The International Journal of Psychosocial Rehabilitation
Promoting the Psychosocial Functioning of Young Adults
through Psychiatric Residential Rehabilitation:
A Qualitative Evaluation of the Making a Significant Change (MASC) program

 

Melinda Kelly PGDipPsych
University of Ballarat
melindak@ballarat.catholic.org.au
 
 
Candice Boyd PhD
University of Ballarat
c.boyd@ballarat.edu.au
 

 

 


 Citation:
Kelly, M. & Boyd, C. (2006). Promoting the Psychosocial Functioning of Young Adults through Psychiatric Residential
Rehabilitation: A Qualitative Evaluation of the Making a Significant Change (MASC) program.
 
International Journal of Psychosocial Rehabilitation. 
10 (2), 139-153 .

 

Corresponding author:  Dr Candice Boyd
Rural Adolescent Mental Health Group
Centre for Health Research and Practice
University of Ballarat
Ballarat, Victoria, 3353, Australia.
  

Abstract
Aims and purpose of the study
This research evaluated the Making a Significant Change (MASC) program – the only residential psychosocial rehabilitation program for young adults in the Grampians region of Victoria, Australia.  The program provides intensive support and rehabilitation services to young people aged 16 to 24 years who have a mental illness and are at risk of developing further mental health disabilities. This evaluation aimed to establish a holistic view of the program with a focus on the process of rehabilitation rather than a pure examination of the outcomes.  The purpose of the evaluation was to provide descriptive data for key stakeholders in the service so that the impact of intervention approaches could be gauged. 
Methods
A qualitative methodology explored the attitudes and perceptions held by consumers and staff of the MASC program. Data were collected through in depth semi-structured interviews with seven participants (four consumers and three staff).  These data were triangulated with consumers’ case histories and individual program plans.
Findings
The evaluation found that all of the domains of psychosocial functioning were covered efficiently within the MASC program and that skills learnt during this process built resiliency enabling most consumers to obtain a comfortable lifestyle for themselves.  Areas of program delivery which could benefit from revision included modification of the initial stages of entry into the program and immediately after discharge from acute inpatient hospital admissions. The importance of considering the needs of staff to overcome feelings of frustration and complacency was also highlighted.
Key Words: Psychiatric Residential Rehabilitation, Young Adults, Qualitative Methods


Introduction
An estimated 634,000 young adults in Australia experience a mental health disorder (Blair, Burthon, Silburn & Zubrick, 2000). The issues related to mental illness for young adults are complex and reach into many domains of an individual’s life. The first episode of a disorder can exacerbate normal developmental issues experienced during this life stage, affecting psychosocial functioning that is critical to an individual’s social and emotional wellbeing (Harrop & Trower, 2003). Studies have indicated that psychotic disorders, anxiety disorders and mood disorders produce deficits in psychosocial functioning in adolescence and adulthood. Such deficits include impaired academic and occupational functioning, social difficulties, poor peer relationships, lowered life satisfaction, increased adversity, increased treatment utilization, criminal arrests and reduced global functioning (Gotlib et al., 2003; Reinherz, Giarconia, Carmola Wasserman & Silverman, 1999).
 
High-risk behaviours can foster further serious deficits in psychosocial functioning for young adults experiencing mental illness (Davis et al., 2000). Such high-risk behaviours include increased alcohol and drug use, self-harming, unsafe sexual behaviour, reckless driving, aggression toward others and an increased risk of suicide (Drake, McLaughlin, Pepper & Minkoff, 1991; Siegfried, 1998; Rayner & Warner, 2003; Burnely, 1994). The risk of suicide is exacerbated by complex social issues such as family breakdown, unemployment, low self-esteem, homelessness, poverty and drug and alcohol abuse (Burnely, 1994). Further disabilities once established can prove to be resistant to change in later adulthood (Blair et al., 2000).
 
Promoting Psychosocial Functioning as a Treatment Modality
Findings from past research suggest that effective intervention with young adult consumer groups require approaches that target multiple complex domains in order to foster resilience and build skills (Fuller, 1998; Fuller, McGraw & Goodyear, 2002; Kosky, 1992 & Nemec & Furlong – Norman, 1989). A large Australian found young people perceived support, belonging, sense of citizenship, ability to contribute, a sense of mastering and connectedness to family and peers as important skills for promoting resilience and well being (Fuller, 1998). When effective, such intervention approaches act to reduce the impact of suicidal ideation, self-harming behaviours, aggression, substance abuse and mental health issues (Kosky, 1992; Nemec et al., 1989). Psychosocial interventions employ techniques aimed at decreasing symptoms and maladjustment by improving adaptive and social functioning (Gotlib et al., 2003; Geller, Zimmerman, Williams, Bolhofner & Craney, 2001). Such processes include the attainment and development of skills through learning and motivation to improve affect, cognitive processes, behaviour, interpersonal interactions and self-confidence. 
 
