East Asian Arch Psychiatry 2014;24:104-9

ORIGINAL ARTICLE

Prof. Alan Rosen, Professorial Fellow, School of Public Health, Faculty of Health and Behavioural Sciences, University of Wollongong; Clinical Associate Professor, Brain and Mind Research Institute, Sydney Medical School, University of Sydney; Deputy Commissioner, Mental Health Commission of New South Wales, Australia.
Mr Paul O’Halloran, Director MHINDS (Mental Health International Networks for Developing Services); Senior Clinical Psychologist, Consultant Assertive Community Treatment, Western Sydney Local Health District, Australia.

Address for correspondence: Prof. Alan Rosen, Mental Health Policy Unit, Brain & Mind Research Institute, PO Box 110 Balmain, NSW, Australia 2041. Tel: (61) 419 124 095; Fax: (61-2) 9810 8733;
Email: alanrosen@med.usyd.edu.au

Submitted: 13 June 2014; Accepted: 22 August 2014

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Introduction

Complexity is a normal part of the mental health arena and the treatment, care and resolution of such complexity should be the “bread and butter” of all mental health service providers. In this way, we encompass the full gamut of bio- psycho-socio-cultural-environmental factors and domains in our endeavours for supporting recovery. As most mental illnesses have been found to be multifactorial in aetiology, it should be no surprise that their most effective remedies are multimodal.1 Severe mental illness, its treatment, rehabilitation, and personal efforts to recovery do not easily lend themselves to explanation by a single paradigm. An exclusively biological, psychological, social, or cultural model of care is unable to satisfactorily explain or guide intervention into the complexities of mental illness and the impact these problems have on individuals, their families, and their wider communities. While each domain can be a necessary component of care and treatment, overall, a singular and narrow approach is not sufficient to guide recovery-oriented care and practice. Many elements of a person’s life can be impacted by mental illness; consequently, treatment and support require a holistic approach focused on need. For many individuals, this may involve simply supporting self-help capabilities. For many others, this will extend to a wider system of responses made up of clinical and disability support services, family and carer support, as well as government and non-governmental organisation (NGO) service provision.

Attempts at coming to grips with this inherent complexity can often lead to fracturing in our understanding and a fragmenting of our ways of working into separate compartments, which may hinder us from adopting the integrative and more holistic approach needed. We see this in the many artificial divides that emerge, including the way service-level models of care are organised, at the level of individual clinical and rehabilitation practice and even in our conceptual understanding of mental health problems. This is readily apparent in the divides that often exist between clinical treatment and the need for psychosocial rehabilitation and disability support, between hospital- and community-based service models, between the priorities of public, private and NGO sub-systems and, now even more worryingly, between the recovery approach and evidence- based practice.

Recovery Concepts and Practices

Recovery can be an elusive concept. From the lived experience of consumers and their families as well as the scientific literature, recovery emerges as a highly variable construct with differences in definition, outcome, key components, and measurement.^2,3 Common themes do emerge however, with the core elements of recovery approaches emphasising the need for enabling self-determination and self-management, empowerment and supporting personal growth with the need for creating choice and opportunities for meaningful social and community participation.⁴ Some contemporary definitions see recovery as something that cannot be done to or for consumers by service providers. From this perspective, while it remains ultimately something consumers do, services and interventions can be made more effective and conducive for supporting the individual recovery journey and experience. That is, recovery can be supported by creating the nurturing conditions, enabling platform, and encouraging environment necessary for assisting personal efforts.

There is also growing additional scientific evidence of the effectiveness of several specific elements of the recovery approach. Warner⁵ highlights the evidence-supporting elements of a recovery approach including optimism about outcome, interpersonal support and empowerment through increased sense of internal locus of control, or mastery through personal choice, decision-making and low internal stigma, and the value of paid employment.

