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A More Comprehensive Treatment Approach
Towards a More Comprehensive Treatment Approach to Mental Disorders:
Argentina and the United States
Alisa Tirado Strayer
Haverford College
December, 2012
Advised by Benjamin Le and Arancha García del Soto
Haverford College
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A More Comprehensive Treatment Approach
Thanks to Arancha Garcia del Soto for being an unwearied thought partner and dedicated
listener through this process, Jovan Yglecias and also the Proyecto Suma team for answering
every vague, open-ended question to help me find a direction for my paper, and my family for
reading over each draft and being incredibly supportive through this past year.
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Table of Contents
Table of Contents……………………………..…………………………………………………3
Introduction……………………………….…..…………………………………………………4
Policy, Legislation, and Financing……………………………..………………………………13
Argentina……………………………..………………………………………….13
United States……………………………..………………………………………19
Facilities……………………………………………………………………………………..…24
Limitations of the Mental Health System…………..…………………..………………………28
Towards a More Comprehensive Community Approach……………………………..………..37
Conclusions……………………………..……………………………………………………...44
References……………………………..…………………………………………………….....46
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While Latin America and the United States are separated by geography, language and
culture, surprising similarities are in evidence as these countries have moved toward
deinstitutionalizing their psychiatric populations. Both countries struggle with serious gaps in
service that are leaving patients 1unable to construct their own lives after being discharged from
their “so-called” therapeutic environments (Mechanic, McAlpine, & Olfson, 1998; MDRI &
CELS, 2007). While treatment strategies vary within and between countries, extended and
often costly treatment in both countries do not lead to improved patient health. The comparison
outlined in the paper is especially relevant because Argentina is presently undergoing the
process of deinstitutionalization as an attempt to make mental health a higher priority. Because
The United States underwent that process beginning in the 60s, it provides insight into
problems and challenges that can arise from transforming the mental health system away from
institution-based care (Smucker, 2007). The cross-cultural comparison is quite relevant today
because Argentina is attempting to make mental health a higher priority, yet outcome studies in
the United States indicate that deinstitutionalization has not materially succeeded in improving
the overall well-being of the patient.
This paper highlights the differences between the two systems in their approaches to
mental health care and identifies parallel shortcomings both countries fail to overcome. The
conclusion suggests strategies useful for both countries to address some of these complexities.
In this thesis I will be discussing the role that government decisions, public facilities, and home
environments have as barriers to the partner’s movement towards well-being. To understand
the extent of which partners are affected by the present mental health treatment system and the
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The term “patient” will be used when discussing individuals with mental illnesses who have no
perceivable control over their treatment. “Partner” refers to individuals with mental illnesses
who are active participants in designing their treatment.
A More Comprehensive Treatment Approach
way to create the most cohesive and effective care system, it is essential to consider the family
situation and construct treatment approaches which more fully utilizing community resources.
In order to discuss treatment for this population, it is necessary to first understand the
affected population: what are the symptoms and difficulties attached to having a mental
disorder, what are the patterns of co-morbidity with drug or alcohol addiction, does this
population struggle with homelessness, and how are they affected by laws and policies, and
their home environment (Epstein, Barker, Vorburger, Murtha, 2002). This paper posits that the
people struggling with these problems are seriously restrained in their recovery process due to
the lack of a cohesive approach to these challenges.
Of the disorders that are most often seen to pose the greatest difficulties to clinics are
bipolar disorder, schizophrenia, and major depressive disorder2 (Garay & Korman, 2008;
Gianfrancsco, Wang & Yu, 2005). To understand the difficulties of having one of these
challenging disorders, it is necessary to have a better understanding of the symptoms and the
effects they have on the individual experiencing them and also on the family. It is important to
note that length, severity of each different episode, and remission period varies person by
person.
Bipolar disorder
Bipolar disorder is characterized by mood swings that move from mania to depression
(Miklowitz, 2008). Mania can be described as a period when someone is overly euphoric or
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All of these disorders vary substantially from case to case in symptomatology and emergence.
Each of these disorders has been seen in children, however it more commonly emerges in early
adulthood (early-mid twenties). This is not to say that people who are diagnosed in their
adulthood do not show behavior that is perceived to be disturbing or strange by family members
or others in the community. With the emergence of these illnesses in individuals, key
educational and social development is severely interrupted usually seriously affect long-term
cognitive functioning.
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irritable, experiencing rapidly changing moods, have fast-paced thoughts and speech, decreased
inhibitions, paranoid or grandiose delusions, and significant increased activity of spending,
drug, or alcohol intake. During times of depression these individuals feel hopeless and
worthless, unable to experience pleasure, have a preoccupation with death, and exhaustion
(Torrey & Knable 2002). Presently the standard approach to treating bipolar disorders includes
monitoring patient health in an inpatient ward, providing them with medication and limited
therapy, stabilizing the patient and depending on the response to the medication, discharge
(Nivoli, Murru et al., 2012).
Schizophrenia
Schizophrenia, considered one of the more mysterious and debilitating disorders,
presents very different symptoms (Van Os & Kapur, 2009). Symptoms can range from the
emergence of new cognitions such as delusions and hallucinations, the disappearance of
cognitions such as emotional or social withdrawal, incomprehensible thought and speech, and
affective flattening, or symptoms can be more of an erratic behavior such as having
inappropriate affect or behavior considering the context (Picchioni & Murray, 2007).
Usually this will require hospitalization because few families or communities know how
to respond to such a drastic change in behavior (Marsh & Lefley, 2003). Hospital stays
generally last between a few days to a week during this acute phase. During the acute phase
the treatment procedure is to first confirm the initial diagnosis of schizophrenia and then to
move towards stabilization through antipsychotic drugs (Bellack, Buchanan, & Gold, 2001).
Following discharge, the patients are often directed to outpatient services to continue receiving
medication and also for psychosocial support, such as group therapy and behavioral therapy
(Bellack, Buchanan, & Gold 2001).
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Major Depressive Disorder (MDD)
Major depressive disorder (MDD) is characterized by a person becoming sad or irritable,
often without an external cause or after the external cause of the emotions is no longer actively
disturbing. This mood change is accompanied by a combination of unusual patterns of eating,
sleeping, or sexual desire, inability to experience pleasure, crying, or suicidal ideation
(Belmaker & Agam, 2008).
Once a patient either feels unable to take care of their lives themselves (and there is no
family support) or they threaten or attempt to commit suicide, they will then be entered into an
inpatient hospital or clinic. There they will be prescribed antidepressants or electroconvulsive
therapy to get help in the stabilization process (Berton & Nestler, 2006). Usually patients see
improvement in their disorder in 4-12 weeks, with the medication taking a few weeks to begin
to have a noticeable effect (Berton & Nestler, 2006; Bschor & Adli 2008). While undergoing
ECT and medication trials, acute therapy also is a key part of helping patients work through
their depression and finding ways of coping with their depression. Once the acute phase of the
episode has stabilized, then the patient’s continuation with outpatient medication and
maintenance therapy is essential for preventing relapsing into another depressive episode
(Richards, 2011). This outpatient therapy aids the patient’s transition back to pre-morbid levels
of functioning at home and work (Bschor & Adli 2008; Leiderman, Lolich, Vázquez, &
Baldessarini, 2012).
However there is more to understanding the experiences that patients undergo when
being treated than just identifying their symptoms. Patients may also be struggling with
problems of drug and alcohol addiction, financial difficulties, homelessness, limited social
support, and loss of control over their own lives. Each of these problems causes more barriers
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to patients’ ability able to work with their disorder and not feel so incapacitated by their
difficulties.
Additional difficulties are present in this population due to drug and alcohol comorbidity that often comes hand in hand with a severe mental illness (Epstein, Barker,
Vorburger, Murtha, 2002; Drake, O’Neal, & Wallach, 2008; Inchaurraga, 2003; Richter, 1998;
Sun, 2012). When there are substance abuse problems on top of their mental disorder, there are
additional barriers to medication management, financial planning, and self-care. Not only are
they unable to effectively care for themselves, but if they are living in a half-way house or in
their family homes, there are very few living situations tolerant to a substance-dependent
individual because substance abuse makes it very difficult to motivate to work towards
treatment (Folsom et al., 2005).
