Outpatient Commitment - An Asylum in the Community
(Re-Read Text pp. 169 to 176)
Does outpatient commitment recreate an asylum in the community? why or why not? Give at least 3 reasons for your answer, and then reply to one of your classmates.
I do think, in a sense, mental health hospitals have become community based. I can draw from my observations as an ACT case manager in Vermont. There were two staffed group homes that come to mind that I visited on a weekly basis. Both homes housed people with severe and persistent mental health disabilities. Both homes had 24 hr staff and were located in rural setting, many miles away from the nearest town. Clients were given medication on a strict regimented basis. Clients rarely left the home, but when they did, is was often with their case manager. Occasionally, case management would chaperone a group of clients in the community. It seems like it was the woods took the place of the asylum walls and heavy medication replaced the restraints. Even clients who lived “independently” in town were closely monitored by the ACT team. Every week it would be my turn to deliver medication to various clients at their homes. It was in some client’s treatment plans that the staff would not leave until the client had taken their medication. Each morning the Act Team would sit around a table and discuss how to keep people out of the hospital. We never talked about their hopes, dreams, or goals. We were very much managing our clients rather than assisting them in their recovery. So yes, I have seen firsthand how the mission of the old asylum still exists in many forms in our communities
Thanks for this account, Geoff. After reading for this post, I felt ACT more closely recreated the asylum in the community compared to a model such as the clubhouse. As a VR counselor, whenever I worked with clients with ACT services it always came across as a support team in the caretaker role; treating clients almost as if they were lucky to be in the community and a life confined to this setting was the best they could hope for.
Hi Dustin, I didn't necessarily want to discredit ACT as it is an EBP. I would say that my understanding of ACT then is not what it is today. I think my role in implementing the ACT model would be considered contributing to its low fidelity.
Though we do not have ACT programs in our area, I have often felt there were many benefits to many aspects of this approach. All approaches do need to honor the wishes and decisions of the person receiving treatment. It would seem to me the individual's choices and voice an be honored within the ACT treatment.
Geoffrey, your post was very interesting to ready. As I first considered this, I approached the question more from a philosophical level and discussed true outpatient commitment as not creating asylum in the community -meaning that it shouldn't when approached in the right way. But your post puts it in very concrete terms that really shows how easily treatment in the community mirrors the asylum, and I fear that this is a more realistic picture of how it ends up really looking. In the situations where you've seen mental health workers wait to ensure that the client takes their medication, I wonder what things would look like if they did not. What are the outcomes if those mental health workers simply trusted the client's ability to choose what is right for them even if it means not taking the medication? I would love to know more about these clients; what would happen if they simply opted not to take the medication? Do you feel that these mental health workers would be equipped to find another path to recovery?
Franco Basaglia determined that certain conditions needed to be established to prevent creating and asylum in the community. The first condition is one that I do not believe is always met or consistently met, the belief and understanding that a person with mental illness is a citizen with rights. This does not seem to be the first response when a person is being considered for community inclusion and is showing active signs of mental illness.
However, as a vocational rehabilitation counselor, I have the opportunity to meet with people who have mental illness and want to engage in employment. The people who enter vocational rehabilitation are ready for a social cooperative and "two-way traffic" into the community. A job can be an invitation into the community instead of a foothold on the perimeter of tolerance. A job in which the employee is well skilled is a place to show the person rather than the illness. This is a place to become a coworker and identity becomes based on community accepted norms.
Fountain House has created a venue that utilizes all the conditions that were expressed for community integration: community integrated activities, social cooperatives, coordination with marginalized groups, and advocacy. 20 years ago, High Hopes Clubhouse was opened by the director of Fountainhouse and it continues to instill citizenship in its members. In Waterville, Maine, the members of High Hopes Clubhouse are part of the community and the community is not an asylum. Members are active in the community and the community through employment and civil groups is active at Clubhouse. This is an intentional community approach that works and it is continuously working to change the climate for people with mental illness.
I do believe that many communities have become asylums but work and inclusion through two-way interaction can build freedom.
Work is definitely a great way to promote inclusion and two-way interaction. I am very interested in the clubhouse model-we don't have clubhouse in my area. I have been trying to think of some ways to incorporate some of the ideas into what we do have here.
