Darwin TELIAS, MD
Director, Rehabilitation Department, Mental Health Center, Beer-Sheva (MHCBS), and Ben Gurion University of the Negev.
Ala FRONSKY, R.N
Head Nurse, Outpatient Department, MHCBS.
Roberto UMANSKY, MD
Director, Outpatient Department, MHCBS, and Ben Gurion University of the Negev.
Telias, D., Fronsky, A., Umansky, R., (2000) Developments in psychitric rehabilitation:
a therapeutic trip. International Journal of Psychosocial Rehabilitation. 5, 53-60
The paper describes the process of preparation of inpatients to be discharged from a psychiatric facility to live in sheltered quarters in the community. The results of a two-year follow-up seem to indicate that this preparation greatly enhanced the ability of the patients to stay in the community, specially those patients who were referred to half-way houses. The paper also describes the efforts of the patients to improve their life style, and engage in activities which are normal for the rest of the population, like planning and taking a vacation trip abroad. The groupal procedure used to improve the patients’ social skills is also described.
In the last decade there has been a general impulse all over the world to desinstitutionalize mental patients (1). The movement, which started in the USA and in Italy, mostly due to economic reasons, has spread to most advanced countries (2).
Nevertheless, the practical difficulties, the lack of knowledge and experience, and the lack of uniformity in the goals to be achieved in different countries, have created much controversy, and many attempts at desinstitutionalization failed, due to lack of adequate preparation, both in the community facilities aimed at receiving the patients once desinstitutionalized, and in the patients themselves, before being moved from hospital beds to more open facilities.
The Mental Health Center Beer Sheva (MHC) has developed a system of preparation which, according to results, seems appropriate for Israel. It is possible that the system cannot be exactly adapted to other countries, but some of the techniques which were developed may certainly be replicated elsewhere.
1) - Antecedents
The Rehabilitation department of the MHC organized, starting in 1995, a rehabilitation school which provided a series of courses in order to prepare chronic schizophrenics to leave the hospital where they had been admitted for the last average 14 years, and pass to live in new facilities, called Hostels, or Half-Way Houses, being developed in the community. The school provided courses on very basic elements of independent living:- Personal Hygiene;Courses were provided by members of the staff of the Rehabilitation Department, and did not require additional funding.
- Mental illness and the effects of medication (why is it advisable to
continue complying with medication);
- Basic cooking;
- Creating and managing a shoe-string budget;
- Applying to organisms in the community (such as the Municipality, gas
and electric companies, etc.)
- Free community resources available and not-generally-known;
- What to do with your spare time without getting bored.
Those courses covered the four basic elements enunciated by Hersen & Bellack (4,see below). Some other elements of resocialization (5) were covered by other 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 (6); 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 (7).
The Outpatient Department, which had to receive those patients for follow up treatment, developed a day-care unit. The liaison unit at the Outpatient Department 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 (three of them have been created so far, with different degrees of autonomy for the inhabitants, and a fourth is in the process of being opened).
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 or as assistants in the Maintenance and Cleaning department, for a very low salary. Patients are also provided with lunch in the premises of the MHC. This salary, although very low, together with the hot meal provided, assist the patients to square their budgets.
The day-care unit provides placements in the different working areas, including some in the community or in sheltered workshops outside the MHC. It also provides the patients with medical follow-up, including application of injectable medication, social worker services and house visiting when necessary. General 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 (8), and patients take their medication by themselves, although the containers are periodically checked.
In the period 1997-1998, the Rehabilitation Department passed to the care of the day-care unit of the Outpatient Department 48 patients, of which 40 were referred to hostels, and the other 8 preferred to live either by themselves or with their families. 85% of the patients had diagnosis of schizophrenia or schizoaffective disorder, the others had diagnosis of affective disorder. They had been admitted in different hospitals for an average of 14 years.
Of the 40 patients placed in Hostels, 32 (80%) were still doing well at two year follow-up. The eight patients who preferred to dwell with their families had a much higher relapse rate, in excess of 50% (9). 8 patients living in the hostels had to be readmitted, of whom, 7 were readmitted for only a few days, and only one patient had to be readmitted for a long time. The 23 patients admitted in one of the hostels, including 3 patients who had undergone a brief readmission, decided that they had the same rights as everybody else, and that if it is normal in Israel to take a vacation trip abroad, they would also take one of those trips, just like the rest of the population.
