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International Journal of Mental Health Promotion
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Experiences of clients who have made the transition from the psychiatric hospital to community service provision: a phenomenological approach
Patricia Mannix-McNamara , Elizabeth Carew Eichholz , Agatha Vitale & Didier Jourdan
a b a c a a

Department of Education and Professional Studies, Faculty of Education and Health Sciences, University of Limerick, Ireland
b c

Mary Immaculate College, Limerick, Ireland

Health Education in Schools' Research Team, IUFM d'Auvergne Clermont Université, Université Blaise Pascal, PAEDI EA 4281, F-63000, Clermont-Ferrand, France Published online: 08 Mar 2012.

To cite this article: Patricia Mannix-McNamara , Elizabeth Carew Eichholz , Agatha Vitale & Didier Jourdan (2012) Experiences of clients who have made the transition from the psychiatric hospital to community service provision: a phenomenological approach, International Journal of Mental Health Promotion, 14:1, 44-56, DOI: 10.1080/14623730.2012.665342 To link to this article: http://dx.doi.org/10.1080/14623730.2012.665342

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bMary Immaculate College. Faculty of Education and Health Sciences. the replacement of long-stay hospitals with community-based alternatives. 2001). 2006). cHealth Education in ´ .c Downloaded by [Universidad Autonoma de Barcelona] at 01:52 16 July 2013 Department of Education and Professional Studies.International Journal of Mental Health Promotion Vol.1080/14623730. 2006). physical and social health and well-being. 1.665342 http://www. Elizabeth Carew Eichholza. 2004). PAEDI Schools’ Research Team.com . February 2012. in many cases the community services needed for comprehensive care are not available. The WHO (2005) endorses as necessary. F-63000 Clermont-Ferrand. The results indicate that participants experienced a significant change in their lives in relation to their psychological. It could be argued that deinstitutionalization generated a shift in client experience in relation to their health and well-being. The promotion of mental health and the prevention. No. can have favourable outcomes for people experiencing mental health problems. University of Limerick. France. 1984) identifies the provision of comprehensive and easily accessible community-based mental health services as its central aim. Keywords: mental health promotion. Agatha Vitaleb and Didier Jourdana. community. communities and nations. IUFM d’Auvergne Clermont Universite EA 4281. WHO.doi. it is important to examine clients’ lived experiences of such a move. Diminished mental health can have significant impact on individuals and their families (Corrigan & Miller.org/10. Universite ´ Blaise Pascal. Irish policy such as Planning for the Future (Department of Health. While each country needs to find its own way forward in accomplishing the aims of deinstitutionalization and integration (Becker & Killian. 2005).2012.tandfonline. This is the aim of the present study which was based on a phenomenological approach. However. psychiatric hospital. Mannix McNamara. 14. Ireland.ie ISSN 1462-3730 print/ISSN 2049-8543 online q 2012 Taylor & Francis http://dx. treatment. the delivery and implementation of mental health services in a wide range of community-based settings. phenomenology a Introduction Mental health and well-being are fundamental to the quality of life and the productivity of individuals. This raises the question as to whether the move from the longstay hospital has been positive or not for health of clients. care and rehabilitation of mental health problems are important public health priorities (Ryan. the national policy document for *Corresponding author. Therefore.m.mcnamara@ul. & Deasy. families. Email: patricia. Deinstitutionalization. enabling people to experience life as meaningful and to be creative and active citizens (World Health Organization [WHO]. Limerick. A Vision for Change (Department of Health. 44–56 Experiences of clients who have made the transition from the psychiatric hospital to community service provision: a phenomenological approach Patricia Mannix-McNamaraa*. aiming to replace the isolated and large institutions. Freedom for selfdetermination and living in an environment that gives them autonomy is at the core of their personal experience. Ireland. 2006.

