CHAPTER 4: Treatment Settings and Therapeutic Programs

Chapter 4: Treatment Settings and Therapeutic Programs

Key Terms:
o Assertive Community Treatment (ACT): community-based programs that provide many of the services
that are necessary for successful community living; includes case management, problem-solving, social
skills training, support, teaching on a 24/7 basis
o Case Management: management of care on a case-by-case basis, representing an effort to provide
necessary services while containing costs; in the community, case management services include assessing
medical and psychiatric services and providing assistance with tasks of daily living such as financial
management, transportation, and buying groceries
o Clubhouse Model: community-based rehabilitation; an intentional community based on belief that men
and women with serious and persistance psychiatric disability can and will achieve normal life goals
when given the opportunity, time, support, and fellowship
o Criminalization of Mental Illness: refers to the practice of arresting and prosecuting mentally ill
offenders, even for misdemeanors, at a rate of four times that of the general population in an effort to
contain them in some type of institution where they might receive needed treatment
o Day Treatment: treatment programs in which clients attend during the day and return home or to the
community at night
o Evolving Consumer Household (ECH): a group-living situation in which residents make the transition
from a traditional group home to a residence where they fulfill their own responsibilities and function
without on-site supervision from paid staff
o Interdisciplinary (Multidisciplinary) Team: treatment group composed of individuals from a variety of
fields or disciplines; the most useful approach in dealing with the multi-faced problems of clients with
mental illness
o Partial Hospitalization Programs (PHPs): structured treatment at an agency or a facility for clients living
in the community; designed to help clients make a gradual transition from being an inpatient to living
independently or to avoid hospital admission
o Recovery: improved quality of life, beyond just symptom control, including personal growth,
reintegration into the community, empowerment, increased independence, and pursuit of life goals like
any other person
o Residential Treatment Settings: long-term treatment provided in a living situation; vary according to
structure, level of supervision and services provided
o Stigma: dealing with the shame of a mental illness
Objectives:
o Discuss traditional treatment settings
Inpatient hospital treatment: today, inpatient units must provide rapid assessment, stabilization
of symptoms, and discharge planning, and they must accomplish goals quickly. When the client is
stable, the clinicians and client can identify long-term issues for the client to pursue in outpatient
therapy. Some inpatient units have locked entrances. This has both advantages and disadvantages.
Advantage: protection against the outside world in a safe and secure environment. Disadvantage:
making clients feel confined or dependent and emphasizing the staff members power over them.
Short inpatient stays: The VA has piloted a START program as an alternative to
inpatient hospital admission. They did this to improve veterans self-esteem and feelings
of self control. Veterans have the same improvement in symptoms and functioning as
those treated at a VA hospital, but they are typically more satisfied with the services. The
cost is about 65% lower than treatment in the hospital.
Long-stay clients: used for people with severe and persistent mental illness and require
acute care services. Used for clients who were hospitalized before deinstitutionalization
and remain hospitalized despite efforts at community placement.

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CHAPTER 4: Treatment Settings and Therapeutic Programs

