Women in refuge: Syrian women voicing health sequelae due to war traumatic experiences and displacement challenges

OBJECTIVE

The Syrian war created a mass exodus of people to neighboring countries. Jordan hosts approximately 1.4 million Syrians who sought refuge and protection. This research represents an effort to understand the subjective narratives of Syrian refugee women's war traumatic experiences and displacement challenges while living in Jordan and the consequences on their physical and mental health.

METHODS

Data gathered between March and June 2014 included 24 in-depth interviews with Syrian refugee women who sought services from humanitarian organizations in Jordan. Interviews were conducted in Arabic and were audio recorded. A team of four researchers translated and transcribed the interviews. Group narrative methodology was utilized to analyze the interviews.

RESULTS

The study suggests that Syrian refugee women experienced diverse war atrocities including shelling, loss of property, separation from family members, and threats to their lives and their beloved ones, among a few. In Jordan, they reported on multiple displacement challenges, which are perceived as a continuous traumatic experience, as well as somatization. Narratives of women also included sequelae to their physical and mental health due to such stressors. Barriers to obtaining physical and mental health services are discussed, including inadequate medical treatment, lack of mental health services, and stigma on mental health, which might be associated to somatization of mental illnesses.

CONCLUSION

It is crucial that humanitarian organizations and host countries like Jordan bear the responsibility to enhancing accessibility to comprehensive trauma-focused physical and mental health services for Syrian refugees in a culturally and gender sensitive manner.

RNA-Regulated TRA-1 nuclear export controls sexual fate

TRA-1, a member of the GLI family of transcription factors, is required for C. elegans female development. We find that TRA-1 has a sex-specific distribution consistent with its role in female development: nuclear TRA-1 is higher in hermaphrodite intestines and in specific germline regions than in males. TRA-1 patterns rely on nuclear export since treatment with leptomycin B, a CRM1-dependent export inhibitor, increases nuclearTRA-1 in males. TRA-1 export requires TRA-1 binding to the tra-2 3' untranslated region (3' UTR), as disruption of binding increases nuclear TRA-1 and female development. Our data are consistent with coexport of a TRA-1/tra-2 mRNA complex reducing TRA-1 nuclear activity, and identify an interesting RNA-based mechanism for controlling transcriptional activity and cell fate determination.

Factors in the use of coercive retention in civil commitment evaluations in psychiatric emergency services

OBJECTIVE

The authors examined whether factors other than civil commitment criteria influence the involuntary retention of patients who are evaluated for civil commitment in psychiatric emergency services in California general hospitals.

METHODS

Logistic regression analysis was used to determine whether admission criteria, institutional constraints, social biases, and procedural justice indicators contributed to the use of coercive retention in the evaluations of 583 patients in the psychiatric emergency services of nine California county general hospitals.

RESULTS

Of the 583 patients, 109 (18.7 percent) were retained against their wishes. Clinicians relied primarily on admission criteria in making the decision to retain a patient, which suggests that patients were generally afforded procedural due process during the evaluation in the psychiatric emergency service. Staff workload was a possible factor in violations of due process.

CONCLUSIONS

Psychiatric emergency services need additional resources to ensure procedural due process protection for patients who are being evaluated for civil commitment.

Quality of care for psychiatric emergency service patients presenting with substance use problems

Psychiatric emergency service assessments of 683 patients were observed to better understand the quality of care substance users receive and the effects of clinicians' attitudes toward their patients on such care. Findings run counter to those of previous reports in that substance users, once recognized, are likely to receive better care than other patients.

Measuring clients' satisfaction with self-help agencies

OBJECTIVE

Clients' satisfaction with their involvement in treatment decisions has been largely overlooked in the formulation of satisfaction measures. The authors describe the development of a scale that assesses clients' satisfaction with services and with their involvement in treatment decisions.

METHODS

Long-term users of four client-operated mental health self-help agencies were interviewed at baseline (N=310) and six months (N=248) using the 11-item Self-Help Agency Satisfaction Scale (SHASS). The scale was developed on the basis of consumers' input about their satisfaction with services and their involvement in treatment decisions. To explore the relationship between satisfaction as measured by the SHASS and outcomes, the six-month interview included four outcome measures-independent and assisted social functioning, symptom severity, and a sense of personal empowerment. Internal consistency, stability, and discriminant validity were evaluated.

