The right to live independently and be included in the community.

The segregation and isolation of people with disabilities are global problems, rooted in legislation and policy, social norms and traditional practices. The right to live independently and be included in the community, contained in article 19 of the United Nations Convention on the Rights of Persons with Disabilities, was created to combat the phenomenon of institutionalization and to spur efforts towards its eventual eradication. This essay offers a commentary on article 19, drawing on its drafting history, on the interpretation provided by the responsible UN body and on the efforts by that body to monitor and encourage compliance. It emphasizes the extent of the transformation required to realize the full ambition of the article and the need for cooperation across UN treaty bodies.

Deinstitutionalization and other factors in the criminalization of persons with serious mental illness and how it is being addressed.

One of the major concerns in present-day psychiatry is the criminalization of persons with serious mental illness (SMI). This trend began in the late 1960s when deinstitutionalization was implemented throughout the United States. The intent was to release patients in state hospitals and place them into the community where they and other persons with SMI would be treated. Although community treatment was effective for many, there was a large minority who did not adapt successfully and who presented challenges in treatment. Consequently, some of these individuals' mental condition and behavior brought them to the attention of law enforcement personnel, whereupon they would be subsequently arrested and incarcerated. The failure of the mental health system to provide a sufficient range of treatment interventions, including an adequate number of psychiatric inpatient beds, has contributed greatly to persons with SMI entering the criminal justice system. A discussion of the many issues and factors related to the criminalization of persons with SMI as well as how the mental health and criminal justice systems are developing strategies and programs to address them is presented.

Development of atypical parental behavior during an inpatient family preservation intervention program.

Since failed reunification is a detrimental outcome for children, particularly infants and toddlers, the aim of this study was to gain insight into support to families in multiple-problem situations to help them achieve sustainable good-enough parenting. Therefore, we examined outcomes of an assessment-based inpatient family preservation program. We prepared a thorough target-population description (n = 70) using file analysis. Next, we examined atypical parental behavior during the intervention using the Atypical Maternal Behavior Instrument for Assessment and Classification with a repeated measures design (n = 30). The family files revealed a great number of issues at the family, parent, and child levels, such as practical matters, problems in parent functioning and between parents, and difficulties in the broader environment. We found a significant decline in three dimensions of atypical parental behavior over time. This program has great potential in supporting vulnerable families in their pursuit of family preservation.

Debido a que un fracasado intento de reunificación es un resultado perjudicial para los niños, particularmente los infantes y niños muy pequeñitos, la meta de este estudio fue adquirir percepciones en cuanto al apoyo a familias en situaciones de problemas múltiples para ayudarles a lograr una crianza sostenible suficientemente buena. Examinamos, por tanto, resultados de un programa de paciente interno para la preservación de la familia (FP) basado en evaluación. Preparamos una detallada descripción de la población de enfoque (n = 70) usando análisis de registros. Examinamos conductas atípicas de los padres durante la intervención usando el Instrumento de Conducta Materna Atípica para Evaluación y Clasificación (AMBIANCE) con un diseño de medidas repetidas (n = 30). Los registros familiares revelaron un gran número de asuntos al nivel de la familia, los padres y los niños, tales como asuntos prácticos, problemas en el funcionamiento de los padres y entre padres, y dificultades en el más amplio entorno. Encontramos una baja significativa en tres dimensiones de conducta atípica de los padres a lo largo del tiempo. El programa FP tiene un enorme potencial para apoyar a familias vulnerables en su esfuerzo por preservar la familia.

