That any sane nation, having observed that you could provide for the supply of bread by giving bakers a pecuniary interest in baking for you, should go on to give a surgeon a pecuniary interest in cutting of your leg, is enough to make one despair of political humanity. George Bernard Shaw, The Doctor's Dilemma
 
 

By permitting chronic patients to live on the streets, clothed in tattered rags, scavenging through trash for sustenance, and sleeping over street grates for warmth, have we not allowed the concept of least restrictive environment to reach its surrealistic endpoint?" Frank R. Lipton, 1993.
 
 

This course will cover the various mental health services and programs for adults, children, and youth. It will discuss the roles that social workers perform in promotion, prevention, treatment and rehabilitation services to persons with mental illness, developmental disabilities and substance abuse problems. Contemporary policy issues in mental health services, particularly as they relate to larger political and social trends will be discussed. Legislation, ethical issues, stakeholder controversies and social movements affecting services to persons with mental illness will also be discussed. The historical context of services marred as they were by social control measures and stigmatizing practices will be assessed. The impact of race, gender, ethnicity, sexual orientation, and social class on mental health policies and services will be examined. The course will also examine the potential and actual role of various self-help, mutual aid, and natural/informal helping systems.
 
 

Course Content

The process and politics of mental health policy making and program development will be examined from the perspective of historical, contemporary, and future models of the mental health system. Alternative approaches to defining mental health and mental illness, developmental and other disabilities, and substance related disorders will be studied. Epidemiological findings related to the incidence and prevalence of disorders and the utilization of mental health services will be examined. Local, state, and national models of mental health programs including self-help and advocacy programs will be reviewed. These programs will represent a range of approaches to promotion, prevention, treatment, and rehabilitation services, along with a range of financing, and service delivery mechanisms. Individual rights, especially as they relate to involuntary treatment and professional conduct will be discussed.
 
 

Attention will be given to persons with mental illness, developmental disabilities, learning disabilities, and substance abuse disorders—or combinations of these conditions—with a special focus on individuals with severe and persistent mental conditions. US mental health policy will be examined as it is enacted in programs and services, social entitlements, financing arrangements, and organizational missions. Associated ethical and value dilemmas will be examined within an American as well as comparative historical and cultural context. The major focus of the course will be on public policies and services, with simultaneous examination of the relationships among the increasingly overlapping public, non-profit and for-profit sectors. Special consideration will be given to how the contemporary mental health system is experienced by economically disadvantaged persons, women, gay male, lesbian, bisexual and transgendered (LGBT) persons, and persons of color.
 
 

Mental health policy can be defined in a number of ways. A definition that is especially relevant to practitioners refers to policy as a course of action or trend that finds expression in goals, objectives, programs and services. This definition emphasizes implemented policy, that which actually takes place in the provision of services. Policies do not have to be, and often are not, recorded in written documents. This definition turns on whether a discernible course of action or a recurring pattern exists rather than whether there is written documentation. This definition also helps us understand that written "policy" documents are not policy if they do not influence the course of action. (Perhaps you can think of a policy in an agency you are familiar with that is not recorded, e.g. preference for cost saving measures. Or a "policy" document that is not, e.g., paper work requirements are ignored to provide more services.

on notes to 636agenda1.ppt notes 1) No axis 2 diagnoses since they disqualify managed care. Likewise for ADHD at least in some places must have oppositional and defiant disorder

Troublesome residents are overmedicated

2) Thurs and F riday for field instruction-announced but not implemented

Preferential option for poor

Referrals available to a wide network of services

Right to 2nd opinion or change of providers

3) Practitioner mediation of benefits

Practitioner’s interpretation of rule that new intake be completed for each new admission.

Authorization of larger number of outpatient sessions based on utilization reviewer’s trust of provider
 
 
 
 

Policy results from a number of influences. There are broad cultural, economic and political influences (e.g., the strong present economy). More specifically, policy is influenced by laws, court decisions, managed care strategies, service bureaucracy directives, Medicaid and Medicare policies, employee benefit programs, funding formulas, insurance regulations, agency organizational structures and so on. These "big picture" influences are shaped or mediated by local circumstances and practices. Indeed, big picture influences are sometimes substantially altered or even reversed at the local implementation level (e.g., practitioner management of benefits, cutting of red tape). Local actions may also instigate "big picture" changes via feedback loops between system levels (e.g. in highlighting risk exposure).

