i

THE ROLE OF GUARDIANSHIP IN THE COURSE OF TREATMENT AND

TREATMENT OUTCOME FOR INDIVIDUALS RECOVERING FROM SEVERE

MENTAL ILLNESS

by

Thea L. Rothmann, M.A.

University of Nebraska, 2006

Adviser: William D. Spaulding

The purpose of this study was to evaluate the role of guardianship in treatment

and treatment outcome for people recovering from severe mental illnesses (SMI) in a

psychiatric rehabilitation context. Research in the intersecting field of mental health care

and the law is in its nascence. Using the unifying theory of therapeutic jurisprudence,

this study investigates the clinical correlates of guardianship in a population of people

with SMI. An archival database from an inpatient psychiatric rehabilitation program in a

Nebraska state hospital was used in analysis. This was an ideal context and population

for the study because this group of people is highly affected by the legal constructs

evaluated in this investigation. The archival database contained comprehensive clinical,

demographic, and outcome data for all participants. This included assessments of

neurocognition, social cognition, symptomatology, behavioral functioning, and treatment

compliance. In addition, outcome data regarding discharge location and rehospitalization

were available. Two main hypotheses were put forth towards the overall purpose of this

iistudy. First, it was hypothesized that people with guardians would demonstrate lower

overall functioning at the time of admission and throughout the course of treatment

across multiple domains when compared to those without guardians. Second, it was

hypothesized that people with guardians would be discharged to more restrictive

community placements than those without guardians, but that they would have a lower

rate of rehospitalization. Partial support for both hypotheses was obtained. Results

suggest that, in Nebraska, people with guardians can be discriminated from those without

guardians based on behavioral functioning. In addition, people with guardians were

found to have a longer length of stay. Other areas of clinical functioning assessed –

neurocognition, social cognition, symptomatology, and treatment compliance – were not

found to differ between those with and without guardians. People with guardians were

discharged to more restrictive settings and there is some evidence that they were

rehospitalized sooner than those without guardians. This is the first known study to

empirically investigate the role of guardianship in the recovery of people with SMI.

iii

Table of Contents

List of Tables and Figures...............................................................................................................................ivDEDICATION.....................................................................................................................................................VACKNOWLEDGEMENTS....................................................................................................................................VICHAPTER 1 - INTRODUCTION............................................................................................................................1CHAPTER 2 – LITERATURE REVIEW..................................................................................................................4

Severe Mental Illness and Psychiatric Rehabilitation.................................................................................4Intersection between Mental Health Care and the Law..............................................................................6Guardianship...............................................................................................................................................8Related Studies...........................................................................................................................................10Present study..............................................................................................................................................19

CHAPTER 3 - METHOD....................................................................................................................................23Design Overview........................................................................................................................................23Setting........................................................................................................................................................23Participants................................................................................................................................................24Measures....................................................................................................................................................26

Demographic and Clinical Characteristics..........................................................................................26Neurocognition Measures.....................................................................................................................27Social Cognition Measures...................................................................................................................29Behavioral Functioning Measures........................................................................................................30Symptomatology Measures...................................................................................................................31Treatment Compliance Measure...........................................................................................................32Outcome Measures................................................................................................................................32

Procedure..................................................................................................................................................35Data Collection.....................................................................................................................................35Data Cleaning.......................................................................................................................................38Data Analysis........................................................................................................................................38

CHAPTER 4 – RESULTS....................................................................................................................................40Demographic and Clinical Characteristics of People with Guardians at CTP........................................40Hypothesis 1...............................................................................................................................................48

Functioning at admission......................................................................................................................49Neurocognitive functioning..............................................................................................................49Social cognitive functioning.............................................................................................................54Behavioral functioning.....................................................................................................................56Treatment compliance......................................................................................................................59Symptomatology...............................................................................................................................60

Functioning over the course of treatment.............................................................................................63Neurocognitive functioning..............................................................................................................63Social cognitive functioning.............................................................................................................65Behavioral functioning.....................................................................................................................66Treatment compliance......................................................................................................................71Symptomatology...............................................................................................................................72

Hypothesis 2...............................................................................................................................................75Outcome................................................................................................................................................75

Discharge location...........................................................................................................................75Rehospitalization rate......................................................................................................................76

CHAPTER 5 – DISCUSSION...............................................................................................................................79General Discussion....................................................................................................................................79Limitations of the Present Study................................................................................................................88Future Directions.......................................................................................................................................89

REFERENCES...................................................................................................................................................92Appendix .....................................................................................................................................................102

iv

vLIST OF TABLES & FIGURES

TABLE 1. DEMOGRAPHIC AND CLINICAL CHARACTERISTICS OF PARTICIPANTS (N=162)

TABLE 2. GUARDIANSHIP STATUS OF PARTICIPANTS (N=162)

TABLE 3. RELATIONSHIP BETWEEN AXIS I DIAGNOSIS AND GUARDIANSHIP STATUS (N=162)

TABLE 4. RELATIONSHIP BETWEEN RACE AND GUARDIANSHIP STATUS (N=162)

TABLE 5. GUARDIANSHIP STATUS BY DEMOGRAPHIC AND CLINICAL CHARACTERISTICS MULTIVARIATE ANALYSIS OF COVARIANCE (MANCOVA)

TABLE 6. MEAN SCORES AND STANDARD DEVIATIONS FOR DEMOGRAPHIC AND CLINICAL VARIABLES AS A FUNCTION OF GUARDIANSHIP STATUS AND AGE

TABLE 7. STANDARDIZED CANONICAL COEFFICIENTS AND STRUCTURE WEIGHTS FROM DISCRIMINANT ANALYSES OF DEMOGRAPHIC AND CLINICAL VARIABLES TO PREDICT GUARDIANSHIP STATUS

TABLE 8. GUARDIANSHIP STATUS BY NEUROCOGNITIVE VARIABLES (GROUP 1) AT ADMISSION BETWEEN GROUP MULTIVARIATE AND UNIVARIATE STATISTICS

TABLE 9. GUARDIANSHIP STATUS BY NEUROCOGNITIVE VARIABLES (GROUP 2) AT ADMISSION BETWEEN GROUP MULTIVARIATE AND UNIVARIATE STATISTICS

TABLE 10. GUARDIANSHIP STATUS BY NEUROCOGNITIVE VARIABLES AT ADMISSION ONE-WAY ANALYSES OF VARIANCE (ANOVAS)

TABLE 11. GUARDIANSHIP STATUS BY SOCIAL COGNITIVE VARIABLES AT ADMISSION BETWEEN GROUP MULTIVARIATE AND UNIVARIATE STATISTICS

TABLE 12. GUARDIANSHIP STATUS BY NOSIE SUBSCALES AT ADMISSION ONE-WAY ANALYSES OF VARIANCE (ANOVAS)

TABLE 13. STANDARDIZED CANONICAL COEFFICIENTS AND STRUCTURE WEIGHTS FROM DISCRIMINANT ANALYSES OF NOSIE SUBSCALES TO PREDICT GUARDIANSHIP STATUS

TABLE 14. GUARDIANSHIP STATUS BY BPRS FACTOR SCORES AT ADMISSION BETWEEN GROUP MANOVA

TABLE 15. GUARDIANSHIP STATUS BY BPRS ITEMS ONE-WAY ANALYSES OF VARIANCE (ANOVAS)

TABLE 16. GUARDIANSHIP STATUS BY COGLAB REPEATED MEASURES ANOVAS

TABLE 17. MEAN SCORES AND STANDARD DEVIATIONS FOR NOSIE TOTAL ASSETS AT ADMISSION, 6 MONTHS, AND 12 MONTHS AS A FUNCTION OF GUARDIANSHIP STATUS

TABLE 18. GUARDIANSHIP STATUS BY NOSIE SUBSCALES REPEATED MEASURES ANOVAS

TABLE 19. MEANS AND STANDARD DEVIATIONS ON NOSIE SUBSCALES AT ADMISSION AND 12 MONTHS AS A FUNCTION OF GUARDIANSHIP STATUS

TABLE 20. RELATIONSHIP BETWEEN LEVEL OF DISCHARGE LOCATION RESTRICTIVENESS AND GUARDIANSHIP STATUS (N=147)

FIGURE 1. NOSIE TOTAL ASSETS SCORES OVER TIME AS A FUNCTION OF GUARDIANSHIP GROUP

viDEDICATION

For my Dad . . .

You are missed muchly.

viiACKNOWLEDGEMENTS

I had intended for graduate school to take me out of the Midwest for a while, but will be forever

grateful I decided to come to Nebraska. I wish to express my gratitude to my advisor, William Spaulding,

for just the right amount of direction and more than enough inspiration throughout my graduate career. I

could not have found a better supervisory committee for this dissertation and am thankful for the collective

wisdom of Mario Scalora, Brian Wilcox, and Robert Schopp. I am also grateful for the encouragement and

mentorship from Cal Garbin and support of Mary Sullivan and the entire staff and all the participants at

CTP. Finally, Mark Krejci from Concordia College deserves my thanks for steering me into psychology in

the first place.

To the UN-L Serious Mental Illness Research Group, members past and present, I am grateful to

have been among you. I especially want to offer many thanks to Jason Peer for raising the bar in our

research lab just beyond my reach, so I was always striving for more. I am glad that both Jason Peer and

Srividya Iyer were able to take the walk through graduate school with me, sharing times of struggle and

success. This project would not have been possible if not for the NRSA fellowship awarded to Myla

Browne, a member of the UN-L Serious Mental Illness Research Group. To those who continue to fund

research in this much-needed and oft-overlooked area, you have my gratitude.

To my fellow transient Lincolnites, I will be forever indebted to you for maintaining my sense of

humor and sanity and for always keeping my social calendar on powerbook and my costume drawer

overflowing. My far-away-friends - you know who you are - have always “been there” for me and opened

their hearts and doors at a moment’s notice; I couldn’t be luckier. My Mom and Dad have supported me

110% since Day 1. All the good things in me I got from them. My Mom has put up a brave front this past

year so that I could continue to pursue my dreams and I am grateful for her courage. Finally, I am

overwhelmed and overjoyed that Guy has stuck with me through the end of this adventure and is joining

me for all the rest of life’s adventures.

1CHAPTER 1 - INTRODUCTION

The Role of Guardianship in the Course of Treatment and Treatment Outcome for

Individuals Recovering from Severe Mental Illness

The relationship between the legal system and mental health system is a tenuous

one. Research on the two separate but intersecting fields has received increasing interest

over the last fifteen years (e.g., Wexler, 1988; Wexler, 1990; Wexler & Winick, 1991;

Winick, 1995; Monahan, Hoge, Lidz, Roth, Bennett, Gardner, & Mulvey, 1995;

Slobogin, 1995; Spaulding, Poland, Elbogin, & Ritchie, 2000; Schopp, 2001). However,

much of this research remains theoretical in nature with few applications in clinical

settings. There are exceptions (for examples regarding coercion, see Hoge, Lidz,

Eisenberg, Gardner, Monahan, Mulvey, et al., 1997; McKenna, Simpson, & Coverdale,

2003; regarding involuntary commitment, see Strachan, 2004; Ridgely, Borum, & Petrila,

2001; regarding legal status and self-report of symptoms, see Hopko, Averill, Cowan, &

Shah, 2002). If the legal system allows itself to be informed by the current science of

psychopathology and treatment, it may more fully serve its purpose of protecting the

individual or society. Likewise, if mental health providers become more aware of the

legal system and its impact on mental health care, they may better equipped to pass the

benefit on to consumers to help them navigate the system and optimize their recovery.

Bridging the gap between mental health law theory and application is the intention of this

study. In particular, the role of guardianship as it pertains to the recovery from severe

mental illness for people in psychiatric rehabilitation is evaluated.

2Two main hypotheses were put forth towards the overall purpose of this study.

First, it was hypothesized that people with guardians would demonstrate lower overall

functioning at the time of admission and throughout the course of treatment across

multiple domains when compared to those without guardians. Second, it was

hypothesized that people with guardians would be discharged to more restrictive

community placements than those without guardians, but that they would have a lower

rate of rehospitalization.

An archival database constructed with nearly ten years of clinical data from an

inpatient psychiatric hospital was used in this study. Clinical data on multiple levels of

functioning, consistent with the multidimensional nature of impairments in SMI, was

available for analyses. Data on symptomatology, neurocognitive and social cognitive

functioning, treatment compliance, and behavioral functioning were used in analyses. In

addition, data regarding discharge location and rates of rehospitalization following

discharge were available. There were two main groups being compared in this study.

First, there are those with court-appointed guardians, referred to as the Guardian group.

Second, there are those without court-appointed guardians, referred to as the No Guardian

group.

While these two groups are the primary focus of analyses, several other groups

were evaluated since these distinctions were not mutually exclusive. Specifically, some

people with guardians were admitted with a Voluntary per Guardian (VpG) legal status

while others were admitted following civil commitment (CC). These legal statuses will

be discussed further below. Therefore, there are subgroups based on legal status and

guardianship: the VpG Guardian group and the CC Guardian group. Another variation

3on these groupings which was explored in analyses is based on whether the guardian was

acquired before or after admission to treatment. The resulting groups from this

distinction are: the Guardian Admission group and the Guardian Acquired group. A final

variation which was explored was whether or not the guardian was a family member.

This dissertation, then, takes on the following structure. First, current

conceptualizations of SMI and optimal treatment practices are addressed. Next, there is a

brief discussion of the intersection between the legal and mental health systems,

including the concept of therapeutic jurisprudence. Then, a review of guardianship, the

area of focus for this proposal, is presented. Finally, research relevant to this area is

discussed. The study addresses several specific questions. First, this study addresses

whether or not people with guardians differ in any way from those who do not have

guardians with regards to specific areas of functioning including neurocognition, social

cognition, treatment compliance, behavioral functioning, and symptomatology. This

study aims to identify ways in which people with guardians differ from those without

guardians at the time of admission to the psychiatric rehabilitation program and over the

course of treatment. Second, this study identifies ways in which people with guardians

differ with regards to outcome from those without guardians. Specifically, the rate of

rehospitalization and the discharge location of those with guardians are compared to

those without guardians. Finally, exploratory analyses delve into within-group

differences regarding guardianship. That is, the impact of whether or not the guardian is

a family member, whether or not guardianship was acquired before or after admission to

the psychiatric rehabilitation program, and whether or not the legal status of the person is

Voluntary per Guardian (VpG) or Civil Commitment (CC) is investigated.

4CHAPTER 2 – LITERATURE REVIEW

Severe Mental Illness and Psychiatric Rehabilitation.

A majority of individuals categorized under the rubric of SMI are those diagnosed

with schizophrenia spectrum disorders. Increasingly, research efforts in schizophrenia

seek to understand schizophrenia not as a disorder with a single causal deficit but as a

biosystemic disorder in which component processes are in a state of dysregulation

(Spaulding, 1997). These components include processes related to neurophysiology (i.e.,

neurotransmitter systems), neurocognition (i.e., basic cognitive functions such as

attention and memory), social cognition (i.e., higher order cognitive functions such as the

formation of beliefs and abstract reasoning), and sociobehavioral functioning (i.e.,

performing behavioral activities in a socially meaningful context) (Spaulding, Sullivan, &

Poland, 2003). Therefore, we understand the course of the illness, its nature, the deficits

present, and the recovery process as reflections of varying degrees of dysregulation

within the person (Ciompi, 1989; Spaulding, 1997; Spaulding et al., 2003) and between

the person and their environment (Strauss, 1989). Dysregulation in one domain may

affect functioning in another domain, in a precarious balance of reciprocal interactions

(Spaulding, 1997). This differs from the dominant medical model perspective of mental

illness as proceeding in a linear cascade from molecular levels of functioning to molar

levels of functioning (e.g., a bacterial infection). Understanding severe mental illness as a

multidimensional model of reciprocal processes calls for interventions which target

multiple domains in order to re-regulate the system.

Significant advances have been made in specific psychopharmacological and

psychosocial treatments for severe mental illnesses, including schizophrenia (see

5Spaulding et al., 2003; Hofman & Tompson, 2002; American Psychological Association

[APA], n.d.; McEvoy, Scheifler, & Frances, 1999; Lehman, Thompson, Dixon, & Scott,

1995; Kendall, 1998). The advent of more effective antipsychotic medications in

particular shaped service delivery for individuals with SMI, prompting a shift toward

deinstitutionalization in the 1950s and 1960s. Greater emphasis was then placed on

community care, which was not well-established at the time, with only brief hospital

stays being necessary to stabilize symptoms with medication (Cook & Wright, 1995).

Well-known today are the failures of deinstitutionalization with the resulting increase in

criminalization and homelessness of the mentally ill. We have learned that antipsychotic

medications are rarely sufficient in and of themselves to treat all levels of functioning

impaired by the disorder. Researchers estimate that twenty-five to fifty percent of patients

with schizophrenia experience residual medication resistant symptoms, which highlights

the importance of psychosocial interventions (Garety, Fowler, & Kuipers, 2000;

Spaulding, Johnson, & Coursey, 2001).

Despite the advances made in treatment strategies, outcomes remain modest

(Wallace, Liberman, Kopelowicz, & Yaeger, 2001). As a group, people with

schizophrenia have much in common, but at the same time there is considerable

heterogeneity, with each individual representing a unique set of impairments, requiring

multiple approaches in varying combinations. Any specific treatment addresses only a

subset of an individual’s problems. Heterogeneous patient characteristics and multiple

treatment approaches create complexity in choosing the appropriate application of

treatment and contribute to modest treatment outcomes. Psychiatric rehabilitation has

emerged as an approach to organize a diversity of treatments and target multiple levels of

6functioning.