RESULTS

Factor analyses confirmed that the SHASS has two subscales, one assessing service satisfaction and the other assessing satisfaction with involvement in treatment decisions. The scale and its subscales showed high internal consistency, moderate stability, and discriminant validity. The SHASS subscales showed modest associations with two of four outcome measures-assisted and independent social functioning.

CONCLUSIONS

The SHASS is a brief instrument that can be used to measure clients' satisfaction with their involvement in treatment in mental health self-help agencies.

Social work in a managed care environment

Managed care has created a new service environment, eliminating distinctions that have sustained social work ideology and the profession throughout its history. This paper reviews important features of managed care, considers changes it has brought to practice ideology, the practitioner/client relationship, and the practice environment, including social work employment. The paper discusses the new opportunities, challenges and problems that have emerged with this approach. While social workers should not embrace managed care, they should not run from it or blindly oppose it. They need to aggressively pursue it, fighting its major drawbacks, while adapting to a competitive market place. Given the current managed care market, the social work profession is now in the right place, at the right time, with the right skills, and available at the right price. It must now take on a leadership role to maintain its competitive position, protect its clients and insure quality practice.

Factors associated with involuntary return to a psychiatric emergency service within 12 months

OBJECTIVE

This study examined patient characteristics and other factors that contributed to the involuntary return of patients to a psychiatric emergency service within 12 months of an initial evaluation in the service. The findings were used to consider whether the pressure to limit duration of hospital stays under managed care contributed to the patients' return to the emergency service.

METHODS

Structured observations of evaluations of 417 patients admitted to the psychiatric emergency service were completed at seven county general hospitals in California. Twelve months after the initial evaluation, mental health and criminal justice records were reviewed for evidence of the patients' return for emergency psychiatric evaluation at any of the seven hospitals. Factors associated with patients' return to the psychiatric emergency service were evaluated using multivariate modeling.

RESULTS

Of the 417 patients initially evaluated, 121, or 29 percent, were involuntarily returned to the psychiatric emergency service within 12 months. The likelihood of involuntary return was increased by a psychotic diagnosis and indications of dangerousness at the initial evaluation. Having insurance also increased the likelihood of involuntary return.

CONCLUSIONS

The patient's initial condition in the psychiatric emergency service was found to be the best predictor of involuntary return. Brief hospitalization--an average of six days--after the evaluation did not have a significant prophylactic effect, perhaps because the reduced length of inpatient stay in the managed care environment did not allow adequate resolution of the patient's clinical condition.

Health status of homeless and marginally housed users of mental health self-help agencies

The study discussed in this article investigated the health status of 310 homeless and marginally housed people to determine the usefulness of mental health self-help agencies (SHAs) in addressing their physical health needs. The study compared self-reported health problems among SHA users with similar reports and clinical assessments of other homeless or marginally housed populations. Findings indicate that frequencies of health problems among respondents were similar to those of other homeless or marginally housed groups and that the study group had a higher prevalence of HIV infection and tuberculosis than the general population. Because this hard-to-reach group actively seeks SHAs, these organizations may be uniquely suited to health outreach, education, testing, and treatment.

Social networks and psychological disability among housed and homeless users of self-help agencies

We look at the effects of psychological disability on social networks and support of homeless and non-homeless individuals. We analyze a survey of 310 long-term users of client-run mental health agencies. Psychological disability is negatively associated with network characteristics for housed individuals, but not for the homeless. There is a positive relationship between psychological distress and network size for the homeless who receive SSI while homeless individuals who do not receive SSI show a negative, non-significant association. We suggest the financial resources of SSI enable network members to become expressively involved with homeless individuals with relatively more psychological disturbance.

