facilities for psycho social rehabilitation
TRANSCRIPT
Renjulal 090504009
FACILITIES FOR PSYCHOSOCIAL REHABILITATION
INTRODUCTION
Rehabilitation services can be seen under the following categories
Rehabilitation in the hospital
Rehabilitation in the community
I. REHABILITATION IN THE HOSPITAL
Rehabilitation starts from the hospital. It starts from the day of hospitalization
Encourage positive planning by patients
Working with patients and family members
Working with natural and professional systems
Modify the living environment
Modify the hospital environment
£ Milleu therapy
Milleu therapy is given to recognize all interpersonal and environmental forces
to develop an atmosphere that facilitates client’s growth, rehabilitation, and
restoration of health.
£ Therapeutic community:
It focused attention primarily on the psychiatric unit as a social system in
which staff and patients reciprocally influence one another for better or worse
depending on the way in which system functions.
£ Establish the skills of dependence
£ Reduce the length of stay in the hospital
Renjulal 090504009
Purposeful Nurse – patient relationship
£ Structured day activity
£ Family member involvement
£ Establish outside contact
£ Formal introduction of laws rules and regulations
II. REHABILITATION IN THE COMMUNITY
Partial hospitalization
Half way homes
Quarter way homes
Sheltered workshops
Day care centres
Foster homes
Mental health emergency care
Self help group
Vocational rehabilitation
CLUBHOUSE MODEL
The Clubhouse Model is a comprehensive group approach that focuses on practical issues
in informal settings (Bond, 1995). Clubhouses are community-based rehabilitation programs
for people with psychiatric disability offering vocational opportunities, planning for housing,
problem-solving groups, case management, recreational activities, and academic preparation.
Individuals can learn or regain skills necessary to live a productive and empowering life. The
Clubhouse Model provides for the societal, occupational, and interpersonal needs of the
person as well as medical and psychiatric needs (Fountain House, 1999).
Renjulal 090504009
a) PARTIAL HOSPITALIZATION
Partial hospitalization program is "one step away" from actual hospitalization. It is used to
treat mental illness and substance abuse. In partial hospitalization, the patient continues to
reside at home, but commutes to a treatment centre up to seven days a week. It focuses on
overall treatment of the individual, rather than purely safety.
1) DAY HOSPITALIZATION
Day hospitalization is most popular and frequently used in India. It has a structural treatment
set up where the patient from home and other institutions attends from 8 am to 5pm and after
that they will go back to the same place from where they came. It provides social and
occupational and vocational rehabilitation for the services. It is also used for crisis
intervention.
Advantages of day hospital are:
There is no separation from family and friends
The personal identity is maintained
The self esteem will not become low when compare to in-patient care
The social sigma to the patient will be less
They have all professional contact in day time with various therapeutic activities and
family contact in night
The day time can be used for maintaining social and vocational roles
There is a possibility of regression and the face of life stresses is reduced
The cost of the day hospitalization is less than that of total hospitalization
The cost effectiveness of day hospitalization compared to that of in-patient
hospitalization is 1: 3
Renjulal 090504009
Disadvantages of day hospitalization are:
It is not possible to manage acute family distress
Aggressive and self destructive patients cannot be treated
It is easier for a day patient than an in-patient to drop the treatment
Some patients may depend on others
Logically not feasible to some group of patients
2) NIGHT HOSPITALIZATION
This is another method of easing the transition from hospital to the community life. Patient
goes to work in the morning and return to the hospital at the night. It will offer support until
the patient feels secure enough to get a full discharge. Night hospitalization will be used for
only few weeks.
3) EVENING AND WEEKEND HOSPITALIZATION
This is relatively newer alternative to the routine hospitalization. One possible indication is
patients who are getting special therapeutic procedures like group therapy etc can come to
hospital during the evening and weekends. It is practiced in some countries for the relief of
care taker during weekends.
b) HALF WAY HOME
Halfway housing is a therapeutic approach that appeared in the USA in the 1960s, advanced
by a group of people who worked in psychiatric hospitals and were looking for a new
treatment modality for the mentally ill. The main objective in establishing such facilities was
to provide a viable alternative to both large-scale psychiatric hospitals and small family
environments to which severely mentally ill patients were sent once they were discharged.
