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FACILITIES FOR PSYCHOSOCIAL REHABILITATION

INTRODUCTION Rehabilitation services can be seen under the following categories Rehabilitation in the hospital Rehabilitation in the community I. REHABILITATION IN THE HOSPITAL Rehabilitation starts from the hospital. It starts from the day of hospitalization Encourage positive planning by patients Working with patients and family members Working with natural and professional systems Modify the living environment Modify the hospital environment Milleu therapy Milleu therapy is given to recognize all interpersonal and environmental forces to develop an atmosphere that facilitates clients growth, rehabilitation, and restoration of health. Therapeutic community: It focused attention primarily on the psychiatric unit as a social system in which staff and patients reciprocally influence one another for better or worse depending on the way in which system functions. Establish the skills of dependence Reduce the length of stay in the hospital

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Purposeful Nurse patient relationship Structured day activity Family member involvement Establish outside contact Formal introduction of laws rules and regulations

II. REHABILITATION IN THE COMMUNITY Partial hospitalization Half way homes Quarter way homes Sheltered workshops Day care centres Foster homes Mental health emergency care Self help group Vocational rehabilitation

CLUBHOUSE MODEL The Clubhouse Model is a comprehensive group approach that focuses on practical issues in informal settings (Bond, 1995). Clubhouses are community-based rehabilitation programs for people with psychiatric disability offering vocational opportunities, planning for housing, problem-solving groups, case management, recreational activities, and academic preparation. Individuals can learn or regain skills necessary to live a productive and empowering life. The Clubhouse Model provides for the societal, occupational, and interpersonal needs of the person as well as medical and psychiatric needs (Fountain House, 1999).

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a) PARTIAL HOSPITALIZATION Partial hospitalization program is "one step away" from actual hospitalization. It is used to treat mental illness and substance abuse. In partial hospitalization, the patient continues to reside at home, but commutes to a treatment centre up to seven days a week. It focuses on overall treatment of the individual, rather than purely safety. 1) DAY HOSPITALIZATION Day hospitalization is most popular and frequently used in India. It has a structural treatment set up where the patient from home and other institutions attends from 8 am to 5pm and after that they will go back to the same place from where they came. It provides social and occupational and vocational rehabilitation for the services. It is also used for crisis intervention. Advantages of day hospital are: There is no separation from family and friends The personal identity is maintained The self esteem will not become low when compare to in-patient care The social sigma to the patient will be less They have all professional contact in day time with various therapeutic activities and family contact in night The day time can be used for maintaining social and vocational roles There is a possibility of regression and the face of life stresses is reduced The cost of the day hospitalization is less than that of total hospitalization The cost effectiveness of day hospitalization compared to that of in-patient hospitalization is 1: 3

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Disadvantages of day hospitalization are: It is not possible to manage acute family distress Aggressive and self destructive patients cannot be treated It is easier for a day patient than an in-patient to drop the treatment Some patients may depend on others Logically not feasible to some group of patients 2) NIGHT HOSPITALIZATION This is another method of easing the transition from hospital to the community life. Patient goes to work in the morning and return to the hospital at the night. It will offer support until the patient feels secure enough to get a full discharge. Night hospitalization will be used for only few weeks. 3) EVENING AND WEEKEND HOSPITALIZATION This is relatively newer alternative to the routine hospitalization. One possible indication is patients who are getting special therapeutic procedures like group therapy etc can come to hospital during the evening and weekends. It is practiced in some countries for the relief of care taker during weekends.

b) HALF WAY HOME

Halfway housing is a therapeutic approach that appeared in the USA in the 1960s, advanced by a group of people who worked in psychiatric hospitals and were looking for a new treatment modality for the mentally ill. The main objective in establishing such facilities was to provide a viable alternative to both large-scale psychiatric hospitals and small family environments to which severely mentally ill patients were sent once they were discharged.

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The halfway housing system was implemented to alleviate the social isolation experienced by the mentally ill in communities; to demystify the universal medical model, in which patients are considered ill all of the time while in the hospital; and to provide a functional environment without imprisonment. MEANING It is the transition facility for mental patients who no longer need the full services c hospital but are not yet completely ready for an independent living. It is a transitional supervised residence assigned to help the patient after discharge from inpatient setting It is temporary residence where various kinds of social skill training are given to this patient: make readjustment to the social life and employment in the community. AIM To maintain a climate of health and develop and strengthen the normal capacities and normal responsibilities and prepares them in the normal living in the community. To alleviate the social isolation experienced by the mentally ill in communities To improve the self concept Encourage to develop self image To improve self worth OBJECTIVES To create a structured environment To develop a living skills in the resident To provide an opportunity for the personal growth and family involvement To provide temporary residential placement