The Making a Significant Change Program
The ‘Making a Significant Change’ program (MASC) is provided by Centacare in Victoria within their psychiatric disability rehabilitation and support service (PDRSS). Such programs are designed to compliment clinical mental health services by providing psychosocial assessment, rehabilitation and support (Department of Human Services, 2003). Non-government organisations in the community manage these programs statewide (Department of Human Services, 2003).  The MASC program services the Grampians region operating from the regional city of Ballarat. The total population of the Grampians region is estimated at 202,952 residents (Australian Bureau of Statistics, 1999). Of the total population, an estimated 23,888 residents are aged between 16 and 24 years (Department of Infrastructure, 2000).
 
The MASC program provides intensive support and rehabilitation services to young people aged 16 to 24 years who have a mental illness and are at risk of developing further mental health disabilities. Examples of common illnesses within the consumer group are schizophrenia, bipolar affective disorder, and depression. The MASC program is a relatively new program, operating since 1999. The program aims to provide short-term intensive support to improve the mental health status and quality of life of consumers (Centacare & Ballarat Psychiatric Fellowship, 1998).  The promotion of psychosocial functioning aims to decrease high risk behaviours, build skill mastery and improve self confidence before young adults are supported to reintegrate into their own rural communities (Centacare & Ballarat Psychiatric Fellowship, 1998). A solution-oriented approach is adopted to compliment the framework of psychosocial rehabilitation in order to guide “the process of facilitating an individual’s restoration to an optimal level of independent functioning in the community…” (Cnaan et al., 1988).
 
There are three levels of support offered by the MASC program: Intensive rehabilitation is provided within a residential rehabilitation setting that is staffed seven days per week from 8 am to 10.30 pm, with the option of twenty-four hour support if the need arises (Thorne & Davis, 2000). The second level of support involves home-based outreach in which consumers work with staff on a less intensive basis. Support is offered to assist consumers and where necessary carers, with the transition phase of returning to local communities (Thorne & Davis, 2000). The third level of support involves,secondary consultation, where staff work closely with rural providers of services to establish continuity of care throughout the transition phase and to ensure ongoing care where necessary after the consumer exits the program (Thorne & Davis, 2000).
 
Each level aims to support consumers maintain their mental health and overcome high-risk behaviours by building skills in the areas of mental health, budgeting, recreation, social skills, motivation, education, employment, working toward living independently, utilizing community services and family reconciliation (Thorne & Davis, 2000). Individual program plans are used to explore and identify the goals of consumers, establish a plan of action and to monitor progress (Thorne & Davis, 2000).
 
Aims of the Study
This study aimed to establish a holistic view of the program with a focus on the process of rehabilitation rather than a pure examination of the outcomes. The first aim was to determine the attitudes and perceptions that participants had toward the role of rehabilitation within the recovery process for young adults experiencing mental illness. The second aim was to identify the attitudes and perceptions participants had toward the intervention strategies currently employed. The third aim was to ascertain the extent to which it is perceived that the lives of consumers had changed from participating in rehabilitation. The fourth aim was to explore the participant’s perceptions of what the future holds for consumers.


Method
Participants
The study involved seven participants, three staff members and four consumers. Demographic information obtained from consumers included age, gender, primary diagnosis, secondary diagnosis, identified high-risk behaviours and length in program. To build a profile of the MASC consumer population, demographic information was obtained for each individual who had accessed the program during the time of its existence (i.e., 1999 to 2004). The mean age of all consumers was 21.16 years of age (N=57). The mean length of time spent in the program was 8.42 months. The most commonly occurring primary diagnosis was schizophrenia (45.6%), followed by a drug induced psychotic episode (19.3%), depression (15.8%) and bipolar affective disorder (8.8%). Co-occurring mental illness was noted in 45.6% of consumer cases. Drug induced psychotic episodes (30.8%) were the most common co-occurring diagnosis followed by depression (19.2%). The most frequent high-risk behaviours acknowledged at time of entry into program for all consumers were drug and alcohol abuse or dependence (82.5%), previous acute inpatient admissions (73.7%), previous suicide attempt (42.1%), self-harming behaviour (36.8%) and history of aggressive acts towards others (36.8%).
 
Materials
Semi structured Interviews
Semi-structured interviews were considered to be the most effective method of acquiring an overall view of the program whilst allowing the exploration of alternative issues if they arose.
 
