Mental Illness Treatment – History of Community Orientation
In the early days of mental illness treatment in the United States, those suffering from severe and chronic problems such as schizophrenia, retardation, depression and insanity were often relegated to the asylum (Trickett, et al., 2011). Prior to World War II, most patients were committed to governmental institutions only if families could afford their care. Those patients considered by law enforcement to be the most dangerous to themselves and others were usually committed to state institutions or jailed. If a mentally ill patient did not fall into these categories, they were often institutionalized for short periods of time and then released back into the general community. The system was unorganized, underfunded, and lacking in preventative care and sufficient treatment for those suffering from mental illness (Gilliam, 2010). Institutionalization was viewed as the primary solution for dealing with those with mental handicaps. This also included those with varying learning disabilities, dementia, autism, and other conditions that were often feared and misunderstood at the time.
A need for a shift was apparent by the mid-nineteenth century. Conservative ideas about individualized care were waning by the 1950s (Kelly, 2010). There was a growing outcry for more attention to public health and the impact of the social conditions grappling the country during that era – discrimination and racism, poverty, unemployment, and illiteracy and lack of access to education and opportunity. In addition, many veterans were returning from war with major issues that would not be properly studied and defined for years. Many were addicted to alcohol and drugs, shell-shocked and otherwise traumatized by the atrocities of war and the role they had played in. As a result, adjusting back to civilian and family life proved difficult and contributed to domestic issues such as child/spousal abuse and violence (Gilliam, 2010).
Such troublesome situations would often trigger a snowball of behavioral health issues that began to appear across the society (Ginn, et al., 2009). Psychotherapy was no longer viewed as a cure all for treating mental illness; rather, it was becoming clear that whole communities were being impacted by the ravages of a lack of sufficient treatment for mental illness, and it would take whole communities – coupled with psychotherapy - to adequately address the problems (Trickett, et al., 2011).
The first step was to move to the deinstitutionalization of mentally ill patients. Those who could benefit from regular outpatient treatment released from inpatient facilities and moved into rehabilitative care that would allow them to develop the psychosocial skills necessary to integrate and function as normally as possible within their communities and larger society (Ginn, et al., 2009). Community Mental Health Centers were tasked with many essential services, including emergency care, inpatient/outpatient services, education, assessment, and by the 1970s, drug and alcohol treatment programs (Kliewer, et al., 2009). However, there were no mandatory requirements that forced the extremely mentally ill into state hospital care, even when it was recommended by clinicians. This lead to skyrocketing costs and a failure of the community mental health centers to provide the adequate rehabilitative aftercare for many who¸ in actuality were better candidates for hospitalization. The community orientation still held promise, but it was becoming clear that state mental hospitals needed to be improved to offer more robust treatment options. The 1970s marked increased focus on appropriate medications and treatment, renewed interest in state funded programs and long-term patient care and well-being (Kelly, 2010).
The overall adaptation and movement to the community orientation was not overnight. Many mentally ill patients who would have been committed to half-way houses or mental hospitals were spared and qualified for more flexible treatment options. Others, however, were still ostracized by society, denied employment opportunities, incarcerated, or fell victim to vagrancy after frustrated family members could no longer cope with or care for them (Gilliam, 2010). The community orientation set out to help the most vulnerable mentally ill patients by establishing the proper access to care and support structures within the community. It also attacked the root of many disorders such as severe depression and the disease of alcoholism by erecting early interventions before problems became full-blown pathologies (Kelly, 2010). Today, we owe programs such as Alcoholics and Gamblers Anonymous, Head Start, suicide hotlines, and many community drug rehabilitation programs to the early clinicians who developed the community orientation (Gilliam, 2010).
The community orientation has been described by many as “pragmatic, practical, social, and holistic” (Trickett, et al., 2011). It is viewed primarily as a systems approach to the treatment of mentally illness – not only is psychotherapy relevant and necessary, there are also many roles to be played in nonprofessionals such as family members, church leaders, educators, and policy makers (Gilliam, 2010). Without also addressing social inequities such as the lack of education and basic resources or unfair arrest policies, it is impossible to adequately improve the conditions facing many mentally ill individuals. The community orientation advances the idea that the patient is only one part of the picture in need of treatment. Often the entire picture needs adjusting. This approach has proven quite beneficial for the most marginalized populations such as those living in urban poverty, the elderly, minority groups, and children who may face mental health issues (Kelly, 2010). By focusing on prevention, personal health and well-being, empowerment and activism, social change can be influenced and support systems created that protect the needs and welfare of the mentally ill.
Community psychology began to truly take off in the 1980s, mobilizing clinicians everywhere to acknowledge the social structures that aided in the mental demise of American communities. Some of the basic principles of the community orientation include the idea of adaptation in which the surrounding social and historical context of a mentally ill individual must be considered before appropriate treatment can be implemented. The orientation also takes into account the idea of emphasizing the resources and strengths that patients do have, rather than their limitations. In addition, supporters of the community orientation offer that in treating the mentally ill it is importance to examine the interplay and interdependence of systems. How does change in one area of a patient’s life affect another? For example, if you treat a veteran’s post-traumatic stress disorder, how will the interventions you choose also impact his family, his prospects for a job, and/or his alcoholism? Community psychologists posit that everything is connected and cannot be treated in isolation.
The effect on patients and communities has been positive. Empowerment is a central theme of the community orientation. Because it is rooted in a systems approach to addressing behavioral health, social justice – in research and action – is often at the crux of all interventions and treatment plans (Ginn, et al, 2009). Community psychologists are agents of social change, believing that the health of society resides in community life and connections (Gilliam, 2010). Policies must be equitable and unprejudiced. Diversity must be embraced and valued. The marginalized must have a voice. Individuals must be strengthened not through treatment alone, but through prevention and early intervention. Everyone must participate in making America a better place and curtailing the issues that impact the mental stability of citizens. Community organizations must connect and collaborate, leveraging each other’s resources and strengths to support others facing mental health challenges.
The result of the community orientation has been a greater psychological sense of community and greater self-confidence for those who have been treated under this model (Kelly, 2010). Further, its foundation of social advocacy has led to many important mental health policy changes that have resulted in greater access to care and governmental support for programs and solutions that not only assist the mentally ill in leading more successful lives, but also better society as a whole.
References
Gillam, S. (2010). Practical ideas on how to teach community orientation. Education for Primary Care, 21(2), 116-117.
Ginn, G. O., Shen, J. J., & Moseley, C. B. (2009). Community Orientation and the Strategic Posture of Hospitals. Hospital Topics, 87(3), 11-18.
Kelly, J. G. (2010). More Thoughts: On the Spirit of Community Psychology. American Journal of Community Psychology, 45(3/4), 272-284. doi:10.1007/s10464-010-9305-1.
Kliewer, S. P., McNally, M., & Trippany, R. L. (2009). Deinstitutionalization: Its Impact on Community Mental Health Centers and the Seriously Mentally Ill. Alabama Counseling Association Journal, 35(1), 40-45.
Trickett, E. J., Beehler, S., Deutsch, C., Green, L. W., Hawe, P., McLeroy, K., & Trimble, J. E. (2011). Advancing the Science of Community-Level Interventions. American Journal Of Public Health, 101(8), 1410-1419. doi:10.2105/AJPH.2010.300113.
