Title:
Supporting
recovery:
challenges
for
in-home
psychiatric support workers
Nicole Shepherd, Tom Meehan, Seiji Humphries
Published by Emerald Publishing in Mental Health Review Journal (2014) Vol 19, No. 2.
DOI: http://dx.doi.org/10.1108/MHRJ-07-2013-0027
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Structured Abstract:
Purpose: The concept of recovery is well accepted internationally as a guiding vision for
mental health services. This article highlights the challenges faced by in-home psychiatric
support workers in implementing this vision in their work with clients with severe psychiatric
disability.
Design: The findings reported here are based on interviews with 27 support workers and 10
managers of organisations providing support services.
These were collected as part of
evaluations of two supported housing programs carried out between 2010 and 2011.
Findings: Challenges faced by support workers coalesced around two areas: (1) balancing the
need to provide care with the need to promote autonomy and (2) developing an effective
working relationship while working mainly within a clients’ home.
Implications:
These challenges for support workers highlight tensions within the recovery vision that are not
easily resolved. To ensure high quality, recovery-oriented care services are provided, support
workers need access to training courses that focus on challenging areas of this work and should
be provided with regular professional supervision.
Originality/value:
Existing literature on support workers has generally focused on the nature of the role and
support worker interactions with other health workers. In this paper, we highlight difficulties
faced by support workers in implementing the vision of recovery in their work. The paper
provides important information for policy makers and managers who are designing service
delivery systems that aim to promote recovery.
Keywords:
Recovery, support workers, home care, psychiatric disability, supported housing
Introduction
The recovery model for mental health services is now well established internationally as a
framework for the provision of mental health services (Anthony, 1993, Corrigan and Ralph,
2005). Common themes in consumer accounts indicate that recovery involves developing new
meaning and purpose in life, taking responsibility for one’s illness, renewing a sense of hope,
being involved in meaningful activities, managing symptoms, overcoming stigma, and being
supported by others (Deegan, 2003, Davidson et al., 2005). In spite of a broad agreement to
support recovery, the implementation of recovery-oriented practice remains a challenge for
mental health services (Le Boutillier et al., 2011). This paper focuses on the challenges of
implementing recovery-orientated practice by those working as in-home support workers –
those who provide ‘non-clinical’ support to enable people with psychiatric disability to live in
the community
Support workers are relatively new to the mental health workforce in Australia. The mental
health system has a dualistic structure, with a split between government and non-government
(not-for-profit) service providers that loosely maps onto a split between clinical and nonclinical workers. The involvement of the private sector is relatively minimal (Community
Services and Health Industry Skills Council, 2009). National mental health reforms underway
since the 1990s have promoted the growth of the non-government sector to provide non-clinical
services, such as lifestyle support, to people with severe and persistent mental illness living in
the community (Commonwealth of Australia, 2009). The support workers employed by nongovernment mental health organisations (NGOs) are part of an expanding workforce - funding
for the sector in one state (Queensland) has increased fivefold since 2006 (Health and
Community Services Workforce Council, 2012).
This rapid expansion has triggered some
commentators to raise concerns about the capacity of this workforce to deliver quality services
and suggest that there is a need to further develop the skills and knowledge of support workers
(for example National Health Workforce Planning and Research Collaboration, 2011,
Psychiatric Disability Services of Victoria (VICSERV), 2010, Victorian Government
Department of Health, 2011).
The non-clinical support provided by support workers aims to foster independence in clients
and includes a range of activities with varying levels of complexity. Support workers assist
their clients with household activities such as shopping, cooking, budgeting, and cleaning.
Support workers also assist clients to access community activities and provide advocacy
services (Manthorpe et al., 2010, Warner et al., 1998). The time support workers spend with
clients is measured in hours as opposed to minutes, as is the case for clinical workers (for
example, as measured by Australian Institute of Health and Welfare, 2012). A typical session
of support is generally 3 hours, and support workers may work on weekends or outside ordinary
working hours, when other health professionals are not usually available. This availability
provides a sense of psychological assurance for people (Oliver et al., 1996). When compared
to the services offered by health professionals, support workers offer what Murray and
colleagues (1997) describe as a “refreshing ordinariness” – they are ordinary people whom
their clients may liken to a friend. Their independence from the potentially coercive power of
government health workers allows the development of a more egalitarian relationship.
