psych NUR 448 UNIT 3 chapter 22: Therapeutic Environments in Various Treatment Settings

Inpatient settings - Intensive/acute care units (locked units)

24-hour structured inpatient locked unit Emphasis on short-term, intense therapeutic interventions to provide rapid evaluation and stabilization of symptoms Criteria for admission - danger to self or others or - gravely disabled Voluntary or involuntary Severity of illness high, requiring close supervision and intervention by nursing staff ---> Acute psychiatric units provide 24-hour structured inpatient treatment within a locked setting. Treatment emphasis is on short-term, intense therapeutic interventions designed to provide the patient with rapid evaluation and stabilization of symptoms. Criteria for admission to an acute psychiatric unit include danger to self, danger to others, and gravely disabled. Patients may be admitted on either a voluntary or an involuntary basis. The severity of patients' illnesses tends to be quite high, requiring close supervision and intervention by nursing staff. The presenting problems include acute and severe or persistent mental illnesses, organic brain syndrome, detoxification from alcohol or drugs, acute situational or emotional distress, suicide threats or attempts, and medication adjustments. Staff includes psychiatrists, social workers, registered nurses, licensed practical nurses, certified nursing assistants, psychologists, marriage and family therapists, and occupational or recreational therapists.

Community Treatment Settings - Group Homes

6- to 12-bed program located in a neighborhood setting staffed with nonclinical paraprofessionals who provide specialized 24/7 homelike milieu Structured program creating a physically, emotionally, psychologically safe environment Children and adolescents Adults ---> with moderate psychological needs who either are too young or lack the skills necessary to function in an independent living situation Psychoeducation, individual and group therapy, and medication management ---> Staff members are expected to support the residents in life skills development. Residents are expected to abide by the house rules, which are clearly communicated during community group meetings. Therapeutic activities, such as psychoeducation, individual and group therapy, and medication management, may be offered in-house or accessed through community providers as needed. Nursing staff are not always employed in these settings but rather serve as consultants. Group homes for children or adolescents require a 24-hour structured supportive and educational milieu. Residents may have a history of suicidal or homicidal thoughts or impulses, but no immediate plan of intent and no recent exacerbation of symptoms. Children may be having moderate to severe functional problems in school or community settings (e.g., school suspension, involvement with the law) because of the inability to accept age-appropriate direction or supervision from the parent or guardian. Typically, the poor impulse control experienced by the child or adolescent is expressed through periodic verbal aggression directed toward self and others, interfering with the development of successful interpersonal relationships. For some older children and adolescents convicted of sexually aggressive behavior, a specialized group home setting may be an option over a locked juvenile detention facility.

Inpatient settings - Presenting problems on locked units

Acute and persistent mental illness Organic brain syndrome Detoxification from alcohol or drugs Acute situational or emotional distress Suicide threats or attempts Medication adjustment Staff members include PMHNPs, psychiatrists, social workers, RN, LPN, CNA, psychologists, marriage and family therapists, occupational and recreational therapists.

Inpatient settings - Substance abuse unit

Detoxification Acute inpatient medical and psychiatric stabilization and treatment ---> Substance abuse treatment centers provide detoxification and acute inpatient medical and psychiatric stabilization and treatment to individuals who are seeking help with an identified drug or alcohol problem. Admission criteria are based on the need for an inpatient level of care that may include detoxification from alcohol or opioids, including prescription narcotics, and detoxification and stabilization for patients in pain management programs. Therapeutic activities on substance abuse units include rigorous patient education, mindful relaxation, breathing techniques to manage acute negative affect and cravings, and cognitive restructuring techniques targeting the interactions of cognitions, emotions, and behaviors

Inpatient settings - Co-Occurring Disorders Inpatient Units

Dual-diagnosis unit focuses on co-occurring disorders of substance abuse and mental illness in a psychiatric hospital setting. - simultaneous resolution of medical and psychological crises - detoxification - psychotherapy and group activities ---> During hospitalization, patients begin to build the skills, knowledge, and motivation to abstain from substance misuse and to maintain gains achieved toward positive outcomes. These patients are at increased risk of suicidal behaviors, violence, and discharge against medical advice. After patients are stabilized medically and psychologically, they are referred to co-occurring disorder programs in the community setting.

