Mental Health Promotion For People With Mental Illness

Reorienting Health Services

Mental health services can be seen on a continuum. On one end would be those that deal exclusively with the biological aspects of the illness. As a set of purely biological interventions, this component would tend to exist outside the parameters of mental health promotion. Examples of these kinds of services include monitoring and administration of medications and other medical treatments such as electro-convulsive therapy.

Towards the other end of the continuum are services that are more weighted to psychosocial approaches, where it is possible to orient the delivery of the service to health and recovery. These could include cognitive-behavioural therapy, "psychoeducation" (about the illness), and rehabilitation services that enhance recreation, employment, or housing. In this regard, mental health services are an important piece of the overall picture of mental health promotion. However, whether the focus is more biological or psychosocial, there are still ways to deliver services that are, or are not, mental health promoting. Service providers can take a mental health promotion approach to their task by focusing not just on problem solving for the client, but by reaching out and connecting the person to some of the resources, perhaps untapped, already existing in community, and by promoting the person's capacities, autonomy, and choice.

What Do Consumers Tell Us About Services?

Within the context of mental health programs within and outside institutional settings persons with mental illness have identified approaches that promote mental health:

• Information is shared with program participants.
• Participants have multiple options from which to make choices.
• Participants are encouraged to become experts in their own care.
• Success and failure are okay. Staff and participants embrace the concept of the dignity of risk and the right to failure.
• The emphasis is on growth rather than behaviour management.
• Peer support, self-help and mutual support are valued and encouraged.
• Staff provide support for participants' pain and anguish, their anger and fear. There is room to feel, and it is okay to feel bad.
• Staff are available to respond as human beings, as fully human, to participants.
• Staff have an attitude of hope and optimism not despair or pessimism.
• Staff use an individualized approach to working with participants. Programs are changed to fit people's needs -- participants are not asked to change to fit into the programs.
• People with psychiatric disabilities are part of the staff and serve as powerful role models to program participants.
• Participants have a voice and a vote in developing programs rules, policies and procedures.
• Participants are included in staff hiring and in annual performance evaluations for staff.
  (Canadian Mental Health Association, NS Division, 1996)

Conversely, consumers have a lot to tell us about service environments, within and outside the hospital, which reinforce dependence, compliance, and powerlessness. Unfortunately, even the mental health system itself can erode a patient's sense of self-worth. In the same study, the following negative service characteristics were listed:

• The "sick role" is the prescribed role. There is nothing meaningful to do. One becomes an "in-valid."
• Obedience is valued. Trial and error learning is seen as problematic and undesirable. A person with strong opinions that differ from staff opinions is said to be treatment resistant or non-compliant.
• Fear of punishment is used to coerce compliance and obedience.
• Basic rights are turned into privileges to be earned. Often, this results in people learning to protect themselves from loss by not wanting and not caring about anything. If you don't want anything, nothing can be taken from you.
• Staff has low expectations of participants. Mental illness is seen as a prophecy of doom.
• Staff is professionally distant while expecting participants to move closer and establish trusting relationships.
• Participants are taught to distrust their own perceptions.
• Staff view it as their job to make decisions in the "patient's best interest."
• There are few, if any, options to choose from.
• No people with psychiatric disabilities who could serve as role models are
  working in the program.
• Self-help and mutual support are not valued and encouraged.
  

The Example of Housing Programs

Among the determinants of health, housing is an important contributor to mental health. But government policy and decision-makers and mental health service providers need to be aware that there are approaches to housing that promote mental health, and other approaches which promote dependency. The following example is taken directly from an unpublished discussion paper on housing from the Centre for Addiction and Mental Health, 2002.

The Review of Best Practices in Mental Health Reform, produced in 1997 by the Health Systems Research Unit, Clarke Institute of Psychiatry, reviewed research evidence relevant to the reform of mental health systems. Despite some methodological weaknesses in the research to date, numerous studies show that:

• Community residential programs can successfully substitute for long-term inpatient care,
• Supported housing can successfully serve a diverse population of persons with psychiatric disabilities if support networks are in place and monitored,
• Consumer choice is associated with housing satisfaction, residential stability and emotional well-being, and
• Consumers prefer single occupancy units with support available on request.

The Best Practices report recommends a shift of resources and emphasis to supported housing options that incorporate the following key elements:

• Use of generic housing dispersed widely in the community,
• Provision of flexible individualized supports which vary in type and intensity,
• Consumer choice,
• Assistance in locating and maintaining housing,
• No restrictions on the length of time a client can remain in the residence, and
• Case management services that are not tied to particular residential settings but are available regardless of whether the client moves or is hospitalized.

This endorsement of supported housing is balanced in Best Practices by the recognition that a range of options is needed. People with severe and persistent mental illness vary considerably in their needs and preferences, and no single housing model can be expected to successfully accommodate everyone.

Since Best Practices, Parkinson, Nelson and Horgan (1999) and Newman (2001) have summarized evidence of the qualities and features of housing settings that produce positive outcomes for people with serious mental illness. This evidence demonstrates that social support, good housing quality, favorable locations in the community, privacy, a small number of residents, and residential control and choice all contribute to overall satisfaction and emotional well-being. These housing characteristics are typically features of alternative models and are rarely observed in custodial housing programs.

Most custodial housing does not conform to good practice, let alone best practice. Nonetheless, custodial housing is the most common form of housing available. Steps have been identified to re-develop these settings so that they can reflect some of the practices associated with alternative housing models (Pulier & Hubbard, 2001). These include:

• An upgrade of the physical plant, including issues such as location, access to transportation and community services, improved physical quality and safety, improved accessibility, a reduction in the number of residents, introduction of more common areas, and the introduction of personal storage areas;
• The introduction of home-like amenities, including personal decorations and comfortable furniture;
• In house programming, including group and personal empowerment, skills development; and
• Collaboration with a psychosocial rehabilitation centre, including vocational services and rehabilitation.

