The International Journal of Psychosocial Rehabilitation

Innovation in the Group Home Design:

 Applying ‘Group-as-a-Whole’ to a Fairweather Lodge

 

 Diana J. Semmelhack, Psy.D., L.C.P.C.
Midwestern University
 
Larry Ende, Ph.D., MSW
Therapist

Tanya Gluzerman, MA
Doctoral Intern

Karen Farrell, Psy.D.
Director of Training, Midwestern University

Clive Hazell, Ph.D.
DeVry University

Theresa Schultz, Ph.D.
Midwestern University




Citation:
Semmelhack D, Ende L, Gluzerman T, Farrell K, Hazell C & Schultz T. (2010). Innovation in the Group Home Design: Applying
 ‘Group-as-a-Whole’ to a Fairweather Lodge. International Journal of Psychosocial Rehabilitation. Vol 15(1) 5-17

---

Abstract

This study explored the impact of a modified Fairweather Lodge on the development of group cohesion and self-efficacy for nine severely mentally-ill clients.  The Fairweather Lodge model is a psychosocial rehabilitation model combining congregate living with collaborative employment.  It differs significantly from traditional group homes with “Lodge” members assuming almost complete autonomy with regard to establishing  rules and procedures, as well as in taking primary responsibility for site operations.  Employment and Lodge member independence are emphasized. Our modified version of the model highlights the group-as-a-whole therapeutic position.  This perspective, originating in the Tavistock tradition, focuses on the group-as-a-whole’s contribution to the tasks of connection and rehabilitation versus any given individual’s actions. Consultant interpretations address processes operating outside the current awareness of the group that might impede the task (anxiety, depression, etc.).  Group members  work together to promote growth. Ten subjects completed the 16-week evaluation period in the Control Group setting (standard group home) and nine subjects were evaluated under the modified Fairweather Lodge Model.  Baseline measures of self-efficacy and cohesiveness before the start of treatment were compared between groups by unpaired t-tests.  Significant changes from baseline were determined in each group by repeated measures analysis of variance with Tukey Tests used for post-hoc testing.  There was no difference between the Control and Experimental Groups at baseline.  After the 16 week treatment, an individual’s sense of self-efficacy (on average) did not change in the Control Group, but increased by 45% in the Experimental Group. The Lodge setting also produced a 35% increase in cohesiveness from baseline to 16 weeks of treatment.

---

Introduction

Group homes were developed by mental health workers in the 1960’s and 1970’s as part of the deinstitutionalization movement. This movement involved the closing of public hospitals and the transfer of services for the mentally ill into the surrounding community, where they could be provided in “the least restrictive environment” (Bachrach, 1980). Group homes are typically small residential facilities located within a community. They are intended to simulate family life.   

Unfortunately, the deinstitutionalization process fell short. According to the National Alliance on Mental Illness (NAMI, 2008), of those individuals with a severe mental disorder only 40% receive needed treatment services on any given day. This results in homelessness, imprisonment, and at times violence. Forty-two of the fifty states have less than half the minimum number of beds needed to house the mentally ill. Many severely mentally-ill individuals are forced to reside in long-term care facilities or nursing homes (highly restrictive environments), designed to provide care for people unable to care for themselves (National Center for Health Care Statistics, 1999). The population of mentally-ill individuals residing in these facilities is growing. Many of these individuals are under the age of 65 and have few other housing options. The lack of housing and treatment for the mentally ill, in our view, is a national crisis.

In response to this crisis, we propose that, contrary to what is implied by existing opinion, the application of an analytic “group-as-a-whole” model of therapeutic treatment to community living (in the context of a Fairweather Lodge) can improve the basic effectiveness of the group home design. This conclusion in turn may help strengthen the argument for developing new group homes. Our study suggests that clients with severe mental illness can benefit from treatment often considered intellectually and emotionally beyond them. We examine our approach to treatment as it positively affects two key factors of group home life: group cohesion and the self-efficacy of group members. We applied group-as-a-whole treatment to a group home (a Fairweather Lodge) partly because the treatment appears well designed for alleviating and responding to the severe isolation which individuals with mental illness tend to suffer from. Group homes are intended to counteract this isolation.

The Fairweather Lodge
A typical group home stresses maintenance and provides 24 hour supervision. There are few treatment options offered beyond medication management. There is limited focus on developing group cohesion or self-efficacy through team building, vocational training or psychotherapy. Typical group homes offer residents few opportunities for exploring their need for positive relationships, or the impact of isolation and depersonalization (due to mental illness) on their psychological well-being (Edelson, 1970).

