COMMUNITY MENTAL HEALTH PRACTICE
Factors that Hinder Effective Community Health Practice
In 2003, concerns about gaps in the evidence-based practice of community mental health practice were first raised in Texas, United States (Painter, 2012). Despite the increase in the knowledge base on successful treatments of mental health conditions, public mental health systems have remained behind in applying knowledge from various research studies. According to Bond and Drake (2014), identifying factors that support the initial implementation and sustenance of evidence-based practice is an important step in ensuring the extensive availability of such practices. Beidas and Aarons (2013) claim that evidence-based treatments for adolescents with psychosocial anomalies take many years to reach the community setting. Consequently, government systems have mandated behavioral health reforms using policies and other approaches in response to the call for the implementation of evidence-based treatments.
Accessibility to community mental health services is an equally important factor. Certain groups of individuals, such as the homeless (Stickley, 2005), veterans, and military service members (Mohatt & Boeckmann, 2017) are prone to psychological disorders but have difficulty accessing treatment for their conditions.
Different factors have been implicated in hindering the use of evidence in the treatment and management of mental health cases within the community setting. Factors such as lack of funds to promote evidence-based practices, inadequate infrastructures, and deficiencies in evidence of working treatment hinder the application of EBP (Painter, 2012). This paper discusses the roles that these factors play in the usage of evidence in community mental health practice. Specifically, the roles played by politics, economy, society, and environment in the effective treatment and management of mental health cases by implementing evidence-based practice within the community will be explored.
Community-based Mental Health Teams
Community-based mental health services are a recent trend in the health care system in developed nations. Fox (2013) reports that the major trends in the area of mental health are the transition towards community-based care and deinstitutionalization, the increase in patient-based care, and the increased focus on accountability and cost-effectiveness, which have had great effects on the practice of mental health. These trends have led the way for the shift making community-based mental health services and inter-professional team-based practice. In the United States, this trend has been driven by some factors, namely, the closure of psychiatric hospitals, the transition towards deinstitutionalization, and government policies to reduce in-patient bed days, and boost cost-effectiveness (Malonne, Marriot, Newton-Howes, Simmonds, & Tyrer, 2007, cited in Fox 2013).
Interprofessional teams are a common facet of community-based mental health practice (Fox, 2013). According to Fox (2013), community mental health practice employs two types of teams: multidisciplinary and interdisciplinary. In multidisciplinary teams, healthcare professionals assume generic roles and involve in learning and performing the same tasks. It also entails the combination and collaboration of professionals of separate disciplines on different cases of mental health illnesses, although a primary provider serves a single client and provides all the essential services on the caseload. On the other hand, interdisciplinary teams involve the combination of separate disciplines into a single team, serving a particular client collaboratively to collect the medical history, assess, make prescriptions, and determine the roles and responsibilities of each team member. Unlike in multidisciplinary teams, each team member acts in his or her capacity as a specialist in the area he or she has training and certification.
Community mental health stakeholders have stressed the use of multidisciplinary teams and generic work, although a few have resisted this change. Nevertheless, some experts opine that sticking to discipline-specific roles and conventional professional boundaries does not match the new perspective in mental health care (Lloyd, King & Basett, 2002). One such expert argued that professionals “need to look at how they can achieve a balance between performing generic roles and discipline-specific skills if they wish to maintain a profile in mental health” (Lloyd et al., 2002, p. 94). Such boundaries constrain professionals, thus limiting their practice (Pattison, 2006). Such boundaries coupled with hierarchies hinder change and compromise the success of teamwork. On the contrary, generic roles as the foundation of multidisciplinary teams allow team members the flexibility of thoughts and work, such that they can adjust to changing demands with little or no training. In fact, generic work promotes the care continuum, enables the provision of high-quality services, improves the accessibility of care, and development of inter-professional teamwork (Lloyd et al., 2002). However, multidisciplinary teams have been criticized for being inefficient and leading to poor quality of care for clients besides undermining the professionalism of different team members (Fox, 2013). Therefore, more research still needs to be conducted on the best attributes of teams in providing health care.
Over the past years, mental health has transformed to ensure improved care provision. Sawyer (2008) observed that mental health practice had increased its focus on the assessment and management of risks that consumers pose. In this light, many community-based services have made risk a key concern and an organizing principle for the treatment and/or management of cases. The shift in focus is driven primarily by deinstitutionalization and the expansion of community-based care. Further, the institution of neoliberal governance in the public sector; increased demands for accountability and regulatory control through external reviews, quality assurance, and audits; and growing demand for mental health services have in part contributed to the shift in paradigm (Sawyer, 2008).
