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Computer training for the young adult patient with chronic mental illness.

Patients in state-operated psychiatric hospitals today are generally the most chronic of the mentally ill population. Vocational rehabilitation staff rely on such activities as sheltered workshops and facility maintenance tasks as primary arenas for job training. Through a pilot vocational training program in computers, some patients have shown an aptitude for this challenging work despite their psychiatric impairments.

Vocational rehabilitation is considered by many mental health professionals to be one of the most important aspects of treatment. Lamb (1982) asserts that "work therapy geared to the capability of the individual patient should be the cornerstone of community treatment" (p. 176). Bennett (1983) found that employer exposure to the employee with a mental illness changed the attitudes of citizens and professionals about the employability of the mentally ill. Anthony and Liberman (1986), after a review of the literature suggest that persons who are severely psychiatrically disabled have skills that are positively related to measures of rehabilitation outcome and that these persons can also learn other skills. Furthermore, they state that rehabilitation outcome is improved by skill development, intervention and environmental resource development.

It is indicated that vocational rehabilitation should begin as early as possible after admission since prolonged periods without rehabilitation can lead to loss of vocational functioning. For example, Farkas, Rodgers, and Thurer (1987) found that in a group of deinstitutionalized persons with mental illness (n=43, mean age=40) who had not received inpatient vocational training, none improved significantly in vocational functioning over a period of 5 years after discharge. This suggests the importance of vocational training during the hospitalization period and after discharge. Despite this indication, proper vocational rehabilitation may not always be available in either inpatient or outpatient mental health systems. A list of four serious impediments to the integration of vocational rehabilitation strategies into the mental health system was compiled by Harding, Strauss, Hafez, and Lieberman (1986): rigidity, isolation, compensatory ad hoc operations, and narrow frames of reference of mental health service providers. However, the findings of Anthony and Jansen (1984) in a review of the literature are encouraging. They determined that psychiatric symptomatology, diagnostic category, intelligence, aptitude and personality tests are poor predictors of future work performance. This determination is important for the vocational rehabilitation counselor to consider when designing work programs for persons suffering from schizophrenia or other severe chronic mental illnesses.

The onset of schizophrenia, the most chronic and debilitating mental illness, occurs at a crucial stage in life, namely the transition into adulthood. During this period (age 18-25) most young adults are in the process of determining their career goals or testing various jobs or occupations. Schizophrenia disrupts this entire process and often the victims face difficult problems in developing vocational skills or interests. Both the positive symptoms (hallucinations, delusions) and negative symptoms (alogia, anhedonia) of schizophrenia, as described by Andreason, 1982 and Andreason and Olsen, 1982, intensify this debilitation, making it difficult for the victim to function with other people in either a living or work environment. It is the extent of this debilitation which contributes greatly to the 70% unemployment of those with chronic mental illness (Goldstrom and Manderscheid, 1982).

Generally, vocational rehabilitation for the person suffering from schizophrenia is encouraged when symptoms begin to stabilize. However, Anthony and Liberman (1986) state that "even if symptoms persist, rehabilitation can proceed within the limits of the individual's capability to respond to training and supportive interventions" (pp. 545-546). Given the chronicity of the mental illness afflicting patients in state-operated psychiatric hospitals, this treatment position is appropriate in directing the vocational rehabilitation approach.

Setting

As a means of addressing the need for innovative vocational rehabilitation strategies with persons suffering from severe mental illness, a computer training program was initiated by the authors on the Evaluation and Training Unit (ETU) at the Rochester Psychiatric Center (RPC). The ETU is a joint venture between the New York State Office of Mental Health and the University of Rochester Department of Psychiatry. Besides providing public psychiatry training for psychiatric residents, the unit also promotes innovative treatment, research, and the development treatment modalities for persons suffering from schizophrenia. The ETU is a 50-bed unit with a mean patient age of 27 (range 18-45). The population is 69% male and the most frequent diagnosis is schizophrenia (65%) using DSM III-R criteria. Patients have had a median of 4 hospitalizations. The mean length of stay on the unit is currently six months.

Program Design

The computer training program was designed by vocational rehabilitation staff on the ETU based on the theories of William Anthony and others (Anthony, 1979, Anthony, Cohen, & Cohen, 1983). The goals of the program are to increase the self-esteem of the participants, provide hands-on experience with the computer and introduce the participants to software packages which are widely used in business, institutional and educational settings.

The computer can be an ideal vocational and clinical rehabilitation tool for the person with a chronic mental illness. Computers can provide not only a certain insulation from the pressures of constant social interaction but also structure and the encouragement of concentration and experimentation. With slow-paced instruction along with support and encouragement, both the higher functioning person in psychiatric remission as well as lower-functioning individuals with active symptomatology can respond positively to this type of program.

The course is taught in the RPC Rehabilitation Center, a modem building on the hospital campus. The classroom is large and well-lighted, is painted white and has windows. Each student uses one computer, all of which are the IBM PS/2 Model 30 with color monitors. Each computer has a slightly different configuration (i.e., RAM greater than 640K, hard disk drive greater than 20 megabytes, different printers, external 5.25" disk drives) and students are encouraged to experiment with different machines.

