Learn how social factors promote mental health, influence the onset and course of mental illness, and affect how mental illnesses are diagnosed and treated. This course explores how our understanding of mental health and illness has been influenced by social attitudes and social developments in North America and around the world. The course begins by situating our contemporary mental health practices in historical context, then looks at different aspects of mental health, mental illness and mental health services and their connections to what’s going on in our social environment.
1.6 Community-based mental health care
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From the course by University of Toronto
The Social Context of Mental Health and Illness
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From the lesson
Welcome and A Brief History of Madness
We begin with a quick orientation to the course and continue with our first lecture topic: A brief history of madness.
Meet the Instructors
Charmaine WilliamsAssociate Professor
Faculty of Social Work
So the problems of deinstitutionalize required us to develop of comprehensive
network of community based mental healthcare that really wasn't in place
when the institutionalization had started.
This network of care needed to respond to what were now complex needs of people
living with mental illness in the community.
Whereas before the asylums and the hospitals had really taken care of all of
their needs. Now when people were out in the community
we needed to think about places for ex-patients to live.
places things that they could do. Work to do,
social, and recreational activities to promote quality of life.
So, this all had to be part of that circle of care.
It was also harder to involve people in their care sometimes, because the only
circumstances under which we could oblige people to, to present for care was when
things had become extreme. Like the situations where people could be
a harm to themself or others. So, the model of care that was developed
was called rehabilitation. The use of that term really communicated
the hope that now we had interventions that could be applied to someone with a
diagnosis of mental illness and restore them to a state of health and something
that we would call, normal life. As the twentieth century is coming to a
close we were prepared to think about mental illness with a lense of a
bio-psycho-social perspective. Now we'll be thinking, we'll be talking
more about the bio-psycho mental health in the next lecture.
But what it basically meant was that we had some idea of the word completely
clear in the details of it that the origins of mental illness lay in
biological, psychological and social circumstances.
That was the legacy of years of fileiii medical research as well as the influence
of people who'd study the psychology of mental illness and introduce psycho
therapies. And the activists in social theorist who
drew connections between social conditions and the creation of ill mental
health. There is an understanding that we need to
attend simultaneously to the biological, psychological, and the social aspects of
mental illness. And even if some,
were convinced that the basis of mental illness was biological, that is somehow
based in the brain. Then we still could agree that the
psychological and social environment played an important role in bringing on
mental illness. That it played a role in how people were
able to live with mental illness, and it could probably play a role in preventing
mental illness. So we started to talk about psychiatric
and psychosocial rehabilitation. These transliteration describes the same
set of activities however medical specialist mostly thinking of psychiatric
and nurses tend to use the word psychiatric because they are including
medical treatments in that. For other mental health professionals
like social workers, occupational therapists and recreation of therapists,
the term psychosocial rehabilitation is used to describe their work in the area
of the psychological and social aspects of mental illness.
The biological part of rehabilitation included treatment with medications, and
other treatments including ec, electrocon convulsive therapy or ETC.
the early medications have been quite harsh in their effects on people taking
them, but this has improved a great deal. And many people not all, but many do get
positive effects from taking medications for mental illness.
Contemporary ECT is also quite different from the ECT that is so often portrayed
in those movies from the 1950s. The intensity of the treatments are much
lower, and people receive anesthesia during those treatments.
And the kind of effects that we used to say like, see like major losses of memory
are not, are not a problem in the same way anymore.
Some think of ECT as a last resort treatment but over time it is being used
more precisely and with very good effects for some patients.
the biomedical treatments for mental illness are growing all the time.
New medications, even surgeries, magnets, light therapies.
They're all kinds of possibilities that we now have for working with the
biomedical aspects of mental illness that weren't available before.
One thing that we have certainly learned from our past is that we have to be
cautious in, in our efforts in these areas.
And that all treatments of course need to be supported by the best possible
research evidence available. This is also true for psychological
treatments. We are fortunate to be in a time when
there are many psychological treatments that are supported by research evidence
and known to be effective treatments for many mental disorders.
In addition, there are psychological interventions that are focused on
supporting compliance with recommended treatment.
Admittedly, this is mostly focused on supporting adherence to prescribed
pharmacological treatments. fostering insight into illness is also an
important part of psychosocial rehabilitation because insight, which is
the understanding and awareness of having a mental illness is believed to be
crucial to fost treatment adherence. The concept of insight is actually a
tricky one. There are many opinions about what it is
and whether it's a good or bad thing. But that's a discussion we'll pick up in
a future lecture. Social treatments are also very
important, and these are really designed to support the capacity to live in the
community. There is certainly a goal to have people
living independently, despite their diagnosis.
