The International Journal of Psychosocial Rehabilitation

Ethical and Social Dilemmas Surrounding
Community-based Rehabilitation in Costa Rica

Julie M. Aultman, Ph.D
Enid Campos Villegas, M.D
Northeastern Ohio Universities College of Medicine (NEOUCOM)

Aultman J.M. & Villegas E.C. (2004). Ethical and Social Dilemmas Surrounding Community-based
 Rehabilitation in Costa Rica
  International Journal of Psychosocial Rehabilitation. 8, .

Contact Information:
Julie M. Aultman, Ph.D.
Northeastern Ohio Universities College of Medicine (NEOUCOM)
4209 State Route 44, PO Box 95, Rootstown, Ohio  44272, United States

The National Psychiatric Hospital in Costa Rica is the only hospital that provides healthcare services for chronically, mentally ill patients.  One type of psychiatric service at the National Psychiatric Hospital that specifically aims to meet patients’ biological, psychological, and social needs is community-based rehabilitation (CBR).  Patients receiving rehabilitative care at the hospital are able to develop basic living and communicative skills as a healthcare team helps patients learn how to live with their mental disorders in a community outside of the hospital environment. Though CBR is beneficial to the clinical and social welfare of patients and their families, programs have not been fully developed and implemented into the community due to a lack of resources and support by the national healthcare system in Costa Rica, corresponding agencies, and community leaders.  The national healthcare system, known as the Caja Costarricense de Seguro Social (CCSS), prides itself on its aim to bring healthcare to everyone within the borders of Costa Rica.  However, this aim has not been realized partially due to Costa Rica’s current economical problems associated with an unstable global economy; financial constraints have greatly impaired the CCSS’s ability to support programs that deliver healthcare beyond the basic needs of patients.  However, even those programs specifically designed for meeting the basic needs of patients such as CBR for the mentally ill are not being supported by the CCSS.  Besides reasons of financial instability, the CCSS may also be hesitant in supporting CBR because of the program’s unknown effectiveness in helping patients.  While small-scale efforts at the National Psychiatric Hospital have been made to predict the effectiveness of CBR, it remains unclear, from ethical and social points of view, as to whether the positive effects outweigh the possible moral dangers associated with the implementation of mental health rehabilitation programs in Costa Rica.  

The focus of this paper is to explore the ethical and social dilemmas associated with the deliverance of psychiatric care as a basic need in Costa Rica through CBR.  However, before these ethical and social dilemmas are identified and examined through critical ethical analysis, I first describe the history and current status of the National Psychiatric Hospital of Costa Rica and the services it provides to patients with debilitating acute and chronic mental disorders.  This research is based on interviews conducted with healthcare providers, clinical and community observations, and reflections on the ethical dilemmas surrounding community-based rehabilitation in Costa Rica.  This paper concludes with recommendations on how resources should be made available to patients with mental illnesses and whether community-based rehabilitation would be a beneficial program for Costa Rica in light of some relevant ethical and social concerns.

Background: Costa Rica’s National Psychiatric Hospital
The National Psychiatric Hospital of Costa Rica, known as Hospital Nacional Psiquiatrico Presbítero Manuel Antonio Chapuí, is located in Pavas, a town outside of the capital of San Jose.  The Minister of Justice, Dr. Carlos Durán, founded this hospital in 1890 after noticing that many prisoners in the San Jose jails were mentally ill and should not be incarcerated with criminals.  Instead of incarcerating the mentally ill, he built the National Psychiatric Hospital to provide care and treatment.  The National Psychiatric Hospital was the first European-style asylum in Costa Rica, which initially housed about 325 patients (Gallegos and Montero, 1999).  The number of patients entering the hospital grew exponentially throughout the 20th century and a dramatic shift from asylum-based care to hospital-based care occurred in the mid-twentieth century as professional healthcare teams began to take an interest in caring for and treating patients with mental illnesses.  To provide mental healthcare services to the growing mentally ill population, the hospital was moved from downtown San Jose to Pavas (about 20 minutes outside San Jose) in 1974.

