Board-and-Care Home Wanderers

Board-and-Care Home Wanderers H. Richard

Lamb, MD

\s=b\ At six-month follow-up, 32 of 101 psychiatric patients in a board-and-care home had moved on. In this sense a considerable proportion of this population is not a static group. A relationship was found between moving on and having resided in the board-and-care home 12 months or less, being younger than 30 years of age, having goals to change something in one's life, and hospitalization during the preceding year. Repeated attempts at independent living appeared to stem from a search for autonomy and a sense of mastery, and resistance to the pull of dependency. Moving on, for some, seemed to be an attempt at a geographical solution to internal problems. Ambivalence and the need of both residents and families for respite appeared to be reflected in moves back and forth from living with each other. (Arch Gen Psychiatry 37:135-137, 1980)

in board-and-care or homes to become static and in is there some movement in and out of these new the community? To what extent are persons willing to give up the protection and lack of pressure of these settings to try to cope with the stresses and demands of living more independently? In the previously reported, first part of this study of residents of one board-and-care home, 42% had been there five years or more.1 On the other hand, as we shall see in this report, there is a sizable number who are not static but move from one place to another. What are the characteristics of this group? Where do they go and for what reasons? What can we learn about this movement that will aid us in better understanding these persons in their new lives in the community?

psychiatric patients tend Do long-term institutionalized, asylums

board-and-care home within the past three years, and location within the central part of Los Angeles so that community facilities

would be at least theoretically accessible by bus. No two boardand-care homes are exactly alike. While the facility chosen differs in physical appearance, size, staffing, and in some policies from other board-and-care homes in Los Angeles, there is nothing to suggest that it is grossly dissimilar to other board-and-care homes in the area. In the previously reported study, it was found that 92% of the 101 subjects had conditions diagnosed as psychotic. Thirty-two percent exhibited overt major psychopathology, manifesting severe symptoms in at least two of the three categories of delusions, hallucinations, and thought disorder; nine of ten either had never lived alone or had failed in their last attempt to do so. Half had no goals for changing anything in their lives. Ninety-five percent utilized community facilities, mostly eating places and supermarkets. It was concluded that board-and-care homes offer an asylum from life's pressures, a degree of structure, and some treatment, especially medication supervision; for many long-term patients, these homes have taken over the functions of the state

hospital.

SUBJECTS AND METHODS

This is the second part of a previously reported study of 101 persons living in a board-and-care home about two miles from the downtown area of Los Angeles.1 Board-and-care homes for psychiatric patients in California are unlocked and provide a shared room, three meals a day, dispensing of medications, and

After a full explanation of the nature of the study had been provided, informed consent was sought from all residents current¬ ly living in the facility and then from all newly admitted persons until the desired sample was obtained. One hundred eight resi¬ dents were approached; six declined to participate and one had an organic brain syndrome that made meaningful communication impossible, leaving a sample of 101 persons. An in-depth interview was conducted with each resident. An interview guide was prepared covering demographic data, perti¬ nent history, and all aspects of their current lives. Though all items in the interview guide were covered, an attempt was made to develop an informal, comfortable, and wide-ranging conversation. A second interview was conducted about a month later. Through¬ out the course of the study, there was also much informal chatting with residents in the halls and dayrooms. In addition, the medical records kept in the facility were consulted: these included discharge summaries from referring professionals and institu¬ tions and progress notes by the private psychiatrists who visit the

minimal staff supervision. The setting was described in some detail in the previously reported, first part of the study. In brief, a board-and-care home was looked for that would meet the following criteria: large enough to provide an adequate sample, licensed for residents younger than age 65, an administration that would both permit and cooperate with the study, no other research conducted in the

board-and-care home for medication management. Other informa¬ tion was obtained from the staff. The board-and-care home was revisited six months after the conclusion of the first part of the study to determine how many of the study subjects had moved on and where they had gone. This information was obtained by interviewing the staff and by consulting the board-and-care home residents' records.

Accepted for publication July 23, 1979. From the Department of Psychiatry, University of Southern California School of Medicine, Los Angeles. Reprint requests to Department of Psychiatry, University of Southern California School of Medicine, 1934 Hospital Place, Los Angeles, CA 90033 (Dr Lamb).

