Structural Barriers to Citizenship: A Mental Health Provider Perspective.

This study employed a citizenship measure to explore mental health providers' views of citizenship to support the societal participation of people with mental illnesses, with citizenship defined as a person's (or people's) strong connection to the 5Rs of rights, responsibilities, roles, resources and relationships and a sense of belonging that is validated by others. Providers identified key structural barriers to full citizenship for clients. Their comments reflect openness to citizenship as a framework for understanding their clients and the need for greater access to normative community life, but also skepticism regarding providers' and public mental health centers' abilities to incorporate citizenship approaches in current care models. Findings suggest there are challenges to implementing "citizenship-oriented care" in public mental health settings, but efforts to address these challenges can support the goal of "a life in the community."

New Directions in the Historiography of Psychiatry.

Gerald Grob's work in the history of psychiatry over the course of almost fifty years created a model for how historians might successfully situate mental health in its social and political context, and how inseparable it was from this context. Over the last twenty years, the field has grown tremendously. Historians have incorporated categories of analysis like gender and race, methodologies like cultural history and intellectual history, and sought to continue Grob's quest to understand American mental health history as a critical component of American history writ large. In this piece, we suggest several potential areas for future study. Building on Grob's work on the asylum, we focus on the continued need to explore the texture of lived experience for both practitioners and those experiencing mental illness, both within and beyond the institution. In an era when the politics of deinstitutionalization continue to shape the modern mental health enterprise, we suggest that further examination of the consequences of deinstitutionalization is both inherently rich and relevant to contemporary mental health practice. Finally, we discuss opportunities for historians to engage with policymaking and social justice, pointing to incarceration and juvenile justice as two especially relevant areas for further study.

Social and clinical dimensions of citizenship from the mental health-care provider perspective.

OBJECTIVE: Citizenship is a theoretical framework regarding social inclusion and community participation of people with mental illnesses. It is defined by a person's connection to rights, responsibilities, roles, resources, and relationships. The application of this framework in public mental health settings is in its early stages. This study was an exploration of mental health providers' views of the potential contribution of this framework. METHOD: Eight focus groups were conducted with 77 providers on teams in a large mental health center. A 12-item brief version of a 46-item measure of citizenship was a starting point for discussion of the relevance of the framework and citizenship supports in public mental health care. RESULTS: Two themes were presented: social, including relatedness, stigma, and meaningful choices, and clinical, including client empowerment and barriers to citizenship work in clinical settings. These themes are discussed in relation to the introduction of citizenship-oriented practices in mental health care. Participant comments reflect openness to the concept of citizenship and the need for greater access to normative community life for clients, but also skepticism regarding the ability of providers and mental health centers to incorporate citizenship approaches in current care models. CONCLUSION AND IMPLICATIONS FOR PRACTICE: Findings suggest there are challenges to developing and implementing citizenship supports in public mental health settings based on social and clinical factors and limitations. However, it is also noted that efforts to address challenges through consultation and education of providers can support the goal of a life in the community for persons with mental illness. (PsycINFO Database Record

Recovery in Mind: Perspectives from Postgraduate Psychiatric Trainees.

OBJECTIVE: The authors assessed psychiatric trainees' understanding of recovery-oriented care, a therapeutic philosophy with varied meanings but wide purchase in contemporary mental health policy. METHODS: Four cohorts of residents were presented with a clinical vignette as part of a written curricular evaluation and asked what it would mean to engage the patient from a recovery-oriented perspective. Responses were subjected to qualitative analysis, with the analysts examining each cohort independently, then meeting to discuss their findings and build consensus on the most pertinent themes. RESULTS: Nine themes emerged in trainees' understanding of recovery-oriented care: (1) a person is more than his or her illness; (2) hope; (3) an emphasis on patient goals; (4) taking a collaborative approach; (5) an emphasis on level of social function; (6) valuing subjective experience; (7) psychosocial interventions; (8) empowerment of the patient; and (9) persistence of traditional attitudes. CONCLUSIONS: Residents revealed an understanding of recovery that reflected many, but not all, of the guiding principles in the Substance Abuse and Mental Health Services Administration's 2010 working definition. For many of these trainees, recovery-oriented care signified a shift in the traditional power dynamic between physician and patient that allowed patients to take an active role in their own care. Residents also recognized the importance of hope and the complexity of their patients' social identities, though some trainees had difficulty reconciling a collaborative approach with their perceived responsibilities as physicians. If educators wish to incorporate elements of the American Psychiatric Association's Recovery to Practice initiative into their curricula, they would do well to recognize residents' variable receptivity to elements of the model.