Evaluations of services providing non-clinical support show a high degree of satisfaction
among their clients (Clarkson et al., 1999, Murray et al., 1997, Meehan et al., 2011, Meek,
1998).
Existing literature on support workers in health and social care has described the role (for
example, Moran et al., 2011, Huxley et al., 2006, Manthorpe et al., 2010, Mitchell, 2008), the
impact of support workers on existing health care teams (for example, McCrae et al., 2008,
Meek, 1998), and the perceptions support workers have of their work (for example, Fleming
and Taylor, 2007, Pace, 2009). This paper adds to this literature by considering the challenges
for support workers in implementing recovery-based practice in their work with people with
severe and persistent mental illness.
Background to the present study
Since the mid-1990s, several States in Australia have implemented supported housing
programs. In these programs people with serious mental illness are provided with independent
housing (through a government department of housing), clinical case management, and nonclinical in-home support delivered by support workers (Meehan et al., 2011, Mitchell, 2008,
Mitchell, 2009, Muir et al., 2005). One of the first programs to take this approach was ‘Project
300’ in Queensland. This program was established in 1995 with the aim of assisting 300 people
with psychiatric disability to move from institutional care to supported living in the community.
The program involved a cooperative arrangement between the government departments of
Health, Housing and Disability Services. In 2006, the Housing and Support Program (HASP)
was introduced, based on a similar model to that of Project 300. This program targeted those
in acute inpatient units who were unable to be discharged due to the severity of their disability
and lack of other accommodation. In both of these programs, the government funded nongovernment organisations to provide the non-clinical support component of the services
available to clients. This arrangement is similar to service delivery in New Zealand (Pace,
2009) but different to models of service provision elsewhere, where support workers may be
employed directly by public mental health services (Murray et al., 1997), or directly by service
users (Morgan, 2004, Ungerson, 2005).
Method
Evaluations of both Project 300 and HASP were carried out by the authors in 2010 and 2011.
In both evaluations, a mixed methods research design was used, involving surveys and
interviews with stakeholders in the program: clients; support workers and their managers in
non-government support agencies; case managers in government mental health services; and
government staff from the housing department and disability services department. This paper
reports on the results from the interviews with 27 support workers and 10 managers of nongovernment organisations that were contracted by the government to provide non-clinical
supports to clients in one or both programs (most agencies supported clients on both the HASP
and P300 program). Informed consent was obtained in writing from all participants prior to
data collection. Both evaluations were approved by an accredited Human Research Ethics
Committee.
Interviews were used to obtain an in-depth understanding of support worker perceptions of
their role, how their clients had been going as participants of the supported housing program
and their perception of the program overall. Interviews followed a semi-structured format and
took between 30 minutes and 1 hour to complete. Most were conducted on the premises used
by the non-government agencies. Of the 37 participants interviewed, 21 were employed with
agencies in metropolitan areas, with the remainder from regional areas. Twenty-six were
female and they ranged in age from late 20s to early 60s. The average length of time the
workers had been assisting clients was five years, with a maximum of 14 years.
To recruit support workers to the study, managers of non-government organisations
approached individual members of their staff to ask them to participate in the interviews. This
may have resulted in a potential bias in the sample towards experienced staff who had
supported clients for a number of years. A study of the Queensland NGO mental health sector
identified that staff retention was a major problem for the sector (ConNetica Consulting, 2009);
therefore the results obtained through this recruitment technique may not be generalisable to
the wider support worker workforce.
All interviews were audio-recorded and transcribed verbatim. These transcripts were imported
into the NVivo 8 qualitative data analysis software package (QSR International, 2008). The
initial analysis was driven by the need to evaluate the success of the programs in supporting
people with severe mental illness to live in the community. Themes were identified based on
commonalities in the transcripts using an inductive approach (Patton, 1990). These themes
were refined through discussions with members of the research team, and a cross-sectional
indexing system was established to code the interviews within NVivo (Mason, 2002). One of
the aims of the broader evaluation was to gain an understanding of how support workers
working with people with serious mental illness living in the community perceived their work.
