the ‘business’ of mental health and social inclusion ...€¦ · indefensible. to deny people...

THE AUSTRALIAN JOURNAL ON PSYCHOSOCIAL REHABILITATION Autumn 2010

THE ‘BUSINESS’ Of mENTAL HEALTH AND SOCIAL INCLUSION SpECIAL poST-ConFEREnCE EdITIon

is published by

psychiatric disability Services of Victoria (VICSERV) Level 2, 22 Horne Street, Elsternwick Victoria 3185 Australia T 03 9519 7000, F 03 9519 7022 [email protected] www.vicserv.org.au

Editors Wendy Smith, policy and Research Manager, psychiatric disability Services of Victoria (VICSERV).

Kristie Lennon, Resources Coordinator, psychiatric disability Services of Victoria (VICSERV).

newparadigm Editorial Advisory Group Joan Clarke, Allan pinches, Chris Mcnamara, Wendy Smith, Kristie Lennon.

ISSn: 1328-9195

CopyrightAll material published in newparadigm is copyright. organisations wishing to reproduce any material contained in newparadigm may only do so with the permission of the editor and the author of the article.

DisclaimersThe views expressed by the contributors to newparadigm do not necessarily reflect the views of psychiatric disability Services of Victoria (VICSERV).

psychiatric disability Services of Victoria (VICSERV) has an editorial policy to publicise research and information on projects relevant to psychiatric disability support, psychosocial rehabilitation and mental health issues. We do not either formally approve or disapprove of the content, conduct or methodology of the projects published in newparadigm.

ContributorsWe very much welcome contributions to newparadigm on issues relevant to psychiatric disability support, psychosocial rehabilitation and mental health issues, but the editor retains the right to edit or reject contributions.

Cover photo and all conference photos by Shane Bell www.shanebell.com

EDITORIAL Wendy Smith

WHAT IS THE UNfINISHED BUSINESS?Measuring the business Marion Blake

Reconceptualising the relationship between mental illness and homelessness Guy Johnson

Revolving or evolving doors? The unfinished business of delivering good practice services Robyn Martin

Carers’ experiences of the mental health system in relation to suicide dr Margaret Leggatt and Marina Cavill

From paradigm to practice: incorporating recovery-oriented principles through organisational and practice change Belinda Cash

Addressing health inequalities for people with severe and enduring mental illness in a community health service Gerard Reed

‘I just want to wear sexy lingerie…’ A consumer’s experience of a Weight Management Group model Benjamin Flood, Simone Tassone and Kate nunan

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DesignedbyStudioBinocular

From consumer participation to leadership: walking the talk CatherineSmith

Determining subjective conceptualisations of recovery from schizophrenia SandravanLith

Sovereign selves or social beings?: The practitioner’s role in constructing the subjectivity and sociality of the consumer MarkFurlong

Somali mental health projectAhmedTohow

From family work to work: unexpected pathwaysJanetGlover,EliseWhatleyandDrPeterMcKenzie

Consumer participation in research LeiNing,WayneWeavelandSallyWoodhouse

YOUR SAY… Member profile – Aspire, A Pathway to Mental Health PhilipHose

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Book Review ByAntheaTsismetsi

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Wendy Smith, PolicyandResearchManager

04newparadigm Autumn2010

Psychiatric Disability Services ofVictoria(VICSERV)

EdItORIAl

On the last two days of April this year around 800 people came to Melbourne’s iconic MCG to attend the biennial VICSERV Conference – Unfinished Business: pathways to social inclusion. People came from far and wide across Australia, a New Zealand contingent from across ‘the ditch’ and presenters from Scotland, England and the United States. On offer was an impressive range of presentations around the theme of what needs to be done, and what is being done, to create a truly inclusive society for people affected by mental illness and those who care for them.

Thisconferencehadanincreaseonpreviousyearsinthenumberofevidenced-basedpresentationsandthoseshowcasingpromisingpracticelikelytobuildtheevidencebasearoundthevalueofpsychosocialandrecoveryapproachestomentalillness.WorkcurrentlybeingundertakenonVICSERV’sbehalfhasproducedaliteraturereviewthatdocumentskeyevidencetoprovewhatwedoimprovesthelivesofpeopleaffectedbyamentalillnessandiscosteffective.Thisworkwillbeprofiledinupcomingeditionsofnewparadigm.

Therewasagoodrepresentationattheconferencefrompeoplewhouse,orhaveused,mentalhealthservicesandtheircarers.Thisgroupaccountedforalmostaquarterofalldelegatesandmorethanadozenpresentations.Itwasobviousthatthepeerworkforceismakingsignificantcontributionstothedevelopmentanddeliveryofcommunitymanagedmentalhealthservicesandpolicy.Thiseditionofnewparadigmcontainsarticlesfromfiveofthepresentations.

Acommonrefrainduringandafteranyconferenceisabouthowharditistopickandchoosewhattoseewhensomanygoodpresentationsareonoffer.Onceuponatime,agrandtomeofconferenceproceedingswouldhavebeenpublishedaftertheeventcontainingallthepapersthatweregiven.Thesedays,presenterstendtousePowerPointandnotes.Also,formatssuchaspanelsandworkshopscan’teasilybetranscribed.Weput

outacalltoallthosewhohadsubmittedanabstractormadeapresentationtowriteitupforpublicationinnewparadigm.Wewererewardedwithsufficientmaterialforthiseditionandthebasisoftwoforthcomingeditionsoneconomicparticipationandoneonearlyinterventionandyoungpeople.Thankyoutoallthesepeoplewhoworkedtoverytightdeadlines.

Thispost-conferenceeditionleadsoffwithanarticlewrittenforusbyPlatformNZCEO,MarionBlake.Provocative,sincereandimaginative,Marionwritesaboutthecomplexityof‘measuringthebusiness’ofNGOmentalhealthservicesandwhetherornotwhatwedoismakingadifference.GuyJohnsonwasinvitedtospeakattheconferenceaboutresearchheandacolleagueundertookintothenatureandextentsofmentalillnessamongstthehomelesspopulation.Todatewehaveonlyhadestimatesofbetween30and90percent.Guytellsuswhatthetruefigureisandhowhefoundout.Thereareotherarticlesbyacademicswithaninterestinmentalillnessthatmakeinterestingreading.

Asmentionedabovetheconsumer/carervoiceisstrong.Apresentationthatreceivedalotofpositivefeedbackanddiscussionattheconferenceandsince,iswrittenbyGerardReedonbehalfofDouttaGallaCommunityHealthService,onrespondingtothephysicalhealthneedsofpeopleaffectedbyamentalillness.Wearedelightedtopresentithereforawideraudience.

Pleaseenjoythisedition,especiallythosewhoweren’tabletomakeittotheconference.WithafederalandVictorianelectionduelaterthisyear,amajornationalhealthreformandfurthermentalhealthreformstofollowin2011,thelandscapeinwhichthe2012VICSERVconferencewillbesetislikelytobeconsiderablychanged.

KindRegards,

Wendy Smith PolicyandResearchManager

WHAt IS tHE UNFINISHEd BUSINESS?



Ithinkweneedtousethewordsthatpeoplewhoexperiencementalillnessandaddictionusetodescribetheirworld.Wordslikepoverty,unemployment,homelessness,poorphysicalhealth,loneliness,disconnection,isolation,lackofrespectandstigma.Thecatchallphrase‘socialinclusion’feelstomelikefudgingthehugeagendaofsocialchangethatbothourcountriesneedtoaddress.

In New Zealand, we often begin our gatherings, presentations or meetings with an acknowledgement of the ancestors or a reflection or wisdom. So, in that spirit, I would like to acknowledge the ancestors of the mental health and addictions world. For centuries, these people continue to take acts of courageous leadership, defiance, support, creativity and curiosity, and these actions have improved things for others.

Iwanttoalsoacknowledgethewomen,menandchildrenwhohavelosttheirliveswithinthementalhealthsystemsoftheworld.And,forthoseofuswholiveindemocraticandrichcountries,Ithinkitisimportanttorememberthattherearestillcountriesintheworldthatroutinelycage,tortureandhumiliatepeoplewhoarementallyill.

WhenIarrivesomewhere,Iliketounpackmyluggage...

So,Iwouldliketobeginbyunpackingabitofmyownbaggage.Firstly,IwillprobablyusetheexpressionmentalhealthandaddictioninonedrawofbreathasthatisthewayservicesareconfiguredinNewZealand.Thatdoesnotimplythattheyare,ineverydaypractice,joinedup,butitdoesindicatethesignificantamountofoverlap.Thedemarcationzonepatrolledvigorouslybysomecliniciansis,Ibelieve,indefensible.Todenypeoplementalhealthservicesbecausetheyarestilldrinkingorusingdrugsorfailingtoaddressaddictionissuesinamentalhealthsettingisunacceptable.

Anotherthing–thetitleofVICSERV’sconferenceisUnfinishedBusiness:pathwaystosocialinclusion.Ithinkthatsocialinclusionanditssoulmate,socialexclusion,areweaselwords–thatis,wordsthatareevasive,ambiguousormisleading.Thementalhealthandaddictionworldisoftenaccusedofdoublespeakorspeakinginwhatoneofmycolleaguescalls‘alphabet’language.

Measuring the business

Marion Blake, CEO,PlatformCharitableTrust,NewZealand



SocialinclusionlanguagewasimportedtoNewZealandfromtheUKwhereitwasknownassocialexclusion,untilthatwasfelttobepejorative.Ithinkweneedtousethewordsthatpeoplewhoexperiencementalillnessandaddictionusetodescribetheirworld.Wordslikepoverty,unemployment,homelessness,poorphysicalhealth,loneliness,disconnection,isolation,lackofrespectandstigma.Thecatchallphrase‘socialinclusion’feelstomelikefudgingthehugeagendaofsocialchangethatbothourcountriesneedtoaddress.

Onelastunpackistoacknowledgehowfarwehavecome,inwhatisarelativelyshorttime.In1854,thefirstasylumwasbuiltinNewZealand.Priortothat,patientswerehousedinagaolwhereitwassaid‘thattheirrecoverywashighlyproblematical,andtheirdeathalmostcertain’1.

Wenowhavenoinstitutions;instead,wehaveacomprehensiverangeofmentalhealthandaddictionservicesthroughoutthecountrythatprovide:

•Employmentopportunities•Home-basedsupport•Residentialrehabilitation•Housing•Youthsupport•Peersupport

•Education•Disabilitysupport•Communitydevelopment•Family/whanausupport•Dayactivities•Recreation•Telephonesupport•Prisondrugrehabilitation•Packagesofcare•Women’sservices•Needleexchangeprograms•Counselling•Creativeactivities

the New Zealand context

•NewZealandpopulation–4,364,925,(Sydney4,504469)

•Thegovernmentspendsabout$1.1billiononmentalhealthandaddictionsandaboutathirdofthatisspentpurchasingservicesfromNGOs,whicharemainlycommunity,non-profitagencies

•TheMinistryofHealth,MinistryofSocialDevelopmentand,toalesserextent,DepartmentofCorrections,arethemaingovernmentfunders


byMarionBlake

Ourchallengenowistorememberourrootsassocialactivistsandnotbeintimatedbyourdependencyupongovernmentfundingtocompromiseourautonomyandroleaschangeagents.Contractdeliverableshaveputusatriskofcompliancebecomingourmantraandoutcomesouractivity,ratherthanmeasurementsthatarecriticaltogrowth,substanceandunderstandingwhatisgoingonaroundusandhowouractionsareaffectingothers.

•Twenty-oneDistrictHealthBoardsundertakelocalpurchasing

•Therearearound300NGOscontracted.

However,NewZealand’shealthservicesarebeginningtolookquitedifferentasourcountryfacesuptotheimpactofanewpoliticalregimeandthecurrenteconomicenvironment.

FollowingnineyearsofaLabourGovernment,aNationalGovernmentwaselectedin2008.TheGovernmenthassupplyandconfidencearrangementswithboththeMaoriPartyandtheActParty.OneoftheearlyactionsofthenewGovernmentwastoundertakeareviewofthepublichealthanddisabilitysystem.Thisresultedinthesystemstrugglingtofinanciallysustainitselfandthepublichavinghugeexpectationsofthesystem.

TheNationalPartyHealthPolicyischaracterisedbyshiftingcareclosertohome,andthecreationofIntegratedFamilyHealthCentres(enhancedGP-leadprimaryhealthcare).Ithasastrongerfocusonsafety,quality,valueformoney,shiftingresourcesfrombureaucracytothefrontlineandreducingwaste.Infact,ithasahealthenvironmentthatpaysattentiontodoctorsandnurseswithastrongclinicalleadership.

Tothiscocktailmix,addaworldwiderecessionandacountrywithalevelofhouseholddebtthatisonlysurpassedbyIceland.NewZealandisborrowing$240millionperweektosustainourpublicservicesaswetrytotradeourwayoutoftherecession.Thebudgetthismonthindicatesthatfundinginhealthmay(ifwearelucky)remainthesameratherthanreduce.Thiswill,however,puthugepressuresonmanagingthecosts,currentoverspendanddebtofthepublichealthprovidersandwillinevitablyhaveconsequencesforthecommunityservicestheypurchase.

Overall,itisaninterestingandcomplexenvironment,especiallytoengageasocialagendaofmentalhealthandaddictions.But,whyletagoodcrisisgotowaste?Theresponseofcommunityorganisationshasbeentobecomeincreasinglyvocalaboutasuccessfultrackrecordoveralongperiodoftimeofrespondingtochangingdemands,ourabilitytorunefficientsocialbusinessandtoprovideinnovativeservicesolutions.

Thementalhealthandaddictioncommunityorganisationswanttopositionourselvesasthe‘value-for-mental-health-money’optionforthegovernmentandwebelievewearethefrontlineofservicedelivery.Onbehalfofourmembers,PlatformhasrecentlypublishedFrontline–The community mental health and addiction sector at work in New Zealand2.Thisprovidesacontemporaryoverviewoftheactivityoftwenty-firstcenturycommunityorganisationsthatprovidementalhealthandaddictionservices.

Westillmaynotknowwhatcausesmentalillnessoraddiction,butitisevidentthataperson’sexperienceofthedebilitatingeffectscanbesignificantlyinfluencedbyarangeofsocialimpacts.Thisincreasestheurgencyforcommunityorganisationstobeabletoquantifyandmeasurethecontributionofservices,supports,activities,interventionsandopportunitiestheyprovidetothementalhealthsystem.

Theworkofthesectorisnotwellunderstood.Mythsabout‘dogooders’andcharitiesrunbyenthusiasticvolunteers,stillaboundandthatcertainlydoesnotrepresentNewZealand’smentalhealthandaddictionNGOsector.Itisamulti-milliondollarindustry,employingthousandsofpeoplerunningsomeofAustralasia’smostefficientandinnovativesocialbusinesses.

Why do we find it so hard to update the public and political perception of the critical work we do?

Ibelievethereareanumberofreasonswhyourmeasurementofcommunityactivityhasbeendifficult.Notleastoftheseisthecomplexity.Therearemanythingshappeningatthesametimeandmosttraditionalmeasurementsaresingularandlinear.Anexampleisthedifferencebetweentwosimplefields:

•Measuring the performance of the organisation: arewedoingwhatwesaidwewould?

•Measuring the impact we have on the individuals we support:arewemakingtherightdifferenceinpeople’slives?

Inrelationtothemeasurementoforganisationalperformance,manyofthecontractedmentalhealthandaddictioncommunityprovidershaveadaptedtotheproliferationofmarketandbusinessmodels,withinthehealthsector.Theyhavelearnedtoplaythegamethatsupportsthisbizarre

marketeconomywherethetradedcommodityisthelivesofvulnerablepeople.

ThecommunitysectorhasbeenactivelyencouragedinNewZealandtousebusinessmodelsandagovernancestructureupliftedfromtheboardroomsofindustry.Thismightworkwell,ifyouaremanagingaproductorabusinesswhereyouhaveamarketorcustomersthathavechoice.Corporategovernancemodelscanworkwellinsomeofthelargeragencies,butitisabitofastretchforsmalleragencies.Insayingthat,Iamnotdismissingthecriticalneedforgoodgovernance,stewardshipandaccountabilityofcommunityagenciesandtheirleadership.Ourroleinourcommunitiesisaseriousone.

Therearearangeoforganisationalperformancemodelsthathavebeenmodifiedtomeettheneedsofthenon-profitsector.AnexampleofthisistheimpactoftheworkofKaplanandNorton,inThe Balanced Scorecard,(1996)3.Thiswasanearlyexamplethatappealedtomanyinthecommunitysector,asitlinkedorganisationalmeasurementtothepurposeorthe‘whatfor’ofanorganisation.Italsopromotedtheuseofabalancedrangeofperformancemeasures.Theoriginalfourmeasures:financial,customer,internalprocess,innovationandlearning,nowmakeupsix,withcommunity/environmentandemployeesatisfactionhavingbeenadded.Themodelhasalsobeenadaptedforthenon-profitsector,isinactiveuseintheUSandencouragedbymanybusinessadvisorswhoconsultintothecommunitysectorinNewZealand.

ItisalsoimportanttonotetheuniqueinfluenceinNewZealandofsomeindividuals,suchasProfessorMikePratt,andhisworkonPeakPerformingorganisations,4andtheUniversityofWaikato,whomakeacontributiontotheMentalHealthandAddictionExecutiveLeadershipandManagementProgram,leadbyanotherNGO,BlueprintforLearning5.

Theapproachtothisvariesimmenselybasedonwhatyousetouttodo.AnexampleofthisisintheareaofsupportedemploymentandthesuccessofIndividualPlacementandSupport(IPS).ThemodelofactivityisdescribedandtheevidencenowshowsthatIPShelpsmorepeoplefindjobs,increasetheirincomeandimprovethequalityoftheirlives.AccordingtoEngland’sSainsburyCentre6forMentalHealth,thereisincreasingevidencetosuggestthatitcanleadtolong-termexpendituresavings,asthosewhofindworkmake

reduceduseofmentalhealthservices.Whatagreatstoryofmeasuringthebusiness.Itmakesacompellingcaseforthegooduseofthegovernment’sscarceinvestmentfromthepointofviewofallofsociety.

Measuringtheoutputshasbeenpartofthecontractuallandscapeformanyyearsnowandthishasbeenaccompaniedbygrowingcynicisminthecommunitysectoraboutitsusefulness.Thesemeasuresareusuallycompliancedriven,retrospectiveandoftenjustplainsilly.Theclassicmeasureforresidentialprovisionis‘howmanybednights’?Whatvaluedoesthissortofreportingaddtoourunderstandingofeffectiveness,orwhatwehavedonetomakesomeone’slifeanybetter?

TheNewZealandMinistryofHealthhasundertakenanambitiousplanformentalheathinformationgathering,calledPRIMHD–theProgramfortheIntegrationofMentalHealthData7.Theprogramstartedwiththe21DistrictHealthBoardsreportingdataandthisisnowprogressingtootherserviceproviders.Theinformationiscollectedbyaperson’sNationalHealthIndexnumber:auniquenumberforeverypersoninNewZealand.Communitymentalhealthandaddictionproviderswillreportwhentheservicetothepersonstartedandwhenitstopped,andagainstactivitycodes.Theprogrampromisedmuchanditstillisveryearlydaysforthereportingofcommunitysectoractivity,buttherewillneedtobesomepracticalsector-leadinnovationifthesectorisgoingtobeabletobenefitfromPRIMHDorotherinformationdevelopmentsintheshortterm.

Thepossibilityofimposed,ponderousandcumbersome‘onesizefitsall’,sectormeasuresforadiversecommunitysector,hasbeentheimpetusforthecreativeKiwiDNAtokickinandtobefair,wehavecalleduponsomeAustralianstohelpus.Themeasurementofprogramsusingprogramlogicmodelshasbeenmyownpersonalbreakthroughandwhilstitsoundsveryintellectualitabsolutelytalkstothecomplexityoftheissueswearegrapplingwith.

Programlogicshowsaseriesofexpectedconsequences,notjustasequenceofevents.Figure01showstherationalebehindaprogram/projectorstrategy–whatisunderstoodtobethecause-and-effectrelationshipbetweenactivities,outputs,intermediateoutcomesandultimateoutcomes.




byMarionBlake

WhenprogramlogicmeetstheAustralianevaluator,DrJessDart8,westarttogetsometraction.Jesshasplayedwithmeasuringandevaluatingcomplexsystemsforalongtimeandhasevolvedsoundsystemsthatvalidatethe‘morereal’activityweperform.

TheMentalHealthCommission’spublicationTe Haererenga mo te Whakaoranga 1996–2006 – The Journey of Recovery for the New Zealand Mental Health Sector9,saidthat‘creatinganewsupportworkoccupationalgroupinghadbeenagreatworkforceachievementandhasbeenaspecificNewZealandinnovation.’

In2007,Platform,inpartnershipwithourcolleaguesatTePou10,setoutonourownjourneytovalidateanddescribethevalueandtheroleofcommunitysupportworkersandthecontributiontheymaketorecoveryoutcomesinthemental

healthsystemofourcountry.Weusedacombinationofmethodstoexplorethiscomplexquestion;programmelogic,storiesofsignificantchange,openspacetechnologyandsomewemadeup.WeproducedaPerformance Story Reportthatdescribedwhatwedidandourresults.Itcontainsaresultschartthatmapsandacknowledgestheworkofmultiplestakeholdersandorganisationswhoseworkhasbeenbothfoundationalandinfluentialintheprocessofcontributingtotherecoveryoutcomesapproachforourcountry.ThisincludespolicydocumentsandotherareassuchastheLikeMindsLikeMine11,thepublicawarenessanti-stigmacampaign,thedevelopmentofnationaltrainingforcommunitysupportworkersandtheincreaseduseofpeersupport.

Thepointofthisisthatachievinggoalsinoneareais,inevitably,linkedtoactivityinotherareas,butourachievementisinterdependent.

Figure 01: ProgramAction–LogicModel

Needsandassets

Symptomsversusproblems

Stakeholderengagement

Consider:

MissionVisionValuesMandatesResourcesLocaldynamicsCollaboratorsCompetitorsIntendedoutcomes

What we invest

StaffVolunteersTimeMoneyResearchbaseMaterialsEquipmentTechnologyPartners

What we do

Conductworkshops,meetingsDeliverservicesDevelopproducts,curriculum,resourcesTrainProvidecounselingAssessFacilitatePartnerWorkwithmedia

Who we reach

ParticipantsClientsAgenciesDecision-makersCustomersSatifaction

Short term

LearningAwarenessKnowledgeAttitudesSkillsOpinionsAspirationsMotivations

Medium term

ActionBehaviourPracticeDecision-makingPoliciesSocialaction

Ultimate impact

ConditionsSocialEconomicCivicEnvironmental

INPUTSSITUATION PRIORITIES OUTPUTS OUTCOMES – IMPACT

ASSUMPTIONS/EXTERNAL FACTORS

EVALUATION Focus–CollectData–AnalyseandInterpret–Report



InNewZealand,anumberofthelargermentalhealthandaddictionprovidersareusingavarietyofmethodsofevaluation.Forexample,RichmondNewZealand13iscurrentlyusinginterventionlogictoevaluatetheirworkandthishasmeanttrainingover200people.Pathways14havedevelopedsoftwarethatisdesignedtousemultiplesourceinformationtosupportdecisionmaking.WALSHTrust15isleadingsomethinkingbasedonKenWilbur’sfourquadrants,tothinkhowfundingmightbeallocatedtopostinstitutionalservices.Equip16hasalonghistoryofusingoutcomemeasurestoinformtheshapeofservicesandthisjustasmallsample.

Weneedtoconstantlythinkcreativelyabouthowwetacklethecomplexityofmeasuringthebusiness.Sometimesweneedtostandbackandlookatthewholesystemtoseehowthingswork.Weneedtoexperimentattheedgesandnottakeourdefaultaroundmeasuringsuccessjustintheuseofnumbersandbodycounts.Itisalsotimelytobeginthinkingbeyondservicesandorganisationsandthecontractparadigmthathassiloedtheservicessetuptoservethepublic.Theexperiences,issuesandviewsaboutthehealthcontractingenvironmentinNewZealand,asexperiencedbycommunity

organisations,weredescribedlastyearinareportpublishedbyPlatform,NgOIT 2008 NGO-DHB Contracting Environment17.Themostsignificantrecurringissueinthereportisthefundamentalneedformutuallyrespectfulrelationshipsbetweenthefundersandthecommunityorganisationsandadesiretosolvetheproblems,notjustlegallymanagethecontract.

Itseemsthatthekeytothesocialchangeagendaneedstobetofindwaystoconnectourcommunities,notjustthepeoplewhohaveachievedasupportentitlementviatheir‘DSMIV’diagnosis.CharlesLeadbeateraleadingUKinnovativethinkerarguedintheGuardian18lastyearthatsupportiverelationshipsarethekeytotacklingsocialills.Hewrote:

‘The key will be to redesign services to enable more mutual self-help, so that people can create and sustain their own solutions. The best way to do more with less is to enable people to do more for themselves... Enabling people to come together to find their own, local solutions should become one of the main goals of public services. Services do a better job when they leave behind stronger, supportive relationships for people to draw on and so, not need a service.’


byMarionBlake

Weneedtoconstantlytothinkcreativelyabouthowwetacklethecomplexityofmeasuringthebusiness.Sometimesweneedtostandbackandlookatthewholesystemtoseehowthingswork.Weneedtoexperimentattheedgesandnottakeourdefaultaroundmeasuringsuccessjustintheuseofnumbersandbodycounts.Itisalsotimelytobeginthinkingbeyondservicesandorganisationsandthecontractparadigmthathassiloedtheservicessetuptoservethepublic.

Itwasencouragingtoreada‘think’piecefromSustainableFuture,aNewZealandthinktank,calledThe Information Age is Dead. Long Live the Imagination Age. ItquotesMalcomGladwellwhowroteBlink, The Tipping Pointand,morerecently,Outliers.Gladwellsaid:

‘We have come to confuse information with understanding…’

Thepiecegoesontosay:

‘Accumulating vast stores of information is not enough, it needs to be used to gain meaningful and sustainable ways of living, working and playing.’

