Neighborhood psychiatry: New community approach

Neighborhood health and multiservice centers are increasingly becoming a means of delivering medical care to communities. This paper describes the function of a “neighborhood psychiatric team,” using a “family life center” as a base of operations for a comprehensive preventive and treatment program in one neighborhood of Boston. This program consists of direct treatment services to neighborhood residents, consultation with health and social service professionals and paraprofessionals in the Family Life Center itself, and consultation with other community agencies. The advantages of working in a neighborhood-early intervention in crisis with individuals and agencies, accessibility to the entire family, integration with general health services, easy follow-up and aftercare of recently discharged psychiatric patients-are described with case examples.     

A program of industrial consultation by a community mental health center

A staff member of a community mental health center provided consultation services to untrained industrial counselors at a large private corporation. Characteristics of “newer” workers, ethnically different from supervisors, are described. Attitude change is the key, but difficult to bring about. The consultant had full cooperation of the counselors, but never gained full support from management. The article describes procedures for training counselors and successful and unsuccessful efforts to reach foremen.     

Special role and role expectation of black administrators of neighborhood mental health programs

This paper attempts to portray the role conflict and ambiguity of black administrators in community mental health programs. The paper is not about mental health programs themselves but rather focuses on the problems of blacks in leadership positions in such programs. The implication of this paper is that blacks cannot escape being black despite their professional position or training. They are regarded by their superiors, colleagues, staff, and the community as performing what Hughes called a "racial function." This function presents an interesting dilemma. On the one hand, the black administrators are recruited and employed out of the needs expressed by the black community. On the other hand, their white superiors determine whether they remain in those positions. To offend either group risks the loss of their position. The black community and white employer sometimes make conflicting demands on these black administrators. The result is that blacks find themselves unable to please either. Blacks have reacted by withdrawal from the black community or resignation from the organization. This paper attempts to explain these conflicts. Although the problems of black administrators are called special cases it does not mean that other ethnic groups have not experienced any or all of these problems. It is called a special case because the black community is undergoing a special and unique kind of socioeconomical transition. Black administrators in other types of public organizations will recognize some of the conflicts described in this paper.     

A collaborative-interactive model for mental health consultation: Teacher inservice education by psychiatric clinicians

Primary prevention of emotional disorders is often cited as a goal in community mental health consultation. The daily contact with children and parents by the classroom teacher can yield effective prevention, if the teacher is appropriately prepared to act as a resource, and by clinicians given an awareness of emotional difficulties in children and their parents. Though consultation is often described as facilitative of change, typically discussions of such programs emphasize technique rather than content. Presented here is acollaborative model based upon a didactic input of humanistic psychology, upon which educator and clinician draw as they become allies in pursuit of answers to questions raised in current examples from the teacher's classroom experience. Excerpts and results of the model's effectiveness are given.     

Problems and challenges for the mental health professional consulting to a Community Action Organization

There is an evident lack of theoretical and empirical literature on the special issues of consultation to anti-poverty agencies. Three such issues are examined in relation to Schein's group process consultation model and Caplan's consultee-centered administrative consultation model. The importance of clinical skills for such work is apparent in the need for the consultant to respond to the interaction among intra- and interpersonal dynamics of anti-poverty workers and the oppressive forces of poverty in which they live and work. As such, the dichotomy presented by Reiff (1971) between the community mental health professional (emphasis on the person) and the community psychology professional (emphasis on the system) seems artificial.The wise counsel of Drs. Milton Shore, Forrest Tyler, William Claiborn, and Mr. Daniel Hurley during preparation of this paper is gratefully acknowledged.     

A comparison of black and white women with binge eating disorder

OBJECTIVE: Binge eating disorder was introduced in DSM-IV as a psychiatric disorder needing further study. This community-based study describes the relationship between race and clinical functioning in black and white women with and without binge eating disorder. METHOD: A group of 150 women with binge eating disorder (52 black, 98 white) and a race-matched group of 150 healthy comparison subjects were recruited from the community. Eating and psychiatric symptoms were assessed through interviews and self-report. RESULTS: Black and white women with binge eating disorder differed significantly on numerous eating disorder features, including binge frequency, restraint, history of other eating disorders, treatment-seeking behavior, and concerns with eating, weight, and shape. Black and white healthy comparison subjects differed significantly in obesity rates. CONCLUSIONS: For both black and white women, binge eating disorder was associated with significant impairment in clinical functioning. Yet, racial differences in clinical presentation underscore the importance of considering race in psychopathology research.     

