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close this bookPartners for Mental Health - The Contribution of Professionals and Non-professionals to Mental Health (WHO, 1994, 110 p.)
View the document(introduction...)
View the documentForeword
View the documentInternational Council of Nurses - ''The Current Status of Mental Health/Psychiatric Nursing and Some Future Challenges''
View the documentWorld Federation of Occupational Therapists - ''Occupational Therapy in Mental Health Care1''
View the documentWorld Organization of National Colleges, Academies and Academic Associations of General practice, Practitioners/Family Physicians (WONCA) - ''The Professional Role of General Practitioners in Mental Health''
View the documentWorld Psychiatric Association - ''The Now and Future Role of Psychiatrists''
View the documentCommonwealth Pharmaceutical Association - ''Pharmaceutical Services to the Mentally III and Mentally Handicapped''
View the documentInternational Union of Psychological Science - ''Psychology and Health''
View the documentInternational Sociological Association Working Group on Sociology of Mental Health - ''Sociology's Contribution to the Study of Mental Health''
View the documentWorld Federation for Mental Health - ''The Voluntary Sector: Passage to Empowerment for Volunteers, Consumers and Advocates''
View the documentNational Association of Psychiatric Survivors - ''Speaking for Ourselves: Former Psychiatric Patients organizing and speaking out''

(introduction...)

WHO/MNH/MND/94.5
Original: English
Distr. General

DIVISION OF MENTAL HEALTH
WORLD HEALTH ORGANIZATION
GENEVA

© World Health Organization, 1994

This document is not a formal publication of the World Health Organization (WHO), and all rights are reserved by the Organization. The document may, however, be freely reviewed, abstracted, reproduced or translated, in part or in whole, but is not for sale or use in conjunction with commercial purposes.

The views expressed in documents by named authors are solely the responsibility of those authors.

This document assembles position papers prepared by several NGOs on their members' contribution to mental health and mental health care.

They cover a variety of domains such as training, research and care, in addition to addressing topics specific to each NGO.

Key-words: mental health, mental health care, nurses, occupational therapists, general practitioners, psychiatrists, pharmacists, psychologists, sociologists, volunteers, consumers.

Foreword

On 10-11 June 1991 WHO Division of Mental Health organized a consultation to discuss the contribution of different professional roles to mental health. It was attended by representatives of several professional non-governmental organizations (NGOs) related to the mental health field, as well as representatives of consumer organizations.

In the final report on this consultation (Doc.: MNH/MND/91.18) one of its main conclusion is indicated as:

"There was an overall impression that when we talk about roles in mental health there are more of common shared roles than specificities, with some variations according to the type of action to be performed, e.g. promotion, prevention, treatment or rehabilitation. The most common shared roles concern inter-personal relationships, counselling and education."

Among the several recommendations put forward by the consultation, there were:

"WHO should:

9. Assemble position papers on the roles of each profession and of consumers, prepared by the respective NGOs, and edit them as a special publication.

10. Distribute copies of the report of this consultation, as well as of the future publication on the same topic to:

a) members of ministries of health and education (who are in charge of manpower and budgets);

b) professional and consumer NGOs; and

c) frontline workers (who are looking for desirable standards, guiding principles and can be very helpful in moving from one stage to another)."

Following Recommendation 9. above, several NGOs were contacted and requested to produce the position paper mentioned therein. An outline was prepared indicating the main topics the position papers should cover. They included:

a) a short description of the profession/role, highlighting the most relevant historic landmarks in the development of the profession/role;

b) past, current and future problems related to the role and to training necessary for acquiring skills specific to that role.

c) main similarities and differences in practising the role in developing and developed countries.

d) prospects for the future of the role.

Despite a clear request from WHO, not all NGOs followed this outline and in a few position papers the situation in developed countries received much more attention than in developing countries, probably reflecting the real regional development of the profession in those countries. However, at least for the role of psychiatrists, a more in-depth discussion of their role in developing countries, in many of which they predominate over other professions, is a situation to be discussed and eventually modified.

Some NGOs produced a position paper which represents their official position (e.g. the International Council of Nurses and World Federation of Occupational Therapists) and therefore do not have an individual author, whereas other NGOs opted for commissioning the position paper to one of their members (e.g. World Psychiatric Association and World Federation for Mental Health), whose name is indicated.

Also, despite all WHO efforts, it was not possible to obtain position papers from every profession relevant to the mental health field (e.g. social workers, neurologists), due to either difficulty in identifying the competent NGO representing that profession or a lack of cooperation from some NGOs approached.

Since, as indicated in most papers, several roles are rapidly evolving and given the time span with which different contributions were made available to WHO, it may be necessary to update the information contained in this document in the near future. In that occasion we hope to broaden the coverage of position papers included, reflecting the changes taking place in the field of mental health.

Comments on this document are welcome and should be addressed to:

Dr J. M. Bertolote
Senior Medical Officer
Division of Mental Health
World health Organization
1211 Geneva 22
Switzerland

International Council of Nurses - ''The Current Status of Mental Health/Psychiatric Nursing and Some Future Challenges''

International Council of Nurses

The International Council of Nurses (ICN) is an independent, nongovernmental federation of national nurses' associations (NNAs) in over 100 countries, representing over 1.2 million nurses worldwide.

Founded in 1899, ICN is the oldest and largest international professional organization in the health care field. Since its inception it has been working for the improvement of health services and the recognition of nursing's vital role in health care.

As a representative body, ICN works closely with international organizations on matters affecting health in all parts of the world.

As a federation of nurses' associations, ICN encourages its members to develop nursing standards, work on health policy development, and advance the nurse's economic position. With its broad-based and flexible services and programmes, ICN is a valuable resource for associations seeking guidance in many areas, including greater involvement in health-related government policymaking and planning.

Nurses, as educated professionals responsible for the wellbeing of their patients, must modify their customary image by becoming the patient's advocate in all areas of their professional competence and in all health care situations. ICN helps nurses to:

- take a stand on issues affecting health care and promotion
- get involved in the development of health care policy and health care planning, and

- safeguard human rights in areas that are the responsibility of nurses.

1. Introduction

Up to the mid-20th century, nursing's role in mental health/psychiatric care was predominantly linked to conditions and attitudes prevailing in psychiatric/mental institutions. For the most part, nurses worked in settings where they had received their training and consequently had an institutionalised perspective of patient care. Patients' human needs - those of self-respect, quest for independence, and self-esteem - were often ignored.

Although significant changes in models of care have occurred during the intervening years, two major relatively new developments have dramatically altered the mental health/psychiatric field this past decade, including the roles and functions of mental health/psychiatric personnel. These concern the major advances in all fields of basic and clinical neuroscience and thus approaches used to diagnose and treat mentally ill persons, and the influence of social, economic and political factors on patient care, e.g. deinstitutionalisation of persons with mental disorders.

2. Mental Health and Human Rights

The Preamble of the Declaration of Luxor on Human Rights For The Mentally Ill adopted by the World Federation for Mental Health on 27 January 1989, upholds the inalienable rights of persons "publically labelled or professionally diagnosed, treated or confined as mentally ill, or suffering from emotional distress". It states that "difficulty in adapting to moral, social, political or other values in itself should not be considered a mental illness" and regrets that persons inappropriately labelled continue to be confined as mentally ill. The Declaration stresses that "the fundamental rights of mentally ill persons shall be the same as those of all other citizens and that these include, among others, the right to dignified, humane and qualified treatment..." (1).

The slow public and professional response to instigate changes in the treatment and care of patients with mental disorders can be attributed to many cultural, social and physical factors. In some countries, this neglect is a leftover from the days when social deviance was thought to be a natural outgrowth of innate depravity, deserving punishment and discipline (2, 3). Around the turn of the century in the United Kingdom, the medical practitioner's assumption about mental illness was that it was worse than disease and "that people who were seen to be disordered were dangerous" (4). Laws, even up to 1955, were mainly designed for the protection of society in that they reflected the belief that mental patients were dangerous (5).

It was not until the late 1940s when the United Nations Universal Declaration of Human Rights was passed that a wider public debate began on the rights of persons with mental disorders and their institutional care. Although attitudes of both the public and health professionals have begun to change, there still remains an underlying entrenched prejudice against mental illness. Even the Alma Ata Declaration on primary health care does not explicitly include mental health care as one of its essential elements although it can perhaps be inferred (6).

The international nursing community adopted its first Code of Ethics in 1953 at the time when the Grand Council of the International Council of Nurses met in Brazil (7). This Code, which was revised in 1973 and reaffirmed by the Council of National Representatives in 1989, has been translated into many languages and speaks of the four fundamental responsibilities of the nurse: to promote health, to prevent illness, to restore health and to alleviate suffering. Furthermore it states that the need for nursing is universal, and that inherent in that is respect for life, dignity and rights of man, unrestricted by consideration of nationality, race, creed, colour, age, sex, politics or social status. Although The Code for Nurses holds no judiciary power, it does provide nurses with a guide for action based on the fundamental values and needs of society.

3. Extent of the Problem

Mental illness takes an enormous toll. According to a World Health Organization (WHO) report on 48 of the world's most prevalent diseases, mental disorders affect approximately 200 million people (8). It is unlikely that the extent of the problem is accurately reflected in this figure, as, for example, mental illness caused by episodic or insidious wife or child abuse often go unreported. Armed conflict, violence, and displacement are other situations which have lasting detrimental effects on their victims, especially children. A study of children living in Northern Ireland found that psychological disorders and mental illness increased considerably among children and adults during the 1968 riots and violence in Belfast (9). Considering that there are world-wide approximately 25-30 million refugees and internally displaced persons, exclusive of those affected by armed conflict, the magnitude of the actual number of people who might be suffering from some form of mental disorder becomes staggering.

4. Impact of Social and Scientific Developments

First launched in the 1950s, deinstitutionalisation has brought chronically mentally ill patients out of hospitals and into communities. Many factors have contributed to this revolution in the care of the mentally ill, among which was the human rights concern to release institutionalised patients from their often enforced confinement.

In communities where deinstitutionalisation has been carefully planned, benefits have been substantial and individuals previously committed to long-term in-patient care have been successfully integrated back into society. But this has not been done without costs. In New South Wales, for example, it was recognised early that increased levels of training and retraining were needed for all staff involved in the development of community based mental health services. Implementation of the programme included the upgrading of existing community mental health services and provision of a variety of different living arrangements, e.g. hostels and group homes. Rehabilitation (living skills centres, activity centres) and community support teams were also provided to assist both the clients and their families (14). Other groups that have alleviated the burden of care for families are self-help organizations and concerned citizens groups.

However, deinstitutionalisation can lead to great human suffering if ill conceived and poorly supported. In some industrialised countries, large numbers of persons with chronic mental disorders have been thrust into unprepared communities. Financial constraints, lack of political commitment and professional inertia have led to: inadequate numbers of appropriate alternative care facilities; mosaic staffing patterns and inconsistent qualifications of staff; sporadic linkages and referrals for care and treatment; and poor continuity of care. Consequently, readmissions are high and the number of homeless chronically mentally ill persons has increased. Among these are young people addicted to alcohol or other drugs who cannot or are hard to engage with traditional health care and community services.

McBride notes that there is a shift away from the behavioural sciences to the neurosciences in the organizing frameworks of psychiatry. "Imaging techniques now permit looking into the living human brain to identify structural defects in specific regions... New drugs are being developed to correct biochemical imbalances. The study of genetics is moving away from a focus of rare disorders to common ones with growing attention to enzyme deficiencies" (16). These new developments have revolutionised the management of patients with mental disorders, especially in countries with easy accessibility to psychotropic drugs.

In many developing countries improvement in the care and treatment of patients with mental disorders have been negligible, because of traditional concepts surrounding mental illness. In some societies such patients are thought to be cursed, while in others they are worshipped since they are believed to represent spirits or are messengers of God. Many of these societies reject modern concepts of psychiatric and mental health, as they do not relate culturally relevant alternative approaches to traditional beliefs (17). It is especially in this domain that more research and resources are needed.

5. Psychiatric Versus Mental Health Nursing

The distinction between psychiatric disorders and mental health problems is vague. This confusion is reflected in the various names used to describe the field, e.g. psychiatric and mental health nursing, psychiatric nursing, mental health nursing, or psychosocial nursing and a reason for the use of 'mental health/psychiatric' in this paper. According to McBride, the "name problem was itself connected with existing conceptualizations both of whether mental illness and mental health exist on the same continuum and whether psychiatric nurses have a distinct role to play in treatment of brain disorders". Current emphasis on mental health rather that on psychiatric care, she notes, "may have been prompted by the wish of practitioners to identify with nursing's health-oriented perspective rather than with the medical model..." (18).

"Psychiatric nursing is dead. Long live mental health nursing!", a quote recently reported in a nursing journal from the UK (19), supports this assumption. The change in emphasis reflects the way in which the philosophy of nursing itself has changed, according to the article. The Royal College of Nursing's Society of Psychiatric Nursing will change its name to the Society of Mental Health Nursing.

The core of the issue concerns nursing's quest to establish its own identity relative to patient or client care. In the past, psychiatric nursing's identity, particularly in mental health/psychiatric institutions, has been strongly influenced by whatever model of patient care was practised in the setting. The four main models were: the medical, psycho-therapeutic, behavioural and socio-therapeutic models. Each model, which formed the basis for professional practice, attempted to explain psychiatric disorders based on its own conceptual framework (20).

Although no universal model of mental health/psychiatric nursing has yet emerged, the core of what constitutes nursing can be found in the following, which is ICN's definition of nursing.

"Nursing,... encompasses the promotion of health, prevention of illness, and care of physically ill, mentally ill, and disabled people of all ages, in all health care and other community settings.... the phenomenon of particular concern to nurses is individual, family and group responses to actual or potential health problems. The unique function of nurses in caring for individuals, sick or well, is to assess their responses to their health status and to assist them in the performance of those activities contributing to health, recovery, or to dignified death, that they would perform unaided if they had the necessary strength, will, or knowledge and to do this in such a way as to help them gain full or partial independence as rapidly as possible..." (21).

6. Mental Health/Psychiatric Nursing Education

6.1 Historical Perspectives

Early mental health/psychiatric training schools prepared direct entrance nursing personnel, i.e. students did not receive a basic education in general nursing. Such schools were placed within psychiatric hospital settings to ensure a steady supply of nursing personnel conforming with institutional needs. Their numbers, however, are steadily declining.

The inclusion of mental health/psychiatric nursing subjects as part of a general nursing syllabus is a relatively new phenomenon. In 1933, for example, when the ICN Board of Directors and the Grand Council met in Paris and Brussels for the Quadrennial Congress, a resolution was passed by delegates from 30 countries to endorse the principle that mental nursing and hygiene be included in the general curriculum of all schools of nursing (22).

In the US, it was not until 1937 that the body responsible for accrediting schools of nursing considered psychiatric nursing to be an essential component of general basic nursing education, and even in the 50s it was still not generally recognised that psychiatric nursing content was helpful for the entire spectrum of nursing practice (23).

The development of mental health/psychiatric nursing as a post-basic nursing speciality started in the late 40s in the United States. The development of specialties, according to Hoeffer and Murphy, can be attributed to three social forces: new knowledge pertinent to the field, technological advances, and the response to public need or demand. It was in response to the public's need for an increase in the supply of mental health professionals that gave the US National Institute of Mental Health the impetus in 1948 to provide funds to establish the first advanced programme in mental health nursing in the U.S. (24).

6.2 Basic specialisation versus post-basic specialty preparation

The governing body of the ICN, the Council of National Representatives (CNR) accepted as a policy in 1985 The Report on the Regulation of Nursing'. The policy the CNR approved is that programmes of nursing education should generally parallel those for other professions as to setting, level, academic credentials, control, and general standards and that one of those standards should be "liberal and professional education preparing for the general practice of nursing in all settings, primary secondary, and tertiary." (25) According to the Report, the scope of preparation and practice of a nurse is: the capacity and authority to practise primary, secondary, and tertiary health care competently as a generalist in all settings and branches of nursing, and the capability and legal responsibility to supervise and direct auxiliaries. The scope of preparation and practice of a nurse specialist is defined as: advanced education and expertise in a branch of nursing, built upon the nurse base of competence and authority for generalist practice in all settings and branches of nursing.

The fundamental question of what it means to be a 'nurse' and the related issue - the merits of basic specialisation versus general nursing education - are still, however, being debated by nurse leaders. As pointed out by Butterworth, there "is a common level which all nurses should and could attain if they all have 'caring' at the centre of their interpersonal dealing with patients" (26).

One of the central principles upon which the position taken by the CNR is based relates to the development of the nursing profession and its potential social contribution. It sets forth that increases in the complexities of health care and its social milieu call for the heightened capabilities of nurses, as citizens and practitioners to meet new challenges. To encourage the development of nursing's potential, educational requirements should include liberal, social, scientific, and technical education; and nursing service standards should reflect the changing health care needs and enhanced professional capacities (27). Such a foundation, ICN believes, is laid during the generalist preparation for practice. The debate is how to develop post-basic specialist programmes which arise from a model of generalist nursing practice, and yet expand the nurses role into the specialty domain in a way that builds and develops nursing skills, provides quality care controls, assures credibility to the consumer, as well as meeting the particular needs of that specialty.

All nursing students in basic general nursing programmes apparently now study mental health/psychiatric subjects, although the length of the study, its placement within the curriculum and the intensity of clinical experiences vary considerably from country to country and even from province to province or city to city within a country. Mental health/psychiatric subjects are either taught as individual courses or integrated with other themes throughout the curriculum. For example, under a course heading 'Health Promotion', the psycho-social needs of persons in different age groups may be identified and, using the nursing process, students learn about such problems as addiction, depression, child abuse or stress.

The skills, knowledge and attitude that nursing students are expected to demonstrate at the end of such a programme allow them to assess an individual's psychological state and, within a general nursing framework, to plan and implement nursing interventions. Without further preparation or supervision, however, the roles of graduates of basic comprehensive or traditional nursing programmes in relation to caring for mentally ill persons are necessarily limited. Such roles may include:

- assessing the individual and his/her immediate environment and planning therapeutic nursing interventions;

- providing direct care, including distribution of medications and monitoring for their effects;

- teaching individuals and families skills, e.g. of daily living, and educating them on preventive mental health measures;

- interacting and liaising on the individual's and family's behalf with other care providers or services;

- consulting with other team members, both inside and outside institutions on continuity and coordination of care and its overall management;

- acting as the patient's and family advocate to influence decisions;

- evaluating and revising treatment plans and schedules.

Specialty education at the post-basic and graduate levels builds upon basic nursing competencies and stresses the interdependent roles of other mental health/psychiatric team members. Such programmes prepare nurses to apply a broad array of intellectual and interpersonal skills to change in some beneficial way the lives of people in both institutional and community settings (31), for example, in caring for children and adolescents and elderly who are mentally ill.

6.3 The Constraints

Major economic, social and political constraints hinder the development of nursing education in general and mental health/psychiatric nursing education in particular.

The 1989 Report of the Director-General to the WHO Executive Board noted, for example, that "All developing countries report that only very meagre financial resources are allotted to nursing education" and that "many nurse teachers.... have no teaching qualifications". Furthermore, according to the Report, "even when community experience is indicated in the syllabus, often in practice it is not provided, or the hours are drastically reduced..." (32).

Economic constraints and lack of political will have kept educational opportunities and salaries for nurses at a minimum. Few countries have continuing education programmes available for nurses.

Low salaries also affect mental health/psychiatric nursing education. One country reported that all well qualified nurses had left the country for better paying jobs elsewhere and that this had created a critical situation, as most colleges of nursing had no qualified psychiatric instructors left to teach the students. Such personnel shortages also cause a great void of leaders in the clinical area, limiting improvement of nursing services for mentally ill persons.

A further complicating element in the educational sphere is the preparation of many different levels and categories of nursing personnel, whose functions upon graduation are more closely linked with the absence or presence of other mental health professionals, such as psychiatrists or psychologists than with their educational preparation (33). In the absence of other mental health professionals, nurses may be thrust into positions of making clinical decisions concerning individual patients for which they have not been adequately prepared.

In countries where symptoms of mental illness are still closely linked with cultural taboos, beliefs and superstitions, a mental health/psychiatric curriculum based on Western ideas is at times used for lack of alternative. Often, such curricula are disease-oriented, hospital- based, overspecialised and out of line with the mental health needs of the people (34). Unfortunately, not enough research has been carried out in the socio-anthropological sphere to determine which traditional approaches to care and treatment of mentally ill people are effective. It is not surprising, therefore, that many people in those countries prefer the services of traditional healers over those of 'modern' medical care which, at times, constitutes prison-like conditions with only minimally trained personnel to provide custodial care.

Many countries are reporting a drop in enrolment of students at the basic level and an even greater reduction in the number of students indicating a preference for psychiatric nursing either immediately upon graduating from a basic programme or choosing to study it at higher level following basic nursing education (35, 36). Specific reasons for this decline were not given. Nevertheless, from available information certain assumptions can be made:

- changes in mental health services and treatment and the placement of patients in community settings has led to role diffusion, creating uncertainty about what the future for mental health/psychiatric nurses will hold;

- unpleasant student experiences in clinical settings, remaining prejudice and fear, and lack of mental health/psychiatric nurse role models are discouraging students from choosing the field;

- health personnel shortages are resulting in understaffed units in institutions and large client load in community settings, standards of nursing care are difficult, if not impossible to maintain, leading to professional frustration and 'burn-out';

- students are aware that a career structure and other incentives in the field are inadequate or lacking;

- continuing education opportunities are limited.

Redressing some of these problems requires strong nursing leadership, political commitment and an infusion of funds. The future of mental health/psychiatric services will continue to depend to a large extent on the functions and roles carried out by nursing personnel. In turn, the quality of those services will be greatly influenced by the educational preparation of its practitioners and their living and working conditions. Culturally appropriate basic and continuing education, based on national needs and resources, and adequate remuneration and opportunities for career advancement are necessary for nursing personnel to perform at the standards of mental health nursing practice that the profession has set for itself.

7. Mental Health/Psychiatric Nursing Practice

7.7 In Transition

In developed countries, the care of persons with mental illness was, up to the mid-20th century, largely provided in public psychiatric institutions staffed predominantly by aides (37). Much of the care in these institutions was custodial and trained nursing personnel performed traditional roles - e.g. bathing, feeding, toileting and dressing, and preventing patients from harming themselves and others. In subsequent years, other functions were added, such as assisting with hydrotherapy, electroshock or insulin coma, while counselling patients only recently emerged as a role.

Today, in many countries, psychiatric/mental health nurses are the only mental health professionals to have the twenty-four-hour responsibility for patients in the in-patient or institutional settings, and therefore, are the prime care givers and monitors of patient progress.

With refinement of clinical skills through ongoing supervision of practice, a generalist nurse should be able to assume, among other roles, the following (adapted from American Nurses' Association Standards of Child and Adolescent Psychiatric and Mental Health Nursing Practice (38)):

- therapist who shares the responsibility for providing an atmosphere in which all activities and behaviours are focused on the therapeutic care of the individual;

- counsellor or teacher;

- collaborator with other mental health and psychiatric professionals in assessing the needs and planning for the care of the individual and family;

- advocate and change agent who provides for the physical, mental health and other needs of the individual;

- promoter of mental health with individuals, families, groups and communities;

- participant in the research process and implementor of research findings.

In addition to the roles of a generalist nurse, graduates of specialty programmes who have had supervised clinical experiences may be expected to assume the following roles, among others (adapted from American Nurses' Association Standards of Child and Adolescent Psychiatric and Mental Health Nursing Practice (38)):

- therapist, e.g. psycho, play, drama for individuals, groups and families;

- clinical supervisor of patient care staff and graduate nursing students;

- administrator of mental health and psychiatric nursing services;

- educator of nurses and other care personnel in a variety of institutional and community settings;

- consultant to professional and nonprofessional persons or groups concerned with the general welfare, education and care of individuals;

- researcher who contributes to the theory and practice of mental health and psychiatric nursing through research in this field or a related field.

Mental health/psychiatric nurses have been in the vanguard as positive agents for change in many countries. For example, in Uganda, psychiatric clinical officers - nurses who have received advanced training at Makerere University - are highly respected mental health practitioners who are fully responsible for mental health/psychiatric services, particularly in rural areas. Similar advanced educational programmes for nurses have been developed in Botswana, Lesotho and Zambia (40).

In the UK, nurses launched a rehabilitation centre to help mentally disturbed patients learn many of the skills needed to move towards less restricted life-styles in the community or in institutions. Based on research findings, the rehabilitation programmes help people to lead a better quality of life, for example, through learning 'living skills' (41).

In many countries, nurses are conducting research and demonstrating patient outcomes related to nursing care, such as studies on sleep deprivation, effects of homelessness, aspects of the addictive cycle and high risk pregnancy.

Innovative mental health/psychiatric programmes initiated by nurses can probably be found in every country; however, major constraints impede their widespread development.

7.2 Constraints

It appears that some mental health/psychiatric nurses have not easily adapted to the deinstitutionalisation of the mentally ill, possibly because psychiatric nursing has not identified its unique professional perspective (42). Nurses, according to Nolan, have adopted a 'lay' or 'common sense approach' which prevents them from realising their full therapeutic potential. He claims that training has not helped since it has failed to provide nurses with the skills needed to engage patients in therapeutic relationships.

Pollock, using a small sample for a study on the work of community psychiatric nursing, found that nurses with limited resources and lack of direction were establishing their own modus operandi and defining their own work practices while trying to produce the best match of needs to resources (43). Barnum calls this the "nursing's angel complex": the notion that no matter what pittance of support nurses get, they can fly (44).

Simpson, having examined selected research reports on community psychiatric nursing (CPNs), noted that "on the one hand ... CPNs are enthusiastically embracing a new role with a client group not appropriate for psychiatric (medical) intervention, and on the other.... they are not equipped to do so" (45). He claims that there "appears to be no research at all indicating whether community psychiatric nursing interventions are, in fact, systematic and rooted in sound theoretical and research-based practice". Barratt notes that CPNs are a relatively new group of carers and are still experimenting with their role within society while, as Brooker reports, they are in a rapidly developing area of mental health nursing (46,47).

In many developing nations, where there is usually one psychiatric hospital for the entire country, problems of mental health and psychiatric nursing are closely linked to other problems of general health and socioeconomic origin, but above all, according to Wankiiri, to inappropriate organization, inappropriate curricula and manpower shortages (48). The author states:

"The few existing psychiatric hospitals are for the most part old custodial institutions-overcrowded, understaffed and rarely able to provide more than just chemical therapy and electroconvulsive therapy. Their forbidding appearance also greatly contributes to the negative image of psychiatric nursing among the public...."

The isolation of the mentally sick in uncongenial surroundings has led to a situation in which most African health workers in the rural areas are unwilling or unable to follow up such patients. They do not regard the promotion of community mental health, the prevention of mental illness, and the identification and management of mentally sick patients as their responsibility.

