Community support for the long-term mentally ill.

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Community Support for the Long-Term Mentally Ill a

Cheryl L. Runyan MSW & Geraldine Faria PhD

b

a

Psychosocial Director, Sedgwick County Department of Mental Health, Wichita, KS, 67214 b

Associate Professor in the School of Social Work , University of Akron , Akron, OH, 44325-8001 Published online: 26 Oct 2008.

To cite this article: Cheryl L. Runyan MSW & Geraldine Faria PhD (1992) Community Support for the Long-Term Mentally Ill, Social Work in Health Care, 16:4, 37-53, DOI: 10.1300/J010v16n04_03 To link to this article: http://dx.doi.org/10.1300/J010v16n04_03

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Community Support for the Long-Term Mentally I11 Cheryl L. Runyan, MSW Geraldine Faria, PhD

ABSTRACT. In attempting to mcct the needs of the long term mentally ill, community support programs are often hampered by social, political and economic barriers, especially the lack of community support. This article describes the development of one community support program and the strategies used to deal with these obstacles. Through empowerment, education, community involvement and avoidance of duplication, the community has become a willing and active participant in the program, and the program has become an integral part of the community.

Community support programs were initiated by the National Institute of Mental Health in 1977. They were established to meet the needs of people with long term mental disorders resulting from deinstitutionalization. These programs were to consist of a broad array of flexible, available, and accessible services that encourage, among other things, natural support systems, both mutual and selfhelp, and consumer and community involvement (National Institute of Mental Health, 1982). Since that time, a wide variety of community-based programs have been developed. However, community Cheryl L. Runyan is Psychosocial Director at Sedgwick County Department of Mcntal Health. 630 North St. Francis. Wichita, KS 67214. Geraldine Faria is Associate Professor, School of Social Work, The University of Akron, Akron, OH 44325-800 1. A version of this paper was presented at the National Association of Social Workers Conference, Philadelphia, PA, 1988. Social Work in Health Care, Vol. 16(4) 1992 O 1992 by The Haworth Ress, Inc. All rights reserved.

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programs that meet the complex needs of the long term mentally ill are "still the exception rather than the rule" (Libassi, 1988, p. 88). Cited in the literature are many obstacles to the development of community-based services to the long term mentally ill. For example, Rapp and Chamberlain (1985) note the lack of trained personnel to work with this population and the lack of community support as two significant impediments to community care and integration. A lack of political and economic support also has been identified as a barrier to effective community care (Salem, Seidman & Rappaport, 1988). In regard to economic support, Dowell and Siege1 (1985) state: ". . . funding for community support is highly problematic . . . a comprehensive community support system such as specified by the NIMH guidelines is very expensive to create." In addition, the long term mentally ill often are unwanted by their families, the community, and community-based social services as well (Johnson & Rubin, 1983). In order to effectively meet the complex needs of the long term mentally ill, community support programs must find creative ways to overcome these obstacles. The following is a description of the development of one community support program and the ways in which some of these barriers have been overcome.

PROGRAM DESCRIPTION Community Support Services (CCS), a part of Horizons Mental Health Center, is located in Hutchinson, Kansas, a rural community of 45,000 people. It began in 1984 with one social worker who served as program coordinator, and a block grant of $19,688 which covered 90 percent of the coordinator's salary for developing the program. Currently, the staff has doubled to two full-time social workers. The program has a budget of approximately $101,100, a block grant of $20,707 for staff salaries, and serves over sixty clients. A limited amount of funding comes from billing clients for targeted case management services. However, services are provided regardless of the client's ability to pay. CSS provides services similar to those included in most community support programs. It offers case management services which


