Thursday, March 31, 2011

Making Inpatient Rehabilitation Environments More Similar to the Community

I want to talk about one of my pet peeves - the disparity between inpatient rehabilitation programs and real community life for people with severe and persistent mental illnesses.

Most inpatient wards now state that their goal is to return people to the community. Therefore, they should be designed around preparing people for community living. However, it still seems that some are focused on keeping clients and staff comfortable where they are. As a result, clients end up spending most of their day doing activities that they will not be able to do in the community.

 
This means that when a client does leave, he or she must not only change living environment and social supports, but also change the way he or she uses time in a significant way. I really feel that this ends up making the transition to community more difficult. If the goal really is successful transition to the community, shouldn't the inpatient environment be made as similar as possible to the community?

 
I started off working on an inpatient rehabilitation program, and then changed to working in the community. I have met many of the people who I saw in hospital, later in the community. The majority of my clients in the community live in poverty. If they are well enough, they can maintain employment, usually for low wages, but most are unable to work and receive Income Assistance or CPP Disability. Income Assistance is pitifully low, as is CPP Disability, and if you smoke (as the majority of people with schizophrenia do), it is impossible to make ends meet without the assistance of food banks and soup kitchens.

 
For the purpose of this blog, I am talking about long-term rehabiliation programs, and not acute inpatient programs. From what I have seen, the long-term programs have people who are more severely disabled by their mental illness than the acute programs. The percentage of people in acute programs having a higher standard of living would be higher.

 
Here are some of the issues I see:
  • Full cable TV on the ward. I don't even have full cable TV, because I do not feel like I can afford it. Clients spend most of their days watching the TV, which makes things nice and comfortable for them and for staff. What are they going to do with their time when they cannot afford cable?
  • Cigarette rationing. Staff handing out cigarettes to clients one at a time on a certain schedule e.g. one an hour. Again, this makes things nice and comfortable for the client and staff. The client does not run out of cigarettes and start bumming them from other people,which usually results in conflict.
  • Horticultural therapy. Great idea - I have read articles about the therapeutic benefits of gardening. However, when clients leave, most are going to be living in apartments without access to a garden. How about learning to take care of a plant or two in containers instead of a large outdoor garden?
  • Sheltered work programs. These can give clients a great feeling of productivity. The only problem is that these are no longer available in the community, and the research that I have read suggests that if anything, participating in a sheltered work program decreases a person's ability to find and keep competitive employment. I can see how this would happen, as I saw workers miss doing their job for several days, with no consequences. Many inpatients are not mentally stable enough yet to obtain or maintain competitive employment, but how about focusing on supported volunteering which can be maintained after discharge?
  • Computers with internet access on the ward. I am a bit undecided about this. I believe that learning to use technology is quickly becoming an essential ADL, and part of our role is to ensure clients have equal access to this technology, and the opportunity to learn to use it. However, my clients generally cannot afford computers and internet access, and must learn to use public use computers. I think it may be a good idea to have computers on the ward to be able to teach people to use them, but it needs to be followed up by teaching people to access public use computers e.g. take regular fieldtrips to the library to use the computers there.
  • Unrealistic activities. Often clients are shuffled from one group to another - their time is scheduled for them. They become used to being told what activity to do instead of choosing. I have spoken to many people who have told me that they enjoyed doing crafts in hospital, but have not done them since discharge. Often the materials are too expensive or too difficult to obtain. Clients participate in elaborate meal preparations including main dish, side dish, dessert, and sometimes even appetizers. In the community, my clients are always looking for inexpensive one-pot meals. One frequent activity was taking clients for "drives", and sometimes stopping for coffee. Very few of the clients will ever have the opportunity to go for drives in the community.
In my previous post, I discussed how important it is to have meaningful ways to spend your time. If you all of a sudden lose your main leisure and productivity activities, it makes it much more difficult to stay well.

 
Many community resources can be accessed from a hospital setting, and I have seen some progression toward this, but I believe it needs to be even more. The goal of inpatient rehabilitation should not be just to help a person become well enough for discharge. It should also be to help a person develop the skills to stay discharged, and lead a happy, fulfilling life.

 

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