To add to these pressures, in low-income families there is extra stress on the family
because they are financially restricted in their access to mental health services (Clark et al.,
1994; Dupére & Perkins, 2007; Gianfrancesco, Wang, Yu, 2005). This puts further pressure on
the family to either handle all care for their ill family member themselves or put them in state
funded inpatient hospitals. Often however, they are unable or disinterested in taking over the
care of their ill family members, thereby leaving the patients to live on the streets. When they
are homeless, they are extremely vulnerable to very traumatic experiences and violence that
augments the stressors in their life.
After the emergence of a severe mental illness, partners are faced with a changing world
where they are considered incapable of competent thought and thereby told what to do, when to
do it, and how to do it, or they are given no instruction at all (Lefley 1997). Without that
structure, it is difficult to control their lives and organize all the responsibilities they have,
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whether it is filling out the proper paperwork for social security disability income (described
later in this paper) or taking proper care of themselves (bathing, sleeping consistently, eating,
etc.). But with that structure, they never learn how to be autonomous and work within the
limitations of their disorder. In either situation, within their family, they become a burden
because of the dependant nature that is often fostered by treatment facilities and families. This
can create complex negative relationships within the household and destroy the social support
bond that the family could provide in an ideal situation. Additionally, due to their often-erratic
behavior, patients are unable to sustain friendships or receive substantial social support (KohnWood & Wilson, 2005). Therefore patients are left to deal with their situation often alone.
As seen in this portrait of the population, because of the combination of difficulties that
they are dealing with (mental illness, often addicted to drugs or alcohol, have limited resources,
and are transitioning into adulthood and independence) and because of deinstitutionalization in
both Argentina and the United States, they become the responsibility of their family. Once the
family member is let out of an inpatient facility, they are rarely given long-term or communitybased treatments (Rosenheck, Kasprow, Frisman, Liu-Mares, 2003). They are advised to go to
the outpatient services that were associated with the hospital they were in previously, but there
is usually very limited follow-up with the patients beyond that suggestion. This essentially
provides the patient with two options: return to their family (if that is an option) or live on the
streets (Folsom et al., 2005).
Ultimately, the problem is that this population of severely affected mental health partners
is not being helped by the current poorly-equipped system and so they most often are left
without long-term support. Furthermore, even if the family is the main caretaker, they are
given little to no training or support in dealing with these problems. With limited therapeutic
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support, it is almost a certainty that the patient will return to an inpatient hospital, jail, or
rehabilitation in a short amount of time following release (Wang et al., 2005).
In order to illustrate this picture, I will be outlining Argentina and the United State’s
policies, the facilities that should be carrying out these policies, and the highly visible
limitations of this system. Once the present mental health system is depicted, options of how to
approach meeting the needs of the caretakers and partners in this process will be offered as
holistic alternatives to better serve these individuals. Ultimately this paper strives to show how
the present approach to mental health treatment disturbs partners’ ability to establish their own
lives and gain autonomy from their treatment process and suggest alternatives that can address
these goals and facilitate the education and inclusion of all affected actors.
Argentina3
In Argentina, despite the new policies and legislation that are trying to redirect mental
health services towards deinstitutionalization, institutionalization is still very much active today
(MDRI & CELS, 2007). This is in part because the patients have no other place to go,
particularly if they are homeless or live in the “villas,” the ghettos in the outskirts of the city.
However, because the therapy and medication prescriptions are designed for patients
who will stay in the hospital for an extended period of time, the treatments are directed toward
stabilizing the mentally ill patient with drugs rather than on preparing them to return to their
communities (Moldavsky, Savage, Stein, Blake, 2011). Once they leave the clinic, they are
unprepared to deal with their daily interactions. Combine these poor preparations for the world
outside of the institutions with very limited follow-up treatment from the hospital and limited
3
This paper focuses on the city of Buenos Aires, the capital of Argentina, an urban, wellresourced city, but this is not to say that the rest of the country has these same services. Services
are allocated province by province, therefore provinces that are not well funded do not receive
adequate mental health services (Moldavsky, Savage, Stein, Blake 2011; WHO 2011).
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communication between different service providers about the incoming partners, and this
creates a constant pattern of people being brought back to the government facilities shortly after
being released. Services outside of the wealthier areas of Buenos Aires have even more limited
services, presenting an even bleaker picture for the patients there (Moldavsky, Savage, Stein,
Blake, 2011; WHO, 2011, WHO, 2005).
California
California’s mental health system also perpetuates the stagnation of its partners by not
providing ways to transition from being hospitalized to being back to their communities (Wang
et al., 2005). However California does not face the same kinds of problems that are present in
Buenos Aires. While Argentina is presently trying to move towards deinstitutionalization,
California went through that phase of their mental health system in the 1970s and 80s (Benson,
1994). Both then and now, the mental health patients who rely on the state for their services
remain the same: often homeless, struggling with substance abuse, estranged from their family
and friends, with their illness not radically improving over time. The hope was that the end of
institutionalization would allow for more personalized treatments and for communities to find
ways for these members of their community to join in a healthy and holistic manner. However,
this has yet to become a reality.
Instead what presently exists is a pattern where patients cycle through different
government programs such as the prisons, rehabilitation clinics, or emergency psychiatric
services in hospitals (Wang et al., 2005; Grant et al., 2011). Because there are not long-term
institutions, patients are brought to these services for short-periods of time where they are
stabilized through medication for no more than a week and then they are dismissed back into
their communities without any substantial follow-up procedures. These state facilities are
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overcrowded and understaffed so that although medication is usually regularly provided (in
quite high dosage to keep the patients subdued) additional services are not provided in a
manner that adapts to the individual needs of a patient or helps them to move towards not
depending on these short-term holding cells that they are rotated through (Gold Award, 2001).
A major problem with this system is that it not only encourages people to remain dependent on
the system, but it also does little to get them out of negative environments (homelessness,
living situations with heavy drug use, or prostitution). Therefore their care ends up being thrust
on either their families or alone without being able to stop the cycling. Because families are
not trained and are not usually welcome to join in the treatment process of their loved one,
when the family member is returned to their household, there are very limited steps that they
can take to be of help (Gold-berg-Anold, Fristad, Gavazzi, 1999). In rural environments, this is
even truer (Kohn-Wood & Wilson, 2005; MRHRC, 2010).
Essentially what we see in both Buenos Aires and California, is a stagnation of healing
when it comes to treating mental health disorders either due to a hold-cell type of treatment
approach or due to a short-term cycling system that forces system dependency on the patients.
Because mental health treatment in Argentina and the United States often takes partners outside
of their environment, provides them with stabilizing treatment, and then discharges them back
to where they were before (home, halfway house, or the streets), when they are placed back in
their environment, the family is unsure of what condition their loved ones are in (Lefley, 1997).
Ultimately the problems that emerge from these systems are the same: patients and their family
members are lost once there is not this state facility to take care of the patient when their
symptoms are exacerbated. But to create significant change in the system, there would have to
be far more community involvement and that is something that many non-afflicted members of
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the community are not interested in. Until the community and family unit is recognized as an
agents of change and knowledge and a group who also needs support from services when
treating an ill family member, progress will continue to be very limited.
Policy, Legislation, and Financing
Many actors influence how the mental health system is organized, but the government
has played a particularly important role in creating policy, legislation, and financing that
structures what partners can receive for treatments. For the purposes of this paper, policies are
defined as ideal desires of what health care should cover and provide treatment for, legislation
are the laws that are enforced (to varying degrees), and the financing refers to the national laws
that dictate what kind of support people with disabilities are eligible. Argentina is a unique
situation due to it’s public health care and only recent progression towards developing policies
and laws regarding mental health advocacy. In the United States, a country with extensive
government legislation that mandates what can be designated as appropriate action or not, there
are an abundance of rules that overlap and add to the complexity of receiving integrated
treatment.
