About the Book

• The Lady and the Unicorn: A Psychological Metaphor



• Dreaming�With Eyes Wide Open: Schizophrenic Hallucinations



• Information Processing in Schizophrenia



• Clarification of our Clinical versus Forensic Function: Dual Relationship



• Art Psychotherapy



• Lord of the Rings: A Psychological Metaphor



• Aviation Psychology



• So, You have just been Passed by a Girl! A Holley Carborator may help



• Approaches in Memory Rehabilitation



• Memory Enhancement Module



• Negaunee Center



• The Final Transition



• Is Deinstitution- alzation a Misnomer



• Token System: a Psychiatric Case Study



• A Token Economy System: Inpatient Psychiatric Population



• Insight: An Aspect of Neurocognition

With the ever-increasing emphasis upon deinstitutionalization of the mentally ill (MI), administrative and clinical staff at the community level are experiencing increasing pressure to provide effective and successful community placements. This changing focus on the care and treatment offered to the MI represents a new, or at least newly invigorated, philosophy, which forms the very basis of the community mental health system. The transition is marked by changes in our societal values, which have shifted from an institutionalized model of care to a more humanistic and least restrictive orientation. As a society, we are hopefully becoming more tolerant of deviance, more accepting of individual differences and more respectful of individual rights. In light of our knowledge and treatment regarding mental disorders, we no longer feel threatened to the point of isolating the MI from our society and community. Institutions have now become only a priority placement in cases of acute psychosis, which would require twenty-four hour supervision for protection of the person and/or the community. The inpatient hospital is seen currently as the most restrictive, but very integral, component in the residential care continuum. The status of the institution as a viable option for care could only be challenged when we, as professionals, have mastered the cause of mental disorders.

The inpatient care setting is only one end of a long continuum of residential care available for the treatment of the mentally ill. The purpose of this paper is to examine the opposite end of the continuum, referred to as the community placement's "Final Transition".

One of our cultural values is the ideal of independence. Independence is also one of the ways of measuring an individual's quality of life. For MI individuals, this issue of independence is directly related to their ability to function adequately, within their life and community.

The ability to function independently is measured by the person�s skill to care for their basic needs. Therefore, the nature of mental disturbances can be accurately described on a functional/dysfunctional continuum. Although, we as a treatment team, sometimes inadvertently subject others to our own cultural values, this issue of eventual independence within the residential continuum must remain the treatment objective. During the movement along the residential care continuum, there are hundreds of Basic Living skills to be accomplished. Reihman, Wolford, Knapp, MacCallum and Murry (1983), have indicated that adequate functioning level on the 'basic need skills' dimension may be important to a supportive, structured and successful residential placement. These skills represent both internal and external criteria for assessing one's capacity to care for oneself. Therefore, movement through the continuum of care is primarily determined by the ability of a resident to function independently.

When we examine the community residential setting, it in itself represents a continuum of care based upon individual's functioning level. This residential continuum is characterized in terms of most to least restrictive community based settings. The goal in community placement is primarily concerned with how the two factors, of functioning level of the resident and restrictiveness of the setting, are interrelated. Community placement attempts to assure that the discharged resident is within the least restrictive residential setting for their functioning level. Put in other words, the more dysfunctional a resident is, the more restrictive the setting. As the residents improve through time and treatment, their improved functioning level provides the driving force for movement along the residential continuum.

During the past decade we, mental health professionals, have been occupied with the logistical problems of the deinstitutionalization movement. As each component of the residential continuum was carefully planned and put into place, we were successful in the establishment of a variety of residential settings such as; Room and Board Homes, Adult Foster Care (AFC), Group Homes, Alternative Institutional Settings (AIS), Nursing homes, etc. Each step would achieve a gradual decrease in the individual's utilization of state facilities. Yet movement, the inherent quality of a residential continuum, was missing. It appeared that there was little or no movement through the residential continuum. Instead, movement was static, a one-to-one reduction of individuals into the community from the state hospital facilities based solely upon the beds that were developed, funded, and available. Movement from one residential setting to another seemed non-existent, no matter how well the resident was functioning. This was primarily a factor of not having a viable residential placement alternative for the higher functioning individuals to transition back into the community.

An alternative now available to higher functioning clients is the semi-independent apartment. The term "semi-independent" refers more to the continuing nature of community mental health support provided to the resident versus the physical setting of the apartment. It has a new meaning, depth and a more holistic understanding of the plight of the mentally ill in their transition back into the community. In the past, semi-independent apartments were established only as another form of housing. When the person was ready to be discharged, they were expected to leave and find their own apartment. This proposition would be extremely frightening for the resident and would be the realization of perhaps their worst fears, being displaced and abandoned. With our experience treating the MI, we realize that residents should not have to leave their current semi-independent apartment, instead we need to find and develop other apartments in the community; we do not necessarily need to close their cases upon discharge to a semi-independent living situation; and we have a dual responsibility and are accountable to both, to the MI residents and to the community.

