Mental Health Consumers as Transitional Aides: A Bridge from the Hospital to the Community.

The move toward deinstitutionalization of individuals with severe mental illness (CMI) has placed increased demands on the community to provide mental health care services to individuals who would have previously remained for months or years in the care of state hospitals. Making a successful transition from hospitalization to the community offers an individual a higher degree of independence, as well as greater opportunity to maintain employment and to develop more stable, adaptive interpersonal relationships. Additionally, people who make a successful community transition often experience a higher quality of life than those who spend a major portion of each year confined to a state mental hospital (Bond & McDonel, 1991). However, despite the establishment of publicly funded Community Mental Health Centers (CMHC), there remains a large number of people with mental illness who, for a variety of reasons, do not receive adequate care in the community (Test & Stein, 1978; Cutler, 1992; Sherman, 1992).

Many persons with severe mental illness, once discharged from the hospital, often never connect with the CMHC for available services (Boyd & Henderson, 1978; Schwartz, Spitzer, Muller, & Fleiss, 1980; Goering, Wasylenski, Farkas, Lancee, & Ballantyne, 1984; Benda, 1991; Moseley, 1994). Accordingly, a recent report by the Policy Research Project on Financing Care for the Chronically Mentally Ill (Warner, Harris, Kier & Rodriguez, 1990) indicated a widespread need for greater coordination of services between state hospital and CMHCs. During the five years from 1984 through 1988, the report found that about 56% of the persons admitted to state hospitals received a CMHC referral at discharge. Moreover, this study found that 44% of persons admitted to state hospitals completely disappear from the records somewhere between the hospital and the CMHC. In addition, despite their high potential for "falling between the cracks" once out of the hospital, only about 11% were provided case managers (Harper, Hoover, Jung, & Rienstra, 1990).

A review of the literature on case management and continuity of care found that mental health consumers were being successfully trained as case manager assistants and peer counselors in several communities throughout the United States (Sherman & Porter, 1991). Based on information obtained from individuals during hospitalization, it was hypothesized that community services usage consistent with discharge treatment plans could be increased by providing high-risk individuals with a trained peer to work as a Transitional Aide (TA). Based primarily on the work done by Sherman (1991) and Toprack (1990), the following training program was designed.

Three objectives were evaluated. The first objective concerned the feasibility of training individuals with severe and persistent mental illness to work as TAs. The second objective was to obtain a preliminary measure of the effectiveness of the TAs in facilitating CMHC attendance. Finally the retention and recidivism rate of the trainees was evaluated.

Method

The most difficult and critical decisions in implementing a consumer training protocol involve participant selection criteria. Acceptance into the training program required each applicant to meet the following criteria:

   1) Demonstrate successful management of a severe DSM III-R Axis I mental
   illness through use of community resources for a period of at least thirty
   days.

   2) Have had at least one previous hospitalization for mental illness.

   3) Be at least 18 years of age.

   4) Possess academic skills commensurate with high school level based on the
   Wide Range Achievement Test-Revised.

   5) Have a valid driver's license or be familiar with and currently using
   mass transit.

   6) Have a supportive social network available, as demonstrated by
   involvement in local supported living activities, residing with family, or
   have regular interaction with other people on a daily basis.

   7) Indicate desire to work with other consumers.

It should be noted that we did not exclude applicants based on Axis II diagnoses, nor on severity of Axis I. If the individual demonstrated the ability to manage his/her own mental health symptoms, was stable on medication, and met the functional criteria above, he/she was accepted for training. In order to determine level of functioning, each applicant was administered a thorough clinical interview, the Cornell Index to assess level of physical and emotional symptomatology, and the WRAT-R to determine the level of academic achievement.

Participants

Area agencies, including vocational rehabilitation facilities, supported living centers, and community mental health centers were provided with our selection criteria and asked for referrals. It was decided that a maximum of eight participants would be trained in the initial phase of the program. Thirty-five individuals were referred. Twenty of those referred expressed interest in participating. Based on the above criteria, eight participants were selected. Of the twelve not selected, educational level and cognitive impairment (severe memory problems, disorganized thinking, and lack of available support system as determined through interview) were the primary reasons for exclusion. These twelve individuals were referred back to their caseworkers for supported employment.