According to Peplau, what is most "needed now are psychiatric nurses within the profession to track research findings, coming from all sciences, and to serve as interpreters of those findings for the nursing profession" (49).

Mental health/psychiatric nursing practice cannot be viewed in its entirety without looking at the issues that influence its practitioners. In most countries, there are widely reported shortages of nursing personnel. Many studies have shown reasons for this: poor working conditions, low salaries and limited career opportunities, increased demand for highly trained nurses but a decreased pool from which to recruit young people, lack of professional autonomy and a low image of the field.

Improving the educational preparation of mental health/psychiatric nurses, and developing a research data bank and a solid theoretical foundation on which to base their practices, must go hand in hand with better working conditions (e.g. salary and remuneration), greater autonomy within an interdisciplinary setting, opportunities for further educational advances and career development, and participation in policy-making. In addition, needs and resources studies must be conducted to provide valid data on nursing personnel, to be used with some consistency in staffing services.

8. Nursing Legislation

According to the ICN Regulation of Nursing Study, in a large majority of countries the regulations governing nursing practice are inadequate for dealing with the complexity and expansion of the nursing role to meet today's health care needs (50). Based on the findings of the study and recognising the worldwide nature of the problem, the International Council of Nurses launched a global project to involve national nurses' associations and senior nurses in the ministry of health in the critical examination of national nursing legislation and regulations with the aim to bring about necessary changes. As a result, many NNAs are now more acutely aware of the actions that need to be taken to redress the problem and have begun the initiatives.

9. National Nurses' Associations (NNAs)

Several mental health/psychiatric specialty branches within national nurses' associations have developed standards for practice and for education that spell out desired levels of performance, situations or conditions, and criteria - which can be used for comparison. Furthermore, NNAs and their specialty groups have made submissions to government authorities on such issues as:

- the delivery of services to mental clients as a priority in 1990;

- the legal status of mentally ill people;

- proposals for new mental health legislation;

- statement of nursing needs to increase appropriations for mental health/psychiatric care;

- sale of liquor bill;

- standards for informed consent;

- safe staffing levels;

- changes in levels of education;

- upgrading of physical facilities;

- proposals concerning community care for adult mentally ill and mentally disabled people and the health of those in prison;

- substance abuse.

10. Future Developments

Looking into the future, mental health/psychiatric nursing education at the general basic level will focus largely on prevention and concepts of healthy living, and will include theory and clinical experience in public policy, biological-psychological basis of behaviour, social psychology, sociology, normal physiology, and will be based on 'humanistic-holistic caring' as the central core of all nursing practice. The generalist nurse will be mainly concerned with preventive and promotive aspects of mental health in all settings - e.g. homes, schools, clinics, hospitals, factories.

The nursing care of mentally ill persons both in institutions and in the community will be provided by nurses prepared at the post-basic or graduate level, working individually and within interdisciplinary mental health teams. Using an integrated theoretical perspective, their approach to care will provide for "a range of services including supportive care, rehabilitative care and crisis intervention as well as more traditional forms of psychotherapeutic interventions" (52). In addition, mental health/psychiatric nurse specialists will carry out many functions related to the promotion of mental health and the prevention of mental illness in a broad variety of settings, across the age span, infant to geriatric.

Post-basic and other graduate programmes will be able to attract an adequate number of well-qualified applicants because mental health/psychiatric nursing is respected for its special skills and knowledge autonomy, opportunity for innovation, and availability of supportive supervision, as well as the opportunity it provides to influence policy decision which both directly and indirectly affect mental health/psychiatric services. These services will be culturally relevant and integrated within the primary health care system of the nation. In addition, mental health/psychiatric nurses' expertise will be publically recognised and financially rewarded.

11. Summary of Nursing Issues

(Note that the following issues vary worldwide, some being more prevalent than others)

General issues

- There remains prejudice against any behaviour perceived to be bizarre, deviant, strange or nonconformant, and society, including health professionals has sometimes cruel ways of dealing with people exhibiting such behaviours.

- The development of mental/psychiatric health as a complex psycho-socio-health discipline has been relatively slow compared to other fields such as surgery. Consequently, humanistic, holistic and scientific methods to deal with the problems are not yet well formulated.

Policy-making and Political Will

- Continuing low priority is given to all aspects of mental health/psychiatric, including: funding for education, services, research, facilities, supplies, health personnel development; changing laws, acts and recognition of human rights violations; prevention of unemployment, substance abuse, person abuse, eg child, spouse, the elderly; promotion of recreation, leisure and relaxation.

- A clear framework for national decision-making in mental health is lacking.

- Mental health has yet to become an integral component of primary health care.

- Nurses, for the most part, have been excluded from participating in policy decision-making at all administrative levels.

Nursing Practice

- There appears to be no clear 'nursing framework' on which mental health/psychiatric nursing services can be modelled.

- There is a general shortage of effective mental health/psychiatric nurses' role models.

- While some nurses view the changes that are taking place in the mental health/psychiatric field as a positive development for nursing, others fear role diffusion.

- More clinical research is needed to determine the specific effects of nursing interventions on patient outcomes.

- Regulations and laws governing mental health/psychiatric nursing practice are outdated or absent.

- Inadequate salaries, lack of a career structure, poor working conditions, increased demand for highly trained professional staff and few incentives are contributing to the mental health/psychiatric nursing personnel shortage.

- Mental health/psychiatric nursing personnel functions appear to be more closely linked with the absence or presence of other mental health professionals than with their educational preparation.

Nursing Education

- Mental health/psychiatric nursing education is changing from a medical to a nursing orientation.

- Lack of both financial and human resources, coupled with political inertia have seriously affected the necessary development of training programmes for mental health/psychiatric nursing personnel at the in-service, post-basic and graduate levels.

- The number of programmes preparing direct entrance mental health/psychiatric nurses is decreasing.

- More programmes for preparing post-basic and graduate level mental health/psychiatric nurses are being offered but still remain inadequate.

- There is a critical shortage in some countries of qualified mental health/psychiatric nurse educators to teach at the basic, post-basic and graduate levels.

- The mental health/psychiatric nursing curriculum in some countries is culturally inappropriate.

- Inappropriate or unpleasant clinical experiences and ineffective instructional techniques for students can have long lasting negative effects, such as fear of mentally ill people or unwillingness to work in the field.

12. Recommendations to national nurses associations and governments

Nursing Practice

- Support the development of a mental health/psychiatric framework on which national policy decisions can be based.

- Support and/or undertake clinical research studies to determine what specific effects various nursing interventions have on patient outcomes.

- Carry out mental health/psychiatric nursing personnel needs and resources studies at country level that fit into national health plans.

Nursing Education

- Develop plans at country level to meet educational needs of all levels of mental health/psychiatric nursing personnel, including continuing education needs.

- Support the development of culturally relevant curriculum models.

- Develop guidelines for clinical practice for nursing students.

- Develop guidelines for curriculum development.

Nursing Education and Nursing Practice

- Involve mental health/psychiatric nursing personnel at all levels of policy decision-making.

- Support the development of leaders and role models, especially in clinical settings.

- Support the development of managers and educators.

- Support the development of career structures including in clinical settings and the determination of educational preparation for different grades/steps.

- Propose incentives or other ideas to increase the attractiveness of mental health/psychiatric nursing, e.g. greater autonomy.

13. References

1. The World Federation for Mental Health. The Declaration of Luxor -Human Rights For The Mentally Ill, adopted 17 January 1989 by the Nile Congress at Luxor.

2. News Focus. The hell called Leros, Nursing Times, 85(39), 1989, p. 18.

3. Mc Causland M. Deinstitutionalization of the mentally ill: Oversimplification of complex issues. Advances in Nursing Science, 9(3), 1987, pp 24 - 33.

4. Lemmer B & Smits M. Facilitating change in mental health. Chapman and Hall, London, 1989, p. 1.

5. Curran W J & Harding T W. The law and mental health: Harmonizing objectives. World Health Organization, Geneva, 1978, p. 10.

6. WHO & UNICEF. Primary health care. A Joint Report. Geneva, 1978.

7. Bridges DC. A history of the International Council of Nurses 1899-1964 Philadelphia, J B Lippincott Co. 1967, p. 168.

8. WHO Features. No 140, April 1990.

9. Fraser M. Children in conflict. London, Penguin, 1974, p. 208. (As reported in: Children in situations of armed conflict. UNICEF, No. E/ICEF/1986 (CRP 2, 10 March, 1986, p. 8.)).

10. Slavinsky A. Psychiatric nursing in the year 2000: From a non-system of care to a caring system. Image-Journal of Nursing Scholarship 16(1) 1984, pp 17-20.

11. McClausland M. Deinstitutionalization of the mentally ill: Oversimplification of complex issues. Advances in nursing science, 9(3), 1987, pp 24-33.

12. Peplau H. Tomorrow's world. Nursing Times, 7 January, 1987, PP 29-32.

13. Features. A new paradigm in mental health. Mental Issues, 19 June 1989, pp 18-20.

14. Features. A new paradigm in mental health. Mental Issues, 19 June 1989, p. 19.

15. Breust M. Institutionalization versus living in the community: psychiatric deinstitutionalization and nursing in New South Wales. In: Issues in Australian Nursing 2. Ed: G Gray & R Pratt, Churchill Livingstone, Melbourne, 1989, p. 72.

16. McBride A B. Psychiatric nursing in the 1990s. Archives of Psychiatric Nursing 4 (1), 1990, pp. 21-28.

17. Asuni T. Existing concepts of mental illness in different cultures and traditional forms of treatment. In: Mental Health Services in Developing Countries, Papers presented at a WHO Seminar on the Organization of Mental Health Services, Addis Ababa, 1973. World Health Organization, Geneva, 1975.

18. McBride A B. Psychiatric nursing in the 1990s. Archives of Psychiatric Nursing 4(1), 1990, pp 21-28.

19. Focus on mental health nursing. Nursing Standard, 25(4) 1989, pp. 28-30.

20. Mckenna H. A pill for every ill. Nursing Times, 86 (10) 1990, pp 28-309.

21. ICN Definition of nursing. Approved by the CNR, 1987.

22. Bridges D A. History of the International Council of Nurses: 1899-1964. J B Lippincott Co Philadelphia, 1967, p. 88.

23. Slavinsky A. Psychiatric nursing in the year 2000: From a non-system of care to a caring system. Image-Journal of Nursing Scholarship 16(1) 1984, p. 18.

24. Murphy S & Hoeffer B. The evolution of sub-specialities in psychiatric and mental health nursing. Archives of Psychiatric Nursing, 1(3), 1987, pp 145-154.

25. Butterworth T. The future training of psychiatric and general nurses, Nursing Times, 80(30), 1984, pp 65-66.

26. International Council of Nurses, Report on the regulation of nursing. Prepared by Margretta M Styles, ICN, Geneva, 1986, p. 49.

27. Styles M. Project on the regulation of nursing - 1984. International Council of Nurses. Geneva, 1984, p. 46.

28. Barratt E. Community psychiatric nurses: their self-perceived roles. Journal of Advanced Nursing, 14,1989, pp 42-48.

29. International Council of Nurses, Responses to Questionnaire sent to a sample of 23 national nurses' associations on: Mental Health/psychiatric Nursing, October 1989.

30. The role of nursing and midwifery personnel in the strategy for health for all. WHO, Report by the Director-General to the Executive Board, EB83/6, 17 October, 1988, p. 10.

31. Peplau H. Tomorrow's world, Nursing Times, 7 January, 1987, p. 31.

32. Peplau H. Tomorrow's world, Nursing Times, 7 January, 1987, p. 11.

33. International Council of Nurses, Responses to Questionnaire sent to a sample of 23 national nurses' associations on: Mental Health/psychiatric Nursing, October, 1989.

34. Wankiiri V. Mental health and psychiatric nursing in Africa. World Health Forum. 5. 1984, pp 334-337.

35. Breust M. Institutionalization versus living in the community: psychiatric deinstitutionalization and nursing in New South Wales. In: Issues in Australian Nursing 2. Ed: G Gray & R Pratt, Churchill Livingstone, Melbourne, 1989, p. 72.

36. Aiken L. Unmet needs, p. 124.

37. Mechanic D. Nursing and mental health care: Expanding future possibilities for nursing services, In: Nursing in the 1980s. Ed. Linda Aiken, J B Lippincott Co., Philadelphia, 1982, pp 343-358.

38. American Nurses' Association, Standards of child and adolescent psychiatric and mental health nursing practice. Kansas City. American Nurses' Association. 1985, p. 5.

39. American Nurses' Association. Standards, p. 6.

40. Wankiiri V. Mental health and psychiatric nursing in Africa. World Health Forum, 5, 1984, pp 334-337.

41. Carlisle D A. School for normal living. Nursing Times, 85(41), 1989, pp 16-17.

42. Nolan P. Face value, Nursing Times, 85(35), 1989, pp 62-65.

43. Pollack L. The work of community psychiatric nursing. Journal of Advanced Nursing, 13. 1988, pp 537-545.

44. Barnum B. Nursing's image and the future. Nursing and Health Care, January, 1989, pp 19-21.

45. Simpson K. Community psychiatric nursing - a research based profession. Journal of Advanced Nursing, 14, 1989, pp 274-280.

46. Barratt E. Community psychiatric nurses. p. 48.

47. Brooker C. An investigation into the factors influencing variation in the growth of community psychiatric nursing services. Journal of Advanced Nursing, 12, 1987, pp. 367-375.

48. Wankiiri V. Mental health and psychiatric nursing in Africa. World Health Forum, 5, 1984, pp 334-337.

49. Peplau H. Tomorrow's world. Nursing Times, 7 January, 1987 p. 32.

50. Styles M. Project on the regulation of nursing - 1984. International Council of Nurses. Geneva, 1984, p. 101.

51. Styles M. Project on the regulation of nursing - 1984. International Council of Nurses. Geneva, 1984, p. 104.

52. Slavinsky A. Psychiatric nursing in the year 2000: From a non-system of care to a caring system. Image-Journal of Nursing Scholarship 16(1) 1984, p. 19.

World Federation of Occupational Therapists - ''Occupational Therapy in Mental Health Care1''

World Federation of Occupational Therapists

This is the official international organization for the promotion of occupational therapy, The Federation aims to promote international co-operation among occupational therapy associations, between therapists and allied professional groups, through international congresses, job exchanges, research and publications. Liaison with WHO and international non-governmental organizations is an important aspect of developing co-operation. The Federation promotes internationally recognized standards for education of occupational therapists and seeks to maintain the ethics of the profession and to advance the practice and standards of occupational therapy.

A country with an occupational therapy association is eligible to become an associate member of WFOT and any country with a WFOT-approved educational programme may become a full member.

The inaugural meetings of the Federation were held in 1952 and the 10 member countries held their first international congress in 1954. By 1991 there were 37 member countries, including associates.

1. Introduction

Throughout the world, occupational therapists are employed in working with people of all ages, who have a wide variety of psychiatric problems. Occupational therapists receive a wide education in biological, medical and behavioural sciences, and professional skills and techniques. Clinically-based studies form an important part of the course. Occupational therapy is a highly practical profession and the therapist has to be perceptive of people's needs and able to build up their confidence. While it is necessary to be able to work with others in a team, the therapist also makes independent judgements.

Leff (1) states that despite cultural variations in the presentation of illness, there are more similarities than differences in management, and this is the position in occupational therapy, where practice varies according to local cultural needs and requirements but there are many features in common. This paper describes the development of the World Federation of Occupational Therapists, the role of the occupational therapist and the contribution which the profession can make to patient care.

2. Current position

Although occupational therapy has its roots in antiquity, it has developed as a profession during the twentieth century. As advances in medicine have paved the way for rehabilitation, therapists have become involved in promoting functional independence for patients with a wide range of problems and diagnoses. Practice in the psychiatric field is more developed in some countries than others but there has been a rapid expansion during the past few years, with therapists developing new areas of work and establishing practice in countries which have not previously had any input from the profession.

In general however, there is an international shortage of qualified occupational therapists and this is exacerbated by the demands created by medical and social factors. Unless there is an increase in staff, particularly in countries where services are newly established, the development of the profession will be seriously curtailed.

3. Where do occupational therapists work?

Occupational therapists may work in a variety of locations, ranging from hospitals and community centres to the patient's own home. This may include acute and general psychiatry, rehabilitation, care of the chronically mentally ill, or special services such as forensic, substance abuse or paediatric units. Work with the elderly mentally ill is an area which is assuming increasing importance, particularly in the West.

4. What do occupational therapists do?

Occupational therapy is the treatment of physical and psychological conditions through the use of selected activities. The aim is to enable patients to reach their own optimal level of independence, within the personal, economic and social areas of life. Wing (2) has stated that the amount of time spent doing nothing is directly related to the extent of the patients recovery and a key feature of occupational therapy is the active involvement of the patient in purposeful activity. One of the core skills of the therapist is activity analysis, which enables him or her to grade programmes to meet the needs of the individual. An important part of the job is to observe and record progress, write and present reports, and recommend future action.

5. Referral for occupational therapy

In the hospital context, patients will normally be referred to occupational therapy by the doctor or a member of the multi-disciplinary team. In other settings it may be a family member or carer who initiates contact and it is also possible for self-referrals to be accepted. In the latter situation, it is essential for the occupational therapist to be able to contact the medical officer in charge of the case in order to ensure good cooperation and the best possible treatment.

6. Assessment

Initially, the therapist assesses each patient in order to establish a baseline for treatment (3). Assessment may be carried out through the use of standardized or non-standardized procedures, by observation of the patient in a variety of contexts or through consultation with other professionals and significant people in the person's life. In reaching an understanding of problems and abilities the patient's participation is essential.

7. Planning treatment

Once a list of problems and abilities has been identified, the occupational therapist and the patient together draw up a plan, incorporating as aims of treatment the goals which they have identified as being important both immediately, and in the long term. Once a period of treatment has elapsed, progress will be reviewed and the aims of treatment modified in order to meet any changes indicated. Regular evaluation of this type is important in assessing the patient's progress and also in determining the efficacy of treatment procedures.

8. Treatment

Treatment may be planned according to a variety of theoretical perspectives. The use of these will vary according to the philosophy adopted by any particular hospital unit e.g. a behavioural or a psychotherapeutic approach, or a model of treatment devised by the profession, such as the Model of Human Occupation (4). In all contexts, co-operation with other members of staff, relatives and volunteers is essential in achieving a balanced treatment programme. The importance of teamwork cannot be minimized.

In acute and general psychiatry occupational therapists work with individuals or groups of neurotic or psychotic patients, using wide ranging activity programmes which often focus on domestic and social activities (5). An example of this would be assisting a young schizophrenic person to adapt to independent living, paying particular attention to learning to buy food and make meals.

For many people, relaxation techniques, stress and anxiety management will also be relevant. Occupational therapists will also help patients to consider their lifestyle in order to achieve a balance of time for themselves.

A psychotherapeutic approach may be adopted in which the patient is encouraged to express emotions through the use of creative media such as art, music or drama. An activity could be modelling different family members in clay in order to discuss and explore relationships. Practice of different modes of behaviour and newly acquired skills is an integral aspect of this work.

In the context of rehabilitation, the therapist works with patients who require a longer period of treatment. This may mean preparing chronic patients for discharge, often after long periods in hospital, or refining skills in order to maximize the individual's competence to cope with life in the community. The therapist may work with groups of patients in transitional care (group homes or occupational schemes) or within a specialized rehabilitation unit. Practical training in community living skills and domestic management may be augmented by educational activities (reading, writing and numeracy) and social skills groups.

For some patients it will be appropriate to consider work skills. Programmes are devised for individuals to improve existing skills or, where necessary, to give opportunity to try out alternatives as part of a prevocational assessment (6). If indicated, job analysis will be carried out and job seeking skills will be practised and referrals made to relevant training resources.

Planning for leisure time is also important in order to achieve a balanced lifestyle or to alleviate the social isolation experienced by many patients. The therapist liaises with voluntary or self help organizations which offer social support.

Some therapists work with chronic mentally-ill patients in long term care, aiming to enhance quality of life, minimizing the effects of institutionalization and encouraging individuality. This includes the organization of structured programmes providing activities which promote both physical and mental health. Younger chronic patients have different needs, and here the therapist seeks to stimulate involvement in projects which maintain community integration.

An important aspect of programmes for chronically mentally ill people is contact with families. Co-operation with relatives is always essential but in the case of chronic psychotic patients, the occupational therapist may be involved in support groups and in educating families about the effects of illness and how problems may best be managed.

In countries where the numbers of elderly people are increasing, the contribution of the occupational therapist assumes particular importance in the management of illness (7). Old people may suffer from the same types of psychiatric illness as other age groups and the occupational therapist provides treatment accordingly. In addition, chronic organic brain disease (dementia) requires that the therapist assesses the elderly person's ability to function safely outside hospital. Home visits to determine domestic and personal skills will be an important feature of this work. The use of reality orientation techniques assists in reducing the effects of confusion and the therapist may be involved in assisting carers to help elderly people to maintain contact with reality. The use of labels and diaries can be of value here.

In special units, programmes necessarily vary according to the focus of the unit. Assessment and treatment through play, and family therapy, will be of paramount importance in a child or adolescent unit. In a substance abuse unit, identification of patterns of behaviour leading to the abuse of drugs or alcohol will precede programmes aimed at enabling the person to explore and practice alternative methods of coping. In forensic units, behaviour modification programmes may be used in order to promote a structured environment or opportunities may be provided for the appropriate release of aggression. Assessment of inter personal relationships may be crucial to diagnosis (8).

Not all treatment is hospital-based and the role of the occupational therapist in community mental health is becoming widely recognized. Many of the types of treatment described above may take place in the patient's own home or a community centre. In the West, hospital closures mean that many patients require follow up support to ease the transition from hospital to community. In some regions, mobile teams provide sessional input as an alternative to hospitalization and the creation of community mental health teams has resulted in new possibilities for the development of services.

In developing countries there is a tendency for qualified therapists to be employed in central locations in order to establish services. Little mention is made of occupational therapists in relation to the national plans in countries where primary health care programmes are being developed. This is an area in which the profession has much to contribute in an educational and consultative role. Some draft programmes indicate a mental health focus in primary health care and may also include community based rehabilitation. Here, the potential role is enormous! The occupational therapist can devise programmes to promote personal life skills, domestic management or vocational rehabilitation. Encouraging families to integrate their sick members into ordinary life activities and educating communities about psychiatric illness, will be important in promoting good practices in mental health.

In countries where there is a severe shortage of therapists working in the psychiatric field, the occupational therapist may work with a group of rehabilitation assistants and thus spread the benefits of treatment to a greater number of people.

Educating community support workers is an important task in creating awareness and sensitivity to the needs of patients, particularly if qualified staff are in short supply. In addition, this is appropriate to the principle of any community developing programmes relevant to its own particular needs.

9. Organization of staff and services

The establishment of an effective management structure is crucial in providing an efficient service. Occupational therapy managers should liaise with governments in order to plan, establish and evaluate appropriate services.

A career structure which enables staff to gain promotion and maintain clinical contact is valuable in retaining experienced practitioners. Ongoing post-qualification education should be encouraged, together with opportunities for research.

It is important to recognize that occupational therapy assistants (helpers) have a valuable role to play in augmenting the role of the therapist (9). Some staffing structures make provision for this, through employment of technical staff whose craft skills, for example carpentry or pottery, contribute to treatment.

10. The future

The stresses of twentieth century life; for example large scale disasters, urbanization, unemployment and war, create mental health problems throughout the world. This has particular implications for people with chronic mental illness and it is necessary that occupational therapists are involved in initiatives directed at providing support for such people and their families. Centres such as those following the Fountain House Model (10) could provide an example for occupational therapy intervention.

The psychiatric problems of patients with HIV or AIDS are as yet largely unknown, but current occupational therapy programmes for HIV positive babies and developmentally delayed children suggests that there is scope for involvement with AIDS sufferers of all ages (11).

Ongoing role clarification is critical (12). Identification of core skills is important in explaining the role of the occupational therapist to other professions, and in working effectively where there are areas of overlap.

In the era of quality assurance and marketing of services, occupational therapists need to do more research to evaluate their contribution to psychiatry in order to identify efficacy of care and prioritise areas for involvement.

Co-operation with non-governmental organizations, governments and local agencies is essential for the development of the profession in the manner which can be most effective for the good of the people throughout the world.

11. Notes

1. Paper prepared by Clephane Hume, Department of Occupational Therapy, Queen Margaret College, Edinburgh, United Kingdom, on behalf of the World Federation of Occupational Therapists.

12. References

1. Leff J. Psychiatry around the globe - a transcultural view, 2nd ed. London, Gaskell/Royal College of Psychiatrists, 1988.

2. Wing J, Brown G. Institutionalism and schizophrenia, Cambridge, Cambridge University Press, 1970.

3. Hume C. Introduction to assessment and treatment planning. In: Hume C and Pullen I. Rehabilitation in Psychiatry. Edinburgh, Churchill Livingstone, 1986:5.

4. Keilhofner G, Burke J. A model of human occupation. Part 1, conceptual framework and content. American Journal of Occupational Therapy, 1980, 34(9):572-581.

5. McCallion L. Acute admission. In: Creek J. ed. Occupational therapy and mental health. Edinburgh, Churchill Livingstone, 1990:18.

6. Kramer L W. SCORE. Solving community obstacles and restoring employment. New York, Haworth Press, 1984.

7. Blair S. The elderly. In: Creek J ed. Occupational therapy and mental health. Edinburgh, Churchill Livingstone, 1990:21.

8. Lloyd C. Evaluation and forensic psychiatry. British Journal of Occupational Therapy, 1915, 48(5):137-140.

9. Jay P. Occupational therapy helpers and assistants in health care and social services, London, Disabled Living Foundation, 1991.

10. Fountain House. A descriptive booklet, Lahore, 1985.

11. Williams J K. Values and life goals: clinical interventions for people with AIDS. Occupational Therapy in Health Care, 1990, 7(2, 3, 4) P55-68.

12. Fidler G. The challenge of change to occupational therapy practice. In: Occupational Therapy in Mental Health. Haworth Press Inc., 1991, 11(1):1-II.

World Organization of National Colleges, Academies and Academic Associations of General practice, Practitioners/Family Physicians (WONCA) - ''The Professional Role of General Practitioners in Mental Health''

John Horder

General Practitioner,
98 Regents Park Road
London NW1 8UG

World Organization of National Colleges, Academies and Academic Associations of General Practice, Practitioners/Family Physicians (WONCA)

The Colleges and Academies which are members of this international organization are national bodies, distinct from universities. Their shared, overall purpose is to encourage and maintain high standards in the branch of medicine described above. They follow a pattern of which the earliest example is the Royal College of Physicians of London, founded in 1518 (in order to distinguish trained physicians from untrained competitors). The earliest example from general medical practice is the American Academy, which was founded in 1947. Although the development of such colleges occurred earliest in English speaking countries, it is now more widely disseminated. There are, at present, 38 countries with institutions in membership.

