Learn how social factors promote mental health, influence the onset and course of mental illness, and affect how mental illnesses are diagnosed and treated. This course explores how our understanding of mental health and illness has been influenced by social attitudes and social developments in North America and around the world. The course begins by situating our contemporary mental health practices in historical context, then looks at different aspects of mental health, mental illness and mental health services and their connections to what’s going on in our social environment.
3.5 The social context of treatment access
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來自 University of Toronto 的課程
The Social Context of Mental Health and Illness
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從本節課中
The social context of diagnosis and treatment of mental illnesses
與講師見面
Charmaine WilliamsAssociate Professor
Faculty of Social Work
So, I'm starting us off with this slide that talks about the social distribution
of treatment. This is some information that is
excerpted from the Pilgrim and Rogers textbook, that's one of the suggested
sources for the course. And in that chapter, what they're talking
about is how who you are makes a difference in terms of the kind of mental
health care treatment that you can access.
So, we've already talked about the fact that our treatment options in the mental
healthcare system are constrained because of social issues and political issues.
What this actually introduces now is the idea that even within those constraints,
it's possible that because of who you are, you may not have access to the full
range of treatment options that are available.
And what the Pilgrim and Rogers book really gets us to think about is how that
is connected to other social problems in our society, how it's a representation of
the kind of issues that we're already facing in terms of inequities in social
distribution. If I look at this list, I am certainly
reminded of the research that says Afro-Caribbean people in the UK are more
likely to be facing involuntary treatment than other groups.
the fact that men are more likely to receive coercive treatment we've
certainly seen that in Canada with our community treatment orders.
There are more men on those community treatment orders, and actually, if you
look at racial and ethnic minority groups in that context as well,
what you often see is that people are receiving, are being put on to this
mandatory outpatient treatment orders after not refusing treatment, but not
being able to get voluntary treatment. So, actually that course of treatment
method is a replacement, a substitute for voluntary accessible care.
And then on that final point about psychotherapy being offered mainly to
White, well-educated, and younger people, there's a literature that speaks very
clearly to the fact that psychotherapy simply isn't offered to many populations
because of assumptions and let's face it, stereotypes.
Maybe even sexist, racist, age, or stereotypes about who benefits from
psychotherapy and who's interested in it. And so clinicians, service providers make
these decisions without actually consulting clients.
They decide that this type of client is suitable for psychotherapy and another
one is not. And this type of client needs to be in,
on mandatory outpatient treatment but but somehow isn't a good candidate, candidate
for a voluntary outpatient treatment. And as Pilgrim and Rogers suggest, this
has to do with larger social issues. So that's what we're talking about in
this section on treatment access. So, let's start by defining the term,
access. Many people understand access to services
as just meaning whether or not people can actually get into services, but service
access actually means much more. Service access refers to the capacity to
receive services and also receive benefit from services.
So, for example, it's not enough that there's a healthcare center in your
neighborhood. It's not considered a fully accessible
healthcare service unless people are able to receive services from it and people
receive the same benefits from that service regardless of their race, gender,
class, disability status, sexuality, etc. There are many things that create
barriers to full access of services. Some of these things are, some of these
things are issues that prevent people from receiving care, things that prevent
people from receiving care in a timely manner,
things that prevent people from receiving care that is effective, care that will
actually help them, and things that prevent people from receiving care under
safe circumstances or from receiving care that is actually safe for them.
These are all factors that contribute to the mental health disparities that we see
among, among marginalized populations. And they are the kind of issues that are
being signaled, when the social determinants of mental health refers to
health services as one of the determinants.
Some of the barriers that have been identified as being relavent to mental
healthcare services include, user fees and insurance requirements.
Even in regions where there is a state-sponsored or universal healthcare
plan, people may not be able to access mental healthcare because they need to
pay additional fees or can only afford it if it is covered by private insurance.
There may be men, mental health cares available without fees.
But sometimes, an additional barrier is created by long waiting times for
receiving those services. Lack of information about services could
be another barrier. If you are in the right networks and you
may know about what services are available and how they can be accessed,
but if you're not in those social networks, you may not have that
information and therefore, are not able to get that kind of help.
A group that often faces this barrier is immigrants or newcomers to a country.
But certainly, social class and basic literacy, can also make a difference in
terms of access to information about mental healthcare services.
Language barriers are another barrier. It is very difficult to access effective
mental healthcare if the person who is providing service does not speak the same
language as the person who is seeking services.
This is an issue that is especially pronounced in the context of mental
healthcare because communication between the clinician and the client is the
primary method for assessment, diagnosis, and treatment.
Simple unavailability of services is a barrier to receiving mental healthcare.
Some people simply do not have a service to access.
