Stateofthe Art Psychiatric Rehabilitation Day Programming

One of the most important contributions of organizations such as the United States Psychiatric Rehabilitation Association (USPRA) and publications such as the Psychiatric Rehabilitation Journal and the American Journal of Psychiatric Rehabilitation is that they bring together professionals, consumers, family members, and others from all philosophies of PsyR. This coming together, which has grown year by year, has helped to synthesize the best elements of these different program types into what we consider today's state-of-the-art program. PsyR services are still largely idiosyncratic, but the best programs contain many of the same elements, though in differing amounts.

From the clubhouse movement, we get a strong respect for each individual's quality of life and those things that support quality of life: employment, housing, social supports, and membership in the community. This translates into many support initiatives that go far beyond treating the mental illness itself. State-of-the-art programs are instrumental in securing housing for their members, have one or more vocational rehabilitation elements (see Chapter 9), support their members' efforts to further their education (see Chapter 10), and help provide opportunities for building social supports and networks. Clubhouses,

CONTROVERSIAL ISSUE Psychiatric Rehabilitation Day Programming: An Effective Rehabilitation Setting or an Obsolete Service?

While psychiatric rehabilitation day programming is still a widely employed service modality, there are a number of researchers, service providers, and consumers who are strongly critical of its continued use. As you read about the pros and cons of day programming, consider what factors you think should be considered in settling this issue.

Psychiatric rehabilitation day programs were established all over the United States to address the needs of newly deinstitutionalized individuals. As such, they were some of the first widely employed community-based service modalities for persons with severe and persistent mental illnesses. In an effort to provide effective services for their recipients, many, but certainly not all, of these programs have evolved over the years. The clubhouse movement and advances in psychiatric rehabilitation knowledge have influenced much of this change. Today's PsyR day program should incorporate evidence-based practices, provide comprehensive and individualized services, have a recovery orientation, and be responsive to new knowledge and developments in psychiatric rehabilitation. Large numbers of persons with severe mental illnesses still receive services through this modality. Many rely on these programs for services, support, and recreation.

Strong criticisms have been raised concerning the continued use of PsyR day programs. Much of this criticism is based on the notion that the field has moved beyond the concept of providing treatment and rehabilitation in segregated facility-based settings and now has better ways to provide services. Newer models such as assertive community treatment, supported employment, and supported housing meet the individual needs of persons by design. These new services start by considering the preferences of the individual (e.g., what kind of job is desired, what kind of housing), are offered in the environments in which the individual wants to live, work, and socialize, and are less stigmatizing than attending a mental health clinic or program. In addition, services such as assertive community treatment and supported employment are evidence-based practices, which means they produce dependable results if they are carried out properly.

In studies of the conversion of day programs to supported employment programs, employment rates have increased without apparent negative outcomes in other areas such as hospitalization, home-lessness, and incarceration rates (Bond et al., 2001; Drake et al., 1996). A study by Becker and her colleagues (2001) compared two Rhode Island psychiatric day programs that converted to supported employment programs with another Rhode Island program that did not and found the same results: Employment increased but negative effects did not. Those who were not served in employment received a comprehensive case management and outpatient service.

Proponents of day programming have argued that many consumers require a structured and supportive environment to prepare them to assume normalized roles in the community. The studies cited above suggest that day programming may not be a requisite component of a comprehensive mental health system.

for example, tend to be open in the evenings and on weekends because their members' social lives and recreation are important.

The development of a nationwide network of clubhouse programs helped give birth to the psychosocial rehabilitation movement. The clubhouse network was also instrumental in the creation of the International Association of Psychosocial Rehabilitation Services (IAPSRS), now USPRA. Today, some clubhouses belong to both USPRA as organizational members and to the national clubhouse movement, the ICCD.

From the partial hospitalization movement, our state-of-the-art program gets its emphasis on medication, medication management, and symptom and medication education for consumers and their families. This aspect is important because the major mental illnesses are biologically based diseases and their symptoms can be controlled with medication. It is also believed that the best long-term outcomes are achieved if psychotic episodes are dealt with effectively and in a timely fashion.

Although it would be wrong to give the impression of universal agreement about how things should be done, PsyR is no longer divided between groups with totally different philosophies and strategies. Rather, the field has matured to the point where we agree on most of the goals, values, and principles, but still debate the proper mix of these elements to address the needs of those receiving services. Take the idea of empowerment for example. Many people use this term and many professionals believe it is an important PsyR element. But, there is still little agreement as to just what the term empowerment means and whether it is a good idea in every situation. Consider the issues spelled out in Box 6.3.

BOX 6.3

Empowerment: Will We Know It If We See It?

Empowerment is something that comes from within a person, rather than something that is done to a person. Someone who is empowered may have a sense that what they think and feel counts, that their wishes are important, and that they have choices to make. The best a program can do is create an environment that encourages empowerment. In a PsyR day program member empowerment might manifest itself in many ways. There might be a strong consumer committee or governing body, members might hold supervisory positions, and they might help to collect data to evaluate the program. Staff members at some programs try to engender some of these activities but find that they are rejected by service recipients. Empowerment, like recovery, is a personal and complicated phenomenon.

Can you tell whether a program milieu empowers its members? In many programs the consumers and staff give a great deal of "lip service" to the importance of empowerment. In other programs, the issue of empowerment is not discussed unless it is raised by a visitor. Does speaking about empowerment indicate that a program is empowering? Apparently not. A study done by students of the first author of this text found an inverse relationship in programs between consumer empowerment and talking about empowerment. In short, programs that said they were empowering tended to be less empowering than programs that didn't mention the term at all.

Some measures have been devised to evaluate the program milieu (Wolfensberger, 1980; Moos, 1974). These scales do not claim to measure empowerment directly. Instead, they touch on many related issues such as normalization and control. While empowerment is considered an important ingredient of PsyR programming, there is still no agreement on an objective way to measure it. Using a participatory action research approach, which involves researchers working hand-in-hand with consumers, a group of researchers developed an empowerment scale that holds some promise of capturing the essence of this term for individuals diagnosed with severe mental illnesses (Rogers, Chamberlin, Ellison, & Crean, 1997).

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