Serving the homeless mentally ill: Mental health linkage

A substantial amount of research on homeless mentally ill individuals within the last 5 years has clarified their numbers, characteristics, and service needs. Research is lacking, however, on effective service models. A Mental Health Linkage model is presented, derived from practice principles in the literature, including outreach, community integration of mental health services, and meeting clients on their terms. The model is described and data on client characteristics and service operations are presented from three demonstration sites. Significant differences in client characteristics were found, indicating the heterogeneity of this population across different community contexts. When evaluated against practice principles and the program's intent, research results suggest the model's success in serving the target group by providing them with linkage and housing. Barriers identified through the demonstration projects' experiences are substantial, however, and warn of the challenges that services to homeless mentally ill individuals face within mental health agencies and within their communities.     

Relation Between Children's Perceptions of Maternal Mental Illness and Children's Psychological Adjustment

Evaluates how a child's subjective perceptions of a mentally ill parent's psychiatric symptoms and parenting skills relate to the child's psychological adjustment. In this study, 57 children and their mothers, half of whom were mothers with a severe and chronic mental illness, participated in a research protocol that included a directed observation of mother-child dyads and measures of parenting style, parent psychopathology, child behavior, and child's self-perceptions. The results indicated that children's subjective perceptions of parents' behavior are important variables in a child's adjustment.     

Providing independent housing for the homeless mentally ill: A novel approach to evaluating long-term longitudinal housing patterns

The provision of adequate housing for the severely mentally ill homeless has been considered a prerequisite for successful treatment. Whether or not providing access to independent housing environments without on-site support is an effective means for stabilizing this population in the community is far less studied. Preference studies indicate a strong desire for access to independent housing, but little is known about the ability of mentally ill homeless persons to remain in independent housing when such access is provided. The McKinney Homeless Research Demonstration Project in San Diego, CA evaluated the effectiveness of using Section 8 certificates as a means of providing independent housing to the severely mentally ill homeless. Three hundred sixty-two clients took part in a long-term experimental study employing a randomized factorial design. Clients were assigned to one of two types of supportive case management (comprehensive vs. traditional) and to one of two levels of access to independent housing (using Section 8 certificates). Innovative longitudinal summaries of housing outcomes were developed based on clients' patterns of living over time. Nine different patterns of living arrangements were identified, ranging from continuous occupation of independent housing to consistently unstable housing. Access to Section 8 housing markedly increased the probability of achieving stable independent living arrangements and of continued contact with case management services. A subset of clients in all experimental conditions followed less successful housing patterns, indicating the need to develop different service programs for individuals with different needs. Overall, however, access to independent housing had very positive effects on residential stability. © 1996 John Wiley & Sons, Inc.     

The chronically mentally ill in primary care

The role of primary care physicians in addressing the needs of chronically mentally ill patients is examined from three perspectives: assessing community prevalence; treating chronic medical problems in the context of other human service needs; and treating specific types of chronic mental disorders. About 30% of primary care patients were found to have at least one Research Diagnostic Criteria mental disorder, five-sixths of which had a duration greater than 1 year. However, about 9% of patients had some impairment and 2% had severe impairment associated with a mental disorder. Although affective disorders have the highest overall rates, personality, psychotic, and anxiety disorders contribute the greatest proportion of severe disability.     

Priorities for research on mental health in primary care settings

A Delphi study was conducted with a multi-disciplinary group of experts attending a conference on mental illness in primary care settings. Respondents' priorities for research which could maximize benefits for service developments in this field were elicited by asking them to distribute hypothetical annual research budgets among (a) 6 mental health priority areas, and (b) 7 subjects 'needing' investigation within the primary care priority area. The respondents' three top-ranked priority areas for research were: (1) primary care; (2) the elderly mentally ill; and (3) chronically disabling mental illness. Their three top-ranked subjects for investigation within the primary care priority area were: (1) the effectiveness of treatment measures; (2) the problems of mental health presenting to primary care services; and (3) the training requirements for family doctors in psychiatric skills. The results are discussed with reference to the method used and to the economic concepts of programme budgeting and marginal analysis.     

