Learning Objectives
By the end of this section, you will be able to:
- Describe the main types of treatment settings
- Identify advantages of each treatment setting
- Identify disadvantages of each treatment setting
The word milieu describes the environment in which mental health treatment occurs. There are many different milieus to consider when thinking about treatment settings. In milieu therapy, clients are treated in a structured, safe environment where their participation in day-to-day routines, communities, and relationships is the method of therapy. Milieu therapy dates back to the 1950s residential treatment of emotionally disturbed children (Smith & Spitzmueller, 2016). In more recent years, the type and role of milieu has expanded from primarily inpatient environments to community environments where interactions occur between health-care/nursing staff and the client and between clients sharing experiences. Some examples of milieu settings include inpatient behavioral health units, outpatient therapists’ offices, community mental health centers, methadone clinics, and substance use rehabilitation programs. Within this therapeutic setting or milieu, the client learns positive coping skills, appropriate reactions to and communication with others, and practical applications of the therapeutic experience to their lives outside of the treatment environment. Treatment settings themselves are as varied as the clients who need treatment. The clinician and the client must work together to find the most appropriate fit for treating the presenting symptoms.
Types of Treatment Settings
The chosen site for the treatment is based on the type and acuity of a client’s symptoms and the ability to treat them safely outside of the inpatient setting. More specifically, decisions about treatment environments are based on safety of the person and others, the person’s mental capacity at the time of care, and, in some cases, state laws (Pirotte & Benson, 2023). Choosing the least restrictive effective environment, however, is the overriding goal. A least restrictive environment is one in which the client receives the most effective treatment that places the fewest restrictions on their life. These environments take into consideration a person’s personal rights to be able to choose where they receive care, their ability to make decisions, their right to be involved in collaborative care with their treatment providers, and their right to refuse care or request a different type of care than that recommended by the health-care provider.
There are many different types of mental health services offered in the community, for example:
- Patient-centered medical homes are comprehensive, coordinated, patient-centered models of primary care (AHRQ, n.d.). This type of setting offers mental health and medical care all in one facility. This often encourages the client to keep up with their medical care because they are already comfortable receiving their mental health care in the same setting.
- Community mental health centers offer free, low-cost, or sliding scale care for those who lack resources to pay for mental health care. These centers are typically in the center of town making them convenient, especially if transportation is a barrier to care.
- County programs, such as Comprehensive Community Services (CSC) or Community Support Programs (CSP), offer intensive case management services that allow a person to live in their own home with the support of trained personnel who assist them with transportation to health-care provider appointments, running errands, peer support services, and care coordination.
- Forensic nursing is an area of specialty that provides nursing care in correctional facilities, including psychiatric-mental health care. The advantage to this type of program is that an incarcerated person can continue to receive their mental health medications. The disadvantage is that many programs lack funding to provide a psychiatrist who sees the incarcerated people as often as is needed for their mental health needs. There is also lack of coordination with local community systems to provide appropriate mental health care to individuals upon release from correctional facilities, leading to relapse and recidivism.
- Psychiatric home care provides community-based treatment for clients who are homebound. The client is able to continue to live in their own home with the support of the visits they receive from their assigned nurse. Remaining at home helps clients to feel like they have autonomy.
- Certified peer specialists are people in recovery who support clients by helping them with lived experience examples and by providing hope. Peer specialists offer support by sharing their own experiences with a client. The support offered through this type of interaction can increase a person’s hope that they, too, will be able to recover.
- Telepsychiatry provides therapy and services through videoconferencing. This option became very popular during COVID-19 and there are now many applications that clients can access directly from their phones so that they can talk to a therapist at any time. Telepsychiatry through a therapist’s office requires scheduled appointments at specific times. This may not be an option for people who live in rural areas without internet connection, who do not have cell phones or computers, or for those who feel more comfortable talking to a therapist face-to-face.
