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A PRAGMATIC APPROACH TO MENTAL HEALTH AFTERCARE AND PARTIAL HOSPITALIZATION a
b
Jeffrey A. Kelly PhD , Janne Patterson MA & Everett E. Snowden MSW
c
a
Assistant Professor of Psychiatry, University of Mississippi Medical Center, Department of Psychiatry and Human Behavior, Jackson, MS 39216 b
Psychologist, Jackson Mental Health Center Title XX Daycare Program c
Director, Jackson Mental Health Center Title XX Daycare Program Published online: 26 Oct 2008.
To cite this article: Jeffrey A. Kelly PhD , Janne Patterson MA & Everett E. Snowden MSW (1979) A PRAGMATIC APPROACH TO MENTAL HEALTH AFTERCARE AND PARTIAL HOSPITALIZATION, Social Work in Health Care, 4:4, 431-443, DOI: 10.1300/J010v04n04_06 To link to this article: http://dx.doi.org/10.1300/J010v04n04_06
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A PRAGMATIC APPROACH TO MENTAL HEALTH AFTERCARE AND PARTIAL HOSPITALIZATION
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Jeffrey A. Kelly, PhD Janne Patterson. M.A. Everett E. Snowden, M.S.W.
ABSTRACT. Over recent years, there has been increased attention to providing viable community-based alternalives to inpatient psychiatric care. Although there i s increased demand for aftercare or daycare sociaUpsychological communit y treatment, funding sources also mandate more clearcut andprecise demonstrations of therapeuticandprogram effectiveness. This paperdescribes a pragmatic new approach to doycare fortheemotionally disturbed Thecentmlaspects of thisapproachare: the behauioral identification of clearcut psychosocial treatment goals. contractual negotiation of treatmentplans. a skill remediationapproach to treatmentand objectiueeualuationofclient improvement. B y adopting practical and individually-tailored treatment goals and modalities, and by incorporating objectiue evaluative criteria into a daycare program's treatment components, it is possible to moreaccurately assess client improvement.
Since passage of the Community Mental Health Center Act of 1963, there has been considerable attention paid (and energy expended) to develop low cost, community-based alternatives to inpatient hospitalization. Daycare and partial hospitalization approaches havereceiveda substantial amount of attention since they potentially 1) offer a low cost alternative to inpatient hospitalization; 2) when used in conjunction with inpatient facilities, can serve to shorten inpatient stays; and 3)provide a partial care vehicle to facilitate community reentry and reintegration for persons who had previously been hospitalized, often for many years. Recent court rulings concerningpatients' rights to active treatment have, appropriately, decreased the use of hospitaliza-
J e f f r e y A. Kelly. PhD. is Assistant Professor o f Psychiatry IPsychology) at the University of Mississippi Medical Center: Janne Patterson. M.A. is the Psychologist and Everett E. Snowden. M.S.W. is the Director o f the Jackson Mental Health Center Title X X Daycarc Program. T h e authors extend their appreciation t o Gwen W e s t for her preparation o f this paper. Requests for reports should be sent to: J e f frey A . Kelly, Department o f Psychiatryand Human Behavior. University o f Mississippi Medical Center. Jackson. M S 39216. T h e Title X X Daycare Program is funded b y the Mississippi Department o f Public Welfareand the C i t y o f J a c k s o n ,Mississippi. Said WorkinHealthCare.Vol.4(4)Summer1979 01979 by TheHaworth Pless.AUrightsreserved.
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tion for principally custodial care purposes; and pragmatic legislativeeconomic concerns have reduced the census in large inpatient psychiatric facilities. Yet, while one might argue compellingly for the discharge of many long-term psychiatric patients into the community, it is equally clear that there is little humaneness in discharging clients into anenvironment which they areill-equipped to handle. Coupled with these client care concerns, aftercare and daycare programs are also facing closer scruting from external funding sources, especially with respect to cost accountability and programltreatment evaluation. As funding sources diminish, and existing sources become more concerned with clear demonstrations of program and treatment effectiveness, it is no longer acceptable to use poorly-defined, imprecise definitions of program objectives, treatment modalities and patient improvement. Pragmatic new approaches are needed. Rickelman (1968)in a critically evaluative paper has noted that daycare programs are frequently characterized by: (patientcare)objectivesthatseem todealonly with uerbalabstractions.I t is conducive to general applause to state that part of a patient's resocialization process involves increasing his self-esteem, but how is the patient's self-esteem increased? How did this (self-esteem)improvementaid in thepatient's resocialization?And how can one tell if the patient's self-esteem has been boosted at all? It is difficult to identify standards andprinciples in theapplication of daycare seruices to mentally illpatients. This difficulty further illuminates the need for research to identify specific treatmentprocesses within each day hospital setting, so thatprinciplesofpatients carecan be formulated.
Other recent investigators have further elaborated the need for practical approaches to daycare programs (Aime, 1973; Austin, Eieberman, King & Derisi, 1976; Beard, 1972; Freitas &Johnson, 1975).In the current paper, we will describe an aftercare program which has, as its aim, the treatment of clients through: 1)the behavioral identification of specific clearcut treatment goals; 2) contractual negotiation of treatment plans between the staff and each client; 3) a skill-training approach, in which identified self-sufficiency and self-support skill deficiencies are systematically remediated; and 4) objective evaluation of client improvement. By adopting pragmatic, specific, objectively-defined treatment and assessment procedures, it is possible to more effectively evaluate client improvement and accumulate ''reliable'' data on program effectiveness. The Jackson Mental Health Center of Jackson, Mississippi received a grant from the Mississippi Department of Public Welfare under Title XX and matchingfunds from the City of Jackson, to operate a Day Care Program in a single county catchment area of approximately 200,000
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persons. Clients are eligible for the program provided they meet certain low income criteria and are accepted regardless of psychiatric diagnosis and history of previous hospitalizations. Sixty patients are served by the program and each attends at least three days weekly. The Title XX aftercare program operates from 2:30 p.m. until 8:00 p.m. each day. The late afternoon-evening hours were selected since they do not preclude client's involvement in daytime community activities, such as jobs, job training or school. Although patient characteristics vary somewhat as persons enter and leave the program, the population served is highly diverse. Ages range from 20 to 72 years, 92 percent have had previous inpatient psychiatric hospitalizations (80 percent a t the state hospital) and diagnoses range from adjustment reactions and personality disorders to neurotic and psychotic disorders. The modal diagnosis of persons enrolled in the program is chronic undifferentiated schizophrenia. Clients reside in the community, at boarding (halfway)houses, with their own families or they live independently. PRAGMATIC PLANS, BEHAVIORAL ASSESSMENT AND NEGOTIATED TREATMENT AGREEMENT As Rickelman (1968)has pointed out, one of the most common difficulties in programs providing mental health services is the identification of treatment goals. In the past, we haveoften beencontent to identify, as objectives, characteristics such as "resocialization," increased "self-esteem," greater "independence," reduced "social dependency" and so on. Few persons would disagree that such aims are highly important goals in therapeutic aftercare programs. But how does one accurately assess these psychological-socialconstructs and, more importantly, how does one identify causal relationships between therapeutic treatments and improvement in such areas? These questions are crucial with respect to program accountability and evaluation. Somewhat paradoxically, the f i s t concern of our program's staff when initially evaluating a new client is the discharge or termination of that patient. More precisely, our first question is what identifiable deficits does that individual have which are preventing his or her autonomous or independent community functioning? What areas of functioning will require treatment or remediation? In general, we conceptualize these to be of two types: "intraindividual" psychiatriclpsychological disturbance and sociaVenvironmenta1skill deficits. The intraindividual disturbance factors include such difficulties as poorly controlled psychotic behaviors, cognitive disorders, organic deficits, anxiety and so on. But beyond such intraindividual disorders, research on the effects of
