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Intensive case management and the multi-problem client : an evaluation of the inter-ministerial project Bradley, Gerald 1991

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INTENSIVE CASE MANAGEMENT AND THE MULTI-PROBLEM CLIENT: AN EVALUATION OF THE INTER-MINISTERIAL PROJECT by G e r a l d B r a d l e y B.A., U n i v e r s i t y o f P.E.I.; M.A., N a t i o n a l U n i v e r s i t y o f I r e l a n d ; B.S.W., U n i v e r s i t y o f B r i t i s h Columbia, A THESIS SUBMITTED IN PARTIAL FULFILMENT OF THE REQUIREMENTS FOR THE DEGREE OF MASTER OF SOCIAL WORK IN THE FACULTY OF GRADUATE STUDIES (School of S o c i a l Work) We accept t h i s t h e s i s as conforming t o the r e q u i r e d s t a n d a r d THE UNIVERSITY OF BRITISH COLUMBIA September, 1991 ©Gerald Bradley, 1991 In presenting this thesis in partial fulfilment of the requirements for an advanced degree at the University of British Columbia, I agree that the Library shall make it freely available for reference and study. I further agree that permission for extensive copying of this thesis for scholarly purposes may be granted by the head of my department or by his or her representatives. It is understood that copying or publication of this thesis for financial gain shall not be allowed without my written permission. Department of Soc ia l C/docfc The University of British Columbia Vancouver, Canada Date DE-6 (2/88) i i A b s t r a c t The purpose of t h i s study i s t o a s s e s s i f the I n t e r -M i n i s t e r i a l P r o j e c t (I.M.P.)/ an i n t e n s i v e case management p r o j e c t j o i n t l y sponsored by the G r e a t e r Vancouver Mental H e a l t h S e r v i c e s S o c i e t y , the F o r e n s i c P s y c h i a t r i c S e r v i c e s , 2and Vancouver A d u l t P r o b a t i o n , i s a s s o c i a t e d with a r e d u c t i o n i n the number of i n s t i t u t i o n a l bed day use of a non-random s e l e c t i o n o f 25 o f i t s c l i e n t s . The i n s t i t u t i o n a l venues c o n s i d e r e d were a l l B r i t i s h Columbia p r o v i n c i a l c o r r e c t i o n a l i n s t i t u t i o n s , the F o r e n s i c P s y c h i a t r i c I n s t i t u t i o n , and the p s y c h i a t r i c wings o f any g e n e r a l h o s p i t a l or any p r o v i n c i a l p s y c h i a t r i c h o s p i t a l . B y u s i n g a p r e -t e s t , p o s t - t e s t one group design, w i t h comparisons b e i n g made a t the one y e a r b e f o r e and d u r i n g p o i n t , and the two y e a r b e f o r e and d u r i n g p o i n t , the r e s u l t s i n d i c a t e a s i g n i f i c a n t r e d u c t i o n i n i n s t i t u t i o n a l bed day use a t both time p e r i o d s . By examining the dependent v a r i a b l e i n each of i t s component p a r t s — c o r r e c t i o n s , f o r e n s i c , and mental h e a l t h — r e s u l t s i n d i c a t e t h a t a l t h o u g h over-a l l i n s t i t u t i o n a l change a t the one y e a r and two y e a r f o l l o w - u p p o i n t s o b t a i n s s t a t i s t i c a l s i g n i f i c a n c e , i t i s o b t a i n e d o n l y through the g r e a t change i n c o r r e c t i o n s bed day use and no change i n e i t h e r f o r e n s i c or mental h e a l t h bed day use. There i s a l s o some i n d i c a t i o n that some of the savings i n bed days incurred by corrections might have been owing to bed days expended by the mental health system. Despite design l i m i t a t i o n s which resulted i n an i n a b i l i t y to i n f e r causation, the study shows that intensive case management i s associated p o s i t i v e l y with a reduction i n corrections system use by multi-problem c l i e n t s . There i s also a suggestion that there might be a t r a n s f e r r i n g of bed day use out of the corrections system and into the mental health system. Given these findings the author concludes that intensive case management might be seen as an e f f e c t i v e community intervention, both at reducing i n s t i t u t i o n a l use, and f o r d i r e c t i n g use towards i n s t i t u t i o n s more properly suited to the needs of multi-problem c l i e n t s . i v T a b l e of Contents Page A b s t r a c t i i L i s t o f T a b l e s v i i L i s t o f Appendices v i i i D e d i c a t i o n i x I n t r o d u c t i o n 1 Chapter 1 The M u l t i - P r o b l e m C l i e n t D efined 3 I n t r o d u c t i o n 3 H i s t o r y of D e i n s t i t u t i o n a l i z a t i o n 3 D e s c r i p t i o n s of Subgroups 7 The Young A d u l t C h r o n i c 7 The Dual Diagnosed 11 The Homeless M e n t a l l y 111 13 The M e n t a l l y 111 Offender 15 Comorbidity 18 The M u l t i - P r o b l e m C l i e n t 18 Summary 22 2 I n t e n s i v e Case Management as a Community I n t e r v e n t i o n 23 H i s t o r y of Case Management 23 D e f i n i t i o n s of Case Management 24 D e s c r i p t i o n s of What a Case Manager Does 26 V D e f i n i t i o n of Intensive Case Management 28 History of the I n t e r - M i n i s t e r i a l Project as an Intensive Case Management Program 28 A Li t e r a t u r e Review of Intensive Case Management Projects 31 Experimental Designs 31 Quasi-Experimental Designs. 33 Negative Findings 33 Case Management Projects i n the Vancouver Area 34 Summary 35 De f i n i t i o n s Used i n the Present Study 39 3 Methodology 40 The Independent Variable: Intensive Case Management 40 The Dependent Variable: I n s t i t u t i o n a l Use 40 Hypothesis 44 Time Parameters of the Study 47 Sample 47 Design 51 Limitations Due to Design 51 Data Analysis 55 4 Results 57 v i H y p o t h e s i s V e r i f i c a t i o n , 57 5 D i s c u s s i o n 62 One Year R e s u l t Compared t o Two Year R e s u l t s 64 Summary of R e s u l t s 65 References 69 Appendices 76 v i i L i s t of Tables Table Number Page 1 Pre-Test and Post-Test Results, One Year and Two Year Follow-Up 61 2 Answer To Question (1): Do You Have Any Such Cli e n t s on Your Caseload? 78 3 Answer To Question (2): I f "Yes," How Many of These Cli e n t s on Your Caseload?... 80 4 Frequency of Performance Scale and Average I n t e r - M i n i s t e r i a l Project Scores 91 v i i i L i s t of Appendices Appendix A Appendix B Appendix C Appendix D Appendix E Appendix F Operationalizing the Multi-Problem C l i e n t Questionnaire, Consent Form, Lette r s of Authorization The I n t e r - M i n i s t e r i a l Project as an Intensive Case Management Project. C l i e n t and Diagnosis L i s t Raw Data T r a n s i n s t i t u t i o n a l i z a t i o n i x In c ompleting t h i s work I would l i k e t o thank the s t a f f and c l i e n t s o f the I n t e r - M i n i s t e r i a l P r o j e c t . 1 I n t r o d u c t i o n The p u r p o s e o f t h i s s t u d y i s t o a s s e s s whether i n t e n s i v e c a s e management i s a s s o c i a t e d w i t h a r e d u c t i o n i n t h e i n s t i t u t i o n a l bed day use by m u l t i - p r o b l e m c l i e n t s . More s p e c i f i c a l l y , t h e i n t e n t i s t o a s s e s s i f t h e advent o f t h e I n t e r - M i n i s t e r i a l P r o j e c t ( I . M . P . ) , an i n t e n s i v e c a s e management p r o j e c t s p o n s o r e d j o i n t l y by t h e F o r e n s i c P s y c h i a t r i c S e r v i c e s , t h e G r e a t e r V a n c o u v e r M e n t a l H e a l t h S e r v i c e s S o c i e t y , and Vancouver A d u l t P r o b a t i o n , has been p o s i t i v e l y a s s o c i a t e d w i t h a change i n t h e i n s t i t u t i o n a l r e c i d i v i s m r a t e s o f a non-random sample o f 2 5 o f i t s c l i e n t s . As a n c i l l a r y q u e s t i o n s o f i n q u i r y t h i s s t u d y a l s o e x p l o r e s (a) w h e t her o r n o t any improvement i n i n s t i t u t i o n a l bed day use o c c u r s as t h e l e n g t h o f I.M.P. i n v o l v e m e n t i n c r e a s e s , and (b) how changes i n i n s t i t u t i o n a l bed day use impact t h e c o r r e c t i o n s , f o r e n s i c , and m e n t a l h e a l t h systems i n d i v i d u a l l y . T h i s a r e a s h o u l d be o f s i g n i f i c a n c e t o s o c i a l work f o r two main r e a s o n s . F i r s t o f a l l , what i s commonly d e f i n e d under t h e g e n e r a l r u b r i c o f i n t e n s i v e c a s e management, community i n t e r v e n t i o n s w h i c h i n c l u d e f u n c t i o n s o f l i n k i n g , m o n i t o r i n g , a s s e s s i n g , and advocacy, a r e seen by many as b e i n g synonymous w i t h s o c i a l work. S e c o n d l y , t h e r e i s a s m a l l b u t g r o w i n g body o f l i t e r a t u r e w h i c h s u g g e s t s t h a t t h e s o c i a l work p r o f e s s i o n i s a v o i d i n g t h e a r e a o f i n t e n s i v e c a s e management o f t h e c h r o n i c m e n t a l l y i l l , and t h a t t h i s i m p o r t a n t a r e a o f c a r e i s b e i n g m a i n t a i n e d by t h e n u r s i n g p r o f e s s i o n and o t h e r p a r a p r o f e s s i o n a l s . Such w r i t e r s as Deitchman (1980) and K u r t z , - B a g a r o z z i , and P o l l a n e 2 (1984) suggest that the reason f o r t h i s avoidance i s that the desire to p r o f e s s i o n a l i z e and the desire to engage i n the humble tasks of what i s seen as poverty work, often operate i n an inversely c o r r e l a t i o n a l fashion. Hopefully, the present study w i l l be seen as an example of s o c i a l work research operating counter to t h i s trend. In other research projects throughout the l i t e r a t u r e , intensive case management has generally been shown to be e f f e c t i v e intervention f o r reducing p s y c h i a t r i c h o s p i t a l recidivism. However, no other study has considered r e c i d i v i s m rates of e i t h e r corrections i n s t i t u t i o n s or forensic p s y c h i a t r i c i n s t i t u t i o n s , as part of the dependent vari a b l e . This i s despite the f a c t that i t i s now generally accepted that chronic mentally i l l use these systems i n much the same way that they use the mental health system, fo r reasons as varied as r e s p i t e and care. The present study may be seen as a new departure as i t includes these two i n s t i t u t i o n a l systems as part of i t s outcome measures. One of the shortcomings of many r e l a t e d research projects i s that they have not been s p e c i f i c about what the intervention e n t a i l s nor to the group to which the intervention i s being applied. In the present study, Chapter 1 concerns i t s e l f with def i n i n g the term multi-problem c l i e n t . The term i s used i n a very s p e c i f i c sense i n the Vancouver system of p s y c h i a t r i c aftercare, and i t overlaps with other well-known terms. Likewise, the intervention i s examined i n d e t a i l i n Chapter 2, with some attempts made to v e r i f y that the project under scrutiny i n t h i s paper, the I n t e r - M i n i s t e r i a l Project, i s an intensive case management project. 3 Most e v a l u a t i v e s t u d i e s use e i t h e r a two group randomized r e p e a t measures d e s i g n , o r a one group p r e - t e s t p o s t - t e s t d e s i g n . Because o f e t h i c a l and environmental l i m i t a t i o n s , t h e methodology used was t h a t o f a p r e - t e s t , p o s t - t e s t one group d e s i g n . The implementation o f and l i m i t a t i o n s o f t h i s t y p e o f d e s i g n are d i s c u s s e d a t l e n g t h i n Chapter 3. The s t a t i s t i c a l a n a l y s i s of t h e p r e - t e s t and p o s t - t e s t data occupy th e c e n t r a l p a r t o f Chapter 4. The r e s u l t s , d i s c u s s e d a t l e n g t h i n Chapter 5, i n d i c a t e t h a t i n t e n s i v e case management i s a s s o c i a t e d f a v o u r a b l y w i t h a r e d u c t i o n i n i n s t i t u t i o n a l bed day use. However, a f u r t h e r examination of t h e s e r e s u l t s shows t h a t t h i s r e d u c t i o n does not appear i n a l l t h r e e systems i n the same way. Chapter 5 concludes w i t h a l i s t o f t h e most important f i n d i n g s o f t h i s study and i n c l u d e s as w e l l recommendations f o r f u r t h e r r e s e a r c h . 4 Chapter One The M u l t i - P r o b l e m C l i e n t D e f i n e d I n t r o d u c t i o n The l i t e r a t u r e devoted t o d e s c r i b i n g both t h e m u l t i - p r o b l e m c l i e n t and treatment i n t e r v e n t i o n s i s s p a r s e and l o c a l i z e d t o the Vancouver system o f p s y c h i a t r i c a f t e r c a r e . I t i s c o n f i n e d t o the u n p u b l i s h e d works of a ha n d f u l o f Vancouver r e s e a r c h e r s and program p l a n n e r s . In o r d e r t o s u c c e s s f u l l y a s c e r t a i n what i s meant by the term, m u l t i - p r o b l e m c l i e n t , i t i s h e l p f u l t o examine t h e h i s t o r i c a l c o n t e x t i n which i t arose. I t i s a l s o h e l p f u l t o examine a number of o t h e r r e l a t e d terms which are d i s c u s s e d a t l e n g t h throughout the l i t e r a t u r e . H o p e f u l l y , a f t e r having examined a number o f thes e well-known groups w i t h which the m u l t i - p r o b l e m c l i e n t shares many f e a t u r e s , then a c l e a r d e f i n i t i o n can be made. H i s t o r y o f D e i n s t i t u t i o n a l i z a t i o n In o r d e r t o f u l l y understand what c o n s t i t u t e s a m u l t i - p r o b l e m c l i e n t , one must begin w i t h a b r i e f h i s t o r y o f d e i n s t i t u t i o n a l i z a t i o n . T h i s i s because many o f the groups which are now r e c o g n i z e d i n present-day community p s y c h i a t r y owe t h e i r o r i g i n t o events t h a t o c c u r r e d almost t h i r t y y e a r s ago. In the 1950's, a number of f a c t o r s combined t o r e s u l t i n t h e d i s c h a r g e o f thousands o f m e n t a l l y i l l people i n t o t h e community. The most important o f these events was the i n v e n t i o n o f p h e n o t h i a z i n e m e d i c a t i o n s , which suppressed many of the o v e r t symptoms o f severe psychopathology. Another f a c t o r was the i n c r e a s i n g p r e s s u r e brought about by the growing c i v i l r i g h t s c o n s c i o u s n e s s o f the 5 f i f t i e s and s i x t i e s to t r e a t i n d i v i d u a l s i n the l e a s t r e s t r i c t i v e s e t t i n g . There was also a growing optimism which created the b e l i e f that magnanimous things would stem from "the community" and "community psychiatry." The end r e s u l t was the p o l i c y now known as d e i n s t i t u t i o n a l i z a t i o n , a p o l i c y of such importance that i s now often refer r e d to as the t h i r d great revolution i n the care of the mentally i l l (Steinhart, 1973) . (The f i r s t two were the creation of the "mental hygiene" movement i n the e a r l y twentieth century and the invention of the phenothiazine medication i n the 1950's). D e i n s t i t u t i o n a l i z a t i o n was an exodus, a mass movement of people. In 1959 i t was estimated that there were approximately 559,000 people i n p s y c h i a t r i c h ospitals throughout the United States. By 1988 t h i s number was approximately 13 0,000 (Surber, Dwyer, Ryan, Goldfinger, and Kelly, 1988). Thus over a t h i r t y year period, the p s y c h i a t r i c hospital population i n the United Sates was reduced by over seventy f i v e percent. S i m i l a r trends were observed i n Canada. For example, i n Toronto, the number of inpatient beds decreased from 370 per 100,000 population i n 1955 to 69 per 100,000 in 1977 (Wasylenki, Plummer, and Littman, 1981). This represents a decrease of over eighty percent. In B r i t i s h Columbia, d e i n s t i t u t i o n a l i z a t i o n commenced l a t e r . Riverview Hospital, the sole p r o v i n c i a l p s y c h i a t r i c h o s p i t a l , d i d not begin discharging patients i n great numbers u n t i l the 1960's. In 1960 i t was estimated that Riverview's inpatient population was 5,500. By 1968 i t had been reduced to 3,430. By 1978 i t was 1,721 (Ministry of Health, 1979). In 1990 i t was estimated as being under 1,000. Thus i n the 30 year period between 6 1960 and 1990 t h e p a t i e n t p o p u l a t i o n o f R i v e r v i e w H o s p i t a l was reduced by r o u g h l y e i g h t y one p e r c e n t . The many problems t h a t f a c e d t h e d e i n s t i t u t i o n a l i z a t i o n movement a r e now w e l l documented (Brown, 1984; Dorwatt, 1980; Freedman, 1984). C h i e f among these was t h a t money f o r programs d i d not f o l l o w the d i s c h a r g e d m e n t a l l y i l l i n t o t h e community (Pepper, 1990). There was evidence t h a t t h i s money s t a y e d w i t h the i n s t i t u t i o n s , f o r , as Pepper f u r t h e r notes, t h e annual g e n e r a l budgets o f many p s y c h i a t r i c h o s p i t a l s a c t u a l l y i n c r e a s e d d u r i n g the c r i t i c a l y e a r s o f d e i n s t i t u t i o n a l i z a t i o n . The same was t r u e f o r Ri v e r v i e w H o s p i t a l . As The Report o f the Mental H e a l t h P l a n n i n g  Survey (1979) showed, d e s p i t e the f a c t t h a t p a t i e n t p o p u l a t i o n had f a l l e n d r a s t i c a l l y , n u r s i n g and support s t a f f i n c r e a s e d d u r i n g the c r i t i c a l y e a r s o f 1968-1978. Another key problem appeared t o be t h a t no one was g i v e n the r e s p o n s i b i l i t y o f s e a r c h i n g out, t r e a t i n g , and b e i n g h e l d a c c o u n t a b l e f o r the care of the most s e r i o u s l y m e n t a l l y i l l (Wasylenski, 1989). T h i s huge d i s c h a r g e d p o p u l a t i o n was l e f t , i n most c i r c u m s t a n c e s , t o fend f o r i t s e l f . I f a c h r o n i c m e n t a l l y i l l p erson d i d not p r e s e n t a t a l o c a l mental h e a l t h c e n t r e , i t was w i t h i n no one agency's mandate t o go out and attempt t o engage t h i s person i n treatment. Concern about d e i n s t i t u t i o n a l i z a t i o n and t h e many problems i t had c r e a t e d o c c u p i e d a c e n t r a l p a r t o f the l i t e r a t u r e o f the 1970*3 (Levine, 1980). The ge n e r a l consensus was t h a t i t was p o o r l y planned and p o o r l y implemented (Holden, 1972) . Another major c o n c l u s i o n was t h a t i t produced a system o f p s y c h i a t r i c a f t e r c a r e which was d i s j o i n t e d , uncoordinated, and f u l l o f s e r v i c e gaps 7 ( F u l l e r - T o r r e y , 1989) . Another problem t h a t was i d e n t i f i e d was t h e l a c k o f a c l e a r i d e a as t o what c o n s t i t u t e d the c h r o n i c m e n t a l l y i l l p o p u l a t i o n . W r i t e r s such as F u l l e r - T o r r e y (1986) began t o suggest t h a t what was b e i n g seen as one huge group of people, d e f i n e d as t h e c h r o n i c m e n t a l l y i l l , was i n r e a l i t y a c o l l e c t i o n o f v a r i o u s s u b s e t s o f people o f d i f f e r e n t d i a g n o s t i c c o n s t e l l a t i o n s . Barnes and Toews (1986), i n t h e i r review of the l i t e r a t u r e , suggested t h a t the r o o t s of the problem l a y i n the f a c t t h a t both the term " c h r o n i c " and " i l l n e s s " had too many p e r i p h e r a l i d e a s l o o s e l y a s s o c i a t e d w i t h them. Thus the l i t e r a t u r e o f the 1980 *s began t o wi t n e s s the d i s c o v e r y o f a number of marginal groups w i t h i n the g e n e r a l c a t e g o r y o f the c h r o n i c m e n t a l l y i l l . These i n c l u d e d such groups as the young a d u l t c h r o n i c , the dual-diagnosed, t h e m e n t a l l y i l l o f f e n d e r , and the homeless m e n t a l l y i l l . A l l o f these subgroups shared a common theme. These were the people who were o f t e n d e s c r i b e d as h a v i n g " f a l l e n through the c r a c k s , " where the " c r a c k s " r e f e r r e d t o gaps i n the p o o r l y c o o r d i n a t e d system o f p s y c h i a t r i c a f t e r c a r e . S i n c e each o f these subgroups o v e r l a p s w i t h the p o p u l a t i o n o f the p r e s e n t study, the mul t i - p r o b l e m c l i e n t , each w i l l be d e s c r i b e d f u r t h e r . D e s c r i p t i o n s o f Subgroups The young a d u l t c h r o n i c p a t i e n t . I t i s g e n e r a l l y b e l i e v e d t h a t t h i s important group was f i r s t noted by Pepper, K i r s h n e r , and Ryglewicz (1981). In t h e i r work, Pepper and h i s c o l l e a g u e s d e s c r i b e d p a t i e n t s who, d e s p i t e the f a c t t h a t they had spent v e r y l i t t l e time i n p s y c h i a t r i c h o s p i t a l s , p r e s e n t e d w i t h a h i g h degree of psychopathology and imp a i r e d s o c i a l 8 f u n c t i o n i n g . T h i s was d i s t u r b i n g , as t h i s was t h e f i r s t group of p e o p l e who had been the r e c i p i e n t s of a mental h e a l t h system not e ntrenched i n the o l d t h i n k i n g o f days b e f o r e d e i n s t i t u t i o n a l i z a t i o n . These were people who were t h e p r o d u c t s of community p s y c h i a t r y , and they were f a r i n g much worse i n the community than the o l d e r , i n s t i t u t i o n a l i z e d p a t i e n t s . Pepper e t a l (1981) d e s c r i b e d t h i s group as f o l l o w s : [ T h i s i s ] . . . a p o p u l a t i o n of young a d u l t c h r o n i c p a t i e n t s who have spent r e l a t i v e l y l i t t l e time i n h o s p i t a l s but who p r e s e n t p e r s i s t e n t and f r u s t r a t i n g problems t o community c a r e g i v e r s i n mental h e a l t h and o t h e r s o c i a l s e r v i c e s systems. We are r e f e r r i n g t o people between the ages o f 18 and 30 or 35 who are p s y c h i a t r i c a l l y and s o c i a l l y i m p a ired, so s e r i o u s l y , t h a t they are c o n t i n u a l l y and r e c u r r e n t l y c l i e n t s of mental h e a l t h and o t h e r s o c i a l s e r v i c e a g e n c i e s over a p e r i o d of y e a r s . . . D i a g n o s t i c a l l y , these young a d u l t s c a r r y a v a r i e t y of l a b e l s — s c h i z o p h r e n i a , o t h e r p s y c h o s i s , and p e r s o n a l i t y d i s o r d e r s prominent among them. Although they p r e s e n t a v a r i e t y of symptom p r o f i l e s , they share two o v e r a r c h i n g c h a r a c t e r i s t i c s : t h e i r severe d i f f i c u l t i e s i n s o c i a l f u n c t i o n i n g , and t h e i r tendency t o use mental h e a l t h s e r v i c e s i n a p p r o p r i a t e l y , i n ways t h a t d r a i n the time and energy of c l i n i c i a n s y e t do not conform t o v i a b l e treatment p l a n s . (p.463) Pepper e t a l (1981) a l s o p o i n t e d out t h a t t h i s was a new group, born out of the i n t e r f a c e between changing s o c i a l p r e s s u r e s , the l a c k o f r e l e v a n t a f t e r c a r e s e r v i c e s , and the i n a b i l i t y of c l i n i c i a n s t o d e a l w i t h the type of s h i f t i n g back and f o r t h between dependence and h o s t i l i t y c h a r a c t e r i s t i c o f t h i s type of c l i e n t . Pepper and h i s c o l l e a g u e s c o i n e d the terms " h o s t i l e - d e p e n d e n t " and " h e l p - s e e k i n g / h e l p r e j e c t i n g " t o d e s c r i b e t h i s c l i e n t ' s s t y l e of a c c e s s i n g mental h e a l t h s e r v i c e s . They d e s c r i b e d t h i s group as more c o m p l i c a t e d than the o l d e r d e i n s t i t u t i o n a l i z e d p a t i e n t because o f t h e many s o c i a l problems they had a l o n g w i t h t h e i r p s y c h i a t r i c problems. 