o More homelike and less institutional

o Clients report improved functioning, fewer aggressive episodes and increased
satisfaction with their care. Some clients stay, others resettle into the community.
o Can be used for respite care or crisis resolution. Criteria: clients perception of
being in crisis and needing more structured environment. Client is more likely to
perceive their situation more accurately and ask for help to avoid
rehospitalization.
o We have crisis resolution teams (CRTs) or home treatment teams to assist clients
in dealing with mental health crises without hospitalization; they enter crisis
houses that lead to greater satisfaction with services, improved informal peer
support, and fewer negative events compared to inpatient settings.
o Some patients with dual diagnosis require frequent or longer hospitalizations
Case management: usually nurses or social workers who follow the client from
admission to discharge and serve as liaisons between the client and community resources,
home care, and third-party payers. They work with clients on a broad range of issues such
as needing medical and psychiatric services and tasks of daily living such as using public
transportation, managing money and buying groceries.
Discharge planning: this is based on the clients individual needs; includes med
management, education, timely outpatient appointments, and telephone follow-up.
o How adequate the discharge planning is can determine how long the person can
remain in the community.
o Some impediments to successful discharge planning include alcohol and drug
abuse, criminal or violent behavior, noncompliance with med regimens, and SI.
People discharged with marginal discharge plans are readmitted more quickly
and more frequently than those who have better discharge plans.
o Some clients are unsuccessful with their established d/c plan. Paying attention to
the psychosocial factors, their preference on follow-up services, including the
family, and their familiarity with outpatient providers is critical to a successful
d/c plan.
o Relapse prevention is an essential component of d/c planning. Interventions
include symptom education, service continuity, and establishment of daily
structure.
o A holistic approach to reintegrating persons into the community is the best way
to prevent repeated hospital admission and improve quality of life for clients.
Community programs should include social services, day treatment and housing
programs, all geared toward survival in the community, compliance with
treatment recommendations, rehabilitation, and independent living. Assertive
community treatment (ACT) programs provide many of the services that are
necessary to stop the revolving door of repeated hospital admissions punctuated
by unsuccessful attempts at community living.
o Describe different types of residential treatment settings and the services they provide
Group homes: house 6-10 residents who take turns cooking meals and sharing household chores
under the supervision of staff persons.
Supervised apartments:
Board and care homes: provide a room, bathroom, laundry facilities and one common meal each
day.
Assisted living: available in many states, but may vary a great deal in regard to services provided
Adult foster care: may care for one to three clients in a family-like atmosphere, including meals
and social activities with the family.

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Halfway houses serve as temporary placements that provide support as the clients prepare for
independence.
Independent living programs are often housed in apartment complexes, where clients share
apartments. Staff members are available for crisis intervention, transportation, assistance with
daily living tasks, and sometimes drug monitoring.
Respite/crisis housing: for short-term temporary shelter; these clients may lie in group homes or
independently but have a need for respite from their usual residences due to feeling overwhelmed,
or cannot cope with problems or emotions. Respite provides increased emotional support and
assistance with problem-solving in a setting away from the source of the clients distress.
o Describe community treatment programs that provide services to people with mental illness
Community support programs and services provide psychiatric rehab to varying degrees,
depending on the resources and funding thats available. Too few programs are available
nationwide to meet the needs of people with mental illness. Some of the services include social
and recreation services, symptom control, med management.
Clubhouse models provide members with daytime work activities focused on the care,
maintenance, and productivity of the clubhouse; evening, weekend, and holiday leisure activities;
transitional and independent employment support and efforts; and housing options. Members are
encouraged and assisted to use psychiatric services at local clinics or private practitioners. They
are guarantee 4 rights of membership: a place to come to, meaningful work, meaningful
relationships, and a place to return to (lifetime membership).
ACT (Assertive Community Treatment) programs are the most effective approaches to
community-based treatment for people with mental illness. Its believed that skills training,
support, and teaching should be done in the community where it was needed rather than in the
hospital. Marx conceived this idea in 1973 in Madison, WI, while working at Mendota State
hospital.
Components:
o multi-disciplinary team
o client responsibility for primary provider of services
o ameliorating (improving) or eliminating the debilitating symptoms of mental
illness
o improve client functioning in adult social and employment roles/activities
o decrease familys burden of care
o implement individualized, ongoing treatment plan based on clients needs
o involving all needed support systems for holistic treatment
o promote mental health with vast array of resources and treatment modalities
o use team meetings to discuss strategies to improve clients care
o 24hr services to include respite, crisis intervention to deflect unnecessary
hospitalization and destabilization with unnecessary ED visits
o measure client outcomes
o Identify the factors that distinguish recovery programs from traditional treatment
Recovery usually involves the management of a chronic or potentially recurring illness or
problem that requires specific actions, behaviors, and treatments to pursue, maintain, or sustain
recovery and optimal wellness.
o Identify barriers to effective treatment for homeless people with mental illness
frequent shifts between the street, programs, and institutions
Compared to homeless people who are NOT mentally ill, mentally ill homeless are homeless
longer, spend more time in shelters, have fewer contacts with family, spend more time in jail, and
face greater barriers to employment

