alternatives to institutional care for people with mental health problems

8/2/2019 Alternatives to institutional care for people with mental health problems

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Every Institution not only carries within it the seeds of its own

dissolution, but prepares the way for its most hated rival.

William Inge 1922

Historical context

The transition from the hospital dominated system of treatment of mental illness to a

more holistic, community based model has been a fractious evolution requiring not

only a review of simple bricks and mortar, but a revolution in attitudes and theory for

all involved in the process.

It would be heartening to suppose that the move to community care was a decision

born from embracing sound humanitarian principles. However, in reality the birth of

the British model had firmer roots in economic policy than in an acceptance of

holistic principles. The hospital closure programme, which rolled with indecent haste

during the 1980s and 90s, grew more from the desire to save money on in-patient

treatment and this was reflected in the deeply flawed community infrastructure that

grew from the ashes.

Little attention was paid to the successes and failures of other established models in

the US and Italy. The British system frequently replaced or relocated dependency

inducing mental health systems previously found in the long stay hospitals with

identical models situated in the wider community. Hospital staff, more often than not

inexperienced in person centred approaches and often institutionalised themselves,

were re-employed in new community services. This re-deployment of staff, without

the necessary re-education often led to a simple replication of an outmoded system

that reinforced the service users role as a dependent patient. To the dismay of

mental health activists the new system was neither revolutionary nor client

centred. To compound an already unacceptable series of mistakes, no effort had been

made to accompany this change with a parallel process of education for the public.

Socialised to believe that people suffering from mental health problems constituted a

danger to the community, the general public and the media mounted a campaign that

broadly vilified those entering the community from the hospitals.


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With no government defined template for the development of community based

services, what replaced the old system was often ill conceived and more often than

not merely replicated attitudes of old but with a lower budget. The British community

care system, grew on an ad hoc basis, with little idea of progression or development

for users of the service. Isolated Islands of Service were developed in indecent

haste to speed up the de-institutionalisation process. Drop-ins and statutory day

centres became the cutting edge of community development, delivered rather than

constructed in partnership with service users. It came as no surprise that many

patients who had been decanted from the old asylums actively demanded to return to

them.

The old asylums had fallen into disrepute over a period of years, being seen as old

fashioned, outmoded and costly. However their closure and fundamental rejection

had witnessed a throwing out of the baby with the bath water. Many ex-patients felt

isolated, unsupported and unwelcome in the community and hankered for the

perceived security and continuity of the old regime. The old institutions often

provided a meaningful existence in terms of occupation. Farms, workshops, bakeries

and organised groups, regularly a feature of the asylum had disappeared when the

bulldozers arrived, to be replaced when community services were erected by a dearth

of constructive activity. The new services offered little in the way of occupation-

service users were frequently left to their own devices. Day centre activities were

frequently focused on the existence of a pool table or a television set. The ethos of

containment remained intact. Community services targeted exclusively on the needs

of the chronically ill, and outcome measures were unclear.

Over the 1990s specific events changed attitudes and service delivery perceptively.

During 1993 at least two high profile cases were highlighted by the media to further

their anti community care campaign. The murder of Jonathan Zito by schizophrenic

Christopher Clunis on the London Underground followed by the drama of Ben

Silcock, another schizophrenic, throwing himself into the lions cage at London Zoo

brought the issue of mental illness in the community into the public arena in a way

that had not been seen before. Guided by Fleet Street, the debate was promoted to the

front pages of the tabloid newspapers and television. Although the fundamental issue


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was safety from the psycho-killers that the public were at risk from, the anti

community care campaign had a positive side effect for the world of mental health.

The lack of community based resources for mental health became public knowledge

really for the first time. During the early to mid nineties, public enquiry after public

enquiry raised the issue of insufficient community resources.

It became increasingly apparent to all that could look that the UK did not possess a

strategic plan for community care. No template existed for effective and proven

service development.

In reality there were some individual local providers who provided high quality

services but there was no even distribution across the country. Service development

since the hospital closure programme had not only been ad hoc but had also been ill-

served by negative territorial disputes between Health agencies, Social Services and

the voluntary sector. In short, the three main sectors for service delivery were unable

to recognise each others importance in terms of strategic planning or co-operation.

Health and Social Services departments, coming from different ideological

backgrounds had very different views on exactly how mental illness could be

effectively treated. The two views, one dominated by medication and the other by

social work process failed to work together. No identifiable joint agency strategy

existed as a result of this sectarianism. Health developed its own system of

community care while social services developed another. Unnecessary duplication of

processes, assessments and poor services was the inevitable result. The voluntary

sector at this time represented the most dynamic sector perhaps benefiting in some

way from being stuck between the two warring factions, but totally dependent on the

financial crusts that fell from the statutory table.

