Question

What are some of the strengths and weaknesses of the current mental health system (if any)?

How have things changed since the beginning of the mental health system in the United States?

How would you improve the current mental health system?

Answer 1

Health is an end result of the interaction of a large number of factors like genetic potential, environmental (both physical and social), exposure to noxious agents, and receipt of personal health services.

Many health systems have traditionally adopted a view of mental disorders based on pathologies and the risk individuals have towards mental disorders. However, with this approach, mental disorders continue to cost billions a year for the healthcare system.

Among the other factors recognized as important to health are: good housing, safe transportation, clean air and water, noise abatement, economic conditions that provide adequate nutrition, clothing, and leisure; critical too, are legal and social systems in which human beings are able to interact with dignity and freedom, and-for children-the family and the educational environment.' Indeed, most recognize that changes in these factors may have contributed more to improvement of the health of children in the United States in the last half century than all the much heralded advancements in medical care of the same period.

Comprehensive health care can be defined as follows: complete, competent, continuous, coordinated, compassionate, and community-oriented. But the degree to which our children receive such comprehensive care, and its effectiveness, are not known, and we cannot prove that any one type of care results in improved health; there are few reported studies, and methods of evaluation are crude. The goals of health services include the elimination or reduction of death, disease, disability, dysfunction, discomfort, and dissatisfaction.

There has been too much concentration on mortality as the end point. The goal of health care has moved beyond mere survival (although too many infants still die in this country) to positive health, meaning optimal functioning. One of the major tasks of health services research is to develop more refined, reliable, and valid operational measures of the effects of health care and thus provide the basis for modifying care in the future.

Mental health services are the means by which effective interventions for mental health are delivered. The way these services are organized has an important bearing on their effectiveness and ultimately on whether they meet the aims and objectives of a mental health policy.

The various components of mental health services are categorized below:
I) Mental health services integrated into the general health system can be as broadly grouped as those in primary care and those in general hospitals. Mental health services in primary care include treatment services and preventive and promotional activities delivered by primary care professionals. Among them, for example, are services provided by general practitioners, nurses and other health staff based in primary care clinics. The provision of mental health care through primary care requires significant investment in training primary care professionals to detect and treat mental disorders. Such training should address the specific needs of different groups of primary care professionals such as doctors, nurses and community health workers. Furthermore, primary care staff should have the time to conduct mental health interventions. It may be necessary to increase the number of general health care staff if an additional mental health care component is to be provided through primary care.

II) Community mental health services can be categorized as formal and informal. Formal community mental health services include community-based rehabilitation services, hospital diversion programmes, mobile crisis teams, therapeutic and residential supervised services, home help and support services, and community-based services for special populations such as trauma victims, children, adolescents and the elderly. Community mental health services are not based in hospital settings but need close working links with general hospitals and mental hospitals. They work best if closely linked with primary care services and informal care providers working in the community. These services require some staff with a high level of skills and training, although many functions can be delivered by general health workers with some training in mental health. In many developing countries, highly skilled personnel of this kind are not readily available and this restricts the availability of such services to a small minority of people.

III) Institutional mental health services include specialist institutional services and mental hospitals. A key feature of these services is the independent stand-alone service style, although they may have some links with the rest of the health care system.

The history of mental illness in the United States is a good representation of the ways in which trends in psychiatry and cultural understanding of mental illness influence national policy and attitudes towards mental health. The U.S. is considered to have a relatively progressive mental health care system.

For much of history, the mentally ill have been treated very poorly. It was believed that mental illness was caused by demonic possession, witchcraft, or an angry god. If someone was considered to be possessed, there were several forms of treatment to release spirits from the individual. The most common treatment was exorcism, often conducted by priests or other religious figures: Incantations and prayers were said over the person’s body, and she may have been given some medicinal drinks. Another form of treatment for extreme cases of mental illness was trephining: A small hole was made in the afflicted individual’s skull to release spirits from the body. Most people treated in this manner died. In addition to exorcism and trephining, other practices involved execution or imprisonment of people with psychological disorders. Still others were left to be homeless beggars. Generally speaking, most people who exhibited strange behaviors were greatly misunderstood and treated cruelly. The prevailing theory of psychopathology in earlier history was the idea that mental illness was the result of demonic possession by either an evil spirit or an evil god because early beliefs incorrectly attributed all unexplainable phenomena to deities deemed either good or evil. These people were considered to be witches and were tried and condemned by courts—they were often burned at the stake. Worldwide, it is estimated that tens of thousands of mentally ill people were killed after being accused of being witches or under the influence of witchcraft. Asylums were the first institutions created for the specific purpose of housing people with psychological disorders, but the focus was ostracizing them from society rather than treating their disorders. Often these people were kept in windowless dungeons, beaten, chained to their beds, and had little to no contact with caregivers. Despite reformers’ efforts, however, a typical asylum was filthy, offered very little treatment, and often kept people for decades.