Implemented policy is influenced by such factors as the information, skills, connections and commitments of the practitioner. These more local and immediate factors moderate--for good or ill--the way the big picture influences become operational in practice. Thus an important focus of the course will be on how the implementing practitioner makes policy through her interpretations of directives and through discretionary actions. It is further assumed that as practitioner discretionary actions become patterned, policy is made. Some of these practitioner generated policies may draw inspiration from the advocacy efforts of consumers and family members. Some of their concerns include relieving distressing symptoms, improving social functioning, addressing joblessness and homelessness, combating stigma, and overcoming oppressive aspects of the service systems outwardly designed to serve them.

Policy effectiveness, measured in terms of the quality of services delivered and the generation of positive client or customer outcomes for multicultural populations, is an important focus of the course. Policies, or programs and services, will be evaluated in terms of their: a) meeting a demonstrable need and demand, b) use by intended populations, c) adequacy, d) accessibility e) satisfaction ratings, f) quality, g) effectiveness, h) risk, i) restrictiveness, j) cost and k) level of community support. These criteria should be considered from the point of view of the various stakeholders and actors in the client system, e.g. customer, family, direct care staff, professional groups, local officials, state mental health agency, etc. They should also be considered from the perspective of multicultural groups and ethnic/minority persons which include: seniors, women, poor or low income persons, LGBT persons, members of oppressed ethnic groups, or persons with disabilities. As a separate issue, we will consider the politics and propriety of referring to people who have contact with the system as consumers, survivors, customers, self-identified persons with an illness, clients or patients.

Particular attention will be given to community-based services for people with serious mental illness. These services can be grouped as follows: 1)"case" management (a term for which no agreed upon substitute has emerged despite its dehumanizing connotations) and assertive community treatment (ACT) programs; 2) psychosocial rehabilitation programs including Fountain House, Trailblazer and Full Circle community programs with special emphasis on the most promising of their supported education and employment components; 3) supported housing programs including Fairweather Lodges, adult foster care homes, supported apartments, and nursing homes; 4) consumer-provider programs including JIMHO and other peer counseling and consumer advocacy and drop-in programs, and 5) Self-help, mutual aid and support programs including Recovery Inc., Manic-Depressive and Depressive Association, Schizophrenics Anonymous, National Empowerment Center affiliates, National Mental Health Consumers Association, and numerous other non-mental-health-specialty--but potentially relevant--groups such as Alcoholics Anonymous, Compassionate Friends, Overeaters Anonymous, Adult Children of Alcoholics (and Al-Anon) groups.
 
 

Know that many personal troubles cannot be solved merely as troubles, but must be understood in terms of public issues — and in terms of the problems of history-making. Know that the human meaning of public issues must be revealed by relating them to personal troubles — and to the problems of individual life. C. Wright Mills. The Sociological Imagination. New York: Oxford, 1959, p. 226.

Counterpoint: Know that not all personal troubles (e.g., a child’s death from cancer) have an immediate cause or solution in the public sector. Know too that sometimes agencies set up to "address" problems such as housing, may actually insulate the community from the problem and discourage potentially helpful individuals and family members from taking responsibility? Similar views have given rise to more personalistic approaches such as those espoused by the Catholic Worker. TJP
 
 

Course Objectives

l. Demonstrate knowledge of the historical context of mental health policies and services, and apply this knowledge in making a critical analysis of existing and proposed mental health systems.

2. Identify the social work practitioner’s role in mental health policies and services in relation to:

a) initiating and modifying policy and programs through their service providing activities and other professional activities, e.g. advocacy, public education, service coordination.

3. Explain how public health concepts and epidemiological data are used in developing and changing policies and monitoring mental health programs.

4. Identify and analyze the effects of oppression, discrimination, stigma and other negative social influences on consumers of mental health services.

5. Analyze current mental health policies, legal issues, delivery systems, service settings, target populations, service approaches, in relation to contemporary social work practice in mental health.

6. Use knowledge about the etiology of mental illness and other disabilities and the effects of labeling to design prevention and promotion programs for the prevention of illness and promotion of health.
 
 

Relationship to Curricular Themes

1. Multicultural Issues

Multicultural issues are presented in relation to the various definitions of mental health, mental illness, disabilities, and substance related disorders. Data from epidemiological studies are examined in order to focus on racial/ethnic/cultural groups and other populations at risk in regard to (a) incidence and prevalence rates; (b) acceptability, access, availability, and utilization of services.
 
