MENTAL HEALTH: CHAPTER 4: Treatment Settings and Therapeutic Programs:

Partial Hospitalization Programs (PHPs):

- Are designed to help clients make a gradual transition from being inpatients to living independently and to prevent repeat admissions. - In day treatment programs, clients return home at night; evening programs are just the reverse. - The services that different PHPs offer vary, but most programs include groups for building communication and social skills, solving problems, monitoring medications, and learning coping strategies and skills for daily living. Individual sessions are available in some PHPs as are vocational assistance and occupational and recreation therapies. - Each client has an individualized treatment plan and goals, which the client develops with the case manager and other members of the treatment team Program Goals: •Stabilizing psychiatric symptoms •Monitoring drug effectiveness •Stabilizing living environment •Improving activities of daily living •Learning to structure time •Developing social skills •Obtaining meaningful work, paid employment, or a volunteer position •Providing follow-up of any health concerns - Clients in PHPs may complete the program after an inpatient hospital stay, which is usually too short to address anything other than stabilization of symptoms and medication effectiveness. - Other clients may come to a PHP to treat problems before they really start, thus avoiding a costly and unwanted hospital stay. - Others may make the transition from a PHP to longer term outpatient therapy.

Psychosocial Nursing in Public Health and Home Care:

- Clinical practice issues such as substance abuse, domestic violence, child abuse, grief, depression, and many others - Psychosocial nursing is an important area of public health nursing practice and home care. - Public health nurses working in the community provide mental health prevention services to reduce risks to the mental health of persons, families, and communities. - Examples include primary prevention, such as stress management education; secondary prevention, such as early identification of potential mental health problems; and tertiary prevention, such as monitoring and coordinating rehabilitation services for the mentally ill. - The clinical practice of public health and home care nurses includes caring for clients and families with issues such as substance abuse, domestic violence, child abuse, grief, and depression. - In addition, public health nurses 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.

Psychosocial Nursing in Public Health and Home Care: Secondary Prevention:

- Early identification of mental health problems

SPECIAL POPULATIONS OF CLIENTS WITH MENTAL ILLNESS: Homeless Population:

- Homeless people with mental illness have been the focus of many studies. - For this population, shelters, rehabilitation programs, and prisons may serve as makeshift alternatives to inpatient care or supportive housing. - Frequent shifts between the street, programs, and institutions worsen the marginal existence of this population. - Compared with homeless people without mental illness, mentally ill homeless people are homeless longer, spend more time in shelters, have fewer contacts with family, spend more time in jail, and face greater barriers to employment. - Persons reported that being homeless and having a mental illness was the basis of more discrimination than the color of their skin. - For this population, professionals supersede families as the primary source of help. - Providing housing alone does not significantly alter the prognosis of homelessness for persons with mental illness. - Psychosocial rehabilitation services, peer support, vocational training, and daily living skill training are all important components for decreasing homelessness and improving quality of life. - In the early 1990s, the federal government authorized a grant program to address the needs of people who are homeless and have mental illness. - The program Projects for Assistance in Transition from Homelessness (PATH) funds community-based outreach, mental health, substance abuse, case management, and other support services. - Some limited housing services are available, but PATH works primarily with existing housing services in the given community - People who have been chronically homeless were able to maintain housing that was obtained for them through supported housing programs. - However, with no other services, these individuals remained socially isolated and didn't participate in the community. Interventions designed to improve social relationships and community activity are necessary to improve their quality of life - The Center for Mental Health Services initiated the Access to Community Care and Effective Services and Support (ACCESS) Demonstration Project in 1994 to assess whether more integrated systems of service delivery enhance the quality of life of homeless people with serious mental disabilities through the use of services and outreach. - ACCESS was a 5-year demonstration program located within 15 U.S. cities in nine states that represented most geographic areas of the continental United States. - Each site provided outreach and intensive case management to 100 homeless people with severe mental illnesses every year. - Positive sustained outcomes of this project included increased social support, less psychotic symptoms, and fewer days in the hospital, and participants were intoxicated fewer days when they had a positive relationship with their assigned case manager. - This project has served as a model for a variety of services in different states.