Case Histories
ndividual program plans, activity timetables and communication notes that record the daily activities of consumers were used to produce a series of case histories. Individual program plans are a mandatory component of the program and reflect a number of the programs’ key aspects. These aspects include mental health, drug dependencies, physical health, family, education, personal appearance, hygiene, diet, budgeting, creative personal expression, vocational training, exit plan and are used to  identify difficulties for consumers, set goals, monitor current status and record action taken to date. Individual program plans are reviewed on a six monthly minimum basis.
 
Data Triangulation
Data triangulation refers to the use of multiple sources of data for providing information (Flick, 2002; Goodrick, 2004; Patton, 2002). For the purpose of this study, the process involved building thematic conceptual matrices of the information obtained from staff interviews, consumer interviews and case histories (see Miles & Huberman, 1994 for more on matrix displays). 
 
Procedure
Ethical approval was granted by the University of Ballarat’s Human Research Ethics Committee. All ethical principles were followed in the course of conducting research.
 
Interviews were conducted for approximately an hour and a half and were audiotaped. Interviews were conducted by the first author, who was also a casual employee within MASC at the time.  This dual role was managed by stressing to all participants that the research was being conducted by the University of Ballarat
 
The staff interviews were performed on an individual basis by the first author. Interviews with consumers were conducted as a group interview at the request of participants. The audio recordings of interviews were transcribed following completion. Transcripts were compiled following the qualitative data preparation and transcription protocol developed by McLellan, MacQueen and Neidig (2003).
 
Process of Data Analysis
An approach to thematic coding based on constant comparative methods was used to analyse the transcribed interview data (see Dye, Schatz, Rosenberg, & Coleman, 2000 for description of this processs) . Data analysis was carried out by the first author and revised in consulation with the second author who acted in a supervisory capacity. In addition to the data obtained from interview, summaries of communication notes and activity timetables obtained from individual program plans were made. Data were then built into matrix displays to allow ease of comparison across cases and cross-referencing between program documents and the attitudes and perceptions of participants.  The final results comprise a series of thematic descriptions, incorporating data from these multiple sources as well as selected quotations from the study’s participants.  Themes also relate back to the study’s four main research aims.
   
Results
 
Theme 1: Attitudes and Perceptions Participants Had Toward the Role of Rehabilitation within the Recovery Process
They wouldn’t be in this program if they hadn’t had a major psychiatric episode…that they didn’t have high-risk behaviours like drug abuse or self harm or suicidal thoughts…or all of the above (staff)
 
Perceived Purpose of Rehabilitation
Participants perceived the purpose of the program was to restore consumer’s previous levels of overall functioning to enable them to live independently within the community.  It was perceived that to achieve this, the program served as a place to establish social networks within a supportive and non-judgemental environment free from stigma. 
 
Some of these guys have done some pretty horrific things in the past and been in some really quite… antisocial settings so to actually be accepted for some of that stuff where no one else has accepted them is a really good starting point” (staff).
 
It pulls people out of holes a lot you know… someone I knew was like… in real trouble and MASC pulled em out of trouble and gave em a fresh start in a new place” (consumer).
 
Programs like ours are there to transit these kids through that pretty rough stage and they come out the other end… having learnt to be independent (staff).

 
The Perceived Role of Rehabilitation in Overcoming Mental Health Issues and High Risk Behaviours
I didn’t even know what psychosis was I just thought things (laughs) weren’t going well (consumer).

Common perceptions of the role of rehabilitation in overcoming mental illness were to restore self-esteem and confidence through support and education on precipitating factors. Prevention and intervention to overcome high-risk behaviours and links into other agencies were identified as being important within the recovery process. Cross references with individual program plans highlighted the role of the program in supporting consumers through the differing phases of illness.
 
Yeah I lost a lot of confidence from my last…psychosis so… I gotta build it back up again (consumer).
 
It’s been like a year now and I haven’t used em coz I know if I do I will probably get sick again and end up in psychosis and end up back in the psych ward and I will probably never come good again (consumer).
 
There’s a lot of agencies and things that they’ve got access to that help you in a lot of different ways (consumer).
 
If there’s drugs and stuff happening…if you’re at home and you stuff up a couple of times and you’re gone, but you get a few chances to realize what’s the right thing to do (consumer).
 
Promotion of Daily Living Skills and General Health and Well-being
Daily living skills identified as being promoted within the program were cooking skills, personal hygiene, personal care, budgeting, and cleaning skills. Cross references with individual program plans also identified physical health, personal appearance and diet.
 
So, the funding is around daily living and ensuring that they’ve got the skills to look after themselves. So, it’d be you know making sure that they learn how to cook, clean…” (staff).
 
