NAME : AROCKIA JOICE A

CLASS : 2ND YEAR- MSW

SUBJECT : PSYCHIATRIC SOCIAL WORK

TOPIC : CONCEPT OF COMMUNITY PSYCHIATRY

AND

COMMUNITY BASED REHABILITATION

DATE OF

SUBMISSION : MARCH 11, 2019

 Content

 Community psychiatry

 Introduction

 History

 Characteristics of community psychiatry

 Types of community services

 Problems of community mental health centre

 Community mental health team

 Community based rehabilitation

 Principles of CBR

 Components of CBR

 CBR personnel

 Implementation of CBR

 References
 Concept of Community Psychiatry and Community Based Rehabilitation

Introduction

According to the American Heritage Medical Dictionary community psychiatry can be defined
as “Psychiatry focusing on detection, prevention, early treatment and rehabilitation of emotional
and behavioral disorders as they develop in a community.”

In simple words it can be defined as provision of psychiatric services within the community with
the aim of achieving full integration into the community. This community psychiatry is client
centered as it focuses more on the integration of the client into the community and it also has a
commitment to the community.

History of Community psychiatry

The community psychiatry was born in 1963 and has been referred as “third psychiatric
revolution”. The first revolution was the enlightenment age which was followed by the viewing
of mental illness as sin and witchcraft. The second revolution was about the development of
psychoanalysis. The community psychiatry movement was made possible because of the psycho-
pharmacology, so the community psychiatry movement has to be referred as fourth psychiatric
revolution.

The concept of community has its antecedent in Clifford Beer’s mental hygiene movement and
Adolf Meyer’s recommendation of establishment of treatment centers in the community. The
period from 1955 to 1980 was an era of deinstitutionalization in USA and other western
countries consisting of discharging of mentally ill patients from the mental hospitals and caring
for them in the community. This formed as the base for the development of community
psychiatry.

The World Health Organization (WHO) recommended delivering mental health services through
the Primary Health Care system. In India, models of psychiatric services in the Primary Health
Center (PHC) setting were simultaneously made at PGI, Chandigarh in 1975 and NIMHANS,
Bangalore in 1976.
Characteristics of community psychiatry

The basic model of community mental health was defined by Gerald Caplan in 1967. The
predominant characteristics of community psychiatry are

1. Responsibility to a population for mental health care delivery.

Commitment to a population implies a responsibility for planning. The plan should
contain all the mental health needs and also the resources available to meet that needs.
The responsibility is not restricted to a particular group but all including children, aged,
minorities, chronically ill, acutely ill and those who live in geographically distant areas.
The services that are provided should be acceptable to their cultural background and also
known to the population.
2. Treatment close to the patient in community based centers.
The provision of the service near to the client’s residence or the work place will provide
an easy access to the client to seek the service. This can be provided by the establishment
of mental health centre in every area to provide the outpatient service, crisis intervention
and consultation education services.
3. Provision of comprehensive services.
Community mental health has to be viewed as a total system and not as a single service.
It suggests that system needs a lot of services to meet the needs of the total population.
The major 5 required services: Emergency services, outpatient services, inpatient
services, consultation and education services. Public law 94-63 required the additional
services like services for children, aged, screening before hospitalization, follow up
services, alcoholism services and drug abuse services.
4. Multi-disciplinary team approach.
The community mental health team includes psychiatrists including a child psychiatrist,
clinical psychologist, clinical Social Workers, nurses, occupational and recreational
therapist. There could be paraprofessionals with less than a high school education often
from a minority or poverty background to a person with master’s level training in a field
not traditionally considered mental health.
 Initially psychiatrists were in charge of the clinical treatment program but the Public law
94-63 changed it. Now any qualified mental health professionals- psychologist, Social
Worker, Mental health nurse or psychiatrist can assume that responsibility.
5. Providing continuity of care.
Continuity of care may be provided by having a single therapist follow a given patient
through emergency services, hospitalization, partial hospitalization as a transition to the
community and outpatient treatment as follow up. It may also be provided with the
exchange of information and team responsibility for the patient when there is an
involvement of different therapist. The continuity of care raises the issues like
confidentiality and protection of patient’s civil rights.
6. Emphasis on prevention as well as treatment.
One of the basic aspects of community psychiatry is commitment to prevention (In direct
service) and treatment (Direct service). There are three types of prevention evolved from
the public health model. They include:
 Primary prevention - Elimination of factor that causes illness.
 Secondary prevention – Early identification and treatment at the beginning of the
disease.
 Tertiary prevention – Rehabilitation or elimination of disability after the acute
phase of the illness.
7. Avoidance of unnecessary hospitalization.
8. Consumer participation.
Community should participate in the decisions about the mental health care needs and
programs. This is because the mental health services will be more appropriate when the
public participates.