Outpatient Treatment
Outpatient treatment occurs in the community; it means receiving a health-care treatment with no overnight stay. Clients often visit their primary care provider first when concerned about their mental health. If a client has a more severe mental health challenge, they are typically referred to specialized psychiatric care providers, such as psychiatrists, psychiatric-mental health advanced practice registered nurses/nurse practitioners, psychologists, social workers, counselors, or other licensed therapists.
In terms of outpatient treatment, clients may see a therapist to discuss ongoing issues, get assistance developing positive coping skills, and determine triggers that worsen symptoms. A client may be connected to a community mental health center where they attend appointments with their psychiatrist or therapist and can participate in group therapy. A person with a severe mental illness (SMI), a mental illness that interferes with a person’s ability to function in life, may be followed closely by a case manager from, for instance, an Assertive Community Treatment (ACT) program, which has a team available 24/7, so that person can continue to live independently. An ACT program offers a team of specially trained case managers who support their clients by providing transportation to medical and mental health appointments; help with transportation for errands, such as grocery shopping; and assist with care coordination, such as scheduling appointments with various doctors. Another such service is Comprehensive Community Support, which “focuses on five life domains: independent living, learning, working, socializing and recreation” (Presbyterian Medical Services, 2023, para 1). This type of program, and others like it, promote resilience by teaching clients about community resources and how to access/use them. Outpatient treatment is the primary goal—and often the best route—for most people dealing with a mental illness.
Some community mental health centers encourage training clients who have gone through mental health issues and are working on their recovery to become certified peer specialists (see 6.3 Peer Support). One thing that a peer specialist might be trained to do is run Wellness Recovery Action Plan (WRAP) groups. These programs provide tools and teach participants how to create action plans to live a safe and healthy life (Advocates for Human Potential, 2023).
Advantages
Outpatient settings can be more convenient, less expensive, encourage longer-term client/counselor relationships, keep the client working, and are more amenable to family support. In outpatient settings, clients are cared for in or near the communities in which they live. For those with limited access to transportation, a community health center is often easily accessible via foot or public transport. Over time, clients build trusting rapports with their therapists, leading to better long-term outcomes. Other advantages include clients being able to continue with their daily activities and having close support from their families. This option is also more cost-effective than inpatient treatment, especially for clients with jobs who can continue to work. Clients can also immediately apply what they are learning from their outpatient treatment provider to their daily lives.
Disadvantages
In rural areas, there may not be access to a local health-care center, requiring the client to travel long distances to receive mental health care. This can cause barriers, such as lack of transportation for those who do not drive or an inability to take off time from work to travel a long distance for an appointment. An additional problem in some areas is a general lack of mental health providers, which decreases the availability of appointments and the flexibility to find times that are convenient for the client. Moreover, some outpatient treatment centers have access to fewer specialized resources than inpatient offerings and offer less supervision than inpatient options.
Patient-Centered Medical Homes
A patient-centered medical home (or the medical home model) provides comprehensive, coordinated, client-centered models of primary care. These facilities are not available in every community, but the trend to provide medical homes is a national initiative through the Agency for Healthcare Research and Quality (AHRQ, 2022). Nurses can access the AHRQ website for more information on finding local medical homes. The medical home model, developed by the Veterans Health Administration, is an example of a proactive, primary care, interdisciplinary team based on client-centered, holistic care, and active communication and coordination among providers. This model is considered effective for clients with complex health-care needs. Core elements of the medical home model distinguish it from traditional primary care, such as:
- Clinical outreach: Outreach to people without homes, individuals in shelters, and to those in community locations, such as soup kitchens
- Low threshold access to care: Open access with walk-in capacity and flexible scheduling (i.e., clients do not need an appointment to be seen by their care team)
- Integrated services: Several different kinds of health-care providers in one location, for example, a psychiatrist, a therapist, and a health-care provider; mental health services and primary care services are located close to each other
- Sustenance needs: Food or food vouchers, hygiene kits, clothes, bus passes, other transportation assistance
- Health-care management: Integrated with community agencies with an emphasis on ongoing, continuous care
- Continual staff training: Focusing on development of care skills for those without homes
Advantages
Clients are seen where they feel comfortable and accepted. The lack of need for an appointment means that clients can walk in when they are feeling capable of getting to the medical home and are willing and ready to see a provider. Because of the variety of services offered in one place, this model is convenient to those clients who have work, transportation, and time considerations. Seeing a variety of different providers in different settings may prove overwhelming or practically impossible. This type of setting works well for those clients with a distrust for medical providers based on their cognition or prior poor treatment or for individuals with multiple medical comorbidities. Examples of clients having cognitive problems include those experiencing acute psychiatric symptoms, such as paranoia or hearing negative voices (auditory hallucinations), a person born with cognitive disabilities, or a person who has dementia. Any of these people may have also had a poor prior treatment experience due to things like perceived stigmas from those providing care, being discharged from a medical provider’s practice due to missed appointments (this happens due to lack of transportation, not feeling well enough to attend the appointment, or even forgetting the appointment due to their illness), or being unable to build a rapport with that provider.