Communication was poor or non existent, there was no strategic agreement as to how

services should be best developed (either locally or nationally), the main service

providers could not work effectively together, the public had high levels of concern

over safety and community care, the media portrayed mental illness as a stigma, there

were insufficient services and service users remained isolated and impotent in society.

In essence community care was not working.


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A step in the right direction.

As the 1990s drew to a close it became apparent that mental health services were not

going to change without governmental intervention and coercion. The main

protagonists had largely ignored Ten years of recommendations for positive change

by the Department of Health and independent agencies.

The National Service Framework, finally produced by the labour government at the

close of the century for the first time demanded co-operation between agencies. More

importantly for the first time lay down some basic values as to what mental health

services should be seeking to achieve in terms of user involvement, strategic services,

assessment and the image of mental health. The NSF demanded accountability, the

existence of multi-agency implementation teams and the establishment of key

standards of care for mental health and as such it represented a move in the right

direction, however late.

It may be that over the next three to five years a system of mental health in the

community may be developed on a national scale that effectively meets identified

needs. Cynics will point to a lack of resources to implement the NSF, low levels of

public education and internal chaos in the statutory sector to suggest otherwise.

This general historical over view of the slowly developing British model represents a

pertinent lesson in how NOT to achieve positive change. The UK Community Care

system has grown on an ad hoc basis, without the essential education and philosophy

that should accompany fundamental shifts in policy. Lessons can and should be

learned from the UK experience when societies look for alternatives to institutional

treatment of mental illness.

The following pages seek to look at some of the essential components of effective

community approaches to mental health from philosophy to practical applications.

No single discipline represents the cure. All aspects are pieces of a jigsaw of

treatment that cannot produce a clear picture without all of the pieces being present.


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The Conceptual Foundation.

You can tell a civilised society by the way it treats

its most vulnerable members

If we accept that the vast majority of adults suffering from mental illness do not need

the safety of an institution for their treatment then we should seek to examine what is

the purpose of community based mental health services.

The old system of hospital based treatment produced a philosophy based on

containment and dependency. A regime that delivered to rather than involve theservice user in treatment. A system that perhaps had little or no identified outcomes

apart from life long membership of a minority group with few opportunities or little

expectation in wider society.

Modern systems should seek to include individuals in society rather than isolate them.

This fundamental concept has to be addressed proactively by mental health agencies.

Social inclusion is not as simple as merely closing hospitals and releasing patients

into society. Inclusion needs a considered strategic approach and should be the most

basic aim of all services.

Over the following pages I will look at several pieces of the jig saw that are essential

if a realistic alternative to hospital treatment can be established.

User Involvement and self advocacy

Community Care Planning ,Risk Assessment and Management

Community Services

Housing

Not all of the components are service delivery based; some may be attitudes and ways

of working rather than processes or systemic. Equally not all of the service pieces

may be exclusively mental health based. It should be said that this short list should

not be considered to be exhaustive. There are several other key pieces of


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community hardware such as Community Mental Health Teams, Assertive Outreach

Teams and Community Psychiatric Nursing that could have been included. The four

chosen ones represent the basics of a workable; user focused system that embraces co-

operation between both statutory and voluntary agencies.

What is essential however is the existence of a strategy of clear progressive pathways

that both professionals and service users can easily identify and understand. In

essence a simple two-tiered pathway can be used to underpin almost all mental health

and mainstream services . There should exist a clear pathway from the hospital

through the community towards disengagement from mental health services for those

adults with mental health problems who are able to achieve social inclusion and

integration. The experiences along this pathway should be empowering and break any

dependency that is associated with either treatment regimes or the mental health

condition itself. The pathway should be constantly monitored and reviewed by both

service users and staff to ensure that individual aims are achieved.

Equally, there should exist support systems and services that seek to engage adults

with mental health problems who, by virtue of their age or mental health condition are

unlikely to ever progress very far down the yellow brick road towards total social

inclusion and employment.

It should also be acknowledged that other specialist services for mental health groups

with specific needs should also be in existence. Individuals with substance abuse

difficulties, dual diagnosis with learning disabilities or physical disabilities or victims

of abuse should have access to specialist support. Once again, it is the ethos of

empowerment and social inclusion that should pervade rather than the anachronistic

dependency inducing philosophy of old.

This different way of thinking that underpins modern mental health services involves

a fundamental shift in attitudes and can be illustrated by the following diagram which

highlights some of the philosophical shifts essential for positive progress.