Types of Community Psychiatric services

1. Community mental health center.

The centers provide services like emergency services, child and adult services and so on.
The treatment provided in the center includes medication administration, individual and
 family therapy, psych education. They also may provide rehabilitation services in the
form of structured day program, vocational and residential services.
2. Psychiatric home care.
The service is provided in the home of the patients who are unable to access the services
due to circumstances like physical or mental conditions. The psychiatric nurse would
visit that type of patients one to three times per week. She also act as a case manager who
coordinates the different services required.
3. Partial hospitalization
It is similar to the inpatient service but the difference is that the patient returns home
daily in the evening under the care of a family member.

Problems of Mental health center

Some of the problems faced by the mental health center are

1. Neglect of the chronically ill.

The community should have a comprehensive spectrum of services for
deinstitutionalizing the chronically ill but the community mental health centers did not
take up this particular issue seriously.
2. Accessibility and availability for the underserved.
In mental health programs the underserved are children, aged, rural population and
minority groups. Although there are outpatient services and services to address adult
problems, the services to address child problems remain nonexistent.
It also does not give priority to elderly thinking that the psychiatric conditions in elderly
are not treatable. So, large numbers of the elderly are put in nursing homes and
institutional care.
Because of the geographical location and lack of mental health professionals rural
population are regarded as underserved. Rural areas lack the variety of human services
programs and the skills in organization
 Minority groups have a higher number of social problems due to their social and
economic disadvantages. They do not understand mental illness or they are influenced by
the stigma associated with it.
3. Financial problems
It was initially thought that community mental health centers can be funded by shifting
the resources from the state government. It was not successful for 2 reasons. One is that
new programs always require a start up funds and the other is that community mental
health centre was established as the program outside the government and not the
responsibility of the state department of mental health.
4. Health and social service models.
Mental health services center has been criticized to move from a health model towards a
social service model. This is because that solution of the social problems can prevent
medical illness.
5. Second-class services.
The people think that the services in the center are for poor people. Their thoughts are
enhanced by the concepts of the poor quality of care in the centers, diminished
psychiatric involvement, focus on the resolution of social problems and the clear
visibility of under privileged persons in the governance boards.
6. Low profile
Only few known about the centers. Those who are tend to the stereotype avoid it. The
centers were asked to increase their visibility because of which few became visible but
few did not attempt it due to lack of services and to avoid the possibility of
overwhelming.

Community mental health team

It should include:

Psychiatrist – medical doctor with special training in mental illness and behavioral problems.
Diagnoses the condition and prescribes medical treatment.

Clinical psychologist – performs psychiatric testing

Psychiatric Social Worker – Community resource education , discharge planning

Psychiatric nurse – administers medications, conducting group education sessions

Occupational and recreational therapist – incorporates leisure activities to have a healthy

coping

And other administrative staff to provide services likes hospitalization, follow-up, residential
services, consultations and education.

Community based rehabilitation (CBR)

Community based rehabilitation is a strategy within community development for the

rehabilitation, equalization of opportunities and social integration of all people with disabilities.
It is implemented through the combined efforts of disabled people themselves, their families and
communities, and the appropriate health, education, vocational and social services. It is a holistic
approach involving physical, social, employment, educational, economic and other needs.

In CBR, community means a group of people with common interests who interact with each
other on a regular basis or a geographical, social or government administrative unit.

Principles of CBR

The principles of CBR are overlapping, complimentary and inter-dependent – they cannot be
separated one from the other. The principles are

1. Inclusion
It can be referred to as the removal of the barriers that prevent the access of disabilities
into the main stream. The barriers could be environmental, physical, attitudinal and
technological. These barriers should be removed because they prevent the disabled
people in political, civic, social, cultural and economic activities.
It also means the convergence that is involving the disabled people in the campaigns,
struggles and activities on other issues which does not involve about their disability.
 It also means inclusion of all forms of impairment – physical, sensory, communicative,
mental health and illness, intellectual and development disabilities.
It also involves inclusion of people who are traditionally excluded and discriminated.
They are women, people with multiple and severe disabilities, people of particular
religion, beliefs, ethnic, caste or community background, refugees, people with
HIV/AIDS.
2. Participation
The people with disability know best about what they need. So, the disabled people
should be involved as active contributors of CBR program policy making to
implementation and evaluation.
It also means people with disability being a critical resource within any CBR program
like providing training, making decisions and so on. It requires the flexible use of own
language without discrimination or stigma.
3. Sustainability
The aim of every program should be sustainability which means everlasting that is the
benefit should not be short term but it should be there in the future generation also.
Strong link between Government Organization, NGOs, community based organizations
and disabled people’s organization will contribute the sustainability.
4. Empowerment
The outcome of the CBR should be a change in the mindset of the disabled people from
the passive receiver to the active contributor. The essence is that people with disabilities
and their families take responsibility for their development. The approaches for
empowerment can be social mobilization, political participation, communication, self
help groups and disabled people’s organization.
5. Self advocacy
It means that people with disability should define the goals and processes themselves.
Self advocacy is not an individual one but the collective one. It means the self
determination. It means mobilizing, representing, organizing and creating space for
interaction and demands.
Components of CBR