However, it is not seen as the only desired goal.
You'll see that part of psychosocial rehabilitation is providing opportunities
for people to develop the skills to function in the community.
Some of it is very practical things like supporting people in safe living
environments. some like family psycho-education, which
is educating people about living with mental illness and, and also educating
their family members. these are really designed to help support
the network of people that surround a person that is diagnosed with mental
illness. And others, like recreation therapies,
are focused on helping people to find ways to express themselves creatively and
to enhance their well being and quality of life.
Not everyone is going to need all of these biomedical, psychological and
social services. It's going to depend on how a person is
affected by their illness. But the availability of such treatments really
represents the range of services and supports that are now seen to be part of
a comprehensive plan of psychosocial rehabilitation.
For people who need long-term or intensive support, a plan of psychosocial
rehabilitation usually is coordinated by a mental health professional who will
play the role of a case manager. This title is becoming outdated.
People who are diagnosed with mental illnesses have been very vocal about not
wanting to be seen as cases that need to be managed.
Yet, whatever term you choose to use, it has proven valuable to have someone who
is strategic in arranging services for individual clients and coordinating what
is happening to support that person's life in the community.
This can include increasing the level of support, if necessary.
And facilitating hypothesis, sorry, facilitating hospitalization if it is
needed. Day treatment and partial hospitalization
can also be part of an increase in support as well.
These are available to different extents in different countries.
and these services and crisis services are designed to help people who may be
experiencing periods of increased illness.
but still making it possible for them to maintain their, maintain themselves in
the community. Other services like clubhouses, social
clubs, etcetera, are more focused on promoting the mental health of people
with mental illnesses. They can provide nonjudgmental spaces
where people can socialize, develop new skills, volunteer, etcetera.
And I know I've spoken to some clients that find these to be very important
parts of their plan because it allows them to be in a nonjudgmental space and
really have the opportunity to develop other skills.
As we move through the 1990's other services became part of the psychosocial
rehabilitation approach. Addiction services became very important,
important because we began to understand that the level of co-occurring mental
health and substance use problems was extremely high.
It became clear that there was a need into creating addiction and mental health
services so that people who were dealing with both could get help from people with
appropriate expertise. Family services have been part of mental
health services since the institutionalization and they were
largely organized around supporting families in their caregiving roles.
sometimes targeting family dynamics that we're believed to be affecting a
diagnosed famly member's course of illness.
Now family services also includes work that is done with family members to
support them in their own right. And can also include parenting support
for diagnosed individuals who are parents.
Finally, the mental health care system has also extended it's bio psychosocial
perspective by very, working very hard to integrate more effectively with primary
health care services. This integration has been both to ensure
that people who are diagnosed with mental illness are getting appropriate general
health care, and also to ensure that people who are seeking general health
care are getting appropriate mental health care.
primary health care is really seen as one of the best places to promote mental
health and prevent serious mental health problems.
So, connections between these two systems are quite important.
The new era of post institutionalization community based mental health care,
that's a mouthful, is not without its tensions as well.
In the past, the worry was that patients who stayed in institutions would be
institutionalized. You will remember the reference to
institutional syndrome in Liz Johnsons documentary.
We worry that the institution make patients apathetic, over dependent, and
unable to function in the outside world. Now that those institutions are less
available, there are less hospital beds available in mental health centers and
general hospitals, and fiscal restraint makes everyone concerned about keeping
lengths of stay in hospital as brief as possible.
Now that institution-based care is only for people who are really acutely ill.
And often only those that meet the criteria of potial, potential harm to
self or others will be admitted. The new worry we have is that people who
need care will have difficulty getting it, and will not have the time they need
to get well enough to deal with life outside the hospital once they are
discharged from care. There is some people who think we
actually haven't gone far enough with the institutionalization Or at least that we
haven't gone as far as needed with ensuring that the rights of people
diagnosed with mental illness are upheld and their able to fully exercise their
self determination. Most mental health acts still have
provisions in them that allow professionals to overrule the judgment of
a patient that is seen as not having the capacity to make sound decisions about
their care. The belief that a patient does not have
insight into their illness introduces the possibility of a return to a
paternalistic model of care in which family members or mental health
professionals can make their own decisions about what are the best
interests of someone. We've struggled to find perfect answers
to the question of where the balance of self-determination and protection of the
community should be. It really depends on the situation.