The World Association was formed in 1972. Ifs overall purpose is achieved by:

1. providing a forum for exchange of knowledge and information between member organizations of general practitioners/family physicians;

2. encouraging and supporting the development of academic organizations of general practitioners/family physicians;

3. representing the educational, research and service provision activities of the general practitioner/family physician before other organizations and/or forums concerned with health and medical care.

It exists to support, but not to control it's constituent bodies. Ifs most important achievement hitherto has been to create an International Classification of Health Problems in Primary Care (ICHPPC) (1). This is based on the World Health Organization's classification of disease, which was not originally designed with a view to primary care.

GENERAL MEDICAL PRACTICE

General medical practice (in some countries 'family practice') can claim the longest history of any branch of medicine, starting whenever and wherever the roles of the physician and priest become distinct. It survives today as the most general among many specialized branches of medicine. The need for it has become increasingly obvious as the logic of specialization leads to increasing subdivision, fragmentation and high costs.

The following statements about this role have been agreed by the World Organization of Colleges, Academies and Academic Associations of General Practitioners/Family Physicians.

"High quality primary health care depends on the availability of well-trained general practitioners or family physicians as members of health care teams in the community.

The general practitioner or family physician is primarily responsible for providing comprehensive health care to every individual seeking medical care.., either directly or through the services of others - according to the health needs and resources available within the community which he/she serves. He or she cares for the individual in the context of the family and the family in the context of the community, irrespective of race, religion, culture or social class; is clinically competent to provide the greater part of their care, after taking into account the cultural, socio-economic and psychological background; takes responsibility for providing comprehensive and continuing care to patients."

This role is distinct from any other in medicine because of ifs combination of accessibility, broad range, continuity and the capacity to integrate the assessment and management of clinical problems when, as so frequently, these are related one to another.

PART ONE

1. Introduction

The role of the general practitioner must first be set into a context. It would be short-sighted to launch immediately into describing the challenge of mental health problems only as they are presented in a doctor's consulting room. They exist in homes and working places. People do not always consult doctors. The responses now used by general practitioners are not the only ones possible; those used by others could suggest directions in which general practitioners' roles should develop. The introduction therefore sets the context by considering the extent and nature of mental health problems as they are seen through population surveys.

2. The magnitude of the problem in the general population

Surveys of a total population or of a random population sample in their homes suggest that around 150 per 1000 persons at risk have mental health problems at any one time of enquiry. These figures are based on Australia (2), Greece (3), Uganda (4), United Kingdom (5,6), USA (7, 5, 9, 10).

There are wide variations in prevalence rates (75-200 per thousand). They are attributable less to geographic location than to differences in method - especially in decisions about where to draw a precise line between those who have mental health problems - "psychiatric cases" - and those who do not; or between different degrees of severity of disturbance or impairment.

In the United States, prevalence rates of mental disorders per thousand subjects from five sites in the ECA Program study (10) are reported as 154, 191 and 322 for one month, six months and lifetime, respectively. Psychiatric disorders are consistently found to be more common among women than men (11, 12). Rates are higher for people who are separated, divorced or unemployed.

The challenge of such findings in all populations and communities studied does not need to be laboured.

2.1 What is a "case"?

We cannot evade the problem of defining what constitutes a mental health problem. Without discussion it would remain unclear whether, in what follows, we had in mind

1) only those problems which cause significant or severe disturbance and impairment or

2) every problem which might be detected by exhaustive methods of survey and enquiry.

Our context is the professional role of general practitioners. Whatever the type of morbidity they deal with - physical, psychological or social - they face both minor and major deviations from health or normality. To take into account only the most severe forms of psychological disturbance would therefore be obviously inappropriate.

Forms of psychiatric interview and screening questionnaires are now numerous.

The questionnaire most often used is the general health questionnaire (GHQ) (13) designed as a community research tool, it will allow the identification of persons with emotional disorders.

The standardized interview most often used in international studies of psychiatric illness is the Present State Examination (PSE) (14).

We believe that the figure of 150 per thousand persons suffering from emotional disturbances does include patients whose problems, though real enough, would not be classified as "major".

"Anxiety" and/or "depression" are diagnoses used to account for at least two-thirds of the cases detected in community surveys. Depression is the single most common psychiatric diagnosis among random samples of a community (with a typical rate of 60 per 100 - UK or USA (15)). The only study comparing the United Kingdom with an African village by the same methods showed rates to be three times as high in Africa (4). Alcohol and drug abuse are increasingly common in all countries. In developing countries mental disorders secondary to infective illness and to other organic pathology are also common. Half the population being under 15, a large burden of child and adolescent disorders is found (16).

2.2 Who do people consult?

In the face of all the types and degrees of problems described, some people cope by themselves or within family and friends. They do this either by seeking solutions or by accepting what seems inevitable or by not recognizing that there is a problem when this is obvious to those near them.

It is important here, as in the rest of the field of health and illness, to recognize the extent of self-care. But it is not the focus of this paper. This is concerned with the role of one professional group among the many whose members people consult.

But who do people consult, apart from relatives and friends? The range must vary greatly in different cultures or countries. In countries similar to the United Kingdom there are clergy, counsellors, lawyers, nurses, pharmacists, the police, psychologists, as well as medical practitioners and psychiatrists. There are also practitioners of alternative or complementary medicine. As a general proposition, where GPs are found, they form the profession most frequently consulted for mental as for other health problems. They are usually already known and trusted and are traditionally the first Port of call. This is certainly true in the United Kingdom (17).

The situation in developing countries is characterized by severe shortage of trained staff of all grades. Doctors are a scarce resource, a scarcity that is often worsened by emigration. The doctor-patient ratio can range from one doctor to over a million population in rural areas to one to a thousand population in urban areas. In Africa traditional healers, herbalists and village health workers play a very important part. In South East Asia large numbers of people see traditional medicine practitioners for mental health problems. Magic and ritual are important elements in such treatment and are resorted to even by educated families, since there is a culturally determined belief in the efficacy of these rituals. Increasingly, however, people are turning to modern medicine. The need to train general practitioners in mental health is therefore urgent in developing countries, but at the present time it may be more realistic to rely on village health workers. They might have six to ten years' schooling and only three months' training in general health care. They are expected to refer people with anything more than the simplest problems to the next level, staffed usually by a health worker with 10-12 years of schooling and 2-3 years' health training. Less often physicians provide this level of care (18).

Given the steady development of specialization in all fields of medicine, it might be expected that in the most developed countries people with mental health problems predominantly consult psychologists or psychiatrists. Community surveys in Israel, which identify 45% of patients in general practices as having psychiatric symptoms, found that the vast majority of them were not referred for psychiatric help (19, 20). In the United States of America the situation may be changing. Earlier evidence (9, 21) suggested that only one person with a psychological disorder in five saw a mental-health professional; three out of five were served in the primary care outpatients sector. Nine out of ten depressed patients had seen a primary-care physician only. More recent evidence (22), mainly from urban areas, suggests that between a quarter and a third of ambulatory visits by persons with mental disorders were made to mental health specialists but the figure depends above all on their availability.

In general, even in countries where direct consultation with mental health specialists might seem most likely to occur, this is the exception rather than the rule. The reasons are obvious. First - the ratio of mental health specialists to general physicians is one to five (specialists tending to congregate in conurbations); second - the physical symptoms which so frequently accompany mental problems, as described above, lead sufferers naturally towards doctors perceived to deal with such problems. Although attitudes may be changing, this route is usually more acceptable to patients, many of them being reluctant to recognize the nature of their problem or to risk being labelled as psychiatric.

The ratio of psychiatrists to primary care physicians is even lower in the United Kingdom (1-26) than in the United States. In developing countries the ratio is incomparably lower. It is estimated that in South East Asia, for example, there are less than 750 psychiatrists (almost all in urban areas) for a population that exceeds 280 million.

2.3 Individuals or teams?

In naming the different professions consulted, it may seem to have been implied that each one works in isolation from the others. This is very often the case, but the increasing complexity of medical and social care increasingly requires collaboration and teamwork. This is usually better developed within psychiatric hospitals than in community services outside them. However, many examples of close cooperation between general practitioners, community psychiatric nurses, psychologists, counsellors and sometime social workers, working with one community, can be found in the United Kingdom and the United States and doubtless in other countries of similar development. A particularly interesting change has occurred in the United Kingdom, whereby a significant proportion of psychiatrists now spend regular periods of time working in the setting of primary care (23) - so linking the primary care team with the psychiatric team based within the hospital system.

Teamwork can involve workers with limited training. An interesting example has been developed at Porto Alegre, Brazil, where auxiliary health workers and health volunteers are members of primary teams trained to deal with physical, psychological and social aspects of illness in all members of a family while integrating preventive, curative and rehabilitative interventions (24).

2.4 What proportion of those with mental health problems consult general practitioners?

There have been a number of studies in the United Kingdom and the United States which have shown the general relationship between morbidity and consultation with doctors. This can be illustrated by Figure 1 in the Annex (25, 26, 27).

Thus in a population of a thousand in any period of one month, about 750 persons will experience symptoms of some form of ill-health, however minor. Only 250 will consult physicians - about one in three.

Does this general pattern apply to mental health problems? In a London population it was found that only about a third of those individuals identified in a community survey as having significant psychiatric disorder had consulted a GP within the previous two weeks (28).

The longer the period of observation, the higher the proportion consulting.

Not surprisingly, people with more severe problems are more likely to consult (29).

But all these studies come from countries at a particular stage of development. In less developed countries, consultation with trained physicians is much more difficult because of their relative rarity in a community, their distance and cost.

PART TWO

3. The Role of General Practitioners and Primary Care Teams

3.1 The frequency and nature of mental health problems among patients seen In primary care clinics

Studies reviewed from the United Kingdom and the United States showed that mental disturbance was found in 11%-36% of primary care patients (30). Goldberg and Williams found 35%-40% (U.K) (13). Three reasons mainly account for this wide range.

First, health problems are often expressed to doctors in physical terms or accompany coincidental physical disorders. But the boundary between physical and mental is hard to define in theory and difficult to recognize in practice. For example, is insomnia a physical or a mental problem? Second, the attitude of physicians to patients with mental illness has been shown to vary. Some are prone to deny its presence or underestimate its importance; others are prone to attribute psychological causes more often than can be justified. These are matters of prejudice. Third, skills in assessment vary. All these influences account for variation in detection and recognition by primary care physicians (11).

Available evidence suggests that the frequency of mental disturbance encountered in clinics in less-developed countries is the same or greater. It has been reported that 20% of the patients attending a walk-in clinic in a Kenyan suburb had a psychiatric disorder (3). A study, using various strict criteria in Columbia, India, Sudan and the Philippines found rates varying from 10.6% to 17.7% (32). In a primary care-setting in Brazil, a rate was found for minor psychiatric morbidity of 40% (33% conspicuous and 13% hidden) (33). Cheng, studying medical attenders in Taiwan (34), found 44.4% of "psychiatric cases".

Experience in general practice clinics is largely consistent with the findings from population surveys described above. It confirms the higher consultation rate of women than men - especially middle-aged women; likewise the predominance and variety of physical symptoms; likewise the dominant importance of anxiety and depression in all cultures (35, 36). In a study of patients attending general practices, a large and slowly changing group of patients was found with chronic mental health problems, alongside a small and rapidly changing group with new disorders of recent onset (37).

General practitioners are consulted about problems which are close to, or part of, the ordinary life of most people. Their work inevitably takes in reactions of thought, feeling and behaviour which cannot be considered to be disease or illness. For example, anyone realizing or even wrongly suspecting that they had cancer, would be likely to feel anxious or depressed. People bereaved of wife or husband would be abnormal if they did not grieve. General practitioners deal every day with such threats and losses - problems in living - usually about family, work, or money, in varying degrees of severity.

It is a common experience to be faced with people bringing multiple problems -often a mixture of physical, psychological and social problems. To disentangle what matters most out of the confusion is the doctor's first and most essential task.

New problems in developing countries have come to resemble those elsewhere -drug abuse, alcoholism and chronic stress reactions. In addition there are problems of juvenile delinquency, family breakdown and loneliness.

"Most psychiatric patients have a common core of symptoms which relate to mood disturbances - notably anxiety, depression, fatigue, irritability and sleep disturbance. The exceptions fall into two groups - on the one hand ... hypomania, certain forms of schizophrenia and some organic states...; and on the other hand, various kinds of abnormal personality which may occur without the critical symptoms of mood disorder..." (15).

But general practice studies in both the United Kingdom and the United States shows that, for every patient who complains of these mainly emotional symptoms, at least twice as many offer a combination of emotional and physical symptoms (38, 39). Physical symptoms are even more common in developing countries (40). Minor and transient disorders occur far more commonly than major; they are often indistinguishable from experiences accepted by most people as part of normal life. At the other extreme, major ones can be incapacitating, prolonged, destructive of family life and lead to suicide.

Mental health problems may also show themselves in ways other than mental or physical symptoms. There may be criminal offenses, absenteeism from work, suicide attempts, alcoholism, traffic accidents or, in the case of children, withdrawal from school.

Apart from the physical presentation of many mental health problems, there are two other important linkages.

First, anyone suffering from a primary physical disorder will often have cause to be anxious or depressed. Moreover, even the fear of life-threatening or incurable illness may have the same effects.

Second, it has been repeatedly demonstrated that people who contend with significant mental health problems are at greater risk of other concomitant physical disorders.

Weyerer has reviewed these issues in detail within general practice settings (41). Goldberg (42) has indicated the proportion of cases falling in the five possible categories:

- not psychiatrically ill:

67%;

- physical illnesses with secondary psychiatric illness:

1%;

- unrelated physical and psychiatric illness:

8%;

- somatization:

19%;

- entirely psychiatric illness:

5%.

All these linkages have a bearing on the question of which professional roles and types of training are most appropriate for the tasks of detecting and assessing mental health problems.

It is important to consider the issues of severity and duration from the evidence about population studies rather than about patients attending general practitioners, since the former are more likely to include a representative proportion of minor cases.

Community studies of depression and anxiety show that depression is most often a recurrent disorder, anxiety being more continuous. But in a follow-up of seven years, it was found that just over a quarter of the patients with depression ran a chronic course and were never free of symptoms (43, 44). At the other extreme, a similar proportion showed remission or recovery after 5-7 years.

3.2 The response of the general practitioner and primary care team: Detection and Recognition

In most countries almost all general practitioners accept that it is their business to respond to mental health problems (45).

It is clear from what has been said that the problems of hidden morbidity in this particular field make detection and recognition the essential first tasks.

The detection of depression is particularly important because of its frequency, its many disguises and the possibility of care which can be both supportive and effective. One disguise is in increased anxiety, another is increased frequency of consultation, another the anxiety of a close relative and finally a variety of physical symptoms. Watts (46) listed ten symptoms most commonly presented in his rural general practice as 1) tiredness 2) headache 3) anxiety 4) depressed mood 5) backache 6) insomnia 7) pains in the chest 8) dyspepsia 9) giddiness 10) pains in the trunk, arms and legs.

General practitioners also have many opportunities for recognizing alcoholism and drug abuse. They need to be grasped for similar reasons (47, 48).

Once a doctor or nurse suspects that he or she is dealing with a mental health problem, its nature has to be assessed. This can, of course, mean the choice of a diagnostic category - "depression", "schizophrenia", "drug addiction", "organis psychosis". These labels, though useful, are less so than similar labels in other fields of medicine and can even be harmful. "Assessment" can also imply the search for causes. Such assessment may point to a useful form of intervention. Though obviously complex and difficult, the issue of causation is of central importance. Evading it leads easily to routine or inappropriate prescribing of psychotropic drugs and to rejection of the patient as a unique person. Understanding of multiple causation is essential. Biassed pursuit of one type of cause, to the neglect of all others, is another common reason bringing harm to patients.

Traditionally understood as seeking the help of a psychiatric specialist for assessment, treatment or hospitalization, referral may also be to other members of a primary care team. In either case, the form and quality of communication matter greatly (49). Mutual acquaintance between professionals is especially valuable, since personal preferences have a larger influence here than in other fields of mental health care. Such acquaintance cannot be assumed in large conurbations.

Patients are referred to psychiatrists for assessment, treatment, hospitalization and sometimes because of difficulty in the GP's relationship with a patient. In many countries it is normal for patients to be referred back to the general practitioner when some special need has been fulfilled. In the United Kingdom only about one patient in twenty with mental health problems is referred to a psychiatrist.

3.3 Continuity of care

Recurrence and chronicity of mental health problems call for continuity of care. The nature of some disorders - for example schizophrenia or dementia -does not permit that the onus for keeping contact can be on the patient. General practitioners, although accustomed to offering a continuous service for physical disorders, may need the help of other team-members to ensure contact with such patients, many of whom lose touch with or never reach psychiatric clinics (50, 51). Where general practitioners or primary care teams (or psychiatric teams) have a responsibility for a defined list of people or a defined area, computers have provided a valuable means towards effective continuity of care.

General practitioners can use their frequent contact with patients to recognize changes in behaviour or in consultation habits. Frequent consultations about a child may indicate hidden trouble in a parent or in the relationship between both parents.

3.4 Prevention

Overall, the preventive element in the role of general practitioners and primary care teams has increased in recent decades. This claim can be supported with evidence, certainly in the United Kingdom (52, 53). It could include some evidence about beneficial outcomes, for example in relation to immunization or the discouragement of cigarette smoking. The inevitable links between prevention, care and cure can be realistically represented by the term "anticipatory care", implying both a way of thinking and a set of actions (54).

In the context of mental-health problems it is difficult to point with assurance to preventive actions within the scope of routine general practice which can be demonstrated to be effective. An optimistic view might claim that opportunities for preventive action are legion, for instance in preventing anxiety or depression. But this view must meet such challenges as having to provide evidence that specific interventions do "reduce the future incidence of symptoms among people who are relatively free of them or who are suffering from symptoms not severe enough to be defined as cases" (55). Reliable studies which provide such evidence are few. Most are examples of secondary or tertiary prevention - that is early treatment or ways of limiting disability resulting from mental disorder. As with treatment, preventive interventions can be physical or psychological or social.

As an example of prevention by physical means, once a patient is recognized to be liable to episodes of depression of sufficient severity, the use of anti-depressive drugs either intermittently or continuously is justified and in many cases effective in preventing or limiting recurrence (National Institute of Mental Health, 1988).

As an example of psychological intervention, the studies of Parkes (56) and Raphael (57) comparing the effect of counselling for bereaved relatives at high risk of psychiatric disorder against a control group show convincing evidence of benefit. Much of what they did would be repeatable by general practitioners and others in the primary care team with a little training. Indeed this form of support has long been provided, but only by a minority of doctors (58).

An example of social intervention involving social workers attached to a primary care team was reported by Corney (59). She was able to show that social workers were effective in preventing some acute episodes of depression in women lacking social support from becoming chronic illnesses. Cooper et al. (60) showed a number of benefits to patients and clients with chronic neurotic illness from practices which had a social worker attached, compared with those attending practices which had no social worker.

These are all reports of controlled research studies. However, the routine experience of general practitioners would claim the impression that many other preventive functions are worthwhile. "Reassurance" is an old and comprehensive term but when aimed with precision and offered with understanding, it does indeed seem to relieve anxiety in patients, for instance, facing operations or unwelcome medical verdicts, fearing childbirth; or in those whose fears are based on some misunderstanding of their condition; or in those who approach some crisis in their work or family life - even those of normal life such as marriage or retirement (54).

The supportive role of the familiar trusted doctor or nurse must be accepted as a role of great importance in all countries; especially as the support of the extended family is less available than it was in the past (61).

In some less developed countries, the problem of family size may have important consequences for mental health. Larger families are known to have more such problems (61). The number of orphans has increased. Thus such an apparently unrelated action within the scope of general medical practice as family planning can have important preventive benefits in the present context. This example must suffice to represent many others.

Treatment, if it is not to be merely symptomatic, depends on an effort to assess the influence of such causes as are commonly recognized. General practitioners use both physical and psychological approaches, usually combined (62).

Psychotherapy is usually simple and untutored. However, many efforts have been made in recent years to provide general practitioners with limited understanding of emotional problems in their patients, in themselves and in consultations. Among the most ambitious examples, the work of Michael and Enid Balint has been influential in many countries (63). Although it is a minority of general practitioners who have done this type of training, its influence has spread indirectly to many others (64).

Some evidence of the effectiveness of both psychologists and counsellors, when working with GPs, has been provided by Anderson and Hasler (65), Earll and Kincey (66) and Robson et al. (67).

There are many "social" interventions available to the general practitioner - for example, certifying sickness absence from work, seeing more than one member of a family simultaneously when there is conflict between them, arranging convalescent holidays, acting as an advocate in many different situations. Cooperation with social workers is discussed at length by Corney (68). Cooperation is obviously desirable, but mutual understanding is sometimes difficult.

Since the trend in many countries to discharge patients "into the community", the role of general practitioners in, caring for patients in hostels or half-way houses has become important (69).

3.5 Management

Medical care is increasingly carried out by groups of people rather than by individuals, although the relationship of one group member to one patient may still be of great therapeutic importance. This one-to-one relationship is not excluded by working in a group, but it is easily diluted unless care is taken.

Groups, whether of doctors or of different professionals, are unlikely to work effectively or harmoniously unless someone attends to the processes which can favour these aims. Teamwork" implies that people make their differing contributions to a shared purpose. Purposes or objectives are often assumed to be obvious, appropriate and shared by different members of a group nominally working together. Experience shows that these assumptions do not always conform to reality.

Although doctors and nurses have always been concerned to offer the highest possible quality of service and sought means to achieve this, it is only in the last twenty years that serious attempts have been made to assess quality, so that accurate comparisons can be made between a particular element of care offered in one practice with that offered in another; or between what has been done in the past in a practice and what will be done in future, after introducing some measure intended to improve what is offered. Such review of performance ("audit") entails constructive self-criticism or criticism from colleagues or patients. This important principle has its application in the mental health field as in other fields. An example might be the systematic scrutiny of the prescribing of all psychotropic drugs in a practice with a view to identifying variations between doctors, discussion of appropriateness and, if necessary, subsequent change in usage (70).

In less developed countries the role of the general practitioner is likely to vary from the description above. It is likely to include a greater responsibility for advanced disease and a larger element of hospital work. It may also require more time in cooperating with less highly trained colleagues and in processes of mutual education and understanding.

4. Strengths and Limitations of the General Practitioner

Although trends culminating in the Alma Ata Declaration and promoted by WHO have pointed to the general practitioner as a key figure in the organization of health services at local level, it has already been indicated in this paper that there are alternative agents in dealing with mental health problems. In developed countries the issue of direct access to specialists in mental health remains open. The claim of greater expertise is strong. It is therefore important to look critically at the strengths and weaknesses of the general practitioner and the primary care team in dealing with mental health problems.

General practitioners cannot be regarded as a uniform group. They show great variation even within one country, for instance in regard to prescribing, or the use of special investigations or in referral to specialists. This paper is especially concerned with variations between them in their perception of the importance of the mental versus the physical aspects of their work and in their resulting knowledge, skills and tolerance in dealing with these patients. Shepherd (11) showed, for example, a ninefold variation in their capacity to recognize a psychiatric problem. There is a tenfold variation in the level of prescription of psychotropic drugs.

Basic medical education in most countries concentrates on physical issues and does not form an ideal preparation for work with patients who find psychological distress harder to bear than-physical (29) and who make twice as many visits to general practitioners as persons without such problems (28, 71, 44).

4.1 Strengths

In most developed countries general practitioners are numerous (one to 1000-4000 population) and evenly distributed and accessible. (But there are still developed countries where rural districts are less well served than urban, despite their need for this particularly appropriate form of medical service). They offer coverage which cannot be provided by psychiatrists because of their smaller numbers.

Their most important function -assessment and diagnosis of new problems - lends itself readily to the inclusion of mental health problems, especially as these are so often presented in physical disguises or associated with other coincidental physical problems. Where general practitioners have a special postgraduate training, this is broadly based and, in recent decades, has given increasing emphasis to the psychological and social aspects of medicine.

Potential contact between general practitioners and their patients is relatively continuous (in the United Kingdom, where patients register with a particular doctor, the average duration is now about six years). This is of great importance in dealing with recurrent and chronic problems, as those of mental health tend to be. Past knowledge of a patient's illness experience can be valuable in anticipating recurrences. Ongoing responsibility favours preventive ways of thinking and acting.

The strengths already described contribute to the ideal of the personal doctor - someone who is familiar, trusted and able to act as advocate and adviser in choosing or dealing with other medical and social agents. The integrating role of the personal doctor grows in importance as specialization follows its own logic of increasing sub-division. General practitioners can be trained to think in a balanced way about the physical, psychological and social aspects of their patient's situation.

Patients with mental-health problems value the presence and support of a known person. They do not always look for action.

The trained general practitioner can have a particular value in the present context in avoiding unnecessary, harmful and expensive investigations, referrals and treatments.

4.2 Limitations

Mental-health problems are difficult for some general practitioners to tolerate or understand. This relates partly to their training, but partly to a doctor's personality and motives for choosing medicine as a career.

It is difficult for some doctors to listen, to avoid being directive, to withhold their own prejudices or refrain from criticism. These qualities are more necessary in dealing with mental health problems than with other ones.

Lack of sufficient time for consultation is a weakness in some health services. It is generally accepted that mental health problems on average require rather longer consultation than other problems (72, 73). Physical presentation of these problems can easily lead the doctor into difficulty or the patient into harm through unnecessary investigations and interventions - even sometimes unnecessary surgery. "Fixation" into these false trails can create a complication which can create a complication which cannot afterwards be resolved. Clearly such cases also involve the waste of precious economic resources (74, 75, 76).

Goldberg and Blackwell (38), showed that, for every two patients recognized by GPs, another one goes undetected although their scores on General Health Questionnaire assessment are no different. Hoeper et al. (77) found an even larger level of failure. When patients somatize their distress, they have only a 47% chance of it being recognized, compared with a 95% chance when they present psychological complaints. Ormel and Giel (76) showed clearly that recognition has a substantial impact on outcome.

In regard to assessment and treatment, evidence is confusing as to whether those GPs who are more interested and more skilled in mental health refer less or more patients (78, 11). There are economic consequences here also. But the evidence from the United Kingdom does confirm that the attachment of psychiatrists to larger general practices does reduce both out-patient referrals and hospital admissions (23).

One point of detail must be made about physical treatment. It is a frequent experience that general practitioners make heavy prescribing of tranquilizers. Their prolonged use has led to problems of habituation (79), but there has also been inappropriate use. For instances in treating depression, tranquilizers have been seen as a substitute for anti-depressive drugs which are more specific and effective. There are also problems over insufficient dosage. These problems, like those of detection, can be remedied if doctors have access to continued training and appreciate the need for it.

