Mental Health: Practice Interventions
Abstract and Keywords
This entry focuses on services for adults with severe mental illness, specifically the five psychosocial interventions considered evidence-based practices. The emergence of psychiatric rehabilitation, the only professional discipline designed to serve a specified population, is described. The primary historical practice approaches, which are the foundation for psychiatric rehabilitation, are discussed. Each of the five evidence-based practices is then described with the empirical supporting evidence. The emphasis on this population and interventions were selected as social workers are the major providers for this population and frequent implementers and developers of these interventions.
Keywords: severe mental illness, psychiatric rehabilitation, evidence-based practice, assertive community treatment, family psychoeducation, supported employment, integrated treatment for co-occurring substance abuse disorders, illness management and recovery
Adults with a severe mental illness have a critical need for a combination of psychopharmacological treatment and psychosocial service interventions if they are to both reduce the symptoms of the disorders and improve the functional disabilities that result from these severe illnesses. This synergistic role of medication and psychosocial interventions was greatly clarified by a study by a prominent social worker, Gerard Hogarty, where he undertook an experiment that assessed four conditions in the aftercare of those with schizophrenia released from hospitals: medication alone, sociotherapy alone, medication and sociotherapy, and a control condition. The key finding was that those receiving both medication and sociotherapy, a combination of supportive therapy, social case work, and rehabilitation counseling, had the best functional outcomes (Hogarty & Goldberg, 1973; Hogarty, Goldberg, & Schooler, 1974). Since this landmark study, further research by Hogarty as well as others has supported this finding. A recent eulogy to Hogarty in a leading psychiatry journal noted, “His seminal studies provided proof that combining psychosocial treatments with pharmacotherapy leads to better outcomes than monotherapies” and his studies were conducted with unique creativity, impeccable science, and infectious enthusiasm (Lehman & McGlashan, 2006, p. 1677).
This entry will focus on the psychosocial intervention portion of the equation, as social workers are frequently the primary providers as well as participants in the development of these interventions. Initially, a description of those with severe mental illness will be provided, along with definitions of key terms, followed by a discussion of psychiatric rehabilitation. Then a description of the five psychosocial evidenced-based practices for this population, accompanied by supporting empirical evidence, will be presented.
Who Are Adults with Severe Mental Illness?
Adults with severe mental illness are those with psychotic disorders, which primarily include those diagnosed with schizophrenia, bipolar, and major affective disorders. Individuals with borderline personality and anxiety disorders may also be included if they have a disability resulting from the disorder. Although not everyone with these disorders has a psychiatric disability, many do. A psychiatric disability is defined as an inability to achieve commonly accepted age-appropriate milestones in major life domains due to a mental disorder. As a result of these social functional deficits, adults with severe mental illness characteristically tend to be unemployed, unmarried, and to have difficulty with interpersonal relationships. Given their lack of employment, they tend to be economically disadvantaged and are often financially supported by federal disability benefit programs. In addition, this population is extremely vulnerable to a variety of psychological, medical, and social problems, including cognitive deficits, poor health status, and having relatively high rates of substance abuse, physical and psychological trauma, homelessness, criminal justice involvement, and loss of custody of their children. Therefore, they require a variety of psychosocial interventions from a diversity of human service systems.
Since the late 1980s (the psychosocial rehabilitation movement was earlier than this—the 1960s), the professional practice field of psychiatric rehabilitation has emerged and coalesced from a diversity of specialized program approaches and models designed to address the psychosocial problems and functional disabilities of this population. Interestingly, this is one of the few professional practice fields limited to serving a very specific population. The most widely accepted definition of psychiatric rehabilitation is “to help persons with psychiatric disabilities to increase their ability to function successfully and to be satisfied in the environments of their choice with the least amount of ongoing professional intervention” (Anthony, Cohen, Farkas, & Gagne, 2002, p. 101). The rehabilitation practice interventions encompass programs and strategies that are aimed at employment, education, housing, and other aspects of social functioning and community living. Consequently, psychiatric rehabilitation is systematic practice efforts that help adults with severe psychiatric disabilities progress in their own process of recovery (Corrigan, Mueser, Bond, Drake, & Solomon, 2008). These rehabilitation practices are in contrast to treatment which refers to psychiatric medications and psychotherapy. Traditional insight-oriented psychotherapy is not generally used with this population as research has found these interventions to have negative consequences for those with schizophrenia (Drake & Sederer, 1986).
Psychiatric rehabilitation has its roots in a diversity of practice orientations. One of the major impetuses was the psychosocial rehabilitation center movement that emanated from Fountain House, a program started by discharged psychiatric patients in the late 1940s. Psychosocial centers give “members” the opportunity to work, recreate, and live in the community in an atmosphere of support, respectfulness, and acceptance (Rutman, 1993). Members work in the program by preparing the noon-day meal, being receptionists, and engaging in other tasks necessary to operate the program functionally. Center programming includes educational, vocational, and social groups, as many of the original agencies were administered by social group workers. The particular program model developed by these agencies is the Clubhouse model (http://www.iccd.org/default.aspx), which is a central meeting place for members. This program model is now incorporated into many comprehensive mental health agencies.