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A Different Way of Thinking

Moving Away From Moving Towards

FOCUS ON SERVICES FOCUS ON INDIVIDUALS

Fitting people into a service. Listening to People

Focusing on what it is Focusing on what it could be.

Professional Control Empowering People

Building Programmes Building Community

Responding to control from the top Changing structures that limit

This differentway of approaching working with mental health needs to underpin all

aspects of service development and delivery. The old ideology led inexorably to

clienthood whilst modern services should lead to citizenship.


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User Involvement and Self Advocacy

The things that stand out about the workers we identify as empowering are such

things as being treated as individuals and real people. They engage us as equals

rather than distancing themselves and seeing us as dependent clients. Part of this is

recognising the expertise that we have gained from our lives by living as a user.

Service User

It is often asked by workers form other disciplines, Why Involve Service Users at

all? In mental health work there are several compelling reasons to do so, such as

The essence of user involvement is to promote psychological rehabilitation and

recovery, their involvement and participation as a partner in the process breaks

dependency and leads to empowerment and self-esteem.

Like any consumer of services, mental health service users should have the

resources and authority to hold service providers accountable for the quality of

services they receive.

User Involvement changes staff / client relationships and build trust.

Service content needs to reflect user concerns and priorities. Working together

with users develops ownership and helps break the dependency culture and

develops equality.

Effective User involvement is a developmental pathway in itself, the theme of

identifiable pathways runs though all progressive aspects of mental health work. User

Involvement has three stages of development, starting with the basics of advocacy

leading to local service level involvement and ending up at the level of strategic

involvement. It has been a common mistake in developing user involvement to try to

involve service users at a strategic level of service planning in isolation, without the

foundations of advocacy and service level involvement. Inevitably, to ignore


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progression will lead to failure. User Involvement is developmental and should be

part of a pathway towards independence wherever possible. If services induce

dependency then involvement will be ineffective and unattainable.

Stage 1 - Advocacy and self care in Mental Health

Advocacy can be defined as: Supporting an individual to speak for themselves, or

acting as a voice for another.

The benefits detained patients can derive from an advocate have become more and

more apparent in recent years. An advocate is someone who can represent and defend

the views, needs, wishes worries and rights of patients who do not feel able to do this

themselves. Advocacy can also help patients participate and make decisions.

Advocates are wholly independent, they represent their patients without taking a view

on their best interests.

Many service users feel dis-empowered, those in hospital more so. They may be

detained against their will and experience loss of liberty or choice. Often people say

that they are not believed or listened to by hospital staff with respect. Add to this the

symptoms of the illness, side effects of medication, which can affect the persons

thinking or their ability express themselves clearly, then the person can feel very

frustrated and unable to express their views and wishes clearly.

Many people do of course, have family and friends to support them, but this is not

always ideal. The family member might believe they are speaking up for the person

and acting in their best interest, but in reality there may be conflicts. What the family

member or friend thinks is the best course of action, may not be what the service user

really wants. This is where independent Advocacy can help.

Most Advocates are independent, and clearly this is the best model. In many cases

advocacy services are funded by local health authorities or by social services.

However the projects are usually managed independently by local mental health

charities, and non- profit making organisations. It is vital that the Advocate can work

independently of the hospital or community where they are based. At times the


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Advocate may have to challenge senior members of staff on behalf of the service user,

and this can only really be effective if the advocate does not have a professional

conflict of interest.

The Advocate can help the service user in many ways, e.g.:

Support at meetings, case conferences, and reviews

Help in understanding human rights

Information about medication

Assistance in accessing health records

Help in making a complaint

Help in securing leave or discharge from hospital

Advice about community resources

Referral to appropriate agency on Welfare Issues

The Advocate will always act on the instruction of the service user, and will not set

the agenda the client always decides. It is important that the service user and the

advocate agree on the most appropriate and correct level of advocacy for the

particular situation.

In an ideal world, everybody should be able to speak for themselves Self Advocacy.

However it is not an ideal world, and in most cases the service user will initially ask

the advocate to offer supportive advocacy or full advocacy. As time passes, and

confidence is restored the service user is often able to self-advocate.

The Royal College of Psychiatrists Report on Patient Advocacy dated February 1999

generally supports advocacy and states;


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Advocacy allows people to communicate what they need and want to say and to

argue for a better service from health care professionals, the assumption can be

made that without advocacy these aims would be less likely to be achieved.

Psychiatrists are encouraged to work with advocacy schemes, to encourage their

development and to promote availability of adequate funding.

