Part III Those with severe and persistent illness have not been adequately recognized; these individuals require long-term care, and there is a notable lack of efficacious treatment technology Majority of individuals receive treatment from general hospitals that offer both general medical car and psychiatric care Close to 20% of inpatient care is provided by private psychiatric hospitals, while 16.4% is provided by public, state, and county mental hospitals Most clients now receive care on an outpatient basis Most clients of mental health services will see a psychiatric nurse or social worker Psychiatrics make decisions about medication while other mental health professionals proved therapy or supportive case management Paraprofessionals ? those who provide direct care but lack formal qualifications or direct authority over clients Professionals ? who possess a qualifying degree Four phases: Institutionalization ? (late 1800s to mid 1900s) ? mental hospitals as primary locus of care Deinstitutionalization ? (1950s ? 1970s) ? mental hospitals de-emphasized in favor of community-based care Consolidation of community-based care - (1980s to early 1990s) ? emphasis placed upon coordinating and integrating community mental health services, developing centralized authorities, and extending services to those most in need Managed care - (early 1990s to present) ? cost cutting and rationing of mental health services and contracting out services to private providers (i.e. privatization) Institutionalization Erving Goffman - ?Total? institution designed to care for those who are ?felt to be incapable of looking after themselves and a threat to the community? A total institution represents a closed world, where all of the individual?s needs are met and life is highly regimented and controlled Many individuals with severe, persistent mental illness still face the likelihood that they will spend some time in a state mental hospital Dowdall ? argues that mental hospitals are ?maximalist? organizations ? that is they live very long lives and are unusually resistant to change Most of the several hundred state mental hospitals created since 1773 are still in existence The average state spends 57% of its state mental health dollars on hospitals Patient population has fallen sharply since 1950 Communities fight to maintain hospitals because they provide local jobs Many now provide a range of outpatient and rehabilitation services to assorted groups of clients Deinstitutionalization The process of closing state hospitals and the transfer of inpatients to community-based mental health services, began in the 1950?s Public asylums were little more than warehouses for the ?custodial care of the poor and immigrant insane? Inpatient care could stigmatize individuals and prevent their return to society Provided little therapy or treatment; instead they acted as custodial functions and ensured that basic needs were met Harsh critics charged that asylums served primarily to control those with mental illnesses and to violate their constitutional rights 1950s and 1960s saw the advent and expansion of psychotropic drugs 1960s resulted in a series of court cases that mandated care in the least restrictive environment, psychotropic drugs provided community mental health workers with the technology to actually maintain patients in the community With the shift from hospital to community, individuals become clients rather than patients State?s police powers ? parens patriae functions ? ability to commit an individual involuntarily ? to protect the community from potential harm ?Least restrictive? mandates that health officials and courts find or create settings that allow patients to move from large custodial state institutions to facilities that: Are smaller, less structured, and integrated into the community Allow for independent living Advances in drug therapy allowed community-based care to become a reality Prozac ? depression Clozaril ? schizophrenia Prolixin ? schizophrenia ? may also affect the motor movements of patients, resulting in Parkinson-like symptoms Akinesia ? weakening and general muscular fatigue Akathisia ? the jitters Dyskinesia ? neck spasms, stiffness, grimacing, and speech impairment Tardive dyskinesia ? rhythmical involuntary movements of the tongue, face, mouth or jaw - a neurological disorder whose symptoms may persist after the individual is taken off the medication Medications used to treat bipolar disorder and severe depression (lithium and prolixin) are less likely to produce side effects and more likely to be effective in reducing the symptoms of the illness Medications used to control the symptoms of schizophrenia are most likely to produce long lasting side effects President Kennedy ? the Community Mental Health Centers Act of 1963 ? directed each state to develop a statewide plan designating catchment areas that would serve 75,000 to 200,000 people. The legislation was designed in such a way that a federal agency, the National Institute of Mental Health (NIMH) would deal directly with localities and CMHCs, bypassing state governments CMHC had many roles including: To provide focused individual competency-building programs To coordinate agencies that serve the mentally ill (transportation, housing, income maintenance, vocational rehabilitation, crisis intervention, and emergency hospitalization) To promote social support networks for those with mental illnesses The CMHCs neither directly reduced hospital populations nor served the needs of those with severe mental illness They served new patient populations; those with less acute disorders and segments of the middle class, sometimes referred to as the ?worried well? For former hospital patients, the CMHC became part of the ?shuffle to despair? as they revolved in and out of state hospitals The CMHCs were inadequately funded, and work with chronic patients involves greater expenditures of time with very little professional return Those with severe of persistent mental illness are often viewed as the least desirable clients Consolidation of Community-Based Care Decline in funding due to President Reagan?s Omnibus Reconciliation Act of 1980 NIMH provided funding for training programs and services research, and it also contributed to the development of the Community Support Program (CSP). CSP provided