prism: the psychiatric rehabilitation integrated service model—a public psychiatric hospital model...

Administration and Policy in Mental Health Vol. 24, No. 6, July 1997

PRISM: THE PSYCHIATRIC REHABILITATION INTEGRATED SERVICE MODELmA PUBLIC PSYCHIATRIC HOSPITAL MODEL FOR THE 1990s

David Starkey and Barbara A. Leadholm

ABSTRACT: The Massachusetts Depar tment of Mental Health 's Metro South Area developed an inpat ient psychosocial rehabil i tat ion model called PRISM (The Psychiatric Reha- bilitation Integrated Service Model) which emphasizes skill deve lopment and pat ient participation. This article describes the transformation of a state hospital into a rehabil i tat ion t rea tment facility using the PRISM model. This approach has the potential to improve quality of life, decrease relapse, and increase the efficiency and responsiveness to pat ient needs of public sector hospitals.

The pace of change in mental health systems parallels the rapid changes taking place in health care. Service delivery as well as the availability and extent of services are undergoing rapid transformation. Managed mental health care emphasizes cost control, efficiency, and strict utilization management. While private sector hospitals have been significantly affected by shortened lengths of stay and stricter criteria for admission and limits on billable services (Fowls, 1994), state psychiatric hospitals have struggled to cope with patients who are treatment "resistant" or who need continuing care services beyond what the private sector is willing to provide. This article describes PRISM (The Psychiatric Rehabilitation Integrated Service Model), an approach that addresses the need to change significantly the

David Stm'key, Ph.D., is with the Massachusetts Department of Mental Health and Cambridge Hospital, Harvard Medical School. Barbara Leadholm, M.S., M.B.A., is with Green Spring Health Services, Bos- ton.

Address for con'espondence: Barbara Leadholm, Green Spring Health Services, Inc., 5565 Sterrett Place, Suite ,500, Columbia, MD 21044-2644.

497 �9 1997 Human Sciences Press, Inc.

498 Administration and Policy in Mental Health

status quo at a traditional state facility, Medfield State Hospital, through the application of psychosocial rehabilitation principles throughout the entire facility.

In the Massachusetts Department of Mental Health's Metro South Area, one of seven geographic divisions of the state's public mental health agency, where mental health consumers have lived with increasing success in community settings, the dichotomy between the hospital and the community has grown wider. Patients in the state hospital appeared more "institutionalized" in their behavior and expectations, and their overall functional level seemed to decrease over time as their more functional counterparts succeeded in community placements. The state hospital patients had poor community living skills, a limited desire to live in community settings and, with passing time, an increased likelihood of continuing to live in the state hospital indefinitely.

In fact, the effects of institutionalization are widely known. Goffman (1968) noted that living in a "total environment" such as a locked psychiatric unit, where autonomy is limited and routines are rigid and unyield- ing tends to make individuals passive, dependent, and helpless. In some ways the effects of institutionalization are similar to and may serve to rein- force the interpersonal isolation, lack of autonomy, and loss of community living skills found in patients with schizophrenia. The negative symptoms of schizophrenia, including lack of initiative, outside interests or energy, are similar to the effects of institutionalization described by Goff- man. More recent studies of long-term patients with schizophrenia have tended to be more optimistic than past studies (Busfield, 1986). The latter work in particular raises the question of the extent to which some examples of "chronic" schizophrenia are an artifact of environmental and psychosocial conditions, some of which exist in state hospital systems, leading to chronicity as a "self-fulfilling prophecy" (Harding, Zubin, & Strauss, 1987).

In contrast to the situation in inpatient settings, consumers of public mental health services in community settings regularly discussed the need to increase opportunities that supported "empowerment" (e.g., consumer choice, jobs, and independent housing). There was insistence on a consumer goals focus as found in the psychosocial rehabilitation approach to mental illness and a demand that public resources be redirected to creat- ing a n d / o r leveraging increased educational and vocational opportunities. There was support for an approach that promoted an understanding of mental illness as a condition requiring rehabilitation rather than long-term "treatment." They emphasized the need to identify the strengths and skills required to reach their highest potential (Leadholm & Kerzner, 1995).

