The purpose of this study was to evaluate and access the challenges facing mental health consumers to retain or rebuild a meaningful and valued life. The study was based on looking at mental health statistics, examining current trends in mental health services, treatments, pharmacology, and dual diagnosis management, and rehabilitation, vocational, educational, and transitional services.
This paper is based partially on a report that came out of an invigorating collaboration between Surgeon General David Satcher, M.D., Ph.D., Substance Abuse and Mental Health Services Administration (SAMHSA), and (NIMH) who strive to improve the availability, accessibility, and quality of mental health services and support; conducting research on mental illness and mental health.
This thesis gives my understanding of what this challenge involves, how this can be facilitated by supports within society at large, while evaluating the current policies and service provisions that are available. By exemplifying the current non-governmental organizations (NGO) that are already in place, I then give a synopsis of what agencies/services and resources would be required to necessitate rebuilding a meaningful and valued life for mental health patients.
One in four Americans; people of all ages, races, incomes and social stratus will suffer from some form of mental illness in their lifetime. During the course of a year, more than 54 million Americans are affected by one or more mental disorder. (NMHA Tellioglu, 2009) An estimated 22.1 percent of Americans ages 18 and older suffer from a diagnosable mental disorder in a given year (NIMH, 1998) while an astonishing 5.4 percent of adults have severe mental illness. (Surgeon General, 1997). The number of people in Ireland admitted to psychiatric hospitals has dropped by 28% since 1997 with an increase in people treated in community psychiatric facilitiesââ‚¬"numbering 20,000 - 30,000 a year. (Irishhealth.com, 2009) Such statistics only begin to capture the level of pain and disruption in individuals, families, and communities for which mental illness is responsible.
What is the definition of mental illness? According to the criteria in the American Psychiatric Association's Diagnostic and Statistical Manual of mental disorders (DSM-IV) it is a diagnosable illness that results in functional impairment that substantially interferes with or limits one or more major life activities. Some diagnoses are considered more severe such as schizophrenia, bipolar disorder, and major depression. Disability refers to the degree of limitation an illness imposes on the ability to function in life areas, such as relationships, work, independent living, and managing finances and medical care. People with mental disorders used to be thought of as a detriment to society and were removed from the community; kept in institutions and psychiatric hospitals.
Patients were heavily sedated, given electroshock therapy, forgotten by professionals and family, and their condition further deteriorated, giving little or no hope of recovery.
More recent research on long term recovery of individuals with mental illness shows a much better prognosis. Seven major retrospective studies done in Germany, Switzerland, Japan, and the U.S. show recovery rates of 46 - 68% for those with severe forms of mental illness without being institutionalized. (Harding, Zahniser, Zubin and Strauss 1984-1987)
Recovery is defined as people with mental illness regaining the ability to work, live independently, maintain meaningful relationships, and contribute to their communities in a variety of ways. (Continuum, 1997)
Neuropsychiatric disorders are the second greatest cause of burden of disease after cardiovascular disease, accounting for 40 percent of chronic disease. Serious mental illness can be fatal with suicide as the cause of death among adults second only to traffic accidents. "More than 90% of people who kill themselves have a diagnosable mental disorder," (Baylor study, 2009) although not all with mental disorders will necessarily commit suicide; but the pain, hopelessness, and disordered thinking can lead to suicide and the impact is immeasurable.
Our nation's physical healthââ‚¬"as a wholeââ‚¬"has never been better. Cancer and HIV/AIDS once termed as terminal are increasingly distinguished as treatable, survivable, and curable ailments. Medical research proves the inextricably intertwined relationship between mental health, physical health and well-being. (David Satcher, 1999) Fortunately, leaders in mental health, intensely devoted advocates, scientists, government officials, and consumers have been insistent that mental health flow in the mainstream of health. With the progress the medical profession has made with disorders of the mind such as dementia and Alzheimer's there has also been improvement in understanding mental illness. Dementia is a loss of cognitive function with an inability to think, learn, or perceive due to changes in the brain caused by trauma or disease with blood vessel disease due to illnesses such as diabetes and hypertension as the biggest risk factors. If the illness/illnesses are treated the dementia can be reversed. Dementia is caused by a condition whereas Alzheimer's is a particular physical condition. Some of the early signs of Alzheimer's and dementia can include depression. Many medical problems mask as, co-occur with, or exacerbate psychiatric crises. Any patient exhibiting psychiatric symptoms needs a medical evaluation since physical illness can masquerade as mental illness. What many people fail to understand is that dementia, Alzheimer's, diabetes, and mental illness are all diseases that a person has no control over.
