The Mental Health System 1656-2009

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Topics covered include the history of the mental health system, where the stigma against the mentally ill originates, possibilities for healthy mental health, and statistics on violence.

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The Mental Health System 1656-2009

  1. 1. Michal Willinger Positive Psychology 8th June, 2010 Inserting Positive Psychology into the Mental Health System Synopsis The following presentation will present facts, information and media clips relating to the mental health system. All the facts I will present here are true and may be cross- referenced by scholarly, peer-reviewed journals as to their validity. Media clips contain straight facts as interpreted by relevant subjectivities within the mental health system and bear no exaggerations or inferences. This is the history and present state of the worldwide mental health system as it is right now. It is the aim of this presentation to guide our understanding of current closed unit psychiatric care of major mental illness in a historical context. Most of our work here as been done for us by Michel Foucault, an academic and researcher who taught and wrote on the history of thought-systems. From a historical context the presentation directs us toward not only recognizing the thought-system paradigm we reside in currently, but concrete steps toward shifting our paradigm in alignment with principles of Positive Psychology. Positive Psychology in particular seeks to use growing-tip statistics, practical idealism and viable alternatives in order to meet goals set forward to meet human happiness and well-being. Pioneered by Martin Seligman, the field can apply to the mental health system in specific and important ways. Once a historical context of thought and positive psychological applications have been proposed, we will conclude with what we are able and may do next to move from theory toward action. Creating viable happiness for major mental disorders is not only possible, but likely given the correct methodology. It must first require an opening of previously held models of mental illness and willingness to absorb a new thought-system of what it means to identify and treat cases of mental illness. PART I: TODAY AND YESTERDAY From the Patient’s View First and foremost, the experience of mental illness is by nature patient-focused. In any model, mental illness begins at the individual level of experience and the societal reaction against it. Please take the first few minutes of this presentation to watch this video created by a patient confined in a unit for attempted suicide. With music and text, she expresses her story in simple words that give us a sense of what it means to address
  2. 2. the mental health system from a patient-centered approach. This testimony is accurate to a typical inpatient experience.1 What is normal? The origin of mental health “Those who suffer and complain about themselves are usually classified as "neurotic"; those whose behavior makes others suffer , and about whom others complain, are usually classified as "psychotic."”2 Dr. Thomas Sczaz writes the above in 1974 after decades of engagement with the mental health system. Mental illness is first defined sometime during the Renaissance, which, according to Prof. Michel Foucault, is the beginning of man’s break with reality becoming considered something other than a normal phase of the life process. Overall to date, Foucault in several published works provides us with the most comprehensive overarching history of not only the coming of definitions of mental illness, but the sociopolitical structure that enforces, delivers and perpetuates it. To understand the mentally ill we must first understand what was once a dangerous enemy of European urban society: leprosy. From the time of Christ, leprosy was common and thought to be contagious. We now know that 95% of most populations are naturally immune to the bacteria that causes leprosy and that it is spread through nasal drip or close respiration. So the city-dwellers of the Middle Ages had some reasoning in sequestering lepers. Jews and lepers were the only groups Christian society required to wear special clothing to identify themselves as such. Lepers were also made to carry a special begging bowl, a bell and were even sometimes declared legally dead by the state so it could legally seize their assets. In urban France, Germany and England, lepers resided in special in-city colonies. In France alone, there were as many as 19,000.3 By the 17th century, leprosy was virtually eliminated in Europe, much like the world is virtually eliminated of smallpox today. In 1656, King Louis XIV of France found himself with thousands of abandoned institutions with no one to put in them. He issued an Edict to re-build the largest former leper home, re-named it L’Hôpital Général, and filled it with 4,000 Parisian criminals, alcoholics and gamblers, and mentally ill. The new containment plan was so effective that soon Germany, England and the rest of Europe