Interdisciplinary Relationships and Approaches in Community Mental Health

Nancy Marlett and Svetlana Shklarov

Abstract

The transformation of mental health systems is associated not only with changing programs, policies, or structures of services, but also with changing beliefs and relationships of people involved. This article explores interdisciplinary relationships and approaches in community mental health through a conceptual model that includes three distinct but complementary spheres: community psychiatry (health focus), psychosocial rehabilitation (coping), and recovery (consumer strength and personal meaning). By applying this model the authors examine the history and current models of service, explore professional roles and practices, and suggest ways to include the voices of consumers in a new social reality of community care.

Introduction

This article explores a conceptual model of community mental health that grew out of our experiences during the Canada Russia project. Through it we explore the connection between the development and transformation of services and systems with the changing beliefs and relationships of people involved. Our reflections on the Canada-Russia knowledge exchange suggest that mental health reform, regardless of the country or culture, is associated not only with changing programs, policies, or structures of mental health, but also with the shift in power balances, perceptions, beliefs, and relationships. By relationships we mean the ways in which people in different roles perceive and interact with each other; for example, psychiatrists and their patients, or professionals of various disciplines with each other.

The ideas presented grew out of on our interaction with colleagues from Russia during training sessions, brainstorming, and group work. They represent an amalgam of ideas to stimulate thought and debate. We hope to be able to challenge readers to think openly and flexibly about what has transpired and what is possible.

A model of three coexisting approaches

When distinctly different ideas and systems come together in a partnership, underlying beliefs and established relationship patterns come to the surface and can be understood in a new light, and transformed. The focus for Canadians was to take stock of the state of our community practice and the major philosophical shifts that had taken place in forty years of deinstitutionalization. Russians were looking for community alternatives that could reduce the rate of institutionalization and to increase the likelihood of persons being discharged successfully. Through sharing, we had the opportunity to think beyond our comfortable professional existence and to consider alternative ways of thinking and practicing.

The model used in this chapter emerged from the first training session in Russia as a way to honour the strong biological treatment traditions in Russian psychiatry and to introduce both community-based psychosocial rehabilitation programs and the potential of consumer led initiatives. Three distinct but complementary spheres emerged: community psychiatry (health focus), psychosocial rehabilitation (coping), and recovery (consumer strength and personal meaning) (see Figure 1). As we found later, this is a general conceptual model, which can be applied to various systems and countries.

Figure 1. Three approaches to community mental health

The three approaches: community psychiatry, psychosocial rehabilitation, and recovery are seldom distinct, and elements of each would ideally be present in any particular community. By considering them separately we hope to examine the differences in history and services, explore the roles, practices and relationships of each, and suggest ways to include the voices of consumers in a new social reality of community care.

Community Psychiatry

Psychiatry deals with the manifest impairments related to mental disorders. The problems are seen at the cellular or micro level and are internal to the body. The assumption is one of disease, and the goal is to identify, treat, and control deviant conditions by using outcome based interventions. If underlying biological and physiological problems are dealt with, the assumption is that patients will be cured.

Recent advances in science provided invaluable perspectives for psychiatric treatment. New possibilities of pharmaceutical control of symptoms have led to the subsequent drop in hospitalization (Kirby & Keon, 2004; Greenland, Griffin & Hoffman, 2001). It may seem that psychiatric research has given rise to the need for community options because hospital stay is no longer the only choice of action.

In Canada, the insufficiency of a biological approach was demonstrated during the mental health reform and deinstitutionalization of the 1960s - 1970s, when people were discharged from institutions when their psychiatric conditions improved with medications, without appropriate community supports. Many congregated in large cities where few supports existed to secure employment, housing, and treatment. Those who had lived in large institutions were reluctant to seek help for fear of being returned to institutions where they had little personal control. The resultant homeless ghettos raised fears of safety, both for those who were homeless and those in contact with them. It has taken almost thirty years for the tide of public opinion to turn and for persons with mental illness to trust community based services. We have learned that medications alone are not sufficient, and social transformation occurs only when life in communities is adequately supported. For this to happen there were three distinct steps: psychiatry first had to declare publicly that it was possible to treat symptoms without being hospitalized. Second, there needed to be a network of community based supports and third a critical mass of successful patients, living full lives and helping each other.