9 Young a d u l t c h r o n i c p a t i e n t s l i v i n g i n t h e community are s o c i a l l y and p s y c h o l o g i c a l l y d i f f e r e n t from o l d e r d e i n s t i t u t i o n a l i z e d p a t i e n t s , and from t h o s e never-i n s t i t u t i o n a l i z e d , o l d e r c h r o n i c p a t i e n t s who a r e sometimes i n c l u d e d among the "new c h r o n i c s . " Younger p a t i e n t s are d i f f e r e n t because f a i l u r e i s new t o them; because they a r e s t i l l s t r u g g l i n g t o be l i k e t h e i r age-mates; because they have not l e a r n e d , as have d e i n s t i t u t i o n a l i z e d p a t i e n t s , t o be d o c i l e and do as they are t o l d ; because t h e y a c t out—many take d r u g s — i n the manner of withdrawn o r r e b e l l i o u s youth; and because they . are as l i k e l y t o blame mental h e a l t h p r o f e s s i o n a l s as they are t o t u r n f o r them f o r h e l p . (p.464) Robbins, S t e r n , Robbins, and M a r g o l i n (1978) had noted a s i m i l a r group a few years b e f o r e , but had not been a b l e t o b r i n g t h e type of compassion t o the t o p i c t h a t Pepper was c a p a b l e of d o i n g . They r e f e r r e d t o t h e i r group as "unwelcome p a t i e n t s . " Indeed, Robbins and h i s c o l l e a g u e s even went as f a r as t o recommend t h a t such an i n d i v i d u a l not be admitted t o h o s p i t a l " u n l e s s the c l i n i c a l p a t t e r n changed" ( p . 4 4 ) . Although they appeared t o focus on t h e n e g a t i v e q u a l i t i e s of t h i s group, the group d e s c r i b e d possessed c h a r a c t e r i s t i c s s i m i l a r t o t hose o f t h e young c h r o n i c . W i t h i n the l a r g e group of c h r o n i c p a t i e n t s i s a s m a l l but p r o b l e m a t i c subgroup of i n d i v i d u a l s who a r e i n a s t a t e of d i s e q u i l i b r i u m because they cannot adapt t o the community and cannot remain out of h o s p i t a l . T y p i c a l l y , they a r e young men w i t h few s o c i a l or v o c a t i o n a l s k i l l s who respond t o s t r e s s w i t h rage, o f t e n augmented by a l c o h o l i s m o r drug abuse. Although t h e i r symptoms respond w e l l t o the h o s p i t a l environment, they r e f u s e t o remain more than a s h o r t time, e i t h e r r e q u e s t i n g d i s c h a r g e or e l o p i n g . . . T h e y are d i s r u p t i v e and unmanageable i n the h o s p i t a l . They o f t e n i n s u l t s t a f f o r o t h e r p a t i e n t s and t h r e a t e n s t a f f who do not comply w i t h t h e i r wishes. They accept medicine, but r e j e c t any s u s t a i n e d t h e r a p e u t i c program, (p.44) Other r e s e a r c h e r s , most n o t a b l y Schwartz and G o l d f i n g e r (1981), were impressed by the h i g h number of p e r s o n a l i t y d i s o r d e r s found among groups of h i g h u s e r s of emergency mental h e a l t h s e r v i c e s . In keeping with o t h e r f i n d i n g s , Schwartz and G o l d f i n g e r noted how t h i s group tended t o be male (80%) , young (90% were under 10 35 y e a r s o f age) , s i n g l e (90%) , unemployed (90%)., and h e a v i l y i n v o l v e d i n drugs and a l c o h o l . They a l s o i l l u s t r a t e d the same h e l p - s e e k i n g / h e l p - r e j e c t i n g , or h o s t i l e - d e p e n d e n t way o f r e l a t i n g t o t h e mental h e a l t h system t h a t Pepper and h i s c o l l e a g u e s had noted. W i t h i n the emergency s e r v i c e s , t h e s e p a t i e n t s , f r e q u e n t l y brought i n i n v o l u n t a r i l y , are o f t e n angry, demanding, h o s t i l e , and u n c o o p e r a t i v e . T h e i r b e haviour towards the i n t e r v i e w e r and t h e i r a f f e c t i v e s t a t e may s h i f t d r a m a t i c a l l y d u r i n g an i n t e r v i e w , o f t e n l e a d i n g the i n t e r v i e w e r t o c o n c l u d e t h a t t h e i r r e q u e s t s are m a n i p u l a t i v e and i l l o g i c a l . A l t hough they b e g i n by dependently begging f o r whatever i n t e r v e n t i o n s the c l i n i c i a n s can o f f e r , they d i s d a i n f u l l y r e j e c t any treatment p l a n proposed. Such behaviour may f u r t h e r a l i e n a t e and confuse the emergency t h e r a p i s t , l e a d i n g t o f e e l i n g s of impatience, anger, and the wish t o r e j e c t t h e p a t i e n t , (p.44) E l y (1985), i n her work i n o r g a n i z i n g groups foc u s e d on the most t r o u b l e d p s y c h i a t r i c i n p a t i e n t s , d e s c r i b e d a s i m i l a r group. V a r y i n g s l i g h t l y from ot h e r w r i t e r s , her p e r s p e c t i v e seemed t o be more c o n c e n t r a t e d on the aspect o f an u n d e r l y i n g p e r s o n a l i t y d i s o r d e r . I t was t h i s f e a t u r e which she f e l t brought about many of the t h e i r problems i n a d j u s t i n g t o community l i f e . Indeed i t was t h e p e r s o n a l i t y d i s o r d e r , i n E l y ' s o p i n i o n , which caused such s t r o n g c o u n t e r t r a n s f e r e n c e r e a c t i o n s i n h e l p i n g p r o f e s s i o n a l s . E l y r e f e r r e d t o her new group as " s c h i z o p a t h s . " The author and o t h e r c l i n i c i a n s use the term " s c h i z o p a t h " t o d e s c r i b e young a d u l t s who have been diagnosed as c h r o n i c s c h i z o p h r e n i c s but who, i n r e m i s s i o n , o f t e n p r e s e n t as c h a r a c t e r - d i s o r d e r e d or s o c i o p a t h i c i n d i v i d u a l s . They r e g u l a r l y abuse drugs and a l c o h o l and g e n e r a l l y appear t o be wending t h e i r way through l i f e v i a m a n i p u l a t i o n , d e c e i t , and bravado. However, t h i s unsavoury facade i s q u i t e f r a g i l e . These i n d i v i d u a l s do not have the e m otional backup t o s u s t a i n such c h a r a c t e r o l o g i c a l manoeuvres. They a r e empty, sad, v u l n e r a b l e people who d e s p e r a t e l y use every s h r e d o f ego s t r e n g t h a v a i l a b l e t o s u r v i v e , (p.5) In keeping w i t h the views of o t h e r a u t h o r s , E l y d e s c r i b e d her 11 " s c h i z o p a t h s " as predominantly young, male, angry, drug dependent or drug a b u s i v e , and treatment r e s i s t a n t c l i e n t s . L i k e Pepper e t a l (1981) she s p e c u l a t e d t h a t much o f t h e i r d y s f u n c t i o n a l behaviour was owing t o a need t o p r o t e c t themselves from t h e thought o f the b l e a k f u t u r e they were f a c i n g . ...these young men review t h e i r c u r r e n t s i t u a t i o n and t h e i r l i v e s , g r i e v e f o r the l i f e a mbitions t h e y had p r i o r t o becoming mental p a t i e n t s , and q u i c k l y f a l l back i n t o the morass o f drugs and a l c o h o l t h a t c l e a r l y i s an attempt t o d u l l t he p a i n . The same wish t o a v o i d the p a i n and emptiness i n t h e i r l i v e s , coupled w i t h the i n a b i l i t y t o d e l a y g r a t i f i c a t i o n , gets p l a y e d out i n the arena o f m e d i c a t i o n . These c l i e n t s tend t o view m e d i c a t i o n e i t h e r as a p o t e n t i a l panacea f o r a l l t h e i r i l l s or as a "downer," as something t h a t b r i n g s them back t o a p a i n f u l r e a l i t y . Thus they e i t h e r beg and manipulate people t o get more m e d i c a t i o n o r they r e s i s t t a k i n g i t altogether....[We] have r e a l i z e d t h a t the t r a i t o f t h e s e young men t h a t has a l i e n a t e d c a r e g i v e r s — t h e w i l l i n g n e s s t o beg, borrow, or s t e a l t o get what they n e e d — i s , i n essence, the source of t h e i r ego s t r e n g t h . I t i s a coping mechanism f o r s t r e e t l i f e and needs t o be viewed by p r o f e s s i o n a l s w i t h i n the environmental c o n t e x t from which i t a r i s e s , (p.8) The appearance of the young a d u l t c h r o n i c was a d i s t u r b i n g phenomenon. In many ways i t made the b u s i n e s s o f c a r i n g f o r the c h r o n i c m e n t a l l y i l l an item of more s e r i o u s concern because young people were i n v o l v e d . The l i t e r a t u r e on the young a d u l t c h r o n i c a l s o r e v e a l e d the importance of substance abuse i n c r e a t i n g complex, d i a g n o s t i c c o n s t e l l a t i o n s , which l e a d s t h e way t o the next c a t e g o r y , the "dual-diagnosed." The dual-diagnosed. While the term dual-diagnosed i s most commonly used t o r e f e r t o i n d i v i d u a l s who have an a l c o h o l and drug problem and a mental i l l n e s s , i t i s a l s o used by s p e c i a l i s t i n the f i e l d o f mental r e t a r d a t i o n t o r e f e r t o i n d i v i d u a l s who are both m e n t a l l y r e t a r d e d and who have a mental i l l n e s s . Although i n c i d e n c e r a t e s v a r y a c c o r d i n g t o t h e d e f i n i t i o n s o f v a r i a b l e s used and type o f methodology employed, f i n d i n g s show t h a t t h e r a t e s o f mental i l l n e s s among the m e n t a l l y r e t a r d e d i s v e r y h i g h , somewhere between 30 and 67.3 p e r c e n t (Campbell and Malone, 1991). The 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 m e n t a l l y r e t a r d e d i s an ar e a t h a t has not been d i s c u s s e d t o the same e x t e n t as t h 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 t h e m e n t a l l y i l l , a lthough many o f t h e same mist a k e s d i d occur ( G u a l t i e r i , 1989). The term dual-diagnosed i n the l i t e r a t u r e o f p s y c h i a t r i c a f t e r c a r e has come t o r e f e r t o i n d i v i d u a l s who have problems s u f f i c i e n t l y severe t o warrant a d i a g n o s i s both i n t h e area o f mental i l l n e s s and substance abuse. E s t i m a t e s o f a c t u a l numbers v a r y a c c o r d i n g t o how one d e f i n e s "abuse" and "substance." Kofoed and Keys (1988) estimated t h a t upwards o f 37% o f peo p l e w i t h substance abuse problems a l s o had p s y c h i a t r i c problems w a r r a n t i n g a mental h e a l t h d i a g n o s i s . Approaching t h i s from the o t h e r d i r e c t i o n , Drake and Wallach (1989) e s t i m a t e d t h a t up t o 1/3 of a l l 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 s had sev e r e drug and/or a l c o h o l problems. Furthermore, they found t h a t d u a l diagnosed people tended t o be younger, predominantly male, more apt t o be treatment r e s i s t a n t , unable t o manage f o r themselves i n the c r u c i a l areas o f housing, p e r s o n a l hygiene, money management, and t h e s t r u c t u r i n g o f spare time. They a l s o showed g r e a t e r t e n d e n c i e s towards h o s t i l i t y , s u i c i d a l a c t i v i t y , and r e h o s p i t a l i z a t i o n . V a r i o u s d u a l - d i a g n o s i s p r o j e c t s a r e o n l y now b e i n g s e t up throughout North America with an emphasis on v i e w i n g the two a s p e c t s o f the c o n d i t i o n , mental i l l n e s s and substance abuse, as int e r - d e p e n d e n t f a c t o r s . There has a l s o been some movement i n t h i s 13 d i r e c t i o n from community mental h e a l t h c e n t r e s as treatment p h i l o s o p h i e s now frame the problem as i n t e r - d e p e n d e n t areas o f concern. The most r e c e n t annual r e p o r t o f t h e G r e a t e r Vancouver Mental H e a l t h S e r v i c e s S o c i e t y (1990) shows t h a t many o f t h e mental h e a l t h teams now r e c o g n i z e the h i g h p e r c e n t a g e o f d u a l diagnosed p a t i e n t s among t h e i r g e n e r a l c a s e l o a d s . The homeless m e n t a l l y i l l . A nother subgroup t h a t has come t o prominence d u r i n g t h e e a r l y e i g h t i e s i s t h a t o f the homeless m e n t a l l y i l l . Homelessness, as d e f i n e d by the I n t e r n a t i o n a l Year o f S h e l t e r (I.Y.S.H.C.) f o r the Homeless Committee (1986), " i s the absence o f a permanent home over which i n d i v i d u a l s have p e r s o n a l c o n t r o l and which p r o v i d e s the e s s e n t i a l needs o f s h e l t e r , p r i v a c y , and s e c u r i t y a t an a f f o r d a b l e c o s t " (Oberlander and F a l l i c k , 1986). A c c o r d i n g t o t h e I.Y.S.H.C, the homeless i n c l u d e people w i t h no s h e l t e r f o r v a r y i n g p e r i o d s o f time, those without permanent s h e l t e r , t h o se o c c a s i o n a l l y u s i n g emergency s h e l t e r , and those l i v i n g i n substandard d w e l l i n g s c o s t i n g i n excess o f 30% o f t h e i r t o t a l income. A r e c e n t Time  Magazine f e a t u r e a r t i c l e e s t imated t h a t t h e r e were over 2 m i l l i o n homeless people i n the U n i t e d S t a t e s (Lamar, 1988). Although most r e s e a r c h e r s agree t h a t t h e homeless are a heterogeneous group (Surber e t a l , 1988), most contend t h a t t h e r e i s c o n s i s t e n t l y h i g h r a t e s o f mental i l l n e s s r a n g i n g between 30% t o 50% (Lamb and Lamb, 1990; M o r i s e t t e and M c l n t y r e , 1989; Surber e t a l , 1988; Quick, 1990). The i n c i d e n c e r a t e o f substance abuse among the homeless i s a l s o v e r y h i g h . In one r e p o r t completed by Rosenheck and Leda (1991) of a nation-wide study o f homeless U.S. m i l i t a r y v e t e r a n s , 84% were found t o have a d i a g n o s i s o f e i t h e r o r 14 both substance abuse and mental i l l n e s s . S t u d i e s o f the homeless show t h a t t h i s group tends t o c o n t a i n a h i g h percentage o f young, male, m e n t a l l y i l l and drug and a l c o h o l i n v o l v e d i n d i v i d u a l s . In Arana's (1990) study o f the homeless m e n t a l l y i l l admitted t o a Ba l t i m o r e mental h e a l t h c e n t r e , 75% were between 18 and 3 9 years o f age, w i t h a l a r g e r e p r e s e n t a t i o n o f males (62%), and unattached (92%), i . e . w i t h o u t a roommate, spouse, o r c l o s e f a m i l y attachments. They were a l s o l i k e l y t o be unemployed (100%) . They were found t o have a v e r y h i g h i n c i d e n c e r a t e o f a d u a l - d i a g n o s i s c o n s i s t i n g o f a mental i l l n e s s and a substance abuse problem (31%), but were r e l a t i v e l y low i n the area of s c h i z o p h r e n i c d i a g n o s i s (26%). The group i l l u s t r a t e d a moderate r a t e o f p e r s o n a l i t y d i s o r d e r (42%). Of s p e c i a l note, a s m a l l number (4%) were diagnosed as b e i n g m e n t a l l y handicapped. Lamb and Lamb's (1990) study o f a s i m i l a r h o s p i t a l program i n C a l i f o r n i a c o r r o b o r a t e d Arana's r e s u l t s . Lamb and Lamb found the average age o f h i s study group t o be 31 y e a r s o f age, w i t h a l a r g e p a r t o f t h e sample (75%) being male. However, t h e i n c i d e n c e r a t e o f s c h i z o p h r e n i a was found t o be almost double t h a t o f the B a l t i m o r e study (66%). In keeping w i t h the f i n d i n g s o f the B a l t i m o r e study, substance abuse was v e r y h i g h (68%). The Lambs f u r t h e r noted t h a t a l a r g e percentage o f the study group (74%) had been a r r e s t e d a t l e a s t once, almost h a l f o f t h e s e f o r v i o l e n t c r i m e s . D e s p i t e the f a c t t h a t these two s t u d i e s d i f f e r e d i n some are a s , both authors concluded t h a t c o n t r a r y t o p o p u l a r o p i n i o n , when o f f e r e d s e r v i c e s , the homeless m e n t a l l y i l l were l i k e l y t o acc e p t them. In the Baltimore study, 78% of the group accepted an 15 a f t e r c a r e p l a n , and a s i z e a b l e p r o p o r t i o n o f t h i s group was s t i l l i n t reatment two y e a r s l a t e . S i m i l a r l y , t h e C a l i f o r n i a study found t h a t 53% o f the sample accepted placement i n board and c a r e f a c i l i t i e s , and another 10% accepted placement w i t h r e l a t i v e s o r f r i e n d s . Taken i n t o t a l , 2/3 o f t h e C a l i f o r n i a study group ac c e p t e d some s o r t of community placement when o f f e r e d . The C a l i f o r n i a study a l s o d i s c o v e r e d a c o r r e l a t i o n between age and an i n d i v i d u a l ' s w i l l i n g n e s s t o accept h e l p . I t found t h a t those under th e age of t h i r t y were more l i k e l y t o r e f u s e h e l p and t o deny t h e i r i l l n e s s than those over t h i r t y . Lamb and Lamb concluded as f o l l o w s : The homeless m e n t a l l y i l l p r e s e n t us w i t h one o f our g r e a t e s t c h a l l e n g e s ; the younger among them are perhaps the g r e a t e s t c h a l l e n g e of a l l . The younger persons a r e more apt t o have l i f e g o a l s , t o deny t h e i r dependency and t h e i r i l l n e s s , and t o be unready t o come t o terms w i t h l i v i n g i n a s h e l t e r e d , segregated, low-pressure environment... I t may be t h a t t h i s i s the group t h a t most c r i e s out t o us t o s e t a s i d e our p r e c o n c e i v e d i d e a l o g i e s , t o come f a c e t o f a c e w i t h c l i n i c a l r e a l i t y , and t o do what i s n e c e s s a r y t o p r o v i d e them wi t h support, p r o t e c t i o n , treatment, and r e h a b i l i t a t i o n , (p.305) The m e n t a l l y i l l o f f e n d e r . The term m e n t a l l y i l l o f f e n d e r has been i n t e r p r e t e d w i t h marked i n c o n s i s t e n c y by a number o f a u t h o r s . Monahan and Steadman (1983) used the term to d e s c r i b e f o u r subgroups: those found not g u i l t y by reason of i n s a n i t y ; those found u n f i t t o s t a n d t r i a l ; m e n t a l l y i l l sex o f f e n d e r s ; and m e n t a l l y i l l p r i s o n inmates who are sent t o mental h o s p i t a l s f o r treatment w h i l e s t i l l i n custody f o r c r i m i n a l o f f e n s e s . Other w r i t e r s such as Jemelka, T r u p i n , and C h i l e s (1989) use the