Which of the following disciplines most likely would be included as part of the interdisciplinary team? A. Physician's assistant B. Physical therapist C. Pharmacist D. Dietician

C. Pharmacist - Rationale: The pharmacist would be a member of the interdisciplinary team when medication, management of side effects, and/or interactions with nonpsychiatric medications are complex. o A physician's assistant, physical therapist, and dietician are not typically involved as members of the psychiatric interdisciplinary team.

Is the following statement true or false? Board and care homes are an example of a partial hospitalization program.

False - Rationale: A board and care home is an example of a residential treatment setting. o A day treatment program is an example of a partial hospitalization program.

Clubhouse Model:

- In 1948, Fountain House pioneered the clubhouse model of community-based rehabilitation in New York City. - There are 300 clubhouses in 33 countries worldwide and numerous related programs based on Fountain House/Clubhouse principles - Fountain House is an "intentional community" based on the belief that both men and women with serious and persistent psychiatric disabilities can and will achieve normal life goals when given opportunity, time, support, and fellowship. The essence of membership in the clubhouse is based on the following four guaranteed rights of members: •A place to come to •Meaningful work •Meaningful relationships •A place to return to (lifetime membership) - The clubhouse model provides members with many opportunities, including 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, which are usually local clinics or private practitioners. - The clubhouse model recognizes the physician-client relationship as a key to successful treatment and rehabilitation while acknowledging that brief encounters that focus on symptom management are not sufficient to promote rehabilitation efforts. - The "rehabilitation alliance" refers to the network of relationships that must develop over time to support people with psychiatric disabilities and includes the client, family, friends, clinicians, and even landlords, employers, and neighbors. - The rehabilitation alliance needs community support, opportunities for success, coordination of service providers, and member involvement to maintain a positive focus on life goals, strengths, creativity, and hope as the members pursue recovery. - The clubhouse model exists to promote the rehabilitation alliance as a positive force in the members' lives. - The clubhouse focus is on health, not illness. - Taking prescribed drugs, for example, is not a condition of participation in the clubhouse. - Members, not staff, must ultimately make decisions about treatment, such as whether or not they need hospital admission. - Clubhouse staff supports members, helps them obtain needed assistance, and, most of all, allows them to make the decisions that ultimately affect all aspects of their lives. - This approach to psychiatric rehabilitation is the cornerstone and the strength of the clubhouse model.

Is the following statement true or false? In the clubhouse model, the relationship between clients is most important.

False - Rationale: With the clubhouse model, the physician-client relationship is the most important.

Treatment Settings: Inpatient Hospital Treatment:

- In the 1980s, inpatient psychiatric care was still a primary mode of treatment for people with mental illness. - A typical psychiatric unit emphasized talk therapy, or one-on-one interactions between residents and staff, and milieu therapy, meaning the total environment and its effect on the client's treatment. - Individual and group interactions focused on trust, self-disclosure by clients to staff and one another, and active participation in groups. - Effective milieu therapy required long lengths of stay because clients with more stable conditions helped provide structure and support for newly admitted clients with more acute conditions. - By the 1990s, the economics of health care began to change dramatically, and the lengths of stay in hospitals decreased to just a few days. - Today, most insured Americans are under some form of managed care. - Managed care exerts cost-control measures such as recertification of admissions, utilization review, and case management—all of which have altered inpatient treatment significantly. - The growth of managed care has been associated with declining admissions, shorter lengths of stay, reduced reimbursement, and increased acuity of inpatients. - Therefore, clients are sicker when they are admitted and do not stay as long in the hospital. New financial penalties are assessed for institutions with high readmission rates, which have intensified efforts to reduce rehospitalization. - Today, inpatient units must provide rapid assessment, stabilization of symptoms, and discharge planning, and they must accomplish goals quickly. - A client-centered multidisciplinary approach to a brief stay is essential. - Clinicians help clients recognize symptoms, identify coping skills, and choose discharge supports. - 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.

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 United Kingdom, 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. - 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. - Crisis care systems and CRT hold promise as a more cost-effective alternative to hospitalization - Clients with a dual diagnosis usually require more frequent or longer hospitalizations than those 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 because of 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

INTERDISCIPLINARY TEAM: Recreation Therapist:

- Many recreation therapists complete a baccalaureate degree, but in some instances, persons with experience fulfill these roles. - The recreation therapist helps the client to achieve a balance of work and play in his or her life and provides activities that promote constructive use of leisure or unstructured time.