Ilikethisbecauseitcallsontheconnectionbetweeninformation,itsuseandwisdom.Inthemeantime,whilewewaitfortheImaginationAgetokickin,thereisanimperativeformorecapacityandinformationliteracyinthecommunitysectortosupportorganisationstocollecttherangeofinformationthatwillenablethemtounderstandandanalysetheimpacts,benefitsandchangesoftheiractivity.

Perhapsweneedtoexperimentwithwhatnetworkedorganisationscouldlooklike.Forexample,isthereacapacityforagenciestocollaboratewithsomeofthecommonfunctionsofinformationcollection,outcomemeasures,evaluationpilotsanddatareportingtofundersthroughsomesortofhubarrangement?Let’snotjustgatherinformation;let’sshareitanduseitandtrainpeopletousetheinformationtheyalreadyhave.Whatisitthatstopsusimplementingourideas?Whatstopsthegovernmentbeinginterestedintheradicalchangethatisneeded?Weknowthatwhatishappeningnowisnotsustainable,doesn’twork,andinsomecaseshindersprogress.Whatarethethingsthatimpedetheconnectionsofcommunitythatareobviouslycriticaltoaddressthe‘exclusion’ofmanyofourcitizens,includingmanywhohaveexperienceofmentalillnessandaddictions?

Imagineifwewereabletousetheskillthatmuchofthementalhealthandaddictionsworkforcehasdevelopedintheartofbuildingrelationships,tojoinupsomeofthedisconnectionsthatnotonlypeoplewithmentalillnessandaddictionsoftenexperience,butalsomanypeopleinourcommunities.Perhapswearethesecretingredientforsocialchange.

Imaginelookingattheindustryofmentalillnessasbeingastoxicasthetobaccooralcoholindustry,wherepeoplegetrichfromthemiseryofothers?Isthecommunitysectorcomplicitwithperpetuationofthestatusquo?Arewegivingawayourvisionandpassiontothecontractculture?Whatarewefailingtoname?

Ourchallengenowistorememberourrootsassocialactivistsandnotbeintimatedbyourdependencyupongovernmentfundingtocompromiseourautonomyandroleaschangeagents.Contractdeliverableshaveputusatriskofcompliancebecomingourmantraandoutcomesouractivity,ratherthanmeasurementsthatarecriticaltogrowth,substanceandunderstandingwhatisgoingonaroundusandhowouractionsareaffectingothers.

References

1 Mosley,M.,(1885),Illustrated Guide to Christchurch and Neighbourhood,J.T.SmithandCo.,Christchurch

2 Accessedat:http://www.platform.org.nz/file/Documents/frontline_ngo.pdf

3 Kaplan,R.S.,Norton,D.P.,(1996),The Balanced Scorecard: Translating Strategy into Action, HarvardBusinessSchoolPress,Boston

4 Gilson,C.,Pratt,M.,Roberts,K.,Weymes,E.,(2000),Inspirational Business Lessons form the Worlds Top Sports Organisations,TexerePublishing,NewYork

5 Accessedat:http://www.blueprint.co.nz/page/12-Welcome

6 SainsburyCentreforMentalHealth,(2009),Commissioning What Works: The economical and financial case for supported employment,London,accessedat:http://www.scmh.org.uk/pdfs/briefing41_Commissioning_what_works.pdf

7 Accessedat:http://www.moh.govt.nz/primhd

8 See:http://www.clearhorizon.com.au/

9 Accessedat:http://www.mhc.govt.nz/users/image/resources/2007%20publications/te_haererenga.pdf

10 See:http://www.tepou.co.nz/page/23≠Welcome

11 Accessedat:http://www.likeminds.org.nz/page/5-Home

12 Accessedat:http://www.clearhorizon.com.au/category/publication/msc-publications/

13 See:http://www.richmondnz.org/

14 See:http://www.pathways.co.nz/page/5-Welcome

15 See:http://www.walsh.org.nz/

16 See:http://www.equip.net.nz

17 Accessedat:http://www.platform.org.nz/file/Documents/ngoit-book-07.pdf

18 Accessedat:http://www.guardian.co.uk/society/2009/jul/01/public-services-reforms



Clearlymanyoftheapparently‘crazy’behaviouralpatternsobservedinthehomelesspopulationthatleadtotheconclusionthemosthomelesspeoplehavementalhealthproblemsare,infact,survivalstrategies.Thesestrategiesmakesenseintheeconomicallyandsociallydepletedcontextofhomelessness.Theyshouldnotbetakenassignsofmentalillness.

Reconceptualising the relationship between mental illness and homelessness

Guy Johnson, ResearchFellow,AustralianHousingandUrbanResearchInstitute,RMITUniversity

No account of homelessness is complete without some systematic attention to mental illness. While there is abundant evidence that the prevalence of mental illness is much higher among the homeless than in the general community there is no clear agreement about the nature and extent of the relationship.

Somestudies,typicallythosefromaclinicalperspective,reporttheprevalenceofmentalillnesstobeintherangeof70–80percent(Herrman,McGorry,Bennett,vanReilandSingh1989;Reilly,Herrman,Clarke,NeilandMcNamara1994;Hodder,TeessonandBuhrich1998).Incontrast,studiesfromasociologicalperspectivereportmuchlowerrates,oftenaround20–30percent(SnowandAnderson1993;AustralianInstituteofHealthandWelfare2007;Flatau2007;Johnson,GrondaandCoutts2008).

Clinicalstudiesreporthigherratesforthreereasons.First,theyoftenuseabroaddefinitionofmentalillnessthathas‘beenstandardisedonmoredomiciledpopulations’,(Snow,Baker,AndersonandMartin1986).Askingapersoniftheyhavefelt‘down’,‘depressed’or‘anxious’inthelastfourweeks(Hodderetal.1998,p.p.99–100),couldnot,inanymeaningfulway,betakenasanindicationofmentalillness.Mosthomelesspeoplewouldanswer‘yes’,notbecauseofmentalhealthproblems,butbecauseofthematerialconditionsoftheirexistence.

OneofthemostwidelycitedstudiesDown and Out in Sydney(Hodderetal.1998),reportedthat75percentofthehomelesshadmentalhealthproblems.Butthey,likeotherclinicalresearchers,includedalcoholanddrugproblemsintheirdefinitionofmentalillness.Problematicdrinkingisdefinedas‘12ormoredrinksinanyoneyear’(Teesson,Hodderand

GuyJohnsonattheVICSERVConference




byGuyJohnson

Buhrich2003:467).Thisremindsusthattheprevalenceofanyphenomenonisstronglyconditionedbythewaythephenomenonisdefined.

Second,clinicalstudiesoftentargetanarrowsectionofthehomelesspopulation.TaketheDown and Out study.Itdrewitssampleof210frominnercityhostels,wasoverwhelminglymaleandhadamedianageof40.Thisraisesthequestionofhowrepresentativetheirsampleis.Itisquitelikelythatitisarepresentativesample,butonlyofthechronicallyhomelessandthisisanimportantdistinction–noteveryonewhobecomeshomelessendsupchronicallyhomeless.

Further,thechronicallyhomelesstendtohavedifferentcharacteristicstotherestofthehomelesspopulation,withmuchhigherratesofproblematicsubstanceuseandmentalhealthproblems(Leal,Galanter,DermatisandWestreich1998;PhelanandLink1999;vanDoorn2005).Perhapsabetterexampleillustratesthepointabouttheimpactofdifferentsamplingstrategies.OnestudyintheUSfoundthat96.6percentofthehomelesshadmentalhealthissues(Liptonetal,1988).GiventheyrecruitedrespondentsfromtheBellevuePsychiatricEmergencyRoom,thisishardlysurprising.

Finally,clinicalresearchreliesononce-offsurveys,whichareoftenfarremovedfromthesocialcontextthatshapestheday-to-daylivesofhomelesspeople.Forexample,clinicalresearchersdefineapersonwithananti-socialpersonalitydisorderassomeonewho:

‘...fails to plan ahead, or is impulsive as indicated by one or both of the following:

a) travelling from place to place without a pre-arranged goal for the period of travel or a clear idea when the travel will terminate,

b) a lack of fixed address for a month or more1.’

Interpretingthesebehavioursassymptomaticofmentalillnessisproblematic,asthesebehavioursareoftenadaptiveresponsestothepredicamentofhomelessnessitself.Manyresearcherswhofocusonthe‘livedexperience’ofhomelessnesshavefoundthathomelesspeopleareoftenoverwhelmedbythe‘consumingcharacteroftheimmediatepresent’.Withafocusongettingthenextmeal,gettingmoneytogetherandfindingaccommodation,thisgenerallymeans

thereis‘littleornoplanning’andthereisalwaysa‘lastminuteimmediacyorurgencyabouttheirneeds’,(BedfordStreetOutreachService1997:5).SnowandAnderson(1993:170)characterisethisday-to-day,moment-by-momentexistenceasa‘presentorientation’,whichisanadaptivepractisearisinginresponsetothecontingenciesofhomelessness.

Clearlymanyoftheapparently‘crazy’behaviouralpatternsobservedinthehomelesspopulationthatleadpeopletotheconclusionthemosthomelesspeoplehavementalhealthproblemsare,infact,survivalstrategies.Thesestrategiesmakesenseintheeconomicallyandsociallydepletedcontextofhomelessness.Theyshouldnotbetakenassignsofmentalillness.

Thisisnotsimplyanacademicissue,asthehighratesreportedinclinicalstudiesoftenfindtheirwayintothepublicdomainandreinforceexistingprejudicialstereotypesofthehomeless.Forinstance,inlateDecember2004,The AgenewspaperinMelbourne,arguablythecitiesmostrespectedbroadsheet,headlinedastorywith‘80%ofhomelesshavementaldisorder’.ThisstorythenbecamethebasisforsubsequentarticlesinThe Ageandothermediaoutlets.Theoriginalarticlewasunquestionedandeachsubsequentquotingofitcontributedtoadistortedperceptionofhomelesspeople.

Publicattitudes,notsurprisingly,paintasimilarpicture.ArecentsurveyofpublicattitudestowardsthehomelessinMelbournefoundthat81percentidentifiedmentalillnessasaprimarycauseofhomelessness.Furthermore,advocatesandpolicymakersoftenrelyonthesestudieswithoutnecessarilyunderstandingtheirlimitations.Forexample,theAustralianGovernment’sFourth National Mental Health Plan: An agenda for collaborative action,statesthat‘Australiadatasuggestthatupto75percentofhomelessadultshaveamentalillness’(2009:17).

Complicatingmattersfurtheristhatcommunityandgovernmentreasoningoftenproceedsalmostautomaticallyfromattributetocause–itispresumedthatifsomeoneismentallyillthenitistheirmentalillnesswhichcausedhomelessness.Mentalillnessisnotjustusedtodescribehomelessness,butalsotoexplainitandthisreflectsapowerfultendencybywhichcertaincharacteristicsdisplacethepeoplewhopossessthem.However,quantifyingtheprevalenceof



mentalillnessamongthehomelessisonething,attributingcauseisanentirelydifferentmatteraltogether.

Thisdrawsattentiontotheissueoftemporalsequenceorwhatiscommonlyunderstoodasthedebateaboutcauseandconsequence.Whileresearchershaveobservedthatmentalillnesscanbeacauseofhomelessnessforsomepeople,itcanalsobeaconsequenceofhomelessnessforothers.Fewstudies,however,haveattemptedtounpackandquantifythetemporalrelationshipbetweenmentalillnessandhomelessness.

InthefollowingsectionIsummarisefindingsfromarecentpaperbyChrisChamberlainandI2.Inthatpaperwedrewonaonasampleof4,291homelesspeopletoinvestigatetheprevalenceofmentalillnessinthehomelesspopulationandwhethermentalillnessprecededorfollowedhomelessness.Weusedtheculturaldefinitiontodefinehomelessness(ChamberlainandMackenzie1992).ThisisabroaddefinitionandistheoneusedbytheAustralianBureauofStatisticstoenumeratethehomelesspopulationateachcensus.Withrespecttomentalillness,weappliedanoperationalratherthanaclinicaldefinitionthatincluded:

•thoseindividualswhoapproachedtheagencyseekingareferraltoamentalhealthservice

•thosewhowerecurrentlyinorhadbeeninapsychiatricfacility,and

•thosewhosecasenotesidentifiedmentalillnessasanissue.

Findings

Thefirsttaskwastoestablishtheoverallprevalenceofmentalillnessinoursampleof4,291.Weidentifiedthat1,337people,or31percentofthesample,hadmentalhealthproblems.Thisisasignificantsubgrouptobesure,butaminoritynevertheless.

Whenwedistinguishedbetweenmentalhealthissuesthatwerepresentpriortohomelessnessandthosethatemergedfollowinghomelessness,wefoundthat634peoplehadmentalhealthproblemspriortobecominghomelessforthefirsttime.

table 1:Mentalillnessidentifiedornotidentifiedbeforehomelessness

Number Per cent

Mental health problems identified 634 15

Not identified 3,657 85

TOTAL 4,291 100

Inthepublicdomain,mentalillnessisregularlyseenasthemaincauseofhomelessness,yetourdataindicatesthat,mentalillnessisthecauseofhomelessnessforonly15percentofthehomelesspopulation.Overstatingtheroleofmentalillnessin‘causing’homelessnessisworryingfortworeasons.First,whenattributionsofcauseareincorrectitcanleadtoinappropriatepolicyandprogramdesign.Ifthehomelesspopulationconsistsmostlyofthementallyill,itwillneeddifferentservicesthanifthemajorityofthehomelesspopulationconsistsofworkerswhohaverecentlylosttheirjobs.Second,focussingonmentalillnessasacausalfactorindividualisesanddepoliticisestheissue.Viewinghomelessnessasaproblemcausedbymentalillnessfocusesattentionontheindividualanddivertsitfromthestructuralfactorsthatcontributetohomelessness.

Thenexttaskwastodeterminehowmanypeoplewithmentalhealthproblemsdevelopedthemaftertheybecamehomeless.Table2showsthatjustoverhalf(53percent)ofthe1,337peoplewithmentalhealthproblemsdevelopedthemaftertheybecamehomeless.

table 2:Mentalillnessidentifiedbeforeorafterhomelessness

Number Per cent

Mental health problems before homelessness

634 47

Mental health problems after homelessness

703 53

TOTAL 1,337 100


byGuyJohnson

Thisishardlysurprisingwhenyouthinkaboutit.Whenpeoplearehomelesstheyconfrontastressful,chaoticandunpredictableenvironment.Theyencounteraworldfullofpovertyanduncertainty;aworldwhereviolence,abuse,socialrejectionanddegradationarecommon.Forsomepeoplethebrutalmaterialconditionsandthedevaluedsocialidentityattachedtohomelessness,combinedwithtraumaticbackgroundsandhighlevelsofsubstanceuse,contributetotheemergenceofmentalhealthissues.Withlittlesupportandfew,ifany,socialnetworks,homelesspeoplewithmentalhealthproblemsareacutelyvulnerabletoexploitationandviolenceandtheycommonlywithdrawtoavoidthepredatorypracticesofotherhomelesspeople.Chronicisolationisacommonanddevastatingoutcome.

Irrespectiveoftemporalorder,manystruggletoovercomethecomplexbarriersthatrestrictaccesstotheservicesystem,andasaresult,manyarehighlytransient,cyclinginandoutofhomelessshelters,hospitalsandboardinghousesoverlongperiodsoftime.Wefoundthat80percentofhomelesspeoplewithmentalhealthissueshadbeenhomelessforoneyearorlongerandthatmostpeople(81percent)withmentalhealthissueshadexperiencedtwoormoreepisodesofhomelessness.

ItiswidelyknownthatwhentheRuddGovernmentcametopoweritidentifiedhomelessnessasanationalpriorityand

subsequentlyallocatedsignificantfundingtoachieveitsheadlinegoalofreducinghomelessnessbyhalfby2020(FaHCSIA2008).OnepriorityoftheRuddGovernmentistobreakthecycleoflong-term,episodichomelessness.However,unlesstheprogramlogicthatunderpinsthecurrentconfigurationofhomelessserviceschanges,thiswillbeadifficulttask.

InAustralia,servicesforhomelesspeoplearegenerallyfocusedonprovidingshort-term(crisis)andmedium-term(transitional)accommodation,andaccesstothisaccommodationiscontingentuponclientsacceptingsupportdeliveredthroughacasemanagementprogram.Theassumptionunderpinningthisapproachisthatpeople’smentalhealthissuesmustbeaddressedbeforetheycanbeconsideredforpermanentaccommodation.However,itisdifficulttoaddressmentalhealthissueswhenpeopleareincrisisortransitionalaccommodationiftheycontinuetofeelinsecure.Furthermore,somehomelesspeoplewithmentalillnessdonotengagewithcasemanagersandtheyarecommonlyexcludedfromservices,whileotherscannotgetintoaccommodationbecausetheytrytoresistthestigmaofbeinglabelled‘mentallyill’,andassertthattheydonotneed‘treatment’or‘support’(NSWOmbudsman2004).

Fortunately,therehavebeensignsofashiftawayfroma‘treatmentfirst’approach.Thisshiftcanbetracedtoaseminal

...Itisdemeaning,unfairandinaccuratetothemajorityofthehomelesspopulationtofocustoomuchattentionontherelationshipbetweenmentalillnessandhomelessness.Todosodeflectsattentionawayfromthemorepervasivestructuralcausessuchasfamilybreakdown,insufficientincomeandalackofaffordable,appropriatelylocatedhousing.Forhomelesspeopledirectlyaffectedbythesestructuralfactors,thecauseandsolutiontotheirproblemslieoutsidethemedicalarena.



paperwrittenbytwopsychiatristsintheUSwhochallengedtheassumptionsunderpinninga‘treatmentfits’approach(CohenandThompson1992).Theyarguedthatyouwouldgetbettermedicaloutcomesifmedicalinterventionsweredeliveredinastable,safeplace.Theirargumentcorrespondedwithalong-heldbeliefamongsocialresearchersthatpeoplearehappierwhenthereisasenseoforder,continuityandpredictabilityintheirlives.Overthelast15years,researchersinterestedinthepsychosocialbenefitsofhousinghaveusedtheideaof‘ontologicalsecurity’todrawattentiontotheimportanceofahomeasaplaceofconstancyinthesocialandmaterialenvironment(DupuisandThorns1998),aplaceinwhichpeoplefeelfreefromsurveillanceandfreetobethemselves(Saunders1990).

Whatemergedfromastrongerfocusontheimportanceofstabilityandpredictabilitywasanapproachthatgaveprioritytopeople’shousingneeds,beforeaddressingtheirmentalhealthissues.Thisisknownasthe‘housingfirst’approachanditisincreasinglypopularintheUnitedStates(Tsemberis1999).Thehousingfirstapproachofferspeoplepermanentaccommodationandthenallowsthemtoengagewithasupportworkerattheirownpace.Inthisapproach,accesstohousingisnotconditionalonpeopleacceptingsupport.Thisisamoreeffectivewayofbuildinglong-termrelationshipswithclients,becausesupportrelationshipsareenteredintovoluntarilyanddonotentailcoercion(Gronda2009).

Thereisquantitativedatatoindicatethatitismoreeffectivetoprovidehousingtohomelesspeoplebeforetheyreceivetreatmentformentalhealthissues.Tsemberis(1999)comparedthehousingretentionratesoftwogroupsofchronicallyhomelesspeoplewithamentalillness:139peoplewentintosupportivehousingand2,864wentintoaresidentialtreatmentprogramthatusesaseriesofstepstograduallymovepeopletoindependentliving.Tsemberis(1999)foundthatthehousing-retentionratewas84percentforthoseinthesupportivehousingprogramoverathree-yearperiod,whereasthehousing-retentionratewasonly59percentforthosewhoreceivedtraditionalservicesoverashorter,two-yearperiod.Otherstudiesreportsimilarresults(Culhane,MetrauxandHadley2002;Rosenheck,Kasprow,FrismanandLiu-Mares2003;Tsemberis,GulcurandNakae2004;Padgett,GulcurandTsemberis2006;Padgett2007).

Thehousingfirst/supportivehousingapproachhasthreestrengths.First,itexplicitlyengageswiththesocialmodelofhealthandwellbeing.Thismodelisbasedontheargumentthathealthandwellbeingcouldnotbereducedtoquestionsaboutmedicalintervention,butwereafunctionofabroadrangeofsocial,economic,culturalandenvironmentalfactors.Puttinghousingfirmlyinthemixsignificantlyimprovesthepossibilityofreducinglong-termepisodichomelessnessaswellasimprovingthehealthandwellbeingofhomelesspeople.

Second,thehousingfirstapproachrecognisesthatsupportingpeoplewithamentalillnesstoretaintheirhousingcanbetimeconsuming.Currently,themedianlengthofstayforpeopleinsupportedaccommodationissevendays(AustralianInstituteofHealthandWelfare2008:ix).Thisisinsufficienttimeforserviceproviderstoaddressthecomplexneedsofpeoplewithmentalillnesses,andsupportthemindevelopingpositiverelationshipswithfriendsandneighbours,whichareoftenessentialiftheyaretoavoidbecominghomelessagain(Perese2007;Padgett2007).

Third,thehousingfirstapproachalsorecognisesthatitiscommonforpeoplewhohaveschizophreniaorbipolardisordertoneedlong-termsupportiftheyexperiencefurtherepisodesofill-health.‘Breakingthecycle’meansprovidinglong-termsupporttoformerlyhomelesspeoplewhohavementalhealthissues.Giventherightmaterialandemotionalsupport,eventhemostchronicallyhomelesspeoplecanmaintainsecureaccommodation.

Conclusion

Thereislittledoubtthatratesofmentalillnessamongthehomelesspopulationaremuchhigherthanamongpeopleinthegeneralcommunityanditisclearthatasignificantminorityofhomelessindividualshavementalhealthproblems.Forthosepeople,theimportanceofpermanent,safehousinglinkedtolong-termsupportcannotbeunderstated.However,itisdemeaning,unfairandinaccuratetothemajorityofthehomelesspopulationtofocustoomuchattentionontherelationshipbetweenmentalillnessandhomelessness.Todosodeflectsattentionawayfromthemorepervasivestructuralcausessuchasfamilybreakdown,insufficientincomeandalackofaffordable,appropriatelylocatedhousing.Forhomelesspeopledirectlyaffectedbythesestructuralfactors,thecauseandsolutiontotheirproblemslieoutsidethemedicalarena.


byGuyJohnson

References

1SeeDiagnosticandStatisticalManualIII-R

2Forafullpapersee:Are the Homeless Mentally Ill?ByGuyJohnsonandChrisChamberlainAustralianSocialPolicyConference,UniversityofNewSouthWales,8–10July,2009

AustralianInstituteofHealthandWelfare(2007),Homeless SAAP clients with mental health and substance use problems 2004–05: a report from the SAAP National Data Collection,Canberra,AIHWcat.noAUS89

BedfordStreetOutreachService(1997),Guide to Outreach,BedfordStreetOutreachService,Melbourne

Chamberlain,C.,Mackenzie,D.,(1992),UnderstandingContemporaryHomelessness:IssuesofDefinitionandMeaning,Australian Journal Of Social Issues,27(4),p274–297

Cohen,C.,Thompson,K.,(1992),HomelessMentallyIllorMentallyIllHomeless?American Journal of Psychiatry,149(6),p816–823

Culhane,D.,Metraux,S.,etal.,(2002),Theimpactofsupportivehousingforhomelesspeoplewithseverementalillnessontheutilisationofthepublichealth,corrections,andemergencysheltersystems:TheNewYork–NewYorkInitiative,Housing Policy Debate,13(1),p107–163

DepartmentofFamilies,Housing,CommunityServicesandIndigenousAffairs,(2008),The Road Home: A National Approach to Reducing Homelessness,FaHCSIA,Canberra

Flatau,P.,(2007),Mental Health Outcomes Among Clients of Homelessness Programs, Parity / newparadigm,September,p13–16

Herrman,H.,McGorry,P.,etal.,(1989),PrevalenceofSevereMentalDisordersinDisaffiliatedandHomelessPeopleinInnerMelbourne,The American Journal of Psychiatry,146(9)p1179–1184

Hodder,T.,Teesson,M.,etal.,(1998),Down and Out In Sydney: Prevalence of mental disorders, disability and health service use among homeless people in inner Sydney,SydneyCityMission,Sydney

Johnson,G.,Gronda,H.,etal.,(2008),On the Outside: Pathways in and out of homelessness,AustralianScholarlyPress,Melbourne

Leal,D.,Galanter,M.,etal.,(1998),CorrelatesofProtractedHomelessnessinaSampleofDuallyDiagnosedPsychiatricInpatients,Journal of Substance Abuse Treatment,16(2)p143–147

NSWOmbudsman,(2004),Assisting homeless people – the need to improve their access to accommodation and support services. Final report arising from an Inquiry into access to, and exiting from, the Supported Accommodation Assistance Program,NSWOmbudsman,Sydney

Padgett,D.,(2007),There’snoplacelike(a)home:OntologicalsecurityamongpersonswithaseriousmentalillnessintheUnitedStates,Social Science and Medicine,64,p1925–1936

Padgett,D.,Gulcur,L.,etal.,(2006),HousingFirstServicesforPeopleWhoareHomelessWithCo–OccurringSeriousMentalIllnessandSubstanceAbuse,Research on Social Work,16(1),p74–83

Phelan,J.,Link,B.,(1999),WhoAre‘theHomeless’?ReconsideringtheStabilityandCompositionoftheHomelessPopulation,American Journal of Public Health,89(9)

Reilly,J.,Herrman,H.,etal.,(1994),Psychiatricdisordersandserviceusebyhomelessyoungpeople,The Medical Journal of Australia,161(3)p429–432

Rosenheck,R.,Kasprow,W.,etal.,(2003),Cost-effectivenessofSupportedHousingforHomelessPersonswithMentalIllness,Arch Gen Psychiatry,60,p940–951

Snow,D.,Anderson,L.,(1993),Down on their luck: A study of street homeless people,UniversityofCaliforniaPress,Berkeley

Snow,D.,Baker,S.,etal.,(1986),TheMythofPervasiveMentalIllnessamongtheHomeless,Social Problems,33(5),p407–423

Teesson,M.,Hodder,T.,etal.,(2003),AlcoholandOtherDrugUseDisordersAmongHomelessPeopleInAustralia,Substance Use & Misuse,38(3–6),p463–474

Tsemberis,S.,Gulcur,L.,etal.,(2004),HousingFirst,ConsumerChoice,andHarmReductionforHomelessIndividualsWithaDualDiagnosis,American Journal of Public Health94(4),p651–656

vanDoorn,L.,(2005),Phasesinthedevelopmentofhomelessness–abasisforbettertargettedserviceinterventions,Homeless in Europe,Winter,p14–17

...Whenattributionsofcauseareincorrectitcanleadtoinappropriatepolicyandprogramdesign.Ifthehomelesspopulationconsistsmostlyofthementallyill,itwillneeddifferentservicesthanifthemajorityofhomelesspopulationconsistsofworkerswhohaverecentlylosttheirjobs.Second,focussingonmentalillnessasacausalfactorindividualisesanddepoliticisestheissue.Viewinghomelessnessasaproblemcausedbymentalillnessfocusesattentionontheindividualanddivertsitfromthestructuralfactorsthatcontributetohomelessness.

