To love and to work: The next major mental health reform goals

Amongst all the criticisms of public mental health services and the debates about early intervention for psychosis it is easy to lose sight of improvements in the mental health service landscape that have occurred over the last 50 years or so. How many now would have first-hand recollections of the asylum era that extended into the 1960s and 70s? Who recalls the large stand-alone hospitals with their dehumanising practices, their bare halls and squalid bathrooms where the mentally ill smoked, paced or shuffled endlessly? With the accelerated closure of beds in the 1980s and 90s, and the failure to shift resources to community-based services we saw the mentally ill exploited in sub-standard boarding houses, homeless and untreated, or accommodated in overcrowded hospitals and in prisons. The first Australian national survey of psychosis (Jablensky et al., 2000) provided a snapshot of people with psychotic disorders at the tail end of that period. Over 10 years later the second national psychosis survey (Morgan et al., 2012) has given us a contemporary picture in the wake of a number of mental health reforms.

In the past decade inpatient admissions, both voluntary and involuntary, declined by 36% overall; use of outpatient or community clinics increased by 23%; access to community rehabilitation or day programmes rose by 61%; non-government organisations (NGOs) extended their role from 19% to 27% of people with psychosis; general practitioner visits went from 77% to 88%; the proportion using supported accommodation doubled to 10.9% (homelessness more than halved, down from 13% to 5%), while the proportion living in rented accommodation had gone up from 34% to 49% (Morgan et al., 2011). Many of these changes reflect an increased investment in community-based delivery of ambulatory care in accordance with policy directives of the National Mental Health Strategy, and increased investment in NGO services with the Third National Mental Health Plan. Investment in supported accommodation, while heading in the right direction, still has some distance to travel.

Two targets for reform

However, change for the better has not been uniform, and two areas of stagnation stand out. First, past month employment remains unacceptably low at 22.2%, a figure unchanged since the first survey in 1997–98 (Waghorn et al., 2012), and the proportion reliant on government payments also remains stable at 85%. Weeks not worked in the past year were 43.7 and 42.4 in the first and second surveys, respectively (Neil et al., submitted). Participants in the second survey ranked the twin problems of financial matters and lack of employment first and third, respectively, among their leading challenges for the next 12 months.

The second area in which lack of change is striking is in the degree of loneliness and social isolation experienced. In the first and second surveys the proportions reporting being single and never married was 64% and 61%, respectively, those reporting having no friends remained constant at 13%, and those reporting a need for more friends consistently hovered at 45–47% (Morgan et al., 2011). In the second survey loneliness and social isolation ranked second after financial matters as the major challenge in the coming year (Morgan et al., 2012). Social exclusion is underpinned by reduced abilities to socialise, with 63% showing evidence of impairment in social functioning (Stain et al., 2012).

Obviously, the next tranche of mental health reforms must go beyond community treatment or support services and be directed at enhanced participation, specifically increased participation in the workforce and increased participation in community life.

The evidence base for efficacy of interventions in these areas is strong. First, with regard to employment, about which several important articles have recently appeared in this journal (Harvey et al., 2013; Lockett and Bensemann, 2013; Morgan, 2013; Waghorn, 2013), current best evidence clearly favours supported employment programmes that use an individual placement and support (IPS) model that entails full integration between the clinical mental health services and intensive employment assistance (Bond, 2004; Bond et al., 2008; Crowther et al., 2001). This intervention is supported by high-quality evidence and has a medium effect size. Since over two-thirds of people with psychosis want to work, and the efficacy of the above model has been demonstrated, it ought to be possible to roll out programmes based on this model with the result of increasing rates of employment, reducing the proportions relying on government support payments and increasing median income, with appropriate 10-year targets set in all three of these domains to be reached by the time of a third national survey of psychosis.

