What is Community Mental Health?
The Encyclopedia of Mental Disorders defines Community Mental Health as “a decentralized pattern of mental health, mental health care, or other services for people with mental illnesses.” Community-based care is meant to be a cheaper alternative to the more costly treatment in a hospital by supplementing and decreasing the need for inpatient treatment. Since such care is based in community settings, it is more accessible and responsive to local needs than care in a central hospital. Community mental health assessment, which now goes by the name psychiatric epidemiology, measures the rates of mental disorder so that evidence-based mental health care systems can be developed and evaluated (Polgar, n.d.).
The World Health Organization (WHO) states that community mental health services are more accessible to people living with severe mental disabilities, are also more effective in taking care of their needs compared to mental hospitals, and are also likely to have less possibilities for neglect and violations of human rights, which are too often encountered in mental hospitals (Media Centre of WHO, 2007).
The WHO felt in 2007 that the need for community mental health services was especially urgent since, in spite of a clear message from WHO in 2001, only a few countries have made adequate progress in this area. Also, in many countries, the closing of mental hospitals is not accompanied by the development of community services, leaving a service vacuum. Dr Catherine Le Galès-Camus, Assistant Director-General of WHO’s cluster on Noncommunicable Diseases and Mental Health said, “This topic should matter to everyone because far too many people with mental disorders do not receive any care. The immediate challenge for low-income countries is to use primary health care settings, particularly through community approaches that use low-cost, locally available resources to ensure appropriate care of these disorders.” (Media Centre of WHO, 2007)
Origins of Community Mental Health
Institutionalization of the mentally ill was the norm back in the 19th century. But, even back then the reform movement called “moral treatment” began, which called for assigning the mentally ill to normal roles and benign environments. This movement recognized the importance of the mentally ill participating in education, work, social activities, and other such normal roles, which was thought to be beneficial to them. At the turn of the 20th century, a shift in focus from treatment to custodial care was seen. As the quality of care declined and psychotropic drugs were introduced, those with mental illnesses were reintroduced to the community, where community mental health services were designated as primary care providers (Wikipedia contributors, 2019).
The modern community mental health care movement largely took root in the US, to begin with, and then spread its roots over the next several decades. In 1946 President Harry Truman signed the National Mental Health Act which, for the first time in the US history, generated a large amount of federal funding for both psychiatric education and research. It also led to the founding of the National Institute of Mental Health (NIMH) in 1949. Towards the end of the 1940s and beginning of the 1950s, Luther Youngdahl, the then governor of Minnesota, kick started many community-based mental health services. He also championed the humane treatment of the mentally ill in state institutions (Wikipedia contributors, 2019).
It was not until the 1950s that major psychiatric medications started to be introduced. At the high point, there were close to 600,000 people in inpatient settings in state hospitals. And then, many factors—new medications, patient’s rights, budgetary implications of maintaining large numbers of psychiatric institutions, criticism that they were nontherapeutic—combined into a movement to change psychiatric care. President John F. Kennedy declared in February 1963, “I am proposing a new approach to mental illness and to mental retardation. This approach is designed, in large measure, to use Federal resources to stimulate state, local, and private action. When carried out, reliance on the cold mercy of custodial isolation will be supplanted by the open warmth of community concern and capability. Emphasis on prevention, treatment, and rehabilitation will be substituted for desultory interest in confining patients in an institution to wither away.” (Sadock, et al., 2017)
In October 1963, President Kennedy signed into law the Community Mental Health Act (also known as the Mental Retardation and Community Mental Health Centers Construction Act of 1963). This Act radically changed the delivery of community mental health services and led to a new era of optimism. It also led to the starting and development of comprehensive community mental health centers throughout the US. It helped the mentally ill who were “warehoused” in institutions and hospitals move back into their communities. Along with this law, the development of more effective medications and new approaches to psychotherapy made community mental health care a viable solution (National Council for Behavioral Health, n.d.).