2005) can have favourable outcomes for clients (Fuller.. this contestation has been more to do with the lack of provision of comprehensive community services in replacement of those previously located in the hospital resulting in unintended consequences such as homelessness and lack of access to services. As reported by The Inspector of Mental Health Services (Mental Health Commission 2010). 2005). the analysis of the implementation of A Vision for Change by the Mental Health Commission (an independent statutory body established under the Irish Mental Health Act 2001 to safeguard high standards in the delivery of mental health services) shows disappointing results. 2007b) found little evidence of the individualized treatment or care that Lamb and Bacharach (2001) advocate. & Moran. 2001). Community-based services potentially offer more opportunities for client empowerment (Ryan et al.International Journal of Mental Health Promotion 45 the promotion and implementation of mental health services. Underpinning the policy of deinstitutionalization is the principle that a recovery approach should inform every level of the service provision. the benefits of community-based service provision are recognized in Irish policy as an important aspect of client care. in many cases the community services needed for comprehensive care are not readily available. In Ireland research funded by the Health Research Board into community residential care (Tedstone. In order to understand this it is important to examine client experiences of deinstitutionalization. Researching the experience of vulnerable people requires long-term work with individuals in order to build respectful and empowering relationships that create the conditions for the Downloaded by [Universidad Autonoma de Barcelona] at 01:52 16 July 2013 . and where possible. also advocates communitybased service as a core value of quality mental heath service provision. This raises the question as to whether the move from the long-stay hospital has been positive or not for health and well-being of clients who have made the transition. Deinstitutionalization which in effect is the replacement of psychiatric care from long-stay hospitals with community-based care alternatives (WHO. 2009b). Therefore. 2007a. 2007b. Doherty Walsh. 2006). Indeed. those requiring hospitalization are still accommodated in Victorian buildings unfit for patient care. offering a range of comprehensive interventions and should reflect best practice for addressing any given mental health problem. Successful deinstitutionalization requires service planning tailored to individual needs. most persons with severe mental illness significantly benefit (WHO. However. Where community services are available and comprehensive. to complete independence. Walsh. Tedstone Doherty. 2009a. 1997. However. This quality service is described as being able to provide person-centred multidisciplinary care that is adapted to individual need. 2005). The Mental Health Commission (2010) report describes that in 2009 there was only limited change of a positive nature on the ground with no major improvements in the quality of care and treatment. 1997). deinstitutionalization has become a dominant mental health public policy in many western industrialized countries. the community services necessary for the replacement of the long-stay hospital are not systematically available and are not developing at the pace needed (Fuller. The debate remains that while the success of deinstitutionalization has been contested. WHO. It also advocates that services should be delivered by skilled professionals working together in community-based multidisciplinary teams. Lack of progress overall in achieving the aims of A Vision for Change is damaging to the dignity of those with mental illness (Mental Health Commission. informed by client voice and must be part of a broader spectrum of continuity of care (Lamb & Bachrach. rather than in terms of the veracity of deinstitutionalization per se. In the last decade. & Moran. The rationale behind the move from large residential care settings was that community residences would fulfil a therapeutic and rehabilitation function such that persons with persistent mental illness would move from higher to lower levels of support.

Data collection The investigator. A comprehensive approach to informed consent proposed by Mauthner. Birch. The interviewer was aware of the potential influence of the researcher in interviews and therefore was careful not to dominate the interview. The research aims and objectives. 2007). This is why the researchers adopted a phenomenological approach which prioritized the lived experience of the client. Prior to the interview. Participants Nine residents took part in the study (five from the first residence and four from the second). spent several months meeting with staff and participants. Participants were interviewed in a venue of their choosing. The intention of this research was to enquire into the different experiences and perceptions of a range of clients who had experienced long-term stay in hospital and who had moved to community residences. The research was not primarily concerned with explaining the causes but rather sought to describe how the everyday world was experienced by the participants (Denscombe. The interview process was underpinned by the principle that the interviews were contributing to the construction of knowledge in a situated manner and rather than seeking universal knowledge (Kvale. not working in the residences in which the participants lived. It was deemed important to facilitate the interviewees to talk freely about the topics they raised and questions were only asked to seek clarification. The researchers sought to understand the clients experience and to understand the meaning that they placed on these experiences. carried out over the period of 1 year. Methods A qualitative phenomenological research approach similar to that of Casserly. residents who showed interest in the research and who fitted the selection criteria met the researcher on individual basis for more detailed information on the study. 1997). expression of their lived experience. The recruitment of participants was supported by the clinical nurse managers of the two residences.46 P. illustration or further exploration (Parahoo. 2007). McNamara et al. with an age range of 20– 66 years. Ethical considerations There were ethical considerations that were held as inviolable and that were negotiated with participants in order to safeguard their rights. sought to qualitatively explore the lived experiences of clients who made the transition from institutional-based care to community service provision. Participants’ average time spent in various institutions varied from 1 to 13 years. Henry. and Marshall (2008) was adopted for this study. The sample consisted of five females and four males. The investigator met with each participant several times as was needed by participants to ensure comfort with giving their informed consent resulting in a substantial amount of recorded material at the end of the study. Downloaded by [Universidad Autonoma de Barcelona] at 01:52 16 July 2013 . the process was explained to participants. Participants were unknown to the researchers and were competent and willing to give written informed consent. and Jessop (2002) was applied. Following initial contact.M. and had been living in their community residence for more than 1 year (see Table 1). Individual interviews were adopted as the data collection method. with a background in mental health. Coady. This study. All participants were interviewed individually.

