The International Journal of Psychosocial Rehabilitation

The Psychosocial Rehabilitation Needs of Residents
of a Half -Way House for Mental Health Care Users in Durban, South Africa


Barbara Simpson,PhD
School of Social Work and Community Development
University of KwaZulu- Natal
Durban
South Africa

Thamary Zambuko, B.S.S. (Social Work)
Masters student

School of Social Work and Community Development
University of KwaZulu- Natal, Durban, South Africa

Correspondence to: Dr B Simpson
School of Social Work and Community Development
University of KwaZulu- Natal
Durban
South Africa
Simpson@ukzn.ac.za

Half-way houses were originally established to provide intermediary care between hospital and community living for mental health care users (MHCUs). They were intended to provide on-going rehabilitation and support to MHCUs who had been newly discharged from hospital for a limited period of time following which the person would be able to move to independent housing. In many cases, however, this has not happened and half-way houses have become a form of supported housing for people living with psychiatric disabilities.

Grace Home (a pseudonym to protect the identity and privacy of the residents) is a half-way house in Durban that provides accommodation for 45 people. Two care-givers work shifts, a psychiatric nursing sister works half day during the week and a social worker visits once per week. The ratio of male to female residents is approximately 60:40 and nearly 80% of residents are white. Sixty percent of the residents are over the age of 40 and 27% are over the age of 50. More than half the residents have been living at the Grace Home for over 11 years and 25% have stayed there for between 16 and 20 years. For many residents, Grace Home has thus become their permanent home. Grace Home has a number of recreational programmes – an exercise programme every morning is compulsory and residents are encouraged to join in other activities such as music classes. Attempts are made to encourage residents to gain employment and move to more independent living arrangements, but these are ad hoc and seem driven by the motivation of individual residents. The management and residents of Grace Home identified the need for a well developed, comprehensive psychosocial rehabilitation programme.

This article describes the first phase of a research project to develop, implement and evaluate a psychosocial rehabilitation programme at Grace Home. The overall research project uses a intervention  research design (Thomas and Rothman, 1994) but this article focuses on the analysis phase which aimed at identifying the psychosocial rehabilitation needs of residents at Grace Home.  The article begins with a literature review which describes psychosocial rehabilitation and then discusses the research study. The results are analysed and implications for the development of a psychosocial rehabilitation programme at Grace Home are then discussed.

PSYCHOSOCIAL REHABILATION: A BRIEF LITERATURE REVIEW
Psychosocial rehabilitation aims at the long term recovery and maximum self sufficiency for mental health service users (Barton, 1999). It differs from acute care which focuses on symptom control and from traditional forms of treatment which include medication and psychotherapy. Psychosocial rehabilitation does not exclude these aspects but expands to include ways to foster social interaction, to promote independent living, and to encourage vocational performance. The focus is on teaching skills and providing community supports so that the individuals with psychiatric disabilities can function in social, vocational, educational and familial roles of their choice with the least amount of supervision from the helping professionals  (Littrell & Littrell, 1998; Sheth, 2005)
Psychosocial rehabilitation is underpinned by two essential assumptions. The first is that people are motivated by a need for mastery and competence in areas which allow them to feel more independent and self-confident and the second is that new behaviour can be learned and people are capable of adapting their behaviour to meet their basic needs (Cnaan, Blankertz, Messinger & Gardner, 1988.)  In psychosocial rehabilitation, intervention is oriented to empowerment, recovery and competency (Barton, 1999) and programmes should be designed to capitalize on an individual’s strengths (Littrell and Littrell, 1998). 

Psychosocial rehabilitation therefore includes a range of social, educational, occupational, behavioural and cognitive interventions that seek to improve the role performance of mental health services users. Barton (1999) states that interventions typically fall into four service domains. The first is skills training which involves systematic skills building through psycho-educational and cognitive-behavioural interventions. The second is peer support which includes self help and advocacy networks and these usually occur in non clinical settings with a minimum of professional support. The third domain is that of vocational services and these services aim to help people work toward recovering vocational roles. The fourth domain is that of consumer and community resource development. This includes direct services such as family education and support but also indirect services which seek to create an infrastructure of community support.  