Cheryl L. Runyan and Geraldine Faria

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link clients to community resources. Housing for clients from the local state hospital is provided through the Independent Living Program. The program has four apartments, including furniture supplied by Horizons Mental Health Center through donations and grants. CSS subsidizes the rent and utilities with a special purpose grant from the state. Clients are taught basic living skills which include money management, shopping, cooking, and personal hygiene, as well as survival skills, such as what to do when the electricity goes off. Social activities are offered through a variety of group experiences such as a bowling group, exercise group, problem solving group, humor group, and a resume writing group. CSS provides vocational and educational services. Vocational services include a pre-vocational group and volunteer jobs. Referrals are also made to Vocational Rehabilitation Services. Educational services involve the educational preparation of clients, primarily through referrals to Vocational-Technical Programs, the local community college for GED completion and other courses of study, and the public library for its reading program. CSS also provides a variety of family support services. Individual family support is offered in home or office visits. At a group level, families are offered workshops that pertain to their collective concerns. At the community level, CSS staff collaborate with the local Alliance for the Mentally Ill group in sponsoring workshops and media forums.

PROGRAM PHILOSOPHY While the CSS program is similar in content to others of its kind, it is based on a unique philosophy that affects the nature and extent of service delivery. CSS can best be described as a communitybased case management program which utilizes an adult education, systems oriented approach. Central to the program's philosophy are the concepts of community and linkages. Martin and O'Comor define community as a linkage network or a loosely coupled system which includes other systems and has extensive ties with its environment (1989). As applied within the CSS program, the concept


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of community encompasses families and other small groups, as well as libraries, fast food restaurants, convenience stores, churches, social service agencies, the police, and any other group, organization, or institution with whom mentally ill clients may come in contact. Linkages are defined as "ties or connections between systems andlor the component parts of systems" (Martin & O'Connor 1989, p. 228). Since the overall goal is community care and integration, the major function of CSS is to assist mentally ill clients in developing community linkages when there are none, and enhancing those linkages that already exist. In carrying out its primary function, CSS utilizes a variety of ideas, models and perspectives from within and outside the mental health field. For example, elements of the Fountain House program in New York, Seligman's notions of learned helplessness (1976), Beauregard's local and hierarchal systems (1977). Germain and Gitterman's Life Model of Social Work Practice (198O), Modrcin, Rapp and Chamberlain's case management model (1985), and parts of various adult learning models (Knowles, 1972; Barbe & Swassing, 1979; Memmott & Brennan, 1983) have been incorporated. Information from Eisenberg et al. (1984) on chronic illness and its effects on individual development and the family Life cycle, Cousins' ideas on the therapeutic effects of humor (1979) and Olson and Henig's behavioral management strategies for brain injured adults (1983) also have been included. In effect, the CSS program incorporates any information that will aid in the understanding of, and the development of linkages between mentally ill clients and the various social systems with whom they interact. In addition to the concepts of community and linkages, the CSS philosophy encompasses a strengths perspective similar to that outlined by Weick et al. (1989). This perspective focuses on peoples' capacities, talents, skills, and resources rather than the pathological aspects of their personalities or behaviors. The emphasis on peoples' strengths is maintained through the application of five guiding strategies. These strategies have been extremely useful in developing the CSS program. The first strategy is empowerment, that is, helping clients to take advantage of their assets by building on wellness. This means treating clients as essentially normal, capable, functioning human beings



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who happen to have a mental disorder. It involves discouraging learned helplessness and encourages building on clients' interests, talents, and abilities, teaching them to take an active part in managing their disease and controlling their own lives. The second strategy is education. The basic approach is to educate everyone from his or her own perspective while sensitizing each person to the perspective of others. In this sense, lectures on mental illness per se are not sufficient. Education must include the specific "how to's" so that people can improve their ability to accomplish what they need to do. Clients need to learn how to manage their illness. Families need to learn how to react to and cope with disconcerting symptoms and behaviors. Social service agency staff and other community personnel need to learn how to respond effectively to clients' needs within the context of doing the job they are hired to do. The third strategy is community involvement. The approach is to get everyone involved in the program in some way, utilizing whatever they have to offer. This includes money (even nickels and dimes), volunteer hours, in-kind donations, or free consultation on program development. Getting everyone involved fosters community investment in the program. It allows for multiple benefactors so that no one carries a load to the point of burning out from giving. It also gives people a sense of ownership of the program and makes the program an integral part of the community. The fourth strategy, which builds on community involvement, is avoidance of duplication. Rather than creating new services, the strategy is to expand services by utilizing and combining what is already naturally available in the community. The fifth strategy is flexibility, aided by cautious optimism. The approach is to expect nothing and anticipate anything and everything, be it positive, negative, or both. The CSS philosophy has been a major force in guiding the program's creation and development. It also has been instrumental in overcoming many of the barriers that the program has encountered. It views clients as responsible adult learners who need some assistance in gaining access to community resources. But it also sees the community as an ally who, with some assistance, can effectively provide for the needs of the long term mentally ill.