In 1975, community mental health care was integrated into the Costa Rican mental health care system with much hesitation due to the fear that community mental health would replace the mental hospital (Gallegos and Montero, 1999).  In 1978 the Pan American Health Organization and World Health Organization (PAHO/WHO), along with the Colombian government, met to discuss the needs of mental healthcare, i.e., making mental healthcare accessible to all. They made recommendations for developing and implementing programs with “wide coverage, multidisciplinary teams, and coordinators” (Gallegos and Montero, 1999, p. 27).  Although it was evident that there was a need for effective programs, there were several obstacles for developing and implementing such programs. Gallegos and Montero (1999, p. 27) write, “the obstacles facing Costa Rica derived from a lack of will to promote changes and an insufficient number of psychiatrists in public positions (i.e., planners and decision makers) interested in implementing change.”

In 1982, several recommendations were presented to Costa Rican health authorities for improving community mental healthcare throughout the country.  Besides coordinating mental health services with the national health system, it was recommended that mental hospitals should be replaced by community facilities.  Additional recommendations were made to set up a national mental health network, which addresses all levels of prevention, along with the placement of psychiatric beds in general hospitals (Gallegos and Montero, 1999).  Since the 1980’s psychiatric beds have been set up in general hospitals in the San Jose area, including the Children’s Hospital, but these beds are for acute psychiatric patients and are centrally located in the capital area, resulting in a seriously low percentage of psychiatric beds throughout the entire country.   Although there are some developments moving toward a national mental health network that addresses all levels of prevention, no such network is fully functional at this time.  Also, since recommendations were made, community facilities have not yet been fully developed and implemented to improve the mental health status of patients or as a way to replace The National Psychiatric Hospital, which still remains the center of mental health services.  Unfortunately, because there is only one hospital able to care for and treat both acute and chronically ill patients, this limits access to the greater population in need of mental health services.  Nevertheless, the National Psychiatric Hospital has made considerable efforts to provide the best care possible given the lack of resources, e.g., medical technology, clinicians, and the support of other healthcare professionals.

Currently (2002-03) the National Psychiatric Hospital has 811 beds and in 2001 had about 3900 discharges.  Of the 811 beds, 400 are used for chronically ill patients, who permanently live at the hospital and the remaining beds are used for acute patients who stay for a short period of time (the average stay is 20 days). The hospital provides care and treatment to men, women, adolescents, pediatric patients, and geriatric patients.  Patients are typically received in the emergency room with an observational unit, and those patients with acute disorders are then admitted to the intensive care unit so clinicians can determine the extent of the patient’s mental and/or physical condition.  Although women, men, adolescents, and the elderly are separated into different areas of the hospital, the general organization of the hospital is based on the needs of patients and the level of ease in caring for these patients.

The National Psychiatric Hospital is divided into six units or wards.  The first two wards, Wards 1 and 2, are used for acutely ill, easily handled patients.  Wards 3 through 6 are used for patients who are difficult to manage and who require intensive rehabilitation conduct programs.  Ward 5, also referred to as “transitional home”, contains chronic patients who are self-sufficient and enrolled in a therapy program called “Daily Life”.  The “Daily Life” program teaches and guides patients in activities such as cooking, shopping, dressing and bathing.  Once the patients are able to complete daily life tasks and manage their lives within the hospital they are transferred to group homes, or independent houses known as “Las casitas”, which are located behind the hospital grounds.  There are also public and private rehabilitation centers where patients from ward 5 can go to for further psychiatric care and support.   If a patient is unable to move into a group home or one of the country’s rehabilitation centers, then they must remain in the hospital until a place is available.  However many patients who are able to live outside of the hospital cannot due to lack of space and resources.

Although the National Psychiatric Hospital does not have regular access to current medical technologies, it does have the support of a laboratory, electroencephalogram (EEG), and an electro convulsive therapy unit, which provides more than 6000 therapies a year (about 20-25 per day).  There is also a medical unit, providing care and treatment of physical disorders by internal medical physicians.  As well as in-patient services, there are also outpatient services handling more than 1000 patients and offering a variety of individual and group therapy programs.  One program, called “Daytime Hospital” gives patients the opportunity to develop skills to do simple tasks, i.e., producing merchandise that is sold to the public such as piñatas and articles of clothing.

