Elements of the Evidence Based Practice Integrated Dual Disorder Treatment

Since integrated treatment is associated with positive outcomes, programs that are carried out according to the integrated dual disorder treatment (IDDT) model are predicted to produce better outcomes for the consumers they serve. To determine how faithful or how well a program resembles the IDDT model, the IDDT Fidelity Scale was developed. (This scale can be downloaded from the Substance Abuse and Mental Health Services Administration website at Some of the items on the IDDT Fidelity Scale...

Risk among Biological Relatives

Resume For Medical Data Abstractor

The probable genetic component of these illnesses is illustrated by examining changes in the probability of developing these conditions. In the general population, for persons who do not have relatives with these conditions, the risk for schizophrenia ranges from about one-half of 1 to 1 . If one parent or sibling has the disorder, the risk is 10 times larger, jumping to 5 to 10 (Torrey, 2001). If both parents have the disorder, the probability of developing the illness can be nearly 50 ....

Carls Story

Carl first attempts to get into the workforce are representative of some of the problems people face in pursuit of their working goals. His story also illustrates some of the differences between transitional employment and supported employment. As you read this case, consider the following questions 1. Why did Carl's first attempts at employment fail 2. What were the differences between Carl's TE and SE experiences 3. Is SE the best strategy for every person like Carl 4. What will be required...

The Role of the Job Coach

Regardless of the supported employment approach, the primary support person to the supported employee is the job coach. In the early days of SE, the job coach typically arranged for the worker to be placed in a job and then provided training and support to the worker at the job site. Today, supports that are provided off the job site are more common. Previously, the job coach often educated the employer about disabilities and effective ways to teach the new employee and also tried to facilitate...

Assertive Community Treatment An Evidence Based Practice

Assertive community treatment is one of the most widely utilized evidence-based practices (EBP). As this chapter has pointed out, ACT has many positive characteristics for both the consumer and the service delivery system. Essentially, comprehensive services including medication, counseling, case management, rehabilitation, substance abuse services, and other specialized supports are provided to the consumer in the environments of his or her choice. ACT is a highly normalized service. The...

The Story of Joanna An Experience of the Linear Continuum Approach

Joanna is a 32-year-old woman who has never had a home of her own as an adult. She was diagnosed with a severe mental illness in her senior year of high school. She spent the next 10 years shuffling back and forth between psychiatric hospitals and her parents' home. When Joanna was 28 and residing at a state institution, her parents informed her and the hospital staff that when she was ready for discharge they could not take her back home. They were in the process of selling their house and...

Phases of Schizophrenia

The duration (see Box 2.2, Criterion C) of an episode of schizophrenia must persist for at least 6 months for an accurate diagnosis to be made (APA, 2000). The symptoms a person experiences during an episode may vary considerably depending on which phase of the illness is present. The prodromal phase (before the full syndrome) is a period of deterioration in functioning and increase of symptoms, both positive and negative. In The Story of Paul, from Chapter 1, Paul's inability to focus on...

Stigma and Discrimination

One of the greatest barriers to employment for people with a psychiatric disability is stigma, which was discussed in detail in Chapter 1. This stigma has several sources. The most obvious source of stigma, which we have all experienced, is the frequently negative characterization of people with mental illness by the mass media. This is reflected in many of the attitudes about mental illness held by laypersons. Media reports often leave the false impression that a person with mental illness is...

Symptoms and Etiology of Severe and Persistent Mental Illness

Persistence of Symptoms over Time 33 The Symptoms of Schizophrenia 33 Positive and Negative Symptoms 34 Delusions 34 Hallucinations 36 Thought Disorders 37 The Experience of Symptoms 37 Lack of Awareness of One's Own Symptoms as a Symptom 39 Phases of Schizophrenia 40 How the Phases of Schizophrenia Affect Consumers' Lives 41 Mood Disorders 42 How Are Schizophrenia and Mood Disorders Different 45 Relevance to Psychiatric Rehabilitation 46 Mental Illness and Developmental Disability 48 Mental...

Benefits to Peer Providers and Mental Health Systems

A number of studies were done to examine the potential benefits of peer-delivered services for the persons providing the services. Most of these studies used qualitative research methods such as interviews with peer providers (Solomon, 2004). Sherman and Porter (1991) found that peer providers had fewer hospitalizations after becoming providers. Peer providers have also reported a number of quality-of-life improvements (Armstrong, Korba, & Emard, 1995 Mowbray, Moxley, & Collins, 1998)....

Positive and Negative Symptoms

According to the official manual of the American Psychiatric Association (APA, 2000), Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM-IV-TR), the characteristic symptoms of schizophrenia can be categorized into two broad groups positive symptoms and negative symptoms. The positive symptoms appear to reflect an excess or distortion of normal functions, whereas the negative symptoms appear to reflect a diminution or loss of normal functions (APA, 2000, p....

