Self-help organizations facilitate mutual assistance in helping communities. They offer a vehicle for people with a common problem to gain support and recognition, obtain information on, advocate on behalf of, address issues associated with, and take control of the circumstances that bring about, perpetuate, and provide solutions to their shared concern. Self-help organizations may be small informal groups, confined to interactive support for their members, commonly called self-help groups, or differentiated and structured multiservice agencies, mutual assistance organizations referred to as self-help agencies. Such agencies are generally directed and staffed by “self-helpers” and distinct from professionally-led organizations. In these agencies, self-helpers are well-represented as board members with the right to hire and fire professionals in the organization Self-help groups and agencies empower members through shared example and modeled success. Of late, community-based professionally-led organizations have attempted to integrate self-help principles into their support service offerings, reflecting ongoing financial and ideological dynamics in systems of care. This effort has led to the development of peer professional helpers, known as peer support specialists, whose contribution to the helping professions are defined by their lived experience. Spread throughout the world, self-help groups, agencies and integrated peer support specialists are considered a major community resource for enabling people to help themselves. This chapter looks at the development, the content, and the effectiveness of self-help organizations and peer support specialists within professionally-led community-based systems of care.

This review of the literature investigates how attitudes toward the mentally ill affect their involvement in the community and what can be done to enhance such involvement. The author draws conclusions from research on these issues and makes recommendations for policy based on the findings.

Outpatient civil commitment (OCC) requires people with severe mental illness (SMI) to receive needed-treatment addressing imminent-threats to health and safety. When available, such treatment is required to be provided in the community as a less restrictive alternative (LRA) to psychiatric-hospitalization. Variance in hospital-utilization outcomes following OCC-assignment has been interpreted as OCC-failure. This review seeks to specify factors accounting for this outcome-variation and to determine whether OCC is used effectively. Twenty-five studies, sited in seven meta-analyses and subsequently published investigations, assessing post-OCC-assignment hospital utilization outcomes were reviewed. Studies were grouped by structural pre-determinants of hospital-utilization and OCC-implementation-i.e. deinstitutionalization (bed-availability), availability of a less restrictive alternative to hospitalization, and illness severity. Design quality at study completion was ranked on causal-certainty. In OCC-follow-up-studies, deinstitutionalization associated hospital-bed-cuts, when not taken into account, ensured lower hospital-bed-day utilization. OCC-assignment coupled with aggressive case-management was associated with reduced-hospitalization. With limited community-service, hospitalizations increased as the default option for providing needed-treatment. Follow-up studies showed less hospitalization while on OCC-assignment and more outside of it. Studies using fixed-follow-up periods usually found increased-utilization as patients spent less time under OCC-supervision than outside it. Comparison-group-studies reporting no between-group differences bring more severely ill OCC-patients to equivalent use as less disturbed patients, a success. Mean evidence-rank for causal-certainty 2.96, range 2-4, of 5 with no study ranked 1, the highest rank. Diverse mental health systems yield diverse OCC hospital-utilization outcomes, each fulfilling the law's legal mandate to provide needed-treatment protecting health and safety.

Background

Outpatient civil commitment (OCC), community treatment orders (CTOs) in European and Commonwealth nations, require the provision of needed-treatment to protect against imminent threats to health and safety. OCC-reviews aggregating all studies report inconsistent outcomes. This review, searches for consistency in OCC-outcomes by evaluating studies based on mental health system characteristics, measurement, and design principles.

Methods

All previously reviewed OCC-studies and more recent investigations were grouped by their outcome-measures' relationship to OCC statute objectives. A study's evidence-quality ranking was assessed. Hospital and service-utilization outcomes were grouped by whether they represented treatment provision, patient outcome, or the conflation of both.

Results

OCC-studies including direct health and safety outcomes found OCC associated with reduced mortality-risk, increased access to acute medical care, and reduced violence and victimization risks. Studies considering treatment-provision, found OCC associated with improved medication and service compliance. If coupled with assertive community treatment (ACT) or aggressive case management OCC was associated with enhanced ACT success in reducing hospitalization need. When outpatient-services were limited, OCC facilitated rapid return to hospital for needed-treatment and increased hospital utilization in the absence of a less restrictive alternative. OCC-studies measuring "total hospital days", "prevention of hospitalization", and "readmissions" report negative and/or no difference findings because they erroneously conflate their intervention (provision of needed treatment) and outcome.