Psychiatric deinstitutionalization and its cultural insensitivity: consequences and recommendations for the future.

Despite the plethora of models and strategies for addressing issues that surround the chronically mentally ill, there remains a paucity of literature that addresses the specific implications of deinstitutionalization on racial minorities. Racial minorities comprise a significant number of the homeless, jailed, and geriatric mentally ill. History and current reality suggest the reasons why some chronically mentally ill blacks and their families have feared the impact of deinstitutionalization. This article examines the Ohio State Department of Mental Health's response to these issues as a possible prototype for statewide coordination for deinstitutionalization.     

Psychological Perspectives in Chronic Childhood Illness

Special perspectives in clinical work, consultation, and researchwith chronically ill children are elaborated. Clinical workwith the chronically ill requires a focus on the impact of illness-relatedstress on the entire family, and a consideration of coping asa process which varies with the stage and severity of physicaldisease. Moreover, the comprehensive care of chronically ill,children takes place in a highly charged interpersonal context.This process can disrupt communication among staff, can raisedifficult ethical questions and uncertainties, and should involvea close dialogue among various professional disciplines. Researchin chronic illness has been dominated by a personality-focusedparadigm associated with a counterproductive focus on differencesbetween chronically ill and physically healthy children anda neglect of factors which contribute to successful coping infamily, school, and social settings. Future research might profitablybe directed toward a study of the chronically ill children'sadjustment in various life contexts, the evaluation of the efficacyof psychosocial interventions, and exploration of how the survivorsof childhood chronic illnesses negotiate key developmental transitions.     

Relationship between the Millon Clinical Multiaxial Inventory-II and coolidge axis II inventory in chronically mentally ill older adults: A pilot study

The purpose of this study was to investigate the relationship between two self-report measures of personality disorders in older chronically mentally ill inpatients. A random sample of 30 chronically mentally ill (DSM-III-R schizophrenia, schizoaffective disorder, recurrent major depression) inpatients aged 55 and older completed the Millon Clinical Multiaxial Inventory-II (MCMI-II) and the Coolidge Axis II Inventory (CATI). The personality inventories were concurrently administered in counterbalanced fashion to assess concurrent validity of the CATI and MCMI in this older adult group. Data were submitted for correlational analysis. Median concurrent validity (raw score sums) between the CATI and MCMI-II for the 13 personality disorder scales was moderate (r = .55). Individual scale correlations ranged from −.13 for schizoid disorder to .88 for borderline disorder. Individual scale correlations were somewhat lower than previously reported values, but were above .54 for 7 of 13 disorders. Findings provide preliminary support for use of the CATI and MCMI with chronically mentally ill elders. Suggestions for future research are offered. © 1997 John Wiley & Sons, Inc. J Clin Psychol 53 : 559–566, 1997.     

HIV seroprevalence in a chronically mentally ill population.

This article describes a study undertaken to determine the prevalence of human immunodeficiency virus (HIV) infection and risk factors associated with HIV infection in a chronically mentally ill population. Patients were eligible for inclusion in the survey at their first outpatient or inpatient admission to a Maryland state psychiatric hospital between August 1990 and July 1991. Demographic and risk behavior information was collected, and unlinked HIV antibody testing was performed on blood specimens drawn for routine clinical purposes. Of 533 patients surveyed, 31 patients (5.8%) were infected with HIV. The prevalence of HIV infection was 36.4% among female patients reporting intravenous drug use and 14.5% among their male counterparts. The prevalence of HIV infection among homeless patients was 10.1%; 88.9% of those HIV infected also reported intravenous drug use. On admission, 90% of patients reported no knowledge of their HIV antibody status; 4.1% of these patients were HIV infected. The data confirmed the risk of HIV infection in this population of chronically mentally ill individuals. Risk reduction programs designed specifically for individuals with chronic mental illness need to be developed.     

