Intruduction by Jack Rosberg

The Anne Sippi Clinic bases its treatment on establishing therapeutic alliances between the staff and the residents and on fostering a warm and trusting environment that will support residents in their efforts to improve the quality of their lives. The program itself includes daily or weekly psychotherapy groups and individual sessions, as well as social and recreational activities.

The residents at the Clinic represent a wide range of functioning abilities, with many functioning at a very low level, and certain individuals exhibiting deficits in basic hygiene, lack of social awareness and social skills, and a low level of motivation. Although the staff provided some training in these areas in the course of daily interactions with the residents, Jack Rosberg, long an advocate of the healing effect of the therapeutic alliance, felt that more training needed to be provided to the residents in order to improve their ability to take care of themselves. He proposed a psychosocial rehabilitation program designed to provide more structured support and guidance in the areas of daily living skills, communication, time management, social awareness, motivation, and establishing and pursuing quality of their functioning and to prepare them for living in the community.

The rationale for this additional programming was based on addressing the following issues. Individuals with schizophrenia commonly do not know how to use time productively when not in therapeutic sessions, and are frequently, restless, bored, and listless. They spend a great deal of time in bed, and focus their waking activities on eating, and smoking. Finally, they are not adequately prepared in activities of daily living, social skills, and community awareness.

The following article represents the genesis of the program; its rationale, goals and an outline of its implementation. Furthermore, it investigates the issues encountered in developing a rehabilitation program, the benefits of such a program, its integration within a psychotherapeutic environment, and future directions.

STARTING THE PROGRAM

On September 21st, 1998, the beginnings of a formalized rehabilitation program were initiated at the Anne Sippi Clinic. It started with a morning exercise group and community meeting, in order to increase activity levels and motivate residents to maintain their hygiene, grooming, and other aspects of daily living. Staff and interns met with residents to help them determine appropriate basic goals for themselves in the area of hygiene, group attendance, and community meals. The daily routine of the Clinic was put on a more consistent schedule in terms of serving meals, showering and dressing. Residents were also asked to eat together in the dining room during set time periods. Soon an additional morning group was added, where the residents were divided into a men's group and a women's group to work on more personal issues.

This new programming would assist the case managers (line staff) in how to work with residents on the primary Activities of Daily Living (ADLs). In addition, weekly staff meetings to address rehabilitation programming were instituted to increase communication, and plan for the new program.

PROGRAM OUTLINE

The rehabilitation program at the Anne Sippi Clinic is designed to assist adults with a history of severe illness to gain needed motivation and skills to re-enter their communities as functioning members of society. Regular programming represents a focus for the time when residents are not in therapeutic sessions. Within this, systematic instruction in daily routines and behavior training was initiated in order to facilitate behavior and attitude changes necessary to improve the residents’ daily functioning and quality of life.

MORNING PROGRAM

The program itself was developed step by step, with discussion and readjustment along the way. Initial goals were improvement in activity levels through exercise and attendance of groups in the morning, improved hygiene, grooming and eating habits. These issues are primarily addressed in the community meetings.

Now that some of the basic hygiene issues have been attended to, this community meeting is frequently divided into much smaller groups, each facilitated by a staff or an intern. The groups are either split heterogeneously, with residents who function at higher levels interrelating and discussing issues; or homogeneously with residents who function at higher levels addressing community living issues and residents who function at lower levels focusing on activities of daily living such as hygiene and laundry.

OUTLINE OF MORNING ACTIVITIES

Wake-up, hygiene and grooming is scheduled between 7:00 a.m. and 8:30 a.m. Breakfast is served between 8:30 a.m. and 9:30 a.m.

Exercise:
At 9:30 a.m. each morning, a 30-minute group aerobic program is conducted by a case manager. This program is designed to increase flexibility, strength, and endurance as well as to provide motivation and assist in weight management.

