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Morrison-Valfre’s
FOUNDATIONS of
MENTAL HEALTH CARE
in CANADA
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Morrison-Valfre’s
FOUNDATIONS of
MENTAL HEALTH CARE
in CANADA
CANADIAN AUTHORS US AUTHOR
Boris Bard, RN, MSc, ACMHN Michelle Morrison-Valfre, RN, BSN,

Manager, Neurology Service MSN, FNP
Health Care Educator/Consultant
University Health Network Health and Educational Consultants
Toronto, Ontario Forest Grove, Oregon
Eric MacMullin, RN, MSN

Professor
Bridging to University Nursing Program
School of Community and Health Studies
Centennial College
Toronto, Ontario
Jacqueline Williamson, RN, MEd, PhD

Professor
Practical Nursing Program
School of Health and Community Services
Durham College
Oshawa, Ontario
MORRISON-VALFRE’S FOUNDATIONS OF MENTAL HEALTH CARE
IN CANADA ISBN: 978-1-77172-233-9
Copyright © 2022 by Elsevier, Inc. All rights reserved.
Adapted from Foundations of Mental Health Care, Sixth Edition, by Michelle Morrison-Valfre,
Copyright © 2017, by Elsevier, Inc.
978-0-323-35492-9 (softcover)
All rights reserved. No part of this publication may be reproduced or transmitted in any form or by any
means, electronic or mechanical, including photocopy, recording, or any information storage and retrieval
system, without permission in writing from the publisher. Reproducing passages from this book without such
written permission is an infringement of copyright law.
Requests for permission to make copies of any part of the work should be mailed to: College Licensing Offi-
cer, access ©, 1 Yonge Street, Suite 1900, Toronto, ON M5E 1E5. Fax: (416) 868-1621. All other inquiries should
be directed to the publisher, www.elsevier.com/permissions.
Every reasonable effort has been made to acquire permission for copyrighted material used in this text and to
acknowledge all such indebtedness accurately. Any errors and omissions called to the publisher’s attention will
be corrected in future printings.
This book and the individual contributions contained in it are protected under copyright by the Publisher
(other than as may be noted herein).
Notice
Practitioners and researchers must always rely on their own experience and knowledge in evaluating and
using any information, methods, compounds or experiments described herein. Because of rapid advances
in the medical sciences, in particular, independent verification of diagnoses and drug dosages should be
made. To the fullest extent of the law, no responsibility is assumed by Elsevier, authors, editors or con-
tributors for any injury and/or damage to persons or property as a matter of products liability, negligence
or otherwise, or from any use or operation of any methods, products, instructions, or ideas contained in
the material herein.
Library of Congress Control Number: 2020947856
VP, Education Content: Kevonne Holloway

Content Strategist (Acquisitions, Canada): Roberta A. Spinosa-Millman
Director, Content Development: Laurie Gower
Content Development Specialist: Martina van de Velde
Publishing Services Manager: Catherine Jackson
Senior Project Manager: Claire Kramer
Design Direction: Bridget Hoette
Last digit is the print number: 9 8 7 6 5 4 3 2 1

To my wife, Kira Bard, who always loves and supports me.
To the memory of 6 million Jewish victims of the Holocaust and the memory of
the Righteous Among the Nations who helped some to survive, leading, among
other things, to the new edition of this book.
Boris Bard
To my family, Rita, Bob, Rose, Colin, Linda, and Shirley for a lifetime
of support and encouragement. Special thanks to Chris Gray just for
being there and more thanks than I have words to express to my mentor
and friend, Professor Jonathon Bradshaw.
Eric MacMullin
To my beloved husband, Adolph; my cherished friend Marian

McCollum; and to you, dear reader.
May you leave this book richer in the knowledge of human behaviour.
Michelle Morrison-Valfre

REVIEWERS
Sharon Clegg, BSc(PT) Kelly McNaught, RN, MN

Physiotherapist Nursing Faculty
Faculty of Physiotherapy Technology Nursing Education and Health Studies
Dawson College Grande Prairie Regional College
Montreal, Quebec Grande Prairie, Alberta
John Collins, PhD, MA, Dip. Ed(NT), BA(Hons), DPSN, Holldrid Odreman, RN, MScN-Ed, PhD
CMS(dist.), RN, RPN Professor of Nursing
President/CEO, John Collins Consulting Inc. School of Nursing
Instructor, BSN Program Niagara College
Vancouver Community College Welland, Ontario
Vancouver, British Columbia
Kathlyn Palafox, BSN, BCPID
Cheryl Derry, RN, CAE Practical Nursing Program Coordinator
Instructor, Practical Nursing Secondary Senior Educational Administrator
School of Health and Human Services Canadian Health Care Academy
Assiniboine Community College Surrey, British Columbia
Brandon, Manitoba
Angela Rintoul, NP, MN-ANP
Thomas Gantert, RN, MBA, PhD Coordinator
Professor of Nursing Bachelor of Science in Nursing Program
Fanshawe College Algonquin College
London, Ontario Pembroke, Ontario
Treva Job, RN, PHCNP, RN(EC), MEd, PhD(c)

Professor
Faculty of Nursing
Georgian College
Barrie, Ontario
Eric MacMullin, RN, MSN

Professor
Bridging to University Nursing Program
School of Community and Health Studies
Centennial College
Toronto, Ontario
vii

TO T H E I N ST RU C TOR
Morrison-Valfre’s Foundations of Mental Health Care in Unit IV, Patients With Psychological Problems, explores
Canada, first edition, is intended for students and practition- common behavioural responses and therapeutic interven-
ers of the health care professions. Basic and advanced learn- tions for illness, hospitalization, loss, grief, and depression.
ers will find the information in this text useful and easy to Maladaptive behaviours and mental health disorders are
apply in a variety of practice settings. Students in fields such described in chapters on somatoform, anxiety, eating, sleep-
as nursing, social work, respiratory therapy, physiotherapy, ing, mood, sexual, and dissociative disorders.
recreational therapy, occupational therapy, rehabilitation, The chapters in Unit V, Patients With Psychosocial
and medical assisting will find concise explanations of adapt- Problems, relate to the important social concerns of anger
ive and maladaptive human behaviours, as well as the most (and its expressions), suicide, abuse and neglect, acquired
current therapeutic interventions and treatments. immunodeficiency syndrome (AIDS), and substance use.
Practising health care providers—all who care for patients Sexual and personality disorders are also discussed. Chapters
in a therapeutic manner—will find this book a practical and on schizophrenia and chronic mental illness focus on a multi-
useful guide in any health care setting. disciplinary approach to treatment. The text concludes with
At its core, this text has three main goals: a chapter titled “Challenges for the Future,” which prepares
1. To help soften the social distinction between mental students for the coming changes in mental health care.
“health” and mental “illness”
2. To assist all health care providers in comfortably work-
ing with patients who exhibit a wide range of maladaptive
STANDARD FEATURES
behaviours • Several key features are repeated throughout the text:
3. To apply the concepts of holistic care when assisting Objectives stated in specific terms and a list of Key Terms
patients in developing more adaptive attitudes and behav- (most with pronunciations) and page numbers.
iours • The nursing process is applied to specific mental health
Unit I, Mental Health Care: Past and Present, provides a challenges throughout the text, with emphasis on multi-
framework for understanding mental health care. The evolu- disciplinary care. This helps readers understand the inter-
tion of care for persons with mental challenges from primitive actions of several health care disciplines and determine
to current times is described. Selected ethical, legal, social, where they fit in the overall scheme of managed care.
and cultural issues relating to mental health care are explored. • A continuum of responses describes the range of behav-
Community mental health care is explained, followed by iours associated with each topic.
chapters pertaining to theories of mental illness and comple- • Development throughout the life cycle relates to the
mentary and alternative therapies. A chapter on psychothera- aspect of each personality being studied.
peutic medication therapy ends the unit. • Clinical disorders include behavioural signs and symp-
Unit II, The Caregiver’s Therapeutic Skills, focuses on toms based on the DSM-5.
the skills and conditions necessary for working with patients. • Therapeutic interventions include multidisciplinary treat-
Eight principles of mental health care are discussed and then ment, medical management, application of the nursing pro-
applied to the therapeutic environment, the helping rela- cess, and pharmacological therapy.
tionship, and effective communications. Material devoted • Each chapter concludes with Key Points that serve as a
to self-awareness encourages readers to develop introspec- useful review of the chapter’s concepts.
tion—a necessary component for working with people who
have behavioural difficulties. Readers explore common basic
human needs, personality development, stress, anxiety, crisis,
FEATURES OF THE FIRST CANADIAN EDITION
and coping behaviours. The section concludes with a descrip- The First Canadian Edition builds on the work of the venerable
tion of the basic mental health assessment skills needed by US-based text. Information specific to Canada and Canadian
every health care provider. research, programs, and practices has been included, giving
The patients for whom we care are the subject of Unit III, readers a current and clinically relevant perspective on the
Mental Health Challenges Across the Lifespan, which focuses state of mental health care in Canada.
on the growth of “normal” (adaptive) mental health behaviours Throughout the text, a focus on the Canadian health care
during each developmental stage. The most common mental system and the influence of the Canada Health Act have been
health challenges associated with children, adolescents, adults, maintained. Medications referenced are currently used and
and older persons are discussed using the Diagnostic and available in Canada.
Statistical Manual of Mental Disorders (DSM-5) as a frame- Where applicable, DSM-IV diagnoses and references from
work. A chapter on dementia and Alzheimer’s disease discusses the American Psychiatric Association have been updated to
the care of patients who have cognitive impairments. the current DSM-5.
ix
x TO THE INSTRUCTOR
Increased attention to Indigenous health and healing prac- • Th

e holistic approach to care offers readers a view of the
tices has also been included, along with expanded exploration “whole person” context of health care delivery.
of other vulnerable populations in Canada. • NEW Critical Thinking Questions at the end of each
An appendix featuring the Canadian Standards for chapter encourage students to reflect on specific topics
Psychiatric-Mental Health Nursing, from the Canadian and scenarios, develop problem-solving skills, and con-
Federation of Mental Health Nurses, has been added to the sider how they might address current health care issues in
end of the book for student reference. practice. Suggested Answers to these questions, to guide
The authors have worked from the perspective that men- class discussion, are found on the Evolve website.
tal health and addiction disorders are primarily chronic and • References encourage further exploration of the topics
genetic, setting treatment goals to maximum recovery as presented in the chapter. For easy access, the references are
opposed to curative. found at the end of each chapter in the book.
• The Glossary of Key Terms, written in an easy-to-under-
stand format, follows the text and is also available on the
LEARNING AIDS Evolve website.
Because the majority of mental health care takes place outside
the institution, the book emphasizes the importance of using ANCILLARIES
therapeutic mental health interventions during every patient
interaction. The following features encourage the reader’s For Instructors
understanding and are designed to foster effective learning We recognize that educators today have limited time to pre-
and comprehension: pare for classroom and clinical activities. Therefore we provide
• The two-colour design stimulates learning and calls atten- a rich collection of supplemental resources for instruct-
tion to the important terms and concepts within the text. ors within the Evolve Resources with TEACH Instructor
• Selected Key Terms with phonetic pronunciations and a Resource, including:
specific page reference to where the term can be found are • TEACH Lesson Plans, based on textbook learning object-
listed at the beginning of each chapter, and each Key Term ives and providing a roadmap to link and integrate all
appears in colour at the first or most detailed mention in the parts of the educational package. These straightforward
text. Complete definitions are located in the Glossary. Terms lesson plans can be modified or combined to meet your
with phonetic pronunciations were selected because they are unique teaching needs.
either (1) difficult medical, nursing, or scientific terms or (2) • PowerPoint Presentations, including approximately
words that may be difficult for students to pronounce. 800 slides with i-clicker questions and talking points for
• Throughout the text, cultural aspects of various mental instructors.
health principles are explored in Cultural Considerations • ExamView Test Bank, with more than 800 multiple-choice
boxes to encourage further thought and discussion. and alternate-format examination-style questions. Each
• Critical Thinking boxes pose questions designed to question provides the correct answer, rationale, topic,
stimulate critical thinking. client need category, step of the nursing process, objective,
• Case Studies with thought-provoking questions encour- and cognitive level.
age readers to consider the psychosocial aspects of pro- • Open-Book Quizzes for each chapter in the textbook,
viding therapeutic care in both community and hospital with separate answer guidelines.
settings. • Suggested Answers to the Textbook Critical Thinking
• Medication Alert boxes prepare readers for the com- Exercises offer instructor guidance for classroom discus-
plexity of therapy with psychotherapeutic medications, sion about the Critical Thinking Questions found at the
including identifying drug interactions and potentially end of each chapter.
life-threatening side effects. • Answer Key to the Study Guide.
• Descriptions of each mental health disorder are drawn
from DSM-5 criteria. For Students
• Multidisciplinary Sample Patient Care Plans demonstrate In the Student Resources section of the Evolve website, there
the application of the therapeutic (nursing) process to the are more than 300 Review Questions with rationales for both
care of individuals with various mental health disorders. correct and incorrect responses; an accompanying online
• Nursing diagnoses are stated in multidisciplinary terms Study Guide; Suggested Answers to the in-text Critical
within a holistic framework. Thinking Questions; and an Audio Glossary.
TO THE STUDENT
Critical Thinking Boxes contain thought-provoking scenar-

READING AND REVIEW TOOLS ios and critical thinking questions.
Objectives introduce the chapter topics.
Cultural Considerations address the mental health needs of
Key Terms are listed with page number references, and culturally diverse patients.
selected difficult medical, nursing, or scientific terms are
accompanied by simple phonetic pronunciations. Key terms Medication Alert boxes identify the risks and possible
are considered essential to understanding chapter content adverse reactions of psychotherapeutic medications.
and are defined within the chapter. Key terms are boldfaced in
the narrative and are briefly defined in the text, with complete Sample Patient Care Plans are multidisciplinary and address
definitions in the Glossary. how members of the health care team work collaboratively to
meet patient needs.
Each chapter ends with (1) Key Points that reiterate the chap-
ter objectives and serve as a useful review of concepts, (2)
Additional Learning Resources, and (3) Critical Thinking
EVOLVE RESOURCES
Questions. Be sure to visit your textbook’s Evolve website (http://evolve.
elsevier.com/Canada/Morrison-Valfre/) for a Study Guide, an
Complete References at the end of each chapter cite evi- Audio Glossary, Review Questions, and more!
dence-informed information and provide resources for
enhancing knowledge.
CHAPTER FEATURES
Case Studies contain critical thinking questions to help you
develop problem-solving skills.
xi

ACKNOWLED GEMENT S
Canada is a country of immigrants. English is my fifth language. I am grateful to my daughter,

Shelly Bard, for her help with this book.
Boris Bard
Much appreciation to Professor Lisa-Marie Forcier for her assistance with research and clinical
scenarios and for her dedication to battling the stigma of mental illness.
Eric MacMullin
No text is written alone. The continued support of my husband, Adolph; of my friend Marian
McCollum; and of other colleagues has provided the energy to complete this project when
my own energy was low. The guidance, expertise, and encouragement from my editors Nancy
O’Brien, Becky Leenhouts, and Mike Sheets are much appreciated. I also thank all the health care
providers who so freely share their time and expertise with those who want to learn more about
the dynamic and complex nature of human behaviour.
Michelle Morrison-Valfre
The product you are holding in your hands or viewing on your screen exists as a result of a great
deal of work, research, and review. Although authors tend to get the most obvious credit (after all,
it is our names that appear on the cover), a text of this nature would be entirely impossible if not
for the work of many dedicated publishing professionals.
Although we have worked diligently to “Canadianize” the venerable Morrison-Valfre text,
many other unsung heroes have toiled away to make this text as valuable to you, the reader, as
humanly possible. Although it would be almost impossible to list them all, there are three individ-
uals we would like to thank specifically.
Content Strategist/Acquisitions person extraordinaire Roberta Spinosa-Millman recognized
the need for a specifically Canadian, fundamental text that addresses how we—as Canadians—
approach, treat, and recognize mental health. Roberta pulled together three very different auth-
ors/mental health practitioners and set the foundation for us to work together to produce what
we consider to be an excellent text and reference. Thank you, Roberta, for the dual opportunities
of producing a text of this nature and of allowing us the honour to work together.
Somehow balancing Zen-like patience along with a subtle ability to kindly motivate and dir-
ect, Content Development Specialist Martina van de Velde worked extensively to ensure that our
efforts were consistent and relevant. Many, many thanks to her for her collaboration, profession-
alism, and kindness. Again, for the times we did not get chapters completed on time, missed a
deadline, or simply forgot, we offer apologies and, in equal measure, sincere admiration.
Finally, our “almost at the finish line” copy editor, Jerri Hurlbutt, who has a keen eye for detail,
word, and idea flow and for use of reference and Internet-accessible information, took a some-
times rough draft and turned it into something of equal measures of accuracy and art. Jerri has
also motivated and inspired us with her efficiency and work ethic. We simply cannot imagine this
final product without Jerri’s input and direction.
There are many, many others who were involved in getting this text from our brains into your
hands, and to those far-too-anonymous people, we also give our sincere thanks. Sales staff, printers,
clerical workers, technicians, and others have all played a vital role in making this text available.
Boris Bard
Eric MacMullin
Jacqueline Williamson
xiii