Methods:  Observations and Analysis
To understand the key social and ethical dilemmas involving community-based rehabilitation for mentally ill patients living in Costa Rica, I carried out participant observation in the summers of 2002 and 2003 at the National Psychiatric Hospital; I observed what healthcare teams and their patients experience while working and living within and outside of the hospital environment.  To support my observational findings I interviewed clinicians and nurses working at the National Psychiatric Hospital and discussed with area families, including two families I lived with, their perceptions of mental disorder and the benefits and burdens of CBR.  I also reviewed recent proposals by clinicians at the National Psychiatric Hospital for the initiation and development of mental healthcare programs in Costa Rica.   My analysis of the ethical and social dilemmas surrounding CBR is supported by a review of recent literature on community psychiatry and rehabilitation programs for physically and mentally disabled persons around the world.

Findings: Developments toward Community-based Rehabilitation
Patients at the National Psychiatric Hospital receive medications, psychotherapies, and electro convulsive therapies depending on the type of mental disorder they have and on the frequency of symptoms associated with the disorder.  Although these methods are useful for meeting some of the biological and psychological needs of patients, community-based rehabilitation programs have the potential to meet all of the biological, psychological, and social needs of patients.  These social needs include providing spiritual support, acknowledging cultural differences, developing communicative and other social skills for interacting with others, and creating a network of friends and co-workers who view and respect the patient as a person, and not as a disease or illness.  As Drake, Green, Mueser, and Goldman (2003, p. 434) explain, while somatic and psychosocial treatments focus on controlling illness, rehabilitative interventions “primarily aim toward improving functioning and quality of life rather than reducing the symptoms of the illness.”

Developments have been made to integrate hospital-based care with community-based care as a way to show the CCSS and community leaders that community mental health is beneficial for treating patients and meeting all of their biopsychosocial needs.  Instead of institutionalizing mentally ill patients in a static, clinical environment, the philosophy of the National Psychiatric Hospital is to allow patients to develop important daily life skills, recognize and accept their physical and mental disabilities, and get effective medical treatment so as to rehabilitate them for community integration.

In helping patients develop important daily life skills, healthcare professionals at the National Psychiatric Hospital have implemented a task-based program known as “Daytime Hospital” where patients can learn important skills such as reading/writing, sewing, woodworking and working with crafts (some of which can be sold to buyers outside of the hospital community).  Daytime Hospital is run by the CCSS and functions as a halfway rehabilitation center.  Patients are supervised by social workers and occupational therapists though the majority of assistance and supervision is provided by volunteers.  Similar halfway rehabilitation centers are located in Desamparados, Hatillo, Naranjo, and Alajuela, (located near San Jose) and are supported by the community, the CCSS, and the National Rehabilitation Center, a publicly funded organization that has made successful attempts to implement these community-based programs throughout Costa Rica.  Most of the patients working at the halfway rehabilitation centers outside of the National Psychiatric Hospital have supportive families; they have the freedom to work during the day at the centers and then leave for home in the afternoon. 

 Clinicians, social workers, therapists, and volunteers working at these halfway rehabilitation centers believe that having the opportunity to learn skills not only builds patients’ self-esteem but also gives them the freedom to gain some control over their lives.    Those who contribute to these programs oversee the work that is done by the patient, but more importantly, are able to guide and provide emotional and psychological support to the patient when needed.  Unfortunately, the “Daytime Hospital” program, like many CBR programs, lacks significant financial and clinical resources, and because of this, some of the halfway centers have closed due to a lack of funding, thus forcing patients back into their homes or out on the streets. 

In another ward of the hospital, several areas are designed for the Daily Life program, a program where healthcare professionals help patients develop a sense of independence by teaching them important personal care skills.  Patients learn how to shop for food and clothing, cook, bathe and dress themselves.  These basic skills are viewed by healthcare professionals as therapeutic for some patients, e.g., calming the anxious or emotionally disturbed patient, and providing a critical step for others who are able to take on the responsibilities of daily living in a community.