In order to assist them fulfill their wish, the day-care unit of the Outpatient Department had to undertake special tasks to insure adequate preparation of the patients.
2) Material and Methods
The principal task for the staff was to ensure that compliance with medication should be total, if relapses or any other mishaps were to be avoided during the trip.
In order to enhance compliance, the nurse of the day-care unit organized a course(10) (11) (12), which in part reinforced the material the patients had learned in the previous course at the Rehabilitation Department, and in part introduced new elements, which were thought to be important for the new goal (13).
The principal points thought to be in need of stressing during the course were (14):1) - That patients understood that their disease was chronic, and that they would need medication for most or all of their lives;These points were chosen based on the theoretical framework on which the program was based. The theoretical framework was provided by the psychodidactic approach of Hersen and Bellack (4), and the work of Liberman (14, 15) on social skills training. Hersen and Bellack remark several issues in the psycho-social approach to the treatment of mental patients:
2) - That patients understood that there was a connection between taking medication and avoiding symptomatology and improving functioning;
3) - That patients understood that they should not stop medication even if they felt better or well;
4) - That patients understood and knew the side effects of medication, and the ways to cope with them.
5) - That patients understood that it was within their reach to comply with medication;
6) - That most patients understood that they could be helped by relatives or staff when they had some problem with compliance;
7) - That patients developed sufficient confidence in their doctor or nurse as to be able to ask for help when needed;
8) - That patients would comply with their medication during the three months that the preparation program went on.1) - This approach cares of the social aspects which are an important component in the life of mental patients.The goal of the approach is to change the social behavior of the patients without changing their other aspects. The higher the social skills of the patient, he becomes less anxious and depressed, and feels less incapacitated and more self-confident.
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.
Wilkinson & Canter (16) propose some definitions of social skills: Some people define them 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 different circumstances. The individual brings to every situation his own set of values, ideas and beliefs, and his personal style.
Fundamentally, social skills training, according to Liberman (15), was divided in the following stages:
1) - Problem definition: training the patient to identify his deficitarian behavior in order to recognize areas where behavior should and could be improved;Development of the training course:
2) - Inventory of assets: This most important item aims at allowing the patient, who usually suffers from a very poor self image, that he has a series of assets he may use and develop in order to improve his problem solving capacity;
3) - Establish a reinforcing therapeutic alliance: This permits to improve the patient’s self-image and also permits the positive therapist to bring forth some negative elements without hurting the patient’s fragile self-image. This requires establishing rapport, showing concern, expressing empathy, and demonstrating competence;
4) - Goal setting: this requires the patient to focus his attention on specific areas and not to disperse in the pursuit of sometimes unachievable expectations. Setting specific and concrete interpersonal goals is perhaps the most challenging step in the behavioral procedures comprising social skills training;
5) - Behavioral rehearsal: Patients usually do not achieve a high degree of proficiency in their skills from the beginning, the task requires lengthy rehearsal, usually by means of role playing;
6) - Shaping: Shaping is the building of complex sequences and chains of social behavior through successively reinforcing small steps along the way;
7) - Prompting (or cueing): is a technique which enables us to reinforce positive elements even before such elements actually occurred, or when those elements appear only seldom in everyday life in the therapeutic milieu. The therapist must be very active;
8) - Modeling: demonstrating to the patient a determinate behavior or skill as an example, in such a form that the patient may understand it and rehearse it;
9) - Homework and practice in vivo: homework assignments are regularly given to the patients in order to control their compliance with the treatment and to ensure that they acquire sufficient skills in each of the topics.
Patients were divided into two groups, one with fourteen patients, and the other with nine. Each group participated in ten two-hour meetings (with a fifteen minute interval). Patients were taught to speak freely and to explain their feelings about the disease. For example: when asked what was the disease they suffered from, some of the patients explained that schizophrenia was like the flu, other explained that they felt depression, or heard voices, others stated that they had fear, others that they had strange thoughts.
When asked about what it was to have a mental disease, they explained that it was to have something wrong in the brain, some bad materials in the brain. Others said that something bad was running after them to hurt them, or that the person who was sick from mental disorders was a person who did not catch reality as it is. In their opinion, mental patients stop functioning, do not want to get up in the morning, detach themselves from the environment and the surroundings.