Recently, two U.S. organizations devoted to advocacy and housing for the mentally-ill population (we shall leave them nameless) collaborated to bring about a Fairweather Lodge group home (the first of its kind in its state). A group-as-a-whole treatment model was gradually introduced, creating the basis for this study. The Fairweather Lodge group home model was developed by Dr. George Fairweather in 1963 in response to the deinstitutionalization movement. His is a psychosocial rehabilitation model, combining congregate living with collaborative employment. The model focuses on rehabilitation and the promotion of autonomy for Lodge members (Fairweather, 1964; 1980). A “Lodge” is an affordable dwelling whose members share running the home, including domestic chores and the purchase and preparation of food. Unlike in most traditional group homes, Lodge residents make their own house rules and manage their own activities. Moreover, they collaboratively design and run a small business. Such businesses may offer cleaning services, printing, furniture building, etc.

The Lodge model stresses part-time employment and Lodge member interconnectedness.  Unlike in traditional group homes, where staff members provide 24 hour on-site control over the day-to-day operations of the facility, Lodge staff duties are limited to mentoring, advising, mediating, and helping in emergencies. Lodge staff includes one Lodge coordinator and one vocational trainer, who remain on-site during weekday hours only. A Lodge thus costs much less to run than a typical group home.  Research supports the effectiveness of the Lodge model (Fakhoury et al., 2002).

The Group-as-a-Whole Model
This study explores the impact of a modified Fairweather Lodge on the development of group cohesion and self-efficacy for nine severely mentally-ill clients. The modification consists in applying the group-as-a-whole treatment model to the Lodge.  This model, rooted in the Tavistock tradition, focuses on the group-as-a-whole’s contribution to the group and to individuals’ actions.  

According to the group-as-a-whole model, staff interpretations of group behaviors take into account unconscious group processes (anxiety, depression, etc.) that operate outside the current awareness of the group, processes that may interfere with the major tasks of connection and rehabilitation. Interpretations are made by a “consultant.” These interpretations teach group members to become more sensitive to underlying group dynamics and one’s own role within them. A group-as-a-whole therapeutic perspective was fostered through 1) bi-weekly group psychotherapy sessions and 2) a social psychological perspective maintained by staff that any given individual’s behavior is influenced by the whole group, and not solely by individual psychodynamics. The group-as-a-whole model involves some integration of psychodynamic theory. The exact nature of this theory is not prescribed, but one quite frequently finds elements of traditional and object-relations theory in Tavistock consultations (Hazell, 2005).

The group-as-a-whole process refers to those conscious or unconscious dynamics  relevant to the group as a specific psychological construction. One of the most extensively discussed group-as-a-whole processes in the empirical literature is group cohesion. As we will consider shortly, group cohesion plays a fundamental role in the ability of a group to be therapeutic. In our study, without prompting, the Experimental Group (the group applying the group-as-a-whole model) began to explore dynamics that interfered with group cohesion and worked to overcome them. Beyond considerations of cohesion, the group-as-a-whole can be perceived, experienced, and represented in the minds of the members with a range of positive and negative qualities (Greene, 1999). The group can be experienced, for example, as the unconscious “good mother” with protective and holding abilities (Scheidlinger, 1974). The group can be experienced as the unconscious “bad mother,” who can annihilate an individual (Agazarian, 1989). These opposite experiences of the group, formed from shared projections, have been well described in the literature.  Other group processes examined  serve defensive or work-avoidant needs (Bigelow, 1998). Bion (1951) explored fundamental assumptions of unquestioned dependency (for example, on the consultant), fight–flight, or again the delegation of a strict, turn–taking pattern of exchange of ideas, all often arising due to anxiety among the group members (Rioch, 1970). Such  assumptions and processes need to be dealt with via interpretation or confrontation by the consultant in order to shift the group toward more task-oriented and less defensive behavior (Ettin, 1992; Yalom & Leszcz, 2005).

A consultant working in the Tavistock tradition might, for example, sense that a group that is discussing the desire to go on a trip may be avoiding the task at hand.  The consultant may address this discussion with a group-as-a-whole interpretation by stating, “This group is uneasy about dealing with something in this room and desires to move away from it, to go on a trip instead, rather than to address this uneasiness.”  The consultant became aware of the group’s escape from the task through members’ comments on events outside of the group’s process.  The consultant’s interpretation was intended to re-focus the group’s discussion back on the dynamics developing in the here and now.

 To deal with anxieties, groups can form us– versus–them, or in–versus–out polarities where some members disown aspects of themselves and project them into some other part of the group, or into an external group. (Agazarian, 1997). These externalizations are usually a defensive means that can undermine accomplishing the group’s task. The process of splitting and externalizing needs to be dealt with by the consultant.

The approach of the consultant interpreting the dynamics of the group stresses the interconnectedness among members. This appears to reduce the tendency for scapegoating when discussing particularly controversial subjects. In addition, the approach contributes to the development of a holding environment, which encourages  clients to share and to face painful issues.  (Semmelhack, Ende, Hazell, Hoffman, and Gluzerman, 2009).

