Chat with us, powered by LiveChat Inpatient Psychiatric Unit Deinstitutionalization played a significant role in shaping the current - Study Help
  

Inpatient Psychiatric Unit

Deinstitutionalization played a significant role in shaping the current roles of psychiatric social workers. Psychiatric social workers work on inpatient psychiatric units and provide services to individuals with mental illness and their families. Most inpatient psychiatric units are unique clinical settings where doors to the units are locked from the inside and from the outside. Patients are not free to leave the units at will, and visitors to the units are monitored closely. Psychiatric social workers work with patients who voluntarily seek care and others who are involuntarily admitted. In the simplest of terms, inpatient psychiatric care today focuses on stabilization and referral to a lower level of care. Psychiatric social workers create, negotiate, and implement discharge plans. They also provide limited clinical services, usually in the form of group interventions.

To prepare for this Assignment:

Review this week’s resources. Think about the roles and functions of a psychiatric social worker in inpatient psychiatric care settings. Focus on practice skills. Consider the philosophy of psychiatric social work.

In a 4-page paper:

· Explain the philosophy that drives psychiatric social work in caring for patients with mental illness.

· Explain the primary goals of psychiatric social workers.

· Describe the roles and functions of psychiatric social workers on interdisciplinary inpatient psychiatric teams.

· Compare differences and similarities in roles, practice skills, and functions between psychiatric social workers in inpatient units and non-psychiatric medical social workers in other types of medical units or healthcare settings.

Support your Assignment with specific references to resources, using appropriate APA 7 format and style. You are asked to provide a reference list for all resources, including those in the resources for this course.

C O M M E N T A R Y

Changes in the Conceptualization of Personality Disorder:
The DSM-5 Debacle

Thomas A. Widiger

Published online: 6 October 2012

� Springer Science+Business Media New York 2012

Introduction

Lanier, Bollinger, and Krueger (2011) provide an overview

of proposed changes to the diagnosis and classification of

personality disorders to appear in the forthcoming fifth

edition of the American Psychiatric Association’s (APA)

Diagnostic and Statistical Manual of Mental Disorders

(DSM-5). They are correct that the proposed changes to the

personality disorders section are fundamental, and in some

respects may represent a true paradigm shift in how a

mental disorder is conceptualized and diagnosed. As

expressed by the Chair of the DSM-5 Personality and

Personality Disorders Work Group (PPDWG), ‘‘the work

group recommends a major reconceptualization of per-

sonality psychopathology’’ (Skodol 2010, ‘‘Reformulation

of personality disorders in DSM-5,’’ para. 1). I do not

myself disagree with some of the more radical proposals

that are being made, but a difficulty I do have is the sur-

prisingly liberal threshold that has been accepted for

making any such revisions (Frances 2009; Widiger 2011).

In addition, one point of strong agreement with Lanier et al.

is that the construction of DSM-5 is in a state of ‘‘flux,’’ to

the point that it is frankly difficult to predict or anticipate

what may in fact happen to the diagnosis of personality

disorders.

Lanier et al. state that the proposals for DSM-5 consist of

four major changes (see Table 1 of Lanier et al.): (1) a

change to the definition of personality disorder to require the

presence of a pathology of identity integration, integrity of

self-concept, and self-directedness in order for a diagnosis to

be made; (2) an assessment of level of self and interpersonal

dysfunction; (3) the deletion of five diagnoses; and (4) the

inclusion of a six domain (37 trait) dimensional trait model.

However, since this paper was written, there have been quite

a few significant changes to these (and other) proposals.

Prototype Matching

Missing from the Lanier et al. list of changes was a deci-

sion by the PPDWG to abandon diagnostic criterion sets

for prototype matching (Skodol 2010; Skodol et al. 2011).

One of the, if not the, major innovation of the third edition

of the APA diagnostic manual (i.e., DSM-III; APA 1980)

was a shift away from the unreliable prototype matching to

the requirement that a mental disorder diagnosis include a

systematic and comprehensive assessment of a specific and

explicit set of diagnostic criteria (Spitzer et al. 1980). The

criterion sets of DSM-III increased dramatically the ability

of researchers to conduct reliable, replicable, and valid

research. As expressed recently by Kendler et al. (2010),

‘‘the renewed interest in diagnostic reliability in the early

1970s-substantially influenced by the Feighner criteria-

proved to be a critical corrective and was instrumental in

the renaissance of psychiatric research witnessed in the

subsequent decades’’ (p. 141). One of the benefits of this

renaissance was the highly published Collaborative Lon-

gitudinal Studies of Personality Disorders (CLPS), which

used as its primary measure a semi-structured interview

that systematically assessed the DSM-IV personality dis-

orders’ specific and explicit criterion sets (Skodol et al.

2005).

Nevertheless, the PPDWG proposed to abandon diag-

nostic criterion sets for prototype matching, in which one

matches one’s perception of a patient with a 10–17

T. A. Widiger (&)
Department of Psychology, University of Kentucky, Lexington,

KY 40506-0044, USA

e-mail: [email protected]

123

Clin Soc Work J (2013) 41:163–167

DOI 10.1007/s10615-012-0419-9

sentence paragraph description of a prototypic case

(Skodol 2010; Westen et al. 2006). ‘‘To make a diagnosis,

diagnosticians rate the overall similarity or ‘match’

between a patient and the prototype using a 5-point rating

scale, considering the prototype as a whole rather than

counting individual symptoms’’ (Westen et al. 2006,

p. 847). Rather than require a researcher or a clinician to

spend 2–4 h carefully assessing each diagnostic criterion,

with prototype matching ‘‘clinicians could make a com-

plete Axis II diagnosis in 1 or 2 min’’ (Westen et al. p. 855)

because one does not assess each individual sentence

within the narrative description. Instead, the clinician

matches their perception of the patient with the overall

gestalt. The diagnosis is reduced from a systematic

assessment of each of the nine diagnostic criteria for DSM-

IV-TR borderline personality disorder (or each of the 13

sentences within the DSM-5 narrative description of a

prototypic case) to simply a single judgment: whether the

patient’s personality appears to match the set of sentences,

considered together as a unified whole.

This proposal was made despite the fact that there is a

considerable body of research to document the poor reli-

ability and validity of prototype matching (Widiger 2011;

Zimmerman 2011), a considerable body of research to

support the reliability and validity of specific and explicit

criterion sets (Zimmerman 2003), and no research that has

compared directly the reliability or validity of indepen-

dently administered prototype matching with specific and

explicit criterion sets. Skodol (2010) cited in support of

prototype matching studies conducted using the Personality

Assessment Form (PAF). However, the authors of these

studies in fact acknowledged that they used prototype

matching only because at the time their study began semi-

structured interviews to assess the DSM-III criterion sets

were not yet available (Shea et al. 1987). Pilkonis et al.

(2011) have since indicated their significant concern that

prototype matching permits diagnosticians to ‘‘interpret

each prototype narrative in potentially different ways,

opening the door to a host of known problems with cog-

nitive heuristics, such as salience and availability biases’’

(p. 73).

The only empirical support beyond the early PAF

research was a validity study by Westen et al. (2006) and

an interrater reliability study by Westen et al. (2010), both

of which included fundamental methodological flaws. For

example, in the case of the validity study, the clinicians

who provided the prototype ratings also provided the cri-

terion diagnoses, the latter even provided prior to their

provision of the prototype ratings. Frankly, using this

methodology, it would be difficult to obtain weak results,

as the clinicians were simply confirming their own recently

made judgments. If this criterion contamination was not

problematic enough, the ratings were provided for patients

the clinicians already knew extremely well (in treatment on

average for 16 months), which is not the situation in which

diagnostic criterion sets are typically used. With respect to

the reliability study, these prototype ratings were obtained

in the course of a 4.5 h standardized interview, inconsistent

with the purported method of prototype matching. In

addition, there was a clear possibility that the assessments

were again not in fact blind to one another. The clinicians

who provided the ratings were graduate students working

together within a psychological clinic. It is not uncommon

in such a setting for student clinicians to discuss amongst

themselves their diagnostic impressions of new clients (and

in some cases initial clients are discussed together at formal

case meetings).

In response to the critiques of prototype matching

(Widiger 2011; Zimmerman 2011), the PPDWG was com-

pelled to abandon their proposal for prototype matching and

to include instead diagnostic criterion sets (Siever 2011). In

sum, it now appears that this major innovation for DSM-5 has

been rejected. However, rather than work from the diag-

nostic criterion sets that were developed for DSM-IV-TR and

have since been used in a substantial body of empirical

research (e.g., Skodol et al. 2005), the PPDWG has appar-

ently decided to construct brand new criterion sets by arbi-

trarily combining the self and interpersonal pathologies that

they think will be specific to each respective personality

disorder along with a list of traits they again think will likely

be diagnostic of each personality disorder.

Deletion of Diagnoses

The PPDWG also intends to delete half of the diagnoses;

more specifically, the dependent, narcissistic, paranoid,

schizoid, and histrionic personality disorders. The primary

reason for their deletion is to reduce diagnostic co-occur-

rence (Skodol 2010). Diagnostic co-occurrence has been a

significant problem for the categorical diagnoses (Widiger

and Trull 2007) but sacrificing fully half of them would

seem to be a rather draconian approach for addressing this

problem. In addition, it does not speak well for the credi-

bility of the field of personality disorder to be so willing to

sacrifice half of its coverage in order to address diagnostic

co-occurrence, as if half of what we have been diagnosing

and treating for the past 30 years was not worth the clinical

attention (Widiger 2011). Persons will still have dependent,

schizoid, paranoid, histrionic, and narcissistic personality

traits despite their diagnoses being deleted (if not, then it is

unclear why there is any need to include these traits within

the dimensional model). Lack of adequate coverage has

been a problem of comparable magnitude to diagnostic

co-occurrence (Verheul and Widiger 2004). This problem

will be magnified substantially in DSM-5.

164 Clin Soc Work J (2013) 41:163–167

123

In addition, significant questions have been raised with

respect to the rationale for which diagnoses to delete. There

does appear to be as much, if not more, empirical support

for the narcissistic and dependent personality disorders

(two diagnoses to be deleted) as there is for the avoidant

and obsessive–compulsive personality disorders (Bornstein

2011; Ronningstam 2011). Zimmerman (in press) suggests

that it is no accident that four of the five diagnoses being

retained (i.e., avoidant, obsessive–compulsive, schizotypal,

and borderline) were the focus of the CLPS project,

spearheaded by the Chair of the PPDWG (Skodol et al.

2005).

Skodol et al. (2011) provides a review of the literature

which they suggest indicates support for the decision to

delete the dependent and narcissistic personality disorders in

favor of the avoidant, obsessive–compulsive, antisocial,

borderline, and schizotypal. However, even if one confines

the decision to the studies cited by Skodol et al. one does not

discover much support for the decision (Mullins-Sweatt et al.

in press). For example, one of the reasons given for a

weakness in the validity of dependent personality disorder

was a difficulty in discerning its prevalence because the

prevalence purportedly fluctuates widely from study to

study. However, in the seminal review of epidemiology by

Torgersen (2009), cited by Skodol et al. the fluctuation in

prevalence was actually worse for the schizotypal (ranging

from 0.0 to 3.2 across the studies that were considered),

antisocial (0.0–4.5), borderline (0.0–3.2), avoidant

(0.4–5.0), and obsessive–compulsive (0.0–9.3), the five to be

retained, than it was for the dependent (0.4–1.8). Dependent

personality disorder was also said to be associated with only

moderate to low impairment in functioning, but its level of

impairment has been consistently higher than has been

obtained for the obsessive–compulsive in the studies con-

sidered by Skodol et al. (Mullins-Sweatt et al. in press).

Finally, Skodol et al. indicated that dependent was one of the

two least common personality disorders in the community,

according to the review by Torgersen. However, this was not

in fact the case. According to Torgersen’s review, with

respect to the median rate across the studies he considered,

dependent had a higher prevalence rate than schizotypal (and

higher than three other personality disorders), and, when

considering the pooled rate across these studies, a higher

prevalence within the community than either schizotypal or

borderline.

In any case, the decision of what to retain and what to

delete might in fact be moot, as it now appears that there

may not in fact be a personality disorders section, or at

least if there is one, it could very well be reduced to a

skeleton of its former self that is unlikely to survive any

future harsh winter. Siever (2011) indicates that a repre-

sentative of the PPDWG agreed with representatives of the

schizophrenia disorders work group to move schizotypal

personality disorder out of the personality disorders section

into a new class of schizophrenia-spectrum disorders. Its

primary coding will be as a schizophrenia-spectrum dis-

order, not as a personality disorder (the latter will only be

noted parenthetically for historical purposes). A similar

proposal is being pushed heavily for a shift of antisocial/

psychopathic personality disorder into a new class of (child

and adult) disruptive behavior disorders, wherein it would

also receive its primary diagnostic coding and noted only

parenthetically that it used to be classified as a personality

disorder (Siever 2011). If these new proposals are enacted,

the personality disorders section will be left with just three

diagnoses (i.e., avoidant, obsessive–compulsive, and bor-

derline), and it is difficult to imagine that the section could

then survive (Widiger 2011).

Dimensional Trait Model

It is evident that the diagnosis and classification of person-

ality disorder is shifting toward a dimensional trait model

(Widiger and Simonsen 2005). It has in fact been suggested

that the primary contribution of DSM-5 will be a shift of the

entire diagnostic manual toward a dimensional model of

classification (Regier 2008). This will be most clearly evi-

dent with the personality disorders, which will include a 6 (or

5) dimensional model of maladaptive personality, including

37 (or 25) lower-order traits that can be used to provide an

independent description of each particular patient and/or be

part of the diagnostic criterion sets for each respective per-

sonality disorder. Lanier et al. (2011) describe well many of

the benefits and advantages of this shift.

Lanier et al. (2011) also document well how this proposal

is well aligned with the five-factor model (FFM) of general

personality structure. An integrative dimensional model of

normal and abnormal personality offers quite a few benefits

(Krueger and Eaton 2010; Widiger and Trull 2007). It

addresses the many fundamental limitations of the categor-

ical model (e.g., heterogeneity within diagnoses, inadequate

coverage, lack of consistent diagnostic thresholds, and

excessive diagnostic co-occurrence). It provides a more

comprehensive and individually specific description of each

patient’s normal and abnormal personality structure, thereby

facilitating more precise and informative research concern-

ing etiology and pathology, and more specific and distinct

treatment decisions (Widiger and Mullins-Sweatt 2009).

Finally, it transfers to the psychiatric nomenclature a wealth

of knowledge concerning the origins, childhood antecedents,

stability, and universality of the dispositions that underlie

personality disorder (Widiger and Trull 2007).

Lanier et al. also indicate, however, that the authors of the

DSM-5 dimensional trait model disavow some of the con-

nection with the FFM; more specifically, that compulsivity is

Clin Soc Work J (2013) 41:163–167 165

123

not a maladaptive variant of conscientiousness and oddity or

peculiarity is not a maladaptive of openness (Clark and

Krueger 2010; Krueger et al. 2011). The rationale for this

position is unclear, as there is a considerable body of

empirical research that supports the relationship of com-

pulsivity to conscientiousness and oddity to openness

(Widiger 2011). In addition, failing to acknowledge this

continuum results in a model that lacks coherence or

consistency, as if some dimensions of maladaptive per-

sonality are on a continuum with general personality

structure (i.e., emotional instability or dysregulation,

antagonism, detachment, and disinhibition) whereas others

(i.e., compulsivity and oddity), are for no apparent reason

qualitatively distinct from general personality structure.