David Starkey and Barbara A. Leadholm 499

Although acute psychiatric inpatient care was deemed necessary for conditions that resulted in occasional relapses, some consumers, advocates and mental health professionals challenged the relevance of traditional day treatment and long-term state hospital stays, regarding them as not helpful or even detrimental to potential functioning. They believed that both modalities failed to teach people with mental illness the vital skills necessary to navigate successfully in the community. These treatment choices were also viewed as contributing to institutionalization. As consumers adapted to the peculiar circumstances of institutional life, they si- multaneously lost their ability to function in the non-institutional world. While biological models of treatment had progressed substantially with the use of a new generation of anti-psychotic medications, including clozapine and resperidone (Cardoni, 1995; Higgins, 1995; Manschreck, 1994; Pickar & Hsaio, 1995), the inpatient milieu and inpatient psychosocial treatment had not kept pace.

The Psychiatric Rehabilitation Integrated Service Model described here differs from other rehabilitation models by addressing the effects of institutionalization in addition to the problems created by mental illness itself. For the hospital to play a meaningful role in the longer term treatment of schizophrenia, its function must be, in part, to avoid institutionalization. To be efficient and optimally effective in its methods, its treatment must focus on recovery of function and skill development. The model must engage all staff in developing a new identity and philosophy in their work with patients, transforming the organization in its approach toward assisting patients in coping with their illness.

PATIENT POPULATION

The continuing care or long-term aspect of Medfield State Hospital was exemplified by survey data from the winter of 1992. Out of a total of 210 patients, over 50% had been continuously institutionalized for longer than 2 years, and over 40% for at least 5 years. The phrase, "continuously institutionalized," is used to refer to continuous inpatient hospitalization at or prior to hospitalization at Medfield, as long as it was uninterrupted. In addition, 33% of all patients had no foreseeable discharge date or discharge plan, indicating that their treatment teams were not hopeful that these individuals would ever leave the hospital. These were patients left behind after deinstitutionalization and aggressive community housing development. Their presence posed particularly difficult issues concerning treatment, risk, and community integration. Forty-five percent of Medfield patients were taking the new generation of antipsychotic medications. In


line with research cited previously, a substantial portion showed some degree of improvement, but this was not sufficient in itself to lead to discharge for all patients.

DEVELOPMENT OF THE MODEL

Although a review of current approaches that work with long-term, institutionalized patients with schizophrenia was carried out, no prepackaged programs seemed to address the multiple needs of this population. Exist- ing rehabilitation models did not elaborate on how to work with the most impaired patients in the state hospital system, nor did they take into ac- count the latest thinking about skill development, recovery of function, patient participation and empowerment.

The work of Anthony (Anthony, Cohen, & Farkas, 1990), Liberman (Liberman et al., 1993), and others referred to in the literature as psychiatric rehabilitation, offered a promising, if incomplete, approach for this patient group. Psychiatric rehabilitation is defined as "assisting persons with long-term psychiatric disabilities increase their functioning so that they are successful and satisfied in the environments of their choice with the least amount of ongoing professional intervention" (Anthony et al., 1990). In the psychiatric rehabilitation literature there is an analogy made between mental illness and serious physical illness, since both require rehabilitation to promote full recovery. This approach focuses on developing the skills needed to increase functioning that has been lost or was never acquired due to the illness, and assesses environmental demands to determine what additional supports are required for the individual to live in a particular setting. In addition, practitioners of psychiatric rehabilitation insist upon the full participation of the individual in setting goals and planning how to reach them. Participation increases compliance and helps to create a more positive treatment alliance.

Psychiatric rehabilitation research has demonstrated that success in learning skills and applying them in community settings are unrelated to the severity of psychiatric symptoms (Anthony et al., 1990). Likewise, the specific nature of treatment is more important than whether it occurs in the hospital or in the community (Anthony et al., 1990). In addition, traditional inpatient therapies, such as psychotherapy and pharmacotherapy, do not in themselves determine rehabilitation outcome for those with a long-term mental illness. Therapies aimed at reducing symptoms and pro- ducing insight may have these particular effects. They can be unrelated to the skills necessary for work, living with others or managing the stresses of community life (Anthony et al., 1990). These findings supported a belief that the basic elements of psychiatric rehabilitation might be applicable to


all state hospital patients in spite of severe impairments and long periods of institutionalization. They could provide a needed addition to current biological treatments, particularly with the treatment resistant patients still remaining, as part of the long-term state hospital population.

Although the basic ideas of psychiau'ic rehabilitation are common cur- rency in community settings, little has been written about the application of these ideas to an institutionalized population. The majority of attempts at psychiatric rehabilitation have been made with higher functioning patients already living in the community, or specially selected groups of state hospital patients seen as most able to benefit from psychiatric rehabilitation interventions and had "discharge potential" (Craig, Peer, & Ross, 1989). In addition, few studies have focused on the relationship between hospital treatment modalities and the rate of recidivism. Available studies suggested that certain skills lengthened community tenure as did a model that integrated hospital and community treatment methods (Anthony et al., 1990; Becker & Bayer, 1975; Bellak & Meuser, 1993; Hogarty et al., 1986; Jacobs & Trick, 1974). Specific types of family interventions also showed a significant effect on recidivism (Anderson, Reiss, & Hogarty, 1986). However, a model for use with the majority of state hospital inpa- tients based upon these findings had not been developed.

