g fo rp oes schizophrenia ireland o rk ionals lucia ...42 penrose wharf, cork t. 021 4552044 f. 021...

TowardsRecovery

Principles of good practice in the treatment,care, rehabilitation and recovery of peoplewith a diagnosis of schizophrenia and relatedmental disorders.

A joint publication of Schizophrenia Ireland/Lucia Foundation and

the Irish Psychiatric Association

July 2003

Schizophrenia IrelandLucia Foundation

Eastern Regional Health Authority Area38 Blessington Street, Dublin 7t. 01 8601620 f. 01 8601602 e. [email protected]

Southern Health Board Area42 Penrose Wharf, Corkt. 021 4552044 f. 021 4553633 e. [email protected]

Western Health Board AreaWestside Resource Centre,Seamus Quirke Road, Galwayt. 091 524322 f. 091 524345 e. [email protected]

South Eastern Health Board Area5 Priory Court, Dean Street, Kilkennyt. 056 7756210 f. 056 7756209 e. [email protected]

Midland Health Board Area55 Dublin Street, Longfordt. 043 42366 f. 043 42367 e. [email protected]

Mid-Western Health Board AreaUnit 14 A&B, Clonroad Business Park, Ennist. 065 6844874 f. 065 6844964 e. [email protected]

North Eastern Health Board AreaC.I.C., 1 Brews Hill, Navan, Meatht. 046 23859 f. 046 23859 e. [email protected]

Confidential Telephone Helpline: 1890 621 631Monday, Wednesday, Friday 12noon – 4pmTuesday 3.30pm – 7.30pmThursday 10am – 2pm

Website: www.sirl.ie


Correspondence Address:Caroline SharkeyIPA Administrative AssistantC/O Newcastle HospitalGreystones, Co Wicklow

t: 353-1-2819001 ext 266f: 353-1-2819325e: [email protected]

How to contact us:

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3Towards Recovery2

Foreword

The impetus for this document arises from a number ofconcerns.

Schizophrenia Ireland has been receiving anecdotal reportsabout people’s experiences with mental healthcare services.These experiences vary from examples of exceptional standardsof care and treatment to stories of poor and almost neglectfulexperiences. The Irish Psychiatric Association has highlightedmarked inconsistencies in levels of service provision betweenHealth Boards in its report, “The Stark Facts”. These imbalancescontribute to and sustain an uneven spread of clinical strengthsand deficiencies. Both organisations wish to address solutionswhich will make delivery of mental healthcare more equitableand effective countrywide, and in doing so add to theemerging dialogue about the need to improve standards ofcare in mental healthcare services.

Both organisations recognise that a collaborative approachrepresents the best way forward to ensure that the service userand provider can achieve high quality services. Thus werecognise a need to compile principles of care that set outuniform goals which might be acceptable and achievable to keystakeholders within an Irish context.

“Towards Recovery” is a new initiative aimed at achieving acollaborative position on the principles that should underpinand guide the delivery of services for people with schizophreniaand their families in Ireland. The document has been compliedafter close collaboration and consultation between the twoorganisations. It is the beginning of setting objectives by whichservices can be compared and improved. It is hoped that otherswill adopt it as a basis to guide service developments for thefuture, in the knowledge that it represents the views ofimportant contributors to this process.

We also hope that in the future “Towards Recovery” will beseen as a precursor to the development of more detailedstandards of care for the provision of mental health careservices throughout Ireland.

Mr. Kevin JonesChairperson of Schizophrenia Ireland

Dr. Justin BrophyChairperson of the Irish Psychiatric Association

‘Towards Recovery

is a new initiative

aimed at achieving a

collaborative position

on the principles that

should underpin and

guide the delivery

of services for people

with schizophrenia

and their families in

Ireland.’

Towards Recovery

5Towards RecoveryTowards Recovery4

Preamble

The need for a defined vision of our psychiatric servicesrelevant to the 21st century is long overdue. We eagerly awaitthe national policy framework review promised in the healthstrategy report Quality and Fairness: A Health System for You.We also await a set of standards that will provide a qualitybenchmark for all mental health services. Both of theseelements will, no doubt, add to the groundswell ofdetermination around the country to once and for allabandon outdated and inadequate services.

The Mental Health Act 2001 speaks explicitly of the need torespect the right of the person to dignity, bodily integrity,privacy and autonomy when considering the care or treatmentof a person experiencing mental illness.

The need to involve all participants in the planning anddelivery of services cannot be over emphasised. The healthstrategy speaks of empowerment as being part of its vision.The essential ingredient of empowerment is equality. Withequality comes the possibility of partnership and participationand a move away from a deficit view of mental illness to afocus on wellness and recovery. In such a partnership, peoplebecome active participants in their own good health.

