Consumer-driven innovations for psychiatric inpatient unit therapeutic group programs:

Going "modular" and better targeting to consumers' needs.

Prepared by Allan Pinches, Consumer Consultant for Mental Health.

( With conceptual development and additional research by Sue Robertson. )

Section 1: Overview: Towards some "fresh approaches" in psychiatric inpatient unit therapeutic group programs

This discussion paper outlines some consumer suggestions for change and development in psychiatric inpatient unit therapeutic group/ activity programs.

The document is designed to stimulate discussion. Nothing is stated or implied to be "set in concrete" and there is enormous potential for creatively and co-operatively developing some of the models suggested herein, in a mode of partnership between staff and consumers.

It is believed that the approaches outlined here - which would mean not just some new groups but a whole new and more responsive system of group programs - would go a long way toward increasing the levels of consumer satisfaction with the any Psychiatric Inpatient Service. We believe they would also greatly enhance service effectiveness.

Suggested new approaches toward optimising ward programs - to reflect consumer perspectives - involve a fourfold approach:

Restoration of the pre-eminence of therapeutic group programs as an important part of consumers' hospital treatment - encouraging in consumers a pro-active approach to treatment - together with promoting a support-enhanced and more needs-targeted program structure.

Some innovative re-structuring of program forms and content, drawing on current and high quality information and advice from various disciplines.

Increasing the degree of staff specialisation -- and utilising existing special skills -- through establishment of "portfolios" of developed expertise in some key consumer-needs areas, and having a key role in group programs targeting particular needs.

A new integrated consumer needs assessment, treatment planning and resource-linking process to help consumers identify areas needing to be worked on, having a say in approaches to be used, and linking them with appropriate staff, consumers and information resources. Also, attention to exit planning and community supports.

The key recommendation is for the development of a "modular" group program structure which would provide for a range of program units or "modules" on specific mental health issues to be prepared and maintained on "standby", and for these elements to be "activated" when required for small groups of consumers with similar issues, depending on the actual configuration of needs present in consumers on the ward at any given time.

Thus if there are, for example, two or five consumers with drug and alcohol issues on the ward - or "voices" or depression issues - they would be able to work through activities in group program modules specifically activated for them, which would be tailored to the types of collective therapeutic and psychoeducational needs they may be experiencing. It is envisaged that there would also be built-in scope for individualised counseling and support. Naturally such a program would need to be sensitively applied on the ground, with careful consultation with consumers about how such programs may help meet some of their needs/ goals for recovery and offering choices.

Actvities could be adapted to allow them to be worked through by individuals, if a group process is not possible or appropriate. (It is acknowledged that a some psychiatric inpatient units have been experimenting with "modular" type program content for some time, and this is to be commended.

However the activities suggested here are somewhat different in that they are more particularly targeted to consumer high-need areas/ issues, they are "activated" according to needs present on a ward at any given time and would involve setting up a new assessment, treatment planning and resource linking process.)

The proposed "modular" approach to programs would allow "clustering" of therapeutic treatments for particular consumers and take advantage of potential synergies in group learning and peer support which are possible with groups of consumers who share similar issues.

A guiding principle and rationale for a new consumer-needs targeted "modular" approach to ward programs.

This proposed model is based on a key principle being increasingly articulated by consumers that clinical service systems and methods which fail to provide specific opportunities for consumers to pro-actively work toward their recovery - rather than being passive recipients of medication - are inherently dispempowering.

The over-arching rationale for our suggested approaches is that because patients these days have quite short hospital stays and are presenting with very serious mental health problems/ needs, this indicates a need for urgent, intensive and targeted group and/ or individual therapeutic interventions, to address needs consumers are presenting with and assist and empower them to cope with and better address their issues when they return to their lives in the community.

These suggestions are based on first-hand experience of mental health services since 1980 and speaking to literally hundreds of consumers both informally and in formal consultation/ developmental roles for more than a decade. It also draws on established consumer knowledge in a number of areas.

It is envisaged that the "modular" program units could be prepared as activity "packages" that could be run by staff fairly interchangably, but would most desirably be overseen and/or operated by staff with "portfolios" of developed expertise in specific areas.

