The Mental Patient Comes Home.

AIMS AND METHOD 

To examine the vocational status of people with longer-term mental health problems in the inner London Borough of Wandsworth. Data collected over 10 years on 1 April each year as part of an annual census of adults with longer-term mental health problems using community mental health and rehabilitation teams were analysed to examine the vocational status of these groups.

RESULTS 

Within the borough unemployment rates among people with longer-term mental health problems increased steadily during the 1990s, despite a decreasing rate of general unemployment for the majority of that period. Unemployment among people with long-term mental health problems increased from 80% in 1990 to 92% in 1999, and the unemployment rates among those with a diagnosis of schizophrenia increased from 88% in 1990 to 96% in 1999.

CLINICAL IMPLICATIONS 

Work and employment is important in health as well as social functioning. Greater attention to vocational issues in clinical teams is required: the challenge for mental health services is to make employment interventions of demonstrated effectiveness available to all who need them.

Unemployment rates among patients with long-term mental health problems: A decade of rising unemployment

Work therapy is a widespread form of sociotherapy. In contrast to pharmacological and somatic forms of treatment, proof of efficacy is difficult to produce in multimodal therapy of schizophrenic patients on account of the many methodological problems involved. Within the framework of an extensive study on the vocational rehabilitation of mentally ill patients, we carried out a naturalistic follow-up study of 83 schizophrenic patients attending outpatient work therapy. The sample, which comprised 44 men and 38 women with a mean age of 35 years (± 8.5 years), can be seen as regionally representative. The courses of illness and rehabilitation were documented prospectively at annual follow-ups over a 3-year period. Most of the probands were chronically mentally ill patients with a history of frequent and long-term hospitalisation. At the end of the 3-year period, 22% of the patients were integrated into the open labour market, 26% were working in sheltered employment, 23% were still in work therapy, and 29% were unemployed. Two-thirds had achieved their stated rehabilitation objectives. The 3-year rehabilitation outcome was strongly dependent on the patients’ subjective expectations. Other factors proving to be predictors of successful rehabilitation were less pronounced psychopathological symptoms (ADMP), better social functioning (GAS), a higher level of education and an early introduction to work therapy. Work therapy appears to have a favourable impact on hospitalisation rates.

Work therapy for schizophrenic patients: results of a 3-year prospective study in Germany.

Chronic social disablement is caused by three types of factor: impairment, e.g. slowness in schizophrenia; social disadvantage, e.g. lack of opportunity to develop social or vocational skills; and an underconfidence or unduly low self-esteem which is reactive to impairment and disadvantage. The last of these factors is particularly evident in ‘institutionalism’, a condition in which the individual comes to acquire a contentment with institutional life and wishes to lead no other. Many long-stay patients in large mental hospitals used to be ‘well-institutionalized’ but it became recognized that retraining and rehabilitation could lead to successful resettlement outside hospital. For a time these striking successes suggested to some theorists that abolishing the hospitals would abolish disablement as well but it is now quite clear that this is not the case. Chronic impairments still occur and create a continuing need for sheltered environments. The frequency and type of problems still arising are discussed in the light of recent surveys in England. One small group requires highly-staffed accommodation, others need less supervised day and residential settings; all need long-term care. It is emphasized that some people living at home with relatives also have chronic mental disabilities as have a high proportion of the destitute. Such problems are less frequent than formerly but they still require detailed medical and social attention.

Who becomes chronic

British contributions to theoretical and applied social psychiatry have been determined in large part by a traditional empiricism and by developments in social welfare legislation over the past 70 years. The establishment of a national health service covering the whole population and the attempt to provide comprehensive social services have created special opportunities for epidemiological research and for practical community psychiatry. These developments have by no means been uniform throughout the country, and there has been plenty of scope for individual initiative. Open-door policies, domiciliary visiting, social and occupational rehabilitation, therapeutic communities, and long-term continuity of care were first introduced in pioneering centers and subsequently adopted elsewhere. The idea that disorders such as schizophrenia not only have the character of acute illnesses but can also take the form of chronic disabilities has led to recognition of the fact that services must be tailored to the needs of individuals, and to an emphasis on the importance of the family and other social environments. There is a readiness to capitalize on successes and to learn from mistakes, assisted by a wide range of evaluative studies, which promises well for the future.

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Social Psychiatry in the United Kingdom: The Approach to Schizophrenia

While work has a significant effect on a person’s life, his psychological state or his illness, it is not easily incorporated into the treatment and management of the psychiatrically ill. Doctors and nurses tend to believe that the sick need rest, not labour. They and the public often equate work with industrialisation and confuse it with a dehumanised assembly line and piecework model of human relations. This view is oversimple, for it neglects the equally dehumanising effects of idleness and unemployment. By using work to help people to adapt in society, one does not endorse society’s norms nor expect people to conform to them. To adapt socially is to be able to deal with the complexities of everyday living. Such adaptation may lead to wealth or poverty, happiness or unhappiness or may involve attacking, neglecting or upholding the established social order. It may be more important to adjust to family life than to work pr leisure, although for economic and social reasons both are very intimately related to family adjustment. Everyone has views on work. It is not only protestants who subscribe to what is known as “the protestantwork ethic”, or non-protestants who have visions of work in dark, satanic mills.

Douglas Bennett

Papers

Techniques of Industrial Therapy, Ergotherapy, and Recreative Methods