The program is designed to run approximately eight weeks. Classes meet twice weekly (Monday and Wednesday afternoons at 1:15) for one hour. There is no break scheduled during class time. Handouts are provided for each session and the end result of each class is a printout of that day's work. The first two sessions provide basic introduction to the computer and the workings of PC DOS (Disk Operating System). Three packaged computer programs are then covered: WordPerfect (Ver. 5.0), Lotus 123 (Ver. 2.1) and dBase (Ver. III+). These programs were chosen because they are generally considered to be industry standards and therefore are most often used in businesses or institutions.

Curriculum

Section 1: (2 Classes) History and DOS

The first class provides some history of the PC and a "tour" of the computer hardware. The tour includes locating the on/off switch, examining the keyboard, and explaining the monitor and its difference from the central processing unit (CPU). Students are also shown the printer, hard disks, floppy disks, disk drives and the attachment of various cables. During this section it is emphasized that the computer is a "dumb machine" and can do nothing without the user telling it what to do. We also illustrate that the computer is not attached to other computers and can get no information other than what the user types in through the keyboard. The possibility of deleting information or damaging the computer is covered but students are strongly encouraged to experiment.

The second class touches on the important role of the Disk Operating System (DOS) and some simple DOS commands. File structure, the relevance of ASCII format and directories/subdirectories are also briefly introduced and explained.

Section 2: (6 Classes) WordPerfect

WordPerfect is the first computer program addressed. This word processing program serves as an ideal starting point given its conceptual similarity to the typewriter. WordPerfect functions (bold, underline, center text, etc.) are introduced and illustrated through various exercises. Text handling techniques (block, move, copy, etc.) are covered in the later part of the course, also involving exercises. The final assignment encompasses all commands and functions to successfully troubleshoot and repair a two-page document.

Section 3: (5 Classes) Lotus 123

In the transition to learning a new program, it is explained that computers can work with text but are used most often as a tool for working with numbers. The spreadsheet program Lotus 123 is introduced primarily as an accounting tool and is illustrated through accounting examples. Practice spreadsheets are constructed for various purposes (budget, portfolio management). Students learn how to design the data file, how to input data and how to construct formulas for producing the desired output (column totals, row totals, cell combinations, etc.). Graphs and reports are constructed during the last classes and printed using the Lotus PrintGraph option.

Section 4: (3 Classes) dBase III+

dBase III+ is introduced as a program that exploits the computer's ability to handle both text and numerical data. This is the most difficult of the programs to grasp conceptually and this is explained to the students before the instruction begins.

The primary exercise which spans all three classes is constructing a small mailing list database. Students construct the data fields and enter the data after they edit and append the data files. Other exercises include sorting and indexing the database. Finally a report is constructed and printed.

Due to the limited number of computers, there are currently only six available student slots. We found this to be a manageable number for only one instructor since instruction requires frequent one-on-one help during class. The first course sequence was comprised of patient students only. The subsequent courses, however, were altered to include two Vocational/Recreational/Occupational Therapy staff, first from the ETU and then from other inpatient units within RPC. This was introduced because of the staff's interest in developing the course on a larger scale to reach more patients on other units hospital-wide. The instructors noticed that the presence of these staff in the classes seemed to have a positive effect on the other students. Patients could see that staff also made mistakes and, for example, had difficulty grasping a certain topic or had trouble getting a document to print. Staff were also available to informally help other students who were having difficulties. It was not uncommon for a staff member to sit with a patient while both of them struggled through an exercise.

After the second course sequence, a patient who had just "graduated" was invited to co-teach the next course. Although the co-teacher was unable to finish the entire course in that capacity it was found to be a very helpful addition to the course. The next co-teacher was a Vocational Rehabilitation Counselor who took the position with the intention of teaching the course for the next sequence, training both patients and other staff who might teach at a later date.

Discussion

The program has been provided to 30 students overall (23 patients and 7 staff) between 6/89 and 9/90. Classroom computers are provided specifically for patient use by Rochester Psychiatric Center/NYS Office of Mental Health. Approximately half of the students completed the full classroom course with varying degrees of success. One student, as mentioned above, went on to co-teach the course. Four students have performed paid computer work on the unit and three others have gone on to more advanced courses. The remaining students take advantage of the computer designated for their use on the ETU in varying degrees.

The patients participating in the course mirror the population of the ETU. They suffer from a chronic mental illness and are in approximately their fifth inpatient hospitalization. Most are schizophrenic (76.5%) and they are divided evenly between females (50%) and males. The age range is 20 to 42 years with a mean of 31.45.

