UBC Theses and Dissertations

UBC Theses Logo

UBC Theses and Dissertations

Chronic mental patients in three-quarter way housing : effect on quality of life Hooper, Grace Jacqueline 1984

Your browser doesn't seem to have a PDF viewer, please download the PDF to view this item.

Item Metadata

Download

Media
831-UBC_1984_A5 H65.pdf [ 5.06MB ]
Metadata
JSON: 831-1.0096000.json
JSON-LD: 831-1.0096000-ld.json
RDF/XML (Pretty): 831-1.0096000-rdf.xml
RDF/JSON: 831-1.0096000-rdf.json
Turtle: 831-1.0096000-turtle.txt
N-Triples: 831-1.0096000-rdf-ntriples.txt
Original Record: 831-1.0096000-source.json
Full Text
831-1.0096000-fulltext.txt
Citation
831-1.0096000.ris

Full Text

CHRONIC MENTAL PATIENTS IN THREE-QUARTER WAY HOUSING EFFECT ON QUALITY OF LIFE by GRACE JACQUELINE HOOPER B.S.W. ,• The U n i v e r s i t y o f B r i t i s h Columbia, 1982 A THESIS SUBMITTED IN PARTIAL FULFILLMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK in THE FACULTY OF GRADUATE STUDIES The School of S o c i a l Work We accept t h i s t h e s i s as conforming to the r e q u i r e d standard THE UNIVERSITY OF BRITISH COLUMBIA June 1984 © G. J a c q u e l i n e Hooper, 1984 In presenting t h i s thesis i n p a r t i a l f u l f i l m e n t of the requirements for an advanced degree at the University of B r i t i s h Columbia, I agree that the Library s h a l l make i t f r e e l y a v a i l a b l e for reference and study. I further agree that permission f o r extensive copying of t h i s t h e s i s f o r s c h o l a r l y purposes may be granted by the head of my department or by h i s or her representatives. I t i s understood that copying or p u b l i c a t i o n of t h i s t h e s i s f o r f i n a n c i a l gain s h a l l not be allowed without my written permission. Department of 5 g e-' f t f rtorK  The University of B r i t i s h Columbia 1956 Main Mall Vancouver, Canada V6T 1Y3 Date June , fHf-A B S T R A C T The purpose of the study was to d i s c o v e r i f t h r e e - q u a r t e r way housing had an e f f e c t on the q u a l i t y o f l i f e of c h r o n i c mental p a t i e n t s i n the community. To determine the e f f e c t , f i v e areas were i n v e s t i g a t e d : number o f h o s p i t a l and c r i s i s hos te l admiss ions and days o f i n s t i t u t i o n a l i z a t i o n , the independence o f the p a t i e n t s i n b a s i c l i v i n g s k i l l s , the s i z e and i n t i m a c y of the p a t i e n t s ' s o c i a l support system, the s e v e r i t y of t h e i r symptomatology, and the three most meaningful a c t i v i t i e s which gave them s a t i s f a c t i o n i n s t r u c t u r i n g t h e i r t i m e . From publ ished l i t e r a t u r e , measures were adapted and a random sample o f 50 r e s i d e n t s of a t h r e e - q u a r t e r way housing program and 20 a p p l i c a n t s to the same program were surveyed by s t r u c t u r e d i n t e r v i e w . E a r l i e r s e l f - r e p o r t data were r e a n a l y z e d . The a p p l i c a n t s were surveyed again a f t e r 12 months when they had become r e s i d e n t s . Th ree -quar te r way housing s t a f f repor ted on the a p p l i c a n t group w i th the Progress E v a l u a t i o n Sca les i n order to v a l i d a t e the s e l f - r e p o r t measures. H o s p i t a l i z a t i o n admiss ions and p a t i e n t s days of i n s t i t u t i o n a l i z a -t i o n decreased c o n s i d e r a b l y when p a t i e n t s were i n r e s i d e n c e . Independence was found to be a t an acceptab le l e v e l f o r community l i v i n g but t h i s was found to be due to the s t r i c t sc reen ing process i n t o . t h e program. i i i . S o c i a l networks of the r e s i d e n t s , and the a p p l i c a n t s . when they became r e s i d e n t s , were found to be approaching normalcy or w i t h i n a normal range. The i n c r e a s e i n casual r e l a t i o n s h i p s from a p p l i c a n t to r e s i d e n t s t a t u s was s t a t i s t i c a l l y s i g n i f i c a n t . Symptomatology was l e s s severe f o r the r e s i d e n t group than the a p p l i c a n t group; the change i n most measures of symptomatology items was s t a t i s t i c a l l y s i g n i f i c a n t f o r the a p p l i c a n t group pre and post r e s i d e n c y . Meaningful a c t i v i t i e s f o r the p a t i e n t s d i d not change i n the d i r e c t i o n o f inc reased p r o d u c t i v i t y or more a c t i v e p u r s u i t s r a t h e r than p a s s i v e , i s o l a t e d p u r s u i t s when they became r e s i d e n t s , but s a t i s f a c t i o n w i th t h e i r a c t i v i t i e s was expressed by a l a r g e m a j o r i t y of those q u e s t i o n e d . In the view of the p a t i e n t s s t u d i e d , and supported by the d a t a , t h r e e - q u a r t e r way housing c reated an e f f e c t on q u a l i t y of l i f e by s i g n i f i c a n t l y improving the mental h e a l t h o f the r e s i d e n t s i n a normal i zed environment which i s l e s s c o s t l y than halfway housing a l t e r n a t i v e s and r e q u i r e s l e s s s u p e r v i s i o n . i v . TABLE OF CONTENTS Page ABSTRACT i i LIST OF TABLES v LIST OF FIGURES v i i INTRODUCTION 1 L i t e r a t u r e Review 2 Conceptual Framework 35 Hypotheses 37 Design 39 METHOD 41 S e t t i n g 41 Subjects 42 Measures 46 RESULTS 55 DISCUSSION 85 Summary 104 REFERENCES 107) APPENDIX 113 V . LIST OF TABLES Table Page 1 . D iagnos is o f Res idents and A p p l i c a n t s 58 2 . Housing C h a r a c t e r i s t i c s o f Res idents and A p p l i c a n t s Before They Moved i n t o Coast Foundation 59 3 . No. o f Admissions o f Res idents to I n s t i t u t i o n s i n the Three Years P r i o r to and Subsequent to L i v i n g i n Three-quar te r Way Housing 63 4 . No. of I n s t i t u t i o n Days of Res idents i n the Three Years P r i o r to and Subsequent to L i v i n g i n Three -quar te r Way Housing , 64 5 . Average No. of Admissions o f A p p l i c a n t s per P a t i e n t per Month i n the Three Years P r i o r to Th ree -quar te r Way Housing and One Year Subsequent to Housing 66 6. Average No. of I n s t i t u t i o n Days per P a t i e n t per Month i n the Three Years P r i o r to Th ree -quar te r Way Housing and One Year Subsequent to Housing 67 7. Mean No. o f S o c i a l R e l a t i o n s h i p s by Type, of R e s i d e n t s , A p p l i c a n t s Time 1 T e s t i n g , and A p p l i c a n t s Time 2 T e s t i n g When They Had Become Res idents 70 8 . Mean No. o f S o c i a l R e l a t i o n s h i p s by Type, of Residents Compared w i th the Mean No. o f S o c i a l R e l a t i o n s h i p s o f A p p l i c a n t s Time 1 T e s t i n g 71 9. Mean No. o f S o c i a l R e l a t i o n s h i p s by Type, o f A p p l i c a n t s a t Time 1 Compared w i t h A p p l i c a n t s When They Became Residents a t Time 2 73 1 0 . Comparison o f the Symptomatology o f the Residents w i t h A p p l i c a n t s Time 1 T e s t i n g 74 1 1 . Comparison of the Symptomatology o f A p p l i c a n t s Time 1 and the A p p l i c a n t s When They Became Residents Time 2 76 ' v i . Page 1 2 . Three A c t i v i t i e s Rated Most Meaningful by the P a t i e n t s i n the S t r u c t u r i n g of The i r Time 78 1 3 . A s s o c i a t i o n between R e s i d e n t s ' S e l f - r e p o r t o f S e l f Esteem and S t a f f Rat ing of S e l f Esteem 82 14 . A s s o c i a t i o n between Residents ' S e l f - r e p o r t of Optimism and S t a f f Rat ing o f Fee l ings and Mood 83 v i i . LIST OF FIGURES F igure Page 1 . Conceptual Framework o f E f f e c t o f Th ree -quar te r Way Housing on Q u a l i t y of L i f e of Chronic Mental P a t i e n t s 3 8 2 . . Percentage Age D i s t r i b u t i o n o f Res idents and A p p l i c a n t s 56 I N T R O D U C T I O N Over the past two decades c h r o n i c mental p a t i e n t s have been re leased from i n s t i t u t i o n s or have not been h o s p i t a l i z e d because of the nat ionwide p o l i c y to decrease mental h o s p i t a l p o p u l a t i o n s . Instead mental p a t i e n t s have been r e l e a s e d to the c o m m u n i t y - a t - l a r g e or to s p e c i a l i z e d f a c i l i t i e s w i t h i n the community such as halfway housing or t h r e e - q u a r t e r way hous ing . Although the l i t e r a t u r e on halfway housing programs i s growing , l i t t l e i n f o r m a t i o n e x i s t s as to the e f f e c t on the c h r o n i c mental p a t i e n t p o p u l a t i o n of m i n i m a l l y s u p p o r t i v e housing - t h r e e - q u a r t e r way housing -which seeks to normal i ze the environment of the mental p a t i e n t w h i l e p ro -v i d i n g a peer group, and a smal l measure o f s u p e r v i s o r y suppor t . Halfway housing i s seen to encompass a l l the housing types which are not normal by community standards i n c l u d i n g shared accommodation i n a v a r i e t y o f s e t t i n g s such as boarding homes, or o ther communal l i v i n g w i t h s u p e r v i s o r y s t a f f . T h r e e - q u a r t e r way housing i n c o n t r a s t i s normal ized housing and i n c l u d e s s a t e l l i t e housing such as severa l p a t i e n t s s h a r i n g a s u i t e i n an apartment b lock w i t h p a r t - t i m e or o c c a s i o n a l s u p e r v i s i o n , or p a t i e n t s l i v i n g independent ly i n s e l f - c o n t a i n e d u n i t s i n an apartment b lock s p e c i f i c a l l y f o r p a t i e n t s , w i t h p a r t - t i m e or occas iona l s u p e r v i s i o n and s o c i a l i z a t i o n o p p o r t u n i t i e s and programs. 2. To determine whether or not t h r e e - q u a r t e r way housing has an e f f e c t on the q u a l i t y o f l i f e o f c h r o n i c mental p a t i e n t s a number o f quest ions need to be answered. W i l l p a t i e n t s i n t h i s housing have more or l e s s h o s p i t a l i z a t i o n s than they had i n o ther s e t t i n g s ? W i l l the p a t i e n t s have adequate bas ic l i f e s k i l l s to f u n c t i o n i n the community a f t e r having been i n s t i t u t i o n a l i z e d and dependent upon o thers? W i l l the d i s t r e s s i n g symptoms o f mental i l l n e s s change f o r the b e t t e r or worse? W i l l the p a t i e n t s be ab le to cope comfor tab ly o u t s i d e o f h o s p i t a l ? W i l l t h e i r s o c i a l network system i n t h i s environment be l a r g e enough to support them i n t imes of emotional upset and f u l f i l t h e i r needs o f normal s o c i a l i z a t i o n ? W i l l they become product i ve c i t i z e n s ? Or w i l l they be s a t i s f i e d to l i v e non -p roduc t i ve but comfor tab ly s t r u c t u r e d l i v e s ? This study w i l l determine answers to these quest ions through an a n a l y s i s o f i n t e r v i e w s w i t h p a t i e n t s i n a t h r e e - q u a r t e r way housing program, and i n t e r v i e w s w i t h a p p l i c a n t s to the same program before and dur ing r e s i d e n c y . The q u a l i t y o f l i f e of these p a t i e n t s w i l l be i n v e s t i -gated by dete rmin ing the i n c i d e n c e of h o s p i t a l i z a t i o n before and dur ing r e s i d e n c y , by de te rmin ing the independence o f the p a t i e n t s i n terms o f b a s i c l i v i n g s k i l l s , by measuring the s i z e and in t imacy o f the p a t i e n t s ' s o c i a l network, by examining t h e i r symptoms o f mental i l l n e s s , and by l o o k i n g a t t h e i r d a i l y a c t i v i t y and the s a t i s f a c t i o n de r i ved from i t . L i t e r a t u r e Review Several decades ago ch ron ic mental p a t i e n t s would have been l i v i n g f o r long per iods or permanently i n mental i n s t i t u t i o n s . The p o l i c y 3 . o f d e i n s t i t u t i o n a l i z a t i o n o f those w i t h p s y c h i a t r i c d i s o r d e r s has seen many thousands o f fo rmer l y h o s p i t a l i z e d people move i n t o the community on both s i d e s o f the A t l a n t i c s i n c e the n ineteen s i x t i e s . In 1955 i n the U.S. there were 559,000 p a t i e n t s i n s t a t e h o s p i t a l s ; by 1980 t h i s f i g u r e had dropped to 138,000 and o u t p a t i e n t episodes had inc reased t w e l v e f o l d ( T a l b o t t , 1980: 4 3 ; Goldman, 1983: 1 3 1 ; O k i n , 1983: 578) . This mass exodus i s r e f l e c t e d i n B .C . s t a t i s t i c s . In 1954 Riverv iew H o s p i t a l repor ted 3,481 p a t i e n t s ; by 1981 the case load had dropped to 1,097 p a t i e n t s , and r e g i s t e r e d o u t p a t i e n t s had r i s e n to 19,425 a c c o r d i n g to the annual r e p o r t o f the B .C . M i n i s t r y o f H e a l t h . In the expanding economic times o f the s i x t i e s there was a push fo r s o c i a l j u s t i c e and the a l l e v i a t i o n o f s u f f e r i n g : proponents o f mass d i scharges from h o s p i t a l opined t h a t a r c h a i c mental i n s t i t u t i o n s were dehumanizing and a n t i t h e r a p e u t i c and t h a t care i n the community would lead to r e h a b i l i t a t i o n ( W i l l i a m s e t a l . , 1980: 6 3 ) . The d e c l i n e i n p o p u l a t i o n o f the l a r g e i n s t i t u t i o n s has been a s c r i b e d not on ly to the c i v i l l i b e r t a r i a n ph i losophy o f the t i m e , (Bachrach , 1978: 575) but a l s o to the advent o f psychot rop ic drugs which c o n t r o l l e d symptoms o f s e r i o u s mental i l l n e s s to the ex tent t h a t p a t i e n t s cou ld l i v e o u t s i d e h o s p i t a l ( W i l l i a m s e t a l . , 1980: 6 3 ; C l a r k e , 1979: 4 6 1 ; Borus , 1981: 339) . Other c a u s a t i v e f a c t o r s c i t e d were World War IT and the f a c t t h a t two m i l l i o n Americans were r e j e c t e d by the armed fo rces because o f p s y c h o l o g i c a l impairment , prompting the m i l i t a r y to push f o r reform ( Bennet t , 1979: 517; C l a r k e , 1979: 4 6 1 ) . Aviram and Segal argued t h a t a p p r o p r i a t e l e v e l s o f income maintenance through p u b l i c a s s i s t a n c e programs were the major f a c t o r r e s p o n s i b l e f o r the mass movement from i n s t i t u t i o n s 4. (Av i ram, S e g a l , 1977: 1 6 2 ) . In Great B r i t a i n d e i n s t i t u t i o n a l i z a t i o n was a t t r i b u t e d to the i n i t i a t i o n o f the Welfare S t a t e and o r g a n i z a t i o n o f the Nat iona l Heal th S e r v i c e (Bennet t , 1979: 517) . I n f l u e n c i n g thought a t t h i s time was Thomas Szasz (The Myth of Mental I l l n e s s ) who argued t h a t s e r i o u s mental i l l n e s s d i d not e x i s t and t h e r e f o r e l a r g e expensive i n s t i t u t i o n s d i d not need to e x i s t (Borus , 1981: 3 3 9 ) . In h o s p i t a l a l l the needs o f p a t i e n t s were looked a f t e r . ' In the community they r e q u i r e a f t e r c a r e , f i n a n c i a l a s s i s t a n c e , l o w - c o s t s u p p o r t i v e housing and a range o f o ther s e r v i c e s provided i n h o s p i t a l . Those who are d ischarged from i n s t i t u t i o n s w i thout these a ids f r e q u e n t l y end up back i n h o s p i t a l because o f a recur rence o f symptoms brought on by inadequate a f t e r c a r e augmented by poor environmental c o n d i t i o n s w i thout suppor t . High readmiss ions have led to a r e v o l v i n g door syndrome: by 1972 readmiss ion had c l imbed to 64% i n the U.S. and Canada ( T a l b o t t , 1980: 4 5 ) . The readmiss ion r a t e a t R iverv iew Hosp i ta l i s c u r r e n t l y 71%, and the d i s p o s i t i o n o f p a t i e n t s i n the community has led p s y c h i a t r i s t s to term d e i n s t i t u t i o n a l i z a t i o n a n a t i o n a l d i s g r a c e ( T a l b o t t , 1980: 4 3 ) . The danger o f the c u r r e n t emphasis on p u t t i n g people out i n t o the community o f t e n means t h a t they are abandoned i n the name o f personal freedom and the l e a s t r e s t r i c t i v e envi ronment , but they d o n ' t know how to fend f o r themselves (Lehmann, 1976: 5 ) . I t has been argued t h a t d e i n s t i t u t i o n a l i z a -t i o n i s workable i f high q u a l i t y a f t e r c a r e i s a v a i l a b l e , i f funds are d i v e r t e d to community programs, i f s u c c e s s f u l models o f community care are adapted w i d e l y and i n n o v a t i o n s are made ( C l a r k e , 1979: 4 7 6 ) . R e a l i s t i c goals must be formulated . for the p r e v i o u s l y i n s t i t u t i o n a l i z e d . I t i s u n r e a l i s t i c to assume t h a t former p a t i e n t s w i l l o b t a i n adequate hous ing , 5 . r e t u r n to employment and a high l e v e l o f s o c i a l f u n c t i o n i n g on t h e i r own. The most t h a t can be a n t i c i p a t e d i s t h a t , w i th h e l p , they can f u n c t i o n as comfor tab ly as normals i n the community (Lamb, 1981: 1 0 6 ) . An improved q u a l i t y o f l i f e compared to t h a t i n an i n s t i t u t i o n i s dependent on good l i v i n g c o n d i t i o n s and high q u a l i t y back-up i n s t i t u -t i o n a l care (Lamb, 1981: 1 0 8 ) . In Vancouver there i s high q u a l i t y back-up c a r e . E x - p a t i e n t s can choose to a t tend p r i v a t e p s y c h i a t r i s t s or o u t p a t i e n t t reatment i n c l u d i n g d r u g s , therapy and "brokerage" f u n c t i o n s by the community care teams o f the Greater Vancouver Mental. Hea l th S e r v i c e . There are a l s o p s y c h i a t r i c beds i n general h o s p i t a l s i n the area fo r those who s u f f e r decompensat ions, and secondary r e f e r r a l to R iverv iew H o s p i t a l s t i l l e x i s t s f o r the more s e r i o u s l y i l l who need l o n g e r - t e r m c a r e . I t i s w i d e l y recognized t h a t the q u a l i t y o f l i f e o f c h r o n i c mental p a t i e n t s i n the community depends to a s i g n i f i c a n t ex tent on adequate hous ing , e s p e c i a l l y a s i t u a t i o n i n which the p a t i e n t i s not i s o l a t e d . Needed f o r t h i s group i s a continuum o f housing types rang ing from s h o r t - s t a y c r i s i s h o s t e l s to halfway housing or boarding homes, and to independent l i v i n g i n c o - o p e r a t i v e apartments and s t a f f e d apartment b locks w i t h s e l f - c o n t a i n e d s u i t e s ( t h r e e - q u a r t e r way h o u s i n g ) . Some have r e h a b i l i t a t i v e programs, o thers are m i n i - i n s t i t u t i o n s w i t h the same warehousing c h a r a c t e r i s t i c s tha t l ed to c r i t i c i s m of the l a r g e a r c h a i c mental i n s t i t u t i o n s . For the a c u t e l y i l l , Lehmann d e s c r i b e s h o s p i t a l i z a t i o n as f a r p r e f e r a b l e to dumping p a t i e n t s i n t o the c o m m u n i t y - a t - l a r g e . H o s p i t a l a t l e a s t prov ides s h e l t e r , good f o o d , p r o t e c t i o n from r i d i c u l e and f a c i l i t i e s f o r r e c r e a t i o n and planned and s h e l t e r e d work (Lehmann, 1976: 5) . 6. Mosher and Menn d e s c r i b e a c reated envi ronment , S o t e r i a House, i n San F r a n c i s c o , model led a long the l i n e s o f R.D. L a i n g ' s K i n g s l e y H a l l which was s t a r t e d i n 1966 i n the United Kingdom. S o t e r i a House i s s t a f f e d w i t h n o n - p r o f e s s i o n a l s whose r o l e i s to share as equals i n the exper ience o f s c h i z o p h r e n i c s undergoing exacerbat ions o f t h e i r i l l n e s s ( W i l s o n , 1982: 9 ) . Res idents have been found to s tay longer i n r e s i d e n c e than c o n t r o l s i n h o s p i t a l but they need fewer or no n e u r o l e p t i c d rugs . The exper imental group o f r e s i d e n t s used l e s s o u t p a t i e n t c a r e , e x h i b i t e d more independence and were s i g n i f i c a n t l y more p roduct i ve than a group o f c o n t r o l s r e c e i v i n g t r a d i t i o n a l t rea tment . Mosher and Menn admit t h a t the exper ience was demanding f o r s t a f f , burn -out was a problem and s t a f f turnover h i g h , however t h e i r ev idence showed t h a t a s u p p o r t i v e " f a m i l y " atmosphere was j u s t as e f f e c t i v e d u r i n g an acute phase o f s c h i z o p h r e n i a as h o s p i t a l i z a t i o n w i t h l a r g e amounts o f d rugs . One hundred and s i x p a t i e n t s p laced in: 58 f o s t e r homes i n three prov inces o f e a s t e r n Canada were fo l lowed up f o r e ighteen months to a s c e r t a i n changes i n symptomatology and s o c i a l adjustment (Tcheng-Laroche , 1976: 1 3 ) . The r e s u l t s f o r the researchers were to an ex tent d i s a p p o i n t i n g : the exper imental group of p a t i e n t s d e c l i n e d i n the number o f v i s i t o r s , the amount o f t ime i n bed inc reased and the hope f o r an independent l i f e d e c l i n e d s i g n i f i c a n t l y . Those who improved the most compared to the c o n t r o l group o f 28 h o s p i t a l i z e d p a t i e n t s , were l o n g -term c h r o n i c s , showing t h a t t h i s group cou ld be s a f e l y moved i n t o the community to exper ience an improved q u a l i t y o f l i f e . In homes w i t h r e l a -t i v e l y l i t t l e s u p e r v i s i o n the best r e s u l t s were o b t a i n e d , suggest ing tha t halfway houses w i t h minimal s u p e r v i s i o n and inc reased s o c i a l i n t e r a c t i o n might lead to inc reased r e h a b i l i t a t i o n . 7 . Halfway housing such as p s y c h i a t r i c boarding homes i n Vancouver v a r i e s from the r e h a b i l i t a t i o n - o r i e n t e d Loma S o c i e t y program f o r under -t h i r t i e s w i th an a l l o w a b l e s i x month s tay i n r e s i d e n c e to l a r g e homes o f permanent res idence such as Tay lor Manor which prov ides i n t e r m e d i a t e care to c h r o n i c s c h i z o p h r e n i c s , those w i t h o r g a n i c b r a i n syndrome and p s y c h o g e r i a t r i c s . The t y p i c a l "ha l fway" house has a p o p u l a t i o n o f about 15 c h r o n i c mental p a t i e n t s who share bedrooms. I t prov ides t w e n t y - f o u r hour s u p e r v i s i o n , prov ides m e a l s , superv i ses m e d i c a t i o n , a s s i s t s w i th a c t i v i t i e s o f d a i l y l i v i n g , and has l i t t l e or no o rgan ized a c t i v i t y , work, or s o c i a l involvement o ther than the c o n t a c t o f those who l i v e i n c l o s e p rox imi t y to one another ( O z a r i n , W i t k i n , 1975: 1 0 2 ) . Often p a t i e n t s have to abide by s t r i c t r u l e s governing meals and r e t i r i n g so t h a t these p s y c h i a t r i c boarding homes o r halfway houses are sometimes seen as i n s t i t u t i o n a l . . U s u a l l y the inmates spend too much time i n bed and watching t e l e v i s i o n . Whether or not t h i s v e g e t a t i v e l i f e i s p r e f e r a b l e to f u l l i n s t i t u t i o n a l i z a t i o n i s q u e s t i o n a b l e because l a r g e h o s p i t a l s do prov ide some programming, o c c u p a t i o n a l and r e c r e a t i o n a l therapy . However a m a j o r i t y o f r e s i d e n t s of halfway houses s t a t e a preference f o r t h e i r l i f e i n the community over h o s p i t a l i z a t i o n . Another more in formal type o f halfway housing i s the f i v e halfway houses of the Mental P a t i e n t s A s s o c i a t i o n i n Vancouver, in which tasks are s h a r e d , meals are prepared communally, and a l l d e c i s i o n s a f f e c t i n g the community are made by the house " f a m i l y " a t mandatory weekly meetings together w i th two s t a f f members. M e d i c a t i o n - t a k i n g and personal care are the r e s p o n s i b i l i t y o f the i n d i v i d u a l . In some homes, p r e s c r i p t i o n d r u g - t a k i n g i s n ' t encouraged and " f r e a k - o u t s " may r e s u l t ; i n o t h e r s , 8. r e s i d e n t s are urged c o n s t a n t l y to a t tend community care teams and take t h e i r m e d i c a t i o n . R e h o s p i t a l i z a t i o n from the houses i s low. A 1977 survey found an annual 6% r e t u r n r a t e i n terms o f p a t i e n t days spent , i n a c r i s i s hoste l or i n h o s p i t a l . However the housing i s g e n e r a l l y sub -standard w i t h l i t t l e p r i v a c y . B i z a r r e behaviour i s u s u a l l y t o l e r a t e d k i n d l y i n the houses and generous ac ts o f emotional and other forms o f support are l i t t l e s h o r t o f n o b l e . P i l o n and Marcot te repor ted on H a b i t a t 2525, a halfway house on the grounds o f S t . - M i c h e l - A r c h a n g e H o s p i t a l , Quebec C i t y , which runs on the p r i n c i p l e o f n o r m a l i z a t i o n . Res idents keep t h e i r own space t i d y , take t h e i r own m e d i c a t i o n , are c a r e f u l of t h e i r appearance, o r g a n i z e t h e i r own l e i s u r e a c t i v i t i e s i n the community, enter a s h e l t e r e d workshop a t a low wage, and then become par t o f a work t r a i n i n g program i n the Quebec H i l t o n h o t e l . S t a f f o f the H a b i t a t 2525 team i n c l u d e p s y c h o l o g i s t s , s o c i a l w o r k e r s , v o c a t i o n a l guidance workers and a c o n s u l t a n t p s y c h i a t r i s t . A f t e r n e a r l y three y e a r s , o n e - h a l f the r e s i d e n t s had l e f t and were earn ing minimum wage. The average leng th o f s tay was ten months and the r e t u r n r a t e was 12%. The r e s u l t s o f the program are i m p r e s s i v e . They p o i n t up the n e c e s s i t y fo r a h igh r a t i o o f w e l l - t r a i n e d s t a f f and w e l l - p l a n n e d programs i n order to ach ieve r e s u l t s as good and are not i n d i c a t i v e o f the usual d i s p o s i t i o n o f e x - p a t i e n t s i n the community ( P i l o n , M a r c o t t e , 1 9 7 6 : ' 4 1 ) . Th ree -quar te r way hous ing , i n c o n t r a s t to halfway h o u s i n g , i s a normal i zed housing s i t u a t i o n which would be acceptab le to o ther members o f the c o m m u n i t y - a t - l a r g e . 9 . Near - independent l i v i n g p r t h r e e - q u a r t e r way housing i s t y p i f i e d by a sponsor who rents an apartment or a house and s u b l e t s i t to severa l m e n t a l l y i l l persons . E i t h e r i n d i v i d u a l l y or as a group the p a t i e n t s care f o r themselves and prepare t h e i r own f o o d . ' T y p i c a l l y there i s some s u p e r v i s i o n o f the upkeep o f the d w e l l i n g and some m o n i t o r i n g o f the p a t i e n t s so t h a t they cont inue to r e c e i v e o u t p a t i e n t t reatment and make use o f community r e c r e a t i o n a l resources (Toml inson, Cumming, 1976: 2 5 ) . An experiment i n t h r e e - q u a r t e r way housing i s d e s c r i b e d by Chi e n . In the area immediately sur rounding Boston S t a t e H o s p i t a l are 25 c o - o p e r a -t i v e apartments p r o v i d i n g 104 beds f o r c h r o n i c mental p a t i e n t s . P a t i e n t s l i v e i n one apartment i n a t h r e e - d e c k e r house, the l a n d l o r d i n another and the t h i r d i s rented to someone i n the community. P a t i e n t s a t tend a c t i v i t y programs or the day care cen t re i n the h o s p i t a l . They are encouraged to cook t h e i r own meals and look a f t e r t h e i r own m e d i c a t i o n . At the beg inn ing o f the p a t i e n t s ' s tay the l a n d l o r d prov ides meals and a s s i s t a n c e . As time passes he works toward having them care e n t i r e l y f o r themselves . A l l apartments are v i s i t e d a t l e a s t once a week by the h o s p i t a l Cooperat ive Apartment Team. I f p a t i e n t s do not turn up to the depot med ica t ion s t a t i o n on the h o s p i t a l grounds the team v i s i t s the apartments and a d m i n i s t e r s med ica t ion t h e r e . P a t i e n t s have eva luated the program p o s i t i v e l y . V i r t u a l l y a l l o f them, s a i d t h a t l i f e i n the a p a r t -ments i s b e t t e r than l i f e i n the h o s p i t a l ( C h i e n , 1973: 7 ) . Q u a l i t y o f l i f e i s improved to the ex tent tha t housing c o n d i t i o n s are normal i zed to resemble t h a t o f the c o m m u n i t y - a t - l a r g e . 