Running Head: CREATING NEW POSSIBILITIES

Chapter Aims

3. To better understand the need for liberation experienced by persons with serious mental health problems.

4. 2. To consider societies’ roles in contributing to and addressing serious mental health problems.

5. To examine what persons with serious mental health problems are doing to promote liberation and wellness.

6. 4. To consider how we can use principles and values of community psychology to promote liberation, wellness, and recovery along with the efforts of persons with serious mental health problems.

Introduction

In this chapter, we will consider how the values, key concepts, and tools of community psychology can be helpful in joining persons with serious mental health problems (smhp) on their journeys to liberation and wellness. While much is written about the treatment of mental health problems, some of which can assist persons with smhp reach their goals for recovery, the scope of this chapter is what community psychology can contribute to these efforts. In terms of health promotion, it considers what resources and practices can help persons with smhp address their needs for well-being (e.g., housing, work, meaningful social relationships). In terms of liberation, it examines social responses to mental health deviancy and discusses possibilities for supporting increased self-determination of persons with smhp. In terms of prevention, it explores universal strategies for primary prevention of smhp and critiques community psychology and mental health fields for relatively little work in this area.

The overarching goal for this chapter is to examine how action, research, and policy can help create pathways for persons with smhp to achieve their goals for liberation and wellness. The chapter begins by reviewing the historical context of how communities have responded to the needs of persons with serious mental health problems. Second, using community psychology’s ecological metaphor introduced in chapter 4, the chapter presents a discussion about the emerging role of persons who have received psychiatric treatment in changing societies’ responses. Third, it prompts us to consider how supporting these developments is consistent with the values and principles of community psychology presented in chapters 2 and 3. Finally, this chapter presents examples of action and research that promote liberation and wellness for persons with histories of smhp where efforts of community psychologists have supported these goals.

Deviancy, Social Control, and Self-Determination

Persons who have histories of serious mental health problems must traverse three major societal thoroughfares in their journeys to liberation and wellness: deviancy, social control, and self-determination. That is, there are competing tensions in how societies respond to persons who experience disruptions in emotional, cognitive, and interpersonal life, especially when these disruptions have a profound impact on an individual’s functioning. For people with serious mental health problems (smhp), we often label their behavior, thinking, or even the persons themselves, as deviant from the norms of society. In their journeys, people with smhp must respond to how their communities define and address deviance. Similarly, the exercise of self-determination by persons with smhp is greatly affected by the opportunities that are afforded to persons who are judged to be deviant.

Judgements concerning deviancy often lead to decisions about the need for social control that are at odds with the cultural value of promoting self-determination. The notion of a phenomenon deviating from a norm can be simply descriptive (e.g., the tallest student in a class) and would be more accurately labeled as a matter of diversity. However, typically the notion of deviancy includes the social dimension of devaluing the persons because of some personal characteristic (Wolfensberger & Tullman, 1983). Box 21.1 presents one view of the pain and cost associated with being labeled deviant because of mental health problems, as well as some

[Insert Box 21.1 about here]

Box 21.1

“To me, mental illness meant Dr. Jekyll and Mr. Hyde, psychopathic serial killers, loony bins, morons, schizos, fruitcakes, nuts, straight jackets, and raving lunatics. They were all I knew about mental illness, and what terrified me was that professionals were saying I was one of them. It would have greatly helped to have had someone come and talk to me about surviving mental illness – as well as the possibility of recovering, of healing, and of building a new life for myself. It would have been good to have role models – people I could look up to who had experienced what I was going through – people who had found a good job, or who were in love, or who had an apartment or a house on their own, or who were making a valuable contribution to society” (Deegan, 1993, p.8).

ideas about alternative responses. In the hoped-for circumstance, persons with smhp can exercise self-control, self-determination, and have access to the resources that allow them to choose how they want to live. In more troubling situations when the life circumstances or behavior of a person is judged by herself or others as sufficiently deviant, some element of external social control is sanctioned (e.g., hospitalization). Mental health professionals typically have the responsibility to make decisions about when circumstances pass the threshold of deviancy and require intervention.

In the last twenty years, however, the pervasiveness of the need to control mental health deviancy has been increasingly challenged by persons with serious mental health problems, their family members, and a small but growing number of mental health professionals (Carling, 1995; Nelson, Lord, Ochocka, 2001). This emerging view observes that professional service providers’ approaches to smhp emphasize concerns about behavioral and cognitive deviancy and needs for safety and social control. These approaches, however, typically do not allow for meaningful consideration of the consequences of these practices or the missed opportunities to promote well-being and recovery. By not considering the negative consequences of social control or the prospect of life improvements from greater self-determination, a mental health deviancy focus concentrates almost solely on people’s problems to the exclusion of their current or potential capabilities. The situation is a bit like trying to repair a badly damaged road during the darkness of night. You rely on past experience and training to choose where to focus your spotlight and, consequently, repair what you can see. You can develop effective procedures and humane practices to quickly repair the identified problems within your sight. However, problems arise if you never shine the light of your analysis outside of the area where you have been trained to focus. Your repairs will be incomplete and you won’t consider what you might be able to do to prevent the need for repairs. Therefore, it would not be too surprising that travel on the road of responses to smhp would continue to be difficult for many people; you may repair some of the potholes but miss rockslides, loose gravel, or other problems that hinder travel. Furthermore, if do not use the experience of persons who have traveled this road and know many of its problems, you will miss opportunities to improve the conditions for subsequent travelers.

