1. Community Mental Health
Chapter 11
Community Mental Health

2. Chapter Objectives (1 of 2)
After studying this chapter, you will be able to:
Define mental health and mental disorders, and explain the prevalence of mental disorders in the United States.
Explain what the DSM-5 is, and give an example of its limitations.
Give an example of how cultural differences can impact the diagnosis of mental disorder.
Cite specific examples of the causes of mental disorders.
Define stress and explain its relationship to physical and mental health.
Briefly trace the history of mental health care in America, highlighting the major changes both before and after World War II.
Define the term deinstitutionalization and list and discuss the forces that brought it about.
Describe community mental health centers as alternatives to state psychiatric hospitals.
Identify the major problems faced by people with mental illness who are homeless.
Describe some legal and practical issues affecting how society should deal with the problem of mental illness and violence.

3. Chapter Objectives (2 of 2)
Describe mental health courts, outpatient commitment, and the use of “legal leverage” to compel treatment.
Describe the challenges facing law enforcement personnel when dealing with community residents who are struggling with acute symptoms of severe mental illness.
Define primary, secondary, and tertiary prevention as they relate to mental disorders, and give an example of each.
List and briefly describe the basic approaches to treating mental disorders.
Define self-help groups, give examples, and explain how they are helpful to their members.
Describe what “recovery” means for people with mental illness in the U.S., and for those in less developed countries such as India or Tanzania.
Explain what is meant by psychiatric rehabilitation and list the kinds of services provided by effective programs.
Identify key clinical, multicultural, practical, and political challenges faced by the community mental health care system today.
Explain the federal government’s role in supporting healthcare services to people with mental illness with respect to “parity” in insurance coverage, the Affordable Care Act, and integrative care.

4. Introduction (1 of 2)
Mental illness – leading cause of disability in North America and Europe
~20% of American adults have diagnosable mental disorders during a given year
Only 38% receive treatment
Needs of people with mental illnesses diverse
Services required to meet needs include therapeutic and social services

5. Introduction (2 of 2)
President's New Freedom Commission on Mental Health (2003). Achieving the Promise: Transforming Mental Health Care in America. Rockville, MD: Author, 20.
Causes of disability for all ages combined: United States, Canada, and Western Europe, 2000.

6. Definitions Mental health Mental illness Mental disorders
Emotional and social well-being
Mental illness
All diagnosable mental disorders
Mental disorders
Health conditions characterized by alterations in thinking, mood, or behavior associated with distress and/or impaired functioning

7. Good Mental Health Adults with good mental health are able to:
Function under adversity
Change or adapt to changes around them
Maintain control over their tension and anxiety
Find more satisfaction in giving than receiving
Show consideration for others
Curb hate and guilt
Love others

8. Classification of Mental Disorders
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5)
Published by American Psychiatric Association
Most influential book in mental health
Classifies disorders based on behavioral signs and symptoms rather than definitive tests or measurements of brain or another body system
Challenges to diagnosis include comorbidity and lack of cultural competence

9. Causes of Mental Disorders
Symptoms can arise from various causes:
Poor prenatal care, postnatal environment, genetics, environmental factors, brain function impairment, substance abuse, maladaptive family functioning, stress
PTSD

10. Stress: A Contemporary Mental Health Problem
Stress – one’s psychological and physiological response to stressors
Stressors
General adaptation syndrome
Fight or flight reaction
Diseases of adaptation
Experts recommend combination of physical, social, environmental, and psychological approaches to managing stress
Courtesy of Cpl. Brian Reimers/U.S. Marines

11. Suicide and Substance Abuse
Led to an unexpected rise in death rates among middle-aged white Americans between 1999 and 2014
Prevalence of alcohol and other drug abuse a social indicator of mental illness problems

12. History of Mental Health Care in the United States
Response to mental illness characterized by periods of enthusiastic reform followed by periods of widespread ambivalence

13. Mental Health Care before World War II
Colonial America – people with mental illness cared for by families or private caretakers
Institutionalization first appeared in 18th century
Population growth led to institution growth
Harsh treatments and unpleasant conditions

14. The Moral Treatment Era
Began in 1792
Belief that environmental changes can affect the mind and alter behavior
Move people from settings causing life stressors into rural, peaceful setting
Appeared to have success and became widely acceptable
Overcrowding due to population growth

15. The State Hospitals (1 of 2)
Supposed to provide therapeutic environment, based on close personal relationships between patients and well-trained staff
Deterioration of services occurred as chronic nature of mental illness was discovered; long-term or lifetime stays were the norm
Maximum capacities quickly reached; personalized care lost; restraints became more practical; staff turnover high