Course of Bipolar Disorder When Taking Lithium

What typically transpires when someone with bipolar disorder takes lithium Compared to many of the clinical studies described earlier, the results from the field are mixed and disappointing. Lithium does not seem to consistently reduce the risk of recurrence of manic episodes as often as might be expected. Silverstone, McPherson, Hunt, and Romans (1998) examined the effectiveness of lithium in preventing recurrent episodes of bipolar disorder over a 2-year period following hospital discharge....

References

R., Geller, J. D., & Harvey, H. H. (1970). Systems approach to day hospitalization. Archives of General Psychiatry, 22, 550-559. Beard, J. H., Propst, R. N., & Malamud, T. J. (1982). The Fountain House model of psychiatric rehabilitation. Psychosocial Rehabilitation Journal, V(1), 47-53. Becker, D. R., Bond, G. R., McCarthy, D., Thompson, D. Xie, H., Gregory, G. J., & Drake, R. E. (2001). Converting day treatment centers to supported employment programs in...

Beyond Self Help Categories of Peer Provided Services

Self-help groups are just one way that persons who have severe mental illnesses help others who are coping with similar challenges. There are also other categories of peer-delivered services, which have been defined as services provided by individuals who identify themselves as having a mental illness who are specifically employed to help other consumers (Solomon, 2004 Solomon & Draine, 2001). Almost from its inception, the field of substance abuse counseling recognized the benefits of...

The Case Manager

The case manager is both a psychiatric rehabilitation Jack of all trades and the single point of responsibility at the core of the case management service. This PsyR generalist carries out the functions listed earlier by performing many different roles, including but not limited to case manager, integrator, expeditor, broker, ombudsman, advocate, primary therapist, individual representative, personal program coordinator, systems agent and continuity agent. (Baker & Intagliata, 1992, p. 217)...

Case Management

The term case management can mean widely different things to PsyR professionals from around the world. Despite the varied treatment procedures these differences usually represent, there is fairly good agreement about the goals of a case management system. Case management refers to any process or method for insuring that the consumer is provided needed services in a coordinated, effective and efficient manner (Baker & Intagliata, 1992, p. 215). The use of the term case management has also...

Full Support Model Assertive Community Treatment Model

In addition to providing the five basic case management functions, the full support model directly provides most or all of the necessary services for its clients. Thus there is little or no emphasis on referring clients to other existing community services. In other words, case managers utilizing the full support model are providing basic case management services plus a variety of rehabilitative and treatment services with a multidisciplinary team that typically includes a psychiatrist, nurse,...

Medication Side Effects

Side effects of psychotropic medication are particularly important. They can be very severe and harmful to the individual. Some common side effects are increased appetite, hormonal difficulties (e.g., failing to menstruate), motor difficulties (e.g., shuffling gate), muscular problems (e.g., stiffness), dryness of mouth, blurred vision, impotence, low blood pressure, seizures, and immune system reactions. The burden of side effects can be illustrated by looking at two common and very troubling...

The Independent Living Movement

The previously mentioned paradigm shift, from a linear continuum model of residential programming to a supported housing approach, was inspired in part by the efforts of people with physical disabilities to move away from institutionalized care and find innovative ways to live independently. Deegan (1992) describes the Independent Living (IL) Movement as comprised of three interrelated activities. The first is a grassroots advocacy movement led by people with physical disabilities who banded...

Supports and Professional Development

Considering the many advantages of employing peer providers and the fact that the transition from consumer to provider can be difficult, the ongoing provision of supports both inside and outside of the work environment and the education and training needs of peer providers must be considered. Skilled supervision is essential for peer providers who are dealing with both typical professional growth and development issues and the unique challenges outlined earlier. Supervisors who are working with...

History of the Supported Education Model

Services to help people with psychiatric disabilities access educational opportunities and overcome the many barriers to education addressed in the preceding section began to emerge in many places around the country in the 1980s. In 1981 the term supported education (SEd) was first used by psychiatric rehabilitation pioneers, such as Karen Unger at the Boston University Center for Psychiatric Rehabilitation. She recognized the importance of postsecondary education in enhancing quality of life,...

The Stigma of Severe Mental Illness

When someone has a severe mental illness, the diagnosis itself can cause serious problems. As Hall, Andrews, and Goldstein (1985) point out Schizophrenia is . . . a sentence as well as a diagnosis. The person labeled schizophrenic carries a powerful stigma to which other people may react with fear and rejection. Because the symptoms of these diseases can affect how a person thinks, feels, behaves, and communicates, the effects of the diseases are often apparent to other people. Unlike common...

