FROM THIS HOSPITALIZATION

Total Times Specific Gains Mentioned and Mentioned Questionnaire Numbers

5 No longer feel so depressed - 5, 14, 17, 20, 24 3 Better able to communicate with other people - 12, 14, 21 2 How to sleep - 2, 22 2 How to be more realistic about my personal expectations - 2, 25 2 Desire to not come back to this unit - 5, 16 2 No longer so very critical of myself - 12, 20 2 A little bit of insight about how my mind works - 15, 23 2 Know more about what I have to work on— more aware of my problems - 17, 23 2 Feel more like being with people - 22, 24 1 How to cope in.a more reasonable way with problems, stress, etc, - 2 1 How to live without drugs - 2 1 How to identify how I feel— self pity, manipulation, depression, etc.; have more control of my feelings; can now break the vicious circle - 2 1 Helped me to see my behavior and how I can change it - 3 1 Gained an understanding of a different kind of illness, mental illness - 5 1 Amazed at how staff can be so calm and listen - 5 1 Can now stand on my own two feet - 5 1 High blood pressure improved - 6 1 Have fewer headaches now - 6 1 Chance to be myself - 9 1 Have matured a lot - 8 1 Now better able to take care of myself - 8 1 Less anemic - 9 1 Thinking straighter - 9 1 Have fewer physical complaints - 9 1 Ready to complete therapy; this time I stayed in therapy until I changed - 11 142

Total Times Specific Gains Mentioned and Mentioned Questionnaire Numbers

1 Ready to give up script my parents wrote for me— failure - 11 1 Ready to succeed - increase in my self- confidence - 11 1 Know now who I am; not crazy any more - 12 1 Family communication has greatly improved - 12 1 Feel closer to God; believe in miracles now - 12 1 Don't know, but I feel changed in a positive way - 13 1 Learned how to better get along in a mental hospital - 15 1 Realization that I need to slow down and not get involved in so many things - 16 1 Realization that I can't go without sleep ^ 16 1 Got my thoughts together more; recognize some of my previous behavior as inappropriate - 18 1 No longer on medication - 9 1 Realizing that I have to work within the laws of society - 19 1 Realizing that people all have different feelings toward different things, but they all want the best for themselves - 19 1 Better able to control my emotions by verbally expressing them - 19 1 More open about sharing my true emotions - 19 1 Helped me to evaluate myself and to plan more definite goals - 20 1 Feel much more at ease with myself; much of my anxiety and fear has dissipated - 20 1 Have learned that some people have the same problems I do - 21 1 Should get to know people before you judge them - 21 1 Appetite is better - 22 1 More concerned with appearance; feel more like dressing up - 22 1 Motivation to lose weight and counseling in dieting - 25 APPENDIX Q

QUESTION #7: GAINS FROM THIS HOSPITALIZATION CATEGORIZED

Total Times Specific Gains Mentioned and Mentioned ______Questionnaire Numbers ______

1. Feelings About Self 5 No longer feel so depressed - 5, 14, 17, 20, 24 2 How to be more realistic about my personal expectations - 2, 25 2 Desire to not come back to this unit - 5, 16 2 No longer so very critical of myself - 12, 20 2 A little bit of insight about how my mind works -15,23 2 Know more about what I have to work on; more aware of my problems - 17, 23 1 How to cope in a more reasonable way with problems, stress, etc. - 2 1 How to identify how I feel--self-pity, manipulation, depression, etc„ Have more control of my feelings; can now break the vicious circle - 2 1 Helped me to see my behavior and how I can change it - 3 1 Gained an understanding of a different kind of illness, mental illness - 5 1 Can now stand on my own two feet - 5 1 . Chance to be myself - 8 1 Have matured a lot - 8 1 Now better able to take care of myself - 8 1 Thinking straighter - 9 1 Ready to complete therapy; this time I stayed in therapy until I changed - 11 1 Ready to give up script my parents wrote for me— failure - 11 1 Ready to succeed; increase in my self- confidence - 11 1 Know now who I am; not crazy any more - 12 1 Feel closer to God; believe in miracles now - 12 1 Don’t know, but I feel changed in a positive way - 13 143 144

Total Times Specific Gains Mentioned and Mentioned ______' Questionnaire Numbers

1 Realization that I need to slow down and not get involved in so many things - 16 1 Got my thoughts together more; recognize some of m y .previous behavior as inappropriate - 18 1 Better able to control my emotions by verbally expressing them - 19 1 More open about sharing my true emotions - 19 1 Helped me to evaluate myself and to plan more definite goals - 20 1 Feel much more at ease with myself; much of my anxiety and fear has dissipated - 20 1 More concerned with appearance; feel more like dressing up - 22

