by Kamna Handa, MD; Jeffery Grace, MD; Eileen Trigoboff, RN, DNS; Josie L. Olympia, MD; Diane Annalett, MD; Thomas Watson, RN, MSN; Mon C. Poulose, MD; Tufail Muzaffar, MD; Frank L. Noyes, PhD; Anne Kabatt, LCSW-R; Sharon Cushman, LCSW-R; Maryann Antonelli, LCSW-R; Ginger Baxter-Banks, MSW; and David Newcomer, BA

Drs. Handa, Grace, Trigoboff, Olympia, Annalett, Poulose, Muzaffar, and Mr. Watson are from Buffalo Psychiatric Center in Buffalo, New York; Drs. Grace, Trigoboff, and Olympia are also with the State University of New York at Buffalo; and Dr. Noyes, Ms. Kabatt, Ms. Cushman, Ms. Antonelli, Ms. Banks, and Mr. Newcomer are from Northwest Community Mental Health Center, Buffalo, New York

Psychiatry (Edgemont) 2009;6(4):32–36

Funding

There was no funding for the interviews, development, and writing of this article.

Financial disclosure

The authors report no relevant conflicts of interest or commercial ties with respect to this material.

Abstract

Continuing day treatment programs focus on community stabilization through comprehensive individualized rehabilitation. They promote recovery through a variety of practical clinical therapeutic interventions. This empirically based report describes a continuing day treatment program’s rehabilitation of four clients with schizophrenia, chronic type in a western New York mental health clinic who were in each of the specialty services: a two-phase program, a program for seniors, and a program for co-occurring substance dependence. Some particularly difficult psychiatric symptoms of schizophrenia were successfully treated in this continuing day treatment program. Each of these clients showed improvements in their symptoms and overall community adjustment that may well have been unobtainable with less intensive outpatient treatment.

Key Words

continuing day treatment, chronic schizophrenia, healthcare economics, recovery
outpatient treatment

Introduction

Continuing day treatment (CDT) programs focus on community stabilization through comprehensive individualized rehabilitation and provide a unique level of care. CDT programs promote recovery through a variety of practical clinical therapeutic interventions. They are designed to “maintain or enhance current levels of functioning and skills, to maintain community living, and develop self awareness and self esteem through the exploration and development of strengths and interests.”[1] CDT programs assist those with schizophrenia to acquire skills, including improved engagement and reduced hospital recidivism.[2]

The New Freedom Commission on Mental Health has a vision of recovery “when everyone with a mental illness will recover…with essentials for living, working, learning, and participating fully in the community.”[3] Harding’s definition of recovery describes people taking medications and having some symptoms while regaining meaning and purpose after the catastrophic events of mental illness.[4,5]

Characterizations from some grass-roots efforts define recovery not as a cure, but as a process and an attitude, a stance, a way of approaching the day’s challenges. Recovery is one of development and change, accepting adverse impacts, having a sense of involvement and control over one’s life, cultivating hope, and using supports. A vital feature includes clients seeing themselves as capable of recovery despite the nonlinear nature of the path of recovery.[6,7] Collaborating in solution-focused work and active treatments with informal caregivers and professionals is the antithesis of the passive recipient of professional interventions.

CDT program curriculum

CDT program curriculum comprise the full spectrum of therapeutic interventions, are client-centered, and benefit individuals with varying backgrounds, illness severity, and cultures. Herz et al[8] reported that controlled studies have shown this curriculum is effective in the care and treatment of clients with acute schizophrenia, particularly in decreasing rehospitalizations and preserving social role functioning. The Oka et al[9] study compared this curriculum to outpatient treatment for clients with schizophrenia at four facilities over six months. The study demonstrated that clients with schizophrenia were treated more effectively with improved psychiatric symptomatology in a CDT program. Thirteen percent of the outpatients were readmitted due to symptom exacerbation; whereas, all the CDT clients remained in the community. Yoshimasu et al[10] examined the efficacy of this type of curriculum on readmission to inpatient psychiatric treatment. The impact of CDT on preventing or delaying readmission for schizophrenic outpatients was significant for the two years following inpatient treatment.