This has not been the position held previously by the

proponents of dimensional models of personality disorder,

including the authors of the model for DSM-5 (e.g., Clark

2007; Markon et al. 2005).

There are, however, important ways in which the

dimensional trait model proposed for DSM-5 is different

from the FFM. First, it does not actually include any nor-

mal personality traits, thereby failing to provide a truly

integrative model. The DSM-5 proposal is confined to

maladaptive personality traits, and thereby will not be able

to identify the normal variants of the traits could in fact be

quite useful, if not important, for treatment planning, such

as openness that can suggest a responsivity to insight,

reflective, and dynamic therapies, agreeableness and

extraversion that can suggest a receptivity to group, mari-

tal, and other forms of interpersonal therapy, and consci-

entiousness that can suggest a willingness and ability to

withstand the rigors of dialectical behavior therapy

(Widiger and Mullins-Sweatt 2009). In addition, the model

is entirely unipolar, failing to recognize the bipolarity of

personality structure that has been empirically very well

supported (Markon et al. 2005; Widiger 2011). The

absence of this bipolarity contributes to the failure of the

proposed model to recognize a number of important mal-

adaptive personality traits, such as the glib charm and

fearlessness of psychopathy (low neuroticism), gullibility

and meekness of dependency (high agreeableness), and

closedness to feelings of alexithymia (low openness).

In fact, like almost everything else for DSM-5, the

dimensional model has apparently changed since the paper

by Lanier et al. was accepted for publication. The model

proposed at this current moment in time is a 5 domain

model (emotional dysregulation, detachment, antagonism,

disinhibition, and peculiarity), with 25 lower-order trait

scales. The basis for this shift appears to be due simply to a

recent factor analysis conducted by member(s) of the

DSM-5 PPDWG (Siever 2011), rather than being guided by

the considerable body of existing research. This may reflect

the wider tendency of the DSM-5 process (Frances 2009) to

allow work group members to rely on their own prefer-

ences and their own studies rather than seeking a more

consistent historical continuity guided by a wider scientific

literature.

Conclusions

In sum, Lanier et al. are indeed correct that DSM-5 per-

sonality disorders are likely to be much different than the

DSM-IV-TR personality disorders. Some of these signifi-

cant changes could reflect major improvements in how

disorders of personality are conceptualized and diagnosed.

However, the proposals vary considerably in the extent to

which they have compelling empirical support. Even a

member of the DSM-5 PPDWG has opined that ‘‘the DSM-

5 proposal is a disappointing and confusing mixture of

innovation and preservation of the status quo that is

inconsistent, lacks coherence, is impractical, and, in places,

is incompatible with empirical facts’’ (Livesley 2010,

p. 304), characterizing the overall effort as an expression of

‘‘incoherence and confusion’’ (p. 304). The major accom-

plishment of the fourth edition of the APA’s diagnostic

manual was not in the development of surprising new

content but rather in the careful, cautious, and systematic

method with which it was constructed. The authors of the

forthcoming fifth edition may have turned this priority on

its head, emphasizing instead radical changes without first

conducting careful, systematic, thorough, or objective

reviews of the scientific literature.

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Author Biography

Thomas A. Widiger is the T. Marshall Hahn Professor of Psychology
at the University of Kentucky. He was the Research Coordinator for

DSM-IV and the 2010 recipient of the Distinguished Scientist Award

by the Society for a Science of Clinical Psychology.

Clin Soc Work J (2013) 41:163–167 167

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  • Changes in the Conceptualization of Personality Disorder: The DSM-5 Debacle
    • Introduction
    • Prototype Matching
    • Deletion of Diagnoses
    • Dimensional Trait Model
    • Conclusions
    • References

Article

Transcultural Psychiatry 48(3) 284–298 ! The Author(s) 2011

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DOI: 10.1177/1363461511402867 tps.sagepub.com

Cooperation and contention in
psychiatric work

Seth D. Messinger
University of Maryland, Baltimore County

Abstract

This article discusses the social organization of psychiatric work in the psychiatric

emergency department of a public general hospital located in New York City, based

on ethnographic research conducted from 1999 to 2001. Case studies of the care of

two patients with ambiguous symptoms are discussed. The analysis applies the ‘‘differ-

ences approach’’ developed by Mol and colleagues which focuses on the way different

professions provide divergent explanations and ontologies for symptoms and illness.

The cases illustrate the ways in which social structural constraints are compelling psy-

chiatry to become a multidisciplinary specialty.

Keywords

cities, political economy, psychiatry, public hospitals, social organization of work

Many patients who present to psychiatric emergency departments in large urban
centers in the US have multiple problems, which go beyond the disciplinary range
of psychiatry and require the services of other occupations that thus far have served
in positions subordinate or ancillary to psychiatrists (Freidson, 1988). These prob-
lems include co-morbidity of mental illness and drug or alcohol dependence, and
problems including unemployment, poverty, homelessness, and other social ills.
The presence of this wide variety of co-morbidities coupled with a relative scarcity
of hospital inpatient beds has altered the social landscape of psychiatry. Once
ancillary occupation groups, like addiction counseling, now have a claim on the
provision of beds which are key hospital resources as well as access to networks of
placements through outpatient substance abuse rehabilitation programs. This gives
members of these ancillary groups greater professional authority, creating the con-
ditions where they are able to reorganize their working relationships with

Corresponding author:

Seth D. Messinger, Department of Sociology and Anthropology, University of Maryland, Baltimore County,

1000 Hilltop Circle, Baltimore, MD 21250, USA.

Email: [email protected]

psychiatrists. At times, these collaborative efforts can be described as cooperation.
Alternatively, these once ancillary clinical occupational groups can thwart the
efforts of psychiatrists to diagnose and admit patients to the inpatient unit, causing
contention. In this article, I will illustrate these processes through a close reading of
two patients’ experiences in the psychiatric emergency department.

The argument that I present here claims that in order to understand how
psychiatry is practiced in settings where a variety of pressures such as social
service cuts, scarcity of beds and other resources, along with challenges facing
indigent and largely underserved patients, we must investigate this practice not
as a singular profession but as a multidisciplinary one. Berg and Mol’s (1998)
‘‘differences approach’’ emphasizes on how different clinical specialties can focus
on the same organ or dysfunction yet have ontological distinctions that critically
shape their practice. This approach is particularly useful in understanding the
challenges faced by clinicians in the psychiatric emergency department, in which
psychiatrists work to understand their patients’ distress as products of endoge-
nous disorders, while addiction counselors, social workers and psychologists
view this distress as a product of the patients’ entanglements in a complex
social world. These two groups of clinical workers negotiate diagnoses and
treatment plans through their cooperation, or alternatively, through intense
debates over the key question: ‘‘what is wrong with the patient’’ (Luhrmann,
2000).

The ‘‘differences’’ approach is concerned with how different clinical specialties
approach the disease or bodily organ from distinct ontological perspectives, as well
as with how multidisciplinary clinical programs approach complex therapeutic
challenges (Berg & Mol, 1998; Mol, 1998, 2003). Two examples of this approach
to the study of clinical work are germane to the issues I discuss in this article. Mol
(1998, 2003) investigates the different modes of diagnosis and clinical understand-
ing when various medical specialties identify atherosclerosis. She traces the distinc-
tions in ways of knowing atherosclerosis across different medical specialties
illustrating how this disorder is enacted by practitioners in relation to a shifting
terrain that is dependent on the context of where atherosclerosis is observed (in the
thickened walls of the artery by a pathologist or in a patient’s complaint by an
outpatient physician).

Gremillion’s (2003) ethnographic work on a treatment unit for adolescents
with anorexia nervosa provides an example of how conflict emerges between clini-
cians where different professional perspectives exist uneasily. In an account of a
debate between a psychiatrist and a pediatrician over whether a particular
patient could be discharged from the unit, the pediatrician staked her position
on the basis of the patient’s weight, arguing that it was still dangerously low.
The psychiatrist agreed about the low weight but argued that the patient had
developed increased insight into her situation and had strengthened her determi-
nation to eat. Here the anorectic patient is perceived in two distinct ways: the pedi-
atrician is addressing the biomedical problem of an underweight individual who is
at risk for malnutrition. In contrast, the psychiatrist is looking at the complex

Messinger 285

transformation being wrought by the patient and endorsing an emerging will to eat
that should be supported despite continuing low weight (Gremillion 2003, p. 65).

Among the psychiatrists in the Urban Hospital psychiatric emergency depart-
ment, mental illness was understood along strict biomedical lines. Disorders and
diagnostic criteria were laid out in weekly seminars where attending psychiatrists
taught residents how to identify symptoms and to understand their relationships to
each other and to specific disorders. In contrast during morning report and in other
conferences members of the ancillary professions, including addiction counselors
and social workers, added a more complex perspective, discussing patient symp-
toms in terms of their drug use, family situations, employment status and social
networks (among other factors). The realities of specific patient’s experience of
distress were constructed in ways that reflected the ontological positions con-
structed from the standpoint of these different professions. These ontological dis-
tinctions set the stage for the forms of cooperation and contention that I will
describe.

Setting

This study was conducted between 1999 and 2001 at Urban Hospital, a public
hospital in New York City. Urban serves a primarily low income population of
African Americans, Latinos, a sizable immigrant community originating in the
Caribbean and Africa, as well as substantial numbers of undocumented
immigrants.

Urban Hospital is a major institution for the neighborhood. The hospital has
been the site where generations of community residents have been born, treated for
illnesses, and died. However, by the year 2000, many community members felt the
hospital was surviving on borrowed time. Adding to their anxiety, a new ambula-
tory care unit was built raising fears that a shift in the hospital’s mission was
imminent and that the number of beds might soon be reduced. People from the
hospital and the neighborhood were also concerned that Urban Hospital’s rela-
tionship with two private medical centers was a harbinger for its transformation
from a community hospital to a research center.

Urban Hospital was connected to a network that included two private hospitals.
These private hospitals were in a much stronger position to control their flow of
work. In busy periods their psychiatric emergency departments could go ‘‘on diver-
sion,’’ which meant that ambulances transporting patients were directed to alter-
native hospitals, often Urban. During my fieldwork, Urban’s 16 bed psychiatric
emergency department frequently would have over 20 patients. These patients
would be placed on beds in the hallway or were placed in reclining chairs that
were made up as beds in a patient lounge area. In these situations, which occurred
when the inpatient psychiatric units were filled or overfilled, psychiatrists and
addiction counselors and social workers would huddle together working out dis-
positions to the community’s network of substance abuse rehabilitation agencies or

286 Transcultural Psychiatry 48(3)

to longer-term state psychiatric facilities. As Rhodes (1991) pointed out in her
ethnography of a psychiatric acute care center, the scarcity of inpatient beds and
the challenge of locating an open admission slot for a difficult patient provides a
constant struggle for clinicians. The end result in a place like Urban Hospital is that
the ability to locate or reserve admission slots confers a significant amount of
prestige and influence.

Urban Hospital’s psychiatry department, like many of its other clinical depart-
ments, is largely made up of physicians who trained in foreign medical schools and
immigrated to the United States, often after several years of medical work abroad
(Katz, 1992).

1
Nearly all the resident psychiatrists accepted a slot in the residency

program because it was available, not because it was a first choice. Most had also
applied to internal medicine or some other non-surgical specialty. The fact that
many of the residents are ‘‘accidental’’ psychiatrists makes Urban a compelling
place to conduct a study of issues of training, professional socialization, and the
practice of psychiatry. Urban’s status as a public hospital means that it serves a
very diverse array of patients. As a public hospital Urban would presumably have
the largest diversity of psychiatric illness to treat, making it a rich training envi-
ronment for the residents (cf. Mizrahi, 1986).

Methods

Using participant observation in the context of an ethnographic investigation of
the social organization of work, training environments, and clinical practice, I
collected data on a daily basis between 1999 and 2001. The research involved
observation of emergency department practices and interviews with the clinical
staff members. I was able to attend morning report meetings and had access to
all the clinicians. I also had access to the patient areas of the emergency department
and was able to observe patients when they were not being physically examined or
receiving treatment. However, if a patient had signed a consent form I was able to
sit in with them on some meetings with psychiatrists or other clinicians after receiv-
ing oral permission from both the patient and the clinician. In this article all names
are pseudonyms (including the hospital name). Measures to ensure confidentiality
included anonymous codes and pseudonyms that were provided as a rule.

2
The

study was approved by the Institutional Review Board (IRB) at both Teachers
College, Columbia University and at the hospital site. All participants were
informed about the objectives and gave informed consent.

Results

While Urban Hospital kept a sequential log of admissions to its psychiatric emer-
gency department it did not collect data tracking repeat admissions, admissions by
diagnoses, or other historical information. That said, during the period of my

Messinger 287

research it appeared that the majority of patients treated in the Urban Hospital
psychiatric emergency department had a history of previous psychiatric contact.
These patients were generally regarded as easy to diagnose and were generally
perceived as offering little challenge in the development of a treatment plan. This
was because in most cases their existing diagnoses were reapplied and their links to
outpatient care were reestablished. In contrast, the two patients that I discuss
below had no record of contact with Urban Hospital’s psychiatric department
and they did not report being treated at other facilities. As I will illustrate these
patients are more likely to engender the kinds of inter-clinical debate which lead to
cooperation or contention among the various clinicians in the emergency depart-
ment. The two cases that are the focus of this paper represent the common dis-
tinctions made between patients without a psychiatric history. The first case is
representative of patients who present with psychiatric symptoms and a positive
toxicology screen for alcohol and/or drugs. The second case represents patients
with symptoms that have unclear origins and which do not lend themselves to
existing psychiatric disorders and which ultimately are seen to fall under the cat-
egory of ‘‘problems with living.’’

Cooperation

The first case study provides an example of multi-disciplinary cooperation in which
clinicians came together to address the particular challenges in developing a diag-
nosis, treatment plan and disposition. These challenges include the opacity of the
patient’s symptoms in the context of chronic drug and alcohol use as well as his
unstable housing situation and intangible elements of his personality that made
him difficult to place in an inpatient bed or treatment facility.

Late one evening, an African American man in his 40s arrived at the locked
doors of the Urban Hospital psychiatric emergency department. He was let into the
triage area where he was initially searched by a hospital police officer. After waiting
a few moments he was interviewed by a psychiatric resident accompanied by a
nurse who measured his blood pressure and his temperature. During the interview
the man, who said his name was Avery, gave a complex and detailed account of a
series of interpersonal conflicts that had frightened him enough to seek help. He
had first gone to the medical emergency department around the corner and they
had suggested he come here.

Avery described a series of escalating conflicts with his neighbors and with the
building superintendent in his apartment building. These conflicts stemmed from
his separation from his girlfriend. According to Avery they had broken up and she
had moved into the basement of the building. He said that she then had a series of
sexual encounters with neighbors and the building superintendent, and that when
these men had discovered that she had HIV they blamed Avery for their exposure.
Avery said that he thought they were planning to assault him and that he could
hear them planning it through the walls and the floor of his apartment. He also said
that he was being watched all the time because he heard voices describing his

288 Transcultural Psychiatry 48(3)

activities. For example, when he was brushing his teeth he could hear a voice saying
‘‘now he is brushing his teeth’’ or when he was walking through his apartment he
could hear a voice saying ‘‘he’s going from the kitchen to the living room.’’

