According to the World Health Organization, mental health conditions are increasing worldwide. These reports claim a 13% rise in mental health conditions over the last decade with mental health conditions now accounting for approximately 1 in 5 years lived with disability. Furthermore, it is estimated that depression and anxiety cost the global economy US$ 1 trillion each year.
While there does seem to be a desperate need for more mental health service; in many circles, there is vigorous pushback and complaints against our current service models of treatment. Some of the more serious allegations may be summarized as follows:
- Treatment serves the needs of the institution first (i.e., by providing jobs, status) rather than the needs of the client-patients
- Treatment is a form of social control used against those who do not fit in or cannot adapt to the current laws, regulations and norms of society
- Treatment is often educated guesswork, and the client-patients are often subject to involuntary (or uninformed) participation in these experiments
- Treatment creates a sense of dependency within the client-patients; they do not get better, rather they become more dependent on services to function
Although these claims have all been disputed, they each bear some degree of truthfulness. The problem is even more complicated when considering that, historically, transitioning clients to alternative service models (e.g., community care) has lead to disastrous results. Whatever the critiques of the current service model, there does seem to be some near-universal agreement on what actually constitutes effective care. The great humanistic psychologist, Carl Rogers, summarized a few of these principles:
1_The therapist and client-patient are in “psychological contact”
2_The client-patient is in a state of vulnerability
3_The therapist is able to receive that vulnerability with care and focused attention on the client-patient
4_The therapist experiences positive regard for the personhood of the client-patient, without any strings attached (i.e., independent of problem or financial compensation)
5_The therapist is able to empathize and understand the client-patient’s internal frame of reference
6_The therapist is able to effectively communicate understanding and positive regard to the client-patient
Since Rogers’ time, other equally important principles have been discovered including the need for the patient-client to feel effective at what they do, and in charge of fulfilling their potential in the world. I would like to highlight one more: the need to feel in service to something or someone. Ironically, this has always been known in mental health. Ask nearly any nurse, physician, psychiatrist, or psychologist why they entered their field and they will respond with some affirmation of a need to help others. To be sure, this need can be easily exploited in those that avail their physical and psychic energy to others. Most of us are familiar with the words burnout, vicarious trauma, and compassion fatigue—each of which describes some type of maladjustment or disorder that may result from not properly balancing our service-needs with other physical, psychological and social needs. This caution notwithstanding, the need to be in service is such a powerful motivator and benefactor for health care providers that it is simply astounding that this need has not been more recognized and afforded to the actual recipients of the health care. In psychological parlance, this might be considered a blind spot. Although times may be a changin’
increasing client empowerment and helping them feel useful again, may not only decrease service utilization in the long-term but also tap into a long-ignored therapeutic that we can all use to turn the tide in treating mental health conditions.
The history of institutionalized care (at least in the West) has largely been based on paternalistic “moral” models of care developed in the 19th century. These models have and continue to demonstrate success in effecting remission of illness and reintegration into society. However, there is also recognition, both in Europe and America, of often gross inefficiencies—perhaps by design—that do not benefit the recovery of the client-patient and might even serve to create a lifelong dependency on external care. To address the frustrating (and degrading) revolving door of service utilization, there is now an emerging alternative trend in non-profit work which includes the service recipients (i.e., client-patients) in decision-making; increasing their stake-ownership, and even granting them paid roles within the service agency. This form of ‘care’, which is essentially focused on increasing client empowerment and helping them feel useful again, may not only decrease service utilization in the long-term but also tap into a long-ignored therapeutic that we can all use to turn the tide in treating mental health conditions.
People have—and will always have—a need to matter and to belong; to feel useful and to be productive. This is not simply an anecdotal claim. Consider what happens when people do not feel useful. The holocaust survivor and eminent psychiatrist, Dr. Viktor Frankl recounts, for example, how the Nazi prison guards attempted to crush the spirits of their captives by imposing back-breaking work upon them (i.e., moving heavy stones from one pile to another) and then depriving that work of any meaning (having to move the stones back to the original pile the following day). In a similar, but obviously more humane, set of experiments, the researcher Dan Ariely demonstrated that participants who completed a menial task and subsequently learned that their labor was pointless were much more likely to become unmotivated, disengaged and game the system to avoid work. This makes sense when we realize that their work was not only unrewarded but fundamentally not respected. Health care workers and patients alike may wonder at whether the hospitals, schools and clinics may also, unwittingly, be creating ‘busy work’ for their patients only to disregard it for more ‘important’ matters. The question then becomes: why would we design institutions for ‘health’ that may also create unmotivated, disengaged and avoidant patients?
Those that were protected and told that there was ‘nothing for them to do’ actually reported more traumatic distress and disability afterwards than those who were directly involved in the helping.
Let’s look at what happens when people in distress when they are given a strong sense of purpose. For example, it has been documented (see here and here for more information) that during the bombing of London during World War II—a period referred to as “the blitz”—the rates of psychiatric admissions actually decreased. These rates, of course, went up afterwards but during the actual event it seemed that people were not being admitted to mental hospitals. Now there are many plausible reasons for this—it could be that admissions were closed or restricted as hospitals became unsafe or overburdened with other casualties. However, there is also the claim that during the actual crisis, the mentally ill (or neurotics as they were often called then) were busy doing tasks such as administering aid or driving ambulances. They felt too useful to be hospitalized! One of the world’s foremost experts on trauma, Dr. Bessel van der Kolk, recalls how survivors of a flooding in Asia were either sequestered from the damage or directly involved in rescue and aid efforts. Those that were protected and told that there was ‘nothing for them to do’ actually reported more traumatic distress and disability afterwards than those who were directly involved in the helping. This finding seems to also hold for the survivors of Hurricane Katrina. In 2001, the psychiatrist Derek Summerfield was in Cambodia researching chemical antidepressants. He recalled meeting a farmer who had lost a leg due to a landmine explosion. His research team tried to treat the man with therapy and even provided him an artificial limb. However the depression persisted. It was only after they had bought the man a cow that his depression remitted. What gives? Well, apparently, having the cow allowed the man to be a productive member of his farming community. By restoring his usefulness they had restored his health. This phenomenon has also been proposed as a factor to explain why people with schizophrenia and other psychotic illnesses appear to fare better in third-world countries (where they presumably have limited access to quality mental health care) than in first-world or developed nations. In these societies, the mentally ill might be better integrated into society—perhaps by necessity—and given tasks to support the community rather than be removed and isolated from work, friends and home life.
We can help people develop higher expectations for themselves and for their therapy, increase their hope and self confidence, and help them feel relevant and useful to the community.
Towards the end of his life, Dr. Aaron Beck, the founder of cognitive therapy (one of the most popular forms of psychotherapy in the world), even suggested that shifting client-patients from a “patient mode” to an “adaptive mode” (e.g., socializing, working, engaging in meaningful activities) may help even the most dysfunctional individuals achieve some level of recovery. A whole new paradigm for therapy is emerging. A leading theory in motivation suggests that people have a fundamental need to independently complete activities that contribute to the wellbeing of the wider community (e.g., family, work, neighborhood) of which they are themselves a part of.
It seems that we are at a threshold moment in mental health care. We are beginning to acknowledge the powerful psychosocial medicine that results from unlocking the hidden potential within most, if not all, of the client-patients who receive service. We can help people develop higher expectations for themselves and for their therapy, increase their hope and self confidence, and help them feel relevant and useful to the community. In other words, we can help direct our service users towards service giving. This approach can work alongside with the more traditional methods of caring for, educating and protecting our client-patients. However, we must be aware that the old, paternalistic models on which our current mental health care system is based have already outlived their use.
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