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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

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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).

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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

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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.

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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

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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

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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.

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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

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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

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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

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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

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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

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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.

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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.

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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.

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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

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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.

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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

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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.

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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

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