The International Journal of Psychosocial Rehabilitation


A SCHOOL FOR MENTAL HEALTH INPATIENT PREPARATION FOR REINSERTION IN THE COMMUNITY.

Roberto UMANSKY, MD
Director, Outpatient Department, Mental Health Center Beer-Sheva, and Ben Gurion University of the Negev

Darwin TELIAS, MD
Director, Rehabilitation Department, Mental Health Center Beer-Sheva, and Ben Gurion University of the Negev.

Eti TZIDON
Director, Social Work Department, Mental Health Center Beer-Sheva, and Ben Gurion University of the Negev

Moshe KOTLER, MD
Director, Mental Health Center Beer-Sheva, and Ben Gurion University of the Negev.
 

Citation:
Umansky R., Telias, D., Tzidon, E., Kotler, M. (1999). A school for mental health inpatient preparation
for reinsertion in the community. International Journal of Psychosocial Rehabilitation. 4 65-72



Correspondence to be addressed to: Roberto Umansky, MD., Director, Outpatient Department, Mental Heath Center, Beer-Sheva, P O Box 4600, Beer-Sheva, ISRAEL, or to the email:  teliaska@zahav.net.il

Abstract

The paper describes the preparation program for discharge of patients to the community at the Beer-Sheva Mental Health Center in Israel.

The program consists of: 1) A rehabilitation school, which functions within the framework of the rehabilitation department; 2) A follow-up unit which functions within the framework of the outpatient department.

Cooperation between departments was found to be essential for the success of the project.

Course contents for the rehabilitation school are described.

Results were positive in excess of 80%, success described as patients who were discharged to the community and were not readmitted during the two-year follow up.



Introduction
A new policy of mental health in Israel at the beginning of the 1990ís called for the creation of new facilities in the community, to receive mentally ill people who so far had been admitted in hospitals. A system had to be created to prepare the patients to pass to their new environment in the community, trying to avoid in as much as possible the risk of relapse and readmission.

The idea of desinstitutionalizing mental patients is relatively new (1), and it is mostly based on economic reasons. The cost of mental health has always been among the highest in medicine (2), (3) because most patients have the tendency, or need, to remain hospitalized, and because most professionals are (or were) of the idea that those patients could never be well in the community.

Until recently, the concept prevailed that a separation between patients and community should be kept, with the double purpose of: on the one hand, to provide the patients with a sanctuary where they would not be attacked or exploited (4); on the other hand, to rid the community of the threat posed by mental health patients, sometimes really aggressive and dangerous, and in any case, always feared by public at large.

Changes in the concept of mental illness and in the role attributed to institutions in the care of the mentally ill were brought about by economic pressures on society, together with new awareness on individual rights. The process of desinstitutionalization, severely criticized by most professionals (5), was started in the USA and in Italy.

Public at large was not consulted about those first efforts at desinstitutionalizing psychiatric patients, and protests about the state of desinstitutionalized mentally ill, who for the most part were simply abandoned in the streets, without shelter or adequate care, were waved aside under the excuse that economic gains for society were enormous and therefore desinstitutionalization was desirable.

More rational methods of desinstitutionalization were called for, and these were advocated by a number of professionals in different countries, including the USA and Italy, (6).

Newer, more powerful and less risky neuroleptic medication, with less side effects (although very expensive (7),(8)), permitted a better preparation of patients for desinstitutionalization, with higher chances to stay in the community after discharge.

Also, new insight into the natural history of mental diseases, like the psycho-didactic approach of Hersen and Bellack (9), led to the development of newer methods of psychosocial treatment.

Among the issues remarked by these authors in the psycho-social approach to the treatment of mental patients, we want to stress:

1.  This approach cares for the social aspects, which are an important component in the life of mental patients.

2.  The approach considers that mental patients profit from the learning process.

3.  The approach tries to provide the same education to dysfunctional patients by the use of limited goals and systems.

4.  The approach supposes a positive result from treatment, irrespective of diagnosis and chronicity of the illness.

This approach tries to change the social behavior of the patients without changing their other aspects, based on the premises that when the social skills of the patient are higher, he becomes less anxious and depressed, feels less incapacitated and more self-confident.

Some definitions of social skills were proposed by Wilkinson & Canter (10): for example, these authors define social skills as the possibility of using behaviors which receive a positive reinforcement, and to avoid behaviors which receive negative reinforcement or punishment. Efficiency of the individual from the social standpoint depends on what he proposes to achieve in determinate circumstances. A behavior which may be appropriate in some circumstances may be inappropriate in a different context. The individual brings to every situation his own set of values, ideas and beliefs, and his personal style.

