Congregate Living for the Mentally Patients as Tenants ABBIE
S.
Senior
Social
BURGER,
M.S.W.
Worker
LEAH KIMELMAN, Administrative Social
M.S.W. Work Supervisor
ABRAHAM LURIE, Director, Department
PH.D. of Social
CHARLES Chairman,
Work
Services
J. RABINER, M.D. Department of Psychiatry
Long
IslandJewish-Hillside
New
Hyde
Park,
New
Medical
Center
York
The authors describe an apartment-living project for chronic mental patients releasedfrom the Hillside Division of the Long Island Jewish-Hillside Medical Center. The apartments, which are rented by the hospital and sublet to the patients, are located in modern, wellmaintained
high-rise
buildings
within
commuting
dis-
lance from the hospital. To avoid creating a psychiatric ghetto, the project rents no more than two apartments in buildings of a hundred or more units. The hospital was able to rent the apartments by assuring the landlords that the hospital would be a financially responsible tenant and that staff would be in continuing contact with the patients, would be available to the landlords if problems arose, and would remove troublesome tenants. Some of the problems encountered by the patients in the program are described, as are guidelines for selecting those who have a reasonable chance of benefiting from such a program. Division of the Long Island JewMedical Center started a small demonstration project in congregate living for patients being released from the hospital. Closely linked to an aftercare program, it was intended to give patients an opportunity to test out the gains made in the hospital in a situation that simulates the life of independent adults but also provides support services. We decided to create an apartment program, rather than a halfway house, for several reasons. One important factor was financial; the cost of an apartment program would be markedly lower. Apartment living #{149}In 1973
the Hillside
ish-Hillside
The authors’ mailing Center is New Hyde
590
address Park,
at Long Island New York 11040.
HOSPITAL
Jewish-Hillside
& COMMUNITY
Medical
PSYCHIATRY
III:
would also conform to the residential life styles of other adults in the community. We were sensitized to community concerns about other aftercare programs and did not wish to reproduce a psychiatric ghetto that would be the target of public criticism. We looked for apartments in scattered locations because we knew that realistically our patients would at times be involved with police and other agencies, and widely scattered apartments would make the program less conspicuous. Since the goal was to help the patients assume an acceptable role in the community, we felt they should be surrounded by a real and not a patient community. Underlying our approach was the belief that people have a right to live anywhere they choose and can afford, and that if patients create problems, their problems should be handled by community agencies just as everyone else’s are. Additionally we knew that emotionally ill people live in every community, and that as long as they pay their rent and do not make inordinate demands on landlords, other tenants, or services, they blend into the general population. For those reasons, we began to look for apartments in modern, well-maintained apartment complexes in an urban area within commuting distance of the hospital. Predictably, landlords were not eager to rent to the hospital. However, we appealed to their business sense and not to their humanitarianism, and in a relatively short time we were able to rent one apartment in each of several high-rise buildings of a hundred or more units. Initially we worked with one landlord who owned several buildings within walking distance, and later with two landlords. What sold the landlords was the idea of the hospital as a reliable tenant, capable of paying the rent regularly and on time, carrying insurance for property damage, and willing to remove tenants who created problems that could not be resolved satisfactorily. Of course, there was great anxiety about mental patients as tenants-would they look peculiar, talk to themselves, or jump off roofs? We acknowledged that those possibilities existed, but there was also the possibility that one of the regular tenants might do the same things. We offered the landlords an interview with the prospective tenants and the following protection:
.
All hospital, program.
tenants either
would be in regular in the day hospital
treatment or the
Predictably,
at the aftercare
.