CONTENTS
UNIT I Mental Health Care: Past and Ethics, 23

Present Ethical Principles, 23
Codes of Ethics, 24
1 The History of Mental Health Care, 2 Ethical Conflict, 24
Early Years, 3 Laws and the Legal System, 25
Ancient Societies, 3 General Concepts, 25
Greece and Rome, 3 Legal Concepts in Health Care, 25
Middle Ages, 4 Laws and Mental Health Care, 26
The Renaissance, 5 Patient–Caregiver Relationship, 26
The Reformation, 5 Adult Psychiatric Admissions, 26
Seventeenth Century, 5 Areas of Potential Liability, 26
Eighteenth Century, 5 Patient Restraint, 27
Nineteenth Century, 6 Care Providers’ Responsibilities, 28
Twentieth Century, 7 The Reasonable and Prudent Caregiver Principle, 28
Psychoanalysis, 7 4 Sociocultural Issues, 31
Influences of War, 7 The Nature of Culture, 31
Introduction of Psychotherapeutic Medications, 8 Characteristics of Culture, 32
Adult Community Mental Health Programs, 8 Influences of Culture, 33
Twenty-First Century, 8 Health and Illness Beliefs, 33
2 Current Mental Health Care Systems, 10 Cultural Assessment, 35
Mental Health Care in Canada, 10 Communication, 35
Mental Health Care in Industrialized Countries, 11 Environmental Control, 36
Norway, 11 Space, Territory, and Time, 37
The United Kingdom, 11 Social Organization, 37
Australia, 11 Biological Factors, 38
The United States, 11 Culture and Mental Health Care, 38
Care Settings, 12 5 Theories and Therapies, 41
Inpatient Care, 12 Historical Theories, 42
Outpatient Care, 12 Darwin’s Theory, 42
Delivery of Community Mental Health Services, 13 Psychoanalytical Theories, 42
Community Care Settings, 14 Psychoanalytical Therapies, 44
Advocacy, 15 Transference and Countertransference, 44
Therapy, 15 Analytical Psychotherapy, 44
Crisis Intervention, 15 Other Theories, 45
The Multidisciplinary Mental Health Care Team, 15 Developmental Theories and Therapies, 45
Care Team, 16 Cognitive Development, 45
Patient and Family, 16 Psychosocial Development, 46
Patient Populations, 16 Behavioural Theories and Therapies, 46
Impact of Mental Illness, 18 B.F. Skinner, 47
Incidence of Mental Illness in Canada, 18 Other Behavioural Therapies, 48
Economic Issues, 18 Humanistic Theories and Therapies, 48
Social Issues, 18 Perls and Gestalt Therapy, 48
3 Ethical and Legal Issues, 21 Maslow’s Influence, 48
Values and Morals, 22 Rogers’s Patient-Centred Therapy, 49
Acquiring Values, 22 Current Humanistic Therapies, 49
Values Clarification, 22 Systems Theories, 49
Rights, 23 Cognitive Theories and Therapies, 50
Patient Rights, 23 Cognitive Restructuring Therapies, 50
Care Provider Rights, 23 Coping Skills Therapies, 50
xv
xvi CONTENTS
Problem-Solving Therapies, 50 Special Considerations, 78

Reality Therapy, 50 Adverse Reactions, 78
Sociocultural Theories, 51 Nonadherence, 78
Mental Illness as Myth, 51 Informed Consent, 79
Biobehavioural Theories, 51
Homeostasis, 51
Stress Adaptation Theory, 51 UNIT II The Caregiver’s Therapeutic
Psychobiology, 52 Skills
Psychoneuroimmunology, 53
Nursing Theories, 53 8 Principles and Skills of Mental Health Care, 82
Psychotherapies, 53 Principles of Mental Health Care, 83
Individual Therapies, 53 The Mentally Healthy Adult, 83
Group Therapies, 53 Mental Health Care Practice, 83
Online Therapy, 54 Do No Harm, 83
Somatic Therapies, 54 Accept Each Patient as a Whole Person, 83
Brain Stimulation Therapies, 54 Develop Mutual Trust, 84
Pharmacotherapy, 55 Explore Behaviours and Emotions, 84
Future Developments, 55 Encourage Responsibility, 85
Encourage Effective Adaptation, 86
6 Complementary and Alternative Therapies, 58
Provide Consistency, 88
Definition of Terms, 59
Skills for Mental Health Care, 89
Allopathic Medicine, 59
Self-Awareness, 89
Complementary Medicine, 59
Caring, 89
Alternative Medicine, 59
Insight, 90
Integrative Medicine, 59
Risk Taking and Failure, 90
Holistic Care, 59
Acceptance, 90
Health Canada’s Licensed Natural Health Products
Boundaries and Overinvolvement, 90
Database, 59
Commitment, 91
Body-Based CAM Therapies, 60
Positive Outlook, 92
Whole Medical Systems, 60
Nurturing Yourself, 92
Biologically Based Therapies, 61
Body-Based Practices, 62 9 Mental Health Assessment Skills, 95
Energy-Based CAM Therapies, 62 Mental Health Treatment Plan, 95
Mind-Body Medicine, 62 DSM-5 Diagnosis, 96
Energy Medicine, 64 Nursing (Therapeutic) Process, 96
Technology-Based CAM Applications, 65 About Assessment, 97
CAM Approaches to Mental Health Care, 65 Data Collection, 97
CAM Mental Health Therapies, 65 Assessment Process, 98
Words of Caution, 66 The Patient at Risk, 100
Adverse Effects, 66 Obtaining a History, 100
Implications for Care Providers, 66 Effective Interviews, 100
Physical Assessment, 101
7 Psychotherapeutic Medication Therapy, 68
Mental Status Assessment, 102
How Psychotherapeutic Medication
General Description, 102
Therapy Works, 69
Emotional State, 102
Classifications of Psychotherapeutic
Experiences, 102
Medications, 70
Thinking, 103
Antianxiety Medications, 71
Sensorium and Cognition, 104
Antidepressant Medications, 72
Mood-Stabilizer Medications, 73 10 Therapeutic Communication, 107
Antipsychotic (Neuroleptic) Medications, 74 Theories of Communication, 108
Signs and Symptoms, 76 Ruesch’s Theory, 108
Patient Care Guidelines, 76 Transactional Analysis, 108
Assessment, 77 Neurolinguistic Programming, 109
Coordination, 77 Characteristics of Communication, 109
Medication Administration, 77 Types of Communication, 109
Monitoring and Evaluating, 78 Process of Communication, 109
Patient Teaching, 78 Factors That Influence Communication, 110
CONTENTS xvii
Levels of Communication, 110 Self-Esteem Needs, 137

Verbal Communication, 110 Self-Actualization Needs, 137
Nonverbal Communication, 111 Variables of the Therapeutic Environment, 138
Intercultural Communication, 111 Admission and Discharge, 138
Intercultural Differences, 111 Adherence, 138
Therapeutic Communication Skills, 112
Listening Skills, 112
Interacting Skills, 112 UNIT III Mental Health Challenges Across the
Nontherapeutic Communication, 114 Lifespan
Barriers to Communication, 114
Nontherapeutic Messages, 114 13 Challenges of Childhood, 142
Problems With Communication, 114 Normal Childhood Development, 143
Communicating With Mentally Troubled Common Behavioural Challenges of Childhood, 143
Patients, 117 Mental Health Challenges of Childhood, 145
Assessing Communication, 117 Environmental Issues, 145
Homelessness, 145
11 The Therapeutic Relationship, 120
Abuse and Neglect, 147
Dynamics of the Therapeutic Relationship, 120
Problems With Parent–Child Interaction, 148
Trust, 121
Parent–Child Conflicts, 148
Empathy, 121
Emotional Challenges, 148
Autonomy, 121
Anxiety, 148
Caring, 122
Depression, 149
Hope, 122
Somatoform Disorders, 149
Characteristics of the Therapeutic
Post-Traumatic Stress Disorder, 149
Relationship, 123
Behavioural Challenges, 149
Acceptance, 123
Children and Violence, 149
Rapport, 123
Children and Electronic Media, 150
Genuineness, 123
Attention-Deficit/Hyperactivity Disorder, 150
Therapeutic Use of Self, 124
Disruptive Behavioural (Conduct) Disorder, 151
Phases of the Therapeutic Relationship, 124
Challenges With Eating and Elimination, 152
Preparation Phase, 124
Eating Disorders, 152
Orientation Phase, 125
Elimination Disorders, 152
Working Phase, 125
Developmental Challenges, 153
Termination Phase, 126
Intellectual Development Disorder, 153
Roles of the Care Provider, 126
Learning Disorders, 153
Change Agent, 126
Communication Disorders, 154
Teacher, 126
Pervasive Developmental Disorders, 154
Technician, 127
Autism, 154
Therapist, 127
Schizophrenia, 155
Problems Encountered in the Therapeutic
Therapeutic Actions, 155
Relationship, 127
Meet Basic Needs, 155
Environmental Problems, 127
Provide Opportunities, 156
Problems With Care Providers, 127
Encourage Self-Care and Independence, 156
Problems With Patients, 128
14 Challenges of Adolescence, 160
12 The Therapeutic Environment, 131
Adolescent Growth and Development, 161
Use of the Inpatient Setting, 132
Physical Development, 161
Crisis Stabilization, 132
Psychosocial Development, 161
Acute Care and Treatment, 132
Common Challenges of Adolescence, 162
The Chronically Mentally Ill Population, 132
Internal (Developmental) Challenges, 162
Goals of a Therapeutic Environment, 133
External (Environmental) Challenges, 162
Help Patients Meet Needs, 133
Teens and Electronic Media, 165
Teach Psychosocial (Adaptive) Skills, 133
Mental Health Challenges of Adolescence, 165
The Therapeutic Environment and Patient
Behavioural Disorders, 165
Needs, 134
Emotional Disorders, 166
Physiological Needs, 134
Mood Disorders, 167
Safety and Security Needs, 135
Eating Disorders, 167
Love and Belonging Needs, 136
xviii CONTENTS
Chemical Dependency, 168 Therapeutic Interventions, 205

Personality Disorders, 169 Assessment, 205
Sexual Disorders, 169 Interventions for Patients Living With Alzheimer’s
Psychosis, 170 Disease, 205
Suicide, 170 Caregiver Support, 207
Therapeutic Interventions, 171
Surveillance and Limit Setting, 171
Building Self-Esteem, 171 UNIT IV Patients With Psychological
Skill Development, 171 Challenges
15 Challenges of Adulthood, 174
18 Managing Anxiety, 211
Adult Growth and Development, 174
Continuum of Anxiety Responses, 212
Common Challenges of Adulthood, 176
Types of Anxiety, 212
Internal (Developmental) Challenges, 176
Types of Anxiety Responses, 212
External (Environmental) Challenges, 178
Coping Methods, 212
Mental Health Challenges of Adults, 180
Defence Mechanisms, 213
Crisis, 213
Health Care Interventions, 180
Self-Awareness and Anxiety, 215
Preventing Mental Illness, 180
Theories Relating to Anxiety, 215
16 Challenges of Late Adulthood, 183 Biological Models, 215
Overview of Aging, 183 Psychodynamic Model, 215
Facts and Myths of Aging, 184 Interpersonal Model, 216
Physical Health Changes, 185 Behavioural Model, 216
Mental Health Changes, 185 Other Models, 216
Research and Aging, 185 Anxiety Throughout the Life Cycle, 216
Common Challenges of Older Persons, 186 Anxiety in Childhood, 216
Physical Adaptations, 187 Anxiety in Adolescence, 217
Health Care Services, 187 Anxiety in Adulthood, 217
Psychosocial Adaptations, 188 Anxiety in Older Persons, 217
Mental Health Challenges of Older Anxiety Disorders, 217
Persons, 190 Separation Anxiety Disorder, 218
Elder Abuse, 191 Selective Mutism, 218
Dementia, Depression, and Delirium, 191 Specific Phobia, 218
Therapeutic Interventions, 192 Social Anxiety Disorder, 218
Age-Related Interventions, 192 Panic Disorders, 218
Mentally Ill Older Persons, 192 Agoraphobia, 219
Mental Health Promotion and Prevention, 193 Generalized Anxiety Disorder (GAD), 219
Obsessive-Compulsive and Related
17 Cognitive Impairment, Alzheimer’s Disease, and
Disorders, 219
Dementia, 196
Obsessive-Compulsive Disorder (OCD), 219
Confusion Has Many Faces, 196
Body Dysmorphic Disorder, 220
Normal Changes in Cognition, 196
Hoarding Disorder, 221
The Three “D’s” of Confusion, 197
Hair-Pulling Disorder (Trichotillomania), 221
Medications and the Older Population, 197
Excoriation Disorder (Skin Picking), 221
Patients With Delirium, 197
Substance-/Medication-Induced Obsessive-
Finding the Cause, 199
Compulsive and Related Disorder, 221
Treating Delirium, 200
Obsessive-Compulsive and Related Disorder
Patients With Dementia, 200
Due to Another Medical Condition, 221
Symptoms of Dementia, 200
Other Specified Obsessive-Compulsive and Related
Gentle Persuasive Approach, 201
Disorder, 221
Dementia Care, 201
Unspecified Obsessive-Compulsive and
Causes of Dementia, 202
Related Disorder, 221
Alzheimer’s Disease, 202
Trauma- and Stressor-Related Disorder, 221
Symptoms and Course, 202
Reactive Attachment Disorder, 221
After the Diagnosis, 204
Disinhibited Social Engagement Disorder, 222
Principles of Management, 204
CONTENTS xix
Post-Traumatic Stress Disorder (PTSD), 222 Substance-/Medication-Induced Depressive

Acute Stress Disorder, 222 Disorder, 252
Adjustment Disorder, 223 Depressive Disorder Due to Another Medical
Other Specific Trauma- and Stressor-Related Condition, 252
Disorder, 223 Other Specified Depressive Disorder, 253
Unspecific Trauma- and Stressor-Related Unspecified Depressive Disorder, 253
Disorder, 223 Bipolar and Related Disorders, 253
Therapeutic Interventions, 223 Bipolar I Disorder, 253
Bipolar II Disorder, 254
19 Illness and Hospitalization, 227
Cyclothymic Disorder, 254
The Nature of Illness, 228
Substance-/Medical-Induced Bipolar and Related
Stages of the Illness Experience, 228
Disorder, 254
Effects of Illness, 229
Bipolar and Related Disorder Due to Another
The Hospitalization Experience, 230
Medical Condition, 254
Situational Crisis, 230
Other Specified Bipolar and Related Disorder, 254
Psychiatric Hospitalization, 231
Unspecified Bipolar and Related Disorder, 254
Psychosocial Care, 232
Treatment and Therapy, 255
Pain Management, 234
Medication Therapies, 256
Discharge Planning, 234
Nursing (Therapeutic) Process, 259
20 Loss and Grief, 236
22 Physical Challenges, Psychological Sources, 262
The Nature of Loss, 236
Role of Emotions in Health, 263
Characteristics of Loss, 237
Anxiety and Stress, 263
Loss Behaviours Throughout the
Childhood Sources, 264
Life Cycle, 237
Common Psychophysical Challenges, 264
The Nature of Grief and Mourning, 238
Theories of Psychophysical Disorders, 264
The Grieving Process, 238
Somatic Symptom and Related Disorders, 265
Stages of the Grieving Process, 238
Cultural Influences, 265
The Dying Process, 240
Somatic Symptom Disorder, 266
Age Differences and Dying, 240
Illness Anxiety Disorder, 266
Terminal Illness, 240
Conversion Disorder, 267
Cultural Factors, Dying, and Mourning, 241
Psychological Factors Affecting Other Medical
Stages of Dying, 241
Conditions, 268
Other Specified Somatic Symptom and Related
Hospice Care, 242
Disorder, 268
Meeting the Needs of Dying Patients, 243
Unspecified Somatic Symptom and Related
Loss, Grief, and Mental Health, 243
Disorder, 268
21 Depression and Other Mood Disorders, 247 Factitious Disorder, 268
Continuum of Emotional Responses, 248 Other Conditions That May Be a Focus of Clinical
Theories Relating to Emotions and Their Attention, 269
Disorders, 248 Malingering, 269
Biological Evidence, 248 Implications for Care Providers, 269
Other Theories, 248
23 Eating and Sleeping Disorders, 272
Emotions Throughout the Life Cycle, 249
Feeding and Eating Disorders, 273
Emotions in Childhood, 249
Pica, 274
Emotions in Adolescence, 249
Rumination Disorder, 274
Emotions in Adulthood, 250
Avoidant/Restrictive Food Intake Disorder, 274
Emotions in Older Persons, 250
Anorexia Nervosa, 274
Characteristics of Mood Disorders, 250
Bulimia Nervosa, 276
Depressive Disorders, 250
Binge Eating Disorder, 277
Disruptive Mood Dysregulation
Obesity, 277
Disorder, 250
Guidelines for Intervention, 279
Major Depressive Disorder, 251
Sleep–Wake Disorders, 280
Major Depressive Disorder With Specifiers, 251
Insomnia Disorder, 281
Persistent Depressive Disorder (Dysthymia), 252
Hypersomnolence Disorder, 281
Premenstrual Dysphoric Disorder, 252
xx CONTENTS
Narcolepsy, 282 26 Outward-Focused Emotions: Violence, 310

