'Severe and enduring mental health problems' is the category description for people in secondary care in the UK. The description applies to anyone who's been sectioned or who is under the care of a Community Mental Health Team (CMHT). People with severe and enduring mental health problems live with their conditions, cope and often recover from their illness. Not necessarily full recovery but a return to mainstream life while coping with the longterm condition.
The care provision for secondary or 'severe and enduring' clients is different from the primary care pathway. Primary care clients are under a GP and have access to psychological therapies such as cognitive behaviour therapy (CBT) and counselling. Secondary care clients can also receive therapy, but delivered through the Community Mental Health Team and not through GP referral.
Severe and enduring mental health conditions can mean extra limitations for certain clients. Limitations above and beyond the condition itself, barriers on the individual's return to mainstream. It shouldn't be the case but it is sometimes. At a crucial stage, the recovery path is held back by what amounts to a reinforcement of something that Professor Pat Deegan has described as 'a career in mental health'.
Current practice around mental health care delivery emphasises as quick a return to mainstream life as is possible and viable. But the length of time that an individual may have spent in hospitals and under the benefits that are geared to support him or her, can prevent, delay or permanently impair the return to mainstream. A 'severe and enduring' diagnosis may mean access to appropriate support, but it may also mean a long term stay in the mental health system, supported but cut off from aspiration and opportunity. This can still be the case after a patient is discharged and living in the community.
Clinical and community teams expend a lot of effort in signposting clients back to mainstream and onto a recovery pathway. The practical ability to reach for these opportunities may be impaired by a loss of self-worth and empowerment by the time he or she is directed to this part of the care plan. Clients with severe and enduring conditions may comply in being signposted to mainstream providers because they feel it is required by their teams or because they fear not doing so might lead to losing benefits, not because they have made a genuine individual choice.
JVT
Wednesday, 10 November 2010
Monday, 25 October 2010
How mainstream is roadblocked
For many years mainstream has been perceived and practised as a key component of the care pathway in mental health provision.
At several stages of the pathway into mainstream there are roadblocks. These can occur from the individual client, from services, even from families and carers. An individual can feel apprehensive of stepping over the threshold into mainstream activities. This can be for a variety of reasons, ranging from self-stigma or from being so long in the mental health system that independence seems a very distant option.
Dr. Pat Deegan's belief is that too often the health system can encourage what she calls 'a career in mental health' and nothing else. This viewpoint is based on her experience as a service user and it still holds true.
A great deal is being achieved by service users themselves to challenge the roadblocks. This is particularly true where creative and personalised use of direct payments and individual budgets have really taken off around the UK. It hasn't happened everywhere but some immensely inspiring stories and testimonials can be viewed at the NMHDU website
Creative use of direct payments in mental health recovery is currently sporadic. Inevitably, this will increase as the move towards personalisation and invididual budgets spreads to become policy all over the UK. This is the planned scenario for what could be as early as 2013.
Where the personalisation pilot schemes are not operating, the entire perception of direct payments and mainstream can be frankly primitive. Individuals under a care plan have a right to direct payments which is often supported wholeheartedly by local direct payments departments. Scandalously, DP can still be denied by the Community Mental Health Teams, even where it is proposed for an individual by the client's own key worker, carer and the client him or herself. This is because direct payments comes out of the Community Mental Health Team budget and is sometimes vetoed by senior members of the team on financial grounds. What this amounts to is direct intervention to block recovery.
Of course any client is free to fund their own mainstream recovery pathway and many do. The outcomes in this area alone (south-west London) have often been formidable. A composer who has funded her own recordings and launches now has self-employment through her music. Many are those who have accessed adult education courses and further training. Individuals have re-accessed faith venues which they had previously felt unable to enter for many years.