In order to help Avery feel more calm, the resident who interviewed him gave
him an injection of a standard medication combination often administered at
Urban Hospital that was referred to as ‘‘a five and two’’ meaning five milligrams
of haloperidol (a neuroleptic) and two of lorazepam (an anxiolytic). After he was
‘‘medically cleared’’ through a brief physical examination, Avery had blood drawn
in order for the psychiatrists to get a toxicology screen. Avery was assigned to a bed
and promptly fell asleep. After I left, the resident wrote up his notes to present
Avery’s case to the team the next day at morning report.

The morning report is the most elaborate ‘‘rounds’’ presentation of the day in
the psychiatric emergency department. In attendance are the attending psychia-
trists, two or three psychiatric residents, Dr. Maye the psychologist, Ms. Crusoe,
the addiction counselor, one of the social workers, and one of the nursing staff. In
addition, medical students, physician assistant students, psychology and social
work interns, case managers from outside agencies (who may have clients in the
emergency department). The morning after Avery came to the emergency depart-
ment the admitting resident Dr. Oba, presented the details of his case to the assem-
bled team. Overnight the hospital lab returned the results of Avery’s bloodwork
showing the presence of heroin. Furthermore, in a subsequent interview with him
conducted by a nurse it was reported that he was a habitual heavy user of cocaine
and heroin as well as alcohol.

The discussion of Avery in morning report, which took about 15 minutes,
ranged across several diagnostic possibilities. Dr. Oba took Avery’s belief that he
was going to be assaulted as evidence of a paranoid delusion. He also presented
Avery’s report of hearing his neighbors angrily talking about him and describing
his activities as two forms of auditory hallucination, which were clear evidence of
schizophrenia (American Psychiatric Association [APA], 2000).

Ms. Crusoe disagreed with Dr. Oba and told the group that the patient had
‘‘talked about cocaine and alcohol use both of which could be responsible for the
hallucinations.’’ The attending psychiatrist also supported her position reminding
Dr. Oba that, ‘‘While you’re right. . . the commenting voices are a powerful sign of
schizophrenia, until we know more about him I agree with Ms. Crusoe. Alcohol
alone has been associated with auditory hallucinations including those that seem to
be commenting or describing the patient’s activities.’’

At the conclusion of the discussion, the morning report team agreed that the
diagnosis for Avery could only be ‘‘substance induced psychotic disorder.’’ This led
to a brief discussion of the various disposition options. One possibility was to
admit Avery to the inpatient unit at Urban Hospital, but the social worker men-
tioned that, in light of Avery’s report about conflict with his neighbors and building
superintendent, they might have to consider Avery as unstably housed or homeless,
which meant that he could not be discharged without a home or a residential
facility to go to. This led to a brief renewal of the possible diagnosis discussion

Messinger 289

because the choice of problem to emphasize (psychiatric disorder versus substance
dependence disorder) would have implications for where Avery could be sent.

Over the rest of that day and the following I was able to talk to two psychiatric
residents and to Ms. Crusoe (the addiction counselor) about Avery and about what
would likely happen to him. The psychiatric residents continued to argue that
Avery likely had schizophrenia, pointing to the commenting hallucination as well
as to the persistence of his delusional belief that there was a plot to assault him.
Added to this, the daytime resident, Dr. Randolph, argued that Avery had a delu-
sional denial of illness which was further evidence of a primary psychotic disorder.

In contrast, Ms. Crusoe argued that Avery was a drug addict and that his
symptoms needed to be understood in that context. She was determined to have
Avery admitted either to the inpatient unit or to a residential treatment facility
because, in her view, only in a secured, structured institutional setting could Avery
receive the kind of care he needed.

Although, Ms. Crusoe agreed with the psychiatrists that Avery had a mental
illness, she disagreed over the specifics, seeing it as an addiction disorder rather
than a psychotic disorder, but she had no doubt that it was persistent and intrac-
table. What distinguished her position from the psychiatrists was that she did not
locate the disorder in Avery’s body or brain but in the social context within which
he lived. Interestingly, while she defined his problem as one stemming from social
factors, her notion of social context was limited to immediate behavioral conse-
quences. She did not identify poverty, unemployment, or other more obviously
social structural factors in her analysis of Avery’s situation. She advocated admit-
ting Avery to the hospital or to a similar setting because, in her professional view,
he needed the structure to develop new habits and a new social identity and net-
work that was based on being sober.

During the four days that Avery was in the emergency department, Ms. Crusoe
and the psychiatrists negotiated his disposition. Avery also became involved in
these decisions at least indirectly through his actions. While his first day was largely
spent sleeping or being interviewed, over the next three days the nurses found his
behavior challenging. He complained vocally about the food, had loud arguments
on the pay phone, and was found smoking a cigarette butt in the men’s room.
Ms. Crusoe bitterly joked that she was less inclined to accept that Avery’s story
about being the target of an assault was delusional: ‘‘he’s a tremendous pain in the
ass; I’d be looking to hurt him too.’’

Ms. Crusoe’s perspective about Avery’s diagnosis and the best treatment options
available for him emerged as the predominate view held by the team. This shift
from debate to cooperation was based on the evidence that the team collected from
Avery’s narrative about his fears, the voices he heard, and his description of his
drug and alcohol use, complemented by the laboratory toxicology tests. One of the
residents mentioned that Avery’s behavior in the emergency department had also
led him to change his mind. ‘‘There is something about how he intrudes on the
nurses, what he complains about, that does not seem like a symptom of psychosis.
I’m not sure what is wrong with him in the whole picture, but I don’t think a psych

290 Transcultural Psychiatry 48(3)

unit is the right place for him.’’ The residents and physician assistants sped up their
efforts with Avery, working with him on the proper medication dosages to take as
well as running a number of physical tests to make sure he had no health issues that
would obstruct his admission to a drug rehabilitation program. Ms. Crusoe and her
social work colleagues started working through their networks to find a place for
him. Despite these efforts, there were no available beds either in the programs that
they contacted or, for that matter, in the hospital’s detoxification unit.

The attending psychiatrist and Ms. Crusoe met with Avery and encouraged him
to accept an admission to the hospital’s inpatient psychiatric unit to begin the
detoxification process, pending the availability of a bed in a residential treatment
facility. Avery agreed to this and was admitted to one of the two inpatient units.
However, according to the attending psychiatrist assigned to the inpatient unit,
Avery immediately requested to be discharged and provided his apartment address
as his home. He was released and did not go to a residential drug rehabilitation
program. I draw attention to this in order to point out that the kind of interdis-
ciplinary cooperation that I am describing does not automatically entail a desirable
clinical outcome, rather it illustrates the fluid and distributed nature of authority
that can influence both diagnosis and treatment planning.

Patients like Avery are increasingly present in psychiatric emergency depart-
ments (Larkin, Claassen, Emond, Pelletier, & Camargo, 2005). They often present
with a combination of symptoms of psychiatric disorders and drug and alcohol use.
These patients fall between the discrete boundaries of specific clinical occupational
groups like psychiatry and addiction counselors. As in the case with the clinical
occupational groups discussed by Mol and others, these patients straddle the onto-
logical divide between the biomedical psychiatric model of mental illness being in
the head, and the addiction counseling model, which sees these pathologies as
rooted in social systems. Beyond the diagnostic difficulties and limited treatment
options, there are substantial constraints on the broader hospital and residential
treatment facilities that make it increasingly difficult to find a place for patients in
these situations. Whether a consequence of deinstitutionalization or a byproduct of
recent neoliberal innovations throughout municipal governance, there is both a
decline in fiscal support for the expansion of public hospital psychiatric inpatient
beds as well as an increased push to close or privatize public hospitals. Psychiatric
departments have had to adjust to face these new circumstances. One way in which
they have adjusted is to distribute diagnostic and treatment authority to previously
ancillary clinical occupational groups, in part out of recognition that non-medical
and non-psychiatric treatment approaches can be effective for the patients who are
increasingly looking to psychiatric emergency departments for help.

Contention

This second case study provides an example of contention between representatives
of clinical occupational groups. ‘‘Caroline,’’ like Avery, came to the emergency
department with symptoms that led to divergent diagnostic conclusions.

Messinger 291

However, the context of her symptoms again revealed a divide between ways of
seeing and understanding psychiatric symptoms. In this case, the resulting conten-
tion in practice led to a kind of diagnostic and therapeutic stasis.

Early one evening Caroline, an 18-year-old woman, was brought to the psychi-
atric emergency department by police officers, who were accompanied by her
mother. According to her mother, Caroline had suffered a series of emotional
losses in recent days. Her boyfriend of several months, who she felt very strongly
about, broke up with her to go out with Caroline’s cousin, who was also her best
friend. As a result of these events, Caroline became increasingly withdrawn, never
leaving her apartment and rarely leaving her bedroom. She also refused to eat.
According to Caroline’s mother, who was interviewed by the social worker, after a
few days of this she encouraged Caroline to ‘‘get over it.’’ Caroline became inten-
sely angry. She began to ‘‘tear apart’’ the apartment, breaking pictures, throwing
things around her bedroom and the family living room. When she threw a clock
through the window looking out over the balcony her mother called the police.
When the police arrived Caroline was standing on the balcony amidst shattered
glass leaning out over the building court several floors below. She did not resist the
entreaties of a police officer to come into the apartment. When she did she was
handcuffed and brought down to the patrol car which took her to Urban Hospital.
At the hospital, she was released from the handcuffs and was interviewed separately
by a nurse, a social worker, and a psychiatric resident. She was medicated with
lorazepam and given a bed.

During the next morning report, the psychiatric resident who had admitted her,
Dr. Odinma, presented her case to the treatment team. He reported the narrative
above, and added that during his interview with her she was tearful. However, he
also said that her behavior was erratic, she would become suddenly angry, then
suddenly laugh. She also gave evidence of being paranoid by suggesting that her
cousin and her boyfriend had planned this in order to hurt and humiliate her. The
resident explained he had given Caroline a provisional diagnosis of brief psychotic
disorder (APA, 2000, pp. 329–332) with a rule out for schizophreniform disorder.
When other clinical workers expressed surprise about this rule out diagnosis, the
resident explained that coupled with Caroline’s violent outburst in her apartment
and her labile mood during her interview she might be exhibiting the schizophrenia
symptoms of ‘‘disorganized behavior’’ (APA, 2000, p. 314) and ‘‘bizarre thought’’
(APA, 2000, p. 324). Both of these symptoms need to be recurring in order for the
diagnosis of schizophrenia, but at Urban Hospital it was common practice for a
one-time occurrence leading to a hospital admission to be sufficient for the
diagnosis.

After the morning meeting ended Dr. Maye, the psychologist, interviewed
Caroline. The interview, which Dr. Maye described for me, led her to discount
the violent behaviors that led to the patient’s admission to the emergency depart-
ment. Dr. Maye preferred to elicit the patient’s own report about her emotional
state during her recent interpersonal upheaval. During morning report the next
day, Dr. Maye suggested that Caroline’s behavior needed to be seen in the context

292 Transcultural Psychiatry 48(3)

of her recent relationship losses. The psychologist argued that the patient was
suffering from an ‘‘adjustment disorder’’ and was having difficulty accommodating
her new …

O R I G I N A L P A P E R

Advances in the Conceptualization of Personality Disorders:
Issues Affecting Social Work Practice and Research

Paul Lanier • Sarah Bollinger •

Robert F. Krueger

Published online: 17 February 2011

� Springer Science+Business Media, LLC 2011

Abstract This article provides a review of the research

that has informed the proposed changes to the DSM-5

conceptualization of personality psychopathology with a

focus on implications for social work practice and research.

A paradigm shift to a dimensional model is likely to

replace the current categorical model of personality dis-

orders and will have profound implications for the pro-

fession. While establishing a diagnostic system that is

grounded in empirical knowledge is the primary benefit,

this tool will also be more consistent with social work’s

orienting theories and values. Social workers should gain

knowledge about the proposed changes and actively par-

ticipate in the review process.

Keywords Personality disorders � DSM-5 � Five-factor
model � Clinical social work

Clinical social work is now the nation’s largest provider of

mental health services with over 250,000 social workers

certified, licensed, or receiving clinical supervision to

diagnose and treat mental disorders (Harkness 2010; Center

for Workforce Studies 2006). According to the federal

government’s Center for Mental Health Services, there

were over 70,000 social workers employed by mental

health organizations in 2000 compared to about 20,000

psychiatrists and 20,000 psychologists (Mechanic 2008).

The Diagnostic and Statistical Manual of Mental Disorders

(DSM-IV-TR) (American Psychiatric Association [APA]

2000) is currently being revised for a 2013 release of its 5th

edition. Given the primacy of this diagnostic instrument and

the leading role that social workers play in mental health

treatment, it is vital that the social work profession not only

becomes aware of the proposed changes, but also critically

examines these changes from a social work perspective.

The portion of the DSM-IV-TR that will arguably

experience the most significant change will be the per-

sonality disorders (PDs). The current DSM-IV-TR is based

on a discrete categorical approach with an assumption that

diagnoses have clear boundaries (Maser et al. 2009).

Informed by a substantial body of research, the conceptu-

alization of PDs has moved towards a continuous, dimen-

sional scheme within a hierarchical structure (Markon

2009; Krueger and Eaton 2010). This paradigm shift is

quite significant and will have dramatic implications for

both clinical practice and research. An overview of the

empirical literature supporting this shift and the clinical

implications will be discussed with emphasis on the impact

to the field of social work.

Historical and Current Conceptualization

of Personality Disorders

The general diagnostic criteria for PDs consists of a pattern

of inner experience and behavior that deviate from the

expectations of an individual’s culture manifested in cog-

nition, affectivity, interpersonal functioning, or impulse

control. The current DSM-IV-TR distinguishes ten subtypes

of PDs organized within three clusters: paranoid, schizoid,

schizotypal (Cluster A), antisocial, borderline, histrionic,

P. Lanier (&) � S. Bollinger
George Warren Brown School of Social Work, Washington

University in St. Louis, One Brookings Drive, CB# 1196,

St. Louis, MO 63130, USA

e-mail: [email protected]

R. F. Krueger

Department of Psychology, University of Minnesota,

Minneapolis, MN, USA

123

Clin Soc Work J (2013) 41:155–162

DOI 10.1007/s10615-011-0333-6

narcissistic (Cluster B), and avoidant, dependent, and

obsessive–compulsive (Cluster C). Consistent with the

DSM-IV-TR, the World Health Organization’s Interna-

tional Statistical Classification of Diseases and Related

Health Problems (ICD-10) specifies PDs separate from

other clinical disorders as Disorders of Adult Personality

and Behavior (World Health Organization 1993). Estimates

of the prevalence of any PD in the general population have

ranged from 9.0 to 15.7% (Samuels et al. 2002; Crawford

et al. 2005; Lenzenweger et al. 2007). The most common

PDs found in the National Comorbidity Study Replication

(NCS-R) were avoidant (5.2%), schizoid (4.9%),

schizotypal (3.3%), and obsessive–compulsive (2.4%),

with common co-occurrence of PDs and comorbidity with

other disorders (Lenzenweger et al. 2007).

While there is disagreement on seemingly basic issues,

such as where PDs should exist in the DSM, the work

groups charged with updating the DSM must attempt to

balance the myriad empirical studies with considerations of

clinical utility (First 2010). Although these revisions may

change, there has been a major reconceptualization of

personality psychology that has led to a proposed refor-

mulation of PDs in the DSM. These proposed revisions can

be found online (www.dsm5.org) and registered users are

Table 1 Proposed Changes to DSM-5 Personality Disorders

(1) Definition PDs represent the failure to develop a sense of self-identity and the capacity for interpersonal functioning

that are adaptive in the context of the individual’s cultural norms and expectations.

