The George Washington University School of Public Health

And

Health Services

The final paper of

Alexandru Paziuc

Rethinking

Mental Health

And

Community Center

For Development, Integration and

Surveillance in Mental Health

June , 2004

1
 Contents

1. Introduction

2. Why mental health and mental illness

3. Defining mental health and mental illness

4. Causes of mental illness

5. The American models:

6. The Romanian experiences

7. The SWOT analysis

8. Solutions

9. Conclusions
1
 Rethinking Mental Health

Community Center for Develop, Integration and Surveillance in Mental Health

The paper proposes to describe why it is necessary rethinking mental health and offer models and new ways
to realize it.

In first chapter I tried to prove why mental health and mental illnesses have to become an important issue on
national and international agenda. Offering some definition you will see how difficult is to define mental
health and mental illnesses. Describing biological, psychological and socials causes, and also some
mechanism will see how complex is mental health and mental illnesses and necessity to have an integrative
point of view at all of this. Americans models for community mental healthcare services impress by
organization, support, and outcomes.

We will continue to describe and analyze the efforts and changes that have taken place in mental
healthcare services in the post-communist period at Campulung Moldovenesc, Bucovina. We will then refer
to how we started and continue to build a new image for the mental healthcare services in the community. In
addition, we will illustrate our attempts at changing stigma, the mentality, the stereotypes and the negative
social behaviors toward “taboo” subjects such as mental health and mental disorder, psychiatric hospital and
community mental healthcare services and people with mental disorders. In this process, we will describe
how consumers, organized into an NGO, played and will continue to play an important role. They proved that
they are more interested in changes, and that they can do it. We will try to underline the ways in which
relationships evolved between professionals and beneficiaries of the psychiatric services, families and
volunteers from the community, and how they managed to work together to build a cohesive team in which

1
lack of trust, fear, closed doors, disdain, inutility, isolation and lack of care, turned into respect, collaboration,
responsibility, utility, trust, freedom and mutual support. After the SWOT analysis of region we try to find
solutions like Community Mental Healthcare services, pilot hospital, and creating a Community Center for
Development, Integration and Surveillance in Mental Health which will help police makers to make viable
and realistic change in mental health policy.

Why Mental Health or Mental illness?

Human civilization has repeatedly been threatened by events such as war, earthquakes, revolutions,
and disease. Whereas revolutions and natural catastrophes have a beginning and an end, many human
diseases have no end in sight. Although people no longer suffer from the bubonic plague or measles, they
continue to suffer from mental health problems and which have now become international health priorities.

According to the WHO World Health Report 2001, mental and neurological disorders are extremely
prevalent and account for 12% of the global burden of disease, second only to infectious disorders (23%).
Neuropsychiatric disorders represent a larger burden then AIDS, malaria, and tuberculosis combined (10%)

Recent developments in the assessment of global disease burden have underscored the importance of
mental disorders and stimulated a reexamination of international health priorities. Mental disorders and
related conditions were notably neglected in the past because of their limited mortality.

Although mental health has now just begun to receive appropriate attention corresponding to the
enormous impact of mental illness in all countries - poor, middle and even high-income - until recently it has
been little more than a footnote to the broader discussion of international health priorities.

A recent assessment of disability-adjusted life years (DALYs) lost in different regions for various
diseases, conditions, and injuries has upwardly revised the burden of disease in low and middle-income
countries attributable to neuropsychiatric conditions to 10.5%, with an additional 1.5% attributed to
intentional self-injuries including suicide. Corresponding figures in high–income countries are 23.5% for
neuropsychiatric conditions and 2.2% for intentional self injuries (WHO, 1999).

Neuropsychiatric illnesses affect children and adolescents as well as adults (over 80% of psychiatric
inpatients are younger than 54) and impose high costs on social and medical plans. Age-specific figures
illustrate the relative scope of the problem even more dramatically. Five of the 10 leading causes of disability

1
in low-and middle-income countries among persons between 15 and 44 years old are because of mental
health and behavioral problems. Unipolar major depression is the leading cause of disability, accounting for
9.9% of all DALYs in this age group. All together, these five (unipolar depression, bipolar affective disorder,
alcohol and drug dependence, psychosis, posttraumatic stress disorder) conditions account for almost 22% of
all DALYs in the most productive years of life. The gender distribution is 25.6% women and 10.4% men.
Each year in the USA depression affects about 17 million American adults (American Psychiatric
Association, 1998 and National Mental Health Association 1997). Twenty-three percent of the American
adults (age 18+) suffer from a diagnosable mental disorder in a given year. Nine to thirteen percent of
children (9-17 years old) have a serious emotional disturbance with substantial functional impairment due to
a mental illness and 5-9% suffer from extreme impairment (Introduction to Health Care and Public Health:
The Mental Health System, Nov. 20, 2003). One in four women and one in 10 men will confront depression
at some point in their lives (American Psychiatric Association 1998). People with severe, untreated
depression have an estimated suicide rate of 15 percent (National Depressive and Manic-Depressive
Association, 1999) and in 2001 WHO reported that suicide worldwide causes more death every year than
homicide or war.

Projections from the analysis of the global burden of disease suggest that mental disorders will
increase as the epidemiological health transition continues. According to the same statistics (WHO), in 2020
mental health problems encompass be more than 15% of all diseases. Unipolar major depression will
becoming the second-ranked cause of lost DALYs, after cardiovascular diseases.

Mental disorders are disabling and costly. They affect the employment and productivity of the person
with the disorder as well as secondarily seriously impacting the person’s family. Part of this economic burden
is obvious and measurable while another part is impossible to measure. Among the measurable components
of the economic burden are health and social services needs, lost employment and reduced productivity,
impact on families and caregivers, levels of crime and the negative impact of premature mortality.

Some studies, mainly from industrialized countries, have estimated the aggregate economic costs of
mental disorders. One such study (Rice et. al 1990) concluded that the aggregate cost for the USA accounted
for about 2.5% of the gross national product. The indirect cost for mental illness was estimated to be $79
billion annually taking into account medical expenses, days missed from work, lost productivity, and
premature death. Absenteeism from work alone amounts to $12 billion per year (American Psychiatric
Association and American Psychological Association, 1999). Studies from Europe have also estimated the
expenditure on mental health service costs as a percentage of the GNP: in the Netherlands, this was 23.2%
(Meerding et al. 1998), and in the United Kingdom for inpatient expenditure alone, it was 22% (Patel &
Knapp 1998).

Mental disorders lead to high health services utilization, and a high rate of utilization of other
formally delivered services including social services, housing, education, and even the criminal justice

1
system. Though scientific estimates are not available for other regions of the world, there is no reason to
believe that the costs of mental disorders as a proportion of the overall economy are not high there as well.
Although estimates of direct costs may be low in countries where there is low availability and coverage of
mental health care, these estimates are spurious. Indirect costs arising from productivity loss account for a
larger proportion of overall costs than do direct costs. Furthermore, low treatment costs (because of lack of
treatment availability) may actually increase the indirect costs by increasing the duration of untreated
disorders and associated disability.

All these estimates of economic evaluations are most certainly underestimates, since lost opportunity
costs to individuals and families are not taken into account.

For the individual and his or her family, a mental disorder can have disastrous costs and can tip them
into poverty. Poor people are far more likely to have symptoms of mental distress (Narayan, 2000) than are
more well off individuals.

Statistics and economic data show that mental health problems are seriously underestimated. There is
still a lack of understanding and interest from state and decision-making authorities regarding the politics of

mental health and psychological suffering. At the beginning of the 21st century, mental health as well as
mental illnesses, due to their bio-psycho-social and spiritual determinism, are not only an issue concerning
the psychiatrist-psychologist-social worker team, but have become a community and even national and
international problems.

This analysis demonstrates that the importance of mental health on the international public health
agenda has been seriously underestimated, resulting in considerable preventable suffering, disability, and
mortality. Although the burden of mental illness is huge, attention to mental health policy in international
public health planning often fall far shorts of needs. This is an especially tragic state of affaires because many
mental disorders are now treatable. The full extent of the deficit is difficult to assess because international
databases do not show the percentage of the national health burden allocated to mental health services. The
governments must become aware that the problems of mental health have enormous consequences - social,
economic, and political - now and especially in the future. Governments must understand that mental
disability is not shameful, a dishonor or a humiliation - it is an illness, and alike physical illness, it is
treatable, especially when the treatment is begun early. Consequently governments have to agree to improve,
develop and support a psychiatric network where databases can be developed which will represent the actual
situation. These data will help the stakeholders to design mental health programs, to sustain and fund these

1
programs, and which will help them better formulate mental health policy.

Governments that “are sleeping” can create monsters (e.g. terrorism) and these “monsters” can affect
all of us (bioterrorism, wars, etc).

Therefore, it is clear that mental health is an integral part of our overall health. It is a part of our life,
which must be synergistically integrated with physical health into societal well-being.

Defining mental health and mental illness; Perspectives

In the past, scientists tried to define health and mental health simply as “absence of disease or illness
or symptoms”. There are many definitions now, which demonstrate how complex and difficult is to define
health, mental health, and mental illness, to include all factors, biological, psychological, psychosocial,
cultural, spiritual, political and economical which play an important role in the determinism of mental health.

According to the World Health Organization, “health is a state of complete physical, mental and
social well-being and not merely the absence of disease or infirmity”. In the same time, mental health is the
balance between all aspects of social, physical, spiritual and emotional life. It impacts on how we manage our
environment and make choices in our lives. It is interaction between us and ourselves, between others, and
us, between us and our surroundings which are in continuous transformation. It is our ability to meet our
needs and life’s demands and to be satisfied with it. But what happens when we do not like what we hear,
see, feel or think about us or around us (tragedy, threats, adversity, trauma, stress and others)? Are we happy
or unhappy? Or maybe we are insensible. Anyway, the unbalance was produced.

DSM IV (American Psychiatric Association) mental disorder is “clinically significant behavioral or

psychological syndrome or pattern that occurs in an individual and that is associated with present distress
(e.g. a painful symptom) or disability (i.e. impairment in one or more important areas of functioning) or with
a significantly increased risk of suffering death, pain, disability or an important loss of freedom…”

The intra-psychic conflict, in time, is going to produce disabilities to the physical body and will affect
our responses in social life throughout inadequate behaviors attitudes and emotions. Therefore, it is clearly
that mental health is an integral part of our overall health. Mental illness is a form of deviant behavior. It

1
arises when the individual’s thought processes, feelings, or behaviors deviate from usual expectations or
experience and the person affected or others in the community define it as a problem that requires
intervention. Typically the concept has two aspects. First, the thoughts, feelings, and behaviors that are said
to stem from mental illness are distressing or disruptive in some fashion. Second, the problem is believed to
arise from some dysfunction in the person, some aspect of his or her mind and body that is not functioning,
as it should. Embodied in this relatively simple statement are great complexities and many uncertainties.

From a lay point of view, mental illness is usually recognized by highly bizarre behavior that makes
no sense to the observer. From a sociological perspective, the observer takes the role of the “other” and tries
to understand the motives underlying what the actor says and does. Behavior that departs radically from
expected patterns and for which the observer can identify no reasonable motive is said to be “crazy”. Such
behavior may include bizarre and meaningless talk, having visions and seeing and hearing things that others
do not see or hear, and behaving in ways that are bizarre for no apparent purpose. People readily distinguish
between behavior they think is “bad” and behavior they think of as “sick”. To the extent that they perceive a
self-interested motive in the behavior, they are likely to think of it is bad. Behavior that seems to make no
sense, in contrast, is more likely to be characterized as sick.