This article describes a CDT program’s rehabilitation of four clients with chronic schizophrenia in a western New York mental health clinic. This program offers strategies facilitating recovery for those with schizophrenia through an emphasis on team approaches, relationship building, repetition, and positive regard.

This CDT program has specialty services for adults with schizophrenia: a two-phase program, a program for seniors, and a program for co-occurring substance dependence. The CDT Phase I is an intensive program with a major focus on behaviors, symptoms, and interpersonal skills. Therapeutic groups and individual counseling, in addition to other therapeutic activities, are offered. These groups are geared toward basic issues, such as personal hygiene, understanding medication, physical activities, and exercise. The CDT Phase II is a less intensive program offering core services. It is designed to provide a daily structured environment and emphasizes interpersonal relationships and leisure skills development. The seniors program makes special efforts to assess cognitive and physicial abilities for aging clients and designs treatment accordingly. The fully integrated substance abuse treatment program is for people who have co-occurring substance use disorders. The CDT program has interdisciplinary teams that include rehabilitation counselors, social workers, psychiatrists, and nurses.

Typical CDT referrals are people who have not been successful in other outpatient settings. This includes those individuals who cannot remain sufficiently stable to avoid hospitalization or cannot remain in a community setting with a less intensive level of care (i.e., outpatient clinic treatment). This CDT program provides additional structure and breadth of services for these clients.

Clients and staff meet to evaluate the client’s difficulties and strengths initially and work toward agreed-upon goals in a formal treatment review process every three months. The following parameters guide the evaluation and drive what is incorporated into the treatment plan’s relevant goals and methods: psychiatric symptoms; hospitalization; living arrangements; finances; social network and relationships; substance abuse; attendance, participation, and engagement in treatment; leisure time; work activities; activities of daily living; physical health; antisocial behaviors; and medication management. The evaluation rates performance and the presence of symptoms from absent to extreme.

CDT program interventions are individualized and built on abilities and needs. They emphasize daily client input and program component adjustments. The client’s environment, as well as barriers to improvements and recovery, are evaluated on an ongoing basis. The CDT program consists of partnerships in goal planning, symptom management, group meetings, cognitive skills training, personal fitness, stress management and relaxation, nutritional skills, community awareness, social skills, music therapy, and medication management. CDT capitalizes on community emphasis with regular excursions, weekly psychiatric appointments, and home visits to review the situation in the client’s environment. CDT programs are designed to mimic the demands of family life, employment, leisure management, and community living so that learning with repetition and support is accomplished in a safe environment.

The medication management module includes a supervised self-administration medication program. The client’s medications are discussed to enhance understanding of how and why daily medications are necessary. Concerns about medications are discussed with the clients and involvement is encouraged. An important component is the opportunity to develop insight into the benefits of medication. Taking medication is routinized through rehearsal of how medications are part of everyday activities. This is a vital service for clients whose high levels of medication nonadherence typically raise their risk of symptom exacerbation or relapse requiring inpatient treatment. In situations when clients cannot remain consistent in managing their medications, staff explore with the client the useful, helpful, and beneficial impacts of medications. Modeling and training are an integral part of this module. There is also access to pro re nata (PRN) or as-needed oral medications, a feature not typically available in other outpatient treatment settings.

This CDT program has current low rehospitalization rates ranging from 0 to 7 percent in the various programs.[11] The positive impact that CDT programs have on healthcare economics is demonstrated by reduced recidivism to inpatient care. In addition, clients have the successful experience of remaining in the community with an enhanced quality of life and sense of accomplishment and competence. The recovery process is continuous, and clients are expected to be in CDT programs for long periods of time.

The staff-to-client ratio in CDT programs is responsive to each client’s level of symptomatology. The ratio is highest (1:7) with individuals who have just started in the program and for those who have symptom exacerbations. As symptom levels decrease over time, the phased transitions within CDT programs varies with decreased staff-client ratios (1:10) in the less intensive phase and in the seniors program.