Newer models of psychosocial rehabilitation like the assertive
community treatment teams have taken treatment into the community to reach
patients who are not necessarily willing or able to bring themselves in for care.
This model has made it possible for many people who would otherwise require
hospitalization to receive care and support in a much less restrictive
environment. But there were initial claims that these
teams would not take no for an answer. Which made some people worry about
potential coercion or overriding of patients' wishes.
If you remember the stake holder analysis from the deinstitutionalization stegment,
segment, I'm sure you can imagine that the perspectives on this are varied.
Families and communities were tremendously relieved to know that
someone would be willing to come to a patient rather than waiting for them to
come in for care. Many patients as well valued this and
speak very positively of having 24 hour, hour access to support and somebody who
is willing to see them in their homes. But some feel that individuals with
mental illness do not have the same latitude as others to refuse treatment.
And assertive community action team seems to demonstrate this.
We don't see assertive community treatment teams for people with other
chronic illnesses, like heart disease or diabetes.
And people are certainly likely not to adhere to treatment, or follow through on
other treatment recommendations with those illnesses as well.
A major step forward in terms of challenging the autonomy and
self-determination of people diagnosed with mental illnesses,
and mental illnesses has been the implementation of mandatory outpatient
treatment in many western nations. These treatment orders, sometimes called
community treatment orders, so that contracts between patients and their
doctors that oblige them to accept treatment or face hospitalization,
possibly with police intervention to get them there.
These treatment orders allow mental health professionals extend the reach of
mental health acts that only allow involuntary hospitalization if people are
a harm to themselves or other people. Now, they can be mandated into outpatient
treatment based on the possibility of future harm.
Again, it's difficult to strike an appropriate balance between honoring
autonomy and self-determination, while also attending to the perceived best
interests of an individual, families, and the communities surrounding.
This balance is sometimes something that I try to explore int the paper that I
wrote with this colleague Mfoafo-M'Carthy When we were looking at community
treatment orders, and really we had to ask ourselves, is this one step forward
for the system but maybe two steps back for clients?
Again, these are not easy questions to answer.
. Finally, as we move into the twenty first
century the world is attempting as a whole to put mental health on the agenda
and prioritize it in an international effort to, to promote global mental
health. The world health organization has
published a great deal about the world wide burden of mental illness.
And as part of a global mental health movement they are encouraging
collaborations between nations to strengthen the infrastructure for mental
illness treatment and mental health promotion across nations.
An important aspect of this world wide effort is to recognize,
people diagnosed with mental illness as a vulnerable community.
Who defines the vulnerability of these people based on the criteria you see
here. And I'm sure that you can see already
from our discussion, that many of the things that are listed here apply to
people who are diagnosed with mental illnesses,
especially now that they are living in communities.
Another concern is that we are fortunate enough to be living in a time when we can
have optimism about mental illness. That's not the unfortunate part.
There are a good evidence based treatments available, and there are world
wide efforts to make those treatments widely available.
We have an agenda for mental health promotion and enriching, and we have data
that says that people who are diagnosed with mental illnesses, even the illnesses
we call serious and persistent illnesses, will experience some kind of relief from
it. Yet we have a system that still functions
as though once a person is a patient, they never stop being a patient.
When do people stop being seen as patients client,
consumers, or users of mental health services.
What can we do about the vulnerability that the World Health Organization said
is a test of being a person who has a mental illness?
And is this permanent sick role and this vulnerability all there is to living with
a mental illness. This kind of thinking, that all there
really was, that once you were diagnosed with a mental illness, basically, your
life was about case managers and rehabilitation and vulnerability, is
something that people who are diagnosed with mental illnesses have really
resisted, and the ongoing work of what we might still call a survivor movement or a
service user movement. It's hard to know what term to use now,
really has contributed to a shift in the way that we think about living with
mental illness over the long term. That shift is what's come to be known as
the recovery movement, and it's interesting to think that professionals
tend to refer to recovery from mental illness or recovery as a possibility,
whereas, I find that the people who have been diagnosed with mental illness will
talk about recovery as a movement. So that really shows you that there's
some difference in terms of how these different groups think about recovery.
But the good thing is that this has converged into something that is
affecting the way that mental health care is organized as we move into the 21st
Century. So that's what we'll be talking about
next.
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