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This thesis is about developing a recovery ethos for psychiatric services in New Zealand. The argument of the thesis is that currently a procedural ethos is dominant in psychiatric services in New Zealand, based on eclectic ways of facilitating recovery. Recovery from mental illness, is based on the criteria of symptom reduction and functioning and can be further refined to have a client and professional perspective. Rather than using an eclectic approach to facilitating recovery the thesis argues for a pluralistic approach, where the virtues, the relationship with professionals, client narrative and the psychiatric community become central to decision making, rather than principle based procedures. The thesis is an argued, applied philosophical thesis in terms of methodology. The scope of the thesis is psychiatric services and the focus is broadly ethical decision making. There are three main divisions to the thesis. Part 1 is concerned with clarification of the main terms used in the thesis. This involves exploring the historical background to the concept of recovery, clarifying the concept of recovery itself and providing an argument for giving greater prominence to the term mental illness over the term mental disorder. Part 2 identifies the main problem of the thesis, namely the procedural ethos, and the problems it is causing clients suffering from mental illness in facilitating their recovery. Part 3 shows what is involved in developing a recovery ethos for psychiatric services in New Zealand.

Vol. 2, Case studies, confidential. / Die benadering wat in hierdie studie toegepas is, is dié van die psigiatriese maatskaplike werker. Dit beteken dat die fokus hoofsaaklik op die psigo-maatskaplike aspekte van homoseksualiteit, sowel as die maatskaplike funksionering van die homoseksuele persone, gerig is. Die basiese kennis van die psigiatriese maatskaplike werker is geleë in persoonlikheidsontwikkeling wat ten nouste met die psigo-seksuele ontwikkelingstadia saamval. Gesinsdinamika sowel as persoonlikheidsdinamika is dus faktore wat as essensiële studiemateriaal deur die psigiatriese maatskaplike werker beskou word. Die studie moes egter uitgebrei word om ander aspekte ook te behels, veral weens die hoogs-gekompliseerde en menigvuldige aard van hornoseksualiteit as verskynsel. Sosiologiese faktore wat die sosiale milieu van die mens grotendeels bepaal, moes ingesluit word, asook die toepassing van sosiale sanksies wat ten nouste saamhang met verskynsels soos stigma, konflikte en baie ander veranderlikes. Regsaspekte kon allermins oor die hoof gesien word - hulle bepaal die raamwerk waarin homoseksueles lee£ en weerspieël in belangrike wyses die houdings van die gemeenskap. Terapie moes ook bespreek word, beide om die bydrae van maatskaplike werk te bestudeer en om die bydraes van ander beroepe in verband te sien.

Background – People with functional impairments have unmet needs and they are not given the support and service they are entitled to. According to international studies, early measures and treatment may slow down the outbreak of mental illness and relieve its course. Aims - To elucidate and compare both somatic poor health and social needs of people with either physical or mental functional impairments in a rural district, and to explore and compare how different personnel in the primary health care service and psychiatric services are able to detect early signs of psychosis. Moreover, to find out how early signs of psychosis are detected in primary health services, and to explore the patients’ pathways to the GPs. Methods – In studies I and II, people with severe functional impairments were offered a screening health examination followed by an interview. Three vignettes were presented to personnel in the primary health care service and the psychiatric services in study III. The participants were asked to detect any signs and symptoms of psychosis in the vignettes. In studies IV and V, notes in primary health care records were studied during a period of two years and six months, respectively, before a diagnosis of psychosis was made by the general psychiatric services. Results – People with severe functional impairments had poorer health and more problems with their ADL (Activities of Daily Life), economy/work and Quality of Life than people in general. Among the groups studied, people with mental impairments had the poorest living conditions. There were no differences between the participants in study III regarding sex, age and occupation; and the participants detected the signs and symptoms in the vignettes to a high