This generated the Community Mental Health program in the 1960s and 1970s. This federal plan involved bringing mental health to the community with the intended construction of 1,500 community mental health centers. Assuming 200,000 patients would be assigned to each center, the projection was 300 million people could be served. The intention to move patients out of the chronic hospitals led to the deinstitutionalization era of psychiatric patients launched in the 1960s and continuing for decades (Sadock, et al., 2017).
In 1977, the NIMH initiated its Community Support Program (CSP), which established the ten elements of a community support system listed below (Wikipedia contributors, 2019):
- Responsible team
- Residential care
- Emergency care
- Medicare care
- Halfway house
- Supervised (supported) apartments
- Outpatient therapy
- Vocational training and opportunities
- Social and recreational opportunities
- Family and network attention
As these services became more diverse and comprehensive, it also became clear that the addition of treatment services for addiction disorders was also very much essential. So, providing comprehensive mental health and addictions services is the goal of community-based behavioral health organizations today—labeled as “behavioral healthcare”. Community-based mental health and addictions care is still a more effective option than institutionalization keeping in mind the access to quality healthcare and cost to the taxpayer and private payer (National Council for Behavioral Health, n.d.).
Features of Community Mental Health (Thornicroft, et al., 2016)
Community mental health care encompasses:
- A population approach,
- Viewing patients in a socio‐economic context,
- Individual as well as population‐based prevention,
- A systemic view of service provision,
- Open access to services,
- Team‐based services,
- A long‐term, longitudinal, life‐course perspective, and
- Cost‐effectiveness in population terms.
It also includes a commitment to social justice by addressing the needs of traditionally underserved populations, such as ethnic minorities, homeless persons, children and adolescents, and immigrants, and to the provision of services where those in need are located and in a fashion that is acceptable as well as accessible.
Community mental health care includes (1) An illness perspective: focus upon people’s deficits and disabilities, and also (2) A recovery perspective: focus upon their strengths, capacities, and aspirations. Services and supports thus aim to enhance a person’s ability to develop a positive identity, to frame the illness experience, to self‐manage the illness, and to pursue personally valued social roles. Thus, community mental health care also emphasizes the strengths of the families, social networks, communities and organizations that surround people who experience mental illnesses.
Community mental health care brings together (1) Evidence‐based medicine: A scientific approach to services that prioritizes using the best available data on the effectiveness of interventions, and (2) Practical ethics: Mentally ill have the right to understand their illnesses, to consider the available options for interventions and their effectiveness and side effects, and have their preferences reflected in the shared decision making.
So, we can characterize community mental health care as comprising the principles and practices needed to promote mental health for a local population by:
- Addressing population needs in ways that are accessible and acceptable;
- Building on the goals and strengths of people who experience mental illnesses;
- Promoting a wide network of supports, services, and resources of adequate capacity; and
- Emphasizing services that are both evidence‐based and recovery‐
Viable options available to implement community mental health care include (Media Centre of WHO, 2007):
- Integrating mental health care within the primary health care system;
- Rehabilitating long-stay mental hospital patients in the community;
- Implementing anti-stigma programs for communities;
- Initiating population-based effective preventive interventions; and
- Ensuring full participation and integration of people with mental disorders within the community.
Current Scene of Community Mental Health (Sadock, et al., 2017)
During the 1990s, the consumer-initiated movement called “recovery” became an influential ideology for advocates and mental health care systems. The ideology includes hope, self-management, pursuing personal goals, finding meaning in life, and participating fully in the community. Since rehabilitation is patient-centered, recovery goals coincide with rehabilitation goals.
Psychiatric rehabilitation uses three basic approaches: creating opportunities, providing supports, and increasing skills. In practice, these are combined. To illustrate, let us see three current approaches: Housing First, Individual Placement and Support, and technology tools, such as FOCUS.