The primary contribution of modern-day mental health research is the degree to which it's mended the destructive split between "mental" and "physical" health. Researchers recognize the brain is the integrator of thought, emotion, behavior, and physical health. Yet, despite research and unprecedented knowledge about the brain and human behavior, mental health is often disregarded and ailments of the mind remain masked in ignorance and misunderstanding.
The challenges involved with retaining or rebuilding a meaningful and valued life for persons with mental illness are innumerable.
The closing of mental health institutions, psychiatric wards, community mental health centers, residential facilities and diversion programs has reflected a trend for the entire nation stemming partly from the government's policy of treating the mentally ill in the community, rather than in institutions. (Independent News & Media. 1997) Since 1970, 90 percent of public psychiatric hospitals have closed; available beds in NHS psychiatric wards alone dropped by 50,000 since 1980. (Sheriff, 2007)
Even when there are adequate mental health facilities patients need to have medication and continual therapy to retain stability. With the closing of mental health systems clients will need additional support in finding a way to continue their treatment regimens. This is especially true for those with bi-polar and schizophrenic disorders who need to be monitored for treatment compliance.
With a devastating loss of mental-health services throughout the world, individuals have relapsed, scores of patients have been forced to reside in local nursing homes, become homeless, or end up in correction systems. In 1996, E. Fuller Torrey, prominent psychiatrist/mental health advocate, stated, "Quietly but steadily jails and prisons are replacing public mental hospitals as the primary purveyors of public psychiatric services for individuals with serious mental illness in the U.S." With federal funding cuts agencies who could offer services spend more time worrying about who is going to pay for what, rather than how to prevent relapse or suicide. With an inadequate supply of mental health services and providers there is a presence in society of "at risk" people manifesting mental disorders leading to destabilizing conditions that affect society as a whole. Alcohol and illicit drug use is associated with violence, criminality, antisocial behaviors and the inability to develop into productive citizens of countries and communities. With the lack of mental health dual diagnosis treatment, patients often develop behavior that places them into the legal system; jailed or imprisoned, causing an interruption in their treatment that can lead to radical decline in functioning. Detective Tony Morales, Phoenix Police Department says, "...all our officers have to be part-time psychiatrists." Gabe Morgan, Sheriff of Newport News, Virginia says, "Acute care for the mentally ill was once provided by psychiatric hospitals but many who are severely ill are living in our communities, where the burden of managing symptomatic and psychotic behaviors often falls on law enforcement.... Jails were never intended to be treatment facilities but they are replacing psychiatric hospitals." Markowitz, Northern Illinois University reports results of an influential study on how psychiatric hospital capacity impacts crime rates. Data from 81 cities around the country showed communities with greater access to psychiatric beds have lower rates of arrests and crime. (Sheriff, 2007)
While troubled individuals are more likely to seek help from their physician than a psychiatrist, (Kiesler, 1980) countless physicians are not trained to deal with mental problems nor willing to spend time listening to anything other than physical symptoms. (Eisenberg, 1977; Engel, 1977; Knowles, 1977; Reiser, 1981).
Another challenge is that emergency rooms are becoming the most utilized form of care for those in crisis because mental health service providers are unavailable after hours and on weekends and the ER is not allowed to turn people away. Badly equipped to handle respite/mental health care patients become unnecessarily hospitalized or are medicated until they can see a psychiatrist if available.