Group Cohesiveness
Our study measured the effects of group-as-a-whole treatment on group cohesion and self-efficacy. Group cohesion can be defined as feelings of trust, belongingness, and togetherness experienced by group members (Burlingame, Earnshaw, Hoag, Barlow, Richardson, Donnell, 2002). There is increasing agreement that cohesion is the best definition of the therapeutic relationship in a group (Burlingame, et al., 2002). Cohesiveness appears to be as important, if not more important, in describing a patient’s improvement, than what theoretical orientation a therapist adheres to (Norcross & Godfried, 2001). Cohesion is defined in a group setting as to multiple alliances (e.g. member-to-member, member-to-group, member-to-therapist, group-to-therapist) (Burlingame, et al., 2002).  We examined group cohesion both because of its  importance for group therapy and because of its ability to counter the isolation characteristic of the severely mentally ill.

Bion (1951) has stated that we are group animals at war with our groupishness. He suggests that while as group animals we desire to be in groups, we also fear groups and what they can do to us and others. There is a field of forces that each human being must negotiate--forces pulling us towards the group and forces pulling us away from the group. The net effect of this force field results in the individual’s level of membership or belonging to a group. When this force field is aggregated across all of the members of a group, one could call the result the group’s cohesiveness.
According to Yalom, Houts, Zimerberg, and Rand (1967), group cohesiveness predicts successful outcomes in group therapy. The development of cohesiveness appears to have a curative effect (Yalom, 2005).  Marmarosh, Holtz, and Schottenbauer (2005) agree, finding cohesion to be a primary group factor, “‘directly related to curative group factors such as “collective self-esteem” (i.e., the self-esteem one gains by being a member of a group) and “hope for the self” (similar to optimism) (p. 36).

Self-efficacy
We also examined the effects of group-as-a-whole treatment on self-efficacy in members. Self-efficacy is a crucial concept in the work of psychologist Albert Bandura. According to Bandura, self-efficacy indicates “the belief in one’s capabilities to organize and execute the courses of action required to manage prospective situations” (1999, p.2). In more common language, this means that self-efficacy represents an individual’s belief in her ability to succeed in the situations she encounters. Self-efficacy affects our  motivation, behavior, and emotional states.  

We examined self-efficacy because it is key to the development of autonomy, a major issue for the Fairweather Lodge, as well as for the group home in general. We believe group-as-a-whole treatment improves self-efficacy because it raises self-esteem and helps members to internalize the group as a soothing object which can be called upon in times of stress. These factors can reduce anxiety and thereby increase both ego functioning and task orientation.

Most individuals have goals they would like to achieve and aspects of their lives they would like to change. Bandura (1999) has found that self-efficacy plays a vital role in how people approach their goals, tasks, and challenges. He suggests that individuals with a strong sense of self-efficacy tend to view challenging problems as tasks to be mastered; tend to develop a strong commitment to their activities; and tend to recover quickly from setbacks. On the other hand, Bandura suggested that individuals with weak  self-efficacy tend to avoid challenging tasks, focus on personal failings, and quickly lose confidence in their abilities.  

According to Bandura, self-efficacy begins to form in early childhood. It then develops throughout life as we process new experiences and acquire new skills. Bandura  has pointed to four major sources of self efficacy: mastery experience, social modeling, social persuasion, and psychological responses. He proposed that in mastery experiences we perform a task successfully, which strengthens our sense of self-efficacy. On the other hand, continuous failure in responding to challenges weakens self-efficacy. As for social modeling, Bandura suggested that witnessing others successfully completing a task strengthens the observer’s belief that she can master it. In social persuasion, the encouragement of others convinces people that they have the skills to succeed. Finally, psychological responses play an important role in self-efficacy. Bandura suggested that emotional states, moods, physical reactions, and stress all affect how we feel about our abilities.

Previous Research
Some key problems have confronted researchers studying group home effectiveness. Most of the studies have been non-controlled follow ups, cross sectional surveys, or non-randomized controlled trials (Fakhoury, Murray, Shepherd, & Priebe, 2002). There have been few outcome studies regarding the effectiveness of housing. There are difficulties due to practical and ethical problems that make randomized controlled trials hard to conduct. Fakhoury and colleagues report that the most common type of research has been cross-sectional, but one cannot determine causality from this research (Fakhoury et al., 2002). Despite growth in group housing,  little research has been done on the effects of living arrangements, or the support available to residents (Nelson, Walsh-Bowers, & Hall, 1998).