Selected participants ranged from 31 through 50 years of age. There were two women and six men. Two had GEDs, four had high school diplomas, one had a B.S. degree and one had a M.S. degree. Psychiatric diagnoses included Axis I categories of Paranoid Schizophrenia(2), Bi-polar Disorder(3), PTSD(1), and Depression(2). The number of years since initial diagnosis ranged from two to seventeen.

Materials

In order to develop a curriculum for the TA program, a task analysis of the requirements for the job was conducted. To simplify the procedure, each task was broken down into three fundamental components. That is, each task was analyzed with regard to: 1) the type and amount of information that the TA would need to gather: 2) facts needed to comprehend and accurately process the information gathered; and 3) instruction about the appropriate response for that situation. With this in mind, a curriculum was developed to teach the trainees how to apply these principles in working with people who have severe mental illness.

Design and Procedure

The training curriculum consisted of a 180-hour didactic course combined with a 320-hour apprenticeship training experience. Table 1 lists each topic covered in the didactic portion and the amount of time given to it. Each section of the training protocol was taught by a specialist in the area.

Table 1. Topics Covered In The Didactic Component of the TA
Training Program

    Topic                                                      Hours

Orientation and Introduction to Mental Health Services            6
Destigmatization and Desensitization to Labels                    3
Familiarization with Use and Purpose of DSM Diagnostic Labels     3
How to Assess Level of Function/Mental Status Examination         6
Ethical Conduct, Professionalism, & Maintaining Boundaries        6
Proactive Crisis Planning/Crisis & Suicide Intervention          12
Medication Types and Side Effects/CPR & First Aid Cert.          18
Behavior Management & Behavior Contracts                          6
Preventive Management of Aggressive Behavior                     16
Substance Abuse, Signs, Symptoms & Management                     6
Vocational Assistance Training                                    6
Consumer Advocacy/Communication & Assertiveness Training          9
Community Resources/Financial Entitlement/Application            18
State Hospital Tour & Introduction                                8
Case Management & Service Linkage                                24
Exams & Review                                                   24

(*) Nine hours of this section were included as a weekly 90-minute support group which continued through the training and after employment. There were three exams at 2-hours each, and reviews were three hours on every Friday of the training period.

Following completion of the classroom section, each trainee took part in a 320 hour apprenticeship experience. This apprenticeship was the result of a cooperative agreement between project directors, CMHC Administrators, State Hospital Administration, and a local supported living and supported employment agency affiliated with the CMHC. Confidentiality and ethics were an integral part of the classroom experience, but the CMHC staff supervised trainees during the apprenticeship in order to ensure that CMHC clients' rights were protected. Each trainee was paired with CMHC staff to get a hands-on learning experience. During this apprenticeship, trainees accompanied their assigned agency staff members on site visits, during intake interviews, and began participating in client/service provider interactions.

Table 2 (page 38) shows the areas involved and the number of hours each trainee received.

Table 2. Apprenticeship Sites and Time Allocated for TA Trainees

CMHC Area or Department                          Hours

Continuity of Care/State Hospital Liaison Team    40
Casemanagement                                    40
Local Clinics and Social Work Staff               40
Special Projects Department                       40
Supported Housing                                 40+
Supported Employment                              40+
Hospital Milieu                                   80+

In addition to the more formal educative components of the program, an integral aspect of the training protocol was a weekly support group. This group was facilitated by a clinical psychologist who had no involvement with the didactic or apprentice training and by a psychology intern. In this group, the trainees had the opportunity to discuss fears, concerns, and frustrations about the training and their upcoming employment. The trainees also utilized this group to work out group differences and examine misunderstandings with their fellow trainees. For example when a trainee felt that he/she was being excluded by one or more of the others from attendance at team meetings, or when a trainee was perceived by the others as being too argumentative at lunch, the group provided a place to learn to assertively and appropriately manage these issues. At the end of the training, the TAs were asked about the training program. All off them indicated that the support group was one of the most helpful aspects of the program and asked to have it extended into the employment phase.

In order to fit into the system at the point where the most serious service gap existed, the TAs would need to familiarize themselves with components of both hospital and community systems and to become comfortable with staff members at both sites. Once hired, the TAs would work with their peers at the state hospital, where they would be assigned to individuals being readied for discharge within the next 14 to 21 days.

