community support work

Getting a Senseof CommunitySupport Work

A review of literature onparadigms to support people

who experience mental illness

Disclaimer This publication was prepared under contract to the New Zealand Ministry of Health. The copyright in this publication is owned by the Crown and administered by the Ministry. The views of the author do not necessarily represent the views or policy of the New Zealand Ministry of Health. The Ministry makes no warranty, express or implied, nor assumes any liability or responsibility for use of or reliance on the contents of this publication.

Published in June 2001 by Ministry of Health

PO Box 5013, Wellington, New Zealand

ISBN 0-478-26156-X (Book) ISBN 0-478-26157-8 (Internet)

This document is available on the Ministry of Healths Web site: http://www.moh.govt.nz

Getting a Sense of Community Support Work iii

Foreword

Community Support Work is a critical component of the continuum of care delivered by the non-government sector to people who have ongoing mental health problems and high support needs. Up until the early 1990s people who used mental health services had relatively few choices available to assist them to reintegrate into their community of choice and enjoy the rights and responsibilities of citizenship. The past 10 years of deinstitutionalisation in New Zealand has accelerated the development of a policy direction that emphasises more and better community based support options available to people with mental health problems and high support needs. This ideology has been embodied in the Mental Health Strategy Looking Forward 1994, Moving Forward 1997 and the Mental Health Commissions Blueprint for Mental Health Services in New Zealand 1998. Consumers, families and providers have been proactive in researching and testing different systems of support to ensure relevance between what is offered and what is needed. These systems place a higher focus on wellness, health maintenance and independent living. New systems do not develop overnight, time and resources are need to plan collaboratively and strategically on the evolution of integrated support for people with mental health problems. This literature review highlights that, whilst New Zealand has been doing community support we have not been recording our outcomes. We hope that the salient issues raised in this review will prompt debate within the sector and that debate will lead to enhancing the culture of quality improvement that already exists within the mental health sector.

Janice Wilson Deputy Director-General Mental Health Directorate

iv Getting a Sense of Community Support Work

Acknowledgements

Sincere thanks to Marion Blake, Lois Ford, Hugh Norris and the helpful staff from Wellink; the previous and ongoing good works of all New Zealand researchers, namely, Bridgeman et al, as well as Roen and Cameron; and all overseas researchers, writers and practitioners cited in this review. My gratitude to Suzy Stevens and John Wade for their illuminating advice on this review document, and to Rob Warriner and Bram Kukler for their support.

About the author

Bridget Caird is a private researcher with an MA (Hons) degree in social policy. In her work, Bridget often draws upon her own experience of mental and spiritual enigma.

Getting a Sense of Community Support Work v

Contents

Introduction 1 Objectives 1 Limitations 2 New Zealand 2 Themes 2

Origins of Community Support Work 4

What is Community Support Work? 6

Paradigms of Community Support Work 8 The Clubhouse way 8 The Programme for Assertive Community Treatment (PACT) way 10 The Strengths or Development/Acquisition way 12 The Village way 17 The Italian way 20

Development and Explorations of Community Support Work in New Zealand 23

Northern research 23 Southern research 31

Salient Issues 40 Social inclusion turning mental health services outwards 40 Recovery 41 Reciprocity and interdependence 43 Boundaries and ethics 43 Peer support between community support work staff and between service users 45 Outcomes and consequences 45

Conclusion 47

Glossary 48

References 49

Getting a Sense of Community Support Work 1

Introduction

Perhaps the essence of community support work is its newness ... pioneering spirit which prevents rigidity and promotes growth. This is the very opposite to institutionalisation (Roen 1999).

Objectives The overall objective of Getting a Sense of Community Support Work has been to cast a wide net over the international and national status of community support work in order to provide support workers, service managers and policy makers and funders with a building block for the emergent foundation of community support work in New Zealand. To this end, the review provides an entry point to community support work approaches that overseas organisations use. This review also presents evolving New Zealand literature on development and practice of community support work, to support people who experience mental illness. As the review is not exhaustive, it does not purport to cover all types of community support work, nor all debates on issues around its development, internationally or locally. However, some of the most widespread and well-known paradigms are described. Descriptions of community support work functions and characteristics are taken directly from (and sourced directly to) writing by model1 proponents and practitioners. With some models there is a lack of available empirical and research data against which to check the accuracy or validity of some claims and outcomes. For example, international literature available on the Village programme in Los Angeles County strongly and positively emphasised the strengths and abilities of members (consumers) whilst de-emphasising disability and illness, yet provided only limited examples to illustrate practice and context. Conversely, both the Strengths and Trieste literature explicitly and richly linked ideology and practice, as well as suggesting ways to reconcile problem areas in both. In reviewing these models, it was an advantage to be able to read about authors critical reflections on paradigm feasibility and their nuances. This linking of theory and ideology to important subtleties and paradoxes of practice and experience certainly enhanced the credibility of these models from a readers perspective. It was also clear that those models that encouraged and provided for self-reflexive analysis in these areas mirrored best practice at the coal-face from workers, such as through active peer support and consistent evaluation.

1 The terms model and paradigm are used interchangeably in this review.

2 Getting a Sense of Community Support Work

Limitations One of the limitations of conducting this review has been the lack of literature in New Zealand. One possible reason is that community support work providers have been so busy developing their services over the past four years, they had had little time for writing.2 Moreover, there is no writing by Pacific providers and very little tngata whenua content. However, it appears that the community support work option has made it easier for Mori and Pacific providers to offer culturally appropriate services (Wade 1999) as a good counterbalance to mainstream and clinical mental health services.

New Zealand The New Zealand community support work experience is recent compared with some overseas environments. Some parts of the United States, namely Wisconsin, Kansas, Boston, New York and Los Angeles, along with Trieste in Italy have been speaking the language and walking the talk of community support work for 10 to 50 years. In Manhattan, New York, the original Clubhouse was set up by and for ex-psychiatric patients in 1948 and it still operates today. By contrast, self-proclaimed community support work ventures in New Zealand are at most five years old. On the other hand, it is only since the mid-1980s that western mental health professionals have entertained the notion of a community support system for people with mental illness. As Carling (1995) has pointed out, this is a very short time for the transformation of a whole field in terms of mental health professionals beliefs about people, what they desire, and how they should be served.

Themes Three interlinking themes run through the literature reviewed. First, providers are moving away from focusing on rehabilitation as treatment and care, and towards recovery theory and models whose definition and implementation are controlled by service providers. Increasingly, it appears that these models and those who implement them in services are making commitments to a holistic service orientation and user self-determination. The second theme is an awareness of mental illness problems as community and social issues in both the source of problem and responsibility for solution. From the literature it is clear that providers do not see this approach as absolving individual responsibility; instead it identifies a clear and relevant context around problems, thus successfully integrating the what, how and who of illness and mentality beyond the individual.

2 Due to lack of context between community support work services in written form, important factors such as

demographics and service population records have not been included.


In the reviewed literature the third prominent theme is a movement away from pathology and diagnosis and towards a focus on individual and community strengths. These three themes appear in various forms across different practice methods: the original community support work venture of the Clubhouse model in 1948 New York; Programmes for Assertive Community Treatment (PACT); the Strengths model; the Village model; and Italys Trieste experience. They also are evident in lesser known models and the emerging shape of community support work in New Zealand. These themes sharply distinguish community support work as an authentic, increasingly rigorous and progressive approach to mental health and wellbeing in its own right.


Origins of Community Support Work

Perhaps in part it is the politicisation of the mystery of mental illness (paradoxically, not all of which is mysterious at all) by psychiatric and pathological models of help that has borne severe and negative outcomes for many people who experience mental illness (Caird 2001).

