Original Research
Client and Community Services Satisfaction With an Assertive Community Treatment Subprogram for Inner-City Clients in Edmonton, Alberta Pierre Chue, MBBCh, FRCPC1, Philip Tibbo, MD, FRCPC2, Evelyn Wright, BScN, MS3, Jelle Van Ens, BA, BSW4 Objectives: To evaluate client and agency satisfaction with a specific assertive community treatment subprogram, known as inner-city support, developed in Edmonton to target the inner-city population, and to determine the demographics and potential needs of this population. Method: Clients were administered questionnaires based on the Client Satisfaction Questionnaire and the Satisfaction With Life Scale. We also conducted a face-to-face interview. We contacted and similarly surveyed 18 community agencies. Results: The program was well received, although areas for improvements included dissemination of information and hours of operation. Clients also requested more input regarding the development of activities. Clients were predominantly male with a diagnosis of schizophrenia comorbid with substance abuse and antisocial personality disorders, a history of forensic contact, homeless, and dependent on social assistance. Conclusion: Among the population with serious and persistent mental illness, inner-city clients represent a particularly disadvantaged subpopulation that may benefit from specialized community programs. (Can J Psychiatry 2004;49:621–624) Information on author affiliations appears at the end of the article. Clinical Implications · Inner-city populations may benefit from specific programs within the context of community mental health services. · Such programs may be cost-effective. · Inner-city clients have an interest in their health care services. Limitations · There was no control group. · Quality of life changes before and after enrolment in inner-city support (ICS) were not examined. · There were no data on psychiatric contacts during or after ICS.
Key Words: assertive community treatment, community psychiatry, inner city, serious and persistent mental illness he components of assertive community treatment (ACT) and its application to different populations have been well described (1–5). However, homeless clients suffering from serious and persistent mental illness (SPMI) represent a particularly difficult population: even within an ACT model, it remains difficult to engage such clients and to provide a treat-
T
Can J Psychiatry, Vol 49, No 9, September 2004 W
ment milieu that is both attractive and sufficiently flexible to respond to their particular needs (6–12). Inner-city support (ICS), a specific subprogram of the existing ACT program, was developed in Edmonton, Alberta, as a unique resource for individuals with SPMI who live and (or) spend their time in the inner city. Outcome data from the existing ACT program 621
The Canadian Journal of Psychiatry—Original Research
have been previously presented (13,14). However, ICS lacked formal evaluation, and we therefore conducted a survey of client and agency satisfaction. The ICS therapists are based in the Boyle Street Community Services Cooperative, one of the inner-city cooperatives that provides a broad range of social services for inner-city residents. The Co-op is not specific to those with mental illness; it operates on a drop-in basis and does not require formal referral. The therapists attempt to engage clients and encourage their participation in program activities. They monitor clients’ mental states; provide health teaching and support in accessing appropriate psychiatric and medical care; and offer practical assistance in the areas of housing, finances, and nutrition. Clients are encouraged to develop their abilities through recreational activities and through individual and group projects where they can earn money, interact socially, and learn a skill.
Methods During 1997, we formulated and distributed satisfaction surveys to ICS clients and to inner-city agencies. We also conducted face-to-face interviews. The client satisfaction surveys included several measures. The first was the Client Satisfaction Questionnaire (CSQ 8), a self-report measure with 8 items rated on 4-point Likert scale. Added to it were an additional Likert-type question and open-ended questions regarding specific service components and potential for improvement (15). The second measure was the Satisfaction With Life Scale (SWLS), a self-report measure with 5 items rated on 7-point Likert scale (16). The third measure was a Satisfaction Interview Survey (SIS), a face-to-face interview comprising 9 questions with responses ranked from “very dissatisfied” to “excellent,” as well as 6 open-ended questions. The agency SIS was similar to the client SIS, with 9 ranked questions and 4 open-ended questions.