All tenants would have a job, be enrolled in school, or participate in a rehabilitation activity five days a week. Professional staff would hold weekly meetings with tenants at the hospital and periodic meetings at the apartment to ensure that reasonable standards of cleanliness were being maintained. This pattern could be varied if needed. If a crisis occurred, an emergency meeting would be arranged with the patients, therapists, families, or landlord, as determined by the nature of the problem. S The hospital would remove a tenant who caused serious problems so that the landlord would not have to be involved in legal eviction proceedings. Staff would be available to tenants and the landlord if a problem arose, as would a 24-hour emergency telephone service. This was our professional, carefully considered approach. However, we owe a debt to an anonymous man who, as one landlord was shaking his head skeptically, leaped onto the roof of a car and began shouting, I won’t pay the rent! I won’t pay the rent!” When we pointed out that he was not one of our patients, the landlord conceded and said we could have the apartments. The hospital made security deposits for the apartments and furnished and subsequently sublet them to groups of three to five patients. Currently there are eight apartments, with a maximum occupancy of 31 patients. The patients usually stay at least six months and can stay up to a year. They are expected to conform to reasonable norms for tenants established by the landlord in regard to cleanliness, noise, parties, and other aspects of apartment living.
rent to the hospital However, we appealed to their business sense and not to their humanitarianism. What sold them was the idea of the hospital as a reliable tenant.
.
.
“
THE
PATIENT
REFERRALS
Initially we expected that patients referred to the program from the inpatient services would have shown some capacity to live independently and cooperatively, to function in a job or at school, to learn from treatment, and to take responsibility for following through on their discharge plans. However, we soon found that those expectations were unrealistic, because the patients who had those capabilities usually decided to make their own living arrangements. Consequently most of the patients referred had long histories of unsuccessful adaptations, limited achievements, chronic dependency, and multiple hospitalizations. Frequently the motivation to move away from the family came from the therapist or the family, not from the patient. This situation became evident as patients who, according to the referral form, were in “desperate need” of living accommodations or had “no alternative” or whose families were “destructive” repeatedly rejected apartments as they became available. This experience led to the formation of a waiting-list
landlords
were not eager to
group that patients must attend regularly to keep their referral active. In this group, which meets weekly, a social worker and a social work assistant provide orientation to the apartment program and deal with issues of separation, anxiety about living with others, and expectations about apartment living. Patients have an opportunity to express their doubts and aspirations and decide whether they are ready to risk leaving their families or the isolation of a room at the Y or a welfare hotel to live in a shared apartment. Simultaneously staff can observe how the patient relates to others, his degree of self-control, and the appropriateness of his behavior. They can share concerns in those areas with the patient and referring staff, which also includes inpatient, day hospital, and aftercare staff. All the staff of the apartment-living program are assigned to the aftercare department and work part time in the apartment program. They include a director, who is a senior social worker; four master’s-degree social workers; and approximately four graduate social work students, social work assistants, or volunteers. The staff work in four two-person teams, each of which is assigned to two apartments. The teams visit the patients in their apartments monthly; they also arrange emergency meetings with patients, landlords, or both as necessary. In addition, there is a monthly meeting involving parents and families, patients, and staff. The family’s initial involvement often reflects the wish both to separate from the patient and to retain him, the fear that the patient will or will not make it without them, and the worry and the hope that the hospital will be better parents than they have been. Later, as the family experiences what life is like without the patient, they may act on the anger and rejection that has festered over the years; once physical separation is achieved, few families want to return to their former, totally life-sustaining roles. Hospital staff are available to provide consultation, help, and feedback to patients living in the apartments, but it is the patients’ responsibility to find a way to live together that is reasonably comfortable for them as well as for the landlord and neighbors. Patients are encouraged to assume some responsibility for each other so that they form a mutual support system. They are asked to alert the apartment social worker or their therapist if
VOLUME
29 NUMBER
9 SEPTEMBER
1978
591
