Gold Award: A Community Treatment Program Mendota Mental Health Institute Madison, Wisconsin

An unusual community treatment program at the Mendota Mental Health Institute in Madison, Wisconsin, has demonstrated that patients who would otherwise be treated in mental hospitals can be successfully treated in the community without shifting the burden of care to their families. Called Training in Community Living, the program is staffed by former hospital employees, who have been retrained to work with the patients in their homes and at their jobs, and to assist them with the various activities of daily living. Virtually all of the patients in the program, including those who are highly symptomatic, chronic, and dependent, have been treated without hospitalization.

The program developed out of the investigators' clinical experience and the resulting belief that the persistent high rate of treatment failures was closely related to deficits in coping skills required to maintain an adequate community adjustment. They see most patients who are hospitalized as having a limited ability to meet the goals and demands of life; they have difficulties with work habits, socialization, leisure-time activities, and other aspects of living. They also have powerful dependency needs often expressed as an aggressive dependency on their families or on institutions. Most have been dependent one way or another all their lives. They also share a capacity to develop severe psychiatric symptomatology when confronted with only mild to moderate degrees of stress. All those factors lead to a tenuous community adjustment, with the patient usually hovering on the brink of rehospitalization.

Hospitals have been unsuccessful in dealing with the specific problems of such patients, and, in the opinion of the investigators, they have frequently compounded them by reinforcing dependency and fostering institutionalization. Most community programs have also failed; such patients are frequently uncooperative, and few programs are equipped to assertively reach out and provide the intensive treatment required.

Training in Community Living is designed to overcome those deficiencies. Funded in part by a grant from the National Institute of Mental Health, it has been in operation since September 1972. (A predecessor, from which the basic model evolved, was a 12-month pilot effort called the Prevention of Institutionalization Program.) The current program, which represents a major expansion of the pilot project into an alternative for the mental hospital, was developed by Leonard I. Stein, M.D., Mary Ann Test, Ph.D., and Arnold J. Marx, M.D. Both programs were made possible through the strong support of Lee A. Ecklund, M.D., the institute director.

The goals in the Training in Community Living program are primarily to enhance patients' community adjustment, to decrease time spent in institutions, and ultimately to prevent the development of the chronic patient role. Additionally the program focuses on decreasing patients' symptomatology and increasing their self-esteem and satisfaction with life. The program is being evaluated by comparison with a control group, most of whom receive progressive intensive hospital treatment and community aftercare.

All who seek admission to the institute's inpatient services and who meet certain criteria are assigned to either the program or the control group. The criteria are residence in the county, age between 18 and 62, and diagnosis other than severe organic brain syndrome or primary alcoholism. Assignments are made at random after the patient's eligibility has been determined. Patients remain in the community program for 14 months, during which they are gradually linked with appropriate community services. Data are collected on both groups for 36 months from time of entrance into the respective programs.

A patient assigned to the program is immediately interviewed by William Knoedler, M.D., a psychiatrist who is unit chief of the community treatment staff. Every effort is made to avoid hospitalization; it is reserved for patients who are imminently suicidal or homicidal, or who are so severely psychotic as to require high dosages of medication only feasible in the hospital's highly structured environment.

Treatment consists of participation in a full schedule of daily living activities in the community, and pharmacotherapy where appropriate. The staff help the patient find a place to live in a rooming house, apartment, YMCA, or elsewhere, and assist him in such activities as doing laundry, shopping, cooking, eating in restaurants, grooming, budgeting, and using transportation.

Staff also give patients sustained and intensive assistance in finding a job or sheltered workshop placement, and then remain in daily contact with them and their supervisors to help with problems arising in the job. Patients are taught to use their leisure time constructively and to develop effective socialization skills; staff prod them to become involved in relevant recreational and social activities in the community and frequently accompany them to such functions if needed. In all interactions, staff play down the patients' symptomatology and stress their assets. The program is highly flexible so as to provide whatever assistance the patients may need. Initially staff have daily, even hourly, contact with patients; the time spent with them is gradually diminished as they progress in the treatment program. Work with patients' families and significant others is directed toward breaking pathological dependent relationships.

The 18-member staff include a psychiatrist, a psychologist, a social worker, an occupational therapist, five nurses, and nine aides. A rented house in downtown Madison serves as their base of operations, and they gather there twice a day to share information, revise treatment programs as necessary, and plan the next shift's work schedule. They work in two shifts so that a full staff is available from 7 a.m. until 11 p.m. seven days a week. A member of the professional staff remains on call at night to give 24-hour coverage for patients.

The staff implementing the program all had traditional psychiatric hospital backgrounds. Retraining for work in the program involved discussion sessions to acquaint them with its basic theoretical and operational guidelines and the problems that could be expected in treating highly symptomatic patients outside the hospital. Brainstorming and role-playing techniques were used to help staff work out ways of managing various kinds of problems. They also familiarized themselves with the housing, recreation, transportation, and shopping offered in various neighborhoods.

Using mental hospital personnel to staff this kind of community program was found to have both advantages and problems. Among the advantages were their experience in and commitment to working with severely ill patients and their orientation toward working with patient behaviors. They were also used to a team approach and were willing to rotate shifts to keep the program operational 16 hours a day. The major problems arose in the transition from a highly structured hospital setting, where there is little individual decision-making, to an unstructured setting requiring a great deal of initiative and willingness to make decisions quickly. However, the training and support during the early stages of the program helped ease the transition and enabled staff to take on increased responsibility.

For the program to succeed required that it be fully accepted by the community. Therefore, before it began, conferences were held with all relevant community agencies to establish close working relationships. Members of the local police force, floor supervisors in sheltered workshops, landlords of rooming houses, and others were assured that they were not expected to be therapists or to change their way of working; they were told to treat the patients the same as they would anyone else. Staff emphasized they would be available 24 hours a day to assist them if needed.