Of the original study group of 101 persons, 21% had made at least one unsuccessful attempt at independent living within the preceding two years and had then returned to the board-and-care home; 22% had come directly from

THE SETTING

RESULTS

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another board-and-care home; and 10% had a pattern of shuttling between family and board-and-care home. In looking at factors in relationships with family that resulted in movement, we found that 8% of the 101 persons had come to the board-and-care home immediately after a hospitalization precipitated by an act of violence, and for half of these (4%) there had been no further contact with family, even though five years or more had passed at the time of our study; 22% seemed to have exceeded, in nonviolent ways, the family tolerance of them on a fulltime basis, but for the past two years, and in some cases for as long as 12 years, there had been regular contact with the family; 3% had resided at home until, with advancing age, the parents seemed unable to take care of the patient any longer; and 6% had resided at home until the mother (in one case the grandmother) died. At six-month follow-up, 32 of the 101 persons (32%) in the original study group had left the board-and-care home. Ten were living independently, including three people who moved out together to share an apartment; nine had moved to another board and care home; seven had returned to their families; two had left to live with a boyfriend or girlfriend; one had entered a drug rehabilitation program; two had moved into a half-way house; and one person's whereabouts was unknown. There is a relationship (see Table) between having left the board-and-care home during the six-month follow-up period and several other factors: (1) length of residence at the board-and-care home (of those who left, 69% had resided at the board-and-care home 12 months or less; of those who remained, only 22% had resided there 12 months or less); (2) age (of those who left, 34% were younger than 30 years of age; of those who remained, 12% were younger than 30 years of age); (3) whether or not they had goals or had a desire to change anything in their lives, such as social or vocational activity or living situation; whether or not the attainment of these goals appeared to be realistic (of those who left, 69% had goals; of those who remained, 38% had goals); (4) hospitalization during the preceding year (of those who left, 47% had been hospitalized during the previous year; of those who remained, 23% had been hospitalized during the previous year).

Factors and Relationship to Leaving Board-and-Care Home, Six-Month Follow-up Data Moved Away No. (%)

Still In Residence No. (%)

22(69) 10(31) 32 (100)

15(22) 54(78) 69 (100)

Length

of residence* 12 mo or less More than 12 mo Total affected

Age, yr** Younger than 30 and older Total affected Goals** Yes

30_

11 21

(34)

(66) 32(100) 22 (69)

No_10 (31 ) Total affected

32

(100)

Hospitalization in previous year*** Yes 15(47) 17 (53) No Total affected 32(100) •P < .001. **P< .01. ***P< .02.

_8(12) 61 (88) 69(100) 26

(38)

43 (62) 69 (100)

16(23) 53 (77)

69(100)

COMMENT

This study suggests that a sizable proportion of this board-and-care home population (about one third) is not a static group, at least in terms of changing their place of residence. At six-month follow-up, 32% of the residents of the board-and-care home had left. Of the original study group, one fifth (21%) of the sample had made at least one unsuccessful attempt at independent living within the prior two years and had then returned to the sanctuary of the board-and-care home, either directly or via the hospital. During the six-month follow-up period, ten persons left to attempt independent living; for all but one this was a repeated pattern. In talking with these persons who had moved out on their own during the prior two years and/or during the six-month follow-up period, what seemed to emerge was a denial of their dependency and a search and yearning for autonomy and a sense of mastery with regard to handling the pressures of living independently. After varying periods of time these persons were willing again to give up their autonomy in exchange for the protection and absence of pressure found in a boardand-care home. After failing in yet another attempt at

independent living, they were ready to retreat to a setting

where the rewards of life are simple and the demands few. When residing in a board-and-care home, within very broad limits, their freedom of movement is unrestricted. For instance, in the facility where this study was carried out, everyone is free to come and go at any hour. To be sure, living in a board-and-care home presents some prob¬ lems: the constant requests for cigarettes from other residents, the frequent theft of one's possessions, or the occasional insensitivity of staff. However, if one is willing to lower one's expectations and can accept a limited environment, it can be a not unsatisfactory place to live. The basic needs of life are provided for, the pressures are few, and other persons are available for whatever level of socialization the person wants and can tolerate. And tolerance here for unusual behavior is greater than in the mainstream of life. Twenty-two of the original sample of 101 persons had come directly from another board-and-care home; nine of the 32 who left in the six-month follow-up period had gone on to a different board-and-care home. Many residents expressed the thought that another board-and-care home would solve one or more of their problems, such as being influenced to drink by friends, feeling bored and depressed, feeling they had no friends and that at another facility it would be easier to find friends, or feelings of general dissatisfaction with life and that this would improve if only they could move. While there were valid reasons for the move in some cases (such as wanting to try a smaller facility with a family-like setting to see if this would improve their functioning or quality of life), in many others it appeared to be an attempt at a "geographical solution" to what was in actuality the resident's internal

problem.

