Social Work and Global Mental Health

Research and Practice Perspectives

Serge Dumont, Myreille St-Onge

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781317993834
• Edition: 1
• Topic: Medicine
• Subtopic: Health Care Delivery

This book presents respected experts, researchers, and clinicians providing the latest developments in social work knowledge and research. It discusses the latest in mental health research, information on violence, trauma and resilience, and social policies. Different mental health and social work approaches from around the world are examined in detail, including holistic, ethnopsychiatric, and interventions that place emphasis on recovery, empowerment, and social inclusion. This superb selection of presentations—taken from the 4th International Conference on Social Work in Health and Mental Health held in Quebec, Canada in 2004—comprehensively examines the theme of how social work can contribute to the development of a world that values compassion and solidarity. The volume offers a unique opportunity for practitioners, researchers, and others in the field to explore respected experts' experiences and research which can spark further development of knowledge that can ultimately enrich humanity as a whole. This timely resource springs from the emerging tradition of the sharing of knowledge, an idea now deeply rooted in the international community of social workers in the areas of health and mental health. This volume is extensively referenced and includes figures and tables to clearly detail information.

This book is enlightening reading for practitioners, administrators, educators, researchers, and students of social work.

This book was published as a special issue of Social Work in Mental Health.

Section I: Mental Health Research in Social Work

Mental Health Services Research and Its Impact on Social Work Practice with Adults Who Have Severe Mental Illness

Phyllis Solomon, PhD

Mental health services research formally was established in 1956 with amendments to the U.S. National Mental Health Act (NIMH, 1991). The roots of the research domain are in investigations that examined the public psychiatric hospitalization, from admission to care within the facility, and finally, to discharge (Hohmann, 1999; Mechanic, 1989). As the nature of care for adults with severe mental illness (SMI) has grown more complex, so too has the research. But the purpose of this research has remained steadfastly focused on ensuring the most effective care for those suffering from severe psychiatric disorders, with the ultimate goal of improving the quality of life of those affected by these disorders as well as their family caregivers (Hohmann, 1999). Consistent with this purpose the U.S. Department of Health and Human Services issued a plan in 1991 titled Caring for People with Severe Mental Disorders: A National Plan of Research to Improve Services. Two more recent reports assessing the status of care for persons with mental illness also issued by the U.S. federal government have called for research in this domain in order to transform the mental health system of care nationally, The President’s New Freedom Commission on Mental Health (2003) and Mental Health: A Report of the Surgeon General (1999). The Surgeon General’s Report noted the “importance of a solid research base for every mental health and mental illness intervention,” for “establishing mental health policy on the basis of good intentions alone can make bad situations worse” (p. viii). In this presentation we will examine what some of the accomplishments of this research domain have been and where it needs to go in the future.

The relevance of mental health services research is central to social workers in the U.S., because they are the most prevalent professional providers of mental health care, even more so than psychiatrists and psychologists. Although these mental health service positions may be case managers, family educators, or other service providers, these positions are often held by social workers, but may be filled by individuals trained in other professions as well. The significance of this research to social work will be demonstrated as this report: first, defines and delineates this research domain; second, discusses services and services research for adults with SMI from an historical perspective; and finally, suggests future research directions to ensure the most effective service provision for this very vulnerable population. I will use some of my own research to illustrate particular points.

Defining and Delineating Services Research

Services research investigations examine “a continuum of complexity” from service programs to organizations to mental health service delivery systems to the intersection of various systems with mental health such as social welfare and criminal justice (Hargreaves & Shumway, 1989). As in social work, services research deals with all levels of service intervention strategies, from macro, mezzo, and micro levels. The importance of this area of research was recognized by The U.S. Federal government in 1992 legislation that required the National Institutes of Mental Health, Drug Abuse, and Alcohol Abuse & Alcoholism to expend 15% of their budgets on health services research. This legislation included the following definition for health services research, “endeavors that study the impact of the organization, financing and management of health services on the quality, cost, access to and outcomes of care” (Federal Register, section 409, 1992).

The U.S. National Plan of 1991 previously referred to, further delineated mental health services research into two categories of research, Service Systems and Clinical Services Research. Service systems investigations focus on the macro and mezzo levels by examining organization, financing, administration, and integration of mental health services. This research focuses on service delivery systems and the organizations that comprise these systems. Clinical services research deals with the micro level by researching the process, quality of care, and effectiveness of services and programs (Attkisson et al., 1992; Steinwachs et al., 1992).