- Housing First: Research shows that people with the most severe mental disorders and social disadvantages like poverty and drug addiction need safe housing, supports, and treatment. So, permanent housing is a basic human right. “Continuum of Care” model requires clients to complete a progressive housing program model starting from outreach to transitional housing to end with permanent housing. If clients do not meet the “housing readiness” expectations for each step, such as maintaining sobriety or adhering to prescribed medications, then clients do not advance to permanent housing and/or potentially return to homelessness.
- Individual Placement and Support (IPS): Also known as evidence-based supported employment, it emphasizes the patient’s personal preferences for work, a rapid job search (without extensive pre-employment assessment or training), and individualized supports as needed. Employment specialists provide practical assistance. Jobs are typically part-time, beginning at just a few hours per week and expanding over time. Studies show that IPS supported employment produces substantially better employment outcomes.
- Technology Tools: People with psychiatric illnesses use contemporary technologies in a manner similar to the general population. Survey studies suggest that around 90 percent of people with schizophrenia access the internet regularly, use email, and make good use of social media, online forums, chat rooms, and blogs. Mobile devices can also house apps designed to facilitate patient illness self-management. FOCUS, the first smartphone intervention specifically designed for people with schizophrenia, can be activated to prompt users multiple times a day with questions about their symptoms, social functioning, mood, medication adherence, and sleep. Depending on users’ responses, the system launches brief interactive interventions designed to both give the individual skills they can use at that moment (e.g., relaxation strategies, medication reminders, social skills tips), as well as train the user in techniques that can be generalizable to a range of scenarios (e.g., cognitive restructuring, hypothesis testing, behavioral activation, distress tolerance).
Final Word on Community Mental Health: The Balanced Care Model (Thornicroft, et al., 2016)
Based on the available evidence we can say that a model of care including solely hospital-based provision will be insufficient to provide adequate access to care and continuity of follow‐up. At the same time, there is not strong evidence that community‐based services alone can suffice during mental health crises. Hence, the balanced care model is called for, which provides both hospital and community-based service.
The balanced care model suggests that, in low‐income countries, more of the available resources should be invested in staff for primary health care and community settings. These staff should identify the cases, assess them, and give them pharmacological and psychosocial treatment. The few specialist mental health care staff (usually in more developed regions) should provide for training and supervision of primary care staff, and attend to complex cases and cases which cannot be managed in primary care.
In middle‐income countries, in addition to a continuing emphasis upon primary care, five key elements of general adult mental health services need to be invested in (1) outpatient/ambulatory clinics; (2) community mental health teams; (3) acute inpatient care, even though there continues to be relatively weak evidence about several aspects of inpatient care or highly supported alternative settings; (4) long‐term community‐based residential care, with an appropriate range of support; and (5) options for work and occupation.
In high‐income countries or settings, in addition to primary care services and to the provision of general adult mental health services, a series of specialized services should be provided, as resources allow. These services will need to be provided in the same five categories as mentioned for middle‐income countries.
Media Centre of WHO, 2007. Community mental health services will lessen social exclusion, says WHO. [Online]
Available at: https://www.who.int/mediacentre/news/notes/2007/np25/en/
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National Council for Behavioral Health, n.d. Community Mental Health Act. [Online]
Available at: https://www.thenationalcouncil.org/about/national-mental-health-association/overview/community-mental-health-act/
[Accessed 17 Oct 2019].
Polgar, M., n.d. Community mental health. [Online]
Available at: http://www.minddisorders.com/Br-Del/Community-mental-health.html
[Accessed 17 Oct 2019].
Sadock, B. J., Sadock, V. A. & Ruiz, P., 2017. Kaplan and Sadock’s Comprehensive Textbook of Psychiatry. 10th ed. Philadelphia: Wolters Kluwer.
Thornicroft, G., Deb, T. & Henderson, C., 2016. Community mental health care worldwide: current status and further developments. World Psychiatry, 15(3), p. 276–286.
Wikipedia contributors, 2019. Community mental health service. [Online]
Available at: https://en.wikipedia.org/wiki/Community_mental_health_service
[Accessed 17 Oct 2019].