The research team felt that a contribution could be made to the scholarly literature to add
insights gained through working on the evaluations. After a review of the literature, we found
the work of Le Boutillier et al., (2011) particularly helpful in highlighting the challenges of
implementation of recovery-oriented practice and this was used as a lens for the current paper.
Results
The results described below have been structured around two of the domains of recoveryoriented practice identified by Le Boutillier et al. (2011) particularly relevant for support
workers: promoting citizenship and building a working relationship. It was difficult for the
workers to find the correct balance between the need for care and promoting client autonomy
to facilitate citizenship. Building a working relationship while working mainly in a client’s
home presented difficulties in terms of establishing boundaries and worker safety.
Balancing care provision and the promotion of autonomy
Kravetz and Hasson-Ohayon (2012) describe balancing the need for care and promoting
autonomy, as the “needs-rights antinomy”. By taking Anthony’s (1993) oft-cited quote
defining the recovery vision for people with serious mental illness, Kravetz and HassonOhayon identified the following contradictory elements within it: the need to receive care for
a serious and disabling illness; the right to self-determination. They suggest there are no easy
ways to strike a balance between these. We found this tension in two areas of support work:
the completion of housework and client participation in community activities.
Housework
In terms of clients’ household chores, a range of views were expressed about whether and how
support workers should be involved in the completion of such tasks. Overall, most support
workers saw their role as one of prompting, encouraging and supporting the client to do their
own housekeeping.
This viewpoint was based on two principles: firstly, that home
maintenance is a life skill that support workers need to encourage clients to develop; and
secondly, that the home is a workplace and therefore must be a safe environment for support
workers. The perspective of many workers is illustrated by the following:
[With regards to cleaning] I guess “assisting” is what we’d mainly be doing. The idea being to
motivate them to be doing things independently themselves… if someone’s capable of doing
the dishes, it’s not that we don’t want to help them. But especially with the medication
sometimes, they use that as a bit of an excuse – “I’m lethargic and tired”. So you could easily
be doing everything while they sit back and watch TV, so that’s not what part of our job’s
about. So we’ll assist them and encourage them and motivate them in any way we can.
[Support worker 1]
Some support workers reported that doing chores with clients provided an opportunity to build
rapport with them. Others encouraged clients to do their own housekeeping, but would do
chores if they felt that their clients were too unwell to complete these tasks on their own.
The need of support workers’ to safely carry out their work requires clients to maintain their
home in a relatively clean and tidy condition. However, this may conflict with the principle of
respecting the autonomy of the client, as one service manager expressed:
It’s difficult. Because it is their home, and we are visitors. But in saying that, it is also a
workplace, so we have to provide a safe environment for our workers. But yeah, we have had
contentious issues over the years. And generally if the home is unsafe, then we have to talk to
the client about providing a safe work environment…we have to be really careful in what we
see as clutter and dirt, as long it is a safe place for the client and the worker, we’ve got to
remember it’s not our issue.
[Manager 1]
In addition to the issue of workplace safety, another factor raised in this context was the
requirements for clients as tenants of public housing to keep their home in a reasonable
condition. Kravetz and Hasson-Ohayon (2012) needs-rights antinomy can be seen here in the
balance to be struck between the need for clients to maintain their homes to a standard
acceptable to their landlord and their rights as citizens to choose the environment they want to
live in. There is no easy answer to resolving this tension. However, if the condition of the
client’s housing is placing the client, the support workers or others in the building at risk, then
some form of intervention will be required.
Inspiring hope and promoting citizenship
Le Boutillier (2011) identified promoting citizenship as one of the common domains of practice
identified in recovery-oriented guidelines. To promote citizenship a service needs to “support
people who live with mental illness to reintegrate into society and to live as equal citizens”
(p.1474). Social inclusion and meaningful occupation are central to this idea of citizenship.