(2) Levels of functioning

4 = Extreme impairment

3 = Serious impairment

2 = Moderate impairment

1 = Mild impairment

0 = No impairment

Self Identity integration: Regulation of self-states; coherence of sense of

time and personal history; ability to experience a unique self and

to identify clear boundaries between self and others; capacity for self-reflection

Integrity of self-concept: Regulation of self-esteem and self-respect; sense

of autonomous agency; accuracy of self-appraisal; quality of

self-representation (e.g., degrees of complexity, differentiation, and integration)

Self-directedness: Establishment of internal standards for one’s

behavior; coherence and meaningfulness of both short-term and life goals

Interpersonal Empathy: Ability to create an accurate model of another’s thoughts

and emotions; capacity for appreciating others’ experiences;

attention to range of others’ perspectives; understanding of social causality

Intimacy and cooperativeness: Depth and duration of connection with others;

tolerance and desire for closeness; reciprocity of regard and support

and its reflection in interpersonal/social behavior

Complexity and integration of representations of others: Cohesiveness,

complexity and integration of mental representations of others;

use of other-representations to regulate self

(3) Types

5 = Very good match

4 = Good match

3 = Moderate match

2 = Slight match

1 = No match

Antisocial/

psychopathic

Antagonism and disinhibition

Avoidant Negative emotionality, introversion, and compulsivity

Borderline Negative emotionality, antagonism, disinhibition, and schizotypy

Obsessive–

compulsive

Compulsivity, negative emotionality, introversion, and antagonism

Schizotypal Schizotypy, introversion, and negative emotionality

(4) Trait domains and facets

3 = Extremely descriptive

2 = Moderately

1 = Mildly

0 = Very little or not at all

descriptive

Negative

emotionality

Emotional lability, anxiousness, submissiveness, separation insecurity,

pessimism, low self-esteem, guilt/shame, self-harm, depressivity, suspiciousness

Introversion Social withdrawal, social detachment, restricted affectivity, anhedonia,

intimacy avoidance

Antagonism Callousness, manipulativeness, narcissism, histrionism, hostility,

aggression, oppositionality, deceitfulness

Disinhibition Impulsivity, distractibility, recklessness, irresponsibility

Compulsivity Perfectionism, perseveration, rigidity, orderliness, risk aversion

Schizotypy Unusual perceptions, unusual beliefs, eccentricity, cognitive dysregulation,

dissociation proneness

156 Clin Soc Work J (2013) 41:155–162

123

asked to provide feedback and comments. The system on

the website is in flux and will be continually revised. The

four proposed changes (Table 1) are found in the general

definition of PDs, five severity levels of personality func-

tioning, five PD types, and six personality trait domains

and their corresponding facets.

As DSM-IV-TR diagnostic criteria are ‘‘poorly defined

and not specific to personality disorder’’ (Livesley 2010,

para. 1), the work group first recommends retaining the

diagnosis of PD, but suggests a new general definition.

Under the proposed definition, PDs ‘‘represent the failure

to develop a sense of self-identity and the capacity for

interpersonal functioning that are adaptive in the context of

the individual’s cultural norms and expectations’’ (APA

2010). ‘‘Adaptive failure’’ is manifested in either (or both)

an impaired sense of self-identity or a failure to develop

interpersonal functioning. Additionally, there must be an

extreme level of at least one personality trait, stability

across time, and evidence that the adaptive failure is not

just the consequence of another mental disorder, substance

use, or another medical condition (APA 2010).

The second change, a dimensional measurement of

personality functioning, would be used to describe the

severity of the disorder on a zero to four scale ranging

from ‘‘no impairment’’ to ‘‘extreme impairment’’ for both

self and interpersonal functioning. Current DSM-IV-TR

severity indicators and the Axis V GAF lack adequate

specificity for determining the severity of personality

psychopathology (Bender 2010). Additionally, recent

research has found that in assessment of PDs, determina-

tion of severity is the most important predictor of current

dysfunction and prognosis (Hopwood et al. in press). The

constructs used to determine severity level are categorized

under self (identity integration, integrity of self-concept,

self-directedness) and interpersonal functioning (empathy,

intimacy and cooperativeness, complexity and integration

of representations of others). One argument supporting the

scale approach to impairment is that severity becomes

‘‘obvious with dimensions’’ and allows for continuity

between normal and maladaptive behaviors or cognitions

(Maser et al. 2009).

Third, there will be a reduction in the number of PD

types from 10 to 5. The retained types will be borderline,

antisocial/psychopathic, schizotypal, avoidant, and obses-

sive–compulsive. Dropped from the DSM list of types

would be paranoid, schizoid, histrionic, narcissistic,

dependent, depressive, and negativistic (the last two being

PDs described in the appendix of DSM-IV; Skodol 2010).

The proposed diagnostic rubric will include a description

of each PD type in a narrative format that includes a brief

overview of functional deficits and typical trait configura-

tion. There will be a dimensional rating of the match for

each type and for the personality traits associated with each

type. These changes are justified by ‘‘the excessive co-

morbidity among DSM-IV personality disorders, the lim-

ited validity for some existing types, arbitrary diagnostic

thresholds included in DSM-IV, and instability of current

DSM-IV PD criteria sets’’ (Skodol 2010, para. 1). The

dropped types from the DSM-IV-TR and the residual PD-

NOS diagnosis will be subsumed under a general PD

diagnosis with the descriptive trait profiles providing the

salient information regarding the disorder.

Lastly, there has been growing consensus that ‘‘normal

and abnormal personality variation can be treated within a

single, unified framework’’ (Markon et al. 2005, p. 139).

Therefore, it is recommended that individuals be rated on a

dimensional scale of six higher-order personality trait

domains. Within each domain, there are more specific

lower-order facets that comprise each domain. In addition

to being empirically validated, there are a number of rea-

sons why the use of traits as the essential diagnostic criteria

for PDs is beneficial. According to the work group (Clark

and Krueger 2010; Krueger and Eaton 2010), trait profiles

eliminate both comorbidity and PD-NOS, clarify within-

diagnosis heterogeneity, increase diagnostic stability, and

acknowledge the continuous nature of personality. Practi-

tioners will be more confident that their diagnosis is correct

and that it will be clearly distinguishable from other

diagnoses. The empirical work that undergirds the rationale

for a mixed categorical-dimensional system for diagnosis

will be described further (Maser et al. 2009).

Five-Factor Model and Diagnosis

Researchers have found overwhelming support for a ‘‘Big

Trait’’ model of personality structure that has been repli-

cated across cultures, languages, and ages using advanced

psychometric and analytic techniques (Marsh et al. in

press; Ashton et al. 2004; Ashton and Lee 2009; De Raad

et al. 2010). This development is viewed as ‘‘one of the

most important accomplishments of personality and

research’’ (Markon 2009, p. 1). There has been notable

consensus around a ‘‘Big Five’’ or Five Factor Model

(FFM) (McCrae and Costa 1985; Goldberg 1990; Saucier

2009). These factors are Neuroticism, Extraversion,

Agreeableness, Conscientiousness, and Openness.

There is considerable evidence that the structure of PDs

strongly relate to four of the five trait domains of the FFM.

However, the Openness factor has been found to be unre-

lated to PDs in meta-analyses (Clark and Krueger 2010;

O’Connor 2005; Saulsman and Page 2004). These same

studies found that the FFM did not provide adequate cov-

erage of specific traits found in Obsessive–Compulsive PD

and Schizotypal PD (Saulsman and Page 2004). As the

DSM is a tool to diagnose maladaptive functioning,

Clin Soc Work J (2013) 41:155–162 157

123

appropriate emphasis on abnormal personality structure is a

requirement. Thus, domains of Compulsivity and Schizo-

typy were added to provide full coverage of both normal

and abnormal personality with a six domain model, pend-

ing further empirical examination on how these domains

relate to the other four domains. As shown in Table 1,

these six domains (Neuroticism, Extraversion, Agreeable-

ness, Conscientiousness, Compulsivity, and Schizotypy)

correspond to the six proposed trait domains for the DSM-5

(Negative Emotionality, Introversion, Antagonism, Disin-

hibition, Compulsivity, and Schizotypy) although there is

still debate over how the domains should be named (Costa

and McCrae 2010).

There is already some indication that the FFM will

provide an improvement in diagnostic and clinical utility.

One study found that clinicians preferred the FFM to the

DSM for describing case vignettes (Samuel and Widiger

2006). Perhaps most important, the interrater reliability

using the FFM exceeded categorical diagnosis for proto-

typic and non-prototypic cases. Thus the FFM not only

performs more reliably, it also provides the opportunity for

deeper assessment and diagnostic utility exceeding the

diagnosis-by-prototype approach of the DSM (Clark 2007).

There are currently several standardized instruments that

can be employed to assess PD dimensions, including the

Revised NEO Personality Inventory (Costa and McCrae

1992), the Structured Interview for the Five Factor Model

(Trull et al. 2001), and the Schedule for Nonadaptive and

Adaptive Personality (Clark 1993).

Hierarchical and Dimensional Conceptualizations

The FFM represents one of the many models of personality

structure that attempt to describe both normal and abnor-

mal personality within a single framework (Eysenck 1947;

Cloninger 1987) and more recently, under a single inte-

grative hierarchy of superordinate and subordinate traits

(Markon et al. 2005). The main question is whether PDs

are ‘‘discrete clinical conditions or arbitrary distinctions

along dimensions of general personality functioning’’

(Widiger et al. 2009, p. 243). Currently, two people may

receive the same diagnosis, but present with different

personality traits and meet different criteria of the disorder

(Trull and Durrett 2005; Widiger et al. 2009). The cate-

gorical versus dimensional debate has been all but resolved

in recent years in favor of the dimensional approach.

The question then becomes how to accomplish a shift to

a dimensional model and which system to use. Concerns

about clinical utility and communication have been

expressed (Clark 2007). Although a dimensional system

would be more complex, it is specifically the invalid sim-

plicity of the previous system that should be addressed in

order to provide a more informed process of diagnosis and

treatment (Verheul 2005). FFM measures exhibit excellent

psychometric properties, making them reliable and valid

instruments to assess PDs and distinguish traits (Clark

2007). Thus, a ‘‘hybrid model’’ combining types and traits

assessed using dimensional ratings (mixed categorical-

dimensional system) has received preliminary empirical

support and is presented as the proposed model for the

DSM-5 (Skodol 2010; Maser et al. 2009; Morey et al. under

review).

In evaluating the proposed changes to the DSM-5, it is

evident that advances in the conceptualization of PDs were

considered in developing the recommendations. Personality

traits will be measured using a standardized dimensional

measure to determine the underlying personality structure of

the client. With a dimensional view of the level of functional

impairment and types that exhibit divergent and convergent

validity, these changes represent a revolutionary shift in the

way in which PDs are diagnosed and treated.

Implications for Clinical Social Work

There is evidence that clinicians already think dimension-

ally when considering patient characterization and that the

DSM has sacrificed clinical utility to mimic medical cate-

gorization (Maser et al. 2009). In the field of social work

some have taken this point beyond the dimensional versus

categorical debate of diagnosis. There is a strong position

that the use of the DSM is incongruent with the history and

focus of the profession (Kirk and Kutchins 1992; Kirk

2005). Indeed two national surveys of clinical social

workers use of the DSM-III (Kutchins and Kirk 1988) and

the DSM-IV (Frazer et al. 2009) found that while it is being

commonly used as clinical tool, its primary purpose is for

management of insurance reimbursement. Only half of the

respondents in the DSM-IV study indicated that they would

use the reference if it was not required. Kirk and Kutchins

(1992) have organized a reasonable opinion that the labeling

and medicalization of psychosocial problems directly

inhibits the understanding of the individual client, a key

feature of clinical social work. Further, they suggest that

social workers should pause before accepting the pairing of

the DSM and the insurance billing system. Although these

concerns are legitimate, the release of the DSM-5 is inevi-

table and fast approaching. Given this fact, perhaps a more

tenable position for social workers would be to purposefully

join the DSM-5 conversation by supporting and adding to

those changes that encapsulate cardinal social work per-

spectives and values (Frazer et al. 2009).

As social workers conscientiously anticipate the changes

that will occur with the release of the DSM-5, it is imper-

ative to evaluate how these changes relate to the

158 Clin Soc Work J (2013) 41:155–162

123

profession’s orienting theories. For example, Ecological

Systems Theory, derived from the person-in-environment

perspective, grounds social work practitioners and

researchers in an understanding that people and environ-

mental systems mutually influence one another (Hepworth

et al. 2010). Social workers are trained to look not only at

individual psychopathology, but also to evaluate disorder as

embedded in a deep social, cultural, and political fabric that

may obscure, complicate, or augment pieces of the indi-

vidual psyche. A dimensional approach to mental health

diagnoses encourages social workers to use this broader

lens in reaching the root of the problem rather than dealing

only with the surface level manifestations. For example, in

assessing the client’s trait profile, not only will issues of

functional impairment be incorporated, but social workers

will be able to expand their understanding of personality

structure while using their unique skills grounded in clinical

social work theory to integrate other factors that may con-

tribute to a complex personality structure. Social workers

are trained to look for factors beyond the individual diag-

nosis that will aid in helping the client, and this orienting

theory is critical to articulate as we conceptualize the

changes being made in the DSM-5.

Additionally, the core values of the profession center on

a strengths-based perspective, which will be better sup-

ported by the dimensional approach to diagnosing PDs.

Hepworth’s (Hepworth et al. 2010) seminal textbook on

clinical social work practice distinguishes several cardinal

values of the social work profession consistent with the

Code of Ethics of the National Association of Social

Workers (NASW 1999). Three of these that are directly

applicable in framing this discussion can be paraphrased as:

(1) respect for the inherent dignity and worth of the indi-

vidual, (2) respect for self-determination and independent

decision making, and (3) respect for unique characteristics

of diverse populations. In the current model, a PD diagnosis

implies that the client is inherently flawed and deviant. A

dimensional approach to understanding PDs could poten-

tially minimize the stigma associated with such a diagnosis.

With an integrated, dimensional model, ‘‘a personality

disorder no longer would be conceptualized as something

that is qualitatively distinct from normal personality func-

tioning. Personality disorders simply represent the presence

of maladaptive variants of personality traits that are evident

within all persons.’’ (Widiger et al. 2009, p. 246).

Although the dimensional approach will maintain the

term ‘‘personality disorder,’’ the definition of disorder

would center on adaptive failure manifested in either (or

both) an impaired sense of self-identity or interpersonal

functioning (APA 2010), as opposed to disorder indicating

deviance. While still correctly termed ‘‘disorder,’’ this

modification of the definition from deviant to maladaptive

is of vital importance in how we understand the concept.

The evaluation of a disorder is placed on a continuum of

normality rather than seen as a fundamental and patho-

logical abnormality. This is a profound shift in conceptu-

alizing mental illness that will be critical in aiding

clinicians’ work in empowering clients toward attaining

greater levels of health and self-sufficiency.

Approaches to Assessment, Diagnosis, and Treatment

In reflection of the inherent values and characteristics of

social work, the process of mental health treatment will

inevitably be impacted by these changes. One of the pri-

mary roles of the clinical social worker is to assess and

diagnose mental disorders. The clinical social worker is

trained to provide a differential diagnosis to determine the

presenting condition, determine a reasonable prognosis,

formulate a treatment plan, and make appropriate referrals.

Clinical social workers are trained to use the DSM-IV-TR in

conjunction with a thorough biopsychosocial assessment to

determine the course of action within a framework of

evidence-based practice.