followed suite. By royal decree, the new “hospitals” were outside the jurisdiction of judicial law. They used two main methods of control for the inmates: isolation and physical restraint. Often the hospital also withheld food and water, took away bedding or other amenities, induced forced labor and used iron chains on the neck, wrists and ankles to control and “cure” inmates. The result was that the hospital was usually at maximum capacity and that at any time 1% of the population of Paris was held there.4 Hospital inmates are poor. Guards do not differentiate between addicts, mentally ill and criminals. Parallel to the bourgeoning use of the hospital in confining society’s unwanted is the advent of the medical industry. In the next portion we will describe in detail the reforms of 1801 under Dr. Pinel and his extremely influential Treatise on Insanity. France decrees that the mentally ill are now under the charge of physicians, not
  3. 3. prison workers, and in 1830 the “asylum” is invented exclusively for curing the mentally ill. However, the asylum continues the leper condition of confinement under the control of modern medicine.5 A power structure is developed to both serve and deceive the mentally ill. The explicitly-stated goal is to eliminate their sense of self-power. Methods are without limit to what the L’Hôpital has utilized in the past and even earlier with leprosy victims: seclusion, isolation, restraint and withholding of basic needs. Save that iron shackles are replaced with the straight-jacket, nights in a wet dungeon are replaced with dipping in cold water, and an urban environment is replaced by a rural one. Yet who is deemed “mad” to begin with? By 1800, madness is divided into five categories, according to Foucault, by the preponderance of psychiatric writers of the time: someone who thinks they are superior to everyone; someone who is raving, or in a rage; someone who is in passions with or without delusions; someone who has too many incoherent ideas and conflicting speeches with or without delusions; and someone who is melancholic.6 Note that there is not yet any genetic, biological or pathological explanations for mental illness, such as epilepsy or syphilis. To understand our mental health system today is to understand Dr. Philippe Pinel’s ‘moral treatment’ movement in 1801 with his famous Treatise and the systematization of the confined and newly-distinct mentally ill from society’s other deviants (notably criminals and addicts). Dr. Pinel became interested in the insane after a friend died from suicide. He visits the Hôpital frequently and takes scrupulous observations on the insane, who at the time make up 200 of the 4000 inmates and have a separate wing where they are confined in cells. His handbook includes instructions of how to subdue people, describing how the supervisor must keep a certain amicable and authoritative tone while servants surround the inmate and each grab a limb. He then goes into cures involving forced isolation and a uniquely personalized “stripping of sovereignty” whereby punishments are increased until there is total submission and compliance with the authority and policies of the hospital. The hospital is encouraged to sever contact between friends and family in order to admonish old power relationships that may interfere with gaining total control over the patient. According to Pinel, the hospital cures through permanent visibility, absolute authority, isolation and the insane witnessing the insanity of others.7 And these methods are all still in use today (Remember the testimony in our opening video by the depressive patient; and if you are interested, also refer to the addendum of personal stories with this presentation paper.)8 Voices and Images of Present-Day Here in the presentation we will listen to the testimony of both a patient and nurse inside a modern-day closed unit. The nurse explains the daily routine and the nature of the work of the staff, while the patient describes her experience from the other side of the same process. We will also see a 2008 incident from a New York hospital where a
  4. 4. woman slumps over and proceeds to die in the presence of two guards, who watch her passively. It is two hours later before a passing attendant from another unit sees the woman and proceeds to act. The entire incident is filmed on a surveillance camera. Now that you have heard both the nurse’s and patient’s testimony, and seen a patient-attendant interaction, take careful notice of how the Hôpital-Pinel institutional model has crystallized the leper-mentality into the mental health system. First, the nurse is able to speak confidently of the use of restraints and seclusion, as well as forced medications and confinement, as a logical part of the curing process. In fact, the methods of seclude, restrain and withhold are centuries old and derive from the sequestering of an infectious population. Ignorant of these origins, the nurse is able to use Pinelian terminology to reason these methods into a curing process that is in essence an offshoot of a criminal isolate-punish-subdue