PSYCHIATRIC REHABILITATION INTEGRATED SERVICE MODEL (PRISM)

In January 1993, the Metro South Area developed an inpatient model called PRISM. The purpose of the model was fivefold: to utilize a psychosocial rehabilitation framework to link community and hospital methods of providing mental health services; to prepare patients residing in the state hospital for community living and to reduce recidivism by maintaining a n d / o r increasing skills; to avoid institutionalization by developing structures that support active involvement in treatment and the unit milieu; to improve the quality of life for patients remaining for long periods in the hospital setting, and to develop a psychosocial model that was complemen- tary and additive to the already existing psychiatric treatments such as pharmacotherapy. PRISM required a major shift in thinking to move the state hospital from a caretaking to a psychosocial rehabilitation model. It recognized that patients with schizophrenia and other long-term major mental illnesses frequently require rehabilitation to achieve or return to a higher level of functioning. It necessitated patients' personal involvement with treatment decisions and identifying skills to increase functioning for coping with the effects of what can be a life-long illness.

For the model to be successful, hospital management needed to engage the entire hospital organization in developing the implementation plan


and recogniz ing the value of the p roposed interventions. An implementa- t ion commi t t ee was fo rmed consisting of the chief opera t ing officer, the area clinical director, the depu ty area director, the clinical d i rectors o f all the disciplines and the d i rec tor of staff deve lopmen t and training. This g roup met weekly t h r o u g h o u t the implementa t ion process to di rect and manage major implementa t ion issues. In addit ion, a PRISM co o rd in a to r was ident if ied on each unit to oversee the day to day workings of the mode l and help facilitate PRISM activities. Th e latter g ro u p also me t weekly with the area clinical d i rec tor for supervision, and both g roups me t toge ther mon th ly to communica t e about the progress o f implementa t ion . This a r r a n g e m e n t provided good communica t ion between the hospital ad- minis t ra t ion and the uni t level, and involved individuals f rom all disciplines o f the clinical staff at bo th levels.

Since a major goal was to r educe the effects of insti tutionalization, tradi- t ional rehabil i ta t ion p rogramming , usually consisting of skill t raining inde- p e n d e n t of the uni t milieu, was avoided. A model was deve loped that ad- dressed the na ture of the unit milieu ( though t to be a major source of insti tutionalization) and inc luded p rog rammin g c o m p o n e n t s bo th on and off the units. A major aspect of PRISM is that every area of the hospital must have a rehabil i ta t ion focus if all patients are to benefi t . If there is an off-unit p rog ram focus on rehabil i tat ion, but on-unit activities are o f a tra- dit ional caretaking nature , change is unlikely to occur in a maximally effective way.

As a first step, uni t structures were def ined to maximize patients ' involvement in their own t rea tment and un i t /o rgan iza t iona l funct ioning. Ef- forts to increase patients ' involvement in their own t r ea tmen t included:

�9 pa t ient part icipat ion in t rea tment p lanning meet ings �9 t r ea tmen t plans with a rehabil i tat ion focus that emphas ized the pa-

tient 's goals, skill deve lopmen t and external supports �9 the t rea tment plan's "problem" list r econcep tua l ized as obstacles to

reaching a pat ient 's goals �9 pat ient part icipat ion in team meet ings twice per m o n t h with the pa-

t ient cons idered to be part of the team, no t the object o f the discus- sion

�9 t r ea tmen t teams that were encou raged to talk directly to pat ients ra ther than to mee t separately

Efforts to increase pat ient involvement in un i t /o rgan iza t ion func t ion ing included:

�9 primari ly informat ional meet ings run by staff res t ruc tured to community meet ings co-led by staff and patients


�9 formation of patient advisory committees on each unit to monitor patient concerns; interaction with unit staff leaders to resolve these issues

�9 monthly meetings between the hospital chief operating officer and patient advisors

�9 staff training emphasizing interaction and patient choice rather than simply enforcing rules and routines

In addition to structural changes on the units, staff provided both skill building opportunities and supports to increase the likelihood of their ability to participate meaningfully. Treatment planning skills groups were established to discuss the function of treatment planning, to help patients formulate goals and to identify obstacles to goal achievement. A support person was assigned to each patient advisory committee to assist patients in learning how to structure a meeting and articulate concerns. The support person was instructed not to censor or modify the content of the meetings. Through this system of structures and supports, patients were provided opportunities to participate in treatment and milieu issues while concomi- tantly learning the necessary skills to do so on an ongoing basis. These skills were thought to be transferable to a patient's daily life and as a means of negotiating the mental health system both in the hospital and community.

