Mental Health: A Report of the Surgeon General

Figure 2-5a. Annual prevalence of mental/addictive disorders and services for adults

Percent of Population (28%) With
Mental/Addictive Disorders
     (in one year)

Percent of Population (15%) Receiving
    Mental Health Services*

Diagnosis and
No Treatment
(20%)

Treatment and No Diagnosis,
Other Mental Health Problem
  Inferred 57%)

Diagnosis and Treatment (6%)

Figure 2-5b. Annual prevalence of mentaUaddictive disorders and services for adults

Percent of Population (28%) With            Percent of Population (15%) Receiving
Mental/Addictive Disorders                    Mental Health Services*

(in one year)

Diagnosis and
No Treatment
(20%)

1     (in one year)

Percent of Population Receiving
  Specialty Care (6%)

Percent of Population Receiving
General Medical Care (5%)

   r   Percent of Population Receiving
      Other Human Services and
.       Voluntary Support (4%)

--

--

'

Due to rounding, it appears that 9 percent of the population has a diagnosis and receives treatment. The actual
figure is closer to 6 percent, as stated in the text. It also appears that 6 percent of the population receives
services but has no diagnosis, due to rounding. The actual total is 7 percent, as stated in the text.

**

For those who use more than one sector of the service system, preferential assignment is to the most
specialized level of mental health treatment in the system.

Sources: Regier et al., 1993; Kessler et al., 1996

76


The Fundamentals of Mental Health and Mental Illness

Percent of Population (21%) With           Percent of Population (21%) Receiving
MentaVAddictive Disorders                    Mental Health Services
    (in one year)                       (In one yefar)

Figure 2-6a. Annual prevalence of mentapaddictive disorders and servfces for children

Diagnosis and
No Treatment
(11%)

Treatment and No Diagnosis,
Other Mental Health Problem
   Inferred (11%)

Diagnosis and Treatment (10%)

Figure 26b. Annual prevalence of mentaVaddictive disorders and services for children

Percent of Populatlon (21%) With
MentaUAddictlve Dlsorders
    (In one year)

Percent of Populatlon (21%) Receiving
    Mental Health Services

  k   (in one year)

Diagnosis and
No Treatment
(11%)

--.

`9

_------_------- ----
  Percent o! Population Receivir
     Specialty Care (8%)
         -_---_--_---
     rcent of Population Receiving
       General Medical Care (1%)
        ----e--e----

--_

- L -

Percent of Population
Receiving School
Services (11%)

' ~~~~~o~~o~~aiio~~~~ -
     Other Human Services and
      Voluntaw Suooort (1%)
-----------`-AL-L-i

---

o * For those who use more than one sector of the service system, preferential assignment is to the most
specialized level of mental health treatment in the ???????

Source: Shaffer et al., 1996

77


Mental Health: A Report of the Surgeon General

  An era of "moral treatment" was introduced
from Europe at the turn of the 19th century,
representing the first of four reform movements in
mental health services in the United States
(Morrissey & Goldman, 1984; Goldman &
Morrissey, 1985) (Table 2-10).
The first reformers, including Dorothea Dix and
Horace Mann, imported the idea that mental illness
could be treated by removing the individual to an
asylum to receive a mix of somatic and psychosoci-
al treatments in a controlled environment
characterized by "moral" sensibilities, The term
"moral" had a connotation different from that of
today. It meant the return of the individual to
reason by the application of psychologically
oriented therapy" (Grob, 1994). The "moral treat-
ment" period was characterized by the building of
private and public asylums. Almost every state had
an asylum dedicated to the early treatment of
mental illness to restore mental health and to keep
patients from becoming chronically ill. Moral
treatment accomplished the former objective, but it
could not prevent chronicity.

Shortly after the Civil War, the failures of the
promise of early treatment were recognized and
asylums were built for untreatable, chronic
patients. The quality of care deteriorated in public
institutions, where overcrowding and underfunding
ran rampant. A new reform movement, devoted to
"mental hygiene," began late in the 19th century. It
combined the newly emerging concepts of public
health (which at the time was referred to as
"hygiene"),  scientific medicine,  and social
progressivism. Although the states built the public
asylums, local government was expected to pay for
each episode of care. To avoid the expense, many
communities continued to use local almshouses and
jails. Asylums could not maintain their budgets,
care deteriorated, and newspaper exposes revealed
inhuman conditions both in asylums and local

I9 According to a student of the originator of moral treatment,
Philippe Pinel, "moral treatment is the application of the faculty of
intelligence and of the emotions in the treatment of mental
alienation" (Grob, 1994).

welfare institutions. State Care Acts were passed
between 1894 and World War I. These acts
centralized financial responsibility for the care of
individuals with mental illness in every state
government.  Local government took the
opportunity to send everyone with a mental illness,
including dependent older citizens, to the state
asylums. Dementia was redefined as a mental
illness, although only some of the older residents
were demented. For the past century the states have
carried this responsibility at very low cost, in spite
of the magnitude of the task.

The reformers of the "mentaihygiene" period,
who formed the National Committee on Mental
Hygiene (now  the National Mental Health
Association [NMHA]), called for an expansion of
the new science, particularly of neuropathology, in
asylums, which were renamed mental hospitals.
They also called for "psychopathic hospitals and
clinics" to bring the new science to patients in
smaller institutions associated with medical
schools. They opened several psychiatric units in
general hospitals to move mental health care into
the mainstream of health care. The mental
hygienists believed in the principles of early
treatment and expected to prevent chronic mental
illness. To support this effort, they advocated for
outpatient treatment to identify early cases of
mental disorder and to follow discharged
inpatients.

Treatments were not effective. Early treatment
was no more successful in preventing patients from
becoming chronically ill in the early 20th century
than it was in the early years of the previous
century. At best, the hospitals provided humane
custodial care; at worst, they neglected or abused
the patients. Length of stay did begin to decline for
newly admitted inpatients, but older, long-stay
patients filled public asylums. The financial
problems and overcrowding deepened during the
Depression and during World War II.

Enthusiasm for early interventions, developed
by military mental health services during World
War II, brought a new sense of optimism about

78


The Fundamentals of Mental Health and Mental Illness

Table 2-10. Historical reform movements in mental health treatment in the United States

ommunity Mental Health     1955-l 970   Community mental health center  Deinstitutionalization,
                                      social integration
          x -_.  ,< (. . . . ." `,. m__*_ /A"_. *;*s ,    %^ * ,* ,"F,F7F
       *. ,  ". "i,. a. x " --.e 1 ea_-I _.a?;.4a1_  ." 5-r xrr E..,,.r,.*-.a*~
Community Support      1975-present  Community support          Mental illness as a social welfare

Sources: Morrissey & Goldman, 1984; Goldman & Morrissey, 1985

treatment by the middle of the 20th century. Again,
early treatment of mental disorders was
championed and a new concept was born,
"community mental health."- The NMHA figured
prominently in this reform, along with the Group
for the Advancement of Psychiatry. Borrowing
some ideas from the mental hygienists and
capitalizing on the advent of new drugs for treating
psychosis and depression, community mental health
reformers argued that they could bring mental
health services to the public in their communities.
They suggested that long-term instituti'onal care in
mental hospitals had been neglectful, ineffective,
even harmful. The joint policies of "community
care" and "deinstitutionalization" led to dramatic
declines in the length of hospital stay and the
discharge of many patients from custodial care in
hospitals.
  Concomitantly, these policies led to the
expansion of outpatient services in the community,
particularly in federally funded community mental
health centers. Federal legislation beginning in the
mid-1960s fueled this expansion through grants to
centers and then through the inclusion of some
(albeit limited) mental health benefits in Medicare
and Medicaid. The latter was particularly
important, because it stimulated the transfer of
many long-term inpatients from public mental
hospitals to nursing homes, encouraged the opening

of psychiatric units in general hospitals, and
ultimately paid for many rehabilitation services for
individuals with severe and persistent mental
disorders.

  The dual policies of community care and
deinstitutionalization, however, were implemented
without evidence of effectiveness of treatments and
without a social welfare system attuned to the
needs of hundreds of thousands of individuals with
disabling mental illness. Housing, support services,
community treatment approaches, vocational
opportunities, and income supports for those unable
to work were not universally available in the
community. Neither was there a truly welcoming
spirit of community support for "returning" mental
patients. Many discharged mental patients found
themselves in welfare and criminal justice
institutions, as had their predecessors in earlier
eras; some became homeless or lived in regimented
residential (e.g., board and care) settings in the
community.

The special needs of individuals with severe
and persistent mental illness were not being met
(General Accounting Office, 1977; Turner &
TenHoor, 1978). Early treatment did not prevent
disability, although new approaches to treatment
would eventually reduce morbidity and improve
quality of life. A fourth reform era (197%present),
called the "community support" movement, grew

79


Mental Health: A Report of the Surgeon General

directly out of the "community mental health
movement." This new reform movement called for
an end to viewing and responding to chronic mental
disorder only as the object of neglect, by favoring
acute treatment and prevention. Reformers
advocated for developing "community support
systems," with an expanded vision of care and
treatment as encompassing the social welfare needs
of individuals with disabling mental illness. The
emphasis favored the view that individuals could
once again become citizens of their community, if
given support and access to mainstream resources
such as housing and vocational opportunities
(Goldman, 1998). At first, mental health treatments
were deemphasized in favor of social supports, but
newer medications, such as SSRIs and novel anti-
psychotic drugs, and more effective psychosocial
interventions,  such as assertive- community
treatment for schizophrenia (Chapter 4), facilitated
the objectives of community support and recovery
in the community.