Community Meeting:
After a break, the residents meet in the dining room at 10:15 a.m. for a community meeting, conducted by the rehabilitation director and assisted by the case managers. This meeting reviews the daily program schedule and goals, and discusses issues relevant to the residents’ needs. It also provides education on hygiene, social skills, problem-solving, self-discipline, and anger management. Residents have the opportunity to voice concerns and make suggestions as well as participate in rehabilitation activities. This meeting may either take the form of a single group, or divide into a number of smaller groups each run by a case manager or intern (as discussed above).

Men’s and Women’s Rehabilitation Training:
At 11:00 a.m., men and women each meet separately under the direction of the case managers to work on issues specific to male and female hygiene, grooming, sexuality and Sexually Transmitted Diseases (STD’s). This group also raises issues pertinent to social relations, courtship, gender identity, and self presentation. Residents are able to discuss personal matters in a more intimate setting in a way they may not feel comfortable expressing or bringing up in a mixed gender group. In addition to gender specific topics, issues related to diet and weight management, independent living skills, personal goals, and career and educational aspirations are discussed. Participation in creative activities such as writing tasks assists residents to increase self-expression and raise self-esteem.

AFTERNOON PROGRAM

Once the morning activities had been established and the residents accustomed to a more regularized routine, an afternoon work program was introduced to increase the residents' sense of responsibility, self-efficacy, and self-esteem. These paid work groups consist of gardening, painting, food/provisions shopping, room maintenance, woodworking, and yard maintenance. At the same time, additional instructional and creative groups were initiated in the afternoon, evenings, and weekends, such as art class, ceramics, conversation skills, cooking, crafts, and reading.

Work Groups
The following workshops represent a psycho-social work and rehabilitation program that is undertaken by residents in the afternoon hours, between 1 and 4 p.m., Monday to Friday. This activity is supervised by the rehabilitation director, and assisted by the case manager supervisor. An integral aspect of each work group is learning how to take direction, manage time, focus and concentrate for increasingly longer periods of time in order to increase job and educational skills that will transfer to and be successful in the general community.

1. Gardening / Landscaping:
Residents work with a therapist and case manager in the vegetable garden and rose garden, as well as the patio and other areas bordering the clinic in order to grow produce for the kitchen and beautify the Clinic. They learn how to dress appropriately for working with soil and plant material, how to use gardening tools, and how to clean tools when finished. They learn which vegetables are seasonally appropriate, how to prepare soil, and how to weed, water, plant, and harvest produce. They learn about plants, insects, compost, and how to landscape as well as how to select, budget, purchase and transport necessary garden materials.

2. Painting:
Residents work with maintenance staff in painting offices and bedrooms as well as the outside of the Clinic. They will learn how to mix paints, use brushes and rollers, prepare rooms for painting, dress appropriately for painting, clean up painting and brush materials and restore rooms to former order each day when they are finished.

3. Room Maintenance:
Residents work with a case manager organizing and cleaning the residents’ rooms and personal possessions. They learn how to decorate and organize rooms for both beauty and accessibility as well as maximization of usable space. They proportion space in such a way that both residents of each room have equitable shares of space and furniture, and fold, organize and put away clothing in dressers and closets. They learn how to use a broom and dustpan, mop and cleaning equipment, and dress appropriately for cleaning and how to clean themselves after finishing.

4. Shopping Skills:
Residents work with the dietary supervisor learning how to count and apportion funds, understanding the value and cost of shopping items, and selecting which items are important and needed for diet and daily living, and also how to manage time while shopping. Residents are taken on field trips to practice their shopping skills, learn how to manage time while shopping, and increase awareness of others. One of the goals of this group is to assist the dietary supervisor with weekly shopping, so the residents will have hands-on experience with budgeting, selecting, purchasing, and transporting goods from the store.

5. Woodworking:
Residents work with a case manager in learning how to use woodworking tools and different kinds and sizes of wood in order to produce garden furniture, and other wood crafts for the Clinic and for sale. They will learn how to work from designs, how to cut wood according to specifications, how to measure, and how to use manual and power tools in a safe and precise manner under close supervision.