Puisque la réunification échouée est un résultat détrimentaire pour les enfants, en particulier les nourrissons et les jeunes enfants, le but de cette étude était d'explorer le soutien aux familles dans des situations avec de nombreux problèmes afin de les aider à atteindre un parentage durable et suffisant. Nous avons donc examiné les résultats d'un programme de maintien familial (abrégé ici MF en français) fondé sur l'évaluation et en hospitalisation. Nous avons préparé une description approfondie de la population cible (n = 70) en utilisant une analyse par dossier. Nous avons examiné le comportement parental atypique durant l'intervention en utilisant AMBIANCE, l'instrument de comportement maternel atypique pour l'évaluation et la classification avec une conception à mesures répétées (n = 30). Les dossiers familiaux ont révélé un grand nombre de problèmes au niveau de la famille, du parent et de l'enfant, tels que des problèmes pratiques, des problèmes dans le fonctionnement du parent ou entre les parents, et des difficultés dans le milieu plus large. Nous avons trouvé une baisse importante sur trois dimensions du comportement atypique parental au fil du temps. Le programme MF offre de grandes possibilités dans le soutien aux familles vulnérables dans leur quête de maintien familial.

La rehabilitación psicosocial entre la desinstitucionalización y la recuperación / Psychosocial rehabilitation between deinstitutionalization and recovery

En este artículo se propone una revisión de los aspectos conceptuales y de las prácticas que han venido caracterizando la rehabilitación psicosocial (RPS) en los últimos 60 años, esto es, desde los inicios de la desinstitucionalización psiquiátrica hasta la actualidad, en que los nuevos valores y prácticas de la recuperación (con una mayor participación y protagonismo de los usuarios) están adquiriendo cada vez más relevancia. Se abordan las dos dimensiones nucleares de la RPS: las técnicas de intervención y los contextos biográficos, sociales y asistenciales, teniendo en cuenta los aspectos más relevantes de la experiencia internacional y prestando una atención especial a la evolución y la situación actual de la cuestión en España (AU)

This article offers a review of both the conceptual aspects and the practices of psychosocial rehabilitation in the last 60 years, that is, from the beginning of psychiatric deinstitutionalization to the present, which is growingly influenced by the new principles and practices of recovery and a stronger involvement and participation of users of mental health services. Two core dimensions of psychosocial rehabilitation will be assessed: intervention strategies and biographical, social and care contexts. The most relevant aspects of the international experience are considered, focusing specially on the evolution and present situation of the field in Spain (AU)

Intentional collaboration: addressing transitions in care for people with severe and persistent mental illnesses.

This commentary explores transitions in care for people who have severe and persistent mental illnesses and reside in long-term care communities. Challenges and historical approaches as well as barriers to successful transitions are examined. Recent policy changes in North Carolina are discussed and contextualized in emerging evidence-based practices that emphasize intentional collaborative efforts.

Avatares de la cronicidad: políticas, instituciones, dispositivos y terapeutas / Ups and downs of chronicity: policies, institutions, mechanisms and therapists

Se abordan diferentes vectores que hacen a la problemática de la cronicidad. El individual, del paciente; el sociopolítico; el inherente al lugar del terapeuta, los dispositivos, las instituciones en el abordaje de los pacientes crónicos. Se realiza un recorrido temático y de autores que tiende a repensar la posición del terapeuta (psiquiatra, psicólogo, psicoanalista) ante estos pacientes. Ubicados a veces como inclasificables o refractarios, que -como se ha dicho- en la valoración de los profesionales son intrínsecamente difíciles y poco "gratificantes", nos llevan a considerar los ideales de salud, las expectativas, así como las incomodidades de los modelos de tratamientos y dispositivos institucionales.

Chronicity is approached from several angles: that of the individual patient, the sociopolitical background, the therapist’s role, the institutional framework for the treatment of chronic patients. Relevant themes are discussed and authors visited that contribute to fresh thinking regarding the position of the therapist (psychiatrist, psychologist, psychoanalyst) towards these patients. More often than not, these patients are classified as unclassifiable, or refractory. As it has been said before, this implies that from the professional's viewpoint these patients are intrinsically difficult and "little rewarding". This raises the question of health ideals and expectations, as well as the institutional inconveniences of current models of treatments and institutional devices.