Your last statement that work and inclusion can build freedom is a significant one. People with or without a mental illness is a citizen with rights. One of the effects from the stigma on people with a mental illness is they are not able to be normal, take care of themselves, and not able to work. In our past readings and in other classes, it has stood out that when people are healthier when working (whether it is part time, full time, or even in a volunteer opportunity). Being part of a community can mean many things and you are right, it needs to be a 2 way street...maybe even 3 way - community, citizen, and medical professionals.
Liz, thank you for your comments and the reminder of some of the more successful outpatient commitment communities. I think that you are right that employment is a great place to start in terms of ensuring social inclusion and providing a positive path to treatment and recovery. Work provides a connection to the community and a sense of purpose that cannot be emulated in any other way. Employment acts as a protective factor that supports mental health and overall wellness.
This is a complex issue partly because people with serious mental health diagnoses continue to be viewed in negative and stereotyping ways. The move toward deinstitutionalization created a push for community resources, including ACT and other programs. While the idea of getting people back into the community is a start, doing so without including the people with the mental health diagnoses in the ideas, planning, and implementation of plans fails to actually include them in the community.
People with serious mental health diagnoses continue to struggle in the community with inadequate access to counseling, transportation, housing, and inclusion in community events. As was pointed out by Howie in the video, many people with mental illness are independent and would rather be homeless than utilize programs that are in place. That is very sad.
Work is one way people with mental illness can experience inclusion in the community. People with mental illness who are involved in services through agencies often seem to experience directive and even sometimes coercive treatment. Providers, who want to ensure safety and well-being, can easily fall into the role of feeling they know best and pushing people to fall their prescribed treatments. Questioning or not wanting to follow prescribed treatment continues to be viewed by many in the treatment provider realm as non-compliance rather than choice.
I also continue to see the concept that people with mental illness need to be protected. They are seen as somehow inferior in their ability and right to experience life in its entirety including goals, dreams, and failings. That view of needing to protect others who are viewed as less capable leads to treating people as if they have fewer rights. That is what I see happening to people diagnosed with mental illness. They are led to believe they are not capable of work. They are treated as if they aren't able to make their own decisions. They are often treated like "naughty children" when they don't "comply" with decisions made by "the team."
The Clubhouse model promotes inclusion in the community. People diagnosed with mental illness are partners. We do not have clubhouse, or ACT for that matter, in our area. It would be interesting to see what would happen if we did.
Toni, your post is spot on in the sense that community based treatment for folks with MI can be directive or even coercive in nature. For the short time I had case manager job we never as an ACT team spoke about client’s goals and certainly did not encourage work. I think I had one meeting with a VR counselor with an ACT client. I can’t recall what the meeting was about and I certainly had no clue what VR was at the time. It’s not a leap to suggest that some of us VR counselors today have similar experiences working with uninformed case managers. This is not to fault case managers, but more to point out how treatment professional’s roles are still so separate. VR counselors handle work and case managers do everything else. Or at least that is the impression. The lack of collaboration is such an issue. I think both VR counselors and case managers dis-empower people with MI. In both instances we have been the almighty gate-keeper. Case managers work with medication managers to determine if people are well-enough to do anything. If people with MI are deemed “stable” and sent to VR, it is now the VR counselors chance to hold the power. VR counselors get to approve or shoot down vocational goals. I was taught to use a critical eye before supporting a job goal. So critical in fact, that it has hard for a client to suggest a vocational goal that I couldn’t poke several holes through. Today, when I’m working with clients I try to be “open to anything” and in fact that is exactly what I say. I feel like this ignites a sense of hope into clients when they feel that they are in charge and anything is possible. As a VR counselor I’m no longer the gatekeeper, I have become the dream coach.
I think collaboration is very important, yet often various providers do not know what other programs do or offer. Providers do the best they can and certainly want to do what they believe is best. The idea of being a dream coach instead of a gatekeeper is excellent.