Psychosocial rehabilitation services in South Africa are not well developed and are hampered by a lack of coherent mental health policies.  Briefly, the South African situation is as follows. In 1997, the “National Health Policy Guidelines for Improved Mental Health in South Africa” (Department of Health, 1997a) were developed, and read in conjunction with the “White Paper for the Transformation of the Health System in South Africa” (Department of Health, 1997b) advocated a human rights approach and a community based approach to mental health. Unfortunately these policy guidelines were never adopted as formal policy and the National Directorate: Mental Health and Substance Abuse is at present drafting a new national mental health policy (Lund, Kleintjies, Campbell-hall, Mjadu, Petersen, Bhana, Kakuma, Mlanjeni, Bird, Drwe, Faydi, Funk, Green, Omar, & Flisher, 2008).  However, services to people with mental health problems are guided by The Mental Health Care Act, No 17 of 2002 which aims (amongst other things) “to provide for the care, treatment and rehabilitation of persons who are mentally ill” which clearly indicates the intention that services should include a rehabilitation focus.  A formal psychosocial rehabilitation policy for South Africa still needs to be finalized but in its draft form, it supports a recovery based perspective and provides an overview of the services needed to promote recovery and the social integration of people with mental health problems (Lund, et al, 2008). 

THE RESEARCH STUDY
Problem statement and aim of the study
No psychosocial rehabilitation programme is currently in place at Grace Home and the need for such a programme has been identified by the management of the facility. Any programme should be based on the needs of the residents and the aim of the study was to develop, implement and evaluate such a programme. The first phase of intervention research is problem analysis (Thomas and Rothman, 1994) and the aim of this phase was to identify the needs, aspirations and hopes of the residents of Grace Home in respect of psychosocial rehabilitation.

Theoretical framework
The research was guided by ecological systems theory which draws on systems theory and ecology to provide a way of understanding how all parts of a system can affect and influence one another. It details the systems in which each individual operates, that is, the micro system (eg family and friends), the meso-system (eg the interactions between the micro systems), exo-system (eg community resources and social networks) and the macro system (eg policies and legislation) and the ways in which they affect and are affected by one another (Jack & Jack, 2000). Ecological systems theory also provides a framework for understanding the balances that exist between stressful and supportive elements at individual, group and community levels, any or all of which might be identified as targets for action (Jack & Jack, 2000). Ecological systems theory thus has much in common with psychosocial rehabilitation. 

Data collection and analysis
The initial intention was to interview all 45 residents. This however was not possible and a total of 30 people (17 men and 13 women) took part in the study. Some residents were not available at the times when the interviews were being held, some were not able to participate because they were not well at the time, and some chose not to participate. Those who chose not to participate were not asked to give an explanation as residents had been assured that participation was voluntary and it was felt that this assurance needed to be honored.

Two final year undergraduate social work students collected the data using an interview guide. These two students were doing a fieldwork placement at Grace Home and had established positive relationships with the staff and residents. During the research interview, they explored a number of themes which were identified from the literature, namely skills for daily living, management of the illness and symptom control as well as sources of social support, and vocational and housing aspects.

The researchers wrote detailed accounts of the interviews, including as many verbatim quotes as possible. These were analysed manually by noting similarities and differences in each of the themes. The limitations of this method of recording is acknowledged as quotes may not have been totally accurate. However, as suggested by Babbie and Mouton (2001) efforts were made to ensure the trustworthiness of the data by prolonged engagement (the student interviewers spent a considerable amount of time at Grace Home), peer debriefing (on-going discussions with a social worker in the field of mental health) and member checks (a meeting to present the preliminary findings was held with the residents).  This article presents “thick descriptions” of the views of the residents and the research process is presented in detail, all of which contribute to the trustworthiness of the data.


ETHICAL ISSUES
Because of the possibility that the research process might raise psychological discomfort for participants, ethical concerns were given particular consideration. Principles of informed consent, voluntary participation, protection from harm and the protection of their identity guided the study (Babbie and Mouton, 2001). The management of Grace Home supported the research and the project was initially discussed with all the residents at a resident’s meeting where all aspects of the research were explained in detail. At the beginning of each research interview, these issues were once again clarified and each participant was asked to sign a consent form. No tape recorders or cameras were used but participants were asked to give permission for notes to be taken during the interview. No identifying particulars were recorded and this article does not identify the half-way house in any way.  

DISCUSSION OF RESULTS
Skills for daily living
Skills for daily living are those needed to satisfactorily manage community life including personal hygiene, food preparation, housekeeping, shopping, use of public transportation, money management, and community safety skills.

In terms of personal hygiene, all the residents commented that constant attention was given to this aspect. A typical comment was:  “We do have talks about hygiene and we were told that our appearance is important. If we dress up nicely it will make other people realize that we are recovering and are no longer ill.”

