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THE ROLE OF GUARDIANSHIP IN THE COURSE OF TREATMENT AND
TREATMENT OUTCOME FOR INDIVIDUALS RECOVERING FROM SEVERE MENTAL ILLNESS
by
Thea L. Rothmann, M.A.
University of Nebraska, 2006
Adviser: William D. Spaulding
The purpose of this study was to evaluate the role of guardianship in treatment and treatment outcome for people recovering from severe mental illnesses (SMI) in a psychiatric rehabilitation context. Research in the intersecting field of mental health care and the law is in its nascence. Using the unifying theory of therapeutic jurisprudence, this study investigates the clinical correlates of guardianship in a population of people with SMI. An archival database from an inpatient psychiatric rehabilitation program in a Nebraska state hospital was used in analysis. This was an ideal context and population for the study because this group of people is highly affected by the legal constructs evaluated in this investigation. The archival database contained comprehensive clinical, demographic, and outcome data for all participants. This included assessments of neurocognition, social cognition, symptomatology, behavioral functioning, and treatment compliance. In addition, outcome data regarding discharge location and rehospitalization were available. Two main hypotheses were put forth towards the overall purpose of this study. First, it was hypothesized that people with guardians would demonstrate lower overall functioning at the time of admission and throughout the course of treatment across multiple domains when compared to those without guardians. Second, it was hypothesized that people with guardians would be discharged to more restrictive community placements than those without guardians, but that they would have a lower rate of rehospitalization. Partial support for both hypotheses was obtained. Results suggest that, in Nebraska, people with guardians can be discriminated from those without guardians based on behavioral functioning. In addition, people with guardians were found to have a longer length of stay. Other areas of clinical functioning assessed – neurocognition, social cognition, symptomatology, and treatment compliance – were not found to differ between those with and without guardians. People with guardians were discharged to more restrictive settings and there is some evidence that they were rehospitalized sooner than those without guardians. This is the first known study to empirically investigate the role of guardianship in the recovery of people with SMI.
Table of Contents
List of Tables and Figures iv
Dedication v
Acknowledgements vi
Chapter 1 - Introduction 1
Chapter 2 – Literature Review 4
Severe Mental Illness and Psychiatric Rehabilitation. 4
Intersection between Mental Health Care and the Law. 6
Guardianship. 8
Related Studies. 10
Present study. 19
Chapter 3 - Method 23
Design Overview. 23
Setting. 23
Participants. 24
Measures. 26
Demographic and Clinical Characteristics. 26
Neurocognition Measures. 27
Social Cognition Measures 29
Behavioral Functioning Measures. 30
Symptomatology Measures. 31
Treatment Compliance Measure. 32
Outcome Measures. 32
Procedure. 35
Data Collection. 35
Data Cleaning. 38
Data Analysis. 38
Chapter 4 – Results 40
Demographic and Clinical Characteristics of People with Guardians at CTP. 40
Hypothesis 1 48
Functioning at admission. 49
Neurocognitive functioning. 49
Social cognitive functioning. 54
Behavioral functioning. 56
Treatment compliance. 59
Symptomatology. 60
Functioning over the course of treatment. 63
Neurocognitive functioning. 63
Social cognitive functioning. 65
Behavioral functioning. 66
Treatment compliance. 71
Symptomatology. 72
Hypothesis 2 75
Outcome. 75
Discharge location. 75
Rehospitalization rate. 76
Chapter 5 – Discussion 79
General Discussion. 79
Limitations of the Present Study. 88
Future Directions. 89
References 92
Appendix 102
List of Tables & Figures
Table 1. Demographic and Clinical Characteristics of Participants (N=162)
Table 2. Guardianship Status of Participants (N=162)
Table 3. Relationship Between Axis I Diagnosis and Guardianship Status (N=162)
Table 4. Relationship Between Race and Guardianship Status (N=162)
Table 5. Guardianship Status by Demographic and Clinical Characteristics Multivariate Analysis of Covariance (MANCOVA)
Table 6. Mean Scores and Standard Deviations for Demographic and Clinical Variables as a Function of Guardianship Status and Age
Table 7. Standardized Canonical Coefficients and Structure Weights from Discriminant Analyses of Demographic and Clinical Variables to Predict Guardianship Status
Table 8. Guardianship Status by Neurocognitive Variables (Group 1) at Admission Between Group Multivariate and Univariate Statistics
Table 9. Guardianship Status by Neurocognitive Variables (Group 2) at Admission Between Group Multivariate and Univariate Statistics
Table 10. Guardianship Status by Neurocognitive Variables at Admission One-Way Analyses of Variance (ANOVAs)