Wing (11) stressed the relations between the medical and the social aspects of treatment, care and prevention. He mentioned the change-over from big institutions toward a more open but much looser system of smaller units managed by a multidisciplinary staff as the chief innovation made during the 40 previous years.

Baronet and Gerber (12) reviewed four models of psychiatric rehabilitation: assertive community treatment, case management, vocational rehabilitation and educational rehabilitation. They concluded that results were independent from the modality used, and that skills learned in one life domain may generalize, to a moderate extent, to other areas. They claimed that the four rehabilitation models had varied effects on the outcome variables, and part of the variability in the findings seemed to be related to client characteristics.

Material and methods
The Mental Health Center (MHC) in Beer-Sheva, Israel, comprises a 400-bed admission facility, an emergency and an outpatient departments, and provides mental health services for a catchment area of nearly 500.000 inhabitants in the southern part of Israel. The Department of Rehabilitation of the MHC comprises 52 beds, 32 of which are aimed at external rehabilitation.

Within the framework of these 32 external-rehabilitation beds a school was created, where patients who had recovered enough from their illness as to be able to abandon hospital, could be prepared to stay in some sheltered facility in the community, following trends also applied in other parts (13) .

The creation of sheltered facilities in the community, called "Hostels", or "Half-Way houses", by private entrepreneurs was also promoted, under the auspices of the Ministry of Health.

The rehabilitation school provided courses on very basic elements of independent living:

- Personal Hygiene; that means teaching the patients to bathe daily, change clothes and bed lining frequently, and keep the environment (the ward milieu in this case, aiming at the home or hostel milieu later on) reasonably clean and tidy.

- Mental illness and the effects of medication; that is, teaching the patients what are the symptoms of their diseases and how to recognize them early enough as to ask for help in time, instead of hiding them until it is too late and readmission is needed; why is it advisable to continue complying with medication, and for how long; accepting the advise of the medical staff in this respect, conveying to the staff the undesirable effects of medication in order to correct them, instead of simply discontinuing treatment.

- Basic cooking; that is, how to prepare a weekly menu with a low budget, how to shop for the essentials of this weekly menu, how to prepare the meals, what to do with leftovers, adequate ways to keep food taking into consideration the warm climate in Israel in general and in the Negev area in particular.

- Creating and managing a shoe-string budget; how to avoid overspending, where to shop for less money, how to obtain discounts, bargain sales and the like; where in the community to apply for reductions in rent, water, electricity and price of other commodities, taking into consideration the advantages offered by the different services to handicapped people; how to save in banking charges, interest rates and other such items.

- Applying to organisms in the community (such as the Municipality, Electric company, etc.); this item tends to re-socialize the patients in their contact with daily problems they usually had not to deal with because they had been in hospital for a long time an/or their families had taken care of those details. The course was established after having observed the degree of frustration many ex-patients showed when confronted with bureaucratic procedures they had never heard about, which in some cases proved so exasperating for some patients as to require medication changes or even short admissions.

- Free community resources available and not-generally-known; like concerts, exhibitions, galleries, public libraries, guides to discount places and other amenities usually obtainable for free in most communities, but which usually go unheard of by most of us.

- What to do with your spare time without getting bored; that means teaching the patients how to distribute their time trying to avoid the social isolation usually preferred by most mentally ill persons, how to vary activities during the day to avoid unnecessary routine, where to look for company, even if the company is that of other mentally ill people, but not only; how to look for voluntary organizations which usually give a helping hand to others, and other such possibilities. The improvement of social contacts improves the patientís perception of quality of life (14).

At the end of each course patients had to pass an examination and received a certificate of the completion of the course.

Courses were provided by members of the staff of the Rehabilitation Department, and did not require additional funding.

Those courses covered the four basic elements enunciated by Hersen & Bellack.

Independently of the rehabilitation school, and together with it, other elements of resocialization were covered by different activities carried out in the ward: Group activities on news read in the newspapers or heard in the radio or television, with the dual purpose of 1) Keeping the patients in contact with the surrounding reality of the external world, and 2) To promote dialogue and communication among the patients; Active intervention of the patients in preparing some of the collective activities, like cleaning the ward (there are no cleaning personnel in the ward), preparing religious or national festivities (which in Israel are the same thing); Collective visits to a social club for mentally ill people which functions outside the hospital walls; Encouragement of some "normal" social activities which are generally not considered in hospitals, like ordering a pizza on the phone and sharing it with friends.