This would naturally have implications for the service's recruitment and training activities, which could be factored in over time. It is acknowledge that there are quite a number of staff who have already undertaken extra training in a number of consumer high-needs areas, but the problem has been twofold:

Firstly, it is acknowledged that there are a number of practical constraints and barriers systemically, due to lack of resources, staffing levels and rostering problems - which tend to gravitate against consumers with particular needs as "a matter of course" being matched up with staff with skills in those areas; and secondly, in the absence of a co-ordinated and regulated system for matching up staff with special skills with particular special consumer needs, this currently happening on a largely ad hoc basis.

There would be a need for an enhanced assessment and treatment planning processes, which would seek to match a consumer's needs with the appropriate staff, fellow-consumers and other resources, within a co-ordinated framework.

Key areas of special expertise for staff "portfolios" we consider necessary to meet needs many consumers are presenting with include:

Drug and alcohol issues, including appropriate psychosocial contextual and harm minimisation work; dealing with post traumatic stress problems related to sexual abuse/ assault; working through family of origin/ relationship/ parenting issues; anger management and other emotional problems; dealing with positive symptoms such as "voices"and thought disorders; countering depression through cognitive means and addressing causal issues; strategies for alleviating negative symptoms, particularly in longstanding consumers; and psychoeduation and linking to community support/ rehabilitation/ self-development/ pre-vocational resources, particularly for consumers relatively new to the system.

Of course other issues/ categories could be added and some categories merged, subject to further research, and in the implementation of a modular program system various different areas of therapeutic work mixed and matched as indicated as appropriate.

Such a program modules would need to be developed with the active collaboration of consumers, who could take part in workshops and group/ individual consultations aimed at developing programs which would effectively target specific areas of need. Consumer based research and innovative service models being developed elsewhere could also inform these processes.
Targeting some high-needs areas for consumers


We consider that there is strong evidence of high consumer needs in areas such as:

*  psychoeducation needs regarding particularly schizophrenia and bipolar disorder;

*  drug and alcohol issues;
*  information about rights and responsibilities in the mental heath system, including strategies to get the most benefit from services, complaints processes, and facts needed to negotiate personally appropriate treatment plans and modalities.
*  sexual post trauma and related problems;

*  grief and loss issues from life experiences;

*  extra attention needed for general health issues as a complication psychiatric illness;

*  recreation planning, overcoming access barriers and associated confidence building work with consumers, to facilitate some aspects of recovery through recreation including sport, planning and saving money for entertainment needs, and other forms of active and passive recreation. This could involve NAMHS staff with recreational interests of skills and/or external agencies such as Outdoors Inc; and,

*  family/ relationship/ parenting issues, which remain under-recognised and under-addressed in the system.

*  cross-cultural issues and information sharing with carers.

*  support and coping/ change strategies regarding social exclusion and isolation resulting from living on benefits, community stigma about mental illness, poor employment chances, social avoidance, barriers to accessing both generic and mental health services, sub-standard housing, alienation from families, loss of living skills and self esteem from longstanding illness and past institutionalisation. All of these areas could be addressed in supportive ways and appropriate linkages and referrals recommended, with full follow-up.

*  education and pre-vocational resource exploration and linkages (with full follow-up) including literacy and numeracy, and preparations for further education and training.

Some possible ways forward... (including low cost options.)

*  This document is put forward as a positive new direction for psychiatric inpatient units to adapt to their own local conditions. There is potential in this proposed framework to:

*  explore (and support/ amend/ qualify) the merits of the proposals,

*  highlight and try to solve the inevitable systemic barriers and constraints,

*  identify the "realtime" links to conditions within each service, such as official forms and consumer pathways and community support and assistance links,

*  identify and log inpatient unit skills posessed by staff, arising from special training and experience as well as working out implications for staff training requirements.

*  work up a step-by-step plan for developing a new program system including timelines, who-does-what action planning,
*  "workshopping" a process for researching, developing and implementing the proposed new "modular" program system.

IMPORTANT NOTE: It is intended that in any such a service development process, consumers would be involved in real and meaningful roles.
It is also possible - and we think both desirable and easily justifiable financially as a one-off, service quality improvement initiative - that an innovative grant to develop a "modular" and consumer needs-targeted program may be able to be applied for with the Department of Human Services in Victoria, and by relevant departments in other areas. However, in the event of special funding not being available, this should not prevent an attempt to develop and trial the new "modular" approach.
If this goes ahead as a project for program development, the tasks could be managed internally in a service, perhaps using a variety of human resources, knowledge resources from the best available information locally and overseas in relevant discipline areas (eg drug and alcohol, sexual assault counselling, ethnic community agencies etc) together with active input from consumers, who would also play a (co-) facilitational role in various consultative processes.

