Ch. 4

Chapter Four: Treatment Settings and Therapeutic Programs

Key Terms

  • Assertive Community Treatment (ACT)

    • Community-based programs that provide necessary services for successful community living.

    • Services include:

    • Case management

    • Problem solving

    • Social skills training

  • Mental Illness

    • Refers to the practice of arresting and prosecuting mentally ill offenders, including misdemeanors.

    • The prosecution rate for this population is four times that of the general population.

  • Day Treatment

    • Treatment programs where clients attend during the day and return home or to the community at night.

  • Dual Diagnosis

    • Describes a client with both a substance use disorder and another psychiatric illness.

  • Interdisciplinary/Multi-disciplinary Team

    • A treatment group composed of individuals from various fields, essential for addressing the multifaceted problems of clients with mental illness.

  • Partial Hospitalization Programs (PHPs)

    • Structured treatment at an agency or facility

    • Aims to help clients make a gradual transition from inpatient care to independent living or to avoid hospital admission.

  • Recovery

    • Encompasses improved quality of life beyond symptom control, including:

    • Personal growth

    • Reintegration into the community

    • Empowerment

    • Increased independence

    • Pursuit of life goals, similar to that of any individual.

  • Residential Treatment Settings

    • Long-term treatments provided in various living situations, varying in structure, level of supervision, and services provided.

  • Stigma

    • The negative perceptions associated with mental illness, leading to discrimination.

  • Telehealth

    • Delivery of mental health services through information and communication technology.

Learning Objectives

  • Discuss traditional treatment settings.

  • Describe different types of residential treatment settings and their services.

  • Describe community treatment programs serving people with mental illness.

  • Identify factors distinguishing recovery programs from traditional treatment.

  • Identify barriers to effective treatment for homeless individuals with mental illness.

  • Discuss collaboration in community-based practice and health care disparities.

Health Care Systems & Managing Care

  • Mental health care has transformed significantly over the last fifty years.

  • Prior to the 1950s, humane treatment was primarily conducted in large state facilities for individuals with chronic and persistent mental illness.

  • Clients are often sicker upon admission and do not remain in hospitals as long as before.

  • New financial penalties have been implemented for institutions with high readmission rates, incentivizing the reduction of rehospitalization.

  • Inpatient units are now required to provide:

    • Rapid assessment

    • Stabilization of symptoms

    • Discharge planning

    • Accomplishing these goals quickly is essential.

  • A client-centered multidisciplinary approach is crucial for brief stays in inpatient treatment settings.

Discharge Planning

  • An important aspect in inpatient treatment is the formulation of effective discharge plans:

    • Environmental supports such as housing, transportation, and access to community resources.

    • Plans should be tailored to individual client needs, encompassing:

    • Medication management

    • Education

  • Box 4.1: PHP Goals

    • Stabilizing psychiatric symptoms

    • Monitoring the effectiveness of medications

    • Stabilizing the living environment

    • Improving activities of daily living

    • Learning to structure time

    • Developing social skills

    • Obtaining meaningful work or engaging in volunteer positions

    • Providing follow-up for any health concerns

  • Each client is to have an individualized treatment plan developed collaboratively with the case manager and other team members.

  • Common goals in PHPs include:

    • Vocational rehabilitation

    • Medical, dental, and psychiatric care

    • Psychosocial rehabilitation programs as needed.

Assisted Living Services

  • Availability varies considerably by state.

  • Some agencies provide comprehensive services, while others offer only shelter.

Quality Improvement in Organizations

  • Organizations must commit to ongoing quality improvement, resource allocation, and technological support.

  • The work environment should be adaptable to manage and celebrate change to foster a recovery culture.

Goals of Psychiatric Rehabilitation

  • Box 4.3: Goals

    • Recovery from mental illness

    • Personal growth

    • Quality of life improvement

    • Community reintegration

    • Empowerment

    • Increased independence

    • Decreased hospital admissions

    • Improved social functioning

    • Improved vocational functioning

    • Continuous treatment

    • Increased involvement in treatment decisions

    • Enhanced physical health

    • Restoration of sense of self.