22newparadigm Summer2010


UnfinishedBusiness:VICSERVMentalHealthConference2010

Acrossallgroups,themessageisclear:serviceuserswanttobeinthedriver’sseatwhenitcomestowhatisprovidedandhowitisprovidedtothem.Theywanttobetreatedascompetent,articulateandpartofthesolution.Thisisnotparticularlyprofound,butwehavelostourwayinmanyareasofservicedeliveryandpolicy.Thementalhealthconsumermovementcontinuestoremindusthattheyaretheexperts,andmustbeunderstoodincontext.

Robyn Martin, PhDCandidate,RMITUniversity,andDirectorofFieldwork,Lecturer,CurtinUniversityofTechnology

Revolving or evolving doors? the unfinished business of delivering good practice services



If policy makers and service providers are to deliver services that facilitate journeys of recovery, good practice is needed. Good practice refers to ‘what works’ across a range of areas from policy initiatives, to service delivery, to evaluation of outcomes (Parmar and Sampson 2007). Terms like ‘good practice’ are used frequently in health and human services, just as terms like ‘client’ or ‘person centred’, ‘partnership’, ‘collaboration’, ‘critical reflection’, ‘person in context’ and ‘professional relationship’. Despite the regular application of these terms, it’s time to stop and critically examine how these terms and associated concepts improve and enhance recovery journeys.

ThisarticlerepresentsfindingsfromaPhDstudyonwhatfacilitatesthecreationofsustainablepathwaysoutofhomelessnessforadultwomen.Thirty-fivewomenparticipatedinthefeminist,criticalsocialworkinformedstudy.Thesewomenhaveengagedinvariouslevelsanddegreesthroughoutthelifeoftheproject,withanumberenactingco-researcherandcollaboratorroles.Interviewswiththewomenweresemi-structuredandfocussedontheirexperiencesinto,withinandoutofhomelessness.

Fifty-fourpercentofthewomenreportedseriousmentalhealthissueswhiletheremainderreportedhighlevelsofdisturbanceanddistressasaresultofthefactorsthatledtotheirexperienceofhomelessness.Inadditiontothe35womeninterviewed,25policymakers,serviceprovidersandpolicyinfluencerscontributedtheirviewsonwhatleadstowomen’shomelessness,whatconstitutesgoodpracticeandwhatcreatesunhelpfulpracticesinserviceprovisionandpolicymaking.Datafrominterviewshasinformedthediscussionsonwhatconstitutesgoodpracticeinserviceprovision.

Key principles that guided the research:

1 Womenwhohavelivedexperiencesofarangeofissuesaretheexpertsontheirsituationsandarecapableofarticulatingwhattheyneedtoachievetheiraspirations.

2 Recoveryispossible(Anthony,1993;ColemanandSmith,2003)andrelevanttoarangeofexperiencessuchasmentalhealth,substancemisuse,homelessnessanddomesticandfamilyviolence.

3 Theactivitiesofpractitioners,researchersandpolicymakersareinformedbytheirvalues,beliefsandexperiences.This,inturn,createscertainpositionsthatpeopleoccupyinrelationtoissues(TaylorandWhite,2000).

Good practice is person centred

‘She knew that I would never stuff up again. She believed in me. She knew that I would do right from now on and that this would never happen again’, (Tracy).1

HighlightedinaquotefromTracy(aserviceproviderparticipant),akeycomponentofbeingpersoncentredisconveyingasenseofhopeintheperson’sabilitytolearnandgrowfromtheirexperiences.Thismeansseeingthepersonasanactiveparticipantandagentinresolvingwhateversituationtheyexperience.Similarly,conveyingbeliefintheperson’scapacityandabilityisfundamentalandoftenservesasamajorturningpointinanindividual’sjourneyofrecovery:

‘They believed in me… that’s something I’ve seldom had in my life. They didn’t see this mad, stressed woman, they saw who I really was. They even knew that I was extremely capable – even before I recognised it. They knew that I would get through it’, (Elsie).

Good practice ‘de-centres’ practitioners

Aperson-centredapproachpositionspractitionersasfacilitatorsandenablerswhoprovideopportunitiesandpromotechoices.Toenactthisrolemeanstowalkalongsidetheperson,astheyareinthedriver’sseatofassessmentsandinterventions.Thissuggeststhatpractitionersarede-centred,continuallyandcriticallyreflectingontheirvalues,beliefs,aspirationsandexpectationsfortheperson.De-centredpractitionersartfullyassesswhentheyneedtobecloselyinvolvedwiththepersonorstepback,allowingthepersontotestoutnewideas,decisionsandbehaviours.

De-centredpracticerequirespractitioners,agenciesandpolicymakerstorelinquishtheideathattheycancontrolthepersonandtheoutcomesoftheinterventions(Bentall,2004).Thisdoesnotimplyadisinterested,dispassionatepractitionerordistancedpolicyresponses,ratheritrequiresinvolvementandinvestmentintheperson’srecoveryjourney,withouttheburdenofenmeshedboundariesbetweenworkerandclient,

(Beddoe&Maidment,2009).De-centredpractitionersareacutelyawareofthewayinwhichtheirpersonalandprofessionalbiographies,experiences,knowledge,skillsvaluesandbeliefsystemsinfluenceandinformtheirpractice.Thisconstitutescriticallyreflectivepractice(Allan,2009).

Good practice involves meaningful partnerships

Partnershipisatermusedfrequentlywhenreferringtotheworkthatoccursbetweenpractitionersandclients,aswellasbetweendifferentpartsofservicedeliverysystems(Adams,2005).Inthiscase,itreferstocollaboration,reciprocity,criticalreflectiononpower,commitmentandenactmentofnon-judgementalattitudes.ThequotesbelowreflecttheexperienceofLenorewhoidentifiedthatstaffsawherasaperson,notanumberor‘justanotherclient’.Inthequotefromtheserviceprovider,reflectionontheprivilegeofbeinginvitedintopeople’slivesisevident.

‘They treat me as a person’, (Lenore).

‘I often say to people “thank you so much for allowing me to walk beside you today… that was a great honour.” It’s very honouring to have been allowed in. And I think… that combats that overwhelming sense of gratefulness I think people experience’, (service provider).

Other person-centred principles for good practice

Otherperson-centredprinciplesinvolvepractitionerswhoaredeeplyunderstandingofwhatitmeansforpeopletoseekhelp,whilstacknowledgingthepotentialvulnerabilityandshameinvolvedwhenpeopleseekassistanceforissuestheyfind,themselves,unabletomanageontheirown.Developingandmaintainingcontextualisedunderstandingsofpeoplepromotesperson-centredpracticebyconsideringtheimpactoffactorssuchasage,gender,culture,sexuality,(dis)ability,socialconnectedness,lifeskills,historyandbiographies,education,employment,trainingandsocio-economicstatus(Allan,2009).

Professionalrelationshipsarecentraltoperson-centredpracticeandwhilstgoodpracticeexamplesmayappearrelativelyinformalorcasual,theyarealwaysevidentlyprofessional.Timely,respectfulandappropriatechallengesarecentraltoagoodpractice,professionalrelationship.



Revolving or Evolving Doors? The unfinished business of delivering good practice services byRobynMartin

Professionalrelationshipsarecentraltoperson-centredpracticeandwhilstgoodpracticeexamplesmayappearrelativelyinformalorcasual,theyarealwaysevidentlyprofessional.Timely,respectfulandappropriatechallengesarecentraltoagoodpractice,professionalrelationship.

‘It felt good for me to know… my boundaries… and this feeling that I never had before of… being able to be whoever I wanted to be. I could just express myself however I wanted’, (Gertie).

Where does this leave us?

Acrossallgroups,themessageisclear:serviceuserswanttobeinthedriver’sseatwhenitcomestowhatisprovidedandhowitisprovidedtothem.Theywanttobetreatedascompetent,articulateandpartofthesolution.Thisisnotparticularlyprofound,butwehavelostourwayinmanyareasofservicedeliveryandpolicy.Thementalhealthconsumermovementcontinuestoremindusthattheyaretheexperts,andmustbeunderstoodincontext,(OlsenandEpstein,2007).

Conclusion

Thisarticlehasfocussedonkeycomponentsofgoodpractice.Otherareasnotdiscussedhere,butcoveredinthestudy,includeafocusontheprocessesofgoodpracticesuchasengagement,assessment,workingwithpeopleandevaluatingtheoutcomesofthiswork.Goodpracticeinpolicymakinghasbeenexaminedandinvolvescriticalreflection,partnership(withbothserviceusersandserviceproviders),transparency,puttingserviceusersatthecentre,facilitatingratherthanobstructing,andadeepcommitmentto,andpassionfor,improvingthelivedexperienceofthepeoplewhoarethefocusofthepolicy.

References

1Someparticipantschosetousetheirownname,arguingtheywereproudoftheirlifeexperiencesandwantedotherstoknowthemfortheirstoriesofcourage,survivalandpersonalgrowth.

Adams,R.,(2005),Workingwithinandacrossboundaries:tensionsanddilemmas,inAdams,R.,Dominelli,L.,Payne,M.,(eds),Social work futures: crossing boundaries, transforming practice,PalgraveMacmillan,Hampshire,p99–114

AllanJ.,(2009),Introduction,inAllan,J.,Briskman,L.,Peace,B.,Critical social work: theories and practices for a socially just world,(2nded),Allen&Unwin,CrowsNest

Anthony,W.,(1993),Recoveryfrommentalillness:theguidingvisionofthementalhealthservicesysteminthe1990s,Psychosocial Rehabilitation Journal,16(4),p11–23

Beddoe,L.,Maidment,J.,(2009),Mapping Knowledge for Social Work Practice: Critical Intersections,CengageLearningAustralia,Melbourne

Bentall,R.,(2009),RolloverKraepelin,Mental Health Still Matters,p16–23

Coleman,R.,Smith,M.,(2000),Working to Recovery: Victim to Victor II,2nded.,P&PPress,Kilbride

Olsen,A.,Epstein,M.,(2007),Theconsumerofmentalhealthservices,inMeadows,G.,Singh,B.,Grigg,M.,(eds),Mental health in Australia: Collaborative Community Practice,2nded.,Oxford,Melbourne,p193–195

Parmar,A.,Sampson,A.,(2007),EvaluatingDomesticViolenceOutcomes,British Journal of Criminology,47,p671–91

Taylor,C.,White,S.,(2000),Practising reflexivity in health and welfare: making knowledge,OpenUniversityPress,Buckingham



In 2009, the Victorian Mental Health Carers Network undertook a project to explore the service delivery experienced by family carers providing care to relatives who had either attempted or completed acts of suicide. Two focus groups were formed, one metropolitan (consisting of six carers) and one rural (having nine carers). The relatives who had completed an act of suicide ranged between 15 and 27 years of age, but first attempts at suicide tended to occur earlier in life when relatives were aged between 11 and 24 years. This article explores

the quality of care received by consumers and family carers in regards to suicide, and identifies recommendations for improved mental health service delivery.

Risk factors leading to suicide

Life eventsFamilycarersreportedthattheirrelatives’suicidalitywasaffectedbynumerousriskfactors,includingpsychosocialfactors(suchaschildhoodabuse,academicfailure,familybreakdown,lossorchangeinemployment,bullying,physical

Unresponsivementalhealthserviceswereviewedbyfamilycarersasamajorriskfactorcontributingtotheeventualsuicideoftheirlovedones.Familycarersreportedthatdespitevoicingtheirsafetyconcerns,relativeswerenotadmittedtohospitals,treatmentinterventionsweretoobrieftobeeffective,dischargewasprematureandpost-dischargesupportwasnotprovided.

dr Margaret leggatt, Consultantand Marina Cavill, ProjectManager,VictorianMentalHealthCarersNetwork

Carers’ experiences of the mental health system in relation to suicide

disability)andtofactorsdirectlyrelatedtotheirmentalillness(suchasstigma,ineffectivesymptommanagement,refusaltotakemedication,co-morbidsubstanceabuseanduntreatedexacerbationsofpsychiatricsymptoms).

Unresponsive mental health servicesUnresponsivementalhealthserviceswereviewedbyfamilycarersasamajorriskfactorcontributingtotheeventualsuicideoftheirlovedones.Familycarersreportedthatdespitevoicingtheirsafetyconcerns,relativeswerenotadmittedtohospitals,treatmentinterventionsweretoobrieftobeeffective,dischargewasprematureandpost-dischargesupportwasnotprovided.Further,familycarersfromtheruralfocusgroupreportedalackofrurally-basedspecialistmentalhealthservices,underminingthequalityofcareavailabletoat-riskconsumersintheseareas.

Familycarersspokeofnotknowingwheretoturnforassistancefortheirsuicidalfamilymember,andoftheneedtoapproacharangeofagenciesbeforehelpwasreceived.CarersmostlyfoundtheCAT(CrisisAssessmentandTreatment)teamstobeunresponsiveto,ordismissiveof““theirneedsinacrisissituation,ascapturedinoneparticipant’ssatiricalcharacterisation:‘CAT–Can’tAttendTodayteam,“CallAgainTomorrowteam’.Similarly,familycarersdidnotgenerallyconsiderthepolicetobeaninformedorsafeoptionattimesofcrisis,questioningtheirabilitytomaintainconsumersafetywhenconfrontedwiththreateningbehavioursorpsychosis(i.e.policeshootingofmentallyillpersons).

Quality of care received Carersreportedahighdegreeofvariationinthequalityofcaredelivered,dependingontheimmediateprecursortoseekingassistanceandthevenueinwhichcaretookplace.

Emergency DepartmentsInthecaseofpsychiatricsymptomsandsuicidality,carersindicatedthatEmergencyDepartments(EDs)placedgreateremphasisondiagnosisthanontheprovisionoftreatment.FamilycarersreportedthatEDstaffdidnotseektheirinputregardingtheirrelatives’suicidalintentorharmfulbehavioursand,ifofferedbycarers,suchinputoftenwentunheeded.MultiplefamilycarersindicatedthatthislackoflisteningandconsultationbyEDsactedasacontributingfactortoaconsumer’ssubsequentsuicide,withpoorconsultationresultingintheincomplete/inaccurateassessmentofaconsumer’ssuiciderisk,needforinpatientadmissionandforfurthermonitoring.

Familycarersassociatedlarger,better-resourcedEDswithenhancedqualityofcare.Inparticular,theyconsideredthecareprovidedbyexperiencedpsychiatricregistrarsin

metropolitanhospitalsofhigherqualitythanthatprovidedbygeneralistdoctorsinruralhospitalEDs,whowereperceivedaslackingsuitableexpertise,resourcepoorandlessabletodeveloprapportwithpatients.Further,somefamilycarersindicatedthatsmallruralEDshadrefusedthemservice,tellingfamilies:

•We do not treat young girls who self harm

•The family is draining the service’s resources

•We don’t do walk-ins; call an ambulance’.

Psychiatric inpatient unitsCarersreportedfeelingexcludedfromallaspectsoftheirrelatives’treatmentwithinpsychiatricinpatientunits(althoughChildandAdolescentMentalHealthServices(CAMHS)tendedtobetheexceptiontothis).Familycarersfeltthatstaffdidnotconsiderittheirroletoengagewiththecarersorofferthememotionalsupport,withruralfamilycarersalsocitingalackofknowledgeandunderstandingofmentalillnessamonginpatientunitstaff,andaresistancetowardsimprovingtheirknowledge.Familycarersalsodemonstratedaconcernaroundadmittingconsumerswithdifferentpsychiatricillnesses(forexampledepressionandpsychosis)tothesamewardregardingwellbeingandsafety.

Furthertothis,familycarersindicatedthatinpatientunitsplacedgreateremphasisondischargeplanningthanontheimplementationofpsychologicaland/orpharmacologicaltreatmentplans.Somefamilycarersequatedthiswithalackofconsumer-focussedcareandanunder-resourcedservicesystem:

‘… With all these suicide attempts he ended up in the hospital. They were very short of beds so were doing their best to get rid of him all the time.’

Poordischargeplanningwasanotherkeyissueidentified,withfamilycarersindicatingthatconsumerswereregularlydischargedhomeeitheraloneorwithoutcarersbeinginformed.Further,forruralfamilycarers,thelackoftransitionalsupportavailableforconsumersfollowingacuteadmissions(i.e.step-downunits)wasaseriousissue.

Lack of communication between servicesAconsistentlackofcommunicationbetweenCATteams,community-basedmentalhealthservices,EDstaff,inpatientpsychiatricservices,andGeneralPractitioners(GPs)regardingthepresentation,riskassessment,treatmentanddischargeplanningofconsumerspresentingwithsuicidality,wasanotherkeyconcernraisedbyfamilycarers.Theyindicatedthatthislackofcommunicationresultedinadiscontinuityofcare,alackofongoingriskassessmentandpoorfollow-uppostdischarge.



Lack of dignity and respect, information and support for carersFamilycarersindicatedthatthecareprovidedbymentalhealthprofessionalswasoftendisrespectfulandunsupportive.Asonefamilycarernoted:

‘As a carer, I’m treated with disdain, I feel frustrated, and I still feel patronised… as if I’m some kind of blight on… that’s how I feel as a result of the body language and the kinds of things that are said.’

Furthertothis,familycarersdiscussedfeelingstigmatisedbystaffandblamedfortheirfamilymembers’repeatedsuicideattemptsorself-harmingbehaviours:

‘You’ve got small hospitals who don’t understand people with mental illness, don’t understand families and don’t want to. Families are being stigmatised for bringing them there.’

‘Mothers and fathers are blamed for lacking parenting skills if their child has a mental illness. Professionals imply: “What have the parents done?” It is shifting, but it’s still around.’

Carersalsospokeoffeelingabandonedorneglectedfollowingtheirfamilymembers’suicideoractofself-harm.Theyspokeofnotbeingofferedimmediateorongoingemotionalsupport,despitehavingexperiencedatraumaticanddistressingevent.Astwocarersnoted:

‘There’s nothing for parents, you’re so in shock, there’s nobody for you to talk to.’

‘I was left to rot in my own juices.’

Notably,carersindicatedthatservicesdidnotprovidethemwithinformationaboutsuicidality,ordiscusswiththemwhattolookoutforpost-discharge,whotocontactifconcerned,howtocareforalovedonefollowinganattemptedsuicideorhowtoactintheeventofafuturesuicideattempt.

Carer supportFamilycarersindicatedthattherewerenoassessmentsmadebyacutecareormentalhealthservicestaffregardingtheirownpsychosocialoremotionalsupportneeds.Onecarerreported:

‘I was left to cope on my own, to the point where I had a nervous breakdown’.

Familycarersalsospokeofalackofsupportofferedtobereavedfamilies:

‘I had not heard a word from these people, my son is now dead… absolutely nothing was offered afterwards… I just thought they would call us and talk to us but there was nothing… It would have been helpful to at least have it acknowledged that my son had existed.’

Onefatherevenspokeofhisconcernthathisfamily’sbereavementneedscamesecondtothedesireofstafftoprotectthemselvesagainstpotentiallitigation:

‘A couple of nurses were terrific but they closed up shop when she died… this wall of silence’.

Familycarersalsoindicatedthatfewreferralsweremadetomeetconsumers’andcarers’socialandemotionalneeds(i.e.griefcounselling).Thosefamilycarerswhodidreceivefollow-upsupport,didsoviaattendanceatacommunity-basedcarersupportgroup,orviatheregionalcarerconsultant.Onlytwocarersspokeofreceivingsupportdirectlyfromamentalhealthserviceclinician,withonefamilycarerreceivinggood,fortnightlysupportfromOrygenYouthHealth,andanotherfamilycarerhavingregularcontactwithhiswife’spsychologistafter‘makinglotsofnoise’.

Allofthefamilycarersinthefocusgroupsfeltthatiftheyhadbeenlistenedtoandsupported(withinformationandcopingstrategies),andiftheirfamilymemberhadreceivedmorecomprehensivecare,outcomesfortheirlovedonemayhavebeendifferent.Whilstsuchimprovedoutcomescannotbeguaranteed,itisnonethelessvitalthatmentalhealthprofessionalstakenoteofthekeymessagesconveyedthroughthesecarers’experiences:

Family carers must be treated with respect. they must not be ignored, blamed or isolated in their grief.

Familycarersusedtheirexperiencestoidentifyarangeofservicechangesthatcouldenhancethecareprovidedtoconsumersatriskofsuicideandtheirfamilies:

Provide improved training of medical staff in EDs and mental health services in suicide risk assessment.Cliniciansrequireclearassessmentandmanagementguidelinesforusewithconsumerswhoareatriskof,orwhohave

Carers’ experiences of the mental health system in relation to suicide

byDrMargaretLeggattandMarinaCavill

‘Ihadnotheardawordfromthesepeople,mysonisnowdead…absolutelynothingwasofferedafterwards…Ijustthoughttheywouldcallusandtalktousbuttherewasnothing…Itwouldhavebeenhelpfultoatleasthaveitacknowledgedthatmysonhadexisted.’

attempted,suicide.Adherenceshouldbeclearlydocumentedwithinthepatient’smedicalfile.Incasesofsuicide,anauditoftheservice’sadherencetotheseguidelineswouldassisttomaintainqualityofcareandtopromoteclinicalaccountability.

Corroborative sources, such as carers, should be accessed (where possible) in the initial and ongoing assessment of suicide risk.EDsandotherservicesshouldcommunicatewithcarerstoobtaininformationregardingtheconsumer’ssuicidalintent,currentlifestressors,behaviouralchanges,andavailablesocialsupports.

Educate all health professionals regarding provisions in legislation for informing carers in cases of suicidal intent,sothatcarersareawareoftheirlovedone’ssuicidality.

When conducting a suicide risk assessment, medical staff need to be mindful of particular diagnoses associated with increased risk of suicidesuchasdepression,schizophrenia,substanceabuse,andborderlinepersonalitydisorder.Inaddition,acomprehensiveriskassessmentoughttoincorporateanevaluationofshortandlong-termriskfactorsthatmayfurtherexacerbatesuiciderisk(i.e.psychosocialstressors,interpersonalproblemsorconflicts).

Improved communication and consultation is needed with family carers regarding treatment and management planning, discharge planning, and follow-up/monitoring arrangements of consumers following a suicide attempt, or in the case of increased psychiatric symptoms.Informationaboutsuicide(verbalandwritten),crisisresources

andcopingstrategiesneedtoberoutinelyprovidedtocarersofconsumerspresentingtoEDs,psychiatricinpatientunitsormentalhealthservicesfollowingasuicideattempt.

Resources are needed to develop more step-down units for consumers transitioningfrompsychiatricinpatientunitsbackintothelocalcommunity,ensuringthattheyarenotdischargedintoavacuum,thereforelesseningtheriskoffutureharm,ordeath.

Family carers require support inEDs,psychiatricinpatientunitsandmentalhealthserviceswhenpresentingwithalovedonefollowingasuicideattemptoractofsuicide.Theyrequireappropriatepsychologicalsupport,referraltoexistingsupportsandskill-basedsupport/copingprograms.

Theexperiencesoffamilycarerssharedinthisprojectprovideaninvaluableopportunitytoexplorehowmentalhealthservicescanbettersupportconsumersandcarersinresponsetoattempted,orcompletedactsofsuicide.Thisexplorationofcarerexperiences,togetherwiththeidentificationofservicerecommendations,mayenablechangesinthisdifficultandcomplexarea.

From paradigm to practice: incorporating recovery-oriented principles through organisational and practice changeBelinda Cash,FieldPlacementCoordinator,SchoolofSocialWorkandSocialPolicy,LaTrobeUniversity

Thereisaneedtoreviewcurrentpolicesandpracticesaroundinteragencywork,withtheviewtodevelopingclearerguidelinesconducivetomorerecovery-orientedpractices.Thiswouldimprovechannelsofcommunication,establishcaseconferencingandcoordinationguidelines,andclarifytherolesandresponsibilitiesofeachorganisationtoreducerepetitionofservicesandpromoteeaseofaccessforconsumersandfamilies.

In order to improve the quality and consumer focus of mental health services, it is critical that recovery-oriented principles are incorporated into the practice of clinical mental health staff. This research stemmed from observations of the incongruence between literature and policies espousing recovery and social inclusion, and the attitudes and practices carried out by clinical staff at the ground level.

Whiletherehasbeensomeprogresstowardrecoveryinareassuchaspolicychangeandimprovedconsumerparticipation,therecontinuestobesignificantissuesandchallengestotheintegrationofrecovery-orientedpracticeswithintheclinicalmentalhealthsetting.

Oneoftheprimaryissuesassociatedwiththetransitiontorecovery-orientedcareinAustraliaisapoorunderstandingofrecovery,andsubsequently,thetranslationoftheseprinciplesintopractice.

Whiletheconceptofrecoveryislargelybasedoncurrentdirectionsformentalhealthcare,itrequiressignificantperceptualchangestowhatwealreadydowithinthementalhealthsystemandhowwedothings(Curtis,2001).Literaturehighlightsconcernsthatthewholenotionofrecoverycouldbecomelostordilutedifpracticesthatexistaresimplyrenamed‘recovery’,orifrecovery-orientedservicesareaddedontowhatisalreadyoffered,particularlyifunderlyingphilosophiesandpracticesremainunchanged(Nehls,2000).