The voluntary support network expanded with
an emphasis on "recovery," a concept introduced
by service users, or consumers, who began to take
an active role in their own care and support and in
making policy. From their inception in the late
197Os, family organizations, such as the National
Alliance for the Mentally Ill and the Federation of
Families, advocated for services for individuals
who are most impaired. As discussed later in this
chapter, consumers,  who also call themselves
"survivors," have formed their own networks for
support and advocacy and work with other
advocacy groups such as the National Mental
Health Association and the Bazelon Center for
Mental Health Law.

The de facto mental health system is complex
because it has metamorphosed over time under the
influence of a wide array of factors, including
reform movements and their ideologies, financial
incentives based on who would pay for what kind
of services, and advances in care and treatment
technology. Each factor has been important in its
own way. The hybrid system that emerged serves

many diverse functions. Unfortunately for those
individuals with the most complex needs, and who
often have the fewest financial resources, the
system is fragmented and difficult to use to meet
those needs effectively. Efforts at integrating the
service system and tailoring it to those with the
greatest needs are discussed, by age group, in
subsequent chapters of the report. Many problems
remain, including the lack of health insurance by 16
percent of the U.S. population, underinsurance for
mental disorders even among those who have health
insurance, access barriers to members of many
racial and ethnic groups, discrimiiation, and the
stigma about mental illness, which is one of the
factors that impedes help-seeking behavior.

Overview of Cultural Diversity and
Mental Health Services

The U.S. mental health system is not well equipped
to meet the needs of racial and ethnic minority
populations. Racial and ethnic minority groups are
generally considered to be underserved by the
mental health services system (Neighbors et al.,
1992; Takeuchi & Uehara, 1996; Center for Mental
Health Services [CMHS], 1998). A constellation of
barriers deters ethnic and racial minority group
members from seeking treatment, and if individual
members of groups succeed in accessing services,
their treatment may be inappropriate to meet their
needs.

Awareness of the problem dates back to the
1960s and 197Os, with the rise of the civil rights
and community mental health movements (Rogler
et al., 1987) and with successive waves of
immigration from Central America, the Caribbean,
and Asia (Takeuchi & Uehara, 1996). These
historical forces spurred greater recognition of the
problems that minority groups confront in relation
to mental health services.

Research documents that many members of
minority groups fear, or feel ill at case with, the
mental health system (Lin et al., 1982; Sussman et
al., 1987; Scheffler & Miller, 1991). These groups
experience it as the product of white, European

80


culture, shaped by research primarily on white,
European POpUlatiOUS.  They may find only
clinicians who represent a white middle-class
orientation, with its cultural values and beliefs, as
well as its biases, misconceptions, and stereotypes
of other cultures.

Research and clinical practice have propelled
advocates and mental health professionals to press
for  "linguistically and culturally competent
services" to improve utilization and effectiveness
of treatment for different cultures. Culturally
competent services incorporate respect for and
understanding of, ethnic and racial groups, as well
as their histories, traditions, beliefs, and value
systems (CMHS,  1998). Without culturally
competent services, the failure to serve racial and
ethnic minority groups adequately is expected to
worsen, given the huge demographic growth in
these populations predicted over the next decades
(Takeuchi & Uehara,  1996; CMHS, 1998;
Snowden, 1999).

This section of the chapter amplifies these
major conclusions. It explains the confluence of
clinical, cultural, organizational, and financial
reasons for minority groups being underserved by
the mental health system. The first task, however,
is to explain which ethnic and racial groups
constitute underserved populations, to describe
their changin g demographics, and to define the
term "culture" and its consequences for the mental
health system.

Introduction to Cultural Diversity and
Demographics
The Federal government officially designates four
major racial or ethnic minority groups in the United
States: African American (black), Asian/Pacific
Islander, Hispanic American (Latino),20 and Native
American/American Indian/Alaska Native/Native
Hawaiian (referred to subsequently as "American
Indians") (CMHS, 1998). There are many other

I0 The term "Latino(a)" refers to all persons of Mexican, Puerto
Rican, Cuban, or other Central and South American or Spanish
origin (CMHS. 1998).

racial or ethnic minorities and considerable
diversity within each of thg four groupings listed
above. The representation of the four officially
designated groups in the U.S. population in 1999 is
as follows: African Americans constitute the
largest group,  at 12.8 percent of the U.S.
,population; followed by Hispanics (11.4 percent),
Asian/Pacific Islanders (4.0 percent), and American
Indians (0.9 percent) (U.S. Census Bureau, 1999).
Hispanic Americans are among the fastest-growing
groups. Because their population growth outpaces
that of African Americans, they are projected to be
the predominant minority group (24.5 percent of
the U.S. population) by tGe. year 2050 (CMHS,
1998).

Racial and ethnic populations differ from one
another and from the larger society with respect to
culture. The term "culture" is used loosely to
denote a common heritage and set of beliefs,
norms,  and values. The cultures with which
members of minority racial and ethnic groups
identify often are markedly different from
industrial societies of the West. The phrase
"cultural identity" specifies a reference group-an
identifiable social entity with whom a person
identifies and to whom he or she looks for
standards of behavior (Cooper & Denner, 1998). Of
course, within any given group, an individual's
cultural identity may also involve language,
country of origin, acculturation,2' gender, age,
class,  religious/spiritual  beliefs, sexual
orientation", and physical disabilities (Lu et al.,
1995). Many people have multiple ethnic or
cultural identities.

The historical experiences of ethnic and
minority groups in the United States are reflected

?' Acculturation refers to the "social distance" separating members
of an ethnic or racial group from the wider society in areas of beliefs
and values and primary group relations (work, social clubs, family,
friends) (Gordon, 1964). Greater acculturation thus reflects greater
adoption of mainstream beliefs and practices and entry into primary
group relations.
z Research is emerging on the importance of tailoring services to
the special needs of gay, lesbian, and bisexual mental health service
users (Cabaj & Stein, 1996).

The Fundamentals of Mental Health and Mental Illness

81


Mental Health: A Report of the Surgeon General

in differences in economic, social, and political
status. The most measurable difference relates to
income. Many racial and ethnic minority groups
have limited financial resources. In 1994, families
from these groups were at least three times as likely
as white families to have incomes placing them
below the Federally established poverty line. The
disparity is even greater when considering extreme
poverty-family incomes at a level less than half of
the poverty threshold-and is also large when
considering children and older persons (O'Hare,
1996). Although some Asian Americans are
somewhat better off financially than other minority
groups, they still are more than one and a half times
more likely than whites to live in poverty. Poverty
disproportionately affects minority women and
their children (Miranda & Green, 1999). The
effects of poverty are compounded by differences
in total value of accumulated assets, or total wealth
(O'Hare et al., 1991).
  Lower socioeconomic status-in terms of
income, education, and occupation-has been
strongly linked to mental illness. It has been known
for decades that people in the lowest
socioeconomic strata are about two and a half times
more likely than those in the highest strata to have
a mental disorder (Holzer et al., 1986; Regier et al.,
1993b). The reasons for the association between
lower socioeconomic status and mental illness are
not well understood. It may be that a combination
of greater stress in the lives of the poor and greater
vulnerability to a variety of stressors leads to some
mental disorders, such as depression. Poor women,
for example, experience more frequent, threatening,
and uncontrollable life events than do members of
the population at large (Belle, 1990). It also may be
that the impairments associated with mental
disorders lead to lower socioeconomic status
(McLeod & Kessler, 1990; Dohrenwend, 1992;
Regier et al., 1993b).

Cultural identity imparts distinct patterns of
beliefs and practices that have implications for the
willingness to seek, and the ability to respond to,

mental health services. These include coping styles
and ties to family and community, discussed below.

Coping Styles

Cultural differences can be reflected in differences
in preferred styles of coping with day-to-day
problems. Consistent with a cultural emphasis on
restraint, certain Asian American groups, for
example, encourage a tendency not to dwell on
morbid or upsetting thoughts, believing that
avoidance of troubling internal events is warranted
more than recognition and outward expression
(Leong & Lau, 1998). They. have little willingness
to behave in a fashion that might disrupt social
harmony (Uba, 1994). Their emphasis on willpower
is similar to the tendency documented among
African Americans to minimize the significance of
stress and, relatedly, to try to prevail in the face of
adversity through increased striving (Broman,
1996).

Culturally rooted traditions of religious beliefs
and practices carry important consequences for
willingness to seek mental health services. In many
traditional societies, mental health problems can be
viewed as spiritual concerns and as occasions to
renew one's commitment to a religious or spiritual
system of belief and to engage in prescribed
religious or spiritual forms of practice. African
Americans (Broman, 1996) and a number of ethnic
groups (Lu et al., 1995), when faced with personal
difficulties, have been shown to seek guidance from
religious figures.23

   Many people of all racial and ethnic
backgrounds believe that religion and spirituality
favorably impact upon their lives and that well-
being, good health, and religious commitment or
faith are integrally intertwined (Taylor, 1986;
Priest, 1991; Bacote, 1994; Pargament, 1997).
Religion and spirituality are deemed important
because they can provide comfort, joy, pleasure,
and meaning to life as well as be means to deal

u Of the 15 percent of the U.S. population that use mental health
services in a given year, about 2.8 percent receive care only from
members of the clergy (Larson et al., 1988).