Argentina
Throughout the 20th century, Argentina experienced a series of dictatorships, which
brought on a very extended period repression. However, throughout this time and particularly
in the late 1950s there was a movement towards more therapeutic and creative approaches
toward mental health care and treatment. During several regime changes between the 50s and
70s, mental health reformers continued to work on significant reforms affecting family
abandonment, the ineffectiveness of large asylums, the development of psychiatric clinics in
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general hospitals, and overall alternative treatment practices focusing on rehabilitation and
social regeneration instead of on confinement and segregation (Albard 2008).
Then in the 1970s, political instability, in addition to the quick succession of several
regimes, brought on a period of horrific terror led by the government against any suspected
revolutionaries. As psychologists and psychiatrists made up a large part of the liberally minded
population the government feared they were frequently fired or disappeared, thereby creating a
tremendous loss of employees and leaders in the psychological world in Argentina. To take the
place of these reform-minded mental health workers were many of the previous guards and
psychiatrists whose focus was on containment of people with mental health disorders, instead
of trying to bring them back into the community. In total during these six years of terror and
repression, the government is thought to have killed up to thirty thousand people, with an
estimate of thirteen thousand bodies still missing (Albard 2008; Garcia, Rodríguez, Koslow,
1989; Moldavsky, Savage, Stein, Blake, 2011; MDRI & CELS, 2007).
Now, there is a generation of professionals missing and although there is a vibrant culture
of mental health care and treatment, Argentina has yet to recover completely. It is still working
to emerge from this period of repression and create legislation for mental health care. Much of
the legislation that has been developed thus far has not improved the lives of its citizens
because of not having the infrastructure or sufficient resources to implement the laws (Albard
2008; Ceriani, Obiols, Michaelewicz, 2009).
Policies
With a history tainted with so many human right violations, Argentina has worked hard to
create laws that promote justice and equality across all dimensions of the society. As a result of
this effort, Argentina has created policies that, although following internationally promoted
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ideas for creating a holistic and ideal society, they are very difficult to enforce (Ceriani, Obiols,
Michaelewicz, 2009; Moldavsky, Savage, Stein, Blake, 2011). In addition, most of the mental
health legislation has been very recent. This is most likely due to their history of having a
repressive government for so many years and now the population has a general distrust of any
government legislation that tries to take too firm of a hand in their lives.
Presently, Argentina has a mental health policy, which was initially formulated in 1957 and
then revised in 2001 with input from politicians, mental health professionals, NGOs, and public
servants. This policy touches on mental health ideals for the nation. The three component of
the policy are:
1. Education and promotion of treatment approaches for mental health issues (community and
professional education and promotion for the understanding and treatment of mental health
issues)
2. Country-wide prevention and treatment programs
3. Rehabilitation programs for mental health and drug and alcohol treatment
Regular funds for implementation for these three components were allocated, but not at the
funding level required. As Argentina has a federal governance structure, different regional
mental health programs and approaches are in place in each of the different provinces.
Presently there is no overall enforcement or planning system in place. Professional working
groups are currently attempting to standardize standards and approaches of treatment across the
provinces (WHO 2005).
In 2001 the Programa de Asistencia Primaria en Salud Mental ley 25.421 (Program for
Mental Health Services in Primary Care, Law 25.421) was passed, establishing that everyone
who enters the country has the right to free mental health care, included in primary care
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services. It also states that these primary care services provide for the rehabilitation and social
reinsertion of persons with mental illnesses. However, as stated previously, for these types of
policies, there is little enforcement or follow-through on these laws, so the majority of public
psychological care is based primarily on institutional care (CELS 2007).
Legislation
For national legislation on mental health, there is only one newly created law presently
in place: The Ley National de Salud Mental, ley 26.657 (National Mental Health Law #26.657)
(2010). This law first restates the dedication to protecting mental health rights for all Argentine
residence, following UN guidelines. When they outline the appropriate approach modalities
they state that treatment should include an interdisciplinary team (technicians, workers trained
in mental health care, etc…), should take place beyond the limits of one’s hospitalization stay,
and that when prescribing medicine it must only be for therapeutic purposes, not for
punishment. As for hospitalizations, it demands that they only be for therapeutic aid for the
partner, lasting for as little time as is possible, with the staff completing evaluation, diagnosis,
and developing reasons justifying hospitalization (signed by at least two professions in the
hospital—one being a psychologist or psychiatrist) by the end of the first forty-eight hours of
hospitalization. It also demands that 10% of the overall health budget of the country goes to
mental health services (Moldavsky et al., 2011). These policies have yet to be even partially
implemented.
Financing
The budget for mental health services varies significantly by provinces by 0.5%-5% of
that provinces health budget. Nationally, 68% of the mental health budget goes to psychiatric
hospitals, leaving community mental health resources under-financed.
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At a national level, the primary sources for mental health financing in descending order
are taxed-based public funding, obras sociales (union-based social insurance), private insurance
companies, out-of-pocket expenditures by the family (WHO, 2005). Each province has a
public health policy that provides for free coverage for specified mental health services.
However it’s resources are quite limited, particularly in rural areas. Local councils and
provincial governments provide the funding for large psychiatric hospitals. However, these are
not well financed and in the rural communities, workers are often undertrained and/or work
voluntarily. “Argentina has a total of 20,945 beds with half being public sector financed and
half being privately financed” (WHO, 2005).
Argentina has a very unique health care system in comparison to the United States.
There is complete national public coverage of health care services—their motto is that that
health care is a universal right regardless of nationality, socioeconomic status, or income. As
soon as a person enters the country, they are eligible to receive medical care, including mental
health services. This health care system is made up of three mechanisms to cover a variety of
services: the public sector funded by the government through taxes, private sector financed
through voluntary insurance, out of pocket payments and obras sociales where worker’s unions
will provide health and mental health care insurance for each employee and their immediate
family (IRBC, 2001; Belmartino, 2000; WHO, 2005).
Buenos Aires
Policies
Due to the limited number of policies at the national level, each province is left to create
their own policies and legislation and try to enforce those based on the resources they have.
This creates a wide diversity of resources across the different provinces. The province of
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Buenos Aires, being where the capital is also held, has particularly strong funding and is able to
provide more resources to people. However, this does not mean that the policies that exist are
enforced any more regularly than the national policies. They remain equally difficult to
achieve due to the lofty missions of these policies, legislation, and lack of financial support.
There are two primary policies in place in the province of Buenos Aires: the 1996 Basic
Health Law No. 153 and the Mental Health Law of the city of Buenos Aires, No. 448, passed in
2000. The Basic Health Law, among statures directed toward other health problems, requires
city governments to enforce progressive deinstitutionalization and calls for a focus on social
integration when treating mental health disorders. In 2000, the Mental Health Law was passed
as a way of restating many of the same goals of the Basic Health Law, but in a law specifically
directed toward mental health goals instead of only general health care. In this law mental
health care is guaranteed as a right of all residents in the city of Buenos Aires. It additionally
calls for deinstitutionalization and for the people who are presently institutionalized it is
demanded that they receive rehabilitation and social reinsertion in place of hospitalization. It
also puts forth that the Buenos Aires mental health system will be based on prevention,
promotion, and protection of mental health and those affected by mental health problems,
particularly through eliminating asylum-based treatment and moving toward community mental
health services instead. But it does not mention any review of detentions by any kind of
impartial review body, protecting against arbitrary detentions (Ceriani, Obiols, Michaelewicz,
2009; Moldavsky, Savage, Stein, Blake, 2011; WHO, 2005).
Legislation
No provincial laws beyond those at the federal level.
Financing
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It is the same system as at the federal level.