Mental health professionals often appraise behavior in ways similar to the appraisals of lay people.
Professionals identify mental illness through reports or observations of deviant behavior, bizarre speech and
expressions of affect, and indications that the person is feeling unusual degrees of pain as in severe
depression or anxiety. Like general public, they try to differentiate deviance that results from rational motives
and uncommon life stresses (such as bereavement) from deviance that arises from mental functions that have
gone wrong in some way. The difficulty is that there are few clear criteria or objective tests for making this
distinction. Like the general lay public, their own limited social and cultural background can mislead mental
health professionals. Also these problems are not as formidable as they may seem for the practicing mental
professional. Most professionals do not go into the general population looking for mentally ill people to treat.
They practice in hospitals, clinics, and offices and they wait for patients who are refer themselves (because
they feel distressed) or patients who are referred by doctors, family members, and others because of some
manifest problem. To the extent that the consultation is voluntary and the therapist is dedicated to helping in
manner that is consistent with the patient’s wishes, ambiguity about definitions is no major problem because
both patient and professional share a commune goal. However, definition becomes a serious problem in the
case of involuntary treatment, in deciding whether treatment will be covered under insurance coverage for
mental illness in litigation and the judicial process, and in carrying out mental health research in community

1
populations. Thus, it becomes essential to delve into definitional matters more thoroughly.

Evaluations of the presence of mental illness are typically made by judging behavior, and the values
of the observer substantially influence these judgments. Assessments of social adjustment and evaluations of
nonconformity with respect to community and family expectations are dependent on what individuals regard
as right and proper, which is shaped by culture and the social context in which people live. Differences in
religious, social, and political values lead people to different commitments, and priorities and behavior that
may seem bizarre from one cultural perspective can be perfectly acceptable from another.

There have been many debates about whether people who struggle against the accepted norms of their
community are more or less healthy than those who conform comfortably. Were Germans who fought against
their Nazi government at the risk of their lives, or Romanians who engaged in civil disobedience to protest
the Ceausescu’s communist regime and participate at the Revolution since 1989, more or less healthy than
those who comfortably adjusted to the social milieu and went on living their lives in ordinary ways? Some
psychoanalysts have argued that people who struggle against tyranny are more psychologically healthy than
those who are docile and simply conform to current ways of thinking (Eric Fromm). Moreover, there is much
evidence that some of the most creative people in history were driven individuals who were terribly unhappy
and out of sync with their social context. Creativity itself is a form of deviant behavior that requires
individuals to break from usual assumptions and understandings in developing entirely new perspectives and
approaches.

The impossibility of arriving scientifically at a definition of mental health does not stop professionals
from searching for this holly grail, and there is no lack of criteria suggested for differentiating the healthy
from unhealthy. People who pursue this venture seek to define aspects of social character and personality that
could conceivably be viewed as independent of social context. Among the themes emphasized are social
sensitivity, the capacity for environmental mastery, a unifying outlook on life, self-acceptance, a sense of
humor, empathy with others, and the like (Jahoda 1958). However attractive these traits may be, they remain
cultural judgments and not universal characteristic of mental mechanisms. Why should self-acceptance be
healthy? It is through self-criticism and striving to improve ourselves that we often make progress. Too ready
self-acceptance inhibits motivation and makes us complacent. We can agree that social sensitivity is an
attractive trait, but often insensitivity and single-mindedness contribute to extraordinary achievement.

People vary a great deal in their internal dispositions. Some are highly introspective, very much
concerned with their own thoughts and feeling. As a result they may know themselves better but also

1
experience more psychological distress. Others are relatively uninterested in their inner states and direct most
of their attention to external events. Persons with these contrasting orientations seek different occupational
outlets. Persons in engineering tend to be low on introspectiveness whereas artists, poets, novelists, and
others in the arts tend to be much higher. Persons who make good astronauts and who readily tolerate the
risks and loneliness of space travel, tend to be low on introspectiveness. Their focus on the outer environment
assists in task completion and limits diversions. The point here is that people have many types of traits and
dispositions and generally try to sort themselves into social contexts compatible with their needs and
dispositions Persons who do well in one context often do less well in others.

It is difficult to imagine human behavior that is completely independent of social context. All of these
illustrate that mental illness is far more difficult and slippery concept than it may seem. It is certainly
biological, but then so is all human behavior because mind is a part of our biological system. The definition
of mental illness is arbitrary and culturally conditioned, but all societies recognize persons with serious
mental illness as being different and treat them in special ways (like stigma…). However, the manifestations
of psychological pathology are socially defined and societal meaning systems and social definitions very
much shape the course of these conditions. Sociological studies have much to contribute to developmental
and disease perspectives both, because human biology and development must occur in a social context. Then
we maybe will understand the WHO’s definition for health, what means “well being” and we could act for
prevention.

Causes and mechanisms of mental illnesses

There are a lot of theories that try to explain the causes of mental illness. The new concept, bio-
psycho-social (and spiritual) succeeds to embrace all causes who induce and support mental illnesses

I). From a biological point of view, mental disorders are illnesses like any other; they are disease of
the body, specifically disease of the brain. The goal of a biological approach to psychiatric disorders,
therefore, is to understand how disruptions in brain functioning lead to the development of psychiatric
disorders.

The brain is conceptualized as an integrated system of command centers composed of bodies of nerve
cells connected to each other by branches that communicate through electrical impulses and chemical and
molecular exchanges. Instructions for the synthesis and metabolism of these chemical and molecular

1
messengers (neurotransmitters) and complex proteins that form other components of this communication
system are coded in DNA. These chemical exchanges are conceptualized as the biological substrate of
thought, emotion, memory, judgments and feelings- the components of what we think about our inner life and
the arenas that are affected in psychiatric disorders.

The brain can be “broken” at many points in this system, as when the neural command centers
malfunction, the connection is disrupted, the chemical balances and feedback loops are not working, the
protein are not synthesized in appropriate quantity or quality, or the implicated genes are mutated. Biological
researches are look for brain dysfunction in all of these areas. The goal of such research is to provide a
coherent picture of the pathophysiology of the disorders. For example, a genetic defect may be related to the
synthesis of a protein involved in a particular type of chemical communicator that is present in the area of the
brain producing the symptoms of the disorder where damage has been located.

The search for anatomical and functional brain deficits has gained new impetus from technological
advances in brain imaging that enable the examination of brain structure and function in living persons. The
main imaging techniques for brain structure are CAT (computer aided tomography) and MRI (magnetic
resonance imaging) and for brain functioning are PET (positron emission tomography and SPECT (single-
photon emission computed tomography).

As we know the brain is composed of billions of nerve cells of different sizes and shapes. The
neuron’s functioning and the neuronal communication system (synapses, receptors and neurotransmitters) are
the basis of theories of psychiatric disorders at this level of organization.

There are three main groupings of classic neurotransmitters: cholinergic (acetylcholine), biogenic
amines (dopamine, norepinephrine, serotonine), and amino acids (GABA, glycine, and glutamate). Different
parts of the brain use different neurotransmitters, but brain locations using the same neurotransmitters
perform different functions, and create redundancy and plasticity in the system.

The hypotheses that schizophrenia is related to an excess of dopamine, and that depression is related
to a dysfunction of norepinephrine and serotonin, are probably the most researched and viable current
theories in the neurochemistry of these disorders. The best evidence for this hypothesis comes from the
mechanism of antipsychotic medications that block the transmission of these neurotransmitters between
neurons. New and advances researches in drug therapies come to added to our understanding of the chemistry
of the brain and neuronal communication. These new drugs, (known as “atypical” antiopsychotics, like

1
clozapine, risperidone, olanzapine) have changed the schizophrenia evolution also offering new hope to
many people with severe psychiatric disorders. In the same time the complex interaction among
neurotransmitters, the specification of multiple receptors for the same neurotransmitters, and complexities in
second messenger systems all require more sophisticated explanations (Kaplan et al. 1994).

The genetic component of the biological revolution in psychiatry has had perhaps the greatest
influence on popular imagination. Familial aggregation, twin and adoptee studies, come to complete our
knowledge about mental diseases. Linkage studies have produced numerous headlines in recent years with
the discovery of the location of the genes associated with Huntington’s disease, Alzheimer’s, and others
diseases. Once located, the genes can be isolated and their functions identified. Thus the pathophysioloy of
disorder and treatment could be specified (U.S. APA World Congress New York 2004).

II). If the biological/medical approaches views mental illness as a disease or physical defect in the
brain or body, than psychological approach treats mental illness as sickness or abnormality in the mind or
psyche. Psychologists focus attention on individual factors that produce abnormal thought, feelings, and
behaviors. Psychologists also provide therapies that try to alleviate the distress caused by mental illness. I
will try to provide an overview of the views of human nature, abnormality, and treatment found in four
psychological models of mental illness.

Psychoanalytic model, which originated with Freud assumes that people are closed energy systems
motivated by a variety of drives. Abnormality can be understood developmentally in that early childhood
events affect adult functioning. Psychoanalytic treatment generally involves helping the individual to achieve
insight and to free the energy from unhealthy purpose by catharsis.

A second model is the cognitive-behavioral, which emphasis cognition and learning. People are viewed as
information processing systems that attempt to maximize pleasure and minimize pain. All types of learning
(classic conditioning, operant conditioning, and modeling) must be placed in a cognitive context- that is
learning take places within a thinking context. Abnormalities arise when individuals are placed in highly
unusual situations or have unusual ways of thinking. Interventions encourage adaptive habits and teach
individuals to perceive the world more accurately and to solve problems more efficiently.

The third model is the Humanist-Existential Phenomenological Approach model (Abraham Maslow,
and Carl Rogers) it emphasizes the need for self –actualization rather than diagnosis of mental illness. The
focus lies in the individual’s experience of the world and in creation of a supportive atmosphere characterized
by genuineness, empathy, and unconditional positive reward.

A final model is the family system approach, which sees most problems, is originating in the family.
Accordingly, couples or family therapy is undertaken, where the therapist intervenes to develop healthy ways
of relating to one another.

1
 Each model works well with some types of problems and falls short with others. An integrate
approach may be best, where one identifies the purposes best suited for a particular model.

III). The social approaches focuses on factors external to the individual - the environmental or social context
- and view mental illness as a breakdown in the face of overwhelming environmental stress. Also from the
biological and psychological approaches, the determinants of mental illness are internal- “in” the person (in
the physical body or in the mind) From a sociological approaches, the cause is external – in the environment
or in the person’s social being.

Within the social approach, there are three dominant theories of mental illness etiology, the origins or causes
of a disorder. These are stress theory, structural strain theory, and labeling theory.

Stress theory assumes that accumulations of social stressors can precipitate mental health problems.
Hans Selye, a physiological researcher, introduced the term “stress” and “stressors,” and described three
physical stages of reaction when the person exposed to prolonged noxious stimuli. He called these three
stages the general adaptation syndrome (1930).

Because laboratory studies convincingly showed a relationship between prolonged or repeated stress
exposure and disease in animals, speculation turned to the effects of stress of human beings. Researchers
began to focus on social stressors – in particular, on major life events (Holmes & Rahe). They defined life
events as major changes in people’s lives that require extensive behavioral readjustments. They hypothesized
that extensive readjustment of behavior could overtax a person’s ability to cope or adapt, thus leaving the
person more vulnerable to physical and mental illness, injury, or even death. To test this hypothesis, Holmes
and Rahe first went through the medical records of Navy personnel, recording the most common life events
that preceded Navy men’s doctors’ visit and hospitalizations, abstracting a list of 43 major life events. They
asked groups of people to judge (independently of another) how much behavioral readjustment each event on
their list required.

Copyright @1998 Information Technology - Roane State Community

College. Last revised: February 15, 2000 by A. Whittenberg.

National Safety Council affirms that “an unintentional-injury death” every five minutes 1999. But

1
how many people suffer because of this death (spouse, children, brooder, sister, parents, grand parents,
friends, colleges or partners and so on). So how many people suffer in each five minutes because one person
death an unintentionally-injury? Or we prefer to see only the top of the iceberg?