While recovery is a unique and personalised journey for an individual, as a conceptual approach, it can also provide a unifying framework for guiding the development of quality services. Recovery is more an approach rather than a specific model of care and, accordingly, is relevant to all aspects of practice and service delivery.⁶ In fact, recovery comprises an unsettled number and range of variables, forming overlapping clusters of items and dimensions in the empirically tested rating scales available. So, it constitutes a promising but as yet unstable construct for measurement.² We should aspire for all our interventions to be recovery-oriented, not categorising some interventions such as functional rehabilitation as recovery-oriented and others such as clinical treatment as not. If interventions are based on individual choice, are humane and empowering, evidence-based, alleviate suffering and distress, and are potentially healing, then they should be included under the recovery umbrella. The Recovery Approach can also be applicable within the context of some, and hopefully rare, circumstances when involuntary treatment is necessary. By using the established evidence-based repertoire of interactive and collaborative interventions, respecting and amplifying individual choice and the therapeutic alliance more systematically, and ensuring the right to safe and effective treatment and support, continued recovery can be supported. These interventions, along with active listening, joint decision-making and the use of advanced directives, facilitate practice within a recovery paradigm and, together, work to minimise involuntary treatment. If involuntary treatment is ultimately required then, together, we must face and accommodate the apparent contradiction between free will autonomy and communal determinism, societal concern and playing safe, as we all do in many other aspects of everyday life.¹

This more integrated perspective on recovery recognises the need of many individuals who suffer from the intrusive clinical aspects of the illness for additional support to assist their personal recovery such as symptom relief through both medical and psychological treatment. An integrated perspective also recognises the disabling aspects of the illness on an individual’s functioning and the need for psychosocial disability support.

Multi-layered Complexity of Recovery

Delving deeply into the multi-layered complexity of the recovery paradigm reveals the interrelationship of the personal, clinical and functional dimensions of recovery, providing a more effective way of understanding the great variation in recovery outcomes, as well as the importance of evidence-based practice for building quality recovery- oriented service provision.⁷

Viewing recovery from these angles, arguably, enables a clearer view for service users and families, and certainly a better understanding for service providers of how the personal, clinical, and functional or psychosocial disability aspects of recovery relate to and can be better integrated into more person-centred interventions and support. Personal recovery is about getting one’s life back on track after the onset of illness. It is more concerned with psychosocial disability and the support needed to better manage the functional impact of the illness and to enable greater community participation. Clinical recovery is more focused on reducing incapacity and suffering by achieving symptom relief and personal control through clinical intervention and treatment, including learning self-management strategies. Most people in continuing contact with public mental health systems would not be considered as having fully recovered. Rather they would be considered as being ‘in recovery’,⁸ i.e. having an ongoing need in varying ways, for both clinical and psychosocial disability supports to maintain and improve prospects for their personal recovery.

Recovery, from the service perspective of providers, can also be an empowering and integrative values-based framework for the development and organisation of quality services. Firstly, at the service level, the recovery approach helps frame what a good-quality mental health service should look and feel like for consumers and their families. There is increasing convergence from multiple perspectives on what constitutes a good-quality mental health service.^9-12 The emerging findings from research, practice- based evidence and, increasingly, including the voices of consumers and carers, clearly point towards the need for developing comprehensive and integrated systems of care with their centre of gravity firmly in the community.^13-16 An effective mental health service must make sense to individuals with mental illnesses, their families and to their service providers, where all providers understand their own therapeutic and support roles in relation to individuals and their family, and to other providers and agencies. Individuals with mental illnesses and their families need to feel they have been well supported, effectively treated, and practically helped to restore and / or sustain their mental health and well-being.

Policy and Principles of Recovery-oriented Services

Additionally, the advent of an increasing number of mental health commissions in different states and countries of the world has enabled mapping of a common agenda for these nations and also, increasingly, for global mental health.¹⁷ As stakeholder groups in the potentially formidable mental health community, we all need to work towards securely building the so-called “Four Corner Posts” outlined below,¹⁸ of Mental Health Care Policy to be delivered in all countries. In some arenas, this may initially involve provision of mental health service implementation by technical and itinerant service proxies and via enhanced primary health care in some poorer nations and more remote settings. The 4 Corner Posts of Mental Health Care Policy are described below.

Human Rights Enabling

This should be not just human rights–compatible but (in line with Declarations and Conventions of the United Nations¹⁹) needs to be actively pursued. This entails systematically implementing repertoires of evidence-based methods to replace as many involuntary orders as possible with voluntary care, as well as to systematically diminish reliance on seclusion and restraint.¹ It includes:

• the human right to effective and evidence-based, recovery enabling and acceptable interventions;
• the right to optimal autonomy plus integrated person-centred care;
• the need for All-of-Health, All-of-Government, and All-of-Community integrated care with personalised choices, and attention to all the support needs and physical care to eliminate the lifespan gap for individuals living with mental illnesses;
• the right to be engaged and cared for by a service provider in the team whom you recognise as “one of your own”, i.e. from your own community or culture. These may include aboriginal community controlled health services and aboriginal mental health workers, transcultural bilingual counsellors, and peer support workers.