10. Quality of life. Q u a l i t y o f l i f e i s a t o p i c tha t permits many d e f i n i t i o n s and has no s tandard index a l l o w i n g the mon i to r ing o f changes. Some authors r e f e r to the q u a l i t y of l i f e as i n c l u d i n g such b a s i c needs as hea l th and s a f e t y ; e d u c a t i o n , s k i l l s and standard o f l i v i n g ; income; economic e q u a l i t y ; human h a b i t a t ; a r t , s c i e n c e and f r e e time ( T e r l e c k y j , 1975: 1 6 ) . Others see the q u a l i t y o f l i f e as having more to do w i t h "h igher needs" fo r g rowth , esteem, freedom, and the p leasure o f meaningful r e l a -t i o n s h i p s and meaningful work. "Thus q u a l i t y o f l i f e might be de f ined as a sense o f w e l l b e i n g , a dynamic blend o f s a t i s f a c t i o n s t h a t d i f f e r s from one person to another and changes over t ime" (The Q u a l i t y o f American l i f e , 1980: 1 1 ) . Bigelow perce ived the q u a l i t y o f l i f e o f c h r o n i c mental p a t i e n t s l i v i n g i n the community as encompassing independence, s o c i a l network, symptomatology, and meaningful a c t i v i t y i n the s t r u c t u r i n g o f time (B ige low, 1977) . These are the four i n d i c a t o r s chosen to i n v e s t i g a t e the q u a l i t y o f l i f e of c h r o n i c mental p a t i e n t s i n t h r e e - q u a r t e r way hous ing . I t i s assumed t h a t the b a s i c needs o f t h i s c h r o n i c group are met s i n c e a s s i s t e d income, s h e l t e r , hea l th care and p s y c h i a t r i c care are p r o v i d e d . Independence. Two quest ions need to be addressed i n the c o n s i d e r a t i o n o f independence as a measure o f q u a l i t y o f l i f e . Is independence a s i g n i f i c a n t measure o f q u a l i t y o f l i f e f o r c h r o n i c mental p a t i e n t s i n t h r e e - q u a r t e r way housing? How can independence best be measured? The l i t e r a t u r e i n d i c a t e s t h a t independence i s a d e s i r a b l e goal i n the t reatment o f 1 1 . r e h a b i l i t a t i o n o f p a t i e n t s . Personal freedom and independence have long been p r i n c i p l e s worthy o f d e f e n d i n g . Independent l i v i n g has always been "the u n d e r l y i n g r a t i o n a l e of e s t a b l i s h e d models o f r e h a b i l i t a t i v e s e r v i c e s and. . .has now been l e g i t i m i z e d as a r e h a b i l i t a t i o n model i n i t s own r i g h t " (De Loach, 1983: x i ) . Independent l i v i n g s e r v i c e s are cons idered those s e r v i c e s , i f s u c c e s s f u l , t h a t r e s u l t i n d i s a b l e d people l i v i n g " t o t a l l y s e l f - s u f f i c i e n t l i v e s , f reed from the need to r e l y on o thers fo r t h e i r s e l f - c a r e needs" (De Loach, 1983: 3 2 ) . P a t i e n t s who were presumably independent p r i o r to t h e i r mental breakdown f i n d t h a t the process o f i n s t i t u t i o n a l i z a t i o n p laces them i n a t o t a l l y dependent p o s i t i o n . In an i n s t i t u t i o n every aspect o f l i f e i s cared f o r . Food i s s u p p l i e d , as are r e c r e a t i o n , s o c i a l i z a t i o n , medica -t i o n , the rapy , f i n a n c i a l support , l o w - c o s t hous ing , employment or v o c a t i o n a l r e h a b i l i t a t i o n , p r o t e c t i o n , s u p e r v i s i o n and c r i s i s i n t e r v e n t i o n (Pepper , Ryg lewicz , 1982: 389; Borus , 1981: 3 4 0 ) . Conformity r a t h e r than independence i s encouraged i n h o s p i t a l (Ok in , 1983: 5 7 8 ) . Discharge from h o s p i t a l f r e q u e n t l y presumes the a b i l i t y to resume independent f u n c t i o n i n g but many p a t i e n t s get caught up i n repeated a d m i s s i o n s . Of those who are not r e h o s p i t a l i z e d but remain i n the community, many do not l i v e independent l y . Of 1.7 m i l l i o n i d e n t i f i e d as deve lop ing a prolonged severe emotional d i s a b i l i t y i n the U . S . , 750,000 or 44% are i n nurs ing homes where a l l t h e i r bas i c needs are met ( T a l b o t t , 1980: 4 4 ; 1981: 700; O k i n , 1983: 5 7 7 ) . Lamb views as i l l u s o r y the e x p e c t a t i o n t h a t r e l e a s e e s w i l l exper ience the f u n c t i o n i n g of normals . The most t h a t can be a n t i c i p a t e d i s an improvement i n the q u a l i t y o f l i f e f o r 1 2 . people l i v i n g i n a n o n - h o s p i t a l s e t t i n g where there i s the advantage o f freedom o f movement (Lamb, 1981: 106) . Not o n l y i s independence h i g h l y valued s o c i a l l y but evidence a l s o e x i s t s tha t e x - p a t i e n t s va lue t h e i r independence keen ly . A s i g n i f i c a n t number l i v e l i t e r a l l y on the s t r e e t i n preference to h o s p i t a l i z a t i o n or o ther i n s t i t u t i o r i a l 1 i v i n g even though the c o n d i t i o n s o f t h e i r e x i s t e n c e are minimal and o f t e n h a r s h . The e x - p s y c h i a t r i c s t r e e t people i n Los Angeles have been est imated to number between 7,000 and 15,000 i n the s k i d road area . o f t h a t c i t y ( F a r r , 1983) . In New York the "space c a s e s " number 36,000 homeless c h r o n i c a l l y m e n t a l l y i l l ( B a x t e r , Hopper, 1982: 394) . These people p r e f e r the harshness o f the s t r e e t to the l o s s of t h e i r independence i n i n s t i t u t i o n s . Measures of -independent function. The measure o f independence i s complex and m u l t i f a c e t t e d . A measure o f independence must i n c l u d e a l l o f those a c t i v i t i e s o f d a i l y l i v i n g and s e l f - c a r e which one must perform i n order to f u n c t i o n i n the community a t an adequate and a c c e p t a b l e l e v e l . A ten year review o f the l i t e r a t u r e in the a c t i v i t i e s o f d a i l y l i v i n g and the e v a l u a t i o n o f d i s -a b i l i t y revea led t h a t a g reat deal has been w r i t t e n about the c h r o n i c a l l y i l l e l d e r l y and the p h y s i c a l l y d i s a b l e d . Less has been c h r o n i c l e d about the we l l e l d e r l y and the m e n t a l l y r e t a r d e d , and l i t t l e has been w r i t t e n concern ing the move from dependence to independence o f the e m o t i o n a l l y d i s a b l e d . De Loach 's (1983) p i o n e e r i n g monograph i s the f i r s t major work to g ive p e r s p e c t i v e on the s u b j e c t o f independent l i v i n g r e h a b i l i t a t i o n , 1 3 . d e s p i t e the f a c t t h a t d e i n s t i t u t i o n a l i z a t i o n o f mental p a t i e n t s has moved a t a b r i s k pace i n the l a s t th ree decades. Some measures o f independent l i v i n g have been developed p r i m a r i l y f o r the m e n t a l l y r e t a r d e d . The D i s a b i l i t y Assessment Schedule i s a b r i e f sc reen ing dev ice f o r the m e n t a l l y re ta rded which i n c l u d e s s e c t i o n s on s e l f - h e l p , v i s i o n and h e a r i n g , communicat ion, l i t e r a c y and 23 items on behaviour a b n o r m a l i t i e s such as e c h o l a l i a (Holmes, 1982) . One i tem on domestic s k i l l s i s the on ly i tem adaptable to independent l i v i n g s k i l l s o f c h r o n i c mental p a t i e n t s . The Adapt ive Behaviour S c a l e deals w i th such statements as " i n i t i a t e s most o f own a c t i v i t i e s " ; " w i l l pay a t t e n t i o n fo r more than f i f t e e n m i n u t e s " ; " recogn i zes own f a m i l y " ( Leva , 1976)., but has no items r e l e v a n t to a p s y c h i a t r i c p o p u l a t i o n . Other s c a l e s have been developed p r i m a r i l y to assess the e l d e r l y and c h r o n i c a l l y i l l . S idney Katz had descr ibed the Index o f Independence i n the A c t i v i t i e s of D a i l y L i v i n g (ADL) which measures b i o l o g i c a l and psychosoc ia l f u n c t i o n s and was developed to study the t reatment and prognosis o f the c h r o n i c a l l y i l l e l d e r l y . I t measures the degree o f independence i n such c a t e g o r i e s as b a t h i n g , d r e s s i n g , t o i l e t i n g , t r a n s f e r , cont inence and feed ing (Katz e t a l . , 1963; K a t z , 1970: 2 0 , 2 6 ) . However, none o f these are a p p l i c a b l e to d ischargees from p s y c h i a t r i c hospi t a l s . Alan J e t t e s t u d i e d n o n - i n s t i t u t i o n a l i z e d i n d i v i d u a l s w i th p o l y -a r t i c u l a r d i s a b i l i t y w i t h a subset o f ADL items i n f i v e a r e a s : p h y s i c a l m o b i l i t y , t r a n s f e r s , home c h o r e s , k i t c h e n chores and personal care ( J e t t e , 1980: 8 5 ) . Most items were s p e c i f i c a l l y l i n k e d to p h y s i c a l ' i n c a p a c i t y , 14. such as those repor ted by Bebb ington , 1977; K l e i n , B e l l , 1982; B e r g e l , 1981; Evans, 1981; Zuck, 1980; Lane, 1974. J e t t e drew on the. work o f . Katz i n deve lop ing an index o f ADL. . D e n i s t o n and J e t t e used a p i l o t G e r i a t r i c A r t h r i t i s P r o j e c t Funct iona l S tatus Instrument which i n c l u d e d d r i v i n g , shopp ing , us ing a t e l e p h o n e , housekeeping and personal care among o ther items s p e c i f i c to the p h y s i c a l l y i n c a p a c i t a t e d . I t was developed to t e s t the hypothes is t h a t a m u l t i d i s c i p l i n a r y h e a l t h team could improve the q u a l i t y of l i f e o f o l d e r a d u l t s s u f f e r i n g from a r t h r i t i s ( D e n i s t o n , J e t t e , 1980) . Bloom and Blenkner used a Contentment Index to assess the personal s a t i s f a c t i o n of o l d e r people l i v i n g i n the community (Bloom, B l e n k n e r , 1970) . They and o ther w r i t e r s i n the g e r i a t r i c f i e l d cons idered d e t a i l e d items which d i d not apply d i r e c t l y to the independence o f c h r o n i c mental p a t i e n t s (Warren, 1974; Akhtar e t a l . , 1973; K u r i a n s k y , 1976) . Sarno 's Funct iona l L i f e Sca le i n c l u d e s a number o f items which cou ld be u t i l i z e d i n a measure o f independence o f c h r o n i c mental p a t i e n t s . Sarno 's r a t i o n a l e f o r the s c a l e i s t h a t exper ience has shown that the l e v e l o f p h y s i c a l f u n c t i o n as evidenced i n a p le thora of measures r a t i n g the e l d e r l y i n f i r m and the p h y s i c a l l y i n c a p a c i t a t e d g ives no c l u e as to the a b i l i t y o f the p a t i e n t to f u n c t i o n i n a r e a l l i f e s i t u a t i o n (Sarno et a l . , 1973: 214) . The Funct iona l L i f e S c a l e , a performance measure, c o n s i s t s o f 44 items from which one can a s c e r t a i n the f u n c t i o n i n g c a p a b i l i t y o f t h e . i n d i v i d u a l . I t d e s c r i b e s the here-and-now s i t u a t i o n o f the p a t i e n t r a t h e r than h i s c a p a c i t y to do more, and lends credence to the f a c t t h a t h i s i n c a p a c i t y may not be due to powerless l imbs but to h i s f e a r o f appear ing i n p u b l i c , or the f a c t tha t others may be h e l p i n g him to a l a r g e 1 5 . degree. The items are ra ted by an o b s e r v e r , and ra ted i n a continuum of f i v e po in ts ranging from " d o e s n ' t perform the a c t i v i t y a t a l l " to " n o r m a l " . S tud ies were c a r r i e d out to e s t a b l i s h r e l i a b i l i t y and i n t e r n a l c o n s i s t e n c y and these e s t a b l i s h e d the s t a b i l i t y of the r a t i n g s over t i m e . The s c a l e items i n c l u d e areas o f s o c i a l i n t e r a c -t i o n , o u t s i d e a c t i v i t i e s such as shopping and u s i n g p u b l i c t r a n s p o r t a -t i o n , home a c t i v i t i e s l i k e performing housekeeping chores such as c l e a n i n g , and p repar ing m e a l s , a c t i v i t i e s of d a i l y l i v i n g such as grooming and d r e s s i n g , and c o g n i t i o n (Sarno e t a l . , 1973: 220) . L ike Sarno , Swi tzky and R o t a t o r i in t roduced a new measure which they c a l l the Community L i v i n g S k i l l s Assessment Inventory . They po in t out tha t t h i s inst rument i s adaptable to the e m o t i o n a l l y d i s t u r b e d as we l l as the m u l t i p l y handicapped and r e t a r d e d , and draw a t t e n t i o n to the a c t u a l i t y t h a t matching i n d i v i d u a l behav ioura l competencies w i th f u n c t i o n a l l i v i n g s k i l l s necessary f o r the i n d i v i d u a l to be placed i n the community has r a r e l y been i n v e s t i g a t e d . A l l too o f t e n a l a c k o f these s k i l l s has l e d to the e a r l y r e t u r n o f an i n d i v i d u a l to an i n s t i t u t i o n or an i n s t i t u t i o n a l r e s i d e n c e . Because o f the p reva len t movement of the i n s t i t u t i o n a l i z e d i n t o the community, deve lop ing s t r a t e g i e s of i n t e r v e n t i o n i s c r u c i a l to s u c c e s s f u l placement i n the community. The authors prov ide a d e s c r i p t i o n o f s k i l l s i n e i g h t a r e a s : d r e s s i n g , personal hyg iene , e a t i n g , housekeeping, care o f c l o t h i n g , food p r e p a r a t i o n , s e l f - m e d i c a t i o n and use o f f u n c t i o n a l equipment such as w h e e l c h a i r s . S k i l l areas were 16. i d e n t i f i e d by community res idence o p e r a t o r s ; the n e a r l y 200 items i n the e i g h t areas were generated' by p r o f e s s i o n a l s t a f f . The invento ry i s scored by p r o f e s s i o n a l or p a r a p r o f e s s i o n a l o b s e r v e r s . Items are r a t e d on a seven po in t performance s c a l e . Items which are not a p p l i c a b l e i n every case such as hand l ing whee lcha i rs are scored n/a. In te robserve r agreement was 80%. Accord ing to the authors the data can a l s o be used i n the e s t a b l i s h m e n t o f t r a i n i n g o b j e c t i v e s by i n d i c a t i n g d e f i c i t f u n c -t i o n i n g . Data on the use fu lness o f the i n v e n t o r y was c o l l e c t e d over two years i n which 100 re ta rded were p laced i n community l i v i n g arrangements. P r i o r r e c i d i v i s m was 15%. Subsequent to the use o f the invento ry r e c i d i v i s m was reduced to 3% ( S w i t z k y , R o t a t o r i , 1978) . De Loach (1983: 76) has cata logued the techniques and concepts she found to be s i g n i f i c a n t to independent l i v i n g . She c a t e g o r i e s four major areas of concern to the d i s a b l e d : personal ad jus tment , domestic ar rangements , management s k i l l s and s o c i a l ad jus tment . Wi th in these areas 131 items are l i s t e d , c o v e r i n g the f a c t o r s a f f e c t i n g adjustment to d i s -a b i l i t y : home maintenance, food p r e p a r a t i o n , se l f -management , c h i l d c a r e , f i n a n c i a l management, adjustment w i th f a m i l y and o t h e r s , e x p e c t a t i o n s o f s e x u a l i t y , use o f l e i s u r e t i m e , use o f community support s e r v i c e s , housing arrangements , knowledge of the wor ld o f work, and t r a n s p o r t a t i o n arrangements. The cata logue i s uneven i n t h a t some items cover a broad area o f i n t e r e s t such as " r e c o g n i t i o n / a p p l i c a t i o n o f a b i l i t i e s tha t can be used to develop and/or p a r t i c i p a t e i n a c t i v i t i e s " w h i l e o thers are narrowly s p e c i f i c such as "use o f e l e c t r i c can o p e n e r , " "use o f c o f f e e p o t s " , " c l o t h i n g fea tu res to look f o r i n r e a d y - t o - w e a r c l o t h i n g " . The items 17. d e s c r i b i n g personal adjustment and s o c i a l adjustment may be d e s i r a b l e components o f independent l i v i n g but are not b a s i c s k i l l s and are t h e r e f o r e not adaptable as measures o f independence o f ch ron ic mental p a t i e n t s i n t h r e e - q u a r t e r way hous ing . None o f the measures perused seem adaptable i n t h e i r e n t i r e t y to the independent l i v i n g o f mental p a t i e n t s i n the community, however personal exper ience has i n d i c a t e d areas which are a p p l i c a b l e . When p a t i e n t s were r e l e a s e d i n s u b s t a n t i a l numbers i n t o the community i n the l a t e s i x t i e s and e a r l y s e v e n t i e s from Riverv iew H o s p i t a l i n C o q u i t l a m , B . C . , many o f them were w i thout funds or s h e l t e r . V ia the p a t i e n t grapevine a s i g n i f i c a n t number had heard o f the Mental P a t i e n t s A s s o c i a t i o n d rop -i n cent re which was opened in 1971. The d ischargees f l o c k e d to the cent re l o o k i n g f o r s h e l t e r and help i n o b t a i n i n g f i n a n c i a l a s s i s t a n c e . Vo lunteers and knowledgeable e x - p a t i e n t s a i d e d the re leasees i n d e a l i n g w i t h govern -ment agencies to o b t a i n w e l f a r e payments. Owing to an acute demand f o r l o w - c o s t h o u s i n g , the A s s o c i a t i o n acqu i red f i v e houses over a . p e r i o d o f severa l y e a r s . The r e s i d e n c e s , which housed 10 to 12 e x - p a t i e n t s e a c h ; were operated on the s e l f - h e l p p r i n c i p l e . Everyone took par t i n house-keeping t a s k s , shopping and c o o k i n g . Shar ing o f s k i l l s was encouraged. Most o f the e x - p a t i e n t s , p a r t i c u l a r l y the young men, had no s k i l l s i n shopp ing , money management, c o o k i n g , housekeeping and personal hygiene because o f t h e i r l a c k o f home t r a i n i n g , or t h e i r mental i l l n e s s and sub-sequent i n s t i t u t i o n a l i z a t i o n . By way o f p a t i e n t i n s t r u c t i o n and a good deal o f exper imentat ion these b a s i c l i v i n g s k i l l s were a c q u i r e d , and a "money management" a l lowance was paid to each r e s i d e n t by M .P .A . so. t h a t d ischargees c o u l d become accustomed to budget t ing funds f o r t h e i r lunches and o ther e s s e n t i a l i t e m s . I n s t r u c t i o n was a l s o prov ided i n banking so 18. t h a t r e s i d e n t s were a b l e to w r i t e cheques f o r t h e i r room and board and a c q u i r e t h i s s k i l l i n order to c a r r y out necessary banking p r a c t i c e s i n t h e i r subsequent l i f e i n the community a t l a r g e . Where n e c e s s a r y , ex -p a t i e n t s were shown how to use the t r a n s p o r t a t i o n system. They were in t roduced to community resources l i k e r e c r e a t i o n cent res and encouraged to make use o f them. P r a c t i c a l l y a l l o f the d ischargees had been r e c e i v i n g med ica t ion i n h o s p i t a l . Most were r e c e i v i n g o u t p a t i e n t a f t e r c a r e but had to l e a r n to s u p e r v i s e t h e i r own m e d i c a t i o n . Some were n e g l i g e n t i n t h i s area and decompensated, r e q u i r i n g h o s p i t a l i z a t i o n , but many came to accept t h i s r e s p o n s i b i l i t y . In the s e l f - h e l p model , they encouraged one another to remember the r i t u a l o f s e l f - m e d i c a t i n g . Those who d i d not have a f a m i l y p h y s i c i a n were l i n k e d to a hea l th c l i n i c or a general p r a c t i t i o n e r i n order to look a f t e r t h e i r own h e a l t h needs. Any measure of independence i n the a c t i v i t i e s o f d a i l y l i v i n g o f c h r o n i c mental p a t i e n t s must t h e r e f o r e i n c l u d e such items as money management and b a n k i n g , shopp ing , p repar ing w e l l - b a l a n c e d m e a l s , care o f personal hyg iene , care o f l a u n d r y , d e a l i n g w i t h community and government a g e n c i e s , use o f t r a n s p o r t a t i o n , housekeeping, s k i l l s , s u p e r v i s i o n o f m e d i c a t i o n and l o o k i n g a f t e r hea l th needs. The Long Term Care Assessment Form used by the B .C . M i n i s t r y o f Heal th i n c l u d e s items u s e f u l f o r the ADL assessment o f the d i s a b l e d . In a d d i t i o n to ADL items such as a m b u l a t i o n , t r a n s f e r , b a t h i n g , d r e s s i n g , grooming, e a t i n g and e l i m i n a t i o n c o n t r o l there are s e l f care items i n food p r e p a r a t i o n , housekeeping, shopp ing , t r a v e l l i n g , t e l e p h o n e , medicat ions and t r e a t m e n t s , w h i c h , when s c a l e d by a f i v e p o i n t s c a l e e l a b o r a t i n g on the range o f dependence, present a comprehensive p i c t u r e o f the Long Term Care a p p l i c a n t . 1 9 . The measure which seems most a p p l i c a b l e to the p s y c h i a t r i c popu la t ion l i v i n g i n the community i s the Assessment o f C l i e n t Independence o f the Great Vancouver Mental Health S e r v i c e . Developed wi th c l i e n t input at the Mt. P leasant Community Care Team, the measure c o n t a i n s 12 i t e m s : grocery shopp ing , shopping f o r other e s s e n t i a l s , p repar ing w e l l - b a l a n c e d m e a l s , l a u n d r y , c l e a n i n g apartment or room, b u d g e t t i n g , personal hygiene and grooming, use of h e a l t h s e r v i c e s , use of r e c r e a t i o n a l r e s o u r c e s , use o f community resources such as govern -ment or s o c i a l a g e n c i e s , use o f a v a i l a b l e t r a n s p o r t a t i o n , and s o c i a l i z a -t i o n s k i l l s . The s c a l e d e s c r i b i n g the items ranges through "no a s s i s t a n c e " to "a l o t o f a s s i s t a n c e " . There i s no i n d i c a t i o n where or when t h i s measure has been used. Themeasures prepared to t e s t the c h r o n i c a l l y i l l e l d e r l y , the m e n t a l l y re ta rded and the p h y s i c a l l y d i s a b l e d c o n t a i n few items r e l e v a n t to c h r o n i c mental p a t i e n t s i n the community and some are of an unwieldy length so these were not u t i l i z e d . P r i o r exper ience o f the dependence o f c h r o n i c mental p a t i e n t s i n the Mental P a t i e n t s A s s o c i a t i o n suggests a number o f f a c t o r s to cons ide r i n p repar ing a measure o f independence. These same f a c t o r s were those i temized i n the Assessment o f C l i e n t Independence of the G .V .M .H .S . For i t s re levance to c h r o n i c mental p a t i e n t s i n t h r e e - q u a r t e r way housing t h i s assessment was adopted f o r the study to be used to t e s t the independence of t h i s group. The i tem on s o c i a l i z a t i o n s k i l l s was d e l e t e d because a separate measure to examine s o c i a l network would i n d i c a t e these s k i l l s . 20. Social network. Another i n d i c a t o r .of q u a l i t y o f l i f e fo r c h r o n i c mental p a t i e n t s i s t h e i r s o c i a l p a r t i c i p a t i o n . S o c i a l networks have been v a r i o u s l y d e f i n e d . Speck and Athreave (1973) desc r ibed s o c i a l networks as a l l those human r e l a t i o n s h i p s t h a t have a l a s t i n g impact on the l i f e o f the i n d i v i d u a l ; those f a m i l y members, k i n , neighbours and f r i e n d s to which most o f us are connected throughout our l i v e s - those persons w i t h whom we exchange e m o t i o n a l , p h y s i c a l , economic and i n f o r m a t i o n a l s u p p o r t , the group t h a t forms our n a t u r a l support system. Caplan (1974) d e s c r i b e d support systems as an endur ing pat te rn o f s o c i a l t i e s which are o f major s i g n i f i c a n c e i n m a i n t a i n i n g our p s y c h o l o g i c a l and p h y s i c a l i n t e g r i t y . Hammer (1978) has s t a t e d t h a t s o c i a l networks are the f o c a l i n d i v i d u a l ' s d i r e c t s o c i a l c o n t a c t s , the r e l a t i o n s h i p s among them, and t h e i r r e l a t i o n s h i p s w i t h o thers who are not r e l a t e d to the f o c a l person . Because o f the w i d e l y repor ted l i n k to r e h o s p i t a l i z a t i o n , the s o c i a l network v a r i a b l e i s cons idered a major c o n s t i t u e n t o f q u a l i t y o f l i f e . Why are s c h i z o p h r e n i c s s o c i a l l y i s o l a t e d ? The general c h a r a c -t e r i s t i c s o f s c h i z o p h r e n i a are not a t t r a c t i v e to o t h e r s . They i n c l u d e b l u n t i n g o f emot ions , queer and odd behav iour , s e c l u s i v e n e s s , s u s p i c i o u s -n e s s , exaggerated s e l f - c o n s c i o u s n e s s , i m p u l s i v e n e s s , c h a r a c t e r i z e d by a p p a r e n t l y purposeless a c t s , o v e r - d e f e n s i v e n e s s , d e l u s i o n s , poor a t t e n t i o n , poor judgment, poor appearance and some degree o f general d e t e r i o r a t i o n (Shakow, 1979: 1 7 0 ) . Even when the person i s mainta ined on med ica t ion some o f these c h a r a c t e r i s t i c s are present to a c e r t a i n degree . A l l o f these t r a i t s c o n t r i b u t e to the s o c i a l i s o l a t i o n o f s c h i z o p h r e n i c s . S o c i a l 2 1 . networks may have been long absent or may break down f u r t h e r w i th each per iod o f acute d i s o r d e r . S o c i a l t i e s are a b a s i c human need: someone to t a l k t o , to g ive and r e c e i v e a f f e c t i o n , to depend on and be depended.on, to share problems w i t h , and to exper ience "a sense o f be long ingness" ( G r e e n b l a t t e t a l . , 1982: 978) . G reenb la t t e t a l . i n rev iew ing the s o c i a l network l i t e r a t u r e found s t u d i e s t h a t have i n d i c a t e d t h a t s o c i a l bonds p r o t e c t and support mental h e a l t h and may a l s o prevent p h y s i c a l or mental breaks downs dur ing s t r e s s f u l t i m e s . Being par t o f a network a i d s p r o b l e m - . , s o l v i n g a b i l i t i e s , boosts s e l f - e s t e e m and s e l f - c o n f i d e n c e and g ives not on ly emotional sustenance but p r a c t i c a l a s s i s t a n c e as w e l l . Family members form the nucleus o f emotional support i n t imes o f c r i s i s w h i l e f r i e n d s and neighbours a l s o make c o n t r i b u t i o n s which are sometimes equal to or g rea te r than tha t o f r e l a t i v e s . Measures of social network. Researchers have found t h a t m e n t a l l y i l l and normal persons have q u i t e d i f f e r e n t s o c i a l networks both i n q u a n t i t y and q u a l i t y . In one study those who were e m o t i o n a l l y d i s a b l e d repor ted a s o c i a l network h a l f the s i z e o f t h a t o f a normal p o p u l a t i o n ; the people they knew a l s o knew each o t h e r , thus p r o v i d i n g a denser network l e s s d i s p e r s e d than normals and a f f o r d i n g fewer l i n k s to o ther s o c i a l groups ( G r e e n b l a t t et a l . , 1982: 979) . Another study repor ted tha t i f more p o s i t i v e s o c i a l t i e s cou ld be in t roduced or r e s t o r e d i n a s c h i z o p h r e n i c ' s l i f e t h a t the . p a t i e n t would have more support i n times of s t r e s s . (G reenb la t t e t a l . , 1982: 980) . 22. G r e e n b l a t t and h i s c o l l e a g u e s looked a t the environments where mental p a t i e n t s have b e n e f i t t e d s o c i a l l y , such as boarding homes and halfway houses , and c o - o p e r a t i v e apar tments , a l l w i t h p o s i t i v e outcomes. H o s p i t a l behaviour m o d i f i c a t i o n programs have promoted s o c i a l i z a t i o n by rewarding p a t i e n t s who are s o c i a l l y a c t i v e . Those who succeed i n a c q u i r i n g s o c i a l s k i l l s have lower r e c i d i v i s m r a t e s than those who f a i l or have not been t r a i n e d i n these s k i l l s . M u e l l e r found t h a t among the f a c t o r s a s s o c i a t e d w i th high r a t e s o f psychopathology were the absence o f adequate s o c i a l t i e s or s o c i a l suppor t , and t h a t incongruent groups have fewer network t i e s and exper ience g reater s o c i a l i s o l a t i o n ( M u e l l e r , 1980: 1 4 8 - 9 ) . M u e l l e r a l s o repor ted tha t a group o f p s y c h o t i c s had very smal l pr imary networks , h i g h l y i n t e r -connected , s m a l l e r and denser . He argued t h a t a l though those w i t h p s y c h i a t r i c d i s o r d e r s have networks s m a l l e r i n s i z e than normals , w i t h the p r o p o r t i o n tha t are k i n h igher f o r s c h i z o p h r e n i c s , r e s u l t s w i th regard to network d e n s i t y and in te rconnectedness are l e s s c l e a r ( M u e l l e r , 1980: 150) . Henderson conducted an experiment w i t h 50 p s y c h i a t r i c p a t i e n t s and 50 normals i n Canberra . He found t h a t p a t i e n t s had fewer good f r i e n d s , fewer contac ts w i t h persons o u t s i d e the nuc lear f a m i l y , and fewer attachment f i g u r e s . A high l e v e l o f i n t e r - o b s e r v e r r e l i a b i l i t y was achieved i n a p i l o t study and t h i s r e l i a b i l i t y was mainta ined throughout the major s tudy . On the b a s i s of t h i s study Henderson e t a l . g e n e r a l i z e d t h a t mental h e a l t h was a s s o c i a t e d w i th having severa l good f r i e n d s , many c o n t a c t s , and a number o f attachment f i g u r e s (Henderson et a l . , 1978: 8 5 ) . 