formed by case managers typically includes medication and symptom monitoring; crisis planning and emergency response; teaching of life skills to promote client independence (budgeting, money management, cooking, shopping, housekeeping, parenting, use of public transportation); psychoeducation (e.g., signs and symptoms of schizophrenia, the negative effects of co-occurring substance abuse, influence of stress on course and severity of mental illness); coping and social skills training; supportive counseling; family educa - tion and support; coordinating and/or providing specialized services for co-occurring substance use disorders; and social integration—helping to fortify and expand clients’ natural social supports and community involvement. Given that people with schizophrenia tend to have very limited social networks, en - hancing social supports is a critical function of case management. The quality of social supports is associated with a number of factors, including a sense of self-efficacy and per - sonal empowerment. Social supports can be either naturally occurring or orchestrated as part of formal case management interventions. Enhancing social supports may take many forms, ranging from encouraging clients to try out mutual-help groups, such as Alco - holics Anonymous; facilitating the development of a consumer group for persons with mental illness; or linking clients with church and other groups of interest. Case managers may have to help clients optimize the potential benefits from social supports by helping them to improve their social skills. Case managers are in a unique position to provide social skills training in the com- munity, including demonstration and practice of selected skills and positive reinforcement for utilizing skills appropriately. Certainly, enhancing social skills in persons with schizo- phrenia is challenging, and results vary based on the client’s level of social deficit, as well as the seriousness of co-occurring problems, such as substance abuse. Rather than broad- based efforts, case managers might focus on one or two specific circumstances in which the client would likely benefit most from improvement (e.g., engaging in light conversa- tion on the job or reducing argumentative interactions with acquaintances in the client’s social club environment). Teaching self-monitoring skills to clients enables them to begin to link certain ad- verse circumstances or experiences with the potential for relapse, and perhaps to identify emotional upset, discouragement, suicidal thoughts, anger, conflict or other troubling ex - periences as a “warning signal” to seek social supports or to contact someone on their mental health team to reduce the likelihood of further problems. Case managers also can identify areas of opportunity where clients can practice their social skills and stress man - agement skills to reduce the likelihood of crises and enhance their sense of self-efficacy, confidence, and overall well-being. EVIDENCE SUPPORTING CLINICAL CASE MANAGEMENT There is relatively little outcome research specific to clinical case management due in part to the ambiguity in distinguishing clinical case management from other, similar derivations of the ACT model (e.g., intensive community treatment, continuous treat - ment teams). In reviewing both the descriptive and the outcome literature, one encoun - ters a variety of what can generically be referred to as “clinical skills” embedded in various case management models, with the exception of a straightforward brokering- type case management, in which various services are procured and loosely coordinated for the client. Clinical case management activities are not consistently represented in the literature, but they seem to include some or all of the following: relationship build - ing and therapeutic engagement processes; psychosocial assessment; psychoeducation 314 V. SYSTEMS OF CARE with individuals and families; skills training in the community via modeling and in vivo practice; substance abuse counseling; and so forth. Less is known about the level of training in clinical case management skills or the level of expertise with which these skills are applied. Nevertheless, when case management models that include some clinical skills are compared with service brokering models, evidence suggests that they do result in mod - estly superior outcomes that include reduced hospitalizations and improved psychosocial functioning. To illustrate, one experimental comparison by Morse and colleagues (1997) demonstrated differential outcomes between an ACT program and broker-style case man - agement. In the ACT program, practitioners cultivated a positive working relationship with clients, emphasized practical problem solving, enhanced community living skills, provided supportive services, assisted with money management, and facilitated transpor - tation. By contrast, in brokering, case managers purchased services from various agencies and helped clients to develop treatment plans. ACT provided considerably more services overall (including housing, finances, health and support) and resulted in greater client sat - isfaction and better psychiatric ratings. However, no differences emerged with regard to substance abuse outcomes. As is typically the case in ACT