Psychosocial Nursing in Public Health and Home Care: Tertiary Prevention:

- Monitoring and coordinating psychiatric rehabilitation services

INTERDISCIPLINARY TEAM: Psychiatric Social Worker:

- Most psychiatric social workers are prepared at the master's level and are licensed in some states. - Social workers may practice therapy and often have the primary responsibility for working with families, community support, and referral.

INTERDISCIPLINARY TEAM: Occupational Therapist:

- Occupational therapists may have an associate degree (certified occupational therapy assistant) or a baccalaureate degree (certified occupational therapist). - Occupational therapy focuses on the functional abilities of the client and ways to improve client functioning, such as working with arts and crafts and focusing on psychomotor skills.

Assertive Community Treatment (1973):

- One of the most effective approaches to community-based treatment for people with mental illness is ACT - Marx, Test, and Stein (1973) conceived this idea in 1973 in Madison, Wisconsin, while working at Mendota State Hospital. - They believed that skills training, support, and teaching should be done in the community where it was needed rather than in the hospital. - Their program was first known as the Madison model, then "training in community living," and finally, ACT, or the program for assertive treatment. - The mobile outreach and continuous treatment programs of today all have their roots in the Madison model. - An ACT program has a problem-solving orientation; staff members attend to specific life issues, no matter how mundane. - ACT programs provide most services directly rather than relying on referrals to other programs or agencies, and they implement the services in the clients' homes or communities, not in offices. - The ACT services are also intense; three or more face-to-face contacts with clients are tailored to meet clients' needs. - The team approach allows all staff to be equally familiar with all clients, so clients do not have to wait for an assigned person. - ACT programs also make a long-term commitment to clients, providing services for as long as the need persists and with no time constraints. - While service is not time-limited, it may not be lifelong either. In keeping with the recovery model focus, transitioning from ACT services to less intensive services needs thoughtful planning and purposeful actions. - Strategies to support transition include building skills and planning for increased independence, relationships with new providers, coordination and integration of new services into daily routine, and celebrating transition as a success, not a loss. - ACT programs were developed and flourished in urban settings. - They have also been effective in rural areas, where traditional psychiatric services are more limited, fragmented, and difficult to obtain than in cities. - Rural areas have less money to fund services, and social stigma about mental illness is greater in rural areas, as are negative attitudes about public service programs. - Rural ACT programs have resulted in fewer hospital admissions, greater housing stability, improved quality of life, and improved psychiatric symptoms. - This success occurred even though certain modifications of traditional ACT programs were required, such as two-person teams, fewer and shorter contacts with clients, and minimal participation from some disciplines. - ACT programs have also been successful in Canada and Australia in decreasing hospital admissions and fostering community integration for persons with mental illness. - CRTs discussed previously are based on the ACT model and have been established in several different countries around the world. - In New York, ACT services have been modified to include services designed to prevent arrest and incarceration of adults with severe mental illness who have been involved in the criminal justice system.

Residential Settings:

- Persons with mental illness may live in community residential treatment settings that vary according to structure, level of supervision, and services provided - Some settings are designed as transitional housing with the expectation that residents will progress to more independent living. - Other residential programs serve clients for as long as the need exists, sometimes years. - Board and care homes often provide a room, bathroom, laundry facilities, and one common meal each day. - Adult foster homes may care for one to three clients in a family-like atmosphere, including meals and social activities with the family. - Halfway houses usually serve as temporary placements that provide support as the clients prepare for independence. - Group homes house six to 10 residents, who take turns cooking meals and sharing household chores under the supervision of one or two staff persons. - 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. - In addition to on-site staff, many residential settings provide case management services for clients and put them in touch with other programs (e.g., vocational rehabilitation; medical, dental, and psychiatric care; and psychosocial rehabilitation programs or services) as needed. - Assisted living services are available in many states, but may vary a great deal in regard to services provided. - Some agencies provide a broad range of services; others provide shelter but few services. Types Of Residential Settings: •Group homes •Supervised apartments •Board and care homes •Assisted living •Adult foster care •Respite/crisis housing - Some agencies provide respite housing, or crisis housing services, for clients in need of short-term temporary shelter. - These clients may live in group homes or independently most of the time but have a need for "respite" from their usual residences. - This usually occurs when clients experience a crisis, feel overwhelmed, or cannot cope with problems or emotions. - Respite services often provide increased emotional support and assistance with problem-solving in a setting away from the source of the clients' distress. - A client's living environment affects his or her level of functioning, rate of reinstitutionalization, and duration of remaining in the community setting. - In fact, the living environment is often more predictive of the client's success than the characteristics of his or her illness. - A client with a poor living environment often leaves the community or is readmitted to the hospital. - Finding quality living situations for clients is a difficult task. - Many clients live in crime-ridden or commercial, rather than residential, areas. - The evolving consumer household is a group living situation in which the 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. - One of the problems with housing for people with mental illness is that they may have to move many times, from one type of setting to another, as their independence increases. - This continual moving necessitates readjustment in each setting, making it difficult for clients to sustain their gains in independence. - Because the evolving consumer household is a permanent living arrangement, it eliminates the problem of relocation. - Frequently, residents oppose plans to establish a group home or residential facility in their neighborhood. - They argue that having a group home will decrease their property values, and they may believe that people with mental illness are violent, will act bizarrely in public, or will be a menace to their children. - These people have strongly ingrained stereotypes and a great deal of misinformation. - Local residents must be given the facts so that safe, affordable, and desirable housing can be established for persons needing residential care. - Nurses are in a position to advocate for clients by educating members of the community.

Short-Stay Clients:

- 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 those with longer hospitalizations. However, the trend is away from inpatient stays and toward the use of alternatives to hospitalization. - Sometimes, clients in crisis will stay in the emergency department of a hospital (a practice known as boarding) in the hope that this period of time will allow the person to avoid admission and/or be able to benefit from less intensive services. - For example, short-term residential treatment was utilized for a group of clients, most of whom were discharged to the community with no inpatient treatment - 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 an START program is approximately 65% lower than treatment in the hospital.

PSYCHIATRIC REHABILITATION AND RECOVERY:

- Psychiatric rehabilitation, sometimes called psychosocial rehabilitation, refers to services designed to promote the recovery process for clients with mental illness - Recovery goes beyond symptom control and medication management to include personal growth, reintegration into the community, empowerment, increased independence, and improved quality of life as the beginning of the recovery process. - But it doesn't stop there. Higher level goals and expectations characterize later stages of recovery , not unlike those for any person—which is the point of recovery. - One of the challenges of moving toward a recovery model of care is creating and managing the change this requires, both for individual staff and throughout the organization. - The organization must make a commitment to ongoing quality improvement, provide necessary resources and technologic support, and reward creative thinking. - The work environment needs to anticipate, manage, and celebrate change for a "recovery culture" to flourish. - Community support programs and services provide psychiatric rehabilitation to varying degrees, often depending on the resources and the funding available. - Some programs focus primarily on reducing hospital readmissions through symptom control and medication management, while others include social and recreation services. - Too few programs are available nationwide to meet the needs of people with mental illnesses. - Psychiatric rehabilitation has improved client outcomes by providing community support services to decrease hospital readmission rates and increase community integration. - At the same time, managed care has reduced the "medically necessary" services that are funded. - For example, because skills training was found to be successful in assisting clients in the community, managed care organizations defined psychiatric rehabilitation as only skills training and did not fund other aspects of rehabilitation such as socialization or environmental supports. - Clients and providers identified poverty, lack of jobs, and inadequate vocational skills as barriers to community integration, but because these barriers were not included in the "medically necessary" definition of psychiatric rehabilitation by managed care, services to overcome these barriers were not funded. - Another aspect of psychiatric rehabilitation and recovery is the involvement of peer counselors or consumer providers. - Programs employing peers found improvement in client functioning satisfaction with programming, self-confidence, and hope for recovery. - A review of several studies involving peer support of varying types showed that peers were better able to reduce inpatient use and improve many recovery outcomes - Sharing on social media provided informal or naturally occurring peer support via YouTube videos. - Persons with severe mental illness who shared in this manner found that this provided peer support, minimized social isolation, provided hope, shared day-to-day coping strategies, connected them to peers, and shared experiences of medication use and seeking mental health care. - Peer counselors can also be part of more structured delivery of services, including education about illness, recovery, medication, and services; topics of hope, self-love, pleasure, and finding happiness; and responding to crisis calls. - An added benefit of peer counseling is the peer counselor pursues his or her own recovery by giving back or making meaningful contribution to the community.