Mentalhealthcarehashistoricallyoperatedfromaprimarilymedicalframework,which,bynature,isoftennotcongruentwiththeconceptofrecovery.Manytraditionalmodelsoftreatmentoperatefromtheassumptionthatthereissomethingwrongwithaconsumerthatneedstobefixed(SirisandBermanzohn,2003);aperceptionthatcanleadtoconsumersbeinglabelledasadiagnosis,forexample,‘aschizophrenic’,ratherthan‘anindividualwithschizophrenia’(Houghton,2007).

Thecultureofanorganisationcanalsoprovideabarriertotheintegrationofrecovery-orientedprinciples.Therecoveryparadigmrequiresstaffattitudestofocusonhopeandstrengths,yetthereisatendencyforclinicians,employedwithinthemedicalmodel,tofocusondeficitsratherthanonindividualstrengths(Torrey,GreenandDrake,2005).Thislackscongruencewiththeprinciplesofrecovery-orientedserviceprovision,reinforcingtheideathatthemedicalmodeltreatsthesymptomsoftheillness,nottheindividual(Houghton,2007).Negativeattitudestowardparticularclientgroups,suchasthoseexperiencingschizophreniaorborderlinepersonalitydisorder,presentstheadditionalchallengeofovercomingassumptionsthatthereisalackofhopeforrecoveryforindividualsintheseclientgroups(Nehls,2000).

Otherorganisationalissues,suchasalackofappropriatesupervisionandinadequateresourcescanalsoposebarrierstoimplementingrecovery-orientedpractice.Whenorganisationsoperatewithlowstaffnumbers,thereisatendencytoprovideprimarilycrisis-focusedinterventions,whichcanlosesightoflonger-termgoalsinfavouroffunctionaloutcomes(Torrey,GreenandDrake,2005).Theincreasingemphasisonevidenced-basedtreatmentswithinmentalhealthalsoraisesthechallengeofoutcomemeasurement,withrecoverybeingalesstangibleoutcomethantraditionalpsychotherapyandsymptomfocusedtreatments(Nehls,2000).Thisposesthechallengeofhow‘recovery’or‘recovering’canbemeasured,givenitdoesnotneatlyfitthescientificnatureofmedicine(Nehls,2000).

Methodology

Principlesofrecoveryarepresentinthepolicyandplanningthatguidementalhealthservices,suggestingmentalhealthcliniciansworkcollaborativelywithconsumerswithinabroadrecoveryframework.Thereis,however,limitedresearchinto

whetherornottheactualpracticesofmentalhealthworkersreflecttheseideas(EllisandKing,2003).Difficultieswithacceptingandimplementingchangestopracticecouldbeassistedbycollaboratingwithstaffabouttheimplementationofrecovery-orientedpractices.

Thisstudyaimedtospecificallyaddressissuesinthetranslationofrecovery-orientedprinciplesintopractice,byidentifyingandanalysingbarrierstopracticechangeasperceivedbymentalhealthclinicians.TheresearchwasconductedinacommunitymentalhealthserviceinaregionalVictoriancentrewithacatchmentareaofaround40,000people.Allservicestafffromacute,continuingcareandrehabilitationteamswereinvitedtoparticipateintheresearch,butonlycasemanagementstaffelectedtodoso.Thisresultedintwofocusgroupsbeingconducted,withtwelvestaffparticipating.Eachfocusgroupcommencedwiththefacilitatorprovidingadefinitionofrecoveryandanoverviewofkeyrecovery-orientedprinciples.

Acasestudydemonstratingalivedexampleofrecoverywasthenpresentedtoassistparticipantsincontextualisingtheconceptsofrecoveryinapracticalexample.Eachfocusgroupwasthenencouragedtodiscusswhattheyperceivedtobetheopportunitiesandbarrierstotheintegrationofrecovery-orientedprinciplesintotheirpractice.Alldatafromeachfocusgroupwasrecorded,transcribedandanalysed.

• the mental health serviceAconsiderablenumberofthemeslinkedbacktothementalhealthservice,withparticipantsviewingtheorganisationanditscultureashavingconsiderableimpactonpotentialchangestowardarecoveryorientation.

Service coordination, profile and partnerships Participantsidentifiedthatservicesinthelocalareawereseentoworklargelyinisolationwithpoorcommunicationandcoordinationbetweenagencies,leadingtoablurringofrolesandrepetitionofservices.Thisisunhelpfultobothclientgroupsandtothebroadergoalofimplementingrecovery-orientedservices.Asidefromtheobviousbenefitsofimprovedreferralpathwaysandclearerlinesofcommunication,workingwithotheragenciessignificantlyimprovespsychosocialoutcomessuchasemployment,housingandeducation,tosupportbettersocialinclusionforconsumers(Lloyd,TseandDeane,2006).



From paradigm to practice: incorporating recovery-oriented principles through organisational and practice change

byBelindaCash

Staff attitudesStaffattitudeswereseentohaveasignificantimpactontheportrayalofrecoverytoclients,withparticipantsidentifyingtheneedforunderlyingattitudestobecomemoreconsumerfocused.Whileitwasacknowledgedthatsomecliniciansdemonstratedthisinpractice,itwasnotsupportedbythemajorityofstafforintheunderlyingcultureoftheorganisation.Concernswerealsoidentifiedthattheorganisationalculturecansupportprofessionalbiasestowardparticularclientsandclientgroups,whichposesasignificantbarriertorecovery.Negativeattitudestowardparticularclientgroupscancreateassumptionsthatthereisalackofhopeforrecoveryindividualsintheseclientgroups(Nehls,2000).

• Understanding recovery Thedatareflectedconcernsthatattitudestowardrecoverycanplayakeyroleinservicedelivery,withalackofunderstandingabouttheterm,presentingasignificantchallengetotheintegrationofrecovery-orientedprinciplesintopractice.Whilesomeparticipantsdemonstratedagoodunderstandingoftheconceptofrecovery,itwasevidentthatasignificantnumberstilldidnotfullygrasptheconceptorhowitwouldlookinpractice.

Previousresearchhassuggestedthattrainingonrecoveryprinciplesincreasesthehopefulnessofprofessionalsandleadstoanincreaseinrecovery-orientedattitudes(Lloyd,TseandDeane,2006).Thisiscrucialinincreasingstaffunderstanding,acceptance,andultimatelytheintegrationofrecovery-orientedprinciplesintopractice.Opportunitiesforstaffdevelopmentwouldalsoenableclarificationforthosewhoclaimthatrecovery-orientedpracticeisalreadyoccurring,asitcanremindstaffoftheincongruencebetweenwhatissaidandwhatisactuallyoccurringinpractice(Nehls,2000).

• the medical modelParticipantsreflectedonthedifficultyofintegratingtheprinciplesofrecoverywhileworkinginaframework,whichfavourssymptom-focusedtreatmentandoutcomemeasures.Arecovery-orientedparadigmrequirespractitionerstolookbeyondthemedicalmodel(Lloyd,TseandDeane,2006),whererecoveryisanintegralpartofpracticeandcomplementsthemedicalmodel.

Theprimarypurposeofacommunity-basedmentalhealthservicenecessitatesaclinicalorientation;thechallengeisinintegratingprinciplesofrecoverywithinthisenvironment.Inadditiontotherequiredperceptualshift,thereisaneedtoconsidercurrentassessmenttools,treatmentplansandoutcomemeasuresutilisedbymentalhealthservices.Theinformationgeneratedbythesetoolsisunquestionablyusefulingatheringinformationtodeterminegoalsand

interventions.Theissueliesintheimplementationofthesetools,toensureconsumersarenotsimplyseenasasourceofinformationforacliniciantothendeterminegoalsanddirecttreatments.Itneedstobeaprocessledbyconsumersforthemselves.

• the language of recoveryParticipantsnotedseveralchangesinthelanguageofmentalhealthservices,withregardtotheterms‘remission’,‘rehabilitation’and‘recovery’.Alsoofinterestwastheobservationbyoneparticipantthatnon-governmentorganisationsseemtobeembracingthelanguageandpracticesofrecoverymorerapidlythanclinicalmentalhealthservices.

• Health promotion

Participantsidentifiedtheneedforimprovedhealthpromotionbytheservice.Thiswasseenasanopportunitytoworktowardamorerecovery-orientedsystemthroughaddressingtheattitudesofthewidercommunityregardingmentalhealthservicesandmentalillness.Mentalhealthpromotionactivitiescouldbeusedtoachieveanumberofoutcomes,suchasimprovedcommunityawarenessandeducationtoreducestigmaandsocialisolationforpeopleexperiencingamentalhealthdisorder.Theycouldalsobeusefulinincreasingtheunderstandingofgoodmentalhealthcareandsupportsavailablewithinthecommunity,andimprovingliaisonswiththemediatoproducemorepositivestoriesaboutmentalhealthandrecovery.

Thisresearchinvestigatedtheopportunitiesandbarrierstotranslatingrecovery-orientedprinciplesintopractice.Aconsiderablenumberofthemeslinkedbacktothenatureofthementalhealthservice.Participantsfelttheorganisationalculturehadasignificantimpactonthepotentialforintroducingchangetowardarecovery-orientedpractice.Ofparticularnotewasconcernaboutnegativestaffattitudesandalackofpartnershipswithotheragencies.Theneedforstaffattitudestobebasedonhopeandstrengthsisacrucialbasisfromwhichrecovery-orientedpracticecanoccur.

Thefindingsidentifiedthat,whilesomeparticipantsdemonstrateagoodunderstandingofrecoveryprinciplesandreflectthisintheirpractice,therecontinuestobeconsiderableconfusionabouttherecoveryparadigmandhowthiscanbeimplemented.

Generally,clinicianswhoreporteddemonstratingarecoveryorientationintheirpractice:

• Heldapositiveattitudeaboutrecoveryandtheirapproachtopractice

• Practicedinaconsumer-focused/strengths-orientedmanner



From paradigm to practice: incorporating recovery-oriented principles through organisational and practice change

byBelindaCash

• Maintainedhopeandoptimismaboutthepossibilityofrecovery

• Didnotsupportorcondoneprofessionalbiastowardspecificclientgroups

• Hadnotpracticedwithininstitutionalsettings,sotendedtobeeithernewlytrainednursingoralliedhealthstaff.

Essentially,therewasastrongfocusonblamingtheserviceorbroadersystemforthereasonsfornotbeingabletoactinamorerecovery-orientedmanner,thoughitcouldbestronglyarguedthatthereisnotaneedforadditionalresourcesormajorstructuralchangesforrecovery-orientedpracticetooccurrightnow.Evenwithoutadditionalresourcesorfundstosupporttheshifttorecovery-orientedcare,thechangecouldoccurimmediatelythroughchangesintheperception,attitudesandpracticesofclinicalstaff.

• Implications for practice Recoveryneedstobeanintegralpartofservicedelivery,anditisanticipatedthateducationdesignedtoincreaseafocusonconsumer-ledandstrengths-basedpracticewouldassisttheunderstandingandintegrationofrecovery.Trainingcouldalsobeusedtoclarifymisconceptions,improvepersonalandprofessionalvaluesaboutthecapacityforrecovery,addressnegativestaffattitudesandbiasestowardparticularclientgroups,discouragenegativelanguageandsupportclinicalpracticestobecomemorestrengthsandconsumerfocused.

• Thereisaneedtoreviewcurrentpolicesandpracticesaroundinteragencywork,withtheviewtodevelopingclearerguidelinesconducivetomorerecovery-orientedpractices.Thiswouldimprovechannelsofcommunication,establishcaseconferencingandcoordinationguidelines,andclarifytherolesandresponsibilitiesofeachorganisationtoreducerepetitionofservicesandpromoteeaseofaccessforconsumersandfamilies.

• Thereisalsoaneedtoreviewthecurrentimplementationofassessments,individualserviceplanningandoutcomemeasures,toincreasetheirconsumerfocus.

• Considertheappointmentofclinicalstaff,includingpsychiatristsandmedicalstaff,whopracticefromastrengths-basedframeworktoassistintheintegrationofrecoveryintoservicedelivery.

References

Curtis,L.C.,(2001)Avisionofrecovery:AframeworkforPsychiatricRehabilitationServices,DiscussionpaperforNorthernSydneyAreaMentalHealthService,Sydney

Ellis,G.,King,R.,(2003)Recoveryfocusedinterventions:Perceptionsofmentalhealthconsumersandtheircasemanagers,Australian e-Journal for the Advancement of Mental Health,2(2),accessedat:www.auseinet.com/journal/vol2iss2/ellis/pdf

Houghton,S.,(2007)ExploringHope:Itsmeaningforadultslivingwithdepressionandforsocialworkpractice,Australian e-Journal for the Advancement of Mental Health,6(3),accessedat:www.auseinet.com/journal/vol6iss3/houghton/pdf

Lloyd,C.,Tse,S.,Deane,F.P.,(2006)Communityparticipationandsocialinclusion:Howpractitionerscanmakeadifference,Australian e-Journal for the Advancement of Mental Health,5(3),accessedat:www.auseinet.com/journal/vol5iss3/lloyd/pdf

Nehls,N.,(2000)Recovering:AProcessofEmpowerment,Advances in Nursing Science,22(4),p62–70

Siris,S.G.,Bermanzohn,P.C.,(2003)TwoModelsofPsychiatricRehabilitation:ANeedforClarityandIntegration,Journal of Psychiatric Practice,9(2),p171–175

Torrey,W.C.,Green,R.L.,Drake,R.E.,(2005)PsychiatristsandPsychiatricRehabilitation,Journal of Psychiatric Practice,11(3),p155–160

Theprimarypurposeofacommunity-basedmentalhealthservicenecessitatesaclinicalorientation;thechallengeisinintegratingprinciplesofrecoverywithinthisenvironment.Inadditiontotherequiredperceptualshift,thereisaneedtoconsidercurrentassessmenttools,treatmentplansandoutcomemeasuresutilisedbymentalhealthservices.

Addressing health inequalities for people with severe and enduring mental illness in a community health serviceGerard Reed,GeneralManager,MentalHealthandHealthPromotion,DouttaGallaCommunityHealthService

Addressingthephysicalhealthneedsofpeoplewithsevereandenduringmentalillnessinoursmallcorneroftheworldhasrequired,andcontinuestorequire,long-termorganisationalcommitmentateverylevel,includingsignificantfinancialinvestmentandadeterminationtodevelopanorganisationalcultureinwhicheverypersonsharesavision.Itrequiresenormousrelentlessness–andthat’sjustinourlittleplace.

Recently I have had a spate of visits to the dentist after years of neglecting my dental health. The catalyst for my re-emergence was an excruciating toothache that worsened just prior to Christmas last year. Three days before Christmas, I had a wisdom tooth removed and a tooth next to it that had grown sideways into it. Following this, I have had numerous visits to deal with the fall-out – so to speak. Only a few weeks ago, I was lying on the dental chair with a ridiculous pair of goggles on. Hovering above me were two imposing figures wearing masks and a bright light that shone into my face. The dentist was giving me my options for service. I must say I felt utterly powerless to be able to seriously negotiate. At the end of a 45-minute scraping and filing of my teeth, the same dentist said to me, still lying prostrate on his chair, ‘Now make sure you keep them clean’! I regressed into the little Grade-Two boy who was sent back to Prep because I could not behave like a good Grade-Two boy!

Iamnotproudofmyhealth-serviceavoidingbehaviour,yetitisconsideredtypicalofamaleinhis40stodoso.Butitstrikesmethatourwayofdeliveringhealthcareisprofoundlydehumanising.Forpeoplewithsevereandenduringmentalillness,itseemstomethedisincentivestoseekinghealthcarearetenfold.Alreadydepersonalisedbyamentalhealthsystemthatreliesprincipallyoncoerciontodeliverservices,it’snowonderthathealthcareseekingamongstthisgroupislow.

Physical health outcomes for people with mental illness

Theresultisnothinglessthantragic.Althoughtheliteraturediffersinactualyearsoflifelost,itisconsistentinfindingthatpeoplewithsevereandenduringmentalillnesshavealifeexpectancyoflessthanaround20yearsthanthatofthegeneralpopulation1.Moredamningisthatthesedeathsare,forthemostpart,duetoavoidableand/ortreatablecauses.





Cardiovasculardiseaseisthegreatestkiller2,andwhilstdeathsfromcardiovasculardiseaseshavefalleninthegeneralpopulationinAustraliainthepasttenyears,ithasincreasedforpeoplewithsevereandenduringmentalillness–principallythroughChronicObstructivePulmonaryDisease.

Metabolicsyndrome,whichincludesobesity,hypertensionandhyperglycaemia,increasestheriskofcardiovasculardiseaseandishighlyassociatedwithschizophrenia,bipolardisorderandunipolardepression3.Obesityisamajorriskfactorfordiabetesandheartdisease,isbothpreventableandtreatableanditsprevalenceisalarminglyhighinpeoplewithsevereandenduringmentalillness.

Strangely,whilstincidenceratesofcancerseemnottodifferamongpeoplewithmentalillnessandthegeneralpopulation,peoplewithmentalillnessare30percentmorelikelytodiefromacancerdiagnosis4.

Forthirtyyears,theevidencehasbeenaccumulating.Studieshaveshownconsistentlypoorphysicalhealthoutcomesforourgroup.Yetitisnoteasytoseeifanythinghasbeendoneaboutit.

Why is it so?

InarecentOpinionPieceinThe Age‘Mentallyillremainsecond-classcitizens’,(24thApril2010),ProfessorPatMcGorrywrote,‘Althoughhealthistrulyholistic,ourhealthsystemrespondswithanapartheid-likedivisionbetweenmindandbody.’EntryintothementalhealthsysteminVictoriaisnotentryintothehealthsystem.Inadditiontothissplithealthsystem,evidencesuggeststhatpsychiatristsconsiderthephysicalhealthcareofpsychiatricpatientstobeneithertheirresponsibility,norwithintheircompetence5.

Thereisevidencethatthe(lackof)health-careseekingbehaviourbypeoplewithmentalillnessalsocontributestotheoutcomes6;itisclearthatpeoplewithmentalillnessratetheirphysicalhealthasahighpriorityandwanthelptoaddressit.

Our response at doutta Galla Community Health Service: organisational change

Communityhealthisuniquelyplacedtocoordinateaccessandengagementacrossabroadrangeofhealthdisciplinesandprogramsinresponsetoawiderangeofhealthconditions.

DouttaGallaCommunityHealthServiceisoneorganisationcomprising:

• AGPclinicwithfiveGPsofferinginexcessof10,000occasionsofservice

• Elevendentalchairs

•Comprehensivealliedhealthservicesincluding:•Physiotherapy•SpeechPathology•OccupationalTherapy•Podiatry•Nursing

• Arangeofprogramstargetingclientswithcomplexneeds

• Afullrangeofpsychosocialrehabilitationprogramsforpeoplewithsevereandenduringmentalillness.

EachoftheseisfundedbyadifferentpartoftheDepartmentofHealthandhasdifferentdataandoutcomerequirementsand,untilfouryearsago,eachoperatedinitsownsilo,seeingpeople,butnotnecessarilyconnectingwithotherpartsoftheorganisation.

Eachhealthdisciplinebringsitsowndiscipline-specificcultureandmodelofcare.Further,DouttaGallaCommunityHealthServiceis,likemanycommunityhealthservices,anamalgamationofpreviouslyindependentservices,includingthementalhealthprogram.Despitethefactthattenyearshaveelapsedsincetheamalgamation,therewas,andstillis,strongculturalinfluencesfromeachoftheorganisationsthatmerged.

Theorganisationbegantoaskthequestions:Weprioritiseandworkwiththemostdisadvantagedinourcommunity,sowhatishappeningtoourmentalhealthclients?Dotheyhaveadoctorandadentist?Arewescreeningfordiabetesandcardiovasculardisease?Areourstaffawareofthedatashowingtheoutcomesinphysicalhealthforpeoplewithsevereandenduringmentalillness?

Addressing health inequalities for people with severe and enduring mental illness in a community health service

byGerardReed

Figure 01: TheAlignmentModel(PatrickLencioni)

PURPOSE

Ability Attitude

Capability Values

Strategy Culture

LEADERSHIP

Talent Commitment

And,sobeganaprocessoforganisationalculturalchange.Anymajororganisationalchangerequiresthealignmentofstrategyandculture.Figure01showswhatneedstobeinfluencedtoachievesignificantorganisationalchange:

Overarching strategy

Ouroverarchingstrategywastomakementalhealthclientspriority-oneclientsforallservicesintheorganisation.Whilstthestrategyissimpleandclear,itsimplementationiscomplexandaffectstheorganisationateverylevel.

AnyorganisationalchangeofthismagnitudemusthavetheabsolutesupportandcommitmentoftheBoard,theCEOandseniormanagers.Toensureaclearpurposeandcommittedleadership,wedidthefollowing:

• Workedwitheveryoneintheorganisation(includingclients,otherkeystakeholdersandpartners)onarticulatingandagreeingtoorganisationalvaluesthatunderpinnedeverythingwedid.

• SetaStrategicPlanthatclearlyidentifiedourcommitment

tocreatinganintegratedservicemodelthatachievedpositiveoutcomesformentalhealthclients.

Wewereawarethatinpullingdifferentlevers,wewouldalterallpartsofthesystem.Forexample,makingmentalhealthclientspriority-oneclientsfordentalserviceshadthefollowingimpacts:

• Highernon-attendancefordentalappointmentswithsignificantimpactsonincomefordentalservices(~$20,000p/a)

• Blowoutinwaitinglistsforotherclientsofcommunityhealthservices

• Newdemandsondentalstaffandfront-of-housestaffwhohadtobecompetentandconfidentincommunicatingwiththisclientgroup

• Newdemandonclientswhohadtobecomfortableinaccessingadifferentservicesite(somentalhealthstaffhadtofacilitatethis).

AlloftheaboveentailedfurtherinvestmentandanunwaveringcommitmentfromtheBoardandfromthedentalteam.

TheExecutiveManagementteamneededbothcommitmentanddeterminationtobetterunderstandeachother’sprograms,sowebeganregularpresentationswithintheteamoutliningprogramhistory,aims,fundingissues,reportingrequirements,policydirections,staffingissuesandgeneralchallenges.

Strategy: capability, talent and ability

Inadditiontoanoverallstrategythatidentifiedourpriority-oneclients,wehadtoensurethatourorganisationbuiltthecapability,talentandabilitytodeliverthevision,whichincludesthefollowing:

• Documentationforstaffinadvertising,positiondescriptions,recruitmentandorganisationliteratureclearlyarticulatesthatwe[DouttaGalla]workwithandprioritiseclientswithmentalhealth/complexneedsandthismeansthatemployeesofDouttaGallamustsharethisvision

• The introductionofacentralintakesystem

• CareCoordinationbecameacrucialpolicymakingbody,sowiderepresentationfromacrosstheorganisationbecameimperative



Addressing health inequalities for people with severe and enduring mental illness in a community health service

byGerardReed

• Webeganworkingonthedevelopmentof(andarecurrentlypiloting)aCommonComprehensiveAssessmenttoolacrosstheorganisationaspartofanEarlyInterventioninChronicDisease(EICD)project

• Wehavebegunareformofmentalhealthservicesthatrequiresamoresystematicaccountableapproachtoservicedeliveryandincludesanawarenessof,andactionon,peoples’broaderhealthneeds

• Wehaveensuredmoreactiveparticipationofmentalhealthservicesincriticalorganisation-widedecision-makingbodies.Forexample,clinicalgovernance:

•Broadeningperspectivesbeyondthetraditionalhealthclinicalgovernanceagenda;beyondissuesofinfectioncontrol,equipmentsterilisationtoconsideringbroaderriskstoclientssuchashomelessness,AODvulnerability,andclinicalriskstostaff

• Anotherexampleisqualityandpolicy:•Ensuringpoliciesareappropriateforallclients.For

example,AODpolicythatstatesanyclientsaffectedbyalcoholorotherdrugscannotreceiveservice(appropriateforwhereconsentisrequiredforaprocedure,butinappropriate[withoutfurthernuance]forworkingwithclientswithmentalhealthand/orcomplexneeds).

Culture: values, commitment, attitude

Strategyalonewasnotenoughtoachievechange.Weneededtoensuretheculture(values,commitmentandattitude)oftheservicesourclientswereaccessing,werestronglyalignedwiththecultureofDouttaGalla.Thisrequiredarticulatingourvaluesandgettingdowntothedetails:

• Language-ensuringlanguagesupportedacommongoale.g.‘yourclients/ourclients’

• Workingwitheachdiscipline-specificcultureandensuringlanguagewasconsistentacrosstheorganisation

• Dealingwiththe‘We’re-already-doing-that’factor,andcommentslike‘Yes,youare,butwewantyoutodoitmoreanddifferently’

• Ensuringstaffacrossprogramsknowoneanother(it’shardertobeuncooperativewithsomeoneyou’vemet,whereyouknowtheirnameandface)

• Ensuringfront-of-housestaffwereincluded(e.g.thisstaffgrouparecurrentlyjoiningde-escalationtrainingofferedtomentalhealthanddentalstaff)

• Dealingwithstigma.Itbecameclearthroughconversationswithintheorganisationthatourstaffsharedcommonmisconceptionsaboutpeoplewithmentalillness,suchasthemythof‘dangerousness’.

Progress to date

Fouryearsdownthetrack,wehavemadesomeprogress:

• Increasedutilisationofmedicalanddentalservicesforpeoplewithmentalillness(althoughexactdataisstilldifficulttoaccess)

• Utilisedmentalhealthnursesasadditionalresources

• Establishedcentralintakeandacomprehensiveassessmenttool

• TheEICDprojecthasbroughtPDRSpracticetotheforefront.Mentalhealthservicesareconversantwiththekeyworker/carecoordinationprinciplesthatunderpinEICDdevelopments

• Committedchampionsfromwithinboththemedicalanddentalteamswhoappealtomentalhealthserviceswhenreferralsslowdown.

