WORKING TOWARDS RECOVERY

Shane Martin, B.A., H.Dip.Ed., Dip.Psych., MSc.Psych.,Reg.Psychol.,Ps.S.I.Rehabilitation Psychologist

WORKING TOWARDS RECOVERY

Ireland of 2006 The Reality of Mental Illness Mental Health Services since 1984 The crucial role of work within recovery

Challenges ahead

Mental Health in Ireland: SETTING THE CONTEXT

Ireland has undergone considerable social change in past 20 yrs.

Population up by half a million ( nearly 4m currently)

Age structure- fewer chlidren, more older people

Much wealthier. GDP (Gross Domesic Product) tripled in last 10 yrs

High unemployment of 1980’s evaporates ( 15% then, 4% now)

Mental Health in Ireland: SETTING THE CONTEXT

Today – serious inequalities exist

Relative income poverty still high by EU standards

Family structure has changed

More people living alone ( 22% of all households, 2002)

Mental Health in Ireland: SETTING THE CONTEXT

114,000 lone parent families

Main carers were women. Now more women in the ‘formal’ workforce ( 50% of 15-64 yr.s olds employed)

Less informal health care available

Ethnic and cultural structure has changed. ( 6% born outside of Ireland in 2002 – 10% currently)

QUALITATIVE CHANGES HARDER TO COUNT……..

Society is more rushed

People are working longer, commuting more

Modern lifestyle supported by new money (mostly credit) New pressures to sustain it

Less caring, shortage of volunteers

QUALITATIVE CHANGES HARDER TO COUNT……..

More materialistic

Youth have more freedom

Drug abuse

Crime

The Reality of Mental Illness

Lots of depression, anxiety, stress

Thousands suffer in silence

Thousands of lives shattered

Thousands of families shattered

The Reality of Mental Illness

Inadequate resources and supports

Treatment/supports have been inadequate for many thousands over the years

Mental Illness

WHO IS VULNERABLE?

WHY ARE PEOPLE VULNERABLE?

WHAT DO THEY NEED ?

Who are these people?

Looking back…………

Understanding of mental illness has been changing over the decades

1870’s asylyms for ‘everything’

2000’s community-based approach; evidence-based approach

A medical approach predominates

Hospitalisation

In recent decades….. De-institutionalisation Community-orientated model emerges Service-users ‘voice’ is louder and being heard

Medical approach – Societal approach

Recovery Model becoming a standard

‘PLANNING FOR THE FUTURE’ (1984)

Examined psychiatric services

Proposed a new model of mental health care

More comprehensive

Multi-disciplinary approach

‘PLANNING FOR THE FUTURE’ (1984)

Community care

Better co-ordination of services

Care within the home

Community-based services

Support for families

DEVELOPMENTS FOLLOWING ‘PLANNING FOR THE FUTURE’

General Hospital Psychiatric units – 8 in 1984, 22 in 2004

Psychiatric beds decreased by 67% in same period

Resident patients and admissions have also decreased

The Silent Revolution……………..

1984 2004

In-patients in psychiatric 12,484 3,556

Hospitals

Long-stay patients 7,086 1,242

(>5 yrs.)

New Long-stays 2,083 615

(>1 yr. < 5 yrs)

The Silent Revolution……………..

1984 2004

Admissions 28,830 22,279

First admissions 8,746 6,136

Outpatients 200,321 212,644

Day HospitalAttendees 0

162,233

Day Centre 0 413,771

The Silent Revolution……………..

1984 2004

Psychiatric beds 12,484 4,121

General HospitalPsych. Units 8

22

Day Hospital Places 0 1,022

Day Centre Places 0

2,486

Other significant developments

Mental Health Act (2001) Mental Health Commission Inspector of Mental Health Services

The reality on the ground Mental Illness is still here The menu of potential interventions/ supports is very limited

Stigma still alive and well Enduring mental illness – now within the community rather than the hospital

Enduring mental illness Unemployment within this group is approximately 85% (VandenBoom & Lustig, 1997)

Integration through Employment; are these people part of the ‘dream’?

Between 60-70% want to work Tiny fraction avail of S.E.

Enduring mental illness Work is extremely important in a person’s life, providing direct ecomonic and social benefits and contributing to self-esteem and quality of life. (Fabian & Coppola, 2001)

All important but elusive goal Unemployment often an inroad to mental illness

Unemployment blocks recovery

Enduring mental illness Bias, stigma, discrimination among persons with enduring mental illness in the area of employment

Vocational placements limited to areas as food service, gardening. laundry and janitorial service

THE FOUR F’S (Garske & Stewart, 1999) Food Flowers Folding Filth

But can these clients work? Traditionally mental health practice emphasied the stabilisation of symptoms

The protection of people with enduring mental illness from the expectations and stresses of normal adult life and community roles

But can these clients work? Tried intermentiate steps in highly protected.segregated settings

Sheltered Workshops Pre-Vocational Work Units Enclave jobs Businesses managed by Mental Health Services

But can these clients work? A Step-wise approach to prepare for competitive employment

Low expectations – long lasting

But can these clients work? During 1980’s Wehman and Moon (1988) conceptualised supported employment as a ‘place-and-train’ model

Reversing the practice of pre-vocational training prior to finding a job

Evidence-based supported emplyemnt is clearly established since late 1990s

Not widely implemented (Bond, Becker et al.,2001)

But can these clients work? “..substatial increases in rates of compettitive employment without adverse outcomes.” (Drake et al, 1994; Drake et al 1996; Bailey et al, 1998; Becker et al, 2001)

“..clients, families and providers preferred supported employment.” (Torrey et al. 1995)

But do they get jobs? One review (Bond et al, 1997) 58% obtained competitive employment within 12-18 months compared to 21% in the vocational training centres.

In Hartfort, Connecticut – over 24 month period supported employment clients had better employment outcomes than those in rehabilitation programmes (Mueser et al. 2004)

But do they get jobs? Research demonstates consistently that clients do not experience negative consequences such as increased symptoms, hospitatisation, suicide, drop-out etc

Most clients obtain part-time jobs (starting at 10 hours) Longer tenure when jobs are consistent with their preferences (Frarbaugh and Bond 1996)

But do they get jobs? One 10-year follow up study showed that clients in supported emplyment did better in terms of satisfaction and job tenure (Salyers et al, 2004)

What kind of S.E. is this? Competitive jobs based on a person’s preferences for type and amount of work

Rapid job seeking when person expresses interest ( self-intiated)

Minimal pre-vocational preparation and assessment

Follow-one supports

Pre-requisites Service-user at the heart of it – tailored to each unique individual

Adequate training of job coaches Partnership with relevant health professionals – a team approach

Supervision facility for job coaches

Pre-requisites Real jobs! Support continues from the job coach for as long as it’s needed

Flexibilty, sensitivity, Empathy, hope

Challenges? Ownership Negotiation Partnership Training New Systems