The Malta Independent 25 May 2018, Friday

Mental Health (2): Reintegration into the community

Malta Independent Sunday, 14 March 2010, 00:00 Last update: about 5 years ago

For many years, people with mental health conditions were locked up and kept away from society. Today, it is a different story. As much as possible, people who suffer from mental health conditions – one in every four people experiences such problems at some part of his or her life – are treated in hospital and, once recovered, they are returned to the community. Some need assistance, which is given to them, and the more independent they become, the more they can reintegrate into society. The sad part is that society has still to accept them completely, and many find it hard to get a job

On the road to recovery

The sound of keys takes on a new meaning when one enters a ward in a mental health hospital. In other hospitals, there are established visiting hours which allow relatives and friends to spend some time with their loved one without disturbing hospital work and other patients. At Mount Carmel Hospital, there are a number of wards that are locked up not to keep visitors away, but to keep the patients inside.

This is necessary, explained the nurse, Sally Zammit, who is stationed at Female Ward 1. Patients kept in acute wards need constant attention, and are not allowed to roam freely. They move from the dormitories to the common areas together and follow strict procedures for their own safety.

The women kept here range from teenagers to octogenarians, and when asked why they are grouped together, Ms Zammit said that it is not possible to divide the patients according to their age groups because of space restrictions and nurse availability.

This area also leads to a small garden where the patients can go for some fresh air and a small gym where they can do some physical exercise.

These patients are regularly assessed and once they are found to be well enough, they are moved to rehabilitating wards, the first step that will eventually lead them back to life within the community. The rehabilitating wards are not locked, and patients are allowed to move around the hospital building and grounds.

Opening another door with another key, Nurse Zammit showed me five small rooms where people with a severe condition that could lead them to being aggressive are kept until the medication they are given stabilizes them. This is done for their own safety and that of other patients. There are five rooms, each with just a bed and a toilet, which are monitored via CCTV.

Then there is what is called the forensic room, where women who need treatment for their mental condition but who, at the same time, need to be guarded are kept.

The nurses develop a very strong personal relationship with patients, and their kindness and assistance goes a long way in helping rehabilitate patients. Their greatest satisfaction is when they see their patients walking out, hopefully never to return.

Purposeful activity

Occupational therapists are among the key members of multidisciplinary teams who deal with mental health patients, Catherine Galea, head of the OT department at Mount Carmel Hospital, said.

Their major role is to provide purposeful activities for the patient aimed at maintaining and improving all the skills of function and independence which are required by a person in daily life, but who become dysfunctional due to psychological difficulties.

OTs look at the person as a whole, so the three main functions of the individual – self-care, productivity and leisure – are assessed for dysfunction and incorporated in the treatment programme, Ms Galea said.

Sessions are carried out in the OT department, a building just outside the main gate of the hospital, as well as in wards. These activities include bathing, grooming, laundry, domestic tasks, cooking, budgeting and shopping skills.

Other activities are held to recreate the working environment to which a client would be returning. These include limited industrial work, information technology and clerical duties, woodwork, sewing and household tasks.

Leisure activities include art, pottery and music, and OTs themselves regularly organise activities in which they also take part. A recent case was a Carnival party. A hall that can take up to 250 people is also being refurbished.

Individual and group therapy sessions are held regularly, and clients can also make use of a gymnasium.

Ms Galea said that before being discharged, OT staff involve the client in a number of sessions to ensure smooth resettlement in the community. The support of the family is of utmost importance in this regard. Use of public transport, bank facilities, money handling and utilization of neighbourhood facilities are typical activities.

These are followed by regular home visits during which the reintegration of the client into society is monitored.

There is a great emphasis on the quality of life of their clients, Ms Galea insisted. “By helping them acquire the necessary skills to lead a healthy life, we are giving them the means with which they could find their rightful place in society.”

Healthy lifestyle

Psychologists were the last of the professionals to be included in the multi-disciplinary team that deals with people suffering from mental health conditions at Mount Carmel Hospital, Martin Micallef, chief of the Psychology Department said.

And this was when they moved from the philosophy of custodial care, by which people were kept in hospital for as long as possible, to rehabilitative and therapeutic care, by which people were and are given the necessary treatment, but then are helped back into society.

The role of psychologists is to support mental health patients to overcome their anxieties and fears, and help them lead as healthy a lifestyle as possible once they return within the community. Clients are assisted in learning how to deal with problems and tackle them before they grow and become, to the individual involved, insurmountable.

Mr Micallef said that patients are encouraged to lead a balanced life, one where work and pleasure complement each other. Counselling works wonders at helping people understand better what they need to do in the circumstances they find themselves in, and to return to lead an independent life as much as is possible.

New concept

Louise Xerri, head of the Social Work Department at Mount Carmel Hospital, said that the stigma that surrounds people with a mental illness is unfortunately still too high in Malta.

Referring to a research study she carried out in 2004 – but which she said is still relevant today – it was shocking to find out that people were still discriminating against those who suffered from a mental condition.

“There were many who did not want to have people who suffered from a mental condition to live next door, or who did not want to employ them. Some would not even want to rent their property to them,” she said.