Recently,IwasarrivingatameetingatourKensingtonsite,wherebothourGPclinicandadentalserviceoperate.Aclientwithmentalhealthissuesandcomplexneedswasatreception.Hewasbanginghisfistonthecounter,demandingappointmentsthatverydaywithbothadoctorandadentist.Onceuponatime,hewouldhave,mostlikely,beenremovedbypolice.However,thereceptionistsandotherworkersaroundmanagedthesituation.Theclientsawadoctorthatdayandgotadentalappointmentthenextday(whichhefailedtoattend!)Whilsttheclient’sbehaviourwasabhorrent,the

responseofthestaffinvolvedwasindicativethatwehavemadeprogress.Thereare,ofcourse,manyotherstoriesthatwouldindicatewehavealongwaytogo…andwedo.Butwehavemadeastart.

Addressingthephysicalhealthneedsofpeoplewithsevereandenduringmentalillnessinoursmallcorneroftheworldhasrequired,andcontinuestorequire,long-termorganisationalcommitmentateverylevel,includingsignificantfinancialinvestmentandadeterminationtodevelopanorganisationalcultureinwhicheverypersonsharesavision.Itrequiresenormousrelentlessness–andthat’sjustinourlittleplace.

ThechallengetodothisformentalhealthclientsacrossVictoriaisahugechallenge.Itwilltakeenormouscommitmentandrelentlessnessfromoursectortoachieverealoutcomes.Itrequiresafundamentalchangeofstrategyandrelentlessnessinouradvocacy.Whilstwespendmuchenergyadvocatingforbetterresourcingformentalhealth(asweshould),weneedtospendequalenergyadvocatingforaccesstohealthservicesforourclients.Thefutilityofhelpingpeopletobementallywellandthenlettingthemdie20yearsearlyisjustalltooreal.

References

1Holman,D.Lawrence,Jablensky,A.,(2001),Preventable physical illness in people with mental illness,UniversityofWesternAustralia,Perth,

2Meyer,J.M.,Nasrallah,H.A.,(eds),(2003),Medical illness and schizophrenia,AmericanPsychiatricPublishingInc.,WashingtonDC

3Lambert,J.R.,Timothy,Velakoulis,Dennis,Pantelis,Christos,(2003),Medical comorbidity in schizophrenia,MJA,178,(9Suppl.),S67–S70

4VICSERV(2008)Pathways to Social Inclusion: Health inequalities, Background Paper,VICSERV,Melbourne

5Lambert,J.R.,Timothy,Velakoulis,Dennis,Pantelis,Christos,(2003),Medical comorbidity in schizophrenia,MJA,178,(9Suppl.),S67–S70

6Ibid

Theorganisationbegantoaskthequestions:Weprioritiseandworkwiththemostdisadvantagedinourcommunity,sowhatishappeningtoourmentalhealthclients?Dotheyhaveadoctorandadentist?Arewescreeningfordiabetesandcardiovasculardisease?Areourstaffawareofthedatashowingtheoutcomesinphysicalhealthforpeoplewithsevereandenduringmentalillness?

‘I just want to wear sexy lingerie…’ A consumer’s experience of a Weight Management Group model

Benjamin Flood,PeerFacilitator,Simone tassone,SocialWorker,andKate Nunan,OccupationalTherapist,InnerSouthCommunityHealthService

Barrierstoweightmanagement,suchasdifficultyaccessingnutritiousfood,findinglow-costexercise,andpoormotivationandself-confidence,wereallelementsthatconsumerswerehavingdifficultymanagingontheirown.ThisfeedbackledtothedevelopmentofaWeightManagementGroup.

Inner South Community Health Service has a recovery-focused Mental Health Program (MHP) that encompasses PDRS services, a Personal Helpers and Mentors Program and Assertive Mental Health Outreach. Throughout the MHP, staff had noticed that consumers were frequently identifying weight gain as a key health concern.

In2008,aneedsassessmentwascompletedwithconsumersoftheMHPtodeterminewhetherornotweightmanagementwasaconcernandwhatinterventionstheywouldconsidertoaddresstheissue.Theassessmentresultsindicatedthatconsumerswerefindingindividualinterventionssuchasdieting,attendingdieticianandhealthpractitionerappointmentswerenotaddressingtheirneeds.Barrierstoweightmanagement,suchasdifficultyaccessingnutritiousfood,findinglow-costexercise,andpoormotivationandself-confidence,wereallelementsthatconsumerswerehavingdifficultymanagingontheirown.ThisfeedbackledtothedevelopmentofaWeightManagementGroup.

WithdirectionfromconsumersoftheMHPasix-weekeducation-basedgroupwasoffered.Thefocusofthegroupwasonweightmanagement,ratherthanpromotingextremeweightloss,withkeymessagesaboutdevelopingahealthylifestylewiththesupportofthegroup.Structurededucationsessionsincluded:

•Managingweightandmedication•Healthyeatinganddrinking•Mealplanningandsmartshopping•Mindfulnessandeating•Physicalactivity•Goalsetting

Facilitatorsandpresenterswerefromarangeofcommunityhealthdisciplinesincludingdietetics,psychiatricnursing,physicaleducation,socialwork,andoccupationaltherapy.Presentationsandwrittenmaterialwereprovided,withemphasisonparticipantsdirectingtheirownweightmanagementgoals.



Participantsweresuppliedwithahealthyeatingandphysicalactivitydiarytorecordexercise,lifestylechangesandhealthmeasurementssuchasweight,waistcircumference,bodymassindex(BMI),bloodpressure,cholesterol,bloodsugarandlipidslevels.Consumers’GPswerealsoinvolvedinthisprocessofcollectinghealthmeasuresandtheyreceivedwrittenfeedbackabouttheirpatient’sprogresswithinthegroup.Manyofthesevenparticipantsinthefirstcycleofthegroupmadesignificantchangestotheirdietandlifestyleandhaveeitherstabilisedorlostweight.

Afollow-onfortnightlysupportgroupwasfacilitatedforparticipantstoprovidepeer-supportfortheirweightmanagementgoals.Themembersdecidedthesessioncontent,anddiscussedtopicssuchas‘emotionaleating’andhowtounderstandthenutritionalpanelsonfoodpackaging.Overthesixmonthsofthesupportgroup,theparticipantswereincreasinglyreliantoneachotherforsupportandsharingideastowardchangestheycouldmake.Thishighlevelofsocialsupportwasanunanticipatedoutcomeandencouragedstafftoconsiderutilisingapeerfacilitatorinthesubsequentcyclesofthegroup.

Hereisourcurrentpeerfacilitator’sjourney…

I was asked to share my experiences attending this Weight Management Group, both in its initial year, 2009, and currently in 2010, so I would like to bring forth some salient points. When I was first told about the group by my case manager, I was extremely overweight. I weighed 136 kilograms and couldn’t see much prospect at improving my health situation. I had low motivation to exercise, couldn’t seem to gain control of my appetite or diet, felt weighed down and sedated by medication, and there seemed to be unsurpassable barriers to improving the situation.

When asked to take a blood test to ascertain blood sugar and cholesterol levels, I received a shock when my blood sugar registered at a level which required further tests for diabetes. As my mother has struggled with diabetes for over a decade, I immediately felt an urgent need to more closely monitor my physical health, and I altered my diet overnight. I began to eat only three times a day, for the first time in 19 years, and ate only foods low in sugar and fat.

As the group progressed, week by week, I found the ongoing structure useful, as the weekly weigh-ins would inspire me to be strict with my eating habits. I also found that certain

information presented by guest speakers during the initial six-week period proved surprisingly useful. I began to experiment with low glycaemic index, high protein and high fibre foods to alter longstanding eating habits and develop a more sustainable, long-term plan for altering my weight.

After four or so months, I lost my first twenty kilograms. I was incorporating exercise in the form of 40 minutes of fast walking per day. I also found motivation, as, over the preceding years, I dropped from 136 kilograms to 106.

I was asked to be peer facilitator of the subsequent group for 2010. I found the current participants to be highly responsive to both my story and to any advice I presented. The supportive environment that the participants of the group create is a welcome corrective to the individualistic focus that permeates our culture.

I am still trying new strategies; I have doubled my daily walking to 90 minutes a day, and am currently still losing up to three kilograms per month. I have reached a weight I never considered plausible only a brief year ago.

At times I have found psychiatric services to be insufficiently responsive to the needs of severely overweight clients, whereas this group had resulted in significant changes to my life. While the barriers that seem to restrict weight loss among users of psychiatric services are all too real, such as low amounts of money, prohibitive access to exercise services, and sedating medications, I was able to see that with determination there are ways around such problems.

As I currently participate in the group, I am happy to see people attempt new behaviours and try more sustainable options towards their weight loss goals, and it is for this reason I see an ongoing need for the promotion of groups such as these on a wider basis.

Throughthisindividual’slivedexperienceofparticipatingintheWeightManagementGroup,itcanbeacknowledgedthatsharingsuccesseswasanextremelypowerfultoolforotherparticipants.Manyofthecurrentparticipantsinthegrouphavementionedthattheymaynothavecontinuedtoattendiftherehadnotbeenthepeerfacilitatortheretosharehisexperienceandprovidesupport.Thismodel,includingpeersupport,hasbeenagreatsuccessanditishopeditwillcontinuewithfurtherevaluationoftheGroup’seffectiveness.

Keynotespeakers:GregorHendersonandTinaMionkowitz



The Queensland Alliance is the peak body for the mental health community sector in Queensland and its leadership and development team is managed and staffed by people with a lived experience of mental health issues. This article examines the secret to the team’s success: walking the talk, by creating welcoming, respectful spaces both in the office and at events.

language

Peoplecanbepassionateabouthowtheyarereferredto.Assomanypeoplewhohavesurvivedthementalhealthsystemareusedtobeinglabeledbysomeoneelse,theleastIcandoisrespecttheirchoice[oflabel].Ihavefoundtheleastoffensivephrasetomostpeopleis‘apersonwithalived

experienceofmentalhealthissues’.Iwilluseavarietyofwordsandphrasesthroughoutthisarticle.

Where we have come from

Consumer participation = existing situation + a consumer

‘Consumerparticipationcanbeamajorwayofimprovingtheservice,improvingpeople’slivesandassistingpeopletobeinvolvedinthewidercommunity.Broadly,itisaboutthepersonbecomingempowered,gettingmorecontrolovertheirlifeanddestiny,havingmoreopportunitiesinlife,andhavingsupportinpursuingthem’,(Pinches,A.,Robertson,S.,2004).

Anewapproachincludescreatingwelcoming,respectful,safespacesthatengageandvalueallpeople.Ournewapproachassistspeoplewithalivedexperienceofmentalhealthissuestodeveloptheirleadershipskillsbyusingpersonalnarrativesasatoolforstrongerparticipationandengagementwithservicesandthecommunity.

From consumer participation to leadership: walking the talkAn innovative approach that combines consumer leadership, creative process and story that is transforming lives and inspiring social inclusion.

Catherine Smith, LeadershipandDevelopmentTeamManager,QueenslandAlliance

Unfortunately,25yearsofthegrowing‘consumermovement’hasnotbeenabletochangetheessenceofmodelsandstructuresthatnowallowlimitedorconditionalconsumerparticipation.Consumerrepresentatives,consumerconsultantsandpeerworkerscanallfacelimitationsthatinclude:

•Littleornoexperienceandalackoftrainingorsupport•Unclearroles,varyingrelevanceandinformationoverload•Exaggeratedsenseofrisk–stereotypingandfear•Lesspoweranddifferentexpectationsfor‘peer’

Likepushingsquarepegsintoroundholes,wearetryingtopushconsumersintoamodelthathasnotbeentailoredtofittheirrequirements.Thiscanleadtoconditionalparticipation.

A new approach…

Includescreatingwelcoming,respectful,safespacesthatengageandvalueallpeople.Ournewapproachassistspeoplewithalivedexperiencetodeveloptheirleadershipskillsbyusingpersonalnarrativesasatoolforstrongerparticipationandengagementwithservicesandthecommunity.

Our underlying beliefs

•Everyonehasastory•Weallhavesomethingtocontribute•Weareallcreativebeings•Wearealltheauthorsorleadersofourownlivesand

leadershiptakesmanyforms•Weparticipateandengageinthingswherewefeelwe

canmakeameaningfulcontributionwhetherthatisincommunityactivities,services,workorotherenvironments.

ThestaffandmanageroftheleadershipanddevelopmentteamoftheQueenslandAllianceallpositivelyidentifyashavingadirectlivedexperienceofmentalhealthissues.Thismeanswearenotonlyencouragingconsumerparticipation,butlivingconsumerleadership:walkingthetalk!Peopleinvolvedinourworkshopshavecomeuptousand,throughconversation,realiseweidentifytoo.Thisisoftenreceivedwithasurprised:‘Areyouoneofus?’

Overthelastthreeyears,theteamhastrialled,developedandconsolidatedmanyactivitiesbasedonpersonalnarrativeandcreativeprocesseswherepeoplewithalivedexperienceareinvolvedatalllevelsofplanningandimplementation.

Agroupofpeoplewithmentalhealthissuesidentifiedtheywantedtochangethementalhealthsystemandthewaysocietyviewsmentalillness.TheygottogetherandformedaPublicSpeakersBureauin2007.Weknowthisstrategyofdirectpersonalcontactwithpeoplewhoexperiencementalillnessisthebestapproachtochangingattitudesandbehaviours.(Martin,N.,2010).

Theleadershipanddevelopmentteamsupportsspeakerswithrehearsals,presentationanddebriefing:essentialfactorsinthesuccessoftheSpeakersBureau.Peopleinvolvedcameupwiththeideaofastorytent,whichprovidesasafeandinformalspaceforpeoplewithalivedexperiencetosharestoriesoftheirjourney.Aftereachstoryhasfinishedthereareopportunitiesforquestions,feedbackandimpromptustorytellingbymembersoftheaudience.

NowtheSpeakersBureauhasexpandedtoincludeagroupofstorytentfacilitatorsandstorytellersandiscalledtheAgentsofChangeNetwork.TheNetworkmeetsonceamonthforinformationsharingandnetworkingandsometimesinvitesguestspeakers.Throughouttheyear,varioustrainingworkshopsareheldtoimprovetheskills,confidenceandleadershipqualitiesofinterestedmembersoftheNetwork.TheNetworkisexpandingandmovingtowardselfsufficiencyaspublicawarenessgrowsandpeoplearewillingtopayforpresentationsandworkshopfacilitation.

Theteam’sBiennialForum,TheDanceofLife,isentirelyplanned,organisedandrunby,withandforpeoplewithalivedexperience.Thistwo-dayeventinvolvinganentertainmentevening,storytent,artdisplayandkeynotespeakerwasattendedby80people.TheleadershipanddevelopmentteamalsoworkstoensurepeoplewithlivedexperienceplayasignificantroleintheQueenslandAlliancebiennialconferenceAlteringStates.

Althoughexistingelsewhere,in2009,andforthefirsttimeinQueensland,weheldaWalkofPride.ThiseventwasinitiatedbyARAFMIandco-organisedwithRecLinkandtheQueenslandAlliance,andrepresentedbytheleadershipanddevelopmentteam.ItwasaneventtoconnecttheconsumermovementandMadPridewithallpeoplewithalivedexperienceofmentalhealthissues,theirfamilies,friendsandotherallies.Weputtheeventoutthereandmanyorganisations,servicesandindividuals,includingtheDeputy



From consumer participation to leadership: walking the talk

byCatherineSmith

PremierofQueensland,TheHon.PaulLucas,andthemedia,gotinvolvedtoraiseawarenessandfightstigma.Itwasaveryvisibledayforthelargelyinvisibleissueofmentalhealth.Weweresurprisedthatover350peopleattendedandthethreeorganisationsagreedtoholdanannualWalkofPrideonWorldMentalHealthDay,10thOctobereachyear.

Theseactivitiesallincreasedtheconfidenceofparticipantsandprovidedvaluedroles.People’sexperienceswiththeleadershipanddevelopmentteamactedaslaunchingpadstogetemploymentorbecomemoreinvolvedinQueenslandAllianceactivities,theirservicesorcommunityevents.

Wehavefoundthisnewapproachleadstogenuineparticipation.

Moving forward

Itworksandyoucandoittoo!

Theprocessesweuseareapplicabletomanycontextsandarenotexclusivetopeoplewithlivedexperienceofmentalhealthissuesordisability.Theyarethebasisforgoodfacilitationandinclusionwhenrunninganygroups,meetings,consultations,training,feedbacksessions,weddings,parties-anything!

Createaculturewhereitisokaytohaveago,makemistakes,berespectfulandhavealaugh.Invitepeopletolookafterthemselvesandtakebreakswhenneeded.Buildconnectionsandcheckinonhowallarefeeling(includingyou).Identifywhathelpsandhinderspeopletoparticipate.

the main barriers are:

•Self consciousness.Whowillsingtheloudest?Onoroffkey?• Time.Ittakestimeandefforttobuildrelationships,training,

support,andcoordinategroups• Resources.Ourleadersneedtobepaid•Fear and stigmaaboutmentalillnessandpsychiatricdisability.

So,wearecomingfromconditionalparticipation,usinganewapproachtocreategenuineparticipationandspreadingthewordtomovetowarduniversalparticipation.And,universalparticipationis,ineffect,deliveringonpeople’sfundamentalhumanrights.

FINDOUTMORE:ContactCatherineSmithbyemail:

[email protected],ifyouwanttoknowmoreabouttheworkatQueenslandAllianceortheleadershipanddevelopmentteam.

References

Chang,C.,(2008),IncreasingMentalHealthLiteracyviaNarrativeAdvertising,Journal of Health Communication,13,p37–55

Corrigan,P.,(2003),Beat the stigma: Come out of the closet.PsychiatricServices,54(10),p1313

Gordon,S.,(2005),The Power of Contact,CaseConsulting,Wellington

Pinches,A.,Robertson,S.,(2004),NewSynthesisPartnerships:Developingconsumer–collaborativevisionsandstrategiesincommunitymentalhealthservices,New Paradigm,(September,2004)p6

(AllcitedinMartin,N.,(2010),From Discrimination to Social Inclusion,QueenslandAlliance,Brisbane,accessedat:http://www.qldalliance.org.au/news/items/314431-upload-00002.pdf)



At the beginning of 2009, I faced an exciting challenge: developing a research project for my Postgraduate Diploma of Psychology that would achieve my personal aspiration of assisting those experiencing mental illness. I had been working as an outreach worker at Lantern (formally known as Reach Out Mental Health) for over three years and, through this role, was frequently inspired by the struggles and triumphs of those attempting recovery from mental illness.

Thus,whenthereleaseofBecause mental health matters: Victorian mental health reform strategy 2009–2019 (DepartmentofHumanServices,2009)directedmentalhealthservicestobecome‘recovery-oriented’,Idecidedmyresearchprojectwouldexplorewhat‘recovery’frommentalillnessmeansinpractice.

Whilstrecoveryhadbeenimplementedinservices,suchasPsychiatricDisabilityRehabilitationandSupport(PDRS)services,formanyyears,theterm‘recovery’firstappearedinAustralianpolicyonlyasrecentlyas2003(AustralianHealthMinisters,2003).Maybethisisbecause,asIsoondiscovered,

thereisnoconsensusregardingthedefinitionofrecoveryandtherearemultipleandvarieddefinitionsoftheterm(e.g.Andresen,Oades,andCaputi,2003;Anthony,1993;DHS,2009;Onken,Craig,Ridgway,Ralph,andCook,2007;Ramon,Healy,andRenouf,2007).

Assomanyrecoverydefinitionshadbeendevelopedbymedicalprofessionalsand/orresearchers,Isoughtperspectivesofrecoveryheldbythosedirectlyaffectedbymentalillness,withthehopethatthiswouldassistusalltogainclarityandconsensusonwhatrecoveryis.Afterall,theseindividualsarethepeoplewiththelivedexperienceofmentalillnessandrecovery,andtheintroductionofpolicy-directedrecovery-orientedpracticewillimpactheavilyonthem.

BasedonaqualitativeresearchdesigncalledPhotovoice(WangandBurris,1994;1997),Iprovidedparticipantswithcamerasandaskedthemtotakearangeofphotosthatshowedwhattheydofortheirrecoveryandwhatrecoverylooksliketothem.Ilaterinterviewedparticipantsaboutwhatthesephotosdepictedaboutrecovery.

‘Well,totallyrecoveredtomewouldmeannomedication…ifyou’rerecovered,you’dbelivingamainstreamlife…I’djustwanttostipulateit’s‘recovery’,not‘recovered.’’

determining subjective conceptualisations of recovery from schizophrenia

Sandra van lith, PsychosocialRehabilitationOutreachWorker,EACHSocialandCommunityServices



ThisPhotovoiceapproachhadalreadybeenusedtoexploreexperiencesofthoselivingwithseverementalillness(McNamara,2009;Thompson,Hunter,Murray,Ninci,RolfsandPallikkathayil,2008)andtoassistindividualstoovercome(self)stigmaaboutmentalillness(Johnson,Russinova,andGagne,2008).

Therewasquiteabitofinterestinmyresearchprojectand13participantsfromImpactSupportServices,PeninsulaSupportServicesandLanternparticipated.Allhadadiagnosisofschizophreniaorschizoaffectivedisorder.

Therecoveryconceptdescribedbymyresearchparticipantswasquitebroadandcomplex,andisbeyondthescopeofthisarticletocomprehensivelyaddress.Hence,Iwillfocushereonthetwomajorfindingsandtheirimplications.

Firstly,recoverywasdefinedintwodistinctways.Somedescribedrecoveryasanoutcome,suchasnolongerrequiringmedications,nolongerhavingsymptomsorgainingemployment.Participantsholdingthisperspectivedescribedsomedoubtabouttheirpotentialtoachieverecovery.

Wilma:

‘Recovery would be no medication and just being normal… I don’t know what normal is...’

Alternatively,recoverywasdescribedasaprocessinvolvingsuchmeansasdevelopment,maturity,learning,timeandintenseeffort.Participantsholdingthisperspectiveexpressedmorehoperegardingtheirpotentialtoachieverecovery.Byconsideringrecoveryaprocess,therewouldbenofailing-simplyajourneyinvolvingtrial,errorandlearningalongtheway.

Schooby:

‘Over time it’s [recovery is] possible... I suppose you’ve gotta learn from your mistakes and try and not let them happen too often.’

StormBoy:

‘It’s very much a learning process. It’s part of life… It’s part of growing up also as an adult, from a child or a teenager into adult [hood]... I always wanted to keep changing and make room for change. I wanted to keep going... To me, recovery is life... You’re moving on.’

SuperMan:

‘That’s your growth. Trees are very tall. So our recovery is a long, big journey.’

Theseoutcomeandprocessperspectivesofrecoveryarenot,however,mutuallyexclusive,andsomeparticipantsexpressedbothperspectives.

Sean:

‘I haven’t got all the way there… schizophrenia isn’t something you just go [clicks fingers] and it’s gone. It’s something that will always be with me and leave scars even if I do get well.’

Jackhound:

‘Well, totally recovered to me would mean no medication… if you’re recovered, you’d be living a mainstream life… I’d just want to stipulate it’s ‘recovery’, not ‘recovered.’’

Thisfindingoftwowaysofperceivingrecoverysuggestsaneedforincreasedawarenessregardinghowweusetheterm.Forexample,shouldIbespeakingtosomeonefromaprocessperspective,whilsttheyhaveanoutcomeviewpointofrecovery?Ifso,we’dactuallybetalkingaboutdifferentthings.Therefore,Iencourageeveryonetocarefullyconsiderhowtheyperceiverecoveryandhowtheyusethisterminconversationwithothers.

Giventhesedifferingperspectivesofrecovery,Iquestionwhetherservicesshouldbeencouragingclientstoadoptcertaindefinitionsofrecovery,suchasaprocessapproachthatwouldlikelyfostermorehopeaboutthepotentialtoachieverecovery.But,ifthisweretohappen,wouldthisbetothedetrimentofthosewhoholdadifferingperspectiveofrecovery?

Andwhataboutwhenhealthprofessionalsaskclientstodeterminetheirrecoverygoals?Isthisnotimplyinganoutcomeapproach?Tome,thesequestionsfurtherhighlighttheneedforclarityandconsensusaroundthedefinitionofrecovery.

Secondly,recoverywasconsistentlydescribedbyresearchparticipantsasfindingafitinmainstreamsociety.Thisfitwasparticularlyachievedthroughparticipantshavingsocialconnectionandengagementinarangeofactivitiesthatbestmettheirindividualidiosyncraticwantsandneeds.

Determining subjective conceptualisations of recovery from schizophrenia

bySandravanLith

Bill:

‘Well, we humans are social creatures. We have to have contact with others of our kind otherwise we’d go stark raving mad.’

Honda4:

‘There are a lot of things you can do. You can have a bath. You can have a laugh. You can have a nice lunch with a nice beautiful lady. You can take in a band at a pub. There is a lot. Go for a ride on your motorbike. There are a lot of things you can do rather than double or triple your medication.’

Myresearchfoundthatrecoverybestoccurswithinmainstreamsocietalsettings,whileinvolvingarangeofactivitiesandfacilitatingsocialconnection,suggestingthatrecovery-orientedpracticeneedstooccurinthebroadercommunity.Itmaybethathavingseparateprograms,suchasdayprograms,maynotbeaseffectiveasholdingprogramsoutinsociety.Socialgroups,artgroups,andthelike,couldallbeheldinmainstreamsettings.

Finally,throughtakingpartinthisresearchproject,threeparticipantsinformedmethattheyhadconsideredwhatrecoverymeanstotheminmoredepththantheyeverhadpreviously.Twoparticipantsplannedtocontinueexploringwhatrecoverymeanstothemevenaftertheresearchprojectfinished.Thus,afurtherimplicationfromthisresearchisthatcarryingoutasimilarexercisecanbeusedtohelpothers,morecomprehensively,exploretheirownperspectivesandunderstandingsofrecovery.Infact,twoorganisationshaveinformedmethattheyareconsideringdoingso.

IwouldliketothankstaffandparticipantsfromLantern,ImpactSupportServicesandPeninsulaSupportServicesfortheirinterestin,supportof,andcontributionsto,thisresearchandforgivingtheirvaluableinsightsintotheirunderstandingsofrecovery.AdditionalthanksgotoProfessorLenoreMandersonandDrCameronDuffofMonashUniversity,whoprovidedguidance,feedbackandongoingsupportthroughouttheresearchprocess.

ThankyoutoEACHSocialandCommunityServicesforsupportingthepresentationofthisresearchatthisyear’sVICSERVUnfinishedBusinessconference.

