Psychosocial rehabilitation as treatment in partial care settings: service delivery for adults with chronic mental illness.

Psychosocial Rehabilitation as Treatment in Partial Care Settings: Service Delivery for Adults with Chronic Mental Illness

Astudy of partial care programs serving adults who have chronic mental illness was conducted through the Colorado Division of Mental Health's (CDMH) Faculty Fellowship Program. The following question provided the basis for our research: To what extent does rehabilitation as treatment exist in partial care programming for the adult with chronic mental illness? While the results of this research are specific to the programs surveyed in Colorado, our findings and recommendations should be of interest to those rehabilitation professionals, including rehabilitaiton counselors who are concerned with rehabilitation service delivery in mental health settings.

It is generally agreed taht "the ultimate goal of rehabilitation [is] the independent, effective, and full functioning of the client ..." (Thomas, Butler, & Parker, 1987, p. 65). More specifically, in terms of "psychosocial functioning," Bozarth and Barry (1980) cite the following definition from the First Institute of Rehabilitaiton Issues in 1974: "The degree to which a client demonstrates social and psychological adaptability which serves to enhance feelings of security, adequacy, functioning capability, emotional stability, and social interaction" (p. 144).

Partial care services in mental health settings are defined as the "provision of a planned therapeutic program during most or all of the day or in the evening to persons who need broader programs than are possible through outpatient visits, but who do not require 24-hour hospitalization" (Redick, Witkin, Bethel, & Mandersheid, 1985, p. 8). Partial care services may also be referred to as "partial hospitalization," a "community support program,c or "day treatment." As regard the relationship between partial care programming and rehabilitation, FAlloon and Talbot (1982) have observed that "day treatment has a specific role in the community rehabilitation of patients with psychiatric illness associated with handicaps in social role performance, and that the goals of a successful rehabilitation program can be derived from an analysis of the functional needs of individual patients who enter the program" (p. 279). Shore (1986) has defined rehabilitation in mental health settings as "a wide array of nonmedical interventions" (p. 15). He suggested that "rehabilitation programs emphasize social and vocational training" with examples such as "vocational counseling ... problem-solving and money mangement skills" (p. 15).

Perhaps Solomon's (1959) observation that "the lack of social adaptation of many of the patients looms larger than the matter of work skills" (p. iv) hold true today. Most recently, Lefley (1988) has suggested that "rehabilitation and traditional psychiatric treatment . . . should not be considered discrete categories but rather a seamless process of therapeutic intervention" (p. 21) in an effort to allow consumers of services increased opportunities to improve socialization skills. As psychosocial rehabilitation philosophy and intervention strategies become more accepted and even welcomed in mental health settings, rehabilitaiotn professionals should become more interested in determining the extent to which partial care programs can be characterized as rehabilitative in purpose and design. This study represents an initial attempt at such an assessment.

Methodology

The research methodology involved a survey of all public partial care programs located within Colorado. The 16 programs which responded to the survey represent 80% of the CDMH funded adult partial care programs in Colorado. While an average of 64% of the open cases in Colorado public sector adult programs are persons with chronic mental illness, the 16 programs which responded to the survey reported an average of 85% of their open cases to be adults with chronic mental illness.

A review of the literature relevant to mental health partial care programs and to psychosocial rehabilitation was conducted in order to determine what attitudes and techniques are typically associated with psychosocial rehabilitation programs. Using this information, a questionnaire (1) was constructed to measure the extent to which partial care program cooridnators in Colorado adhere to rehabilitaiton philosophy, employ staff whose attitudes are congruent with a rehabilitation approach, utilize rehabilitation intervention structures, and implement rehabilitation treatment modalities.

In order to examine program philosophy and normative attitudes of staff, program coordinators were asked two questions which required rating the importance of selected rehabilitation concepts and staff attributes. Each item for both questions was rated from 1, "not important," to 4, "essential." The program coordinators were asked, "To what extent do the following items represent intervention strategies believed to be important in your program?" and "To what extent are the following attitudes important regarding staff selection and retention?" Fifteen items were selected for these analyses on the basis of general agreement in the literature as to their relevance in psychosocial rehabilitation practice (see e.g., Anthony, 1982; Black and Kase, 1986; Dincin, 1985; and Stroul, 1986).

