Evaluating mental health care reform: Including the clinician,client, and family perspective

This article suggests one direction that theory building might take to develop a stronger conceptual foundation needed to test the effect on clients of reforms in the financing and organization of mental health care delivery systems. The authors recommend that health status outcomes be measured from three perspectives: the client, who can best report his or her own subjective experience of illness; the clinician, who is the best source of information about the client’s disease; and the family, which is the best source of information about the effects on members’ health status of caring for a mentally ill family member. The authors also recommend that measurement of health status should be multidimensional.     

Internalizing stigma associated with mental illness: findings from a general population survey in Jamaica.

OBJECTIVES: The culture of stigma associated with mental illness is particularly intense when persons who are normally victims of that stigmatization (mentally ill persons and their family members) themselves act negatively toward others whom they associate with mental illness. We attempt to determine the extent of this internalization and assimilation of stigmatizing attitudes, cognitions, and behaviors in persons who are at risk for such stigmatization in Jamaica. METHODS: Data from a 2006 national survey on mental health were analyzed. Demographic variables, the presence or absence of mental illness in respondents and in their family members, and responses pertaining to behaviors and attitudes toward mentally ill persons were examined. Subsamples (respondents with mental illness, respondents with a family member with mental illness, respondents with neither) were compared using the chi-square test. RESULTS: Respondents with family members with mental illness were less likely to demonstrate a number of different manifestations of stigmatization than others (P=0.009-0.019). Respondents with mental illness showed no difference in the demonstration of a number of different manifestations of stigmatization from other respondents (P=0.069-0.515). CONCLUSIONS: The small number of mentally ill respondents resulted in low statistical power for demonstrating differences between that subgroup and other respondents. The significantly more positive attitudes and behavior of respondents with family members with mental illness suggest that some benefit may be gained by creating more opportunities for the general public to interact with persons with mental illness.     

An explication of treatment ideology among mental health care providers

This paper presents an exploratory analysis of the treatment ideologies of mental health care providers who work with the chronically ‘mentally ill.’ Treatment ideology is understood as the complex set of beliefs providers hold about the aetiology of mental illness, the role of the client and the provider, and the efficacy of various treatments or interventions. A case study of a large, urban mental health care organisation providing care to the chronically‘mentally ill’was conducted in 1992. The author attended a series of staff retreats, administered a questionnaire, and completed in-depth interviews with 22 providers. A typology reflecting two dimensions that juxtapose alternative treatment preferences was developed to represent the range of treatment ideologies uncovered. The first dimension reflects differing conceptions of the role of the provider (supportive or facilitative) and the second dimension reflects differing treatment goals (adjustment or autonomy). This typology was then theoretically extended to include a custodial role for the provider and a treatment goal oriented toward social control of clients. Further study of providers in differing organisation settings is needed to determine the salience of these typologies. Research must also investigate the development and consequences of treatment ideologies, with critical attention focused on the consistency (or inconsistency) of treatment ideologies within a given system, the professional and organisational sources of differing preferences for treatment, and the effect of various belief sets on health care services and outcomes.     

The residential needs and preferences of persons with serious mental illness: A comparison of consumers and family members

This study reports on a systematic statewide effort to determine the residential needs and preferences of two important groups: primary consumers of mental health services and family members of consumers. Two comparable surveys regarding the residential needs of consumers were conducted. In all, 314 consumers and 459 family members participated in the survey. A comparison of the preferences of family members and consumers suggests that family members more often prefer congregate living situations and more staff support than do consumers. Consumers more often express a desire to reside by themselves without staff and without other persons who are mentally ill. While the direct comparison of preferences from these two constituencies has limitations, these data do suggest significant variability in needs and preferences voiced by consumers and their family members; discrepancies that need to be addressed by mental health policymakers and planners.     

Risks to mental health patients discharged into the community

The advances in pharmacological and psychosocial treatments in the 1950s and 1960s facilitated the movement of care for increasing numbers of mentally ill people from the institutions to the community. This represented a radical change in mental health strategy and practice and has brought with it new sets of risks. Due to inherent stigmatisation and some well publicised cases of violence and murder, there is a perceived risk to the public from community-based mentally ill people. The findings of many studies have illustrated this and have led to the isolation and rejection of large numbers of people who have mental health problems. This has increased the risk to mentally ill people of victimisation and harassment from members of the public. Kelly and McKenna (1997) have shown that this takes many forms and occurs within and outside the home. Most worrying these latter risks can increase the former where some mentally ill people carry weapons to protect themselves. This in turn can increase public fear and raise stigmatisation. Furthermore, the lack of support and belonging can increase the risk of self-harm among the mentally ill. A more general risk is that for many deinstitutionalisation simply means transinstitutionalisation where incarceration in large mental hospitals is being replaced by incarceration within community based houses and flats. To assuage these risks mentally ill people still require social support and protection. The asylum the place may have disappeared but asylum the function is still required.     

