Selected Research Papers in Social Change, Education, Labour Market, and Criminology Volume II

Basic data Gender (per cent) Male 55.9% Female 44.1% Age (years) Mean 57.8 STD 19.0 Range 23–93 Duration of deinstitutionalisation (months) Mean 42.9 STD 13.4 Range 6–68 Type of accommodation (per cent) Nursing homes 40.5% Old people’s homes 13.8% Residential homes 21.5% Staffed group homes 19.0% Private 5.2% Duration of hospitalisation (years) Mean 19.3 STD 13.9 Range 1–49 Diagnosis (per cent) F2 schizophrenia 48.2% F7 mental retardation 28.0% F1 psychothrop. subst. 9.3% F0 organic disease 8.5% GAF (points) Mean 31.0% STD 13.8% Range 5–70 Ability to be interviewed (per cent) Fully able 54.2% Partially able 11.0% Not able 34.8%

N=116
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Former long-stay patients had been hospitalised on average for 19.3 years with a maximum of 49 years. Nearly half are diagnosed as people suffering from schizophrenia, 28% are mentally retarded and about 9% were diagnosed for each of psychotropic drug abuse (F1) and organic diseases (F0). GAF points show a very low average point of 31 on a scale from 0 to the optimum of 100. As mentioned above, former long-stay patients were seriously chronically mentally ill, in some cases very old, and suffering from mental retardation. It was not very surprising that only half of them were fully able to be interviewed; it’s distressing that a third could not be interviewed at all. Hence data on objective and subjective indicators are only based on n=34 to 67 cases.

4 Results

To answer the first research question, concerning the costs, a brief outline about steps in calculating direct cost is presented. Details can be found in Grausgruber et al. (2006: 51–56; 141–145). First, data about service utilisation during the sixmonth follow-up has to be gathered. These data were collected by staff, caregivers and health insurance companies.

As can be seen in Table 4, the sample group had 23,040 contacts to or utilisations of mental health care services. Definitively predominant was utilisation of accommodations, insofar as one day living in a nursing home or in a staffed group home has been judged as one contact. During the observation period patients used on average 7.6 services per week, a consequence of accommodation utilisation. As can be seen, nearly all members of the study sample used accommodations (Grausgruber et al., 2066: 153ff). Table 4 presents not only data on how many services had been used but also how many contacts could be registered.

Table 4: Service utilisation: observation period 1.7.2001 – 31.12.2001

Services Services contacted in n of contacts %

%

N=116 (*: 1 day = 1 contact)

Accommodation* 97.4 20.365 88.39

Occupational services* 12.1 1.003 4.35

General practitioners 73.4 679 2.95

Psychiatrists 59.4 372 1.61

Leisure clubs 8.6 350 1.52

Psychiatric hospital* 9.6 144 0.63

Other consultants 32.0 91 0.39

Ambulances 10.4 21 0.09

Other services 4.4 15 0.06

Total 23.040 100.00

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About three out of four attended general practitioners, about 60% received assistance from psychiatrists and one-third used other consultants. It’s remarkable that only 10% needed psychiatric hospital services. But all these utilisations and contacts are far behind the intensive use of accommodation. Contacts with occupational services amount to only about 4%; contacts to general practitioners are about 3%. The predominance of accommodation and the marginal significance of all other psychiatric services are apparent.

In a next step, costs of service utilisation were computed. Costs had been calculated differently, based on per diem (day) rates (for example residential facilities, accommodation) and on hospital charges – so-called LKF points, a kind of achievement-oriented funding of hospitals (Hagenbichler, 2010). Costs of other services like general practitioners, ambulances, psychiatrists, other consultants and other services are based on case-based lump sums and individual specifications or reimbursement, while contacts with leisure clubs and occupational services are based on the facility budgets and were subdivided into hourly rates. Costs of outpatient medical services were obtained directly from the health insurance carrier. For further details see Grausgruber et al. (2006: 161–177).

Table 5 presents total direct costs, average costs per person and average costs per user. Altogether direct costs for the community-based psychiatric care of the former long-stay patients during the six months amounted to 1.7 million euros, meaning average costs per person of €14,666. This means costs per person and per day of about €80. As expected, the greatest proportion of costs concerns accommodation. Compared with this amount, all other service costs are extremely low, though costs for occupational services amount to over €4,000 per user. Direct costs for psychiatric hospital care are also remarkable. Particularly costs for medication, psychoactive drugs and other medication as well as costs for psychiatrists or general practitioners are very low. Accommodation accounts for 87% of all costs, an explicit indicator of the predominance of living facilities.