PART THREE

5. Strategies for Development and Improvement

5.1 Education and training

The pattern by which future general practitioners, like other doctors, receive a common basic education in a university medical school and a post-qualification training specific to one branch of the profession has recently been established in a number of countries. But it is not yet universal. Life-long readjustments to what was learned at the start of a career are now essential, because of changes in society and in science and technology. Continuing education is needed for this reason, but also to maintain enthusiasm and a habit of critical reflection in those whose work is largely practical, sometimes pressurized and often exhausting.

5.1.1 Undergraduate basic medical school

In 1950 the education of medical students was entirely based in hospitals and concerned overwhelmingly with normal and abnormal bodily functions. Since then, in the United Kingdom and the United States, there has been an increase in attention to psychology, sociology, anthropology, epidemiology and psychiatry. More recently, a variety of influences have been shifting the focus of medical education from its traditional base towards the world outside the hospital. This shift favours greater awareness of mental health problems. It has also included the involvement of general practitioners as teachers and the creation of professorial departments of primary care in medical schools.

It is no longer the purpose of undergraduate medical education to train "safe" general practitioners by the time of qualification. What is learned about mental health at this stage must be relevant to all future careers in medicine. So, essential learning must be basic and cover, for example, the skills of communication or the routines of collecting information which can lead to an awareness of the wide range of symptoms and behaviour which may reveal mental health problems among others. Such practical experience must be supplemented by knowledge of the main features of the mental disorders which occur commonly or have the most important effects; by familiarity with the principle of multiple causation and its application to prevention and treatment; and by opportunities for students to discuss their difficulties in dealing with unusual personalities and unusual behaviour. These examples of basic learning, necessary for any career in clinical medicine, will be relevant in any country, although the concepts used must be adjusted to the particular culture.

5.2 Specific postgraduate education

The special training of general practitioners after qualification should develop similar themes in greater depth mainly in the setting of general practice itself. There is a particular need to emphasize recognition of mental problems when they are disguised and to provide experience and supervision in helping patients themselves to recognize the nature of their problem. This is often difficult for them to do.

Canadian workers (80) studying the general issue about what elements in primary care consultation give positive outcomes, stressed the importance of agreement between doctor and patient about the nature of the problem. In the field of mental health problems such agreement is especially dependent on careful discussion.

The period after qualification is also the time when methods of treatment must be learned, whether in the proper use of psychotropic drugs, simple forms of psychotherapy, social interventions or by calling in other agencies to help.

Psychiatric emergencies, including the threat of suicide, are important in all cultures and require specific training for their management; so too the management of alcoholism and substance abuse.

Direct experience of patients at this stage may expose a doctor to the problems in his own relationship with them. If these are to be faced or helped, small group learning (or rarely one-to-one discussion with a trainer) offers the most promising educational approach, providing that the teacher has suitable skills.

In some countries general practitioners have themselves become accustomed to the role of teacher and enjoy supportive educational networks. But even then, the help of psychiatrists, psychologists and others is needed in what is an area of complexity, difficulty and uncertainty.

Training which is confined at this stage to work in psychiatric hospitals, though it can be valuable, is not sufficient because it will prove to be relevant only in part to the needs of the future general practitioner (20).

Selected references to articles about training in psychological skills for primary care are listed in Appendix 1 of Sartorius et al. "Psychological Disorders in General Medical Settings" (81).

5.3 Continuing education

Continuing education must above all be based on the problems encountered from day to day by the doctor and must be closely related to his or her existing attitudes, skills and knowledge. There is, of course, also a need to introduce new ideas. Here, again, general practitioners will require the help of others - psychiatrists, psychologists and sociologists.

In the United Kingdom, although older doctors may be accustomed to lectures, younger ones prefer discussion in small groups (82). This is consistent with the principle of active learning and the need of adult learners to give as well as to receive. Balint seminars offer a well-established example of one appropriate method used in many countries (63). Current cases form the essential focus of these seminars. They are concerned, above all with the problems of the relationship between doctor and patient, even when the case has predominantly physical aspects. Members of the seminar teach each other and learn from each other, in the presence of a group facilitator, who may or may not be a psychiatrist.

The selection of topics in this sort of small group work will usually be problem-based and therefore unlikely to be systematic or comprehensive. It may need to be supplemented by other methods. Learning is increased when the learners have a large say in the choice of topic, but there is a risk that they will choose what interests them, to the neglect of their ownareas of ignorance (83).

The organization of continuing education for general practitioners is now extensive in some countries and opportunities copious. The evidence from controlled studies about the capacity of educational initiatives at this stage to create lasting change in behaviour is, however, disappointing (84, 85).

Much attention is now being given in many countries to quality assessment (performance review or "audit") as an active method of continuing education. By these terms is implied a systematic examination of some unsatisfactory aspect of clinical work or organization, whether by the doctor or by others, followed by a change in method; after an interval, re-examination on the same aspect to test improvement. Accurate measurements are used for comparison whenever possible. This approach, originating in the United States (86) is as relevant to mental health problems as to others, but may be more difficult to apply to them. It is a promising development, but too recent for its widespread application in primary care to be assessed.

The educational value of a psychiatrist working in the setting of primary care is discussed below. The principles involved are relevant to working with a psychologist, a counsellor, a psychiatric nurse - always subject to the educational skills of the individual in question (20).

5.4 Training of health-workers

To confine discussion of training to the training of general practitioners would be to neglect the fact that in large areas of the world they are not to be found. Something must be said about the training of those who fill this gap - taking the village health worker as an example. This training should concentrate as much on the psychological aspects of health care generally as on specific mental disorders, e.g. the skills of communicating well with patients and of taking account of their own beliefs and expectations. Priorities in dealing with mental disorders are likely to include the management of emergencies, maintenance treatment for chronic conditions and, in some countries, the use of medication for states of excitement (16, 24).

6. Health Services Organization

6.1 Within a practice or primary care team

Given the varying attitudes and abilities of general practitioners, partnerships and group practices may find one or more members especially interested or skilled in dealing with mental health problems. Ideally they should be shared equally by all partners, but this is not realistic. Since some of these problems demand above average expenditure of consultation time, this must be understood by all partners.

Recent work has demonstrated numerically what has been long suspected. A study involving varying appointment intervals (72) has shown that longer consultations favour the likelihood of detection and treatment for mental health problems. Howie's study of fast and slow doctors confirms this (73).

Consultation length in general practice is the resultant of many different influences - ratio of doctors to population, methods of payment, efficiency of organization, patient attitudes and, not least, doctor attitudes. Some of these influences can be modified -for instance, by delegation. In countries where payment is by item of service, it has been unusual to identify payments for psychotherapy. When reimbursement for this was instituted in Canada, a dramatic rise in the amount of psychotherapy provided by general practitioners was observed (87).

6.2 Cooperation

This may be within a primary care team - so with nurses, psychiatric nurses, counsellors, social workers or receptionists. It may be with the psychiatric team - psychiatrists, psychologists, psychiatric nurses. Included must also be cooperation with carers and with patients themselves, since a basic principle, where possible, is to foster self-esteem and independence.

Trained counsellors are now attached to an increasing number of practices in the United Kingdom, promising a large new resource for short-term psychotherapy (88, 89). However, this paper will, concentrate on cooperation with psychiatrists and psychologists.

The traditional method of communication is by letter. Among others, Pullen and Yellowlees (49) have proposed the essential characteristics required for this form of communication. Telephone discussion of a difficult case is a method much valued by many GPs.

In the United Kingdom there has been a steady development for ten years by which increasing numbers of psychiatrists and psychologists spend time in the setting of general practice. For example, this may now be true for half the psychiatrists in Scotland. There has been dispute about whether the cases seen are less severe than those seen in hospital out-patients, but a recent study in London (90), using standardized measures, showed that both groups had similar degrees of physical and social dysfunction and comparable levels of psychiatric morbidity. Chronic schizophrenia, alcohol and drug problems predominated in primary care, while personality problems and affective psychoses were more common in out-patients.

The reaction of patients, general practitioners and psychiatrists to this form of working has been consistently favourable (91).

Where there has been separation of health and mental health services as in the United States, there have been low rates of referral. When they have been brought together through integrated organizations, attachment schemes or linkage models, primary care doctors are more likely to identify mental disorders and to use mental health specialists for consultation and referral (92).

The WHO Regional Office for Europe working party on psychiatry and medical care (93) has stressed that "the crucial question is not how the general practitioner can fit into the mental health services, but rather how the psychiatrist can collaborate most effectively with primary medical services, and reinforce the effectiveness, of the primary physician as a member of the mental health team."

7. Research

There has been a rapid development of research in this field in the last twenty years, particularly in Australia, Germany, the United Kingdom and the United States of America.

7.1 Defection of mental health problems

Methods of improving the proportion of hidden problems detected in primary care have been examined in existing studies (76, 94). Further studies are needed to test the outcome of these methods and their application in different types of practice, different countries - and by team members other than doctors. The use of simpler screening tools needs further trial both for detection and for following progress of cases.

A related issue is how to ensure recognition of vulnerable groups at special risk of anxiety and depression, e.g. the physically ill, the disabled, the bereaved, the seriously deprived (for example, unmarried mothers), people approaching retirement, children of divorced or divorcing parents and those known to have been seriously depressed in the past. Who among them needs extra support? Which team member is best suited to provide this?

7.2 Assessment and classification

Methods of communication in the consultation have been the subject of many recent studies (95). Their influence on outcomes is a particularly interesting focus for further study (96). So, too, the comparison of methods used by different types of professionals engaged in primary care.

The classification of mental health problems is still unsatisfactory - whatever the setting. Following Jenkins et al. (97), neither the international classification of diseases (ICD) nor the international classification of health problems in primary care (ICHPPC) can be applied consistently by general practitioners. A multi-dimensional approach is desirable; but it is certainly not yet in use by general practitioners. Jenkins proposed a four-dimensional system - psychological symptoms, social problems and supports, personality difficulties and physical disorders. Something simpler is needed.

The mixed states of anxiety and depression, at mild and moderate levels of intensity, especially need attention.

7.3 Responses/Treatment

The most obvious needs for research concern the effectiveness of treatments, whether physical, psychological or social. Since there is usually competition for resources, their relative cost is also an important consideration.

Further evaluation of single psychological methods is needed, not least in order to diminish the use of tranquilizers. Psychological methods which can be used by nurses and social workers and others are needed.

The personal difficulties of doctors or nurses dealing with patients with mental disorders create problems of relationship which need analysing. Those frequent attenders sometimes referred to as "heart-sink" offer an interesting focus in this connection.

7.4 Teamwork

The outcome of different forms of collaboration between different types of professional - experiments whereby psychiatrists, psychologists and community psychiatric nurses work in general practice settings are particularly important. What sort of problems are presented to them? Is this method cost-effective compared with alternatives?

7.5 Organization

Care by general practitioners or in community mental health clinics? Evaluation of self-help groups? Methods of ensuring that no undue proportion of secondary-care staff time is devoted to people with less severe disorders at the expense of the more severe. Evaluation of a model practice.

8. Influencing attitudes to mental illness

As has been mentioned earlier, there is a wide range in the attitudes or habitual reactions of different general practitioners to mental as compared with physical illness. Attitudes will include their estimate of the importance of these problems, compared with physical ones; their capacity to detect them; their interest in them; time spent in dealing with them and tolerance of patients presenting them. To varying extents they may share the sense of stigma which patients have themselves. There may be a wide discrepancy between the attitudes of doctors and those of patients, for whom mental suffering can be more overwhelming, mysterious, frightening and disruptive of all important aspects of living than physical illness of comparable severity.

In less-developed countries this discrepancy is exacerbated by the persistence of life-threatening physical illness - mainly infective in nature - which preoccupies the attention and resources of sparse medical services at all levels.

General practitioners, since their proper concern spans all these areas, are in a good position to influence opinion - whether of patients, other professionals or policy-makers (through personal contacts or through representative organizations). As methods of intervention and prevention develop and understanding of causes increases, the need to use this influence becomes more urgent, while the negative image of mental health problems diminishes. The need to conceal them is less powerful than it was when help was less available.

Policy-makers are by no means themselves immune to mental health problems. There are famous examples where problems experienced in a politician's family have led to valuable publicity and a switch of resources to mental health care.

9. Influencing attitudes to general practice

In all developed countries the role of the general doctor has been threatened in the last fifty years by the development of specialization and the benefits which have resulted from it. In the United States, for example, the ratio of generalists to specialists dropped dramatically between 1930 and 1970 (98). Many people have questioned whether there is any future role in medicine for generalists.

Paradoxically, the increasing development of specialization, by fragmenting clinical practice and medical education, has revealed an increasing need for coordination and continuity. These can only be provided by generalists. Moreover, they alone can provide a widely accessible and broadly oriented point of entry to a system of medical care.

The revaluation of general practice, which has occurred in many developed countries more recently, is due partly to this realization, partly to economic influences and partly to the efforts of general practitioners to put their own house in order.

The high and ever rising cost of specialist and hospital care has pointed to generalist and home care as a possible and less costly alternative. Their provision in health maintenance organizations in the United States has been shown sharply to reduce the extent of hospitalization (99). There has been a similar demonstration in Sweden (100). Overall, however, it is uncertain whether home care is in reality cheaper than institutional care. The difference is probably marginal (101, 102, 103).

In mental health, the flight from hospital care has been based also on the discovery that long-term psychiatric hospitalization produces its own harmful effects and on the belief that care outside hospitals is ideally better for patients. The reality does not always match with the belief.

In a number of countries, general practitioners have united to take responsibility for developing their own role in medicine - by defining it; creating a special training for it, introducing it as a university discipline, conducting research and representing it to other institutions, including governments. In particular, Colleges and Academies of General Practice have started in many countries and these are linked through the World Organization of National Colleges and Associations of General Practice (WONCA). In some countries the effects have been dramatic. In the United Kingdom, for example, this branch of medicine is, since 1978, a leading career choice for final year students and young qualified doctors (thirty years ago it was usually the career undertaken only if a doctor failed to enter a career of first choice). There has been a striking change in the attitude of specialists who now see general practitioners as doctors with a different, but complementary and effective, role which allows them to concentrate on what they themselves do best.

This change has not yet occurred in all countries of similar development. In less-developed countries there are still influences which result in the building of prestigious specialist hospitals - unsupported by the "community" services which allow them to function efficiently.

10. Conclusions

Improvements in mental health and in the care of people with mental health problems depend to a large extent on the development of primary care, where the general practitioner is at present the central figure. Where the potential of general practice goes unrecognized, resources are withheld or the role is devalued (as, for instance, in countries where the most promising students are always selected or attracted into specialist careers), the field of mental health and illness is deprived of a positive force which could be widely available to it.

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Figure 1. Monthly prevalence estimates of illness in the community and the roles of physicians, hospitals and university medical centres in the provision of medical care (adults sixteen years of age and over).

World Psychiatric Association - ''The Now and Future Role of Psychiatrists''

Alfred M. Freedman, M.D.

Professor and Chairman Emeritus
Department of Psychiatry/New York Medical
College
Visiting Professor, Harvard Medical School

World Psychiatric Association

The World Psychiatric Association was founded in 1961, replacing the International Society for the Organization of World Psychiatric Congresses set up in 1950. It was admitted into official relations with WHO in 1965. Its mandate is to advance international cooperation in the field of psychiatry by coordinating on a worldwide basis the activities of its Member Societies and in other ways promote activities designed to lead to increased knowledge in the field of mental health and better care for the mentally ill.

It has 80,000 members grouped into some 80 National Member Societies distributed in 75 countries. WPA organizes World Psychiatric Congresses every five years and also holds regional and interregional scientific meetings during which there is exchange of information concerning the problems of mental diseases and the strengthening of relations between psychiatrists working in various fields and between societies existing in different countries.

1. Introduction

Studies of the role and status of psychiatrists presently and in the future tend to focus on the individual psychiatrist in regard to his or her practice, ideology, income, content of educational programs (with particular attention to skills and knowledge) and demography. These are extraordinarily important and valuable. However, it must be noted at the outset that psychiatrists in all their activities are actually in the midst of a matrix of very important forces that make necessary many aspects of their life and practice. A few of the forces can be mentioned now and others will be delineated below. First, the world-wide recession is having serious impact at the present time and will influence training and practice for many years to come. Private and national health programs are being restricted in growth or cut and too often mental health budgets are the first victim. Secondly, there has been a vast change in the manpower distribution in the "health-industry" complex. In the earlier part of the century doctors and M.D.s, made up the bulk of those providing services while as the years have progressed more and more non-M.D.s have entered the field and assumed important roles. In the United States, for example, 7.6% of the health-industry were M.D.s in 1988 (1). This is further compounded by the rise of corporate medicine and various forms of group practice (2). Third, newer technologies give promise of major alterations in the individual who will be administering diagnostic procedures as well as treatment. However, it must be emphasized at the outset that the overall knowledge and skills of the psychiatrist are indispensable for a successful Mental Health Program, although there may be alterations in the psychiatrists' role in the future.

In regard to the second and third points above, Professor Gavin Andrews (3) has made several very important observations and investigations. He points out that "the traditional role of psychiatrists as a central figure in the delivery of mental health services is changing." In his report, Professor Andrews addresses three issues, who diagnosis, who treats, and which treatments are used. All of these issues could alter the traditional role of the psychiatrist as the brightest star in the constellation of those who deliver mental health services. In regard to diagnosis, the specific diagnostic criteria described in DSM-III-R (4) and ICD-10 (5) not only made a great improvement in uniformity of diagnosis throughout the world but have given guidelines as well as criteria for diagnosis to psychologists, social workers and even lawyers. DSM-IV and ICD-11 will, it appears, advance the establishment of further criteria with widespread agreement (6). This agreement, as Professor Andrews points out, makes possible the application of structured diagnostic interviews to private practice and even has led to the establishment of computer programs to administer these interviews (3). He cites a number of uses of the computer program; clinicians may use it as a second opinion, community clinics may utilize such programs where psychiatrists are not available, students can be trained in diagnosis with such programs. Professor Andrews and his colleagues have already tested such computer programs and found that patients accept both the interview administered by an individual as well as that administered through a computer and found that both are equally acceptable. As such programs are further refined, one can see the possibility of most diagnoses being made utilizing the computer particularly where psychiatrists are in very short supply as in many developing countries or where the case loads are overwhelming. Psychiatrists may eventually be limited to those cases that are questionable or ambiguous or merely to certify computer results. In any event, psychiatrists will not have the exclusive responsibility as diagnosticians in mental health.

The issue of who treats should probably be more accurately stated as who is not treated. The Epidemiologic Catchment Area (ECA) study that was carried out by the National Institute of Mental Health in the United States showed that approximately 20% of the population had suffered a disorder that fulfilled criteria of DSM-III within the previous six months (7). Of that 20% only 20% sought or received any attention from professional health workers or others such as a pastoral counsellor (8). Thus, at most 4% were receiving any sort of treatment, however brief. This is not too different from Australian reports that state that between 2.5 and 3.0% of the population are currently in treatment for a mental disorder, however, excluding drug and alcohol disorders (2). If the latter were added then the total would approach the United States figure. It is noteworthy that in the ECA study more than 50% of the patients were seen by non-psychiatrists (7). Along the same lines, Gavin Andrews reports that "psychiatrists are directly responsible for only 1 in 5 patients in treatment, and the majority of persons with mental disorders will not be treated, directly or indirectly by a psychiatrist (2). What role does this leave for the psychiatrist? Since, as has been indicated the majority of patients are diagnosed and treated by general practitioners and other non-psychiatric physicians and a variety of mental health professionals and workers, the question arises in regard to the competence of their activities. Clearly in many of the situations supervision by a psychiatrist would be beneficial. This involves a training of all those who are involved in the diagnosis and treatment of individuals with mental disorders particularly the recognition of cases that require consultation or referral to a psychiatrist. Likewise, psychiatrists in such situations need training in supervision of community workers and general practitioners (8). Such training is sorely needed, as well as sensitivity training so that the supervision will be meaningful and accepted. Too often the arrogance and contempt of the psychiatrist negates the supervision.

Above all, the welfare and benefit of the patient is paramount. There should be no place for interdisciplinary rivalry, sometimes to the point of sabotaging the activity of those who are perceived or mis-perceived as competitors or enemies. Professor Morton Kramer has predicted a "pandemic" of mental illness in the 21st century (9). Yet, figures worldwide show such an enormous number of individuals at risk who have mental disorders and are not receiving treatment. This is occurring in a country with one of the highest number of individuals per capita in mental health in the world. If only part of that 80% could be brought to professional attention the resources would undoubtedly be overwhelmed. In 1970 it was estimated if every individual in the U.S. above the age of 15 were seen for 3 hours a year it would require at least 40,000 psychiatrists or other mental health professionals. Extrapolating to the present it would require 80,000 psychiatrists. If one adds children and adolescents the need would increase by at least 50% and exhaust available resources (10). It is essential that all in the mental health field address themselves to the promotion of mental health through public education in order to bring many of those who are suffering to facilities in order to receive adequate treatment. Psychiatrists can play a very important role in this endeavour but not exclusively. This will require collaborative efforts among professionals, ancillary staff and the public.

Raising the question, which treatment, unleashes a torrent of controversies? Psychotherapy is widely practised throughout the world but up to the present time there are no critical evaluations of the effectiveness of various forms of psychotherapy that are universally accepted. Studies range from those demonstrating benefit to those equating psychotherapy with placebo to those that report no benefit at all (11, 12, 13). Thus, one cannot fault others apart from psychiatrists and also clinical psychologists from practicing psychotherapy. However, this remains a troublesome issue. Biological therapies, particularly psychopharmacology have had critical evaluation with various double-blind studies. There have also been limited studies, for example, in mild to moderate depression comparing the effectiveness of a psychopharmacologic agent with interpersonal therapy and cognitive therapy (14). Over the long run, particularly interpersonal therapy and drug therapy seem to have similar outcomes with the cognitive therapies slightly behind. Over the short run there is some advantage to the psychopharmacologic agent. It would appear that in the administration of psychopharmacologic agents this should be the exclusive responsibility of psychiatrists and other physicians. However, there are numerous efforts, some with success, of clinical psychologists and others to obtain permission for prescribing drugs. The possibility remains that over time there will be enough success to these endeavours to further limit the practice of psychiatrists or at least to increase the competitiveness of other practitioners. It is well known that the majority of psychotropic drugs are prescribed by general practitioners, internists and surgeons.

Throughout this paper it must be emphasized that every nation must develop appropriate roles in mental health configured to the economy, manpower, traditions, history, culture and national health delivery system. Policies and programs from developed countries cannot be transferred intact to developing countries. Each has much to learn from each other.

There is an interesting illustration of the influence of external factors on practice when comparing psychotherapy in the United States and Australia. Psychotherapy reimbursement in Australia is open ended and psychotherapy is of much longer duration than in the United States where reimbursement for psychotherapy is sharply limited, if available at all (2). Thus, out of necessity, in the United States brief psychotherapy is receiving increasing attention and acceptance. This confirms the frequent statement that reimbursement often determines how medicine is practised and what modality is used, not what is best for the patient.

2. Trends in the delivery of services for the mentally ill

Another trend that will be influencing which treatment to administer in the future is the proliferation throughout the world of various treatment manuals for psychiatry. Australia during the past decade has produced 10 treatment outlines built on the basis of a review of the literature, of a survey of current practice and of advice from three or four elected experts (2). The American Psychiatric Association and the World Health Organization have also prepared or are preparing treatment manuals. While in every case there is avoidance of resenting the one and only best treatment for every category of mental illness, still it provides a guideline for treatment and justification of a procedure that can very well be utilized by professionals other than psychiatrists. One cannot deny the value of such manuals in codifying appropriate treatments but it does set very definite limits on experimentation and innovation. Further, in the United States we have seen in the famous Osheroff case (15) where a hospital was sued by a patient who had a depression for allegedly treating him only with psychoanalytic psychotherapy instead of with anti-depressant drugs. The lower court held that this constituted malpractice and awarded the patient $250,000 in damages. The case aroused a furor with sharp arguments between psychopharmacologists and psychotherapists, including psychoanalysts (16). While appeal was pending, the case was settled out of court but this is an indication of the hazards of specifying what is best treatment. The further implication is the great necessity for evaluation studies in various therapeutic modalities so that one has a data base to be able to say what is best for a particular patient at a particular time. This is a major task for future psychiatrists. Further, it may not be just one treatment but the combination of treatments, for example, psychotherapy and psychopharmacology that is best for certain patients with certain diagnosis (17, 18). This very important task is critical or else in the words of Professor Andrews, in the case of Australia, "The psychiatrists' continued endorsement of psychodynamic psychotherapy meaning that they 're becoming identified with an unproven and very expensive treatment" (2). Research must address not only neurosciences but research projects in regard to delivering services efficiently, with a high level of success proven by evaluation and inexpensively.

As a result of the above-mentioned trends and particularly the influence of economic limitations one can anticipate greater attention to crisis intervention and brief psychotherapy. Long term therapy will be inhibited by fiscal constraints as well as questions in regard to the efficacy of psychotherapy in general and long term therapy in particular. More and more in developed countries psychiatrists will be devoting the bulk of their time to serious psychotic illnesses. The treatment of problems of living, effort to improve the quality of life and possibly long term therapy will be managed by professionals in the mental health field other than psychiatrists. This is a developing trend that can already be discerned in developed countries and has always been true in developing countries.

During this century we have witnessed a steady evolution of the site of most treatment of the mentally ill. In the early part of the century most treatment by psychiatrists occurred in large government hospitals or private asylums. After World War II psychiatric units were opened in general hospitals accompanied by restriction of admittance as well as the discharge of patients from government hospitals, this latter tendency has become known as "De-Institutionalization" (19). This phenomenon taking place in many countries has been attributed to a variety of causes ranging from psychopharmacologic utilization to civil liberty enthusiasts and egregious conceptual errors on the part of leading psychiatrists. Upon careful study, at least in the United States, it has been demonstrated that a major factor in the development of "de-institutionalization" has been the initiation of a reimbursement procedure by the government, which made it profitable for state governments to discharge patients from government hospitals to the community and to prevent the admission of mentally ill patients to state hospitals and thus keeping them in the community. The regulations authorized reimbursement only for mentally ill patients in the community while denying reimbursement to patients in governmental mental hospitals.

A concomitant of the proliferation of new psychiatric units in general hospitals has been the emergence of consultation and liaison services. This has resulted not only in the development of a new sub-specialty of psychiatry but has facilitated closer working relationships between psychiatry and other medical specialties (20).