system. As Pinel describes, the self-sovereignty of the patient is left entirely in the hands of the psychiatrist, who is enforced by the supervisors and attendants who pose as servants but are actually informants. Now that the asylum is back in the urban environment from the countryside, the attendants take on a much more sinister role from attend-and-comply to observe-and-ignore, as is exemplified in the death of the Jamaican patient in King’s County Hospital. Although the electroshock therapy patient can describe her experience in frustration, her overall attitude is still one of submissive powerlessness to an all-encompassing medical authority, infallible to either judicial or civil law.9 There is neither a way in not a way out to the modern-day psychiatric system. The nurse seems to have us convinced the secrecy and security is instituted for safety. Yet the same system principles have existed for centuries, well before the modern-day notion of “safety” came to fruition in mainstream discourse. Intake Laws: Universality and Jurisdiction Most countries in the world have adopted Dr. Philippe Perlin’s ‘moral model’ and the classic L’Hôpital-based asylum in its legal, medical and confinement model.10 Generally speaking, the intake process can be summarized as 1) public complaint; 2) official approval for detainment and 3) coercive compliance with detainment. In the first step, a person notifies emergency services, either medical or criminal, about the behavior of a suspicious person. Once the emergency service arrives, they must secure the approval of a psychiatrist or government official to confine the person in a psychiatric unit. In the third step, when approval is granted, the person is now entirely up to the discretion of emergency services. If it is an ambulance, for example, upon a psychiatrist’s approval they are allowed to use strapping and forced injections for any reason. Most ambulances use forced injection as routine procedure and it is very difficult for a person to talk their way out of once the call has been made.11 If it is the police, than methods used to bring in a person might include police holds and handcuffs. A special note on step two of the process is that to acquire official approval usually takes place in a short phone call in which emergency services relays either first- hand observation or second-hand information to gain approval for confinement. On the one hand, this makes ridding the area of a questionable person quick and without
  5. 5. difficulty for the medical worker or policeman. On the other hand, it proves a huge question of human rights for the person experiencing the process from the other side. Second-hand accounts can be exaggerated or based on miscommunications common during psychosis or mania. First person observations are after a person has already been confronted with police or medical personnel who have no intention on objectively hearing their side of the story, but rather are intent on securing approval to move ahead with the situation. Such a situation often induces aggression that police in particular are not trained to deal with and can exacerbate an impression of aggression, which is later passed along to psychiatric personnel.12 The police and mental health Police are such an integral part of the intake process that in a survey administered in the United States on confrontations with mental illness, over 75% indicated a desire for further training on these situations.13 Another problem with police involvement is that judgments about whether to deliver a person to psychiatric or criminal processing has to made and is based on inconsistent criteria, such as race, age and appearance. This is a problem known as “criminalization” of the mentally ill. Human rights law and mental health Dr. Thomas Sczaz writes, “There is no medical, moral or legal justification for involuntary psychiatric interventions. They are crimes against humanity.”14 Other psychiatrists see it as a curative model designed in the long-term interests of the patient; although we will see statistical evidence calling the curative results of the current psychiatric system into question. Does the 1948 UN Convention on Human Rights apply to those exhibiting signs of mental illness? The United Nations’ World Health Organization currently acknowledges the problem of forced detainment for the mentally ill but has yet to reach a decision on whether the system’s confinement and medical coercion model constitutes human rights violations.15 PART II: STIGMA What does a mentally ill person look like? Now that we have a historical context in which to view present day mental illness, who exactly are we talking about when we say, ‘the mentally ill?” Does Pinel’s definition still apply? Today for the purposes of this presentation, we will talk about mental illness from the perspective of the Big Three: schizophrenia, bipolar and depression. We choose these in our inquiry into inserting positive psychology into mental illness because they are responsible for the majority of hospitalizations on closed psychiatric units worldwide.