Combined Treatment Medication and Psychosocial of Major Depression

Depression can often be a chronic disorder with a high risk of relapse that requires active treatment, often with a combination of medication and psychotherapy. Identifying which individuals would particularly benefit from psychosocial as compared to pharmacological approaches and developing an understanding of the mechanisms of action of these therapies remain major challenges (Scott & Watkins, 2004). In the treatment of major depression, behavioral therapy, cognitive-behavioral therapy,...

Peer Operated Services

A peer-operated initiative is developed, controlled, and operated by individuals who identify themselves as having a diagnosis of a mental illness. Nonconsumers may also be employed to contribute to service delivery and or the administration of the program, but consumers clearly direct the entire service delivery process including planning, policy development, direct service provision, and program evaluation. These programs, which address the social and emotional needs of consumers, are...

Psychosocial Treatments of Bipolar Disorder

Colom, Vieta, Martinez, Jorquera, and Gasto (1998) review and critique the different types of psychotherapy employed in the treatment of bipolar disorder. To date, none have established efficacy in controlled clinical trials regarding outcomes such as hospitalization, relapses, or suicidal behavior. This is in contrast to the numerous controlled studies highlighting the effectiveness of medication. Instead, a psychoeducational approach, either individually or in a group, seems to be the most...

Assertive Community Treatment and Case Management

The Need for Continuity of Care 193 Awareness of the Need for Care Coordination at the National Level 196 Case Management 196 The Case Manager 198 Models of Case Management 199 Expanded Broker Model 199 Rehabilitation Model 200 Strengths Model 200 Full Support Model (Assertive Community Treatment) Model 200 The Story of Micky 201 Evaluating Case Management 203 The Development of Assertive Community Treatment 204 Evaluating Training for Community Living 206 Evolution into ACT 206 When Is a...

Limitations on the Research Evidence

Though the evidence cited in the literature has tended to support the effectiveness of IDDT, questions have been raised about the validity of the research studies. One important source that has questioned the validity of IDDT comes from the Cochrane Review. First becoming widespread in the 1990s, Cochrane reviews focus on specific medical specialties or subspecialties, systematically gathering all relevant data generated from controlled clinical trials. Named for one of the earliest proponents...

Contents

Part I Understanding the Nature of Severe and Persistent Mental Illness Chapter 1 The Experience of Mental Illness An Introduction to Psychiatric Rehabilitation The Stigma of Severe Mental Illness 13 Chapter 2 Symptoms and Etiology of Severe and Persistent Mental Illness Relevance to Psychiatric Rehabilitation 46 Chapter 3 Course, Treatment, and Outcome of Severe and Persistent Mental Illnesses Do Rehabilitation Services Matter 78 Treatment 79 Biological (Somatic) Treatments 79 Psychosocial...

Atypical or Second Generation Antipsychotic Medication

Clozapine, first introduced in the 1950s, but not widely used in the United States until the 1990s, and a number of other antipsychotics are a heterogeneous group of medications that are commonly referred to as the atypical antipsychotics. The atypicals differ significantly from one another in terms of the neurotransmitter receptors that they occupy, such as different types of dopamine receptor and serotonin receptors. However, they all act as dopamine antagonists to some extent (see Chapter...

The Symptoms of Schizophrenia

Schizophrenia is the most common disorder of persons who utilize psychiatric rehabilitation services (Arns, 1998). Diagnosing schizophrenia is difficult and takes time, in part because the symptoms of schizophrenia are so varied and numerous. As yet, there is no single definitive sign that indicates schizophrenia is present. Other serious disorders must be ruled out first. For example, many drug reactions look strikingly like schizophrenia during the acute phases of the illness, hence the term,...

Fairweather Lodges

During the early years of deinstitutionalization, a social scientist named George Fair-weather recognized the difficulties that discharged people were having with community adjustment. In response he designed an experimental program to provide a long-term supportive residential environment that also addressed individuals' social and vocational issues. What began as a research study evolved into a distinct PsyR approach known as the Fairweather Lodge model. Fairweather began his research at a...

Boarding Homes and Single RoomOccupancy Residences

A 1981 study done by Goldman, Gattozzi, and Taube estimated that at that time in the United States, 300,000 to 400,000 persons with severe mental illness were living in boarding homes, or what are also called board and care facilities. Boarding homes have existed in this country as a residential option for many kinds of people for hundreds of years. They generally involve provision of a room, meals, and other services such as laundry and housekeeping for a weekly or monthly fee. They are...

The Dilemma of Functional Expectancy and Independence Dependence Revisited

The dilemma of functional expectancy and the independence dependence dilemma were discussed earlier in terms of their burden to family members. These two factors also present a potential burden to the person with mental illness. Living with one's family, especially one's family of origin, presents constant reminders of disabilities and unful filled plans and aspirations that may not be helpful at all. For example, there may be the daily stress of being presented with the fact that one is not...