In this emerging view of collaborative efforts to address smhp, those helping an individual with smhp need to address concerns about diversity of ability, strengths, and needs (c.f., Carling, 1995; Nelson, Lord, and Ochocka, 2001). This requires deliberate efforts to recognize strengths, to persevere in creative efforts to promote and develop those strengths, and a commitment to a view of recovery that supports the realization of individual and collective journeys to liberation and wellness. In all but the most exceptional cases, such a broadened scope of recovery can not be accomplished by one approach to helping (e.g., clinical treatment, community development, self-help). This chapter is written from the standpoint that there is a limit to how much clinical practices can be revised to support wellness and liberation because of its problem orientation and focus on personal deficits. However, as a growing number of mental health professionals have demonstrated, revised clinical practices can be very effective in addressing concerns of deviant functioning and safety, while also being one component of a journey that an individual can use to develop personal capacities and utilize social opportunities that promote wellness, liberation, and recovery.

Competing Tensions in Helping Professions

Before a brief discussion of historical context, I want to further ground our consideration of liberation and wellness for persons with smhp at the intersection of these three tensions. When social workers, nurses, mental health workers, psychiatrists, and psychologists respond to help persons experiencing serious mental health problems, they are conferred a social role of helping the person to fit into society. If a person is evaluated as being (a) too vulnerable to take care of oneself, (b) at risk to harm oneself, or (c) a threat to harm others, the role of these mental health professionals is to ensure the safety of the person and those who may encounter the person in crisis. These helpers may act to stabilize the crisis situation, to assist the person in maintaining self-control, and if need be, to confine the person. Thus these helping professionals have dual charges of being agents of compassionate care and agents of social control. Combining society’s interest to have compassionate care for persons who are experiencing crisis with interests in maintaining safety often puts these service providers in awkward situations that have profound consequences for persons with smhp (i.e., deciding to involuntarily detain and hospitalize someone in the “best interest” of the community or of the person).

This view of the social control role of mental health professions may seem overstated. However, consider how you would respond to the needs of a person whose thinking, behavior, and life circumstances are routinely labeled as “deviant” in society.

Joseph does not trust many people. Although he sometimes recognizes that it is hard for others to believe, he thinks that people put thoughts in his head or even broadcast what he is thinking on T.V. Joseph often feels threatened by others and is quick to lash out if people “invade his space”. In fact he has been arrested several times for assault and has been subsequently hospitalized in regional facilities against his will. Joseph wants to live in his own apartment and have a job, but he can’t afford an apartment by himself and doesn’t have any good references for employment. He has sold sex for money to sustain himself. Although he has had sexually transmitted diseases, he is not currently HIV positive. During warm months, Joseph sleeps on the street, but he tries to get a bed at a homeless shelter during the winter.

Now, imagine that you are a mental health professional assigned to work with Joseph. How would you answer the following sets of questions:

A) Social control: What are your obligations (and that of your agency) to protect Joseph from getting into situations where he may be a victim of assault as a result of one of his many arguments with people?, to avert serious injury or death from sleeping outside during cold weather?, to prevent him from contracting HIV?, or to protect others from harm he may do when feeling threatened?

B) Deviancy: How do you (and your agency) respond to business owners and city council representatives who don’t want “homeless, crazy people” scaring away customers from downtown? What might you do to reduce Joseph’s fear of others and his tendency to strike out when he feels threatened? What can you do to address the awkward social interactions and discrimination that Joseph encounters when trying to buy a sandwich at a downtown store?

C) Self-determination: How do you help Joseph respond to his feeling of being pushed to the margins of society? How can you help him gain access to an affordable, decent apartment of his own? How can you help him to have more power over decisions in his life?

In my experience as a North American community psychologist working in clinical settings, the choices for responding to such a scenario revolve around the balance of issues of maintaining safety and social control for all involved, defining deviancy and deciding whether or how it should be addressed, and promoting self-control and self-determination.