82


The Fundamentals of Mental Health and Mental Illness

with death, suffering, pain, injustice, tragedy, and
stressful experiences in the life of an individual or
family (Pargament, 1997). In the family/com-
munity-centered perception of mental illness held
by Asians and Hispanics, religious organizations
are viewed as an enhancement or substitute when
the family is unable to cope or assist with the
problem (Acosta et al., 1982; Comas-Diaz, 1989;
Cook & Timberlake, 1989; Meadows, 1997).
Culture also imprints mental health by
influencing whether and how individuals
experience the discomfort associated with mental
illness. When conveyed by tradition and sanctioned
by cultural norms,  characteristic modes of
expressing suffering are sometimes called "idioms
of distress" (Lu et al., 1995). Idioms of distress
often reflect values and themes found in the
societies in which they originate.
  One of the most common idioms of distress is
somatization, the expression of mental distress in
terms of physical suffering. Somatization occurs
widely and is believed to be especially prevalent
among persons from a number of ethnic minority
backgrounds (Lu et al., 1995). Epidemiological
studies have confirmed that there are relatively
high rates of somatization among African
Americans (Zhang & Snowden, in press). Indeed,
somatization resembles an African American folk
disorder identified in ethnographic research and is
linked to seeking treatment (Snowden, 1998).
  A number of idioms of distress are well
recognized as culture-bound syndromes and have
been included in an appendix to DSM-IV. Among
culture-bound syndromes found among some Latin0
psychiatric patients is ataque de nervios, a
syndrome of "uncontrollable shouting, crying,
trembling, and aggression typically triggered by a
stressful event involving family. . . " (Lu et al.,
1995, p. 489). A Japanese culture-bound syndrome
has appeared in that country's clinical modification
of ICD-10 (WHO Znternafional Classification of
Diseases, 10th edition, 1993). Taijin kyofusho is an
intense fear that one's body or bodily functions
give offense to others. Culture-bound syndromes

sometimes reflect comprehensive systems of belief,
typically emphasizing a need for a balance between
opposing forces (e.g., yin/yang, "hot-cold" theory)
or the power of supernatural forces (Cheung &
Snowden, 1990). Belief in indigenous disorders and
adherence to culturally rooted coping practices are
more common among older adults and among
persons who are less acculturated. It is not well
known how applicable DSM-IV diagnostic criteria
are to culturally specific symptom expression and
culture-bound syndromes.

Family and Community as Resources
Ties to family and community, especially strong in
African, Latino, Asian, and Native American
communities, are forged by cultural tradition and
by the current and historical need to assist arriving
immigrants, to provide a sanctuary against
discrimination practiced by the larger society, and
to provide a sense of belonging and affirming a
centrally held cultural or ethnic identity.
Among Mexican-Americans (de1 Pinal &
Singer, 1997) and Asian Americans (Lee, 1998)
relatively high rates of marriage and low rates of
divorce, along with a greater tendency to live in
extended family households, indicate an orientation
toward family. Family solidarity has been invoked
to explain relatively low rates among minority
groups of placing older people in nursing homes
(Short et al., 1994).

  The relative economic success of Chinese,
Japanese,  and Korean Americans has been
attributed to family and communal bonds of
association  (Fukuyama, 1995). Community
organizations and networks established in the
United States include rotating credit associations
based on lineage, surname, or region of origin.
These organizations and networks facilitate the
startup of small businesses.

There is evidence of an African American
tradition of voluntary organizations and clubs often
having political, economic, and social functions
and affiliation with religious  organizations
(Milburn & Bowman, 1991). African Americans

83


Mental Health: A Report of the Surgeon General

and other racial and ethnic minority groups have
drawn upon an extended family tradition in which
material and emotional resources are brought to
bear from a number of linked households.
According to this literature, there is "(a) a high
degree of geographical propinquity; (b) a strong
sense of family and familial obligation; (c) fluidity
of household boundaries, with greater willingness
to absorb relatives, both real and fictive, adult and
minor, if need arises; (d) frequent interaction with
relatives;  (e) frequent extended family get-
togethers for special occasions and holidays; and
(f) a system of mutual aid" (Hatchett & Jackson,
1993, p. 92).

Families play an important role in providing
support to individuals with mental health problems.
A strong sense of family loyalty means that, despite
feelings of stigma and shame, families are an early
and important source of assistance in efforts to
cope, and that minority families may expect to
continue to be involved in the treatment of a
mentally ill member (Uba, 1994). Among Mexican
American families, researchers have found lower
levels of expressed emotion and lower levels of
relapse (Karno et al., 1987). Other investigators
have demonstrated an association between family
warmth and a reduced likelihood of relapse (Lopez
et al., in press).

Epidemiology and Utilization of Services
One of the best ways to identify whether a minority
group has problems accessing mental health
services is to examine their utilization of services
in relation to their need for services. As noted
previously, a limitation of contemporary mental
health knowledge is the lack of standard measures
of "need for treatment" and culturally appropriate
assessment tools. Minority group members' needs,
as measured indirectly by their prevalence of
mental illness in relation to the U.S. population,
should be proportional to their utilization, as
measured by their representation in the treatment
population. These comparisons turn out to be
exceedingly complicated by inadequate under-

84

standing of the prevalence of mental disorders
among minority groups in the United States.24
Nationwide studies conducted many years ago
overlooked institutional populations, which are
disproportionately represented by minority groups.
Treatment utilization information on minority
groups in relation to whites is more plentiful, yet,
a clear understanding of health seeking behavior in
various cultures is lacking.

The following paragraphs reveal that disparities
abound in treatment utilization: some minority
groups are underrepresented in ,the outpatient
treatment population while, at the same time,
overrepresented in  the inpatient population.
Possible explanations for the differences in utili-
zation are discussed in a later section.

African Americans

The prevalence of mental disorders is estimated to
be higher among African Americans than among
whites (Regier et al., 1993a). This difference does
not appear to be due to intrinsic differences
between the races; rather, it appears to be due to
socioeconomic differences. When socioeconomic
factors are taken into account, the prevalence
difference disappears. That is, the socioeconomic
status-adjusted rates of mental disorder among
African Americans turn out to be the same as those
of whites. In other words, it is the lower
socioeconomic status of African Americans that
places them at higher risk for mental disorders
(Regier et al., 1993a).

African Americans are underrepresented in
some outpatient treatment populations, but over-
represented in public inpatient psychiatric care in
relation to whites (Snowden & Cheung, 1990;

24 In spring 2000, survey field work begins on an NJMH-funded
study of the prevalence of mental disorders, mental health
symptoms,  and related functional impairments in African
Americans, Caribbean blacks, and non-Hispanic whites. The study
will examine the effects of psychosocial factors and race-associated
stress on mental health, and how coping resources and strategies
influence that impact. The study will provide a database on mental
health, mental disorders, and ethnicity and race. James Jackson,
Ph.D., University of Michigan, is principal investigator.


Snowden, in press-b). Their underrepresentation in
outpatient treatment varies according to setting,
type of provider, and source of payment. The racial
gap between African Americans and whites in
utilization is smallest, if not nonexistent, in com-
munity-based programs and in treatment financed
by public sources, especially Medicaid (Snowden,
1998) and among older people (Padgett et al.,
1995). The underrepresentation is largest in
privately financed care, especially individual
outpatient practice, paid for either by fee-for-
service arrangements or managed care. As a result,
underrepresentation in the outpatient setting occurs
more among working and middle-class African
Americans, who `are privately insured, than among
the poor. This suggests that socioeconomic
standing alone cannot explain the problem of
underutilization (Snowden, i998).

African Americans are, as noted above,
overrepresented in inpatient psychiatric care
(Snowden, in press-b). Their rate of utilization of
psychiatric inpatient care is about double that of
whites (Snowden & Cheung, 1990). This difference
is even higher than would be expected on the basis
of prevalence estimates. Overrepresentation is
found in hospitals of all types except private
psychiatric hospitals.25 While difficult to explain
definitively, the problem of overrepresentation in
psychiatric hospitals appears more rooted in
poverty, attitudes about seeking help, and a lack of
community support than in clinician bias in
diagnosis and overt racism, which also have been
implicated (Snowden, in press-b). This line of
reasoning posits that poverty, disinclination to seek
help, and lack of health and mental health services
deemed appropriate, and responsive, as well as
community support, are major contributors to
delays by African Americans in seeking treatment
until symptoms become so severe that they warrant
inpatient care.

" African Americans are overrepresented among persons
undergoing involuntary civil commitment (Snowden, in press-b).

The Fundamentals of Mental Health and Mental Illness

Finally, African Americans are more likely than
whites to use the emergency room for mental health
problems (Snowden, in press-a). Their overreliance
on emergency care for mental health problems is an
extension of their overreliance on emergency care
for other health problems. The practice of using the
emergency room for routine care is generally
attributed to a lack of health care providers in the
community willing to offer routine treatment to
people without insurance (Snowden, in press-a).

Asian Americans/Pacific &landers
The prevalence of mental .illness among Asian
Americans  is difficult to determine for
methodological reasons (i.e., population sampling).
Although some studies suggest higher rates of
mental illness, there is wide variance across
different groups of Asian Americans (Takeuchi &
Uehara, 1996). It is not well known how applicable
DSM-IV diagnostic criteria are to culturally
specific symptom expression and culture-bound
syndromes. With respect to treatment-seeking
behavior, Asian Americans are distinguished by
extremely low levels at which specialty treatment
is sought for mental health problems (Leong & Lau,
1998). Asian Americans have proven less likely
than whites, African Americans, and Hispanic
Americans to seek care. One national sample
revealed that Asian Americans were only a quarter
as likely as whites, and half as likely as African
Americans and Hispanic Americans, to have sought
outpatient treatment (Snowden, in press-a). Asian
Americans/Pacific Islanders are less likely than
whites to be psychiatric inpatients (Snowden &
Cheung, 1990). The reasons for the underutilization
of services include the stigma and loss of face over
mental health problems,  limited English
proficiency among  some Asian immigrants,
different cultural explanations for the problems,
and the inability to find culturally competent ser-
vices. These phenomena are more pronounced for
recent immigrants (Sue et al., 1994).

85


Mental Health: A Report of the Surgeon General

Hispanic Americans

Several epidemiological studies revealed few
differences between Hispanic Americans and
whites in lifetime rates of mental illness (Robins &
Regier, 1991; Vega & Kolody, 1998). A recent
study of Mexican Americans in Fresno County,
California, found that Mexican Americans born in
the United States had rates of mental disorders
similar to those of other US. citizens, whereas
immigrants born in Mexico had lower rates (Vega
et al., 1998a). A large study conducted in Puerto
Rico reported similar rates of mental disorders
among residents of that island, compared with those
of citizens of the mainland United States (Canino et
al., 1987).