Scientific Literature and Meetings

Starting from a small group of psychiatrists, psychologists, social workers, and other professionals working and publishing in related areas, PsyR research has come into its own during the last three decades. The first regular issue of Schizophrenia Bulletin, a quarterly journal of the National Institute of Mental Health, was published in 1974. This journal was dedicated to facilitating the dissemination and exchange of information about schizophrenia. In 1977 the IAPSRS and the Boston...

Pharmacological Treatment of Bipolar Disorder and Mania

Lithium is a mood stabilizer that has been used as a treatment for bipolar disorder in the United States since 1970 and was being used in other countries even earlier. It is an effective medication for both the treatment of acute mania and the prevention of the recurrence of both manic and depressive symptoms in bipolar disorders (Keck & McElroy, 1998). Belmaker (2004) and Keck and McElroy (1998) reviewed numerous studies showing that lithium reduces the symptoms of acute mania. Like...

Models of Case Management

There are a large number of case management programs around the country composed of service elements and philosophies borrowed from different program models. Despite this diversity, a number of identifiably unique models of case management exist and can be defined. Solomon (1992) identified four general types of commonly practiced case management 3. Strengths model (Rapp, 1998) 4. Full support model (assertive community treatment). A short explanation of each of these models is provided in the...

Lack of Awareness of Ones Own Symptoms as a Symptom

Although not explicitly included as one of the symptoms of schizophrenia or other severe and persistent mental illnesses, a lack of awareness of the symptoms themselves by the persons with the disorder seems to be a common characteristic of the illness. This is especially evident during the acute phase of the disorder. Individuals seem unaware of the fact that their symptoms are, in fact, symptoms of an illness. It seems that the disordered brain, attempting to make sense of its own state,...

The Severe Mental Illnesses

Serious and persistent mental illnesses, like the one that struck Paul, affect many people in our society and around the world. In the United States approximately 2.1 to 2.6 of the population have a mental illness that is severe enough to reduce their ability to perform living and working tasks effectively (International Association of Psychosocial Rehabilitation Services IAPSRS , 2001). This translates to 5,250,000 to 6,500,000 people in the United States. The President's New Freedom...

The Values of Psychiatric Rehabilitation

The values that underlie most, if not all, PsyR services relate directly to the goals that PsyR tries to achieve. Values are general attitudes that influence the professional's behavior in many ways. In fact, PsyR practitioners may hold these values without articulating them since they are embedded in the designs of the programs they work in and the service strategies they carry out. As you review the following five PsyR values, consider how they relate to the goals of PsyR. 1. Everyone Has the...

Supported Housing A Better Approach to Residential Services

In 1991 Paul Carling and Priscilla Ridgway (1991) identified a set of principles for community residential rehabilitation 1. The rehabilitation approach avoids the notion of placement in favor of choice (p. 72). 2. Rehabilitation-oriented residential services seek to expand consumer control, minimize rules and external structuring (e.g., staff), and maximize active consumer responsibility for day-to-day problem solving and promoting mutual support, self-help, and consumer-operated services (p....

Individual Placement Models

The individual placement model is the most individualized approach to SE. In this model, a job coach works with an individual to identify and achieve the person's vocational goal. The services used to achieve this goal will differ depending on the client's needs and wishes as well as the agencies' approach. The best-defined examples of the individual placement model for people with mental illness are the individual placement and support approach (IPS) articulated by the New Hampshire-Dartmouth...

Collaboration between Consumers and Providers

Self-help initiatives have gained both momentum and credibility in recent years, and have become essential elements in the recovery of many people who have severe mental illnesses. For some, self-help groups and other peer support services are an important adjunct to the professional psychiatric and rehabilitation services that they receive. For others, peer support initiatives represent a true alternative to the mental health system. PsyR providers and mental health administrators refer people...

Unique Challenges for Persons with Psychiatric Disabilities

In addition to these barriers encountered by many college students, people with psychiatric disabilities face a number of unique challenges. Perhaps the most obvious challenge is the mental illness itself. The case of Paul, explored in Chapter 1, clearly illustrates how acute psychiatric symptoms such as hallucinations and delusions can interfere with one's ability to focus on course material or sometimes even get to class. However, even when major symptoms are in remission, many people...

Reasons Medications Fail

Psychotropic medications must be tried for a sufficient length of time and under appropriate psychiatric supervision. However, traditional antipsychotic medications fail initially about two-thirds of the time, requiring a change in treatment strategy. A psychiatrist may determine that a particular medication is ineffective because symptoms do not improve, side effects are intolerable, or relapse occurs (Leucht et al., 2003). Initial medication failure decreases to about 50 of the time when...