term t o d e s c r i b e any i n d i v i d u a l i n a j a i l o r p r i s o n who has a d i a g n o s a b l e major mental i l l n e s s . S t a t e d most simply, the m e n t a l l y i l l o f f e n d e r may be d e f i n e d 16 as anyone who has a r e c o g n i z a b l e mental i l l n e s s and who comes i n t o c o n t a c t w i t h any branch of the c r i m i n a l j u s t i c e system. These branches may i n c l u d e p o l i c e i n t e r v e n t i o n , a r r e s t , d e t e n t i o n , c o u r t appearance, b a i l , s e n t e n c i n g , and i n c a r c e r a t i o n . T h i s group might i n c l u d e p e o p l e who commit crimes as a d i r e c t r e s u l t o f t h e i r mental i l l n e s s , and those whose c r i m i n a l a c t i v i t y i s not r e l a t e d t o t h e i r mental i l l n e s s . I t i s now g e n e r a l l y b e l i e v e d t h a t because o f the d e a r t h of community programs f o l l o w i n g i n the wake o f d e i n s t i t u t i o n a l i z a t i o n , many o f the c h r o n i c m e n t a l l y i l l a r e b e g i n n i n g t o s u r f a c e i n the c r i m i n a l j u s t i c e system. Unable t o c a r e f o r themselves they t y p i c a l l y are i n c a r c e r a t e d f o r vagrancy, s h o p l i f t i n g , o r minor a s s a u l t s , crimes a s s o c i a t e d with poverty, poor judgement, o r a l a c k o f s o c i a l s k i l l s . T h i s emergence has been r e c e n t l y termed the " c r i m i n a l i z a t i o n " of the c h r o n i c m e n t a l l y i l l . Abramson's (1972) d e s c r i b e d t h i s p r o c e s s as f o l l o w s : I f the e n t r y of persons e x h i b i t i n g m e n t a l l y d i s o r d e r e d b e h a v i o u r i n t o the mental h e a l t h system of s o c i a l c o n t r o l i s impeded, community p r e s s u r e w i l l f o r c e them i n t o t h e c r i m i n a l j u s t i c e system of s o c i a l c o n t r o l . F u r t h e r , i f t h e mental h e a l t h system i s f o r c e d t o r e l e a s e m e n t a l l y d i s o r d e r e d persons i n t o the community prematurely, t h e r e w i l l be an i n c r e a s e i n p r e s s u r e f o r use of the c r i m i n a l j u s t i c e system t o r e i n s t i t u t i o n a l i z e them....From my own vantage p o i n t as a p s y c h i a t r i c c o n s u l t a n t . . .mentally d i s o r d e r e d persons are b e i n g i n c r e a s i n g l y s u b j e c t e d t o a r r e s t and c r i m i n a l p r o s e c u t i o n . . . . P o l i c e seem t o be aware of the more s t r i n g e n t c r i t e r i a under which mental h e a l t h p r o f e s s i o n a l s are now a c c e p t i n g r e s p o n s i b i l i t y f o r i n v o l u n t a r y d e t e n t i o n and treatment, and thus regard a r r e s t and booking i n t o j a i l as a more r e l i a b l e way of s e c u r i n g i n v o l u n t a r y d e t e n t i o n o f m e n t a l l y d i s o r d e r e d persons. Once the c r i m i n a l j u s t i c e machinery i s invoked, i t i s f r e q u e n t l y h a r d t o s t o p . (p.15) T e p l i n ( 1 9 8 4 ) c a l l e d t h e s a m e p r o c e s s " t r a n s i n s t i t u t i o n a l i z a t i o n , " t h a t i s , the t r a n s f e r r i n g o f the c h r o n i c m e n t a l l y i l l from the back wards o f the mental h o s p i t a l s o f 17 the 50's and 60"s t o the back c e l l s i n l o c a l j a i l s o f t h e 70's and 80's. B o r z e c k i and Wormith (1985) d e s c r i b e d t h e c r i m i n a l j u s t i c e system as the l a s t p o s s i b l e step i n a s o c i a l c o n t r o l system t h a t has been g r e a t l y d e p l e t e d s i n c e d e i n s t i t u t i o n a l i z a t i o n . As they s t a t e , t h e c r i m i n a l j u s t i c e system i s t h e system o f d e f a u l t , t h e system " t h a t j u s t c a n ' t . s a y no." In o t h e r words, i t i s a system t h a t cannot r e s o r t t o cut-backs, s t r i c t e r a d m ission c r i t e r i a , and hidden b l a c k l i s t s t o keep people out o f t h e i r i n s t i t u t i o n s . In the o p i n i o n of many w r i t e r s , j a i l s have become the poor person's mental h e a l t h f a c i l i t y . I t i s v e r y d i f f i c u l t t o determine the exact number o f m e n t a l l y i l l o f f e n d e r s i n j a i l and p r i s o n p o p u l a t i o n s . E s t i m a t e s v a r y a c c o r d i n g t o the d e f i n i t i o n of "mental i l l n e s s " and " o f f e n d e r " used by the r e s e a r c h e r , as w e l l as t o the t y p e o f methodology used. Monahan and Steadman (1983) surveyed a t o t a l o f 307,276 o f f e n d e r s i n American s t a t e and f e d e r a l p r i s o n s and found an i n c i d e n c e r a t e of mental i l l n e s s of 6 .5%. S i m i l a r l y , i n a l a t e r study, Steadman, F a b i s i c k , Dvoskin, and Holsheen (1987) surveyed a sample o f 3,684 o f f e n d e r s i n New York s t a t e p r i s o n s and found an i n c i d e n c e r a t e o f 8%. In Canada, H o l l e y and A r b o l e d a - F l o r e z (1988) i n a survey of p r o v i n c i a l l y j a i l e d i n d i v i d u a l s i n A l b e r t a , found a v e r y h i g h i n c i d e n c e r a t e of 65%. In Vancouver, B r i t i s h Columbia, Hart and Hemphill (1989) , i n a survey of the Vancouver P r e t r i a l S e r v i c e s Centre, found an i n c i d e n c e r a t e of 23.8%. D e s p i t e t h e g r e a t v a r i e t y among f i n d i n g s , one b a s i c t r e n d seems t o be apparent: t h a t m e n t a l l y i l l o f f e n d e r s are more l i k e l y t o be found i n l a r g e numbers i n l o c a l p r i s o n s and p r e t r i a l c e n t r e s ( i n s t i t u t i o n s t r a d i t i o n a l l y used f o r minor o f f e n s e s and t o h o l d those a w a i t i n g t r i a l ) , than i n 18 p e n i t e n t i a r i e s ( i n s t i t u t i o n s used t o house i n d i v i d u a l s c o n v i c t e d o f more s e r i o u s crimes.) Co m o r b i d i t y . C o m o r b i d i t y i s the term used t o d e s c r i b e c o n d i t i o n s comprised by a combination o f diagnoses. What a l l o f t h e s e s u b g r o u p s — t h e young a d u l t c h r o n i c , the dua l diagnosed, the m e n t a l l y i l l o f f e n d e r , and the homeless m e n t a l l y i l l — h a v e i n common as c o n s t r u c t s i s t h a t they a re i d e n t i f i e d by the c e n t r a l t e n e t o f s e v e r e mental i l l n e s s w i t h the added f e a t u r e o f one o t h e r d i a g n o s i s , e i t h e r s o c i a l o r p s y c h i a t r i c . These f e a t u r e s i n c l u d e youth, c r i m i n a l i t y , homelessness, and substance abuse. In t h i s r e g a r d they a r e a l l c o n s t r u c t s comprised o f two inter - d e p e n d e n t v a r i a b l e s . Each o f the aforementioned c a t e g o r i e s i s i d e n t i f i a b l e by o n l y one c h a r a c t e r i s t i c , such as homelessness o r c r i m i n a l i t y , a l o n g w i t h the common denominator o f mental i l l n e s s . One then wonders what frame o f r e f e r e n c e might be used t o d e s c r i b e a group which has a l l o f t h e problems o f a l l o f these groups. T h i s l e a d s us i n t o the next group, the multi-problem c l i e n t , a term which i s a s s o c i a t e d w i t h the Vancouver system of p s y c h i a t r i c a f t e r c a r e . As a term i t s y n t h e s i s e s a l l the v a r i o u s groups d i s c u s s e d up t o t h i s p o i n t . The m u l t i - p r o b l e m c l i e n t . In Vancouver's downtown e a s t s i d e s e r v i c e s e c t o r — c o m m o n l y c a l l e d " s k i d r o w " — t h e r e has r e c e n t l y been a g r e a t d e a l o f focus on a s m a l l group which subsumes the f e a t u r e s o f a l l t h e aforementioned groups. T h i s group i s unique i n t h a t i t i s not e n t i r e l y d e s c r i b e d by the common terms which only suggest two types o f problems. T h i s group i s p r e s e n t l y known, r a t h e r i n a u s p i c i o u s l y , as the m u l t i -problem c l i e n t . Buckley (1990) d e f i n e s the term as f o l l o w s : 19 "Multi-problem" i s a c a t c h a l l term used to describe those i n d i v i d u a l s with mixed symptomatology and multiple d i a g n o s i s — not j u s t "dual"—who cannot or w i l l not be accommodated with the mandate of most e x i s t i n g service agencies....This group of i n d i v i d u a l s has a v a r i e t y of s o c i a l , behaviourial, and oftentimes medical problems which r e s u l t s i n t h e i r involvement with numerous service agencies....At various times, mu l t i -problem i n d i v i d u a l s w i l l d i s p l a y the following c h a r a c t e r i s t i c s : they are non-compliant, uncooperative, v e r b a l l y abusive, threatening and manipulative; they are occasionally v i o l e n t to e i t h e r or both property and others; and they are extremely d i f f i c u l t , i f not impossible, placement problems. Diagnostically these people can s u f f e r from paranoid schizophrenia, a b i - p o l a r i l l n e s s , a paranoid disorder, a borderline, a n t i - s o c i a l or sociopathic personality disorder; organic brain syndrome, mental retardation and chronic substance abuse. Usually they comprise a mixture of many of these, (p.2) Using the main features of Buckley's (1987) de s c r i p t i o n (see Appendix A, "Operationalizing the Multi-Problem C l i e n t " ) , i t appears that the group i s characterized by a d i s t i n c t diagnostic c o n s t e l l a t i o n of f i v e e s s e n t i a l features. These include (a) severe psychopathology, usually comprised of a major mental i l l n e s s , a personality disorder, substance abuse, or, to a lesser extent, mental retardation; (b) a h i s t o r y of treatment resistance; (c) a h i s t o r y of involvement with the c r i m i n a l j u s t i c e system; (d) a h i s t o r y of excessive use of i n s t i t u t i o n s (not j u s t p s y c h i a t r i c i n s t i t u t i o n s but criminal j u s t i c e system i n s t i t u t i o n s as w e l l ) ; and (e) because of a - d, a c e r t a i n amount of infamy, or a c e r t a i n reputation, within the l o c a l i z e d system of care of one medium sized c i t y , namely Vancouver. Thus for the purposes of t h i s study, the term multi-problem c l i e n t w i l l be defined as an i n d i v i d u a l who has a l l of these features. The term multi-problem person i n t h i s context i s used i n a s p e c i f i c and d i s t i n c t fashion p a r t i c u l a r to Vancouver. I t i s not found i n the l i t e r a t u r e of p s y c h i a t r i c aftercare as a s p e c i f i c 20 c l i n i c a l c o n s t r u c t . In the s o c i a l work l i t e r a t u r e , t h e term has been used i n a v e r y g e n e r a l sense, u s u a l l y synonymous w i t h the customary i d e a o f a person w i t h a l o t o f problems. In t h i s paper, the term m u l t i - p r o b l e m c l i e n t , r e f e r r i n g t o t h e c o n t e x t o f the Vancouver system o f p s y c h i a t r i c a f t e r c a r e , d e s c r i b e s something v e r y unique and s p e c i f i c . I t r e f e r s t o a p a r t i c u l a r c o n s t e l l a t i o n of p s y c h i a t r i c and accompanying s o c i a l f e a t u r e s which goes beyond t h o s e suggested by p r e v i o u s terms. The term i n t h i s c ontext appears t o have o r i g i n a t e d w i t h Buckley (1987), and then been used by o t h e r Vancouver r e s e a r c h e r s , most n o t a b l y Corrado (1987) and T i e n s (1988). I t has gone through a number of r e f i n e m e n t s : i n the m i d - e i g h t i e s t h i s same group was r e f e r r e d t o as "multi-systems abusers," but the term was changed because i t was f e l t t o be too p e j o r a t i v e (R. Buckley, p e r s o n a l communication, May 15, 1988) . In time i t appeared t o have gained so much acceptance t h a t i t served as the t o p i c f o r a two day c o n f e r e n c e sponsored by the M u l t i - S e r v i c e Network (1989) i n Vancouver. I t s e a r l i e r form, "multi-systems abuser," appeared i n The Mental H e a l t h C o n s u l t a t i o n Report (1987), t h e b l u e p r i n t f o r a l l mental h e a l t h s e r v i c e i n B r i t i s h Columbia throughout the 1990's. I t i s e s t i m a t e d t h a t 25-30% of o u t p a t i e n t mental h e a l t h p a t i e n t s are those who have been d e s c r i b e d as d i f f i c u l t and m u l t i - s y s t e m u s e r s . The young (18-35) a r e o v e r - r e p r e s e n t e d i n t h i s group. Often they have had l i t t l e o r no h o s p i t a l i z a t i o n , are noncompliant w i t h t r a d i t i o n a l o f f i c e - b a s e d treatment, and have few p e r s o n a l care, s o c i a l or j o b s k i l l s . Substance abuse i s o f t e n an e x a c e r b a t i n g problem. A l t h o u g h t h i s group i s r e l a t i v e l y s m a l l , i t i s important t o note, as i t s members tend t o use p r o p o r t i o n a l l y more s e r v i c e , o f t e n i n a r e v o l v i n g - d o o r f a s h i o n . There i s much evidence t o suggest t h a t t h i s group may be consuming a d i s p r o p o r t i o n a t e l y l a r g e p a r t of our mental h e a l t h c a r e d o l l a r , (p.3) I t appears t h a t the term m u l t i - p r o b l e m c l i e n t has enjoyed a 21 c e r t a i n p o p u l a r i t y among Vancouver mental heath workers and program p l a n n e r s . I t i s a dynamic concept t h a t i n c o r p o r a t e s both n o t i o n s o f p s y c h i a t r y and s o c i o l o g y . However, as a r e s e a r c h c o n s t r u c t , t h e r e a r e some s e r i o u s c o n c e p t u a l and m e t h o d o l o g i c a l l i m i t a t i o n s . The main l i m i t a t i o n i s t h a t the term has not been used w i t h any s o r t o f c o n s i s t e n c y throughout the l i t e r a t u r e . R e s e archers who have s t u d i e d t h i s p o p u l a t i o n have d e a l t w i t h t h i s problem o f d e f i n i t i o n i n a v a r i e t y o f ways. Corrado (1987) i n h i s c o s t e v a l u a t i o n o f 10 cases r e f e r r e d t o the M u l t i - S e r v i c e Network (M.S.N), a case c o o r d i n a t i n g and p l a n n i n g agency which s p e c i f i c a l l y t a r g e t s multi-problem c l i e n t s i n Vancouver, made no o v e r t r e f e r e n c e s t o the term. He merely r e f e r r e d t o h i s s u b j e c t s as "cases" d e a l t w i t h by the M u l t i - S e r v i c e Network, and suggested t h a t i f t h e r e was any homogeneity about t h i s s m a l l group i t was t h a t they were expensive c l i e n t s because of t h e g r e a t amount of community s e r v i c e s they used. T i e n s (1988) used t h e term m e n t a l l y  d i s o r d e r e d i n d i v i d u a l s w i t h m u l t i p l e problems. and he o p e r a t i o n a l i z e d the term t o stand f o r i n d i v i d u a l s who consumed, over a two yea r p e r i o d , s e r v i c e s from R i v e r v i e w H o s p i t a l , F o r e n s i c P s y c h i a t r i c I n s t i t u t e , and the G r e a t e r Vancouver Mental H e a l t h S e r v i c e s S o c i e t y . The assumption here was t h a t t h e r e was a r e c o g n i z a b l e group of people (estimated a t 457) who, f o r a w h i l e a t l e a s t , embark upon a c a r e e r o f p e r i p a t e t i c c o n t a c t w i t h i n p a t i e n t c a r e , o u t p a t i e n t c a r e , and c o n f l i c t w i t h the l e g a l system. Beggs (1979) i n a much e a r l i e r work, conducted a survey o f s e v e r a l downtown e a s t s i d e agencies and d i s c o v e r e d a group o f what she c a l l e d " d i f f i c u l t c a s e s " (estimated a t 147) w i t h f e a t u r e s o f severe p s y c h i a t r i c symptomatology, a l c o h o l and drug abuse, l a c k o f 22 s u i t a b l e housing, h i g h s e r v i c e consumption, g r e a t m o b i l i t y , and who were a l s o o f g r e a t expense t o m a i n t a i n . I t appears t h a t t h e Beggs work was completed b e f o r e the word i n both i t s forms, m u l t i - s y s t e m s  abuser and mu l t i - p r o b l e m c l i e n t , came i n t o p o p u l a r use. In these t h r e e r e l a t e d s t u d i e s o n l y T i e n s (1988) has p r o v i d e d a s p e c i f i c , o p e r a t i o n a l i z e d d e f i n i t i o n f o r the concept. For t h e purpose o f t h i s study, Buckley's (1987) d e f i n i t i o n r a t h e r than T i e n s ' (1988) d e f i n i t i o n , was used f o r two b a s i c reasons: F i r s t o f a l l , the f i v e p o i n t i n c l u s i o n c r i t e r i a reduced from Buckely's d e f i n i t i o n i s the c r i t e r i a t h a t t h e I n t e r -M i n i s t e r i a l P r o j e c t , the p r o j e c t under study, uses t o i d e n t i f y c l i e n t s i n i t s t a r g e t group. Secondly, Buckley's d e f i n i t i o n , d e s c r i b i n g as i t does many of the s o c i a l problems t h a t o c c u r as a r e s u l t o f t h i s p o p u l a t i o n ' s severe psychopathology, appears more encompassing than any oth e r d e f i n i t i o n . Summary T h i s c h a p t e r has t r a c e d the e v o l u t i o n o f s e v e r a l subgroups w i t h i n the huge c a t e g o r y of c h r o n i c m e n t a l l y i l l t hrough the e a r l y days of d e i n s t i t u t i o n a l i z a t i o n . I t has a l s o been i l l u s t r a t e d how the Vancouver c o n s t r u c t , the multi-problem c l i e n t , i s i n t h i s same t r a d i t i o n . . While t h i s group i s s i m i l a r t o o t h e r sub-groups d e s c r i b e d i n the l i t e r a t u r e , i t i s i n r e a l i t y a c a t e g o r y unto i t s e l f . Vancouver program p l a n n e r s have been aware o f the uniqueness o f t h i s group f o r some time, w i t h t h e r e s u l t t h a t a number o f programs have been c r e a t e d s p e c i a l l y f o r them. The I n t e r - M i n i s t e r i a l P r o j e c t , the program e v a l u a t e d i n the f o l l o w i n g c h a p t e r s , i s an example of one of these programs. 23 Chapter Two Intensive Case Management as an Intervention  Introduction This chapter describes the intervention of intensive case management evaluated i n t h i s study. In order to f u l l y understand what i s meant by intensive case management, a review of the l i t e r a t u r e concentrating on history, d e f i n i t i o n , and evaluation i s provided. How the I n t e r - M i n i s t e r i a l Project f i t s into the area of intensive case management i s also discussed as well as d i f f i c u l t i e s i n evaluating model programs elsewhere i n North America. History of Case Management I t i s now generally believed that during the c r i t i c a l years of d e i n s t i t u t i o n a l i z a t i o n , e f f e c t i v e community treatment interventions were lacking (Schulberg and Baker, 1975) . There were a few model programs i n i t i a t e d i n a v a r i e t y of settings, (Lamb, Heath, and Downing 1969; Anthony 1979), but for the most part, e f f e c t i v e community interventions were inconsistent and often encountered tremendous resistance from both the community and the i n s t i t u t i o n a l systems (Levine 1980) . One noted community intervention was that devised by Stein and Test (1980). Both Leonard Stein, a p s y c h i a t r i s t , and Mary Ann Test, a s o c i a l worker, were employees at the Mendota State Hospital i n Madison, Wisconsin. Using the h o s p i t a l as a base, they commenced working with newly-discharged patients i n the community on tasks of d a i l y l i v i n g such as cooking, shopping, and medication compliance, and found i n evaluating the project that the high r e c i d i v i s m rates of chronic mentally i l l p atients could be reduced. The concept was c a l l e d Training i n Community L i v i n g (T.C.L.). Although not a novel idea, i t was a new departure f o r mental health professionals because i t took the emphasis away from the more abstract aspects of mental health care such as counselling and psychotherapy, and placed i t i n the more concrete area of teaching s k i l l s f o r s u r v i v a l . In time t h i s new type of intervention was c a l l e d intensive case management. Over the years, case management became so well regarded that i t has now become a major focus of p o l i c y and f i s c a l reform of the mental health system (Rapp and Chamberlain, 1991) . The l i t e r a t u r e devoted to case management i s voluminous and s t i l l growing ra p i d l y . There appears to be two major themes to t h i s l i t e r a t u r e : works devoted to coming to some sort of d e f i n i t i o n as to what constitutes case management, and works devoted to describing or evaluating various case management projects. D e f i n i t i o n s of Case Management As an intervention, there i s very l i t t l e consensus as to what case management e n t a i l s . I n t a g l i a t a (1982) i s generally regarded as the writer who f i r s t set the parameters f o r a d e f i n i t i o n of case management. He described i t as a "...process, or method, for ensuring that consumers are provided with whatever services they need i n a coordinated, e f f e c t i v e , and e f f i c i e n t manner." What he meant by consumers were the chronic mentally i l l p atients l i v i n g i n the community. Schwartz (1982) defined case management as a process of "...providing a c l i e n t / p a t i e n t with an i n d i v i d u a l who i s ultimately responsible for coordinating the c l i e n t ' s care and treatment i n the l e a s t r e s t r i c t i v e s e t t i n g . " Ashley (1988) defined i t somewhat more generally as "a new focus on managed service d e l i v e r y . . . n e i t h e r a new a c t i v i t y or a new concept." Lamb (1980) defined the r o l e of case manager as being a "broker of s e r v i c e " for c l i e n t s / p a t i e n t s caught up i n a disorganized and fragmented system of care. S i m i l a r l y , Fuller-Torrey (1986) saw case management as a programmatic response to the breakdown i n the c o n t i n u i t y of care following i n the wake of d e i n s t i t u t i o n a l i z a t i o n . He described i t as "the glue that binds the otherwise fragmented services into arrangements that respond to the unique and changing needs of patients. 