Disadvantages
Not all communities have this sort of medical model available. Some practices that try to follow this model find that it is financially difficult. They need to be reimbursed at higher dollar amounts in order to make health-care providers within their practice interested in pursuing the work, and the required documentation that goes into developing this model can be prohibitive. They also may find the need to hire extra personnel whose job it is to specifically communicate and coordinate care with other area specialties and offices (Budgen & Cantiello, 2017).
Link to Learning
This TED talk discusses the use of digital tools to fight the stigma associated with getting mental health treatment.
Telehealth Home Care Treatment
COVID-19 led to increased availability of telehealth appointments both through traditional therapists’ offices and online applications. In telehealth, health-care providers use digital technologies to deliver medical care, health education, and public health services by remotely connecting multiple users in separate locations. Nurses must be aware of potential barriers affecting client use of telehealth (i.e., lack of internet access or lack of support for individuals learning new technologies), as well as state and federal policies regarding telehealth and their nursing license across state lines.
Link to Learning
The telehealth hub at the Department of Health and Human Services website provides telehealth information tabs for clients and providers, including licensing requirements and interstate compacts.
Teletherapy is mental health counseling over the phone or online with videoconferencing. When engaging in teletherapy, nurses should treat clients as if they are sitting across from them and should focus on eye contact and empathetic expressions to build a connection, just like during a face-to-face encounter (Telehealth.hhs.gov, 2021). Group therapy can also take place via telehealth. Connecting clients through telehealth can build community, reduce feelings of isolation, and provide a forum to share new perspectives. Group therapy, even through telehealth, can create a sense of belonging and build a trusted support system (Telehealth.hhs.gov, 2021).
Advantages
Clients can receive services within the comfort of their own homes where they feel safe and less anxious. The use of telehealth and teletherapy can also provide a connection to services and support that may otherwise have been inaccessible. This option provides “therapy at the fingertips” for those who are tech-savvy. It is more cost-effective, is convenient, saves time, offers access that may not have been available otherwise, and eliminates other stigma sometimes associated with seeking mental health services.
Disadvantages
The lack of internet connection in some rural areas and homes eliminates the option for in-home treatment through teletherapy. Plus, there may be more distractions in a client’s home during a therapy session and the connection between client and provider may suffer or take slightly longer to develop than when in person. Some clients are not appropriate candidates for in-home or teletherapy due to the acute nature of their symptoms. These clients include those who are actively suicidal or at risk for self-harm and those with cognitive, hearing, or vision problems (DeCarlo et al., 2020).
Home Care
In many cases, when someone thinks of home care nursing, they are thinking of the medical care given to some clients after they are discharged home from the hospital but need follow-up for a limited time to help with things like dressing changes, ostomy care, or even to check on newborn wellness. But some home care facility teams may also include psychiatric nurses who provide in-home visits to homebound clients. This type of care is a way of keeping clients in their homes, in the least restrictive environment, so that they can live as normal a life as possible while still receiving mental health treatment. The home care psychiatric nurse provides regularly scheduled visits to the client to monitor any psychiatric symptoms they may be having, provides safety checks to ensure the client is not having any suicidal urges, does medication checks to make sure the client is taking their medication as prescribed, helps with coordination of other medical or community services, and may even draw labs so that the client does not need to leave their home for these services. Combining existing home care programs with the option of in-person or telehealth visits has increased wellness in these clients (Boland, 2018).