coordinated case management; assessment, identification, and diagnosis of those in need of crisis intervention (to prevent hospitalization); psychiatric treatment; support fro activities of daily living; psychosocial rehabilitation; client advocacy; and residential, vocational, and recreational services At present a number of federal programs reimburse individual care for chronic patients; these programs include Supplemental Security Income (SSI) [no other income, or income below poverty level], Social Security Disability Insurance (SSDI)[had to have worked and become disabled], and Medicare. Medicare ? people over age of 65 Medicaid ? low income families One consequence of the community mental health-care movement has been relying as rehabilitation as a treatment modality Rehabilitation ? the treatment goal is the improvement of social functioning and not merely the relief of symptoms Treatment provides a socialization function ? clients learn appropriate social norms and skills needed to ?fit in? Those with mental illnesses should be treated not as subjects but as active agents, with control and autonomy over their own lives and decisions Managed Care Defined as ?a set of techniques used by or on behalf of purchasers of health care benefits to manage health care costs by influencing patient care decision making through case-by-case assessments of the appropriateness of care prior to its provision? Managed care is any system that seeks to control access to care or that seeks to regulate the type and amount of care received. Precertification ? services must be preapproved before a patient may receive them Concurrent review (also referred to as case management) ? occurs when there is ongoing review of treatment at regular intervals. The purpose here is to allocate services, select less costly treatments, and ensure that those most in need receive appropriate care Gatekeepers ? primary care providers who are responsible also fro allocating mental health care Managed care controls costs by limiting access to services and by limiting the utilization of more costly services while encouraging the use of less costly services. Also emphasizes measurable success, or outcomes ? a problematic feature for mental health care, where treatment success is more difficult to define or measure Managed health care pursues the following goals: Functional improvements Measurable outcomes within a reasonable time frame Utilization of less costly services when possible Most managed care plans do not cover chronic mental illness in their standard benefit packages, and generally insufficient amount of money is given for mental health care The Domenici-Wellstone amendment ? effective Jan. 1, 1988 ? prohibits different annual reimbursement levels and lifetime caps for mental health. However, the legislation is limited in that it affects only those plans that already cover mental health, and those plans may elect to drop it Managed care companies have a financial incentive to have more providers at lower levels of professional training because the fees will be lower. Consequently, outpatient networks consist primarily of social workers and psychologists Medicare?s prospective payment system (PPS) is a form of managed care that relies on a preset reimbursement for a given diagnosis related group (DRG). ?Carve out? arrangements ? where a managed care firm may contract its mental health services to a specialty mental health provider State mental health authorities (SMHA) have also embraced managed care Utilized managed mental health-care vendors ? that is, managed care firms that offer their services to help state and local mental health authorities manage care Managed care is a strategy that may increase availability of treatment, contain costs, and increase quality, but it could result as well in denial of needed treatment, reduction in quality of service, and cost shifting to patients, families, professionals, and the community. The National Association for Health Quality (NAHQ) is another organization that seeks, by establishing standards, to improve the quality of care provided to enrollees of managed care organizations National Alliance for the Mentally Ill ? found that managed care is failing to bring the best clinical practices to those with sever mental illness Americans with Disabilities Act (ADA, passed in 1990) ? mandates that employers must hire those with mental handicaps who are qualified to perform the essential functions of the job and to provide reasonable accommodations for these employees. Both measures (parity and ADA) point toward greater recognition, and perhaps acceptance, of mental health problems, and they may lead the way to an improved mental health service system The MHPA may prevent your large group health plan from placing annual or lifetime dollar limits on mental health benefits that are lower - less favorable - than annual or lifetime dollar limits for medical and surgical benefits offered under the plan. Psychiatric Rehabilitation Services and Outcomes: An Overview Psychiatric Rehabilitation Enhancement of quality of life through prevention of unnecessary rehospitalization Developing strategies to manage symptomatology and to develop skills that will enable persons with mental illness to lead productive lives in the community A goal-oriented program for the mentally ill which provides coping experiences toward improved living in the community Usually includes services of vocation, residential, socialization, education, personal adjustment, and the prevention of unnecessary hospitalization Informal Staff members are active participants Biopsychosocial ? approach suggests that the rehabilitation process should take a holistic stance, acknowledging that mental illness affects areas of clients lives as intrapsychic functioning, vocational and education achievement, social interactions, and physical health and well-being Client choice ? clients are actively involved in decisions surrounding treatment Participate in developing treatment plan Rehabilitation plans ? are necessary to address the goal areas that clients choose to work on. These plans detail the changes that occur in clients? lives and environments and are continually updated to reflect those changes PSR services are delivered on an ongoing basis for as long as the client needs