Mental health consumers who find adequate in-patient treatment often face a void when trying to bridge the gap between relapse or hospitalization and living life in the community. In their quest to achieve recovery, they find little or no intermediate services available. While pharmacotherapy can treat the symptoms of mental illness when taken as directed it cannot restore a sense of value of self nor lift the burden carried by the patient. With no way to progress through rehabilitative therapies and develop coping and life skills a person who has been hospitalized, imprisoned or institutionalized will have little hope reintegrating into society and their mental health will only decline. Often, the result is the revolving door phenomenon with a cycle of deterioration, relapse and re-hospitalization or being arrested for petty crimes, released and arrested again. (Psychiatric Services, November, 2003)
Another very real and insidious challenge is the impact of stigma, shame, and isolation associated with mental illness constituting a major barrier against seeking treatment. The graphic portrayal of those labeled with a mental diagnosis confronts the patient living with a serious mental illness to try to navigate beyond the arduous challenges presented by the illness itself. Strides have been made against stigma, yet too frequently mental health is spoken of in whispers and shame. Stigma and an unwarranted sense of hopelessness for recovery from mental illness have erected barriers. These barriers have made their way into churches where those with severe mental illness have turned to seek assistance from their local pastor. Some well meaning Christians throw bible verses or phrases such as "if you had enough faith" or "just give it to God" in an effort to solve the problem by fixing the person with mental illness because of their lack of knowledge or understanding. The mentally ill may get support for awhile with prayers, talks on faith, loving and trusting God, but if the person is not progressing as they had hoped then any interest in helping may wane. Serious roadblocks arise when those with mental illness try to find encouragement from their church and get no support or try to talk to their therapist about their faith or religious beliefs and he/she responds in a negative or unsupportive way when hearing about God. Having a relationship with Jesus Christ can give great comfort and hope and provides strength for working through spiritual issues which is an essential part of healing and rehabilitation. God works through people who are willing to help a person to rebuild their life. If a church fails to give support many mental health consumers then make serial connections with church after church trying to find respite and may stop going to church and even worse; turn away from God. "Those whose mental illness is dismissed by clergy are not only being told they don't have a mental illness; they're also being told they need to stop taking their medication which can be a very dangerous thing." (Baylor, 2008) The unique internal pain of those who have a serious mental illness is only exacerbated when a pastor or members of a congregation fail to understand their condition, or even resents them or their illness because they are unable or unwilling to accept them like Jesus would. Support is essential for recovery of mental illness. Where does a person go when there is little or no treatment available, nor support from family, friends, church or therapists? People who seek God find what they need in time of hardship. Individuals can find support on the internet from mental health forums, blogs and websites. Too many other people that have no answer have given up and have died needlessly.
Formidable financial barriers impede needed mental health care from too many people both those with adequate health insurance or one of the 44 million Americans who lack health insurance. If they do not have medical insurance or have other financial problems it can be difficult for the mentally ill to obtain medical care, counseling or medication. Even if they do have medical insurance, many insurance policies either do not cover the cost of treatment for mental illnesses or they only allow a minimum of 12 - 30 sessions of counseling a year, depending on the insurance policy. Unlike some physical diseases which may be cured with antibiotics or surgery, mental illnesses may need consistent management. For example, there is no cure for schizophrenia. Without continual treatment, these clients decline and may become homeless or worse. For those mental disorders that can be resolved such as post traumatic stress disorder, 12 sessions are not sufficient. It is not feasible to expect a veteran who has been in active combat for 3 years to heal in three months or a woman who has been abused for most of her life to recover with so few therapy sessions a year. Patients need consistent ongoing treatment without their progress being impeded by financial and insurance restrictions. Some insurance companies have made exceptions through managed care to trade inpatient days for outpatient days to accommodate the patient needing more therapy and psychiatric sessions but this is usually limited to amending the policy for one year at the most.
There is substantial research indicating that the majority of the chronically mentally ill can function outside of institutional settings where mental health services are available. A number of community support services were positively evaluated showing evidence patients can be effectively maintained in non-institutional community placement. (Kiesler, 1982) A wide range of non-governmental organizations and community support interventions vary across a spectrum from crisis clinics designed to prevent rehospitalization (Formenhaft, Kaplan, & Langsley, 1969) to small self governing communities (Fairweather, 1980) such as mental health drop in centers and psychosocial clubhouses. (Taber, 1980)
Primary health care physicians that are able to identify common mental disorders are facilitating and advocating support and treatment for mental health consumers, providing basic medication and psychotherapeutic interventions, while referring complex cases to community mental health services.
Other provisions include 24 hour crisis hotlines offering support and encouragement; helping move the person from a state of crisis/feeling suicidal to empowering them to develop and rely on coping skills.
In many countries, community mental health teams provide home-based crisis intervention services through 24 hour mobile outreach, assisting in stabilization, visiting people, helping consumers at high risk for hospitalization; providing one-on-one intensive case management, rehabilitation, and follow up.
In many countries hospital diversion programs redirect people in crisis to community-based facilities such as mental health crisis shelters, family based crisis homes, apartments with in home-like milieu, or hostels as alternatives to hospitalization helping hundreds of people each year stay in the community and avoid the expense, stigma and trauma of hospitalization. Many provide the same recovery model as psychiatric inpatient treatment facilities and have found with proper support, compassion, understanding, professional mental health, and peer counseling the need for hospitalization is diminished or greatly reduced.