Living with a mentally ill parent: exploring adolescents' experiences and perspectives

Although a considerable body of research has described the implications of parental mental illness, the perspectives of children and adolescents have rarely been addressed. In this article, I explore adolescents' experiences in everyday life, based on an action-oriented study of a Norwegian online self-help group for adolescents (aged 15 to 18) with mentally ill parents. The analysis was conducted through participant observation of the group for 2 years. The adolescents experienced a variety of difficult challenges related to their parent's mental illness: lack of information and openness; unpredictability and instability; fear; loneliness; and loss and sorrow. However, they also discussed strategies for active management of the challenges arising from the family situation. I argue that these adolescents can be understood as vulnerable as well as active participants in managing their everyday lives. I emphasize the importance of including perspectives of children and adolescents in further research so as to improve health care for families with parental mental illness.     

The effects of alcohol abuse among the new chronically mentally ill

In recent years, there has been a growing recognition of the high incidence of alcohol abuse among the new generation of chronically mentally ill. This article reports on a study that tracked a subgroup of the chronically mentally ill, those discharged from state psychiatric hospitals, through an entire community mental health aftercare system and its major auxiliary human service agencies. Those who were assessed by hospital discharge social workers as having a need for alcoholism services were found to be less likely to be referred for aftercare and to make contact with aftercare agencies post discharge; and for those with an alcoholism problem who do make contact, they generally received less service than those who did not have a need for alcoholism services. The professionals in both the mental health and alcoholism fields need to work together to better meet the needs of the chronically mentally ill with an alcohol problem.     

The Effects of Alcohol Abuse Among the New Chronically Mentally Ill

In recent years, there has been a growing recongition of the high incidence of alcohol abuse among the new generation of chronically mentally ill. This article reports on a study that tracked a subgroup of the chronically mentally ill, those discharged from state psychiatric hospitals, through an entire community mental health aftercare system and its major auxiliary human service agencies. Those who were assessed by hospital discharge social workers as having a need for alcoholism services were found to be less likely to be referred for aftercare and to make contact with aftercare agencies post discharge; and for those with an alcoholism problem who do make contact, they generally received less service than those who did not have a need for alcoholism services. The professionals in both the mental health and alcholism fields need to work together to better meet the needs of the chronically mentally ill with an alcohol problem.     

Families of chronically mentally ill people: siblings speak to social workers

Twenty siblings of chronically mentally ill people discussed their emotional responses to the mental illness of their brother or sister. The findings were drawn from a study that was part of the author's practice experience as a social worker in a community mental health setting. The findings also paralleled the author's life experiences as a sibling of a chronically mentally ill person. Sibling emotional responses were categorized into grief and loss phases of denial, anger, bargaining, depression, relief/respite, and acceptance. Siblings believed that their expressions of grief and loss were impaired by characteristics of mental illness and by mixed messages from the mental health system. The siblings recommended inclusion of siblings in client treatment; support and education for siblings; clear communication between social worker and family; a social worker focus on family strengths; and, most of all, effective client intervention. The sibling perspective points out the salient need for social workers to use their ecological, person-in-environment training to facilitate healthier family support networks for chronically mentally ill people.     

Living with the mentally ill: Effects on the health and functioning of other household members

Based on data from the National Health Interview Survey Mental Health Supplement, 1989 (NCHS, 1991), this article compares health outcomes for respondents living with someone who is mentally ill (N = 776) with a randomly selected subsample of respondents not living with someone identified as mentally ill (N = 716). When other predictors of health are controlled, sharing a household with a mentally ill person is associated with poorer self-reported physical health, increased risk of reporting some activity limitation, and increased service utilization—both greater risk of hospitalization or visiting a physician, and a greater number of days hospitalized and number of physician visits among those utilizing these services. The severity and duration of mental illness have little effect across health outcome measures. Impaired health and increased utilization of medical care among persons living with someone who is mentally ill suggest hidden costs to individuals, to families of the mentally ill, and to the service system.     