Patients are not necessarily in remission when they are considered for the course. Weekly ratings are done on each ETU patient using the Nurses' Observation Scale for Inpatient Evaluation (NOSIE) (Honigfeld, Gillis, & Klett, 1966). The NOSIE is a 5 point scale (range 0=Never to 4=Always) designed to rate how often the patient exhibited certain behaviors on the ward over the past three days. In order to demonstrate the general level of symptomatology for the participating patients, the behaviors rated highest on the following NOSIE items at the start of the course are outlined in Table 1. All patients are considered candidates for the course despite their level of symptomatology.
NOSIE Items Rated Highest at Start of Course
Shows no interest in activities
around him/her 77%
Does not keep clothes neat 52%
Rarely laughs or smiles at
funny comments/events 65%
Rarely starts a conversation with others 77%
Does not talk about his/her interests 88%
Table 1


Those patients who have expressed interest in the course are referred by their vocational rehabilitation counselor and patients who have experience with computers or a similar field are invited to participate. We have observed that even regressed or actively psychotic patients can respond well to either the structure or isolation of working with the computer. However, those patients are the most difficult to retain in the classroom situation and generally require individual attention. It is for these patients that an individualized computer orientation program has been established on the ETU and the interest for the program has been greater than anticipated. There are some students who realize that they dislike working with computers.

Although they are encouraged to stay for the duration of the course or to come in for individualized sessions, they are free to drop out of the course at any time. When the classes are finished students are presented with certificates stating that they had completed the course.

We did not formally test each student's success during the course but rather presented comprehensive exercises at the end of each section which had to be completed in class. Although students were expected to complete the exercises on their own, each received much positive support and encouragement. Our quantitative and clinical evaluation of the program is that it is successful based on the students' interest in the course, the number of students involved, the number of students completing the course and those who express a continued interest after the course is completed. Self-esteem appears to increase in the students. They are proud of their involvement in the course and will talk with both patients and staff about computers and even make suggestions as to how computers can be used to resolve a particular problem.

This type of vocational training program offers a unique opportunity for those persons recovering from severe mental illness to acquire a marketable skill. Acquisition of this skill or even familiarity with computers can give that person a competitive edge when applying for jobs in the community or in other situations such as working with computerized machinery in a sheltered workshop. We have observed that gaining this knowledge seems to have a positive effect on the patient's self-esteem and future studies should measure changes in self-esteem after completion of such a program. The program is currently in the process of being expanded throughout the psychiatric center. This expansion will benefit more patients and allow a research protocol to be instituted to gain a better understanding of the impact the program may have on self esteem and strengthening vocational functioning.

Author Notes

Partial support for the computers and research on the ETU is provided by the Committee to Aid Research to End Schizophrenia (C.A.R.E.S.). Send reprint requests to John Crilly, University of Rochester, Department of Psychiatry, 300 Crittenden Blvd., Box R-Wing, Rochester, New York, 14642.

References

Andreason, N.C. (1982). Negative symptoms in schizophrenia. Definition and reliability. Archives of General Psychiatry, 39, 784-788. Andreason, N.C. and Olsen, S. (1982). Negative v. positive schizophrenia. Definition and validation. Archives of General Psychiatry, 39, 789-794. Anthony, W.A. (1979). Principles of Psychiatric Rehabilitation. Baltimore, MD: University Park Press. Anthony, W.A., Cohen, M., and Cohen, B. (1983). The philosophy, treatment process and principles of the psychiatric rehabilitation approach. New Directions in Mental Health, 17, 67-79. Anthony, W. A. and Jansen, M. (1984). Predicting the vocational capacity of the chronically mentally ill: Research and policy implications. American Psychologist, 39, 537-544. Anthony, W. A. and Liberman, R. P. (1986). The practice of psychiatric rehabilitation: historical, conceptual, and research base. Schizophrenia Bulletin, 12:4, 542-559. Bennett, D. H. (1983). The historical development of rehabilitation services. In Watts, F. N. and Bennett, D. H., (Eds.) Theory and Practice of Psychiatric Rehabilitation. (pp. 15-42). New York, NY: John Wiley & Sons, Inc. Farkas, M.D., Rogers, E. S., Thurer, S. (1987). Outcome of long-term hospital patients left behind by deinstitutionalization. Hospital and Community Psychiatry, 38, 864-870. Golstrom, I. and Manderscheid, R. (1982). The chronically mentally ill: A descriptive analysis from the uniform client data instrument. Community Support Services Journal, 2, 4-9. Harding, C.M., Strauss, J. S., Hafez, H., Lieberman, P.B. (1986). Work and mental illness: I. Toward an integration of the rehabilitation process. Journal of Nervous and Mental Disease, 175, 317-326. Honigfeld, G., Gillis, R.D., Klett, C.J. (1966). NOSIE-30: A treatment-sensitive ward behavior scale. Psychological Reports, 19, 180-182. Lamb, H. R. (1982). Treating the Long-term Mentally Ill. San Francisco, CA: Jossey-Bass. Received: August 1991 Revision: December 1991 Acceptance: January 1992
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Author:Timvik, Ulrika
Publication:The Journal of Rehabilitation
Date:Jul 1, 1993
Words:2856
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