17.1 Care as a Social Issue

The existence of mental suffering, like that of physical suffering, raises social and moral questions. Who, if anyone, is responsible for caring for those who cannot care for themselves?

What to Do with Individuals with Severe Mental Disorders? A Brief History

Through most of history, Western cultures felt little obligation toward people with mental disorders. During the Middle Ages, and even into the seventeenth century, people with serious mental disorders—called “madness” or “lunacy” (and today most often diagnosed as schizophrenia)—were often considered to be in league with the devil, and “treatment” commonly consisted of torture, hanging, burning at the stake, or being sent off to sea in “ships of fools” to drown or be saved, depending on divine Providence. By the eighteenth century in Europe and North America, people with severe mental disorders were often “put away” in hospitals and asylums, often under poor conditions. Although reformers in Europe (for example, Philippe Pinel) and the United States (for example, Dorothea Dix) campaigned for better treatment, the practice of “warehousing” people with mental illness continued until the middle of the twentieth century. A major change in the treatment of people with severe mental disorders occurred in the 1950s, inspired by several factors: an increase in the number of Ph.D. programs in clinical psychology to train psychologists to treat the mental health problems of World War II veterans (Routh, 2013), disenchantment with large state institutions, and especially the development of antipsychotic drugs. That change was deinstitutionalization. With medication capable of controlling some of the most severe symptoms of mental illness, people could be returned to the community, many living in transitional homes or receiving outpatient care.

Since the beginning of the deinstitutionalization movement, the number of chronic patients in state mental institutions in the United States has been greatly reduced—from about 600,000 in 1955 to about 100,000 in the early twenty-first century (Torrey et al., 2011)—but it is debatable whether the quality of life of those who would formerly have been in asylums has been improved. They have generally not been integrated into the community but are living on its fringes. Roughly 200,000 of them are homeless, and many more—upward to 2 million—are in prisons, usually for minor crimes such as trespassing or theft (Fleishman, 2004; Torrey et al., 2011). By one estimate, as many as 16 percent of people in American prisons have a serious mental disorder (Torrey et al., 2011).

Most people with a severe mental disorder do not commit violent crimes, although their rate of engaging in violent behavior is somewhat higher than in the general population (Monahan, 2010). For example, whereas about 2 percent of people without a severe mental disorder have assaulted another person, approximately 12 percent of people with schizophrenia, major depression, or bipolar disorder have. However, because most people with a mental disorder are not violent, it is very difficult for mental health professionals to make long-term predictions about who will be violent and who will not (Mills et al., 2010), although predictions of imminent violence are more accurate (Otto & Douglas, 2010).

In addition to those who are homeless or incarcerated, many thousands of other people with a mental disorder are living in rundown rooming houses and understaffed nursing homes (Lamb, 2000). The more fortunate minority are living in long-term residential-care facilities, or group homes, which provide room and board, supervise medication, and offer assistance with problems of daily living (Fleishman, 2004). The alternative to hospitalization that was envisioned—improved care in a community setting—was never fully realized.

A Positive Development: Assertive Community Treatment

Since the 1970s, an increasing number of communities have developed outreach programs, often referred to as assertive community treatment (ACT) programs, aimed at helping individuals with severe mental illness wherever they are in the community (DeLuca et al., 2008). Each person with mental illness in need is assigned to a multidisciplinary treatment team, which typically includes a case manager, psychiatrist, general physician, nurse, and social workers. Someone on the team is available at any time of the day, seven days a week, to respond to crises. Each patient—whether living on the street or in a boarding house or with family—is visited at least twice a week by a team member, who checks on his or her health, sees if any services are needed, and offers counseling when that seems appropriate. In addition, the team meets frequently with family members who are involved with the patient, to support them in their care for the patient.

A number of well-designed research studies have shown that such programs can be highly effective in reducing the need for hospitalization and increasing patients’ satisfaction with life (Coldwell & Bender, 2007; Nelson et al., 2007). Such programs are expensive to operate, but they generally save money in the long run by keeping individuals with mental illness out of hospitals, where their care is much more expensive (Lehman et al., 1998; The Schizophrenia Patient Outcomes Research Team [PORT], 2004). Despite such evidence, the majority of people with schizophrenia and their families in the United States do not receive such services.