Breathing-Related Sleep Disorders, 282 Social Factors and Violence, 311
Circadian Rhythm Sleep–Wake Disorder, 282 Theories of Violence, 312
Parasomnias, 283 Abuse, Neglect, and Exploitation Within the
Other Sleep Disorders, 283 Family, 312
Guidelines for Intervention, 283 Domestic Violence, 313
Intimate Partner Abuse, 313
24 Dissociative Disorders, 286
Abuse During Pregnancy, 314
Continuum of Self-Concept Responses, 287
Child Abuse, 314
The Healthy Personality, 287
Adolescent Abuse, 317
Self-Concept Throughout the Life Cycle, 287
Elder Abuse, 318
Self-Concept in Childhood, 287
Sexual Abuse, 318
Self-Concept in Adolescence, 287
Abuse, Neglect, and Exploitation Within the
Self-Concept in Adulthood, 288
Community, 318
Self-Concept in Older Adulthood, 288
Violence Against Health Care Workers, 318
Dissociative Disorders, 288
Violence, Trauma, and Crime, 318
Characteristics, 288
Group Abuse, 319
Depersonalization/Derealization
Mental Health Disorders Relating to Violence, 320
Disorder, 289
Post-Traumatic Stress Disorder, 320
Dissociative Amnesia and Dissociative Amnesia
Rape-Trauma Syndrome, 320
With Fugue, 289
Dissociative Identity Disorder, 291
Special Assessments, 321
Trance, 291
Treating Victims of Violence, 321
Other Specified Dissociative Disorders, 291
Preventing Violence in Your Life, 321
Treatments and Therapies, 292 27 Inward-Focused Emotions: Suicide, 327
Continuum of Behavioural Responses, 328
Myths About Suicide, 328
UNIT V Patients With Psychosocial Impact of Suicide on Society, 328
Challenges Cultural Factors, 328
Social Factors, 329
25 Anger and Aggression, 297 Dynamics of Suicide, 330
Anger and Aggression in Society, 299 Characteristics of Suicide, 330
Gender Aggression, 299 Categories of Motivation, 331
Aggression Throughout the Life Cycle, 299 Theories About Suicide, 332
Scope of the Problem Today, 300 New Biological Evidence, 332
Theories of Anger and Aggression, 300 Effects of Suicide on Others, 332
Biological Theories, 300 Suicide Throughout the Life Cycle, 333
Psychosocial Theories, 300 Suicide and Children, 333
Sociocultural Theories, 301 Suicide and Adolescents, 333
The Cycle of Assault, 301 Suicide and Adults, 333
Trigger Stage, 301 Suicide and Older Persons, 334
Escalation Stage, 301 Therapeutic Interventions, 335
Crisis Stage, 302 Assessment of Suicidal Potential, 335
Recovery Stage, 302 Therapeutic Interventions for Suicidal Patients, 336
Depression Stage, 302
28 Substance-Related Disorders and Addictive
Disruptive, Impulse-Control, and Conduct
Disorders, 340
Disorders, 302
The Role of Chemical Substances in Society, 341
Oppositional Defiant Disorder, 302
Substance Use and Age, 341
Intermittent Explosive Disorder, 303
Scope of the Problem Today, 343
Conduct Disorder, 303
Categories of Abused Substances, 343
Antisocial Personality Disorder, 303
Severity of Impact and Legality, 343
Pyromania, 303
Alcohol, 343
Kleptomania, 303
Caffeine, 346
Cannabis, 346
Assessing Anger and Aggression, 304
Hallucinogens, 347
CONTENTS xxi
Inhalants, 347 Psychopaths and Sociopaths, 378

Opioids (Narcotics), 348 Fearful Cluster, 379
Sedatives (Hypnotics or Anxiolytics), 349 Therapeutic Interventions, 379
Stimulants, 349 Treatment and Therapy, 379
Tobacco (Nicotine), 350 Nursing (Therapeutic) Process, 380
Other Medications, 351
31 Brain Function, Schizophrenia, and Other
Characteristics of Substance Use and Abuse, 351
Psychoses, 383
Stages of Addiction, 351
A Few Facts About Our Brains, 384
Substance-Related Disorders and Addictive
Brain Function, 384
Disorder, 352
Normal Brain Function, 385
Similarity Between Addiction and Other
Abnormal Brain Function, 386
Disorders, 352
Psychosis, 388
Three Main Malfunctions Leading to Addiction, 352
The Schizophrenia Spectrum, 388
Delusional Disorder, 388
Assessment, 353
Brief Psychotic Disorder, 388
Treatments and Therapies, 354
Schizophreniform Disorder, 388
Relapse, 356
Schizophrenia, 388
Nursing/Therapeutic Process, 356
Schizoaffective Disorder, 391
29 Sexuality and Sexual Disorders, 360 Substance/Medication-Induced Psychotic
The Continuum of Sexual Responses, 361 Disorder, 391
Self-Awareness and Sexuality, 361 Psychotic Disorder Due to a Medical Condition, 391
Sexuality Throughout the Life Cycle, 362 Catatonia Associated With a Mental Disorder, 391
Sexuality in Childhood, 362 Other Specified Schizophrenia Spectrum and Other
Sexuality in Adolescence, 362 Psychotic Disorder, 393
Sexuality in Adulthood, 363 Unspecified Schizophrenia Spectrum and Other
Sexuality in Older Adulthood, 363 Psychotic Disorder, 393
Sexuality and Disability, 363 Therapeutic Interventions, 393
Sexual Orientation, 363 Treatments and Therapies, 393
Gender Identity, 364 Nursing (Therapeutic) Process, 394
Gender Identity Terminology, 364 Special Considerations, 395
Paraphilic Disorders, 365 Nursing Responsibilities, 399
Other Specified Paraphilic Disorders, 365
32 Chronic Mental Health Disorders, 402
Unspecified Paraphilic Disorder, 365
Scope of Mental Illness, 403
Therapeutic Approach, 366
Public Policy and Mental Health, 403
Sexual Dysfunctions, 366
Effects of Deinstitutionalization, 403
Gender Dysphoria, 366
Experience of Chronic Mental Illness, 403
Pornography, 367
Meeting Basic Needs, 403
Access to Health Care, 403
Psychosexual Assessment, 368
Characteristics of Chronic Mental Illness, 404
Nursing/Therapeutic Process, 368
Behavioural Characteristics, 405
30 Personality Disorders, 372 Physical Characteristics, 405
Continuum of Social Responses, 373 Psychological Characteristics, 405
Personality Throughout the Life Cycle, 373 Special Populations, 405
Personality in Childhood, 373 Children and Adolescents Living With Chronic
Personality in Adolescence, 373 Mental Illness, 406
Personality in Adulthood, 374 Older Persons Living With Chronic Mental
Personality in Older Adulthood, 374 Illness, 406
Theories Relating to Personality Persons With Multiple Disorders, 406
Disorders, 374 Providing Care for People Who Are Chronically
Biological Theories, 374 Mentally Ill, 406
Psychoanalytical Theories, 374 Inpatient Settings, 406
Behavioural Theories, 374 Outpatient Settings, 407
Sociocultural Theories, 375 Psychiatric Rehabilitation, 407
Personality Disorders, 375 Therapeutic Interventions, 407
Eccentric Cluster, 376 Treatments and Therapies, 407
Erratic Cluster, 377 Nursing (Therapeutic) Process, 408
xxii CONTENTS
33 Challenges for the Future, 414 Obligations of Care Providers, 419

Changes in Mental Health Care, 414 Providers of Care, 419
Change in Settings, 415 Expanded Role for Nurses, 420
Challenges Created by the Canadian Health Care Making Change in the Health Care System, 420
System, 415 The Change Process, 421
Long-Acting Injectables, 416 Other Challenges, 422
Homelessness, 416 The Challenge to Care, 422
The Canadian Charter of Rights and A Look to the Future, 422
Freedoms, 417 Appendix
Cultural Influences, 417 A. Mental Status Assessment at a Glance, 424
The Mental Health Care Team, 418 B. A Simple Assessment of Tardive Dyskinesia
Team Members, 418 Symptoms, 425
Mental Health Care Delivery Settings, 418 C. Canadian Standards for Psychiatric-Mental Health
Change and Mental Health Patients, 418 Nursing, 426
Competency, 418 Glossary, 429
Empowerment of Patients, 418 Index, 441
Obligations of Patients, 419
UNIT I
Mental Health Care:
Past and Present
1
1
The History of Mental Health Care
OBJECTIVES
Upon completion of this chapter, the student will be able to: 5. Discuss the effect of World Wars I and II on attitudes
1. Develop a foundational understanding of mental health toward people with mental illnesses.
and mental illness. 6. State the major change in the care of people with
2. List the major factors believed to influence the mental illnesses that resulted from the discovery of
development of mental illness. psychotherapeutic medications.
3. Describe the role of the Church in the care of the 7. Describe the development of community mental health
mentally ill during the Middle Ages. care centres during the 1960s and 1970s.
4. Compare the major historical contributions made 8. Discuss the shift of mentally ill patients from institutional
by Philippe Pinel, Dorothea Dix, Dr. C.K. Clarke, care to community-based care.
and Clifford Beers to the care of persons with mental 9. Discuss political influences on mental health care.
disorders.
OUTLINE
Early Years, 3 Twentieth Century, 7
Nineteenth Century, 6 Twenty-First Century, 8
KEY TERMS
catchment (KĂCH-mĭnt) area (p. 8) lobotomy (lŏ-BŎT-ә-mē) (p. 7)
deinstitutionalization (dē-ĭn-stĭ-TOO-shәn-lĭ-ZĀ-shәn) lunacy (LOO-nә-sē) (p. 4)
(p. 8) mental health (MĒN-tăl) (p. 2)
demonic exorcisms (dē-MŎN-ĭk ĔK-sŏr-sĭs-әms) (p. 4) mental illness (p. 2)
electroconvulsive therapy (ē-lĕk-trō-kŏn-VŬL-sĭv THĔR- psychoanalysis (sī-kō-ă-NĂL-Ĭ-sĭs) (p. 7)
ә-pē) (ECT) (p. 7) psychotherapeutic (SĪ-kō-THĔR-ә-PŪ-tĭk) medications
health–illness continuum (cŭn-TĬN-ū-әm) (p. 2) (p. 8)
humoral (HŪ-mŏr-ăl) theory of disease (p. 3) trephining (tre-PHIN-ing) (p. 3)

Mental/emotional health is interwoven with physical health. and fruitfully, and is able to make a contribution to his or her
Behaviours relating to health exist over a broad spectrum, community” (World Health Organization [WHO], 2018).
often referred to as the health–illness continuum (Fig. 1.1). Mentally healthy people successfully carry out their activities
People who enjoy robust health are placed at the higher-level of daily living, adapt to change, solve problems, set goals, pri-
wellness end of the continuum. Individuals with significant or oritize challenges, and enjoy life. They are self-aware, directed,
multiple health challenges are typically placed at the continu- and responsible for their actions. People who are able to cope
um’s opposite end. Most of us, however, function somewhere well are generally considered to be mentally healthy.
between these two extremes. As we meet with the stresses Mental health is influenced by three factors: inher-
of life, our coping abilities are repeatedly challenged and we ited characteristics, childhood nurturing, and life circum-
strive to adjust in appropriate ways. When stress is physical, stances. The risk for developing ineffective coping behaviours
the body calls forth its defence systems and wards off illness. increases when problems or deficits exist in any one of these
When stress is emotional or developmental, we respond by areas. Mental illness can impact an individual’s ability to
using our established coping behaviours or sometimes creat- cope effectively, carry out daily activities, accurately interpret
ing new (and hopefully effective) coping behaviours. reality, execute sound judgement, and have accurate insights
Mental health is the ability to exist in “a state of well-being into the many challenges of daily life.
in which the individual realizes his or her own abilities, can Society’s understanding of the causes of mental health
cope with the normal stresses of life, can work productively challenges has changed dramatically throughout our history
2
CHAPTER 1 The History of Mental Health Care 3
(Table 1.1). As we have advanced in our knowledge of anat- masks and noises, incantations, vile odours, charms, spells, sac-
omy and physiology, our beliefs around mental health disor- rifices, and fetishes” (Kelly, 1991). Physical treatments included
ders have gone from being based in superstition to grounded blood-letting, massage, blistering, inducing vomiting, and the
in biochemical and behavioural investigations. practice of trephining—cutting holes in the skull to encourage
the evil spirits to leave. Generally, members of primitive soci-
eties with bizarre behaviours were allowed to remain within
EARLY YEARS their communities as long as their behaviours were not dis-
Illness, injury, and mental illness have concerned humanity ruptive. Severely ill or violent members of the group were often
throughout history. Physical illness and injury were easy to driven into the wilderness to fend for themselves, away from
detect with nothing but the five senses. Mental illness was the safety and support the community offered.
something different—something where the cause could not
be seen, felt, or obviously understood—and therefore a con- Greece and Rome
dition to be feared. Superstitions and magical beliefs dominated thinking until
the Greeks introduced the idea that mental illness could be
Ancient Societies rationally explained through observation. The Greeks incor-
Although historical records on ancient societies are vague, it porated many ideas about illness from other cultures. By the
can be assumed that some care was given to sick or injured sixth century bce, medical schools were well established. The
people. Some early societies believed that everything in greatest physician in Greek medicine, Hippocrates, was born
nature was alive with spirits. Illness was sometimes thought in 460 bce. He was the first to base treatment on the belief
to be caused by the influence of evil spirits or demons. that nature is a strong healing force. He felt that the role of
Treatments for mental illness focused on removing the de- the physician was to assist in, rather than direct, the healing
mons or evil spirits. Magical therapies made use of “frightening process. Proper diet, exercise, and personal hygiene were his
mainstays of treatment. Hippocrates viewed mental illness
as a result of an imbalance of humors—the fundamental ele-
HEALTH–ILLNESS CONTINUUM ments of air, fire, water, and earth. Each basic element had
a related humor or part in the body. An overabundance or
lack of one or more humors resulted in illness. This view (the
Severe Illness High-Level Wellness
humoral theory of disease) persisted for centuries.
Risk factors to Plato (427–347 bce), a Greek philosopher, recognized life
functioning in all as a dynamic balance maintained by the soul. According to
dimensions Plato a “rational soul” resided in the head and an “irrational
Fig. 1.1 The health–illness continuum, ranging from high-level well-
soul” was found in the heart and abdomen. He believed that
ness to severe illness, provides a method of identifying a patient’s if the rational soul was unable to control the undirected parts
level of health. of the irrational soul, mental illness resulted.
TABLE 1.1 History at a Glance