  6. 6. Who gets the Big Three? The answer is, everyone and anyone. The top row of photos are randomly selected photos of bipolar illness support group members, excluded the man on the right who was simply photographed by a curious bystander in Norway. Then there are prototypical “crazies” you might see in a big city environment like New York City or Tel Aviv, exemplified by the old woman, the woman in the orange tutu, the man in the skullcap and the man with the large Afro. Though it is impossible to say with any rightful certainty, at first glance we might assume these to be people exhibiting the positive symptoms of schizophrenia. Finally, we have celebrities. Celebrities of all varieties have had major mental illness. Clockwise from left to right, Mahatma Gandhi and Jesus can easily be said to have suffered from delusions of grandeur and delusional psychoses associated with bipolar mania. Marilyn Monroe and Elvis Presley suffered from major depression, while Mozart is agreed to have had bipolar disorder and Rita Hayworth, at the end of her career, paranoid schizophrenia. The simple truth may be that there is no such thing as crazy. Only that, in every lifetime, there is a time and place for everything.16 Mental Illness and Violence Perhaps some of you have been asking yourselves, Aren’t mentally ill people violent and scary? Doesn’t society need to be protected from psychotics? The statistically-backed, scientifically tested answer is, Not really… sort of. In other words, there are numerous studies on psychosis and violence, but there are as many positive findings as negative correlations, making the overall result at best inconclusive, and at worst, slightly negative.17 Prior to the 1990s, the conventional view held that there is no association (e.g., Teplin, 1985) or at least no demonstrable association (Monahan, 1981/1995; Rabkin, 1979) between mental disorder and violence. A late-1990’s Danish study found that schizophrenic men were 4.6 times more likely to commit violence and women 22.3 times more likely to commit violence than the general population. A 1998 global study found a slight negative correlation (r=-.04) between major mental illness and violence (Bonta et. al.) Confounding factors explaining inconclusive studies are young age, co-morbid substance abuse, personality disorders and low socioeconomic status that come hand-in-hand with large scale diagnosed mental illness. Some studies eliminate significant findings when controlling for these factors and some do not, still finding an association in the positive or negative.18 A meta-study conducted last year found overall about a 55% increase in likelihood of violence, as an aggregate, aggressed by the mentally ill population. However, the authors decided to include verbal remarks in their definition of violence, and noted that the likelihood of violence upon strangers, or, in other words, persons unknown to a mentally ill person, was equivalent to the likelihood of aggression committed by a person who is not mentally ill. And finally, a positive schizophrenic is 250% more likely to be attacked by someone than to attack someone.19
  7. 7. Mental Illness and Prejudice Perhaps one of the most endangering aspects of mental illness is the socially- acceptable stigma against the mentally ill. ‘Stigma’ is the term afforded to describe the effect of “coming out” with a mental illness to others and the ostracizing, ridicule and diminished quality-of-life experienced as a result. Despite the huge numbers of people with symptoms of mental illness, terms like “crazy,” “wacko,” “loony,” “schizoid,” and “psycho” are used to insult and dismiss people without consideration. First, I find it essential to highlight just how many people we are talking about. 25% adults and children will have the effects of a mental disorder within one year. 10% of people will suffer from a disorder in their lifetime. 2-6% of adults suffer from an MMI. Depression is the largest cause of disability and contributing factors are alcohol dependence and dementia. Sufferers are equally male and female. 140,000 people committed suicide in highly developed countries in 2005. Northern latitudes have more successful suicides than southern latitudes.20 A typical re-admission rate for major mental illness was confirmed in the USA and Canada to be about 20%. A Taiwan study between 2001 and 2003 showed a rate of 30% in one month, in a causative association with length of stay and caseload per psychiatrist. Shorter stays and higher per-psychiatrist caseloads are highly associated with higher re-admission rates. So overall the costs of mental health, including absenteeism from work, comes to between 6-10% of a given country’s GDP.21 That is to say, what distracts the labor force bears high costs to productivity. Given that major mental illness and its symptoms are so prevalent in at least a quarter of the population’s everyday life during any given year, what