Avatares de la cronicidad: políticas, instituciones, dispositivos y terapeutas / Ups and downs of chronicity: policies, institutions, mechanisms and therapists

Se abordan diferentes vectores que hacen a la problemática de la cronicidad. El individual, del paciente; el sociopolítico; el inherente al lugar del terapeuta, los dispositivos, las instituciones en el abordaje de los pacientes crónicos. Se realiza un recorrido temático y de autores que tiende a repensar la posición del terapeuta (psiquiatra, psicólogo, psicoanalista) ante estos pacientes. Ubicados a veces como inclasificables o refractarios, que -como se ha dicho- en la valoración de los profesionales son intrínsecamente difíciles y poco "gratificantes", nos llevan a considerar los ideales de salud, las expectativas, así como las incomodidades de los modelos de tratamientos y dispositivos institucionales.(AU)

Chronicity is approached from several angles: that of the individual patient, the sociopolitical background, the therapists role, the institutional framework for the treatment of chronic patients. Relevant themes are discussed and authors visited that contribute to fresh thinking regarding the position of the therapist (psychiatrist, psychologist, psychoanalyst) towards these patients. More often than not, these patients are classified as unclassifiable, or refractory. As it has been said before, this implies that from the professionals viewpoint these patients are intrinsically difficult and "little rewarding". This raises the question of health ideals and expectations, as well as the institutional inconveniences of current models of treatments and institutional devices.(AU)

Hawai'i's "Going Home Plus" project: a new option to support community living.

The Going Home Plus project facilitates the transition of individuals from hospitals, nursing facilities, and intermediate care facilities for the mentally retarded (ICF-MRs) into community settings. The project is a collaborative effort between the State of Hawai'i Department of Human Services (DHS), the University of Hawai'i Center on Disability Studies and their community partners to help elderly and younger persons with disabilities who have been living in an institution for at least six months and express a choice for community living. The project, which provides services such as transition coordination and telemedicine, strives to become a valuable resource for institutionalized patients, their families, and medical professionals.

[Mental health, rights and citizenship: the law office as an agent for social inclusion]. / Saúde mental, direitos, cidadania: o escritório de advocacia como agência para inclusão social.

The Psychiatric Reform discusses issues related to the inclusion of individuals that suffer from mental disorders, having as its main project the construction of citizenship through the reconstruction of their rights and recognizing that mentally ill individuals are in a condition of exclusion because of their very condition, the work and the social fragility. The Centro de Atenção Psicossocial Prof. Luiz da Rocha Cerqueira intends to interfere in the exclusion condition of mentally ill individuals through a number of projects, among them its Law Office, a social service agent that, by promoting alliances, offers to its users the possibility to reach higher and higher levels of management of their lives. The purpose of this study was to characterize the users of the Law Office and verify the importance of such intervention to them. Four users were interviewed and were asked to evaluate the service. They showed understanding of the fact that the service makes their insertion into the world of rights easier and therefore may be considered an important technology in mental health.

Saúde mental, direitos, cidadania: o escritório de advocacia como agência para inclusão social / Salud mental, derechos, ciudadanía: la oficina de abogacía como agencia para la inclusión social / Mental health, rights and citizenship: the law office as an agent for social inclusion

A Reforma Psiquiátrica discute questões relacionadas à inclusão dos loucos no mundo, tomando como projeto principal a construção da cidadania, ante a reconstrução dos Direitos, reconhecendo que os doentes mentais se encontram em condição de exclusão, pela própria condição, pelo trabalho e fragilidade social. O Centro de Atenção Psicossocial Professor Luiz da Rocha Cerqueira pretende interferir na condição de excluído do doente mental, por meio de projetos, entre eles o Escritório, que é um dispositivo de agenciamento social, promotor de alianças, que proporciona a possibilidade de os indivíduos atingirem patamares cada vez mais elevados de gerenciamento de suas vidas. Este estudo teve como objetivos principais caracterizar o usuário do Escritório e verificar a importância dessa intervenção para eles. Foram realizadas entrevistas com quatro usuários, os quais avaliaram o serviço, compreendendo que ele facilita a inserção no mundo dos direitos e, portanto, pode ser considerado como importante tecnologia em saúde mental.