The definition of health as defined by the World HealthOrganisation and chosen by the Department of Health andChildren to underpin its health strategy is a “complete state ofphysical, mental and social well-being and not merely theabsence of disease or infirmity.” There is widespreadacknowledgement that good health is attained and sustainedbetter within communities than in institutional settings. This isparticularly true for people with mental health difficulties andthe families and friends who support them. Communitytreatment should consequently be the objective of users,carers and services wherever possible.

Indeed, despite fragmentation and strain in service delivery,the presence of considerable consensus on a modern mentalhealth service is making itself felt more and more every day.

“Towards Recovery” is a contribution to the consolidationof this developmental process, and has been designed to bebroad in scope and flexible in detail. Crucially, it has beendesigned to be reflective of the views of people using thepsychiatric services, their families and mental healthprofessionals.

Principles of good practicein the treatment, care, rehabilitation andrecovery of people with a diagnosis ofschizophrenia and related mental disorders.

1 Early Identification

2 Establishment of a Therapeutic Alliance

3 Treatment Settings – Primary care

4 Community Mental Health Team

5 Home Treatment

6 Day Hospital

7 Hospital Units

8 Comprehensive Assessment

9 Pharmacological Interventions

10 Psychosocial Interventions

11 Involuntary Admission

12 Information, Education and Support

13 Physical Environment

14 Accommodation

15 Recovery

16 Specialised Rehabilitation

17 Advocacy

18 Support Groups

‘The need to involve

all participants in the

planning and delivery

of services cannot be

over emphasised.’


EarlyIdentification

Early intervention and identification programmes should

be the norm in mental healthcare services nationally.

There is significant evidence thatsuch programmes can lead to earlyinitiation of treatment withimproved long-term prognosis. Theshorter the period of time betweeninitial presentation and diagnosis,the greater the long-termprognosis for a sustained recovery.

Establishment of aTherapeutic Alliance1 2

In all situations it is essential that a therapeutic alliance is

established between the person receiving treatment, the mental

healthcare team and family members. Such an alliance will

ensure that everyone is working towards the same goals in a

supportive partnership.

Actions towards this includeassessing the person’s psychiatricstatus, developing an overalltreatment and recovery plan,enhancing adherence to thetreatment plan and promotingearly recognition of episodes andinitiation of treatment.

Providing information andeducation regarding the conditionand its treatments, increasingunderstanding of and adaptationto the psychosocial effects of theillness, providing programmes toenhance family coping skills,facilitating access to services andcoordinating resources among themental health service and othersystems of care.


Treatment Settings –Primary care

It is important that there are clearly agreed and understood

methods of referring individuals for prompt, specialist psychiatric

assessment by their local G.P. service.

Most people who developschizophrenia for the first time willseek help from their generalpractitioner. In some situations animmediate emergency referral mayneed to be made but, in general, itis preferable that a member of thecommunity mental health sectorteam carries out the initialassessment. In some circumstancesthe general practitioner mayinitiate treatment withappropriate medication before theindividual is seen by the specialistpsychiatric service, which shouldbe in the shortest possible time.

Community MentalHealth Team

Each team should be adequately staffed so that physical,

psychological and social interventions are available.

The Community Mental HealthTeam (CMHT) is an appropriateand effective way to deliver therange of treatment interventionsfor those with a first episode ofschizophrenia. Every personexperiencing psychiatric distressshould have access to a CMHT.The CMHT should have a range ofexpertise, which allows them tosupport the individual and theircaring relatives.

3 4


Home Treatment

Home treatment should be available and adequate

resourcing of home treatment teams in all parts of the country

should be a priority.

Home treatment teams, either ontheir own or as part of a CMHT,can provide a responsive, high-quality method of delivering acutecare for those with schizophrenia.Such teams usually need moreclinical resources thanconventional services.

5 Day Hospital

Such services should be available to facilitate the delivery

of a full range of treatment options including acute care.

There is good evidence availableindicating that acute day hospitalscan provide efficacious and cost-effective treatment of the acuteepisode of schizophrenia as analternative to inpatient treatment.Such day hospitals need to beadequately staffed and resourcedso that they can provide acutetreatment for a person during anacute episode.

6

ComprehensiveAssessment

A comprehensive assessment of the person’s physical

health, psychological health and social needs should be carried

out. Such assessment should involve the individuals themselves.

An individual may need access toother members of themultidisciplinary team in additionto a psychiatric assessment.Members of this team include apsychiatrist, mental health nurse,psychologist, psychiatric socialworker and occupationaltherapist. Other people who maycontribute to the assessmentinclude family carers and generalpractitioners. In somecircumstances with the consent ofthe individual, a relative oradvocate may be included in theassessment process.