Prise en charge des signalements de personnes non connues par des équipes de secteur en psychiatrie adulte

Community psychiatry teams are regularly required to take care of people's worrying situations (neighborhood trouble, home withdrawal, suicidal discourse, hostility, etc.). Despite this being a common activity in community psychiatry, we have found very little literature on the subject. However, this type of intervention often raises ethical, legal and organizational questions. A six-month survey leads to the analysis of 61 reports of individuals not previously known by the community psychiatry team. There is almost an equal number of men and women. People being reported are aged between 31 and 60, and 80% are unemployed. People reporting to psychiatric services are members of the family in most cases. The report's reasons are mostly neighborhood disorders, delusional ideas, and social withdrawal. Ten per cent of these reports have been redirected to an emergency department straight away. The answers to the reports are quite diverse according to the severity elements collected. The different actions after a report are: proposal for a consultation in the outpatient clinic (48%), home visit (35%), no intervention (17%), home visit followed by an hospitalization (9%). In 5% of the cases, a psychiatric consultation was proposed to the person reporting his relative. As a conclusion, working on report of patient's situation allowed us to evaluate 40% of the non-urgent situations and to propose sufficient mental health care. In this article, we describe the work of a multi-professional group from different areas in Paris. Sharing our practices leads to the elaboration of a guide for report's care and an information-gathering file to help the professionals in those types of interventions.     

Drinking patterns of black and white men in the West Midlands

The limited amount of evidence available from mortality statistics, mental hospital in-patient admission rates and community surveys appears to indicate that people of African-Caribbean origin resident in Britain have fewer alcohol-related problems than the white population. However, there are no systematic data on the normal drinking habits of random and representative samples of the black population of Britain, or the true extent of alcohol-related problems in the whole population. A survey of the drinking habits and alcohol-related problems of random samples of 200 black men and 170 white men from the Birmingham and Wolverhampton areas is reported. Black men were much less likely to report regular drinking and to report drinking large amounts of alcohol. They were far less likely to have got drunk in the past year, and scored lower on most items of an Alcohol Problems Scale. Age was the only demographic variable associated with drinking levels in both groups, and the link was more tenuous in the black than the white group. There were no generational differences found. Religious observance and belonging to a Pentecostal Church were found to be major differences between the black and white groups, and strongly associated with moderation in relation to aleohol.     

Differences in sleep between black and white adults: an update and future directions

Meta-analyses and other previous reviews have identified distinct ethnic/racial differences in the quantity, quality, and propensity for sleep disorders between black and white adults. The present article reviews the meta-analytic evidence along with recent epidemiological, community, and clinical studies to clarify what is known and not known about sleep differences between these two groups. Black individuals tend to have poorer sleep continuity and quality, excessively short or long sleep duration, greater sleep variability, and greater risk of sleep apnea than white individuals. The data suggest that these differences are attenuated yet persist in the face of several relevant confounders such as socioeconomic status, occupational factors, neighborhood context, and comorbidities. However, little is known about the mechanisms that explain ethnic disparities in sleep. We propose a conceptual model of potential mediators for future testing as well as other questions in need of investigation.     