Community-focused Mental Health Services

The focus of mental health services must be moved from being hospital-based to community-centred. De- institutionalisation has stalled in many jurisdictions and lands, it has often only been partially achieved, and it needs to be kick-started again and completed. We need to shift the centre of gravity of mental health services from being so hospital-centric, with community “outreach” only when convenient for staff, to mobile community-based care and support, with “in-reach” to hospital only when necessary.^13,16

Quality and Evidence-based: Optimising Quality Services and Workforce Training

This requires implementing both evidence-based interventions (contents) and the necessary service delivery systems (infrastructure or vehicles for delivery of interventions), for example, early intervention approaches for a wide range of mental health conditions (similar to what is being done in oncology and cardiology). This includes the need for retraining of service providers, especially the development and qualification of a peer workforce, to provide more accessible, welcoming, trauma-informed, and congenial services for service users and families, ensuring the community mobility and recovery-orientation of services.

Equity of Service Provision

This entails that:

• region by region, locality by locality, we need to reform our mental health services with equity of provision and with adequate proxies for evidence-based service delivery systems for rural, remote, transcultural, and co-occurring disorders;
• all people with severe and enduring mental illness get equal access as other citizens to sufficient technological and psychosocial solutions, including adequate physical care and support to obtain stable accommodation, employment, or other purposeful occupations;
• there is parity of expenditure with other medical and surgical disciplines and government-wide interventions on social determinants, commensurate with percentage of health burden. Parity involves correcting the current disparity between the proportion of the national health budget which goes into mental health (e.g. 6% to 7% in Australia) equivalent to only half of the actual health burden due to mental illness (13% in Australia).²⁰

Underlying and anchoring each cornerstone must be the policy foundations of:

• adequate and stable financing;
• effective governance;
• continuing quality improvement, evaluation, and research;
• workforce development, training, supervision and communities of practice.

Core Components of Care and Treatment

Built upon this foundation of evidence-based, recovery- oriented and human rights enabling framework of policy and principles are the necessary core components of treatment and care. Essentially these are the structures and processes of care provision. These include the teams and service delivery systems (the vehicles),²¹ as well as the menu of evidence- based interventions (the treatment and support contents contained and carried within the service delivery vehicles to consumers and families in need).²² These components should be clearly demonstrated to produce the best outcomes as well as being the most cost-effective.²³ These components will need to enable easier access and pathways to care when and where needed. These will include earlier detection and intervention of disorders, especially during critical periods such as first-episode psychosis²⁴ for younger people. Additionally, these components should include 24-hour mobile crisis response and acute community-based treatment teams²⁵ for all age-groups, along with low-key, unlocked, residential 24-hour staffed respite centres,²⁶ which together will provide community-based alternatives to inpatient admission where people can be safely and cost- effectively treated in the community.

Mobile assertive community treatment for young people and adults with persistent, turbulent conditions, which would otherwise lead to many hospital admissions, are also an essential component of care.^27,28 More recent developments of the model and research include inclusion of peer workers and adoption of the recovery paradigm, both of which are entirely compatible.²⁸ While there has recently been some questioning in the UK of the effectiveness of assertive outreach,²⁹ variations in outcome of studies have largely been demonstrated to be due to a lack of model fidelity.³⁰ This model of care remains one of the most solid evidence-based approaches with numerous randomised controlled trials demonstrating the effectiveness of this way of delivering treatment and support to people with very complex needs, who are frequently disengaged from more standard levels of service provision.

There will also be a need for case management or care coordination services, providing a much needed but less intensive continuity of care coordination approach.^31-34

Specific interventions will need to include access to the wide array of evidence-based and holistic range of bio- psycho-socio-cultural interventions required, encompassing clinical as well as the social and environmental supports necessary to enable recovery.³⁵ This means access to modern medications to optimise symptom control and minimise or eliminate unwanted side-effects. Nowadays, access to evidence-based psychological therapies for the full range of problems and disorders is also an essential component of contemporary care. These include a range of psychological therapies,^36-39 family and multiple family interventions^40,41 for affective disorders and psychosis, cognitive remediation for psychosis,⁴² and dialectical behaviour therapy for borderline states and self-harming.⁴³ Integrated and staged approaches using motivational interventions for working with people, who have co-occurring disorders such as mental illness and substance abuse, are also part of the necessary portfolio of evidence-based care.^44,45 Moreover, access to cost-effective psychosocial interventions, supporting social inclusion and creating opportunities for accessing secure housing, employment and education, while reducing stigma and preventing discrimination are also essential.⁴⁶