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SOCIAL WORK IN HEALTH CARE
long term institutionalization also provides clear evidence that chronic psychiatric patients have lost many of the practical, everyday social and environmental skills requisite to community functioning (Goffman. 1961; Herz, Endicott, Spitzer & Mesnikoff, 1971; Zwerling & Wilder, 1964).Presumably as a result of both psychiatric incapacitation and the undemanding totalcareprovided by many institutions, clients have also lost self-careand self-sufficiencyskills they will need in order to survive independently. The overall aims of our aftercare program are to increase economic self-support, personal self-care and self-sufficiency, to decrease the probability of social abuse and exploitation of the clients, to provide an alternative to unnecessary hospitalization and to provide for rehospitalization only if it becomes necessary. The same set of goals are translated into individual treatment plans, but in more specific terms tailored to the needs of each particular client. For example, when a client enters the program, the staff considers what specific factors contribute to that patient's lack economic self-support. Does the individual lack job training? What sorts of employable skills does the person have? If full-time employment is not possible due topsychiatricdisability, could the client handle part-time work if helshe continued in the late afternoon-evening program? Is vocational rehabilitation referral an appropriate option? Is job interview training needed? Is poorly controlled psychotic behavior the difficulty and is medical regulation needed? When medication is albered, what are the specific systems targeted for change? Based upon the answers to such questions, it is possible to identify options which might lead to decreasedeconomic dependence. Personal self-care and self-sufficiencv deficits are identified based upon staff observations, client reports and reports from the client's familv. Can the individual cook for himself or herself? Does the client lack personal grooming or hygiene skills? Can the individual identify goals and plan strategies to attain them? Is the person so passive that assertive or social skills training is indicated? Can hobbies or avocational pursuits be developed, and what social or community activities can be encouraged to prevent the client from becoming as dependent on ourprogram as he or she was on the inpatient institution? The aim, again, is to develop self-support and self-suifficiencyskills, and to remediate those sociaUenvironmentaldeficits contributing to the client's social dependency. Once treatment priorities have been established by the staff during the first week of aftercare attendance, our observations are discussed individually with the client. Our treatment approach requires the active participation of the patient to help establish his or her own treatment goals during the first week of attendance. By involving the client in the negotiation of his own treatment plan, and by setting clearcut, well-de-
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fined treatment goals, it is possible to objectively plan treatment goals and maintain a clear sense of treatment direction. Although contractually-defined treatment has been frequently advocated in individual and group psychotherapy (Calhoun, 1974; hayes, 1976; Olson and Greenbery, 1972; Welch, 1976)it has not generally been extended to aftercare of daycare treatment. Treatment plans are established in a meeting including several of the program's key personnel (M.S.W. Director, Social Workers, Consulting Psychiatrist, Consulting Psychologist, Psychotherapists, Recreational and Occupational therapists) and the client. Areas most frequently targeted in our program's treatment plans include: enhanced medication compliance procedures, personal hygiene improvement, cookinglhomemaking skill training, family therapy, s e cia1 skills or assertion training, problem-solving training, job interview training, vocational rehabilitation goals and consumer education. When the program staff and the client have consensually agreed upon a set of several treatment priorities, these goals are formally established into a treatment plan record. A sample treatment plan format is presented a s Figure 1.This format was developed by the staff of the Jackson Mental Health Center. As the figure illustrates, problem areas targeted for treatment are described in clearcut, behaviorally-referented S ~ ~ modality (e.g.. interms anda brief statement of the -D ~ -O D O treatment dividual therapy, problem-solving or social skills, groups, OT, e t i ) accom~anieseach ~ r o b l e mdescri~tion.An initiation date indicates when the plan was put into effect, and a review date is established to assess progress toward the goal. On this review date, the staff and client inde pendently evaluateprogresss made toward achieving the goal usinga 5point rating scale (from least favorable to highly favorable outcome). Treatment goals become re-defined and re-negotiated throughout the client's enrollment in our program, a s earlier goals were reached and new problem areas become evident. By defining treatment goals and treatment modalities a s a matter for joint, collaborative discussion between the client and the staff, i t is possible tominimize the likelihood of poorlyspecified therapeutic outcome criteria and to more actively involve the &ent in hisher-own treatment program. This is in contrast -to traditional aftercare therapeutic programs, which frequently have imposed global or diffuse treatment goals or modalities upon patients without their active participation in determining them, and ind'ependent of each patient's own particular needs. SKILL REMEDIATION AND TREATMENT EVALUATION In order to remediate social or self-sufficiency skill deficits, i t is necessary to tailor our program's particular treatment in-
.COCTAI, WORK IN HEALTH CARE SAMPLE TREATMENT CLAN ~ H ~~ . R ~tam. ~ ~ Jackse.". Misrilrippi
J ~ C ~ S O .M
JOHN SMITH
N~~~
I
8/1/77
Cam Numb..
001
PRESENTING PROBLEM: Problam No.
Date Entered
No. of h r r i o n r
1
8/2/77
1
30
2
9/1/77
2
10
Dale Rerolted 10-1-77
3 -
PLAN: problem Number ~ ~ ~ 1 ,1.:
1
Modality
PROBLEM-SOLVING GROUP AND OCCUPATIONAL THEPAPY
USE PROBLEM-SOLVING GROUP FEEDBACK TO HELP OETERHINE JOB CHOICES AND ARRIVE AT VOCATIONAL PLANNING DECISIONS
2.
USE OCCUPATIONAL THEPAPY TO IRPROVE ATTENTION SPAN. PERCEPTUAL-MOTOR SKILLS AND
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EYE-HAND COOROINATION RELEVANT TO EMPLOYMENT Least Fworable
Outcome:
Ler5 Than EXPBC~~
Expmted
Bette, Than Expected
Most Favorable
Q
Patient
1
2
3
ssni~icant other (WIFE)
i
2
3
Tb
5
Therapist
1
2
3
4
0
Initiation Date
Review Date
9-2-77
. -. .. .. Problem Number
I.
Z
~~~~t~~~~ ~
~
OVER TEN ROLE-PLAYING SESSIONS,
d
~JOB l INTERYIEY i ~ ~ TWINING
USE JOB INTERVIEU TQAINING
TO INCREASE CLIENT";
ABILITY AND SKILLS TO CONVEY SELF I N MoRE POSITIVE MNNER TO POTENTIAL EMPLOYERS
2.
USE THIS TRAINING TO REDUCE CLIENT'S DISCOMFORT WHEN TALKING TO OTHERS
Outcome:
Least Favorable
Lerr Than
Er~ecled
Expected
Better Than Experled 4
Patient
1
2
3
Sgnilncant Other
1
2
3
Theraptst
I
2
3
Initiation Dale
9-1-77
M m Favorable 5 5
4
5
Review Date
terventions to the individual's problem areas. Tables 2 and 3 present several sample problem areas and some of the treatment interventions offered by our program which are applicable to these problems. In contrast to many traditional programs, the Title XX program does not assume that all clients will require the same interventions. Therefore, treatment modality "options" are selected and negotiated with each individual. Not all clients are enrolled in each treatment activity, and clients may progress from one activity to another as their treatment goals change.