Tornatzky, Fegus, Avella, and Fairweather (1980) showed that the Lodge provided a better track record in terms of recidivism and employment than most other forms of community aftercare. Persons who were members of the Lodge on average remained within the community much longer than their matched pairs in other community treatment programs. Lodge residents were more frequently employed, and the cost of operating Lodge programs was less than that of other programs. When the Lodge became completely self-governed by the members, it also could be somewhat self-supporting by the employment income of members, which provides a further measure of the cost-effectiveness of establishing a Lodge (Tornatzky et al., 1980).
Though there has not been extensive research done on the effectiveness of the Fairweather Lodge model, some other research has been compiled. Onaga, McKinney, and Pfaff (2000) examined the variables behind the success of the model by looking at 74 Lodges throughout the nation. One main theme that surfaced was that Lodges were similar to families in that they emphasized mutual support, shared resources, common goals, a sense of community, a nurturing environment, and an integration of values.

Haertl (2004) explored factors contributing to the success of clients in a Fairweather Lodge through a mixed design study.  The results indicated that success in the Fairweather Lodge model depended on the following variables: willingness to work, assimilation to the community environment, receptivity to peer support, work and living skills, ability to experience a higher quality of life, empowerment, sense of community, and independence.

Limited research has been conducted on the utility of the group-as-a-whole model in creating a sense of cohesion or self-efficacy with severely mentally-ill populations housed in community based settings (Hazell, 2005; Semmelhack, Hazell & Hoffman, 2008). Most of the work available on the group-as-a-whole methodology provides qualitative descriptions of group process, not empirical studies conducted with control groups.  According to Kapur, Ramage and Walker (1986), since the 1960s analytic group work with institutionalized populations has been de-emphasized. The analysis of transference issues and in-depth emotional material is deemed largely inappropriate and impractical.  A study by Semmelhack, Hazell, and Hoffman (2008) suggests outcomes to the contrary. They found a significant decrease in anxiety and a trend toward decreased depression after 30 weeks of group-as-a-whole work with severely mentally-ill individuals residing in an inpatient setting. A significant increase in cohesiveness after group-as-a-whole work under these circumstances was also found (Semmelhack, Hazell, Ende, Hoffman, & Gluzerman, 2009).

Method
Setting
The Experimental Group resided in a Fairweather Lodge located in a home in a middle-class neighborhood.  The home had four bedrooms, four bathrooms, a living room area, TV room, large kitchen, dining room and recreation area.  The Control Group members resided in a typical group home setting in the state where the study took place.

Participants: Experimental Group
There were nine residents in the Experimental Group, all of whom had been given a major Axis I diagnosis according to the Diagnostic and Statistical Manual of Mental Disorders Text Revision (DSM-IV-TR) (American Psychiatric Association, 2000).   The population ranged from 40 to 60 years of age. Three members were diagnosed as having Paranoid Schizophrenia, two Major Depression, and four  Schizoaffective Disorder. None of the participants was diagnosed with an Axis II disorder. All of them had experienced childhood trauma, including sexual, emotional, or physical abuse, or neglect. Additionally, all had made at least one suicide attempt.  All members had at least average intelligence, measured upon admittance into the facility through the administration of a Kaufman Brief Intelligence Test (K-BIT) (Kaufman & Kaufman, 1990).

Participants: Control Group  
The ten members of the Control Group were matched with the Experimental Group on gender, age and intelligence.  Members of the Control Group had similar Axis I diagnoses.  They too showed an absence of Axis II diagnoses.  Like those in the Experimental Group, all individuals had a history of suicide attempts and childhood trauma.  Control Group members were engaged in traditional group home treatment, which included training or psychotherapy on an as needed basis in addition to medication management.

The total sample consisted of nineteen clients (eight men and eleven women).  The Control Group included five men and five women, the Experimental Group five men and four women. All participants were European American.  

Instruments
Group Attitude Scale (GAS). The study measured cohesiveness using the Group Attitude Scale (Evans & Jarvis, 1986). This questionnaire consists of 20 self-report items. The items relate to several aspects of cohesiveness, including attractiveness, belongingness, and well being. They address the broadness of the concept of cohesiveness. The measure requires the participants to respond to statements such as, "People in my work group work together well," and, "I feel like I am really part of my group" before and after the 16-week treatment period by placing an "X" on a continuous scale labeled from 0 to 100.  Members of the Experimental and Control Groups were asked to indicate how they felt about group membership (the group being the members of their group home).                            

In several studies of the original Group Attitude Scale, the measure coefficient alpha has ranged from .90 to .97 at various points in the lives of groups studied. The validity and reliability data obtained to date on the scale suggest that the instrument has promise as a measure of sense of belonging to a group (Evans & Jarvis, 1986).    General Self-Efficacy Scale (GSES).  We measured self-efficacy using Jerusalem and Schwarzer’s (1992) General Self-Efficacy Scale (GSES).  The GSES has been used to measure improvements over time in self-efficacy. It was developed in Germany in 1979 by Matthias Jerusalem and Ralf Schwarzer and was later revised and adapted to 26 languages (Jerusalem & Schwarzer, 1992). The scale was originally created to assess a general sense of perceived self-efficacy and to predict coping with daily hassles, as well as to determine how one adapts to stressful life events. The GSES was designed for the general adult population, including individuals age twelve and up. The scale is self-administered. It takes, on average, four minutes to administer. As regards scoring, responses are made on a 4-point scale. After administration, the responses to all 10 items are summed up and yield a composite score ranging from 10 to 40. Higher scores indicate stronger patient belief in self-efficacy.