Psychopathology of white mentally ill immigrants to Jamaica

Object: To test the hypothesis that white immigrants to a predominantly black country have a different pattern of psychopathology from the native population.Method: The psychopathology (DSM IIIR) of white immigrants to Jamaica seen in the author's private practice between 1979 and 1990 was compared with the psychopathology of a control sample of native Jamaicans matched with the immigrant sample for age, sex, and social class.Results: There was no statistical difference in the major diagnoses mood disoder (35%), anxiety states (27%), and schizophrenia (20%) between the immigrant and control groups. White immigrants to this black country did not develop schizophrenia at higher rates than the native born. White mentally ill immigrants to Jamaica move into social class positions at a significantly higher level (p<0.005) than those of their parents with whom they grew up in their home country. This was significantly different (p<0.005) from their Jamaican controls. Two case studies are presented to illustrate these findings.Conclusions: The political/economic situation which exists in black postcolonial countries like Jamaica provides a protective social environment for white immigrants, which buffers them from the etiological conditions that engender schizophrenia in immigrants to other countries with predominantly white populations.     

Psychopathology of white mentally ill immigrants to Jamaica

Object: To test the hypothesis that white immigrants to a predominantly black country have a different pattern of psychopathology from the native population.Method: The psychopathology (DSM IIIR) of white immigrants to Jamaica seen in the author's private practice between 1979 and 1990 was compared with the psychopathology of a control sample of native Jamaicans matched with the immigrant sample for age, sex, and social class.Results: There was no statistical difference in the major diagnoses mood disoder (35%), anxiety states (27%), and schizophrenia (20%) between the immigrant and control groups. White immigrants to this black country did not develop schizophrenia at higher rates than the native born. White mentally ill immigrants to Jamaica move into social class positions at a significantly higher level (p<0.005) than those of their parents with whom they grew up in their home country. This was significantly different (p<0.005) from their Jamaican controls. Two case studies are presented to illustrate these findings.Conclusions: The political/economic situation which exists in black postcolonial countries like Jamaica provides a protective social environment for white immigrants, which buffers them from the etiological conditions that engender schizophrenia in immigrants to other countries with predominantly white populations.     

Community impact of group homes for mentally ill adults

The phenomenon of resistance to the establishment of group homes for mentally ill adults is well-documented. The extent to which such homes, once established, do or do not create problems for communities is less clear. The current study examined the impressions of residents of a group home neighborhood one year or more after the establishment of the home. Forty-one residents of group home neighborhoods and thirty-nine residents of control (non-home) neighborhoods responded to a survey about their impressions of how a group home had affected or (for controls) would affect their neighborhoods. More than one fourth of the group home neighbors did not even know that they were living near a home. Those who did know tended to report a negligible impact of the group homes on things such as property values, neighborhood crime, resident safety, and distressing incidents in the community. Most of these residents also indicated that they were satisfied with the group home in their neighborhoods. The actual experience of group home neighbors was far more favorable than what residents of the control neighborhood anticipated, despite lack of differences in demographic characteristics or overall attitudes toward community care of mentally ill persons. Results support the view that the feared consequences of group home establishment in residential neighborhoods do not occur and that such homes may gain reasonable acceptance after they are established.     

The significance of sociocultural variables in the psychiatric treatment of black outpatients

Given the relatively high incidence of mental disorder among urban blacks and the present emphasis on treatment of psychiatric patients via community mental health centers, it was the purpose of this paper to seek answers to the following questions: (1) To what extent do catchment-area blacks apply for treatment from the community mental health center? (2) What are the treatment implications with regard to diagnosis and disposition? (3) What, if any, is the significance of black patients seeking treatment from a white middle-class community mental health center?The fact that catchment-area blacks apply for service with the least frequency of any group suggests they perceive the center differently than other applicants. Background characteristics of the black applicants in general were in the expected direction, i.e., low socioeconomic status. This factor, however, tended to obscure class differentials within the black group, with particular reference to individual values, aspirations, and symptoms. In addition to psychopathology, blacks were found to present specific sociocultural variables that exerted a determining influence on type of treatment offered. Factors of language, cognitive style, appearance, and behavior of black patients were likely to be mislabeled as pathological and/or deficient and not amenable to traditional forms of outpatient treatment. A bias against black males was evident in the consistently less favorable disposition against clinic treatment. The staff person of initial contact, generally a white female social worker or nurse, tended to see black males as hostile, angry, inappropriate, and in need of hospitalization, whereas black females tended to arouse either less fear or more sympathy. The virtual absence of a diagnosis of psychoneurosis among black patients is striking. The implications of this finding are far-reaching. Absence of such a diagnosis serves as a potent justification to exclude patients from outpatient treatment, particularly individual psychotherapy. Decisions regarding treatment and techniques of treatment are dependent upon the conceptualization, social class, and scientific frame of reference of the therapist. Therapists who evaluate patients for treatment with supercilious solipsisms perpetuate the myth of “unsuitable for treatment” with regard to blacks that effectively reduces many to the ranks of the therapeutically deprived. Traditional methods of outpatient treatment will not be effective with many ghetto blacks unless some perceptual change on the part of white middle-class therapists occurs. Appraisals of motivation, expectation, insight, and goals of treatment of the practictioner himself are prerequisites for reaching black patients on an ambulatory basis. Blacks have the necessary and sufficient conditions for outpatient treatment, including individual psychotherapy. They bring to treatment not only salient clinical features of pathology but specific sociocultural variables. Recognition of differential perceptions according to race will avoid inappropriate labeling of these perceptions as illness, thereby freeing both therapist and patient to communicate effectively, which is, after all, the heart of the therapeutic process.     