The shift to community-based care for mental health cases implies that services experience new and intensified risks in their day-to-day operations (Sawyer, 2008). To begin with, they must handle higher needs, complexity, and acute cases, aggravated by early discharges and delays of admissions due to growing demand. Second, frontline community mental health workers face hazards more than their hospital counterparts do because a majority of community services are delivered in unregulated locations, unlike psychiatric hospitals where the work environment is more regulated. Lastly, community services’ structure and infrastructures are poor compared to hospitals, compromising the effectiveness of handling high levels of complexity and needs associated with mental health services consumers.
British researchers have made considerable advances in risk management studies related to community-based welfare and health services. Kemshall (2002) suggested the possibility of a risk management approach causing a narrowing in service responses, in conjunction with a drop in service quality and flexibility reported by Culpitt (1999) and Parton (1998) in their research. Kemshall (2002) cautioned that dedication to risk management creates new exclusions and bias in service provision because clients perceived as high-risk will be prioritized over those perceived as low-risk. Many British academics criticized the risk management approach because of its potential to reshape the professional identities of frontline staff by increasing supervision by administrators; thereby, undermining professional discretion and autonomy (Sawyer, 2008).
Social/community work has unique strengths that include but are not limited to a focus on understanding the client in his or her environment and assessing his or her family structure and function, and social networks (Bland 2007, cited in Sawyer, 2008). However, the focus on risk approach that most social work services assume counters these strengths. Consistent with Sawyer’s (2008) study conclusion, stress on risk “individualize and decontextualise the client,” leading to the deskilling of social workers, because it reduces opportunities for the growth of their specialty. In addition, it greatly compromises job satisfaction leading to staff turnover.
Awareness of the availability of community services for mental health patients has a great effect on the utility of community-based mental health services. Uncertainty regarding where to go to get treatment, including for mental illnesses, has been identified in the literature as a major obstacle to seeking community-based treatment as well as hospital treatments (Buckley, Brimson, & Reyment, 2017). Consequently, health staff including mental health should communicate effectively with the public to create service awareness and mobilize them to seek treatment for their diverse illnesses. Worth noting, awareness and access to health services vary between metropolitan areas and rural areas due to the media for communicating health information. According to Buckley et al. (2017), word of mouth, medical service providers, and local print media are the commonest forms of communication about health service availability in rural areas, while the use of the internet and social media is the main source of information in metropolitan settings.
However, the rural population is increasingly embracing technology, especially the Internet and social networks that they easily access through their smartphones. Among the various groups of health services, Buckley et al. (2017) found that the public had the least knowledge of service availability. Buckley and colleagues (2017) highlighted that the availability of mental health services in Australia had become a major political issue with many calls for extra funding and services.
Aarons, Wells, and Zagursky (2009) explored the factors purported to hinder or promote the use of EBP in community mental health services. These researchers asserted the complexity of implementing EBP. They proposed that service providers use cross-system methods to expose divergent and convergent views about public mental health services. Program directors and agencies should support public mental health staff and share information with the administrator as well as policymakers regarding the effectiveness of EBP and compatibility with the needs and preferences of clients. The agency and the government also need to be forefront in facilitating clinicians to present and apply EBPs and resolve the concerns of mental health consumers in the community setting.
Aaron et al. (2009) identified 14 factors perceived as promoting or hindering the use of EBP in community health settings. These factors relate to the concerns about the strength of the EBT, the way agencies with scarce resources can bear the costs that come with adopting new therapeutic modalities, the effects on the clinical practice, and concerns of consumers about stigma and quality.
Aarons and colleagues (2009) identified the availability of resources as a key factor in the successful implementation of EBP in community-based mental health services. This aspect of public health can be underfunded and often grapples with a high rate of staff turnover of more than 25% per year. On the other hand, current evidence indicates that the correct application of EBP may reduce mental health staff turnover. In addition, mental health personnel has a restricted ability for securing resources to facilitate the implementation of EBP in the community. Notably, mental health services and social services face competing priorities of statutes that may prioritize funding for increasing costs for Medicaid and prisons over them.
In the United States, different laws and policies govern the delivery of mental health services in the community. In California, for instance, Mental Health Services Act imposes a 1% tax on $1 million annual, personal income to be set aside to fund mental health care. This demonstrates the role that politicians play in determining the delivery of mental health care including community-based ones. However, the uncertainty of future allocations to the sector discourages agency executive directors and administrators from investing in EBP in community mental health programs.