is the attitude of the general public toward the mentally ill?22 In Canada, 80% would feel very or somewhat comfortable around someone using a wheelchair) while it is less comfortable being around persons with ‘hidden’ or ‘internal’ disabilities (i.e. 46% would feel very or somewhat comfortable around someone with chronic depression) (Canadian Attitudes Towards Disability Issues, 2004). In Switzerland, two-thirds of the public surveyed favored revoking drivers’ licenses of persons withmental illness (Nordt et al., 2006). In the United Kingdom, 70% of people diagnosed with a major mental illness reported that they or someone in their family experienced prejudice as a result of mental illness (Mental Health Foundation, London, UK, 2000). 58% of the UK public thought that a mentally ill person cannot work in a normal job, such as a bank clerk. In Israel, 40% replied that they would not want a person with mental illness
  8. 8. living in their neighborhood; 88% said that they would not let a person with mental illness take their children to school; and 50% replied that they are willing to help a person with mental illness but are not willing to be his or her friend. In all countries surveyed, the ones to hold the highest negative views on the mentally ill were, remarkably, psychiatrists (Caldwell & Jorm, 2001; Lauber et al., 2006; Nordt et al., 2006). Common labels included ‘dangerous,’ ‘unpredictable,’ ‘unreliable,’ and ‘lazy.’ Psychiatrists tended to have low expectations about long-term outcomes, display an unwillingness to interact with, live next to and form romantic relationships with people with mental illness. Dangers of these sorts of attitudes promote dehumanizing clinical practices, damaging the work of recovery, healing and rebuilding lives (Angell et al., 2005; Deegan, 1997, Sartorius, 1998). Patients’ satisfaction, although it is always surveyed, was not available on journal databases such as PsychNet. Available surveys that I discovered consisted of three positive accounts of outpatient clinical programs. Two other British surveys on questionnaire-form effectiveness mentioned 66% of patients experiencing “adverse events;” as in abuse, detainment, forced injections, strapping or isolation, and that nearly half of mental health workers suffered from stress-related burnout from their jobs.23 24 Two-thirds of official complaints recorded in one hospital surveyed in the US in 2006 were about the hospital system and the hospital staff. In all media worldwide, persons with mental illness are represented as violent, dangerous, unpredictable, and criminal-like (Sartorius & Schulze, 2005; Stuart, 2006b; Sullivan et al., 2005; Wahl, 1995). Thus, media reinforces a stigma against the well- being of people diagnosed with mental illness, those who are appointed to heal them, and the society expected to receive them. Some attempt has been made to change the language by which we refer to mental illness, such as “spiritual emergency”25 rather than “psychotic/manic episode” and other terms sensitive to the process from a patient’s viewpoint. I suggest that there is a dichotomous relationship between the confinement, restraint, seclusion and forced-medication model and the ongoing stigma on mental illness. A negative spiral ensues where mental health workers and patients are forced to relieve cognitive dissonance by accepting false negative viewpoints more easily adopted than a challenge to medical authority. As evidenced earlier in the presentation, the Leper Paradigm of sequestering society’s contagious, who evolved to deviants, and then split to prisoners and mental patients, has persisted precisely because psychiatrists have yet to challenge Pinel’s model, which is little more than a more humanitarian treatment of the original iron chains and damp stone cells of Paris’ L’Hôpital Général. Later on, we’ll discuss some reasons why.
  9. 9. PART III: INSERTING POSITIVE PSYCHOLOGY Marty Seligman and Growing-Tip Statistics Marty Seligman, the founder of a psychological science known as “Positive Psychology” had the notion that to study well-being, we ought to study the crème de la crème of the phenomena we seek to explain. Rather than look at depressed people and ask why they are unhappy, Seligman looked at happy people and asked what made them that way.26 In this presentation, I pose the question to you of how we can apply Seligman’s growing-tip statistic conception to the mentally ill. Who are the people who flourish in spite of, or outside of, the formalized psychiatric mental health system? If we were to find enough of them, what kinds of questions would we want to ask? Practical Idealism Positive Psychology posits that ideals can be implemented in a practical way. In some countries, psychiatric wards are already taking on basic positive psychological principles such as a pleasant environment (e.g. bright colors, living plants, thought- provoking art, natural wood and soft