Psychiatric rehabilitation is a complex, integrated approach which optimizes

treatment outcome for those with severe mental illnesses by targeting multiple levels of

functioning, consistent with the conceptualization described above. It is hardly a new

concept, beginning nearly four decades ago (e.g., Anthony, Buell, Sharratt, & Althoff,

1972; Paul & Lentz, 1977). Psychiatric rehabilitation can include

psychopharmacological interventions, contingency management, social skills training,

occupational skills training, individual and group therapy, family intervention strategies,

independent living skills training, and more.

As mental illness conceptualizations and treatment strategies have evolved, so

have the laws, legal procedures, and legal roles surrounding them. The legal context of

psychiatric rehabilitation creates more complexity. Often, individuals are subject to

involuntary treatment and some have others making surrogate decisions on their behalf

which may diminish their autonomy1 and involvement in treatment. Considerations such

as these can have a profound impact on how treatment and rehabilitation is provided and

perhaps on the outcomes of treatment.

Intersection between Mental Health Care and the Law.

Both the legal system and mental health system have always shared at least one

commonality: addressing deviance in society. Both are designed to address those

behaviors which fall outside of a socially constructed range of normal, acceptable, or

condoned behaviors. Care for those with mental illnesses had previously been reserved

1 While “autonomy” can have varying definitions, it is used here and throughout this dissertation to refer to an individual’s right to make self-regarding decisions. For a more in depth discussion of autonomy and its varying definitions as it pertains to competence and commitment, see Schopp, 2001.

7as a responsibility of the communities or families of individuals with mental illness. The

legal system exerted little authority over the mental health care system – for better or for

worse. Then, asylums were created to care for these individuals. In the United States,

these asylums were characterized by some as a zoo-like public spectacle in the late 1700s

and early 1800s (Whitaker, 2002). The era of moral therapy in the mid-1800s was

trumped by the early 1900s eugenic movement which characterized the mentally ill as

“unfit to breed.” Since these early times in the development of mental health care

systems, the legal system has been juxtaposed between what it sees as protecting the

rights or interests of the individual (e.g., deinstitutionalization) and the interests of

society (e.g., civil commitment). A far cry from early history on mental health care,

today, the legal system has not left any corner of the mental health care system unturned.

We now have all kinds of psycholegal concepts: competency to stand trail, the Not Guilty

By Reason of Insanity defense, parens patriae and police power civil commitment,

outpatient commitment, guardianship, limited (or specific) guardianship, durable power

of attorney, advanced directives, rights to treatment and rights to refuse treatment, and

many others.2 What is more, the arm of the law finds itself bent over mental health care to

a far greater extent than it does even in general physical health care (Winick, 1996a).

Out of this mire of legal concepts in mental health care has emerged a unifying

theoretical approach called therapeutic jurisprudence (TJ). TJ recognizes that the legal

system itself acts as a social force which can impact mental health outcomes in both

positive and negative ways and asks how the legal system may promote well-being 2 It is not within the scope of this study to discuss all of these concepts in detail. However, it should be noted that aspects of police power commitment (e.g., Not Guilty/Responsible by Reason of Insanity – NGRI/NRRI; competency to stand trial - CST), in particular, are out of the scope of this review in that the archival database does not come from a forensic population. It is germane, however, to discuss issues relevant to guardianship, such as parens patriae civil commitment and competency.

8(Schopp, 1999; Slobogin, 1995; Wexler & Winick, 1991; Wexler, 1990; in severe mental

illness, Spaulding et al., 2000). TJ, then, becomes a framework for research investigations

such as the one proposed here to determine how the legal system can be therapeutic, or,

on the other hand, anti-therapeutic.

Guardianship.

While the legal system has not always exerted authority over mental health care,

guardianship has long been a traditional practice if not a codified one. Historically,

common law in Rome and England allowed for the nation to exert authority over an

incompetent person’s estate. Parens patriae, from which the guardianship process gains

authority, was borne out of this tradition (Reisner, Slobogin, & Rai, 1999). Parens

patriae is essentially the provision for the government to act as a parent to its citizens for

the expressed purpose of preventing harm. Guardianship, then, allows the decision-

making power for adults with mental disabilities who are deemed incompetent by the

court (or children, due to their minority status alone) to be given to a designated person

who is often a family member, but may also be a non-family member (e.g., lawyer,

member of an advocacy group).

Guardianship varies by jurisdiction and many forms of guardianship have

developed (in Nebraska, see Neb.Rev.St. §30-2619 & §30-2630). For example, the scope

of guardianship may vary; it may be full (general) or limited (specific).3 Full

guardianship allows the appointed guardian the authority to make decisions in all areas

conferred upon by law while limited guardianship refers to any guardianship which is 3 Durable power of attorneys and advance directives (see Winick, 1996b, for a discussion) are offshoots of the mechanism of guardianship. Both serve the purpose of allowing individuals in a period of competency to plan for future periods of incompetence by expressly dictating their desires for treatment, or refusal of treatment. However, like limited guardianship, they have received much praise, but they have not been widely practiced.

9limited to certain areas of decision making, presumably those in which the individual is

deemed incompetent (e.g., estate management; Neb.Rev.St. §30-2601). For the purpose

of the proposed study, guardianship with the afforded decision making authority over at

least treatment-related issues is of focus. Limited guardianship is an appealing, but not

often exercised, mechanism which reflects that being incompetent in one area of life does

not mean that an individual is incompetent in all areas of life. It allows an individual to

make self-regarding decisions in areas of life in which competence remains intact.

In addition, the duration of guardianship varies. Some states limit the time frame

over which the period of guardianship lasts or requires that the finding of incompetence

be reevaluated. However, in other states, the finding of incompetence is indefinite unless

someone (the ward or interested party) files a petition for a hearing to determine that the

individual is no longer incompetent (Neb.Rev.St. §30-2623).

The nature of the decision-making guardians use also varies. Sometimes,

guardians as surrogate decision-makers may be instructed to make the decision in an

individual’s best interests (which may or may not be the decision the individual would

have made if he or she was competent at the time) and, sometimes, guardians are

instructed to make a substitute decision (making the same decision the individual would

have made were he or she competent to do so, which may or may not be in the

individual’s best interest) (Reisner et al., 1999).

Finally, the basis for guardianship varies. Without a finding of incompetence, the

previous points are moot since a court will not appoint a guardian without it. Originally,

criteria primarily revolved around whether or not the person could care for himself or

herself. Later, however, the Uniform Probate Code was developed and it remains in

10widespread use. The Uniform Probate Code was designed to focus on the quality of

cognitive processes used in decision-making. That is, an incapacitated person is one who

“by reason of mental illness, mental deficiency, physical illness or disability, or advanced

age . . . or other cause . . . lacks sufficient understanding of capacity to make or

communicate responsible decisions concerning his person” (Uniform Probate Code §5 as

quoted in Reisner et al., 1999, p.869). The focus here is not on the decision that is made,

but rather on the process of making it. As an alternative to the Uniform Probate Code,

some states use a “functional” approach which harkens back to original criteria and

involves the impairment of ability to perform “minimal” activities of daily living (Reisner

et al., 1999).

Related Studies.

While few studies have examined guardianship, several have looked at the

relationship between mental illness and competency to consent to treatment. In

particular, the MacArthur Treatment Competence Study was designed specifically to

address the concerns of policymakers and clinicians alike regarding the decision-making

capacities of people with mental disorder. The study was conducted at three sites by Paul

Appelbaum, Thomas Grisso and colleagues. The articles generated by this study examine

the decision-making capacity of patients hospitalized with mental illness as it compares

to patients hospitalized for medical illness and a matched sample of non-patients from the

community (Appelbaum & Grisso, 1995; Grisso, Appelbaum, Mulvey, & Fletcher, 1995;

Grisso & Appelbaum, 1995).

Appelbaum and Grisso began their study by identifying the legal standards

associated with the determination of competence and developing measures to assess

11decision-making abilities in those areas. Roth and colleagues were among those to

originally discuss the evolving legal standards for determining competence (Roth, Meisel,

& Lidz, 1977). The standards were later refined by the work of Roth, Appelbaum, and

Grisso, among others (Roth et al., 1982; Appelbaum & Roth, 1982; Drane, 1984; Tepper

& Elwork, 1984; Grisso, 1986; Appelbaum & Grisso, 1988). The four areas of decision-

making competence identified as relevant to the legal system are as follows: the ability to

state a choice, to understand relevant information, to appreciate the nature of one’s own

situation and the potential consequences, and to reason rationally with information

(Appelbaum & Grisso, 1995). These four legal standards for assessing competence to

consent to treatment were used to develop the three MacArthur Treatment Competence

Research Instruments, Understanding Treatment Disclosures (UTD), Perceptions of

Disorder (POD), and Thinking Rationally About Treatment (TRAT; Grisso, Appelbaum,

Mulvey, & Fletcher, 1995). While the authors have deemed these instruments

inappropriate for use in a clinical context due to the time and complexity associated with

their administration, they have developed a tool for use by clinicians called the

MacArthur Competence Assessment Tool-Treatment (MacCAT-T; Grisso, Appelbaum,

& Hill-Fotouhi, 1997). It has since been used in studies regarding decision-making in

psychiatric contexts (e.g., Palmer, Nayak, Dunn, Appelbaum, & Jeste, 2002).

The results of the initial studies conducted using the UTD, POD, and TRAT

indicated that people diagnosed with schizophrenia and depression did indeed show

deficits in their decision-making abilities (Grisso & Appelbaum, 1995) as compared to

medical patient and community non-patient control groups. In particular, people

diagnosed with schizophrenia scored significantly lower than their matched non-patient

12community counterparts, with 52% showing impairment in at least one area, in contrast

to 12% of medical inpatients and 4% of community non-patients. People diagnosed with

depression likewise showed impairment in decision-making, though to a lesser degree.4

Despite the overall finding of impaired decision-making, there was considerable

heterogeneity among the group hospitalized for mental illness leading to the conclusion

that one cannot make a blanket statement regarding impairment in decision-making

solely on the basis of having a mental illness.

In fact, Grisso and Appelbaum (1995) found that a majority of people with

schizophrenia demonstrated adequate decision-making capabilities, as defined by the

researchers, in at least one of the three areas assessed. For any one measure, only one out

of four people with schizophrenia scored in the impaired range. This finding is important

since many jurisdictions use only one or a combination of the four legal standards

discussed above as opposed to all four. In addition, even when considering all measures,

nearly half of those diagnosed with schizophrenia performed adequately on the four

measures combined.

A subgroup emerged to explain, in part, the lower scores on the decision-making

measures by the group of people diagnosed with schizophrenia. Grisso and Appelbaum

(1995) identified that those who demonstrated deficits were by and large those with more

severe symptomatology (e.g., delusions, disorganized thinking) and when assessed after a

two-week period of treatment (i.e., hospitalization with antipsychotic medication),

improvement in all decision-making areas was evident for those whose symptomatology

had decreased.

4About ¾ of the patients hospitalized for depression performed adequately on the four measures combined.

13The current study takes place in a context in which the vast majority of

participants are diagnosed with schizophrenia and have arrived in treatment because they

have been civilly committed or because of a decision made by a guardian to hospitalize.

In either case, the competence of the person to consent to treatment has been questioned.

The MacArthur studies are relevant to the current study in that they identified impairment

in decision-making for people with mental illness, especially those with schizophrenia.

However, they also identified considerable heterogeneity in decision-making abilities

among those with mental illness, leaving important questions about whose competence

regarding treatment decisions should be questioned. There are several key differences

between the research of Appelbaum and Grisso and the current study. In particular, the

current study takes place in the context of a psychiatric rehabilitation program lasting

between nine and 18 months for people with a chronic mental illness rather than an acute

setting. In addition, participants in this program are admitted only after a period of

stabilization in an acute context such that the decrease in symptomatology with

medication as seen in the Grisso and Appelbaum (1995) sample is unlikely to occur since

acute symptoms have already diminished prior to admission. Furthermore, in the current

study, treatment is considered involuntary in nature whereas in the Grisso and

Appelbaum (1995) study, 55.9% of those diagnosed with schizophrenia were considered

voluntary admissions while only 27.5% were considered involuntary and 16.7% were

considered emergency admissions. These key contextual differences offer the current

study an important new set of data from which to consider the questions of competency

and decision-making.

14Grisso and Appelbaum (1995) accurately point out that the competence to consent

to treatment is almost exclusively only questioned when an individual refuses treatment.

However, their study suggests that a far greater number of people consent to treatment

without adequate decisional capabilities than refuse treatment (Appelbaum & Grisso,

1995). Aside from the contextual differences described above, the current study is also

unique in that it employs a measure of treatment compliance which will help to delineate

how treatment compliance is associated with different legal statuses of individuals,

including those who are civilly committed and/or those who have guardians. While this

study does not include an explicit measure of decision-making such as the measures

developed and used in the MacArthur studies, a measure of insight which includes

subscales regarding need for treatment and awareness of illness as well as extensive

assessments of cognitive functioning is included in the database.

Clinical research on guardianship for individuals with SMI is limited. Some work

has been done in the UK, though these limited studies remain mostly descriptive in

nature, regarding patterns of use of guardianship (e.g., Shaw, Hatfield & Evans, 2000,

Hatfield, Bindman, & Pinfold, 2004). Most research in the area of mental health law as it

pertains to individuals with SMI has been in the related area of civil commitment. There

is overlap in theory and in practice between the processes of guardianship and civil

commitment, but they remain distinct legal processes.

One main distinction between guardianship and civil commitment statutes, as far

as they pertain to treatment, is regarding competency. While a finding of incompetence is

a necessary component for the appointment of guardianship, this is no longer the case for

civil commitment. Prior to 1970, parens patriae civil commitment and guardianship

15were indistinguishable with regards to treatment (Reisner et al., 1999). In fact, civil

commitment carried with it the presumption of incompetence, “de facto.” Today,

however, in most jurisdictions, including Nebraska, civil commitment does not require a

finding of incompetence. In fact, there is an explicit rejection of incompetence in many

civil commitment statutes. For example, the Nebraska civil commitment statute (§83-

1068) specifically states that, “subjects in custody receiving treatment shall have the right

to be considered legally competent for all purposes unless they have been declared

legally incompetent.” Furthermore, the mental health board (or other decision-making

body) does not have the authority to declare incompetence; a separate hearing regarding

competency must be held to do so. However, the statute also goes on to declare that an

individual who is civilly committed retains the right “to refuse treatment, except such

treatment as is essential in the judgment of the medical health professional in charge…

to…substantially improve [the patient’s] mental illness” (Neb.Rev.St. §83-1068). This

raises the question, what does it mean to be afforded the right to refuse treatment if you

cannot refuse treatment that somebody else thinks will help? It appears that the true

underpinnings of civil commitment remain an apparent assumption that people with

mental illness lack adequate decisional capacity – at the very least, in areas regarding

treatment – consistent with the de facto determination of incompetence civil commitment

previously held. Herein lies the problem. Current statutes in the area of parens patriae

civil commitment are incoherent. While explicitly denying the presumption of

incompetence for people with mental illnesses, the implicit premise in the statutes is the

assumption of incompetence. If it is, in fact, an empty promise, Schopp (2001) questions

how civil commitment under parens patriae authority is warranted.

16After all, recall that parens patriae authority is a provision for the government to

intervene to prevent its citizens from coming to harm. If someone poses a danger to only

his or her self, the state’s only justification for intervention is that the person is

incompetent to make that decision. Whereas, if someone poses a danger only to his or

her self and is competent, the state has no justification for intervention under parens

patriae authority.

Essentially, then, guardianship and civil commitment differ, at least semantically,

in the inclusion (guardianship) or exclusion (civil commitment) of a legal finding of

incompetence. The distinction between the two is not to say that an individual with a

guardian cannot be civilly committed, or, vice versa, that someone who is civilly

committed can not have a guardian, but the means by which they enter and exit treatment

settings may differ. Civil commitment is sought for the sole purpose of involuntary

treatment for an individual whereas guardianship may invade the individual’s autonomy

on multiple levels, including treatment-related decision making. Through the lens of

therapeutic jurisprudence, we ask the questions: Is the distinction between the two a

helpful or therapeutic one? Does it serve a functional purpose? However, it is no longer

helpful to ask these questions outside of a clinical context. We must begin to ask

questions such as: What are the correlates of legal status to clinical functioning? How do

we identify which legal mechanism is the most beneficial for a given individual? We

cannot begin to answer questions about the utility or efficacy of these legal mechanisms

without a greater understanding of the clinical characteristics of individuals for whom

these legal mechanisms are designed.

17Guardianship has been posed as an alternative to civil commitment and this raises

some important questions about the clinical characteristics of those with guardians and

those without guardians (Spaulding et al., 2000). The proposed study does not intend to

advocate for one approach or the other. Rather, it intends to provide a scientific basis for

answering the relevant questions. For example, do those with guardians have

demonstrably different functional capacities than those who do not have guardians, which

would suggest a need for different legal mechanisms? There are reasons to think that

people with SMI in a psychiatric rehabilitation program with guardians differ from those

without guardians, and there are reasons to think that they don’t. One might presume that

since a person with a guardian has been found incompetent to make self-governing

decisions in some area of life, this person has a lower level of functioning compared to

someone who has not been found incompetent. One might see this difference become

apparent in the course of illness. That is, the long-term nature of a full (as opposed to

limited) guardianship implies more pervasive and chronic impairments in that person

such that a surrogate decision-maker is needed to help the individual navigate through

life. On the other hand, the fact that civil commitment typically ends when the period of

hospitalization ends implies that these individuals have a more cyclic course involving

periods of recovery in which they may effectively govern all aspects of their own lives

independently. On the continuum of autonomy afforded them, then, one would expect

these two populations to differ functionally with those with guardianship having

relatively lower overall levels of functioning. However, it may also be anticipated that at

the beginning of treatment differences in functioning are imperceptible since all people

have experience an exacerbation of their illness at that time; only as treatment progresses

18will differences emerge with those with guardians demonstrating less recovery in areas of

impairment indicating more constant or chronic functional impairments than those

without guardians.