The sustainability of community-based mental health services is equally important, as it ensures the continued availability of the services and the welfare of the community served. Bond, Drake, McHugo, Peterson, Jones, and Williams (2014) examined the rates of sustainability and associated factors 6 years following the implementation of 5 EBP in 49 locations in the National Implementation Evidence-Based Practices Project. From the survey of states, 47% of the locations sustained the EBP for 6 years, 37% discontinued the practice together, and 16% restarted it. Agency leaders from the failed sites attributed the failure to insufficient funding, lack of prioritization, and staff-based issues. In relation to these barriers, the researchers proposed sufficient funding, continuing supervision, and monitoring for fidelity and results as possible promoters of the sustainability of EBP in community mental health services.
Different groups of people exist in every community. These groups have a different prevalence of mental health illnesses. Homeless people top the list of groups with the most prevalent mental sickness. According to Stickley et al. (2005), the majority of homeless people have mental health conditions. Homelessness aggravates the experience of psychosis. Being homeless is a stressful condition characterized by physical discomfort, exposure to cold weather, isolation from people, loss of purpose, family, income, inadequate access to health services, oppression, discrimination, stigmatization, and victimization, among others. Because of such experiences, the mental states of homeless people are prone to deteriorate to the extent of breaking down. A homeless person may become distrustful of others and assume the role of learned helplessness.
The other group of people with high mental health prevalence is veterans and military service men and women. Many factors including persistent stigma, lack of an understanding of mental health, and pessimistic attitudes about treatment are the main obstacles to access to mental health services within the community setting (Mohatt & Boeckmann, 2017). As a result, very many cases of untreated mental health illnesses are found within the group. Such high rates of untreated cases of mental illness among veterans and service members render developing appropriate programs for minimizing obstacles to community-based mental health services a national priority.
Mohatt et al. (2017) point out that more veterans and military officers seek help from community members including clergy, and primary care physicians than from mental health professionals. Consequently, identifying effective interventions to increase this population from accessing effective mental health services has the potential to have significant public health effects. Education programs can help resolve barriers to accessing mental health services for community-dwelling veterans and servicemen. These barriers include stigma, knowledge deficiency about mental health services in the community, pessimistic attitudes towards mental health services, and a strong inclination towards self-reliance.
A country’s economic status affects the way community-based mental health services to their clients. A major event in the economy such as a recession can have a significant effect on the efficiency of such facilities and programs. Sweeney and Knudsen (2014) studied the effect of the 2007-2009 recession on mental health organizations in Ohio and the adaptive strategies they use to mitigate its effects. This study provides an understanding of the role economy plays in community-based mental health services. At the beginning of the economic downturn, the tax bases of many states began to deplete thereby reducing budgetary allocations to all the ministries, including the Ministry of Health. Specifically, the government reduced subsidies for mental health services in the public sector against the increasing demand for mental health services associated with the recession (Abramson 2009; Hodgkin & Karpman, 2010 cited in Sweeney et al., 2014). Consequently, community-based mental health facilities were faced with the task of balancing the budget to accommodate reductions in revenue and increasing demand for mental health services. This reaction complies with the assumption in environmental uncertainty theory.
According to the environmental uncertainty theory, the external environment of an organization consists of economic, demographic, regulatory, and technological. Instability in any of the parts can disrupt operations and usually need a strategic approach to offset the consequences (Bourgeois, 1985 cited in Sweeney et al., 2014).
The effects of the downturn economy threaten the integrity of community-based mental health facilities. When a country economically performs poorly, it means that the rate of unemployment rises. This situation increases the risks of mental illnesses leading to increased demands for mental health care in the community.
The economic effects of a community-based facility differ based on its location. Sweeney et al. (2014) observed that rural-based community mental health has fewer resources than those based in urban centers. As a result, resource scarcity incapacitates such community-based mental health facilities making them unable to provide treatment to clients with lower service needs. Consequently, an economic downturn makes the caseloads of rural-community-based mental health services change noticeable, while urban-based community mental health services would not be noticeable.
Deinstitutionalization has significantly impacted not only the mental health system but also the consumers, the agency as well as the providers (Kliewer, McNally, & Trippany, n.d.). Because of deinstitutionalization, severe cases of mental illnesses have been exposed to a new challenge of living in a community setting that is usually hard to solve. This situation has a significant effect on how the agencies must respond to such consumers of this care, which translates to the increased complexity of their work.
Initially, state-operated psychiatric hospitals have been the major component in the treatment of people with serious and persistent psychosis, where such cases were kept in asylums, away from a community setting. This approach was necessary because of various reasons: i) the view of the public about psychotic individuals, ii) the idea that the mentally ill can only be helped in enclosed settings, and iii) scarce resources at the community level (Patrick, Smith, Schleifer, Morris, & McClennon, 2006).