According to elaborations of stress theory (Lazarus & Folkman et al 1984) the modest correlation between
stress exposure and symptoms occurs because many individuals have extensive coping resources and use
effective coping strategies when handling stressful demands, thus buffering the negative psychological
impacts of those demands. “Coping resources” refer to social and personal characteristics that people rely on
when dealing with stressors. A key social resource is one’s social network, from which one can obtain
emotional and practical support when facing stressors (social support is emotional or practical assistance
received from significant others such a control or mastery over life. People who have high self-esteem and
those who strongly believe that they are in control of their lives are more likely to engage in active problem-
solving efforts to overcome difficulties or to use a variety of coping strategies flexibly to meet stressful
demands (Folkman 1984, and Pearlin 1990).

Coping strategies are usually defined as behavioral or cognitive attempts to manage situational demands that
one perceives as taxing or exceeding one’s ability to adapt. Of crucial importance to sociologists of mental
health is the finding that life events and chronic strains- as wel as social support, self-esteem, and a sense of
mastery- are unequally distributed in the population, leaving some groups of people (e.g. women, the elderly,
the very young, unmarried, those of low socioeconomic status) both more likely to experience certain
stressors and more vulnerable to the effects of stressors in general (Turner 1995). These key findings point
very clearly to the important role that social factors can play in the etiology of mental illness and
psychological distress. Moreover, the theory suggest an explanation for higher rates of mental disorder and
psychological distress found in lower-status, disadvantaged groups which are more likely to be expose to
stressors and less likely to have important coping resources.

The advantages of stress theory are several. First, the theory focuses on aspects of the individual’s current
situation, which the biological and psychological approaches tend to de-emphasize or ignore. Second, it helps
to explain why psychological distress and disorder occur more frequently in lower- status groups than in
higher-status groups patterns that the biological and psychological perspectives have difficulty explaining
parsimoniously. Third, stress theory allows for more direct empirical testing than the biological and
psychological approaches do. Conventional survey and interview methods allow researchers to mesure key
concepts (e.g. stress, coping, social support) and to test relationships among them explicitly, unlike biological
studies where researchers can only infer an association between serotonin uptake and major depression from
the effects of specific drugs. Similarly, psychological researchers must assume a relationship between
childhood’s traumatic experiences and mental illness from the effects of psychotherapy, which often unearth
such past experiences.

The treatment implications of stress theory are straightforward and quite different from biological and
psychological approaches. To treat or prevent mental illness one needs to change the individual’s situation
(eliminating or reducing stressors), teach the person different coping responses (allowing better management
of stressors), or bolster personal and social resources (e.g. by increasing available social support, raising self-
esteem, or empowering a stronger sense of control). Because directly changing people’s life situations can be
intrusive and expensive, interventions aimed at people’s actual sources of stress are less frequently attempted
than efforts aimed at their coping strategies or their personal and social resources. Some well-crafted
experiments (Price et al. 1988) show quite clearly that interventions which change people’s coping strategies
and which bolster their social support do, in fact, reduce their emotional reactions in response to major life
events (e.g. diagnosis of cancer, major surgery, divorce, unemployment). Thus, stress theory offers real
promise for devising preventive mental health interventions.

1
Structural strain theory

“Structural strain theory” is an umbrella term that covers a number of more specific sociological
hypotheses about mental illness etiology. In contrast to stress theory, which focuses on specific events and
strain as causal factors in people’s mental health, structural theory locates the origins of distress and disorder
in the broader organization of society, where some social groups are disadvantaged in comparison to others.
Merton’s anomie theory of evidence provides a useful example of structural strain theory. Anomie theory try
to explain not only mental illness but the occurrence of deviant behavior in general including criminal,
addictive, and rebellious behavior.

Mentor uses the term anomie to describe the gap between cultural gap like desires for financial
success, and the structural means to those goals like access to adequate education and employment. He
argues that people who experience anomie adapt to dilemma in one of several possible ways: by changing
their goals, pursuing alternative means, or both. So Merton described five adaptive responses:

1. “Conformists” who are people who continue to adder to culturally shared goals and to pursue
legitimate means to those goals, despite awareness that these efforts are unlikely to pay off.

2. “Ritualists” are those who reduce their aspirations (give up the possibility of ever achieving success)
yet continue to behave in socially acceptable ways ( they perhaps finish high school and work steadily
at some low-paying, low-prestige job).

Neither conformist nor ritualist responses create major social problems.

3. “Innovators” are people who continue to desire and seek wealth but resort to illegitimate means to
reach that goal; innovators are essentially society’s criminals, from simple thieves to executive
engaged in fraud and tax evasion

4. “Retreatists” are people who give up the goal of success and do not attempt to follow legitimate
avenues. Instead, they retreat from the world into substance abuse or mental disorders.

5. “Rebels” are people who reject both goals and the socially acceptable means to those goal new
avenues; these are people who lead or participate in social movements or, more threateningly, riots
and rebellions.

Most theorists of structural strain theory sustain that mental illness is an adaptive response to
structural strain; more specifically, it is response to finding one’s legitimate roads to valued rewards
irrevocably blocked. It is important to note that this blockage is due not to one’s own inadequacies but to the
structure or hierarchical organization of society, which unfairly privileges the desire and efforts of some
social groups over others.

Structural strain theory suggests that, in order to prevent or reduce mental illness in society, one must
intervene in fairly- scale ways (for example, by creating guaranteed income programs to eliminate the strains
of unemployment or by instituting voucher systems to equalize acces to educational opportunities. Because
structural solutions to the problem of mental illness require massive (and usually expensive) social programs

1
that are difficult for policymakers to legislate and fund, the preventative implications of structural strain
theory usually go untested.

Labeling theory or societal reaction theory consider that the diagnostic and the treatment of mental
illness may exacerbate the conditions of people called mental ill. Labeling theory is based on one key idea:
people who are labeled as deviant and treated as deviant become deviant. Deviance refers to rule breaking or
violation of norms. In the case of mental illness, symptoms of psychiatric disorders are themselves viewed as
normative violations. Symptoms essentially break taken-for –granted rules about how people should think,
feel, and behave.

Labeling theorists (Becker 1973, Rosenham 1973, Goffman) assume that everyone violates norms at
some time in their lives for a multitude of reasons. Reasons for rule breaking can include biological causes
(fatigue, undernourishment, genetic abnormalities, illness), psychological causes (unhappy childhood, a need
for attention, internal conflicts, low self-esteem, antisocial personality), sociological causes (role conflict,
peer pressure, exposure to stressor), cultural causes (following subcultural norms that differs from those of
dominant society, religious believes), economic causes (poverty, a need for money, buying prestige in the
eyes of others), and even miscellaneous reasons (carelessness, accidents, sheer ignorance of the rules).

Most often, rule-breaking acts are ignored, denied, or rationalized away by family, friends, and the
rule breakers themselves. However, when individuals’ norm violations are frequent, severe, or highly visible,
or when rule breakers are low in power and status relative to agents of social control (i.e. police, social
workers, judges, psychiatrists), rule breakers are much more likely to be publicly and formally labeled as
deviant (in this case, mental illness) and forced into treatment.

Why is public, official labeling so important? Once labeled and in psychiatric care, rule breakers
begin to experience differential treatment on the basis of their label. People labeled mentally ill or disturbed
are stereotypically viewed as unpredictable, dangerous to themselves or others, unable to engage in self-care,
and likely to behave in bizarre ways. These stereotypes cause others, even mental hospital staff, to treat
patients as though they where irresponsible children. Mental patients hear jokes about creasy people, are
reminded of their past failures activities (leaving the hospital grounds without permission, using showers or a
razor without staff present, making private phone calls, driving a car, returning to work, voting, seeing family
or friends at will, etc.). One consequence of differential treatment, then, is blocked access to normal
activities. Differential treatment also leads to association with similar deviants. In hospitals or treatment
centers, patients spend more time in the company of other mental patients than nonpatients. This in turn

1
allows socialization into the mental patient’s subculture; one a learns deviant worldview, or a deviant set of
values, which reinforces adopting a simple life within the safe, protective walls, windows, doors, of the
hospital. In short people who are labeled as deviant and treated as deviant become deviant. Mental illness
become issue around which one’s identity and life become organized – a “deviant career”.

The treatment implications of labeling theory are quite different from those of stress and structural
strain approaches. Potential ways to reduce or prevent mental illness include

• Changing social convention that define “normal “thoughts, feeling, and behaviors;

• Attacking widely held misperceptions of the mentally ill;

• Avoiding the formal diagnosis and hospitalization of individuals for aberrant behavior;

• Reducing the length of stay of hospitalized individuals to prevent them from acquiring a deviant
identity.

Conclusions

No one approach of mental illness – biological, psychological, or sociological- can completely explain its
origins. For example, even if deficits of certain neurotransmitters in the brain were shown to be directly
responsible for major depression (a biological explanation), the onset of depressive episode is probably due
to multiple factors operating simultaneously: a person’s gender, age, social class, number of current stressful
experiences, past unresolved psychological conflicts, and perhaps a lack of social support Each broad
theoretical approach to mental illness tends to focus on only certain kinds of causes (biological,
psychological, or sociological ones) and thus each approach inadvertently de- emphasizes the importance of
other cause. Also socials causes are the most likely to be ignored or neglected in the field of mental health.
Mental illness is not randomly distributed in the population, but is social patterned. Patients in treatment are
not a random set of individuals, but once again are socially patterned. Effective treatments, excellent
hospitals, and beneficial community services are not equally available, but yet again are socially patterned.
Grasping the impact of these social inequalities in the experience in mental disorder, in the quest for
treatment, and in the availability of mental health services is crucial for a well-rounded understanding of the
causes and consequences of mental disorder.

1
 American models

In this year, when I am staying in US, I have had opportunity to meet a lot of people, professionals,
who are working in mental health field, and also the consumers of mental healthcare services. Also I had
possibility to make sites visits where I have met models of community mental healthcare services. I was
impressing, and I was learning a lot about what I have to do in the future.

I visited Green Door, and Woodly House in Washington DC, Fountain House, Venture House, and
International Clubhouses Center for Development, in New York.

The “Clubhouse” is a community model, which has experienced a rapid growth over the past decade
that helps, educate and training men and women with a mental illness to work and to live independently. This
model was conceived as an intentional therapeutic community composed both of people who have a serious
mental illness and generalist staff who work within the Clubhouse. People/consumers who are part of this
community program are called members, not patients, consumers, or clients.

Membership can be anyone with a history of sever mental illness, with the diagnostic have been given
by psychiatrist, and unless that the person poses a significant and current threat to general safety of the
clubhouse community. Membership is for life so members have all the time they need to secure their new life
in the community.

Also membership can be voluntary and without time limits. The highest quality of care and
information are available to consumers and families, regardless of their race, gender, ethnicity, language, age,
or place of residence. The program promote rights of membership, including choice in type of work activities
and whether to work at all, choice the way that they use the clubhouses and in the selection of staff worker
with whom they want work.

There are not agreements, schedules, contacts or rules to impose participation off members. They
have equal access to every clubhouse activities or opportunity without differentiation by gender, age, raise or
based on diagnosis or level of functioning. They have accesses to all personal records kept by the Clubhouse,
and at their choice are involved in the writing of all records reflecting their participation in the activities of
clubhouse. These records are to be signed by both member and staff. Members have right to re-entry into the
clubhouse after any length of absence, unless their return poses a threat to the clubhouse community.

However, rights of membership are balanced by member responsibilities without differentiation

1
between consumers and staff workers. Members are expected to run their Clubhouses by taking on essential
tasks. When clubhouse is doing well, credit must be given to the membership upon whom the Clubhouse is
dependent for its survival. Reversing the typical provider-recipient role in mental health services, a
Clubhouse sends a clear message to its members that they are capable, competent, and needed. Work, both as
a volunteer service, a Clubhouse and as paid employment outside the Clubhouse, is the focus of every
Clubhouse.

Because recovery is the common goal, recognized outcome of mental health services, the stigma
surrounding mental illnesses is reduced, reinforcing the hope of recovery for every individual with mental
illness. They provide an effective reach out system to clients who are not attending, becoming isolated in
community or hospitalized.

