Reintegration through recreation.

"Sometimes it is just not so easy to have fun. You almost have to learn how to have fun. Sometimes when you have been mentally ill you punish yourself or don't think you are allowed to have the same type of breaks that everyone has to have, which includes fun and recreation and rebuilding yourself. This program (RTR) encourages you to start where you are and to enjoy what's available around you and what you like. Maybe one of the important things about the program is that the emphasis is on what you want to do and what you'd like to have happen."

Reintegration Through Recreation (RTR) is an innovative program whose mission is to provide the necessary skills and supports to individuals with severe and persistent mental illness, so they may have satisfying and successful lives which include freely chosen and supported recreation and leisure.

Approximately two percent of the population suffers from a serious mental illness. The causes of these brain diseases remain unknown, but are probably multiple and not the fault of the individual or his or her family. In addition to having a brain disease, people with serious mental illness are significantly functionally impaired for an indefinite period of time in many of the primary activities of life, including social interactions and relationships, concentration and decision-making, home making, self care, employment, education and recreation. The problems of people with serious mental illness are compounded by stigma and discrimination, which may partially explain their limited involvement in community recreation experiences.

People who have a severe and persistent mental illness may be the most under-represented group of people with disabilities to be served by community parks and recreation and commercial recreation providers. Society's misperception of these individual's needs and abilities, consumers, reluctance to expose themselves to an unknown and potentially harsh environment, media misrepresentation and a lack of accurate information on positive and reasonable ways to offer inclusive and accessible services all contribute to a pattern of exclusion for these citizens.

Although parks and recreation departments are not mandated to offer treatment and rehabilitation services, they do have a responsibility to offer accessible and inclusive services to all citizens. Reintegration Through Recreation provides one model for promoting their full participation in life and saying that it is okay and necessary to have fun and learn healthy ways to access the things that many of us take for granted.

We know from our surveys and interviews with consumers and families that they are most concerned about issues such as improved quality of life, freedom of choice, pleasure, the opportunity to master skills, more environmental supports, less stigma and ways to plan for free/unstructured time. The majority of people with severe and persistent mental illness live in our communities, not in hospitals or day treatment programs or other segregated settings. Their dreams and needs are not all readily addressed in separate settings. Currently there are quality therapeutic recreation programs in many traditional medical treatment settings. However, there are limited TR services beyond the hospital, especially those that have as their mission the focus on individualized community reintegration. There are also many quality community-based psychosocial rehabilitation programs, but they often have limited resources that are devoted to individualized community reintegration in the area of recreation and social needs.

With this realization, The Center for Recreation and Disability Studies in the Curriculum for Leisure Studies and Recreation Administration at the University of North Carolina-Chapel Hill applied for and was awarded a three year demonstration grant from the Rehabilitation Services Administration, Office of Special Education and Rehabilitation Services of the United States Department of Education to develop, implement and evaluate a mental health community reintegration program. The purpose of this project (RTR), is to offer individualized therapeutic recreation services to people with severe and persistent mental illness in order to enhance their rehabilitation, community adjustment, leisure satisfaction and quality of life. RTR is based in the individual's community so that he or she can make personal choices that can promote independence, dignity, individuality and community inclusion.

The goals of RTR include:

* an improved adjustment to home

and community

* successful community life

* more varied recreational interests

and skills

* an expanded social network and

resources

* improved problem-solving and

decision-making skills

* the ability to follow through on

independently chosen and

planned recreation choices

* more satisfaction with free time.

The principles underlying RTR emphasize a psychosocial rehabilitation approach, which is defined as "restoring or creating a life of acceptable quality for people who suffer from a mental illness." A crucial goal of rehabilitation is improving the quality of life as defined and experienced by the consumer and actively involving the participant as a collaborator in his or her care.

Therapeutic recreation has much to offer people with mental illness in their quest for an acceptable life. TR professionals must consistently and eloquently reinforce the value and benefits of leisure and recreation, to modify traditional and customary views of recreation as a secondary goal and means of intervention, a diversionary tactic or due only as a reward for other achievements.