From my perception of mental health services available in our community it does appear as if the asylum has been recreated in the community. Davidson, Rakfeldt, & Strauss (2010) summarized a key point on whether outpatient treatment recreates asylum in the community when they stated: “It was crucial in all of these circumstances that the staff not take over the situation and resolve it for the person, as this would be to lapse back into the asylum role of caretaker” (p. 176). I think outpatient treatment services in the community recreate asylum when this fundamental rule is not followed. Davidson et al. (2010) discussed that we recreate institutions in the community by viewing the staff as in charge of or responsible for the person with mental illness. We are not recreating institutions in the community when we support (with our role as being more of a mediator) people with mental illnesses to be able to live fully as citizens of their communities. As Davidson et al. (2010) pointed out, there are lessons to avoid repeating such as accepting long-term disability and artificial mental health settings as the best people can hope or work towards.
Hi Dustin, I think it depends on the resources in the communities and awareness of the concept of inclusion. For the most part, I agree it recreates the asylum if the staff takes over the situation and solves the problems for the client. How are they to learn how to be independent if others are doing the recovery work for them? Last, yes LTD can help with return to work efforts however many people have a disability mindset after 6 months out of work (the average time for LTD to kick in or Elimination Period).
Dustin, I appreciate yours and Davidson's point regarding the way in which power and authority affect treatment. I can see how reliance on the clinician tends to create an institutionalized environment regardless of the physical setting. By supporting the belief that client's are in charge of their own treatment, we ensure that outpatient treatment does not mirror the asylum and we maximize the chance that treatment is individualized to each client.
I think that in many ways asylums have been recreated in the community. I encounter quite a few individuals in my work who seem trapped in a hopeless cycle. I've seen many individuals living on a limited income, without access to reliable transportation, and dependent on case managers to help coordinate many aspects of their lives. I believe there is a strong mentality of the "professionals knowing best" which continues to place the person with mental illness in a position without much control. I was working with a woman who lost her case manager due to changes with section 17 services and she was left reeling because she had become so dependent on these services. She disappeared from VR services for a time because of this but I kept her case open and eventually she resurfaced in a really positive way. She has taken charge of her life and is making strides towards her goal of becoming employed. Normally I advocate for someone to access case management and community support services because it can help individuals access important resources that may be difficult to access by oneself. But at times I do feel that this places people with mental illness into the role of passive recipient, rather than empowered individuals with hopes and dreams. And I certainly am not placing blame in any one place because I think we have an entire system that has created this mentality.
Hi Sandy, it definitely is a double edged sword with accessing resources but not having a person become a pawn in someone's game. Some case managers are highly skilled in empowering and teaching but many take on a parental role that does not allow the person to make choices like an adult.
Sandra, I agree that we have some great programs and services to help people with mental illness, but once in that system it does make it harder to be independent sometimes. I know there is the struggle of trying to do everything you can for someone with limited time and funding, that can cause this cycle. I hope that the change that we are seeing in new programs that focus on independence and goal attaining will continue and provide more opportunities in the future.
Sandra, thank you so much for your post. While I think it is important that we provide individualized treatment and outpatient supports to clients, I too have seen how significantly these can be relied on just as heavily as they would in an institutionalized setting. How do we balance providing support while teaching and enabling clients to access supports in the long-term? For some clients this may be easily accomplished because they are eager to learn and operate without as much one-on-one support. Others, however, might not be so eager to learn. And of course, the other question with this is, "Is that okay too? Is the goal of recovery to eventually get a place where a client is happy and healthy and operating without mental health supports or is the goal to find a balance and function happily and healthily in life with mental health supports as needed? I would lean toward the latter since recovery can mean different things for different people.
I think many programs that help individuals with mental illness live outside the hospital focus more on the medication being the treatment instead of focusing on the freedom aspect. If medication would solely be enough treat patients then they would still be in the hospital. Sometimes though well intentioned program can be do imitate an asylum outside the hospital when they don't focus on the clients they work with and their personal goals and connections in the community. Then we have great programs like the clubhouse which really focus on bringing people together and building useful skills through interaction. I believe that society's stigma against mental illness creates the perception that these clients do not know whats best for themselves. This makes it harder for individuals with mental illness to be heard when they advocate for themselves, whether it be about their medication or what they aspire for. There is also a lack of funding for many programs that trickle down to employees that are doing the bare minimum with clients in the community. Poverty limits everyone and people with mental illness suffer as well with limited or no services at all and end up feeling hopeless in the system. There are many different ways that our mental health system is still failing the people in the most need and creating a asylum outside the hospital, but there are programs that have good and bad aspects and some that are on the right track. I am hopeful that future brings more awareness and stigma reducing elements to our society that make everyone feel included and well.