programs, staff-to-client ratios were much smaller (about one-eighth) than that in the brokering case management condi - tion. Thus, it is hard to determine in this exemplar and in similar studies whether the better outcomes for ACT were the result of more services, different services, or qualita- tively better service delivery. Considerable limitations in most of the research on case management interventions in general include the aforementioned lack of clarity in model conceptualization, along with inadequate sample size, lack of pretreatment data on clients, problems with random assignment of cases, high rates of attrition, limited use of standardized measures, viola- tions of statistical assumptions, lack of multivariate analysis, poor distinctions among treatment conditions, and lack of attention to intervention fidelity (i.e., faithfulness to the practice model). Notwithstanding these limitations, tentative conclusions about the effectiveness of clinical case management can be drawn. Case management shows positive outcomes in clients’ lower hospital stays overall, increased social contact and social functioning, in - creased satisfaction with life, some reduction in symptoms (perhaps through medication compliance), increased family and patient satisfaction, improved social functioning, and better adjustment to employment and independent living. Although tying specific dimen - sions of clinical case management to specific outcomes is difficult, a few reports offer evi - dence that the therapeutic relationship between the case manager and the client may be a key factor that accounts for the modest superiority of clinical case management over bro - ker-style approaches. TREATMENT GUIDELINES FOR CLINICAL CASE MANAGEMENT If one extrapolates from controlled outcome research on clinical practices with the seri - ously mentally ill, it is reasonable to hypothesize that much can be done to improve the effectiveness of clinical case management through the incorporation of some of the fol - lowing treatment strategies: 1. Engagement and motivational enhancement skills. 2. Nurturing a sound therapeutic relationship. 3. Crisis intervention. 31. Clinical Case Management 315 4. Conducting comprehensive psychosocial assessments (e.g., mental status, psy - chosocial, substance abuse, and material/social supports). 5. Offering psychoeducational services to individuals and families regarding men - tal illness, substance abuse, and the importance of medication compliance. 6. Designing and implementing monitoring and evaluation strategies. 7. Using standardized measures. 8. Employing standard problem-solving skills. 9. Using role play, rehearsal, and corrective feedback to improve specific behav - ioral deficits. 10. Providing skills training, graduated exposure, and practice in the community to improve overall psychosocial functioning and generalize behavioral competen - cies. The challenge of clarifying and improving clinical case management must include de - velopment of a curriculum of skills that can be incorporated into the role of case man - ager. Feasibility depends on commitment to a number of structural service issues, includ - ing training, supervision, ongoing monitoring and evaluation, and the use of fidelity measures to maintain treatment quality. These steps also make clinical case management programs more amenable to much-needed controlled outcome research. The scope of therapeutic services provided by clinical case managers is likely to vary considerably across treatment systems. The actual clinical functions performed by clinical case managers may be a controversial issue given that many of the psychotherapeutic in- terventions described in this chapter may be seen as the domain of master’s- or doctoral- level clinicians. However, not all treatment teams have graduate-level trained specialists at their disposal, and the services provided by these clinicians may be limited, leaving the ongoing direct care largely to assigned case managers. Practically speaking, it is likely that much of the therapeutic work with seriously mentally ill clients falls to the staff member who has the most frequent contact with cli- ents, the case manager. However, there are considerable obstacles to effective incorpora- tion of clinical skills into routine case management activities. Case management is stress- ful and generally low-paying work, often resulting in high staff burnout and rapid employee turnover. These problems put strain on the treatment delivery system and are detrimental to client care, which depends on stable, responsive, ongoing services provided by compassionate caregivers. Understandably, clients often become discouraged when their assigned workers repeatedly terminate employment. The client is, yet again, faced with establishing another relationship of unknown duration. This scenario tends to be less problematic on ACT teams that share caseloads, which encourages clients to interact with multiple staff members; however, less intensive case management programs may as - sign only one worker as the single contact point for a larger caseload of clients. These in - terruptions in the continuity of care are likely to increase client relapses and treatment costs. Recruiting, training, and retaining highly skilled case managers require