Proposed changes to regulations in Chapter IV and Chapter VI appear to contradict each other. Chapter IV, p. 26 appears to propose a change wherein groups must be capped at 10. However, in Chapter VI p. 16, this language is included but crossed out, indicating intention to remove this requirement.
If there is a recommendation to require a 10-person limit to group programming, I would like to recommend against adding a requirement to limit groups to no more than 10 participants for psychosocial rehabilitation. The addition of this requirement would lead to the need for significant staffing additions to support facilitation of several additional groups, which is difficult to justify at the Medicaid reimbursement rate for PSR services. It would also lead to a number of structural changes to programming which are not requested or desired by consumers. Regarding clinical appropriateness of this recommendation, capping a group at 10 is not beneficial for several reasons. When group attendance is capped at 10, it is almost guaranteed that some percentage of individuals enrolled in the group will not attend on a given day due to symptom or other internal or external barriers, leaving the actual real number of attendees in the group much lower than expected. When serving the SMI population in a group setting, medium to large-sized groups are typically more beneficial to allow for increased variability in perspective and individual experience, which promotes participants’ ability to learn from each other. Small groups tend to have lower energy which discourages individuals from sharing and engaging with each other. Larger groups allow more flexibility for consumers to engage and participate in the way that is most beneficial for them. Although smaller groups are beneficial for certain targeted skill-teaching topics such as cooking, most other psychoeducational topics that are best learned through discussion, role-play activities, and other media are better facilitated in a medium to large group setting. Although I cannot speak to clinical appropriateness of this recommendation to other types of group treatment, I can say with confidence that it is not appropriate for psychosocial rehabilitation.
As a former PRS client, I absolutely agree with the 10 person limit for psychosocial programming groups. Too often, day programming providers financially exploit their clients by providing remedial programming to as many people as possible. At PRS, I went to big group skill building classes that consisted of tic tac toe tournaments, or so-called nutrition groups that consisted of discussions related to which soda was the healthiest to drink.
Day programming agencies need to take their roles seriously, and provide appropriate, personalized psychosocial support to their clients as individuals. The big group approach turns people with severe mental illness into a faceless commodity where we are no longer individuals. Under Emily Hollidge and PRS's approach, the degrading big programming is geared towards intellectually disabled clients, and clients with higher education are treated as if we are intellectually disabled. Psychosocial programming needs to be differentiated towards the different kinds of clients with severe mental illness, as people with doctorate degrees, like me, also develop SMI, and are also PRS clients. Under Emily Hollidge's big group programming, I was subjected to skill building programming for people with intellectual disabilities with devastating results. Emily Hollidge's big group programming at PRS was so harmful to my self-esteem that I tried kill myself repeatedly after leaving PRS and was repeatedly psychiatrically hospitalized and was even treated in the emergency room due to a suicide attempt. But Ms. Hollidge and the PRS staff do not care about these outcomes for their clients, just as long as the big group programming makes their job slightly easier, and they can pay themselves more money after not having to hire more staff or provide personalized attention.