There are more formalized highly structured approaches to learning social skills for community living based on social learning theory. These programs began in the hospitals. The UCLA group headed by Robert Liberman developed highly structured, curriculum-based behavioral modules to learn new skills for adults with severe mental illness. These curriculums are currently available for purchase (http://www.mentalhealth.ucla.edu). More recently, psychiatric rehabilitation skills training has incorporated cognitive interventions to compensate for cognitive deficits of this population and to teach concrete skills in the environment in which they are to be used (Glynn et al., 2002; Penn & Mueser, 1996; Velligan, Ritch, Maples, Bow-Thomas, & Dassori, 2002). Other approaches to rehabilitation focus on improving an individual's own resources by modifying the environment, offering supports, or selecting an environment that will help clients to succeed at their own goals. This may mean finding a job or housing arrangement that can accommodate the needs, deficits, and strengths of the client. The rehabilitation approach includes the provision of supports, teaching problem-solving techniques, as well as coping skills in situ, and has resulted in the development of a variety of support models, for example, supported employment, supported housing, and supported education.
Consumers themselves have developed a number of peer support approaches, including consumer-operated services and mutual aid/peer support groups (Clay, 2005). It is not surprising that these consumer programs and practices have close ties to psychiatric rehabilitation, given the value placed on empowerment and the history of the psychosocial center movement being founded by consumers themselves.
Probably the most influential person in the articulation of psychiatric rehabilitation practices and values is William Anthony of the Boston University Center for Psychiatric Rehabilitation (http://www.bu.edu/cpr/). His training was that of physical rehabilitation and he argued for the equal status of psychiatric disabilities with physical disabilities. His writings stress the importance of social skill training as well as the need to provide environmental supports and modifications for adults with psychiatric disabilities. He was very much a leader in infusing federal policy initiatives with psychiatric rehabilitation practices and orientation. For example, the federal Community Support Program that influenced program models, practices, and philosophy of serving adults with severe mental illness in the community from 1980 to early 2000 came from the writings and the work of Anthony and his Center staff as well as the psychosocial center directors (Corrigan et al., 2008). The philosophies were client-centered, strengths-based approaches, respect for the client, and client self-determination. The most recent policy promotion of the federal government to transform the mental health system to a recovery orientation which emerged from the President's New Freedom Commission on Mental Health (2003) was initially articulated by Anthony in the early 1990s. However, consumers had been writing personal stories of recovery for years. Recovery in this context does not mean cure or cessation of signs, symptoms, and functional disabilities associated with psychiatric illnesses, but it refers to identifying, selecting, and pursuing goals that are personally meaningful and important to the individual, despite the symptoms of the illness and the resulting disability (Solomon & Stanhope, 2004). “[A] recovery orientation consists of changing the nature of the relationship between providers and service recipients to enact power-sharing, addressing the need for providers to subscribe to hope in their dealings with recipients, incorporating individualization in treatment (recovery) planning through recipient goal-setting, and strengthening recipients' autonomy rather than promoting increased dependence” (Felton, Barr, & Clark, 2006, pp. 112–113).
Psychosocial Evidence-Based Practices for Adults With Severe Mental Illness
For years, the Community Support Program put forth monographs promoting certain program models for working with adults with severe mental illness. Many of these made good clinical and experiential sense, given the needs of the population. However, all too frequently these interventions lacked empirical evidence to warrant saying that they were truly effective in reaching desirable outcomes for those with psychiatric disabilities. Since early 2000, five psychosocial interventions have achieved the level of evidence-based practice (EBP) and all fall within the domain of psychiatric rehabilitation (Drake, Merrens, & Lynde, 2005). These EBPs are assertive community treatment, family psychoeducation, supported employment, illness management and recovery (IMR), and integrated dual disorders treatment, and each will be described here. The Substance Abuse and Mental Health Services Administration has developed draft toolkits to assist in their implementation and is currently in the process of finalizing them (http://mentalhealth.samsa.gov/cmhs/communitysupport/toolkits/).
Assertive Community Treatment
The most well-known of the EBPs is assertive community treatment, which was developed by Stein and Test, a psychiatrist and a social work faculty member, respectively. Assertive community treatment is a self-contained, comprehensive intervention delivered by a multidisciplinary team comprising a psychiatrist, nurse, social worker, case managers, and other specialized professional providers contingent on client needs, such as substance abuse, employment, or benefit counselors. The team provides social services, rehabilitation, and psychiatric treatment in the community 24 hours a day, seven days a week to meet client needs on a time-unlimited basis. The team functions with a low client-to-staff ratio, shared caseloads, and assertive outreach to clients. The service program is designed for those with the most severe and persistent symptoms of mental illness, which is estimated to be about 10–20% of the population served in the public mental health sector. The team members offer all services, including medication management, individual supportive counseling, crisis intervention, and skill and behavioral training. Numerous systematic reviews (Corrigan et al., 2008) have consistently concluded positive outcomes for decreased hospitalizations, improvement in stable housing, consumer and family satisfaction, and cost reduction. Other positive outcomes—decreased psychiatric symptoms, improved social functioning, vocational functioning, quality of life, and adherence to prescribed medication—have been inconsistent (Corrigan et al.).