However, there are also reasons to believe these populations do not differ. The

reasons for which an individual interacts with the legal system are complicated and there

is no one straight road to guardianship, civil commitment or treatment, in general. For

example, family involvement for people with SMI varies greatly. If one person has an

active family and another does not, the former may be more likely to have a guardian

than the latter, independent of their functional abilities, simply because a family member

sought it. Or, an individual may repeatedly receive involuntary inpatient treatment based

on a series of civil commitments, typifying a more chronic course that may be better

served through guardianship, but no interested party seeks guardianship on behalf of the

individual. Convolutions such as these suggest that we need to know more about the

legal process and its correlates to the clinical picture for people with SMI.

To date, there are no empirical studies conducted in a clinical setting that compare

the characteristics of people with court-appointed guardians to those who do not have

guardians. A major factor contributing to the paucity of research in this area is the

substantial methodological problems associated with this kind of research. The impact of

legal mechanisms on SMI likely takes years to demonstrate full, measurable effects.

Likewise, then, it takes years to accumulate the needed data in order to be able to

understand this process.

Another important consideration of this type of research is the clinical context.

The psychiatric rehabilitation setting is an appropriate starting place for a study of this

19nature. Individuals in this setting have almost exclusively arrived there through civil

commitment or guardianship proceedings, making this the population most affected by

these processes. Also, because the rehabilitation setting targets multiple levels of

functioning, it is most likely to bring about change in the things associated with the need

for guardianship or civil commitment. For example, it targets aspects of neurocognitive

functioning associated with decision making, such as attention and executive functioning.

The archival database to be utilized in the proposed study is ideal for this type of

research. It affords the opportunity to study two populations under a similar set of

clinical circumstances. For the vast majority of people in the psychiatric rehabilitation

setting from whose data this database is constructed, treatment is typically viewed as

“involuntary.” That is, they have either been civilly committed (CC) by the state or a

guardian has made the decision regarding admission for treatment, likely without the full

support or consent of the person, resulting in a “Voluntary” per Guardian (VpG)

admission. Significantly, this data has been accumulated over the course of seven years,

allowing for a preliminary look at the therapeutic consequences of these legal

mechanisms and the longitudinal effects of psychiatric rehabilitation treatment for these

individuals. It must be reiterated that the proposed study is highly exploratory in nature

since there is no previous research on the clinical differences between those with and

without guardians. This is a critical first step in the analysis of the role of guardianship in

the treatment of SMI.

Present study.

The present study has two primary objectives:

201. To determine if there is a pattern of differential functioning for individuals with or

without guardians across various levels of functioning. In general, it is anticipated

that individuals with a guardian will demonstrate lower overall functioning than those

without guardians. For the most part, those in the “other” group consist of individuals

who have been civilly committed, but do not have a guardian. As described above,

these are individuals for whom the court maintains, at least in theory, that they are

presumed competent. For those with guardians, however, there has been a legal

finding of incompetence. Because of this, it is predicted that those individuals who

have a guardian will show demonstrably lower functioning in the clinical setting.

Therefore, it is hypothesized that the legal distinction will correlate with clinical

functioning. Specifically, the groups will differ in statistically significant ways across

all domains of functioning measured (neurocognitive, social cognitive,

symptomatology, behavioral functioning, and treatment compliance).

A. Upon Admission. It is predicted that at the time of admission, individuals with

guardians will demonstrate lower overall functioning than those without

guardians on neurocognitive, social cognitive, and behavioral functioning

measures. In addition, it is anticipated that those with guardians will have

lower levels of treatment compliance and higher levels of symptomatology.

B. Over the course of treatment. It is predicted that overall differences in

functioning, symptomatology, and treatment compliance will remain over the

course of treatment. It is hypothesized that as a result of rehabilitation there

will be an increase in neurocognitive functioning, insight into disorder,

internal locus of control, and behavioral functioning and a decrease in external

21locus of control, symptomatology, and treatment compliance for those with

and without guardians. That is, it is anticipated that both groups will show

improvement in functioning over the course of rehabilitation. However, while

the overall pattern of improvement will not differ between groups, it is

predicted that significant differences will remain between those with

guardians those without guardians in all areas with those individuals with

guardians demonstrating lower functioning, higher symptomatology, and

lower treatment compliance.

2. To determine if there is a pattern of differential outcome following discharge for

individuals with guardians from those without. While previous research does little to

inform hypotheses in this area, it is generally hypothesized that there will be

differences between groups in terms of treatment outcome. Specifically:

A. Discharge disposition. It is predicted that discharge disposition will differ

between the two groups in that individuals with guardians will be discharged

to a more restrictive setting. This hypothesis is based on the idea that the legal

status of the individual may influence treatment providers’ notions such that

there is an assumption that individuals with guardians require higher levels of

care and supervision.

B. Rehospitalization rate. It is predicted that there will be a greater rate of

rehospitalization for those without guardians than those with guardians. This

hypothesis is founded on the functional basis for guardianship. That is, if an

22individual has a guardian, the state has seen to it that this person is “protected”

whereas an individual without a guardian is not afforded this same protection.5

Based on the results of these analyses, exploratory analyses will be undertaken to

glean additional information about the role of guardianship in the psychiatric

rehabilitation of individuals with SMI.

5 Outpatient commitment may be a confounding variable in investigation of this project goal. It is important to note that outpatient commitment has been found to be successful in some cases, but not in others. Its utility is still being examined (Ridgely, Borum, & Petrila, 2001; Petrila, Ridgely, & Borum, 2003; Hiday, Swartz, Swanson, Borum, & Wagner, 2003).

23CHAPTER 3 - METHOD

Design Overview.

The primary purpose of this study was to assess the relationship of guardianship

to functioning before, during, and after treatment. The participants with guardians were

compared to those without guardians to determine if any differences existed. Univariate

and multivariate analyses were conducted within and between the two groups across with

respect to overall functioning using multiple measures described below. In addition,

within-group analyses of the participants with guardians were conducted.

Setting.

The Community Transition Program (CTP) is an inpatient unit at the Lincoln

Regional Center (LRC) a public state psychiatric hospital in Lincoln, Nebraska. This 40-

bed inpatient unit hosts a comprehensive psychiatric rehabilitation program for those

most disabled by mental illness in the State of Nebraska. Individuals are typically

discharged to a less restrictive setting after a 9 to 18 month period of intensive treatment.

Treatment engagement is fostered through the use of contingency management with a

backbone in social learning theory. The regimen includes pharmacotherapy,

psychoeducational groups and classes to target improved management of symptoms and

disorder, and training aimed at improving occupational, leisure, and social skills. The

treatment is designed to target multiple levels of functioning for individuals with SMI,

rather than only targeting an isolated area of dysregulation (e.g., symptoms). As such,

treatment does not focus on clinical diagnosis. Rather, treatment plans are individualized

and based on making incremental gains in compromised areas of functioning and

capitalizing on areas of relative strength of the individual. Treatment plans are designed

24by a multidisciplinary treatment team including nurses, social workers, psychiatrists, and

psychologists. In addition, program participants are encouraged to be active members of

their own treatment team for the purpose of increased engagement in treatment. Hence,

the CTP refers to patients as “participants” instead of patients. Treatment and

Rehabilitation of Severe Mental Illness (Spaulding et al., 2003) outlines the theoretical

underpinnings and practical applications of this innovative, state-of-the-art treatment

technology.

The Lancaster County Community Mental Health Center (LCCMHC) also

contributed data to this study. Since a majority of participants from CTP are served by

LCCMHC upon discharge, data collected as part of ongoing program evaluation at

LCCMHC pertaining to outcome such as rehospitalization rate, discharge location, and

community functioning were obtained from LCCMHC records.

Participants.

Participants discharged from the CTP program from 1996 through December

2004 contribute data to the archival database utilized in this study. The CTP program

participants were not directly involved in any specific research procedure. Rather, the

database includes the ongoing clinical data collected as part of the routine assessment

process described further below at the CTP and additional data gathered thro ugh chart

review.

As a criterion for admission, participants of the CTP have a chronic, but stable

Axis I major mental disorder. This sample represents a severe and treatment refractory

subpopulation. These are individuals for whom other short-term treatments have proved

unsuccessful and who are now involved in an intensive long-term rehabilitation program.

25

Table 1Demographic and Clinical Characteristics of Participants (N=162)

Demographic and Clinical Variables N Mean (SD) or Percentage

Age (range: 19 to 66) 162 40.45 (11.83)Education, # of years in school (range: 7 to 19 years) 158 12.47 (2.14)Length of stay at CTP in days (range:145-2745 days) 162 659.54 (373.99)Age at first hospitalization (range: 46 to 50) 158 21.04 (8.28)Number of hospitalizations in lifetime (range: 1 to 15) 156 9.09 (4.44)Gender (n=162) Male 87 53.7% Female 75 46.3%Race/Ethnicity (n=162) Caucasian 144 88.9% African American 11 6.8% Hispanic 2 1.2% Native American - - Asian American 2 1.2% Other 3 1.9%Marital Status (n=162) Single 104 64.2% Married 8 4.9% Divorced 43 26.5% Widowed 3 1.9% Separated 4 2.5%Legal Status (n=162) Civil commitment (CC) 118 72.8% Voluntary per guardian (VpG) 35 21.6% Not responsible by reason of insanity (NRRI) 5 3.1% Voluntary (V) 4 2.5%Primary Axis I Diagnosis (n=162) Schizophrenia, Paranoid Type 55 34.0% Schizophrenia, Chronic/Undifferentiated Type 49 30.2% Schizoaffective 37 22.8% Bipolar 8 4.9% Psychotic Disorder NOS 1 .6% Pervasive Developmental Disorder 1 .6% Impulse Control Disorder 1 .6% Other 10 6.2%Axis II Diagnoses (n=156) None 79 50.6% Borderline 10 6.4% Paranoid 12 7.7% Antisocial 6 3.8% NOS 31 19.9% Other 18 11.5%

6 In Nebraska, psychiatric diagnosis can function to disqualify an individual for developmental disability services, so the average age of onset (or age of first psychiatric hospitalization) is sometimes unusually low.

26Diagnoses largely consist of schizophrenia spectrum disorders (87%). In

addition, 25.3% have comorbid substance abuse (22.8%) or dependence (2.5%)

diagnoses. Table 1 summarizes the major demographic and clinical characteristics of the

participants.

Initially, the archival database included 177 participants. However, 12 of these

admissions were “return participants,” meaning they had previously completed treatment

at CTP. Because available outcome data in the database pertains to the most recent

admission to CTP, all previous admissions before the most recent one were excluded

from analyses to maximize the number of valid cases available for analyses. After

excluding participants with multiple admissions, 165 participants remained. Three of the

165 participants stayed less than two months in the CTP program and were therefore

excluded from analyses since treatment effects could not be evaluated as there was not

adequate time to participate in the CTP rehabilitation program. The resulting sample size

for use in this study was 162.

CTP participants are ideally suited for this study because a vast majority are either

civilly committed or admitted by a legal guardian. In either case, treatment is typically

viewed as involuntary in that most do not decide for themselves to enter the program.

For every individual who is admitted to the CTP program with a VpG legal status, three

are admitted via CC. In addition, as described further below, many of the people who are

civilly committed also have a guardian. This study examines guardianship in particular.

It is estimated that one third to one half of CTP participants are affected by guardianship.

Measures.

Demographic and Clinical Characteristics.

27Through chart review at CTP, information regarding the demographic and clinical

characteristics of participants was included in the archival database. These variables

included gender, age, number of years in school, race/ethnicity, marital status, legal

status, number of previous hospitalizations in the participant’s lifetime, age of first

hospitalization, Axis I and Axis II psychiatric diagnoses, length of stay at CTP, and other

relevant variables.

Neurocognition Measures.

1) Repeatable Battery for the Assessment of Neuropsychological Status (RBANS;

Randolph, 1997). The RBANS is a brief neurocognitive screening test (approximately 25

minutes) ideal for individuals who may lack attentional capacity for longer assessments.

There are two forms of the RBANS (Form A and Form B), which intend to minimize the

practice effects of repeated administrations. There are twelve subtests on the RBANS

which are grouped into five neurocognitive domains. The RBANS yields five domain

scores including immediate memory, delayed memory, attention, language, and

visuospatial/constructional functioning. In addition, a total index score represents overall

cognitive functioning. The convergent validity of the RBANS with other

neuropsychological constructs, like memory and intelligence, has been established in

people diagnosed with schizophrenia (Gold, Queern, Iannone, & Buchanan, 1999;

Hobart, Goldberg, Bartko, & Gold, 1999). In addition, sensitivity to patterns of cognitive

impairment in SMI and general reliability and validity have been evaluated (Gold et al.,

1999; Hobart et al., 1999). The RBANS total score is the primary measure of interest in

this study.

282) COGLAB (Spaulding, Garbin, & Dras, 1989). COGLAB was created as a

computerized test battery comprised of tests common in the psychopathology literature.

Currently, CTP standard assessment includes two of the tests from the battery, focusing

on attention and executive functioning - the Span of Apprehension (SPAN) task and the

Card Sorting Task (CST; an adaptation of the Wisconsin Card Sorting Task). SPAN hits

and false alarms provide a measure of attention and CST perseverative and random errors

serve as a measure of executive functioning. Good discriminant validity was

demonstrated between individuals diagnosed with schizophrenia and controls in an early

study of the COGLAB (Spaulding et al., 1989). The results from large multivariate

studies conducted with normal and patient populations indicate overall acceptable

psychometric properties of the COGLAB (Spaulding, Hargrove, Crinean, & Martin,

1981; Spaulding et al., 1989).

3) Rey Auditory Verbal Learning Test (RAVLT; Schmidt, 1996). The RAVLT ,

is a seven trial list-learning task with alternative forms consisting of 15 words presented

in an auditory format. Participants are instructed to recall as many words as they can

from the list immediately following each of five trials. A distractor trial is then presented

consisting of a different list of 15 words and participants are required to recall as many

words from this distractor list. Finally, participants are required to recall as many words

as possible from the original list without it being presented again. In general, the

RAVLT provides a measure of verbal memory. The number of words remembered after

the fifth trial is the most commonly used RAVLT score. Good discriminant validity

between memory impaired vs. memory intact patients and normal vs. neurological

patients has been demonstrated, as well as adequate test-retest validity (Schmidt, 1996).

294) Rey-Osterrieth Complex Figure Test (RCFT; Rey, 1941): This is a test of

visuoconstructional ability and nonverbal memory. It is comprised of four tasks: a copy

trial, immediate recall trial, delayed recall trial, and a recognition task. Figures are scored

using the 18-point scoring system, originally developed by Osterrieth (1944), and

outlined in Meyers & Meyers (1995).

5) The Trailmaking Test (A&B) (Army Individual Battery, 1944). This two part

test assesses attention, visual scanning, and information processing. In Part A,

individuals connect circles numbered 1 through 25 by drawing a line sequentially from

beginning to end as quickly as they can. In Part B, individuals complete a similar task

alternating between numbers and letters. Performance is measured by subtracting the

number of errors from the total possible score, resulting in two scores, one for each trial.

Social Cognition Measures

1) Inventory for the Measurement of Self-Efficacy and Externality (I-SEE;

Krampen, 1991). The I-SEE provides a measure of global attributional style, or locus of

control. It is comprised of 32 items which are each rated on a six point Likert scale

ranging from strongly disagree to strongly agree. The measure consists of four primary

scales: “internality” (i.e., “whether I have an accident is based on my own behavior”);

“self-concept of one’s own competence” (i.e. “I can do many things to protect my self-

interest”); “powerful others’ control beliefs” (i.e., “other people often prevent my plans

from becoming reality”); and “chance control beliefs” (i.e., “whether I fall ill is a matter

of chance”). These scales are combined to yield two composite scales a general external

scale (“externality”) and a general internal scale (“self-concept of one’s own efficacy”)

30which represents participant’s beliefs about their self-efficacy. Krampen (1991)

established reliability for the two composite scales.

2) Insight Scale (IS; Birchwood, Smith, Drury, Healy, Macmillan, & Slade,

1994). This brief self-report measure (8 items) allows participants to choose one of three

responses: agree, disagree or unsure, for each item. It yields a total score and three

subscale scores representing David’s (1990) three domains of insight. The three

subscales, therefore, are: “need for treatment” (i.e., “I do not need medication”), “ability

to relabel psychotic experiences” (“some of my symptoms were made by my mind”), and

“awareness of illness” (“I am mentally well”). This measure of insight focuses on insight

into functional impairment rather than specific illness categorizations. Internal

consistency and test-retest reliability were demonstrated by Birchwood et al. (1994).

Behavioral Functioning Measures.

1) Nurse Observation Scale for Inpatient Evaluation (NOSIE-30; Honigfeld,

Roderic, & Klett, 1966). This measure is a 30-item behavioral checklist format completed

by nursing staff at CTP has responses from zero (never) to four (always). Two psychiatric

technicians complete the checklist weekly for each participant. Items cover six areas of

ward functioning: social competence (“refuses to do ordinary things expected of him or

her”), social interest (“tries to be friendly with others”), neatness (“keeps clothes neat”),

irritability (“gets angry or easily annoyed”), psychoticism (“talks, mutters, or mumbles to

self”), and motor retardation (“is slow-moving or sluggish”). When summed, these six

areas represent a total assets score. Adaptive functioning scales (i.e., social interest) are

positively weighted and maladaptive scales (i.e., irritability) are negatively weighted

when determining the total assets score. This measure has been widely used as part of the

31psychiatric rehabilitation treatment and is a routine assessment in the treatment program.