1430). This was done on multiple levels. Female 9. 2006). The four basic ethical principles of respect for persons. Male 6. assumptions. the organization and the ‘external world’. Male 4. Male Age 25 49 51 50 56 49 66 65 50 No.5 12 1 1 5 6 14 15 Downloaded by [Universidad Autonoma de Barcelona] at 01:52 16 July 2013 Notes: Nine residents took part in the study (five from the first residence and four from the second). and try to generate labels to capture the essence of meaning as participants intended. starting from how it affected participants individually to how they perceived their relations with other users and staff members. of years in residence 2. the researchers identified their assumptions and potential biases in order to minimize the impact on the interpretation of the phenomenon. In choosing a reflective bracketing approach. Client 1. The sample consisted of five females and four males with an age range of 20–66 years. 1430). . see Figure 1). p. Female 3. This was carried out first in each transcript and then common themes/trends were identified across the transcripts. Results Participants provided rich descriptions of their experiences of both the psychiatric hospital and the community-based residence. Each transcript was read several times by two researchers in order to identify ideas and meaning expressed. patterns and trends. the researcher’s background. Each theme is described individually and illustrated by quotations from the interviews.5 5 10 4 10 47 No.5 4. biases. Direct quotations from transcripts were identified which exemplified each theme. Female 5. p.International Journal of Mental Health Promotion Table 1. Female 8. Female 7. This research was granted ethical approval from the local Health Services Executive ethics committee. 2004. Data analysis The researchers adopted a reflective bracketing analysis approach. Finally. Interview transcripts were analysed thematically. This form of phenomenological bracketing was adopted because it calls upon the researcher to have thoughtful and conscious self-awareness (Gearing.5 12/13 10 6. Parahoo (1997) identifies that phenomenological data can be analysed by searching for themes. After several meetings and time to consider participation. theories or previous experience to see and describe the phenomenon’ (Gearing. participants signed a consent form indicating their willingness to partake in the study. non-maleficence and justice were adhered to (LoBiondo-Wood & Harber. of years in hospital 1 1. all the related themes were clustered into domains. The themes and the domains are arranged in a manner that could facilitate the understanding of participants’ experience of living in an institution (previously) and in the residential care (currently. 2004. Male 2. beneficence. assumptions and values were made explicit. the confidentiality of the study and freedom to withdraw without prejudice were discussed in detail. Data were grouped into themes. Participants Demographics. Bracketing in phenomenological research is ‘A scientific process in which the researcher suspends or holds in abeyance his or her presuppositions.

