Enriching our understanding of vulnerability through the experiences and perspectives of individuals living with mental illness

ABSTRACT

Vulnerability is a central concept in research ethics and typically serves to identify individuals or groups whose participation in research prompts specific concerns or warrants special consideration. While theoretical discussions on vulnerability have contributed valuable insights to discussions of mental health research and care, they have not been enriched thus far by stakeholder perspectives. This oversight has important consequences for the ways in which we frame vulnerability. It misses the far-reaching insights and experiential knowledge of mental health research participants whose experiences this ethics concept ultimately seeks to capture. In view of this gap, our study combines a pragmatist ethics framework and interpretive phenomenological analysis of qualitative interviews to explore user perspectives on the notion of vulnerability through the lived experiences of mental health research participants and patient-advocates. Importantly, these perspectives offer essential clues to address the difficulties of operationalizing concerns for vulnerability in concrete and practical ways. They help refine our understanding of this key ethics concept.     

Assisted Living Facility Administrator and Direct Care Staff Views of Resident Mental Health Concerns and Staff Training Needs

This community needs assessment surveyed 21 administrators and 75 direct care staff at 9 larger and 12 smaller assisted living facilities (ALFs) regarding perceptions of resident mental health concerns, direct care staff capacity to work with residents with mental illness, and direct care staff training needs. Group differences in these perceptions were also examined. Both administrators and directcare staff indicated that direct care staff would benefit from mental health-related training, and direct care staff perceived themselves as being more comfortable working with residents with mental illness than administrators perceived them to be. Implications for gerontological social work are discussed.     

Positive Connections: a programme for children who have a parent with a mental illness

Mental health professionals working with parents who suffer from a mental illness often overlook the children within the family. Children whose parents are mentally ill face numerous obstacles to their own emotional development and these children are at higher risk for developing mental illnesses than other children. These risks can be decreased if protective or positive interventions are available for the children. This article will describe the development and implementation of Positive Connections, an effective intervention programme specifically designed for children whose parents have been diagnosed with a mental disorder. The effectiveness of this programme has been evaluated using both qualitative and quantitative research strategies, and the results are presented.     

Experiencing breast cancer in the context of mental illness in New Zealand

ABSTRACT

This study aimed to explore the experiences of women with mental illness who had also experienced breast cancer diagnosis and treatment, in particular, to identify barriers and facilitators to cancer treatment. Semi-structured interviews were conducted with ten breast cancer survivors who had had contact with secondary mental health services prior to their cancer diagnosis. Thematic analysis was used to identify key themes. Participants described positive experiences of cancer treatment, expressing surprise at both how well they coped with diagnosis and treatment and how well they were treated by services. Many contrasted this with their less positive experience of mental illness and mental health services. The women interviewed were active participants in their cancer treatment and did not report feeling stigmatised because of their mental health experiences. A lack of connection between cancer and mental health services was described, but this was not regarded as necessarily a bad thing. This study begins to counter the stereotypes of the difficult patient or the person unable to understand and cooperate in their own care which are prevalent in the literature. Further work is needed to understand the reasons for disparities in cancer outcomes.     

Mental Health Service Utilization Among Frail,Low-Income Elders

Abstract

This study was conducted to determine the extent to which service providers in a community-based care program accurately identified and referred elders with symptoms of depression. Interviews were conducted with 79 frail, low-income elders, with the CES-D used to gauge depressive symptomatology. Reviews of their case files were then conducted to determine first, the extent to which case managers recognized depressive symptoms and second, the extent to which respondents who screened with significant symptoms were referred for mental health services. Results suggest an imperfect association between CES-D scores and case managers' perceptions and referrals. Less than 1/3 (31%) of those who screened for depression received counseling.     

Schizophrenia: The Impact of Parental Illness on Children

This research sets out to discover what impact parental schizophreniamakes on a child’s life. It focuses on the daily lifeand experiences of children. Their health, education, familyand leisure activities are examined. Contact with helping agenciesand their unmet needs are investigated. The sample was drawnfrom the children of patients attending the mental health servicesin South West Dublin. They were matched with a control groupof children of well parents. The majority of children who haveone parent with schizophrenia had similar profiles to the childrenof well parents in the areas of physical health, positive familyfeelings, friendships, hobbies and household tasks. In a numberof other areas, however, differences were found. Sample childrenhad more psychiatric disturbance, more problems associated withschool, less contact with relatives and spent more time at home.The children had little access to services and were upset byhospital visiting. The need for an educational programme andsupport for these children was demonstrated. It is recommendedthat a more co-ordinated approach is required by both adultand child mental health services in order to meet their needs.     

