Residential Facilities as the New Scenario of Long-Term Psychiatric Care

Giovanni de Girolamo; Mariano Bassi

Disclosures

Curr Opin Psychiatry. 2004;17(4) 

In This Article

Outcome Data

Under this heading we include not only a few longitudinal studies, but also different investigations exploring discharge rates and QOL of residents.

The most important longitudinal study providing data about patients resettled in residential facilities is the Team for the Assessment of Psychiatric Services (TAPS) project, carried out in the greater London area and assessing the 5-year outcome of a representative cohort of 523 patients discharged from two mental hospitals to a variety of community residences (specific information about number of residents living in various types of residential facilities is not given).[26**] Although there was no change in the patients' clinical state or in their problems of social behaviour, they gained domestic, community living skills and more freedom than in the previous hospital setting, they acquired friends, and they wanted to remain in their current state. In the framework of the same project, a specific analysis has recently focused on a subgroup of 61 long-stay psychiatric inpatients, initially regarded as unsuitable for community placement and followed up for 5 years.[27*] Substantial improvements occurred in clinical and social functioning which enabled 29 patients (40% of the study group) to be resettled in various residential facilities, gaining better access to community amenities and living more independently.

Other follow-up studies have consistently shown good community tenure in most patients resettled in residential facilities, although clinical improvements were often of limited magnitude.[28,29,30,31,32,33]

Violence risks of severely mentally ill patients may represent a significant problem for community resettlement. A prospective study has analysed assaultive behaviour, in the course of 6 years, directed against staff by 554 male and 472 female residents of several residential facilities, originally discharged to these facilities from Massachusetts state hospitals in the early 1990s.[34] Observed rates of assault were found to decline by 61%; men and women had similar rates of aggression. Such a result is consistent with figures obtained in the recent TAPS study,[26**] and seem to show that violence and aggressiveness may settle down in most residents as they become more and more acquainted with their place of residence and feel comfortable in their living environment.

While there has been much qualitative research carried out in traditional mental hospitals (e.g. Goffman's pioneering work), qualitative studies conducted in residential facilities have been very sparse.[35,36] Such work, however, may represent (if carried out with appropriate, rigorous methodology) an important tool to thoroughly assess residents' daily life, their needs, expectations, concerns and habits.

Current data on residents' turnover show that discharge to independent living represents an infrequent event. In the Italian PROGRES study,[4**] during the course of an entire year (1999), more than a third of residential facilities (37.7%) did not discharge any patients and 31.5% discharged only one or two patients.[4**] Also in the 5-year TAPS follow-up study, very low rates of turnover were shown for patients discharged to community residences.[24] In general, even when optimal treatment is provided to all long-term patients, a substantial proportion of nonresponders will remain and for many patients residential facilities will probably be 'homes for life'.[37*]

The issue of discharge from residential facilities to independent living is closely related to the model of residential care adopted. In the past, a 'continuum' dimensional model has been proposed as the most appropriate for planning and managing residential facilities in the context of a wider system of mental health care.[38,39] This model posits that there are different residential settings with various levels of support and restrictiveness: the most intensive treatment is offered in the most restrictive setting. The patient can move along the continuum, from more restrictive to more open environments, and patients' needs have to be matched to the most appropriate setting based on their level of functioning. Carling[40**] has summarized the main criticisms to this model (referred to by him as the 'sheltered housing model'): (1) it often confuses housing and treatment needs, and this may lead to unnecessary dislocations through successive moves, because improvements in functioning often require a move to another setting; (2) alternative housing is often not available at precisely the time when the person's needs change; (3) acquiring skills for independent living in an artificial environment such as a residential facility may not ensure that those skills will be generalized and saved in another setting.

So far, no countries have shown that it is feasible to set up, on a nationwide scale, a system of residential care based on a continuum model. An alternative to the dimensional sheltered housing model may be represented by a categorical 'supported housing' model. Within this model there are, on the one hand, high-cover residential facilities and, on the other hand, residential facilities with limited cover, and a flexible system of on-site support can allow a temporary increase in the quantity of required help in less intensive settings when patients face a crisis. While in the continuum model the system provides fixed levels of supervision and patients are expected to move around as they get better (or worse), in the supported housing model, aside from residential facilities with 24 h support, the remaining facilities are organized according to flexible levels of supervision around 'ordinary' housing options, and staff are expected to move around according to the fluctuating needs of patients. For both models, a problem faced by the high-cover residential facilities may be the difficulty in providing individually centred, individually sensitive care. If mismatches occur between levels of dependency and levels of supervision (more often in the direction of too much supervision), there is the risk of decreasing functioning by overproviding, especially if the staff are undertrained.

An important implication of the supported housing model is that discharge to independent living should not necessarily be considered a (feasible) target. A substantial number of patients may remain indefinitely within the residential network, while other objectives (e.g. clinical stabilization, ensured compliance, QOL improvements, etc.) become the objective of the intervention. Longitudinal studies, using large, representative samples of residents, are needed in order to clarify the feasibility of this model on a large scale.

The issue of residents' QOL is important for two reasons: first, as just noted, for many residents these settings represent 'homes for life'; second, several critics of deinstitutionalization have argued that the institutional change has sometimes been less substantial than advocated by many, or even only 'cosmetic', and that residential facilities might represent 'small asylums'. In the years 2000-2004 five studies have assessed residents' QOL, and they have consistently shown that 'subjective' QOL among patients living in residential facilities was generally better than subjective QOL of patients living in traditional hospital settings, and residents are generally satisfied with their residential status.[41,42,43,44,45] These studies, however, have also shown that subjective and 'objective' QOL (that is, evaluated by external raters) are weakly correlated, and substantial improvements in living conditions may not be rapidly reflected in parallel improvements in subjective satisfaction.

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