8


Hospital Units

The hospital unit should beappropriate for the care of theacutely ill and staffed byadequately trained medicalnursing and paramedical staffcapable of dealing with crisissituations. Early discharge to acommunity setting should be anobjective.

7Treatment in an acute hospital unit may be the most

appropriate setting for the management of the acute episode

of schizophrenia. The environment of such units should aim to

promote recovery, should be safe and should be able to provide

a full range of therapeutic activities.

PharmacologicalInterventions

Atypical antipsychotic drugs should be considered in

the first-line treatment of schizophrenia. The prescribing

of medication should be based on best evidence and with

attention to possible side effects, the individual’s life

circumstances and attitudes to medication.

There is incontrovertible evidencethat antipsychotic drugs areeffective in the treatment ofacute episodes of schizophreniaand that they reduce relapserates.

In general, the use of morethan one antipsychotic drugshould be avoided. If side effectsoccur, the nature and dosage ofthe antipsychotic should bereviewed and modified toeliminate the need for additionalmedication. This process of reviewshould include consultation withthe individual and caring relativesor advocate where agreed. Nomedication should be restrictedon the grounds of cost alone.

PsychosocialInterventions

It is important that there is access to psychosocial

interventions, which help to maximise the individual’s recovery

as well as preventing relapse.

These interventions includeeducational programmes, familyinterventions, social skills training,vocational rehabilitation, daycentre programmes and cognitive-behaviour therapy. During thistime it is important thatantipsychotic medication iscontinued. Full recovery from anacute episode of schizophreniamay in some cases be incomplete

9 10



InvoluntaryAdmission

Involuntary admission to a psychiatric hospital must

always be used as a last resort. Where there may be a

significant risk of harm to self or others or where the individual

refuses to seek treatment and his/her health is being seriously

harmed, it may be necessary for someone to be committed to

hospital against his/her will.

The current mental healthlegislation requires a relative tomake an application (althoughthere is provision for circumstanceswhere a relative is not available)and a doctor (usually theindividual’s general practitioner) tomake a medical recommendationfor admission as a temporarypatient. The individual is thenbrought to an approved centre(usually the local psychiatric unit)where he/she is assessed by aconsultant psychiatrist withintwelve hours and is admitted as atemporary patient (involuntaryadmission), admitted as avoluntary patient or not admitted.

Information,Educationand Support

The person and family members should be given all the

necessary information, education and support to understand

the diagnosis, treatment and care programme.

This should be seen as thebeginning of an ongoingdialogue. While respecting theindividual’s rights toconfidentiality and privacy, carersand family members shouldreceive adequate information in aform that is understood.Opportunities should be affordedto return and discuss matters asthey see fit. Relatives and serviceusers should be provided witheducation, support course and asupport group when appropriate.

11 12

The process of involuntaryadmission is a traumatic anddevastating occurrence for theindividual and his/her family. Itshould be a primary aim of allprofessionals involved toacknowledge and respect thesensitivities of the whole familyand respond appropriately.


PhysicalEnvironment

All mental health facilities should be of a high

standard of hygiene, decor and maintenance. Privacy, safety

and comfort should also be facilitated.

The privacy and dignity of theperson in residential or hospitalsettings should always berespected. Such facilities shouldnot be seen as permanent, asindividuals’ long term abodesshould be in a domestic type unit.

Accommodation

There is a need for a range of accommodation which can

provide support as required.

High support, medium supportand low support residentialaccommodation should beavailable for those who need tomake the transition toindependence, or return to theirhome over a longer time frame. Itshould be acknowledged thatsome people may always requiresome degree of supportedaccommodation. Additionally,there is a need for a range ofsocial housing to facilitate peoplewho no longer require supportedhousing.

13 14


Recovery

At times a partnership process should be adopted

with the aim of facilitating the recovery process.

Individuals need to be equalpartners in their recovery process.Attendant issues such as stigma,social isolation and low self-esteem must be considered in theformulation of the recoveryprocess. This may occur in thecontext of treatment, support andeducation courses. An improvedlevel of public awareness isessential to long term stability andrecovery, and is the responsibilityof statutory, professional andvoluntary organisations.

SpecialisedRehabilitation

A small number of individuals will have ongoing difficulties

in reaching independence. These individuals require more

intensive specialised multidisciplinary rehabilitation interventions.

Such interventions might includeCognitive Behaviour Therapy,anxiety management, confidenceand self esteem enhancement,assertiveness and personaldevelopment, vocational training,as well as general supportivepsychotherapy and counselling.Staff should be qualified andsupported in ongoing professionaldevelopment so that they are wellinformed of current good practicein relation to treatment andmanagement issues. A range ofresidential rehabilitation settingsshould be available to supplementhigh quality therapeutic dayrehabilitation programmes.