Advantages
There are several advantages to mental health home care. Visits to a client’s home can allow nurses to ensure the client’s understanding of and monitor adherence with a client’s medication. The home visit provides socialization to a person who might otherwise feel isolated, and the level of intimacy between the RN and the client grows as the client becomes more comfortable having the RN in their home. Home visits offer an opportunity to meet the client where they are, understand their surroundings, and see what limitations and safety obstacles the environment may pose. For instance, there may be fall risks from scatter rugs or a lack of shower rails. The nurse can make environmental safety recommendations to the client and family based on home observations. The nurse has the added benefit of observing the connection between family members and the client and providing overall support and education to the entire family (Boland, 2018).
Disadvantages
In rural areas where there may be a lack of mental health services available, a single nurse may be required to travel many miles to see clients within the home environment. Travel time makes home visits less efficient, and the nurses can see fewer clients in a day because of transport time between appointments. Other concerns for the nurse include safety of being in the client’s home, amount of time spent in the appointment, especially if family is present, and maintaining professional boundaries.
Substance Use Rehabilitation
The treatment of substance use disorder is called substance use rehabilitation; it takes place in a variety of settings because no one way works best for everyone. It may entail use of medication to reduce cravings, group therapy, family education, and a long-term recovery process. The treatment of substance use disorder is typically delivered in freestanding programs in hospitals, residential, or outpatient settings that vary in the frequency of care delivery, the range of treatment components offered, and planned duration of care. As clients progress in treatment and begin to meet the goals of their individualized treatment plan, they often transfer from clinical management in residential or intensive outpatient programs to less clinically intensive outpatient programs that promote client self-management (Substance Abuse and Mental Health Services Administration & Office of the Surgeon General, 2016).
As with all treatment, the amount of time that a client spends in treatment is based on what substances they have been using and their individual needs. An example of a typical progression for someone who has a severe substance use disorder might start with three to seven days in a medically managed withdrawal program, followed by a one- to three-month period of intensive rehabilitative care in a residential treatment program, followed by an intensive outpatient program (two to five days per week for a few months), and later a traditional outpatient program that meets one to two times per month. Many people seek the help of a medically managed withdrawal program to get them through their detox symptoms and ensure that they can safely withdraw from the substance/s they have been using. Depending on the substance used, there may be certain medications to help the client through this period. In the case of a person who has been using alcohol as their drug of choice, this type of withdrawal support can be lifesaving as withdrawal from alcohol can dangerously increase blood pressure and cause seizures or death. For clients whose current living situations are not conducive to recovery, one approach is to recommend outpatient services in conjunction with recovery-supportive housing. Best practices recommend that clients with serious substance use disorders stay engaged for at least one year in the treatment process, which may involve participating in three to four different programs or services at varying levels of intensity, all of which are ideally designed to help the client prepare for continued self-management after treatment ends (Substance Abuse and Mental Health Services Administration & Office of the Surgeon General, 2016). For example, medication assisted treatment (MAT) is evidence-based and methadone clinics are helpful to people recovering from opiate addiction.
Advantages
Offering a variety of programs to a person with a substance use disorder enables them to feel autonomy in the process of choosing their treatment. Programs can be chosen based on location, type of services offered, cost and insurance coverage, and personal preference. When choosing a program, an individual may choose something that is close to where they live so that they can continue to have the support of their family and friends. Some people want a holistic program that offers medical, psychological, and spiritual wellness, while others prefer a spiritual-only-based program. For many people, cost is the biggest factor, so they have to choose a program that accepts insurance or Medicaid/Medicare. People who are not limited by a specific budget have a much larger variety of programs from which to choose, which allows for individual preferences in determining treatment.
