Daniel J. Kauffman, Ph.D.
Warren State Hospital (WSH), a state operated mental health facility in western Pennsylvania, has been in existence for well over 100 years. Since it opened its doors in 1880, WSH has always tried to provided the people it serves with the most up to date type of treatment available for their conditions. The hospital serves individuals in its general population with various types of mental illness including Schizophrenia, Organic Brain Syndrome, Affective and Adjustment Disorders. This includes people who are Dually Diagnosed (DD)individuals who have mental retardation and some type of mental illness.
People with mental health disorders respond to treatment at various rates. Some people respond quickly to treatment and their stay at the hospital is relatively shortusually less than a year on the hospitals Admissions Unit. People whose illness is more treatment resistant and who must stay at the hospital for an extended period of time move to the Hospitals Continued Treatment Unit (CTU). This unit also has the highest proportion of persons with DDabout 22% of the total number of persons residing on the unit.
Due to the more treatment resistant nature of their condition, the CTU patients historically had become less prone to participate in treatment-oriented programs. Over the extended length of their stay, these persons had gotten into a more self-centered, dependent, pleasure-seeking mode at the hospital. Staff members found it extremely difficult to get them to attend, and if they did attend, to participate in, treatment-oriented groups. A variety of different reward systems were tried to encourage attendance and participation in groups, including Point Programs and Individual Behavior Management programs, as well as group trips and rewards for persons who attended groups on at least a semi-regular basis. None of these reward systems appeared to have any significant impact in increasing group attendance.
A Continuous Quality Improvement (CQI) Committee was established to try and increase involvement in programs. A variety of different techniques were tried to increase the CTU residents involvement in treatment oriented activities, with little success. While the CQI Committee made some progress in increasing program participation, the majority of these persons were participating in an average of only 4.4 hours of treatment activities per week. The people with DD participated in an average of 1.85 hours of treatment activities per week (See Table 1).
Average Number of Treatment Hours / Day / Patient
Pre-Mall Post-Mall % Increase
CTU 1 3.5 250%
DD .37 3.5 845%
A literature review was conducted in an effort to find a way of increasing CTU involvement in treatment activities. This research revealed a program at Middletown Psychiatric Center in Middletown, New York that used the concept of a Treatment Mall to treat mentally ill patients (Bopp, Ribble, Cassidy, & Markoff, 1996). This treatment technique utilized an approach that took the patients off of their living areas to an areacalled a Treatment Mallwhere a variety of disciplines offered various treatment-oriented psycho-educational groups throughout the day. The Mall also contained a Cafe and Boutique. Groups ranged from Stress Management to Understanding Mental Illnessand one even used acupuncture. Because no one could be left on the living areas unattended, all persons were required to go to the Treatment Mall, but did not have to attend groups once at the Mall. Of course, persons who chose to stay in the quiet area could not earn tokens to spend at the Cafe and Boutique. The approach, while relatively simple, appeared to substantially increase patient involvement in treatment activities.
A team of staff from WSH was assembled to go to Middletown to observe the program and make recommendation regarding starting such a program at WSH. After an evaluation of the Middletown program, the Team recommended that WSH design and implement such a program. The hospitals Executive Staff, after reviewing the report and interviewing various team members, agreed to the implementation of a Treatment Mall program with the hospitals CTU residents, including the people with DD. After six months of planning, renovation to the physical plant, and program preparation, the Treatment Mall opened on July 17, 1998.
Patients on CTU averaged about one hour of active treatment per day prior to the start of the Treatment Mall. The persons with DD, however, averaged only .37 hours per day. In both cases, the lack of involvement in programs was generally due to self-choice. Programs were offered in day rooms on the living units, so, if a person became bored with a group, wanted to sleep, or go to the Hospitals canteen, they would simple leave a group or not show up for the group. There was nothing the Group Leader could do to prevent them from leaving or to force them to attend a group. A variety of techniques had been tried over the years, from special treats to paying patients to attend using canteen coupons integrated into special behavioral programs, but none of these techniques was very successful in getting people to attend activities on a consistent basis. Sometimes people became quite verbally, and in some case physically, aggressive when badgered to attend groups.
With the advent of the Treatment Mall, the average amount of active treatment increased to 3.5 hours per day for 91% of the residents of CTU including the DD patients. That was a 250% increase in active treatment per day for the average resident and an 845% increase for the DD residents.
The increased stress placed on patients by attendance at activities was of concern to some staff members, who believed that it might result in a decrease in social adjustment skills or increased psychiatric symptoms. In order to address these concerns, further assessments were performed, using the Brief Psychiatric Rating Scale (BPRS). BPRS is a subjective measure of a persons psychopathology, consisting of clinical ratings along 18 different dimensions defined by symptom categories (Rhodes, 1988). The sum of these 18 ratings yields a single gross measure of psychopathology. The mean score for all CTU residents prior to the start of the Treatment Mall was 36.63 and after the implementation of the Treatment Mall this score decreased to a mean of 32.05. The persons who were DD had a Pre-mall mean score of 30.32 and a Post-mall mean of 29.32 (See Table 2). The reduction in this score indicates that the average patients psychiatric symptoms were actually decreasing. They were in effect experiencing an improvement in their mental health.