The initial group of apartments was secured with the expressed purpose of moving higher functioning residents from semi-independent group homes into the community. Therefore, it can be clearly seen that the initial population was reflective of the highest functioning individuals within our system. But even these individuals were not moved until the semi-independent apartment structure was totally established. Although the residents appeared to be functioning well in the supervised setting of the semi-independent group homes, we realized that only with intensive clinical and social support could they make this transition to the community successfully.

The project's sample population focused primarily upon the mentally ill who had a diagnosis of schizophrenic, chronic type. Five individuals ranging in age from 25 to 55 were selected to form the initial group. All individuals selected were considered stabilized by not having exhibited any psychotic or behavioral problems for the past year. Apartments were rented for between $100.00 to 200.00 per month, an economically realistic amount for these residents. They were furnished for less than $200.00 each, with most of the furnishings coming from garage sales. The only other requirement was that the apartments had to be within walking distance of bus routes, shopping, and laundry facilities.

Six apartments were secured and the operating corporation paid the initial security deposit, which was reimbursed by the resident in small monthly payments. The reason for reimbursement through the resident�s subsidy served several purposes:

1. It provided the required security deposit for the apartment.
2. It allowed a reasonable payment plan, which was financially more economical for the mentally ill resident.
3. This was a pseudo-forced savings plan of reimbursement, which provided for the residents a security deposit for future apartment.

Total unconditional support was given to these residents. Initially, everything that could be done was done. This set the stage for success. The support included cleaning, painting, being on call, solving any problems, and anything else that was needed. Both the project director and the resident went together and applied to every Social Service agency in existence, for any and all services such as Food Stamps, Social Security Income (SSI), General Assistance (GA), Free Food Banks, and Housing Commission for Section 8 rent subsidy assistance.

This Section 8 program subsidizes low income rent without affecting the residents' other social services program determinations. The residents' eligibility status for other programs was not affected because the rent subsidy money was sent directly to the landlord and did not come directly to the resident. Perhaps the only program that was minimally affected was food stamps, which is based upon the individual's available monthly income, which increased as a result of the subsidy program.

We recommended that this additional money then be used to secure a telephone. With a telephone available, the resident could make their own appointments and secure assistance or any number of other services to develop their independence.

Needless to say, with any new program concept there arose numerous problems, but nothing mental health workers have not struggled with and solved before. For example, funding, public relations, resources, programming, furnishings, leases, income requirements, policies and procedures, entrances and exit criteria were some of the problems challenging the success of the program.

Prejudice and discrimination were pervasive from landlords who did not want to rent to the MI for various reasons, most of which were based upon not fully understanding the nature of the mental disorder. In securing apartments, it was a policy of this residential corporation to tell the prospective landlords that the individual's were mentally ill. This in itself created problems, but it demonstrated the ethical framework in which the concept was founded. In addition, not telling the landlords, may have created the distrust that would have, as in most cases, created failure.

The factors of prejudice and discrimination could be overcome primarily by a thorough assessment of the individuals functioning level, to assure they were indeed capable of independent living. This was done by an interdisciplinary team in an attempt to guarantee a successful transition. Fraker (1986) found that pre-placement assessments of the individual�s ability to function in the community have also been found to be an essential variable for success in community placement. In addition, it helped to then "promise the moon" to the landlord. For example: 1) if the resident broke anything it would be replaced; 2) if there was a problem, the landlord was to immediately call the project director with the promise that the problem would be taken care of, i.e. decompensation, aggression, and property damage. In certain instances, this was also cogently put to the landlord as "If you currently have problems with any of your regular tenants, you have to take care of it, but with the semi-independent apartment tenants, we will take care of it.

Perhaps the most striking feature of this residential concept was the unconditional support for the resident in this final transition towards independence. Cochran, Sran and Varano (1977), have recommended a number of steps to be taken in the relocation process. They found that including staff in the process demonstrated to the client that they cared about the client's needs and desires. Also prior to movement a pre-placement visit was arranged for the client. This visit helped to decrease any anxiety the client was experiencing as a result of the relocation process. Furthermore, involving the client in the actual preparation for the move and activating a supportive network of family and friends was considered to be beneficial to the overall success of the individual�s transition back into the community.

The fear of change can be perhaps the most debilitating behavioral variable for mentally ill residents. Even if the residents are not adapted nor satisfied in their present situation; at least it is predictable and secure. To relocate to a new situation is extremely frightening for him or her, creating overwhelming stress and anxiety. As Cohen, Conroy, Frazer, Snelbecker, and Spreat, (1977) have shown, a resident transitioning from one institution to another setting experiences many similar stressors as in the initial institutionalization. Ambivalence also plays a role in the individuals' transition to independence. Ambivalence is the feelings of both wanting and not wanting this implicit responsibility and freedom of moving independently. In light of these psychological aspects, structuring and limiting the events changing in their life is important in lowering their overall anxiety and stress. It has been suggested, "Because stress can serve to either impair or facilitate functioning, only knowledge of persons' prior coping skills and their success or failure can predict their stress reactions. Prior failure in coping skills can mean decreased functioning, depression, withdrawal, anger, and fear as reactions to stress."(Weinstock, Wulkan, Colon, Coleman and Goncalves, 1979, p.385) Being aware of the "change factor" and the fear associated with it will enable the professional to assist the resident in making a successful transition to the semi-independent living situation. Gradually, introduce the resident to this new environment, demonstrating its predictability, then consistently and reliable offer support and reassurance to the resident. This will provide the necessary stability and safety for a successful transition.