Renjulal 090504009
The halfway housing system was implemented to alleviate the social isolation experienced by
the mentally ill in communities; to demystify the universal medical model, in which patients
are considered ill all of the time while in the hospital; and to provide a functional
environment without imprisonment.
MEANING
It is the transition facility for mental patients who no longer need the full services c hospital
but are not yet completely ready for an independent living.
It is a transitional supervised residence assigned to help the patient after discharge from
inpatient setting
It is temporary residence where various kinds of social skill training are given to this patient:
make readjustment to the social life and employment in the community.
AIM
To maintain a climate of health and develop and strengthen the normal capacities and
normal responsibilities and prepares them in the normal living in the community.
To alleviate the social isolation experienced by the mentally ill in communities
To improve the self concept
Encourage to develop self image
To improve self worth
OBJECTIVES
To create a structured environment
To develop a living skills in the resident
To provide an opportunity for the personal growth and family involvement
To provide temporary residential placement
Renjulal 090504009
To provide activity, responsibility and freedom to the resident
To develop skill for independency and social training
To strengthen the remaining potentials
DURATION
Minimum of one year to consolidate the gain achieved over a period of time. This gives the
sufficient time for them to adjust to the family and to home environment.
THEORETICAL BASIS OF HALF WAY HOME
Two conceptual theoretical models for halfway houses have been proposed: the family model
and the social model. Residence function is based on a typical familiar group inserted in a
social organization.
FEATURES
Half way home provides structured environment where residents are treated as an individual
and learns all social living skills and provides opportunity for personal growth and focus on
family involvement. Clients are expected to take care of the activities of daily living.
Half way homes are categorized according to gender, age, diagnosis, and prognosis.
ACTIVITIES IN HALFWAY HOUSE
Each day morning meeting to discuss the core duties of the day and a chairperson will
be appointed on rotation basis for a week
Group counseling
Recreational activities
Home visiting
Job placement
Renjulal 090504009
Follow-up counseling
Educational and vocational program
Additional activities such as religious activities etc
Social skill training
Training in independent skills.
FAMILY INVOLVEMENT Periodic visit to see local guardians and family members. All programs of the homes are
organized to increase the family involvement and thereby commitment and participation in
the therapeutic efforts.
Education to the family members should be stressed and important issues related to, handling
of the problems, details of the illness, doubts and myths about the illness must be discussed
and clarified.
It is an opportunity to exchange the information and to set realistic goals keeping the
uniqueness of the individual.
c) QUARTER WAY HOMES
MEANING
Quarter way home is a sizeable reservoir of the chronically ill patients who are sufficiently
improved to live in a family setting but who either have no relatives or have relatives who
will not accept them to their homes.
Renjulal 090504009
CHARACTERISTICS
Clients have deep institutional dependence resulting from many years of hospitalization and
are resistant to any change in its symbiotic existence. Within the traditional hospital setting
the client finds food, shelter, security and protection. Group living arrangement restores the
lost social habits and re-establishment of more normal behavioral patterns. The personnel
motivate the clients towards the community, while guiding and supporting to recover soon.
d) LONG STAY CARE HOMES
These centers are available for women patients. It is indicated for socially disabled mental
patients who cannot live independently and who needs care. It is expected that only a small
portion of its residence can eventually be discharged back to the community.
e) DAY CARE CENTERS
In these centers behavioral modification techniques are used in addition to vocational
training. These agencies also provide job placement services for the clients.
f) FOSTER HOMES
It is a home in which a patient recovering from mental illness is placed in a voluntary family
by a social agency for family care. The family is paid by the agency. The placement may be
temporary or permanent. Patient gets a home like environment.
g) SELF HELP GROUP
Self help group in the community will help the individual as well as the family members
E.g. Alcohol anonymous
Renjulal 090504009
h) MENTAL HEALTH EMERGENCY CARE
Hot line: telephone line maintained by the trained personnel for the purpose of providing
crisis intervention
Walk-in-clinic: 24 hour psychiatric clinical emergency room in which they diagnose or
therapeutic service is rendered without an appointment.
