The International Journal of Psychosocial Rehabilitation

Participants’ Reported Experiences of an
Irish Psychiatric Residential Rehabilitation Programme


Barbara A. Price, B.A. Psy., M.A.
 (Cluain Mhuire Family Centre)
and
Barbara C. Western, B.A. Psy.
(Cluain Mhuire Family Centre)

Correspondence to:                                
Barbara Western, 22 Woodstown Heath, Knocklyon D16, Dublin, Ireland
barbarawestern@eircom.net
Abstract
Individuals currently participating in the high, medium and low support components of the Cluain Mhuire Residential Rehabilitation Programme (RRP) in Dublin, Ireland were asked to give an account of their experiences of the programme and their evaluation. Participants completed two questionnaires containing qualitative and quantitative questions. Demographic information was sought on age, marital status and cultural identity as well as information on their current living and employment status. A qualitative section at the end of this questionnaire gave participants the opportunity to state their own understanding of the reasons for being in the programme and their expectations of the programme. Secondly, participants completed a standardised questionnaire called Measuring Psychosocial Rehabilitation Outcomes (MPRO) that provided them with the opportunity for self-evaluation. The MPRO assesses quality of life issues, beliefs around empowerment and the ability to influence and control one’s life using a rated scale that provides scores on four main outcomes: 1) Subjective Quality of Life (SQOL); 2) Mastery (M); 3) Empowerment (EMP); and 4) Programme Satisfaction (PROG). A qualitative section at the end of this questionnaire gave participants the opportunity to evaluate what are the most and/or least satisfactory aspects of their time within the RRP.

The data was statistically analysed to evaluate whether there are correlations between a participants’ living status and the four outcome measures on the MPRO – Subjective Quality of Life, Mastery, Empowerment, and Programme Satisfaction- and if there are any positive or negative correlations between these four outcome measures.

The results indicate that a participants’ level of residential support can be statistically significant in correlation to their self-evaluation, with those in high support scoring the lowest on PROG (p=0.01) and those in medium support scoring higher and more consistently. There were also significant correlations within the four outcome measures on the MPRO (p=0.01 to p=0.05).

Keywords:  psychosocial rehabilitation; evaluation; programme satisfaction
Introduction
“The main tasks of psychiatric rehabilitation are: (1) to assist in reintegrating psychiatrically disabled persons into the community and (2) to maintain their ability to function independently…in other words, psychiatric rehabilitation practitioners attempt either to reduce the patient’s dependence on the mental health system of people and facilities, or to reinforce whatever level of independence from the system the patient has been able to achieve.” (Anthony Cohen and Vitalo, 1978, p.365)

The term psychosocial rehabilitation is currently most often used to describe those programmes with a focus on providing the least restrictive setting, avoiding hospitalisation and providing skills training. Fields (1990) criticizes a lack of discernment and definition with regard to residential programmes, and claims the same term is often applied to very different programmes. He provides a definition: “the purpose of residential treatment programmes is twofold: (1) to provide treatment alternatives for those individuals who would otherwise be left in acute and longterm hospitals or other institutional settings, including jails, due to the severity and seriousness of their disabilities; (2) to utilize a range of residential settings to transition the mental health system from an institutional dependency to a community based services perspective”(p.107).

Fields (1990) explains that “on a programmatic level, residential treatment programmes are therapeutic communities designed to assist clients to stabilise from a crisis, to develop and implement a community support plan, and to interact with other people, staff members and clients, in order to strengthen interpersonal skills and identify individual goals….the programmes should be active in the life of their communities and not isolated facilities” (p.109).