The most basic reform, however, remains the transformation of these settings away from the custodial model (Centre for Addiction and Mental Health, 2002).

Developing Healthy Public Policy

Shifts toward health and recovery are also possible on a system level. This is not only important philosophically, but can be a more rational investment of resources. Mental health systems that are developed based on individuals' needs create dependency and encourage people to constantly return to seek further services. That focus ensures that no matter how great the amount of human and financial resources spent on these systems, they will never be enough to supply the demand. But systems can be based instead on individuals' capacities and strengths, and rooted in the fundamental belief that individuals, groups and communities have the capacity to look after and maintain their own mental health and to gain the knowledge, skills and resources to do so. Such changes in philosophy and practice will reduce unnecessary access to the health care system and will ensure lower health care costs.

CMHA's Framework for Support proposes a number of interrelated steps that must be taken to reform service systems. These steps, which inform the discussion that follows, all contribute to systems which are more supportive of mental health promotion.

Invest in the Capacities of Consumers to Help Themselves

The range of activities that consumer groups are carrying out for themselves, without input from service agencies, has broadened dramatically in the last decade. Policy in this area should address the direct provision of funding to consumer controlled organizations, the structure of these organizations-how they can best tap the skills and capacities of people who have used the mental health system-and the need to build provincial and territorial networks of consumer controlled organizations.

Fully Involve Consumers and Families in Service Design and Delivery

This step recognizes the value of knowledge generated by life experience, and brings consumers in as partners in planning, operating and evaluating the mental health service system. It is encouraging that every provincial mental health policy document developed over the last few years espouses a system that is consumer/client-centred, or consumer/client-focussed. Ideally, this term "means not only that consumers must be involved in mental health policy development and planning, but also in the delivery of mental health services that affect them. Recognition is also given to consumer participation in broader roles at the community level in regards to promotion and prevention activities" (Galipeault, 1997).

This goal cannot be achieved without consumer knowledge and skills development to ground their involvement. Just as mental health systems provide resources for educational opportunities and training for service providers and policy makers, there is a similar obligation to provide the same opportunities for consumers. This will help to ensure that future mental health policies are grounded in a more pragmatic approach that "start(s) with people, not services or administrative models" (Trainor, Pomeroy and Pape, 1997).

Reinvest Institutional Dollars in Recovery-Oriented Community Services

As a critical component of mental health promotion, recovery must be viewed within a mental health policy context and be incorporated within mental health policies and plans at all levels. Some "essential services in a recovery-oriented system" have been identified as: treatment; crisis intervention; case management; rehabilitation; enrichment (engaging consumers in fulfilling and satisfying activities); rights protection; basic support; self-help; and wellness. Planning across services must be guided by consumer outcomes, and evaluation based on the standard of a recovery system. In addition, it is important for a service agency's mission to include the vision of recovery, and for the leadership to reinforce this vision (Anthony, 2000).

Since recovery is best understood and defined by consumers themselves, these policies and plans naturally require the involvement of consumers as a basic tenet to their development. Commitment and financial support from all levels of government is therefore needed to ensure that consumer involvement is meaningful and effective.

Develop Service Models that Build Access to the Elements of Citizenship; Develop Positive Accommodation Strategies

Too often consumers face a dilemma. If they look for work or educational opportunities in regular settings, they confront either overt discrimination or lack of practical support in accommodating to the new situation. On the other hand, if consumers look for these opportunities within the mental health system, they often become "clients" of services rather than regular students or employees.

In order to maximize people's mental health, service models need to support independent living and enhance participation in life as an ordinary citizen. This often requires working with consumers and the larger community to change structures, such as workplaces and educational institutions that may have kept people excluded (Trainor, Pomeroy, Pape, 1997). In workplaces, this may involve evaluating discriminatory recruitment and hiring practices, defining the essential functions of the particular job and the job-related limitations caused by the mental disorder, and making provisions for flexible work options. In education settings, access is enhanced by flexible practices in regard to, for example, admission criteria, work deadlines, course requirements, or taking of tests. A comprehensive mental health policy will recognize the importance of this other side of community inclusion and include measures such as research, data collection and public education to address it.

Make Generic Community Services and Supports Accessible and Part of Coordinated Planning

Many consumers report that the services offered by generic community agencies (that do not focus specifically on mental illness) are critical to their mental health - more important, in fact, than formal mental health services. Despite the importance of these resources such as social assistance, public housing, religious institutions or recreation services, they are frequently left out of service planning. Representatives of the generic system should be involved in a coordinated process of planning and delivering services to people with mental disorders, and encouraged in making their services accessible to this population.

By shifting the service focus from provider of service to facilitator of more natural helping resources, systems can promote community inclusion and enhance people's capacity to deal with their own mental health issues. This requires establishing networks with various community resources, creating linkages and developing new kinds of collaborative strategies. At the federal government level, it suggests collaborative approaches with voluntary sector, interdepartmental linkages within government departments and collaboration with provincial governments. It also requires a shift in the characterization of consumers in terms of their illness (problem) to one that views people in a more holistic fashion and as having strengths, capacities and gifts to contribute.

Re-Orient Educational Curricula and Professional Development

Medical professions have to take into account how current university and college curricula fit into a recovery orientation to service delivery. To do so, the basis for developing individual assessment and treatment plans has to focus on strengths and capabilities rather then on needs. Consumer-led sensitization training across the spectrum of services as well as re-education and ongoing professional development for current mental health service providers can lead the way in shifting the system's focus to promotion of health.

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