United Nations Decade for Disabled Persons
1961-1992
International Expert Meeting
Social Integration and Vocational Rehabilitation
for Persons with Mental Disabilities
Velm near Vienna
6-11 December, 1991
Paper No. 9
Psychiatry in Austria
Between help and control
Possibilities and Difficulties of Social Integration
and Vocational Rehabilitation
for Persons with Mental Disabilities
Gert LYON
Beratungszentrum für psychische und soziale Fragen
Graz/Austria
BERGGASSE 17, 1090 VIENNA, AUSTRIA, TEL. (1) 31 45 05 - 0, CABLE: EUROSOCIAL WIEN, FAX 31 45 05 - 19 ELECTRONIC MAIL: BITNET
X0261DAA@AWIUNI11
1. Introduction
Psycho-social deviant behavior is indeed seen as illness but it is still a stigma with manifold negative social consequences. Persons with mental disabilities evoke fear in many of us who are confronted with them because tonal symbolize a specific threat since they are questioning basic sacral rules end norms. In contrast to other patients they ere not able or willing to accept their role and to define themselves as needy for help and to seek for competent treatment. Numerous empirical researchers have proven that patients of lower social layers are diagnosed mare severe, that effort of treatment is lower, that help and rehabilitation are rather substituted by measures with disintegrative consequences (i.e.; retirement) and control as compared to patients of higher social layers.
The asylum which symbolizes disintegration end custodial care is increasingly recognized as anachronistic an dysfunctional. The most important international trends within the last 15 years were:
Usually these trends are basing interpreted as reform of psychiatry.
2. The so-called reform of psychiatry in Austria
In all the above mentioned indicators psychiatry in Austria ranged very low as compared to the industrialized states and it was/still led coined by the tragical inheritance of the nazi-era, by the lack of resources and by the very low public attention for its problems. Comparatively late in Austria there is a reform movement top, although a reform of psychiatry in the sense of a nationwide coordinated program has not taken place.
E. TALUS, a prominent Austrian researcher, states just 3 crucial points of psychiatric reforms in this country:
As the first future-oriented-ambulant model for adequate care of clients end psychiatric patients the "BeratungsZentrum für psychische and soziale Fragen in Graz"
was already founded 1978.
Later on similar services have been established in almost every country of the state; they are run on different organizational and professional levels and altogether show a respectable job-performance. Partly they are outfitted with multi-professional teems, they offer
manifold forms of counseling end psychotherapy, they sometimes also run a dayclinic am a daycarecenter end they cooperate with volunteers, with selfhelp-groups (for example AA-groups) and wall-organized groups of relatives (HPE). Many of these services suffer from underequipment in concern of personnel and finances. The most comprehensive and coordinated changes have taken place in Vienna, where 1979 the city government has voted in favor of a far-reaching "Zielplan für die psychiatrische and psychosoziale Versorgung".
In the traditional hospitals the mainly control-Oriented, "hard" reactions of psychiatry for deviant behavior have started to be replaced by "softer" and rather help- and integration-oriented charges.
Recently we can observe a counter approach such as the growing application of ECT.
Within the last 10 years, the number of beds in psychiatric institutions and involuntary intake have ascended.
Differenciations of the approaches (sectorisation in Salzburg, Vienna and Styria; therapeutic specialization in Carinthia) and democratic changes have taken place in the big asylums.
Two legal innovations substantially have improved the situation:
3. Unresolved problems of psychiatric care in Austria
Claims:
4. Vocational rehabilitation for persons with mental disabilities
Agricultural and handcrafting big-family-households 20 which naturally belonged the disabled, mentally disturbed end old-aged, were definitely not idyllic but hard farms of life and production and they were stable and lasted for centuries.
Like an elementary force the market oriented industrialization around. 1800 dashed social life into 3 pieces:
Pre-industrial solidarity between strong and weak-ones was replaced by the social institution of the state for the sake of undisturbed production. The state transfers taxes into social institutions. In order to weaken the blame to favor the "lazy" and the "social parasites" the state always junctimizes welfare-donation with more or less humiliating forms of control.
All who work with social deviant persons have to act within the close attention of help and control.
Vocational rehabilitation for persons with mental disabilities is ONE
aspect of the "SOCIAL QUESTION":
Homes for the old-aged, orphanages, prisons, asylums, psychiatric infirmaries were the traditional answers of the social state.
In the asylums occupational therapy was applied in order to gain control, adaptation and to reduce costs and symptoms.