23. Brugha et a l . . r e p l i c a t e d Henderson's study w i th 50 non -psychot i c p a t i e n t s and 50 normals i n a p s y c h i a t r i c o u t p a t i e n t c l i n i c i n D u b l i n . Normals were pa i r -matched to p a t i e n t s a c c o r d i n g to age , s e x , m a r i t a l s t a t u s and o c c u p a t i o n . They were t e s t e d w i th the S o c i a l I n t e r a c t i o n Schedule developed by Henderson. Contact w i t h . e a c h member o f the s u b j e c t ' s pr imary group was recorded over a week, as were non-pr imary group c o n t a c t s , hours of s o c i a l i n t e r a c t i o n and whether or not the i n t e r a c t i o n was p l e a s a n t , unpleasant o r n e u t r a l . The i n t e n s i t y of the i n t e r a c t i o n on. a three par t s c a l e was a l s o n o t e d . P a i r e d and unpaired t - t e s t s were used to t e s t the d i f f e r e n c e s between means. The Wilcoxon matched -pa i rs t e s t - was used on comparisons o f b o r d e r l i n e s t a t i s t i c a l s i g n i f i c a n c e . The experiment conf i rmed t h a t p s y c h i a t r i c o u t p a t i e n t s and normals d i f f e r e d . The p a t i e n t s had fewer c l o s e f r i e n d s , c l o s e r e l a t i v e s and attachment f i g u r e s . R e l i a b i l i t y was s a t i s f a c t o r y and the f i n d i n g s of Brugha e t a l . conf i rmed the f i n d i n g s of Henderson (Brugha et a l . , 1982: 5 3 ) . G reenb la t t and h i s c o l l e a g u e s were so impressed .w i th the importance o f a s t r o n g s o c i a l network t h a t they recommended s o c i a l networking should be taken i n t o account i n mental h e a l t h p lann ing on the f o l l o w i n g b a s i s : i n d i v i d u a l t reatment plans should i n c l u d e assessment of a p a t i e n t ' s s o c i a l network i n both h o s p i t a l and.home environments'. P r o f e s s i o n a l s should work to r e p a i r or r e c o n s t r u c t t h e i r p a t i e n t ' s s o c i a l supports by working w i t h h is support groups. S o c i a l support s e r v i c e s such as halfway houses and c o - o p e r a t i v e apartments should be e s t a b l i s h e d i n the community. L inks between a p a t i e n t ' s s o c i a l systems should be par t o f h is t reatment p l a n . Community changes should be cogn i zan t of s o c i a l support systems i n p lace t h a t c o u l d be d isconnected by change. G r e e n b l a t t e t a l . condluded 24. t h a t a p a t i e n t ' s mental i l l n e s s cou ld be improved by i n t e r v e n t i o n s t h a t made h is e x i s t i n g network more s u p p o r t i v e or by the a d d i t i o n of support people - new f r i e n d s , p r o f e s s i o n a l c a r e g i v e r s , or support groups l i k e A . A . or s u p p o r t i v e housing (G reenb la t t e t a l . , 1982: 983) . Fro land e t a l . found i n t h e i r study comparing mental p a t i e n t s and o u t p a t i e n t s w i t h a normal group t h a t the fo rmer ' s personal s o c i a l network was s m a l l e r i n s i z e w i t h fewer t i e s w i t h k i n , fewer long - te rm f r i e n d s and l e s s i n t e r a c t i o n w i th f a m i l y , f r i e n d s and r e l a t i v e s (F ro land e t a l . , 1979: 8 5 ) . M i t c h e l l and T r i c k e t t repor ted t h a t a l a r g e number o f authors have found tha t those w i t h p s y c h i a t r i c d i s o r d e r s , both psychot i c and n e u r o t i c , have networks which compare unfavourably w i th normal p o p u l a t i o n s , w i t h fewer network l i n k a g e s , fewer c l o s e r e l a t i o n s h i p s , more v a r i a t i o n i n r e l a t i o n s h i p s and more dependent r e l a t i o n s h i p s . C l i e n t s tend to use t h e i r l i n k a g e s l e s s in t imes o f s t r e s s , t h e i r l i n k a g e s a re more one-s ided than normals and i n t i m a t e l i n k s are f a r fewer . The d e s i r a b l e l i f e q u a l i t i e s i n the wor ld o f the s c h i z o p h r e n i c are those s u p p l i e d by s o c i a l networks and support systems and by e s t a b l i s h i n g a new environment f o r s c h i z o p h r e n i c s . These authors found t h a t s c h i z o p h r e n i c s were more l i k e l y to be r e h o s p i t a l i z e d i f t h e i r networks were smal l ( M i t c h e l l , T r i c k e t t , 1980: 3 6 ) . Sokolovsky and h i s c o l l e a g u e s a l s o found t h a t there was an i n v e r s e r e l a t i o n s h i p between network s i z e and the l i k e l i h o o d o f r e t u r n to h o s p i t a l (Sokolovsky e t a l . , 1978: 1 4 ) . M u r r e l l suggested t h a t one method o f i n t e r v e n t i o n i s to r e l o c a t e the i n d i v i d u a l i n t o a d i f f e r e n t system that i s more s e n s i t i v e to h i s 2 5 . or her requirements or to c r e a t e a new system f o r s p e c i a l popu la t ions to which no present s o c i a l network i s s u f f i c i e n t l y respons ive ( M u r r e l l , 1973) . I n t e r v e n t i o n which helps i n d i v i d u a l s to s t rengthen t h e i r s o c i a l support systems w i l l decrease t h e i r v u l n e r a b i l i t y and i n c r e a s e t h e i r sense of be long ing i n a n a t u r a l l y o c c u r r i n g network o f i n t e r p e r s o n a l r e l a t i o n s h i p s ( M i t c h e l l , T r i c k e t t , 1980: 3 9 ) . Sokolovsky and h i s team s t u d i e d e x - p a t i e n t s i n a Manhattan s i n g l e - r o o m occupancy (SRO) hote l to determine t h e i r personal networks i n r e l a t i o n to t h e i r p s y c h i a t r i c d i a g n o s i s and how t h i s r e l a t e d to community a d a p t a t i o n or the need f o r r e h o s p i t a l i z a t i o n . Of 31 persons i n the sample who had been r e s i d e n t over two y e a r s , o n e - h a l f had been r e h o s p i t a l i z e d a t l e a s t once . The high r e h o s p i t a l i z a t i o n group had the fewest s o c i a l l i n k s . At g r e a t e s t r i s k were those tenants who had no l i n k s o u t s i d e the hote l and h a d n ' t entered the i n t e r n a l s o c i a l o r g a n i z a -t i o n (Sokolovsky e t a l . , 1978: 1 1 ) . Accord ing to Hammer, a normal i n d i v i d u a l ' s s o c i a l network c o n s i s t s o f perhaps 6 to 10 i n t i m a t e l y known i n d i v i d u a l s and an a d d i t i o n a l 30 or so i n d i v i d u a l s who are a l s o r e g u l a r l y seen by the s u b j e c t f o r a t o t a l o f about 4 0 . The range i n her data and o ther data she was a b l e to f i n d was about 25 to 50 w i t h a mean s l i g h t l y l e s s than 40 (Hammer, 1978) . P a t t i s o n e t a l . repor ted a mean o f 22 .4 persons i n the s o c i a l network o f normals ( P a t t i s o n e t a l . , 1979: 6 4 ) . The approach taken i n Bigelo.w's (1977) q u a l i t y o f l i f e study was to i n v e s t i g a t e the q u a n t i t y and q u a l i t y o f network t i e s w i th k i n , c l o s e f r i e n d s and acqua in tances , i n a sample o f 50 m e n t a l l y i l l c l i e n t s 26. o f community mental h e a l t h teams. The s i z e and in t imacy o f the p a t i e n t s ' s o c i a l network .was noted i n the three areas o f k i n , c l o s e f r i e n d s and acquaintances and was compiled i n n a r r a t i v e fo rm. Bigelow summarized the f i n d i n g s q u a l i t a t i v e l y r a t h e r than s c o r i n g s p e c i f i c s c a l e s . His c a t e g o r i e s o f s i z e and i n t i m a c y of network t i e s w i t h the three f r i e n d s h i p types seemed most ada'ptable to the b r i e f examinat ion envisaged by the researcher r a t h e r than the i n - d e p t h s t u d i e s over t ime by o ther a u t h o r s . Accord ing to M u e l l e r , network d e n s i t y and in terconnectedness of r e l a t i o n s h i p s of s c h i z o p h r e n i c s and o ther e m o t i o n a l l y d i s a b l e d persons, are not so important as the s i z e and in t imacy o f the s o c i a l network upon which Hammer, P a t t i s o n e t a l . and Bigelow c o n c e n t r a t e d . The approach decided upon i n i n v e s t i g a t i n g the s o c i a l networks of ch ron ic mental p a t i e n t s was to adopt the s t r a t e g y o f d i s c o v e r i n g the s i z e and in t imacy o f the p a t i e n t s ' s o c i a l network w i th k i n , c l o s e r e l a t i o n s h i p s and casual r e l a t i o n s h i p s . Symp tomato logy. Symptoms which are t y p i c a l of s c h i z o p h r e n i a even when the i n d i v i d u a l i s mainta ined on med ica t ion inc lude , an exaggerated importance o f s e l f , l a c k o f i n s i g h t , base less f e a r s , b l u n t i n g o f a f f e c t , heightened a n x i e t y , per iods o f d e p r e s s i o n , d i s t u r b e d s l e e p , s o c i a l i s o l a t i o n , r e s t -l e s s n e s s , l a c k o f a f e e l i n g of s a f e t y , poor s e l f - e s t e e m , l a c k o f conf idence and i n d e c i s i v e n e s s . Many o f these symptoms a l s o apply to the anxious p e r s o n , the manic depress i ve i n the depress i ve phase o f h is i l l n e s s and those s u f f e r i n g from a d e p r e s s i v e d i s o r d e r . These are the d e b i l i t a t i n g e f f e c t s o f i l l n e s s which n e c e s s i t a t e s p e c i a l i z e d f a c i l i t i e s f o r the 27. m e n t a l l y i l l , i n t e r f e r e w i t h t h e i r chances o f l e a d i n g a normal and produc-t i v e l i f e and i s o l a t e them from others to the ex tent tha t they are i n inc reased danger o f emotional c r i s e s and r e h o s p i t a l i z a t i o n . Measures of symptomatology. Symptomatology i s an important component of q u a l i t y o f l i f e to the c h r o n i c mental p a t i e n t . What was wanted was a b r i e f and c o n c i s e means to assess the v a r i a b l e o f symptomatology - the s t a t e o f the c h r o n i c p a t i e n t ' s mental h e a l t h i n terms o f w i d e l y recogn ized symptoms of a n x i e t y and depress ion , -and those t r a i t s necessary f o r f u n c t i o n i n g a t a s u i t a b l e l e v e l i n the community such as s a t i s f a c t o r y d e c i s i o n - m a k i n g and problem-s o l v i n g and a sense o f s e l f - w o r t h . Rapid assessment inst ruments are t o o l s a v a i l a b l e to assess such t r a i t s and symptoms and were cons idered f o r t h e i r re levance to a p o p u l a -t i o n o f mental p a t i e n t s l i v i n g i n the community. In general RAI 's are s h o r t , easy to a d m i n i s t e r and complete . They prov ide a means f o r a t t a c h i n g a numerical v a l u e to a c l i e n t ' s c o n d i t i o n and fo r i n d i c a t i n g the degree to which a c l i e n t has t h a t c o n d i t i o n by having the c l i e n t r a t e h i m s e l f or h e r s e l f on s c a l e s . That there i s a need f o r a s s e s s i n g symptoms i s e v i d e n t by the number o f r a t i n g s c a l e s a v a i l a b l e ; however, a l l do not meet the requirement o f i n c l u s i v e n e s s , the need to be s h o r t and s i m p l e , and the a b i l i t y to be q u a n t i f i e d . Max Hamilton has s t a t e d t h a t the d e s c r i p t i o n and d e f i n i t i o n of the p o p u l a t i o n from which a sample i s drawn i s o f fundamental importance but a p rob lemat i c area f o r r e s e a r c h ; d i a g n o s t i c c a t e g o r i e s are u n r e l i a b l e 28. but r a t i n g s c a l e s are i n v a l u a b l e ( H a m i l t o n , 1959: 5 0 ) . The s c a l e he developed i s intended f o r use w i t h those diagnosed as s u f f e r i n g from a n x i e t y - found i n a g i t a t e d d e p r e s s i o n , o b s e s s i o n a l s t a t e s , o rgan ic dement ia , h y s t e r i a and s c h i z o p h r e n i a . Twelve groupings of symptoms, and the p a t i e n t ' s behaviour a t the i n t e r v i e w , were the 13 v a r i a b l e s o f the s c a l e , i n c l u d i n g anxious mood, t e n s i o n , f e a r s , i n s o m n i a , c o g n i t i v e changes, d e p r e s s i o n , general somatic symptoms, c a r d i o v a s c u l a r , r e s p i r a t o r y , g a s t r o - i n t e s t i n a l , g e n i t o - u r i n a r y , and general autonomic symptoms. Each o f the v a r i a b l e s was de f ined by a s e r i e s o f 90 i n d i v i d u a l d e s c r i p t o r s such as f a t i g u a b i 1 i t y , i n a b i l i t y to r e l a x , t a c h y c a r d i a , e t c . ( H a m i l t o n , 1959: 5 4 ) . Assessments were made on a f i v e p o i n t s c a l e rang ing from none to very severe and g r o s s l y d i s a b l i n g . The r e l i a b i l i t y o f the s c a l e was determined by 35 p a t i e n t s be ing ra ted on two occas ions by two i n t e r -v iewers s i m u l t a n e o u s l y . The weighted mean o f the c o r r e l a t i o n s based on the sum o f crude scores f o r each p a t i e n t was . 8 9 . A l e s s s o p h i s t i c a t e d measure to assess a n x i e t y d i s o r d e r s i s t h a t developed by Zung who wanted an ins t rument which was s h o r t and s i m p l e , a v a i l a b l e i n two formats so t h a t both the p a t i e n t and an observer cou ld complete them us ing the same s e t o f c r i t e r i a , and i n c l u s i v e w i t h r e s p e c t to symptoms of a n x i e t y (Zung, 1971: 3 7 1 ) . The ins t rument i s comprised o n l y o f the most commonly repor ted symptoms of a n x i e t y , and i n c l u d e s 20 s ta tements , f i v e o f which are s t a t e d i n a symptomat ica ! l y p o s i t i v e way. Typ ica l statements o f the S e l f - r a t i n g Anx iety Sca le i n c l u d e . "I f e e l l i k e I'm f a l l i n g apar t and go ing to p i e c e s " ; "I f e e l more nervous and anxious than u s u a l " ; "I get u p s e t . e a s i l y o r f e e l p a n i c k y " ; "my arms and legs shake and t remble" (Zung, 1971: 3 7 5 ) . The four p o i n t r a t i n g s c a l e ranges 29. from "none or a l i t t l e of the t ime" to "most or a l l o f the t i m e " . Two hundred and t w e n t y - f i v e p a t i e n t s o f va r ious d i a g n o s t i c groups were t e s t e d w i t h the s c a l e and those who had a d i a g n o s i s o f a n x i e t y d i s o r d e r obta ined scores s i g n i f i c a n t l y h igher than those o f o ther d i a g n o s t i c groups. In rank o r d e r , mental d i s i n t e g r a t i o n , t remors , body aches and p a i n s , a n x i o u s n e s s , apprehens ion , nausea, f e a r , panic and p a l p i t a t i o n r a t e d higher i n s e v e r i t y than o ther symptoms. C o r r e l a t i o n between o b s e r v e r - r a t e d scores and p a t i e n t - r a t e d scores was r = .74 (Zung, 1971: 378) . With regard to d e p r e s s i o n , a d j e c t i v e c h e c k l i s t s - and o l d standbys l i k e the Beck Depression i n v e n t o r y and the Zung S e l f - R a t i n g Depression Sca le were rev iewed. Beck et a l . developed an invento ry o f 21 c a t e g o r i e s o f depress ion c o n s i s t i n g of 89 sentences . These were scored by an i n t e r -v iewer who read the sentences to a p a t i e n t and asked f o r the most a p p r o p r i a t e response d e s c r i b i n g h i s or her symptom (Beck e t a l . , 1961: 5 6 5 ) . Zung prepared the S e l f - R a t i n g Depression S c a l e which i s s i m i l a r i n format and conta ins the same number o f i tems as h i s a n x i e t y s c a l e , and i n c l u d e s statements such as "I have c r y i n g s p e l l s or f e e l l i k e i t " ; "I f e e l down-hearted and b l u e " ; "I f e e l t h a t o thers would be b e t t e r o f f i f I were d e a d " ; "I have t r o u b l e s l e e p i n g a t n i g h t " and 16 other statements (Zung, 1965: 66) S leep d i s t u r b a n c e , i n d e c i s i v e n e s s , d i u r n a l v a r i a t i o n and psychomotor r e t a r d a t i o n ranked h ighes t i n s e v e r i t y o f a l l the i t e m s . Zung ra ted the presence o f s l e e p d i s t u r b a n c e as an important i f not the most important symptom i n depress i ve d i s o r d e r w i t h r e s p e c t to d i a g n o s i s . Prager prepared a l i s t o f c l i e n t - d e v e l o p e d measures. Unexplained a n x i e t y and f e a r were ranked as items w i t h the h ighest order o f s e v e r i t y when tes ted w i t h c l i e n t s of a community mental hea l th cent re ( P r a g e r , 1980: 8 ) . 30. In p repar ing a measure to o b t a i n a c l e a r p i c t u r e as to the sense o f w e l l b e i n g o f c h r o n i c mental p a t i e n t s i n t h r e e - q u a r t e r way housing i t was decided not to i n c l u d e items i n d i c a t i n g p s y c h o s i s . Most i f not a l l o f the r e s i d e n t s of the housing who are diagnosed as s c h i z o p h r e n i c are mainta ined on med ica t ion and c l o s e l y monitored i n the rapy , t h e r e f o r e such quest ions would be i n a p p r o p r i a t e f o r a p o p u l a t i o n a l r e a d y l i v i n g i n the community and p r e s e n t i n g not f l o r i d but r e s i d u a l symptoms. In o rder to i n v e s t i g a t e f e e l i n g s of both a n x i e t y and depress ion i n a s h o r t e a s y - t o - u s e measure, i t was decided to i n c o r p o r a t e on ly those items which appeared i n s e v e r a l s c a l e s , were ranked as high s e v e r i t y i t e m s , or had been f r e q u e n t l y mentioned i n personal exper ience w i t h m e n t a l l y i l l c l i e n t s . A n x i e t y and f e a r were i n c o r p o r a t e d from the Prager , Hamilton and Zung s c a l e s . S leep d i s t u r b a n c e was used from the Hamilton and Zung l i s t s . F e e l i n g s o f sadness (depressed p e s s i m i s t i c mood) was inc luded from the P r a g e r , Hamil ton and Zung s c a l e s . S o c i a l wi thdrawal was used from the Bigelow q u a l i t y of l i f e study and the Zung depress ion s c a l e . Items o f s e l f - e s t e e m , s e l f - c o n f i d e n c e , a sense of s e c u r i t y and the a b i l i t y to make d e c i s i o n s and s o l v e problems were inco rpora ted from the Bigelow s t u d y , r e c o g n i z i n g t h a t these t r a i t s are necessary f o r f u n c -t i o n i n g a t an adequate l e v e l i n the community. To i n c o r p o r a t e more than these ten items from the w i d e l y used standard s c a l e s would be to produce a l i s t too unwieldy to use i n a s h o r t per iod o f t ime w i t h i n t e r v i e w e e s . I t was hoped t h a t the items used i n the l i s t , together w i t h items s c a l i n g l o n e l i n e s s and o p t i m i s m , would, present an honest p i c t u r e o f the c u r r e n t s t a t e o f c h r o n i c mental p a t i e n t s i n t h r e e - q u a r t e r way housing as to t h e i r symptomatology. 3 1 . Meaningful activity. The c h r o n i c mental p a t i e n t i n t h r e e - q u a r t e r way housing u s u a l l y has an abundance of f r e e t i m e . I f t h i s t ime i s s t r u c t u r e d w i t h meaningful a c t i v i t y , the q u a l i t y o f l i f e can be enhanced. The meagre l i t e r a t u r e on the s u b j e c t o f meaningful a c t i v i t y or the p o s i t i v e s t r u c t u r i n g of t ime i s conf ined main ly to the f i e l d o f ge ronto logy . Many g e r o n t o l o g i s t s c l a i m t h a t the meaningful use o f l e i s u r e c o n t r i b u t e s to s a t i s f a c t o r y adjustment to r e t i r e m e n t , but what i s meant by meaningfu l? " B a s i c a l l y the concept o f meaning over laps w i th t h a t o f s a t i s f a c t i o n so t h a t an exper ience or a c t i v i t y which i s mean-i n g f u l i s s a t i s f y i n g as w e l l " (Weiner , Hunt, 1981: 4 4 4 ) . S tud ies have found t h a t the l e v e l o f meaning der i ved from work and l e i s u r e were s i m i l a r . When the Work -Le isure A t t i t u d e Inventory was a d m i n i s t e r e d to a group o f For t Lauderdale r e t i r e e s , a s i g n i f i c a n t p o s i t i v e c o r r e l a t i o n was found between 8 o f 13 work and l e i s u r e c o n c e p t s ; i n o ther words , r e t i r e e s s a t i s f i e d w i t h c e r t a i n aspects o f t h e i r past work exper ience were a l s o s a t i s f i e d w i t h these same aspects i n t h e i r l e i s u r e (Weiner , Hunt, 1981: 4 4 4 ) . Roadburg found t h a t when people r e t i r e o r age tha t t h e i r p e r c e p t i o n o f l e i s u r e tends to move from p r o d u c t i v i t y towards p l e a s u r e . A c t i v i t i e s he c a t e g o r i z e d as l e i s u r e were r e a d i n g / w r i t i n g ; t e l e v i s i o n ; cards/games; w a l k i n g ; a r t s / c r a f t s / h o b b i e s / s e w i n g ; v i s i t i n g f a m i l y / f r i e n d s ; p h y s i c a l a c t i v i t y ; g a r d e n i n g ; f i s h i n g ; h u n t i n g ; t r a v e l / c a m p i n g ; out ings/ d r i v i n g ; e a t i n g o u t ; l i s t e n i n g to r a d i o / r e c o r d s ; d a n c i n g ; a t t e n d i n g s p o r t i n g e v e n t s ; c l u b s / o r g a n i z a t i o n s ; c o o k i n g / e n t e r t a i n i n g ; a l l r e l a x i n g a c t i v i t i e s ; v o l u n t e e r i n g ; s l e e p i n g ; housework; shopping (Roadburg, 1981: 144) . 32. • B ley repor ted t h a t when the e l d e r l y were- asked by q u e s t i o n n a i r e why they attended c e r t a i n a c t i v i t i e s , the major f i n d i n g revea led t h a t the e l d e r l y weren ' t seek ing i n t i m a t e t i e s but were a t t r a c t e d by a program, an o p p o r t u n i t y to be usefu l to o t h e r s , or the wish to be w i th people i n general ( B l e y , 1973: 3 6 6 ) . Overs opined t h a t most i n d i v i d u a l s i n our c u l t u r e b e l i e v e t h a t earn ing money j u s t i f i e s e v e r y t h i n g e l s e (Overs , 1976: 2 2 ) . However i n pursuing an a v o c a t i o n a l a c t i v i t y the q u e s t i o n whether i t i s use fu l or meaningful to the i n d i v i d u a l i s o f pr imary importance . There are non-monetary values o f work which are a l s o a p p l i c a b l e to l e i s u r e p u r s u i t s : 1. A job structures a s u b s t a n t i a l portion of the a v a i l a b l e time. In ei t h e r a paid job with r e -quired work hours or a systematic l e i s u r e pursuit plan, the i n d i v i d u a l i s r e l i e v e d of continual decisionmaking about what to do with his time. 2. A required d a i l y schedule with work or l e i s u r e i s a useful antidote to mild depression or anxiety. The a c t i v i t y requires s u f f i c i e n t a ttention so that the i n d i v i d u a l i s d i s t r a c t e d to some extent from absorption i n h i s own problems. We are a l l f a m i l i a r with t h i s phenomenon, and we say, " I t snaps you out of i t . " 3. Many jobs and some l e i s u r e a c t i v i t i e s have a supportive s o c i a l structure. There are f r i e n d s , or at l e a s t acquaintances, to have lunch and coffee breaks with (Overs, 1976: 22). People who are most comfor tab le i n s o c i a l s i t u a t i o n s can have t h e i r needs s a t i s f i e d i n v o l u n t e e r work or by j o i n i n g l e i s u r e groups where these needs are met. In a r e c e s s i o n p r a c t i c a l l y no one who i s s e v e r e l y d i s a b l e d and m a r g i n a l l y q u a l i f i e d w i l l be h i r e d i n the w o r k p l a c e . For these i n d i v i d u a l s who are unable to secure work the development o f l e i s u r e goals i s e s s e n t i a l . Overs c a t e g o r i z e s the n ine major groups o f 33. a v o c a t i o n a l a c t i v i t i e s as games; s p o r t s ; nature a c t i v i t i e s ; c o l l e c t i o n a c t i v i t i e s ; a r t and music a c t i v i t i e s ; e d u c a t i o n a l , enter ta inment and c u l t u r a l a c t i v i t i e s ; v o l u n t e e r a c t i v i t i e s ; c r a f t s , and o r g a n i z a t i o n a l a c t i v i t i e s (Overs , 1976: 2 3 ) . He concluded t h a t l e i s u r e o f f e r s a c h a l l e n g -ing new d i r e c t i o n i n which v o c a t i o n a l e v a l u a t i o n and work adjustment may expand to meet c l i e n t needs which are f r u s t r a t e d by l a c k of work o p p o r t u n i t i e s . In a study o f the i n t e r r e l a t i o n s h i p o f l e i s u r e and mental h e a l t h , a sample o f Houston a d u l t s was surveyed by s t r u c t u r e d i n t e r v i e w con -c e r n i n g l e i s u r e a c t i v i t i e s , va lue p r e f e r e n c e s , s o c i a l a t t i t u d e s and va r ious aspects o f mental h e a l t h (Gordon et a l . , 1973: 1 3 ) . A concep-t u a l i z a t i o n o f l e i s u r e ranged from very high involvement i n t e n s i t y (dancing and d r i n k i n g : p a r t i c i p a t i o n i n s p o r t s or e x e r c i s e ) to very low i n t e n s i t y ( c u l t u r a l consumpt ion; t e l e v i s i o n v i e w i n g ; s o l i t u d e ) . An a d d i t i o n a l study o f the p a r t i c i p a n t s ' goals and va lues was r e l a t e d to the l e i s u r e f i n d i n g s . The data supported the c o n t e n t i o n t h a t goals and va lues have a determin ing impact on cho ice o f l e i s u r e a c t i v i t y : among the most powerful determinants i s e d u c a t i o n , another i s personal growth. The amount o f l e i s u r e p a r t i c i p a t i o n , e s p e c i a l l y the a c t i v e , p a r t i c i p a t o r y forms o f l e i s u r e are p o s i t i v e l y c o r r e l a t e d w i th measures o f p s y c h o l o g i c a l w e l l b e i n g . The data of Gordon e t a l . show t h a t "the a c t i v e and s o c i a l and e x t e r n a l forms o f a c t i v i t y r a t h e r than the p a s s i v e , i n d i v i d u a l and home-bound forms, are p r e d i c t i v e of p s y c h o l o g i c a l w e l l b e i n g " (Gordon et a l . 1973: 2 2 ) . He concluded t h a t he and h i s c o l l e a g u e s have obta ined e m p i r i c a l support f o r the b e l i e f that a c t i v e l i f e s t y l e s r e s u l t i n p leasure and reduce l o n e l i n e s s , depress ion and the a n x i e t y o f i s o l a t i o n , a p o s i t i o n a l s o taken by K u e n s t l e r (1976: 636) and F a s t i n g (1982: 1 1 7 ) . 34. Measure of meaningful activity. From the c a t e g o r i e s o f above-mentioned authors and from the f i n d i n g s o f the q u a l i t y o f l i f e study by B ige low , a l i s t o f a c t i v i t i e s was p repared , rang ing from high i n t e n s i t y involvement such as r e g u l a r s p o r t s a c t i v i t i e s and c o m p e t i t i v e work f u l l - t i m e to low i n t e n s i t y p u r s u i t s such as main l y watching t e l e v i s i o n , l i s t e n i n g to the r a d i o , main l y s t a y i n g home a l o n e . Those l e i s u r e a c t i v i t e s which r e q u i r e spending money such as t r a v e l , f i s h i n g , h u n t i n g , d r i v i n g , o u t i n g s , were not i nc luded s i n c e the c h r o n i c mental p a t i e n t s under study are v i r t u a l l y a l l below the poverty 1 e v e l . Because most c h r o n i c mental p a t i e n t s are r e c i p i e n t s o f a s s i s t e d income and are t h e r e f o r e deemed unemployable, i t was not expected t h a t many r e s i d e n t s o f t h r e e - q u a r t e r way housing would be i n v o l v e d i n c o m p e t i -t i v e or even s h e l t e r e d work, f u l l - t i m e or p a r t - t i m e . What was a n t i c i p a t e d d e s p i t e the s e r i o u s i l l n e s s o f the p a t i e n t s was t h a t they had somewhat normal ized the s t r u c t u r e o f t h e i r t ime to i n c l u d e what was f o r them the most s a t i s f a c t o r y and meaningful a c t i v i t y which cou ld be expected o f a w i d e l y d i v e r s i f i e d group o f people w i t h r e s i d u a l symptoms. Actua l p r o d u c t i v i t y i s a s t rong s o c i a l e x p e c t a t i o n and a source o f g r a t i f i c a t i o n i n c l u d i n g h igher income, the o p p o r t u n i t y to make s o c i a l c o n t a c t s , a f e e l i n g o f use fu lness - and a s i t e o f major impairment i n mental i l l n e s s . Gunderson and Mosher (1975: 9 0 2 ) , es t imated t h a t the c o s t o f s c h i z o p h r e n i a i s i n l o s t p r o d u c t i v i t y , the y e a r l y c o s t y i e l d s a f i g u r e from $8 b i l l i o n to $11 b i l l i o n i n 1973 d o l l a r s . The c o s t i s e q u a l l y great i n l o s s o f s o c i a l s t a t u s , i d e n t i t y as a worker , and l o s s o f morale among c l i e n t s who cannot get and keep work i n a t i g h t and d i m i n i s h i n g labour market . 