Why research doesn't yield treatment

This article has presented examples from nursing research with chronically mentally ill clients that illustrate problems with utilization of nursing research in this field. Obstacles to utilizing research in clinical practice include (a) difficulty in identification of treatment goals; (b) difficulty in measurement of treatment outcomes; (c) diversity of psychotherapeutic interventions; (d) attrition of clients over a relatively short period of time; and (e) variation among clients with regard to degree of impairment, response to medication, and social support. These problems were examined using the criteria described by Fawcett (1982) for utilization of research findings: scientific merit, clinical relevance, and clinical evaluation. Limitations for utilizing findings from research with the chronically mentally ill were illustrated in the areas of scientific merit and clinical evaluation. However, studies of the chronically mentally ill and their treatment showed definite clinical relevance, indicating the need for further research with the chronically mentally ill.     

Deinstitutionalization: a public policy perspective

1. Deinstitutionalization was initiated in an era of social reform to protect the rights of the mentally ill; however, a strong research base was absent and led to major flaws in the policy's implementation. 2. The chronically mentally ill are frequently poor advocates for themselves and, without even the most simple needs fulfilled, end up homeless. 3. The homeless mentally ill require comprehensive support systems with assured continuity of care. An emerging concept to deal with this issue is that of case management. 4. The mental health professional can strive to influence future public policy as patient advocate and nonpartisan educator.     

Mental Illness and the Criminal Justice System

This is the second essay in a two‐part series exploring the relationships between mental illness, criminal behavior, and the criminal justice system. The number of mentally ill persons in prisons and jails has increased substantially over the last several decades, and there are currently more people with mental illness behind bars than there are in mental hospitals. In this essay, we place these trends within a broader historical context of the social control of mental illness in the United States. We identify how and why mentally ill persons have come to be overrepresented in the criminal justice system and highlight the unique challenges this population poses for police, courts, and correctional facilities. Finally, we review several recent innovations in policy and practice that may help alleviate that burden of criminal justice involvement on mentally ill offenders, as well as the burden of mentally ill offenders on the criminal justice system.     

OUTPATIENT COMMITMENT AS BOTH SOCIAL CONTROL AND LEAST RESTRICTIVE ALTERNATIVE

Outpatient commitment (OPC) permits compulsory outpatient treatment of the mentally ill. This study examines the wider institutional or normative purposes of OPC: greater social control of the mentally ill in the community and a less restrictive environment than inpatient commitment. OPC's ability to meet these contradictory institutional demands—social control and greater individual liberty—is explicated by the institutional theory of organizational activity and based on two data sources. First, case studies of four community mental health centers reveal the organizational beliefs that define OPC as social control and/or a least restrictive patient environment. Second, data collected in North Carolina from patients ordered to OPC and their primary therapists demonstrate that in practice OPC does provide both a least restrictive alternative as well as greater community social control.     

Independent living for the chronically mentally ill

1. Many of the systems problems faced by the chronically mentally ill and their caregivers could be ameliorated by applying the principles of primary nursing. 2. Psychiatric nurses as primary caregivers of the chronically mentally ill can intervene at the client level (assessment, education, medication monitoring, family counseling) and at the systems level (networking, boundary-spanning, advocacy). 3. Psychiatric nurses are a natural and largely untapped resource for improving the care of the chronically mentally ill in the community.     

Social class, mental illness, and social mobility: the social selection-drift hypothesis for serious mental illness

The assumptions and methods of previous studies of the social selection-drift hypothesis for serious mental illness are examined by using comtemporary log-linear methods for social mobility analysis. The null hypothesis of no difference in intergenerational social mobility between seriously mentally ill and general population control groups cannot be rejected in previous studies by Birtchnell (1971), Goldberg and Morrison (1963), Langner and Michael (1963), and Turner and Wagenfeld (1967). The findings of this study suggest that previous empirical support for intergenerational social mobility differences is an artifact of not controlling for group differences in origins and destinations when collapsed origin-by-destination tables are analyzed. This study suggests that intergenerational social mobility differences between seriously mentally ill and general population groups in previous studies provide very little, if any, empirical support for social selection-drift processes in serious mental illness.     

Caring for Persons with Serious Mental Illness

Abstract

This article places evidenced-based knowledge of practice within the social context of care and proposes five policy objectives and specific policy and program changes to address care needs of people with serious mental illness. In spite of demonstration programs that provide the basis for proposed policy initiatives throughout the United States, treatment provision for this population remains inadequate and their safety and well-being continues to be at risk. The authors suggest that treatment initiatives need to be tied to stable policies protecting the mentally ill from adverse social context changes. The authors conclude that policies are needed that will enhance housing assistance, independent social functioning, personal empowerment, and treatment engagement. In addition, efforts are needed to make better use of inpatient hospital care, to better understand the role of assisted treatment, and to better develop consistent long-term fiscal support for the seriously mentally ill. They offer specific policy recommendations for changes in HUD programs, Medicaid and Medicare funding, and treatment programming that address these needs.     