considerable effort from administrative and supervisory staff. Optimally, clinical case managers should be given ongoing training, support, and regular clinical supervision to foster effective therapeutic skills, to monitor client progress, to deal with challenging clients, and to guard against professional burnout. The role of clinical case manager often becomes a delicate balancing act that involves providing services for clients, meeting productivity demands, advocating for various purposes, documenting services, and conducting other administrative tasks. Therefore, teaching effective time management strategies should be considered in the training and supervision of case managers. Nevertheless, despite these 316 V. SYSTEMS OF CARE recommendations, additional incentives, such as assistance with graduate education, may be required to retain skilled case managers in the mental health system. Mental health agencies and state universities might consider forming consortiums to encourage skilled case managers to advance professionally and remain in community support programs in managerial and supervisory roles, so that they may train and supervise the next genera - tion of clinical case managers. In conclusion, despite the challenges of incorporating clini - cal skills into the traditional case management role and retaining experienced workers, clinical case management interventions, when used judiciously and assertively, can pow - erfully enhance treatment protocols for clients with schizophrenia. Clinical case manage - ment has the potential to be not only the key integrating element in a complex system of care but also the main catalyst for improving clients’ psychosocial well-being and long- term recovery. KEY POINTS • Case managers play a vital role in coordinating multiple services and improving access to the social, material, and environmental resources deemed necessary for clients with schizophrenia to achieve independent living in the community. • Continuity of care should be a guiding principle in case management approaches for treat - ment of schizophrenia to avoid fragmentation of services that can undermine even the most efficacious therapeutic interventions. • Optimal case management services should be delivered by a multidisciplinary team that can provide assertive outreach, 24-hour coverage, and long-term, open-ended treatment in clients’ natural environments. • Core functions of case management include promoting client engagement and follow through in treatment; acting as the primary client contact; brokering of services; advocacy and liaison functions; and providing a wide array of psychotherapeutic interventions. • Case managers should be well-versed in the range of evidence-based practices for people with schizophrenia; clinical interventions and services should be flexible and tailored to suit each client’s particular needs and goals for recovery. • Administrators and supervisory staff members should ensure that case managers receive ongoing training, support, and clinical supervision to foster effective therapeutic skills, to maintain professional treatment boundaries, to reduce job burnout, and to curb high staff turnover. REFERENCES AND RECOMMENDED READINGS Carey, K. B. (1998). Treatment boundaries in the case management relationship: A behavioral per - spective. Community Mental Health Journal, 34(3), 313–317. Grech, E. (2002). Case management: A critical analysis of the literature. International Journal of Psychosocial Rehabilitation, 6, 89–98. Harris, M., & Bergman, H.C. (1987). Case management with the chronically mentally ill: A clinical perspective. American Journal of Orthopsychiatry, 57, 296–302. Hromco, J. G., Lyons, J. S., & Nikkel, R. E. (1997). Styles of case management: The philosophy and practice of case managers. Community Mental Health Journal, 33(5), 415–428. Kanter, J. (1989).Clinical case management: Definitions, principles, components. Hospital and Com - munity Psychiatry, 40, 361–368. Morse, G. A., Calsyn, R. J., Klinkenberg, W. D., Trusty, M. L., Gerber, F., Smith, R., et al. (1997). An experimental comparison of three types of case management for homeless mentally ill persons. Psychiatric Services, 48, 497–503. Mueser, K. T., Bond, G. R., Drake, R. E., & Resnick, S. G. (1998). Models of community care for se - 31. Clinical Case Management 317 vere mental illness: A reviewof research oncase management. SchizophreniaBulletin, 24(1), 37– 74. Mueser, K. T., Noordsy, D. L.,Drake, R. E.,& Fox, L.(2003). Integrated treatment for dualdisorders: A guide to effective practice. New York: Guilford Press. O’Hare, T. (2005). Schizophrenia. In T. O’Hare, Evidence-based practices for social workers: An interdisciplinary approach (pp. 56–102). Chicago: Lyceum Books. Scott, J. E., & Dixon, L. B. (1995). Assertive community treatment and case management for schizo - phrenia. Schizophrenia Bulletin, 21(4), 657–668. Williams, J., &Swartz, M. (1998).Treatment boundariesin the casemanagement relationship: Aclin - ical case and discussion. Community Mental Health Journal, 34(3), 299–311. Ziguras, S. J., & Stuart, G. W. (2000). A meta-analysis of the effectiveness of mental health case man - agement over 20 years. Psychiatric Services, 51, 1410–1421. 