Mean Standard Range
Pre- Mall (CTU) 36.63 12.47 18 - 72
Post-Mall (CTU) 32.05 10.26 18 - 70
Pre - Mall (DD) 30.32 9.35 18 - 50
Post - Mall (DD) 29.32 6.95 21 - 47
The Efficiency of Functioning Scale (EFS-55) was chosen to evaluate the residents social adjustment. The EFS-55 is a subjective rating scale that measures social adjustment and independence skills (Lamb, 1997). The residents EFS-55 Scores were evaluated to determine if there had been any significant changes in these areas. The Pre-mall mean EFS-55 score for all the CTU residents was 41.46 and Post-mall this score increased to a mean of 44.96. This indicates that the average person attending the Treatment Mall was improving in his/her social adjustment and independence. The scores of the residents who were DD went from a mean of 35.09 to a mean of 36.03. Although this was not a statistically significant increase, it indicates an improvement in a positive direction in the areas of social adjustment and independence for this group.
EFS - 55 Scores
Mean Standard Range
Pre-Mall (CTU)41.4613.5415.4 - 86.6
Post-Mall (CTU)44.96 15.317.1 - 90.5
Pre-Mall (DD) 35.0910.8218.33 - 58.62
Post-Mall (DD) 36.03 10.25 12.02 - 62.27
To determine if the Mall was having an effect on common types of living area incidents, six different types of incidents were evaluated. Categories included falls, assaults/fights, injuries, unauthorized absences, self abuse, and smoking violations. Table 4 illustrates the incidents in each of these categories on CTU Pre- and Post-Mall.
Incident Rate Change from
Per 100 Census Pre-Mall to
Per month on CTU Post-Mall
Incident Jan. - June July - Dec. Percentage
Category 1998 1998 Change
Falls 7.68 7.35 4.2% decrease
Assaults/Fights 8.45 5.65 33.1% decrease
Injuries 10.90 8.40 22.9% decrease
Unauthorized Absences 2.77 1.92 30.7% decrease
Self-Abuse 1.62 2.55 57.4% increase
Smoking Violations 15.85 16.55 4.4% increase
The rate of selected incidents fell after the start of the Mall in four of six categories. The rates of assaults, injuries, and unauthorized absences actually fell after the start of Mall program. The changes in these areas were rather dramatic, with assaults decreasing 33.1%, injuries falling 22.9%, and unauthorized absences experiencing a 30.7% reduction. There was a slight increase of 4.4% in smoking violations, which is believed to be fairly trivial. The most significant increase, 57.4%, occurred in the category of self-abusive behavior. This is a category, however, with a low initial base rate, 1.62 incidents per month Pre-mall and 2.5 incidents per month Post-mall. Interestingly, of the Pre-mall incidents, only two involved residents with DD and none of the Post-mall incidents involved DD residents.
A conservative interpretation of the data would indicate that the Mall made a significant impact on three of the six incident categories. There were significant decreases in the number of incidents of assaults, injuries, and unauthorized absences after the Malls implementation.
The implementation of the Treatment Mall was hoped to increase the number of people who would be discharged from the CTU. Prior to the start of the Mall, Jan. 1 - June 30, 1998, 15 people (13%) were discharged from CTU. During the initial six months of the Malls operation, July 17 - Dec. 31, 1998, 12 people (10.9%) were discharged from CTU. The decrease in discharge rate was about two percent, but was very similar to the number of people discharged during the same time frame in 1997, before the implementation of the Mall. One should keep in mind that a number of factors besides patient readiness influence discharges, including availability of placement sites and needed services.
The implementation of the Treatment Mall approach on persons requiring long term psychiatric care has had a number of positive consequences:
1.The Treatment Mall has had a significant impact on peoples attendance at therapeutic activities, particularly those persons who have DD, increasing their participation in activities from 0.37 hour per day to 3.5 hours per day.
2.The Treatment Mall has resulted in an improvement in social skills, as evidenced by scores on the EFS-55. In the case of people with DD, score improvements may reflect a better understanding by the staff.
3.The Treatment Mall has resulted in an lessening of psychiatric symptoms as evidenced by the scores on the BPRS Rating scale.
4.The Treatment Mall has resulted in a decrease in the incidents of assaults and fights on CTU. These incidents frequently involved persons with DD, who were unoccupied, and misinterpreted events around them, causing them to become physically aggressive toward other residents and/or staff.
5.The Treatment Mall has resulted in better resident monitoring, thus reducing the incidents of unauthorized absences on CTU for all residents, including people with DD, who staff frequently feared would wonder away.
6.The Treatment Mall appears to have dramatically reduced the incidents of self-abusive behaviors among people who have DD, indicating that when they are occupied with activities, they are less likely to self-abuse.
Bopp, J., Ribble, D., Cassidy, J., & Markoff, R. (1996). Re-engineering the state hospital to promote rehabilitation and recovery. Psychiatric Services, 47, 697-701.
Lamb, P. J. (1997). The 55 EFS (Efficiency of Functioning Scale) in Middletown Psychiatric Center Treatment Mall. Middletown, NY: Middletown Psychiatric Center.
Rhoades, H. M. & Overall, J. E. (1988). The semistructured BPRS interview and rating guide. Psychopharmacology Bulletin, 24, 101-104.
Daniel J. Kauffman, Ph.D.
Warren State Hospital
33 Main Drive
North Warren, PA 16365-5099