Psychosocial Rehabilitation

Here the focus shifts from the symptoms of the disease and their pharmaceutical treatment to management of psychiatric 'disability' (deficit of function). Treatment targets the overcoming of the deficits in functioning that result from the underlying biological impairment of mental illness. Therapy or education attends to the psychological, behavioural, and social aspects of living with a mental illness. The process of psychosocial rehabilitation consists of assessment of skill deficits, remediation and teaching of the identified deficits, and the transfer of these new or revived skills into community activities. In overcoming deficits the assumption is that people are able to be accepted, productive, and independent because they can function normally.

Many psychosocial programs in North America are outside of psychiatric institutions, run by the voluntary sector and there is a strong movement away from segregated services. In some European countries governments run community industries and housing for those with mental illness. Early attempts at deinstitutionalization saw psychosocial programs in institutions with full medical funding, but as the locus of programming moved outside of institutions, the health funding was replaced by welfare or social protection funding. Welfare funding comes with the expectation that programs will reduce social costs when people become gainfully employed. In countries that have limited resources for health and welfare, there is more reliance on families and small home based industry.

While some medical rehabilitation staff followed patients from the hospitals into community settings, there is an increasing tendency to separate medical from psychosocial approaches, to consolidate the separation of control of symptoms from functional teaching and support. Disciplinary credentials in community work are less important than functional expertise and the ability to network (e.g., employers, leisure options). However, there is an increase in functionally based professions, such as Community Mental Health, Supported Employment, Social work, Disability Management, Vocational rehabilitation, Recreational therapy, and Case Management. Each has its own training requirements and credentialing. In Russia, psychosocial rehabilitation has not yet differentiated from health professions where nurses, psychologists, psychiatrists, social workers are employed largely in the institutional settings. Specialized training programs are still scarce, and the culture of psychosocial rehabilitation is not separated from psychiatric in- or outpatient facilities.

Psychosocial rehabilitation, especially in the early stages, relied heavily on assessment as a way of being seen as legitimate by health professions. The most common assessment tool was the functional checklist that was a standardized listing of skills that might be expected in the community (for example, Gurovich & Shmukler, 2002; Marlett, 1971). These checklists are good indicators of general health and coping, and therefore are helpful in assessing readiness for discharge or monitoring progress through interventions. However, it is clear that completing a checklist does little to improve functional competence without follow up with training to remediate the identified deficits.

The standard assessment-intervention link is an individual written plan (IWP) that translates assessment into goals and training expectations. In Russia, similar tools are called "psychosocial itinerary" or "psychosocial map." At the individual level, these IWPs can establish new relationships. Staff, patients, and families are each validated as having responsibilities as part of the team.

The IWP was combined with behaviour modification in the early stages of deinstitutionalization in North America, because it created the expectation that deviant behaviour could be reduced and functional skills increased. While behaviour modification had the unfortunate side effect of increasing dependence on external forces, the IWP in combination with medication was a powerful treatment alliance.

IWP creates the expectation of change, innovative teaching models, removing the barriers to acceptance, and applying ecological approaches complete the process.

In institutions, where the environment is controllable, the established techniques of Applied Behavior Analysis seem to be enjoying a return to favour. Token economies are still practiced, where patients earn tokens for looking after themselves, following routines, working, and behaving well, which they then spend on better meals, furnishings, treats, or money. Other techniques such as reality therapy where natural consequences are employed to teach patients the consequences of their actions are also possible when staff can control what patients do and what they have access to (see Wallin, 2004 for current use of token economies). These techniques are of little use in community settings where clients are not easily controlled.