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CHAPTER 4: Treatment Settings and Therapeutic Programs

Persons reported that being homeless and having a mental illness was the basis of more
discrimination than the color of their skin.
o Discuss issues related to people with mental illness in the criminal justice system
The rate of mental illness in the jailed population has been increasing faster than that of the
general population. Offenders generally have acute and chronic mental illness and poor
functioning, and many are homeless. Reasons they are involved in the criminal justice system
include deinstitutionalization, more rigid criteria for civil commitment, not enough community
support, economizing (cutting corners, skimping) on treatment for mental illness, and the
attitudes of police and society.
Criminalization of mental illness refers to the practice of arresting and prosecuting mentally ill
offenders, even for misdemeanors, at a rate of four times that of the general population in an
effort to contain them in some type of institution where they might receive needed treatment.
However, if some offenders received the treatment they needed, some wouldve never engaged in
criminal activity to begin with.
Public concern about the potential danger of people with mental illness is fueled by the media
attention that surrounds any violent criminal act committed by a mentally ill person. However,
not every mentally ill person represents a significant danger, but this doesnt stop people from
clinging to stereotypes of the mentally ill as people to be avoided, feared, and institutionalized.
People with mental illness are more likely to be victims of violence, both in prison and in the
community.
People with mental illness who are in the criminal justice system face several barriers to
successful community integration: poverty, homelessness, substance use, violence, victimization,
rape, trauma, and self-harm.
o Discuss the difficulties faced by military veterans both during and following service
Post-traumatic stress disorder, major depression is prevalent among active duty military service
members.
Increased suicide rate, twice that of civilians
Also increased rate of homicide, injury, and physical illness
Three or more deployments is positively correlated with PTSD, depression, bipolar disorder, and
anxiety disorders; also, sleep disorders, substance use, cardiovascular disease, smoking,
homelessness, and marital and family dysfunction
They are reluctant to seek treatment due to fear of stigma or perceived stigma of mental illness.
OCD is moderately higher and more prevalent in veterans.
Military sexual traumas are more widespread and common than most would think.
o Describe roles of different members of a multidisciplinary mental health-care team
Pharmacist: medications, management of side effects and/or interactions with nonpsychiatric
meds
Psychiatrist: physician certified in psychiatry by the American Board of Psychiatry and
Neurology; primary function is to diagnose mental disorders and prescribe medical treatments
Psychologist: has a doctorate in clinical psychology, practices therapy, conducts research,
interprets psychological tests; may participate in the design of therapy programs for groups of
individuals
Psychiatric nurse: experience working with clients with psychiatric disorders
Psychiatric social worker: prepped at masters level; practice therapy and have the primary
responsibility working with families, community support, and referral
Occupational therapist: focus on functional abilities of clients, ways to improve client
functioning, such as arts and crafts and focusing on psychomotor skills
Recreation therapist: helps the client achieve a balance of work and play in his or her life and
provides activities that promote constructive use of leisure or unstructured time

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CHAPTER 4: Treatment Settings and Therapeutic Programs

Vocational rehabilitation specialist: determines clients interests and abilities and matches them
with vocational choices; assist with job seeking, job retention skills, and pursuit of further
education
o Identify the different roles of the nurse in varied treatment settings and programs
Public health nurses working in the community provide mental health prevention services to
reduce risks to the mental health of persons, families, and communities.
They care for children in schools and teach health-related subjects to community groups and
agencies.
Mental health services that public health and home care nurses provide can reduce the suffering
that many people experience as a result of physical disease, mental disorders, social and
emotional disadvantages, and other vulnerabilities.
Jails, homeless shelters, requiring nurses to practice in a more autonomous and independent
manner

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UNIT 1: Current Theories and Practice