Ialsowisheveryonewhoisworkingontheirownrecoverythebestofluck.

References

Andresen,R.,Oades,L.,Caputi,P.,(2003),Theexperienceofrecoveryfromschizophrenia:Towardsanempiricallyvalidatedstagemodel,Australian and New Zealand Journal of Psychiatry,37(5),p586–594

Anthony,W.A.,(1993),Recoveryfrommentalillness:Theguidingvisionofthementalhealthservicesysteminthe1990s,Psychosocial Rehabilitation Journal,16(4),p11–23

AustralianHealthMinisters,(2003),National Mental Health Plan 2003–2008,AustralianGovernment,Canberra

DepartmentofHumanServices,(2009),Because mental health matters: Victorian Mental Health Reform Strategy 2009–2019,DHS,MentalHealthandDrugsDivision,Melbourne

Johnson,D.,Russinova,Z.,Gagne,C.,(eds),(2008),Usingphotovoicetofightthestigmaofmentalillness,Rehabilitation and Recovery,4(4),p1–4

McNamara,S.,(2009),Voices of recovery,CenterforPsychiatricRehabilitation,Boston

Onken,S.J.,Craig,C.M.,Ridgway,P.,Ralph,R.O.,Cook,J.A.,(2007),Ananalysisofthedefinitionsandelementsofrecovery:Areviewoftheliterature,Psychiatric Rehabilitation Journal,31(1),p9–22

Ramon,S.,Healy,B.Renouf,N.,(2007),RecoveryfrommentalillnessasanemergentconceptandpracticeinAustraliaandtheUK,International Journal of Social Psychiatry,53(2),p108–122

Thompson,N.C.,Hunter,E.E.,Murray,L.,Ninci,L.,Rolfs,E.M.,Pallikkathayil,L.,(2008),Theexperienceoflivingwithchronicmentalillness:Aphotovoicestudy,Perspectives of Psychiatric Care,44(1)p14–24

Wang,C.,Burris,M.A.,(1994),Empowermentthroughphotonovella:Portraitsofparticipation,Health Education and Behaviour,21(2),p171–186

Wang,C.,Burris,M.A.,(1997),Photovoice:Concept,methodology,anduseforparticipatoryneedsassessment,Health Education and Behaviour,24(3),p369–387

A recent study set out to examine how mental health case managers and private psychotherapists understood the health and wellbeing, as well as the problems and symptoms, of their consumers. Rather than a general enquiry into this matter, the project had a specific focus: do practitioners consider, and if so, to what extent and in what specific ways, the consumer’s friendships and family relationships, their social connectedness, in their theorising as well as in their everyday practice?

Atitsbase,theprojectwasstimulatedbyacriticalhypothesis:mighttheconventionalclinicalapproachtomentalhealthcare,andtopsychotherapymorebroadly,emphasisethevaluesofautonomyandselfdetermination,privacyandchoice,attheexpenseofthosethatrelatetopromotinghumansocialityandthequalityoftheperson’sinterdependencies?Thatsuchapossibilitymightbeworthinvestigating,inpart,arosefromtheresearcher’scloseto20years’experienceintheadjacentfieldsofmentalhealthandpsychotherapy.Therewereotherpromptstotheproject,notleastofwhichwasthedevelopingprofileofthe‘socialmodelofhealth.’

‘Loneliness[is]onthelistofriskfactorsforillhealthandearlydeathrightalongsidesmoking,obesityandlackofexercise.’Basedonsuchstatisticalarguments,thesocialmodelofhealthisestablishingaprofile,notjustwithleft-leaningacademicsbutalsowithgovernments.Thisworkputsforwardadivergingparadigmtothereceived,expert-centred,emphaticallyclinicaltemplateforhealthcare.

Sovereign selves or social beings?: the practitioner’s role in constructing the subjectivity and sociality of the consumerMark Furlong, SeniorLecturerandDirectorofUndergraduateStudies,SchoolofSocialWorkandSocialPolicy,FacultyofHealthSciences,LaTrobeUniversity





Sovereign selves or social beings?: The practitioner’s role in constructing the subjectivity and sociality of the consumer

byMarkFurlong

Social exclusion and the emerging social model of health

ResearchundertakenbySirMichaelMarmot,RichardWilkensonandtheHarvardCentreforPublicHeath,amongstothers,offersakeyperspectiveonthephenomenaofsocialexclusion,astatusthatsoendangersmanywithin,andbeyond,thementalhealthfield.Initiallyderivedfromsocialepidemiology,thisresearchexpresses,andisconstituting,anemerging‘socialmodelofhealth’thatactivelyconsiderstheinfluenceoflargerdimensionsofsociallife,suchasaccesstoemploymentandhousing(BerkmanandGlass,2000;RyffandSinger,2001;KawachiandBerkman,2003:Marmot,2005;VicHealth,2005;Wilkinson,andPicket,2009).Italsoconsiderstheeffectsofaperson’sintimateandsocialrelationships–withthedomainofwhatmightbetermed,the‘locallysocial’(Furlong,2009).

Acrossnationsinthe(so-called)developedworld,sotheargumentgoes,comparativeoutcomesonabroadsetofindicesofhealthandwelfare,whatWilkinson,andPicketterm‘socialandhealthproblems’,arerelatedtodifferentialsininequalityandstigma,farmorethantheysimplyreflectanation’shealthandwelfareexpenditures.CubaandtheUSA,forexample,haveroughlyequivalentmortalityratesbutthelatterspendseighttimesmorepercapita.Inotherwords,theemergingsocialmodelofhealthdisputes,oratleastde-centres,thestatus,whichhastraditionallybeenaccordedtothemodern,clinicalmodelofcare.Thisalternativemodelseemstosay:adesignforhealthcarebasedonexpensive,highlyspecialistservicesmaybelikenedtolookingforyourkeyswherethelightisbrightest–butnotwherethekeyswerelost.

InRichardWilkinsonandKatePickett’sThe Spirit Level: Why More Equal Societies Almost Always Do Better(2009),itisarguedthatifhumansareacknowledgedandincluded,theirhealthtendstobebetter–andtheconversealsoapples:ifaperson,oragroup,is‘dissed’,ignoredorrejected,theirhealth,wellbeingandselfrespectislikelytosuffer.Theaggregateofaperson’ssocialrelations,itisargued,arecomposedofone-off,aswellaslonger-term,interactionswith‘significant-others’:betweenthosewithwhomwemore

orlessregularlysocialise,aswellasthosewithwhomwehavemoreformalorregularcontacts,includingbutnotrestrictedto,thosewithwhomwehavefamilyorromanticties.Theseinteractionsalsoincludeourimmediatecontactswithprofessionalsinconsultingroomsaswellasstrangersonthestreet,allofwhomcanignoreoracknowledge,honouror‘diss’us.Includedinthissetofrelationsareourworkmates,friends,theregularsweareincontactwithwhileweshop,drive,interactwithonthenet,andsoforth.

Howaretheselinkages,orabsenceoflinkages,important?Oneexamplemightsuffice:CacioppoandPatrickreportintheirremarkableLoneliness: Human Nature and the Need for Social Connection,that‘loneliness[is]onthelistofriskfactorsforillhealthandearlydeathrightalongsidesmoking,obesityandlackofexercise.’Basedonsuchstatisticalarguments,thesocialmodelofhealthisestablishingaprofile,notjustwithleft-leaningacademicsbutalsowithgovernments.Thisworkputsforwardadivergingparadigmtothereceived,expert-centred,emphaticallyclinicaltemplateforhealthcare.Italsoprovidesanimportantplatformforastudythatfocusesonsocialconnectedness–inthiscaseaninvestigation,howeverpreliminary,intotheextent,andthemanner,inwhichpractitionersconcernthemselveswiththesocialityoftheirconsumers.

the study

Giventheevidencelinkingsocialinclusionwithwellbeing,itfollowsthatpractitionersshouldbeguidedbythisresearchinhowtheclient’spresentingissuesareconstructed,howtheprocessofgoalsettingisundertakenand,moreglobally,howtheseactorsconceptualisewhatitistobehuman.Inordertoexaminethisquestion,thestudyexaminedhowcasemangersandpsychotherapiststheorised,andconductedtheirpracticewithrespectto,theirclient’ssignificant-otherrelationships.Thatis,towhatextent,andinwhatconcreteways,dopractitionersconsidertheirclients’current,andprospective,interpersonalnetworksintheirday-to-daypractice?Giventhepossibility,howeverunlikely,thatpractitionersmaybeinadvertentlyignoring,attenuatingorevenantagonisingrelationshipsbetweentheirprimaryclientsandthatperson’s‘significant-othernetwork’,theprojectsetouttoinvestigatethispossibilitytheoreticallyaswellasempirically,albeittoalimitedextent.

the theoretical component

Theinitialcomponentoftheprojectbeganwiththeidentificationofrelevantcontextualfactors,asetthatwasfinalisedtoincludeideological,cultural,theoretical,customary,legal,organisationalandpractice-specificphenomena.Theeffectofthesefactorswasconcludedtobethat‘thehumansubject’tendedtobeconstructedwithinthetextsofpsychiatry,psychologyandpsychotherapyasanautonomousagent.Further,withinthesetexts,understandingsofhealth/pathologywerethenconfiguredwithrespecttothisascriptionofautonomy.

Threediverseintellectualtraditionswerethensurveyedfortheircapacitytoactasalternativevantagepointsfromwhichthisprevailingviewoftheselfcouldbecriticallyreviewed:

•‘Non-mainstream’traditionsofthought:feminist,cross-cultural,systemic,ethicalandspiritual

•Contemporarycriticaltheory•Socialepidemiologyresearchreports,whichlinkhealth

outcomeswiththequalityofpersonalrelationships.

Thissurveyyieldedtheconclusionthat–howevertheselfmightbeunderstood–aconcernforthequalityof‘significant-otherrelationships’waswarranted.Thisreviewalsoconcludedthattheimageoftheselfasanautonomousunit,andthespecificationofhumanhealthandpathologyderivedfromthisimage,ishistoricallyandculturallyanomalous.

the empirical component

Mindfulthattheimageofthehealthywesternsubjectasafree-stranding,sovereignentityremainsdominant,thesecondcomponentoftheprojectsoughttointerrogatethisconclusionininterviewswithcurrenthumanserviceworkers.Twenty-twosemi-structuredinterviewswithmentalhealthworkersandprivatelypracticingpsychotherapistswereundertaken.

Asapreliminarystep,acomplexinterviewschedulewasdeveloped.Thisschedulehadseveraldistinctcomponents.Participantswereaskedtodiscussanumberofconstructs,suchastheirattitudetoMaslow’shierarchyofhumanneeds.Ofthesecomponents,themostsignificantinvolvedaskingparticipantstoconsider,andthenrespondto,acomplexvignette.Thisvignettewasgiveninwritingtoeachparticipant,(seeTable01).

Followingthematiccontentanalysesofthedatafromthiscomponent,inconjunctionwiththecumulativeresponsestoothercomponents,aclearresultwasobtained:intervieweesrarelypresentedtheirclientsasembedded,relationalentitiesintheiraccountsoftheirpractice.Onthecontrary,clientstendedtobepresentedasifthesepeoplewereprimarily,andoftenquiteexclusively,autonomoussites–individualswhowere,moreorless,damaged,withrespecttotheircapacitytobe‘incharge’oftheirlives.Thatis,thecapacityforagency,ratherthanconnection,wasfarmoreinfocusfortherespondents.

Wecometobewhatwearetreatedasbeing:eitherweareencouragedtobe,andtothinkofourselvesassocialbeings,creaturesoftheherdwhohaveaccountabilitiesaswellasrights,or,wearetaughttoseeourselves,andtoactas,sovereignentities,individualswithourownneedsandinterests.

Withfewexceptions,thiswasthepatternacrossthetwopractitionersub-groups:onlymarginalattentionwasgivento‘affectionate,intimateandfamilyrelationships.’More,theattentionthatwasgiven,tendedtobeblamingand/orpessimisticconcerningtheprospectsforclientsbeingabletodevelopsupportiverelationshipsinthefuture.Neitherpsychotherapistnorcasemanagersheldadiscerniblydifferentview(Furlong,2008;2010).

discussion

Howmightthesefindingsbeunderstood?Practitionerswanttohelp,aredeeplycommittedtoassisting,theirconsumers.Thisacknowledged,isitpossiblethathelpingmayinadvertentlyignore,evendisrupt,theconsumersprospectsforrelationships?Forexample,whatconceptuallyunitesthedisparatepsychotherapeuticapproaches–cognitivebehaviouraltherapyandpsychoanalysis,experientialtraditionsandthemorerecent‘newage’iterations–isthateachoftheseapparentlydistinctpracticesplacestheconsumeratthecentreofthepicture.

Intermsoftheparticularimpactofthispositioning,Bauman(2003;58)suggeststhisteachestheconsumertohave:

More self-appreciation, self-concern and self-care, more attention to the… inner ability for pleasure and satisfaction – as well as less ‘dependence’ on others and less attention to other’s demands for attention and care. Clients who diligently learned the lessons and followed the advice faithfully should… ask themselves more often the question ‘what’s in it for me?’

Inthisanalysis,thepremiseisthatpractitionersandtheirtheoriesarenotneutralintheirinfluence.Rather,theconsumeris‘reformed’,seriouslyinfluencedovertime,intheircontactswithpractitioners.Rose(1999;42),anhistorianofthepsychotherapiesandunofficialbiographeroftheTavistockCentre,putsitthisway:

The psychotherapies, the languages of the psychotherapies, their explanations, their types of judgment, their categories of pathology and normality, actually shape, have a proactive role in shaping, the subjectivity of those who would be their consumers. I think in those circumstances it’s not surprising that people will understand themselves in analogous kinds of ways (to their therapists) when they go into the psychotherapies and will often find a certain kind of hope and comfort (in this story).

Wecometobewhatwearetreatedasbeing:eitherweareencouragedtobe,andtothinkofourselvesassocialbeings,creaturesoftheherdwhohaveaccountabilitiesaswellasrights,or,wearetaughttoseeourselves,andtoactas,sovereignentities,individualswithourownneedsandinterests.

Puttingitfartoobrutally,theresultsofthestudyareexplicable,evenpredictable,ifitisunderstoodthathumanservicepracticeexpresses,andisconstitutedby,aspecificlegal,policy,organisationalandprofessionalhabitus(Bourdieu,1998),thatprivileges‘theindividual’.Thislocationisanormativecontext–aforgethatshapestheformrespectablepracticehastotakeasitisthetemplateinrelationtowhich‘legitimate’practicemustconform.

Whatarethespecificationsofthistemplatewithrespecttotheclient’sinterpersonalworld,totheprospectsforsocialitythatwasthespecificconcernoftheproject?Thecriticalreviewoftherelevantmulti-disciplinaryliteratureidentifiedthefollowingcontextualstipulations:mindfulofsomevariationsbetweendifferenttherapeuticiterations,thatpractitionersmustdemonstrateanabidingconcernwith:

•Thesetofnotesthatsummonupthemagicchordofhumanindependence:thevaluesofautonomy,selfdetermination,choice,confidentiality,personalprivacyandentitlement

•Thenecessitythattheprofessionalandtheclientbecomeanenclave,anexclusivedyad,wherethebondbetweentheprofessionaland‘myclient’isbasedontheprofessionaluncriticallyaligningthemselveswiththeperspectiveofthisperson.Forexample,whentheclientsays‘Iamnotunderstoodbymypartner’,or‘IamnotgettingenoughofwhatIwantinthisfriendship’,thepractitionerwillaccept,ratherthanquestion,thisdisposition

•Endowingtheworkingallianceor,moregrandly,the‘therapeuticrelationship’betweenthepersonandthepractitionerwithaclose-to-sacredstatusasthecorrectiveand/orrescuingdimension

•Minimising,eveneliding,theprimacyofsignificant-otherlinkages–bothinthepresentandintothefuture


byMarkFurlong,PhD54

newparadigm Autumn2010



byMarkFurlong

•Discounting,evendisqualifying,theexpectationthattheclienthasanaccountabilityfortheirinterpersonalbehaviours,thatisthepractitionerwillactinamannerthatissupportiveandnon-intrusivewithrespecttotheclient’sinterpersonalbehaviour,unlessthisbehaviourissoegregiousastobespecificallyoutlawed.

Suchnormsaremutuallyreinforcingandarethereforeactivelyrecursiveintheiroperations.Yet,ofcourse,suchasetofnormsdonotexistinavacuum.LikeaRussiandoll,thepracticehabitusisembeddedinalargerconcentricbodythatisthetimeandplace,whichframesthespecifichabitus–whatcriticaltheoriststermthelargerculturalandhistoricalmilieu.Withrespecttothewestern,(so-called)firstworldmilieu,whatarethearraigningfeaturesofthismilieu,what

keyattitudesandvaluesareprivilegedandreproducedinthisspace?

Itis,ofcourse,ofnosurprisethatthevariableschampionedbywesternculturestipulateindependenceandpersonalcontrol,theidealofself-relianceandofpersonalrights,thatthelocusofcontrolshouldbeinternaltotheindividual,andsoforth.Thisisalmostexactlythesuiteofvaluesthatarecontendedinthetherapies,asetwhichis,notcoincidentally,consonantwiththeprocessof‘individualisation’(Bauman,2001,2003;Beck,andBeck-Gernsheim,2002;ElliotandLemark,2005;Giddens,2003).Thisprocesshasadvancedtosuchanextentthateachpersonisnowquiteawarethattheyare‘condemnedtobefree’tore-cycleaphrasefromexistentialism(Rose,1989).

Vignette

Lennieisa27-year-oldunemployedmanwithschizophreniawholives‘rough’whenheisnotinemergencysheltersorothershort-termplaces.Lenniehasproblemswithhisthinkingandbehaviour,hasnounderstandingofhisillnessandissociallyisolated.Hesometimesusesmarijuanaandalcoholand,althoughthisoccasionalsubstanceabuseisnotgoodforhismoodorhisthoughtprocesses,hisproblemsarepredominantlymentalhealthrelated.Youareacasemangerinanoutreachmentalhealthserviceandalthoughyoufindhimfriendlyenoughandabletotalkfairlywellwhenspokento,youhavebeenstrugglingtoengagehiminthe(offandon)timeshehasbeenonyourcaseloadoverthelastthreeyears.Hetellsyou‘Iwanttobeleftalone.’

Background

Lenniehadan,apparently,unproblematic,althoughperhapssomewhatisolated,childhoodandschooling.Hewantedtoleaveschoolat16toworkinarelative’sbuildingcompany.At19,whilststilllivingathomeandworking,hebecamemoreandmorewithdrawnandwasobservedtohavebecome‘bizarre’inhisthinking.AfteranumberofconsultationswithhisfamilydoctorhewasreferredtoanItalian-speakingprivatepsychiatrist—hisfamilyareItalianandheisbi-lingual—andshortlyafter

hewasgivenadiagnosisofschizophrenia.Lenniedidnotacceptthisdiagnosisatthattimeandstillcontinuestodenyhehasanillness.

Forthenextfiveyears,Lenniecontinuedtoresideathomewithhisparentsandfoursiblings(twoareolder;oneisyounger)andwasalternativelywithdrawnandaccusatory.Duringthisperiod,therewasasteepdeteriorationinfamilyrelations.Aftermanyintenseand,attimes,verballyintimidatingarguments,Lenniewasaskedtoleaveandhasbeenof‘nofixedaddress’eversince.Hehasbeenonadisabilitypensionforthelastfiveyears.

Sincehisfirstepisode,Lenniehashadmorethanadozenhospitaladmissions.Althoughheisoftenfriendlyandsociallycompetent,heappearstohavelittleornoinsightorself-managementcapacity.Healsocontinuestoberesistanttotreatment,unmotivatedandblunted.

Withoutworryingaboutresourcequestions,ifyouhadamagicwand,whatgoalswouldyousuggestareappropriate/whatdoesheneed?

•Shortterm•Mediumterm•Longerterm




byMarkFurlong

Giventhisscript,atthelevelofculturalanalysis,itfollowsthatpsychotherapistsandmentalhealthworkerswill‘execute’thewarrantthatthisprocessspecifies.Thisisnottosaythatthetroublesofmanyconsumerswillnotberesolvedbyhelpfulpractitioners.Atahigherlevelofanalysis,itmaybethat‘we’,thegestaltofallconsumers,maybebeingtaughttoraisethedust,tocomplain,Iamlonelyandmisunderstood,Iamanxiousandprecarious,onlythentocomplainthatwecan’tsee(Roseneil,2007).

Thisconclusionmayrepresentadisrespectfullineofthoughttosome:howcouldwellmeaningandwelltrainedprofessionalsandpractitionerswithabackgroundinpsychologyandnursing,medicineandsocialwork,beimplicatedinsocialisingtheirclientstowardsthesepeoplebecomingdisconnectedandself-centred?Howeverdistastefultheideamaysound,thepossibilitymaybe,tosomesignificantextent,accurate.

Consumersofmentalhealthservicesareundoubtedlysociallyexcluded.Thishaslongbeenunderstoodtobetheresultoftheprevailingsocialattitudesandthenatureofamentalhealthcondition.Giventhiscontextitwouldbeasavageironyifthisunfortunatestateofaffairswas,atleastinpart,aconsequenceofthedesignofthesystemthatwasputinplacetoofferassistancetotheconsumer.Thatmentalhealthprofessionalsandpsychotherapistsmaybeunwittinglypromoting,mightevenbeaformalvectorfor,thespreadofanomieandtheprocessofindividualisationisthereforeaproblemworthcontesting.And,ofcourse,therearealternativewaysofpracticing(Colgate,2004;Furlong,2003;Jenkins,2009).

References

Bauman,Z.,(2001)The Individualized Society,PolityPress,Cambridge

Bauman,Z.,(2003)Liquid Love: On the Frailty of Human Bonds,PolityPress,Cambridge

Beck,U.,Beck-Gernsheim,(2002)Individualization: Institutionalized Individualism and its Social and Political Consequences,Sage,London

Berkman,L.,Glass,T.,(2000)Socialintegration,socialnetworks,socialsupportandhealth,inBerkman,L.,Kawachi,I.,(eds)Social Epidemiology,OxfordUniversityPress,NewYork

Bourdieu,P.,(1998)Practical Reason: On the Theory of Action,Polity,Cambridge

Cacioppo,J.,Patrick,W.,(2009)Loneliness: Human Nature and the Need for Social Connection,W.W.Norton,NewYork

Colgate,C.,(2004)Just between You and Me: The Art of Ethical Relationships,PanMacmillan,Melbourne

Elliot,A.,Lemert,C.,(2006)The New Individualism: The Emotional Costs of Globalisation,Routledge,London

Furlong,M.,(2003)Critiquingthegoalofautonomy:Towardsstrengtheningthe‘relationalself ’andthequalityofbelongingincaseworkpractice,The European Journal of Social Work,6(1),p5–19

Furlong,M.,(2008)Capturedbythegame:Mightafocusonthetherapeuticrelationshipdiminishtheattentionthatisgiventotheclient’sintimatenetwork?,The Australian and New Zealand Journal of Family Therapy,29(1),p25–33

Furlong,M.,(2009)Isthevocabularyofhealthandwell-beingcolonizing‘thesocial?’,Arena,103,p34–40

Furlong,M.,(2010)Psychotherapyasvectorforanomieandisolation,Psychotherapy in Australia,16(2),p38–43

Giddens,A.,(2002)Runaway World: How Globalisation is Re-shaping our Lives,ProfileBooks,London

Jenkins,A.,(2009)Becoming Ethical,RusselHouse,Dorset

Kawachi,I.,Berkman,L.,(2003)Neighbourhoods and Health,OxfordUniversityPress,NewYork

Marmot,M.,(2005)Socialdeterminantsofhealthinequalities,The Lancet,365,p1099–1104

Rose,N.,(1989)Governing the Soul,London,Routledge

Rose,N.,(1999)Interrogatingthepsychotherapies:AnInterviewwithNikolasRose,Psychotherapy in Australia,5,p40–46

Roseneil,S.,(2007)Suturedselves,queerconnections:PersonallivesatthecuttingedgeofIndividualisation,inHoward,C.,(ed.)Contested individualisation: Debates about contemporary personhood,PalgraveMacmillan,NewYork

Ryff,C.,Singer,B.,(2001)Emotion, Social Relationships, and Health,OxfordUniversityPress,NewYork:seeespeciallySeeman,T.,(2001)Howdoothersgetunderourskin?

Wilkinson,R.,Picket,K.,(2009)The Spirit Level: Why More Equal Societies Almost Always Do Better,AllenLane,London

VicHealth,(2005)A Plan of Action: Promoting Mental Health and Wellbeing,VictorianHealthPromotionFoundation,Melbourne



Since 1990, large numbers of Somali refugees have migrated to Australia under the Refugee and Special Humanitarian Program and the Family Reunion Program. Most of them live in Melbourne’s northern suburbs. The number of Somali migrants increased from 3,000 in 1996 to 11,000 in 2006, with 62.2 per cent living in Victoria (ABS, 2006).

Currently,mostsettlementprogramsfocusonintegration,butculturalbarriers,mistrustoftheAustralianservicesystemandlastingimpactsofpre-migrationexperienceshindertheseprocesses.Asaresult,manyadultmenandwomenexhibitsymptomsofpost-traumaticstressdisorderwithseveredepressionandanxiety(Bailey,2006).InordertobestrespondtotheneedsofCALDcommunitiessuchasSomaliclients,itisimportanttobemindfuloftheiruniqueculturalunderstandingofmentalhealthandmentalillness.

traditional perspectives of mental health

AccordingtoSomalis,healthisGodgiven,butindividualsare

responsibleformaintaininggoodhealth.ThebeliefisthatpeoplecannotprotectthemselvesfromfutureillnessesbecauseGodistheultimateguardianofhealth.TheSomalicommunitybelievesthatapersonwithamentalillnessis‘crazy’.Theyassociatepeoplelivingwithamentalillnessaspeoplewhoareviolent,unpredictableorhaveanintellectualdisability.