Analyses within the CTP population have yielded Pearson correlations between 0.68 and

0.72 for all scales (Penn, Mueser, Spaulding, Hope, & Reed, 1995; Spaulding et al.,

1999b). Also, a recent reliability update of this measure confirms it remains reliable in

modern treatment settings, with inter-rater reliability on the total assets score at 0.76, on

maladaptive scales at 0.68, and adaptive scales at 0.75 (Lyall, Hawley, & Scott, 2004).

Symptomatology Measures.

1) The Brief Psychiatric Rating Scale – Extended Versions (BPRS-E;

Lukoff, Nuechterlein, & Ventura, 1986; Van der Does, Linszen, Dingemans, Nugter, &

Scholte, 1993). To evaluate symptoms, the BPRS-E is used routinely at CTP. In general,

the BPRS-E is widely used to assess changes in psychiatric symptoms. Using a Likert

scale from 1 (symptom is not present) to 7 (symptom is very severe), clinicians rate

individuals based on interview content and general behavior on 24 items. The BPRS-E is

a widely used instrument and reliability and validity have been demonstrated across

several studies (Bailley, Lachar, Rhoades, Diefenbach, Espadas, & Varner, 2004).

Reliability analyses in one study yielded Cronbach’s alpha of 0.76 (Perlick, Rosenheck,

Clarkin, Sirey, & Raue, 1999). Factor analyses on the former 18-item version and the

newer 24-item version have yielded four, five, and six factor solutions of symptom items

(e.g., Guy, 1976, Spaulding, Reed, Sullivan, Richardson, & Weiler, 1999a; Panos, 2004;

Perlick, et al., 1999; Burger et al., 1997). The six-factor solution validated by Spaulding,

Fleming, Reed, Sullivan, Storzbach, & Lam (1999a) was used in this study because the

original validation took place with the same population. A standard principal component

analysis of the BPRS (Spaulding et al., 1999a) yielded six factors: Psychotic

32Disorganization, Hallucinations/Delusions, Paranoia, Emotional Blunting,

Agitation/Elation and Anxiety/Depression.

Treatment Compliance Measure.

1) Rehabilitation Noncompliance (RNC) As part of the rehabilitation program for

all CTP participants, data are kept on the extent to which they are participating actively in

the rehabilitation program. Instances of noncompliance may include not attending to

activities of daily living, refusing to attend groups and classes, not following program

rules, and the like. These data are often used in the context of the contingency

management programs which are incorporated into most CTP treatment plans. The CTP

program infrastructure includes a computerized system for collection of this behavioral

data based on the contingency management interventions. The data collection is subject

to monthly fidelity checks by trained graduate students to ensure behaviors are being

recorded accurately and contingencies are being implemented correctly. Rehabilitation

Noncompliance (RNC) data is collected on a weekly basis and, for the purposes of this

study, are measured as an average number of weekly instances of noncompliance during

the last three months of each six month period. The last three months were selected

because behavior management programs are established during the first month of

treatment and further refined during the first few months of treatment making initial RNC

data less reliable due to frequent changes in programs. Choosing six month period is

primarily due to the fact that it coincides with the assessments completed at CTP at six

month intervals.

Outcome Measures.

331) Rehospitalization rate. One of the most primary goals of psychiatric

rehabilitation is the prevention of future hospitalizations and the decrease of inpatient

hospital days and use of emergency services (Iyer, Rothmann, Vogler, & Spaulding,

2005; Cook, Pickett, Razzano, Fitzgibbon, Jonikas, & Cohler, 1996; Anthony, Cohen, &

Vitalo, 1978). The inclusion of data from LCCMHC is a critical part of analyzing

outcome from the CTP program since a majority of participants are served through

LCCMHC upon discharge from CTP. Recent program evaluation activity at the

LCCMHC has established a rehospitalization data tracking program and the data

available here was cross-checked with chart reviews at CTP and chart reviews and

interviews with staff at LCCMHC. While outcome is often calculated on the basis of

number of rehospitalizations or the amount of days in the hospital following discharge,

this method can potentially be confounding. Since the archival database in this study

includes people discharged from CTP back in 1996 all the way up to people discharged

from CTP in December 2004, people may range in the amount of time since discharge

from 150 days to 3,285 days. Therefore, the number of hospitalizations or hospital days

as a measure of outcome may be misleading because the amount of possible time in the

community varies. To control for this variability, the rehospitalization rate may be

operationalized in several different ways. For example, Paul and Menditto (1992)

recommend that rehospitalization rate will be derived based on the amount of continuous

community tenure during the first six months following discharge in order to control for

different amount of times since discharge. Setting an arbitrary timeframe such as Paul

and Menditto suggest of six months, nine months, or twelve months following discharge

is one way to address the potential time confound. This study also explores other ways of

34addressing this such as the percentage of hospital days out of all hospital and non-hospital

days since discharge and the survival rate (or how long before the first rehospitalization).

2) Discharge disposition. The restrictiveness and nature of the setting to which

individuals are discharged from the CTP will also serve as a measure of outcome. There

are at least 35 different discharge locations to which people go following CTP. Less

restrictiveness (e.g., independent living) is characteristic of better outcome. For the

purposes of this study, there were essentially four categories of discharge location from

most to least restrictive: 1) Regional Center transfer, 2) Psychiatric Residential

Rehabilitation, 3) Assisted Living, and 4) Independent living. These categories were

conceptualized based on interviews with the CTP program director and CTP social

workers who are primarily responsible for discharge planning and most familiar with

community services. The broadest of all these categories is Assisted Living because the

levels of care within the Assisted Living category in the state of Nebraska vary

considerably. These four categories do not encompass all discharges from CTP. For

example, the categories do not include nursing homes or developmentally disabled (DD)

group homes. Very few individuals are discharged to nursing homes, which would be

considered more restrictive than even psychiatric residential rehabilitation, but discharges

such as this from CTP are rare and typically due to the person’s medical rather than

psychiatric condition, so are not included here. Likewise, very few people are discharged

to DD settings because one of the exclusion criteria from admission to CTP is

developmental disability. However, following admission, a few people have qualified for

DD services. These discharges are not included in analyses since their discharge services

are conceptually different than a majority of participants at CTP.

35Procedure.

Data Collection.

An archival database was used in this study. Most of the archival data comes

from the CTP clinical archives, but additional data pertaining to outcome and community

functioning was collected from LCCMHC. Clinical data are routinely collected as part of

the CTP program and contribute significantly to the database. In addition, extensive

chart review at both CTP and LCCMHC added additional data regarding hospitalization

history and general clinical and demographic characteristics. Data from 162 participants

discharged from the CTP program between 1996 and December 2004 were used in

analyses.

CTP. All participants complete a comprehensive clinical assessment upon

admission to the CTP program and most of these assessments are repeated at six month

intervals throughout a person’s hospitalization in order to monitor treatment response and

inform future treatment planning decisions. Currently these assessments primarily

include measures of neurocognitive and social cognitive functioning. Clinical

psychology graduate students or trained clinical assistants administer and score all

measures according to standardized instructions. Scoring is assisted by several

computerized scoring programs. One significant change occurred in the routine

assessment battery during the nine year period from which the archival data was

extracted. The RBANS and social cognitive measures were added to the assessment

battery between 2000 and 2001 when new admissions arrived during that time. The

RAVLT was phased out at that time in order to maintain that the assessment battery

could be completed in a manageable amount of time. Therefore, individuals discharged

36before 2000 do not have RBANS and social cognitive data. Likewise, people who

entered the program at the time of the change do not have RAVLT data. Nevertheless,

assessments continued to be collected at six-month intervals and therefore biannual

neurocognitive and/or social cognitive data is available for most participants.

In addition, assessments of behavioral, social, and overall functioning are

regularly completed in the context of the general milieu. For example, psychiatric

technicians complete NOSIE assessments on a weekly basis. The monthly average of the

weekly ratings were included in the present database, making monthly NOSIE data

pertaining to each person’s ward functioning available. Most participants also have

behavioral management programs in place which monitor specific behaviors identified on

individualized treatment plans such as rehabilitation noncompliance (RNC), as described

above. These behaviors are monitored and tracked continuously in individualized

tracking forms. The RNC data and other behavioral management data are entered into

Excel spreadsheets as the number of instances of the target behavior each week. Data

entry and management is completed by a trained clinical psychology graduate student on

a monthly basis to be used in treatment progress meetings. At the time of extraction, the

data is subjected to fidelity checks to monitor if the behaviors are being correctly

recorded and contingencies implemented as intended.

For the present study, the first 18 months of rehabilitation were followed

resulting in the maximum number of possible data points for each person as four

neurocognitive and social cognitive measure time points, 18 monthly NOSIE total assets

scores, and 72 weeks of RNC data. The 18 month time period was selected because the

average length of stay at CTP is around 18 months which maximizes the amount of data

37available at any given time point. A majority of treatment in terms of psychoeducational

skills training is delivered within this time frame, as well. A qualitative analysis

completed as part of program evaluation of the CTP program in February 2005 indicated

that people with the most protracted lengths of stay were associated with legal status (i.e.,

court approval and availability of appropriate community placement for NRRI

participants), severe treatment-resistant aggression, and long waiting lists for specific

community placements (e.g., residential rehabilitation in Omaha, developmental

disability services).

The current format of the archival database does not lend itself to pre-post

analyses. Future studies may consider reformatting the archival database so as to have an

admission data point and a discharge data point (or the assessment closest to discharge)

as an approximation of pre- and post- rehabilitation functioning.

LCCMHC. Extensive chart review and interviews with LCCMHC staff were

completed by a dedicated clinical psychology graduate student involved in program

evaluation activity as part of an assistantship at LCCMHC. In addition, after collecting

hospitalization data, the data was cross-checked with LRC records through chart review

to ensure its accuracy. Not all CTP participants were served by LCCMHC upon

discharge and hospitalization data for those individuals was obtained through LRC

records whenever possible.

After the archival database was completed with data from both settings, two

graduate students completed additional quality assurance checks. Data was subjected to

cross-checking with original and computerized archival data to ensure its reliability and

accuracy.

38Data Cleaning.

Before analyses, data were examined for skewness and potential outliers. It was

necessary to ensure normal distribution of the dependent variables because most of the

analyses used in this study assume normality. Distributional skewing and asymmetrical

outliers can both produce skew and therefore transformation and/or outlier windsorizing

were applied only after examining the nature of the skew. Any dependent variables that

demonstrated a skewed distribution (skewness > +/- 1.00) without outliers were

normalized using conservative transformation procedures. All variables were able to be

brought within acceptable skewness range (<+/- 1.00) by using the most conservative

transformation procedure (i.e., square root). Using Tukey’s Hinges, the data were

systematically screened for outliers. All outliers were included after a windsorizing

procedure which replaces extreme values with the highest acceptable value (Hoaglin,

Mosteller & Tukey, 1983). A few variables required both square root transformation and

windsorizing of extreme outliers in order to normalize the distribution. Using the above

procedures, all variables were cleaned to within acceptable skewness range with the

exception of the rehospitalization data. The nature of this data prevented transformation

or windsorizing. Therefore, the rehospitalization data were analyzed disregarding skew.

However, follow-up analyses were conducted by creating categorical variables to further

corroborate the results.

Data Analysis.

This study is highly exploratory in nature, but, in general, aims to determine if

there are differences between those who have guardians and those who do not. Towards

this end, analysis of variance (ANOVA) and its variants are the primary analytic strategy

39involved. Whenever possible, multivariate analysis of variance (MANOVA) was utilized

in order to control Type I error and to take into account correlations between the many

dependent variables. Group was the between-subjects factor and each set of measures

served was the within-subjects factors. In some cases, discriminant analyses were used to

determine if guardianship status could be predicted from a given set of variables. In

addition, evaluating the relationships between categorical variables was accomplished

through Chi square analysis.

40CHAPTER 4 – RESULTS

The overall purpose of this study was to examine the role of guardianship in

treatment and outcome for people recovering from SMI. Two primary hypotheses were

put forth towards this overall aim. First, at the time of admission, it was predicted that

people with guardians (Guardian group) would demonstrate lower overall functioning

with regard to neurocognitive, social cognitive, and behavioral functioning and would

have lower levels of treatment compliance and higher levels of symptomatology than

those without guardians (No Guardian group). In addition, it was predicted that this

pattern would continue throughout the course of treatment such that the Guardian group

would continue to demonstrate lower overall functioning despite improvement in all

areas for both the Guardian and No Guardian groups. Second, a pattern of differential

outcome would be evident such that those in the Guardian group would be discharged to

more restrictive settings but have a lower rate of rehospitalization than those in the No

Guardian group. Each hypothesis is evaluated in turn below.

Before proceeding to evaluate the hypotheses, descriptive analyses of the

demographic and clinical characteristics of people with guardians at CTP are described.

Since previous studies have not evaluated guardianship, these analyses were exploratory

in nature.

Demographic and Clinical Characteristics of People with Guardians at CTP.

Of the 162 participants in this study, 76 (46.9%) were affected by guardianship.

That means the participant either had a guardian at the time of admission (n = 62) or

acquired one during the stay at CTP (n = 14), see Table 2. Of the 76 people with

guardians, 50% were male and 50% were female (n = 38 for both). This means that

4143.6% of men at CTP have guardians whereas 48.7% of women have guardians; this

difference is not significant, X2(1) = 0.88, p = .35. The guardian often is a family

member, but that is not always the case. In this sample, 61.3% had family members

serving as the guardian. Sometimes, however, an attorney, advocate, or other person

serves as guardian. It was slightly more likely for the guardian to be a family member if

the participant was admitted to CTP with a guardian (n = 39 out of 62, 62.9%) than if the

guardian was acquired during the stay at CTP (n = 7 out of 7, 50%), but this difference is

not significant, X2 (1) = 0.93, p = 0.34.

Table 2Guardianship Status of Participants (N=162)

Demographic Variables N PercentageGuardian at Time of Admission to CTP Program (n=162) Yes 62 38.3% No 100 62.3%Guardian Acquired During CTP Stay (n=100) Yes 14 14.0% No 86 86.0%Guardian is a Family Member (n=76) Yes 46 60.5% No 29 38.2% Unknown 1 1.4%

Many people who have guardians nevertheless arrive at CTP via CC rather than

as VpG admissions. Of the 78 people admitted via CC, 26 people (33.3%) had guardians

at the time of admission. That leaves 36 people out of the 62 people admitted with a

guardian who are admitted VpG (58.1%). An additional 14 people acquired guardians

during their CTP stay, bringing the percentage of people who have a guardian, but whose

legal status is “civilly committed” to over half, 51.3%.

42To further evaluate the relationship between guardianship and other demographic

and clinical characteristics, those who acquired guardians after CTP admission (n = 14)

were included with those that were admitted with a guardian (n = 62) for a total of 76

people in the “Guardian Group” and 86 people in the “No Guardian Group.” Since

everyone in the Guardian Group has been determined to be incompetent, whether before

admission or during their inpatient hospitalization at CTP, and in need of guardianship by

the court, it is appropriate to place them in the same group for the following analyses.

However, follow-up analyses will determine if there are in fact differences within the

category of guardianship, including whether the guardian was acquired after admission,

whether the legal status was VpG or CC, and whether the guardian was a family member.

Analyses using the Guardian vs. No Guardian distinction revealed a pattern of

relationships among several demographic variables. Despite the relative homogeneity of

diagnoses at CTP (i.e., the predominance of schizophrenia), there is a significant

relationship between diagnostic subtype and guardianship status, X2 (4) = 8.33, p = .04

(See Table 3). Those diagnosed with Schizophrenia, Chronic/Undifferentiated Type

appear more likely to have a guardian than those diagnosed with Schizophrenia, Paranoid

Type. There was no relationship identified between guardianship status and Axis II

diagnoses.

There was also a significant relationship between guardianship and race. When

those participants identified as African American, Hispanic, Asian American, or Other

were combined into one category, called “Non-White,” and compared to those identified

as Caucasian, or “White”, there is a significant relationship with guardianship, X2 (1) =

434.96, p = 0.03 (See Table 4). This suggests that people who are not White are less likely

to get a guardian than those who are White.

Table 3Relationship Between Axis I Diagnosis and Guardianship Status (N=162)

Guardianship Status

Axis I Diagnosis GuardianNo

Guardian Total

Schizophrenia, Paranoid Type 20 35 55

Schizophrenia, Chronic/Undifferentiated Type 31 18 49

Schizoaffective 15 22 37

Other7 10 11 21

Total 76 86 162

Table 4Relationship Between Race and Guardianship Status (N=162)

Guardianship StatusRace Guardian No Guardian Total

White 72 72 144

Non-white 4 14 18

Total 76 86 162

Finally, guardianship status was evaluated with regard to age, length of stay at

CTP, age at first hospitalization, number of previous hospitalizations in lifetime, and

years of education. Because any difference in age between the groups would simply be a

result of the amount of time each person would have to acquire a guardian, age was

included as a covariate in subsequent analyses. Bivariate correlations for this and later

7 Other includes diagnoses such as, but not limited to, the following: Bipolar Disorder, Dementia, Psychotic Disorder NOS, Pervasive Developmental Disorder, Impulse Control Disorder, and Asperger’s.

44analyses are included in the Appendix (See Table A1). A 2 (guardianship status) x 4

(clinical and demographic characteristics) multivariate analyses of covariance

(MANCOVA) was conducted with age as the covariate to test for differences between the

Guardian and No Guardian groups. MANCOVA revealed a significant between-group

difference, F (4, 142) = 2.99, p = .02, η2 = .078 (See Table 5).

