The International Journal of Psychosocial Rehabilitation

Met and Unmet Needs of Persons with
Severe Mental Illness in a Half Way Home


Kamlesh Kumar Sahu, M.A, M.Phil. PSW
Programme Coordinator
Paripurnata (centre for Psychosocial Rehabilitation)
Former Lecturer, RFPG College for PSR, Bangalore, India
1912, Panchasayar Road
P.O Panchasayar, Kolkata – 700094 (India)
Web: www.paripurnata.org


Sophia C. A., M.A, M.Phil. M&SP
Former Lecturer, RFPG College for PSR, Bangalore, India

Dharitri R., M.A., D M&SP, Ph.D
Professor, RFPG College for PSR, Bangalore, India

Kalyanasundaram S., M.D.
Professor of Psychiatry & Principal, RFPG College for PSR, Bangalore, India
Richmond Fellowship PG College for Psychosocial Rehabilitation
‘Chetana’ No. 40 – 1/4, 6th Cross, Vajpeyam Gardens
Ashoknagar, Banashankari, 1st Stage, Bangalore – 560050 (India)
 Web: www.rfpgcol.com



Citation:
Kamlesh KS, Sophia CA, Dharitri R & Kalyanasundaram S. (2010). Met and Unmet Needs of Persons with Severe
 Mental Illness in a Half Way Home  International Journal of Psychosocial Rehabilitation. Vol 15(2) 13-22





 

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Introduction:
Assessment of needs of persons with mental illness is an essential task of the mental health professionals (Issakidis C, Teesson M. 1999) in order to plan, develop and evaluate mental health services. It is essential to understand this in order to enable them to achieve, maintain or restore an acceptable or optimal level of social independence or quality of life. The persons with severe mental illness constitute an incredibly diverse population, numbering in millions, shares needs unique to themselves in the areas of treatment, rehabilitation and environmental support. In recent years these areas of the mental health system are given more importance in order to give proper care to the patients by assessing their needs.

The needs of all humans include basic survival needs (food, clothing, housing, transportation, financial resources, and personal safety); health care needs (mental health care, physical health care including dental care); and social-connectedness needs (friends, a group to belong to, a role in life, and a meaning or purpose in life). Needs are cantilevered rather than hierarchical with each need supporting all other needs. One unmet need that adversely affects all needs is the ability to adapt to stressors, and achievement of well-being (Hansell, 1976). According to Abraham Maslow (1985), the individuals’ whole life – perceptions, values, strivings and goals, is focused on the satisfaction of a set of four needs, which are arranged in a hierarchy. They are physiological needs for food, water, sex and sleep in the lower level. One step above these are safety needs for feeling safe and secure in ones life. In next level, these are social needs for love and belongingness, appreciation to fit in to a network of social relationship. Above all these needs, there are the esteem needs to develop self- respect, gain the approval of others and achieve success. At top of the hierarchy are self- actualization needs to become concerned not  only concerning one’s selfish interest but also with issues that affect the well - being of others. He points out that, the higher level needs cannot be activated, until lower level needs have been satisfied.

Harry Stack Sullivan (1985) defines 'needs' as 'needs for satisfaction' and 'needs for security’. The need for satisfaction includes physical needs- air, water, food, warmth. Emotional needs to be secured include needs for human contact and expressing ones talents and capacities. Here, interpersonal relationships are of central concern, which leads to tender responses to human needs. According to him failure to meet these needs result in loneliness and anxiety.
Although the concept of need is used internationally, there is no consensus about the precise meaning of the term. Psychological theories have employed concepts of need as a basis for understanding action, such as Maslow’s hierarchy of needs (Maslow, 1985). Psychiatrists; by contrast, use measurement of need to inform service provision.

In Britain the Inspectorate and community Care Act (1990) defines needs as “the requirements of individuals to enable them to achieve, maintain, or restore an acceptable level of social independence or quality of life” (Department of Health social services Inspectorate, 1991). This definition equates need with level of social functioning. Thus need arises as a result of social disablement, which occurs when a person experiences lowered psychological, social and physical functioning in comparison with the norms of society (Wing, 1986).

An objective of need assessment is to help those persons with mental illness to communicate clearly about their difficulties. The mental health professionals are concerned with assessing the persons' unmet needs that are sufficiently serious to merit interventions by service. For care- givers, assessment is an opportunity both to act as advocates for the mentally ill people and to help them access support and respite services themselves. The other purpose of assessment of needs is to make various social and political concerns aware of the plight of the mentally ill people and initiate them to take the necessary steps to improve their quality of life.