The function of the unit structures was also designed to overcome the effects of institutionalization by increasing participation in structured activities to increase self-advocacy and understanding of the mental health system. While not skill building in the traditional sense, their function was to increase patients' self esteem, proficiency in articulating their perceptions and needs and awareness of how to participate in a more meaningful way in the hospital experience. PRISM differs from the therapeutic community model in that it does not place a value on expression of personal feelings, including anger, but rather provides structured opportunities for individuals to learn and practice skills in a supportive environment. The model stresses education and learning rather than insight.

In addition to a focus on structured patient involvement in unit activities, this model also differed from traditional psychiatric rehabilitation programs in its attempt to include all patients, even those who appeared to be functioning at the lowest levels. This is consistent with the philosophy of psychiatric rehabilitation (e.g., that all patients can benefit from rehabilitation, and the degree of improvement is not necessarily correlated with severity or type of psychiatric symptoms). To increase the likelihood that all patients could benefit from skill building activities, existing skill building modules were modified to reach lower functioning a n d / o r cog- nitively impaired individuals. In part, these modifications included sim- plification of language, increased repetition, shorter group sessions and a


greater number of sessions over a longer period of time. The modules that served as the basis for the simplified versions included the Basic Conversa- tion (social skills), Symptom Management and Recreation Modules developed by Liberman (Liberman et al., 1993) as well as modules on basic hygiene and self-care and community living skills that were created by hospital staff.

The hospital also developed a locked day program for patients at risk of harm, greatly expanding the number of patients who could participate in programming activities off their units. This program focused on functional skills (primarily activities of daily living and social skills) and prepared patients to move to unlocked settings where higher level skills (symptom management and community survival) could be taught. Overall, the goal was to develop a rehabilitation facility for all patients in which the principles of psychiatric rehabilitation were carried out in every part of the hospital rather than in one specialized area for higher functioning individuals only. Even non-clinical departments, such as dietary and maintenance, were asked to participate in developing patient skills. As examples of the latter, patients were given food choices at meals, and selected their own clothing from an on-grounds boutique, rather than having clothing allot- ted to them on the wards.

CHANGING STAFF ROLES

The initial implementation of PRISM raised concerns on the part of staff who were trained to adhere to traditional roles and viewed patients as unable to participate in their own rehabilitation/treatment. In particular, it was communicated that the caretaking approach in which most major and minor life decisions were made for patients had to shift so that patients could become involved in a meaningful way in their own treatment. It was not uncommon to hear that "our patients are not able to contribute to a treatment plan." It was even more common for staff to complain that they did not have time to involve patients in treatment planning or team meetings because they were already overworked and team schedules were filled. The idea that severely impaired patients could be rehabilitated to lead more meaningful lives challenged the basic assumptions of many staff members' previous training and orientation.

A basic staff assumption was that patients needed to be "taken care of ' rather than challenged or allowed to become more independent. For some staff, the learned expectation of being needed conflicted with the modified expectation of helping patients become more independent and capable. This also highlighted the fact that the traditional state hospital model, which can lead to dependency and helplessness, may have at -


tracted at least some staff for whom this was an important factor. If patients no longer depended entirely upon staff, some staff questioned their own value a n d / o r role with regard to the patients. F'or individuals who equated their own worth with being needed by and caring for others, self worth declined as patient empowerment increased. Their antidote to de- clining self worth was to question the value of the model, judging it as a source of potential harm to patients rather than a help. The dynamics of working with the resistance of staff proved to be as important and difficult as any administrative or clinical change necessitated by PRISM itself. This underlines the need for organizational commitment to implement successfully a model that transforms the hospital's philosophy and approach toward the work it does.

Another psychological concern for staff involved the issue of control. As patient participation increased, many staff perceived their own level of control to be decreasing. Use of the word "empowerment" caused conster- nation among some staff who believed this gave patients license to make rules and run the wards as they chose, regardless of the wishes and perhaps against the judgment of staff. Interestingly, implementation of PRISM was confounded with human rights issues, such as a patient's right to refuse treatment as guaranteed by law. The model was perceived as permissive, lacking the "structure" a person with mental illness needed to conform his or her behavior to social norms. In fact, the model provided units with more structured activity and demanded that patients and staff take more responsibility for engaging in constructive activity. The movement toward dialogue was a great leap for many staff who perceived patients as needing to be controlled rigidly in order to maintain safety.