Table 5Guardianship Status by Demographic and Clinical Characteristics Multivariate Analysis

of Covariance (MANCOVA)

Univariate

Multi-variate

Length of Stay

Years of Education

Age First Time

HospitalizedPrevious

Hospitalizations

Variable F (4, 142) F (1, 145) F (1, 145) F (1, 145) F (1, 145)

Age (Covariate) 16.01** 2.36 13.72*** 38.24*** 2.05

Guardian 2.99* 9.77** 4.00* 1.61 <.001

*p<.05, **p<.01, ***p<.001

Follow-up analyses were conducted using ANCOVAs, still controlling for age,

which revealed a significant difference between groups in length of stay, F (2,159) =

10.95, p = .001, η2 = .064, and number of years of education, F (2,155) = 4.70, p = .03, η2

= .029. The difference in age at first hospitalization between those with guardians and

those without guardians approaches significance, F (2,155) = 3.43, p = .07, η2 = .022.

There was no significant difference between groups on the number of previous

hospitalizations, F (2,153) < .001, p = .995. The means and standard deviations for each

group, Guardian and No Guardian, for these variables are shown in Table 6.

Table 6

45Mean Scores and Standard Deviations for Demographic and Clinical Variables as a

Function of Guardianship Status and AgeGuardian No Guardian

M SD M SD

Length of Stay 770.68 373.20 564.14 356.18

Years of Education 12.19 1.98 12.66 2.35

Age First Hospitalized 20.27 7.85 20.47 7.54

Number of PreviousHospitalizations 9.19 4.51 8.99 4.46

The covariate, age, was examined separately using a one-way ANOVA which

revealed that those with guardians are older than those without guardians (Ms = 42.69,

38.48, respectively; F (1,160) = 5.25, p = .02, η2 = .032), as expected.

Discriminant analyses were used to determine whether guardianship status

(Guardian v. No Guardian) can be predicted with length of stay, age of onset, age at first

hospitalization, and number of previous hospitalizations. The discriminant function is

significant with a Wilk’s lambda of 0.92, (p =0.02). The canonical discriminant function

has an R2-canonical of 0.08, with 62.2% correct re-classification (92 out of 148). The

model is better at classifying people without guardians correctly (65 out of 80, 81.3%)

than those with guardians (27 out of 68, 39.7%). Table 7 shows the standardized

canonical coefficients and the structure weights, revealing that predominantly length of

stay, and to a lesser degree, level of education contributed to the multivariate effect.

These results are consistent with the MANCOVA analyses described above.

Exploratory analyses were conducted to determine any within-group differences

for those with guardians. A small group of people (n = 14) acquired guardians after

being admitted to CTP. This group is hereafter referred to as the “Guardian Acquired”

46group and the group who had guardians at the time of admission is referred to as the

“Guardian Admission” group. Because the Guardian Acquired group had very few

people, results of the following analyses can only be considered exploratory. When

comparing the Guardian Acquired group (n = 14) to the Guardian Admission group (n =

62), no significant differences emerged on any of the variables analyzed above, all Fs <

1.97, all ps >.16. These results suggest that the Guardian Acquired group does not differ

significantly from the Guardian Admission group, strengthening the argument for

combining these two groups into the overall Guardian group.

Table 7Standardized Canonical Coefficients and Structure Weights from Discriminant Analyses

of Demographic and Clinical Variables to Predict Guardianship StatusStandardized Coefficients Structure Weights

Length of Stay .937 .972

Years of Education -.249 -.369

Age First Hospitalized .106 -.043

Number of PreviousHospitalizations .029 .078

Furthermore, when comparing the Guardian Acquired group (n = 14) to the No

Guardian group (n = 86), two significant differences were found, congruent with those

described above between the Guardian and No Guardian groups. First, those who

acquired guardians have a significantly higher mean length of stay than those who never

had guardians [Ms = 892.13 and 564.76 days, respectively; F (1, 91) = 10.49, p = .002, η2

= .103]. Second, the Guardian Acquired group is significantly older than the No

Guardian group, [Ms = 46.12 and 38.48 years of age, respectively; F (1, 91) = 3.86, p

= .05, η2 = .041]. To further explore the nature of the Guardian Acquired subgroup within

47the Guardian group, a 2 (guardianship status) x 4 (clinical and demographic

characteristics) multivariate analyses of covariance (MANCOVA) was performed, with

age as the covariate. This was identical to the previous analysis, but excluded the

Guardian Acquired group from analysis. Therefore, the comparison was between the

Guardian Admission subgroup and the No Guardian group. Results showed that the

overall between-group difference is not statistically significant, F (2, 132) = 1.93, p =

0.11. Only when the small N Guardian Acquired group is added to the larger N Guardian

Admission group to form the overall Guardian group do the differences between those

with guardians and those without reach statistical significance in multivariate analyses.

Without the Guardian Acquired group, the univariate difference between the Guardian

Admission and No Guardian groups on length of stay remains significant, F (1, 133) =

7.551, p = 0.01, η2 = .054. The differences between years of education, age of onset, and

number of previous hospitalizations are nonsignificant, all Fs < 0.97, all ps >.33. These

results suggest that the Guardian Acquired group may contribute more than just statistical

power to the analyses identifying differences between the Guardian and No Guardian

groups. The merging of the Guardian Acquired and Guardian Admission groups for

subsequent analyses was warranted to offer greater power to the multivariate analyses,

however within-group differences were still explored.

When exploratory analyses were repeated to identify any differences between

people whose guardians are family members and those who are not, no significant

differences emerged, all Fs < 2.91, all ps > 0.09. Likewise, comparing people with

guardians whose legal status was CC to those with a VpG status, no significant

differences on demographic or clinical variables were found, all Fs < 3.01, all ps > 0.09.

48To summarize the results of the descriptive analyses, those with guardians were

found to have significantly longer lengths of stay and a slightly lower level of education.

A relationship between race and guardianship was identified indicating a greater

likelihood of having a guardian if participants were Caucasian. In addition, those

diagnosed with Schizophrenia, Chronic or Undifferentiated Type had a greater likelihood

of having a guardian than those with diagnosed with Schizophrenia, Paranoid Type. The

Guardian group was relatively homogenous on demographic and clinical variables with

regard to whether the guardian was acquired before or after admission, whether the

guardian was a family member and whether the person was admitted VpG or CC.

Hypothesis 1

The first hypothesis of this study was to determine if there is a pattern of

differential functioning between people with guardians and those without across several

levels of functioning. Specifically, it was predicted that at the time of admission, people

with guardians would demonstrate lower neurocognitive functioning, less insight, less

treatment compliance, poorer behavioral functioning, lower assessment of self-efficacy,

higher external locus of control, and higher levels of symptomatology when compared to

those without guardians. Similarly, it was predicted that this overall pattern of

differences in neurocognitive, social cognitive, and behavioral functioning as well as

symptomatology and treatment compliance would remain the same over the course of

treatment with those with guardians demonstrating lower functioning than those without

guardians across all measures. It was, however, anticipated that improvements on all

variables would be evident over the course of treatment for both groups.

Functioning at admission.

49Neurocognitive functioning.

The RBANS, RCFT, RAVLT, COGLAB Asarnow task, COGLAB Card Sort,

Trails A& B, and WRAT were included in analyses as measures of neurocognitive

functioning. Bivariate correlations for the neurocognitive variables included in analyses

are included in the Appendix, see Table A2. All correlations are in the expected

direction. It was hypothesized that people with guardians would demonstrate lower

overall neurocognitive functioning than those without guardians.

Table 8Guardianship Status by Neurocognitive Variables (Group 1) at Admission Between

Group Multivariate and Univariate Statistics

Multivariate F (6, 12) = .403, p=.863 Univariate

Neurocognitive Variables M(SD) F df pRAVLT Guardian No Guardian

8.14 (2.93)8.60 (2.07)

.10 1, 17 .75

COGLAB Asarnow Hits Guardian No Guardian

24.61 (4.26)25.29 (3.93)

1.67 1, 17 .21

COGLAB Asarnow False Alarms Guardian No Guardian

5.14 (1.92)3.54 (1.57)

.30 1, 17 .59

COGLAB Card Sort Random Errors Guardian No Guardian

27.79 (20.21)28.20 (24.63)

.001 1, 17 .97

COGLAB Card Sort Perseverative Errors Guardian No Guardian

20.79 (11.76)23.00 (9.46)

.14 1, 17 .71

WRAT Guardian No Guardian

59.14 (9.10)64.80 (19.54)

.77 1, 17 .39

To assess this hypothesis, neurocognitive variables were entered into MANOVA

with guardianship status as the between subjects variable. Because the RBANS, Trails,

and RCFT were added to the routine assessment battery after phasing out the RAVLT,

50two MANOVAs were done to accommodate the time period for both sets of measures

and maximize the number of valid cases. The first MANOVA included the RAVLT,

COGLAB Asarnow (hits and false alarms) and Card Sort (perseverative and random

errors), and the WRAT. The 2 (guardianship status) x 6 (neurocognitive measures)

MANOVA revealed no significant between group differences (See Table 8).

The second MANOVA included the RBANS, RCFT, COGLAB Asarnow and

Card Sort, Trails A & B, and the WRAT. This 2 (guardianship status) X 12

(neurocognitive measures) MANOVA revealed no significant between group differences

(See Table 9).

Despite not having any significant MANOVA results, univariate ANOVAs were

conducted to maximize the power available to detect any differences in the

neurocognitive variables because an extremely low number of valid cases in the

MANOVA analyses may have prevented any significant differences from being detected.

However, these follow-up one-way ANOVA analyses revealed a significant difference on

only one of the neurocognitive variables between guardianship groups, Fs < 2.19, ps >

0.14, (See Table 10). The one exception was on COGLAB Asarnow false alarms. Those

with guardians have a significantly higher number of false alarms than those without

guardians, F (1, 92) = 3.82, p = 0.05, η2 = .040. However, this isolated finding does little

to support the hypothesis, especially considering the number of analyses conducted.

Table 9Guardianship Status by Neurocognitive Variables (Group 2) at Admission Between

Group Multivariate and Univariate Statistics

Multivariate F (6, 12) = .403, p=.863 Univariate

51

Neurocognitive Variables M (SD) F df pRBANS Total Guardian No Guardian

78.00 (23.07)73.25 (15.59)

.16 1, 9 .70

COGLAB Asarnow Hits Guardian No Guardian

26.00 (2.65)25.88 (2.47)

.01 1, 9 .94

COGLAB Asarnow False Alarms Guardian No Guardian

4.49 (3.36)2.04 (.67)

2.12 1, 9 .18

COGLAB Card Sort Random Errors Guardian No Guardian

18.00 (14.42)17.00 (13.56)

.01 1, 9 .92

COGLAB Card Sort Perseverative Errors Guardian No Guardian

14.33 (9.50)18.75 (14.69)

.23 1, 9 .65

RCFT Copy Guardian No Guardian

29.33 (6.43)32.75 (4.13)

1.13 1, 9 .32

RCFT Immediate Memory Guardian No Guardian

11.55 (1.41)14.12 (1.21)

.22 1, 9 .65

RCFT Delayed Memory Guardian No Guardian

9.56 (1.41)13.71 (1.34)

.60 1, 9 .46

RCFT Recognition Guardian No Guardian

17.33 (4.16)19.88 (1.73)

2.28 1, 9 .17

Trails A Guardian No Guardian

28.58 (16.17)40.76 (19.83)

.89 1, 9 .37

Trails B Guardian No Guardian

80.58 (54.96)84.50 (29.65)

.03 1, 9 .88

WRAT Guardian No Guardian

67.67 (32.65)61.25 (14.92)

.219 1, 9 .65

52Table 10

Guardianship Status by Neurocognitive Variables at Admission One-Way Analyses of Variance (ANOVAs)

Neurocognitive Measures M(SD) F df pRBANS Total Guardian No Guardian

72.81 (16.95)75.38 (13.66)

.41 1, 56 .53

COGLAB Asarnow Hits Guardian No Guardian

24.39 (3.85)25.50 (3.46)

2.19 1, 92 .14

COGLAB Asarnow False Alarms Guardian No Guardian

4.26 (1.52)2.63 (.93)

3.82 1, 92 .05

COGLAB Card Sort Random Errors Guardian No Guardian

21.85 (14.77)24.69 (18.21)

.71 1, 96 .40

COGLAB Card Sort Perseverative Errors Guardian No Guardian

21.61 (13.30)23.12 (14.32)

.31 1, 96 .58

RCFT Copy Guardian No Guardian

28.68 (5.58)31.26 (5.81)

1.71 1, 33 .20

RCFT Immediate Memory Guardian No Guardian

15.23 (1.79)12.49 (1.56)

.69 1, 33 .41

RCFT Delayed Memory Guardian No Guardian

14.02 (1.82)13.29 (1.87)

.05 1, 33 .83

RCFT Recognition Guardian No Guardian

21.07 (6.13)18.50 (5.25)

1.76 1, 33 .19

Trails A Guardian No Guardian

43.38 (16.50)38.05 (15.86)

1.75 1, 63 .19

Trails B Guardian No Guardian

98.18 (28.45)87.45 (33.20)

1.84 1, 60 .18

WRAT Guardian No Guardian

61.21 (14.10)65.38 (11.52)

2.23 1, 83 .14

RAVLT Guardian No Guardian

8.80 (3.52)9.53 (3.52)

.81 1,74 .37

53In addition, examination of the means between these two groups reveals that some

differences on neurocognitive variables, though not statistically significant, are

counterintuitive. That is, contrary to hypothesis, on certain measures those without

guardians demonstrated poorer neurocognitive functioning than those with guardians.

For example, as expected, people with guardians have fewer hits and more false alarms

on the COGLAB Asarnow task, take longer on Trails A and B, and have lower RBANS

total, RCFT copy, RAVLT, and WRAT scores than those without guardians. On the

other hand, contrary to hypothesis, those with guardians have fewer perseverative and

random errors on the COGLAB and higher scores on the RCFT immediate memory,

delayed memory, and recognition tests. Therefore, there is no clear pattern indicating

lower neurocognitive functioning for those with guardians.

Exploratory analyses within the guardianship group based on whether the

guardian was acquired before or after admission, whether the guardian was a family

member, and whether the person with a guardian was admitted CC or VpG using one-

way ANOVAs revealed only two marginally significant differences. On the WRAT,

those who acquired guardians (n = 9) had a lower score than those who had guardians at

admission (n = 34), Ms = 53.44, 63.27, respectively, F (1, 41) = 3.67, p = .06, η2 = .082.

Also on the WRAT, those whose guardians were family members (n = 29) had lower

score than those whose guardians were not family members (n = 14), Ms = 58.72, 66.36,

respectively, F (1, 41) = 2.89, p = .097 η2 = .066. There were no differences on any of the

other neurocognitive variables on any of the three within-group dimensions, all Fs <

2.38, all ps >.14.

54Overall, contrary to hypothesis, these results suggest that participants with

guardians do not significantly differ from those without guardians at the time of

admission, with respect to neurocognitive functioning. However, given the one

significant finding supporting the hypothesis, differences in neurocognitive functioning

will be assessed to determine if the difference on COGLAB false alarms remains stable

over time. In addition, there do not appear to be substantial within-group differences in

neurocognitive functioning for the Guardian group.

Social cognitive functioning.

The I-SEE, a measure of attributional style, and the Insight Scale, a measure of

insight into functional impairment and need for treatment, were used to examine social

cognitive differences between the two groups. It was hypothesized that people with

guardians would demonstrate lower insight than those without guardians. In addition, a

lower assessment of self-efficacy and greater external locus of control as measured by the

attributional measure was expected for those with guardians than those without

guardians. The bivariate correlation matrix for the social cognitive measures and their

subscales can be found in the Appendix, see Table A3. One relationship to note was a

significant negative correlation between total insight and self-efficacy. This is somewhat

counterintuitive in that the relationship suggests that participants with lower insight have

a greater assessment of their self-efficacy. Because this study predicted higher levels of

insight and higher self-efficacy for those without guardians, the negative correlation

between these two scales makes it difficult to support that hypothesis.

55To assess the relationship between social cognitive functioning and guardianship

status, the composite scales of the I-SEE, self-efficacy and externality, and the total

insight score were entered as within subjects factors into a MANOVA with guardianship

status as the between groups factor. The 2 (guardianship status) x 3 (measure)

MANOVA revealed no significant differences for any of the social cognitive variables

between guardianship groups (See Table 11). This suggests that, contrary to hypothesis,

participants in this sample with guardians do not differ with regard to social cognitive

functioning than those without guardians.

Table 11Guardianship Status by Social Cognitive Variables at Admission Between Group

Multivariate and Univariate Statistics

Multivariate F (3,42) = .145, p=.93 Univariate

Social Cognitive Measures M(SD) F df pI-SEE Self-Efficacy Guardian No Guardian

69.06 (8.52)67.88 (8.03)

.23 1, 43 .75

I-SEE Externality Guardian No Guardian

48.00 (10.66)49.32 (13.69)

.13 1, 43 .21

Insight Total Score Guardian No Guardian

7.93 (3.95)7.64 (3.89)

.06 1, 43 .59

Exploratory analyses using one-way ANOVAS revealed no significant differences

within the guardianship group based on whether the guardian was acquired before or after

admission or whether the guardian was a family member, all Fs < 3.17, all ps > .09. On

the I-SEE externality composite scale, those admitted VpG (n = 13) had a higher score

(M = 56.46) than those admitted via CC (n = 9, M = 44.44), F (1, 20) = 5.14, p = .04, η2

56= .204. There were no other significant differences on social cognitive variables for those

admitted VpG versus those admitted via CC, all Fs < 1.80, all ps > .20.

Behavioral functioning.

The NOSIE total assets score was used as a measure of general behavioral

functioning. It was expected that those in the Guardian group would demonstrate poorer

behavioral functioning than those in the No Guardian group. As hypothesized, a one-way

ANOVA revealed a significant difference, F (1, 148) = 7.92, p = .006, η2 = .051, on total

assets between those with guardians (M = 149.94) and those without guardians (M =

160.18) indicating lower behavioral functioning at admission for those participants with

guardians.