The half-way house requires all residents to clean their rooms (all the residents have private rooms) and to take care of their personal belongings. There is also a roster and everyone has a turn to clean the bathrooms and remove the garbage.  In these respects, then, residents have the opportunity to take responsibility for daily chores. However, only two residents work in the laundry and the main meal of the day is supplied by a catering company. Residents therefore have little chance to practice washing, ironing and cooking which are all important skills necessary for independent living. One participant noted that she wanted to live alone but wondered how she would manage, “I would battle to cook since my mother used to do the cooking for me.”

Most of residents were of the opinion that they could use public transport and do their own shopping although one said that he needed help and could only manage going to a nearby petrol station to buy sweets.

Management of illness and symptom control
An important aspect of preparation for community living is learning how to manage one’s condition which includes complying with medication and communicating with medical personnel (Umansky, Telias, Tzidon, & Kotler, 1999).  Only six participants said they understood their illness and felt that the medication was appropriate and helpful in controlling their symptoms. Most residents were not happy with their medication. They complained that it made them tired and sleepy and in some cases, nauseous. One resident was concerned that this would reduce her chances of getting a job, “Imagine if I fall asleep while on duty!” One resident believed that she had been wrongly diagnosed -after watching a television programme she believed that her symptoms more closely resembled another psychiatric illness. Most of these residents indicated that they did not like speaking to the doctors about their problems with the medication. Doctors, they complained, were busy and not always willing to listen.

At this half-way house, all medication is administered by the staff. Some residents felt that this was unnecessary and wanted to assume responsibility for this. They explained that when they went out for weekends to visit their families, they coped well and were able to manage on their own and they were of the opinion that they should be encouraged to be more independent.

Social support systems
Families
Relationships with families were complicated. Many residents recalled experiences of domestic violence, alcoholism and sexual abuse in their families of origin which they believed contributed to them developing a psychiatric illness. One participant said: “I never had a place I call home. Since from an early age my parents were alcoholics and they moved us from place to place.  They used to fight and abused us when angry and I ran away when I was sexually abused by my step dad.”    

Some residents felt that their families abandoned them because of their illness.  One resident described her family as “hating” her. She explained that she had tried reaching out to her mother but that her negative and rejecting attitude had caused her to have a relapse. Another resident, a mother of three children, explained how her ex- husband would not allow her to see the children and how after a particularly nasty altercation, she had a bad relapse which, in the opinion of her ex-husband, proved his point. 

Several residents described guilt at “being a nuisance” to their families. “I wouldn’t like them to feel obligated” and “I wouldn’t want to impose on them” were typical comments.

Four participants felt that their families discriminated against them because they were not able to contribute financially to the family. Family members who were working were seen to be the family “favourites” and were treated with respect, while the person at Grace Home was treated rudely and their opinions about family matters were not taken seriously. A resident described how her family had taken advantage of her when she was incapacitated. They had taken her house and withdrawn her savings and were not prepared to give them back to her. She wanted to consult a lawyer but did not know how to access one.

On the other hand, a number of residents reported good and supportive family relationships. One person said, “I have two sisters, we are very close. One lives close by and I visit her on week-ends. My son also visits me almost every week. ”  Another described how she spends weekends at her mother’s home but feels the place is too small for to move there permanently.

Other residents described their relationships with their families as good but, in fact, had very little contact and seemed to prefer it that way. Some had relatives who live overseas which also made contact difficult.

Friends
The positive impact of quality friendships is seen in the following two quotes from residents: “I have a friend who fetches me every two weeks and we just chill at his house” and “I have a friend who picks me up and we go to play tennis, after that we have a meal and a few drinks. This really makes me feel good and wanted.”

For some residents, belonging to a faith community was important and helped them feel part of the community. One resident described her friend from church who she meets at the shopping centre for shopping and tea. Another described her pastor as her friend.

 However, most of participants had difficulty making friends outside the half-way house. In some cases, this was attributed to the stigma associated with mental illness. According to one participant: “The moment people know that you come from (the half-way house) they withdraw their friendship because they do not want to be associated with mentally ill people.”

In other cases, the residents’ lack of social skills made making friends difficult. One resident described how her mind went blank and she couldn’t think of what to say during a conversation. Another simply said “I don’t know how to relate to people who aren’t mentally ill”.
 
Housing aspects
Most of the residents said they would like to move out of Grace Home with half of them saying that they would like to live in a flat on their own. The reasons ranged from “I am a private person and need my space staying in a flat by myself will give me the peace that I want” to “Staying in a house with my friends gives me the freedom to do my own stuff and enjoying going to have drinks with my friends without being monitored. I think it will be cool.”
 
