In Canada, the field of mental health has seen significant changes in a relatively short period of time. Although the field of mental health in Canada continues to evolve, this book is based on the view that it is worthwhile at this time in the early years of the twenty-first century to take stock of where we are and where we can be on the way. The perceived need for this book came from the author's impression that there was currently no single text available that addressed both clinical and structural aspects of mental health practice in the Canadian context.
Are there procedures and approaches used by mental health professionals that actually cause more harm. Is cost containment the overriding concern when determining what constitutes "best practice" in mental health? This book is based on the author's experiences as a case manager, administrator and researcher in a large, multisite community psychiatric health service.
This experience, along with an undergraduate education concentrated in the biological sciences, led to an appreciation for the role of medicine and psychiatry in improving the lot of persons with mental health problems. Also subject to interpretation are the terms that refer to the various players in the mental health system. A more contentious issue is how to refer to users, or recipients, of mental health services.
More recently, a number of mental health programs have replaced “client” with “consumer,” although the limitations of the former term appear to apply to the latter. However, given the length and breadth of the DSM, a more practical answer is to look at the eligibility criteria used by public mental health programs in Canada. The source used for this purpose in most mental health settings in Canada is, as noted, the American Psychiatric Association's Diagnostic and Statistical Manual.
While in theory all conditions described therein could be considered mental disorders – such as “caffeine intoxication,” for example – only a smaller number of them are considered eligible and appropriate for services in publicly funded community mental health programs. (Goodwin and Guze 1996). For these reasons, people with depression may not seek help from mental health professionals. Another group that has historically been underserved by public mental health centers in Canada are those suffering from anxiety disorders – such as agoraphobia, obsessive-compulsive disorder (OCD) and post-traumatic stress disorder (PTSD).
This raises the question: why are these approaches not regularly offered in public mental health centers? Unemployment and underemployment of mental health clients means that many of these individuals will live in poverty. Surveys have determined that people with mental health problems are overrepresented among homeless populations: about one in three.
Violence and Mental Disorder
Probably the most difficult aspect of the diagnosis of a mental disorder is the stigma that accompanies it – a “traumatic death sentence” in the words of a recipient of psychiatric services (Capponi et al. This was illustrated by a large-scale study conducted in Pennsylvania as part of the MacArthur Violence Risk Assessment Study, an ongoing multi-site project (Steadman et al. 1998).Researchers followed 1,136 patients discharged from psychiatric wards for one year and found that their risk of violence did not differ from baseline levels in the community, except among those identified as that they abuse drugs or alcohol.
The clinical challenge here concerns the finding that individuals with mental disorders are unfortunately more vulnerable to substance abuse than members of the general public (Regier et al. 1990).6. Fourth, violence by people with mental disorders is usually directed against intimates, especially family members, rather than strangers—the same pattern seen in the general public (Arboleda-Florez 1998; Estroff et al.). Finally, people with mental disorders are disproportionately victimized. itself, with one study finding that the 331 clients in the sample had experienced two and a half times the rate of violent victimization as the general population (Hiday et al. 1999).
Stigma is also one of the main reasons why people with mental health problems delay or avoid treatment (Arboleda-Florez 2003). For example, a study conducted in Israel found that 80 percent of patients referred to a psychiatrist by their primary care physician declined the referral because of the stigma associated with receiving psychiatric care (Ben Noun 1996). Even mental health professionals may be reluctant to disclose "in treatment" status: a survey of psychiatric residents in New York found that while 61 percent stated they would tell their supervisor they were in psychotherapy, only 4 percent said they would. reveal that they are taking antipsychotics (reported in Barkhimer 2003).
Among this group, those who said they needed treatment were asked why they did not seek it: the most common reasons were that they preferred to manage it themselves (31%), that they could not avoid it ( 19%), and that they were afraid to ask or were afraid of what others would think (18%) (subjects could choose more than one answer). The link between mental illness and violence is particularly strong in public perception, despite evidence to the contrary (see box). Respondents were asked how likely it was that the person described in the vignette would do something violent to others: a third (33%) indicated that violence was somewhat or very likely in the case of the depressed person, with the number of the person with schizophrenia was 61 per cent, although there was no violence in any of the vignettes (the numbers were somewhat higher for the drug user and the alcohol abuser and significantly lower for the "troubled person").
One of the most troubling accusations concerns the role that mental health professionals themselves may play in contributing to stigma. An example of the latter is the term "chronic", which was used in psychiatry as an adjective ("chronic mental illness", "chronic episodes") and, even worse, as a noun.
Changing Minds: Public Education
This term, while still in use, has been dropped from Canadian psychiatric training manuals, although there is always concern that replacement words such as "persistent" will eventually take on the same negative connotation (Lesage and Morissette 2002). A Canadian Mental Health Association publication (British Columbia Division 1999, 8) provides examples of other value-laden terms used by professionals, such as "low/high functioning", "inappropriate", "noncompliant" and "treatment resistant". ”. When dealing with a loaded term like "schizophrenia," therapists must sometimes walk a very fine line, on the one hand dealing with the need to demystify mental illness and be "up front" with the client about diagnosis and on the other page. on the other, concerns about how psychiatric brands are perceived by others, such as employers and landlords.
For example, while 59 percent of respondents in Stuart and Arboled-Florez's (2001) Alberta study identified the cause of schizophrenia as a "brain disease" or "other biological factor"—consistent with the. Another example of an anti-stigma intervention comes from Calgary, which aimed to “assess the extent to which print news coverage of schizophrenia and mental illness can be directly influenced by providing more accurate background information to reporters and helping them develop a more positive story” (Stuart 2003, 652). To this end, a senior editor was hired, newspaper staff were invited to anti-stigma events, and mental health service providers acted as liaisons and provided expert opinions.
Newspaper stories about mental illness were analyzed over an eight-month, pre-test baseline period and over a sixteen-month post-test period. It was found that while positive mental health stories increased in number (33%) and length (25%) over the post-test period, negative stories also increased in number (25%) and length (100%). In her comments on this and other studies, Arboleda-Florez suggests that broad or "generic" approaches to mental health, especially among already trained subjects, may not be as effective as targeting specific beliefs using "specifically focused interventions". among small groups such as high school students.
Regarding the genesis of erroneous beliefs, Link and colleagues note that people "develop beliefs about mental illness early in life from family histories, personal experiences, peer relationships, and media portrayals of people with mental illnesses." In terms of media, a relatively recent example that caused some controversy was the Jim Carrey film comedy Me, Myself and Irene (released in 2000), which featured a split-faced/personable Carrey along with the caption "from gentle to mental". ” on the billboard—resulting in legitimate protests from advocacy organizations (see also Wahl 1995). Göring, Wasylenki, and Durbin (2000) note that in Canada, when mental health issues are covered at all, the media tends to focus on negative issues such as homelessness and violence. Historically, advocacy groups such as the Canadian Mental Health Association and the Schizophrenia Society have taken on the role of public education.
2 Treatability may refer, at least indirectly, to legal criteria for involuntary hospitalization; in British Columbia, for example, the Mental Health Act states that people with mental disorders can be hospitalized against their will if they seek "treatment in or through a designated institution." 20 percent of major depressive disorder; 20 percent of panic and obsessive-compulsive disorders; 10 percent of social phobia (comorbid with avoidant personality disorder); and 10 percent substance abuse disorders (primarily drug addiction). The figures here apparently have an empirical basis, although the source is not given.