16. The State Hospitals (2 of 2)
1940, population in state mental institutions was nearly a half million
Staff case loads so large, only subsistence care possible
Electroconvulsive Therapy (ECT) introduced in response
Lobotomies practiced
Appearance of new medications in 1950s made widespread use unnecessary

17. Mental Health Care after World War II
National Institute of Mental Health (NIMH) established
To foster and aid research related to cause, diagnosis, and treatment of neuropsychiatric disorders
To provide training and award fellowships and grants for work in mental health
To aid states in the prevention, diagnosis, and treatment of neuropsychiatric disorders

18. Deinstitutionalization
Deinstitutionalization – discharging of thousands of patients from state mental hospitals
Propelled by economics, idealism, legal considerations, and antipsychotic drugs

19. Community Mental Health Centers
Mental Retardation Facilities and Community Mental Health Centers Act
Community mental health centers – fully staffed centers originally funded by the federal government providing comprehensive mental health services to local populations
Five core services
Problem of transinstitutionalization
Community Support Program

20. Mental Health Care Concerns in the United States Today
Experiences of people with serious mental illness have improved significantly in past 50 years
Challenges remain:
How to provide services to the homeless
Changing perception that mental illness is linked to extreme violence
Resolving problems of those with mental illness who are incarcerated

21. Homelessness
2.1 million adults experience homelessness over the course of a year
80% temporarily homeless, 10% episodically homeless, 10% chronically homeless
About half of all homeless adults have substance use disorders, major depression, and other co-occurring mental illness
Successful interventions include provision of housing and services they need

22. Mental Illness and Violence
Extreme violence relatively rare in people with mental disorders
Much of risk attributable to comorbid factors
What should be done to prevent violence is unclear
Constitutional issues related to individual freedoms, privacy, and other rights

23. Mental Health Care in Jails and Prisons
Rates of serious mental illness in U.S. correctional facilities are three to four times the rates in the general population
Correctional facilities designed to confine and punish, not to treat disease
Lack of space, adequate number of qualified treatment personnel, and timely access to services
Once released back into community, more likely to commit crime if untreated

24. Prevention
Primary, secondary, and tertiary prevention applicable to mental disorders
Primary – reduces incidence of mental illness and related problems
Secondary – reduces prevalence by shortening duration of episodes
Tertiary – treatment and rehabilitation

25. Treatment Approaches Goals of treatment of mental disorders
Reduce symptoms
Improve personal and social functioning
Develop and strengthen coping skills
Promote behaviors that make a person’s life better

26. Psychopharmacology
Psychopharmacological therapy – treatment with medications
Conditions for which medications exist include schizophrenia, bipolar disorder, major depression, anxiety, panic disorder, and obsessive-compulsive disorder
Other biomedical therapy – ECT

27. Psychotherapy Psychotherapy – treatment through verbal communication
Numerous approaches
Cognitive-behavioral therapy
More likely to be successful in less severe cases or when used in conjunction with other approaches

28. Technology
Use of technology in treatment via telephone, video conferencing, Internet, , computer software
Benefits
Delivers flexible help directly to clients’ living environments
Lowers cost to patient
Increases privacy of patient
May reduce feelings of coerciveness

29. Self-Help Groups
Self-help groups –concerned members of the community who are united by a shared interest, concern, or deficit not shared by other members of the community
National Alliance on Mental Illness (NAMI)

30. Psychiatric Rehabilitation
Primary objective is most often recovery rather than cure
Psychiatric Rehabilitation – current recovery-oriented services
Services include medication, therapy, adaptive skills, changing environment through accommodations at work or school
Practices must be evidence-based

31. Challenges Facing Mental Health Care in the United States
Multiple services needed
Staff turnover relatively high
System is decentralized and fragmented
Lack of licensed providers in rural and low-income counties
Lack of cultural competence among providers

32. Government Policies and Mental Health Care
Following deinstitutionalization, government’s role in funding and policy became substantial
Medicaid
Mental Health Parity and Addiction Act of 2008
Parity – concept of equality in healthcare coverage for people with mental illness and those with other medical issues or injuries

33. The Affordable Care Act of 2010
Medicaid coverage for individuals with mental disorders grew
Individuals with mental disorders disproportionately benefit from coverage expansions
They tend to have lower incomes and are less likely to be insured
Communities may lack infrastructure to adequately meet needs of newly insured

34. Discussion Questions
How can community mental health centers work to reach 100% of their territory in need?
What role can schools play in supporting mental health in children and adolescents?