From the 1950s onwards there has been an increasingly significant change in service emphasis from people with mental illness in institutional care towards community models of response, care and support. Key reasons for this change include:

the introduction and use of antipsychotic medications

greater financial cost of mental health services, including inpatient psychiatric care

the development and growth of community psychosocial treatment and rehabilitation services

concerns over patient/client rights and quality of life, and a dramatic growth in awareness of civil and human rights among people with mental illness and their families (Chamberlain et al 1999; Nettleton 1995).

Also related to the increasing awareness of civil and human rights, the movement towards de-institutionalisation has been linked with the academic social constructionist debate, an important strand of the sociology of health and illness (Nettleton 1995). Since the 1970s social constructionists have been critical of the assumptions of medical practice in general, which they consider to be congruent with the patriarchal and capitalist society in which it is located. Psychiatry in particular has come under close scrutiny, leading to a distinct anti-psychiatry movement which argued that much of mental illness is simply a social construction invented by psychiatrists who act as powerful agents of social control (Nettleton 1995). Charles Rapp (1998) has pointed out that traditional protocol among the helping professions, including social work, involves identifying and labelling particular pathologies and weaknesses of clients and then prescribing treatment to correct the functional deficits. By the early 20th century, with the growth of empirical and apparently more rational scientific theories to define peoples problems, clinical diagnosis to identify and treat perceived human deficits was under way. Rapp argued that this tradition is strongest in mental health services for adults with severe and persistent mental illnesses. Consistent with this view, University of Kansas research has found that too often, as a result of this pathology paradigm, the achievements and options for people with persistent mental illness are seriously constricted, and their quality of life is often inadequate. Furthermore, unemployment and loneliness dominate many peoples lives, and most find themselves segregated from the rest of society (Rapp 1998).


Community support work is typically modelled around psychosocial rehabilitation (Carling 1995; Ragins 1995). The two main roots of psychosocial rehabilitation are:

a service user movement with an anti-medical focus, among people who experience mental illness with an awareness of and concern for their rights. This movement arose primarily as a reaction against psychiatry. It emphasises self-help, social integration, countering stigma, empowerment, and strengths over weaknesses, health over illness and, increasingly, a recovery orientation

psychiatric rehabilitation, characterised by a stress vulnerability-coping competency model, as developed at Boston University.3 Clients are taught skills (eg, symptom management, social skills, vocational skills, educational skills, activities of daily life) to overcome deficits, reduce stress and develop community resources. With this model, it is expected that the person will manage stress more effectively, become less vulnerable to illness and be better able to cope.

Ragins (1995) has described the development of community support work as a merging of these two roots of psychosocial rehabilitation into a recovery and rehabilitation model whilst excluding harmful aspects of the medical model. The process occurs as consumers and providers recognise that both perspectives have many common goals and shared techniques. In sum, as a service model to support people who experience mental illness, community support work has emerged as the exclusively clinical and institutional thinking and practice have shifted to community locations and community ideals. In explaining the shift, the consensus is that it was facilitated by a combination of therapeutic factors, economic factors and, most importantly, a reconceptualisation of how to respond to people who experience mental illnesses. Together, these factors strengthened challenges to the former pathological/medical model.

3 The Boston Centre Psychiatric Rehabilitation model has a rich history/evidence of practice. It is now taught

at postgraduate level at Auckland University of Technology, directly involving Marion Farkas, who contributed to the models development. Robert Liebermans Rehabilitation model in California has also been well researched and used by others eg, Auckland Healthcare rehabilitation services. Whilst the Boston model focuses on developing and maintaining internal/individual skills, Liebermans work is heavily focused on skills teaching modules.


What is Community Support Work?

The very existence of community support workers continues to challenge traditional clinical models, to break down the professional/patient dichotomy, and to question notions of dependence and independence. In this era of de-institutionalising mental health services, community support workers are pioneers (Roen 1999).

As Laurie Curtis (1997) has described them, community support work practices (also called community support services or CSS, support in the community and case management) typically focus on practical day-to-day supports that help people experiencing mental illness to navigate or overcome barriers to attaining and maintaining the basic elements of a regular life. The elements sought include decent housing, satisfying work, mutual caring, intimate relationships and usual life roles. Barriers may include poverty, stigma, disconnection with family and friends, or interruptions in goal attainment because the disorder is cyclic and sometimes there are cognitive difficulties. Community support workers generally work with clients in their own communities, in their living, learning, social and working environments, and spend several hours or more with a client each week. Support is structured around client needs and goal establishment; in other words, the support is to be what the person requires to meet their goals. Goals may be anything from cooking a meal to catching a bus, problem solving, finding a girlfriend or boyfriend, completing a university degree, gaining employment, getting fit, making new friends or reconnecting with family.

The most important community support work training comes from the University of Life life experience, raising kids, having a mortgage and having to budget, shop, prepare meals etc (Cameron 2000).

From the community support workers standpoint, in relation to best practice, the most important aspect of the goal focus is to ensure that any naming, re-evaluation or achievement of goals is client-driven and client-owned in both process and outcome (Curtis and Hodge 1994; Rapp 1998). Another way to look at community support work is to address the concept of community, how it relates to people and indeed to peoples experiences of mental illness. Italian psychiatrist Roberto Mezzina (2000) depicted community as a place that is either empty or full, a place of exchange and return, but also with its own rules and therefore deviancy, interests, conflict and ... exclusion. The idea of community refers to a social totality that individuals either move with or enter into conflict with, because community is a basis for inter-human relations, establishing bonds, values, rules and consequently institutions and social practices. As Mezzina pointed out, in mental health pedagogy community is a largely Anglo American social psychiatric concept. In this view community care refers to the creation of living space to enhance the potential for help, as opposed to the separation of a total institution. In contrast, the Italian experience of community (territorio) refers more to local physical context that is made up of key elements such as resources, networks, access, geography and policies. In this sense, territorio as it relates to mental health care is a place


that can heal but likewise generates the contradictions that lead to mental suffering, which can be either concealed or revealed. Carling (1995) and others (Curtis 1997; Deegan 1988) have drawn attention to a dimension of rights and participatory promotion, which is important in defining community support for people with mental illness:

The basic belief of the community integration movement is that all people, including people with disability labels, have a right to full community participation and membership ... This goal will not be achieved primarily through professional services, but rather through peer support and self help as well as through physical, vocational and social integration into mainstream community activities, jobs, housing, and relationships with non- disabled persons ... [This is not an assertion that] professional services are unimportant, but that to be effective, such services must be controlled by their users (Carling 1995).

In New Zealand research, Roen (1999) has emphasised that a key element of community support work is the important role of workers in supporting people to do things for themselves, as opposed to their role of doing things for them. Expanding on this view, Curtis (1997) and Deegan (1988) have pointed out that although community support work is essentially not performing tasks such as doing someones laundry, dishes or gardening, some community support workers may engage in such tasks with consumers during the relationship, without compromising the overall focus on goal setting and achievement.


Paradigms of Community Support Work A paradigm is a model or way of perceiving the world and solving problems. Covey (1989) provides a useful explanation of both the purpose and limitations of paradigms:

The word paradigm ... is commonly used today to mean a model, theory, perception, assumption, or frame of reference ... its the way we see the world ... in terms of perceiving, understanding, interpreting. A simple way to understand paradigms is to see them as maps. We all know that the map is not the territory. A map is simply an explanation of certain aspects of the territory. It is a theory, an explanation, or a model of something else.