1. All are characteristics of ACT except which? a.Services are provided in the home or community. b.Services are provided by the client's case manager. c.There are no time limitations on ACT services. d.All necessary support systems are involved in ACT.

b.Services are provided by the client's case manager.

3. Which intervention is an example of primary prevention implemented by a public health nurse? a.Reporting suspected child abuse b.Monitoring compliance with medications for a client with schizophrenia c.Teaching effective problem-solving skills to high school students d.Helping a client apply for disability benefits

c.Teaching effective problem-solving skills to high school students

2. Inpatient psychiatric care focuses on all the following except a.brief interventions. b.discharge planning. c.independent living skills. d.symptom management.

c.independent living skills.

4. The primary purpose of psychiatric rehabilitation is to a.control psychiatric symptoms. b.manage clients' medications. c.promote the recovery process. d.reduce hospital readmissions.

c.promote the recovery process.

5. Managed care provides funding for psychiatric rehabilitation programs to a.develop vocational skills. b.improve medication compliance. c.provide community skills training. d.teach social skills.

c.provide community skills training.

6. The mentally ill homeless population benefits most from a.case management services. b.outpatient psychiatric care to manage psychiatric symptoms. c.stable housing in a residential neighborhood. d.a combination of housing, rehabilitation services, and community support.

d.a combination of housing, rehabilitation services, and community support.

Characteristics of Later Recovery:

•Accepting illness •Managing symptoms effectively •Being actively engaged in the community •Having meaningful social contact •Coping with family relationships •Valuing self and others

Self-Awareness Issues:

- Psychiatric-mental health nursing is evolving as changes continue in health care. - The focus is shifting from traditional hospital-based goals of symptoms and medication management to more client-centered goals, which include improved quality of life and recovery from mental illness. - Therefore, the nurse also must expand his or her repertoire of skills and abilities to assist clients in their efforts. - These challenges may overwhelm the nurse at times, and he or she may feel underprepared or ill-equipped to meet them. - Mental health services are moving into some nontraditional settings such as jails and homeless shelters. - As nursing roles expand in these alternative settings, the nurse does not have the array of backup services found in hospitals or clinics, such as on-site physicians and colleagues, medical services, and so forth. - This requires the nurse to practice in a more autonomous and independent manner, which can be unsettling. - Empowering clients to make their own decisions about treatment is an essential part of full recovery. - This differs from the model of the psychiatrist or treatment team as the authority on what is the best course for the client to follow. - It is a challenge for the nurse to be supportive of the client when the nurse believes the client has made choices that are less than ideal. - The nurse may experience frustration when working with mentally ill adults who are homeless or incarcerated or both. - Typically, these clients are difficult to engage in therapeutic relationships and may present great challenges to the nurse. - The nurse may feel rejected by clients who do not engage readily in a relationship, or the nurse may feel inadequate in attempts to engage these clients.

INTERDISCIPLINARY TEAM:

- Regardless of the treatment setting, rehabilitation program, or population, an interdisciplinary (multidisciplinary) team approach is most useful in dealing with the multifaceted problems of clients with mental illness. - Different members of the team have expertise in specific areas. - By collaborating, they can meet clients' needs more effectively. - Members of the interdisciplinary team include the pharmacist, psychiatrist, psychologist, psychiatric nurse, psychiatric social worker, occupational therapist, recreation therapist, and vocational rehabilitation specialist. - Not all settings have a full-time member from each discipline on their team; the programs and services that the team offers determine its composition in any setting.

Psychosocial Nursing in Public Health and Home Care: Primary Prevention:

- Stress management education

INTERDISCIPLINARY TEAM: Psychologist:

- The clinical psychologist has a doctorate (Ph.D.) in clinical psychology and is prepared to practice therapy, conduct research, and interpret psychological tests. - Psychologists may also participate in the design of therapy programs for groups of individuals.

