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There are some individuals with severe and persistent mental illnesses who cannot be managed by primary and secondary services and who require tertiary care. Such clients are characterized by aggressiveness, noncompliance with medication, and dangerousness. Tertiary care program elements include psychosocial rehabilitation, sophisticated medication management, and behavioural approaches. Tertiary care may be delivered through assertive community treatment and/or specialized outreach teams, community residential programs, or hospital-based services. Increasingly, organized systems have been developed to ensure that individuals meet criteria for tertiary care and receive the most appropriate level of care. Most importantly, the delivery of tertiary care must not be tied to particular settings or time frames, and level of care must be delinked from model or location of care in order to create flexible, efficient, effective mental health services.

There is a complex interplay between physical and emotional factors in the rahabilitative process after amputation of a limb. Although this is recognized by those working in the field of rehabilitation medicine, an overview of the literature indicates that there is comparatively little psychosocial research, education, and innovative programming. The authors have initiated such a program and have incorporated it into the routine of an inpatient amputee unit. The approach involves the utilization of basic techniques of supportive group therapy in the discussion of recurrent themes which have emerged as major concerns among amputees. Experiences amputees help new patients to anticipate potentially stressful situations, thus encouraging increased reliance. Having professionals present allows for the clarifying of medical and/or technical issues and the group setting provides a relaxes atmosphere conducive to educative discussion of physical and psychosocial concerns.

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