To get you into things you got to do to get into the normal rhythm of what you have to do in life (consumer).
 
It was acknowledged that the promotion of well-being worked to rebuild trust, overcome fear and hopelessness. Techniques used to do this incorporated the encouragement of positive family relationships, re-establishing social networks, participation in recreational activities, vocational and educational support.
 
You do a bit of fun stuff and give yourself good ideas of what to do in the future, have a few experiences, you know always having people there to talk to that are intelligent and know what you’re talking about (consumer).
 
I liked being the footy head and knowin’ a lot of people I like that, I really did like getting along with heaps of people and havin’ lots of friends and stuff n I think that’s what broke me for ages (consumer).

 
Theme 2: Attitudes Participants Had Toward the Intervention Approaches Currently Employed and the Perceived Effectiveness of Those Interventions
 
If you can’t build that rapport with the young person then really you’re not going to be able to work on any of the other issues. You get a small window and as soon as that window opens, you need to jump in, get in before they shut the window and hopefully you can actually get on with it and move forward (staff).

Attitudes towards the Program as an Intervention Strategy
Recurring patterns of consumers feeling ‘pushed’ whilst in the program occurred across participants.  It was identified that the reactions to being pushed were dependent on the phase of illness. Other patterns indicated that interventions employed mostly made consumers feel safe, supported, and secure.  Consumer participants expressed appreciation toward the program for aiding participants to feel well again.
 
It’s pushing you to be doing stuff and that’s when it sucks, when your in the depths of depression and you just want to be sitting there (consumer).
 
I really didn’t like being pushed much… but it is a good thing coz it keeps you active… it keeps your mind active, keeps you healthy (consumer).
 
It was good for me in the whole sense of I wanted to get to a safe place, MASC felt like a very safe place coz like you were being supervised sort of… (consumer).
 
They definitely helped me out a lot just to get well again after the psych ward basically (consumer).
 
Formal Strategies
Formal strategies explored were the use of a solution-oriented approach and individual program planning. Attitudes toward these approaches varied across cases. Issues influencing the effectiveness of individual program plans included time availability and motivation. Cross-referencing indicated that they were particularly useful in exploring creative personal expression, family relationships, physical health and budgeting. Substance use and mental health components had mixed outcomes. Education and training had poor outcomes with cross-referencing demonstrating a lack of interest in pursuing these goals any further.
 
The workers are too busy to pull out everybody’s IPP everyday to have a look and read through four pages (staff).
 
It’s mainly just paperwork really, at least that’s what I seem of em (consumer).
 
I thought IPPs helped… I had to do things a certain way and I got it done and I got it done the way I wanted it coz it helps you to set goals. Oh, but sometimes when you don’t want to do anything, when you don’t want to be doing anything it sucks (consumer).
 
We are not dwelling on what happened in the past or what the problem is… we’re actually trying to look at you know achieving goals for the future (staff).
 
 
Informal Strategies
Numerous informal strategies were identified. These included activity timetables that were recognised across cases as effective on a day-to-day basis, role modelling, psychoeducation and the use of general discussion. Cross-referencing with individual program plans identified the use of ultimatums, intensive key support, music groups, accessing short courses, liaison with other agencies, redefining self-boundaries, intensive communication, identity kit lists and stress management sessions.
 
With your work timetable, on a weekly basis you can pull from that IPP and actually keep it active on a weekly basis (staff).
 
Role modelling is the big thing for this program, staff are expected to role model socially acceptable practice (staff).
 
Earlier on I used to talk to [name] every morning for two hours, every morning we used to sit down and have a cup of coffee and a smoke and just talk (consumer).
 
Specialised Strategies
Across cases, harm minimisation approaches were consistently reported as an effective way of reducing the severity of high-risk behaviours. Other interventions identified were the use of urine screens, drug diaries and consultancy and collaboration with external specialised services. External services included a drug and alcohol withdrawal unit, drug and alcohol counsellors, peer support networks, community psychology services and the utilisation of case management from psychiatric services.  Cross-referencing further revealed the use of alcohol agreements, random breath testing, and implementation of post withdrawal strategies.
 
You know it relaxes me I enjoy it but only in moderation. It fucks me up if I have too much… (consumer).
 
It’s quite strange that three pieces of paper and a little coloured book may be the answer for some of these young people (staff).
 
Depending on what the consumers needs are quite often find that they don’t want extra people. They would rather… deal with their issues in house and you know that is a concern because the staff aren’t actually employed as drug and alcohol workers or dual diagnosis workers (staff).
 
