A Framework for Support
A Framework for Support is CMHA’s central policy regarding people with mental illness. This third edition retained the integrity of the model and is now positioned within the current context of population health, health promotion, and recovery. A Framework for Support, Third Edition, offers the best of something old and something new; and while the Framework has grown and changed over time, its original core principles continue to be as vibrant and relevant as ever.
People with mental illness, their families, and the mental health professionals who try to support them are currently in a state of dynamic tension. At no other time in history have there been in place the knowledge and understanding, the range of techniques, and the human resources to create the kind of revolutionary change in the lives of consumers that is now possible. New therapies, the emergence of evidence-based programs, a new awareness of population health factors, and consumer and family empowerment all contribute to this powerful mixture.
The source of the tension is clear. It can be found in the gap between what we know we can do and what we are actually doing. We can intervene early in psychotic illness and dramatically improve its course, but in most cases we do not. We can house people effectively in ways that support independence and dignity, but in many cases we do not. We can support people in regular work and school settings, but in most cases we do not. We know that consumers can help each other if they have the resources, but in most cases they do not. The list could be longer.
Balancing these problems are successes. There are dozens of examples of effective and successful programs, treatments, and other models of support that are now in place and operating. There is also a rapidly increasing number of consumer and family stories that speak volumes about the possibility of recovery and a dignified life in the community. These stories show that the future is to some degree already at hand.
If the ingredients of change are in place, what is holding us back? There are many factors, with perhaps political will, imagination, and money being the top three. Political will is needed at a time when stigma and discrimination against consumers remain stubbornly entrenched. The ability to imagine, to look at the situation now and see in it the seeds of a different future, is also vital. This applies to the imagination of the public about their fellow citizens, of families about their relatives, of consumers about themselves, and of professionals about their clients. Money is needed to shift to new programs and ways of providing support, but it is money well invested in the long term because the individual and social costs of mental illness are lowered.
The Framework for Support focuses on three core areas to mark the way forward. The three areas are community, knowledge, and the personal resources needed to cope with mental illness. The focus on community serves to anchor our thinking in the real process of consumers’ lives in society. It balances the service-focused bias of older policies by calling for full partnerships with consumers and families, and by recognizing the complex range of factors that shape the lives of consumers in the community. The focus on knowledge offers a model that fully engages the wide range of knowledge that we now possess. This includes, but goes beyond, best practices and evidence-based concepts to outline a rich convergence of kinds of understanding that range from the scientific to the experiential. The focus on personal resources redefines the inner landscape of consumers from a repository of illness and symptoms to a dynamic mixture of skills and capacities that can successfully confront illness. Taken together, these focal points and other elements of the Framework model describe a process for moving ahead.
Structure of the Framework Model
The major goal of the Framework model – people with serious mental illness living fulfilling lives in the community – requires a clear vision of the future if it is to become a reality. We start with three fundamental assumptions and three conceptual models to address them:
- That the way in which Canadian communities provide services and supports to people with mental illness needs to be reformed and restructured. Part 1 of the Framework outlines a conceptual model, the Community Resource Base, which rethinks the nature of services and supports.
- That the most basic ways in which we think about and understand mental illness need to be re-examined and changed. Part 2 of the Framework proposes a conceptual model, the Knowledge Resource Base, which brings into focus the diverse kinds of information relevant to this task.
- That the way in which consumers are seen as people needs to be changed and enriched with a focus on the capacities required to successfully deal with mental illness and enhance mental health. Part 3 of the Framework introduces the concept of the Personal Resource Base as a model for understanding consumers as actors who can direct their own recovery process.
The first of these assumptions, that services and supports need to be reformed and restructured, is widely accepted across Canada. Most provinces now have plans to change services and develop new models, though the service paradigm still dominates the search for solutions. It is hoped that the concepts and ideas that flow from the Community Resource Base and are outlined in Part 1 will continue to shift the balance so that non-service approaches are included in our thinking, and will contribute to this process of reform.
The second assumption, that our fundamental understanding of, and attitudes towards, mental illness need to be rethought, is less a part of the current debate in the field. The point is not simply that public attitudes need to be changed, but that important aspects of the knowledge base available to us are ignored or under-utilized by many groups including professionals, policy makers and the public. The knowledge base that is available in Canada today is in fact extensive. On the one hand, mental illness has been formally studied by both clinical disciplines and the social sciences. On the other hand, rich cultural and ethnic traditions in Canada represent knowledge from past and present experience. More recently, consumers have begun to develop and communicate their own ways of thinking about and understanding mental illness. Families, too, are able to contribute to our understanding on the basis of their intimate association with consumers. All of these approaches have strengths and weaknesses. But whether the issues are negative, such as stereotypes in the media or narrow clinical perspectives which ignore social factors, or positive, such as the new insights provided by consumers exploring the direct experience of mental illness, the point remains the same. The various types of knowledge that we have are not being effectively synthesized and utilized. This area is explored in Part 2 using the Knowledge Resource Base.