A psychiatric nurse's role

1. Homelessness in America is a result of complex social, political, and economic forces; approximately one third to one half of the homeless have severe emotional problems. 2. The person with chronic mental illness who is also homeless will face numerous obstacles when the need for psychiatric care arises. 2. The person with chronic mental illness who is also homeless will face numerous obstacles when the need for psychiatric care arises. 3. The federal government is beginning to address the problems of the homeless chronically mentally ill population by establishing pilot programs in Veterans Administration hospitals. 4. The psychiatric nurse is in a unique position to provide services to those who are homeless and mentally ill.     

Nurse entrepreneurs

1. Supervised Environmental Living Facility (SELF) is a nurse-developed, non-profit, community-based, supervised apartment program for the chronically mentally ill. It provides comprehensive supportive and rehabilitative services to the chronically mentally ill, allowing them to re-establish themselves as part of the community. 2. SELF is based on the philosophy that a person needs assistance according to the extent that the illness affects the individual's ability to live safely and optimally. 3. Nurses can be entrepreneurs by seeking and creating innovative models for the delivery of services to specialized populations.     

Strategies for improving education

1. An extensive curriculum is required to prepare mental health professionals to adequately assess, plan, and implement the necessary comprehensive treatment plan and to sufficiently develop relevant social policy. 2. A majority of professionals believe they were not adequately trained in the care of the chronically mentally ill; this may be a result of the trend of integrating the teaching of mental health nursing concepts into the baccalaureate curriculum. 3. Frequently there is a lack of mental health professional role models. Nursing faculty are in an excellent position to implement innovative practice models. 4. Learning from a multidisciplinary team may increase the likelihood that students will apply these approaches to the chronically mentally ill.     

Characteristics of the homeless mentally ill in case management: Differentiation using major diagnostic categories

The homeless mentally ill are more disabled than other homeless people and require more services, but important variations exist. This study examined relationships between broad Axis I diagnostic clusters and demographic and service variables for 328 clients receiving case management at a community program for the chronic mentally ill homeless. Demographic characteristics, medical history, educational, psychological, and marital history, and case management variables were examined for psychotic, affective, and miscellaneous other clients. Differences were found in such areas as suicide attempts and current suicide status, psychiatric treatment history, education, overall impairment of functioning, length of time homeless, and time in case management but not in status at termination or number of services required. Psychotics had lower adaptive functioning, spent less time in case management, but had as successful outcomes as affective clients. Psychiatric diagnosis provides information that might assist case management for the homeless mentally ill.     

The social support. Social dissupport continuum

A person's network embodies "the good, the bad, and the ugly" of all social relationships. The nature of these relationships may be conceptualized as a continuum between social support and social dissupport. Social support, as a product of relationships that facilitate growth, generates self-esteem and assists in assuming appropriate societal roles. Social dissupport represents those relationships that hinder growth and/or promote disintegration. Clinically, nurses either formally or informally assess the degree of social support, but neglect the overall social support/dissupport ratio. The MSNI profiles the person's perception of social support/dissupport on four levels of social relationships and is an efficient instrument in assessing who is in the social network, what is provided, perceived helpfulness, and expectations. Preliminary use of the instrument with parents of the long-term mentally ill, acutely and long-term mentally ill clients, students, and a variety of clients of graduate students enrolled in a crisis intervention course are promising. Thus, nurses must be prepared to confront their clients' perceptions of the professional's role and to modify and adapt those interactions to facilitate goal achievement.     

Conceptualizing psychosocial nursing in the jail setting

1. The deinstitutionalization movement led to the release of thousands of mentally ill patients, many of whom were incarcerated as a way of dealing with their disturbed behavior. More restrictive civil commitment laws have also contributed to the number of mentally ill who are incarcerated. 2. Health care and security can be perceived as competing interests in the correctional institution. These competing interests may also be perceived as sources of conflict because each interest aims towards divergent goals that interfere with the other. 3. A problem central to the inadequate services for the mentally ill offender is that few people are aware of the poor conditions for this population. Correctional and mental health organizations must educate the public about the plight of the mentally ill offender.     