Perceptions of the Work Carried Out by Staff 
Across cases, it was perceived that staff members were conducting their work well. Staff participants identified that the area was frustrating and that the work was difficult. However, their responses indicated that they perceive their positions and the work that they conduct as rewarding. Consumer participants described feelings of admiration of the staff’s ability, feelings of grief during periods of staff turnover and that they are very involved in the lives of consumers.
I don’t know if they could improve, they interact unreal I reckon, they really get in-depth in all their lives pushin’ the right directions and stuff you know, they do a good job I reckon (consumer).
 
One of the big things for staff is that we get complacent with what we’re working with. We forget that these people are in the program for a reason and they are the extreme end of the scale and I mean we’re working with them everyday (staff).
 
 
Strategies Employed by Staff to Overcome Feelings of Frustration
Strategies that were reported as useful for staff were the feedback from external sources, the role of supervision, using a positive outlook, and the ability to separate professional and personal roles.
 
I’ve learnt that what I thought were the important issues sometimes aren’t the important issues (staff).
 
I think over that five year period I learnt to look for more positive then I have negatives (staff).
 
It’s extremely important that staff actually meet supervision guidelines (staff).
 
I have learnt over the years that you have to have a cut off point between your life and the young people that your working with (staff).
   
Theme 3:  Extent to Which the Lives of Consumers Had Changed Resulting From Participating In Rehabilitation
 I guess making friends in new places is good and figuring out them people aren’t everything in your life and other things are more important like your actual proper friends and your family and that you’re living a good life and stuff is better then worrying about a handful of people and what they dislike about ya (consumer).
 
Short Term Impact
The expansion of social networks was identified by all participants in the study. Other persistent patterns emerging across cases were improved family relationships, restoration of confidence, a sense of belonging, attachment and acceptance and the development of positive outlooks, which included hope for the future, aspirations, and goals.
 
That was the most important thing, finding companionship and good friends really (consumer).
 
So, I’ve always wanted to do something with my music so in the next however long if something happens and I actually get to play somewhere that will be a good thing (consumer).
 
We’ve actually taken them out and done stuff like jumping off cliffs with all the safety harnesses on and all that sort of stuff. So that they can actually experience you know that it’s ok to jump off a cliff… its safe, you know it’s just as safe to go out and go for a job (staff).
 
Long Term Impact
Perceived changes that continue to influence the lives of consumers into the future included improved employment prospects, relocation from their place of origin, obtaining a sense of achievement and the establishment of family relationships in situations where they previously did not exist. Cross-references with individual program plans showed consistent changes across cases showing that participants were maintaining healthy family relationships, completed training programs, and currently living independently with intensive outreach support.
 
They’ve actually achieved stuff and they’re actually happy with their lives. And there’s people out there who are still using drugs but their living independently and they’re happy with their lives and they’re actually moving forwards (staff).
 
This young person actually sess their child on a monthly basis now with supervision and that child is actually going to have a father in his life (staff).
 
Some of the guys leave the Grampians region altogether, they decide that it’s better to have a fresh start (staff).
 
 
Influence on Well Being and the Daily Living Skills of Consumers
Improved overall functioning and improved nutrition and diet were reported across all cases. Other consistent patterns were improved physical health, overcoming fears and improved levels of life satisfaction. Cross references with individual program plans highlighted changes across cases related to improved personal hygiene and physical health and an ability to manage own finances.
 
The feedback that we get from family and other people are that yes this person is doing really, really well compared to what they were before they came into the program (staff).
 
We can go shopping, we can get videos, we can drive down the street, we can get takeaway, we can go away, we can go back to [town] but leave whenever we want, we can go on a holiday up the Murray and go fishin’ (consumer).
 
 
Influence on the Management of Mental Health Issues and High Risk Behaviours
A theme that emerged across all cases was that the mental health status of consumers improved with a reduction in high risk behaviours.  Furthermore, raised awareness of the impact of high risk behaviours was thought to improve insight and assist consumers to overcome negative issues related to mental illness. Cross-referencing indicated that all participants showed a reduction in substance use over the course of their time in the program and that their illnesses were currently in remission.
 
Feeling healthy like you know I’m not sick in the head or the body or anything like that and I’ve got friends and social networks and I’ve got family (consumer).
 
He’s reduced his drug use… his mental health improved, and his social shills improved… so it was working on drugs worked into mental health worked into social skills (staff).
 
 
Theme 4: Participants’ Perceptions of What the Future Holds For Consumers
Immediate Future
A theme that emerged across all cases was that participants perceived a future for consumers where they would have to deal with a lack of anonymity and social stigma. For example, there was a perceived inability for consumers to return to their place of origin. Other patterns across staff cases was the perception that some consumers will be able to overcome their mental illness and others will need long term psychiatric care in the future. 
 