Frank would first need to be evaluated to determine if he is in need of detoxification. A suicide assessment is also important, as Frank is using alcohol, has a history of depression, and describes himself as devastated by the DUI and the loss of the use of the company car, as well as the job mandate to obtain treatment. Frank may profit from an inpatient unit substance abuse unit. After discharge, Frank should attend a day treatment center for co-occurring disorders (alcohol and depression). He can benefit from developing coping skills to manage anxiety, frustration, and problems of daily living. He can examine his current relapse and focus on ways to prevent further relapse. Frank needs to attend AA and obtain a sponsor.

Frank is a 43-year-old Caucasian man who has been having problems with alcohol and depression for many years. Frank has had years of sobriety and would "begin using" after a crisis. Recently, Frank almost lost his job after he was stopped by a policeman and issued a DUI. A portion of Frank's job is using the company car. Frank was devastated and increased his use of alcohol. The job demanded that he receive care for his alcohol abuse. What programs would be appropriate for Frank? Why would he need each program?

Occupational therapy

Occupational therapists are trained professionals concerned with the functional abilities of patients as these abilities affect their capacity to work and perform tasks of daily living Master skills for: - self-care - work - play ---> Occupational therapists assist patients in mastering skills needed for self-care, work, and play. Activities of daily living are used by the occupational therapist to help people with mental disorders achieve maximal functioning and independence at home and in the workplace Occupational therapy assists patients in improving their concentration, focusing their minds, giving structure to their day, providing opportunities to socialize and interact with others, relieving boredom, and aiding in their recovery

B. An inpatient psychiatric short-term unit Has a lethal plan that's been thought out - actively suicidal

Ruth is a 28-year-old married woman, mother of two, who has called the suicide hot line. Her marriage has been conflicted lately, and she recently confirmed that her husband is having an affair. Her youngest child has significant physical problems that require her to be home full-time to care for him. After learning about her husband's affair, Ruth began to plan how to die. She contacted her sister to request her help in taking care of her children. She began to think about jumping from a local bridge. She described herself as feeling desperate. What setting would be appropriate for Ruth's care? A. A state inpatient long-term facility B. An inpatient psychiatric short-term unit C. A community mental health center D. An intensive outpatient program

Therapeutic Activities

The following types of therapeutic activities are offered in psychiatric settings in both inpatient and outpatient environments: (1) occupational therapy (2) recreational therapy (3) psychoeducation (4) group therapy (5) spirituality groups (6) community meetings Many different disciplines are involved in enhancing the effectiveness of the therapeutic modalities offered to patients in the recovery process.

Community meetings

addressing daily needs associated with community living Inpatient or community setting ---> Community meetings provide a forum for addressing the daily needs associated with community living, and may take place in an inpatient or community setting. For example, a halfway house may have daily morning meetings to welcome new patients, review program rules, and make general announcements about the day's activities. Community meetings also allow patients to initiate discussions of community or individual concern and receive feedback from staff and other patients. Patient-patient and patient-staff conflicts may occur, requiring a skilled group leader to assist the involved individuals in handling the situation in a positive fashion. Common patient-patient concerns involve control of the television, the radio being played too loudly, and personal hygiene (e.g., someone is not bathing regularly) Community meetings are not forums for discussing the individual treatment needs and issues of patients; rather, they serve to address daily aspects of being in the treatment environment.

Group therapy

an opportunity to get input from others, can work with large number of patients, and is economical Gain new insight, knowledge, and perspective Feeling of acceptance and belonging Accountable to group of people with similar struggles Type of group therapy depending on purpose intended - cognitive behavioral, psychodynamic, systems, interpersonal, family systems, etc. ---> Groups are an economical way of working with a large number of patients. The many benefits associated with group therapy include (1) an opportunity to address issues with input from others (gain new insight, knowledge, and perspective) (2) feeling of acceptance and a sense of belonging (3) being accountable to a group of people with similar struggles

Recreational therapy

assist patients to find activities to balance work and play Exercise group ----> Leisure time is important for all individuals and is useful in promoting mental health. For the psychiatric patient, recreational activities are an important intervention in meeting treatment outcomes. Recreational therapists and occupational therapists assist patients in finding activities that help them learn to balance work and play. Individualized plans of care may involve exercise groups, such as aerobics or strength training. The level and type of exercise are determined based on the abilities of the patient. The benefits of exercise in modulating depression and anxiety have been well documented. Exercise therapy is also a therapeutic outlet for agitation and aggression