Home visit: home visit is conducted by community health nurse and community mental
health nurse
i) VOCATIONAL REHABILITATION
It involves the provision of those vocational services i.e., vocational guidance, vocational
training and selective placement, designed to enable a disabled person secure and retain
suitable environment. The phases of vocational rehabilitation are:
1) Vocational assessment
a) Clinical assessment: assessing for residual psychiatric symptoms which may affect his
ability to function
b) Social assessment includes assessing family support , attitude of a family members
and economic status of the family
c) Psychological assessment includes assessing confidence and motivation of the patient
and self esteem
d) Vocational assessment includes assessing physical strength, hand co-ordination,
attention and concentration
Renjulal 090504009
2) Vocational counselling
It includes the informing the patients and the family members regarding the type of training
available.
3) Vocational training
Course content
Duration training
Incentives
Assessment of the progress
Imparting skills
Supervision
4) Job exploration
Selecting suitable job
Placement of the client in the job
Checking the facilities available
Evaluating the work performance
5) Follow up it includes evaluation of the four dimensions
Clinical dimensions
Social dimensions
Psychological dimensions\
Vocational dimensions
Renjulal 090504009
j) SHELTERED WORKSHOP:
Sheltered workshop is work oriented rehabilitation facility with a controlled working
environment to fulfill individual's vocational needs. In this workshop long term mentally ill
patients can utilize their experience and abilities by relearning. It helps in progress towards a
normal living and economic independence. The individuals can earn the salaries for
production in the workshop. Sheltered workshop have low staff patient ratio when compare to
psychiatric day training centre. Patients’ works are supervised by non trained staff. Patients
are referred from day hospital to sheltered workshop to practice the skills they acquired
earlier.
k) CORRECTIONAL HOME
Correctional homes are for young children who have been found guilty of an offence that
would be categorized as a crime if committed by an adult.
INSTITUTIONS IN INDIA WHICH PROVIDES PSYCHO-SOCIAL
REHABILITATION
GOVERNMENT SECTOR
1) Centre for Rehabilitation, Central Institute of Psychiatry, Ranchi
Male and female occupational therapy unit, Sheltered workshop and vegetable garden
and fruit orchard is present
2) Centre for Comprehensive care and rehabilitation, NIMHANS, Bangalore
The day care facility has a structured programme consisting of activities like
physical exercises, yoga training, independent living skills training, behaviour modification
and recreational activities done by a trained multidisciplinary team of mental health
Renjulal 090504009
professionals Other specialised services like vocational training, social skills training,
cognitive rehabilitation, IQ assessment, disability assessment and arrangement of social
benefits are also done.
3) IMHANS, Kerala
IMHANS is an autonomous institution established by the State Government of Kerala in
1983
4). Institute of Mental Health, Chennai
Industrial therapy centre and Occupational therapy centre is functioning there The
Industrial Therapy Centre (ITC) established in the 1972 runs Hospital canteen, Bakery, Cover
making unit, Candle making unit, Chalk piece unit, Soft toy unit etc. Improved patients are
employed in the above said units Occupational Therapy Centre caters to rehabilitation needs
of the Institute. It has bookbinding, tailoring, weaving, blacksmith, painting, carpentry units,
improved patients are imparted training
NONGOVERNMENTAL ORGANIZATIONS
1) Occupational Therapy Units, ANTARA, P.O. Dakshin Gobindapur, Kolkata
ANTARA’s rehabilitation program focuses on restoring wellness
2) The Richmond Fellowship Society
Renjulal 090504009
The Richmond Fellowship Society (India) provides rehabilitation therapy in short-
and long-term care homes, vocational training and outreach care and mental health
programmes in rural areas.
Bangalore Branch - Rehab homes, Day Care, MSc in Psycho Social Rehabilitation and short
term professional training
Delhi Branch - Rehab homes, Day Care
Sidlaghatta Branch - Day Care, Clinics and rural projects
Lucknow Branch - Day Care and outreach clinic
4) Vishwas Day Care Centre with Vocational Training
Provides halfway home and day care centre
5) VIMHANS (Vidyasagar Institute of Mental Health and Neuro-Sciences New Delhi
6) Shraddha Rehabilitation Foundation- Mumbai
7) MANAS -A Society for Mentally Disturbed Persons Their Families and Friends,
Kolkata
MANAS try to coordinate the different families towards building up of a long-term
residence for the chronically ill mental patients.
