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This study explores the patient opinions about the helpfulness of the External Rehabilitative Activities (ERA) delivered in two residential facilities for psychiatric rehabilitation.
We administered a Questionnaire developed to assess general helpfulness, helpfulness of specific therapeutic processes and satisfaction with the ERA to a sample of 46 psychiatric patients participating in at least three external activities.
The External Rehabilitative Activities, tested by the ERA-Questionnaire, were considered helpful or very helpful by most of the patients. The therapeutic process with the highest score was “relaxation”, followed by “general helpfulness”, “socialization”, “knowledge of social context”, “community integration”. The least-valued process was “autonomy”.
This pilot study has shown that psychiatric patients consider ERA helpful and rate more helpful the specific therapeutic processes, such as relaxation and socialization, that assure symptomatic relief and interaction with the outside world.
An important effort of psychiatric rehabilitation programs is to counteract the negative social consequences of severe and persistent mental illness, such as exclusion, social isolation and stigmatizing experiences .
In a more comprehensive model of rehabilitation, alongside very structured treatment programs, psychiatric leisure rehabilitation can play an important role in impeding the process of desocialization . In fact, leisure or recreational activities, usually not associated with stressful expectations of success and facilitating socialization, help to enhance social relationships, community integration and, lastly, the quality of life of the psychiatric patients [2, 3].
In the community mental health services, many kinds of leisure or recreational activities are usually planned, including sports, arts, entertainment or several external rehabilitative activities usually consisting in day trips [2, 4].
In Italy, the closure of Mental hospitals caused a remarkable development of a widespread variety of Community services, including psychiatric rehabilitation facilities . Rehabilitation treatment(s) often include a program of External Rehabilitative Activities (ERA), which normally consist in day trips or walks to go to cultural shows, the cinema and eating out.
In light of the importance of the patients’ involvement in the evaluation of treatment and outcome , an interesting area of research explored patients’ views about the benefits of their psychiatric treatment [8-10]. In connection with this, a previous study carried out in our psychiatric rehabilitation residential unit examined patient opinions on the helpfulness of several planned treatment programs .
Given the need for a better understanding of this area, in this pilot study we aimed to explore the patient opinions about the helpfulness of the ERA delivered in two residential units for psychiatric rehabilitation.
Patients were recruited in two psychiatric inpatient(s) units, located in Ferrara, Northern Italy.
The first one, equipped with 16-beds, is part of the Unit of Clinical Psychiatry, University of Ferrara, and provides short to medium-term psychiatric rehabilitation treatment for acute or sub-acute severe psychiatric conditions. The second facility, equipped with 32-beds, is part of the Department of Mental Health in Ferrara, and provides long-term psychiatric rehabilitation treatment for chronic severe psychiatric conditions.
In both facilities treatment includes medication, individual psychological support, group psychotherapy and rehabilitative activities including ERA.
During a 14-month recruitment period (between November 1, 2008, and January 1, 2009) all psychiatric patients admitted to the residential facilities, with a stable psychopathological status permitting them to participate in the program of the ERA were screened for inclusion. Only patients participating in at least three external activities were included.
All patients were informed of the aims of the study and gave written consent to participate.
At admission, all the patients underwent a psychiatric interview for diagnosis according to the ICD-10 criteria. Sociodemographic and clinical data were also gathered.
In addition, the Global Assessment of Functioning (GAF), a widely used 100-point scale to rate the social, occupational and psychological functioning of adult psychiatric patients and the Spitzer Quality of Life Index (SQL-Index) , a general scale measuring five dimensions (activity, daily living, health, support of family and friends, and outlook on the quality of life) were administered by a trained psychiatrist (BB).
After they participated in the ERA, a researcher (FM), not belonging to the staff to minimize bias toward the ERA, asked patients to complete a self-administered 8-item Questionnaire. The Questionnaire, based on research findings by Rudnik  was developed through focus groups in our units. The sample of clinicians that participated in the focus groups was composed of different professional figures: four psychiatrists, four psychiatric nurses, two rehabilitation therapists and two social workers, that habitually participate in the external activities. The group generated a list of possible therapeutic processes involved in ERA. The first therapeutic process referred to the possibility that the ERA were helpful in improving relationships with others, and was called “socialization”. The second process, that we called “community integration”, referred to the possibility that the ERA were helpful in improving the degree to which an individual lives and participates in his/her community and interacts with neighbors. The third process, “knowledge of social context”, referred to the possibility that ERA were helpful in improving the degree of knowledge of the history and characteristics of his/her town and the place where the subjects lives. The fourth process, “relaxation”, referred to the possibility that the ERA were helpful in improving the degree of anxiety. The fifth process, “autonomy”, referred to the possibility that the ERA were helpful in improving the competencies to manage an independent life. The processes were transformed into specific questions, obtaining an 8-item Questionnaire (ERA-Q). Of the eight questions, six refer to the opinions on helpfulness of the ERA, such as general helpfulness (e.g. “Did carrying out activities outside of the facility seem helpful to me?”) and helpfulness of single processes of socialization, community integration knowledge of social context, relaxation and autonomy (e.g. “Did external activities help me to socialize with others?”), another one single item refers to general satisfaction and the last one refers to which specific external activities (i.e., cultural exhibitions, the cinema and eating out) were more helpful. The final ERA-Q was brief, easy and sufficiently flexible and aimed to rate the patient opinions on the helpfulness of specific processes and general satisfaction of the ERA on a 5-point Likert scale (from 0=”not at all” to 4=”very helpful”). We used Cronbach’s alpha coefficient to assess the internal consistency of the questionnaire, obtaining an alpha coefficient of 0.79.
