other programs (e.g., vocational rehabilitation; med-
ical, dental, and psychiatric care; psychosocial reha-
bilitation programs or services) as needed.
Some agencies provide respite housing, or crisis
housing services, for clients in need of short-term, tem-
porary shelter. These clients may live in a group home
or independently most of the time but have a need for
“respite” from their usual residence. This usually oc-
curs when the client experiences a crisis, feels over-
whelmed, or cannot cope with problems or emotions.
Respite services often provide increased emotional
support and assistance with problem solving in a set-
ting away from the source of the client’s distress. One
such program is START in San Diego County, Califor-
nia. Acute care services, delivered in a facility in a res-
idential neighborhood, provide an alternative to more
expensive hospitalization. Each year, the six START
programs in San Diego County provide 24,000 days of
care to 3000 adults with psychiatric illness.
Boydell et al. (1999) found that a client’s living en-
vironment affected his or her level of functioning, rate
of reinstitutionalization, and duration of remaining in
the community setting. In fact, the living environment
was more predictive of the client’s success than were
the characteristics of his or her illness. A client with
a poor living environment in the community would
leave the community or be readmitted to the hospital.
This study showed the need for finding quality living
situations for clients, which is often a difficult task.
Boydell et al. (1999) also found that many clients were
living in crime-ridden or commercial, rather than res-
idential, areas.
Frequently residents oppose plans to establish a
group home or residential facility in their neighbor-
hood. They argue that having a group home will de-
crease their property values, and they may believe that
people with mental illness are violent, act bizarrely in
public, or will be a menace to their children. These peo-
ple have strongly ingrained stereotypes and a great
deal of misinformation. Local residents must be given
the facts so that safe, affordable, and desirable hous-
ing can be established for persons needing residential
care. Nurses are in a position to advocate for clients by
providing education to members of the community.
Evolving Consumer Households
The evolving consumer household (ECH)is a
group-living situation in which the residents make
the transition from a traditional group home to a res-
idence where they fulfill their own responsibilities and
function without on-site supervision from paid staff
(Ware, 1999). This concept was developed as part of the
Boston McKinney Research Demonstration Project in
the early 1990s, which is sponsored by the National
Institute of Mental Health. One of the problems with
housing for people with mental illness is that they
may have to move many times, from one type of set-
ting to another, as their independence increases. This
continual moving necessitates readjustment in each
setting, making it difficult for clients to sustain their
gains in independence. Because the ECH is a per-
manent living arrangement, it eliminates the problem
of relocation.
During the demonstration project, it was found
that poverty among people with mental illness was a
significant barrier to maintaining housing, which
psychiatric rehabilitation seldom addressed (Ware &
Goldfinger, 1997). Residents often rely on government
entitlements, such as Social Security Insurance (SSI)
or Social Security Disability Insurance (SSDI), for
their income, which averages $400 to $450 per month.
Although many clients express the desire to work,
many cannot do so consistently. Even with vocational
services, the jobs available tend to be unskilled and
part-time, resulting in income that is inadequate to
maintain independent living. In addition, the SSI sys-
tem is often a disincentive to making the transition
to paid employment: the client would have to trade
a reliable source of income and much-needed health
insurance for a poorly paying, relatively insecure job
that is unlikely to include fringe benefits (Ware &
Goldfinger, 1997). The authors believed that both psy-
chiatric rehabilitation programs and society must
address poverty among people with mental illness
to remove this barrier to independent living and
self-sufficiency.PSYCHIATRIC REHABILITATION
PROGRAMS
Psychiatric rehabilitation, sometimes called psycho-
social rehabilitation, refers to services designed to
promote the recovery process for clients with mental
illness (Box 4-3). This recovery goes beyond symptom
control and medication management to include per-
sonal growth, reintegration into the community, em-
powerment, increased independence, and improved
quality of life (Wilbur & Arns, 1998). Community sup-
port programs and services provide psychiatric reha-
bilitation to varying degrees, often depending on the
resources and funding available. Some programs
focus primarily on reducing hospital readmissions
through symptom control and medication manage-
ment, whereas others include social and recreation
services. There are not enough programs available
nationwide to meet the needs of people with mental
illness.
Hughes (1999) stated that the likelihood of achiev-
ing even minimal treatment goals is unlikely without
a broad array of psychosocial, vocational, and housing
services, even though these services are typically not76 Unit I CURRENTTHEORIES& PRACTICE