degree (75% of all signs and symptoms). In all, 152 patients (22 with schizophrenia/ schizoaffective disorders, 41 with schizophrenia preceded by other psychotic disorders and 89 with persisting psychiatric disorders) with the diagnosis of psychosis made by the general psychiatric services were included in study IV and V. There were notes in 77% of the primary health records during the two-year study period, and 70% of these notes were about psychiatric signs and symptoms, which means that the GPs detected signs and symptoms of psychosis in 2/3 of the cases. The analysis of the patients’ visiting patterns to GPs showed that many patients did not visit their “own” primary health care centre or their “own” GP. Furthermore, many patients had no contact with the primary health care service at all, and the subgroup with schizophrenia/schizoaffective disorders visited the primary health care service less frequently than the other groups. Main conclusion – People with severe functional impairments must be granted regular contacts with a GP, whose role must be: to identify and motivate the patients; to detect when there are needs for care and social needs; to function as a representative for the patients; to inform the patients about their rights and to guide them to other social or health authorities. The GPs detected early signs and symptoms of an emerging psychosis to a high degree, which would make early intervention possible. The more visits to the GPs, the more symptoms were detected, and out of all signs and symptoms with psychiatric content noted, the GPs would have suspected an emerging psychosis in almost every second patient who visited them. To detect early signs and symptoms of psychosis is difficult, and whenever in doubt, primary health care personnel must be able to consult psychiatric professionals. Otherwise we may miss the opportunity to intervene in an early phase of the illness. Additional training could also mean better understanding and earlier detection of people at risk of an emerging psychosis.

Aboriginal youth are overrepresented at Vancouver Island’s Youth Forensic Psychiatric Services (YFPS) clinics. Despite this, research on Aboriginal young offenders is very limited. Information of the unique needs of Aboriginal young offenders is needed to enhance culturally appropriate forensic services. The goal of this study was to identify psychosocial characteristics associated with delinquent behaviour that distinguish Aboriginal young offenders from non-Aboriginal young offenders. Utilizing data of 638 reports (168 Aboriginal young offenders and 470 non-Aboriginal young offenders) from the YFPS databank, logistic regression models were used to predict being an Aboriginal young offender, from 24 psychosocial characteristics. Aboriginal young offenders were differentiated based on 12 significant factors. Key findings were: Aboriginal youth were almost 5 times more likely to report alcohol use, 3 times more likely to be incarcerated and 3 times more likely to have lived with a step-parent, a non-parent and to be removed from their families for 1-2 months, than non-Aboriginal youth. The results are preliminary; significant amounts of unknown data was found for both ethnic groups in the YFPS databank. This study is an important first step in laying the foundation for empirical research on Aboriginal young offenders necessary for culturally appropriate treatment services. / Graduate

Objetivo: Este trabalho tem os seguintes objetivos: (a) analisar a mudança do atendimento nos Centros de Atenção Psicossocial (CAPS) entre 2004 a 2009 em Porto Alegre, Rio Grande do Sul, (b) descrever o perfil dos pacientes atendidos nos CAPS do Rio Grande do Sul no mesmo período e (c) descrever, com base populacional, o alcance dos CAPS. Método: Foi realizado um estudo transversal com base em dados públicos do Sistema de Informações Ambulatoriais (SIA-SUS) e Cadastro Nacional de Estabelecimentos de Saúde (CNES), disponíveis no site do Departamento de Informática do SUS (Sistema Único de Saúde)- DATASUS–, www.datasus.gov.br, no período de 2004 a 2009. Foram analisadas as frequências da produção ambulatorial dos serviços CAPS, em Porto Alegre e no Rio Grande do Sul, no período de 2004 a 2009, e calculado o Índice de Cobertura – IC de CAPS / 100.000 habitantes. Resultados: O estudo evidenciou que de 2004 a 2009 houve: (a) expansão em 142,5% dos CAPS no Brasil (de 605 para 1.467 unidades), 100% no Rio Grande do Sul (de 70 para 144 CAPS); (b) evolução oposta da produção ambulatorial entre o estado do Rio Grande do Sul e a capital do estado, com duplicação de procedimentos de cuidado intensivo no