Another important aspect of territory is that one should never assume automatic right of entry. It is entirely possible to take a good map and apply it to the wrong territory, with dire and possibly tragic results, depending upon the weather, your supply of good boots and enough water, and whether you can avoid enemies and traps. Many people would say that this analogy is a reasonably accurate, if rather soft, way of conveying the experience of millions of people with mental illness when they are in the frequently harsh environment of psychiatric and institutional treatment, without alternative therapies or strategy. Some limitations of models or paradigms are that they may be perceived and operated as static and complete rather than reflexive and developmental in nature. Nonetheless, some paradigms or ways of operating will yield to environmental factors more readily than others. In addition, as the literature reviewed in this section demonstrates, it is possible to set community support work standards for practice yet still be reflexive and able to adapt and transform with your environment. Paradigms of community support have developed different styles, establishing distinct characteristics and patterns of operation that have been replicated over time across different locations. The major paradigms reviewed here have standards for consistency, stated methods of practice and an international profile. Other less known yet equally rational programmes of community support are emerging; they are incorporated within the final section of this review (Salient issues).

The Clubhouse way

Clubhouses provide seriously mentally ill individuals with a supportive network, friends, a sense of belonging, friends, housing, friends and jobs (Flannery and Glickham 1996: xi).


Origins

The Clubhouse paradigm of providing community support to people with ongoing and persistent mental illnesses is the original community support model. With its roots in a philosophy that people who experience mental illness are more than their illnesses, the model began to be implemented when Fountain House in Manhattan, New York was purchased in 1948. The house was started by a small group of ex-psychiatric patients who had been coming together informally for peer support at the YMCA and on the steps of the New York public library for several years. Calling themselves We Are Not Alone (WANA), the group sought private sponsorship to purchase the building that enabled WANA and its supporters to begin to provide non-residential support, companionship and activities for other former psychiatric patients. There are now almost 300 similar Clubhouse programmes internationally.

Features

In 1989 the Fifth International Seminar on the Clubhouse Model, held in St Louis, resulted in 37 international Clubhouse standards. These standards embody key features of the Clubhouse model, which are summarised below.

Membership is voluntary and without limits. It is open to anyone with a history of mental illness.

Members choose the way they use the Clubhouse, and choose the staff with whom they work. There are no agreements, contracts, schedules, or rules intended to enforce participation of members.

All Clubhouse meetings are open to both members and staff. There are no formal member-only or staff-only meetings where programme decisions and member issues are discussed.

Clubhouse staff numbers are sufficient to engage the membership, yet low enough that carrying out responsibilities is only possible with member involvement.

The Clubhouse is located in its own physical space that is separate from mental health centres or institutions and provides easy access to public transport.

Members have the opportunity to participate in all the work of the Clubhouse, including administration, research, intake and orientation, out-reach, hiring, training and evaluation of staff, public relations, advocacy and evaluation of Clubhouse effectiveness.

The Clubhouse is open at least five days a week, with usual workday hours and a work ordered day focus. All work is designed to help members regain a sense of self-worth, purpose and confidence. It is not designed to be job-specific training.

The Clubhouse enables its members to return to paid work through transitional employment and independent employment supports as part of its service. Therefore the Clubhouse does not provide employment to members through in-house business, segregated Clubhouse enterprises, or sheltered workshops.


Members and staff of the Clubhouse provide community support services. These include help with benefit entitlements, housing and advocacy; support in accessing educational and vocational resources; and assistance in finding quality medical, psychological, pharmacological, and substance abuse services in the community.

The Clubhouse provides education to members, focusing on basic literary and computer skills. Members are also major resources for tutoring and teaching in these programmes.

The standard asserting all meetings are open to both Clubhouse members and staff has generated the most controversy and resistance amongst mental health professionals. Yet as Flannery and Glickham (1996) stated, this standard lies at the very heart of Clubhouse philosophy that it is a member-driven programme:

Its a hard concept for mental health professionals to accept, because even if they believed in the value and vision of the clubhouse model, their training often had been in a hierarchical form of staff-patient interaction. And one of the most familiar aspects of traditional patient care is the staff only meeting where patients progress is assessed.

Practice before theory

A unique feature of the development of the Clubhouse model is that it has emerged out of years of operation not theory (Flannery and Glickham 1996). It was not until 1982 that the first article on Clubhouse concepts and practice was published in a professional journal (Flannery and Glickham 1996). To this day, consumers and mental health professionals interested in learning about the Clubhouse model are encouraged to spend time at Fountain House. They learn through a three-week on-site participatory programme called Colleague Training.

The Programme for Assertive Community Treatment (PACT) way

PACT was the ultimate key to my functioning again. The help, support and superb workers helped me deal with my problems, while staying out of the hospitals. I was not treated as an ill person, but as a human being who has suffered greatly from mental illness and who, most important, needed support and friendship (Dylan Abraham, consumer, PACT; emergency services support counsellor, Madison, Wisconsin; NAMI 2000).


Description

The Programme for Assertive Community Treatment (PACT or ACT)4 is an early community support work model that originated in Wisconsin in the late 1960s. It is a highly individualised programme for people with long-term, ongoing and intermittent treatment needs who are not helped by traditional outpatient models of case management and linkage and brokerage. A practical multidisciplinary team of three to five people provide support by visiting the service user in their own home or community. The team includes a psychiatrist and nurse, Masters-level social workers, alcohol and drug specialists and vocational specialists. Frequently team members are also consumer-providers or peer specialists.5 The teams aim is to build a respectful, collaborative, trusting, recovery-oriented relationship between staff and consumers. In essence, support is provided through a mobile one stop shop that covers all aspects of community living. Services cover medication, crisis intervention, social and vocational support, leisure, housing, primary health care, family planning and support to obtain advocacy. The team also deals with legal issues; if the person goes to jail, they continue to visit in jail. The PACT psychiatrist is a full team member, rather than a consultant. Model advocates say that the advantage of this structure is that the psychiatrist participates in the full context of a generalised support model where, in principle, no team members professional expertise ranks above that of another. Where appropriate, the team also involves and meets with consumers families, providing support and advice on mental health and illness.

Features

PACT support is characterised by a strong focus on individual goals. Team members support people to set and achieve goals without any preconceived notions or limits as to what the goals might be. Accordingly, an important element of the PACT model is its emphasis upon individual choice. For example, although the team provides clinical expertise and diagnosis, clients do not have to take medication and the team will continue to work with individuals who choose not to. Care plans are developed and updated collaboratively with clients and staff, based on the persons goals. In Wisconsin, 80 percent of PACT consumers are voluntary, whilst the other 20 percent come to the service from court orders. Key features of the PACT model are that it:

contains multidisciplinary teams

strongly emphasises employment

is a 24-hour, seven-day service

4 This section is referenced to the NAMI web site (2000).

5 An increasing movement is the employment of prosumers, people with mental illness who are also mental health professionals, within mental health teams (Frese and Davis 1997).


emphasises choice, without requirements that the consumer adapt to or follow prescriptive rules of a treatment programme

has minimum standards

is goal-focused

is recovery-focused

establishes an oversight/advisory committee to govern each PACT service, comprising 10 to 15 people of which 50 percent must be consumers or members of their families.

Expansion

The United States National Alliance for the Mentally Ill, a large political advocacy group, is promoting full PACT implementation across the USA by 2002. At the time of writing, six states have PACT: Delaware, Idaho, Michigan, Rhode Island, Texas and Wisconsin. To help implement PACT, the NAMI Anti Stigma Foundation has produced a manual for PACT start-up, The PACT Model of Community Based Treatment for Persons with Severe and Persistent Mental Illnesses: A manual for PACT start up. The manual is accompanied by the national PACT minimum standards, which were developed after PACT advocates became concerned that some community support work programmes were using the PACT name for understaffed and undertrained teams that lacked key services such as substance abuse or vocational support.

The Strengths or Development/Acquisition way

Implementing the Strengths model elevates the consumer from a passive recipient of services to the director of the process. It affirms the person not as a patient, or client, or even as a consumer but instead as a citizen ... working from the Strengths model help(s) others reclaim full citizenship, replete with all the rights and responsibilities that come with citizenship (Rapp 1998).