‘Not a good person’: family stigma of mental illness from the perspectives of young siblings

The purpose of this paper is to critically examine family stigma as one form of the stigma of mental illness in child and youth mental health. Presented are the outcomes of a thematic content analysis of in‐depth, semi‐structured interviews conducted with seven (n = 7) young siblings, ages 13 to 21 years old, with a brother or sister identified as having a mental‐health issue. The focus of the interviews was on the ways the siblings experienced their other sibling's mental health and how those experiences shaped their sense of self and family. From the analysis, young siblings had predominately negative experiences, struggled with making sense of their brother or sister and the family as ‘flawed’ against the mental illness as ‘bad’ and experienced considerable family stress and overt family stigma. Current practice theories fail to consider the complexity of these factors and, in doing so, fail to adequately explain the nature and extent to which stigmatization occurs for immediate family members. The importance of peer support and understanding stigma in social work practice with children and their families is discussed.     

Racial Differences in Attitudes Toward Professional Mental Health Treatment: The Mediating Effect of Stigma

Stigma associated with mental illness continues to be a pervasive barrier to mental health treatment, leading to negative attitudes about treatment and deterring appropriate care seeking. Empirical research suggests that the stigma of mental illness may exert an adverse influence on attitudes toward mental health treatment and service utilization patterns by individuals with a mental illness, particularly African Americans. However, little research has examined the impact of stigma on racial differences in attitudes toward seeking mental health treatment. This study examined the hypothesis that stigma partially mediates the relationship between race and attitudes towards mental health treatment in a community-based sample of 101 African American and White older adults. Multiple regression analyses and classic path analysis was utilized to test the partial mediation model. Controlling for socio-demographic factors, African American older adults were more likely to have negative attitudes toward mental health treatment, and they also reported more public and internalized stigma than their White counterparts. As hypothesized, the relationship between race and attitudes toward mental health treatment was partially mediated by internalized stigma, suggesting that internalized stigma may cause older adults to develop negative attitudes about mental health treatment. The partial mediation model was not significant for public stigma, however. Implications for social work research and practice are discussed.     

Exploring perceptions of mental health clients and professionals about Buddhism‐based therapies at mental health hospitals in Vietnam

With 80% of Vietnamese people holding key Buddhist beliefs, Buddhism has great impact on the thoughts, emotions, and behavior of Vietnamese people. However, almost no Buddhism‐based psychosocial interventions are offered at formal psychiatric hospitals across Vietnam, nor is there any plan to incorporate these interventions into mental health care. This exploratory study examines the perceptions of mental health clients and staff regarding the effectiveness of Buddhism‐based therapies (BBTs) in mental health treatment in Vietnam, using ethnographic observation and in‐depth interviews with 24 patients and eight professionals at the only psychiatric hospital employing BBT. Participants strongly believed in the positive impact of BBT to help clients manage or improve their symptoms. However, clients and staff advised that BBT should not be used alone; rather it should be used in combination with medication and was best employed for stress‐related disorders. They unanimously supported incorporating BBT into the formal mental health system, especially if the therapies were well developed through collaboration between Buddhist monastics and mental health professionals. Results of the paper suggest that Vietnam should think strategically about developing and incorporating BBT into the formal mental health care system.     

Are the Homeless Mentally Ill?

In Australia, it is widely believed that most homeless people have mental health issues and that mental illness is a primary cause of homelessness. This paper uses information from a study of 4,291 homeless people in Melbourne to investigate these propositions. The research found that 15 per cent of the homeless had mental health issues prior to becoming homeless. This challenges the community perception that mental illness is the primary cause of homelessness. The research also found that 16 per cent of the sample developed mental health issues after becoming homeless. Homelessness causes mental health issues for some people, particularly anxiety and depression. The claim that most homeless people are mentally ill sends the wrong message to policy makers about the services that are needed to assist homeless people.     

Support for and From Aging Mothers Whose Adult Daughters are Seriously Mentally Ill

This article discusses, from the grandmother’s perspective, the ways in which support is exchanged in families coping with serious mental illness. A strengths perspective was utilized to identify ways in which family members help each other. Employing a qualitative approach, this study focuses on interviews obtained from a sample of 22 aging mothers, aged 52–90, who are in contact with their daughters who have a mental illness. Grandmothers provided several kinds of support to their mentally ill adult daughters and to their grandchildren, who also supported the aging mother in numerous ways. As social workers seek to assist individuals with mental illness, it is important to assess the existing strengths of their intergenerational family context.     