Stage 2 Service Level and Local User Involvement

There has to be a need for users to become involved in their own recovery. Once the

fundamental principles of user involvement have been established through hospital

and community advocacy then the process can be developed within local services.

Service level user involvement cannot be achieved overnight. It is a long process that

starts with raising the confidence of individuals who may not have any to start with.

User involvement & communication can be a mixture of formal and informal

processes within a locality. User training is essential as is the training of staff tounderstand fundamental principles There are several potential areas of practical

application including.

Development of self help groups

User operated services

User involvement in service policy making

User involvement in service design

User involvement in service delivery

User involvement in staffing and recruitment.

User involvement in evaluation.

User involvement in training


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Stage 3 Strategic Level- User Involvement

The UK model now promotes the involvement of service users at a strategic level up

to and including national policy planning. It can be argued that it is only after the

experience of locally based empowerment that this strategic involvement can be

achieved. Service users should be involved in longer term planning committees and

development groups to provide a service user respective to important issues.

The success of developing effective service user involvement depends heavily on the

attitudes of professional staff and their willingness to progressively disengage from

the active role. It has to be recognised that at the more acute end of the treatment

spectrum i.e. At the hospital, levels of user involvement in their own treatment may

well be low, whilst the interventionist role of staff may be high. However, as patients

are discharged to the community, the role of staff should be reduced in treatment

whilst simultaneously the part played by service users in their own treatment should

be raised.

The involvement of service users in treatment can be best illustrated in the user

focused Care Programme Approach, a system of assessment and review of the

progress and treatment of mental health sufferers in the community.


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The Care Programme Approach

CPA was introduced into England and Wales in 1991 to provide an effective

framework for mental health work in the community.

Its four main elements are;

Systematic arrangements for assessing the mental health and social needs of

people accepted in specialist mental health services.

The formation of a care plan that identifies the health and social care requirements

from a variety of providers

The appointment of a key worker to keep in close touch with the service user and

to monitor and co-ordinate care.

Regular reviews and where necessary, agrees changes to care plan with the

service user and other professionals.

All mental health service users have a range of needs which no one treatment, service

or agency can meet. Having a system that allows a service user access to the most

relevant response is essential. The principle is getting people to the right place for the

right intervention at the right time. This principle is, of course, particularly important

in the case of individuals who need the support of a number of agencies and services

and there are some who, as well as their mental health needs will have a learning

disability or a drug / alcohol problem. In all these cases a co-ordinated approach from

the relevant agencies is essential to efficient and effective care delivery. No one

service or agency is central to such a position. Service users themselves provide the

focal point for care planing and delivery.


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Effective care co-ordination should facilitate access for individual service users to the

full range of community supports they need in order to promote their recovery and

integration. It is particularly important to provide assistance with:

Education

Housing

Employment

Leisure

and to establish appropriate links with the criminal justice system and any benefits /

information / advice agencies.

Establishing Need Through a CPA System (Assessment)

For the sake of consistency and clarity over levels of user need, and therefore the

expected response, definitions should be centrally defined. In the UK there are two

levels of identified need in the CPA system.

1) Standard CPA

2) Enhanced CPA

If an individual does not fit the criteria for these two categories they will not be

considered for specialist community mental health interventions.

The characteristics:

Standard CPA

They require the support or intervention of one agency or discipline or they

require only low key support from more than one agency or discipline.

They are more able to manage their mental health problems


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They have an active informal support network

They pose little danger to themselves or others

They are more likely to maintain appropriate contact with services.

Enhanced CPA

People on Enhanced CPA are likely to have the following characteristics.

They have multiple care needs, including housing, employment etc. requiringinter-agency co-ordination.

They are only willing to co-operate with one professional or agency but they have

multiple care needs.

They may be in contact with a number of agencies (including criminal justice)

They are more likely to require frequent and intensive interventions perhaps with

medication management.

They are more likely to have mental health problems co-existing with other

problems such as substance misuse.

They are more likely to be at risk of harming themselves or others.

They are more likely to disengage from community services.

Once a service user has been assessed by social workers and medics for their health

and social care needs then the CPA care plan is created as a response. The care plan

should be user focused and include their personal aims and aspirations. The six

monthly review processes, where the service user meets in the community with allpeople involved in his care and treatment is used to evaluate the effectiveness of all


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interventions and proactively plan for the next six-month period. The needs and

wishes of the service user is the focal point of CPA. The emphasis of effective CPA

planning is not on the organisational needs of professionals but on the individual

needs of the service user.

Part of effective CPA processes is the role played by risk assessment and

management. Risk assessment is inextricably linked to Care Planning as it involves

identifying and controlling risks to the individual.