Deinstitutionalization.

This paper treats the issue of the treatment of the chronically mentally disabled. The author challenges the feasibility of plans for the treatment of the chronically disabled outside of mental institutions and questions whether in actuality there has been a sufficient commitment (moral, professional, and financial) to the local noninstitutional care of this population. The history of treatment of the mentally disabled over the past three centuries is reviewed. The failure of the community mental health center movement during the 1960s is described, and the reasons for that failure are presented. A note of extreme caution is sounded as behavioral scientists and mental health planners devise methods of caring for the chronic population, lest courses be embarked upon that have been given inadequate consideration and planning.     

Women empower women: volunteers and their clients in community service

The study is aimed at examining the relationship between psychological empowerment of women volunteers and their clients in community volunteer projects in Israel. Based on an ecological approach, the study also aimed at examining whether the variables that explain empowerment of women who volunteer also explain empowerment of their clients. The sample included 148 women, who were divided into 74 volunteer‐client pairs. Psychological empowerment of volunteers did not correlate significantly with psychological empowerment of clients. However, the volunteer women's motives for volunteering and the quality of the volunteer–client interaction correlated positively with psychological empowerment of the clients. Empowerment of volunteers was explained primarily by social motives, by the quality of interactions with their clients, and by the quality of the volunteer's interaction with the coordinator of volunteer activity. In light of the findings, practical recommendations are offered for empowering women volunteers and their clients in community settings. © 2011 Wiley Periodicals, Inc.     

Referrals to social workers: a comparative study of a local authority intake team with a general practice attachment scheme

We studied clients seen by social workers in two settings, one a conventional intake team in a social services department and another where clients were referred to social workers attached to a primary health care team.

In both groups a high proportion of clients were either physically ill or disabled and the attachment group had a high proportion of clients with mental ill health. A large proportion of both groups were elderly and in general they had similar characteristics.

However, clients referred to intake teams were more likely to be unemployed, to be living on benefits in council or rented accommodation, and to have had some contact with social services before. The attachment group consisted of more women who were either housewives or working, living on either their own earnings or their husbands', and were more likely to own their own homes and not to have had previous contact with social services.

Clients referred to attached social workers were more likely to have an emotional or relationship problem, and many had practical problems as well. The implication is that attachment schemes will tap a wider section of the community and that the additional clients will have as many and as severe problems as clients referred to intake teams.

     

Psychiatric rehabilitation and staff development: Educational and organizational models

Despite their demonstrated success in several research studies, the social learning strategies that comprise psychiatric rehabilitation have not been widely used to care for severely mentally ill patients in real-world settings. One way this deficiency has been addressed is by educating staff on how to use these strategies. Staff members who participate in educational approaches to staff development — based on principles of operant and vicarious learning — quickly acquire the rehabilitation skills and are able to perform them competently. However, follow-up research suggests that organizational barriers impede the subsequent introduction and maintenance of newly acquired skills at the home program. Organizational development strategies attempt to overcome barriers like staff burnout and insufficient collegial support by helping the line-level treatment team develop a user-friendly rehabilitation program that meets the team's perceptions of appropriate intervention. The purpose of this review is to compare and contrast the educational and organizational models of staff development. This comparison will outline directions for future efforts at developing effective rehabilitation programs.     

TRADITION,PSYCHOANALYSIS AND THE THERAPEUTIC COMMUNITY

This paper addresses fundamental aspects of the notion of tradition in order to try to understand the foundations of the therapeutic community by drawing on the philosophy of Hans‐Georg Gadamer and the psychoanalytic thought of Jacques Lacan. The authors argue that, although a Kleinian reading of the therapeutic community has been dominant, a hermeneutic approach can enrich our understanding through its emphasis on language, community and dwelling. This leads to a discussion – with the use of case examples drawn from the authors' work in therapeutic communities for the severely mentally ill – of memory, community and remembering, full speech, and the intersubjective nature of being (Heidegger's Mitsein) which situates us not just within tradition but within a specific set of traditions.     