3 5 . The p r o d u c t i v i t y expected was i n vo lun teer work, and i n v o l v e -ment in t ime-consuming hobbies such as h a n d i c r a f t s . A l i s t of a c t i v i t i e s was prepared from Roadburg i n c l u d i n g r e a d i n g , watching t . v . , w a l k i n g , h a n d i c r a f t s , l i s t e n i n g to the r a d i o , s p o r t s a c t i v i t y , c o o k i n g , v i s i t i n g f r i e n d s , and from personal exper ience w i th the a c t i v i t i e s of c h r o n i c mental p a t i e n t s i n c l u d i n g such items as t a k i n g bus r i d e s , v i s i t i n g c o f f e e shops and v o l u n t e e r work, keeping i n mind tha t the data of Gordon e t a l . show t h a t p s y c h o l o g i c a l we l l being i s a r e s u l t o f s o c i a l and e x t e r n a l forms o f a c t i v i t y r a t h e r than p a s s i v e , home-bound forms. The l i s t o f a c t i v i t i e s was open-ended so tha t i n t e r -viewees could add a c t i v i t i e s impor tant to them. In o rder to i n v e s t i g a t e which of these a c t i v i t i e s would be the ones pursued by c h r o n i c mental p a t i e n t s i n t h r e e - q u a r t e r way housing i t was decided to request t h a t the study p o p u l a t i o n choose th ree a c t i v i t i e s most important to them i n s t r u c t u r i n g t h e i r t i m e . Weiner and Hunt have s t a t e d t h a t the concept o f the meaningful use o f f r e e t ime ove r laps w i t h that of s a t i s f a c t i o n . In view o f t h i s b e l i e f a s imp le s c a l e o f s a t i s f a c t i o n was prepared to t e s t i n te rv iewees as to the amount o f s a t i s -f a c t i o n found i n those major a c t i v i t i e s i n l w h i c h they spend t h e i r t i m e . Conceptual Framework The purpose o f t h i s study i s to i n v e s t i g a t e the e f f e c t s o f t h r e e -quar te r way housing on the q u a l i t y o f l i f e of c h r o n i c mental p a t i e n t s . The e f f e c t s o f t h r e e - q u a r t e r way housing become the independent v a r i a b l e which i s i n v e s t i g a t e d . The dependent v a r i a b l e s which r e f l e c t the implemen-: t a t i o n o f the independent v a r i a b l e are independence, s o c i a l network, 36. symptomatology and meaningful a c t i v i t y . A lso i n v e s t i g a t e d are elements o f demographic data and the i n c i d e n c e o f h o s p i t a l i z a t i o n and b r i e f emotional c r i s e s or decompensations which r e q u i r e c r i s i s hos te l i n t e r v e n t i o n . The conceptual framework determin ing the boundaries of the study shows two a l t e r n a t i v e courses o f . a c t i o n : to leave the c h r o n i c mental p a t i e n t s i n t h e i r present h o u s i n g , or to move them i n t o t h r e e - q u a r t e r way hous ing . In te rven ing v a r i a b l e s i n the implementat ion process are tenant s e l e c t i o n from the a p p l i c a t i o n process to t h r e e - q u a r t e r way housing and a c t u a l s c r e e n i n g i n t o the program to awai t r e s i d e n c y . Adjunct v a r i a b l e s which have an i n f l u e n c e on the c l i e n t s ' a b i l i t y to f i t i n t o t h r e e - q u a r t e r way housing are programs i n the teach ing o f b a s i c l i f e s k i l l s such as c o o k i n g , o f f e r e d a t some community care teams o f the Greater Vancouver Mental Heal th S e r v i c e . Other i n f l u e n c e s to be cons idered i n t h i s contex t are the p a t i e n t s ' m o t i v a t i o n to succeed i n suc .h ;hous ing , to cont inue i n t h e r a p e u t i c a f t e r c a r e a t a community care team or some o ther t h e r a p e u t i c s i t u a t i o n and to cont inue t a k i n g psychot rop ic m e d i c a t i o n as p r e s c r i b e d . Unintended consequences o f a move i n t o t h r e e - q u a r t e r way housing are r e h o s p i t a l i z a t i o n o r c r i s i s hos te l placement. Some p a t i e n t s f i n d that the s t r e s s o f a major change i n t h e i r l i f e such as a move i n t o d i f f e r e n t housing p r e c i p i t a t e s an emotional c r i s i s . Others may f i n d t h a t they cannot cope independent ly and are fo rced to r e t u r n to the more dependent s i t u a t i o n o f a superv i sed board ing home. B r i d g i n g v a r i a b l e s i n c l u d e t h r e e - q u a r t e r way housing s t a f f a s s i s t a n c e , an improved env i ronment , and s o c i a l i z a t i o n programs designed 37. to promote i n t e r p e r s o n a l i n t e r a c t i o n and the r e s u l t i n g expansion o f the i n d i v i d u a l ' s suppor t i ve s o c i a l network. C o n s t r a i n t v a r i a b l e s over which a t h r e e - q u a r t e r way program has no c o n t r o l i n c l u d e funding by the p r o v i n c i a l M i n i s t r y o f H e a l t h . A c u t i n funding would be expected to have a s e r i o u s e f f e c t on a t h r e e -quar ter way program, w i t h a r e s u l t i n g decrease i n s t a f f and program a c t i v i t i e s . Funding has thus f a r been assured but there i s no guarantee t h a t i n a t ime o f r e s t r a i n t the present l e v e l o f funding w i l l c o n t i n u e . The hoped- for consequences to be r e a l i z e d from implementat ion o f the process are t h a t some tenants w i l l move on i n t o the community to l i v e complete ly on t h e i r own, and tha t o thers who have reached an optimum l e v e l o f f u n c t i o n i n g but s t i l l r e q u i r e minimal support w i l l remain as permanent r e s i d e n t s . The conceptual framework i s summarized i n F igure 1 . Hypotheses As a r e s u l t o f t h r e e - q u a r t e r way housing i t i s hypothesized t h a t the q u a l i t y o f l i f e of c h r o n i c mental p a t i e n t s w i l l change i n the f o l l o w i n g ways: 1. S i g n i f i c a n t changes w i l l be observed i n the incidence of h o s p i t a l i z a t i o n and the number of. days of i n s t i t u t i o n a l i z a t i o n . 2. S i g n i f i c a n t changes w i l l be observed i n inde-pendence as measured by s k i l l s i n d a i l y l i v i n g . 3. S i g n i f i c a n t changes w i l l be observed i n the seve r i t y of symptoms of mental i l l n e s s . adjunct variable independent wrui 'e br'idg/nj varieties umnftnde. I canityoence-S OoostVai'nf vurikt/e crease Ut /3.CN a»td p r » 5 r « w « * 5 depfcncfpwt v a r i a b l e s life *< defined by ckavi^e ' n '• . f>0 Spitt-l i zat i on Syntj'td'H^toid^y independence |. j o e 1 4 / n e t w o r k * meam'njfu j 4lf i 1/ i ty {Convey choices move , w ' * ' 0 fommun'ty »« ones «wn CO 00 3 9 . 4. S i g n i f i c a n t differences w i l l be observed i n the t o t a l numbers of casual acquaintances and intimate r e l a t i o n s h i p s of the patient's s o c i a l network. 5. S i g n i f i c a n t changes w i l l be observed i n productive and s o c i a l pursuits and passive, i s o l a t e d pursuits i n the meaningful a c t i v i t y reported by the patients. Design This i s a two -par t s tudy . The f i r s t i s a r e a n a l y s i s o f c r o s s -s e c t i o n a l comparat ive data c o l l e c t e d i n January , 1983, a t which t ime a random sample o f 50 r e s i d e n t s i n t h r e e - q u a r t e r way housing was compared w i th 20 a p p l i c a n t s on a w a i t i n g l i s t . The l a t t e r was a purpos ive sample because the a p p l i c a n t s were the o n l y a v a i l a b l e s u b j e c t s who had been screened . They were matched through the sc reen ing process to the r e s i d e n t group by reason o f t h e i r a c c e p t a b i l i t y to t h r e e - q u a r t e r way hous ing . A l l s u b j e c t s were in te rv iewed a t t h a t time and data were c o l l e c t e d on the v a r i a b l e s o f independence, s o c i a l network, symptomatology and meaningful a c t i v i t y . A lso c o l l e c t e d were data on h o s p i t a l i z a t i o n and demographic i terns. The second par t of the study i s a f o l l o w - u p o f the o r i g i n a l a p p l i c a n t s to o b t a i n l o n g i t u d i n a l data to v a l i d a t e the f i r s t c r o s s -s e c t i o n a l d e s i g n . A l l o r i g i n a l measures were used i n the f o l l o w - u p . In a d d i t i o n , a s a t i s f a c t i o n ques t ion i n r e l a t i o n to the use of f r e e t ime i n meaningful a c t i v i t y was a p p l i e d to supplement the q u a l i t a t i v e data of tha t v a r i a b l e . Another a d d i t i o n was a v a l i d a t i o n measure o f p a t i e n t c u r r e n t s t a t u s which was completed by t h r e e - q u a r t e r way* housing s t a f f . The des ign o f the study i s a q u a s i - e x p e r i m e n t a l , p a r t i a l l y c o n t r o l l e d f i e l d s t u d y , d e s c r i p t i v e and exp lanatory i n r e l a t i o n to the 4 0 . type of i n f o r m a t i o n produced. The 1983 comparison o f 50 r e s i d e n t s and 20 a p p l i c a n t s was on an ex post f a c t o b a s i s . The second par t o f the study - the f o l l o w - u p o f a p p l i c a n t s who became r e s i d e n t s over the course o f a year - was on a p r o s p e c t i v e bas i s s i n c e t h i s group was measured a t two p o i n t s i n t i m e , before and dur ing r e s i d e n c y . The a d d i t i o n a l v a l i d a t i o n measure completed by housing s t a f f was ex post f a c t o . The i n f o r m a t i o n gathered was main l y q u a n t i t a t i v e , a l though q u a l i t a t i v e data were c o l l e c t e d i n the form o f anecdota l comments on the dependent v a r i a b l e s so as to e n r i c h the f i n d i n g s . 41 . M E T H O D S e t t i n g Subjects f o r the study were s e l e c t e d from the p o p u l a t i o n of four apartment b locks o f 106 main ly bache lor s u i t e s operated by the Coast Foundation S o c i e t y i n Vancouver. S ta r ted i n 1974 the apartment p r o j e c t houses those ch ron ic p a t i e n t s who are deemed capable o f f u n c t i o n i n g i n a m i n i m a l l y s u p p o r t i v e environment w i t h the support o f t h e i r peers (Toml inson , Cumming, 1976: 2 5 ) . The Coast Foundation apartment program s u p p l i e s s e l f - c o n t a i n e d modern bachelor s u i t e s a t a r e n t equal to the s h e l t e r v a r i a b l e of the r e s i d e n t s ' a s s i s t a n c e income. A communal lounge i s l o c a t e d i n each apartment b lock as a foca l p o i n t f o r program a c t i v i t y , s o c i a l i z a t i o n and the a l l e v i a t i o n o f l o n e l i n e s s . Weekly c o f f e e hours and weekly cooking c l a s s e s w i t h r e s u l t i n g communal d inners are held i n the lounges to promote s o c i a l i n t e r a c t i o n . At a mandatory monthly meeting o f a l l t e n a n t s , concerns are shared and a d d i t i o n a l a c t i v i t i e s are p lanned. A r e s i d e n t manager cares f o r each b u i l d i n g and maintenance. An apartment b lock community mental hea l th worker termed a " s o c i a l c o o r d i n a t o r " i s on c a l l on a twenty - fou r h o u r . b a s i s f o r personal c r i s i s i n t e r v e n t i o n and c o u n s e l l i n g i n each b u i l d i n g . By d a i l y involvement w i th r e s i d e n t s , s t a f f are ab le to p rov ide guidance i n the s t r u c t u r i n g o f t ime i n s u i t a b l e r e c r e a t i o n a l or v o c a t i o n a l 42. a c t i v i t i e s and to a c t as " f r i e n d s " i n c o - o p e r a t i o n w i t h each i n d i v i d u a l ' s t h e r a p i s t . The o b j e c t i v e s o f the Coast Foundation housing d i v i s i o n are to house those e x - p a t i e n t s who have reached a p lateau o f f u n c t i o n i n g a b i l i t y , and those who can be prepared to move on i n t o the community -at -l a r g e ; to i n c r e a s e the number o f days the r e s i d e n t s s u c c e s s f u l l y l i v e i n the community as measured by r e h o s p i t a l i z a t i o n s and i n c i d e n c e s o f decompen-s a t i o n ; to i n c r e a s e the demonstrated l e v e l s o f l i v i n g s k i l l s o f the r e s i d e n t s and to i n c r e a s e the l e v e l s o f s o c i a l involvement through an expanded s o c i a l network. A lso expected i s the i n c r e a s e of normative behaviour o f the r e s i d e n t s to a l e v e l adequate f o r community l i v i n g and an i n c r e a s e i n the numbers o f pr imary and secondary resources used i n the community. Residence i s not t i m e - l i m i t e d s i n c e i t i s recogn ized t h a t the process o f adapt ing to community l i v i n g v a r i e s w i d e l y from person to person . Some tenants w i l l remain permanently i n the p r o j e c t and o thers w i l l move on to independent l i v i n g i n the community. Subjects The r e s i d e n t s o f Coast Foundation housing are fo rmer l y h o s p i t a l i z e d people who are c h r o n i c a l l y m e n t a l l y i l l and i n r e g u l a r t reatment w i t h p r i v a t e p s y c h i a t r i s t s o r t h e r a p i s t s o f the community care teams o f the Greater Vancouver Mental Health S e r v i c e . They are screened i n t o the program by a s c r e e n i n g committee o f Coast Foundation comprised of housing d i v i s i o n s t a f f , a tenant of the program and a p s y c h i a t r i c s o c i a l worker to a s c e r t a i n i f they are i n need o f h o u s i n g , i f they have b a s i c l i v i n g s k i l l s f o r community l i v i n g and i f they are i n ongoing a f t e r c a r e which 4 3 . prov ides therapy and m e d i c a t i o n . They are accepted i n t o the program i f they pass the s c r e e n i n g and a l s o r e c e i v e a p o s i t i v e r e f e r r a l from t h e i r pr imary t h e r a p i s t as to t h e i r s u i t a b i l i t y f o r t h i s hous ing . Residents. The p o p u l a t i o n s t u d i e d was a homogeneous group of c h r o n i c mental p a t i e n t s who came i n t o t h r e e - q u a r t e r way housing from h o s p i t a l , from boarding homes and t r a n s i t i o n a l hous ing , and from substandard &and i s o l a t e d l i v i n g c o n d i t i o n s i n the community. They were i n cont inuous a f t e r c a r e , r e c e i v i n g p s y c h i a t r i c med ica t ion f o r the a l l e v i a t i o n o f symptoms o f mental i l l n e s s , main ly s c h i z o p h r e n i a but a l s o i n c l u d i n g manic d e p r e s s i v e , depress i ve and a n x i e t y d i s o r d e r s . The r e s i d e n t s surveyed i n the Hooper (1983) study had been tenants o f Coast Foundation main ly from two to four y e a r s . Seventy names were s e l e c t e d from a l i s t of 106 r e s i d e n t s by randomly p u l l i n g names out o f a c o n t a i n e r . Nine people re fused to be i n t e r v i e w e d , one was i n h o s p i t a l , one was out o f town, two had moved out o f the b l o c k s , and f i v e names w e r e n ' t used because a quota o f 50 had been reached . The random sample of 50 r e s i d e n t s was in te rv iewed i n a c r o s s - s e c t i o n a l 1983 s t u d y , and data were c o l l e c t e d to measure t h e i r c u r r e n t s t a t u s i n terms of independence, s o c i a l network, symptomatology and meaningful a c t i v i t y . A lso c o l l e c t e d were data on t h e i r h o s p i t a l i z a t i o n i n the three years p r i o r to r e s i d e n c e i n Coast hous ing , and t h e i r h o s p i t a l i z a t i o n s i n c e l i v i n g i n Coast . 44. Applicants. The a p p l i c a n t s to Coast housing came from the same background and were s i m i l a r to the r e s i d e n t s , having passed through the same s c r e e n i n g p rocess . The 20 a p p l i c a n t s who had been screened i n t o the program were in te rv iewed i n the c r o s s - s e c t i o n a l 1983 study and data were c o l l e c t e d on the same measures o f independence, s o c i a l network, symptomatology and meaningful a c t i v i t y . The i r prev ious h o s p i t a l i z a t i o n s were a l s o r e c o r d e d . For the 1984 l o n g i t u d i n a l study 15 o f the 20 a p p l i c a n t s who had become r e s i d e n t s were in te rv iewed aga in a f t e r twelve months. Of the a t t r i t i o n o f f i v e a p p l i c a n t s , one found a l t e r n a t i v e housing before a vacancy occur red and d e c l i n e d to move i n . One moved out w i t h i n three weeks because o f a p e r s o n a l i t y c l a s h w i t h another t e n a n t . One underwent surgery and l a t e r moved out o f town. Two women d e c l i n e d to be r e - i n t e r v i e w e d because they found the f i r s t i n t e r v i e w made them uncomfor tab le . Each o f these f i v e people i s known by the i n t e r v i e w e r . They had no ou ts tand ing problems or d i f f e r e n c e s from the other i n t e r v i e w e e s which would a f f e c t the r e s u l t s o f the l o n g i t u d i n a l s tudy . The r e - i n t e r v i e w covered the same ground as the 1983 s t u d y . As a v a l i d a t i o n check o f the o r i g i n a l measures, Coast Foundation s t a f f completed a su rvey , u s i n g the Progress E v a l u a t i o n S c a l e s , o f 17 o f the o r i g i n a l 20 a p p l i c a n t s , e x c l u d i n g the three a p p l i c a n t s who were not r e s i d e n t a t the t i m e . Th is survey was completed a t the same time as the r e - i n t e r v i e w i n g . 4 5 . Procedure. At Tenants Counci l monthly meetings i n each apartment b lock the impending i n t e r v i e w procedure o f the r e s i d e n t s was d e s c r i b e d . This was fo l lowed by a l e t t e r to a l l tenants in fo rming them i n d e t a i l about the i n t e r v i e w , the hope t h a t they would consent to ;be in te rv iewed and the assurance t h a t they cou ld r e f u s e w i thout j e o p a r d i z i n g t h e i r tenancy . S t a f f members were n o t i f i e d when names were s e l e c t e d and'because o f t h i s two s u b j e c t s ' names were dropped as not being we l l enough to take par t i n the survey . One woman was l a r g e l y out o f touch w i t h r e a l i t y and was very b e l l i g e r e n t and the o ther was i n a s t a t e o f extreme a n x i e t y . I n t e r -viewees were then phoned to arrange a meeting t ime and p lace a t t h e i r conven ience . S o l i c i t a t i o n o f i n t e r v i e w s w i t h a p p l i c a n t s was undertaken a f t e r each p a t i e n t passed the s c r e e n i n g procedure , and i n t e r v i e w dates and l o c a t i o n s were arranged a t the a p p l i c a n t s ' convenience . For the second study - the f o l l o w - u p o f the a p p l i c a n t s - the same procedure was u s e d : a f i r s t c o n t a c t by l e t t e r and a f o l l o w - u p phone c a l l to arrange the i n t e r -v iew. Most people chose to be in te rv iewed i n t h e i r own homes a l though two chose the Coast Foundation housing d i v i s i o n o f f i c e , two chose the Coast a c t i v i t y c e n t r e and one chose a c o f f e e shop. Th'e •Interview. Whenever p o s s i b l e the i n t e r v i e w e r s a t bes ide the i n t e r v i e w e e , c o n s c i o u s l y a v o i d i n g a c o n f r o n t a t i o n a l posture w i t h e m o t i o n a l l y f r a g i l e peop le . The i n t e r v i e w e e was thus a b l e to read what was being s c a l e d or w r i t t e n so as to a l l a y a n x i e t y . The in te rv iewees were assured they were 46. g r a n t i n g a favour by being in te rv iewed and were reassured tha t the data would remain c o n f i d e n t i a l and t h a t i n no way would t h e i r answers e i t h e r j e o p a r d i z e t h e i r tenancy or j e o p a r d i z e the a p p l i c a n t s ' acceptance to the program when a s u i t e became a v a i l a b l e . The i n t e r v i e w s were q u i t e d i f f e r e n t . Some in te rv iewees were s t r a i g h t f o r w a r d , some were confused , and needed p a t i e n t e x p l a n a t i o n and more t ime than o t h e r s , some were r e t i c e n t and needed encouragement, and a few were very anxious and r e q u i r e d a g e n t l e approach. In a l l cases the i n t e r v i e w s were cont inued u n t i l the i n f o r m a t i o n r e q u i r e d was obta ined and documented, and u n t i l the i n t e r v i e w s ended on a r e a s s u r i n g and p o s i t i v e no te . No i n t e r v i e w s were a b o r t e d . Measures Measures completed by housing coordinator\ Progress Evaluation Scales. The f o l l o w - u p v a l i d a t i o n measure o f 17 o f the 20 o r i g i n a l a p p l i c a n t s w i t h the Progress E v a l u a t i o n Sca les was conducted by the housing c o o r d i n a t o r o f Coast Foundation together w i t h the s o c i a l c o o r d i n a t o r s o f the apartment b l o c k s . The housing c o o r d i n a t o r who knows a l l the r e s i d e n t s completed the assessments , w i th i n p u t from the s o c i a l c o o r d i n a t o r from each apartment b lock to update and expand on any i n f o r m a t i o n about the tenants o f which the housing c o o r d i n a t o r wasn ' t aware. Rat ings were made on the b a s i s of t h i s i n f o r m a t i o n and the c o o r d i n a t o r ' s knowledge o f the t e n a n t s . The p a t i e n t s were not invo l ved i n t h i s s tudy . The sample s i z e was 1 7 , because, as pointed out e a r l i e r , one p a t i e n t d e c l i n e d to move i n , and two had moved o u t . 4 7 . A program outcome measure, the Progress E v a l u a t i o n Sca les are made up o f seven s c a l e s each c o n s i s t i n g of f i v e l e v e l s w i t h the c h a r a c -t e r i s t i c s of each l e v e l d e s c r i b e d . For purposes o f q u a n t i f y i n g , the f i v e l e v e l s o f the s c a l e s are ass igned va lues o f 1 to 5 , from the most patho-l o g i c a l to the h e a l t h i e s t l e v e l s o f f u n c t i o n i n g i n each o f seven areas such as " A t t i t u d e toward s e l f " or s e l f - e s t e e m . The lowest l e v e l score c h a r a c t e r i z e s negat ive s e l f - e s t e e m most o f the t i m e , the middle l e v e l por t rays an almost equal n e g a t i v e - p o s i t i v e a t t i t u d e and the h ighes t l e v e l i s c h a r a c t e r i z e d as having a p o s i t i v e a t t i t u d e toward o n e s e l f most o f the t i m e . The f i r s t o f the seven s c a l e s , "Fami ly R e l a t i o n s " was s u b s t i t u t e d by " Independence". In format ion about f a m i l y r e l a t i o n s h i p s was not a v a i l -a b l e to the c o o r d i n a t o r s but independence was r e a d i l y o b s e r v a b l e . This i tem was prepared by the r e s e a r c h e r , f o l l o w i n g the format and d e s c r i p t i o n s o f the other s u b - s c a l e s . I t was c h a r a c t e r i z e d by f i v e d e s c r i p t i o n s rang ing from heavy dependence to a s t a t e of a lmost complete independence, to conform wi th the c h a r a c t e r i z a t i o n s o f the o ther s i x i t e m s . To use the s c a l e s the c o o r d i n a t o r s ass igned a va lue to each o f the seven s c a l e s d e s c r i b i n g best the c u r r e n t f u n c t i o n i n g l e v e l o f the i n d i v i d u a l concerned. With v a r i o u s c l i e n t samples numerous s t u d i e s were c a r r i e d out w i t h these s c a l e s over e i g h t y e a r s , to study t h e i r psychometr ic p r o p e r t i e s such as r a t e r r e l i a b i l i t y , e t c . ( I h i l e v i c h e t a l . , 1981: 4 5 6 ) . In an e a r l y study o f the P . E . S . s c a l e s a s t a f f member s a t i n on an i n i t i a l i n t e r v i e w of the c l i e n t by the t h e r a p i s t and independent ly ra ted the 4 8 . c l i e n t ' s present s t a t u s . A sample o f 20 c l i e n t s was r a t e d . R e l i -a b i l i t y es t imates f o r c u r r e n t s t a t u s ranged from .49 f o r "Prob lems" to a high o f .86 f o r " G e t t i n g a long w i th o t h e r s " . The median r e l i -a b i l i t y f o r present s t a t u s was .65 ( I h i l e v i c h e t a l . , 1981: 4 5 7 ) . S t a b i l i t y o f r a t i n g s over occas ions was examined by having 65 a d u l t p a t i e n t s f i l l out r a t i n g s c a l e s on two occas ions two weeks a p a r t . The i r t h e r a p i s t s a l s o ra ted them on two o c c a s i o n s . There was l i t t l e i f any sys temat i c v a r i a n c e a t t r i b u t a b l e to occas ions o f r a t i n g on any o f the s c a l e s , nor any d i f f e r e n t i a l t rend over occas ions between r a t i n g s o f c l i e n t and t h e r a p i s t . Well f u n c t i o n i n g members o f the community, i . e . those r e q u i r i n g no s e r v i c e s should o b t a i n h igher scores than the e m o t i o n a l l y d i s t u r b e d . To t e s t t h i s assumption 261 n o n - p a t i e n t s i n va r ious jobs and school programs were compared to 270 male and female o u t p a t i e n t s . S e l f - r a t i n g s on a l l seven s c a l e s s i g n i f i c a n t l y d i f -f e r e n t i a t e d p a t i e n t and n o n - p a t i e n t groups. A l l d i f f e r e n c e s were in the expected d i r e c t i o n . I t i s t h e r e f o r e ev ident tha t the P . E . S . Sca les are capable o f making v a l i d d i s c r i m i n a t i o n s among p a t i e n t s and n o n - p a t i e n t s as to t h e i r e m o t i o n a l , i n t e r p e r s o n a l and community ad justment . P r e - t e s t i n g o f the P . E . S . s c a l e s w i th the f o l l o w - u p group o f 17 new r e s i d e n t s o f Coast Foundation was c a r r i e d out by the housing s t a f f who found no problem w i t h the s c a l e s . 4 9 . Because the s u b - s c a l e s o f the P . E . S . s c a l e s d i d not match the items chosen f o r the s e l f - r e p o r t measures i n s u b j e c t m a t t e r , c r o s s - t a b u l a -t i o n s were a p p l i e d on ly to those s u b - s c a l e s which seemed to be measuring the same t r a i t s . Outcome of Independence o f the P . E . S . sub-rscales was compared w i t h Independence o f the s e l f - r e p o r t measure. C r o s s - t a b u l a t i o n s were a p p l i e d to the A t t i t u d e toward s e l f s u b - s c a l e o f the P . E . S . s c a l e s and S e l f - e s t e e m o f the s e l f - r e p o r t measures. They were a p p l i e d to the Fee l ings and mood s u b - s c a l e o f the P . E . S . s c a l e s and L o n e l i n e s s , Sadness, Anx ie ty and Optimism of the s e l f - r e p o r t measuresto see i f a r e l a t i o n s h i p occur red between these i t e m s . The Problems s u b - s c a l e o f the P . E . S . s c a l e s was a l s o c r o s s - t a b u l a t e d w i t h L o n e l i n e s s , Sadness , A n x i e t y and Optimism o f the s e l f -r e p o r t measures to see i f a r e l a t i o n s h i p e x i s t e d between these i t e m s . No o ther items o f the P . E . S . s u b - s c a l e s were deemed to be s i m i l a r enough to the items o f the s e l f - r e p o r t measures to examine concur rent v a l i d i t y . Measures completed by researcherwith residents. Independence Scale. For the purpose o f t h i s s t u d y , independence f o r c h r o n i c mental p a t i e n t s i s d e f i n e d by the items o f the f o l l o w i n g measure. The Independence s c a l e i s adapted from the Assessment o f C l i e n t Independence used by the Greater Vancouver Mental Heal th S e r v i c e . The measure conta ins 12 i t e m s : g rocery shopp ing , shopping f o r o ther e s s e n t i a l s , p r e p a r i n g w e l l - b a l a n c e d m e a l s , l a u n d r y , c l e a n i n g apartment or room, b u d g e t t i n g , personal hygiene and grooming, use o f h e a l t h s e r v i c e s , use o f 50. r e c r e a t i o n a l r e s o u r c e s , use o f community resources such as government o r s o c i a l a g e n c i e s , use o f a v a i l a b l e t r a n s p o r t a t i o n , and s o c i a l i z a t i o n s k i l l s . The i tem on s o c i a l i z a t i o n s k i l l s was not used because i t would d u p l i c a t e the separate s o c i a l network measure. . The two items on shopping were combined and an item on personal s u p e r v i s i o n o f med ica t ion was i n c l u d e d . The independence s c a l e t h e r e f o r e i n c l u d e s 11 items to be s c a l e d " y e s 1 , "need a s s i s t a n c e " , " n o " , to such quest ions as "Are you a b l e to budget your own money and. manage banking?" Each o f the items dea ls w i t h a common a c t i v i t y of d a i l y l i v i n g designed to cover a l l those a c t i v i t i e s necessary f o r a normal l i f e i n the community. The s c a l e i s q u a n t i f i e d f o r s t a t i s t i c a l purposes w i t h "yes" r a t i n g 3 , "need a s s i s t a n c e " r a t i n g 2 , and " n o " , 1 . Social Network Scale. As i n d i c a t e d i n the l i t e r a t u r e r e v i e w , the s o c i a l network s c a l e measures the s i z e and i n t i m a c y o f the p a t i e n t ' s s o c i a l network, o u t l i n e d by va r ious authors as the most important data to be c o l l e c t e d and to be compared w i th the network s i z e o f normals . The l a t t e r , a c c o r d i n g to Hammer and o thers have a mean o f s l i g h t l y l e s s than 40 i n d i v i d u a l s w i t h a range o f 25 to 50 , w i th 6 to 10 o f these being i n t i m a t e l y known i n d i v i d u a l s . Therefore s o c i a l network f o r the purposes o f t h i s study i s de f ined as the-number o f one ' s c l o s e and casual r e l a t i o n s h i p s . C lose r e l a t i o n s h i p s are those s o c i a l t i e s which are i n t i m a t e i n nature and occur on a r e g u l a r and f requent b a s i s . The s o c i a l network s c a l e has s i x quest ions r e q u i r i n g a c t u a l number o f i n t i m a t e f r i e n d s and casual a c q u a i n t a n c e s , w i t h i n the apartment 51 . b l o c k s , o u t s i d e i n the community, and such l i n k s w i th k i n . The quest ions were worded i n these areas to help f a c i l i t a t e the p a t i e n t ' s r e c a l l o f h i s c l o s e and casual r e l a t i o n s h i p s . C lose r e l a t i o n s h i p s and casual r e l a t i o n s h i p s were then t o t a l l e d . Symptomatology_ Scale. In order to i n v e s t i g a t e the c u r r e n t s t a t e o f symptomatology i n a s h o r t e a s y - t o - u s e measure, high s e v e r i t y items and items r e c u r r i n g i n severa l w i d e l y used s c a l e s as i n d i c a t e d by the l i t e r a t u r e were i n c o r p o r a t e d . A n x i e t y , f e a r and f e e l i n g s o f sadness were used from the P r a g e r , Hamilton and Zung s c a l e s . S leep p a t t e r n was i n c o r p o r a t e d from the Hamilton and Zung s c a l e s . Items o f s o c i a l w i t h d r a w a l , s e l f -esteem, s e l f - c o n f i d e n c e , a sense o f s e c u r i t y and the a b i l i t y to make d e c i s i o n s and s o l v e problems were used from the Bigelow s tudy . Lone-l i n e s s and out look f o r the f u t u r e were inco rpora ted from personal exper ience w i t h depressed p a t i e n t s . In a l l , 12 items form the symptomatology s c a l e which i s desc r ibed i n f i v e l e v e l s - " a l w a y s " , "most o f the t i m e " , "somet imes" , "hard ly ever" to " n e v e r " . "Always" i s ra ted as 5 , "never" as 1 f o r s t a t i s t i c a l purposes. F ive o f the quest ions were presented i n a negat ive format to balance the q u e s t i o n n a i r e f o r the reader and prevent r e p e t i t i v e s c o r i n g i n the same l e v e l s . These f i v e items must be s c a l e d i n r e v e r s e . Quest ion 1 3 : "In your present l i v i n g s i t u a t i o n i s your s l e e p i n g pa t te rn s a t i s f a c t o r y ? can be s c a l e d 5 f o r "a lways" through to 1 f o r "never " . 