An interactive videodisc as a tool in the rehabilitation of the chronically mentally ill: A preliminary investigation

Computers in Human Behavior, Voi. 7, pp. 57-73, 1991 Printed in the U.S.A. All rights resea'ved.

0747-5632/91 $3.00 + .00 Copyright © 1991 Pergamon Press plc

An Interactive Videodisc as a Tool in the Rehabilitation of the Chronically Mentally ILL: A Preliminary Investigation Barbara A. Olevitch and Brian J. Hagan Missouri Institute of Psychiatry

A b s t r a c t - - The acceptability and educational effectiveness of an interactive videodisc simulation designed to teach stress management, medication compliance, and other community living skills to the chronically mentally ill was studied. The disc, called How to Get Out and Stay Out: The Story of Cathy, was studied in a sample of patients with a diagnosis of schizophrenia or schizoaffective disorder. Two groups were compared: the experimental group had the opportunity to try the simulation repeatedly and saw the story turn out better or worse for Cathy depending upon the choices that they made for her. The control group saw some very limited scenes from the disc and gave their opinions about it but did not make choices and see consequences. Acceptability was found to be high; the p a r t i c i p a n t s enjoyed the disc and u n d e r s t o o d how to use it. Comparison of the groups' pre- and post-videodisc scores on two measures (the Wellness-Maintenance Questionnaires, and a modified version of the Community Adjustment Profile) showed that the experimental group made significantly greater gains on the Wellness-Maintenance Questionnaires than the control group. The results suggest that even when used as a stand-alone educational device, the videodisc can contribute to a psychiatric patient education program.

INTRODUCTION In recent years, there has been an increasing awareness in the field o f mental health that i n d i v i d u a l s w h o are c h r o n i c a l l y v u l n e r a b l e to s e v e r e m e n t a l illness can decrease their likelihood o f relapse and rehospitalization if they master skills such Dr. Olevitch (formerly Dr. Rosenberg) was a P o s t d o c t o r a l F e l l o w at the Missouri Institute of Psychiatry, Department of Psychiatry, University of Missouri-Columbia, during the research study reported here. Mr. Hagan was a Research Assistant at the Missouri Institute of Psychiatry. The authors would like to thank Dr. James L. Hedlund, director of the Missouri Institute of Psychiatry, for valuable counsel and support throughout this project. Requests for reprints should be addressed to B. A. Olevitch, P.O. Box 28911, St. Louis, MO 63132. 57

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as stress management, medication compliance, and the seeking of social support (Zubin, Steinhauer, Day, & van Kammen, 1985). Effective methods of teaching these skills to groups of psychiatric patients exist (Berkowitz, Eberlein-Fries, Kuipers, & Leff, 1984; Hersen, 1979; Kinney & Lindsey, 1980; Leff, Kuipers, Berkowitz, Eberlein-Fries, & Sturgeon, 1982; Liberman, Mueser, Wallace, Jacobs, Eckman, & Massel, 1986), but they are very labor-intensive. It is therefore important to develop psychoeducation materials and tools to supplement and enhance current psychoeducational efforts. The interactive videodisc is a new technology, which combines the educational capabilities of the laserdisc player and the microcomputer. The microcomputer receives responses from the viewer and directs the videodisc player to show particular sequences according to the nature and pace of these responses. Waiting time is negligible. This medium can convey information in an interesting manner that compensates to some degree for the handicaps of the psychiatrically impaired in receiving information. Previous research has indicated that psychiatric patients can interact with computer devices and feel positively about doing so (Erdman, Greist, Klein, Jefferson, & Getto, 1981; Greist & Klein, 1980; Greist, Klein, Erdman, & Jefferson; 1983a, 1983b; McCullough, Farrell, & Longabaugh, 1986). An educational videodisc for the chronically mentally ill has been produced (Denton, 1988; Olevitch & Hagan, 1989; Rosenberg & Hagan, 1987a, 1987b). The videodisc, entitled How to Get Out and Stay Out: The Story of Cathy, is a simulation that conveys the message that psychiatric wellness occurs as a result of a combination of medication compliance and stress management activities. The videodisc focuses on a fictional female psychiatric patient, Cathy, who leaves the hospital at the beginning of the story. On her first day out of the hospital, she encounters a minor problem. If the viewer selects for Cathy to take her medication and selects choices for Cathy to engage in stress management activities such as talking to somebody, relaxing, thinking her problem over, and so forth, then the viewer sees Cathy sleep well that night and enjoy herself in the community the next day. On the other hand, if the viewer selects for Cathy not to take her medication and not to engage in stress management activities, then they see Cathy experiencing a recurrence of symptoms. At the end of the program, the viewer has the option of hearing a narrator comment on the choices that they made. (For more detail on the videodisc itself and on the rationale for the videodisc and its development, see Olevitch and Hagan, 1989.) The purpose of this study was to explore the reactions of chronically mentally ill patients, both in the hospital and in the community, to the How to Get Out and Stay Out videodisc with the purpose of answering the following questions: 1. Can patients with a psychotic diagnosis follow the instructions necessary to interact with an educational videodisc program? 2. Can the program engage their attention? 3. Can it be demonstrated that they learn anything from the program? 4. Are their responses to the program related to other aspects of their behavior? In order to measure learning and changes in behavior, three measures were used. The In'st, called the Wellness-Maintenance (Wellness) Questionnaire, was designed by the authors to measure attitudes and knowledge about the areas of psychiatric wellness covered on the Cathy videodisc. The second, a modified version of the