M. People ignore you Won't accept at home Structure Relationship with others Ugly people Strangers Noisy . but I felt ten times worse in there (Participant 8). Some felt that the institution limited their capacity for self-care.. Nice Lovely kind hearted . Friends Know each other . Independant Take care of myself More freedom Choices Nice Homely Respectful . One participant discussed feeling forced to wear ‘shabby jackets’ that were ‘rotated’ between patients and he perceived the wearing of them as ‘a sort of punishment’: Do you know the shabby old dirty old jackets? There would be stains down the front.. Experiences at individual level Previously From an individual perspective.. They articulated feeling much more freedom and independence: . they relate to the community residence.. In the first column. and that in most cases it exacerbated their existing mental health problems: I didn’t feel well before I went in there. They were designed for to keep you quiet (Participant 4). the words relate to the experience of the psychiatric hospital and in the second..... The nurses cut my hair (Participant 7) and the removal of the independence of being able to make choices to wear their own clothing... . I had long hair down my back. the experience of living in the residential community setting seemed to have a positive impact on participants’ sense of well-being... Not belonging . For each domain.. . Depressing Upsetting Dark .. participants’ keywords from the interviews are provided. Currently Overall. Clients’ experience in relation to the move from the psychiatric hospital to community service provision.. Other key themes emerging from the analysis were participants’ health and mental health improvements and areas of improvements for residential care. Go down town People talk you . they were hospital clothes.48 P. Common to all participants was the belief that being in the institution de-personalized them. Analysis revealed five domains in relation to clients’ experience. Downloaded by [Universidad Autonoma de Barcelona] at 01:52 16 July 2013 Well being Frightening Sad Not feel well ..... Relationship with staff Unfriendly Intimidating Shouting . And they cut my hair. sad (Participant 7)... McNamara et al. Client experience Relationship to external world Afraid Didn't like to see me . Nice . participants described their experiences of being in a psychiatric hospital in negative terms such as psychologically distressing (Participant 2) and frightening . including their own personal hygiene. Figure 1. Didn't mind . They described specific experiences to exemplify this as: I was small. They perceived that institutionalization negatively affected their well-being.. they cut my hair.. for example: I found really hard to keep myself clean you’d have the nurses giving you a hand to wash and you lose your independence (Participant 8)..

Noise levels were also cited as frightening: People were breaking windows and doors were banging and it was frightening (Participant 8). but we’re all kind and different but we meet and chat here (Participant 8). with short coats. I can take care of myself. I can go down town here. They described experiences such as: Being told what to do with force (Participant 4). Currently Almost all participants considered the other residents of the 24 community-based service differently. I like to buy a few things all right. They was an increased sense of being able to take care of themselves. I have a few friends here. . I’ve different jobs to do in the house. I can do my own laundry. Participants’ experiences of the staff Previously Staff members of the institution were generally described by participants as unfriendly and intimidating. I can buy things at the shop. I can do gardening. 49 This new sense of freedom was also related to feeling that they had more choice: I definitely have a lot of more freedom. I feel we know each other enough to be friends. including being able to decide what to wear. I do those. ironing. Downloaded by [Universidad Autonoma de Barcelona] at 01:52 16 July 2013 More economic independence was important: I have loads of choices. I was kind of afraid all right (Participant 9). Experiences of relations with other users Previously All participants indicated feeling intimidated by other patients while in the psychiatric hospital: There were a lot of ugly people there and I was nervous (Participant 3). . This friendship with other residents helped them to engage more in social activities. They were strangers to me (Participant 4). I have my money. and swimming and go bowling (Participant 3). I can go out at night till even 12 o’clock. I’d chat away here. . I didn’t like it at all . . They were all talking. I think I nearly have it too good sometimes I can go for a smoke. I can buy what I like (Participant 7). What more do I want? (Participant 4). I have much freedom here. . The same participant who said that he was forced to wear shabby jackets’ in the institution said of the community residence: I got that new pants there and I have the shoes a while (smile). I take care of my own washing. I go to the art classes here (Participant 9). . Access to work training was also positively indicated: I help with the plants and the weeds . like hospital coats. it was noisy (Participant 5). They were making noise there. . I do my jobs. There were strange people in there. I get up in the morning and I am ready for the day (Participant 8). art. We all look out for each other here . I’m really happy here now. I have a new coat I have a lot of clothes and good shoes (Participant 4).International Journal of Mental Health Promotion I am more independent. more able to look after myself (Participant 2). they perceived them as friends and they felt that they could rely on each other: I’m friends with everybody.

