At the intersection of lay and professional social networks: how community ties shape perceptions of mental health treatment providers.

BACKGROUND: The therapeutic alliance is a critical determinant of individuals' persistence and outcomes in mental health treatment. Simultaneously, individuals' community networks shape decisions about whether, when, and what kind of treatment are used. Despite the similar focus on social relationship influence for individuals with serious mental illness, each line of research has maintained an almost exclusive focus on either 'inside' (i.e. treatment) networks or 'outside' (i.e. community) networks, respectively. METHOD: For this study, we integrate these important insights by employing a network-embedded approach to understand the therapeutic alliance. Using data from the Indianapolis Network Mental Health Study (INMHS, n = 169, obs = 2206), we target patients experiencing their first major contact with the mental health treatment system. We compare patients' perceptions of support resources available through treatment providers and lay people, and ask whether evaluations of interpersonal dimensions of the therapeutic alliance are contingent on characteristics of community networks. RESULTS: Analyses reveal that providers make up only 9% of the whole social network, but are generally perceived positively. However, when community networks are characterized by close relationships and frequent contact, patients are significantly more likely to report that treatment providers offer useful advice and information. Conversely, when community networks are in conflict, perceptions of treatment providers are more negative. CONCLUSION: Community-based social networks are critical for understanding facilitators of and barriers to effective networks inside treatment, including the therapeutic alliance. Implications for community-based systems of care are discussed in the context of the USA and global patterns of deinstitutionalization and community reintegration.

The profession of medicine and the public: examining Americans' changing confidence in physician authority from the beginning of the 'health care crisis' to the era of health care reform.

Recent work on the sociology of the professions, in general, and on the profession of medicine, in particular, target dramatic changes in the organization of social institutions, "boundary work" among professionals, and the implications of both for professional power. However, public attitudes cited in theories as a critical linchpin of professional status remain relatively unexplored in the face of these changes and widespread contentions of public dissatisfaction. Using data from the 1976 National Survey of Access to Care (Aday, Andersen, and Fleming 1980) and the 1998 General Social Survey (Davis, Smith, and Mardsen 1998), we take advantage of a unique opportunity to compare the public's attitudes across a 20-year period. We examine individuals' evaluations of the way physicians do their work and their ability to confront health problems. Three findings support a complex view of public sentiments. First, while public confidence in physicians remains relatively high, we document a crystallization of attitudes reflecting greater negative and fewer positive sentiments. Second, while neither the structure of attitudes nor the role of sociodemographic characteristics in explaining attitudes has significantly shifted over time, in 1998 health status and insurance status are correlated with negative attitudes. Third, using General Social Survey time trend data on the confidence in medicine compared to other professions (science and education), we find support for a general public response to social institutions, with confidence in medicine tracking closely with confidence in science in level, and education in pattern. We end with four possible explanations of our findings, including and a general discussion of the role of the public in the professional status of physicians and its implications for social change in the institution of medicine.

Public conceptions of mental illness: labels, causes, dangerousness, and social distance.

OBJECTIVES: The authors used nationwide survey data to characterize current public conceptions related to recognition of mental illness and perceived causes, dangerousness, and desired social distance. METHODS: Data were derived from a vignette experiment included in the 1996 General Social Survey. Respondents (n = 1444) were randomly assigned to 1 of 5 vignette conditions. Four vignettes described psychiatric disorders meeting diagnostic criteria, and the fifth depicted a "troubled person" with subclinical problems and worries. RESULTS: Results indicate that the majority of the public identifies schizophrenia (88%) and major depression (69%) as mental illnesses and that most report multicausal explanations combining stressful circumstances with biologic and genetic factors. Results also show, however, that smaller proportions associate alcohol (49%) or drug (44%) abuse with mental illness and that symptoms of mental illness remain strongly connected with public fears about potential violence and with a desire for limited social interaction. CONCLUSIONS: While there is reason for optimism in the public's recognition of mental illness and causal attributions, a strong stereotype of dangerousness and desire for social distance persist. These latter conceptions are likely to negatively affect people with mental illness.

The public's view of the competence, dangerousness, and need for legal coercion of persons with mental health problems.