6. Yard Clean-Up:
Residents work with a case manager in cleaning up around the Clinic, both outside on the grounds and inside in the hallways and dining room. They pick up the trash, and sweep the smoking area, parking lot, patio, behind the laundry room, and also in the dining room and in the hallways. They will also pick up cigarette butts in all areas, including the lawn area and around garden furniture. They learn how to use a broom and dustpan, how to increase awareness of cleanliness, and how to appreciate a clean, tidy and aesthetically pleasing living environment.

Instructional Groups

1. Conversation:
Residents work with interns on improving their social and conversational skills, increasing their ability to make eye contact, listen and respond to others, follow topics, and take turns while conversing.

2. Cooking:
Residents work with a case manager in the kitchen and dining room preparing and cooking food items for group and resident consumption. They learn how to clean their hands properly, and use sterile gloves when preparing food. They also learn how to read and follow menus, clean and cut food items and how to prepare them in appropriate order for mixing and cooking. They learn the safe use of the stove and the oven and how to use time management in preparation and cooking. Residents will be advised how to wrap food and preserve it.

3. Reading:
Residents work with an intern in the art room reading appropriate material. Either in a group format or one-to-one reading, they further their vocabulary, and improve diction, pronunciation, and projection. In the group, residents will learn how to increase concentration, listen to others, and assist others. They will also learn leadership skills in how to run the reading group if requested. In the one-to-one format, residents work on similar skills, including supervised teaching of residents with lower abilities. They also gain experience, where necessary, regarding their understanding of the English language. They discuss the meaning of what they have read and gain insight into their own and others’ perceptions of reading material, while continually relating what they learn to their own day to day living environment.

EVENING AND WEEKEND PROGRAM

During the evening and weekends, residents participate in a number of recreational, artistic and sports activities.

1. Art Class:
Residents will work with a case manager learning how to use various art mediums such as paint, acrylics, crayons, and markers. They will work from still life, pictures, and their imagination in order to increase expression of feelings, ideas, aspirations, increase their self esteem, and beautify their rooms.

2. Crafts:
Residents work with a case manager learning how to make jewelry, decorate ceramics, make seasonal crafts, and how to knit and crochet. They learn how to select a project, plan use of materials, maintain focused attention, and follow a task to completion. In addition, these activities increase their fine motor skills, concentration and creativity.

3. Recreation and Outings
Residents also participate in sports and exercise activities, including basketball, volleyball, weight training, and hiking. They participate in community outings that increase their familiarity and ease in negotiating their environment outside the Clinic. They increase community living skills such as appropriate communication and social skills, shopping and making purchases, practicing self-control and frustration tolerance, finding their way around their environment, and becoming more aware of how to function independently.

ISSUES ENCOUNTERED

Staff:
Case managers are the staff primarily targeted to maintain the routine of this new program. Through meetings, training, motivation, and reinforcement they have become capable leaders of the activity and work groups and have shown initiative in providing needed programming and instruction. One of the key methods of implementing a successful work schedule for the staff, was that their interests and perceived strengths were made an integral part of the new programming. Rather than being resentful of an enforced work routine, they are able to display their talents within their specific work program.

Residents:
Individuals suffering from schizophrenia typically have difficulty normalizing their daily routine, particularly getting out of bed in the morning. Many are accustomed to staying up late and sleeping until lunch-time. They are unaccustomed to showering, dressing and eating according to a structured or semi- structured schedule, and need prompting and support to get out of bed and come to groups or to participate in exercise. With this support given, the majority of the residents come to morning groups on a regular basis, with little or no prompting. Although there are still some residents who are inclined to stay in bed, it has been made a priority for certain therapists, counselors, and case managers to approach and work with them outside of groups.

Logistics:
Other concerns, in many ways much less significant, had to be confronted in establishing the rehabilitation program. The logistics concerning coordination of activities has been solved by improved communication between staff, and between staff and residents. Creating a more structured dietary routine and nutritional program has been taken on by the dietary supervisor, and a healthier, more balanced diet has been introduced.