Hi Michelle, I think you're right that there is a perception in society that individuals with mental illness do not have the ability to make well informed choices and that it is up to the professionals (counselors, case managers and others) to be the guiding force. But that dynamic is not conducive to real recovery. As long as we continue to think of people with mental illness as incapable of making sound decisions who need to be guided step by step, then we will continue to see these same patterns.
To me, outpatient commitment feels similar to an asylum situation in some instances, as the care and treatment plan tends to be more driven by the medical professional, as opposed to the patient. Even though deinstitutionalization has occurred, people struggling with a mental illness (who do not have it controlled) do have rights; however, if confinement is a pending alternative, this freedom does not seem as free of a choice as it should be for any citizen in the U.S.
The question is difficult to answer since some communities may have stronger personal/medical support and social systems than others. Inner cities might have less community-based funded programs then a suburb due to money and resources focused on recovery. Also, the community’s awareness for inclusion, providing work opportunities, and simple social focus on helping and understanding those with a mental illness also play a role. Outpatient care with strong community inclusion would not be like an asylum, to me.
The mental health system and community based programs need to create and maintain a collaborative partnership when focusing on outpatient commitment programs. It seems like some of the places we read about like the Fountain House and Act will not emulate asylums of the past but allow for inclusion. Creating opportunities for work is also an important aspect, not similar to the asylum effect.
It is so important for all citizens to have the opportunity for inclusion. Fountain House and the clubhouse are governed by standards, one of which is a guaranteed place to be. Family is a guaranteed place to be for many people but sometimes active mental health issues can destroy this without support. Informed consent without coercion would help citizens make choices without creating the community asylum.
As we consider whether or not outpatient commitment merely recreates asylum in the community, we must consider the traits of both the outpatient supports and those of asylums in general. As we’ve explored asylums throughout these past few weeks, three elements have stood out as especially significant; their tendency to isolate patients from family, friends and their everyday lives, their tendency to over-medicate patients, and their tendency to minimize patient-choice and voice in treatment. A commitment to outpatient treatment in the community, however, is a commitment to empowering patients to be the dominant voice in their treatment path while supporting and encouraging community involvement and social interaction with friends and family members and reducing reliance on medication. True commitment to this kind of outpatient treatment does not recreate an asylum in the community, however, because outpatient commitment requires mental health supports, the line between the two could easily muddled and crossed if clinicians are not careful in their approach. Clinicians must remain dedicated in their actions and uphold such beliefs for their patients as their patient’s human rights to: choose their treatment method, be socially included as important, contributing members of their community, and to be provided with supports and treatment that are individualized to them. By remaining commitment to ensuring their client’s human rights, choices in individualized treatment, and involvement in their communities, clinicians can work to ensure that outpatient treatment does not recreate asylums in the community. To do so, physicians must recognize that their clients are people first and patients second, and they alone have the power to choose their treatment path; the physicians job is to merely educate and present options and then provide the treatment as chosen by the client. They must not hold in-patient treatment as a contingency consequence for struggles in out-patient treatment. They must refrain from using medication as a crutch and a mere tool for managing symptoms, and instead use it cautiously as tool toward recovery. Physicians must provide supports that enable them to be active members of their communities and families which means helping them find and keep jobs, access everyday resources such as the post office, bank, and grocery store, utilize transportation, and develop communication and advocacy skills that enable them to build positive relationships with friends, family, and coworkers while overcoming mental health issues. Supporting social inclusion also means educating the public and supporting policies that create environments in which mental illness does not have a negative connotation to it and rather is viewed merely as a normal, accepted issue that humans struggle with. Above all else, physicians must ensure that these outpatient supports and treatment are individualized to each client and that each client is able to access one-on-one support as they navigate their everyday lives, communities, and mental health needs.