lighting). Note the photograph of a Swedish closed unit. How does it compare to the video footage we saw of the Jamaican patient who collapsed and was ignored by two attendants? Can you imagine yourself inside either of these units for a period of 44 days, the average stay for a forcibly-confined Israeli showing symptoms for positive schizophrenia? In particular, note the difference in costs. Colored paint is no more expensive than white. Soft recessed lighting is possible to be made as energy-efficient as florescent lighting. Natural sunlight reduces the need for electricity. Highly-laminate wood floors can prevent costly injuries compared to hard linoleum. Is this really any more expensive? Other cost-free initiatives in accordance with principles of Positive Psychology would be empathy-based therapy, where meetings are designed to be centered on the patient rather that the psychiatrist. Physical exercise and outdoor activities are also free and a huge factor in measured well-being, particularly in depression.27 Viable Alternatives More than any other concept you come away with in this presentation, I want you to remember these facts on a special project that took place between 1971 and 1983 in San Francisco, California, under the leadership of Dr. Loren Mosher. The Soteria Project operated under the notion that perhaps it was possible to cure the worst prognoses of mental illness in an environment cheaper, free from restraints, forced medications and isolation, and lax on security, assuming the best of a person in
  10. 10. their capacity to be independent and well, rather than the worst. The results of the project were astonishing to the mental health community, including Dr. Mosher himself, and were replicated in at least two other similar projects in the United States and Switzerland. Taking the worst cases of schizophrenia from a “normal” San Francisco psychiatric ward, Mosher had non-medical personnel attend to them in a comfortable home with open doors and a backyard. Patients received one-on-one attention, education, group activities and at no time received any psychotropic medications. After two months their rates of recovery were at 90%, on par with the hospital cases. Except after a two- year follow-up, 90% of hospitalized patients had been re-admitted, while 90% of Soteria patients hadn’t. Mosher had proven that acute positive schizophrenia could be treated outside the L’Hôpital-Pinel confine-and-restrain model. He also showed that his cure lasted beyond the psychosis and into the life of the patient, where the typical remission rate virtually disappeared.28 PART IV: CONCLUDING REMARKS Why hasn’t more been done? Similar to the question of violence, you’re probably asking yourself, If this is all true, why haven’t things changed by now? The answer is complicated, but can be boiled down to three simple categories. The first is history. We are still inside a leprosy-based conception of sequestration and treatment for mental illness. Foucault pretty convincingly showed us, before his death in 1984, that the history of mental illness is a model of confinement meant for people with contagious, horrifying diseases. From lepers, to criminals, and finally the mentally ill, our models are still catching up to our science. Very slowly. But why slowly? The second category of the answer also answers this question, which is that change is risky, and it involves big players. National government, local government, pharmaceutical interests and insurance companies are all heavily invested in the mental health system just the way it is now. A growth-minded capitalism doesn’t press innovations in the population sector involving mental illness, because it overlaps too much with public dependence. Investment in people who are chronically dependent on others don’t matter so much to helping expand goods and services. Changing the mental health system to a Soteria-model could change all that. But change is risky and it will take a big push to get all those big players, stuck on the mainstream Leprosy Paradigm, to see it. The third is public knowledge. By their nature, psychiatric units are completely closed and controlled. Information is intentionally barred from the public, even close friends and family. Our only influences, then, come from movies and television, who in turn have a commercial interest to reinforce the stigma, who in turn reinforces leprosy- based thought-systems. But on a positive note, there is more out there than ever before in