OBJECTIVES: The authors examined Americans' opinions about financial and treatment competence of people with mental health problems, potential for harm to self or others, and the use of legal means to force treatment. METHODS: The 1996 General Social Survey provided interview data with a nationally representative sample (n = 1444). Respondents were given a vignette based on diagnostic criteria for schizophrenia, major depression, alcohol dependence, or drug dependence, or a "control" case. RESULTS: The specific nature of the problem was the most important factor shaping public reaction. Respondents viewed those with "troubles," alcohol dependence, or depression as able to make treatment decisions. Most reported that persons with alcohol or drug problems or schizophrenia cannot manage money and are likely to be violent toward others. Respondents indicated a willingness to coerce individuals into treatment. Respondent and other case characteristics rarely affected opinions. CONCLUSIONS: Americans report greater concern with individuals who have drug or alcohol problems than with persons who have other mental health problems. Evaluations of dangerousness and coercion indicate a continuing need for public education.

Closing of a state hospital: an overview and framework for a case study.

This article introduces the trends in deinstitutionalization, the limitations of previous research, and the design and research questions of the Central State Hospital (CSH) closing studies. Previously, the central engine of deinstitutionalization has been the downsizing, and not the closing, of facilities to decrease available beds. Only 14 state hospitals closed between 1970 and 1990. However, since 1990, 40 hospitals have closed. Moreover, beginning in 1993, for the first time since deinstitutionalization began, funding for state psychiatric facilities was less than for community-based services. Previous research on both the downsizing and closing of hospitals has focused predominantly on relatively short-term clinical and social outcomes of patients. The current study is a multidisciplinary, longitudinal, multiple-stakeholder study of the closing of a state-run, long-term care facility in Indiana. The articles that follow focus on the clinical, psychological, social, and attitudinal outcomes for patients, workers, families, and the public following the closing of CSH.

The changing hopes, worries, and community supports of individuals moving from a closing long-term care facility.

This study examines client's hopes, worries, and social networks before, one year, and two years following release from a long-term care facility. More clients expressed hopes than worries before closure but, over time, hopes decreased and worries increased significantly. Before closing, independence was cited most often as a hope, followed by work and finances. Criminal opportunities headed up concerns, followed by mental health treatment, finances, living arrangements and independence. Over time, respondents were less excited about independence and living arrangements but more hopeful about social opportunities and everyday practicalities. Worries relating to family increased while concerns about deviance decreased. Respondents reported an average increase in network ties but the proportion of family members decreased while professional supports and ties with former CSH patients increased. The trends highlight particular vulnerability at the one-year point, the necessity of viewing movement into the community as a nonlinear process, and the importance of marking outcomes periodically.

The closing of Central State Hospital: long-term outcomes for persons with severe mental illness.

This study examined the clinical/community functioning of long-stay patients following closing of a large state psychiatric hospital. Two overlapping samples were followed: (1) the tracking project collected information on patient location, treatment provision, legal contacts, and level of functioning (LOF) and followed all discharged patients and (2) the research study subsample, drawn from the final group of discharged patients, gathered information on quality of life (QOL), LOF, and general physical and mental health. At follow-up, patients were functioning equal to or better than prior to discharge. There were consistent improvements in QOL (especially safety and occupational satisfaction) and LOF (especially housing and income/benefits). Fewer than 27% of patients discharged into the community were rehospitalized, and fewer than 4% were either in jail or homeless after 24 months. The study demonstrates that even persons who have been hospitalized for extremely long periods can do well in the community.

"Stakeholder" attitudes over time toward the closing of a state hospital.

For four groups--patients (N = 80), their families or lay caregivers (N = 120), hospital workers (N = 124), and the public (N = 108)--attitudes toward the decision to close the only long-term, urban state hospital are traced over time. Initially, patients were most supportive of the closing decision (65.4%), followed by family members (39.8%), the general public (27.8%), and workers (10.4%). A majority of all groups favored fixing the hospital. Almost half of the clients and more than half of other stakeholders expressed concerns about homelessness. Most attitudes were consistent despite respondents' sociodemographic characteristics. The overall profile of group attitudes remained remarkably stable, although there was a good deal of change in individuals' positions. Public support for fixing the hospital decreased significantly, and differences among stakeholders regarding homelessness disappeared. These findings reinforce the importance of ascertaining different constituencies' positions and recognizing the slowly changing response of stakeholders even under massive and successful policy change.

The effects of hospital closure on mental health workers: an overview of employment, mental and physical health, and attitudinal outcomes.

This article examines the physical, psychological, and attitudinal impact of the closure of Central State Hospital (CSH) on its former employees. Eighty-five former CSH employees were interviewed at two points in time, preclosure and postclosure. Data on the psychological and physical health and employment attitudes of workers were collected prior to and eight months after organizational closure. Over time, workers had more positive attitudes about the hospital closure as well as reporting less depression, less work stress, and use of more coping strategies at postclosure. However, at post-closure, they also reported increased work conflict, lower income, and a more pessimistic outlook toward their future. Implications for hospital closure are discussed.