Although healthcare professionals at the National Psychiatric Hospital are preparing patients for community integration through their basic skills programs, it remains unclear as to whether the focus should be on CBR for delivering optimum care to mentally ill patients.  The publicly-funded National Rehabilitation Center, along with the CCSS, have tried to develop and implement various programs, such as “The Daytime Hospital” program, but since there is a lack of adequate resources for implementing and expanding these programs, making CBR central to mental healthcare in Costa Rica, these programs are insufficient for delivering optimum care to mentally ill patients.  Unfortunately several hospitalized patients (an estimated 200 patients) are ready to live and work within their communities, but they may face a lifetime of hospitalization if they cannot get the help they need through CBR programs that are financial stable and rich in resources.  However, as I have found, in order for CBR to be successful in countries such as Costa Rica, financial stability and resource dependability are not enough for helping patients with mental illnesses.  In determining whether Costa Rica is ready for CBR, one must take into account several ethical and social considerations.  Several questions need to be answered.  For example, is CBR more or less restrictive than involuntary hospitalization (Davis, 2002), are communities willing to support CBR programs even when members fear mental illness, will healthcare professionals and volunteers protect the patient’s right to privacy, etc.?

Is Costa Rica Ready for CBR?
In looking at community-based psychiatry, Szmukler (1999, p. 363) recognizes that several developing countries, such as Costa Rica, are dramatically moving from hospital based programs to community based rehabilitation programs.  In this shift to community-based psychiatry, e.g., CBR programs, multidisciplinary approaches in care and treatment are identifiable; such approaches in treatment recognize that patients with mental diseases are biological, psychological, and social persons.
When looking at community psychiatry there is a clear shift from institutional based medicine to community based medicine where there is an expansion in the network of caregivers and services and a development in the dynamic relationship between the medical community and the community at large.  Szmukler (1999, p. 364) writes that community based psychiatry “aims to establish a network of services offering crisis interventions continuing treatment, accommodation, occupation, and social support which together help people with mental health problems to retain or recover social roles as close to normal as possible for them.”  Although a team of physicians, nurses, and other healthcare professionals may work with patients in the hospital setting, the number of non-professional and professional caregivers increases once the patient enters the community.  Friends, family, social workers, governmental and non-governmental organizations, group home personnel, employers, etc. may all contribute to the overall care of the patient, including his or her biological, social, spiritual, and cultural needs.   It is in community psychiatry where the network of healthcare providers is as complex as the environment in which care is delivered. 

Besides providing psychotropic drugs and psychological interventions, such as psychotherapy, CBR programs are designed to integrate patients into a community where they can work towards regaining or developing basic living skills.  Although these basic living skills can be taught within a hospital, as I observed at the National Psychiatric Hospital, it is not until the patient is outside of the controlled environment of the hospital when he or she can apply and fully understand the implications for learning basic living skills. 

CBR can have a profound effect on patient’s physical, psychological, and social wellbeing; patients develop a sense of independence and learn to control their lives without letting their mental disorders control them.  Although, reaching goals of independence and self-sufficiency can be a difficult process for both patient and community even when CBR programs are in place and fully functioning.   Contributing to this difficult process are several social and ethical dilemmas surrounding CBR.  In highlighting these social and ethical dilemmas it becomes clear that CBR may not, given the current financial status of CCSS and the unsustainable nature of CBR programs in general (Turmusani, Vreede, and Wirz., 2002), be an appropriate course of action for Costa Rica.  

Ethical and Social Dilemmas Surrounding Community-based Rehabilitation
While the shift from hospital-based medicine to community-based medicine may benefit individual patients’ health there are some possible concerns to consider.   First, as Szmukler explains, the shift from hospital to community-based medicine may exert pressure to discharge patients quickly (Szmukler, 1999).  Although the goal of this shift in medical practice is to rehabilitate patients for community living, this goal can only be achieved with careful planning and monitoring.  Patients ought to meet and maintain standards set by the healthcare institution(s) prior to their community integration, the role of healthcare professionals and others involved in CBR should be one of “allies and resources”, and the community should be well informed of CBR and related policies prior to their participation (Turmusani, Vreede, and Wirz 2002).  Community mental health may become an unachievable or unrealizable goal if responsible community health leaders do not properly plan, deliver, and evaluate CBR programs.  For example, if community health leaders do not provide information about procedures, possible obstacles, and the goals of CBR in a clear and comprehensible manner, especially to patient-participants, CBR programs are subject to failure.  Singh (2000, p. 414) writes that community mental health teams are often criticized for their “ambiguous and overambitious aims, and their tendency to neglect people with the most challenging health- and social- care needs”.  If community mental health workers, including clinicians, community leaders, social workers, nurses, and others, are unwilling to work together as a team and are not fully committed to the careful planning and implementation of CBR, the program is subject to failure and the patient’s health is in jeopardy.  The community mental healthcare setting is a resource-poor system (Christensen, 1997 p. 6) and without a team-approach in delivering care, clinicians may carry the burden of assuming the role of gatekeeper, or worse yet, fail to meet their patients’ needs.