Community Treatment Settings - Day treatment center for dual diagnosis

day treatment setting for comorbidity of mental disorder and substance addiction disorder Receive intensive, coordinated community-based mental health and substance abuse treatment by a team of professionals Group sessions Develop coping skills to manage anxiety, frustration, and problems of daily living Relapse prevention, AA, NA, secure a sponsor ---> Patients with co-occurring disorders are more difficult to treat successfully than patients with either substance abuse diagnosis or a mental disorder. Rather than parallel treatment for mental health and addictions, patients receive intensive, coordinated community-based mental health and substance abuse treatment provided by a team of professionals. Interventions found to be successful at day treatment centers are extensive and comprehensive. Group sessions are useful in motivating patients with co-occurring disorders to set goals. Day treatment centers offer an integrated approach that focuses on patients developing coping skills to manage the anxiety, frustration, and problems of daily living. Lectures, videos, and discussions on relapse prevention are crucial aspects of the program and assist patients in identifying their high-risk situations and in practicing alternative coping strategies. These patients are also encouraged to attend Alcoholics Anonymous or Narcotics Anonymous groups and to secure a sponsor.

Psychoeducation

educating patients and families regarding symptom recognition and management Provide social support. Share information to assist adaptation to living with a chronic illness. Prepare for discharge. ---> The goal of psychoeducation is to provide social support and share information relevant to the mental disorder to assist patients in their adaption to living with a chronic illness. Empirical evidence has shown that understanding mental illness helps patients and their families cope more positively with the illness

Spirituality groups

instilling hope and encouraging patients to look at faith or spirituality as resources for their recovery Run by chaplain or mental health treatment team professional Focus on forgiveness, grief, meaning in life

STATE FACILITIES - Psychiatric hospitals

long-term treatment of severely psychotic patients and forensic individuals Highly restrictive Treatment malls providing rehabilitation and recovery Skills-based relapse prevention programs Cognitive-behavioral programs to reduce symptom severity Psychoeducational meetings ---> Traditionally, state psychiatric hospitals provided long-term treatment to individuals with intellectual and developmental disabilities, chronic psychiatric disorders, and forensic cases. In 1999, there was an aggressive movement toward deinstitutionalization as a result of the Olmstead decision making "unjustified isolation" of individuals with cognitive disabilities in institutions a violation of the Americans with Disabilities Act. Population characteristics in state psychiatric hospitals have changed, reflecting an increase in forensic patients who are more severely psychotic. The environment at state psychiatric hospitals is highly restrictive. In some facilities, treatment malls are built and used to provide programs focused on rehabilitation and recovery. The rehabilitative focused approach employs: (1) skills-based relapse prevention programs to decrease recidivism rates (2) cognitive-behavioral programs to decrease symptom severity (3) psychoeducation to improve patients' knowledge of their illness Daily and weekly activities, such as community meetings, anger management, gardening, and computer skills groups, are geared toward the goal of community reintegration

Inpatient settings - Child-adolescent unit

offers comprehensive psychiatric assessment, stabilization, and short-stay intensive treatment to children and adolescents aged 2 to 17 years old who have complex psychiatric conditions Common conditions: - severe depression - bipolar disorders - impulse-control disorders - phobias - other anxiety disorders - schizophrenia - other psychotic disorders - eating disorders Staff include an extensive interdisciplinary team, including a dietitian Individual group and family therapy Psychopharmacology consultation Schoolwork Play with peers Behavior management Time-out, level or step problems, skills training groups, and seclusion protect patients from harming self or others. ----> The child-adolescent unit must meet specific age-appropriate criteria in terms of the physical environment and the treatment activities offered. Patients' schedules include time for individual, group, and family therapy; psychopharmacology consultation; and schoolwork. Time is also included for patients to play with their peers. Cognitive-behavioral therapy is the most common approach utilized with this population. Time-out, level or step programs, skills training groups, and seclusion all are approaches used to protect patients from harming themselves or others. Medication use to control disordered children and youth are highly utilized yet very controversial. Child and family-centered care - treatment focuses on patient and family working together to address issues that led to the hospitalization - parents spend significant time with children at hospital. - modifications are made for special circumstances associated with children who have grown up in foster care or group home settings

STATE FACILITIES - Forensic psychiatric hospitals

patient convicted by the court of a criminal offense and has a diagnosed mental illness Most restrictive Patients charged with criminal offense and too dangerous to reside in community Strict rules and regulations to ensure safety Correctional officers, controlled doors, metal detectors, checkpoints Staff must maintain respect and be aware of patient's feelings ---> The buildings are designed with maximum security to prevent patients from escaping. Guard-controlled doors, metal detectors, and strategically placed checkpoints throughout the facility are common features of state forensic facilities. Nurses are expected to demonstrate respect for the humanity of the patient regardless of the crime committed. Nurses must interact with these offenders in an ethical manner, cognizant of the fact that they are mentally ill. Providing care to this population is very complex, and requires a high degree of training and education.