Estado (de 209.923 para 424.500), e redução de quase 50% dos mesmos na Capital (de 10.487 para 5.577); (c) aumento de 76% na cobertura do CAPS medida através do Índice de Cobertura no Estado (de 0,52 para 0,91), (d) redução de desigualdades regionais (em 2009, 37% das 19 regiões apresentavam Índice de Cobertura abaixo de 0,90, enquanto em 2010 passou para 10%) e (e) persistência do déficit global (49,04% da população do estado ainda residindo em municípios com cobertura Insuficiente, ou seja com IC abaixo de 0,90). Conclusão: Constatou-se a persistência de cobertura Insuficiente de CAPS para 49,04% da população do estado (IC abaixo de 0,9). Dez anos depois da implementação da Portaria nº 336/2002, que definiu os 3 modelos de serviços dos CAPS (I, II, III) e a sua finalidade (atendimento de transtornos mentais graves e persistentes), ainda encontramos no estado regiões de saúde com Índice de Cobertura Insuficiente, e principalmente, quase a metade da população vivendo em municípios com cobertura Insuficiente. Adicionalmente, em Porto Alegre, constatou-se uma redução no atendimento de pacientes nos centros de atenção psicossocial, o que mostra que a população-alvo dos CAPS está utilizando outros serviços que não o CAPS, ou não está utilizando os serviços montados para ela, por diferentes motivos (filtros, barreiras de acesso, opção por outros tipos de pagamento ou convênios). O estudo mostra necessidade de investigações adicionais para responder as questões levantadas, sobre o caminho que os pacientes tomaram, se estão em tratamento em outros locais não diretamente financiados por SUS (convênios, planos de saúde, sociedades beneficentes) ou se estão ficando fora dos serviços de saúde, confinados à cuidado na família e comunidade, somente utilizando o SUS na reativação da doença, emergências ou serviços gerais de saúde. / Objective: This paper aims: (a) to analyze the change in service at Psychosocial Care Centers (CAPS) in Porto Alegre, Rio Grande do Sul, from 2004 to 2009; (b) to describe the profile of patients at the CAPS in Rio Grande do Sul in the same period; and (c) to describe the scope of the CAPS on a population basis. Methods: We conducted a cross-sectional study based on public data from the Outpatient Information System (SIA-SUS) and the National Register of Health Establishments (CNES), available at the Department of the SUS (Unified Health System) - DATASUS-, www.datasus.gov.br from 2004 to 2009. We analyzed the frequencies of production generated from CAPS services by SIA in Porto Alegre and in Rio Grande do Sul from 2004 to 2009, and calculated the Coverage Ratio - CI CAPS / 100,000 inhabitants. Results: it was observed that from 2004 to 2009: (A) there was an increase of 142,5% in the number of CAPS in Brazil (from 605 to 1,467) and in Rio Grande do Sul they also increased from 70 to 144 (more than 100%); (B) there was a reduction of outpatient intensive care services in the capital city, Porto Alegre, in the period (from 10,487 to 5,577) while in the state of Rio Grande do Sul such services doubled (from 209,923 to 424,500) in the same period; C) there was an increase of 76% (0.52 to 0.91 CAPS/100.000 inhabitants) in the Coverage Ratio of Rio Grande do Sul, (d) there was an inequality reduction in health regions in 2009 (37% CI of 19 regions with below 0.90 in 2009 to 10% in 2010). (e) there was a persistent overall deficit (49,04% of the state population still lived in cities with inadequate coverage, with CI below 0.90 CAPS/100.000 inhabitants). Conclusion: Persistent Insufficient coverage (CI below 0,9) was found in 49.04% of the state population in 2009. Ten years after the implementation of Ordinance No. 336/2002, which defined the three service models of CAPS (I, II, III) and their purpose to care for severe mental disorders, we still find health regions with Low Index Coverage in the state and almost half the population living in cities with Insufficient Coverage. Furthermore, we also observed that there was a reduction in service in CAPS in Porto Alegre, showing that the target population is either resorting to other services rather than CAPS or not enjoying the benefits of available services for various reasons. This study shows the need of further investigation to answer some remaining questions about what directions patients have taken, if they are being treated somewhere else in private hospitals or by private medical plans, not funded by the SUS, if they are not being treated at all, or perhaps if they are being cared by their families or communities and only use health services provided by the SUS when the disease strikes back or in health emergencies.