United States
Policy
In 2003, the “new freedom commission on mental health” that, at the request of the
president, issued a report entitled, “achieving the promise: transforming mental health care in
America”. In 2004, the US Center for Mental Health began working with the states to
implement the six goals of this report. These goals included:
1. Early detection of mental illness,
2. Universal coverage of mental illness with access to effective treatment and support,
3. Acceleration of the use of technology to help access mental health care and information,
4. Eliminate the geographical and social status disparity in access to mental health services,
5. Increased focus on research and evaluation of mental health services,
6. Improved epidemiological and demographic research on frequency and causation of different
forms of severe mental health issues (ex/: why poor areas have so much more of specific types
of disorder)
(WHO, 2005: America)
Legislation
A series of national mental health legislation in the past decade and a half have focused
on funding programs for children and adolescent mental health, increasing parity between
mental health and health care benefits, confidentiality of partner records and claims processing,
and mandated psychiatric treatment throughout the criminal justice system.
Ex/:
The Public Health Service Act (1944):
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The Health Insurance Portability and Accountability Act (1996)
Mental Health Parity Act (1996)—updated in 2005
The Children’s Health Act (2000)
(WHO, 2005: America)
Financing
At the national level, there are a series of methods of providing funding for health
services: Medicaid, Medicare, Supplemental Security Income, and social security disability
income. There is also private insurance if you can afford that, but most of the population that
this paper is focusing on will not be able to purchase private insurance.
Medicaid is a health and long-term care coverage program set up for low-income
individuals and families, people with disabilities. States and federal government jointly finance
this program with each state establishing and administering their own Medicaid program. This
includes type, amount, duration, and range of services, which are loosely outlined by federal
guidelines. These services range from doctor visits, emergency care, hospital care, prescription
drugs, vision, hearing, and long-term care (CMS, 2012).
Medicare, often confused with Medicaid, is a social insurance program that is
exclusively funded by the federal government. It provides people 65 or older, people under 65
if they have disabilities, and people with end stage renal disease with coverage for their hospital
bills, medical insurance coverage, and prescription drugs (CMS, 2012).
Supplemental Security Income (SSI) is another governmental program that helps lowincome people receive stipends that help meet the their basic needs for food, clothing, and
shelter. This is provided to people over 65 years of age, blind, or disabled and live in the
United States. Resources can only be provided in cases where people have limited income
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(money you earn or receive from other sources) and limited resources (anything that could be
converted to cash. For an individual it must be less than $2,000 and for a couple less than
$3,000) (SSO, 2012).
The final source of federal funding is the Social Security Disability Income, which is
only for disabled or blind individuals who require income supplements because of a notable
disability. Depending on the duration of the disability, SSDI can be supplied on either a
temporary or permanent basis. Additionally income of the disabled individual is not relevant to
whether or not they receive services. But what is relevant is if they are able to perform a
substantial gainful activity, able to perform any work in the economy, and if it is severe (SSO,
2012).
The primary sources for US mental health financing are in descending order: private
insurance, federal and state tax-based programs, out-of-pocket expenditures by the partner. In
2005, the United States spent 6% of the total health care budget on mental health programs and
services. While the United States does not yet have a universal health insurance program
(depending on the upcoming election), about 17% of the population is without any form of
insurance. Federal programs such as Medicaid and Social Security Disability Insurance have
increasingly been funding coverage for those with the most severe mental health issues. The
Federal Supplemental Security Income (SSI) for severely disabled low-income populations and
Social Security Disability Insurance (SSDI) for workers and family members who are
experiencing severe mental health problems. Eligibility for these two programs result in
coverage by Medicaid or Medicare for certain types of mental health problems (WHO, 2005:
America).
California
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Policy
No others besides federal level.
Legislation
The legislation in California has been built upon the legislation of the United States to
act as a specialized group of laws to create a health care that responds to the direct needs and
ideals of the population living there. The passing of the Mental Health Services Act (2004)
suggests that California’s politicians are making mental health care an emerging priority. The
Mental Health Services Act was set up to increase the mental health services available by
placing an additional one percent tax on individual taxable income that exceeds one million
dollars (WHO, 2005).
Prior to the Mental Health Services Act, there was a series of other mental health care
legislation which was passed which also provided more structure to the way community
members can have more say in mental health care. In 2002, Laura’s Law, which permits courts
to order someone to enter into assisted outpatient treatment and or take antipsychotics in cases
where the individual is showing obvious signs of not being able to care for themselves, are in
declining condition, are not yet either at risk of harming themselves or others but could turn
towards that, and have not followed up or not complied with treatment (NAMI, 2010).
There have also been a several sections of the California Welfare and Institutions Code
that were developed regarding involuntary commitment: section 5150, 5120, and 5270 (CWIC).
Section 5150 describes when someone can be involuntarily confined to an inpatient hospital by
a clinician or officer for up to 72- hours against their will. This is only acceptable if the patient
is a danger to themselves or other, or gravely disabled to the point where they cannot care for
themselves. During this time, they will be assessed and diagnoses to make sure they do qualify
A More Comprehensive Treatment Approach 23
for hospitalization. If they do, then they are offered voluntary admission to the hospital, and if
they refuse, it will take a second form, the 5250, to hold the person for another 14 days without
their permission. To continue the involuntary hold for any longer, it is necessary to have a
5270 hold written which leads to an additional thirty day involuntary psychiatric hold on top of
the 72-hour and 14 day hold (Bruckner, Yoon, Brown, & Adams. (2010).
Financing
As described above, Medicaid is a program that coordinates federal and state funding for
health care within a state. In California, Medicaid is administered through its own program
named Medi-Cal, which decides what health programs and services need to be available to the
public. Medi-Cal is eligible to the same people as Medicaid: persons 65 or older, persons under
21 years of age, adults between 21-65 if they have children under 21 who require support,
disabled persons, certain refugees, and pregnant women. Medi-cal is the name for the way in
which the state of California interpret the policies constructed for Medicaid and the way the
state funds half of the costs of medical care for the population named above. Medicare, social
security disability income, and supplemental security income all remain to be key features of
financing at the state level. Each of these funding mechanisms have very little appropriation
for community-based services. The funding is largely focused on hospital and licensed
practitioner treatment (HPC, 2012).
State mental health programs and services have been developed to augment gaps in the
federal programs. However, as budget cuts over the last five years have mounted, state funding
for both inpatient and community services for children and adults with serious mental illnesses
have been significantly downsized or eliminated. In California, “which has cut over $750
million of its mental health budget in recent years, the governor has suspended mandates on
A More Comprehensive Treatment Approach 24
counties to provide mental health services to special education students, meaning that the
burden of providing and paying for their care has been shifted to the school systems, which are
also struggling with limited resources” (Disability Rights California, 2010). These cuts at the
state level, in combination with a lack of funding for even mandated programs at the federal
level, have caused individuals experiencing severe mental health issues to use emergency
rooms and hospital based treatment rather than a more systematic and community based
programs.
Facilities
Buenos Aires Facilities
Argentina has a very unique health care system in comparison to the United States.
There is complete national public coverage of health care services—their motto is that that
health care is a universal right regardless of nationality, socioeconomic status, or income. As
soon as a person enters the country, they are eligible to receive medical care, including mental
health services. This health care system is made up of three sections to cover a variety of
services: the public sector funded by the government through taxes, private sector financed
through voluntary insurance, out of pocket payments and obras sociales where worker’s unions
will provide health care insurance for each employee and their immediate family (Immigration
and Refugee Board of Canada 2001; Belmartino 2000; WHO 2005).
