Nicole Shepherd 1,2 & Tom Meehan 1,3 1 Service Evaluation and Research Unit, The Park – Centre for Mental Health, Wacol, Queensland, Australia 2 School of Social Science, University of Queensland, St Lucia Queensland Australia 3 Discipline of Psychiatry, University of Queensland, Herston, Queensland, Australia

From asylum to community care Deinstitutionalisation increased in 1990s Facilities now restructured to “rehabilitation units” New Community Care Units (24 hour residential care) are still being built Acute care provided in general hospitals Government community mental health services Non-government organisations (NGOs) who provide support services Commitment to recovery-oriented service delivery

Service Type Non-government organisations Government Health Services Service HistoryGrassroots community orgns. Medical Work Roles"Non-clinical skills""Clinical skills" Number of organisations in each State or territory Table 1. The dualistic structure of the community mental health sector in Australia

Two occupations Support workers Lifestyle support tasks Emotional support Practical support Community access Advocacy No minimum qualifications Paid around $20-22/hr Case Managers Clinical case management model Assessment and planning of care Monitoring of symptoms and medication Health professionals from nursing, social work, psychology, occupational therapy Statutory authority invested under the Mental Health Act 2000

In home psychiatric care Moving from institution to community based care creates a relatively new “task area” Growth of NGO providers -new occupation – mental health support worker What impact does this have on the “system of professions”?

Questions How do members of different occupations negotiate their claim on this task area? What kind of division of labour emerges? When does conflict occur? What do our findings mean for the sociology of occupations/professions?

System of professions DisturbanceContestTransformationBalance Abbott, A. (1988) The System of Professions

Methods Secondary analysis of data collected through evaluations of two supported housing programs for people with serious mental illness in Queensland, Australia carried out in 2010 and 2011.

Summary of Results Negotiating the division of labour Disagreements Negotiated locally by support workers Settlement appears to have occurred in a straightforward manner Support workers feel case managers are not there when needed Case managers feel support workers should be doing more with clients

Division between clinical and non- clinical work Clinical Medication management Symptom monitoring Organising hospital admissions if required. Non-clinical Assistance with daily living Transport to appointments Community access Advocacy

Division of labour We would have our meetings, our discussions. You know, Joe needs to go to this appointment and we’d go “no that’s OK, we’ll do that”...so that left the case manager to do their important stuff. Not saying what we were doing wasn’t important, but they need to focus on the clinical side of things. [Support worker]

Division of Labour I said to [case manager]…‘you do this part, we do that part, you’re the clinical part and we’re non- clinical’…Sometimes [the staff] were wanting our staff to go in- …they were almost treating our staff like they were clinical staff and that’s a problem …its like ‘we are not clinicians, and we’ll never be- that’s not something we aspire to be’- there’s a place for that, and you do that. We don’t do that. [HASP NGO support worker]

Division of Labour When I first became a Case Manager in 1998 I was able to take people to the shops and I was able to do this and that, now with our workloads, especially all the paperwork we’ve got to do now you don’t do that, it’s more crisis intervention. So that part of our job has fallen on the NGOs. [Metropolitan Case Manager]

Disagreements Support workers: Frustration over difficulty in contacting case managers (they don’t return phone calls) I would say through my experience over the years, contact to the Mental Health Services is a one-way street. I would say out of every 100 phone calls, 99 of them would be made from here to there, not the reverse. No matter what the scenario, no matter what the request. Case managers change frequently Clients get “closed” to case management

Absence of case managers And another guy, I’ve been working with for 4½years and never knew he had [a case manager]... the reason she gave me on the phone, for why she hasn’t really spoken to me before was that “you guys have so much input into him and he’s going really well. I haven’t had to come in very much”. [Support worker]

Absence of case managers He needs a case manager, and he wouldn’t be the only one. There are many clients without a case manager. And to me, that means that I myself or my coordinator has to make decision about whether [the client] needs extra care or not, and I don’t think that’s good enough. We’re not medically trained...We need a back up. [Support worker]

Disagreements Case Managers Difference in opinion about need for hospitalisation Support workers are doing maintenance, not recovery Don’t encourage independence Don’t follow a mutually agreed plan

Hospitalisation I think that our tolerance for when they become unwell is different to theirs because we’ve become very... focused on trying to keep people out of hospital when they’re unwell you know; and NGOs I guess don’t have that same pressure, and there’s a lot of conflict about and disagreement about when somebody should be brought into hospital … so we find that difficult. [Case Manager]

Maintenance [When] I go out there, and each time I go out there the things that we have discussed aren’t being done. Like he hasn’t washed his face, if I haven’t seen him for two weeks, he hasn’t washed his face since then, he’s completely dishevelled, and all the things we’ve said are the primary things aren’t done… I just wonder if he is seen as one of those who is too difficult, so people think, I’ve got a three hour shift, Ill just do the shopping… [Case Manager]

What is the nature of the relationship? Overall – the relationship tended to be distant, with the relationship maintenance work falling onto the NGO Support workers felt frustrated that case managers weren’t there when needed for clinical decision making Case managers perceived that NGOs were maintaining people in the community but not working to a rehabilitation plan

No turf war Case managers were happy to give up tasks in order gain something more valuable – control over time. We didn’t see competition to claim turf – rather professional workers were keen to give away turf DisturbanceConcessionTransformationBalance

Tasks in community mental health Lifestyle Support Assistance with daily living Community access Psychosocial rehabilitation Encourage goal setting Empowerment Skill building Clinical support Crisis intervention Medication management Clinical Medication management Symptom monitoring Organising hospital admissions if required. Non-clinical Assistance with daily living Transport to appointments Community access Advocacy Vacancy in system

Implications for mental health policy From Day room to Lounge room? Source: Google

Why no turf war? Mental health professionals work in interprofessional teams, therefore the link between any one profession and the jurisdiction is already undermined Support workers are not a big threat because they are not organised Mental health services are underfunded There is a vacancy in the system (lack of rehabilitation services)

Sociological Implications Under what conditions do professionals compete, and when do they concede turf? Does Abbott’s model cease to apply under conditions of resource limitation?