Table 5: Total costs, average costs per person and per user: observation period 1.7.2001 – 31.12.2001, N=116 Services Total costs (€)Average costs per Users Costs per user

person (€) Accommodation 1,483,122 12,786 113 13,125

Occupational services 57,142 493 14 4,082 Psychoactive drugs 53,560 462 105 510 Psychiatric hospital 38,129 329 12 3,177 Other medications 28,416 245 99 287 General practitioners 14,400 124 103 140 Leisure clubs 17,669 152 10 1,767 Other consultants 3,757 32 37 102 Custodial assistance 2,442 21 8 305 Ambulances 1302 11 11 118 Psychiatrists 825 7 9 92 Other services 451 4 6 75

Total 1,701,215 14,666

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In the last stage we compare total direct costs with those costs found in the case of long-term hospitalisation in the central mental hospital in the state capital Linz. Mean costs of community-based care during the six months of €14,666 – represented by the thick line in Figure 1 – stand in contrast to the mean costs of €35,435 for long-term hospitalisation. It’s obvious that costs are differently distributed, that jerky leaps can be observed and that a small minority of patients in the community generate more costs than they would in a long-term ward in the mental hospital. This €35,435 over the six months is equivalent to €193,60 per day, which is the official per-day charge for hospitalisation for (new) chronically mentally ill patients (Grausgruber et al., 2006: 205ff).

Figure 1: Cost comparison: community-based care versus long-term ward in mental hospital: observation period 1.7.2001 – 31.12.2001, N=116

Average Costs of long-term inpatient hospitalization €35435

Mean Costs of “community-bases” care € 14.666

As can be seen immediately, mean costs of the new community-based care for former long-stay psychiatric patients are only a fraction of the costs of a long-term ward in a mental hospital. In detail, costs are only 41.4% of the costs of long-term hospitalisation (€14,666 instead of €35,435). This is a very similar result produced by Häfner and colleagues (1986) or by Rössler/Salize (1997). Admittedly there are some differences in the study population – both mentioned studies focus on people suffering from schizophrenia – but insofar as mental health care systems exhibit similarities, comparisons are admissible. But this finding only partly endorses the results of the well-known TAPS study in the UK, where costs for the

Deinstitutionalisation of Psychiatric Long-Stay Patients in Upper Austria 44

 

deinstitutionalised mentally ill were “...marginally but significantly greater than hospital costs” (Beecham et al., 1997: 106).

We can sum up a first result: direct costs of the new more or less communitybased care are substantially lower than costs in a long-term ward. But how is the quality of life and how far are needs met? Detailed information concerning objective and subjective indicators of quality of life is presented in Grausgruber et al., 2006 (107–135, 198–203).

Data concerning objective data show mixed findings: on the one hand it is obvious that former long-term patients have no problems with safety, but social contacts and leisure time activities for example are generally low.

Table 6: Objective indicators of quality of life: selected main areas (availability in per cent) in T2

Indicators per cent Get financial support 98.5% Watched television in the last four weeks 89.6% Bought food in the last four weeks 68.7% Have a single room 65.7% Have good friends who can be approached 58.2% Occupation 52.2% Attended an event/pub in the last four weeks 52.2% Prepared meals in the last four weeks 17.9% Received a visit from family members each week 17.9% Drug abuse 0.0% Victim of crime 0.0%

N=67 people able to be interviewed

Table 7: Subjective indicators of quality of life: level of satisfaction in T2 (mean) Sub-dimensions Level of satisfaction in per cent * Mean

Safety (2) 94.5% 1.32 Occupation/pension (3) 83.0% 1.53 Accommodation (4) 82.5% 1.67 Friends/social contacts (2) 76.0% 1.92 Leisure activities (2) 72.8% 1.98 Mental health (2) 75.2% 2.06 General well-being (1) 62.1% 2.06 Family/partnership (3) 71.8% 2.08 Physical health (2) 75.1% 2.24 Financial situation (1) 58.5% 2.29

N: 34–67 people able to be interviewed; () quantity of indicators per sub-dimension in parentheses; * combined: very and pretty satisfied

If we glance at the subjective aspects of quality of life we are able to find high levels of satisfaction. On a 1–5-point scale people define themselves as very or pretty satisfied, ranging from 95% in safe in the community, around 75% in social

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contacts and mental health to about 60% in general well-being and finance. As in six of the ten dimensions the “cut-off point of 75%” could be reached and in only two dimensions is the average score is well below, a second finding for a good quality of life can be concluded.