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Community Adjustment Profile (Evenson, Sletten, Hedlund, & Faintich, 1974) (MCAPS), was a behavior rating scale filled out by someone who had an opportunity .tO observe the subjects. The third was the subjects' performance on the simulation itself. It was hypothesized at the outset that the subjects who had the opportunity to practice with the videodisc repeatedly would achieve more desirable simulation outcomes after their practice than before. It was also hypothesized that practice on the simulation would result in cognitive changes that could be measured by the Wellness Questionnaire and, ultimately, behavior changes that could be measured by the MCAPS. It was, moreover, hypothesized in designing the study that the community sample would begin at a higher level than the inpatient sample on all of these three measures.

METHOD

Subjects A total of 30 subjects participated. Inpatients (N = 18) were drawn from wards at St. Louis State Hospital. Community residents (N = 12) were drawn from residential care facilities associated with the Community Placement division of St. Louis State Hospital. All subjects met the following criteria: 1. Primary current diagnosis of "schizophrenia" or "schizo-affective disorder" as determined by chart review; documentation in the medical chart of the occurrence of major psychotic symptoms and of a history of impairment of at least six months duration, as required for the DSM-III diagnosis of "schizophrenic disorder." 2. between age 21 and 65; 3. at least two psychiatric hospitalizations; 4. no history of mental retardation or organic brain syndrome or "special schools"; 5. able to leave the ward with the experimenter; 6. not hospitalized as a forensic patientl; 7. able to see and hear well enough to "see a television program" (by chart review and self-report); and 8. able to read and concentrate well enough to complete 6 sample items in the same format as the items on the Wellness Questionnaire.

Brief Overview of the Experimental Procedure and Design Each subject i~ the study participated in two individual video sessions. Before their fn'st video session, each subject f'dled out the Wellness Questionnaire. Their behavior was also rated on the MCAPS. After the two video sessions, they each again f'dled out questionnaires and their behavior was again rated. Subjects assigned to the experimental group spent their video sessions going through the complete How to Get Out and Stay Out interactive videodisc program, whereas subjects assigned to the control group saw only brief introductory sequences of the disc and were interviewed about their opinions on the brief video that they had seen.

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Equipment and ComputerProgramming The How to Get Out and Stay Out videodisc is a 30-minute CAV-format laserdisc, which was played on a Pioneer LDV-6010 videodisc player. The videodisc player was controlled by an external microcomputer, a Compaq Deskpro. Since the Pioneer 6010 contains an interface, the connection between the serial port of the Compaq Deskpro and the laserdisc player was a straight-through 25-pin RS232 cable. The subjects indicated their choices by touching the screen of the Sony 1271Q monitor, which was fitted with a resistive touchscreen. A 25-pin cable connected the touchscreen and a second serial port of the Compaq. The computer program controlling the videodisc program was written in BASICA. All menus used in the videodisc program were on the videodisc; thus, no graphics overlay card was necessary. All statistical analyses were performed using SPSS/PC+ (Norusis, 1988) or SPSSX (Norusis, 1985). Instruments

Wellness questionnaire. The Wellness Questionnaire was developed to serve as a measure of whether the viewers of the Cathy disc were mastering the content of the disc, that is, realistic expectations, medication compliance, the seeking of social support, problem solving, cognitive restructuring, and relaxation. Pairs of items covering the aspects of these topics that were illustrated in the Cathy story were written for two parallel Forms, A and B, so that each contained 25 True-False statements and 10story items. The following are examples of the True-False statements: Clumsy people should stay home. Healthy people always know what they are doing. If anything goes wrong, I should go back to stay in the hospital. Once you feel bad, it doesn't matter what you do.

Story items were built around situations that were similar but not exactly the same as the story on the disc, for example: John forgot which day he was supposed to help the boarding home manager, but he is embarrassed to tell the manager. He should: a. Tell him anyway so that he'll know when he is supposed to help. b. Not tell him, even if it means missing his turn to help.