The Strengths paradigm of providing community support to people with severe and ongoing mental health needs was developed at the University of Kansas in the early 1980s. A core premise of the Strengths model is that traditional professional mental health paradigms are weakened by the dominance of problems, deficits and pathology in understanding and responding to mental illness. By paying attention to peoples inability rather than their ability to cope, traditional approaches have been preoccupied with problem identification, problem assessment and problem solving. The Strengths perspective offers an alternative to this preoccupation with the negative aspects of people and society. Based on a belief that all people have goals, talents and confidence and all environments contain resources and opportunities, Strengths model practitioners focus on possibilities, not problems; on options, not constraints; and on wellness, not sickness. In essence, the Strengths model of community support work is a set of methods and perspectives that encompass empowerment (Rapp 1998).


Resources

Using the Strengths model, community support workers work in a one-to-one relationship with the client to identify, secure and sustain the internal resources (aspirations, competencies, confidence) and external resources (social relations, opportunities) that people have or require to enhance their quality of life and wellbeing. Quite simply, the community is viewed as the source of mental health.

The work with clients should not be directed to their symptomatology, psychosis, or, for that matter, problems, weaknesses, and deficits. Rather the work should focus on what the client has achieved so far, what resources have been or are currently available to the client, what the client knows and talents possessed, and what aspirations and dreams the client may hold ... As Disraeli stated: The greatest good you can do for another is not just to share your riches but to reveal to him his [sic] own (Rapp 1998).

Entrapping and enabling niches

The Strengths model contains the key idea of enabling and entrapping niches for the individual and environment. Niches parallel a persons major life domains such as living arrangements, work, finances, education, social relationships, health, spirituality and leisure. The Strengths model assumes that the quality of niches that people inhabit determines their achievement and quality of life (Rapp 1998). Outlined below are the broad characteristics of enabling and entrapping niches. However, it is recognised that most niches tend to lie somewhere in between the two extremes, with both enabling and entrapping elements. In entrapping niches:

there is stigma and social isolation/exclusion

people associate with their own kind and their social world is limited and restricted

people are totally defined by their social category, eg, a schizophrenic, bag lady, criminal or junkie rather than a parent, daughter, student, resident or employee

gradations of reward or status are lacking

there are few incentives to set realistic longer term goals or to work towards them

reality feedback is lacking ie, few natural processes lead people to recognise and correct their own unrealistic perceptions and interpretations of themselves and their environment

people have little chance to learn the skills and expectations that would facilitate transition

economic resources are sparse, which often leads to unproductive stress.


Traditionally, too, society has often created entrapping niches to care for people with mental illness, which reduces individual self-choice and care and increases feelings of dependency (Rappaport 1985, cited in Rapp 1998). In enabling niches:

people are not treated as outcasts

people turn to their own kind for support and self-validation; the niche gives them access to other perspectives, so their social world is less restricted

people are not defined solely by their social category and are accepted as having valid aspirations and attributes apart from their social category

people get good reality feedback so that they are able to attend to unrealistic perceptions or interpretations of themselves or their environment

people have opportunities to learn skills and expectations that open up other opportunities and possibilities

resources are adequate, and competence and quality are rewarded. The Strengths model recommends that to influence the recovery process and enhance peoples quality of life, the major focus of community support work should be the identification and creation of enabling niches.

Functions

There are five sequenced functions of the Strengths model (Rapp 1998).

1. Engagement and relationship start from the initial meetings with a potential consumer. The purpose is to begin to develop a collaborative, helping partnership.

2. Strengths assessment is the process of gathering information regarding peoples life domains. The goal is to collect information on personal and environmental strengths as a basis for working together.

3. Personal planning creates a mutual agenda for work between the client and worker, focusing on achieving the goals that the client has set. A primary activity is the generation of options from which the client can choose.

4. Resource acquisition is concerned with gaining the resources desired by clients to achieve their goals and ensure their rights, to increase each persons assets. To be successful, community support workers need wide perspectives on community and a wide range of interpersonal and strategic skills.

5. Continuous collaboration and graduated disengagement, often thought of as monitoring, address the ongoing modification of goals and tasks that determine how much consumers are able to engage in activities noted on their personal plan. Community support workers are less concerned with client compliance with their plan, and more concerned with a persons ability to use his or her own strengths creatively on a day-to-day basis. Graduated disengagement refers to the self-helping behaviour that replaces the community support workers role in various areas.


Rights

A fundamental principle of the Strengths model is that people have the right to determine the form, direction and content of the support or help they receive and therefore community support workers should do nothing without a clients informed and prior approval (Rapp 1998). The Strengths model aims to invest in, and reflect, individual idiosyncrasies rather than homogenise peoples needs. However, by putting a premium on positives rather than negatives, and on identifying options and possibilities rather than affirming problems, Strengths practice does not simply ignore problems and their significance to individuals. Rather, problems are no longer the star performers in peoples lives, but minor characters with small roles. As Rapp (1998) explains, citing from Weick and Chamberlain (1997):

There are three ways of putting problems in their proper place: (1) we recognise problems only in their proper context, (2) we adopt simpler ways of talking about problems, and (3) we pay less attention to the problem.

Charlene Syx (1995) wrote critically of the many well intentioned but entrapping and oppressive practices of some community support work services for people with mental illness.

For in a good faith effort to help ... mental health providers ensconce people in a protective bubble, shielding them from their community and ultimately their future. Had I been encased in that bubble, I cant help wonder if I, too, would now be trapped, working in a clerical unit or running for Clubhouse president.

Syx (1995) emphasised real community integration, not segregation, and change and movement, not utilisation. Her examples include making links to the community instead of purchasing buildings for people to gather in, and providing subsidies for public transport instead of buying vans to transport people. Another important focus in Strengths methodology is to work for and with, rather than against, peoples expectations, interpretations and experiences. All individual goals must be treated as sincere aspirations and not rejected as unrealistic. Rapp (1998) cites a poignant example from Bleach and Ryan (1995) to show how well this approach can work for people.

Mrs. J. was due to be discharged into the community after several years of hospital residence ... she was considerably panicked. She stated her wants in terms of residence in a nursing home with no responsibility plus daily care activities ... Once a trusting relationship had been established, Mrs. J. divulged that she hated the idea of living in a home and going to day centres, and that she really wanted to be the Queen. She challenged the practitioner to work towards that aim. Without promising too much, the practitioner began to work out with Mrs. J. what she thought the Queen did that was worth aiming for. It emerged that Mrs. J. believed that the Queen did not have financial or administrative worries, she always knew where she was going to live, people respected her because she helped them, and, most importantly, she had companions and ladies in waiting who helped her and kept her company. The subsequent assessment stated that Mrs. J. needed a strong


sense of financial security and the guarantee of help with day to day organisation, she needed to move to one location and be promised that she need never move again, she needed to feel that she was helping people and be respected for it, and she needed some old fashioned companionship. Mrs. J. eventually began considering sharing a house with another person being discharged who was already a firm friend and an effective organiser both of good works and administration.

Problems identified with generalist models of community support (or generic approaches that treat all clients as the same) are that they homogenise peoples needs. As Rapp has inferred (1998), such approaches can be a significant waste of client and support worker energy.

In the vocational domain, for example, women clients will often state their job interests as some form of domestic or secretary, despite one woman having a profound interest in art, another having a long time gardening hobby, and still another being devoted to animals. But they have all been socialised to accept that the job for them is at Holiday Inn at minimum wage. The irony is that these women are not necessarily even interested in keeping their apartments or room ... orderly and clean. Then we wonder why clients do not follow through on job opportunities or fail to keep jobs ...

