The author draws attention to andcharacterized the multiple meanings of the term"community psychiatry" which has been understoodas a certain moral message (the friendly communityidea), an organizational system (the communitymodel of psychiatric health care), a method of treatment and rehabilitation (community treatment) orhas situated psychiatric issues in the context oragainst the backdrop of other social problems (socialecology). He also reviews the present situation andthe positive and negative contingencies affecting the feasibility of implementation of the goals of communitypsychiatry in Poland. He emphasizes the importanceof today's solutions for the future.
The author reviews the research onsociety's attitudes towards mental illness, the mentallyill and psychiatric institutions, carried out inPoland in 1963-1999. The following demographic and social variables had the greatest bearing onsocial attitudes: level of education, age, occupationalstatus, socio-economic status and place of residence.In 1963-1999 many positive changes tookplace in society's attitudes, particularly in terms of increased knowledge and information about psychiatric problems, relative weakening of hostilityand negativity towards the mentally ill, increasedsocial support for the development of traditionaland community centers andforms of therapy andwidespread acceptance of involuntary treatment injustified cases. But on the other hand one can stillobserve many signs of apprehension, fear, hostilityand prejudice in the form of negative stereotypesand relatively large social distance with respect tothe mentally ill.
The authors compare the results of two consecutive surveys of the opinions of Polishsociety concerning mental illness, conducted in 1996and 1999.
Objective. The purpose of the secondsurvey was to assess the stability or change of opinionsregistered in the first survey.
Subjects and method. The surveys were conducted by CBOSinterviewers on representative, random-addresssamples of 1088 (July 1996) and 1003 (December1999) respondents. The same questions were askedboth times.
Results. The opinions on mental illnessand the mentally ill were very stable. One respondentin three admitted to knowing some mentally ill person.Pejorative ways of defining the mentally ill predominate in the social stereotype of mental illnessalthough a slight shift in the positive direction was found in 1999. No significant changes were registeredin the level offear of mental illness and thenature of the cognitive attributions to the mentallyill. Several of these attributions, in which patientsare described as "troublesome, helpless victims"were endorsed by almost all respondents whereassuch attributes as "aggressiveness" and "sensitivity"were more controversial. Social distance with respectto the mentally ill has not changed since 1996, nomatter how it is measured. Level of declared friendlinesstowards the mentally ill has not changed and islower than it is towards patients with such problemsas "misfortune for which the person is not to beblamed" (physical or mental disability) but higherthan towards persons with health problems which areoften interpreted in terms of "deliberate violation of social norms" (AIDS, drug dependency, alcoholism).Respondents declared more friendliness thanthey observed in others. No changes were found insocial distance expressed in terms of refusal of permissionto the mentally ill to engage in certain socialroles –the intensity of this refusal depends on theextent to which a role involves responsibility forother people. Although global indices of stabilityremained stable groups differing in their social Descriptionsrevealed considerable shifts in this variable.Polish society has considerable trust in psychiatricinstitutions which are responsible for thetreatment of the mentally ill.
Conclusions. The presentedresults suggest considerable stability of thesocial stereotypes which are conducive to negativestigmatisationof and distancing from the mentally illand may give way to educational measures andefforts to modify opinions with the purpose of alteringexisting stereotypes and alleviating stigmatization and social distance.
Although community psychiatry hasa rich tradition in the Netherlands and one of the mostfamous Dutch psychiatrists was a community psychiatrist,community psychiatry still functioned ratherpoorly in the seventies. There was no lack of money,but cultural and social factors and a fragmentedstructure of the mental health system hampered goodperformance. Governmental legislation created newopportunities. The government forced institutionsto co-operate with each other and allocated money tofinance new programs of care. It is now the turn to themental health workers to create new ways (or rediscoverold ways) to help mentally disturbed persons tosurvive in the community and lead a dignified life.
For several epidemiological reasonsthe number of chronic mental patients in our communitiesis increasing. Major responsibility for thesepatients is now being shifted to out-patient forms ofcare and the significance ofrehabilitation is increasing.It is generally accepted that this form of interventionmust be both comprehensive and individuallytailored to the patient and his/her community. Thismeans that we need to develop structures capable ofintegrating these two aspects ofrecovery. We knowmuch more than we used to about the needs andexpectations ofpatients and their families: communityteams, patient clubs, crisis intervention centers,various employment outlets. More and more frequentlythe urgent question is not: what has to bedone? but: how to do it? Many new options havedeveloped in recent years. In particular, non-governmentorganizations have become increasingly moreactive. One example of this activity is "Back to theCommunity", a project which the Association forPsychiatric Rehabilitation in Białystokcarriedout in co-operation with Stichting StedenkontaktEindhoven-Białystok, a Dutch organization.
The authors present the assumptionsunderlying the organization of mental health care inaccordance with the criteria of community psychiatry.They share their 10 year experience in the implementationof changes in the system of mentalhealth care and recovery from chemical dependencyin what used to be the Toruńadministrative districtand conclude that the recent health care reform hashad a negative effect on the mental health caresystem which is largely based on out-patient care.
The authors present the most salientinformation about variousforms ofprotected housinggleaned from a meta-analysis of articles published ineight internationaljournals in 1993-1999. They reviewthe definitions and types of protected housingand the prevalence of this form of care. They alsopresent a synthesis of the outcome research on thisform of care and the processes involved.
The authors present a contemporaryapproach to the place and function of occupationalrehabilitation and employment in the rehabilitationof schizophrenic patients together with existing experiencesand plans to implement to model in a comprehensiverehabilitation system which is being developedin Cracow. They express their belief that ifoccupational rehabilitation of many schizophrenicpatients is to be ultimately successful special systemsof stable employment must be developed inparallel to those which already exist on the market.It is necessary to develop forms of employmentwhich are both within patients' range and which areable to survive the competition on the free market(for example civic companies –ed.).
An attempt is made to indicate themost important problems faced by communityself-help houses. It is based on practical observationsobtained by the personnel of several houses (locatedin the region of Gorzów and Zielona Góra) in thecourse of their normal activity. The main conclusionsare as follows. First, thorough analysis of the specific needs in the environment should precede foundation of community self-help houses. Second,scope of their activity should be diversified (separateoffers for mentally ill, mentally retarded, personswith dementia and possibly many others). Last butnot least, appropriate regulations for daily activityand principles of documentation handling should beestablished. Community self-help houses may beregarded as a good alternative to the health caresystem and therefore their competencies should becarefully defined.
The aim of this study was to elaboratea set of standards for the structure and functioningof two types of self-help communityhouses (day stay and residential) in accordancewith the provisions of the Mental Health Act as of1994. The respondents participating in the studydemonstrated a high level of acceptance for thedraft of standards. It is to be expected that suchstandards should contribute to much better observanceof the requirements of the Mental Health Actand to improvement of the quality of self-help communityhouses.