We got our suppers there. They would be shouting at you to get up (Participant 3). McNamara et al. . it’s dark. Once I got used to it then I didn’t mind (Participant 1). Experiences of the organization/structure Previously Almost all participants used negative adjectives in describing the psychiatric hospital.50 P. The first time I didn’t fancy it very well there. The nurse makes sure he gets up in the morning (Participant 6). However. You are allowed out for a few hours (Participant 6). They treated us very bad. The hospital building was described as: an old dark building. They (the nurses) wouldn’t talk to you at all. That was frightening you know (Participant 4). . I wasn’t listened to at all (Participant 7). Well there are three beds in my room. . Living in the community residence enhanced participants’ sense of freedom: I have a feeling of belonging here (Participant 8). . The most common adjectives used were: depressing (Participant 5). we got tea and toast at night (Participant 8). You can play music at night and you can watch television. (The blankets) they’re handy. distressing (Participant 2).M. lovely (Participant 1). . Lack of communication was cited as disempowering: I was frightened. I have an electric blanket with it. They (the staff) wouldn’t tell you anything. upsetting. . Like a hotel (Participant 4). . I didn’t like the mornings. listening to music and nice people (Participant 2). They put us in the cold to walk around the grounds but they didn’t go out themselves at all (Participant 7). They described the nurses as: nice. I wouldn’t leave it for the world (Participant 1). . I have a chair (smiles and shows to the researcher her recline chair) (Participant 1). They (the nurses) help you (Participant 2). Currently Participants’ description of their residence was generally positive: It’s nice and homely . They are fine and warm’ (Participant 3). I have more freedom here (Participant 7). It’s old fashioned. I like television and I can watch it until about 11:00 pm (Participant 1). Downloaded by [Universidad Autonoma de Barcelona] at 01:52 16 July 2013 Currently All participants were more positive about their community-based carers. Very kind-hearted people . You don’t feel safe there. It is respectful here. It is like a foreign holiday here. There are two next door. You are watching your back all the time (Participant 8). frightening (Participant 4). and its dreary . They wouldn’t half answer you . They also felt that they were able to keep their belongings: Look (he shows a blanket with a smile) I have a good lot. rough (Participant 9). Only one participant described her relations with staff members positively: The nurses were nice. one participant did say: I didn’t mind. I was at the door and the head nurse said: ‘Take him down there’. . I liked there.

In some cases. their relationships were far from being idyllic: It is not that I don’t want to talk to them (family). It is not my birthplace and what happened in the past is not my fault (Participant 2). My sister and brother. a freak. (Participant 7). They wouldn’t know what to do with me . Participants’ experiences external relations Previously During their stay at the psychiatric hospital. afraid to go to the outside world. the move into the community decreased the frequency of family visits: It’s not too bad here but it makes me sad because it’s far away from home (Participant 7). It would be 12 o’clock and we’d have Santa and all that! (Participant 7). she was busy she was looking after them (siblings) and didn’t want me hanging around the place (Participant 4). . People would sometime ignore you (Participant 9). While some participants were still in contact with their family members. And not everyone felt a sense of belonging: I don’t have a feeling of belonging here (Participant 8). We went out for Christmas dinner. you know. Downloaded by [Universidad Autonoma de Barcelona] at 01:52 16 July 2013 Participants felt abandoned by their family members in the institution: My father didn’t want me there he kind of turned me out into the hospital. They won’t accept me at home. Everybody salutes me. there was a clear sense that they felt not fully integrated in the community: The shops are really nice. a weirdo because you’re in mental hospital (Participant 2). they felt able to engage in activities outside the residence: We go to hear (name of the musician) playing often in (names town). In one instance. We went out for dinner. it was not perceived as without potential for improvement: I just don’t know. calling you a scumbag. including their own family members as negative and often intimidating: I was afraid to go out. I don’t know why! (Participant 7). Perceived improvements after moving to community residences Participants perceived the move to residential care as having a positive effect on both their general health and mental health: I’m fine now because I’m on one blood pressure tablet now in the morning. They (the family members) didn’t like to see me at all (Participant 9). I just find it difficult to express myself to them. they wouldn’t let me stay at home. Boys can be hurtful. However. and my blood pressure is checked every single day (Participant 1). . Currently Some of the participants felt that the move to community residential care improved their relations with the outside world: It’s not as bad here as it was when I lived in the hospital: When I go down town here people will talk to you (Participant 7). I would like to go away with my sister (Participant 5).International Journal of Mental Health Promotion 51 However. I have learned how to cope better now. participants perceived their relations with the external world. My mother hadn’t any time for me. . but I wouldn’t say I’m part of the community.