International Perspectives on the Use of Community Treatment Orders: Implications for Mental Health Social Workers

Substantial changes to mental health law and policy have occurredthroughout the Western world during the last decade. The drifttowards control, particularly in the form of Community TreatmentOrders (CTOs), has profound implications for the role of mentalhealth social workers, yet this issue is rarely discussed inacademic literature. This paper seeks to redress this gap inknowledge by examining aspects of law, policy and practice usingthree case studies: Victoria, Australia; Ontario, Canada; andregions of the UK. The paper begins by critically reviewingselected literature on CTOs, revealing competing claims aboutefficacy and their impact upon service users¹ and practitioners.A discussion of policy and practice contexts in the three jurisdictionsis then presented and supported with a typology, to illustratecontrasts and comparisons. In their conclusions, the authorsassert that mental health social workers often have a crucialpart to play in the implementation of CTOs but that this isnot always acknowledged in law and organizational policy. Socialworkers’ roles and responsibilities need to be more explicitlyidentified in mental health law. At the same time, there shouldbe a continuing debate about how such coercive powers fit withcodes of ethics and practice standards, at national and internationallevels.     

A critical review of mental health and mental health‐related policies in China: More actions required

In China, there are over 170 million people suffering from mental illness. However, there is a lack of a critical review of the policies governing the provision of mental health services. Drawing on the framework of mental health policy developed by the WHO, this article critically examines mental health policies regarding legislation, financing, model of care and delivery, as well as manpower and the training of mental health professionals in China. This analysis raises a number of policy‐related questions concerning the lack of community‐based psychiatric services, inadequate coverage of mental health services in the rural areas, poor standard of education and an insufficient number of trained mental health professionals, and insufficient protection of the human rights of people with mental illness. The article ends by urging the various levels of governments to make a firm commitment to improve mental health care for people with mental illness in China.     

Differences by Race in Social Work Students’ Social Distancing,Treatment Options,and Perceptions of Causes of Mental Illness

ABSTRACT

Research has shown that racial and cultural differences are related to the degree of social distancing associated with mental illness, beliefs about what causes mental illness, and what treatment options are best; however, there is little information on how this may manifest in social workers’ perceptions of these issues. This cross-sectional survey analyzed the differences in perceptions by race of 835 students enrolled in social work classes in the United States. Results indicated that individuals who self-identify as African American/Black expressed the greatest social distance concerning mental illness. Whites were most likely to endorse the use of medication and were least likely to normalize mental illness. The most frequently endorsed mental health provider varied according to racial/ethnic groups. Our findings show that future research may be needed to further investigate the conceptualization of the role of social work among different groups. The need for self-reflection and keeping biases in check are discussed as implications for social work practice and education. Suggestions for working with diverse clients, including religious diversity, are offered as well.     

Connecting and engaging with health and social care: Exploring the core components of a telephone and web-mediated family navigation prevention service

Early engagement with health care, mental health care, and social services can promote the well-being of children and families. How practitioners can best support family engagement with these services however remains largely unknown. To address this gap in knowledge, data from a voluntary 12-week telephone and web-mediated family navigation preventive intervention called Navigate Your Way were subject to mixed-methods analysis. Twenty-nine caregivers and five family navigators contributed data to the study. Thematic analysis of weekly navigator check-ins, participant closing interviews, navigator discharge notes, and lab meeting notes was conducted and followed by quantitative analysis of navigator effort across project activities. Results were then mixed to illuminate the essential conditions for supporting family connection to health care, mental health care, and social services. Qualitative analysis identified themes related to empathic engagement and person-centred navigation as central to connecting families to needed services. Quantitative analysis of navigator effort identified participant outreach, weekly check-ins, service identification, and ongoing supervision as essential navigation activities. Together, providing an environment that is supportive, consistent, flexible, person-centred and tailored to families' specific needs are important for connecting to health and social care.     

