Mikal Cohen

Serving street-dwelling individuals with psychiatric disabilities: outcomes of a psychiatric rehabilitation clinical trial.

OBJECTIVES This study tested a psychiatric rehabilitation approach for organizing and delivering services to street-dwelling persons with severe mental illness. METHODS Street-dwelling persons with severe mental illness were randomly assigned to the experimental program (called Choices) or to standard treatment in New York City. We assessed study participants at baseline and at 6-month intervals over 24 months, using measures of service use, quality of life, health, mental health, and social psychological status. The average deviation from baseline summary statistic was employed to assess change. RESULTS Compared with persons in standard treatment (n = 77), members of the experimental group (n = 91) were more likely to attend a day program (53% vs 27%), had less difficulty in meeting their basic needs, spent less time on the streets (55% vs 28% reduction), and spent more time in community housing (21% vs 9% increase). They showed greater improvement in life satisfaction and experienced a greater reduction in psychiatric symptoms. CONCLUSIONS With an appropriate service model, it is possible to engage disaffiliated populations, expand their use of human services, and improve their housing conditions, quality of life, and mental health status.

Prediction of vocational outcome based on clinical and demographic indicators among vocationally ready clients.

This study examined the clinical and demographic correlates of work skills and vocational outcome for persons with psychiatric disabilities. The same clinical, demographic, work skills, and vocational outcome instruments were administered to 275 persons working toward their vocational goals at three psychosocial rehabilitation centers. Data regarding vocational outcomes were collected quarterly over a period of 3 1/4 years. Using multivariate statistical techniques, clinical and demographic variables that predict work skills and future vocational outcomes were identified. The implications of the findings for program administrators, system planners, and researchers are discussed.

Understanding the current facts and principles of mental health systems planning.