Research studies into the measurement of rehabilitation outcomes have found that there is a need for baseline analysis in this area, as programme evaluation is contingent on continuous assessment of the delivery of rehabilitation programmes (Hawthorne et al., 1994, p. 152). Gathering this data will hopefully provide an opportunity for researchers in years to come to obtain information on the programmes offered within the Cluain Mhuire Residential Rehabilitation Programme (RRP) and to measure the improvements, or need for change, within the programme. Indeed there is much to be said for creating a culture of research and ongoing programme evaluation within the RRP, bearing in mind that “assessment of rehabilitation outcome must be more than a research activity. It should be an ongoing responsibility of each practitioner “(Anthony et al., 1978, p.379). Issues such as quality of care, the cost effectiveness of programmes and, most importantly, the benefit to the client can be dramatically and positively affected by this kind of research.

Such evaluations have been encouraged by researchers who posit that “the main tasks of rehabilitation are to assist clients in re-integrating into the community and to maintain their ability to function independently” (Anthony et al., 1978, p.365). A key to comprehensive evaluation must include the participants’ satisfaction of the services. An evaluation model that includes a self - evaluation component is preferable to an evaluation conducted by non - treatment personnel”. (Anthony et al., 1978, p. 379).

The Cluain Mhuire Residential Rehabilitation Programme
The Cluain Mhuire Residential Rehabilitation Programme (RRP) addresses differing levels of need and provides a transition from institutional dependency to a community- based services perspective such as that advocated by Fields (1990, p.107). However, there has not yet been an evaluation provided by residents nor a compilation of information gathered on their current circumstances. To date, there has been substantial movement through the programme, with an average of about seven people making a transition each year. Occasionally, those who have made such a transition to a lower level of support discover that they need to return to a higher level once again.

The RRP is a component of the Cluain Mhuire Mental Health Service and run under the auspices of the Hospitaller Order of St. John of God. The emphasis is on helping participants to move through the different phases of the programme with a focus on rehabilitative possibilities based on individualised assessment. The ultimate aim is for re-integration into the community where appropriate.

Previously named the Community Living Programme, the RRP was so named after a review in 2000, which recognised the increased need to focus on rehabilitation and the attainment of skills in helping people, re-integrate into the community. Largely, the programme encompasses many different elements, examples of which are: residential, educational, medical, the teaching of social and domestic living skills and recreation. All participants maintain outpatient contact with their psychiatrist. Participants are required to pay a weekly rent and are encouraged to maintain regular payment. Rent covers all domestic expenses and the programme funds group recreational activities.

 The three phases of the RRP are 1) High Support, 2) Medium Support and 3) Low Support.

Those individuals residing in Oropesa¹, the high support component of the RRP, are in most cases referred by their medical team from St John of God Hospital. Oropesa is a 20-bed hostel in the community and the level of support is designed for those individuals who have been identified and assessed as being most suitable to participate in the skills training offered within the Residential Rehabilitation Programme. Participants of the programme are usually expected to engage in outside activities that are either provided by the service  - for example, day centres or workshops - or other agencies accessed by participants themselves. Staff encourage maintenance of self-care. Meals are prepared by kitchen staff and participants are requested to help in maintaining cleanliness in the building. Medication is either supervised or unsupervised depending on the needs and capabilities of the individual participants. There are a minimum of two staff members on duty at all times (24 hrs).

The participant is assigned two keyworkers who will over a period of time, work with them in formulating and actualising personal goals, the achievement of which are necessary for transition through the programme. A link worker is on duty to facilitate keyworkers with such goals as improving self care, budgeting and initiating daily activity as well as management of anxiety/stress and support in coping with current life issues.

A medium support environment, Avila², is provided elsewhere in the community, and caters for fifteen people. There are alternately one or two staff members on duty on a twenty-four hour basis. Each participant at Avila is assigned a keyworker who will help to build upon the goals that have been met within the high support component and to continue programme plans adapted to a medium support environment.  This is usually based on the improvement/attainment of daily living skills such as cooking and shopping, budgeting and self care i.e. hygiene. There is also support in managing anxiety, stress, grief or any current issues in participants’ lives. Participants are expected to engage in the routine activities of the hostel and to maintain room hygiene.