Although rates of mental illness may be similar
to whites in general, the prevalence of particular
mental health problems, the manifestation of
symptoms, and help-seeking behaviors within
Hispanic subgroups need attention and further
research. For instance, the prevalence of depressive
symptomatology is higher in Hispanic women
(46%) than men (almost 20%); yet, the known risk
factors do not totally explain the gender difference
(Vega et al., 1998a; Zunzunegui et al., 1998).
Several studies indicate that Puerto Rican and
Mexican American women with depressive
symptomatology are underrepresented in mental
health services and overrepresented in general
medical services (Hough et al., 1987; Sue et al.,
1991, 1994; Duran, 1995; Jimenez et al., 1997).

Native Americans

American Indians/Alaska Natives have, like Asian
Americans and Pacific Islanders, been studied in
few epidemiological surveys of mental health and
mental disorders. The indications are that
depression is a significant problem in many
American Indian/Alaska Native communities
(Nelson et al., 1992). One study of a Northwest
Indian village found rates of DSM-III-R affective
disorder that were notably higher than rates
reported from national epidemiological studies
(Kinzie et al.,  1992). Alcohol abuse and

dependence appear  also to be especially
problematic, occurring at perhaps twice the rate of
occurrence found in any other population group.
Relatedly, suicide occurs at alarmingly high levels.
(Indian Health Service, 1997). Among Native
American veterans, post-traumatic stress disorder
has been identified as especially prevalent in
relation to whites (Manson, 1998). In terms of
patterns of utilization, Native Americans are
overrepresented in psychiatric inpatient care in
relation to whites, with the exception of private
psychiatric hospitals (Snowden & Cheung, 1990;
                              ,
Snowden, in press-b).

Barriers to the Receipt of Treatment
The underrepresentation in outpatient treatment of
racial and ethnic minority groups appears to be the
result of cultural differences as well as financial,
organizational, and diagnostic factors. The service
system has not been designed to respond to the
cultural and linguistic needs presented by many
racial and ethnic minorities. What is unresolved are
the relative contribution and significance of each
factor for distinct minority groups.

Help-Seeking Behavior

Among adults, the evidence is considerable that
persons from minority backgrounds are less likely
than are whites lo seek outpatient treatment in the
specialty mental health sector (Sussman et al.,
1987; Gallo et al., 1995; Leong & Lau, 1998;
Snowden, 1998; Vega et al., 1998a, 1998b; Zhang
et al., 1998). This is not the case for emergency
department care, from which African Americans
are more likely than whites to seek care for mental
health problems, as noted above. Language, like
economic and accessibility differences, can play an
important role in why people from other cultures do
not seek treatment (Hunt, 1984; Comas-Diaz, 1989;
Cook & Timberlake, 1989; Taylor, 1989).

Mistrust
The reasons why racial and ethnic minority groups
are less apt to seek help appear to be best studied

86


among African Americans. By comparison with
whites, African Americans are more likely to give
the following reasons for not seeking professional
help in the face of depression: lack of time, fear of
hospitalization, and fear of treatment (Sussman et
al., 1987). Mistrust among African Americans may
stem from their experiences of segregation, racism,
and discrimination (Primm et al., 1996; Priest,
199 1). African Americans have experienced racist
slights in their contacts with the mental health
system, called "microinsults" by Pierce (1992).
Some of these concerns are justified on the basis of
research, cited below, revealing clinician bias in
overdiagnosis of schizophrenia and underdiagnosis
of depression among' African Americans.
Lack of trust is likely to operate among other
minority groups, according to research about their
attitudes toward government-operated institutions
rather than toward mental health treatment per se.
This is particularly pronounced for immigrant
families with relatives who may be undocumented,
and hence they are less likely to trust authorities
for fear of being reported and having the family
member deported. People from El Salvador and
Argentina who have experienced imprisonment or
watched the government murder family members
and engage in other atrocities may have an
especially strong mistrust of any governmental
authority (Garcia & Rodriguez, 1989). Within the
Asian community, previous refugee experiences of
groups such as Vietnamese, Indochinese, and
Cambodian immigrants parallel those experienced
by Salvadoran and Argentine immigrants. They,
too, experienced imprisonment, death of family
members or friends, physical abuse, and assault, as
well as new stresses upon arriving in the United
States (Cook & Timberlake, 1989; Mollica, 1989).
  American Indians' past experience in this
country also imparted lack of trust of government.
T.hose living on Indian reservations are particularly
fearful of sharing any information with white
clinicians employed by the government. As with
African Americans, the historical relationship of
forced control, segregation, racism, and

discrimination has affected their ability to trust a
white majority population (Herring, 1994;
Thompson, 1997).

Stigma

The stigma of mental illness is another factor
preventing African  Americans from seeking
treatment, but not at a rate significantly different
from that of whites. Both African American and
white groups report that embarrassment hinders
them from seeking treatment (Sussman et al.,
1987). In general, African Americans tend to deny
the threat of mental illness ind strive to overcome
mental health problems through self-reliance and
determination (Snowden, 1998). Stigma, denial,
and self-reliance are likely explanations why other
minority groups do not seek treatment, but their
contribution has not been evaluated empirically,
owing in part to the difficulty of conducting this
type of research. One of the few studies of Asian
Americans identified the barriers of stigma,
suspiciousness, and a lack of awareness about the
availability of services (Uba, 1994). Cultural
factors tend to encourage the use of family,
traditional healers, and informal sources of care
rather than treatment-seeking behavior, as noted
earlier.

Cost

Cost is yet another factor discouraging utilization
of mental health services (Chapter 6). Minority
persons are less likely than whites to have private
health insurance, but this factor alone may have
little bearing on access. Public sources of insurance
and publicly supported treatment programs fill
some of the gap. Even among working class and
middle-class African Americans who have private
health insurance, there is underrepresentation of
African Americans in outpatient treatment
(Snowden, 1998). Yet studies focusing only on
poor women, most of whom were members of
minority groups, have found cost and lack of
insurance to be barriers to treatment (Miranda &
Green, 1999). The discrepancies in findings suggest

The Fundamentals of Mental Health and Mental Illness

87


Mental Health: A Report of the Surgeon General

that much research remains to be performed on the
relative importance of cost, cultural, and
organizational barriers, and poverty and income
limitations across the spectrum of racial and ethnic
and minority groups.

CIinician Bias

Advocates and experts alike have asserted that bias
in clinician judgment is one of the reasons for
overutilization of inpatient treatment by African
Americans. Bias in clinician judgment is thought to
be reflected in overdiagnosis or misdiagnosis of
mental disorders. Since diagnosis is heavily reliant
on behavioral signs and patients' reporting of the
symptoms, rather than on laboratory tests, clinician
judgment plays an enormous role in the diagnosis
of mental disorders. The strongest evidence of
clinician bias is apparent for African Americans
with schizophrenia and depression. Several studies
found that African Americans were more likely
than were whites to be diagnosed with
schizophrenia, yet less likely to be diagnosed with
depression (Snowden & Cheung, 1990; Hu et al.,
1991; Lawson et al., 1994).

In addition to problems of overdiagnosis or
misdiagnosis, there may well be a problem of
underdiagnosis among minority groups, such as
Asian Americans, who are seen as "problem-free"
(Takeuchi & Uehara, 1996). The presence and
extent of this type of clinician bias are not known
and need to be investigated.

Improving Treatment for Minority
Groups
The previous paragraphs have documented
underutilization of treatment, less help-seeking
behavior,  inappropriate diagnosis, and other
problems that have beset racial and ethnic minority
groups with respect to mental health treatment.
This kind of evidence has fueled the widespread
perception of mental health treatment as being
uninviting, inappropriate, or not as effective for
minority groups as for whites. The Schizophrenia
Patient Outcome Research Team demonstrated that

African Americans were less likely. than others to
have received treatment that conformed to
recommended practices (Lehman & Steinwachs,
1998). Inferior treatment outcomes are widely
assumed but are difficult to prove, especially
because of sampling, questionnaire, and other
design issues, as well as problems in studying
patients who drop out of treatment after one session
or who otherwise terminate prematurely. In a
classic study, 50 percent of Asian Americans versus
30 percent of whites dropped out of treatment early
(Sue & McKinney, 1975). However, the disparity in
dropout rates may have abated more recently
(O'Sullivan et al., 1989; Snowden et al., 1989).
One of the few studies of clinical outcomes, a pre-
versus post-treatment study, found that African
Americans fared more poorly than did other
minority groups treated as outpatients in the Los
Angeles area (Sue et al., 1991). Earlier studies from
the 1970s and 1980s had given inconsistent results
(Sue et al., 1991).