For others though, living alone was not feasible. They acknowledged that rent was expensive and that sharing of resources would be important.  These residents felt that a group home with a few people would be a good idea. One resident wanted to live in a group home because he felt he would “get into trouble” if he was on his own. One person wanted to go to an old age home.

Two participants who had partners would like to move out of Grace Home and set up home together while others talked about the longing for a partner with whom to share a home - “I would like to find a husband and live in a flat happily ever.” Another resident commented wistfully, “I would like to live in a flat with a girlfriend but it is difficult to have a girlfriend ever since I got sick.”

Vocational aspects
Residents had a wide range of previous work experience. This included civil engineering technician, army officer lieutenant, computer technician, baker, assistant nurse, till operator, salesman, artist, architect, marketing manager, business person, recruiting agent and commodities trading planner. Their illnesses had impacted negatively on their ability to work and very few of the residents of Grace Home were employed at the time of the research. Most of the residents indicated however that they would like to be employed.

Six residents from Grace House work as car guards. They have received training and are registered. One resident has progressed to head car guard and was proud to report that he now gets paid leave. “Now I can live normal life, he commented.” Another resident was proud of her efforts to improve herself. She did a computer course and applied for a supported employment job as an office administrator and now earns about R3000.00 per month.

For many of the residents, being ill had interrupted their education and training and they did not know how to proceed. Fees were identified as barriers to accessing further education and training. Typical comments were: “I passed matric and I have started Information and Technology, I am very good with computers. I dropped because I got sick. But I don’t know how to get a scholarship” and “The problems I have are not knowing where to go in order to continue with adult school and also where to get financial help. I will be very glad to go back to school because I was very clever.”

Not only was the need for vocational training identified, but life skills for coping in the work environment were lacking. Some were concerned about their monthly clinic appointments and how they would explain the need to take time off if they had permanent jobs.  One resident said that although he wants to work, he would have a problem waking up for work everyday. Working with other people and having to concentrate would be difficult for some. They were also particularly worried about how they would cope with stress. Typical comments were: “It will be difficult for me to cope with meeting deadlines, pressure, and working quickly. I need to do things in my own time.” and “I can only cope with a minimum amount of stress”.

DISCUSSION AND RECOMMENDATIONS
A number of themes, all of which have implications for psychosocial rehabilitation, emerged from this study.  The first concerns the importance of individualized treatment which is central to the notion of psychosocial rehabilitation. A basic principle of pyschosocial rehabilitation is that rehabilitation needs must be determined in the context of the individual (Mowbray, Nicholson and & Bellamy, 2003) and that individual treatment plans should specifically be tailored to meet the needs of the MHCU as a unique person (Bachrach, 2000). The research findings indicate clearly that residents did not have individual treatment plans and that there was no long- term planning in respect of the residents. Treatment plans should be based on a comprehensive assessment of the MHCUs strengths, challenges and most importantly, their vision of how they want their future to be.

Drawing up individual treatment plans together with the resident, would serve several purposes. Goal setting, according to Egan (2002:250) helps “clients to focus their attention and action …. (and) helps to mobilize their energy and effort”. An individual treatment plan would provide hope and motivation for the individual to move forward. It would also be useful from an organizational point of view and could assist the management of Grace Home in terms of planning future admissions and discharges. Some residents may not be able to live independently and will need on-going support and supervision. Management would need to decide whether Grace Home offers permanent supported accommodation for these individuals or whether transfer to other facilities might be a better option. In view of the fact that just over a quarter of the residents are over 50, planning for their care as older persons in the not too distant future seems to be a priority. Other residents might be able to live, with support, either independently or with their families but unless specific long- term plans are made nothing is likely to happen. 

The second theme to emerge was the need for skills training in a number of areas. For many  MHCUs,  being exposed to institutionalized and custodial care for many years, has resulted in lowered self-esteem, an inability to socialize and interact, lack of motivation, skills, knowledge and resources to function in the community (Ekdawi, 1994). Chan, Lui, Wan & Yau (2002) suggest that skills training and social adjustment to independent living should be the main service objectives of half-way houses. Skills training has been subjected to much research and the available evidence indicates that systematic skills building through curriculum based psycho-educational and cognitive-behavioural interventions has a wide range of outcomes including symptom reduction, community adjustment, relapse prevention, and medication compliance (Barton, 1999). 