Changes for the mentally ill elicit fear and anxiety. "Simply insisting that patients engage in an activity which they have avoided in the past was likely to cause considerable anxiety" (Leitenberg, 1976, p.152). Underlying this transition is the individual's own overwhelming fear of being abandoned. The mentally ill have experienced this feeling of abandonment in a number of different ways; the first being their own sense of alienation. The individuals have experienced the feelings of being different from those around them. In the second instance, they have experienced life differently as a result of their disability i.e., hallucinations, delusions, etc. Thirdly, the resident may have, in the past, strained their interpersonal relationships to the point that their family, friends, and neighbors have abandoned them.

For these reasons, it is important to offer complete and unconditional support to the resident who is undergoing this final transition back into the community. In fact, during this transition, it is clinically indicated to offer more instead of less intensive support to the person.

Even for professionals, obtaining needed services for the mentally ill resident in our society is a very complicated task. Discovering and determining what services are available, what the eligibility requirements are, and how services are interrelated, are difficult tasks. Therefore, since the MI individuals cannot usually perform that task, it becomes our job as professionals to assist them in obtaining at least the most basic type of support services, as well as teaching the person how to maintain these services. This was accomplished in a number of different ways: 1) We kept the resident informed of any new services that became available; 2), We prepared a handbook to identify and guide the resident to existing community resources; 3) We actually took the resident to apply for available services that they may not have done on their own. Rather surprisingly, the residents knew of some services that we were not aware of; therefore, the sharing of information between the residents also became invaluable.

Social Support was achieved through the concept of community meeting. Once per month all residents that were involved in this project met together. The meeting included the other semi-independent apartment residents and the interdisciplinary team. The meetings also included other group home residents that were preparing to move into the semi-independent apartment project. This was a way of introducing them to a natural system of support and becoming gradually more familiar with the idea of living independently. A recent study by Fraker (1985) has indicated professional intervention was necessary to facilitate the successful transition of the residents back into the community. This intervention helped by lowering anxiety and resistance towards community placement by gradually presenting the idea of movement and change.

One of our purposes of the monthly community meeting was to resolve any emotional or psycho-social concerns that emerged during the previous month. Another purpose was to answer any questions or solve any problems they may have regarding their new life style: cooking, apartment maintenance, obtaining services, etc. The concept of support was also important in establishing a natural folk support system including both staff members and residents. Developing a folk support system within the community is essential. It has been found "that when compared with a 'normal' population, the social support networks of people with a mental illness are deficient or impoverished" (Crotty & Kulys, 1985, p.301). This system of support includes the individual's family, friends, and neighbors.

Clinical support took the form of structuring daily activities, provided through Day Treatment Centers and, through therapeutic crisis intervention as necessary. The resident i.e. school, work, and volunteer employment could substitute the Day Treatment programming for other structured activities. Structured activity has been found to be an essential ingredient for progress and success. A new study reported that "...we endeavor to return our patients to the work force as soon as possible, and we believe that returning to work is a concrete indicator of treatment progress We have therefore broadened the definition of employment to include all constructive and productive activities such as volunteer work" (Hsia and Herman, 1985, p.777). Our concept was one of total structure and support. This structure was later gradually faded as these residents were able to experience community living more independently.

Examining the variables, which play an important role in the successful transition of the mentally ill back into the community, one must consider the resident's readiness for community placement. This can be accomplished by a thorough assessment of this individuals' functioning level based upon his/her degree of accomplishment of the advanced living skills. In addition, providing a stable and safe environment, which limits unpredictable changes, such as moving, were important variables for a successful transition back into the community. Structuring one's environment lowers the overall stress and anxiety levels for MI individuals. Other factors such as consistent and ongoing support both socially as well as clinically have been successful in the transition of the person back into the community.

With the major thrust towards deinstitutionalization, we as professionals are challenged to develop a viable community residential continuum. This continuum of care can provide the necessary emotional, psychological, and environmental support for the successful transitions of mentally ill back into the community. "Although the residential services system is a component of the broader service delivery system, it is the component that more directly touches clients and that should be expected to have the most powerful impact on adjustment" (Sigelman, Novak, Heal and Switzky, 1978, p.69). This new alternative for care of the mentally ill has been met by the mental health professional with creativity, resourcefulness, and dedication. That sense of commitment in addition to the unconditional support and encouragement for the mentally ill individual, are the basis for the success of the community mental health movement.