The state mental health services planning encouraged by Pub.L. 99-660, TitleV, will be a very different process from the services planning of previous decades. The services planning stimulated by this new legislation will be influenced by a philosophy and set of values that contrast markedly with past services planning. In this article, service planning principles are articulated that can guide the planning of a comprehensive community-based service system. Yet, no matter how well crafted the plan; its worth is based on what it does for the people being served. New technology exits to change the program structures and staff competencies in ways that will lead to better client outcomes. The challenge of successfully implementing these new service plans will only be met when mental health authorities directly support the use of the new technologies. It appears that mental health system planning in the 1990s will be influenced by a vision and a philosophy that is very different from previous mental health planning efforts. Stimulated by a developing consensus about the underlying philosophy of community support and rehabilitation (Anthony, 1992; Parrish, 1989; Turner & TenHoor, 1978), mental health planning is riding a wave of optimism about what could be, realistically tempered by a trough of pessimism about what currently exits and how much needs to be done. The articles in this section describe this future vision and present reality (Chamberlin & Rogers, 1990; Kennedy, 1990; Romeo, Mauch, & Morrison, 1990; Weisburd, 1990). The Model Plan for a Comprehensive, Community-Based System (National Institute of Mental Health (NIMH), 1987), a technical assistance document to help state implement Pub.L. 99-660 (State Comprehensive Mental Health Plan Act, 1986), is imbued with the community support and rehabilitation philosophy that undergrads this new vision. This philosophy specifically includes (a) understand the person with mental illness as a person first, with basic needs and goals similar to other members of the community; (b) involving consumers and family members in system planning and implementation activities; (c) recognizing the family as a resource to the helping effort; and (d) developing services that are consumer-centered and empowering. This philosophy is the foundation for service system planning. It must also be reflected in the overall mission of the state plan. The NIMH (1987) has provided the following example of a mission statement as one that is consistent with this new philosophical base: To implement programs and services that assist adults with severe, disabling mental illness to control the symptoms of the illness; to develop the skills and acquire the supports and resources they need to succeed where they choose to live, learn, and work; and to maintain responsibility, to the greatest extent possible, for setting their own goals, directing their own lives, and acting responsibly as members of the community. (p. 12) To develop new plans that incorporate this philosophy, planners must not only think differently about the possibilities for consumers in their future service system, they must also think smarter. They must do away with their outdated assumptions and be guided by current knowledge and principles. Old Planning Myths and New Planning Principles Planners of a comprehensive community-based system must be armed with new knowledge; they must be disarmed of old planning assumptions. A description of 10 facts and principles about which planners must be knowledgeable in order to plan follows. 1. Consumers of mental health services can identify realistic goals for themselves that can then be factored into planning a system’s services. Previous system wide planning efforts seemed to mistakenly assume that persons with severe psychiatric disabilities will not be able to come up with goals or that the goals they come up with will be destructive (e.g., will harm someone) or unrealistic (e.g., wants to be an astronaut). The fact is that, if given the opportunity and support, most clients can identify realistic goals that planners can use as the basis for their service system design. When consumers are asked about their goals in a supportive manner, the goals they mention are the same goals that other persons would mention-satisfying jobs, decent places to live, a chance to return to school, and a reduction of psychological distress. System planners must ensure that their planning proceeds from a good understanding of the goals of the persons whom the system is designed to serve. 2. The mission of the state department of mental health is to help people function better so that they can become more successful and satisfied in their various living, learning, working, and/or social environments, with the least amount of ongoing assistance from agents of the mental health system. This mission is a variation of the mission suggested in the model plan (NIMH, 1987). The key difference between this suggested mission and prior descriptions of the mission of state mental health departments is that the focus of the preferred mission is on outcomes for the clients rather than on process objectives for the mental health authorities. Historically, the state level mission has been to provide “comprehensive services” or “continuity of care” are quality control objectives that may or may not achieve client outcomes. When clients are asked what their ultimate mission or goals are, none of them indicate “comprehensive services” –neither should mental health service systems. 3. The role of the state hospital in the system plan should be consistent with the state department’s overall mission. Historically, system-level mission statements have incorrectly written that the elimination of state hospital beds was a major element of the mission of the state department of mental health. However, the ultimate focus of the plan should be on the hospital’s role, not the size. The hospital is apart of the community, and a community-based system of services, the hospital is designed, like other services, to help people live successfully in the community, not simply to keep them out the community or keep them in. The emphasis in the plan is on creating services consistent with the mission of the system, and not simply on eliminating beds. Bed reduction is a byproduct of a successfully achieved mission, not a mission in and of itself. 4. Improving client functioning, and not simply maintaining people in the community, must be a part of the system’s mission. A maintenance-only mission is yesterday’s mission. A variety of programs have demonstrated their capacity to maintain people in the community (e.g. Cannady, 1982; Stein & Test, 1980). Although such programs have not yet been routinely implemented nationwide, a system mission of community maintenance reflects yesterday’s accomplishments and values. Consumers “maintained” in the community are now asking, where can I go in it? What can I do in it? Helping persons with psychiatric disability to grow in the community, rather than just to survive in the community, must be the focus of the system’s mission. 5. Psychiatrically disabled persons’ skills and supports relate to community outcomes more strongly than do their symptoms. System planners must ensure that their services provide for skill development and support development, and not just symptom relief. Both new and old service dollars need to be directed at programs that focus on skill and support development outcomes. System planners must realize that persons with psychiatric disabilities are limited not only by their major psychiatric symptoms but primarily by their persistent social vocational deficits and exaggerated emotional response to stressful life events. The substance of a system’s service delivery programs must reflect this fact. 6. Persons who are psychiatrically disabled need different services, at different times, and at different levels of intensity. Persons with psychiatric disabilities do not need the same kinds of services. Thus, the service system must develop a large range of service alternatives, packaged differently for different clients. These unique services for each client are tied together by a common mission. The individual service package flows from the person’s goals and an assessment of the skills and supports needed to achieve these goals. For example, the type of housing in which one resides need not dictate the kind and intensity of services one receives, or vice versa. The fact is that persons should receive the kinds of services they need and want, no matter what their housing situation. System planners must tie their services to the person and not to the house. A client shouldn’t have to live in a group home in order to receive the kind of services he or she needs, or attend day treatment to live in the type of home he or she wants. A wide range of services must be provided over the wide range of housing options, which increasing and decreasing levels of intensity and support as needed by the client. One shouldn’t have to continually change residences in order to get more, less, or different services. 7. Many persons with psychiatric disabilities don’t want the services the system provides because they often find these services unappealing, inappropriate, or demeaning. The high attrition rates of mental health programs are not a function of client deficits, but rather service deficits. Thus, system planners must constantly check to see if the services created are consistent with the philosophy and values of a community-based services system (NIMH, 1987). Explicit statements of values in the plan provide one yardstick against which implementation can be judged. The values specified in the plan can do more than help make the planners feel good; they help the implementers of the plan do good. Some persons with psychiatric disabilities who want and need services won’t seek them out. Systems of the

A psychiatric rehabilitation treatment program: Can i recognize one if i see one?