The main theme is self-governance with participants’ meetings held weekly, where menus are planned and shopping duties allocated. Participants take turns to cook and to shop while observing budgetary limits. All necessities are met by the hostel budget including food and cleaning materials. Group recreational activities are funded by the hostel and participants are encouraged to access activities in the community that are conducive to their goals and may be funded where appropriate. Most participants take unsupervised medication where appropriate.

Those who have successfully completed the other modules move to one of the low support hostels³ with the eventual aim of moving to private or local authority housing. This comprises three houses on housing estates in the Stillorgan/Blackrock area. Each house contains four/five residents, each with their own room. Two staff members are available within flexible working hours. Rent relief can be claimed, unlike in the other hostels. Staff inspect the homes and ensure that they are kept to a good standard in terms of hygiene. Group activities are funded by the service and are facilitated by staff. Residents are expected to have a daily activity where possible. Since this research was initiated there has been an added component to low support in the provision of a unit specifically for those who will imminently make the transition from supported living to independence with an outreach service.

The aim of this study is to provide an overview of the current circumstances of those participating in the RRP, which we hope will help to identify and meet their needs to the maximum level, and will help in assessing outcomes. Overall we hope that information gleaned would provide valuable knowledge for future planning and an information base for future studies. We also hope to promote a greater awareness of the issues in psychosocial rehabilitation today.

This study will address the hypothesis that:

The Residential Rehabilitation Programme benefits the participant in terms of quality of care, employment, empowerment and independence. The benefits of the programme are related to progressive movement through the Residential Rehabilitation Programme.

1. Oropesa is the place name of an area in Spain where St John of God spent his childhood. He lived and worked here as a shepherd until adulthood, when he left to join the Spanish army.
2. Avila is a reference to Father John de Avila who was a minister living in Grenada whom John looked up to as a mentor. He became a very good friend of John’s and was instrumental in guiding John through his spiritual conversion.
3. Ardmeen, Allen Park and Leopardstown Avenue are the names of the three houses , or low support hostels, that are  nestled in the communites of Blackrock and Stillorgan.

Method
Demographic questionnaire:
An adapted questionnaire produced by the US based Human Services Research Institute (HSRI) was used to seek demographic information such as living status, age, marital status, income, employment status, time spent in the RRP and readmissions to hospital. Two qualitative questions at the end of the questionnaire asked for people’s expectations of the programme and their reasons for being part of the programme, in their opinion.
 
Measuring Psychosocial Rehabilitation Outcomes (MPRO)
The MPRO is a scale devised by the research committee of the International Association of Psychosocial Rehabilitation Services in cooperation with the Evaluation Center at the Human Services Research Institute (HSRI) in the US.  It is specifically designed to measure the perspective of programme users in a number of areas that are relevant to the goals of psychosocial rehabilitation programmes. The four areas focused on were:

1)    Subjective Quality of Life (SQOL) - assesses overall perception of well-being.
2)    Empowerment (EMP) - assesses the individual’s sense of his/her rights and opportunities to control his/her life and services received.
3)    Mastery (MAST) - assesses the individual’s beliefs around ability to control and influence his/her own life.
4)    Programme Satisfaction (PROG) - assesses satisfaction with the programme.

The questionnaire contains 20 questions, with five questions for each variable. Participants rated their answers on a scale, which measured the extent to which they agreed or disagreed with the statements made. Questions were scored and added with an average figure taken for each individual for all four variables and an average overall score for each variable.

Lower scores indicated less satisfaction with the programme, or a lower sense of well being, while higher scores indicated the opposite. At first glance the lowest overall average score was for Mastery, followed by Subjective Quality of Life, and then Empowerment and the highest score was Programme Satisfaction. The use of a computer statistical package (SPSS) helped to analyse the data for differences between the four variables and their relation to the three levels of support.