The Psychiatric Reform discusses issues related to the inclusion of individuals that suffer from mental disorders, having as its main project the construction of citizenship through the reconstruction of their rights and recognizing that mentally ill individuals are in a condition of exclusion because of their very condition, the work and the social fragility. The Centro de Atenção Psicossocial Prof. Luiz da Rocha Cerqueira intends to interfere in the exclusion condition of mentally ill individuals through a number of projects, among them its Law Office, a social service agent that, by promoting alliances, offers to its users the possibility to reach higher and higher levels of management of their lives. The purpose of this study was to characterize the users of the Law Office and verify the importance of such intervention to them. Four users were interviewed and were asked to evaluate the service. They showed understanding of the fact that the service makes their insertion into the world of rights easier and therefore may be considered an important technology in mental health.

La Reforma Psiquiátrica discute cuestiones relacionadas a la inclusión de los locos en el mundo, tomando como proyecto principal la construcción de la ciudadanía, por medio de la reconstrucción de los Derechos, reconociendo que los enfermos mentales se encuentran en condición de exclusión, por la propia condición, por el trabajo y fragilidad social. El Centro de Atención Psicosocial Profesor Luiz da Rocha Cerqueira pretende interferir en la condición de excluido del enfermo mental, por medio de proyectos, entre ellos la Oficina, que es un dispositivo de agenciamento social, promotor de alianzas, que proporciona la posibilidad de que los individuos alcancen niveles cada vez más elevados de gerenciamiento de sus vidas. Este estudio tuvo como objetivos principales caracterizar al usuario de la Oficina y verificar la importancia que tiene para ellos esa intervención. Se llevaron a cabo entrevistas con cuatro usuarios, los cuales evaluaron el servicio, comprendiendo que él facilita la inserción en el mundo de los derechos y, por tanto, puede ser considerado como una importante tecnología en salud mental.

[Assessing deinstitutionalization of the nursing home area of a large state mental hospital from the point of view of patients and staff]. / Der Enthospitalisierungsprozess des psychiatrischen Heimbereichs eines ehemaligen Grosskrankenhauses aus Patienten- und Mitarbeitersicht.

OBJECTIVE: Within the deinstitutionalization process of a large psychiatric hospital, the development of two cohorts of patients with chronic schizophrenia is compared over a two-year period: patients living in the hospital's nursing-home area (n = 50) vs. patients already released to two social therapeutic hostels (n = 51). Results of the cohort study were compared with assessments of nurses working in the nursing home (n = 55), focusing on their subjective views of the deinstitutionalization process and its impact on their working conditions. METHODS: Patients are assessed through yearly home-visits in their place of residence. The instruments used measure several outcome parameters: psychopathology, social disabilities, subjective quality of life, and normative needs for care. Concurrent staff assessments were conducted using standardized survey instruments focusing on current working conditions and quality of teamwork. Nineteen nurses participated in qualitative interviews evaluating the deinstitutionalization process. RESULTS: For all measures, patients living in the nursing home show significantly worse outcomes. Furthermore, during the study period 34 % experienced a change in their living situation with which they were dissatisfied. Needs for care and the number of areas of "unmet" need increased significantly for this subgroup. Patients living in social therapeutic hostels demonstrate stable levels of psychopathological symptoms, social disabilities, and needs for care. Assessments indicating a deterioration in patients' subjective quality of life focus mainly on areas important for social contacts. Regarding "personal concerns" and "insecurity at work", ratings from nursing home staff were significantly worse than those of a reference group from several other health care institutions (n = 224). Staff showed a tendency to give higher ratings for their opportunities to participate in decisions, in contrast with the low ratings for chances to improve their knowledge in the workplace, a result which may indicate a lack of prospects. In general, staff faces the conundrum of being asked to adopt a new mental health care paradigm while organisational structures are being eliminated and insecurity about career opportunities is increasing. CONCLUSION: To adequately manage deinstitutionalization of care, all participating parties must be involved in the process as early as possible to clarify expectations and to demonstrate commitment to future opportunities in the new system.