Jeffrey A. Kelly TABLE 2 TAILORING TREATMENT MODALITIES TO PROBLEM AREAS All0 SKILL DEFICITS Probl em-area P o t e n t i a l l y employable, b u t l a c k s employment due t o p s y c h i a t r i c l s o c i a l disability Treatment m o d a l i t i e s
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Occupational Therapy, used t o assess
Psychological Evaluation. t o assess
and i n c r e a s e p a t i e n t ' s a b i l i t y t o work
p a t i e n t ' s i n t e l l e c t u a l resources.
independently, a c q u i r e manual d e x t e r i t y
p o s s i b i l i t y of organic o r perceptual
and f i n e eye-motor c o o r d i n a t i o n .
disorders, t o estimate p r o b a b i l i t y of successful employment.
Recreational Therapy, t o assess and i n c r e a s e p a t i e n t ' s p h y s i c a l resources Vocational R e h a b i l i t a t i o n R e f e r r a l , f o r and s t r e n g t h . s h e l t e r e d workshop t r a i n i n g ( i f needed) o f f u l l v o c a t i o n a l a p t i t u d e assessment Job I n t e r v i e w S k i l l s T r a i n i n g , u s i n g ( i f appropriate) r o l e - p l a y i n g , videotape feedback and behavior rehearsal procedure t o enhance t h e p a t i e n t ' s a b i l i t y t o convey
Standard Employment I n t e r v i e w , l i a i s o n
himselflherself positively i n job
r o l e w i t h s t a t e employment s e r v i c e ,
interviews.
c o m u n i t y employers, e t c .
Group therapy consists of both problem-solving groups and social skills training groups. These two types of groups are semi-independent of one another, although - -patients may- Dartkipate in both. Problem-soluinggroups are oriented towards helping each patient identify significant problem areas, and then acquiring the ~ractical~lanninnskills necessary to resolve those difficuities. Led b; two t h e r - ~ i s t seach . ~roblernsol;ing group of 8-10persons utilizes ro"le-playing, &oup and videotape feedback. modeling. discussion and behavioral contracting ~rocedures. Problem areas ideGified and pursued in these groups are usually those areas which had been previously identified and targeted in the participants' treatment plans. Since other clients are present in these groups, the support, reinforcement and feedback provided by fellow clients
-
-.
SOCIAL WORK IN HEALTH CARE TABLE 3 TAILORING TREATMENT MODALITIES TO PROBLEM AREAS AND SKILL DEFICITS Problem area Lacks cooking, self-grooming and consumer s k i 1 l s , which prevent person from l i v i n g more independently
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Treatment m o d a l i t i e s
Consumer education, designed t o g i v e
Cookinqs S k i l l s Class, used t o increase
i n d i v i d u a l s rudimentary a r i t h m e t i c
p a t i e n t ' s knowledge o f n u t r i t i o n and
s k i l l s t o determine and compare p r i c e s
p r a c t i c a l a b i l i t y t o prepare meals
when shopping, information concerning
w i t h o u t supervision.
shopping, how t o f i n d "values" when purchasing.
S e l f - c a r e and personal a t t r a c t i v e n e s s s k i l l s , used t o teach the e s s e n t i a l
Social S k i l l s t r a i n i n g , using group
of good grooming (hygiene, s k i n and
r o l e p l a y i n g and videotaped feedback
h a i r care, cosmetics, e t c . ) and
t o teach more a p p r o p r i a t e conversational
cleaning-laundry-ironing s k i l l s .
and i n t e r p e r s o n a l s k i l l s .
plays a major role in the development of each participant's problemresolution skills, Social skills groups are utilized primarily for the purpose of teaching interpersonal/social and self-care abilities. We have observed that one of the major factors that impairs the social re-integration of psychiatric clients into the community is their social "differentness.'' A major barrier to effective resocialization is created when an individual is easily identified in the community as an "ex-mental patient" due to personal &lor appearance idi~s~ncracies. The socialdeficits whichcharacterizemany formerly institutionalized clients may thereby lead t o a "vicious cycieWeffect in which persons avoid contact with psychiatric clients because they are very difficult to respond to socially. If others actively avoid them, this reduces the Uelihood that the client win have opportunities to interact appropriately with better adjusted individuals and to learn more adaptive prosocial skills. Thus. social skills deficits lead to interpersonal avoidance in the c o m u n i t y a n d seriously undermine the likelihood that the individual will model, be rewarded for and learn appropriate social behavior. Under
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such circumstances, it is likely the client will continue his or her inappropriate interpersonal style or simply drift further into isolation. The social skills groups permit us to intervene directly and actively in this pattern. In social skills group, clients are taught appropriate conversational talents, assertion skills, grooming or appearance skills and cooperative social behavior. This is achieved through extensive roleplaying, behavior-rehearsal, videotaped feedback, relaxation training and contractually-defined assignments for increased social activities outside our program. Social skills training enables us to identify and to remediate basic sociaUinterpersona1deficits before encouraging clients to engage in community activities in which they might otherwise encounter alienation, discomfort and failure. Individual Psychotherapy is offered as a treatment modality for clients requiring individual G n t i o n . In general, individual therapy is ofdifficulties. those in acute crises fered for clients with extensive ~ersonal or those unable to verbalize relevant material in groups. Sessions are arranged once weekly, although two to three contacts per week are occasionally needed. Individual psychotherapy is performed by our program's M.A. psychologist, M.S.W. social worker-director, consulting clinical psychologist and consulting psychiatrist. Psychotherapy includes both crisis-intervention and long-term treatment. Although the approaches taken in individual therapy are somewhat eclectic they are always of a contractually-defined, goal-oriented nature. In order to strengthen the therapeutic effectiveness of individual sessions, the entire program staff is informed of the areas pursued individually. This allows for weekly coordination of goals in the overall treatment plan to maximize theefficacy of theprogram. Occupational Therapy has often been the ill-defined and clinically neglected stepchild of therapeutic aftercare programs, used principally to fill gaps in patients' time schedules. Although occupational therapy does encourage the expression of creative thinking and does promote a sense of personal accomplishment and pride, we have also found occupational therapy to be an excellent direct behavior sample of the client's work-related skills. Short of observing the individual's performance in an actual vocational setting, careful observation of a client's performance in OT is a useful predictor of later job or vocational rehabilitation success. Given the fact that maintaining rapport with community employment training agencies requires the referral of clients who will ultimately succeed in jobs, it is imperative to assess carefully client skills relevant to work success. Our occupational therapy staff evaluates each client's fine motor coordination, manual dexterity, perceptual functioning, ability to follow directions, attention span and response to supervision. High functioning in these areas has been associated with our clients' successful experiences when referred for sheltered or standard em-
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ployment. Occupational therapy can servenot only toassess, but also to remediate, deficits ineachof theseareas. Recreational Therapy is utilized in the program to facilitate social interaction, enhance perceptual-motor coordination, promote emotional maturity through sportsmanship and provide the opportunity for tension release and relaxation. Medical and ~svchiatricservices are provided by a part-time consultingpsychiatristwhoexarnines eachclient ona regularbasis. The psychiatrist and a part-time clinical psycholohst - also wrovides in-servicetraining and con-sultation service; fbr the program-staff. A half-t'ime nurse complements the medical-psychological-psychiatric services by routinely performing weight, blood pressure and vital signs screenings of "at risk" clients. Finally, an aftercare program is, by definition, transitional and not terminal or static in nature. Clients are persons who, a s a result of psychiatric or social disability, have been institutionalized and require reintegration or re-socialization into the community. Outreach-social workers employed by our program bridge the gap between an individual's enrollment in the program and his or her resumption of more independent functioning. Our outreach-social workers regularly make followup contact with clients as they enter vocational programs, enter schoolor enroll in trainingprograms. By actively maintaining therapeutic contact following clients' participation in the aftercare program, one can reduce the likelihood that the client will "relapse" into their former social dependency.