Community Treatment Settings - Day treatment

patient stabilization, rehabilitation, and recovery in a community outpatient setting Maintain or enhance current level of functioning Maintain community living Develop self-awareness Scheduled activities Recovery model, a process, attitude of hope, and sense of control over life ---> Day treatment is similar to the partial hospitalization program in that patients attend the scheduled activities for a prescribed number of hours and specified frequency. Day treatment programs represent a midpoint between hospitalization and outpatient clinic visits. Handa and colleagues reported on a continuous day treatment program for patients with a diagnosis of schizophrenia. The treatment program employed a recovery model, whereby patients are treated for mental illness with the goal of living, working, learning, and participating fully in the community. Characteristically, recovery is not viewed as a cure but rather as a process; it is viewed as an attitude of hope and a sense of control over one's life. The recovery model is gaining prominence in the mental health field as consumers and families are advocating for a recovery-oriented approach that is person-centered rather than illness-focused.

Inpatient settings - Medical-psychiatric unit

provides care for individuals with mental illness and coexisting medical problems in need of hospitalization ---> Medical-psychiatric units are specially designed for mentally ill patients with coexisting medical problems who are in need of hospitalization. These specialized units are equipped to address the comorbid conditions simultaneously, improving outcomes. Nurses working on these units must have knowledge of psychological disorders, psychotropic drugs, medical diseases, and medications. The focus of therapeutic activities depends on the nature of the psychological and medical infirmity. Some geriatric psychiatric units have been reclassified as medical-psychiatric units because of the large number of medical problems in this population

Inpatient settings - Geropsychiatric unit

provides care to patients who have a psychiatric disorder, one or more acute or chronic health conditions, and normal age-related physical changes Alzheimer's disease Schizophrenia Fall prevention ---> Population demographics reflect an increasingly aging population with medically complex conditions. Patients on geropsychiatric units have a psychiatric disorder, one or more acute or chronic health conditions, and an array of normal age-related physical changes. The most commonly occurring mental disorders include Alzheimer disease, depression, bipolar disorder, anxiety disorder, delirium, and schizophrenia. Additionally, older patients are at increased risk for medical complications related to hypertension, kidney disease, Parkinson disease, heart disease, and numerous other chronic physical problems Specific considerations related to the treatment environment are dictated by the unique needs of this medically compromised older adult population with psychiatric problems. The physical structure of geropsychiatric units must be designed with the frail, elderly, cognitively impaired patient in mind. For example, the unit should be free of unnecessary noise to counter the vulnerability of older patients to sensory overstimulation. A smaller unit with fewer patients has been shown to improve interaction not only among patients but also between patients and staff. Older patients with dementia may experience confusion and disorientation leading to difficulty navigating the hospital environment. Interventions such as environmental cues have been found to be helpful in geropsychiatric settings. Environmental cues may include: (1) large orientation boards on which the date, time, and location of daily events are posted (2) clearly marked names or graphic images (e.g., bathrooms, bedrooms with patients' names on the doors) (3) color coding of different locations Falls are of great concern on the geropsychiatric unit. Inventor and colleagues reported that 22% of the older adult population in this setting take more than four prescribed drugs, increasing their susceptibility to drug interactions and falls. Because older patients are likely to have impairment in mobility, balance, and vision, increased lighting and simple, uncluttered rooms facilitate comfort and safety. The importance of the environment for patients in a geropsychiatric unit is evident by the increasing number of studies on facility design and planning. These studies have shown an association between the environmental design of the unit and patients' level of improvement in regard to variables such as self-care, agitation, and mood. Group therapy, for patients able to participate, might involve issues such as grief and loss. For less cognitively functional patients, group therapy might involve orientation, memory enhancement, and reminiscence activities in a more structured format.

Community Treatment Settings - Partial hospitalization

short-term, ambulatory treatment program for patients transitioning from acute psychiatric inpatient unit Reduce re-hospitalization Successful integration into community setting Full day psychiatric rehabilitation services Psychoeducation Psychiatric medication evaluation and monitoring Individual and group therapy ---> Regulatory agencies and third-party payers require a registered nurse in these facilities to attend—at the minimum—to urgent care matters that might arise, and to assist with medication administration and management. Treatment is structured similarly to the inpatient environment, but patients are considered safe enough to be able to return to their residence in the evening. After completing a partial hospitalization program, patients are stepped down to a community mental health center for day treatment or outpatient care.