1 1 In the past few years, a number of writers have struggled with the lack of consensus as to a p r a c t i c a l d e f i n i t i o n of case management. Bachrach (1989), examining several d e f i n i t i o n s , stated that there were a c t u a l l y two types of case management services and, therefore, two types of d e f i n i t i o n s . There were those that were system-oriented, macro-focused and therefore r e q u i r i n g a "brokerage" type of d e f i n i t i o n . In t h i s type of service the case manager would act as a type of broker, or coordinator, of required services. Then there were those that were indi v i d u a l - o r i e n t e d , micro-focused and therefore c a l l i n g for more of a " r e l a t i o n s h i p " type of d e f i n i t i o n . In t h i s type of service the case manager would l i k e l y provide the most important ingredient, spending time with the c l i e n t , himself/herself. Extrapolating upon the theories of Harris and Bergman (1988), two program planners employed at the Community Connections Program i n Washington, D.C., Bachrach defined the individual-oriented type of case management as "an i n t e r a c t i o n a l phenomenon that consists of more than the mere sum of i t s constituent parts, [in] that the r e l a t i o n s h i p between patient 26 and case manager i s the es s e n t i a l ingredient." Deitchman (1979), i n a much e a r l i e r paper, found the same b i f u r c a t i o n happening with the d e f i n i t i o n and made the d i s t i n c t i o n between "coordinating case management pr o j e c t s , " and "intensive case management projects." Coordinating case management projects, he stated, were more l i k e l y to work with the system, while intensive case management projects were more l i k e l y to work with the i n d i v i d u a l . He used the analogy of the t r a v e l agent (coordinating case management project) versus the t r a v e l l i n g companion (intensive case management projects) to describe the diff e r e n c e . In the present study, case management i s of the intensive case management type. Descriptions of What a Case Manager Does Other writers have sought to define case management i n much more functional terms. They attempted to define i t by describing what a case manager does as opposed to what the term means. Hargreaves et a l (1984) described case management as comprising f i v e e s s e n t i a l functions: an assessment of the c l i e n t ' s needs; planning a service strategy to meet those needs; linkage of the c l i e n t to appropriate or needed services; monitoring both the c l i e n t ' s service p a r t i c i p a t i o n and services' a b i l i t y to d e l i v e r t h i s service; and advocacy when the c l i e n t i s accepting service or i f i t i s denied. S i m i l a r l y , S u l l i v a n (1981), l i s t e d the duties of a case manager as monitoring, l i n k i n g , integrating, expediting and planning. Likewise, Int a g l i a t a (1982), defined the case manager's job as assessing a c l i e n t ' s needs; developing a comprehensive care plan; arranging for services to be delivered; monitoring and assessing services; and evaluating service plans and follow-up. In 27 f a c t , v a r i a t i o n s on the theme of these f i v e core functions have resul t e d i n the J o i n t Commission on A c c r e d i t a t i o n of Hospitals (J.C.A.H.), a health care regulatory body i n the United states, designating assessment, planning, l i n k i n g , monitoring, and advocacy as the f i v e functions t y p i c a l of case management (Kurtz et a l , 1984) . Despite the s p e c i f i c i t y of the case manager's duties, a l l of these tasks may s t i l l be performed by a coordinating case management project which has no d i r e c t contact with c l i e n t s . The question remains, when does a case management project become an "intensive" case management project? Is i t , as Deitchman (1979) suggests, the point at which the case manager has face-to-face contact with the c l i e n t ? Bachrach (1990) provides the answer to t h i s question. She sees case management as occurring only when a human service generalist "assures c o n t i n u i t y of care by coordinating services at the c l i e n t l e v e l . " I t appears to be t h i s concept of "at the c l i e n t l e v e l " that i s c r i t i c a l . I t c a l l s for someone who i s constantly aware of the c l i e n t ' s needs, and the only way to achieve t h i s awareness i s through regular contact. A community mental health worker carrying a caseload of 35-40 indivi d u a l s i s not as l i k e l y to be aware of c l i e n t ' s changing needs as an intensive case manager who i s carrying only a caseload of 10. In describing the e s s e n t i a l features of a good case management project, Bachrach also l i s t s aggressive outreach, d i r e c t service provision, c r i s i s intervention, and program/resource development. According to Bachrach i t seems that a case management project can only become "intensive" when i t has something to be intensive about—namely, a caseload of c l i e n t s 28 the case managers see on a regular basis. Thus the main difference between an "intensive" case management project and a coordinating case management project i s the presence of a d i r e c t service component to the program with a small enough client-worker r a t i o to ensure some sort of intensivety of s e r v i c e . D e f i n i t i o n of Intensive Case Management For the purpose of t h i s study, intensive case management w i l l be defined to be a type of community based p s y c h i a t r i c intervention characterized by f i v e e s s e n t i a l features. These include: (a) an emphasis on developing a strong r e l a t i o n s h i p between the c l i e n t and the case manager (and therefore c a l l i n g f o r a small client-worker r a t i o ) ; (b) an emphasis on the tasks of l i n k i n g , advocating, assessing and monitoring; (c) an emphasis on teaching the type of concrete s k i l l s required of an i n d i v i d u a l with p s y c h i a t r i c and concomitant s o c i a l obstacles to function outside of i n s t i t u t i o n s i n the community; and (d) an o v e r - a l l commitment to the idea that the case manager i s the primary agent for ensuring that the community functioning of the c l i e n t i s maximized. History of the I n t e r - M i n i s t e r i a l Project as an Intensive Case  Management Program In the early 1980's in Vancouver's downtown eastside, several managers from the Ministry of S o c i a l Services and Housing (then c a l l e d the Ministry of Human Resources), the Forensic P s y c h i a t r i c Services, Greater Vancouver Mental Health Services Society, Vancouver Adult Probation, and the Alcohol and Drug Commission commenced a ser i e s of informal meetings to discuss the growing problem of i n d i v i d u a l s who had " f a l l e n through the cracks." These were people who had mental health problems, alcohol and drug problems, and who were constantly appearing i n probation o f f i c e s , b a i l o f f i c e s and court. These were people who were generally r e f e r r e d to as "multi-systems abusers." There was also some concern expressed about the fac t that t h i s group tended to be appearing i n larg e r numbers i n l o c a l j a i l s . The general consensus was that apart from the grave problems these people possessed on t h e i r own, the system was act u a l l y aggravating t h e i r problems by constantly r e f e r r i n g these c l i e n t s from one agency to the next, hoping that somewhere along the l i n e someone would take r e s p o n s i b i l i t y f o r them. The end r e s u l t of these discussions was that i n 1985 a case coordinating agency c a l l e d the Multi-Service Network (M.S.N.) was created. I t was planned that the M.S.N, would r e g u l a r l y hold case conferences on the most complex cases i n an attempt to e s t a b l i s h a service strategy, to document t h i s service strategy, and.to ensure that t h i s service plan would be put into e f f e c t . The M.S.N, d i d not provide any d i r e c t service to c l i e n t s , but instead coordinated, monitored, and gave advice to the services already working with the c l i e n t . In t h i s respect i t might have been viewed as a coordinating case management, as opposed to an intensive case management, project. A f t e r two years of operation, i t was found that there were s t i l l a small number of c l i e n t s who were not being adequately as s i s t e d . In response to t h i s , managers from Greater Vancouver Mental Health Services Society, Forensic P s y c h i a t r i c Services, and Vancouver Adult Probation Services decided to create an i n t e r -agency team to focus on t h i s r e l a t i v e l y small target group. I t was hoped that by creating a "hands on" team which would go out and engage t h i s c l i e n t group "on t h e i r own t u r f " i n t h e community, some o f t h e s e v e r e problems encountered by t h i s group c o u l d be d e a l t w i t h . I t was f e l t t h a t i n o r d e r t o a c c o m p l i s h such a t a s k t h e f o l l o w i n g i n g r e d i e n t s were necessary: a s m a l l w o r k e r - c l i e n t r a t i o (no more t h a t t e n t o one) ; a community based, as opposed t o o f f i c e based, treatment s e t t i n g ; and a focus on the t a s k s o f d a i l y l i v i n g , as opposed t o c o u n s e l l i n g or o t h e r more a b s t r a c t i n t e r v e n t i o n s . A l though t h e o r i g i n a l p l a n n e r s were not u s i n g t h e g u i d e l i n e s o f T r a i n i n g i n Community L i v i n g and o t h e r t e s t e d programs i n the U n i t e d S t a t e s , t h e i r methods were v e r y c l o s e t o those o u t l i n e d i n the l i t e r a t u r e (R. Buckley, p e r s o n a l communication, May 1989). As a r e s u l t , the I n t e r - M i n i s t e r i a l P r o j e c t (I.M.P.) was c r e a t e d i n January o f 1987 wit h one s t a f f each of from the G r e a t e r Vancouver Mental H e a l t h S e r v i c e s S o c i e t y and t h e F o r e n s i c P s y c h i a t r i c S e r v i c e s , and one p a r t - t i m e s t a f f from Vancouver A d u l t P r o b a t i o n . On December 31, 1990, the data c o l l e c t i o n p o i n t o f t h i s study, the I.M.P. s t i l l operated under the same mandate and the same s t y l e o f s e r v i c e d e l i v e r y . An examination of t h e job d e s c r i p t i o n o f the i n d i v i d u a l case managers ( c a l l e d "workers" by the I.M.P.), i l l u s t r a t e d t h a t the f u n c t i o n s o f assessment, l i n k i n g , m o n i t o r i n g , advocacy, and p l a n n i n g were s t i l l o f paramount importance. A t the time of t h i s e v a l u a t i o n , the I.M.P. s t i l l m a intained the same c l i e n t - w o r k e r r a t i o , u s u a l l y under t e n t o one, which a l l o w e d f o r g r e a t e r c l i e n t c o n t a c t . T h i s was i n comparison t o o t h e r o u t - p a t i e n t p s y c h i a t r i c s e r v i c e s i n Vancouver such as the S t r a t h c o n a Mental H e a l t h Team, which m a i n t a i n e d a w o r k e r - c l i e n t r a t i o o f 48-1, or the Broadway Mental H e a l t h Team (58-1) o r the Mount Pleasant Team (35-1), (Greater Vancouver Mental Health Services Society, 1990). On average, the I.M.P. saw t h e i r c l i e n t s 2.8 times a week. This was i n comparison to the Strathcona and other mental health teams which usually saw t h e i r chronic patients, on the average, once every 3 to 4 weeks to administer long-acting neuroleptic medications. Measured on an intensive case management frequency of a c t i v i t y scale (Kutz, Bagarozzi, and Pollane, 1984) (see Appendix C, "The I n t e r - M i n i s t e r i a l Project as an Intensive Case Management Project"), the I.M.P. showed that i t performed a l l of the 26 tasks t y p i c a l of an intensive case management project, h a l f of these on a weekly or d a i l y time frame. Some of these tasks included conducting telephone intakes, conducting o f f i c e intakes, performing emergency screening, taking s o c i a l h i s t o r i e s , conducting family interviews, forming service plans, arranging case conferences, taking, c l i e n t s to appointments, meeting with other agency s t a f f , v i s i t i n g with c l i e n t s i n other f a c i l i t i e s , interceding for c l i e n t s to obtain service, interceding i n personal disputes, and others. Because of t h i s i t was assumed that the I.M.P. was an intensive case management project, and not a coordinating case management project or any other s i m i l a r type of service. A L i t e r a t u r e Review of Case Management Evaluations  Experimental designs. The f i r s t published study of an intensive case management project was that reported by Stein and Test (1975). Using a randomized two-group design, they found that with the intervention of intensive case management, hos p i t a l rates and symptom l e v e l s f o r chronic mentally i l l patients could be reduced, occupational 32 f u n c t i o n i n g i n c r e a s e d , and the p a t i e n t ' s o v e r - a l l q u a l i t y o f l i f e , measured on r e l e v a n t psychometric t o o l s , improved. Marx 's (1980) study, a g a i n u s i n g a randomized two-group d e s i g n , found t h a t a l t h o u g h h o s p i t a l i z a t i o n r a t e s f o r c h r o n i c p a t i e n t s were reduced, symptom l e v e l s remained the same.- Furthermore, he a l s o found t h a t o n l y s o c i a l f u n c t i o n i n g , and not o c c u p a t i o n a l f u n c t i o n i n g , was improved w i t h i n t e n s i v e case management. S t e i n and T e s t (1980) repeated t h e i r experiment once a g a i n and found the same r e s u l t s : h o s p i t a l i z a t i o n r a t e s were reduced, symptom l e v e l s reduced, and o v e r - a l l f u n c t i o n i n g i n c r e a s e d . A l s o added t o t h i s study was an economic e v a l u a t i o n which i n d i c a t e d t h a t c l i e n t s a t t a c h e d t o an i n t e n s i v e case management p r o j e c t c o s t the mental h e a l t h system l e s s money to m a i n t a i n . Mulder (1985), r e p e a t e d the same experiment u s i n g a s i m i l a r methodology and found t h a t , a l t h o u g h h o s p i t a l i z a t i o n r a t e s were reduced and t h e case managed study group found t o be l e s s expensive t o m a i n t a i n i n the community, t h e r e tended t o be more s u i c i d a l b e h a v i o u r among the study group. Bond (1989), used a two-group randomized methodology, and found t h a t h o s p i t a l r a t e s were reduced f o r t h e study group, but t h a t community f u n c t i o n i n g , both o c c u p a t i o n a l l y and s o c i a l l y , was not a l t e r e d . He a l s o found t h a t c l i e n t s r e c e i v i n g i n t e n s i v e management s e r v i c e s were more s a t i s f i e d w i t h t h e i r c a r e than c o n t r o l s r e c e i v i n g o r d i n a r y mental h e a l t h f o l l o w - u p s e r v i c e s . J e r r e l and Hu (1989), used a two-group randomized d e s i g n , and found t h a t although t h e r e was some d i f f e r e n c e i n h o s p i t a l r a t e s between case managed s t u d i e s and unattached c o n t r o l s , i t was not found t o 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 . They a l s o found no n o t i c e a b l e d i f f e r e n c e between the two groups' q u a l i t y o f l i f e . 33 Morse ( u n p u b l i s h e d , r e p o r t e d i n O l f s o n , 1990), u s e d a two-group randomized d e s i g n and found t h a t w i t h homeless m e n t a l l y i l l p a t i e n t s r e c e i v i n g c a s e management s e r v i c e s , homeless days c o u l d be r e d u c e d . There was a l s o an i n c r e a s e i n c l i e n t s a t i s f a c t i o n w i t h t h e q u a l i t y o f s e r v i c e t h e y were r e c e i v i n g . T h e i r l e v e l o f symptomatology, however, was not e f f e c t e d . Q u a s i - E x p e r i m e n t a l d e s i g n s . B o r l a n d (1989), used a one group r e p e a t measures d e s i g n and found t h a t a l t h o u g h h o s p i t a l i z a t i o n r a t e s f o r 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 s were r e d u c e d , a c u t e c a s e s were r e l y i n g more h e a v i l y upon o t h e r p a r t s o f t h e s e r v i c e systems such as emergency s h e l t e r s and b o a r d i n g homes. W r i g h t (1989), used t h e same methodology, and found t h a t h o s p i t a l a d m i s s i o n s were reduced and t h a t c l i e n t s were more s a t i s f i e d w i t h t h e t y p e o f s e r v i c e t h e y were r e c e i v i n g . S t e i n and Diamond (1985), used a r e p e a t measures d e s i g n and v e r i f i e d t h e e a r l i e r f i n d i n g s o f S t e i n and T e s t (1975) t h a t h o s p i t a l a d m i s s i o n s were r e d u c e d t h r o u g h i n t e n s i v e c a s e management. C u t l e r , Tatum, and Shore (1987) used r e p e a t measures on t h r e e non-randomly a s s i g n e d g r o u p s , a c a s e managed group, a group who r e g u l a r l y a t t e n d e d a d r o p - i n c e n t r e , and group w h i c h r e c e i v e d r e g u l a r m e n t a l h e a l t h c a r e . They found t h a t a l t h o u g h t h e c a s e managed group were h o s p i t a l i z e d f o r fewer days, t h e i r symptoms were n o t any l e s s s e v e r e t h a n t h e o t h e r two g r o u p s , n o r was t h e i r community f u n c t i o n i n g any b e t t e r . F u r t h e r m o r e , t h e i r o v e r - a l l q u a l i t y o f l i f e was worse t h a n t h e group t h a t r e g u l a r l y a t t e n d e d t h e d r o p - i n c e n t r e . N e g a t i v e f i n d i n g s . O n l y F r a n k l i n , S o l o v i t z , Mason, d e m o n s , and M i l l e r (1987), u s i n g a two-group randomized d e s i g n , have r e p o r t e d n e g a t i v e f i n d i n g s i n t h e area of h o s p i t a l admissions. In a comparison of two groups o f 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 s they found t h a t those who were the r e c i p i e n t s of a case management s e r v i c e were, i n f a c t , h o s p i t a l i z e d a t a h i g h e r r a t e than unattached c o n t r o l s . Furthermore, a l t h o u g h they found t h a t o c c u p a t i o n a l f u n c t i o n i n g was improved t o some degree, both groups r e p o r t e d no s i g n i f i c a n t i n c r e a s e i n t h e i r o v e r - a l l q u a l i t y o f l i f e . F r a n k l i n and h i s c o l l e a g u e s made an i n t e r e s t i n g s p e c u l a t i o n i n s u g g e s t i n g t h a t s i n c e advocacy was a c e n t r a l f u n c t i o n of case management, i t seemed l i k e l y t h a t c h r o n i c m e n t a l l y i l l c l i e n t s might be h o s p i t a l i z e d a t a g r e a t e r r a t e when someone, such as a case manager, was championing t h e i r cause. Case Management P r o j e c t s i n the Vancouver Area In Vancouver, case management p r o j e c t s have been the o b j e c t of much l e s s r i g o r o u s methods of e v a l u a t i o n . Corrado (1987), i n h i s c o s t measurement study of a non-random sample o f 10 c l i e n t s of the M u l t i - S e r v i c e Network (a case c o o r d i n a t i n g as opposed t o i n t e n s i v e case management p r o j e c t ) , found t h a t c o s t s were g r e a t l y reduced, but not e q u a l l y t o a l l a s p e c t s of the c a r e system. He found t h a t c o s t s t o the C o r r e c t i o n s system ( j a i l , c o u r t , p r o b a t i o n , e t c . ) were moderately i n c r e a s e d ; t h a t c o s t s t o the M i n i s t r y of S o c i a l S e r v i c e s and