Interaction With Family

Of the 32 persons who had left by the time of the six-month follow-up, seven had returned to their families. A number of observations on the 101 persons in the original study group are noteworthy here. Ambivalence about living with their families was prominent on the part of many residents when they discussed their feelings and attitudes toward their relatives. As many residents described their family situations and as observed by the


board-and-care home staff, there also appeared to be much ambivalence on the part of families toward the residents. The return home of seven former residents by six-month follow-up appeared to reflect one facet of this ambiva¬ lence. In 10% of the original study group there was a pattern of shuttling between family and board-and-care home. It appeared that the residents exceeded the family's toler¬ ance in a variety of ways, but after a period of respite from each other, while the resident was living in the boardand-care home, both the resident and family were willing to

try living together again. original study

In another 8% of the

group, the boardand-care home placement had come about immediately after an episode of violence on the part of the patient. In half these cases there had been no contact with family since that incident, even though at least five years had passed; in the other half contact between patient and family was maintained. In these latter cases, it seemed

that

living

in the board-and-care home

placed enough

distance between the patient and the family so that further contact now seemed safe. About one fifth of the residents (22%) seemed to have exeeded, in nonviolent ways, the family tolerance of them on a full-time basis, but with the relationship diluted by the resident living in the board-and-care home, there continued to be regular contact between these residents and their families over long periods of time. In 3% of the original study group, as the parents had become older, they seemed unable to deal with or take care of the patient any longer. Their tolerance of their off¬ spring's behavior appeared to have diminished with their

advancing

age.

Six percent appeared to have done well at home through¬ out their lives without hospitalization until the mother, or as happened in one case, the grandmother died. With the absence of the maternal figure, the remaining family members seemed unable or unwilling to have the resident at home.

Moving On found A relationship was between residents having moved on from the board-and-care home at the six-month follow-up and one or more of the following factors: having resided there 12 months or less, being younger than 30 years of age, having goals to change something in one's life, and having been hospitalized during the preceding year. While we have no data that would further interpret these findings, we can speculate on some possible explana¬ tions. There is a striking difference between the number of persons who had moved on at the six-month follow-up and the number who had remained in terms of the length of time they had resided at the board-and-care home; 69% of those who had moved on had resided there only 12 months or less, while 78% of those who remained had resided there more than 12 months. It should also be noted here that in the previously reported part of the study, it was found that 41% of the entire group of 101 persons had been there five years or more. As several residents put it, "The longer you stay here, the harder it is to leave." Perhaps many of those who had moved on by the six-month follow-up were trying to escape the pull of dependency and avoid the feelings of despondency on leaving behind the newcomer phase in a board-and-care home and beginning to look around at the fellow residents and to feel that one will never leave.2 Those who moved on tended to be younger and perhaps

were come

not yet ready to give in to this to terms with living in a

pull of dependency and sheltered, segregated,

environment. Those who moved on were more apt still to have life goals; some residents of the board-and-care home may see leaving the comparatively static milieu of the home as a necessary part of the process of realizing their goals. Such a struggle for achievement or to make life changes may

low-pressure

take its toll in terms of increased hospitalization, as has been seen when severely disabled patients are placed in a high-expectancy environment.3 4 This may explain the rela¬ tionship between having moved on at six-month follow-up and hospitalization during the preceding year: striving to attain one's goals may precipate decompensations that require hospitalization. Still another possibility is that the group hospitalized within the preceding year was less stable psychiatrically, and their moving on may have been a way of seeking relief of symptoms and conflicts through movement and real or fantasied better conditions in the next situation, or an inability on their part to assess and utilize their current situation because of their instability. It should be emphasized that the residents who have moved on, the subjects of this study, are not among that group of "psychiatric hoboes" who are seen so frequently in the public hospitals and emergency rooms of our large cities, those persons whose type or degree of psychopathol¬ ogy render them unable to relate to persons or places for more than brief periods of time-persons who frequent the missions and sleep under bridges. These persons are not found in this study, primarily because most board-and-care home operators have learned to screen out applicants who will not remain except for a brief period of shelter: if the residents do not remain long enough to receive their general relief checks or their Supplemental Security Income checks, the facility will not be paid. The operators of these homes, therefore, check into the past history of placements and hospitalizations of potential residents; the operators' livelihood depends on their ability to screen out the most transient people. It should be noted, however, that the dynamics of the movement of some board-and-care home patients, as suggested by this study, are somewhat similar to the wandering of the "psychiatric hoboes"; the difference is largely one of degree. The group remaining at six-month follow-up had resided at the board-and-care home longer, were older, tended less to have goals for themselves, and fewer had been hospital¬ ized during the preceding year. In general, it would appear that this group had settled into the routine of boardand-care home life, given up whatever earlier goals they may have had and settled for a more limited existence, and, using hospitalization as the criterion, tended to have stabilized to a greater degree. These persons seemed to have given in to the pull of dependency or to have "weighed" the costs of striving and possible resulting

decompensation.

References 1. Lamb HR: The new asylums in the community. Arch Gen Psychiatry 36:129-134, 1979. 2. Reynolds DK, Farberow NL: Endangered Hope, Experiences in Psychiatric Aftercare Facilities. Los Angeles, University of California Press, 1977. 3. Lamb HR, Goertzel V: High expectations of long-term ex-state hospital patients. Am J Psychiatry 129:471-475, 1972. 4. Weinman B, Kleiner RJ: The impact of community living and community member intervention on the adjustment of the chronic psychotic patient, in Stein LI, Test MA (eds): Alternatives to Mental Hospital Treatment. New York, Plenum Press Inc, 1978, pp 139-159.
