Mental health care has undergone profound changes
in the past 50 years. Before the 1950s, humane treat-
ment in large state facilities was the best available
strategy for people with chronic and persistent men-
tal illness, many of whom stayed in such facilities for
months or years. The introduction of psychotropic
medications in the 1950s offered the first hope of suc-
cessfully treating the symptoms of mental illness in
a meaningful way. By the 1970s, focus on client rights
and changes in commitment laws led to deinstitution-
alization and a new era of treatment (McGihon, 1999).
Institutions could no longer hold clients with mental
illness indefinitely, and treatment in the “least re-
strictive environment” became a guiding principle and
right. Large state hospitals emptied. Treatment in the
community was intended to replace much of state-
hospital inpatient care. Adequate funding, however,
has not kept pace with the need for community pro-
grams and treatment (see Chap. 1).
Today people with mental illness receive treat-
ment in a variety of settings. This chapter describes
the range of treatment settings available for those with
mental illness and the psychiatric rehabilitation pro-
grams that have been developed to meet their needs.
Both of these sections discuss the challenges of inte-
grating people with mental illness into the community.
The chapter also addresses two populations who are
receiving inadequate treatment because they are not
connected with needed services: homeless clients and
clients who are in jail. In addition, the chapter de-
scribes the multidisciplinary team including the role
of the nurse as a member. Finally it briefly discusses
psychosocial nursing in public health and home care.
TREATMENT SETTINGS
Inpatient Hospital Treatment
In the 1980s, inpatient psychiatric care was still a
primary mode of treatment for people with mental
illness (McGihon, 1999). A typical psychiatric unit
emphasized talk therapy,or one-on-one interactions
between residents and staff, and milieu therapy,
meaning the total environment and its effect on the
client’s treatment. Individual and group interactions
focused on trust, self-disclosure by clients to staff and
one another, and active participation in groups. Ef-
fective milieu therapy required long lengths of stay
because clients with more stable conditions helped
to provide structure and support for newly admitted
clients with more acute conditions (McGihon, 1999).
By the 1990s, the economics of health care began
to change dramatically, and the length of stay in hos-
pitals decreased to just a few days. Today most Amer-
icans are insured under some form of managed care.
Managed care exerts cost-control measures such as
recertification of admissions, utilization review, and
case management—all of which have altered inpatient
treatment significantly. The growth of managed care
has been associated with declining admissions, shorter
lengths of stay, reduced reimbursement, and increased
acuity of inpatients. Therefore clients are sicker when
they are admitted and do not stay as long in the
hospital.
McGihon (1999) maintains that inpatient hospi-
tal units must change their approach to inpatient care
if they are to be effective (that is, if they are to meet
clients’ needs given the constraints on admission and
length of stay). She believes that many units are still
trying to function according to the milieu therapy ap-
proach, which is no longer practical or effective for in-
patients. Today inpatient units must provide rapid
assessment, stabilization of symptoms, and discharge
planning, and they must accomplish goals quickly. To
meet these goals, McGihon has proposed the PACED
model, which is a client-centered, multi-disciplinary
approach to a brief stay.
Pacing treatment is one of the important concepts
of the PACED model. Clinicians learn to help clients
recognize symptoms, identify coping skills, and choose
discharge supports. Once the client is safe and stable,
the clinicians and the client identify long-term issues
for the client to pursue in outpatient therapy.SCHEDULED INTERMITTENT
HOSPITAL STAYS
A unique approach to providing inpatient care for
people who seek it is scheduled, intermittent inpatient
hospital stays (Dilonardo et al., 1998). A study con-
ducted in a Veterans Administration hospital fol-
lowed two groups of people with severe and persistent
mental illness who were frequently admitted to the
hospital. One group had predetermined, scheduled
admissions to the inpatient unit over a 2-year period;
the other group used hospital admission during crises
only, as they had been doing. At the end of the 2 years,
the number of hospital stays for the two groups was
similar, but there were remarkable differences: the
group with scheduled admissions had higher self-
esteem, greater feelings of control over their lives, and
fewer negative and physical symptoms than the other
group. The authors suggested that the group with cri-
sis admission perceived coming to the hospital as a
failure, whereas the group with scheduled admission
saw admission as successful implementation of their
treatment plan. The authors believe that inpatient
care is important in the continuum of services, and
that scheduled admissions might be an alternative
for delivery of inpatient care to those who continue to
need it.4 TREATMENTSETTINGS ANDTHERAPEUTICPROGRAMS 73