I argue that social control is neither bad nor good by itself, but can be evaluated in how it is applied and for what reasons. Most would agree that some element of social control is needed in community life. For example, after the events of September 11, 2001, I am interested in greater control and inspection of what people bring on airplanes. However, I am also concerned about the potential implementation of these new controls going too far, particularly as they may affect who can get on airplanes. My point here is that we rely on professionals to shape societal norms and to carry out social control functions. These include airport screeners, police officers, teachers, clergy, and mental health professionals among others. For the field of mental health, a central question to consider is how this social role is fulfilled and what unintended consequences may result from their actions. I argue that this is best accomplished in any “helping profession” when there is an open dialogue with persons whom we are trying to serve about what is helpful or harmful in our practice, and what we can do to support them. The perspective and interventions promoted by community psychologists can make unique contributions to these efforts by helping to create community structures that are tolerant of diversity and do not primarily respond to deviance by isolating and pushing to the margins those that are deemed deviant.

Community Responses to Serious Mental Health Problems

A tension between these competing interests of social control, deviancy/diversity, and self-determination has existed throughout history for persons with serious mental health problems. For thousands of years, there have been a range of viewpoints in how to identify and how to respond to mental health deviancy/diversity. I argue here that varied combinations of how these interests can be balanced to provide care have been present throughout history and have been expressed in a variety of societal, organizational, and individual responses to mental health problems. The important questions for each community, and those who want to change them, are (1) how to balance these interests given their espoused values, and (2) what priority will be given to ameliorative and to transformative approaches to change. In the examples presented above, an increased emphasis on the values with most potential to promote transformative change (e.g., social justice, holism, accountability) would likely lead to a search for ways to de-emphasize mental health professionals role in social control and ameliorative care to search for more opportunities to create community structures that promote self-determination and wellness. Just like balancing a budget, this tension is never resolved in a community, but must be repeatedly addressed as the weight of priorities and values change over time.

Historical Background

Accounts left by the ancients of Western civilization record that societies often attributed very deviant and outlandish behavior to be a sign of supernatural possession (citation). During the European Middle Ages, severely aberrant behavior was seen as a sign demonic manipulation requiring exorcism or imprisonment. In some instances, bizarre behavior was interpreted to be evidence of witchcraft and was “treated” by public flogging, or even capital punishment (citation). However, the history of societal responses to deviance is not restricted to theories of confronting demonology and negative social control. At times, particular religious communities have provided sanctuary and comfort to those who have been cast out due to judgements of deviance (Pargament, 1997; Kloos & Moore, 2001; Nelson, Lord, & Ochocka, 2001). Native healers of aboriginal peoples throughout the world have traditions of responding to emotional upset by restoring a balance of person, nature, and spirit (Asuni, 1990; Hazel & Mohatt, 2002). In some spiritual traditions, experiences of visions and hearing voices, some of which can be considered symptoms of mental health problems, have been (and are) celebrated rather than viewed as phenomena that require control or are manifestations of mental health problems (e.g., Hildegard von Bingen, citation).

From the 4^th century B.C.E., Greek and Roman forebears of modern Western medicine viewed the disordered mind as an appropriate topic for scientific study, as well as the several medieval physicians who protested against demonizing practices (Rappaport, 1977). They were interested in defining and treating a problem so that persons can exercise more self-determination. Although their conceptualization of the phenomena associated with smhp was an advance, their methods of intervention were often crude by standards of today. For example, during the Age of Enlightenment, treatments included submersion in vats of nearly freezing water, blood letting (i.e., planned bleeding through laceration or parasite), and even using hot glass to burn the skin of patients (citation). Although not recorded in graphic detail, it is likely that the most common practices of the “average person” living in communities of the past are those that continue today: (a) ignoring or not associating with persons who are considered deviant, (b) hiding them from view, or (c) actively ostracizing them from their communities.

Societies’ Settings for Addressing SMHP

The history of modern mental health treatment can be traced to the actions of Phillipe Pinel in 18^th Century France, where ostracizing and imprisoning persons with serious mental health problems was the status quo. Pinel was interested in reforming these practices and instituting “humane treatment”(citation). He unshackled those who were chained and asserted that hospital care should be provided to those with smhp rather than prison. In essence, Pinel made the creation and reform of settings to address concerns of persons with smhp a matter of social importance and deliberation that continues to this day.

Creating Settings. The most common response to concerns about care for persons with smhp has been the creation of specialized hospitals or clinics. In colonial America, Quaker activists formed the Pennsylvania Hospital in Philadelphia to provide care to the sick and mentally ill ( Rappaport, 1977). Based upon their convictions of compassion and justice, forming a hospital was a radical measure to treat people with smhp better than neglect, prison, or ostracizing them. The emphasis on medical care and professionalization of that care that accompanied the founding of hospitals changed the dominant paradigm for understanding smhp from matters of demonology or moral failing to be one of illness. Pinel and others (e.g., Benjamin Rush) promoted the search for a “cure to illness” for persons with emotional problems.