History at a Glance View of Mental Illness Events
Greece and Rome Imbalance of humors Plagues, the (Christian) Church cared for mentally ill
Middle Ages Demonic possession Bedlam institution for mentally ill, 1247; witch hunts
Renaissance Brain disorder, possession by devil Treatment remains inhumane
Reformation Demonic possession, some reasoning Church stopped caring for the sick
Seventeenth and Demonic possession Quakers opened asylums
eighteenth centuries Pinel advocated humane care
Treatment remained harsh
Nineteenth century Disease of the mind, may be curable D. Dix, Dr. C.K. Clarke advocated humane care
B. Rush wrote first text on mental illness
Two-class system of private and public care
Twentieth century Freud’s psychoanalytical theories, Effects of World Wars I and II advance study of
behaviour can be changed mental illness
Psychotherapeutic medications were introduced
Mentally ill were deinstitutionalized
Twenty-first century Biochemical imbalances Lawmakers defining national health policies
Physical causes of mental illness investigated
4 UNIT I Mental Health Care: Past and Present
The principles and practices of Greek medicine became insane, it had to be the result of some external force. The
established in Rome around 100 bce, but most physicians still moon and lunar cycles were often associated with aberrant
thought that demons caused mental illness. The practice of behaviour, thus the term lunacy was coined, meaning “a dis-
frightening away evil spirits to cure mental illness was reintro- order caused by a lunar body” (Alexander & Selesnick, 1966).
duced, and its use continued well into the Middle Ages. Based In time, large institutions were established, and mentally ill
on historical evidence, Romans seemed to have shown little individuals were housed in “lunatic asylums.” Despite some
interest in the body or mind. Most Roman physicians pro- improvements in caring for such individuals, magical influ-
vided symptomatic relief and “wanted to make their patients ences were still used to explain the torments of the mind.
comfortable by pleasant physical therapies” (Alexander &
Selesnick, 1966), such as warm baths, massage, music, and Superstitions, Witches, and Hunters
peaceful surroundings. The Church’s doctrine of imposed celibacy failed to curtail
By 300 ce, multiple epidemics killed hundreds of thou- many of the clergy’s sexual behaviours, and so began an
sands of people and desolated the land (Alexander & antierotic movement that focused on women as the cause
Selesnick, 1966). Churches often became sanctuaries for of men’s lust. Women were thought to be easily influenced
the sick, and soon hospitals were built to accommodate the by the devil and other external magical forces that stirred
high numbers of sufferers. By 370 ce, Saint Basil’s Hospital men’s passions. As the historians Alexander and Selesnick
in England offered services for sick, orphaned, crippled, and (1966) note, “Psychotic women with little control over voi-
mentally troubled people. cing their sexual fantasies and sacrilegious feelings were
the clearest examples of demoniacal possession.” This cam-
Middle Ages paign, in turn, flamed the public’s mounting fear of men-
Dark Ages tally troubled people.
From about 500 ce to 1100 ce (in the Western world), priests Witch-hunting was officially launched in 1487 with the
cared for the sick as the (Christian) Church developed into a publication of the book the Malleus Maleficarum, or The
highly organized and powerful institution. Early Christians Witches’ Hammer. This was considered to be a guidebook on
believed that disease was “God’s retribution for personal or the prosecution of witches in a court of law (Kramer, 2019).
hereditary sin” (Ferngren, 2016). To cure mental illness, priests Soon thereafter, Pope Innocent VIII and the University of
performed demonic exorcisms—religious ceremonies in Cologne voiced support for this “textbook of the Inquisition.”
which patients were physically punished to drive away the evil As a result of this one publication, women as well as children
possessing spirit. Fortunately, Christian charity tempered these and mentally ill persons were tortured and burned at the stake
practices as members of the community cared for the mentally by the thousands. There were few safe havens for individuals
ill with concern and sympathy. with mental illness during these troubled times.
As time passed, medieval society declined. Repeated The first English institution for mentally ill people was
attacks from barbaric tribes led to chaos and moral decay. initially a hospice founded in 1247 by the sheriff of London.
Epidemics, natural disasters, and overwhelming taxes sig- By 1330, Bethlehem Royal Hospital had developed into a
nificantly reduced the size and influence of the middle class. lunatic asylum that eventually became infamous for its brutal
Cities, industries, and commerce disappeared or became treatments. Violently ill patients were chained to walls in
much reduced. “The population declined, crime waves small cells and were often used to provide entertainment for
occurred, poverty was abysmal, and torture and imprison- the public. Hospital staff would charge fees and conduct tours
ment became prominent as civilization seemed to slip back through the institution. Less violent patients were forced
into semi-barbarianism” (Donahue, 1996). Only monasteries to wear identifying metal armbands and beg on the streets.
remained as the last refuge of care and knowledge. Individuals who had mental health challenges were harshly
Throughout the Middle Ages, medicine and religion were treated in those times, but Bethlehem Royal Hospital, com-
interwoven. However, by 1130 laws were passed forbidding monly called Bedlam (Fig. 1.2), even with the documented
monks to practise medicine because it was considered too abuses, was a moderately preferable option.
disruptive to their way of life (Amundsen, 1978). As a result, By the middle of the fourteenth century, the European
responsibility for the care of sick people once again fell to continent had endured several devastating plagues and epi-
family members and the community at large. demics. One quarter of the earth’s population, more than
In the late 1100s, a strong Arabic influence was felt in 60 million people, perished from infectious diseases dur-
Europe. Knowledge of the Greek legacy had been retained and ing this period. The feudal system lost power and declined.
improved upon by the Arabs. They had extensive knowledge Cities began to flourish and housed a growing middle
of drugs, mathematics, astronomy, and chemistry, as well as class. As nursing historian Donahue (1996) notes, “Luxury
an awareness of the relationship between emotions and dis- and misery, learning and ignorance existed side by side.”
ease. The Arabic influence resulted in the establishment of Society was beginning to demand social reforms around
learning centres, called universities. Many were devoted to the employment and payment for work done. Ironically, as the
study of medicine, surgery, and care of the sick. age of art, medicine, and science dawned, the hunting of
Problems of the mind, however, received only spiritual “witches” became even more popular. It was a time of great
attention. Church doctrine still stated that if a person was contradictions.
Church and became known as Protestants. As a result of this

separation, many hospitals operated by the Catholic Church
began to close. Once again, the poor, sick, and mentally ill
were turned out into the streets.
Seventeenth Century
During the seventeenth and eighteenth centuries, develop-
ments in science, literature, philosophy, and the arts laid the
foundations for the world we know today. Reason slowly
began to replace magical thinking, but a strong belief in
demons nonetheless persisted. The 1600s produced many
great thinkers, and knowledge of the secrets of nature brought
a sense of self-reliance. However, many people remained
uncomfortable with these changes in the sciences and other
areas and once again moved toward the security of witch-hunt-
ing as a means of protecting themselves from the un-
explainable.
Fig. 1.2 Bethlehem Royal Hospital in London. (William Hogarth, “The In the seventeenth century, conditions for the mentally ill
Rake in Bedlam,” c. 1735. From the series titled The Rake’s Prog-
ress. Copyright The British Museum, London.)
were at their worst. While physicians and theorists were mak-
ing observations and speculations about insanity, patients
were bled, starved, and beaten into submission. Treatments
The Renaissance for the mentally troubled remained in this unhappy state until
The Renaissance began in Italy around 1400 and spread the late eighteenth century.
throughout the European continent within a century.
Upheavals in economics, politics, education, and commerce Eighteenth Century
brought the world into focus. The power of the Church During the latter part of the eighteenth century, psychiatry
declined to some degree, as an intense interest in material gain developed as a separate branch of medicine. Inhumane treat-
and worldly affairs developed. At the same time, the medieval ment and vicious practices were openly questioned. In 1792,
view of the naked body as sinful changed into more positive Philippe Pinel (1745–1826), the director of two Paris hospitals,
perceptions of the human form as a result of work by artists liberated patients from their chains “and advocated accept-
such as da Vinci, Raphael, and Michelangelo. Thousand-year- ance of the mentally ill as human beings in need of medical
old anatomy books were replaced by volumes with art dis- assistance, nursing care, and social services” (Donahue, 1996).
playing realistic anatomical drawings. Observation, rather During this period, William Tuke, a member of a religious order
than ancient theories, revolutionized many of the ideas of called the Quakers, helped to established asylums of humane
the day. care in England. Initially a businessman, Mr. Tuke devoted
Sixteenth-century physicians, relying on observation, much of his time to raising funds to open the York Retreat, a
began to record what they saw. Mental illness was at last being residential treatment centre where the mentally ill were to be
recognized with much less bias than before. By the mid-1500s, cared for with kindness, dignity, and decency (Reisman, 1991).
behaviours were accurately recorded for melancholia (depres- In the American colonies the Philadelphia Almshouse was
sion), mania, and psychopathic behaviours. Precise observa- erected in 1731. It accepted sick, infirm, and insane patients
tions led to classifications for different abnormal behaviours. as well as prisoners and orphans. In 1794, Bellevue Hospital
Mental problems were now thought to be caused by some in New York City was opened as a pesthouse (a shelter or
sort of brain disorder—except in the case of sexual fantasies, hospital for people who were suffering from infectious dis-
which were still considered to be God’s punishment or to eases) for the victims of yellow fever. By 1816 the hospital had
be possession by the devil. However, despite great advances enlarged to contain an almshouse for poor people, wards for
in knowledge about the brain and mental illness, the actual the sick and insane, staff quarters, and even a penitentiary.
treatment of mentally troubled people remained ineffective In 1835, in New Brunswick, on the site of a former cholera
and inhumane. hospital, a provincial lunatic asylum was established, making
it the first dedicated mental health facility in British North
The Reformation America (Austin, Kunyk, Peternelj-Taylor, et al., 2019).
Another movement that influenced the care of the sick—the In spite of some advances, the care and treatment of people
Protestant Reformation—occurred from 1517 to 1648. Many with mental illness remained harsh and indifferent. The prac-
people were displeased with the conduct of the clergy and tice of allowing poor people and family members to care for
widespread abuses occurring within the Catholic Church. the mentally ill continued well into the late 1800s and was
Martin Luther (1483–1546), a monk who had questioned only slowly abandoned. Actual care of mentally ill persons in
many of the teachings, philosophy, and restrictions of the the United States did not begin to improve until the arrival
church, and his followers broke away from the Catholic of Alice Fisher, a Florence Nightingale–trained nurse, in
Fig. 1.5 Circulating swing and bed. (Redrawn from U.S. National
Fig. 1.3 A patient in chains in Bedlam, London’s notorious Bethle- Library of Medicine, Bethesda, MD.)
hem Royal Hospital. (Courtesy U.S. National Library of Medicine,
Bethesda, MD.)
NINETEENTH CENTURY
Changes that occurred during the early 1800s had an enor-
mous impact on the care of the mentally ill population. In the
early to middle parts of that century, events like the attempted
US invasion of Canada and ongoing rebellions against British
rule in Upper and Lower Canada resulted in countermeasures
to usher in political stability. Quebec, Ontario, Nova Scotia,
and New Brunswick became the first four provinces to form
a confederation. Many political processes became stable as a
result of this confederation, including a more organized and
structured medical care for their populations, which included
the mentally ill.
One of the most important figures in nineteenth-century
psychiatry was Dr. Benjamin Rush (1745–1813). His book,
Diseases of the Mind, was the first psychiatric text written
in the United States, advocating clean conditions (good air,
lighting, and food) and kindness. As a result of Rush’s efforts,
mentally troubled people were no longer caged in the base-
Fig. 1.4 Tranquilizing chair. (Courtesy U.S. National Library of Medi-
ments of general hospitals. However, only a few institutions
cine, Bethesda, MD.) for insane persons were available in the United States at this
time, and even fewer were in Canada.
1884. In Canada, the Hôtel Dieu, located in Quebec, pro- During the 1830s, attitudes toward mental illness slowly
vided some institutional care for “indigents, the crippled, and began to change. The “once insane, always insane” concept
idiots”; however, standards of care remained low (Hurd, 1973; was replaced with the notion that cure might be possible in
Sussman, 1998). some circumstances. A few mental hospitals were built, but the
By the close of the eighteenth century, treatments for people actual living conditions for most patients remained deplorable.
with mental illness still included the medieval practices of It was not until 1841 that a 40-year-old schoolteacher
bloodletting, purging, and confinement (Fig. 1.3). Newer ther- exposed the inherent cruelty and inhumanity of the system.
apies included demon-expelling tranquilizing chairs (Fig. 1.4) Dorothea Dix was contracted to teach Sunday school at a jail
and whirling devices (Fig. 1.5). The study of psychiatry was in in Massachusetts. While there, she saw both criminals and
its infancy, and those who actually cared for insane people still mentally ill prisoners living in squalid conditions. For the
relied heavily on the methods of their ancestors. next 20 years, Dix surveyed asylums, jails, and almshouses
throughout Canada, the United States, and Scotland. It was Found Itself, recounted the beatings, isolation, and confine-
not uncommon for her to find mentally ill people “confined ment of a mentally ill person. As a direct result of Beers’s
in cages, closets, cellars, stalls, and pens . . . chained, naked, work, the Committee for Mental Hygiene was formed in 1909.
beaten with rods and lashed into obedience” (Dolan, 1968). In addition to prevention, the group focused on removing
Dix presented her findings to anyone who would listen. the stigma attached to mental illness. Under Beers’s energetic
The public responded so well to Dix’s efforts that millions of guidance, the movement grew nationwide and ultimately had
dollars were raised, more than 30 mental hospitals through- a global impact. The social consciousness of a nation had
out the United States were constructed, and care of the men- finally been awakened.
tally ill greatly improved.
By the late 1800s, a two-class system of psychiatric care Psychoanalysis
had emerged: private care for the wealthy and publicly pro- In the early 1900s, a neurophysiologist named Sigmund
vided care for the remainder of society. The newly con- Freud published an article that introduced the term psycho-
structed mental institutions were quickly filled, and soon analysis to the world’s vocabulary. Freud believed that forces
chronic overcrowding began to strain the system. Cure rates both within and outside the personality were responsible for
fell dramatically. The public became disenchanted, and men- mental illness. He developed elaborate theories around the
tal illness once again was viewed as incurable. Only small, theme of repressed sexual energies. Freud was the first to
private facilities that catered to the wealthy had some degree succeed in “explaining human behavior in psychologic terms
of success. In the absence of funding from the government, and in demonstrating that behavior can be changed under
some facilities had evolved into large, remote institutions that the proper circumstances” (Alexander & Selesnick, 1966).
became partially self-reliant, while still dependent on dona- The first comprehensive theory of mental illness based on
tions and benefactors. observation had emerged, and psychoanalysis began to gain a
By the close of the nineteenth century, many of the gains in strong foothold in America (see Chapter 5).
the care of mentally ill persons had been lost. Overpopulated
institutions could offer no more than minimal custodial care. Influences of War
Theories of the day gave no satisfactory explanations about During the first World War, in the United States and to a lesser
the causes of mental health challenges, and current treat- degree in Canada, men were drafted into military service as
ments remained ineffective. It was a time of despair for men- rapidly as they could be processed. Some, however, were con-
tally troubled people and those who cared for them. sidered to be unfit mentally to engage in battle. As a result,
Dr. C.K. Clarke, a graduate of the University of Toronto, the US government called on Beers’s Committee for Mental
became highly influential in the delivery of mental health ser- Hygiene to develop a more efficient process for screening and
vices in Ontario and, ultimately, Canada. As early as 1881, treating mentally ill soldiers. The completed plan included
Dr. Clarke and his brother-in-law, Dr. William Metcalfe, methods for early identification of mental problems, removal
advocated for the removal of restraints as a regular practice of mentally troubled personnel from combat duty, and early
in mental health institutions. Sadly, Dr. Metcalfe was attacked treatment close to the fighting front. The committee also rec-
by a paranoid patient and killed; however, Dr. Clarke con- ommended that psychiatrists be assigned to station hospitals
tinued to advocate for more humane treatment for the men- to treat combat veterans with acute behavioural problems
tally ill (Pos, Walters, & Sommers, 1975). The Clarke Institute and provide ongoing psychiatric care after soldiers returned
of Psychiatry, a world-renowned treatment facility, opened to their homes.
in Toronto in 1966 and was named in honour of Dr. Clarke. Because of the war, a renewed interest in mental hygiene
In 2002, the Clarke Institute became part of the Canadian was sparked. During the 1930s, new therapies for treating
Mental Health Association (CMHA). insanity were developed. Insulin therapy for schizophre-
nia induced 50-hour comas through the administration of
massive doses of insulin. Passing electricity through the
TWENTIETH CENTURY patient’s head (electroconvulsive therapy [ECT]) helped to
The 1900s were ushered in by reform movements, marked improve severe depression, and lobotomy (a surgical pro-
by the beginnings of political, economic, and social changes. cedure that severs the frontal lobes of the brain from the
For the first time in history, disease prevention was empha- thalamus) almost eliminated violent behaviours. A new
sized. For the mentally ill population, however, conditions class of medications that lifted spirits of depressed people,
remained intolerable, until 1908 when a single individual the amphetamines, was introduced. All these therapies
began a crusade that would improve the lives of millions of improved behaviours and made patients more receptive to
mentally ill individuals. Freud’s psychotherapy.
Clifford Beers was a young student at Yale University when During World War II, many draftees were still rejected for
he attempted suicide. Consequently, he spent 3 years as a enlistment because of mental health problems. A large num-
patient in mental hospitals in Connecticut. Upon his release ber of soldiers received early discharges based on psychiatric
in 1908, Beers wrote a book that would set the wheels of the disorders, and many active-duty personnel received treat-
mental hygiene movement in motion. His book, A Mind That ment for psychiatric issues.
The effects of the Korean War of the 1950s, the Vietnam no longer necessary. It was believed that people with mental
War of the 1960s and 1970s, and other armed conflicts disorders could live within their communities and work with
contributed significant knowledge to the understanding their therapists on an outpatient basis.
of stress-related problems. Post-traumatic stress disorders
became recognized among soldiers fighting wars. Today, Adult Community Mental Health Programs
stress disorders are considered the basis of many emotional As the population of people with mental illnesses shifted
and mental health problems. from the institution to the community, the demand for
community mental health supports expanded. To meet this
Introduction of Psychotherapeutic Medications demand, adult community mental health programs were
Psychotherapeutic medications are essentially chemicals developed.
that exert an effect on the mind. These drugs alter emotions, At these centres, the needs of people with mental health
perceptions, and consciousness in several ways. They are used challenges might be met. Physicians (psychiatrists), nurses,
in combination with various therapies for treating mental ill- and various therapists would develop therapeutic relation-
ness. Psychotherapeutic medications are also called psycho ships with patients and monitor their progress within the
pharmacological agents, psychotropic drugs, and psychoactive community setting. Each centre was to provide comprehen-
drugs. sive mental health services for all residents within a certain
Even by the 1950s, despite the many significant gains geographic region, called a catchment area.
in treatment options, effective therapies were still limited. It was believed that community mental health centres
Treatments consisted primarily of psychoanalysis, insulin would provide the link in helping mentally ill people make the
therapy, ECT, and water/ice therapy. More violent patients transition from the institution to the community, thus meet-
were physically restrained in straitjackets or underwent lo- ing the goal of humane care delivered in the least restrictive
botomies. Medication therapy consisted of sedatives (chloral way. Unfortunately, most chronically mentally ill people were
hydrate and paraldehyde), barbiturates (phenobarbital), and “dumped” into their communities before realistic strategies,
amphetamines that quieted patients and rendered them less programs, and facilities were in place.
of a nuisance to the public and caregivers but did little to treat Community mental health centres expanded throughout
their illnesses. the 1980s, but funding remained inadequate and sporadic.
In 1949, an Australian physician, John Cade, discov- Demands for services overwhelmed the system and many
ered that lithium carbonate was effective in controlling the services began to close their doors, reduce supports, or
severe mood swings seen in bipolar (manic-depressive) limit the number of patients they would see, leaving a large
illness. With lithium therapy, many chronically ill patients population of vulnerable people on their own with little to
were again able to lead normal lives and were released no support.
from mental institutions. Encouraged by the apparent
success of lithium, researchers began to explore the possi-
bility of controlling mental illness with the use of various
TWENTY-FIRST CENTURY
new drugs. In 2006, the National Alliance for Mental Illness (NAMI) con-
Chlorpromazine (Thorazine) was introduced in 1956 ducted the “first comprehensive survey and grading of adult
and proved to control or reduce many of the bizarre mental health care systems conducted in more than 15 years”
behaviours observed in schizophrenia and other psycho- in the United States (it was updated in 2009) (NAMI, 2009).
ses (Keltner & Folks, 2005). The 1950s concluded with the The results revealed a fragmented system, poorly equipped
introduction of imipramine, the first antidepressant. Soon to meet the needs of its target population. Recommendations
other drugs, such as antianxiety agents, became available focused on increased funding, availability of care, access to
for use in treatment. care, and greater involvement of consumers and their fam-
As more patients were able to control their behaviours ilies.
with drug therapy, the demand for hospitalization decreased. Today, many of our population’s most severely men-
Many people with mental disorders could now live and func- tally ill people still wander the streets in abject poverty and
tion outside the institution. At this time, governments began homelessness as a result of an inability to access resources.
the movement called deinstitutionalization, the release of Adult community mental health centres have closed their
large numbers of mentally ill persons into the community. doors or drastically reduced their services. The original
The introduction of psychotherapeutic drugs opened the goals of comprehensive care, education, rehabilitation, pre-
doors of institutions and set the stage for a new delivery vention, training, and research were lost in the efforts to
approach, community-based mental health care. curtail costs.
The 1960s were filled with social changes. With the intro- Countries such as Canada, the United States, the United
duction of psychotherapeutic drugs came the concept of the Kingdom, New Zealand, and Australia are faced with similar
“least restrictive alternative.” If patients could, with medica- mental health care issues. It is in the best interests of all coun-
tion, control their behaviours and cooperate with treatment tries to accept the challenge of providing for our societies’
plans, then the controlled environment of the institution was mental and physical health care needs.
KEY POINTS