One problem for Costa Rica is overambitious mental healthcare teams and not-so-ambitious communities who may be reluctant to participate and work together as a team toward CBR for persons with mental illnesses.  Even though the culture of Costa Rica is that of close-knit families and communities whose major concern is their health, Costa Ricans generally have a laid back attitude when it comes to getting things done, including the development and implementation of healthcare programs.  In some respects this attitude can be viewed as a healthy one as they experience less stress and anxiety in trying to meet deadlines, keep appointments, and satisfy their customers, friends, or family.  However, this attitude can be especially problematic after a project or program has been initiated; it takes a long time for a project or program to be fully implemented and assessed.   Thus, in order for CBR to be a significant part of mental health care in Costa Rica, healthcare professionals and community members need to be willing to participate and work together, and work with a strong commitment to improve patients’ mental health through rigorous CBR program development and assessment. 

Another problem that often occurs when mental healthcare teams are overambitious is improper outpatient treatment; patients may be coerced to live in the community or discharged too quickly from the hospital.  If patients are coerced to live in the community as an alternative to hospitalization, paternalistic healthcare teams are interfering with the patient’s freedom to choose and act with self-determination regardless if CBR will be the best course of action to meet the healthcare needs of the patient.  Christensen (1997, p. 8) writes, “In essence, the concept of paternalism represents a classic example of a conflict between meeting a client’s needs (as determined by the provider) versus respecting a client’s rights to self-determination.  Involuntary commitment, forced medication, and coerced out-patient treatment are some modes of psychiatric practice viewed as paternalistic.”   Unlike involuntary or coerced hospitalization and forced medication (where the justification to act paternalistically is to protect the patient from harming himself/herself and others), if a patient is coerced or discharged too quickly there is no moral justification. The patient is wrongfully forced into an unconfined environment that will most definitely harm rather than protect him or her.  Not being able to cope with daily living outside of the hospital may lead to further physical and mental distress, possibly making the patient feel like a failure as he or she reverts to abnormal thoughts and behaviors experienced and expressed prior to rehabilitation.  Having been institutionalized for an extended amount of time, combined with having a debilitating mental disorder, the patient’s first experiences outside of the institution can be especially detrimental to his or her psychological and physical well being if he or she has not been properly prepared to live in an often disorderly and confusing community environment. 

A related concern regarding CBR is that rehabilitation is not a permanent solution for delivering the kind of care or treatment the patient needs.  This may be an important concern if rehabilitation is viewed as a single goal – helping the mentally ill person to live within a community.  If a patient can learn to cook, clean, dress, and work while receiving necessary medical treatments outside of the hospital, the patient appears to be getting the type of care he or she needs.  However, this type of rehabilitation program, focusing on just the medical and social needs of the individual is subject to failure and is not a permanent solution.  A rehabilitation program that can meet the psychological needs of the patient as well as the social and medical needs will less likely fail.  An effective rehabilitation program recognizes the changing psychological needs of the patient as he or she integrates into a community. 

If the patient appears to be ready for discharge, that is, has shown considerable progress and success in his or her basic skills programs and has begun to develop interpersonal skills that would assist the patient in adapting to a new environment, then CBR should be an option for this patient.  However, the difficulties lie in determining which skills are necessary for living outside of the hospital and when a patient has sufficiently developed those skills.  Furthermore, once a patient has been discharged, how will healthcare providers, along with community members, adequately help the patient to maintain those skills?  These difficulties can be resolved with careful planning and assessment, though many countries like Costa Rica do not have the resources and management to do this, which brings us to a second dilemma for CBR: there are not enough healthcare providers to assist in rehabilitation programs.  