The third crucial dimension concerns needs. Table 8 presents the results of the questions of whether there appears to be demand for support and whether community mental health services do meet these needs. As mentioned above, patients as well as staff were asked for their assessments. For a precise description concerning counting needs and unmet needs see Grausgruber et al., 2006 (74–101, 193ff).

Columns 2 and 3 present the judgements of patients, and columns 4 and 5 those of staff. Rows 2 and 4 contain frequency of identified needs, and columns 3 and 5 the amount of unmet needs in total.

Table 8: Needs and unmet needs mentioned by patients and staff in T2 Patients Staff Domains

needs identified

(n) unmet needs

% needs identified

(n) unmet needs %

Housing 61 3.3 65 0.0

Food and nutrition 59 8.3 61 0.0

Household management 57 15.5 60 1.5

Finance 56 17.2 61 9.2

Mental health 41 70.7 50 0.0

Money 39 12,5 45 4.6

Occupation 33 3.0 33* 50.8*

Personal hygiene 30 73.3 54 3.1

Physical health 26 23.1 48 0.0

Information on disease 21 95.2 47 3.1

Leisure activities 14 35.7 46 9.2

Social contacts, friends 10 100.0 19 4.6

Safety 7 0.0 20 0.0

Sexual life 6 67.7 11 7.8

Family, partnership 5 100.0 23 4.6

Drug, alcohol abuse 1 50.0 7 1.5

N = 67 people able to be interviewed and corresponding judgements of the staff * Staff judge patients only as partly fit for employment.

We can find interesting results. First, it is not surprising but well known that sometimes major discrepancies could be observed between the met and unmet needs observed by both groups (Hofmann/Priebe, 1996). Staff detect in all aspects a greater need than patients. Second: patients highlight many more unmet needs than staff. Whereas the staff are apparently convinced that the new services care accurately and comprehensively, some former mental patients report suffering from unmet needs.

Most differences are to be found in the domains of social interactions, including social contacts to friends, to family, sexual life, hygiene and the broad context of

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illness. Summarising from the viewpoint of patients, only basic needs are met; especially some needs in mental health and social interaction are by far not fully met.

5 Summary and conclusions

Summing up we can emphasise: direct costs of the community-based care are only 41.4% of long-term care in a mental hospital. Satisfaction is on a fairly high level, and from the viewpoint of staff there are hardly any needs which are not supported by new community mental health services. But former long-term patients agree only on the narrow area of accommodation, and not with regards to social interaction.

What conclusions can be drawn from these findings? From the viewpoint of staff and mental health services, the results are convincing that the experience of deinstitutionalisation in Upper Austria has been highly successful and means a win-win situation: former long-term psychiatric patients as well as the public profits from this new model; it’s a cost-efficient alternative. Patient assessments of quality of life and needs however indicate some considerable shortcomings in mental health services to meet the needs of former long-stay patients. Further efforts are necessary in these fields.

But despite these criticisms, deinstitutionalisation has apparently run successfully and means a forward-looking development of community-based mental health services and not a simple trans-institutionalisation. There is no way back. This is also the desire of the former long-stay patients. When asked whether they want to return to mental hospital, all consistently say “no!”.

But as in other western countries, despite all efforts a new challenge emerges and new questions arise. Up to now mostly older long-term patients have been discharged, but now we find a new kind of “new long-stay psychiatric patient” – not old people, but young, difficult and mostly homeless people. An initial small preliminary study (B37) in a sheltered home for homeless people in the state capital Linz for over 120 people has shown that a large number – potentially about 40–60% of them – have mental problems to a greater or lesser degree. A second indicator is the growing group of young mentally ill patients (Leff, 1997: 169ff; Salize et al., 2001) who live on the border between the mental hospital and the street and who are unwilling to accept support from traditional mental health services.

Psychiatric care and community-based psycho-social services are confronted with a bigger challenge than up to now: to define and to organise care for these “new long-stay patients” and for the “difficult to place”.