The SAS-JMP 7 statistical software was used to describe the variables (descriptive analysis) and to examine the association between socio-demographic and clinical data with the instrument used (Spearman correlation, ANOVA).
During the study period, of the 56 patients screened for inclusion, 46 accepted to participate in the study.
There were 17 men (37%) and 29 women (63%), with 18 (38.2%) being less than 45 years of age and 28 (60.9%) 45 years or over. More than two-thirds lived alone (n=31, 67.4%) and nearly one-half of the patients had 8 years of education. Most patients were unemployed (n=38, 82.2%). Diagnosed according to ICD-10 criteria, nearly one-half of the patients suffered from schizophrenia and related psychosis (n=25, 54.3%), and one-third had affective disorders (n=14, 30.4%); personality disorders were diagnosed in 7 subjects (15%). The majority of patients had an age at illness onset between 25 to 35 years and a total numbers of psychiatric admissions between 5 to 10. With regard to the length of stay in the facilities, 19 patients (41%) stayed for less than 3 months and 21 (45%) for more than 1 year.
At study inclusion, the GAF total score was 54 (± 12.6), and the QL-Index total score was 4.9 (± 1.7).
The percentage of the patients’ responses to the single ERA-Q are presented in Fig. (11). The general satisfaction with the ERA-Q was high (mean score 3.1 ± 0.8). All specific processes tested by the ERA-Q were considered helpful or very helpful by most of the patients. The item with the highest score was “relaxation” (3.2 ± 0.6), followed by “general helpfulness” (3.1 ± 0.7), “socialization” (3.0±0.8), “knowledge of social context” (2.8±0.7), “community integration”(2.7±0.7), and “autonomy”(2.6 ± 0.8).
Table 11 reports the activities and their frequency of attendance. The type of activities considered more helpful was “eating out” (n=28, 60.9%), followed by “cultural shows” (n=10, 21.7%) and “the cinema” (n=8, 17.4%).
No association was found with sex, diagnoses, age at illness onset, length of stay in the units, and GAF, with the ERA-Q. The QL-Index, was significantly correlated with ERA-Q general satisfaction (p < 0.05).
Psychiatric leisure or recreational activities are widely planned in routine clinical practice and can play an important role in psychiatric rehabilitation with the aim of improving social relationships, community integration and reducing social isolation . However, there is a lack of studies in this area of research. To our knowledge, this is the first study setting out to investigate patients’ opinions on external rehabilitative activities.
The main finding was that the majority of patients rated the general helpfulness of the ERA as helpful. This result is consistent with those that emerged in other studies, reporting that free walking, free passes or trips, as forms of freedom, are considered very helpful in psychiatric care whereas restrictions and isolation are considered less helpful [8-11]. Moreover, the value accorded to external rehabilitative activities confirmed the importance of a community psychiatric care with few restrictions and much social interaction with the outside world [11, 13].
With regard to the helpfulness of specific therapeutic processes of external activities, relaxation and socialization were considered more helpful, whereas knowledge of social context, community integration and autonomy were considered less helpful.
A possible explanation for this might be that external activities (usually pleasant and relaxing walks that provide physical exercise, distraction and have a low stressful expectation) combine different therapeutical factors such as relaxation, distraction, physical exercise and pleasant activities, that documented a useful efficacy in the treatment of psychiatric disorders [14, 15].
The importance of socialization might be related to the problem of loneliness among severe mentally ill patients . Probably, the possibility to reduce the subjective experience of loneliness and their difficulty in making and keeping friends, might be more useful for psychiatric patients than just the knowledge of social context or community integration.
This study had some limitations. First, we cannot interpret the rating of helpfulness as a rating of efficacy, yet the use of a questionnaire can be an interesting way to recognize and describe the patients’ opinions and to increase patient involvement in planning therapeutic strategies. A second limitation regards the fact that the ERA-Q has not been validated and represents a first pilot instrument to assess external rehabilitative activities. A third issue has to do with the well-known problem inherent in all research on patient satisfaction. In fact, several biases may influence satisfaction measurement both in psychiatric and medically ill patients. The fear of prejudice from health care professionals in case of negative feedback, the feeling that the staff are really interested in satisfaction or the need to please them are some common variables influencing patients’ responses in satisfaction surveys [17-19]. Other limitations concern the small sample of patients participating in the study and the lack of a control group, both factors limiting the power of the findings.
This preliminary study has shown that psychiatric patients consider ERA helpful and rate more helpful the specific therapeutic processes, such as relaxation and socialization, that assure symptomatic relief and interaction with the outside world. More research is needed to better understand the psychometric properties of the questionnaire we used and its feasibility in other research settings. Future studies on the current topic are also recommended in order to understand which rehabilitative activities can be improved and which may be considered less helpful. This could also enhance our comprehension of the possible relationship between helpfulness and both efficacy of treatment and clinical outcome of psychopathological conditions.
The research group wishes to thank Alirra Grocke for her support in revising the English of the manuscript.