Historical Context of Services Research

With the process of deinstitutionalization, care was no longer confined to psychiatric institutions. Consequently, there was a growing recognition of the need for a diversity of supports and services for persons who were affected by this policy. By the late 1970s the U.S. National Institute of Mental Health had established the Community Support Program (CSP), which developed the Community Support System model of care that recognized that treatment in and of itself was insufficient and that an array of life supports and rehabilitation services was needed (Stroul, 1993).

Psychiatric rehabilitation—a central orientation of this model of care—refers to a diversity of psychosocial service interventions that are directed at changing the skills and/or environmental supports of adults with SMI (Flexer & Solomon, 1993). The practice of psychiatric rehabilitation is extremely consistent with social work practice in that the two intervention strategies employed are client skill development and environmental resource development (Anthony & Liberman, 1986). Like social work, psychiatric rehabilitation is very value-based in believing in client self-determination and empowerment and building on a client’s personal strengths by assisting the client in learning coping strategies to manage the symptoms of the illness and the deficits that result and in developing a supportive environment in which the client can function at his/her optimal level (Hughes, 1994; Sands & Solomon, 2001). Psychiatric rehabilitative service interventions include vocational, residential, social/recreational, educational, and case management (Rutman, 1994). Much of psychiatric rehabilitation was initially provided (from the late 40s to the late 70s) by psychosocial rehabilitation centers that were very much influenced by group work practitioners. Psychiatric rehabilitation evolved from the clubhouse programs (Mueser et al., 1997). Therefore, psychiatric rehabilitation has been closely aligned with the consumer self-help movement, as the first clubhouse program, Fountain House in New York City, was established by consumers (Mueser et al., 1997).

Justifying the Need for Psychiatric Rehabilitation for Discharged Psychiatric Patients

Psychiatric rehabilitation for persons with SMI has been central to much of my research. When I was deinstitutionalized along with the patients in 1974, this experience directed my research interest into the service system arena to determine the access and community service utilization of patients leaving the state psychiatric hospitals. The study that I designed based on the conceptualization of the Community Support System model tracked 600 patients for a period of one year, from their discharge from two psychiatric receiving hospitals through their experiences with the diversity of agencies that comprised the service delivery system. These service agencies included county welfare department, local bureau of vocational rehabilitation, social security office, community mental health centers, specialized community psychiatric programs (e.g., a psychosocial agency), a residential work program, and group residential facilities.

The study participants were patients who had numerous and lengthy hospitalizations, yet they received very little in terms of mental health services in the community. Almost three quarters made contact with agencies within the year or prior to readmission, but many received only about two hours of services a month. Further, most did not receive rehabilitative services, but rather medication management, some broker case management, and public financial assistance. Thus, we noted that the system was not geared to improving the level of social functioning of this client population. We recommended the need for a more creative and aggressive approach to vocational rehabilitation, increased use of psychosocial rehabilitation services, the need to address substance abuse problems, and to collaborate with families and consumers in responding to the needs of the population (Solomon, Gordon, & Davis, 1984a&b; 1983). The study findings foreshadowed much of what have been and continue to be the issues for the past two decades in serving this population. Interviewing in depth 60 randomly selected clients from the 600, we found that these clients had the same desires as the rest of us: they wanted a job, a home, and significant others in their lives.

In the closing paragraph of the book published on the study findings, we reported an incident that occurred at the time we were recruiting the study sample, which is quoted in the following:

A woman patient stood nearby as one of the research assistants attempted to secure consent from another patient for participation in the study. The bystander apparently did not want to be left out. With the sardonic, yet offbeat touch characteristics of many patients, she called out. “Don’t pass me over. If you polish me up, I might just be the Hope Diamond.” (Solomon et al., 1984a, p. 185)

The sense of hope for individuals with psychiatric disability and belief in their capabilities to grow and change has been a theme throughout much of my research. The one thing in the patient’s quote that today I would take issue with is providers not polishing her up, but working with her to acquire the skills and resources for her to polish herself up. The idea is to do with clients, not for clients, although it is too frequently easier to do for clients, rather than to teach. These are again seen in another study I undertook to assess the barriers to community placement of patients from an extended psychiatric care facility (Solomon, Beck, & Gordon, 1988a&b; Solomon & Gintoli, 1989). These themes are consistent with social work and psychiatric rehabilitation values and approach to service provision and demonstrate further the need for a rehabilitation orientation to servicing this client population (Solomon, 1986–87; Solomon, & Davis, 1986; Solomon, Davis, & Gordon, 1984a).