1. Creating a positive attitude towards people with disabilities

This component is essential to ensure equalization of opportunities for people with
disabilities within their own community. It can be created by involving them in the
process and implementation, transferring knowledge about disability issues to community
members.
2. Provision of functional rehabilitation services
The people with disabilities require assistance to overcome their limitations due to their
disability. CBR workers should be given training about the primary rehabilitation therapy
in the following areas of rehabilitation like medical, eye care services, hearing service,
physiotherapy, occupational therapy, speech therapy, psychological counseling etc.
3. Provision of education and training opportunities
People with disability should acquire equal access to educational opportunities and to
training that will enable them to make the best opportunities that occur in their lives.
CBR workers should be trained to provide basic levels of service in the following areas:
 Early childhood intervention and referral, especially to medical rehabilitation
services.
 Education in regular schools.
 Non-formal education where regular schooling is not available.
 Special education in regular or special schools.
 Sign language training.
 Braille training.
 Training in daily living skills.
4. Creation of micro and macro income-generation opportunities
People with disabilities should have access to micro and macro income-generation
activities. In slums and rural areas, income-generation activities should focus on locally
appropriate vocational skills. The training of the people with disability with the skills can
be done by the community members who needs minimal assistance.
5. Prevention of care facilities
 People with extensive disability need assistance. When they do not have families or the
families do not care for them then they must be provided with long term care facilities
where they can get assistance which they need.
6. Prevention of the cause of disabilities
Simple measures can prevent disability. Proper nutrition is one of the ways of preventing
disability. Another important way is the detection and early treatment. Other activities
like decrease in the number of accidents encourage people to have healthy lifestyle.
7. Management, monitoring and evaluation
Effective management process has an influence on the efficiency and effectiveness of the
CBR program. The impact of program activities must be measured on a regular basis.
Data must be collected, reviewed and evaluated to make sure that the objectives of the
program are met. By doing this the success and failure of a CBR program can be
measured accurately.

CBR Personnel

Helander have described three levels of CBR as perceived by WHO and by UNDP. These refer
to the three level of services.

 They are grass root level workers who provides services in the community.
 Mid levelworkers who organize and support the above mentioned workers.
 Professionals to whom referrals can be made from the community or who refers user to
the community.

They are the key persons in the implementation of CBR. They are the usual person who is in
contact with the family. They act as local advocates, provide liaison and continuity of care
instead of professionals and act as directors to remove social and physical barriers.

The basic concept is the decentralization of responsibility and resources both human and
financial resources.
Steps in the implementation of CBR

1. Identification of person requiring rehabilitation services.

2. Assessing the disabilities and needs for rehabilitation of the person who has been
identified.

3. Provide the basic services through Primary Health Center (PHC), such as providing
drugs, dressing materials, protective footwear, counseling and training in self care.

4. Introduce the disabled person to ‘Village Health & Sanitation Committee’ along with
his/her problems or issues.

5. Refer the person with disability to secondary or tertiary care center for physical
rehabilitation services, like ulcer care, physiotherapy, surgical treatment, treatment of eye
complications, prostheses and so on. Another essential part is the follow up services.

6. Facilitating the accessibility of the disabled person to ‘socio-economic rehabilitation

services’ through social welfare department by a ‘CBR worker’. A health supervisor,
MPW, ANM, AWW, ASHA, or even a volunteer can play the role of CBR worker. Joint
efforts by ‘Village health & sanitation committee is required.

7. Review meetings by all stake holders, to discuss the progress of CBR project or
individual’s problems will help in the rehabilitation process of the person

8. Coordination with social welfare department and working jointly.

9. Education of people to reduce stigma need to be carried out simultaneously and jointly so
that rehabilitation activities can be carried out smoothly.

10. Participatory Evaluation of CBR services at definite intervals will provide a way for
effective and sustainable rehabilitation
 References

1. (n.d.). Retrieved from Community Based Rehabilitation: http://nlep.nic.in/pdf/cbr.pdf

2. Economic and social commission for asia and the pacific understanding community-
based rehabilitation. (1998). Disability Information Resources .

3. Feldman, J. M. (2015). History of Community Psychiatry. Research Gate .

4. Haseem, S. (n.d.). Retrieved from Community mental health community psychiatry:

http://www.uobabylon.edu.iq/eprints/publication_10_16484_241.pdf

5. (2004). Meeting Report on the development of guidelines for Community Based

Rehabilitation (CBR) programmes . Geneva.

6. Raghavendran, D. (2016, 12). Slideshare. Retrieved from

https://www.slideshare.net/sramragh/community-psychiatry

7. Wirz, S. (n.d.). Retrieved from Training of CBR Personnel:

http://english.aifo.it/disability/apdrj/selread100/cbr_training_wirz.pdf