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To provide activity, responsibility and freedom to the resident To develop skill for independency and social training To strengthen the remaining potentials DURATION Minimum of one year to consolidate the gain achieved over a period of time. This gives the sufficient time for them to adjust to the family and to home environment. THEORETICAL BASIS OF HALF WAY HOME Two conceptual theoretical models for halfway houses have been proposed: the family model and the social model. Residence function is based on a typical familiar group inserted in a social organization. FEATURES Half way home provides structured environment where residents are treated as an individual and learns all social living skills and provides opportunity for personal growth and focus on family involvement. Clients are expected to take care of the activities of daily living. Half way homes are categorized according to gender, age, diagnosis, and prognosis. ACTIVITIES IN HALFWAY HOUSE

Each day morning meeting to discuss the core duties of the day and a chairperson will be appointed on rotation basis for a week Group counseling Recreational activities Home visiting Job placement

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Follow-up counseling Educational and vocational program Additional activities such as religious activities etc Social skill training Training in independent skills.

FAMILY INVOLVEMENT Periodic visit to see local guardians and family members. All programs of the homes are organized to increase the family involvement and thereby commitment and participation in the therapeutic efforts. Education to the family members should be stressed and important issues related to, handling of the problems, details of the illness, doubts and myths about the illness must be discussed and clarified. It is an opportunity to exchange the information and to set realistic goals keeping the uniqueness of the individual.

c) QUARTER WAY HOMES

MEANING Quarter way home is a sizeable reservoir of the chronically ill patients who are sufficiently improved to live in a family setting but who either have no relatives or have relatives who will not accept them to their homes.

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CHARACTERISTICS Clients have deep institutional dependence resulting from many years of hospitalization and are resistant to any change in its symbiotic existence. Within the traditional hospital setting the client finds food, shelter, security and protection. Group living arrangement restores the lost social habits and re-establishment of more normal behavioral patterns. The personnel motivate the clients towards the community, while guiding and supporting to recover soon. d) LONG STAY CARE HOMES These centers are available for women patients. It is indicated for socially disabled mental patients who cannot live independently and who needs care. It is expected that only a small portion of its residence can eventually be discharged back to the community. e) DAY CARE CENTERS In these centers behavioral modification techniques are used in addition to vocational training. These agencies also provide job placement services for the clients.

f) FOSTER HOMES It is a home in which a patient recovering from mental illness is placed in a voluntary family by a social agency for family care. The family is paid by the agency. The placement may be temporary or permanent. Patient gets a home like environment. g) SELF HELP GROUP Self help group in the community will help the individual as well as the family members E.g. Alcohol anonymous

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h) MENTAL HEALTH EMERGENCY CARE Hot line: telephone line maintained by the trained personnel for the purpose of providing crisis intervention Walk-in-clinic: 24 hour psychiatric clinical emergency room in which they diagnose or therapeutic service is rendered without an appointment. Home visit: home visit is conducted by community health nurse and community mental health nurse i) VOCATIONAL REHABILITATION It involves the provision of those vocational services i.e., vocational guidance, vocational training and selective placement, designed to enable a disabled person secure and retain suitable environment. The phases of vocational rehabilitation are: 1) Vocational assessment a) Clinical assessment: assessing for residual psychiatric symptoms which may affect his ability to function b) Social assessment includes assessing family support , attitude of a family members and economic status of the family c) Psychological assessment includes assessing confidence and motivation of the patient and self esteem d) Vocational assessment includes assessing physical strength, hand co-ordination, attention and concentration

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2) Vocational counselling It includes the informing the patients and the family members regarding the type of training available. 3) Vocational training Course content Duration training Incentives Assessment of the progress Imparting skills Supervision

4) Job exploration Selecting suitable job Placement of the client in the job Checking the facilities available Evaluating the work performance

5) Follow up it includes evaluation of the four dimensions Clinical dimensions Social dimensions Psychological dimensions\ Vocational dimensions

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j) SHELTERED WORKSHOP: Sheltered workshop is work oriented rehabilitation facility with a controlled working environment to fulfill individual's vocational needs. In this workshop long term mentally ill patients can utilize their experience and abilities by relearning. It helps in progress towards a normal living and economic independence. The individuals can earn the salaries for

production in the workshop. Sheltered workshop have low staff patient ratio when compare to psychiatric day training centre. Patients works are supervised by non trained staff. Patients are referred from day hospital to sheltered workshop to practice the skills they acquired earlier. k) CORRECTIONAL HOME Correctional homes are for young children who have been found guilty of an offence that would be categorized as a crime if committed by an adult. INSTITUTIONS REHABILITATION GOVERNMENT SECTOR 1) Centre for Rehabilitation, Central Institute of Psychiatry, Ranchi Male and female occupational therapy unit, Sheltered workshop and vegetable garden and fruit orchard is present 2) Centre for Comprehensive care and rehabilitation, NIMHANS, Bangalore The day care facility has a structured programme consisting of activities like physical exercises, yoga training, independent living skills training, behaviour modification and recreational activities done by a trained multidisciplinary team of mental health IN INDIA WHICH PROVIDES PSYCHO-SOCIAL