Some hospitals have dispositional care, an alternative to hospital stays, adjacent to the ER to facilitate a short stay with discharge as the goal, offering short term acute treatment for psychiatric and substance abuse issues. Outpatient day-treatment is available in a highly structured environment and offer support services upon discharge. A study shows that 80% were successfully diverted from the hospital at considerable savings. Treatment was comparable to those admitted to psychiatric hospitals.
Vocational/rehabilitation services help mental health consumers attain independent living skills necessary to move into or remain in more independent level of housing within the community. These programs teach skills such as cooking, nutrition, personal grooming, using public transportation, job skills, budgeting money, health and dental care and assistance achieving a job and/or academic education. While the goal is to stay out of crisis and prevent hospitalization these programs are primarily designed to help consumers reenter society and/or achieve a full community life. Clients take responsibility for their care with moderate support from community-based case managers who make weekly in-home visits to monitor progress and provide assistance.
These particular models vary from country to country depending on various factors including the sociocultural context, how health services are organized and the availability of financial and human resources.
For success, psychiatric treatment and rehabilitation needs to have integrated, seamless approaches aimed at restoring persons with major mental disorders to their best possible level of functioning and quality of life. How can this be facilitated by supports within society? Effective treatment of serious mental illness goes far beyond inpatient hospitalization and offers individuals the opportunity for community reintegration. (American Psychiatric Association, 2004) Inpatient treatment facilities would be available only for those with severe needs or those at risk to themselves or others. Hospitalization would be brief, minimally disruptive and rehabilitation services within the community could be seamlessly implemented as quickly as possible. (American Psychiatric Association, Kopelowicz and Liberman, 2003) Clients would move through a care continuum including psychiatric diagnosis and treatment, pharmacotherapy, dual diagnoses/addiction treatment, physical assessment, behavioral modification, neurocognitive science, 12-step recovery programs, employment, housing, criminal justice, education, and relapse prevention. Rehabilitation would include teaching life and coping skills, managing symptoms, dealing with memory, decision making, problem solving, and management of anger and stress. Community based programs would include residential services, crisis intervention, hospital diversion and relapse preventative resources, mental health research, and other service providers designed to reintegrate the mentally ill into society. Patients would be educated about their illness to grasp management and proper use of psychiatric medications. The perfect model would include guaranteed access to necessary medicines for people with mental health problems at a cost that the health care system and the individual can afford in order to achieve appropriate prescription and use of these medicines. Having an adequate number of psychiatrists and counselors for outpatient treatment in areas that formerly had only a few or none is essential.
There is a need to improve coordination between health care providers and governmental and private mental service providers along with community based programs for the mentally ill to advance and improve the referral system and evaluate if the needs of mental health consumers are being met.
The government could support mental health consumers by creating laws that restrict discrimination of treatment among insurance providers. Mental illness needs to be viewed as equal to other form of physical disabilities. Mental illness is not a lack of willpower. Medication for depression is just as vital as insulin is for the diabetic. The threat of suicide for mental illness is as dangerous as a heart attack is for heart disease.
Promoting good mental health for people of all countries will require scientific know-how but, even more importantly, a societal resolve that we will make the needed investment; not for budgets but for each of us to educate ourselves and others about mental health/illness, and to confront the attitudes, fear, and misunderstanding that remain as barriers before us. (David Satcher, M.D., Ph.D., Surgeon General)
To remove the stigma and secrecy surrounding mental illness families, churches and others who once offered no support need to sustain those who suffer in shame.
There is still a long way to go with reintegrating and rebuilding the lives of those with mental illness. I have learned however that mental health consumers grow emotionally during this process we call recovery through enhanced self esteem, meaningful work, connections to others, a sense of hope and empowerment. They grow physically through increased fitness, improved diet and nutrition, and better health care. They grow intellectually through a better understanding of their disability, effective coping mechanisms, and the development and implementation of personal goals. They grow spiritually through pastors and churches that are willing to offer support, understanding and biblical counseling. It is through our connections with people who are experiencing mental illnesses that we will continue to learn and to grow in our knowledge about mental illness and recovery and have some of the best, richest relationships we could possibly have.
In conclusion, the World Health Organization predicts that in the next 20 years more people will be affected by depression than any other cause of ill health worldwide. With this knowledge I would like to challenge the world, our nation, our countries, our cities, our communities, both physical and mental health care models, researchers, our employers, and our citizens to take action to collaborate with mental health consumers. There is no health without mental health and mental health is fundamental to quality of life and to the most creative and productive life that people can live. (Indian Journal, 2006)
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