5 2 . Meaningful activities list. A l i s t o f a c t i v i t i e s was prepared from Roadburg and from personal exper ience o f the a c t i v i t i e s of c h r o n i c mental p a t i e n t s , mindfu l t h a t Gordon et a l . made the p o i n t t h a t p s y c h o l o g i c a l w e l l b e i n g i s a s s o c i a t e d w i t h a c t i v e and s o c i a l a c t i v i t i e s r a t h e r than p a s s i v e , homebound a c t i v i t i e s . However, Bigelow has pointed out t h a t f o r some c h r o n i c mental p a t i e n t s , watching t . v . and pass ive p u r s u i t s may be optimum a c t i v i t i e s f o r those w i th s i g n i f i c a n t patho logy , and e x p e c t a t i o n s o f p r o d u c t i v i t y may be un-r e a l i s t i c . I f such people are s a t i s f i e d w i th t h e i r d a i l y a c t i v i t i e s and f e e l comfor tab le w i t h them, t h i s i s the more r e a l i s t i c measure o f what i s m e a n i n g f u l . The meaningful a c t i v i t i e s s e c t i o n o f the measures l i s t s 20 suggested a c t i v i t e s such as " s h e l t e r e d work par t t i m e " , " vo lunteer work" , " v i s i t i n g w i t h f r i e n d s or r e l a t i v e s " , "mainly watching t . v . " , and i n v i t e s the i n t e r v i e w e e to l i s t o ther a c t i v i t i e s i f those l i s t e d are not h i s major p u r s u i t s . Three a c t i v i t i e s which are the most important to the respondent are chosen. Each a c t i v i t y i s s c a l e d "yes" 2 , or "no" 1 . A s a t i s f a c t i o n s c a l e accompanies the measure. To be ra ted i n four l e v e l s i t i s scored a t 4 f o r "very s a t i s f i e d " , 3 f o r " s a t i s f i e d " , 2 f o r " d i s s a t i s f i e d " and 1 f o r "very d i s s a t i s f i e d " w i th the three most important a c t i v i t i e s chosen by the i n t e r v i e w e e . Demographic data. The par t o f the measures devoted to demographic data l i s t s 22 i tems i n c l u d i n g age , sex , e d u c a t i o n , r e f e r r a l s o u r c e , d i a g n o s i s , former 53. h o u s i n g , income, years of p s y c h i a t r i c s e r v i c e , type and frequency o f a f t e r c a r e . Some items c o n t a i n a range o f answers. " D i a g n o s i s " o f f e r s f i v e cho ices to the r e a d e r : s c h i z o p h r e n i c / p s y c h o t i c , manic d e p r e s s i v e , d e p r e s s i v e d i s o r d e r , a n x i e t y d i s o r d e r and p e r s o n a l i t y d i s o r d e r . Choices are numbered from one to f i v e f o r s t a t i s t i c a l purposes . Hospitalization. H o s p i t a l i z a t i o n i s covered i n some d e t a i l by 16 items which break down i n s t i t u t i o n a l i z a t i o n i n t o admiss ions to h o s p i t a l , h o s p i t a l day c a r e , and "Venture" c r i s i s h o s t e l . Questions a l so r e f e r to the i n s t i t u t i o n entered and the time per iod covered by i n s t i t u t i o n a l i z a t i o n . Because the average r e s i d e n t i n the 1983 study had been l i v i n g in t h r e e -quar te r way housing from two to four y e a r s , h a l f the quest ions covered i n s t i t u t i o n a l i z a t i o n i n the th ree year pe r iod p r i o r to l i v i n g i n such hous ing , and h a l f the quest ions r e f e r to i n s t i t u t i o n a l i z a t i o n i n the pe r iod s i n c e r e s i d e n c y . These quest ions were a l s o asked o f the a p p l i c a n t s i n the f o l l o w - u p study a l though t h e i r per iod o f r e s i d e n c y ranged from three months to a year when i n t e r v i e w e d . These quest ions are scored by a c t u a l numbers o f i n s t i t u t i o n a l i z a t i o n s and numbers of days i n s t i t u t i o n a l i z e d . Method of S t a t i s t i c a l A n a l y s i s Frequency d i s t r i b u t i o n s were compi led f o r demographic d a t a , i n c l u d i n g h o s p i t a l i z a t i o n s and o ther i n s t i t u t i o n a l i z a t i o n s , f o r the measure o f Independence and f o r the Meaningful a c t i v i t i e s s c h e d u l e . 54. Because o f low f requenc ies and unbalanced d i s t r i b u t i o n s of these data extended s t a t i s t i c a l a n a l y s i s was not p o s s i b l e , but c ross t a b u l a t i o n s were u t i l i z e d to look a t the a s s o c i a t i o n s between s e l e c t e d v a r i a b l e s and to prov ide some i n d i c a t i o n s o f t r e n d s . ' Cross t a b u l a t i o n s were u t i l i z e d v i n a comparison o f s u p e r v i s o r y s t a f f assessments o f the p a t i e n t s and p a t i e n t s ' s e l f - r e p o r t s . In l o o k i n g f o r d i f f e r e n c e s between the c u r r e n t s t a t u s of r e s i d e n t s and a p p l i c a n t s , t - t e s t s were a p p l i e d to s o c i a l network v a r i a b l e s . T - t e s t s were a l s o u t i l i z e d to examine d i f f e r e n c e s i n the s c a l e d v a r i a b l e s o f the Symptomatology measure between the two samples , and to examine the d i f f e r e n c e s between the Time 1 measure o f a p p l i c a n t s and the Time 2 measure of a p p l i c a n t s when they had become r e s i d e n t s , r e g a r d i n g t h e i r s o c i a l network and t h e i r symptomatology. 55. R E S U L T S Demographic information: residents and applicants. The r e s i d e n t sample o f 50 was made up o f 26 men and 24 women. Average age o v e r a l l was 44 y e a r s , S_D = 1 3 . 3 . The a p p l i c a n t c o n t r o l group o f 20 was evenly d i v i d e d by sex w i t h an average age of 36 y e a r s , S_D = 9 . 6 , p o r t r a y i n g a midd le -aged p o p u l a t i o n n e a r l y evenly d i v i d e d by sex and a l l but two o f s i n g l e s t a t u s . Comparative age d i s -t r i b u t i o n i s shown i n F igure 2 . Near l y 60% o f both groups had earned a t l e a s t pa r t o f a secondary school e d u c a t i o n ; 30% o f the r e s i d e n t s and 35% o f the a p p l i c a n t s had pos t - secondary s c h o o l i n g . The m a j o r i t y o f r e s i d e n t s i n t e r v i e w e d were l o n g - t e r m tenants o f t h r e e - q u a r t e r way hous ing , n e a r l y t w o - t h i r d s having l i v e d i n the a p a r t -ment b locks between one and four y e a r s , t h e r e f o r e most r e s i d e n t s sampled were ab le to d e s c r i b e themselves i n r e l a t i o n to the housing program wi th knowledge gathered from c o n s i d e r a b l e e x p e r i e n c e . \ More than h a l f o f the r e s i d e n t s were r e f e r r e d to t h r e e -quar te r way housing by the community care teams of the Greater Vancouver Mental Heal th S e r v i c e , whereas n e a r l y t w o - t h i r d s o f the a p p l i c a n t s had heard o f the housing program through f r i e n d s . In the e a r l y years o f 56. / 57. the housing program the community care teams were the pr imary means o f r e f e r r a l to the housing r e s o u r c e . By 1983 when the a p p l i c a n t s were i n t e r v i e w e d the housing program had become w e l l e s t a b l i s h e d i n the community i n i t s n ine years o f o p e r a t i o n . I ts a v a i l a b i l i t y to mental p a t i e n t s had become wel l -known by word-of -mouth v i a the p a t i e n t g r a p e - ' v i n e and a l though most r e f e r r a l s o f a p r o f e s s i o n a l nature cont inue to be made by the community care teams, the m a j o r i t y o f a p p l i c a n t s now s e l f -r e f e r on the adv ice o f f r i e n d s . The m a j o r i t y o f the r e s i d e n t s were diagnosed as s c h i z o p h r e n i c , 56% compared to the a p p l i c a n t s ' 60%. Other d i s o r d e r s were manic d e p r e s s i o n , depress i ve d i s o r d e r , a n x i e t y d i s o r d e r and p e r s o n a l i t y d i s o r d e r as shown i n Table 1 . Housing c h a r a c t e r i s t i c s of both groups were s i m i l a r , w i t h most having l i v e d a l o n e , and a t h i r d having r e s i d e d i n p s y c h i a t r i c boarding homes p r i o r to res idency i n Coast Foundation apartment b l o c k s . Former housing types f o r most r e s i d e n t s and a p p l i c a n t s inc luded rooms which were not s e l f - c o n t a i n e d , s u i t e s which were s e l f - c o n t a i n e d , p s y c h i a t r i c board ing homes and Mental P a t i e n t s A s s o c i a t i o n houses. Other types which accounted f o r the few remaining people were hote l rooms, f a m i l y homes, h a r d - t o - h o u s e s h e l t e r s such as Lookout , home-shar ing and h o s p i t a l . Housing c h a r a c t e r i s t i c s are shown i n Table 2 . Source o f income was comparable, w i th t w o - t h i r d s o f the r e s i d e n t s and over h a l f of the a p p l i c a n t s r e c e i v i n g Handicapped Persons Income A s s i s t a n c e . Only one r e s i d e n t and one a p p l i c a n t were employed. Severa l were r e c e i v i n g s o c i a l a s s i s t a n c e which i s u s u a l l y paid to those under 30 i n p re ference to H . P . I . A . unless the i n d i v i d u a l has a 58. Table 1 * Diagnosis o f Residents and A p p l i c a n t s Res idents % Appl i c a n t s % S c h i z o p h r e n i c / p s y c h o t i c 28 56 12 60 Manic d e p r e s s i v e 5 10 3 15 Depressive d i s o r d e r 12 24 3 15 Anx ie ty d i s o r d e r 3 6 2 10 P e r s o n a l i t y d i s o r d e r 2 4 0 0 50 100 20 100 N h 50 N = 20 Diagnoses were obta ined from agency records and i t should be noted t h a t they are s u b j e c t to change, and would have been made o r i g i n a l l y by v a r i o u s p r o f e s s i o n a l s . Table 2 Housing C h a r a c t e r i s t i c s o f Res idents and A p p l i c a n t s Before They Moved i n t o Coast Foundation Res idents % Appl i c a n t s % L i v i n g a lone 23 46 7 35 L i v i n g w i t h r e l a t i v e ( s ) 5 10 6 30 L i v i n g i n a boarding home t r a n s i t i o n a l housing or 16 32 6 30 Communal l i v i n g 5 10 0 0 H o s p i t a l 1 2 1 5 50 100 20 100 N = 50 N = 20 6 0 . poor prognosis and i s deemed permanently unemployable a t an e a r l y age. Other sources of income i n c l u d e d Old Age P e n s i o n , G a i n , D.V.A. p e n s i o n , e s t a t e income, Canada Pension P lan D i s a b i l i t y , and U . I .C . Only one o f the r e s i d e n t s and one a p p l i c a n t were r e c e i v i n g i n excess o f a poverty l e v e l income, s e t a t $ 7 4 7 . 5 0 per month i n l a r g e Canadian c i t i e s by the e Nat iona l Counc i l o f Wel fare i n 1 9 8 2 . A l l o thers were r e c e i v i n g w e l l below t h i s l i m i t at l e s s than $ 6 0 0 per month. Length o f some form of p s y c h i a t r i c s e r v i c e averaged 1 6 y e a r s , S T J = 9 . 8 , f o r the r e s i d e n t s ; 1 2 y e a r s , SJj = 6 . 2 , f o r the a p p l i c a n t s , both groups being f a i r l y c h r o n i c p s y c h i a t r i c c o n v a l e s c e n t s . Fo l low-up care f o r both groups was t y p i c a l l y attendance a t a community care team. Frequency o f attendance was comparable, w i t h one quar te r a t t e n d i n g once a week, one quar te r every two weeks, and approx imate ly 4 0 % v i s i t i n g once a month. The c h r o n i c nature o f the i l l n e s s o f the p o p u l a t i o n i s evidenced by the number o f t h e i r h o s p i t a l i z a t i o n s . Average number of h o s p i t a l i z a -t i o n s o f the r e s i d e n t s was 4 , SD = 2 . 5 , and a range o f 0 to 1 0 . Mean h o s p i t a l i z a t i o n s o f the a p p l i c a n t s was 7 , SJj = 5 . 7 , w i t h a range o f 1 to 2 5 . The d i f f e r e n c e i n the number o f h o s p i t a l i z a t i o n s between the r e s i d e n t s and the a p p l i c a n t s i s e x p l a i n a b l e because o f the a p p l i c a n t s ' younger mean age , and c u r r e n t h o s p i t a l i z a t i o n p o l i c y . The average h o s p i t a l i z a t i o n 1 5 to 2 0 years ago was a g reat deal longer than today . People are now admit ted more f r e q u e n t l y and u s u a l l y no longer than a month or s i x weeks which a l lows s t a b i l i z a t i o n on med ica t ion but prevents dependency on i n s t i t u t i o n s and the d e t r i m e n t a l e f f e c t s o f i n s t i t u t i o n a l i -z a t i o n . The f i g u r e s do not i n c l u d e h o s p i t a l i z a t i o n s of under 2 4 hours 6 1 . such as an o v e r n i g h t s tay i n the emergency department o f a h o s p i t a l because o f an overdose. Nor do they i n c l u d e any i n t e r v e n t i o n which i s not o f an i n - p a t i e n t n a t u r e . C h r o n i c i t y i s the on ly u s e f u l f i n d i n g from the frequency o f i n s t i t u t i o n a l i z a t i o n . What the f i g u r e s do not revea l i s the s e r i o u s n e s s o f the i n t e r v e n t i o n : e i g h t s h o r t h o s p i t a l i z a t i o n s o f a few days ' or weeks' d u r a t i o n cannot be compared w i th one admiss ion which l a s t s 10 y e a r s . The t o t a l d u r a t i o n o f a l l h o s p i t a l i z a t i o n s was not compi led because a s i g n i f i c a n t number o f those i n t e r v i e w e d had f i r s t been h o s p i t a l i z e d many years ago , i n some c a s e s i h o ther par ts of Canada, and the i n f o r m a t i o n would probably not be r e l i a b l e . Hospitalization three years prior to, and subsequent to three- quarter way housing residence. What i s more r e l e v a n t to the study than the number o f past h o s p i t a l i z a t i o n s i s the number and d u r a t i o n of h o s p i t a l i z a t i o n s i n the three years before r e s i d e n c e and i n the span o f t ime s i n c e r e s i d e n c e . Three years was chosen as a c u t - o f f p o i n t s i n c e the m a j o r i t y of the r e s i d e n t sample had been tenants o f t h r e e - q u a r t e r way housing f o r two to four y e a r s . A lso examined i n t h i s t ime span was the number and d u r a t i o n o f h o s p i t a l day care admiss ions and the number and d u r a t i o n o f Venture ( c r i s i s h o s t e l ) a d m i s s i o n s . H o s p i t a l i z a t i o n s subsequent to res idency were v e r i f i a b l e from Coast Foundation r e c o r d s . Only those s e l f - r e p o r t e d h o s p i t a l i z a t i o n s i n the three years p r i o r to res idency were not v e r i f i e d . Conf i rmat ion o f t h i s i n f o r m a t i o n was not sought duetto the degree o f a n x i e t y provoked 62. when c l i e n t s were asked to s ign h o s p i t a l r e l e a s e o f data forms. H o s p i t a l i z a t i o n s are a very t raumat i c i n c i d e n t i n a person 's l i f e and w e l l remembered as to t ime and d u r a t i o n . The degree o f accuracy i n r e p o r t i n g of h o s p i t a l i z a t i o n data s i n c e r e s i d e n c y has borne t h i s o u t . F i f t y per cent o f the r e s i d e n t sample were h o s p i t a l i z e d as i n - p a t i e n t s i n the three years p r i o r to r e s i d e n c e . Only 12% have been h o s p i t a l i z e d s i n c e , which i s equal to the high r i s k f a c t o r o f 10 to 15% o f those screened i n t o the housing program. At each s c r e e n i n g i n t o the program of about 20 to 25 a p p l i c a n t s , two or th ree people are accepted who are a t high r i s k o f being re turned to boarding homes, h o s p i t a l s , or o ther dependent s e t t i n g s . They are c h a r a c t e r i z e d by more severe symptoms, l a c k o f p r o d u c t i v i t y , and more h o s p i t a l i z a t i o n s i n the p a s t . The r a t i o n a l e i s t h a t peer support and the example o f o thers w i l l help i n t e g r a t e the high r i s k people i n t o the program. Pressure has been exer ted on Coast Foundation by the M i n i s t r y o f Heal th to accept high r i s k c l i e n t s from the Fernwood community p r e p a r a t i o n program a t R iverv iew H o s p i t a l and t h i s has been done w i t h some s u c c e s s , w i th one Fernwood graduate coping w e l l i n one of the b locks f o r over three y e a r s . Admissions of the r e s i d e n t sample to Venture decreased s l i g h t l y : 20% were admit ted to Venture i n the three years p r i o r to r e s i d e n c y ; 16% were admit ted s i n c e r e s i d e n c y . Tables 3 and 4 show i n s t i t u t i o n a l i z a -t i o n o f r e s i d e n t s p r i o r to and s i n c e r e s i d e n c y . Average l e n g t h o f s tay i n p s y c h i a t r i c f a c i l i t i e s was 61 days d u r a t i o n p r i o r to r e s i d e n c y ; 21 days s i n c e r e s i d e n c e . H o s p i t a l day care s tays were shortened from 99 days to 44 days average s t a y . Venture s tays dropped from an average o f 9 days to 7 days . Table 3 No. of Admissions o f Res idents to I n s t i t u t i o n s i n the Three  Years P r i o r to and Subsequent to L i v i n g i n  Th ree -quar te r Way Housing Type Hospi t a l I n p a t i e n t H o s p i t a l Day Care Venture Total Pre Coast housing 47 11 17 75 Post Coast housing 8 3 13 24 Table 4 No. of I n s t i t u t i o n Days o f Res idents i n the Three Years P r i o r to and Subsequent to L i v i n g i n Th ree -quar te r Way Housing Type Hosp i ta l I n p a t i e n t Hosp i ta l Day Care Venture Total Pre Coast housing 2860 1088 149 4097 Post Coast housing 172 132 86 390 6 5 . I n s t i t u t i o n a l i z a t i o n of a p p l i c a n t s fo l l owed the p a t t e r n of the r e s i d e n t s , w i th s l i g h t l y more than h a l f o f the sample h o s p i t a l i z e d as i n p a t i e n t s i n the three years p r i o r to res idency and the number o f admiss ions n e a r l y e q u a l l i n g the sample s i z e . Table 5 shows the average admiss ions of p a t i e n t s per month. Average i n s t i t u t i o n a l i z a t i o n of a p p l i -cants per month pre and post r e s i d e n c y i s shown i n Table 6 . A one year per iod was used because most a p p l i c a n t s had been r e s i d e n t s f o r a f u l l year a t Time 2 t e s t i n g . Independence. When assessed w i th the Independence s c h e d u l e , r e s i d e n t s and a p p l i c a n t s were observed i n p r a c t i c a l l y a l l cases i n t h e i r homes so t h a t a l a c k o f personal hygiene or l a c k of a b i l i t y to perform housekeeping chores was obvious to the r e s e a r c h e r . In n e a r l y a l l cases l i v i n g e n v i r o n -ments a t t a i n e d a f a i r l y high standard of neatness and c l e a n l i n e s s . A l l 50 r e s i d e n t s were capable o f m a i n t a i n i n g t h e i r personal hygiene and grooming, were capable of s u p e r v i s i n g t h e i r own med ica t ion and looked a f t e r t h e i r own t r a n s p o r t a t i o n needs. A l l but one or two d i d t h e i r own shopp ing , looked a f t e r t h e i r p h y s i c a l h e a l t h needs, managed t h e i r own budget t ing and b a n k i n g , sought t h e i r own r e c r e a t i o n resources and had no problems d e a l i n g w i t h government and s o c i a l a g e n c i e s . Three people r e q u i r e d a s s i s t a n c e i n doing t h e i r own laundry and p repar ing m e a l s . S i x i n d i v i d u a l s repor ted .needing a s s i s t a n c e i n doing t h e i r own housekeeping c h o r e s . In a l l cases those r e q u i r i n g a s s i s t a n c e d i d so Table 5 Average No. of Admissions per P a t i e n t per Month of App l i cants , i n  the Three Years P r i o r to Th ree -quar te r Way Housing and i n  the One Year Per iod Subsequent to Housing Type Hosp i ta l I n p a t i e n t Hosp i ta l Day Care Venture Total Pre Coast Housing .03 ,01 .003 .043 Post Coast housing .01 0 . 0 .02 .03 N = 15 67. Table 6 Average No. of I n s t i t u t i o n Days per P a t i e n t per Month of A p p l i c a n t s i n  the Three Years P r i o r to T h r e e - q u a r t e r Way Housing and i n  the One Year Per iod Subsequent to Housing Type H o s p i t a l I n p a t i e n t H o s p i t a l Day Care Venture Total Pre Coast Housing 1 .2 .83 .02 2.05 Post Coast Housing . .06 0 .0 .05 .11 N = 15 68. because o f p h y s i c a l h e a l t h problems or problems of a g i n g . The a p p l i c a n t s a t Time 1 t e s t i n g were ab le to perform every i tem of the Independence schedule except f o r two i n d i v i d u a l s who r e q u i r e d a s s i s t a n c e i n p repar ing meals and one who needed help i n budget t ing and bank ing . Apart from these i s o l a t e d examples, r e s i d e n t s and a p p l i c a n t s managed very w e l l on t h e i r own d e s p i t e t h e i r sometimes lengthy s tays i n i n s t i t u t i o n s and p s y c h i a t r i c boarding homes where a l l b a s i c needs were met and med ica t ion s u p e r v i s e d . When the a p p l i c a n t s became r e s i d e n t s they were assessed aga in w i t h the same inst rument and were found to be independent i n every i tem of the measure. The high degree of independence o f the r e s i d e n t s , the a p p l i c a n t s a t Time 1 t e s t i n g , and Time 2 t e s t i n g when they had become r e s i d e n t s r e f l e c t s the t i g h t s c r e e n i n g procedure to enter t h r e e - q u a r t e r way hous ing . I f a p p l i c a n t s seem i n c a p a b l e o f performing b a s i c l i v i n g s k i l l s they are not accepted i n t o t h i s type o f hous ing . Those r e s i d e n t s who become p h y s i c a l l y d i s a b l e d through d i s e a s e or aging are prov ided w i t h homemakers through the M i n i s t r y o f Human Resources. Social network. Residents o f t h r e e - q u a r t e r way housing were found to have e s t a b l i s h e d a number o f i n t e r p e r s o n a l r e l a t i o n s h i p s i n the apartment b l o c k s , an average o f 7 a c q u a i n t a n c e s , SJj = 6 , and one c l o s e f r i e n d , SD = 1 . 2 . Casual acquaintances t o t a l l e d an average o f 1 8 , and t o t a l c l o s e r e l a t i o n s h i p s averaged 5 , f o r an o v e r a l l average t o t a l o f 2 3 . A p p l i c a n t s ' Time 1 t e s t i n g showed a t o t a l o f casual r e l a t i o n s h i p s o f an average of 1 0 , w i th a t o t a l average o f c l o s e r e l a t i o n s h i p s averag ing 4 69. f o r an o v e r a l l average t o t a l of 14 . A p p l i c a n t s ' Time 2 t e s t i n g , a f t e r they had become r e s i d e n t s , showed a mean t o t a l o f 20 a c q u a i n t a n c e s , a mean t o t a l o f 7 c l o s e r e l a t i o n s h i p s f o r an o v e r a l l mean t o t a l of 27 i n d i v i d u a l s i n t h e i r s o c i a l network. Table 7 shows a raw data comparison i n the mean number o f s o c i a l r e l a t i o n s h i p s by type between the sample o f r e s i d e n t s , the sample o f a p p l i c a n t s , and the l a t t e r when they had become r e s i d e n t s . When the data are c l u s t e r e d , i . e . when a l l casual r e l a t i o n s h i p s i n present hous ing , i n the community, and w i th r e l a t i v e s are cons idered t o g e t h e r , and when a l l c l o s e r e l a t i o n s h i p s are cons idered t o g e t h e r , the t o t a l d i f f e r e n c e between the r e s i d e n t s and the a p p l i c a n t s i n average casual r e l a t i o n s h i p s i s s t a t i s t i c a l l y s i g n i f i c a n t ( t = 4 . 1 2 , d f = 6 7 . 9 5 , £ < .01) and the d i f f e r e n c e i n t o t a l mean c l o s e r e l a t i o n s h i p s approaches s i g n i f i c a n c e (_t = 1 . 3 6 , df = 55..81 ,• £ = . 1 8 ) . A n a l y s i s o f the s o c i a l networks o f the 50 r e s i d e n t s , and 20 a p p l i c a n t s Time 1 , shows tha t the d i f f e r e n c e between acquaintances i n the r e s i d e n t s ' present housing and the a p p l i c a n t s ' present housing i s s t a t i s t i c a l l y s i g n i f i c a n t ( t = 4 . 9 7 , df = 67.47 , £ < . 0 1 ) . C lose r e l a t i o n s h i p s o f r e s i d e n t s i n t h e i r present housing compared to c l o s e r e l a t i o n s h i p s o f the a p p l i c a n t s i n t h e i r present housing approaches s i g n i f i c a n c e (t_ = 1 . 5 4 , df = 6 8 , £ = .10) as do d i f f e r e n c e s between the two groups regard ing t h e i r acquaintances i n the community (t^ = 1 . 3 5 , d_f = 6 1 . 8 3 , £ = . 1 8 ) . The comparison o f the s o c i a l network o f r e s i d e n t s w i t h a p p l i c a n t s a t Time 1 t e s t i n g i s shown i n Table 8 . 70. Table 7 Mean No. o f S o c i a l R e l a t i o n s h i p s by Type, o f R e s i d e n t s ,  A p p l i c a n t s Time 1 T e s t i n g , and A p p l i c a n t s Time 2  Tes t ing When they had Become Res idents Network V a r i a b l e s Residents A p p l i c a n t s A p p l i c a n t s Time 1 Time 2 Casual acquaintances i n housing Close f r i e n d s i n housing Close f r i e n d s i n community Casual r e l a t i o n s h i p s w i t h k in Close r e l a t i o n s h i p s w i t h k i n 7.04 1.90 6.80 .90 .45 1.00 Casual acquaintances y I n commum ty 2.28 2 .20 4 .33 3 .26 2.65 2.53 2.04 1.55 1.60 Mean t o t a l 23.12 14.45 27.26 N = 50 N = 20 N = 15 Table 8 Mean No. of S o c i a l R e l a t i o n s h i p s by Type, o f Res idents  Compared w i t h the Mean No. o f S o c i a l R e l a t i o n s h i p s  of A p p l i c a n t s Time 1 Tes t ing V a r i a b l e Mean SD DF t Value Acquaintances R 7.04 6.03 C 7 „ - , ! i n housing A 1.90 2.61 67.47 4 .97 ** Close f r i e n d s R .90 1.16 , R 2 , , - , i n housing A .45 .94 ^ Acquaintances R 7 .60 7.56 fil R . J -, ? l -i n community A 5 .70 4.07 ' 1 Close f r i e n d s R 2.28 2.42 fiR2 i n community A 2 .20 1.70 Casual r e l a t i o n s h i p s R 3 .26 4.14 f - Q l po w i t h k i n A 2 .65 1.98 b b ' b y Close r e l a t i o n s h i p s R 2.04 1.96 q . J 0 c w i t h k i n A 1 .55 1 .23 ' 1 ** £ < .01 ^separate v a r i a n c e es t imate u t i l i z e d 2 pooled v a r i a n c e es t imate u t i l i z e d R = r e s i d e n t s A = a p p l i c a n t s R „ = 5 0 A„ = 20 7 2 . A n a l y s i s o f the s o c i a l networks o f the a p p l i c a n t s at Time 1 and the a p p l i c a n t s when they had become r e s i d e n t s a t Time 2 por t rayed i n Table 9 shows tha t the d i f f e r e n c e between acquaintances i n present housing i s s t a t i s t i c a l l y s i g n i f i c a n t (t_ = - 2 . 7 6 , df = 1 4 , £ < . 0 5 ) . A comparison o f acquaintances i n the community a t Time 1 and Time 2 i s s t a t i s t i c a l l y s i g n i f i c a n t ( t = - 2 . 7 9 , d f = 1 4 , £ < . 0 5 ) . The d i f -ference between c l o s e f r i e n d s i n the community a t Time 1 ^ and Time 2 i s a l s o s t a t i s t i c a l l y s i g n i f i c a n t (t = - 3 . 1 9 , d_f - 1 4 , £ < . 0 1 ) . Symp tomato logy. The i n t e r v i e w i s p r i m a r i l y an i n d i r e c t means o f o b t a i n i n g i n f o r m a t i o n from the c l i e n t ; the d i r e c t means would be to observe h i s or her behaviour under n a t u r a l c o n d i t i o n s . S t r u c t u r e d i n t e r v i e w s wi th the r e s i d e n t s and a p p l i c a n t s to t h r e e - q u a r t e r way housing revea led the ex tent o f symptoms o f a n x i e t y , d e p r e s s i o n , s o c i a l withdrawal and the a b i l i t y to cope w i t h l i f e i n the community. Fee l ings o f s a d n e s s , s e l f - e s t e e m , making d e c i s i o n s , f e e l i n g s o f s e c u r i t y , and s o c i a l withdrawal d i f f e r e n t i a t e d the two groups a t a s t a t i s t i c a l l y s i g n i f i c a n t l e v e l as shown i n Table 1 0 . The f i f t y r e s i d e n t s scored a mean o f 3 . 6 6 , . S O = .8 out o f a p o s s i b l e score o f f i v e i n coping w i th f e e l i n g s o f sadness compared to the a p p l i -c a n t s ' 3 . 1 5 , S_D = . 8 . The r e s i d e n t s scored a mean o f 4 . 0 6 out of 5 , SD = . 7 i n e x p r e s s i n g t h e i r s e l f - e s t e e m whereas the a p p l i c a n t s scored 3 . 4 , SD = . 7 . In a s s e s s i n g t h e i r a b i l i t y to make d e c i s i o n s the r e s i d e n t s scored a h igh of 4 . 