CASE EXAMPLE Citing an example of the program's overall effectiveness is thecase of C. L., a 24 year old male enrolledafter hospitalizationfor a schizophrenic episode. It was his fourth hospitalizationin as many years. Initially, he was socially and cognitively retarded, exhibited extreme anxiety with trembling. and was unable to maintain eye contact. Upon the recommendation of his psychiatrist, individual therapy was instituted on a 3 times weekly basis in conjunction with the other components of the program. The socialization effect of both Occupational and Recreational therapy led to his being less frightened of people and to his recognition that social skills training was necessary. He began r e sponding both to staff and to peer influencelinput in these groups and became actively involved in his problem-solving group. At this point, the individual therapy was decreased to once weekly. As this individual was interested in obtaining employment (he had worked previously)he was enrolled in Vocational Rehabilitation,participatingin a sheltered workshop. This was paralleled in the program by a 12 week group in Job Interview Training. C.L. is now working full time and attending an evening class once a week. His participation in the program has diminished to the extent of seeing his therapist once weekly and participatingin a high-functioning group on heterosocial skills.
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TREATMENT AND PROGRAM EVALUATION
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As funding sources and review agencies appropriately come to scrutinize social service programs for solid evidence of program or treatment effectiveness, it becomes crucial to build objective evaluation criteria into program development. In the Title XX aftercare program, this is achieved by both global assessment of the program's impact and the more molecular evaluation of each treatment modality. In all cases, the central evaluative questions are: (1)do we have objective, consensually-validated evidence that clients improve over time in our program?; and (2)can we demonstrate that improvement is, in fact, attributable to participationin certain therapeutic aspects a s treatment modalities of the program? GlobalAssessment of Client Change. The determination of overall client improvement can be made from any of three perspectives: the staff's evaluation of change, the client's own report of his1 her improvement; and evaluation of client change by "significant others" in the client's own environment, such a s family, friends, employer, etc. Improvement from each of these perspectives can be assessed using either hard, empirical data (observational ratings, psychometric or psychosocial ratings, records of PRN medication requests, behavioral assessment) or more descriptive but less precise reports (staffingnotes, anecdotalreports, etc.). Within two weeks of eachclient'senrollment in our program, five staff members evaluate the client using a standardized rating form devised by our staff. Usinga 10-pointscale for eachitem, the staff members evaluate the client's physical hygiene and appearance, problem-solving skills, socialinterpersonal skills, extraversion and attention span. Each staff member evaluates each client in these areas based on the staffperson's own direct observation of the client, and without discussing the rating with any other staff. Thus, we obtain quantified, independent ratings of the client from five different staff perspectives. The individual staff ratings can be averaged together to yield a single score (from 1 to 10)on each of the scale's twelve questions. Every three months, the client is re-evaluated by the same staff members using the same rating form. By repeating these ratings, it is possible to derive change or improvement scores (change in the average staff rating) for each functioning area sampled in the form. Because five staffpersons evaluate each client and they do so independently of one another, this procedure yields "hard" or empirical verification of client immovement over time. We are currently in the process of analyzing these change scores to determine what dem&raphiE group of clients (based on age, diagnosis, chronicity of disorder, etc.) are most likely to benefit from our program.
SOCIAL WORK IN HEALTH CARE
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Similarly. the treatment plans negotiated between the client and the program staff are reviewed periodically to determine progress in each treatment goal area. Both the staff and the client formally assign a score rating (on'5-point scale)to assess the denee to which the planned treatmenCgoal was actually achieved. 1f the goal was n i t adequately achieved either from the -perspective of the staff or.the client, that goal may be re-defined and re-negotiated. If a goal has been successfully achieved, new treatment contracts are negotiated with the client. During monthly staffings of each client, treatment goals and progress towards them are systematically reviewed by all staff members. Again, however, treatment progress and outcome (goal) criteria are made explicit and are quantified by both staff and clients whenever possible. Evaluation of Treatment Modalities In addition to overall change ratings, we apply similar evaluative criteria to our program's individual treatment modalities, including occupational therapy, recreational therapy, cooking skills groups, job interview training, group therapy and individual therapy. Occupational and recreational therapy staffs have developed quantified rating scales to assess client attention span, fine motor dexterity, perceptual-motor skills, quality of work produced, response to supervision and frequency of somatic complaints. These scales are completed biweekly by the occupational and recreational therapy staffs, and ratings are quantified and recorded to assess improvement. One of our criteria for recommendation for employment and vocational rehabilitation placement is highnumerical ratings on the occupational therapy evaluation. Currently, our program is gathering data which will enable us to better predict success or failure in a vocational placement based upon our quantified observationalratings. Observational evaluation need not always take the form of rating scales. With the advent of more economical videotaping equipment, includingportablevideotaperecorders, it is possible to tapegroup psychotherapy and social skills training procedures for therapeutic, training and research purposes. During our program's job interview training, we record the client's roleplayed job "interviews" with a staff person acting as the interviewer. Over the course of training sessions, we can keep, and later evaluate videotapes of roleplayed job interviews to objectively determine whether the client is using newly-acquired interviewing skills. Aftercare programs can serve as effective vehicles to facilitate the community reentry of psychiatric patients. In the past, however, many programs have lacked clearcut goals and evaluation criteria. By adopting a contractually-oriented approach to aftercare treatment plan, by
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utilizing objective behavioral descriptions of client self-careand social skills deficiencies and then by tailoring skills training strategies to remediate thosedeficiencies,it is possible to more effectively assist the clients during their re-integrationintothecommunity.
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REFERENCES Aime, D. Philosophy and structure of a day treatment center. Journal of Psychiatric NarsingandMental HealthSeruices. 1973.11.27-30. Austin. N. K..Liberman. R. P.. King. L. W., DeRisi. W. J . A comparative evaluation of Lwoday hospitals. Jo~onrnalofNeruoiisandMentalDisease. 1976,167,253-262. Beard. B. H. Patterns of utilization in a psychiatric day hospital. Texas Medicine. 1972. 68.74-80. Calhoun, J. F. Modifying the academic performance of the chronic psychiatric patient. JournalofConsr~ltingandClinicalPsychology. 1974.42.621. Freitas, L. &Johnson. L. Behavior modification approach in a partial day treatmenLCenter. JorrrnalofPsychiatric NursingandMental HealthSeruices. 1975.27.14-18. Goffman. E. Asylums: Essays on the social situation of mental patients and other inmates. New York: Doubleday andcompany. 1961.p. 13. Hayes. L. A. The use of group contingencies for behavioral control: A review. Psychological Bulletin. 1976.83.557-578. Herz. M. I.. Endicott. J.. Spitzer, R. L., & Messnikoff. A. Day versus inpatient hospitalization:Acontrolledstudy. AmericanJournalofPsychiatry. 1971.127.107-118. Olson. R. P. & Greenbery. D. J. Effects of contingency contractingand decision-making groups with chronic mental patients. Journal of Consulting and Clinical Psychology. 1972.38376-383. Rickelman. B. Someproblemsof day hospitalsincommunity careof the mentally ill. Communiw MentalHealth JournaL 1968.4.425-433. Welch. .I. Verbalcommunicatinn training: A procedure coaugment contingency training. Jotcrnalof BchauiorTherupy aud L'xpenmrntal Psychiatry. 1976.7.301 4 0 3 . Zwerlinr. I. & Wilder. J. F A n evalualionof theaoolicahililv of the dav hosoital In treatment i f acutely disturbedpatients. l s r a e l i ~ n n &o f ~ s ~ c k t r196;. y , 2.1'62-185,
e.