Also a clubhouse is considered to be a place where people with mental disorders come to rebuild their
life. They learn to work together, to have trusted each other’s, to encourage, supporting and finding the hope.
Every opportunity provided is the result of the efforts of the members and small staff, who work side by side,
in a unique partnership. One of the most important steps members take to receive ward greater independence
is Traditional Employment, where they work in the community at real jobs.

Members also find help in securing housing, advancing their education, training, obtaining good
psychiatric and medical care and maintaining government benefits.

The Clubhouse proposes a lot of services for their members who built hope that plays an integral role
in an individual’s recovery. The basic services offered by every clubhouse is the club itself, a place where
people who are disabled by serious mental illness can go to spend time and take part in meaningful activities.

Also each Clubhouse promote: supported education, community based employment, work oriented
day program, supporting housing, community support services, advocacy, crisis assistance, transportation
assistance, assistance with entitlements and so on.

Clubhouses like Green Door develop new program, which help members who have to continue the
psychiatric treatment like Daily Services.

Woodly House promotes more houses in community for group and also individual.

Fountain House has a farm where members work together and produce food.

1
 The International Center for Clubhouse Development works to develop clubhouse programs
throughout the world. It is an international human rights effort working to disperse stigma and the injustices
associated with mental health. The mission for the ICCD is” a global network creating opportunities for
people living with mental illness to be respected members of society”. The vision is “to lead a strong
worldwide alliance of club house community programs”. They are concern to the “ “conviction that recovery
from mental illness is possible when it involves the individual in a community that offers hope, respect, and
opportunities for work, a good home, education and friendship. Also ICCD is the coordinating center for
clubhouse training, education, technical assistance, quality assurance and information exchange.

Overall, Clubhouse promotes a lot of services where people who are disabled by serious mental
illness can go to spend time. All of these services and functions are regulate in Standards for Clubhouse
Programs.

The core support services for any clubhouse are the Work-Ordered Day, Transitional Employment,
and Independent Employment.

During the Work-Ordered-Day, members work side by side with the staff and other members on joint
tasks within their clubhouse “work unit”. Tasks include clerical work, food preparation, building
maintenance, and intake of new members, attendance recording, and telephone answering. Also carried
responsibilities for coverage, of employee absences and job training in Transitional Employment,
administrative tasks, and accounting.

Transitional Employment Programs (TEPs). TEPs are not segregated, mainstream jobs in community
businesses paying at least minimum wage, which are reserved for clubhouse members through agreements
with employers. The clubhouse assumes full responsibility for hiring and training members to work each job.
If employees are unable to go to work, than members and staff from this unit have to cover the absence. TEP
is intended to be preparation for independent employment and each job is time limited to about six months
per member The member who finish one job can continue another job.

Supported Employment. The clubhouse encourages and helps members get and keep competitive job.
Also the clubhouse kept records of the number of members employed competitively, job information and/or
earnings from members’ employment.

Recently only ICCD has initiated services research studies and, to date has published only descriptive
studies of clubhouse effectiveness

1
 The clubhouse model has experienced a rapid growth over the past decade.

Till now, the networks of ICCD are more than 400 clubhouse programs operating in 29 countries
around the world. 150 clubhouses have substantial compliance with the Standards for Clubhouse Programs
and are certified (accredited) by the ICCD

All of these prove that clubhouse model is more acceptable by consumers and better integrated in
community. Active participation in a clubhouse reduces hospitalizations for people with mental illness by as
much as 48% (Wilkinson, 1992). Also regarding cost effectiveness, clubhouse model reduced significantly
costs associated with member’s hospitalization (Wilkinson, 1992) and clubhouses have lower direct and
indirect costs as compared with another popular community mental health service model (MA, EIDP 2001).

The Romanian experience

“OPEN HOSPITAL” model

Situated in the heart of Upper Moldavia – Bucovina, Campulung Moldovenesc is an extremely

picturesque place at the foot of the legendary Rarau Mountain. It lies at 530 km from Bucharest, the capital
of Romania and is also situated on the main railway line and highway that connect Moldavia with
Transylvania and Maramures, other two big and important regions of Romania. Campulung is about 79 km
from Suceava, the capital of the Suceava County. The main railway line Iasi – Cluj – Timisoara as well as the
national highway 17 (E 571) goes right. Owing to its geographical position, which is extremely favourable,
the town is also a starting point for many touristic routes in Bucovina, especially for the visiting famous
medieval monasteries ranked in the UNESCO patrimony Humor, Voronet (painted in its famous “blue of
Voronet”), Vatra Moldovitei, Sucevita and Putna. These historic monuments are valued as unique in the
world, the exterior fresco of the monasteries constitute outstanding worldwide tourist attraction. In the center
of the town the tourists can visit the Museum of Wood Carving and the collection of Wooden Spoons –
professor Ioan Tugui, unique in Europe, regarding the exhibits and arrangement conception. Nature has been
extremely generous with this legendary land, so the tourist stopping here can choose from a wide range of
natural and anthrop tourist sites, most of the former constituting geological, forestry, botanical and mixed
parks. All of these are located in exceptional natural scenery, in a mountainous irregular area, the relief
offering a fascinating landscape, moving on from the sweet curvatures of the domes to massive massifs, such

1
as Giumalau, or steep peaks, laced with limestone adornments, such as those of the massif Rarau. The land is
mostly covered with evergreen and leafy tree woods, streaked with swift streams.

Documents first mention Campulung Moldovenesc (Moldavian Longfield) in the time of Prince

Alexander the Kind on 14th April 1411. During the Middle Age the place that took its name from the long
shuttle like valley along the Moldova River, was the center of the ward of Campulung, which included 15
villages on the valley of the Moldova, the Bistrita and the Dorna rivers. In 1716 Dimitrie Cantemir wrote in
his “Descriptio Moldaviae” that the inhabitants of this country organized themselves in a kind of independent
republic and refused to take orders from any local boyar. The Peace of Kuciuc-Kainargi in 1774 decided that
Upper Moldavia should be annexed to Austro-Hungarian Empire. As an immediate result German and

Slavonic colonization followed. A town let in 1794 and acknowledged as a town at the beginning of the 19 th
century, Campulung Moldovenesc knew a steady economical, social and a cultural development, and its
population increased. In 1923 the town becomes the residence of the Campulung Bucovina district. In 1995
Campulung Molodovenesc becomes a municipium (municipal town) with over 20,000 inhabitants.

As result of its historical evolution the Campulung land has a multicultural and diversified character
emphasized by the large number of ethnic groups living harmoniously alongside with Romanians: Poles,
Hutsuls, Hebrews, Germans, Rutens, Armenians, Russians, Gypsies and Ukrainians. The cultures and
mentalities of the inhabitants form a real mosaic. Because of both its large number of ethnic groups and
location in mountainous area the population is organized in small rural communities, a big village having
under its administration more small villages located in environs. Often the communication amongst the
villages is poor enough, some of villages being isolated especially during the wintertime. At the same time
the roads are not so good. Sometimes the only way of communication is the phone-line. It is electricity but no
gas. The Campulung Moldovenesc town has a small local radio station named Radio Nord, working in co-
operation with BBC, set up on August 2003 and has not local TV station

By the contributions and donations of the Romanian Orthodox Church Fund from Bucovina,
mayoralties and people from Campulung Moldovenesc, Vatra Dornei and a large number of villages from the
environs in 1885 was started the construction of the Town Hospital in Campulung Moldovenesc. The
building was finished in 1889. The hospital started to work with 40 beds distributed on two sections, internal
and surgery. Till 1983 the hospital develops by raising of new outbuildings, working like General Hospital. In
1983 the medical services are moved in the new building by raising of a bigger and modern hospital with
more than 400 beds. In the old building is organized the Psychiatric Section of the General Hospital with 70

1
beds. The Section of Psychiatry represented a new medical service, working for a large geographical area,
including also the towns Vatra Dornei and Gura Humorului (both of them around 40 km far from Campulung
Moldovenesc) and their distributed rural area (approximately 300,000 inhabitants) with different problems,
sometimes incompatible.

Since July 1st 1999 has become a self-standing hospital based on the Health Ministry Ordinance
no.447/June 28, 1999. This separation moment, 1999, represents an important step in the reform of the
psychiatric services’ quality from this area. The causes that have determined this separation are well-known,
functioning also at the national level: the great distance between services, dysfunctions in the supply with
medication and food distribution, lack of funds for current repairs, impossibility to employ qualified
personnel (e.g. psychologist, ergo-therapist) but only disciplinary transfers from other units,
misunderstandings concerning the need for psychiatric assistance services diversification (e.g. psychotherapy,
ergo-therapy), the permanent tendency of the leadership to view this unit as a unit of socially assisted
persons, old persons or chronically sick persons.

Also the necessity of a modern approach of the psychiatric therapy and a specific management were
essential to obtain the autonomy.

Since 1999 the hospital functions with 80 beds divided into 2 units (males and females) and has in its
structure a 20 places day service, a mental health laboratory, night duty provided by the hospital
psychiatrists and by other doctors from the territory, a sports room where psychotherapy activities take place
(group psychotherapy, AA meetings, melotherapy and relaxation), workshops of ergo-therapy (tailoring,
painting, ceramics, weaving, knitting, carpentry), own reception and statistics service, pharmacy, laundry
and kitchen.

Also, since 1999 it was possible the change of the medium level sanitary and auxiliary personnel
(over 50%) and completion of personnel for adequate and qualified alternative activities. The whole
personnel enrolled in computer training since the hospital has now a computer network for key services
(hospitalizations, statistics, account, psychiatrist, psychologist, pharmacist) which eases our work (presently
we work with less than 50% of the personnel according to the norms prescribed by the Health Ministry) and
enabled Internet connection, facilitating in such a way communication by sending and receiving information,
as well as direct participation at auctions for acquisition of medication, sanitary materials and supply. Also,
we are in preparation of a site (www.anton.ro) that will present our accomplishments and needs, but
especially in order to share our experience with others and to learn from others.

1
 The evolution of the specialized personnel:

Medical Assistants Auxiliary Psychologist Priest Ergo-

doctors personnel therapy
instructor

1993 1 10 14

1994- 2 7 13
1995

1996- 2 11 14
1997

1998- 2 11 13 1
1999

2000- 2 14 14 1+1 social 1 1

2001 assist.

2002- 2+1NPI 16 16 2+social 1 2

2003 assist.

Starting from 1998, a chapel has been arranged inside the hospital and the religions service and ritual-
therapeutic activities are provided by a priest who, since 1999 is employed by the hospital. Because we are
placed in an area of profound religious reverberations, this chapel and the religious service provided have
had a special positive impact on the community, allowing us to open more the gates toward the community.
Presently, at religious ceremonies, besides the patients participate more and more persons from outside the
hospital, fact that leads to a direct contact with the community, to a transparence of the psychiatric
activities from the hospital and to a change (in time) of the community’s mentality toward the psychiatric
hospital and the personnel that works here, toward the person with psychological disabilities and toward
the psychological illness.

If we analyze the situation of the hospitalizations from the last 10 years, we can notice a rise from

1
1284 in 1994 to 2441 in 2003 and also a rise in the number of days spent in hospital from 23.656 to 31.145.
The number of outpatient visits in the territory has risen from 2151 (1994) to 13129.

Year Hospitalisations Days of Outpatient

hospitalisation visits

1994 1284 23 656

1995 1327 22 820

1996 1339 21 961

1997 1429 21 986

1998 1401 22 418

1999 1610 21 833 905

2000 1817 25 587 4020

2001 2444 31 684 2237

2002 2376 35 463 7768

2003 2441 31 145 13129

The Budget of the Psychiatric Hospital from Câmpulung Moldovenesc during 1999 (2nd
semester) – 2003 is presented as it follows:

1
 Total Total costs Personnel Material Medical and Capital
incomes out of costs costs, out sanitary costs
which: of which: materials
costs

1999 1 256 623 1 256 623 524 545 732 078 310 119

2000 3 787 000 3 787 000 2 001 391 1 536 638 616 896 248 971

2001 7 313 162 7 313 162 2 932 256 2 335 616 532 107 2 045 290

2002 8 284 051 8 284 051 3 937 545 3 318 811 1 135 169 1 027 695

2003 9 875 050 9 875 050 5 018 703 4 648 556 1 474 089 207 791

2004 8 644 261 8 644 261 5 374 800 3 269 461 707 914

We mention that during 1999-2004 the national health program 40.13 was in development.