Demonstrating Further the Need for Rehabilitation: The Intersection of Mental Health and the Criminal Justice Systems

As deinstitutionalization progressed, adults with SMI were observed in other human service delivery systems, the homeless shelter system, the welfare system, and more recently in the child welfare system, and the criminal justice system. In response to this population being homeless and in the criminal justice system, in 1989 I designed a clinical service intervention study to assess the effectiveness of a program, entitled the Program for Assertive Community Treatment (PACT) developed for discharged psychiatric patients in Madison, Wisconsin and found to be an effective alternative to hospitalization (Stein and Test, 1980; 1985).

The study was a randomized trial in which adults with SMI leaving jail who were homeless were randomly assigned to one of three conditions: PACT, individual intensive forensic case managers (an existing service), or the usual community mental health system of care. PACT is a self-contained service program delivered by a team of providers, including a psychiatrist, a nurse, case managers, and other specialized providers contingent on the characteristics of target population. Staff to client ratios is very low, usually 1 to 10. The team provides intensive supports, skill teaching, and assistance with environmental supports. Given the nature of the PACT program, the study hypotheses were that those assigned to PACT team would have improved psychosocial functioning, clinical, and quality of life outcomes, including more stable housing, more support system members, and fewer interactions with the criminal justice system than either of the other two conditions, and further, the forensic individual case managers’ clients would have better outcomes than the usual system of care. We found that there were no differences among the three conditions with regard to any of these outcomes. However, although not statistically significant, there was a tendency for those receiving PACT to have a greater chance of being reincarcerated than the other two conditions. Overall 46% were reincarcerated at least once within the year of follow-up, with 60% of the PACT clients being reincarcerated, 40% of the intensive forensic case management, and 36% of those receiving usual care (Solomon & Draine, 1995a).

These findings required an explanation, as they were certainly of clinical significance. In further exploration we found that the PACT case managers were working very closely with the criminal justice system. Prior to the clients being released from jail, case managers would go with clients to court for their hearing and would request the judge to place specific stipulations on the clients remaining in the community, such as taking prescribed medication and keeping appointments with the case manager. If the client did not adhere to these stipulations, the case managers worked with the probation and parole officers to technically violate the client. Consequently, the client would be reincarcerated on a technical violation. We found that the PACT case managers were essentially monitoring the clients, they were an extra pair of eyes for probation and parole officers, and therefore, were more likely to observe any violations made by the clients (Solomon & Draine, 1995a).

Two lessons learned from the results of this study were: a lack of fidelity to an intervention can be detrimental for clients and that monitoring without also providing rehabilitation can produce negative consequences for clients. It also seemed that some clients might be returning to jail for treatment purposes, rather than because of criminal activity. The jail from which study participants were coming had a well-developed mental health program, a 65-bed acute inpatient psychiatric program, and an ambulatory psychiatric program. At same time the involuntary commitment procedure in the community imposed very restrictive criteria for hospital admission. Therefore, if clients were not adherent to their medication regime and as a consequence had an exacerbation of their illness, it was easier for case managers to obtain a technical violation of their stipulations with subsequent incarceration than to obtain admission to a psychiatric hospital.

This phenomenon led me to conduct another study that assessed the use of incarceration as a treatment alternative. This study was designed to assess the criminalization hypothesis, that individuals with mental illness enter the criminal justice system due to a lack of access to mental health treatment (Solomon, Draine, & Marcus, 2002). In order to accomplish this objective adults with SMI who were on probation and parole were followed from the point of intake in the psychiatric probation/parole units for 15 months or to reincarceration, whichever occurred first. The primary study focus was to examine the extent to which mental health treatment and adherence explained technical charges as opposed to new criminal charges. The idea was that mental health treatment would prevent the need for future use of jail for treatment purposes. The major findings were that the receipt of intensive case management was associated wi...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• Notes on Contributors
• Introduction
• Section I: Mental Health Research in Social Work
• Section 2: Violence, Trauma, and Resilience
• Section 3: Social Policy
• Index