FortheSomalicommunity,thecauseofmentalillnessispredominatelyspiritualormetaphysical.Forinstance,theyperceivementalillnesstobeapunishmentfromGodorevilspirit.Theyalsobelievetheillnesscanbebroughtonbyoneselforanotherpersonthroughcursesorbadbehaviour.Traditionaltreatmentsincludemediationprovidedbyreligiousleadersortraditionalhealers.

AdEC’s Somali mental health education project

ADEC’sTransculturalMentalHealthProgramreceivedfundingtoprovidementalhealtheducationtotheSomalicommunityinMelbourne’snorth.Duetoculturalneeds,ADECemployedafemaleandamalebilingualworkerfrom

Currently,mostsettlementprogramsfocusonintegration,butculturalbarriers,mistrustoftheAustralianservicesystemandlastingimpactsofpre-migrationexperienceshindertheseprocesses.Asaresult,manyadultmenandwomenexhibitsymptomsofpost-traumaticstressdisorderwithseveredepressionandanxiety.

Somali mental health project

Ahmed tohow, CommunityDevelopmentOfficer,TransculturalMentalHealthAccessProgram,ADEC



theSomalicommunityaswellasacoordinatorfortheprojecttocarryoutthisproject.Theteamstudiedthetargetgroup’sneedsthroughdiscussionswithSomalicommunityleadersandcommunityworkers.

ADEC’sTransculturalMentalHealthProgramthenconductedfocusgroupswiththeyouthoftheSomalicommunityaswellasthematureageSomalimenandwomen(genderdivided).Bothmatureagegroupsrequestedmentalhealtheducation,whereastheyoungSomalicommunitymemberswereseekingtodevelopabrochurewithgeneralmentalhealthinformationandservicecontacts.

Information requested by the Somali community

Thefourcommonrequestsidentifiedfromthefocusgroupsregardingtheinformationprovidedaboutmentalillnesswere:

•Psycho-education(whatmentalillnessis)•Normalisingmentalillness•Knowledgeonhowtoidentifyearlysignsofmentalillness•Mentalhealthservicesandresourcesavailable.

Phase I – AdEC’s response to mature age people (both female and male)

ThefirstphaseofADEC’sresponsewastoprovidementalhealtheducationtothematureagegroups.Mentalhealthserviceproviders,suchastheVTPU,NorthernDivisionofGeneralPractitioners(NDGP),AustinSECU,andtheMigrantResourceCentre(MRC)weredelightedtohavetheopportunitytobeinvolvedinthementalhealtheducationforumswithSomalimenandwomenanddiscusseddiversetopics.

NDGPledadiscussionon‘howtotalktoyourdoctors’,andpresentedsomewaysinwhichethniccommunitiescanaccessGPservicesintheirlocalarea.Inthesameforum,aguestspeakerfromtheAustinSECUdiscussedatopicon‘dealingwithacrisis’,whattoexpectifyouneedtogotohospitalandhowtomanagemedication.ThespeakerfromtheAustinensuredserviceswereculturallyappropriateandthatpeoplefromethnicbackgroundswereallowedvisitsfromtheirfamilymembersinordertoengageinspiritual/traditionalhealingmethodswhilereceivingprofessionaltreatment.ADECinvitedsomeSomalicommunityandspiritualleaderstospeaktotheircommunityonthe‘importanceofhelpseeking’regardingmentalhealthissues.

TheoverallforumpresentationsfocusedonaneverydayperspectiveofhealthandwellbeingaswellassomeoftheunderstandingsthatcomefromWesternculture,andtheparticipantswerequiteengagedthroughoutthesessions.Therewerediscussionsaroundmentalhealth,mentalillnessandgeneralhealth,stressandstressfullifeevents,commonmentalhealthproblems,andthekindofhelpavailable.

Some of the issues raised by Somali (mature) men:

•WouldAustralianhealthcareprovidersbelieveaSomalipatient’sideasandbeliefs?

•Therewasafeelingof‘mismatch’betweenSomalis’culturalbeliefsandthoseofAustraliansregardinghealthandillness

•TherewasabeliefthatAustraliansweremorelikelytolabelsomebehavioursSomalisseeas‘normal’,asamentalillness.ThiswasduetothehardshipSomalishaveexperiencedintheircountryoforigin

•ThecommunityinSomaliaviewandtreatpeoplewithmentalillnessdifferentlytotheAustraliancommunity.Somalislabelpeoplewithamentalillnessas‘crazy’andlookdownuponthem(stigmatisation)

•Wouldtreatmentformentalillness‘cure’SomalisiftheyadheredtoAustraliantreatment?

Some of the issues raised by Somali (mature) women:

•Therewasaprimaryconcernfortheirchildren,andtheyspentmuchtimeworryingandstressingabouttheirchildren’swellbeingandsafetyinAustralia

•Therewasaviewthatmanyofthe‘problems’thatexistinAustraliadonotexistinSomalia,suchaspaedophiliaandhomosexuality

•Movingoutofhomepriortomarriageandrelationswithmembersoftheoppositesexarenotacceptableintheircountryoforigin

•DescriptionsofhowtheircommunityinSomaliawassaferthanAustraliawheretheyweresurroundedbysocialsupportsincludingfamilyandneighbours

•DescriptionsofdifficultyadjustingtotheirsmallerlivingspaceandthelackofinteractionwithothersinAustralia

•Needtoknowwheretogotoforhelpifneeded.

Somali mental health project

byAhmedTohow

Phase 2 – AdEC’s response to Somali youth groups (male and female)

ThesecondphaseoftheprojectwasaseriesofworkshopstodesignabrochureforSomaliyouth.ADEC’sTransculturalMentalHealthProgramconsultedwithHeadspace,ayouthmentalhealthexpertorganisation,tosupportandprovidesomedirectionwhereneeded,whiletheSomaliyouthsworkedontheirbrochure,whichwasfinalisedafterfoursessions.

Thefinalproductwasayouth-appropriatebrochurecalled,You are not alone.Thiswasfollowedbyaformallaunchofthebrochure,whererelevantagenciesandindividuals,suchasNorthernMelbourneHeadspace,Frontyard,membersfromtheAustralianSomaliYouthAssociation(ASYA),andthelocalMPwereinvitedtoattend.

ThisbrochurewaswritteninEnglishastheyoungSomalisinthegroupspeakEnglishanditwasfeltthatitwouldbemoreaccessible.ThebrochuresweredistributedtomentalhealthservicesandtoplaceswhereSomali’scongregate.ThebrochurewasalsopresentedatVICSERV’sUnfinishedBusinessconferenceinAprilthisyear.

Throughtheproject,ADECwasabletode-mystifysomeofthebeliefsinthecommunity,buildbridgesbetweenlocalsupportservicesandpeoplefromaSomalibackgroundand,inreturn,educateAustralianservicesabouttraditionalSomalitreatments.

FINDOUTMORE:AToolKitforotherservicesworking

withtheSomalicommunityisavailablefromADECbyphoning0394801666oremailingahmed@adec.org.au.

References

Crisp,J.,(2003),Anewasylumparadigm?Globalisation, migration, and the uncertain future of the international refugee regime,(UNHRC),WorkingPaperno.100,viewed20thSeptember,2005,accessedat:www.unhcr.ch

Iredale,R.,Mitchell,C.,Pe-pua,R.,andPittaway,E.,(1995),Ambivalent Welcomes: the settlement experiences of humanitarian entrants families in Australia,BIMPRandDIAC

Laitin,D.,(1977),Politics, Language, and Thought: The Somali Experience,UniversityofChicagoPress,Chicago

Lindner,EvelinGerda,(2001),HumiliationandtheHumanCondition:MappingaMinefield,Human Rights Review,2(2),p46–63

Nsubuga-Kyobe,A.,Dimock,L.,(2002),African Communities Settlement Services in Victoria. Towards Better Delivery Models,AustralianMulticulturalFoundation,DIMMIAandLatrobeUniversity

Robinson,J.,(1999),Joined Hands Brings Success,aresourcefromserviceprovidersworkingwithSomalipeople,EcumenicalMigrationCentre,Melbourne

Bailey,M.,(2006),Depression or Thinking too much?: Concepts of Mental Illness in the Somali Community in Melbourne,MastersTheses

FortheSomalicommunity,thecauseofmentalillnessispredominatelyspiritualormetaphysical.Forinstance,theyperceivementalillnesstobeapunishmentfromGodorevilspirit.Theyalsobelievetheillnesscanbebroughtonbyoneselforanotherpersonthroughcursesorbadbehaviour.Traditionaltreatmentsincludemediationprovidedbyreligiousleadersortraditionalhealers.

Keynotespeaker,RufusMay



Our first response to the idea behind the Unfinished Business conference was to wonder about how working with families may relate to or support social connection and inclusion. We were also curious about how such relational work may contribute to people returning to work.

Wecametotheconclusionthatitmakessensetoacknowledgeapathwayfromourrelationshipwithfamily,toourconnectionswithothersocialgroupsandsettings,includingtheworkplace.Weallhavemultiplerolesandgroupsornetworks,thatprovide

asenseofbelonging,butifweconsiderthefamilytobeourprimarygroup,thenourbelongingheresetsthefoundationfordevelopingfurthersocialconnections.

Ouridentitywithinourownfamilyismultifacetedanddynamic.Itcanchangeovertimewithage,health,maritalstatusandparentalstatus.Allthesethingsleadtochangeinhowfamilymembersrelatetoeachother.Adramaticchangeinafamilymember’smentalhealthcanalsoleadtodramaticchangesinhowfamilymembersrelatetoeachother.Family

Formanypeoplewithamentalillnessandtheirfamilymembers,therecanbearuptureinrelationshipsonmanyfronts:atschoolorwork,withfriends,andwithinthefamily.Externalsocialnetworkscandepletewithsomenetworksdroppingoutaltogether.Theearlydatafromourevaluationshowsveryhighlevelsofsocialisolationfromafriendshipscaleamongbothcarersandconsumers.Thewholefamilyseemstobecomemoreisolatedandlessconnected.Pathwaystosocialinclusioncanseemlikealabyrinth.

From family work to work: unexpected pathways

Janet Glover, ProgramManager,andElise Whatley,FamilyWorker,BuildingFamilySkillsTogether,Minddr Peter McKenzie,CarerAcademic(mentalhealth),TheBouverieCentre,FacultyofHealthScience,LaTrobeUniversity

rolescanalsobeaffected,whereashiftfrombeingapartnertoalsobeingacarercantakeplace.Inmanyofthefamiliesweworkwith,livingwithmentalillnesscancauseonceassumedrolestobecomequitefluid.

Attheonsetoftheillnessandthenattimesofrelapse,familiesoftengothroughaperiodofcrisisand/oratraumawherethepressuresonfamilyrelationshipscanbeverystressfulanddisruptive.Sometimesthiscanresultinlossofconnectionwithothersandencouragefeelingsofalienation.Ontheotherhand,familiesoftendemonstrateresilienceinthefaceofthesepressuresandcanfindwaystocopeandmoveforward.

defining social exclusion

Wewouldliketouseadefinitionof‘socialexclusion’tostartusthinkingabouthowamovetowards‘socialinclusion’maytakeplace.‘Socialexclusioncanbedefinedasamultidimensional process of progressive social rupture[emphasisadded],detachinggroupsandindividualsfromsocialrelationsandinstitutionsandpreventingthemfromfullparticipationinthenormal,normativelyprescribedactivitiesofthesocietyinwhichtheylive’,(Silver,2010).Employmentcanalsobeseenas‘normal,normativelyprescribedactivities’,(Silver,2010).Unemployment,ontheotherhand,canbeseenasakeycauseofsocialexclusion,asitdeprivesanindividualaccesstomaterialwellbeingthroughearninganincomeandtosocio-culturallyvaluedidentitiesandrolesaroundparticipationintheworkforce.

Ingeneral,theprocessofsocialexclusionoccursovertimeandinmanyareasofone’slife,throughbreakingorstraininglinks,oneafteranother,withimportantsocialconnections.Relationshipsbetweenpeopledeteriorateorendcompletely.Asthesesociallinksweaken,youcanloseyourplaceinacomplexsocialstructure.

Formanypeoplewithamentalillnessandtheirfamilymembers,therecanbearuptureinrelationshipsonmanyfronts:atschoolorwork,withfriends,andwithinthefamily.Externalsocialnetworkscandepletewithsomenetworksdroppingoutaltogether.Theearlydatafromourevaluationshowsveryhighlevelsofsocialisolationfromafriendshipscaleamongbothcarersandconsumers.Thewholefamilyseemstobecomemoreisolatedandlessconnected.Pathwaystosocialinclusioncanseemlikealabyrinth.

Social inclusion: rebuilding and repairing the links

Takingasystemicperspective,thefamilyistheprimaryplacewherethebeginnings,orroots,ofoursocialidentityandskillsareshaped.TheworkwedoinBuildingFamilySkillsTogether(BFST)invitesfamiliestocometogethertomeetandlearnskillsthatassisttheminbuildingandrepairingrelationallinksthatpromoteandsupportsocialinclusionpractices.

Therearemanychallengestothewholefamilywhenmentalillnessisafactor,butBFSTfamilyworkhelpstheprocessofrenegotiatingandrebuildingbetterrelationshipsthroughunderstandingthefamilies’experienceandtheeffectsofmentalillnessonfamilies.BFSTalsoworksdirectlywithfamilymembersregardingcommunicationwithinthefamilyandworkingthroughproblemstogetherandprovidesaforumforcollaborativediscussionandplanning.Animportantaspectofsocialinclusionisthatnotonlyareyouconnectedwithothers,butyoualsohaveskillstonegotiateandworkwithotherstoreachyourgoals.Wewouldarguethat,workingwiththefamilybytakingsmallstepstowardsbettercommunication,solvingproblemsandworkingtowardsgoalsasafamily,encourageslargerstepstowardssocialinclusionandconnectionwiththewidercommunity.

BFSt and Behavioural Family therapy (BFt)

Despitethebeneficialeffectsofmedicationsonpsychiatricdisorders,drugsalonerarelyeliminateallthesymptoms,andclientscanstillexperiencesignificantdifficultiesinassumingmajorsocialrolessuchasemployment.Theroleandsupportofthefamilyinclientsassumingsuchroleshasasignificantimpact.

BFTwasidentifiedasthepreferredmodeloffamilyinterventionfortheBFSTMindprogrambecausethereissolidevidencethatthisformofpsycho-educationalfamilyworkreducesrelapseratesinconsumers,reducescarerburdenandimprovesrelationshipsforfamilies.Evidencefromover40randomisedtrialsdemonstratesthepotentialofthisapproachtokeeppeoplewellinthecommunity,suchas.

•Reductionsinrelapseandadmissionrates•Reductionsofbetween20percentand50percent•Decreaseinsymptoms•Increasedparticipationinvocationalrehabilitation




byJanetGlover,EliseWhatley,andDrPeterMcKenzie

andemployment•Improvedfamilywellbeing–reducedburden•Reducedcostsofcare

(McFarlane,etal,2003;MueserandGlynn,1999).

What is BFt and what are some of its objectives?

BFTisastructured,butflexiblemodeloffamilyintervention,directedandshapedaccordingtothefamily’sneedsandrespondsastheseneedsevolve.Itisresponsivetotheparticularneedsofthefamilythroughanemphasisonengagementandassessment.Importantelementsofthisprocessarethenotingofthestrengths,goalsandchallengesofeachfamilymemberandthefamilyasawhole.

OneofthekeyprinciplesofBFTisthatthefamilyisseenasthegreatestresourceinassistinganindividualinmanagingstressandachievingtheirgoals.Atthesametime,thismodeloffamilyworkdrawsoutandstrengthensthefamily’sassetsbydevelopingandpracticingessentialskillsaroundcommunicationandproblemsolving.Thisapproachclearlytargetstheefficiencyofthefamilyinreducingstressandconflictandthus,vulnerabilitytorelapseandnegativesymptoms.

AkeygoalintheearlystagesoftheBFTmodelistoharnessandpromotecollectiveunderstandingofthesignsandeffectsoflivingwithamentalillnessthroughclearcommunicationandworkingandplanningcollaborativelyaroundproblemsandgoals.Inthisrespect,themodelencouragesconsensus.

Atthecoreofthistypeoffamilyworkisapsycho-educationalapproachbasedonsociallearningprinciples.Here,thefamilyworker’srolecouldbeconsideredasmoreofa‘coach’.Thispracticalskillsapproachfocusesonpositivereinforcementofspecificstylesofinteractionsthatdecreasestressinfamilyrelations.1

the main elements of the BFt model are:

•Engagement•Assessment:

Eachindividualfamilymember;family’scommunicationandproblemsolvingabilities

•Education/Informationsharing:Incorporatingconsumers,carers,clinicians’experienceandunderstandingaroundtheconditionandrelapsepreventionstrategies

•Communicationskills•Problem-solvingskills•Boostersessions

BFTinvolvesaninitialmeetingwiththefamily.Afterengagement,familymeetingsareusuallyscheduledweeklyforanumberofsessionsandthenmovetoafortnightlyfrequency.Eachsessionlastsforonehourandcanbehomeorcentrebased.Theaveragelengthoftheworkwitheachfamilyis12to16sessionsandrangesfromaperiodofsixtoninemonths.

the main assumptions of the BFt approach

Weacknowledgethatthefamilyisdoingthebesttheycanunderdifficultcircumstances,whilstcopingwiththeeffects

OneofthekeyprinciplesofBFTisthatthefamilyisseenasthegreatestresourceinassistinganindividualinmanagingstressandachievingtheirgoals.Atthesametime,thismodeloffamilyworkdrawsoutandstrengthensthefamily’sassetsbydevelopingandpracticingessentialskillsaroundcommunicationandproblemsolving.





ofmentalillness.Nevertheless,theprovisionofrelevantinformationandfacilitatingthesharingofindividualexperiencesandunderstandingaboutlivingwithmentalillnessareessential.Atthesametime,promotingthefamily’sabilitytoidentifythesignsandacknowledgetheeffectsandpatternsofstressandillnessthatleadtorelapseorpromotenegativesymptoms,arekeypracticesofthemodel.

Weknowthatthroughenhancinginteractiveskills,basedaroundcommunicationandproblemsolving,strengthensfamily’sdefusingandcopingabilities.This,inturn,supportstheminworkingtowardspersonalandcollectivegoals.Wealsoknowthatfortifyingthefamily’sresourcesandskillstothepointatwhichtheworker’shelpandcoachingisnolongernecessary,empowersthefamilytoindependentlyaddresstheirproblemsandworktowardstheirgoals.

Finally,theBFTapproachispremisedonattendingtotheneedsofallfamilymembers.Thispromotesabalanceforindividualfamilymemberstoworkontheirownneedsandgoalswhilesupportingtheneedsandgoalsofthepersontheycarefor.

Family work in practice

AssessmentinBFSTislargelybasedonthefamily’sideasabouttheirgoals,andwhattheywouldliketoachievethroughfamilywork.Thisiscombinedwiththeirviewsontheirstrengthandskillsinworkingoutday-to-daydifficulties,andtheworkers’observationsofthefamiliesproblem-solvingandcommunicationskills.

SomefamilieswhohavecompletedtheBFSTprogramdescribetheircommunicationskillsasgood,andthattheyalreadytalktoeachotheralot.Inthesecases,familieshavechosentogotoBFSTforhelpinunderstandingsignsofbecomingunwellandtolearnmoreabouthowtomanageinacrisis.Manyfamiliesintheprogramhavenothadtheopportunitytodothistogetherasafamily.Someconsumerssaidtheyare‘sickofbeingsick’,andwouldliketobedoingaswellasotherpeoplelivingwithmentalillness.Oneconsumertoldushowmuchdifficultyhehadinday-to-dayplanning,ashedidnotknowhowhewouldbefeelingphysicallyormentallyandthiswasasignificantbarriertoemploymentandstudy.Consumersandtheirfamiliescanfeelhelplessinthefaceofsymptomsofmentalillness,buttheystillhavehopethatthingscanandwillbedifferentfortheminthefuture.

AsBFSTworkers,weintroducetheideathatitispossibletohavesomecontrol(whichiswhatfamilieshavebeensearchingfor),andwelookatearlywarningsignswiththem,whichgivesthemanopportunitytodothistogetherasafamily.Eachfamilymemberoftennoticesdifferentthingssoweareabletodevelopaplanofactiontogether.Followingthesesessions,thefamiliesmayhaveachangedexpectationthatitispossibletopredictwhatmighthappen,andacttostaywellinawaythatissupportiveofeachother.Weprovideopportunitiesforfamilymemberstosharetheirexperiences,andastructureforhowtheycanusetheseexperiencesinthepresentandfuture.

Throughoutthefamilywork,wereferbacktotheplanandtoindividualfamilymembers’goals,andthefamiliesalsoreferbacktoandadapttheseaswegoalong.AttheendofBFSTsomefamiliestoldusthattheyarerecognisingsignsandactingonthemfaster,andhaveasharedunderstandingaboutwhathappensandwhattheycando.Peoplewhohaddifficultyplanningaheadhavenowstartedmakingplans.ThisistheunexpectedpathwayinBFST,asasmallnumberofconsumersandcarershavedevelopedtheconfidencetoplan,lookfor,getvocationalsupportandfindajob.

Inourimmediateresponsetotheconferencetheme,weironicallyexcludedourownfamilyworkasbelongingtoalegitimatepathwaytosocialinclusion.Sincethen,we’vereconsideredourworkandbelievethatitreallyallowsgreatopportunitiestoopenupwithinfamilies.Webelieveithasaplaceinthethinkingaroundsocialinclusion,suchasbeingonesteptowardsworkingormaintainingworkforbothcarersandconsumers,andinparticipatinginfamilylife.

References

1TwoimportanttextsthatdescribetheBFTmodelare:FamilyWorkManual(Falloon,Faddenetal.,2004)&BehavioralFamilyTherapyforPsychiatricDisorders(Mueser&Glynn,1999)

Falloon,I.,Fadden,G.,Mueser,K.,Gengerich,S.,etal.(2005),Familyworkmanual,TheWestMidlandsFamilyProgram,Meriden

McFarlane,W.R.,Dixon,L.,Lukens,E.,Lucksted,A.,(2003),Familypsychoeducationandschizophrenia:Areviewoftheliterature,Journal of Marital and Family Therapy,29(2),p223–245

Mueser,K.,Glynn,S.,(1999),Behaviouralfamilytherapyforpsychiatricdisorders(2nded.),NewHarbingerPublications,Oakland

Silver,H.,(2007),SocialExclusion:ComparativeAnalysisofEuropeandMiddleEastYouth,Middle East Youth Initiative Working Paper,p15,accessed11thMay2010at:http://en.wikipedia.org/w/index.php?title=Social_exclusion&oldid=350273861





Consumer participation in research is a recent development in mental health system reform, which brings a fresh perspective to the research community. Despite potential limitations associated with conducting consumer research, it is an effective form of research directly addressing consumers’ needs, expectations and priorities. However, in order for this innovative approach to reach its enormous potential, it is important that necessary supports are in place. This will require that the research community review some of its more traditional perspectives, so that consumer research can be embraced. The importance of consumer research cannot be underestimated, as it has the potential to create better relationships between consumers and researchers, which can facilitate greater knowledge and understanding, and subsequently support cultural change in mental health research and mental health system reform at large.

Consumerparticipationinresearchhasmadenoticeablecontributionstomentalhealthsystemreform.Forinstance,themodernconceptofrecoverywasdevelopedbasedonconsumerliterature.1Inparticular,PatriciaDeeganisaconsumer

researcherwhohasbeenwidelyreferredtoasthe‘prophet’oftheconceptofrecoverybycoiningthetermin1988.PriortocompletingherPhD,Deeganreceivedadiagnosisofschizophreniaandwasabletoutilisethislivedexperiencelaterinherresearchcareertoillustratetheadvantagesofconsumerresearch.2Whileconsumerparticipationinresearchhadlongbeenusedtoassistintheshapingofvariouspoliciesandservices,3–5itwasfollowingsomeconsumers’pioneeringworkthatthementalhealthsectorbegantoactivelyadoptthisimprovementinitiative.However,concernscontinuetoberaisedregardinghowconsumerresearchalignswithmoretraditionalresearchapproaches,aswellashowconsumerscanbestbeinvolvedinresearch.

the importance of consumer participation

Theconceptofinvolvingconsumersinthedevelopmentofproductsandserviceshasbeenrelativelylongstanding,withearlystagesrecognisedinurbanplanninginthe1960s.3Ratherthanconsumersbeingviewedaspassiveobjects,consumerparticipationreferstotheiractiveinvolvementinresearch,evaluation,anddecision-makingprocessesrelatingtotheservice.6Consumerparticipationisconsideredtobeof

Coupledwithpositiveinteractionwithconsumerandcarerresearchers,theresearchprocesswasfoundtobegenerallytherapeuticandempoweringwithsomeparticipantsreportingthattheyfeltlistenedtoandhighlyvaluedfortheirinput.Thisfeedbackhasfurtherenforcedtheresearchteam’sbeliefthattheresearchprocessisjustasimportantastheoutcome.

Consumer participation in research

lei Ning, DeputyDirectorandProjectManager,Wayne Weavell,SeniorProjectOfficer,Sally Woodhouse,ProjectOfficer,VictorianMentalIllnessAwarenessCouncil(VMIAC)

particularimportanceinhealthcarebecausetherearefewalternativeindicatorsinascertainingtheeffectivenessofservices.7Inthe1970s,theWorldHealthOrganisationindicatedthatsuchparticipationisakeycomponentofeffectiveprimarycare,whichwaslaterembeddedasoneoftenprinciplesintheDeclarationofAlma-Ata:

‘The people have the right and duty to participate individually and collectively in the planning and implementation of their health care’.8

Morerecently,ithasbeenacknowledgedthatconsumerparticipationismorethanjustaright,withpotentialbenefitsforboththeconsumerandtheservice,particularlyinrelationtothementalhealthsector.Withinthecontextofmentalhealth,‘consumer’referstopeoplewhouse,haveused,orareeligibletousementalhealthcareservices.9In1993,thereleaseoftheBurdekin Reportdescribedhowgreatsufferingcanbecausedfortheconsumerthroughtheexperienceofsocietalstigmaanddisempowermentinthementalhealthsystem.10Atasimilartime,theWorldHealthOrganisation’sConsumer participation manual11recognisedthatasaconsequenceofexperiencewiththementalhealthsystem,consumersareideallypositionedtomakeamajorcontributiontothestructureanddeliveryofmentalhealthservicesandthattheserviceswillbenefitfromtheirexpertise.Anemergingapproachtowardsharnessingthislived-experienceexpertiseisthedevelopmentofconsumerparticipationinresearch.