After securing the Hospitaller Order of St. John of God Ethics Committee approval, individual programme participants were posted a letter of information and a letter of consent along with a stamped addressed envelope and a return date prior to commencement of the project. Letters of consent were to be posted or dropped into sealed boxes in Avila and Oropesa. After the return date, the MPRO, demographic questionnaire and stamped addressed envelope were posted individually.  Again, participants were asked to either return the questionnaire by post or to leave them in sealed boxes located securely in the offices of Avila and Oropesa by a certain date. Other staff members were briefed on the ethical concerns. The researchers were contactable in the event of any queries. Estimated time to complete the questionnaires was approximately 20 minutes and participants were given four weeks to return the completed questionnaires. The study related to the RRP only and not to the service as a whole. All consultants’ permission was sought and any opinions/concerns regarding individual residents were invited. No funding was requested or obtained for the purpose of this project.

Subjects
Fifty participants of the Cluain Mhuire Residential Rehabilitation Programme were provided with the demographic questionnaire and the MPRO. Twenty-four RRP participants responded (48%). The age range of the 24 participants was 19 to 65 years old (mean = 42, median = 44). Sixteen were male and eight were female.

Results
Demographic questionnaire:
48% of RRP programme participants took part in the study. The average age was 42. Only two respondents had been married and one was divorced/separated. All other respondents were single (92%).

22 responded that they are Irish with two failing to answer that question.

7 (29.16%) of the study participants were residing in Low Support, 5 (20.8%) were in Avila, the medium support setting, and 12 (50%) were residing in Oropesa, the high support component of the RRP.

When asked about their current employment status, 8 (33.3%) cited that they were in a sheltered workshop. 4 (16%) said they were currently unemployed. 3 (12.5%) were on a training course such as Roslyn Park, a service provided by the Rehab group, and another 4 (16%) classified themselves as actively seeking employment. 3 (12.5%) said they were employed outside of St John of God services. One person said they were studying and another said they were starting their own business.

16(66%) had been previously employed, with occupations being or having been; library assistant, real estate apprentice, gardener, secretarial work, cashier, commis chef, maintenance technician/ production, advertising copywriter, babysitter, data input, accounts assistant

The hours of those currently engaged in outside activities ranged from 9 to 40 hours a week. Income ranged from €17 to €335.75 per week of those who were earning a salary. Of three people employed independently, two were permanent and one was temporary.

19 (79.16%) had some kind of educational qualification. 3(12.5%) were educated to degree level, 13 (54.16%) to cert level and 3(12.5%) to diploma level. 7 (29.16%) had attended third level institutions, a further 7 (29.16%) had attended technical/ vocational colleges and 3 (12.5%) had attended community courses.

14(58%) cited the disability allowance as their main source of income.

The average age at first hospitalisation was 23 yrs. The average time spent in the RRP was 6.5 yrs and the average number of self-reported readmissions to hospital since being admitted to the RRP was 2. The lowest rate of self reported readmission to hospital was in medium support with the rate of re-admission from medium support being one third that of high support and a quarter of that of low support.

Qualitative Questionnaire
Four qualitative questions were asked. The first question asked respondents what were the reasons for their referral to the RRP. Overall six out of twenty four people cited diagnostic criteria alone for their admission to the RRP such as anxiety/depression and schizophrenia. Two others used more general terms such as “I have an illness” or “mental health”. The majority of the above eight were in the High support component. Seven reported that they were in the RRP in order to live independently/learn new skills. All but one of these seven was in Med/Low support. Three cited accommodation needs as being their main reason for admittance to the RRP. Two of these respondents were in the high support component. Three others cited conflict with family or inability to function alone. Three did not answer.

Table 3. 

	SQOL	EMP	MAST	PROG
SQOL     Pearson Correlation                Sig. (2 Tailed)                N	1 .               24	.668** .000 24	.307 .145 24	.440* .032 24
EMP       Pearson Correlation                Sig. (2 Tailed)                N	.668** .000 24	1 . 24	.594** .002 24	.681** .000 24
MAST     Pearson Correlation                Sig. (2 Tailed)                N	.307 .145 24	.594** .002 24	1 . 24	.310 .141 24
PROG     Pearson Correlation                Sig. (2 Tailed)                N	.440* .032 24	.681** .000 24	.310 .141 24	1 . 24