There is also high-quality evidence for the efficacy of social skills training in improving social interaction, and the effect size is moderate to large (Kurtz and Mueser, 2008; Pfammatter et al., 2006). The same interventions also improve general psychopathology and reduce relapse rates, but the evidence here is of moderate quality and medium effect size (Kurtz and Richardson, 2012; Pfammatter et al., 2006). The study of social cognition is a relatively new area of research and approaches to social cognitive remediation based on social cognition research, such as correction of underlying problems in detecting, interpreting and responding to social cues, are fairly recent, but they have a growing evidence base and apparently satisfactory generalisability (Kurtz and Richardson, 2012). The more traditional approaches to social skills training and the newer social cognitive remediation techniques have sufficiently robust evidence of efficacy to warrant their more widespread availability in clinical and rehabilitation services. Whether there is any advantage in combining these approaches with neurocognitive remediation (known to be efficacious in improving a range of cognitive functions; see McGurk et al., 2007) has not yet been determined. As with IPS programmes, 10-year targets could be set such as an increase in the proportion who are married or in a relationship, reduction in the proportion reporting a need for friends, a rise in the proportion engaged in family life, including having dependent children living with them, and fewer reports of feeling lonely and socially isolated.

It is not sufficient for jobs to be merely available or opportunities provided for social interaction. There must be an assertive approach to support individuals in searching for and maintaining competitive employment, and there must also be active engagement with patients to assist in improving their social skills so that connecting with other individuals and communities can be made easier and more successful. While workforce participation alone may bring gains in social connectedness, it remains the case that many patients who work still feel a sense of social exclusion and severe difficulties in forming intimate social bonds. Participation in work and social life are the next critical goals for mental health service reform in relation to the psychoses. Progress on these two fronts alone may well have knock-on benefits for the widespread problems of physical ill health and substance abuse comorbidity – although that is a hypothesis, not a guarantee.

Barriers to reform

What may be the barriers to making progress in workforce and social participation? In the domain of supported employment, there are several structural disincentives in Australia and in New Zealand restraining the wider adoption of more intensive and evidenced-based employment services (Waghorn, 2013). Contracted providers in the national network of disability employment services in Australia are, in theory, able to adopt all the evidence-based principles of the IPS approach. Yet many providers fail to acknowledge this evidence, or adopt partial or weak implementations that necessarily lead to mediocre results. Others claim that working with more severely disabled persons, such as public mental health service users, would threaten their financial viability. Yet we know this is not the case. An effective IPS service integrated within a community mental health team can expect to attain employment commencements for 60% or more of all volunteers, regardless of severity or complexity of mental illness, forensic and substance abuse issues (Bond et al., 2008). This is double the employment commencement rate currently being achieved. In 2010 Australian disability employment services achieved employment commencements for less than 30% of clients with a psychological, substance abuse or psychiatric disorder. The structural issue most likely responsible for discouraging the adoption of evidence-based practice appears to be the three-monthly service fees. These are paid for each client on the books, whether or not employment outcomes are attained, and in total can exceed the milestone payments paid when employment is successful. The fees drive high caseloads to levels where the provider could be accused of over-servicing, because they simply cannot then provide the service intensity intended for this programme. Billions could be saved if these service fees were abolished. To do so requires a shift to outcome-based funding alone, away from the current dual case-based and outcome-based funding. This would increase the focus on performance and encourage the adoption of evidence-based practices (Waghorn, 2013).

Social skills interventions and social cognitive remediation will face the usual barriers that sound evidence-based psychosocial interventions always encounter on attempts to introduce them into mental health services. In the absence of financial incentives, the task is inevitably one of management and clinical governance, and sometimes it is a question of resources. Fortunately, there are mental health professionals trained with the knowledge base and expertise necessary to implement social skills programmes and social cognitive remediation interventions, so that given the right kind of support in the service environment a successful roll-out of these programmes ought to be possible as well.

Conclusion

To work and to love are fundamental human rights and there is nothing inherent in psychosis to rule out the enjoyment of those rights.

It is time to take the next big step forward in mental health reform, to move from institution-in-the-home to inclusion in full participation in the life of the community through work and social engagement.