Social networks and patterns of use among the poor with mental health problems in Puerto Rico.

OBJECTIVES: This study uses the recently developed Network-Episode Model (NEM) to examine the nature and correlates of utilization among Puerto Ricans reporting mental health problems. The NEM highlights two issues: (1) examining the patterns or combinations of lay and formal use that individuals employ and (2) reformulating how the availability and content of social networks influences patterns of care. METHODS: Using data from the 1989 Mental Health Care Utilization Among Puerto Ricans Study (probability sample of 1,777 individuals living in low-income areas of the island), the authors focus on the patterns and correlates of use for 365 Puerto Ricans reporting service use for mental health problems in the previous year. RESULTS: A combination of clustering and multinomial logit techniques indicates that there are six unique care patterns. Two patterns include the use of mental health providers and are associated with different contingencies. CONCLUSIONS: In general, patterns of use are shaped by age, education, gender, and illness severity. Larger, more supportive networks decrease the use of patterns of care that include formal health care providers, and decrease direct entry into the mental health sector. These results are in line with NEM's predictions for lower class populations and help clarify inconsistencies in previous research on social networks. The implications of this perspective for health services research and treatment are discussed.

How people get into mental health services: stories of choice, coercion and "muddling through" from "first-timers".

Previous work examining how individuals enter mental health treatment comes either from the health services utilization tradition, which implicitly assumes that clients make decisions to seek care, or from the socio-legal perspective, which examines how clients are forced into care. This paper draws from the Network-Episode Model to systematically consider the different social processes through which people come to enter psychiatric treatment by exploring the "stories" told by individuals making their first major contact with the mental health system. We combine the use of qualitative and quantitative methods to examine data from the Indianapolis Network Mental Health Study, a longitudinal study of individuals in treatment at the largest public and voluntary facilities in the city. We analyze detailed self-reports of how they came to use mental health services, classifying these stories as "choice," "coercion," or "muddling through". Using multinomial logit analyses, we examine how factors such as gender, race and diagnosis shape the types of stories that individuals tell. The preliminary results indicate that fewer than half of the stories (45.9%) match the notion of choice underlying the dominant utilization theories. Almost a quarter of respondents (22.9%) report coercion and nearly one-third (31.2%) tell stories that lack a clear agent. Diagnosis and social networks tap differences in how individuals experience entry into care. Individuals diagnosed with bipolar disorder or who have larger, closer social networks are more likely to tell stories of coercion. We discuss the theoretical, methodological, and clinical implications of findings drawn from this examination of clients' stories.

New ethical challenges to mental health services research in the era of community-based care.

Research on the use and effectiveness of mental health services conducted across a wide variety of settings, under new and diverse state-based legal statutes, and requiring the linking of a variety of existing and proposed data sources raises a number of ethical considerations. These new conditions are reviewed in the context of federal regulations for the protection of human subjects and, in particular, informed consent. Illustrations, suggestions, and resources are offered from recent experiences in a longitudinal, multisource study of the impact of a hospital closing on individual consumers, families, workers, and system costs.

Health, illness, and healing in an uncertain era: challenges from and for medical sociology.

The current situation in health care organizations, among providers and for people, dramatically challenges the "business as usual" roles of medicine, government, insurance companies, the community, and the university. Health care reform marks the first attempt in a century to consider a reconstruction of the social contract between society and medicine. While sociology stands as one of the earliest social sciences to systematically study the health care arena and create a health-focused subfield, there is a perception, not without support, of a desertion of identity from within, an encroachment by other areas from without, and abandonment by the parent discipline. We argue that these situations in medical arenas and in research fields require serious rethinking. The key lies in understanding how these phenomena are related to each other and to larger social forces, and how they offer opportunities, rather than signal limitations, to medical sociologists. We turn to the theoretical tools of sociology to help unravel the complicated challenges that face both policymakers and researchers. After framing these issues in a sociology of knowledge perspective, we use the case of "utilization theory" to illustrate the connections between society and systems of care (as well as studies of them) and to create a future agenda. We end by raising three basic questions: (1) Why is a sociological perspective critical to the understanding of change and reform in health care? (2) Why is medical sociology critical to the survival of the general sociological enterprise? and (3) Why is general sociology critical to the research agenda in medical sociology?