In addition to program philosophy and staff attitudes, data were sought to determine the extent to which rehabilitation treatment techniques are currently being used in Colorado programs. The program coordinators were asked, "With what percentage of your program's client population are the following assessment strategies, . . . intervention structures, . . . [and] treatment modalities used?" Fifteen items describing assessment and treatment techniques were used as indicants of the rehabilitation approach. As above, these items were selected from a comprehensive literature review.

Subsequent to obtaining results from the questionnaires, four programs (25% of the Colorado programs responding) were selected as locations for site visits. At these programs, follow-up interviews were conducted with program staff; program treatment activities were also observed. While a random sample of the 16 programs would theoretically have allowed for the greater generalization of our results, these four programs were purposely chosen on the recommendation of CDMH administrative staff in order to obtain data from partial care programs in major populations centers with well-established psychosocial rehabilitatio components.

Results

For the most part, partial care program coordinators believe that rehabilitation philosophy and attitudes are very important if not almost essential, for staff they employ. In particular, emphasis is placed in programming upon improving client capabilities while at the same time employing staff who have respect for long term clients (see Table 1). There is less emphasis, however, upon processes also important in rehabilitation such as client involvement on advisory boards, and client evaluations of staff. The willingness of staff to use behavioral techniques is also rated somewhat less important by the staff coordinators.

With regard to the actual implementation of rehabilitation intervention, program coordinators reported that a majority of clients receive assessments congruent with rehabilitation strategies (see Table 2). Behavior observation is the most widely used of these as strategies; on the average, 82% of the clients in each of the programs receive this type of assessment. A smaller proportion of clients, however, receive treatment based upon an environmental resource assessment. Approximately two-thirds, of the clients receive in-vivo assessments, functional assessment, and assessment of client assets.

The implementation of rehabilitation as treatment, however, is less consistently provided to clients than are assessments. While four rehabilitation intervention structures and treatment modalities are used with approximately two-thirds of the clients, six of the ten items are provided to substantially smaller proportions of clients (see Table 2). Specifically, client participation in goal setting, social skills training, the learning of problem-solving skills, and community living skills are quite widely implemented. However, only one-half of the clients in a given program experience individual or in-vivo skills training, role-playing opportunities, or environmental resource development.

Behavioral therapy is not widely employed, although behavioral techniques have been traditionally utilized by rehabilitation practitioners. According to Bozarth and Barry (1980), "The simplicity of these [behavioral] approaches and their derivation from large bodies of psychological research on learning and motivation have resulted in their widespread adoption in rehabilitation" (p. 113). Transitional skills training was reported to be given to the smallest percentage of clients (36%). While partial care programs appear to provide some of the services associated with transition, program staff may not view these interventions as essential in a client's treatment even though such skills are critical in order to achieve a more independent status. According to Nosek (1987), "The primary service provided by . . . [transitional] programs is skill training in such areas as... financial management, consumer affairs, mobility, educational-vocational opportunities, medical needs, living arrangements, social skills, time management, functional skills, sexuality, and so forth" (p. 215).

Observations and interview data from the site visits complement these written responses of the program coordinators. Typically, programs visited started the day with a community meeting. The structure and purpose of a community meeting would determine whether or not it was "rehabilitative." One program for example, began the day with a community meeting and a flexible time frame for the meeting to conclude. Clients were actively involved in structuring their day's activities (learning to take responsibility, learning to structure their time, initiating). Team building was an important part of the meeting, with clapping and cheers to reinforce an individual's improved behavior. The lack of focus on time also allowed for a spontaneous concert by clients--first, "Happy Birthday," then a rousing version of Charle Daniels' "Long-Haired Country Boy," followed by the "Green, Green Grass of Home," and the beginning strains of "La Bamba"--exquisite guitar playing by two "low-functioning" clients and a powerful example of focusing on clients' assets and capabilities.

In general, however, partial care program staff were not aware of rehabilitation as an integrated treatment approach. They knew "vocational rehabilitation" but not rehabilitation as an overall philosophy with a set of specific intervention strategies suitable for utilization in mental health settings. For example, according to Anthony, cohen, and Cohen (1984), "the deliberate increase in client dependency can lead to an eventual increase in the client's independent functioning" (p. 140). Providing transportation can be an important step in facilitating independence for partial care clients. Yet most programs visited saw providing transportation as only contributing to client dependency. Certainly providing transportation would be an essential step toward independence in a community where public transportation is not adequate. (A good measure of adequacy might be whether or not staff use public transportation to get to work. If not, it would probably be a reasonable assumption that expecting clients to use it would be too large ot a step in their rehabilitation.)