Ethnopsychopharmacojogy

There is mounting awareness that ethnic and
cultural influences can alter an individual's
responses to medications (pharmacotherapies). The
relatively new field of ethnopsychopharmacology
investigates cultural variations and differences that
influence the effectiveness of pharmacotherapies
used in the mental health field. These differences
are both genetic and psychosocial in nature. They
range from genetic variations in drug metabolism to
cultural practices that affect diet, medication
adherence, placebo effect, and simultaneous use of
traditional and alternative healing methods (Lin et
al., 1997). Just a few examples are provided to
illustrate ethnic and racial differences.
Pharmacotherapies given by mouth usually
enter the circulation after absorption from the
stomach. From the circulation they are distributed
throughout the body (including the brain for
psychoactive drugs) and then metabolized, usually
in the liver, before they are cleared and eliminated
from the body (Brody, 1994). The rate of

88


The Fundamentals of Mental Health and Mental Illness

metabolism affects the amount of the drug in the
circulation. A slow rate of metabolism leaves more
drug in the circulation. Too much drug in the
circulation typically leads to heightened side
effects. A fast rate of metabolism, on the other
hand, leaves less drug in the circulation. Too little
drug in the circulation reduces its effectiveness.
There is wide racial and ethnic variation in drug
metabolism. This is due to genetic variations in
drug-metabolizing enzymes (which are responsible
for breaking down drugs in the liver). These genetic
variations alter the activity of several drug-
metabolizing enzymes. Each drug-metabolizing
enzyme normally breaks down not just one type of
pharmacoiherapy, but usually several types. Since
most of the ethnic variation comes in the form of
inactivation or reduction in activity in the enzymes,
the result is higher amounts -of medication in the
blood, triggering untoward side effects.
For example, 33 percent of African Americans
and 37 percent of Asians are slow metabolizers of
several  antipsychotic  medications  and
antidepressants (such as tricyclic antidepressants
and selective serotonin reuptake inhibitors) (Lin et
al., 1997). This awareness should lead to more
cautious prescribing practices, which usually entail
starting patients at lower doses in the beginning of
treatment. Unfortunately, just the opposite typically
had been the case with African American patients
and antipsychotic drugs. Clinicians in psychiatric
emergency services prescribed more oral doses and
more injections of antipsychotic medications to
African American patients (Segel et al., 1996). The
combination of slow metabolism and overmedica-
tion of antipsychotic drugs in African Americans
can yield very uncomfortable extrapyramidal side
effects (Lin et al., 1997). These are the kinds of
experiences that likely contribute to the mistrust of
mental health services reported among African
Americans (Sussman et al., 1987).

*' Dystonia (brief or prolonged contraction of muscles), akathisia
(an urge to move about constantly), or parkinsonism (tremor and
rigidity) (Perry et al., 1997).

Psychosocial factors also can play an important
role in ethnic variation. Comphance with dosing
may be hindered by communication difficulties;
side effects can be misinterpreted or carry different
connotations; some groups may be more responsive
to placebo treatment; and reliance on psychoactive
traditional and alternative healing methods (such as
medicinal plants  and herbs) may result in
interactions with prescribed pharmacotherapies.
The result could be greater side effects and
enhanced or reduced effectiveness of the
pharmacotherapy, depending on the agents involved
and their concentrations (Lin.et al., 1997). Greater

awareness  of ethnopsychopharmacology is
expected to improve treatment effectiveness for
racial and ethnic minorities. More research is
needed on this topic across racial and ethnic
groups.

Minority-Oriented Services

Through employment of minority practitioners and
the creation of specialized minority-oriented
programs, community-based, publicly supported
mental health programs have achieved greater
minority representation than are found in other
mental health settings (Snowden, 1999). Mental
health care providers who are themselves from
ethnic minority backgrounds are especially likely to
treat ethnic minority clients and have been found to
enjoy good success in retaining them in treatment
(Sue et al., 1991).

The character of the mental health program in
which treatment is provided has proven particularly
important in encouraging minority mental health
service use. Research has shown that programs that
specialize in  serving  identified minority
communities have been successful in encouraging
minorities to enter and remain in treatment (Yeh et
al., 1994; Snowden et al., 1995; Takeuchi et al.,
1995; Snowden & Hu, 1996). Modeled on programs
successfully targeting groups of recent immigrants
and refugees, minority-oriented programs appear to
succeed by maintaining active, committed
relationships with community institutions and

89


Mental Health: A Report of the Surgeon General

leaders and making aggressive outreach efforts; by
maintaining a familiar and welcoming atmosphere;
and by identifying and encouraging styles of
practice best suited to the problems particular to
racial and ethnic minority group members. A
challenge for such programs is to meet specialized
sociocultural needs for clients from various
backgrounds. The track record of minority-oriented
programs at improving treatment outcomes is not
yet clear for adults but appears to be positive for
children and adolescents (Yeh et al., 1994).
There is a specialized system of care for Native
Americans that provides mental health treatment.
The Indian Health Service (IHS) includes a Mental
Health Programs Branch; it offers mental health
treatment intended to be culturally appropriate.
Urban Indian Health Programs also provide for
mental health treatment. The IHS Alcohol-
ism/Substance Abuse Program Branch sponsors
services on reservations and in urban communities
through contracts with service providers. Most
mental health programs in the IHS focus on
screening and treatment in primary care settings.
Due to budgetary restraints, IHS is able to provide
only limited medical, including mental health,
coverage of Native American peoples (Manson,
1998).
  Many tribes  have moved toward self-
determination and, as a result, toward assuming
direct control of local programs. When surveyed,
these tribal health programs reported providing
mental health care in a substantial number of
instances, although questions remain about the
nature and scope of services.  Finally, the
Department of Veterans Affairs and many state and
local authorities provide specialized mental health
programming targeting persons of Native American
heritage (Manson, 1998). Little is known about the
levels and types of care provided under any of these
arrangements.

Cultural Competence

Advocates and policymakers have called for all
mental health practitioners to be culturally
competent: to recognize and to respond to cultural
concerns of ethnic and racial groups, including
their histories, traditions, beliefs, and value
systems (CMHS, 1998).

Cultural competence is one approach to helping
mental health service systems and professionals
create better services and ensure their adequate
utilization by diverse populations (Cross et al.,
1989). It is defined as a set of belfaviors, attitudes,
and policies that come together in a system or
agency or among professionals that enables that
system, agency,  or professionals to work
effectively in cross-cultural situations (Cross et al.,
1989). This is especially important because most
mental health providers are not racial and ethnic
minority group members (Hernandez et al., 1998).
Using the term "competence" places the
responsibility on the mental health services
organization and all of its employees, challenging
them all to become part of a process of providing
culturally appropriate services. This approach
emphasizes understanding the importance of
culture and building service systems that recognize,
incorporate, practice, and value cultural diversity.

There is no single prescribed method for
accomplishing cultural competence. It begins with
respect, and not taking an ethnocentric perspective
about behavior, values, or beliefs. Three possible
methods are to render mainstream treatments more
inviting and accessible to minority groups through
enhanced communication and greater awareness; to
select a traditional therapeutic approach according
to the perceived needs of the minority group; or to
adapt available therapeutic approaches to the needs
of the minority group (Rogler et al., 1987). One
effort to promote cultural competence has been
directed toward mental health services systems
and programs.  The Center for Mental Health
Services has developed, with national input, a
preliminary set of performance indicators for
"cultural competence" by which service and

90


funding organizations might be judged. Cultural
competence in this context includes consultation
with cross-cultural experts and training of staff, a
capacity to provide services in languages other than
English, and the monitoring of caseloads to ensure
proportional racial and ethnic representation. The
ultimate test of any performance indicator will be
documented by improvements in care and treatment
of ethnic and racial minorities.
Another response  has been to develop
guidelines that more directly convey variations
believed necessary in the course of clinical
practice. An appendix to DSM-IV presents
clinicians with an Outline for Cultural Formulation.
The guidelines are intended as a supplement to
standard diagnosis, for use in multicultural environ-
ments and for the provision of a "systematic review
of the individual's cultural background, the role of
the cultural context in the expression and
evaluation of symptoms and dysfunction, and the
effect that cultural differences may have on the
relationship between the individual and the
clinician" (DSM-IV).

  The Outline for Cultural Formulation covers
several areas. It calls for an assessment of cultural
identity, including degree of involvement with
alternative cultural reference groups; cultural
explanations of illness; cultural factors related to
stresses, supports, and level of functioning and
disability (e.g., religion, kin networks); differences
in culture or social status between patient and
clinician and possible barriers (e.g., communi-
cation, trust); and overall cultural assessment.
Others have focused attention on the process by
which mental health practitioners must engage,
assess, and treat patients and on understanding how
cultural differences might affect that process
(Lopez et al., in press). Viewed from this
perspective, the task is to maintain two points of
view-that of the cultural group and that of
evidence-based mental health practice-and
strategically integrate them with the aim of valuing
and utilizing culture, context, and practice in a way
that promotes mental health.

The Fundamentals of Mental Health and Mental Illness

This capacity has a dual advantage. The
practitioner comes to understand the problem as it
is experienced and understood by the patient and,
in so doing, gains  otherwise inaccessible
information on personal and social reality for the
`patient, as well as a sense of trust and credibility.
At the same time the practitioner is able to plan for
and implement an appropriate intervention. It is
through a facility and a willingness to switch from
a professional orientation to that of the client and
his or her cultural group that the clinician is best
able to implement guidelines for cultural
competence such as those specified in DSM-IV
(Mezzich et al., 1996).

In the end, to be culturally competent is to
deliver treatment that is equally effective to all
sociocultural groups. The treatments provided must
not only be efficacious (based on clinical research),
but also effective in community delivery. The
delivery of effective treatments is complicated
because most research on efficacy has been
conducted on predominantly white populations.
This suggests the importance of both efficacy and
effectiveness studies on racial and ethnic
minorities.

At present, there is scant knowledge about
treatment effectiveness according to race, culture,
or ethnicity (Snowden & Hu, 1996). Rarely has
research evaluating standard forms of treatment
examined differential effectiveness. In fact, the
American Psychological Association's Division of
Clinical Psychology Task Force, which tried to
identify the efficacy of different psychotherapeutic
treatments, could not find a single rigorous study of
treatment efficacy published on ethnic minority
clients (Chambless et al., 1996). Nor have studies
been carried out on the efficacy of proposed
cultural adaptations of treatment in comparison
with standard alternatives. Only as more knowledge
is gained will it become possible to mount a full-
fledged and appropriate response to racial and
ethnic differences in the provision of mental health

care.

