Development of vocational training systems for patients with intellectual disability in Poland.

BACKGROUND: The problem of employment of people with intellectual disabilities is present in many countries. The literature on this topic draws attention to the fact that the improvement of the situation in this area is conditioned by changes in government policies, practices of employers and adequate preparation to undertake professional duties by persons with intellectual disabilities. OBJECTIVE: The objective of this review was to explore the changes in vocational rehabilitation forms in Poland. RESULTS: As one of the ways to solve this problem since 1991 in Poland the so called Workshops of Vocational Therapy have been created. According to the regulations the Workshops were designed for adults with intellectual disabilities, aged over 16 years with a total incapacity of gaining an employment, for which occupational therapy was a form of social rehabilitation. The further step in this process was the establishment of Vocational Activation Centers, with which high hopes were associated. They were expected to be an intermediate link in the creation of career paths from rehabilitation forms ultimately to open labor market. In practice it turned out that the creation of these Centers in Poland has been too slow. CONCLUSIONS: This raised the necessity to change the attitude from the concept of matching the participant to work and to the new environment, which frequently ends as a trauma, to the concept of matching jobs to people. New initiatives and new rehabilitation programs are developed based on this attitude.

Changes needed in the care for sheltered persons: a multistate analysis from Hurricane Katrina.

OBJECTIVES: Following Hurricane Katrina, nearly 1,400 evacuation shelters were opened in 27 states across the nation to accommodate the more than 450,000 evacuees from the gulf region. The levee breaks in New Orleans and storm surge in Mississippi brought about significant morbidity and mortality, ultimately killing more than 1,300 people. The purpose of this study was to summarize the health needs of approximately 30,000 displaced persons who resided in shelters in eight states, including prescription medication needs, dispersement of durable medical equipment, and referrals for further care. METHODS: The first available 31,272 medical encounters forms were utilized as a convenience sample of displaced persons in Louisiana, Mississippi, Texas, Alabama, Georgia, Tennessee, Missouri, and Florida. This medical encounter form was completed by volunteer nurses, was standardized across all shelters, and included demographic information, need for acute or preventive care, pre-existing medical conditions, disposition referrals, need for prescription medication, and frequency of volunteer providers who providing care outside of their first-aid scope. RESULTS: Sheltered persons who received only acute care numbered 11,306 (36.2 percent), and those who received only preventive/chronic care numbered 10,403 (33.3 percent). A similar number, 9,563 (30.6 percent) persons, received both acute and preventive/chronic care. There were 3,356 (10.7 percent) sheltered persons who received some form of durable medical equipment. Glasses were given to 2,124 people (6.8 percent of the total visits receiving them) and were the most commonly dispense item. This is followed by dental devices (495, 1.6 percent) and glucose meters (339, 1.1 percent). Prescriptions were given to 8,154 (29.0 percent) sheltered persons. Referrals were made to 13,815 (44.2 percent) of sheltered persons who presented for medical care. The pharmacy was the most common location for referrals for 5,785 (18.5 percent) of all sheltered persons seeking medical care. Referrals were also made to outpatient clinics 3,856 (12.3 percent), opticians 2,480 (7.9 percent), and public health resources 1,136 (4.3 percent). Only 1,173 (3.8 percent) sheltered persons who presented for medical care and were referred to the emergency department or hospital for further care. CONCLUSIONS: Hurricane Katrina illustrated the need to strengthen the healthcare planning and response in regard to sheltered persons with a particular focus on primary and preventive care services. This study has reemphasized the need for primary medical care and pharmaceuticals in sheltered persons and shown new data regarding the dispersement of durable medical equipment and the frequent need for healthcare beyond the shelter setting as evidenced by referrals.

Why employment in integrated settings for people with disabilities?

This paper reviews the reasons why work in integrated settings for people with disabilities is important. Current controversial issues in employment of people with disabilities are discussed. These issues are sheltered work versus supported employment and natural supports versus the job coach model.

[The connection between labor integration and prognosis of schizophrenic patients: an 8-year follow-up study]. / Zusammenhang zwischen der Arbeitsintegration schizophrener Patienten und mittelfristigem Krankheitsverlauf. Ergebnisse einer 8-Jahres-Katamnese.

This study reflects the labour-situation of 67 DSM-III schizophrenic outpatients in an 8-year follow-up. About 50% of the patients had less than 20 hours of work a week on the average--most of them in work therapy or sheltered work-places. Many of them changed their location of work. Patients with an initially good prognosis (MPS) had a good outcome, regardless if they had a normal job and worked about 30 hours a week or worked about 20 hours in a sheltered place. For patients with a poor prognosis even the integration in a sheltered working place was difficult.

[Occupational status of Saxony social psychiatry service clients as a result of the reunification of Germany]. / Zur beruflichen Situation von Klienten Sozialpsychiatrischer Dienste Sachsens im Gefolge der deutschen Wiedervereinigung.