Partial care staff, in general, were open, energetic, and caring as regards their clients and each other. They would be supportive of the individual client who chooses gainful employment as a goal, but they do not believe all clients should be required to have this goal. They believe that clients should strive for independence from the mental health system, but their expectation is that clients would not survive such independence.

Discussion

This research has provided a first step in Colorado toward answering the question, "To what extent does psychosocial rehabilitation as treatment exist in partial care programming for the adult with chronic mental illness?" Results from the questionnaire indicate that partial care program staff adhere philosophically to many of the concepts associated with rehabilitation; however, in practice, there appears to be room for increased utilization of rehabilitation assessment strategies, rehabilitation intervention structures, and rehabilitation treatment modalities. Thus while a majority of adult clients may receive some form of assessment necessary for rehabilitation as treatment, it is important to note that rehabilitation intervention structures and treatment techniques, such as behavioral therapy and transitional skills training, are less widely employed.

During the four site visits, partial care program staff readily admitted that they were, in fact, unaware of rehabilitation as an integrated systematic intervention methodology. They were unaware of rehabilitation as a profession. As an intervention, they were primarily familiar with the vocational aspects of rehabilitation. The conclusion that partial care staff are, for the most part, unfamiliar with some aspects of rehabilitation as intervention is not meant to imply that they are uninterested. In fact, in terms of philosophy, it would appear that public partial care programs are generally in agreement with psychosocial rehabilitation advocates as to the importance of certain key attitudes and intervention strategies. With training and adequate resources, philosophy can be more fully extended to practice.

Since 1980 Colorado has encouraged rehabilitation as treatment in partial care programs funded by CDMH. This research has provided preliminary empirical understanding of the extent to which prior efforts have influenced public programs. This first attempt to collect systematic data regarding the incorporation of a rehabilitative approach in Colorado's public partial care programs has also been useful to the state mental health authority's current planning process. Under the new CDMH mission statement, all community-based partial care programs will be expected to provide rehabilitation services. These services will include "training and education to promote the development of (1) social skills, (2) leisure time management skills, and (3) vocational and/or other appropriate role skills." Furthermore, "development of, and assistance in accessing community resources and vocational opportunities" must also be provided by the programs (Colorado Division of Mental Health, 1988).

Recommendations

* True rehabilitation as treatment should comprise an integrated set of philosophical assumptions, attitudes, assessment strategies, intervention structures, and treatment modalities. A more comprehensive and integrated understanding of a psychosocial rehabilitative approach to treatment should be promoted in partial care settings. Staff should receive inservice training regarding the history of the rehabilitation movement in this country and its philosophy. They should also acquire a basic understanding of the intervention processes associated with rehabilitation. Such knowledge would be essential not for developing program goals and objectives, but also in assisting clients to develop rehabilitative goals and objectives.

* This survey also indicated that rehabilitation as treatment could be expanded to a larger percentage of clients within these programs. For example, planning emphasis should be placed upon in-vivo skills training and upon staff acquiring and using behavioral therapy skills.

* Current obstacles to providing rehabilitation assessments, intervention structures, and treatment modalities need to be identified and eliminated so that a greater percentage of clients may receive rehabilitation services. For example, mental health administration should become involved in changing the system of Medicaid reimbursement and other third-party payments to include individual skills training in the environment of need for persons with severe psychiatric disability.

* Finally, additional data is needed. Less than a third of all partial care programs surveyed have participated in a treatment outcome study. What outcomes would be expected given rehabilitation as treatment? Would an independent living outcome be as valued as a gainful employment outcome? How do consumers perceive the shift from traditional psychiatric treatment to a more comprehensive rehabilitation approach? Is such a shift desired by consumers?

The expertise of rehabilitation professionals in working with persons who have physical disabilities has long been acknoledged. In recent decades rehabilitation practices have been introduced and, to some extent, adopted in mental health settings. This study suggests that partial care programs can provide rehabilitation professionals with fertile ground in which to further develop and implement rehabilitation as treatment.

(*1) A copy of the questionnaire utilized in this study is available upon request from the senior author.

References

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