• Mental health is the ability to cope with and adapt to the • Standards for the care of the insane population improved
stresses of everyday life. during the mid-1800s until huge waves of people over-
• Mentally healthy people are self-aware, directed, and whelmed the mental health care system, causing the con-
responsible for their actions. ditions to deteriorate.
• Mental illness is an inability to cope that results in impaired • A book written by Clifford Beers about his experience as
functioning. a mental patient set the mental hygiene movement of the
• Mental health is influenced by inherited characteristics, early 1900s into motion.
childhood nurturing, and life circumstances. • By the 1920s, Sigmund Freud’s psychoanalytic theor-
• The causes and treatments of mental illness were based ies became a popular method for treating emotional
in superstition, magical beliefs, and demonic possession problems.
from primitive societies into the 1800s. • The psychological effects of the First and Second World
• Priests cared for the sick and exorcised demons, but men- Wars highlighted the need for comprehensive mental
tally troubled people were treated with care by the Chris- health care and focused research on post-traumatic stress
tian community during the Middle Ages. disorder (PTSD).
• By the late Middle Ages, large asylums housed the insane, • With the introduction of psychotherapeutic drug treat-
and the belief that witches were the carriers of the devil ment, many psychiatric institutions closed.
led to the burning of thousands of women, children, and • Community mental health centres were built during the
mentally ill people. 1970s, but a change in political climate and funding left
• By the 1500s, psychotic behaviours were being accurately the project uncompleted and countless mentally ill people
observed and recorded, but the Reformation movement with reduced or no treatment options.
returned many insane people to the streets as church sanc- • Today, ongoing cost restraints challenge us to develop
tuaries closed. comprehensive, fiscally conscious care for society’s men-
• During the 1800s, Americans Dr. Benjamin Rush and tally ill members.
Dorothea Dix and Canadian Dr. C.K. Clarke advocated for
the humane care of mentally ill people.
ADDITIONAL LEARNING RESOURCES

Go to your Evolve website (http://evolve.elsevier.com/ including the online Study Guide for additional learning
Canada/Morrison-Valfre/) for additional online resources, activities to help you master this chapter content.
CRITICAL THINKING QUESTIONS

1. W
hat current mental health stigmas may have begun hun- 2. H ow has technology improved mental health care?
dreds of years ago? How many can you think of? How 3. What current social processes help to preserve the rights and
would you respond to the family of a newly diagnosed dignity of mental health patients? Do you believe those pro-
schizophrenic, who may believe these stigmas to be true? cesses are adequate? If not, what more could be done?

Kramer, H. (2019). The hammer of witches: Malleus Maleficarum:

REFERENCES The most influential book of witchcraft. e-artnow.
Alexander, F. G., & Selesnick, S. T. (1966). The history of psychiatry. National Alliance on Mental Illness (NAMI). (2009). Grading the states:
The New American Library. A report on America’s health care system for serious mental illness.
Amundsen, D. (1978). Medieval canon law on medical and surgical https://www.nami.org/Support-Education/Publications-Reports/
practice by the clergy. Bulletin of the History of Medicine, 52(1), Public-Policy-Reports/Grading-the-States-2009
22–44. https://www.jstor.org/stable/44450442?seq=1 Pos, R., Walters, J. A., & Sommers, F. G. (1975). Historical
Austin, W., Peternelj-Taylor, C., Kunyk, D., et al. (2019). Psychiatric note: D. Campbell Meyers, 1863–1927: Pioneer of Canadian
& mental health nursing for Canadian practice (4th ed.). Wolters general hospital psychiatry. Canadian Psychiatric Association
Kluwer. Journal, 20(5), 393–403. https://journals.sagepub.com/doi/
Dolan, J. (1968). History of nursing. Saunders. pdf/10.1177/070674377502000510
Donahue, M. P. (1996). Nursing: The finest art (2nd ed.). Mosby. Reisman, J. M. (1991). Series in clinical and community psychology. A
Ferngren, G. B. (2016). Medicine & health care in early Christianity. history of clinical psychology (2nd ed.). Hemisphere Publishing.
The Johns Hopkins University Press. Sussman, S. (1998). The first asylums in Canada: A response
Hurd, H. M. (Ed.). (1973, Originally printed 1916–1917). The to neglectful community care and current trends.
institutional care of the insane in the United States and Canada: Canadian Journal of Psychiatry, 43(3), 260–264. https://doi.
(Vol. IV). Arno Press. org/10.1177/070674379804300304.
Kelly, L. Y. (1991). Dimensions of professional nursing (6th ed.). World Health Organization (WHO). (2018). Mental health: Strength
Pergamon Press. ening our response. Author. https://www.who.int/news-room/
Keltner, N. L., & Folks, D. G. (2005). Psychotropic drugs (4th ed.). fact-sheets/detail/mental-health-strengthening-our-response
Mosby.
2
Current Mental Health Care Systems
OBJECTIVES
Upon completion of this chapter, the student will be able to: 5. Describe components of the case management method of
1. Describe the current mental health care systems in mental health care.
Canada, Norway, the United Kingdom, Australia, and the 6. Discuss the roles and purpose of the multidisciplinary
United States. mental health care team.
2. State one major difference between inpatient and 7. Name high-risk populations served by community
outpatient psychiatric care. mental health centres.
3. Explain the community support systems model of care. 8. List community-based mental health services for high-
4. List settings for community mental health care delivery. risk populations.
OUTLINE
Mental Health Care in Canada, 10 Consultation, 14
Mental Health Care in Industrialized Countries, 11 Resource Linkage, 15
Norway, 11 Advocacy, 15
The United Kingdom, 11 Therapy, 15
Australia, 11 Crisis Intervention, 15
The United States, 11 The Multidisciplinary Mental Health Care Team, 15
Care Settings, 12 Care Team, 16
Inpatient Care, 12 Patient and Family, 16
Outpatient Care, 12 Patient Populations, 16
Community Support Systems Model, 12 Impact of Mental Illness, 18
Delivery of Community Mental Health Services, 13 Incidence of Mental Illness in Canada, 18
Community Care Settings, 14 Economic Issues, 18
Case Management, 14 Social Issues, 18
Psychosocial Rehabilitation, 14
KEY TERMS
advocacy (ĂD-vә-kә-sē) (p. 15) inpatient psychiatric (ĬN-PĀ-shәnt sī–k-Ē-ăt-rĭc) care
case management (KĀS MĂN-ăge-MĬNT) (p. 14) (p. 12)
community (kă-MŪN-ĭ-tē) mental health centres (p. 13) multidisciplinary (MŬL-tĭ-dĭ-sĭ-plә-nă-rē) mental health
community support (kă-MŪN-ĭ-tē să-PŎRT) systems care teams (p. 16)
(CSS) model (p. 12) outpatient (ŎWT-PĀ-shәnt) mental health care (p. 12)
consultation (KŎN-sŬl-TĀ-shәn) (p. 14) psychosocial rehabilitation (sī-kō-SŌ-shәl RĒ-hă-bĭl-ә-
crisis intervention (KRĪ-sĭs ĬN-tәr-VәN-shәn) (p. 15) TĀ-shәn) (p. 14)
homelessness (HŌM-lĕs-nĕs) (p. 18) recidivism (rē-SĬD-ĭ-vĭz-әm) (p. 12)
resource linkage (RĒ-sŏrs LĒNK-әg) (p. 15)

Around the world, roughly 40% of countries have no men-

tal health policy and 30% have no mental health care plan.
MENTAL HEALTH CARE IN CANADA
The global median percentage of government health budget By the late 1960s, Canada had adopted a government-ad-
expenditures for mental health is just under 3%. In addi- ministered health insurance plan, which includes an array
tion, many countries have poor coordination between men- of mental health services. Today a “single-payer arrange-
tal health care and other health services (Dudley, Silove, & ment” is used in the Canadian health care system, which is
Gale, 2012). based on five principles: public administration, accessibility,
10
CHAPTER 2 Current Mental Health Care Systems 11
BOX 2.1 Principles of the Canada Health Act Financing and delivery of health care services occur on three
(1984) levels. Health policy is legislated, and health service delivery is
monitored by national authorities. Hospitals and specialized
• P ublic Administration: Provincial insurance programs medical services are managed by Norway’s 19 counties, whereas
must be publicly accountable for the funds they spend. primary health care services are organized on the municipal
Provincial governments determine the extent and amount
level. Mental health care is available to all citizens of Norway.
of coverage of insured services. Moreover, management
of provincial health insurance plans must be carried out by
a not-for-profit authority, which can be part of government
The United Kingdom
or an arm’s-length agency. All British citizens are provided health care through a govern-
• Accessibility: Canadians must have reasonable access to ment-managed national health care system. The Secretary for
insured services without charge or paying user fees. Social Services is responsible for setting fees for private health
• Comprehensiveness: Provincial health insurance pro- care providers, budgets for hospitals, and salaries for hospital
grams must include all medically necessary services. The physicians. Parliament allocates funds for the health care system
Canada Health Act defines comprehensiveness broadly to and regulates the rates at which general practitioners are paid.
include medically necessary services “for the purpose of Tax revenues provide most of the financing for health care.
maintaining health, preventing disease, or diagnosing or Mental health care is available for all British citizens as part
treating an injury, illness or disability.”
of the standard benefit package. Physician services, emer-
• Universality: Provincial health insurance programs must
insure Canadians for all medically necessary hospital and
gency surgeries, hospital stays, and prescription drugs, along
physician care. The condition also means that Canadians with preventive, home, and long-term care, are all provided
do not have to pay an insurance premium in order to be by the government. Eye care is not included and dental care
covered through provincial health insurance. is limited, but all other basic health care needs are provided.
• Portability: Canadians are covered by a provincial insur- Private insurance is also available.
ance plan during short absences from that province.
Australia
Modified from Canadian Nurses Association (CNA). (2000). Fact sheet:
The Canada Health Act. Author. https://www.cna-aiic.ca/∼/media/cna/ Australians are provided an interesting mix of health care
page-content/pdf-en/fs01_canada_health_act_june_2000_e.pdf plans. The government provides a public health plan that cov-
ers all public hospitals and physician services. Also available is a
comprehensiveness, universality, and portability. Each guid- national private plan, which supplements the basic public plan.
ing principle is explained in Box 2.1. In addition, numerous private insurance plans are available for
Each province or territory organizes, administers, and eye care, rehabilitative services, and psychiatric treatment.
monitors the health care delivery system of its citizens. National health care is financed by a tax on all citizens
Benefits may vary, but all Canadian citizens are eligible for above a certain income. Policy and budget decisions are made
diagnostic, emergency, outpatient, medical, hospital, conva- at the federal level. Individual states are responsible for the
lescent, and mental health services. The agency responsible administration and delivery of health care services that are
for the health of Canadians is Health Canada. It provides available through local government agencies, semi-volun-
technical and financial support for each provincial health tary agencies, and profit-oriented, nongovernmental organ-
care program, enforces federal food and drug laws, promotes izations. The Mental Health Bill of 2013 addresses fairness,
health, and administers social welfare programs. accountability, and inclusion of significant others when car-
Across Canada, physician-provided mental health care ing for the mentally ill in Australia’s basic health plan.
is covered by provincial/territorial health care systems. This
is not the case for other allied health professionals, such as The United States
psychologists, social workers, or mental health counsellors. Health care in the United States is based on the private insur-
Approximately 80% of psychologist consultations occur ance model. Currently, approximately 90% of US citizens are
within the private for-profit system (Steele, Dewa, Lin et al., covered by private insurance or public programs (Medicare
2007; Government of Canada, 2006). and/or Medicaid), leaving roughly 10% having no health care
coverage. Rates vary by state, with Texas having the highest
MENTAL HEALTH CARE IN INDUSTRIALIZED rate of uninsured and Massachusetts having almost 100%
COUNTRIES coverage. With the introduction of the Affordable Care Act
(ACA; Obamacare) system of health care delivery, the rate of
Norway health care coverage increased; however, implementation of
Like other European countries, Norway has adopted a this model is at risk because of changes in government and
national insurance system. The National Insurance Act of individual states rejecting ACA coverage.
1967 provides access to health care for everyone living in The distinction between public and private mental health
Norway. Employees contribute a percentage of their wages care financing is beginning to blur. Federal funds (Medicare)
and pay out-of-pocket fees for health care until a “payment and state funds (Medicaid) are being used to cover costs
ceiling” (about $175) is reached. Thereafter, all services are in both the private and public sectors. Currently, Medicare
covered except adult dental care. funds about 30 to 50% of all state mental health systems.
psychiatric care support services is sometimes outpaced by