The whole concept of risk assessment is a controversial subject for many. If risk

assessment and management are to have any meaning they should be focused on the

needs of the service user and not on the demands of wider society. Other key

groups and individuals have a negative interest in risk assessment, such as;

The government needing to be responsive to media representation and its

influences on public perceptions.

The public fearful of the incidents which are reported and the linking of these to

the policy of community care.

The employer mindful to fulfil obligations set out in national guidance and

legislation.

The multi-disciplinary team - needing to put into operation the policies of the

organisation and wishing to avoid scrutiny of the serious incident inquiry.

The mental health professional issues of self-preservation are perfectly

legitimate influences on individual practice.

The unfortunate side effect of risk assessment is that a fear of risk and the need to

counter its perceived threat can often be at the expense of the service user. It is the

right of the service user to take risks; it is part of the recovery process.


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Risk assessment in the UK system is broken down into five main categories;

Aggression & Violence

Severe Self Neglect

Suicide & Self Harm

Exploitation

Other

It is perhaps only the first category that fulfils the publics misconception of mental

illness sufferers as being a danger to society. The vast majority of people with severe

and enduring mental health problems are no more dangerous than the general

population. Only 17 % of people convicted of homicide had symptoms of mental

illness at the time of offence. (1997 Appleby Report). However, this perception

remains relatively unaltered in the minds of the public.

Risk Assessment has become an essential element of good mental health practice.

Risk Assessment is not, however, a simple mechanical process of completing pro-

forma. Risk assessment is an ongoing and essential part of the CPA process. All

members of the team, when in contact with service users, have a responsibility to

consider risk assessment and risk management as a vital part of their involvement, and

to record their consideration.

Risk cannot simply be considered an assessment of the danger an individual service

user poses to themselves or others. Considerations also needs to be given to the users

social, family and welfare circumstances as well as the need for positive risk taking.

The outcome of such consideration will be one of the determinants of the level of

multi agency involvement.


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Risk assessment and risk management is at the heart of effective mental health

practice and needs to be central to any training developed around the CPA. Staff must

also consider the extent to which they might need support from colleagues, other

services or agencies, especially when someones circumstances change unexpectedly.

When the documents have been completed, the information gathered needs to be

organised to facilitate the process of writing a treatment plan. In line with CPA

documentation, the persons problems should be identified and prioritised. The

second aim is to establish the aims of the treatment. Once the problem(s) to be solved

have been identified, the aims of the treatment should follow logically from them.

Such as;

Problem. Past history of self harm through taking multiple overdoses.

Aim of Treatment To reduce the risk of harm to self.

The Action Plan should describe in detail the action taken to meet the aims of the

treatment. The action outlined should be practical and specific. The detail should

show how, where, when and by whom this is to be done.

As with all care plans the management plan needs to be regularly reviewed and the

date of this should be documented on the form. Equally as with all care plans it is

essential to include the service user in the risk management process. It is good

practice to have a service user decide what actions he or she would expect from

professionals if a situation of risk were to arrive in the community. It is common

practice in the UK for service users to carry a crisis card with them at all times that

describes what actions should be taken should relapse occur.

Having been assessed for needs and risks, and having received a care package that is

aimed at maintaining, supporting and treating the service user in the community, the

individuals potential success is pivotal around the availability and suitability of

meaningful community services.


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Community Services

It is in the area of community service development that the concepts of pathways,

social inclusion, progression and user focused involvement can be put most

effectively into practice. Historically the community service in the UK developed in

the absence of a cohesive strategy, as mentioned earlier. The effect of a lack of

planning was the development of unrelated islands of service with poor levels of

communication and little or no meaningful interaction. The individual service user

fairs badly in this scenario, and services developed in such haphazard ways often find

themselves blocked with service users with no obvious route for development.

Services need to be locally planned with service users to provide a spectrum of

responses to identified needs. There should be clear lines of referral that allow for

movement and clear objectives for individual services with measurable outcomes. In

essence a service user should know why he or she is there and what they expect to

achieve from attending mental health day services.

At the acute end of the spectrum, community based injection clinics and communitybased occupational therapy should be available for those with acute needs. Services

such as these are characterized by high levels of medical professional input and lower

levels of service user involvement. Assessment procedures and short term focused

interventions are usually carried out by statutory service staff.

During the early post in-patient stage of recovery there should be community based

provisions with support structures built into them such as Drop-ins, weekend and

evening activities, advice and information projects and counselling services. There

should exist active links to the mainstream (non-mental health) leisure and education

facilities in the locality. At this point in the pathway there should also be preparation

for work projects, training and long-term employment projects for those unlikely to

return to the open employment market. It is at this level that user involvement in

decision making at service and local level should become firmly established.