PURPOSE: Evaluating the establishment of social psychiatry services (SPS) in Saxony was part of a public health research project. METHOD: One of the variables in a specifically designed assessment instrument--used in 8 SPS during the period 08/95-01/97--was the retrospective statement concerning changes in the client's vocational situation caused by the social upheavals in 1989. RESULTS: 40.6% (n = 335) answered in the affirmative. Men are significantly overrepresented in the group with vocational changes; compared to the population without vocational changes the proportion of currently unemployed persons (56%) is five times higher; only 16% are still employed. Neurotic/personality disorders as well as brief mental disturbances and dependency disorders are more frequent than in the whole SPS-clientele.--The most important constellation (19%) identified by a configuration-frequency analysis is that of patients with prolonged psychotic disorders (started < 1990, not associated with dependency disorder) who were employed at sheltered workplaces during the GDR-period despite of their mental disorder. CONCLUSION: Following the political German reunification possibilities of vocational rehabilitation have deteriorated and up to now the number of newly established alternatives in regional mental health services is insufficient.

["Out of the picture"--self-evaluation of the occupational status of chronic schizophrenic patients in united Germany]. / "Weg vom Fenster"--Die Selbstbeurteilung der beruflichen Situation chronisch schizophren Erkrankter in den neuen Bundesländern.

PURPOSE: This study is based of the documentation of drastic changes in the vocational life of chronically schizophrenic individuals in the New German Länder. With the political and economic transition since 1989, the employment rate of those suffering from chronic schizophrenia dropped from 50% to 7%. Currently most of them receive a disability pension. METHOD: Using a qualitative study design, we addressed the question as to what extent the disability pension can substitute for occupation of those in question. 45 chronically schizophrenic patients who are currently in outpatient treatment were interviewed to understand the role of work and disability pension in their lives. RESULTS: Positive and negative aspects of work and disability pension and their interaction as seen by the participants in our study are described. In a life of discontinuity disability pension offers a security which most of our interviewees would not like to give up. Other needs, however, especially the need for social integration, are not met by disability pension. A part-time job beyond sheltered facilities would offer them the possibility to benefit from the positive psycho-social function of work without challenging their security. Implications for vocational rehabilitation are discussed.

[Rehabilitation of psychiatrically ill and handicapped patients--historical, conceptual and scientific aspects]. / Rehabilitation psychisch Kranker und Behinderter--Historische, konzeptuelle und wissenschaftliche Aspekte.

Since the early days in the 19th century, psychiatry has been dealing with chronic courses of illness and mental disabilities. The 1975 German "Psychiatry Enquete Report" has played a major role in achieving progress in the care system, allowing mentally ill patients with impending or established handicaps to be rehabilitated or to have long-term care of varying intensity and even at home. In particular, differentiated and graduated systems of sheltered accommodation, a sheltered labour market and leisure-time support have been created. Rehabilitation may induce a response in the disabled patient and improve his skills. It may, however, also be aimed at finding or structuring an adequate living environment to enable the patient to cope. A distinction must also be drawn between early and late rehabilitation: late rehabilitation applies primarily to those patients whose disabilities have become relatively irreversible after protracted illness. The objective in this case is to maintain social integration. Early rehabilitation is desirable today if functional deficits and impairments are found to occur in conjunction with a mental illness. If a substantial disability remains in spite of intensive efforts towards rehabilitation, adequate re-integration of the affected patient may be achieved by adapting the living environment. Although the practical state of development is promising, a large number of theoretical and scientific problems remains unsolved. The topic of psychiatric vocational rehabilitation in particular is raising more and more questions. There is a lack of information on the number of chronically mentally ill patients in the community and their needs, i.e. on the number of potential users. Further studies are needed to investigate the effects, the efficacy and the course of psychiatric rehabilitation.

Psychiatric day centres--the Singapore experience.

Psychiatric Day Centres are an important aspect of psychiatric community services and care. In Singapore we have developed our Day Centres with the needs of our own patients in mind. At present there are four Psychiatric Day Centres and they focus on vocational and psychosocial rehabilitation. A wide range of structured activities are provided at each of the Day Centres and the programmes are individualised as far as possible to meet the needs of each patient. A multidisciplinary team looks after each patient. This paper outlines the historical aspects of Psychiatric Day Centres and highlights the objectives of the Day Centres administered by Woodbridge Hospital. Patients are grouped into three categories according to their occupational and social skills; programmes and care are provided according to their needs. Of the one hundred and eighty attenders, the sex distribution is almost equal and they are mainly in the twenty to forty-nine age group. Schizophrenia is the most common illness among the attenders and the majority are in the Sheltered Work Group. More than half of them had attended a Day Centre for between one to two years and less than a third had recent admissions to hospital.

Institute "Jakes"--an experiment which ceased to exist.

Institute "Jakes", which sheltered psychiatric patients, was apparently the most unorthodox part of the health care delivery system in the former Yugoslavia. Bosnian war led to severe destruction of the Institute and to death of many of its patients. The "Jakes" experience deserves attention and description.

Enterprise-based sheltered workshops in Nanjing. A new model for the community rehabilitation of mentally ill workers.