In order to comply with the fourth of Hersen and Bellackís points, maintaining a positive approach irrespective of diagnosis and chronicity, the staff of the rehabilitation department maintained a policy of progress despite temporary setbacks in individual patients, caused by their disease or by external causes.

It must be taken into consideration that some of the patients had been admitted in different hospitals, including MHC Beer-Sheva for over 20 years, and the average stay in hospital was nearly 14 years before discharge with this new plan.

Total length of the rehabilitation course was between 9 months and one year, with flexibility to retain one occasional patient if he/she needed some more time.

A liaison unit, dependent of the Outpatient Department of the MHC was created to take special care of patients .

This liaison unit created a special day-care unit for the management of some 40 to 50 patients, who were engaged in the re-entry process, and who were discharged from the Rehabilitation Department to the Hostels (four of them have been created so far, with different degrees of autonomy for the inhabitants). The day care unit, comprising a doctor, a nurse and a social worker, provides the patients with occupation in the Occupational Therapy department of the MHC (15), or as assistants in the Maintenance and Cleaning department, for a modest salary. Patients are also provided with lunch in the premises of the MHC. This salary, low as it is, and the hot meal provided, assist the patients to square their budgets.

Besides providing placements in the different working areas, including some in the community or in sheltered workshops outside the MHC, the day-care unit also provides patients with medical follow-up, including application of injectable medication, social worker services and house visiting when necessary. Non-psychiatric medical needs are covered by one of the medical insurance companies existing in the community, which are paid for by a special tax applied to every citizen in Israel.

To assist patients to comply with medication, a nurse provides them with special weekly pill containers, and patients take their medication by themselves, although the containers are periodically checked.

When patients finish the rehabilitation school and are accepted in the hostel, they stay in touch with the rehabilitation department, that means that they come to the hospital every morning, and go to the hostel after lunch. The day-care unit of the outpatient department is included in this stage, and patients gradually pass from the inpatient setting to the outpatient setting in a gradual fashion, usually during two or three months.

Results:
In the years 1997-1999 the rehabilitation unit passed to the care of the outpatient department 69 patients. 13 additional patients had been passed to the care of the first hostel, in 1996.

Of those 69 patients:

61 were referred to hostels;

2 were referred to sheltered houses;

2 decided to live by themselves;

3 returned to live with their parents;

1 was referred to a senior citizensí residence.

TABLE 1 Results
 

Referred to:
Ner.
Readmitted
Percent
Hostel
40
8
20
Parents
3
2
66
By themselves
2
1
50
Sheltered house
2
0
0
Senior citizens residence
1
0
0
 
Of the 61 patients who were referred to hostels, 8 had one re-admission during this follow-up period, mostly for terms of under one month. None of the patients had more than one re-admission. Only one of the readmitted patients stayed in hospital for longer than three weeks.

Of the 3 patients who passed to live with their parents, 2 were readmitted several times, totaling seven admissions between the two.

Of the 2 who decided to live by themselves, one was re-admitted for a long period (more than three months).
 

Conclusions
It is our opinion that the preparation for re-entry the patients underwent in the rehabilitation unit, which included various and specific psychosocial intervention strategies in addition to the optimized use of medication (16) correctly predicted most of the problems they would later find during their lives in the community.

The preparation assisted the patients to face every-day problems with a certain basis which enabled them, for the most part, to cope adequately with difficult living conditions. The adequate attitude of the staff, fruit of long discussions and agreements, certainly assisted in the good results obtained (17), and definitely did not impede the re-entry process.

It is also our opinion that the existence of the day care unit in the outpatient department contributed greatly to the ability of the vast majority of those patients to stay in the community. Not taking into consideration the 21 patients referred to hostels in 1999, 80% of the patients referred to hostels during 1997 and 1998 stayed in them without readmission.

Experience with patients who were discharged before the beginning of this program, and before the formation of the facilities in the community which received them (day care unit, hostels), shows that the percentage of patients who succeeded in staying in the community increased dramatically. Kaplan and Saddock (18) state that it is estimated that only between 20 and 30% of all schizophrenic patients are able to lead somewhat normal lives, which is rather different from the 80% of our sample not being readmitted during the follow-up period.

This 80% result is well within what was achieved in other places (19).

We also agree with Anthony (20) that participation in psychosocial rehabilitation programs appear to have a salutary effect on symptoms and work skills.


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