318 V. SYSTEMS OF CARE CHAPTER 32 STRENGTHS-BASED CASE MANAGEMENT CHARLES A. RAPP RICHARD J. GOSCHA Case management has traditionally been viewed as an entity (usually a person) that co- ordinates, integrates, and allocates care within limited resources. The primary functions have been seen as assessment, planning, referral, and monitoring. The notion is that a sin- gle point of contact is responsible for helping people with psychiatric disabilities receive the services they need from a fragmented system of care. The assumption is that people who receive these benefits and services will be able to live more independently in the com- munity and that their quality of life will improve. The unadorned broker model of case management has been shown in multiple studies to be an ineffective model of practice. Enhanced case management models, such as assertive community treatment, and clinical and strengths-based models, have emerged over the last 25 years. The strengths model of case management was developed by a team at the University of Kansas School of Social Welfare beginning in the early 1980s. It has gone through almost 25 years of development, refinement, testing, and dissemination. This chapter summarizes the research, theory, principles, and methods of the strengths model. It also provides a case example for a glimpse of the model in practice and to help distinguish the practice from more traditional problem- or pathology-based approaches. RESEARCH ON THE STRENGTHS MODEL Nine studies have tested the effectiveness of the strengths model in people with psychiat - ric disabilities. Four of the studies employed experimental or quasi-experimental designs, and five used nonexperimental methods. Positive outcomes have been reported in the ar - eas of hospitalizations, housing, employment, reduced symptoms, leisure time, social sup - port, and family burden. In the four experimental studies, positive outcomes outweighed by a 13:5 ratio the outcomes in which no significant difference was reported. In none of the studies did cli - 319 ents receiving strengths case management do worse. The strengths model research results have also been remarkably resilient across settings. Consistency has been shown even within studies. Three of the studies had multiple sites with different case managers, super - visors, and affiliations, with a total of 15 different agencies. The two outcomes areas in which results have been consistently positive are reduc - tion in symptoms and enhanced quality of community life. The three studies (two experi - mental and one nonexperimental) using symptoms as a variable all reported positive out - comes. This included findings that people receiving strengths model case management reported fewer problems with mood and thoughts and greater stress tolerance and psy - chological well-being than the control groups. Although the studies used a variety of measures, which we term enhanced quality of community life (e.g., increased leisure time in the community, enhanced skills for successful community living, increased social sup - ports, decreased social isolation, and increased quality of life), people receiving strengths model case management had enhanced levels of competence and involvement in terms of community living. Eight of the nine studies using these types of measures reported posi - tive outcomes that were statistically significant. Other outcomes that seem to be strong indicators of the effectiveness of strengths model case management include reduced hospitalization (three out of six studies showing positive outcomes), vocational (two out of two showing positive outcomes), and housing (two out two showing positive outcomes). THE PURPOSE AND THEORY OF STRENGTHS The purpose of case management in the strengths model is to assist people to recover, reclaim, and transform their lives by identifying, securing, and sustaining the range of resources—both environmental and personal—needed to live, play, and work in a normal interdependent way in the community. A case manager works to “identify, secure, and sustain” resources that are both external (i.e., social relations, opportunities, and re- sources) and internal (i.e., aspirations, competencies, and confidence) rather than to focus only on external resources (brokerage model of case management) or internal resources (psychotherapy or skills development). It is the dual focus that contributes to the creation of healthy and desirable niches that provide impetus for achievement and life satisfaction. The strengths theory posits that a person’s quality of life, achievement, life satisfac - tion, and recovery are attributable in large part to the type and quality of niches that he or she inhabits. These niches can be understood as paralleling a person’s major life do - mains, such as living arrangement, work, education, recreation, social relationships, and so forth. The quality of the niches for any individual is a function of his or her aspira - tions, competencies, and confidence, and the environmental resources, opportunities and people available. Recovery as an outcome is a state of being to which people aspire. It comprises two components, the first of which concerns an individual’s self-perceptions and psychologi - cal states. This includes hopefulness, self-efficacy, self-esteem, feelings of loneliness, and