Course of Mood Disorders

Although there is some evidence that the course of schizophrenia does not progressively worsen for the majority of individuals with that diagnosis, some studies suggest that the course of chronic or recurrent mood disorders may worsen over time (Kessing, 1998 Kessing, Andersen, Mortensen, & Bolwig, 1998). Outcomes studies of 2 to 5 years' duration have found that for individuals with bipolar disorder, recurrent episodes lead to deterioration in both social and vocational functioning (Keck...

Efficacy of Antipsychotic Medication

A large body of evidence supports the efficacy of antipsychotic medication in the treatment of schizophrenia, with more than 100 well-controlled studies showing that 50 to 85 of persons will improve significantly with reductions in hallucinations, delusions, thought disorders, and bizarre behavior (Lehman & Steinwachs, 1998). Those who experience symptom relief with an antipsychotic medication typically will be prescribed this medication for at least 1 year after the acute symptoms have been...

Etiology Summary

Summarizing all available evidence on the etiology of schizophrenia, Walker et al. (2004) reached the conclusion that both genetic (inherited) and prenatal (before birth) factors can give rise to a vulnerability to schizophrenia. The subsequent processes, which affect the development of neurons in the brain, especially those that occur during adolescence and exposure to stressful events, can trigger the behavioral expression of this vulnerability. Walker and colleagues point out that the...

The History of the Self Help Movement

Self-help and mutual support among persons coping with severe mental illnesses has been an important part of psychiatric rehabilitation since the field's beginning. In fact, there are some peer support initiatives that predate the establishment of PsyR as a distinct practice. For example, the group of ex-psychiatric patients described in Chapter 6, who dubbed themselves WANA (We Are Not Alone) in the 1940s, and then went on to establish Fountain House, began as a self-help group. Alcoholics...

Evidence Based Practices

From its earliest beginnings, psychiatric rehabilitation has sought, usually by trial and error, to develop effective services for persons with severe mental illness. This process has led to the existence of a large number of essentially idiosyncratic services, some of which are effective and some not. The adoption of an evidence-based practice approach is addressing this problem. The EBP process employs controlled clinical trials to identify effective services and define the critical elements...

The Future of ACT and Case Management Approaches

What is the future of ACT and related approaches Gary Bond and his colleagues (2005) have made a number of predictions (see box for a profile of Gary Bond). They believe the basic ACT model will continue to improve in two ways. First, ACT will systematically incorporate EBPs such as illness management (Chapter 3), motivational interviewing for dual disorders (Chapter 8), supported employment (Chapter 9), and family psychoeduca-tion (Chapter 13) into its service package. Second, ACT will be...

The Case against the Linear Continuum Approach

Joanna's story illustrates a number of reasons why the linear continuum approach to residential treatment has been criticized in recent years. One inherent flaw in this approach is the requirement that consumers make frequent changes in their living situation. For most people, moving from one home to another is a stressful event. It means abandoning routines and settings that have become comfortable and getting used to a whole new place. Such changes are often hard to deal with for people...

The Story of Dara

Besides demonstrating an important point about the physiological basis of severe mental illness, Dara's experience provides a good illustration of the importance of educating families and consumers. As you read the following story, consider what the family should have known and what effect their not knowing had on their attitude about Dara's chances for recovery. Dara's family was upset enough about her latest episode as they called it. A 54-year-old, married woman with two children, Dara had...

Some Ineffective Treatments

In the past, some treatments deservedly received a bad name for their ineffectiveness or actual harm in helping people with serious and persistent mental illness. There were efforts to treat people with schizophrenia without antipsychotic medication (available since the 1950s) and with only psychotherapies, such as traditional insight-oriented individual and group therapy. These resulted in very poor outcomes for the treatment recipients (Hogarty, 1993 Lehman & Steinwachs, 1998)....

Features of Effective Vocational Services

Several researchers have attempted to guide effective vocational services by identifying the characteristics, circumstances, or experiences related to or predictive of vocational success. This has proven to be a difficult task. In an extensive review of the literature, Anthony and Jansen (1984) concluded that past work experience is the best predictor of employment success. They also found that, counter to what is often believed within the populations of persons with serious mental illness,...

Are Peer Delivered Services Better than Other Services

Another group of studies found that peer-delivered services produced some superior outcomes when compared to services offered solely by nonconsumer providers. Programs that utilized peer providers resulted in a reduction in the use of hospital and crisis services when compared to traditional programs (Clarke et al., 2000 Edmunson, Bedell, Archer & Gordon, 1982 Klein, Cnaan, & Whitecraft 1998). Clarke and colleagues (2000) compared an assertive community treatment (ACT) team that included...

Class Exercise

The following vignette describes a situation that has ethical implications. Carefully read the vignette and then consider the questions that follow. Eric is a 29-year-old man with a history of many psychiatric hospitalizations. He has been referred to a number of PsyR programs in the past, but has been difficult to engage. Eric's symptoms typically include restlessness, confusion, and paranoia, and while he seems to respond well to antipsychotic medications, he frequently refuses to take them....