I do think, in a sense, mental health hospitals have become community based. I can draw from my observations as an ACT case manager in Vermont. There were two staffed group homes that come to mind that I visited on a weekly basis. Both homes housed people with severe and persistent mental health disabilities. Both homes had 24 hr staff and were located in rural setting, many miles away from the nearest town. Clients were given medication on a strict regimented basis. Clients rarely left the home, but when they did, is was often with their case manager. Occasionally, case management would chaperone a group of clients in the community. It seems like it was the woods took the place of the asylum walls and heavy medication replaced the restraints. Even clients who lived “independently” in town were closely monitored by the ACT team. Every week it would be my turn to deliver medication to various clients at their homes. It was in some client’s treatment plans that the staff would not leave until the client had taken their medication. Each morning the Act Team would sit around a table and discuss how to keep people out of the hospital. We never talked about their hopes, dreams, or goals. We were very much managing our clients rather than assisting them in their recovery. So yes, I have seen firsthand how the mission of the old asylum still exists in many forms in our communities
ReplyDeleteThanks for this account, Geoff. After reading for this post, I felt ACT more closely recreated the asylum in the community compared to a model such as the clubhouse. As a VR counselor, whenever I worked with clients with ACT services it always came across as a support team in the caretaker role; treating clients almost as if they were lucky to be in the community and a life confined to this setting was the best they could hope for.
DeleteHi Dustin, I didn't necessarily want to discredit ACT as it is an EBP. I would say that my understanding of ACT then is not what it is today. I think my role in implementing the ACT model would be considered contributing to its low fidelity.
DeleteThough we do not have ACT programs in our area, I have often felt there were many benefits to many aspects of this approach. All approaches do need to honor the wishes and decisions of the person receiving treatment. It would seem to me the individual's choices and voice an be honored within the ACT treatment.
DeleteGeoffrey, your post was very interesting to ready. As I first considered this, I approached the question more from a philosophical level and discussed true outpatient commitment as not creating asylum in the community -meaning that it shouldn't when approached in the right way. But your post puts it in very concrete terms that really shows how easily treatment in the community mirrors the asylum, and I fear that this is a more realistic picture of how it ends up really looking. In the situations where you've seen mental health workers wait to ensure that the client takes their medication, I wonder what things would look like if they did not. What are the outcomes if those mental health workers simply trusted the client's ability to choose what is right for them even if it means not taking the medication? I would love to know more about these clients; what would happen if they simply opted not to take the medication? Do you feel that these mental health workers would be equipped to find another path to recovery?
DeleteFranco Basaglia determined that certain conditions needed to be established to prevent creating and asylum in the community. The first condition is one that I do not believe is always met or consistently met, the belief and understanding that a person with mental illness is a citizen with rights. This does not seem to be the first response when a person is being considered for community inclusion and is showing active signs of mental illness.
ReplyDeleteHowever, as a vocational rehabilitation counselor, I have the opportunity to meet with people who have mental illness and want to engage in employment. The people who enter vocational rehabilitation are ready for a social cooperative and "two-way traffic" into the community. A job can be an invitation into the community instead of a foothold on the perimeter of tolerance. A job in which the employee is well skilled is a place to show the person rather than the illness. This is a place to become a coworker and identity becomes based on community accepted norms.
Fountain House has created a venue that utilizes all the conditions that were expressed for community integration: community integrated activities, social cooperatives, coordination with marginalized groups, and advocacy. 20 years ago, High Hopes Clubhouse was opened by the director of Fountainhouse and it continues to instill citizenship in its members. In Waterville, Maine, the members of High Hopes Clubhouse are part of the community and the community is not an asylum. Members are active in the community and the community through employment and civil groups is active at Clubhouse. This is an intentional community approach that works and it is continuously working to change the climate for people with mental illness.
I do believe that many communities have become asylums but work and inclusion through two-way interaction can build freedom.
Work is definitely a great way to promote inclusion and two-way interaction. I am very interested in the clubhouse model-we don't have clubhouse in my area. I have been trying to think of some ways to incorporate some of the ideas into what we do have here.