Race as a factor in the perceived importance of the use of psychotropic medication

The importance of getting medication as a reason for contacting an outpatient psychiatric service was studied from the perspective of white (N=265) and black (N=42) patients, together with their white interviewers. Interviewers rated the importance of getting medication as greater among blacks than whites. However, the finding did not seem to reflect difference in patient demography or disturbance, nor did it seem due to racial bias. Largely, it reflected a greater importance ascribed to getting medication by black patients, themselves.     

Anxiolytic-like effect of phytoestrogen genistein in rats with long-term absence of ovarian hormones in the black and white model

Postmenopause is mainly characterized by a reduction of ovarian hormones, which is accompanied by a major incidence of physical disorders and mood swings. Clinical and experimental evidence suggest that phytoestrogens could be used to ameliorate these alterations associated with menopause. However, the phytoestrogen effects on anxiety in rats with long-term absence of ovarian hormones, is unknown. Consequently, in the present study the authors compared the anxiolytic-like effect of phytoestrogen genistein (0.25, 0.5 y 1.0 mg/kg, i.p.) in Wistar rats with 12-weeks postovariectomy in the black and white model and in the open field test, and it was compared with diazepam (1.0 mg/kg, i.p.). In the black and white model, genistein (0.5 y 1.0 mg/kg) and diazepam reduced the latency to enter and increased the time spent into the white compartment; also, significantly increased frequency and time spent in exploration toward white compartment was seen, as compared with the control group (p < 0.05). In the open field test, genistein and diazepam increased grooming and rearing, without significant changes in locomotor activity, as compared with the control group. In conclusion, phytoestrogen genistein produces an anxiolytic-like effect in Wistar rats with long-term absence of ovarian hormones in the black and white model, supporting the hypotheses that phytoestrogens could be used to ameliorate anxiety associated with menopause.     

Transcultural issues in the dynamics of a Balint clinical reflection group for community mental health workers

The author presents transcultural issues in the content, process, and group dynamics of consecutive meetings of a Balint clinical reflection group for community mental health workers at Inala, Australia. Balint work and the context and evolution of the group process are briefly described, as is the consultative research methodology. The process of a Balint group meeting is reported in detail, following the author's consultation with group members. The collaborative work of a culturally diverse team of mental health professionals is examined in the context of discussion of a practitioner-patient relationship in which transcultural, gender, and family conflicts were the focus of affective and cognitive dissonance. For mental health workers engaging with communities of cultural diversity, Balint reflection groups can facilitate insight into cultural countertransferences that adversely affect clinical work. The group served to support the caseworkers' engagement with patients of different cultures, and provided a safe environment for the creative consideration and exploration in fantasy of the emotional pressures and complex ethical dilemmas related to boundaries in transcultural client-practitioner relationships, including those in which open discussion would otherwise be avoided.     

