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PubMed2000

Architecture signifying social control: the restoration of asylumdom in mental health care?

Prior to the era of community care, the asylum has been an architectural manifestation of the power of psychiatry and the State. Asylumdom was a period in which custodial warehouses were used by the State to store sections of the population considered to be 'unreasonable'. There are signs, however, of a re-birth of asylumdom in both the UK and Australia. For example, there is a projected growth in the number of 'secure units' in the community, and a growing concern with issues of security and risk management in mental health care. Furthermore, new technologies for containment and surveillance are being installed in acute inpatient psychiatric units. Once again the asylum will symbolize emphatically the authority of the State (and its agencies of social control), and re-emphasize the exclusion of 'unreason' from the 'reasonable' society.

Architecture↗
PubMed2002

Risk assessment and management: a community forensic mental health practice model.

In Victoria, the Crimes (Mental Impairment and Unfitness to be Tried) Act (1997) reformed legal practice in relation to the detention, management and release of persons found by a court to be not guilty on the grounds of insanity or unfit to be tried. This Act provides a legal structure for such 'forensic patients' to move from secure inpatient facilities into the community. This new legislative landscape has generated challenges for all stakeholders and has provided the impetus for the development of a risk assessment and management model. The key components of the model are the risk profile, assessment and management plan. The discussion comprises theory, legislation, practice implications and limitations of the model. Practice implications concern the provision of objective tools, which identify risk and document strategic interventions to support clinical management. Some of the practice limitations include the model's applicability to risk assessment and management and its dependence on a mercurial multi-service interface in after-hours crisis situations. In addition to this, the paper articulates human limitations implicit in the therapeutic relationship that necessarily underpins the model. The paper concludes with an exploration of the importance of evaluative processes as well as the need for formal support and education for clinicians.

Community Mental Health Services↗
PubMed2003

The new neighbor: experiences of living next door to people suffering from long-term mental illness.

The transition from hospital to community care for people with long-term mental illness is of growing concern. The aim of the present study was to illuminate if and how people with long-term mental illness have affected their neighbourhood after re-establishing themselves in apartments of their own. Nineteen neighbours of group homes for people with long-term mental illness, in seven different communities in eastern Norway, have been interviewed. The grounded theory procedures as well as the constant comparative method were employed to analyse the findings. From the data, one main category was identified: the need for information.

Adaptation, Psychological↗
PubMed2002

Comparison of user assessed needs for care between psychiatric inpatients and supported community residents.

The aim of the present study was to compare user assessed needs for care for psychiatric patients in inpatient settings with that of residents in supported community residences. The Camberwell Assessment of Need was administered to 75 patients and residents in different housing settings. Residents in supported community settings had more needs for care (8.1), than patients in inpatient settings (5.8), partly because of differences in duration of illness. A greater proportion of those living in supported community residences reported needs in the areas of psychotic symptoms, accommodation, food, daytime activities, sexual expression and looking after the home. There were no differences in numbers of unmet needs. Relatives and friends provided emotional and social support predominantly in the areas of company and psychological distress. In conclusion, living in supported community residences does not imply more unmet needs, or less adequate response to needs from services, despite a greater number of needs being reported. In some areas of need, relatives and friends play an important role in the provision of support.

Adolescent↗
PubMed2002

Need assessment and quality of life in outpatients with schizophrenia: a 5-year follow-up study.

The present study is a 5-year follow-up of patients with schizophrenia who were in-patients for more than 3 months in 1993. In all, 19 patients fulfilled the criteria and were interviewed 6 months after their discharge. Seventeen of them also participated in a follow-up 5 years later. Their needs were independently rated by themselves and by their key workers according to the Camberwell Assessment of Need (CAN, research version 3.0). The interview with the patients also included quality of life assessed by the Quality of Life Scale (QLS-100). The results from CAN showed a difference when using a cut-off point for higher vs. lower problem at 10 needs. Using this cut-off point, five patients at the baseline and one at the follow-up had higher problems. The need ranking with key workers showed a correlation of rho = 0.68 at the baseline and rho = 0.74 at the follow-up. QLS-100 showed that the patient's total number of unsatisfied items were significantly higher (p = 0.01) at the baseline than at the follow-up. At the follow-up, full insight into their illness was shown by most of the patients. There are several possible explanations associated with the increased quality of life, e.g. less unsatisfied items among some patients and greater autonomy at the follow-up.

Activities of Daily Living↗
PubMed2003

Integrating mental health care into residential homes for the elderly: an analysis of six Dutch programs for older people with severe and persistent mental illness.