 

2. Social Change and Social Justice

The study of the mental health service delivery system provides students opportunity for assessment of the system in terms of injustice and the effects of stigma and discrimination or those with psychiatric labels to populations at risk. The objectives of social change and social justice are explored in relation to legal issues and individual rights that pertain to mental health policy making and program development.

3. Promotion and Prevention

An examination of the community mental health movement allows for an emphasis on promotion of mental health and prevention of mental illness and disabilities is explored in the context of research on risk and protective factors related to mental health prevention programs and how the knowledge can be translated into effective interventions.

4. Social Science

Social and behavioral science conceptual frameworks and empirical findings are presented throughout the course on such topics as: epidemiology of disorders and disabilities; causes of illness and disability; program evaluations on the effectiveness of community-based mental health programs; financing of mental health services; and services to women, ethnic minorities, and economically disadvantaged populations.

Schedule
 
 

1-11	Overview: Description, Objectives and Assignments. Implemented policy as distinguished from declared policy. Psychosocial clubhouse programs  AMI of Washtenaw County Mtgs, Information, AMI Office 734-994-6611 Jan 11 Landing the Right Job, 7:30 St Clare’s Episcopal Church/Temple Beth Emeth, 2309 Packard, Ann Arbor Jan 13 7pm AMI Public Education Committee (All welcome) NEW Center, 1100 N. Main St, Ann Arbor
1-18	Martin Luther King Day  Jan 20 7pm AMI Board Meeting (All welcome), NEW Center
1-25	Come prepared to choose the article for which you will be the discussion leader. Indicate three preferences and rank order them.  Policy Perspectives. Assertive Community Treatment Programs. Mechanic Chapters 1-3
2-1	Epidemiology of mental health problems and services; Four Lives; Mechanic Chapters 4-5
2-8	Financing Mental Health Services. Managed Care. Mechanic Chapters 7-8 Bonnie  February, 8, AMI meeting: Civil Commitment, Guardianship Issues7:30 St Clare’s Episcopal Church/Temple Beth Emeth, 2309 Packard, Ann Arbor,
2-15	Responsive and ethical practice in managed care environments. Mechanic Ch 9 48 hours
2-22	Service innovations in a multicultural environment Mechanic 10-12
3-1	Spring Break
3-8	Consumer and Family Advocacy including advocacy approaches for persons with developmental disabilities. Sullivan; Fellin; Lachance & Santos March 8, AMI meeting: 7:30 St Clare’s Episcopal Church/Temple Beth Emeth, 2309 Packard, Ann Arbor Troubled Children - Robert Sain and Debby Snyder
3-15	Children and Adolescents. Sheehan; Harding, et al. Paper due, if not making presentation
3-22	Older Adult and Elderly Services. Dolgoff & Gordon; Simons; Troester
3-29	Alcohol and Drug Abuse Services APA Practice Guideline
4-5	Memo or letter assignment due Scott & Dixon; Strom-Gottfried. Memo or letter due  April 12, This is What We Think: Making Your Voice Heard - Virginia Koster AMI meeting, 7:30 St Clare’s Episcopal Church/Temple Beth Emeth, 2309 Packard, Ann Arbor
4-12	Whither psychotherapy--as a mental health service? Consumer Reports; Seligman  April 12, This is What We Think: Making Your Voice Heard - Virginia Koster AMI meeting, 7:30 St Clare’s Episcopal Church/Temple Beth Emeth, 2309 Packard, Ann Arbor
4-19	Organized Self-Help, Consumer Provided Services, Informal Help. Karp; Ouimette, Powell, Take home exam available.
4-26	Take home exam due

 

Text: Mechanic, D. (1999). Mental health and social policy, 4th ed. Boston: Allyn and Bacon. Book is available from Ulrich’s Bookstore, Michigan Union, and Michigan Book and Supply

The coursepack ($26.04) is available from Dollar Bill Copying , 611 Church St. (near S. Univ and Church, 665-9200).
 
 

As you read, consider how much fashion influences our responses to new ideas. As an example, consider a review from the Journal of the American Medical Association for October 14, 1939, which called Alcoholics Anonymous "a curious combination of organizing propaganda and religious exhortation. The one valid thing in the book is the recognition of the seriousness of addiction to alcohol. Other than this, the book has no scientific merit or interest."