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professionals Other specialised services like vocational training, social skills training, cognitive rehabilitation, IQ assessment, disability assessment and arrangement of social benefits are also done. 3) IMHANS, Kerala IMHANS is an autonomous institution established by the State Government of Kerala in 1983 4). Institute of Mental Health, Chennai Industrial therapy centre and Occupational therapy centre is functioning there The Industrial Therapy Centre (ITC) established in the 1972 runs Hospital canteen, Bakery, Cover making unit, Candle making unit, Chalk piece unit, Soft toy unit etc. Improved patients are employed in the above said units Occupational Therapy Centre caters to rehabilitation needs of the Institute. It has bookbinding, tailoring, weaving, blacksmith, painting, carpentry units, improved patients are imparted training

NONGOVERNMENTAL ORGANIZATIONS

1) Occupational Therapy Units, ANTARA, P.O. Dakshin Gobindapur, Kolkata ANTARAs rehabilitation program focuses on restoring wellness 2) The Richmond Fellowship Society

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The Richmond Fellowship Society (India) provides rehabilitation therapy in shortand long-term care homes, vocational training and outreach care and mental health programmes in rural areas. Bangalore Branch - Rehab homes, Day Care, MSc in Psycho Social Rehabilitation and short term professional training Delhi Branch - Rehab homes, Day Care Sidlaghatta Branch - Day Care, Clinics and rural projects Lucknow Branch - Day Care and outreach clinic 4) Vishwas Day Care Centre with Vocational Training Provides halfway home and day care centre 5) VIMHANS (Vidyasagar Institute of Mental Health and Neuro-Sciences New Delhi 6) Shraddha Rehabilitation Foundation- Mumbai 7) MANAS -A Society for Mentally Disturbed Persons Their Families and Friends, Kolkata MANAS try to coordinate the different families towards building up of a long-term residence for the chronically ill mental patients. 8) MON Foundation- A Social Outreach Initiative, Kolkata 9) ANJALI, Kolkata ANJALI works with a group of people who have suffered both stigma and are voiceless. ANJALIs mission is to move from institutionalization to full rehabilitation of people with mental illness, ensuring participation and consent of the mentally-ill in all decisions related to her life. Life skills training, Occupational therapy, Organizing shelter and Recreation and relaxation therapy are the major initiatives of ANJALI.

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10) ANTARA - A WHOLE VILLAGE, Kolkata ANTARA provides shelter, care, treatment and rehabilitation to the destitute & very poor persons suffering from mental disorders including drug addiction & alcoholism. ANTARA runs Work Therapy Projects, ANTARA InfoTech Vocational Training Centre and a number of training programmes. ANTARA is centred at Antaragram: which is located at a village in the district of South 24 Parganas. 11) ARDSI - Caring the People with Alzheimer's and Other Dementia Related Diseases 12) ANADANIKETAN - A HOME AWAY FROM HOME, Kolkata 13) PARIPURNATA - A HALF-WAY HOME, Kolkata Paripurnata is a short stay home for women who have been committed to the hospital for mental illness in Pavlov Institute. Paripurnata which provides them with life-livelihood skills and helps to rehabilitant they back into their families communities. 14) Sailendranath Guha Thakurata Institute (SANGATI), Kolkata Sailendranath Guha Thakurata Institute (Sangati) is a societal engaged in social educational research and vocational studies. Its target client is mentally retarded children. Its facilities include: day care centre educational & vocational training facility; counselling, psychological assessment and parental training.

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REFERENCE 1. Sadock BJ, Sadock VA. Kaplan and Sadocks synopsis of psychiatry, Behavioural sciences/clinical psychiatry.10th ed. Philadelphia: Lippincott Williams and Wilkins publishers; 2007 2. Granlick A. The psychiatric Hospital A therapeutic instrument. Newyork: Brunjer; 1969 3. Lloyd C. Vocational rehabilitation and mental health.UK: John Wiley & Sons; 2010. 4. Townsend M C. Psychiatric mental health nursing. 5th ed. New Delhi: J P Publishers; 2004. 5. Budson RD. The Psychiatric Halfway House- A Handbook of Theory and Practice. 1st ed. Pittsburgh: University of Pittsburgh Press; 1978. 6. Golomb SL, Kocsis A. The halfway house-On the road to independence. 1st ed. Brunner/Mazel Publishers; New York: 1988. 7. Reis AD, Laranjeira R. Halfway Houses for Alcohol Dependents: From Theoretical Bases to Implications for the Organization of Facilities. Hospital das Clnicas da FMUSP; 2008 December; 63(6): 827832.