Situational assessments ? observations of persons demonstrating skills in naturalistic settings ? are used in place of traditional diagnostic Use of in vivo environments and community settings as well as the inclusion of non disabled partners in the treatment process Delivered to clients in the community, at their homes, and at the workplace Relationships that emphasize advocacy and partnership are developed PSR Program Models Fairweather Lodges and Clubhouses Clients reside together, work at a small community business, and co-facilitate the program with staff Developed in NYC at Fountain House Offers vocational training, social activities, housing assistance, and adult education courses Assertive Community Treatment (ACT) Consist of teams of interdisciplinary staff ? social workers, nurses, and psychiatrists ? who provide case management and skills training services directly to clients in the community, rather than requiring clients to visit a specific service site Teaching clients how to take medication, social skills training, independently living skills training, and strengthening clients? support systems by working with family and friends Skills Training Programs Teaching clients the social, intellectual, and physical skills needed to live in the community Teach clients new behaviors that they will adopt through training and practice. Clients work in small groups of ten or fewer individuals who are led by a trainer Sessions 2-3 times a week for about an hour ? 6-12 months Supported Education Improving clients? academic skills through remedial reading and math courses, assessment and treatment of learning disabilities, and college preparatory classes Clients attend college classes with other non disable students Mental health services available to them In vivo social skills training The Nature of PSR Outcomes Reduction of Unnecessary Psychiatric Hospitalization Research has document that PSR services are effective in reducing both the number and length of inpatient admissions Clients who participated in a clubhouse model spent significantly fewer days in the hospital compared with clients who participated in a peer support groups ACT clients experienced a significant reduction in the number of inpatient admissions from the ear prior to receipt of services to one year after receipt of services Vocational Outcomes These vocational services effectively increase clients? ability to find and keep paid jobs in the community PSR clients who are immediately placed in jobs had higher employment rates, earned higher salaries, and reported higher levels of job satisfaction when compared with those who undergo lengthy pre-employment training Residential Outcomes Most PSR clients prefer to live in settings that maximize their autonomy and privacy, opt for living with nondisabled persons rather than other clients, and prefer staff assistance on an as-needed rather than on-site basis Educational Outcomes Studies have found that clients who receive PSR educational services are more likely to return to college on a full-time basis Social Skills Research has found that skills training is an effective tool in helping clients reduce symptoms and improve personal interaction PSR programs may help clients practice and improve their skills through evening and weekend recreational activities and holiday parties, which provide clients with opportunities for interaction as well as peer support Client Satisfaction Overall, clients are satisfied with the PSR services they receive Clients requested increased program hours, staff, and transportation Clients reported that increased collaboration between clients and staff was needed Quality of Life Studies suggest that PSR programs do help clients improve their quality of life Found that clients who felt empowered also noted significant improvements in social relationships, health, and residential situations Issues in Studying PSR Outcomes The likelihood that treatments will influence different outcomes in various ways coexists alongside the possibility of unintended negative outcomes Ex. Ongoing vocational services may enhance job retention while increasing social coping difficulties because of challenges of full social integration into the lives of co-workers Normalization: means rendering services in an environment and under conditions that are culturally normative. This approach not only maximizes an individual?s opportunities to learn, grow and function within generally accepted patterns of human behavior but it also serves to mitigate social stigma and foster inclusion. Normalization principle ? people have the right to be treated, as close as possible, like everybody elso An Introduction to the Mental Health Consumer Movement People with mental illness deal with both disabilities and stigma Stigma produces social degradation and limits social interaction for individuals with mental illness Stigma is the most detrimental Consumer movement is an effort by people with metal illness to establish control over psychiatric treatment and the sever social stigma that attends a psychiatric diagnosis From mental Patient to Mental Health Consumer Once discharged, patients received care from CMHCs Patients? rights groups were formed by relatively small numbers of people who had undergone psychiatric hospitalization Worked to improve conditions in hospitals and community treatment centers Laing and Thomas Szasz ? claiming that the system of care was itself a major cause of psychiatric distress They declared themselves ?psychiatric survivors? because they had endured what they saw as harsh and unwarranted treatment in psychiatric institutions Discharged patients frequently lacked money, job skills, and social supports essential in the transition to community life The client role was somewhat less restrictive than the patient role Many people had difficulty negotiating a fragmented system of services while struggling with conditions of severe mental illness, social isolation, and limited finances Emergence of the Mental Health Consumer The term ?consumer? has been in use within the movement since the early 80s As mental health consumers, activists acknowledge the existence of mental illness but also claim the right to choose the types of services they want to use Consumer/survivor/ex-patient Resources for Consumer-Run Organizations