Program environments of self-help agencies for persons with mental disabilities

Leaders of self-help agencies (SHAs) aspire to develop program environments that are different from community mental health agencies (CMHAs). This article addresses two questions. Do consumers' perceptions of SHAs approximate the characteristics leaders think ought to typify such agencies? Do SHA and CMHA consumers differ in their program perceptions? Using the Community-Oriented Program Environment Scale, leader expectations of ideal SHA environments were obtained from a national survey of 189 consumer-run agency heads, perceptions of actual environments from interviews with 310 SHA consumers, and perceptions of CMHAs from questionnaire responses of 779 consumers in 54 programs. SHA reality conforms to ideology in offering opportunities for consumers to experience involvement, support, and autonomy in the receipt of needed service. While showing only modest differences from CMHAs on relationship and treatment characteristics, SHA consumers differ in their perceived control over program rules, a fact previously found significant in promoting positive outcomes.

Quality of care and use of less restrictive alternatives in the psychiatric emergency service

OBJECTIVE

The study examined factors affecting clinicians' decisions in the psychiatric emergency service about referring patients to less restrictive alternatives to inpatient care. Indicators of quality of care and the severity of the patient's condition were a particular focus.

METHODS

Trained mental health professionals observed the evaluations of 425 patients in seven California county general hospitals. Multivariate modeling was used to examine variables thought to predict disposition to alternative care.

RESULTS

Less restrictive alternatives were available for 61 percent of the 425 patients and were used for 39 percent; they were overlooked by clinicians in 14 percent of cases and considered but not used in 8 percent. Patients' need for a controlled hospital setting, as indicated by the severity of their condition, was most important in determining use of hospital alternatives. Quality of care, especially the clinician's ability to engage patients in treatment at a level appropriate to their functioning, was also a significant predictor of whether alternative care was considered or used.

CONCLUSIONS

Under managed care, clinicians are under extreme economic pressure to use less restrictive alternatives, thereby reducing costly inpatient care. To ensure quality of care in general hospital emergency services, the development of supervised hospital alternatives is crucial. Clinicians should be encouraged to engage patients in treatment if appropriate use of alternative care is a goal.

Race, quality of care, and antipsychotic prescribing practices in psychiatric emergency services

OBJECTIVE

The study examined whether the prescription practices of clinicians in psychiatric emergency services differed for African-American patients. Prescription of antipsychotic medications and its relation to quality of care was a particular focus.

METHODS

Data from 442 independently observed evaluations of patients in psychiatric emergency services were examined using multivariate analyses. The observations were made during a five-year period at four urban general hospitals in California.

RESULTS

Clinicians in the four emergency services, most of whom were Caucasian, prescribed more psychiatric medications to African Americans than to other patients and devoted significantly less time to their evaluations. African Americans received more oral doses and more injections of antipsychotic medications, and the mean 24-hour dosage of antipsychotics (1,321 milligrams) was significantly higher than for other patients (825 milligrams). The tendency to overmedicate African-American patients was lower when clinicians' efforts to engage the patients in treatment were rated higher.

CONCLUSIONS

The results highlight the importance of efforts to engage African Americans in the treatment process and the need for clinical skills and training to help bridge cultural distances.

Health and a residential care population

This article describes the health status of 234 severely mentally ill (SMI) persons residing in California's supervised residential care facilities in 1973. Relocated in 1983, 63.2% reported their health as good to excellent. Over the follow-up period 80.8% maintained their SSI benefits, insuring them of health insurance coverage. Surprisingly the follow-up sample, believed to be at high risk of increased physical morbidity, compared quite favorably to low income subsamples of the National Health Interview Survey (NHIS). The SMI reported better health, access to and utilization of health services. Differences were particularly striking in the poor health category with NHIS respondents reporting poor health 3.5 times more frequently than SMI sample numbers. These results offer some support for the contribution of health insurance benefits and supervised residential settings to positive health outcomes of this vulnerable population.

Criminality of the mentally ill in sheltered care: are they more dangerous?

The sample of mental patients in sheltered care has a lower arrest rate than the general population in California in all categories of crimes, except for violent crimes. For violent crimes, the sheltered-care population is likely to be arrested at 1.33 times the rate of the state population, even when the heterogeneity of aggravated assault was taken into consideration. This indicates empirically that the mentally ill in sheltered care are more dangerous than the general population. For prediction of criminality, four factors are found to be significant predictors of resident criminality after 1973: (a) prior crime history, (b) age, (c) use of alcohol and drugs, and (d) sex (male). Among these factors, prior crime history is the single most powerful predictor of resident criminal activity. This is another confirmation of most of the previous research findings. Although there have been controversies over the issue of the dangerousness of the mentally ill, the results of this study, overall, support the most recent findings of studies in which the mentally ill population pose greater threats to the community than the general population. Now it is time to consider more specific and practical measures to monitor and carefully follow up the discharged population, especially those with prior crime history, and prevent further violent crimes. This will in turn help to promote the reintegration of the mentally ill in the community.