Support workers reported that encouraging participation in the community was a difficult
aspect of their work. The following quote is from a support worker who had worked with clients
over a number of years and described “giving up” on trying to motivate clients to engage in
community activities:
So I’ve sort of come to the conclusion that if they don’t want to do anything like that [participate
in the community], well that’s fine. If they just want to go for a walk or watch TV, or whatever,
that’s their quality of life. That’s what they want to do.
[Support worker 2]
As part of inspiring hope, most workers encouraged their clients to set goals. However
supporting goal oriented behaviour was difficult against fluctuations in a client’s illness.
Workers described needing to be flexible and understanding when clients do not actively
pursue their stated goals. This was articulated by one worker as follows:
So a person that we work with can articulate their goal and say this is really what I want to
achieve. And we can have all the things in place to do that, but if they then decide “Well I don’t
want to do that”, then what we have to do is then give them space, there’s no way we can force
that …you have to be prepared to be flexible. This particular line of work requires flexibility,
you sort of go with the moment. Sometimes it can be just a pure babysitting role, that’s what
we’re doing. Other times we are just powering on to achieve things. So I would say some of
the barriers just personally is just being able to be patient and be flexible to allow things to take
their natural course.
[Support worker 3]
Developing an effective working relationship
The second main area of challenge identified by support workers related to development of an
effective working relationship within the context of a person’s home. The spatial context of
care is an important factor in shaping the work carried out by the support worker (Sims-Gould
and Martin-Matthews, 2010). The provision of services in the “social” space of the home, as
opposed to the “medical” space of the clinic (Lilly, 2008), can lead to confusion over
boundaries and expectations. A support worker is not a common sense category like “doctor”,
“nurse”, “cleaner” or “friend”, and therefore there are no established frameworks for
interaction (Goffman, 1961).
The interactional work of establishing boundaries and
expectations of the support worker role needs to take place with each client. This potential for
blurred boundaries has been raised by other researchers studying care relationships (Mears,
2009). We identified two contentious issues for support workers delivering home-based care:
negotiating the boundary between friend and worker and managing challenging client
behaviour, including aggression.
Boundaries between friend and worker
A central idea for the treatment of people with mental illness is the importance of the
therapeutic relationship (Cahill et al., 2012, Le Boutillier et al., 2011) and this is particularly
important for the support worker role (Evans and Moltzen, 2000). However, when the setting
in which the establishment of this relationship takes place is the home or community, support
workers may be more likely to be seen as friends, compared to workers in other settings. A
further factor at play here is the more egalitarian nature of the working relationships owing to
support workers’ lack of coercive authority over clients, as opposed to case managers and other
government mental health staff. The support workers interviewed for the study appeared to
have varying perspectives in terms of the closeness of the relationship they developed with
their clients. For example, in the quote below, the support worker describes enjoying without
reservation the relationships she has built up over the years with her clients, many of whom see
her as a friend:
I just...like them. I like, they’re all just unique and special and they’re just so nice. And they’re
so thankful, and they’re so appreciative of the support. And the fact that, a lot of them now,
they still see me as a support worker, but as a friend as well. And they just appreciate the fact
that someone wants to give them the time of day. And I think that’s a major thing. I’ve had
clients of mine come over for Christmas day and things like that.
[Support Worker 2]
However, other workers described the tendency for clients to view the relationship as a
friendship as a potential problem. As the goal of support work was to encourage independence
and integration into the community, fulfilling a need for friendship was seen as reducing
clients’ motivation to form “natural” relationships. This view was expressed by one support
worker as follows:
I think one of the problems with the service we’re providing is that in some ways we become
their friends. We are not, but as part of the role we do provide a level of contact that can be
articulated as friendship to them. So some of them identify us as friends; we’re not just workers,
we’re friends. And I guess by doing that …that probably stops them from looking outside for
friendship.
[Support worker 4]
Dealing with challenging behaviour and aggression
Responding to the difficult behaviour of clients was raised by support workers as another
challenge of their role. One support worker described working with an aggressive client as
follows:
… that particular client, he is not very stable… I’m in the process of educating him about it.