A small sample of 12 schizophreni~ subjects was recruited for a pilot study of the Wellness Questionnaires prior to the beginning of the main study reported here. Each pilot subject was asked to fill out both Form A and Form B. Ten completed the task. The total-score correlation between Form A and Form B was .77 for the True-False items and .73 for the Story items (p < .01). There was no significant mean difference between the scores for Form A and Form B. Several minor revisions were made in the questionnaires after the pilot testing, such as rewording a few ambiguous items and eliminating items which were answered correctly by all pilot subjects. The Wellness Questionnaires were printed in large type, for the convenience of

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the subjects, and were administered individually with the experimenter in the room with the subject. In order to assure that each subject was literate enough and alert enough to complete the Wellness Questionnaires, before each administration, the subject was given the instructions for the Wellness Questionnaires along with six easy items of the same format, for example, "Today is S u n d a y . . . T r u e . . False." If the subject answered any of these items incorrectly, their participation in the study was not continued. Half of the subjects in each group received Form A before their video sessions and Form B afterwards. The other half were given the questionmires in reverse order. Two items on the Wellness Questionnaires referred to "voices," for example, "the voices I hear at times . . . . " A few subjects objected to filling out these items, stating that they heard no voices. In these cases, the subject was told to skip the item and was given credit for the item. The M C A P S . A m o d i f i e d version of the short form of the C o m m u n i t y Adjustment Profile (Evenson, Sletten, Hedlund, & Faintich¢~!9~'/4) (MCAPS) was used as a behavior rating scale. The following are examples of items from the original Community Adjustment Profile: "During the past 3 months - - has said, 'I am bad or useless': 1. Not that I know of., 2. Sometimes., 3. Often., 4. Very often; . . . . During the past three months - - has threatened to attack or harm another person: 1. Not that I know of., 2. Once., 3. Several times., 4. Often." For purposes of this study, the time specification in each item was changed from "During the past 3 months," to "During the past week." Because of the focus of this study upon day-to-day clinical changes in subjects who were either in the hospital or in the community, items that reflected slow-changing status variables, such as whether the subject received Social Security, and items that reflected experiences that were unavailable to inpatients, such as whether the subject "entertained friends at home" or whether the subject was "hospitali z e d . . , overnight," were deleted. In order to shorten the scale, some repetition was eliminated. This shortened scale, called the MCAPS, contained 42 items and was filled out by a member of the staff of the inpatient wards or community residential facilities who knew the subject and who had at least some opportunity to observe them during the period of the study. Scores on the first 39 items ranged from 1 to 4. The choice indicating the most desirable behavior ~ always scored ~ts 4 points and the choice indicating the least desirable behavior as 1 point. The total of items 40-42 (these items were checklists of positive behaviors) r~aged from 0 to 17. Thus, total MCAPS scores had a possible range of 39 to 173, with higher scores indicating more desirable behavior. Simulation score. All choices made by the subjects on all trials of the simula-

tion were recorded, printed out, and quantitatively scored. This score, called the Simulation Score, measured the extent to which the subject selected for Cathy to engage in medication compliance and self-help activities. Points were awarded as follows: First self-help activity, 3 points; subsequent self-help activity, 1 point; 2, medication compliance, 2 points; eats dinner with someone, 1 point; immediate return to the hospital, -1 point; and replying that a particular character who encouraged Cathy to get into an argument was helpful, -1 point. There were 10 possible self-help activities, including having Cathy talk to people, relax, reorganize, or think her problem over. The range of possible total scores was from -1 to 15.

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Procedures Charts on each ward or at each residential care facility were searched for subjects who met the criteria for inclusion in the study (see above). All potential subjects were approached individually in the same manner. They were told that the experimenters were working on a new video program for psychiatric patients and that we would like them to see it and give their opinions on it. Those who agreed to participate in the study were assigned in rotating order to the experimental and control conditions. Insofar as possible, equal numbers of experimental and control subjects were recruited from each ward and from each residential care facility. Subsequent analysis confu'med that the experimental and control groups did not differ significantly in sex, age, or educational level. After the subject had read and signed the consent form and filled out the Wellness Questionnaires, and after a staff member had filled out an MCAPS on the subject, the first video session was scheduled. Generally this was the day after the subject had first been approached.