To be referred to a TA, individuals had to meet the following criteria:

   1) be 2-6 weeks pre-discharge

   2) referred for community treatment

   3) prior history of repeated non-compliance with follow-up appointments

   4) prior and repeated crisis service usage and hospitalizations

It was decided that persons participating in a newly established furlough program would be an optimum group likely to benefit from working with a TA. These individuals are given the opportunity to return to the community on a trial basis without formal discharge. Typically, these are consumers with a history of multiple failures at community integration and/or who have the least family and social support in the community.

The TAs would begin working with their assigned clients in the state hospital 2 to 3 weeks before discharge. This would allow time for a supportive alliance to be formed that would continue in the community. While their clients were still in the hospital, the TAs would join the treatment team and attend team meetings and staffings to learn about discharge and treatment planning. During the week before discharge, if the treatment team deemed it appropriate, the TA and the client would come into the community in order to locate and become familiar with the particular clinic to which the client would be referred following discharge. In the case of geriatric clients, who are often discharged into nursing home care, the TA would visit the nursing homes and help prepare their clients for their new living arrangements. Post-discharge appointments were made before the client left the hospital.

Once the client was back in the community, the TAs worked to: 1) asssess the need for additional support or social services and to evaluate any gaps in aftercare service; 2) identify problem areas that may not have been apparent at the time of discharge; and 3) share information that might increase the likelihood of success (e.g., techniques for negotiating bus schedules, getting more manageable appointment times, and communicating with physicians and other service providers.).

The post-discharge working alliance with the TA was to be maintained until the person kept appointments at the clinic for two months, or until the TA and other members of the community mental health care-system were no longer able to contact the client. This latter circumstance would include times when a client left no forwarding address or no telephone number, and no friend or relative could assist in locating them.

It was anticipated that the TAs' community-based involvement with a particular client would lessen as the clients settled into the community, thus allowing the TAs to shift their attention back to new dischargees. Each TA was referred from six to ten individuals in the hospital, plus up to ten dischargees. Thus, at any one time each TA worked with up to twenty clients combined between hospital and community.

Tracking Data

The current project developed out of a larger study tracking the course of community transition and reintegration of consumers discharged from a state hospital. Baseline attendance at the CMHC following discharge was established by selection of 213 men and women were selected who had referrals for follow-up treatment in the CMHC service system. Because these individuals were not referred to a TA, this group is called the Non-Assisted group. The CMHC attendance of this group was followed through computer tracking data maintained by state and county mental health services systems.

At the end of one year of tracking, each individual was classified as an Attender or Non-attender. Non-attenders were those people who: 1) failed to show up for any scheduled appointments, or 2) maintained CMHC contact for less than one month during the year. Therefore, it was possible to account for individuals who never connected with the CMHC, as well as those who came once or twice but dropped prematurely out of the system.

Each client who was referred to a TA was also tracked for 12 months via a computerized activity log maintained by the CMHC. Outcome data for persons whose transition was assisted by a TA is based on the four TAs employed by the CMHC.

During the training project the TAs received a stipend out of project funds. Due to the experimental nature of the project, they were paid an amount that would allow them to retain their current disability benefits.

Results

Consumer Training Project

All eight trainees completed the didactic portion of the training protocol. Three trainees decided not to continue after the apprenticeship training; one did not continue because of mental health reasons; another was uncomfortable around people who were psychotic and/or aggressive; the third trainee was offered and accepted employment as a mental health aide in a half-way house. The initial follow-up data was successful to the point that four full-time employment positions were created by the CMHC. A fifth TA was hired by a private mental health service agency. At the end of the first year, the six trainees remained employed (including the one employed prior to the end of training). At two year follow-up, five of the original six TAs remained employed. Three are employed full-time in the CMHC system and two are privately employed as case manager assistants. One TA resigned after 23 months of employment, but has since accepted a job as an assistant in a homeless shelter.

During the first 90 days of placement with the CMHC the four TAs employed by the CMHC were referred a total of 74 cases. The data presented below is based on the 55 TA-Assisted individuals who were discharged into the community by the end of the first 90 days.

CMHC Attendance

As in the case of the Non-Assisted group, consumers in the TA-Assisted group were similarly discharged from the hospital with a referral for follow-up in the CMHC system and were provided the assistance of a TA who was a trained mental health services consumer. One major difference between the Non-Assisted and TA-Assisted consumers was that the individuals referred to the TAs were selected on the basis of previous history of noncompliance with aftercare treatment plans. Thus, these persons were considered to be at high-risk for clinic non-attendance. The two groups were compared for equality of variance with regard to age, gender, and pattern of CMHC use. No significant differences in the variances were found. Therefore, the two groups appear to be similar.