It could be argued that deinstitutionalization generated a shift in client experience in relation to their health and well-being. I feel I am getting better here (Participant 3). and Tannahill’s (2000) model of health can help us to understand the client’s experience.. It’s not like that here (Participant 6). For these authors health is conceptualized as a continuum between a positive health (PH) pole and a negative health (NH) pole. Yes I got better. I smoke less (Participant 3). Doherty Walsh. Downie. There was a sense that some of the younger participants considered the residence as transition to independent community living. it is noteworthy that Tedstone. I would like to help anyone I could help (Participant 2). In this model. WHO. McNamara et al. I used a nebulizer in the hospital and I don’t need that here. My goal is to get a job. For example. The results of the interviews indicate that participants experienced a significant change in their lives in relation to their psychological. I’d like to learn how to cook (Participant 3). I don’t know.52 P. and that their hope was to be able to get their own accommodation and be economically independent. Downloaded by [Universidad Autonoma de Barcelona] at 01:52 16 July 2013 Staying down in the smoker’s room that gives you cramps in your legs. Tannahill. They should do more things like swimming and art and normal stuff. I have more freedom. This was not dramatic or radical but is important nonetheless in terms of client self-esteem. 2007b. they need someone. I’m less breathless here. It’s nicer here. Discussion The focus of this study was to qualitatively explore the experiences of clients who made the transition from institutional-based care to community service provision. Sitting down all day and watching telly (referring to hospital). You want to get out do a walk and get exercise and lose weight (Participant 6). I’m capable of getting a job and living independently. I stopped imagining things. This PH pole comprises both concepts of true well-being (which has its roots in positive self-concept and empowerment and the belief in the self as having a positive . mainstream employment or mainstream housing. I don’t feel I want to stay here for the rest of my life. 2005). My dream is to live in a house and not to be afraid.M. These findings reflect similar empirical work conducted in this field. I am feeling fine. They raised concerns about the potential difficulties in making the transition to independence: Residents may find it hard to move so I suppose they need counselling or to be told more about the community. I’m more in a working form. Those who had moved to community residences were content with their location and preferred the independent living. However. which suggests that the move from institutional to residential care is beneficial for users (Tedstone Doherty et al. My mind was in a rut in the institution. 2007a. which was linked to lack of specialized multi-disciplinary rehabilitation teams. That’s not a life at all. physical and social health and well-being as a result of moving to community-based care. Their focus became about doing more and engaging with their health more: People should go out more. giving more information. health promotion becomes a process of helping people to improve their health by endeavouring to support them to move along the continuum towards the PH pole. I’m happier now (Participant 4). and Moran (2007b) also show that very few of the community residencies were providing cognitive behavioural therapies or activities that promoted community integration. to help them before they move to the community (Participant 4). I’d like to become an advocacy worker.