Integrating mental health care into residential homes for the elderly is a potentially effective model to address the complex care needs of older chronically mentally ill people. Because no research was available on the implementation of such integrated care in practice, six programs already operating in the Netherlands were analyzed. At the administrative level, three types of cooperative arrangements existed: a psychiatric hospital renting a unit in a residential home for the elderly, a psychiatric hospital stationing mental health professionals in a residential home on a permanent basis, and a residential home employing its own psychiatrically trained staff. At the operational level, contrasting views emerged on the relation-ship between physical and mental health care; these were delivered separately or in integrated form. In either case, the employees trained as elder care workers or as psychiatric nurses had difficulties understanding each other because they held different ideas about good-quality care. These care visions can be characterized as the care-giving approach (care workers) versus the problem-oriented and the rehabilitation approaches (nurses). At the housing level, two models existed: mentally ill patients having apartments in a separate unit (concentrated housing) or located throughout the facility (dispersed housing). The most promising model appears to be the one in which a psychiatric hospital assigns mental health professionals to work in a residential home, where they remain administratively and operationally distinct from the standard residential services. Whether or not the psychiatric residents should be housed in separate units could not be decided based on this study.

Activities of Daily Living↗
PubMed2000

[Rehabilitation concepts of schizophrenic patients treated in community psychiatry].

In a cohort of patients with chronic schizophrenic disorders (n = 115) characterized by many social deficits and a high level of psychopathology, suggestions concerning rehabilitation were examined in an exploratory way and analysed referring to their relevance for community psychiatric care. The schizophrenic patients were followed up 1 and 12 months after discharge from hospital using an extensive array of instruments (among others: Needs for Care Assessment, Berlin Inventory of Care Needs). Included was a guided interview focusing on patients' subjective views relevant for the course of the disorder and for therapeutical procedures. Using a content analysis of the verbal material received at both points of study, the following main defining elements of the term rehabilitation (or reintegration, resp.) could be identified from the patients' perspective: vocational reintegration, independent residential setting, recovery of normality, and acceptance of responsibility. The rate of individualized confirmation in each category established after the first interview was between 75% and 93% 1 year after discharge from hospital.--Results from multiple and logistic regression analyses demonstrate that a higher degree of differentiation concerning individual rehabilitation suggestions exerts influence on the extent of subjective and normative needs for (psychiatric) care at the first point of study and moreover can be identified as a predictor of the decrease in the normative needs for care during the study period. To differentiate schizophrenic patients' suggestions referring to this subject can therefore be declared a therapeutical task. Furthermore it is a must to adjust individualized expert-based and subjective suggestions concentrating especially on the patients' main point of emphasis, i.e. vocational rehabilitation.

Adult↗
PubMed2001

[How do mentally ill homeless persons evaluate their quality of life].

Besides pronounced deficiencies in psychiatric research concerning homeless mentally ill in Germany, studies concerned with the quality of life of homeless mentally ill were missing until now. This study reveals in a representative sample of 102 homeless people from the City of Mannheim, Germany that--compared to the homeless without psychiatric disorders of the sample--the mentally ill homeless (prevalence 68.6%) have significantly different subjective views of their quality of life regarding the items "state of health", "physical capabilities" and "support from others". The differences were even stronger if the homeless mentally ill were compared to a group of non-homeless mentally ill schizophrenic patients (n = 104), cared for in the City's well-equipped community care services. Community care patients reported a significantly better quality of life in respect of 11 items. These results were seen as a success of the concept of community-based mental health care. The consequences for improving care strategies for homeless mentally ill are discussed.

Activities of Daily Living↗
PubMed2001

[Community-based rehabilitation for severely ill psychiatric patients?].

A central aim of reformatory efforts, as a consequence of the "Psychiatrieenquete" 1975 (a fundamental report of the situation of psychiatry in Germany), had been dehospitalisation of patients with chronic mental illness and their reintegration into the community. Despite a meanwhile well-developed range of community-based services, patients with severe mental illness only rarely get adequate care by these services. This holds especially true for patients with an unfavourable course of disease such as schizophrenia, severe personality disorder, skid-row alcoholism with multiple problems or for patients with double diagnosis. The reasons are barriers set up by the various services and their underlying concepts as well as structural problems in the health care system. Adapted to the special needs for help of these patients, we present a model for the community-based care of this group, combining elements of community psychiatry, addiction treatment and help for the homeless.