2„ Feelings in Relation to Others

3 Better able to communicate with other people - 12, 14, 21 2 Feel more like being with people - 22, 24 1 Amazed at how staff can be so calm and listen - 5 1 Family communication has greatly improved - 12 1 Learned how to better get along in a mental hospital - 15 1 Realizing that I have to work within the laws of society - 19 1 Realizing that people all have different feelings toward different things, but they all want the best for themselves - 19 1 Have learned that some people have the same problems I do - 21 1 You should get to know people before you judge them - 21

3. Physical Well-Being

2 How to sleep - 2, 22 1 How to live without drugs - 2 1 High blood pressure improved - 6 1 Have fewer headaches now - 6 , 1 Less anemic - 9 1 No longer on medication - 9 1 Have fewer physical complaints - 9 1 Realization that I can’t go without sleep - 16 145 Total Times Specific Gains Mentioned and Mentioned Questionnaire Numbers 1 Appetite is better - 22 1 Motivation to lose weight and counseling in dieting - 25 , APPENDIX R

QUESTION #8: SUGGESTIONS FOR IMPROVING THE CARE ON 7 EAST

Total Times Specific Suggestions Mentioned and Mentioned Questionnaire Numbers

2 Not enough games to play on the unit - 12, 19 2 More group outings - 18, 24 1 Better control on the number of people con­ tacting a specific patient - 2 1 Better screening of personnel who come in contact with patients (disliked a particu­ lar staff member) - 2 1 Be more flexible about rising time and bed time - 3 1 Staff should spend less time playing games (cards, etc.) among themselves - 5 1 Booklet needed that is distributed to patients• for orientation to unit, explanation of patient classification system, etc. - 11 1 Better scheduling of weekends with more recreational activities included - 11 1 Consider use of prepackaged medication a waste of time and money - 11 1 Staff could be a little more understanding and friendly at times; stop playing games with people's heads; exercise better judgment about when to push patients - 12 1 Staff should strive for more self-awareness - 12 1 Take me off my medicine; I feel foggy and confused - 13 1 Food too bland - 15 1 Need a pool table - 15 1 Music therapy everyday, sing-a-longs - 16 1 More outings outside, especially walks - 16 1 Do away with (behavior modification) point system for patients - 1 9 1 Need a new stereo - 19 1 Need more books and magazines - 19 1 Need more understanding between patients and staff - 19 1 Give orientation book to patient right away - 20

146 147

Total Times Specific Suggestions Mentioned and Mentioned Questionnaire Numbers

1 Include in orientation book more information about what is expected of patients - 20 1 Obtain more comfortable beds - 21 1 Need more space for recreation on the unit - 21 1 Longer athletic period - 23 1 More athletic equipment (volley ball, putting equipment) - 23 1 More social activities on the unit - 24 1 ' Eliminate creative movement - 2 5 .1 Better job of keeping kitchen cooking supplies well stocked - 2 5 APPENDIX S

QUESTION #8: SUGGESTIONS FOR IMPROVING THE CARE ON 7 EAST CATEGORIZED

Total Times. Specific Suggestions Mentioned and Mentioned Questionnaire Numbers 1„ Recreation-Physical

2 Not enough games to play on the unit - 12, 19 1 Better scheduling of weekends with more recreational activities included - 11 1 Need a pool table - 15 1 More outings outside, especially walks - 16 1 Longer athletic period - 23 1 More athletic equipment (volleyball, putting equipment) - 23 1 More social activities on the unit - 24 1 Eliminate creative movement - 25

2» Recreational-Mental

2 Not enough games to play on the unit - 12, 19 2 More group outings - 18, 24 1 Better scheduling of weekends with more recreational activities included - 11 1 Music therapy every day; sing-a-longs - 16 1 Need a new stereo - 19 1 Need more books and magazines - 19 1 More social activities on the unit - 24

3„ Verbal Interaction

1 Staff could be a little more understanding and friendly at times; stop playing games with people's heads; exercise, better judgment about when to push patients - 12 1 Need more understanding between patients and staff - 19

148 149 Total Times Specific Suggestions Mentioned and Mentioned ______Questionnaire Numbers_____ . 4. Creature Comforts 1 Food too bland - 15 1 Obtain more comfortable beds - 21 1 Need more space for recreation on the unit 21 1 Better job of keeping kitchen cooking supplies well stocked - 25

Staff Supervision

1 Better control on the number of people con­ tacting a specific patient -,2 1 Better screening of personnel who come in contact with patients (disliked a particu­ lar staff member) - 2 1 Be more flexible about rising time and bed time - 3 1 Staff should spend less time playing games (cards, etc.) among themselves - 5 1 Booklet needed that is distributed to patients for orientation to unit, explanation of patient classification system, etc. - 11 1 Staff should strive for more self-awareness - 12 1 ' Do away with (behavior modification) point system for patients - 19 1 Give orientation book to patients right away -

20 ' 1 Include in orientation book more information about what is expected of patients - 20

Diagnostic and Medical Services

1 Consider use of prepackaged medication as a waste of time and money - 11 1 Take me off my medicine; I feel foggy and confused - 13 SELECTED BIBLIOGRAPHY

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