Not all these initiatives require direct payments. Many are free to access or funded by individual clients from their own pockets. Where direct payments is a requirement it can often make a crucial difference
At several stages of the pathway into mainstream there are roadblocks. These can occur from the individual client, from services, even from families and carers. An individual can feel apprehensive of stepping over the threshold into mainstream activities. This can be for a variety of reasons, ranging from self-stigma or from being so long in the mental health system that independence seems a very distant option.
Dr. Pat Deegan's belief is that too often the health system can encourage what she calls 'a career in mental health' and nothing else. This viewpoint is based on her experience as a service user and it still holds true.
A great deal is being achieved by service users themselves to challenge the roadblocks. This is particularly true where creative and personalised use of direct payments and individual budgets have really taken off around the UK. It hasn't happened everywhere but some immensely inspiring stories and testimonials can be viewed at the NMHDU website
Creative use of direct payments in mental health recovery is currently sporadic. Inevitably, this will increase as the move towards personalisation and invididual budgets spreads to become policy all over the UK. This is the planned scenario for what could be as early as 2013.
Where the personalisation pilot schemes are not operating, the entire perception of direct payments and mainstream can be frankly primitive. Individuals under a care plan have a right to direct payments which is often supported wholeheartedly by local direct payments departments. Scandalously, DP can still be denied by the Community Mental Health Teams, even where it is proposed for an individual by the client's own key worker, carer and the client him or herself. This is because direct payments comes out of the Community Mental Health Team budget and is sometimes vetoed by senior members of the team on financial grounds. What this amounts to is direct intervention to block recovery.
Of course any client is free to fund their own mainstream recovery pathway and many do. The outcomes in this area alone (south-west London) have often been formidable. A composer who has funded her own recordings and launches now has self-employment through her music. Many are those who have accessed adult education courses and further training. Individuals have re-accessed faith venues which they had previously felt unable to enter for many years.
Not all these initiatives require direct payments. Many are free to access or funded by individual clients from their own pockets. Where direct payments is a requirement it can often make a crucial difference
Thursday, 26 August 2010
Rachel Perkins Guardian interview August 25th 2010
The phrase "going against the grain" could have been invented for Rachel Perkins. Bring up any contemporary issue surrounding mental health and, chances are, the Mind Champion of the Year will come back with a question about why a particular approach is being taken and then advocate for an alternative.
State benefits, a hot topic, is a case in point. As someone who describes herself as "a child of old Labour", Perkins appears slightly uncomfortable that her views on benefits are in some ways in line with those of the Conservative and Liberal Democrat coalition government. She says she is "torn" by some Conservative plans, such as caps on housing benefit, yet is in agreement with the proposal for "tapering" benefit payments so that people are incentivised to work. "So that every hour that someone works counts," she says.
Equal citizens
She goes on to argue that the focus by some campaigners on defending entitlement to benefits can reinforce the perception that people with mental health difficulties need to be cared for, rather than being thought of as equal citizens. "Instead of talking about the right to work, we are now talking about the right to benefits. I don't think that's terribly healthy," she says.
"Every human being gains their self-worth from being able to contribute to their communities – and let's face it, the most socially sanctioned way to do that is with work."
Perkins, a clinical psychologist, is probably best known for her impressive efforts to get people with mental health problems back into work, and has spearheaded employment programmes at South West London and St George's mental health trust.
Civil rights is at the core of what Perkins advocates, and she raises the topic frequently. Discussions around mental illness should resemble those around physical disability, she says, where the emphasis has been successfully rooted not on impairment but in a "rights-based agenda". In part, her inspiration heralds from a strand of mental health advocacy in the US that promotes a "peer support" approach to recovery and firmly places mental health in the realm of a broader rights agenda.
The difficulty for mental health campaigners in Britain, she suggests, is that they can end up ghettoised when they should be tapping into wide-ranging issues around exclusion. Equally, too many of the messages put out about mental illness are couched in negative terms, she claims. "The mental health movement has spent so long looking inwards at the sort of services people get, not better lives. One of the things I really hated about the mental health world was its aura of doom and gloom. It was always, 'You can't do anything because of stigma and prejudice.' [The] image of possibility often gets lost in the conversation about stigma. I'm not some romantic, but [change] is possible."