Over the last several decades there has been a tremendous growth in the number of community-based settings that indicate that they provide rehabilitation programming to persons with severe psychiatric disabilities. Questions can be raised, however, as to the extent to which these settings are actually providing programs that are rehabilitative in nature. Ten essential ingredients of rehabilitation programming are presented for use in discriminating between programs that are rehabilitation oriented and programs which are rehabilitation in name only. The articulation of these ten essential ingredients can serve as a guide for the continued development of community-based settings which attempt to provide comprehensive rehabilitation programming.

Characteristics of mental health case management: results of a national survey

In the last several years, state mental health authorities throughout the United States have assigned a high priority to the funding, development, and operation of case management programs. Although the concept of case management has been in existence for over a decade, there is still confusion regarding the definition of case management and the identification of alternative case management approaches. Recognizing this confusion, the Center for Psychiatric Rehabilitation undertook a comprehensive study to determine the state of case management practice today. This article reports on the results of a national survey of case management programs and describes the characteristics of the programs themselves, the case managers, the clients they serve, and the systems within which they operate. Implications of these findings for a definition of case management are discussed.

Psychiatric rehabilitation programs: putting concepts into practice?

Mental health settings serving the severely psychiatrically disabled or the long-term chronic client have begun developing a rehabilitation orientation in an attempt to increase their effectiveness with this group. The authors have, in an earlier work, described basic elements of a rehabilitation program. These elements have been refined. Forty rehabilitation-oriented community and hospital agencies were assessed in terms of the presence or absence of these elements of a rehabilitation approach. Results indicate that the programs in the agencies clearly value client involvement and a program focus on improving skill and resource utilization. These concepts, however, are only beginning to be systematically implemented in practice.

Professional pre-service training for working with the long-term mentally ill.

The knowledge base with respect to helping persons with long-term mental illness is expanding dramatically. Specific skills can be identified as critical for those who work with the long-term mentally ill. In contrast to in-service training, preservice (university-based) programs have been slow in offering relevant skills-based curricula. A model is proposed for describing current and future pre-service curricula. Curricula can be categorized as to whether it provides exposure, experience, or expertise in working with the long-term mentally ill. More than ever before the pre-service training programs seem ripe for the introduction of skill-based curricula relevant to helping persons who are psychiatrically disabled.

Effectiveness of technical assistance in the development of psychiatric rehabilitation programs

Most mental health programs need technical assistance to develop effective psychiatric rehabilitation programs. This article discusses how psychiatric rehabilitation was introduced into three community mental health programs and describes the elements of a psychiatric rehabilitation program and the phases of a technical assistance process. A case study illustrates how technical assistance consultants can be trained to develop psychiatric rehabilitation programs. Barriers and facilitators to the technical assistance are discussed in the context of several other technical assistance studies.

The Future of Psychiatric Rehabilitation

Since 1979, Boston Universitys Center for Psychiatric Rehabilitation has provided leadership in accumulating a body of knowledge relevant to the rehabilitation of persons with serious mental disorders. The centers mission has encompassed evaluative research, knowledge dissemination, training, and service demonstration. The center has made a profound and broad impact upon the way that psychiatric (or psychosocial*) rehabilitation services are delivered in the United States. These include developments of innovative rehabilitation intervention models such as supported employment [1], supportive housing [2,3], and supported education [4,5]; developing and field-testing technology to teach the practitioner skills of psychiatric rehabilitation [6]; examining vocational outcomes and predictors of those outcomes [7,8]; developing and demonstrating interventions to promote wellness [9,10]; and researching issues such as functional assessment and the relationship among functioning, symptoms, and outcomes [11,12].

Interpersonal skill practice as a component in effective parent training

This study emphasizes the importance of including parental practice of skills in an effective, interpersonal-skill parent-training program. In particular, it is stressed as being most effective to include parental practice with the child as a component within the actual training session. Using a training approach developed by R. R. Carkhuff and emphasizing this parent-child practice component, parents were trained in interpersonal skills. At the conclusion of 15 hours of training, the parents were significantly better able to attend to and respond to their children than before the training. Additionally, the parents saw themselves as much improved in these areas.