Introduction

To understand the course, treatment, and outcome of severe and persistent mental illness, one must consider the interrelatedness of these three areas. The course of an illness is its natural history, that is, the sequence of events throughout the length of the illness. For persons experiencing severe and persistent mental illness, this course can be lifelong and marked by a risk of recurrence of severe symptoms. Treatment is defined as any action designed to cure a disease or reduce its...

Self Advocacy and the ExPatient ConsumerSurvivor Movement

Self-advocacy can be defined on two levels. When an individual stands up to defend one's own personal or civil rights, including the right to receive high-quality treatment and rehabilitation services, he or she is involved in a form of self-advocacy. The other type of self-advocacy is when people band together to rally support for a common cause. The history of self-advocacy among people coping with severe mental illnesses dates back to mid-19th century England and the formation of the Alleged...

Standards for Creating Psychiatric Rehabilitation Professionals

USPRA, formerly known as IAPSRS, the largest organization of psychiatric rehabilitation professionals in the United States, has taken the initiative in establishing PsyR as a profession. This effort includes the establishment of a national test-based professional certification, the Certified Psychiatric Rehabilitation Practitioner, and accredited program standards through the Council on the Accreditation of Rehabilitation Facilities (CARF) and the Council on Accreditation (COA). In addition,...

Long Term Course of These Diseases

Until recently, the long-term prognosis for a person with a severe mental illness such as schizophrenia was considered bleak. Even the American Psychiatric Association manual, Recidivism Rates by Follow-up Periods Friedman, von Mering, and Hinko (1966) Franklin, Kittredge, and Thrasher (1975) Friedman, von Mering, and Hinko (1966) Friedman, von Mering, and Hinko (1966) Length of follow-up period not the same for every patient in the study. b Data were presented for individual hospital wards. c...

People with Mental Illness as Parents

Parents with a serious mental illness face the challenges that every other parent faces, often have the additional burden of being a single parent, and, in addition, they have specific, unique challenges associated with having a severe and persistent mental illness. Some of the universal challenges of parenthood include the economic burdens of caring for children, the need to develop and apply new skills to provide effective childrearing, and the need for social support from the extended...

Implementing the Supported Housing Approach

Some PsyR residential services are in the process of completing a paradigm shift from the stepwise linear continuum approach to a supported housing approach (Ridgway & Zipple, 1990). This shift involves a number of changes, not only in the type of services that are provided, but also in staff attitudes and in how financial resources are structured. Key changes in service provision strategies include a shift in staff responsibilities, which requires a different set of skills and attitudes. In...

Stateofthe Art Psychiatric Rehabilitation Day Programming

One of the most important contributions of organizations such as the United States Psychiatric Rehabilitation Association (USPRA) and publications such as the Psychiatric Rehabilitation Journal and the American Journal of Psychiatric Rehabilitation is that they bring together professionals, consumers, family members, and others from all philosophies of PsyR. This coming together, which has grown year by year, has helped to synthesize the best elements of these different program types into what...

The Symptoms of Mental Illness

Mental illnesses may present a wide variety of symptoms. The symptoms of the severe mental illnesses can be classified into two categories positive symptoms and negative symptoms. Positive symptoms refer to what is added to the individual because of the disease. Psychoses, the faulty interpretation of reality due to incorrect sensory perceptions (hallucinations) or thoughts (delusions), are good examples of positive symptoms. Negative symptoms refer to things that the individual has lost...

Guiding Principles of Psychiatric Rehabilitation

The guiding principles of psychiatric rehabilitation comprise a set of rules that can be applied to specific situations in order to achieve the goals and reflect the values of the field. In a sense, they constitute rules of thumb that PsyR practitioners can refer to when faced with important decisions. The principles are important tools for providing day-today guidance in clinical situations and for systematizing the practice of PsyR. Although the higher order values and goals are widely shared...

What Does the Term Psychiatric Rehabilitation Mean

In the helping professions, the term rehabilitate means to restore to an optimal state of constructive activity. Of course, what is optimal is relative to the individual. An individual's optimal level of constructive activity depends on several factors. How well a person functions depends on how severe the illness is at the time, the severity of the disability, the abilities he or she still possesses, the outside supports that are available, and what some theorists call the stage of recovery....

Obsolete Etiological Theories

The scientific community has made real progress in its understanding of the etiology of the major mental illnesses. At the same time, the public is still exposed to a number of discredited or obsolete theories about what causes major mental illness. Most of these obsolete theories center on early childhood psychological trauma or abusive family environments as causal factors. Harding and Zahniser (1994) describe the familial role in etiology as one of the great myths about schizophrenia. While...