RecruitmenL

Video sessions. Certain procedures were common to both the experimental and control group video sessions. Each subject was seen individually. In order to avoid any extraneous influences of the relationship with the experimenter, the experimenters consistently took care to keep conversation as innocuous as possible. If subjects brought up matters that seemed to have clinical importance, it was suggested that they discuss these matters with the members of their treatment team. During the session, the subject was seated directly in front of the video monitor. The experimenter sat in the same room but out of the direct line of vision of the subject (while they were watching the video), in order to avoid any possibility of biasing the subject's responses to the videodisc. In order to maintain the blindness of ward or residential facility raters with regard to whether the subject was in the experimental or control group, participants in both groups were asked not to discuss the experiment with other patients on the ward or with staff. (Staff had been instructed to remind them of this.) Subjects in both the experimental and the control g.roups were seen for two sessions, one week apart. Both experimenters conducted sessions, but once a subject began with a particular experimenter, they continued with the same experimenter. E x p e r i m e n t a l group. The experimental group, included six inpatients and six com-

munity residents. At the beginning of the f'n'st video session, the experimenter verbally gave the subject the following General Instructions: This is the special video that I was telling you about. Do you see this woman here on the screen? Her name is Cathy and she is leaving the hospital. You will have a chance to make some choices for Cathy while you are watching the video. There will be some instructions about how to make your choices. Just follow the instructions. When the subject indicated that the General Instructions were understood, the experimenter continued by giving the following Test Instructions: As I said, you will have a chance to make some choices for Cathy. This time, we would like you to make whatever choices will keep Cathy as well as possible.

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The subject's Simulation Score on this first trial was called the First Simulation Test Score ( l s t STS). At the end of the simulation, the interactive program moved into the Feedback section, and a narrator came onto the screen to explain to the subject: Now you've seen how the story end&l. If you try the program again and make different choices, the story will end differently. Then the narrator asked the subject for a yes-no answer to several questions such as, "Would you like to talk a little about how the story ended?" and "Would you like to hear a little about the choices that you m a d e ? " If the subject replied in the affirmative, they would see a rerun of video sequences from the story with the narrator's voice providing commentary, for example: Good. You took a chance and had Cathy tell Sue what happened. Cathy felt great after talking to Sue. Sue was friendly and she really knew how to be a good listgnet. The viewer could see up to six feedback comments, depending upon what choices they made and whether they agreed to hear the feedback. After the fh'st trial of the simulation was completed, the experimenter continued by giving the Practice Instructions, which were as follows: This time we would like you to watch the same video except this time, instead of only choosing whatever you think would keep the main character as well as possible, we would like to give you the chance to make whatever choices you would like to. Feel free to make choices that you are curious about just to see what would happen. All runs of the simulation, including the practice trials, offered the option to hear narrator feedback. At the end of the practice trial, if at least 20 minutes remained, the subject was invited to do another practice trial. The following week the subject began with a practice trial, and if 20 minutes had not elapsed, they were permitted another practice trial. For the final trial o f the simulation, they were once again given Test Instructions: Now you've had a chance to get to know what happens to Cathy when you make certain choices. Now kve would like you to try the program again. This time, we would like you to stop making choices just because you are curious to see what would happen. This txme, we would like you to make whatever choices will result in the very best ending for the story. Make whatever choices you think will resuk in the best ending for Cathy even if it means seeing things over again that you have already seen. Do you understand? Their Simulation Score for this final trial was called the Second Simulation Test Score (2nd S TS). C o n t r o l group. The control group included six inpatients and six community resi-

dents. Video sessions for the control group consisted of seeing some selected sequences from the Cathy videodisc and answering some questions (see below). The e x p e r i m e n t e r s , location, and video e q u i p m e n t were the same as f o r the experimental group. The selected video sequences did not include the problem that formed the focus of the interactive video for the experimenta 1group, nor were any of the educational sequences on medication compliance or stress management, and

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SO forth, shown. The subject was not given any opportunity to make choices for Cathy. Instructions to the subject were as follows: This is the video we were telling you about. It isn't finished yet. We would just like you to see the beginning and then we have some questions we would like to ask you. The video sequences for the fh'st session showed Cathy leaving the ward, being wished well by the nurses, arriving at the boarding home and being introduced to other residents. Questions for the fwst session were: Do you like this video so far? What'do you think of the main ehacaeter? Do you think she seems like a real patient leaving the hospital? Do you think she can stay out of the hospital? Do you think she is anything like you? Video sequences for the second session showed Cathy going to a store, buying something and taking a silent walk in the park. The subjects were asked: Do you think Cathy enjoyed her first day out of the hospital7 Do you think she can stay out of the hospital? and so forth. The subject was permitted to talk as long as they wished in response to each question. The total session ranged from 20 to 40 minutes.