Many Patients, Few Resources
Unfortunately developing countries such as Costa Rica do not even have enough healthcare providers to help all people receive basic care, especially those with mental disorders.    If CBR programs were to be implemented in Costa Rica without having enough healthcare teams to assist both hospitalized and non-hospitalized patients, such programs would fail; patients living in the hospital or out in the community would not receive adequate care.   Because there are not enough resources currently in Costa Rica to implement effective CBR programs, measures ought to be taken to either acquire these necessary resources, e.g., more psychiatric teams, or forgo rehabilitation programs until resources can be made available.  Unfortunately, regardless of having a national healthcare system, the people of Costa Rica are not receiving adequate mental healthcare and the programs that can provide more and better mental healthcare services cannot be implemented due to a lack of resources.  This, I believe, is partially due to the division between physical and mental illnesses.

Although many of the psychiatrists in Costa Rica practice Western medicine with the view that physical and mental illnesses are not easily separable, the CCSS does not view mental healthcare as a priority, as evidenced by the lack of hospitals, psychiatrists, and technology needed to diagnose and treat patients with mental illnesses.  While Costa Rica has made great strides in delivering healthcare to its citizens, the focus is on basic and preventative care through better education and country-wide immunization programs.  Success has been measured by low infant mortality rates, a decline in childhood diseases and diseases associated with poor nutrition, and life expectancy rates equivalent to first order nations such as the United States and Japan.  However, there has been a significant rise in spousal and child abuse and drug and alcohol related diseases.  Although these problems do not go unnoticed, they are not always viewed as physical and mental healthcare problems that can be identified and treated by community intervention and support.  These types of problems may continue to rise if mental healthcare is viewed as a separate and distinct form of healthcare and if there is a lack of will to provide mentally ill patients with the resources they need.

Public Fears
    Another dilemma for healthcare professionals, patients, and the community are the public fears surrounding mental illness.  Depending on the cultural background of the community these fears may vary.  Some members of the Costa Rican community may believe that mental illness is a distinct, contagious entity, which should be contained, i.e., mentally ill persons should be confined to a medical institution to prevent the spread of the disorder.   Others believe that the mentally ill persons pose a risk to the community either by harming themselves or others within the community and claim to have witnessed public displays of aggression and self-mutilation, e.g., “A crazy [autistic] man banged his head against a stone wall repeatedly until he bled to death” (story told by a woman from San Jose, 2003).  Stories about mentally ill patients murdering innocent bystanders or making obscene public gestures are not uncommon.   Many of these stories are fabricated and are intended to scare their readers and listeners in the same manner as ghost stories.   The greatest fear lies in not the fear of being harmed by someone with a mental illness but the fear of having to care, protect, and accept the mentally ill person.  Though cases of mentally ill patients inflicting harm on themselves or others are rare, by educating and training community members and patients about mental disorders and the persons who have them fears can be lifted and possible harms can be prevented.  Szmukler (1999, p. 374) explains, “Fear of the mentally ill is omnipresent.  Care in the community treads a fine line.  If it is not managed successfully ‘there is a danger that progress over recent decades in emphasizing the individuality of patients and affirming their rights (and responsibilities) within a therapeutic relationship could be compromised by early resort to unnecessary inpatient supervision and coercive models of care”.

Even though the public may be supportive of CBR and have little or no fears about having mentally ill patients integrate into the community, many community members may not understand their role in helping the patient acquire the freedom and dignity that s/he deserves.   Some community members may believe that ‘helping’ means monitoring the patient’s every move, fixing any mistakes that are made by the patient, or doing things that the patient is capable of doing for himself/herself, e.g., preparing meals, cleaning, and so forth.  Although these members of the community believe they are helping, they are infringing upon the patient’s rights and responsibilities and are doing more harm than good by not permitting the patient to learn from his or her mistakes or by not allowing the patient to develop a sense of pride by completing his or her own daily tasks.    Other members of the community may ignore or shun the patient, not because they are fearful of the patient and his or her illness, but because they do not know how to help.  This too is problematic for the patient because s/he may feel ashamed, believing s/he is doing something wrong, or embarrassed that s/he is different from other members of the community.   Again, to eliminate the stigmas associated with mental illness and to respect the patient’s dignity and self-worth, the community needs to be informed of how to help patients without infringing on their rights and responsibilities.