Finding sufficient space for groups, especially when dealing with cold and rainy weather which curtails the outdoor groups, remains an intermittent problem. Thus far, these occasions have been used to work on writing skills as a large group, or on room maintenance in smaller groups.

Motivation:
Motivation for both staff and residents was a major consideration in the implementation of the new program, i.e., what would provide sufficient incentive for people to consider overcoming a habit of behaving and thinking. The issues related to whether to use a token economy for motivation came under discussion and ultimately, criticism. Jack is insistent that motivation should remain primarily intrinsic based on personal relationships with staff and the resident’s supported desire to improve their lives. He feels it is demeaning to adults to be given a cigarette or candy for attending groups or cleaning their room. The afternoon work program does pay residents for work accomplished, and residents may purchase or order items from a Clinic store with the pay they receive.

Over time, we have found that in order to help residents with learning and performing tasks, we have had to overcome their attitude of learned helplessness. Jack has emphasized the disturbing fact that in certain institutional settings, residents are told (or it is assumed) that they cannot do anything on their own because they are sick. Subsequently residents came to believe, not that they had an illness, but that they were the illness - it becoming their identity, and mode of being. Supporting and maintaining this instilled ‘way of life’ represents the antithesis of the Clinic’s ethos, and as such, great importance has been placed on eliminating this self-perpetuating stigma.

Many residents are simply not used to going to groups or working, and are easily frustrated and discouraged. They are also used to doing very little, and this habit was difficult to overcome. The primary issue is to provide them with the opportunity to accomplish their goals. This has to be reinforced through repetition, prompting, constructive feedback, praise, and encouragement to overcome their inertia.

PRACTICAL INSTRUCTION

Essentially, tasks had to be broken down into smaller segments and modeled for the residents. Staff had to be patient and go slowly, repeating instructions, guiding and modeling, and giving residents at different ability levels tasks that were appropriate to their skill and attention level. For example, the issue of tooth-brushing within the hygiene program: Residents had to be informed how often one should brush, at what times in the day, the correct method off brushing, and the reasons why one brushes.

Regarding workshops, this may mean that a resident is given the job of sanding the cut-out wood pieces in a woodworking group, nailing a nail into a board, or watering with assistance and prompting in the gardening group. Staff often has had to fill in the parts of the sequence or structure that residents are not yet ready to handle. These are elements in developmental training referred to as scaffolding, which is a combination of shaping and modeling. In this way, staff work with the resident in the area and level that they are able to handle in order to increase the resident’s competence and skill.
First, staff assist residents by:

1: Modeling, through demonstration and guidance.

2: Shaping more accurate approximations of skills needed, through influence and reinforcement.

3: Encouragement, through positive support and constructive criticism.
Residents are encouraged to:

1: Incrementally increase their expectations of themselves, by building competence levels steadily according to each individual’s capability.

2: Develop a routine by instilling these programs and expectations on a daily basis.

3: Increase their self of discipline, by creating a sense of commitment to goals and tasks.

Via these methods a number of residents have been able to improve their practical skills, their ability to focus and concentrate, and their sense of discipline, responsibility and reality orientation. In addition, they have gained a sense of pride in accomplishment. In achieving goals that previously they (and others) thought they could not accomplish, and had not been given the opportunity to accomplish, they have changed their sense of perspective from one of hopelessness to one of hopefulness.

PROGRESS

The original goals of the program had been to increase the residents’ ADLs, social skills, motivation, and desire to change, along with decreasing a lethargic and apathetic state. By implementing meaningful activity, the hope is to distract the residents from their positive symptoms of schizophrenia (e.g. hallucinations) and to prompt and motivate them away out of their negative symptoms (e.g. poverty of thought and speech). Many of these goals are being accomplished by the residents who have participated in the program.