Under this system there are a wide variety of facilities and services provided, but for the
purposes of this paper, I will only be focusing on the facilities and services that low-income
mental health patients are usually directed to. The facilities used are in-patient hospitals either
used exclusively for mental health care or with a specific ward for mental health services and
outpatient hospital or clinic services. The three primary inpatient hospitals are the Jose Tibucio
A More Comprehensive Treatment Approach 25
Borda Interdisciplinary Psychiatric Hospital, a hospital only for men, the Braulio A. Moyano
Psychiatric Hospital, which only serves women with mental illnesses, the Dr. Carolina Tobar
Garcia Children’s Hospital, and the half-way house Psycopathologic Center Aranguren. Within
these in-patient hospitals, there is often a segregated ward that holds inmates who have been
transferred from a prison setting to the mental hospital if their crime was deemed to be
influenced by their mental disorder. There are no psychiatric beds in prison for inmates with
mental disorders (WHO 2005).
The in-patient hospitals provide medication, therapy, beds, food, and depending on the
hospital, there can be activities such as a radio groups, classes to get a degree, or performances
of bands or plays. The delegation of services for each patient depends on their symptoms, but
for situations where people are primarily in the hospitals for an unlimited time due to them not
having a place to move to, they will often not be receiving any services besides food and shelter
(MDRI & CELS 2007). In the outpatient hospital and clinic services, patients are provided with
medication, day treatment programs, group therapy, a specified amount of therapy, and
occasionally support through job searches (MDRI & CELS 2007).
Across Argentina there are 225 facilities that have psychiatric beds (half in public
psychiatric institutions, half in public institutions); about 6 psychiatric beds in hospitals across
the country per 10,000 people, however this statistic demonstrates how these facilities and
resources are organized to be almost exclusively in highly concentrated areas (WHO 2005). Of
these psychiatric beds in Argentina 80% are occupied by patients staying for more than a year,
15% for stays between three months to a year, and 5% are for staying lasting under three
months (WHO 2005).
A More Comprehensive Treatment Approach 26
For populations that are located on the outskirts of the city, generally the poor
immigrant or indigenous populations, getting to hospitals located in the city can be very
difficult and unaffordable. Therefore, mini-clinics have emerged called “salas”. There is very
limited treatment and services, but because it is such an ignored population who lives there,
few politicians try to improve their resources.
Recently, there has also been the emergence of halfway houses where patients are being
delegated to after they are stabilized and are capable of living, at least in part, independently.
In these halfway homes, the patients are provided with group therapy, food, and social
company. Within this environment, patient’s have more autonomy to find ways to engage with
their communities and peers in a less restrictive atmosphere (MDRI & CELS, 2007).
California Facilities
Following a similar pattern as Buenos Aires, California has in-patient and outpatient
facilities, halfway houses but also has services within prisons. Although all of these facilities
exist at the governmental level, smooth transitions from service to service do not exist, creating
additional difficulties for the patient’s movement towards a functioning life as well as
movement towards social reinsertion into their community.
Of the inpatient hospitals and clinics, the services that are provided are a diagnostic
evaluation, 24-hour a day care, counseling for the patient (and sometimes the family),
medication, and some discharge aftercare care. Outpatient treatment is used as a follow-up to
inpatient stays and for less severe cases, providing care, but less intensive constant care. This
provides the patient with the opportunity to develop their own life while still regulating their
symptoms and working out a lifestyle, with some help, that fits their psychological needs.
Services that are generally provided are individual, group, and family therapy, information and
A More Comprehensive Treatment Approach 27
referral to specific services that best fit their needs, recreational activities, and socialization
(California Gov., 2012).
Halfway houses are provided for people of all ages, providing them with a therapeutic
living environment for people who need a more structured lifestyle than what most outpatient
care will offer, but also are presently able to care for themselves without being a danger to
themselves or anyone else, therefore do not require inpatient psychiatric hospitalization
(California Gov., 2012). In this household, services are geared towards the specific needs of
each resident, often having the patient become the primary partner in deciding what help they
do or do not need. Depending on the severity and the aid a patient needs, they will be directed
to a house that will match their need level. Particularly for children and youth who have mental
health problems, their facilities will often have additional support because they may have a
harder time adjusting to placements. Services at these halfway homes or residential treatment
facilities include crisis stabilization, bio-psychosocial assessment, care management,
medication management, therapy, and often for children’s facilities there are on-grounds
schools (California Gov., 2012).
The final kind of facility that provides psychological services to people with severe
mental health disorder that I will discuss are the services provided in prisons. In California, the
prisons will provide services to people who has current symptoms and/or requires treatment for
the disorders included on the DSM’s Axis I mental disorders list. Of the mental illnesses that
we will be looking at, this includes schizophrenia, bipolar I disorder, and major depressive
disorder. The services provided to these inmates are crisis intervention, a bed outside of their
cell for severe cases who need to be monitored for usually no more than ten days,
psychotherapy sessions, medication, outpatient services such as group therapy, and preparing
A More Comprehensive Treatment Approach 28
the inmate for their discharge back into the community (Mental Health Services Delivery
System, 2009).
Limitations of The System
Due to this grouping of legislation, policies, methods of financing, and the enforcement
of the mental health policies, current treatment is presently quite distant both in Argentina and
the United States from what researchers and advocacy workers believe would best help people
struggling with chronic mental health disorders. By examining the limitations presented in the
section above, there are some key problems present in both environments that are limiting the
potential improvement of well-being that the mental health system could provide.
Buenos Aires
When comparing California’s effectiveness of treatment with Buenos Aires treatment
approaches, there are very similar problems, but they arise from different sources. The same
three major barriers to an effective treatment approach are financial limitations, accessibility,
and limited alternatives to the traditional treatment approaches and psychoanalytically trained
professionals.
Although laws are in place to protect the rights of mental health partners, there continue
to be many shortcomings as to the options on how to fund and enforce the laws. There is a
disconnect between the ideals of the country and its ability to provide those services to their
people. A large reason why this barrier to implementation exists is because of a lack of
financial ability to support the laws that are developed. While laws such as the “Mental Health
Law of the city of Buenos Aires No. 448” requires the city government to enforce progressive
deinstitutionalization and calls for action towards social reintegration of mental health partners,
to be able to shut down the mental health institutions there would need to be set up alternative
A More Comprehensive Treatment Approach 29
facilities, but presently Buenos Aires does not have the economic ability to support the
development of or the staffing of new alternative facilities (Moldavsky, Savage, Stein, Blake,
2011; MDRI & CELS, 2007).
The same problem exists in the new National Mental Health Law which states that all
treatment of mental health disorders should include an interdisciplinary team and that it should
exist beyond the institutions or inpatient facilities. This would require much more money to be
funneled to mental health work so that they could attract a wider range of professionals to work
within the team. Additionally, to provide follow-up to partners, although follow-up has been
shown to ultimately be a more cost-effective method of treating mental disorders, there would
need to be an allocation of the mental health fund directed towards follow-up treatments, which
is not very established or well researched yet (Biernie, 2009; Cusack et al., 2010). Until
Argentina can develop a more achievable set of goals and laws for itself, then the mental health
system will continue to underperform since the goals set are too far off from where the system
is presently.
The second problem in Argentina is how accessibility to services, similar to the United
States, is limited. In large urban centers like Buenos Aires accessibility is less severe of a
problem, but in the areas outside of these Argentine cities, facilities and the diversity of
services is deplorable. Particularly in the “villas” or shanty towns where the poorest members
of the community live, generally located on the outskirts of town, there are no health, much less
mental health, facilities present. There is a struggle to get appropriate medication, enough
beds, and basic services for mental health partners (WHO 2011; WHO, 2005; Ablard, 2008).
Because of these limited resources in rural areas of Argentina, even more responsibility to care
for the ill family member falls on the well family members.
