In individuals insanity is rare, but in groups, parties, nations and epochs it is the rule.
—Friedrich Wilhelm Nietzsche, Beyond Good and Evil
Min, age 25, was of Chinese descent and lived in the United States. Not only was she convinced that her psychiatrists did not understand her illness, she was also convinced that they did not understand her Chinese values.
Min had drifted in and out of a large state hospital because of what her doctors called schizophrenia. Each time she entered the hospital, she was given medication that eased her symptoms, particularly her hallucinations and the imaginary voices talking to her. When medicated, Min would develop better contact with those around her, take better care of her daily needs, and then be released from the hospital to her family’s care. However, her parents worked hard to support the family, which included Min’s brother and sister. Her siblings were in school. Therefore, Min was alone much of the time. Because her family was not available to supervise her medications, she often forgot to take them. Eventually, she would become out of control, which would prompt the family to call the psychiatrist, who, after some pleading from the family for intervention, would tell them to return Min to the hospital.
Such was Min’s state. She would leave the hospital only to return. She would take her medication and be briefly liberated from her symptoms only to forget the medication later. She is one of the country’s chronically mentally ill who seem to be in desperate need of long-term, coordinated intervention but who are not necessarily receiving it.
This chapter examines the plight of Min and others like her. It will begin with some historical highlights and move to the issue of deinstitutionalizing the mentally ill. While examining deinstitutionalization, discussions focus on how to measure the success of moving individuals out of institutions as well as the common alternatives to institutionalization. Interestingly, many of the early alternatives have been tantamount to reinstitutionalization. Newer programs are coming into place. The question is whether they do what they have been intended to do. Can there be an effective tertiary prevention program, keeping patients out of institutions and reintegrating them successfully into the community? First, we examine the question of how many people are like Min, that is, how many people in our community have to contend with mental health disorders.
AFTER READING THIS CHAPTER, ONE SHOULD BE ABLE TO ANSWER THE FOLLOWING QUESTIONS
1. What is epidemiology? What do estimates of mental illness in the population tell us?
2. How might different models of mental illness focus us on different ways to intervene?
3. What is the historical and contemporary context to deinstitutionalization?
4. What are some alternatives to dealing with mental health following deinstitutionalization?
5. How does prevention play a role in dealing with mental health issues?
6. What are some research bases to the devising of prevention programs?
In the early 1980s, the National Institute of Mental Health (NIMH) surveyed the psychiatric status of more than 20,000 people in five cities. This study, known as the Epidemiologic Catchment Area (ECA) Study, attempted to estimate and describe the incidence and prevalence of psychiatric disorders meeting the criteria of the Diagnostic and Statistical Manual of Mental Disorders, 3rd edition (DSM-III). For example, in a comparison of three communities, Robins et al. (1984) estimated that the lifetime prevalence rate of a given DSM-III disorder was 28.8 percent, 38.8 percent, and 31.0 percent, respectively, in New Haven, Baltimore, and St. Louis. Note that there are variations in numbers, as we would expect different cities to have different characteristics. The researchers’ intention is to gather data from enough sites in the United States so as to get a representative sample of rates from across the nation and come to some estimate of problem rates in the United States as a whole. Findings suggest that men and women are equally likely to be afflicted with psychiatric disorders. This study leads us to estimates of one-year prevalence (having symptoms during the previous year) of anxiety disorders at 13 percent, of major depression at 6.5 percent, and schizophrenia at 1.3 percent. Nineteen percent of the sample is believed to have some psychiatric disorder. A second multiple-site study sponsored by NIMH in the 1990s provides estimates based on the DSM-III Revised, a different set of criteria (Kessler et al., 1994). This study is called the National Comorbidity Study (NCS). The one-year prevalence estimates for this study are: anxiety disorder 18.7 percent, major depression 10 percent, any psychiatric disorder 23.4 percent. Lifetime prevalence for having a psychiatric disorder is 50 percent. However, 17 percent of the population has multiple diagnoses (comorbid), and the most severe cases have the highest concentration of disturbances. A third estimate of mental health epidemiology was conducted in 2000–2002. This study is called the National Comorbidity Study, Replication (NCS-R), and is based on the Diagnostic Statistical Manual IV criteria for psychiatric disorders. Results using these criteria yield an anxiety disorder percentage of 18 percent for one-year prevalence, major depression prevalence of 6.7 percent, and any psychiatric disorder prevalence of 26.2 percent (Kessler, Chiu, Demler, & Walters, 2005). Again, a small proportion of the population has the worst symptomatology and multiple disorders. In both NCS reports, less than half of those with diagnosable disorders are in treatment.
Findings from the ECA, NCS, and NCS-R are consistent with the Midtown Manhattan Study, a longitudinal study investigating the prevalence of psychopathology from 1952 to 1960. Across several decades, from multiple sites, using a variety of measurement criteria, the findings seem consistent that mental health issues are a part of our communities. They are not a trivial part, because mental health issues should affect half of us sometime during our lifetime.
Also notably consistent over time, the most recent epidemiological study (Kessler et al., 2005) finds that the general practitioner M.D. has seen the highest rise in treatment demands. This is reminiscent of the findings by Gurin, Veroff, and Feld (1960), who found similar reports of medical doctors being the people most likely to be consulted regarding psychological problems.