DeleteYour last statement that work and inclusion can build freedom is a significant one. People with or without a mental illness is a citizen with rights. One of the effects from the stigma on people with a mental illness is they are not able to be normal, take care of themselves, and not able to work. In our past readings and in other classes, it has stood out that when people are healthier when working (whether it is part time, full time, or even in a volunteer opportunity). Being part of a community can mean many things and you are right, it needs to be a 2 way street...maybe even 3 way - community, citizen, and medical professionals.
DeleteLiz, thank you for your comments and the reminder of some of the more successful outpatient commitment communities. I think that you are right that employment is a great place to start in terms of ensuring social inclusion and providing a positive path to treatment and recovery. Work provides a connection to the community and a sense of purpose that cannot be emulated in any other way. Employment acts as a protective factor that supports mental health and overall wellness.
DeleteThis is a complex issue partly because people with serious mental health diagnoses continue to be viewed in negative and stereotyping ways. The move toward deinstitutionalization created a push for community resources, including ACT and other programs. While the idea of getting people back into the community is a start, doing so without including the people with the mental health diagnoses in the ideas, planning, and implementation of plans fails to actually include them in the community.
ReplyDeletePeople with serious mental health diagnoses continue to struggle in the community with inadequate access to counseling, transportation, housing, and inclusion in community events. As was pointed out by Howie in the video, many people with mental illness are independent and would rather be homeless than utilize programs that are in place. That is very sad.
Work is one way people with mental illness can experience inclusion in the community. People with mental illness who are involved in services through agencies often seem to experience directive and even sometimes coercive treatment. Providers, who want to ensure safety and well-being, can easily fall into the role of feeling they know best and pushing people to fall their prescribed treatments. Questioning or not wanting to follow prescribed treatment continues to be viewed by many in the treatment provider realm as non-compliance rather than choice.
I also continue to see the concept that people with mental illness need to be protected. They are seen as somehow inferior in their ability and right to experience life in its entirety including goals, dreams, and failings. That view of needing to protect others who are viewed as less capable leads to treating people as if they have fewer rights. That is what I see happening to people diagnosed with mental illness. They are led to believe they are not capable of work. They are treated as if they aren't able to make their own decisions. They are often treated like "naughty children" when they don't "comply" with decisions made by "the team."
The Clubhouse model promotes inclusion in the community. People diagnosed with mental illness are partners. We do not have clubhouse, or ACT for that matter, in our area. It would be interesting to see what would happen if we did.
Toni, your post is spot on in the sense that community based treatment for folks with MI can be directive or even coercive in nature. For the short time I had case manager job we never as an ACT team spoke about client’s goals and certainly did not encourage work. I think I had one meeting with a VR counselor with an ACT client. I can’t recall what the meeting was about and I certainly had no clue what VR was at the time. It’s not a leap to suggest that some of us VR counselors today have similar experiences working with uninformed case managers. This is not to fault case managers, but more to point out how treatment professional’s roles are still so separate. VR counselors handle work and case managers do everything else. Or at least that is the impression. The lack of collaboration is such an issue. I think both VR counselors and case managers dis-empower people with MI. In both instances we have been the almighty gate-keeper. Case managers work with medication managers to determine if people are well-enough to do anything. If people with MI are deemed “stable” and sent to VR, it is now the VR counselors chance to hold the power. VR counselors get to approve or shoot down vocational goals. I was taught to use a critical eye before supporting a job goal. So critical in fact, that it has hard for a client to suggest a vocational goal that I couldn’t poke several holes through. Today, when I’m working with clients I try to be “open to anything” and in fact that is exactly what I say. I feel like this ignites a sense of hope into clients when they feel that they are in charge and anything is possible. As a VR counselor I’m no longer the gatekeeper, I have become the dream coach.
DeleteI think collaboration is very important, yet often various providers do not know what other programs do or offer. Providers do the best they can and certainly want to do what they believe is best. The idea of being a dream coach instead of a gatekeeper is excellent.