A More Comprehensive Treatment Approach 30
Additionally, limited diversity of approaches and number of trained professionals
utilized in mental health treatment approaches also hurts the patients who are relying on the
system. Of the approaches available, long-term (lasting more than one year) psychoanalytic
therapy is the primary focus used when approaching therapy. This is a long-term treatment
approach that in crisis situations does not provide immediate relief or aid to the individual
struggling with a severe mental health problem. There are very limited short-term
behavioral/cognitive therapeutic approaches or more alternative treatment modalities. In fact,
68% of all mental health funding is for long-term inpatient treatment (Moldavsky, Savage,
Stein, Blake, 2011). In this kind of drawn-out, therapist centered treatments, the partners are
not able to take power of the recovery process themselves. This is also a problem because the
long-term therapeutic work is usually psychoanalytically focused. This excessive focus on
psychoanalytic work in part due to the history of oppression when mental health workers were
forced to go into private practice out of fear of being more easily identified if working for
social change (Ablard, 2008). The problem with psychoanalytic therapy is that it is meant for
long-term approaches and in-depth analysis of what, in one’s history, has led to their present
condition. However, the chronic and severe mental health challenges discussed in this paper
require crisis intervention and socialization, not historical insight.
Not only is psychoanalytic therapy the primary option used, but few alternative
treatment approaches are offered (Inchaurraga, 2003). Again this traces back to the history of
Argentina and the elimination of such treatment methods. Although in recent years there has
been a greater focus on social reinsertion, it is still a very uncommon service for clinics or
especially hospitals to provide. There is not an established system that smoothly aids a
partner’s transition from the intensive inpatient wards, or even the outpatient services, to
A More Comprehensive Treatment Approach 31
socializing with people of all backgrounds and conditions. This generally leads partners to
remain in their houses, unmotivated to begin reentry into society, ultimately ending in another
relapse. Little by little, people are working to find what alternatives will work best, but there is
a way to go before any new treatment models will be implemented, especially because there is
limited data or research being done throughout Argentina about the needs of this population or
the most effective approaches (Moldavsky, Savage, Stein, Blake, 2011).
There is also a lack of clinical guidelines structuring appropriate medications for
different mental health conditions. Leaving it up to individual physicians who are not trained
in mental health treatment leads to prescribing medications that are often not necessarily
supported by clinical evidence (Moldavsky, Savage, Stein, Blake, 2011).
Another key problem is that mental health training is almost exclusively for
psychologists and psychiatrists, not for primary care doctors, nurses, or other non-certified
community resources, such as pastors and school personnel (Moldavsky, Savage, Stein, Blake,
2011). As seen in the United States, partners are regularly interacting with people outside of
the mental health world and these interactions could be used to create a more fluid treatment
approach. Whether it is training local community leaders, religious leaders, school teachers,
general practitioners, police force or family members, having more widespread knowledge
about these disorders and how to react to them would be very beneficial to the population. For
religious leaders and general practitioners who could be in a more therapy-like situation with
these partners, they would need extra training. With the inclusion of more people into the
treatment approach, not only would some of the stigma hopefully begin to dissipate within the
community, but then mental health treatment would begin to seem less daunting if it could be
included into a more casual atmosphere as well as going to their therapist. This would also
A More Comprehensive Treatment Approach 32
hopefully take some of the pressure, as mentioned before, off of the family members to be the
sole caretakers of their ill family member.
California
In the United States, there are three main limitations: financial, particularly given the
present economic downturn, accessibility of services, and training for people who will be
interacting most frequently with these partners.
Financially, with cuts to Medicaid funding California is forced to cut back on mental
health services particularly those affecting the availability of community care (NAMI, 2011).
Medicaid is the largest source of financing public mental health services, accounting for almost
50% of all public sector mental health spending. “Many states have used Medicaid creatively
to expand their spending on mental health, while decreasing state expenditures. For every
dollar that a state spends on Medicaid, it receives one or more federal dollars, depending on the
particular state’s relative wealth and it’s corresponding federal Medicaid matching rate”
(NAMI 2011). The Federal Stimulus Funds that occurred in 2009-11 temporarily increased the
federal match for Medicaid. However, on June 30th 2011, these federal stimulus funds expired
and virtually every state was forced to significantly reduce funding for these programs. For
example, California has reduced by 21.2% their funding for mental health programs and
services from 2009-12. This negative percent change was the 7th highest of all 51 states
causing a total drop in mental health funding of $764 million. In the last year (2011-2012),
California reduced it’s funding for mental health by 5.9% (NAMI 2011).
All states, and in particular California, are increasingly reliant on federal Medicaid
funds to supplement the drop in their own services, the Federal Medicaid budget has ballooned.
This trend is unlikely to continue as current federal legislation is proposing stricter limits to
A More Comprehensive Treatment Approach 33
Medicaid funding control that will increase the unmet need for services for poor and severely
disabled populations (NAMI 2011). For example, California has proposed cuts of an additional
$1.4 billion of state contribution to the Medicaid program (Pecquet 2011). This would in-turn
reduce federal matching funds by at least the same amount, further reducing funding for the
poorest and most severely impaired of that state.
Due to significant cutbacks in the National Institue of Mental Health (NIMH), there are
increasingly limited resources focused on experimental/pilot programs testing the efficacy of
short-term treatment programs and the use of non-licensed community members, such as
ministers and nursing staff. Furthermore, the National Committee for Quality Assurance
(NCQA) is no longer actively funding evaluation programs on alternative treatment approaches
for severe mental health conditions such as schizophrenia, bipolar disorders, and other longterm disability mental health issues. Without this data collection and outcome of treatment
assessment, it is difficult to develop new and innovative solutions for community based
treatment long-term solutions (Luterman 2011).
Additionally since the policies affecting treatment were put in place in the eighties and
nineties, the funding has not continued to effectively map to those policies. The money that
was once directed towards these community-based treatments no longer exists because it is put
in more conventional programs. This is despite the fact that community projects are the ones
that have seen substantial improvement in their partners (Gianfrancesco, Wang, & Yu, 2005).
Beyond funding, accessibility to services is another significant barrier preventing
mental health partners from being able to receive the help they need (Bonynge, Lee, & Thurber,
2005; Kohn-Wood & Wilson, 2005; MRHRC, 2010). There is not a method in place for
ensuring that lower resourced rural communities are receiving the same degree of care as is
A More Comprehensive Treatment Approach 34
present in the urban settings. Since rural areas are not major foci for a government because
there are fewer people inhabiting the land, fewer gains received by outside investors, and less
vocal population due to their location and separation from the rest of the country, it is these
areas that most often are sidelined and given fewer resources or funding than larger counties
where there is a greater population. Therefore people struggling with these mental health
disorders are left to either abandon their home town so they can receive better structured
services or they have to make due with the services present in the community. These services
tend to have an inadequate supply of trained psychologists and psychiatrist or community
resources and only the most basic therapy. With this limited type of treatment available it is
not surprising that the partners are highly likely to end up either constantly in an inpatient ward,
jail, or drugged to a state of nonfunctioning. If they remain in the community, again the brunt
of the caretaking will fall on family members (Bonynge, Lee, & Thurber, 2005; Kohn-Wood &
Wilson, 2005; MRHRC, 2010).
Presently, with the bureaucratic and confusing mental health coverage system, people
with mental health disorders must untangle the confusing web of Medicare, SSI, SSDI, and
Medical to be able to cover the many costs of their medication, therapy, housing, and outpatient
services. For someone who is not suffering from hallucinations or severe depression it would
be a struggle to understand what services are covered by which policy, so expecting partners to
maneuver through that system alone seems overly hopeful. If they cannot decipher the system,
then they are left without a mode of paying for any mental health services. That significantly
limits the accessibility they have to any mental health services.
A final main shortcoming of the treatment approaches in California that I will mention
is that there is extremely limited training given to people interacting daily with people with
A More Comprehensive Treatment Approach 35
mental health disorders (Chien & Norman, 2009; Fox, 2012; Goldberg-Arnold, Fristad,
Gavazzi, 1999; Lefley, 1997). This includes people such as family members, religious leaders
(priests, rabbi, etc.), community leaders in youth groups or community centers, or general
practitioners working in local hospitals. When approaching mental health treatment, there is
often an elitist attitude towards who can treat severe mental health issues; that only
psychologists, psychiatrist, or sometimes social workers can affectively help people struggling
with mental disorders (Carr et al. 2004). However, if we can utilize the wide network of people
interacting with this population, then not only can we make treatment more casual and less
disruptive to their normal schedule, but we can also hopefully lessen the burden placed on the
caretakers that usually are the main community members dealing with these problems daily.