The role of personal enjoyment and meaningfulness is critical to feelings of life satisfaction. These values are not always easy to obtain, due to barriers such as the lack of necessary skills, limited positive experiences with fun and pleasure, and negative attitudes. Recreation is a medium that can offer opportunities for flexibility, choice, individuality, decision-making. Elements that RTR stresses are the maximization of personal strengths, membership in one's community, skill development and mastery, and the ability to fit into the setting(s) of one's choice. The emphasis is on the "here and now," doing and taking action, personal responsibility, problem-solving that produces real and valued solutions and becoming a participant in one's own community, as opposed to membership in only segregated groups or settings.

RTR uses an individualized leisure education program based on the premise that free time is often misused and/or unsatisfying and that leisure may be the best context for self-determination and normalization. Leisure education needs to focus on developing skills that can increase recreation participation, satisfaction and mastery. These skills may include identifying personal interests, needs and resources; specific activity skill development; exploring community resources; practicing the use of skills in the community setting of choice; and using problem-solving and decision-making skills. Providing strictly diversional activities or offering only segregated experiences can offer dependency, which then undermines such goals as autonomous functioning and ensuring a desired quality of life.

Leisure education can also encourage self-directed, freely chosen, healthy and pleasurable choices. However, for leisure education to be effective it must go beyond mere leisure awareness and become the ability and confidence to take personal action. The client must be able to choose to participate independently in meaningful experiences. It is crucial to stress that the individual is capable and responsible for his or her leisure and that he or she can change and improve his or her present leisure status. Leisure requires a cluster of skills to ensure success. Our client's definitions of recreation and leisure frequently include choices and goals beyond a list of traditional recreational activities. Many RTR participants are interested in mastering the skills that will allow them access to an indefinite array of leisure and life opportunities. It is the job of the therapeutic recreation specialist (TRS) to facilitate this learning in the way best for each client, not to mandate specific recreation choices.

RTR has developed a systematic leisure education program that is individualized for each participant based on his or her identification of relevant problems and self-selected goals. The overall components of our leisure education program have been translated into units (see accompanying chart) that serve as a road map for the collaboration between each participant and TRS. A variety of written exercises are available for use with each unit. We use these assignments to promote personal learning and the generalization of skills beyond scheduled appointments. The challenge is to put these components into action in away that is relevant and useful. The sequencing and importance of each component varies per individual.

RTR is now offered in Durham and Wake counties in North Carolina, and services are linked to a state psychiatric hospital, Dorothea Dix Hospital and the local community mental health centers. RTR works with patients preparing to leave the hospital, targeting those who have had insufficient time to adequately plan for their social and community re-entry. RTR also serves people residing in the community when we feel that an individualized approach to community integration would decrease their social isolation, increase their leisure satisfaction and participation, especially in independently selected and initiated community involvements, and aid in overall community rehabilitation. Typical reasons for referral include social isolation, difficulty with free or unstructured time, complaints of boredom, unfamiliarity with the community, few friends, poor follow through on personal interests and goals, difficulty with group interactions and thus limited ability to tolerate other psychosocial rehabilitation services, and/or specific skill deficits that could be improved with an individualized learning approach.

After receiving the referral, the arranges a meeting with the prospective client and the referring service provider. The TRS reviews the purpose and format of RTR and then offers the consumer the option of participating. The core of RTR is the collaboration between the participant and the TRS in the leisure education program. The TRS promotes the client's independent follow-through on self-selected activities, supports the client during actual community activity participation, helps develop specific life skills, and evaluates these new experiences with the participant.

The amount of time the TRS and client work together depends on the individual, his or her goals, learning pace and environmental supports. Currently there is one full-time TRS in each county. We have found the average ratio of TRS to clients is 1:15, with an additional two to four clients in the discharge/ follow-up phase. We generally see clients once a week at the beginning of their participation in RTR, and then, as we enter the discharge phase, we schedule the appointments less frequently to promote generalization and independence. The average number of months a client is actively involved in RTR is ten to 12. We are now beginning to accummulate more follow-up data and will be analyzing it for client outcomes, cost of service, and client and service provider satisfaction. We feel that providing such an individualized service can be cost-effective and relevant when it produces valued and lasting consumer outcomes and is compared to the cost of other traditional TR service programs.