The average hospitalization period dropped from 18,4 days to 12,7. This drop in the hospitalization
period was and is possible (harder and harder, though), firstly due to the use of modern psychiatric
medication in sufficient doses and minimum side effects and training of the patient in other activities and
alternative therapies.

Generally, we aim at shortening as quickly as possible the psychiatric episode and continuing the treatment in
the day-service, then in the mental health laboratory, starting from the premise that persons with
psychological disorders can be more efficiently helped if they are maintained in connection with their family,
friends, colleagues and if the curative measures are associated with prevention and rehabilitation measures.

We gave a special importance to the interpersonal relationships starting from the principle that
beyond cloth, bathrobe and pajamas there is a person with his/her needs, worries, imperfections and beliefs.
We learned together that the mutual esteem and respect, the feeling of being useful and the responsibility can
have a therapeutic effect; that the feeling of freedom of movement and expression are more benefic than

1
isolation, closed doors and windows. Thus, the patient became not only ‘object’ of therapy, but also
‘instrument’ in other people who were suffering therapy, integrating himself gradually with well-defined
roles and responsibilities in the therapeutic team.

Unfortunately, regarding the outpatient service activity, the great number of visits, but especially the
lack of qualified personnel, changed this service into a follow-up assistance only concerning prescription of
medication. Moreover, there weren’t yet in our territory, mental health assistance services that could take
over the person with mental disabilities, offer her/him new life alternatives, guide him/her, accompany
her/him, support her/him, encourage her/him in her/his efforts to come back to a normal life preventing thus
relapses. The lack of such community mental assistance services, the discontinuous treatment connected with
the high costs of psychiatric medication, inconsistent programs, the lack of understanding and
communication with the family, but especially the stigma, isolation tendency, marginalisation and rejection,
wrong conceptions and attitudes of the community towards the person with psychological disability make
these persons unable to find their place in the community, favoring relapses and chronicization of the illness
and long hospitalization. Or, especially this chronicization of the illness leads to unexpected negative
attitudes and behaviors of the patient aimed firstly toward himself, determining suicide, or toward the family
and the community. In time, this chronicization and complication of the illness has an impact on the familial,
social, economic and political pan, with much higher and harder to bear costs for a country in transition.

That’s why, as much as we would try to make the conditions and the treatment in a psychiatric
hospital better, all is futile, if the family, the community and the society do not get involved more in
creating and developing these community mental assistance services

Thus, it appeared necessary the establishment and extending of a nongovernmental mental health
organizations network in order to facilitate promotion of democratic and civil society values. In particular,
the network aims at developing organizations that work for the reform in the mental health field and
inclusion in this activity of the recipients, that traditionally have been excluded from decision-taking that
regard them directly, as well as the initiation of moving the weight center from basic care institutions,
psychiatric hospitals basically, toward community institutions. In western Europe this change has occurred in
the ‘70s under the pressure of the civil societies, which fought for respecting the human rights for persons
with mental disabilities, for regaining the society respect and offering of a chance for social reintegration. In
Central and Eastern European countries, this change will be able to take place after the community will
modify its mentality, becoming aware of the active role that it should take in decision making processes that
regard it or have an impact on it.

In 1995, during the difficult period of the relationships between the psychiatric unit and the District

1
Hospital there was an opportunity for some of the personnel of the psychiatric unit together with the patient,
families and community officials to establish a nongovernmental organization which, from outside the health
system, could fight for their rights.

Now, after 10 years of activity, it is interesting to notice the symbiosis that has been created between
the governmental psychiatric hospital, suffocated by a bureaucratic legal system and this NGO
organization, which, from outside, managed to permanently cut short this bureaucracy enabling some of the
above mentioned achievements. For instance, when the hospital couldn’t buy an object (TV, automatic
laundry machine) because it’s value was over a certain amount that would require needs reports that should
receive approvals, solicitations and a lot of waiting, the Foundation came in buying the object for the hospital
to use.

ORIZONTURI FUNDATION

The “Horizons” Foundation is a charitable organization, with a nongovernmental, apolitical and

spiritual character that activates in the mental health field since 1995.

The mission of the organization is to support the recipients of mental health services to regain trust in
their own powers, to develop abilities and skills that will enable them to lead an independent life and to
educate and sensitize the community in the sense of raising the level of understanding and acceptance of
persons with mental health problems.

The purpose of “Horizons” Foundation is to inform and educate persons with mental health problems
about their problems and to change the society’s mentality regarding the concept of mental illness.

The objectives of “Horizons” Foundation are:

• To inform and educate persons with mental health problems about the health problems they are
dealing with;

• To develop permanent occupational therapy and ergo-therapy activities for the recipients of the
mental health services;

• To educate the community in the sense of raising the level of understanding and tolerance for persons
with mental health problems.

1
 The activities of the “Horizons” Foundation are based on voluntary services performed by its members and
other people who understand the organization’s mission and wish to support its development.

The persons who benefit from the organization’s activities are recipients and ex-recipients of psychiatric
services.

The past and current activity of the organization:

• Publishing since 1995 of the first quarterly magazine (currently 3 times a year) from Romania made
entirely by the beneficiaries, the magazine “A FI – TO BE” with an informative, instructive and
cultural character, conceived to facilitate the beneficiaries-society relationship; it helps making the
community aware of the problems faced by the persons with mental disabilities. The magazine was

the 1st activity that allowed the beneficiaries to get involved into something important. Exclusively
the beneficiaries do the choice of materials and typing. The magazine is their “voice” by which they
can share with the others experiences from their life, the problems and the talent being a way to put
down on paper all the best they have. Through writing they feel strong, useful and respectable,
managing to attract the attention of the local community and not only.

• Establishing some workshops for the occupational therapy and ergo-therapy activities (traditional
sowing, carpets weaving, painting on wood and canvas, pottery, tailoring) for the members of the
organization, persons with mental health problems.

• Establishing a firm, whose only associate is the “Horizons” Foundation, and through which the
organization can commercialize the products of the work-shops for occupational therapy and ergo-
therapy for the purpose of self-financing.

• Organizing weekly meetings for the members of the organization wherein current social problems
and personal problems are discussed.

• Organizing meetings with the persons who use for the first time the psychiatric services in order to
offer them information about the role and activities of the organization.

• Club activities and monthly anniversary of every person’s birthday.

• Experience exchange with Romanian and foreign nongovernmental organizations that work in the
same field of activity.

1
 • Participation since 1995 to all Regional Workshops organized by the Hamlet Trust – London for
organizations that work in the mental health field from Central and Eastern European countries.

• Participation at the seminary “New ways of life” organized by the Hamlet Trust in Hungary (May,
1997) and Slovenia (May, 1998).

• Participation at the seminary “Organizational development in Romania” organized by the Hamlet

Trust together with the Romanian League for Mental Health (May, June, August, October, 1998).

• Participation at the seminary “Organizational development in Romania” organized by the Hamlet

Trust together with the Romanian League for Mental Health (September, November, 2000).

• Participation at the seminary “Training and trainers” organized by the Hamlet Trust and the
Romanian League for Mental Health (May, September, 2001).

• Organizing the 1st National Conference of the Persons with Mental Health Problems (June 1996)
together with the Hamlet Trust – London in Câmpulung Moldovenesc.

• Organizing the seminary “New ways of life” for organizations form Romania (October 1997) together
with the Hamlet Trust – London in Câmpulung Moldovenesc.

• Running the program “Roads towards politics in mental health” in partnership with the Hamlet
Trust – London, starting January 2003 for 2 years.

The beneficiaries have been and are involved in planning, implementing, monitoring and developing
different projects (pottery, painting, tailoring). Their points of view are respected and used in developing
those projects.

The beneficiaries are responsible for organizing current activities.

Taking in account the good co-operation over almost ten years Hamlet Trust decided to work in
partnership with Orizonturi Foundation on the “Pathways to Policy” Programme. The official launch of the
programme in Romania, at Campulung Moldovenesc, was held on 8-10 April 2003 period. On 8 and 9 April
was held in the conference room of the Hotel „Zimbru” the training „Pathways to policy”. The training
offered to the 25 participants, persons from different fields of activity and users of mental health services the
opportunity to be part of the participatory planning of the future activities and events of policy in mental
health and drew the Local Policy Forum. The activity started from the premise that the policy is something in

1
which all interested parts, including the users of mental health services, can participate and it is not only the
prerogative of the government and bureaucrats. On 10 April, in the same room, was held the Open Forum
with a large participation, approximately 80 people, among them careers, families and friends of persons with
mental health problems, the mayor and vice-mayor, town councilors, managers of banks, institutions and
private firms, and representatives of local and county press. The result of joint work and co-operation
trainers-participants materialized in the setting out of the role and the activities of the forum, the
identification of the five local policy issues in mental health:

1. The change of the mentality so that to avoid the stigma about the persons with mental health
problems;

2. The lack of education and information;

3. The lack of the alternatives (community services);

4. The lack of the involvement of the local institutions and of the cooperation among them;

5. The lack of financial, material and human resources (psychologists, therapists, social workers).

The Psychiatry Hospital from Campulung Moldovenesc is working for a big area preponderantly rural
with lack of information about mental health problems, poor communication, transport difficulties on the
roads and the lack of the ambulance service within the hospital. In consequences the rural population has
not immediate access to the hospital sometimes not only the persons having a crisis are able to get to the
hospital in due time. The frequent problems that the people living in the rural area are confronting with are
the specific problems for this kind of area, the alcoholism, family violence and especially the violence
against the women, isolation and loneliness, stigma about mental health problems.

Regarding the last activity, the program “Pathway to policy”, the “Orizonturi” Foundation (OF)
assumed the role of disseminating the new politics ideas in mental health in the population, so that the
population, being informed, can exert organized pressure on the authorities in order to make real changes in
the mental health field, changes that are requested by the EU, because the hospitals and centralized
institutions are no longer acceptable. The authorities, like in many other fields, report some progress, but the
situation is unchanged actually.

The program, “Pathway to policy” is run in partnership with the Hamlet Trust from London and
contributes to the development of alternative politics in order to improve services in mental health. The
program runs in 5 countries from Central and Eastern Europe (Armenia, Bosnia, Estonia, Kyrgyzstan and
Romania).

1
 In this program, the Hamlet Trust and the partner organizations have a common vision according to
which:

• The beneficiaries of mental health service and the community organizations that work in the field of
mental health create effective long term partnerships with the state, the civil society and businessmen;

• The experience and knowledge of the beneficiaries of the mental health services are respected and
contribute to creating better politics in mental health at the local and national level;

• Politics are part of a continuous learning and development process for all parts involved.

The purpose of the program is to support the beneficiaries and their organizations to work together with
motivated or interested persons to work in the mental health field such that they’ll have a great influence on
politics, practices and procedures in mental health at the local level.

Among the persons motivated and interested to work in the mental health field we count specialists like
psychiatrists, psychologists, social assistants, medical assistants, families and close relatives of the
psychiatric services beneficiaries, politicians, bureaucrats and persons who work in the administrative field
or media, local businessmen.

The program has 4 clear objectives:

1). To create and support a local politics forum that will enable the beneficiaries, the nongovernmental
organizations and the motivated persons to meet and work together regularly in order to develop strategies
and influence politics in mental health;

2). To support local actions that come up through the forum in order to influence politics;

3). To share and develop working knowledge and skills in the field of local politics;

4). To improve the image of the beneficiaries of mental health services as active persons at the political
level through the media.

The program will allow the beneficiaries of mental health services and their organizations to meet and work
with interested persons, including the local administration, enterprises and media through workshops, study
visits, forums and other means.