SPECIAL POPULATIONS OF CLIENTS WITH MENTAL ILLNESS: Active Military and Veterans:

- The prevalence of disorders such as posttraumatic stress disorder (PTSD) and major depression among active duty military service members is greater than their civilian counterparts. - There is also an increased rate of suicide—twice that of civilians—homicide, injury, and physical illness. - The number of deployments, especially three or more, is positively correlated with PTSD, depression, bipolar disorder, and anxiety disorders. - Also common are sleep disorders, substance use, cardiovascular disease, smoking, homelessness, and marital and family dysfunction. - Military veterans have problems with all the issues listed above. - Many times, veterans may be reluctant to seek treatment, or find that treatment isn't readily available. - Dealing with the stigma or perceived stigma of mental illness can also be problematic. - Obsessive-compulsive disorder is moderately higher and more prevalent in veterans than the general population and should be routinely screened by health care providers. - Military sexual traumas are more widespread and common than most would think (and can affect both male and female veterans). - It is associated with an even greater risk for PTSD, depression, anxiety, eating disorders, substance use, sleep disorders, and suicide. - Military veterans benefit from involvement in therapeutic life changes beyond diagnosis and treatment of a mental disorder. - Areas such as diet, exercise relaxation, stress management, recreation, and spirituality need to be addressed to help veterans successfully transition back to civilian or noncombat postings

INTERDISCIPLINARY TEAM: Psychiatrist:

- The psychiatrist is a physician certified in psychiatry by the American Board of Psychiatry and Neurology, which requires a 3-year residency, 2 years of clinical practice, and completion of an examination. - The primary function of the psychiatrist is diagnosis of mental disorders and prescription of medical treatments.

SPECIAL POPULATIONS OF CLIENTS WITH MENTAL ILLNESS: Mental Illness and Incarceration:

- The rate of mental illness in the jailed population has been increasing faster than that of the general population. - It is estimated that the rate of mental illness is five times higher. - Offenders generally have acute and chronic mental illness and poor functioning, and many are homeless. - Factors cited as reasons that mentally ill people are placed in the criminal justice system include deinstitutionalization, more rigid criteria for civil commitment, lack of adequate community support, economizing 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 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 offenders with mental illness had obtained needed treatment, some might not have engaged in criminal activity. Goldman, Spaeth-Rublee, and Pincus (2018) even suggest that a separate "disparities" category would be useful for persons with severe mental illness. - They could be directed toward treatment and supportive services, rather than incarcerated. - A process of decarceration, that is, decreasing numbers of incarcerated persons, is necessary owing to expense and overcrowding. - Among those released will be some of the 350,000 prisoners with a serious mental illness. - This population more rightfully belongs in the mental health system with the treatment, structure, and support needed to address their multiple needs. - This will require increased funding and other resources. - The 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. - Although it is true that people with major mental illnesses who do not take prescribed medication are at increased risk for being violent, most people with mental illness do not represent a significant danger to others. - This fact, however, does not keep citizens from clinging to stereotypes of the mentally ill as people to be feared, avoided, and institutionalized. - If such people cannot be confined in mental hospitals for any period, there seems to be public support for arresting and incarcerating them instead. - In fact, people with a mental illness are more likely to be the victims of violence, both in prisons and in the community. People with mental illness who are in the criminal justice system face several barriers to successful community reintegration: •Poverty •Homelessness •Substance use •Violence •Victimization, rape, and trauma •Self-harm - Some communities have mobile crisis services linked to their police departments. - These professionals are called to the scene (after the situation is stabilized) when police officers believe mental health issues are involved. - Frequently, the mentally ill individual can be diverted to crisis counseling services or to the hospital, if needed, instead of being arrested and going to jail. - Often, these same professionals provide education to police to help them recognize mental illness and perhaps change their attitude about mentally ill offenders. - Detecting mental illness among detainees of inmates can be problematic. - Mental health screening is often performed by law enforcement personnel, meaning it involves the use of a screening tool that is brief and easy to administer, yet accurate. - Tools that are readily available for use in mental health screening include the Brief Jail Mental Health Screen and the Correctional Mental Health Screens (CMHS), available for both men and women (CMHS-M and CMHS-W). - It would be useful if such a screening tool was a standard part of jail admission and intake.