Powerful Youth: Determining Successful Participation in an HIV Support Group for Youth

In this article, the authors report on a qualitative study that explored the use of narrative therapy with a diverse group of older adults dealing with mental health and substance misuse issues. Narrative therapy supports individuals to critically assess their lives and develop alternative and empowering life stories that aim to keep the problem in its place. Although the literature suggests this is a promising intervention for individuals, there is a lack of research on narrative therapy and group work. Aiming to address this gap, the authors developed and researched a narrative therapy group for older adults coping with mental health and substance misuse issues in Toronto, Canada. Taking an ethnographic approach, field notes and interviews provided rich data on how, when, and for whom, such a group could be beneficial. Findings contribute to the literature on group work, older adults, and narrative therapy.     

Does vegetation matter for the criminal behavior among people with serious mental illness?

This study attempts to examine the effect of vegetation on arrests of offenders with and without serious mental illness (SMI). Data from the MacArthur mental health court study were analyzed. Objective arrest data were obtained 12–18 months pre‐ and post‐court involvement between 2005 and 2007. Vegetation data were captured by the normalized difference vegetation index, which can be regarded as a general measure of “vegetation” and linked with GeoID, obtained from the American Community Survey. We analyzed data of sociodemographic factors (e.g., age, gender), crime‐related factors (e.g., age of first arrest), and vegetation in related to the crime on 652 offenders with mental illness. Multilevel negative binomial regression revealed no significant effect of vegetation on arrests among offenders without SMI; however, for those with SMI, a significant variation in vegetation on arrests was found among all study models. Our findings suggest that vegetation is significantly associated with arrests, with a positive effect on reducing the recidivism only among offenders with SMI. Given that practice and policy almost exclusively focus on individual factors of crimes, it is important to have more considerations about how neighborhood factors affect criminal behavior, depending on SMI in order to have more comprehensive methods of crime prevention.     

Integrating Mental Health Parity for Homebound Older Adults Under the Medicare Home Health Care Benefit

Despite high rates of mental illness, very few homebound older adults receive treatment. Comorbid mental illness exacerbates physical health conditions, reduces treatment adherence, and increases dependency and medical costs. Although effective treatments exist, many home health agencies lack capacity to effectively detect and treat mental illness. This article critically analyzes barriers within the Medicare home health benefit that impede access to mental health treatment. Policy, practice, and research recommendations are made to integrate mental health parity in home health care. In particular, creative use of medical social work can improve detection and treatment of mental illness for homebound older adults.     

Collective citizenship: From citizenship and mental health to citizenship and solidarity

Although the concept of citizenship is a widely used theoretical framework within political philosophy, its use in the field of mental health remains underexplored. Within this context, citizenship emphasises the social inclusion and participation of people who are marginalized and offers a more social and relational view of services and support for people with mental health problems than has been common in mental health systems of care. At the same time, however, the citizenship approach has operated in the context of systems of care in the United States that favour highly individualized conceptions of, and approaches to, care, and these systems of care operate in the social and political context of highly individualized concepts of the citizen. In this article building on the work of other citizenship scholars, we argue that a collective form of citizenship, grounded in the 5Rs framework, holds the individual and collective in creative tension. Furthermore, the paper applies this model to the domain of mental health, where people are treated in individualistic ways and experience marginalisation, making the collective dimension imperative and promoting participation, empowerment and the contribution for social change to people with mental health problems. Our theoretical framework of collective citizenship, while geared toward the needs of persons with mental health problems, also contributes to recent citizenship theory on the inclusion of marginalized, stigmatised, and excluded groups. We illustrate the application of this approach through an ethnographic-participant observation case study of a collective citizenship group with which we are associated.     

Adult children of parents with mental illness: Family stigma and coping on sense of self

Family stigma is associated with persistent negative outcomes among adult children of parents with mental illness (ACOPMI). Loss of sense of self has been reported by ACOPMI; however, the role of family stigma on sense of self remains unclear. Additionally, research suggests coping behaviour (i.e. adaptive or maladaptive) influences the effect of stigmatization on sense of self. This study investigated the impact of family stigma and coping on sense of self among ACOPMI (N = 134, 63.4% female). As hypothesized, high family stigma was associated with weak sense of self (p < 0.001), and ACOPMI who endorsed adaptive coping demonstrated higher sense of self than those who coped maladaptively (p < 0.001). Further, coping moderated the relationship between family stigma and sense of self (p < 0.001). Unexpectedly, this relationship was only significant for ACOPMI with adaptive coping skills (p < 0.001). At higher levels of stigmatization, post hoc analysis revealed coping styles did not exert an influence on sense of self. Results suggest family stigma contributes to loss of sense of self among ACOPMI, with adaptive coping being protective only at lower levels of family stigma. Findings highlight the need for a systemic approach to eradicate family stigma.