Housing (Welfare) were moderately i n c r e a s e d ; and t h a t c o s t s t o the M i n i s t r y of H e a l t h (Mental Health) were s u b s t a n t i a l l y reduced. He i n d i c a t e d t h a t although o v e r - a l l s a v i n g s occur, some p a r t s of the c a r e system a c t u a l l y experienced an i n c r e a s e i n c o s t s . Etches (1989) s t u d i e d 86 p a t i e n t s d i s c h a r g e d from R i v e r v i e w and p l a c e d i n p s y c h i a t r i c b oarding homes w i t h n u r s i n g f o l l o w - u p . T h i s arrangment might be seen as a t y p e o f c a s e management program a l t h o u g h he d e s c r i b e d i t as an " o u t r e a c h i n i t i a t i v e p r o g r a m . " He found t h a t o u t r e a c h program p a t i e n t s had t h e i r community t e n u r e i n c r e a s e d from 30% t o 78%., t h a t symptom l e v e l s were r e d u c e d , and community f u n c t i o n i n g i n c r e a s e d . I t i s d i f f i c u l t t o compare t h e s e r e s u l t s t o any o t h e r case management p r o j e c t , as i t i s no t c l e a r what arrangements f o r r e t u r n i n g p a t i e n t s were made between the h o s p i t a l and t h e b o a r d i n g homes. T h i s c l e a r l y confounds the main outcome measure , h o s p i t a l r e c i d i v i s m . A l s o , t h e r e l a t i v e l y advanced mean age o f t h e s t u d y p o p u l a t i o n , a t 43, i s a t l e a s t t e n y e a r s h i g h e r t h a n the mean age o f most s t u d i e s . One might s u s p e c t t h a t t h i s i s an o l d e r i n s t i t u t i o n a l i z e d p o p u l a t i o n t h a t t h e h o s p i t a l was t r y i n g t o move out i n t o a l t e r n a t e c a r e , r a t h e r t h a n a young c h r o n i c p o p u l a t i o n o r a group o f m u l t i - p r o b l e m c l i e n t s . Summary The c o n f l i c t i n g r e s u l t s r e p o r t e d i n t h e l i t e r a t u r e e v a l u a t i n g i n t e n s i v e case management p r o j e c t s p o s s i b l y r e f l e c t s d i f f e r e n t d e f i n i t i o n s and d e s i g n s used i n the s t u d i e s . Taken as a body o f work, t h e l i t e r a t u r e e v a l u a t i n g the many i n t e n s i v e c a s e management programs p r e s e n t s a number o f d i f f e r e n t p r o b l e m s . F i r s t o f a l l , as Rapp and C h a m b e r l a i n (1991) have p o i n t e d out i n t h e i r r e v i e w o f the l i t e r a t u r e , t h e r e appears t o be v e r y l i t t l e s t a n d a r d i z a t i o n o f d e f i n i t i o n s o f the c l i e n t p o p u l a t i o n . Most p r o j e c t s s t a t e v e r y g e n e r a l l y t h a t t h e i r focus i s the c h r o n i c m e n t a l l y i l l , b u t t h i s i s a v e r y l a r g e and somewhat amorphous group t h a t c o u l d r e a l l y c o n t a i n many subgroups w i t h v a r i a b l e h o s p i t a l use and i d i o s y n c r a t i c e f f e c t s upon o t h e r dependent v a r i a b l e s . Some p r o j e c t s do n o t i n c l u d e p e o p l e w i t h a d r u g a n d / o r a l c o h o l p r o b l e m s , o r g a n i c b r a i n syndrome, 36 a d i a g n o s i s o f mental r e t a r d a t i o n , o r a d i a g n o s i s or b o r d e r l i n e o r another p e r s o n a l i t y d i s o r d e r . D e s p i t e t h e m e t h o d o l o g i c a l s u p e r i o r i t y o f r u l i n g out these v a r i a b l e s , one wonders i f the i n t e r v e n t i o n b e i n g measured has any u t i l i t y as c l i e n t s r a r e l y come w i t h a s i n g l e problem c a l l i n g f o r a s i n g l e s o l u t i o n . Secondly, O l f s o n (1990) i n h i s l i t e r a t u r e review notes t h a t the d u r a t i o n o f most s t u d i e s i s too l i m i t e d . Many ar e s u r v e y i n g r e l a t i v e l y s h o r t p e r i o d s of t i m e — s i x months, o r , a t t h e most, one y e a r . S i n c e c h r o n i c m e n t a l l y i l l people s u f f e r from l i f e l o n g c o n d i t i o n s , i t i s d o u b t f u l i f e v a l u a t i o n s o f such s h o r t d u r a t i o n are u s e f u l . I t i s now r e c o g n i z e d t h a t the p a t t e r n o f acuteness, h o s p i t a l i z a t i o n , convalescence, and r e m i s s i o n spans y e a r s i n i t s r e p e t i t i v e o c c u r r e n c e . A s i x month or a one y e a r p e r i o d o f study w i l l l i k e l y miss t h i s important i n f o r m a t i o n . L i k e w i s e , i t i s now acknowledged t h a t any program, i n c l u d i n g a program o f i n t e n s i v e case management, i s l i k e l y t o e x p e r i e n c e good r e s u l t s i n the e a r l y s t a g e s simply because i t i s new and both workers and c l i e n t s e x p e r i e n c e a b r i e f p e r i o d of enthusiasm. The "honeymoon" f a c t o r of a l l new programs i s an e s t a b l i s h e d f a c t , and i t i s an even s t r o n g e r confounding f a c t o r i f the e n t r y p o i n t i n t o a program i s from a f a c i l i t y where some s o r t of d e t e n t i o n o r l o s s of l i b e r t y has o c c u r r e d . I n t e n s i v e case management p r o j e c t s which take t h e i r c l i e n t s d i r e c t l y from p s y c h i a t r i c h o s p i t a l s o r j a i l s might be measuring the b e n e f i t gained from l i b e r t y r a t h e r than the e f f e c t s of i n t e n s i v e case management. T h i r d l y , t h e r e i s some q u e s t i o n as t o whether i t i s t r u l y i n t e n s i v e case management t h a t i s b e i n g s t u d i e d . Few s t u d i e s a c t u a l l y d e f i n e what i s meant by i n t e n s i v e case management. Few studies analyze the job descriptions of the i n d i v i d u a l s providing the service, nor are the key features of an intensive case management program ( p o l i c i e s of outreach, client-worker r a t i o s , and d i r e c t service) often evaluated. There i s v i r t u a l l y no d i s t i n c t i o n made between intensive case management and coordinating case management. I t i s possible that what i s being c a l l e d intensive case management i n one study might be c a l l e d t r a d i t i o n a l mental health service i n another study i n an area with a more developed system of aftercare. The same c r i t i c i s m applies to two-group comparative designs: often the alternate treatment i s not defined. For example, Cutler et a l (1987) , compared a case managed group to a group that received t r a d i t i o n a l mental health follow-up. Depending on what part of North America one l i v e s i n , " t r a d i t i o n a l mental health follow-up" could range anywhere from bi-weekly appointments with a s k i l l e d t h e r a p i s t , to a monthly i n j e c t i o n and a b r i e f chat, to absolute neglect. Thus any improvements i n h o s p i t a l rates, symptom l e v e l s , and community functioning could be s o l e l y as a r e s u l t of some intervention as opposed to none. F i n a l l y , the dependent variable i n p r a c t i c a l l y every case, that of h o s p i t a l admissions, i s never given the intense scrutiny that i t should be given. As Rapp and Chamberlain (1991) have suggested, with the l o c a l i z e d nature of each of these intensive case management projects and the r e l a t i v e l y small numbers of c l i e n t s involved, perhaps there i s a s p e c i a l arrangement between the l o c a l p s y c h i a t r i c hospitals and the intensive case management project to t r e a t case managed studies d i f f e r e n t l y when they present at an emergency waiting room. I f , for example, a chronic mentally 38 i l l person presents at an emergency waiting room and the h o s p i t a l s t a f f know they can phone a case manager who w i l l take the person elsewhere—to a hostel, or some type of community p s y c h i a t r i c f a c i l i t y — t h e n t h i s i s l i k e l y to happen. I f t h i s i s the case, then i t would c e r t a i n l y make a difference i n admission rates between the case managed c l i e n t s and the, supposedly, randomized contr o l s . I t would then be the process (case managers intervening to r e d i r e c t p s y c h i a t r i c emergencies) , not the outcome ( c l i e n t s not needing to go to h o s p i t a l as much because of the intensive case management they are re c e i v i n g i n the community), that i s being evaluated. Given the recent findings of T e p l i n (1987) that many mentally i l l people use l o c a l j a i l s for much the same purpose as l o c a l p s y c h i a t r i c hospitals, i t i s unfortunate that only Wright (1989) and Stein and Test (1981) expand the dependent v a r i a b l e i n t h e i r experiment to include t h i s information. No research project was found which used days spent i n fo r e n s i c p s y c h i a t r i c f a c i l i t i e s as part of the outcome measures. An i n d i v i d u a l s ' r e h o s p i t a l i z a t i o n record during a one-year follow up period might look deceptively admission-free i f t h i s i n d i v i d u a l has spent a l l or part of t h i s time i n a j a i l or a forensic f a c i l i t y . Using only r e h o s p i t a l i z a t i o n rates as an outcome measure reveals a bias i n thinking which assumes that there i s a d i r e c t r e l a t i o n s h i p between h o s p i t a l i z a t i o n rates and degree of symptomatology. As both Rapp and Chamberlain (1991) and Drake and Wallach (1988) have shown, many chronic mentally i l l use hospitals f o r other reasons such as lo n e l i n e s s , hunger, or homelessness. I t i s only by examining a l l i n s t i t u t i o n a l venues that an i n d i v i d u a l ' s community functioning can be t r u l y assessed. 39 D e f i n i t i o n s Used i n the Present Study In the present study, some attempts have been made to avoid the p i t f a l l s of previous studies, f i r s t of a l l by providing a c l e a r d e f i n i t i o n of the population being studied. The subjects of the study are not j u s t loosely described as being chronic mentally i l l , but form a small group of multi-problem c l i e n t s which have the f i v e features outlined i n Buckley's d e f i n i t i o n and which are the same c r i t e r i a used to accept r e f e r r a l s to the I n t e r - M i n i s t e r i a l Project. Secondly, t h i s study c l e a r l y defines the independent v a r i a b l e , intensive case management, as exemplified by the program provided by the I n t e r - M i n i s t e r i a l Project. T h i r d l y , the dependent va r i a b l e , i n s t i t u t i o n a l use—comprised of days i n j a i l , days i n h o s p i t a l , and days i n a forensic p s y c h i a t r i c u n i t — i s an expansion beyond the usual methods of c o l l e c t i n g data on ju s t h o s p i t a l admissions alone. This allows for the fact that many chronic mentally i l l now use j a i l s and forensic i n s t i t u t i o n s i n much the same way as they once used p s y c h i a t r i c i n s t i t u t i o n s . Summary In t h i s chapter, intensive case management has been defined. Various intensive case management projects have been discussed, and t h e i r methods of evaluation examined. The program under evaluation i n the following chapters, the I n t e r - M i n i s t e r i a l Project, has been seen to be t y p i c a l of an intensive case management project. The remainder of t h i s paper w i l l be concerned with assessing whether or not the I.M.P. i s associated with a decrease i n the rates of i n s t i t u t i o n a l bed day use of a sample of i t s c l i e n t s . 40 Chapter Three Methodology Introduction This chapter describes the methodology and the r a t i o n a l e for employing such methodology, used to evaluate the I n t e r - M i n i s t e r i a l Project i n t h i s study. The Independent Variable: Intensive Case Management For the purposes of t h i s study, intensive case management i s defined as that s t y l e of p s y c h i a t r i c aftercare which, by i t s use of a small client-worker r a t i o , attempts to provide comprehensive assistance to severely p s y c h i a t r i c a l l y impaired i n d i v i d u a l s i n a l l aspects a d a i l y l i v i n g with aim to improving t h e i r q u a l i t y of l i f e , adaptation into the community, and thus avoiding a dependence upon i n s t i t u t i o n a l care. This intervention i s characterized by a concentration on the functions of l i n k i n g , assessing, monitoring, l i a i s i n g , and advocacy; a strong emphasis upon b u i l d i n g t r u s t i n g r e l a t i o n s h i p s ; and an emphasis on performing these duties i n the community, as opposed to t r a d i t i o n a l office-bound p s y c h i a t r i c care. Services provided by the I.M.P. are intensive case management services, evaluated i n the present study. Throughout i t s four year h i s t o r y the project has always maintained a worker-client r a t i o of not more than 10-1. As with other intensive case management projects, t h i s low client-worker r a t i o enables greater c l i e n t contact. During the time period January 1, 1990, to December 31, 1990, the workers of the I.M.P. saw i t s c l i e n t s 2.8 times a week. The Dependent Variable: I n s t i t u t i o n a l Use For the purposes of t h i s study, i n s t i t u t i o n a l use i s defined as any day or p a r t i a l day spent i n an i n s t i t u t i o n of t o t a l care. These w i l l include (a) a l l B r i t i s h Columbia p r o v i n c i a l c o r r e c t i o n a l i n s t i t u t i o n s , (b) a l l p s y c h i a t r i c wings of general h o s p i t a l s i n B r i t i s h Columbia or any other province, and/or Riverview or any other p r o v i n c i a l p s y c h i a t r i c h o s p i t a l , and (c) the Forensic P s y c h i a t r i c I n s t i t u t e of B r i t i s h Columbia. (The Forensic P s y c h i a t r i c I n s t i t u t e i s a licensed mental health f a c i l i t y used to assess and/or t r e a t B r i t i s h Columbians who have come int o contact with the l e g a l system because of mental i l l n e s s ) . Other p o s s i b i l i t i e s , venues that might have an i n s t i t u t i o n a l q u a l i t y about them such as d e t o x i f i c a t i o n centres, p s y c h i a t r i c boarding homes, emergency shelters, and corrections half-way h o u s e s — a l l w i l l be considered to be part of the community. Only j a i l s , h o s p i t a l s , and the Forensic P s y c h i a t r i c I n s t i t u t e s w i l l be considered to be i n s t i t u t i o n s . Units are i n terms of days and are i n c l u s i v e . For example, i f a subject was i n j a i l A p r i l 2/83 to A p r i l 10/83, t h i s would be a t o t a l of 9 days as both A p r i l 2'nd and A p r i l 10'th are counted, not merely the difference between the two. Thus p a r t i a l days—days, for instance, when a person i s admitted or discharged part-way through the d a y — w i l l be counted as whole days. This approach has been adopted because i t conforms to the manner i n which B.C. Corrections counts days for terms of sentencing, and i t thus standardizes the method used. When gathering j a i l day t o t a l s , no dif f e r e n c e was made between a day served on remand status and a day served on sentenced status. Each day and p a r t i a l day was counted as one. S i m i l a r l y , 42 when c o l l e c t i n g Forensic P s y c h i a t r i c I n s t i t u t e day t o t a l s , no diff e r e n c e was made between p s y c h i a t r i c remand status, involuntary status, warrant of committal status, not g u i l t y by reason of insa n i t y status, or temporary absence from a c o r r e c t i o n a l f a c i l i t y status. Once again, each day and p a r t i a l day was merely counted as one. When c a l c u l a t i n g h ospital day t o t a l s , only h o s p i t a l days r e s u l t i n g from p s y c h i a t r i c problems were counted. When gathering h o s p i t a l day t o t a l s , no d i s t i n c t i o n was made between voluntary or involuntary p s y c h i a t r i c h o s p i t a l i z a t i o n s . However, days spent i n ho s p i t a l f o r physical reasons were not included. Days spent i n ho s p i t a l f or a physical injury sustained from a s u i c i d e attempt were counted, but only to the degree that these could be described as days i n an acute unit since t h i s could be defined as mental health admission. Follow-up stays f o r physical problems sustained through suicide attempts i n long-term, convalescing, or physiotherapy wards were not counted since these prolonged stays were considered to be physical admissions. S i m i l a r l y , days described by p s y c h i a t r i c h o s p i t a l s as "extended leave" were not counted, even though such days are usually recorded by hospitals to be o f f i c i a l l y part of a patient's stay because p s y c h i a t r i c patients t y p i c a l l y spend "extended leave" days i n the community. I t would have been deceptive to consider these days as days spent i n the hos p i t a l while people were a c t u a l l y at l i b e r t y i n the community. Thus a l l extended leave days were assumed to be days spent i n the community and were counted as such. B r i t i s h Columbia Corrections data was c o l l e c t e d by accessing records kept at the Vancouver Adult Probation o f f i c e . Clearance was authorized by the Local Director. Forensic data was c o l l e c t e d by accessing f i l e s kept at the Forensic P s y c h i a t r i c I n s t i t u t e , Port Coquitlam. Clearance was authorized by the Executive Director. Hospital data was c o l l e c t e d by approaching each consenting subject i n d i v i d u a l l y and asking him/her to give a b r i e f verbal h i s t o r y of a l l p s y c h i a t r i c h o s p i t a l i z a t i o n s and approximate dates. For each h o s p i t a l i z a t i o n , a standard Ministry of Health release of information form (see Appendix B for l e t t e r s of authorization and release of information form) was completed requesting the number of bed days incurred. Once signed by the subject, the form was sent to the appropriate h o s p i t a l . Totals were then c a l c u l a t e d when the number of bed days was returned to the researcher by the h o s p i t a l . Factors confounding the dependent v a r i a b l e . Gathering data i n t h i s way brought to the researcher's attention a number of factors that could influence the outcome of the study. The f i r s t of these was that both B.C. Corrections records and Forensic P s y c h i a t r i c I n s t i t u t e records are l i m i t e d to the province of B r i t i s h Columbia. I f a subject t r a v e l l e d to another province some time during the "before or "during" period and be incarcerated or detained i n a forensic p s y c h i a t r i c f a c i l i t y , t h i s would not appear i n the data c o l l e c t e d . This was seen as being a problem that would l i k e l y confound the pre-test (before) period rather more than the post-test (during) period, f o r i t was observed that while c l i e n t s were on the I.M.P. caseload they usually remained i n B r i t i s h Columbia. Since one of the i n c l u s i o n c r i t e r i a of the I.M.P. was that a c l i e n t be on e i t h e r probation or b a i l , many were bound by a court order l i m i t i n g out-of-province t r a v e l . However, i t i s uncertain what r e s t r i c t i o n s on t r a v e l 44 a p p l i e d i n t h e " b e f o r e " p e r i o d , and i t i s p o s s i b l e t h a t c l i e n t s c o u l d have t r a v e l l e d out of the p r o v i n c e f o r extended p e r i o d s o f time. The same problem d i d not apply t o h o s p i t a l d a t a . I f , d u r i n g a s u b j e c t ' s v e r b a l h i s t o r y about p r e v i o u s h o s p i t a l i z a t i o n s , an o ut-o f - p r o v i n c e h o s p i t a l was named, i t c o u l d be a c c e s s e d i n the same manner as a l o c a l h o s p i t a l w i t h a s t a n d a r d M i n i s t r y o f H e a l t h r e l e a s e o f i n f o r m a t i o n form. However, g a t h e r i n g t h e h o s p i t a l data had o t h e r problems. Merely knowing what h o s p i t a l s t o ac c e s s f o r dat a depended e n t i r e l y upon the s u b j e c t ' s v e r b a l h i s t o r y . I f a s u b j e c t was f o r g e t f u l , e v a s i v e , or o t h e r w i s e erroneous about b e i n g i n a h o s p i t a l , then t h i s i n f o r m a t i o n would not be sought out, and would l i k e l y be missed. The r e s e a r c h e r t r i e d t o c o n t r o l f o r t h i s i n two ways: (a) by a s s u r i n g s u b j e c t s t h a t the number o f bed days o n l y was the i n f o r m a t i o n being sought. I t was thought t h a t i n d i v i d u a l s might be more forthcoming i f they were sure t h a t d i a g n o s i s , treatment, and other e x p e r i e n c e s which might be looked upon n e g a t i v e l y were kept out of s c r u t i n y ; and (b) by i n c l u d i n g i n the r e l e a s e o f i n f o r m a t i o n form the p e r i o d January 1/83 t o p r e s e n t , a p e r i o d w e l l b e f o r e and a f t e r the parameters o f t h e study p e r i o d . T h i s way, i n d i v i d u a l s might be mistaken about t h e a c t u a l d a tes they were i n the h o s p i t a l , but as long as they were c o r r e c t about which h o s p i t a l they were i n , the data c o u l d s t i l l be c o l l e c t e d . H y p o t h e s i s The purpose of t h i s study was t o determine a number o f f a c t o r s , the most important of which was the e f f e c t i v e n e s s o f i n t e n s i v e case management as an i n t e r v e n t i o n t o reduce • • . - . 