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The application of the CSS philosophy is described in the following sections which focus on the creation of the program, and various approaches to working with clients and the community.


PROGRAM BEGINNINGS From the very beginning, the Hutchinson community was a key factor in the development of the program. If CSS truly was to be a community-based program, the community would have to be a willing participant. Consequently, knowledge of what would be acceptable to the community was essential. In this case, the history of the community provided valuable information. The community has had a long tradition of building from within rather than bringing in outside resources. Like many rural communities, outside assistance was viewed as interference. And "helping one's own" was a value strongly shared by the residents. As such, it was advantageous to initially build from within the community rather than to apply for "outside" grants to fund the program. Thus, the coordinator spent a lot of time meeting with community leaders and other key personnel, explaining the needs and purposes of the program and enlisting any support they were able to provide. In starting the program, there were certain obstacles that had to be overcome, specifically the lack of space, funding, and staff. The lack of space at the mental health center and the lack of funding to develop a clubhouse forced the program to be located in various parts of the community-in city parks, shopping areas, fast food restaurants, and clients' homes. The result was that the community became the clubhouse. This continues to be the case. In fact, it is not possible to take a tour of the program by visiting one particular spot. The address of the program is the Hutchinson community, every street and gathering place. At the beginning of the program, lack of funding for a van limited the number of clients who could be transported to group meetings. As a result, group meeting sites had to be centrally located so most clients could walk to the meeting. Transportation was then provided only to clients who lived some distance away. This left most clients responsible for getting themselves to the activity. The



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lack of funding also limited staff size to one person, the coordinator. In order to serve an increasing client population, volunteers were sought and various social work programs were contacted for students interested in doing a field placement at CSS. This resulted in the addition of two volunteers, (a nursing instructor working towards a masters' degree in nursing, and an MSW who wanted experience in working with the long term mentally ill), one MSW student and two BSW students. Although the lack of staff and funding limited the services that could be offered, it did have one positive outcome. It forced CSS personnel to refrain from doing for clients what they could do for themselves.

WORKING WITH CLIENTS As previously stated, at CSS, the key strategies in working with mentally ill clients are empowerment and education. These elements shape the manner in which services are delivered and affect the degree to which tasks are completed by the staff. For example, case management services are usually requested by clients. The only exception is court ordered services. A skiUs assessment is completed to determine the clients' ability to perform certain skills and their level of performance. Treatment plans are then co-developed by the client and the case manager. Time is not spent on educating clients on what they already know. Rather, the focus is on identifying skills that are more immediately needed to effect either maintenance or improvement. Clients are taught symptom control measures and are given instructions on how to make themselves feel better or worse. This allows clients to better handle themselves and to avoid unnecessary problem situations. A workshop called "How to Feel Better" has been used to help clients take more responsibility for their own health. In the Independent Living Program, clients rent directly from the landlord and sign their own leases. Clients also go to the utility companies to place utilities in their own names. When the utility bills arrive, they are given to the CSS staff for payment. At the end of the program, if a client chooses to keep the apartment, the client must assume the rent subsidy difference and pay the utilities. The