One advantage of the proposed changes to the DSM will

be a more accurate and specified diagnosis. As indicated on

the APA’s website, ratings from three assessments will be

used jointly to diagnose a personality disorder, streamlin-

ing the diagnostic process for mental health professionals.

These three assessments include, ‘‘(1) A rating of mild

impairment or greater on the Levels of Personality Func-

tioning (criterion A), (2) A rating of (a) a ‘‘good match’’ or

‘‘very good match’’ to a Personality Disorder Type or

(b) ‘‘quite a bit’’ or ‘‘extremely’’ descriptive on one or more

of six Personality Trait Domains (criterion B), and (3)

Diagnosis also requires relative stability of (1) and (2)

across time and situations, and excludes culturally nor-

mative personality features and those due to the direct

physiological effects of a substance or a general medical

condition’’ (APA 2010) (see Table 1). There is evidence

that a dimensional model that does not rely on arbitrary

boundaries will provide improved clinical utility in clas-

sifying disorder mainly by providing greater uniformity

within diagnostic categories, less comorbidity with other

disorders, and by eliminating the need for the NOS cate-

gory (Widiger et al. 2009; Clark 2007). The practitioner’s

subjective judgment would still be a valuable tool in

diagnosis. However, it would be accurate more often and

based on empirically validated tools that fit with contem-

porary theoretical development.

For the individual, developing a treatment plan begins

with providing an accurate diagnosis. With a dimensional

approach to assessment, it would follow that treatment

options would be more adequately tailored to the individ-

ual. The dose, setting, or treatment approaches that would

Clin Soc Work J (2013) 41:155–162 159

123

be available would likely represent the broader spectrum of

function and personality dimensions. The lack of a valid

organizational structure in the DSM-IV-TR has been one

reason why there have been so few empirical studies

or attempts to develop manualized treatments for PDs

(Widiger et al. 2009). With a diagnostic tool that better

describes the complex array of behaviors that are the focus of

treatment, the clincian would have a more specific starting

point for determining the appropriate treatment plan. Again,

this is consistent with the person-centered treatment

approach central to clinical social work. There is also often a

concern that the long-term goal of recovery or ‘‘cure’’ from a

mental illness is not only too abstract but unrealistic for

clinicians and clients to address. The real focus is on small,

but not insignificant functional improvements and progress

along a continuum. Focusing on incremental changes on a

spectrum could have a tremendous impact on treatment

planning, prognosis, and client motivation.

These changes would also have practical implications

for the training and licensure of clinical social workers.

While there will be challenges in incorporating new

material into existing coursework and in training practicing

social workers, this also represents an opportunity to

expose clinicians to an improved approach to diagnosis. By

incorporating the cutting-edge research in human person-

ality and diagnosis of PDs into coursework and profes-

sional development, social workers will be better trained to

treat clients with PDs.

Implications for Social Work Research

Mental health research is becoming increasingly transdis-

ciplinary. If the social work perspective is going to be

incorporated in lines of research exploring PDs, a firmer

grasp of DSM changes and the empirical evidence that led to

such changes is required. This is in line with the profession’s

value of utilizing evidence-based practices in treating cli-

ents. The primary model of evidence-based interventions

demonstrates a clear relationship between using strong

empirical evidence, incorporating clients’ preferences,

understanding the social context, and drawing on the clini-

cian’s expertise. As new interventions are developed to treat

PDs, dimensional measures of change would provide better

specificity in development and evaluation.

The current DSM system of diagnosis for PDs has been

characterized as arbitrary, unreliable, incomplete, inaccu-

rate, and wrong (Clark 2007; Widiger et al. 2009). With the

bar of scientific rigor continuing to rise, constructs that fail

to exhibit superior reliability and validity should not be

included in research plans or in statistical models. To

diagnose PDs within individuals, the DSM and ICD cate-

gorical systems are the only choice but are empirically

unjustified and atheoretical (Andrews et al. 2009). By

simply moving from a categorical to a dimensional system

of classification, our knowledge of risk factors and disease

progression will improve dramatically. Clinical experience

shows that disorders across the lifetime do not switch from

either being present or absent but often exhibit a florid

presentation of symptoms and dysfunction.

Implementation Challenges

There is some apprehension to a new system of diagnosis.

Like many other suggested changes to the DSM, the pro-

posed PD revisions have generated spirited debate among

experts in the scientific community. The elimination of

narcissistic personality …

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International Journal of Mental Health

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A Model of Deinstitutionalization of Psychiatric
Care across 161 Nations: 2001–2014

Christopher G. Hudson

To cite this article: Christopher G. Hudson (2016) A Model of Deinstitutionalization of Psychiatric
Care across 161 Nations: 2001–2014, International Journal of Mental Health, 45:2, 135-153, DOI:
10.1080/00207411.2016.1167489

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International Journal of Mental Health, 45: 135–153, 2016
Copyright #�Taylor & Francis Group, LLC
ISSN: 0020-7411 print/1557-9328 online
DOI: 10.1080/00207411.2016.1167489

A Model of Deinstitutionalization of Psychiatric Care
across 161 Nations: 2001–2014

Christopher G. Hudson

School of Social Work, Salem State University, Salem, Massachusetts, USA

Abstract: Deinstitutionalization has been ongoing since the 1950s and is a trend that has been
molded by diverse sociocultural conditions and competing ideologies. Key questions from the
literature include its extent and the drivers motivating it, political and financial dimensions, and
consequences in such domains as homelessness, nursing home care, and the criminalization of
the mentally ill. This study specifically addresses questions about the extent of deinstitutionalization
internationally, and the salience of competing explanations of this trend for understanding the extent
of availability of psychiatric beds.

This study employs a secondary analysis of data from the four editions of the World Health
Organization’s Mental Health Atlas, as well as supplemental international databases. It uses a
regression methodology to examine rates of change of psychiatric beds during 2001–2014 in 161
nations. Predictors include key geographic, demographic, socioeconomic, political, cultural, and
service system conditions.

The study reveals deinstitutionalization of inpatient care is far from universal, characterizing
almost a half (45.1%) of the world’s nations. That the overall decline in inpatient beds is close to half
of one percent (−0.41%) per year indicates this is a modest reduction, notwithstanding dramatic
changes in both directions in subsets of nations. The regression model accounts for 55.7%�of the
variation of deinstitutionalization, using several significant predictors. Deinstitutionalization is
associated with income inequality, racial and ethnic diversity, low population density, a high Human
Development Index, psychiatric commitment laws, high incarceration rates, among other conditions.

Keywords deinstitutionalization; psychiatric hospitalization; geography of mental health; community
mental health

The deinstitutionalization of psychiatric beds reflects a long-term and pervasive restructuring of
mental health service systems, both local and national. It is a term that has been used to refer to
various phenomena, ranging from the depopulation of public psychiatric hospitals to changes
that include the development of community mental health services [1]. In the United States,
it is a trend that began in 1955, but in many nations it did not emerge until the 1990s or later.

Given the long history and ideological debates surrounding deinstitutionalization, it should
be noted that research on this trend has rarely advanced beyond the use of uncontrolled descrip-
tive statistics, case studies, and other descriptive methodologies. And it has only been since the
1990s that this trend has been examined in an international context. Much of this work has been

Address correspondence to Christopher G. Hudson, School of Social Work, Salem State University, 352 Lafayette
Street, Salem, MA 01970, USA. E-mail: [email protected]

noncumulative, addressing questions that range from the causes and drivers of deinstitutionali-
zation, to its political dynamics and financial dimensions, and its consequences in such areas as
homelessness, nursing home care, and the criminalization of the mentally ill.

The purpose of this article is not to present a comprehensive review of the considerable
literature on deinstitutionalization, since there are already many excellent reviews [2–6].
Instead, it aims to describe this trend on an international scale and explore potential predictors
of levels of deinstitutionalization of psychiatric care across the world during the 2001–2014 per-
iod. Whereas its detractors often argue that financial savings has been a central motivation [5],
advocates emphasize the ideal of improving community care and assuring the human rights of
psychiatric patients [7]. Commentators have proposed a variety of theories about the drivers of
this trend, which typically include some combination of historical, geographic, cultural, socio-
economic, political, and service system explanations. Most hypothesize that there is a complex
combination of drivers, applicable differentially in varying contexts. Thus, this study aims to
develop an exploratory and descriptive model of conditions that are potentially explanatory
of the extent of deinstitutionalization across all nations for which data is available. It does
this through the use of existing data sources collected by the World Health Organization
(WHO) [8–11] and other international organizations. This study also examines the question
about the extent to which deinstitutionalization has continued to take place on a global scale
during the initial years of the 21st Century (2001–2014).

BACKGROUND

The deinstitutionalization of psychiatric care has taken place primarily in the mental health sys-
tems of developed, usually westernized nations, ones that have experienced a preceding period
involving the building of psychiatric hospitals. For instance, in the United States, a dramatic
expansion in inpatient psychiatric beds took place between 1840 and 1955, from 1 per
100,000 population to 338.9 per 100,000 (calculated from [12]).

The trajectories of deinstitutionalization have varied dramatically, depending not only on the
nation or state considered, but also the type of data examined. Unlike in the United States, in
many parts of the world deinstitutionalization did not begin until the 1970s, ranging into the
1990s or later. In the United States, as a whole, if we consider the number of annual psychiatric
hospital episodes, the population rate of those in public institutions in the United States declined
by 96%�between 1950 and 2010, to the same level as 1850 [13–15]. Nonetheless, reports indi-
cate that in many parts of the world, the mental health systems are still dominated by inpatient
care. A study of 42 low- and middle-income nations, that employed the World Mental Health
Atlas data, found that 80%�of mental health resources continue to be devoted to inpatient care
and little to community mental health [16]. Despite the recent availability of data relevant to
deinstitutionalization from WHO sources, the extent of the phenomenon on a worldwide basis
has not yet been systematically analyzed and reviewed.

Theoretical Perspectives on Deinstitutionalization

Several explanations have been proposed for the contraction in availability of psychiatric beds,
ones for which there is mixed support. In several nations, early drivers include the exorbitant

136 HUDSON

cost of maintaining antiquated hospital systems; the introduction of the first generation of
psychotropic medications in the early 1950s; and a combination of journalistic exposés of
horrible conditions in public psychiatric hospitals, along with the development of alternative
service ideologies and approaches that emphasize short-term care in community settings.

Concurrent with these changes was the development of formal policies aimed at replacing
institutional care with community mental health, such as the Community Mental Health Act
introduced in the United States by President John F. Kennedy in 1963 [17]. Such changes were
only associated with modest declines in institutional care in the 1955 to 1965 period. Some of
the greatest declines, however, took place in the following decades, primarily during the 1965 to
1980 period [13]. Two of the most significant factors introduced during this period involved a
new emphasis on civil rights, particularly, the protection of the civil and procedural rights of
mental patients including the restriction of commitment criteria to the requirement that patients
be dangerous to self or others before they could be involuntarily committed [18]. In addition,
the introduction of a variety of financial incentives to support patients outside of the hospital
is believed to have accelerated the discharge of mental patients to nursing homes, other com-
munity facilities, as well as acute units in general hospitals. In recent years, the introduction
of increasingly stringent cost-containment controls, mainly in the private managed care
insurance market, has also served to minimize length of stay, resulting in the decline of inpatient
hospitalization in specialty psychiatric settings as well as in general hospitals [19].

Even as psychotropic medications and financial incentives are often cited, several other expla-
nations have also been advanced for deinstitutionalization. Novella [8] includes some of these in
his review, emphasizing the role of ideology, specifically the anti-psychiatry and related critiques
of the conventional explanation that focuses on the introduction of psychotropic medications. He
notes that several of these explanations, such as that of anti-psychiatry, professionalization, and
decarceration [2], emphasize the changing power relationships between treaters (primarily psy-
chiatrists) and their clients, and the change to a community context of care as a means of preser-
ving social control relationships and professional hegemony. Novella [5] points out that such
explanations minimize the role of changing cultural and socioeconomic conditions. Other expla-
nations that Novella [5] reviews include the expansion of psychiatric rehabilitation, including
transinstitutionalization in which costs are seemingly reduced by shifting care to community
institutions such as shelters, nursing homes, and prisons. For example, several researchers
[20, 21] have attempted to advance what has come to be known as the Penrose Hypothesis
[22], either that the social controls inherent in psychiatric hospitalization are replaced with those
of jails and prisons, leading to the criminalization of the mentally ill, or that social control is
alternatively pursued either through inpatient mental health care or through prisons.

Although the relative salience of these accounts are debated, especially given their scarce
empirical support, it is clear that some combination of the critique of large institutions, financial
incentives, changing treatment ideologies, and especially a growing focus on the civil rights of
patients have all driven the transition of patient care to community contexts, and that official
policies, such as the Community Mental Health Act (1963) in the United States, may have
played only a secondary role in highlighting and legitimizing such trends. Those who have
pointed out the injustices of premature discharge of patients to the community have emphasized
the extent that deinstitutionalization perpetuates and aggravates inequality. In contrast, others
argue that inequality is minimized by supporting the reintegration of the seriously mentally
ill back into their communities (see [23]).

DEINSTITUTIONALIZATION ACROSS 161 NATIONS 137

National Studies of Deinstitutionalization

Very little systematic or comparable data is available on the extent of deinstitutionalization
throughout the world. There are several scores of publications on the experience in particular
nations and regions that have employed case studies, descriptive statistics, and other
uncontrolled studies. In the United States, commentators include Lamb [20] and others who
have highlighted the precipitousness of the process that the depopulation of state and county
hospitals often occurred prior to the development of community services, and that too much
emphasis has been placed on changing the locus, rather than on improving the quality of care.
A pervasive theme in many nations has been the organizational fragmentation of care due to the
split of responsibility for mental health between local and national authorities that has resulted
in very uneven implementation of the policy.

In Europe, similar themes appear in the literature, especially the slowness in developing com-
munity mental health services [24]. Ireland, for instance, has been cited as a nation that started
out with some of the highest institutionalization rates in the world, and has only slowly reduced
its hospitalization levels, albeit in a geographically uneven manner [25]. In Germany, deinstitu-
tionalization was also reported in some areas in name only, with the transfer of patients to
renamed sections of hospitals [26]. Others have complained that in Scandinavia there has been
limited cooperation among the competing responsible authorities [27]. One report from North
Finland indicates that smaller and less wealthy counties have moved more quickly to
deinstitutionalize, compared to larger counties that have been better able to afford ongoing hos-
pitalization for those in need [28]. Italy, in contrast, has seen some of the most dramatic declines
in psychiatric hospital care in Europe, led by the Psichiatria Democtratica movement inspired by
Franco Basaglia that emphasized the “de-psychiatrization” of mental illness, the loosening of
commitment criteria, and the attempt to liquidate all psychiatric hospitals [29]. Spain also is
reported to have achieved major advances with deinstitutionalization, specifically, the develop-
ment of new decentralized forms of community mental health care that are effectively integrated
with general medical care, but not without some inequities in their geographic distribution [30].

In Australia and New Zealand, the progression of deinstitutionalization has been slow but
steady, nonetheless, with complaints that the process has failed to be associated with systematic
planning or adequate community support systems [31]. Inpatient care in these nations has been
decidedly better than community mental health care [32].

In South America, it has only been in the last few decades that deinstitutionalization has
started to be implemented [4]. Some of the greatest declines of public inpatient care are reported
to have taken place in Uruguay and Paraguay, and to a lesser extent in Chile, Brazil, Columbia,
Venezuela, and Peru [33]. In Brazil, these declines were reported to have been made possible by
the development of acute inpatient units in private hospitals [34].

