MENTAL HEALTH CARE HAS UNDERGONE profound changes in the past 50 years. Before the 1950s, humane treatment in large state facilities was the best available strategy for people with chronic and persistent mental illness, many of whom stayed in such facilities for months or years. The introduction of psychotropic medications in the 1950s offered the first hope of successfully treating the symptoms of mental illness in a meaningful way. By the 1970s, focus on client rights and changes in commitment laws led to deinstitutionalization and a new era of treatment. Institutions could no longer hold clients with mental illness indefinitely, and treatment in the “least restrictive environment” became a guiding principle and right. Large state hospitals emptied. Treatment in the community was intended to replace much of state hospital inpatient care. Adequate funding, however, has not kept pace with the need for community programs and treatment (see Chapter 1).
Today, people with mental illness receive treatment in a variety of settings. This chapter describes the range of treatment settings available for those with mental illness and the psychiatric rehabilitation programs that have been developed to meet their needs. Both of these sections discuss the challenges of integrating people with mental illness into the community. The chapter also addresses two populations who are receiving inadequate treatment because they are not connected with needed services: homeless clients and clients who are in jail. In addition, the special challenges facing military veterans are presented. The chapter also describes the multidisciplinary team, including the role of the nurse as a member. Finally, it briefly discusses psychosocial nursing in public health and home care.
TREATMENT SETTINGS
When the client is safe and stable, the clinicians and the client identify long-term issues for the client to pursue in outpatient therapy. Some inpatient units have a locked entrance door, requiring staff with keys to let persons in or out of the unit. This situation has both advantages and disadvantages. Nurses identify the advantages of providing protection against the “outside world” in a safe and secure environment as well as the primary disadvantages of making clients feel confined or dependent and emphasizing the staff members’
power over them.
Short Inpatient Stays
Planned short hospital stays can be as effective as longer hospitalizations. Patients spending fewer days in the hospital were just as likely to attend follow-up programming and more likely to be employed and have improved social functioning than patients with longer hospitalizations. Patients with planned shorter stays did not have disjointed care or more frequent readmissions to the hospital (Babalola et al., 2014).
The Department of Veterans Affairs (VA) hospital system has piloted a variety of alternatives to inpatient hospital admission that occurs when the client’s condition has worsened or a crisis has developed. Scheduled, intermittent hospital stays did not lessen veterans’ days in the hospital, but did improve their self-esteem and feelings of self-control. Another alternative available to veterans is the short-term acute residential treatment (START) program, located in non–hospital-based residential treatment centers. Veterans treated in the START program have the same improvement in symptoms and functioning as those treated at a VA hospital, but are typically more satisfied with the services. The cost of treatment in a START program is approximately 65% lower than treatment in the hospital.
Long-Stay Clients
Long-stay clients are people with severe and persistent mental illness who continue to require acute care services despite the current emphasis on decreased hospital stays. This population includes clients who were hospitalized before deinstitutionalization and remain hospitalized despite efforts at community placement. It also includes clients who have been hospitalized consistently for long periods despite efforts to minimize their hospital stays. Community placement of clients with problematic behaviors still meets resistance from the public, creating a barrier to successful placement in community settings.
One approach to working with long-stay clients is a unit within or near a hospital that is designed to be more homelike and less institutional. Called hostel or hospital hostel projects (in Canada and the UK), they provide access to community facilities and focus on “normal expectations,” such as cooking, cleaning, and doing housework. Clients report improved functioning, fewer aggressive episodes, and increased satisfaction with their care. Some clients remain in these settings, while others eventually resettle in the community.
The concept of crisis resolution or respite care has been successful in both rural and urban settings. The only criterion for using these services is the client’s perception of being in crisis and needing a more structured environment. A client having access to respite services is more likely to perceive his or her situation accurately, feel better about asking for help, and avoid rehospitalization. There are a variety of services in the United States, as well as England, Norway, Canada, and Australia, called crisis resolution teams (CRT) or home treatment teams designed to assist clients in dealing with mental health crises without hospitalization (Loader,
2014). Clients build therapeutic relationships with providers at crisis houses, which, in turn, lead to greater satisfaction with services, improved informal peer support, and fewer reported negative events when compared with traditional inpatient settings (Sweeney et al., 2014). While some of the positive effects may be related to the acuity of the clients’ crisis or disorder, crisis houses hold promise as a more cost-effective alternative to hospitalization.
Clients with a dual diagnosis usually require more frequent or longer hospitalizations than clients with only a mental illness diagnosis. Dual diagnosis most often refers to clients with a mental illness as well as a substance abuse diagnosis. The term may also refer to clients with a mental illness and a developmental or intellectual disability diagnosis. Clients with dual diagnoses are often more difficult to treat due to more complicated problems posed by two different diagnoses. They tend to have higher rates of nonadherence to treatment and poorer long-term outcomes. Integrated care rather than split or isolated care for the separate diagnoses is recommended (Santucci, 2012).
Case Management
Case management, or management of care on a case-by-case basis, is an important concept in both inpatient and community settings. Inpatient case managers are 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. In the community, the case manager works with clients on a broad range of issues, from accessing needed medical and psychiatric services to carrying out tasks of daily living such as using public transportation, managing money, and buying groceries.
Discharge Planning
An important concept in any inpatient treatment setting is discharge planning. Environmental supports, such as housing and transportation, and access to community resources and services are crucial to successful discharge planning. Discharge plans that are based on the individual client’s needs, including medication management, education, timely outpatient appointments, and telephone follow-up, are more likely to be successful (Kripalani et al., 2014). In fact, the adequacy of discharge plans is a better predictor of how long the person could remain in the community than are clinical indicators such as psychiatric diagnoses.
Case manager
Impediments to successful discharge planning include alcohol and drug abuse, criminal or violent behavior, noncompliance with medication regimens, and suicidal ideation. For example, optimal housing is often not available to people with a recent history of drug or alcohol abuse or criminal behavior. Also, clients who have suicidal ideas or a history of noncompliance with medication regimens may be ineligible for some treatment programs or services. Therefore, clients with these impediments to successful discharge planning may have a marginal discharge plan in place because optimal services or plans are not available to them. Consequently, people discharged with marginal plans are readmitted more quickly and more frequently than those who have better discharge plans.
However, discharge plans cannot be successful if clients do not follow through with the established plan.
Clients do not keep follow-up appointments or referrals if they don’t feel connected to the outpatient services or if these services aren’t perceived as helpful or valuable. Attention to psychosocial factors that address the client’s well-being, his or her preference for follow-up services, inclusion of the family, and familiarity with outpatient providers is critical to the success of a discharge plan.
One essential component of discharge planning is relapse prevention, or early recognition of relapse.
Education about relapse involves both clients and families or significant others. Interventions include symptom education, service continuity, and establishment of daily structure. Clients and families who can recognize signs of impending relapse and seek help, participate in outpatient appointments and services, and have a daily plan of activities and responsibilities are least likely to require rehospitalization.
Creating successful discharge plans that offer optimal services and housing is essential if people with mental illness are to be integrated into the community. A holistic approach to reintegrating persons into the community is the best way to prevent repeated hospital admissions and improve quality of life for clients.
Community programs after discharge from the hospital 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
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services that are necessary to stop the revolving door of repeated hospital admissions punctuated by unsuccessful attempts at community living. Assertive community treatment programs are discussed in detail later in this chapter.