empowerment. The second component closely resembles community integration. In short, people should have the opportunity to live in a place they can call home, to work at a job that brings satisfaction and income, to have rich social networks, and to have available means for contributing to others. It also means avoiding the often spirit-breaking experiences of forced hospitalization, homelessness, or incarceration. Recovery as an outcome involves achieving certain psychological states and a degree of community integration. In life, the two are closely entwined. An increased sense of 320 V. SYSTEMS OF CARE hope can contribute to having more friends or pursuing a job. Increased confidence may lead to enrolling in school. Similarly, obtaining a job may lead to increased feelings of self-efficacy and empowerment. Having an enjoyable date may enhance one’s self-esteem. At the core, the desired outcomes are people’s achievements based on the goals they set for themselves. Although these are highly individualized goals, people do seem to group them into finding a decent place to live or attaining employment and/or an oppor - tunity to contribute, education, friends, and recreational outlets. In other words, people with psychiatric disabilities want the same things that other people want. In addition, be - cause they often experience psychiatric distress, people with psychiatric disabilities want to lessen this distress and avoid psychiatric hospitalization. Like other people, they want choices and the power to decide among their options. Together, these outcomes comprise the quality of one’s life and are achievement or growth oriented. Clients do not speak often of adaptation, coping, or compliance as desired outcomes; rather, they speak of jobs, de - grees, friends, apartments, and fun. PRINCIPLES OF THE PRACTICE The following six principles are derived from the theory. The principles are the transition between the theory, which seeks to explain people’s success in life, and the specific meth- ods that assist people toward that end. The principles are the governing laws or values, or tenets, upon which the methods are based. 1. People with psychiatric disabilities can recover, reclaim, and transform their lives. The thousands of first-person accounts of recovery and the results of longitudinal re- search in several countries lead one to conclude that the capacity for growth and recovery is already present within the people we serve. Our job as case managers is to create condi- tions in which growth and recovery are most likely to occur. 2. The focus is on individual strengths rather than pathology. The work is focused on what the client has achieved, what resources have been or are currently available to the client, what the client knows and talents he or she possesses, and what aspirations and dreams the client holds. The focus on strengths rather than pathology, weaknesses, and problems enhances the motivation and the individualization of the people with whom we work. 3. The community is viewed as an oasis of resources. Although the community may contribute to a person’s distress, it may also be the source of well-being. The community provides life’s opportunities, supportive social relations, and necessary resources. Our work is devoted to identifying and acquiring the community resources necessary for achievement. 4. The client is the director of the helping process. A cornerstone of the strengths perspective of case management is the belief that it is the person’s right to determine the form, direction, and substance of the case management help he or she is to receive. People with psychiatric disabilities are capable of this determination, adherence to this principle contributes to the effectiveness of case management. Case managers should do nothing without the person’s approval, involving him or her in decisions regarding every step of the process. Adherence to this principle enhances empowerment and motivation, and fa - cilitates a strong partnership between the consumer and the case manager. 5. The primary setting for the work is the community. Case management occurs in apartments, restaurants, businesses, parks, and community agencies. An outreach mode of service delivery enhances the accuracy and completeness of assessments, avoids diffi - 32. Strengths-Based Case Management 321 culties in generalizing newly learned skills, increases retention of consumers in service, and provides opportunities for identifying community resources. 6. The case manager–consumer relationship is primary and essential. Without this relationship a person’s strengths, talents, skills, desires, and aspirations often lie dormant and may not be mobilized for the person’s recovery journey. It takes a strong and trusting relationship to discover the rich and detailed tapestry of someone’s life and to create an en - vironment in which a person is willing to share what is most meaningful and important— his or her passion for life. PRACTICE GUIDELINES Engagement The purpose of engagement is to create a trusting reciprocal relationship between the case manager and the consumer as a basis for working together. To facilitate each con - sumer’s recovery journey, the relationship should be a hope-inducing rather than spirit- breaking process. Examples of spirit