Results Of 30 ICS clients, 22 completed the survey (2 female and 20 male; 73% response rate), 5 declined, and 3 were unable to complete the questions. Of the respondents, 92% were male; 70% received social assistance or disability support; 5% had no income; 68% were aged 18 to 44 years; 21% were aged 45 to 64 years; 74% were single, separated, or divorced; 68% were non-Aboriginal; and 46% had completed high school. Schizophrenia was the primary diagnosis in 36%, antisocial personality disorder in 27%, and substance abuse disorders in 18%; 41% had either a previous or current forensic history. Although not living on the street, 23% resided in downtown emergency drop-in hostels where beds are not kept each day, while 77% lived transiently in inner-city group homes run by various agencies. 622
According to responses on the CSQ 8, 73% of the clients were satisfied with the support received; 77% would recommend ICS to a friend; and 82% would return to the program, even though 41% felt they were not getting the support they desired. The mean total CSQ 8 score was 23.5 out of a possible 32 (representing 73.3% satisfaction among all respondents across items). This result is comparable to the mean score of 24.16 obtained in a sample of 96 psychotherapy patients (15). Four clients who attended the program almost daily rated themselves as “very involved” in program development, in contrast to clients who attended less often. Areas of satisfaction included socialization with others, having something to do, receiving help, and being able to learn job skills and (or) upgrade education. Areas of dissatisfaction included a shortage of equipment, lack of space, limited hours of operation, and interpersonal conflicts among clients. The mean SWLS score was 14.27 out of a possible 35, compared with a mean score of 23.5 for a sample of 106 university graduates and 25.8 for a sample of 53 elderly persons (16). While ICS clients were not satisfied with their lives (mean scores were < 3.5 out of a possible 7 on each question of the SWLS), 27% would not change anything if they had to live their lives over. We contacted 24 community agencies, and 18 agreed to complete the agency SIS and face-to-face interview (giving a 75% response rate). These agencies included social service agencies, men’s and women’s shelters, forensic services, a community mental health clinic, staffed inner-city residences, and nonstaffed inner-city agencies. There were no distinguishing characteristics for the agencies that declined to respond. Overall, agencies were 72% satisfied with ICS; satisfaction was highest among social services agencies (77%) and the mental health clinic (82%). From the open-ended questions, ICS was seen to respond to a real gap in service by promoting community integration and client self-sufficiency through a broad range of tailored activities. Overall dissatisfaction was highest among inner-city shelters (33%). Areas of dissatisfaction included inadequate resources, inconsistent communication with referring agencies, hours of operation, and lack of information received about the program.
Discussion In Edmonton, the demographic profile of the ICS clients differed from the profile previously shown among ACT clients (13,14). Although the diagnosis of chronic paranoid schizophrenia was common to both, substance abuse disorders and antisocial personality disorders were more prevalent among the ICS clients. The group comprised predominantly isolated male clients who had a high rate of contact with forensic psychiatric services, who lived transiently in inner-city group homes, and who were thus effectively homeless. W Can J Psychiatry, Vol 49, No 9, September 2004
Client and Community Services Satisfaction With an Assertive Community Treatment Subprogram for Inner-City Clients
Most ACT outcome studies do not differentiate among different client subgroups. Nonetheless, it has been suggested that defined subgroups may be useful in refining programs to suit heterogeneous client needs and that the criteria distinguishing the subgroups may in fact be based upon nonmeasured variables such as preference for type of contact, especially for homeless clients (17–20). Perhaps even more so than with ACT, engagement is a key factor in working with this population. Program location and focus are thought to have a positive influence. Rapport is built very gradually with an experienced therapist who, over time, is able to gain clients’ trust and encourage rather than constrain involvement. This may be particularly important for these clients, who are often turned away from most agencies because of substance abuse issues or unacceptable social behaviours and eventually end up in the criminal justice or forensic psychiatric systems. The combination of psychiatric illness, homelessness, and substance abuse is particularly difficult to treat, even with an ACT approach (21). Although the input of clients, families, and agencies is important, they are generally overlooked when issues of organization and delivery of mental health care are raised, despite the often-strong preferences expressed (22–24). This study therefore specifically targeted clients and community agencies and combined existing satisfaction questionnaires with a face-to-face interview. In this population, real difficulties exist in determining what constitutes a successful community program and in evaluating the “community ability” of the clients involved, given their low functioning levels and the limited frequency of contact (25–27). Despite the difficulties, it remains important to evaluate and develop community programs to ensure that services are provided to those individuals who can most benefit from them. Overall, ICS was well received, although areas of improvement were highlighted. Clients wished to have more input in the development of their activities and to expand the range of possible activities. Studies suggest that getting clients involved in activities of their own choosing results in much greater satisfaction (28,29). This can be important, as ownership of the program can promote attendance. Learning practical skills appears particularly important for these clients and is consistent with the vocational approaches shown to be effective in the literature (30,31). Both clients and agencies felt it necessary to expand in terms of space, money, and staff. Both groups felt the program should run for longer hours than are presently offered. Weekends or holidays can be isolating for persons with mental illness who lack family or community supports. The agencies highlighted the need for effective and continuous dissemination of information about mental health programs. Can J Psychiatry, Vol 49, No 9, September 2004 W
In conclusion, a program such as ICS may enhance the delivery of mental health services to a target population difficult to locate, engage, and treat, even by ACT standards. Adherence to a mental health treatment program is a major hurdle in work with inner-city residents with SPMI. Client satisfaction with the program is a factor that can increase adherence and potentially improve outcome. Further, the success of any community program is likely also linked to the satisfaction of the partner community agencies (32). Despite the continuum of community mental health services that exists in many areas, it still remains easy for such disadvantaged individuals to fall through the cracks unless they are targeted with specific and comprehensive programs (33).