I hate it now, I just go there and I get this eerie feeling, I’m avoiding people and I don’t want to go up the street coz I might see em and I might have to talk to em (consumer).
 
I’m just thinking of a couple of people who have been through this program and they’ve ended up in longer term psychiatric facilities (staff).
 
Long Term Future
 Reported consumer hopes for the future were similar across cases; these included gaining employment, developing romantic relationships, having a license and a vehicle. Other emerging patterns included relocation from place of origin and the resolution of issues after leaving the program.
 
…get another car and get back on the road again, bit more freedom, maybe get a girlfriend one day… maybe have a family one day, buy me own house… yeah… it’d be good (consumer).
 
 For years I’ve wanted to move away somewhere real far away (consumer).
 
Some of the feedback from families… are actually saying hey look, I know it was traumatic when our son or daughter was here but they’ve followed through you know (staff).
 
Mental Health Status
The overcoming of mental illness and resolution of mental health issues in the future was a recurring pattern across cases. Consumer responses indicated that they would not disclose their past psychiatric history to others in the future. Staff responses suggested that it was perceived that the prognosis for consumers was either remission or long term psychiatric care.
 
If I had a girlfriend one day or I just met someone who know nothin’ about mental illness I wouldn’t be saying this sort of stuff (consumer).
 
I actually see a good prognosis for most of the people who come through (staff).
 
You can’t underestimate that some people do need to have longer term support and you know we support… in mental health terms two years is a very short period of time (staff).
 
Well Being and Daily Functioning
Participants perceived that consumers would feel comfortable with their lifestyles, have an improved level of self-esteem and confidence and lead an active lifestyle. It was also perceived that the impact of societal pressure would produce additional challenges for consumers to overcome in the future.
 
So I don’t think its going to get any easier… there may be more challenges (staff).
 
It might not be the way that I see it as ideal or the staff see it as ideal or someone else looking into it but I think that the majority of people will actually achieve something and be living the life they want to live (staff).
 
He just can’t wait to zoom off into the night and go camping all over the different parts that he wanted to see… and he’s you know, I’m well I can do this, I can go and see outside the west Grampians area (staff).
 
Discussion
This study aimed to establish a holistic view of the MASC program with a focus on the process of rehabilitation rather than a pure examination of the outcomes.  Overall, the evaluation revealed that all of the domains of psychosocial functioning were covered efficiently within the MASC program and that skills learnt during this process built resiliency enabling most consumers to obtain a comfortable lifestyle for themselves.  Specific themes emerging from the data enable each of the study’s four main aims to be addressed.
 
Shared and differing perspectives of the impact of psychosocial rehabilitation on the lives of consumers
The first aim of the research was to determine the attitudes and perceptions that participants had toward the role of rehabilitation within the recovery process for young adults experiencing mental illness. The broad range of themes and patterns emerging from the data demonstrated, from a holistic perspective, the impact of psychosocial rehabilitation on the lives of young people with a mental illness.  Overall, the program was seen as a place that was non-judgmental in which young people could feel safe, supported, and rebuild their confidence. This was perceived as serving an important role in alleviating anxiety and fostering an environment where consumers can work on personal issues without the added burden of feeling unsettled. All participants in the present study provided positive feedback regarding the program as a whole. The emphasis of such feedback was on the achievements of the individual consumers. Such positive responses may be a reflection of the use of a solution-oriented approach within the program. Using this approach within the program has trained staff and supported consumers in assessing situations and reframing issues from a positive viewpoint on two levels: first, within the program and second, in the other areas of consumer’s lives.
 
Consumers also commented on the expansion of their social networks, benefits of keeping active, the overcoming of fears, and the restoring hope for the future within a supportive environment. In comparison, staff emphasised issues related to the restoration of overall functioning, equipping consumers with skills to enable them to live independently and the development of positive outlooks. Such differences in the perspectives of staff and consumers may be explained in terms of motivation. Participants within the program are motivated to participate in the program for individual reasons that reflect their stage of psychosocial functioning, i.e., identity formation (Davis et al., 2000). Staff tended to identify in their responses issues that reflect the values reinforced through employment conditions and professional development training.
 