An alternative promoted in 18^th Century England and its colonies, was the model of “moral treatment” and retreat. Treatment was typically provided in a country setting for a small group of persons to live together, recover, and work (Rappaport, 1977, citation). A less stressful environment was seen as critical for rehabilitation. It is likely that the term “asylum” was associated with responses to smhp based upon this model for community response. In fact, King George III of England was reported to have benefitted from such an approach (citation, ). However, this alternative appeared to be effective when persons involved were relatively few and of sufficient social standing to afford such treatment. Migrations of persons and further development of urban problems soon made this approach untenable as a population-wide policy for addressing smhp.

Reforming Settings. The creation of state or regional hospitals for mental illness was a typical a response to dissatisfaction with the inadequacy of previous hospitals, asylums, or other sanctuaries for addressing the need mental health responses for cities of the 19^th and early 20^th century. Reformers in communities argued that special care needed to be created in settings the local or regional governments would dedicate to the care (and segregation) of persons with smhp. By the middle of the 19^th century, those persons whose behavior was most aberrant were again detained in jails and prison. In the U.S., a new reformer emerged in the person of Dorothea Dix, who championed the Asylum Movement (citation). This movement again emphasized the creation of sanctuaries apart from the "poisonous effects" of the then modern urban life. This movement transformed into the creation of state hospitals and sanatoriums across the U.S. However, by the end of the 19th century, the state hospitals had ironically become overcrowded and brutish like the prisons they were meant to replace (citation).

Other reforms of settings have emphasize changing practices of current settings to be more humane and more effective in their practice. In Nigeria, efforts have been made to reform the British-influenced practice of psychiatry by incorporating family members and traditional healing practices in culturally appropriate ways for their practice (Asuni, 1990) The Mental Hygiene movement of the early 20^th century had a mission to reform psychiatric treatment and improve the regional mental hospitals (citations). Mental Hygiene supporters emphasized training more psychiatrists and other professional staff as primary means of improving the conditions of the institutions Rappaport, 1977). Interestingly, the formation of this movement was strongly influenced by a man who had experienced smhp. With Clifford Beers, for the first time, a person with serious mental health problems spoke publically about his experience in the service of making reforms and policy changes. Beers’ book, A Mind that Found Itself, recounted his journey to wellness after developing mental health problems as Yale University undergraduate. However, an opportunity for collaborative work to promote liberation of persons with smhp passed as Mental Hygiene supporters emphasized training more professionalization as the primary means of reform (Rappaport, 1977). It would be another 60 to 70 years until persons with serious mental health problems would re-emerge as powerful voices for reform and change of societies’ responses to deviancy.

De-constructing Settings. Sometimes proponents of social change and mental health policy have decided that reforming settings was no longer a viable strategy. In these cases, settings were dismantled. Throughout industrialized countries over the last fifty years, regional mental hospitals have been closed and new community resources have been developed or were planned to be developed (Fattore, Percudani, Pugnoli, Beecham, & Contini, 2000; Manderscheid & Henderson, 1998; Newton, Rosen, Tennant, Hobbs, Lapsley, & Tribe, 2000) . Between 1972 and 1982, the number of hospitals with over 1,000 psychiatric beds fell considerably (i.e., 50-80%) in Denmark, England, Ireland, Italy, Spain, and Sweden (Freeman, Fryers, & Henderson, 1985). Similar patterns occurred in North America and Australia (Carling, 1995; Newton et. al., 2000).

A new field of mental health intervention was created in response to de-institutionalization, Community Mental Health (e.g., Smith & Hobbs, 1966). With new psychiatric drugs and a new ethic, professionals and politicians dictated that treatment would now be given in community settings. In the U.S. and Canada, Community Mental Health Centers were founded with the charge of promoting the development of care within the community contexts of the persons needing the care. Unfortunately, the aspirations of the architects of the legislation were not realized as community support for persons who were discharged from hospitals diminished in the face of seemingly endless demand for treatment and unmet need for services. In the U.S., over half of aftercare services shifted from state hospitals to community-based facilities, however, state mental health facilities still consumed more than half of the expenditures (Manderscheid & Henderson, 1998). In Canada, Simmons’ (1990) review of mental health policy found that:

Almost every five years from 1930 to 1985, a report, analysis or critique of Ontario’s mental health system appeared, recommending major changes and reforms. Without exception, each recommended a major extension of community mental health services. (Simmons, 1990, p. xiii).

The experience in Italy provides a prominent example of a nation that radically changed its health policy to dismantle hospitals and create alternative settings where “community psychiatry” provided the framework for care (Barbato, 1998; Fattore et. al., 2000). In1978, federal legislation outlawed building new psychiatric hospitals and closed many large institutions. New settings were created, Community Psychiatric Services for defined geographical areas that integrated acute psychiatric units in general hospitals with community-based psychiatric services, such as mental health centers, residential facilities, rehabilitative institutes, and psychiatric out-patient centers. Typically, care is provided by multi-disciplinary teams. These policy changes have reduced the population of public psychiatric hospitals from 60,000 in 1978 to 15,000 in 1994. A similar reduction has occurred in private psychiatric hospitals (Barbato, 1998). This approach to mental health policy, and the approaches of other countries who have embarked on de-institutionalization, emphasize top-down planning by region that focuses on “the overall management of disorder” (Fattore, et. al., 2000) and suggests that consumers were not involved in these reforms in meaningful way.

