David LeCount Report

Future Perspective

New legislation appears to be supporting a continuing movement towards community treatment and placing a greater emphasis on the local municipalities for the provision of services. Many of these initiatives over the next five years will help people with mental health disabilities to achieve greater equity and parity with physical and developmental (cognitive) disabilities, and with services for the elderly. Attendant care in the homes, more work opportunities, and contracting for services should provide more choice and a greater emphasis on social services for psychosocial rehabilitation opportunities. Hopefully, there will be a plan for agencies to work together as a system of care to provide more stratified, comprehensive, integrated, and coordinated services. In paraphrasing Mr. Kadoya's closing remarks regarding the future direction, he would like to see the "life model," along with psychosocial rehabilitation, become the norm, with services being focused on the person's life in the community, coordinated by case management. Mr. Furuya concluded that Japan has to move from these large psychiatric hospitals to community mental health systems.

Impressions of Consumers

By most standards, consumers have difficulty in Japan being accepted and integrated into the community. In Obihiro, housing is built for the consumers without informing the neighbors because it is feared they would unite and prevent it from happening. In Osaka, at a workshop called Parappa, the consumers do not tell the people in the neighborhood that their work setting is for people who have serious mental illness. One of the members revealed that he leaves his apartment during the day because there is the expectation that a young man his age should be working and not staying at home all the time. It is perhaps for these reasons that even services provided in the community are so protective and non-integrated within natural work environments. Few apparent external symptoms were noted in most of the workshop participants. Most appeared quite intact, except for a few that manifested lack of affect and slow motor responses, which may have been medication as well as symptom related. Consumers within the workshops do support each other, and there is genuine acceptance by the staff and the members as they work together to create their "healing" networks. In most of the settings, the consumers are very much alive, sociable, productive, and appreciative of outside attention and approval. Wherever I went their gratitude and appreciation struck me in being visited and thus acknowledgement as a person. Many had a great sense of humor, and were a delight to be around. It is difficult for an outsider to understand why such consumers are living almost guarded lives in segregated environments. It is almost like they are being punished for their illness. It is remarkable that one-third of the consumers are in in-patient settings "due to social reasons." Is this a living part of their fears?

The Yadokerinosato correctly defines their philosophy as everybody living in the community the same as everybody else and for the community inclusion to occur. While understanding this is an evolutionary process, there remains much progress to be made. The environments appear to be highly protective and more like cooperatives and enclaves, but a step in the right direction. Further, they are being increasingly recognized by the establishment in terms of funding. They are also working more closely with the mental health center in Omiya, especially around aftercare or direct acceptance from the in-patient facility. There was a sense at this place that the consumers were happy, felt supported, and had acceptance within their well protected milieu, and were making long-term life plans. Comments were made that, "I am going to write until I die," or, "I'm going to make these craft materials, such as coasters out of rope, the rest of my life." It was good to see and hear people who had a sense of identity within the community and were making life-long commitments and plans.

While it was refreshing to see and experience the interaction of the consumers within the workshop settings in the communities visited, a significant contrast was apparent within a hospital workshop setting. Contrast this to the consumers in the Saitama Comprehensive Mental Health Center working diligently on assembly make-work tasks. In this setting, the consumers did not stop their work, look up, or acknowledge visitors in their presence, as work is taken seriously and staying on task is apparently very important. They were performing simple assembly work, but everybody appeared task oriented as they slowly assembled, manipulated the materials, or went through the motions of work. One person who was cognizant of our presence could not hold her silence any longer, as she laughed out-loud, apparently as a form of nervous release over the recognition and acknowledgement of strangers in her presence. This level of rigidity was not apparent in the community work settings visited. It is my conviction that symptom management can be more productively managed as a part of the work experience in integrated community environments (based on skills, abilities, and interests), as opposed to skills being taught in restrictive (make work) hospital classrooms where generalization to the community is questionable and of questionable benefit to the person.

A brief visit with the Federation of Families showed their apparent support for the community-based services along with interest in medications such as Clozaril and Resperidone; anti-psychotics that are not yet available in Japan. Clozaril in particular has proven to be an effective treatment in Madison for some of the most treatment resistant people in our system. These newer generation of "atypical anti-psychotics," including olanzaopine, that eliminate the extrapyramidal symptoms (e.g. uncontrollable shaking, tremors, etc.), and treat both the positive (e.g. delusions and hallucinations) and negative (e.g. social withdrawal, lack of motivation, etc.) symptoms of schizophrenia, are the primary psychotropics now being administered within our system. As a result, tardive dyskinesia (involuntary movements) is no longer a concern.

Interdisciplinary Teaming

I had the opportunity to participate in a workshop on Interdisciplinary Teams conducted at the National Psychiatric Social Workers Conference in Obihiro. The importance of the interdisciplinary approach was presented from both the in-patient and the community perspective. I want to highlight once again how crucial the concept of interdisciplinary teaming is to the success of community treatment. In operating in the full community, without the protected confinement of a hospital setting, the ability of each professional to understand and value the particular expertise, skills, and abilities of other professions is vital. This requires mutual respect, professional courtesy, and knowing when and how to use each other as consultants or to obtain a second opinion. It also requires implementing the team consensus (even if you personally disagree), having open and honest disagreements, earning your position and respect within the team, realizing that an individual from any discipline can be the team leader, and always backing up each other. Further, it necessitates everybody performing the general roles (such as case management and psychosocial rehabilitation activities), along with role blurring and gap filling. Where would we be if all members of the team operated within the narrow definitions of their defined expertise and roles? The "boundary spanners" (inventing as they go) and "gap fillers" (doing what needs to be done) are significant participants on the team that frequently make things work when all else fails. Consideration also needs to be given to the role of consumers in the provision of services and peer support. The consumer provided service in Madison is our most innovative, inspirational, and creative aspect of our programming, providing services to over 400 people this year.