Because the NOSIE is comprised of three adaptive functioning scales and three

maladaptive functioning scales, further exploratory analyses were conducted to determine

if differences were apparent across all areas of functioning assessed by the NOSIE or

whether the differences were specific to particular subscales. Pearson product moment

correlations revealed significant intercorrelations among all subscales and the total assets

score, except for the relationship between the irritability and social interest subscales. The

bivariate correlation matrix can be found in the Appendix, see Table A4.

Follow-up analyses revealed significant differences between those with guardians

and those without on the social competence, neatness, and motor retardation subscales

(See Table 12). The difference between the two groups on psychoticism approached

significance. All differences were in the expected direction with lower levels of social

competence and neatness and higher levels of psychoticism and motor retardation for

those with guardians than without guardians.

57Table 12

Guardianship Status by NOSIE Subscales at Admission One-Way Analyses of Variance (ANOVAs)

NOSIE Subscales M F Df p η2

Social Competence Guardian 31.71 14.20 1, 148 .0002 .088 No Guardian 34.88Social Interest Guardian 15.21 .46 1, 148 .50 .003 No Guardian 15.92Neatness Guardian 22.09 10.06 1, 148 .002 .064 No Guardian 24.75Irritability Guardian 5.19 1.68 1, 148 .20 .011 No Guardian 4.73Psychoticism Guardian 1.51 3.46 1, 148 .07 .023 No Guardian 1.05Motor Retardation Guardian 7.25 14.02 1, 148 .0003 .087 No Guardian 5.11

Discriminant analyses were used to determine if guardianship status (Guardian v.

No Guardian) could be predicted with the NOSIE social competence, neatness, motor

retardation, and psychoticism subscales. The discriminant function is significant with a

Wilk’s lambda of 0.90 (p = .004), an R2-canonical of 0.099, and 61.3% correct re-

classification (92 out of 150). The model correctly classifies 78.8% of those without

guardians (63 out of 80), but less that half, or 41.4%, of those with guardians (29 out of

70). Table 13 shows the standardized canonical coefficients and the structure weights.

Although the structure matrix identifies all four variables as contributing to the

multivariate effect, the standardized canonical coefficients reveal that neatness and

psychoticism have little unique contribution to the model. This indicates that the most

58efficient model for discriminating between the Guardian and No Guardian groups include

unique contributions from the NOSIE subscales of social competence and motor

retardation. These results are consistent with the ANOVA analyses described above.

Table 13Standardized Canonical Coefficients and Structure Weights from Discriminant Analyses

of NOSIE Subscales to Predict Guardianship StatusNOSIE Subscales Standardized Coefficients Structure Weights

Social Competence -.353 .926

Neatness -.138 -.896

Psychoticism .090 -.785

Motor Retardation .578 .440

Results of NOSIE analyses support the hypothesis that those with guardians

demonstrate poorer behavioral functioning upon admission than those without guardians.

Specifically, those without guardians were better at adhering to a daily schedule (the

social competence subscale) and keeping themselves and their living space neat (the

neatness subscale) than those without guardians. In addition, people with guardians

showed higher levels of lethargy and amotivational syndrome (the motor retardation

subscale) than those without guardians.

When exploratory analyses were repeated to identify differences on the NOSIE

total assets within the Guardian group, no significant differences emerged between the

Guardian Admission and Guardian Acquired groups, F (1, 68) = 0.84, p = .36. There is

also no difference on the NOSIE total assets score between people whose guardians are

family members and those who are not, F (1, 67) = 0.67, p = 0.42. Likewise, comparing

59people with guardians whose legal status was CC to those with a VpG status, there is no

significant difference, F (1, 67) = 0.03, p = .85.

Treatment compliance.

Only participants for whom compliance is thought to be problematic by the

treatment team have a RNC behavior management program as a component of his or her

treatment plan. Therefore, not all participants have RNC data available. Simply having

RNC data may be considered an indicator of compliance in the CTP program. For this

analysis, there were six people with missing data for RNC. In addition, there were 66

people discharged from CTP before computerized data management of RNC data began.

Of the remaining 90 people in the sample, only four people did not have a RNC behavior

management program at any time during rehabilitation. One of these four people was a

Voluntary admission and did not have a guardian. The other three were all admitted via

CC and did not have guardians. Of the 86 people who had RNC data available at some

point during treatment, 46 had guardians and 40 did not, which indicates that compliance

is identified as a problem by CTP treatment teams for people with and without guardians.

People with guardians were expected to demonstrate lower levels of compliance

with treatment than those without guardians. The first time point of data available for

this analysis was the average number of weekly instances of noncompliance during the

second three months of the first six months in treatment. Contrary to hypothesis, there

are no significant differences between the Guardian (M = 2.45) and No Guardian (M =

2.07) groups, F (1, 74) = 0.41, p = .53. This suggests that guardianship status is not

related to treatment compliance.

60Within-group differences in the Guardian group were explored using one-way

ANOVAS. There is a nonsigificant trend between the Guardian Admission and Guardian

Acquired groups, F (1, 39) = 3.17, p = 0.08, with those who acquired guardians having a

higher number of instances of noncompliance (M = 4.36) than those who had guardians at

admission (M = 2.12). However, for this analysis, there were only seven people in the

Guardian Acquired group compared to 34 people in the Guardian Admission group.

There is no significant mean difference on instances of weekly noncompliance between

people whose guardians are family members and those who are not, F (1, 38) = 0.01, p =

0.94. Likewise, comparing people with guardians whose legal status was CC to those

with a VpG status, there is no significant difference, F (1, 38) = 0.08, p =.78.

Symptomatology.

It was anticipated that people with guardians would have a higher level of

symptomatology than those without guardians. Contrary to hypothesis, a one-way

ANOVA revealed no significant mean difference, F (1, 27) = 0.94, p = .34, in overall

symptomatology as measured by the BPRS total score between those with guardians (M

= 45.58) and those without guardians (M = 42.71).

Six factor scores for the BPRS were computed in order to evaluate symptoms

groupings as opposed to the gross overall measure of symptomatology provided by the

total score. The six factors used were Psychotic Disorganization,

Hallucinations/Delusions, Paranoia, Emotional Blunting, Agitation/Elation and

Anxiety/Depression. The bivariate correlation matrix of the six factors and the total

BPRS score can be found in the Appendix, see Table A5. A 2 (guardianship status) X 6

(BPRS factor scores) MANOVA was used to assess whether differences existed between

61groups in symptom areas. There are no significant differences between groups for any of

the symptom factor scores, all Fs < 2.41, all ps >.13, see Table 14.

Table 14Guardianship Status by BPRS Factor Scores at Admission Between Group

MANOVA

Multivariate F (6, 22) = 1.23, p=.33 Univariate

BPRS Factor Scores M (SD) F df pPsychotic Disorganization Guardian No Guardian

6.42 (1.30)6.64 (2.35)

.09 1, 27 .77

Emotional Blunting Guardian No Guardian

5.37 (2.20)4.24 (1.72)

2.41 1, 27 .13

Paranoia Guardian No Guardian

7.77 (1.56)8.50 (2.56)

.78 1, 27 .39

Anxiety/Depression Guardian No Guardian

9.29 (2.19)8.03 (2.80)

1.70 1, 27 .20

Hallucinations/Delusions Guardian No Guardian

6.00 (3.16)5.26 (2.11)

.57 1, 27 .46

Agitation/Elation Guardian No Guardian

3.46 (1.42)3.35 (1.36)

.04 1, 27 .84

Finally, one-way ANOVAs for each of the 24 BPRS items were conducted to

determine if there were differences in any specific symptoms between the Guardian and

No Guardian groups. Only one significant difference emerged. People with guardians

were rated with a higher level of Motor Retardation, F (1,27) = 4.29, p = .05, η2 = .137,

than those without guardians. A marginally significant difference was found between the

groups on Uncooperativeness, F (1,27) = 3.10, p = .103, with those in the Guardian group

being rated at a higher level of Uncooperativeness than those in the No Guardian group.

Results of all the one-way ANOVAs can be found in Table 15.

62Table 15

Guardianship Status by BPRS Items One-Way Analyses of Variance (ANOVAs)

BPRS Items M (SD) F df pSomatic Concern Guardian

No Guardian2.42 (1.83)1.81 (1.32)

1.13 1, 28 .30

Anxiety GuardianNo Guardian

2.74 (1.41)2.17 (1.04)

1.70 1, 28 .20

Depression GuardianNo Guardian

2.63 (1.15)1.22 (1.26)

.79 1, 28 .38

Suicidality GuardianNo Guardian

1.33 (0.65)1.47 (1.06)

.16 1, 28 .69

Guilt GuardianNo Guardian

1.67 (0.89)2.08 (1.07)

1.24 1, 28 .28

Hostility GuardianNo Guardian

1.92 (1.17)2.33 (1.27)

.83 1, 28 .37

Elevated Mood GuardianNo Guardian

1.50(1.24)1.25 (0.65)

.52 1, 28 .48

Grandiosity GuardianNo Guardian

1.67 (1.37)1.53 (1.17)

.09 1, 28 .77

Suspiciousness GuardianNo Guardian

2.83 (1.47)2.53 (1.28)

.37 1, 28 .55

Hallucinations GuardianNo Guardian

1.58 (1.24)1.17 (0.42)

1.78 1, 28 .20

Unusual Thought Content GuardianNo Guardian

2.25 (1.80)2.26 (1.50)

.001 1,27 .98

Bizarre Behavior GuardianNo Guardian

1.42 (0.79)1.67 (1.03)

.51 1, 28 .48

Self-Neglect GuardianNo Guardian

2.17 (0.91)2.00 (0.82)

.27 1, 28 .61

Disorientation GuardianNo Guardian

1.58 (1.16)1.50 (0.85)

.05 1, 27 .83

Conceptual Disorganization GuardianNo Guardian

1.83 (1.12)1.47 (0.80)

1.05 1, 27 .32

Blunted Affect GuardianNo Guardian

2.96 (1.48)2.76 (1.35)

.13 1, 27 .72

Emotional Withdrawal GuardianNo Guardian

2.38 (1.67)2.47 (1.55)

.03 1, 27 .88

Motor Retardation GuardianNo Guardian

2.32 (1.20)1.59 (0.71)

4.29 1, 27 .05*

Tension GuardianNo Guardian

1.50 (0.91)1.29 (0.59)

.55 1, 27 .46

Uncooperativeness GuardianNo Guardian

1.33 (0.49)1.97 (1.18)

3.10 1, 27 .09

Excitement GuardianNo Guardian

1.58 (1.17)1.53 (1.13)

.02 1, 27 .90

Distractibility GuardianNo Guardian

1.46 (0.89)1.41 (0.87)

.02 1, 27 .89

Motor hyperactivity GuardianNo Guardian

1.25 (0.87)1.29 (0.59)

.03 1, 27 .87

Mannerisms and Posturing GuardianNo Guardian

1.25 (0.62)1.24 (0.75

.003 1, 27 .96

*p<.05

63Overall, results of analyses using the BPRS total, BPRS factor scores, and BPRS

items suggest that there is no significant relationship between guardianship status and

level of symptomatology. However, given the low power for multivariate analyses, the

isolated significant items of the BPRS were evaluated over the course of treatment to

determine if a stable pattern existed, as described in the next section.

Within-group analyses based on whether the guardian was acquired before or

after admission, whether or not the guardian was a family member, and whether the

person was admitted VpG or via CC were undermined by the small N for the various

groups. No group based on these distinctions had more than 10 people and one group

had as few as 2. Therefore, no within-group analyses were undertaken based on

symptomatology.

Functioning over the course of treatment.

Neurocognitive functioning.

As described above, it was anticipated that those with guardians would

demonstrate lower neurocognitive functioning than those without guardians over the

course of treatment. Four of the neurocognitive measures were collected throughout the

time period studied, COGLAB Asarnow task hits and false alarms and COGLAB Card

Sort perseverative and random errors. To maximize the number of valid cases, only these

four measures were used in the multivariate analyses. A 2 (guardianship status) x 4 (time)

repeated measure ANOVA was completed for each measure. As can be seen in Table 16,

there are significant main effects for time for all four variables indicating that

neurocognitive functioning overall improved with treatment. Contrary to hypothesis,

none of the main effects for guardianship status are significant, which indicates that

64individuals with guardians do not differ significantly from those without guardians on

neurocognitive functioning as measured by the COGLAB over time. The interaction

between time and guardianship status is also not significant. Follow-up analyses using

one-way ANOVAs confirmed there are no significant differences between the two groups

on any of the four COGLAB variables at six months, 12 months, or 18 months of

treatment, all Fs < 2.57, all ps > .11. Recall that there was a significant difference noted

between groups at admission on COGLAB false alarms; this isolated significant finding

did not remain stable over time.

Table 16Guardianship Status by COGLAB Repeated Measures ANOVAs

Measures

COGLAB Asarnow

Hits

COGLABAsarnow

False Alarms

WCST Perseverative Errors

WCST Random Errors

Variable F (3,31) F (3,31) F (3.32) F (3, 32)

Main Effect Time 376.60*** 4.27** 53.29*** 3.17*

Main Effect Guardianship Status 1.60 .311 .248 .135

Interaction Time * Guardianship Status .74 2.42 1.19 2.44

*p<.05, **p<.01, ***p<.001

Univariate analyses of the RBANS paralleled the above findings with the

COGLAB battery. Specifically, significant improvement on the total RBANS score for

all participants is evident from admission (M = 73.31) to six months of treatment (M =

76.79), t (51) = -2.28, p = .03, from six months of treatment (M = 73.45) to 12 months of

treatment (M = 80.00), t (39) = -4.05, p < .001, and from 12 months of treatment (M =

6577.73) to 18 months of treatment (M = 81.58), t (25) = -2.07, p = .05. However, no

differences at any time point are evident between Guardian and No Guardian groups on

the RBANS total score, all Fs < 0.41, all ps > .53.

Significant improvement over time on the RAVLT is not evident at any time point

for all participants, all ts < 0.90, all ps > .39. Congruent to the findings with the

COGLAB and RBANS, there are no significant differences between the two groups over

time, all Fs < 1.21, all ps > .31.

In summary, results of analyses on neurocognitive functioning at admission and

over the course of treatment suggest that improvements in neurocognitive functioning are

evident over the course of treatment for the entire sample, but that, contrary to

hypotheses, those with guardians do not significantly differ from those without guardians

with respect to neurocognitive functioning.

Social cognitive functioning.

It was anticipated that those with guardians would demonstrate lower insight,

lower assessment of self-efficacy, and higher external locus of control than those without

guardians throughout the course of treatment. MANOVA could not be used to evaluate

change over time in the social cognitive variables as they relate to guardianship status

because fewer data points were available since social cognitive measures were not added

to the routine assessment battery until 2000-01. Using paired sample t-tests with the

overall combined means of the two guardianship groups, change in social cognition with

treatment was tested. From admission to 6 months, there were no significant changes in

insight or attributional style, all ts < 1.15, all ps >.26. However, a significant increase in

the total insight score is evident from 6 months to 12, increasing from an average score of

667.07 to 8.43, t (35) = -2.81, p = .01. From admission to 12 months of treatment, the

increase in insight is marginally significant, t (27) = -1.80, p = .08. There were no

significant changes in attributional style as measured by the composite scales of

externality and self-efficacy on the I-SEE from 6 months to 12 months. However, as

expected, a significant decrease in externality from admit to 12 months was found, t (31)

= 2.27, p = .03. There were no significant changes in self-efficacy as measured by the I-

SEE found to occur with treatment.

One-way ANOVAs were used to determine if there are group differences in social

cognition based on guardianship status at 6 months and 12 months. There are no

significant differences for any of the social cognitive variables between guardianship

groups, all Fs <1.43, all ps >.30, congruent with results of analyses with social cognitive

variables at the time of admission.

This suggests that, contrary to hypothesis, participants with guardians do not

differ from those with guardians in social cognitive functioning. Specifically, there is no

difference in attributional style or in the overall level of insight between the two groups.

Behavioral functioning.

Poorer behavioral functioning over the course of treatment was hypothesized for

those with guardians as compared to those without guardians. A mixed model

MANOVA was used to assess whether differences noted between groups on the NOSIE

at admission persisted throughout treatment. The average monthly total assets scores

during the first, sixth, and twelfth months of treatment were included in analyses. As

hypothesized, the 2 (guardianship status) x 3 (time) repeated measures ANOVA revealed

a significant main effect for time on the NOSIE, F (2, 117) = 20.38, p < .001, η2 =.258,

67indicating that, overall, improvements in NOSIE occur with treatment. As hypothesized,

the between-subjects main effect for guardianship status is also significant, F (1, 118) =

4.11, p = .05, η2 =.034, indicating that differences in behavioral functioning found at

admission as measured by the NOSIE between those with guardians and those without

persist over the course of treatment. The interaction of NOSIE over time with

guardianship status was not significant, F (2, 117) = .23, p < .78. The means and

standard deviations for these analyses are found in Table 17.

Table 17Mean Scores and Standard Deviations for NOSIE Total Assets at Admission, 6 Months,

and 12 Months as a Function of Guardianship Status

NOSIE Total Assets Scores

At Admission Six Months Twelve Months

Guardianship Status M (SD) M (SD) M (SD)

Guardian 149.94 (23.16) 155.65 (23.51) 159.95 (20.21)

No Guardian 160.18 (21.39) 165.40 (23.55) 169.91 (18.45)

Follow up analyses using one-way ANOVAs revealed that differences between

the two groups were significant at six, F (1, 145) = 6.29, p = .01, η2 =.042, and 12

months, F (1, 123) = 8.18, p = .005, η2 =.062 and that they remained in the expected

direction with lower NOSIE total assets scores for those with guardians. It should be

noted that the 18th month time point was not included in the mixed model MANOVA

above because a lower N at that time point decreases the power available for the overall

analyses. In a follow-up one-way ANOVA, differences between the two groups were

found to remain significant at 18 months, F (1, 84) = 5.60, p = .02, η2 =.062, in the

68expected direction, with those in the Guardian group having lower NOSIE total assets

scores (M = 159.18) than those in the No Guardian group (M = 169.65). The NOSIE

total assets scores from admission to 18 months as a function of guardianship status are

displayed in Figure 1.