Clinic attendance for both groups was assessed at 3 months (Non-Assisted n = 151; TA-Assisted n = 55) and 12 months (Non-Assisted n = 213; TA-Assisted n = 74) into the study. Because individuals slated for discharge and referred to one of our groups often had to wait for suitable housing or other arrangements, not all persons in each group were eligible for clinic appointments at the 3-month preliminary analysis; therefore, the sample size al three months is smaller than at 12 months. At three months, 87% of the TA-Assisted consumers were connected with the CMHC compared to only 27% of the Non-Assisted consumers. After a full year, 90% of the TA-Assisted consumers were attending appointments at the CMHC compared to 59% of the Non-Assisted consumers.

Chi-square analyses showed that CMHC attendance by the TA-Assisted group was significantly higher than the Non-Assisted group (n=74,213, df=1, p=.003). These results suggest that the TAs were effective in facilitating use of community services.

Discussion

Throughout the project, weekly meetings were held with the TAs to identify strengths and weaknesses in the training program and to observe the effects of training. It was evident that the TAs experienced severe stress when there were conflicts between the various components of the CMHC system (i.e., when the CMHC changed the treatment plan, or when the client and the team disagreed about aftercare needs, or when discharge was repeatedly delayed or happened before they could meet with their assigned clients, etc.). They managed these difficult times through their weekly support group and by using each other for added help away from work. They found themselves for the first time providing input and offering advice to mental health workers, nursing staff, and physicians. Defining themselves as part of the treatment team and learning the diplomacy and communication skills necessary to interact with two very different service systems (the hospital's and the community's) often resulted in painful self-examination.

The success of this project was dependant upon a number of agencies and organizations working together to provide financial support, office and classroom space, training facilities, and finally, jobs for the trainees. Area agencies participated by allowing the TAs to volunteer part-time and get "on-the-job training," while the larger systems worked out the logistics of integrating them into the discharge planning phase of treatment. This joint effort was paramount in the success of the project. It necessitated open communication between the various components of the system and prompted review of long-held practices and assumptions about mental health consumers.

Another component in making this project a success was to educate the service community about the nature of the training and the function of the trainees. Many people in the service segment began their careers at a time when persons with mental illness were viewed as being unable to participate in their own treatment and certainly were not seen as a resource to help others. Despite the current political emphasis on empowerment and rehabilitation, many people at the service provider level continue to adhere to these earlier views. The presence of this attitude, while clearly held by the minority, needs to be evaluated and educational activity undertaken to facilitate a more adaptive perspective. It is also important to note that after two years of working with TAs, these attitudes are greatly reduced, as evidenced by comments and feedback spontaneously offered by staff members who originally were skeptical. In fact, the preliminary success of this project led to extension of the efforts at training TAs, with the CMHC adding additional consumer employee slots to its table of personnel organization. The CMHC is now doing its own TA training based on the training protocol. The CMHC has also increased the number of consumer-provider roles to include jobs other than that of TA.

If, as has been the case in previous studies (Sherman & Porter, 1991; Toprack, 1991), such trained consumers can continue to provide a useful and cost effective intervention, then there are a number of directions for future study. One particularly important factor that relates to the success of this type of program lies in the determination of a need within the community and the design of a niche where trainees can be employed, with job descriptions developed based on hospital/agency employment standards. This project showed that clients can benefit from an intervention of this type and that mental health consumers can be trained successfully for jobs other than janitorial and litter pick-up.

A vital element in developing a training program of this scope is the selection of TA candidates. At the inception of this program there were no guidelines as to what makes a former consumer an effective TA. Similar programs in other sites have used various entry criteria. Some programs exclude individuals with Axis II diagnoses, some exclude applicants with severe diagnoses such as paranoid schizophrenia, some exclude persons with previous criminal histories. Other programs accept anyone with a desire to work with other mentally ill individuals and allow the regimen of the training program to be the determinant of success. This project used fairly broad entry criteria and showed that even those who meet the criteria for severe and persistent mental illness were successful. It would be of further interest to identify those characteristics that differentiate between successful and unsuccessful trainees.