References 1. Stein LI, Test MA, Marks A. Alternative to the hospital: a controlled study. Am J Psychiatry 1975;132:517–22. 2. Stein LI, Test MA. Alternative to mental hospital treatment: I. Conceptual model, treatment program, and clinical evaluation. Arch Gen Psychiatry 1980;37:392–7. 3. Rapp CA. The active ingredients of effective case management: a research synthesis. In: Rapp CA, Manderscheid RW, Henderon MJ, Hodge M, Knisley MB, Peny DJ, and others, editors. Case management for behavioral managed care. Rockville (MD): Center for Mental Health Services (SAMHSA) and the National Association of Case Management; 1995. p 7– 45. 4. Mueser KT, Bond GR, Drake RE, Resnick SG. Models of community care for severe mental illness: a review of research on case management. Schizophr Bull 1998;24:37–74. 5. Lafave HG, de Souza HR, Gerber GJ. Assertive community treatment of severe mental illness: a Canadian experience. Psychiatr Serv 1994;47:667– 8. 6. Bebout RB, Harris M. In search of pumpkin shells: residential programming for the homeless mentally ill. In: Lamb HR, Bachrach LL, Kass FL, editors. Treating the homeless mentally ill. A Report of the Task Force on the Homeless Mentally Ill. Washington (DC): American Psychiatric Press; 1992. p 159– 81. 7. Caton CLM, Wyatt RJ, Felix A, Greenberg J, Dominquez B. Follow-up of chronically homeless mentally ill men. Am J Psychiatry 1993;150:1639– 42. 8. Centre for Mental Health Services. Making a difference: interim status report of the McKinney Research Demonstration Program for Homeless Mentally Ill Adults. Rockerik (MD): US Department of Health & Human Services; 1994. 9. Drake RE, Ostres FC, Wallach MA. Homelessness and dual diagnosis. Am Psychol 1996;46:1149–58. 10. Federal Task Force on Homelessness and Severe Mental Illness. Outcast on main street. Washington (DC): US Department of Health & Human Services; 1992. 11. Dixon LB, Krauss N, Kernan E, Lehman AF, DeForge BR. Modifying the PACT model to serve homeless persons with severe mental illnesss. Psychiatr Serv 1995;46:684–8. 12. Wasylenki DA, Goering PN, Lemire D, Lindsey D, Lancee W. The hostel outreach program: assertive case management for homeless mentally ill persons. Hosp Community Psychiatry 1993;44:848–53. 13. Tibbo P, Chue P, Wright E. Hospital outcome measures following assertive community treatment (ACT) in Edmonton, Alberta. Can J Psychiatry 1999;44:21–4. 14. Tibbo P, Joffe K, Chue P, Metelitsa A, Wright E. Global assessment of functioning following assertive community treatment in Edmonton, Alberta: a longitudinal study. Can J Psychiatry 2001;46:144–8. 15. Attkisson CC, Zwick R. The clients satisfaction questionnaire. Psychometric properties and correlation with service utilization and psychotherapy outcome. Evaluation Program Planning 1982;5:233–37. 16. Diener E, Emmons RA, Larsen RJ, Griffin S. The Satisfaction With Life Scale. J Personality Assessment 1985;49:71–75. 17. Lehman AF, Dixon LB, Kernan E, DeForge BR, Postrado LT. A randomized trial of assertive community treatment for persons with severe mental illness. Arch Gen Psychiatry 1997;54:1038–43. 18. Dietzen LL, Bond GR. Relationship between case manager contact and outcome for frequently hospitalized psychiatric clients. Hosp Community Psychiatry 1993;44:839–43. 19. Durbin J, Goering P, Wasylenki D, Roth J. Who gets how much of what: a description of intensive case management. Psychosocial Rehab J 1997;20:49–56. 20. McNary SW, Dixon LB, Lehman AF. Who you are may be what you get: defining subgroups by service use in programs for assertive community treatment. Presented at the 151st Annual Meeting of the American Psychiatric Association; 30 May–4 June 1998; Toronto (ON).