Today, there are community mental health centers across the nation. They are located in neighborhoods near the homes of clients, and they provide large numbers of people with mental health services of various kinds and for many kinds of problems. Unfortunately, part of what occurred with deinstitutionalization was that those released from institutions were supposed to go to newly created centers, but the system was not set up effectively. Centers were underfunded, staff was not trained to handle severe illnesses such as schizophrenia, there was high staff burnout, and no provision was made for the other services people needed, such as housing, food, and job training. Without these supports, those people released under deinstitutionalization often ended up homeless. Even today, a large portion of the homeless population is considered to be mentally ill.

Today, instead of asylums, there are psychiatric hospitals run by state governments and local community hospitals focused on short-term care. In all types of hospitals, the emphasis is on short-term stays, with the average length of stay being less than two weeks and often only several days. This is partly due to the very high cost of psychiatric hospitalization, which can be about $800 to $1000 per night. Therefore, insurance coverage often limits the length of time a person can be hospitalized for treatment. Usually individuals are hospitalized only if they are an imminent threat to themselves or others. Most people suffering from mental illnesses are not hospitalized. If someone is feeling very depressed, complains of hearing voices, or feels anxious all the time, he or she might seek psychological treatment. A friend, spouse, or parent might refer someone for treatment. The individual might go see his primary care physician first and then be referred to a mental health practitioner. Some people seek treatment because they are involved with the state’s child protective services—that is, their children have been removed from their care due to abuse or neglect. The parents might be referred to psychiatric or substance abuse facilities and the children would likely receive treatment for trauma. If the parents are interested in and capable of becoming better parents, the goal of treatment might be family reunification. For other children whose parents are unable to change—for example, the parent or parents who are heavily addicted to drugs and refuse to enter treatment—the goal of therapy might be to help the children adjust to foster care and/or adoption.

Some people seek therapy because the criminal justice system referred them or required them to go. For some individuals, for example, attending weekly counseling sessions might be a condition of parole. If an individual is mandated to attend therapy, she is seeking services involuntarily. Involuntary treatment refers to therapy that is not the individual’s choice. Other individuals might voluntarily seek treatment. Voluntary treatment means the person chooses to attend therapy to obtain relief from symptoms. Psychological treatment can occur in a variety of places. An individual might go to a community mental health center or a practitioner in private or community practice. A child might see a school counselor, school psychologist, or school social worker. An incarcerated person might receive group therapy in prison. There are many different types of treatment providers, and licensing requirements vary from state to state. Besides psychologists and psychiatrists, there are clinical social workers, marriage and family therapists, and trained religious personnel who also perform counseling and therapy.

It was once believed that people with psychological disorders, or those exhibiting strange behavior, were possessed by demons. These people were forced to take part in exorcisms, were imprisoned, or executed. Later, asylums were built to house the mentally ill, but the patients received little to no treatment, and many of the methods used were cruel. Philippe Pinel and Dorothea Dix argued for more humane treatment of people with psychological disorders. In the mid-1960s, the deinstitutionalization movement gained support and asylums were closed, enabling people with mental illness to return home and receive treatment in their own communities. Some did go to their family homes, but many became homeless due to a lack of resources and support mechanisms.

Today, instead of asylums, there are psychiatric hospitals run by state governments and local community hospitals, with the emphasis on short-term stays. However, most people suffering from mental illness are not hospitalized. A person suffering symptoms could speak with a primary care physician, who most likely would refer him to someone who specializes in therapy. The person can receive outpatient mental health services from a variety of sources, including psychologists, psychiatrists, marriage and family therapists, school counselors, clinical social workers, and religious personnel. These therapy sessions would be covered through insurance, government funds, or private (self) pay.