The criminal justice/mental health system and the mentally retarded, mentally ill defendant

The mentally retarded, mentally ill defendant calls attention to problems in the relationship between the legal and the mental health systems. This study looks at what happens to a group of retarded offenders found incompetent to stand trial. The study examines differences in court processing and final disposition between mentally retarded and nonretarded defendants found incompetent to stand trial. Virtually all subjects were diagnosed as being psychotic. The mentally ill, retarded defendants spend significantly more time in the hospital, more time in the hospital waiting to be returned to jail, and more total time incarcerated in the criminal justice/mental health system. At a final disposition hearing mentally ill, retarded defendants were significantly more likely to be rehospitalized and less likely to be released to the community. No mentally ill, retarded defendant in this study went to prison. The longer periods of incarceration may stem from an underlying lack of understanding about the ability of retarded defendants to achieve competency. Differences in court disposition may result from a court/mental health professional tendency to select dispositions which are thought to be more 'humane'.     

Community-based care of the mentally ill: a research review

A review designed to assess the state of the art of social work research in mental health discovered that a number of important studies have built knowledge cumulatively on community-based care of the chronically mentally ill. This article highlights the major findings of the studies, as well as their methodological strengths and weaknesses.     

Responding to the needs of the homeless mentally ill

The homeless mentally ill represent a pivotal and urgent challenge to the mental health field in the 1980s. Those homeless who have extended histories of psychiatric hospitalization stand as harsh reminders of the failures of deinstitutionalization, while young mentally ill homeless adults who never have been treated as inpatients testify to the gaps and unrealized promises of community-based care under deinstitutionalization. Homelessness and mental illness are social and clinical problems, respectively, distinct in some ways but intertwined in others. Some of the factors that contribute to homelessness--such as economic deprivations, a dearth of low-cost housing, discontinuities in social service systems, and radical changes in the composition of American families--are felt particularly keenly by many persons who are mentally ill. And symptoms of mental disorders, in turn, frequently impede an individual's capacities to cope with those, as well as other, stressors. Developing appropriate and effective responses to the needs of homeless people who are mentally ill requires precise definition and identification of the target population, innovations in the mental health service system, encouragement of those who staff it to work with homeless mentally ill patients, and public education. Ultimately, however, fundamental answers will be found in an improved understanding of severe mental illness, enhanced treatment capacities, and greater attention to the rehabilitative needs of mentally ill persons.     

Mental health services system research: the National Institute of Mental Health program.

There is a critical need for research to examine the changing mental health services system, to evaluate major innovations in the provision of mental health treatment, and to remove existing barriers to comprehensive and cost-effective care. To achieve these aims, collaboration is needed among government agencies, mental health services programs, academic institutions, and the private sector. The National Institute of Mental Health supports research and research training on the mental health services system primarily through the Division of Biometry and Applied Sciences. This article focuses on the division's three priority research areas of the mental health services system: the provision of mental health care in the primary care sector, the organization and delivery of care for the chronically mentally ill, and financing and reimbursement of care. The various mechanisms of research support are also highlighted.     

Community psychiatric care: from libertarianism to coercion. Moral panic and mental health policy in Britain.

This article discusses recent developments in mental health policy in Britain, focusing on the move towards compulsory supervision of mentally ill people in the community. It is argued that the desire for compulsion reflects moral panic rather than rational appraisal of the undoubted problems with community mental health care. Alternative strategies involving education of the patient and cares, the deployment of psychological treatments of psychosis and an emphasis on the negotiation of treatment plans, are advocated.     

Comprehensive care of pregnant mentally ill women

Since the onset of deinstitutionalization, there has been an unanticipated and dramatic increase in pregnancies among women with chronic mental illness, with no specific planning for how to address the unique clinical needs of this high-risk population. Shortcomings in delivering care to mentally ill women within general health care systems are reviewed, including failure to assist with family planning, failure to observe worsening mental health during pregnancy, inadequate planning for child custody, lack of access to services, and omitted pelvic examinations. Necessary components of a system to provide comprehensive and coordinated care for pregnant mentally ill women are described. These include assessment of adaptation to pregnancy and competency to care for an infant, somatic and psychotherapeutic treatment, parenting skills training, family planning services, outreach, and close liaison with obstetric services. A Chicago-based collaborative program is described as an example of providing comprehensive, specialized care with limited financial resources.     