Conclusions

This investigation finds replicated beneficial associations between OCC and direct measures of imminent harm indicating reductions in threats to health and safety. It also finds support for OCC as a less restrictive alternative to inpatient care.

After one hundred years the family is once again being asked to assume its major function as care-giver for the long-term mentally ill. Is the family able to support chronic mental patients? Is it willing to assume responsibility for these patients? This article addresses these questions, as well as others, and discusses the implications of family policy for community care.

Although England/Wales, Italy, and the United States share a common policy of deinstitutionalization, their mental health systems differ considerably. Each country's civil commitment standards define patient eligibility criteria along one of two primary dimensions--need for treatment or degree of dangerousness. These differential selection criteria result in mental health systems serving different subgroups of the total population. The criteria in England/Wales target older women; in the United States, younger men; and in Italy, a group balanced in age and sex. Implications for the current debate on civil commitment policies are considered.

In this report, the concept of “Home First” is introduced for those children who require long-term, non-kin placements. The term “Home First” connotes a placement engendering stability and continuity; this concept is introduced in conjunction with an evaluation of the historical, theoretical, and empirical evidence surrounding different forms of out-of-home placement, including group-care placements and foster family care. In light of these observations and studies, this report will argue that stability is a major factor, perhaps a necessary if not a sufficient condition, in successful child development. It will argue for the initiation of a new focus on the creation of long-term positive and stable residential placements within the out-of-home care system and show that such placements can and have contributed to the development of healthy, happy, and successful adulthoods. This report offers a bio-psycho-social perspective on child development in out-of-home care. It provides a brief overview of the multiple bio-psycho-social theoretical perspectives that inform us on the necessary role of stability in growth and development and the contribution of instability to dysfunction. This report considers stability in out-of-home care in relation to its associated outcomes and those factors believed to enhance or detract from these outcomes. It reviews the history of substitutive care provision for children and youth and the role of the “stability objective” in that history. Finally, it looks at how child welfare system priorities have influenced stability, and it offers some suggestions for ensuring more stable growth and development in child placement provision.

Outpatient civil commitment (OCC) requires the provision of needed-treatment, as a less restrictive alternative (LRA) to psychiatric-hospitalization in order to protect against imminent-threats to health and safety associated with severe mental illness (SMI). OCC-reviews aggregating all studies report inconsistent outcomes and interpret such as intervention failure. This review, considering those studies whose outcome criteria are consistent with the provisions of OCC-law, seeks to determine OCC-effectiveness in meeting its legislated objectives. This review incorporated studies from previous systematic-reviews, used their search methodology, and added investigations through August 2020. Selected OCC-studies evaluated samples of all eligible patients in a jurisdiction. Their outcome-measures were threats to health or safety or the receipt of needed-treatment exclusive of post-OCC-assignment- hospitalization, the latter being the OCC-default for providing needed-treatment in the absence of an LRA and dependent on bed-availability. A study's evidence-quality was evaluated with the Berkeley Evidence Ranking and the New Castle Ottawa systems. Thirty-nine OCC-outcome-studies in six-outcome-areas directly addressed OCC-statute objectives: 21 considered imminent threats to health and safety, 10 compliance with providing needed-treatment, and 8 conformity to the LRA-standard. With the top evidence-rank equal to one, the studies M = 2.55. OCC-assignment was associated with reducing mortality-risk, increasing access to acute-medical-care, and reducing risks of violence and victimization. It enabled reaching these objectives as a LRA to hospitalization and facilitated the use of community-services by individuals refusing such assistance when outside of OCC-supervision. OCC's appears to enable recovery by reducing potentially life-altering health and safety risks associated with SMI.

In a study of 499 formerly hospitalized mentally ill residents of comunity-based sheltered-care facilities in California, results indicate that rehospitalization serves as a means of, ‘updating’ the chronic patient’s treatment. By returning to the hospital the patient is linked to the service system and its newest benefits accrue to him. In the absence of a care system which can more effectively link chronic patients to available services, rehospitalization may serve an unforseen positive function.