Rehab Rounds: Implementing Psychosocial Rehabilitation With Long-Term Patients in a Public Psychiatric Hospital

South Carolina State Hospital is the second oldest state-operated psychiatric facility in the United States (1). The hospital offers adult and geriatric psychiatry services to consumers with diagnoses of schizophrenia, mood disorders, and personality disorders and dual diagnoses of mental illness and substance abuse. Before 1991 the treatment philosophy emphasized "individualized care" in which staff took care of the patients and tended not to teach skills required for their successful reintegration into the community. The major treatment emphasis was medication given to reduce positive symptoms. Patients received some individual therapy, but expectations were low. Only a few counseling and activity groups were offered.

In 1991 the facility director, Dr. Jaime Condom, invited Psychiatric Rehabilitation Consultants, under the leadership of Robert P. Liberman, M.D., to conduct a needs assessment of all phases of treatment at the hospital. The needs assessment was followed by a three-day workshop on how to use the UCLA Social and Independent Living Skills (SILS) modules (2). The workshop was targeted to direct care staff of all levels, including mental health specialists, registered nurses, doctors, psychologists, social workers, and activity therapists. The needs assessment and the SILS workshop became a blueprint for improvements at the hospital.

The needs assessment recommended that patients with severe and persistent mental illness, including those with a diagnosis of schizophrenia, bipolar disorder, chronic depression, and obsessive-compulsive disorder, would benefit from participation in SILS module groups. Because the majority of patients in the hospital had stays of more than a year (29.4 percent had been in the hospital from one to five years, 18.9 percent from five to ten years, and 7.7 percent for more than ten years), staff had doubts about the effectiveness of these groups for the hospital's patient population. However, after seeing how well patients responded in a demonstration group conducted by the consultants, staff were eager to try this approach.

Several factors helped jump-start the implementation of SILS modules. First, the change had strong administrative support. Second, an interdisciplinary liaison team of staff members, eager to learn new methods of rehabilitation, were chosen to work with the consultants. They later became the driving force in making the needed changes. Third, the hospital offered a salary and status upgrade to entry-level mental health specialists who became credentialed in leading SILS groups. The process for becoming credentialed included taking a four-day workshop, leading a group for a minimum of three months, and demonstrating mastery of group leading skills in a group setting by attaining a score of 80 percent on three evaluations.

The fourth factor that encouraged implementation of the modules was that the hospital already had in place nurse clinicians with primary duties of providing one-to-one and group interventions. They involved the entry-level staff in leading SILS groups with them. Fifth, the staff who would actually be holding SILS groups were chosen to attend the initial workshop. And finally, those who attended the original workshop implemented the modules and techniques immediately after finishing their training.

While the initial implementation of the modules was taking place, staff formed a rehabilitation therapeutics committee with the mission of planning and implementing psychosocial rehabilitation in the hospital. As staff talked about the progress being made by the consumers who participated in the SILS groups, enthusiasm grew.

The composition of the initial rehabilitation therapeutics committee—which included all discipline directors, psychiatric service chiefs, unit directors, and the liaison team—was a key factor in the implementation of the rehabilitation focus. The committee's work was divided among four subcommittees that were responsible for logistics, programming, training and certification, and providing consultation and support. The logistics subcommittee located rooms for SILS group meetings and ordered televisions, videocassette recorders, materials for the modules, and supplies. The programming subcommittee addressed treatment planning and selected two rating scales—the Specific Level of Functioning Scale (3) and the Brief Psychiatric Rating Scale (4)—to assess outcome.

The training and certification subcommittee organized the four-day SILS training workshops, set up a certification system, and helped revise the job description for the mental health specialists to include leading SILS groups. Levels of certification were as follows: level I, completed training; level II, mastered skills; level III, able to rate skills of staff in leading SILS groups; and level IV, able to train other staff in classroom settings. A fidelity checklist developed by Psychiatric Rehabilitation Consultants was used to verify mastery of skills. The checklist included an evaluation of teaching style and of adherence to the module format.

The task of the consultation and support subcommittee was to promote and support the efforts of Psychiatric Rehabilitation Consultants. Support elements included producing a quarterly newsletter, The Rehabilitator, to provide information, support, and recognition to staff; assigning a member to assist with implementation of the SILS modules in each building of the facility; planning yearly retreats; awarding certificates of achievement; and planning recognition ceremonies. All of these motivational techniques have been used consistently over the past six years.

Within six months of the hospital's beginning the SILS training, other state hospitals and mental health center staff were included in the training at their request. To date, more than 500 staff members from four state hospitals and eight mental health centers in South Carolina have been trained in either a full four-day workshop, a two-day workshop for supervisors, or shorter introductory workshops. Group leaders are recertified each year. At this writing, 48 practitioners have attained level II certification.