The items on the GSES relate to several aspects of self-efficacy, including belief in one’s capacity to perform novel and difficult tasks and cope with adversity in various areas of human functioning (Jerusalem & Schwarzer, 1992).  Perceived self-efficacy aids in goal setting and persistence when faced with a setback. Each of the items on the scale points to successful coping while attributing this success to one’s internal ability.

In regard to the scale’s reliability, in samples from 23 nations Cronbach’s alphas ranged from .76 to .90 (Jerusalem & Schwarzer, 1992).   As regards validity, criterion-related validity has been acknowledged in a variety of correlation studies where positive coefficients were correlated with favorable emotions, dispositional optimism, and work satisfaction, and negative coefficients were correlated with depression, anxiety, and stress.  
 
The strengths of the GSES are that the measure has been used internationally with success for two decades and that the measure is suitable for a broad range of applications and populations, including the elderly population, minorities, and others. (Jerusalem & Schwarzer, 1992).  The weakness of this measure is that it does not necessarily assess behavioral change (Jerusalem & Schwarzer, 1992).  Thus the measure may need to be used concurrently with an additional one.     

Procedures
Administration of study measures. Participants in the treatment group were given the GAS (Evans & Jarvis, 1986) and the GSES (Jerusalem & Schwarzer, 1992) by a member of the Lodge staff before the group began (Time 1).  The group ran for 16 weeks, at the conclusion of which participants were again given the GAS and GSES (Time 2). A member of the staff distributed the scales to group members immediately after the end of the 16-week module.  She read the explanation of each measure written on the examination form with no other promoting of which answer would be the correct or more appropriate one. She collected the scales within two hours after the end of the group.  Members of the Control Group were assessed at the same two points by a group home staff member, who distributed the measures following the same protocol as with the Experimental Group.                

Statistical  Analyses
Data are presented as mean and standard deviation. Baseline measures of self-efficacy and cohesiveness before the start of treatment and at 8 and 16 weeks of treatment were compared between groups by unpaired t-tests. Changes from baseline were determined in each group by repeated measures ANOVA with Tukey tests used for post-hoc testing.

Results
Ten subjects completed the 16 week evaluation period in the Control Group settings and nine subjects were evaluated under group-as-a-whole treatment. There was no significant difference between the groups in self-efficacy or cohesiveness determined as baseline measures before the start of treatment (Table 1). (This equality at baseline was particularly surprising since while Experimental Group members had only recently met, Control Group members had resided together for thirteen years.) However, the level of both self-efficacy and cohesiveness were significantly higher for the modified Fairweather Lodge than for the Control Group at 16 weeks of treatment.

Table 1. Agency and cohesiveness during 16 weeks with control and Group-as-a-whole Lodges.

Group	N	Treatment	Agency	Cohesiveness
Control	10	Baseline	61.2 + 17.6	67.1 + 15.9
		8 weeks	62.4 + 14.0	69.8 + 16.8
		16 weeks	61.7 + 12.5	67.7 + 15.1
Group-as-a-whole	9	Baseline	54.2 + 17.3	61.8 + 9.3
		8 weeks	68.4 + 12.7	76.5 + 14.9
		16 weeks	73.8 + 12.5*	83.2 + 12.8*

Mean + standard deviation
* = P < 0.05 compared to Control Group


Self-efficacy did not change in the Control Group, but increased 45% in the Experimental Group from baseline to 16 weeks (figure 1). The group-as-a-whole setting  produced a 35% increase in cohesiveness from baseline to 16 weeks of treatment (figure 2). In contrast, the Control Group showed no significant change in cohesiveness.





Casually collected qualitative feedback from Experimental Group members suggests the apparent utility of the modified Fairweather Lodge model, as well as showing concretely some of its apparent effects. A few examples suggest the tenor of a variety of comments. One member stated,”For the first time in my life, I feel like part of a group.” Another one said, “You know, we are a part of a team. We are all together and for better or worse we can make things happen. I’m not alone. I have you guys backing me.” A third member stated, “I need this group. I’ve never before been understood as a person.” And another remarked, “Coming here makes me feel more confident to face my day.”