Cultural Parallels with Recovery Paradigm

In many South-East Asian communities, as in some other low-to-middle income countries, services may still be inadequate and often still too institutionalised, and both stigma and discrimination remain formidable obstacles to optimal treatment and care, and to restoring marital and work prospects and full citizenship. However, this is counter- balanced in an increasing proportion of these countries by the growing respect and valuing of both realms of the more western evidence-based and technical approaches on the one hand, and the traditional cultural healing factors on the other, including many aspects of the recovery agenda which are increasingly adopted worldwide.^47-49 In many ways, this entails straddling, and where appropriate, honouring and embracing both the collectivist values of traditional societies and the more individualistic notions associated with western aspirations, self-determination, personal choice, and autonomy.¹ This valuing of both cultures concurrently grows, persists and prospers, despite, and in some ways walking hand in hand with, socioeconomic and political developments. This augers well for the ability of these communities to readily understand and appreciate the synergies between these realms, and the need to integrate these approaches for the most optimal outcomes for individuals living with mental illnesses and their families.

Conclusion

Recovery, while being a complex and multi-dimensional construct, has demonstrated potential for being a unifying framework with both personal benefit to consumers and carers while additionally offering a foundation for the quality improvement of services. Mental health services need to be both holistic and integrated in the way clinical treatments and psychosocial disability supports are made accessible and available within a framework of evidence- based practice, to support the personal efforts to recovery. The foundation for building contemporary community mental health systems begins with establishing the ‘recovery approach’ as the core value base demonstrating a way of working that is person-centred, needs-driven, and providing individualised approaches to care. This requires collaboration and engaging with consumers, families, and carers in working alliances which are ethical, culturally sensitive, and human rights–compatible, to promote optimal self-management and independence. Such services need to be community-focused, with treatment and support being provided closer to home and in the least restrictive and as personally enabling environments as possible. Finally, service-level efforts at supporting personal recovery must embrace the evidence base, demonstrating practice that is efficient, effective, and supported by research whenever it exists, and delivered by a well-trained and supervised workforce, including clinical professionals as well as vocational and housing specialists and consumer and family carer peer workers.

So, the recovery paradigm and recovery-oriented practice can provide a unifying bridge between the clinical, functional, and personal or subjective domains of recovery and mental health service endeavours. They can also bridge the realms of both collectivist and individualistic solutions and the realms of healing informed by some traditional practices and of evidence-based technically informed approaches and advances in mental health care.