Therapeutic interventions in this CDT program leading to recovery are exemplified in the following four case summaries. These clients had schizophrenia and benefited from the CDT program. Each client signed a release and informed consent for his or her case to be reviewed and to be interviewed for this publication.

CASE SUMMARIES

Case 1. Mr. X was a 19-year-old, single, African-American man with schizophrenia, paranoid type, chronic. He had a history of multiple hospitalizations since age 14 with an extensive history of learning and behavioral problems despite average intelligence. Mr. X had difficulty integrating into the community with symptoms of bizarre behavior, auditory hallucinations, social withdrawal, agitation, paranoia, and delusional thinking leading to nine psychiatric hospitalizations.

Mr. X was referred from a children’s CDT to this adult CDT when he was 18 years old. Initial assessment and development of his treatment plan incorporated his needs and assets with a recovery-oriented focus. For example, Mr. X would not talk to people and would steal food from any source. Staff addressed this by redirecting his attention to interacting with others. Individual attention and a therapeutic alliance fostered his improvement. Furthermore, his counselor had daily sessions with Mr. X to teach and promote more socially appropriate interactions through modeling and mentoring. Mr. X’s mother was also engaged in this process to direct his continued use of new skills at home. Mr. X rehearsed these skills during his interactions in the CDT program, an option not available in outpatient treatment settings.

Mr. X’s CDT program consisted of daily morning assessments, individual and group counseling, and structured activities to redirect his impulsive behavior. Repetitive redirection eventually allowed more appropriate responses and he did not require hospitalization. He had control of his most disabling psychotic symptoms with the assistance of intramuscular decanoate antipsychotic medication and routine oral and PRN medication. The supportive structure of CDT seemed to facilitate Mr. X’s ability to focus and interact with others without defensiveness or anger. He also had an improved relationship with his mother and increased participation in social and recreational activities.

Case 2. Mr. Y, a 51-year-old single, Caucasian man with schizophrenia, paranoid type, chronic had an extensive history with multiple hospitalizations since the age of 19. Mr. Y spent most of his adult life in psychiatric hospitals. Typically at admission, the client would report hearing voices and describe paranoid delusions. Other symptoms included acute agitation, low tolerance for stress that led to yelling and demanding, self-destructive behavior, impulsiveness, assaults, and physically and verbally threatening behavior. He had poor involvement in aftercare, and made suicide attempts.

Following one hospitalization lasting five years, Mr. Y received outpatient psychiatric treatment and lived in a group home. Despite taking his medication consistently, he continued to need short-term hospitalizations for psychotic and threatening behavior. He attended a partial hospitalization program but his inability to function, even at a low level, necessitated referral to the CDT program for more structured care.

Mr. Y was treated at the CDT for more than a year. Initially, Mr. Y was unwilling to involve himself in activities, and his plan of care included continuous encouragement for participation. Mr. Y was troubled by inappropriate and incoherent speech and could not express his needs. In this CDT program, treatment staff engaged him vigorously and often provided shaping and normalizing interactions with others. Mr. Y always wanted contact and individualized attention from people. The staff would respond to Mr. Y’s inappropriate and incoherent speech by reassuring and focusing on Mr. Y’s expressed needs.

As part of the program, Mr. Y was educated on the positive impact of medication adherence and, through this education and staff support, he started to actively participate in taking his medications. As his social skills improved, Mr. Y was able to live in a supervised residence. The counselor maintained regular interaction with staff at his residence to track his progress and difficulties. Mr. Y demonstrated better stress management skills and fewer angry outbursts while participating in the CDT program.

Case 3. Mr. Z was a 67-year-old, single, Caucasian man with schizophrenia (paranoid type, chronic) diagnosed at age 19. He had multiple hospitalizations lasting between 1 and 3 years. Mr. Z lived in a supervised residence (for 10 years) before he lived in a more independent living situation.