DeleteFrom my perception of mental health services available in our community it does appear as if the asylum has been recreated in the community. Davidson, Rakfeldt, & Strauss (2010) summarized a key point on whether outpatient treatment recreates asylum in the community when they stated: “It was crucial in all of these circumstances that the staff not take over the situation and resolve it for the person, as this would be to lapse back into the asylum role of caretaker” (p. 176). I think outpatient treatment services in the community recreate asylum when this fundamental rule is not followed. Davidson et al. (2010) discussed that we recreate institutions in the community by viewing the staff as in charge of or responsible for the person with mental illness. We are not recreating institutions in the community when we support (with our role as being more of a mediator) people with mental illnesses to be able to live fully as citizens of their communities. As Davidson et al. (2010) pointed out, there are lessons to avoid repeating such as accepting long-term disability and artificial mental health settings as the best people can hope or work towards.
ReplyDeleteHi Dustin, I think it depends on the resources in the communities and awareness of the concept of inclusion. For the most part, I agree it recreates the asylum if the staff takes over the situation and solves the problems for the client. How are they to learn how to be independent if others are doing the recovery work for them? Last, yes LTD can help with return to work efforts however many people have a disability mindset after 6 months out of work (the average time for LTD to kick in or Elimination Period).
DeleteDustin, I appreciate yours and Davidson's point regarding the way in which power and authority affect treatment. I can see how reliance on the clinician tends to create an institutionalized environment regardless of the physical setting. By supporting the belief that client's are in charge of their own treatment, we ensure that outpatient treatment does not mirror the asylum and we maximize the chance that treatment is individualized to each client.
DeleteI think that in many ways asylums have been recreated in the community. I encounter quite a few individuals in my work who seem trapped in a hopeless cycle. I've seen many individuals living on a limited income, without access to reliable transportation, and dependent on case managers to help coordinate many aspects of their lives. I believe there is a strong mentality of the "professionals knowing best" which continues to place the person with mental illness in a position without much control. I was working with a woman who lost her case manager due to changes with section 17 services and she was left reeling because she had become so dependent on these services. She disappeared from VR services for a time because of this but I kept her case open and eventually she resurfaced in a really positive way. She has taken charge of her life and is making strides towards her goal of becoming employed. Normally I advocate for someone to access case management and community support services because it can help individuals access important resources that may be difficult to access by oneself. But at times I do feel that this places people with mental illness into the role of passive recipient, rather than empowered individuals with hopes and dreams. And I certainly am not placing blame in any one place because I think we have an entire system that has created this mentality.
ReplyDeleteHi Sandy, it definitely is a double edged sword with accessing resources but not having a person become a pawn in someone's game. Some case managers are highly skilled in empowering and teaching but many take on a parental role that does not allow the person to make choices like an adult.
DeleteSandra, I agree that we have some great programs and services to help people with mental illness, but once in that system it does make it harder to be independent sometimes. I know there is the struggle of trying to do everything you can for someone with limited time and funding, that can cause this cycle. I hope that the change that we are seeing in new programs that focus on independence and goal attaining will continue and provide more opportunities in the future.
DeleteSandra, thank you so much for your post. While I think it is important that we provide individualized treatment and outpatient supports to clients, I too have seen how significantly these can be relied on just as heavily as they would in an institutionalized setting. How do we balance providing support while teaching and enabling clients to access supports in the long-term? For some clients this may be easily accomplished because they are eager to learn and operate without as much one-on-one support. Others, however, might not be so eager to learn. And of course, the other question with this is, "Is that okay too?
DeleteIs the goal of recovery to eventually get a place where a client is happy and healthy and operating without mental health supports or is the goal to find a balance and function happily and healthily in life with mental health supports as needed? I would lean toward the latter since recovery can mean different things for different people.
I think many programs that help individuals with mental illness live outside the hospital focus more on the medication being the treatment instead of focusing on the freedom aspect. If medication would solely be enough treat patients then they would still be in the hospital. Sometimes though well intentioned program can be do imitate an asylum outside the hospital when they don't focus on the clients they work with and their personal goals and connections in the community. Then we have great programs like the clubhouse which really focus on bringing people together and building useful skills through interaction. I believe that society's stigma against mental illness creates the perception that these clients do not know whats best for themselves. This makes it harder for individuals with mental illness to be heard when they advocate for themselves, whether it be about their medication or what they aspire for. There is also a lack of funding for many programs that trickle down to employees that are doing the bare minimum with clients in the community. Poverty limits everyone and people with mental illness suffer as well with limited or no services at all and end up feeling hopeless in the system. There are many different ways that our mental health system is still failing the people in the most need and creating a asylum outside the hospital, but there are programs that have good and bad aspects and some that are on the right track. I am hopeful that future brings more awareness and stigma reducing elements to our society that make everyone feel included and well.