This attitude must change, she insisted. Often, people with a mental condition are portrayed badly in films and in the media, but one tends to forget that except for the few extreme cases, there are many others who are success stories. People who were institutionalised for many years are now living in the community and it is probable that their neighbours do not even know their medical history.

The problem is that although the concept of how people with a mental condition should be treated has changed – by going from institutionalisation to community care – society has still to accept it.

She said that the Mental Health Act, which was drafted in 2007, has still not been made law, and therefore the prevailing legislation – that which was enacted in the mid-1970s – is antiquated. “By giving the sector a new legal framework in which to operate, I am sure that we can go a long way in giving these people a much better life to look forward to,” she said.

Basic skills

As clinical director and head of psychiatry at Mount Carmel Hospital, Dr Joseph R. Saliba overviews the links that exist between the various professionals involved in the multi-disciplinary teams, which psychiatrists lead.

He explained that each patient is different, and every effort should be made to enable him or her to resettle within the community he or she is accustomed to. Of course, patients who are referred to the hospital for the first time need to be assessed in depth before medication is prescribed and other types of care provided.

By enabling patients to re-acquire basic skills – and by teaching these skills to those who never had them – Mount Carmel Hospital is no longer the institution where people arrived with a reduced possibility of leaving or where they stay longer than needed.

The new way of treating people with mental conditions is to keep them out of the hospital as much as possible and, if the case is serious enough to warrant a stay at Mount Carmel, for the period they spend there to be limited. The services that are being provided within the community are offering the patients a much better chance to reintegrate themselves in society, Dr Saliba said.

It must be remembered that a mental illness is like any other illness. Only the more serious cases end up at Mater Dei Hospital, and so it is for Mount Carmel.

Regular contact

Josephine Mifsud, a psychiatric nurse and team leader, and Mandy Micallef, social worker, both work at the Qormi health centre, which includes the facility of a day centre for people from Qormi, Zebbug and Siggiewi who need psychiatric assistance.

“People who have been to Mount Carmel Hospital find all the necessary assistance here,” Ms Mifsud said. “But we also have patients who are self-referred or sent here by general practitioners. We help them as much as possible to avoid recovery at Mount Carmel Hospital, but there are occasions when they need hospital treatment.”

The way Ms Mifsud described her relationship with patients is one of “between a professional and a friend”. Ethical standards stop psychiatric nurses from getting too close to their patients, but at the same time the offer of a helping hand and the giving of personal attention often does the trick for people with mental difficulties to feel appreciated and start on the road to recovery.

Ms Micallef said that social workers and nurses also visit patients in their home, monitoring any progress or regress in their condition. “Keeping regular contact with our patients enables us to notice even the little differences that indicate whether the patient’s condition is improving or getting worse,” she said.

“We make sure however that our regular presence in people’s homes does not make them dependent on us. The idea is to have them live on their own and our visiting structure is only intended to provide assistance needed and monitor their reintegration,” she said.

People who do not live in the catchment area are not turned away. “If people who reside in areas other than Qormi, Zebbug and Siggiewi drop in with their difficulties we give them the help they need. Often we end up referring them to Mater Dei Hospital,” she said.

Supportive environment

The Qormi Day centre was the first community day centre that was opened in 1995 in the “pilot area” of Qormi, Zebbug and Siggiewi in line with the policy document drafted by the National Mental Health Commission, Ruth Azzopardi, an occupational therapist and team leader said.

The aim of Qormi Day Centre is to assist in the rehabilitation of individuals suffering from mental health conditions within the community. This is done through the provision of a supportive environment and aims at reaching the following objectives: to encourage clients to engage in a daily routine; to enhance quality of life; to offer guidance for re-integration within the local community; to prevent admission to Mount Carmel Hospital; to provide training and re-training of interpersonal and intrapersonal skills and to provide training and re-training of both personal and instrumental activities of daily living.

The centre also aims to provide pre-vocational and vocational training, to act as a focal point for both service users and their carers in times of distress or crisis through continuous support and reassurance, and to promote awareness and provide information about mental health issues within the community for prevention.

Clients who attend Qormi Day Centre include both males and females of various ages who are residents of Qormi, Zebbug or Siggiewi, Ms Azzopardi said.

Staff working at Qormi Day Centre include a senior occupational therapist who is also the team leader, a trainee psychologist, four care workers and one technical staff member.

Holistic approach

Physiotherapy at Mount Carmel is a relatively new discipline in the mental health sector, since it was introduced locally some 15 years ago, Richard Abela, assistant principal physiotherapist said. Three physiotherapists are employed on a full-time basis to enable mental health patients to lead a more pro-active and independent life.

Mental health patients suffer from physical ailments too, as their condition has a negative effect not only on their psychology but also on the way their body functions. This means that interventions on a physical level also have their importance in the holistic approach of treating such conditions.

Mobility and walking difficulties are common in mental health patients, either because of their condition or the side effects of pills they are taking. In older patients, mobility problems are more acute.

The role of physiotherapists at Mount Carmel Hospital is not only one that deals with individual needs, Mr Abela said. Physiotherapists also hold activities and physical exercises for groups at the Young People’s Unit, particularly during the summer months.

Mr Abela said that the more time passes, the more it is clear that physiotherapy is an important factor in the rehabilitation process of mental health patients.

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