Figure 1NOSIE Total Assets Scores Over Time as a Function of Guardianship Group

145

150

155

160

165

170

175

Admission 6 Months 12 Months 18 MonthsTime of NOSIE Ratings

Tot

al A

sset

s Sc

ores Guardian

NoGuardian

Additional follow-up analyses using the NOSIE total assets score at the time of

admission as a covariate revealed that the difference between the Guardian and No

Guardian group at six months was not significant when controlling for functioning at

admission, F (2,142) = 0.62, p = .43, and only marginally significant at 12 months, F

(2,123) = 3.55, p = .06, η2 =.029.

Because of the pattern of results evident at admission on the six NOSIE subscales,

follow-up analyses were conducted to determine if the pattern of results remained the

same over the course of treatment. A 2 (guardianship status) x 2 (time: 6 months and 12

months) repeated measures ANOVA was completed for each of the 6 subscales. As can

be seen in Table 18, there were significant main effects for time on the social competence

69(η2 =.218), social interest (η2 =.304), neatness (η2 =.200), psychoticism (η2 =.036), and

motor retardation (η2 =.131), indicating significant change in all these areas over time.

Improvements were seen in social competence, social interest, and neatness while a

decrease in motor retardation is evident. The significant change over time on the

psychoticism subscale represents an increase in psychoticism as measured by the NOSIE.

There was not a significant main effect of time for irritability, indicating minimal change

over the course of treatment in irritability. Means and standard deviations between

groups can be seen in Table 19. Mirroring the pattern found at admission, significant

main effects of guardianship status are present for social competence (η2 =.069), neatness

(η2 =.076), and motor retardation (η2 =.063). Differences are in the same direction as

evident at admission, with those with guardians having lower levels of social competence

and neatness and higher levels of motor retardation than those without guardians. There

are no significant interaction effects for any of the analyses.

Table 18Guardianship Status by NOSIE Subscales Repeated Measures ANOVAs

NOSIE Subscales

Social Competence

Social Interest Neatness Irritability Psychoticism

Motor Retardation

VariableF (1, 121) F (1, 121) F (1, 121) F (1, 121) F (1, 121) F (1, 121)

Time 33.71*** 52.88*** 30.20*** .65 4.50* 18.26***

Guardianship Status 9.00** .06 9.92** .97 1.88 8.17**

Time * Guardianship Status

.89 .29 .32 .56 .71 1.39

**p<.01, ***p<.001

70Table 19

Means and Standard Deviations on NOSIE Subscales at Admission and 12 Months as a Function of Guardianship Status

Admission 12 Months

NOSIE Subscales M SD M SDSocial Competence Guardian No Guardian

31.0334.17

6.985.47

34.6736.79

5.354.53

Social Interest Guardian No Guardian

15.2715.17

6.086.13

19.2919.83

5.916.38

Neatness Guardian No Guardian

22.0324.31

5.744.62

23.9726.70

4.704.32

Irritabilitya

Guardian No Guardian

5.635.13

6.146.06

5.604.36

5.135.09

Psychoticismb

Guardian No Guardian

1.981.51

3.082.65

2.731.84

3.732.59

Motor Retardation Guardian No Guardian

7.655.51

4.523.50

5.584.34

3.973.34

a, b Note: Standard deviations for these variables are large and results should be interpreted cautiously.

These results suggest that there are significant differences in behavioral

functioning between those with guardians and those without guardians. These results

support the hypothesis that those with guardians have poorer behavioral functioning as

measured by the NOSIE than those without guardians. In addition, it appears that the

differences in specific areas of functioning remain stable over time, even over the course

of rehabilitation.

Finally, while exploratory analyses on the within-group characteristics were only

conducted with the admission data for other domains of functioning, analyses were

repeated for the NOSIE total assets score over time since consistent differences in the

overall Guardian versus No Guardian analyses were found. Analyses indicated that the

71pattern of results described above do not change with respect to within-group

characteristics of guardianship. When one-way ANOVAs were repeated to examine

differences in NOSIE total assets at six months, twelve months, and eighteen months of

treatment, no significant differences were found between the Guardian Acquired and

Guardian Admission groups, all Fs < 0.84, all ps > .48. In addition, there are no

significant differences between people whose guardians are family members and those

who are not on NOSIE total assets, all Fs < 0.34, all ps > .57. Likewise, comparing

people with guardians whose legal status was CC to those with a VpG status, no

significant differences were found, all Fs < 1.96, all ps > .17.

Treatment compliance.

As described above, an average number of weekly instances of noncompliance

was computed for the second three months of each six month time periods of treatment

(i.e. months 4, 5, & 6; months 10, 11, & 12, and months 16, 17, & 18). It was predicted

that those with guardians would demonstrate less compliance with treatment than those

without guardians. Consistent with analyses at admission, a one-way ANOVA revealed

no significant differences on RNC between those with guardians and those without

during the second six months of treatment, F (1, 66) = 0.24, p = .63, or the third six

months of treatment, F (1, 42) = 1.58, p = .22.

As expected, there was a significant decrease in weekly instances of

noncompliance for all participants from the first six months (M = 2.55) to the second six

months (M = 2.04) of treatment, t (61) = 2.15, p = 0.04, indicating an increase in

compliance with the demands of the rehabilitation program. The difference from twelve

months (M = 2.26) to eighteen months (M=1.87) is not significant, t (43) = 1.19, p = .24.

72Follow-up exploratory analyses were conducted to determine if the pattern of

change (i.e., slope) in weekly instances of noncompliance differs between the two groups.

The change in weekly number of instances of noncompliance was calculated by

subtracting the average from the first six month period from the average from the third

six month period. The slope for both groups was negative indicating a decrease in the

number of instances of noncompliance, but there was not a significant difference between

the Guardian (M = -.17) and No Guardian (M = -.30) groups based on the slope, F (1, 38)

= 0.42, p = .52.

These results suggest there is not a relationship between guardianship status and

treatment compliance at admission or over the course of treatment.

Symptomatology.

There were fewer people who had repeated assessments of the BPRS because the

BPRS was added to the routine assessment battery later in this archival database cohort.

Therefore, low N prevented use of repeated measures ANOVA to assess the change in

BPRS over time by guardianship status group. Instead, to maximize the number of valid

cases available for analyses, one-way ANOVAs were completed on assessments

administered at 6 months, 12 months, and 18 months of treatment between guardianship

groups on the BPRS Total Score. Higher symptomatology was predicted in the Guardian

group than the No Guardian group. At 6 months, there is no significant mean difference,

F (1, 47) = 0.003, p = .95, between those with guardians (M = 44.34) and those without

guardians (M = 44.57). Likewise, at 12 months, there is no significant difference, F (1,

37) = 0.26, p = .61, between the groups (M = 41.95, 43.63, respectively). Therefore, the

73lack of a statistically significant difference in symptomatology between groups found at

admission persists at 6 months and again at 12 months.

At 18 months, however, there is a significant difference, in the expected direction,

between groups, F (1, 25) = 7.41, p = .01, η2 =.229, with higher BPRS scores for those

with guardians (M = 47.47) than whose without guardians (M = 37.67). At 18 months,

there are only nine people in the No Guardian group as opposed to 18 in the Guardian

group. The low N for this analysis calls its results into question. In addition, a protracted

length of stay for those with guardians was identified in earlier analyses. Because of the

identified relationship between length of stay and guardianship status, an ANCOVA

analysis with length of stay as the covariate was done to determine whether differences

between the two groups on BPRS total score are still evident when controlling for length

of stay. With this analysis, the significant difference remains between the groups, F (2,

24) = 4.64, p = .04, η2 =.162.

To further evaluate symptomatology, the six BPRS factor scores were analyzed

for group differences. A 2 (guardianship status) X 6 (BPRS factor scores) MANOVA for

each time point, (i.e., 6, 12, and 18 months) was done to assess whether differences

existed between groups in symptom groups. There are no between group effects at any of

the three time points on any of the factor scores, all Fs < 1.67, all ps > .19.

Because isolated differences between groups on individual BPRS items were

found at admission, those analyses were repeated here to determine whether there is a

consistent pattern over time on any particular BPRS items. At six months, there are no

significant differences on any items, all Fs < 3.75, all ps > .06. The two items which

approached significance are Hostility, F (1, 50) = 3.75, p = .06, η2 =.070, and

74Suspiciousness, F (1,50) = 3.09, p = .09, η2 =.058, but both are in the unexpected

direction with those without guardians having higher symptom ratings than those with

guardians. At 12 months, only one significant difference emerged on all items. On

Suspiciousness, people without guardians again have a higher rating on suspiciousness

than those without guardians, F (1, 38) = 3.95, p = 0.05, η2 =.094. The difference

between the groups on Disorientation at 12 months approaches significance, F (1, 37) =

3.24, p = .08, η2 =.080. This difference is in the expected direction with symptom ratings

on disorientation being higher for those with guardians than those without guardians. No

other differences were noted at 12 months, all Fs < 1.44, all ps > .24. Finally, at 18

months, significant differences between the two groups were found on the following

BPRS items: Anxiety, F (1, 27) = 4.67, p = .04, η2 =.148, Elevated Mood, F (1, 27) =

4.28, p = .05, η2 =.137, Bizarre Behavior, F (1, 27) = 4.47, p = .04, η2 =.142, Conceptual

Disorganization, F (1, 27) = 4.27, p = .05, η2 =.136, and Tension, F (1, 27) = 4.47, p =

0.04, η2 =.142. All of these differences were in the expected direction with those with

guardians having higher symptom ratings than those without guardians. However, there

are only 9 people in the No Guardian and 20 people in the Guardian group at the 18

months time point. Overall, analyses of the BPRS items indicate that there is no

consistent pattern over the course of treatment regarding symptomatology between

groups.

In summary, despite the difference noted at Time 4 on the BPRS total score and

the various differences noted on individual BPRS items, results of analyses of the

relationship between symptomatology as measured by the BPRS and guardianship status

75suggest that there is considerable variability in symptomatology and that this is not likely

attributable to group membership.

Hypothesis 2

Outcome.

A pattern of differential outcome was hypothesized for the Guardian and No

Guardian groups. Specifically, it was predicted that those with guardians would be

discharged to more restrictive settings than those without guardians. Conversely, it was

hypothesized that there would be a higher rate of rehospitalization for those without

guardians than those with guardians.

Discharge location.

It was predicted that people with guardians would be discharged to more

restrictive levels of care than those without guardians. Chi square analyses revealed a

significant relationship between the level of restrictiveness of discharge setting and

guardianship status, X2 (3) = 9.70, p =0.02 (See Table 20).

Table 20Relationship Between Level of Discharge Location Restrictiveness

and Guardianship Status (N=147) Guardianship Status

Discharge Location Restrictiveness GuardianNo

Guardian Total

1 – Same or Higher Restrictiveness (LRC Transfer) 1 5 6

2 - Psychiatric Residential Rehabilitation 27 35 62

3 - Assisted Living 34 26 60

4 – Independent Living/Living with Family 4 15 19

Total 66 81 147

76There are no differences in the relative number of people from each group who

went to discharge locations characterized as highest in restrictiveness (i.e., LRC transfers

and Psychiatric Residential Rehabilitation). However, partial support for the hypothesis

is generated by the distribution of discharges to the least restrictive setting, independent

living. Not even 1% of people with guardians were discharged to independent living (n =

4 out of 66) whereas nearly 20% of those without guardians were discharged to

independent living situations (n = 15 out of 81).

Rehospitalization rate.

Following discharge, CTP participants spent and average of 89.1% of days during

the follow-up period in the community rather than in the hospital. Seventy-four of the

123 people with rehospitalization data available were not rehospitalized from the time of

discharge through the time the outcome data was collected. The amount of time for

follow-up period varies considerably because discharges from CTP happened from 1996

until 2004, therefore the number of days between CTP discharge and when the outcome

data was collected was included as a covariate in analyses. There are no significant

differences between those with and without guardians on the total number of days

hospitalized after CTP discharge, the number of days hospitalized within the first 6

months, the number of days hospitalized within the first year, or the number of days

hospitalized in the first year and a half, all Fs < 2.07, all ps > .13. There is, however, a

significant difference in the number of days before the first hospitalization following

discharge F (2, 69) = 5.82, p = .005, η2 =.144. Contrary to hypothesis, people with

guardians were rehospitalized sooner than those without guardians (Ms = 213.46 days

and 268.12 days, respectively). While the differences between groups on the total

77number of hospital days and the number of hospital days in six month intervals following

discharge were not statistically significant, the means were all in the direction suggesting

more hospital days for those with guardians than those who do not have guardians. These

results suggest poorer outcome in terms of rate of rehospitalization for people with

guardians.

As described in the methods section, the rehospitalization data was considerably

skewed and could not be transformed or windsorized into an acceptable skewness range.

This is largely a function of the large proportion of people who were never rehospitalized

during the follow-up period. In order to corroborate the above results since the data used

in the above analyses were skewed, categorical variables of “recidivists” and “non-

recidivists” were created based on all or none cutoff levels. That is, people who were

never rehospitalized were categorized as “non-recidivists” whereas if they were ever

rehospitalized they are “recidivists.” Chi square analysis revealed no significant

relationship between guardianship status and recidivist categorization, X2(1) = 2.22, p

= .14. Likewise, recidivist categorizations were made based on rehospitalization in six

month intervals following discharge (i.e., rehospitalized within that time frame =

recidivist, not rehospitalized within that time frame = non-recidivist). At six months

post-discharge, there is not a significant relationship between guardianship status and

recidivist categorization, X2(1) = 1.20, p = .29. At 12 months post-discharge, again no

significant relationships between guardianship status and recidivist categorizations are

found, X2(1) = 3.29, p = .07. Finally, at 18 months post-discharge, there remains no

relationship between the two variables, X2(1) = 2.22, p = .14.

78In summary, results of analyses of outcome data with regard to guardianship

status indicate that at the time of discharge and during the follow-up period after

discharge, relatively few differences between those with guardians and those without

guardians are evident. However, as hypothesized, people with guardians appear to move

to more restrictive settings at the time of discharge. As for the second part of the

hypothesis, there is no evidence to suggest that people without guardians recidivate more

than those with guardians. To the contrary, there is some evidence that people with

guardians return to the hospital sooner than those without guardians.

79CHAPTER 5 – DISCUSSION

General Discussion.

The purpose of this study was to provide an empirical investigation of

guardianship as it relates to clinical functioning and outcome within an SMI population

involved in psychiatric rehabilitation. To date, no such study is known to exist. In

general, there are no known studies examining the relationship between guardianship and

clinical functioning in any population. Because of the paucity of research in this area,

this study was highly exploratory in nature, giving a first look at the clinical correlates of

the legal construct of guardianship.

Overall, there was mixed support for the hypotheses of the study. In terms of the

first hypothesis evaluating differences between those with guardians and those without

guardians on several domains of functioning at admission and over the course of

treatment, only one stable difference in functioning was identified between the two

primary groups of interest. Behavioral functioning, as measured by the NOSIE, was

poorer upon admission and consistently over the course of treatment for those with

guardians than those without guardians. In general, other areas of functioning evaluated

in this study – neurocognitive functioning, social cognitive functioning, treatment

compliance, and symptomatology – did not differ with regard to guardianship status.

Behavioral functioning may have emerged as the only significant difference between

these two groups because it represents a comparatively molar level of functioning to the

neurocognitive, social cognitive, and symptomatology measures used in this study. It

may be the case that legal decisions regarding guardianship have more to do with molar

levels of behavior rather than molecular levels of cognition and symptomatology.

80Intuitively, this makes sense in that guardianship proceedings, especially those in which a

family member petitions for guardianship, are typically accompanied by testimony

regarding the individual’s behavior in areas such as self-care, finances, work, and

treatment-related decisions. The results of this study suggest that guardianship

determinations for those with severe mental illness in Nebraska are, at least in part,

related to behavioral levels of functioning rather than more molecular levels of

functioning.

Most states, including Nebraska, use the Uniform Probate Code to make judicial

decisions regarding competency and guardianship. This standard defines an

incapacitated person as one who “lacks sufficient understanding or capacity to make or

communicate responsible decisions” (Reisner et al., 1999, p. 869). However, some states

use a more functional approach which considers a person’s ability to complete basic

activities of daily living (Reisner, et al., 1999). While the line between the two

approaches is not at all clear, the findings of this study appear consistent with the latter

despite the fact that Nebraska operates under the Uniform Probate Code. The central

premise of the Uniform Probate Code is the ability to “make or communicate responsible

decisions,” rather than the ability to complete necessary tasks. This distinction means

that people with serious physical impairments, like paralysis due to spinal cord injury,

who are functionally unable to care for themselves would not meet the criteria for

guardianship under the Uniform Probate Code. Therefore, guardianship determinations

under the Uniform Probate Code often include both psychological evaluation of cognitive

capacites and behavioral evidence of functioning level in order to demonstrate that a

person is unable to make or communicate responsible decisions. This study, however,

81identified a relationship between guardianship status and behavioral levels of functioning

and not other domains of functioning considered related to decision-making abilities.

With the exception of behavioral functioning, in general, few differences between

those with guardians and those without with regards to the various domains of

functioning were evident at admission or over the course of treatment. This finding

muddies the waters in terms of bridging that gap between mental health law and theory.

In other words, if the only clinical correlate related to legal findings of incompetence

within this population is in behavioral functioning, the psychological construct of

decision-making seems grossly out-of-line with the legal construct, which may in fact be

the case. The relationship between clinical functioning and guardianship remains unclear

since many of the more molecular measures, as opposed to the molar level of functioning

captured by the NOSIE, are hypothesized to be correlates of decision-making abilities.

