Mental healthcare in the United States has clearly improved since the early 1900s, however the majority of treatment for people with serious mental illness still fails to promote patient autonomy and effectively connect patients with community-based treatment after discharge from inpatient care. Kilbourne et al. (2018) proposed quality measurements for mental healthcare, including validated assessments for patient-centered outcomes and quality of follow-up care, both of which do not currently exist in United States’ psychiatric care. Additionally, with the criminalization of mental illness that followed deinstitutionalization, prisons have become a new kind of mental hospital, far from the vision of community mental healthcare that was promised at the initiation of the deinstitutionalization movement (Primeau, Bowers, & Harrison, 2013).
Despite the inadequate results of deinstitutionalization and psychiatric care in the United States, we continue to spend more on mental healthcare than our Jamaican counterparts: 6% of total healthcare expenditures in the United States versus 5% of total healthcare expenditures in Jamaica (WHO, 2011). Although the difference between these totals appears small, it is striking that Jamaica has more than double the number of outpatient mental health facilities per 100,000 people and 14% of the inpatient psychiatric admissions per 100,000 people when compared to the United States (WHO, 2011). It is clear that Jamaica’s deinstitutionalization movement, although more recent than the United States’, has been much more successful in creating community mental health centers and in decreasing acute admissions. Meanwhile, the United States’ mental healthcare expenditures are now allocated in the form of correctional services funding (Primeau, Bowers, & Harrison, 2013).
In Jamaica, community-based mental healthcare has dramatically improved the social support of people with serious mental illness and has significantly reduced stigma toward these individuals. Hickling, Robertson-Hickling, and Paisley (2011) conducted a qualitative study of attitudes toward people with mental illness following Jamaica’s deinstitutionalization and found that community integration promoted increased insight and care for those suffering from mental illness, as well as negated stigma that, prior to this movement, had been associated with psychiatric hospitals (known as “lunatic asylums” by the general population at the time). Jamaica’s culture places emphasis on collectivism, cited as a main factor in the change of attitude that occurred when patients moved from the isolation of psychiatric hospitals into the social fabric of the country.
Collectivism as a cultural value can both positively and negatively impact psychiatric treatment outcomes. Tse and Ng (2014) addressed both directions of influence in a qualitative study of members of several collectivist and individualist societies. The researchers found that collectivism enhanced family and societal support for psychiatric patients and encouraged patients’ continued participation in society (through work or education) because of the value placed on social capital. Two challenges identified were potential for stronger stigma and possible conflict between patient care goals and family care goals, however both of these concerns have been mitigated to a large degree by the movement into community-based care.
During my immersive experience in Jamaica, I witnessed the effects of a collectivist, patient and family-oriented treatment model firsthand. On the inpatient wards, patients were included in interdisciplinary rounds, asked their opinions on their medication regimens, and given the freedom to develop their discharge plans in collaboration with healthcare providers, social workers, and their family members. In outpatient treatment facilities, patients were employed to work as teachers, cooks, and gardeners within the facility, promoting their independence and enhancing their sense of self. Furthermore, when I inquired about violence toward staff members and between patients in the inpatient setting, an issue that is prevalent throughout United States’ psychiatric facilities, I was informed that no staff members at that hospital had ever been assaulted in the psychiatric unit. While this is anecdotal, it is astounding to hear when considered in comparison to the extreme violence found on many psychiatric units in the US.
When examining both personal experience and available evidence from psychiatric care facilities in the United States and Jamaica, it is clear that there are components of the individualistic culture of the US that are harming the ability to provide truly patient-centered and community-based psychiatric care. An initial step to remedy this situation is new education for providers and families. There are significant ways in which Jamaica’s collectivist ideals promote patient-centered approaches to care: reinforcing family and social support, including the patient in decisions as a member of both the treatment community and larger community, and encouraging continued involvement in the community through work or school. Additionally, advocating for a shift of funding from correctional facilities and inpatient facilities to community-based mental healthcare centers will allow psychiatric patients to reintegrate more successfully into society. Ultimately, investing in the community through time, education, and money is a practice we have yet to learn in the United States, but one that will have a tremendous impact on our psychiatric care.
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