The following skills training programmes would be useful at the Grace Home:
Skills for daily living: In terms of basic personal self care skills, most residents of Grace Home were coping well. However, it was clear that they have little opportunity to practice skills necessary for home maintenance. Nutrition, menu planning and meal preparation, for example, are not part of the every day experience of residents of Grace Home and more opportunities to be involved in these should be introduced to enable residents to prepare for more independent living.
Stress management: Many of the residents talked about their fear of not coping with stress of being with other people and of being in the workplace.   Learning techniques for preventing and coping with stress would be helpful.

Confidence building and assertiveness:  In many ways, the residents of Grace Home were fearful. They expressed fear of applying for employment because that will mean having to tell people about their illness, fear of making friends outside Grace Home because of the stigma associated with mental illness, and fear of being burden to others.  Developing greater confidence and learning how to approach others in social situations would be important perquisites for more independent living.
Management of illness and symptom control: Understanding one’s illness and learning to manage it is an important aspect of psychosocial rehabilitation and the residents of Grace Home would benefit from being encouraged to take more responsibility for their own well being. Educational programmes regarding the nature of psychiatric conditions and the advances in medication are recommended.

Skills training programmes, on their own, however, have not been shown to produce significant employment outcomes (Barton, 1999) and the need for vocational rehabilitation as part of a comprehensive psychosocial rehabilitation programme was evident in this study.  International research evidence indicates that vocational rehabilitation enhances non- vocational outcomes such as functional status and activities of daily living (Chan, Lui, Wan and Yau, et al, 2002). Most of the residents expressed the desire to find meaningful employment but only a handful had been able to do so. Given the wide of range of skills and previous experience of many of the residents it would seem that a vocational rehabilitation programme would be essential.

A number of studies have now demonstrated that supported employment is an effective rehabilitation approach (Burns, Catty & Becker, et al, 2007; Bond, et al, 2008). Meaningful employment leads to improved social integration, normalized peer relationships and a source of identity (Warner, 2009). Successful supported employment programmes have demonstrated a commitment to a competitive employment goal (not a workshop placement), rapid job search and placement and jobs selected on the basis on individual preference, together with follow -up support. (Morris & Llyod, 2004).  Unfortunately, supported employment programmes in South Africa are underdeveloped and in the area in which Grace Home is situated there are no such programmes. Given the lack of resources at Grace Home, a vocational rehabilitation programme at this time would not seem to be feasible. However, it is an area that deserves further attention and a creative option might involve sharing such a programme with other organizations. 

The final major theme to emerge was the lack of social support and in particular, the fractured family relationships that existed for many of the residents.  Social support is essential and it has been found that there is a significant association between good social support and perceived quality of life (Sharir, et al, 2009). The reasons for lack of social support especially from families were varied but some residents were clearly hurt by their childhood experiences and by what they perceived to be on-going unfair treatment by their families. Individual counseling would help residents to come to terms with the hurt and to move forward but counseling for families also seems indicated. Even if they are unable to offer the resident a home, education about the needs of their family members and the advances made in the management of mental illness might be helpful in beginning the process of restoring relationships.  Healing some of the hurt caused by the behaviour of the resident when ill may also help to improve the quality of life of all concerned.

While the results of this study cannot be generalized to the broader population, they are of interest to social workers and health care professionals in the field of mental health and psychosocial rehabilitation. In comparison to many other facilities for people with mental health problems, especially in township and rural areas, Grace Home is fairly well resourced. In addition, a growing body of South African research indicates that many people who have been discharged from hospital to family care receive almost no services and that the burden on families is excessive (Kritzinger & Magaqa, 2000; Lazarus, 2005; van Rensburg, 2005; Reddhi, 2008). If the residents of Grace Home continue to experience so many challenges in respect of pyschosocial rehabilitation, one can only imagine the scale of problems that still need to be addressed. Social workers have an important role to play in identifying needs and designing programmes to address these at individual, family, group and community levels. In addition, if social workers are to be true to their commitment to social justice, they need to be far more vocal in respect of policy development and advocacy for better services for MHCUs.

CONCLUSION
Services to people with mental health problems in general, and psychosocial rehabilitation programmes in particular are underdeveloped in South Africa. This article has identified the need for a psychosocial rehabilitation programme at a particular residential facility for people with mental health problems. Programmes which encourage independent living and increase social skills to cope with the challenges of interacting with people in daily life seem to be most needed and would not require extensive resources to implement. More difficult to implement, but equally important for the long term well being of MHCUs would be vocational and supported housing programmes that would require far more resources.