By contrast, the Strengths approach gives priority to individual idiosyncrasies and tailors resource acquisition and goal attainment to them.

Criticisms

There have been criticisms that the Strengths paradigm is merely positive reframing (Rapp 1998), a technique of redefining a destructive or inappropriate behaviour as a positive action or characteristic. Angry outbursts become instances of assertiveness, and manipulative behaviour becomes a creative strategy to get attention. Rapp notes that although modest reframing can be useful, the foundation of the Strengths model is that everyone has real talents, skills and competencies. Human behaviour is purposeful, goal-directed and therefore powerfully affected by resources and opportunities in the environment. Rather than reframing, the approach involves identifying the elements that comprise the well part of the individual, and emphasising or bolstering these strengths or talents to characterise peoples expectations of self, outlook and self-generated rewards and thus to create a healthy and sustainable existence. Another frequent challenge to the Strengths paradigm is that practitioners claim it is nothing new: their service has always incorporated a Strengths orientation, or abided by its stricture. In a review of actual practices, Saleebey (1996) found they did not fully endorse and apply Strengths-based practice. For example, in services where client choice was emphasised, clients were actually provided with only a few, limited options to choose from.

If a mental health agency has more than a few people working in sheltered workshops or living in group homes, the strengths model is not being practised. If most clients spend the majority of time interacting with other clients or staff, the strengths model is not being practised. If most (written or


oral) descriptions of clients start, end and are dominated by their problems, weaknesses, deficits, and inadequacies rather than their talents, dreams, and achievements, the strengths model is not being practised (Rapp 1998).

Needs

Pivotal to the Strengths paradigm is an understanding of client goals versus client needs. Strengths practitioners have a very clear definition of need:

Needs are defined as human needs necessary to sustain life such as food, shelter, absence of self harm, or dangerousness to others. Needs beyond this should be at the discretion of the client who is helped to convert the need to a statement of what s/he desires (Rapp 1998).

University of Kansas research has found that support services to people with mental illness usually broaden the definition of need beyond basic human necessities to include, for example, need for more structure, wider social networks (ie, more friends and contacts), less isolation or a group home. The Strengths position is that no one needs these factors but some may desire them, and so the community support workers task is to generate options to help the person create a plan to meet those desires (Rapp 1998).

Inadvertent outcomes

In research comparing Strengths practice with traditional, more medical models of treating people with serious mental illnesses, Powell-Standard (1999) found that training in the Strengths paradigm has secondary outcomes and impact. One inadvertent outcome of employing the Strengths approach is that people become empowered to try new areas where they lacked the confidence or willingness to try before. In addition, although the focus was not on minimising symptoms, peoples enhanced quality of life frequently reduce illness symptoms anyway. The maxim that success in one area of life will breed achievements and success in another would appear to ring true for the Strengths paradigm.

The Village way Long Beach, California is the origin of the Village (Integrated Service Agency, ISA) paradigm for community support to people with persistent and serious mental illnesses. This approach grew out of an initiative by families and consumers who in 1987 formed a taskforce to research various mental health systems, with the goal of developing a new model.6

6 This section is based on Mark Ragins (1995). A psychiatrist, Ragins was a founder of the Village model

and is now employed at the Village.


The model has a major training programme, an exchange programme with Japan and at Long Beach operates as a clinical training site for nurses, psychiatrists and social workers. Village advocate Mark Ragins promotes the paradigm as a living laboratory that tests new practices and encourages staff and members to experiment with new ideas and methods.

Features

The three basic elements to the Village style are:

collaborative management teams

case-rated funding

psychosocial rehabilitation/recovery philosophy.

Collaborative case management teams

Similar to PACT (see above), Village multidimensional teams consist of a psychiatrist, a social worker, a nurse and four non-professionals (some are consumers). Each team has responsibility for about 30 members. If a member is hospitalised, the team psychiatrist becomes the treating psychiatrist at the local hospital.

Team and individuals create a Personal Service Plan, which is an action plan for members to achieve their chosen goals.

Staff spend 60 percent of their time with members outside the Village complex, in the community.

Teams offer a 24-hour, seven-day emergency beeper system as an after-hours outreach system, when needed.

Case-rated funding

Each team has its own budget to purchase community services including hospitalisation. Money from the budget goes towards functions such as creating social and employment opportunities for members, increased availability of a psychiatrist, money management services and substance abuse treatment. Budgets are not for institutional care or structured day treatment.

Psychosocial rehabilitation/recovery philosophy

The psychosocial rehabilitation/recovery philosophy emphasises strengths and abilities and de-emphasises illness and disabilities. Teams are supported by a variety of rehabilitation specialists and community integration/outreach specialists who create a menu of social activities to suit individual preferences. Most activities take place outside the Village. The emphasis is on learning by doing rather than classroom-style learning or internal structured programming.


Other features include the following.

There is a substance abuse/recovery specialist and the Village offers dual diagnosis7 anonymous meetings.

With a strong focus on employment, job developers identify job opportunities and encourage and support members in employment.

The Village caf/deli, mini mart, bank, maintenance unit, clerical unit and data entry unit are staffed by members. Members work regular, daily hours and are paid. Members are able to take out loans with the bank.

The Village is governed by an advisory board with 25 percent representation for each of the following groups: consumers, family members, mental health professionals and community members.

Village members evaluate all staff annually. Staff performance reviews directly affect staff chances of earning performance bonuses.

Members leave by choice. After nine years of operation, the Village is still in touch with 50 percent of the original members. It has a 5 percent annual attrition rate. It has no requirements, such as to participate in a drug or alcohol recovery programme or comply with medication to receive services, or a readiness requirement for members to meet before they receive a particular service.

Criticisms

Some excellent characteristics of the Village model are the power balance checks through member input to staff performance evaluations, and the member participation to encourage decision-making equity between staff and members. A less positive characteristic for members may be drawn from the latter part of the following quote:

We try not to provide anything at the Village that our members can find in the community. The obverse is also true. We must provide services and a welcoming community when Long Beach does not. We built our internal community out of the same elements on which a normal community is built ... (Ragins 1995).

This statement suggests that if the raison dtre of membership at the Village is mental illness, the raison dtre of membership in the normal and external community is mental health. This attitude would appear to reflect a message of the exclusiveness of people with mental illness, which may vindicate the social exclusion of people with mental illness from the non-welcoming and apparently mentally healthy Long Beach community. This viewpoint clearly places responsibility for mental health in the domain of the outside world, yet responsibility for mental illness with a small group of select individuals who make up the Village, and its workers.

7 See recovery in the final section, Salient issues. There it is suggested that dual diagnosis is a

reductionist paradigm because all people have complex needs.


Furthermore, although the Village claims to sometimes help members live more successfully in the outside community and sometimes help the community be a better place for members to live in (Ragins 1995), these activities do not reconcile with its overt selectivity and exclusiveness. The Village is clearly self-sufficient and not interdependent through mutual exchange with Long Beach community. Ragins (1995) makes statements such as our members continue to achieve things that we know are impossible, which keeps us vigilant and As with normal people, a members goals often change. Such comments are redolent of the us and them and normal versus abnormal myopic dichotomies of clinical psychiatric approaches dichotomies that people with mental illness have criticised for their long-term debilitating and stigmatising effects. Village methods also entail hierarchical levels of functioning scales. Members fill out some scales, teams fill out others, and both members and staff have input to areas such as personal care and hygiene, social acceptability and activity involvement. One might speculate that this categorical approach to options may be very restrictive for some people whilst harmless for others, given that empowerment and satisfaction are relative to personal experience and expectations (see Bridgeman et al 2000). Further, it might be speculated that, as is found within the Strengths paradigm, areas such as personal hygiene and activity involvement will be improved as a secondary outcome once people become more empowered. Scaling of peoples progress towards conceptions of wellness is at odds with recovery concepts of self-determination and user control over process and outcomes.

