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.