they have a serious worry about an apartment situation, a roommate, or themselves. Once a patient makes the move to an apartment, he is often beset by disappointment that life is still not problem-free. Dependency upon parents may be transferred to staff, and some patients expect staff to resolve conflicts between roommates without involving them Since we have to live with each other’ ‘) and to take over housekeeping chores (“ Since we don’t mind the mess, it’s the staff’s problem”). Through apartment visits and the meetings with patients and others, we began to experience pathology in a three-dimensional way, quite differently from that encountered in an individual interview. For example, patients who were verbal and insightful in the office complained about lack of closet space, when in fact there were two large hall closets that were empty. 0thers could not resolve the problem of who was to use which shelf in the refrigerator. However, our understanding increased when we encountered the belief system behind the arguments: Only bedroom closets can be used for clothes” and Food will be invaded by cooties’ if touched by someone else’s food.” We became more insightful about the schizophrenic reality when patients who complained of loneliness while living alone in a room had the same complaint when living with three roommates; it did not occur to any of them to eat dinner together. If a patient is paranoid, suspicious, and fearful, it is an act of courage to share an apartment. In addition, whatever the causes, many of the patients do not have basic survival skills, and we no longer make assumptions about what has been integrated. For example, the tenants in one apartment complained about the sloppy bedroom of one woman who shared the apartment. A volunteer was assigned to show the woman how to hang up her clothes and make her bed. The volunteer said she would return the following week; on doing so she was gratified to see how neatly the room had been kept. The volunteer said, “Your room looks great. How did you manage it?” The tenant replied, “I slept on the couch in the living room.” Three tenants in another apartment complained that they were not getting their mail. Questioning revealed that in their cumulative life experience with their families (one was 19, another 28, and the third 31), they had never learned that it was necessary to place their names on the mailbox. After explaining that, the apartment worker returned the next week and looked at the mailbox. There she found their names-listed only as Susan, Patricia, and Rochelle. (6
“
“
GUIDELINES
FOR
SELECTION
From our experience with the program, we have uncovered several guidelines for identifying patients who have a reasonable chance of benefiting from the apartment-living program. None of the patients meet all these requirements, but most manage to conform well enough to remain in the program.
592
HOSPITAL
& COMMUNITY
PSYCHIATRY
. . .
The patient must have some motivation for testing himself in a situation that arouses increased anxiety. The patient must be aware that he still needs treatment and program supports from the hospital. The patient who is willing to consider the apartment program as only one of a number of ways to achieve a higher level of functioning usually makes a more realistic decision about apartment living than one who sees it as an emergency placement, or as a last resort not of his own choosing. S The decision to separate from his family can be made only by the patient and his family. The separation can be maintained only if the whole family experiences it as a response to growth, and not as abandonment by the patient or parents, or as a criticism of the family by the hospital staff. The patient, by history and by in-hospital functioning, must have demonstrated an increasing ability to learn from treatment and to control impulsive behavior, including suicide attempts. He should have some capacity to compromise and to live with people who may have different values and life styles. He should have some judgment about what is acceptable behavior in the community and be able to act accordingly. In addition, we have also found several negative predictors of a patient’s ability to handle apartment living. They include a history of violence and illegal activities, inability to care for personal hygiene, and management problems or frequent crises requiring an unusual investment of staff time.
.
EVALUATION
OF
THE
PROGRAM
In 1977 we attempted to locate all 92 patients who had been involved in the program to determine their current level of functioning in several areas-living arrangements, employment, training and formal education, recreation and socialization, and skills in independent living. Twenty-five patients were interviewed in person and five were interviewed by phone; there was minimal telephone contact with 11 patients, and the remaining 51 did not respond to letters or phone follow-up. Of the 30 patients interviewed, 16 were women and 14 were men. Of 1 1 who had lived at home before participation in the apartment-living program, six had returned home, two were living in an apartment with a roommate, and three had other living arrangements. Twenty-four of the patients had reported a minimal social life before participation in the program; 12 indicated it had improved, and an equal number reported no change. Four of the six patients who had an active social life before the program reported some improvement afterward. Eleven patients reported good relationships with their family before the program; at follow-up four indicated that the relationships had improved, and seven indicated no change. Of the 15 patients whose family relationships were not good before the program, eight reported some improvement, and seven no change.