In particular, Perkins gives short shrift to anti-stigma campaigns, which have attracted substantial funding in recent years. "I don't have any evidence that they [work]. I prefer not to use the term stigma, because it attaches to the person. We don't talk about the stigma of race. We talk about racism. The problem with anti-stigma campaigns is that they identify the class of people by their impairment," she says. "I want to see some empirical data [that they help people to get] a home and a job. The bottom line [is] I want to change behaviour."
Discrimination
As her long career in the NHS nears its end, one of the themes that Perkins, 55, intends to persevere with is challenging the expectations of the state and employers when it comes to getting people into work and keeping them there. Mental health awareness training is not the answer to discrimination, she insists, adding that it is wrongheaded to demand that employers do the "heavy lifting" for people with mental health problems in the workplace when the state should do more.
When asked in 2009 by the last government to head a review into how to support more people with mental health problems into work, for example, Perkins proposed that employers be given financial compensation by the state to cover some of the cost of long periods of health-related absence.
The ability to work was vital to how Perkins dealt with her own mental health difficulties, which manifested in the early 1990s. But her ambition goes beyond getting people jobs. She wants a transformation in how mental health is perceived. "We've got to look at civil rights in the context of mental health and citizenship, rather than, 'You are a poor unfortunate.' That kind of thing is a hiding to more discrimination."
Spitting people out
Perkins's career path offers some insight into how her views have evolved. She considered going into academia after finishing her PhD but quickly came to the conclusion that research was dull. She applied to train as a clinical psychologist only to find herself rejected as someone who would "wilt" outside the confines of a university. Undeterred, she applied for and got a job as assistant psychologist at Broadmoor, the high security psychiatric institution.
The experience reaffirmed what she instinctively felt: "I've always been concerned about the way our society is very good at spitting people out at the bottom. That's always bothered me."
Clinical training followed, as well as several other jobs, including stints in "the old state bins", the large Victorian asylums that once warehoused patients. Perkins attributes her belief that work is the best route to a better life to those early experiences. She describes one institution she helped close in 1990: "There were 40 beds to a dormitory. There were four baths in every bathroom. It's not a long time ago. They weren't safe places. Far from it. The average stay in that place was 30 years."
Winning the Mind Champion of the Year award last month is particularly special, says Perkins, because it was voted for by the public. Perkins beat household names such as Bill Oddie and Ruby Wax to take the gong. "I think [winning the Mind award] was much nicer than the OBE [awarded in June]," she says. "Being voted for was much better."
Perkins has no intention of easing into retirement and will be taking up consulting roles. "We've got to totally rethink mental health services," she says. "We need to be building up communities to accommodate mental distress and put professionals back in their boxes. I think what we've done is over-professionalise mental health."
Elaborating, Perkins explains that the irony of improvements in mental health service provision over the past 30 or so years – such as closing large asylums, introducing community-based services, and better access to a range of therapies – is that mental illness has been pathologised in a way that unwittingly promotes social exclusion of "a whole class" of people.
"The more we've developed highly sophisticated mental health services, the more, when we experience distress, we think, 'I've got to go to the experts.' Then [our] nearest and dearest think, 'Oh my god, they are not safe in my untrained hands. I've got to leave it to the experts.'"
It's not that mental health professionals aren't important or that therapy, drugs and other kinds of treatment don't have their place, Perkins insists. It is that an over-reliance on them stalls progress. "I'm not opposed to medication [for mental illness]. It's one of the things I use," she says.
What concerns Perkins is that often when trying to improve services – the recent emphasis by politicians and practitioners on "talking therapies", for example – the bigger questions around civil rights, dignity and independence are lost. "I don't believe that psychological therapy solves all ills. The more we translate the entire human process into therapy the more we render ordinary human misery and disturbance to the experts," she says.
