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Learning Objectives
After reading this chapter, you should be able to:
1.
Discuss traditional treatment settings.
2.
Describe different types of residential and non-residential treatmentsettings and the services they provide.
3.
Describe community care and treatment programmes that provideservices to people with mental health problems.
4.
Identify barriers to effective treatment for homeless people with mentalhealth problems.
5.
Discuss the issues related to people with mental health problems in thecriminal justice system.
6.
Describe the roles of different members of a multidisciplinary mentalhealth-care team.
7.
Identify the different roles of the nurse and other professionals invaried treatment settings and programmes.
Key Terms
•acute inpatient units•assertive outreach•care co-ordinator•clubhouse model•community mental healthteams (CMHTs)•crisis recovery and hometreatment teams•day treatment•early intervention teams•multidisciplinary teams•recovery•prison•residential treatment settings•homeless
 
UNIT 1
• CURRENT THEORIES AND PRACTICE
68
 As discussed in Chapter 1, mental health care has undergoneprofound changes in the past 50 years. Before the 1950s,treatment in large out-of-town asylums was usually theonly available strategy for people with severe mental healthproblems: many of them stayed in such facilities for monthsor years, sometimes receiving humane, sensitive treatmentand care, many times on the receiving end of abuse andneglect. The introduction of psychotropic medications inthe 1950s offered hope of successfully treating the symp-toms of ‘mental illness’ in a meaningful way, while social,political, ideological and economic changes
 
led – haltinglyand painfully – to a focus on ‘community care’ and a newera of care and treatment. Institutions could no longer holdclients with mental health problems indefinitely, and treat-ment in the ‘least restrictive environment’ became a guidingprinciple and right. Large state hospitals gradually closed.Treatment in the community was intended to replace muchof state-hospital inpatient care. Adequate funding, however,has not always kept pace with the need for community pro-grammes and treatment (see Chapter 1).Today, people with mental health problems receive helpin a variety of settings, the majority in the ‘community’. Thischapter describes the range of care and treatment settingsavailable for those with mental health problems and the pro-grammes that have been developed to meet their needs. Bothof these sections discuss the challenges of integrating peoplewith mental health problems with the community in whichthey live. The chapter also addresses two populations that arereceiving inadequate treatment because they are not alwaysdirectly connected with general services: those with mentalhealth problems who are homeless and those in prison. Finally,the chapter describes the multidisciplinary team, including thecrucial role of the nurse as a member of that team.
CARE AND TREATMENT SETTINGS
The division between inpatient settings and ‘community’settings is intended to be far more fluid now than it has beenhistorically. Nevertheless, services can still be broadly seenin terms of ‘inpatient’ settings and ‘community’ settings.
RESIDENTIAL AND INPATIENT SETTINGSAcute Inpatient Settings
Since the closure of the asylums in the 1970s and 1980s, upuntil the present day, inpatient psychiatric care has remaineda primary mode of treatment for people with ‘mental illness’.Many
acute inpatient units
were built in the 1970s and1980s in the grounds of district general hospitals. Even upuntil the past few years, ‘acute’ units frequently had patientswho stayed many months or even years. Day hospitals or
day treatment
centres offered therapy and activity for inpa-tients and – sometimes – for outpatients. A typical psychiatric unit emphasized – until veryrecently – medical treatment: drugs and electroconvulsivetherapy (ECT), allied with some
talk therapy
, or focusedone-to-one interactions between ‘patients’ and staff, and –in rare settings –
milieu therapy
, the exploitation of the totalenvironment and its possible beneficial effect on the client’streatment. Individual and group interactions focused in themain on psychodynamic and humanistic principles andnurses were often central to these processes (although inrecent years this role has increasingly been handed to – ortaken on by – occupational therapists and psychologists).
 
Today, a whole host of policy drivers are beginning topush inpatient units in a direction where they must providerapid assessment, stabilization of ‘symptoms’, reduction of ‘risk’ and effective discharge planning and they must accom-plish goals quickly, all – in theory – within a context of empowerment and
‘recovery’
(Rae, 2007a). A client-centredmultidisciplinary approach to a brief stay is essential and therole of the care programme approach and its care co-ordina-tor (a community clinician, usually a community psychiatricnurse or a social worker) is vital in bridging the gap betweencommunity and hospital. Once the client is ‘safe’ and feeling‘stable’, the relevant clinicians, care co-ordinator and the cli-ent identify longer-term goals for the client to pursue in thecommunity (CSIP/NIMHE, 2007).Most areas now have developed
crisis recovery andhome treatment teams
which ‘gatekeep’ a reducing num-ber of inpatient beds and which are increasingly being seenas integral to acute care: the term ‘transfer’ (between, forexample, inpatient unit and home treatment team) is increas-ingly being used rather than ‘discharge’ (National AuditOffice, 2007). This process has led, in many areas, to patientswho are admitted being more unwell and more disturbedthan previously, necessitating a greater need for training andsupervision for inpatient nurses. Nevertheless, the deliber-ate breaking down of boundaries between ‘community care’and ‘inpatient care’, so that there is a ‘seamless’ acute service,often sharing staff across the settings, appears to be offeringan exciting step forward, away from the sense of admission as‘failure’, away from the sense that so many acute units had of being undervalued by the rest of the services, and away fromthe undoubted neglect and emotional abuse that so oftencharacterized isolated acute inpatient units.The increasing acuity of admitted patients and theincreasing numbers of them who are formally detainedpatients (on a section of the Mental Health Act) has changedthe nature of inpatient care and the demands on nursing andnurses. Increasing numbers of people on acute wards havemajor mental disorders and ‘dual diagnoses’. In addition,there has been a growing emphasis from government – andsociety in general – on the management of ‘risk’ withinmental health services: maintaining a therapeutic approachwhile working with very unwell people whose ‘risk’ is eithervery real or feared adds to the demands on inpatient nurses,as does the vast amount of (mostly justifiable) criticism of inpatient care in the UK over the past decade (Muijen, 2002;Mental Health Act Commission, 2005).Some inpatient units have a locked entrance door,requiring staff with keys (or electronic cards) to let peoplein or out of the unit. This situation has both advantages and
 