8) MON Foundation- A Social Outreach Initiative, Kolkata
9) ANJALI, Kolkata
ANJALI works with a group of people who have suffered both stigma and are
voiceless. ANJALI‟s mission is to move from institutionalization to full rehabilitation of
people with mental illness, ensuring participation and consent of the mentally-ill in all
decisions related to her life. Life skills training, Occupational therapy, Organizing shelter and
Recreation and relaxation therapy are the major initiatives of ANJALI.
Renjulal 090504009
10) ANTARA - A WHOLE VILLAGE, Kolkata
ANTARA provides shelter, care, treatment and rehabilitation to the destitute & very
poor persons suffering from mental disorders including drug addiction & alcoholism.
ANTARA runs Work Therapy Projects, ANTARA InfoTech Vocational Training Centre and
a number of training programmes. ANTARA is centred at Antaragram: which is located at a
village in the district of South 24 Parganas.
11) ARDSI - Caring the People with Alzheimer's and Other Dementia Related Diseases
12) ANADANIKETAN - A HOME AWAY FROM HOME, Kolkata
13) PARIPURNATA - A HALF-WAY HOME, Kolkata
Paripurnata is a short stay home for women who have been committed to the hospital
for mental illness in Pavlov Institute. Paripurnata which provides them with life-livelihood
skills and helps to rehabilitant they back into their families‟ communities.
14) Sailendranath Guha Thakurata Institute (SANGATI), Kolkata
Sailendranath Guha Thakurata Institute (Sangati) is a societal engaged in social
educational research and vocational studies. Its target client is mentally retarded children. Its
facilities include: day care centre educational & vocational training facility; counselling,
psychological assessment and parental training.
Renjulal 090504009
REFERENCE
1. Sadock BJ, Sadock VA. Kaplan and Sadock’s synopsis of psychiatry, Behavioural
sciences/clinical psychiatry.10th
ed. Philadelphia: Lippincott Williams and Wilkins
publishers; 2007
2. Granlick A. The psychiatric Hospital – A therapeutic instrument. Newyork: Brunjer;
1969
3. Lloyd C. Vocational rehabilitation and mental health.UK: John Wiley & Sons; 2010.
4. Townsend M C. Psychiatric mental health nursing. 5th
ed. New Delhi: J P Publishers;
2004.
5. Budson RD. The Psychiatric Halfway House- A Handbook of Theory and Practice.
1st ed. Pittsburgh: University of Pittsburgh Press; 1978.
6. Golomb SL, Kocsis A. The halfway house-On the road to independence. 1st ed.
Brunner/Mazel Publishers; New York: 1988.
7. Reis AD, Laranjeira R. Halfway Houses for Alcohol Dependents: From Theoretical
Bases to Implications for the Organization of Facilities. Hospital das Clínicas da
FMUSP; 2008 December; 63(6): 827–832.
Renjulal 090504009
Halfway Houses for Alcohol Dependents: From Theoretical Bases to Implications for
the Organization of Facilities
Alessandra Diehl Reis and Ronaldo Laranjeira
The purpose of this paper is to supply a narrative review of the concepts, history, functions,
methods, development and theoretical bases for the use of halfway houses for patients with
mental disorders, and their correlations, for the net construction of chemical dependence
model. This theme, in spite of its relevance, is still infrequently explored in the national
literature. The authors report international and national uses of this model and discuss its
applicability for the continuity of services for alcohol dependents. The results suggest that
this area is in need of more attention and interest for future research.
METHOD
This narrative review includes periodical articles obtained from primary data sources dating
from 1960 to 2008, textbooks, and Masters’ and Doctorate degree theses containing relevant
information about halfway houses for alcohol dependents.