It’s a sort of a process that I don’t really like doing because it involves me making some tough
decisions for the client but sometimes these decisions have to be made in order for him to
understand the consequences of behaviours, like you know if you’re going to abuse me and if
you’re going to be angry I don’t want to be around you. And nobody will want to be around
you, and you’re not going to get friends if you keep like this…
[Support worker 5]
For a small number of the younger clients, drug and alcohol misuse was an issue. This was
another example of where support workers needed to balance the tension between respecting
client autonomy, their own views of what constituted healthy lifestyle choices and what they
were willing to do as a worker. For example:
We’ve had to say that we will not purchase alcohol because that was becoming a concern.
We’ll take them to a club or a pub, and quite comfortable for them to have a couple of [drinks],
but not to the Bottle-O to purchase alcohol. We will drop them in the vicinity, you know that’s
what they’re going to do, but they can find their own way home.
[Support worker 6]
The boundary issues discussed above are inherent in any community-based health work. The
potential for these issues to result in conflict between clients and workers is particularly
pertinent given that the quality of the relationship built up between the two was seen as the key
to the success of both of these supported housing programs.
However, managing this
relationship – setting the expectations of the role, negotiating the boundary between being a
friend and worker, and dealing effectively with aggressive behaviour, remains a key challenge
for support workers.
Discussion
Empowerment and establishment of a valued identity are central tenets of recovery-based
practice (Le Boutillier et al., 2011). However, support workers found it difficult to balance
the concept of empowerment with the need to assist with activities such as housekeeping,
setting goals and encouraging community participation. This tension tended to be resolved in
favour of respecting autonomy. A similar finding was reported by Erdner and Magnusson
(2012) who found that psychiatric nurses respected their clients’ autonomy in refusing to
participate in activities, even though this contradicted their knowledge of the benefits of
participation. To successfully negotiate this tension, support workers need to be sensitive to
the state of mind of their client, have a range of strategies that can be used to motivate people,
and also be flexible if the client changes their mind. Workers could be assisted in this regard
through having access to further training in psychological interventions that can enhance client
motivation, such as motivational interviewing techniques, as well as access to regular
professional supervision during which they can discuss the difficulties they face.
The relationship between carers and those they care for is both an expression and the means of
providing good quality care (Meagher, 2006). Empirical research with clients who receive
home based care consistently report that they were most satisfied with carers who treat their
work as “more than a job” and who went beyond the traditional concept of professional
neutrality (Ware et al., 2004, Piercy and Woolley, 1999, Walter and Petr, 2006, Topor et al.,
2009). For people with serious mental illness, feeling of social connectedness is perhaps even
more valued due to the difficulty many have in forming social connections with others (Buck
and Alexander, 2006, Ware et al., 2004). On the other side of the relationship, research with
care workers shows that the emotional rewards of forming relationships with their clients is the
best part of the job (Coogle et al., 2008, Piercy and Woolley, 1999).
The normative framework most commonly referred to by support workers and clients is that of
friendship. In a description of the health support worker role within health visiting teams in
Glasgow (Mackenzie, 2006), befriending sits alongside other support worker tasks such as
emotional/social support, domestic work, advocacy and community work. In a study of service
users’ views of a home based mental health crisis team, Hopkins and Niemic (2007) reported
that clients were particularly satisfied with non-clinical support as the workers became ‘like a
friend’. In a traditional nursing context, Geanellos (2002) suggests that there are many positive
outcomes for clients (and their paid caregivers) that can emerge when friendship is allowed to
develop. She suggests that a concept of “therapeutic friendship” be further explored.
A view expressed by some of the support workers in our study was that if clients viewed their
support workers as friends, this would reduce their motivation to form their own friendships.
However, this notion has been contradicted by empirical research conducted by Tsai, Desai
and Rosenheck (2012). Their study of social integration of men with severe mental illness
showed that rather than professional supports being a substitute for natural supports – they
were in fact complementary. Men who had high levels of professional support were also likely
to have high levels of natural support. They conclude that “professional support and natural
support systems may be interdependent in that one enhances the other and perhaps clients
should be encouraged to rely on both systems as part of social integration” (p.152). If support
workers avoid the formation of close relationships this reduces the opportunity to enjoy the
more rewarding aspect of support work that is often cited as making up for the deficiencies in
pay rates and the unpleasant nature of some work tasks (Piercy and Woolley, 1999).