CARE SETTINGS the mental health needs of a community or catchment area.
In Canada, admission rates to psychiatric inpatient facili- Mentally ill people make use of community services only
ties were at an all-time low by 1983 as mental health care sporadically. This “hit and miss” approach makes effective
was delivered primarily in community settings. However, by care difficult. Many wait until major problems occur before
1988, hospitalizations for mental illness were on the rise and seeking treatment. When services are used, a “Band-Aid”
emergency departments saw huge increases in patients with approach that treats only the presenting concern is often util-
psychiatric issues. Today there are more people in need of ized. As a result, many individuals who end up in the emer-
care than there are treatment settings. gency departments of general hospitals or incarcerated in the
corrections system are in need of inpatient psychiatric care.
Inpatient Care According to the Office of the Correctional Investigator,
Individuals are admitted to inpatient psychiatric care based on Canadian offenders experience mental health challenges at a rate
need. The severity of the patient’s illness, the level of dysfunction, of two to three times more than the general population (Office of
the suitability of the setting for treating the problem, the level of the Correctional Investigator, 2011). Approximately 11% of male
patient cooperation, and the patient’s ability to pay for services offenders have a significant mental health diagnosis, with over
all enter into the decision regarding inpatient psychiatric care. 20% taking a prescribed medication for a mental health issue at
Inpatient care settings can include general mental health units the time they are arrested or apprehended. Slightly more than
that treat a wide variety of challenges, geriatric mental health 6% were receiving some type of outpatient mental health treat-
units that specialize in the treatment of individuals over the age of ment or support. Female offenders appear to be twice as likely as
65, child and adolescent units focusing on those 18 and younger, male offenders to have a mental health diagnosis at admission
and highly specialized psychiatric intensive care units for indi- to a correctional facility, with over 30% having had a psychiat-
viduals who may experience periods of aggression and violence ric admission to a hospital prior to admission to a correctional
as part of their mental health challenges. Other even more spe- facility (Office of the Correctional Investigator, 2011).
cialized units provide expertise in areas such as eating disorders, Unable to cope in the community setting, people with
developmental disorders, and even short-term inpatient resour- chronic psychiatric issues often return to institutions or use
ces for crisis intervention and stabilization. Patients may also community services on a revolving-door basis. This behaviour
be committed to psychiatric care by way of the criminal justice pattern is known as recidivism and means a relapse (return) of
system. These settings are administered in a manner that is sim- a symptom, disease, or behaviour, typically resulting in a visit
ilar to a jail or correctional services facility. The legal aspects of (or revisit) to the local emergency department. Recidivism is
involuntary commitment are discussed in Chapter 3. a major problem in mental health care. It is associated with
Patients who receive inpatient care generally remain in a safe negative treatment outcomes, staff frustration, and inappro-
environment for 24 hours per day with all aspects of care focus- priate use of services. Lower rates of recidivism are seen in
ing on providing therapeutic assistance. Discharge occurs when communities where coordination and cooperation among
patient behaviour has improved and treatment goals have been community agencies and mental hospitals exist.
attained. The majority of patients are discharged back into the Psychiatry and mental health care policies are often based
community. Depending on individual housing options, some on the medical treatment model: identify the symptom and
may be discharged to a group home or other structured setting then treat it. This point of view became inadequate once
or to another institution for longer-term psychiatric care. patients were released into the community. A broader, com-
The most important advantage of inpatient psychiatric munity-oriented, more flexible outlook was needed.
care is that it provides patients with a safe and secure environ-
ment where they can focus and work on the challenges that Community Support Systems Model
brought them into the unit initially. For mentally ill people to function well within their commun-
ities, a wide range of support services is necessary. The commun-
Outpatient Care ity support systems (CSS) model views patients holistically—as
As the emphasis shifts to community mental health care, the
demand for outpatient psychiatric service grows. An out- Mental health Crisis response Health and
patient mental health care setting is a facility that provides treatment services dental care
services to people with mental health challenges within their

home environments. With these services, psychiatric patients Client
identification
Housing
are able to remain within their communities, associating with Clients

normal aspects of everyday life, a considerably more thera- Income support
Protection and
peutic option than a mental health unit in a hospital. advocacy Case
and entitlements
Community-based mental health care occurs within a management
dynamic society. Supervision is limited, and the responsib- Rehabilitation Family and Peer support
services community support
ility for controlling behaviour lies squarely with the individ-
ual. Patients are assessed in relation to their environment and Fig. 2.1 Community support system. (Modified from Stuart,
therapies are designed to assist them in functioning appro- G. W. [2013]. Principles and practice of psychiatric nursing [10th ed.].
priately within their communities. The number of outpatient Mosby.)
BOX 2.2 Examples of Community Services

Serving Individuals Recreation centres
Rape crisis centres Day care centres for young, disabled, or older people
Churches, synagogues, and mosques Family planning agencies
Employment, job-training agencies Family recreation centres and groups
Recreational clubs Shelters for victims of domestic violence
Adult education programs
Literacy programs Serving the Community
Mediation groups Environmental groups
Meals on Wheels Education groups (e.g., Canadian Lung Association, Friends of
Colleges and universities Schizophrenics)
Mental health agencies Utility companies
Community emergency shelters
Serving Families Government agencies
Women, Infants, and Children (WIC) Police and fire departments
Children’s groups (e.g., Boys and Girls Clubs) Fair housing bureau or agency
Nutritional services Prisons
Church groups Performing arts centres
Community “Welcome Wagon” Public forests and parks
Data from Haber, J., McMahon, A. L., & Krainovich-Miller, B. (1997). Comprehensive psychiatric nursing (5th ed.). Mosby.
TABLE 2.1 Community Mental Health Care Delivery

Setting Focus/Services Staff Members Comments
Emergency care Stabilization, assist with the crisis, refer Nurses, social Many chronically mentally ill
(community hospital to appropriate community resources workers, therapists, persons use ED settings as an
EDs, emergency psychologists, entry into the mental health
psychiatric clinics) psychiatric technicians care network
Residential programs Offer a protected, supervised Home care providers, Provide food, shelter, clothing,
(group homes) environment within the community therapists, nurses, supervision, counselling,
technicians, physician vocational training, socialization
Partial hospitalization (day Provides care and treatment for patients Psychologists, therapists, Multidisciplinary care and
treatment centres) who are too ill to be independent; nurses, counsellors, treatment have led to
patients are gradually introduced into social workers, patient success and proven
the community technicians the effectiveness of these
programs
Psychiatric home care Delivers care to patients and families in Psychiatric CNSs, home- Collaborates with patient,
their homes; helps patients and families care providers family, other mental health
transition from institution to home; professionals to provide
crisis interventions; referral to resources ongoing care
Community mental Services include crisis intervention, family Psychologists, therapists, Lack of adequate financing has
health centres counselling, education, care for the nurses, counsellors, resulted in fragmented services
chronically mentally ill, medical care, social workers,
vocational and skills training technicians
CNSs, clinical nurse specialists; ED, emergency department.
individuals with basic human needs, ambitions, and rights. The developed slowly, but the CSS model of mental health care is
goal of the CSS model is to create a support system that fos- proving to be one of the most comprehensive and workable
ters individual growth and movement toward independence concepts for aiding mentally ill persons (Johnson, 2017).
through the use of coordinated social, medical, and psychiatric
services. Effective community support systems are consumer DELIVERY OF COMMUNITY MENTAL HEALTH
oriented, culturally appropriate, flexible enough to meet indi-
vidual needs, accountable, and coordinated. A typical program
SERVICES
may include services such as health care, housing, food, income Mental health services and support systems are available
support, rehabilitation, advocacy, and crisis response (Fig. 2.1). through a variety of community agencies, support groups,
Community mental health centres are outpatient settings and civic organizations. Services focus on prevention, main-
that reflect the CSS model by providing a comprehensive range tenance, and treatment of mental health conditions and
of services. Many have forged strong links with commun- rehabilitation of persons with mental health challenges.
ity agencies, services, and government. Other centres have Some agencies or groups limit their focus to one area (e.g.,
Alcoholics Anonymous focuses on treatment of alcohol CASE STUDY

addiction). Individuals, families, and communities benefit
from the activities of various groups. Box 2.2 lists examples of Joanne is a 59-year-old woman with severe depression, anor-
commonly available community services. exia, and suicidal ideation. The psychiatric home care referral
was an effort by her husband to prevent nursing home place-
Community Care Settings ment. Joanne presented with a 30-year history of scleroderma
(a disfiguring skin condition), numerous surgeries and hospital-
Community mental health services are based on the needs of izations, and a 10-year psychiatric history with numerous sui-
specific populations. In addition, for best outcomes, mentally cide attempts. She has severe anxiety and agoraphobia (fear of
ill people must be treated in the least restrictive manner pos- crowds and open spaces). Her anorexia was severe, with her
sible. Therefore, several services are available in various set- weight at 35 kg (77 lb). Medical and psychiatric problems were
tings throughout the community. See Table 2.1 for examples. interwoven, and she needed comprehensive intervention.
With short institutional stays and the release of people Because Joanne could not leave home and needed medica-
with chronic mental illness into the community, the need for tion management, a psychiatrist made home visits. Companion
home psychiatric care providers to fill the gap between insti- services were supplied while her husband was at work. Her
tution and community is rapidly growing. husband was actively involved in the decision making regard-
ing his wife’s care, but he needed supportive interventions.
Given the wide range of patient needs, multiple professions
Over a 4-month period, Joanne progressed from a severely
have evolved to offer services. Social workers provide support
withdrawn, suicidal person to someone who was dealing with
to individuals, families, and children in need. They also assist her panic attacks, agoraphobia, and scleroderma. Her weight
with everyday problems and challenges, connect their patients had increased to 40 kg (90 lb). Although she would continue to
to community resources, and can diagnose and treat specific cope with a chronic illness, her hopelessness was gone, and
mental health, behavioural, and emotional issues. Occupational her ability to function in her daily life had markedly improved.
therapists have a strong focus on minimizing disability and social She was able to continue living in her home and community
marginalization. Much of their work addresses a patient’s level of with the help of community mental health services.
ability and how that patient is able to function in their day-to-day • What follow-up care would you plan for Joanne?
activities as well as to meet the goals and aspirations they may • What activities would help Joanne meet her social needs?
have. Occupational therapists focus on “doing” as a means to • What resources do you feel would be best for Joanne?
• What short-term and long-term goals might be appropriate
encourage and support change. Psychiatrists are medical doctors
for her and her husband?
with advanced education and training that allows them to diag-
• Do you think that institutional care might be the best
nose and treat mental health conditions. Psychiatrists can also option? Why or why not?
recommend and provide prescriptions for medications to treat or
reduce the severity of many mental health disorders. Peer support Modified from Mellon, S. K. (1994). Mental health clinical nurse
workers are often individuals who themselves have been patients specialist in home care for the 90s. Issues in Mental Health Nursing,
15(3), 229–237.
of the mental health and/or addictions treatment system at some
time in their lives. They offer a unique perspective and use their
own experience to support and guide others facing similar chal- productive patterns of living. A look at each component of
lenges. Psychologists work in a wide range of settings, from the case management may help clarify the process.
community to prisons to mobile crisis teams, and can provide
one-to-one counselling. Psychologists can assess behavioural Psychosocial Rehabilitation
and mental health challenges and provide treatment options to Use of multidisciplinary services to help patients gain the skills
their patients. Psychiatric clinical nurse specialists (CNSs) ease the needed to carry out the activities of daily living as actively
transition from hospital to home for patients and their families and independently as possible best describes psychosocial
and assist patients in navigating the mental health care system. rehabilitation. Patients are first assessed for physical, social,
They also provide psychosocial crisis interventions and collabor- emotional, and intellectual levels of function. Then specific
ate with patients, families, and other professionals to deliver the plans for teaching needed skills are developed. If patients are
most appropriate and cost-accountable psychiatric care. capable of work, vocational rehabilitation is offered.
The psychosocial rehabilitation model of care encourages
Case Management decision making, thus empowering patients. This empower-
Defined as a system of interventions, case management is ment fosters a sense of self-esteem and mastery that results
designed to support mentally ill patients living in the com- in improved coping abilities. As patients feel the success of
munity. The major components of case management are making their own decisions, they are encouraged to take con-
psychosocial rehabilitation, consultation, resource linkage trol of other areas of their lives. Education is also a strong
(referral), advocacy, therapy, and crisis intervention. Patients component of psychosocial rehabilitation because mastering
are involved with the assessment, planning, and evaluation daily living skills motivates patients to practise more product-
of their care. Goals are stated as patient outcomes. Success ive and independent ways of functioning.
is measured in terms of patient satisfaction, improved cop-
ing behaviours, and appropriate use of services. The overall Consultation
goal of case management is to have a successfully functioning In mental health care, consultation is a process in which the
patient able (with support) to avoid relapse and achieve assistance of a specialist is sought to help identify ways to work
effectively with patient challenges. The case management sys- normal circumstances could provoke a crisis for someone
tem relies on the expertise of psychiatrists, nurses, psychol- who has a significant mental health challenge. A crisis results
ogists, social workers, counsellors, and various therapists to whenever we feel that we have lost our ability to use our
find ways for patients to receive the services and support that usual problem-solving and coping skills. Common sources of
help them to achieve their goals. For example, a nurse might crisis include the loss of a loved one, change in employment
work with a patient on reliably taking prescribed medication, circumstances, or being victimized. Experiencing a crisis is
while a social worker might locate supported housing, and a common to all people and is not limited only to individuals
vocational counsellor could seek out an appropriate work set- with previous or pre-existing mental health challenges.
ting. By covering all the bases, care providers hope to main- Crisis intervention describes a short-term, active ther-
tain patients in the least restrictive setting (the community) apy that focuses on solving the immediate problem and
and assist them with their needs. restoring the patient’s previous level of functioning. Crisis
services help stabilize the patient, prevent further deterior-
Resource Linkage ation, and support the patient’s readjustment process. The
The process of matching patients’ needs with the most appro- use of crisis services also results in better distribution of
priate community services best describes resource linkage. resources. Emergency department visits decrease, rehos-
Health care providers have traditionally referred patients to pitalization is reduced or prevented, and law enforcement
other services, but resource linkage adds the component of resources are better focused on those who break the law
periodic monitoring. The advantages of coordinating and link- instead of apprehending individuals with mental health
ing services are several: patients can be more easily moved into challenges. For patients with severe, treatment-resistant
different programs because background information moves mental challenges, a new approach, known as continuous
with them; duplication of services is avoided; and as a patient’s intensive case management, is being used.
level of functioning improves, services can be tailored to sup- A highly flexible model of care, known as assertive com-
port the new, more effective behaviours. With resource linkage, munity treatment (ACT), provides “medical, psychosocial, and
the focus for treatment of patients is on care instead of the more rehabilitation services by a community-based team that oper-
traditional emphasis on psychiatric symptoms and illness. ates 7 days a week, 24 hours a day” (Salkever, Domino, Burns,
et al., 1999). The team usually consists of social workers, nurses,
vocational specialists, occupational therapists, psychiatrists,
CRITICAL THINKING peer support workers, and addictions specialists. Patients are
You are a health care provider who has recently moved to this seen individually and in supportive therapy groups. This team
area. As a staff member in a community mental health clinic, of professionals collaborates with the patient by providing
you are responsible for helping refer patients to appropriate 24-hour supports and assistance, including administration
agencies. of medication, access to community services, attending vari-
• How would you go about locating agencies in the com- ous appointments and follow-up services, and even assistance
munity that provide services for mentally ill individuals?
with activities of daily living. Many patients also live in super-
vised housing arrangements. Table 2.2 provides a summary of
Advocacy the continuous care team’s treatment activities. In short, care
A critical concept of case management, advocacy is providing teams direct the patient’s treatment during all encounters with
the patient with the information to make certain decisions. the mental health care system.
Advocacy for mentally ill people involves more than other areas Intensive case management programs have demonstrated
of health care. Advocates work to protect patients’ rights, help that patients with chronic and severe mental illness can be
to clarify expectations, provide support, and act on behalf of effectively stabilized within the community with appropri-
patients’ best interests. Every person involved in mental health ate support systems. As the pressures of increased demand
care can act as an advocate by supporting community efforts for services and cost restrictions force the system into trying
and policies that encourage healthy living practices. new approaches, mental health care professionals must not
lose sight of the most important element in the equation—the
Therapy patient.
Therapy is provided for each patient based on assessed needs,
patient cooperation, and available services. Medications may THE MULTIDISCIPLINARY MENTAL HEALTH
be included as part of the overall plan of treatment. Therapies
may include the use of counselling, support groups, voca-
CARE TEAM
tional rehabilitation programs, and techniques to assist Professionals working within the mental health system
patients with problem-solving and adaptive behaviours. have various educational backgrounds. In the past, each
would work with patients from his or her particular point
Crisis Intervention of view or specialty. This approach resulted in disjointed,
The crisis intervention component of case management fragmented care. In some cases care providers worked at
is crucial to the success of the patient. People with chronic cross-purposes, leaving patients unsure and confused. The
mental health challenges have great difficulty in coping with need for coordinated assessment and treatment was filled
stress. What may be bothersome or inconvenient under by the multidisciplinary mental health care team concept.
TABLE 2.2 Continuous Care Team the focus of therapeutic interventions, patients contribute
Treatment Strategies important information that may make the difference between
the success or failure of therapeutic plans. Including patients
Setting Mental Health Care Team Interventions and their families in the treatment process reflects a funda-
Community Meets with patients 2–4 times per week mental change in attitude toward those with mental illness
Accompanies patient to appointments and and their families. Today, mental illness is considered to be
other community activities manageable and even treatable.
Helps with daily living/social skill needs
Monitors medications
Nurtures relationships with persons PATIENT POPULATIONS
interested in patient’s well-being
Encourages patient to call team instead of Community mental health care was originally designed to
using ED provide prevention, education, and treatment services for all
Emergency Prearranges for ED staff to notify clinician on members living within an area or catchment. Community
department arrival of continuous care patient mental health services for the general public include crisis
Conducts assessment of patient and interventions, working with businesses to decrease costs and
planning of care jointly with ED physician improve the effectiveness of mental health programs, and
Avoids unnecessary hospitalizations providing aid for individuals and families to adjust to life dif-
Hospital Care team psychiatrist and primary therapist ficulties.
remain in charge of the patient’s case However, in every community, certain groups of people
Helps with decisions regarding admission, are at a higher risk for developing mental health challenges,
treatment, and discharge large or small. They include more obvious populations, such
Coordinates treatment with inpatient staff as homeless people, and more subtle high-risk groups, such
ED, emergency department. as children, families, adolescents, older people, people who
Modified from Arana, J. D., Hastings, B., & Herron, E. (1991). are positive for human immunodeficiency virus (HIV) or are
Continuous care teams in intensive outpatient treatment of chronic experiencing other debilitating chronic illnesses, and veter-
mentally ill patients. Hospital & Community Psychiatry, 42(5), 503–
ans of armed conflicts. People living in rural areas present a
507. ©American Psychiatric Association. Reprinted by permission.
challenge because of the distance between services.
While often ignored, homeless people can be seen in
every town and city in Canada. Studies indicate that between
Care Team 25 and 75% of these individuals have a diagnosable mental
The main purpose of the team approach to treating mental health disorder, which can also include addictions to vari-
illness is to provide effective patient care. The mental health ous substances. Who are the homeless? According to the
care team “provides a forum where psychiatrists, social organization Homeless Hub, a study in Toronto found that
workers, psychologists, nurses, and others can democratic- one third identified as being an immigrant, 45% identified as
ally share their professional expertise and develop compre- belonging to a racialized group, 22% identified as Black, and
hensive therapeutic plans for patients” (Haber, McMahon, & 9% as Indigenous (Aleman, 2016; Hwang, Ueng, Chiu, et al.,
Krainovich-Miller, 1997). The team approach can also be cost 2010). While shelters and temporary housing might be avail-
effective by preventing duplication of services and fragmen- able, many homeless individuals are reluctant or afraid to use
tation of care. Patients and their significant others contribute them. Assaults, sexual abuse, and theft are common occur-
to the plan of care and remain actively involved throughout rences, making shelters less than ideal. Sadly, many homeless
the course of treatment. people feel safer on the street, making it more difficult to pro-
Multidisciplinary mental health care teams exist in both vide consistent and therapeutic services.
inpatient and outpatient settings. The number of team members Patients with HIV infection or acquired immunodeficiency
may vary, but the core of the team is usually composed of a psych- syndrome (AIDS) are using community mental health services
iatrist, a psychologist, a nurse, and a social worker. Other team in ever-growing numbers. People with AIDS face overwhelm-
members, known as adjunct therapists, join the team as needed. ing physical, emotional, and social challenges. Mental health
Each team member holds a degree or certificate in a spe- issues associated with HIV disease include organic problems,
cialized area of mental health. This approach allows patients such as impairments in memory, judgement, or concentration
to be assessed and treated from various points of view. As data progressing to dementia. Psychosocial difficulties include anx-
are compiled, a broad, holistic picture of the patient emerges iety, depression, adjustment disorders, increased substance
and individualized therapeutic plans are developed. Table 2.3 abuse, panic disorders, and suicidal thoughts. In addition,
identifies care team members, their educational preparation, many researchers believe that stress directly affects the immune
and their function. system. Fear of AIDS may hasten the onset of complications.
AIDS-related anxiety can increase everyday apprehension in
Patient and Family the lives of many noninfected people.
No discussion of the mental health team is complete with- Comprehensive community mental health services for
out including the patient. As the consumers of services and people with HIV/AIDS are not yet available in all areas.
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across the clouds like spears of fire threatening revenge. The stone
has remained to the present day, and is known by the name of
“Koreno kardjo (dog) gambi” (stone).
PLATE XXXIV
The “Tjilbakuta” of the great emu ceremony, Arunndta tribe.