In terms of consumer satisfaction, consumers reported feeling that the site of the program was a good place, and the experience of participation overall was also good. They felt safe, secure and supported most of the time. Such feelings have been described as protective or resilient factors against such high-risk behaviours as self-harm, substance abuse and aggression (Fuller et al., 2002). Contradictory responses from consumers pointed to feelings of frustration during certain stages of the program. In particular, a number of consumer responses described a feeling of being pushed. While this is perceived as beneficial by consumers in hindsight, it was not appreciated by them during the initial stages on the program or after being discharged from psychiatric services. Feeling pushed can leave consumers feeling frustrated and misunderstood. These feelings have the potential to interfere with building rapport with young people who have particularly complex needs and prolong the time it takes to realise the therapeutic benefits of the program (Fuller, 1998). Despite this, consumers who participated in this study have passed through all of the stages of the program and reported feeling satisfied with the program overall. Consumers also indicated their respect and admiration regarding the role that staff play within the program.
 
Two opposing viewpoints emerged from the responses of staff regarding levels of their satisfaction with the program. On one hand, it was recognised that day-to-day work is largely stressful with staff working long hours, combating frustration and feelings of complacency. On the other hand, the attitudes of staff were positive in nature and it was recognised that, although the day-to-day work was challenging, as a whole the work was rewarding. Staff emphasised the role of looking for positives, recognising small achievements and establishing day-to-day living skills as the most rewarding components of the program yet little recognition was given to these issues by consumers. The emphasis staff placed on these issues may arise from a need to define achievable goals in which success can be measured to gain job satisfaction from a challenging work environment.
 
Shared and differing perspectives on intervention approaches and program delivery
The second aim of this study was to identify the attitudes and perceptions participants had toward the intervention strategies employed by the MASC program. Consumers highlighted feelings of being pushed during the initial stages of the program as a limitation of service delivery. Entry into the program is often a period where discharge from acute services has recently occurred and psychosocial functioning is at its lowest point. The impact of acute mental illness during this time affects most psychosocial domains on a social, emotional, physical and cognitive level.  Factored into this is the perceived effectiveness of individual program plans as an intervention approach as well as staff feelings of frustration and complacency.
 
Complacency and high levels of frustration affect the patience of staff and the time management of day-to-day tasks. As a result, individual program plans can be neglected. Complacency may be the consequence of a small team working long hours with complex consumer needs on a day-to-day basis. These issues combined with the mandated use of an intervention approach (individual program plans) that are perceived as limited, could further exacerbate staff-related frustration and complacency.
 
Individual program plans were recognised as the most limited intervention approach employed in the program by both staff and consumers. This formal approach tends to be effective only when consumers’ mental health status is stable and they are motivated to reach defined goals. Setting goals related to education and employment is not particularly realistic when basic psychosocial domains are underdeveloped. These two areas of functioning, employment and education are not perceived as important by consumers at this stage in their lives. The lack of interest and motivation from consumers in setting and reviewing goals can frustrate workers when time is limited and goals are being ignored or not being reached.
 
Frustration and feelings of inadequacy in managing the difficulties posed by consumers can lead to negative professional attitudes (Richmond & Foster, 2003). Addressing substance use and misuse puts additional pressure on staff and consumers when staff members are not trained in this area, and external sources employed to deal with such issues may not be well received by staff or consumers. For the future of the MASC program, it will important that staff are trained further in issues of substance use and abuse and be involved in continuing education on the effects of mental illness and its treatment.
 
As a whole, the program as an intervention approach was perceived by staff and consumers as considerably effective in supporting young people with mental illness to obtain improved family relationships, extended social networks, improved confidence and greater self-esteem. Development of these particular areas of a young adult’s life is particularly important to aid consumers in overcoming high-risk behaviours and the impact of mental illness. The rebuilding of skills and informal approaches to intervention were considered to be positive strengths of the MASC program.
 
Whilst working on the complex issues experienced by consumers, obtaining day-to-day functioning skills further promote psychosocial functioning and build resilience for consumers. Interventions that promote and develop skills in daily living and creative personal expression were identified by staff and consumers in this study as important. Improved psychosocial functioning and resilience act as prevention measures against the development of further disabilities in adulthood (Harrop & Trower, 2003; Fuller et al., 2002; Davis et al., 2000). The program appears to foster a positive environment within which consumers feel safe and secure. Feelings of safety and security allow consumers a freedom to develop the differing psychosocial domains, learn about themselves and explore different worldviews influenced through the diversity of staff backgrounds and personalities, social relationships through feelings of belonging and connectedness, and culture through challenging activities and regular meal and movie nights (Gotlib et al., 2003). These facets of self and world exploration are integral components of identity formation that are an important developmental task for young adults as they step into adulthood (Arnett, 2000).
 