Many persons with smhp have encountered difficulties with how de-institutionalization has been implemented. All too often, poverty, poor quality of housing, lack of employment opportunities, discrimination, social isolation and alienation have “greeted” persons in North America who have left large institutions to live in community settings (Chamberlin, 1978; Carling, 1995). Many persons with smhp in Australia have had similar experiences –episodes of homelessness or living in poverty that has placed an additional strain on their relationship with family members (Newton, Rosen, Tennant, Hobbs, Lapsley, & Tribe, 2000).

Limitations of past reforms. One enduring limitation with these reform strategies has been the concentration of resources that rely almost solely on treatment by mental health professionals as the mode for intervention. George Albee (1959, 1968) argued in his report to the U.S. Joint Commission on Mental Health and Mental Illness that it is not possible to train enough professionals to meet the need for intervention. His analysis suggests that this policy decision is based upon a faulty assumption that treatment is the preferred way to address smhp, or in more extreme arguments, the only viable response . As discussed below, we now know that this assumption is not supported empirically supported. Furthermore, forty years of mental health policy and training in the North America following Albee’s critique appear to support his claim; the training of more clinicians through the great expansion of psychology professional schools and social work programs has not kept pace of the need for clinicians in public sector community mental health. Case loads numbers increase while resources for these mental health services are cut (Torrey, et. al., 1990). This history also suggests a corollary to Albee’s maxim: Communities are unlikely to spend the money necessary to train and employ enough professionals to treat all the mental health needs that we suspect is present.

Have you noticed in this brief historical overview that past reforms have a consistent ameliorative focus with very little consideration of transformative possibilities for how smhp can be addressed? Furthermore, the approaches to treatment and rehabilitation reviewed here emphasize ameliorative changes in the lives of persons with smhp. Perhaps this suggests that another approach is need to support transformative changes that can promote liberation from the stigma and discrimination that accompany judgements of mental health deviancy in our societies. Now we consider how the efforts of persons with smhp can help societies pursue such transformative approaches to change.

Changing the Balance?

The Emergence of Consumer/ Survivors in Society’s Efforts to Address SMHP

Over the course of these “modern” reforms in mental health policy and practice, persons with serious mental health problems were seldom included in formal deliberations and decisions about how communities can respond to the realities of mental health problems. By not including all stake holders in addressing the matter of concern, these reforms often overlooked the interdependent nature of addressing mental health problems in community settings. The reforms also overlooked the resources for addressing mental health concerns that is represented in experience and learning of persons with smhp. However, during the last 30 years, the voices of persons with smhp have become increasingly more influential and have greater prominence in how competing interests of social control, deviance/ diversity, and self-determination are addressed (Chamberlin, 1990). Although not universally accepted, many contemporary policy deliberations are strongly influenced by persons who have struggled with their own mental health problems and are acting on behalf of themselves and peers to address their needs.

The emergence of Consumer / Survivor movements has opened the doors to include persons with smhp to a greater extent in decision making. These movements formed in many cities around the world in the 1970s, 1980s, and 1990s (Chamberlin, 1978, 1990; Deegan, 1988). They have dedicated themselves to be a resource for persons with smhp to come together for mutual support and collective action. The terms “consumer”, “survivor”, or “consumer/ survivor” are used in North America by persons with smhp to refer to themselves rather than the terms used by mental health professionals: “patient”, “ex-patient”, or “client”. The use of the term consumer is meant to emphasize the importance of individual choice in using services and the respect given to persons who have rights and expectations about the services they use. The term survivor emphasizes the negative consequences that many persons with smhp have experienced as a result of past mental health treatment; it is also a political statement about past mistreatment, individuals’ resilience in living, and self-determination in current life choices. Some persons with smhp have strong preferences for one term over the other and the identity that they project. The term consumer / survivor, was coined to include the political and personal perspectives of both terms.

Unlike past reforms, Consumer / Survivor Movements have articulated needs and interests that argue for the priority of transformative approaches to change, those that will promote liberation, as well as ameliorative approaches that promote wellness (Chamberlin, 1978; Nelson, Lord, & Ochocka, 2001). Priorities of the movements have included: the need for adequate, affordable housing (Carling, 1995), employment opportunities (cite), self-determination in treatment and life decisions (cite), developing alternatives to treatment (Chamberlin, 1978), pointing out injustice of discrimination based on societal assumptions about persons with smhp (cite), abolition of abusive practices of social control (cite), have been priorities of different movements. Without the articulation of these priorities by persons with smhp, they would not have been made priorities in mental health policy or practices. Consumer / survivor movements accomplished these gains through the formation of advocacy groups and initiatives, expansion of mutual assistance organizations, development of information resources based upon lived experience (e.g., books, education courses, web sites), and forming consumer operated services.