“The moment the sacred object is completed, the Illiyakuta delegates
one of his group to act as its attendant or guardian.”
The snake is an important character in the mythology of practically

every tribe of Australia; in fact most of the permanent water-holes
are supposed to be inhabited by great serpents which guard the
supplies, destroy unlawful consumers or polluters thereof, and
frequently communicate with those spirit ancestors of the tribes who
are descended from the original snake-man still living in the sky. In
many cases the mythic snakes can be recognized in some
characteristic features of the landscape. Take, for instance, the great
artesian spring near Coward Springs Station which is known as
Blanche Cup. This is looked upon as the mouth of a snake, while the
hill immediately at the back of it (Mt. Hamilton) is its head. In
consequence the formation is called “Worma-Kadiabba” (snake’s
head) by the local Arrabonna tribe. The natives have a dread of
these imaginary snake-monsters and prefer not to visit a water-hole
at night; in fact, at any time, day or night, they feel safer in the
company of a man who is “related” to the snake, because he can
protect them and give them the right of approach. The snake is
possessed of evil and will molest any but its totemic “relatives.”
The fundamental conception of the kobong (or totem), so far as
the Australian aboriginal is concerned, is of a religious nature. In the
beginning of all things, the Aluridja say a number of exalted
creatures of human form came out of the earth and were gracious to
their tribes-people. Then appeared a menace in the shape of a
gigantic dog which chased the good people from one place to
another, until they decided to adopt the forms of various animals and
plants, and thereby became either too fleet for the dog or were not
recognized by it. Other good people now descended from the hills
and drove the dog back to its hiding place in a cave where the evil
spirit dwells. The newcomers kindled a fire at the mouth of the cave
and kept the evil beings in captivity whilst the original Deities re-
assumed the human form. Ever after, however, these good creatures
were able to alter their appearance from human to animal at will; but
each individual in his choice adhered to the particular animal or plant
which had saved him from the ravages of the great evil dog.
Eventually they formed themselves into flat slabs of stone or wood,
upon the surfaces of which they scratched the emblems of their
animal representation and the traditions of their long wanderings on
earth. The spirits of these Deities now live in the sky but can return
at any time to re-enter the slab generally known as the “tjuringa.”
Among the Minning at Eucla the larger of these objects are known as
“wagal-wagal,” the smaller as “bobi,” whilst further west, in the
Laverton district, “kaidi” is the prevailing word. It is true, the tjuringa
is not known to all tribes; in which case the Deities are supposed to
have entered such natural objects as rocks, hills, and conspicuous
trees.
The Roper River natives believe that their deified forbears were
molested not by a dog, but by a hideous old woman or witch, who,
by the influence of evil, entrapped them and subsequently ate them.
On one occasion, however, a party of warriors were successful in
decoying her away from her haunts and slaying her. The jubilant
victors decided to cut out the old woman’s tongue as a trophy, but as
they were thus engaged, the tongue flew out of the mouth and spun
round in the atmosphere above them, making a terrible noise as it
did so. The men chased the tongue, but it flew towards a beefwood
tree and embedded itself deeply in the butt; in vain they looked for it
and tried to cut it out; it had become part of the tree. Before
returning, however, the men took a piece of wood out of the tree,
shaped like the woman’s tongue, which they tied to a piece of human
hair-string and swung round their heads with joy. Behold their mixed
feelings of delight and fear when the piece of wood began to howl
with a voice like that of the slain witch! The tribe retained that piece
of wood as a sacred memento of their victory, and they gave to it the
name the witch was known by, namely “Kunapippi.” Nowadays this
object is the equivalent of the central Australian tjuringa.
All tribes recognize the existence of deified ancestors, now real or
spiritual, whom they regard as sacred and worship accordingly. All
ancestors stand in a definite, intricate, and intimate relationship to
some animal, plant, water-hole, or other natural object which they
have at some time or other represented; some indeed in the first
place appeared as animals and later took the human form. They are
now looked upon as being those powers who by virtue of sacred
ceremonial can produce the species they have at some time
incarnated, in plenty or allow it to proliferate. As a matter of fact,
some of the sorcerers of the tribes often declare that they can see
the inside of a sacred rock or tjuringa teeming with young, ready to
be produced.
The Arunndta refer to their “Knaninja” (i.e. “totem” Deities) as
“Altjerrajara,” meaning the Supreme Number; the Aluridja as
“Tukurata” or “Tukutita”; and the Dieri as “Muramura.”
Just as the “totem” ancestor is connected with an animal, plant, or
other natural object, and is embodied in the sacred form of the
tjuringa, so the individual who traces his descent from such ancestor
recognizes a close and mysterious affinity between himself and the
tjuringa which has become his by heredity; henceforth it becomes his
sacred talisman which protects him from evil and procures for him
the means of maintaining his existence.
The emblematic representation of the deified ancestor, based
upon the form of an animal or plant living to-day and in some way
“connected” with the individual, is the “kobong” of the north-western
tribes first referred to by Sir George Grey.
The “totem” is very dear and sacred to the native, and is religiously
protected by him. I well remember on one occasion on the Alberga
River I discovered a small black and yellow banded snake which I
killed. An Aluridja man who was attached to the party at the time was
greatly shocked at this, and, with genuine sorrow, told me that I had
killed his “brother.” Turning to an Arunndta he lamented aloud:
“Kornye! Nanni kallye nuka kalla illum,” which literally translated
means: “Oh dear! This brother of mine is dead.”
One thing is always essential and that is that a native performs
frequent, prolonged, and reverential ceremonies, remote from the
women and children, and in the presence of his tjuringa. Under these
conditions the tjuringa is believed to have powers similar to those of
the Deity it embodies.
When not in use, the tjuringas are stored in caves, the entrances
to which are small and not easily discernible; the ground is
proclaimed taboo to any but initiated tjuringa holders and is strictly
regarded as a sanctum sanctorum. Although the sticks and stones
are the individual property of the tribesmen, the objects are generally
kept together, and only brought out during a religious ceremony. The
old men are the authorized custodians of the sacred collection. The
female tjuringas are included, because even though a woman may
possess one, she must never see it; if she does, accidentally or
otherwise, she is in imminent danger of being killed. No unauthorized
hunter is allowed near the prohibited area under any pretext at all;
even if an animal he has wounded should by accident make for the
sacred ground to breathe its last, the hunter is required by tribal law
and usage to sacrifice it to the divine factors incorporated in the
tjuringa, by leaving it on the spot.
PLATE XXXV
Flashlight photograph of “Illiya Tjuringa” or great emu ceremony, Arunndta

tribe.
“The chief emu man is distinguished by an extra large head-dress called the
‘Illiya Altjerra Kuta.’...”
When on the warpath, a warrior always craves to carry his tjuringa
with him, even though this is not always possible. He firmly believes
that with the talisman kept on his person, or at any rate knowing that
it is nearby, no deadly missile thrown by an enemy will penetrate his
body. The mere knowledge of the fact that his opponent has a
tjuringa with him, and he not, is sufficient to make a coward of the
bravest fighter. Should he be wounded or take ill, one of his “totem-
brothers” endeavours to produce a tjuringa, from which, if the
medicine man considers it necessary, a little powder is scraped and
handed to the patient to swallow with water.
With regard to “totem” animals which form the objects of hunting
expeditions, a man is allowed to kill and eat thereof with some
restriction. He must kill only one animal at a time, and only in
accordance with the method prescribed by the tribal fathers and
handed down to them by tradition. This is usually a straightforward
hunting method, with as little loss of blood as possible. If much blood
should flow, the hunter is obliged to cover it without delay with sand.
If possible, other men should cut up the carcase, and only certain
portions be handed to the “brother” of the slain animal.
Each tribe has an endless variety of objects (animal, vegetable,
terrestrial, meteoric, mythic, and so forth), which may figure as a
“totem.” Any one of these may be the primary motive of a separate
cult or sacred ceremony, but here again the variety is usually
reduced to the number corresponding to the most sanctimonious and
most useful creations affecting the affairs of the particular tribe.
The ceremonies take the form of either a direct worship or a
prayer for increased productivity of a certain plant or animal, either
being offered to the Knaninja or “totem” ancestors living as spirits in
the sky. Usually the two ideas are embodied in one grand ceremony,
and the method of procedure is governed by tradition. Such
ceremonies have been particularly elaborated by the Arunndta tribe,
who refer to them by the same name as that of the sacred object,
namely “Tjuringa”; less frequently they call them “Intitjuma,” the latter
name being applied more to ceremonies without worship.
The Tjuringa ceremonies are divided into grades according to their
importance and sacredness. The water ceremony is ordinarily called
“Kwatje Tjuringa,” but if the “totem” spirit ancestor is invoked to
attend, it goes by the name of “Kwatje Tjuringa Knaninja”; if the
principal spirit ancestor is assumed to be present, the title becomes
“Kwatje Tjuringa Knaninja Knurrendora”; and finally the most sacred
water ceremony of all is the “Kwatje Tjuringa Altjerra Knaninja
Knurrendora.”
As a typical illustration we shall discuss the “Illiya Tjuringa” or
Great Emu Ceremony of the eastern Arunndta groups. The date of
the performance is decided by the senior emu “brother” of the tribe,
the oldest member who claims to be related to the Illiya Knaninja.
Somewhat extensive preparations are made beginning a few days
prior to the opening event. Only fully initiated men take part, but the
women are allowed to witness certain of the most awe-inspiring
stages from a distance. Whilst the younger men are out collecting
leaves, out of which they make the down later to adorn the bodies of
the performers, the older men prepare the sacred ground. Others
slay a number of brown hawks, off which they pull the feathers and
then pluck the down. A suitable site having been selected, the old
men clear it by removing all grass and bush from the surface and
smoothing the sand with their feet. The “brothers” who claim
relationship alike to the great Emu-Man, the Emu-Knaninja, and the
emu itself, thereupon proceed to anoint the sacred ground with their
blood, for which purpose they puncture the median basilic vein of the
forearm with a quartzite chip and allow the fluid of kinship to sprinkle
upon the sand. It is surprising to see the amount of blood sacrificed
by the men on occasions like this; and time after time, when such is
required, the process is repeated. By examining the forearms of an
old stager, one can usually count a number of small scars along the
course of a vein indicating places where a perforation has at different
times been made. A venesection is made after much the same
manner among the various tribes.
The following Arunndta method will serve as an example. A
ligature of hair-string is in the first place tied tightly round the upper
arm, a little above the biceps muscle, after the style of a tourniquet to
check the flow of blood in the veins and thereby distend the vessels.
The man then makes a small longitudinal cut through the skin and
punctures the vein beneath it lengthwise; the blood spurts forth
immediately and is collected in the handle-pit of a shield. When the
flow is to be stopped, the native removes the ligature, and this in
most cases is all that is needed. Should, however, the blood
continue to come, he places a small amount of down over the
incision and presses it against the vein, or winds three or four
strands of fur-string around it. The little pad of down is usually left on
the arm until it dries and falls off. None of the women are allowed to
witness this operation, which is called “Ilgarukna.” The blood, when it
is to be used as an adhesive for the down-decoration, is applied with
a small brush (“ipinja”) made of twigs tied together with fur-string.
Vide Plate XXXIII.
The principal among the emu group is called “Illiyakuta,” and it is
he who directs the performance. He takes his followers to a secluded
place, such as a clump of timber or down a creek-bed, and there the
wooden tjuringas belonging to the ceremony are produced and
painted afresh with red ochre and emu fat.
Down is made out of the white, felty leaves and twigs of Kochia
bush, which the Arunndta call “kemba.” Small quantities of these are
placed upon a flat slab of stone and pounded with a pebble. The
fluffy material which results is next mixed and rubbed by hand with
powdered kaolin or ochre according to the colour required, the white
being known as “wadua,” the red as “wanjerra.”
A sacred object is now constructed which encloses the painted
tjuringas and is called the “Tjilbakuta.” It is about three feet high and
is made in the following way. The tjuringas are laid one on top of the
other and bound together with many lengths of human hair-string,
which completely obscure the shape of the separate pieces. A thick
layer of the stalks of the kangaroo grass (Anthistiria) is laid around
the parcel and kept in position with a few lengths of twine, and then
the whole structure is covered with great masses of human hair-
string wound spirally from top to bottom. A cylinder results which is
decorated with alternate vertical bands of red and white vegetable
down. Into the top of this Tjilbakuta one bundle of emu feathers and
one of black cockatoo tail-feathers are stuck; and often additional
plumes are hung beneath them. The moment the sacred object is
completed, the Illiyakuta delegates one of his group to act as its
attendant or guardian. For the time being his body is decorated with
symmetrically placed, curved ochre bands upon the chest and
vertical bands down the arms; at a later stage he ornaments his
body more elaborately, prior to taking part in the principal
performance; but all the time he remains in his place of hiding beside
the Tjilbakuta. Vide Plate XXXIV.
At the sanctified place close by the other men have been stacking
firewood at different points to illuminate the proceedings during the
evening. Occasionally, too, the Illiyakuta group of men cover a
portion of the ground with a coloured emblem of the traditional emu.
Early in the afternoon of the festive day the men who will take part
in the ceremony at night begin to prepare themselves. Many of the
non-performers help them.
Large quantities of down, both vegetable and birds’, are used to
decorate the bodies. The design is shaped much like a cobbler’s
apron, extending from the neck down the front to the level of the
knees. The greater part of this surface is red, but it is lined with white
and split along the centre by two parallel lines of white. The back is
not decorated at all. The entire surface of the face, including the eye-
lids and beard, is thickly covered with down which is white, except
for an oval red patch around the mouth.
The principal attraction, however, of the sacred emu ceremony is
the head-dress, which is both elaborate and imposing. To prepare it,
the attendant combs back the actor’s hair with his fingers, and
interlaces it with stalks of grass and small twigs in such a way that a
tall conical structure results right on top of the head. This is made
secure and of a uniform exterior by winding much human hair-string
around it, at the same time taking in a plume of emu feathers at the
apex of the cone. The headgear is completely enveloped in red and
white down, extending upwards from the head as alternate vertical
bands. The chief emu-man is distinguished by an extra large
headdress called the “Illiya Altjerra Kuta”; this measures a good
three feet in length, and it embodies, between the apex and the emu
plume, deeply enshrouded with hair-string and down, the sacred
“Illiya Tjuringa.” Other members who are of the same rank as the
“Tjilbakuta” guardian, wear their insignia beneath the emu feathers in
the form of a sickle-shaped rod, which carries at each of its points a
tuft of white cockatoo feathers. All performers cover their person with
a dog-tail appendage which hangs from a thin waistband of human
hair-string. And lastly, they all tie bundles of eucalyptus twigs, with
the leaves attached, to their legs just above the ankles. If possible,
old or half-dried leaves are selected in order that a more pronounced
rustling is produced when the men move about; the noise is made to
imitate the rustle of the wiry feathers of an emu. Vide Plate XXXV.
At nightfall the Tjilbakuta is removed from the hiding place and
planted on the edge of the ensanguined patch. The guardian is thus
given an opportunity to slip away and to attend to his ceremonial
toilet, which is similar to that of the rest of the Tjilbakuta group. When
he returns, the performance is about to begin, and all except he
leave the ground.
The stacks of wood are set fire to by invisible hands, and, so soon
as the flames flare upwards, the silence is broken by the booming
note of a bull-roarer, which is produced some distance off in the
bush.
The Tjilbakuta guardian sits beside the object like a statue, with
his eyes rivetted to the ground immediately in front of him. From
behind him the thud of stamping feet and the rustle of dry leaves
announce the coming of the official performers, while from the other
side the non-performing members step from the darkness and take
up their position by squatting between two fires. When the decorated
men come into view, the latter start beating their boomerangs
together in perfect time to the stamping of the feet of the advancing
actors. They come as a body of five or six rows, one behind the
other, each man holding his hands locked behind his back and
uttering a deep guttural note resembling a pig’s grunt. The folded
hands held over the stern represent the tail, the guttural noise the
call of the emu.
The Illiyakuta, wearing the tall Illiya Altjerra Kuta, is in the front
row, and he is attended on either side by a Tjilbakuta man. The chief
now starts a chant: “Immara janki darrai,” and all the others,
including the sitting men, join in; the same is repeated several times.
When the two parties are opposite each other, the performers
quicken the pace of their stamping and extend their arms sideways,
thereby widening their ranks. After this they retreat to behind the
Tjilbakuta and one hears a shrill chirping note resembling the cry of a
young emu.
The interpretation of this act needs no special elucidation. The
decorated performers are those of the tribe’s manhood who, in all
matters pertaining to the emu, have a right to communicate, through
the Tjilbakuta, with the astral emu ancestor living in the great
celestial domain of the ancestral spirits, which is known as
“Altjerringa.” They are invoking the benign Knaninja or originator of
their particular “totem” species to increase the numbers of emu on
earth for the exclusive benefit of their tribe. It is the Illiyakuta who
imagines that he receives the favourable response from above, and,
when it comes, it is he who imitates the cry of a young emu. It often
happens, however, that the chief persuades himself to believe that
the Great Spirit had not heeded the appeal, in which case the last-
mentioned cry is wanting. The ceremony is repeated time after time.
Altjerringa, it will be observed, is a compound word consisting of
“Altjerra,” the Supreme Spirit, and “inga,” a foot or trail. The implied
idea is that Altjerringa is the “walk-about” of the spirit ancestors,
where they walk, and have always walked, and where the spirits of
all tribes-people eventually hope to find their way.
After this act, the performance becomes less restrained and takes
more the form of a corrobboree. Some of the men seize firebrands
from the burning stacks and hurl them in the direction of the
women’s camp. From the moment of the sounding of the bull-roarer
at the beginning of the ceremony until now the women sat huddled
together, with their faces buried in their hands, thoroughly cowed by
the portentous happenings. When the firebrands come whizzing
through the air and crash into the branches of the trees around them,
sending sparks flying in all directions, they are almost beyond
themselves with fear. But just at this juncture the men call upon them
to look towards the festive ground and behold them dancing. In
obedience to the order, the women’s fears are dispelled and soon
superseded by a noticeable enravishment. They feast their eyes
upon the array of manhood in gala dress, and it is not long ere they
pick up the rhythm of a dance by beating time to the step. Provided
the Tjilbakuta has been removed to a place of secrecy, well out of
reach of accidental discovery, the men entreat the women to come
up and join in the song. Thus the sublime is eventually reduced to
commonplace, and the remainder of the night passes in joviality.
To refer briefly to a vegetable ceremony, we shall select the yam
or “Ladjia Tjuringa Knaninja.” The preparations are much the same
as those of the emu ceremony. An enclosure is first made in a
secluded spot with branches, in the centre of which the “totem” or
Knaninja “stick” is erected. Several men immediately set about to
decorate it with vegetable down as previously described. The design
in this case consists of vertical rows of red circles upon a yellow
ochre background. In addition, a large plume of split eagle-hawk
feathers is stuck into the top of the stick. All ordinary performers
wear conical head-gears or “tdela” made of Cassia twigs, into the
apices of which tightly bound bundles of grass stalks (“gortara”) are
fixed carrying plumes of emu feathers (“mangalingala”) (Plate
XXXVI, 1). Other men have squat, cylindrical bark structures called
“elbola” placed over their heads, which are elaborately decorated
with vertical coils of human hair-string and coloured down.
One of the principal actors represents the “Kuta Knaninja.” His
head-gear consists of two long kutturu, tied together with hair-string
and completely covered with gum leaves, the whole being
subsequently besmeared with blood and decorated with coloured
down. As the assistants are dressing this character, they keep up a
chant sounding like “Winni kutcherai.” Vide Plate XXXVI, 2.
The leading figure is the “Ingada Ladjia Knaninja,” who wears a tall
vertical head-piece which contains the tjuringa of the Ladjia
Knaninja. The tjuringa is, however, not visible, but is covered with
pieces of bark, securely tied over it with hair-string, the whole being
richly decorated with vertical bands of red and white down.
The Great Spirit of the Yam, called “Knaninja Tjilba Ladjia,” when
he leaves Altjerringa, takes up his abode in a cave near Mount
Conway, where the tjuringas are kept, but at night, before the fires
are lit, he is supposed to come to the ceremonial ground and occupy
the decorated “totem” stick described above. During the performance
he is surrounded by all the ordinary performers, who are known as
“Tjilba Ingarrega,” and are directly under the guidance of the Ingada
and Kuta Knaninja.
A group of men who are not decorated sit near one of the fires and
sing while the performers are thus encircling the Ladjia stick:
“Imbanai yinga
Wi ma bana Ladji di bana
Yammana wi ma bana
Jai ra ja ja
Jai ja ja na
Wi ba na na
De a re a ja betja,”
the voices finally fading away to an almost inaudible whisper.