Social Work in Health Care Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/wshc20
A PRAGMATIC APPROACH TO MENTAL HEALTH AFTERCARE AND PARTIAL HOSPITALIZATION a
b
Jeffrey A. Kelly PhD , Janne Patterson MA & Everett E. Snowden MSW
c
a
Assistant Professor of Psychiatry, University of Mississippi Medical Center, Department of Psychiatry and Human Behavior, Jackson, MS 39216 b
Psychologist, Jackson Mental Health Center Title XX Daycare Program c
Director, Jackson Mental Health Center Title XX Daycare Program Published online: 26 Oct 2008.
To cite this article: Jeffrey A. Kelly PhD , Janne Patterson MA & Everett E. Snowden MSW (1979) A PRAGMATIC APPROACH TO MENTAL HEALTH AFTERCARE AND PARTIAL HOSPITALIZATION, Social Work in Health Care, 4:4, 431-443, DOI: 10.1300/J010v04n04_06 To link to this article: http://dx.doi.org/10.1300/J010v04n04_06
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A PRAGMATIC APPROACH TO MENTAL HEALTH AFTERCARE AND PARTIAL HOSPITALIZATION
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Jeffrey A. Kelly, PhD Janne Patterson. M.A. Everett E. Snowden, M.S.W.
ABSTRACT. Over recent years, there has been increased attention to providing viable community-based alternalives to inpatient psychiatric care. Although there i s increased demand for aftercare or daycare sociaUpsychological communit y treatment, funding sources also mandate more clearcut andprecise demonstrations of therapeuticandprogram effectiveness. This paperdescribes a pragmatic new approach to doycare fortheemotionally disturbed Thecentmlaspects of thisapproachare: the behauioral identification of clearcut psychosocial treatment goals. contractual negotiation of treatmentplans. a skill remediationapproach to treatmentand objectiueeualuationofclient improvement. B y adopting practical and individually-tailored treatment goals and modalities, and by incorporating objectiue evaluative criteria into a daycare program's treatment components, it is possible to moreaccurately assess client improvement.
Since passage of the Community Mental Health Center Act of 1963, there has been considerable attention paid (and energy expended) to develop low cost, community-based alternatives to inpatient hospitalization. Daycare and partial hospitalization approaches havereceiveda substantial amount of attention since they potentially 1) offer a low cost alternative to inpatient hospitalization; 2) when used in conjunction with inpatient facilities, can serve to shorten inpatient stays; and 3)provide a partial care vehicle to facilitate community reentry and reintegration for persons who had previously been hospitalized, often for many years. Recent court rulings concerningpatients' rights to active treatment have, appropriately, decreased the use of hospitaliza-
J e f f r e y A. Kelly. PhD. is Assistant Professor o f Psychiatry IPsychology) at the University of Mississippi Medical Center: Janne Patterson. M.A. is the Psychologist and Everett E. Snowden. M.S.W. is the Director o f the Jackson Mental Health Center Title X X Daycarc Program. T h e authors extend their appreciation t o Gwen W e s t for her preparation o f this paper. Requests for reports should be sent to: J e f frey A . Kelly, Department o f Psychiatryand Human Behavior. University o f Mississippi Medical Center. Jackson. M S 39216. T h e Title X X Daycare Program is funded b y the Mississippi Department o f Public Welfareand the C i t y o f J a c k s o n ,Mississippi. Said WorkinHealthCare.Vol.4(4)Summer1979 01979 by TheHaworth Pless.AUrightsreserved.
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tion for principally custodial care purposes; and pragmatic legislativeeconomic concerns have reduced the census in large inpatient psychiatric facilities. Yet, while one might argue compellingly for the discharge of many long-term psychiatric patients into the community, it is equally clear that there is little humaneness in discharging clients into anenvironment which they areill-equipped to handle. Coupled with these client care concerns, aftercare and daycare programs are also facing closer scruting from external funding sources, especially with respect to cost accountability and programltreatment evaluation. As funding sources diminish, and existing sources become more concerned with clear demonstrations of program and treatment effectiveness, it is no longer acceptable to use poorly-defined, imprecise definitions of program objectives, treatment modalities and patient improvement. Pragmatic new approaches are needed. Rickelman (1968)in a critically evaluative paper has noted that daycare programs are frequently characterized by: (patientcare)objectivesthatseem todealonly with uerbalabstractions.I t is conducive to general applause to state that part of a patient's resocialization process involves increasing his self-esteem, but how is the patient's self-esteem increased? How did this (self-esteem)improvementaid in thepatient's resocialization?And how can one tell if the patient's self-esteem has been boosted at all? It is difficult to identify standards andprinciples in theapplication of daycare seruices to mentally illpatients. This difficulty further illuminates the need for research to identify specific treatmentprocesses within each day hospital setting, so thatprinciplesofpatients carecan be formulated.
Other recent investigators have further elaborated the need for practical approaches to daycare programs (Aime, 1973; Austin, Eieberman, King & Derisi, 1976; Beard, 1972; Freitas &Johnson, 1975).In the current paper, we will describe an aftercare program which has, as its aim, the treatment of clients through: 1)the behavioral identification of specific clearcut treatment goals; 2) contractual negotiation of treatment plans between the staff and each client; 3) a skill-training approach, in which identified self-sufficiency and self-support skill deficiencies are systematically remediated; and 4) objective evaluation of client improvement. By adopting pragmatic, specific, objectively-defined treatment and assessment procedures, it is possible to more effectively evaluate client improvement and accumulate ''reliable'' data on program effectiveness. The Jackson Mental Health Center of Jackson, Mississippi received a grant from the Mississippi Department of Public Welfare under Title XX and matchingfunds from the City of Jackson, to operate a Day Care Program in a single county catchment area of approximately 200,000
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persons. Clients are eligible for the program provided they meet certain low income criteria and are accepted regardless of psychiatric diagnosis and history of previous hospitalizations. Sixty patients are served by the program and each attends at least three days weekly. The Title XX aftercare program operates from 2:30 p.m. until 8:00 p.m. each day. The late afternoon-evening hours were selected since they do not preclude client's involvement in daytime community activities, such as jobs, job training or school. Although patient characteristics vary somewhat as persons enter and leave the program, the population served is highly diverse. Ages range from 20 to 72 years, 92 percent have had previous inpatient psychiatric hospitalizations (80 percent a t the state hospital) and diagnoses range from adjustment reactions and personality disorders to neurotic and psychotic disorders. The modal diagnosis of persons enrolled in the program is chronic undifferentiated schizophrenia. Clients reside in the community, at boarding (halfway)houses, with their own families or they live independently. PRAGMATIC PLANS, BEHAVIORAL ASSESSMENT AND NEGOTIATED TREATMENT AGREEMENT As Rickelman (1968)has pointed out, one of the most common difficulties in programs providing mental health services is the identification of treatment goals. In the past, we haveoften beencontent to identify, as objectives, characteristics such as "resocialization," increased "self-esteem," greater "independence," reduced "social dependency" and so on. Few persons would disagree that such aims are highly important goals in therapeutic aftercare programs. But how does one accurately assess these psychological-socialconstructs and, more importantly, how does one identify causal relationships between therapeutic treatments and improvement in such areas? These questions are crucial with respect to program accountability and evaluation. Somewhat paradoxically, the f i s t concern of our program's staff when initially evaluating a new client is the discharge or termination of that patient. More precisely, our first question is what identifiable deficits does that individual have which are preventing his or her autonomous or independent community functioning? What areas of functioning will require treatment or remediation? In general, we conceptualize these to be of two types: "intraindividual" psychiatriclpsychological disturbance and sociaVenvironmenta1skill deficits. The intraindividual disturbance factors include such difficulties as poorly controlled psychotic behaviors, cognitive disorders, organic deficits, anxiety and so on. But beyond such intraindividual disorders, research on the effects of