Throughout RTR the response of service providers in community mental health, hospitals and community recreation services has been positive and supportive. They have noted the ability of clients to achieve levels of unexpected mastery due to the individualized and intensive learning assistance offered. The focus of "recreation" goals has often translated into measurable successes in other life areas. These include the interest and ability to return to work or school, the ability to manage a limited income, decreased reliance on family and professionals for personal needs, increased self-advocacy and increased self-esteem.

RTR challenges community recreation providers to consult with local community mental health centers, advocacy groups such as the Alliance for the Mentally Ill and Mental Health Consumers Organization, and the state TR organization, to explore ways to answer questions about offering services to people with mental illness. We also extend a challenge to therapeutic recreation professionals to explore creative ways of offering a continuum of therapy services to people with disabilities.

EDITOR'S NOTE: For further information on RTR please contact Karen Luken at the Center for Recreation and Disability Studies, CB 8145, 730 Airport Rd., University of North Carolina, Chapel Hill, NC 27599-8145. A comprehensive model program manual and technical assistance will be available for purchase in the fall of 1993.

Case Studies

Susan, 32, a single female with a serious Mental illness, was eager to be involved in RTR and had many personal goals and activity interests. After completing the RTR assessment process and developing rapport with the TRS, she decided to focus her efforts on building transportation skills, feeling that her lack of usable transportation was a significant barrier to being able to independently pursue her interests. At the start of her work in RTR she relied on her parents for getting places, and thus felt very dependent and unable to set her own schedule.

Together the client and TRS designed a personal plan of action that focused on her goal and broke down the skill of bus riding into smaller, more manageable steps. We outlined beginning, middle and exit objectives that would indicate she was making progress toward her goal and also identified specific learning strategies that would enable her to learn how to independently use the bus system. Appointments were spent reviewing bus schedules, locating bus stops, improving her physical stamina so that she could manage the walk to the bus stops (1 to 1 and-one-half miles from her residence), and actually riding the bus to different locations in town that she had selected.

As she became more confident in her skills, we began to link her transportation successes with personally meaningful recreation interests, such as swimming, shopping and eating out. She would travel alone by bus to the selected spots, meeting the TRS for an appointment. These skills and her increased self-confidence were of immeasurable help to her during her recent move into her own apartment. Without the ability to use available city transportation she feels she would not have been able to take this step and to involve herself in other community recreation activities, such as walks at her favorite city park, use of the community swimming pool, and arranging lunch dates with friends. "I think for me feeling as low in confidence as I did, it was crucial that someone was with me and that if I felt at some point we were doing something that was maybe too much of a stretch for me at that time, that we could amend my plan."

We are now working on her graduation from RTR, reviewing her specific accomplishments, including skill mastery, knowledge and a sense of self-determination. We are also discussing her future plans and identifying potential problems and obstacles that could sidetrack her advances. How long someone is involved in RTR depends on the individual participant and their needs and progress. There is a gradual transition from the program, with supportive follow-up as needed.

Travis has been working in RTR for nine months. Right away he knew that he wanted to learn computer skills. It took several months to locate a community class that matched his personal schedule and skill level, but his persistence paid off and he has now completed two introductory courses at a local technical college. Following these successes he then decided to pursue his General Education Diploma and is now enrolled in a GED class that meets four times per week.

Throughout his involvement in RTR he has worked on skills related to money management, social interactions and time use in order to improve his chances of success and independence. Prior to class enrollment, we explored the college campus, reviewed basic study habits and met with his family, all in an effort to maximize his opportunities for success. Money for classes and supplies has been handled with loans, negotiations with family, and improved personal money management. Travis views his interest in computers as both recreational and a possible job opportunity.

Principles of Reintegration Through Recreation:

1. Each person has the right to choose w hat he/she likes to

do, where and with whom he/she will recreate. 2. Meaningful choices are based on increased options,

resources and necessary skills. 3. Consumer involvement and control are crucial for success

and empowerment. 4. The natural environment is the most useful learning

environment. 5. Flexibility is critical. 6. Success is individually defined. 7. Skill development needs to be related to personal goals

and natural settings. 8. Personal responsibility is encouraged. 9. Involvement of family is not to be discouraged. 10. Advocacy needs to address the availability and responsiveness

of support resources.

Reintegration Through Recreation offers education, in formation sharing, skill development, skill enhancement support and advocacy.

Adapted from materials of the Center for Psychiatric Rehabilitation, Boston University.