Table 11. Guardianship Status by Social Cognitive Variables at Admission Between Group Multivariate and Univariate Statistics
Table 12. Guardianship Status by NOSIE Subscales at Admission One-Way Analyses of Variance (ANOVAs)
Table 13. Standardized Canonical Coefficients and Structure Weights from Discriminant Analyses of NOSIE Subscales to Predict Guardianship Status
Table 14. Guardianship Status by BPRS Factor Scores at Admission Between Group MANOVA
Table 15. Guardianship Status by BPRS Items One-Way Analyses of Variance (ANOVAs)
Table 16. Guardianship Status by COGLAB Repeated Measures ANOVAs
Table 17. Mean Scores and Standard Deviations for NOSIE Total Assets at Admission, 6 Months, and 12 Months as a Function of Guardianship Status
Table 18. Guardianship Status by NOSIE Subscales Repeated Measures ANOVAs
Table 19. Means and Standard Deviations on NOSIE Subscales at Admission and 12 Months as a Function of Guardianship Status
Table 20. Relationship Between Level of Discharge Location Restrictiveness and Guardianship Status (N=147)
Figure 1. NOSIE Total Assets Scores Over Time as a Function of Guardianship Group
Dedication
For my Dad . . .
You are missed muchly.
Acknowledgements
I had intended for graduate school to take me out of the Midwest for a while, but will be forever grateful I decided to come to Nebraska. I wish to express my gratitude to my advisor, William Spaulding, for just the right amount of direction and more than enough inspiration throughout my graduate career. I could not have found a better supervisory committee for this dissertation and am thankful for the collective wisdom of Mario Scalora, Brian Wilcox, and Robert Schopp. I am also grateful for the encouragement and mentorship from Cal Garbin and support of Mary Sullivan and the entire staff and all the participants at CTP. Finally, Mark Krejci from Concordia College deserves my thanks for steering me into psychology in the first place.
To the UN-L Serious Mental Illness Research Group, members past and present, I am grateful to have been among you. I especially want to offer many thanks to Jason Peer for raising the bar in our research lab just beyond my reach, so I was always striving for more. I am glad that both Jason Peer and Srividya Iyer were able to take the walk through graduate school with me, sharing times of struggle and success. This project would not have been possible if not for the NRSA fellowship awarded to Myla Browne, a member of the UN-L Serious Mental Illness Research Group. To those who continue to fund research in this much-needed and oft-overlooked area, you have my gratitude.
To my fellow transient Lincolnites, I will be forever indebted to you for maintaining my sense of humor and sanity and for always keeping my social calendar on powerbook and my costume drawer overflowing. My far-away-friends - you know who you are - have always “been there” for me and opened their hearts and doors at a moment’s notice; I couldn’t be luckier. My Mom and Dad have supported me 110% since Day 1. All the good things in me I got from them. My Mom has put up a brave front this past year so that I could continue to pursue my dreams and I am grateful for her courage. Finally, I am overwhelmed and overjoyed that Guy has stuck with me through the end of this adventure and is joining me for all the rest of life’s adventures.
1
Chapter 1 - Introduction
The Role of Guardianship in the Course of Treatment and Treatment Outcome for Individuals Recovering from Severe Mental Illness
The relationship between the legal system and mental health system is a tenuous one. Research on the two separate but intersecting fields has received increasing interest over the last fifteen years (e.g., Wexler, 1988; Wexler, 1990; Wexler & Winick, 1991; Winick, 1995; Monahan, Hoge, Lidz, Roth, Bennett, Gardner, & Mulvey, 1995; Slobogin, 1995; Spaulding, Poland, Elbogin, & Ritchie, 2000; Schopp, 2001). However, much of this research remains theoretical in nature with few applications in clinical settings. There are exceptions (for examples regarding coercion, see Hoge, Lidz, Eisenberg, Gardner, Monahan, Mulvey, et al., 1997; McKenna, Simpson, & Coverdale, 2003; regarding involuntary commitment, see Strachan, 2004; Ridgely, Borum, & Petrila, 2001; regarding legal status and self-report of symptoms, see Hopko, Averill, Cowan, & Shah, 2002). If the legal system allows itself to be informed by the current science of psychopathology and treatment, it may more fully serve its purpose of protecting the individual or society. Likewise, if mental health providers become more aware of the legal system and its impact on mental health care, they may better equipped to pass the benefit on to consumers to help them navigate the system and optimize their recovery. Bridging the gap between mental health law theory and application is the intention of this study. In particular, the role of guardianship as it pertains to the recovery from severe mental illness for people in psychiatric rehabilitation is evaluated.