Parts of the world that have deinstitutionalized the least include Japan; East Asia in general;
and also, until the late 1990s, Israel. Yip [35] reports that in Hong Kong care remains highly
institutionalized, and likewise, Kuno and Asukai [36] contend that in Japan reductions in
inpatient care are unlikely, given both cultural factors, as well as the low cost of hospitalization.
In Israel, in 2000 new rehabilitation legislation was enacted that led to a dramatic shift in care to
community services [37]. Exceptionally little data is published on the experience in Middle
Eastern, African, and many of the developing nations, in part, because of the scarcity of
comprehensive mental health systems.

138 HUDSON

International Mental Health Policy Research1

It has only been in recent years that a body of empirical research has emerged in the larger field
of international mental health policy, but only a small proportion of these studies have focused
on deinstitutionalization. Editorials and commentaries have emphasized dramatic disparities
between the mental health systems of developed and developing nations. Discussions of the
sparsity of resources in the developing nations have repeatedly urged the need for better
integration of mental health into the work of primary care practitioners [38], given the very
low rates of mental health professionals in many developing nations. Similarly, improved public
education has often been recommended, along with the more creative use of nonprofessional
staff, and improved access to psychotropic drugs, all of which have been viewed as cost
effective measures [39]. Finally, editorials regularly urge more consistent and rigorous
collection of data on epidemiology, services, and outcomes [40].

Single and comparative national case studies date back many years, most notably to Kemp’s
compendium, International Handbook of Mental Health Policy [41]. Studies such as Lurie’s
[42] that compares the systems in the United Kingdom, United States, Canada, and New
Zealand highlighted themes of recovery, stigma reduction, developing services for particular
client populations. Increasingly, governments are not being expected to provide services, as
much as to fund and regulate them. A recent comparison of the systems in Australia and China
emphasized the need for developing nations not to rely exclusively on institutional services, and
to emulate those nations, such as Australia, which have moved more aggressively toward the
creation of community service systems [44]. Particular barriers, relevant to China, as well as
to many developing nations, include the lack of professionals and services in rural areas, in part,
due to problems inherent in the poor economies of scale associated with service development in
such sparse environments.

Since the World Development Report [45], the Global Burden of Disease Report [46], and
other international reports, the WHO has increased its research and advocacy efforts in mental
health. These have included the publication of the Mental Health Atlas [8–11] dissemination of
the WHO Assessment Instrument for Mental Health Systems (WHO-AIMS), and the launching
of the Mental Health Gap Action Programme (mhGAP) [47] and the Movement for Global
Mental Health in 2008.

Of particular relevance for the current study, the World Mental Health Atlas is a
compendium of data garnered through a descriptive survey of the mental health systems in
192 countries, conducted most recently in 2014. Areas covered by the survey consist of
questions on the presence of a (i) mental health policy; (ii) a national mental health program;
(iii) mental health legislation; (iv) substance abuse policy; (v) availability of psychotropic
drugs; (vi) the budget for any mental health program; (vii) methods for the financing of mental
health services; (viii) mental health in primary care and training; (ix) service availability, parti-
cularly, psychiatric beds; (x) rates of mental health professionals; (xi) programs for special
populations; and (xii) information gathering systems. Official reports of the results are limited
to simple tabulations, such as those of frequencies and means. Substantial data is missing or
unavailable, particularly for developing nations. Although data reported in the World Mental
Health Atlas [48] reveal that four-fifths of the world’s nations have mental health programs,

1Portions of this section are adapted from [43].

DEINSTITUTIONALIZATION ACROSS 161 NATIONS 139

and seven-tenths (70%) have mental health legislation, with the most pronounced inequities
involving budgets, services, and professionals. Unfortunately, it has been the exception that
such inequities are considered in the context of underlying disparities in mental health con-
ditions and needs. Yet, indicators of need are greater in Europe than in Africa, where the rate
of neuropsychiatric conditions is 3,266 per 100,000 in Europe, compared with 2,538 per
100,000 for Africa. North America, including the United States, is closer to the European
experience, but falling short of Europe in its mental health service coverage [43].

Since the initial dissemination of its World Mental Health Atlas, WHO has continued to
refine its data collection instrument on national mental health systems, and this is now known
as the Assessment Instrument for Mental Health Systems (WHO-AIMS 2.2). It covers the six
domains included in the Atlas and is designed to facilitate cross-country comparisons. As much
as this initiative represents an important advance in the study of national mental health systems,
critics have emphasized the neglect of the political dimensions of mental health policy devel-
opment, minimization of the role of culture in mental health care utilization, and questionable
measurement validity [49].

The WHO World Mental Health Atlas initiative has succeeded in stimulating several other
research efforts aimed at systematically understanding national mental health systems. Most
notable has been the formation of the International Observatory on Mental Health Systems
(IOMHS) at the University of Melbourne. The aim of this institute is to monitor the mental
health systems in low and middle income countries, and to find some way “to rationally classify
mental health systems at national and subnational (provincial and district) levels. Along these
same lines, the Organization for Economic Cooperation and Development (OECD) has been
developing a mental health monitoring systems for its 30 member states, one that looks not just
at services, but at outcomes [50].

With the accumulation of new descriptive data through the Atlas and the WHO-AIMS instru-
ment, the possibility of correlational, specifically, quasi-experimental research in this field has
opened up. Although there have been a variety of correlational studies on the development of
social welfare and social security systems throughout the world, this has not been the case with
mental health due to the lack of data. One of the earliest studies of this type was that conducted
by Pillay [51] who demonstrated a simple but strong 0.84 zero-order correlation between gross
national product (GNP) and rates of mental hospitalization within nine of the OECD states. The
study also shows no significant correlation between GNP and length of stay. Unfortunately,
such zero-order bivariate correlations typically raise more questions than they answer, given
the very small sample size and lack of statistical controls.

To date, the development of the Mental Health Atlas data has enabled several studies of
variations in national mental health policies. World Development Report 1993: Investing in
Health by the World Bank [45] utilized the second wave of this data (2006) to investigate
whether there were one or multiple dimensions characteristics of the development of national
mental health systems, as well as which environmental characteristics are most closely associa-
ted with such development. He found through a factor analysis that three orthogonal or uncor-
related dimensions were identified that are characteristic of the 138 nations: (i) General Mental
Health Services (professionals and inpatient beds), (ii) Public Mental Health Program; and
(iii) Community Mental Health that collectively accounted for 45%�of the variance in the data-
base of WHO predictors. Only one, General Mental Health Services, was substantially explained
(Adj. R2 ¼0.641; p ¼0.001) by the predictors, specifically, by Democratization, distance from

140 HUDSON

Paris, gross domestic product, and Inglehart’s measure of self-expression (versus survival)
values. None of these factors specifically assessed the level of deinstitutionalization, although
the third (and weakest) factor tapped an important element of it (community mental health).

Shen and Snowden (2014) followed up on this study in 2014 to attempt to identify the key
predictors of the history of deinstitutionalization, specifically, whether nations were early or late
adopters, through a regression model of aggregated psychiatric hospitalization data from the
first three waves of the World Mental Health Atlas study, those from 2001, 2006, and 2011.
Unfortunately, despite their sophisticated theoretical review, their hypotheses involving predic-
tors of early versus late adoption of deinstitutionalization remain untested due to the way that
two key variables were operationalized. First, instead of modeling as their dependent variable,
the rate or slope of decline in psychiatric hospitalization (deinstitutionalization), they instead
modeled the absolute rate of psychiatric inpatient care in each of the nations. Unfortunately,
bed rates by themselves cannot be taken as indicative of either absolute or relative declines
in institutional care. Second, their measure of year of adoption of a policy of deinstitutionaliza-
tion consisted of the adoption of a formal mental health policy. Even if adoption of a mental
health policy could have been treated as a proxy for decisions to deinstitutionalize, in many
nations, such as the United States, such formal decisions followed, rather than preceded the
initiation of the trend toward deinstitutionalized care.

Summary and Research Questions

Despite the contributions of these initial regression studies, none of the foregoing studies
address the underlying aim of the current study, namely, understanding the extent and drivers
of the deinstitutionalization of psychiatric care on an international basis. In general, the
results of prior research on both the extent of deinstitutionalization across nations and its
drivers have been either nonexistent or noncumulative due to the diversity of definitions,
methodologies, and measures used. This emerging body of research has had primarily a
heuristic value that points to the plausibility of a variety of competing and complimentary
explanations for the extent that deinstitutionalization has taken place. Several of these
explanations involve economic resources and incentives, and general level of socioeconomic
development, including the level of economic inequality. Likewise, several have involved
culture, specifically, democratization. Closely related is the degree of tolerance for the
mentally ill, their inclusion in the community, and confidence in the possibilities of their
treatment. The introduction of or access to psychotropic medications, as well as new
approaches to psychosocial and rehabilitative treatment, have also been cited as powerful dri-
vers of deinstitutionalization. Particularly important is the emphasis on patient rights and
legal safeguards to unreasonable deprivation of liberty. The current study, thus, specifically
addresses the following three questions:

1. To what extent have there been overall declines in the availability of psychiatric
beds across nations?

2. Have there been significant differences in the level of deinstitutionalization based
on resource availability as reflected by regional and national income levels?

3. To what extent can variations in levels of deinstitutionalization be accounted for
based on national socioeconomic and cultural conditions?

DEINSTITUTIONALIZATION ACROSS 161 NATIONS 141

METHODOLOGY

Overview

This project uses a methodology that is designed to serve descriptive and exploratory aims,
including a regression analysis of data pertinent to the major questions of this study. It
specifically employs a secondary analysis of existing data on psychiatric inpatient care derived
from WHO’s World Mental Health Atlas from 2001, 2006, 2011, and 2014 [8–11], as well as
supplemental international sources.

Data

Information regarding the various features of the mental health services and systems of 201
nations were downloaded from the four online versions of WHO’s Mental Health Atlas. These
nations include the 190 member states of the WHO, as well as 11 associate member states. The
dependent or outcome variable of the study–-changes in inpatient psychiatric care–-was
calculated from the total number of psychiatric beds reported in the four editions of the Atlas,
standardized as population rates. The available two to four rates were then used to calculate the
slope, or …

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| Blogs| NAMI Blog| March 2019 | That Time in the Psych Ward

That Time in the Psych Ward

MAR.
11,
2019

By Katherine Ponte, JD, MBA, CPRP

I have been hospitalized three times. I was given heavily sedating medication much of the time, however I will never forget what I went through. Each time, I was in crisis, at my life’s lowest points, looking for a path forward. Instead, I was treated like I was a threat to others safety, as if I had done something terribly wrong. Instead of receiving care, my experiences left me scarred, stalled and aimless for years afterwards.

 

I Needed Treatment, Not Sedation

My last psychiatric hospitalization was the most painful. I arrived, strapped into a wheelchair, to a chaotic psychiatric emergency room. They separated me from my husband to interview me. After my intake, they placed me on a gurney and forcibly medicated me.

I was left on that gurney in the corridor of a psychiatric ER for two days before an inpatient-psychiatric bed became available. I couldn’t sleep or rest. Another psych patient wailed constantly. I was in internal crisis, yet there was crisis all around me. The last thing I can remember from my experience in the ER was being forcibly medicated one more time.

 

Once admitted to the inpatient ward, I awoke to find myself in leather restraints. There was no one there to explain where I was or why I was being detained or subdued. I didn’t know what was happening. I was alone.

 

As I slowly gained awareness of myself and my surroundings, it became clear that we were under constant watch. The staff was concerned that we were potentially dangerous to ourselves and others. Everything in the psych ward was violence and suicide proof. Even the personal belongings our loved ones brought were carefully checked. I had never been violent or suicidal before in my life. I started thinking: “Am I really this ill?” “Am I really violent and suicidal?” The severity of my illness and all that it meant, the stigma, started to sink in. 

 

I Needed Help, Not Imprisonment 

Treatment seemed to focus on immediate stabilization, rather than long-term health. I saw my assigned doctor infrequently, and more often I saw a resident. I couldn’t see my outside doctor. I was placed on a new medication regimen. I was highly sedated for most of my stay. Many patients never left their room, and others spent the day walking loops around the ward. I never once saw a nurse in my room. 

 

They kept us on a locked down ward. I was never allowed to go outside, not even with an escort. Security guards roamed the floors. I also faced other restrictions, including suspension of computer and phone privileges, in-room confinement and solitary confinement to a seclusion room.

 

At one point, my condition significantly deteriorated, and I fell into a severe manic state. Two security guards picked me up and dragged me to a seclusion room furnished with only a thin red mattress on the floor. They wrapped my arm tightly around my back, pinned me to the floor, and then forcibly medicated me. They left me in a locked room for hours as a guard watched me through a small wire-glass window. When they released me, they placed me on around-the-clock surveillance for a week. They watched me even as I slept.

I Needed Support, Not Isolation 

I desperately needed love, comfort and support from my family during my stay, but it was difficult to stay connected with them by phone or in person. Therewere no phones in the rooms. There were only a couple of payphones located in the hallway. As a policy, staff did not answer calls, only patients could  answer. Often when a patient answered a call from my mother, they would tell her that they didn’t know me, I was not there or they couldn’t find me. There was no way to leave a message. Each time this happened, my mother worried that something might be wrong. She was often unable to reach me for days. 

No visits were allowed in patient rooms, out of a fear that we might injure our loved ones. All visits had to occur in full view of clinicians, security and other patients and their visitors. It was more than a bit uncomfortable for my spouse and I to express our heartfelt emotions at this sensitive time in public view. Even a hug felt awkward when the person next to you had no visitors, which is often the case in the psych ward. These should be among the most private moments families have together, when a loved one is at their worst lows.

 

Visiting hours were three hours shorter per day for the psych ward than “regular” patients. Did we need less love, compassion and human contact?  Were we somehow less worthy or important than “regular” patients? 

 

This Needs to Change

I returned home after each one of my hospitalizations severely depressed. I was too demoralized to appreciate that I was discriminated against. At times, I was made to feel like a criminal being punished, a danger to society. I felt it was all my fault for getting sick in the first place. I felt that I deserved the treatment that I received. I was at a top hospital. This perception fed off the social stigma I already experienced and certainly did not help my recovery.

 

These inpatient experiences traumatize me to this day. We need to focus on how it can be better, to turn psychiatric hospitalization into a constructive turning point towards recovery. The only positive memory I have was of an occupational therapist from my last hospitalization. She treated patients with genuine care and affection. She designed programs not only to occupy us, but to inspire us to get better. She emphasized the power of peer support. She showed me my first example of a high functioning person with mental illness. She planted a seed that my fellow patients and I, struggling as we were, could get better. 

 

I like to imagine a psych ward staffed with empathetic professionals like that therapist, and how much better the experience could be. She helped me get to where I am today, because she cared and shared tools to help me. It felt like this is what a recovery-oriented psych ward should be like all the time. A place that helps sick people recover, as a hospital should. A place that doesn’t treat you like a violent criminal because you have mental illness. A place that shows compassion for how hard it is to go through a mental health crisis. A place that gives you treatment, care and support rather than sedation, isolation and discrimination. 

 

 

Author’s note: I appreciate this opportunity to share my experiences and thank Laura Greenstein of NAMI very much for making this possible and thank you to my wonderful occupational therapist.

