Mental health policy and practice across Europe: an overview

138 Mental health policy and practice
• Assisting service users to find appropriate jobs in the labour market or in
sheltered settings, whereby the principle of ‘first place, then train’ is increasingly
pursued (in contrast to the traditional principle of ‘first train, then
place’). An interesting development in this area is the creation of patient-run
companies and social firms.
• Offering participation in normal societal (especially cultural) activities.
• Providing a satisfactory standard of living, including access to health care and
legal help.
• Working with the service user’s family. This has become the psychosocial
intervention at the micro-level. The types of activities are numerous and
include family therapy, psychoeducational groups for the individual’s relatives,
multiple family groups, family self-help groups and family self-help
organizations. Many interventions are standardized and documented. The
concept of expressed emotion, as elaborated during the 1970s, kicked off
this development (Brown et al. 1962; Kuipers 1979; Bogren 1997) (see also
Chapter 16).
Usually, such interventions are combined with pharmacotherapy, and integrated
treatment plans should be worked out, especially for people with persistent
mental health problems living in the community (see Herz and Marder
2002). Practically no intervention is possible at a macro-level but it is important
to recognize, especially in times of increased migration (for example, in cases of
displaced refugees but also due to globalization impacts – see Chapter 15), that –
at this level – cross-cultural differences have to be taken into account for
each type of psychiatric treatment. At the macro-level we can also locate the
type of health care system in a country, and particularly how these health care
structures (tax-funded or social health insurance systems) influence the availability
and quality of psychiatric care. Health services research and mental
health policy could therefore also be classified as psychosocial endeavours at the
macro-level.
On the meso-level the restructuring of psychiatric services themselves constitutes
an important intervention, but is not dealt with here (see Thornicroft
and Tansella 2004 and Chapter 10). As far as other organizations are concerned,
such as schools, the military or companies, their structure has to be considered;
but intervention in these structures is not the task of psychiatry proper. Since
people with mental health problems today largely live outside psychiatric
institutions and are integrated into ‘normal’ organizations and institutions,
they need to be taken into account within comprehensive mental health plans
and strategies.
The most important developments in psychosocial interventions concern
the inclusion of family members in the management and treatment processes,
especially for people with chronic conditions, and particularly those with
schizophrenia. The role of the professional is somewhat blurred in psychosocial
interventions, and the term ‘professional’ itself may even need
reconsideration. Many approaches are more educational than therapeutic and
since most service users live outside psychiatric institutions, aspects of daily
quality of life have come to the forefront. Concepts such as disability, quality
of life, empowerment and self-help play increasingly prominent roles and