The Stress VulnerabilityCoping Competence Model

The stress vulnerability coping competence model was proposed by two individuals who are well known in the field of psychiatric rehabilitation, William A. Anthony and Robert Paul Liberman (1986). An elaboration of the diathesis stress model described earlier, the stress vulnerability coping competence model provides both a theory about the cause of severe mental illness and an explanatory framework for the impact that psychiatric rehabilitation and treatment interventions can have on the...

The Story of Paul Continued from Chapter

The following aspect of Paul's story covers his attendance at a program and his efforts, with the aid of his counselor Ruth, to achieve his goals. As you read the following story, look for the strategies that Ruth uses to help Paul move toward recovery. Paul was nervous about what to expect on his first day at the program. After getting a short tour of the program from one of the members, he was directed to his counselor, Ruth. Ruth invited Paul to have a seat...

The Development of Clubhouse Programs

During the late 1940s a group of ex-patients from Rockland Psychiatric Center in New York State formed a support group, which met on the steps of the New York City Public Library in Manhattan. The support group members called themselves WANA (We Are Not Alone). A private social welfare group, the National Council of Jewish Women, became aware of the WANA group and began supporting their cause. In 1948, with the help of Elizabeth Schermerhorn, a building on West 47th Street in New York City was...

The Role of Stress

Stress Etiology

Despite what the public is encouraged to believe by the media, severe mental illness is not caused solely by the stress we encounter in our day-to-day lives. E. Fuller Torrey (2001), a psychiatrist and author who has done extensive research in this area, considers stress a minor cause at best. He points out that illnesses such as schizophrenia are not more prevalent in highly stressful times, such as during wars or large natural catastrophes such as floods, plagues, and famines. Nor do we see...

Rogers Story

Roger's story has some similarities with many of the homeless persons you might encounter on the streets of big cities. With a mental illness and co-occurring substance abuse problems, Roger has had a lifetime of difficulty understanding his conditions and trying to fit into society. While some people seem to get all the breaks, others, like Roger, seem born under a dark cloud. As you read about Roger you might consider whether his life to date would have turned out the same had he been born at...

Physical Rehabilitation as a Model for Psychiatric Rehabilitation

Several authors have suggested that the rehabilitation of persons with physical disabilities provides an apt and instructive model or analogy for understanding the rehabilitation of persons with psychiatric disabilities (e.g., Anthony, Cohen, & Farkas, 2002 Deegan, 1988). An obvious benefit of this comparison is that rehabilitation from physical injury or disease is a relatively common and acceptable phenomenon in modern society. Sports figures recovering from injuries sustained on the...

Burden and Stigma

Lefley (1989) discussed both the family burden and the family stigma associated with major mental illness. She noted that the emphasis on the family in terms of experience of mental illness has shifted from causing the disorders to being viewed as potential precipitants of relapse (Lefley, 1989, p. 556). Both the earlier and more recent views cast the family in a very negative light and contribute to the stigma experienced. Lefley (1989) also reports that families fear, sometimes with good...

Course Treatment and Outcome of Severe and Persistent Mental Illnesses

Short-Term Course of These Diseases 72 The Experience of Hospitalization 73 Long-Term Course of These Diseases 73 Course of Mood Disorders 77 Do Rehabilitation Services Matter 78 Not Just New England 79 Treatment 79 Efficacy of Antipsychotic Medication 79 Atypical or Second-Generation Antipsychotic Medication 80 Reasons Medications Fail 81 Medication Side Effects 82 What Are the Best Antipsychotic Medications 83 Do Traditional versus Second-Generation Antipsychotics Have Different Therapeutic...

Physiological Evidence of the Disease Process in the Brain

Psychiatric Rehabilitation

Many persons with schizophrenia and their families attribute the illness to psychological stress alone, a conclusion that is inconsistent with psychiatric research (Holzinger, Kilian, Lindenbach, Petscheleit, & Angermeyer, 2003). However, why would we assume that individuals who experience or observe a condition would necessarily know its origins Does being bald give you insight into the hormonal changes that have taken place to bring about hair loss Certainly not. Summarizing all available...

The Concept of Recovery

An exciting recent addition to PsyR thinking has been the development of a concept of recovery. The idea of recovery represents optimism about the future. Because the conditions associated with a severe mental illness are often lifelong, it was necessary to adopt a new conception of recovery that could coexist with the illness and its symptoms. Today, the concept of recovery from severe mental illness, with its promise of hope for the future, is becoming widely accepted. Based on models of...

Barriers to Education

Clearly supported education SEd has the capacity to greatly enrich the lives of people with psychiatric disabilities. Why then are there still relatively few individuals pursuing educational goals Why, as we will explore later in this chapter, are there so many communities in the United States that do not provide supported education services Some of the barriers to higher education are the same as those for people without disabilities, particularly persons in the lower socioeconomic classes. A...