Also in the post WWII period one witnessed a very important trend namely that of community mental health centres and a variety of community mental health services (18). Although many psychiatrists have looked askance at such developments the importance of community services in the future cannot be denied. Part of the reluctance of psychiatrists to be involved in such community endeavours has been from lack of training to serve in such installations, reluctance to be involved in team work with other disciplines and rather meager financial rewards compared to other opportunities. Part of the problem has been the unfair criticism of community programs that unfortunately, not infrequently, made errors or were mis-managed. Again to look at the United States, one of the major difficulties of community mental health centres was the cessation of anticipated funding for community mental health centres so that only 1/5 of those originally planned were ever built. Soon after their establishment in the United States, for example, there was a general withdrawal of psychiatrists from community mental health centres, leaving these facilities under the direction of psychologists and social workers. Naturally, this resulted in predominance of psychotherapy and social intervention with concentration on individuals with neuroses, personality disorders and problems of living, which, as predicted by some, led to neglect of the seriously mentally ill. Fortunately, in more recent years there has been a trend toward the return of psychiatrists to community mental health centres and one can anticipate steady growth of psychiatrist participation (21). This is essential so that community programs will take care of a broad range of the mentally ill, including those with serious mental illness who reside in the community. Again, such involvement will mean modification of training programs to facilitate the involvement of psychiatrists in community programs. It is noteworthy although the movement from the large government hospital to community programs has been noted, too often training programs are modelled after the situation that existed in the first half of the twentieth century. That is to say the bulk of training programs is with psychotic patients in hospitals, with too little time devoted to patients in ambulatory clinics let alone facilities out in the community. One can expect major changes in this area (8).

3. Sub-specialization and training

Sub-specialization in psychiatry has taken an accelerated growth, particularly in developed countries. This is a natural outcome of increased knowledge that makes it difficult for any one psychiatrist to acquire the knowledge and skills necessary for many areas. Also the opportunities in a sub-specialty at the present time seem more promising than being a generalist. The burgeoning population of the aged in all parts of the world has stimulated the sub-specialty of psychogeriatrics. Likewise the very special problems of children and adolescence have eventuated in the emergence of sub-specialists not only for children but for adolescents. The escalation of substance abuse has fostered the development or sub-specialist in drug abuse and alcoholism. Although there are certain disadvantages in this trend toward sub-specialization, it appears to be an inevitable fact and training programs have to be established to conform to this development.

Training for new roles is of critical importance. As has been pointed out, failure to include training in community activities has had deleterious effects on services and participation by psychiatrists.

Psychiatrists are too often led to believe that they and they only can be leaders of teams in the community and that this role can be assumed irrespective of background and training. The team approach requires mutual trust and recognition that leadership should be assigned to individuals who have the training, background, capacity and time to provide wise and active leadership. Leadership skills and qualities are essential for this role, and psychiatrists may well assume leadership roles where qualified or at other times be valuable and valued members of the team. Psychiatrists must be ready to assume new tasks without abandoning traditional areas of work which may or may not be shared with other disciplines. Above all, the interests of the patient and whatever must be done to provide excellence of service, must be given the highest priority. The psychiatrist must at all times be a patient advocate. In the report on the informal consultation on the contributions of different professional roles to mental health (22) the barriers to the team approach are listed after emphasizing the need for strengthening team work that includes the need for common goals, philosophy and models of action necessary for team effort This report emphasized that the ancient dichotomy between psychological and physical approaches to mental health and illness is an obstacle to team approaches and the solution of this, as will be pointed out below, lies with the commitment to the biopsychosocial approach. A purely social approach can be as deleterious as a purely biological one. In the report the most frequently found barriers to the team approach are listed as follows:

A. Failure to understand other professions' language.

B. Lack of communication.

C. Personal and professional insecurity.

D. The amount of people and of professions involved in and dealing with a single person or family.

E. Administrative and legal obstacles.

The psychiatrist of the future must be trained to conform to community needs so that the community and professional knowledge can be integrated. It must be recognized that there has to be respect for local beliefs and that community programs that meet with success are ones that work with and through people living in a particular area or district. One must have as members of the team individuals that belong to and understand the culture in question.

There are two areas that might be termed missing ingredients both in training and the work of psychiatrists at the present time which will develop increasing importance as time goes on, namely prevention and psychosocial rehabilitation. Primary prevention is possible in certain organic and stress-related syndromes. First class para-natal services as well as attention to mother-child relationships and care of infants from the time of birth through school that integrates health, psychological development and education will be an important area for participation by psychiatrists and others. One can see the beginnings of another sub-specialty in infant psychiatry.

The area of after-care and psychosocial rehabilitation that has been termed tertiary prevention is the second missing ingredient in training and mental health programs. The importance of psychosocial rehabilitation cannot be underestimated and will be an area that will concern psychiatrists and other mental health workers more and more in the future.

Training in research methodology as well as opportunities for research are of utmost importance. While certainly only a small percentage of psychiatrists will wish to devote their careers to research, everyone should be trained in research methodology so that they can evaluate research publications and develop a healthy skepticism to unfounded assertions.

4. Trends in psychiatric manpower

Studies of trends in manpower in psychiatry indicate major changes that are now well under way. Noteworthy is the increasing number of women who are entering medical school as well as psychiatry (23). In the United States this has been of sufficient attention so that the term "feminization of psychiatry" has been utilized. It is not only that increasing numbers of women are entering psychiatric residency in the United States but this is particularly true of the younger medical school graduates indicating that this is a steadily increasing trend. Women still occupy fewer of the positions of power and prestige compared to their numbers in the field of psychiatry; however, this undoubtedly will be changing in the future. What is anticipated is that with the larger number of women entering psychiatry there will be a vast escalation of interest and commitment to social and community programs as well as social concerns. Also the whole field of child development, child care will be greatly stimulated by the presence of women. These two trends certainly will be welcome by all in mental health.

In summary, it is evident that there is a bright future for psychiatrists in a field where there are enormous unmet needs. This can only increase in the future, particularly because of the greater percentage of the elderly in all populations worldwide with most rapidly increasing cohort, those over 85. Mental health problems proliferate with age. The psychiatrist has a very special and unique role in the pantheon of mental health professionals. The psychiatrist's background in the basic natural and biological sciences with knowledge and experience in clinical medicine makes his or her contribution to mental health of inestimable value.

Very impressive developments in the neurosciences and basic biological studies of the brain as well as new technologies give great promise for future innovations in diagnosis and treatment. It is here that the very special training of the psychiatrist makes the physician anindispensable member of the mental health team. However, there have been advances in social and community care that should not be derogated. While the term reductionism in psychiatry has been generally thought to refer to biological reductionism we have seen periods of social as well as psychosocial reductionism. It is of the utmost importance that future training and commitment be to the biopsychosocial model that integrates biological, psychological and social factors with due respect for each category. Only in that way can progress be made in the future. New paradigms are needed for psychiatry and behaviour in general and the biopsychosocial model appears to be the best way of beginning in such new ventures (24). Thus, the psychiatrist of the future will need very broad training and the development not only of traditional knowledge and skills but new ones in the biologic, social and psychologic fields.

Psychiatrists will also be concerned with public education and mental health promotion especially to minimize and one hopes in the future to eliminate the stigma attached to mental illness. The challenges will be great but the opportunities are superb.

5. References

1. Statistical Abstract, Table 669. Washington, United States Government Printing Office, 1991.

2. Starr P. The Social Transformation of American Medicine. New York, Basic Books, 1982.

3. Andrews G. The Changing Nature of Psychiatry. Australia and New Zealand Journal of Psychiatry, 1991, 25:453-459.

4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders, 3rd Edition. Revised - DSMIII-R, 1987.

5. Manual of the International Statistical Classification of Diseases, Injuries and Causes of Death. 10th Revision. Geneva, World Health Organization, 1985.

6. Freedman A M. American Viewpoints on Classification. Integral Psychiatry, 1991, 7:11-15.

7. Myers J K, Weissman M M, Tischler G. et al. Six Months Prevalence of Psychiatric Disorders in Three Communities. Archives of General Psychiatry, 1984, 41:959-967.

8. Freedman A M. New Trends in Psychiatric Education. In: WHO/WPA Joint Meeting on Psychiatric Education for the 21st Century. Fukuoka, Japan, 13-17 March 1989.

9. Kramer M. The Rising Pandemic of Mental Disorders and Associated Chronic Diseases and Disabilities. Acta Psychiatrica Scandinavica, 1980, (suppl. 285), 382-396.

10. Freedman A M. Critical Psychiatry: A New and Necessary School. Hospital and Community Psychiatry, 1973, 24:819-824.

11. Luborsky L, Singer B. Comparative Studies of Psychotherapies. Archives of General Psychiatry, 1975, 32:95.

12. Smith M L, Glass G V, Miller T J. The Benefits of Psychiatry, Baltimore, John Hopkins University Press, 1980.

13. Lambert M J, Shapiro D A, Bergen A E. The effectiveness of Psychotherapy. In: Garfield S, Bergen A. Ed-Handbook of Psychotherapy and Behaviour Change. 3rd Ed. New York, Wiley, 1986.

14. Elkin I, Shea T, Watkins J T. et al. The National Institute of Mental Health Treatment of Depression. Collaborative research program. Archives of General Psychiatry, 1989, 46:971-982.

15. Klerman G. The Psychiatric Patient's Right to Effective Treatment: Implications of Osheroff vs. Chestnut Lodge. American Journal of Psychiatry; 1990, 147:409-418.

16. Stone A A. Law, Science and Psychiatric Malpractice: A Response to Klerman's Indictment of Psychoanalytic Psychotherapy. American Journal of Psychiatry, 1990, 147:419-427.

17. Bevtman B D, Klerman G L. Integrating Pharmacotherapy and Psychotherapy. Washington, American Psychiatric Press, 1991.

18. Freedman A M. Psychopharmacology and Psychotherapy in the Treatment of Anxiety. In: Masserman J. Ed. Current Psychiatric Therapies. Vol. 23. New York, Grune & Stratton, 1986.

19. Freedman A M. Mental Health Programs in the United States: Idiosyncratic Roots. International Journal of Mental Health, 1990, 18:81-98.

20. Lipowski Z S. Consultation-Liaison Psychiatry: The First Half Century. General Hospital Psychiatry, 1986, 8:305.

21. Clark G H. Jr. Psychiatrists' Roles in CMHCs. Hospital and Community Psychiatry, 1991, 42: 1260.

22. WHO Division of Mental Health. The Contributions of Different Professional Roles to Mental Health, Geneva, World Health Organization, 1991, 6.

23. Tina M de, Robinowitz C B, More W W. The Future of Psychiatry: psychiatrists of the Future. American Journal of Psychiatry, 1991, 148:853-858.

24. Freedman A M. Conceptualizing Behaviour; Developing New Approaches. Psychiatrica Fennica, 1991, 22:11-22.

Commonwealth Pharmaceutical Association - ''Pharmaceutical Services to the Mentally III and Mentally Handicapped''

Dave Branford

Unit Pharmacist, Glenfrith Unit/Hon. Principal Lecturer,
Leicester Frith Hospital, Leicester, England.

The Commonwealth Pharmaceutical Association

The Commonwealth Pharmaceutical Association was established in 1970 to represent the profession of pharmacy in all of its aspects. 3 7 national pharmaceutical associations are in full membership.

The principal purpose of the Association is to promote the science and practice of pharmacy throughout the Commonwealth and, in so doing, continuously develop the pharmaceutical component of health care. Its objectives include the maintenance and fostering of high standards of professional conduct, education, practice and research.

One of the Association's major activities during the next four years will be to promote the development of hospital pharmaceutical services, not least within psychiatric establishments.

There is no international data base on the activities of pharmacists in psychiatric care and the Association has not sought such information from its members which are mainly in developing countries. However, the developments which have occurred in Great Britain can be described and these will at least indicate the part that pharmacists can play.

1. Introduction

Prior to the 1950s psychiatric hospitals provided asylum for people with chronic and acute mental illnesses and mental handicap hospitals provided care for people with learning disabilities. Such hospitals were usually situated in isolated locations away from the city from where the inmates originated. Mostly they were locked facilities, frequently self-sufficient in the provision of food from an integral farm or equipment made in their workshops.

Many psychiatric and mental handicap hospitals received until the 1950s a limited range of medicines from dispensaries run by nurses and supervised by the medical superintendents. These dispensaries were often located in the centre of the hospital at the partition which divided the male and female parts of the hospital. A two hatch system usually operated so that the dispenser could supply the likes of paraldehyde draught to either side of the hospital without the requirement to unlock doors. In those pharmacies which did employ a pharmacist, that person was often responsible for a wide variety of stores functions such as drugs, surgical sundries, dressings, and occasionally fulfilling roles such as pulling teeth out and taking blood.

2. Developments in psychiatric care

Following the introduction in the 1950s of a wide range of drugs effective in the treatment of illnesses such as schizophrenia and depression, most psychiatric hospitals employed a pharmacist. Many such pharmacists worked in isolation from pharmacist colleagues and were primarily involved in the supply of drugs to wards and the dispensing of the medicines required to allow patients weekend leave from the hospital. The priority was to develop safe procedures for the supply, administration and storage on wards of medicines. Pharmacists were allowed to inspect wards every 3 months to ensure that such procedures were being adhered to, but were unlikely to be involved in the prescribing process. By the 1960s most hospitals insisted that the prescriber wrote the prescription on a prescription sheet and that medicines were locked in medicine cupboards. Concerns about the security of medicines on wards led to the development in some hospitals of individual supplies for patients rather than ward stocks, and of unit dose systems in others. The unit dose supply system fell out of favour during the 1980s and is now rarely used.

3. The Noel Hall report in the mid-1970s

Following a report called the 'Noel Hall' report, hospital pharmacy in Great Britain was reorganised and isolated pharmacists working within psychiatry or other specialties were brought within the span of control of area pharmacists. This provision of a career structure and satisfactory pay enabled hospital pharmacy to make enormous progress in service provision.

A survey carried out at the beginning of the 80s (1) indicated a very low staffing in many psychiatric hospital pharmacies with many pharmacists being responsible for in excess of 500 beds. A follow-up survey carried out in 1987 (2) showed a slightly reduced number of beds per pharmacist with 2.2 pharmacists and 1.6 technicians providing services to an average 580 bedded psychiatric hospital. Pharmacies that provided services to both psychiatric and mental handicap hospitals showed a staffing of 2.9 pharmacists and 2.4 technicians per 900 beds.

Prior to the 1970s pharmacists rarely left their dispensaries. However, at the beginning of the 80s a number of services were being developed in which, instead of the pharmacists trying to deal with the multitude of requests for assistance over the telephone, they started to visit wards on a regular basis to deal with the problems relating to individual patients' medicines. These services were described as 'Ward Pharmacy'.

It was only a short step then to doctors, nurses and pharmacists realising that, rather than the pharmacist spending much time persuading doctors to change prescriptions after the decision has been made, it made more sense for pharmacists to be involved with the decision in the first place. This process is part of what we now call 'Clinical Pharmacy'. (See Acute Prescribing below).

The development of clinical pharmacy in psychiatry was rather delayed because so few institutions employed more than one pharmacist, but between the mid 70s and mid 80s many pharmacy managers were able to make the case for more pharmacist support. Throughout this period hospital pharmacy made a quantum leap in service provision so that pharmacists working in Psychiatric hospitals were not only able to provide a better service but also had backup and support from the area or district managed services, such as drug information, production services, locum relief and training.

There have been a number of studies looking at the cost-effectiveness of clinical pharmacy services, including some within the arenas of mental illness (3, 4) and mental handicap (5). Most of these have shown that not only does the pharmacist have an impact on the medicines received by people, but that savings are generated by that impact by a reduction in the number of medicines received.

4. Community Care

Since the 1950s the population residing in psychiatric and mental handicap hospitals has been declining. Legislative changes and the development of effective psychotropic drugs has enabled people with such disabilities and illnesses to continue to live in the community in staffed homes or hostels, or in their own homes.

The aim now is for most institutions to be closed. This is resulting in the community pharmacist providing a service to people of a high dependency and with severe chronic mental illnesses, and needing to assist and advise the many carers who are supporting such people.

Within this period of rapid change, roles for three distinct types of pharmacist are emerging; the community pharmacists, the community services pharmacist and the psychiatric pharmacist.

The community pharmacist provides a readily accessible source of medicines and advice about medicines for both patients and carers. This service is currently being extended to include supplying medicines and related advice to residential homes and hostels, the keeping of medication records and the provision of domiciliary services to individual patient's homes. There is currently the opportunity to develop a more specialist supply role within community pharmacy by supplying registered drug addicts.

It is hoped that in the future community pharmacists will be able to develop specialist roles by involvement with local day centres, day hospitals and mental health centres, but currently there is no satisfactory method of remuneration to promote such a development. There are two pilot schemes underway to evaluate such a possible impact of community pharmacists.

Community services pharmacists are usually employed by Health Authorities to provide a liaison and inspectorate role for registered nursing homes, hostels and health centres. The number of such community based facilities is increasing rapidly with the closure of institutions for the elderly, mentally ill and mentally handicapped and standards need to be developed and maintained for the administration and storage of medicines.

Psychiatric pharmacy is one of many developing specialities within hospital pharmacy. As the role of the hospital pharmacist changes towards a more clinical involvement there is increasingly the opportunity for specialization.

5. Acute Psychiatry

Many of the acute psychiatric wards which were previously part of a psychiatric hospital have now been relocated to General hospital sites and represent a significant part of the pharmacy workload of such hospitals. Pharmacists are increasingly being seen as one of the members of the multidisciplinary team providing specialist advice to doctors, nurses, patients and other members of the team about the medicines prescribed. Activities include prescription monitoring for errors, incompatibilities, drug interactions and inappropriate prescribing, the taking of patient drug histories, the maintenance of prescribing records, advising on drug and dosage selection and pre-discharge counselling and training. (6-10) Pharmacists are also becoming involved in clinical audits of prescribing.

As the District General hospital increasingly becomes the focus for psychiatric medical care, it is hoped that such psychiatric pharmacists will be able to develop a wider role offering advice to non-hospital agencies by referral.

6. Chronic Psychiatry

With the change from institutional care to community based care there is the need to review the medicines of patients and prepare them for hospital discharge. Many such patients will have remained in hospital for many years. Pharmacists have been actively involved in the rehabilitation process, both in the review of medicines and in training to self-medicate (11). Programmes usually consist of an initial review based on the evidence of a drug history and clinical notes. Following the review, if there is any need to change the medicines, this is undertaken. Once a stable drug regime is agreed and the simplest regime is available, the patient increasingly takes responsibility for the medicines by firstly receiving one dose at a time and then slowly proceeding to controlling a week's supply of medicines. The ability to self-medicate will be a factor in deciding the style of accommodation and support required by the patient living in the community.

7. Community Teams

With the emphasis of community care being to maintain patients in the community, the role of the community team and the community psychiatric nurse are important. It is rare for pharmacists to be full members of community teams. A trial in Victoria, Australia, of appointing 'consultant pharmacists' as members of community teams was unsuccessful. Currently much of the specialist advice to community teams comes from hospital based pharmacists and the role in relation to community teams is yet to be established.

8. Day Hospitals and Day Centres

The extent to which pharmacists are involved depends largely on how active the prescribing process is. Increasingly day centres are being used by community nurses and psychiatrists as a way of gaining regular access to patients for the giving of depot antipsychotic injections and reviewing progress. Pharmacists are commonly asked to run discussion groups about prescribed drugs for attenders and advise carers.

Pharmacists are commonly involved with day hospitals in the review of medicines, the running of lithium and anticonvulsant clinics and counselling of patients.

9. Mental handicap (learning disabilities)

With very low pharmacy staffing available, the development of pharmaceutical services to the mentally handicapped has been minimal. This is regrettable as pharmacists have been shown to have significant impact in this area, both in the control of epilepsy and challenging behaviours (5, 12).

10. Training needs

The training needs of pharmacists are huge. Community pharmacists are relatively unfamiliar with mental illnesses and feel poorly equipped to assist such patients. Community services pharmacists have in the past been primarily involved with homes and hostels caring for the elderly and again are relatively unfamiliar with mental illnesses. Psychiatric pharmacy is a relatively new specialty within the District General Hospital. Most of the current expertise is within the psychiatric hospitals.

There is also a huge training need to inform other carers about drug treatments in psychiatry. Psychiatry is currently undergoing some degree of deskilling of care staff at a time when drug therapy is becoming more complex. Also, with care staff being scattered and employed by many agencies, they are in danger of becoming out of date with changing trends.

11. References

1. Benfield M, Griffiths G, Preskey D. Pharmacy in psychiatric hospital. Sandoz Publications, 1980.

2. Branford D. Pharmacy Services in Psychiatric hospitals. Pharmaceutical Journal, 1988, HS.24.

3. Cloete B, Heath P. Pharmacist participation in a psychiatric consultant ward round. Pharmaceutical Journal, 1987, 238:42-3.

4. Branford D. Four years of working with chronically disturbed mentally ill patients. Pharmaceutical Journal, 1989, HS32-4.

5. Inoue F. A clinical pharmacy service to reduce psychotropic medication use in an institution for mentally handicapped persons. Mental retardation, 1982, 20, 2:70-74.

6. Council Statement. Benzodiazepines. Pharmaceutical Journal, 1989, 243:220.

7. Ibid. Survey shows wide variation in the teaching of psychiatric pharmacy. Pharmaceutical Journal, 1990, 245:591.

8. Ibid. Pharmacists to control safe use of new schizophrenia drug. Pharmaceutical Journal, 1990, 244:48.

9. Psychiatric Pharmacy Group. Advice to pharmacists in psychiatry. Pharmaceutical Journal, 1989, 242, HS17.

10. Psychiatric Pharmacy Group. Benzodiazepines - advice for hospital pharmacists. Pharmaceutical Journal, 1990, 244:197.

11. Pratt P, Dunnett. Self administration of medicines: a rehabilitation project. Pharmaceutical Journal, 1985, 234:172-173.

12. Branford D. Assessing the drug needs of the mentally handicapped. British Journal of Pharmaceutical Practice, 1984, 6,5:158-170.

International Union of Psychological Science - ''Psychology and Health''

J.J. Dijkhuis, Ph.D.

Professor Emeritus of Clinical Psychology
and Psychotherapy
University of Leiden, The Netherlands.

International Union of Psychological Science

The International Union of Psychological Science (IUPsyS) was founded in 1951 at the XIIIth International Congress of Psychology in Stockholm (Sweden). The Union represents over 200,000 psychologists through its National Member Societies in 50 different countries. Its primary purpose is the development of psychological science, whether biological or social, normal or abnormal, pure or applied. As a member of both the International Council of Scientific Unions and the International Social Science Council, it collaborates in a wide variety of scientific activities wherever human or animal behaviour is involved. International research and special projects are developed under an Executive Committee elected by the Union's Assembly which meets every four years at the time of the International Congress of Psychology. Publications include the International Journal of Psychology, specialized newsletters, and books growing out of special projects. The Union cooperates with WHO through its Committee on Psychology of health.

1. Organizations of psychologists

There are several organizations representing various types of psychologists. The most important of these can be distinguished as follows:

1.1 Global organizations

There are three large global organizations of psychologists; the first is the International Union of Psychological Science (IUPsyS). It includes members from 48 national societies. The second is the International Association of Applied Psychology (IAAP) and the third is the International Council of Psychologists. These organizations have their international congresses at regular times.

1.2 Regional organizations

Also there are two large regional organizations of psychologists, the European Federation of Professional Psychologists Associations (EFPPA) and the Inter American Psychological Society (IAPS). The EFPPA was founded in 1981 in response to the perceived need for European cooperation over a wide range of issues such as professional education and standards of practice programmes in the fields of health and employment, and applied research. Most European countries are represented in the EFPPA, including all the member states of the European Community, with the exception of Ireland. Other member countries include Austria, Estonia, Finland, Hungary, Iceland, Liechtenstein, Norway, Poland, Sweden and Switzerland. More countries in Eastern and Central Europe are applying for membership.

1.3 National organizations

All over the world, there are national organizations of psychologists. The largest, and most structured one is the American Psychological Association (APA). In its own statement: "The purpose of the APA is to advance psychology as a science, as a profession, and as a means of promoting human welfare. It attempts to accomplish these objectives by holding annual meetings, disseminating psychological literature, and working toward improved standards for psychological training and service."

2. The development of psychology (as relevant to health and health care)

2.1 Introductory remarks

The mind-body dualism - more prevalent in Western countries, as opposed to an holistic approach, more prevalent in Eastern countries - focused on the body, neglecting the mind. In this way, focusing on matter and neglecting the mind, medicine developed as a scientific discipline with the body as the object of research and theory. Medical practice was greatly influenced by this development. In the wake of this development, the biomedical approach began to dominate the domain of health care. And it still does, even though the awareness is growing that often psychological factors are influencing disease and illness.

Even psychiatry needed a long time to extend its biomedical approach to include a psycho -logical one. Admittedly, there was no scientific psychology to rely on. The science of psychology was initiated in the 1880s. Its precursors were philosophy and the humanities at large, as well as religion and common sense. The philosophical part was combined with the experimental method as developed in natural and physical science. In this way scientific psychology was born and the study of mind took its place next to the study of matter.

Why did it take so long for psychology to become a scientific discipline? And why did it rise so quickly after it came into existence? These questions are still to be answered. One assumption is that the complexity and the accelerating tempo of activities in the industrial society caused a great deal of maladjustment. There was the necessity of readaptation by changing lifestyles and patterns of relating to others. People became much more aware of their feelings. Scientific study of the "stream of consciousness" (William James) and of human behaviour in general was badly needed. The science of psychology originated from this need, exploring all emotional and behavioural aspects of human life. It covers the "mind-part" of the body-mind duality. In this respect it is complementary to the biomedical approach in health care. However, the mind-body duality as such still exists.

2.2 Psychology: science and practice

It is generally accepted that scientific psychology started in 1879. In this year Wilhelm Wundt founded the first psychological laboratory in Leipzig. He established psychology as an experimental science of its own, although much work in the inquiry of consciousness had already been done by great 19th century's physiologists, like Fechner, Donders and also Helmholtz. Both, experimental and psychophysiological research have greatly influenced the development of scientific psychology. Gradually, its focus changed, from the conscious to the unconscious, to adaptive behaviour and learning, to cognition and emotion. Despite this reorientation, determining psychological variables by psychophysiological measurements has continued to play a major role in psychological research.

Soon after its inception, general psychology split up in several sub-disciplines: developmental psychology, differential psychology, social psychology. At the same time professional psychology originated. The application of psychological theory and research could possibly help to solve practical and emotional problems as may arise in educating children; in dealing with crises across the life span; in assessing people according to their different abilities in performing and coping; in managing conflicts between people.

Today psychology both as a science and a profession has its place in the larger universities of the Western and the Westernized world. Its growth was most impressive in the decades following World War Two. At least courses, and often complete teaching programmes, are available for those students who want complementary knowledge in psychology, or are preparing themselves for a professional career as a psychologist. In the highly industrialized countries, most universities which offer education programmes, also have their own centres of research in psychology. In addition there are quite a few research centres supported by governments or by special foundations.

In the developing countries scientific research in psychology and training in applied psychology are rapidly growing. It may be expected that the situation in these countries will not differ much from the USA, Canada, Western Europe, Australia and Japan before too long.