Extent of recovery
The third aim of this study was to ascertain the extent to which it is perceived that the lives of consumers had changed from participating in rehabilitation. All of the consumers interviewed had accessed the program for more than two years. During this time, they had all had at least one further acute hospital admission. At the time of being interviewed, their mental illnesses were in remission. The extent of recovery reported by the consumers who participated in this study was positively perceived, ,with most young adults living in a way in which they felt comfortable. Improvements were reported in each of the key psychosocial domains of emotional, social, cognitive and physical development. Perceived levels of recovery were mostly at a basic level, providing a strong foundation for further development and recovery at a later stage. Developing strong hopes and dreams for the future further fosters positive steps in the direction of recovery. For those consumers who do not reach a level of recovery within the program, the alternative is long term psychiatric care and alternative support services. 
 
Hopes for the future
The fourth aim of this study was to explore the participant’s perceptions of what the future holds for consumers.  Consumer hopes for the future largely reflect the ‘typical Australian dream’: independence, full time employment, romantic relationships, later marriage and home ownership . These hopes were largely unchanged from those that existed before participants became unwell. Whilst these hopes were relatively unchanged, the consumers interviewed in this study acknowledged that they may require extra support at times in their lives in order to maintain stable mental health if they are to realise these hopes in the future. The staff at MASC who participated in this study expressed support of these dreams, hoping that consumers receive opportunities free from stigma, with a sense of anonymity and independence. Whilst staff appear supportive, they are also wary of the reality for consumers who experience frequent periods of acute illness  requiring future long term support within intensive psychiatric rehabilitation programs.
 
Methodological limitations of the study
Whilst the use of a qualitative research paradigm has provided a data set rich in information, these data are limited to the specific point in time participants were interviewed and as such the context of perceptions are strongly influenced by individuals who do not necessarily reflect the views and opinions of existing and previous members of the MASC community. The group method of interviewing the participants who were also consumers was adopted at the request of participants, and this raises questions regarding the validity of reported perceptions. Furthermore at the time of the study, the researcher occupied a dual role as both a student of the University of Ballarat and also as a casual employee of the MASC program. Whilst this served as beneficial as rapport had already been established with participants, the dual role may have influenced responses from participants and later the interpretation and discussion of results.  The personal philosophical commitments of both the researcher and supervisor to this form of intervention and evaluation technique may have potentially influenced the objectivity of data analysis. The qualitative method of evaluation used to conduct the research also limited the scope of the research project as it proved to be time consuming limiting its capacity to include other important stakeholders such as carers in the interview process.
 
Recommendations
The present study found the MASC program to be an effective intervention approach for young adults experiencing mental illness.  Perceptions of staff and consumers toward the program were largely positive; however, areas of program delivery that could benefit from revision in aid of further strengthening the therapeutic impact of the MASC program were also identified. The following two recommendations are made, based on the results of this evaluation.
 
Recommendation 1 - Modification in the initial stages of entry into the program  and immediately after discharge from acute inpatient hospital admissions. 
Consumers in this study felt particularly vulnerable during the initial period of entry into the program and negative interactions or interventions at this time have the potential to prolong the time it takes therapeutic benefits to have an influence. The interactions and interventions employed during these stages depend strongly on building rapport with consumers. Currently consumers are feeling pushed in a negative way during these times due to the emphasis on formal intervention approaches. Informal approaches were highlighted as the most beneficial and well-received interventions during these times. It is recommended on the basis of this evaluation, that staff revise current practices during the earlier stages of entry into the program and incorporate informal approaches to ensure consumers perceive all stages of program participation in a positive light.

Recommendation 2 – Staff support and professional development
<>It is important within such a program not to overlook the needs of staff to overcome feelings of frustration and complacency. The results of this evaluation highlighted a particular need for staff to receive specialised substance use and dependence training.  Obtaining qualifications in this area may improve the ability of staff to deal with the issues related to substance use and dependence, decreasing frustration levels as a result. 
and not the researcher’s employer. It was also emphasised that any information that the researcher gleaned would only be used for the study and not by the program. Participants were informed that the only accessible data to any person other then the researchers would be in a general format in the final copy of the thesis or journal article.

Conclusions and directions for future research
The strength of a qualitative research project is that it provides a data set that is meaningful and information-rich. The present study provides useful data regarding the perceived impact of rehabilitation in promoting psychosocial functioning in the lives of young adults with a mental illness. In addition, the study has generated a series of themes and patterns to be explored in future research. These future research directions include (1) determining the prevalence and impact of dual diagnosis within psychosocial rehabilitation programs for young adults, (2) comparing of the effectiveness of alternative interventions, and, (4)  investigating relationships and transitions between acute psychiatric services and psychiatric disability rehabilitation and support services,and (4) exploring the impact of rural issues and stigma on the recovery process for young people who access services in a rural setting.

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