NIMH along with NIDA (Nat. Inst of Drug Abuse) and NIAAA (Nat Inst of Alcohol and Alcohol Abuse) were transferred to the National Institutes of Health in 1992. SAMHSA (Substance Abuse and Mental Health Services Administration) was created to deal with service delivery issues. It is composed of three centers: the Center for Mental Health Services, the Center for Substance Abuse Treatment and the Center for Substance Abuse Prevention. These organizations have put a great deal of useful information on the web. As you move through this course consider searching the web to answer questions and explore issues. Sometimes it is best to follow the links offered at some of the more comprehensive sites. Some of my favorites are listed below (please let me know of your favorites so that they may be included here.

A very comprehensive site is: http://pages.nyu.edu/~gh5/gh-w3-f.htm

http://www.lib.umich.edu/libhome/Social.lib/mentalpol.html this is a wonderful one on mental health policy resources prepared by Tammy Rabideau of our Social Work Library

Also try these SAMHSA, NIH and NIMH URL’s:

http://www.SAMHSA.GOV/ http://www.mentalhealth.org/

http://www.health.org/ http://www.drg.nih.gov/

Some other interesting mental health/mental illness addresses are: http://www.coil.com/~grohol/web.htm (Links to many other mental health references) http://www.mentalhealth.com/ Internet Mental Health

http://www.fedworld.gov/ (gateway to federal government information)

http://www.nami.org/ (National Alliance for the Mentally Ill (NAMI))

http://www.cmhc.com/selfhelp/ (American Self-Help Clearinghouse). http://www.lib.umich.edu/libhome/rrs/classes/socwork.html (Social Work References).

http://comnet.org/index.html__auth=guest: (U-M Comnet). http://www.yale.edu/vayale/internet.html (Schizophrenia and Depression). http://uhs.bsd.uchicago.edu/~bhsiung/tips/tips.html (pharmacology tips).
 
 

http://www.mdch.state.mi.us/ Michigan Department of Community Health

http://www.macmhb.org/ (Michigan Association of Community Mental Health Boards).
 
 
 
 

Publications from NIMH, mostly at no-charge, can be obtained from the Information Resources & Inquiries Branch, Room 7C-02, Office of Scientific Information, National Institute of Mental Health, 5600 Fishers Lane, Rockville, MD 20857

Michigan Department of Mental Health, Office of Communications, Lewis Cass Building, Lansing, Michigan 48926 (517) 373-0408; http://www.mdch.state.mi.us/

Please come to class having done the readings and prepared to discuss the topics on the course schedule. Regular attendance is expected. (Please e-mail me if you anticipate an unavoidable absence. Note, however, explanations are unnecessary and not expected. After you have discussed a missed session with class members I can meet with you to discuss "makeup" content. I am sorry I will not be able to loan you personal copies of videos shown in class.)
 
 

1) Discuss article in Mechanic (1999) or in coursepack. Choose one of the articles on the schedule so that we can make adjustments as necessary and identify responsible persons. By the date scheduled prepare a critique of the article that includes: a) a brief summary, b) the most important policy implication(s), and c) the limitations of the article. The critique should be about 300 words and not more than one sheet (preferably 1 page using a small font or, if necessary, two pages on one sheet). Distribute copies to class one week in advance (early volunteers may distribute day of class). (If an absence is unavoidable, arrange to have someone pick up the handouts, or second best, contact the person who led the discussion. The instructor will not have extra copies). Please understand, however, that the discussions may not occur on the scheduled date in order to accommodate guest speakers and other course content. Your flexibility and understanding will be appreciated

Ask someone to be your timer so that your discussion does not exceed 10 minutes (less is OK). Lead a class discussion encouraging critique, elaboration and examples of the points made in the reading. (Grade = 10%, needs more work/credit).

Please see me to discuss your interests (note office hours above). In particular, I would like to discuss your interest in various topics, especially those you are considering for the paper or class presentation assignment. This can be an informal meeting before or after class, or at another time convenient for you. It may be helpful to confer with me more than once, first early in the term, and then again when you are further into the project. If the conference is sufficiently early in the term, it may be useful in sharpening the focus and developing a bibliographic search strategy.
 
 

2) For the second assignment do either the a or b option.