Triple jeopardy: the joint impact of racial segregation and neighborhood poverty on the mental health of black Americans

Purpose

Because segregation may shield blacks from discrimination as well as increase their exposure to concentrated poverty, its net impact on the mental well-being of black Americans is unclear. We investigated the intersection between segregation, neighborhood poverty, race, and psychological well-being.

Methods

Using data from the nationally representative 2008–2013 National Health Interview Survey merged with U.S. Census data, we examined the association between black–white metropolitan segregation (D-index and P-index) and psychological distress (a binary indicator based on the Kessler 6 score ≥ 13) for blacks and whites. Furthermore, we assessed whether neighborhood poverty explains and/or modifies the association. Logistic regression models were estimated separately for blacks and whites as well as for each segregation index.

Results

Higher D- and P-indices were associated with higher odds of psychological distress for blacks. Neighborhood poverty explained some, but not all, of the association. In models that allowed for the impact of metropolitan segregation to vary by neighborhood poverty, higher segregation was found to be detrimental for blacks who resided in high poverty neighborhoods but not for those living in low poverty neighborhoods. We found no evidence that segregation impacts the mental health of whites—either detrimentally or beneficially—regardless of neighborhood poverty level.

Conclusions

The impact of segregation differs by neighborhood poverty and race. The psychological harm of structural racism, resulting in segregation and concentrated poverty, is not additive but multiplicative, reflecting a “triple jeopardy” for blacks, whereby their mental health is detrimentally impacted by the compounded effects of both neighborhood distress and racial segregation.

     

Links between pubertal timing and neighborhood contexts: implications for girls' violent behavior

OBJECTIVE: To investigate links between girls' violent behavior, pubertal timing, and neighborhood characteristics. METHOD: A total of 501 Hispanic, black, and white adolescent girls and their parents were interviewed twice over a 3-year period (1995-1998). Violent behavior was assessed using the Self-Report of Offending Scale and pubertal timing was measured via menarche. This probability sample was drawn from Chicago. To characterize neighborhoods, neighborhood clusters were created. U.S. Census data were mapped onto each neighborhood cluster to represent levels of concentrated disadvantage, immigrant concentration, and residential mobility. The response rate was approximately 70%. RESULTS: More than 25% of girls engaged in violent behavior at the second interview. Controlling for demographic indicators, previous violence, and other psychological factors, no differences were found in violent behavior as a function of menarcheal timing or neighborhood characteristics. Instead, results revealed that early maturers engaged in violent behavior only if they lived in neighborhoods characterized by high concentrated disadvantage. Early maturers in neighborhoods characterized by high concentrated disadvantaged engaged in three times the number of violent acts as early maturers in less disadvantaged neighborhoods. Depressive symptoms and previous violent behavior were also associated with girls' subsequent violent behavior. CONCLUSIONS: Results indicated that girls who experience a double vulnerability--early maturation and neighborhoods of disadvantage--are susceptible to engaging in violent behavior. This suggests the need for clinical evaluation to examine the implications of pubertal timing and the context of girls' behavior.     

Experiences of mental health services by people with intellectual disabilities from different ethnic groups: a Delphi consultation

Background Patient experience of those accessing mental health services has been found to be different between ethnic groups. Although the needs of people with intellectual disabilities (ID) from different ethnic communities are being increasingly recognised, little has been published about their experiences of mental health services. The aim of this study was to establish whether there are any differences in the experiences of people with ID and mental health problems from two ethnic communities in South London. Method A two‐round Delphi process was utilised. White British and Black or Black British service users from a specialist community‐based mental health service for adults with ID completed a specially compiled questionnaire. Statements on participants' experiences, including satisfaction with care, staff members' attitudes, cultural awareness and level of support, were rated using a Likert scale. Results Twenty‐four out of 32 participants (75%) completed both rounds of the Delphi consultation. Consensus (≥80% agreement with the group median) was reached for 20 items in the White group and five items in the Black group. All responses that reached consensus were positive about the services that were being received. The Black group were less positive about a range of their experiences, including the use of medication. Conclusions People with ID from two ethnic groups were able to successfully complete a Delphi consultation regarding their experiences of mental health services. Broad consensus on positive experiences of services was reached in the White group but not for the Black participants.