The program’s cost per patient per year, excluding daily living expenses, is about $5000; that figure includes rent, utilities, furnishings, maintenance, insurance, and the pro-rated cost of social work and clerical time. The cost of the apartment-living program can be compared with the per-patient cost of $17,000 to $20,000 a year in a residential treatment center. For many patients, the period of apartment living coincides with the period of highest functioning in their lives. The pathology has not been cured, but with assistance from staff, the patients have been able to confine their pathology so it does not become a public issue. If patients are unable to do that, it is usually an
indication sheltered needed. themselves
that the stresses are too great and that living situation or rehospitalization But the patients who have been able to have improved ego functioning and
positive
perception
of themselves.
Despite the periodic crises, the landlords have renewed our leases and rented us additional apartments. There has been no outcry from the community or the media. Apparently the landlords’ standards are reflective of others in the community. Our goal is to reinforce autonomous, constructive, socially acceptable behavior so that more landlords will say, as one did, “To tell you the truth, I don’t remember who your patients are. “U
A Positive Look at Boarding WILLIAM Instructor
R. DUBIN, in Psychiatry
ThomasJefferson Philadelphia,
M.D.
Hospital Pennsylvania
BEATRICE CIAVARELLI, Assistant Director ofOutreach
B.A. Services
Horizon House Philadelphia, Pennsylvania The authors report on a project in Philadelphia in which boarding homes were successfully used to house f ormer state hospital patients in a warm and therapeutic environment. The program was established jointly by the Jefferson Community Mental Health Center and Horizon
drew
House,
the
through through
a psychosocial
proprietors close meetings
into
contact and
with seminars
rehabilitation
the
agency.
treatment
professional on various
It
program staff aspects
and of
housing and care. The authors note that their positive experiences with boarding homes and their proprietors run counter to the negative experiences reported in much of the literature. UThe literature appears to be almost unanimous in its condemnation of boarding homes for chronic psychiatric patients released from hospitals.’’ The homes are painted as mini-wards that increase the passivity, isolation, and inactivity of the residents. Yet we found quite a different situation in the catchment area of the JefferDr. Duhin’s Philadelphia,
address at Pennsylvania
the
hospital 19107.
is
11th
and
Walnut
Streets,
a more may be sustain a more
Homes
son Community Mental Health Center, which is affiliated with Thomas Jefferson Hospital in Philadelphia. In fact, we believe that boarding homes are a viable place to house former patients and that the proprietors of the homes can successfully be incorporated into a team-treatment approach. The mental health center and Horizon House, a community-based psychosocial rehabilitation agency, set up and implemented such a team approach. Horizon House is under contract with the center to provide aftercare, rehabilitation, outreach, and housing services to clients. In 1968, in order to find adequate housing for the more seriously dysfunctional clients, the agency established the Horizon House Cooperative Boarding Program which, as the name implies, is a cooperative effort between boarding-home proprietors and Horizon House. The program consists of about 80 boardinghome proprietors, most of them women, who take from one to six residents into their homes. The number in the homes is kept small to maintain a family-like atmos-
1
H. R. Lamb
and
V. Goertzel,
“The
Demise
of the
State
Hospital:
Obituary?” Archives of General Psychiatry, Vol. 26, June 1972, pp. 489-495. 2 H. R. Lamb and V. Goertzel, “Mental Patients: Are They Really in the Community?” Archives of General Psychiatry, Vol. 24, January 1971, pp. 29-34. H. Reich and L. Siegel, “Psychiatry Under Siege: The Chronically Mentally Ill Shuffle to Oblivion,” Psychiatric Annals, Vol. 3, November 1973, pp. 35-55. G. Neidermayer, “Boarding Homes Are Seen as Warehouses of the Helpless,” Region, Vol. 2, October 1976, pp. 12-15. H. B. M. Murphy, B. Pennee, and D. Luchins, ‘ Foster Homes: The New Back Wards?” Canada’s Mental Health, Vol. 20, Supplement No. 71, September-October 1972. A Premature
VOLUME
29 NUMBER
9 SEPTEMBER
1978
593
S.