In the program there will be organized campaigns that will influence at the local level the identified mental
problems, a positive image of the persons with mental health problems will be promoted through the
media, informative bulletins, brochures and good practice guides based on what is learned in this program
will be edited, there will be an attempt to influence the national politics debates through forums involving
the beneficiaries.

The program are running for a 2 year period, 2003-2004, each year are organized forums of local politics.
The mental health issue in rural area, is another subject proposed to Romania, and especially to our

1
 organization, by the initiators of the program.

If the long-term result of this program that the beneficiaries and their organizations influence the local level
mental health politics, the immediate results (till the end of the year 2004) expected are:

• The beneficiaries and their organizations to form new, profound and viable relations with the
motivated persons (public administration and media_;

• The local action initiated by the forums to have a stronger voice in mental health (campaigns, lobby,
public relations);

• The profile of the beneficiaries as active participants in the political process to be better outlined (e.g.
media).

The activities and actions were organized and initiate in according with the five local policy issues
emerging from PW and OF:

1. The change of the mentality so that to avoid the stigma and marginalization;

2. The lack of education and information;

3. The lack of the alternatives (community services);

4. The lack of the involvement of the local institutions and of the cooperation among them;

5. The lack of financial, material and human resources (psychologists, therapists, social workers).

All the members of the forum agreed that the change of the mentality about the mental illness and
the lack of education and information interferes each other. That is why they decided these are the first
issues that the forum has to discuss and to plan actions in order to start the education, information and change
mentality process.

Thinking at the ways of solving these problems the forum has decided that first of all, it needs to find
out how the different people think about the mental illness and persons with mental health problems. Getting
answers at the following questions:

• Who has to do it: NGOs, professionals, representatives of civil society, the school, the church, the
town hall, the users and their families (because they know very well the problems), mass media and a
group coming from forum;

• How: information, education, involvement, reports in mass media, leaflets, questionnaires,

1
 communication, radio station, workshops, round tables, counseling centre and adequate themes at
educational classes;

• Where: schools, hospitals, consulting rooms, big and small collectivities (factories, different
institutions, private firms) church, public places;

• How long time: the same answer = permanently.

The forum decided to start the action “Questionnaire” the participants taking responsibilities and
establishing very clear deadlines regarding the elaboration of the questionnaire, the distribution of it and
analysis and making conclusions.

The questionnaire was distributed much more in high schools. All the members agreed that the young people
can disseminate the information and could be the best promoters of a new mentality. That’s why, as we
observed analyzing the questionnaires from OF too, it is very well to involve as more as possible the young
people in our actions and activities.

340 persons with very different ages and education as well as from different backgrounds (factories,
education, police, health, local administration and business firms) filled the questionnaire. The questionnaire
was distributed also on the street (43 questionnaires). Most of questionnaires were distributed in Campulung
Moldovenesc but we also distributed questionnaires in rural area (Sadova, a village in the neighborhood of
the town).

As it follows I will present the 7 questions of the questionnaire, together with the answering possibilities and
the comments, which could help us to know where we are and what we have to do in the future.

1. What do you think “mental health problems” means (mental disorder)?

Nevertheless there were persons, some of them even with higher education, who didn’t answer
(approximately 25%), or gave irrelevant answers (approximately 16,47%), which means a total of 41,47% of
persons who either don’t know or don’t have a clear idea of what “mental health problems means”.

The most frequent answers were: conduct disorders, disorders of the nervous system, emotional instability,
alcohol addiction, medication addiction, inability to adapt to reality.

2. What is your opinion about persons with mental health problems?

I like to keep a distance 40 11,76%

1
 I accept them as normal persons who have some 263 77,35%
problems

They are indiferent to me 37 10,88%

340
Total

3. Who can solve a mental health problem?

The priest 92 17,32%

The psychiatrist 284 53,48%

The psychologist 126 23,72%

Other specialists (bioenergy, acupuncture, presopuncture, yoga) 29 5,46%

531
Total answers

4. If you would suffer from a mental health problem would you easily accept to be seen by a
psychiatrist and, if needed, to be placed in a psychiatric hospital?

Yes. Why? 297 87,35%

No. Why? 43 12,64%

340
Total

Here are the motives of those who wouldn’t accept to be seen by a psychiatrist and especially to be placed in

1
a psychiatric hospital:

• They reject the idea of being placed in the hospital due to the “labeling” from the society, the shame
associated;

• No mentally ill person accepts his/her illness;

• I don’t feel safe in the hospital, I hate hospitals, it means isolation, fear of the hospital

• I would go to the priest I would try other options, less radical.

5. Name five circumstances when a person seeks psychiatric help?

Even if at the first question many either didn’t know what to answer or gave irrelevant answers, at this
question, with few exceptions, there has been given a variety of answers which, practically, cover the large
spectrum of mental health problems.

The most frequently mentioned were the following situations: depressive states, conduct disorders including
violent behavior, stress, excessive nervousness, insomnias, headaches, emotional instability, alcohol, drugs or
medication addiction, visual or hearing hallucinations.

6. How do you perceive the psychiatric hospital?

A place where you can heal from a mental illness 256 75,29%

Aggravates a mental illness 13 3,82%

Like any other hospital 71 20,88%

Total 340

7. Do you believe that a person with mental health problems can be reintegrated in a community?

Yes. Why? 295 86,76%

No. Why? 45 13,23%

1
 340
Total

Most of the questioned persons consider that a person with a mental health problem can reintegrate in the
community. If we refer to those who answered positively we must emphasize the fact that many times their
motives start with the word “if”, meaning that reintegration is conditioned by a couple of things, which
makes us suppose that these persons are not very much convinced that a person with a mental health problem
can reintegrate in the community. Let’s see some of the motives expressed in such a way: if the illness is not
serious, if s/he is a strong, fighting character, if s/he is healed, if s/he is treated by doctors, if s/he doesn’t
disturb the community, if the society is willing to get him/her back if s/he goes in due time to see a doctor, if
there are healing means, if s/he is taking the medication and the problem doesn’t restrict their intellectual
capacity, if s/he goes to periodical checks and takes the medication, if s/he is no danger for those around
her/him, if the illness is under professional control and the person has a normal behavior.

There are persons who are convinced by the possibility of reintegration in the community of the persons
with mental health problems because these express their motives starting with the word “because”: because
s/he is given a chance, because they can heal, recover, because they can raise their self-esteem, because
they can be treated, because s/he is a human being, and human beings should live among human beings and
not isolated, because besides other people they can easier overcome these problems.

There is a third category of persons who simply offer a motive without “ifs” or “because” such as:
with the community help, by treatment, it’s a person like any other, with goodness, understanding and
patience, any illness is treatable with people’s help human resources are great, cooperation and socialization
have benefic effects, I have experimented it, exclusion is not a solution, people change, can discover that it
has aptitudes that can help her/him, once treated it becomes a common person and has the right to reintegrate
in society, must not be abandoned but helped, can be a treatable and transitory disorder, the conditions can be
created for them to be useful.

If we refer to the persons who answer negatively, these offer motives like: they can’t logically
perceive life and society problems, can create problems, is a dangerous person, the society has not enough
place for the healthy, they should have a place of their own, they are not trustful, can affect the whole
community, can’t make it in the community.

“Yes, they can integrate, but it would be hard for them to fight against people’s prejudice!”

1
 What can be more convincing than this affirmation?

After the analysis of the questionnaire the forum members have established a working strategy
focused on the following activities:

• Publication of educational and informative materials (folders distributed directly by mail, brochures in
market places, schools, factories, shops, railway stations, posters);

• Collaboration with professionals from mass media (especially the local newspaper obtaining a column
dedicated to mental health problems and a specific terms dictionary);

• Collaboration with the local radio station for educational broadcasts;

• Organization of meetings with young people from high-schools from the urban and rural environment
with the purpose of educating them about mental health problems;

• Organization of meetings among the beneficiaries of the mental health services and those who do not
suffer from such problems, especially in the rural areas;

• The establishment of a counseling center;

• Training programs for social assistants from the urban and rural environment on identification and
counseling in mental health problems;

• Raising the number of copies of the magazine “To be” and publication of a bulletin on mental health.

As it can be noticed the forum decided to insist on a stringent problem: the mental health problem in
the rural environment, because the population from this area is majority rural, lacks information about mental
health problems, have reduced communication means, difficulties with transportation and lack an ambulance
service belonging to the hospital. As a consequence the rural population does not benefit from immediate
access to the hospital service and sometimes persons in crisis can’t make it to the hospital in due time.

What we can say is that the efforts of the Psychiatric Hospital from Câmpulung Moldovenesc and the
Horizons Foundation, to open the psychiatry towards the community and the awareness of the community,
about the problems of the persons with mental disabilities, are not futile. We still need partners to join in. The
more we are, the easier will be to find “the way” not only towards community mental healthcare, but also

1
towards the kind that will promote public mental health services.

Also, all of these prove that “open hospital model”, consumers organized in NGO and community of
Campulung Moldovenesc have started the changing’s in mental health field, and that they are preparing to
continue it.

But what we would to do for this in the future?

Pathways to Policy programme might continue based on accumulated experience during the first two years.
Many activities ask for being continued to achieve the planned outcomes. The gained experience during these
two years would be very useful for other organizations with the same field of activity and psychiatric
hospitals. The action area of the local forum must be extended gradually to regional and national level.

The forum should continue like a local, regional or national nongovernmental organism. It would be
good to be organized in work groups with regular meetings that to establish the strategies, target groups,
resources, means and responsibilities. These work groups should be specialized on different problems, each
work group being in touch with the target group.

The new programme should include activities based on the accumulated experience that to continue
the work made during the first two years. The training of the members of the forum, the education of the
young generation, the exchange of the experience with other communities and the intensification of the
information actions and the improvement of their quality can be other activities that should be included in the
programme. The acquired experience and knowledge must be shared with mental health NGOs and
psychiatric hospital from other areas (regions).

SWOT Analysis

After 1989, the economic and social reforms in Romania were too slow and the psychiatry care
system is suffering. The big and outdated hospitals with too many beds, insufficient qualified personnel (1
psychiatrist for 20.000 people, 1 psychologist for more than 100.000 people), austere budgets, increasing
admission generated by social causes (poverty, unemployment, social stress, and so on) have contributed to
increasing up the costs and poor quality of mental care services. With not enough quantitative and qualitative
drugs, without an appropriate treatment, lack of preventive programs and permanent support, mental health
care services in community, the number of patients is permanently increasing. They often fall down again and
return to the hospital. Moreover, poor families refuse to bring them back home and they often choose to
abandon them in long-term hospital generating the hospitalization syndrome.

1
 There are also, a lot of community causes which generate this situation: stigma, people’s
misconception and misunderstanding of mental health, and mental illnesses, the absence of mental health
care services in the community, and possibility for recovering, the absence of family collaboration or their
irresponsibility, shortcomings for adequate health insurance, not enough drug treatment, poverty and
inadequate financial support for ambulatory treatment, lack of human rights, or adequate legislation,
difficulty to find a job or housing rehabilitation depriving them of a decent normal life.These mentalities
often generate a lot of consequences: crowded hospitals, increasing costs, unacceptable medical care and
aggravating sickness. The rehabilitation, recovery and social reinsertion process have become difficult or
impossible.

Where should patients find their place? In a poor and hostile society that has a wrong mentality about
mental illness, which stigmatizes and isolates the individual? In a poor family that does not want him because
he is a burden for everybody? Or, in a crowded hospital where there already exists a large number of patients
and where, little money for drugs, food and staff make life and treatment difficult?

Can we speak about recovery or reinsertion?

Where should they go?

The process of rehabilitation and reinsertion of persons with mental illnesses requires changing the
attitudes and behaviors of the community about mental illness. In the same time, the recovery and the
prevention of relapse is possible when not only the individual is involved but also the families and the
community that have to offer them understanding, support, help, hope, respect, and opportunities for work, a
good home, education and friendship. Further we understood that regardless the fact that we have tried to
change something in our hospital, all is useless if the community does not change its mentality about people
with mental illness and does not support their effort to come back to a normal life.