2 , SJ) = .8 compared to the a p p l i c a n t s 3 . 8 , S T J = . 6 . Fee l ings o f s e c u r i t y o f the r e s i d e n t s scored h ighes t Table 9 Mean No. o f S o c i a l R e l a t i o n s h i p s by Type of A p p l i c a n t s a t Time 1 Compared w i th A p p l i c a n t s When They Became Residents a t Time 2 V a r i a b l e Mean SD DF t Value Acquaintances Al 2. .13 2 .85 i n housing A2 6, .80 5. .26 Close f r i e n d s Al .46 .99 i n housing A2 1 .00 1 .41 Acquaintances Al 5, .60 3, .94 i n community A2 11 , .00 7, .61 Close f r i e n d s Al 2 .46 1 , .84 i n community A2 4 .33 2, .22 Casual r e l a t i o n s h i p s Al 2. .33 2, .02 w i th k i n A2 2, .53 1 , .64 C lose r e l a t i o n s h i p s Al 1 . .40 1 , .18 w i th k i n A2 1. .66 1 , .54 14 - 2 . 7 6 * 14 •1 .10 14 * 1 4 - 2 . 7 9 14 . ** - 3 . 1 9 14 - 0 . 2 8 14 - 1 . 0 0 £ <-.05 £ < .01 Al = a p p l i c a n t s Time 1 A2 = a p p l i c a n t s Time 2 N = 15 74. Table 10 Comparison o f the Symptomatology o f the Res idents With  A p p l i c a n t s Time 1 Tes t ing V a r i a b l e Mean SD DF t Value L o n e l i n e s s R A 3 .40 3 .00 .93 .86 68 1 1.67 Sadness R A 3.66 3 .15 .85 .81 68 1 * 2.30 Optimism R A 3.72 3 .55 .93 .76 68 1 .73 Esteem R A-4 .06 3 .40 .71 .68 68 1 ** 3.55 A n x i e t y R A 3 .78 3.40 1 .03 .94 68 1 1 .42 So lve problems R A 3.96 3 .75 , 7 5 .64 68 1 1 .10 Make d e c i s i o n s R A 4 .22 3.75 .76 .55 68 1 2.50 Fears R A 3 .78 3 .60 1 .03 .88 68 1 .68 Secur i ty R A 4 .50 3 .30 .61 1.12 2 3 . 6 4 2 ** 4.50 SI eep R A 3.88 3 .80 .94 .69 68 1 .34 S e l f conf idence R A 3 .80 3 .45 .83 .82 68 1 1 .59 Wi thdrawal R A 3.84 3 .20 1 .02 .95 68 1 * 2.42 ic ic-k £ < .05 p < .01 1 2 pooled v a r i a n c e es t imate u t i l i z e d . separate v a r i a n c e es t imate u t i l i z e d . R = Res idents A = a p p l i c a n t s R = 50 A = 20 K r n n 7 5 . w i t h a t o t a l o f 4 . 5 out o f 5 , SD = . 6 , whereas the a p p l i c a n t s scored o n l y 3 . 3 , SD = 1 . 1 , and an es t imate o f the r e s i d e n t s ' a b i l i t y to a v o i d s o c i a l withdrawal was 3 . 8 , S_D = 1 .0 compared to the a p p l i a n t s ' 3 . 2 , SD = 1 . 0 . Fee l ings o f l o n e l i n e s s , a n x i e t y , and s e l f - c o n f i d e n c e approached s i g n i f i c a n c e i n d i f f e r e n t i a t i n g the two groups. In a l l i t e m s , the r e s i d e n t s scored h igher than the a p p l i c a n t s . When the a p p l i c a n t s became r e s i d e n t s they were t e s t e d a g a i n . In comparing these r e s i d e n t s a t Time 1 and Time 2 , o p t i m i s m , s e l f - e s t e e m , the a b i l i t y to s o l v e problems, the a b i l i t y to make d e c i s i o n s , f e e l i n g s o f s e c u r i t y , s e l f - c o n f i d e n c e and s o c i a l withdrawal d i f f e r e n t i a t e d the Time 1 and Time 2 measures a t a s t a t i s t i c a l l y s i g n i f i c a n t l e v e l as por -t rayed i n Table 1 1 , and the d i f f e r e n c e i n f e e l i n g s o f l o n e l i n e s s and sadness approached s i g n i f i c a n c e . Fee l ings o f f e a r , f e e l i n g s o f a n x i e t y and s l e e p pat te rn d i d not show a s i g n i f i c a n t change. A l l mean scores were c o n s i s t e n t l y h igher i n the second t e s t i n g o f the a p p l i c a n t s when they had become r e s i d e n t s . Optimism was s c a l e d a t 3 .9 out o f 5 , SD = . 7 ; s e l f - e s t e e m a t 3 . 9 , SD_ = . 5 ; s o l v i n g problems scored 4 . 1 , SD = . 3 ; making d e c i s i o n s 4 . 3 , SJJ = . 6 ; s e c u r i t y reached a h igher l e v e l than a l l prev ious scores a t 4 . 5 out o f a p o s s i b l e 5 p o i n t s ; SD = . 6 ; s e l f - c o n f i d e n c e was ra ted a t 4 . 0 , SD = . 4 ; and a b i l i t y to avo id s o c i a l withdrawal was ra ted 4 . 1 , SJJ = . 9 . Meaningful activity. No a p p r e c i a b l e change was noted i n the s t r u c t u r i n g o f f r e e t ime between the r e s i d e n t s , the a p p l i c a n t s Time 1 and the a p p l i c a n t s Table 11 Comparison o f the Symptomatology o f A p p l i c a n t s Time 1 and  the A p p l i c a n t s When They Became Res idents Time 2 V a r i a b l e Mean SD • DF t Value L o n e l i n e s s Al A2 3 .00 3 .40 .93 .63 14 - 1 . 7 0 Sadness Al A2 3.07 3.47 .80 .64 14 - 2 . 1 0 Optimism Al A2 3.47 3 .93 .74 .70 14 * - 2 . 1 7 Esteem Al A2 3 .33 3.87 .72 .52 14 * - 2 . 2 6 A n x i e t y Al A2 3 .33 3 .60 1.05 .74 - 14 - 1 .07 Solve problems Al A2 3 .66 4 .06 .62 .26 14 * - 2 . 4 5 Make d e c i s i o n s Al A2 3 .73 4.27 .59 .59 14 * - 2 . 4 8 Fears Al A2 3.67 3 .93 .97 .88 .14 - 1 .07 Secur i ty Al A2 3 .20 4 .53 1 .15 .64 14 ** - 3 . 7 0 S leep Al A2 3 .93 3 .93 .59 .70 14 0 .0 S e l f c o n f . Al A2 3.53 4 .00 .74 .38 14 * - 2 . 4 3 Wi thdrawal Al A2 3 .20 4 .06 1 .01 .88 14 ** - 3 . 6 7 •k - k i t £ < .05 £ < .01 Al = a p p l i c a n t s Time 1 ; A2 = appl i c a n t s Time 2 when they hac 1 become r e s i d e n t s . N = 15 77. when they had become r e s i d e n t s a t Time 2 , which i s por t rayed i n Table 1 2 . Time 2 measurements were accompanied by a s a t i s f a c t i o n s c a l e which showed t h a t t h i r t e e n per cent o f the r e s i d e n t s of the Time 2 measurement were "very s a t i s f i e d " w i t h t h e i r a c t i v i t i e s , . 80% were " s a t i s f i e d " and o n l y one, 7%, was " d i s s a t i s f i e d " . Validation of measures by Progress Evaluation Scales. A f t e r the a p p l i c a n t s to t h r e e - q u a r t e r way housing became r e s i d e n t s t h e i r present s t a t u s was assessed by Coast Foundation super -v i s o r y s t a f f w i t h the P . E . S . Sca les which examined Independence, Occupat ion , G e t t i n g a long wi th o t h e r s , Fee l ings and mood, Use o f f r e e t i m e , Prob lems, and A t t i t u d e toward s e l f . Th is assessment served as v a l i d a t i o n o f the s e l f - r e p o r t measures used i n the r e s t o f the s t u d y . The s u p e r v i s o r y s t a f f viewed over 80% of these r e s i d e n t s as main ly independent i n every way or on ly o c c a s i o n a l l y r e q u i r i n g d i r e c t i o n from s t a f f . Less than 20% were seen to be l a c k i n g independence e i t h e r -• i n severa l areas o r a number o f important a r e a s . Almost t w o - t h i r d s o f the r e s i d e n t s were seen to be l a c k i n g i n o c c u p a t i o n a l s k i l l s , seldom or never h o l d i n g a j o b , a t t e n d i n g c l a s s e s o r c a r i n g f o r a home. One quar te r of the sample were seen sometimes to hold a job or take c l a s s e s or r e g u l a r l y work and pursue upgrad ing . Most o f the r e s i d e n t s were judged to be a b l e to get a long w i t h o thers w e l l , w i t h n e a r l y 60% viewed as having r e g u l a r c l o s e f r i e n d s and the remainder having o c c a s i o n a l f r i e n d s . Near ly 30% of the sample was seen to be u s u a l l y i n a good mood and to be as happy, s a d , or angry as the s i t u a t i o n c a l l e d f o r , 78. Table 12 Three A c t i v i t i e s Rated Most Meaningful by the P a t i e n t s i n the  S t r u c t u r i n g o f Thei r Time Residents A p p l i c a n t s Time 1 A p p l i c a n t s when they had become r e s i d e n t s Time 2 Product i ve A c t i v i t i e s Compet i t i ve work, f u l l t ime 1 Compet i t i ve work, pa r t t ime 1 4 2 S h e l t e r e d work, p a r t time 1 3 1 Community work (CIP) 13 2 Vo lunteer work 6 4 3 J o b - s e a r c h i n g 1 B a b y s i t t i n g 1 S o c i a l A c t i v i t i e s V i s i t i n g f r i e n d s / k i n 26 15 11 c . c . team programs 2 1 c o f f e e shop v i s i t s 11 5 3 a p t . lounge v i s i t s 10 1 r e g u l a r s p o r t s 7 1 2 d r o p - i n cent res 8 1 1 w a l k i n g 8 shopping/window 6 2 2 church a c t i v i t i e s 2 4 2 p l a y i n g b r idge 2 CONTINUED 79. Table 12 cont inued Res idents A p p l i c a n t s Time 1 A p p l i c a n t s when they had become r e s i d e n t s Time 2 bus r i d e s 1 pub v i s i t s 1 race t r a c k 1 • S o l i t a r y A c t i v i t i e s h a n d i c r a f t s / h o b b i e s 16 4 4 read ing/s tudy ing 12 4 5 watching t . v . 8 6 7 r a d i o l i s t e n i n g 3 cooking/baking 1 3 home, a lone 1 1 c r e a t i v e w r i t i n g 1 TOTAL 150 3 x 50) 60 (3 x 20) 45 (3 x 15) N = 50 N = 20 N = 1 5 8 0 . w i th an a d d i t i o n a l 50% o c c a s i o n a l l y f e e l i n g nervous or unhappy or angry a l l day. The remainder were viewed as f r e q u e n t l y i n a good mood but o c c a s i o n a l l y nervous , or depressed o r angry f o r days a t a. t i m e . Over h a l f o f the sample was seen to be p a r t i c i p a t i n g i n , as w e l l as c r e a t i n g a v a r i e t y o f r e c r e a t i o n a l a c t i v i t i e s and'hobbies f o r themselves and o t h e r s , whereas severa l people were judged to take par t i n on ly o c c a s i o n a l r e c r e a t i o n a l a c t i v i t y . Near ly t h r e e - q u a r t e r s o f the r e s i d e n t s appeared to s t a f f to have o n l y o c c a s i o n a l m i l d problems or moderate problems. One quar te r were d e s c r i b e d as having m i l d to severe problems o n a more r e g u l a r b a s i s . Coast s t a f f cons idered t h a t t w o - t h i r d s o f the r e s i d e n t s had a p o s i t i v e a t t i t u d e toward themselves much or most o f the t i m e . One quar te r were seen to be e q u a l l y p o s i t i v e or negat ive and the smal l remainder were judged to have a n e g a t i v e ; : a t t i t u d e much of the t i m e . Validation of residents' self-report with the P.E.S.' Scales.  Independence Accord ing to the s e l f - r e p o r t s c a l e s the a p p l i c a n t s who had become r e s i d e n t s scored as independent i n every i tem of the measure o f Independence. The r e s u l t s o f the measurement o f the Independence v a r i a b l e i n the P . E . S . Sca les were not so favourab le w i th l e s s than h a l f the r e s i d e n t s viewed as not r e q u i r i n g d i r e c t i o n from s t a f f . 8 1 . Attitude toward self-sub-scale. F a i r l y c l o s e agreement was shown between S e l f Esteem i n the s e l f - r e p o r t s c a l e and A t t i t u d e toward s e l f i n the P . E . S . Sca les as i n d i c a t e d i n Table 1 3 . E ighty per cent of r e s i d e n t s saw themselves w i t h p o s i t i v e s e l f - e s t e e m always or most o f the t i m e ; s t a f f recogn i zed t w o - t h i r d s o f the r e s i d e n t s i n these c a t e g o r i e s and the remaining t h i r d more negat ive about themselves . Th is was the on ly case i n which r e s i -dents r a t e d themselves more p o s i t i v e l y than the r a t i n g o f s u p e r v i s o r s . Feelings and mood sub-scale. The F e e l i n g s and mood s u b - s c a l e o f the P . E . S . Sca les was . c r o s s - t a b u l a t e d w i t h a l l o f those s e l f - r e p o r t v a r i a b l e s which seemed to f a l l i n t o the same s u b j e c t a r e a : f e e l i n g s o f L o n e l i n e s s , Sadness, A n x i e t y , and Opt imism. In r a t i n g F e e l i n g s and mood, s u p e r v i s o r y s t a f f viewed 80% o f the r e s i d e n t s as u s u a l l y i n a good mood, o c c a s i o n a l l y f e e l i n g nervous , depressed or angry a l l day , but u s u a l l y a b l e to be a p p r o p r i a t e l y happy, sad or angry as the s i t u a t i o n war ranted . However the r e s i d e n t s d i d not view t h e i r f e e l i n g s i n such a favourab le l i g h t . Two - th i rds f e l t sometimes l o n e l y ; n e a r l y t w o - t h i r d s f e l t sad sometimes; i n excess o f o n e - h a l f f e l t anxious more than o c c a s i o n a l l y . Rat ing o f a n x i e t y showed the Teast agreement w i t h Fee l ings and mood. B e s t agreement was shown between Fee l ings and mood and Opt imism, w i th over 70% o f r e s i d e n t s e x p r e s s i n g an o p t i m i s t i c ou t look a l l or most o f the t i m e . This comparison i s shown i n Table 14. 8 2 . Table 13 A s s o c i a t i o n Between R e s i d e n t s ' S e l f - r e p o r t o f S e l f Esteem and  S t a f f Rat ing o f S e l f Esteem S e l f Esteem S t a f f Rat ing S e l f Esteem Negative Pos ./Neg. Posi t i ve Posi t i ve S e l f Rat ing Often Equal Much Time Most Time P o s i t i v e sometimes 0 0 2 1 P o s i t i v e most t imes 1 4 3 3 P o s i t i v e always 0 0 0 1 N = 15 Table 14 A s s o c i a t i o n Between R e s i d e n t s ' S e l f - r e p o r t o f Optimism and S t a f f Rat ing o f Fee l ings and Mood Optimism s e l f - r a t i n g Fee l ings and Mood S t a f f Rat ing O p t i m i s t i c Sometimes O p t i m i s t i c Most Times O p t i m i s t i c Always Good mood sometimes 2 1 0 Good mood u s u a l l y 1 4 2 Appropr ia te good mood 1 3 1 N = 1 5 84. Problems sub-scale. The Problems s u b - s c a l e was a l s o c r o s s - t a b u l a t e d w i t h L o n e l i n e s s , Sadness , A n x i e t y and Optimism o f the s e l f - r e p o r t s c a l e s to i d e n t i f y any a s s o c i a t i o n . Again l i t t l e agreement was n o t e d , w i t h 80% of r e s i d e n t s judged by s t a f f to have on ly o c c a s i o n a l moderate or m i l d problems, whereas s e l f - r e p o r t s i n d i c a t e d a g r e a t e r degree o f d i s t r e s s i n g f e e l i n g s . Best agreement was shown w i t h the Optimism i t e m . Cross t a b u l a t i o n o f both Fee l ings and Mood, and Prob lems, of the P . E . S . Sca les w i t h Optimism i n the s e l f - r e p o r t s c a l e s show a degree o f a s s o c i a t i o n w i th a 47% agree -ment i n both c a s e s . 8 5 . D I S C U S S I O N F ind ings from the demographic data show that the r e s i d e n t s and the a p p l i c a n t s are a homogeneous p o p u l a t i o n w i t h comparable back-grounds i n e d u c a t i o n , former hous ing , d i a g n o s i s , soc io -economic s t a t u s , and type and frequency o f f o l l o w - u p c a r e . Length o f p s y c h i a t r i c s e r v i c e was l e s s f o r the a p p l i c a n t s which was expected because of t h e i r younger average age , 36 compared to 44 f o r the r e s i d e n t group. The d i f f e r e n c e i n age can be exp la ined by the course o f d e i n s t i t u t i o n a l i z a t i o n i n t h i s country which saw the midd le -aged and e l d e r l y r e l e a s e d f i r s t from h o s p i t a l i n s i g n i f i c a n t numbers i n the s i x t i e s and s e v e n t i e s . Hospitalization. I t was hypothesized t h a t the i n c i d e n c e of h o s p i t a l i z a t i o n would change i n terms o f the number o f days o f i n s t i t u t i o n a l i z a t i o n f o r the r e s i d e n t s o f t h r e e - q u a r t e r way hous ing . The r e s u l t s bear out t h i s e x p e c t a t i o n and the n u l l hypothes is t h a t there would be no change i n h o s p i t a l i z a t i o n i s r e j e c t e d . A decreased need f o r r e h o s p i t a l i z a t i o n i s a good measure o f mental h e a l t h . H o s p i t a l i z a t i o n i n terms o f the number of i n d i v i d u a l s h o s p i t a l i z e d and t o t a l p a t i e n t days showed a marked decrease i n both i n p a t i e n t s tays and h o s p i t a l day care s tays s i n c e r e s i d e n t s have been l i v i n g i n t h r e e - q u a r t e r way hous ing . F i f t y per cent o f the r e s i d e n t sample had been h o s p i t a l i z e d as i n p a t i e n t s i n the th ree years p r i o r to r e s i d e n c e i n Coast Foundation hous ing . Only 12% have been 86. h o s p i t a l i z e d s i n c e , over a s i m i l a r per iod o f t i m e . Admissions to Venture have decreased s l i g h t l y , 20% were admitted to Venture i n the th ree years p r i o r to r e s i d e n c e ; 16% have been admitted to Venture s i n c e r e s i d e n c e . Venture placements cannot be expected to change s i g n i f i c a n t l y f o r t h i s p o p u l a t i o n as moderately to s e v e r e l y i l l i n d i v i d u a l s w i l l cont inue to s u f f e r emotional setbacks and s h o r t per iods of emotional c r i s i s due to r e c u r r i n g symptoms. Average l e n g t h o f s t a y i n p s y c h i a t r i c f a c i l i t i e s has s h o r t e n e d . Average i n p a t i e n t h o s p i t a l i z a t i o n was 61 days p r i o r to r e s i d e n c e , average s tay was 21 days s i n c e r e s i d e n c e . H o s p i t a l day care s tays were shortened by more than h a l f : 99 days to 44 days average s t a y . . Venture s tays dropped from an average o f 9 days to 7 days . Not shown by a n a l y s i s of the r e h o s p i t a l i z a t i o n data was any r e l a t i o n s h i p between the leng th of r e s i d e n c e i n t h r e e - q u a r t e r way housing and the s i z e of the s o c i a l .network o f the 6 i n d i v i d u a l s r e h o s p i t a ! i z e d . A l l o f those r e h o s p i t a l i z e d were l o n g - t e r m r e s i d e n t s w i t h a s o c i a l network e q u a l l i n g the average o f the sample. However the 11 i n d i v i d u a l s i n v o l v e d i n both r e t u r n to h o s p i t a l and placement i n Venture have been mainta ined" i n the housing program and have not had to r e t u r n to a more superv i sed s e t t i n g where 7 o f them, 63%, had r e s i d e d p r i o r to moving i n t o t h r e e -quar te r way hous ing . Because no r e l a t i o n s h i p was d iscovered between h o s p i t a l i z a t i o n and s o c i a l network, the p o s s i b i l i t y was exp lored t h a t the i n d i v i d u a l s •-* h o s p i t a l i z e d f e l l i n t o the h i g h - r i s k percentage screened and accepted i n t o Coast Foundat ion . The p r o f i l e s o f the s i x h o s p i t a l i z e d i n d i v i d u a l s showed t h a t two o f the s i x f i t t e d t h i s d e s c r i p t i o n w e l l , and have had a 87. number o f decompensations d u r i n g res idency besides placements i n Venture . The other four r e s i d e n t s , a l l o r i g i n a l l y from boarding homes, have been r e l a t i v e l y s t a b l e over a long per iod o f t i m e , but i n each case had d i s c o n t i n u e d med ica t ion once, and had decompensated s e v e r e l y , r e q u i r i n g r e h o s p i t a l i z a t i o n . Even s o , t h e i r combined h o s p i t a l i z a t i o n was on ly 78 days over a per iod o f Coast Foundation res idency t o t a l l i n g 27 y e a r s . I n s t i t u t i o n a l i z a t i o n of a p p l i c a n t s a t Time 1 t e s t i n g shown i n Table 3 was comparable to r e s i d e n t s i n the three years p r i o r to r e s i d e n c y w i t h the number o f admiss ions t o t a l l i n g 18 per 20 a p p l i c a n t s compared w i t h 47 admiss ions per 50 r e s i d e n t s . S ince res idency o f the a p p l i c a n t s a t Time 2 t e s t i n g , the i n s t i t u t i o n a l i z a t i o n f i g u r e s i n Table 4 seem to have decreased d r a m a t i c a l l y , but t h i s may p a r t i a l l y r e f l e c t the f a c t t h a t the time per iods invo l ved are not the same: three years as opposed to up to one year o f comparison i n the l a t t e r measurement. In view o f the exper ience of the r e s i d e n t s , one would f e e l s a f e i n p r e d i c t i n g t h a t i n s t i t u t i o n a l i z a t i o n s w i l l indeed d i m i n i s h dur ing res idency o f the a p p l i c a n t group, except f o r b r i e f s tays i n the c r i s i s h o s t e l , Venture , of a day or two d u r a t i o n . Independence. " " • In the e a r l y years o f the apartment p r o j e c t i t was thought t h a t former boarding home r e s i d e n t s and recent d ischargees from h o s p i t a l would face a very d i f f i c u l t per iod o f adjustment to independent l i v i n g , having l a r g e l y to fend f o r themselves a f t e r being cared f o r . Some o l d e r , l o n g - t i m e h o s p i t a l p a t i e n t s were a t f i r s t accompanied when s h o p p i n g , , a s s i s t e d i n p lann ing meals and c l o s e l y a s s i s t e d i n b u d g e t t i n g . However 8 8 . i t was d iscovered t h a t t h i s p o p u l a t i o n , d e s p i t e a lengthy background o f dependence i n i n s t i t u t i o n a l i z e d l i v i n g , managed s u r p r i s i n g l y w e l l • on t h e i r own (Toml inson, Gumming, 1976: 2 7 ) . A c t i n g on t h i s i n f o r m a t i o n and e m p i r i c a l f i n d i n g s , Coast Foundation s t a f f now operate on a "deep end" s t r a t e g y : throw them i n t o the deep end o f the pool and hope they can swim. I f i n d i v i d u a l s come forward w i t h problems i n b a s i c s u r v i v a l or e x h i b i t d i f f i c u l t y i n managing money such as borrowing from f e l l o w r e s i d e n t s or being tardy i n paying rent , , s t a f f w i l l s tep i n and help the i n d i v i d u a l to budget through a f i n a n c i a l c r i s i s , make s p e c i a l a r r a n g e -ments to recover overdue r e n t w i thout inconven ienc ing the tenant or as a l a s t r e s o r t arrange w i t h the M i n i s t r y o f Human Resources to a d m i n i s t e r income. R e s i d e n t s , p a r t i c u l a r l y young men who have few .cooking s k i l l s , a re encouraged to o b t a i n l o w - c o s t meals a t the Coast Foundation a c t i v i t y cen t re and to a t tend the weekly cooking c l a s s and communal d inner i n t h e i r apartment b l o c k s . Two a p p l i c a n t s a t Time 1 t e s t i n g who repor ted needing a s s i s t a n c e i n cooking n u t r i t i o u s meals had so lved t h i s problem by the Time 2 t e s t i n g . One had acqu i red a g i r l f r i e n d who prepared meals f o r h im, and the other had made an arrangement w i t h a buddy to share the-r e s p o n s i b i l i t y o f meal p r e p a r a t i o n most n igh ts o f the week. Both a r r a n g e -ments are working w e l l . The o n l y o ther item i n which one a p p l i c a n t i n the Time 1 t e s t i n g repor ted needing a s s i s t a n c e .was i n budget t ing and bank ing . By the Time 2 t e s t i n g she had mastered t h i s s k i l l . A sample o f comments by the r e s i d e n t s i n d i c a t e s t h e i r approval o f the o p p o r t u n i t y to enjoy independence. "I can go to bed and get up when I want; I have a l o t more freedom than I had i n the boarding home." 8 9 . "I l i v e d w i t h my parents u n t i l about th ree years ago but s i n c e then I ' ve been l i v i n g on my own and managing w e l l except when under s t r e s s ; I haven ' t had any s t r e s s s i n c e l i v i n g a t C o a s t . " "Coast has helped me a l o t i n f e e l i n g independent w i t h no p ressureonme a t a l l . I c o u l d n ' t get a long i n boarding homes. I spent e i g h t years i n h o s p i t a l so i t ' s been a g reat change f o r the b e t t e r to l i v e i n d e p e n d e n t l y . " "I eat out a l o t but can cook f o r m y s e l f . " "I took a course i n cooking a t the West Side Team." "I cook r e a l l y s imple m e a l s . " "My p h y s i c a l h e a l t h r e q u i r e s tha t I have a homemaker and M e a l s - o n - W h e e l s . " "I do a l i t t l e house-keeping every d a y . " "At the beginning i t was hard o r g a n i z i n g my day but I have now become more m e t h o d i c a l . " These comments c o n t r a s t to those o f the a p p l i c a n t s a t Time 1 t e s t i n g who n o t e d : " I ' ve been l i v i n g independent ly o f f and on but d o n ' t know much about c o o k i n g . " "I cou ld use a l i t t l e a s s i s t a n c e i n p lann ing and prepar ing m e a l s . " "I may need a l i t t l e help w i t h managing money because I haven ' t been on my own up to now." However o ther a p p l i c a n t s looked forward to managing independent ly i n t h r e e - q u a r t e r way hous ing . " I ' v e been l i v i n g independent ly i n t h r e e - q u a r t e r way hous ing . " I ' v e been l i v i n g independent ly f o r three y e a r s , most ly h o t - p l a t e cooking i n a housekeeping room w i t h p l a s t e r f a l l i n g o f f t h e c e i l i n g " " I ' v e been l i v i n g next door to my mother; I guess I tended to' l e a n on h e r . " "I d o n ' t l i k e boarding homes because I l i k e to be independent . " "I l i v e d on my own before I was i n h o s p i t a l and look forward to doing so a g a i n . " I t was hypothesized t h a t independence i n t h r e e - q u a r t e r way housing would change as measured by s k i l l s i n d a i l y l i v i n g . Because o f the s t i f f s c r e e n i n g procedure those who cannot perform a t a l e v e l 90. adequate f o r independent l i v i n g are not accepted i n t o the program. Apart from the r e s i d e n t s whose p h y s i c a l d i s a b i l i t i e s hamper t h e i r i n d e -pendence, a l l those tes ted a t Time 2 were capable o f performing b a s i c l i v i n g s k i l l s as o u t l i n e d i n the Independence s c h e d u l e . The hypothes is i s t h e r e f o r e l a r g e l y i r r e l e v a n t i n c o n s i d e r i n g , t h i s p o p u l a t i o n . Social network. Because o f the w i d e l y repor ted l i n k between r e h o s p i t a l i z a t i o n and an inadequate s o c i a l network o f c h r o n i c mental p a t i e n t s , the s o c i a l network category was cons idered a major component of the s tudy . I t was hypothesized t h a t the t o t a l numbers of casual acquaintances and i n t i m a t e r e l a t i o n s h i p s would change i n t h r e e - q u a r t e r way hous ing . The hypothes is was supported by the f i n d i n g s ; the change showed an i n c r e a s e i n both casual and i n t i m a t e r e l a t i o n s h i p s . The t o t a l s o c i a l network of the r e s i d e n t s averaged 23 persons , w i t h 18 casua l r e l a t i o n s h i p s arid 5 " c l o s e r e l a t i o n s h i p s , l e s s than Hammer's es t imate o f the norm which she repor ted to be 40 persons , w i t h a range o f 25 to 5 0 , and 6 to 10 i n t i m a t e l y known i n d i v i d u a l s . On the average , however, Coast Foundation r e s i d e n t s ' networks are very c l o s e to the low end o f the normal range o f s o c i a l network, and c l o s e r e l a t i o n s h i p s miss normalcy by on ly one i n d i v i d u a l . On the other hand, the Coast a p p l i c a n t group a t Time 1 t e s t i n g showed an average s o c i a l network, o f 14 i n d i v i d u a l s , s i g n i f i c a n t l y lower than the r e s i d e n t sample , and f a r below the norm mean o f 40 and normal range of 25 to 50 . Casual r e l a t i o n s h p s o f the a p p l i c a n t s numbered an average o f o n l y 10 i n d i v i d u a l s " ; " i n t i m a t e s numbered 4 i n d i v i d u a l s . A f t e r 91. the a p p l i c a n t s moved i n t o t h r e e - q u a r t e r way housing and were r e - t e s t e d a t Time 2 , r e s u l t s showed an average s o c i a l network o f a lmost double t h e i r former number, a t 27 i n d i v i d u a l s , w i t h i n the normal range . Twenty o f these were casual r e l a t i o n s h i p s , 7 were i n t i m a t e s , aga in w i t h i n the normal range o f 6 to TO i n t i m a t e l y known i n d i v i d u a l s a c c o r d i n g to Hammer and o t h e r s . I t might be argued t h a t the a v a i l a b i l i t y o f s o c i a l i z a t i o n a c t i v i t i e s and the communal lounges i n the Coast Foundation apartment b locks ensure tha t s o c i a l networks o f i n d i v i d u a l s i.n t h i s housing w i l l " expand as a r e s u l t o f the programming, however, no one i s coerced i n t o j o i n i n g . a group or v i s i t i n g the lounge . Those who va lue p r i v a c y can s u c c e s s f u l l y keep to themselves throughout t h e i r res idency i f they so w i s h . That they do n o t , but choose to expand t h e i r acquaintances and enter in to f r i e n d s h i p s i s a personal i n i t i a t i v e and one tha t i s undoubtedly r e f l e c t e d i n d imin i shed i n s t i t u t i o n a l i z a t i o n s . That the change i n the number o f casual r e l a t i o n s h i p s a f t e r c h r o n i c mental p a t i e n t s have entered t h r e e - q u a r t e r way housing i s s t a t i s t i c a l l y s i g n i f i c a n t .both i n the case of the r e s i d e n t s a t Time 1 t e s t i n g and the a p p l i c a n t s when they had become r e s i d e n t s a t Time 2 t e s t i n g shows the impact o f t h r e e -quar te r way housing on t h i s p o p u l a t i o n . A p p l i c a n t s a t Time 2 showed a change i n casual r e l a t i o n s h i p s i n present hous ing , a change i n casual r e l a t i o n s h i p s i n the community, and a change i n c l o s e f r i e n d s i n the community, a l l o f which were s t a t i s t i c a l l y s i g n i f i c a n t , showing t h a t t h r e e - q u a r t e r way housing inc reased t h e i r a b i l i t y to make s o c i a l connec-t i o n s not on ly i n Coast Foundation housing but o u t s i d e as w e l l . 