The Italian way

Today, rehabilitation is often talked about while forgetting that the damage/ limitation (Piro, 1986, cited in Mezzina, 2000) encountered in the individual and seen as a social disability is often the result of devastating itineraries for which the service is often indirectly, if not directly responsible. In this perspective, it is our view that chronicity should be reconsidered both as a social and institutional product (Ciompi, 1984 cited in Mezzina, 2000).

With a total population of around 66 million, Italy has seen numbers in mental institutions fall from 48,000 people in the late 1970s to fewer than 300. Legislative change was the catalyst for integrating the alienated people, as people with mental illness were known under old Italian law, into wider society. The key structural reform was the creation of 24-hour community mental health centres (CMHCs). Offering overnight hospitality to guests and limited to 8 to 10 beds, CMHCs originally functioned to make asylum closures possible. Gradually, as new and diverse needs and demands appeared, along with therapeutic and rehabilitation programmes, community participation became part of the overall CMHC perspective.


Roberto Mezzina (2000) has been an active participant in the deconstruction of Italys mental asylums and the development of the community responses to people with mental illness that began in Trieste. The following descriptions of reform to Italian mental health services are from the paper he gave at the Building Bridges Conference, Auckland in March 2000. Mezzina describes the Italian deinstitutionalisation experience, reform and outcomes as a dialectical process:

We ... see the community service as a place which is open, without barriers, which can be traversed and is not compartmentalised either physically or in its institutional culture, where the open door is not just the result of a historical process but connotes a paradigm which constantly challenges us to work within a dialectic of power with the users and remain open to the realities of the society in which we live ... such a place therefore presents itself as both a place for temporary hospitality (open 24 hours limited to 810 beds) and as a place for people to come together (the users in their relationship with the operators, and in their relationships and their integration within the community and with other persons).

As Mezzina explains it, the Italian way of providing support to people with mental illness in communities is not so much a model as a movement of balance for natural community integration. In this movement the players are very conscious of their roles and responsibilities and are critically reflective of their ethical and functional roles as a contribution to the whole. The 24-hour CMHCs are simply a tool to both recognise and supersede the problem of modern psychiatry that objectifies the ill person through their illness. The CMHCs are an alternative combination of knowledge and practical solutions based on an imperative to offer a unique and personally relevant response to everyone within the reality of community. Features of the CMHC are:

accessibility, both physical and bureaucratic, and as a credible point of reference for the community and family members who also use its services

flexible service delivery through collective work and horizontal relationships

integration of social and health responses, especially of psychiatric and non-psychiatric responses

multiplicity of receptors to diverse needs/demand, for example, to new and old service users, demands for both treatment and social emancipation, health information and education

an organisational style that is distinctly not outpatient in orientation

an active presence in the community, involving meeting with different groups, individuals and families, led by the users interests

status as a planning centre through its deliberate connecting structure to possible options and resource combinations in the community

an emphasis on service continuity as a therapeutic approach, offering an unbroken relationship of meaning based on individual life story and on the uniqueness of demands

flexible responses through multiple actors who recognise the rhythms and temporal dimension of daily lives and the interplay between health and illness.


Any problems of illness are understood as problems of community and society rather than exclusively clinical or medical challenges. In this sense, mental illness is problematic as a social construct or as wounds of the social discovered in the lives of others.


Development and Explorations of Community Support Work in New Zealand In New Zealand community support work has been an emerging movement and workforce over the past six years. Community support work service providers have been striving for consistency in practice and standards, with recent efforts to achieve a clearly articulated and agreed national community support work philosophy. Community support work services have also been striving to gain acceptance and understanding from the traditional established professional mental health groups and service providers, as well as to achieve effective working relationships with them. These issues characterise New Zealand community support work against a backdrop of relatively deinstitutionalised mental health services, as a pioneering political movement in community mental health promotion. In terms of community support work uptake and development, it appears that there have been few connections among regional service providers so far, by way of dialogue and peer involvement. The Central region is now adopting community support work frameworks that are similar to the Northern model. Community support work development is at a point where funding bodies and service providers are conducting evaluations and identifying outcomes.

Northern research

The measure of any civilised society is the way in which it responds to its most vulnerable citizens ... if we persist with the reductionism model as a framework for practice ... we will inevitably perpetuate the very conditions and behaviours we are supposedly wanting to change. The emphasis will be on the colonised rather than the coloniser on the culture of poverty rather than the culture of affluence on the deviant, the poor and the dispossessed. Treatment will focus upon symptoms rather than causes (Shirley, cited in Warriner 2000).

Description

Since 1995 a community support work paradigm has developed and expanded across the Northern region. It is a mobile service, operating 6 am to 10 pm seven days a week, for planned contact, with a high staff-to-client ratio of one worker to 15 to 20 clients (Wade 1999). The service:8

8 The following descriptions are from Wade (1999), from Challenge Trust, an Auckland community support

work provider.


involves regular, ongoing contact between support workers and clients

is consumer-directed

includes early intervention and relapse planning

emphasises support needs versus crisis support

includes support needs assessment

undertakes service co-ordination

provides assessment

aims to increase community integration

develops and strengthens relationships, networks, and natural supports

emphasises use of community services rather than specialised mental health programmes.

In terms of its philosophy and style, the northern community support work paradigm is described as a holistic biological, psychological, social, spiritual perspective (Wade 1999). In addition, its philosophy and style are to be:

eternally hopeful and positive

culturally flexible and safe

tenacious, proactive and assertive. In general, support needs assessment assumes people who experience mental illness have the same community living needs as anyone else, while recognising stigma is a barrier to resources. It focuses on:

relationships, work, income, illness, medical care and all life domains

peoples strengths, abilities and resources to achieve goals. Specifically, support staff work with clients to:

minimise symptoms

manage stress

minimise stigma. With the client, support staff develop a service plan that identifies and engages with personal and environmental resources to achieve goals. Working towards those goals often involves direct assistance to access supports, coaching the person to enhance skills and modelling effective skills and behaviour to both the person and community to encourage trust, respect and citizenship.

Service development for Mori and Pacific peoples

Wade (1999) noted that the advent of community support work in and around the Auckland region has had a positive impact on development of services for Mori and Pacific peoples. In his view, the status and numbers of Mori and Pacific staff in the sector have improved, and kaupapa Mori services have increased, because customary models of health care and traditional methods align comfortably with the community support work paradigm.


Psychosocial concepts of community support work are said to relate well to a hauora Mori model. Both are holistic, recognising biological aspects but not focusing on disease or illness. Both focus on peoples strengths and consider the family, social context and environment as involved in the problem and part of the solution. Hauora Mori and psychosocial views include:

te taha tinana, or biological

te taha hinengaro, or mental and psychological

te taha whnau, or social

te taha wairua, or spiritual9 (Wade 1999). Because the Northern community support work model appears to be more aligned to indigenous concepts and approaches to health, it seems well suited to facilitating partnerships that reflect the principles of the Treaty of Waitangi between services. A holistic health model focuses on equitable outcomes and recognises power dynamics among service providers and service users and within communities. Therefore it is well positioned to recognise the unique status of tngata whenua in health promotion and service provision. Its flexibility enables Mori models of health promotion to be contracted for and delivered under the community support work umbrella.

Issues for resolution

In the Northern community support work models, issues that remain in need of resolution are:

establishing clearly articulated, shared core values

developing appropriate training and workforce development

reconciling system- and provider-defined outcomes with consumer-defined outcomes

conceptualising wellness.

