Chapter 35Seriously and
Persistently Mentally Ill,
Homeless, or Incarcerated
Clients
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Many behavioral disorders are complicated by
the presence of chronic emotional, cognitive,
and medical problems which pose significant
challenges for patients, families, and their
care management providers. Such complex
behavioral illnesses, also termed Serious and
Persistent Mental Illness (SPMI), are among
the most complicated and difficult diseases to
successfully treat.
—Comprehensive Neuroscience, 2009
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At any given time, there are many more
people with untreated severe psychiatric
illnesses living on America’s streets than
receiving care in hospitals.
—Nichols, 2008
Yesterday’s state hospitals have morphed
into today’s jails and prisons.
—Nasrallah, 2008
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Learning Objectives
After studying this chapter, you should be able to
• Articulate the effect of a serious and persistent mental
illness (SPMI) on the life of clients so affected
• Discuss the relationship between SPMI and the problems
of homelessness and incarceration
• Explain how deinstitutionalization, transinstitutionalization,
and lack of community services have contributed to the
current problems of those with SPMI
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Learning Objectives (cont.)
• Describe the groups of individuals comprising the
homeless population
• Identify those clients with SPMI at risk for
incarceration
• Compare and contrast mental health and social
service treatments for nursing-home residents, the
homeless, and the incarcerated who are experiencing
SPMI
• Articulate the impact of managed care on the mental
health treatment and continuum of care of those with
SPMI
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Learning Objectives (cont.)
• Discuss the effect of having a member with SPMI on
the family
• Summarize important nursing assessments for the
client with SPMI
• Determine nursing implementations that are
important for a client with SPMI
• Construct a nursing plan of care for a client with
SPMI
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Scope of SPMI
• Major depression, bipolar disorder, and schizophrenia
account for four of the ten leading causes of disability.
• Factors such as substandard housing, unemployment or
underemployment, poor nutrition, lack of preventive
care, and limited access to medical care create severe
stressors for individuals affected with mental illness.
• The physical health of individuals with SPMI is worse than
the physical health of those without SPMI.
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Factors Related to the Current Problems
of the SPMI
• Deinstitutionalization
• Transinstitutionalization
• Inappropriate use and lack of community services
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Categories of Seriously and Persistently
Mentally Ill
• Nursing-home residents
• The homeless
• The incarcerated
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The Homeless
• Risk factors for homelessness
• Special populations of the homeless
– Children, adolescents, and young adults
– Women
– Elderly
• Hate crimes against the homeless
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The Incarcerated
• Factors related to incarceration
• Clients at risk for incarceration
– Clients with impulse control disorders
– Clients with sexual disorders
– Clients with substance-related disorders
– Clients with bipolar disorders
– Clients with personality disorders
• Risk for suicide among incarcerated clients
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The Nursing Process
• Assessment
• Nursing diagnoses
• Outcome identification
• Planning interventions
• Implementation
• Evaluation
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Assessment
• Physical health status
• Current clinical symptoms
• Self-care abilities
• Current living situation
• Coping skills and support systems
• Compliance with medication
• Substance-abuse problems
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Nursing Diagnoses
• Interrupted family processes
• Ineffective health
maintenance
• Imbalanced nutrition: more
than body requirements
• Ineffective role performance
• Disturbed thought processes
• Chronic low self-esteem
• Hopelessness
• Impaired social interaction
• Ineffective coping
• Noncompliance (failure to
take prescribed psychotropic
medications or participate in
long-term psychiatric
treatment)
• Risk for violence: selfdirected or other-directed
violence
• Disturbed sensory perception
(visual and/or auditory)
• Social isolation
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Outcome Identification
• Functional outcomes, especially social and occupational, are generally
more important than symptomatic outcomes.
• Outcomes focus on the following:
– Maintaining client safety
– Establishing and maintaining client self-care
– Establishing client trust and facilitating interaction with staff and
peers
– Decreasing delusional thinking and hallucinatory experiences
– Increasing positive self-statements
– Having the client agree to take prescribed psychotropic
medications
– Provision of family support when available
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Planning Interventions
Planning nursing interventions is dependent on the
following:
• The nurse’s ability to assess the client
• The nurse’s ability to establish and maintain a
therapeutic relationship
– Listen and communicate recognition and
understanding
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Implementation
• Providing a safe environment
• Promoting physical health
• Providing medication management and education
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Implementation (cont.)
• Using cognitive–behavioral therapy
– Orienting to reality
– Promoting self-care
– Enhancing self-esteem
– Providing support
• National Empowerment Center
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Implementation (cont.)
• Employing the psychosocial rehabilitation approach
– Clubhouse program
• Using the Assertive Community Treatment (ACT) model
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Implementation (cont.)
• Providing continuum of care
– Integrated Model Program (IMPACT)
– Respite care for the homeless
– Welcome Home Ministries (WHM)
– Concerns about continuum of care for homeless
clients
– Concerns about continuum of care for incarcerated
clients
– Concerns about managed care
• Educating the family
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Evaluation
• For clients with SPMI, care is ongoing and includes the
provision of support necessary for community living.
• Care is successful if the client can avoid hospitalization
and maintain community housing and support systems.
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Key Terms
• ACT model
• Clubhouse program
• Deinstitutionalization
• Empowerment Model of
Recovery
• Integrated Model Program
(IMPACT)
• Mercy bookings
• Respite care for the
homeless
• Hate crime
• Serious and persistent
mental illness (SPMI)
• Impulse control disorders
• Transinstitutionalization
• Welcome Home Ministries
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Reflection
Reflect on your psychiatric nursing curriculum. Most
curriculums address the issues of chronic mental
illness but may not address psychosocial needs of the
homeless or incarcerated client.
• Are the psychosocial needs of
these clients included in the
curriculum?
• If not, determine why.
• If they are addressed, are the
nursing interventions realistic?
• Explain your answers.
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?