Within the six months that the program has been implemented, the following areas represent a comprehensive, but not exhaustive, list of accomplishments made by the residents. In basic hygiene; there has been an increase of showering, increased grooming including wearing clean clothes, and decreased bed-wetting. Regarding eating habits; there has been an increased use of utensils, a decrease in overeating, and an increase of eating communally in the dining room. Concerning exercise; many residents have accomplished a decrease in weight, and an increase in movement and motivation.

The groups themselves have facilitated increased activity among the residents, a decreased amount of residents remaining in bed and an instillation of a work routine. The work programs have led to an increase in work, an increased sense of pride in self and self-esteem, increased reality testing, and an increase in practical skills. Furthermore, it has fostered greater motivation to work to earn money. The spirit of the residents, and thus of the clinic is one of increased energy, hope and optimism.

THE FUTURE

The program is periodically evaluated and assessed in terms of goals and objectives. Currently we are still looking to have more integration of residents' individual goals with the programming itself, to increase diversity in programming and to provide more educational instruction, such as community living skills and money management. The afternoon work program is seeking to expand into a more product-oriented work program, so that residents will be able to see the results of their labors and to sell what they make.

We still have not adequately solved the issue of whether to have mixed or divided groups of residents who function at different levels. There are advantages and disadvantages to both approaches. In the early stages of the community meeting, the residents who function at lower levels were both dominating and disrupting the meeting, which discouraged other residents from attending. When the focus was on hygiene and dressing, the residents for whom this was redundant felt insulted or patronized. However, separating groups by level of functioning also can be demoralizing for those put in a lower functioning group, even if not identified as such. The decision that has been made so far, dividing into mini-groups of three to four residents with one staff member (as mentioned above), is showing positive effects, but will continue to be monitored and examined.

PSYCHOTHERAPY AND PSYCHOSOCIAL REHABILITATION

An issue that has not yet been adequately addressed is how to integrate psychotherapy with the rehabilitation program. Therapists frequently attend staff meetings to address issues related to particular residents and provide updates and insights, but as of yet mutual knowledge and reinforcement of what these two parts of the treatment program are contributing has not yet been integrated on a formal or systematic basis.

Potentially, an increase in communication within the Clinic could be achieved by the therapists informing the case managers and interns of the routes that they are taking with resident therapy and treatment, and by the staff keeping the therapists aware of their rehabilitation goals and programming with the residents. Practical integration of the disciplines could be furthered by the therapists attending, and occasionally running some of the morning community groups. For example, a movement therapy group has been introduced as part of the men’s and women’s groups, designed to work on therapeutic issues within a nonverbal modality. Within a short period of time, there has been a noticeable input from certain residents who are usually more resistant to attend.

Psychotherapy at the Clinic may be viewed as a process of symptom reduction, decreasing the ‘schizophrenia’ within the person, whereas the aim of the rehabilitation program is to instill, increase, indeed enforce a sense of practical reality within the resident. Although there is an overlap as to the aims and methods of the two disciplines (distinguishing between them may occasionally seem a question of semantics), they do have separate purposes, and any application must take that into account.

CONCLUSION

The rehabilitation program is still in a formative stage, and modifications continue to be made. Based on the programming undertaken so far, the changes introduced have provided an improved atmosphere and a more well-rounded treatment program. There have been positive changes in mood and motivation as well as in functioning. These changes are based primarily on intrinsic motivation provided both by the relationship with residents and staff and from the positive changes that residents have made in their own lives.

We have found that rehabilitation can take place with at all functioning levels with which residents come to the Clinic. What is required is effort and motivation on the part of staff so that motivation may be fostered in the residents. Change occurs at a developmentally appropriate level with staff who are sensitive to the needs and skills that residents currently display. This helps them to consolidate those skills and progress at a realistically appropriate rate, which will include periods of regression alongside the overall improvement. The end goal is not necessarily a cure or a completely normalized individual by society's standards, but improvement in their sense of self-worth and ability to make positive changes. This results in an improved sense of well-being, ability to cope, and a better quality of life.

Written by,
Margaret Caton PhD., PsyD., Matthew Knight B.Sc.

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