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For those able to progress away from mental health services, the pinnacle of service

development should be the existence of userrun services and employment services.

At all points from the hospital onwards the service user should be fully aware of what

is being made available to them by service providers and what he or she can expect

from them. This understanding and clarity should e the function of established

planning procedures manifested in the CPA process.

The issue of work and the existence of employment for those suffering from mental

illness remains high on most agendas. There are a number of benefits excluding the

provision of income. Including:

Social contact

Support

Social Status & Identity

Time structuring and occupation

Activity & Involvement

Personal achievement Potential source of recovery from Mental Illness

For these reasons and many more employment in mental health remains of paramount

importance, not least for the service users who often measure their own wellness by

their ability to be employed.

Historically people with mental health problems have been excluded form theemployment market. It has been suggested that there exists an 85% unemployment

rate amongst people with a mental health diagnosis. A MIND survey (1997) showed

that most employers discriminate against people with mental health problems. An

earlier study in 1995 by the Royal College of Psychiatrists study showed that 30% of

120 companies studies would NEVER employ people with a mental health diagnosis.

There exists a clear need to create a system of mental health employment in most

localities. It should be emphasised that it should be a system that involves


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movement and progression. To often a single employment project becomes blocked

through the absence of opportunities for service users to move on and develop.

The 1992 research by the National Institute of Disability and Rehabilitation showed

that neither diagnosis nor symptoms had much to do with employability. Instead it

depended on employment history, work readiness, inter-personal skills and the desire

to work.

The are measurable benefits of having effective employment services;

The 1994 (Conning and Ekdawi) study shows that between 15% - 40% are people

with psychiatric history are capable of full time employment within three years of

their illness.

People with MH problems are particularly vulnerable to the negative effects of

unemployment.

Clinical deterioration in chronic schizophrenic patients was associated with lack

of occupation. This was the only distinguishing feature of those who improved

with those who didnt

(8 year study, 3 large hospitals, Wing & Brown 1970)

In the community, those who are working are more likely to stay out of hospital

and for longer.

Values and principles in Employment Models

Whatever the employment model there are certain values and principles that must

underpin the project.

It is very important that projects do not pursue some values to the exclusion of others.

For example a project that seeks to empower must not neglect the need to offer

support. Similarly a project that seeks to offer a comfortable and supportive


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workplace must not neglect the opportunity for progression for those that could

benefit from movement.

Service users should be involved in all aspects of the design of services and the

defining of values. Ownership is a key ingredient of successful employment projects.

The following represent the further basic principles that should underpin any

employment project.

NEEDS BASED Services should be designed and operated around the clearly

identified needs of individuals with mental health problems.

They therefore should be needs rather than funding, or

programme model led.

ACCESSIBILITY Services should be equally accessible to all groups in the

community, particularly those that are under-represented.

These may include;

Women

People with physical, sensory and learning disabilities

Ethnic minorities

Those with responsibility for children and others

Alcohol / drug users

Those with criminal records

ORIENTATION TO

THE LOCAL

MARKET Services should be designed and operated in ways that reflect

the characteristics of the local economy and labour market.

Production of goods and services should mirror demand within

the local economy and employment services should carefully

address employer requirements.

USER DRIVEN Services should be organised in a way that meets each users

individual requirements. Users should have as much control as


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possible over the timing, pace and intensity of the services they

receive. They should be supported to participate in service

design, operation and evaluation.

CHOICE Services should offer as much choice as possible in terms of

programmes, settings, skill levels and skill areas.

SUPPORT Services should offer suitable and sufficient support for

individuals to find and keep jobs or meaningful occupation, and

/ or participate in local education and training programmes.

Support should be individually tailored and available on a long-

term basis.

SECURITY Services should provide a supportive environment for service

users.

CONTINUITY Services should be available on a long-term basis. Service users

should be able to re-access services after an episode of illness.

PROGRESSION Service users should have opportunities to progress or develop

if they so wish (for example, build confidence, develop work

skills, acquire qualifications, find employment etc.).

Conversely they should have the opportunity to remain at a

particular level, or in a specific project, if this is what they

want.

FLEXIBILITY Should provide a range of possible outcomes i.e.. paid, unpaid

work, education, training etc.

EMPOWERMENT Services should focus and build upon service user abilities and

strengths and involve uses directly in service planning,

operation and evaluation.


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INTEGRATION Services should be sited in an ordinary community setting.