Alcoholism↗
PubMed2001

[Long-term patients in supported housing after deinstitutionalisation--part V of the Berlin Deinstitutionalisation Study].

OBJECTIVE: In part IV of the Berlin Deinstitutionalisation Study, we reported a positive change in quality of life for 65 resettled patients one year after discharge. In this part, we investigated changes in a longer follow-up period. METHODS: A group of 66 patients discharged into supported housing was assessed one and five years after baseline. Quality of life, needs for care, patients' assessment of treatment, re-hospitalisation and characteristics of care were studied in a control-group design. RESULTS: After five years, 61 % of the patients continued to live in highly staffed settings (mean staff-patient-ratio: 1 : 3.5). Eleven percent had moved on to independent living and 16 % had returned into an institutional setting. Standard mortality ratios were 4.4 (all causes of death) and 62.5 (2 suicides only of schizophrenic patients). After one year patients (n = 20) showed a significant increase in satisfaction with their living situation and more social contacts. Over the longer period of time, there were also favourable changes, which failed to reach statistical significance (n = 24). Average length of inpatient stay per year of the illness was decreased significantly at both follow-ups. CONCLUSIONS: Interpretation of the findings is difficult because of the small sample size and selection effects. Most of the former long-stay patients appear able to live in the community with a significant decrease of time spent in hospital. Whilst patients were particularly satisfied with their accommodation at one year follow-up, this did not lead to a generalised improvement in subjective quality of life and other subjective criteria in the long term. In line with other recent studies on community mental health care one may conclude that small case loads alone do not have major beneficial effects. Further research should evaluate more systematic and targeted models of mental health care in the community in general and of supported housing in particular.

Adult↗
PubMed2002

[Housing and work as criteria of the "Social Integration" of the mentally ill - development in Germany between 1900 and 2000].

AIM: This paper analyses, in what way psychiatrists considered housing and work as criteria of social integration of mentally ill people and what models of care were suggested in Germany throughout the 20th century. METHOD: Publications in 29 German professional and scientific psychiatric journals through the complete period from 1900 to 2000 and monographs were searched for papers on the above issues. RESULTS: Until the second half of the century, integrative initiatives related to housing and work generated in asylums without the aim of a full social integration of the patients. In the activistic concept of NS-psychiatry, work became an obligation for patients and a criterion for selection that decided on life and death. Not until the late 1950s, there again was an orientation towards integration in psychiatric care in both German states. Whilst already in 1963 the "Rodewisch Theses" outlined recommendations for the rehabilitation of the mentally ill already in the GDR (East Germany), a similar mark of reform ideas was published in the "enquete" in the FRG (West Germany) in 1975. In the GDR initiatives were limited to a small number of locations. In the FRG and the re-unified Germany various forms of sheltered housing and work were established - also with significant regional variation. However, a clear discussion of underlying aims and implications for the structure of mental health care was not found in the psychiatric literature. CONCLUSIONS: In the 20th century a tradition of psychiatric ideas related to housing and work did not develop in Germany. Particularly, there were only sporadic contributions from university psychiatry. Work was more frequently explicit subject of discussions than housing. Both areas were - slowly and in discontinuity - established as criteria of integration of people with mental illnesses, which was increasingly accepted as an aim of mental health care.

Deinstitutionalization↗
PubMed2003

[A change of paradigms--an empowerment, a challenge for ambulatory psychiatry].

If one changes the paradigm--what should be changed, what has been changed? Even today, the number of beds at the department head's disposal represents power. Is power the purpose of psychiatry? Rather isn't the purpose the adequate treatment of a mentally impaired persons, about adequate support in a natural environment? In our society, and in particular in psychiatry, the striving for power must be questioned. Our memory of the deportation and the disappearance of mentally ill, of the extermination of "unworthy life", of Hartheim, Grafeneck and Brandenburg is still too fresh. It is imperative to convey the idea of a life worth living even then when this seems hopeless to us. Outpatient psychiatric care has bid farewell to outdated conventional structures, which in their time under certain social conditions had proven not to be unreasonable. Outpatient psychiatric care is about the rediscovery of a sense of life that gives reason for hope. Only the joint contemplation of new resources can bring us forward.

Activities of Daily Living↗
PubMed2003

[The future of psychiatric care--dreams and nightmares].