Senior
Social
BURGER,
M.S.W.
Worker
LEAH KIMELMAN, Administrative Social
M.S.W. Work Supervisor
ABRAHAM LURIE, Director, Department
PH.D. of Social
CHARLES Chairman,
Work
Services
J. RABINER, M.D. Department of Psychiatry
Long
IslandJewish-Hillside
New
Hyde
Park,
New
Medical
Center
York
The authors describe an apartment-living project for chronic mental patients releasedfrom the Hillside Division of the Long Island Jewish-Hillside Medical Center. The apartments, which are rented by the hospital and sublet to the patients, are located in modern, wellmaintained
high-rise
buildings
within
commuting
dis-
lance from the hospital. To avoid creating a psychiatric ghetto, the project rents no more than two apartments in buildings of a hundred or more units. The hospital was able to rent the apartments by assuring the landlords that the hospital would be a financially responsible tenant and that staff would be in continuing contact with the patients, would be available to the landlords if problems arose, and would remove troublesome tenants. Some of the problems encountered by the patients in the program are described, as are guidelines for selecting those who have a reasonable chance of benefiting from such a program. Division of the Long Island JewMedical Center started a small demonstration project in congregate living for patients being released from the hospital. Closely linked to an aftercare program, it was intended to give patients an opportunity to test out the gains made in the hospital in a situation that simulates the life of independent adults but also provides support services. We decided to create an apartment program, rather than a halfway house, for several reasons. One important factor was financial; the cost of an apartment program would be markedly lower. Apartment living #{149}In 1973
the Hillside
ish-Hillside
The authors’ mailing Center is New Hyde
590
address Park,
at Long Island New York 11040.
HOSPITAL
Jewish-Hillside
& COMMUNITY
Medical
PSYCHIATRY
III:
would also conform to the residential life styles of other adults in the community. We were sensitized to community concerns about other aftercare programs and did not wish to reproduce a psychiatric ghetto that would be the target of public criticism. We looked for apartments in scattered locations because we knew that realistically our patients would at times be involved with police and other agencies, and widely scattered apartments would make the program less conspicuous. Since the goal was to help the patients assume an acceptable role in the community, we felt they should be surrounded by a real and not a patient community. Underlying our approach was the belief that people have a right to live anywhere they choose and can afford, and that if patients create problems, their problems should be handled by community agencies just as everyone else’s are. Additionally we knew that emotionally ill people live in every community, and that as long as they pay their rent and do not make inordinate demands on landlords, other tenants, or services, they blend into the general population. For those reasons, we began to look for apartments in modern, well-maintained apartment complexes in an urban area within commuting distance of the hospital. Predictably, landlords were not eager to rent to the hospital. However, we appealed to their business sense and not to their humanitarianism, and in a relatively short time we were able to rent one apartment in each of several high-rise buildings of a hundred or more units. Initially we worked with one landlord who owned several buildings within walking distance, and later with two landlords. What sold the landlords was the idea of the hospital as a reliable tenant, capable of paying the rent regularly and on time, carrying insurance for property damage, and willing to remove tenants who created problems that could not be resolved satisfactorily. Of course, there was great anxiety about mental patients as tenants-would they look peculiar, talk to themselves, or jump off roofs? We acknowledged that those possibilities existed, but there was also the possibility that one of the regular tenants might do the same things. We offered the landlords an interview with the prospective tenants and the following protection:
.
All hospital, program.
tenants either
would be in regular in the day hospital
treatment or the
Predictably,
at the aftercare
.