If the Great Spirit, Ladjia Altjerra Knaninja, is gracious, the tap-root
of the yam will be sent deep down into the earth near the Jay River
and from there spread its laterals all over the country to supply the
needs of the tribe.
When some of the most sacred ceremonies are performed, the
oldest “relatives” of the presiding Knaninja often construct a coloured
drawing upon the consecrated ground, whose purpose is similar to
that of the “totem” stick above described. The drawing is executed in
coloured down, both vegetable and bird. A space of suitable size,
often measuring many feet in length, is cleared of grass and stones,
and sprinkled with water, when it is ready to receive the down. In the
case of, say, the “Ladjia Tjuringa,” the design takes the form of a
number of concentric circles alternately red and white, from the
outermost of which six equally spaced groups of red and white lines
stand out radially. The enclosing border of the design consists
entirely of white down. Vide Plate XXXVII.
Once constructed, this drawing, which is known as “Etominja,” is
zealously guarded by one of the old men. If, peradventure, an
unauthorized person happens upon the sanctified place, he is killed
and buried immediately beneath the spot occupied by the design;
thereupon the ground is smoothed again and the Etominja re-
constructed. Nobody in camp ever hears what became of the
person, and should any relative track him in the direction of the area
known to be tabooed, he is horror-stricken and runs away.
While the old men are re-constructing the Etominja, they sing to
the Knaninja as follows:
“Yedimidimi
Dakarai pa ma taka,
Pa mitu min jai, jin tarai,
Ja ra nai malgada, ja ranai.”
The next, and probably the most important, group of religious

ceremonies is that dealing with Sex-Worship. For years past
peculiarly shaped stones have been found in caves and among the
possessions of the Australian aborigines whose shape was strikingly
suggestive of a phallus, but hitherto no actual phallic ceremonies
have been observed. It was my good fortune to witness such among
the Aluridja, Arunndta, Dieri, and Cambridge Gulf tribes. From
enquiries made of the old men, it appears that in former days this
form of worship was practised considerably more than it is
nowadays. New stone phallus are rarely made by the present tribes;
those in their possession have generally been inherited from
previous generations. The old men have the phallus in their keeping,
and they are very loth to either produce or part with them.
The natives of the King Sound district in the north-west believe the
origin of the phallus to be as follows: In the early times a scourge
was raging among their forefathers, from the effects of which many
were daily dying, when a hairy man and his mate, a woman of
ordinary human form, came to earth from above. The evil was due to
the exhalation of poisonous breath from the gaping jaws of a green
monster resembling a crocodile. The stranger relieved the sufferers
from the awful curse by showing them how to perform an operation
upon their person which taught them to endure pain and protected
them against future ravages of the pestilence. This great and
benevolent stranger then took his departure, but left his name to
designate the surgical operation which to the present day is
performed upon the male members of the tribe; the name, strange
though it may seem, is “Elaija”; and it is known, at any rate, as far
east as Port George IV. But the tribe had become so weak through
the terrible havoc the disease had wrought that the old men called
him back and entreated him to stay. Elaija, however, took from a
dillybag his female companion was carrying, a stone carved after the
shape of a mutilated member, which he gave the name of
“Kadabba.” When the old men gazed upon this object, they took
fright and appealed to Elaija, but the good fellow had vanished. The
stone has remained with the tribe ever since, and through the divine
property Elaija endowed it with, their threatened extinction was
eluded. Moreover, they continued to practise the operation on all
young men because it made their members like the Kadabba of
Elaija, which they knew had the power of multiplying their kind. And
so the Kadabba became a sacred object whose procreative power
they have learned to worship, thinking that by such observance they
would augment their own capacities of sex. Vide Fig. 7.
Fig. 7. Stone phallus, Northern Kimberleys, Western Australia (× 1/2).
One often reads, and I was under the same impression myself
until I became better acquainted with the tribes, that the Australian
natives do not connect the knowledge of conception with any
intercourse which might have taken place between the sexes. This I
find is not altogether correct, although usually the younger people
are kept in complete ignorance on the subject. No doubt strangers
are treated similarly when they put any pertinent questions to the old
men on matters of sex. The old men believe in the duality of human
creation, the spiritual and the material; sexuality is regarded as the
stimulus of corporeal reproduction, but the spirit quantity is derived
through mystic and abstract influences controlled by a “totem”-spirit
or Knaninja. Under these circumstances, it is not surprising to note
that the ceremonies of the phallus are transacted principally by the
old men of the tribe who aim at the rejuvenation of their waning
powers.
It is interesting to see the old men preparing for a ceremony which
is to be dedicated to a Knaninja or Spirit of Sex, because they all
endeavour to conceal the white hairs of their beards by rubbing
powdered charcoal into them. The bark of the cork tree (Hakea) is
used for the purpose; pieces of it are charred, crushed between the
palms, and applied where needed. It is astounding what a difference
this process makes to the appearance, and some of the old grey-
beards really look as though they had been made twenty years
younger by magic.
In the eastern MacDonnell Ranges stands a cylindro-conical
monolith whose origin is believed to be as follows: Many generations
ago, the paternal ancestors of the Arunndta walked from a district
situated, as near as one can gather, somewhere in the
neighbourhood of Ediowie; they were known as the “Kukadja,” and
were characterized by the enormous dimensions of their organs.
These old men or Tjilba of the tribe migrated northwards to beyond
Tennant’s Creek and settled in the productive “Allaia” country which
surrounds the Victoria River. In that same district one finds, even at
the present day, cave drawings of human beings with the anatomical
peculiarities referred to (Fig. 8). At a later time, the head-man of the
Kukadja, named “Knurriga Tjilba,” returned southwards to the
Macdonnell Ranges. While roaming the hills, he espied two young
women sitting on the side of a quartzite cliff, and without deliberation
began to approach them. He was in the act of making lewd overtures
when the guardian of the girls, a crow ancestor, caught sight of him
and hurled a boomerang at him. The missile struck the great man
and cut off the prominent portion of his body, which in falling stuck
erect in the ground. The force of the impact was so great that the
man bounced off the earth and fell somewhere near Barrow’s Creek.
He bled so profusely that a clay-pan soon filled with his blood. Thus
his followers found him, and overcome with sorrow they opened the
veins of their arms to mix their blood with his. Then all the members
of the party jumped into the pool and disappeared for ever.
Fig. 8. Ochre drawing of “Kukadja” men, north of Wickham River, Northern
Territory (× 1/3).
The severed portion of the old man’s body, however, remained just
where it fell and turned to stone. It has long been known as “Knurriga
Tjilba Purra.”
The two young women can also still be detected in the cliff as
prominent rock formations.
The stone has been protected by the tribe as long as the old men
can remember, because they realize that it contains an inexhaustible
number of unborn tribes-people. These mythic, foetal elements are
generally recognized to exist in certain objects of phallic significance,
and are called “rattappa.” The medicine men maintain that they can
at times see the dormant living matter in the stone. It is on that
account that it is regarded as sacred, and every now and then very
secret and worshipful ceremonies are transacted near its base, the
main objects of which are to multiply the future membership of the
tribe and to preserve the sexual powers of the old men.
The Tjilba Purra naturally figures prominently in some of their
ceremonies. In fact, it is reproduced and worn upon the head of the
leading man during the functions. The sacred effigy consists of an
upright column, about two feet high, composed of a stout bundle of
grass stalks, in the centre of which the tjuringa is contained. It is
decorated with alternating bands of red and white down throughout
its length. This upright column represents the “Tjilba” or revered
ancestor whose spirit is invoked to “sit” in the tjuringa; at the top of it
a plume of wiry emu feathers, well powdered with charcoal (“unjia”)
to give it a youthful appearance, takes the place of the forbear’s hair
and beard. Standing at an angle with the central column, a similar
though slightly smaller structure is intended for the “Purra” or
phallus; it carries a plume of white cockatoo feathers at its end to
represent the glans. Vide Plate XXXVIII, 2.
A landmark, of similar significance as the Tjilba Purra of the
Arunndta, exists on the Roper River in the Northern Territory; it is a
pillar of sandstone known as “Waraka.” Waraka is also the name of
the great Spirit Father of the tribe. In very early times this man came
to earth in a semi-human form, and made the country abound in
game, animals, birds, and fish. Then he found a woman on the
shores of Carpentaria Gulf who remained with him as his wife. Many
children came of the union; and Waraka’s mate has since been
looked upon as the mother of the tribe. The woman’s name was
“Imboromba,” and to this day the tribe takes its name after her.
Warraka had an enormous sex characteristic which was so
ponderous that he was obliged to carry it over one of his shoulders.
Eventually the organ became so huge that Warraka collapsed and
sank into the earth. His burden remained, but turned to stone, and is
now looked upon by the local natives as the great symbol of Nature’s
generative power which first produced their game supplies and then
the original children of the tribe; it is revered accordingly.
The Kukata have a somewhat similar legend of the origin of a
stone of phallic significance, the name of the possessor of the large
organ being “Kalunuinti.”
In the extreme north-western corner of Australia, in the Glenelg
River district, the natural stone is replaced by an artificially

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Health and Health Care Delivery in Canada Third Edition

Child Mental Health in Primary Care Dawkins

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To my beloved husband, Adolph; my cherished friend Marian

Sharon Clegg, BSc(PT) Kelly McNaught, RN, MN

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Increased attention to Indigenous health and healing prac- • Th

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Canada is a country of immigrants. English is my fifth language. I am grateful to my daughter,

UNIT I Mental Health Care: Past and Ethics, 23

Problem-Solving Therapies, 50 Special Considerations, 78

Levels of Communication, 110 Self-Esteem Needs, 137

Chemical Dependency, 168 Therapeutic Interventions, 205

Post-Traumatic Stress Disorder (PTSD), 222 Substance-/Medication-Induced Depressive

Narcolepsy, 282 26 Outward-Focused Emotions: Violence, 310

Inhalants, 347 Psychopaths and Sociopaths, 378

33 Challenges for the Future, 414 Obligations of Care Providers, 419

TABLE 1.1 History at a Glance

Church and became known as Protestants. As a result of this

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TABLE 2.1 Community Mental Health Care Delivery

Alcoholics Anonymous focuses on treatment of alcohol CASE STUDY

The “Tjilbakuta” of the great emu ceremony, Arunndta tribe.

The snake is an important character in the mythology of practically

Flashlight photograph of “Illiya Tjuringa” or great emu ceremony, Arunndta

the voices finally fading away to an almost inaudible whisper.

The next, and probably the most important, group of religious

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UNIT I Mental Health Care: Past and Ethics, 23

Narcolepsy, 282 26 Outward-Focused Emotions: Violence, 310

33 Challenges for the Future, 414 Obligations of Care Providers, 419