A reform in mental health policy has to with it.

But who has to do it? Where, how and when it has to be done? The professionals, together with the
patients and their families have tried to find realistic and practical solutions.

The SWOT analysis is an important tool of the strategic planning process, which permits us to scan
the internal and external environment, to identify the problems, and find the solutions. The internal factors
can be classified as strengths (S) or weaknesses (W), and those external as opportunities (O) or threats (T).

1
 Moreover, we can design a SWOT matrix, based on these factors, known as a TOWS Matrix, which
can help us to develop strategies.

These strategies can be classified as:

• S-O strategies pursue opportunities are a good fit to the companies strengths.

• W-O strategies overcome weaknesses to pursue opportunities.

• S-T strategies identify ways that the firm can use its strengths to reduce its vulnerability to external
threats.

• W-T strategies establish a defensive plan to prevent the firm’s weaknesses from making it highly
susceptible to external threats.

For mental healthcare services situation, in Campulung Moldovenesc, the SWOT analysis is shown
below:

EXTERNAL ANALYSIS

Threats

Socio-economic

• Transition period

• Unprivileged area

• Austere budgets

• Low income

• High unemployment

• Revenue collection limits

• Corruption

1
 • Stigma

• Lack of civil society

Political

• Lack of legislation

• Lack of interest in mental health field

• High government turnover (Ministry of Health in special)

Health

• Deteriorating indicators

• Lack of professionals (psychiatrists, psychologists, social workers, occupational therapists)

• Rejection of relatively new professions such as psychotherapist

• Lack of efficient network in MH

• Lack of epidemiological surveillance

• Lack of coherent strategies in MH

• High costs for mental illness drugs

• Limited access for people with MH disorders who live in rural area

• Limited health resources

• A bureaucratic insurance system

• No standards for accreditation and quality

Low level of Education in:

• Community education

1
 • Professional education

• Availability/sharing information

• Knowledge of human rights

Opportunities

Social-economic

• More community mental care services

• Investment/Privatization

• MH in primary care

• Decentralization

• Social protection services

• Integration of mental health services

• Potential income increases

• Potential job increases

• More implication of NGO’s in MH

Political

• A better MH legislation

• A legislative framework for community mental healthcare services

• New strategies in MH

1
Health

• Change within the insurance system based on competitive criteria

• Improved surveillance in MH

• Access to all consumers

• National programs for support of drugs treatment

• Clear definition and criteria for accreditation and quality in MH services

Education

• Developing info networks

• Increasing advocacy skills

• Increasing personal and community awareness

INTERNAL ANALYSIS

Weaknesses

Communication

• Lack of cooperation between institutions

Culture, religion and tradition

• Post-communist mentality

- Fatalism

• No personal responsibility

• Stigmas

1
Strengths

• Willingness of the community to cooperate

• Family support

• Trust in “open hospital” model

• Outcomes of “Orizonturi” NGO

• The consumers’, families’, and professionals’ desire to be involved in managing change.

There are many ways to approach policy: individual advocacy, group advocacy, lobbing for the local and
national agendas and media, organizational development,

These will build stronger and more effective organizations, will enhance and develop civil society and will
increase its role in the community.

SOLUTIONS
1. Development of community healthcare services

2. Improved quality of hospital care services (Hospital Pilot)

3. Creating a center for education, training and surveillance in MH (Community Center for
Developing, Integration, and Surveillance in Mental Health)

1. Development of community health care services is a priority, which reinforces the hope for recovery
for every individual with mental illness. These new healthcare services must focus on increasing consumer’s
ability to successfully cope with life’s challenges, to live, work, learn and fully participate in their community
in facilitating recovery, and in building resilience, not just in managing symptoms. These services and
treatments must be also consumers and families centered and have to offer the consumers, alternatives
therapies and possibilities to choose treatments and providers option and not only oriented to the
requirements of bureaucracy.

In partnership with their health care providers, consumers and families will play an important role in

1
managing funding for their services treatments, housing and support. Gradually placing financial support
under the management of consumers and their families will enhance their choices and responsibilities. By
allowing funding to follow consumers, incentives and creativity will shift toward the system of learning, self-
monitoring, and accountability. This program will give people a vested economic interest in using resources
wisely to obtain and sustain recovery. Consumers also can sustain the system and support the others.

These services have to integrate all the therapies biological (drugs), psychological (psychotherapies) and
socials (sociotherapie). Work is a key component for most people suffering by mental illness and it is also an
important part of recovery.

Community care services can be:

• Community Medical Care Services and

• Community Non Medical Services

Community Medical Care Services are services within community which make the relation between
hospital/unit of psychiatry and community non medical healthcare services At this level, the services are
offered by professionals: psychiatrists, primary care physicians, psychologists, social workers, work
therapists, nurses and so on, for consumer who, first of all, need to continue the therapies focused on
biological and psychological causes and also are treated co-morbidities. The period of participation at this
level is limited by functioning, diagnostic and mental illness evolution. Services such as Daily Services,
Mental Health Laboratory, Home nursing, Mental Health Office, and Center of Crisis in special in rural areas,
are envisaged as the most important and effective services within a community.

Community Non Medical Care services are services that are more connected to the community. At
this level, the general staff together with the consumers, their families and volunteers, provides the services.
The consumers who have some abilities or managerial or educational skills could be part of the staff. Here is
the first place where we could create new jobs for consumers because at this level the treatment is more
focused on social causes for recovery and rehabilitation process.

At this level, there is no time limit for consumes in participating in such services. There are no agreements,
schedule, and contracts or rules intended to enforce participation of members.

Community support activities are centered in the work unit structure of the Community non -medical
healthcare services. They include helping with entitlements, housing and advocacy, as well as assistance, in
finding an appropriate medical, and psychological, and pharmacological services in the communities.

1
 Community non-medical healthcare services are formed by a diversity of services that could offer a
lot of opportunities for consumers needs in the recovery process.

These types of services could be like clubhouse model, or protected housing, or employment services
in community, consulting and advocacy services, or social enterprises.

Social enterprises are a possible alternative in mental health policy.

The social enterprises or a social company is a new concept for the Eastern and Central Europe. If the
social enterprises work almost in each city in Western Europe, no one real social enterprise is set up in
Eastern Europe. The social enterprise comes to solve two problems, which the people with mental health
illness confront with. On the one hand, it is about their social reintegration, their image in the community by
giving them the chance to develop new skills, gain confidence in their own forces, and challenge stigma. On
the other hand, it is about providing consumers opportunities for employment and to earning an income,
“building better lives” on their own. The social enterprise covers the two most important areas of life: the
social and the financial area, changing the environment so as to become a profitable and self-sustainable one.

According to the SWOT analysis in Campulung Moldovenesc, there are a lot of opportunities to
create social enterprises.

Few ideas:

The Green House

The Green House of the city is bankrupt, so it can be licensed to consumers who can grow flowers
and make the city more beautiful. The most important contract could be made with public administration and
solves two problems: to decorate the city and to offer social support for people with mental illness. The
impact over the community will be beneficial for the image of people with mental illness in the community
and could contribute to reducing stigma.

The experience of the previous year has proved that consumers enjoy designing pottery. It is also a
profitable activity and a source of income for the consumers and the hospital as well.

Setting up a laundry in the city which is a necessity both for the consumers and the hospital

1
 Farming

Because we are in a rural area the idea of developing new farms could be challenging. There are a lot
of consumers who enjoy farming who have skills for raising cattle and sheep. Hospital may be interested in
contracting goods with farmers.

Tourism.

Our region is a beautiful mountain area where there are a lot of sights and monasteries, recognized
worldwide for their beauty. In general, the consumers fear to travel far away from their town, families and
therapeutic team. Developing tourism programs for people with mental illness and offering them good
condition (housing, support and professional team if necessary) they could overcome their fears and enjoy
their life. They would also have possibility to meet others consumers and share their experience and
encourage each other.

In conclusion creating new mental healthcare services in community:

- Will increase the role and interest of consumers and their families for changing the quality of their lives;

- Will prevent relapse and enforce the recovery and resilience for consumers;

- Will reduce admission and long hospitalization and its costs;

- Will reduce stigma related mental illness, and people with mental disorder;

- Will create new jobs and access to housing opportunities.

- Will create ways to increase income, generating additional revenue for further developing of the system for
others;

2.Increase quality of hospital care services.

We will continue to develop the “open hospital” model, and thus reduce the gap that it exists between
hospital/professionals and consumers, between hospital and community. Quality of services will be a focus
for both professionals and consumers; they will be more involved in these changes. Therefore, it is necessary

1
to facilitate access of consumers and their families to decision-making. Traditional “reform” measures are not
enough to meet the needs and expectations of consumers and families.

Moreover, the hospital has to become by its condition an instrument of treatment where people with
mental illness will find good conditions, drugs, alternatives therapies, but also understanding, help, respect
and compassion. If it is true that people who are “labeled as deviant and treated as deviant become deviant”,
then people (with social, psychological and biological difficulties), who are treated with respect,
responsibility, trust, understanding, and compassion, have a chance to become normal. Their recovery and
resilience will be faster and stigma related to mental illness, hospital of psychiatry, and professionals would
diminish. The hospital of psychiatry has to correct and reinforce the positive traits of the person with mental
illness. Accordingly, more professionals who apply new alternative therapies, and who have a holistic vision
on the individual are needed.

Transforming the hospital of psychiatry in Campulung Moldovenesc and its model of “open hospital”
into a pilot hospital program will support and stimulate these changes, becoming a model for the others.

These professionals cannot be “produce” over night.

There is also a need to integrate all these services –hospital of psychiatry, community healthcare
services- into the community. The community has to be more involved in these services, to support and
sustain them, to adapt their local policy to the needs of consumers and professionals, to create an
environment where well being is promoted for all. In order to turn these ideas into reality we have to change
our mentality, to learn and teach, to receive information about the experiences of the others, and adapt it all to
local conditions. The professionals have to be aware that the change is necessary. This will increase the
quality of their work and will diminish the gap that exists between them the consumers, and the community.
It is necessary to find new alternative therapies that integrate biological, psychological and social being, and
promote mental health in community.

The consumers have to be aware that their role in this change is very important. This is why they have
to learn how they can do it.

The community has to be aware that mental health has social, economical and political implications
and our well-being depends on how the community solves this problem.

Who, what, and how do we have to participate in this process of awareness and integration, and how

1
can we increase the community’s role and support? How can we evaluate the outcomes and make good
decisions to promote mental health, and prevent/diminish mental illnesses?

Community Center for Development, Integration, and Surveillance in

Mental Health

The findings of the SWOT analysis some external threats (deteriorating indicators in mental health,
lack of professionals, lack of efficient network in MH, lack of epidemiological surveillance, lack of
community and professional education, lack of legislation); opportunities: (decentralization, need of
community by mental care services and their legislative frameworks, advocacy skills, increasing community
awareness, developing info networks); strengths (family support, trust in “open hospital” model, outcomes of
program “Pathways to policy”, desire to change for consumers their families and professionals), lead as to
conclude that it is necessary to create a local center. This center has to integrate and develop the mental
healthcare services, to educate the consumers, their families, the professionals and the community, to make
decisions that promote mental health, to support, help, and sustain the recovery process of people with mental
illnesses.

First of all, this center has to be a non-governmental, apolitical and non-profit institution.

The mission of the Community Center for Development, Integration and Surveillance in Mental
Health is to promote mental health in community.

The vision is toward a strong partnership between mental healthcare services, the local community
and the government; to create a flexible and adaptable network, which permits surveillance of mental health
in the community and good decision-making at local and national level; to prevent and diminish mental
disorders by working to dispel stigma and the injustice associated with mental health; to improve the quality
of mental healthcare services by creating opportunities for recovery of people with mental illnesses.

It has to be led by a team of leaders such as lowers, professionals in mental health, public
administration, consumers and their families, NGOs, business, and private citizens.