Chapter 4
• CARE AND TREATMENT SETTINGS, THE MULTIDISCIPLINARY TEAM AND THERAPEUTIC PROGRAMMES
69
of aggression or ‘non-compliance’ with medication regimesmay be ineligible for some treatment programmes or services.Clients with these impediments to successful discharge/trans-fer planning, therefore, may have a less-than-ideal plan inplace because optimal services and supports are not availableto them. Consequently, people discharged with these plansare readmitted more quickly and more frequently than thosewho have better discharge/transfer plans.Clients do not keep follow-up appointments or referralsif they don’t feel connected to services or if these servicesaren’t perceived as helpful or valuable: attention to psycho-social factors that address the client’s well-being, his or herpreference for follow-up services, inclusion of friends andfamily, and familiarity with outpatient providers are criticalto the success of a discharge plan (Williams, 2004).Prince (2006) found that three types of intervention aresignificant in preventing rehospitalization for individuals withfour or more prior inpatient stays. These interventions aresymptom education, service continuity and establishment of daily structure. Clients who can recognize signs of impendingrelapse and seek help, participate in outpatient appointmentsand services, and have a daily plan of activities and responsi-bilities are least likely to require rehospitalization.Creating successful discharge plans that offer optimalservices and housing is essential if people with mental healthproblems are to be reintegrated into the community. Anholistic approach to reintegration is the best way to preventrepeated hospital admissions and improve quality of life forclients. Community programmes after discharge from thehospital may need to include social services, day treatmentand housing programmes, all geared toward survival in thecommunity, empowered concordance with treatment recom-mendations, recovery and independent living.
 
Crisis resolu-tion/home treatment and assertive outreach team (AOT) pro-grammes provide many of the services that are necessary tostop the revolving door of repeated hospital admissions punc-tuated by unsuccessful attempts at community living. AOTprogrammes are discussed in detail later in this chapter.
Crisis Recovery/Home Treatment Teams
 As mentioned in the previous section, crisis recovery andhome treatment teams have become increasingly importantin their role as ‘bridges’ between acute inpatient settings and‘community’ settings. They are multidisciplinary teams whooften gatekeep beds and whose primary role is usually toprovide – wherever possible – an alternative to admission.
Community Mental Health Teams
Community mental health teams (CMHTs)
– sometimesnow called primary care mental health teams – were tradition-ally (from the 1980s until the past few years) the main com-munity resource for people across the whole range of mentalhealth problems: the vast majority of people in mental healthservices were either cared for by a CMHT or within inpatientservices. The main professional groupings within CMHTs weredisadvantages, and exemplifies the tensions within inpatientcare (Haglund
et al
., 2006; Rae, 2007b). Nurses identifythe
advantages
of providing protection against the ‘outsideworld’ (in particular threats from drug dealers) in a safe andsecure environment as well as the primary
disadvantages
of making clients feel confined or dependent, and emphasizingthe staff members’ power over them.
Psychiatric Intensive Care Units
 According to the 2002 National Minimum Standards,‘Psychiatric intensive care is for patients compulsorilydetained, usually in secure conditions, who are in anacutely disturbed phase of a serious mental disorder. Thereis an associated loss of capacity for self-control, with a cor-responding increase in risk, which does not enable theirsafe, therapeutic management and treatment in a generalopen acute ward’ (NIMHE, 2002). There is much debateabout the primary function and effectiveness of psychiatricintensive care units (PICUs) and their relationship with acutewards and the wider community, but they are increasing innumber in the UK (along with ‘low secure’ units which tendto offer less intensive care to less ‘disturbed’ clients).
Special Hospitals
There are three high-security ‘special hospitals’ in England(Broadmoor, Rampton and Ashworth) and one in Scotland(Carstairs). Rampton has around 400 patients (many withlearning disability), Broadmoor about 270 and Ashworthabout 260. They care for people with mental disordersdetained under the Mental Health Act (including those diag-nosed with personality disorder) who need secure condi-tions due to a history of violence against themselves and/orothers. Nurses play a vital role in the assessment, treatmentand rehabilitation of people within these units.
COMMUNITY SETTINGS
 An important concept in any treatment setting is, of course,discharge planning (or transfer planning), which needs to startfrom the very moment of admission. Environmental supports,such as housing and transportation, and access to communityresources and services are crucial to successful discharge/trans-fer planning. In fact, the adequacy of discharge/transfer plansis a better predictor of how long the person could remain suc-cessfully in the community than are clinical indicators such aspsychiatric diagnoses. As well as many other roles, the care co-ordinator (see below) plays a crucial part in planning a movefrom, say, an inpatient unit into the community.Impediments to successful discharge/transfer planning caninclude alcohol and drug abuse, criminal or violent behav-iour, non-concordance with medication regimens, and sui-cidal ideation. Decent housing is often not available to peoplewith a recent history of drug or alcohol abuse or criminalbehaviour, and clients who have suicidal ideas or a history
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