Resource mobilization theory ? as resources in the social environment increase, assets available to the social movement also increase ?Social movement industry? ? new organizations representing ideological factions within the movement emerge Resources come from a variety of channels, federal, state, local authorities CMHS continues to provide financial support for innovative services that emphasize consumer involvement Consumers have a great deal of free time due to Social Security and state welfare programs that provide some degree of financial support The National Mental Health Consumer Association, formed in 1987, works to ?fight the stigma of mental illness, improve the quality of life of people with psychiatric histories, and empower these people to speak for themselves? From 91-93, CMHS provided grants to ?empower consumers and family members and expand their roles in planning and providing services? These state grants helped establish and enhance local chapters of the National Alliance for the Mentally Ill and state Mental Health Consumer Associations CMHS provided start up funds and ongoing support for a limited time usually 3-5 years After that time MHCAs were expected to obtain continued support from state and local mental health authorities as well as from private foundations NAMI ? a social movement organization founded by family members of people with mental illness ? it was originally formed to counteract a dominant perspective among some psychiatrists that parents, particularly mothers, were the main cause of sever mental illness ?Seriously and persistently mentally ill? was coined by NAMI in order to focus attention on the needs of individuals with long-term psychiatric disabilities Organization endorses the psychiatric definition of mental illness as a type of neurological disease and lobbies at the local and national levels for increased funding for research into causes of and cures for all forms of psychiatric disease Some state and local chapters of NAMI have supported legislation making it easier for families to obtain court orders for involuntary commitment of mentally ill family members Many NAMI members endorse the use of psychiatric treatments, including medication, with or without a patient?s consent The Social Psychology of Movement Participation Social movements provide a person with a way of seeing his or her social circumstances as the product of controllable forces that are not directly attributable to individual abilities, talents or skills Goals are to combat stigma and to reform the mental health system, rather than to change the behaviors of their fellow consumers The search for ?empowerment? Mechanism for reconnecting individuals with social interactions outside the domain of clinical psychiatry and mental health treatment Reframing the Problem of Mental Illness Frames are defined as schemata of interpretation that allow an individual to identify and label life experiences Consumer movement offers an expanded frame for defining mental illness in which symptom relief is but one of several factors important to well being Promotes the ability to develop social roles apart from psychiatric interpretations and controls Antipsychiatry advocates describe mental illness as the inability of so-called sane members of society to tolerate the emotions and perceptions of others Claim that society rejects people who do not ? or cannot ? conform to social norms Mental illness is a problem of intolerance in human societies Providers as Advocates for the Consumer Movement Although providers may support the idea of ?consumer liberation? from an oppressive bureaucratic system of care, they maintain positions of power over consumers that derives from that system Because psychiatric treatments combine both behavioral and pharmaceutical therapies, patients in a psychiatric hospital face a network of relationships and social environments that are heavily determined by their diagnoses The majority of community-based staff are not psychiatrists but rather are paraprofessionals or hold bachelor?s or master?s degrees Psychiatrists are infrequent visitors in many community mental health programs ? assessments of patients, management of meds, and authorization of services that require a licensed physician The community mental health system is largely voluntary Consumer Demands for System Change Virtually all consumer groups agree on the need to reduce public stigmatization of people with mental illness Strong opposition among a small but vocal group of consumers concerning the need to protect confidentiality of patient records Consumer groups compete with one another for scarce funding The Impact of Changes in the Mental Health Service System Public agencies have provided the bulk of services to people with mental illness in state-run psychiatric hospitals In the 2nd half of the century, state hospitals have dissolved into a system of publicly funded community mental health agencies and short-stay inpatient psychiatric units in general hospitals Community mental health organizations have developed coordinated programs of care that provide a range of services not easily recognizable as medical or psychiatric in nature Managed care firms are based on a medical/surgical model for treatment and delivery Mental Illness and the Criminal Justice System To be found guilty of a crime and punished for it: A person must be blameworthy, able to choose rationally to commit the offense When the accused is competent but mental illness interfered with his ability to make rational choices concerning the offense, then that person is not responsible or blameworthy and thus is legally insane or ?not guilty by reason of insanity? NGRI A person needs to understand the nature and purpose of the criminal proceedings and be able to assist counsel in his defense If the accused cannot understand and assist, then that person is ?incompetent to stand trial? IST Parens patriae - it refers to the public policy power of the state to usurp the rights of the natural parent, legal guardian or informal carer, and to act as the parent of any child or individual who is in need of protection, such as a child whose parents are unable or unwilling to take care of him or her, or an incapacitated and dependent individual.
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