Intensive rehabilitation residential units

Transcription

1 1 Intensive rehabilitation residential units Daniel Gélinas, M.Sc., Claude Leclerc, Ph.D. et Alain Lesage, M.D. ( 1 ) In light of the gradual reduction in the number of psychiatric beds and of the subsequent development of new community treatment modalities for severely mentally disordered persons, the mental health care system is faced with the need to develop new residential resources for the treatment and rehabilitation of persons who present with challenging behaviour problems, a poorly controlled symptomatology and/or major social skills deficits (Lesage, 1997). There is no denying that a certain number of persons seriously afflicted with mental illness are refractory to traditional treatments and that the new forms of protected housing or community treatment developed over the past thirty years do not always manage to meet their extensive needs for care, support and constant supervision. Chronicity, which settles in progressively, interacts with the impossibility of accessing existing community resources to confine these people de facto to internment with no hope of developing their rehabilitation potential despite the impact of their illness (Bennett, 1980; Wykes, 1982). In England, researchers have estimated that from twelve (12) to fifteen (15) persons per 100,000 inhabitants fit this profile ( 2 ), that is, they register prolonged stays in psychiatric care units and present with a mental state that disqualifies them from integrating a group home or hostel, which generally demand that residents possess a certain degree of autonomy or self-control (Wykes and Wing, 1982; Young, 1991). This is why it is imperative that the psychosocial rehabilitation movement meet the challenge of reaching the persons hardest hit by illness and provide a long-term outlook for positive change by proposing treatment and rehabilitation modalities adapted to the complex needs of these persons (Lesage, 1997). In this regard, the action plan adopted by Quebec's ministère de la Santé et des 1 The authors are, respectively, a research agent, a professor at the Department of Nursing Sciences of Université du Québec à Trois-Rivières, and a researcher-clinician and professor at the Faculty of Medicine of Université de Montréal. They are associated with the Centre de recherche Fernand-Seguin of Hôpital Louis-H. Lafontaine in Montréal.

2 2 Services Sociaux (1998) provides for needs for long-stay psychiatric beds comparable to the norms established and the reality observed in England (Wing, 1992; Lelliot et al., 1996). Development of a new formula for the treatment and rehabilitation of the persons most disabled by mental illness It is within this context that some twenty years ago British clinicians developed a new treatment approach for these persons by setting up intensive rehabilitation residential units (Wykes, 1982). These are group community residences that simultaneously offer long-term rehabilitation programming, specialized nursing care and intensive clinical support. The patient-staff ratio in these facilities is comparable to that found in short-stay psychiatric care units. When it all began back in the late 1970s, clinicians at London's Maudsley Hospital used a large Victorian house on hospital grounds to offer this clientele a personalized treatment setting with a low ratio of patient to nursing staff. Although the unit used the near-by hospital's auxiliary services through the back door, notably to provide meals and ensure maintenance of the house, patients had the chance to live in a more normalizing environment and could take a first step through the front door towards social reintegration as they were allowed out accompanied by the nursing staff to use neighbourhood social and community resources (Wykes, 1982; Wykes and Wing, 1982). Thereafter, other clinicians modified the parameters of this first experience by developing residential units further away from the hospital with a view to gaining greater autonomy from it, especially regarding the preparation of meals and maintenance. Nevertheless, patients were not initially obliged to take part in the performance of all the tasks related to the residence's functioning if they were unable to, and the nursing staff could count on the support of auxiliary personnel, especially where the preparation of meals was concerned (Goldberg et al., 1985). Thus, over the years, this type of unit has become in England an essential component in the deployment of the complete range of residential resources 2 The British literature refers to this clientele with specific needs as New Long Stay Patients.