References

1. Rosen A, Rosen T, McGorry P. The human rights of people with severe and persistent mental illness: can conflicts between dominant and non- dominant paradigms be reconciled? In: Dudley M, Silove D, Gale F, editors. Mental Health and Human Rights. Oxford: Oxford University Press; 2012.
2. Burgess P, Pirkis J, Coombs T, Rosen A. Australian Mental Health Outcomes and Classification Network: review of recovery measures, February 2010. Available from: http://www.recoverydevon.co.uk/index.php/information-on-recovery/resources/research-docs/review-of-recovery-measures Accessed 12 Sep 2014.
3. Burgess P, Pirkis J, Coombs T, Rosen A. Assessing the value of existing recovery measures for routine use in Australian mental health services. Aust N Z J Psychiatry 2011;45:267-80.
4. Australian Health Ministers’ Advisory Council. A national framework for recovery-oriented mental health services: policy and theory. Available from: http://www.ahmac.gov.au/cms_documents/ National%20Mental%20Health%20Recovery%20Framework%20 2013-Guide-practitioners&providers.PDF. Accessed 12 Sep 2014.
5. Warner R. Does the scientific evidence support the recovery model? Psychiatr Bull 2010;34:3-5.
6. Victorian Department of Health. Framework for recovery-oriented practice. Available from: http://www.recoverydevon.co.uk/download/Framework-Recovery-Oriented-Practice_AUSTRALIA.pdf. Accessed 12 Sep 2014.
7. Davidson L, O’Connell M, Tondora J, Styron T, Kangas K. The top ten concerns about recovery encountered in mental health system transformation. Psychiatr Serv 2006;57:640-5.
8. Davidson L, Roe D. Recovery from versus recovery in serious mental illness: one strategy for lessening confusion plaguing recovery. J Ment Health 2007;16:459-70.
9. Thornicroft G, Tansella M. Balancing community-based and hospital- based mental health care. World Psychiatry 2002;1:84-90.
10. Thornicroft G, Alem A, Antunes Dos Santos R, Barley E, Drake RE, Gregorio G, et al. WPA guidance on steps, obstacles and mistakes to avoid in the implementation of community mental health care. World Psychiatry 2010;9:67-77.
11. Whiteford H, Harris M, Diminic S. Mental health service system improvement: translating evidence into policy. Aust N Z J Psychiatry 2013;47:703-6.
12. Boardman J, Parsonage M. Defining a good mental health service: a discussion paper. London: The Sainsbury Centre for Mental Health; Available from: http://www.centreformentalhealth.org.uk/publications/delivering_government.aspx?ID=507. Accessed 12 Sep 2014.
13. Rosen A, Gurr R, Fanning P, Owen A. The future of community- centred health services in Australia: ‘When too many beds are not enough.’ Aust Health Rev 2012;36:239-43.
14. O’Halloran P, O’Connor N. Crisis? What crisis? Problems in the community — a reflection on progress in developing the model of care for community mental health services in Australia. In: Mendoza J, Elson A, Gilbert Y, editors. Obsessive hope disorder: reflections on 30 years of mental health reform in Australia and visions for the future. Perspectives report. Caloundra, Queensland: ConNetica; 2013: 199- 201.
15. Rosen A, Mental health services: evidence-based components in the continuum of care, Table 11.1 in Mendoza J, Rosenberg S, Bresnan A, and Hopkins J, with assistance from Bennet M, and Rosen A; Chapter 11: Learning from the past ... facing new realities. In: Mendoza J, Bresnan A, Rosenberg S, Elson A, Gilbert Y, Long P, et al, editors. Obsessional hope disorder: reflections on 30 years of mental health reform in Australia and visions for the future. Technical report. Caloundra, Queensland: ConNetica; 2013: 239-51.
16. Rosen A, Gurr R, Fanning P. The future of community-centred health services in Australia: lessons from the mental health sector. Aust Health Rev 2010;34:106-15.
17. Rosen A. Mental health commissions of different sub-species: can they effectively propagate mental health service reform? Provisional taxonomy and trajectories. Ment Health Rev J 2012;17:167-79.
18. Rosen A. Towards a new framework for mental health reform in NSW. Keynote Address, Catholic Social Services Australia Parliamentary Forum, NSW Parliament House, 14 August 2014.
19. United Nations General Assembly. The Principles for the Protection of Persons with Mental Illness and for the Improvement of Mental Health Care, Resolution 119, 46th Session, Meeting 75, December 17 Report A/46/721; 1991.
20. Parnell S, McGorry P. Boost mental health funds. Weekend Australian 2014 Aug 9, p.9.
21. The mental health policy implementation guide. London: Department of Health; 2001.
22. RosenA, Gurr R, Eagar K, Gear C. Mental health funding methodologies: roundtable discussion paper, September 2008. Australian Healthcare and Hospitals Association, The Mental Health Services Conference of Australia and New Zealand, PricewaterhouseCoopers — Health Actuarial and Advisory Practice; 2008.