breaking include restricting people’s choices, im - posing our own standard of living on people, making their decisions for them, and tell - ing people that they are not yet ready for work, a car, or an apartment. In contrast, hope-inducing relationships are built through caring interactions, focusing on people’s strengths, celebrating their accomplishments, promoting choice, helping them achieve goals that are important, and promoting a future beyond the mental health system. En- gagement and the entire case management process occurs in the community, not in the mental health agency. Strengths Assessment The purpose of a strengths assessment is to amplify the well part of an individual by col- lecting information on personal and environmental strengths. The strengths assessment is organized by eight life domains: daily living situation; finances; vocation/education; social supports; health, leisure, and recreational activity; and spiritual/cultural activity. Information is organized in each life domain by the current situation, the future (desires and aspirations), and past situations. A strengths assessment, unlike many assessments, is an ongoing, continuous process. The information is gathered in a conversational manner as the case manager and consumer spend time together. It is critical that case managers collect specific information, avoiding the tendency to rely on pleasant adjectives (e.g., dil - igent, humorous, kind). The inquiry should focus on specific achievements, talents (play - ing the 12-string guitar, skill as a foreign car mechanic), and environmental resources (church choirmaster, playing gin with one’s brother). Personal Planning The purpose of personal planning is to create a mutual work agenda between the case manager and consumer that focuses on achieving goals that the client has set. Goals are inherent to hope and indispensable precursors to achievement. The personal plan lays out the decisions that the consumer and case manager must discuss and upon which they must agree. Their decisions include the long-term goal or passion state - ment, specific tasks needed to pursue the goal, deciding who is responsible, and dates for task completion. The personal plan is in part a “to-do list” for both the consumer and the case manager. 322 V. SYSTEMS OF CARE Resource Acquisition The purpose of resource acquisition is to acquire environmental resources desired by the consumer to achieve goals, to ensure his or her rights, and to increase his or her assets. Primacy is placed on normal or natural resources, not mental health services, because true community integration can only occur apart from mental health and segregated ser - vices. Therefore, work is done with employers, landlords, coaches, colleges, teachers, art - ists, ministers, and so forth. The identification and use of community strengths, assets, and resources are as critical as the identification and use of individual strengths. Often, the case manager helps community resource personnel adjust to accommo - date the desires or needs of a particular person. There are times, however, when adjust - ments are not needed in the setting or in the client, or if needed, the adjustments are very minor. This occurs when the case manager finds the “perfect niche,” where the require - ments and needs of the setting perfectly match the desires, talents, and at times, idiosyn - crasies of the consumer. Harry, a 30-year old man, grew up in rural Kansas, living his whole life on a large farm. He was diagnosed with schizophrenia and entered the state psychiatric hospi - tal. Upon discharge, Harry was placed in a group home, with services provided by the local mental health center. Although not disruptive, Harry failed to meet the group home’s hygiene and cleaning requirements, did not use mental health center services, and resisted taking his medication. It was reported that Harry would pack his bags every night, stand on the porch, and announce that he was leaving, although he never left. Over the next 2 years, Harry’s stay at the group home was punctuated with three readmissions to the state hospital. Although Harry was largely uncommunicative, the case manager slowly began to appreciate Harry’s knowledge and skill in farming, and took seriously Harry’s ex- pression of interest in farming. The case manager and Harry began working to find a place where Harry could use his skills. They located a ranch on the edge of town, where the owner was happy to accept Harry as a volunteer. Harry and the owner became friends, and Harry soon estab- lished himself as a dependable and reliable worker. After a few months, Harry recov - ered his truck, which was being held by his conservator, renewed his driver’s license, and began to drive to the farm daily. To the delight of the community support staff, Harry began to communicate, and there was a marked improvement in his personal hygiene. At the time of case termination, the owner of the ranch and Harry were dis - cussing the possibility of paid employment. CONTRASTING THE STRENGTHS ASSESSMENT AND THE PSYCHOSOCIAL ASSESSMENT David was required to attend the day treatment program 5 days per week as a condi - tion for residing at the program’s transitional living facility. Over the past 2 weeks he had become increasingly more aggressive with staff members and other clients. He was suspended for 1 day the previous week for yelling at clerical staff members who refused to give him bus tickets. David stated that he did not want to be at day treat - ment, that he wanted to go to work. Staff members said that he was not “ready to go to work,” but that he could demonstrate his “work readiness” by his behaviors at the day treatment program. A staff meeting was called to decide what to do with Da - vid. The prevailing thought was that he would probably need to be rehospitalized and have his medications adjusted. 