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Halfway Houses for Alcohol Dependents: From Theoretical Bases to Implications for the Organization of Facilities

Alessandra Diehl Reis and Ronaldo Laranjeira The purpose of this paper is to supply a narrative review of the concepts, history, functions, methods, development and theoretical bases for the use of halfway houses for patients with mental disorders, and their correlations, for the net construction of chemical dependence model. This theme, in spite of its relevance, is still infrequently explored in the national literature. The authors report international and national uses of this model and discuss its applicability for the continuity of services for alcohol dependents. The results suggest that this area is in need of more attention and interest for future research. METHOD This narrative review includes periodical articles obtained from primary data sources dating from 1960 to 2008, textbooks, and Masters and Doctorate degree theses containing relevant information about halfway houses for alcohol dependents. RESULTS Halfway houses for alcohol dependents It is important to note that although the halfway house and therapeutic community (TC) approaches for substance dependence rehabilitation share similar concepts and philosophies, their treatment modalities differ.6 Therapeutic communities were systematically reviewed by Smith et al. (2006) to determine the effectiveness of TCs versus other treatments for substance dependence and to investigate whether their effectiveness is moderated by patient or treatment characteristics. The authors concluded that there is little evidence that TCs offer significant benefits in comparison with other residential treatment or that one type of TC is better than another.18 A halfway house, dry house or sober house is defined as a more accessible transition between hospitalization and life in the community. Its objective is to promote a social support system for alcohol and substance dependents who will benefit from the supportive treatment structure in such a sober environment.19 The main philosophical construct informing this kind of substance abuse treatment program has been the social or community model approach, which gained strength in the 1980s and became embodied by a continuum of recovery services. These models are publicly funded, legally incorporated nonprofit organizations with a heavy emphasis on the community and social environment, the importance of assumption, knowledge and practice to the recovery process, staff-client interactions, and on the importance of employing staff who are in recovery.5,6 Such a model can allow the patients to begin the process of reintegration with

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society while still providing monitoring and support; this is generally believed to reduce the risk of relapse as compared to direct discharge into society.20,21 The treatment diversity offered in these services is very wide. Some include informal treatment and others adopt a 12-step model. The programs, in general, are exclusively for either men or women and it is rare for both genders to be treated in the same program. Program duration varies between one and 320 days. Patients who reside for a longer period of time tend to better reintegrate into society and decrease their likelihood of substance abuse after discharge.20 Some programs focus on introducing the basic concepts of self-care (e.g., maintaining the house, exercise, basic meal preparation) as well as developing money management skills (projecting weekly expenses) and working to understand past actions and how they affected the residents life both positively and negatively.6,22 Studies aiming to evaluate the effectiveness of this treatment modality have identified many methodological issues. The main concerns are the paucity of a control group, intervention variations and outcome analysis, the small sample size, and the reliability of the results obtained. However, they typically report favorable results and show that this approach tends to increase compliance to outpatient treatment.19,23 Studies conducted by Annis & Liban (1979), Ryswyk (1981), Booth (1981), Walker (1982), Baskin (1983), Huselid (1991), Fischer (1996), Davis (2005), and Jason (2007) indicated positive outcomes to treatments offered by various halfway houses. The main positive outcomes were: 1) lower detoxification admission index, 2) lower use of public assistance services, 3) lower involvement with criminal justice or prisons, 4) higher employment commitment after discharge, 5) lower admission to emergency hospitals, 6) lower medical and legal costs to the public, 7) more humanitarian system, 8) a higher degree of satisfaction among residents, 9) lower system costs, and 10) improvement in abstinence levels.20,2428 It was also possible to identify negative outcomes, including a younger population (under the age of 25) and use of multiple drugs associated with primary alcohol use.27,30 According to Pekarik & Zimmer (1992), this model has an average annual cost of US$2900.00 in the USA.31 In Brazil, a network of assistance for substance dependence has been built from a variety of public and private facilities that comprise various care levels, including: specialized outpatient treatment, primary care centers, general hospitals, halfway housing, clinics, drug and alcohol psychosocial attention centers, self-help groups, therapeutic communities and harm reduction programs.17,32,35 Psychiatric hospitals continue to be a treatment option in certain cases in the decentralized network system.36 Despite being considered into the tertiary level of attention,32 we observe in Brazil a lack of therapeutic residences for psychoactive substance users. An adequate halfway house approach employing the therapeutic tradition model for substance users does not exist.