The national attention to deinstitutionalization and least restrictive environment for treatment call increasingly upon community resources to provide services to consumers who previously would have remained in the hospital a much longer period of time. As a result more support is needed for many clients. It is imperative that community interventions be cost-effective. By employing trained paraprofessionals to do direct care work, the rehabilitation counselor, social worker, case worker, and case manager are able to focus on refining treatment plans, coordinating services, and attending to those more complex tasks for which they were specifically educated and trained.

In summary, this project provided a two-fold implication for mental health care service providers to consider:

1. Persons with a history of severe and persistent mental illness and who are consumers of mental health services were successfully trained and employed as transitional aides.

2. Employing trained mental health consumers may enhance the continuity of care for persons with severe mental illness and a poor history of treatment compliance.

Note:

This research was supported in part by the Mental Health Connections, a partnership between Dallas County Mental Health Mental Retardation and the Department of Psychiatry of the University of Texas Southwestern Medical Center. Funding is from the Texas State Legislature and the Dallas County Hospital District.

This project could not have been completed without the cooperation and assistance of the Dallas County MHMR administration and staff, the Superintendent's Office and staff of Terrell State Hospital, and the members of the Research Core of Mental Health Connections. We would like to express our gratitude to these organizations for their support in helping make this project a success.

References

Benda, B.B. (1991). Undomiciled: A study of drifters, other homeless persons, their problems, and service utilization. Psychosocial Rehabilitation. 14(3), 39-67.

Bond, G.R. & McDonel, E.C. (1991). Vocational rehabilitation for persons with psychiatric disabilities: An update. Journal of Vocational Rehabilitation, 1 (3), 9-20.

Boyd, C. & Henderson, W.E. (1978). Improving continuity of care through a state hospital-CMHC liaison program. Hospital and Community Psychiatry. 29(6), 384-386.

Cutler, D.L., (1992). A historical overview of community mental health centers in the United States. In S. Cooper & T.H. Lentner (Eds.) Innovations in Community Mental Health (pp. 1-22). Sarasota FL: Professional Resource Press.

Goering, P., Wasylenski, D.A., Farkas, M., Lancee, W.J., & Ballantyne, R. (1984). From hospital to community: Six-month and two year outcomes for 505 patients. The Journal of Nervous and Mental Disease, 172(11), 667-673.

Harper J.M., Hoover, N.L., Jung, R.G., & Rienstra, J. (1990). Conclusions and recommendations. Financing community care for the chronically mentally ill in Texas,(89) 331-341. Published by the LBJ School of Public Affairs, University of Texas at Austin, Austin Tx, 78713-7450.

Moseley, B. A. (1994) Predicting outcome in persons with chronic mental illness: Risk factors associated with aftercare dropout. Unpublished doctoral dissertation. University of Texas Southwestern Medical Center, at Dallas. Dallas TX.

Sherman, P. (1992). Serving the Chronically mentally ill in the community. Presentation made to the Department of Psychiatry, Division of Psychology, UT Southwestern Medical Center at Dallas, Dallas, TX.

Sherman P.S., & Porter, R. (1991). Mental health consumers as case management aides. Hospital and Community Psychiatry, 45(5) 494-498.

Schwartz, C.C., Spitzer, R. L., Muller, C., & Fleiss, J. (1980). Factors influencing the success of a policy of community care for the chronically ill. National Association of Private Psychiatric Hospitals, 11(5), 27-30.

Test, M.A. & Stein, L.I., (1978). Community treatment of the chronically mentally ill: research overview. Schizophrenia Bulletin, 4(3), 350-364.

Toprack, M.G., (1992). Personal communication about the cost effectiveness of nine residential crisis modalities in Austin and Houston. Texas Department of Mental Health and Retardation, Department of Research and Special Projects. Austin, TX 78711-2668.

Warner, D., Hams, L.C., Kier, S., & Rodriguez, R., (1990). Financing community care for the chronically mentally ill in Texas (89). A report by the Policy Research Project on financing care for the chronically mentally ill in Texas 1990. Lyndon B. Johnson School of Public affairs, the University of Texas at Austin.

Maurice Korman

Martin Lumpkin

Carroll Hughes

University of Texas Southwestern

Medical Center at Dallas

Mary B. Turner, Ph.D, University of Texas Southwestern Medical Center, at Dallas, Department of Rehabilitation Science 5323 Harry Hines Blvd., Dallas, TX 75235-9044.