In the nazi-era value of labor was equalized with the value of life at all. "Who doesn't work shall not eat" - was the motto. Certain diagnoses at first led to the starvation program ("Halbieungserlaß", 1942) and later consequently to physical extermination of ("Aktion T4").
Maxwell JONES, one of the pioneers of psychiatric rehabilitation defines rehabilitation, 1952, in a paper for WHO:
Rehabilitation "is a certain aspect of the process of adoption to recovery from a disease. Every intervention can be called therapy, which aims to produce or accelerate this process.
The concept of reha. has gotten the meaning to describe the sociological aspects of the process of reintegration although there is no reason for separating this aspect (...) (Reha) can be seen as the attempt to outfit the patient with best possible social role, which enables him to attain the maximal activity, which is adequate to his personality and his interests and to which he is apt."
Results of long-term-studies prove that the decisive improvement of the basic disturbance of schizophrenic patients is due to the reduction of time, that the patient spends doing nothing.
WORKING CONDITIONS FOR SHELTERED EMPLOYMENT
Employment effects
Unemployment effects
(source: Dormer, K., ME)
Vocational rehabilitation for persons with mental disabilities in Austria gained attention only in the late 80ies. Counseling-centers and training workshops were successively established in the bigger cities. The most important legal bases for vocational rehabilitation in Austria are the following three:
When we speak about vocational rehabilitation, we always have to regard political economy end the general labor-market. Serious economists prognoses for Austria 1991 end 1992 predict:
This will lead to a aggravation of the structural unequality of the labor-market and to negative social consequences such as long-term unemployment, instable employment-careers of low-qualified persons, of elderly, of women, immigrants end of persons with mental disabilities.
Austria's budget spends only 0,26% of its BIP for active employment/labor-market politics and with this low figure it ranges among the last in the list of OECD-states. Recently the Austrian government has agreed to even more painful cut downs of the social expenses.
In the 70ies the official arm of national social politics was "a job for everybody". Since the government seeks for membership of the European common market, the main-goal is the budget-consolidation. Since then employment rates up to 5% and more are taken into account as inevitable.
Social expenses of all kinds are being controlled much more stingy now. This politics of saving, hits the poor and socially weak ones the most. Counseling and training-centers for vocational rehabilitation have to submit to budget reduction so that their initiators ask themselves:
"How much sense does it make, to work for vocational rehabilitation if the chances for reintegration are so small because of the labor-market and the technological changes, that for the most one third of the persons with mental disabilities there
is a real chance?"
About 25% of the population of Austria suffers from a relevant psychiatric disease which seeks treatment. About 60% of the unemployed persons in Austria suffers farm a relevant psychiatric disease which seeks treatment. Adult psychiatric patients after discharge from the hospital:
Neurosis or psychosis as a for premature retirement:
In Austria there are altogether 930 jobs within "protected workshops" for disabled persons amongst these 10% = 93 for persons with mental disabilities.
A big obstacle for all efforts in the field consists in the discord about competences. Different ministries of the state-government and different politicians of the countra-governments are partionally responsible for the matter of vocational rehabilitation.
5. Social integration
Social integration for persons with mental disabilities virtually are identical with the goal of the community-mental-health-movement.
A person said to be socially integrated if he/she is
Stationery treatment which is avoidable, too long or inadequate can be seen as a paradigm for occasions with disintegrative consequences.
Thus the spectrum of steps to increase social integration which is being offered by the BZ GRAZ, covers professional help in all the areas above mentioned.
|
work |
part 4 |
|
residing |
part 6 |
|
Subsistence and law |
i.e.: lawguidance, help in dealing with offices |
|
sozial and cultural life relationships |
i.e.: patients-club, leisure activities, |
|
dayclinic |
part 6 |
6. The dayclinic in the BZ Graz
Definition and function
Dayclinics are either half- or part-time services, that means they enopen therapeutic possibilities which are comparable to these of a ward in the hospital, however the patients are present 5 days a week and a limited time only. (in the BZ Graz from 9 a.m. to 4 p.m.)
There is conformity (Glascote 69, Finzen 77, Veltin 88) about the function of day clinics that their treatment fulfills the following purposes.
During the beginning years in Graz our main goal was the reintegration of chronic long time hospitalized patients. Later on we put more stress on prevention and the avoidance of unnecessary hospital intakes.
At the beginning allocations were done mainly by the Landesnervenkrankenhaus, while now most of the patients come directly by themselves.