INTERDISCIPLINARY TEAM: Psychiatric Nurse:

- The registered nurse gains experience in working with clients with psychiatric disorders after graduation from an accredited program of nursing and completion of the licensure examination. - The nurse has a solid foundation in health promotion, illness prevention, and rehabilitation in all areas, allowing him or her to view the client holistically. - The nurse is also an essential team member in evaluating the effectiveness of medical treatment, particularly medications. - Registered nurses who obtain master's degrees in mental health may be certified as clinical specialists or licensed as advanced practitioners, depending on individual state nurse practice acts. - Advanced practice nurses are certified to prescribe drugs in many states.

INTERDISCIPLINARY TEAM: Pharmacist:

- The registered pharmacist is a member of the interdisciplinary team when medications, management of side effects, and/or interactions with nonpsychiatric medications are complex. - Clients with refractory symptoms may also benefit from the pharmacist's knowledge of chemical structure and actions of medications.

INTERDISCIPLINARY TEAM: Vocational Rehabilitation Specialist:

- Vocational rehabilitation includes determining clients' interests and abilities and matching them with vocational choices. - Clients are also assisted in job-seeking and job retention skills as well as in pursuit of further education, if that is needed and desired. - Vocational rehabilitation specialists can be prepared at the baccalaureate or master's level and may have different levels of autonomy and program supervision based on their education.

Components of an ACT Program:

•Having a multidisciplinary team that includes a psychiatrist, psychiatric-mental health nurse, vocational rehabilitation specialist, and social worker for each 100 clients (low staff-to-client ratio) •Identifying a fixed point of responsibility for clients with a primary provider of services •Ameliorating or eliminating the debilitating symptoms of mental illness •Improving client functioning in adult social and employment roles and activities •Decreasing the family's burden of care by providing opportunities for clients to learn skills in real-life situations •Implementing an individualized, ongoing treatment program defined by clients' needs •Involving all needed support systems for holistic treatment of clients •Promoting mental health through the use of a vast array of resources and treatment modalities •Emphasizing and promoting client independence •Using daily team meetings to discuss strategies to improve the care of clients •Providing services 24 hours a day that would include respite care to deflect unnecessary hospitalization and crisis intervention to prevent destabilization with unnecessary emergency department visits •Measuring client outcomes on the following aspects: symptomatology; social, psychological, and familial functioning; gainful employment; client independence; client empowerment; use of ancillary services; client, family, and societal satisfaction; hospital use; agency use; rehospitalization; quality of life; and costs

Functioning as an effective team member requires the development and practice of several core skill areas:

•Interpersonal skills, such as tolerance, patience, and understanding •Humanity, such as warmth, acceptance, empathy, genuineness, and nonjudgmental attitude •Knowledge base about mental disorders, symptoms, and behavior •Communication skills •Personal qualities, such as consistency, assertiveness, and problem-solving abilities •Teamwork skills, such as collaborating, sharing, and integrating •Risk assessment and risk management skills - The role of the case manager has become increasingly important with the proliferation of managed care and the variety of services that clients need. - No standard formal educational program to become a case manager exists, however, and people from many different backgrounds may fill this role. - In some settings, a social worker or psychiatric nurse may be the case manager. - In other settings, people who work in psychosocial rehabilitation settings may take on the role of case manager with a baccalaureate degree in a related field, such as psychology, or by virtue of their experience and demonstrated skills. - Effective case managers need to have clinical skills, relationship skills, and liaison and advocacy skills to be most successful with their clients. - Clinical skills include treatment planning, symptom and functional assessment, and skills training. - Relationship skills include the ability to establish and maintain collaborative, respectful, and therapeutic alliances with a wide variety of clients. - Liaison and advocacy skills are necessary to develop and maintain effective interagency contacts for housing, financial entitlements, and vocational rehabilitation. - As clients' needs become more varied and complex, the psychiatric nurse is in an ideal position to fulfill the role of case manager. - In 1994, the American Nurses Association stated that the psychiatric nurse can assess, monitor, and refer clients for general medical problems as well as psychiatric problems; administer drugs; monitor for drug side effects; provide drug and client and family health education; and monitor for general medical disorders that have psychological and physiologic components. - Registered nurses bring unique nursing knowledge and skills to the multidisciplinary team.

Goals of Psychiatric Rehabilitation:

•Recovery from mental illness •Personal growth •Quality of life •Community reintegration •Empowerment •Increased independence •Decreased hospital admissions •Improved social functioning •Improved vocational functioning •Continuous treatment •Increased involvement in treatment decisions •Improved physical health •Recovered sense of self