3 3 needed to take over from psychiatric hospitals following their closure (Beecham and Lesage, 1997; Garety, 1988). Logic and principles underlying this new formula The logic underlying the creation of these intensive rehabilitation units rests on exploiting and combining the reciprocal advantages of the treatment and rehabilitation modalities offered by group community residences and psychiatric care units, while minimizing their respective intrinsic inconveniences. This is why they are alternately referred to as hostel-wards, wards-in-a-house or hospitalhostels. On the one hand, the group community residence dimension (the hostel or house side) allows these patients to access normalizing accommodations and to be stimulated to develop communication skills within the context of a small group. This environment enables them to participate progressively, within the limits of their abilities, in the activities of daily life, such as cleaning their rooms or the common areas in the house. Finally, they have access to opportunities for socialization in the community, as the nursing staff accompanies them outside the residence to use the various social resources available in the neighbourhood. In short, this dimension provides a warm setting that elevates the dignity of these persons and facilitates actualization of their potential for social adjustment despite the severity of the manifestations of their illness (Mayaveram, 1991). On the other hand, the psychiatric care unit dimension (the ward or hospital side) provides the clinical support required by these patients, as experienced nursing staff are on duty 24 hours a day in a very low patientcaregiver ratio. Within this context, the nursing staff is capable of forging a significant relationship with patients and offering an individualized treatment plan with the formulation of clear-cut rehabilitation objectives. Finally, these units generally benefit from the presence of a psychologist who proposes customized rehabilitation programs and ensures a clinical supervision in support of the nursing staff, which is called upon to share the long-term life experience of this difficult and emotionally-draining clientele (Garety and Morris, 1984). In short, this dimension provides an ongoing presence and constant supervision to patients

4 4 who need to be empowered in a positive manner within a long-term outlook aimed at improving and overcoming the heavy lingering effects of their illness. Truth be told, this best-of-both-worlds combination within a single entity makes it possible, on the one hand, for patients who present with excessive behaviour to access a community rehabilitation resource, as they are generally deemed too heavy a burden for conventional group homes. In this regard, the high level of clinical support in hostel-wards makes it possible to tolerate, contain or modify excessive behaviour and to develop growth opportunities patiently. On the other hand, hostel-wards allow these patients to receive all the professional attention they require, given that they need care over a very long period of time, whereas short-stay psychiatric care units are generally designed to deal with acute crises. Thus, this British-made formula seeks simultaneously to reverse the impact of chronicity, which risks becoming rooted following prolonged hospital stays or the use of impersonal institutional practices outside the hospital (Henderson and Thornicroft, 1997). Principal modalities of operation of this new formula This formula rests on the practice of assertive treatment and psychosocial rehabilitation in order to reach the persons most severely affected by mental illness. Within this perspective, it proposes varied intervention modalities that call as much on behaviourist as on analytic approaches. Thus, certain units offer programming that draws on the token economy and residential treatment by stimulating social skills learning through daily life activities, while remaining open to discerning and interpreting emotions felt within the relational sphere with a view to understanding the transfer and counter-transfer phenomena that arise in sharing the daily life experience of this difficult clientele (Hall, 1991; Paul and Menditto, 1992). Shepherd (1995) pointed out that nursing staff supervises the use of cutting-edge medication, such as clozapine, by patients who are refractory to conventional treatments. The individualized treatment plan is formulated on the basis of in vivo observations and an in-depth evaluation of the adjustment difficulties experienced by these patients within the group residence, and its