"Automatic" variant o f the experimental group. This group included six inpatients. The procedure was exactly the same as for the subjects in the experimental group, except that when the simulation was over, feedback was provided automatically. Instead of the narrator asking, "Would you like to talk a little about how the story ended?" and so forth, the narrator announced, "Let's talk a little bit about how the story ended." The viewer heard up to six feedback comments without an opportunity to decline the feedback. Moreover, if the viewers in the "automatic" variant of the experimental condition repeated certain critical undesirable choices on two consecutive trials of the simulation (such as having Cathy not take her medication), a written message appeared on the screen saying, for example, "You let Cathy skip her medication before. Are you sure that you want to let her skip it again?" to which the subject was asked to reply "Yes" or "No." Post-video session measures. Within one day after the video sessions were completed, the subject filled out the alternate form of the Wellness Questionnaires. One week after the last video session, the same staff member who had filled out the MCAPS rating for the subject before the study was asked to complete this rating schedule again. RESULTS AND DISCUSSION

Acceptance of the Videodisc All research subjects, both experimental and control, who began the video sessions participated amicably and successfully completed them. None of the subjects who had a first video session declined to return for the second video session. (Of the

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five subjects who dropped out of the study, three dropped out before the first video session and two declined to complete the'u" final Wellness Questionnaires.) No negative comments about the experience were made by either experimental or control subjects, and some from each group made appreciative comments at the time of the sessions. Moreover, all experimental subjects (and also all of the pilot subjects who were shown the videodisc informally before the study began) were able to use the touchscreen to make choices for Cathy without any instruction from the experimenter other than those that were already on the videodisc. Some asked later on if they could come back to see it again and some commented months later that they still remembered it and that it had helped them.

Outcome of Experimental Measures

Wellness Scores. The average initial Wellness Score for the 30 research subjects was 28.9 out of a possible score of 35 for Form A (SD = 4.8) and 2~8.6 (SD = 4.6) for Form B. Scores ranged from 1,6 to 34. There was a high degree of individual consistency in Wellness Score. For the 30 research subjects, who each took the Wellness Questionnaires twice with approximately one week intervening, the correlation between first score and second score was r = .73 (N = 30, p < .001). The equivalence of Form A and Form B was also high (r = .72, N = 30, p < .001). Cronbach's alpha was .81 for Form A and .78 for Form B (N = 30). There was no significant correlation between Wellness Scores and any of the following demographic variables: Educational level (r = .05, N = 30, NS), Age at first hospitalization (r = .01, N = 20, NS), Length of Hospital Stay (Inpatients only) (r = -.26, N = 18, NS), Age (r = -.00, N = 30, NS). Nor was there any significant difference (t = .94, NS) between mean Wellness Scores for male (X = 28.0, N = 19, SD = 5.2) and female subjects (X = 29.3, N = 11, SD = 2.3). Nor was there any experimenter effect upon Wellness scores (t = .18, df= 25, NS). In order to verify that the direction of response on the items on the Wellness Questionnaires was indeed related to psychiatric status, Wellness Questionnaire responses were collected from a pilot sample of 12 hospital employees. The range of scores was from 31 to 35 (much narrower than the range for the psychiatric sampie). The mean scores, which were 33.3 (SD = 1.4) for Form A and 34 (SD = 1.1) for Form B, were significantly higher than the scores of the psychiatric san~pl~(Form A: t = 4.65, df= 38,p < .001; Form B:t = 6.05, df= 36,p < .001). Thus, the Wellness Scores appeared to be reliable, unrelated to age, sex, or educational level, and a valid indicator of psychiatric status (employee vs. patient). The mean initial Wellness score for the inpatient sample was 28.1 (N = 18, SD = 4.5). This did not differ significantly from the mean score of 29.2 (N = 12, SD = 4.3) for the community residents (t = .64, df = 28, NS). This was interpreted as indicating that the hospital and community samples were composed of patients of very similar,levels of functioning. The community sample were all in supervised living arrangements and were not, in fact, functioning independently. Many of the hospital subjects had been, at various times, and would again be, residents in the same community facilities from which the community sample was drawn. MCAPS. Initial MCAPS Scores ranged from 65 to 124. The overall mean initial MCAPS score for the sample was 94.8 (SD = 14.2). Contrary to expectation, inpatients scored higher than community residents. The inpatient mean was 99.0 (SD = 9.9) and the community mean was 88.4 (SD = 17.4). Further examination revealed