Factors in the quality of patient evaluations in general hospital psychiatric emergency services

OBJECTIVES

The study examined the usefulness of a three-perspective model for determining the quality of evaluations in psychiatric emergency services. The model was used to evaluate the hypothesis that the provision of high-quality care in emergency services is primarily influenced by service objectives related to patients' clinical characteristics rather than by institutional constraints, such as workload or physical facilities, or by social biases, such as clinicians' attitudes toward patients or perceptions of community expectations.

METHODS

The evaluation of 683 persons assessed in nine California public facilities were independently observed. Multivariate techniques were used to test the relative importance of patients' clinical characteristics, possible sources of social bias among clinicians, and institutional constraints in influencing three quality-of-care dimensions: technical quality, the art of patient care, and optimum investment of time.

RESULTS

The findings generally confirmed the hypothesis that patients' clinical characteristics have more influence on the quality of care provided than institutional constraints or social biases. However, one institutional constraint--increased workload demands--led to reduced technical quality and to less than optimal use of time. Further, social biases reflected in the clinician's like for and preconceptions about the patient also influenced the quality of their evaluations.

CONCLUSIONS

The model is a useful tool for examining quality of care in the psychiatric emergency service. Increasing workload pressures negatively affect quality of care.

The quality of psychiatric emergency evaluations and patient outcomes in county hospitals

Quality of care is widely assumed to be related to patient outcomes, but little is known about care in relation to outcomes in county general hospital psychiatric emergency services. It was hypothesized that conformity to professional standards (technical quality) and engagement of the patient (artful care) in psychiatric emergency services evaluations would contribute to improved patient functioning (Global Assessment Scale score) and appropriate disposition. A total of 583 cases in seven facilities were analyzed. Conformity to technical standards of care was associated with retention even after constraints, biases, and admission criteria had been taken into account. Conversely, artful care was associated with lower probability of retention and improved functioning.

Measuring empowerment in client-run self-help agencies

"Empowerment" connotes a process of gaining control over one's life and influencing the organizational and societal structures in which one lives. This study defines and validates three measures: the Personal Empowerment Scale, the Organizational Empowerment Scale, and the Extra-Organizational Empowerment Scale. Measurement efforts are based on observational work, baseline interviews (N = 310), and six month follow-ups (N = 241) in four client-run self-help agencies (SHAs) for persons with severe mental disabilities. All three study scales demonstrated strong internal consistency and stability. They were sensitive to user changes over time and have construct validity.

Characteristics and service use of long-term members of self-help agencies for mental health clients

OBJECTIVE

This study examined the characteristics of long-term members of self-help agencies managed and staffed by mental health clients, why they sought help from the agencies, and how they differed from clients of community mental health agencies.

METHODS

A survey and assessment instruments were used to obtain information on the service utilization of 310 long-term agency members as well as on their resources, history of disability, functional status, psychological disability, health problems, and DSM-III-R diagnosis. Data from management information systems of the self-help and community mental health agencies were used to compare service populations.

RESULTS

The self-help agencies served a primarily African-American population (64 percent), many of whom were homeless (46 percent). Eighty-seven percent had confirmed DSM-III-R diagnoses, and 50 percent had dual diagnoses with moderate to severe substance or alcohol abuse or dependence. They had sought help from the self-help agencies primarily for resources such as food or clothing, for "a place to be," or because they were homeless. Obtaining counseling or help for substance or alcohol abuse was a less important reason for coming to the self-help agencies.

CONCLUSIONS

A high proportion of the persons served by the self-help agencies in the study were homeless and had a dual diagnosis of mental disorder and substance abuse. The self-help agencies provided their clients with material resources while community mental health agencies provided psychotherapeutic and medical care.