91


Mental Health: A Report of the Surgeon General

Rural Mental Health Services
The differences between rural and urban communi-
ties present another source of diversity in mental
health services. People in rural America encounter
numerous barriers to the receipt of effective
services. Some barriers are geographic, created by
the problem of delivering services in less densely
populated rural areas and even more sparsely
populated frontier areas. Some barriers are
"cultural," insofar as rural America reflects a range
of cultures and life styles that are distinct from
urban life. Urban culture and its approach to
delivering mental health services dominate mental
health services (Beeson et al., 1998).
  Rural America is shrinking in size and political
influence (Danbom, 1995; Dyer, 1997). As a
consequence, rural mental health services do not
figure prominently in mental health policy (Ahr &
Holcomb, 1985; Kimmel, 1992). Furthermore, rural
economies are in decline, and the population is
decreasing in most areas (yet expanding rapidly in
a few boom areas) (Hannan, 1998). Rural America
is no longer a stable or homogeneous environment.
The farm crisis of the 1980s unleashed a period of
economic hardship and rapid social change,
adversely affecting the mental health of the
population (Ortega et al., 1994; Hoyt et al., 1995).
  Policies and programs designed for urban
mental health services often are not appropriate for
rural mental health services (Beeson et al., 1998).
Beeson and his colleagues (1998) list a host of
important differences that should be considered in
designing rural mental health services. In an era of
specialized services, rural mental health relies
heavily on primary medical care and social
services. Stigma is particularly intense in rural
communities, where anonymity is difficult to
maintain (Hoyt et al., 1997). In an era of expanding
private mental health services, rural mental health
services have been predominantly publicly funded.
Consumer and family involvement in advocacy,
characteristic of urban and suburban areas, is rare
in rural America. The supply of services and
providers is limited, so choice is constrained.

Mental health services in rural areas cannot achieve
certain economies of scale, and some state-of-the
art services (e.g., assertive community treatment)
are inefficient to deliver unless there is a critical
mass of patients. Informal supports and indigenous
healers assume more importance in rural mental
health care.

Rural mental health concerns are being raised
nationally (Rauch, 1997; Ciarlo, 1998; Beeson et
al., 1998). Model programs offer new designs for
services (Mohatt & Kirwan, 1995), particularly
through the integration of mental health and
primary care (Bird et al., 1995, 1998; Size, 1998).
Newer technology,  such as advanced tele-
communications in the form of "telemental health,"
may improve rural .access to expertise from
professionals located in urban areas (Britain, 1996;
La Mendola, 1997; Smith & Allison, .1998).
Internet access, videoconferencing, and various
computer applications offer an opportunity to
enhance the quality of care in rural mental health
services.

Overview of Consumer and Family
Movements

Since the late 197Os, mental health services
continue to be transformed by the growing
influence of consumer and family organizations
(Lefley, 1996). Through strong advocacy, consumer
and family organizations have gained a voice in
legislation and policy for mental health service
delivery. Organizations representing consumers and
family members,  though divergent in their
historical origins and philosophy, have developed
some important, overlapping goals: overcoming
stigma and preventing discrimination, promoting
self-help groups, and promoting recovery from
mental illness (Frese, 1998).

This section covers the history, goals, and
impact of consumer and family organizations,
whereas the next section covers the process of
recovery from mental illness. With literally
hundreds of grassroots consumer organizations
across the United States, no single organization


The Fundamentals of Mental Health and Mental Illness

speaks for all consumers or all families. In fact,
even the term "consumer" is not uniformly
accepted. Despite the heterogeneity, these
organizations typically offer some combination of
advocacy and self-help groups (Lefley, 1996).
Many users of mental health services refer
to themselves as "consumers." The lexicon is
complicated by objections to the term "consumer."
To some, being a consumer erroneously signifies
that service users have the power to choose services
most suitable to their needs. Those who object
contend that consumers have neither choices,
leverage, nor power to select services. Instead,
some consumers refer to themselves as "surviv&s"
or "ex-patients" to denote that they have survived
what they experienced as oppression by the mental
health system (Chamberlin & Rogers, 1990). This
distinction can best be understood in its historical

context.

Origins and Goals of Consumer Groups
The consumer movement arose as a protest in the
1970s by former patients of mental hospitals. Their
antecedents trace back to the 19th century, when a
handful of individuals recovered enough to write
exposCs expressing their outrage at the' indignities
and abuses inside mental hospitals. The most
persuasive former patient was Clifford Beers,
whose classic book, A Mind That Found Itself
(1908), galvanized the mental hygiene reform
movement (Grab, 1994). Beers was among the
founders of the National Committee on Mental
Hygiene, an advocacy group that later was renamed
the National Mental Health Association. This group
focuses on linking citizens and mental health
professionals in broad-based prevention of mental
illness.

  With the advent of deinstitutionalization in the
195Os, increasing numbers of former patients of
mental hospitals began to forge informal ties in the
community. By the 196Os, the civil rights move-
ment inspired former patients to become better
organized into what was then coined the mental
patients' liberation movement (Chamberlin, 1995).

Groups of patients saw themselves as having been
rejected by society and robbed of power and
control over their lives. To surmount what they saw
as persecution, they began to advocate for self-
determination and basic rights (Chamberlin, 1990;
.-Frese & Davis, 1997). The ,posture of these early
groups was decidedly militant against psychiatry,
against laws favoring involuntary commitment, and
often against interventions such as electroconvul-
sive therapy and antipsychotic medications (Lefley,
1996; Frese, 1998). Groups called Alliance for the
Liberation of Mental Patients, the Insane Liberation
Front, and Project Release met in homes and
churches, drawing their membership from those
with firsthand experiences with the mental health
system. Largely unfunded, they sustained their
membership by providing peer support, education
about services in the community, and advocacy to
help members access services and to press for
reforms (Furlong-Norman, 1988).
  The book On Our Own (1978) by former patient
Judi Chamberlin was a benchmark in the history of
the consumer movement. Consumers and others
were able to read in the mainstream press what it
was like to have experienced the mental health
system. For many consumers, reading this book was
the beginning of their involvement in consumer
organizations (Van Tosh & de1 Vecchio, in press).
Early consumer groups, although geographically
dispersed, voluntary, and independent, were linked
through the newsletter Madness Network News,
which continued publication from 1972 to 1986.
During the same era, the Conference on Human
Rights and Against Psychiatric Oppression was
established and met annually from 1973 through
1985 (Chamberlin, 1990). In 1978, early consumer
groups gained what they perceived as their first
official acknowledgment from the highest levels of
government. The President's Commission on
Mental Health stated that ". . . groups composed of
individuals with mental or emotional problems are
being formed all over the United States"
(President's Commission on Mental Health, 1978,
pp. 14-15). To date, racial and ethnic minority

93


Mental Health: A Report of the Surgeon General

group members are underrepresented within the
consumer movement proportionate to their growing
representation in the U.S. population. There is a
need for more outreach and involvement of
consumers representing the special concerns of
racial and ethnic minorities.

The advocacy positions of consumers have
dealt with the role of involuntary treatment, self-
managed care, the role of consumers in research,
the delivery of services, and access to mental health
services. By 1985, consumer views became so
divergent that two groups emerged: The National
Association of Mental Patients*' and the National
Mental Health Consumers' Association. The former
opposed all forms of involuntary treatment,
supported the prohibition of electroconvulsive
therapy, and rejected psychotropic medications and
hospitalization. The latter organization held more
moderate views for improving rather than
eschewing the mental health service system
(Lefley, 1996; Frese, 1998). Both groups eventually
disbanded, but the differences of opinion that they
reflected became deeply entrenched.

Self-Help Groups

Self-help refers to groups led by peers to promote
mutual support, education, and growth (Lefley,
1996). Self-help is predicated on the belief that
individuals who share the same health problem can
help themselves and each other to cope with their
condition. The self-help approach enjoys a long
history, most notably with the formation of
Alcoholics Anonymous in 1935 (IOM, 1990). Over
time, the self-help approach has been brought to
virtually every conceivable health condition.
  Since the 197Os, many mental health consumer
groups emphasized self-help as well as advocacy
(Chamberlin, 1995), although to different degrees.
Self-help for recovering mental patients initially
emphasized no involvement with mental health
professionals. Over time the numbers and types of

" Later renamed the Nationa
(Chamberlin. 1995).

ivors

self-help groups began to flourish and more
moderate viewpoints became represented. Self-help
groups assume three different postures toward
health professionals: the separatist model, the
supportive model that allows professionals to aid in
auxiliary roles, and partnership models in which
professionals act as leaders alongside patients
(Chamberlin, 1978; Emerick, 1990). The focus of
groups varies, with some groups united on the basis
of diagnosis, such as Schizophrenics Anonymous
and the National Depressive and Manic-Depressive
Association, whereas others are more broad based.
  Chamberlin's influential book and another book
by former patients, Reaching Across (Zinman et al.,
1987), explained to consumers how to form self-
help groups. These books also extended the concept
of self-help more broadly into the provision of
consumer-run services as alternatives (as opposed
to adjuncts) to mental health treatment (Lefley,
1996).

94

Programs entirely run by consumers include
drop-in centers,  case management programs,
outreach programs, businesses, employment and
housing programs, and crisis services (Long & Van
Tosh,  1988; National Resource Center on
Homelessness and Mental Illness, 1989; Van Tosh
& de1 Vecchio, in press). Drop-in centers are places
for consumers to obtain social support and
assistance with problems. Although research is
limited, the efficacy of consumer-run services is
discussed in Chapter 4.

Consumer positions also are being incorporated
into more conventional mental health services-as
job coaches and case manager extenders, among
others. The rationale for employing consumers in
service delivery- in consumer-run or conventional
programs-is to benefit those hired and those
served. Consumers  who are hired obtain
employment,  enhance self-esteem, gain work
experience and skills, and sensitize other service
providers to the needs of people with mental
disorders. Consumers who are served may be more
receptive to care and have role models engaged in
their care (Mowbray et al., 1996).


