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Care in the Community From Asylum to Recovery.

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Presentation on theme: "Care in the Community From Asylum to Recovery."— Presentation transcript:

1 Care in the Community From Asylum to Recovery.
Cormac Walsh Assistant Director of Nursing Dublin North City Mental Health Service

2 Themes Mental Health Legislation and Policy in Ireland
Supported Community Residential Services The Programme for the Homeless Mentally Ill The Future

3 1850 Lunatic Asylum Act (Ireland)
York Retreat.

4 Richmond Lunatic Asylum St Brendan’s Hospital 1814-2013.

5 1945 Mental Treatment Act 1945 Mental Treatment Act; allowed for the voluntary admission of people in Psychiatric Hospitals, made the first step towards Community care allowing patients to be paroled..

6 St Brendan’s Hospital 1966 ‘Top House’

7 1966 Commission of Inquiry on Mental Illness
Goffmann’s characteristics of total institution - asylum (1)  all aspects of life are conducted in the same place under the same authority; (2)  the individual is a member of a large cohort, all treated alike; (3)  all daily activities (over a 24-hour period) are tightly scheduled; (4) there is a sharp split between supervisors and lower participants; (5) information about the member's fate is withheld. 

8 Planning for the Future 1984
Planning for the Future (DoH, 1984) provided the strategic framework that enabled the adult mental health services to evolve from an institutional to a community-based service model and approach. It directed that the psychiatric services should be comprehensive and community-orientated, and aimed at delivering care that was coordinated, integrated, and multidisciplinary (DoH, 1984). Countrywide, mental hospital services embarked on programmes of ward closure that resulted in a decrease in the number of in-patients in mental hospitals from a total of 19,801 in 1963 to 3,556 at the end of A significant rise in community-based facilities paralleled this decline in bed usage, giving rise to over 3,100 community residential places under the care of the mental health services in 2004 (O’Regan and Keogh, 2005).

9 Psychiatric in-patient beds in Ireland 1896 to 2013

10 St Brendan’s Hospital Rehabilitation and Resettlement Programme’
In SBH a formal ‘rehabilitation and resettlement programme’ was established in The primary aim of the programme was to decant the mental hospital of long-stay in-patients to more ‘appropriate’ community residential environments in order to facilitate the closure of the hospital. In conjunction with this programme, comprehensive and integrated community psychiatric services were planned to provide alternative treatment options to people at home. The Programme for the Homeless, ‘NFA Unit’ Sector CMHT, Cabra, Finglas and Blanchardstown. Over a nine-year period the number of in-patients residing in the hospital steadily fell each year from a high of 1200 inpatients in 1986 to 257 in 1994.

11 Community Residences The provision of residential facilities largely depends on two key variables: (1) the extent of informal family support, which can substitute and replace the formal support granted by residential facilities; and (2) the availability of comprehensive community resources, including assertive community treatment programmes (Girolamo et al., 2004; Thornicroft, 2003).

12 Continuum Model The Continuum model posits that there are different residential settings, such as ‘group homes’ and hostels, with various levels of support and restrictiveness; the most intensive treatment is offered in the most restrictive environment. Residents can move along the continuum, from more restrictive to more open settings, the level of supervision is based on the level of assessed need and level of functioning, thus providing a pathway from institutional care into independent living in the community (Girolamo et al., 2004). The ‘continuum’ model has been criticized because it bonds housing and treatment needs, and this may lead to unnecessary dislocations through successive moves as improvement in functioning often requires a move to another setting (Carling 1993). Furthermore, housing is frequently not available at precisely the time when the person’s needs change and skills acquired for independent living in an artificial environment, such as residential facility, may not be transferred and used in another setting (Girolamo et al., 2004).

13 High Supported Community Residences 2005

14 Diagnoses Schizophrenia: 74.9% Schizoaffective disorder: 5.5%
Bipolar Affective Disorder: 12.3% Depression: 2.3% Alcohol Dependence: 0.8% Other: 1.5% No Mental Health Diagnosis: 2.3% Unknown: 0.8%

15 Mental Health Act 2001 Involuntary Admission of persons to approved centre Independent Review of Detention Established the Mental Health Commission “to promote, encourage and foster the establishment and maintenance of high standards and good practices in the delivery of mental health services”. Inspector of Mental Health Services

16 Vision for Change 2006 Vision of Change details a comprehensive model of mental health service provision in Ireland. It proposes a holistic view of mental illness and recommends an integrated multidisciplinary approach to addressing the biological, psychological and social factors that contribute to mental health problems. Principles and values underpinning the Vision include Multidisciplinary; community based; comprehensive; active participation and recovery;

17 Recovery The Recovery approach is a shared philosophy which draws upon evidence concerning the importance of values social roles, such as employment while also emphasizing user determination and positive risk-taking. Personal Responsibility Hope Rebuilding programme Contentment Roles and relationships. Leighton (2005)

18 High Support Community Residences 2011

19 Church Ave 2011 Structure: Small 8 ensuite / bedrooms residence
System: Self staffing / Nursing MDT input / OT Skill mix/sleepover Self catering

20 Turnover 30 individuals admitted in three years 12 moved back Home
118 episodes of respite 2 Individuals at risk of homelessness substance misuse / anti-social behaviour / non-payment of charges 14 have moved to lower supported accommodation provided by HSE. 7 have progressed to independent living

21 Doras Genio funded: Collaboration between HSE Dublin North City Mental Health Services and HAIL Aim: To build a sustainable model of Community Mental Health Rehabilitation that will deliver a range of recovery focused supports

22 The challenge Housing Connections Project
Source high quality secure housing Maintain and support tenancy Independent living as a realistic goal Connections Project Social Roles Valorization Meaningful roles

23 2016 Target High Supported Community Residential Places.

24 Supported Community Residential Strategy 2014-2019
Reduce the number of residents to between 8-10; individual rooms Locate community residences across the catchment area; Cabra, Finglas and Blanchardstown.

25 Homelessness Factors contributing to increased homelessness
Lack of affordable housing Reduced entitlements Growing numbers in poverty Individual vulnerabilities Mental Illness Substance Misuse.

26 Comparison between Homeless and Homeless Mentally Ill
Both groups share backgrounds marked by: Poverty Dependency on welfare Childhood hunger Family unemployment . Homeless Mentally Ill had a higher instance Family violence and abuse Foster care Childhood homelessness

27 Programme for the Homeless
Established in 1979 comprised ‘The Willows’ ‘NFA Day Centre’ moved off campus to Ushers Island in 1997 Three supported Community Residences 24 hr self referral assessment unit, SBH Acute In-patient beds

28 Changes to the programme
Closure of Community Residences Closure of in-patient unit Closure of self-referral assessment unit Assertive Outreach Acess Team Outpatient Clinic 2011 Park Gate Street. Day Hospital 2012 Reconfiguration 2014.


30 Mission The Programme for the Homeless Mental Health Service provides specialist community mental health care and treatment for registered homeless adults with severe mental illness living within Dublin City Centre.

31 Optimism for the future
Primary Care Strategy; strengthening links with MHS National Clinical Care Programmes For episode psychosis Family education Behavioural Family Therapy Eolas Programme Recruitment of full compliment of MDT members. National Housing Strategy for People with Disabilities

32 DIT Campus,

33 Students’ first day

34 Thank you

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