Licensure of sheltered-care facilities: does it assure quality?

In California, licensure was intended to assure a minimum level of quality in sheltered-care facilities for the mentally ill population. This longitudinal study relates characteristics of facilities, their residents, and communities to subsequent licensure and considers differences between licensed and unlicensed facilities at follow-up. Initial interviews were completed in 214 facilities in 1973 six months before the implementation of the California Residential Facilities Licensing Act. Follow-up interviews occurred in 1985. Results indicate that although licensure occurred with greater frequency among facilities serving the most disabled population, licensure neither predicts nor has as its apparent consequence the development of higher-quality facilities. An alternative approach to quality assurance is offered.

Police referral to psychiatric emergency services and its effect on disposition decisions

OBJECTIVE

Some clinicians and researchers have questioned the appropriateness of police referrals to psychiatric emergency services and have suggested that police exercise undue influence on hospital admission decisions. The purpose of this study was to test these assertions.

METHODS

Research clinicians in nine emergency services in California observed staff evaluations of 772 cases and rated patients' symptom severity, danger to self or others, and grave disability. They also reviewed the criminal justice records of these patients both before and for 18 months after the index evaluation. A total of 186 patients referred by police were compared with 577 patients not referred by police.

RESULTS

Patients brought by police were more likely to be subsequently hospitalized, but they were also more psychiatrically disturbed. They were more dangerous to others and more gravely disabled. They were no more likely to have a criminal record than patients not referred by police.

CONCLUSIONS

Police did not exercise undue influence on dispositions nor were the patients they brought in more "criminal" than others.

Empowerment and self-help agency practice for people with mental disabilities

During the past 15 years, there has been tremendous growth in the number of self-help groups and agencies for mental health clients. This article examines the self-help perspective in relation to problems with traditional mental health services and the need for client-run services. Self-help agencies see their goal as empowerment on an individual, organizational, and societal level. They strive to accomplish this by helping members obtain needed resources and develop coping skills; providing means of enhancing members' self-concept and lessening the stigma of perceived mental disability; giving members control in the agencies' governance, administration, and service delivery; and furthering member involvement in social policy-making. The goal of this article is not to endorse the self-help perspective but to use it as the basis for raising research questions that will further the mental health practitioner's understanding of this service modality.

Residential status and the physical health of a mentally ill population

Current literature suggests that severely mentally ill individuals are at high risk for increased physical morbidity and mortality. This study considers the relationship between residential arrangements and the health status of this population. It compares the health status of 234 severely mentally ill individuals living throughout California in sheltered-care facilities, institutions, or the general community. Sheltered-care residence was found to predict positive physical health status when traditional risk factors, as well as risk factors peculiar to this population, were controlled for. The results underscore the value of sheltered-care residence for severely mentally ill individuals who need this type of care. Implications of the results are discussed.

Sheltered care residence: ten-year personal outcomes

A ten-year follow-up study of 393 seriously mentally ill sheltered-care residents examined the type and degree of handicap characterizing the sample and estimated effects of ten-year residence. Results showed higher levels of helper-supported social functioning and of physical and mental health, accompanied by significant reductions in independent social functioning.

Early life experiences and residential stability: a ten-year perspective on sheltered care

The effects of early family losses and disruptions on the ability of seriously mentally disabled individuals to achieve stable living arrangements were investigated. Factors found to predict instability were early losses, early disruptions, psychological symptoms, and youth. Among factors found to predict stability were increased age and a diagnosis of schizophrenia.

Neuroleptic medication and prescription practices with sheltered-care residents: a 12-year perspective

OBJECTIVES

Most adult residents of sheltered-care facilities (board and care, family care, psychosocial rehabilitation, and other supported housing arrangements) for the chronically mentally ill receive neuroleptics. These facilities house over 300,000 mentally ill residents, but neuroleptic prescription practices with this population have not been studied.

METHODS

A probability sample (n = 393) of all adult former psychiatric patients in sheltered care in California was surveyed in 1973; 94% of the located survivors (n = 243) were reinterviewed 12 years later.