This paper describes the development of community mental health services in Nanjing and reports on a retrospective study that compared the two-year outcome for 78 schizophrenic patients who attended four enterprise-based sheltered workshops (experimental group) with that of 78 schizophrenic patients who attended an out-patient clinic (control group). Despite having a longer course of illness and more prior hospital admissions than patients in the control group, at the end of the two years patients treated in enterprise-based sheltered workshops had significantly less psychosocial dysfunction (mean Social Dysfunction Screening Schedule score 3.4 (s.d. 0.2) v. 7.4 (s.d. 0.7), t = 49.2, d.f. 154, P < 0.001) and less severe psychiatric symptomatology (mean Brief Psychiatric Rating Scale score 33.1 (s.d. 2.7) v. 54.1 (s.d. 2.9), t = 47.0, d.f. 154, P < 0.001). Moreover, compared with the control group, over the two year period a smaller proportion of the experimental group experienced a clinical relapse (14.1% v. 38.5%, chi 2 = 5.10, d.f. 1, P < 0.05) or hospital readmission (7.7% v. 21.8%, chi 2 = 10.7, d.f. 1, P < 0.01). We conclude that the organisation of on-site sheltered workshops for mentally ill factory workers is an effective model for promoting community mental health that merits widespread application in China.

Rehabilitation innovations in Central America.

In an extensive qualitative research project sponsored by the Partners of the Americas (32 professional and lay people from Panama, Costa Rica, Nicaragua, Honduras, El Salvador, Guatemala, Belize, the United States and the Dominican Republic) employment opportunities were examined for disabled youth in Central America. Despite economic and attitudinal barriers field researchers found innovations in financing, special education and rehabilitation programming, job development and job placement alternatives for those who live with disability in Central America.

Pathways into sheltered employment.

Work ranks high in the rehabilitation of the mentally ill. Currently sheltered employment is often the only alternative to unemployment. We present a sample of 121 patients working at various facilities for vocational rehabilitation. All of these patients are chronically mentally ill, 77% of them suffering from schizophrenic disorders. With respect to their vocational backgrounds, they represent four groups that had come to the sheltered workplace by various means. One group of young patients had never had gainful employment, a second group had found jobs on the open labour market after onset of their illness, and a third group had been employed both before and after the onset of mental illness. The largest group, however, comprised those patients who had dropped out of normal working life immediately on onset of their illness to work in sheltered employment. The rate of isolation from working life was found to be influenced neither by professional qualification nor by the extent of vocational integration prior to the onset of mental illness. We discuss the consequences of the subjective experience of patients and the opportunities and problems presented in practice by vocational rehabilitation of the chronically mentally ill. A 5-year prospective study on the course of vocational rehabilitation is being designed by our group to provide further information on this subject.

[Vocational rehabilitation of psychiatrically handicapped people]. / Berufliche Rehabilitation psychisch behinderter Menschen.

The article describes the working concepts of "Lankwitzer Werkstätten", a facility for vocational rehabilitation of persons with (chronic) mental illness. The working concept of this sheltered workshop is crafts- and service-oriented. Some 60 rehabilitees and sheltered workshop employees work in four small "shops". Work structures and everyday organization are somewhat unusual in that they follow general labour market conditions as closely as possible. In their working structures, the sheltered workplaces usually do not differ from workplaces in small crafts enterprises of the general labour market. As far as remuneration is concerned, the workshop is in a position to at least envisage levels of pay that will ensure independence from social assistance supplements if the facility's technical equipment can be kept current and work planning made more efficient. Within the limits of the legal possibilities, and making the most of them, both the diagnostic-prognostic benefits of the entry procedure in the work training process as well as the placement opportunities for rehabilitees in the general labour market are being utilized, with occasionally very successful outcomes.

[New types of work for psychiatric patients]. / Neue Formen der Arbeit für psychisch Kranke.

The article reviews the presently available spectrum of work offered to mental patients outside a psychiatric hospital. Various forms of occupation are studied; one of the points of emphasis deals with the recently founded commercial establishments employing mental patients, describing their characteristic features and financing conditions. A quantitative survey of the distribution of these companies is also given.

Model services for treatment/management of the mentally retarded-mentally ill.

Mental illness affects nearly 25-30% of America's mentally retarded population. While a small number of these individuals will require institutional care, it is clearly possible to serve the majority in community-based residential settings. This paper will provide an overview of the various types of mental illness found in the mentally retarded population currently served by the Eastern Nebraska Community Office of Retardation (ENCOR), examine the treatment challenges which the provision of services to this special population have presented, and share recommendations as to how the ENCOR model can assist other communities in serving similar complex subpopulations in a developmental and cost-efficient manner.

[Development of community-based services for the mentally handicapped in the USA--on the way toward an integrated life]. / Die Entwicklung gemeindenaher Dienste für geistig Behinderte in den USA--Auf dem Weg zu einem integrieten Leben.

Services for mentally retarded adults have undergone major changes over the past 15 years in the United States of America. Through the impact of "normalization", the calls for implementing fundamental civil rights for all citizens, and by applying methods of an essentially behavioural nature, services have gradually been moved out of the institutional sector and into the local communities. A regional service delivery model established in the state of Nebraska illustrates this development toward individualized living and competitive employment in the community.