RESULTS
Halfway houses for alcohol dependents
It is important to note that although the halfway house and therapeutic community (TC)
approaches for substance dependence rehabilitation share similar concepts and philosophies,
their treatment modalities differ.6
Therapeutic communities were systematically reviewed by Smith et al. (2006) to determine
the effectiveness of TCs versus other treatments for substance dependence and to investigate
whether their effectiveness is moderated by patient or treatment characteristics. The authors
concluded that there is little evidence that TCs offer significant benefits in comparison with
other residential treatment or that one type of TC is better than another.18
A halfway house, “dry house” or “sober house” is defined as a more accessible transition
between hospitalization and life in the community. Its objective is to promote a social support
system for alcohol and substance dependents who will benefit from the supportive treatment
structure in such a sober environment.19
The main philosophical construct informing this kind of substance abuse treatment program
has been the social or community model approach, which gained strength in the 1980s and
became embodied by a continuum of recovery services. These models are publicly funded,
legally incorporated nonprofit organizations with a heavy emphasis on the community and
social environment, the importance of assumption, knowledge and practice to the recovery
process, staff-client interactions, and on the importance of employing staff who are in
recovery.5,6
Such a model can allow the patients to begin the process of reintegration with
Renjulal 090504009
society while still providing monitoring and support; this is generally believed to reduce the
risk of relapse as compared to direct discharge into society.20,21
The treatment diversity offered in these services is very wide. Some include informal
treatment and others adopt a 12-step model. The programs, in general, are exclusively for
either men or women and it is rare for both genders to be treated in the same program.
Program duration varies between one and 320 days. Patients who reside for a longer period of
time tend to better reintegrate into society and decrease their likelihood of substance abuse
after discharge.20
Some programs focus on introducing the basic concepts of self-care (e.g., maintaining the
house, exercise, basic meal preparation) as well as developing money management skills
(projecting weekly expenses) and working to understand past actions and how they affected
the resident’s life both positively and negatively.6,22
Studies aiming to evaluate the effectiveness of this treatment modality have identified many
methodological issues. The main concerns are the paucity of a control group, intervention
variations and outcome analysis, the small sample size, and the reliability of the results
obtained. However, they typically report favorable results and show that this approach tends
to increase compliance to outpatient treatment.19,23
Studies conducted by Annis & Liban (1979), Ryswyk (1981), Booth (1981), Walker (1982),
Baskin (1983), Huselid (1991), Fischer (1996), Davis (2005), and Jason (2007) indicated
positive outcomes to treatments offered by various halfway houses. The main positive
outcomes were: 1) lower detoxification admission index, 2) lower use of public assistance
services, 3) lower involvement with criminal justice or prisons, 4) higher employment
commitment after discharge, 5) lower admission to emergency hospitals, 6) lower medical
and legal costs to the public, 7) more humanitarian system, 8) a higher degree of satisfaction
among residents, 9) lower system costs, and 10) improvement in abstinence levels.20,24–28
It
was also possible to identify negative outcomes, including a younger population (under the
age of 25) and use of multiple drugs associated with primary alcohol use.27,30
According to Pekarik & Zimmer (1992), this model has an average annual cost of
US$2900.00 in the USA.31
In Brazil, a network of assistance for substance dependence has been built from a variety of
public and private facilities that comprise various care levels, including: specialized
outpatient treatment, primary care centers, general hospitals, halfway housing, clinics, drug
and alcohol psychosocial attention centers, self-help groups, therapeutic communities and
harm reduction programs.17,32,35
Psychiatric hospitals continue to be a treatment option in
certain cases in the decentralized network system.36
Despite being considered into the tertiary level of attention,32
we observe in Brazil a lack of
therapeutic residences for psychoactive substance users. An adequate halfway house
approach employing the therapeutic tradition model for substance users does not exist.