RESULTS

In 1973, 79% received neuroleptics; in 1985, 76%. Polypharmacy decreased, and the elderly remained less medicated than adults. Yet, mean daily neuroleptic doses doubled, more persons received higher doses, and 62% reported adverse effects. Furthermore, high dosing was attributed to psychiatrists rather than other physicians, even when controlling for residents clinical and sociodemographic characteristics.

CONCLUSIONS

Neuroleptic drugs became the staple pharmacological treatment for mentally ill sheltered-care residents. While physicians more cautiously medicated the elderly, they had not reduced doses by 1985, even after a decade of treatment. The specialty of the prescriber was an important factor in preference for high-dose treatment.

Factors affecting SSI support for sheltered care residents with serious mental illness

The complexity of Supplemental Security Income (SSI) regulations and procedures allegedly inhibits eligible persons with serious mental illness from obtaining and retaining support. This study examined factors affecting continued SSI support among 393 sheltered care residents with serious mental illness ten years after an initial positive eligibility determination. At follow-up between 1983 and 1985 of 225 cohort members, 182 were receiving SSI benefits, 28 were eligible for SSI due to their low income but were not receiving benefits, and 15 were income-ineligible. The financially needy were most likely to receive SSI support for longer periods of time, and the most severely disturbed spent the least amount of time on SSI. Income-eligible nonrecipients were likely to be young, transient patients using emergency room services as opposed to receiving outpatient counseling.

A ten-year perspective on three models of sheltered care

Data from three surveys of California sheltered care residents and facilities were used to determine which of three models best describes the use of sheltered care by residents and the provision of services to residents between 1973 and 1983. The continuum-of-care model emphasizes a person's movement along a treatment continuum to greater independence. In the residual model, the focus is on providing habitation for a chronic population from the era before deinstitutionalization. The developmental model emphasizes providing long-term care to persons who seek supported living arrangements at a particular point in their life cycle. Results indicated that the developmental model best describes the way residents used sheltered care, while service provision was based on the continuum-of-care model. In light of these findings, it should be determined whether service provision reflects the actual needs of this population.

Attitudes of sheltered care residents toward others with mental illness

The social acceptance expressed by 234 former mental patients and by the general public toward persons with serious mental illness was compared. Factors that may affect social acceptance of such persons, including personal characteristics and experiences that promote identification with mentally ill persons and the subject's level of psychological distress, were examined. Former patients expressed attitudes that were much more accepting than those of the general public. As hypothesized, individual characteristics and experiences likely to increase former patients' identification with their peers (that is, visible deviant appearance, a high level of involvement within the sheltered care community, and the experience of negative community reactions to a resident's facility) were related to a higher score on a Guttman scale of social acceptance. An increased level of self-reported psychological distress tended to moderate such supportive attitudes.

Effects of sheltered care environments and resident characteristics on the development of social networks

Two hundred and thirty-four members of a 1973 sample of sheltered care residents, three-fourths of whom had schizophrenic disorders, were followed up between 1983 and 1985 to examine the role of supportive and of transitional, high-expectation sheltered care environments in the development of residents' social networks. The influences of revolving-door treatment experiences, psychopathology, and institutionalization were taken into account. The results showed that supportive rather than transitional, high-expectation environments contributed to the development of emotionally and instrumentally supportive social networks. Higher levels of psychopathology and a history of institutionalization resulted in the absence of certain support relationships. Surprisingly, revolving-door treatment experiences were related to positive support and social network outcomes.

A ten-year perspective of mortality risk among mentally ill patients in sheltered care

The ten-year risk of mortality was assessed for a sample of 393 former psychiatric patients who were living in sheltered care settings in California in 1973. Compared with the general state population, residents of sheltered care facilities were 2.85 times more likely to die than would be expected if age-specific rates for the state applied to them. Excess mortality was due to heart disease, cerebrovascular diseases, and all other natural and unnatural causes except malignant neoplasms. The mortality rate of the subjects was closer to that of a low-income subsample of the California population, suggesting that the high mortality rates of patients in sheltered care settings may be due to their low-income status.