It should be mentioned that the situation in the former socialist countries, is complex. In the beginning, the ideology of the USSR did not permit psychology to develop at the same pace as was the case in North America and Western Europe. This changed after the sixties, and now, with the Soviet Union dissolved, and ideological changes taking place, it can be expected that psychological research will be exchanged with centres in the developed countries. It is not unlikely that professional psychology in the former USSR will develop as in most developed countries. Even in China, this development can be expected.

As opposed to the USSR and the People's Republic of China, the place of scientific and professional psychology, in the former socialist countries in Central and Eastern Europe is more similar to that in other European countries. They shared the same tradition before World War Two.

2.3 Psychologists in health care

Since psychologists are operating in health care under different designations, a terminological clarification may be needed. For decades clinical psychologists have been working almost exclusively in psychiatric settings. Gradually, they started to deliver services to other medical specialties, in general hospitals; their focus still being on mental health problems.

Often it is taken for granted that the term "clinical" refers to the medical setting, meaning: assisting people who have fallen ill. Clinical psychologists appear to have their expertise in the assessment and treatment of abnormal behaviour, and in the inquiry of psychological causes and effects of illness and diseases.

It is generally overlooked that the term clinical used in connection with psychology, has a twofold meaning. When it was first used, it denoted the clinical method in psychology. In contrast to methods used in experimental research, clinical research methodologically examined individual people, one at a time. When Witmer started the first psychological clinic, in 1896, at the University of Pennsylvania, he aimed at several forms of guidance (e.g. vocational, educational, industrial) based on the careful examination of the single case. In this sense "clinical" refers to the clinical method in counselling individuals regarding to normal problems.

Nowadays, clinical psychologists are combining both aspects. They are no longer confining themselves to psychiatric or general hospitals nor exclusively to mental health care. To an increasing extent, clinical psychologists are delivering their services in out-patient clinics, in private practices, or in other ambulatory systems, and even in schools and industry. Many clinical psychologists, working in general hospitals, had their share in this development. Their treatment was concerned more with changing life-styles than with solving deep emotional conflicts (1). In fact, they became clinical health psychologists.

Health psychology could not have risen so quickly if psychological research had not come out of the experimental laboratory. In most areas of scientific psychology the need was felt to test hypotheses in real life situations; the same as clinical psychology had done in regard to abnormal behaviour. As a consequence of this shift, psychology as a whole is contributing to the study of healthy behaviour, and its application to health care and health promotion. Much more psychologists entered the field of (clinical) health psychology.

Actually, psychologists have a lot to contribute to health care besides proficient individual help. This goes for informing health workers, training them in special skills, assisting in health education, developing and evaluating programs of health care; all on the basis of psychological theories and techniques. Moreover, psychologists may assist health care systems in dealing with organizational problems, or creating a humane climate, without getting involved in individual problems. Clinical health psychologists are dealing with individual people.

Psychological research contributed largely to the development of behavioural medicine. However, this new branch of health care should not be identified with health psychology, even though many clinical health psychologists are working in this field. As Matarazzo points out, there are three specific areas in the growing field of behaviour medicine. Sensu stricto, the term should be used for the broad interdisciplinary field of scientific investigation concerned with health. The term behavioural health could also be used for an interdisciplinary endeavour that concerns itself with the maintenance of health and the prevention of illness in currently healthy individuals. In his view, health psychology is a disciplinary-specific term defining the primary role of the science and profession of psychology. In his definition: "Health psychology is the aggregate of the specific educational, scientific, and professional contributions of the discipline of psychology to the promotion and maintenance of health, the prevention and treatment of illness, and the identification of etiologic and diagnostic correlates of health, illness, and related dysfunctions" (2).

The present state as well as the future of health psychology are discussed in two recent publications. Weinman identifies as the main areas of health psychology:

- Behavioural risk factors in disease.
- Behavioural maintenance of health.
- Health-illness cognitions.
- Communication/decision making/adherence.
- The treatment environment.
- Coping with illness, disability, etc.

He considers the development in health care and in medicine which are likely to be influential for health psychology, and emphasises the need for specific training of health psychologists (3).

2.4 Professional standards of psychologists

Clinical (health) psychologists are not only practitioners. Their training is based on the scientist-practitioner model, preparing them for both scientific and professional activities in their field of application. Ideally, all clinical (health) psychologists should be active in both areas. Due to their case-loads, few practitioners find time for scientific work. On the other hand, many clinical psychologists are doing research in universities or other centres.

Research in clinical psychology includes single case studies, evaluation of treatment, especially psychotherapy, the development of new methods, program evaluation, the study of behaviour in natural social environment, psychosocial epidemiology; to enumerate the main areas.

In assuring the quality of professional psychology, there are two important issues. One is setting standards for education and training; the other is setting standards for professional behaviour. These standards are needed not only for the commensurability between psychologists themselves, but even more for the information of the consumers of psychological services.

Although there seems to be a global consent that psychology should be practiced only on the basis of a university degree in psychology, still large problems remain. In the first place, university programs and degrees differ from one country to another. And secondly, organizations of professional psychologists consider regular university education insufficient to enter licensed practice, and hence demand postgraduate training.

In the USA, the American Psychological Association (APA) is the organization that is engaged in the accreditation of doctoral programs. "Accreditation is a system for recognizing educational institutions and professional programs affiliated with those institutions for a level of performance, integrity, and quality which entitles them to the confidence of the educational community and the public they serve." (4). The APA accredits doctoral education and training for professional psychology, more specifically for clinical psychology, counselling psychology and school psychology. The APA also accredits predoctoral internship training programs in professional psychology.

In Europe the situation is different. Some countries have systems similar to that of the USA, but most countries are still in the process of developing requirements for practice. In the General Assembly in 1990, the EFPPA-members agreed on optimal standards for training required for independent professional practice. "Preparation for independent practice of psychology comprises at least two components: a core programme and an advanced professional training in psychology. The core programme is concerned with the knowledge and skills relating to psychology as a scientific discipline and is common to all branches and specialisms within psychology. In the advanced component the student will acquire the knowledge and skills which are necessary for independent practice in a chosen field of professional psychology" (5).

The second main issue in promoting and maintaining a highly qualified practice, is setting standards for ethical and professional behaviour in practising applied psychology. Psychologists who are licensed for independent practice should act in accordance with those standards. The APA Ethical Principles includes principles related to responsibility, competence, moral and legal, confidentiality, welfare of the consumer, professional relationships, assessment techniques, and research activities (6). This code mandates that psychologists practice only within their areas of expertise. Moreover, the APA developed the Standards for Providers of Psychological Services, which details the minimally acceptable level of performance that all psychologists, who provide services, should reach or exceed.

Several national organizations of professional psychologists in Europe have developed similar ethical and behavioral codes. Formulating European codes is "work in progress" within the EFPPA.

3. The methods of psychologists

Psychologists who are practising in health care use several tools and methods when working with people; in assisting them in solving their problems. Those tools and methods are developed as a means to gather objective data for making clinical decisions, and as a means to planning of change or developing strategies to produce desired changes (7, 8, 9). Both assessment and therapeutic change are dealt with in this section. In the whole range of psychological methods that constitute the interventional repertoire of psychologists in health care, psychotherapy takes a special place. Psychotherapy is not exclusively practiced by psychologists. For that reason it is discussed separately.

3.1 Psychological assessment

Initially, differential psychology focused on intellectual differentiation. Experimental researchers developed specific instruments to assess differences between individuals. Those instruments became the intelligence tests as used by practising psychologists. Issues like reliability and validity of tests led to the development of test theory; and test construction became a major part of psychometrics, i.e. the application of measurement and mathematics to psychology.

Characterizing people already had a long tradition, not only in daily life, but also in philosophy and literature, before it became modern psychological personology. In psychiatry, characterology had its place next to nosological categories. The application of methods of testing, and of psychological methods in general, to characterology and psychopathology, led to the term psychodiagnostics as it is commonly understood now.

Whereas ability is examined by performance tests, personality testing mainly consists of the use of questionnaires. A world-wide known example is the Minnesota Multiphasic Personality Inventory (MMPI), for exploring neurotic tendencies and the extraversion-introversion dimension. Other tests to gain information about emotional and motivational factors are the so-called projective techniques. Projective techniques are much less statistical and psychometric than standardized questionnaires.

Psychodiagnostics is part of psychological assessment. This holds for applied psychology in general, but particularly for clinical assessment. Psychologists in health care have a lot of questions to answer. As important as a correct diagnosis may be, the question which form of psychotherapy is suitable, cannot be answered by statistical prediction only. Clinical judgment and inference are still needed. For that reason, interviewing and observing the behaviour of the patient, are to be valued as indispensable procedures in the process by which psychologists acquire the necessary information for making decisions. This implies an optimal understanding of the patient. For about two decades there has been a decline in the role of psychodiagnostics in clinical assessment. Recently, a strong revival has taken place, not only due to the need for quick decisions, but also because of the development of new techniques and strategies.

3.2 The interventional repertoire

Even though psychotherapy constitutes a rather extensive part of the interventions of psychologists in health care, their interventional repertoire is not limited to the practice of psychotherapy. The scope of their activities is much larger. To mention a few, crisis intervention, rehabilitation of functions, stress-management, pain-management, terminal care, lifestyle-changes, have become major fields in which knowledge and methods are applied to restore and promote health.

Psychotherapy does not appear to offer proficient help in those cases, at least not in the short run. On the other hand, many methods aimed at helping people in these cases, are derived from psychotherapeutic systems; predominantly from behaviour therapy, or its basic tenets. Many new techniques of behaviour modification are developed as forms of instrumental learning as introduced by Skinner. All behaviour is conceived as learned in the interaction with the environment. Reward and punishment have the effect of increasing or decreasing the learning process. Assertive behaviour and other social skills can be learned in this way.

Many interventions of health psychologists are not individual-directed. They are aimed at influencing community behaviour, as for instance in the Finnish North Karelia Project. Furthermore, principles of health psychology can easily be understood by non-psychologists. They also can be made familiar with basic skills of changing health behaviour (10).

3.3 Psychotherapy

Clinical psychologists and psychiatrists have an equal share in rendering psychotherapeutic services. In a much smaller number specially trained social workers are practising psychotherapy. The practice of psychotherapy is a domain common to many professionals, e.g., clinical psychologists, social workers etc.

Counselling psychology is a special method of applied psychology that was established at a rather early stage. As counsellors, psychologists do not limit themselves to giving advice to their clients. In fact, their aim is much more to assist clients to make their own decisions.

Trained both in psychoanalysis and in experimental psychology, Carl Rogers, transformed counselling in a special branch of psychotherapy which came to be known as client-centered psychotherapy (11).

Psychologists also made large contributions to the development of other new forms of psychotherapy: behaviour therapy, systemic therapy, cognitive therapy; and a number of less known forms of psychotherapy (12).

Actually, estimates about the total number of psychotherapeutic forms range from 200 to 400.

Psychotherapy can be applied in all settings to a whole range of target groups. Whether or not there is specificity in various psychotherapeutic techniques for the treatment of certain disorders or conflicts is still an unresolved problem. Elements of the same body of theory and techniques can be found in all four main systems of psychotherapy.

Why are some people helped by psychotherapy and others not? This issue regards the question Who will benefit from psychotherapy? Under this title Luborsky a.o. reported their research findings on predicting psychotherapeutic outcomes. These findings show that psychodynamic psychotherapy is both complex and effective.

To an increasing extent, the cost-benefit ratio is becoming another main issue in regard to psychotherapy; especially since hourly individual psychotherapy is the predominant procedure for almost three quarters of all outpatient visits and even half the inpatient visits.

4. Current developments

In the preceding sections an overview of the development of psychology, both as a science and a profession, pertaining to health and health care, has been given. For decades psychologists have been using their tools and skills in mental health care. Initially, their contributions were limited to mental health institutions. Gradually they widened their scope. This coincided, as Diekstra and Jansen explained, with changing concepts on health care (13). Today, large numbers of psychologists of various designations are rendering services, not only to individuals who are mentally disturbed or have fallen ill, but they also have their share in health maintenance and health promotion. Until recently, psychologists contributed only on a small scale to prevention. This situation is changing rapidly. Health-risk behaviour can be modified by a variety of psychological interventions. In this section a number of noteworthy developments in psychological health care will be summarized.

4.1 Physical disorders

A great deal of research in determining psychological factors in disease and stress, has been carried out by psychologists; and is still being done. Psychological factors contribute to the genesis of such diseases as: coronary heart disease, cancer, respiratory or neurological disorders. On the other hand, emotional or behavioural disorders may be caused by physical illness, pain, and even medical treatment, for instance surgical stress.

Unhealthy behaviour that may cause physical illness or disorders is highly related to specific patterns of life-style. Changing patterns of life-style is a major endeavour in health psychology (14). Psychologists develop programs for assessing life-style patterns and in assisting individuals to change them.

Management of stress and anxiety is also a major issue in health care which psychologists are investigating. In spite of Selye's contention that "stress is the spice of life", the number of people for whom stress is too spicy, is increasing. Psychologists can assist them in learning to cope with stress (15). The same goes for the management of anxiety (16).

4.2 Suicide prevention

For a long time, it was generally assumed that suicide was mainly committed by adults, who live in highly developed societies, and was connected with severe mental disturbances. Large scale psychological research has established none of these assumptions to be true. The incidence of suicide in developing countries is rather frequent, and the suicide rate in adolescents is extremely high; in fact, similar to the frequency in highly developed countries.

Moreover, the relationship between suicide and severe psychopathology is still unclear. Those data stimulated psychologists to continue research and to develop programmes to aid suicidal individuals, especially adolescents. In those programmes, cognitive therapy is found to be very useful.

4.3 Clinical neuropsychology

Neuropsychological insights developed rapidly during World War One, when brain-damaged soldiers were referred to psychologists for the assessment of specific brain dysfunctions. This is often considered to be the beginning of clinical neuropsychology. Another stimulus came from the assessment and training of veterans of World War Two and the Korean War. The confluence of clinical practice with experimental research brought forth the psychological component of neuroscience (17). A wide array of techniques proved to be beneficial in the assessment of cognitive factors in brain injuries, and in other disorders and diseases, such as diabetes mellitus or Cushings' syndrome. But psychologists also developed techniques and programmes for training. Neuropsychological assessment is also used in predicting everyday functioning; for instance, whether a certain person should be allowed to drive.

Currently, much emphasis is on the rehabilitation of patients who are physically disabled or recovering from somatic diseases. Psychologists no longer limit themselves to training and counselling the many workers who assist in rehabilitating people; or to programme evaluation. They are also developing and applying new training programmes on the basis of neuropsychological studies (18).

Several techniques of behaviour modification have proven to be of great value in the rehabilitation of disabled patients, and to enhance their compliance with medical treatment.

4.4 Gerontopsychology

Because of demographic changes, the care of elderly people with progressive and irreversible, intellectual impairment takes a large proportion of the health care budget. This number is growing, because the greying of the population is increasing (19).

Psychologists contribute in the assessment of "real" senility, such as Alzheimer's disease, but also and even more, to the detection of impairments which result from organic processes or tissue loss. Since most of those impairments are reversible, or can be compensated, psychologists use devices to help people cope with their complaints or redress the impairments (20).

Gerontopsychologists can be of great assistance to elderly people, and society, in changing attributions and attitudes. Undoing learned helplessness in elderly people by cognitive behaviour therapy is very effective. Since more and more aged people are searching for the meaning of life, also other forms of psychotherapy are conducive.

4.5 Community psychology

Community-based treatment of mental patients is not unknown in the history of psychiatry. For centuries it was practiced in the Belgian village of Geel. Another, more recent experiment with treating mentally ill is carried out in the village of Aro (Nigeria). However, community-psychology in mental care, was mainly promoted by the US Community Mental Health Centers Act of 1963. The American Psychological Association, urged research in the new centers, and psychologists were trained in community mental health. Both clinical and social psychologists contributed to the development of this new branch of applied psychology, based on system thinking and on ecological theories. A better understanding of the interactions of individual and community, and of the influence of social structures, will stimulate health care and encourage promotion of health. By developing consultative strategies, community psychology has greatly assisted in establishing self-help groups for individuals who are sharing common problems, such as: alcohol or drugs abuse, being victims of injury or the like; or establishing other social networks. Psychosocial epidemiology, investigating the effects of ecosystems, delivers a major contribution to the development of community psychology.

4.6 Organizational psychology

Paid employment takes a large part in an individual's life, especially in industrialized countries. In industrial organizations as well in other organizations where people are employed, there are many sources of stress, related to the job to be performed, the needed skills, the responsibility of the individual, his role in the organization, and the concerns with his career. For decades, organizational psychology was involved in analysing the structures and the climate of organizations, and also in developing and supervising strategies for organizational change. Recently, clinical health psychologists entered organisations, to assist individual workers and managers in coping effectively with tasks and roles in their work environment. A great deal of research is done, both by clinical and social psychologists in determining stressors in organizations, and also in the relationship between work and family. How do workers manage conflicting commitments? How do crises and stress spill over from one system into the other? Is stress provoked by environmental factors or are stress effects caused by individual coping styles? Selye suggests the last solution, but then there is no agreement as yet on the use of the term stress. Anyhow, much effort is put into the analysis of external factors provoking stress, for instance the culture of one corporation as compared to another.

4.7 Cross-cultural psychology

Differences between industrialized and traditional societies are, time and time again, provoking stress in dealing with international affairs. Politicians are struggling with this problem, but also multinational companies, or people who migrate, are often confronted with ways of living and thinking, controversial to their own.

Living in our own country we are familiar with controversies generated by the different cultures of urban and rural communities. And, to an ever increasing extent, we are confronted with cultural variety, due to international travel and migration. Native groups, minorities and refugees are not only inviting to coexist, but are also demanding our special understanding when they are in need of help.

Cross-cultural studies are necessary contributions to health psychology. For a long time, cross-cultural research has largely been the domain of cultural anthropology mainly conducting ethnographic studies. Early experimental research in psychology started from the premise that psychological characteristics are evenly distributed throughout the humans species. However, empirical studies clearly indicate that cultural and environmental variables influence patterns of behaviour, expression of emotions and even intellectual functioning.

The number of cross-cultural studies rapidly increased after 1950. The great expansion of this new subdiscipline is the result of the increased academic activity of psychologists in developing countries, and also of the introduction of applied psychology in matters of selection and training. The relationship between language and cognition, differences in cognitive style and perception, divergent forms of child-rearing are important fields of cross-cultural psychological inquiry.

Health care in many parts of the world struggles with the problem, how means and measures, proven to be effective in the health care systems in the developed countries, can be implemented in the developing societies; and how traditional healing can be integrated with modern technology. The awareness of cultural factors in health and health care is growing. Many health psychologists are contributing to health care in developing or least developed countries.

They investigate cultural differences in health and disease, including psychiatric disorders. They develop and standardize assessment procedures that can be used by health workers in primary health care, without extensive training in psychology. They are also teaching and training people in universities and paramedical schools.

4.8 Psychologists in primary health care

Cuban psychologists are participating on different levels in the health care systems, but a considerable part of them is contributing to primary health care (21). There is a tendency that psychologists get more and more involved in primary health care. This is the case in rural regions of Norway. Also, to an increasing extent Dutch psychologists are rendering services in primary health care.

Following the trends in the traditional health system in the Western world, psychologists started to contribute to special areas of health care. Clinical psychologists can be distinguished in several branches in accordance with the medical specialties. As has been shown in 2.3., this situation is changing since the rise of health psychology. Much more psychological knowledge and skills are available to clinical psychologists, and also many more psychologists are working in health care, in promoting health: consulting health care systems or in individual care; and quite often on both levels.

As stated by Diekstra and Jansen: "Psychologists, or at least a substantial part of them, should be trained as mental health generalists able to work within the realm and constraints of the primary level or to train, consult, and supervise other PHC (=primary health care - JJD) workers. The training of such a brand of psychologists will therefore have to be quite different from the usual "school-oriented" training in many traditional curricula for clinical psychology. As a result psychologists in health care will find themselves falling essentially into two groups: the specialists and the generalists." (13)

Even if one does not agree with the authors on all implications of their statement, one has to admit that psychologists in health care will either be specialists or generalists. In both capacities psychologists can contribute considerably to the practice of health care.

As generalists, psychologists can join the strategy of the World Health Federation for attaining Health for All by the Year 2000, as presented in the Declaration of Alma Ata (1978).

In the consultation meeting which was organized by the Regional Office for Europe of the World Health Organization in collaboration with the European Federation of Professional Psychologists (1984), participants agreed that psychologists could make greater contributions to programme development within the Regional Office (22).

The contribution of psychologists to programme development will especially apply to public health psychology. Diekstra has identified five central problem areas for the near future:

- The behavioural origins of ill health and disease.
- The relationship between health care and quality of life.
- Early acquisition of health-sustaining behaviours.
- Psychosocial and mental health consequences of emergency and disaster situations.
- The health of health care workers.

He exemplifies those problems and suggests courses of action (23).

Both scientifically and professionally, psychologists are very well placed to encourage the interaction of theory and practice in health care.

5. Concluding remarks

Although psychology made a late start, it had a rapid growth. Today psychological research and education are in the programmes of universities all over the world and also in developing countries.

Professional psychology developed at a slower pace. After its breakthrough following World War Two, its expansion is remarkable. For instance, in Latin America there are more than 150,000 psychologists. Organizations are essential in setting standards for training and practice of professional psychologists.

Professional psychologists have a large array of methods and instruments at their disposal, to assess problems and to aid people in bringing about change. Within a wide range of interventional procedures for behavioural and attitudinal change psychologists contribute significantly to the development of psychotherapeutic techniques.

Psychologists entered mental health care by focusing on the investigation of abnormal behaviour, and the assessment and treatment of mental disorders. Gradually, they also became involved in assessing psychological factors in somatic diseases and assisting patients to reduce or eliminate those factors. However, abnormal psychology shall continue to be of concern to clinical psychologists, but more and more maintaining and restoring health will be the focus of psychologists who are active in health care.

This shift was largely caused by the rise of health psychology. All subdisciplines of psychology are contributing to this new area of theory and practice.

A great variety of psychologists will be available for rendering services in health care. With their education and training they will be of immense value "because they should be able to assess the subjective aspects of health with respectable accuracy and validity." (24).

Psychologists in health care may be employed in individual health care, in prevention and in various forms of health promotion. They will need a training for specific tasks in health care (25, 26, 27, 3). Professional organizations are setting new standards for training and practice. At the moment, there are only standards for individual health care.

Psychologists in health care are well equipped to take their part in effectuating The Mental Health Programme of the World Health Organization (28).

6. Acknowledgments

I am very grateful to colleagues who assisted me in writing this article. Dr. Y. Poortinga kindly supported me in conceiving this paper and commented extensively on its first draft. Prof. dr. R. F. W. Diekstra and Prof. dr. S. Maes generously supplied me with literature on many topics I discuss in this paper. Dr. K. Peltzer gave me permission to use an article still to be published.

7. References

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2. Matarazzo J D. Behavioral health and behavioral medicine. American Psychologist. 1984, 35:807-817.

3. Weinman J. Health psychology in the 1990s. In Drenth P J D, Sergeant J A & Takens RJ eds. European perspectives in psychology. Chichester, John Wiley & Sons, 1990, 2:169-191.

4. American Psychological Association, Graduate study in psychology and associated fields. Washington, APA, 1988.

5. European Federation of Psychologists Associations (EFPPA), Optimal standards. News from EFPPA, 1991, 5:4-5.

6. Edwards H P & Reaves R P. Enforcing ethical behaviour. Disciplinary processes in the U.S. and Canada. (Presented to the 6th General Assembly of the European Federation of Professional Psychologists Associations). Oslo: EFPPA (c/o Norsk Psykologforening, prof. Dahlsgate 18, 0353 Oslo, Norway), 1990.

7. Brown G W, Harris TO eds. Handbook of clinical health psychology. New York, Plenum Press, 1982.

8. Hersen M, Kazdin A E & Bellack A S eds. The clinical psychology handbook. New York, Pergamon Press, 1991.

9. Millon T, Green C & Meagher R eds. Handbook of clinical health psychology. New York, Plenum Press, 1982.

10. Maes S. Theories and principles of health behaviour change. In: Drenth P J D, Sergeant J A & Takens J A eds. European perspectives in psychology. Chichester, John Wiley & Sons, 1990, 2:193-207.

11. Rogers Carl R. Client-centered therapy: Its current practice, implications, and theory. Cambridge Massachusetts, The Riverside Press, 1951.

12. Freedheim D K ed. History of psychotherapy: A century of change. Washington, D.C. American Psychological Association, 1992.

13. Diekstra R F W & Jansen M A. Psychology's role in the new health care systems: The importance of psychological interventions in primary health care. In: Psychotherapy, 1988, 25, 3:344-351.

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18. Filskov S B & Boll eds. Handbook of Clinical Neuropsychology. 2 Volumes. New York, Wiley, 1981,1986.

19. Lehr U. The greying of Europe: A challenge for psychology and psychologists. In: Drenth P J D, Sergeant J A & Takens R J eds. European perspectives in psychology. Chichester, John Wiley & Sons, 1990, 1:483-496.

20. Hussian R A. Geriatric psychology: A behavioral perspective. New York, Van Nostrand Reinhold Company, 1981.

21. Kristiansen S & Soderstrom K. Cuban health psychology: A priority is the primary health care system. In: Psychology and Health, 1990, 4:65-72.

22. Contribution of Psychology to programme development in the WHO regional office for Europe. Amsterdam, European Federation of Professional Psychologists Associations, 1985.

23. Diekstra R F W. Public health psychology: On the role of psychology in health and health care in the 21st century. In: Drenth P J D, Sergeant J A & Takens R J eds. European perspectives in psychology. Chichester, John Wiley & Sons, 1990, 2.

24. Pennebaker J W. The psychology of physical symptoms. New York, Springer-Verlag. New Haven, Yale University Press, 1982.