Renjulal 090504009
The diversity of facilities associated with treatment structure plurality, which addresses the
complexity of patients’ problems (physical and mental health, social, family, professional,
marital, motivational stage, etc.) seems to guarantee the success of the care model proposed
for substance users.32,35,36
National and international experiences
The Oxford House System, founded in Maryland, USA in October of 1975, is a non-
governmental organization (NGO) which presently accounts for more than 20 residences in
many cities. The central principle of Oxford House is to stimulate recovery and provide
housing for alcohol dependents who desire to cease alcohol use and live in sobriety, this
being the major requirement to program inclusion and participation.37
The system is not run
for profit, and every residence is independently and self-sufficiently managed by the residents
themselves. However, there is a set of operative norms and traditions created by democratic
vote. The system also employs a non-professional staff, although outside professionals may
be hired in special situations. The Oxford House is not connected to Alcoholics Anonymous
(AA), but supports resident participation in AA meetings.37
Over the past 12 years, a university research team has been involved in a collaborative action
research project with a community-based, self-run, residential substance abuse recovery
program at Oxford House.29
Spirituality was evaluated among residents in one of the Oxford
Houses; moreover, it was found that 76% participate in AA meetings weekly. It also seemed
that building a social network beyond the walls of the residence is an essential factor in
recovery. A two year follow-up study which evaluated 130 patients in the Oxford House
system indicated positive results as relates to psychoactive substance abstinence.37,38
Jason et al. (2007) observed 150 individuals discharged from residential substance abuse
treatment, including at Oxford House, in a 24-month follow-up study. Their findings suggest
that there was a decrease in substance abuse for residents who lived in Oxford Houses for six
or more months (15.6%), compared both to participants residing in Oxford House for less
than six months (45.7%) and to participants assigned to the usual after-care condition
(64.8%). Results also indicated that both older residents and younger residents living in a
house for six or more months experienced better outcomes in terms of substance use,
employment and self-regulation.30
The Halfway House in Jardim Angela, in the city of São Paulo/SP, Brazil
A halfway house service was operated from late 1999 to September 2003 in the outskirts of
Sao Paulo, an area known for its high exclusion and homicide index (122 per 100 thousand
inhabitants in 1995).40
Technical and financial support came from UNIFESP/UNIAD, the
state public health and a Catholic NGO that had been in the community more than 12 years.
This community, with its high violence indices, had an average of one outlet for every 12
homes, which suggested as a hypothesis the potential of an association between a lack of
culture and leisure centers and alcoholism and violence.41
The neighborhood was reported to
be the most violent region in the world by the United Nations in the late 1990s.40
Renjulal 090504009
The Jardim Angela Halfway House had a 10-bed capacity, and alcohol dependents’ stays
were limited to 30 days. It served 130 patients from October 1999 to November 2001.
The service’s aim was to become a communitarian, temporary home facility supported
mainly by non-specialized staff and/or alcohol dependents in recovery. The home atmosphere
emphasized obtaining health, self respect and binding social support network systems through
abstinence. A psychological sense of community provided a sense of belonging, identity,
emotional connection and well-being.42
Patients were under the care of a communitarian agent 24 hours a day. Agents assisted
patients with meals (prepared by the residents with the help of a cook, who was undergoing a
longer recovery process), personal hygiene, physical company, developing activities and
games, as well as supervision of family visits and phone calls.
Residents received psychiatric, psychological, nurse and social assistance one or two times a
week in an outpatient service center located close to the residence. Volunteers from the
community led activities involving arts and crafts, horticulture, ceramics and yoga therapy.
The residents also went to church if they wished and walked in the morning, accompanied by
agents.
The cost per resident was about US$13.00 per day, with meals, medications and all amenities
included. Funds received through donations from community volunteers notwithstanding, this
project could not be continued due to financial difficulties in maintaining the house brought
on by the end of its sponsorship and lack of a budget.
Today, an infirmary with 10 beds exists in the same house. This service was inaugurated in
2006 and is supported by the local government. A full-time communitarian agent is present.
Similar initiatives may exist in other places in Brazil; however, this has not been documented
in scientific literature.
Renjulal 090504009
An assignment on Psychiatric Nursing
FACILITIES
OF
PSYCHO-SOCIAL
REHABILITATION SUBMITTED TO Mrs. Tessy Treesa Jose
HOD and Professor
Dep. Psychiatric Nursing
MCON, Manipal,
Manipal University
SUBMITTED BY
Mr. Renjulal Y
090504009
MSc Psychiatric Nursing
MCON, Manipal,
Manipal University
Renjulal 090504009