Health queues and waiting lists are a strain on the public and on health workers alike. The idea of a seminar for patients who are on a waiting list for treatment in the outpatient clinic emerged from a situation involving long waiting periods and a desire to do something actively for the patients who were waiting.
An experience from a visit to Madame Tussaud’s in London served as inspiration for taking a more active approach to the waiting lists. For the children, the time spent waiting to get in became the most memorable part of the visit to the wax museum, because somebody had given a thought to those having to queue for an hour, and had therefore engaged clowns and jugglers to provide entertainment.
Without extending the analogy too far, we now arrange seminars four times a year for patients who are on a waiting list for outpatient treatment at Jæren District Centre for Psychiatry. This arrangement requires relatively little in terms of resources, and appears to be well liked by the patients.
When planning the seminar, which we chose to refer to as an introduction seminar, we wished to use the waiting time in a way that was beneficial to the patients. We were not familiar with any similar models, and were therefore unable to draw on experience from elsewhere. Finally it was decided to arrange the introduction seminar over three days, from 12 noon to 3 p.m. over a period of two weeks. When we started in 2003, two seminars were arranged per year, but in 2009 the frequency was increased to four seminars annually.
The content of the seminar has three main components. First, the psycho-educative part, which consists of popularised lectures on general aspects of mental health. In recent years we have concentrated on three topics that recur in each seminar: the conditions and challenges of human life, the basis for a positive self-image, and group therapy – can it be done?
The second main element comprises a presentation of the various forms of treatment that our outpatient clinic offers (Box 1). The presentations emphasise group-based therapies, since these tend to be least well known to the audience and because we wish to encourage more people to make use of such services. Several studies indicate that group-based treatment is more resource-efficient, and that the effect of such treatment is equal to that of individual treatment. This applies to most of the disorders for which patients are referred to psychiatric outpatient clinics (1).
Overview of treatment programmes in the psychiatric outpatient clinic, Jæren DCP
Coping with anxiety, 8 sessions
Coping with depression, 10 sessions
Self-confidence training group, 10 sessions
Active everyday life, cooperation with NLWA
Group-based outpatient clinic, 3 days per week over 4 months
Coping with pain, 8 sessions
The third component is a practical exercise, for which the patients are assigned to groups during the last half hour of every seminar day. The groups are led by nurses who have experience of group work. The participants can ask questions or talk about their expectations, and thereby gain some experience in group participation.
The staff of the clinic is responsible for all professional and practical aspects of the introduction seminars. On the first seminar day, each participant receives a folder with written material describing relevant treatment alternatives and other practical information. Each seminar day is registered and billed as an outpatient consultation. After each seminar, the participants fill in an anonymous evaluation form.
All the seminars have followed the structure described above, but some minor adjustments have been made. One key change was to leave the provision of information on one of the group-based treatment programmes to a former patient who has completed the programme.
Immediately after the introduction seminars, all participants have an exploratory conversation with a doctor or a psychologist at the clinic. The conversations are recorded in the patient’s journal, further treatment plans are discussed with the patient and a preliminary conclusion regarding diagnosis and choice of therapy is made.
The outpatient clinic at Jæren District Centre for Psychiatry is a specialist health service for adults over 18, with a catchment area of 60 500 inhabitants. During the last four years, the outpatient clinic has received 607 referrals per year on average. Its interdisciplinary staffing of 15 man-years includes nine psychologists and three medical doctors.
It is desirable to lead as many as possible of the referred patients through the introduction seminar, although the seminar will not be appropriate for everybody. A selection is made on the basis of information in the referral. Box 2 provides an overview of groups of patients who will not be invited to the seminar.
Groups of patients who are not invited to the introduction seminar:
Serious and emergency conditions, e.g. psychosis or suicidality
Patients with serious personality or behavioural disorders
Patients referred for specific assessment (AD/HD, assessment of medication and similar)
Non-Norwegian speakers who require an interpreter
The letter of invitation, which is sent to the patient with a copy to the referring agency, explains the purpose of the seminar, and the patients receive an overview of the programme for each of the three seminar days. The patients must return a response slip where they state whether or not they will attend the seminar.
A randomly selected, complete year (2009/2010) of referrals to the outpatient clinic has been studied in more detail to obtain an impression of the total flow of patients (Figure 1 in the online version of this article), and the proportion of this flow which is led through the introduction seminar.