15 16


Advocacy

Access to a full range of advocacy services and/or

training in self-advocacy should be available.

Services may be in the form ofself-advocacy, peer advocacy,professional advocacy, groupadvocacy and legal advocacy. Suchservices should be available at allstages of the treatment andrecovery process. Referral to anappropriate agency foradvice/assistance with incomesupport, employment re-training,new skills development andaccommodation is a necessary partof the care programme.

SupportGroups

Referral to a user support group, a relatives’ support

group and the relevant voluntary agency should be a necessary

part of the care programme.

The value of peer support shouldnot be underestimated as avaluable recovery tool. Referral bythe mental health team to a localmental health support groupshould be made as appropriate.Information should be providedon the range of services offered bythe voluntary sector and thepotential benefits of supportgroups should be outlined. Themental health team shouldactively facilitate access to therelevant voluntary organisation.

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About Schizophrenia Ireland About the Irish Psychiatric Association

❛❛

❛❛

Objectives

1 To promote the development of parallel mutual self-help groups for people withschizophrenia and carers.

2 To empower people with schizophrenia and their carers through support, individualadvocacy, information and education.

3 To promote the right to appropriate health, accommodation, employment and otherservices.

4 To advocate for rights and needs and challenge discrimination of all those affected byschizophrenia.

Organisational EthosSI believes that:

■ People with schizophrenia should at all times be accorded the rights, entitlements, and opportunities available to any other member of society on an equal basis, and should be empowered to participate in the life of the community to the fullest possible extent;

■ Relatives and families, the majority of whom are the primary providers of psychiatric care in the community should be accorded full recognition and support by the institutions of the State, and be empowered to address their own needs;

.■ A history of mental illness should never be a cause of discrimination, stigmatisation or prejudice in any form, nor should it inhibit the individual’s right of equal access to training, education and employment; and

■ We should foster a partnership and collaborative approach with all relevant agencies.

Schizophrenia Ireland is the national organisation dedicated toupholding the rights and addressing the needs of all those affectedby schizophrenia and related illnesses, through the promotion and

provision of high-quality services and working to ensure thecontinual enhancement of the quality of life of the people it serves.

Towards Recovery24

Mission StatementThe IPA was set up in 2000 as a new representative body ofPsychiatrists in Ireland with the key objective of raising ourvoice and increasing our focus on the need to provide anddevelop services for mental illness. This grew out of awidespread concern that such was the decline in servicestandards over the last 20 years that a new autonomouswholly Irish Association was the best way forward. Irelandhas very rudimentary development in services compared toother affluent EU countries and mental health services hadslipped off the agenda despite criticisms, huge publicdemand, and the availability and will of the services toprovide better services. Membership is open to trainedpsychiatrists at present but in the future we hope to openmembership to affiliates representing many disciplines andinterests. We intend to continuously heighten public andGovernment awareness of the realities and challenges thatour services pose to users and professionals alike. We arecommitted to continuing this task and accordingly our logo‘Working for professionals, working for patients’ reflectsthese core values.

We are committed to service development allied tohighest service standards as our central objective. Such is thestate of our services that all professional activities andobjectives cannot develop properly without this emphasis.By embracing this issue the IPA believes we have helpedgalvanise collective professional focus toward this end. Weare committed to the view that multi-agency collaborationis the best way to amplify and express our profession’sconcern. Joining our voice under a common platformrepresents the best way forward to muster the public andpolitical will to change to improve services.

Core Values and Objectives


Head OfficeSchizophrenia Ireland, 38 Blessington Street, Dublin 7.

T: (01) 860 1620 F: (01) 860 1602Confidential Helpline: 1890 621 631

Website: www.sirl.ie

Correspondence AddressCaroline Sharkey

IPA Administrative AssistantC/O Newcastle HospitalGreystones, Co Wicklow

T: 353-1-2819001 ext 266F: 353-1-2819325

Email [email protected]

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Acknowledgments

‘Towards Recovery’ was co-authored by the following people:

Dr. Anne Jeffers — the Irish Psychiatric AssociationDr. Eamonn Moloney — the Irish Psychiatric AssociationDr. Justin Brophy — the Irish Psychiatric AssociationJohn Saunders — Schizophrenia IrelandPat Seager — Schizophrenia IrelandKahlil Thompson — Schizophrenia IrelandTim O’Connor — Schizophrenia IrelandBrendan Kenny — Schizophrenia Ireland

We also wish to acknowledge the contributions of a number ofservice users, relatives and mental health professionals who readthrough draft documents and offered their valuable commentsand suggestions.

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