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
of KwaZulu- Natal
B.Social Science (Social Work)
of Social Work and Community
of KwaZulu- Natal
Simpson B. & Sambuko T. (2012). The Psychosocial Rehabilitation Needs Of Residents Of A Half -Way House For
Mental Health Care Users In Durban, South Africa. International Journal of
Psychosocial Rehabilitation. Vol 16(1) 17-26
Correspondence to: Dr B
School of Social Work and Community DevelopmentUniversity of KwaZulu- NatalDurban, South
rehabilitation services are not well developed in South Africa. This
article examines the psychosocial rehabilitation needs of a group of
people living in a half way house in Durban, South Africa. In
depth interviews were held with 30 residents. The challenges
experienced by residents and the areas in which they required services
were identified. Recommendations for the development of a psychosocial
rehabilitation programme are made and the role of social work and
health care professionals in the field of psychosocial rehabilitation
generally is discussed.
Key words: psychosocial rehabilitation, half way house, South Africa.
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
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 Rehabilitation: A Brief Literature Review
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)
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
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
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.
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
Data collection and analysis
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.
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.
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.
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
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
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.”
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
Management of illness and symptom control
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
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.
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.
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.
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
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
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”.
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
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.
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
Discussion and Recommendations
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.
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
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
The following skills training programmes would be useful at the Grace Home:
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.
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
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.
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.
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.
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.
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.
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.
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