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long term institutionalization also provides clear evidence that chronic psychiatric patients have lost many of the practical, everyday social and environmental skills requisite to community functioning (Goffman. 1961; Herz, Endicott, Spitzer & Mesnikoff, 1971; Zwerling & Wilder, 1964).Presumably as a result of both psychiatric incapacitation and the undemanding totalcareprovided by many institutions, clients have also lost self-careand self-sufficiencyskills they will need in order to survive independently. The overall aims of our aftercare program are to increase economic self-support, personal self-care and self-sufficiency, to decrease the probability of social abuse and exploitation of the clients, to provide an alternative to unnecessary hospitalization and to provide for rehospitalization only if it becomes necessary. The same set of goals are translated into individual treatment plans, but in more specific terms tailored to the needs of each particular client. For example, when a client enters the program, the staff considers what specific factors contribute to that patient's lack economic self-support. Does the individual lack job training? What sorts of employable skills does the person have? If full-time employment is not possible due topsychiatricdisability, could the client handle part-time work if helshe continued in the late afternoon-evening program? Is vocational rehabilitation referral an appropriate option? Is job interview training needed? Is poorly controlled psychotic behavior the difficulty and is medical regulation needed? When medication is albered, what are the specific systems targeted for change? Based upon the answers to such questions, it is possible to identify options which might lead to decreasedeconomic dependence. Personal self-care and self-sufficiencv deficits are identified based upon staff observations, client reports and reports from the client's familv. Can the individual cook for himself or herself? Does the client lack personal grooming or hygiene skills? Can the individual identify goals and plan strategies to attain them? Is the person so passive that assertive or social skills training is indicated? Can hobbies or avocational pursuits be developed, and what social or community activities can be encouraged to prevent the client from becoming as dependent on ourprogram as he or she was on the inpatient institution? The aim, again, is to develop self-support and self-suifficiencyskills, and to remediate those sociaUenvironmentaldeficits contributing to the client's social dependency. Once treatment priorities have been established by the staff during the first week of aftercare attendance, our observations are discussed individually with the client. Our treatment approach requires the active participation of the patient to help establish his or her own treatment goals during the first week of attendance. By involving the client in the negotiation of his own treatment plan, and by setting clearcut, well-de-
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fined treatment goals, it is possible to objectively plan treatment goals and maintain a clear sense of treatment direction. Although contractually-defined treatment has been frequently advocated in individual and group psychotherapy (Calhoun, 1974; hayes, 1976; Olson and Greenbery, 1972; Welch, 1976)it has not generally been extended to aftercare of daycare treatment. Treatment plans are established in a meeting including several of the program's key personnel (M.S.W. Director, Social Workers, Consulting Psychiatrist, Consulting Psychologist, Psychotherapists, Recreational and Occupational therapists) and the client. Areas most frequently targeted in our program's treatment plans include: enhanced medication compliance procedures, personal hygiene improvement, cookinglhomemaking skill training, family therapy, s e cia1 skills or assertion training, problem-solving training, job interview training, vocational rehabilitation goals and consumer education. When the program staff and the client have consensually agreed upon a set of several treatment priorities, these goals are formally established into a treatment plan record. A sample treatment plan format is presented a s Figure 1.This format was developed by the staff of the Jackson Mental Health Center. As the figure illustrates, problem areas targeted for treatment are described in clearcut, behaviorally-referented S ~ ~ modality (e.g.. interms anda brief statement of the -D ~ -O D O treatment dividual therapy, problem-solving or social skills, groups, OT, e t i ) accom~anieseach ~ r o b l e mdescri~tion.An initiation date indicates when the plan was put into effect, and a review date is established to assess progress toward the goal. On this review date, the staff and client inde pendently evaluateprogresss made toward achieving the goal usinga 5point rating scale (from least favorable to highly favorable outcome). Treatment goals become re-defined and re-negotiated throughout the client's enrollment in our program, a s earlier goals were reached and new problem areas become evident. By defining treatment goals and treatment modalities a s a matter for joint, collaborative discussion between the client and the staff, i t is possible tominimize the likelihood of poorlyspecified therapeutic outcome criteria and to more actively involve the &ent in hisher-own treatment program. This is in contrast -to traditional aftercare therapeutic programs, which frequently have imposed global or diffuse treatment goals or modalities upon patients without their active participation in determining them, and ind'ependent of each patient's own particular needs. SKILL REMEDIATION AND TREATMENT EVALUATION In order to remediate social or self-sufficiency skill deficits, i t is necessary to tailor our program's particular treatment in-
.COCTAI, WORK IN HEALTH CARE SAMPLE TREATMENT CLAN ~ H ~~ . R ~tam. ~ ~ Jackse.". Misrilrippi
J ~ C ~ S O .M
JOHN SMITH
N~~~
I
8/1/77
Cam Numb..
001
PRESENTING PROBLEM: Problam No.
Date Entered
No. of h r r i o n r
1
8/2/77
1
30
2
9/1/77
2
10
Dale Rerolted 10-1-77
3 -
PLAN: problem Number ~ ~ ~ 1 ,1.:
1
Modality
PROBLEM-SOLVING GROUP AND OCCUPATIONAL THEPAPY
USE PROBLEM-SOLVING GROUP FEEDBACK TO HELP OETERHINE JOB CHOICES AND ARRIVE AT VOCATIONAL PLANNING DECISIONS
2.
USE OCCUPATIONAL THEPAPY TO IRPROVE ATTENTION SPAN. PERCEPTUAL-MOTOR SKILLS AND
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EYE-HAND COOROINATION RELEVANT TO EMPLOYMENT Least Fworable
Outcome:
Ler5 Than EXPBC~~
Expmted
Bette, Than Expected
Most Favorable
Q
Patient
1
2
3
ssni~icant other (WIFE)
i
2
3
Tb
5
Therapist
1
2
3
4
0
Initiation Date
Review Date
9-2-77
. -. .. .. Problem Number
I.
Z
~~~~t~~~~ ~
~
OVER TEN ROLE-PLAYING SESSIONS,
d
~JOB l INTERYIEY i ~ ~ TWINING
USE JOB INTERVIEU TQAINING
TO INCREASE CLIENT";
ABILITY AND SKILLS TO CONVEY SELF I N MoRE POSITIVE MNNER TO POTENTIAL EMPLOYERS
2.
USE THIS TRAINING TO REDUCE CLIENT'S DISCOMFORT WHEN TALKING TO OTHERS
Outcome:
Least Favorable
Lerr Than
Er~ecled
Expected
Better Than Experled 4
Patient
1
2
3
Sgnilncant Other
1
2
3
Theraptst
I
2
3
Initiation Dale
9-1-77
M m Favorable 5 5
4
5
Review Date
terventions to the individual's problem areas. Tables 2 and 3 present several sample problem areas and some of the treatment interventions offered by our program which are applicable to these problems. In contrast to many traditional programs, the Title XX program does not assume that all clients will require the same interventions. Therefore, treatment modality "options" are selected and negotiated with each individual. Not all clients are enrolled in each treatment activity, and clients may progress from one activity to another as their treatment goals change.