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client is also encouraged to begin buying furniture before termination from the program so that the "old" furniture can be removed and another apartment found. For those clients moving into the Independent Living Program, the natural feelings that go along with relocating (e.g., feeling tired of unpacking boxes and hating to put up curtains) are identified and discussed. Staff provides tips and suggestions that they have found useful during moving times and share past feelings of loneliness when moving to a place where they knew no one. In addition, clients already living in the community are encouraged to make contact with new arrivals and invite them to their homes. Clients learn to develop and implement plans for leisure time and social activities. This is done through a variety of group experiences created from clients' suggestions and specific areas of interest. For example, in the Brunch Group, clients learn to be the host for guests in their homes and to organize, prepare, and serve a meal. Because client budgets are generally small, the group prepares a common meal, one where everyone brings an ingredient for the menu. This sharing of resources emphasizes the importance of each member and the need to be responsible for bringing the assigned ingredients, since missing ingredients are not always replaced by staff or other clients. The Friendship Group also encourages clients to entertain in their own homes. This particular group has moved from being staff sponsored to client sponsored. The group now has its own officers and provides its own transportation. In the past, a half credit course, "Introduction to Mental Health/ Mental Illness," was offered for clients at the local community college. Scholarship funds were raised to subsidize half of the tuition. Clients enrolled, were given homework assignments, and upon completion of the course, received a grade and a transcript. More recently, a seminar, "The Psychology of A Long Term Health Disorder," has been offered through continuing education, without charge to clients. Through these courses, clients are provided the opportunity to have a non-threatening experience on a college campus, and are encouraged to consider taking other courses. As the above examples illustrate, providing clients with the necessary knowledge and skill enables them to take more responsibility and control over their disease and their daily lives. And, it enables


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them to become less dependent on the program. This, in turn, allows CSS staff more time to focus on the community as a target for intervention.


WORKING WITH THE COMMUNITY Clients' access to community resources is often problematic because of the community's lack of knowledge, understanding, and skill in dealing with the long term mentally ill. These factors often result in a great deal of resistance to the acceptance and integration of clients into the community. To surmount this barrier, intervention focuses on community involvement, education, and avoidance of duplication. CSS involves the community in many ways. The needs of the program are made known and assistance is sought from the community through articles in the local newspaper, the newsletters of civic groups, and other formal and informal avenues. By capitalizing on the self-help ethos of the community, access to a vast array of resources has been more easily accomplished. The community's response has made it possible for clients to learn how to manage a budget by attending budget counseling sessions at the Salvation Army; to learn unit pricing at the grocery store; and to find temporary jobs at the local Manpower office. It also has been possible for problem solving and humor groups to meet at the library, for craft and fitness groups to meet at various churches, for vocational groups to tow area businesses, and for sports groups to receive free tennis and bowling lessons from the Hutchinson Recreation Services for the Handicapped. Various social and civic organizations have contributed coupons, soap, food, and other items for clients. When the Independent Living Program was started, the community donated such items as kitchen supplies, towels, blankets, furniture, and money. And when transportation was a problem, various church groups provided it. With this kind of involvement, CSS avoids the problem of creating, and possibly duplicating services by utilizing what is already available in the community. Utilizing and combining existing resources also makes it possible


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to expand services with a minimum amount of effort. An example is the recently implemented career development program for clients. The idea for the program was presented to the local community college. The college accepted the idea, made the necessary internal changes to have it fit with their emphasis on vocational programming, and provided the facilities and staff to teach the program. It should be emphasized that the CSS staff did not attempt to alter the college program; the staff merely presented an idea It was the college that decided to make changes in its own system to accommodate the new program. This approach allowed the college to provide a needed service in its own way and from its own perspective. As a result, the college has had a greater investment in the career development program and has been more willing to make it a success. Another mechanism for community involvement is the CSS Task Force. Together with clients, their families, and the mental health staff, representatives from various social service agencies and other community organizations meet to plan for the program's activities and continued development. By incorporating them into the planning process, community members have cultivated a vested interest in the program. In turn, they often have been instrumental in securing needed resources and serving as strong advocates for the program. While many community support programs educate families about mental illness and how to respond to a person with a long term mental disorder, this knowledge is seldom shared with other segments of the community. Too often the client's transition from hospital to home is more difficult because the community is not prepared for it. In recognition of the need to prepare for the client's re-enhy, CSS attempts to educate the community through a variety of formats. Knowledge of long term mental disorders and the CSS program is provided by the staff, volunteers, and students, as well as the clients themselves who describe their illness and the impact it has had on their lives. It is offered through numerous articles published in the local newspapers, interviews on the radio, and speeches delivered to civic groups, Sunday School classes, and university stu-