Accomplishments of Consumer
Organizations
Consumer organizations have had measurable
impact on mental health services, legislation, and
research. One of their greatest contributions has
been the organization and proliferation of self-help
groups and their impact on the lives of thousands of
consumers of mental health services. In 1993, a
collaborative survey found that 46 state mental
health departments funded 567 self-help groups and
agencies for persons with mental disabilities and
their family members (National Association of
State Mental Health Program Directors, 1993). A
nationwide directory lists all 50 states and the
District of.Columbia as having 235 different mental
health consumer organizations (South Carolina
SHARE, 1995).

On a systems level, the consumer movement has
substantially influenced mental health policy to
tailor services to consumer needs. This influence is
described by consumers and researchers as
"empowerment."  A concept from the social
sciences, empowerment has come to be defined by
mental health researchers as "gaining control over
one's life in influencing the organizational and
societal structures in which one lives" (Segal et al.,
1995).

Consumers are now involved in all aspects of
the planning, delivery, and evaluation of mental
health services, and in the protection of individual
rights. One prominent example is the passage of
Public Law 102-321, which established mental
health planning councils in every state. Planning
councils are required to have membership from
consumers and families. Having a planning council
so constituted is required for the receipt of Federal
block grant funds for mental health services. Other
Federal legislation required the establishment of
protection and advocacy agencies for patients'
rights in every state (Chamberlin & Rogers, 1990;
Lefley, 1996).

Another significant development has been the
establishment of offices of consumer affairs in
many state mental health authorities. Offices of

The Fundamentals of Mental Health and Mental Illness

consumer affairs are  generally staffed by
consumers to support consumer empowerment and
self-help in their particular states, A recent survey
of state mental health authorities identified 27
states as having paid positions for consumers in
central offices (Geller et al., 1998). In 1995, the
Federal Center for Mental Health Services hired its
first consumer affairs specialist.
   The consumer movement also has had a
substantial influence on increasing the utilization
of consumers as employees in the traditional mental
health system, as well as in other human service
agencies (Specht, 1988; `U.S. Department of
Education, 1990; Schlageter, 1990; Interagency
Council on the Homeless, 1991). Consumers are
being hired at all levels in the mental health
system, ranging from case manager aides to
management positions in national advocacy
organizations, as well as state and Federal
governmental agencies.

Finally, consumers continue to be involved in
research in several ways: as participants of clinical
research; as respondents who are asked questions
about conditions in their life; as partners in some
aspect of the planning, designing, and conducting
of the research project with professional
researchers in control; and as independent
researchers who conduct, analyze the data, and
publish the results of the research project
(Campbell et al., 1993). The past decade has
witnessed the blossoming of a vibrant consumer
research agenda and the growing belief that
consumer involvement in research and evaluation
holds great promise for system reform, quality
improvement, and outcome measurement (Campbell
et al., 1993; Campbell, 1997). In an effort to
enhance the active role of consumers and others in
the research process, the National Institute of
Mental Health is developing a systematic means of
including public participants in the initial review of
grant applications in the areas of clinical treatment
and services research. This innovation follows up
on a recommendation made by the Institute of

95


Mental Health: A Report of the Surgeon General

Medicine and Committee for the Study of the
Future of Public Health (1988).

Family Advocacy

The family movement has experienced spectacular
growth and influence since its beginnings in the
late 1970s (Lefley,  1996). Although several
advocacy and professional organizations speak to
the needs of families, the family movement is
principally  represented by three large
organizations. They are the National Alliance for
the Mentally Ill (NAMI), the Federation of Families
for Children's Mental Health (FFCMH), and the
National Mental Health Association (NMHA).
NAM1 serves families of adults with chronic mental
illness, whereas the Federation serves children and
youth with emotional, behavioral, or mental
disorders. NMHA serves a broad base of family
members and other supporters of children and
adults with mental disorders and mental health
problems. Though the target populations are
different, these organizations are similar in their
devotion to advocacy, family support, research, and
public awareness.

Fragmentation and lack of availability of
services were motivating forces behind' the
establishment  of the family movement.
Deinstitutionalization, in particular, was a cogent
impetus for the formation of NAMI.
Deinstitutionalization of the mentally ill left
families in the unexpected position of having to
assume care for their adult children, a role for
which they were ill prepared. Another motivating
force behind the family movement was the past
tendency by the mental health establishment to
blame parents for the mental illness in children
(Frese, 1998). The cause of schizophrenia, for
example,  had been attributed to the
"schizophrenogenic mother," who was cold and
aloof, according to a reigning but now discredited
view of etiology. Similarly, parents were viewed as
partly to blame for children with serious emotional
or behavioral disturbances (Melaville & Asayesh
1993; Friesen & Stephens, 1998).

NAM1 was created as a grassroots organization
in 1979 by a small cadre of families in Madison,
Wisconsin. Since then, its membership has
skyrocketed to 208,000 in all 50 states (NAMI,
1999). NAMI's principal goal is to advocate for
impro.ved services for persons with severe and
persistent mental  illness-for example,
schizophrenia and bipolar disorder. Its sole
emphasis on the most severely affected consumers
distinguishes it from most other consumer and
family organizations. Another NAM1 goal is to
transform public attitudes and rtduce stigma by
emphasizing the biological basis of ,serious mental
disorders, as opposed to poor parenting (Frese,
1998; NAMI, 1999). Correspondingly, NAM1
advocates for intensification of research in the
neurosciences. Through state and local affiliates,
NAM1 operates a network of family groups for self-
help and education purposes.

NAMI's accomplishments are formidable. The
organization has become a powerful voice for the
expansion of community-based services to fulfill
the vision of the community support reform
movement. NAM1 has successfully pressed for
Federal legislation for family membership in state
mental health planning boards. It is a prime force
behind congressional legislation for parity in the
financing of mental health services. It also has
made substantial inroads in the training of mental
health professionals to sensitize them to the
predicament of the chronically mentally ill. It has
promoted "psychoeducation," specific information
to family members, usually in small-group settings,
about schizophrenia and about strategies for
dealing with relatives with schizophrenia (Lamb,
1994). Finally, NAM1 has successfully lobbied for
increased Federal research funding, and it has set
up private research foundations (Lefley, 1996).
Similarly, advocacy by parents on behalf of
children with serious emotional or behavioral
disturbances has had a compelling impact.
Advocacy for children was electrified by the
publication  of Jane Knitzer's 1982 book,
Unclaimed Children; shortly afterward, the

96


The Fundamentals of Mental Health and Mental Illness

National Mental Health Association (NMHA)
issued Invisible Children (NMHA, 1983), followed
by A Guide for Advocates to All Systems Failure
(NMHA, 1993). Knitzer chronicled the plight of
families in trying to access care from disparate and
uncoordinated public agencies, many of which
blamed or ignored parents. NMHA, a pioneer in the
mental health advocacy field, assumed a pivotal
role in strengthening the child mental health
movement in the 1980s and early 1990s. Over time,
the Federation of Families for Children's Mental
Health has become another focal point for families,
championing family participation and support in
systems of care and access to services. The
Federation's chapters across the United States offer
self-help, education, and networking (FFCMH,
1999). Through the efforts of these groups and
individuals,  among the- most noteworthy
accomplishments of the family movement has been
the emergence  of family participation in
decisionmaking about care for children, one of the
decisive historical shifts in service delivery in the
past 20 years.

Overview of Recovery
Until recently, some severe mental disorders were
generally considered to be marked by lifelong
deterioration. Schizophrenia, for instance, was seen
by the mental health profession as having a
uniformly downhill course (Harding et al., 1992).
At the beginning of the 20th century, the leading
psychiatrist of the era, Emil Kraepelin, judged the
outcome of schizophrenia to be so dismal that he
named the disorder "dementia praecox," or
premature dementia. Negative conceptions of
severe mental illness, perpetuated in textbooks for
decades by Kraepelin's original writings, dampened
consumers' and families' expectations, leaving
them without hope. A turnabout in attitudes came
as a result of the consumer movement and self-help
activities. They mobilized a shift toward a more
positive set of consumer attitudes and self-
perceptions. Research provided a scientific basis
for and supported a more optimistic view of the

possibility of recovering function (Harding et al.,
1992). Promoting recovery became a rallying point
and common ground for the consumer and family
movements (Frese, 1998).

The concept of recovery is having substantial
impact on consumers and families, mental health
research, and service delivery. Before describing
that impact,  this section first turns to an
introduction and definitions.

Introduction and Definitions
Recovery is a concept introduced in the lay
writings of consumers beginning in the 1980s. It
was inspired by consumers who had themselves
recovered to the extent that they were able to write
about their experiences of coping with symptoms,
getting better, and gaining an identity (Deegan,
1988; Leete, 1989). Recovery also was fueled by
longitudinal research uncovering a more positive
course for a significant number of patients with
severe mental illness (Harding et al., 1992),
although findings across several studies were
variable (Harrow et al., 1997) (see discussion in
Chapter 4).