Jeffrey A. Kelly TABLE 2 TAILORING TREATMENT MODALITIES TO PROBLEM AREAS All0 SKILL DEFICITS Probl em-area P o t e n t i a l l y employable, b u t l a c k s employment due t o p s y c h i a t r i c l s o c i a l disability Treatment m o d a l i t i e s
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Occupational Therapy, used t o assess
Psychological Evaluation. t o assess
and i n c r e a s e p a t i e n t ' s a b i l i t y t o work
p a t i e n t ' s i n t e l l e c t u a l resources.
independently, a c q u i r e manual d e x t e r i t y
p o s s i b i l i t y of organic o r perceptual
and f i n e eye-motor c o o r d i n a t i o n .
disorders, t o estimate p r o b a b i l i t y of successful employment.
Recreational Therapy, t o assess and i n c r e a s e p a t i e n t ' s p h y s i c a l resources Vocational R e h a b i l i t a t i o n R e f e r r a l , f o r and s t r e n g t h . s h e l t e r e d workshop t r a i n i n g ( i f needed) o f f u l l v o c a t i o n a l a p t i t u d e assessment Job I n t e r v i e w S k i l l s T r a i n i n g , u s i n g ( i f appropriate) r o l e - p l a y i n g , videotape feedback and behavior rehearsal procedure t o enhance t h e p a t i e n t ' s a b i l i t y t o convey
Standard Employment I n t e r v i e w , l i a i s o n
himselflherself positively i n job
r o l e w i t h s t a t e employment s e r v i c e ,
interviews.
c o m u n i t y employers, e t c .
Group therapy consists of both problem-solving groups and social skills training groups. These two types of groups are semi-independent of one another, although - -patients may- Dartkipate in both. Problem-soluinggroups are oriented towards helping each patient identify significant problem areas, and then acquiring the ~ractical~lanninnskills necessary to resolve those difficuities. Led b; two t h e r - ~ i s t seach . ~roblernsol;ing group of 8-10persons utilizes ro"le-playing, &oup and videotape feedback. modeling. discussion and behavioral contracting ~rocedures. Problem areas ideGified and pursued in these groups are usually those areas which had been previously identified and targeted in the participants' treatment plans. Since other clients are present in these groups, the support, reinforcement and feedback provided by fellow clients
-
-.
SOCIAL WORK IN HEALTH CARE TABLE 3 TAILORING TREATMENT MODALITIES TO PROBLEM AREAS AND SKILL DEFICITS Problem area Lacks cooking, self-grooming and consumer s k i 1 l s , which prevent person from l i v i n g more independently
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Treatment m o d a l i t i e s
Consumer education, designed t o g i v e
Cookinqs S k i l l s Class, used t o increase
i n d i v i d u a l s rudimentary a r i t h m e t i c
p a t i e n t ' s knowledge o f n u t r i t i o n and
s k i l l s t o determine and compare p r i c e s
p r a c t i c a l a b i l i t y t o prepare meals
when shopping, information concerning
w i t h o u t supervision.
shopping, how t o f i n d "values" when purchasing.
S e l f - c a r e and personal a t t r a c t i v e n e s s s k i l l s , used t o teach the e s s e n t i a l
Social S k i l l s t r a i n i n g , using group
of good grooming (hygiene, s k i n and
r o l e p l a y i n g and videotaped feedback
h a i r care, cosmetics, e t c . ) and
t o teach more a p p r o p r i a t e conversational
cleaning-laundry-ironing s k i l l s .
and i n t e r p e r s o n a l s k i l l s .
plays a major role in the development of each participant's problemresolution skills, Social skills groups are utilized primarily for the purpose of teaching interpersonal/social and self-care abilities. We have observed that one of the major factors that impairs the social re-integration of psychiatric clients into the community is their social "differentness.'' A major barrier to effective resocialization is created when an individual is easily identified in the community as an "ex-mental patient" due to personal &lor appearance idi~s~ncracies. The socialdeficits whichcharacterizemany formerly institutionalized clients may thereby lead t o a "vicious cycieWeffect in which persons avoid contact with psychiatric clients because they are very difficult to respond to socially. If others actively avoid them, this reduces the Uelihood that the client win have opportunities to interact appropriately with better adjusted individuals and to learn more adaptive prosocial skills. Thus. social skills deficits lead to interpersonal avoidance in the c o m u n i t y a n d seriously undermine the likelihood that the individual will model, be rewarded for and learn appropriate social behavior. Under
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such circumstances, it is likely the client will continue his or her inappropriate interpersonal style or simply drift further into isolation. The social skills groups permit us to intervene directly and actively in this pattern. In social skills group, clients are taught appropriate conversational talents, assertion skills, grooming or appearance skills and cooperative social behavior. This is achieved through extensive roleplaying, behavior-rehearsal, videotaped feedback, relaxation training and contractually-defined assignments for increased social activities outside our program. Social skills training enables us to identify and to remediate basic sociaUinterpersona1deficits before encouraging clients to engage in community activities in which they might otherwise encounter alienation, discomfort and failure. Individual Psychotherapy is offered as a treatment modality for clients requiring individual G n t i o n . In general, individual therapy is ofdifficulties. those in acute crises fered for clients with extensive ~ersonal or those unable to verbalize relevant material in groups. Sessions are arranged once weekly, although two to three contacts per week are occasionally needed. Individual psychotherapy is performed by our program's M.A. psychologist, M.S.W. social worker-director, consulting clinical psychologist and consulting psychiatrist. Psychotherapy includes both crisis-intervention and long-term treatment. Although the approaches taken in individual therapy are somewhat eclectic they are always of a contractually-defined, goal-oriented nature. In order to strengthen the therapeutic effectiveness of individual sessions, the entire program staff is informed of the areas pursued individually. This allows for weekly coordination of goals in the overall treatment plan to maximize theefficacy of theprogram. Occupational Therapy has often been the ill-defined and clinically neglected stepchild of therapeutic aftercare programs, used principally to fill gaps in patients' time schedules. Although occupational therapy does encourage the expression of creative thinking and does promote a sense of personal accomplishment and pride, we have also found occupational therapy to be an excellent direct behavior sample of the client's work-related skills. Short of observing the individual's performance in an actual vocational setting, careful observation of a client's performance in OT is a useful predictor of later job or vocational rehabilitation success. Given the fact that maintaining rapport with community employment training agencies requires the referral of clients who will ultimately succeed in jobs, it is imperative to assess carefully client skills relevant to work success. Our occupational therapy staff evaluates each client's fine motor coordination, manual dexterity, perceptual functioning, ability to follow directions, attention span and response to supervision. High functioning in these areas has been associated with our clients' successful experiences when referred for sheltered or standard em-
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ployment. Occupational therapy can servenot only toassess, but also to remediate, deficits ineachof theseareas. Recreational Therapy is utilized in the program to facilitate social interaction, enhance perceptual-motor coordination, promote emotional maturity through sportsmanship and provide the opportunity for tension release and relaxation. Medical and ~svchiatricservices are provided by a part-time consultingpsychiatristwhoexarnines eachclient ona regularbasis. The psychiatrist and a part-time clinical psycholohst - also wrovides in-servicetraining and con-sultation service; fbr the program-staff. A half-t'ime nurse complements the medical-psychological-psychiatric services by routinely performing weight, blood pressure and vital signs screenings of "at risk" clients. Finally, an aftercare program is, by definition, transitional and not terminal or static in nature. Clients are persons who, a s a result of psychiatric or social disability, have been institutionalized and require reintegration or re-socialization into the community. Outreach-social workers employed by our program bridge the gap between an individual's enrollment in the program and his or her resumption of more independent functioning. Our outreach-social workers regularly make followup contact with clients as they enter vocational programs, enter schoolor enroll in trainingprograms. By actively maintaining therapeutic contact following clients' participation in the aftercare program, one can reduce the likelihood that the client will "relapse" into their former social dependency.