Thus, one of the major initial tasks of implementing PRISM was explain- ing the reasoning behind the new structures to staff and helping them to overcome their own learned institutional behaviors. Staff learned slowly that patient participation was indeed a form of treatment and education. Overcoming the passivity and learned helplessness of institutionalization required patients to learn new tasks and assume new responsibilities. It did not, as staff suspected, propose that patients engage in a meaningless free- dom with neither the necessary skills or knowledge to be more effective, whether in or outside of the hospital. Staff were forced to realize their own critical role in facilitating patients' development into higher functioning individuals.

PROGRAM EVALUATION: PRELIMINARY DATA

The efficacy of PRISM is being evaluated by a research program begun in July 1994. Sixty-six patients agreed to participate in the PRISM research

506 Administration and Policy in Mevztal Health

project (out of a total of approximately 130 patients). Data collection in- volves demographic data, clinical status (Clinical Global Impression or CGI), program participation and assessments of quality of life (Quality of Life Interview, short form, (Lehman, 1993)); empowerment (Internal/Ex- ternal Locus of Control, (Rotter, 1966)), and Making Decisions Scale, (Rogers, 1995); functional level (Expanded Routine Task Inventory, (M- len, 1985)); the unit milieu (the Ward Atmosphere Scale, (Moos, 1974); and a patient opinion survey related to PRISM.

As an indication of the effectiveness of the implementation process, of the seven units monitored, four increased their patient participation in team meetings by at least a factor of 10, with all patients on the unit attending team meetings once or twice per month, with the two other units only slightly behind this rate, increasing by a factor of 8 and 7 respectively. The average participation in team meetings at the beginning of the study was 10% of patients attending per month. Eighty to one hundred percent participated monthly by the end of the first year, and on some units participation was more frequent.

Preliminary data indicate that patients in the study for the initial 1 year period are rated as improved on the CGI relative to the previous year with the mean pathology rating dropping from 4.9 to 3.9 (p<.03, two tailed t test). Although other factors cannot be completely ruled out, this may indicate that PRISM has a positive effect on overall mental status ratings. Some patients also report an increase in their subjective quality of life ratings over the first year of the program, with more than twice as many patients reporting that their quality of life has improved versus those who felt the opposite, in spite of continued hospitalization. The difference is not statistically significant for the entire group, most of whom did not change their ratings over the 1 year period. However, for those who did report a change, 17 said that their quality of life had improved, while only 8 said the opposite.

An item analysis of the Ward Atmosphere Scale at 6 months indicated that patients changed their responses significantly in a positive direction on four items, including '~i'he staff act on patient suggestions," "The staff know what patients want," "Patients are encouraged to be independent," and "New treatment approaches are often tried on this ward." These changes are statistically significant at minimally the .05 level as indicated by two tailed t tests. These responses indicate an increased sense that patients are perceiving themselves as having effective input with staff and are expected to be more independent, a major aspect of PRISM.

On the PRISM opinion survey, a list of 10 questions such as, "My treatment team listens to my opinion about my treatment" and "My treatment team has explained my treatment plan to me in a way that I can under- stand," to which patients can respond "always," "sometimes," or "never,"


were asked. Patients reported over twice as many "always" as "never" responses to questions about PRISM activities.

Mthough it will require a longer term analysis to ctetermine if PRISM has a significant effect on discharge or recidivism, based on these early results, the effect of PRISM on patient morale and outlook seems highly positive.

CONCLUSION

The process of change is transforming mental health at every level of the public and private sectors. For state hospitals to play a meaningful role in a reformed health care system, they must increasingly define their mis- sion and goals and target appropriate treatment to the individuals they serve. The traditional insularity of the state hospital must be replaced with new ideas and technology in order to upgrade and modernize the psychosocial treatment of "chronic" and "treatment resistant" individuals. As ad- vances in psychopharmacology have created new opportunities for patients with long-term mental illness to move toward recovery, so can comprehensive and innovative use of psychosocial rehabilitation principles in inpatient settings increase the quality of life and opportunities of this difficult to treat population. PRISM is a model for public sector hospital programs that constitutes one important approach to managing the care of people with long-term mental illness while maximizing hospital resources and po- tentially reducing inpatient stays.

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