In many parts of the world, mental health professionals are scarce and people
seeking help do not have anywhere to go to get that help.
And even in places where services and health professionals may be available,
services may not be available because they're not in locations that are close
to the populations that need them or they operate during days and times when people
can't go to them. That's a service barrier that often
affects people who are working class because they can't leave their jobs to go
to healthcare services. And finally, culturally insensitive,
culturally appropriate, inappropriate, and culturally harmful services are also
a barrier to receiving effective mental healthcare.
You will hopefully remember how this was discussed in the lecture on social
determinants of health and in that paper about colonialism as a determinant of
health. People cannot get effective mental
healthcare if they have to seek it in, in an environment that has no respect for
their culture or understanding of their culture.
And this is something we'll talk about again in the next lecture.
Culturally insensitive and inappropriate services create one kind of barrier.
Systemic racism, sexism, and other types of bigotry and prejudice present another
significant barrier. There has been a great deal of research
that talks about how these kind of systemic issues present problems for
people seeking help in mental healthcare, healthcare system.
And there is wide recognition that services, as a whole, need to be equipped
to not only deal more effectively with cultural difference and other types of
difference, but they must also work from the bottom up to ensure that service
experience and service providers do not expose clients to racism, sexism,
homophobia, and other types of prejudice and discrimination.
All of these issues are addressed in detail in the reading that you have about
racial and ethnic disparities in mental health and mental illness.
So, to summarize, we have a mental healthcare system that we already know is
somewhat constrained in terms of the options it makes available to people
seeking care. And the work that has been done looking
at access and equity in the mental healthcare system suggests that even
within those constraints, there are people who are systematically excluded
from getting the benefits of those available treatments.
So, what's to be done about that situation? Well, the very reason that I
do research on access to health services is that I believe something can be done
about this. I would like to think that there are ways
we can work to make sure that everyone who needs mental healthcare can get it
and benefit from it. And while it's discouraging to consider
that even in a country like the one that I live in, Canada, where we have
universal healthcare not everyone has full access to healthcare.
There are things that can be done to remedy that situation.
The Primm article suggests the following interventions.
I hope you're noticing that this list includes several things that have been
referenced in the lecture in the course already.
Social support seems to suggest intervening to address social
determinants of health. The suggestion of surveillance and
research, which sounds kind of sinister, is actually just a recommendation to do
more comprehensive tracking of the kind of mental health issues various
populations are dealing with. Cultural competency is a term that we
used to talk about increasing the cultural sensitivity of services.
The suggestion of more widespread public health information about mental
healthcare services directly addresses the information barrier that has already
been mentioned. And the assertion that we need
evidence-based approaches takes us back to the idea from an earlier segment that
we want to make sure that whatever we are doing, we have proof that it is having
its intended beneficial effects. The suggestion of social marketing is an
interesting one and one that we are hearing more and more in the context of
healthcare. There are new methods of public education
about health issues that are boring for marketing approaches that are used in the
private sector. Using the methods that are used to sell
goods and services, we hope to sell good health and service
access to the masses. There are a few more interventions that I
would suggest based on coming from a social justice orientation because the
problems of access to service are not just about whether people can get to
services, but also the fact that social inequities contribute to people being
prevented from accessing services. In my mind, questions about access to
services must always be paired with questions about equity in services.
So, coming from that perspective, I would support Primm's suggestion that we need
to target social determinance. But I would say, that we need to target
much more than social support. If we want to be serious about tackling
mental health disparities among marginalized populations, then we have to
look at the broad range of social determinants.
Because, as we've already discussed, the broad range of social determinants
contribute to mental health disparities. I will share Primm's belief that
researchers needed to understand what is going on with communities but I would
advocate for community-based research, which means research that is developed
with communities and done based on priorities identified by communities.
There are many groups who have had negative experiences with researchers
coming in and doing studies that just made things worse for them, sometimes
reinforcing negative stereotypes and increasing stigma that they faced.
Research needs to be done in partnership with communities so that they can
contribute to it meaningfully and ensure that it's actually going to benefit them
rather than marginalizing them further. Finally, I'm a believer in cultural
competency. I think it has a valuable contribution to
make, to imporving health care services for racial and ethnic minority groups and
other groups. But I think we need to challenge our
service organizations and our service provider work force even further by
suggesting that they not only be culturally sensitive but that they
actively work to eradicate racism and other types of oppression that affect the
delivery of services and the experiences of receiving care in the mental
healthcare system. A full discussion of this type of
organizational change in training is beyond the scope of this lecture.
But I just want to leave you with the idea that it's not enough to be sensitive
to the diversity of, of people. We also need to be welcoming, respectful, and
supportive of the diversity of people. So, that bring us to the end of this
lecture. I'm going to do the wrap-up next.