45 i n s t i t u t i o n a l r e c i divism of multi-problem c l i e n t s . Of considerable importance, too, was i t s e f f e c t s over time, and i t s a b i l i t y to impact the corrections, forensic, and mental health systems i n d i v i d u a l l y . In order to address these many questions, a number of hypothesis were posed. Hypothesis # 1 . The primary purpose of t h i s study was to determine i f intensive case management i s an intervention that might be associated with a reduction in the i n s t i t u t i o n a l use of a sample of multi-problem c l i e n t s . Thus the n u l l hypothesis was posed as follows: the number of i n s t i t u t i o n a l bed use days of a group of multi-problem c l i e n t s receiving intensive case management services fo r one year w i l l not d i f f e r from the number of i n s t i t u t i o n a l bed day use days i n the year preceding such case management. Hypothesis #2. Also of i n t e r e s t was the question of whether or not intensive case management might be associated with a reduction i n the i n s t i t u t i o n a l bed use of a sample of multi-problem c l i e n t s at the two year time period. Thus the n u l l hypothesis was posed as follows: the number of i n s t i t u t i o n a l bed use days of a group of multi-problem c l i e n t s receiving intensive case management services fo r two years w i l l not d i f f e r from the number of i n s t i t u t i o n a l bed days i n the two years preceding such case management. Hypothesis #3. Of further i n t e r e s t was the question of how the e f f e c t s associated with intensive case management impacted each of the systems—corrections, forensic, and mental h e a l t h — i n d i v i d u a l l y at the one year period. Thus the f i r s t n u l l hypothesis i n t h i s area was posed: the number of c o r r e c t i o n a l bed use days of mu l t i -problem c l i e n t s receiving intensive case management f o r one year w i l l not d i f f e r from the number of c o r r e c t i o n a l bed use days i n the year preceding such case management. Hypothesis #4. For the forensic system, a s i m i l a r n u l l hypothesis was posed as follows: the number of forensic bed use days of multi-problem c l i e n t s r e c e i v i n g intensive case management f o r one year w i l l not d i f f e r from the number of forensic bed use days i n the year preceding such case management. Hypothesis #5. For the mental health system, a s i m i l a r n u l l hypothesis was posed as follows: the number of mental health bed use days of multi-problem c l i e n t s receiving intensive case management f o r one year w i l l not d i f f e r from the number of mental health bed use days i n the year preceding such case management. Hypothesis #6. Of further i n t e r e s t was the question of how the e f f e c t s associated with intensive case management impacted each of the systems i n d i v i d u a l l y at the two year period. Thus the f i r s t n u l l hypothesis i n t h i s area was posed as follows: the number of co r r e c t i o n a l bed use days of multi-problem c l i e n t s receiving intensive case management for two years w i l l not d i f f e r from the number of co r r e c t i o n a l bed use days i n the two years preceding such intensive case management. Hypothesis #7. For the forensic system at the two year period, a s i m i l a r n u l l hypothesis was posed as follows: the number of for e n s i c bed use 47 days of multi-problem c l i e n t s r eceiving intensive case management for two years w i l l not d i f f e r from the number of for e n s i c bed use days i n the two years preceding such intensive case management. Hypothesis #8. For the mental health system at the two year period, a s i m i l a r n u l l hypothesis was posed as follows: the number of mental health bed use days of multi-problem c l i e n t s r e c e i v i n g intensive case management services for two years w i l l not d i f f e r from the number of mental health bed use days i n the two years preceding such intensive case management. Time Parameters of the Study The maximum amount of time considered i n t h i s study was the two years before an ind i v i d u a l commenced the I.M.P., added to the two years during the project. This was a t o t a l of four years. Since the I.M.P. began Jan. 1, 1987, t h i s meant that the e a r l i e s t possible date being considered was Jan. 1, 1985. However, not every c l i e n t commenced the project on the s t a r t i n g date. Many commenced i t somewhere during the year of 1987 or early 1988. A cut - o f f point to data c o l l e c t i o n was required, and Dec. 31, 1990 was seen as a convenient cut-off point. This meant that the maximum time parameters of the study were from Jan. 1, 1985, to Dec. 31, 1990. The Sample Data was c o l l e c t e d on subjects ( c a l l e d c l i e n t s by the I.M.P.), a l l members of the I.M.P.1s caseload. Between the inception of the project on Jan. 1, 1987, and the cut-off point of t h i s study, Dec. 31, 1990, the project had offered intensive case management 48 services to 70 i n d i v i d u a l s . On Dec. 31, 1990, the project was providing service to 43 i n d i v i d u a l s . Of t h i s group, 17 were involved i n another research project c a l l e d the "Oakalla Project." Of the remaining number (26), c l i e n t s were chosen who f i t the following c r i t e r i a : (a) that they had been with the I.M.P. f o r a minimum of one year; (b) that t h e i r entry point on to the project was not Oakalla c o r r e c t i o n a l i n s t i t u t i o n (these i n d i v i d u a l s were a l l included i n another research p r o j e c t ) ; (c) that they were w i l l i n g to cooperate to the extent that they would sign a release of information forms to allow the researcher to access h o s p i t a l records to gather the number of bed days; and (d) that they had spent some time i n a c o r r e c t i o n a l , mental health, or forensic i n s t i t u t i o n during the research period. The c r i t e r i a of a minimum of one year's tenure on the Project was set because t h i s was seen to be a s u f f i c i e n t amount of time to allow for the therapeutic aspects, i f there were any, of intensive case management to take e f f e c t . A few days, or a few weeks, was not seen as a s u f f i c i e n t amount of time. Also, i n the early days of the project, a number of c l i e n t s commenced with the I.M.P. only to drop out or disappear a few days or a few weeks l a t e r . I t was f e l t that studying such c l i e n t s would not be appropriate as the tenure of t h e i r p a r t i c i p a t i o n was too b r i e f to derive benefits from intensive case management services. Also, some c l i e n t s commenced the project while s t i l l serving time on a mental health or other detention, and i t was f e l t that a one year period was required to allow these persons to be released, given assistance with a community placement, and to await the e f f e c t s of intensive case management services, i f there were any, to take hold. The c r i t e r i a that the entry point be from anywhere other than Oakalla c o r r e c t i o n a l i n s t i t u t i o n was chosen because, as has been mentioned, those having been referred to the project through Oakalla were already being studied by another research project. I t was f e l t that i t would have been to onerous to ask people, some of whom suffered from paranoid disorders or extreme withdrawal, to involve themselves i n two separate research programs, both of which demanded some degree of scrutiny. The c l i e n t ' s cooperation was necessary i n order to access hospital data, and there was a concern that by asking too many questions, i n d i v i d u a l s might be reluctant to cooperate i n t h i s s e n s i t i v e area. The c r i t e r i a that each i n d i v i d u a l had to have spent some time i n an i n s t i t u t i o n some time during the research period was chosen for the obvious reason that the outcome measure was that of improvement or regression i n i n s t i t u t i o n a l use. I f an i n d i v i d u a l had not spent any time i n an i n s t i t u t i o n e i t h e r before or a f t e r the advent of intensive case management, then there was nothing that could e i t h e r be improved or made worse through the intervention. Given these four c r i t e r i a , the research group then consisted of 25 subjects. (Only one subject was deleted from the sample due to the fac t that she/he had never spent any time i n an i n s t i t u t i o n during the study period). Of the group, 9 6% were male (24) and 4% (1) were female. The average age, as of Dec. 31, 1990, was 33 years. Diagnostically, 60% (15) had a primary diagnosis of schizophrenia; 8% (2) had a primary diagnosis of b i p o l a r disorder; and 32% (8) had a primary diagnosis of a serious personality disorder, usually of an a n t i s o c i a l or a borderline type. Of the en t i r e sample, 68% (17) were seen as being "dual diagnosed"—as having a major mental i l l n e s s (either schizophrenia or a bi p o l a r disorder) or a serious personality disorder along with a substance abuse problem. In fact, of the en t i r e group, 56% (14) were found to have the t r i p l e diagnostic c o n s t e l l a t i o n of a major mental i l l n e s s , a personality disorder, and a substance abuse problem. Of the e n t i r e sample, 16% (4) were found to be i n the borderline category of cerebral functioning. (See Appendix D). A l l subjects had a criminal record, and no one subject had any fewer than 3 criminal convictions as an adult. The most common type of criminal conviction was for " t h e f t of private property valued under $2,0000" followed by assault. During the year previous to t h e i r tenure with the I.M.P., the group had spent on average of 90 days i n j a i l , 40 days i n the Forensic P s y c h i a t r i c i n s t i t u t e , and 5 days i n p s y c h i a t r i c h o s p i t a l s . In other words, during the one year period previous to commencing the I.M.P. the group had spent on average 1/3 of t h i s time i n an i n s t i t u t i o n of some type. A l l (25) were single, and 84% (21) were unemployed and recei v i n g regular s o c i a l assistance or handicap be n e f i t s . Of the 16% (4) who were employed, a l l of these people worked only part-time or casually. More than half of the sample, 52% (16) had been referred to the I.M.P. by the Multi-Service Network (M.S.N.), a case documenting and case coordinating agency s p e c i a l i z i n g i n multi-problem c l i e n t s . Another 20% (5) had been re f e r r e d to the I.M.P. by t h e i r probation o f f i c e r . Another 20% (5) had been referred to the project by the Forensic P s y c h i a t r i c Service Outpatient C l i n i c . Another 4% (1) had been r e f e r r e d by crown counsel, and 4% (1) by correc t i o n a l s t a f f at the l o c a l j a i l . Design The study employed a one group pre-test, post-test design. The post-test was the period of time, c a l l e d the "tenure" period, that the subject was receiving intensive case management services from the I.M.P.. These periods were investigated f o r i n s t i t u t i o n a l bed day use both at the one year and the two year point on the project. The pre-test period was the period of time, equal i n length to the "tenure" period, immediately before case management services were being provided by the I n t e r - M i n i s t e r i a l project. Once again, these periods were investigated for i n s t i t u t i o n a l bed day use at the one year and the two year period of time. Thus the pre-test period was i n a c t u a l i t y a "before" period, while the post-test period could be more accurately described as a "during" period. Comparisons were then made between t h i s "before" and "during" period to see i f there was any differe n c e i n i n s t i t u t i o n a l use. Limitations Due to Design The l i m i t a t i o n s of using such a quasi-experimental design as the pre-test, post-test one group design included threats to both i n t e r n a l and external v a l i d i t y . The major threats to i n t e r n a l v a l i d i t y were factors of history, maturation, s e l e c t i o n , and the reactive e f f e c t s of experimental procedures. The major threat to external v a l i d i t y was the i n t e r a c t i o n of s e l e c t i o n bias and treatment. Selection. Undoubtedly the strongest threat to the v a l i d i t y of a study using a pre-test, post-test one group design occurred because a control group was not used. Without a control group, c a u s a l i t y could not be i n f e r r e d . The creation of a c o n t r o l group i n t h i s study was not f e a s i b l e . Since the I.M.P. had already been i n operation over three years at the i n i t i a t i o n of t h i s study, i t was not possible to create a control group r e t r o s p e c t i v e l y . Even i f i t were possible, there was the added concern that since the Inter-M i n i s t e r i a l Project focused on the most severe multi-problem persons i n Vancouver's downtown eastside, the random assignment of i n d i v i d u a l s to treatment or no treatment would have invoked some serious e t h i c a l concerns. The I n t e r - M i n i s t e r i a l Project was created as a service driven, as opposed to a research driven, program. Depriving someone of needed case management services i n order to f i t the structure of a research paradigm was seen as e t h i c a l l y questionable. Maturation. The second largest threat to the i n t e r n a l v a l i d i t y of t h i s study was seen to be i n the area of maturation. Given that i n t h i s study i n d i v i d u a l s were being studied over time, c e r t a i n l y the mere passage of time must always be considered as a r i v a l hypothesis to account f o r any change. However, a c e r t a i n amount of time must be taken into consideration i n order to be able to appreciate the h i s t o r i c a l process of major mental i l l n e s s e s and severe personality disorders, e s p e c i a l l y those of a chronic sort such as t h i s sample of 25 i n d i v i d u a l s possessed. Many major mental i l l n e s s and severe personality disorders are now recognized as having a general pattern of s t a b i l i t y , decompensation, acuteness, patienthood, and convalescence associated with them, and the r e c u r r i n g cycles of many chronic i l l n e s s e s are only f u l l y appreciated through the passage of years. Unlike most other diseases, chronic mental i l l n e s s e s only reveal t h e i r course through the passage of years. Short study periods aimed at ascertaining c e r t a i n aspects of chronic mental i l l n e s s e s are l i k e l y to miss t h i s important point. In t h i s study the maximum amount of time under consideration was four years (two years pre-test plus two years p o s t - t e s t ) . This was considered to be an adequate compromise, long enough to allow the patterns of chronic mental i l l n e s s e s to f l o u r i s h , and short enough to r u l e out the ef f e c t s of aging being considered a r i v a l hypothesis. History. Events that occurred during the time parameters of the study may also have confounded the re s u l t s i n a v a r i e t y of ways. For example, once judges i n p r o v i n c i a l courts became aware of that the I.M.P. was, i n t h e i r opinion, looking a f t e r c e r t a i n mentally i l l i n d i v i d u a l s , they become more apt to give these c l i e n t s probation orders instead of a j a i l sentence. Also, over the time period 1987-1990 , Riverview Hospital, through various p o l i c y changes, c a l l e d for s t r i c t e r admission c r i t e r i a , and i n accordance with The  Mental Health Plan (1987) , used Vancouver General Hospital as a screening unit for admissions to Riverview. As a r e s u l t , fewer people were ho s p i t a l i z e d than i n the years previous to 1987. Reactive e f f e c t s of experimental procedures. Another major threat to the i n t e r n a l v a l i d i t y of t h i s type of design i s that people often a l t e r t h e i r behaviour j u s t because they are part of a special project. While t h i s might be true of a l l I.M.P. c l i e n t s j u s t by vi r t u e of the f a c t that they are receiving s p e c i a l treatment, t h i s i s very d i f f i c u l t to i s o l a t e from what i s being accomplished by intensive case management interventions. Given that one of the main features of intensive case managment i s a " s p e c i a l i z i n g , " or a process of making the worker-client r e l a t i o n s h i p more intense than that t y p i c a l of ordinary mental health services, i t i s very d i f f i c u l t to determine whether changes i n behaviour were owing to the techniques of case management—the l i n k i n g , monitoring, e t c . — o r merely to the f a c t that people were rece i v i n g more attention or some sort of s p e c i a l status. However, retrospective studies can counter for t h i s e f f e c t . Since the commencing date of t h i s evaluation was almost four years a f t e r the beginning of the program, one can s a f e l y assume that subjects were not modifying t h e i r behaviour just because they knew they were part of a research project. They might have been modifying t h e i r behaviour because they were part of an intensive case management program; however, they were not modifying t h e i r behaviour because they were part of an evaluation component of an intensive case management program. Interactive e f f e c t s of s e l e c t i o n biases and intervention. A major threat to the external v a l i d i t y of t h i s type of design i s that the c h a r a c t e r i s t i c s of the subjects chosen often l i m i t s how extensively the findings can be generalized. In t h i s study there were two l e v e l s of s e l f - s e l e c t i o n at work: (a) f i r s t of a l l , c l i e n t s on the caseload of the I.M.P. have already agreed to some extent to involve themselves i n a s p e c i a l project, namely an intensive case management project; and (b) secondly, those who have agreed to be part of the research component have further agreed to be part of a s p e c i a l project. One can always r a i s e the question of j u s t how representative of the multi-problem population i s a group 55 of people who ex h i b i t t h i s l e v e l of cooperation? Some attempts have been made to control for (b) by making what i s required to be part of the research p r o j e c t — t h e signing of a release of information form—as minimal as possible. However, there i s no doubt that some sort of s e l f - s e l e c t i o n has occurred. As a r e s u l t , generalizations to the population of a l l multi-problem c l i e n t s are not possible. The Pre-Test, Post-Test Design as a Compromise. The best sol u t i o n to the many problems encountered i n s e t t i n g up a method to evaluate the effectiveness of the I.M.P. seemed to be by using a pre-test, post-test one group design, or what i s some times ref e r r e d to as a repeat measures design. With t h i s method, the group i t s e l f , p r i o r to the intervention, could stand as i t s own comparison group. This was seen as desirable as i t allowed for the passage of some time and, furthermore, solved any e t h i c a l problems about control c l i e n t s being deprived treatment. The use of such a design represents the c l a s s i c compromise often faced by researchers studying programs or treatments i n r e a l - l i f e s e t tings. Such a compromise i s often an exercise i n negotiating the factors of u t i l i t y , c r e d i b i l i t y , and p r a c t i c a l i t y i n an attempt to bring an evaluative e f f o r t to a project or treatment. While i t has l i m i t a t i o n s , many of which have been discussed, i t was the best possible a l t e r n a t i v e i n attempting to reach the stated research goals. Data Analysis Each of the 8 hypothesis was analyzed using a standard t e s t of s i g n i f i c a n c e . The t e s t that was used was that of the t - t e s t because of i t s superior robustness. Although assumptions of normality can 5 6 be made with many variables, because of the small and rather i d i o s y n c r a t i c group under scrutiny i n t h i s study, there was no reason to assume that i n s t i t u t i o n a l admission rates would perform according to the normal curve. However, recent research (Glass, 1972) has shown that a v i o l a t i o n to the assumption of normality has very l i t t l e e f f e c t upon the t - t e s t . Also, given the great discrepancy between i n d i v i d u a l tenure period i n s t i t u t i o n a l rates and corresponding pre-test i n s t i t u t i o n rates, i t seemed l i k e l y that l i t t l e homogeneity of variance would occur. I t has been shown, however, that the t - t e s t i s s t i l l robust given a lack of homogeneity of variance, just as long as sample s i z e s are kept equal. Since, i n t h i s study, a l l comparisons are i n r e a l i t y part of the same group eith e r i n a "before" or "during" state, then sample si z e s w i l l always be the same. Thus the t - t e s t appeared to the best possible t e s t for t h i s study. For each of the 8 hypothesis, the pretest and posttest means were subject to a t - t e s t . T-tests were performed on (a) the means of a l l i n s t i t u t i o n a l bed day use before and during the one year period; (b) the means of a l l i n s t i t u t i o n a l bed day use before and during the two year period; (c) the means of a l l c o r r e c t i o n a l bed day use before and during the one year period; (d) the means of a l l forensic bed day use before and during the one year period; (e) the means of a l l mental health bed day use before and during the one year period; (f) the means of a l l c o r r e c t i o n a l bed day use before and during the two year period; (g) the means of a l l forensic bed day use before and during the two year period; (h) and the means of a l l mental health bed day use before and during the two year period. This amounted to a t o t a l of 8 t - t e s t s i n a l l . 