Core values

Both Wade (1999) and Warriner (2000) expressed concern that development of deinstitutionalised mental health services in New Zealand lacks an essential articulation and exploration of core values and explicit shared beliefs. To date, New Zealand:

lacks an agreed national direction for community support work development

suffers from service fragmentation

lacks consistency and co-ordination

has experienced tensions between the traditional, clinical mental health services and community support services. In areas, responsibilities and roles remain unclear and relationships are fragile.

9 Pere (1988) noted that Mori concepts can only be interpreted in a limited way in English due to the

interpretational difficulty of expressing the concepts of one culture in the language of another.


Moreover, Warriner (2000) and Wade (1999) have argued that deinstitutionalisation policy can be readily formed with little basis in reality. Certainly, for a consistent national community support work ethos, concepts used by community support work providers in relation to their work such as support, service co-ordination, needs assessment, culturally safe, holistic, consumer-directed, tenacious and assertive require careful definitions that are developed and understood by all stakeholders. Warriner (2000) identified several reasons behind the issues such as fragmentation and tension in service provision. First, they stem from a lack of shared vision and agreement about the appropriate philosophy and style for community mental health. A second reason is difficulty around transforming recovery concepts into practice. Finally, recognition is emerging that wider community and intersectoral involvement is needed to achieve community support work outcomes. Accordingly, Warriner (2000) noted that community support work proponents regard psychiatric and mental health services as unethical when they are provided simply as technical practice and expertise. He suggested that if traditional approaches cannot adapt or transform to the dynamic issues and nuances of community life, such approaches will not survive outside of the institution. It is here that the medical/psychiatric model of mental health parts from holistic paradigms fostered through community support work: scientific ideology based on a reductionist (medical) model centres on diagnosis and fragmentation of the whole person, their needs and desires. This approach is problematic for holistic community mental health development (Warriner 2000).

Training and workforce development

The national certificate course in community support work has been available since 1998. Service provider concerns are that the content does not reflect the support work model and role. For example, training should include:

the role of support needs assessment

boundaries and ethics

an overview of best practice rehabilitation and recovery models

indigenous models of Mori and Pacific peoples (Wade 1999; Warriner 2000). Training should also increase service user involvement in course design and delivery. A strong argument is that providers need more say in and control of the community support work workforce to ensure its relevance and effectiveness. Their greater involvement will in turn mean less control by generic institutions. There is also a concern around professionalisation of the community support work role (Wade 1999; Warriner 2000). That is, it may breed arrogance and workers could start to do to or for rather than with consumers. However, this argument brings into question the meaning and essence of professionalism. Although on the one hand important qualities of respect, integrity and courtesy do not reside in qualifications, on the other hand qualifications may sharpen such qualities and (ideally) provide more assurance of credibility. As Warriner (2000) highlighted, it is important that any training in the area aims to enhance the fundamental personal and relationship aspects of community support work.


Outcomes

According to research on 11 community support work services in the Northern region, which asked a random 20 percent of service users about the effectiveness of these services, users strongly endorsed community support work (Kukler 1999). The consumer-defined outcome domains for community support work were: establishment of positive relationships, access to community supports, unmet needs/service gaps, natural supports and preventative safeguard/liaison. Key outcomes were:

positive relationships, characterised by listening and empathy, scored very highly

consumers did not give high priority to use of natural supports such as family and friends, nor to access to community supports

consumers were turning to their support worker to meet their needs rather than becoming increasingly self-reliant and developing community networks.

As identified by the researcher, a key implication was that workforce development and future training in community support work need to strengthen workers skills and knowledge in community networking, working with families, motivational communication and self-management skills. Based on literature that was not research-based, Wade (1999) has identified desired outcomes from the Northern region model that differ from the consumer-defined outcomes in Kuklers (1999) research. He identified:

system- or provider-defined outcomes of reduced use of psychiatric institutions, reduced criminal involvement, reduced compulsory treatment, and increased satisfaction with service

personal outcomes of decreased stigma and discrimination, more community understanding about mental illness, better housing and self-care, a sense of belonging, health and financial improvement, less professional support and greater independence.

The discrepancy highlights differences among original system- or provider-defined outcomes, personal outcomes sought from community support work and actual outcomes from consumer-defined domains of value and importance as measured in Kuklers (1999) research. It illustrates a need to reconcile system- and provider-defined outcomes with consumer-defined outcomes to ensure that outcomes agreed on as desirable are truly defined by the service users.

Wellness

New Zealand researchers Geoff Bridgeman et al (2000)10 pointed out that although studies show that satisfaction with services correlates with service quality, there is no evidence (as yet) of any relationship between satisfaction and recovery. Kukler (1999) did not attempt to measure service user satisfaction in his research. However, it is important that enthusiasts do not generalise interpretations of the Northern Region Outcomes Project to the extent of claiming service user satisfaction. Research by Corrigan also suggests that

10 This mental health outcomes research project was conducted in partnership with Te Arawa iwi, tngata

whaiora and consumers in mental health services in Rotorua and East Auckland.


expectation influences satisfaction in mental health services and that lower scores in areas such as esteem and quality of life may correlate with lower expectations. Bridgeman et al (2000) constructed an outcomes approach to mental health wellness based on philosopher Ken Wilburs (1996) integrated theory of consciousness and behaviour and Durie and Kingis Te Whare Tapa Wh model.11 An important component of Wilburs philosophy is the value of different truths as a way of understanding evolution and the human condition. Bridgeman et al, reflecting on understandings and perceptions of mental health and wellness from their research, reiterate that a significant problem is that we often celebrate one set of capacities and values whilst excluding others. Drawing widely upon both Western and Eastern philosophy and theories, Wilburs integrated theory of consciousness suggests that evolution and reality consist of four quadrants:

1. interior individual (mind, symbols, concepts, emotions, impulse, irritability, sensation, etc)

2. exterior individual (brain, limbic system, atoms, molecules, etc)

3. interior collective (cultural, mythic, rational, magic, etc)

4. exterior collective (planets, societies, galaxies, division of labour, tribes, families, horticulture, industry, etc).

Although the quadrants are paradoxical to one another, each is valid in its own right.

This is not to say that mental health has not been dominated by one particular quadrant, such as the medical model of the individual exterior (behavioural), or ... large psychiatric institutions in the collective exterior (social/economic) (Bridgeman et al 2000).

The quadrants consist of holons, each with interior (subjective), exterior (objective), individual and collective capacities. For example, Bridgeman et als wellness holon is highlighted and incorporated across different dimensions within each of the four quadrants. In applying Wilburs integrated theory of consciousness to a New Zealand mental health context, Bridgeman et al superimposed Te Whare Tapa Wh over it (2000: 36). The authors described the result:

The wellness holon defines the focus of wellness (how wellness is addressed in each quadrant), the way in which wellness support is provided, and the ... processes that operate within each quadrant. A support process, such as counselling, may have components of all four quadrants, while being primarily focused upon the individual interior, and a wellness activity such as kapa haka (group practice of Mori ritual, dance and song), while centred on the collective interior, may have to address issues in the other four quadrants (eg, motivation, fitness, support systems).

11 Community support work workers and service providers may be less aware of other Mori health models;

see Pere (1988) for more information on Te Wheke (the Octopus).


Bridgeman et al summed up how to sensibly apply Wilburs paradigm to mental health:

The integrative task is not to squeeze the four quadrants into one reality (for that cannot be done) but to live with the contradictions of all four simultaneously.

This emphasis on contradictions within the human condition, environments, theory and philosophy closely mirrors an observation of Warriners (2000) that people and life are contradictory. It implies that there is no one answer (or truth) to what factors best meet peoples support requirements in community mental health.12 Similarly, Wilbur (1996) has shown how exterior truth can be measured empirically and objectively, but a deeper understanding includes an interior dimension one that is subjective and interpretative, that depends on consciousness and introspection:

Truth, in the broadest sense means being attuned with the real. And that implies that we can be out of touch with the real. We can be lost, obscured or mistaken, or wrong in our assessments (Wilbur 1996: 105).