Figure 1: Flowchart of patients referred for outpatient treatment at Jæren District Centre for Psychiatry in the course of one year (1 July 2009 – 1 July 2010)
We reject approximately one-fourth of primary referrals. The most common reasons for rejection are that the patient is resident outside our primary catchment area, or that another type of treatment is recommended, such as treatment for addiction. Of those who are accepted for treatment, altogether 43 per cent are invited to the introduction seminar. Approximately half of those who are invited actually participate in the introduction seminar. These account for just one-fifth of all those who are provided with treatment in the outpatient clinic. One-fourth do not respond to the invitation or report that they are no longer in need of treatment. For these patients, the treatment sequence is discontinued and the referring doctor is informed.
During the nine years that we have arranged introduction seminars, a total of 21 seminars have been held with a total of approximately 460 participants. The number of participants in each seminar has varied from 17 to 32, with an average of 22.
The patients’ experiences
The majority of those who have completed the seminar have responded positively. Practically all participants have completed the anonymous evaluation forms which are handed out on the final day of the course. In this form, the experience of the seminar is assessed in the following areas:
Quality (What was good/less good about it?)
Content (Did you miss anything/would you want more of something?)
Motivation for treatment (Has your attitude to entering treatment changed after participating in the seminar? If so, in what way?)
The assessments of quality and content have been fundamentally positive. The most interesting feedback was found in the responses concerning changes in attitudes to treatment (Box 3).
Examples of anonymous feedback in free text to the question: «Has your attitude to entering treatment changed?»
I was positively surprised that it was easier to be in a group than I had imagined. Have changed my attitude to group therapy.
I have become more motivated to attack the problems.
It no longer seems scary and unfamiliar.
Have gained more insight into things, Easier to see what I need help for.
I became very uncertain about what to choose, since there were many programmes where I could see myself.
I was relieved after attending the course, look forward to starting here.
It was good to meet others in the same situation.
It takes the drama out of entering treatment.
To me, it takes away some of the taboo of mental illness.
It’s good to have started. My motivation is rising.
I don’t feel so different any more. The disease has become more common.
I have become more aware of my own challenges.
This programme was launched to assist in a demanding period for the clinic, with a long and growing waiting list and strains on the staff. However, the introduction seminar has produced other and more important effects, which are especially related to how people perceive entering into a psychiatric treatment process.
Particularly in recent years, user participation has been promoted as a key value in mental health care (2, 3). Studies of the mental health services have shown that patients are not satisfied with the information provided and the opportunities for real participation (4).
In light of the participants’ experience, we claim that the seminar has provided more confidence in the encounter with the staff and other participants. Not least the fact that a previous participant holds a presentation has helped remove the stigma. The information provided has helped clarify the possibilities as well as the limitations of the treatment. We believe that this knowledge has had an empowering effect and has strengthened the patient’s role in the choice of therapy. In addition, we are convinced that for most of the participants, the seminar has been a rewarding form of preparation, since their minds have been activated and their motivation for treatment has been stimulated. Seen as a whole, the responses to the evaluations also signal that the introduction seminars have helped build a good reputation for psychiatry in our region.
Many of the participants have become aware of group treatment as a possibility. Of those who have completed the introduction seminar, approximately half choose and undergo a group-based treatment programme. This has meant a desired shift in the treatment structure. A disadvantage of the group-based programmes, however, is that they function as closed groups that start two to three times per year. Therefore several months may pass before a new group starts. In these cases we will usually provide the patient with individual sessions during the waiting period.
Selection for treatment
The knowledge that the patients obtain about the various treatment programmes enables them to discuss the choice of therapy in a more informed way than they previously could. We may therefore assume that the help provided concurs better with the wishes of the users, and that this helps enhance motivation. Recording attendance for sessions in the outpatient clinic can serve as an objective measure of the motivation for treatment. During the last four years, we have registered that on average patients fail to turn up for sessions in 4.5 per cent of all cases (unpublished data). Nationwide, an average of 20 per cent failure to attend is recorded (5). We assume that the introduction seminar is one factor that can help explain the relatively low frequency of unattended sessions in our outpatient clinic.
Prospects for the future
Our experience with this programme is so positive that there is a broad consensus in the outpatient clinic to continue arranging the introduction seminar. Representatives of other outpatient clinics engaged in adult psychiatry in the country’s regions have attended as visitors to the seminars, and in this way the model has spread to other institutions. The Norwegian Council for Mental Health has selected Jæren District Centre for Psychiatry as one of five centres of excellence, and the introduction seminar is underscored as a source of inspiration to others (6).
In our experience, the introduction seminar is a cost-effective programme that strengthens user participation, enhances the participants’ motivation and promotes participation in group-based forms of treatment. We would have liked to see more of our referred patients in this programme.