It would also be good to utilise in program development along these lines, the services of some of the Occupational Therapy, Social Work, Nursing and Psychology students who are working out work training placements on a ward. The project may also be of interest as a research project to post-graduate students in a relevant discipline. There are many possibilities for research, consultation, development and implementation.

The remainder of this document contains Section 2, ahead of another two sections to be developed in the future in the event that a likely takeup of the approach is signalled.

Section 2 deals with consumers' perceptions about the benefits of pro-active ward programs in terms of their recovery and what they said were marked therapeutic benefits of ward programs.

Section 3 makes suggestions for change and development aimed at increasing the amount and effectiveness of programs offered and enhancing the way programs are structured, to better tailor programs to consumers' individual issues. (Being developed, to be released later)

Section 4 gives some consideration to the barriers and constraints which tend to gravitate against effective programs, including perceived lack of resources and the dominance of medication and the medical model. Some possible solutions to these barriers and constraints are also put forward. (Being developed. To be released later.)

Section 5 examines some of the problems regarding ward programs that consumers have raised, including what is often a scarcity of structured programs or group work at times, and a perceived lack of relevance and depth in any programs. (Being developed, to be released later.)


Section 2: Advantages of therapeutic group programs as expressed by consumers

Consumers say therapeutic group programs - as experienced in some recent stays and as experienced over a considerable period within the psychiatric inpatient system in the past - can be demonstrated to be particularly helpful because they:

*  can help address and give opportunities to actively work on issues believed to have contributed to their hospital admission. This was seen as both helpful and encouraging.

*  lead to a more positive and pro-active ward environment, with better health outcomes for consumers, and less crisis management for staff, who will also have more interesting and rewarding work roles.

*  provide opportunities to get support from staff and fellow consumers, and to participate in peer support and thus help themselves through helping others.

*  enhance consumer knowledge and understanding of their conditions and treatment and develop an improved knowledge base, which would enable them to have more of a say in the development of their treatment plans, both on the ward and during treatment in the community. (ie, case management, GP shared care or private psychiatrist.)

*  educate consumers about their rights and responsibilities in the mental health system, encourage feedback about treatment and services and "nip in the bud" problems regarding their conditions and treatment before they grow too overwhelming.

*  relieve some of the powerlessness that goes with "swimming in problems" during a hospital stay, which can happen due to (varying levels, depending on staff and resources, of) lack of structured activities and the resulting boredom, frustration and acting-out that can result.

*  enhance a consumer's legal rights position, eg becoming "voluntary" or to be able to demonstrate that they can comply with treatment and do not need to be put on a CTO. Without the opportunity to work toward recovery, a consumer is greatly limited in having ways of demonstrating such signs of progress.

*  provide opportunities to share experiences and learn knowledge of other consumer's coping strategies and learn staff suggestions for self-help etc.

*  encourage a pro-active approach to treatment, rather than passive receiving of medication which consumers say leaves out some underlying causal factors of psychiatric illness and disability and consequently some needs remain unaddressed during hospital stays.

*  help build a culture and platform for peer support among consumers.
help make treatment more holistic taking into account aetiology and social factors, not just medical model, which consumers say is too narrow and disempowering and tends to rob them of initiative, beyond "take your medication."

Many consumers believe that there are many other answers apart from medication, but system tends to under-emphasise other approaches. Changes in the system, as part of the processes called "mainstreaming" have tended to add emphasis to the medical model and a moving away from inpatient group therapeutic programs.

Draft only version. May 1999.

Report prepared by Allan Pinches, Consumer Consultant for Mental Health

(With conceptual modelling and additional research by Sue Robertson, BA, (Monash.)

There is a great deal more material under development regarding this model and Allan Pinches and his associates are available to discuss further how we may assist in developing approaches to implementing a "modular" program structure in a psychiatric inpatient unit, or adapt the concept for a psychosocial rehabilitation service.
Allan Pinches,
Consumer Consultant for Mental Health
Bachelor of Arts in Community Development (VU)