In community settings, staff must rely instead on developing self esteem and a desire to succeed through exposing clients to positive activities and adapting those activities so that the person can take part. This approach has been called ecological or environmental in that it focuses on the naturally occurring activities and ways of ensuring that the client feels a part of the activity (Collins, 2004). Routines and equipment can be altered; assistance provided by peers, those engaged in the activity or as staff members (Baumgart, 1991). The goal is to remove staff presence, so that the clients learn that they can succeed, and as they succeed family and staff change their negative attitudes. Of course modeling and role playing are also ways to practice skills that are more appropriate in community settings.

Some of the newer techniques look to remediation of problem solving capacities, rather than teaching specific functional skills. Computer Assisted Cognitive Rehabilitation (Burda et al, 1994; Belluci et al, 2002) targets the underlying processes to improve coping by attempting to revise thinking patterns to improve thinking abilities. Computer or discrete trial training and thinking games such as Captain's Log and Mind Gym (Brekke et al, 2007) have produced significant reductions in negative symptoms of schizophrenia, improved mental flexibility, memory, attention, and real life functioning (McGurk, 2005; McGurk et al, 2007). Although these routines produce results it is interesting that they do not tend to impact self esteem or the feeling of competence (Bellucci et al, 2002).

During our discussions of various psychosocial intervention techniques in training sessions in Russia, the following barriers to patients being motivated and allowed to succeed were identified (see Box 1).

Box 1

The barriers are interconnected and removing one barrier will impact the others. Consumers need to be active participants in any action taken to overcome barriers for they are the ones who need to know about barriers. People soon see that while some of the barriers are personal, most are socially constructed and maintained by forces outside of their influence such as social policy, stigma and poverty. Donilee Loeske's (2005) work on social problem theory is a useful guide to helping consumers and staff understand and counteract barriers and support notions of capacity.

In the short term, psychosocial rehabilitation in institutions will increase expectations and consequently, work load. In the medium term, successful discharge rates should increase. In the long term, there should be pressure to change the culture of institutional care. Psychosocial rehabilitation is essential in community settings to prevent institutionalization and to create a culture of competence and inclusion.

The Recovery approach

This outer sphere is based on the assumption that people gain strength and growth through challenge. People acquire new meanings and new self-value through overcoming the barriers to living a full life with mental illness. A large part of this meaning comes with the understanding of the social and political conditions that promote and maintain the image of deviance and stigma. In North America, the consumer movement that most fully reflects the essence of the third circle began in the early 1990s, and is called Recovery movement (Deegan, 1992, 1995 ). In Russia the first signs of recovery as a construct came with the initiating of the clubhouse movement and the independent parents' and consumer organizations, and with traditionally strong spirit of creative self expression through visual arts.

Some might say that recovery movements have grown from the success of psychosocial rehabilitation in demonstrating that persons with mental health concerns can function and be productive citizens within communities. However, recovery is very uncomfortable territory for professionals, because consumer led models challenge the authority and expert status of professionals. In fact, many movement activists propose that professional control and authority are major obstacles to recovery.

When groups of Russian professionals and consumers came to Canada, we were able to put our beliefs about professional-consumer partnerships to the test. We understood that our most important contribution was not Canadian policies and programs, but an experience in new relationships. We were fortunate in finding a group of mental health consumers (the Alberta Mental Health Self Help Network) to work with us in planning and executing the study tours for the visiting groups. The Russian psychiatrists, policy makers, and consumers were met at the airport by Canadian mental health consumers who took them to their lodgings, helped them become oriented, and became their tour guides and teachers. It was an essential learning experience that could not have happened in Russia where the chasms created by roles and expectations between psychiatrists and patients were too large to bridge.

The Canadian professional group also learned from this partnership. Our consumer partners taught us all that partnerships grow with experience, and trust comes when each partner feels that their contribution is honoured. During the time of our partnership a number of events occurred that indicated the maturity of consumer involvement. First, the number of consumer led programs in Calgary increased dramatically, with many services being at least partially staffed and run by mental health consumers. Second, the Senate Report on Mental Health (Kirby& Keon, 2004) included recommendations to promote consumer involvement in community based services. In Calgary there has been a deepening partnership between psychiatrists and consumer movements to offer both front line interventions and secondary peer support and information services.