Structure of the Mental Health System

Public concern about mental health generally centers on individuals with the most severe disorders, those who cannot care for themselves and who may commit violent crimes. But most people who seek mental health services have milder problems. The kinds of services they seek depend on such factors as the severity of their disorders, what they can afford, and the services available in their community. They may seek help from self-help groups organized by others who suffer from similar problems or disorders (such as Alcoholics Anonymous), from religious organizations, from general practice physicians, or from mental health professionals.

Reaching out In some communities social workers and medical personnel seek out people who are in need, get to know them as individuals, and help them gain access to useful services and means of support.

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Mental Health Professionals

Mental health professionals are those who have received special training and certification to work with people who have psychological problems or mental disorders. The primary categories of such professionals are the following:

• Psychiatrists have medical degrees, obtained through standard medical school training, followed by special training and residency in psychiatry. They are the only mental health specialists who can regularly prescribe drugs. They typically work in private offices, mental health clinics, and hospitals.
• Clinical psychologists usually have doctoral degrees in psychology, with training in research and clinical practice. Some are employed by universities as teachers and researchers in addition to having their own clinical practices. Like psychiatrists, they most often work in private offices, clinics, or hospitals.
• Counseling psychologists usually have doctoral degrees in counseling. Their training is similar to that of clinical psychologists but generally entails less emphasis on research and more on practice. In general, counseling psychologists are more likely than are psychiatrists or clinical psychologists to work with people who have problems of living that do not warrant a diagnosis of mental disorder.
• Counselors usually have master’s degrees in counseling or social work. They receive less training in research and psychological diagnostic procedures than do doctoral-level clinical or counseling psychologists. They often work in schools or other institutions, counseling people who are dealing with school- or job-related problems. They may also conduct psychotherapy in private practice, including specialties like couples or marriage counseling, career counseling, and child guidance counseling.
• Psychiatric social workers usually have master’s degrees in social work, followed by advanced training and experience working with people who have psychological problems. They are most often employed by public social-work agencies. They may conduct psychotherapy sessions or visit people in their homes to offer support and guidance.
• Psychiatric nurses usually have degrees in nursing, followed by advanced training in the care of patients with mental illness. They usually work in hospitals and may conduct psychotherapy sessions as well as provide more typical nursing services.

Where People with Common Mental Disorders Go for Treatment

A large-scale household survey was conducted several years ago, in the United States, to find out where people with mental disorders had sought treatment (P. S. Wang et al., 2005). The survey identified a representative sample of thousands of people who were suffering from clinically significant anxiety disorders, mood disorders (including major depression and bipolar disorders), substance use disorders (alcoholism and other drug abuse or dependence disorders), or intermittent explosive disorder (a disorder involving uncontrolled anger). Of these, 22 percent had received some form of treatment from a mental health professional within the past year, 59 percent had received no treatment at all, and most of the remainder had received treatment from a medical doctor or nurse who did not have a mental health specialty.

The survey also revealed that the typical person with a mental disorder who saw a general practice physician saw that person just once or twice over the course of the year, usually to receive a prescription for drug treatment and/or a few minutes of counseling. In contrast, those who saw a mental health professional met with that person for an average of seven sessions of at least a half hour’s length, mostly for counseling or psychotherapy. Not surprising, the wealthier and more educated a person with a mental disorder was, the more likely he or she was to have met for a series of sessions with a mental health professional for psychotherapy (P. S. Wang et al., 2005).

There are many treatment options for people with mental disorders in the United States, but most people who need the services do not seem to be getting them. Those lucky enough to have good insurance can see private practice mental health professionals, but most go untreated or are seen by a care provider without special training in mental health. Community-based programs have proven successful, but reach only a minority of people with severe mental disorders. What is somewhat shocking is that prisons may be the country’s largest mental health providers, mostly to people who have not committed serious crimes. Society has recognized the importance of treating people with mental disorders, but the cost, the stigma some people associate with seeking treatment, and the difficulty of getting therapy to people who need it make the effective provision of such treatment problematic and not likely to be easily solved.

Support for friends and family of individuals who abuse alcohol and drugs The family and friends of people with a debilitating mental or behavioral disorder often need psychological support themselves, in order to be helpful to their loved one while at the same time preserving their own well-being. Al-Anon is a self-help group run by and for people who have a friend or family member who is addicted to alcohol or another drug. Self-help groups are valuable components of the mental health system that are not directed by mental health professionals.

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