They should support the usage of community facilities and the

development of wide relationships in that community.

QUALITY Services should offer interest, variety and satisfaction. They

should seek to enhance self esteem and social status by

producing valuable outcomes.

COST

EFFECTIVENESS Services should meet needs effectively and efficiently.

There are several distinct models of employment. In every area there is a diversity of

needs: Therefore it is crucially important that a range of services is needed to

provide an employment continuum the key components of which are:

Sheltered work opportunities.

Vocational Rehabilitation

Support into open employment

Education and Training

These components have to be complementary and interdependent. Unless there is

movement or progression, and unless there is access to open employment then

individual projects will either get blocked or when users are ready for employment

there is nowhere for them to go.

Models are NOT set in stone. They should be adapted to meet local need and

availability. They should evolve and change over time, with users involved in

change.

There are numerous models of employment available in the UK that have proved

effective when working with both people with long term mental health problems and

with those who may reintegrate into the open employment market. The followingrepresent thumbnail sketches of some of the main UK models


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Sheltered Work

The provision of unwaged work opportunities within protected and supportive

settings. (E.g.. Industrial therapy units in day hospitals or day centres)

Work Rehabilitation

The provision of unwaged work opportunities within supportive settings but with an

emphasis on the development of work skills, building confidence and progression to

paid employment for some (e.g. Voluntary sector work projects, work rehab services)

Sheltered Employment

The provision of paid employment within protective and supportive environments of

medium to large commercial enterprises. (E.g.. Sheltered workshops, Remploy

factories)

Social Firms and Co-operatives.

The provision of paid employment opportunities within smaller community based

commercial enterprises which aim to pay market level wages and have integrated

workforces.

Consumer run enterprises

Business enterprises in which individuals with mental health problems have full

control over the important commercial decisions.

Clubhouses

Member run facilities where individuals can regain confidence, develop, personal and

work skills and can undertake work experience through Transitional Employment

Programmes. ( a series of time limited, part time, entry level posts within ordinary

employment).


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Supported Education & Training

The provision of intensive support for individuals to participate in education and

training programmes both targeted and mainstream.

Employment Services

Agencies providing a range of help in gaining paid employment, including vocational

guidance, work preparation courses, volunteering, wage subsidy etc.

Supported Employment

The provision of intensive support for individuals to identify, secure and sustain paid

work of their choice in open market. Job coaches in or around the workplace.

Local Exchange Trading Systems

A system whereby people in a locality can exchange goods or services without using

money. Members buy and sell goods or services through a notional currency system.

Further information about working examples of these models are generally available

from the Department of Health website.

Housing

The closure of the large psychiatric hospitals in the UK necessitated the resettlement

of those with a long-term mental illness into the community. With the benefit of

hindsight it would appear that that the closure programme failed to look at future

mental health accommodation needs and produced a system that perhaps to a large

extent merely recreated new institutions in the community centred around a

philosophy of homes for life.

The philosophy of progression is core to successful mental health housing. A culture

that looks beyond containment and seeks to promote independence and movement for

those who are able and security for those who are not.


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It is essential that for those who do not need a home for life the idea that they are

being placed for a tangible reason should be introduced and reinforced through CPA

review procedures. However if movement is promoted, then a system has to be in

place that enables the philosophy to continue. The exercise has to be continuous and

therefore continually monitored.

Mental health housing should have a range of different services responding to a

spectrum of need. Long term residential units with 24-hour support are the broad

base of provision for those with long term conditions and perhaps should be

considered as being almost separate from the facilities that should be available for the

population with more recent mental health problems.

Supported housing with clearly defined outcomes should provide the movement

required if housing systems are not to become blocked. Housing needs are an

essential part of CPA review processes and a system that promotes reducing support a

necessary part of recovery and movement towards independence.

Most UK based Housing Associations accept that the system of Floating Support

could be adapted for use with clients with higher levels of identified need if

augmented levels of support were forthcoming from other agencies such as

community rehabilitation and domicilary support from the statutory agencies.

Supporting People is a new initiative in England and Wales that develops the idea of

floating support and promotes inter-agency co-operation in mental health housing.

The Supporting People programme offers vulnerable people the opportunity to

improve their quality of life through greater independence. It promotes housing-

related services which are cost-effective and reliable, and which complement existing

care services. Supporting People is a working partnership of local government,

service users and support agencies.

The new system promotes housing related support services, which are both cost

effective and planned using a co-ordinated approach and budget. Supporting People

depends on a working partnership of Local Government, the NHS, the National

Probation Service, the Voluntary sector, service users and support agencies.