CASE EXAMPLE Citing an example of the program's overall effectiveness is thecase of C. L., a 24 year old male enrolledafter hospitalizationfor a schizophrenic episode. It was his fourth hospitalizationin as many years. Initially, he was socially and cognitively retarded, exhibited extreme anxiety with trembling. and was unable to maintain eye contact. Upon the recommendation of his psychiatrist, individual therapy was instituted on a 3 times weekly basis in conjunction with the other components of the program. The socialization effect of both Occupational and Recreational therapy led to his being less frightened of people and to his recognition that social skills training was necessary. He began r e sponding both to staff and to peer influencelinput in these groups and became actively involved in his problem-solving group. At this point, the individual therapy was decreased to once weekly. As this individual was interested in obtaining employment (he had worked previously)he was enrolled in Vocational Rehabilitation,participatingin a sheltered workshop. This was paralleled in the program by a 12 week group in Job Interview Training. C.L. is now working full time and attending an evening class once a week. His participation in the program has diminished to the extent of seeing his therapist once weekly and participatingin a high-functioning group on heterosocial skills.
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TREATMENT AND PROGRAM EVALUATION
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As funding sources and review agencies appropriately come to scrutinize social service programs for solid evidence of program or treatment effectiveness, it becomes crucial to build objective evaluation criteria into program development. In the Title XX aftercare program, this is achieved by both global assessment of the program's impact and the more molecular evaluation of each treatment modality. In all cases, the central evaluative questions are: (1)do we have objective, consensually-validated evidence that clients improve over time in our program?; and (2)can we demonstrate that improvement is, in fact, attributable to participationin certain therapeutic aspects a s treatment modalities of the program? GlobalAssessment of Client Change. The determination of overall client improvement can be made from any of three perspectives: the staff's evaluation of change, the client's own report of his1 her improvement; and evaluation of client change by "significant others" in the client's own environment, such a s family, friends, employer, etc. Improvement from each of these perspectives can be assessed using either hard, empirical data (observational ratings, psychometric or psychosocial ratings, records of PRN medication requests, behavioral assessment) or more descriptive but less precise reports (staffingnotes, anecdotalreports, etc.). Within two weeks of eachclient'senrollment in our program, five staff members evaluate the client using a standardized rating form devised by our staff. Usinga 10-pointscale for eachitem, the staff members evaluate the client's physical hygiene and appearance, problem-solving skills, socialinterpersonal skills, extraversion and attention span. Each staff member evaluates each client in these areas based on the staffperson's own direct observation of the client, and without discussing the rating with any other staff. Thus, we obtain quantified, independent ratings of the client from five different staff perspectives. The individual staff ratings can be averaged together to yield a single score (from 1 to 10)on each of the scale's twelve questions. Every three months, the client is re-evaluated by the same staff members using the same rating form. By repeating these ratings, it is possible to derive change or improvement scores (change in the average staff rating) for each functioning area sampled in the form. Because five staffpersons evaluate each client and they do so independently of one another, this procedure yields "hard" or empirical verification of client immovement over time. We are currently in the process of analyzing these change scores to determine what dem&raphiE group of clients (based on age, diagnosis, chronicity of disorder, etc.) are most likely to benefit from our program.
SOCIAL WORK IN HEALTH CARE
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Similarly. the treatment plans negotiated between the client and the program staff are reviewed periodically to determine progress in each treatment goal area. Both the staff and the client formally assign a score rating (on'5-point scale)to assess the denee to which the planned treatmenCgoal was actually achieved. 1f the goal was n i t adequately achieved either from the -perspective of the staff or.the client, that goal may be re-defined and re-negotiated. If a goal has been successfully achieved, new treatment contracts are negotiated with the client. During monthly staffings of each client, treatment goals and progress towards them are systematically reviewed by all staff members. Again, however, treatment progress and outcome (goal) criteria are made explicit and are quantified by both staff and clients whenever possible. Evaluation of Treatment Modalities In addition to overall change ratings, we apply similar evaluative criteria to our program's individual treatment modalities, including occupational therapy, recreational therapy, cooking skills groups, job interview training, group therapy and individual therapy. Occupational and recreational therapy staffs have developed quantified rating scales to assess client attention span, fine motor dexterity, perceptual-motor skills, quality of work produced, response to supervision and frequency of somatic complaints. These scales are completed biweekly by the occupational and recreational therapy staffs, and ratings are quantified and recorded to assess improvement. One of our criteria for recommendation for employment and vocational rehabilitation placement is highnumerical ratings on the occupational therapy evaluation. Currently, our program is gathering data which will enable us to better predict success or failure in a vocational placement based upon our quantified observationalratings. Observational evaluation need not always take the form of rating scales. With the advent of more economical videotaping equipment, includingportablevideotaperecorders, it is possible to tapegroup psychotherapy and social skills training procedures for therapeutic, training and research purposes. During our program's job interview training, we record the client's roleplayed job "interviews" with a staff person acting as the interviewer. Over the course of training sessions, we can keep, and later evaluate videotapes of roleplayed job interviews to objectively determine whether the client is using newly-acquired interviewing skills. Aftercare programs can serve as effective vehicles to facilitate the community reentry of psychiatric patients. In the past, however, many programs have lacked clearcut goals and evaluation criteria. By adopting a contractually-oriented approach to aftercare treatment plan, by
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utilizing objective behavioral descriptions of client self-careand social skills deficiencies and then by tailoring skills training strategies to remediate thosedeficiencies,it is possible to more effectively assist the clients during their re-integrationintothecommunity.
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REFERENCES Aime, D. Philosophy and structure of a day treatment center. Journal of Psychiatric NarsingandMental HealthSeruices. 1973.11.27-30. Austin. N. K..Liberman. R. P.. King. L. W., DeRisi. W. J . A comparative evaluation of Lwoday hospitals. Jo~onrnalofNeruoiisandMentalDisease. 1976,167,253-262. Beard. B. H. Patterns of utilization in a psychiatric day hospital. Texas Medicine. 1972. 68.74-80. Calhoun, J. F. Modifying the academic performance of the chronic psychiatric patient. JournalofConsr~ltingandClinicalPsychology. 1974.42.621. Freitas, L. &Johnson. L. Behavior modification approach in a partial day treatmenLCenter. JorrrnalofPsychiatric NursingandMental HealthSeruices. 1975.27.14-18. Goffman. E. Asylums: Essays on the social situation of mental patients and other inmates. New York: Doubleday andcompany. 1961.p. 13. Hayes. L. A. The use of group contingencies for behavioral control: A review. Psychological Bulletin. 1976.83.557-578. Herz. M. I.. Endicott. J.. Spitzer, R. L., & Messnikoff. A. Day versus inpatient hospitalization:Acontrolledstudy. AmericanJournalofPsychiatry. 1971.127.107-118. Olson. R. P. & Greenbery. D. J. Effects of contingency contractingand decision-making groups with chronic mental patients. Journal of Consulting and Clinical Psychology. 1972.38376-383. Rickelman. B. Someproblemsof day hospitalsincommunity careof the mentally ill. Communiw MentalHealth JournaL 1968.4.425-433. Welch. .I. Verbalcommunicatinn training: A procedure coaugment contingency training. Jotcrnalof BchauiorTherupy aud L'xpenmrntal Psychiatry. 1976.7.301 4 0 3 . Zwerlinr. I. & Wilder. J. F A n evalualionof theaoolicahililv of the dav hosoital In treatment i f acutely disturbedpatients. l s r a e l i ~ n n &o f ~ s ~ c k t r196;. y , 2.1'62-185,
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