Several studies have been done with the aim of assessing the needs of the persons with mental illness. Assessment of ‘felt needs’ forms an important constituent in the planning of mental health services (Wig & Srinivasamurthy, 1981). This would suggest that the first step towards programme planning and delivery of after-care services would be the proper evaluation of subjective needs. Assessment helps persons with mental illness to communicate clearly about their difficulties. The mental health professionals are concerned with assessing the person’s unmet needs that are sufficiently serious to merit interventions by service. For the care-givers, the assessment is an opportunity both to act as advocates for the persons with mental illness and to help them access support and services, themselves. The other purpose of assessment of rehabilitation needs is to make various social and political concerns aware of about needs of the persons with mental illness and encourage them to take necessary steps to improve their quality of life. Needs assessment may strengthen the therapeutic alliance, improve our understanding of priority needs and aid in service development. There are few attempts in India to assess the needs in severe mental disorder. Work is required to ensure that care is targeted explicitly towards unmet need.

Objectives
The present study is intended with the objectives to identify the presence of needs of persons with mental illness living in a Half Way Home setting within a range of domains addressing the following; basic, health, social, functioning and service issues; and to assess the informal and formal help currently being given and to assess the formal help needed.

Materials and Methods Used
This study was conducted in ‘Asha’ Half Way Home run by Richmond Fellowship Society, Bangalore, India. Every consecutive resident (persons with mental illness) with above 18 years of age from either sex were approached to participate in the study. Those who had not given consent, or presented with sensory/neurological disorders or with any chronic physical illness were excluded. Sample consists of 30 consecutive persons (residents) with Severe Mental Disorder (schizophrenia or bipolar affective disorder) according to International Classification of Diseases – 10 (ICD-10; WHO, 1992). Relevant socio-demographic and clinical data collected through the specially designed data sheet. To rule out the psychiatric morbidity, General Health Questionnaire-5 (Shamsundar et al, 1986) was administered on staffs (who were identified as a Key Support Provider (KSP) for the respective resident), and those who scored 1 or more on GHQ-5 was excluded. Met and unmet needs of the residents were cross sectionally assessed with help of KSP using ‘The Camberwell Assessment of Need – Research’ (CAN-R; Phelan and Slade, 1995). CAN-R is intended for research use which assess needs in 22 health and social domains: accommodation, food, looking after the home, self care, daytime activities, physical health, psychotic symptoms, information, psychological distress, safety to self, safety to others, alcohol, drugs, company, intimate relationships, sexual expression, childcare, basic education, telephone, transport, money and benefits. The last domain benefit was not used for this study since it was found not appropriate for this study. For each domain, the goal was to identify whether the service user has any difficulties, and if they do then to establish what level of help they needed and how much they were actually getting it, and whether they are getting the right type of help. All were items coded in the same way. First, the KSP interviewed whether a particular need is present for a particular resident, and if present whether it is met (resulting in a score of 1) or unmet (score of 2). If there is no need (score of 0), the interviewer proceeds to the next item. If there is a need, the respondent is asked for information on the levels of help received from family and friends, help received from formal services and help needed from formal services (help levels are each rated as 0, no help; 1, low level of help; 2, medium level of help; 3, high level of help).

Results and Discussion

Data collected was analyzed using statistical package for social sciences (SPSS) for windows version 10.0. Descriptive statistics were used and the frequency tables were made, results can be discussed under the following headings:-   

Socio-demographic Characteristics of the Residents:  
The mean age of residents was 36.50 ± 8.11. Males 19 (63.3%) were comparatively more than females 11 (36.7%). Mean years of education was 13.87 ± 2.21. Majority of the residents were Hindus (76.7%), in comparison to Christians (13.3%) and Muslims (3.3%). All residents belong to general category. Majority of the residents (70%) were unmarried 13.3%, were married and 16.7% were widow/widower. With regard to area of residence, 80% were from urban background, 16.7% from semi-urban and 3.3% were from rural areas. Majority of the residents (60%) were unemployed, 13.3% were students, home makers, and business persons each 3.3%, and 20% other category. Al most all (96.7%) of the residents were having monthly family income above Rs.10000 except one resident (3.3%) having less then Rs. 10000 monthly. Majority (93.3%) of the residents belonged to nuclear family and only 6.7% belonged to joint family.

Clinical Profile of the Residents:
Majority (76.7%) of the residents were diagnosed as suffering from with schizophrenia and 23.3% were with other disorders. Mean age of onset of illness of residents was 22.07 ± 6.50 years. Residents having mean duration of illness (in years) were 14.93 ± 7.06. Number of hospitalization (in last one year) was 00.73 ± .94.  Mean duration of treatment was same as illness duration and it shows that these persons with mental illness received treatment since the onset of illness. It could be due to the influence of their back ground most of them from upper or upper middle urban families with good educational background.