All tenants would have a job, be enrolled in school, or participate in a rehabilitation activity five days a week. Professional staff would hold weekly meetings with tenants at the hospital and periodic meetings at the apartment to ensure that reasonable standards of cleanliness were being maintained. This pattern could be varied if needed. If a crisis occurred, an emergency meeting would be arranged with the patients, therapists, families, or landlord, as determined by the nature of the problem. S The hospital would remove a tenant who caused serious problems so that the landlord would not have to be involved in legal eviction proceedings. Staff would be available to tenants and the landlord if a problem arose, as would a 24-hour emergency telephone service. This was our professional, carefully considered approach. However, we owe a debt to an anonymous man who, as one landlord was shaking his head skeptically, leaped onto the roof of a car and began shouting, I won’t pay the rent! I won’t pay the rent!” When we pointed out that he was not one of our patients, the landlord conceded and said we could have the apartments. The hospital made security deposits for the apartments and furnished and subsequently sublet them to groups of three to five patients. Currently there are eight apartments, with a maximum occupancy of 31 patients. The patients usually stay at least six months and can stay up to a year. They are expected to conform to reasonable norms for tenants established by the landlord in regard to cleanliness, noise, parties, and other aspects of apartment living.
rent to the hospital However, we appealed to their business sense and not to their humanitarianism. What sold them was the idea of the hospital as a reliable tenant.
.
.
“
THE
PATIENT
REFERRALS
Initially we expected that patients referred to the program from the inpatient services would have shown some capacity to live independently and cooperatively, to function in a job or at school, to learn from treatment, and to take responsibility for following through on their discharge plans. However, we soon found that those expectations were unrealistic, because the patients who had those capabilities usually decided to make their own living arrangements. Consequently most of the patients referred had long histories of unsuccessful adaptations, limited achievements, chronic dependency, and multiple hospitalizations. Frequently the motivation to move away from the family came from the therapist or the family, not from the patient. This situation became evident as patients who, according to the referral form, were in “desperate need” of living accommodations or had “no alternative” or whose families were “destructive” repeatedly rejected apartments as they became available. This experience led to the formation of a waiting-list
landlords
were not eager to
group that patients must attend regularly to keep their referral active. In this group, which meets weekly, a social worker and a social work assistant provide orientation to the apartment program and deal with issues of separation, anxiety about living with others, and expectations about apartment living. Patients have an opportunity to express their doubts and aspirations and decide whether they are ready to risk leaving their families or the isolation of a room at the Y or a welfare hotel to live in a shared apartment. Simultaneously staff can observe how the patient relates to others, his degree of self-control, and the appropriateness of his behavior. They can share concerns in those areas with the patient and referring staff, which also includes inpatient, day hospital, and aftercare staff. All the staff of the apartment-living program are assigned to the aftercare department and work part time in the apartment program. They include a director, who is a senior social worker; four master’s-degree social workers; and approximately four graduate social work students, social work assistants, or volunteers. The staff work in four two-person teams, each of which is assigned to two apartments. The teams visit the patients in their apartments monthly; they also arrange emergency meetings with patients, landlords, or both as necessary. In addition, there is a monthly meeting involving parents and families, patients, and staff. The family’s initial involvement often reflects the wish both to separate from the patient and to retain him, the fear that the patient will or will not make it without them, and the worry and the hope that the hospital will be better parents than they have been. Later, as the family experiences what life is like without the patient, they may act on the anger and rejection that has festered over the years; once physical separation is achieved, few families want to return to their former, totally life-sustaining roles. Hospital staff are available to provide consultation, help, and feedback to patients living in the apartments, but it is the patients’ responsibility to find a way to live together that is reasonably comfortable for them as well as for the landlord and neighbors. Patients are encouraged to assume some responsibility for each other so that they form a mutual support system. They are asked to alert the apartment social worker or their therapist if
VOLUME
29 NUMBER
9 SEPTEMBER
1978
591