Discussion
The findings suggest that individuals with chronic mental illness can benefit from a group-as-a-whole treatment (in this case in a Fairweather Lodge) that speaks to them as human beings who can learn from their relationships. Despite society’s preoccupation with this population’s having limitations, individuals with severe forms of mental illness are human beings who know what it is like to feel validated and connect with others. This is a major factor that group-as-a-whole treatment brings to the table so that group members can connect with each individual member as part of a larger community.

Too many approaches to individuals with mental illness minimize the humanistic aspect with regard to symptom management. While psycho-education plays an imperative role in allowing one to understand and manage symptoms of mental illness, being able to connect with and relate to others raises self-esteem and improves the ability to connect with and reintegrate into society as a whole.

We need not only to teach social skills and to encourage community, but to learn overall how to create the conditions which foster human connectedness. Group-as-a-whole work and the Fairweather Lodge are designed to do this.

In addition to applying the group-as-a-whole treatment approach, we might consider such questions as, how can we provide interpersonal direction? What does it mean to be part of a group? What does it mean to be validated and understood? And, how can we facilitate these crucial social processes?      

When individuals feel like part of a community, they can act more like one. Group cohesion appears to increase self-efficacy in the world. The group becomes internalized as a validating and a soothing object--rather than an alienating one. This raises self-esteem while reducing anxiety. Group cohesion, it appears, helps those with mental illness become more effective actors in the social world.

Study Limitations
Limitations to this study can be addressed in future research.  Reactivity within the repeated measures design may have been a weakness influencing outcomes.  For example, results may have been influenced by the fact that members gained familiarity with the tests given and an awareness that they were part of a study.  Another weakness is the small sample size because it may have attenuated our ability to see significant differences between groups.  Additionally, the small sample size allowed for less reliable measurement and could have affected the results by showing significance where in reality there is none, or obscuring effects that were present.  Because the group of participants was not ethnically diverse, the ability to generalize the results to diverse populations is limited. Finally, as suggested in the “Results,” it may be necessary to add an element of qualitative research to a study like this one in order to establish more clearly the relationship between the concrete Experimental Group process and the statistical results of the  study.     

Conclusion
Our society in the United States creates very limited housing options for people with mental illness. The society places many such people in long-term care centers with few options for treatment other than medication management. Yet many of these individuals can develop the skills they need to integrate into the community. Individuals with severe mental illness need permanent housing options which, like the modified Fairweather Lodge model, are designed to help bring about the conditions required for  client growth. Given the thoughtful cultivation of community and skills, these individuals can learn to meet the harsh demands of the social realities outside the group home.

 

Anderson CM, Hogarty G, Reiss DJ. Family treatment of adult schizophrenic patients- a psychoeducational approach. Schizophrenia Bulletin, 1980; 6(3): 490-505.

Anthony W, Cohen M, Farkas M. Psychiatric Rehabilitation. Boston: Center for Psychiatric rehabilitation 1990.

Anthony W, Liberman R. The practice of psychiatric rehabilitation: Historical, conceptual, and research base. Schizophrenia Bulletin, 1986; 12: 524-559.

Anthony WA, Cohen MR, Vitalo R. The measurement of rehabilitation outcome. Schizophrenia Bulletin, 1978; 4(3): 365-383.

Arvidsson H. Needs assessed by patients and staff in a Swedish sample of severely mentally ill subjects. Nord J Psychiatry. 2001; 55(5):311-7.

Barber J. Mental Health Policy in South Australia: A job half done. Australian Journal of Social Issues, 1985; 20: 79.

Bengtsson-Tops A, Hansson L. Clinical and social needs of schizophrenic outpatients living in the community: the relationship between needs and subjective quality of life. [Cited 28 September 2004.] Available From URL:http://www.ncbi.nlm.nih.gov/entrez/utils/fref.fcgi?http://link.springerny.com/link/service/journals/00127/bibs/9034010/90340513.

Birley J, Hudson B. Community Rehabilitation. In: Watts, FN, Bennett DH (eds.). Theory and Practice of Psychiatric rehabilitation. Chichester: John Wiley & Sons, 1983, 171-189.

Bond GR, Dincin J, Setze P, Witheridge T. "The Effectiveness of Psychiatric Rehabilitation: A Summary of Research at Thresholds" Psychosocial Rehabilitation Journal, 1984; 7(4) April. 

Bond GR, Miller L, Krumwied R, Ward R. "Assertive Case Management in Three CMHCs: A Controlled Study" Hospital and Community Psychiatry, 1988; 39(4) April.

Bond GR. Psychiatric rehabilitation. In Dell Orto AE & Marinelli RP (eds.). Encyclopaedia of Disability and Rehabilitation. New York: Macmillan. 1995

Borland A, McRae J, Lycan C. "Outcome of Five Years of Continuous Intensive Case Management", Hospital and Community Psychiatry, 1989; 40: 369-376.