When Mr. Z began attending the CDT program, he required supervision in all areas of daily living. His behavior was agitated, volatile, and bizarre. He alienated others by his constant, very rapid, and often loud speech. He frequently showered others with saliva when talking. Sudden violent verbal outbursts when disagreed with strikingly interfered with Mr. Z’s social interactions. Most of his conversations centered around old movie stars and jobs he’s held over the years. When talking with others, Mr. Z did not pause to let others speak and became very angry when he was interrupted. He was often impulsive. At times Mr. Z saw himself as a gentleman of traditional values. He kissed women’s hands and became indignant if a man swore in front of a woman. He had, on occasion, dressed as a bus driver, cinema characters, and stated he was a superhero.

Mr. Z moved among the various levels of care available during the 32 years he was with the CDT program, which, for him, included the more intensive program, the less intensive program, and the seniors program. During his involvement with CDT, Mr. Z made incremental, yet steady, improvements in personal hygiene, acting-out behaviors, and budgeting his money. The most important interventions addressed both his psychiatric symptoms and his medical problems. Mr. Z smoked 3 to 4 packs of cigarettes a day and had asthma, congestive obstructive pulmonary disease, and multiple episodes of pneumonia. The physical supports in the CDT program were daily spirometry, encouragement for decreased cigarette smoking, and breathing mindfulness. Mr. Z made improvements in physical health while in the program smoking fewer cigarettes and having fewer breathing problems. He made strides in his interpersonal interactions as well, and went from being continually loud and distrusting to having longer periods of calm and a willingness to participate in discussions and activities without explosive responses to interruptions. He began to accept responsibilities and more consistently took his medication. Mr. Z had only one hospitalization during 32 years he was in the program and had no inpatient care for 27 years.

The CDT program included a structured environment, encouraged interpersonal relationships and reality-based discussions, and assisted with medication management. Mr. Z’s ongoing care was as it would be with any chronic physical illness, such as hypertension, where the maintenance of health involved medication, symptom management, and a relationship with healthcare providers. Mr. Z needed this level of care to maintain his present level of functioning.

Case 4. The final case report is of a client in the treatment program for people with co-occurring disorders: schizophrenia and chemical dependency. This program provided a combination of CDT services, residential services, and substance abuse services. The major goal of this program was to promote recovery. This individual case highlights the use of the substance abuse program.
Ms. L was a 51-year-old, single, African-American woman with profound symptoms of schizophrenia (paranoid type, chronic) and polysubstance dependence. She had 19 psychiatric hospitalizations beginning at age 16 as well as numerous drug rehabilitation program stays. Her substances of abuse included cocaine and alcohol.

Ms. L had symptoms of paranoia, auditory hallucinations, and active responses to them as well as loud and volatile behavior, which had escalated to verbal and physical assaults. She had virtually no ability to relate to others in a civilized manner. For example, when Ms. L was an adolescent, her reported assaultive behaviors toward her family members prompted the client’s removal from the house and subsequent placement into foster care. Ms. L continued to have persistent delusions about being rich from winning the lottery as well as owning a football team.

Ms. L was enrolled in the CDT program for years prior to beginning the CDT program for substance abuse in 2001. Since 2001, she was consistent with the CDT program for substance abuse except for two brief psychiatric nonchemical use admissions precipitated by family crises (20-day and 27-day admissions). With the exception of these two hospitalizations, Ms. L did not require hospitalization during the 13 years of her involvement in the regular CDT program and the CDT program for substance abuse.

While in the program, Ms. L had an individualized treatment plan that accentuated development of alternative activities to drug-seeking behaviors and coping skills to manage her emotional volatility when frustrated. She agreed to random drug screens. Escalation of family arguments were minimized and managed with family involvement in paced contacts. Programmatic discussions on anticipating consequences of her behavior redirected Ms. L’s typical dysfunctional style into a more favorable pattern. Throughout Ms. L’s treatment, her psychiatric symptoms were controlled with intramuscular antipsychotic medication.