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dents. In addition, a special workshop, "Working With Individuals With Long Term Mental Health Disorders," is presented to area agency professionals such as social security staff, budget counselors, welfare department staff and sheriff's department officers, as well as the clergy, convenience store manag&s, and others who may work with CSS clients. The workshop provides information on the theoretical causes, symptoms and occurrence patterns of schizophrenia and affective disorders. The workshop also provides a "how to" format in which participants learn skills for working with clients with these disorders. This includes artificially created "psychotic" experiences and role play sessions in which participants perform the job they normally do with a "client" and a "family member. ' ' Although the aim of this public education effort is to facilitate the client's re-entry into the community, it has resulted in an additional benefit. Having taught agency staff how to work with these clients, fewer case management hours have had to be spent in agency waiting rooms, sitting through interviews, and ensuring that clients receive needed services. Thus, while public education has been initially time consuming, in the long run it has proved to be cost effective because it has freed up staff time to be spent on other important activities. In keeping with the philosophical view of the community as having extensive ties with its environment, the CSS program has expanded its intervention efforts to include the larger political community. State legislators have been invited to participate in cornrnunity workshops co-sponsored by CSS and the Alliance for the Mentally Ill. A number of legislators have also visited the CSS program, during which they take part in a slide presentation about CSS services, meet with clients and listen to their concerns. CSS staff members have also served on various state committees, including a statewide task force which drafted guidelines for the provision of community support programs in Kansas. As a result of these and other efforts, the CSS program has become more visible and the staff has secured a stronger position of advocacy and support from the political community. For example, last year, the CSS staff were invited by a state senator to testify before the Ways and Means


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Committee Interim Study Committee about the cost effectiveness of community based care. Although other groups testified before the Committee, the CSS staff was the only group invited to do so. Community involvement, education, and avoidance of duplication have been extremely useful in reducing resistance to community integration of the mentally ill. Together they also have provided a way of making the community a willing ally in the provision of services to clients. But perhaps the most important strategy in working with the community, as well as with clients, is cautious optimism. Over the years that the program has been in operation, there have been times when resources have materialized where none were thought to exist. There have been times when nothing seemed to work. And there have been times when a seed planted long ago finally blossomed and flourished. In the long run,cautious optimism has proved to be a crucial element in the CSS philosophy. It has helped the staff to deal with disappointment when something does not work, and to not be surprised when it does.

PROGRAM EVALUATION Evaluation of any community support program is a formidable task. Because of the nature and complexity of community support activities, it is difficult to specify the "treatment" variables clearly enough for research purposes (Dowell & Siegal, 1985). Consequently, the question of the overall effectiveness of the CSS program has yet to be answered. However, there are limited data which indicate that the program has made some progress in helping clients improve their status and live more productive lives. The Kansas State Department of Social and Rehabilitation Services (1988) maintains statistics on the vocational/educational status and independent living status of clients served at twenty-five community mental health centers in the state. The most recent, available statistics for the period between July 1, 1987 and June 30, 1988, indicate that the CSS program has made progress in these areas. In regard to vocational/educational status, the program achieved the highest movement index of 2.75, meaning that it had more than twice as many clients improve their vocational/educational status