Recovery movements are many and varied. Some are condition specific: people who hear voices and Mood Disorders Society of Canada for people with depression and bipolar disorder. Others are function related: Clubhouse, consumer-run housing projects, employment services, and dating services. Still others are related to advocacy for all those with mental illness: National Network for Mental Health (NNMH); Canadian Coalition of Alternate Mental Health Resources.

The consumer or recovery movement is typified by the development and growth of the Alberta Mental Health Self Help Network, one of our Canadian partner organizations for the Canada Russia project. It became apparent soon after the deinstitutionalization reform of the 1960s that existing services were not meeting the complex needs of ex patients and in response, psychiatric survivors across Canada came together to reach out to persons with mental illness, their families, and the community at large. Our local group of consumers has now been recognized as an independent organization assisting consumer through information and referral, peer support and counseling, public awareness and advocacy, and a strong presence in public policy arenas.

Internationally, Recovery movements lobby for changes to policy; operate survivor run businesses; produce community theatre and arts projects, and conduct research about needs and lived experiences (see the chapter on the Schizophrenia Society of Alberta in this book).

The support of Recovery movements is gaining strength on many fronts including from governments who are looking for less expensive, less professional alternatives in the face of rising costs. The recovery movement in Mental Health mirrors other successful consumer led initiatives. For example, the Community Living Movement looks to self advocacy of persons with developmental disabilities and the leadership and advocacy skills of their families. The Independent Living movements assert that disabled people are the experts and have the right and obligation to engage in creating policies, supports, and services for their constituents. The growth of disability studies in universities is drawing attention to the cultural richness and competence of communities defined by disability.

Perhaps one of the most widely known forms of recovery movement is the international Clubhouse Movement, which is a network of intentional communities of people who have had their lives drastically disrupted by mental illness, and now need the support of others who believe that recovery from mental illness is possible. It is a membership organization, open to anyone who has a history of mental illness. Membership implies belonging and always having a place where you are welcome, instead of being a client to be served or a patient.

There is much that mental health professionals can do to provide support. Recovery does not mean rejection of help, but those who choose to work directly with consumer groups may have to prove their willingness to work in partnership.

Disciplinary roles in the three spheres

The first (inner) sphere of community psychiatry is mainly oriented towards the biological model of mental health, with the emphasis on medical diagnosis and pharmacological treatment. In this sphere, we have a predominance of medical personnel, mostly psychiatrists and nurses. Russian trained psychiatrists engage in more comprehensive, socially oriented and direct practice, and are therefore likely to be more engaged in mental health reform that embraces all three spheres. Mental health nurses generally manage medical symptoms in care settings, but increasingly they take on other roles - street nurse, case manager, and educator. For example, in England community nurses work as community developers and are trained in psychosocial methods.

In the psychosocial rehabilitation (coping) circle we see workers whose professional identity is defined by the functions they teach and support, for example, employment specialists, family specialists, housing, and recreation. Psychosocial teams are flexible and are led by a team member who can provide leadership to solve the issue at hand. There are few hierarchies in psychosocial rehabilitation in community settings, and the teams may not be long lived-- disbanding when there is no longer a need for the group to be together.

Psychosocial rehabilitation specialists often have a dual professional identity: mental health workers and the trainers of functions they promote. There is always a tension between the two, and this raises questions about education of community workers. Is it more effective to train generic mental health professionals who take on specialties in employment, family education, and other supports, or is it better to recruit people with skills in employment, life skills, or fitness who are interested in mental health, and provide in-service education on the job? There has been a strong feeling among consumers that natural, creative, and supportive relationships outweigh training, and this might suggest that sustainable and flexible community mental health may require trained mental health workers who can support and train those who are motivated to work in community mental health and have relevant community skills.