The third assumption, that how we see consumers, and how they see themselves, needs to be re-evaluated and enriched, is an ongoing topic of debate in Canada. For many years, consumers, members of the family and professional communities, and the Canadian Mental Health Association have been fighting against limiting and disabling views of consumers. These important efforts have been enhanced by the emergence of consumers as advocates, members of planning groups, and as staff in mental health agencies. Despite many successes, impoverished views of consumers and their capacities linger on in the public, and particularly in the professional, imagination. Fortunately, efforts aimed at positive change continue. The Personal Resource Base, discussed in Part 3, brings focus to these and many other complementary efforts to change how we see people with mental illness, and articulates the steps people can take on the road to recovery.
The Framework and Trends in Health Policy
Health policy is a rapidly changing field that generates new theories and paradigms to help make sense of the complexities of human health and well being. Health promotion, population health, and best practices are examples of perspectives that have relevance to how we think about and implement health strategies at the broadest level. The Framework model, on the other hand, focuses specifically on issues faced by people with serious mental illness. The sections below discuss how the Framework incorporates these important trends in health policy and expresses them in the particular field of serious mental illness.
The Framework and Mental Health Promotion
In the past several decades, health promotion has become an increasingly accepted approach to health and wellness. Growing out of the health promotion tradition is a concept of mental health promotion that builds on the same principles of individual and community choice, control, and participation in decisions about health issues and ways to address them. The Framework model, although developed largely outside the mental health promotion field, has many elements in common with mental health promotion. It recognizes the importance of the knowledge and experience of people with mental illness and their families, emphasizes participation in decision making as well as power and control, and focuses on the promotion of mental health and the journey to recovery rather than on simply treating the illness. It can accurately be seen as a mental health promotion model for people with mental illness.
In fact, the model has been used to launch discussions about promoting the health of other target groups. By replacing the person in the centre of the model with other special populations such as seniors or isolated adolescents, it has proven possible to explore new options for mental health promotion.
The Framework and Recovery
Academic research and writings by consumers have successfully challenged the traditional belief that serious mental illness must by definition follow a chronic and deteriorating course. The new perspective is more optimistic and recognizes the reality of recovery. The term recovery, when applied to mental disorders, has a different connotation from the common understanding of recovery in regard to physical illness. Whereas recovery from physical conditions usually implies the absence of illness, recovery from serious mental disorders is a more nuanced phenomenon that may coexist with ongoing symptoms. Consumers’ descriptions of their own experiences are key to any understanding of recovery.
William Anthony, a leader in the field of psychosocial rehabilitation, talks about how recovery involves the development of new meaning and purpose in life as an individual grows beyond the catastrophic effects of psychiatric disability. It can be seen as a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills, and roles and as a way of living a satisfying, hopeful, and contributing life. Because recovery is often described in terms of gaining control over one’s life and the illness (rather than the illness having control over the individual), recovery has significant commonalities with mental health promotion. The recovery perspective is fully consistent with the Framework. The elements that support recovery, including meaningful daily activity (such as work or education); positive family or peer relationships; medications; and recovery-oriented mental health services, are put in a conceptual context in the Framework model. The model also encompasses the idea of a new understanding of illness and of the individual capacity to cope with the challenges it creates. Recovery and the Framework model are discussed more fully in the conclusion of this document.
The Framework and Population Health
Like mental health promotion, the population health approach differs from traditional medical thinking. In an attempt to influence the health status of the population as a whole, it draws on the growing body of evidence about the social and environmental factors that determine health. Work, income, education, housing, and peer and family supports are examples of population health factors. The Framework identifies these factors and describes their importance in working with, and reducing the burden on, more traditional health serivces. By doing so, it attempts to create a unified strategy to promote the overall well being of people with mental illness.
The Framework and Best Practice
Best practice is a way of putting into place health care that is evidence-based. The attempt is made to distill both the available scientific knowledge and practical examples of successful programs and policies into the best strategies for the operation of the health system and the care it provides. In the mental health field in Canada, the 1997 Report on Best Practices in Mental Health Reform, issued by the Federal/Provincial/Territorial Advisory Network on Mental Health, offers guidelines consistent with this approach. The report has been very influential at the program and policy levels and has helped to shape the reform strategies of most provinces and territories.
The Framework is compatible with the best practices approach and foreshadowed it by calling in earlier editions for evidence-based models in mental health services and recognition of the contributions of consumers and families. The Framework itself was recognized in the 1997 report as a best practice in mental health policy.
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