Two main hypotheses were put forth towards the overall purpose of this study. First, it was hypothesized that people with guardians would demonstrate lower overall functioning at the time of admission and throughout the course of treatment across multiple domains when compared to those without guardians. Second, it was hypothesized that people with guardians would be discharged to more restrictive community placements than those without guardians, but that they would have a lower rate of rehospitalization.
An archival database constructed with nearly ten years of clinical data from an inpatient psychiatric hospital was used in this study. Clinical data on multiple levels of functioning, consistent with the multidimensional nature of impairments in SMI, was available for analyses. Data on symptomatology, neurocognitive and social cognitive functioning, treatment compliance, and behavioral functioning were used in analyses. In addition, data regarding discharge location and rates of rehospitalization following discharge were available. There were two main groups being compared in this study. First, there are those with court-appointed guardians, referred to as the Guardian group. Second, there are those without court-appointed guardians, referred to as the No Guardian group.
While these two groups are the primary focus of analyses, several other groups were evaluated since these distinctions were not mutually exclusive. Specifically, some people with guardians were admitted with a Voluntary per Guardian (VpG) legal status while others were admitted following civil commitment (CC). These legal statuses will be discussed further below. Therefore, there are subgroups based on legal status and guardianship: the VpG Guardian group and the CC Guardian group. Another variation on these groupings which was explored in analyses is based on whether the guardian was acquired before or after admission to treatment. The resulting groups from this distinction are: the Guardian Admission group and the Guardian Acquired group. A final variation which was explored was whether or not the guardian was a family member. This dissertation, then, takes on the following structure. First, current conceptualizations of SMI and optimal treatment practices are addressed. Next, there is a brief discussion of the intersection between the legal and mental health systems, including the concept of therapeutic jurisprudence. Then, a review of guardianship, the area of focus for this proposal, is presented. Finally, research relevant to this area is discussed. The study addresses several specific questions. First, this study addresses whether or not people with guardians differ in any way from those who do not have guardians with regards to specific areas of functioning including neurocognition, social cognition, treatment compliance, behavioral functioning, and symptomatology. This study aims to identify ways in which people with guardians differ from those without guardians at the time of admission to the psychiatric rehabilitation program and over the course of treatment. Second, this study identifies ways in which people with guardians differ with regards to outcome from those without guardians. Specifically, the rate of rehospitalization and the discharge location of those with guardians are compared to those without guardians. Finally, exploratory analyses delve into within-group differences regarding guardianship. That is, the impact of whether or not the guardian is a family member, whether or not guardianship was acquired before or after admission to the psychiatric rehabilitation program, and whether or not the legal status of the person is Voluntary per Guardian (VpG) or Civil Commitment (CC) is investigated.
Chapter 2 – Literature Review
Severe Mental Illness and Psychiatric Rehabilitation.
A majority of individuals categorized under the rubric of SMI are those diagnosed with schizophrenia spectrum disorders. Increasingly, research efforts in schizophrenia seek to understand schizophrenia not as a disorder with a single causal deficit but as a biosystemic disorder in which component processes are in a state of dysregulation (Spaulding, 1997). These components include processes related to neurophysiology (i.e., neurotransmitter systems), neurocognition (i.e., basic cognitive functions such as attention and memory), social cognition (i.e., higher order cognitive functions such as the formation of beliefs and abstract reasoning), and sociobehavioral functioning (i.e., performing behavioral activities in a socially meaningful context) (Spaulding, Sullivan, & Poland, 2003). Therefore, we understand the course of the illness, its nature, the deficits present, and the recovery process as reflections of varying degrees of dysregulation within the person (Ciompi, 1989; Spaulding, 1997; Spaulding et al., 2003) and between the person and their environment (Strauss, 1989). Dysregulation in one domain may affect functioning in another domain, in a precarious balance of reciprocal interactions (Spaulding, 1997). This differs from the dominant medical model perspective of mental illness as proceeding in a linear cascade from molecular levels of functioning to molar levels of functioning (e.g., a bacterial infection). Understanding severe mental illness as a multidimensional model of reciprocal processes calls for interventions which target multiple domains in order to re-regulate the system.