The success of the movements can be seen in the growth of mutual aid and self help organizations and their growing acceptance in treatment communities (Kessler, Mickelson, & Zhao, 1997; Chinman, Kloos, O’Connell, & Davidson, 2002), the formation of consumer / survivor advocacy movements with political clout (Davidson, Chinman, Kloos, et. al, 1999; Nelson, Lord, & Ochocka, 2001), representation at governmental agencies charged with policy and funding decisions (e.g., CMHS advisory panels), and the emergence of the recovery metaphor for interventions and accompanying practice (Fisher, 1994; Weingarten, 1994).

From the ecological standpoint presented in chapter 4, there are many niches where persons with smhp can contribute to community, organizational, and individual efforts to address mental health problems. Persons with smhp make contributions in a variety of ways that work “inside” or “outside” of formal mental health systems. These include work as: (a) advocates, (b) community leaders, (c) guides for recovery, (d) service providers, and (e) advisors. Advocates have been successful in pursuing lawsuits to close hospital practices judged to be abusive, provide more resources to community services, protest medial portrayals of smhp. Community Leaders organize Consumer / Survivor organizations, serve on policy making boards of agencies or governments. The role of Guide recognizes the value of the lived experience in recovery journeys to wellness and liberation that persons with smhp can provide to those struggling that professionals can not provide. Mutual aid and self-help groups are founded on this principle and have grown greatly in the last 30 years. The role of Service Provider has emerged in the last 15 years as Consumer/ Provider organizations have created their own services because of dissatisfaction with the services available. These have included crisis respite services rather than emergency rooms (cite), recovery-oriented case management services (cite), housing (cite), and increasingly treatment (cite). Finally, persons with smhp act as Advisors to policy making bodies by serving on committees, consulting with community leaders, or being employed by agencies to develop practices and policies that are more sensitive to the needs of persons with smhp.

The Value of Community Psychology Principles for Addressing

Serious Mental Health Problems

What can community psychology offer in promoting wellness and liberation ... and what can community psychologists do? The framework of community psycholgy’s values, principles and conceptual tools summarized in Table 2.2 is very helpful in organizing an answer to these questions. Perhaps, you want to take a moment to review the table and organize your own answers now that we have discussed some of the issues and problems facing persons with serious mental health problems.

I organize my answers using the principles presented in the table to provide examples of how the conceptual tools can be applied to address the issues raised by the values and problems associated with each principle.

Ecology. In terms of mental health problems, too often person identified as having smhp are credited as being the source of their problems. A commitment to using an ecological approach prompts investigation of issues to seek multiple perspectives at different levels of analysis. This approach can help avoid victim-blaming assessments that impede most efforts to collaborate with persons with smhp to address issues of concern. This approach to problem definition also allows for greater consideration of the needs of “whole person” rather than focusing on the personal deficits of a patient.

Prevention and Promotion. Practices, resources, and skills that promote health and reduce the probability of developing problems are the cornerstones for personal, relational, and collective well-being. While mental health treatment approaches can accomplish some promotion goals on an individual basis, greater attention needs to be paid to community-based and policy efforts to provide resources (e.g., adequate housing) and skills (e.g., relapse prevention) to persons with smhp living in community settings. Primary prevention efforts are virtually non-existent for persons with smhp within community psychology. This may be due in part to a lack of consensus about the causal paths of smhp. This omission is a glaring shortcoming of the field as more attention seems to be paid to children’s prevention than these persons who may be viewed as “beyond prevention”. Community psychologists can do more to effect structural changes necessary to provide resources or skills that can reduce the likelihood to developing smhp or exacerbating vulnerabilities for smhp.

Community. Because of the experience of being pushed to the margins of society, persons with smhp often experience alienation, isolation, and demoralization in their attempts to live in community settings. The promotion of social support networks, opportunities to participate in Self-help/ mutual aid, and social integration into community settings can help to address these issues. The Consumer/ Survivor Movement has emphasized the importance of community, power, and inclusion. Working with consumer / survivor and mutual help movements can help realize these values of caring and compassion for all members of the community.

Power. As presented in the beginning of the chapter, self-determination is often restricted by social control that is invoked in the name of controlling deviant behavior or situations. Persons with smhp often lack the opportunities to control many decisions about their lives. Personal and collective empowerment are necessary pathways to recovery, liberation, and well-being. The consumer/ survivor social change movements are critical resources of society to promote transformative change. Community psychologists can draw attention to oppression, lack of voice that persons with smhp have in many arenas of social life, as well as alternatives to addressing these issues.

Inclusion. Why do serious mental health problems have to be presented as deviance rather than matters of diversity? By changing this focus, persons’ identities may no longer be subsumed by the patient roles. Combined with other principles (e.g., community, power), it offers opportunities for greater self-definition by individuals, communities that can counter stereotypes that are prevalent about smhp. Based upon the value of respect for diversity, consumer / survivor movements and community psychologists can work for greater equity in society for persons with smhp and can create supportive communities which can mediate the stresses of society and personal challenges.