The third ring (recovery) reverses traditional power balance and roles. While the presence and benefits of both inner circles are maintained, these benefits are perceived and used in a different way, in the light of the changed relationships. Compliance achieved through professional control and expertise give way to personal healing and recovery, in which persons who are living with metal illness make decisions regarding services they will choose to use. Professional help is a tool which consumers seek to achieve their unique individual life goals and they do not blindly give up control over their own healing processes.

Initially, in the first training session in the mid-1990s, psychiatry (the inner sphere of our model) was the dominant construct. All questions about employment, housing, and relationships were answered with the need to train more people to recognize symptoms of mental illness and provide early access to dispensary care to reduce symptoms. This was natural since most psychiatrists thought nothing of talking to employers, solving family disputes, teaching cognitive skills. Russia is in a unique position to use this strength to create new integrated models of community psychiatry.

Perhaps the most illustrative example of evolution in the interdisciplinary relationships in Canada has been in the expansion of programs called "shared" mental health care. Shared care distributes psychiatric treatment responsibilities for a patient to a general practitioner with consultation by psychiatrists and mental health professionals. In this collaboration, the general physician (a primary care physician) takes an active role in identifying and handling pharmaceutical care for routine mental health issues. This normalizes mental health as a routine health concern.

Shared care began as multidisciplinary teams where each professional worked within their scope of practice. As these relationships became established, the model evolved to its second form-- introducing interdisciplinary teams to address, addiction, employment, family dynamics, housing, and counseling. In interdisciplinary teams, members set joint goals and share information and some practices (Isomura, Senay, Haldin, & Edworthy, 2002; Kates et al, 1997).

This is leading to a third form, transdisciplinary mental health care where responsibility of different professionals overlap, and each learns to perform the functions of others, with specialists providing back up for risk assessments and interventions (Stelmack, 2005). Each team worker is supervised by the psychiatrist, works directly with the physician and client, and receives ongoing support and education from the team.

This model starts to look like the work routine of a Russian psychiatrist-- a trained clinician who can deal with the variety of complex situations. For example, a transdisciplinary mental health social worker could deal with housing, employment, medication monitoring, counselling, and psychological issues of family relationships in a coherent way. Thus, the disadvantages of fragmentation of services and confused professional identities are significantly reduced.

Conclusion

Let us now review the diagram. The community psychiatry sphere looks inside the person to find the cause of mental illness and overcome it. It can therefore declare that mental illness can be managed and that people can live rich lives. Psychiatrists can demonstrate optimism and new partnerships where ex-patients contribute to the wellness of others with mental illness.

The psychosocial sphere looks at the interaction of the person and his environments to find a way to help the person fit into society and to be a productive citizen. As these programs take hold in community settings, they can demonstrate the capacities of persons with mental illness to learn and be productive citizens.

The recovery sphere claims that persons can survive mental illness and have the right and responsibility to understand how mental illness is sustained by society and how to find their own path with the help of others.

Now that we have highlighted the differences between the spheres, it is important to bring all three into play in transforming community mental health. All three spheres are essential: psychiatry, psychosocial rehabilitation, and consumers. As new professions are created, it would be important that specialists be trained in all three spheres. Professional education is most effective when it includes developing knowledge in three major areas: first, how to understand psychiatric illness, and how to access and encourage treatment; second, how to work effectively to teach skills needed to live, work, play, and contribute in the community; and third, how to encourage and support consumers to find their own way to contribute to society. If new professions are to become active in system reform, they will need to believe in a future where all three spheres are valued.

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Contributors:

Nancy Marlett, PhD, Associate Professor
Community Rehabilitation and Disability Studies Program
University of Calgary
Canada

Email: marlett@ucalgary.ca

Svetlana Shklarov, MD, PhD Candidate, Interdisciplinary Graduate Program
Community Rehabilitation and Disability Studies Program
University of Calgary
Canada

Email: shklarov@ucalgary.ca

International Journal of Disability, Community & Rehabilitation
Volume 6, No. 2
www.ijdcr.ca
ISSN 1703-3381