2a) Describe a program, perhaps one you might visit such as an ACT or clubhouse program, a shelter or breakfast program, in terms of who actually uses it contrasting it with who "should" be using it. Include in the discussion an analysis of the environment or service network within which the program exists. Include also a detailed description of the actual procedures involved in the service program. Evaluate or assess the program in terms of its: a) use in relation to need and demand b) adequacy of procedures, c) accessibility d) satisfaction, e) quality, f) effectiveness, g) risk, h) restrictiveness and i) cost. Some of these criteria will be more important than others depending on the program. Also consider adding some criteria that are specially relevant to your program. Pay special attention to how the program responds (or fails) to the interests of one or more cultural or "minority" groups which are defined as: seniors, women, poor or low income persons, LGBT persons, members of oppressed ethnic groups, or persons with disabilities. Also assess how the program might be evaluated differently by consumers, family members, service providers (organized according to their different interests), third party payers, employer purchasers, the tax paying public, and other stakeholders in your program. Discuss the relative priority you would give to this program compared to others. Include a minimum of six substantive references with at least one of them a major web site with the URL and date accessed.
 
 

2b) Write a paper discussing the insights a work of literature (a novel, short stories, poetry or drama) with significant content on persons from disadvantaged "minority" groups (see definition above). The work(s) should be carefully chosen to ensure that the material contains policy relevant insights and is suitable for policy analysis. Consider that the subjective connection between ourselves and author is made possible by the act of imagining fictional characters and situations. This, of course, requires that we understand and sympathize with a point of view other than our own. By identifying with fictional characters and their situations, we can think in new ways about the kinds of programs and services that might be helpful. To the extent possible, illustrate insights and principles drawn from the work by examples from your own experience. Although technical or professional articles should not be the primary sources, they may be used to supplement the artistic literature. Since this assignment asks you to supply the structure, you may want to get feedback on your ideas by asking questions or making comments in class before committing yourself to a particular approach.

Some examples of works that might be used are:

For assignment 2a or 2b the due date is March 15, 35% of the grade. Suggested length 6-10 pages. Assignment 2a could also be done as a class presentation possibly using powerpoint with handouts.
 
 

Please do not put papers in folders as they make the papers more difficult to handle. Late assignments will be graded down one level (e.g., B+ to B) and will not receive comments except where different arrangements have been made well in advance.
 
 

3) For the third assignment do either the a or b option.

 

 

 
 
 

a) Prepare a letter or memo recommending a specific course of action on a "minority" relevant issue. The issue might also be relevant to "majority" persons but it should have distinctive meaning for one of the following groups of persons: seniors, women, poor persons, LGBT persons, persons from an oppressed ethnic group, or persons with disabilities. The letter or memo should be addressed to a carefully selected policy maker. In your letter or memo be sure to address the arguments against your recommendation. The letter or memo should probably open with the objections (see Simmons in coursepack). The policy maker may be as near as a fellow worker or as distant as a high official. A specific action must be requested though it probably should be a modest one such as a request that the information be forwarded to another person, that a request for an appointment be granted, or that a reply be made to your statement. Support your argument as opportunity and time allows with citations from both general circulation publications such as the New York Times, Wall Street Journal, Washington Post, the Detroit Free Press, or other national serials such as Fortune, Newsweek, or the New Yorker. The point is to use your policy makers reference publications. Specialized, technical publications such as Social Work, American Psychologist, or the American Journal of Psychiatry should be used primarily to supplement the use of general circulation publications unless the person to whom you address the memo regularly refers to this type of publication.
 
 
 
 

b) An alternative assignment involves preparing a brief written report on how you have, or plan to, affect a specific "minority" relevant course of action (policy) in your agency or in another professional environment. A modest number of citations (up to four) from the literature should be used to support the appropriateness of the action you have taken or propose.
 
 

Due date for options 3 a or b is April 5, suggested length, 1-3 pages. If you choose a memo you may wish to put some of your material in an attachment since most busy policy makers will not read more than one page unless they get drawn in by the first page. (Grade = 20%, pass/fail).
 
 

Letter grades, with the numerical equivalents that will be used for the purpose of computing course grade, are: A+ 4.3 rare, A 4.0, A- 3.7, B+ 3.3, B 3.0, B- 2.7, C+ 2.3, C 2.0, C- 1.7, D+ 1.3, D 1.0). There is some flexibility (and sometimes, unreliability) in the grading process, thus I welcome questions and comments. I am especially eager to see gains in critical thinking