they have a serious worry about an apartment situation, a roommate, or themselves. Once a patient makes the move to an apartment, he is often beset by disappointment that life is still not problem-free. Dependency upon parents may be transferred to staff, and some patients expect staff to resolve conflicts between roommates without involving them Since we have to live with each other’ ‘) and to take over housekeeping chores (“ Since we don’t mind the mess, it’s the staff’s problem”). Through apartment visits and the meetings with patients and others, we began to experience pathology in a three-dimensional way, quite differently from that encountered in an individual interview. For example, patients who were verbal and insightful in the office complained about lack of closet space, when in fact there were two large hall closets that were empty. 0thers could not resolve the problem of who was to use which shelf in the refrigerator. However, our understanding increased when we encountered the belief system behind the arguments: Only bedroom closets can be used for clothes” and Food will be invaded by cooties’ if touched by someone else’s food.” We became more insightful about the schizophrenic reality when patients who complained of loneliness while living alone in a room had the same complaint when living with three roommates; it did not occur to any of them to eat dinner together. If a patient is paranoid, suspicious, and fearful, it is an act of courage to share an apartment. In addition, whatever the causes, many of the patients do not have basic survival skills, and we no longer make assumptions about what has been integrated. For example, the tenants in one apartment complained about the sloppy bedroom of one woman who shared the apartment. A volunteer was assigned to show the woman how to hang up her clothes and make her bed. The volunteer said she would return the following week; on doing so she was gratified to see how neatly the room had been kept. The volunteer said, “Your room looks great. How did you manage it?” The tenant replied, “I slept on the couch in the living room.” Three tenants in another apartment complained that they were not getting their mail. Questioning revealed that in their cumulative life experience with their families (one was 19, another 28, and the third 31), they had never learned that it was necessary to place their names on the mailbox. After explaining that, the apartment worker returned the next week and looked at the mailbox. There she found their names-listed only as Susan, Patricia, and Rochelle. (6
“
“
GUIDELINES
FOR
SELECTION
From our experience with the program, we have uncovered several guidelines for identifying patients who have a reasonable chance of benefiting from the apartment-living program. None of the patients meet all these requirements, but most manage to conform well enough to remain in the program.
592
HOSPITAL
& COMMUNITY
PSYCHIATRY
. . .
The patient must have some motivation for testing himself in a situation that arouses increased anxiety. The patient must be aware that he still needs treatment and program supports from the hospital. The patient who is willing to consider the apartment program as only one of a number of ways to achieve a higher level of functioning usually makes a more realistic decision about apartment living than one who sees it as an emergency placement, or as a last resort not of his own choosing. S The decision to separate from his family can be made only by the patient and his family. The separation can be maintained only if the whole family experiences it as a response to growth, and not as abandonment by the patient or parents, or as a criticism of the family by the hospital staff. The patient, by history and by in-hospital functioning, must have demonstrated an increasing ability to learn from treatment and to control impulsive behavior, including suicide attempts. He should have some capacity to compromise and to live with people who may have different values and life styles. He should have some judgment about what is acceptable behavior in the community and be able to act accordingly. In addition, we have also found several negative predictors of a patient’s ability to handle apartment living. They include a history of violence and illegal activities, inability to care for personal hygiene, and management problems or frequent crises requiring an unusual investment of staff time.
.
EVALUATION
OF
THE
PROGRAM
In 1977 we attempted to locate all 92 patients who had been involved in the program to determine their current level of functioning in several areas-living arrangements, employment, training and formal education, recreation and socialization, and skills in independent living. Twenty-five patients were interviewed in person and five were interviewed by phone; there was minimal telephone contact with 11 patients, and the remaining 51 did not respond to letters or phone follow-up. Of the 30 patients interviewed, 16 were women and 14 were men. Of 1 1 who had lived at home before participation in the apartment-living program, six had returned home, two were living in an apartment with a roommate, and three had other living arrangements. Twenty-four of the patients had reported a minimal social life before participation in the program; 12 indicated it had improved, and an equal number reported no change. Four of the six patients who had an active social life before the program reported some improvement afterward. Eleven patients reported good relationships with their family before the program; at follow-up four indicated that the relationships had improved, and seven indicated no change. Of the 15 patients whose family relationships were not good before the program, eight reported some improvement, and seven no change.