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International Sociological Association Working Group on Sociology of Mental Health - ''Sociology's Contribution to the Study of Mental Health''

Rumi K. Price, Ph.D., M.P.E.1
Harsha N. Mookherjee, Ph.D.2
Brent M. Shea, Ph.D.3
Sebastien Reichman, Ph.D4

1. From the Department of Psychiatry, Washington University School of Medicine, U.S.A.

2. From the Department of Sociology and Philosophy, Tennessee Technological University, U.S.A.

3. From the Department of Anthropology and Sociology, Sweet Briar College, U.S.A.

4. From the Clinique des Maladies Mentales, Saint Anne, Paris, France.

1. Introduction

The study of mental health and illness encompasses several disciplines including, but not limited to psychiatry, psychology, social work, public health, nursing, anthropology and sociology. While substantive topics are not distinctive across these disciplines, sociology of mental health, as a subfield and outgrowth of sociology, applies the concepts, perspectives, theories and methods of sociology to phenomena related to mental health and illness, including substance use and abuse. The sociology of mental health thus includes a wide range of topics, such as: theories relating to the spread and distribution of psychiatric and substance use disorders among various population groups; social and cultural factors in the causes of mental diseases; behaviors or actions taken by groups to maintain, enhance or restore mental health or cope with mental illness, substance use disorders or resulting disability; mental health professionals and the organization, financing, and delivery of mental health care services; psychiatric and mental health practice as a social and cultural institution, and its relationship to other social and cultural institutions; people's attitudes and beliefs and social representations concerning mental health, illness, substance abuse, disability, and mental health care providers and organizations; as well as cultural values and responses with respect to mental health, illness, substance abuse and disability.1

Most mental health professionals including psychiatrists, clinical psychologists, psychiatric social workers, psychiatric nurses, and occupational therapists contribute to the areas of mental health and illness, primarily through their psychiatric or mental health practices by treating or counseling patients and, to a lesser extent, by teaching students of these professions. In contrast, sociologists' contributions have traditionally involved research on mental health and dissemination of important findings for public policy. Thus, our present paper is aimed primarily at current and future issues surrounding sociologists' role in mental health from the viewpoint of research needs and public policy.

Sociology of Mental Health and the International Sociological Association. There are two major international organizations in sociology: the International Sociological Association (ISA), and the International Institute of Sociology (US). The US is the oldest Sociological association and has a rich organizational history for established sociologists. Unlike ISA, however, it does not have a section structure representing subfields in sociology. Therefore, our Working Group on Sociology of Mental Health (WG-SMH) within the International Sociological Association represents an international organizational body in sociology clearly identified with the field of mental health and illness.

In this position paper, the Working Group attempts to lay out a foundation for future agenda in Sociological research on mental health and illness, including substance use and abuse. We identify social epidemiological research and research bearing direct impacts on public health and policy, as two major areas needing increased sociological contributions. We also attempt to identify sociology's practical contributions to mental health, beyond its scientific contributions - viewing sociology as an integral part of various professions in the overall field of mental health. Our organizational promotion activities based on our analysis of the current situation of sociology of mental health are described.

2. Historical Background

Sociological exploration into the etiology of mental health and illness can be traced to the beginning of sociology more than a century ago (1). It is usual, however, to consider the sociology of mental health and illness as beginning in the late 1930's, when researchers began documenting the significant relationships between mental illness and social environments using concepts such as social class and residential mobility (2, 3).

Following World War II, the "first-generation" landmark studies of mental health and illness were carried out in the United States (4, 5, 6). Sociocultural and epidemiological studies were also conducted during this period in most regions of the world as well, including Asia (7), Europe (8, 9, 10) and Africa (11). Social psychiatry as a paradigmatic movement to the understanding of mental health and illness flourished during this period (12).

Beginning in the late 1960's and until the early 1980's, sociological research on mental health and illness gradually shifted its focus and approaches. While psychiatry observed the surge of the neo-Kraepelinian paradigm emphasizing the categorical approach to mental illness (13), social scientists shifted their interests from mental illness to mental health problems. Although the effects of macro-sociological variables, in particular, social class, continued to be a focus of debates (14, 15, 16, 17), micro-environmental variables such as social Support and life events began dominating the research on mental health problems (18, 19, 20).

In the United States, researchers with macro-sociological orientations began to apply the deviance approach (21, 22, 23) or the social disorganization (anomie) approach (24) to study mental health and illness, as these approaches became dominant in mainstream sociology during the 1960's and 1970's. These approaches advanced our understanding of some aspects of mental health and illness. Nevertheless, a consequence was a widening gap between sociology and psychiatry; the latter shifted increasingly over the past two decades to biological approaches. Although the gap between sociology and psychiatry was also widening in France during the 1970's, the reasons were quite different: on one hand, psychoanalysis (not biology) became the most influential psychiatric ideology among specialists and the general public, and on the other hand very scarce financial resources were allocated at the national level for sociological studies of mental health and illness. Consequently, the "sociology of psychiatric practices" (25) could never reach a high level of intellectual prestige and autonomy in the medical profession in France.

During this period, medical sociology became a major subfield of sociology in the United States. Notwithstanding a large overlap between medical sociology and sociology of mental health, the former is more distinctive in studying institutional aspects of general medicine as well as psychiatry (26). As impacts of the deinstitutionalization movement grew larger over the two decades, sociological contributions to the understanding of mental health policy (27, 28, 29, 30) added to the growth of medical sociology. A similar trend was observed in France where several sociological and social-psychological studies for the severely mentally ill were carried out utilizing family-based sheltered care facilities (31, 32).

The late 1970's through 1980's marks the flowering of psychiatric epidemiology - a hybrid of sociology (with an application of survey research), epidemiology (in investigation of prevalence, incidence and risk factors of psychiatric disorders), and psychiatry (with standardized assessment of psychiatric cases) (33). The "second-generation" large-scale community mental health surveys were carried out in North America (34, 35, 36), Europe (37), and other parts of the world (38, 39, 40). At the same time, follow-up studies of the first-generation epidemiological studies found many cultural differences as well as overtime changes in the incidence and correlates of mental health and illness (41), reaffirming the importance of sociocultural investigation into the etiology of psychiatric disorders.

A number of sociologists made important contributions to the second-generation studies. Many of them, however, operated outside the traditional discipline of sociology, most frequently in psychiatry and public health. In fact, tension between interdisciplinary researchers engaging in epidemiological research of psychiatric disorders and those in sociology appears to be growing (42, 43). Such a tension is not reducible to the measurement issues of mental illness vis-a-vis mental health problems. Rather, it reflects ostensible differences believed to exist between sociology and psychiatry: sociology purports to explain mental health and illness from a social structural perspective (particularly social control perspective) or from the perspective of symbolic interaction (44, 45); whereas psychiatry tries to understand biological mechanisms manifested in psychiatric disorder.

3. Mental Health Research and the Discipline of Sociology

3.1 Theoretical Approaches

The complexity involved in the etiology of mental health and illness is well expressed in diverse theoretical approaches. Because such a diversity of approaches was in part responsible for diverging disciplines among working sociologists of mental health in developed countries, it is helpful to touch upon these theoretical approaches. We describe three approaches in which sociology has provided essential, landmark contributions to the field of mental health, namely, social learning, societal reaction, and stress approaches. Two other major approaches, psychoanalytic and medical approaches are not discussed here because sociology's impacts on the mental health research from these approaches have been minimal.

3.1.1 Social Learning Approach

This approach was originated in theories of learning and techniques of behavioral conditioning in Skinnerian psychology. From this approach, social behavior was assumed to be learned, therefore, problematic behaviors were thought to be replaceable with appropriate behaviors through behavior modification techniques (46, 47). Behavioral modification has been shown to be effective for some psychiatric problems (48) and substance abuse (49).

Without relying solely on the notion of physiological or psychological conditioning, sociologists have described the learning process from the viewpoints of social control and influence (50, 51). Group norms and peer influences were thought to be the governing principles for learning rather than the principles of reward and punishment. Researchers therefore attempted study the causal mechanism between group membership and influence structure and deviant, bizarre or unacceptable behaviors. This tradition continues in research of mental health and illness, especially in research on substance use and abuse (52).

3.1.2 Societal Reaction Approach

There is a long tradition in sociology of viewing mental illness as a form of deviance: mental illness is thought to be an artifact of social reaction to bizarre behaviors (53, 54, 55). An extreme statement from this perspective reduces mental illness to problems related to sociocultural norms (56). Such a position has been shown to be empirically untenable: cross-cultural studies on behaviors of disturbed individuals suggest that psychotic symptoms such as hallucinations and delusions are universal, despite that contents of symptoms vary by culture (57, 58). Nevertheless, this approach has been successful in pointing out the importance of cultural, situational, and institutional factors in case definition (but not the existence of symptomatology) and treatment selection process. For example, the diagnostic process was found to be influenced by the patient's appearance and demographics (59, 60, 61); and the overrepresentation of minority groups in drug abuse treatment in the United States was attributed to institutional factors rather than reflecting the prevalence distribution of drug abuse in the general population (62).

3.1.3 Stress Approach

A large body of recent literature in medical sociology exists within the stress approach to understanding social psychological mechanisms leading to mental health problems, psychiatric disorders, disability and mental health services utilization (63, 64, 65, 66, 67). In fact, its current dominance is so clear that American medical sociology is often identified with the stress research (68). The notion of stress has been a central concept in sociological research of mental health since the earlier studies in the United States, however, current research distinguishably focuses on understanding the stress process. Thus, although traditional structural variables such as social class and race remain as hypothesized predictors, researchers are increasingly interested in identifying the causal mechanisms leading to the outcomes of interest A series of debates consequently has occurred in recent years over such notions as coping, life events, social support and social networks (69, 70, 71).

Psychiatry shares the stress approach in the categorical concept of post-traumatic stress disorder. Its appearance in psychiatric nosology in the United States (72) was partially political, responding to a large number of reports describing psychiatrically impaired Vietnam veterans (73). During the past several years, however, it has generated psychosocial and epidemiological research on the impact of extreme stress on mental health and psychiatric disorders (74, 75, 76), which is not limited to trauma induced by war experience.

3.2 Diverging Disciplines in Developed Countries

The sociology of mental health has decreasingly been identified with the discipline of sociology in the United States and European countries due to an increased diffusion of its orientation to several disciplines. The interdisciplinary nature of much of current research stems also in part from an increased migration of sociologists engaged in mental health research into other disciplines. A main reason for disciplinary diversion is financial. Since the 1970's, sociology has not been able to sustain the level of financial support it once enjoyed. On the other hand, outside sociology, in particular, in medicine and public health, availability of funding made it possible to allocate academic positions to researchers with social science backgrounds. Some candidates trained in mental health thus began to seek their careers outside sociology (77). In the United States at least, this trend was facilitated by additional facts such as that no existing discipline currently can be identified as the discipline of mental health, and that mental health has never been recognized as mainstream sociology.

Positive consequences of the recent migration into other disciplines include: diffusion of sociological ideas to public health and psychiatry; incorporation of psychiatric and public health ideas into one's own sociological research; and, the opportunity to influence researchers trained in different disciplines, in particular, psychiatrists. On the other hand, the visibility of sociologists in, and sociological contributions to, the field of mental health and illness have been hampered, because important studies and findings have often come out of schools of public health or medicine, despite considerable contributions by sociologists in these institutions. (Obviously there are notable exceptions, e.g., Kessler's large psychosocial study of stress (78)). Further, communication with other sociologists in mainstream sociology is often difficult to maintain, lending the impression that interdisciplinary sociologists are allied with medicine rather than with social science.

3.3 Sociology of Mental Health in Developing Countries

Sociocultural and epidemiological studies carried out by researchers in Pacific-Rim countries have been published in well-circulated journals (79, 80, 81); however, research efforts from Central Asia, Middle-East (except Israel (82)) and Africa, are much less known in the Western literature. Overall, the productivity level in developing countries has lagged far behind developed countries. Concerns regarding developing countries are quite different from those surrounding developed countries, because Western hegemony since World War II over both contemporary mental health research and sociological investigation has led to problematic situations that were specific to developing countries.

Three issues appear important and are highly relevant for our future strategies. The first relates to Euro-American ethonocentrism: contemporary mental health research has tended to ignore cultural aspects of mental health problems as well as indigenous mental health practices (83). Such ignorance by Western researchers is not new, and analogous situations can be found in other fields such as general medicine. However, because developing countries lack a long tradition of sociology, and further sociological approaches developed in the past two decades were themselves reflections of problems in the Western countries, mental health research in developing countries lacks culturally-specific theories, or existing theories that can be uniquely applied to culturally-specific mental health problems and practices.

The second issue is inadequate financial support for indigenous mental health research. Although this can be said about developed countries, the situations in the developing counties are far worse. The developing countries do not really perceive psychiatric disorders and mental health problems as their high priority, given overwhelming domestic problems in other areas (e.g., civil war, famine, poverty). This perception is still prevalent in the countries undergoing rapid social change, where past experiences in western societies (84) would indicate increasing psychiatric and mental health problems. On the other hand, very few funding mechanisms through Western agencies sympathetic to third world research are available, which are aimed at promoting mental health research.

The third issue concerns the manpower problem. There is an insufficient number of native mental health researchers well-trained in the field to produce research which would survive critical review. The number of researchers from developing countries, trained on Western soil, appears to be increasing. Nevertheless, problems are often encountered such as that insufficient time is allowed to absorb new methods and approaches, or that the researchers would become unwilling to go back to their native countries.

Fourth, in developing countries, no professional society has been formed specifically to address the area of mental health from sociological perspectives. In some countries, especially in Asia and Africa, mental health has been in the province of national psychological and psychiatric associations. It is only recently that national sociological and anthropological associations in India, Nigeria, and a few Latin American countries have begun addressing me sociology of mental health. Thus, not only that there is an insufficient number of sociologists in mental heath field, but also organizational mechanisms to promote mental health research are severely lacking in developing countries.

4. Research Agenda for the Future

The Working Group has identified two major areas needing increased sociological contributions to the field of mental health and illness: 1) social epidemiological research of mental health and psychiatric disorders, in particular on research topics that are currently in demand, but which have not received enough attention by working sociologists; and 2) public health and policy related to the urgent issues on which sociologists have not been able to make a large impact.

4.1 Social Epidemiological Research

Research combining sociological and epidemiological approaches has occurred infrequently in the following areas. Although these areas are currently in demand or likely to be in demand in the near future, sociologists' contributions are lagging behind those of researchers in other fields:

Child and adolescent mental health and illness. Past research has demonstrated tremendous impacts of childhood and adolescent behaviors on later adult mental health and illness (85). With the improved reliability and validity of interview assessments for children and adolescents, increasing research and prevention projects on child and adolescent populations are expected in some developed countries (86). Although sociological research has not been absent in this area (87, 88), social scientists' contributions to the understanding of environmental and mental health risk factors influencing current Western problems such as adolescent pregnancy, suicide and homicide, will help provide workable prevention and intervention programs to reduce these unfortunate outcomes.

Population-based survey in developing countries. Existing cross-cultural epidemiological studies in the world regions outside North America owe much to the long-standing initiatives by the World Health Organization (WHO) (41). A decade of the joint venture between the WHO Division of Mental Health, and the United States Alcohol, Drug Abuse and Mental Health Administration (ADAMHA) (89) has now produced standardized psychiatric assessment interviews based on the widely used International Classification of Diseases (ICD) (90) to serve cross-cultural studies of psychiatric disorders and problems (91). Such instruments will allow for comparisons of prevalence and incidence rates among countries not only within the same region, but also across regions. With proper translation and training of interviewers, population-based epidemiological studies in developing countries are feasible now. Such efforts much are needed to understand specific mental health needs of African populations in particular, in which the current climate is focusing only on their physical illnesses.

Abuse and use of psychoactive substances including alcohol, tobacco, and other psychoactive drugs. Although their sociological contributions were often not obvious due to their institutional affiliation, sociologists and other social scientists have actually worked at the leading edge in this area (92, 93, 94, 95, 96). However, a new generation of researchers with social science backgrounds is much needed, given the current magnitude of social problems resulting from substance use and abuse, including its association with HIV infection.

Personality disorders and personality structure. Since the time when sociology turned away from the psychoanalytic approach to instead advocate the deviance approach, personality research in mental health has been conspicuously lacking, and this trend is unlikely to be reversed in the near future. In psychiatry, however, personality disorders are currently in the forefront of inquiry, although nosological schemes of personality disorders still need to be sorted out (97). Sociologists' resistance to including personality factors in the stress process studies is in part ideological. But the accumulated empirical evidence to support the importance of personality is so persuasive that further resistance would alienate sociological research in the field of mental health. Inclusion of personality factors in sociological research does not necessarily endorse heredity or biological factors as the primary antecedents of mental health and illness. To the contrary, behavioral genetics and genetic epidemiology have been sensitive to the importance of environmental factors (98, 99, 100).

4.2 Public Health and Policy

Sociological research can assist in determining the direction of changes on countless public health and policy issues. The Working Group felt, however, that the following three issues are likely to benefit most from increased sociological research. Although we recognize its importance, sociological research on mental health care and utilization was not included, because this is a relatively well-studied area in medical sociology and detailed discussions can be found elsewhere (101).

AIDS/HIV and mental health. Into the third decade since the appearance of AIDS, the global spread of the disease is indeed sobering (102). AIDS being an infectious disease, sociology has much to offer in explicating social processes that affect the course of HIV spread (103, 104). From the mental health point of view, social factors influencing premorbid mental health conditions (which in turn affect the probability, as well as the course of infection) need thorough investigation (105). Such studies will help prevention efforts. Studies on social factors mediating mental health consequences of AIDS/HIV patients will also be valuable as the toll of victims continues to grow. Lastly, research on the impact of AIDS/HIV on community mental health in high prevalence areas would be needed to plan long-term public health strategies. Because AIDS/HIV has often been concentrated in low socioeconomic strata (e.g., migratory labor villages in Central Africa, inner-city ghettos in the United States), individuals in these areas would require community resources to cope with the consequences of AIDS/HIV.

Psychiatric and psychological comorbidity. Recent general-population epidemiological research is primarily responsible for a shift toward the comorbidity paradigm in American psychiatry (106, 107). Currently, however, environmental factors that precipitate or modify the course of comorbidity are not well understood. Studies addressing such issues will be beneficial for identification of individuals at risk for comorbid disorders and problems, and for planning effective intervention and prevention.

The homeless mentally ill. In the developed countries, increasing attention has been given to the homeless in the 1980's. Because low-cost housing is disappearing quickly, the homeless problem is expected to increase even further in the United States. As expected, psychiatric problems have been found to be exceptionally high in this population (108). Because the homeless mentally ill is a very intractable population, careful sociological and epidemiological research (109) on the relationship between homelessness and mental illness can be extremely helpful for intervention efforts.

5. Practical Place of Sociology in the Mental Health Field

Recent communications between the ISA and its constituencies, Research Committees and Working Groups, have focused on the issue of demand for sociology. Serious dialogue has accumulated in assessing the role of sociology in scientific communities as well as in wider public and private sectors. Similar questions can be asked more specifically about sociology of mental health. In an earlier section, we argued that, although disciplinary diversion diminished the visibility of sociology, it also facilitated diffusion of sociological inquiry into a wide variety of disciplines such as psychiatry, public health, and epidemiology. We then identified research agenda that are currently in demand in developing countries or are expected be in demand in a near future in developing countries.

We maintain that research is sociology's most identifiable contribution to the overall field of mental health, and that very few sociologists are direct services providers treating or consulting patients (sociologist's role equivalent to clinician's role as a service provider in relation to patients, would be teaching college and graduate students). There are, however, other practical roles that sociologists have frequently fulfilled in the field of mental health beyond their contributions to research. First is consultation services to mental health professionals, rather than sociologists themselves being investigators. For example, a number of sociologists are providing their expertise services on ongoing instrumentation and psychiatric nosology projects headed by psychiatrists (e.g., WHO's CIDI field trial (91), DSM-IV field trial by American Psychiatric Association (110)). Specific expertise of these sociologists were first acquired through their training in sociology and second by their independent investigation work, which proves to be critical for scientific advancement in related fields. This type of services is similar to biostatisticians' services to the medical community for consultations on statistics, for which clinicians are often ill-trained.

The second function of sociologists is training professionals in other fields of mental health so that they be equipped with knowledge about various environmental factors that affect the patient's prognosis. Faculty with social science background in medical school or school of public health frequently teach medical students, nursing students, psychiatry residents, and are also an integral part of faculty development efforts.

The third role may be called the role of "mental health services analyst". Because training in sociology to study variables relating to stratification is naturally suitable for analysis of health care systems, this has in fact been one of the strongest areas of inquiry in medical sociology (101, 111). Outside the research arena, there still appears to be a high demand for systems analysis. The inquiry might be at the level of demographic trends of specific psychiatric disorders in local areas, which would help administrators of local hospitals to decide on the bed allocation. At a higher level, demands appear increasing for inquiry into inequality of health care provision and utilization, which relate to a national strategy for governmental insurance and taxation.

6. Organizational Promotions by the Working Group on Sociology of Mental Health, ISA

To facilitate collaboration in the areas of research identified above both within and across regions, the Working Group endorses an interdisciplinary approach with a global perspective. Specifically, we propose to:

- Form an advisory board to facilitate the interdisciplinary approach. It is clear that mental health research has become increasingly interdisciplinary. It would become increasingly difficult to maintain unidisciplinary studies within sociology, if they are to have substantial impacts on public health and policy. To increase interdisciplinary communication and collaboration, the Working Group began the process of forming an advisory board consisting of well-established senior scholars from several disciplines including sociology, psychiatry, public health, social work, epidemiology and psychology. The advisory board is also expected to provide critical advice about the future directions of the Working Group.

- Utilize international societies as a vehicle to promote the global perspective. Cross-cultural study is valuable in suggesting the etiologic factors of mental health and illness. Such a global perspective would also fill in the critical gap in research capabilities that exist between developed and developing countries, which have been described earlier. The Working Group is in the position of facilitating the global perspective, by virtue of being an international organization. However, we need effective means of providing information about on-going projects from many parts of the world as well as funding and other opportunities available particularly to researchers from developing countries, and disseminating new research findings. Organizational "interlocking" or networking is one effective means of diffusion of information. For this purpose, we have identified several international and national organizations including the US, the International Epidemiological Association (IEA), the Section on Epidemiology and Community Psychiatry within the World Psychiatric Association (WPA), the newly formed Section of Sociology of Mental Health within the American Sociological Association (ASA), and the Sections of Mental Health, and of Alcohol, Tobacco and Drugs, within the American Public Health Association (APHA). The members of the Working Group's current Executive Board have been in touch with the leaders of these organizations.

7. Summary

Most mental health professionals contribute to the field of mental health and illness primarily through their psychiatric or mental health practices by treating or counselling patients. In contrast, sociologists contribute to the field through their research involvement and, through their research findings, addressing pubic health and policy issues most relevant to current problems. The present paper addressed the current and future issues surrounding the sociologist's role in mental health and illness, focusing on research and its contributions to pubic health and policy. Beyond sociologists' role as mental health researchers, we described additional roles: expertise services, teaching, and health systems analysis are three practical roles that sociologists have been and will continue to fulfill in the overall field of mental health.

This paper presented historical background, contemporary approaches, current diverging trends among sociological researchers in developing countries, and shortcomings in developing countries stemming from a lack of sociological tradition and scarce resources for mental health research. Our analysis suggests that the visibility of sociological contributions to the field of mental health and illness has been hampered in the last decade, in part, because of divergence of sociological research into other disciplines. Absence of strong international organizations has impeded international research collaboration and dissemination of findings, so critical for researchers in developing countries.

The Working Group on Sociology of Mental Health (WG-SMH), International Sociological Association (ISA), proposes a research agenda comprised of four areas of mental health and illness research in which sociological contributions are lagging behind those of other fields: research on child and adolescent mental health and illness; population-based epidemiological research in developing countries; research on substance use and abuse including psychoactive drugs and alcohol; and, studies integrating personality disorders, and personality structure with sociological approaches. To facilitate research most relevant to current public policy issues, more sociological studies are needed to better understand: social variables related to psychiatric and psychological consequences of HIV/AIDS patients, social factors influencing mental health conditions among HIV high-risk populations, and the impact of AIDS/HIV on community mental health; social factors related to psychiatric and psychological comorbidity; and the social epidemiology of the homeless mentally ill. The Working Group attempts to increase international collaboration and coordination among working sociologists in several disciplines to enhance further sociological contributions in these identified areas of research and public policy. The existing national and international organizations to promote this movement are identified and future possibilities are discussed.

8. Notes

1. Adapted and extended from a definition of "Medical Sociology" in U.S. Office of Personnel Management, Classification Standard for Sociology, TS-89, Washington, DC: U.S. Government Printing Office, 1988.

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World Federation for Mental Health - ''The Voluntary Sector: Passage to Empowerment for Volunteers, Consumers and Advocates''

Hilda H. Robbins

Delegate-at-Large, World Federation for Mental Health
Alexandria, Virginia, U.S.A.

World Federation for Mental Health

The World Federation for Mental Health was founded in 1948 in London during the Third International Congress on Mental health. Its objectives are: (1) to promote among all peoples and nations the highest possible standard of mental health, defined in the broadest biological, medical, educational, social and cultural terms and prevent mental ill-health; (2) to promote the civil and human rights and welfare of mentally ill persons and their families; (3) to help and encourage member associations in the improvement of mental health services in their own countries; (4) to promote communications and understanding through advocacy and education through publications, consultation, meetings and international congresses; and (5) to further the establishment of better human relations in all possible ways.

Its membership consists of over 100 voting international and national associations active in mental health and over 100 affiliated non-voting organizations interested in supporting but not directly involved in the work of the Federation. There are, also, over 2500 individual members, including a wide range of professionals concerned with mental health as well as former patients and their families.

The WFMH policy-making body meeting annually is an Executive Board elected by an Assembly of members. Biennial congresses are central occasions for in-depth examination of the 'state of art' in mental health, but routine work is done through nine regional offices and central committees set up for specific tasks representing most of the important aspects of mental health which are reflected in the NEWSLETTER appearing 5 times a year. WFMH maintains official relations with most organizations of the United Nations system, including the United Nations itself and its bodies (UNICEF, UNHCR) and specialized agencies (WHO, UNESCO), etc. Especially close collaborative liaison is maintained with WHO.

"I know of no safe depository of the ultimate powers of society but the people themselves; and if we think them not enlightened enough to exercise their control with a wholesome discretion, the remedy is not to take it from them, but to inform their discretion by education."

T. Jefferson

1. Introduction

Many people claim that volunteers, consumers (users of certain health services) and vocal advocates for social action have wrought more constructive change in the United States for the country than most of the military victories, many of the technological advances and all the political rhetoric. Of course those who make this unabashed claim have usually been the very volunteers, consumers and advocates who have been in the front line of successful activitism which brought about significant and long-lasting social change. But they make no apology for the claim nor did they see it as exaggeration or braggadocio.

This chapter will summarize some of the benefits of encouraging, supporting and nurturing volunteer activists; enumerate the basic principles of successful advocacy; and finally, will discuss some of the contributions of volunteers and consumers in the mental health field.

2. The Voluntary Sector in the USA

Regrettably these observations are derived almost entirely from experience and writings of activists in the United States but undoubtedly the principles are applicable and the examples could be multiplied a thousand fold by dedicated volunteers throughout the world. Apparently the voluntary sector has had more participants and perhaps stimulated more motion in the United States.

The voluntary sector, as it is frequently called, the independent sector, the nonprofit sector or the third sector is the least studied, the least written about, the least discussed of any part of American Society. However it is almost totally ignored in formal education. The President of Carnegie Corporation of New York went through 50 textbooks used in history, civic and social studies in elementary senior high, college and universities and found no reference to volunteers or voluntary and philanthropic organizations. A student can have an excellent education and never really grasp what this third sector means to free people.