5 5 application is negotiated with them in order to respect their own pace and preferences. Emphasis is placed on strengths rather on pathology, and the nursing staff place a good deal of importance on the quality and quantity of interactions that take place between caregivers and residents, with a view to maintaining a low level of expressed emotion (Ball et al., 1992). These patients are generally extremely sensitive to stress and their deviant behaviour is a priori a strategy employed to cope with it. This is why it is important to be attentive to the life experiences and dynamics of these persons, as stress contributes to the appearance of the symptomatology and subsequent deterioration associated with schizophrenia (Leclerc et al., 1997). Hence, it is necessary to resort to a team structure in order to maintain cohesion, to measure out interventions and regularly revise treatment and care plans. Finally, the caregiver staff recruited for these intensive rehabilitation residential units must manifest the explicit desire to work with this clientele, as this formula depends enormously on the development of relational aptitudes in order to empower these patients in a positive manner within a context involving accompaniment and long-term rehabilitation (Watts and Bennett, 1983; Lavender, 1985; Hogg et al., 1992). Results observed in England over the past twenty years The various studies conducted over the years within units inspired by the original model developed at London's Maudsley Hospital showed that patients registered an improvement in basic skills and social functioning, and an increase in the amount of time dedicated to domestic chores and leisure activities in the community (Wykes, 1982; Shepherd et al., 1994; Creighton et al., 1991). For example, certain authors demonstrated that hostel-ward residents, despite the severity of their impairments, registered more social contacts in the community and within protected workshops in a hospital than did patients living in the hospital or in a conventional group home (Dilks and Shattock, 1996). Progress is achieved slowly and the duration of a patient's stay is not a function of his capacity to move to lighter residential resources thereafter. In this connection, Reid and Garety (1996) reported the case of a patient who remained in a hostel-

6 6 ward 16 years before integrating a conventional group home, whereas other patients managed considerable progress within a two-year period. Nonetheless, it appears that the mean duration of stay recorded at the first hostel-ward of London's Maudsley Hospital ( 3 ) was about five years. Although certain units registered mixed results, it must be pointed out that the sites studied departed from the modalities originally put forth by the proponents of this new formula (Reid and Garety, 1996). In this regard, Allen et al. (1993) reported the case of a hostel-ward that increased the patient-caregiver ratio and, by so doing, compromised the impact of this key ingredient to the success of this formula based on a personalized approach. Similarly, Staufenberg and Bridges (1991) reported the experience of another hostel-ward that was shut down because it used facilities that were too vast in order to accommodate too great a number of residents, thereby undermining the normalizing nature of the hostel-ward model. In short, the British experience has taught us that positive results are closely related to the application of the treatment and rehabilitation principles laid down during the early experiences with this model (Wykes, 1982), which were later corroborated by clinicians committed to the same objective of improving the quality of life of these patients heavily impaired at the psychological and social level (Golberg et al., 1985; Gibbons and Butler, 1987; Simpson et al., 1989). Generally speaking, the British experience suggests that patients admitted to hostel-wards can be divided into three groups. One third remains in this resource permanently, a second third eventually integrates lighter resources following a long rehabilitation process, and the last third must return to hospital owing to the presence of extremely challenging behaviour that nullifies the rehabilitation efforts deployed within this framework (Hirsch, 1992; Reid and Garety, 1996). In this connection, Bridges et al. (1994) showed that it is necessary to have specialized psychiatric care units in hospitals in order to provide long-term treatment for this last group of patients, for whom both short Denmark Hill began operating in 1977 and the results reported by Reid and Garety (1996) cover a period of 16 years. Despite the proven effectiveness of this resource,

7 7 stay hospitalization and residence in a hostel-ward fail to meet all their specific needs. In conclusion: a matter of equity Given the current budget restrictions, it may be tempting to dismiss this formula, which seems costly at first sight owing to the use of specialized personnel at a low patient-caregiver ratio. A cost-benefit analysis demonstrated that, although the operating costs of a hostel-ward were higher than those of a long-stay psychiatric care unit in a large hospital, they were nevertheless lower than those of a short-stay psychiatric care unit designed to deliver intensive care. Moreover, Health and Welfare Canada (1997)[check reference?] identified and described the experience of a hostel-ward set up in British Columbia ( 4 ), referring to it as an exemplary practice essential to the pursuit of the mental health services reform. In light of ongoing cuts in long- and short-stay psychiatric beds (Lecomte, 1997), the question of what will happen to this clientele becomes all the more pressing, as the risk is strong that they will not receive the appropriate treatment and rehabilitation services that their psychiatric condition demands. Lesage (1996) illustrated from an epidemiological standpoint that a small number of persons with severe and persistent mental disorders consumed a large portion of the available mental health resources on account of their needs for care and treatment. As long as our health care system embraces the principle of universality as the modality for access to care, it is imperative that no one ever be left by the wayside in the pursuit of psychiatric services reform. To this end, we must look upon the formula of hostel-wards developed by our British colleagues as a glimmer of hope that affords the most severely impaired persons the opportunity to overcome their illness and re-integrate community life. It is quite simply a matter of equity. these authors point out that the unit was shut down following budget cuts. 4 The Seven Oaks program in Victoria, B.C.