Perkins's continued outspoken views on what still needs to change in the mental health arena are likely to ruffle the feathers of her fellow professionals and, if the ideas she promotes are eventually adopted, they could radically alter the way services are delivered.
State benefits, a hot topic, is a case in point. As someone who describes herself as "a child of old Labour", Perkins appears slightly uncomfortable that her views on benefits are in some ways in line with those of the Conservative and Liberal Democrat coalition government. She says she is "torn" by some Conservative plans, such as caps on housing benefit, yet is in agreement with the proposal for "tapering" benefit payments so that people are incentivised to work. "So that every hour that someone works counts," she says.
Equal citizens
She goes on to argue that the focus by some campaigners on defending entitlement to benefits can reinforce the perception that people with mental health difficulties need to be cared for, rather than being thought of as equal citizens. "Instead of talking about the right to work, we are now talking about the right to benefits. I don't think that's terribly healthy," she says.
"Every human being gains their self-worth from being able to contribute to their communities – and let's face it, the most socially sanctioned way to do that is with work."
Perkins, a clinical psychologist, is probably best known for her impressive efforts to get people with mental health problems back into work, and has spearheaded employment programmes at South West London and St George's mental health trust.
Civil rights is at the core of what Perkins advocates, and she raises the topic frequently. Discussions around mental illness should resemble those around physical disability, she says, where the emphasis has been successfully rooted not on impairment but in a "rights-based agenda". In part, her inspiration heralds from a strand of mental health advocacy in the US that promotes a "peer support" approach to recovery and firmly places mental health in the realm of a broader rights agenda.
The difficulty for mental health campaigners in Britain, she suggests, is that they can end up ghettoised when they should be tapping into wide-ranging issues around exclusion. Equally, too many of the messages put out about mental illness are couched in negative terms, she claims. "The mental health movement has spent so long looking inwards at the sort of services people get, not better lives. One of the things I really hated about the mental health world was its aura of doom and gloom. It was always, 'You can't do anything because of stigma and prejudice.' [The] image of possibility often gets lost in the conversation about stigma. I'm not some romantic, but [change] is possible."
In particular, Perkins gives short shrift to anti-stigma campaigns, which have attracted substantial funding in recent years. "I don't have any evidence that they [work]. I prefer not to use the term stigma, because it attaches to the person. We don't talk about the stigma of race. We talk about racism. The problem with anti-stigma campaigns is that they identify the class of people by their impairment," she says. "I want to see some empirical data [that they help people to get] a home and a job. The bottom line [is] I want to change behaviour."
Discrimination
As her long career in the NHS nears its end, one of the themes that Perkins, 55, intends to persevere with is challenging the expectations of the state and employers when it comes to getting people into work and keeping them there. Mental health awareness training is not the answer to discrimination, she insists, adding that it is wrongheaded to demand that employers do the "heavy lifting" for people with mental health problems in the workplace when the state should do more.
When asked in 2009 by the last government to head a review into how to support more people with mental health problems into work, for example, Perkins proposed that employers be given financial compensation by the state to cover some of the cost of long periods of health-related absence.
The ability to work was vital to how Perkins dealt with her own mental health difficulties, which manifested in the early 1990s. But her ambition goes beyond getting people jobs. She wants a transformation in how mental health is perceived. "We've got to look at civil rights in the context of mental health and citizenship, rather than, 'You are a poor unfortunate.' That kind of thing is a hiding to more discrimination."
Spitting people out
Perkins's career path offers some insight into how her views have evolved. She considered going into academia after finishing her PhD but quickly came to the conclusion that research was dull. She applied to train as a clinical psychologist only to find herself rejected as someone who would "wilt" outside the confines of a university. Undeterred, she applied for and got a job as assistant psychologist at Broadmoor, the high security psychiatric institution.