The two counter-balancing sectors are the government and business or industry. In totalitarian states virtually all activity is in essence, governmental - and the little that is not, is heavily controlled or influenced by government. Almost everything is bureaucratized and is the subject to central goal-seating and rule-making.

In the nations that the world thinks of as democracies there is in contrast, a vast area of activity outside of government - and not connected with for-profit business and industry. Of course, both the for-profit business world and this third non-profit voluntary sector have many dealings with government. But both sectors vigorously defend their independence - recognizing that their very vitality depends on the extent to which they can hold themselves free of central bureaucratic control and regulation. Besides the vast body of health and welfare organizations it includes religious organizations, schools and colleges, libraries and museums, performing arts groups, neighbourhood organizations, citizens action groups, research centres and countless other categories. You get quite a potpourri when you realize the Girl/Boy Scouts, the Red Cross, the Philadelphia Orchestra, the Black Women's Caucus and our small but extremely active Neighbourhood Watch are all active ingredients of this very substantial voluntary sector, the common characteristics are that they are private, nonprofit and are devoted to serving the general welfare, not merely the self-interests of their members.

Although size is not the best measurement of this sector it is useful to note that in the US these institutions have annual outlays of more than $80 billion dollars. The giving in dollars is divided as follows:

Religion

46.5%

Education

14.5%

Health and Hospitals

13.9%

Social Welfare

10.5%

Arts and Humanities

8.2%

Civic and Other

6%

These figures are from Giving U.S.A. which is published by the American Association of Fund-Raising Counsel.

A survey by Gallup Poll of where and to whom we do our "volunteering" breaks down in a different way:

Religion

19%

Health

12%

Education

12%

Recreation

7%

This same Gallup survey serves up the fascinating information that the woman who works outside the home is more likely to volunteer than the one who does not.

Many people believe that most giving is done by foundations and corporations, however, as important as that portion is, it represents only 10% of all that is given. Ninety percent comes from individuals. Another inaccurate assumption is that wealthy people represent the bulk of individual giving. In fact, about half of all charitable dollars come from families with income under $25,000. It is also interesting to note that families with income under $10,000 contribute about 3 times more of their income than do people in the $50,000 to $100,000 bracket (3.85% compared to 1.35%). And even families with income of $5,000 and less, the average given in 1981 was $238 which was about 5% of their income.

You may question why I go into such detail regarding the financial support of the voluntary sector. The answer is simple and fundamental - the health, viability and influence (translate all those adjectives as "power") is in direct ratio to the financial stability of the sector as a whole and the financial stability of every organization included therein.

Why is it so important that these thousands of organizations and millions of volunteers (over 50 million in the US) be nurtured and these enormous sums of money be spent wisely and usefully?

3. Functions of the Voluntary Sector

In the publication called "The Third Sector: Keystone of a Caring Society", Waldemar Nielsen, Senior Fellow, Aspen Institute for Humanistic Studies, enumerates and gives examples of what the voluntary sector "does for the spirit and character of our society and for the freedom and fulfilment of each of us". I will summarize and paraphrase from his work.

First and most obvious this sector delivers a range of vital services. These hardly need identifying but it is well to note that in so-called "welfare" services alone, over 37,000 agencies receive funds just from the United Way - funds which mean the alleviation of human distress for over 70 million Americans.

The second general function performed by the voluntary sector is that it strengthens the other two sectors and makes them work better. Institutions in this sector other than the religion often operate in parallel with the government agencies carrying out similar programmes. For instance both Harvard and Stanford Universities are small institutions compared to state universities in many of the States. They are nonetheless crucially important both because of their excellence and because they provide a standard of measurement, a stimulus that helps invigorate and improve both public and private higher education. The US Government uses the service systems of many private nonprofit organizations to carry out legislatively mandated programmes through grants and contracts.

Because of strong constituencies and a tradition of independence nonprofit institutions are an important check on the excesses of government and a corrective to some of its worse deficiencies. At a time when Big Government is more massive and more intrusive its collaboration with nonprofit agencies is a means of decentralization, of testing a variety of approaches and of generating the active participation and involvement of citizens. This can provide an antidote to the sense of powerlessness and alienation felt by considerable numbers of people today -particularly the poor, disabled, and ethnic minorities.

A third function is the humanizing force which is provided by the activities of volunteers in this sector. Volunteerism embodies a profoundly important concept -namely that a good citizen of a decent society has a personal responsibility to serve the needs of others. The concept is simple, universal, and ageless, and surely therein lies the distinction between a brutalizing society and a caring and responsible one.

Another way by which volunteerism serves to humanize our life is by providing the means of expression for all those spiritual, social and creative needs of individuals that government or the army or the factory or office simply cannot satisfy. This is one-of the most available and inexpensive ways by which each of us can go about our own personal pursuit of happiness.

The fourth function Nielsen calls the ultimate contribution of the Voluntary Sector - namely what it does to ensure the continuing responsiveness, creativity and self-renewal of a democratic society. Volunteers are a stubborn and belligerent protection against nonfeasance and malfeasance by government. They have been called the "mediating structures" standing between the citizen and the dangers of political and corporate misconduct.

4. Attributes of the Voluntary Sector

When organizing the umbrella organization called "Independent Sector", Gardner (1980) (1) listed what he called the "attributes of the voluntary sector that make it a powerfully positive force in the world". Those attributes, often quoted and reprinted, include:

4.1 Freedom from Constraints

Compared with government and business, the independent sector is relatively free. A group interested in a particular idea or programme does not have the need of government to deal with huge constituencies, nor the need of the mass merchandiser to find a lowest common denominator. If a handful of people want to start a new religious sect they need seek no larger consensus.

4.2 Pluralism

Americans have always believed that, within the law, all kinds of people should be allowed to take the initiative in all kinds of activities. And out of that pluralism has come virtually all of our creativity. Freedom is real only to the extent that there are diverse alternatives. The independent sector offers a rich variety of initiatives, goals, values and beliefs.

4.3 An Environment for Innovation

Every institution in the independent sector is not innovative; but the sector provides an environment for innovation and creativity. The sector provides a free marketplace whose attributes are in some respect not unlike those of the business marketplace. There is a continuous emergence of new ideas and initiatives. New entities can form overnight - and dissolve just as swiftly. There is freedom to try - and freedom to fail. There is in the sector something of the extravagant redundancy of nature - a thousand ideas can spring up in a single week. If 999 of them blow away before the week is over, so be it; the following week another hundred thousand will spring up. The ideas that survive the winnowing will be those that appear to serve some purpose.

In the typical bureaucracy, five new ideas a week would create a painful overload. No bureaucracy could permit a thousand ideas to spring up and if they did spring up it certainly couldn't allow most of them to blow away. To do so would imply that some official had failed - either in letting the idea spring up, or in not nurturing it after it did.

Virtually every significant social change of the past century - the abolitionists, the populists, the suffragettes, those who sought legislation against child labour, the civil rights movement, the environmentalists, mental health consumer groups - all these and many more sprang up in the nonprofit arena.

4.4 A Home for Nonmajoritarian Ideas

An idea that is controversial, unpopular or strange has little chance in either the commercial or the political marketplace. But in the loose world of the nonprofit sector it may very well find the few followers necessary to nurse it to maturity.

The sector is the natural home of nonmajoritarian impulses, movements and values. It comfortably harbours innovators, maverick movements, groups which feel that they must fight for their place in the sun, and critics of both liberal and conservative persuasion.

Institutions of the independent sector are in a position to serve as the guardian of intellectual and artistic freedom. Both the commercial and political marketplaces are subject to levelling forces that may threaten standards of excellence. In the independent sector, the fiercest champions of excellence may have their say.

4.5 Individual Initiative

The freedom from constraints, the pluralism and the constant emergence of new ideas, all provide a strong stimulus to individual initiative and responsibility. The sector preserves in the individual a sense of "the power to act." As in the for-profit sector there are innumerable opportunities for the resourceful to start something, explore, grow, cooperate, lead, make a difference. At a time in history when individuality is threatened by the impersonality of large scale social organization, the sector's emphasis on individual initiative is a priceless counterweight.

4.6 Opportunities for Participation

To deal with the ailments of our society today, individual initiatives isn't enough: there has to be some way of permitting a natural linkage between individual and community. In the independent sector, such linkages are easily forged. Citizens banding together can tackle a small neighbourhood problem or a great national issue. Obviously government provides, through the ballot, the basic constitutional instrument of participation. The enormously varied forms of participation that spring up in the independent sector are not more important - but they greatly increase the possibilities open to the individual.

4.7 An Instrument of Community

The past century has seen a more or less steady deterioration of American communities as coherent entities with the morale and binding values that hold people together. "Our sense of community has been badly battered, and every social philosopher emphasizes the need to restore it. What is at stake is the individuals sense of responsibility for something beyond the self." A spirit of concern for one's fellow is virtually impossible to sustain in a vast, impersonal featureless society. The independent sector permits the survival of mediating structures that often get squeezed out by modern large-scale organizations. Only in coherent human groupings (the neighbourhood, the family, the community) can we keep alive our shared values - and preserve the simple human awareness that we need one another. The countless organizations of the independent sector permit the expression of caring and compassion; they make possible a sense of belonging, of being heeded, of allegiance and all the other bonding impulses that have characterized humans since the prehistoric days of hunting and food gathering.

4.8 Grassroots vitality

At a time when the continued vitality of the society requires some measure of decentralization, the independent sector offers an escape from central control and central definition, an escape from clearances with a distant bureaucracy. It makes possible a significant role for relatively small grassroots structures.

4.9 The Monitoring of Government

The institutions of the sector are in a position to monitor, evaluate and criticize government. They can set standards. They can propose alternative public policies.

5. Principles of the Voluntary Sector

Each "movement" or "cause" develops a strategy to achieve "the goal" and this strategy must of necessity consider specific circumstance such as timing, available resources - both human and financial - the target for change, and the strength of opposition. But no matter what variables exists in different movements, no matter what the pace of action or the anticipated strength of the opposition there are a few basic principles which must be followed by any organization engaged in advocacy.

Time for good research could probably chronologize the ratification of these principles from the confrontations of the Old Testament through the Renaissance to the civil unrest of Eastern Europe on to the world-wide demands for non-nuclear coexistence. These principles have been tested, modified and retested for generations.

First, affective citizen action requires stamina. To have impact requires sustained effort. There is always a strong resistance to change - the status quo is a known situation - comfortably familiar. Experience has shown that a waxing and waning of enthusiasm soon saps the energy and effectiveness of any advocacy group.

Second, the movement must have a clear focus and set rigid priorities, lest it be pulled in all directions by tangential concerns. An advocacy organization can't just shout "see what we hit!", and announce, "that was the target." A cause worth getting excited about has only one or two specific goals that are true to the mission of the movement.

Third, the organization and especially the leadership of an advocacy agency must have accurate and detailed knowledge of how "the system" works. This thorough understanding is what puts a professional cutting edge on what might otherwise just be unbridled volunteer enthusiasm. When challenging or initiating legislation this means knowing the timetable of the government process. Legislation originating in the Washington office must go through an authorization process in one committee, then an appropriation process in another committee and finally an allocation process by the administration - an entirely different division of government. Following the passage of long and complicated legislation by the Parliament an even more tedious process of "writing the regulations" must be closely and carefully scrutinized less the intent of the legislation is not misinterpreted or manipulated to another viewpoint. Knowing where to pressure, who to pressure and when to pressure is the key to keeping the original goal in tact. Knowledge of the system includes knowing the structure, the personalities and the pitfalls. High-mindedness and blind emotion are not substitute for citizen skills.

Frequently for maximum effectiveness advocacy groups form coalitions and alliances. These are best seen as ad hoc arrangements for a specific purpose. With the freedom to tackle or challenge anybody and any action, and also the freedom to coordinate and cooperate and coalesce with any other group, a good organization can mobilize ten million people in one week. This can be one way of flushing out and identifying opponents at the same time that common allies are reinforced. Allies within the system or the institution which is targeted for change should not be overlooked.

Advocacy associations require visibility and they have learned that accusations and confrontations are not the most productive routes. Joining "the problem" and "the solution" as the subject of public discussion gains quantity and quality of supporters. If the general public is apathetic it must be aroused - if indignant, it must be channeled. Credibility must be ingrained in the leaders and all participants. Visibility without credibility makes for a very vulnerable position. Already available information must be researched and analyzed. Surveys and questionnaires require careful construction to acquire accurate and honest information. Use of specific facts, figures and case histories, are more persuasive than generalities. All these factors are useful to build credibility.

In addition to visibility and credibility, an advocacy organization must have accountability. Fiscal information, budgets and audited financial reports are required and must comply with Federal and State laws in order to be eligible for special tax advantages. Equally important is accurate reporting to all who are involved, the community and especially to those who provide financial support. A stable financial base is essential: causes aren't sustained and organizations don't survive by just doing good things.

Developing people power is an obvious component of good advocacy. Policy-makers look beyond angry shouts to see if there are real constituents and voters behind the noise. The more people involved the wider the web of influence.

Salaried staff must have a comprehensive understanding of social action and community organization. Staff persons can mobilize and maximize the efforts of the volunteers. Staff also provide the continuity as the volunteer leadership may change from time to time.

All the principles which have been discussed are important but endurance is the most important. Again quoting John Gardner "The first requirement for effective citizen action is stamina. The forces of social change are powerful and deeply rooted. To have any impact on them requires sustained effort. Next a group must focus to have impact."

Even with adherence to these principles a membership may become frustrated and even rebellious if the group is not organized for action: not to discuss, not to study, not to issue reports, not to spawn committees, not to pass resolutions, not to educate, not to preach and moralize. Dag Hammersjold, first secretary of the United Nations commented "In our era, the road to holiness, necessarily passes through the world of actions".

6. Voluntary Action and Mental Health

It is no accident that volunteers in the mental health movement have always included the strong voice of consumers of the services. What is known today as the National Mental Health Association was founded by Clifford Beers in 1909 as the National Committee for Mental Hygiene -the voice of the consumer. Shortly after Beers graduated from Yale University he spent three years involuntarily confined in several different mental hospitals where the conditions were deplorable and the treatment cruel and inhuman. Upon his release he wrote a moving book, A Mind that Found Itself (1981) (2). His vivid description of the way he and other patients had been treated became widely read. But he did not stop at just exposing a horrendous situation, he began to organize a vocal group of citizens who were willing to become identified with what was then (and still is for many persons), a stigmatized, frightening and unpopular disability - mental illness.

From that beginning in 1909 the consumer-citizen involvement and voice in all aspects of mental health and mental illness has had a tremendous impact on the changes that have shaped the overall system and the individual services. Through the years the various activities of citizen mental health associations have achieved noteworthy improvements at the local, state and national levels, and have provided a continuity of concern and an avenue for action for persons with mental illness. A second strong wave of citizen concern was fomented by the conscientious objectors of World War II who had been assigned to work in state mental hospitals. Their first-hand experience produced a flood of shocking exposes in the nations newspapers and magazines. The condition of America's mental hospitals and the inhuman treatment of mental patients had changed very little from the conditions suffered by Clifford Beers and described in his book 40 years before.

These men were a dedicated and determined corps who were in a position to mobilize strong support and in 1950 were able to merge the interest of several mental health advocates into what is now the National Mental Health Association. NMHA is now recognized as the health organization having the broadest base of activist lay-citizens in the country. The most significant part of that broad base has consistently been consumers. However the major concern of some consumers has not always coincided with some of the positions of the NMHA. Some of the more radical consumers calling themselves prisoners and victims of the mental health system and strongly denouncing and rejecting every kind of psychiatric treatment, formed small independent groups starting about 20 years ago. With the growth of community based mental health services more and more consumers were in a position to meet and organize another kind of organization more amenable to the appropriate and limited use of some psychotropic drugs and other modalities of treatment. In many instances consumer groups grew among the residents of half-way houses or support groups which were connected to Mental Health Associations.

Another impetus for more consumer activity came about with the organization of the National Alliance for the Mentally Ill (NAMI) about 12 years ago. This group which began primarily as support groups for the families of persons diagnosed as mentally ill has become a strong voice for improved treatment and biological research. Some consumers are included in this group but again the agendas were often divergent and the direct consumers formed groups independent of NAMI.

In the early 80's there was sufficient momentum to bring together direct consumer groups which were organized all across the country Very quickly the leadership skills among this group of direct consumers were put to good use in writing bylaws, developing goals and mission statements, forming a structure for affiliation and membership. Within one year of that first nationwide meeting the National Mental Health Consumers Association (NMHCA) was incorporated and has since held annual meetings. Today they are one of the strongest advocate organizations in the country.

Equally important with the successful lobbying efforts of the group is the advance that has been achieved in gaining meaningful and full participation in the decision-making process in many places and at many levels. The success in establishing and operating profitable small businesses is growing every month. Job placement of members in competitive employment has also increased due to the assistance in skill development as well as instruction regarding applications for work. Perhaps the initiative in training members to become mental health providers will bring more significant changes in direct service to others who are users of the service than any other of the services of the NMHCA.

Many of the strong proactive consumer groups of today started as self-help groups of former hospitalized mental patients. Not only did these contribute to the formation of the NMHCA but these groups helped set the pace and the style of most other self-help groups which have been called an American invention. Now there are hundreds of thousands of self-help groups. One writer in The New Yorker in 1990 writes "The self-help mode is entirely practical. It spawns not philosophies but practices, not theories but ways of living. Its strength is its foundation in the realities of people's lives".

The consumer movement in New Zealand has had the benefit of leadership by a very articulate consumer, Mary O'Hagan. She has also been instrumental in beginning the foundation for a worldwide consumers' organization, which has the encouragement of the World Federation for Mental Health. She wrote in Mental Health News, spring 1990:

"Mental illness workers must recognize that consumers belong to a slightly different culture to them. It's a culture that is more experiential than technical, less formal and hierarchical, founded on pain rather than success. It's a culture of people whose self-image has been shot to pieces, either by others who don't want to know us or those who try to help us but don't know how."

Cicero said "Freedom is participation in power." It is not unreasonable to believe that the participation in power that was written into the American constitution and the freedoms that were protected in the Bill of Rights laid the framework for the growth of a vital Voluntary Sector, vocal advocacy groups and valid volunteer consumer voices. The strength and the influence of these elements of American society add up to empowerment. This empowerment is much more than just a license or permit to act, indeed it is an imperative, a challenge to act. There is a real sense of relevance in being where the action is and this motivates hundreds of millions of ordinary citizens into assuming the role of a responsible citizen advocate.

The two most successful and most inspiring consumer advocates in a 200-year history are alive, "working, writing and challenging the system", today. They have encouraged millions to believe that consumer empowerment can really happen. Nader (1986) (3) (reminds us that, "A small number of citizens throughout our country's history have kept the flame of citizenship burning brightly to the benefit of millions of their less engaged neighbours, These true patriots have known that democracy comes hard and goes easy."

And again, Gardner (1980) reminded us at the time of the bicentennial in 1976, " Nations decay, only the citizens, critical and loving, can bring them back to life".

7. Future Perspectives

Although it is important not to exaggerate the worth of voluntary effort and the giving that supports it, it is also important not to underestimate how much this participation means to our opportunities to be unique and free as individuals and as a society. Through our voluntary initiative and independent institutions even more Americans worship freely, study quietly, are cared for compassionately, experiment creatively, serve effectively, advocate aggressively and contribute generously.

There is an encouraging and optimistic outlook about the vigour and activity of most segments of the Voluntary Sector. The peace movement that helped end the war in Vietnam is revived and growing as a strong voice against nuclear war throughout the world; environmentalists organizations are quite vocal regarding cleaning up toxic waste, acid rain, asbestos insulation and keeping the water, air, earth and factory livable. Most encouraging of all is the response of the population to the new direction that many health and safety agencies have taken - putting out a message of prevention and wellness promotion. Hard liquor sales are down; seat belt laws are increasing and auto fatalities are down; the diet and nutrition patters of millions have been altered due to the consistent message of heart, lung, cancer, stroke, diabetes and other health agencies. Led by the Children's Defense Fund, one of the most effective lobbying groups in the country, there has been a halt and some restoration of the funding for many programmes for poor children; the elderly are a powerful force regarding desirable and necessary health and social services; minorities have seen some progress in the hiring of blacks, hispanic and Asians on police forces, in school systems and in the marketplace. However, the minorities and the women's movement have many more battles and skirmishes before real equality is won.

Perhaps the most intractable problem in which the Voluntary Sector and the government both have enormous jobs is in combatting and treating the abuse of hard drugs including alcohol. There is growing concern and action - almost entirely in the Voluntary Sector - to prevent teenage pregnancies. We are slowly becoming aware that most of the health, mental health and mental retardation problems could be prevented if there were no premature and low birth weight babies. In the mental health arena there is grave concern that a move toward re-institutionalization is being discussed in some areas. This has been exacerbated by a growing number of homeless persons in many urban centres. However, that part of the community service systems that has been appropriately funded has proved its value and there is confidence that continuing pressure to allocate funds to build reliable and workable community support systems for mentally disabled persons will prevail.

8. References

1. Gardner J. Toward a Pluralistic but Coherent Society. University Press of America. Lanham, MD, 1980.

2. Beers C. A Mind that Found Itself. University of Pittsburgh Press, Pittsburgh, 1981.

3. Nader R. The big boys: styles of corporate power. Pantheon, New York, 1986.

National Association of Psychiatric Survivors - ''Speaking for Ourselves: Former Psychiatric Patients organizing and speaking out''

Judi Chamberlin

Member: Board of Directors
National Association of Psychiatric Survivors
Boston University, Boston, MA, U.S.A.

1. Former Psychiatric Patients Movements

Over the past twenty years, increasing numbers of former psychiatric patients have become involved in self-help and advocacy activities such as individual and systems advocacy, legislative monitoring, peer support, and the development and operation of user-run alternative services and businesses.

Certain overarching principles unite former patient organizations, including:

- Self-determination;

- Challenging (or questioning) commitment/involuntary treatment laws and practices;

- Challenging (or questioning) the medical model of mental illness;

- Protection and expansion of legal rights;

- Meeting people's needs through alternative non-psychiatric means, particularly client-run services;

- Dealing with issues around stigma and discrimination.

Because this is a grassroots movement, the particular conditions that affect people's lives become the chief issues for their groups. It has been remarkable, however, how universal these issues are despite such differences. Newsletters, slogans and campaigns often parallel almost exactly similar efforts from country to country, not because one group has copied from another, but, more usually, because people's experiences as psychiatric patients are remarkably similar.

2. Specific Issues

One issue all groups have confronted is the question of language and terminology. People use a variety of terms to describe themselves: mental patients, psychiatric inmates, clients, service users, psychiatric survivors, and mental health consumers. Although different groups use different terms, or use a variety of terms because no one term is satisfactory to all, this issue illustrates a basic principle - that people are reclaiming language to define themselves and their experiences, and that this reclaiming process is an important part of self-determination. Because the experience of being defined as mentally ill is one of the loss of self-determination, the question of language and terminology takes on particular importance.

In all countries, psychiatric survivors (the term that I prefer, and the one that is used by the US organization, the National Association of Psychiatric Survivors) confront issues of mistreatment, discrimination, poverty, paternalism, and the widespread belief that we are incapable of knowing our own best interests or in advocating for ourselves. Our first task is always the same: to reclaim the right to speak for ourselves, and to combat the internalized oppression that makes us often doubt ourselves and our perceptions. To do this we have had to invent new language and to redefine our experience.

The process of redefinition leads to a new and deeper understanding of our own experiences (what professionals may think of as "symptoms" or "the disease process"). For example, in England and Holland, conferences have been organized by and for people who experience common behavioral manifestations, such as hearing voices or engaging in self-harming behavior (which are termed "symptoms" by psychiatry), at which people have gathered to discuss the meanings that such activities have in the contexts of their lives. There is a profound difference between labelling behavior as a symptom, as psychiatrists do, thus divorcing it from the context and any possible meaning it may have to the individual, and survivors exploring that behavior in the mutually supportive environment of peers.

3. Questioning Established Practices

This exploration leads to the questioning of established psychiatric practices, as people have discovered again and again that recontextualizing and reclaiming their experience clarifies what psychiatry had obscured. Thus, the doubtfulness that many survivors feel about psychiatric diagnoses, neuroleptic drugs and the practice of involuntary commitment grows out of the realization that these practices have been damaging not just personally, but systemically. Indeed, many people who started out believing that their individual experiences were aberrational instances of mistreatment have discovered through consciousness-raising that, instead, they are routine, and that the problem is not preventing the occasional instances of "mistreatment", but in altering the fundamental power relationships that place anyone labelled a "mental patient" at the bottom, not to be believed by virtue of "mental illness".

Because of the universal existence of involuntary commitment, psychiatric patients do not have the choices that medical patients commonly have. A medical patient who finds a particular medication or treatment unhelpful or uncomfortable can simply stop using it, or can seek out another doctor, or a non-medical source of help. A psychiatric patient, on the other hand, usually stands in a different relationship to the treater than does a medical patient. Often the "patient" has not sought treatment, and does not define his/her problems as medical in nature; it is another person (often a relative or friend, sometimes the police or other agent of society) who has decided that the person's behavior is aberrant and indicates the need for psychiatric care. The power of the state can then compel the person to accept treatment, and impose various penalties for attempts to refuse.

4. Empowerment

It is essential that former patients gain an active role in determining policies and practices if the mental health system is to change in meaningful ways that are responsive to the expressed needs of the people who are receiving services.

Traditionally, mental health policy has been made by mental health professionals (primarily psychiatrists) and governmental representatives. In recent years, the number of interest groups has broadened; family members, particularly, have become influential in public policy debates, and non-psychiatric professionals have also become much more prominent. But it is still difficult for authentic "consumer" voices to be heard - those that are actually receiving services, and not those who claim to speak "for" them, or "in their best interests".

Organizing among present and former patients presents many difficulties. The constituency is largely poor, difficult to reach, and often engrossed in meeting basic survival needs. What is remarkable, given these difficulties, is how much has been accomplished.

In the US, a growing network of self- help services are run without the participation of mental health professionals, and with funding provided by the mental health system. In Europe, particularly, Britain, Holland and the Nordic countries, former patient organizations play a significant role in policy-making, and there are well-organized local and national groups.

The formation, in 1991, of both the European Client Unions' Network at an organizational meeting in Zandfoort Holland, and of the World Federation of Psychiatric Users in Mexico City, shows the determination of these organizations to develop better international communication and to make their voices heard in policy-making, service delivery, and evaluation. Both of these international groups publish newsletters and are attempting to enlarge their constituencies, which is difficult because of extremely limited funding.

However, the need for such organizations is very strong, and the determination of their membership to reach out and to make their influence felt is an indication of Just how deeply former patients want to insure mat our voices are heard and that our concerns are taken seriously.