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References

rdAmerican Psychiatric Association (1987): Global Assessment of Functioning Scale GAF, Diagnostic and Statistic Manual (3 Revised), American Psychiatry Press: Washington DC

Bachrach, L.L. (1997): Lessons from the American experience in providing communitybased services. In: Leff, (ed): 21-36 Becker, T./Knapp, M./Knudson, H.C. et al., (1999): The EPSILON Study of schizophrenia in five European Countries. Design and methodology for standardising outcome measures and comparing patterns of care and service costs. Br J Psychiatry 175: 514-521

Beecham, J./Knapp, M. (1992): Costing psychiatric interventions. In: Thornicroft, G./Brewin, C.R./Wing, J. (eds.): Measuring Mental health Needs. Gaskell: London, 163-183

Beecham, J./Hallham, A./Knapp, M. (1997): Costing care in hospital and in the community. In: Leff, (ed): 93-108

B37 – Sozialverein B37 (2010): Jahresbericht 2009, (dl 10.5.2011 http://www.b37.at/download/jahresbericht_b37_2009.pdf) Belknap, I. (1956): Human Problems of Mental Hospitals, Mc Graw Hill: New York Dowdall, G.W (1999): Mental Hospitals and Deinstitutionalization. In: Aneshensel,

C.S./Phelan, J.C. (eds): Handbook of the Sociology of Mental Health. Kluwer Academic/Plenum Publishers: New York Boston, 519-537

Goffman, E. (1961): Asylums, Anchor: New York Grausgruber, A./Grausgruber-Berner, R./Haberfellner, E.M. (2006): Enthospitalisierung

psychiatrischer Langzeitpatienten in Oberösterreich. Eine Evaluierung der Versorgungskosten, des Hilfebedarfs und der Lebensqualität. Edition pro mente: Linz

Häfner, H./an der Heiden, W./Buchholz, W. et al., (1986): Organisation, Wirksamkeit und Wirtschaftlichkeit komplementärer Versorgung Schizophrener. Nervenarzt 57: 214226

Hagenbichler, E. (2010): Das österreichische LKF-System. (Hrsg.): Bundesministerium für Gesundheit, Wien

Hofmann, K./Priebe, S. (1996): Welche Bedürfnisse nach Hilfe haben schizophrene Langzeitpatienten? – Probleme der Selbst- und Fremdbeurteilung von “Needs”. Fortschr. Neurol. Psychiat 64: 473-481

Hofmann, K. (2003): Enthospitalisierung und Lebensqualität. Psychiatrie Verlag: Bonn Kay, S.R./ Fiszbein, A./Opler, L.A. (1987): The positive and negative syndrome scale

(PANSS) for schizophrenia. Schiz Bull 13: 261-276 Knapp, M./ Beecham, J. (1990): Costing mental health services. Psychol Med 20: 893-908 Leff, J. (ed.) (1997): Care in The Community. Illusion or Reality? Wiley & Sons:

Chichester/New York etc. Leff, J. (1997): The Downside of Reprovision, in: Leff (ed): 167-187 Mechanic, D./Rochefort, D.A. (1990): Deinstitutionalization: An Appraisal of Reform. In:

Annu. Rev. Sociol 1990, 16: 301-327 Oliver J. (1991): The social care directive: development of a quality of life profile for use in community services for the mentally ill. Soc. Work Soc. Sci. Rev. 3: 5-45 Oliver, J./ Huxley, P./ Bridges, K./ Mohamad, H. (1996): Quality of Life and Mental Health

Services. Routledge: London/New York Phelan, M./ Slade, M./ Thornicroft, G. et al. (1995): The Camberwell assessment of need:

the validity and reliability of an instrument to assess the needs of people with severe mental illness. Br J Psychiatry 167: 589-595

Priebe, S./ Hoffmann, K. (1993): Berliner Lebensqualitätsprofil (BLP), unveröffentlichtes Manuskript

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Priebe, S./ Heinze, J./ Jäckel, A. (1993): Berliner Bedürfnisinventar (BeBI), unveröffentlichtes Manuskript

Priebe, S./ Hoffmann, K./ Isermann, M./ Kaiser, W. (1995): Lebensqualität, Bedürfnisse und Behandlungsbewertung langzeithospitalisierter Patienten. Teil I der Berliner Enthospitalisierungsstudie. Psychiat Praxis 23: 15-20

Roick, Ch./ Killian, R./ Matschinger, H./ Bernert, S./ Mory, C./ Angermeyer, M.C. (2001): Die deutsche Version des Client Sociodemographic and Service Receipt Inventory. Ein Instrument zur Erfassung psychiatrischer Versorgungskosten. Psychiat Prax 28, (Suppl. 2): 84-90

Salize, H.J./ Rössler, W. (1997): Kosten der gemeindepsychiatrischen Versorgung – eine Effektivitätsanalyse am Beispiel der Schizophrenie, Forschungsbericht, Mannheim

Salize, H.J./ Horst, A./ Dillmann, C. et al. (2001): Needs for mental health care and service provision in single homeless people. Soc Psychiatry Psychiatr Epidemiol: 36 (4), 207-216