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that the low community scores were entirely attributable to consistently low scores at one community facility. The community mean for all facilities excluding this one was 96.28 (SD = 18.5, N = 7), whereas the mean for this facility was 77.4 (N = 5, SD = 7.92). The difference between this facility and the others was reflected in a significantly higher variance for the initial MCAPS scores in the community sample than in the inpatient sample (F = 3.10, p < .05). It was hypothesized that the difference in rating level for this facility reflected a difference in rater expectations rather than a difference in level of functioning of the subjects. Simulation test scores. First STS ranged from -1 to 15 with a mean of 7.2 (N = 18, SD = 4.5). One third of both the inpatients (4 out of 12) and the community residents (2 out of 6) ended their first simulation with Cathy hospitalized. First STS did not correlate with Education (r = -.05, N = 18, NS), Age (r = .15, N = 18, NS), or Age at first hospitalization (r = .17, N = 18, NS). Nor was the mean 1st STS different for males (7.09, N = 11, SD = 4.9) than for females (7.3, N = 7, SD = 4.2), t = .09, df= 16, NS. There was also no experimenter effect upon score (t = .33, df= 15, NS). There was, however, a significant relationship between 1st STS and length of hospitalization, such that subjects whose current hospitalization had been longer scored lower (r = -.76, N = 12, p < .01). Relationship between Wellness, MCAPS and STS. Because of the greater variance among the community MCAPS scores, all correlations involving MCAPS scores were computed for the entire sample and also for the inpatient and community samples separately. Initial Wellness Scores and initial MCAPS scores were significantly related for the inpatient sample (r = .54, N = 18, p < .025) but not for the community sample (r = .12, N = 12, NS) or the combined sample (r = .24, N = 30, NS). Initial Wellness Scores were significantly related to 1st STS in the inpatient sample (r = .54, N = 12, p < .05) as well as in the combined sample (r = .50, N = 18, p < .025) but this relationship could not be demonstrated for the community sample (r = .54, N = 6, NS) because of its small size. The relationship between initial MCAPS score and 1st STS was also statistically significant in the inpatient sample (r = .64, N = 12, p < .025) but not in the combined sample (r = .36, N = 18, NS), or in the community sample (r = -.30, N = 6). Thus, for the inpatient sample at least, the Wellness Questionnaire scores were significantly related to two very diverse measures of functioning, the simulation scores, and the MCAPS. This indicates that, besides their use as achievement tests for the Cathy videodisc, the Wellness Questionnaires have the potential to be developed into a valid, more "general-purpose," measure of the cognitive-emotional functioning of psychiatric inpatients.

Effect of the Experimental Conditions Effect Upon Wellness Scores "Automatic" variant o f the experimental condition. The rationale for creating the "automatic" variant of the experimental condition was the concern that subjects would not elect to hear the feedback and that its benefit would therefore remain untested. This concern was not substantiated. Subjects in the experimental

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condition elected to hear an average of 97% of the feedback that they were offered on their first trial of the simulation. Although this percentage declined to 86% and then to 79% on subsequent practice trials, it was still considered to be a sufficiently high percentage. It was also noticed that subjects in the "automatic" condition seemed somewhat impatient with the feedback, as manifested by fidgeting, looking at the time, and so forth. In order, to compare the "automatic" variant condition with the experimental and control conditions in the inpatient sample, a difference score was calculated for each subject comparing their Wellness Score before and after the video sessions. The inpatient experimental group made an average gain of 3 points (N = 6, SD = 4.15). The subjects in the "automatic" variant condition, on the other hand, had an average loss of -.5 points (N = 6, SD = 3.27). The control group showed an average gain of .17 (N = 6, SD = 2.63). The overall F ratio comparing these three means suggested that the differences between them were probably not negligible (F = 1.78, df = 2, p < .25). Contrasts showed that the difference between the "automatic" variant group and the experimental group approached significance (t = 1.78, ~/f= 15, p < .10). This pattem of findings and observations was interpreted as indicating that the opportunity to choose whether to hear the feedback was a factor that enhanced the subject's likelihood of learning from the interactive videodisc. For this reason, only the experimental and control conditions were used for the community sample.3 Experimental and control groups. The mean Wellness Scores for the experimental and control groups before and after the video sessions (inpatients and community residents combined) are shown in Figure 1. The experimental group made greater gains in their Wellness Scores than the control group, but their scores also began at a higher level. This raises the question of whether higher initial Wellness Scores were associated with greater gains in Wellness Score. This was not the case. The correlation between initial Wellness Score and gain in Wellness Score (post-video minus pre-video) was .26 (N = 24, NS). In order to study the pattern of response for subjects who began at different levels, subjects were classified into groups according to their initial Wellness Score. Initial Wellness Score level was considered in the "High" range for scores 32 or above, in the "Medium" range for scores between 28 and 31 (inclusive) and in-the"Low" range for, scores less than 28. The Wellness Score means for the experimental and control groups, classified according to initial Wellness Score level, can be seen in Figure 2. It is clear from the group means shown in Figure 2 that it is not the "High" group which accounted for the experimental group gain in Wellness score. Indeed, this group did not improve at all, whereas the Low and Medium experimental groups increased their scores considerably after the videodisc sessions (moving, respectively, into the medium and the high ranges, whereas the control groups remained in t_hesame range where they began)4. A repeated measures analysis of variance with three factors - - Group (Experimental or Control), Initial Wellness Score Level (Low, Medium, or High), and Time (Before or After the Video Sessions) - - confLrmed that the improvement in the experimental group's Wellness Scores was significantly greater than that of the control group (F = 6.42, df = 1, p < .05, for the interaction between Group and Time). This is evidence for the educational effectiveness of the videodisc in teaching the principles contained in the Wellness Questionnaires.