Milieu Therapy

Day programs and some psychiatric hospital wards were largely based on a treatment strategy for providing services called milieu therapy. Milieu, a French term that literally means environment, refers in this case to the physical, social, and cultural setting of the program. Milieu therapy is a technique based on the idea that every aspect of a treatment setting or environment can be used to help achieve therapeutic or rehabilitation goals or results. Milieu therapy can be a very powerful tool...

Researching the Principles of Psychosocial Rehabilitation

In an important set of studies, Cnaan and his colleagues 1988, 1989, 1990 addressed the lack of clarity around the definition of psychosocial rehabilitation PSR . Note PSR and PsyR are different terms for the same set of practices. They believed that the lack of agreement on the definition of PSR causes several problems. Lack of a clear definition tends to render any term, such as psychosocial rehabilitation, meaningless, since anything might be termed or labeled PSR. This all-inclusiveness...

The Burdens of Family Living for the Person with Mental Illness

Up to this point this chapter has dealt with the burden of care associated with living with a relative with mental illness. But does family life present any unique stresses or burdens to the person with mental illness As already stated, in the past, it was inaccurately assumed that family living was not only stressful, but also a possible cause of mental illness. Today we understand that this is not the case, but there is some evidence that a particular emotional environment of high expressed...

Psychiatric Rehabilitation Ethics

A code of ethics is an intellectual framework that is consistent with the principles and values of a profession. It helps us analyze and make decisions when faced with moral choices. All professions e.g., medicine, law, psychology have a specific code of ethics. An important step in the evolution of PsyR from a service provision approach to a distinct profession was the development and adoption in 1996 of a Code of Ethics for Psychiatric Rehabilitation Practitioners by IAPSRS now called USPRA ....

Three Levels of Family Involvement

The burden experienced by family members varies based on their level of involvement with the member who is ill. Terkelson 1987a proposed that there are three tiers of family involvement. In the immediate family, most often one individual, usually but not always a woman who is the mother, wife, sister, or daughter of the person with mental illness, assumes the role of principal caregiver. Much of her daily life becomes a series of illness-related occupations and preoccupations. She acknowledges...

Goals Values and Guiding Principles of Psychiatric Rehabilitation

Physical Rehabilitation as a Model for Psychiatric Rehabilitation 110 The Concept of Recovery 111 Goals, Values, and Guiding Principles 112 The Goals of Psychiatric Rehabilitation 113 The Values of Psychiatric Rehabilitation 115 Guiding Principles of Psychiatric Rehabilitation 119 A Proposed Integrated-Structural Model of Psychiatric Rehabilitation 125 Psychiatric Rehabilitation Ethics 126 Researching the Principles of Psychosocial Rehabilitation 130 Researching and Promoting Recovery 132 The...

Supported Employment

Supported Employment is really part of a social movement. It represents inclusion of people with disabilities into the fabric of community settings. DiLeo in Roberts, 1996, p. 12 With the advent of supported employment, people with the most severe disabilities, who were thought to have no vocational potential and were therefore denied access to vocational services, were finally given a chance in the workplace. Initially designed for people with severe developmental disabilities, supported...

Guiding Principles of PsyR

Equally challenging is the implementation of the guiding principles of PsyR Individualization Hospitals are geared toward serving groups, sometimes very large groups in a similar, apparently efficient manner. This works against the individualization of all services. Mall programs, discussed later, are an example of how programming can be individualized. Maximum client involvement, preference, and choice In the acute phase of the illnesses, maximum involvement by the patient is difficult,...

Stages of Change A Case Study Applying Motivational Interviewing

If an individual's treatment process consists of passing through stages, the psychiatric rehabilitation professional's task becomes helping the individual move from one treatment stage to the next. In short, the professional helps the individual accomplish the tasks of the stage he or she is currently in and encourages movement to the next stage. A specific strategy to accomplish this, motivational interviewing, has been developed by Miller and Rollnick 2002 . Defined as a client-centered,...

The Goals of Psychiatric Rehabilitation

As we stated above, the goals of PsyR represent the objectives of PsyR services. These are what all PsyR services strive to achieve for their clients. In that sense, goals are guidelines for service and go hand in hand with PsyR values. The combination of goals and values helps determine the guiding principles. Our review of several efforts to identify these ideas Anthony et al., 2002 Anthony amp Nemec, 1983 Cnaan, Blankertz, Messinger, amp Gardner, 1988, 1989, 1990 International Association of...

Consumer Centered Approach

Consumer-centered therapy, introduced by Carl Rogers in the 1940s, was a substantial departure from the traditional psychoanalytic therapies of that time. Sometimes called Albert Bandura 1977 formulated a social learning paradigm that defines five learning steps an individ- 3 ual goes through when effectively acquiring a new skill. These steps are very similar to the strategy adapted for skills training by both the Boston University direct skills teaching and UCLA skills training rehabilitation...