32. Strengths-Based Case Management 323 [...]... choice of medication is dependent on the specific issues of the patient Often, patients who have had adherence problems may be placed once again on their initial treatment regimen, although an attempt should be made to address the cause of the nonadherence Otherwise, high-potency antipsychotics are often used (either first- or second-generation drugs), according to either the clinical needs of the... of others, and treatment of the patient Although complex, the Tarasoff principle (Tarasoff v Regents of the University of California, 19 76) , which is not standard for all states, provides a commonly used legal 342 V SYSTEMS OF CARE framework for decision making when third parties are being threatened (Felthous, 1999) According to the California Supreme Court decision, the principle, known as Tarasoff... as a part of the treatment plan, or at the request of the patient, if the clinical treatment team is in agreement Care must be taken to ensure that the rights and dignity of the patient are upheld, and that the patient is a part of the decision-making process to the greatest extent possible Seclusion rooms can be used for multiple purposes, including isolation and reduction of sensory stimulation of. .. use of a measure American Journal of Orthopsychiatry, 68 , 2 16 232 van Veldhuizen, J R (in press) A Dutch version of ACT Community Mental Health Journal C H A P TE R 34 EMERGENCY, INPATIENT, AND RESIDENTIAL TREATMENT MOUNIR SOLIMAN ANTONIO M SANTOS JAMES B LOHR Although the current goal of treatment for patients with schizophrenia is to maintain clinical stability in an outpatient setting, patients often... individuals with schizophrenia spectrum disorders, with the most persistent and devastating levels of impairment, who have not successfully engaged with less intensive, office-based mental health services Well-run ACT programs must attend to both clinical skills development and model specifications The ACT organizational framework is well suited to implementation of evidence-based clinical interventions,... of an ACT team ACT services are aimed at clients with high service needs and an array of complicating life circumstances The level of clinical skill among team members should be sufficiently high to meet the challenge of providing intensive, recovery-oriented ACT services Ongoing training specifically geared toward clinical skills development among practitioners should be a priority at all levels of. .. commitment period are available There is often one type of short-term commitment for further medical evaluation and treatment, and rapid stabilization (usually for a period of days, often 3 days), and another type that may often follow the shorter one, involving a longer period (in terms of weeks) for more comprehensive evaluation and further treatment stabilization Of course, involuntarily committed patients... Commission on Accreditation of Healthcare Organizations (JCAHO) standards Length -of- Stay Issues One of the biggest challenges in the development of inpatient treatment programs is the need to provide a therapeutic experience despite patients’ length of hospital stay, which has shortened over the years Many facilities are still utilizing treatment models (e.g., certain forms of group treatment) designed... type of restraint should be used for the shortest possible period of time, with frequent reassessment of the ongoing need for it Acceptable uses for restraints include prevention of imminent harm to the patient or others when alternative means are ineffective or inappropriate; prevention of disruption of the treatment program, or of violence or damage to the environment; decreasing stimulation of the... for clients who have already attained high levels of self-management of their illness Based purely on clinical considerations, however, ACT services have been found to be beneficial to clients spanning a wide spectrum of symptom severity and disability Step-Down ACT Programs As previously discussed, the ACT model was originally conceived of as a time-unlimited service There is now greater recognition . competen - cies. The challenge of clarifying and improving clinical case management must include de - velopment of a curriculum of skills that can be incorporated into the role of case man - ager lack of pretreatment data on clients, problems with random assignment of cases, high rates of attrition, limited use of standardized measures, viola- tions of statistical assumptions, lack of multivariate. psychoeducation (e.g., signs and symptoms of schizophrenia, the negative effects of co-occurring substance abuse, influence of stress on course and severity of mental illness); coping and social