The therapeutic concept Graz
We see our dayclinic as one which tries to offer crisis-intervention as well as rehabilitation. It synthesizes social-rehabilitative and psycho-therapeutic work.
In pursing those goals the vocational-rehabilitation plays a great role. It is carried on by occupational therapy within the dayclinic-program and close cooperation with the allied vocational counseling and vocational-training-center. After all it is our main objective to create a work-like situation within a protected atmosphere.
Furthermore it is essential to consider the specific situation of each participant, to search together for the limits between under- and overdemand, to find the proportion of necessary support end reasonable charge.
Depending on the dayclinic participant's starting level we give much attention to cultivate
The patient's motivation often reaches a higher degree if produced goods (for example musical instruments) can be sold.
Due to negative experiences we stopped industrial production.
PSYCHOTHERAPY: Psychotherapeutic work is provided in the one-to-one sessions, in groups and within the family-like structure of the therapeutic community.
The members of the team present a kind of family-substitute.
Qualities such as warmth, security, encouragement to be initiative, tolerance of regression are just as necessary as restaurating reality without pushing it.
ACTIVATION: Dayclinics can be compared to schools of life. Patients who have been hospitalized for a long time have to reacquire skills such as to deal with money, shopping, to cope with the sphere of duty. Each person is to be supported to regain his/her maximum of autonomy and optimal social participation. To achieve these goals excursions end journeys proved to be very successful. Three times a year a full-week journey is organized, every other week there is a half-day-excursion which is also open to other clients and often accompanied by volunteers.
FINIAL INFORMATION TO THE DAYCLINIC-PROGRAM: Every month there are counseling-sessions concerning psychopharmaca. Information is given about effects and side-effects in order to improve the user's responsibility, motivation and critical usage of these drugs and compliance.
Also once a month there is a meeting called "social group" which provides information about social end legal questions.
Following activities are so called "open activities", which means they are not only attended by dayclinic patients but also by other clients and guests: musical therapy, swimming, large groups and cafeteria, therapy, theater-animation-group and excursions, cooking a.s.o.
Furthermore there is a WEEKLY DAYCLINICMEETING for staff-members only. Those meetings are needed to discuss recent topics, to bring together all the information and to coordinate all activities. On this basis advantages of a multi-professional team taking care of psychotic patients became apparent. Staff-members of such a team can bring about the necessary position and flexibility to function as a bowl for the scattered self in times of psychotic crisis.
7. Residing
Entire western Europe is experiencing a crisis in politics of residing. Especially larger cities are more and more confronted with the exceeding demand for acceptable and affordable housing space.
The major causes are:
The term therapeutic commune is apt for a variety of cared for ways of living, which differ in terms of care intensity and goals:
1) Therapeutic commune:
Therapeutic communes offer a structured day- and therapy-program . The main object is social rehabilitation of the patient. The duration of stay is limited. Such communes are being used for adolescents, drug addicts, alcoholics and schizophrenic patients.
2) Professionally cared for communes:
Daily and weekly visits serve the purpose to increase the patients self-responsibility and to teach them how to supply themselves with necessities.
Those communes can be planned as permanent or as transitional service.
3) cared for single living:
This type of living is the closest to the "normal" situation.
4) Staffmembers and patients live together:
This type of commune represents an "antipsychiatric" approach and it is mostly indicated for younger patents , for addicts end for persons with character-disorders.
5) Self-help commune:
This type of commune can be initiated by professionals , who give support in the beginning end later on slowly withdraw themselves.
Number of places in transitional residential
homes and communes fee persons with mental disabilities in Austria (1990)
|
Country |
Number of places |
|
Wien |
44 |
|
Niederösterreich |
36 |
|
Oberösterreich |
96 (30 are about to be prepared) |
|
Salzburg |
47 |
|
Kärnten |
29 |
|
Tirol/Osttirol |
70-80 |
|
Vorarlberg |
80 |
Altogether the number of places in transitional residential homes and communes for persons with mental disabilities in Austria is estimated to range at 600.
Literature
|
M. COPONY, |
"Die Tagesklinik als integraler Bestandteil einer |
|
K. DÖRNER, |
Arbeit für alle macht des Sozialsystem überflüssig |
|
CH. FLECK, |
"Wohnen und Politik" |
|
R. FORSTER, |
Wo steht die "Psychiatriereform"? |
|
CH. RACHBAUER, |
Arbeits- und Beschäftigungsmodelle in Österreich |
|
E. SCHULLER, |
"Wage für psychisch Erkrankte" |