Bradshaw J. A Taxonomy of Social Need. As cited in: Mc Lachlan (ed.). Problems and Progress in Medical Care. 7th edition. London. Oxford University. 1972; 71-82. In: Brewin CR, Wing JK, Mangen SP, Brugha TS, Mac Carthy. Principle and Practice of measuring needs in long term mentally ill: the MRC needs for care assessment. Psychological Medicine. 1987; 17: 971-981.

Brugha TS, Brewin CR, Wing JK, Mangen SP. Needs for care among the long term mentally ill: A report from the Camberwell High contact Survey. Psychological Medicine. 1998; 18(2): 457-468.

Brunt D, Hansson L. Comparison of user assessed needs for care between psychiatric inpatients and supported community residents. [Cited 30 March 2005.].Available From URL:http://www.ncbi.nlm.nih.gov/

entrez/utils/lofref.fcgi?PrId=3046&uid=12445111&db=pubmed&url=http://www.blackwellsynergy.com/openurl?genre=article&sid=nlm:pubmed&issn=0283-9318&date=2002&volume=16&issue=4&spage=406         

Carling PJ. Housing and supports for persons with mental illness: Emerging approaches to research and practice. Hospital and Community Psychiatry, 1993; 44: 439-449.

Carson VB, Arnold EN. Mental health nursing: The nurse-patient journey. Philadelphia: W. B. Saunders Co 1996.

Chien WT,  Norman I. Educational needs of families caring for Chinese patients with schizophrenia.  Journal of Advanced Nursing. 2003; 44(5): 490-8.

Cole NJ, Brewer DL, Allison RB, Branch CHH. Employment characteristics of discharged schizophrenics. Archives of General Psychiatry, 1964; 10: 314-319.

Dincin J, Witheridge T. "Psychiatric Rehabilitation as a Deterrent to Recidivism", Hospital and Community Psychiatry 1982; 33.

Dion G, Anthony W. Research in psychiatric rehabilitation: A review of experimental and quasi-experimental studies. Rehabilitation Counseling Bulletin, 1987; 30: 177-203.

Fairweather G,  Fergus E. "The Lodge Society: A Look at Community Tenure as a Measure of Cost Savings". Michigan Lodge Dissemination Project, Michigan State University, 1988.

Foldemo A, Bogren L. Need assessment and quality of life in outpatients with schizophrenia: a 5-year follow-up study. [Cited 25 March 2005.] Available From URL:http://www.ncbi.nlm.nih.gov/entrez/query.fcgi? cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12445109

Fromm E. The sane society. New York: Rinehart 1955: p.25.

Hammaker R. "A Client Outcome Evaluation of the Statewide Implementation of Community Support Services" Psychosocial Rehabilitation Journal, 1983; 7(1) July.

Hancock GA, Reynolds T, Woods B, Thornicroft G, Orrell M. The needs of older people with mental health problems according to the user, the carer, and the staff. [Cited 25 March 2005.] Available From URL: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=12949848

Hoult J, Reynolds I. "Schizophrenia: A Comparative Trial of Community Oriented and Hospital Oriented Psychiatric Care", Acta Psychiatrica Scandinavica, 1984; 69.

House of Commons. The National Health Service and Community Care Act. London: HMSO 1990.

Hughes R. Psychiatric Rehabilitation is an Essential Health Service for Persons with Serious and Persistent Mental Illness. [Cited 30 March 2005.]  Available From URL: www.uspra.org/pdf/PSRessential.pdf

Hume C. Assessment and Evaluation. In: Hume C, Pullen I (eds.). Rehabilitation of Mental Health Problems: An Introductory Handbook. USA: Churchill Livingstone 1994: 141-174.

Kulhara P, Avasthi A, Sharan P,Sharma P, Malhotra S, Gill S. Assessment Of Needs Of Patients Of Schizophrenia. Indian Journal of Psychiatry. 2001april; 43 (supplementary).

Lukoff D, Liberman RP, Neuchterlein KH. Symptom monitoring in the rehabilitation of schizophrenic patients, Schizophrenia Bulletin, 1986; 12: 578-591.

Maslow A. A theory of Metamotivation: the biological rooting of the value life. Journal of Humanistic psychology. 1967; 7: 93-127.

Middelboe T, Mackeprang T, Hansson L, Werdelin G, Karlsson H, Bjarnason O,Bengtsson-Tops A, Dybbro J, Nilsson LL, Sandlund M, Sorgaard KW.

The Nordic Study on schizophrenic patients living in the community. Subjective needs and perceived help. [Cited 25 March 2005.] Available From URL: http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=11418270

Mulder R. "Evaluation of the Harbinger Program, 1982 - 1985", Lansing, Michigan Department of Mental Health, 1985.