The experience reaffirmed what she instinctively felt: "I've always been concerned about the way our society is very good at spitting people out at the bottom. That's always bothered me."
Clinical training followed, as well as several other jobs, including stints in "the old state bins", the large Victorian asylums that once warehoused patients. Perkins attributes her belief that work is the best route to a better life to those early experiences. She describes one institution she helped close in 1990: "There were 40 beds to a dormitory. There were four baths in every bathroom. It's not a long time ago. They weren't safe places. Far from it. The average stay in that place was 30 years."
Winning the Mind Champion of the Year award last month is particularly special, says Perkins, because it was voted for by the public. Perkins beat household names such as Bill Oddie and Ruby Wax to take the gong. "I think [winning the Mind award] was much nicer than the OBE [awarded in June]," she says. "Being voted for was much better."
Perkins has no intention of easing into retirement and will be taking up consulting roles. "We've got to totally rethink mental health services," she says. "We need to be building up communities to accommodate mental distress and put professionals back in their boxes. I think what we've done is over-professionalise mental health."
Elaborating, Perkins explains that the irony of improvements in mental health service provision over the past 30 or so years – such as closing large asylums, introducing community-based services, and better access to a range of therapies – is that mental illness has been pathologised in a way that unwittingly promotes social exclusion of "a whole class" of people.
"The more we've developed highly sophisticated mental health services, the more, when we experience distress, we think, 'I've got to go to the experts.' Then [our] nearest and dearest think, 'Oh my god, they are not safe in my untrained hands. I've got to leave it to the experts.'"
It's not that mental health professionals aren't important or that therapy, drugs and other kinds of treatment don't have their place, Perkins insists. It is that an over-reliance on them stalls progress. "I'm not opposed to medication [for mental illness]. It's one of the things I use," she says.
What concerns Perkins is that often when trying to improve services – the recent emphasis by politicians and practitioners on "talking therapies", for example – the bigger questions around civil rights, dignity and independence are lost. "I don't believe that psychological therapy solves all ills. The more we translate the entire human process into therapy the more we render ordinary human misery and disturbance to the experts," she says.
Perkins's continued outspoken views on what still needs to change in the mental health arena are likely to ruffle the feathers of her fellow professionals and, if the ideas she promotes are eventually adopted, they could radically alter the way services are delivered.
Sunday, 25 July 2010
Mainstream - the Cascade Effect
As a social inclusion bridge builder I work with clients with severe and enduring mental health diagnoses. They are referred or they self-refer with the desire to access mainstream life domains.
Clients aspire to a variety of mainstream choices. It might be volunteering or befriending, it may be arts activities, it might be employment or running your own business. Client aspirations may include sports, faith, education, training or a selection from any or all of these.
Enabling individuals with a 'severe and enduring' background is not always a straightforward process although it certainly can be sometimes. A client can be introduced to a mainstream outlet and it can work for him or her almost immediately. Other clients may be unready for mainstream for a variety of reasons. They may suffer a relapse before accessing the mainstream environment. They may visualise mainstream as another form of day service or statutory support system, which it isn't.
Equally, clients can sometimes express a wish to access mainstream out of a misplaced fear that not accessing it might in some way affect their payments and benefits. It can be a long process before the value and rewards of mainstream are understood.
What is true is that clients who successfully access or re-access mainstream in turn become examples of mainstream's effectiveness. Signposting to mainstream as part of the mental health recovery pathway is undoubtedly effective, even if it does not work for everyone straight away.
Mainstream also helps to sustain recovery in the individual and even better, it can propagate more success and recovery out of its own resources. An example of this would be the musician who successfully links up with a mainstream recording studio. After months of regular rehearsal the musician is invited by the studio manager to contribute to a recording session. I witness this kind of beautiful outcome and its benefits for the client in my work as an arts bridge builder.