Fevered Decisions: Race, Ethics, and Clinical Vulnerability in the Malarial Treatment of Neurosyphilis, 1922-1953.

Physicians deliberately inoculated marginalized patients with malaria, using them as reservoirs to facilitate malarial fever therapy for syphilitic patients. The history presents ethical questions in an evolving historical context.

Erving Goffman's asylums and institutional culture in the mid-twentieth-century United States.

Sociologist Erving Goffman based his seminal work Asylums (1961) on a year of field research at St. Elizabeths Hospital in Washington, DC. Goffman described the mental hospital as a "total institution," in which regimentation dominated every aspect of daily life and patients were denied even the most basic means of self-expression; rather than promote recovery, such conditions produced the sorts of disordered behavior for which men and women were ostensibly admitted. A closer look at the changes transforming St. Elizabeths around the time of Goffman's research reveals a far richer portrait of institutional culture. Group therapy, psychodrama, art and dance therapy, patient newspapers, and patient self-government-each of which debuted at the hospital in the 1940s and 1950s-provided novel opportunities for men and women to make themselves heard and to take their fate into their own hands. While these initiatives did not reach all of the patients at St. Elizabeths, surviving documentation suggests that those who participated found their involvement rewarding and empowering. Goffman explicitly set out to describe "the social world of the hospital inmate." His failure to appreciate fully the capacities of his subjects, however, appears to have led him to underestimate the importance of these developments.

'These strangers within our gates': race, psychiatry and mental illness among black Americans at St Elizabeths Hospital in Washington, DC, 1900-40.

During the early decades of the twentieth century, William Alanson White and the medical staff at St Elizabeths Hospital in Washington, DC, developed an ambitious programme for US psychiatry wherein the profession would dedicate itself to the reconstitution of mentally-fit and socially-productive American citizens. The racist assumptions beneath this programme led most physicians at the institution to expect little more than deference, dependence and common labour from their black patients, preventing them from comprehending the impact of substandard and racially-segregated care. Black men and women were acutely aware of the injustices they faced. When they rejected elements of the hospital's medical regimen, these patients were also rejecting a social vision that consigned them to the margins of US civic life.

The influence of personal familiarity on object naming, knowledge, and use in dementia.

Reports of semantic dementia patients have shown more accurate identification and use for personal objects than unfamiliar analogs of the same objects (e.g., personal comb versus experimenter's comb) [Bozeat, S., Lambon Ralph, M. A., Patterson, K., & Hodges, J. R. (2002). The influence of personal familiarity and context on object use in semantic dementia. Neurocase, 8, 127-134; Snowden, J. S., Griffiths, H., & Neary, D. (1994). Semantic dementia: Autobiographical contribution to preservation of meaning. Cognitive Neuropsychology, 11, 265-288]. Despite potential clinical implications, the personal object advantage has not been explored in various dementia populations. Sixteen mild to moderate dementia patients were tested with 12-15 of their personal objects and laboratory analog objects. Four tasks were administered: Naming, Gesture, Semantic/Script Generation, and Personal Object Decision (i.e., Is this yours?). Although 25% of the sample performed at chance in identifying personal objects as their own, participants generated more specific information (t=2.3, p=.03) and more accurate gestures (t=2.4, p=.03) for personal objects. Thus, the personal object advantage was observed for script/semantic knowledge and movement sequences, and should be considered in residential planning for various dementia patients.