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The new system is aimed at (for example)

support to older people in sheltered housing, or support to those who wish tocontinue living in their own homes but need some help to do so.

supported housing for people with learning difficulties who can move out of

institutional care and into the community if they are helped to do so

housing for people with long term mental health problems, who can move out of

hospital if regular support is provided to help them cope with living independently;

The Supporting People programme aims toprovide the means of enabling them to

settle in a new home, and learn basic life skills that other people take for granted like

how to pay rent, shop for food, organise going to regular training and so on. Stable

housing tenancies enables them to take the necessary steps forward towards

independence and stability.

People with learning difficulties or mental health problems can often find themselves

living in institutional care such as hospitals, which are not only unsuited to their needs

but are also an expensive form of housing provision. Their quality of life can be

immeasurably enhanced by being enabled to live in the community, perhaps in a

shared house or other supported accommodation, and sometimes eventually in

independent housing with support. Again Supporting People services enable such

individuals to gain the life skills and provide the basic support which can sustain them

in the community, and promote their growth and development to be a part of the local

community rather than confined to an institution. They also provide them with the

necessary support to enable them to take part in programmes of education and

employment training.

Supporting People and new mental health housing initiatives have the essence of user

empowerment, recovery, social integration and independence and the cornerstones of

their philosophy.


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Modern Mental Health Services

Conclusion A system based on Recovery

The last forty years has seen the move from the Institutions to the Community. This

has led to a shift in emphasis from containment, medical treatment (only) and

protection for the individual and society. The new system places importance on the

idea of recovery and support. No longer the permanent patient.

The UK experience of community care should be examined if not for any other

reason than learning to avoid making the same mistakes.

The role of education in the entire process of de-institutionalisation cannot be

overestimated. One of the major shortfalls in the UK process was the overlooking of

the education process. It is essential that several key groups are fully aware of the

facts around mental illness and not left to rely on the stereotypes that societies have

repeatedly fed them for generations. The general public needs to be prepared in

advance for alternatives to institutional treatment; they need to understand the safety

aspect and their risk to violence.

Equally important professional workers in all agencies should be prepared for the

fundamental shift in emphasis that is required if treatment is focused in the

community rather than in the hospital setting. It comes as no great surprise to many

that staff educated in the institutions remain as institutionalised as many of the

patients and without support are unable to make the necessary conceptual shifts.

Communication and cooperation between agencies is fundamental to a successful

community based system. In the early days of community care, many public

enquiries into serious incidents led investigators to lay blame at the lack of effective

communication. Health, Social Services and voluntary sector agencies all have


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crucial parts to play at different stages of the recovery process. Assessments should

be multi-disciplined and CPA processes should involve all agencies.

Modern community mental health systems have certain immovable foundations that

cannot be ignored if the move from institutional treatment is to be successful:

Modern systems are User Directed.

The user is the centre of the system. This necessitates the gradual reduction in

the role of the expert for those working in mental health. The

progressive style is one of facilitation and partnership. Any system

must use

1. User consultation as part of evaluation and monitoring

2. User groups as a forum for change

3. User led and run services as part of the recovery continuum

4. CPA, assessment and reviews systems to ensure personal development.

Modern systems are family supporting.

Support must be given to the families of service users; they are often an important

part of the recovery process. Family members should receive Education and

information about mental illness if they are to succeed in a supportive role.

Modern systems are oriented to outcomes and recovery.

Unlike the old system, community care has the right to take part in society as

the fulcrum of its existence. The service user has a responsibility in the own

recovery. Key outcomes affecting quality of life of the user are crucial and emphasis

should be placed not only on the illness but also on issues such as, housing, education,

employment and leisure.

Modern systems are characterised by Best Practices


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Attention should be paid to gender and ethnicity of those with mental health problems

and reasonable adjustments should be made to include these issues in treatment.

Modern systems should be whole systems, not exclusively mental health. New

systems look at the whole person and all the influences that determine the success of

the social process.

Although this paper has looked at certain key areas of successful community

work, a whole system should have:

Individual tailored personal development plans.

Including

1. health,

2. social,

3. employment,

4. housing

5. education.

Community mental health teams that are multi-disciplined and offer ongoing

support and routine medical support.

Crisis support systems that can respond appropriately to prevent hospital

Assistance with benefits and finance through advocacy and advice centres.

The capacity to respond to special issues such as substance abuse, homelessness,

criminal behaviour, suicide prevention etc.

Support for wellness i.e. counselling, psychotherapy and good quality

healthcare.

Developed social networks and peer support systems

alternatives to institutional care for people with mental health problems

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