This concept is probably closest to the Strengths community support work model and the Trieste experience. For both approaches, support in the community for people with serious and persistent mental illnesses is only ethical if practitioners are critically self-reflective on their role and on the systems they operate within, valuing service users as directors of process and outcomes. Responsible community support therefore includes a multitude of possibilities and pathways to diverse resources both for the service user (such as the freedom to choose widely and wisely) and for the support worker (such as training, peer support and career extension). The following were key results from Bridgeman et als (2000) research.

Service users had consistent and distinct views of their illness, which differed from the views of caregivers and service providers.

Only questions directly accessing cultural issues distinguished between Mori and mainstream positions.

There was a major difference between Mori and mainstream elder positions on the meaning of wellness, and a dominance of mainstream perceptions of wellness across other groups.

Service users had a stripped-down view of wellness that reflected the low expectations of that group. Expectations of wellness were very low compared with those of service providers.

12 Again, the one size fits all style of traditional mental health services has been challenged as unsuitable for

peoples different needs.


In relation to constructions of wellness, Bridgeman et al (2000: 910) found the following.

Whine and tne emphasise the collective.

Whine emphasise relationships13 (collective exterior) and trust/awhi (collective interior), while tne were more concerned with spiritual qualities (collective interior). For example, Whine: The family got together and awhied and supported me; Tne: I strongly recognise my mauri, my spiritual side of myself my wairua.

Womens consumer groups and whine were the only service user groups to identify trust/awhi and relationships as being important to wellness. These qualities were also important to families and whnau.

Safety and protection were important to families and whnau, an area almost never identified by consumers/tngata whaiora.

Service providers and kaiawhina had expectations of wellness balanced across all four quadrants, which suggests a generous, balanced and holistic perception of wellness.

Rangatahi and younger people were concerned with motivation.

Older people and pakeke were concerned with hygiene, sleep and basic coping, perhaps reflecting years of involvement with mental health services and institutions.

Collective concepts of trust, love, protection, and individual interior concepts of choice and fun were almost entirely absent from views of wellness held by service users.

Mainstream and Mori communities perceptions of wellness came from opposite ends of the holon. Community elders (city and community councillors) were very individualistic in their responses eg, emphasising the freedom to act, ability to cope and behaving in a socially acceptable way (individual interior). Kaumatua and kuia emphasised collective interior qualities such as trust and spirituality as essential to wellness.

Tngata whaiora emphasised individual exterior factors, eg, getting off medication, drugs and alcohol and not having psychotic thoughts, whereas mainstream consumers wellness depended more on the individual interior: having goals and motivation, being happy and not stressed.

Consumers saw their community as stigmatising and mental health services as supportive.

Tngata whaiora saw medication as an instrument of cultural control, whereas consumers saw it as a necessary burden.

Service users rated themselves as relatively untroubled by symptoms and reasonably satisfied with the mental health services they received, but statements around wellness revealed major areas of anger and frustration, particularly for tngata whaiora.

13 Similarly, US researcher Cogan (1998) found that women value relationships as central to their mental

health. Contrary to traditional psychological theories that emphasise autonomy, Cogan proposed that womens development is primarily relational and that the self can only develop fully in the context of connectedness: an inner sense of connection to others is central to womens identity and place in the world; when it is disrupted, womens mental health is seriously compromised.


Adding to Wades (1999) recommendations, Warriner (2000) and Kukler (1999), suggest that outcome data collection on community support work will be improved by sampling and measuring community experiences and perceptions of mental wellness, alongside those groups that are already included (the services users, providers and families/whnau). This point is particularly pertinent given that the essence of community support work is community outreach and integration. Without them, community support work advocates risk promoting and reporting the value of community integration and holistic recovery-oriented services in papers and conference discussions, whilst actual community integration and individual recovery lag far behind the vision. Accordingly, Bridgeman et al (2000) suggest that tracking expectations of wellness may be a valuable outcome tool in this area:

Why are service users expectations of wellness so low, and what can be done to raise them? This is to say that a critical outcome is the improvement of expectations, and that dissatisfaction with services may well be a better outcome than satisfaction.

Southern research Two extensive studies of South Island community support work have been undertaken. Roen (1999) and Cameron (2000) both sought to gain a picture of community support work from interviews and focus groups with consumers and tngata whaiora, community support workers, service providers, community mental health teams and needs assessors. Roens research covered Christchurch providers Comcare, Stepping Stone, Richmond Fellowship, Te Karakura Trust and Healthlink South. Camerons research was commissioned by Comcare Charitable Trust (a Christchurch community support work provider) and PACT (a community support work provider in Southland and Otago) to evaluate community support work in Southland, Otago and Christchurch. Key issues from both research projects are highlighted and illustrated with excerpts from the interviews and focus groups and, where relevant, are discussed in relation to the wider literature. Although methodology is not the primary concern of this review, it is noteworthy that for the part of Roens research that addressed kaupapa Mori services and tngata whaiora experiences, Adrian Te Patu conducted Mori-only focus groups. Community support work has grown in Christchurch and Southland since 1996. It is not clear from the research whether providers have modelled their services on any particular paradigms. However, it would appear that the Southland organisation PACT has adopted a team approach to support.


Comparison with Northern research

In regard to key community support work issues, the following similarities and differences between the Northern region and Southern region have been identified.

Education and training concerns in the Southern region parallel those in the Northern region. Some conflict between traditional mental health professionals and community support work providers is similar to Northern provider concerns.

Clients and community support workers in the Southern region see a problem of hospitalisation as failure.

Southern community support work research makes no mention of the recovery concept, in sharp contrast with Northern region research.14

The reports from both Cameron and Roen conveyed some discriminatory and stigmatising assumptions and beliefs among non-consumer respondents. For example:

Groups identified as more likely to slip through the cracks included those with dual diagnosis; living in rural areas, with limited insight into their illness or minimal willingness to work towards goals; who may endanger workers (Roen 1999).

By contrast, the Strengths paradigm and Trieste experience turn such assumptions around with a critical awareness that historically mental health treatment and professionals have, ironically, damaged clients/patients. Furthermore, it is a Strengths premise that of course people are willing to work towards goals and get jobs, as long as they are the right goals and the right job; accordingly the right process for people to identify their goals and aspirations must be engaged. In addition, nowhere in the Strengths or Trieste literature is insight into ones illness listed as a prerequisite for quality of life. Although neither paradigm minimises the value of insight into ones state of health, both point to insight into ones strengths and the importance of interdependence as crucial features of the pathway to recovery.

Issues for resolution

In their research on community support work in the Southern region, Roen (1999) and Cameron (2000) identified the following issues as in need of resolution:

addressing work-related issues such as workload, peer support and recruitment

addressing gender issues in mental health care and recovery

dealing with waiting lists

recognising the value of community support workers

establishing a favourable employment culture that offers leadership, passion and commitment

14 Following the Celtech research (Cameron 2000), a large Southern region community support work provider

has pointed out that its community support work service does incorporate a recovery approach.


ensuring regional flexibility and diversity in future community support work developments

improving community support work knowledge and sensitivity in identified areas

addressing the balance of attitudes and qualifications

addressing negative perceptions of hospitalisation.

Work

There was a strong perception that in some services, workers were being expected to do too much, and needed more peer support (Roen 1999: 56). Tngata whaiora felt that Mori workers went the extra mile for them where Pkeh workers did not. They also felt that the kaupapa Mori community support service should be expanded (Roen 1999). Cameron (2000: 5

community support work

Documents

mental health sector

new zealand ministry

mental health services

mental health strategy

ongoing mental health

health maintenance

new zealand researchers

new zealand isbn