 

Katherine Ponte is a mental health advocate, writer and entrepreneur. She is the founder of ForLikeMinds, the first online peer-based support community dedicated to people living with or supporting someone with mental illness, and Bipolar Thriving, a recovery coaching service for caregivers and their loved ones affected by bipolar disorder. She is also the creator of the Psych Ward Greeting Cards program in which she personally shares her recovery experiences and distributes donated greeting cards to patients in psychiatric units. She is in recovery from severe bipolar I disorder with psychosis. She is also on the board of NAMI New York City. 



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Social Workers and Their Integral Role in Interdisciplinary Team Care

Social Workers and Their Integral Role in Interdisciplinary Team Care

Posted by The John A. Hartford Foundation
on March 28, 2013

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We believe very strongly that interprofessional teams provide the best care, especially for older people with serious multiple chronic conditions. In direct care as a geriatric social worker, I worked very closely with physicians, psychiatrists, nurses, physical therapists, as well as home health aides and family caregivers. It never occurred to me that my colleagues in other disciplines might not know what a social worker contributes to the team.

But recently, I had a conversation with a very knowledgeable physician who asked: “What is the difference between a nurse and a social worker?” I was also dismayed that the InterProfessional Education Consortium (IPEC) did not initially include the discipline of social work, but after Hartford’s strong advocacy it now does. And because of the Hartford Foundation’s sponsorship, social work is now included in the Institute of Medicine Global Forum on Interprofessional Education.

So, in honor of the closing of Social Work Month this March, I would like to bring attention to the important role of my fellow social workers.

The National Association of Social Workers (NASW) gives the following description of the profession and the powerful role social workers play in supporting individuals and families:

Social Work is the profession of hope—fueled by resilience and advocacy. Social Workers matter because they help millions of struggling people every day dream differently.

In the United States, more than 650,000 of these highly trained professionals know how daunting and immobilizing life’s tragedies and obstacles can be. But they also witness the sheer determination of countless individuals and families to achieve different lives. Sometimes, all it takes to help people get on the right path is guidance toward what is possible. Other times, social workers are an immediate lifeline in crisis—providing access to resources and new life options.

Those served by social workers possess many strengths that keep them fighting for a better future despite personal and systemic barriers to success. They climb toward what is possible rather than simply accepting what the current situation may be. Professional social workers help combine these client strengths with effective personal and public advocacy.

It is with these concepts in mind that NASW has announced the theme for Social Work Month 2013 as “Weaving Threads of Resilience and Advocacy: The Power of Social Work.”

Now more than ever before in health care delivery, the profession of social work is needed. As health care systems are being held accountable for the continuum of care of discharged patients in order to avoid penalties for 30-day hospital readmissions and emergency room visits, knowledge of, and experience with, community-based social services will be incredibly valuable.

Social workers in community-based organizations provide person-centered care and focus on solutions for issues related to social determinants of health, such as lack of financial resources and social isolation, which contribute to the revolving door syndrome of re-hospitalizations. Social workers—whether in the community, hospital, or other institutional settings—coordinate with caregivers and community resources to broaden the circle of team care which ultimately provides a more comprehensive and continuous care plan.

At the Hartford Foundation, we are moving away from funding in the silos that separate the health care professions and will engage in more work to support health care for older people in interdisciplinary teams. I want to make sure those teams understand the critical role of social workers and keep their doors open to including them. As NASW states, social workers will help weave all the threads that are important to sustaining the resilience of our older people with serious multiple chronic conditions. Who wouldn’t want to include the expert helping hands of social workers to assist in providing care to these complex older patients?

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Social Work in Health Care

ISSN: 0098-1389 (Print) 1541-034X (Online) Journal homepage: https://www.tandfonline.com/loi/wshc20

Developing and sustaining a practice-based
research infrastructure in a hospital social work
department: Why is it important?

Sara Tischler, Melissa Webster, Daniela Wittmann & Kathleen Wade

To cite this article: Sara Tischler, Melissa Webster, Daniela Wittmann & Kathleen Wade
(2017) Developing and sustaining a practice-based research infrastructure in a hospital
social work department: Why is it important?, Social Work in Health Care, 56:1, 1-12, DOI:
10.1080/00981389.2016.1247409

To link to this article: https://doi.org/10.1080/00981389.2016.1247409

Published online: 07 Nov 2016.

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Citing articles: 1 View citing articles

ARTICLES

Developing and sustaining a practice-based research
infrastructure in a hospital social work department: Why is
it important?
Sara Tischler, LMSWa, Melissa Webster, LMSWa, Daniela Wittmann, PhD, LMSWb,
and Kathleen Wade, PhD, MSWc

aDepartment of Social Work/Psychiatry, University of Michigan Health System, Ann Arbor, Michigan, USA;
bDepartment of Social Work/Urology, University of Michigan Health System, Ann Arbor, Michigan, USA;
cPatient and Family Center, University of Michigan, Ann Arbor, Michigan, USA

ABSTRACT
The future of hospital social work departments depends on their
ability to demonstrate their effectiveness, efficiency, and conse-
quently, their value to their host organizations. In order to
demonstrate and enhance social work’s contribution, research
activities of various kinds must be encouraged. These include
research consumption as well as production and utilization by
clinicians, supervisors, managers, and administrators. The authors
sought to develop a sustainable research environment in a large
social work department of an academic health system. Continued
work is needed to understand practice-research “best practices”
within hospitals and how to ensure their sustainability within an
ever changing health care environment.

ARTICLE HISTORY
Received 6 June 2016
Revised 15 September 2016
Accepted 8 October 2016

KEYWORDS
Health system; hospital;
practice-research; social
work

The need for practice-research in social work

Social workers in the United States are mandated by the National Association
of Social Workers’ Code of Ethics to continually develop and enhance practice
competencies (National Association of Social Workers, 1999). Within the field
of social work, there has been a demand for accountability that goes beyond
documentation, service delivery, and compliance with policies. The future
of hospital social work is contingent upon the ability of social workers to
demonstrate how they add value within the larger organization. This requires
social work leadership to play a pivotal role in helping staff transition from a
solely care delivery model to a research-informed intervention model.

Research that emanates from practice and is conducted by practitioner-
researchers or by practitioners in collaboration with researchers can demon-
strate the cost-effectiveness and overall worth of social work interventions
(Davis, 2004). Thus, one of the major tasks of social work administrators and
managers becomes providing opportunities and any necessary training to

CONTACT Sara Tischler, LMSW [email protected] Department of Social Work/Psychiatry, University
of Michigan Health System, 4250 Plymouth Road, Ann Arbor, MI 48109.

SOCIAL WORK IN HEALTH CARE
2017, VOL. 56, NO. 1, 1–12
http://dx.doi.org/10.1080/00981389.2016.1247409

© 2017 Taylor & Francis

incorporate practice-based research into the daily work of staff. In this
context, the need for evaluation and outcomes management has become
ever more critical in the allocation of resources, training, and staffing.

According to the Substance Abuse and Mental Health Services
Administration, social workers are the largest group of mental health service
providers in the United States (Substance Abuse and Mental Health Service
Administration, 2006). There are more health and mental health trained social
workers than psychologists, psychiatrists, and psychiatric nurses combined,
yet resources for many hospital social work departments are diminishing.
Funders are eager to see that what they have been reimbursing is actually
making a difference in the lives of patients (Palinkas & Soydan, 2012).
Orme and Powell (2007) assert that, to improve professional practice and
demonstrate effectiveness, research production and utilization must be
encouraged, but research by whom and from where?

To answer these questions, funding institutions look to academically-based
researchers. By contrast, this article will describe the development of a
practice-based research program embedded in a large social work depart-
ment, designed to increase social work research endeavors and provide a
research infrastructure needed to sustain these intramural efforts.
Overcoming professional and organizational barriers to implementation
will also be addressed. Nine essential elements will be described that encom-
pass the platform and how this model can be replicated.

Historical perspective on research development in hospital social
work in the United States

Although practice-based research can provide a way for social work practi-
tioners to disseminate and discuss their scientific questions and potential
treatment interventions, research has not historically been a key priority in
social work training. Yet, when social work was emerging strongly as a
profession in health care during the second half of the 20th century, research
activity was also beginning to develop. This was particularly evident in the
field of cancer care, with the appearance of social work in published peer
reviewed journals. In 1969, Reid and Shyne conducted an experiment in
which the outcomes of two social work approaches were compared. A short-
term, problem solving approach to treatment was found to be more effective
than a long-term, open-ended, psychosocial approach. These findings had a
considerable impact on the profession of social work. Based on this study,
Reid and Epstein (1977) developed a task-centered approach to social work
practice, meeting the demand for measurable outcomes and cost efficiency.

Practice wisdom and supervision were the traditional methodologies for
the development and transfer of knowledge in social work. As a result, new
discoveries could not be easily translated to other disciplines or the field of

2 S. TISCHLER ET AL.

health and mental health in general. Moreover, training in the construction
of knowledge through scientific inquiry and research methods had not been
typically offered in any depth in social work curricula. This posed further
professional challenges and led to a shortage of tools with which to advance
the visibility of its contribution to the understanding of the human experi-
ence in health care. In 1991, the director of the National Institute of Mental
Health, Lewis Judd, MD, in his report on the development of social work
knowledge, stated: “There is a crisis in the current development of research
resources in social work. Contributions of research to the knowledge base of
social work practice lag far behind the dynamic growth of the profession and
professional education” (National Institute of Mental Health, 1991). This was
a call to action that could not be resisted.

The need to support social work practice with evidence of effectiveness,
efficiency, and “fidelity” to practice guidelines was also brought about by a
new development in health care. The ascendancy of the Diagnostic Related
Groups (DRGs) as a method of reimbursement in the 1980s put pressure on
social work to prove that its interventions made a difference. Furthering a
research agenda in social work became a priority. Under the leadership of
director Dr. Grace Christ, Memorial Sloan Kettering Cancer Center became a
leader in this endeavor. Christ and colleagues describe the implementation of
a 2-year writing seminar to assist staff in preparing research papers and
presentations, followed by the development of a dedicated research unit,
paid for by philanthropic funds (Christ, Siegel, & Weinstein, 1995). This
allowed for the addition of a full-time research director with a track record of
getting grants and being published. Emphasis was placed on independent
research with some collaboration with other mental health professionals.
Other medical professionals welcomed collaboration with social workers,
which allowed for increased access to patient groups.

Unfortunately, the Memorial Sloan Kettering Cancer Center experience
was more unique than typical. While Christ and colleagues advocated for
hospital-wide projects focused on social work assessment and intervention,
this methodology did not have much success. Three possible reasons were a
lack of institutional support for social work research, lack of training, and likely
the pressure of both direct practice and increasing bureaucratic responsibilities,
which some have interpreted as an ongoing and enduring reluctance of
clinicians to engage in research (Epstein, 2010).

Ideally, building a research infrastructure and culture within an agency
creates opportunities for teamwork, mentoring, collaboration, and innovation.
Rather than an additional burden, a research-friendly environment can
empower social work practitioners. In fact, in recent years, the enthusiasm
for research by practitioners has increased globally, as evidenced by the
existence of conferences such as the International Conference on Practice
Research and the International Conference on Social Work in Health and

SOCIAL WORK IN HEALTH CARE 3

Mental Health. As Wade and Neuman (2007) suggest, the results of research
can reinforce the individual intellectual and organizational resource investment
in the roles social workers perform. However, still today, regardless of the
potential benefits that would be derived by the cultivation of a hospital-based
research culture and infrastructure, few social work practitioners are actively
engaged in research (Palinkas & Soydan, 2012).

Historically, research development has facilitated the advancement of
other health care professions such as dietetics, nursing (Kilpatrick, 2008),
occupational therapy, and the field of medicine as a whole. Additionally, the
field of clinical psychology has historically been more research-oriented, with
the terminal degree being a doctorate. Health social work will similarly
benefit from an increased focus on research, and it will benefit more if
there are contributions to knowledge from practice as well as to practice. In
any profession, research is the foundation of successful practice. Knowledge
creation, whatever its source, not only validates the efforts of practitioners,
but it also promotes the well-being and empowers practitioners with tools of
self-reflection and empirical enquiry. Likewise, social workers in health care
must participate as full partners with each other and with other disciplines
that have already cultivated research cultures.

Integrating social work practice and research

Although there is a desire to integrate research training and appreciation into
graduate social work education, for most students, there are no meaningful
opportunities to participate in research activities during their training, nor do
they appreciate its value (Dodd & Epstein, 2012). Social work faculty members
are rarely involved in health care research at a practice level and cannot
provide the mentorship necessary to integrate practice and research.
Therefore, newer health care social work professionals lack the ability or
competency to take integrated practice frameworks into the field.
Recognizing that practice and research should be a two-way street: The
Council on Social Work Education (CSWE) identifies engagement in
research-informed practice and practice-informed research as a “core compe-
tency.” To become accredited by the CSWE, schools of social work must use
the core competencies to design their curriculum (CSWE, 2008).

The CSWE Commission on Research works to promote education-based
research in schools of social work. This is done by identifying and advocating
for resources that advance the profession’s research agenda and identifying
emerging areas of research and research methodologies in social work educa-
tion. The commission encourages and promotes the development of curricu-
lum tools and professional development opportunities with the goal of
improving the teaching of research in schools of social work. It also works
with CSWE stakeholders to advance the profession’s research agenda in higher

4 S. TISCHLER ET AL.

education, government agencies, and the public. It is concerned with helping
to build databases that promote innovation in education and strengthening the
link between research and practice. Progress toward these goals is reviewed
annually, and goals are amended.

Recognizing the need, a few organizations have expanded their roles in
promoting research, and social work researchers have achieved greater visi-
bility and influence. At the Mount Sinai Department of Social Work, clinical
data mining—the extraction and analysis of existing clinical data—was pio-
neered and used to further practice-based research within a number of
specialties in the field (Epstein & Blumenfield, 2001). Practitioner-Research
projects at Mount Sinai were funded by modest amounts of endowment
money, foundation money, and physician-contributed money. In June
2014, the Silberman School of Social Work at Hunter College and Mount
Sinai co-sponsored and held the 3rd International Conference on Practice
Research (ICPR), highlighting the integration of research into everyday social
work practice throughout the world. This initiative to highlight practice
research and bring together experienced and “emerging” practitioner-
researchers from the United States and 21 other countries was convened by
Irwin Epstein, then occupant of the Helen Rehr Chair in Applied Social
Work Research at Silberman and Adjunct Professor at Mount Sinai. The
Conference, held at Silberman in New York City, aimed to recognize gaps
between practice organizations and research efforts, identify models for
exchange, and examine strategies for building collaborations among practi-
tioners and researchers. Its theme was “Building Bridges, Not Pipelines:
Promoting Two-Way Traffic between Practice and Research.” Although the
historical context changes as each country grapples with the integration of
research into social work practice, many of the challenges remain the same,
i.e., funding, time, and a lack of alignment within academic research.

The organizational setting

Cognizant of the cultural shift toward research informed practice and moti-
vated to deliver high quality care, the leadership of another large, academic
social work department sought to develop a sustainable research culture and
infrastructure with a long-term goal of integrating research into practice. The
social work department is one of the largest in the United States with over
200 social workers in an academic tertiary care health system. Given the
limited research resources, it was critical to be strategic and set achievable
goals through which to build several integrated, mutually supportive compo-
nents. The social work department’s director took on the role of a champion
of social work research by encouraging staff members who were interested in
research to work together and engage in a variety of activities that gradually
formed the foundation on which the first steps into the research enterprise

SOCIAL WORK IN HEALTH CARE 5

could be made. In the absence of the hospital administration’s financial
support for social work research, volunteerism on the part of these self-
selected individual staff members became critical start-up currency.