Another example - again from music bridge building - is the guitarist client who uses a studio regularly and invites a friend to join him during the session. The friend may well be another mental health service user who has never successfully engaged with mainstream despite the best efforts of the bridge building service. Where services have been unsuccessful a friendship and peer network can do the job far more effectively.
Mainstream reaches the places other services cannot reach and in the process it is able to create a cascade effect - a continuing path of development, recovery and individual growth.
Clients aspire to a variety of mainstream choices. It might be volunteering or befriending, it may be arts activities, it might be employment or running your own business. Client aspirations may include sports, faith, education, training or a selection from any or all of these.
Enabling individuals with a 'severe and enduring' background is not always a straightforward process although it certainly can be sometimes. A client can be introduced to a mainstream outlet and it can work for him or her almost immediately. Other clients may be unready for mainstream for a variety of reasons. They may suffer a relapse before accessing the mainstream environment. They may visualise mainstream as another form of day service or statutory support system, which it isn't.
Equally, clients can sometimes express a wish to access mainstream out of a misplaced fear that not accessing it might in some way affect their payments and benefits. It can be a long process before the value and rewards of mainstream are understood.
What is true is that clients who successfully access or re-access mainstream in turn become examples of mainstream's effectiveness. Signposting to mainstream as part of the mental health recovery pathway is undoubtedly effective, even if it does not work for everyone straight away.
Mainstream also helps to sustain recovery in the individual and even better, it can propagate more success and recovery out of its own resources. An example of this would be the musician who successfully links up with a mainstream recording studio. After months of regular rehearsal the musician is invited by the studio manager to contribute to a recording session. I witness this kind of beautiful outcome and its benefits for the client in my work as an arts bridge builder.
Another example - again from music bridge building - is the guitarist client who uses a studio regularly and invites a friend to join him during the session. The friend may well be another mental health service user who has never successfully engaged with mainstream despite the best efforts of the bridge building service. Where services have been unsuccessful a friendship and peer network can do the job far more effectively.
Mainstream reaches the places other services cannot reach and in the process it is able to create a cascade effect - a continuing path of development, recovery and individual growth.
Sunday, 18 July 2010
Incredible Stories
Click on Incredible Stories for some incredible and inspiring stories about personalisation, human growth, direct payments and social inclusion.
Friday, 16 July 2010
Social Health
From www.answers.com by Ian McDowell:
"The concept of social health is less intuitively familiar than that of physical or mental health, and yet, along with physical and mental health, it forms one of the three pillars of most definitions of health. This is partly because social health can refer both to a characteristic of a society, and of individuals. "A society is healthy when there is equal opportunity for all and access by all to the goods and services essential to full functioning as a citizen" (Russell 1973, p. 75). Indicators of the health of a society might include the existence of the rule of law, equality in the distribution of wealth, public accessibility of the decision-making process, and the level of social capital.
The social health of individuals refers to "that dimension of an individual's well-being that concerns how he gets along with other people, how other people react to him, and how he interacts with social institutions and societal mores" (Russell 1973, p. 75). This definition is broad—it incorporates elements of personality and social skills, reflects social norms, and bears a close relationship to concepts such as "well-being," "adjustment," and "social functioning."
Formal consideration of social health was stimulated in 1947 by its inclusion in the World Health Organization's definition of health, and by the resulting emphasis on treating patients as social beings who live in a complex social context. Social health has also become relevant with the increasing evidence that those who are well integrated into their communities tend to live longer and recover faster from disease. Conversely, social isolation has been shown to be a risk factor for illness. Hence, social health may be defined in terms of social adjustment and social support—or the ability to perform normal roles in society.