AIM: The paper aims to identify perspectives for future mental health care. METHOD: Personal reflection based on the history of mental health care, own experience and current developments. RESULTS AND DISCUSSION: Mental health care and the relationship between patients and professionals within it have changed significantly in the last five decades. Current developments may be seen as characterised by a) a widening remit of mental health care with an increasing clientele with non-severe mental disorders; b) re-institutionalisation for the severely mentally ill, e.g. with a rising number of forensic beds; and c) a tension between consumer orientation in a post-modern society and dominance of evidence-based medicine. Mental health care has always lived in a balance between social control and therapeutic aspiration. Yet, we now seem to witness a stronger split between the two with re-institutionalisation for patients with severe mental illnesses who might upset the public on one hand, and a growing private market of various treatment options for patients who actively seek treatment and can--directly or indirectly--pay for it on the other. This leads to the anticipation of positive as well as negatives scenarios for the future which are briefly described and contrasted.

Deinstitutionalization↗
PubMed2004

["How Nice that Someone is Interested in me for a Change"].

OBJECTIVE: To obtain indicators for the setup and further development of appropriate provisions for relatives of long-term schizophrenia patients in Tyrol (Austria), the quality of life of the main caring relatives of these patients was assessed and compared to that of a control group from the general population. In addition we were interested in identifying variables that may be useful predictors of the relatives' quality of life. METHOD: Fourty-four relatives of long-term schizophrenia patients and 90 controls of the general population were included in the study. To assess their quality of life we employed the generic questionnaire WHOQOL-100, complemented by own questions reflecting the special situation of the relatives. RESULTS: The quality of life of the relatives was significantly lower than that of the general population in almost all domains assessed. Fear of discrimination, concern about the care of the patient in later life and the feeling of a lack of security because of the patient correlated significantly with a reduced quality of life of the relative. Living in separate households went along with a higher quality of life of the relative. The association between the relatives' quality of life and their involvement in self-help groups or patient participation in social-psychiatric rehabilitation was unexpectedly low. CONCLUSIONS: The results of our investigation indicate in which domains there is a need to improve mental-health services and to develop and extend efforts of self-help groups in order to raise the quality of life of relatives of long-term schizophrenia patients.

Activities of Daily Living↗
PubMed2004

[The impact of social welfare policies on the deinstitutionalisation of the mentally ill in Germany].

OBJECTIVE: In Germany the competent institution for supported housing for mentally ill and handicapped persons is traditionally the regional welfare authority, while welfare authorities on state (Lander) level hold the competencies for accommodation in hostels and homes: Assessment of the impact of policies that try to overcome this separation of competencies. METHOD: 1. Analysis of the practise of distributing the competencies for accommodation for mental ill and handicapped persons in the 16 German Lander. 2. Assessment of the supply with accommodation for mental ill and handicapped persons in the Lander. 3. Investigation of a possible relationship between distribution of competencies for accommodation and number of accommodation in supported housing and hostels/homes. RESULTS: Data about available accommodation in supported housing and hostels are inconsistently limited and available. As far as this data can be interpreted, Lander that have the administrative and particularly financial competency for accommodation uniquely organised, generally offer more supported housing. At the same time they provide relatively less accommodation in hostels and homes. Despite having the competencies for accommodation uniquely organised, some Lander continue to provide accommodation for mentally ill persons predominantly in hostels and homes. CONCLUSION: A comprehensive and between the Lander comparable system of documentation of accommodation for mentally ill and handicapped persons is highly needed. Unique organisation of competencies for accommodation of mental ill and handicapped persons is a necessary - however not commensurate precondition for the increase of the supply in supported housing. Beyond that, other factors seem to be influential, such as political will, attitudes towards the mentally ill, interests of hostel providers, pre-existing hostel infrastructure. In respect of these factors more research is needed.

Deinstitutionalization↗
PubMed2006

[Needs for care of former long-stay-patients living outside of the psychiatric hospital].

OBJECTIVE: The aim of this study was to assess the needs for care of 116 former long-stay patients during the first 42.9 months after discharge. METHOD: Patients and mental health professionals rated needs using the "Berliner Bedürfnisinventar" (Berlin Needs for Care Inventory). RESULTS: Out of a total of 16 needs areas, patients reported a mean number of 7.6 needs, therapists reported 10 needs. Patients with lower global functioning scores showed a significantly lower number of needs, while patients living in psychiatric nursing homes and patients with learning disabilities had a significantly higher number of needs. In most areas, agreement between patients' and therapists' assessment was good to moderate. In most areas the rate of unmet versus total needs was above 90 %. Patients received help almost exclusively from institutions or mental health services. CONCLUSION: The care needs of discharged patients were generally met and placement in institutions was considered appropriate.

Activities of Daily Living↗