Nagaswami V, Valecha V, Thara R. Rehabilitation needs of schizophrenic patients- A preliminary report. Indian Journal of Psychiatry, 1985; 27: 213-220.

Ochoa S, Haro JM, Autonell J, Pendas A, Teba F, Marquez M. Met and unmet needs of schizophrenia patients in a Spanish sample. Schizophrenia Bulletin. 2003; 29(2):201-10.

Parameshwaran R. Assessment of needs in the community: An exploratory study. Indian Journal of Psychiatry. 2002; 44(supplementary).

Richard C, Warner. The Quality of Life of people with Schizophrenia in Boalder, Calardo and Balogna, Italy. Schizophrenia Bulletin. 1998; 24(4), 559-568.

Rogers ES, Walsh D, Massotta L, Danley K. "Massachusetts Survey of Client Preferences for Community Support Programs: Final Report." Unpublished manuscript, Center for Psychosocial Rehabilitation, Boston, MA, 1991. In: Vocational Rehabilitation in Schizophrenia. Schizophrenia Bulletin, 1995; 21(4): 645-656.

Rosales Varo C, Torres Gonzalez F, Luna-Del-Castillo J, Baca Baldomero E, Martinez Montes G. Assessment of needs in schizophrenia patients. [Cited25 March 2005.]Available from URL:http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt =Abstract&list_uids=12106519

Rosenfield, S. and Neese-Todd, S. "Elements of a Psychosocial Clubhouse Program Associated with a Satisfying Quality of Life," Hospital and Community Psychiatry, 1993; 44.

Ruggeri M, Leese M, Slade M, Bonizzato P, Fontecedro L, Tansella M. Demographic, clinical, social and service variables associated with higher needs for care in community psychiatric service patients. The South Verona Outcome Project 8. [Cited 19 March 2005.]. Available From URL: http://www.ncbi.nlm.nih.gov/entrez/utils/lofref.fcgi? PrId=3055&uid=15022048&db=pubmed&url=http://dx.doi.org/10.1007/s00127-004-0705-0

Ruud T, Martinsen EW, Friis S. Chronic patients in psychiatric institutions: psychopathology, level of functioning and need for care.  Acta Psychiatrica Scandinavica. 1998; 98(5): 427-8.

Gandotra S, Paul SE, Daniel M, Kumar K, Raj H, Sujeetha S. A Preliminary Study of Rehabilitation Needs of In-patients and Out-patients with Schizophrenia. Indian Journal of Psychiatry. 2004; 46(3): 244-255

Seeman MV. Schizophrenia in women. [Cited 19 March 2005.]. Available from URL:http://www.medscape.com/viewarticle/420033+camberwell+assessment+of+need+scale+study.

Slade PD, Bentall R. Psychological treatments for negative symptoms. British Journal of Psychiatry, 1989; 155: 133-135.

Stein L, Test M. "Alternative to Mental Hospital Treatment: I. Conceptual Model, Treatment Program, and Clinical Evaluation", Archives of General Psychiatry, 1980; 37.

Sullivan HS. Tensions Interpersonal and International: A Psychiatrist’s View. In: Cantril H (ed.). Tensions that cause war. Urbana, Ill: University of Illinois Press. 1950; 79-138.

Taly AB, Murali T. Disability due to mental illness. In: Taly AB, Murali T (eds.).  Foundations and Techniques in Psychiatric Rehabilitation. Bangalore: NIMHANS 2001; 43-46.

Tanzman B. An overview of surveys of mental health consumers’ preferences for housing and support services. Hospital and Community Psychiatry.1993; 44: 450-455.

Taube C, Morlock L, Burns B, Santos A. "New Directions in Research on Assertive Community Treatment", Hospital and Community Psychiatry, 1990; 41(6).

Wallace C, Liberman R. "Social Skills Training for Patients with Schizophrenia: A Controlled Clinical Trial", Psychiatry Research, 1985; 15: 239-247.

Walters K, Iliffe S, Tai SS, Orrell M. Assessing needs from patient, carer and professional perspectives: the Camberwell Assessment of need for Elderly people in primary care. [Cited 25 March 2005.] Available From URL:http://www.ncbi.nlm.nih.gov/entrez/utils/fref.fcgi?http://ageing.oupjournals.org/cgi/pmidlookup?view=reprint&pmid=11191242

WHO. Burden of Mental and Behavioural disorders. In: The World Health Report 2001 Mental Health: New Understanding New Hope. Geneva: WHO 2001; 19-45.

Wig NN, Srinivasamurthy R. An approach to organizing rural psychiatric services. A report from WHO project “Strategies for extending mental health care”. Geneva, Switzerland; W.H.O.1981

Wing JK. The cycle of planning and evaluation. In: Wing JK (ed.). Long-term Community Care: Experience in a London Borough. Psychological Medicine.1986; Monograph supplement No.2: 41-55.