8 8 References ( 5 ) BALL, R. A., MOORE, E., KUIPERS, L., 1992, Expressed Emotion in community care staff, Social Psychiatry and Psychiatric Epidemiology, 27, BEECHAM, J., LESAGE, A., 1997, Leçons britanniques d'un transfert de ressources: le système de dotation par patient, Santé mentale au Québec, 22 (2), BENNETT, D., 1980, The chronic psychiatric patient today, Journal of the Royal Society of Medecine, 73, BRIDGES, K., DAVENPORT, S., GOLDBERG, D., 1994, The need for hospital-based rehabilitation services, Journal of Mental Health, 3, CREIGHTON, F. J., HYDE, C. E., FARRAGHER, B., 1991, Douglas House: Seven Years Experience of a Community Hostel Ward, British Journal of Psychiatry, 159, DILKS, S., SHATTOCK, L., 1996, Does community residence mean more community contact for people with severe, long-term disabilities? British Journal of Clinical Psychology, 35, GARETY, P. A., MORRIS, I., 1984, A new unit for long-stay psychiatric patients: organization, attitudes and quality of care, Psychological Medicine, 14, GARETY, P., 1988, Housing, in LAVENDER, A., HOLLOWAY, F., (eds), Community Care in Practice, John Wiley and Sons, Chichester, GIBBONS, J. S., BUTLER, J. P., 1987, Quality of Life for «New» Long-stay Psychiatric In-patients: The effects of Moving to a Hostel, British Journal of Psychiatry, 151, GOLDBERG, D. P., BRIDGES, K., COOPER, W., HYDE, C., STERLING, C., WYATT, R., 1985, Douglas House: A New Type of Hostel Ward for Chronic Psychotic Patients, British Journal of Psychiatry, 147, HALL, J., 1991, Ward-based Rehabilitation Programmes, in WATTS, F. N., BENNETT, D. H., (eds), Theory and Practice of Psychiatric Rehabilitation, John Wiley & Sons, Chichester, HENDERSON, C., THORNICROFT, G., 1997, Le statut de la désinstitutionnalisation en Grande-Bretagne, Santé mentale au Québec, 22 (2), HIRSCH, S. R., 1992, Services for the severe mentally ill- a flanning blight, Psychiatric Bulletin, 16, HOGG, L., HALL, J., 1992, Management of Long-term Impairments and Challenging Behavior, in BIRCHWOOD, M., TARRIER, N., Innovations in the Psychological Management of Schizophrenia, John Wiley and Sons, Chichester, HYDE, C., BRIDGES, K., GOLDBERG, D., LOWSON, K., STERLING, C., FARAGHER, B., 1987, The Evaluation of a Hostel Ward: A Controlled Study using Modified Cost-Benefit Analysis, British Journal of Psychiatry, 151, LAVENDER, A., 1985, Quality of care and staff practices in long-stay settings, in WATTS, F. N., (ed) New Developments in Clinical Psychology, The British Psychological Society/ John Wiley & Sons, Chichester, LECLERC, C., LESAGE, A., RICARD, N., 1997, La pertinence du paradigme stresscoping dans l'élaboration d'un modèle de gestion du stress pour personnes MAYAVERAM, A., 1991, Clinical support in a homely setting: Hostel wards for long-term psychiatric care, The Professional Nurse, 7 (2), atteintes de schizophrénie, Santé mentale au Québec, 22 (2), Persons interested in obtaining copies of the articles cited can contact Daniel Gélinas at Hôpital Louis-H. Lafontaine at Montreal (QC) Canada by telephone at (514) , ext or by at <daniel.gelinas@ssss.gouv.qc.ca>.

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