Disadvantages
Programs that are self-pay only and not covered by insurance, Medicaid, or Medicare can pose huge barriers to those struggling with substance use disorders. Clients also must be motivated to change as assessed by the health-care team when presenting treatment options to the client. Prochaska’s Stages of Change (Figure 5.2) illustrate the cyclical pattern of substance use treatment, recovery, and relapse that can become a barrier to ongoing wellness (Krebs, 2018). Clients can become discouraged and stigma surrounding substance use can prevent people from seeking and continuing to receive the help that they need.
Cultural Context
Overdoses in Native Americans
As the opioid crisis continues in the United States, nurses should be aware of the high overdose rates (OD) among Native Americans. Statistics of OD rates put this cultural group in second place, behind White people. The highest mortality rates are in Minnesota, Washington, Alaska, and Oklahoma (Venner, K. L. et al., 2018).
Treatment concerns for Native Americans involve a lack of western medicine health-care providers who recognize that healing for many Native Americans is holistic in nature. Their traditional medicine wheel allots equal importance to mental, physical, emotional, and spiritual health contributing to a person’s overall health. Although clinical studies have proven that medication-assisted treatment for opioid addiction has a much higher rate of response than only using psychosocial treatments, there are many barriers to Native Americans using this method of treatment: lack of cultural training, lack of access to medication resources, limited access to prescribers and high turnover rate of those prescribers, discrimination received by Native Americans, and the Native Americans’ differing beliefs about length of time that it is acceptable to continue taking a medication (Venner, K. L. et al., 2018).
As a nurse, you can bridge the cultural gap that might occur when providing substance use care in a treatment facility. You can do things like assign clients of similar ages to the same support groups, incorporate cultural preferences, and include the family in care planning. Doing these things helps the client feel that their whole identity has been validated.
The Substance Abuse and Mental Health Services Administration (SAMHSA) is required to help direct federal resources under the Tribal Law and Order Act of 2010 (SAMHSA, n.d.). It helps the tribes set up Tribal Action Plans (TAPs) to ensure that tribes have the resources and programs to address issues with substance use and recovery.
Partial Hospitalization and Intensive Outpatient Services
A step-down program for clients who require a higher level of care and support than that offered by outpatient treatment but who do not need twenty-four-hour supervision is called a partial hospitalization program (PHP). They are usually available six to eight hours a day during the workweek and are located on the hospital grounds. Services range from counseling, medication management, and education to clinically intensive programming, such as individual or group therapy. These services are less intensive and less restrictive than inpatient programs and are appropriate for clients living in an environment that supports recovery but who need structure to avoid relapse. One step down from partial hospitalization are intensive outpatient services. These services still require that the client attend therapy several times a week but allow the person to maintain their regular daily schedule with extra support.
Advantages
This type of program generally offers specially trained doctors, nurses, and social workers as well as other members of the interprofessional team, but allows the client to live in their own home with their family. They can return to work on a limited basis (depending on the number of days the psychiatrist prescribed for attendance). This is considered a less restrictive environment option than being in an inpatient unit as it gives the person more autonomy.
Disadvantages
While the client can have effective follow-up with nurses and therapists in these group-based programs, they may not be able to return to work in full capacity as soon as they would like. And while the treatment itself is intensive, during the evening hours, the client may feel increased stress as they must rely on what they have learned to begin to care for themselves without the assistance of others. The home environment is also an important consideration. Where and with whom a person lives can affect their ability to handle daily stressors, especially if they are having mental health difficulties. An unstable home environment will not provide the support that a person needs when they are transitioning out of the hospital setting. A client also needs to be able to follow the schedule of the partial hospitalization program (PHP) or intensive outpatient program (IOP), have transportation to the facility, and be able to participate in treatment at the site. Additionally, they need to be stable and safe enough to remain in an outpatient setting for treatment.
Inpatient Treatment
Clients with acute mental health symptoms, or those who are at risk for hurting themselves or others, may be hospitalized. These clients are often initially seen in the emergency department for emergency psychiatric assessment. Clients may seek voluntary admission, or in some situations, may be involuntarily admitted after referral for emergency evaluation by law enforcement and/or health-care providers.