Characteristics of sheltered care facility operators in California in 1973 and 1985

During the past 20 years, sheltered care homes have become the primary supervised community residence for mentally ill patients outside of licensed hospitals. To determine factors associated with sheltered care operators' remaining in business, follow-up interviews were conducted in 1985 with operators of 151 sheltered care facilities in California whose operators had been surveyed in 1973. Fifty-five of the original operators continued to operate the facility at 12-year follow-up, and 96 were new to the facilities since 1973. Compared with the original operators, the new operators were younger and better educated, were more likely to be men, and were more likely to be totally dependent on the business for their income. Operators who were members of local associations for sheltered care operators were more likely to have remained in business over the 12-year period, as were those who owned facilities with more than six beds.

Civil commitment standards and patient mix in England/Wales, Italy, and the United States

Although England/Wales, Italy, and the United States share a common policy of deinstitutionalization, their mental health systems differ considerably. Each country's civil commitment standards define patient eligibility criteria along one of two primary dimensions--need for treatment or degree of dangerousness. These differential selection criteria result in mental health systems serving different subgroups of the total population. The criteria in England/Wales target older women; in the United States, younger men; and in Italy, a group balanced in age and sex. Implications for the current debate on civil commitment policies are considered.

Civil commitment in the psychiatric emergency room. I. The assessment of dangerousness by emergency room clinicians

Critics of the dangerousness standard for civil commitment contend that there is no professional standard for the evaluation of dangerousness. We used Three Ratings of Involuntary Admissibility, a reliable index of behavioral indicators of danger to self, danger to others, and grave disability, and found that when combined into weighted patterns these indicators predicted disposition decisions of 70 clinicians in five psychiatric emergency rooms over 251 cases. A concurrent measure of perceived dangerousness, Clinician's Global Ratings of patients on these criteria, yielded similar results. We conclude that clinicians in California psychiatric emergency rooms apply a shared concept of dangerousness that can be described in behavioral terms.

Civil commitment in the psychiatric emergency room. II. Mental disorder indicators and three dangerousness criteria

Proponents of return to a "need for treatment" standard for civil commitment contend that the current dangerousness standard forces psychiatrists to neglect severely ill patients in favor of those who are less ill but dangerous to others. Among 198 psychiatric emergency patients in five facilities, those rated as most dangerous on Three Ratings of Involuntary Admissibility, a reliable index of indicators employed by clinicians in evaluating danger to self, danger to others, and grave disability, were also most severely ill on diagnostic and symptomatic assessments of mental disorder. Clinicians' Global Ratings of patient dangerousness on the three criteria were similarly related to severity of diagnosis and symptoms. Perceived dangerousness was associated with major mental disorder and severity of most symptom types, especially impulsivity. Danger to self was the criterion related to the fewest indicators of mental disorder.

Civil commitment in the psychiatric emergency room. III. Disposition as a function of mental disorder and dangerousness indicators

In 251 evaluations observed in five California public psychiatric emergency rooms, patients who were retained, whether new to the system or having histories of hospitalization, rated higher on measures of danger to self, danger to others, and grave disability than patients who were released. They were also more severely symptomatic and more often given major diagnoses. The combination of dangerousness and mental disorder predicted disposition for 93% of new patients and 88% of recidivist patients. Impulsivity was the most influential aspect of mental disorder.

Indexing civil commitment in psychiatric emergency rooms

A reliable prototype index, Three Ratings of Involuntary Admissibility (TRIAD), was developed to reflect the way psychiatric emergency room clinicians apply legal criteria for involuntary commitment. The interrater reliability coefficients--Pearson's r--of the TRIAD system for rating patients are 0.94, danger-to-self score; 0.89, danger-to-other score; 0.77, grave-disability score; and 0.89, total-admissibility score. TRIAD scores accounted for 82 percent of 89 disposition decisions in two metropolitan county hospital psychiatric emergency rooms. Study results indicate that (1) psychiatric emergency room clinicians shared constructs of danger to self, danger to others, and grave disability; (2) these constructs are reliably applied in actual cases; (3) TRIAD is a valid reflection of these constructs; and (4) case disposition is predictable from the severity of the patient's status with regard to these criteria.

Application of involuntary admission criteria in psychiatric emergency rooms

The authors developed Three Ratings of Involuntary Admissibility (TRIAD) to reflect the way clinicians in psychiatric emergency rooms apply legal criteria for the involuntary commitment of patients. Using TRIAD to rate patients on danger to self, danger to others, and grave disability, psychiatric social workers observing patients and clinicians correctly predicted 82 percent of 89 dispositions in two metropolitan county hospitals. These results indicate that clinicians agree on the meaning of the legal criteria and are able to apply them consistently.