92. With a broadened s o c i a l support system p a t i e n t s are a t l e s s r i s k of s e r i o u s emotional c r i s e s (G reenb la t t e t a l . , 1982: 980; Henderson e t a l . , 1978: 8 5 ; M i t c h e l l , T r i c k e t t , 1980: 36 ; Sokolovsky e t a l . , 1978: 1 4 ) . That a change i n f a m i l y r e l a t i o n s h i p s between the r e s i d e n t s and a p p l i c a n t s was not s t a t i s t i c a l l y s i g n i f i c a n t i s not s u r p r i s i n g s i n c e r e l a t i o n s h i p s w i th f a m i l y members cont inue over t ime and can be expected to remain r e l a t i v e l y unchanged. Gomments of. the r e s i d e n t s showed the s a t i s f a c t i o n engendered by the o p p o r t u n i t y fo r expanded s o c i a l i z a t i o n . "I 'm s a t i s f i e d . I d o n ' t have anybody o u t s i d e much but I have f r i e n d s i n C o a s t . " 'c"I'm always meeting new p e o p l e . " " I ' v e got more f r i e n d s s i n c e I moved i n t o Coast . I have a r e a l l y f u l l s o c i a l l i f e ; sometimes I d o n ' t have enough time to be on my own." "I have f r i e n d s i n my church and I 've made f r i e n d s here i n the b l o c k . " "I make f r i e n d s e a s i l y . I haven ' t been c l o s e to my f a m i l y because they d r i f t e d away when I was f i r s t i l l , but I a p p r e c i a t e my f r i e n d s . " "I haven ' t found too many people-who share my i n t e r e s t s but I have kept f r i e n d s from t h e . b o a r d i n g home who are a t Coast now." "In the boarding home you are fo rced to a s s o c i a t e w i t h people whether you l i k e them or n o t , but i n Coast you can choose your f r i e n d s and you d o n ' t have to l i v e w i t h them." "I have more f r i e n d s i n Coast than anywhere." "Because I have an apartment o f my own I can ask people o v e r . " "Somebody t o l d me t h a t I w o u l d n ' t get to know people i n the b lock but t h a t i s n ' t t r u e ; I ' ve made f r i e n d s h e r e . " The a p p l i c a n t s a t Time 1 t e s t i n g presented a d i f f e r e n t p i c t u r e . "I cou ld use more f r i e n d s . I hope to meet more people i n Coast when I move i n . " "I l o s t my o l d f r i e n d s when I was i n h o s p i t a l . I'm s o r t o f 93. i n between o l d f r i e n d s and new f r i e n d s . " "I v i s i t people I know a t the Coast b l o c k . " "I would l i k e to know a d i f f e r e n t group o f people - people I have more i n common w i t h . " " I ' d l i k e a f u l l e r s o c i a l l i f e because I 've got l o t s o f t ime on my hands and l i f e i s p r e t t y l o n e l y . " " I ' d l i k e more f r i e n d s . " "I need s o c i a b i l i t y . " These same people a year l a t e r when they were r e s i d e n t s were s a y i n g : "I have a couple o f r e a l l y c l o s e f r i e n d s and have b e n e f i t t e d from t h i s . " "I 'm s a t i s f i e d w i t h the number o f acquaintances I have . " " I 'm s a t i s f i e d w i t h my s o c i a l l i f e . " "I would l i k e to have a g i r l f r i e n d . " "My s o c i a l l i f e i s g r e a t . I have enough f r i e n d s . " "I get around more s i n c e I l e f t the boarding home." "A b i g problem i s not having enough money to do t h i n g s . " " I ' v e been j o i n i n g new groups l i k e the B r i t a n n i a C e n t r e . " " I 'm s a t i s f i e d . " Having a c h o i c e o f whether or n o t . t o a c t on o p p o r t u n i t i e s to expand t h e i r c i r c l e o f acquaintances and f r i e n d s , r e s i d e n t s tend to choose to do so and d e r i v e a high l e v e l o f personal s a t i s f a c t i o n from t h e i r expanded s o c i a l network. A s o c i a l system w i t h i n or approaching normalcy i s o f major importance i n reduc ing the r i s k o f emotional c r i s i s , g i v i n g meaning to the s t r u c t u r i n g o f t i m e , and reduc ing s e r i o u s symptomatology. Symp tomato logy. I t was hypothes ized t h a t the s e v e r i t y o f symptomatology would be a l t e r e d i n t h r e e - q u a r t e r way hous ing . This was e m p h a t i c a l l y shown by 94. the scores o f r e s i d e n t s , and the a p p l i c a n t s when they became r e s i d e n t s , compared to the scores o f a p p l i c a n t s i n the Time 1 t e s t i n g when they were l i v i n g i n boarding homes and v a r i o u s other s e t t i n g s i n the community. Those i n d i c a t o r s which d i f f e r e n t i a t e d a p p l i c a n t s and r e s i d e n t s a t a s t a t i s t i c a l l y s i g n i f i c a n t l e v e l m e r i t f u r t h e r d i s c u s s i o n . Fee l ings o f sadness are a good i n d i c a t o r o f d e p r e s s i o n . Near ly h a l f of the r e s i d e n t s repor ted t h a t they never or ha rd l y ever f e e l sad and h a l f s a i d they f e l t sad on ly sometimes, r e v e a l i n g tha t the v a s t m a j o r i t y are f r e e o f s e r i o u s depress ion i n t h i s j th ree -quar ter way hous ing . One r e s i d e n t who sometimes f e e l s sad s a i d t h a t she goes to the apartment lounge i n order to a l l e v i a t e these f e e l i n g s by m i n g l i n g w i t h o t h e r s . She at tends the c o f f e e hour and d inner so t h a t she can meet and t a l k to people and "get my mind o f f mysel f and my f e e l i n g s . " One man s a i d , "In a b e t t e r environment you f e e l l e s s d e p r e s s e d . " An o p t i m i s t i c ou t look f o r the f u t u r e was expressed by n e a r l y t w o - t h i r d s o f the r e s i d e n t s . C o n s i d e r i n g t h a t the m a j o r i t y o f r e s i d e n t s are deemed unemployable and are s t r u g g l i n g to get by on a sub -pover ty l e v e l ' income i t i s hear ten ing t h a t so many o f them have an o p t i m i s t i c o u t l o o k . In d i s c u s s i o n w i t h the r e s i d e n t s i t was c l e a r t h a t good h o u s i n g , a smal l but steady income and the a v a i l a b i l i t y o f he lp from the community care teams and Coast Foundation s t a f f a l l a s s i s t the r e s i d e n t to m a i n t a i n a favourab le view o f the f u t u r e . The a p p l i c a n t s when they had become r e s i d e n t s scored opt imism h i g h e r , a t 3 .93 out o f 5 , SD = . 7 , than the e a r l i e r s c o r i n g of r e s i d e n t s . Th is may r e f l e c t the hopeful ou t look f o r the f u t u r e o f people i n a r e l a t i v e l y new s i t u a t i o n which seems to hold promise o f more f r i e n d s , more a c t i v i t i e s and more p o s s i b i l i t i e s fo r s e l f - i m p r o v e m e n t . 9 5 . C r u c i a l to a s u c c e s s f u l s o c i a l adjustment i s a sense o f s e l f -esteem. Over 80% o f the r e s i d e n t s repor ted f e e l i n g good about themselves always or most o f the t i m e . D i f f e r e n c e s i n s e l f - e s t e e m between the two groups a t both measures were s t a t i s t i c a l l y s i g n i f i c a n t . Reported s e l f -esteem seems somewhat h igher than one would expect i n a moderately to s e v e r e l y e m o t i o n a l l y d i s a b l e d p o p u l a t i o n , and much h igher than one would f i n d i n a h o s p i t a l i z e d p o p u l a t i o n g iven the l a t t e r ' s sense o f f a i l u r e , l o s s o f d i g n i t y , powerlessness and dependence. S e l f - e s t e e m seemed to be r e l a t e d to the achievement of independence. Being ab le to manage on t h e i r own was fo r a number o f tenants a l a r g e boost i n t h e i r f e e l i n g s o f s e l f -w o r t h . One r e s i d e n t r e l a t e d t h a t she f e l t much b e t t e r about h e r s e l f now t h a t she cou ld e n t e r t a i n her f r i e n d s and f a m i l y i n her own s u i t e . One man s a i d , "I t h i n k being independent and being on my own has made me f e e l b e t t e r about myse l f and f e e l b e t t e r g e n e r a l l y . " Another s a i d , "Be ing on my own i n Coast has g iven me the freedom to come, and go as I want and has done a l o t f o r my s e l f - e s t e e m . " An everyday requirement f o r independent l i v i n g i s the a b i l i t y to s o l v e problems. Some r e s i d e n t s noted t h a t eve ry th ing was done f o r them i n h o s p i t a l or i n a boarding home but now that they are on t h e i r own they have developed s e l f - r e l i a n c e i n t h i s a r e a . Obta in ing feedback and check ing th ings out w i t h o thers i s important to the r e s i d e n t s i n d e a l i n g w i t h p r o b l e m - s o l v i n g and i s i n d i c a t i v e o f a b e n e f i c i a l coping s k i l l i n l i v i n g independent ly i n the community. One woman s a i d , "I used to have to depend on o ther people to s o l v e my problems but now I can manage on my own which has been a boost to my s e l f - e s t e e m . " Another s a i d , "I f e e l b e t t e r than I used to f e e l . I f I have problems I 've learned to phone f r i e n d s , or the 96. community care team, o r my p r i e s t or d o c t o r , and t a l k to them." Another echoed t h i s sent iment : " I t helps to t a l k my problems over w i th my worker . I f e e l one hundred per cent b e t t e r than I used to when I s u f f e r e d from d e p r e s s i o n . I t ' s a gradual t h i n g , to be ab le to face your problems. I t h i n k med ica t ion helps t o o . " A man s a i d , "I d o n ' t run away from my problems l i k e I used t o . " Res idents and a p p l i c a n t s made a measurable d i s t i n c t i o n between p r o b l e m - s o l v i n g and making d e c i s i o n s , which was an area of concern i n d e v i s i n g the Symptomatology schedule as to whether a c l e a r d i s t i n c t i o n e x i s t e d between the two concepts . Making d e c i s i o n s i s a necessary p a r t of coping on one 's own and was seen by r e s i d e n t s as one o f the most important f a c t o r s i n t h e i r success a t e s t a b l i s h i n g themselves i n indepen-dent l i v i n g . Residents a t both f i r s t and second measurements ra ted themselves over 4 .2 out o f 5 , i n being a b l e to manage t h i s s k i l l . As i n p r o b l e m - s o l v i n g , o b t a i n i n g feedback was a major coping mechanism i n d e c i s i o n - m a k i n g . Res idents check out d e c i s i o n s w i th t h e i r t h e r a p i s t , d o c t o r , f r i e n d s , f a m i l y and housing s t a f f . That the l a r g e m a j o r i t y of r e s i d e n t s r e p o r t no problem i n t h i s area i n d i c a t e s t h a t d e s p i t e a c o n s i d e r a b l e amount of psych ic d i s t r e s s t h i s p o p u l a t i o n can cope w e l l i n independent l i v i n g . The f requent re fe rences to r e c e i v i n g feedback from a t h e r a p i s t p o i n t s out the importance of back-up support from the community care teams to a housing resource o f e x - p a t i e n t s . A sense o f s e c u r i t y r e c e i v e d the h ighes t r a t i n g from the r e s i d e n t s , 4 . 5 out o f 5 , S_D= . 6 . Over 90% o f the r e s i d e n t s f e l t secure always or most o'f the t ime and mentioned the importance o f s e c u r i t y i n t h e i r comments. "I f e e l s a f e r here than I have i n most p l a c e s . I have 97. no f e e l i n g s o f personal danger l i k e I used to h a v e . " "I f e e l r e a l l y s e c u r e . " " I t ' s secure i n the b l o c k . I know the people and noth ing has ever been taken from the laundry or anywhere." "The most impor tant t h i n g about Coast i s the f e e l i n g o f s a f e t y and s e c u r i t y ; most o f the time I d o n ' t need a h o s p i t a l anymore." A sense o f s e c u r i t y i n one 's home e n v i r o n -ment i s c r u c i a l i n a mental p a t i e n t ' s l i f e which i s o f t e n beset by a n x i e t y and f e a r s . One woman t o l d a s t o r y about how she had been o s t r a c i z e d by f e l l o w tenants i n her former housing and e v i c t e d by the l a n d l o r d as u n d e s i r a b l e a f t e r she had " f r e a k e d out" and been h o s p i t a l i z e d . Having to make a s t r e s s f u l change i n r e s i d e n c e hard on the heels o f a h o s p i t a l i z a -t i o n i s enough to cause a recur rence o f symptoms and f u r t h e r i n c a r c e r a t i o n . Those who l i v e i n t h r e e - q u a r t e r way housing are we l l aware, from the example of o t h e r s , t h a t i l l n e s s , however b i z a r r e , w i l l be l a r g e l y t o l e r a t e d . His or her s u i t e w i l l be kept a v a i l a b l e f o r a person 's r e t u r n from h o s p i t a l or Venture . And Coast s t a f f and f e l l o w r e s i d e n t s w i l l welcome the person home - whereas i n the p r i v a t e s e c t o r a t e n a n t ' s r e t u r n from a mental h o s p i t a l i s l i k e l y to provoke a r e a c t i o n o f f e a r , s u s p i c i o n and r e j e c t i o n , p a r t i c u l a r l y i f p o l i c e and an ambulance accompanied the d e p a r t u r e . By p r o v i d i n g a secure environment fo r r e s i d e n t s , t h r e e - q u a r t e r way housing reduces a p p r e c i a b l y the s t r e s s i n a c h r o n i c mental p a t i e n t ' s l i f e , e n a b l i n g the i n d i v i d u a l to add to h i s or her bank account of emotional s t a b i l i t y and subsequent ly to be a b l e to expand emotional energy i n o ther areas of l i f e . S e l f - c o n f i d e n c e was viewed by the r e s i d e n t s i n r e l a t i o n to t h e i r general w e l l b e i n g , independence and meaningful a c t i v i t y or p r o d u c t i v i t y . 98. One man s a i d h i s s e l f - c o n f i d e n c e had improved s i n c e he had been a r e s i d e n t and was r e l a t e d to the f a c t t h a t he f e l t g e n e r a l l y b e t t e r . Severa l o thers s a i d t h a t t h e i r conf idence had i n c r e a s e d s i n c e they l e f t boarding homes and found themselves a b l e to manage on t h e i r own. One man who saw h i m s e l f as c o n f i d e n t o n l y sometimes s a i d , "I used to be a very s e l f - c o n f i d e n t pe rson ; I'm not so c o n f i d e n t anymore s i n c e I broke down." Episodes o f acute i l l n e s s are c o n f i d e n c e - s h a t t e r i n g . In a p o p u l a t i o n o f f o r m e r l y h o s p i t a l i z e d people the number o f those who have regained or mainta ined t h e i r s e l f - c o n f i d e n c e i s remarkab le . A score o f 4 out o f 5 , SD = .9 d i f f e r e n t i a t e d the Time 2 t e s t i n g o f the a p p l i c a n t s who had become r e s i d e n t s from the a p p l i c a n t s a t Time 1 t e s t i n g i n the a b i l i t y to avo id withdrawal and s o c i a l i s o l a t i o n . These are wel l -known symptoms of s c h i z o p h r e n i a , depress ion and the d e p r e s s i v e phase o f manic d e p r e s s i v e i l l n e s s . One r e s i d e n t s a i d t h a t he f i g h t s h i s s e l f - i m p o s e d r e t r e a t from the wor ld by f o r c i n g h i m s e l f to at tend c o f f e e hours and communal d inners i n the b l o c k . Another s a i d t h a t when th ings are bad f o r him he "ho les up" f o r a few days , then fo rces h i m s e l f out i n t o the company o f o t h e r s . The f a c t tha t f e e l i n g s o f a n x i e t y , f e a r s and . s leep ing p a t t e r n d i d not change s i g n i f i c a n t l y i n the two measures i n d i c a t e s tha t these aspects o f mental i l l n e s s are i n h e r e n t i n the d i s e a s e and are not g r e a t l y improved by an improved envi ronment . General comments on mental h e a l t h showed i n s i g h t on the p a r t o f the r e s i d e n t s and revea led t h a t they recognized f a c t o r s which were c r u c i a l to improvement i n t h e i r emotional s t a b i l i t y . " I / f e e l my mental h e a l t h i s p r e t t y good - b e t t e r than i t used to b e . " "My mental h e a l t h 99. has improved by g e t t i n g away from a boarding home and being more i n d e -pendent . " "I never have breakdowns anymore." "I hear v o i c e s but they d o n ' t bother me anymore." "The community care team has helped me a l o t and so has the support o f Coast h o u s i n g . " " I 'm doing b e t t e r s i n c e I moved i n t o Coast ; I'm on l e s s m e d i c a t i o n than I used to b e . " "My mental h e a l t h i s b e t t e r than when I was l i v i n g i n a h o t e l . My r e l a t i v e s t h i n k so t o o . " "Meet ing and g e t t i n g to know more people i n Coast has h e l p e d . " "I d o n ' t have the s t r a i n and t e n s i o n I used to have . " "There 's no pressure on y o u ; y o u ' r e l e t be y o u r s e l f here and w i thout pressure I f e e l w e l l . " "I can be w i t h people when I want company. The s u i t e i s b r i g h t and c h e e r f u l . " " I 'm f e e l i n g very good - b e t t e r than I have f o r twenty y e a r s . " Meaningful activity. By v i r t u e o f the f a c t t h a t most of the r e s i d e n t s and a p p l i c a n t s are r e c i p i e n t s o f Handicapped Persons Income A s s i s t a n c e and are t h e r e f o r e deemed unemployable, i t was not expected tha t many of e i t h e r group would be i n v o l v e d i n c o m p e t i t i v e or even s h e l t e r e d work and t h i s was borne out by the f i n d i n g s . P r o d u c t i v i t y i s a s t rong s o c i a l e x p e c t a t i o n and a source o f g r a t i f i c a t i o n i n c l u d i n g h igher income, the o p p o r t u n i t y to make s o c i a l c o n t a c t s , a f e e l i n g of use fu lness - and a s i t e o f major impairment i n mental i l l n e s s . Gunderson and Mosher, 1975, est imated t h a t 80% of the c o s t o f s c h i z o p h r e n i a i s i n l o s t p r o d u c t i v i t y . The c o s t i s e q u a l l y g reat i n l o s s o f s o c i a l s t a t u s , i d e n t i t y as a member o f the work f o r c e , and a l o s s o f morale amongst p a t i e n t s who cannot get and keep work i n a t i g h t and d i m i n i s h i n g labour market . Expected p r o d u c t i v i t y of t h i s p o p u l a t i o n l i e s i n the area o f the community involvement program and v o l u n t e e r work. 100. U n f o r t u n a t e l y the p r o v i n c i a l government has d i s c o n t i n u e d the community involvement program which meant so much to the d i s a b l e d i n t a k i n g p a r t i n community work, and being reimbursed f o r t h e i r expenses. What can be hoped f o r i s t h a t c h r o n i c mental p a t i e n t s w i l l i n v o l v e themselves i n s o c i a l a c t i v i t i e s and e s t a b l i s h a comfor tab le d a i l y r o u t i n e from which they w i l l d e r i v e s a t i s f a c t i o n . The three measurements, o f the r e s i d e n t s , the a p p l i c a n t s , and the a p p l i c a n t s when they had become r e s i d e n t s showed an approx imate ly equal number i n v o l v e d i n s o c i a l p u r s u i t s such as v i s i t i n g w i t h f r i e n d s and r e l a t i v e s , or r e g u l a r l y going to c o f f e e shops or d rop -i n c e n t r e s . A comparable number a l s o spent time on s o l i t a r y p u r s u i t s such as reading and watching t e l e v i s i o n . No change was noted between the d i f f e r e n t measurements o f a c t i v i t i e s . The hypothes is t h a t meaningful a c t i v i t y would change i n p r o d u c t i v i t y and s o c i a l p u r s u i t s compared to p a s s i v e , i s o l a t e d p u r s u i t s was not shown by the d a t a . However the a p p l i c a n t s a t Time 2 who had become r e s i d e n t s , d i d s t r o n g l y express s a t i s f a c t i o n w i t h t h e i r d a i l y r o u t i n e which i s a good i n d i c a t i o n t h a t d e s p i t e d i s t r e s s i n g r e s i d u a l symptoms c h r o n i c mental p a t i e n t s can r e a l i z e contentment from t h e i r d a i l y a c t i v i t y . S ince p r o d u c t i v i t y and community involvement programs are not r e a l i s t i c goals f o r t h i s p o p u l a t i o n , expec ta t ions o f ch ron ic mental p a t i e n t s must cen t re on the development o f s o c i a l p u r s u i t s e i t h e r i n v o l u n t e e r work or i n a c t i v i t i e s such as those recorded i n the s t u d y . 101 . Validation of measures by Progress Evaluation Scales. C r i t e r i o n v a l i d i t y represents a p r a c t i c a l approach to v a l i d a -t i o n . V a l i d i t y i s determined on the b a s i s of the measuring procedure . and i s thus e m p i r i c a l l y based. In t h i s case the concur rent v a l i d i t y i s dependent on the r e s u l t s o f the s e l f - r e p o r t measures agree ing w i th the f i n d i n g s o f the P . E . S . S c a l e s . That the items o f the P . E . S . Sca les were not i d e n t i c a l w i t h the s e l f - r e p o r t s c a l e s presents a s e r i o u s c h a l l e n g e i n e s t a b l i s h i n g v a l i d i t y . Those t r a i t s which seemed to be i d e n t i c a l , such as Independence and A t t i t u d e toward s e l f o f the P . E . S . Sca les w i t h Independence and S e l f - e s t e e m o f the s e l f - r e p o r t s c a l e s were examined, as, were Fee l ings and Mood, and Problems o f the P . E . S . w i t h i tems o f L o n e l i n e s s , Sadness, Anx ie ty and Optimism o f the Symptomatology measure which seemed to be comparable . -Because measurements o f Independence d i d not agree i t i s probable t h a t s t a f f us ing the P . E . S . Sca les were not measuring Independence i n the b a s i c a c t i v i t i e s o f d a i l y l i v i n g but s c o r i n g a c c o r d i n g to the amount o f a d v i c e they o f f e r e d from time to time to the r e s i d e n t s being a s s e s s e d . S e l f - e s t e e m i n the s e l f - r e p o r t s c a l e s and the P . E . S . Sca les showed f a i r l y c l o s e agreement and were the on ly a s s o c i a t i o n s examined which i n d i c a t e d a more p o s i t i v e out look by r e s i d e n t s than r a t i n g s , by s u p e r v i s o r s . Superv i so rs may f e e l tha t s e l f - e s t e e m a u t o m a t i c a l l y s u f f e r s when other t r a i t s are not ra ted h i g h l y , however the s e l f - e s t e e m scores 102. do not r e f l e c t t h i s p o s s i b i l i t y : s e l f - e s t e e m was the t h i r d h ighes t score o f the r e s i d e n t s a t Time 1 t e s t i n g w i t h the a p p l i c a n t s and shows t h a t c h r o n i c mental p a t i e n t s do have a favourab le a t t i t u d e toward themselves d e s p i t e o ther d i s t r e s s i n g symptoms and a g e n e r a l l y n o n - p r o d u c t i v e l i f e s t y l e . That s t a f f viewed r e s i d e n t s as f e e l i n g b e t t e r than they viewed themselves was a t rend obvious throughout the remainder o f the comparisons. The Coast Foundation s t a f f repor ted a high percentage o f r e s i d e n t s f u n c -t i o n i n g we l l i n regard to t h e i r F e e l i n g s and mood, and coping we l l w i th Problems. On the o ther hand, the r e s i d e n t s repor ted a r e l a t i v e l y h igh l e v e l o f a n x i e t y , sometimes f e e l i n g l o n e l y and s a d , w i t h few r e p o r t i n g freedom from these f e e l i n g s . The p i c t u r e presented i s one o f a group o f c h r o n i c mental p a t i e n t s w i th s i g n i f i c a n t r e s i d u a l symptoms, p a r t i c u l a r l y o f a n x i e t y , c o n v i n c i n g s t a f f t h a t they are b e t t e r than they f e e l . The comparison o f the s e l f - r e p o r t s c a l e s w i th the P . E . S . Sca les was g e n e r a l l y weak. V a r i a b l e s i n most cases were too d i s s i m i l a r to show much a s s o c i a t i o n and those which would have been expected to show a marked a s s o c i a t i o n such as Independence were probably measuring d i f f e r e n t aspects o f the same v a r i a b l e . The P . E . S . Sca les are inadequate as a s t r o n g means o f v a l i d a t i o n o f the s e l f - r e p o r t r a t i n g s . b u t i n d i c a t e d t h a t housing s t a f f r a t e p a t i e n t s h igher i n terms o f absence o f d i s t r e s s i n g symptoms than the p a t i e n t s r a t e themselves . This may be a r e f l e c t i o n o f the f a c t t h a t s t a f f are o n l y m i n i m a l l y s u p p o r t i v e and do not know most r e s i d e n t s very w e l l . The P . E . S . Sca les would probably be a d m i n i s t e r e d more s u c c e s s f u l l y by the p a t i e n t s ' i n d i v i d u a l t h e r a p i s t s than by housing s t a f f who do not see r e s i d e n t s on a r e g u l a r b a s i s as t h e r a p i s t s do. 103. Implications for social work practice. The c i v i l l i b e r t a r i a n ph i losophy of the s i x t i e s led to mass d i s c h a r g e s from mental h o s p i t a l s on t h i s c o n t i n e n t . Dehumanizing and a n t i t h e r a p e u t i c i n s t i t u t i o n a l i z a t i o n was expected to g i ve way to r e h a b i l i t a -t i o n i n the community and a b e t t e r l i f e fo r mental p a t i e n t s i n the f u t u r e . For the more f o r t u n a t e mental p a t i e n t s who were not s e t a d r i f t i n urban c e n t r e s , l i f e i n the community has meant i n c a r c e r a t i o n i n boarding homes and n u r s i n g homes. The r u l e s , s u p e r v i s i o n and r e g u l a t e d l i f e i n these homes are r e m i n i s c e n t o f h o s p i t a l ; the t . v . - c e n t r e d l i v i n g rooms are l i k e the day-rooms o f p s y c h i a t r i c wards and the homes themselves are l i k e m i n i - i n s t i t u t i o n s , w i t h l i t t l e o p p o r t u n i t y f o r a normal i zed l i f e or p r i v a c y f o r the inmates . The l i t e r a t u r e abounds wi th d e s c r i p t i o n s o f supposedly s u p e r i o r board ing home programs,.however these programs do not pretend to o f f e r a normal ized e x i s t e n c e . a n d what they do o f f e r i s u s u a l l y a t a high c o s t to the suppor t ing l e v e l o f government or agency. Th ree -quar te r way housing which i s a r e l a t i v e l y r e c e n t concept i n a f t e r - c a r e should be one o f the f i r s t cho ices i n the development o f support s e r v i c e s fo r the e x - p a t i e n t . Coast Foundation exper ience has shown t h a t c h r o n i c mental p a t i e n t s from a v a r i e t y o f superv i sed s e t t i n g s can cope w e l l i n m i n i m a l l y s u p p o r t i v e t h r e e - q u a r t e r way h o u s i n g , i n a normal i zed envi ronment . An unknown percentage of c h r o n i c mental p a t i e n t s who cannot l i v e independent ly or a d m i n i s t e r t h e i r own med ica t ion w i l l cont inue to r e q u i r e the s u p e r v i s i o n o f boarding and nurs ing homes but a l a r g e number should be a b l e to enter t h r e e - q u a r t e r way housing when they leave an i n s t i t u t i o n a l s e t t i n g . 104. S o c i a l work p r a c t i t i o n e r s who are r e s p o n s i b l e fo r the deve lop -ment o f s u p p o r t i v e housing f o r c h r o n i c mental p a t i e n t s should be aware t h a t m i n i m a l l y s u p p o r t i v e t h r e e - q u a r t e r way housing i s l e s s c o s t l y than other v a r i e t i e s . T h r e e - q u a r t e r way housing can a l s o be e a s i l y converted i n t o market housing should a need f o r p a t i e n t s no longer e x i s t . Coast Foundation apartments are s u b s i d i z e d by the B .C . M i n i s t r y o f Heal th a t a 1983 per diem of $ 1 0 . 