Previous research has identified relationships between cognitive functioning,

symptomatology, and decision-making (e.g., with psychiatric symptomatoloty, Grisso,

Appelbaum, & Hill-Fotouhi, 1997; with neurocognition, Shurman, Horan, &

Nuechterlein, 2005; Hutton et al., 2002). Since guardianship requires a legal finding of

incompetence and incompetence implies impaired decision-making, it is surprising that

no clear distinctions between those with guardians and those without guardians were

evident on measures of neurocognition. Likewise, since higher psychiatric

symptomatology has been linked to impaired decision-making (Grisso, Appelbaum, &

Hill-Fotouhi, 1997), it is surprising that this study did not identify symptomatology as

related to guardianship status. The lack of convergence between the current study and

previous studies may be because of varied conceptualizations of the construct of

82decision-making. Take the research cited above, for example. While the work of

Appelbaum, Grisso, and colleagues used a measure that is theoretically based on the legal

standards associated with findings of incompetence, the measure of decision-making used

in the work of Shurman, Horan, and Nuechterlein was the Iowa Gambling Task (Bechara,

Damasio, Tranel, & Anderson, 1994) which involves selecting cards that have varying

punishment and reward profiles. It is hard to imagine two measures that seem more

dissimilar, at least in terms of face validity. However, they are discussed as both

measuring “decision-making abilities” – and perhaps they do. While correlates of

decision-making are often sought in terms of symptomatology, neurocognitive variables,

brain injury, diagnosis, etc., the relationship between measures of decision-making and

legal incompetence has not been studied. It probably comes as no surprise, then, that this

study questions if psycholgical assessment of decision-making is at all similar to legal

assessment. It is likely the case that the psychological construct of decision-making is

not as closely related to the legal construct of decision-making as we might presume. It is

also possible that while the constructs are fairly similar, the way they get operationalized

in the treatment and legal contexts varies.

Another potential explanation for the hypotheses of this study going largely

unsupported may be found in the nature of the population from which study sample was

drawn. Because of the severity and chronicity of psychiatric disorder within the CTP

population, the general lack of differences between groups is perhaps attributable to the

overall high level of impairment present in this specific population. That is, the CTP

participants represent a particularly treatment-refractory population and differences in

functioning between groups those with guardians and those without guardians may be

83less apparent than they would be in a less severe or less chronic psychiatric population

with more variability. Discriminating between any groups within the CTP population

may require not only the existence of differences, but substantial differences. That is not

to say that there is not considerable heterogeneity within this group, but it may mean that

fine, subtle differences between groups may be hard to detect, and these differences may

or may not be meaningful. This conclusion is congruent with studies which have had

difficulty detecting treatment effects between groups in the CTP setting (Spaulding,

Reed, Sullivan, Richarson, & Weiler, 1999b).

Since this study identified relatively few differences in functioning based on

guardianship status, one wonders if there were a “screening procedure” of sorts,

hypothetically speaking, as a standard component of admission if all people would be

appointed guardians. As in, would every person in this population meet the legal criteria

for a finding of incompetence? Now, this study is not intended to suggest that the entire

population of the psychiatric rehabilitation program at the state hospital in Nebraska is in

need of guardianship. Rather, it raises questions regarding the lack of specificity in the

legal criteria for guardianship and the reasons for which guardianship is acquired. We

may presume that most people with mental illnesses have guardians because their

disorders are particularly severe and/or chronic. Since the population in this study is by

nature both severe and chronic, there must be another factor involved in guardianship

since only around half in this study were affected by guardianship. This third factor

could be described as the resources the person has available in terms of family support

and involvement, financial assets, and the like. This study did not evaluate the aspects of

individual resources which may have led to guardianship, but did identify a greater

84likelihood of having a family member as a guardian at admission than if the guardian was

acquired during hospitalization. Further study of “the road to guardianship” is needed.

In summary, results pertaining to the first hypothesis of this study regarding

differences in functioning as a function of guardianship indicate that most differences are

apparent in the area of behavioral functioning. Differences between groups in other areas

of functioning seem negligible. Therefore, one clinical correlate to guardianship, as

identified by this study, is behavioral functioning.

With regards to the second hypothesis of this study regarding outcome, again,

there was only mixed support. Results suggest that people with guardians are discharged

to more restrictive settings than those without guardians. People with guardians in this

study were rarely discharged to an independent living situation whereas nearly one out of

every five people who did not have guardians went on to independent living following

discharge from CTP. There are at least two probable driving forces behind this pattern of

discharge. First, treatment teams involved in planning discharges may not consider

independent living an option for a person who has been found incompetent. Treatment

teams are aware of the social history of each person and it is likely that any independent

living situation for people with guardians prior to admission at CTP has failed. In fact,

results from this study support this theory. Because behavioral functioning, including

social competence and neatness, were related to guardianship status it could be inferred

that people with guardians were unable to maintain adequate self-care or an appropriate

level of care for an apartment or home. Based on past failures in independent living,

treatment teams may be less inclined to consider it as a future discharge option. Second,

and perhaps even more likely, discharges are largely dictated by the community providers

85themselves. That is, the less restrictive the setting is, the less likely it would be to accept

someone who has a guardian. The availability of a guardian might make a client more

attractive to some providers. Therefore, those with guardians are likely placed in more

restrictive settings than those without guardians.

The second part of the outcome hypothesis pertained to rate of rehospitalization.

Results of this study cannot be used to fully substantiate nor disprove the notion that

people without guardians have higher rates of rehospitalization and that guardianship

may serve as a protective mechanism from rehospitalization. However, results suggest

that, on the contrary, those with guardians are rehospitalized sooner following discharge

than those without guardians. In reality, access to inpatient hospitalization is facilitated

by having a guardian because a VpG admission may be used instead of more time-

consuming civil commitment proceedings. This may account for the relatively faster

return to the hospital for those with guardians. However, as is the case in this study,

exploratory analyses revealed that a fair amount of people with guardians do not return to

the hospital until they are civilly committed. More qualitative analyses or case studies

regarding rehospitalization rate for those with guardians and those without may be

warranted to further evaluate this hypothesis.

Finally, exploratory analyses provided further insight into the nature of

guardianship. Longer lengths of stay were found to be associated with those with

guardians. The protracted length of stay among those with guardians is partially

attributable to those who acquire guardians while at CTP. Often, guardians are acquired

at CTP because it has been determined by the treatment team that it will be difficult to

find a community placement for an individual unless a guardian is in place prior to

86discharge. As noted earlier, community providers sometimes make decisions about

whether to accept a new admission based on whether or not a guardian is in place.

Therefore, not only are lengths of stay protracted for this group because of identifying an

appropriate placement, but often because community placements sometimes prefer or

require guardianship to be established prior to placement at the facility. The court

proceedings to establish guardianship alone extend the length of stay for those acquiring

guardians at CTP.

Longer lengths of stay for those with guardians may also suggest that this

subpopulation is a particularly treatment-refractory subpopulation within CTP. However,

an alternative explanation to there being a subpopulation of non-responders is that

instead, there is a subpopulation of people with high interepisodic symptomatology. The

seemingly anomalous finding of a significant difference in total BPRS scores at 18

months, with those with guardians having a higher level of symptomatology than those

without guardians, may be evidence of a group with higher symptomatology at admission

that does not decrease over the course of treatment.8 At admission and early on in

treatment, higher symptom ratings for this group may have been masked by an overall

higher level of symptoms early in treatment that, for most, decreased with treatment.

Only later in treatment, then, when many have been discharged and most of those

remaining have experienced symptom reduction, do those whose symptom picture has

remained largely unchanged – and comparatively higher - become identifiable. If this is

the case, coupled with the finding those with guardians have a longer length of stay, high

8 Post hoc analyses using change scores on BPRS total from admission to 18 months were attempted, but the valid N was only 4. With all possible combinations of change scores (e.g. admission to 12 months, 6 months to 12 months), the largest attainable N was 14, with 6 in one group and 8 in the other.

87interepisodic symptomatology may prove to be a vulnerability factor for having a

guardian. Further investigation is needed.

The difference in level of education found between the two groups is probably

due to an earlier age of onset of disorder9 for those with guardians which would have

truncated their education. Since those with guardians were not different from those

without guardians with regard to neurocognitive functioning, it seems unlikely that actual

cognitive ability contributed to the difference between the groups on years of education.

A few anomalous findings in the study deserve discussion. At 18 months of

treatment, more differences in symptomatology on BPRS items were found between

groups. However, while several items on the BPRS showed significant differences at

different time points, there was no stability to these differences over time. As discussed

earlier, those with guardians who are still in treatment at 18 months may have higher

interepisodic symptomatology. Results may also simply be affected by the low number

of people available at that time point for analyses.

Finally, none of the results of this study suggest differences in functioning or

outcome for people whose guardians are family members or not or people who are

admitted via civil commitment or Voluntary per Guardian.

Before moving on to discuss limitations of this study and areas for future

research, a word of caution is warranted. Because the population in this study does

represent a particularly severe and chronic subpopulation of those with mental illnesses,

those who are civilly committed and those who have guardians in this population are

likely quite different from those who are civilly committed or have guardians in the

9 The difference between groups on age of onset approached statistical significance.

88general population. Since this area of research has important policy implications and

because policy surrounding guardianships is constantly evolving, it is important to

acknowledge that any conclusions drawn from this study regarding guardianship may or

may not generalize to the larger population of those with guardians. However, since the

population in this study is among the most highly affected by guardianship, results

represent a significant contribution both to the literature and to future policy decisions.

Limitations of the Present Study.

The goal of identifying correlates of clinical functioning to the legal construct of

guardianship in this study potentially missed one key intermediate variable: decision-

making. One weakness of this study is that it did not include an explicit measure of

decision-making ability. Since this study utilized archival clinical data, only measures

part of routine assessment at CTP were available. While poor cognitive functioning has

been linked to impaired decision-making (e.g., Shurman, Horan, & Nuechterlein, 2005;

Hutton et al., 2002) and this study included various measures of neurocognitive

functioning as well as a measure of functional insight, no relationship was identified

between guardianship and these molecular levels of functioning. It may be that a more

global measurement of decision-making would better capture the relationship between

impairments in decision-making and the legal finding of incompetence as opposed to the

more molecular level of functioning that was captured by the measures in this study.

Because the NOSIE captures a more molar level of functioning and identified differences

between the groups, it seems logical that a more global measure of decision-making

might better discriminate between these two groups. The MacCAT-T (Grisso,

89Appelbaum, & Hill-Fotouhi, 1997) is one example of the kind of measure that could be

employed towards this goal.

Another limitation of this study was low power for several key analyses due to

missing data and/or changes in the clinical assessment battery. The use of multivariate

analyses in this study was undermined by a low number of valid cases on many of the

variables over time. Therefore, conclusions about differences between groups, or the

lack thereof, over the course of treatment are tentative due to insufficient power.

However, consultation of a standard power table reveals that given the F-values obtained

for most results in this study, an infinitely large sample size would likely have been

necessary to detect any differences between groups (Friedman, 1982; Cohen, 1988).

Therefore, it seems unlikely that any effects were “missed.” On the other hand, due to

the exploratory nature of this study, many analyses were conducted, inflating the Type I

error rate. Confident rejection of the null hypothesis is complicated because of the risk of

experimentwide Type I error. At any rate, this study explored the characteristics of

guardianship such that future studies in this area can make more informed research

hypotheses using stricter constraints in research design to circumvent problems related to

lack of power and missing data.

Future Directions.

Areas of needed research have already been alluded to in the above discussion.

Specifically, a replication or study similar to the one undertaken here, with more defined

hypotheses and greater power is needed to further clarify the characteristics of those with

guardians. Likewise, a similar study in a broader population would allow for more

generalizability of results. Finally, a study – or perhaps, initially, a series of case studies

90– examining the different events proceeding guardianship hearings and the resources

available to each person is necessary to better understand why some people end up with

guardians and others do not given the relative lack of differences in functioning that this

study identified.

In addition, as implied above, research studies using a more molar or explicit

measure of decision-making are needed. The purpose of such a line of research would be

two-fold. First, whether or not current measures of decision-making (e.g., MacCAT-T,

Grisso & Appelbaum) in fact measure what they purport to measure with regards to legal

incompetence must be established. While the MacCAT-R is theoretically based on the

legal standards related to decision-making (Appelbaum & Grisso, 1995; Roth, Meisel, &

Lidz, 1977), no validation within a population of people determined to be legally

incompetent has been conducted. Therefore, using measures of decision-making to

identify correlates to clinical functioning is moot until a relationship between the

psychological construct and the legal construct has been established. Studies identifying

correlates of decision-making to various clinical variables have not been conducted

within a population defined as legally incompetent. Or, if they have, legal status has not

been considered in analyses. Such a study might simply include measures of decision-

making, like the MacCAT-T, within a population such as the one in this study to

determine if the measures make distinctions between those with guardians (who have

been found legally incompetent) and those without guardians.

In general, more empirical, as opposed to theoretical investigations, of the

concepts found within the intersecting field of mental health law are needed. The current

91study is a critical first step in identifying the relationship between the legal construct of

guardianship and the clinical functioning of those defined by it.

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102

APPENDIX:

BIVARIATE CORRELATION MATRICES

103Table A1

Bivariate Correlations for Demographic and Clinical Characteristics Used in MANOVA Analyses with Guardianship Status

1 2 3 4

1 - Length of Stay -

2 - Age .127 -

3 – 3 - Years of Education -.180* .251** -

4 – 4 - Age at First Hospitalization -.069 .458** .337* -

5 – 5 - Number of Previous Hospitalizations

.037 .114 -.135 -.190

** Correlation is significant at the 0.01 level (2-tailed).* Correlation is significant at the 0.05 level (2-tailed).

104Table A2

Bivariate Correlations for Neurocognitive Variables1 a 2 3 4 5 6 7 8 9 10 11 12

1 - RAVLT Trial 5-

2 - COGLABAsarnow Hits

0.40**

-

3 - COGLAB Asarnow False Alarms

-0.25*

-0.32**

-

4 - Card Sort Random Errors

-0.38**

-0.26*

0.36**

-

5 - Card Sort Perseverative Errors

-0.27*

-0.21*

0.20 0.48**

-

6 - RCFT Copy . -0.06 0.09 0.36 0.14 -

7 - RCFT Immediate Memory

. 0.17 0.38 -0.11 -0.35 0.46**

-

8 - RCFT Delayed Memory

. 0.17 0.31 0.16 -0.19 0.54**

0.94**

-

9 - RCFT Recognition

. 0.08 0.06 -0.74**

-0.23 -0.17 0.40**

0.31 -

10 - Trails A 0.08 -0.52**

0.21 0.34 0.38 -0.14 -0.18 -0.31 -0.07 -

11 -Trails B -0.62*

-0.15 0.18 0.73**

0.48**

-0.27 -0.42*

-0.41*

0.06 0.56**

-

12 - WRAT 0.56**

0.06 -0.23 -0.27 -0.08 0.31 0.43**

0.32 0.22 0.04 -0.19 -

13 - RBANS Total . 0.12 -0.18 -0.36 -0.31 0.53**

0.72**

0.69**

0.45**

-0.24 -0.37**

0.59**

a Note: The RAVLT was phased out of regular use at CTP when the Rey Complex Figure Test and RBANS battery were added. As can be seen here, there were no participants with assessments from both time periods from which to compute correlations.** Correlation is significant at the 0.01 level (2-tailed).* Correlation is significant at the 0.05 level (2-tailed).

105Table A3

Bivariate Correlations for Social Cognitive Variables

1 2 3 4 5 6 7 8 9

1- Total Insight -

2 - Ability to relabel psychotic experiences

.887**

-

3 - Awareness of Illness .894**

.669**

-

4 - Need for Treatment .887**

.743**

.710**

-

5 - I-SEE Self-Efficacy -.326*

-.286 -.263 -.330*

-

6 - I-SEE Self-concept of ones’ own self-competence

-.236 -.158 -.282 -.184 .791**

-

7 - I-SEE Internality -.241 -.257 -.098 -.308*

.823**

.324*

-

8 - I-SEE Externality -.008 -.045 .145 -.137 -.276*

-.427**

-.016 -

9 - I-SEE Powerful Others Contol Beliefs

-.088 -.112 .102 -.246 -.116 -.176 .004 .899**

-

10 - I-SEE Chance Control Beliefs

.070 .030 .148 .000 -.377**

-.587**

-.032 .908**

-.633**

** Correlation is significant at the 0.01 level (2-tailed).* Correlation is significant at the 0.05 level (2-tailed).

106Table A4

Bivariate Correlations of NOSIE subscales

1 2 3 4 5 6

1 - NOSIE Total -

2 - Social competence .85** -

3 - Social Interest .62 ** .40** -

4 - Neatness .83** .70** .47** -

5 - Irritability -.63** -.60** -.12 -.43** -

6 - Psychoticism -.53** -.49** -.21* -.37** .47** -

7 - Motor Retardation -.72** -.72** -.49** -.65** .21* .23**

** Correlation is significant at the 0.01 level (2-tailed).* Correlation is significant at the 0.05 level (2-tailed).

107Table A5

Bivariate Correlations of BPRS Total Scores and Factor Scores

1 2 3 4 5 6

1 - BPRS Total -

2 - Psychotic Disorganization .69** -

3 - Hallucinations/ Delusions .60** .25 -

4 - Paranoia .58** .62** -.07 -

5 - Emotional Blunting .19 .15 -.20 .06 -

6 - Anxiety/Depression .62** .06 .50** .16 -.22 -

7 - Agitation/Elation .48** .37* .24 .38* .07 -.22

** Correlation is significant at the 0.01 level (2-tailed).* Correlation is significant at the 0.05 level (2-tailed).