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• Experimental n Control 32-

300 0 ¢I) m

29-

28. m o

27-

26-

!

I

I

Before

After

Figure 1. M e a n W e l l n e s s Scores for the experlmerltal ( N = 12) and control ( N = 12) groups before a n d after the video s s s s l o n s .

The concepts tested by the Wellness items are considered by the authors to be elementary assumptions from which many conclusions are derived. From a cognitive perspective, the substitution of a false premise at this basic level could lead the individual to draw inappropriate conclusions that would have negative cognitive and behavioral consequences. Therefore, the experimental group's gain of several points in Wellness Score is considered to be clinically promising. The three way interaction between Level, Group, and Time was not significant (F = 1.65, dr= 2 , p = .22). This indicates that the difference in pattem between the high Wellness scorers and the other groups, although suggestive of a greater benefit from the videodisc for low-functioning subjects, was not statistically significant.

Effect Upon Simulation Scores The expectation that subjects in the experimental condition would show an improved understanding of the simulation contingencies by scoring higher on 2nd STS than on 1st STS was disconfu'med. Instead of rising from the 1st STS mean of 6.2 (N = 12, SD = 3.5), the 2nd STS declined to 5.9 (N = 12, SD = 5.6). This was largely attributable to several inpatients who elected for Cathy to return to the hospital immediately. The comments of these subjects, as logged by the experimenters, indicated that some subjects did not know the simulation paths well, some were still "playing" in spite of the f'mal Test Instructions, and some felt that immediate return to the hospital was the best ending to the story given the other options that they had seen most recently. Changes in procedure such as allowing another

Interactive videodisc in rehabilitation

69

IOw Wellness Scorers 29-

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Figure 2. Mean Wellness Scores for the experimental and control groups before and after the video sssslons for Low, Medium, and High scorers on the Initial Wellness Qusstlonnelres. The Low group Included 4 experimental and 6 control subjects. The Medium and High groups each had 4 experimental and 3 control subjects.

try afterwards might have clarified the degree to which the subjects were familiar with the simulation paths. The subjects whose simulation scores declined nevertheless shared the overall trend for Wellness scores to rise. The average gain in Wellness score for subjects whose simulation score declined was .5 (N = 8, SD = 2.8). Although these subjects did not do well on the final "test," their intermediate practice runs may nevertheless have helped them to become familiar with some of the educational content of the disc.

Effect Upon the MCAPS Neither the experimental nor the control group improved in their MCAPS ratings, nor was there any significant difference between the experimental a n d c o n t r o l groups. The mean MCAPS for the experimental group was 91.7 (SD = 12.5) before the video sessions and 90.8 (SD = 15.4) afterwards. For the control group, these scores were 92.7 (SD = 15.3) before and 92.0 (SD = 18:0) afterwards.

70

Olevitch and Hagan Table 1. Items Included in the Alert Score

(1) has talked without making sense. (2) has been able to keep mind on what he or she is doing. (3) has acted as if unable to make decisions about simple, everyday things (4) has done things which do not make sense. (5) has forgotten to do important things on time. (6) has shown good judgment. (7) has had periods of not being as sharp as usual. (8) has had periods of being unable to remember things.

Although the overall MCAPS ratings did not improve as a result of the videodisc sessions, it was reasoned that the MCAPS measured a very heterogenous set of behaviors and that some subset of MCAPS items might have been affected by the experiment. The focus of the Cathy disc was not upon any particular behavior such as sociability but, rather, on an approach to stress management that gave equal weight to diverse methods of achieving wellness. One viewer of the disc may have learned something about seeking social support. Another may have learned about rational restructuring; in any of these cases, the goal was to achieve a certain state of mind in which stress and symptoms were well managed. The improvement of the experimental group in Wellness Scores indicated that they absorbed some of the message of the videodisc. Thus, if there was some area of their observable behavior that would be affected, it might be the extent to which they were perceived as alert, lucid or reasonable or as having a clear consciousness or mental "presence." In order to determine whether this was the case, eight MCAPS items were selected as being pertinent. The sum .of each subject's score on these items was called their Alert score. See Table 1 for a listing of the Alert items.The Alert score had a possible range of 4 to 32; a score of 32 would indicate the highest level of "alermess." For an analysis of the Alert score, scores were classified according to three factors: Group (Experimental or Control), Initial Wellness Score Level (Low, Medium, or High), and Time (Before or After the video sessions). The group means before and after the video sessions are shown in Figure 3. A repeated measures analysis of variance of the three factors showed that the 3-way interaction between Group, Wellness Level, and Time approached significance (F = 2.84, df= 2, p < .10). Analysis o f t h e separate Levels of initial Wellness Score revealed that the interaction between Group and Time was significant for the group whose initial Wellness Scores were at the Low level (F = 8.33, df = 1, p < .05). Thus, for subjects at the Low level of initial Wellness Score, a positive effect of the experimental condition upon observable behavior related to Alermess was demonstrated.