To address the institutionalization of people with severe mental illnesses, the former President of the United States, Kennedy, passed the Community Mental Health Centers Act (CMHCA) in 1963. The new statute restructured the mental health services provision, as well as the providers of these services. Treatment was no longer restricted to professionals and a range of non-medical professionals could provide treatment for mental illnesses (Kliewer et al., n.d.). Deinstitutionalization of Mental health care was inspired by the discovery of the first antipsychotic drug in 1954.
However, deinstitutionalization of mental health services has its drawbacks, which outweigh its benefits. According to Kelly and McKenna (2004 cited in Kliewer et al., n.d.), the community fears people with mental disorders, regarding them as dangerous. Such views cause rejection, victimization, stigmatization, as well as harassment of people with severe mental illnesses. Such treatment of severely mentally ill persons makes them prone to self-harm because of a lack of support. Moreover, deinstitutionalization has led to increased homelessness because the severely mentally individuals find refuge in the street once they are discharged from institutions.
Many factors affect the effectiveness of community-based mental health services. Evidence-based practice has been proposed as the best approach to ensure the effective delivery of mental health care at the community level. However, community-based mental health centers have challenges implementing and sustaining EBP. In addition, politics and the economy shape the delivery of mental health care in community settings. The 1963 CMHCA caused the largest impact on the mental health service due to the deinstitutionalization of the previously institutionalized severe mental health cases. Similarly, the economy of a state or country means that less resource availability to treat mental health cases, leading to high caseloads in community mental health centers. The local, state and the federal government should adequately fund community-based mental health services to allow them to handle the increasing number of mental cases. Also, extensive education should be conducted throughout the community to increase awareness of the available mental health services in the community. The CMHCA should be amended to institutionalize severe cases of mental illnesses.
Aarons, G. A., Wells, R. S., & Zagursky, K. (2009). Implementing evidence-based practice in community mental health agencies: A multiple stakeholder analysis. American Journal of Public Health, 99 (11), 2087-2096.
Beidas, R. S., & Aarons, G. (2013). Policy to implementation: Evidence-based practice community mental health – study protocol. Implementation Science, 1-9.
Bond, G. R., Drake, R. E., McHugo, G. J., Jones, A. M., & Williams, J. (2014). Long-term sustainability of evidence-based practices in the community mental health agencies. Adm Policy Ment Health, 228-236.
Buckley, D., Brimson, S., & Reyment, J. (2017). Community awareness of the availability of health services and information-seeking practices across a large health service district in rural Australia. International Journal of Healthcare Management, 10 (1), 66-54.
Culpitt, I. (1999). Social policy and risk. London: Sage.
Fox, V. (2013). Professional roles in community mental health practice: Generalist versus specialist. Occupational Therapy in Mental Health, 29, 3-9.
Kemshall, H. (2002). Risk, social policy and welfare. Buckingham: Open University Press.
Lloyd, C., King, R., & McKenna, K. (2004). Generic versus specialist clinical work roles of occupational therapists and social workers. Australian and New Zealand Journal of Psychiatry, 38, 119–124.
Malone, D., Marriott, S., Newton-Howes, G., Simmonds S., & Tyrer, P. (2007).
Community mental health teams (CMHTs) for people with severe mental
illnesses and disordered personality. Cochrane Database of Systematic Reviews,
Mohatt, N. V., Boeckmann, R., Winkel, N., & Mohatt, D. F. (2017). Military mental health first aid: Development and preliminary efficacy of a community training. Military Medicine, 1576-1583.
Painter, K. (2012). Evidence-based practices in community mental health: Outcome evaluation. The Journal of Behavioral Health Services & Research, 39 (4), 434-442.
Pattison, M. (2006). OT-Outstanding talent: An entrepreneurial approach to practice. Australian Occupational Therapy Journal, 53, 166–172.
Sawyer, A.-M. (2008). Risk and new exclusions in community mental health practice. Australian Social Work, 61 (4), 327-341.
Stickley, T., Hitchcock, R., & Bertram, G. (2005). Social inclusion or social exclusion? Homeless and mental health. Mental Health Practice, 8 (9), 26-30.
Sweeney, H. A., & Knudsen, K. (2014). The impact of the Great Recession on community-based mental health organizations: An analysis of top managers’ perceptions of the economic downturn’s effects and adaptive strategies used to manage the consequences in Ohio. Community Mental Health Journal, 50, 258-269.