Commitment and Depowerment. Community psychologists can examine their research and action practices to see where they can share power with persons who have smhp. The principle of collaborating to accomplish the principles discussed above requires self-examination, mutual accountability in relationships with persons who have smhp, and creating structures that allow for such collaboration (e.g., advisory panels, advocacy offices). Furthermore, community psychologists can identify where societal or community structures that contribute to discrimination and oppression of persons with smhp, seek to end collusion with them, and work for the dismantling of these structures.

Exemplars of Promoting Wellness and Liberation

This chapter closes with examples of action and research that create pathways to support persons with smhp to achieve their goals for wellness and liberation. While there are many topics and examples that could be cited, I focus on issues related to housing and living in community settings.

Housing: Research and Action

Finding supportive community environments is a persistent challenge for many persons with serious mental health problems. While the housing interests of persons with smhp are very similar to general populations (Lambert, Ricci, Harris & Deane, 2000; Carling, 1995), they often do not have the resources to obtain their housing choices. Relatively few persons with smhp live in stable, decent housing (Carling, 1990; 1995). Poor quality of housing, distressed neighborhoods, and lack of affordable apartments contribute to many of the difficulties people with smhp experience as they interact in community settings. Even when persons have their own apartments, the rising cost of housing and the reduction in affordable housing stock make many residential arrangements tenuous. Sandra Newman (1994) has observed that persons with smhp in the U.S. move from one housing situation to another at more than twice the rate of the general population. She has referred to this phenomenon as chronic residential mobility, and has characterized it as a social correlate of smhp that restricts a person’s ability to make social ties and integrate into community settings. Housing issues have become a concern to a range of mental health professionals because housing problems have been documented to contribute to a cycle of increased smhp symptomatology and exposure to harmful community environments (e.g., Breakey & Fischer, 1995; Dickey, Gonzalez, Latimer, & Powers, 1996; Drake, Wallach, Teague, Freeman, Paskus, & Clark, 1991).

While not a large number of community psychologists focus their work on housing issues for persons with smhp, the contributions of community psychology’s principles and conceptual tools can be of assistance to persons who hold similar values. Community psychologists can address housing issues of concern to persons with smhp in several ways:

(a) increasing housing options, (b) work to make housing more affordable, (c) investigate the relationship between housing / neighborhood quality and persons well-being, and (d) facilitating social support and natural supports related to the housing.

Geoff Nelson and colleagues have critically reviewed housing approaches for persons with smhp and advocated for expanding housing choices and availability (e.g., Nelson & Smith-Fowler, 1987; Nelson, Walsh-Bowers, Hall, 1998; Parkinson, Nelson, & Horgan, 1999) . Through their research they have found that a majority of housing in North America is custodial in nature (i.e., emphasizing higher levels of oversight and social control). However, Parkinson, et al, have argued that the emphasis needs to be altered to include more permanent, supported housing is a better alternative for those who embrace the values of community psychology. Supported housing emphasizes self-determination of persons with smhp in market housing where tenants hold their lease. These community psychologists provide good examples of how research findings can be used to argue for changes in laws and allocations of resources. Psychologists can also train others in how to present the data and evaluate programs.

Psychologists and others have also worked to expand the availability of housing through housing subsidies that will allow persons to move into an apartment. The acquisition of subsidies is a central component of supported housing approaches. Research on housing subsidies fount that persons’ participation in these supported housing programs was associated with increased housing stability and residential tenure (Hurlburt, Hough, & Wood, 1996; Shern, Felton, Hough, et. al., 1997; Tsemberis, 1999). Housing stability has also been associated with reduced hospitalizations (Dickey, Gonzalez, Latimer, et. al., 1996) and increased supportive contact with one’s family (Wood, Hurlburt, Hough, and Hofstetter, 1998). There is also some indication that supported housing as a mental health services strategy realizes a cost benefit in reduced service use compared to other housing interventions (Dickey, Latimer, Powers, Gonzalez, & Goldfinger, 1997). Documenting the success of these policies is an important role for community psychologists. Evidence, such as from research, is typically required before new funds can be released .

A third line of mental health housing research has a broader scope of inquiry that includes neighborhood and community factors related to clients’ housing. The importance of community environments has received the least emphasis in mental health research, but appears to be a promising area of inquiry. For example, the rate of neighborhood disorder (e.g., abandoned housing, high amount of vandalism, problematic public behavior) is associated with greater fear of crime, depression, anxiety, and somatic symptoms (White, Kasl, Zahner, & Will, 1987). The fear of crime and the social climate of the neighborhood may be particularly relevant for persons with smhp as they experience higher rates of crime than the general population (Newman, 1994). Furthermore, individuals with smhp appear to function better in communities that are perceived to be more tolerant and supportive (Newman, et. al., 1994). Conversely, neighborhoods that are distressed (i.e., lack economic and social resources) are often associated with poor mental health outcomes (Wandersman & Nation, 1998), and those with high rates of residential turnover make it difficult to establish local social support networks (Sampson & Groves, 1989, Newman, 1994). Perhaps in a few years, more information will be known that can help to maximize consumer / survivors well-being in the housing settings of their choice.