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than it had clients who declined in this area. In regard to independent living status, CSS also achieved the highest movement index of 7.50, indicating that it has helped clients gain more independence in their living arrangements. Additional information on the program's effectiveness has come from the clients themselves. As part of a project at the University of Kansas School of Social Welfare (1988) a group of CSS clients were asked for feedback regarding the program. Although the information, in the form of excerpts of interviews, does not constitute hard research data, it does provide some qualitative evidence of the program's progress. All of the clients interviewed discussed the wavs in which the staff has been heloful to them and how their experience at CSS has been distinctly different from prior encounters with the mental health system. The following quote illustrates not only the clients' sentiments but also the essence of what the CSS program is all about: She usually comes to people's homes . . . She usually doesn't have them go to her place at Horizons because she wants them to feel comfortable where they are at when she counsels them. She asks 'Where would you like to meet?' I think there is a choice there. . . . we meet at the mall or park . . . it's more normal just like anybody else. I'm more comfortable going into the community than into an office. Do other therapists do that? No, Cheryl's the first one I've (ever) had that would do that. You know, I've had quite a few therapists in the last ten years but Cheryl's helped me the most. She has because she gave me hope. I didn't have no hope before. I thought I was just going to blow it . . . I used to carry knives on me 'cause I was so paranoid and the only difference between then and now is that she gave me hope, so I don't feel like I have to carry knives on me for protection. (p. 5) As the above data indicate, the CSS program has made some progress. But it also has its problems and limitations. First of all, the program does not adequately serve all of the long term mentally ill in its five county catchment area. The majority of clients served come from Reno County, the county in which the progam is based.


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Because of limited staff resources, CSS has been unable to offer services within the other four counties. Only those clients who are able to travel to Reno County are served. Although the mentally ill population in these counties is comparatively small, the need for incounty services still exists. As a beginning attempt to meet this need, CSS has begun to offer its program one day a month in Pratt County. But without additional staff, further expansion of the program is impossible. Limitations in staff resources also have prevented other needs from being met. CSS would like to develop crisis teams who could monitor clients in their homes and quickly intervene during periods of crisis, thereby reducing the need for hospitalization. In regard to family education, current programming focuses on the needs of the family who has been involved with the mental health system for many years. CSS would like to develop a continuum of educational programs which would also meet the needs of the family with a newly diagnosed member. As stated previously, the problem of inadequate staff has been dealt with, in part, through the use of masters and bachelor level social work students. While this has allowed for expansion of services to clients, there are certain disadvantages. Students are at CSS for two semesters at most, and only one semester if it's a block placement. Because of the continual rotation of students through the program, the stability needed by the long term client is disrupted. In addition, because field placements normally coincide with the academic year, students are sometimes absent-mostly during the summer. This affects programming such that there is a substktial reduction in the number of activities which staff is able to ~rovide. Thus, the use of students to deal with staff shortages is, best, a temporary solution. In the long run, increased funding needs to be secured so that additional, and permanent staff can be hired. This would allow for the expansion of existing services and the creation of new services to meet the needs of the long term mentally ill. As noted previously, the evaluation of a community support program is not an easy task. But this does not obviate the need for more specific documentation of program effectiveness. Evaluations of the effectiveness of case management, similar to that conducted


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by Goering et al. (1988), needs to be carried out. Periodic, longterm follow-up of clients is necessary not only to monitor client progress, but also to provide ongoing feedback to program planners about what works and what doesn't. As Goering and her colleagues aptly state: Knowing what outcomes are influenced by what types of specific programs will provide valuable information for program planning and set the stage for the continued exploration of how programs make a difference in the lives of severely mentally disabled individuals. (p. 276) CONCLUSIONS

Although the CSS program continues to struggle with staff and funding limitations, it has successfully overcome one of the major impediments to community care and integration of the long term mentally ill-lack of community support. This has been accomplished through utilizing the strategies of empowerment, education, community involvement and avoidance of duplication. At first glance, these strategies appear to be fairly simple and straightforward, since, in one sense, they represent very basic social work practice principles. In reality, they are highly complex because they require the sophisticated assessment and intervention skills of advanced generalist practice. Because these strategies involve working with every segment of the community, they require not only sound clinical skills, but also skills in case management, social networking, locality development, grass-roots organizing, social planning, lobbying, and advocacy. Since generalist practice aaditionally has been reserved for work with mral communities, community support programs in urban areas may be averse to using this approach, opting instead for a more specific case management approach that focuses primarily on the client. However, if true "community" care and integration is to be achieved, the community cannot be ignored. It must be counted as an ally and it must become a major target of intervention. Just as clients must be pre-