Two years after the initial visit by Psychiatric Rehabilitation Consultants, a psychosocial rehabilitation coordinator was appointed at the hospital, and a psychosocial rehabilitation service was formally established. Gradually, staff members were added to the service, and the functions of the rehabilitation therapeutics committee were transferred to them. Staff from the psychosocial rehabilitation service led SILS groups, provided training and resources for other staff members, began group regularity checks to monitor the percentage of groups that were held as scheduled and collected and processed survey data. In addition, the director of the Department of Mental Health offered a newly renovated building on the facility's campus to serve as a consumer rehabilitation and learning center. The center contains group meeting rooms, conference and training space, office space, and a computer lab for consumers.

Since the original visit by Psychiatric Rehabilitation Consultants, programming for the hospital has changed dramatically. A new treatment plan and process emphasizing patients' strengths, needs, and goals has been implemented. The number of SILS groups and groups based on SILS principles has increased threefold, and the frequency with which groups are conducted on schedule has jumped from 40 percent in 1992 to 96 percent in 1997. Moreover, the number of staff leading SILS groups has doubled in the past two years, while adherence to the SILS method has been maintained. In evaluations using a short version of the fidelity checklist, groups' adherence to the method averaged 94 percent in 1996 and 95 percent in 1997.

After the SILS groups were conducted for two years, patients were surveyed about their satisfaction with the groups. At a time when the SILS groups represented 31 percent of all groups available at the hospital, 83 percent of patients reported liking a SILS group best. In addition, 75 percent of patients surveyed reported understanding their medications better, 58 percent reported understanding their mental illness better, and 83 percent reported communicating better with others.

Anecdotal evaluation was equally positive. One patient, who had been in the hospital for ten years, frequently yelled when he wanted something. In his conversational skills group, he was taught that being loud meant that he did not want to have a conversation. Staff in the group and consistently on the ward would put their hands out in a stop position and say, "You're shouting, so I know that you don't really want to talk to me" and would then walk away. The patient learned that to be heard, he needed to approach others and speak using a conversational volume. After several months of attending a basic conversation skills group, he was discharged to a boarding home. The staff there were taught to use the same technique, and some five years later, this man has not required rehospitalization.

Mental health specialists whose employment status had been upgraded after they became certified in use of the SILS modules were surveyed in 1994 to determine their impressions of their new position and of their effectiveness with consumers. High percentages of these mental health specialists felt they had more responsibility in the new position (90 percent), more job knowledge (86 percent), more self-esteem (64 percent), and greater effectiveness with consumers (95 percent).

The psychosocial rehabilitation department has grown to ten full-time staff members. Current priorities include providing better programming for patients with dual diagnoses, developing a grooming program that can be implemented throughout the hospital, checking SILS groups for quality, establishing pre- and posttests for all structured groups, and establishing a more effective process for capturing outcome measures. Staff of the psychosocial rehabilitation department are working on modules focused on HIV and AIDS, anger management, assertiveness, and values.

A supplement to the SILS medication management module was written to provide guidance for staff on teaching patients basic information about major medication groups. A resource book that lists and describes the structured materials available for use in groups has been developed and made available to all clinical staff. Workshops are provided periodically on new materials.

Implementing psychosocial rehabilitation techniques at South Carolina State Hospital has facilitated the successful community placement of a large number of patients who had long inpatient tenures. For many of them, rehabilitation has made a significant difference in their quality of life. We believe that the rehabilitation model has produced a parallel improvement in the quality of care delivered by the hospital and in the morale of its employees.

Afterword by the column editors:

Rosalind Smith and her colleagues have demonstrated that in the right circumstances, and with an effective dissemination strategy (5), psychiatric rehabilitation techniques can be integrated into the day-to-day operations of a large state hospital. Their experiences at South Carolina State Hospital remind us of the benefits of providing state-of-the-art biopsychosocial treatment to the most seriously and persistently mentally ill patients.

In addition, their efforts suggest that rehabilitation procedures such as skills training can begin in the hospital and continue without interruption into the community, linking inpatient and outpatient facilities in a common treatment philosophy and a matching set of treatment techniques. Skills training provides a sturdy bridge for patients to traverse in making the transition from hospital to community life. Moreover, this modality empowers patients and staff alike, moving them from "therapy" to "education."

Ms. Smith is director of psychosocial rehabilitation at South Carolina State Hospital, 2100 Bull Street, P. O. Box 119, Columbia, South Carolina 29202. Alex Kopelowicz, M.D., and Robert Paul Liberman, M.D., are editors of this column.