Wing, J.K./ Brown, G.W. (1970): Institutionalism and Schizophrenia. A comparative study of three mental hospitals, 1960-1868. Cambridge University Press: London

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II. New Ways of Teaching in Higher Education

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Nicoleta Socaciu / Simon Haagen / Bernhard Prosch
Drive-by sociology – an activating teachinglearning framework

1 Sociology in daily life…

Drive-by sociology is meant as an innovative way of teaching the idea that sociology is everything else but just theory. Sociological phenomena happen everywhere where people are, were or perhaps will be. Drive-by sociology wants to bring into view all those sociological moments in daily life – wants to encourage the transfer from theory to life by using methods which are common in different fields of sociology.

The basic idea of drive-by sociology is rather simple. It's named after so-called “drive-by shootings”, which means a shooting carried out from a passing vehicle. Those brutal shootings were popular during the gang fights in the prohibition era in the USA: “The deviant gangster culture and its practice of drive-by murders was created and developed in this violent era in America” (Yablonsky, 1997: 30). Drivebys involve gangsters in hit-and-run tactics with “spontaneous action, with no special planning or motive, whose targets can include anyone in the line of fire (Yablonsky, 1997: 202). Nowadays, the term “drive-by shootings” is also used in a much more peaceful way for shooting photographs from inside moving cars (Steinmetz, 2006; Bradford, 2005).

As you can imagine, drive-by sociology is also less bloody. But the basic scheme is the same:

• Show up • Act • Leave These three steps follow in quick succession. In the context of drive-by sociology students go to a public place (normally by metro) and show up. There, they act: do a short observation and note impressions. After leaving the drive-by location, back in university observations are discussed and everybody tries to build hypotheses based on the observations.

According to this scheme, members of our teaching team held two complete seminars at the Economic Department of the University of Erlangen-Nuremberg. Additionally, we organized drive-by exercises for students in our first-year introductory course and for an international student seminar.

Drive-by sociology – an activating teaching-learning framework 53

2 Goals and organizational framework

The motivation for inventing this method was our search for a way to teach sociology sustainably. Not only to put theory into the students' heads, but also make them see the contents of those theories around them and link both. Because one experience in teaching sociology was that students are less and less able to find research questions on their own, build hypotheses, or just to develop a sociological way of thinking. Or in other words they had problems connecting sociological theories with their daily lives. During their studies of sociological theory and empirical methods they learn a lot about how to test hypotheses but nothing about where those hypotheses come from.

The main question to answer was very simple and difficult at the same time: Where can you find sociology? Our answer is: Everywhere! This answer can be rather surprising for students... So the main aim of the course was to qualify students to realize the sociological context in their environment. Therefore we had to leave the lecture hall, go out into the wild – of Nuremberg's city – and help the students to open their eyes to see the world with a sociological view. So, the main goal of this teaching-learning method is to train sociological data collection in an open field of everyday life and to find explanations for these findings. But beyond this, our method can also be helpful for creating new views and questions for empirical research.

Within the two mentioned complete seminars on drive-by sociology we worked with about 20 to 25 students in the last third of their sociological studies. The meetings took place every two weeks for a double lesson (3 hours). The courses started at the university with some input, like refreshing their knowledge about the research process, types of hypotheses or parallels between the last observation and other fields of sociological research. Then the group started into town. The students did not know where we were going, so they could not think about expectations or build prejudices about it.

The places we visited in Nuremberg were:

• The main square (market place) • The airport • A big park in the center of Nuremberg • A deprived area at the periphery of the city • A multicultural district near the town center (also including an old graveyard) • The famous Nuremberg Christmas market • In addition the students had the possibility to write about a free subject, something they realized or found interesting in their leisure time

The students’ task was to watch what they saw, take notes and then get back to the university. There everybody presented the notes and tried to give an interpretation to the others, which was discussed. The most interesting discussions started when there were drawn completely opposite conclusions out of the same observations by different students.
Drive-by sociology – an activating teaching-learning framework 54

After every lesson the students had one week to write a short essay (about one page) where they described their observation and logically deduced a hypothesis from this observation. Possible steps within this essay were:

• What could be observed? • What were possible causes for that? • What are further interesting questions? • Are there occasions for research? • What are possible research questions? • What hypothesis can be derived? To that essay they received direct feedback by email from the teaching staff until the next meeting one week later. The next lesson always started with the possibility to ask questions about the last lesson, the essay, or the feedbacks. At the end of the semester the students had to choose one of their essays and write a scientific sociological term paper about one of their hypotheses.