623
The Canadian Journal of Psychiatry—Original Research
21. Meisler N, Blankertz L, Santos AB, McKay C. Impact of assertive community treatment on homeless persons with co-occurring severe psychiatric and substance use disorders. Community Ment Health J 1997;33:113–22. 22. Goering P, Paduchak D, Durbin J. Housing homeless women: a consumer preference study. Hosp Community Psychiatry 1990;41:790–4. 23. Rosenheck R, Lam JA. Homeless mentally ill clients and providers perceptions of service needs and clients use of services. Psychiatr Serv 1997;48:381–6. 24. Tanzman B. An overview of surveys of mental health consumers’ preferences for housing and support services. Hosp Community Psychiatry 1993;44:450–5. 25. Brekke J, Test M. A model for measuring the implementation of community support programs; results from three sites. Community Ment Health J 1992;28:227–47. 26. Barker S, Barron N, McFarland B. A community ability scale for chronically mentally ill consumers. Part I. Reliability and validity. Community Ment Health J 1994;30:363–83. 27. Barker S, Barron N, McFarland B. A community ability scale for chronically mentally ill consumers. Part II. Applications. Community Ment Health J 1994;30:459–72. 28. Champney TF, Dzurec LC. Involvement in productive activities and satisfaction with living situation among severely mentally disabled adults. Hosp Community Psychiatry 1992;43:899–903. 29. Arns PG, Lonney JA. Work, self and life satisfaction for persons with severe and persistent mental disorders. Psychosocial Rehab J 1993;17:63–79. 30. Becker DR, Drake RE. Individual placement and support: a community mental health center approach to vocational rehabilitation. Community Ment Health J 1994;30:193–205.
31. Anthony WA, Blanch A. Supported employment for persons who are psychiatrically disabled: a historical and conceptual perspective. Psychosocial Rehab J 1987;11:5–23. 32. Katz LJ. Interagency collaboration in the rehabilitation of persons and psychiatric disabilities. J Voc Rehab 1991;1:45–57. 33. Stroul BA. Community support systems for persons and long term mental illness: a conceptual framework. Psychosocial Rehab J 1989;12:9–26.
Manuscript received May 2003, revised, and accepted January 2004. 1 Associate Clinical Professor, Department of Psychiatry, University of Alberta; Clinical Coordinating Psychiatrist, Community Living Program, Edmonton, Alberta. 2 Clinical Fellow, Alberta Heritage Foundation for Medical Research; Director, Postgraduate Training Program in Psychiatry, University of Alberta, Edmonton, Alberta. 3 Former Program Manager, Community Living Program, Edmonton, Alberta. 4 Social Worker, Inner City Support Program, Edmonton, Alberta. Address for correspondence: Dr P Chue, Community Living Program, 3rd Floor, 9942 - 108 Street, Edmonton, Alberta. e-mail:
[email protected]
Résumé : Satisfaction des clients et des services communautaires quant à un sous-programme de suivi intensif en équipe dans la communauté pour des clients du centre-ville d’Edmonton, Alberta Objectifs : Évaluer le taux de satisfaction des clients et d’un organisme quant à un sous-programme spécifique de suivi intensif en équipe dans la communauté intitulé soutien au centre-ville et élaboré à Edmonton pour cibler la population du centre-ville, et déterminer les données démographiques ainsi que les besoins éventuels de cette population. Méthode : Nous avons administré aux clients des questionnaires fondés sur le questionnaire de satisfaction des clients et l’échelle de satisfaction de vie, et avons également mené des entrevues en personne. Nous avons communiqué avec 18 organismes communautaires que nous avons interrogés de façon semblable. Résultats : Le programme a été bien reçu, même si les aspects à améliorer incluaient la diffusion de l’information et les heures d’ouverture. Les clients demandaient aussi d’avoir leur mot à dire dans l’élaboration des activités. Les clients étaient principalement des hommes sans abri, ayant un diagnostic de schizophrénie comorbide avec toxicomanie et troubles de la personnalité antisociale, des antécédents avec la médecine légale et dépendaient de l’aide sociale. Conclusion : Au sein de la population souffrant de maladie mentale grave et durable, les clients du centre-ville représentent une sous-population particulièrement désavantagée qui peut tirer avantage de programmes communautaires spécialisés.
624
W Can J Psychiatry, Vol 49, No 9, September 2004