Family psychoeducation is an adjunctive intervention for families with a relative having a severe psychiatric disorder who is involved in treatment. There are a number of models, but all encompass providers joining and collaborating with families to develop an alliance, educating them about their relative's illness, teaching problem-solving skills, creating social supports for the family, and assisting in the development of skills to cope with the relative's illness. One of the models was developed by two social workers, Anderson and Hogarty (Anderson, Reiss, & Hogarty, 1986), and another, McFarlane's Multifamily Groups (McFarlane, 2002), has included involvement of social workers. Research has found no advantage of one model of family psychoeducation over another, due to the similarity in service elements (Corrigan et al., 2008). The critical elements appear to be education, family support, psychopharmacology, case management for the relative with a psychiatric disorder, and a minimum of 9-month participation in the intervention. Strong positive outcomes are fewer relapses, reduced rehospitalizations, and consequently, cost-effective (Corrigan et al., 2008). There are briefer and less intensive family educational interventions (where the ill relative is not required to be in treatment) that are widely offered, including one by the National Alliance for Mental Illness called Family-to-Family (www.nami.org). However, these educational interventions have not as yet achieved EBP status.
Supported employment is an approach to assist clients to obtain and maintain competitive jobs consistent with their individual goals, preferences, strengths, and abilities. A supported employment team composed of at least two employment specialists works collaboratively with the mental health treatment team and assists the client with all stages of employment—identifying, finding, and maintaining a job (Drake et al., 2005). The key element is integration of vocational and mental health services. Other essential elements are rapid job search by beginning job finding soon after program entry and support provided overtime, contingent on client needs and desires. Evidence has found higher rates of competitive employment when compared with those by traditional approaches to vocational rehabilitation, as well as less time to first job, longer job tenure, and higher earnings (Drake et al., 2005).
Integrated Treatment for Co-occurring Substance Abuse Disorders
This service approach is to treat both mental illness and substance use disorders by the same team of providers in the same location at the same time. The core components of the service are integration (as opposed to either sequential or parallel service), comprehensiveness, assertive outreach, reduction in negative consequences, time-unlimited service, treatment provision consistent with client's stage of recovery, use of multiple psychotherapeutic modalities, and offering a sense of hope (Drake et al., 2005). Research has found positive outcomes in such domains as substance abuse, psychiatric symptoms, housing, hospitalizations, arrests, functional status, and quality of life (Drake et al., 2005).
Illness Management and Recovery
IMR is a series of weekly sessions lasting 3–6 months in which providers assist clients to develop personal strategies for coping with mental illness and moving forward with their lives. Frequently, IMR is provided to a group of clients, but can be offered individually. Consistent with client desires, family members and other supporters may read educational handouts, attend sessions, assist clients in developing and enacting a plan for coping with their symptoms, help to reduce symptomatic exacerbations of the illness in order to prevent relapses, and assist in pursuing their recovery goals. Components of IMR are educating clients about mental illness, employing strategies to increase medication adherence, training in relapse prevention and in coping skills to effectively manage the illness (Drake et al., 2005). Currently, the limited research on the IMR program entity indicates promise. However, research on the components of IMR has found that education about mental illness improves knowledge; cognitive behavioral interventions, specifically behavioral tailoring (that is, a system of strategies to incorporate medication taking into a client's daily routine), increase medication adherence; relapse prevention programs decrease relapses and rehospitalizations; and coping skills training reduces symptomatic behaviors. Evidence is stronger for the service components than for the program model per se (Mueser et al., 2002).
Regardless as to which human service sector social workers are employed, they are likely to encounter this client population. Involvement in these diversified systems has generated new practice interventions for the population. For example, possible loss of a child's custody has produced specialized parenting programs. Currently service interventions, specifically EBPs, are available on a limited basis and they address a minimum of the population's needs. With further research, emerging best practice interventions, such as consumer-operated services and family education, will likely achieve the status of EBPs. The challenge today is to support the public behavioral health-care system in the implementation of EBPs (McHugo et al., 2007).
We have clearly progressed in the realm of service provision for this highly vulnerable population, but we still have a long way to go, particularly, since new issues are continually arising that need to be addressed. Social workers have played a significant role in the development of these practice interventions and will no doubt continue to do so, as they are the primary providers of service for this population. The main challenge to social work practitioners is to be knowledgeable about the diversity of psychiatric rehabilitation interventions, specifically EBPs, and to be willing and capable to implement them. Another major challenge is to adapt or develop new innovative and effective programs to address the needs of the most vulnerable of this population, those who are involved in the criminal justice system, and those who are homeless, and to protect mothers from losing custody of their children.
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