Self-reported lifetime psychiatric hospitalization histories of jail detainees with mental disorders: comparison with a non-incarcerated national sample

Lack of access to hospitalization is an often-cited risk factor for incarceration among persons with severe mental illness. This proposition is examined by comparing self-reports of lifetime psychiatric hospitalization histories of mentally ill jail inmates with data from a national sample of non-incarcerated mentally ill. Roughly 52% of mentally ill jail detainees reported at least one psychiatric hospitalization, a rate nearly three times that of the comparison group. The data call into question the notion that mentally ill jail inmates have reduced access to psychiatric inpatient treatment, without addressing the adequacy of the treatment received. Longitudinal studies are needed to explore temporal relationships to better understand the relationship between mental health treatment and criminal justice involvement.     

The labor market consequences of family illness

BACKGROUND: This study examines the impact of mental illness on the labor market performance of family members of afflicted individuals. Numerous research projects have attempted to measure the impact of mental illness and related disorders on the ill individual, yet have traditionally neglected estimating potential costs accruing to family members of the ill. AIMS OF THE STUDY: Previous research estimating the impact of illness on the time allocation decisions of family caregivers has been limited in scope. I obtain estimates of the impact of mental illness on the probability of labor force participation and hours of work of all family members. The general analysis used in this study will pave the way for more accurate assessments of the costs of all types of illness and the estimates obtained will provide policy makers with a much more complete picture of the costs of mental illness. METHODS: The main empirical work in this study includes a probit estimation of labor force participation and a tobit regression of hours worked (including sample selection correction). The data sample, taken from the 1987 National Medical Expenditure Survey, is also partitioned by gender to clarify effects of family illness on labor supply for both females and males. RESULTS: Adult males are found to increase their probability of labor force participation in the presence of mental illness in the family (all else equal) when the mental illness is accompanied by a chronic physical illness. However, females are surprisingly found to have no significant impact on their probability of being a member of the labor market when a family member is afflicted with mental illness. On the other hand, hours of work are significantly reduced for both females and males when the mentally ill family member is afflicted with additional illnesses (physical and/or mental). DISCUSSION: Previous studies have traditionally not considered the effects of family illness on males because females are typically found to be the primary caregiver when a family member falls ill. The findings in this study indicate that men suffer reductions in their hours of work in an equivalent magnitude to females. Thus, males should not be ignored when estimating the opportunity costs of illness in families. IMPLICATIONS FOR HEALTH POLICIES: Current federal and state policies provide for some of the medical costs and replace some of the lost income of ill individuals, but generally do not support family members who are negatively affected by illness. This research provides evidence supporting the arguments of advocates for policy to ameliorate the financial burden borne by family members of the ill. IMPLICATIONS FOR FUTURE RESEARCH: The estimates obtained in this study show that women and men both need to be studied when determining the effects of family illness on labor supply, and should be studied separately to obtain clear results. Also, future research should include examining particular mental illnesses to see whether there is a higher cost of one over the other (e.g., schizophrenia versus major depression), as this may provide valuable information to policy makers. In addition, comparison of the costs of psychological disorders to chronic physical illnesses (such as cancer and heart disease) should be undertaken.     

Implications for expressed emotion therapy within a family therapeutic context.

Expressed emotion instruments measure variant levels of criticism, blaming, and anger within families of mentally ill people. Some theorists believe that high levels of expressed emotion predispose schizophrenic patients for relapse. However, recent trends in family therapy indicate that high expressed emotion may naturally result from caring for an ill family member. Families may therefore often feel unfairly blamed by practitioners for causing mental illness. The author examines the usefulness of integrating expressed emotion measures into family therapy from three theoretical perspectives: the transactional perspective, the coping and adaptation perspective, and the systems perspective. Each of these perspectives provides a framework for incorporating expressed emotion measures into the broader context of research on and treatment of schizophrenia. The author postulates that appropriate controls designed to reduce pent-up emotion in families must accompany expressed emotion interventions in family therapy. Appropriate controls might include exercise, meditation, spiritual focus, or membership in a support group.     

Civil commitment of sex offenders to mental institutions: should the standard be based on serious mental illness or mental disorder?

Civil commitment to mental institutions requires that an individual be both seriously mentally ill and dangerous. This principle is erroneously being applied to incarcerated sex offenders nearing release from prison under the theory that they have antisocial personalities or paraphilia disorders, which are called mental illnesses. However, the mental health and legal communities are at odds regarding the use of a diagnosis of personality disorder or paraphilia to justify civil commitment. The author reviews the differences between serious mental illness and mental disorder, the flaws with assessing sex offenders as mentally ill, and the ethical dilemma for social workers employed in mental hospitals.