1 2 . The a l t e r n a t i v e o f p s y c h i a t r i c boarding homes i n B .C . c o s t $19.25 per person per day f o r personal c a r e . By way of compar ison , i n s t i t u t i o n a l i z a t i o n a t 1983 r a t e s was $98.74 per day i n the Venture c r i s i s h o s t e l , and $315.85 per day i n S t . P a u l ' s H o s p i t a l p s y c h i a t r i c ward. An important c o n s i d e r a t i o n f o r s o c i a l work p r a c t i t i o n e r s i n p r a c t i c e and a d m i n i s t r a t i v e r o l e s i n the mental h e a l t h f i e l d i s r e c o g n i -t i o n o f three major concerns r e l a t i n g to housing o p t i o n s f o r e x - p a t i e n t s : tha t housing to be prov ided be as normal i zed a s e t t i n g as p o s s i b l e w i t h o p p o r t u n i t i e s f o r p r i v a c y ; t h a t a s u b s t a n t i a l number o f ch ron ic mental, p a t i e n t s are capable o f managing independent ly and comfor tab ly under normative c o n d i t i o n s , and t h a t f i n a n c i a l advantages are i n h e r e n t i n the t h r e e - q u a r t e r way housing o p t i o n . Summary The purpose o f the study was to d i s c o v e r i f the q u a l i t y o f l i f e o f c h r o n i c mental p a t i e n t s i n t h r e e - q u a r t e r way housing was changed in terms o f h o s p i t a l i z a t i o n s , tha t independence was a t an a c c e p t a b l e l e v e l f o r community l i v i n g , t h a t s o c i a l networks of the p a t i e n t s had changed 105. i n regard to t h a t o f normals , tha t symptoms of mental i l l n e s s had a l t e r e d and t h a t the s t r u c t u r i n g o f f r e e t ime was m e a n i n g f u l . To accompl ish the examinat ion a random sample o f 50 r e s i d e n t s o f t h r e e - q u a r t e r way housing and an a p p l i c a n t group o f 20 i n d i v i d u a l s were s t u d i e d by s t r u c t u r e d i n t e r v i e w . E a r l i e r s e l f - r e p o r t data were r e a n a l y z e d , the a p p l i c a n t s were s t u d i e d again a t a l a t e r p o i n t i n t ime when they had become r e s i d e n t s , and t h r e e - q u a r t e r way housing s t a f f examined the l a t t e r group i n order to v a l i d a t e the s e l f - r e p o r t measures. H o s p i t a l i z a t i o n s were found to have decreased c o n s i d e r a b l y , from 47 admissions i n the three years p r i o r to res idence to 8 admiss ions s i n c e res idence f o r the random sample o f 50 r e s i d e n t s . F i f t y per cent o f the r e s i d e n t s were h o s p i t a l i z e d p r i o r to r e s i d e n c y ; 12% have been hos-p i t a l i z e d s i n c e r e s i d e n c y . Independence was found to be a t an a c c e p t a b l e l e v e l f o r l i v i n g i n the community but t h i s was not a f a c t o r a t t r i b u t a b l e to the hous ing . The t i g h t s c r e e n i n g process i n t o the housing program v i r t u a l l y e l i m i n a t e s those i n d i v i d u a l s who do not possess b a s i c l i v i n g s k i l l s . S o c i a l networks o f the r e s i d e n t group, and the a p p l i c a n t s who l a t e r became r e s i d e n t s were found to be approaching or i n the normal range. The a p p l i c a n t group was found to be l a c k i n g i n the s i z e o f t h e i r s o c i a l support system. Judging from the comments o f the p a t i e n t s , symptomatology was i n a reasonably comfor tab le range f o r the g reat m a j o r i t y of r e s i d e n t s . The changes i n symptomatology from Time 1 to Time 2 t e s t i n g i n most i tems o f the measure were found to be s t a t i s t i c a l l y s i g n i f i c a n t . Both r e s i d e n t s and a p p l i c a n t s were p o s i t i v e about t h e i r ou t look f o r the f u t u r e . The 106. a p p l i c a n t s were more s o c i a l l y i s o l a t e d than the r e s i d e n t s . Most t e l l i n g was the pervas ive f e e l i n g o f s a f e t y of the r e s i d e n t s and the marked l a c k o f a f e e l i n g o f s e c u r i t y among, the a p p l i c a n t s . What was revea led as the most important a c t i v i t y o f both r e s i -dents and a p p l i c a n t s was the time they spent w i th f r i e n d s or f a m i l y members. P r o d u c t i v i t y was l a r g e l y impaired i n the popu la t ion but s a t i s f a c t i o n w i th the manner i n which they spent t h e i r t ime was expressed by a l a r g e m a j o r i t y o f those quest ioned . In the /view o f the c h r o n i c mental p a t i e n t s s t u d i e d and sub-, s t a n t i a t e d by the data there has been an improvement i n t h e i r mental h e a l t h i n t h r e e - q u a r t e r way hous ing , and to t h i s e x t e n t , an improvement i n t h e i r q u a l i t y of l i f e . 107. R E F E R E N C E S A k h t a r , A . , B roe , G . , Crombie, A . , McLean, W. , Andrews, G . , & C a i r d , F. " D i s a b i l i t y and dependence." Age and Ageing 2 (May 1973) : 1 0 2 - 1 1 . A v i r a m , U. & S e g a l , S . "From h o s p i t a l to community c a r e . " Community  Mental Heal th Journal 13 (2) (1977) ; 1 5 8 - 1 6 7 . Bachrach , L. "A conceptual approach to d e i n s t i t u t i o n a l i z a t i o n . " H o s p i t a l ^Community P s y c h i a t r y 29 (9) (September 1978) : 573 -578 . B a x t e r , E. & Hopper, K. "The new mendicancy: homeless i n New York C i t y . " American Journal o f Orthopsychiatry 52 (3) ( J u l y 1 9 3 2 ) : 393 -408 . Bebb ington , A . " S c a l i n g i n d i c e s o f d i s a b l e m e n t . " B r i t i s h Journal o f  P revent i ve & S o c i a l Med ic ine 31 (2) (June 1977) : 1 2 2 - 2 6 . Beck, A . , Ward, C , Mendelson, M . , Mock, J . , & Erbaugh, J . " Inventory o f measuring d e p r e s s i o n . " A r c h i v e s o f General P s y c h i a t r y 4 (June 1961 ) : 561-571 . Bennet t , D. " D e i n s t i t u t i o n a l i z a t i o n i n two c u l t u r e s . " M i l bank Memorial  Fund Quar te r l y 57 (4) (1979) : 5 1 6 - 3 1 . B e r g e l , R. " I n d i v i d u a l assessment procedures fo r mul t ihandicapped and implementat ion o f a s p o r t s program." I n t e r n a t i o n a l Journal  o f R e h a b i l i t a t i o n Research 4 (3) ( 1 9 8 l T i 3 6 5 - 7 8 . B i g e l o w , D. Impact o f community care on q u a l i t y o f l i f e o f s e v e r e l y m e n t a l l y i l l p a t i e n t s . Vancouver, B . C . : Greater Vancouver Mental Heal th S e r v i c e , 1977. B l e y , N. " C l i e n t s ' p e r c e p t i o n s : a key v a r i a b l e i n e v a l u a t i n g l e i s u r e a c t i v i t i e s . " G e r o n t o l o g i s t 13 (Autumn 1973) : 3 6 5 - 7 . Bloom, M . , & B l e n k n e r , M. " A s s e s s i n g f u n c t i o n i n g of o l d e r persons l i v i n g i n the community." G e r o n t o l o g i s t 10 (1970) : 3 1 - 3 7 . 108. B o m s , J . " D e i n s t i t u t i o n a l i z a t i o n o f the c h r o n i c a l l y m e n t a l l y i l l . " New England Journal o f Medic ine 305 (6) (August 6 , 1981) : 3 3 9 - 4 2 . Brugha , T. C a p l a n , G. Chi e n , C. , Conroy, R. , Walsh , N . , Delaney, W., O 'Hanlon , J . , Dondero, E . , D a l y , L . , H i c k e y , N . , & Bourke , G. " S o c i a l networks , a t t a c h -ments and support i n minor a f f e c t i v e d i s o r d e r s : a r e p l i c a t i o n . " B r i t i s h Journal o f P s y c h i a t r y 141 (September 1982) : 2 4 9 - 5 5 . Support systems and community mental h e a l t h , Behav io ra l P u b l i c a t i o n s , 1974. New York: "A new m o d a l i t y f o r t r e a t i n g s c h i z o p h r e n i c s i n the community." In Community management o f the s c h i z o p h r e n i c i n chemical  r e m i s s i o n , e d i t e d by M. K i n g . Proceedings o f a symposium held i n M o n t r e a l , June 7 , 1972. Amsterdam: Excerpts M e d i c a , 1973. M i l bank Memorial C l a r k e , G. "In defense o f d e i n s t i t u t i o n a l i z a t i o n . Fund Q u a r t e r l y 57 (4) ( F a l l 1979) : 4 6 1 - 7 9 . Cohen, C. & S o k o l o v s k y , J . " C l i n i c a l use o f network a n a l y s i s f o r p s y c h i a t r i c and aged p o p u l a t i o n s . " Community Mental Heal th Journal 15 (3) ( F a l l 1979) : 2 0 3 - 1 3 . Cohen, C. & S o k o l o v s k y , J . "Sch i zophren ia and s o c i a l ne tworks . " Sch i zophren ia B u l l e t i n 4 (1978) : 5 4 6 - 6 0 . De Loach , C. Independent l i v i n g : p h i l o s o p h y , process and s e r v i c e s . B a l t i m o r e : U n i v e r s i t y Park P r e s s , 1983. D e n i s t o n , 0 . & J e t t e , A. "A f u n c t i o n a l s t a t u s assessment i n s t r u m e n t : v a l i d a t i o n i n an e l d e r l y p o p u l a t i o n . " Heal th S e r v i c e s Research 15 (1) (Spr ing 1980) : 2 1 - 3 4 . Evans, C. "The p r a c t i c a l e v a l u a t i o n of handicap a f t e r severe s t r o k e . " Phys iotherapy 67 (7) ( J u l y 1981) : 199 -202 . F a r r , R. "The homeless , c h r o n i c a l l y m e n t a l l y i l l i n the Los Angeles ' S k i d Row1 a r e a . " I n t e r n a t i o n a l A s s o c i a t i o n o f Psychosoc ia l  R e h a b i l i t a t i o n S e r v i c e s , 8th Annual Conference , Santa Mon ica , C a l i f . , May 1 9 - 2 1 , 1983, u n p u b l i s h e d . F a s t i n g , K. " L e i s u r e t i m e , p h y s i c a l a c t i v i t y and some i n d i c e s o f mental h e a l t h . " Scandinav ian Journal o f S o c i a l M e d i c i n e , Supplement 29 (1982) : . 1 1 3 - 1 9 . F r o l a n d , C , B rodsky , G . , O l s o n , M . , & S t e w a r t , L. " S o c i a l support and s o c i a l ad justment : i m p l i c a t i o n s f o r mental h e a l t h p r o f e s s i o n a l s . " Community Mental Heal th Journal 15 (2) (1979) : 82 -93 109. Goldman, H. " D e i n s t i t u t i o n a l i z a t i o n : the data demytho log i zed . " H o s p i t a l & Community P s y c h i a t r y 34 (2) (February 1983) : 1 2 9 - 3 4 . Gordon, C , G a i t z , C , & S c o t t , J . "Value p r i o r i t i e s and l e i s u r e a c t i v i t i e s among midd le -aged and o l d e r A n g l o s . " Diseases  o f the Nervous System 34 (January 1973) : 1 3 - 2 6 . G r e e n b l a t t , M . , B e c e r r a , R . , & S e r a f e t i n i d e s , E. " S o c i a l networks and mental h e a l t h : an o v e r v i e w . " American Journal o f P s y c h i a t r y 139 (8) (August 1983) : 9 7 7 - 8 4 . Gunderson, J . & Mosher, L. "The cos t of s c h i z o p h r e n i a . " American Journal  o f P s y c h i a t r y 132 (9) (September 1975) : 9 0 1 - 6 . H a m i l t o n , M. "The assessment o f a n x i e t y s t a t e s by r a t i n g . " B r i t i s h  Journal o f Medical Psychology 32 (1959) : 5 0 - 5 5 . Hammer, M. " S o c i a l networks and s c h i z o p h r e n i a . " Sch i zophren ia B u l l e t i n 4 (1978) : 5 2 2 - 4 5 . Henderson, S . , Duncan-Jones, P . , McAuley, H . , & R i t c h i e , K. "The p a t i e n t ' s pr imary g r o u p . " B r i t i s h Journal of P s y c h i a t r y 132 (1978) : 7 4 - 8 6 . Holmes, N. "The D i s a b i l i t y Assessment Schedu le : a b r i e f s c r e e n i n g dev ice f o r use w i t h the m e n t a l l y r e t a r d e d . " P s y c h o l o g i c a l Medic ine 12 (4) (November 1982) : 8 7 9 - 9 0 . Hooper, J . E v a l u a t i o n o f m i n i m a l l y s u p p o r t i v e apartment program. Vancouver, B . C . : Coast Foundation S o c i e t y , 1983. I h i l e v i c h , D . , G l e s e r , G . , G r i t t e r , G . , Kroman, L . , & Watson, A. "Measuring program outcome: the Progress E v a l u a t i o n S c a l e s . " E v a l u a t i o n  Review 5 (4) (August 1981) : 4 5 1 - 7 7 . J e t t e , A. " F u n c t i o n a l c a p a c i t y e v a l u a t i o n : an e m p i r i c a l a p p r o a c h . " A rch i ves o f P h y s i c a l Medic ine and R e h a b i l i t a t i o n 61 (2) (February 1980) ; 8 5 - 9 . K a t z , S . "Progress i n development o f the-index of ADL." G e r o n t o l o g i s t 10 (1970) : 2 0 - 3 0 . K a t z , S . , F o r d , A . , Moskowitz , R . , J a c k s o n , B . , & J a f f e , M. " S t u d i e s o f i l l n e s s i n the aged: the index o f ADL: a s t a n d a r d i z e d measure o f b i o l o g i c a l and psychosoc ia l f u n c t i o n . " Journal o f the American Medical A s s o c i a t i o n 185 (1963) : 9 1 4 - 1 9 . K l e i n , R..& B e l l , B. " S e l f - c a r e s k i l l s : behav ioura l measurement w i t h K l e i n - B e l l ADL s c a l e . " A rch i ves o f P h y s i c a l Medic ine and  R e h a b i l i t a t i o n 63 (7) ( J u l y 1982) : 3 3 5 - 3 8 . 110. K u e n s t l e r , G. "A p lann ing group f o r p s y c h i a t r i c o u t p a t i e n t s . " American  Journal o f Occupat ional Therapy 30 (10) (November-December 1976) ; 6 3 4 - 9 . K u r i a n s k y , J . "The performance t e s t o f a c t i v i t i e s o f d a i l y l i v i n g . " I n t e r n a t i o n a l Journal o f Aging and Human Development 7 (4) (1976) : 3 4 3 - 5 2 . Lamb, H. "What d i d we r e a l l y expect from d e i n s t i t u t i o n a l i z a t i o n ? " H o s p i t a l  & Community P s y c h i a t r y 32 (2) (February 1981) : 1 0 5 - 9 . Lane, H. " D i s a b i l i t y f a c t o r s . " A rch i ves o f P h y s i c a l Medic ine and  R e h a b i l i t a t i o n 55 (February 1974) : 6 5 - 7 1 . Lehmann, H. "Options f o r t reatment o f the s c h i z o p h r e n i c p a t i e n t . " Canada's Mental Heal th 24 (1) (March 1976) : 3 - 9 . L e v a , R. " R e l a t i o n s h i p among the s e l f - d i r e c t i o n , r e s p o n s i b i l i t y and s o c i a l i z a t i o n domains of the Adapt ive Behaviour S c a l e . " American  Journal o f Mental D e f i c i e n c y 81 (3) (November 1976) : 2 9 7 - 8 . M i t c h e l l , R. & T r i c k e t t , E. " S o c i a l networks as mediators o f s o c i a l s u p p o r t . " Community Mental Heal th Journal 16 (1) (1980) : 2 7 - 4 4 . M u e l l e r , D. " S o c i a l networks : a promis ing d i r e c t i o n f o r research on the r e l a t i o n s h i p o f the s o c i a l environment to p s y c h i a t r i c d i s o r d e r s . " S o c i a l Sc ience & Med ic ine Par t A. 14(2) (March 1980) : 1 4 7 - 6 1 . M u r r e l l , S . Community psychology and s o c i a l systems. New York: Behav iora l P u b l i c a t i o n s , 1973. O k i n , R. "The f u t u r e o f s t a t e h o s p i t a l s : should there be one?" American Journal o f P s y c h i a t r y 140 (5;) (May 1983) : 577-81 . Overs , R. "A v o c a t i o n a l e v a l u a t i o n and work ad justment : a d e t e r r e n t to dependency." Journal o f R e h a b i l i t a t i o n 42 (6) (November-December 1976) : 2 1 - 2 4 , 4 0 , 48 . O z a r i n , L. & W i t k i n , M. "Halfway houses f o r the m e n t a l l y i11 and a l c o h o l i c s : a 1973 s u r v e y . " H o s p i t a l & Community P s y c h i a t r y 26 (2) (February 1975) : 1 0 1 - 3 . P a t t i s o n , E . , L lamas, R . , & Hurd , G. " S o c i a l network med ia t ion o f a n x i e t y . " P s y c h i a t r i c Annals 9 (9) (September 1 9 7 ) : 5 6 - 6 7 . Pepper, B. & Ryglew'icz, H. "Testimony f o r the n e g l e c t e d : the m e n t a l l y i l l i n the p o s t - d e i n s t i t u t i o n a l i z e d a g e . " American Journal o f  O r t h o p s y c h i a t r y 52 (3) ( J u l y 1982) : 3 8 8 - 9 2 . P i l o n , W. & M a r c o t t e , C. "The semi-community environment and the r e i n t e g r a -t i o n of the p s y c h i a t r i c r e s i d e n t : present s t a t u s and ou t look f o r the f u t u r e . " Canada's Mental Heal th 24 (1) (March 1 9 7 6 ) : 4 0 - 1 . m . Prager , E. " E v a l u a t i o n i n mental h e a l t h : enter the consumer." , S o c i a l  Work Research and A b s t r a c t s 16 (2) (Summer 1980) ; 5 - 1 0 . The q u a l i t y o f American l i f e i n the e i g h t i e s . Report o f the Panel on the Q u a l i t y of American L i f e , P r e s i d e n t ' s Commission, f o r a Nat iona l Agenda f o r the E i g h t i e s . Washington, D . C . : 1980. Roadburg, A. " P e r c e p t i o n s o f work and l e i s u r e among the e l d e r l y . " G e r o n t o l o g i s t 21 (2) ( A p r i l 1981) : 1 4 2 - 5 . Sarno , J . , Sarno , M . , & L e v i t a , E. "The Funct iona l L i f e S c a l e . " A r c h i v e s o f P h y s i c a l Medic ine and R e h a b i l i t a t i o n 54 (May 1973) : 2 1 4 - 2 0 . Shakow, D. A d a p t a t i o n i n s c h i z o p h r e n i a . New York: W i l e y , 1979. Soko lovsky , J . , Cohen, C , B e r g e r , D. , & G e i g e r , J . "Personal networks o f ex -mental p a t i e n t s i n a Manhattan SRO h o t e l . " Human  O r g a n i z a t i o n 37 (1) (Spr ing 1978) : 5 - 1 5 . Speck, R. & A t h r e a v e , C. Family networks : r e t r i b a l i z a t i o n and h e a l i n g . New York : Pantheon, 1973. S w i t z k y , H. & R o t a t o r i , A. "Community l i v i n g s k i l l s assessment i n v e n t o r y : an ins t rument to f a c i l i t a t e d e i n s t i t u t i o n a l i z a t i o n o f the s e v e r e l y deve lopmenta l l y d i s a b l e d . " P s y c h o l o g i c a l Reports 43 (3 P t . 2) (December 1978) : 1 3 3 5 - 4 2 . T a l b o t t , J . "The n a t i o n a l p lan f o r the c h r o n i c a l l y m e n t a l l y i l l : a programmatic a n a l y s i s . " H o s p i t a l & Community P s y c h i a t r y 32 (10) (October 1 9 8 1 ) ; 699 -704 . T a l b o t t , J . "Toward a p u b l i c p o l i c y on the c h r o n i c m e n t a l l y i l l p a t i e n t . " American Journal o f O r t h o p s y c h i a t r y 50 (1) (January 1980) ; 4 3 - 5 3 . Tcheng-Laroche, F. "The e f f e c t o f f o s t e r home placement on p s y c h i a t r i c p a t i e n t s : observed changes and c o n t r i b u t o r y f a c t o r s . " Canada's Mental Hea l th 24 (1) (March 1976) : 1 3 - 1 5 . T e r l e c k y j , N. Improvements i n the q u a l i t y o f l i f e . Washington, D . C . : N a t i o n a l P lanning A s s o c i a t i o n , 1975. Toml inson , P. & Cumming, J . "Coast Foundation apartment p r o j e c t . " Canada's Mental Heal th 24 (1) (March 1976) : 2 3 - 2 8 . Warren, H. " S e l f - p e r c e p t i o n o f independence among urban e l d e r l y . " American  Journal of Occupat ional Therapy 28 ( J u l y 1974) : 3 2 9 - 3 6 . Weiner , A. & Hunt, S . " R e t i r e e s ' percept ions o f work and l e i s u r e meanings . " G e r o n t o l o g i s t 21 (4) (August 1981 ) : 4 4 4 - 6 . 112. W i l l i a m s , D . , B e l l i s , E . , & W e l l i n g t o n , S . " D e i n s t i t u t i o n a l i z a t i o n and s o c i a l p o l i c y . " American Journal o f O r t h o p s y c h i a t r y 50 (1) (January 1980) : 5 5 - 6 4 . W i l s o n , H. The S o t e r i a House approach: d e i n s t i t u t i o n a l i z e d r e s i d e n t i a l care f o r the m e n t a l l y d i s o r d e r e d . New York: Grune & S t r a t t o n , 1982. Zuck, D. "Standard f u n c t i o n a l g o a l s . " Phys i ca l Therapy 60 (6) (June 1980) : 7 9 3 - 5 . Zung, W. "A r a t i n g inst rument f o r a n x i e t y d i s o r d e r s . " Psychosomatics 12 (May 1971) : 3 7 1 - 7 9 . Zung, W. "A s e l f - r a t i n g depress ion s c a l e . " A rch ives o f General P s y c h i a t r y 12 (January 1965) : 6 3 - 7 0 . 113. A P P E N D I X Screening I n i t i a l Reeva l . C l o s i n g CI i e n t S i g . Other T h e r a p i s t PROGRESS EVALUATION SCALES Date I n s t r u c t i o n s : C i r c l e one statement to desc r ibe s i t u a -t i o n i n the l a s t two weeks. Name INDEPENDENCE ( i n bas ic l i v i n g s k i l l s ) OCCUPATION (school , job or homemaking) GETTING ALONG WITH OTHERS Is not independent. W i l l probably not be .ab le to . remain i n program. Is mainly independent but o c c a s i o n a l l y requ i res d i r e c t i o n . Does not hold job or care fo r home or go to s c h o o l . Holds r e g u l a r j o b , or c l a s s e s , or does housework (or some combinat ion o f these) but with d i f f i c u l t y . Always f i g h t i n g or dest ruc -t i v e ; or always a l o n e . Lacks independence i n a number o f important areas , Requires s t a f f input r e g u l a r l y . Is main ly independent i n every way. Seldom hoids j o b , or a t tends c l a s s e s , or cares f o r home. Holds r e g u l a r j o b , or a t tends c l a s s e s , or does housework (or some combina-t i o n of these) w i th l i t t l e or no d i f f i c u l t y . Seldom ab le to get a long w i t h o thers w i thout q u a r r e l l i n g or being d e s t r u c t i v e or i s o f t e n a l o n e . Is independent i n most areas but l a c k i n g i n severa l Sometimes holds j o b , or at tends some c l a s s e s or does l i m i t e d housework. Sometimes q u a r r e l - l i n g , but seldom d e s t r u c t i v e ; d i f f i c u l t i e s i n making f r i e n d s . GETTING ALONG (cont inued) FEELINGS AND MOOD Sets a long wi th others most o f the t i m e ; has occas iona l f r i e n d s . Almost always f e e l s nervous, or depressed, or angry and b i t t e r , or no emotions at a l l . Usua l l y i n a good mood, but o c c a s i o n a l l y f e e l s nervous , or unhappy or angry a l l day, USE OF FREE TIME Almost no r e c r e a t i o n a l a c t i v i t i e s or hobbies. Often p a r t i c i p a t e s i n r e -c r e a t i o n a l a c t i v i t i e s and hobbies . PROBLEMS Severe problems most of the t i m e . Occasional moderate probl ems. ATTITUDE TOWARDS SELF Negative a t t i t u d e most of the t i m e . P o s i t i v e a t t i t u d e toward s e l f much o f the t i m e . Gets a long w i t h o thers most o f the t i m e ; has r e g u l a r c l o s e f r i e n d s . Often f e e l s nervous , or de- F requent ly i n a good p r e s s e d , or angry and b i t t e r , good mood but o c c a -or hard ly shows any emotion s i o n a l l y f e e l s f o r weeks a t a t i m e . nervous , or depressed , or angry fo r days a t In a good mood most o f the a t i m e -t i m e ; and u s u a l l y a b l e to be as happy, or s a d , or angry as the s i t u a t i o n c a l l s f o r . Only o c c a s i o n a l r e c r e a t i o n a l P a r t i c i p a t e s i n some a c t i v i t y , or repeats the same r e c r e a t i o n a l a c t i v i t i e s a c t i v i t y over and over a g a i n , or hobb ies . P a r t i c i p a t e s i n , as we l l as c r e a t e s , v a r i e t y o f own r e c r e a t i o n a l a c t i v i t i e s and hobbies f o r s e l f and o thers Severe problems some of the t ime or moderate problems c o n t i nuous ly . Occasional m i l d problems. Moderate problems most o f the t i m e , or m i l d problems almost c o n t i n u o u s l y . Negat ive a t t i t u d e much of the t i m e . P o s i t i v e a t t i t u d e toward s e l f most of the t i m e . Almost equal i n p o s i -t i v e and negat i ve a t t i t u d e toward s e l f . 116. COAST FOUNDATION HOUSING EVALUATION Category 1 . 11 13. 18. 20. 22. Name Address Phone no. E d u c a t i o n : 0 - 8 _ 8 -12 12+ " 2. 4. 6. 8 . R e f e r r a l source : 10. Were you 1 i v i ng: a lone 12. w i th spouse w i th r e l a t i v e / s _ w i th f r iends_ boarding home communal l i v i n g _ o th er P r i n c i p a l source o f income: employment: s/a HPIA 0AP/0AS Ga i n UIC DVA 14. 15. 16. 17, Age Sex Tenant no. How long have y r . y r . y r . you l i v e d a t Coast? 0 - 1 1 - 2 2 - 4 4+ D i a g n o s i s : Schi zophrenic/psychot ic_ manic depress i ve depress i ve d i s o r d e r a n x i e t y d i s o r d e r p e r s o n a l i t y d isorder_ o t h e r _ Former hote l hous ing : room/not s e l f - c o n t a i n e d s t e . / s e l f - c o n t a i n e d f a m i l y home boarding home/MPA t r a n s i t i o n housing (Loma, V i s t a ) h a r d - t o - h o u s e (Lookout , T r iage ) hpspi t a l Venture o th er Income amount 0-600 600-750 750+ How long d i d you l i v e a t your prev ious address? For how long have you been r e -c e i v i n g p s y c h i a t r i c s e r v i c e ? How many t imes have you been h o s p i t a l i z e d ? sav i ngs o ther In the 3 years before l i v i n g i n C o a s t , how many admiss ions to h o s p i t a l ? 19 . How many days t o t a l ? 2 1 . How many admiss ions to h o s p i t a l ' day ca re? 23. Which h o s p i t a l ? _ Which h o s p i t a l ? How many days t o t a l ? 117. 24. How many admiss ions to 2 5 . Venture? 26. S ince l i v i n g i n C o a s t , how many 27. admiss ions to h o s p i t a l ? 28 . How many days t o t a l ? 29 . 30. Which h o s p i t a l ? 3 1 . How many days t o t a l ? 32 . How many admiss ions to 33 . Venture? 34. Do you at tend a Community Care Team? 3 5 . 36 . Do you at tend p r i v a t e \ 37 . p s y c h i a t r i s t ? 38. Other form o f f o l l o w - u p 39 . care? How many days?_ Which hospi t a l ? S ince l i v i n g i n Coast , how many admiss ions to h o s p i t a l day care ? How many days? How o f t e n ? How o f t e n ? How o f t e n ? 118. Category II - Independence 1 . Are you a b l e to look a f t e r your personal hygiene adequate ly? yes need a s s i s t a n c e no 2 . Are you ab le to look a f t e r your laundry needs? yes need a s s i s t a n c e no 3 . Do you manage your housekeeping adequate ly? yes need a s s i s t a n c e no 4 . Are you a b l e to look a f t e r your shopping? yes need a s s i s t a n c e no 5 . Do you manage to cook n u t r i t i o u s meals? yes need a s s i s t a n c e no 6. Do you s u p e r v i s e your own med ica t ion? yes need a s s i s t a n c e no 7. Do you look a f t e r your p h y s i c a l h e a l t h needs adequate ly? yes need a s s i s t a n c e no 8 . Are you ab le to budget your own money and manage banking? yes need a s s i s t a n c e no 9 . Do you look a f t e r your own r e c r e a t i o n a l needs l i k e l i b r a r i e s , or going to community c e n t r e s ? yes need a s s i s t a n c e no 10 . Can you manage to deal w i th government and s o c i a l agencies adequate ly? yes need a s s i s t a n c e no 11 . Do you look a f t e r your own t r a n s p o r t a t i o n needs? yes need a s s i s t a n c e no 12. Could you comment g e n e r a l l y on your f e e l i n g s about your independence? 119. Category I I I - S o c i a l Network Note: Casual acquaintances are people you know w e l l enough to have a cup o f c o f f e e w i t h , but not share i n t i m a c i e s . C lose f r i e n d s are those w i t h whom you can be i n t i m a t e and share your personal thoughts and f e e l i n g s . Do not i n c l u d e t h e r a p i s t s , s o c i a l workers and Venture workers . 1 . How many casual acquaintances do you have i n your present housing? 2 . How many c l o s e f r i e n d s do you have i n your present housing? 3 . How many casual acquaintances do you have o u t s i d e o f your present housing? ' 4 . How many c l o s e f r i e n d s do you have o u t s i d e o f your present housing? 5. How many l o o s e , casual r e l a t i o n s h i p s do you have w i t h f a m i l y ? 6 . How many c l o s e , i n t i m a t e r e l a t i o n s h i p s do you have w i t h f a m i l y ? 7. Could you comment on your s o c i a l l i f e ? 120. Category IV - Symptomatology *1 . In your present l i v i n g s i t u a t i o n are you l o n e l y ? Always Most o f the Time Sometimes Hardly ever Never * 2 . In your present l i v i n g s i t u a t i o n do you s u f f e r from f e e l i n g s of sadness? Always Most o f the Time Sometimes Hard ly ever Never 3 . In your present l i v i n g s i t u a t i o n i s your out look f o r the f u t u r e o p t i m i s t i c ? Always Most o f the Time Sometimes Hardly ever Never 4 . In your present l i v i n g s i t u a t i o n do you f e e l good about y o u r s e l f ( s e l f - e s t e e m ) ? Always < Most o f the Time Sometimes Hard ly ever Never * 5 . In your present l i v i n g s i t u a t i o n do you s u f f e r from unexpla ined a n x i e t y - ( f e e l i n g u p - t i g h t , tense f o r no good reason)? Always Most o f the Time Sometimes Hard ly ever Never 6 . In your present l i v i n g s i t u a t i o n do you f e e l ab le to s o l v e your problems? Always Most o f the Time Sometimes Hardly ever Never 7 . In your present l i v i n g s i t u a t i o n do you f e e l ab le to make d e c i s i o n s ? Always 0 Most o f the Time Sometimes Hardly ever Never * 8 . In your present l i v i n g s i t u a t i o n do you s u f f e r from fea rs t h a t prevent you from doing t h i n g s ? Always Most o f the Time Sometimes Hardly ever Never V 9 . In your present l i v i n g s i t u a t i o n i s your sense o f s e c u r i t y adequate? ( s a f e t y from e v i c t i o n i f you go to the h o s p i t a l ; secure w i t h a l i v e -i n c a r e t a k e r , and secure w i t h o ther tenants nearby whom you know?) Always Most o f the Time Sometimes Hardly ever Never 10. In your present l i v i n g s i t u a t i o n i s your s l e e p i n g pat tern s a t i s f a c t o r y ? Always Most o f the Time Sometimes Hardly ever Never * reverse we ight ing 121 . 1 1 . In your present l i v i n g s i t u a t i o n are you sure of y o u r s e l f ? ( s e l f - c o n f i d e n c e ) Always Most o f the Time Sometimes Hardly ever Never *12. In your present l i v i n g s i t u a t i o n do you have a problem w i t h being wi thdrawn, f e e l i n g i s o l a t e d , l a c k i n g i n s o c i a b i l i t y ? Always Most o f the Time Sometimes Hardly ever Never 1 3 . Could you comment g e n e r a l l y on your f e e l i n g s about your mental hea l th? Category V - Meaningful A c t i v i t y and P r o d u c t i v i t y What are the most important a c t i v i t i e s i n your l i f e ? Choose 3 . - c o m p e t i t i v e work f u l l t ime - c o m p e t i t i v e work par t t ime - s h e l t e r e d work f u l l t ime - s h e l t e r e d work par t t ime - VIP/CIP - v o c a t i o n a l t r a i n i n g - educat ion upgrading - v o l u n t e e r work - s tudy ing/ read ing f o r se l f - improvement - h a n d i c r a f t s - a t t e n d i n g d r o p - i n c e n t r e s , MPA/Kettl e/CMHA/Coast - r e g u l a r spor ts a c t i v i t i e s - s o c i a l i z i n g i n apartment lounge - r e g u l a r l y a t t e n d i n g programs a t community care teams - v i s i t i n g f r i e n d s - s o c i a l i z i n g i n pubs - v i s i t i n g c o f f e e shops r e g u l a r l y - ma in l y watching T .V . - s l e e p i n g - main ly s t a y i n g home a lone - o ther Could you comment g e n e r a l l y on the s t r u c t u r i n g o f your t ime? General comments about Coast Foundation S o c i e t y ? 

Cite

Citation Scheme:

        

Citations by CSL (citeproc-js)

Usage Statistics

Share

Embed

Customize your widget with the following options, then copy and paste the code below into the HTML of your page to embed this item in your website.
                        
                            <div id="ubcOpenCollectionsWidgetDisplay">
                            <script id="ubcOpenCollectionsWidget"
                            src="{[{embed.src}]}"
                            data-item="{[{embed.item}]}"
                            data-collection="{[{embed.collection}]}"
                            data-metadata="{[{embed.showMetadata}]}"
                            data-width="{[{embed.width}]}"
                            async >
                            </script>
                            </div>
                        
                    
IIIF logo Our image viewer uses the IIIF 2.0 standard. To load this item in other compatible viewers, use this url:
https://iiif.library.ubc.ca/presentation/dsp.831.1-0096000/manifest

Comment

Related Items