The extent of mental and physical ill-health of clients referred to social workers in a local authority department and a general attachment scheme.

Information regarding the physical and mental health of clients referred to social workers in a local authority intake team and to a general practice attachment scheme was collected over a 3-month period. Although returns to the Department of Health and Social Security during this period indicated that a very low proportion of clients were physically or mentally ill, it is clear that these figures greatly underestimate the extent of illness present. While social workers operating outside hospital and general practice attachments have been shown to have little contact with medical staff, in this study high proportions of their clients were ill and their social problems were often associated with their illness.     

The acquisition and maintenance of emergency evacuation skills with mildly to moderately retarded adults in a community living arrangement

This study investigated the effects of behavioral training on the acquisition, maintenance, and transfer of fire evacuation skills with mentally retarded adult subjects. Four subjects residing in a moderately supervised community living setting were taught to evacuate their apartments in the event of fire emergencies. A multiple baseline design across subjects was used to evaluate the impact of training on subjects' performance. Training components included instructions, modeling, behavioral rehearsal, feedback, and reinforcement. To facilitate maintenance of responding, all subjects received behavioral programming. Additional training was provided to facilitate responding during actual nighttime fire drills. To enhance the likelihood of generalization, all subjects were trained in their own apartments with actual and simulated fire cues. Assessment was carried out during daytime and nighttime hours. Day and night assessment of responding after treatment termination was also conducted. The results indicated a high level of mastery by all subjects across acquisition and response maintenance training, although only moderate levels of responding were noted during the nighttime period. Implications for future research efforts in the area of emergency responding in community settings are discussed.     

Impact of an educational support group on family participants who take care of their schizophrenic relatives

Using a stress-coping framework, we designed a six-session educational support group offering family caretakers information about schizophrenia, training in problem-solving skills for managing patient behavior, and greater access to social support and community resources. Subjects were recruited though local community mental health centers; 24 subjects participated in one of five identically structured caretakers' groups and another 24 subjects served as matched controls. Results of the multivariate analysis of covariance indicated a significant difference between the experimental and control caretakers following the intervention. Caretakers of the educational support group reported significantly reduced anxiety and personal distress and significantly more active coping behaviors (increased use of community resources and better management of home life with their schizophrenic family member). However, no changes were reported in the frequency of their negative feelings toward their mentally ill family member or in their generalized sense of self-efficacy.     

A note on news staff views of mental illness and its coverage

Questionnaires concerning community attitudes toward mental illness and opinions about news coverage of mental health topics were administered to 26 television news staff and 37 mental health workers. Results showed news personnel have positive attitudes toward the mentally ill and are aware of and concerned about negative stereotyping of mentally ill persons in news programs. The views of news staff were very similar to those of the mental health workers, suggesting substantial common ground for cooperative efforts to combat negative psychiatric stereotypes.     

Homelessness and rehospitalization: The importance of housing for the chronic mentally ill

Many have argued that problems with housing contribute to the high relapse rate among chronic mentally ill patients. Evidence that homelessness is associated with rehospitalization suggests that interventions for housing can reduce relapse rates. In this study, the relative importance of housing services versus psychiatric factors as determinants of rehospitalization, emergency room use, and aftercare compliance is examined. The analysis investigates the relative importance of housing within a community that has high rates of homelessness versus a comparison community with low homelessness rates. Results indicate that when patients need both housing and psychiatric care, services for housing make the critical difference for community tenure.     

Caregiving at the end of life

Meeting the demands of chronic illness and disease states is challenging, at best. Too often, the chronicity of the illness hastens death. The physical, psychological, and sociological changes that accompany the death of an individual require attention and forethought if the life transition is to be made with elegance and grace. This article addresses the caregiving demands for the professional and familial/social support surrounding the chronically ill individual at the end of life. Focus is placed on the preparation of advance directives-legal documents that set clear boundaries for honoring the wishes of the patient.