Consumer participation in research

Althoughitisgenerallyacceptedthatconsumerparticipationshouldbearequirementofhealthcareresearch,thereisconsiderablecontentionsurroundingtheinvolvementofmentalhealthconsumers.Theoverridingissuesaroundthistypeofconsumerparticipationare,firstly,whetherornotitisethicaltoinvolvepeopleinresearchwhentheyarementallyunwell,andsubsequentlythe‘representativeness’oftheconsumerswhoarewellenoughtoparticipate.9,12–13Someresearcherssuspectthatconcernsofrepresentativenessmaybeasubconsciouswayofavoidingconsumerparticipation.12

Conversely,someconsumershavebeenplacedinpositionsofleadingresearchprojects,14whichhasraisedfurtherconcernsaboutthereliability,validityandobjectivityofconsumerresearch.3,13,15–16

Despitetheseconcerns,consumerparticipationinresearchdemonstratessignificantbenefits.Firstly,consumerstendtoenhancetherelevanceoftheresearchbeingundertakenthroughaninherentcapacitytoidentifyinequalities,proposerelevantresearchquestions,indicateappropriatenessofresearchprotocols,provideinsightfulinterpretationsofresults,andassistwiththeimplementationoffindings.6,9,13,16Theinvolvementofconsumersonaresearchteamalsoaidsinrecruitingparticipantsandputtingthematease,astheteam

isconsideredlessintimidatingandmoreamicabletootherconsumers.6,16,17Furthermore,participatinginresearchmayenableconsumerstobuildnewskillsanddevelopconfidencethroughtakinganactiveroleintheircare,allofwhichareconsideredbeneficialtowardsrecovery.15,16Recognisingtheuniquecontributionoflived-experiencetoresearch,FaulknerandThomasstatethat:

‘A marriage of two types of expertise is the essential ingredient of the best mental health care: expertise by experience and expertise by profession’.15

Itisimportantthatpotentialconsumerparticipantsarepresumedtohavecapacity,ratherthanincapacity,andareencouragedtomaketheirowndecisionsaboutparticipation.Similarly,ratherthansimplyfocusingonprofessionaltrainingandqualifications,consumerresearchersshouldbegivenaccesstoappropriateresources,aswellasmentoringandtraining,andethicscommitteesshouldvaluelived-experience.

Models of consumer participation in research

Inthecontextofconsumerresearch,researchersmaybedividedintothreeprimarycategories:professionalresearchers,academicconsumerresearchers,andconsumerresearchers.Professionalresearchersarethosewithacademicqualificationsandexperienceworkinginaprofessionalsetting.6Professionalresearchersmaynothavedirect,livedexperienceasaconsumer,buttheymaydrawontheinputofconsumerswithintheirresearch.Similarly,academicconsumerresearchershaveformalqualifications,researchexperience,andworkinanacademicsetting,howevertheseresearchersalsobringtheirlivedexperienceofmentalhealthorrelatedproblemstotheirworkasaresearcher.6Alternatively,aconsumerresearcherissomeonewhodrawsprimarilyontheirlivedexperienceasamentalhealthconsumerintheirresearch.Consumerresearchersmayormaynothaveformalresearchqualifications.6

Beresfordisconsideredtobetheprincipalacademicresearcheronthistopic,andisinternationallyrenownedforhisworkonconsumerresearch.Beresford9identifiedthreelevelsofconsumerparticipationinresearch.Thefirstlevelisconsumerinvolvementresearch,wherebyconsumersactasadvisorstovaryingdegreesintheresearch.Forexample,consumersareconsultedforadviceaboutcertainaspectsofaprojectsuchasquestionnairedesign,thereviewofplainlanguagestatementsortocontributeasmembersofanadvisorycommittee.9,14,16Thesecondleveliscollaborativeresearch,whichreferstoapartnershipbetweenconsumersandresearchersinallaspectsoftheresearchprocess.9,14

Thethirdlevelisconsumerresearch,whereresearchisinitiated,directedandledbyconsumers.Consumerresearchhasastrongcommitmenttoequalityintherelationshipbetweenresearchersandresearchparticipants.

An illustration of consumer research

TheauthorsofthisarticlearecurrentlyconductingaprojectentitledtheConsumerandCarerExperienceofCareandSupport(C&CExperience)Initiative,whichisbasedonrecommendationsofthereviewof2003–2004Victorianconsumersurveys.18

Theprojectaimstosurveyconsumersandcarersregardingtheirexperienceofcareandsupportwithinmentalhealthservices.Theprojectcommencedinlate2006,whentheconsumerandcarerresearchteamconductedmorethan20state-widediscussiongroupstoconsultwithconsumersandcarersregardingthemesthatwouldbeimportanttoaddressinthesurvey,aswellasconsultingthemaboutthemostappropriateresearchmethodologytocapturetheexperiencesofotherconsumersandcarers.Theconsultationresultswereanalysedtoinformthedesignoftheresearchinstrumentsandmethodology.

Thisapproachaffirmedoneofthemainprinciplesofconsumerresearchwherebyresearchagendaisdeterminedthroughconsultationwithpotentialresearchparticipantstoensurethatitbestreflectstheirneeds,expectationsandpriorities.Themethodologyoftheprevioussurveyswasabolishedduetotheconsultation,andanewandinnovativewaytocombinequantitativeandqualitativeresearchmethodswasestablished.

Thenewmethodologyinvolvedthreetiersofinformationgatheringtoreflecttherichnessofconsumerandcarerexperience,whichquestionnairesalonecannotachieve.Theinformationcollectionwasconductedvia:questionnaires,individualinterviewsandfocusgroups.Insteadofthemail-out/mail-backmethod,thequestionnaireswereadministratedusingcomputerassistedtelephoneinterviews,whichimprovedresponseratessignificantlyfrompreviousconsumersurveys.Theface-to-faceindividualinterviewsandfocusgroupsprovidedfurtheropportunitiesforconsumersandcarerstoarticulatetheirexperiences.

Also,integraltotheeffectivefunctioningofthisresearchprojectwastheequalpartnershipbetweenconsumerandcarerresearchparticipants,serviceproviders,governmentofficialsandtheconsumerandcarerresearchteammemberstoaccommodatetheneedsofallstakeholders.Coupledwithpositiveinteractionwithconsumerandcarerresearchers,theresearchprocesswasfoundtobegenerallytherapeuticandempoweringwithsomeparticipantsreportingthattheyfeltlistenedtoandhighlyvaluedfortheirinput.Thisfeedbackhasfurtherenforcedtheresearchteam’sbeliefthattheresearchprocessisjustasimportantastheoutcome.

Duringtheconsultationwithconsumersandcarers,inactionfrommentalhealthservicesregardingprevioussatisfactionsurveyresultswasidentifiedasaprimaryconcern.Toaddressthisissue,theresearchteamincorporatedthetheoryof

Experience-BasedDesignintoanexcitingnewapproachcalledMentalHealthExperienceCo-design(MHECO).MHECOintegratedtheresearchprojectintoservicequalityimprovementactivitiesthatengagedconsumers,carersandstaffmemberstoredesigntheservicebasedonthefindingsoftheC&CExperience.Thisnewpartnershipapproachprovidedatangiblemodelforconsumerandcarerparticipationandhighlyvaluedtheparticipants’experience-basedexpertise.Thisinnovativeinitiativehasfurtherdemonstratedtheadvantagesandcommitmenttochangeassociatedwithconsumerresearch,andhasconsequentlygarnerednationalandinternationalattention.19

References

1Anthony,W.A.,(2007),Toward a vision of recovery for mental health and psychiatric rehabilitation services,BostonUniversity,Boston

2Deegan,P.E.,(1988),Recovery:Thelivedexperience,Psychosocial Rehabilitation Journal,11(4),p11–19

3Beresford,P.,(2002),Userinvolvementinresearchandevaluation:Liberationorregulation?,Social Policy and Society,1(2),p95–105

4Lammers,J.,Happell,B.,(2004),Researchinvolvingmentalhealthconsumersandcarers:Areferencegroupapproach,International Journal of Mental Health Nursing,13(4),p262–266

5Phillips,R.,(2006),Consumerparticipationinmentalhealthresearch,Social Policy Journal of New Zealand,27,p171–182

6Griffiths,K.M.,Jorm,A.F.,Christensen,H.,(2004),Academicconsumerresearchers:Abridgebetweenconsumersandresearchers,Australian and New Zealand Journal of Psychiatry,38(4),p191–196

7Lloyd,C.,King,R.,(2003),Consumerandcarerparticipationinmentalhealthservices,Australasian Psychiatry,11(2),p180–184

8WorldHealthOrganisation(WHO),(1978),Primary health care: Report of the International Conference on Primary Health Care,WHO,Alma-Ata,Geneva

9Beresford,P.,(2007),Userinvolvement,researchandhealthinequalities:Developingnewdirections,Health and Social Care in the Community,15(4),p306–312

10Burdekin,B.,(1993),Human rights and mental illness, Report of the national inquiry into human rights of people with mental illness,AustralianGovernmentPublishingService,Canberra

11WorldHealthOrganisation,(1993),Consumer participation manual: A document to facilitate consumer participation in the mental health system,WHO,BritishColumbia

12Robert,G.,Hardacre,J.,Locock,L.,Bate,P.,Glasby,J.,(2003),Redesigningmentalhealthservices:LessonsonuserinvolvementfromtheMentalHealthCollaborative,Health Expectations,6(1),p60–71

13Telford,R.,Faulkner,A.,(2004),Learningaboutserviceuserinvolvementinmentalhealthresearch,Journal of Mental Health,13(6),p549–559.

14Rose,D.,(2003),Collaborativeresearchbetweenusersandprofessional:Peaksandpitfalls,Psychiatric Bulletin,27(11),p404–406

15Faulkner,A.,Thomas,P.,(2002),User-ledresearchandevidence-basedmedicine,British Journal of Psychiatry,180,p1–3

16Happell,B.,Roper,C.,(2007),Consumerparticipationinmentalhealthresearch:Articulatingamodeltoguidepractice,Australasian Psychiatry,15(3),p237–241

17Minogue,V.,Boness,J.,Brown,A.,Girdlestone,J.,(2005),Theimpactofserviceuserinvolvementinresearch,International Journal of Health Care Quality Assurance,18,p103–112

18DepartmentofHumanServices,(2005),Review of the 2003–04 Victorian surveys of consumer and carer experience of public mental health services,VictorianGovernment,Melbourne

19VictorianGovernmentDepartmentofHealth,(2006),Consumer and carer experience of support – A mental health quality improvement initiative,DoH,Melbourne

YOUR SAY...

Aspire A Pathway to Mental Health Inc. has its roots in the work of a group of a dedicated and passionate carers and community members who, in the late 1980s, identified the need for a support program for people in our community who have experienced mental illness and their carers. Incorporation and ongoing funding came about in 1995 and the organisation, then known as the Association for the Support of Psychiatric Services (ASPS), began to grow on the pillars of carer support, health promotion and education and individual support through day programs and home-based outreach, all strongly underpinned by consumer and carer involvement.

TheorganisationgrewfromitsWarrnamboolbasetoprovideservicesacrosstheentireSouthwestofVictoriawithregionalofficesinPortland,CamperdownandHamilton.Intheearly2000s,likemanyotherPDRSproviders,Aspiremovedintoa

moreproactiveandrehabilitation-focusedmodelofpractice.Wehave,overtime,developedastrongRehabilitationFrameworkbasedontheBostonUniversityCentreforPsychiatricRehabilitationmodel.In2005,AspirewassuccessfulingainingfundingtooperatesitesacrossTasmaniatodeliverrecoveryprogramsbasedontheRehabilitationFramework.

In2010,Aspireemploysapproximately60staffacrossVictoriaandTasmania.InVictoria,wedeliverrehabilitationandrecovery-basedprogramsinhome-basedoutreachandinskill-orienteddayprogramsacrosstheSouthwest.Over200participantseachyeartakepartintheseprograms.Ruralandregionalteamsexcelincollaboration:fromtheAreaMentalHealthServices,PDRS,andDrugandAlcoholsectors,tothewiderengagementofthecommunityandthenon-healthsectors.Themutualsupportandself-helpgroupDASH(Daily

Nodoubtoneofthegreatestassetsoftheorganisationisapassionateandcommittedgroupofstaffthatvaluenotjustwhattheydo,but,mostimportantly,thosetheyworkwithonaday-to-daybasis.Tobeabletoworkwithatruebeliefinrecovery,hope,respectandvalueempowersusall.

Member profile:Aspire, A Pathway to Mental Health

Philip Hose,StateManagerVictoria,AspireAPathwaytoMentalHealth



ActivitiesandSelfHelp)providespeersupportopportunitiesformembersfromtheWarrnamboolcommunity.

TheSageHillCarers’Serviceprovidessupport,informationandeducationtocarersacrosstheSouthwestandoperatesadiverserespiteprogram,includingtheFaHCSIA-funded(DepartmentofFamilies,Housing,CommunityServicesandIndigenousAffairs)respitefacilityThymeCottageinWarrnambool.OurHealthPromotionandEducationprogramprovidestrainingandeducationtoawidecrosssectionofthecommunity.ThisincludesextensivedeliveryofMentalHealthFirstAid,andYouthMentalHealthFirstAid:alongstandingschoolseducationprograminvolvingconsumersandtrainedfacilitatorsaswellasthe‘ReadthePlay’program,whicheducatesandtrainstheleadersandseniormembersoflocaljuniorsportingclubsincludingfootball,netballandcricket.

OthersmallerbutinvaluableprogramsincludeaHACC-funded(HomeandCommunityCare)programsupportingresidentsoflocalsupportedresidentialfacilities,andavolunteerprogramthatcomplimentsallofourprogramareasandassistsparticipantsintheirvocationaljourney.InTasmania,wearefundedtodeliverarecoveryprogram,wherefocusingstronglyontheRehabilitationFrameworkandencompassinggroupsandcommunitywereakeypartofthis.

Wehavebeenabletoestablish,throughFaHCSIAfunding,aSageHillFamilyandFriendsserviceinthenorthofTasmania,andarekeentoenhancetheopportunitiesforhealthpromotionandeducation.

ArecentreviewoftheAspiremissionstatementhashelpeddefineourVision,MissionandValues.Weidentifiedthekeyvaluesoftheorganisation:Professionalism,Dignity,Integrity,RespectandAuthenticity.(Thefulltextisavailableonourwebsiteatwww.aspire.org.au.)

AspirehasrecentlyundergoneaccreditationwithQUICSA(QualityImprovementandCommunityServicesAccreditation),whichhasputaconstructiveandpositivelightonqualityandhelpedstrengthentheorganisation.ReflectedverypositivelyinouraccreditationfeedbackwastheestablishmentofseniorpractitionersintheRehabilitationFramework,whoprovidetraining,mentoringandsupervisiontostaffinthetoolsandprocessofourworkineachstate.Wearealsodevelopingasuiteofcorecompetenciesforourpracticethatwillinformtrainingandinduction,supervision,appraisalandrecruiting.

Withsuchstronggrowth,andaswelooktowardfurtheropportunities,wehaverecentlybeenreflectingonhowanorganisationlikeAspirecanretainthevaluedhistoryofastrongconsumer-drivenculture.Nolongerareweasmall‘family-like’team,butwemustnotlosesightoftheverypersonalandhumanbasisofwhatwedo.

Nodoubtoneofthegreatestassetsoftheorganisationisapassionateandcommittedgroupofstaffthatvaluenotjustwhattheydo,butmostimportantlythosetheyworkwithonaday-to-daybasis.Tobeabletoworkwithatruebeliefinrecovery,hope,respectandvalueempowersusall.

FINDOUTMORE:TofindoutmoreaboutAspireandtheworktheydo,logontotheirwebsite:www.aspire.org.au,oryoucansendthemanemailattheirVictorianofficeataspire@[email protected].

This photo, by Shane Bell, was taken at the conference and shows one of the delegates taking some time out to ‘express herself’ at the Prahran Mission – Stables Art Studio exhibitor stand.

TheStablesArtStudiooffersstudiospacetoartistswithexperienceof,orwhoareexperiencingmentalillness.TheStablesisavibrant,evolvingandresponsiveprogramofPrahranMission.TofindoutmoreaboutTheStables,contact0396929533orvisitwww.prahranmission.org.au

‘Expression’ section

Book review

‘the Spirit level: Why more equal societies almost always do better’ RichardWilkinsonandKatePickett,PenguinGroup,London,2009

Reviewed by Anthea tsismetsi, PolicyandResearchOfficer,VICSERV

Gregor Henderson, keynote speaker at this year’s VICSERV conference commended The Spirit Level as a text, which wonderfully articulates the reasons why social inclusion is the key to successful health and social reform. What Wilkinson and Pickett suggest has the potential to revolutionise the policy agenda with the focus shifting from the health or social problem itself to the fundamental issue of inequality.

Thebasicpremiseofthebookisthatsocietiesarelikelytohavebetterhealthandsocialoutcomeswherethedisparitybetweenrichandpoorisless.Flowingfromthat,reductioninthegapresultsinthebettermentofhealthandsocialoutcomesforsociety.WilkinsonandPickettshowthatthebenefitsofgreaterequalityareexperiencedbyallsectionsofsociety,notjustthedisadvantaged.

Thecorrelationbetweengreaterinequalityandhealthorsocialoutcomesisstrong.Thesefindingsaresupportedbyvariousplottedgraphsusingdatarelatingto23ofsomeoftherichestcountriesaccordingtotheWorldBankaswellasstatesoftheUSAwhereavailable.

ThehealthandsocialissuesWilkinsonandPickettcompareandanalyseincludedatarelatingtolevelsoftrust,mentalillness(includingdrugandalcoholaddiction),lifeexpectancy,education,obesity,homicide,imprisonmentandsocialmobility.

Itissuggestedthathealthandsocialproblemsdonotimprove,thericheraparticularcountrybecomes.Withsomeoftherichestcountriesexperiencingagreatershareofproblems,thisblowsoutofthewaterthetheorythatcountrieswithgreatermaterialwealth

experiencebetterhealthandsocialoutcomes.Infact,astheauthorspointout‘[w]hereincomedifferencesarebigger,socialdistancesarebiggerandsocialstratificationmoreimportant’,(p27).

Oneofthereasonsputforthastowhyinequalityhassucheffectsisthatindividualsareparticularlysensitivetowhatothersthinkofthem.TheauthorslookatresultsofastudyindicatingamarkedincreaseinanxietyamongstAmericancollegestudentsbetweentheyears1950and1995correlatedwithanincreaseinwhatisdescribedas‘insecurehighself-esteem’,(p37).WilkinsonandPickettconcludethattheriseinanxietyisduetotheperceivedthreatofbeingsociallyevaluatedand,inturn,theinsecuritiesitgivesriseto.Thesefindingsarefurthersupportedbyotherstudiesdetailedinthebook.

Whatisofinterestishowgreaterequalitycanbeachieved.Thegoodnewsis,itdoesnotmatterhowgreaterequalityisachieved,whetheritisbytaxationorotherwisesolongastheresultisthelesseningoftheincomegapbetweenrichandpoor.Onewayinwhichtheauthorssuggestgreaterequalitycanbeachievedisthroughcooperativesandthenot-for-profitsector,asthemotivationofparticipantsisthegreatergoodratherthanachievinggreaterprofits.Thedevelopmentofconsumer-directedmentalhealthservicesisanexampleofpracticalapplicationoftheauthors’suggestion.

The Spirit Levelisamust-readforpolicyadvisers,advocatesandanyoneinterestedininfluencingthehealthandsocialpolicyagenda.OfparticularinterestishowAustraliaistravelling.TheresultsindicatethatAustraliahasalongwaytogoandthatachievementofgreaterequalityremainsforus,‘unfinishedbusiness’.





Collected thoughts – Educational Resource for VCE Psychology

ThisDVD,basedontheshortfilm,Collected Thoughts,hasbeenspecificallydesignedasaresourceforteacherswhoareteachingVCEPsychologyandprovidesanexcellentintroductionforstudentswhowillbevisitingTheCunninghamDaxGallery.ThemainfocusofthisresourceisthelifestoryoftwoMelbourne-basedartistsReneeSuttonandGraemeDoyle,bothofwhomhaveworkswithinTheCunninghamDaxCollection.

BothGraemeandRenee’slifeexperienceswithmentalillnessarestoriesofsurvival,meaningandcelebrationandthisDVDdemonstratestherolecreativityplaysintheirlivesandisaninnovativemeansofbringingthevoicesoftheseuniqueartistsintothepublicarena.

Collected thoughts 3: Richard Mclean

TheCunninghamDaxCollectionpresentsthisshortfilmprofilingtheartandlifeofartist,mentalhealthadvocateandauthorRichardMcLean.ThisfilmdocumentsRichard’sartpractices,artisticinfluences,relationshipsandactivities.ItalsofeaturesinterviewswithRichard,hisfamilyandacolleague.

Collected Thoughts 3,bothadocumentaryandaneducationalresource,providesinvaluableinsightsintooneindividual’sjourneywithmentalillnesswhilehighlightinghiscreativityandfortitude.

The Cunningham Dax Collection, located in Melbourne, is one of the world’s largest collections of creative works made by people with an experience of mental illness and/or psychological trauma. With works dating from the late 1940s to the present day, the collection includes drawings, paintings, textiles, ceramics, mixed media objects and artists’ books acquired from clinical and non-clinical settings.

FormoreinformationaboutTheCunninghamDaxCollection,visitwww.daxcollection.org.au

Both of these DVDs are available for borrowing from VICSERV’s Resource Centre. Please contact the Resources Coordinator if you would like to borrow these items, 03 9519 7000.

New to the Resource Centre

Research has shown that people with a mental illness frequently don’t complete secondary schooling or higher education. Often this is because 75 per cent of serious mental illness has its onset in late adolescence and early adulthood – a milestone period for young people’s education and learning trajectory.

Consequently,muchofthehighlevelofworkforcenon-participationratesamongstpeoplewithamentalillness(72percent)canbeattributedtoalackofeducationalattainment.Careerscanalsobeinterruptedlaterinlifebypsychoticepisodesand/oranxietyanddepressionsoseverethatitmakesitimpossibletofunctionproperlyinthemainstreamworkplace.Whatthisallmeansisthat,asagroup,peopleaffectedbymentalillnesstendtohaveverylowincomesandusuallyexperiencedifficultygettingbackintoeducationandenteringtheworkforce.

We are calling for contributions on this topic.

Weencouragearticlesthatmightcover:innovativeoralternativeapproachestoincreasingeducationandincomelevelsamongstpeopleaffectedbyamentalillness,thevalueofsupportededucationandemploymentprograms,thepeerworkforce,mentalhealthawarenessintheworkplace,socialfirmsandotherrelatedcasestudiesorresearch.

Coming up in newparadigm

TheWintereditionofnewparadigmisonthetopicofeconomicparticipation.

Fromleft:ElizabethCrowther–President,VICSERV,TheHon.LisaNevilleMP–MinisterforMentalHealth,KimKoop–CEO,VICSERV



ABOUt US

VICSERVisamembership-basedorganisationandthepeakbodyrepresentingcommunitymanagedmentalhealthservicesinVictoria.Theseservicesincludehousingsupport,home-basedoutreach,psychosocialandpre-vocationaldayprograms,residentialrehabilitation,mutualsupportandself-help,respitecareandPreventionandRecoveryCare(PARC)services.

ManyVICSERVmembersalsoprovideCommonwealthfundedmentalhealthprograms.

Our Vision

VICSERV envisages a society where mental health and social wellbeing are a national priority and:

•Everyonehasaccesstotimelymentalhealthtreatmentandsupport

•Mentalhealthservicesarerecoveryoriented•Peopleparticipateindecisionmakingabouttheir

ownlivesandtheircommunity•Peopleaffectedbymentalillnesshaveaccessto,and

afairshareof,communityresourcesandservices•Allpeopleareinvolvedasequals,withoutdiscrimination.



As the peak body for the community managed mental health sector in Victoria, we pursue the development and reform of mental health services.

We support members by:

•Promotingrecoveryorientedpractice•Buildinganddisseminatingknowledge•Providingleadership•Buildingpartnershipsandnetworks•Undertakingworkforcedevelopment,t

rainingandcapacitybuilding•Promotingqualityinservicedelivery•Undertakingadvocacyandcommunityeducation

Our Mission

Collaboration (Teamwork)

• Workingtogethertoachievesharedobjectives• Respectingtheknowledgeandskillsofothers• Puttingtheneedsoftheorganisationabove

individualinterests

Inclusiveness

• Listeningtoarangeofviews• Representingandembracingthediversityofthesector• Honouringtheconsumerandcarerexperience

Flexibility

• Proactivelyembracingchangeandnewopportunities• Steppingupandoutfromourrolesandperspectives

whenrequired

Courage

• Takingleadershipbyspeakinguponimportantissues• Encouragingandsupportinginnovation• Persistenceinthefaceofobstaclesanddelays

Integrity

• Doingwhatwesaywewilldoontimeandtothebestofourability

• Listeningandrespondingtomembers• Havingarespectedvoiceandvisibilityinthesector,

broadersystemandingovernment•Beinganhonestbroker

Our Values



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Theabovenamedorganisation(orindividual)herebyappliesformembershipofPsychiatricDisabilityServicesofVictoria(VICSERV)Inc.andnominatestheabove-namedpersonasthecontactpersonforallcorrespondence.Uponacceptanceofthisapplication,PsychiatricDisabilityServicesofVictoria(VICSERV)Inc.isauthorisedtoinsertthenameofthisorganisation(orindividual)intheregisterofmembersoftheincorporatedassociation.WeherebyagreetoabidebytheRulesofPsychiatricDisabilityServicesofVictoria(VICSERV)Inc.

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Psychiatric Disability Services of Victoria (VICSERV) Level 2, 22 Horne Street, Elsternwick Victoria 3185 Australia T 03 9519 7000 F 03 9519 7022 [email protected] www.vicserv.org.au