CONCLUSION

The findings of this study indicated that patients with a diagnosis of schizophrenia could interact with a videodisc educational program and enjoy doing so. It was further demonstrated that, when used according to the procedurestested in this study, the How to Get Out and Stay Out videodisc was effective in raising the scores of schizophrenic subjects on the Wellness Questionnaires, including subjects who scored low on the Wellness Questionnaires at the outset. Low scorers on the

Interactive videodisc in rehabilitation

71

Low Wellness Scorers

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Figure 3. Mean Alert scores for the experimental and control groups before and alter the video sessions for Low, Medium, and High scorers on the InlUal Wellness QuesUonnaires. The Low group Included 4 experimental and 6 control subjects. The Medium and High groups each had 4 experimental and 3 control subjects.

Wellness Questionnaires also showed an improvement in their "alertness" as judged by raters. The study sample was restricted only to subjects who could handle the Wellness Questionnaires, which probably required a higher degree of literacy, concentration, and motivation than the videodisc program itself. The benefit attained by the Low Wellness scorers suggests the utility of further study of patient populations whose level of intellectual functioning is lower than the subjects included in the current study, that is, subjects whose reading level would not permit them to complete the Wellness Questionnaires but who could handle the videodisc menus. The study sample was also restricted to subjects with a diagnosis of schizophrenia. The utility of this disc for nonschizophrenic psychiatric patients would also be a topic of further investigation. The benefit derived by the participants in this study was achieved without the opportunity to discuss the disc with either a therapist or a group. Nor were the sub-

72

Olevitch and Hagan

jects preselected on the basis o f the content being pertinent, that is, subjects w h o were just about to leave the hospital. Also, all subjects were limited to only two sessions with the videodisc, whether they wanted m o r e time or not. Future clinical exploration and research m i g h t also focus u p o n whether the benefit o f the disc can be enhanced b y preselection or b y tailoring individual study p r o g r a m s or b y the addition o f therapist or group discussion. It is h o p e d that in the future, a n u m b e r o f discs would be created, e a c h having a m e a s u r a b l e effect u p o n the teaching o f a limited content area. T h e d e v e l o p m e n t of a diversity o f such teaching materials would provide the tools for a m o r e c o m p r e hensive, c u m u l a t i v e , educational process, w h o s e total effects w o u l d surpass the threshhold for easily observable clinically meaningful behavior change.

NOTES 1. The reason for excluding forensic patients was that their length of stay could not be analyzed along with the length of stay of the rest of the sample, since it could not be interpreted in the same way. 2. One particular self-help scene, which stirred much positive emotion in pilot viewers, was scored as 2 points instead of 1 point. 3. Except for the analysis explicitly comparing the "automatic" variant condition with the other conditions, subjects in the "automatic" variant condition were not included in any other analyses comparing the experimental and control groups before and after the video sessions. They are included, throughout this article, in some correlational analyses. (When they are included with the entire sample, then N =30. When they are included only with experimental subjects, then N =18.) 4. Also, even for the Low and Medium groups combined, with the High group excluded, there was not a significant correlation between initial Wellness Score and gain in Wellness Score (r = .17, N = 17, NS).

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social intervention in the families of schizophrenic patients. British Journal of Psychiatry, 141, 121-134. Libennan, R. E, Mueser, K. T., Wallace, C. J., Jacobs, H. E., Eckman, T., & Massel, H. K. (1986). Training skills in the psychiatrically disabled: Learning coping and competence. Schizophrenia Bulletin, 12(4), 631-647. McCullongh, L., Farrell, A. D., & Longabaugh, R. (1986). The development of a microcomputerbased mental health information system. American Psychologist, 41, 207-214. Norusis, M. J. (1985). SPSS-X Advanced Statistics Guide. New York: McGraw Hill. Norusis, M.J. (1988). SPSSIPC+. Chicago. Olevitch, B. A., & Hagan, B. J. (1989). How to Get Out and Stay Out: An educational videndisc for the chronically mentally ill. Computers in Human Services, 5(3/4), 57-69. Rosenbcrg, B. A., & Hagan, B. J. (1987a). How to get out and stay out: The story of Cathy. (An educational videodisc simulation for the chronically mentally ill). Rosenberg, B. A., & Hagan, B. J. (1987b). How to get out and stay out: The story of Cathy. Presentation at the Annual Nebraska Videodisc Symposium, October 7, 1987. Zubin, J., Steinhauer, S. R., Day, R.,& van Kammen, D. P. (1985). Schizophrenia at the crossroads: A blueprint for the 80s. Comprehensive Psychiatry, 26, 217-240.