David LeCount Report

Housing

Mr. Kadoya and Mr. Teruo Yanaka (Founder of Yadokarinosato) aptly identified housing as one of the most essential needs in being able to discharge people from the hospital. I visited many excellent congregate housing arrangements for consumers who had the ability to live quite independently with some external supportive services. While the current level of housing is appropriate for the great majority of people, it would be even better if it could be more integrated, instead of segregating congregate housing only for persons with mental illness. I did not observe internally staff-supported supervised living arrangements in the community, which is needed to expedite community placement for people with higher levels of needs. In Kawaski, there was a large congregate residential living setting adjacent to the hospital, and one of its uses was as a step, while transitioning into the community. This was somewhat similar to the hostel that was a separate part of the Hokkaido National Hospital. The most supervised living arrangement located in the community that I visited was a part of Yadokerinosato, where the staff stayed on the second floor of a three-story building, housing consumers on the first and the third floors.

Instead, for people with high level need, I am recommending staff-supported living arrangements where consumers and staff are physically together throughout the day within typical home settings integrated in the community. These settings are generally considered to be transitional, where people learn skills to live more independently in their own apartments with external or visiting staff support. My presentation, for example, showed that during the course of a year we serve as many as 563 people in approximately 201 supervised living arrangement beds, or slots, that exist within many different homes and locations interspersed throughout the community. That is, there is a continuum of supervised living arrangements allowing for people to be gradually assimilated into the community. Crisis homes, where a person could stay on average three days, are the most temporary of such arrangements. These placements are typical families that have been recruited and trained for the purpose of opening up their home to have somebody live with them, generally in lieu of hospitalization, and with the back-up and support of our Emergency Services Unit. Other staff intensive living arrangements include group homes, where 6 to 8 people live along with internal staff support, most of which represent our highest need people in the system. Many of them are coming directly from our longest-term institutional placement setting, but have been connected with day services in the community even while they were in-patients. This group represents the smallest percentage of people whose symptoms remain persistent and treatment refractive. Even these people will generally be able to move on to more independent living settings over time. These group homes are licensed by the state as community-based residential facilities (CBRF's), and generally have rotating staff models providing 24-hour-a-day internal support.

In order to keep hospitalization at a minimum as well as being able to maximize people's potential to live in the community, it is essential to have some level of highly supervised living arrangements in the context of the community, as opposed to trying to get people to the point of being able to live independently before they can be discharged from the hospital. My experience is that psychosocial rehabilitation is best accomplished in the community where the daily practical application can be learned as a part of meeting one's needs.

Exemplary Practices

I also observed numerous examples of what can happen through individual initiatives to promote community practice. Based on the convictions of Mr. Kadoya in Obihiro, and Mr. Yanaka in Omiya, the lives of many people have improved after obtaining adequate housing, with some support services, in the community. I was particularly impressed with Mr. Kadoya's ability to obtain support from private individuals with financial means to develop housing opportunities for some of their people in Obihiro. The combined synergies of the public and private sectors are impressive, especially when it involves high quality, safe, and affordable housing for people with special needs. Mr. Yanaka also represents a national model, and an example of what can be accomplished through the personal commitment of one person forming a small nucleus of support, and building an entire community support system. The Yadokerinosato, with over thirty years of experience, has been able to gradually build a network of services, from living arrangements to day supports with work opportunities. While these services and amenities are not completely integrated into the community, the community surrounds them, and because of their presence and ongoing communications, I am assuming there is a certain amount of acceptance and integration. There was a positive overt difference observed in visiting consumers living in this strong support system who were actively invested in what they were doing, taking pride in their work, and looking forward to the future.

In Kawasaki, many lives have been improved through the development of community services in their respective wards, along with an attempt at developing teaming approaches and multiple agencies working together. A good example of this occurs in the Nehemiah Ward, where a group of dedicated professionals representing a variety of service agencies (mental health & welfare), meet on a monthly basis to discuss case management and general service coordination issues. My PowerPoint presentation stressed the importance of core mental health services and the interrelated systems working together as a community system of care. This is an excellent example of what can be accomplished through voluntary efforts. I was also informed that the Psychiatric Rehabilitation Center in Kawasaki has developed an interdisciplinary team that is going out into the community and providing assertive outreach services. This is an essential programmatic element in the development of a community-oriented system.

Community-Oriented Psychiatry

Community-oriented psychiatry was almost non-existent, and it is probably a concept that is not well understood throughout Japan. Unfortunately, without good psychopharmacological community-oriented psychiatry and an understanding of teaming, innovating, promoting the dignity of responsible risk taking, and the sanctioning of community programming, it is most difficult, if not almost impossible, to promote community practices. I did note that some psychiatrists were represented in several of the presentations, and I was particularly impressed with the involvement of a couple of psychiatrists in the Obihiro presentations and site visits.