The program partnered with Ms. L to facilitate her current living situation with her mother, which would not have been possible previously. If she experienced difficulties, Ms. L had access to peer and staff support from the chemical-dependency program 24 hours a day. This CDT chemical-dependency program provided focused substance abuse treatment plus recovery features.

Over the years Ms. L was in the program, she showed improvement in psychiatric symptoms, partnered with medication adherence and improved social network, and showed a reduction in her substance-abuse problem. Ms. L was drug free for more than one year. She also showed improvement in her community living skills.

Discussion

The conclusion reached in this empirically based report is that other outpatient settings may not be equipped to manage these clients’ everyday behaviors. Therefore, such clients may fail treatment, resulting in worsening symptoms and psychiatric hospitalization. Subsequent negative consequences include decreased client quality of life and increased cost to the healthcare system. For these reasons, it is recommended that qualitative and quantitative research be conducted on the contributions CDT makes to patient recovery in order to more fully understand its impact.

The effectiveness of this model can be seen in the low psychiatric hospitalization/rehospitalization rates.[11] This can be accounted for by a rapid response to clients’ decreased functioning and symptom exacerbation in order to maintain clinical achievements. The ongoing assessment of functioning in a CDT program detects these vicissitudes and readily adapts treatment. The clients’ needs propel the structure of their treatment.

Additional indicators of effective care are the clients’ behavioral commitment to and partnering with the treatment process, decreased use or abstinence from substances, decreased criminal justice system involvement, stabilized living situations, and primary care linkages.

These cases illustrate how some particularly difficult psychiatric symptoms of schizophrenia can be successfully treated in this CDT program. Each of the clients described in this article showed improvements in their symptoms and overall community adjustment that may well have been unobtainable with less intensive outpatient treatment. Participation in CDT programs led to an overall increase in these clients’ quality of life and lowered treatment costs compared with inpatient treatment. Clients with schizophrenia exhibit a complex interplay of multidomain psychiatric and substance-abuse symptoms and issues, and as demonstrated in these four cases, complicated symptoms may be best addressed comprehensively in the intensive outpatient treatment offered by the CDT model.

References
1. Office of Mental Health regulations www.omh.state.ny.us/omhweb/policy_and_regulations/587ft_7-04.htm. Accessed 1/9/09.
2. American Psychiatric Association. Practice Guidelines for the Treatment of Psychiatric Disorders. Washington, DC: American Psychiatric Press Inc., 2006.
3. New Freedom Commission on Mental Health. www.mentalhealthcommission.gov/reports/Finalreport/FullReport.htm. Accessed 1/9/09.
4. Harding C. The Vermont Longitudinal Study of Persons with Mental Illness. Part 1. Am J Psychiatry. 1987;144:718–726.
5. Harding C. The Vermont Study of Persons with Mental Illness. Part 2. Am J Psychiatry. 1987;144:727–735.
6. Rethink Recovery www.rethink.org/living_with_mental_illness/recovery_and_self_management/recovery. Accessed 1/9/09.
7. Deegan, P. Recovery as a journey of the heart. Psychiatr Rehab J. 1996;19(3):91–97.
8. Herz MI, Liberman RP, McGlashan TH, et al. Practice guideline for the treatment of patients with schizophrenia. Am J Psychiatry. 1997;154(Suppl):32–34.
9. Oka K, Maeda M, HiranoT, et al. Multicenter study on the effects of daycare therapy on schizophrenia: a comparison of daycare patients with outpatients. Psychiatry Clin Neurosci. 1999;53:505–510.
10. Yoshimasu K, Kiyohara C, Ohkuma K. Efficacy of day care treatment against readmission in patients with schizophrenia: A comparison between outpatients with and without day care treatment. Psychiatry Clin Neurosci. 2002;56:397–401.
11. Northwest Community Mental Health Center. Annual Report. Program Evaluation, Part 1of 8. 2007.