Patient Autonomy and Confidentiality
    As briefly stated above, another difficulty with CBR involves the possible disregard for patient autonomy, which may result in the breakdown of trustful healthcare team-patient relationships.  Recognizing autonomy is recognizing the inherent worth of the patient – the patient as a person.  This means that, as a person, the patient is self-determining and should be permitted to decide what is in his or her own best interests.  Patient autonomy is critical for developing a symbiotic relationship with healthcare professionals where the patient can play an active role in medical decision-making and exert some control over the treatment process without manipulation or coercion.  Although autonomy may be compromised if the patient has a debilitating mental disorder and is unable to make rational decisions, one should not view the patient as a being with no inherent worth or interests.   If a patient is unable to fully understand and make rational decisions, healthcare providers should make an effort to relay pertinent information in a way the patient can understand and respond to through his or her expression of beliefs, values, and opinions.   In cases where CBR has been implemented in developing societies, patients are respected as persons and generally have more autonomous control over their lives as they become fully integrated into the community than if they were to live in a hospital setting.   However, patients may not have control over every aspect of their lives, especially when it comes to healthcare professionals disclosing their private information to third parties, including community members, employers, and agencies participating in CBR.

Information between healthcare professionals and patients is, as a general rule, kept confidential to maintain a trusting therapeutic relationship.  However, there are circumstances in which private information may be made public.  It may be necessary to divulge private information about a patient if not doing so will result in the harm of the patient or others.  For example, in community based rehabilitation it may be necessary to divulge private information, e.g., the patient has a history of violence towards himself or herself, to protect the patient and/or community.  With such information community members who are assisting patients in their daily lives can prevent the patient from harming himself or herself.   The paternalistic act of divulging confidential information to third parties may be viewed as necessary, i.e., to protect and look out for the best interests of the patient.  On the other hand, the disclosure of private information about a patient can lead to unwarranted violations of privacy, thus compromising the psychological well-being of the patient, e.g., making him/her feel inferior, different, etc.

CBR is a way to provide care through a much larger network of both professional and non-professional healthcare providers.  And, as the network expands, confidential information may be passed along without the patient knowing.  However, patients may not know that their private information has been disclosed to third parties, including employers, neighbors, and agencies, and are possibly subjected to unfair treatment as their conditions become exposed.  And, since the patient does not know and has not given prior consent for private information to be released to a third party, s/he cannot act as a self-determining agent and is thus, disrespected as a person.  Even in cases where breaching confidentiality is necessary for protecting the patient and others from harm (i.e., Tarasoff Case), it should be clearly explained to the patient that such private information may be disclosed to third parties and reasons why disclosure is important.   

Conclusions: Recommendations for Mental Healthcare in Costa Rica    
The future of CBR in Costa Rica depends on whether enough resources can be provided, including a sizable increase in the number of psychiatrists, the willingness of the community to help patients, and a better understanding of mental illness and the patient as a person.  In order to provide enough resources to fully implement CBR, mental healthcare must be viewed as a priority.  To date, mental healthcare in Costa Rica is not a priority for the CCSS even though the leading healthcare problems in the country are related to mental illness (e.g., spousal and child abuse and drug and alcohol abuse).  Given the current state of Costa Rica’s mental healthcare system, there is a greater need to focus on delivering mental healthcare services to all who could do with of such services.  And, to do this, efforts to expand clinical resources, especially the number and availability of psychiatrists, should be made prior to any further developments of CBR.  Until there is an adequate number of mental healthcare professionals who can work with community leaders and patients toward a better system of biological, psychological, and social care, along with an understanding of the social and ethical obstacles healthcare teams and patients may face, CBR should be viewed as a future goal.  However, the steps Costa Rica has taken toward this goal should be acknowledged as important ones; by creating various programs such as “Daytime Hospital”, and seeing both the positive and negative effects of these programs, Costa Rica is beginning to understand the clinical, social, and ethical needs of her community and establishing a path toward an even better system of health.


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