  11. 11. the form of live testimony given by former patients on YouTube. One video I saw a girl even had her camera in the emergency room as she was being admitted. It takes a trained eye, however, to take the informational value away from the videos apart from the glamour of the taboo mental hospital experience. Okay, I see your point. But what can I do? How is it that I can help? Think positive! There is something easy you can do, right now. First, watch Sean Blackwell’s YouTube videos on his channel, Bipolar or Waking Up. He paints an alternative viewing of psychosis and depression that is enlightening to any observer, in particular someone who has any personal experience with mental illness. You can also volunteer or visit a mental hospital. Most patients are very bored. Anything that you can bring – whether its food, or a deck of cards – can be a welcome help to ease the day. And seeing a friendly face when you think the whole world has forgotten about you can also make a positive difference. Next year, my team in the New School is starting a volunteer program in the world-famous Loewenstein Rehabilitation Center. It will get you thinking about our hospital protocols and give you experience working with people in sensitive points in their lives – who really need you, too. You can also help me with my Section 12 project! This is an initiative to make a mandatory reading of rights to anyone being forcibly confined through an emergency services process. When someone is arrested they are automatically read their rights according to the “Miranda Law.” Yet no such mandatory reading exists for the mentally ill. It is my hypothesis that much of the observed aggression coming to the psych unit is a direct consequence of patients not knowing what’s going on – not to mention being forcibly strapped and injected in the ambulance on the way to the unit, or taken down and handcuffed by the police without having committed a crime. Finally, educate, inform and circulate truth! The more voices know the truth, the less power the stigma can carry against the mentally ill. Remember, the Big Three are not a person’s choice. No brain is condemned from birth; it is our duty as a society to help these people come to feel loved, welcome and happy in their own skin. “Where there is coercion and disrespect, there is no medicine.” Grace Nichols, 3rd June, 2010.29
  12. 12. 1 Greenwood et. al. Satisfaction with In-Patient Psychiatric Services. (1999). The British Journal of Psychiatry, 174. 159-163. Haw, Camilla et. al. Patients’ Complaints at a Large Psychiatric Hospital. (2010). International Journal of Health Care Quality Assurance, (23), 4. 400-409. 2 Szasz, Thomas S., MD. (1974). The Myth of Mental Illness. New York: Harper Perennial. 3 Foucault, Michel. Madness and Civilization. (1961). London and New York: Routledge Publishing. 4 Ibid. 5 Foucault, Michel. Psychiatric Power. (2003). London: Palgrave MacMillan. 6 Ibid. 7 Ibid. 8 First Person Stories of Forced Intervention and Being Deprived of Legal Capacity. (2007). World Health Organization. 9 Davidson, Larry. (2003). Living Outside Mental Illness. New York and London: New York University Press. 10 Horton, Richard. The Lancet Series on General Mental Health. (2007). The Lancet: DOI:10.1016/S0140-6736(07)61245-8. www.thelancet.com. 11 Kallert, Thomas W. et. al. Differences of Legal Regulations Concerning Voluntary Psychiatric Hospitalization in Twelve European Countries: Implications for Clinical Practice. (2007.) International Journal of Forensic Mental Health, (6), 2. 197-207. 12 Lamb, H. Richard et. al. The Police and Mental Health. (2002). Psychiatric Service Online, (20), 3. www.psychservices.psychiatryonline.org. 13 Ibid. 14 Szasz, Thomas S., MD. The Myth of Mental Illness. 15 Horton, Richard. The Lancet Series on General Mental Health. 16 Willinger, Michal and Feld, Gabriel. (2009). Boston: Back Bay Yoga. 17 Douglas, Kevin S. et. al. Psychosis as a Risk Factor for Violence toward Others: A Meta-Analysis. (2009). Psychological Bulletin, (135), 5. 679-706. 18 Ibid. 19 Abnormal Psychology Lecture, Spring 2008. Psychology Department: Columbia University, New York, USA. 20 De Looper, Michael et. al. Mental Health in OECD Countries. (2008). Organization of Economic Cooperation and Development Policy Brief (November). www.sourceoecd.org. 21 Ibid. 22 All statistics on stigma taken from Tal, Amir et. al. Mental Illness Stigma in the Israeli Context: Deliberations and Suggestions. (2007). International Journal of Social Psychiatry: 1-17. Citations given to referenced studies within Amir et. al’s report as needed. 23 Greenwood et. al. Satisfaction with In-Patient Psychiatric Services. (1999). The British Journal of Psychiatry, 174. 159-163. 24 Evans, Sherrill et. al. Mental Health, Burnout and Job Among Mental Health Workers. (2006). The British Journal of Psychiatry, (188). 75-80. 25 Blackwell, Sean. Bipolar or Waking Up?. (2010). www.youtube.com. 26 Ben-Shahar, Tal. (2010). Positive Psychology; Lectures 1-3. IDC RRIS New School of Psychology: Herzliya, Israel. 27 Ibid., Lectures 6-8. 28 Mosher, Loren R. Soteria and Other Alternatives to Acute Psychiatric
  13. 13. Hospitalization. (1999). The Journal of Nervous and Mental Disease, 187. 142- 149. 29 First Person Stories of Forced Intervention and Being Deprived of Legal Capacity.

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