illness.injury" "true wellbeing (empowerment) and illness (strength. in the way participants perceived the structure they were in.International Journal of Mental Health Promotion 53 Downloaded by [Universidad Autonoma de Barcelona] at 01:52 16 July 2013 contribution to make socially) as well as fitness (associated to physical attributes of strength. The extent of this shift differs for each person. Clients’ experience of health. and in their relations with the external world). (2000). in their relations with other users and staff members. injury. particularly in terms of not owning clothing that was solely for their own use. . unwanted states. mental and social facets of health. 2000). For Downie et al. it is unsurprising that living in a large institution can be experienced as depersonalizing. illness. The description of the ‘sort of punishment’ (Participant 4) in having to wear clothes that are not a personal choice reiterates Goffman’s (1961) landmark study that identified that the psychiatric hospital can generate a mortification process that denies the importance of individuals’ behaviour and possessions which had previously supported their self-image. This model assumes that physical. or ill-health. suppleness and skills). stamina. is associated with disease. etc. or ill-health. see Figure 2). unwanted states. The language of participants suggests that a sense of powerlessness accompanied their experience of being in a psychiatric hospital. social and psychological. The experience of clients in this study moving from the psychiatric hospital could be considered as a shift from the NH pole to the PH pole. etc. the experience of clients moving from the psychiatric hospital could be considered as a shift from the NH pole to the PH pole (physical. In this study. At an individual level. illness. and consequently negatively impacts on experiences of powerlessness. stamina. influence a person’s status between both poles. The NH pole. suppleness and skills)" Negative health pole Client experience Positive health pole To community residences A shift in client experience Figure 2. unwanted states. injury. stamina. health is a continuum between a PH pole and a NH pole.. The NH pole. suppleness and skills).e. individually. given the experiences of participants in the study. This PH pole comprises both concepts of true well-being (which has its roots in positive self-concept and empowerment and the belief in the self as having a positive contribution to make socially) as well as fitness (associated to physical attributes of strength. Disempowerment was evident in participants not being allowed make decisions with regard to personal hygiene or clothing choices. so that improving health refers to increasing the level of health by enhancing PH and reducing NH (Downie et al. This disempowerment was also evident in participants describing being told what to ‘with force’. This feeling of being powerless applied to all level of analysis (i. Lack of empowerment was also From psychiatric hospital Negative health pole Positive health pole Client experience "disease. as assumed by WHO (1986). is associated with disease.

2000). there was a sense that participants did not feel fully integrated in the community. 2010). Being able bond with other clients can have a positive effect on the individuals’ mental health and can help to maximize their rehabilitation process. 1989). Having few friends and being socially isolated are associated with poor therapeutic outcomes (Gill. Mitchell. Not only does community-based care facilitate clients to build relationships with other residents and staff members but it also supports growing links with the wider community. This contrasted greatly with participants’ experience of moving to residential care which appeared to result in having more freedom and choice. & Gilheany. ‘frightening’. The types of relationships that participants in the study had with service providers in community care were clearly more positive than those they has with the hospital staff. Hayes. the data suggest that there might be areas for improvement. Still. Mental health service provision needs to be cognizant of the role that the public policy and the physical and social environment Downloaded by [Universidad Autonoma de Barcelona] at 01:52 16 July 2013 . 2010). For instance. Given the importance of building clients’ social capacity. In relation to service provision. for example. clustering residences for similar-aged individuals may support their engagement in social activities and develop interpersonal capacity. Closer attention needs to be paid to family support and engagement in order to limit clients’ experience of loneliness. and lower in-patient use is essential for successful community integration (Geller. Community-based care helped participants to build relationships with other clients and thus to engage in more social activities. but the data also suggest some insights that may be of benefit in service provision in this field. Participant’s language at this stage was more positive and denoted a growing sense of empowerment and personal engagement with their health.54 P. empowerment can be perceived as a shift in the balance of power from service providers who traditionally held power to clients who have been traditionally powerless having more power and agency in terms of the types of mental health services they access (Greacen. Clearly. 2002.M. evident in the lack of knowledge that participants seemed to have with regard to their treatment and knowledge is an important aspect in empowering clients to engage in selfcare (Greacen. Whittaker. the move to community-based care was felt by participants to have improved their quality of life. Freedom for self-determination and living in an environment that gives them autonomy is at the core of their personal experience. this had to do with an increase in their selfesteem. The overall outcome of moving into community-based care had a positive impact on participants’ sense of well-being. indicating there is still much progress to be made in community integration and in challenging the stigma associated with mental illness (Gill et al.. The majority of participants of this current study indicated freedom as the greatest effect which they associated with the move into the community. A significant advantage in providing care in the community is that it is in the context of service users’ everyday lives. Dickinson. ‘watching your back all the time’ and ‘afraid to go out’. characteristics that Sen (1999) and Naryan (2002) argue are aspects of growing empowerment. They felt freer to act from their own choices and were continuously increasing their control of their lives. This lack of control was manifested in the language of fear that participants used. Community staff were experienced as being as far more balanced and interpersonal. self-confidence and autonomy. McNamara et al. and thus it increases potential for their social networking. A good social network linked with more regular attendance to therapeutic out-patient sessions. The data suggest that moving to the residential care enhanced their psychological empowerment. Conclusion The voices of participants in this study provide a clear mandate for mental health services in Ireland. 2002).

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