Definitions of social health in terms of adjustment derive from sociology and psychiatry. Poor social adjustment forms a common indicator of neurotic illness, and adjustment may be used to record the outcome of care, especially for psychotherapy. Adjustment may be rated subjectively, or it may be judged in terms of a person's fulfillment of social roles—how adequately a person is functioning compared to normal social expectations. Role performance can also indicate the impact of disability, bringing the concept of social health close to that of handicap, which refers to the social disadvantage resulting from impairments or disabilities (World Health Organization, 1980). As norms vary greatly between cultures, however, a challenge lies in selecting an appropriate standard against which to evaluate roles.
Mutual social support is also commonly viewed as an aspect of social health. Support attenuates the effects of stress and reduces the incidence of disease. Social support also contributes to positive adjustment in children and adults, and encourages personal growth. The concept of support underlines the theme of social health as an attribute of a society: a sense of community—or the currently fashionable concept of social capital, which refers to the extent to which there is a feeling of mutual trust and reciprocity in a community—is an important indicator of social health".
Bibliography
Hawe, P., and Shiell, A. (2000). "Social Capital and Health Promotion: A Review." Social Science and Medicine 51:871–885.
Russell, R. D. (1973). "Social Health: An Attempt to Clarify This Dimension of Well-Being." International Journal of Health Education 16:74–82.
World Health Organization (1980). International Classification of Impairments, Disabilities, and Handicaps. Geneva: Author.
— IAN MCDOWELL
"The concept of social health is less intuitively familiar than that of physical or mental health, and yet, along with physical and mental health, it forms one of the three pillars of most definitions of health. This is partly because social health can refer both to a characteristic of a society, and of individuals. "A society is healthy when there is equal opportunity for all and access by all to the goods and services essential to full functioning as a citizen" (Russell 1973, p. 75). Indicators of the health of a society might include the existence of the rule of law, equality in the distribution of wealth, public accessibility of the decision-making process, and the level of social capital.
The social health of individuals refers to "that dimension of an individual's well-being that concerns how he gets along with other people, how other people react to him, and how he interacts with social institutions and societal mores" (Russell 1973, p. 75). This definition is broad—it incorporates elements of personality and social skills, reflects social norms, and bears a close relationship to concepts such as "well-being," "adjustment," and "social functioning."
Formal consideration of social health was stimulated in 1947 by its inclusion in the World Health Organization's definition of health, and by the resulting emphasis on treating patients as social beings who live in a complex social context. Social health has also become relevant with the increasing evidence that those who are well integrated into their communities tend to live longer and recover faster from disease. Conversely, social isolation has been shown to be a risk factor for illness. Hence, social health may be defined in terms of social adjustment and social support—or the ability to perform normal roles in society.
Definitions of social health in terms of adjustment derive from sociology and psychiatry. Poor social adjustment forms a common indicator of neurotic illness, and adjustment may be used to record the outcome of care, especially for psychotherapy. Adjustment may be rated subjectively, or it may be judged in terms of a person's fulfillment of social roles—how adequately a person is functioning compared to normal social expectations. Role performance can also indicate the impact of disability, bringing the concept of social health close to that of handicap, which refers to the social disadvantage resulting from impairments or disabilities (World Health Organization, 1980). As norms vary greatly between cultures, however, a challenge lies in selecting an appropriate standard against which to evaluate roles.
Mutual social support is also commonly viewed as an aspect of social health. Support attenuates the effects of stress and reduces the incidence of disease. Social support also contributes to positive adjustment in children and adults, and encourages personal growth. The concept of support underlines the theme of social health as an attribute of a society: a sense of community—or the currently fashionable concept of social capital, which refers to the extent to which there is a feeling of mutual trust and reciprocity in a community—is an important indicator of social health".
Bibliography
Hawe, P., and Shiell, A. (2000). "Social Capital and Health Promotion: A Review." Social Science and Medicine 51:871–885.
Russell, R. D. (1973). "Social Health: An Attempt to Clarify This Dimension of Well-Being." International Journal of Health Education 16:74–82.
World Health Organization (1980). International Classification of Impairments, Disabilities, and Handicaps. Geneva: Author.
— IAN MCDOWELL
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