In an acute-care psychiatric setting, discharge is the name of the game for patients, doctors, nurses, social workers and occupational therapists. Discharge planning is a challenging process which requires patients to be ready to identify characteristics of their environment, available supports and wellness skills. In order for the process to be successful, it must be a collaborative one in which we as occupational therapists play a vital role.

Being immersed in the acute-care setting, I often found myself wondering how patients really felt about the discharge process: their fears, their anticipations and their readiness.

Through my final project, I was able to gain a deeper understanding. I created a game focused on discharge planning called "Back to Life." This game provided patients with the opportunity to reflect upon and speak candidly about important questions regarding discharge planning. It also served the purpose of empowering patients, as they recognized that they do have the supports and skills needed for staying healthy once discharged from the hospital.

As part of the design of the game, trails of laminated footprints were laid on the floor. Each patient would roll the die, walk the number of footprints, and then answer the given question. The footprints were designed to symbolize the patients' journey from admission to stabilization, from stabilization to discharge, to integration into the community.

The questions were designed to take a holistic approach to discharge planning. They allowed patients to reflect upon skills they had learned while in the hospital, the supports they will utilize after discharge, the perceived challenges they will face, and their goals for the future.

One of the most interesting and valuable questions asked patients about stigma and mental health, which is unfortunately a very real challenge patients will face in society. Their insightful, personal and powerful responses demonstrated both their reluctance to face the insensitivity that awaits, and their pride in their individuality as well as their strength as human beings.

One patient who suffered from depression explained stigma as "a mark that people judge you by. I think people with mental illnesses are victims of stigma. But we didn't ask for this, it is an illness. It is important for us to be open about our illness and not be ashamed of it."

Another patient with chronic schizophrenia elaborated, saying, "People think because we are mentally ill, we are not capable of doing things or being independent. But sometimes it turns out we handle things better than they do."

For therapists working with patients with chronic mental illness, it is important to recognize the "ah-ha" moments that show progress for patients as well as validate what we do as occupational therapists. The game facilitated these types of moments because it allowed patients to look toward their much-anticipated discharges into futures full of possibility. These moments often came about when patients would collaborate, offering feedback or advice on another patient's fears about discharge. Other times, it was the verbalization of meaningful answers and detailed discharge plans that showed significant progress in the hospital.

It is music to our ears to hear patients admitting how important it is to set up a daily medication routine and then have other patients suggest possible ways to do it. Many patients spoke adamantly about the personal strengths and weaknesses they had learned about themselves. Another wonderful part of the experience was to have patients make a plan of people they will call and places they will go if they feel like they are starting to relapse.

One particular patient, who had chronic schizophrenia and displayed extreme negative symptoms during group, was asked to name a positive thing she learned about herself while in the hospital. She responded, "I learned how to have self-esteem and am working on it."

The best part of the game is witnessing patients' journeys, right before your eyes. During their initial evaluations, patients may have been very guarded or disorganized. Yet just a few days later they are actively engaged in the game and able to articulate insightful answers for their discharge planning. My hope is that patients were able to recognize their own transformations as well.

It is often said that a journey of a thousand miles begins with a single step. Hospitalization is the first step in a patient's journey. As occupational therapists, it is our daily joy to help instill the skills needed for each step that follows.

Lori Havrilak, OTS, is a senior in the OT program at Elizabethtown College. She completed her psychosocial fieldwork at the Hospital of the University of Pennsylvania, where she created the discharge group "Back to Life" as her special project. Regular columnist Teresa Hanssens, MS, OTR/L, has practiced in the area of mental health for over 15 years. She is currently employed full time at the Hospital of the University of Pennsylvania. Readers may contact her at 215-662-2814 or Thanssens@msn.com.

Note from Columnist

Periodically, students who have completedaffiliations in mental health at the Hospital ofthe University of Pennsylvania are asked to share exceptional work via this column. The following article describes the effectiveness and ingenuity of a discharge group called "Back to Life,"developed by Lori Havrilak from Elizabethtown College in Elizabethtown, PA.

?Teresa Hanssens, MS, OTR/L