The impact of recent rehospitalization on community adjustment

In a study of 499 formerly hospitalized mentally ill residents of comunity-based sheltered-care facilities in California, results indicate that rehospitalization serves as a means of, ‘updating’ the chronic patient’s treatment. By returning to the hospital the patient is linked to the service system and its newest benefits accrue to him. In the absence of a care system which can more effectively link chronic patients to available services, rehospitalization may serve an unforseen positive function.

Factors in the receipt of therapeutic assistance in community care

Who gets psychotherapeutic aid in a population at risk of reexperiencing mental health problems? The study samples included 499, 18–65 year-old, nonretarded, formerly hospitalized mental patients living in 234 of California’s sheltered-care facilities. The sample of residents and facilities were representative of their respective statewide populations.

At the time of the study 28.9% of the residents were receiving some form of psychotherapeutic aid. The study finds that the environmental context of sheltered-care, including the facility’s philosophy of care and the composition of its resident group, is a powerful determinant of treatment status—more important than such individual characteristics as chronicity or degree of psychopathology. This finding is especially pronounced for women and older residents.

Antipsychotic drugs in community-based sheltered-care homes

This research describes the extent of use of antipsychotic drugs in sheltered-care and examines the effect of these drugs by dosage, age group and psychopathology on rehospitalization and social integration.

Data were collected from a large sample of former mental patients representative of all non-retarded mentally ill between 18 and 65 living in community-based sheltered-care in California.

Findings suggest that antipsychotic drugs, when used with limited medical supervision, have detrimental effects on the social functioning of the least disturbed. While antipsychotics may short circuit the psychotic process and thereby reduce mental hospital readmissions, social programming is necessary to promote better social functioning.

Neighborhood types and community reaction to the mentally ill: a paradox of intensity

Employing data from a statewide study of sheltered-care residents and facilities in California, combined with archival data describing the census tracts in which these facilities are located, the authors analyze the impact of community reaction on sheltered-care residents in different types of neighborhoods. Findings suggest that conservative middle-class communities are most likely to exhibit extreme negative reactions that can have a deleterious impact on the social integration of residents in community care. Liberal, nontraditional neighborhoods conform most closely to the ideal accepting community. In liberal, nontraditional neighborhoods and conservative working-class neighborhoods a moderate level of community reaction actually facilitates the social integration of sheltered-care residents.

Coping styles and factors in male/female social integration

As part of a larger research undertaking which explores the overall life-experience of former mental hospital patients living in community-based sheltered-care facilities in California, predictors of resident social involvement - both within the facility and outside in the community at large - were delineated. In our sample of 499 residents, we found that the types of variables indicating higher levels of social integration differed between male and female residents. The predictors that were most significant for men tended to indicate a coping style based upon access to community resources and feasibility of becoming socially involved. Thus, the opportunities made available to men in sheltered-care facilities tended to be taken advantage of provided the residents' psychological handicap was not too debilitating. Predictors of higher levels of social involvement for women residents on the other hand, involved the acceptability of such behavior as appropriate by the community and the facility operator. Women residents thus appeared to be more sensitive to social, rather than environmental contingencies.

Reintegrating the mentally ill in the community

Substantial reductions in the in-patient census of state hospitals throughout the United States have led to the concentration of large numbers of formerly mentally ill individuals in sheltered living arrangements in local communities. These efforts represent a major change in providing care for the long-term chronic patient. How is the life of this individual affected by community placement? A survey was completed of 499 residents in 234 facilities representing all formerly hospitalized non-retarded mental patients between 18 and 65 years old in California's sheltered care facilities. Results indicate that the social functioning of individuals in the external community is enhanced primarily by the characteristics of the community in which they are placed. In contrast, the social functioning of individuals within the immediate environment of their sheltered living arrangements is most affected by the character of the placement itself. The particular characteristics of communities and facilities found to be most important in addition to the characteristics of the residents which impact on social integration are discussed in the study.