57 Chapter Four Results Hypothesis V e r i f i c a t i o n  Hypothesis #1. A restatement of the primary n u l l hypothesis to be tested i s as follows: that the number of t o t a l i n s t i t u t i o n a l bed use days of a sample (n = 25) of multi-problem c l i e n t s r e c e i v i n g intensive case management services for one year w i l l not d i f f e r from the number of t o t a l i n s t i t u t i o n a l bed days used i n the year preceding such intensive case management. Results indicate that the change i n the mean of the number of i n s t i t u t i o n a l bed days used i n the one year period before I.M.P. and the mean of the number of bed days used i n the one year period during I.M.P. i s s i g n i f i c a n t l y d i f f e r e n t (t = 2.27, D.F. = 74, p.<.05). One must keep i n mind that with a l l systems considered together, a l l t o t a l s are then further divided by 3 . Hypothesis #2. A restatement of the n u l l hypothesis i s as follows: that the number of t o t a l i n s t i t u t i o n a l bed use days of a sample (n = 17) of multi-problem c l i e n t s receiving intensive case management services for two years w i l l not d i f f e r from the number of t o t a l i n s t i t u t i o n a l bed days in the two years preceding such intensive case management. Results indicate that the di f f e r e n c e i n the mean of the number of i n s t i t u t i o n a l bed days used i n the two year period before I.M.P. and the mean of the number of bed days used i n the two year period during I.M.P. i s s i g n i f i c a n t l y d i f f e r e n t ( t = 2.99, D.F. = 50, p.<.05). Once again, one must keep i n mind when 58 a l l three systems are considered together, a l l t o t a l s are then further divided by 3. Hypothesis #3. A restatement of the n u l l hypothesis i s as follows: that the number of c o r r e c t i o n a l bed use days of a sample (n = 25) of multi-problem c l i e n t s receiving intensive case management services for one year w i l l not d i f f e r from the number of c o r r e c t i o n a l bed use days i n the year preceding such intensive case management. Results indicate that the difference i n the mean of the number of co r r e c t i o n a l bed days used i n the one year period during I.M.P. and the mean of the number of bed days used i n the one year period preceding I.M.P. i s s i g n i f i c a n t l y d i f f e r e n t ( t = 2.48, D.F. = 24, p.<.05). Hypothesis #4 A restatement of the n u l l hypothesis i s as follows: that the number of forensic bed use days of a sample (n = 25) of multi-problem c l i e n t s receiving intensive case management services for one year w i l l not d i f f e r from the number of forensic bed use days i n the year preceding such intensive case management. Results indicate that the difference i n the mean of the number of forensic bed days used i n the one year period before I.M.P. and the mean of the number of forensic days used during I.M.P. i s not s i g n i f i c a n t l y d i f f e r e n t . Hypothesis #5. A restatement of the n u l l hypothesis i s as follows: that the number of mental health bed use days of a sample (n = 25) of multi-problem c l i e n t s receiving intensive case management services for one year w i l l not d i f f e r from the number of mental health bed use 59 days i n the one year preceding such intensive case management. Results indicate that the difference i n the mean of the number of mental health bed days used i n the one year period during I.M.P. and the mean of the number of mental health bed days used i n the same period preceding I.M.P. i s not s i g n i f i c a n t l y d i f f e r e n t . Hypothesis #6. A restatement of the n u l l hypothesis i s as follows: that the number of c o r r e c t i o n a l bed use days of a sample of multi-problem c l i e n t s (n = 17) receiving intensive case management f o r two years w i l l not d i f f e r from the number of c o r r e c t i o n a l bed use days i n the two years preceding such intensive case management. Results indicate that the difference i n the mean of the number of co r r e c t i o n a l bed days used i n the two year period during I.M.P. and the mean of the number of correc t i o n a l bed days used i n the same period preceding I.M.P. i s s i g n i f i c a n t l y d i f f e r e n t ( t = 2.73, D.F. = 16, p.<.05). Hypothesis #7. A restatement of the n u l l hypothesis i s as follows: that the number of forensic bed use days of a sample (n = 17) of multi-problem c l i e n t s receiving intensive case management f o r two years w i l l not d i f f e r from the number of forensic bed use days i n the two years preceding such intensive case management. Results indicate that the difference i n the mean of the number of forensic bed days used i n the two year period during I.M.P. and the mean of the number of forensic bed days used i n the same period preceding I.M.P. i s not s i g n i f i c a n t l y d i f f e r e n t . 60 Hypothesis #8. A restatement of the n u l l hypothesis i s as follows: that the number of mental health bed use days of a sample (n = 17) of mult i -problem c l i e n t s r eceiving intensive case management f o r two years w i l l not d i f f e r from the number of mental health bed use days i n the two years preceding such intensive case management. Results indicate that the difference i n the mean of the number of mental health bed days used i n the two year period during I.M.P. and the mean of the number of mental health bed days used i n the same period preceding I.M.P. i s not s i g n i f i c a n t l y d i f f e r e n t . A more de t a i l e d break-down of the dif f e r e n c e i n means between the pre-test and the post-test periods may be seen i n Table 1. 61 Table 1 Pre-Test and Post-Test Results. One Year and Two Year Follow-Up  Points Pre--Test Post-Test One year follow up Mean SD Mean SD 1. Over-all inst.days 44.78 81.69 21.88 48. 58* 2. Corrections 90.80 101.95 37.00 65. 49* 3. Forensic 38.40 77.95 18.64 42. 21 4. Mental Health 5.16 14.88 10. 00 28. 44 N = 25 p. < .05. * denotes s t a t i s t i c a l s i g n i f i c a n c e Two year follow up 5. Over-all inst.days 84.39 138.54 34. 64 61. 18* 6. Corrections 178.70 196.72 67. 11 90. 76* 7. Forensic 48.00 67.19 17. 35 35. 43 8. Mental Health 26.47 48.43 19. 47 22. 82 N = 17 p. < .05. * denotes s t a t i s t i c a l s i g n i f i c a n c e 62 Chapter Five Discussion V e r i f y i n g the Hypothesis Intensive case management services was associated with a reduction of the bed day use for multi-problem c l i e n t s i n t h i s study. However, due to the l i m i t a t i o n s of the repeat measures design, no causation can be inf e r r e d . Causation can only be in f e r r e d when a l l other r i v a l hypothesis are ruled out through the use of more rigorous experimental designs such as the randomized two-group design. Without a control group, r i v a l hypothesis are always tenable, and conclusions must be l i m i t e d to the following: that t h i s group of 2 5 multi-problem c l i e n t s appears to have incurred s i g n i f i c a n t l y lower rates of i n s t i t u t i o n a l recidivism a f t e r the advent of intensive case management. Whether or not intensive case management caused t h i s d i f f e r e n c e i s beyond the scope of t h i s paper, and points to the fact that more research with rigorous designs are required i n t h i s area. These data also showed that rates of reduction of i n s t i t u t i o n a l bed use varied with the type of i n s t i t u t i o n considered. Intensive case management was associated with v a r i a b l e decreases i n corrections, forensic, and mental health i n s t i t u t i o n a l use. Corrections bed use was s i g n i f i c a n t l y reduced, forensic bed use was not s i g n i f i c a n t l y reduced, and mental health bed use was not s i g n i f i c a n t l y reduced. In summary, while t o t a l i n s t i t u t i o n a l bed use was s i g n i f i c a n t l y reduced, i t appeared to be due pr i m a r i l y to decreases i n cor r e c t i o n a l f a c i l i t i e s . Given these r e s u l t s i t would appear that following the intervention of intensive case management, t h i s group of m u l t i -problem c l i e n t s i l l u s t r a t e s a vast improvement at staying out of j a i l , a p o s s i b l e trend i n remaining out of f o r e n s i c p s y c h i a t r i c i n s t i t u t e s , and no change i n remaining out of p s y c h i a t r i c h o s p i t a l s . In fact, according to the raw data, the group i s i n h o s p i t a l f o r s l i g h t l y more days during the periods of intervention than during the corresponding periods of no intervention. This negative dif f e r e n c e i s 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 . In i n t e r p r e t i n g r e s u l t s i t i s necessary to consider whether the p o s i t i v e change shown in the corrections data might, i n part, be owing to the negative change i n the mental health data. There i s already some speculation in the l i t e r a t u r e that these two variables ( p s y c h i a t r i c h o spitals and j a i l s ) might be inter-dependent and what i s at work here i s a dynamic which e x i s t s between these two systems of s o c i a l c o n t r o l . I t i s possible that with the advent of intensive case management services, multi-problem c l i e n t s were not going i n to the corrections system as much because they were going i n to the mental health system more. This seems even more reasonable when one considers that advocacy i s an e s s e n t i a l ingredient of intensive case management intervention, and advocacy works i n opposite d i r e c t i o n s i n the corrections and mental health system. In the corrections system, advocacy i s l i k e l y to produce more lenient sentences or probation or b a i l i n l i e u of incarceration, while i n the mental health system i t i s l i k e l y to encourage doctors, nurses, and other mental health professionals to give multi-problem c l i e n t s greater access to treatment. Studying such a question would require a quantitative analysis aimed at determining i f there i s an 64 inverse c o r r e l a t i o n between days prevented i n the corrections system and days incurred i n the mental health system. This would provide an excellent t o p i c for further research. The lack of change i n bed day use i n f o r e n s i c and mental health f a c i l i t i e s might lead to the conclusion that intensive case management i s a somewhat i n e f f e c t i v e intervention. However, such a conclusion needs to be tempered given the c h a r a c t e r i s t i c s of the population. Given the r e l a t i v e l y high degree of psychopathology, substance abuse, and h i s t o r y of previous i n s t i t u t i o n a l use of t h i s group, one might expect some i n s t i t u t i o n a l use to continue no matter what the intervention. The decrease i n corrections use might be seen as an example of a s h i f t away from the most inappropriate i n s t i t u t i o n , with a somewhat l e s s e r e f f e c t on decreasing the use of i n s t i t u t i o n s which have a component of mental health care about them. This i s very important when one considers that the central unifying feature about t h i s group i s mental i l l n e s s . Regarded i n t h i s way, the intervention of intensive case management may be associated not only with a reduction of i n s t i t u t i o n a l use, but also a r e d i r e c t i n g of i n d i v i d u a l s towards i n s t i t u t i o n s more appropriate to t h e i r needs. One Year Results Compared To Two Year Results The finding of a reduction of i n s t i t u t i o n a l bed day use was maintained for both the one year and two year follow-up period. Although the change at the two year period appeared to be s l i g h t l y stronger than at the one year period, t h i s r e f l e c t s p r i m a r i l y the smaller sample si z e in the two year follow up as compared to the one year follow up. The findings suggest that the change associated with intensive case management continues over time, but 6 5 i t does not suggest that the change i s increased as intensive case management i s increased i n duration. Such a f i n d i n g can only be shown through the use of a more rigorous research design, such as the control-study design. Summary The r e s u l t s of t h i s study can be summarized as follows: Intensive case management was associated with increased community tenure of multi-problem c l i e n t s . T h i s p r o g r a m evaluation of the I n t e r - M i n i s t e r i a l Project showed that t h i s group of multi-problem c l i e n t s resided i n the community longer while on the project than during the same period of time immediately before the project. Given that since the era of d e i n s t i t u t i o n a l i z a t i o n treatment philosophies are in keeping with the b e l i e f that the best treatments occur i n the least r e s t r i c t i v e settings, then the Inter-M i n i s t e r i a l Project appears to be an e f f e c t i v e intervention accomplishing t h i s goal. As a community based program, i t i s c e r t a i n l y to be less r e s t r i c t i v e than any program held within the grounds of i n an i n s t i t u t i o n . Intensive case management was associated with a move towards more mental health use by multi-problem c l i e n t s and less corrections use. Those who are interested i n c o s t - e f f e c t i v e interventions might state the fact that i t costs up to f i v e times as much per day for an emergency bed at h o s p i t a l than a j a i l . However, t h i s argument i s not completely true on two accounts. F i r s t of a l l , a j a i l day i s cheaper than a h o s p i t a l day, but when one considers a l l the other costs associated with processing a person f o r a day i n j a i l — t h e cost of a t r i a l with a judge, a crown counsel, a l e g a l aid lawyer, and witnesses, some of whom might be 66 p o l i c e o f f i c e r — t h e n i t i s , i n f a c t , more ex p e n s i v e . Secondly, t h e r e i s the p h i l o s o p h i c a l argument t h a t i f i n d i v i d u a l s are m e n t a l l y i l l , then they should be c a r e d f o r i n a mental h e a l t h s e t t i n g r a t h e r than a c o r r e c t i o n s s e t t i n g . Given t h e s e a d d i t i o n a l f a c t o r s , i n t e n s i v e case management p r e s e n t s as a f i n a n c i a l l y f e a s i b l e and p h i l o s o p h i c a l l y sound treatment o p t i o n . The c o r r e c t i o n s system might be the most e f f e c t i v e p o i n t i n the system f o r e s t a b l i s h i n g c o n t a c t w i t h m u l t i - p r o b l e m c l i e n t s f o r f u r t h e r i n t e r v e n t i o n s . The use of the c o r r e c t i o n s system by m u l t i -problem i n d i v i d u a l s i s an i n t e r e s t i n g t o p i c and a d e t a i l e d d i s c u s s i o n of i t i s beyond the scope of t h i s paper. (see Appendix F, " T r a n s i n s t i t u t i o n a l i z a t i o n " f o r a more d e t a i l e d d i s c u s s i o n of t h i s t r e n d ) . However, i n terms of engaging the m u l t i - p r o b l e m c l i e n t , the c o r r e c t i o n s system seems t o be an important e n t r y p o i n t . Although most of the sample had c o n t a c t w i t h a l l t h r e e systems, t h e r e were n o t i c e a b l e gaps here and t h e r e . Yet i n o n l y one case, was an i n d i v i d u a l not i n c o n t a c t w i t h the c o r r e c t i o n s system. Besides having a mental h e a l t h d i a g n o s i s , spending some time i n t h e c o r r e c t i o n s system seems t o be another common denominator t h a t t h i s , otherwise, heterogeneous group shared. T h i s might be c o n s i d e r e d an important f i n d i n g f o r program p l a n n e r s who are l o o k i n g f o r ways t o t a r g e t the m u l t i - p r o b l e m c l i e n t . L o c a l j a i l s , a l t h o u g h c e r t a i n l y not the venue o f c a r e f o r the m u l t i -problem c l i e n t , might serve as a t a r g e t p o i n t f o r program p l a n n e r s i n t e r e s t e d i n t r y i n g f u r t h e r i n t e r v e n t i o n s w i t h t h i s type of c l i e n t . There i s a need f o r e v a l u a t i v e and outcome r e s e a r c h p r o j e c t s t o be b u i l t i n t o community i n t e r v e n t i o n s r i g h t a t t h e i r b e g i n n i n g . 67 The type of design used i n t h i s study shows the importance of bui l d i n g evaluation methods into programs at t h e i r inception. Retrospective studies with quasi-experimental designs can only make tentat i v e conclusions. In order to be able to say with greater confidence that an intervention i s e f f e c t i v e , a con t r o l group i s required. In order to set up a proper control group, one must do so at the s t a r t . The findings of t h i s study appear to contradict the findings of the one research project most s i m i l a r to i t , that of Carrado's (1987) evaluation of a population of multi-problem c l i e n t s of the Multi-Service Network. In that work he found that a f t e r M u l t i -Service Network intervention, mental health costs were reduced, corrections costs were increased, and welfare costs (Social Services and Housing) were increased. I f costs were attached to the present study, the following would l i k e l y emerge: welfare costs would be increased (because the subjects are i n the community f o r a longer period of time), mental health costs would be increased, and corrections costs decreased. This d i f f e r e n c e i n findings might be owing to a difference in methodology, a differ e n c e i n what i s being measured—case coordination as opposed to intensive case management—and a difference i n the study group. Even though Carroda picked c l i e n t s of the M.S.N., who given the mandate of the M.S.N., would necessarily be multi-problem c l i e n t s , h i s very small sample (10), undoubtedly influenced h i s r e s u l t s . The i n a b i l i t y to gather large populations when studying the multi-problem c l i e n t group w i l l l i k e l y hamper program planners and researchers i n the future. There i s a need to continue to devise new interventions f or 68 t h i s population. Both the Corrado (1987) Report and t h i s study say, i n one respect, the same thing: that given the i n s t i t u t i o n a l use of t h i s group, multi-problem c l i e n t s w i l l end up costing some part of the system a great deal i n terms of f i n a n c i a l resources. At t h i s point, i t does not appear that t h e i r problems w i l l ameliorate over time; nor w i l l ignoring them improve t h e i r s i t u a t i o n or reduce the cost they represent to the various parts of the care system. I t i s more appropriate to create programs which are meant to engage t h i s group and to help them with t h e i r many problems. These programs should be funded and s t a f f e d by various m i n i s t r i e s f o r t h i s c l i e n t group i s not j u s t the r e s p o n s i b i l i t y of mental health, or corrections, or forensic, but of every part of the system concerned. 