Met and unmet Needs of the Residents:
From Table 1 Findings reveals that there was moderate or better agreement for met needs in all 21 domains of needs assessed. The range of unmet needs (12.54%) identified in important need-domains were less than met needs (29.37%). The areas in which highest proportion of met needs were basic needs (61.1%); which includes; accommodation (70%), food (66.7%), and daytime activities (46.7%) followed by  service needs (38.89 %) which includes; telephone (56.7%), information (43.3 %) and transport (16.7%). Besides meeting any person's basic needs such as adequate family support, socialization, work, housing and nutrition; providing psychiatric and medical care are also indispensable for better functioning and minimal quality of life of the severely mentally ill  (Issakidis C, Teesson M. 1999).
 

 

The residents' most frequently identified four unmet needs were ‘psychotic symptoms’ (40%), ‘company’ (36%), ‘intimate relationships’ (30%), ‘psychological distress’ (23.3%) and ‘day time activities’& ‘looking after the home’  (20%).The staff generally had a good knowledge concerning the residents' need for care but they not know about the sexual expression/problem of 63.3% of residents or it could be because the residents do not disclosed it. Most of the residents were unmarried (70%) and (16.7%) were widow/widower and even married people are living separately; and as a result of this they perhaps had some unmet sexual needs. However the socio-cultural background from where they come from might be one of the important factors which made them unable to express about sexual needs/problems.

Informal or Formal Care Receipt and Formal Care Needs of the Residents:
 From (Table 4) The findings indicate that the residents’ required high help from formal care services in the areas of basic needs such as accommodation and food (70%) followed by the service need in areas of information (45%). They need high formal care in social needs like company (40%) and intimate relationships (40%). Health needs like psychological distress (40%) and psychotic symptoms (30%) of the residents were also found high. In functioning needs such as looking after the home (50%), self care 35% and 30% residents’ needs high help from formal care services.

Table 4 Informal or Formal Care Receipt and Formal Care Needs of the Residents {frequency (%)} Needs domains Informal Care Receipt Formal Care Receipt Formal Care Need No Low Moderate High No Low Moderate High No Low Moderate High Basic                         1.        Accommodation 14 (46.3) 5 (16.7) 5 (16.3) 0 0 0 12 (40.0) 12 (40.0) 0 1 (3.3) 7 (23.3) 16 (53.3) 2.        Food 13 (43.3) 5 (16.7) 3 (10.0) 0 0 0 5 (16.7) 16 (53.3) 0 1 (3.3) 5 (16.7) 15 (50.0) 3.        Daytime activities 7 (23.3) 6 (20) 5 (16.7) 2 (6.7) 0 1 (3.3) 5 (16.7) 14 (46.3) 0 1 (3.3) 7 (23.3) 12 (40.0) Health         0       0       4.        Physical health 3 (10.0) 2 (6.7) 1(3.3) 0 0 1 (3.3) 4 (13.3) 1 (3.3) 0 1 (3.3) 2 (6.7) 3 (10.0) 5.        Psychotic symptoms 4 (13.3) 6 (20.0) 14 (46.3) 1 (3.3) 1(3.3) 3  (10) 8 (26.7) 13 (43.3 0 0 14 (46.3 11 (36.7) 6.        Psychological distress 5 (16.7) 3 (10.0) 10 (33.3) 3 (10.) 0 1 (3.3) 13 (43.3) 7 (23.3) 0 0 15 (50.0) 6 (20) 7.        Safety to others 0 1 (3.3) 3 (10.0) 1 (3.3) 0 0 3(10.0) 2 (6.7) 0 3 (10.0) 2 (6.7) 0 8.        Safety to self 1 (3.3) 0 5 (16.7) 0 0 0 4 (13.3) 2 (6.7) 0 0 4 (13.3) 2 (6.7) 9.        Alcohol 0 0 0 0 0 0 0 0 0 0 0 0 10.     Drugs 0 0 1(3.3) 0 0 0 0 1 (3.3) 0 0 0 1 (3.3) Social                         11.     Company 4 (13.3) 8 (26.7) 10 (33.3) 1 (3.3) 0 1 (3..3) 6 (20) 16 (53.3) 0 2 (6.7) 5 (16.7) 16 (53.3) 12.     Intimate relationships 3 (10.0) 9 (30.0) 4 (13.3) 2 (6.7) 0 2  (6.7) 9 (30) 7 (23..3) 0 1 (3.3) 5 (16.7) 12 (40.0) 13.     Sexual expression 3 (10.0) 0 2 (6.7) 0 1(3.3) 1 (3..3) 3(10) 0 0 1 (3.3) 3 (10) 1 (3.3) Functioning                         14.     Looking after the home 12 (40.0) 4 (13.3) 5 (16.7) 2 (6.7) 0 2 (6.7) 10 (33.3) 10 (33.3) 0 2 (6.7) 6 (20) 15 (50.0) 15.     Self care 9 (30.0) 2 (6.7) 3 (10.0) 1 (3.3) 0 1 (3.3) 4 (13.3) 9 (30.0) 0 1 (3.3) 3 (10) 10 (33.3) 16.     Childcare 0 0 0 1 (3.3) 1(3.3) 0 0 0 1 (3.3) 0 0 0 17.     Basic education 0 0 1 (3.3) 0 0 0 1(3..3) 0 0 0 1 (3.3) 0 18.     Money 1 (3.3) 4 (13.3) 0 0 0 2 (6.7) 3(10.0) 0 0 1 (3.3) 2 (6.7) 2 (6.7) Service                         19.     Information 7 (23.3) 5 (16.7) 5 (16.7) 0 0 3 (10) 8 (26.7) 5(16.7) 0 0 4 (13.3) 12(40.0) 20.     Telephone 10 (33.3) 5 (16.7) 3 (10.0) 0 0 7 (23.3) 2 (6.7) 9 (30.0) 0 2 (6.7) 10 (33.3) 2 (6.7) 21.     Transport 2 (6.7) 3 (10.0) 3 (10.0) 1 (3.3) 1 (3.3) 1 (3.3) 8 (26.7) 8 (26.7) 0 1 (3.3) 6 (20) 3(10.0)