1
 The functions of the Community Center for Develop, Integration and Surveillance in Mental Health
(CCDISMH) are:

1). To educate professionals, primary care, consumers and their families, volunteers and the civil
society for a better quality of mental health care services, and dispel stigma related to mental illness;

2). To bring and communicate new knowledge about mental health/mental illnesses, and exchange
information;

3). To train professionals, primary care physicians, consumers, and volunteers for new alternative
therapies, or people who are going to work in community healthcare services (e.g. home nursing social
enterprise, clubhouse, advocacy, management);

4). To integrate mental healthcare services (hospital of psychiatry, community mental healthcare
services, social services): mental health within general health, and mental health within the community

5). To survey mental health/mental illness in community by creating a network for mental health,
by providing information for action in response to ever-changing needs in mental health status of the
community. In order to understand and meet those needs, an organized approach to planning, developing,
implementing, and maintaining a surveillance system and network is imperative; surveillance can meet a lot
of objectives, including assessment of public mental health status, priorities, evaluation of programs and
outcomes of mental healthcare services leading to research and design new programs oriented to prevention
of mental illness and promoting mental health in the community. A surveillance system would offer,
flexibility and adaptability to the center. Also, surveillance and a network system can supply data for
estimating the situation of mental health problems within population at risk; to understand the etiology of
mental disorders (biological, psychological or social causes) and addressing therapies to the individuals, their
families and the community as well; to document the distribution, find group risk, and spread of a mental
illness associated to alcoholism, drugs dependence, depression, deviants behaviors in order to design
appropriate educational and prevention programs; to detect changes in mental health trends and monitor these
changes; it will help to design new programs and facilitate planning; most important, it will permit direct
control and evaluation of these programs; in conclusion, the local surveillance in MH will be the feed-back of
our local policies in mental health field, of quality of mental healthcare services, and of the community’s
implication.

Objectives of the CCDISMH:

1
 • To reduce the incidence and prevalence of psychiatric disease;

• To reduce the mortality related to psychiatric disease;

• To reduce the other unfavorable consequences of the psychiatric disorders: poor somatic health,
disturbed psychosocial functioning, low social status, family burden;

• To improve the quality of psychiatric services in both the hospital psychiatry and community mental
healthcare services;

• To improve new mental healthcare services and develop mechanisms for surveillance, monitoring and
feedback of the outcomes;

• To change the negative perception of the consumers within the community and to improve their
quality of life;

• To integrate the process of psychiatric care provision into the overall system of health care in the
community;

• To study the causes, consequences and care, related to particular psychiatric disorders;

• To reduce the relapse and trend of long hospitalization sustaining recovery and resilience of
consumers;

• To improve, develop and sustain new alternatives of consumers’ life-style (clubhouses, social
enterprise, micro credits);

• To create a network in mental health and facilitate the exchange of information;

• To educate the community related to mental health and mental illness issues, to increase the
community’s awareness related to it;

Tasks

1. To evaluate the existing mental health activities in the rural area based on a SWOT analysis

2. To identify the population’s mental health care needs;

1
 3. To develop programs for prevention and early interventions in cases of psychosis;

4. To introduce programs for case studies management and psychological and social interventions in the
community;

5. To put in place the organizational basis, the procedures and the regulations for modern psychiatric
service provision;

6. To provide the conditions needed to integrate psychiatric service provision into the in-patient and
outpatient health care services, through integrating a number of psychiatric services into the package
of the primary care physicians in the ambulatory services;

7. To develop a plan for fostering favorable conditions for setting up specialized psychiatric practices
within an easy reach of the population;

8. To develop a plan for setting up day care centres in the specialised group psychiatric practices, the
medical, the diagnostic-consultative centres and the dispensary wards, for people with social
dysfunction;

9. To plan and conduct training/courses with primary care doctors, including specific components,
which would raise their sensitivity toward mental health problems.

10.To plan and conduct training/courses with consumers, their families and volunteers who prove that
they want and can help the others consumers who are in needs;

11.To develop and introduce standards of care for the mentally ill patients in the outpatient primary and
specialised care; to develop the patient’s pathways to care in the outpatient and inpatient services and
to develop new pathways to care, as well as follow-up for the referred cases.

12.To develop a structure for the provision of housing and jobs for consumers within in the community;

13.To develop and implement a legal basis for the rights of the psychiatric patients, as a part of a future
chart for the rights of the patient;.

14.To advocate their interests in front of community and professionals;

15.To facilitates and support the access of consumers to community mental healthcare services.

The stakeholders have to participate at CCDISMH activities. They are consumers and their families;
professionals (psychiatrists, general practitioners, social workers, psychologists, nurses, professionals in
health management), volunteer and so on.

1
 We hope that our projects ( a pilot hospital, new communities mental healthcare services, the
Community Center for developing, integration and Surveillance in Mental Health, a local network for mental
surveillance) would be a good example for others communities, for they may wish to do the same thing.

Step by step, a national mental health network will be creating.

Conclusions

In conclusion, it is necessary to rethink mental health and mental illness. The importance of mental
health has been seriously underestimated, resulting in alarmingly increases of number of people with mental
disorders. Unfortunately, the trend is continuously upward, resulting in considerable preventable suffering,
disability, and mortality. Acceptance of the DALY as an indicator of the burden of disease and related
conditions has begun to make some change because it is a more sensitive indicator of related to mental
disorders than any other indicator.

Why do all these happen in XXIst century? No approach to mental illness, -biological, psychological
and sociological theories- can completely explain its origins.

Rethinking the causes that lead to mental illness is also very important. An understanding of the
biological perspective of psychiatric disorders is important for sociology as the basis for advancing the social
component in biological theories of psychiatric disorders and for using such theories in order to promote the
sociology of mental health. The biological revolution in psychiatry, carries –along with its promise to cure
the disease- the danger of biological reductionism, biological determinism, and the hegemony of biological
explanations for psychiatric disorders and other social problems.

The dominance of the biological perspective in psychiatry was reinforced by the scientific success of
genetic and pharmaceutical research, but that is clearly only a part of the explanation. Sociologists do and
should examine the interrelationship between social and political phenomena and the rise of the biological
revolution. Why does this paradigm have such an appeal in the current social context? Proponents of a
biological perspective suggest that it reduces stigma associated with psychiatric disorders. Has it reduce
stigma? For whom?

Sociological analysis of the social construction of psychiatric disorders are also important,
particularly at this juncture when the number of disorders officially recognized in psychiatry is growing at an

1
unprecedented rate. All behaviors have biological, psychological, and sociological components. The question
is: on which level of organization is the phenomenon defined and why? Deciding to define a phenomenon in
terms of its biological component and call it a “disease” is a political issue, one that demands sociological
analysis. The medicalization of social phenomena and the labeling of biological differences, as “defects”
needs to be discussed. What phenomena should be defined based on their biological representations and
which should not? How are these decisions made, and by whom? What are the consequences of these
decisions? Should phenomena with similar biological representations be considered as the same, regardless
of contextual differences? Researchs in biological psychiatry itself point to the problem of diagnosis; what
may be unitary phenomenon from genetic perspective may be diverse phenomena from neurochimical
perspective. Which theory, definition or mechanism will be most useful depends on the discipline involved.

It is clear that we have to rethink mental health/illness and to integrate biological, psychological and
sociological theories that are most usefully. In consequence, biological, psychological and sociological
therapies have to be integrated, in order to create a balance between physical being, psychological being, and
social being.

Without this integrative understanding we confront the risk of solving the problem only partially and,
by so doing, we may induce relapse, make recovery and resilience difficult and continue to maintain stigma.

References:

National Mental Health and Education Center for Children and Families

www.naspweb.org/center.html

Substance Abuse and Mental Health Services Administration

www.samhsa.gov

Federation of Families for Children’s Mental Health

1
 www.ffcmh.org

President’s New Freedom Commission on Mental Health: Report to the President

www.mentalhealthcommission.gov/reports/finalreport

Center for Studies Health System Change

www.hschange.com

Michael H. Merson, Robert E. Black, Anne J. Mills : International Public Health: Diseases, Programs,
Systems, and Policies

www.hschange.com

Ann E Christian MSW: Introduction to Health Care and Public Health. The Mental Health System
Nov. 20, 2003

Robins & D.A. Reiger (Eds.) (1991). Psychiatric Disorders in America: The Epidemiological
Catchment’s Area Study. New York: free Press

Diagnosis and Statistical Manual; Edition of the American Psychiatric Association’s; DSM III;
APA1980, DSM-III-R (APA1987), and DSM-IV (APA 1994)

Homles & Rahe (1967); Social Readjustment Rating Scale (SRRS). Journal of Psychosomatic Research,
11,213218

www.octech.org/faculty/GueJ/socreadscale.htm

Abrahamson, M.(1980). Sudden wealth, gratification and attainment: Durkheim,s anomie of affluence
reconsidered. AmerSociologicalRev.45; 49-57

Adler, P.T. (1982). An analysis of the concept of competence in individuals and social system Community
Mental Health j. 18; 35-35

Berkman, L.F.& Breslow (1983). Health and Ways of Living; The Alamenda Study New York Oxford
University Press

1
Fromm E. (1941). Escape from Freedom. New York: Holt

Freund, D. & R. Hurley (1995) Medicaid managed care: Contribution to issue of health reform. Annual Rev.
Public Health 16; 473-95

Fountain House (1985) Evaluation of clubhouse model community-based psychiatric rehabilitation; Final
report. National Institute of Handicapped Research, Washington DC.

Folkman, S. & R.S. Lazarus (1980). An analysis of coping in the middle _age community sample J.Health &
Social Behavior 21: 219-39

Folkman, S (1984) Personal control and stress and coping process: A theoretical analysis. J Personality &
Social Psychology 46: 839- 52

Goldman, H. & J.Morrisey (1985). The alchemy of mental health policy: Homelessness and the fourth cycle
of reform. Amer. J.Publc Health 75: 727-31

Goldman, H.(1982). Mental illness and family burden: Apublic health perspective. Hospital & Community
Psychiatry 33: 557-60

Human Development Report 2003 Oxford Press

Horwitz , A (1982). The Social Control of Mental Illness. New York Academic Press

Holmes, T. H. & R.H. Rahe (1967) The social Readjustment Rating Scale. J. Psychosomatic Res. 11: 213-
18

Introduction to Mental Health Care and Public Health. The Mental Health System Nov. 20, 2003

The International Center for Clubhouse Development Annual Report 2003

Jahoda, M. (1958).Current Concepts of Positive Mental Health. New York: Basic Books

Kaplan, Howard H. (Ed) (1983). Psychosocial stress: Trends in Theory and Research. New York: Acad.
Press.

Kaplan, Harold, B.J. Sadock, & J.A.Grebb(1994). Kaplan and Sadock’s Synopsis of Psychiatry: Behavioral
Sciences, Clinical Psychiatry. Baltimore: William & Wilkins.

1
 Merton, R.K. (1983). Social Structure and anomie In Merton (1956/1968:

185- 214).

Michael H. Merson, Robert E. Black, Anne J. Mills : International Public Health: Diseases, Programs,
Systems, and Policies

www.hschange.com

National Mental Health Association

www.nmha.org

Patel, V., & M. Winston (1994).” Universality of mental illness” revisited: Assumptions, artifacts and
new directions. Brit. J. Psychiatry 165: 437-9.

Reiss, D., R. Plomin & E.M. Hetherington (1991). Genetics and Psychiatry: an unheralded window
on the environment. Amer. J. Psychiatry 148: 283-91

Rosenhan, D. (1973). On being sane in insane place. Science 179: 250-8.

Selye, H. (1936) A syndrome produced by divers nocuous agents. Nature 138:32

(1956). The Stress of Life. New York: Mc Graw-Hill.

(1993). History of the stress concept. In Golberger & Breznitz (1993: 7-17)

Vill L., & T Vappu (2001). Integrating mental health services- the Finnish experience. International
Journal of Integrating Care, 1 June 2001

http://www. ijic.org

World Bank Report 1993 www-wds.worldbank.org

1
1