The effort began with highlighting already existing research activity of a
few social work practitioners in a social work research symposium. All social
workers in the health system were invited to attend and continuing education
credits were granted. Further steps were built from this event, based on social
workers’ interest and the availability of modest funds from the department of
social work. A social work research committee was composed from those
social workers who were inspired by the symposium to work on a common
goal—to promote research activity in the department. The social work
research committee continues to build an infrastructure by creating roles,
building partnerships, and learning from past experience. Most of these
social workers had no research experience when they began this journey.

Building the research infrastructure included nine essential components.
Table 1 describes each method as a component. They are as follows: 1) the
creation of venues for social work research awareness and encouragement; 2)
the formation of a social work research committee composed of research
activists and mentors within the department; 3) the establishment of a lead
role to support this committee; 4) collaboration with an existing federally
funded research training program for clinicians in the university’s medical
school; 5) collaboration with school of social work faculty involved in health
research; 6) identification of accessible funding resources for social workers
interested in research; 7) the creation of research databases to collect psy-
chosocial data from patients in a center for sexual health and across the
health system as a whole; 8) the development of a social work assessment
tool; and 9) the development of a career ladder that incorporates research
into the highest category of clinical scholar.

Program development

Over a 6-year period, research activities were highly encouraged, and the
practice-research culture began to emerge. Table 1 describes the results as
both intermediate outcomes and long-term outcomes. Nine elements emerged
sequentially and will be described in order below. These elements were seen as
a natural progression of social workers’ meeting on a regular basis to promote
research throughout the department and have maintained sustainability. 1)
Symposia: The Biennial Social Work Research Symposium was first held in
2009. During 2013 and 2015, it became a regional conference and the number
of attendees and presentations has nearly doubled. 2) The social work research
committee: The vision of the social work research committee is “to be leaders
in cultivating the promotion of hospital-based social work research.” Its mis-
sion is “to support already existing social work practice in the health system

6 S. TISCHLER ET AL.

Ta
b
le

1.
Pr
ac
ti
ce
-o
ri
en
te
d
so
ci
al
w
or
k
re
se
ar
ch

st
ru
ct
ur
e
in

a
h
ea
lt
h
sy
st
em

so
ci
al
w
or
k
d
ep
ar
tm

en
t.

C
om

p
on

en
t

In
te
rm

ed
ia
te

ou
tc
om

e
Lo
n
g
-t
er
m

ou
tc
om

e

V
en
ue

fo
r
so
ci
al

w
or
k
re
se
ar
ch

aw
ar
en
es
s
an
d
en
co
ur
ag
em

en
t

Es
ta
b
lis
h
m
en
t
of

th
e
Bi
en
n
ia
l
So
ci
al
W
or
k

Re
se
ar
ch

Sy
m
p
os
iu
m

20
09

20
11

20
13

20
15

H
ea
lt
h
sy
st
em

16
p
re
se
n
te
rs

35
at
te
n
d
ee
s

H
ea
lt
h
sy
st
em

an
d
sc
h
oo
l
of

so
ci
al
w
or
k

29
p
re
se
n
te
rs

53
at
te
n
d
ee
s

H
ea
lt
h
sy
st
em

an
d
th
re
e

re
g
io
n
al
sc
h
oo
ls
of

so
ci
al

w
or
k

33
p
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se
n
te
rs

10
6
at
te
n
d
ee
s

H
ea
lt
h
sy
st
em

an
d
re
g
io
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al

sc
h
oo
ls
of

so
ci
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w
or
k
an
d

h
ea
lt
h
sy
st
em

s
42

p
re
se
n
te
rs

10
7
at
te
n
d
ee
s

Re
se
ar
ch

co
m
m
it
te
e

Es
ta
b
lis
h
m
en
t
of

vi
si
on

an
d
m
is
si
on

;
ca
d
re

of
re
se
ar
ch

ac
ti
vi
st
s
an
d
m
en
to
rs
;
re
se
ar
ch

ac
ti
vi
ty

co
m
m
un

ic
at
io
n
an
d
d
is
se
m
in
at
io
n
;

2–
3
ye
ar
ly
b
ro
w
n
b
ag

se
m
in
ar
s
w
it
h

re
se
ar
ch

fo
cu
s

C
on

su
lt
at
io
n
s
w
it
h
re
se
ar
ch

co
m
m
it
te
e
m
em

b
er
s
ab
ou

t
re
se
ar
ch

p
ro
je
ct

d
ev
el
op

m
en
t

Es
ta
b
lis
h
m
en
t
of

re
se
ar
ch

n
ew

sl
et
te
r
an
d
w
eb
si
te

44
re
se
ar
ch

p
ro
je
ct
s

10
n
ew

in
ve
st
ig
at
or
s
in

20
14

36
p
ub

lic
at
io
n
s
to

d
at
e

A
p
p
oi
n
tm

en
t
of

a
re
se
ar
ch

le
ad

Es
ta
b
lis
h
m
en
t
of

ac
co
un

ta
b
ili
ty

fo
r

re
se
ar
ch

d
ev
el
op

m
en
t

C
on

ti
n
ui
ty

of
le
ad
er
sh
ip

to
im
p
le
m
en
t
re
se
ar
ch

vi
si
on

an
d
m
is
si
on

C
ol
la
b
or
at
io
n
w
it
h
Pr
ac
ti
ce

O
ri
en
te
d
Re
se
ar
ch

Pr
og

ra
m

(P
O
RT
)
in

th
e
m
ed
ic
al
sc
h
oo
l

C
lin
ic
al
re
se
ar
ch

tr
ai
n
in
g
fo
r
so
ci
al
w
or
ke
rs
;

d
ev
el
op

m
en
t
of

re
se
ar
ch

co
lla
b
or
at
io
n

w
it
h
m
ed
ic
al

d
ep
ar
tm

en
ts
an
d
p
h
ys
ic
ia
n
s

Si
n
ce

20
11
.
10

te
am

s
ap
p
lie
d
to

PO
RT

an
d
w
er
e
ac
ce
p
te
d
,
an
d
1
te
am

is
cu
rr
en
tl
y
in

th
e

tr
ai
n
in
g
p
h
as
e

8
te
am

s
w
er
e
fu
lly

tr
ai
n
ed
,
1
cu
rr
en
tl
y
tr
ai
n
in
g

6
te
am

s
w
er
e
aw

ar
d
ed

p
ilo
t
p
ro
je
ct

fu
n
d
in
g

C
ol
la
b
or
at
io
n
w
it
h
th
e
sc
h
oo
l
of

so
ci
al
w
or
k

Es
ta
b
lis
h
m
en
t
of

an
in
te
g
ra
te
d
h
ea
lt
h

le
ar
n
in
g
co
m
m
un

it
y
w
it
h
fu
n
d
in
g
fr
om

th
e

sc
h
oo
l

Ye
ar
ly
10

m
as
te
r’s

le
ve
l
so
ci
al

w
or
k
st
ud

en
t
sc
h
ol
ar
s
w
h
o
w
ill
p
ar
ti
ci
p
at
e
in

cl
in
ic
al
re
se
ar
ch

p
ro
je
ct
s
in

th
e
h
os
p
it
al
sy
st
em

an
d
in
co
rp
or
at
e
re
se
ar
ch

in
to

th
ei
r
co
n
ce
p
tu
al
iz
at
io
n
of

th
e

so
ci
al

w
or
k
ro
le

Id
en
ti
fic
at
io
n
of

fu
n
d
in
g

Fu
n
d
in
g
fo
r
re
se
ar
ch

is
ex
p
lo
re
d

M
ed
ic
ai
d
m
at
ch
in
g
fu
n
d
s
an
d
fo
un

d
at
io
n
fu
n
d
in
g
is
g
ra
n
te
d
,
11

fu
n
d
ed

p
ro
je
ct
s

M
od

el
d
at
ab
as
e

Se
xu
al

h
ea
lt
h
d
at
ab
as
e

66
4
p
ar
ti
ci
p
an
ts

ac
cr
ue
d

D
ev
el
op

m
en
t
of

a
p
sy
ch
os
oc
ia
l

as
se
ss
m
en
t
to
ol

A
cu
it
y
to
ol

es
ta
b
lis
h
ed

in
th
e
h
ea
lt
h

sy
st
em

’s
el
ec
tr
on

ic
m
ed
ic
al
re
co
rd

D
at
a
an
al
ys
is
to

es
ta
b
lis
h
so
ci
al
w
or
k
p
ra
ct
ic
e
le
ve
ls
of

ac
ui
ty

in
th
e
h
ea
lt
h
sy
st
em

D
ev
el
op

m
en
t
of

a
ca
re
er

la
d
d
er

C
ar
ee
r
la
d
d
er

im
p
le
m
en
ta
ti
on

14
cl
in
ic
al

sc
h
ol
ar

ad
va
n
ce
m
en
ts

w
it
h
fin

an
ci
al
re
m
un

er
at
io
n

SOCIAL WORK IN HEALTH CARE 7

with evidence and to contribute to the development and dissemination of new
evidence-based social work practice in health and mental health.” Some of its
regular activities include mentoring social workers who are interested in
research, developing new training and research opportunities for social work-
ers, and designing venues that could highlight social work practice research
within and beyond the boundaries of the hospital. The committee is respon-
sible for the creation of a research newsletter and website. In total, the health
system has had 44 research projects, 22 investigators, and 10 new investigators
in 2014, and 36 total publications to date. 3) Leadership: The appointment of a
research lead led to accountability for research development and a commit-
ment to an ongoing research vision and mission. 4) Research training: The
research committee developed a partnership with a federally funded research
training program in the university’s medical school, designed to develop
clinician-scientists (Murphy, Kalpakjian, Mullan, & Clauw, 2010). 5)
Partnership with the school of social work: The school of social work funds
10 MSW students each year as integrated health community scholars to
participate in ongoing practice research projects under the supervision of a
social work clinician-scientist. 6) Identification of funding: Medicaid matching
funds have been granted for 11 projects to date. Additionally, foundation
funding has been accessed. 7) The establishment of a model research database:
A sexual health database was designed to collect psychosocial data from
patients who have sexual problems in the context of medical conditions. 8)
The development of a social work acuity tool: A methodology to measure the
psychosocial acuity of patients across a health care continuum that documents
social work activity and leads to resource alignment and distribution (Klett
et al., 2014). 9) The development of a career ladder: Incorporates scholarly
publications, significant primary role in grant writing, and completion of
research training as qualifications for meeting the highest level on the ladder
of clinical scholar. The career ladder provides a framework for the develop-
ment, advancement, and recognition of MSWs. Financial incentives are also
aligned with promotions on the career ladder.

Success in integrating practice and research

Our focus on several initiatives, including research training and collaboration
with social work students, has led to an increased interest in research partici-
pation and furthered the integration of research and practice. The following
three examples illustrate some of the outcomes of the Social Work
Department’s effort to promote the integration of practice and research.

1) The findings from a study that evaluated the impact of a one-day retreat
on couples’ coping with the side-effects of prostate cancer surgery on specific
outcomes (Wittmann et al., 2013) resulted in the adaptation of the findings
of the study to usual care. Prostate cancer survivors and partners now attend

8 S. TISCHLER ET AL.

a pre-operative seminar that prepares them for surgery-related side-effects of
rehabilitation. The effect of the seminar on patients’ and partners’ learning
and expectations has also been evaluated, and the study findings are in press
in a peer reviewed journal. These studies and clinical experience using the
studies’ content formed preliminary data for a foundation funding award for
the development and testing of a web-based intervention for couples coping
with the side-effects of prostate cancer treatment (Paich et al., 2015).

2) Through a study focused on improving emotional and social function-
ing of adolescents with epilepsy, 34 adolescents with epilepsy participated in
a group cognitive behavioral therapy program. Baseline scores suggested that
many participants had difficulties with emotions, concentration, and social
functioning, with parent-reported impact scores significantly worse than
adolescent-reported scores. After the intervention, adolescent-reported pro-
social behavior scores significantly improved. Parent-reported scores
improved significantly at follow-up in several areas of emotional and social
functioning. Adolescents with lower socioeconomic status reported the great-
est improvements (Carbone, Plegue, Barnes, & Shellhaas, 2014).

Finally, 3) a scale that measures the psychosocial acuity of patients and
families across the health system was developed and implemented in the
hospital system’s electronic medical record. All patients seen by social work
receive an acuity score. The psychosocial acuity measure provides data that
documents social work contributions to the care of hospital patients. It
corresponds to a statistics database and can aid in the alignment of resources
as well as allow social work departments to accurately convey the full scope
of value to health system leadership. The biggest strength of the acuity scale
is that it has already been implemented into practice. Future steps for this
measure include dissemination to other health systems in the United States.

Discussion

The department of social work has been successful in creating a culture and
structure which actively supports practice-based research. It has done so by
adopting a multimodal approach that included forming a dedicated body of
social workers, who provided encouragement to colleagues. Additionally, it
developed collaboration with a training program and academic colleagues.
Ultimately, a new generation of clinician-scientist social workers is emerging.
It is this new generation that will continue to carry on the mission.

The department of social work has demonstrated that it is possible, despite
limited resources and lack of institutional support, to reach significant
outcomes, such as the establishment of scientific social work conferences
that focus on social work research in health care, successful competition for
internal and external funding, and completed projects and publications, all of
which lead to improved practice and greater visibility of social workers’

SOCIAL WORK IN HEALTH CARE 9

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NAMI Family & Friends is a 4-hour seminar that informs and supports people who have loved ones with a mental health condition. Participants learn about diagnoses, treatment, recovery, communication strategies, crisis preparation and NAMI resources. Seminar leaders have personal experience with mental health conditions in their families.

Find the NAMI Family & Friends seminar nearest you

NAMI Sharing Your Story with Law Enforcement

The NAMI Sharing Your Story with Law Enforcement presentation program trains peers and families to share their stories during law enforcement trainings, such as Crisis Intervention Team (CIT) training.

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Outreach, Advocacy & Wellness


NAMI Smarts for Advocacy

NAMI Smarts for Advocacy is a hands-on advocacy training program that helps people living with mental illness, friends and family transform their passion and lived experience into skillful grassroots advocacy.

Find the NAMI Smarts for Advocacy nearest you

NAMI FaithNet

NAMI FaithNet is an interfaith resource network of NAMI members, friends, clergy and congregations of all faith traditions who wish to encourage faith communities who are welcoming and supportive of persons and families living with mental illness.

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NAMI Hearts+Minds

The need to focus on mental and physical health simultaneously has never been more important. NAMI Hearts+Minds educates and empowers individuals to better manage their health, mentally and physically.

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Call the NAMI Helpline at 

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In a crisis, 

text “NAMI” to 741741.

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The following are trademarks of NAMI: NAMI, NAMI Basics, NAMI Connection, NAMI Ending the Silence, NAMI FaithNet, NAMI Family & Friends, NAMI Family Support Group, NAMI Family-to-Family, NAMI Grading the States, NAMI Hearts & Minds, NAMI Homefront, NAMI HelpLine, NAMI In Our Own Voice, NAMI On Campus, NAMI Parents & Teachers as Allies, NAMI Peer-to-Peer, NAMI Provider, NAMI Smarts for Advocacy, Act4MentalHealth, Vote4MentalHealth, NAMIWalks and National Alliance on Mental Illness. All other programs and services are trademarks of their respective owners.

Contact Us Main 703-524-7600

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