Regarding the amount of help residents were getting from the formal care services was also found to be high, particularly in the areas of food (70%), accommodation (55%), for management of psychotic symptoms and loneliness (40%). Residents were getting help from formal care services for better functioning, 30% residents are getting help for maintaining their living space and 25% to maintain their personal hygiene.  They were also getting moderate help in almost all areas of need from the formal care services. Major part of the formal care was provided by the half way home, where residents were living. People with mental health problems have complex needs. Care should be provided according to need (Xenitidis K, 2000). Formal care providers or mental health professional have better understanding of the needs of the persons with severe mental illness, so they are able to fulfill their unmet needs.

Informal care provider such as family or friends were providing mild to moderate help to fulfil their needs, 40% residents were getting moderate help to manage their psychiatric symptoms, in terms of taking them for psychiatric consultation and helping them to avail the other formal care services. 25% were moderately helped by informal care providers for the management of there psychological distress. They used to visit them, share their feeling and emotions which helped residents, similarly its help to resolve loneliness (15%). Occasionally family or friends would take them to their home and providing opportunities to participate in different social and family events which helped them to fulfil their various needs. Inadequate knowledge of needs of persons with severe mental illness would be the major reason involved to provide inadequate care from informal care providers such as family and friends. Social attitudes towards persons with severe mental illness cause more distress to the persons and his/her near and dear ones, than the illness itself. The major psychosocial issues related to persons with severe mental illness are: knowledge about illness and its managements, quality of medical management, rejection, overprotection, education, employment, marriage and pregnancy. Informal care provider, such as family or friends has vital roles to play in order to address them.

Residents were Getting Right Type of Service or not:

Professional staff felt that residents were getting the right type of help for almost all needs except for the sexual expression (40%) and psychiatric symptoms (20.8%), and expressed the view that they are not getting right type of service.

Conclusions and Implications

The unmet needs were less than the met needs since residents were getting help from formal service providers followed by informal care givers. Major part of the formal care was provided by the half way home, where residents were living. The results indicated the need for further emphasis on interventions towards the management of psychotic symptoms and psychological distress as well as to focus on interventions concerning the social relations of persons with severe mental illness. Most of the residents had no outside friends or they were unable to maintain intimate relationships with relatives. Some more structured occupational therapy could address the unmet needs in the areas of day time activities and looking after the home. Assessment of different needs of persons with severe mental illness is an essential task of the mental health professionals, and the assessment should be as rigorous and comprehensive as possible focusing both on the individual with mental illness and caregivers and at the community levels (Issakidis C, Teesson M. 1999). Results suggest that fully integrated care, formal and informal is essential to meet the needs of persons with severe mental illness. Residential setting like half way home has a very important role in fulfilling the needs of the persons with severe mental illness.

Small sample size and one way perspectives of assessment for needs are the major limitations of this study since residents and staff may show different perceptions of needs for care therefore multiple perspectives should be taken into account for planning and providing effective needs led psychosocial rehabilitation services and comprehensive mental health care.  
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