Acute-care psychiatric units in general hospitals are typically locked units on a separate floor of the hospital. The purpose is to maintain environmental safety for clients. State-operated psychiatric hospitals serve clients who have chronic serious mental illness. They also provide court-related care for criminal cases where the client was found “not guilty by reason of insanity.” While uncommon, this judgment means the client was deemed to be so mentally ill when they committed a crime that they cannot be held responsible for the act; instead, they require long-term, inpatient mental health treatment.
Advantages
Inpatient mental health treatment runs 24/7 and is monitored by specially trained doctors, nurses, and social workers as well as other members of the interprofessional team. The environment has been created to make safety the priority. It takes clients out of environments that may have been exacerbating to their mental health conditions. Trained staff can modify or quickly change medications that they notice are not having the intended effects or are having intolerable side effects. In other words, in the inpatient setting, it is possible to make quicker pivots in treatment. Having regular access to in-place therapeutic groups helps clients recognize their strengths and build positive coping skills through shared experiences with others.
Disadvantages
Stigma remains high in this treatment setting. Some clients are afraid that “people will find out.” Not wanting anyone to know they are receiving mental health treatment adds to the isolation clients may feel as inpatients. Insurance companies may limit the number of days that a client can remain an inpatient, regardless of health-care providers recommending a longer stay. If the client has been involuntarily admitted to the unit, they may be angry at the health-care provider and staff for keeping them against their will. Taking away a person’s rights can cause them to lose autonomy, which can affect motivation and recovery. Planning for discharge is important, as the same triggers may be present once the client returns to a lesser restrictive environment.
Clinical Safety and Procedures (QSEN)
QSEN Competencies: Client-Centered Care, Teamwork
A thirty-two-year-old female presents to the emergency department stating she has had a seizure and requests something for her “nerves.” The client has a history of alcohol abuse, alcohol withdrawal, and does not have a permanent home. The client is admitted for observation related to alcohol withdrawal. You are the receiving nurse on the PMH unit. Consider how to approach the first two QSEN Competencies.
Client-Centered Care: Assess and respond to a change in client condition/reevaluate after interventions, assess for S/S acute alcohol withdrawal, assess for suicide risk, discuss options for a client who wants to drink alcohol, incorporate client/family input in treatment plan, intervene when conflict or need for client education is noted
Teamwork and Collaboration: Participate in shift-to-shift handoff, reach out to social work to advocate for discharge planning that acknowledges concern regarding homelessness, notify the provider as needed using SBA, receive verbal orders, delegate/seek help as needed
Residential Treatment
Residential treatment includes long-term care facilities, group homes, and supportive/transitional housing. These treatment options are for those people who, because they are not able to be independent, need long-term care for chronic and/or severe mental illness, brain injury, dementia, intellectual and physical disabilities, behavioral issues, and substance use recovery.
Advantages
Clients living in these facilities receive 24/7 care by trained health-care providers in a safe, homelike environment. They have opportunities to engage with others, participate in treatment, and learn positive coping skills to deal with activities of daily living. These facilities are the clients’ homes during their treatment and have additional benefits, such as activities, education, medication management, and group therapy.
Disadvantages
These facilities do not generally serve as acute care treatment centers. When a client has an exacerbation of symptoms or an acute episode of their disorder, the client is often sent to inpatient hospitalization for stabilization. The client does not have a choice of roommates if the facility does not offer private rooms, so there is a chance of conflict between clients with behavioral challenges. Many people who live in residential treatment facilities never move out of this type of living environment. This may be due to lack of family members who can support them, behavior issues that prevent them from living with family, or their own inability to fully immerse themselves in the real world. Stigma often prevents these individuals from being able to move out of a group home; landlords may not be willing to provide housing. Private insurance or Medicaid may not cover costs of this type of treatment. For example, Texas Medicaid does not cover group homes, and most supportive living facilities are self-pay (NAMI Texas, n.d.).