Finally, we consider how housing environments can be used as a fulcrum for efforts to facilitate interpersonal relationships and sense of community that supports wellness. While the development of greater housing options is relatively new, policy makers and service providers have long emphasized the importance of fostering collaborative relationships with people outside of mental health settings who can support successful community living for people with smhp (Glidewell, 1971; Joint Commission on Mental Illness and Health, 1961; Smith & Hobbs, 1966; Rappaport, 1977). People who act as natural supports, in contrast to service providers, interact with an individual in ways that provide assistance or facilitate recovery although they are not employed to do so. These may include neighbors, shopkeepers, church members, or others who interact socially with individuals needing support. In the case of supported housing, people acting as natural supports are seen as potentially more responsive to tenants’ social needs by virtue of being located in the settings where tenants live. Furthermore, they can help make supportive changes in the neighborhood environment and are in a better position than service providers to invite tenants to participate in community activities and organizations. One of the principle, naturally occurring relationships inherent in supported housing is that between a tenant and landlord. Paul Carling, a primary architect of current supported housing programs, has argued that working with landlords should be an essential part of any housing program (Carling, 1995).

For the past six years, I have worked with a housing program to foster better working relationships between tenants, service providers, and landlords/ property managers. As part of these efforts, colleagues and I have developed a Landlord-Service Provider Forum to: (a) to increase knowledge of all stakeholders regarding roles, rights and responsibilities of tenants, landlords, and service providers; (b) to improve communication and shared problem-solving; (c) to increase housing stability of program participants; (d) to retain quality landlords; and (e) to expand the availability of safe, affordable, housing by recruiting new landlords interested in collaboration (Kloos, Zimmerman, Scrimenti, & Crusto, 2002). The forum sessions are facilitated by housing program staff who specialize in building community coalitions. Forum meetings are open to all landlords who rent apartments to people in supported housing programs, their property managers, and to service providers working with tenants participating in the programs. The topics are primarily generated by forum participants and have included: facilitating better communication, addressing barriers to social integration, tenants' experience of homelessness, “moving-in”: the transition to housing, utilizing community resources, reasonable accommodation, promoting stability in housing, recovery and rehabilitation, and discrimination encountered by program tenants.

Participants have appreciated the new insights they have gained into the roles of landlords and service providers as they had not realized the pressures and needs unique to each role. The forum has facilitated better communication and working relationship among participating landlords and service providers. Additionally, newer landlords have learned about alternative courses of action they can take in solving problems from the insights offered by "veteran" landlords participating in the forum. We have found that landlords’ and service providers’ discussions have changed to view tenants more as active partners than as people who have to be “served”. However, landlords and service providers have resisted suggestions about including tenants in the meetings. Thus, we have started a separate forum for tenants to address their housing concerns. We are seeking opportunities to bring the two groups together on particular projects that promote successful experiences with community integration.

Summary

This chapter reviewed the competing tensions in society’s responses to serious mental health problems throughout Western history. The emergence of Consumer / Survivor movements has introduced a new dynamic in how these tensions are balanced; to the greatest extent in history, persons with smhp are actively involved in many personal, communal, and societal deliberations about responses to smhp. Supporting these efforts through their research and action is very consistent with the practice of community psychology.

Decades from now we will be able to evaluate whether the changes spurred by the emergence of consumer / survivor movements reflect the balance of tensions at one moment in time, like other mental health reforms, or are evidence of the dawning of a new dimension in how societies respond to mental health problems. I am optimistic that the emergence or organized mutual help and consumer / survivor creates an effective lobby and significant precedent that persons with smhp will respond to plans for action and help to implement change and preserve gains, especially at micro and meso levels of analysis. However, much work needs to be done to affect change on macro-levels of analysis and investigating what efforts can help to prevent smhp.

I think we must be humble about we don’t understand regarding the “root causes” of serious mental health problems. Like many phenomena, a strategy of multiple levels of analysis is needed to promote wellness and liberation (e.g., economic justice, social stressors, patterns of victimization and trauma within relationships, problematic family experience, neurochemical functioning). Community psychologists can play an important role promoting broader, multilevel understandings of serious mental health problems. Furthermore, we can raise issues and concerns of discrimination, oppression, and other injustice that are experienced by persons with smhp. By standing with persons who have experienced serious mental health problems, community psychology can help to promote empowerment and liberation, which may transform how expectations for how wellness is articulated and expressed.

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