Recovery is variously called a process, an
outlook, a vision, a guiding principle. There is
neither a single agreed-upon definition of recovery
nor a single way to measure it. But the overarching
message is that hope and restoration of a
meaningful life are possible, despite serious mental
illness (Deegan, 1988; Anthony, 1993; Stocks,
1995; Spaniol et al., 1997). Instead of focusing
primarily on symptom relief, as the medical model
dictates, recovery casts a much wider spotlight on
restoration of self-esteem and identity and on
attaining meaningful roles in society.
Written testimonials by former mental patients
have appeared for centuries. These writings,
according to historian of medicine Roy Porter,
"shore up that sense of personhood and identity
which they feel is eroded by society and
psychiatry" (Porter, 1987). What distinguishes the
contemporary wave of writings is their critical
mass, organizational backing, and freedom of

97


Mental Health: A Report of the Surgeon General

expression from outside the confines of the
institution. Deinstitutionalization, the emergence of
community supports and psychosocial rehabili-
tation, and the growth of the consumer and family
advocacy movements all paved the way for
recovery to take hold (Anthony, 1993).
The concept of recovery continues to be defined
in the writings of consumers (see Figure 2-7).
These lay writings offer a range of possible
definitions, many of which seek to discover
meaning, purpose, and hope from having mental
illness (Lefley, 1996). The definitions do not,
however, imply full recovery, in which full
functioning is restored and no medications are
needed. Instead .they suggest a journey or process,
not a destination or cure (Deegan, 1997). One of
the most prominent professional proponents of
recovery, William A. Anthony, crystallized con-
sumer writings on recovery with the following
definition:

   . . . a person with mental illness can
recover even though the illness is not
  "cured" . . . . [Recovery] is a way of living
a satisfying, hopeful, and contributing life
even with the limitations caused by illness.
Recovery involves the development of new
meaning and purpose in one's life as one
grows beyond the catasrrophic effects of
mental illness (Anthony, 1993).
It is important to point out that consumers see
a distinction between recovery and psychosocial
rehabilitation. The latter, which is discussed more
extensively in Chapter 4, refers to professional
mental health services that bring together
approaches from the rehabilitation and the mental
health fields (Cook et al., 1996). These services
combine pharmacological treatment, skills training,
and psychological and social support to clients and
families in order to improve their lives and
functional capacities. Recovery, by contrast, does
not refer to any specific services. Rather, according
to the writings of pioneering consumer Patricia
Deegan, recovery fefers to the "lived experience"

Figure 2-7. Definitions of recovery from

rfnnrlrmfar writinna
"-.m"w...w, I.. .-...a-

7ecovet-y is a process, a way of life, an attitude,
2nd a way of approaching the day's challenges. It
s not a perfect/y linear process. At times our
:ouee is erratic and we falter, slide back, regroup
2nd start again. . . . The need is to meet the
challenge of the disability and to re-establish a
7ew and valued sense of integrity and purpose
within and beyond the limits of the disability; the
sspiration is to live, work, and love in a community
in which one makes a significant contribution
(Deegan, 1988, p. 15).          .

One of the elements that makes recovery possible
is the regaining of one's belief in oneself
(Chamberlin, 1997, p. 9).

Having some hope is. crucial to recovery; none of
us would strive if we believed it a futile effort. . .I
believe that if we confront our illnesses with
courage and struggle with our symptoms
persistently, we can overcome our handicaps to
live independent/y, learn ski//s, and contribute to
society, the society that has traditionally
abandoned us (Leete, 1989, p. 32).

A recovery paradigm is each person's unique
experience of their road to recovery. . . .My
recovery paradigm included my re-connection
which included the following four key ingredients:
connection, safety, hope, and acknowledgment of
my spiritual se/f (Long, 1994, p. 4).

To return renewed with an enriched perspective 01
the human condition is the major benefit of
recovery. To return at peace, with yourse/( your
experience, your world, and your God, is the majo
joy of recovery (Granger, 1994, p. 10).

of gaining a new and valued sense of self and of
purpose (Deegan, 1988).

Impact of the Recovery Concept
The impact of the recovery concept is felt most by
consumers and families. Consumers and families
are energized by the message of hope and self-
determination. Having more active roles in

98


The Fundamentals of Mental Health and Mental Illness

treatment, research,  social and vocational
functioning,  and personal growth strikes a
responsive cord. Consumers' harboring more
optimistic attitudes and expectations may improve
the course of their illness, based on related research
from the field of psychosocial and vocational
rehabilitation (see Chapter 4). Yet direct empirical
support for the salutary, long-term effect of
positive expectations,  on both consumers and
families, is still in its infancy (Lefley, 1997).
The recovery concept likewise is having a
bearing on mental health research and services.
Researchers are beginning to study consumer
attitudes and behavior to attempt to identify .the
elements contributing to recovery. Though still at
an early stage, research is being driven by
consumer perspectives on recovery. Consumers
assert that the recovery process is governed by
internal factors (their psychological perceptions
and expectations),  external factors (social
supports), and the ability to self-manage care, all of
which interact to give them mastery over their
lives. The first systematic efforts to define
consumer perceptions of recovery was conducted
by consumers. The Well-Being Project, sponsored
by the California Department of Mental Health,
was a landmark effort in which mental health
consumers conducted a multifaceted study to define
and explore factors promoting or deterring the well-
being of persons diagnosed with serious mental
illness (Campbell & Schraiber, 1989). Using
quantitative survey research, focus groups, and oral
histories, Campbell (1993) arrived at a definition of
recovery that incorporates "good health, good food,
and a decent place to live, all supported by an
adequate income that is earned through meaningful
work. We need adequate resources and a satisfying
social life to meet our desires for comfort and
intimacy. Well-being is enriched by creativity, a
satisfying spiritual and sexual life, and a sense of
happiness" (p. 28).
  Through  semistructured  interviews  with
consumers about recovery, a subsequent study
identified the most common factors associated with

their success in dealing with a mental illness. They
included medication, community support/case
management, self-will/self-monitoring, vocational
activity (including school), and spirituality
(Sullivan, 1994). Other researchers, also using
semistructured interviews, suggested that the
rediscovery and reconstruction of a sense of self
were important to recovery (Davidson & Strauss,
1992).

These early forays by researchers set the stage
for consumer-driven research efforts to identify
some of the aspects of recovery. A group of
consumers with consultant'researchers developed
the Empowerment Scale (Rogers et al., 1997). After
testing a 28-item scale on members of six self-help
programs in six states, factor analysis revealed the
underlying dimensions of empowerment to be
(1) self-efficacy-self-esteem; (2) power-powerless-
ness ; (3) community activism; (4) righteous anger;
and (5) optimism-control over the future. Other
instruments,  found to have consistency and
construct validity, are the Personal Empowerment
Scale, the Organizational Empowerment Scale, and
the Extra-Organizational Empowerment Scale
(Segal et al., 1995).

  Mental health services continue to be refined
and shaped by the consumer and recovery
emphasis. The most tangible changes in services
come from assertive community treatment and
psychosocial and vocational rehabilitation, which
emphasize an array of approaches to maximize
functioning and promote recovery. Consumer
interest in self-help and recovery has stimulated the
proliferation of interventions for what has been
called "illness management" or "self-managed
care"  for relapse prevention of psychotic
symptoms. Illness management training programs
now teach individuals to identify early warning
signs of relapse and to develop strategies for their
prevention. All of these transformations in service
delivery and research affirming their benefits are
discussed at length in Chapter 4.

Champions of recovery assert that its greatest
impact will be on mental health providers and the

99


Mental Health: A Report of the Surgeon General

future design of the service system. They envision
services being structured to be recovery-oriented to
ensure that recovery takes place. They envision
mental health professionals believing in and
supporting consumers in their quest to recover. In
a groundbreaking article, William A. Anthony
described recovery as a guiding vision that "pulls
the field of services into the future. A vision is not
reflective of what we are currently achieving, but
of what we hope for and dream of achieving.
Visionary thinking does not raise unrealistic
expectations. A vision begets not false promises but
a passion for what we are doing."

Conclusioris

The past 25 years have been marked by several
discrete, defining trends in the mental health field.
These have included:

1. The extraordinary pace and productivity of
scientific research on the brain and behavior;
2. The introduction of a range of effective
treatments for most mental disorders;
3. A dramatic transformation of our society's
approaches to the organization and financing of
mental health care; and

4. The emergence of powerful consumer and

family movements.

Scientific Research. The brain has emerged as
the central focus for studies of mental health and
mental illness.  New scientific disciplines,
technologies, and insights have begun to weave a
seamless picture of the way in which the brain
mediates the influence of biological, psychological,
and social factors on human thought, behavior, and
emotion in health and in illness. Molecular and
cellular biology and molecular genetics, which are
complemented by sophisticated cognitive and
behavioral science,  are preeminent research
disciplines in the contemporary neuroscience of
mental health. These disciplines are affording
unprecedented opportunities for "bottom-up"
studies of the brain. This term refers to research
that is examining the workings of the brain at the
,most fundamental levels. Studies focus, for

example, on the complex neurochemical activity
that occurs within individual nerve cells, or
neurons, to process information; on the properties
and roles of proteins that are expressed, or
produced, by a person's genes; and on the
interaction of genes with diverse environmental
influences. All of these activities now are
understood, with increasing clarity, to underlie
learning, memory, the experience of emotion, and,
when these processes go awry, the occurrence of
mental illness or a mental health problem.
Equally important to the mental health field is
"top-down" research; here, as the?erm suggests, the
aim is to understand the broader behavioral context
of the brain's cellular and molecular activity and to
learn how individual neurons work together in
well-delineated neural circuits to perform mental
functions.

Effective Treatments. As information accumu-
lates about the basic workings of the brain, it is the
task of translational research to transfer new
knowledge into clinically relevant questions and
targets of research opportunity-to discover, for
example, what specific properties of a neural
circuit might make it receptive to safer, more
effective medications. To elaborate on this
example, theories derived from knowledge about
basic brain mechanisms are being wedded more
closely to brain imaging tools such as functional
Magnetic Resonance Imaging (MRI) that can
observe actual brain activity, Such a collaboration
would permit investigators to monitor the specific
protein molecules intended as the "targets" of a
new medication to treat a mental illness or, indeed,
to determine how to optimize the effect on the brain
of the learning achieved through psychotherapy.
In its entirety, the new "integrative neuro-
science" of mental health offers a way to
circumvent the antiquated split between the mind
and the body that historically has hampered mental
health research. It also makes it possible to
examine scientifically many of the important
psychological and behavioral theories regarding
normal development and mental illness that have

100