ReplyDeleteHi Michelle,
ReplyDeleteI think you're right that there is a perception in society that individuals with mental illness do not have the ability to make well informed choices and that it is up to the professionals (counselors, case managers and others) to be the guiding force. But that dynamic is not conducive to real recovery. As long as we continue to think of people with mental illness as incapable of making sound decisions who need to be guided step by step, then we will continue to see these same patterns.
To me, outpatient commitment feels similar to an asylum situation in some instances, as the care and treatment plan tends to be more driven by the medical professional, as opposed to the patient. Even though deinstitutionalization has occurred, people struggling with a mental illness (who do not have it controlled) do have rights; however, if confinement is a pending alternative, this freedom does not seem as free of a choice as it should be for any citizen in the U.S.
ReplyDeleteThe question is difficult to answer since some communities may have stronger personal/medical support and social systems than others. Inner cities might have less community-based funded programs then a suburb due to money and resources focused on recovery. Also, the community’s awareness for inclusion, providing work opportunities, and simple social focus on helping and understanding those with a mental illness also play a role. Outpatient care with strong community inclusion would not be like an asylum, to me.
The mental health system and community based programs need to create and maintain a collaborative partnership when focusing on outpatient commitment programs. It seems like some of the places we read about like the Fountain House and Act will not emulate asylums of the past but allow for inclusion. Creating opportunities for work is also an important aspect, not similar to the asylum effect.
Hi Suzanne,
DeleteIt is so important for all citizens to have the opportunity for inclusion. Fountain House and the clubhouse are governed by standards, one of which is a guaranteed place to be. Family is a guaranteed place to be for many people but sometimes active mental health issues can destroy this without support. Informed consent without coercion would help citizens make choices without creating the community asylum.
As we consider whether or not outpatient commitment merely recreates asylum in the community, we must consider the traits of both the outpatient supports and those of asylums in general. As we’ve explored asylums throughout these past few weeks, three elements have stood out as especially significant; their tendency to isolate patients from family, friends and their everyday lives, their tendency to over-medicate patients, and their tendency to minimize patient-choice and voice in treatment. A commitment to outpatient treatment in the community, however, is a commitment to empowering patients to be the dominant voice in their treatment path while supporting and encouraging community involvement and social interaction with friends and family members and reducing reliance on medication. True commitment to this kind of outpatient treatment does not recreate an asylum in the community, however, because outpatient commitment requires mental health supports, the line between the two could easily muddled and crossed if clinicians are not careful in their approach. Clinicians must remain dedicated in their actions and uphold such beliefs for their patients as their patient’s human rights to: choose their treatment method, be socially included as important, contributing members of their community, and to be provided with supports and treatment that are individualized to them. By remaining commitment to ensuring their client’s human rights, choices in individualized treatment, and involvement in their communities, clinicians can work to ensure that outpatient treatment does not recreate asylums in the community. To do so, physicians must recognize that their clients are people first and patients second, and they alone have the power to choose their treatment path; the physicians job is to merely educate and present options and then provide the treatment as chosen by the client. They must not hold in-patient treatment as a contingency consequence for struggles in out-patient treatment. They must refrain from using medication as a crutch and a mere tool for managing symptoms, and instead use it cautiously as tool toward recovery. Physicians must provide supports that enable them to be active members of their communities and families which means helping them find and keep jobs, access everyday resources such as the post office, bank, and grocery store, utilize transportation, and develop communication and advocacy skills that enable them to build positive relationships with friends, family, and coworkers while overcoming mental health issues. Supporting social inclusion also means educating the public and supporting policies that create environments in which mental illness does not have a negative connotation to it and rather is viewed merely as a normal, accepted issue that humans struggle with. Above all else, physicians must ensure that these outpatient supports and treatment are individualized to each client and that each client is able to access one-on-one support as they navigate their everyday lives, communities, and mental health needs.
ReplyDelete