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The diversity of facilities associated with treatment structure plurality, which addresses the complexity of patients problems (physical and mental health, social, family, professional, marital, motivational stage, etc.) seems to guarantee the success of the care model proposed for substance users.32,35,36 National and international experiences The Oxford House System, founded in Maryland, USA in October of 1975, is a nongovernmental organization (NGO) which presently accounts for more than 20 residences in many cities. The central principle of Oxford House is to stimulate recovery and provide housing for alcohol dependents who desire to cease alcohol use and live in sobriety, this being the major requirement to program inclusion and participation.37 The system is not run for profit, and every residence is independently and self-sufficiently managed by the residents themselves. However, there is a set of operative norms and traditions created by democratic vote. The system also employs a non-professional staff, although outside professionals may be hired in special situations. The Oxford House is not connected to Alcoholics Anonymous (AA), but supports resident participation in AA meetings.37 Over the past 12 years, a university research team has been involved in a collaborative action research project with a community-based, self-run, residential substance abuse recovery program at Oxford House.29 Spirituality was evaluated among residents in one of the Oxford Houses; moreover, it was found that 76% participate in AA meetings weekly. It also seemed that building a social network beyond the walls of the residence is an essential factor in recovery. A two year follow-up study which evaluated 130 patients in the Oxford House system indicated positive results as relates to psychoactive substance abstinence.37,38 Jason et al. (2007) observed 150 individuals discharged from residential substance abuse treatment, including at Oxford House, in a 24-month follow-up study. Their findings suggest that there was a decrease in substance abuse for residents who lived in Oxford Houses for six or more months (15.6%), compared both to participants residing in Oxford House for less than six months (45.7%) and to participants assigned to the usual after-care condition (64.8%). Results also indicated that both older residents and younger residents living in a house for six or more months experienced better outcomes in terms of substance use, employment and self-regulation.30 The Halfway House in Jardim Angela, in the city of So Paulo/SP, Brazil A halfway house service was operated from late 1999 to September 2003 in the outskirts of Sao Paulo, an area known for its high exclusion and homicide index (122 per 100 thousand inhabitants in 1995).40 Technical and financial support came from UNIFESP/UNIAD, the state public health and a Catholic NGO that had been in the community more than 12 years. This community, with its high violence indices, had an average of one outlet for every 12 homes, which suggested as a hypothesis the potential of an association between a lack of culture and leisure centers and alcoholism and violence.41 The neighborhood was reported to be the most violent region in the world by the United Nations in the late 1990s.40

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The Jardim Angela Halfway House had a 10-bed capacity, and alcohol dependents stays were limited to 30 days. It served 130 patients from October 1999 to November 2001. The services aim was to become a communitarian, temporary home facility supported mainly by non-specialized staff and/or alcohol dependents in recovery. The home atmosphere emphasized obtaining health, self respect and binding social support network systems through abstinence. A psychological sense of community provided a sense of belonging, identity, emotional connection and well-being.42 Patients were under the care of a communitarian agent 24 hours a day. Agents assisted patients with meals (prepared by the residents with the help of a cook, who was undergoing a longer recovery process), personal hygiene, physical company, developing activities and games, as well as supervision of family visits and phone calls. Residents received psychiatric, psychological, nurse and social assistance one or two times a week in an outpatient service center located close to the residence. Volunteers from the community led activities involving arts and crafts, horticulture, ceramics and yoga therapy. The residents also went to church if they wished and walked in the morning, accompanied by agents. The cost per resident was about US$13.00 per day, with meals, medications and all amenities included. Funds received through donations from community volunteers notwithstanding, this project could not be continued due to financial difficulties in maintaining the house brought on by the end of its sponsorship and lack of a budget. Today, an infirmary with 10 beds exists in the same house. This service was inaugurated in 2006 and is supported by the local government. A full-time communitarian agent is present. Similar initiatives may exist in other places in Brazil; however, this has not been documented in scientific literature.

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An assignment on Psychiatric Nursing

FACILITIES OF PSYCHO-SOCIAL REHABILITATION

SUBMITTED TO Mrs. Tessy Treesa Jose HOD and Professor Dep. Psychiatric Nursing MCON, Manipal, Manipal University

SUBMITTED BY Mr. Renjulal Y 090504009 MSc Psychiatric Nursing MCON, Manipal, Manipal University

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