Family Needs
To understand why these limitations are so harmful to the well-being of partners and
their home environment, it is essential to look at the difficulties and needs of their caretakers.
Even before official diagnosis or emergence of full symptoms of a mental disorder, often
family members are already accustomed to having difficulties interacting with or observing
strange behavior by pre-morbid family member (Lefley 1996;1997a; 1997b; Bernheim &
Lehman, 1985; Stein & Wemmerus, 2001). This creates stress within the family, but does not
usually cause the kind of distress and conflict that occurs when the disorder is fully active.
When the symptoms fully emerge, there are new difficulties that the family must face
both with and without the ill family member. First, when the partner is hospitalized, there is
separation between the family and the partner, creating more tension and lack of
communication between the family and partner (Marsh & Johnson, 1997). Because mental
health treatment often takes partners outside of their environment, provides them with
A More Comprehensive Treatment Approach 36
stabilizing treatment, and then discharges them back to where they were before (home, halfway
house, or the streets), when they are placed back in their environment, the family is unsure of
the condition of their loved ones (Lefley, 1997).
The studies that have addressed the return of family members to the household highlight
that the main challenges are watching for the reoccurrence of symptoms that are difficult to
foresee, causing anxiety and family disruption. Additionally, the family has a sense of loss
both for the loss of potential for their family member’s future and difference in behavior. This
is especially difficult to handle because as the symptamology decreases, families often begin to
hope that this is the mark of improvement in their loved one’s disorder (Bernheim & Lehman
1985; Eakes, Walsh, Markowski, Cain, & Swanson, 1997; Stein & Wemmerus, 2001). If that
pattern of improvement does not continue, then they feel the loss once more as they see their
loved one struggle to handle their behavior and disorder.
For the parent dealing with a child with a mental disorder, common emotions that are
experienced include anger at their own helplessness, guilt for not being able to care or protect
their loved one or for putting them into institutionalized care, an intense sense of loss at the
potential they may have seen in their child, and concern about the future care of their child
(March & Johnson 1997, Lefley 1997, Kohn-Wood & Willson 2005). Siblings struggle with
embarrassment of their sibling’s behavior, distancing from the family, resentment about
unequal parental attention, and also concern that they could also either be carrying genes that
they could pass on to their children or that they will also start showing symptoms (Lefley,
1997).
Despite this litany of difficulties that family members suffer, recent research has
recognized the positive effects of caring for an ill family member. These include the resilience
A More Comprehensive Treatment Approach 37
and gratification experienced from the role of a caretaker as well as the increased probability in
addition to the increased probability of sustained improvement of the partner (Pickett-Schenk,
Bennett, Cook, Steigman, & Lippincott, 2006; Lefley, 1997).
Because of deinstitutionalization, families are the ones who often spend the most time
with them and are the primary caregivers. They also are the ones who generally know the most
about the partner’s history, personality, and also have insight into the patient’s living situation.
Therefore it is important to make them a larger part of the treatment process. To make that
happen it is important to support them as they take on the difficult task of being the primary
caregivers. Providing them with community based support and bringing them into the
treatment process as active collaborators in developing programs to fit the home environment
will significantly help their loved one move more steadily towards improved well-being (Fox,
2012; Goldberg-Arnold, Fristad, Gavazzi, 1999).
Towards a More Comprehensive Community Approach
Through the history of mental health treatment both in Argentina and the United States,
the same systemic problems have occurred significantly limiting the possibility of ongoing
progress for partners with chronic and severe mental health disorders are entered into a system
where their progress is stagnant, limiting their ability to find a role in society. By taking a more
community-oriented approach to treatment, the stigma of the illness can be reduced, allowing
the partner to more rapidly reintegrate into a more normalized part of society when released for
inpatient facilities. Furthermore, if communities can take over a more significant role in the
treatment of mental disorders, this creates a more supportive ecosystem and helps struggling
families feel less isolated. Bringing the community into the treatment, eases some of the shame
A More Comprehensive Treatment Approach 38
and fear that prevents families from sharing the burden of caring for their loved one and
increases the probability of long-term reentry into society.
Ultimately, although community treatment does place more emphasis on the role of
family members, it also brings a larger support system and basis of caregivers to both the
family members and the people struggling with their mental disorder (Pernice-Duca, 2010;
McDonell & Dyck, 2004). For chronic mental health conditions, treatment that is not
implementable outside of an inpatient hospital is of limited value. Long-term treatment must
be accessiblt for successful reintegrationinto society. Because these are chronic conditions,
without long-term systematic treatment, the dips down into psychosis or depression grow ever
more frequent and severe. For all of these reasons, community care becomes the model of
treatment that is essential for providing care for mental health partners.
In creating a comprehensive treatment approach from looking at family needs and
dynamics, there are three key aspects of treatment that are important to address: the needs of
caretakers of mental health partners, ability of caretakers to work as collaborators in treatment
suggestions/enforcement, and movement towards social involvement of both the partner and
family members in supportive communities.
Needs of caretakers
Helping helpers is based on the idea that the people serving a challenging population
often have needs that are not addressed while they are caring for these other people in need
(Bernheim & Lehman, 1985). To address this need, helpers and caretakers are suggested to
find solutions that will relieve some of the stresses that are put on them in their role as a
supporter. In the context of a family member caring for an ill family member this includes
caretaker therapy, education about the mental health system, common symptoms, and
A More Comprehensive Treatment Approach 39
productive responses to symptoms, support groups, and relief from financial distress (Hatfield,
1978; Bernheim & Lehman, 1985; McDonell & Dyck, 2004; Lefley, 1996; 1997b; GoldbergArnold, Fristad, & Gavazzi, 1999). Each of these aspects of help provide relief and support in
dealing with situations as challenging as watching a loved family member experience such
extreme changes for their future and ability to relate to people in the same way. Therapy for
the family members, whether individual therapy, therapy with the family excluding the ill
family member, and/or therapy with the entire family all serve an important purpose in
reestablishing trust and understanding of one another within a family context.
Family psycho-education is another key aspect to establishing an understanding what it
is like to have a mental disorder and what behaviors are normal (Bernheim & Lehman, 1985;
Goldberg-Arnold, Fristad, & Gavazzi, 1999; Eakes, Walsh, Markowski, Cain, & Swanson,
1997). Psycho-education is in response to many families stating that they want more
information about the symptoms, treatments, and also want suggestions on how to react to
certain behaviors. With that information, the family members are far more capable of handling
difficult situations that occur within the community and the possibility of that occurring
becomes a less anxiety provoking idea. Also, with a consistent form of care, the ill family
member has a less disruptive and unpredictable response leading to fewer negative reactions to
emotional stimuli (Lefley, 1996; 1997b).
For taking care of the needs of helpers, support groups are essential to have as an
accessible resource for family members and partners (Drapalski et al., 2008). For family
members, taking care of a loved one with a mental disorder can be very isolating and
saddening. To have a weekly or biweekly meeting of a group of people from the community
who have gone through or are presently going through similar events, can have a huge impact
A More Comprehensive Treatment Approach 40
on the attitudes a caregiver has toward their loved one’s behavior (Chien & Norman, 2009).
Knowing how other people have struggled and worked through similar difficulties can make
the process of caring for a challenging family member moderately easier. Also, not having to
hide their home life from everyone, which is a common reaction when something so troubling
and personal is going on at home, and feeling able to include others in the struggles that a
caretaker takes on can help normalize the experience of taking care of a sick family member
(Chien & Norman, 2009; Lefley, 1996). It can take some of the weight off of the caretaker if
they can see they do not need to give up their lives to take care of their loved one. They can
both maintain a life outside of the child or spouse and not feel as if they are neglectful.