In answer to these mental health needs, psychology has traditionally responded by providing individual-focused clinical psychological services. As you may recall, the effectiveness of these services was called into question by Eysenck’s (1952) meta-analytic study. Recent psychotherapy outcome studies showed significant positive effects based upon specific therapy techniques and good therapeutic relationships directed to the solution of particular problems (Lamert & Barley, 2001; Norcorss, & Lambert, 2018). But we digress. The basic argument against the clinical orientation is that it is an inefficient and reactive model of treatment of well-entrenched psychological symptoms. This was discussed in Chapter 1
. We elaborate on some of the treatment models here so as to better understand the traditional systems that are in place and the community applications that have, at times, evolved from them.
The standard and traditional model for care is the medical model. Based on the practice of medicine, the assumption is that the patient’s illness is based on internally based dysfunctions. The patient is a passive recipient of knowledge from the expert physician, who provides the answer to the patient’s problems. The patient obediently follows the advice and partakes of the medicine (a preparation or potion that will bring about a cure of the ailment or relief from the physical symptoms). The tradition has among its roots the Greek and Roman physicians who dealt with physical disorders. Both physical and mental health were the result of maintaining a balance. For the ancient Greek philosopher/physician Hippocrates, this was a balance among the four elements within us: phlegm, blood, black bile, and yellow bile. These traditions are believed to be traced to even older Egyptian and Mesopotamian beliefs.
Of course, modern medicine has come a long way from this elementary model. Yet, the procedures are similar in some ways. The patient presents a set of symptoms. These are problems with their physical functioning. Based on the presenting symptoms, there is a diagnosis of what is malfunctioning or out of balance. We might come to understand the etiology or origins and development of the disorder. Once the correct diagnosis is made, there is a prescription of the appropriate medicine or therapy to cure the problem. The next time you go to the doctor, note how the procedure works. He or she will ask what is troubling you, that is, the set of symptoms; then, based on the fit of symptoms to a set of criteria for the various illnesses, he or she will decide what is wrong. He or she will then make a set of recommendations for therapy (bed rest and fluids, or maybe decrease sugar or salt intake) and may provide a prescription of certain medicines to be taken in a particular pattern so as to alleviate symptoms (e.g. fever, chills, low energy), or strengthen the system (increase level of antibiotics in the body), or cure the illness (correct the imbalance). The patient chooses when to come to the doctor. This is most likely when the patient has experienced enough disorder to make him or her believe that help is needed. Most clinical psychologists use this medical model of investigation of symptoms, diagnosis, and prescription of treatment and therapy.
Given the strength of the biological, or medical, model, two authoritative references about mental illness (The Diagnostic and Statistical Manual of Mental Disorders [DSM] and the International Code of Diagnosis [ICD]) have been developed. The medical model leaves at least two important legacies in traditional psychology. One is the reliance on diagnostic labels, as found in the DSM and ICD. The other legacy is the assumption of authority and power by the professional over the patient. Both of these legacies are avoided by community psychologists.
For those of you who are psychology majors or have taken a course in abnormal, child, or personality psychology, Sigmund Freud (1856–1939) will be no stranger. Freud is the father of psychoanalysis. Although many people today disagree with his theories, it cannot be denied that Freud’s influence is felt in psychology as well as in psychiatry. Although Freud believed that biology played an important role in the development of psyches, he argued that most psychological disorders are treatable or curable with the use of free association or verbal therapy. Psychoanalytic treatment takes the form of individual verbal therapy up to five times a week over several years.
Somewhat later, the psychoanalytic approach began to split into two paths: traditional psychoanalytic individual verbal therapy versus biological psychiatry. A German contemporary of Freud, Adolf Meyer (1866–1950), argued for the importance of the interplay between biology, psychology, and environment, but many others preferred only biology as an explanation for mental disorders, after a strict biological-medical model. The traditional psychoanalytic individual verbal therapy model has consistently failed to show its effectiveness with the severely mentally ill (SMI) (Wilson, O’Leary, & Nathan, 1992).
Among the alternatives to Freud coming out of the early 20th century is Alfred Adler. He emphasized the individual’s concern about powerlessness, and the person’s goal of seeking fulfillment in his or her life. Toward this end, Adler’s work was directed at helping people gain this sense of empowerment over their situations. He is credited by some for the psychoeducational movement, which brought knowledge to the people so that they could use it for their lives.
His theory also included gemeinschaftsgefuhl, which translates into “community feeling” or what is typically called social interest. Social interest is the individual’s sense of connection to the people around him. If there is high social interest, the individual feels a part of his family, his neighborhood, his community. If there is low social interest, the individual feels alienated from people and will act in his or her own self-interest without regard to the consequences for others.
Adler theorizes that these social feelings and our feelings about ourselves are heavily influenced by childhood experiences, so his theory also focused on childhood education. The emphasis in the teacher-child relationship is on encouragement of the child and her or his curiosity about the world.
As is surely notable from this description, the emphasis is on developing a healthy individual. Pathology is averted through provision of positive social environments that both empower and set appro...