By the same token, while the support worker-client relationship may have the potential to be
more egalitarian than that evident between people with mental illness and other mental health
professionals, there is still the need for workers to maintain some boundaries in their work in
order to minimize risks of harm and exploitation, as is the case with the therapeutic
relationships developed by other mental health professionals with vulnerable individuals,
particularly in the psychotherapy field. This is a complex area beyond the scope of this paper
to explore in detail, but we point it out here to highlight the difficult challenges support workers
face in developing beneficial working relationships with their clients.
At the other end of the spectrum, challenging behaviour (including aggression) was highlighted
as a difficulty for the support workers in our study. Results from the wider Project 300
evaluation showed that twenty percent of support workers listed challenging behaviour as the
main difficulty in their work, providing examples such as “verbal abuse, aggressive behaviour
towards support worker” and “aggression, mood changes” (Meehan et al., 2012). A study of
aggression towards support workers in New Zealand found that workers perceived patient
aggression to be common (Gale et al., 2009). They also found that the communication style of
the worker affected their risk of experiencing aggression (for example, conveying a sense of
impatience or patient blaming), suggesting that this be an area for future training of support
workers. Protecting workers from aggression is much more difficult to do when work is carried
out within the community as opposed to a clinical setting. Fear of aggression may limit the
ability of the support worker to encourage the client to set and work towards goals.
There is no doubt that negotiating an appropriate level of closeness and developing strategies
for defusing challenging behaviour will remain a challenge for support workers. Evaluations
of the use of paraprofessional support workers in general health and social care have
highlighted the importance of professional supervision (Hiatt et al., 1997, Whipple and Whyte,
2010). For example, in the family support program evaluated by Whipple and Whyte (2010),
support workers received one to two hours per week of reflective supervision by a credentialed
senior social worker or public health nurse, as well as attending bi-monthly meetings that
focused on skill building, information sharing and group case-conferencing. In our study some
supervision was provided by support agency managers, but there was considerable variation in
the duration and content of this supervision. Examining what constitutes effective supervision
for workers supporting clients with serious mental illness would be a fruitful avenue of future
research.
The work involved in providing support to people with serious mental illness living in the
community involves the negotiation of difficult tensions inherent in the recovery vision. To
navigate these tensions requires the use of discretionary judgement, which Freidson (2001)
defines as being involved in tasks where routines need to be altered to fit the individual
circumstance and fresh judgement must be exercised if tasks are to be completed successfully
(p.23). In professional work, discretionary specialization is underpinned by formal knowledge,
abstract theories and concepts. In skilled work, it is underpinned by everyday and practical
knowledge. The question we think requires more attention from policy makers and training
providers is whether everyday and practical knowledge is enough to underpin truly recoveryoriented support work.
A risk identified by others who have examined the introduction of support workers is that they
can in fact act as “band-aids” in a flawed model of care (Giangreco and Doyle, 2002). Results
from our wider evaluation showed that some clinical case managers reduced their contact with
clients on the supported housing programs, as they perceived the clients to be adequately
supported (Meehan et al., 2012). An investigation of the way clinical and non-clinical workers
collaborated in a supported housing program in New South Wales, Australia had similar
findings - that clinical case managers allocated their time to their clients who were not receiving
non-clinical support (Dadich et al., 2013). This may be a positive development in that case
managers may now be spending more of their time with those with the greatest needs. However,
it also raises the question of whether we are relying too much on workers with comparatively
low levels of pay, training and supervision to truly support clients in their recovery.
Conclusion
In this era of post-deinstitutionalisation, new models of care have emerged to support people
with severe mental illness to live in the community. While many of these are based on the
concept of recovery, empirical research is needed to evaluate recovery-based care systems to
ensure that this vision is indeed being implemented. Tensions concerning the implementation
of recovery based practice exist within the service model. Addressing the challenges faced by
workers in supporting the recovery of their clients is likely to be one contribution to the
development of better service delivery systems.
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