The program’s cost per patient per year, excluding daily living expenses, is about $5000; that figure includes rent, utilities, furnishings, maintenance, insurance, and the pro-rated cost of social work and clerical time. The cost of the apartment-living program can be compared with the per-patient cost of $17,000 to $20,000 a year in a residential treatment center. For many patients, the period of apartment living coincides with the period of highest functioning in their lives. The pathology has not been cured, but with assistance from staff, the patients have been able to confine their pathology so it does not become a public issue. If patients are unable to do that, it is usually an
indication sheltered needed. themselves
that the stresses are too great and that living situation or rehospitalization But the patients who have been able to have improved ego functioning and
positive
perception
of themselves.
Despite the periodic crises, the landlords have renewed our leases and rented us additional apartments. There has been no outcry from the community or the media. Apparently the landlords’ standards are reflective of others in the community. Our goal is to reinforce autonomous, constructive, socially acceptable behavior so that more landlords will say, as one did, “To tell you the truth, I don’t remember who your patients are. “U
A Positive Look at Boarding WILLIAM Instructor
R. DUBIN, in Psychiatry
ThomasJefferson Philadelphia,
M.D.
Hospital Pennsylvania
BEATRICE CIAVARELLI, Assistant Director ofOutreach
B.A. Services
Horizon House Philadelphia, Pennsylvania The authors report on a project in Philadelphia in which boarding homes were successfully used to house f ormer state hospital patients in a warm and therapeutic environment. The program was established jointly by the Jefferson Community Mental Health Center and Horizon
drew
House,
the
through through
a psychosocial
proprietors close meetings
into
contact and
with seminars
rehabilitation
the
agency.
treatment
professional on various
It
program staff aspects
and of
housing and care. The authors note that their positive experiences with boarding homes and their proprietors run counter to the negative experiences reported in much of the literature. UThe literature appears to be almost unanimous in its condemnation of boarding homes for chronic psychiatric patients released from hospitals.’’ The homes are painted as mini-wards that increase the passivity, isolation, and inactivity of the residents. Yet we found quite a different situation in the catchment area of the JefferDr. Duhin’s Philadelphia,
address at Pennsylvania
the
hospital 19107.
is
11th
and
Walnut
Streets,
a more may be sustain a more
Homes
son Community Mental Health Center, which is affiliated with Thomas Jefferson Hospital in Philadelphia. In fact, we believe that boarding homes are a viable place to house former patients and that the proprietors of the homes can successfully be incorporated into a team-treatment approach. The mental health center and Horizon House, a community-based psychosocial rehabilitation agency, set up and implemented such a team approach. Horizon House is under contract with the center to provide aftercare, rehabilitation, outreach, and housing services to clients. In 1968, in order to find adequate housing for the more seriously dysfunctional clients, the agency established the Horizon House Cooperative Boarding Program which, as the name implies, is a cooperative effort between boarding-home proprietors and Horizon House. The program consists of about 80 boardinghome proprietors, most of them women, who take from one to six residents into their homes. The number in the homes is kept small to maintain a family-like atmos-
1
H. R. Lamb
and
V. Goertzel,
“The
Demise
of the
State
Hospital:
Obituary?” Archives of General Psychiatry, Vol. 26, June 1972, pp. 489-495. 2 H. R. Lamb and V. Goertzel, “Mental Patients: Are They Really in the Community?” Archives of General Psychiatry, Vol. 24, January 1971, pp. 29-34. H. Reich and L. Siegel, “Psychiatry Under Siege: The Chronically Mentally Ill Shuffle to Oblivion,” Psychiatric Annals, Vol. 3, November 1973, pp. 35-55. G. Neidermayer, “Boarding Homes Are Seen as Warehouses of the Helpless,” Region, Vol. 2, October 1976, pp. 12-15. H. B. M. Murphy, B. Pennee, and D. Luchins, ‘ Foster Homes: The New Back Wards?” Canada’s Mental Health, Vol. 20, Supplement No. 71, September-October 1972. A Premature
VOLUME
29 NUMBER
9 SEPTEMBER
1978
593