Community Support Programs

  • Provide psychiatric rehabilitation to varying degrees, often determined by available resources and funding.

  • Some programs primarily focus on reducing hospital readmissions through:

    • Symptom control

    • Effective medication management

  • Key aspects of recovery include:

    • Accepting illness

    • Effectively managing symptoms

    • Engaging actively within the community

    • Forming meaningful social connections

    • Coping with family relationships

    • Valuing oneself and others.

Clubhouse Model

  • Peer counselors or consumer providers play a vital role in recovery.

  • Membership in a clubhouse is founded on four guaranteed rights:

    1. A place to come to

    2. Meaningful work

    3. Meaningful relationships

    4. A place to return to (lifetime membership)

  • The clubhouse model promotes opportunities for members through:

    • Daytime work activities related to clubhouse maintenance and productivity

    • Evening, weekend, and holiday leisure activities

    • Transitioning to independent employment support

    • Housing options

  • It encourages members to utilize psychiatric services from local clinics or practitioners.

  • Critical connections include friends, clinicians, landlords, employers, and neighbors within the rehabilitation alliance.

Addressing Homelessness in Mental Illness

  • Research indicates a substantial number of homeless individuals with mental illness, necessitating appropriate shelter and rehabilitation programs.

  • Effective reduction of homelessness requires public policy and funding improvements, emphasizing access to care and safe housing.

  • In the 1990s, federal programs were established to help the homeless population with mental illness.

Crisis Services and Military Veterans

  • Some communities have mobile crisis services integrated with police support.

  • The occurrence of mental disorders like PTSD and major depression is notably higher among active military members compared to civilians.

  • The veterans' suicide rate is 1.5 times higher than the general population.

  • Risk factors for veteran suicide include:

    • Transitioning from military to civilian life

    • Combat exposure

    • Access to firearms

  • There has been increased support and services from the veterans administration, as well as private organizations like Wounded Warriors to assist veterans.

Veteran Services

  • Box 4.6: Services for Veterans

    • Inpatient, outpatient, and residential care

    • Programs for homeless or incarcerated veterans

    • Psychosocial rehabilitation and recovery services

    • Specialized programs addressing issues like sexual trauma and substance use

    • Suicide prevention services

  • Discussion on broader areas important for veterans’ mental health such as diet, exercise, stress management, etc.

  • PTSD treated further in Chapter 13.

Interdisciplinary Team Roles

  • Effective teamwork in mental health settings necessitates development of core skills:

    • Interpersonal skills: tolerance, patience, understanding

    • Empathy, genuineness, nonjudgmental attitude

    • Knowledge of mental disorders and communication skills

    • Risk management and assessment abilities

  • Case Manager Role

    • Critical in managed care settings

    • No standard educational program for case managers; diverse backgrounds acceptable

    • Symptom assessment, functional assessment, and skills training roles

  • Key Roles in the Interdisciplinary Team

    • Pharmacist

    • Manages complex medication needs, side effects, and interactions.

    • Psychiatrist

    • Provides diagnosis and prescribes treatments. Requires board certification and residency training.

    • Psychologist

    • Conducts therapy and research, interprets tests, and develops therapy programs.

    • Recreation Therapist

    • Assists in maintaining a healthy balance of work and leisure.

    • Vocational Rehabilitation Specialist

    • Matches client interests and abilities to vocational choices, demonstrating a positive impact on medication adherence.

  • Nursing Role

    • Nurses face challenges in engaging homeless individuals with mental illness, requiring patient relationship establishment and adaptive collaboration.

Critical Thinking Questions

  • How to select consumers for peer counselor roles?

  • Issues related to criminal/violent behavior, non-adherence to medication, and suicidal ideation.

Community Residential Settings

  • Residential settings vary in structure, supervision, and services.

  • Types of settings include:

    • Board and care homes

    • Adult foster homes

    • Halfway houses

    • Group homes

    • Assisted living

    • Independent living programs

  • The ability of clients to remain in the community connects closely to the quality and adequacy of their living conditions.

Conclusion

  • Empowering clients to pursue recovery necessitates a shift from traditional caregiving towards a collaborative approach, aligning services with needs and self-determined goals.