In the second and third meetings, they spoke about their medicines. The patients explained that their medicines affected and improved their thoughts, their behavior, but complained seriously about the side effects of medication, in their words, “You better don’t try them, they make you extremely tired”.
When asked about why they had to take drugs, they answered that “because they were sick”
When asked about what makes them feel well, they answered: “Adequate treatment, motivation for something, will power, treatment of the personal problems of the patient, self-understanding, to go out to have fun, to take the pills on time, to be in touch with people”.
In the fourth and fifth meetings they spoke about side effects of medication. They first received careful explanation about their medications and about the side effects, and then each one spoke about what side effects made him/her feel. After each one had spoken, they received instruction about how to identify side effects, and what to do to avoid them or to reduce them.
Sixth, seventh and eight meeting were devoted to role playing of the effects of medication and of its side effects. In these meetings patients also received instruction through role-playing about the different situations a trip may entail, like arriving to the airport, speaking with the immigration officers, show the passports, and the like.
The last two meetings were devoted to rehearsal of all the material seen in the course, strengthening of points identified as weak, and, very important, distributing to each participant their certificates of completion of the course, a very important point according to previous experiences.
The patients effectively took their trip to Turkey. They 23 of them were accompanied by a nurse and two instructors who worked in the hostel with them.
During the trip there were absolutely no incidents, the patients behaved just like anybody else. Some of them, who were flying for the first time in their lives, were slightly apprehensive, but all in all there were no problems. Once in Turkey, they arrived in the hotel, received their rooms, shared the lives of all the other guests at the hotel, took guided and unguided tours around, with no special difficulties or signs that they were a group of mental patients.
The nurse had taken along great amounts of medication, and was prepared to cope with almost any eventuality, but there was not even need to open the medication case, each patient had been provided with their weekly medication containers, and that was all they needed.
From the above mentioned we may conclude that the social impairment of mentally ill people may be overcome, at least partially, by intensive training and dedicated cooperation of the staff (17).
The work made with this particular group of patients may be divided into three stages: a first stage, accomplished during their period of hospital admission, which enabled them to abandon the hospital and pass to live in the hostel; a second period in which they acclimatized to life in the hostel, and in which they decided that they could do just like anybody else, and decided to take the trip to Turkey; and a third stage in which they prepared this trip.
The first stage, accomplished in the Rehabilitation Department in the hospital, started the process of rehabilitation which would lead the patients to eventually return to the life in the community. This stage may in itself be divided into two periods: in the first, the patients were trained in basic socialization skills, and understanding of their disease (18). The second of these periods, the passage to the hostel itself, required the corporate efforts of the staff of the Rehabilitation Department and the staff of the Outpatient Department, with a very gradual transition from one to the other, and with a deep understanding, on the part of the second personnel, of the needs of the patients and of the direction of the efforts made by the first team.
The second stage required a great involvement on the part of the relatively small staff provided by the Outpatient Department, because the patients were very active, and engaged in new activities almost every week, and they often had to be redirected on the positive goals previously fixed, without letting them wander at will.
The third stage required the cooperative effort of the Outpatient Department staff and of the staff of the hostel, in order to make sure that training was continuous and with an adequate rhythm. The repetition of the subjects already covered in the Rehabilitation Department in this stage was of course only a practical application of the principle of reinforcement of behavioral therapy.
The good results obtained during the trip itself were surprising even for members of the staff involved, and only showed that with the adequate amount of effort (19), much can be achieved in the process of rehabilitation. The good results also triggered the will to repeat the experience. The same group is already planning another trip, and the patients of another of the hostels are beginning to prepare their own vacation trip.
The trip also became an important topic of conversation for the patients, among themselves, but also with other people, thus contributing to their resocialization.
It is important to stress that the process of training created a very strong bond between the patients and the staff, which, in all probability, aided to the success of the process (20).
The fact that a group of those desinstitutionalized patients were able to organize themselves, both economically and logistically, to take a leisure trip abroad, indicates that the quality of life (3) of those persons may be dramatically improved, and that our suppositions concerning the ability of chronic schizophrenics to improve their situation must be seriously reconsidered.
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