Experiencing Stigma and Exclusion: The Influence of Neoliberal Perspectives,Practices, and Policies on Living with Chronic Illness and Disability

Neoliberal perspectives, policies, and practices increasingly affect chronically ill and disabled people's embodied experiences of stigma and exclusion. Neoliberalism emphasizes individual responsibility and self-sufficiency, a limited social safety net, and narrow governmental accountability. Examining pivotal experiences of chronically ill people shows how neoliberalism can frame their alternatives, interactions, and actions. This examination prompts reconsidering Goffman's concept of stigma to include how larger social policies and practices affect experiencing stigma and exclusion and, also, illuminates temporal features of receiving a diagnosis, disclosing illness, and dealing with disabilities and unpredictable bodies. The analysis derives from an ethnographic story and published and unpublished personal accounts from first-hand and library research over the course of my career.     

The history, economics, and financing of mental health care. Part 2: The 20th century

1. To understand how mental health nursing practice was affected by the financing and policy changes occurring rapidly in the second part of the 20th century, sources can only be found in the literature in psychiatry, the social sciences, and economics. There was no psychiatric nursing journal until the 1950s, and no article by a nurse in the general nursing literature about finances. 2. Deinstitutionalization was really transinstitutionalization. Changes in regulations in Medicaid allowed the shifting of mentally ill people who were older than age 65 to nursing homes. 3. Community mental health centers never developed programs to serve people who were seriously mentally ill. Rather than serving clients who were psychotic, the community mental health centers marketed their treatment programs to people with anxieties, who were undergoing divorce, or who had mildly troubled children.     

The experiences of youth serving as caregivers for mentally ill parents: a background review of the literature

Young caregivers of mentally ill parents are a vulnerable population. These vulnerabilities include risks for developmental issues, poor socialization, and poor school performance. The purpose of this background review of the literature is to explore the experiences of young caregivers of mentally ill parents and detect the gaps in the literature. The guiding research questions were: What is the experience of young caregivers of mentally ill parents? and What is the experience for those who witness or must assist their parent during a crisis? The majority of research has been conducted outside the United States, primarily in the United Kingdom, and studies have focused mostly on young caregivers of parents with physical rather than mental illness. No studies focused on young caregivers who witnessed or assisted their mentally ill parent in crisis. Information gained through this review will add to the body of knowledge for child mental health and build a case for additional research.     

ATTITUDES TOWARD THE MENTALLY ILL:

Labeling theory posits that people labeled mentally ill experience negative societal reactions. Past research on this question is contradictory, due primarily to methodological problems. This study overcomes some of these problems by having respondents indicate their willingness to interact with a person with a specific mental disorder, or with an identically behaving person with a specific physical disorder. As expected, respondents reject the mentally ill significantly more than identically behaving physically ill persons, as supports labeling theory. Respondents also consider the mentally ill less predictable and to have less positive outcomes than those with physical illness. These beliefs highly correlate with rejection and account for some, but not all, of the effects of label on rejection.     

Characteristics of the Homeless Mentally III in Case Management: Differentiation Using Major Diagnostic Categories

The homeless mentally ill are more disabled than other homeless people and require more services, but important variations exist. This study examined relationships between broad Axis I diagnostic clusters and demographic and service variables for 328 clients receiving case management at a community program for the chronic mentally ill homeless. Demographic characteristics, medical history, educational, psychological, and marital history, and case management variables were examined for psychotic, affective, and miscellaneous other clients. Differences were found in such areas as suicide attempts and current suicide status, psychiatric treatment history, education, overall impairment of functioning, length of time homeless, and time in case management but not in status at termination or number of senlices required. Psychotics had lower adaptive functioning, spent less time in case management, but had as successful outcomes as affective clients. Psychiatric diagnosis provides information that might assist case management for the homeless mentally ill.     

What Do Social Workers Need to Know About Mental Health Courts?

Abstract

Mental health courts are an emerging strategy to engage mentally ill offenders in treatment and to avoid unnecessary incarceration. These courts began in 1997 based upon the drug court model; there are currently over 70 courts nationwide. These courts are heterogeneous in structure, work with interdisciplinary teams, and seek to engage the consumer in treatment rather than use judicial sanctions. Social workers are integral members of these teams; yet, no research has been published in social work journals on mental health courts. This article explains the background and context of the courts, describes their features, discusses what social workers need to know about mental health courts, and concludes with ideas for how social workers may work effectively with mental health courts.     

Social Work Function in a Caring Society: Abstract Value,Professional Preference,and the Real World

Social work, in its search for a professional foundation, has lost sight of its original social purpose, the need to take care to the weak and helpless groups in a new industrializing society: the severely disabled, neglected children, mentally ill, developmentally disabled, and the enfeebled aged. No other profession is qualified to, or seeks to satisfy this need. This article discusses how the profession could fulfill this social function as a base for its growth, adding other therapeutic, preventive, and social change functions as experimental frontiers rooted in a socially sanctioned foundation available to few other professions.