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pared with certain knowledge and skill to live in the community, so too does the community need to be prepared to accept and provide for its mentally ill citizens. In summary, the CSS program is one example of how the community has been utilized in meeting the complex needs of the long term mentally ill. By taking into account the history and tradition of the community, by taking advantage of what the community has to offer, and by providing the community with the necessary knowledge, understanding and skill to work with mentally ill clients, the community has become an active participant in every facet of the program. And, the program has become an integral part of the community. Through this kind of involvement, the CSS program has become a truly community based support program for the long term mentally ill. REFERENCES Barbe, W.B., & Swassing. R.N., with Milone, M.H., Jr. (1979). Teaching through modality strengths: Concepts and practices. Columbus, OH: Zaner-Bloser, Inc. Beauregard, R.A. (1977). Exploring human services delivery. Journal of Social Welfare, 4 (1) 31-35. Cousins, N. (1979). Anatomy of an illness. New York: Bantam Books. Dowell, D.A., & Siegel, J. (1985). Community support for the long-term mentally ill: Project return. Unpublished manuscript. Eisenberg, M.G., Sutkin, L.C., and Jansen, M.A. (Eds.) (1984). Chronic illness and disability through the life span. Effects on se[f and family. New York: Springer Publishing Company. Germain. C.B., & Gitterman, A. (1980). The life model of social work practice. New York: Columbia University Press. Goering, P.N., Wasylenski, D.A., Farkas, M., Lancee, W.J., and Ballantyne, Ron (1988). What difference does case management make? Hospital and Community Psychiatry, 39, 272-276. Johnson, P.J. & Rubin, A. (1983). Case management in mental health: A social work domain? Social Work, 28, 49-55. Kansas State Department of Social and Rehabilitation Services, Mental Health and Retardation Services. (1988). [Community mental health centers, client status report on Horizons mental health center]. Unpublished data. Knowles, M.S. (1972). Innovation in teaching styles and approaches bascd upon adult learning. Education for Social Work, 8 (2). 34-36. Libassi, M.F.(1988). The chronically mentally ill: A practice approach. Social Casework, 69, 88-96.



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Martin, P.Y., and O'Connor, G.G. (1989). The social environment. Open systems applications. New York: Longman Memmott, J. & Brennan, E. (1983, March). Adult learning and social work education: An adult development model. Paper presented at the Council on Social Work Education, Annual Program Meeting, Fort Worth, TX. Modrcin, M., Rapp, C.A., and Chamberlain, R. (1985). Case management with psychiatrically disabled individuals: Curriculum and training program. Lawrence, KS: The University of Kansas. National Institute of Mental Health. (1982). A network for caring: The community support program. Washington, DC:U.S. Gov-ent Printing Office. Olson, D.A., and Henig, E. (1983). A manual of behavior management strategies for traumatically brain-injured adults. Chicago: Rehabilitation Institute of Chicago. Rapp, C.A. & Chamberlain, R. (1985). Case management for the chronically mentally ill. Social Work, 30, 417-422. Salem, D.A., Seidman, E., & Rappaport, J. (1988). Community treatment of the mentally ill: The promise of mutual-help organizations. Social Work, 33, 403408. Seligman, M.E.P. (1976). Learned helplessness and depression in animals and men In J.T. Spence, R.C. Carson, & J.W.Thibault (Eds.), Behavioral approaches to therapy (pp. 137.156). Monistown, NJ: General Learning Press. University of Kansas, School of Social Welfare. (1988). [Report on Horizons mental health center community support program]. Unpublished data. Weick, A., Rapp, C., Sullivan, W. Patrick, and Kisthardt, W. (1989). A strengths perspective for social work practice. Social Work, 34, 350-354.

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Letter: The elderly mentally ill--whose responsibility?

Hypertrichosis in mentally ill women.

What mentally ill offenders need.

Heat waves and the mentally ill.

The elderly mentally ill--whose responsibility?

Will we save the homeless mentally ill?