69 References Abramsom, M.F. ( 1 9 7 2 ) . The Cr i m i n a l i z a t i o n of Mentally Disordered Behaviour: Possible Side-Effects of a New Mental Health Law. Hospital and Community Psychiatry, 23., (4) , 1 3 - 1 7 . Anthony, W.A., Cohen, M., Farkas, M., and Cohen, B.T. ( 1 9 8 8 ) . C l i n i c a l Care Update: The Chronic Mentally 111 Case Management— More Than a Response to a Dysfunctional System. Community Mental  Health Journal. 2 4 , ( 3 ) , 2 1 9 . Anthony, W.A. ( 1 9 7 9 ) . The P r i n c i p l e s of Ps y c h i a t r i c R e h a b i l i t a t i o n . Amherst, Mass: Human Resources Development Press. Arana, J . ( 1 9 9 0 ) . C h a r a c t e r i s t i c s of Homeless Mentally 111 Inpatients. 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Journal of Nervous and Mental  Disease. 172, (11), 667-673. Wright, R.G., Heiman, J.R., and Shupe, J . (1989). Defining and Measuring S t a b i l i z a t i o n of Patients During Four Years of Intensive Community Support. American Journal of Psychiatry. 146, 1293-1298. 76 Appendix A Operationalizing the Term Multi-Problem C l i e n t In February of 1988 the researcher and two colleagues attempted to address the problem of a lack of general consensus as to what constituted a multi-problem c l i e n t . Two of us were employed as case managers (called "workers") with the I.M.P. (the program under scrutiny i n t h i s paper), and we1wondered i f we were r e a l l y targeting the multi-problem c l i e n t . We began our task by asking i f there r e a l l y was such an i n d i v i d u a l as the multi-problem c l i e n t . To answer t h i s question we constructed a questionnaire and c i r c u l a t e d i t to the l i n e workers of the Greater Vancouver Mental Health Services Society. Our assumption was that i f such an e n t i t y as the multi-problem person did e x i s t , then the professionals who provide f r o n t - l i n e mental health services to the Vancouver community would know of them. Using the guidelines of Buckley's (1987) d e f i n i t i o n as the prototype, we collapsed t h i s d e f i n i t i o n into what we considered to be 5 d i s c r e t e elements. These were (a) multiple diagnosis on Axis I and Axis II (which would diagnosis as disparate as alcohol\drug use\abuse, mental retardation, personality disorders, as well as major mental i l l n e s s e s ) ; (b) treatment resistance; (c) intermittent presence before the courts; (d) repeated contacts with mental health and corrections i n s t i t u t i o n a l systems; and (e) a c e r t a i n "larger than l i f e " reputation or a marked degree of "community infamy." Our r a t i o n a l e here was that rather than lead the informants by asking them i f they knew anything about the m u l t i -problem person, we would ask them i f they recognized a c e r t a i n c o n s t e l l a t i o n of p s y c h i a t r i c and s o c i a l features reoccurring i n c l i e n t s on t h e i r caseload. I f the answer was r e g u l a r l y "yes," then we thought that we could say with confidence that such an i n d i v i d u a l existed. A f t e r l i s t i n g the 5 c r i t e r i a we then asked the following three questions: (1) Do you now have on your caseload any c l i e n t ( s ) who meet a l l 5 of the c r i t e r i a ? (2) I f "yes," how many such i n d i v i d u a l s are on your caseload? (3) Do you think there are a l o t more\a few more\no more i n your team's catchment area than a year ago? (See Appendix B for a complete questionnaire). We then provided each of the eight team d i r e c t o r s of the Greater Vancouver Mental Health Services Society with a packet of questionnaires to d i s t r i b u t e and c o l l e c t at a regular morning intake meeting some day during the f i r s t week of March, 1988. We hoped that by making our questionnaire quick and easy to do we could achieve a better return rate as well as avoid taking time away from regular d a i l y business. Our questionnaire received a return rate of 76% (N=87). A geographical breakdown of respondents and t h e i r answers to question 1 (Do you have any such indivi d u a l s on your caseload?) appears as shown i n Table 2). 77 Table 2 Answer to Question (1): Do You Have Any Such Individuals on Your Caseload? (25%) (75%) Team Yes No Tota l West Side 0 10 10 West End 0 10 10 Mount Pleas. 4 8 12 K i t s i l a n o 3 6 9 Strathcona 9 2 11 Richmond 3 9 12 South 1 10 11 Broadway 2 10 12 Total = 22 65 87 (100%) N = 87, which represents 76% of a l l G.V.M.H.S.S. l i n e workers, 78 A number of confounding factors must be taken into account here. F i r s t of a l l , t h i s was never meant as an attempt at s c i e n t i f i c research, and our questionnaire i s recognizably not a rigorous research instrument. Our e f f o r t s were merely to ascertain i f such a c l i e n t r e a l l y existed. Secondly, i f a person i s very treatment r e s i s t a n t , then i t i s quite l i k e l y that he\she w i l l not be on any mental health worker's caseload. We hoped to counter for t h i s by including question 3 (Do you think there are more\less such i n d i v i d u a l s than there were one year ago) which i s speculative and might provide, i n a very rough sense, some idea of actual numbers. Also, i f a person has repeated contacts with the court and i s i n t e r m i t t e n t l y on probation and b a i l , then i t i s possible that he\she might be followed by Forensic P s y c h i a t r i c Services rather than Greater Vancouver Mental Health. These two services are mutually exclusive i n that a c l i e n t can only be a patient with e i t h e r one or the other at any given time. C e r t a i n l y a more accurate count of actual numbers could have been garnered by surveying Forensic P s y c h i a t r i c Services primary workers as well. Nevertheless, the r e s u l t s do indicate that 25% of a l l Greater Vancouver Mental Health Services primary workers who responded have fir s t - h a n d knowledge of a c l i e n t who has the f i v e main features of Buckley's multi-problem c l i e n t . Furthermore, as Table 3 reveals there i s also some i n d i c a t i o n that t h i s c l i e n t c onstitutes a small group (41) , l e s s than 1% of the Greater Vancouver Mental Health Services Society's t o t a l (1988) caseload. There i s also a tendency of r e s i d i n g towards the inner c i t y core given the r e l a t i v e l y high numbers at the Strathcona Team (18) and the Mount Pleasant Team (7) as i l l u s t r a t e d i n Table 3. 79 \ Table 3 Answer to Question (2): I f "yes," How Many of  These C l i e n t s Do You Have On Your Caseload? Team No. of C l i e n t s West Side 0 West End 0 Mount Pleasant 7 K i t s i l a n o 4 Strathcona 18 Richmond 6 South 2 Broadway 4 Total = 80 The r e s u l t s of the questionnaire point only i n very general d i r e c t i o n s . Along with the confounding factors already mentioned, there are others which include the assumption that each worker i s t a l k i n g only about c l i e n t s on his/her caseload and not c l i e n t s shared with other workers; and the assumption that workers are f a m i l i a r enough with the categories of D.S.M.Ill to know that such features as mental retardation and substance abuse are included i n Axis I and Axis I I . In s p i t e of a l l t h i s , the data does suggest that there i s a d i s t i n c t c o n s t e l l a t i o n of features which designates a c l i e n t that at l e a s t 25% of respondents see on a regular basis. I t also suggests that such a c l i e n t tends to l i v e towards the inner c i t y core i n the catchment areas of teams c l o s e r to what i s known as the "skid row" area, or the downtown eastside. What t h i s does i s to suggest that as a construct, the "multi-problem" person can stand on i t s own as a research e n t i t y . For the purposes of t h i s paper, any future references to the term "multi-problem" c l i e n t w i l l be used to describe an in d i v i d u a l who f i t s the 5 point i n c l u s i o n c r i t e r i a of the questionnaire, or members of caseloads of projects which use the 5 point c r i t e r i a to target t h e i r population. I t should also be noted that the I n t e r - M i n i s t e r i a l Project, the independent v a r i a b l e under scrutiny i n t h i s paper, s t i l l uses the same 5 point c r i t e r i a to designate c l i e n t s appropriate to i t s mandate. 81 Appendix B Release of information Form, Letters of Authorization, and M u l t i - Problem Questionnaire QUESTIONNAIRE 9IA Appendix 8 INTER - MINSTERIAL PROJECT QUESTIONNAIRE INCLUSION CRITERIA: 1. P e r i o d i c a l l y non - compliant with the prescribed treatment plan. 2. Multiple diagnoses on Axis I and/or Axis I I . 3. An established h i s t o r y of repeated contacts with mental health and corrections s e r v i c e s . 4. Intermittently on probation or b a i l . 5. "Notorious reputation" in the community, i e . , well known by l o c a l s ervice providers. 1. Do you now have on your caseload any c l i e n t (s) who meet a l l £mma of the above in c l u s i o n c r i t e r i a ? YES NO 2. IF YES f how many such c l i e n t s are on your caseload?. 3. Do you think there are a l o t more such persons in your Team's catchment area than a year ago? NO A FEW MORE A LOT MORE DON'T KNOW THANK YOU FOR YOUR ASSISTANCE 82 RELEASE OF INFORMATION FORM i Province of British Columbia Ministry of Health MENTAL HEALTH PROGRAMS OR GREATER VANCOUVER MENTAL HEALTH SERVICES AUTHORIZATION FOR RELEASE OF INFORMATION I hereby authorize to release the following information: on (Client's name) (Bbthdate) To NAME OF AGENCY ADDRESS This consent will expire on , or sixty days after the date below. Client's Signature or Person Authorized to sign for client Witness Date H1.TH 31.19 RFV 87/03 83 CERTIFICATE OF APPROVAL TO DO RESEARCH 84 EAVES LETTER 85 RUSSELL LETTER 8 6 EGAN L E T T E R 87 Appendix C The I n t e r - M i n i s t e r i a l Project as an Intensive Case Management  Proi ect An obvious concern to the researcher was whether or not the I n t e r - M i n i s t e r i a l Project was an intensive case management project. Despite the f a c t that i t c a l l e d i t s e l f an intensive case management project, there was s t i l l l i t t l e proof that i t f i t the c r i t e r i a of the independent variable, intensive case management project. A review of the job description of the case managers (c a l l e d "workers" by the I.M.P.) showed that the f i v e functions most commonly outlined i n the l i t e r a t u r e were l i s t e d . These included assessing, l i n k i n g , monitoring, l i a i s i n g , and advocating. However, there was no way of proving that the workers a c t u a l l y d i d these things. Also, although there was evidence that the I.M.P. maintained a worker-client r a t i o (10-1) s i g n i f i c a n t l y lower than the l o c a l mental health team (32-1) , and that they saw t h e i r c l i e n t s more often (2.8 times/week) than the l o c a l mental health team (once every 3 or 4 weeks) , there was a question whether or not t h i s alone constituted intensive case management. In order to v e r i f y whether or not the I.M.P. f u l f i l l e d the c r i t e r i a of the independent variable, intensive case management, the researcher decided to t e s t using a case management assessment t o o l created by Kurtz et a l (1984). This t o o l , c a l l e d the "Frequency of Performance Scale" by the authors, consisted of twenty-six separate duties most commonly performed by case managers i n intensive case management projects i n the state of Georgia, U.S.A.. These were each rated on a s i x point scale of performance from "never" to "several times d a i l y . " The assumption was that i f the I.M.P. scored at a high l e v e l i n the majority of the categories, then i t could be assumed with some confidence that i t was an intensive case management project. The t o o l was given to each of the s i x workers of the I n t e r - M i n i s t e r i a l Project and, once completed, an average score for each of the categories was compiled. A copy of the t o o l and the I.M.P. average score i n each category appears as i n table 4. 88 Table 4 Frequency of Performance Scale and Average I n t e r - M i n i s t e r i a l  Project Scores A c t i v i t i e s Frequency of Performance C i r c l e only one 1 = never; 2 = occasionally; 3 = monthly; 4 = weekly; 5 = d a i l y ; 6 = more than once per day I.M.P. Assessment Score Conduct telephone intakes 1 2 3 4 5 6 3.0 Conduct o f f i c e intakes 1 2 3 4 5 6 2.8 Conduct in-home intakes 1 2 3 4 5 6 1.3 Perform emergency screening 1 2 3 4 5 6 1.6 Take s o c i a l h i s t o r i e s 1 2 3 4 5 6 2.2 Conduct family interviews 1 2 3 4 5 6 1.8 Planning Form service plans 1 2 3 4 5 6 3.6 Discuss c l i e n t s with other s t a f f 1 2 3 4 5 6 5.8 Discuss c l i e n t s with super-v i s o r 1 2 3 4 5 6 5.5 Arrange case conferences 1 2 3 4 5 6 2.8 Attend case conferences 1 2 3 4 5 6 2 . 6 Linking Arrange appointments with agencies 1 2 3 4 5 6 5.2 Take c l i e n t s to other agencies 1 2 3 4 5 6 5.3 Meet with other agency s t a f f 1 2 3 4 5 6 4 . 6 V i s i t with c l i e n t s i n other f a c i l i t i e s 1 2 3 4 5 6 4.6 Help plan c l i e n t s ' discharge from other f a c i l i t i e s 1 2 3 4 5 6 3.6 89 (Table 4 continued) 1 2 3 4 5 6 5.0 2 3 4 5 6 4.5 1 2 3 4 5 6 3.6 1 2 3 4 5 6 3.0 1 2 3 4 5 6 2.0 Monitoring Discuss progress with c l i e n t s Monitor c l i e n t s ' progress by consulting with other agencies Read progress notes Conduct follow-up a f t e r discharge Monitor c l i e n t ' s progress by consulting with families Advocacy Intercede for c l i e n t s to obtain service 1 2 3 4 5 6 4.0 Intercede i n interpersonal disputes 1 2 3 4 5 6 3.3 Take part i n a c t i v i t i e s to encourage resource develop-ment 1 2 3 4 5 6 4.3 90 When i n t e r p r e t i n g t he r e s u l t s o f t h i s survey, some c a u t i o n must be observed f o r t h i s assessment t o o l i s u n v e r i f i e d i n the areas o f r e l i a b i l i t y and v a l i d i t y . However, i t i s d i f f i c u l t t o f i n d an assessment t o o l t h a t i s v e r i f i e d i n t h e l i t e r a t u r e . D e s p i t e t h i s s e r i o u s flaw, t h e r e s u l t s show t h a t t h e I n t e r - M i n i s t e r i a l P r o j e c t performs a l l o f the f u n c t i o n s as a r e g u l a r p a r t o f i t s j o b d u t i e s . In f a c t , i n the areas o f m o n i t o r i n g , advocacy, and l i a i s o n , i t performs many of these f u n c t i o n s on a d a i l y b a s i s . Based on thes e r e s u l t s , one can say w i t h some c o n f i d e n c e t h a t the I n t e r - M i n i s t e r i a l P r o j e c t i s an i n t e n s i v e case management p r o j e c t . 91 Appendix D I n t e r - M i n i s t e r i a l P r o j e c t C l i e n t L i s t and D i a g n o s i s C l i e n t Age S c h i z . P.D. Sub. 7\b. M.R. #1 26 X X 2 46 X X X 3 33 X X X 4 28 X X 5 43 X X X 6 34 X X X 7 32 X X 8 27 X X X 9 32 X X X 10 21 X X 11 33 X X X X 12 33 X X X 13 39 X X 14 25 X X 15 31 X X X 16 28 X X 17 27 X X X 18 42 X X X 19 35 X X X 20 32 X X 21 44 X 22 37 X X 23 48 X X 24 41 X X 25 35 X X S c h i z . = s c h i z o p h r e n i a P.D. = p e r s o n a l i t y d i s o r d e r Sub.Ab. = substance abuse M.R. = mental r e t a r d a t i o n Appendix E Raw Data Corrections Data C l i e n t Before During Change No.Days #1 677 235 442 1430 #2 977 317 660 1398 #3 74 18 56 1386 #4 172 117 55 1376 #5 497 270 227 1341 #6 650 234 416 1317 #7 18 36 -18 1310 #8 6 11 -5 1288 #9 203 0 203 1264 #10 7 28 -21 1188 #11 95 0 95 1127 #12 54 0 54 914 #13 24 28 -4 883 #14 320 120 200 794 #15 191 3 188 792 #16 287 0 287 774 #17 9 121 -112 730 #18 0 2 -2 645 #19 37 9 28 608 #20 146 188 -42 531 #21 11 0 11 524 #22 82 3 79 468 #23 0 0 0 394 #24 26 0 26 386 #25 140 0 140 365 Before = Days i n custody (sentenced and remand) before I.M.P. During = Days i n custody (sentenced and remand) during I.M.P. Change = Difference between before and during. (* A negative number here r e f l e c t s more time spent i n custody while on the I.M.P.) No.Days = Number of days as a c l i e n t on the project 93 F o r e n s i c Data C l i e n t B e f o r e D u r i n g Change No.Days #1 36 0 36 1430 #2 9 49 -40 1398 #3 21 101 -80 1386 #4 0 0 0 1376 #5 21 26 -5 1341 #6 31 28 3 1317 #7 0 138 -138 1310 #8 40 29 11 1288 #9 171 0 171 1264 #10 0 0 0 1188 #11 430 0 430 1127 #12 57 0 57 914 #13 0 14 -14 883 #14 109 0 109 794 #15 81 0 81 792 #16 123 0 123 774 #17 0 0 0 730 #18 0 0 0 645 #19 0 358 -358 608 #20 0 0 0 531 #21 0 0 0 524 #22 85 0 85 468 #23 394 0 394 394 #24 11 86 -75 386 #25 142 0 142 365 M i r r o r = Days i n the F o r e n s i c P s y c h i a t r i c I n s t i t u t e b e f o r e I . M . P Tenure = Days i n the F o r e n s i c P s y c h i a t r i c I n s t i t u t e d u r i n g I . M . P Change = D i f f e r e n c e between b e f o r e and d u r i n g . (* A n e g a t i v e number h e r e r e f l e c t s more days spent i n d e t e n t i o n w h i l e on the I . M . P . ) No.Days = Number o f days as a c l i e n t on t h e p r o j e c t 94 Mental H e a l t h Data C l i e n t M i r r o r Tenure Change No.Day #1 12 26 -14 1430 #2 10 23 -23 1398 #3 135 87 48 1386 #4 0 0 0 1376 #5 0 145 -145 1341 #6 3 5 -2 1341 #7 0 532 -532 1310 #8 82 17 65 1288 #9 4 0 4 1264 #10 49 44 5 1188 #11 0 0 0 1127 #12 169 67 107 914 #13 233 48 185 883 #14 0 0 0 794 #15 7 31 -24 792 #16 32 10 22 774 #17 0 75 -75 730 #18 0 0 0 645 #19 72 0 72 608 #20 0 0 0 531 #21 0 0 0 524 #22 0 135 -135 468 #23 0 0 0 394 #24 0 0 0 386 #25 0 0 0 365 M i r r o r = Days i n p s y c h i a t r i c h o s p i t a l b e f o r e I.M.P. Tenure = Days i n p s y c h i a t r i c h o s p i t a l d u r i n g I.M.P. Change = D i f f e r e n c e between b e f o r e and d u r i n g . (* A n e g a t i v e number here r e f l e c t s more days spent i n d e t e n t i o n w h i l e on the I.M.P.) No.Days = Number of days as a c l i e n t on the p r o j e c t . 95 Total I n s t i t u t i o n s Data (Forensic + Corrections + Mental Health) C l i e n t Before During Change No.Days #1 725 261 464 1430 #2 996 389 607 1398 #3 230 206 24 1386 #4 172 117 55 1376 #5 518 441 77 1341 #6 684 267 417 1317 #7 18 706 -688 1310 #8 128 57 71 1288 #9 378 0 378 1264 #10 56 72 -16 1188 #11 525 0 525 1127 #12 280 67 213 914 #13 257 90 167 883 #14 429 120 309 794 #15 279 34 245 792 #16 442 10 432 774 #17 9 196 -187 730 #18 0 2 -2 645 #19 109 367 -258 608 #20 146 188 -42 531 #21 11 0 11 524 #22 167 138 29 468 #23 394 0 394 394 #24 37 86 -49 386 #25 282 0 282 365 Before = Days i n i n s t i t u t i o n s ( j a i l + h o s p i t a l + forensic) before I.M.P. During = Days i n i n s t i t u t i o n s ( j a i l + h o s p i t a l + forensic) during I.M.P. Change = Difference between before and during. (* A negative number here r e f l e c t s more days spent i n detention while on the I.M.P.) No.days = Number of days as a c l i e n t on the project. 96 Appendix F T r a n s i n s t i t u t i o n a l i z a t i o n The i n s t i t u t i o n a l c a r e e r o f Orpheus, T a b l e 5, one o f t h e 25 i n d i v i d u a l s i n t h i s s t u d y , makes T e p l i n ' s (1987) t h e o r y o f t r a n s i n s t i t u t i o n a l i z a t i o n much more o b v i o u s . T h i s i s e s p e c i a l l y t r u e when one o b s e r v e s h i s v e r y sudden d e s c e n t i n t o t h e c o r r e c t i o n a l system around t h e m i d d l e o f 1979 and h i s r a t h e r c o n s i s t e n t use o f t h i s system u n t i l h i s reemergence i n t o t h e m e n t a l h e a l t h system, a f t e r t h e advent o f i n t e n s i v e c a s e management s e r v i c e , e a r l y i n 1987. Such d a t a makes one wonder how an i n d i v i d u a l , who seems t o be so e n t r e n c h e d i n t h e m e n t a l h e a l t h system, c o u l d so s u d d e n l y become e n t r e n c h e d i n t h e c o r r e c t i o n s system. There a r e c e r t a i n l y many f a c t o r s a t work h e r e , and t h e d a t a i s o n l y a b l e t o i n d i c a t e an a b r u p t change i n t h e t y p e o f i n s t i t u t i o n Orpheus e i t h e r chooses a t h i s own v o l i t i o n , o r has i t chosen f o r him by t h e agents o f s o c i a l c o n t r o l . Such w r i t e r s as T e p l i n (1987) go as f a r as t o s u g g e s t t h a t such an a b r u p t s h i f t r e p r e s e n t s t h e l o s s o f r e s p o n s i b i l i t y shown by t h e m e n t a l h e a l t h system f o l l o w i n g d e i n s t i t u t i o n a l i z a t i o n , and t h e assuming o f t h i s r e s p o n s i b i l i t y , by d e f a u l t , by t h e c o r r e c t i o n s system. Table 5 Orpheus 1s I n s t i t u t i o n a l Career 90 o o 89 oxx X 88 X X X X X xo X 87 X X X X X 86 o X XX XX 85 X X ox 84 X XX X X X XXX 83 X X X X 82 X X X X X X 81 XX X 80 XX X X X XX X ox 79 o X xxo X xo 78 o o o o o 77 o o o o o o 76 o o o o 75 o o 74 o 73 72 o 71 70 o 69 o o 68 o o o Jan Feb Mar Apr May Jun J u l Aug Sept Oct Nov Axis = Years (Jan • 1, 1968--Dec. 31, 1990) X Axis = Months o = h o s p i t a l admission x = j a i l admission B o l d P r i n t = p o i n t (Feb. 1, 1987) a t w h i c h Orpheus commences I . M . P . 

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