Beyond support groups or general support coming from family and friends, it is
important that we change the way that psychologists, community workers, social workers, and
religious leaders interact and support the family (Fox, 2012; Riebschleger, 2001; Carr et al.,
2004). Presently, there are major shortcomings visible when looking at the relationship
between the family and these aid providers. But to fix those shortcomings, aid can be provided
in a slightly different way and still improve upon the results. Following the model of assertive
community treatment (ACT), an intensive approach to mental health care delivery that works to
get people with severe and chronic mental illness involved in the community again, including
job training, opportunities for social relationships, residential independence, money
management, physical health, and overall increased well-being (NAMI, 2007; Smith, Jennings,
& Cimino, 2010; Sono et al., 2012). This is accomplished through services such as homevisits, 24/7 availability of their staff, and care being molded specifically to the environment of
the partner in need. Another version of that model is the forensic assertive community
treatment (FACT), which provides the same basic services, but the aid is directed toward
A More Comprehensive Treatment Approach 41
mentally ill offenders who often cycle through the prison system (Cuddeback, Morrissey, &
Cusack, 2008; Cuddeback & Morrissey, 2011; Cuddeback, Pettus-Davis, & Scheyett, 2011;
Lamberti, Weisman, & Faden, 2004; Mohan, Slade, & Fahy, 2004).
In addition to the ACT and FACT models, training community members is also crucial
for improving the support that partners and family members receive (Carr et al., 2004; Dupére
& Perkins, 2007). When training religious leaders to supplement the role of psychologists, they
can then identify people who are struggling with a mental disorder, can advise them, listen to
them and their families, and provide therapy and care that may appear less intimidating than
going to see a psychologist. Similarly, in training community leaders who are active in the
community and interact with many of the community members, they can both set a model of
how other members of the community can respond to people struggling with a mental illness.
With that kind of support, negative reactions towards mentally ill community members can be
minimized and the community becomes a less intimidating and anxiety provoking place to be.
Finally, having professionals such as police and general practitioners also be trained in how to
respond to a person having a psychotic break or a negative reaction to a stressor limits the need
for extreme measures, and can instead be handled in a calm, therapeutic way that helps the
partner. If they are brought back to an inpatient care facility because of an extreme reaction to
a stressor instead of remaining in their community, that can bring the partner back to ground
level in terms of their improvements in reentering society again. Training each of these people
who otherwise would not be very knowledgeable about what it is like to have a mental illness
or how best to react and/or treat them, also begins to erase some of the stigma that has long
been present for people with mental disorders.
A More Comprehensive Treatment Approach 42
A final aspect of providing support and care to families struggling with mental illness is
providing a kind of substitute care (Lefley, 1996; Golcman, 2012). Often either families are
not able or interested in caring for their mentally ill family member. This creates the need for
alternative housing such as half-way houses that provide therapy, a social atmosphere, care, and
teach the inhabitants how to live more independently when possible. This takes some of the
burden off families, but still provides people with a healthy environment to go to so they are
not forced to live on the streets.
Caretakers as Collaborators
The second segment of community care is to see the caretakers as people who can be
active participants of the process towards well-being (Lefley, 1996). A key problem that exists
with the present system is that intensive services are only provided for a short time and once
released, partners are not provided any kind of consistent care. If professionals, community
workers, and family members all work together to find a program that works for each of them,
then providing constant care is less intensive, allowing for family members to not feel as
burned out and exhausted. If we do not use their knowledge, then the families are still dealing
with the challenges of trying to help their mentally ill family member, but have no recognition
or assistance unless there is an extreme situation.
Additionally, family members see their loved one most and generally are the people
who know them best, so to not utilize that information is hurtful to the progress of the partner.
Therapists need to be in active communication with the families to see what the present needs
of the partner are, and what kind of treatment would be feasible within the environment at
home. If therapists try to treat a partner without considering where and by whom it will be
implemented by or affected by, there are very limited successes that can occur (Fox, 2012).
A More Comprehensive Treatment Approach 43
Social Involvement
A final and equally vital part of community treatment is establishing social reinsertion
for families and partners (Pernice-Duca, 2010; Pickett-Schnek, Bennett, Cook, Steigman, &
Lippincott, 2006; Lefley 1996; Chien & Norman, 2009). Following the emergence of a
psychological disorder in a family, both partners and families often feel isolated and unsure of
how to reengage with their community. This often creates more tension and resentment within
the home, worsening the symptoms of the partner and the reactions family members. If,
however, they can both find ways to engage in activities outside of the house, then this has
been shown to significantly affect the functioning of a family. Joining social outing groups,
work programs, art classes, or any kind of club allows people to have social interactions, learn
skills, develop confidence, and get some separation from the stress within the home or hospital.
This can help the other family members to see their loved one as more than just a helpless
victim or dependent member of the family. It gives them hope and shows how at least in little
steps, their loved one can care for him or herself (Lefley 1996).
Cost Assessment
In assessing the effectiveness of these treatment approaches, it is essential that we also
consider the viability of setting up these treatments based off cost effectiveness and the
government’s willingness to try these alternative measures. Research has been conducted on
the costs of standard and community care as well as the difficulties in attaining accurate
assessments of these costs. These studies have specifically looked at family interventions and
housing alternatives to see how we can format care that aids all actors in the treatment process
(Gianfrancesco, Wang, Yu, 2005). Treatment effectiveness research has found that providing
family management, behavioral intervention, and social support groups all significantly
A More Comprehensive Treatment Approach 44
improve social reengagement and lower the probability of rehospitalization (Mihalopulos,
Magnus, Carter, Vos 2004). Beyond lowering the disability-adjusted life years, it also
substantially lowers the cost of treatment (Mihalopulos, Magnus, Carter, Vos 2004).
For housing alternatives, studies have specifically examined homeless populations and
people who need crisis housing. In studies by Birnie (2009), researchers calculated the costs
from the societal perspective and also from the costs on the family to understand the effect on
all the actors in the mental health care system. Birnie’s study found intensive case management
to be more cost effective than standard care from the governmental and societal perspective
overall, even though agency costs were significantly greater in intensive case management.
Ultimately, it is difficult to know the precise costs of either present or proposed treatments
because of the many variables at play. This clearly needs to be the focus of additional research.
Other studies have investigated what kind of housing support is most effective and cost
effective. One of these examined how rent subsidies, intensive case management, and standard
care compare, ultimately finding that providing partners with rent subsidies, with or without
case management, is the most effective way to ensure partners are able to sustain their living
situation; partners had 16% more housed days when provided with subsidized care rather than
only providing case management and 25% more housed days than when only providing
standard care (Rosenhcek, Kasprow, Frisman, Liu-Mares 2003). From the cost analysis,
subsidized rent was found to be 15% more costly than standard care, costing $45 more than
standard care for each additional day housed. But this trade off of slightly more expensive
treatment for superior housing outcomes has been argued by the authors that it is the
worthwhile trade off (Rosenhcek, Kasprow, Frisman, Liu-Mares 2003).
Conclusions
A More Comprehensive Treatment Approach 45
While Argentina and the United States have different challenges and barriers to effectively
treating their most significantly impacted mental health partners, there is increasing evidence to
suggest that a more comprehensive, community based treatment model could speed social
reintegration and increase long-term emotional stability for chronic partners in both countries.
These treatment models would include the following components:
1. Psycho-education for caretakers covering available services, common symptoms, and ways
to respond to partner’s behavior
2. Improving communication between mental health workers and family members
3. Providing substitute care and housing for partners
4. Utilizing the caretaker’s knowledge to format partner specific care
5. Creating support groups for families struggling with mental disorders
With relatively insignificant investments in community care, a series of minor alterations of
the present systems could lead to a far more effective way of working with mental illness.
Given the relative wealth of both countries, this type of intensive treatment would seem to be
well within our capabilities if we are willing to reprioritize our budget allocations to support
our most chronically impaired citizens.
A More Comprehensive Treatment Approach 46
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