23. Drake RE, Mueser KT, Torrey WC, Miller AL, Lehman AF, Bond GR, et al. Evidence-based treatment of schizophrenia. Current Psychiatry Reports 2000;2:393-7.
24. McGorry PD, Yung AR, Phillips LJ, Yuen HP, Francey S, Cosgrave EM, et al. Randomized controlled trial of interventions designed to reduce the risk of progression to first-episode psychosis in a clinical sample with subthreshold symptoms. Arch Gen Psychiatry 2002;59:921-8.
25. Murphy S, Irving CB, Adams CE, Driver R. Crisis intervention for people with severe mental illness. Cochrane Database Syst Rev 2012;(5):CD001087.
26. Forwood A, Reed C, Reed M, Roose D, Ryan S. Evaluation of the Prevention and Recovery Care (PARC) Services Project. Melbourne, Australia: Mental Health and Drugs Division, Department of Human Services; 2008.
27. Bond GR, Drake RE, Mueser KT, Latimer E. Assertive community treatment for people with severe mental illness: critical ingredients and impact on patients. Dis Manage Health Outcomes 2001;9:141-59.
28. Rosen A, Mueser KT, Teesson M. Assertive community treatment — issues from scientific and clinical literature with implications for practice. J Rehabil Res Dev 2007;44:813-25.
29. Burns T. The rise and fall of assertive community treatment? Int Rev Psychiatry 2010;22:130-7.
30. Rosen A, Killaspy H, Harvey C. Specialisation and marginalisation: how the assertive community treatment debate affects individuals with complex mental health needs. Psychiatr Bull 2013;37:345-8.
31. Mueser KT, Bond GR, Drake RE, Resnick SG. Models of community care for severe mental illness: a review of research on case management. Schizophr Bull 1998;24:37-74.
32. Mueser KT, Bond GR, Drake RE. Community-based treatment of schizophrenia and other severe mental disorders: treatment outcomes. Medscape Ment Health 2001;3:1-24.
33. Ziguras SJ, Stuart GW. A meta-analysis of the effectiveness of mental health case management over 20 years. Psychiatr Services 2000;51:1410-21.
34. Bedell JR, Cohen NL, Sullivan A. Case management: the current best practices and the next generation of innovation. Community Ment Health J 2000;36:179-94.
35. Rosen A, Newton L, Barfoot K. Evidence-based community alternatives to institutional psychiatric care. Med Today 2003;4:90-5.
36. Evidence-based psychological interventions in the treatment of mental disorders: a literature review. 3rd ed. Melbourne: Australian Psychological Society; 2010.
37. Morrison AP, French P, Walford L, Lewis SW, Kilcommons A, Green J, et al. Cognitive therapy for the prevention of psychosis in people at ultra-high risk: randomised controlled trial. Br J Psychiatry 2004;185:291-7.
38. Pilling S, Bebbington P, Kuipers E, Garety P, Geddes J, Orbach G, et al. Psychological treatments in schizophrenia: I. Meta-analysis of family intervention and cognitive behaviour therapy. Psychol Med 2002;32:763-82.
39. Pilling S, Bebbington P, Kuipers E, Garety P, Geddes J, Martindale B, et al. Psychological treatments in schizophrenia: II. Meta-analyses of randomized controlled trials of social skills training and cognitive remediation. Psychol Med 2002;32:783-91.
40. McFarlane WR, Lukens E, Link B, Dushay R, Deakins SA, Newmark M, et al. Multiple-family groups and psychoeducation in the treatment of schizophrenia. Arch Gen Psychiatry 1995;52:679-87.
41. McFarlane WR, Link B, Dushay R, Marchal J, Crilly J. Psychoeducational multiple family groups: four-year relapse outcome in schizophrenia. Fam Process 1995;34:127-44.
42. Wykes T, Huddy V, Cellard C, McGurk SR, Czobor P. A meta-analysis of cognitive remediation for schizophrenia: methodology and effect sizes. Am J Psychiatry 2011;168:472-85.
43. Feigenbaum J. Dialectical behaviour therapy: an increasing evidence base. J Ment Health 2007;16:51-68.
44. Drake RE, Mercer-McFadden C, Mueser KT, McHugo GJ, Bond GR. Review of integrated mental health and substance abuse treatment for patients with dual disorders. Schizophr Bull 1998;24:589-608.
45. Drake RE, Mueser KT. Psychosocial approaches to dual diagnosis. Schizophr Bull 2000;26:105-18.
46. Rosen A. “Must try harder” — Australia’s half-hearted attempts at transition from hospital-centric to community-based mental health services. In: Mendoza J, Elson A, Gilbert Y, editors. Obsessive hope disorder: reflections on 30 years of mental health reform in Australia and visions for the future. Perspectives report. Caloundra, Queensland: ConNetica; 2013: 231-6.
47. Rosen A. What developed countries can learn from developing countries in challenging psychiatric stigma. Australas Psychiatry 2003;11(Suppl 1):S89-S95.
48. Rosen A. Destigmatizing day-to-day practices: what developed countries can learn from developing countries. World Psychiatry 2006;5:21-4.
49. Rosen A, O’Halloran P, Mezzina R. International trends in community mental health services. In: McQuistion HL, Sowers WE, Ranz JM, Feldman JM, editors. Handbook on community psychiatry. New York: Springer; 2012; 389-404.