+ All Categories
Home > Self Improvement > The Blackthorn Garden Project - Centre for Mental Health

The Blackthorn Garden Project - Centre for Mental Health

Date post: 13-May-2015
Category:
Upload: benbeckers
View: 780 times
Download: 0 times
Share this document with a friend
Description:
The Blackthorn Garden Project - Centre for Mental Health
Popular Tags:
66
The Blackthorn Garden Project Community Care in the context of Primary Care 1995 Julia Nehring and Robert Gareth Hill © The Sainsbury Centre for Mental Health, 1995 The Sainsbury Centre for Mental Health 134-138 Borough High Street London SE1 1LB Tel: 020 7827 8300 Fax: 020 7403 9482
Transcript
Page 1: The Blackthorn Garden Project - Centre for Mental Health

The Blackthorn Garden Project

Community Care in the context of Primary Care

1995

Julia Nehring and Robert Gareth Hill

© The Sainsbury Centre for Mental Health, 1995

The Sainsbury Centre for Mental Health

134-138 Borough High Street

London SE1 1LB

Tel: 020 7827 8300 Fax: 020 7403 9482

Page 2: The Blackthorn Garden Project - Centre for Mental Health

2The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

The Blackthorn Garden Project

Community Care in the Context of Primary Care

By Julia Nehring and Robert Gareth Hill

© The Sainsbury Centre for Mental Health 1995

All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, electronic, mechanical, photo-copying, recording or otherwise without the prior permission of the publisher.

ISBN: 1 870480 20 1

Published by

The Sainsbury Centre for Mental Health

134 -138 Borough High Street London

SE11LB

0171 403 8790

Page 3: The Blackthorn Garden Project - Centre for Mental Health

3The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Table of Contents 1. The Blackthorn Garden Project ................................... 5 2. The Co-workers .......................................................... 19 3. The Co-workers’ Views................................................. 30 4. Integrating Community and Primary Care ................. 41 5. Conclusions....................................................................... 51 6. Appendix 1 ........................................................................ 54 7. Appendix 2 ........................................................................ 59

8. References......................................................................... 64

Page 4: The Blackthorn Garden Project - Centre for Mental Health

4The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Acknowledgements The researchers wish to thank the co-workers, volunteers and staff of Blackthorn Garden and the general practitioners and therapists working in the Blackthorn Medical Centre and Trust. We also wish to thank Orly Klein, researcher at The Sainsbury Centre for Mental Health for interviewing agencies referring people to the Garden Project. The study was funded by grants from the Gatsby Trust Charitable Foundation and from the South-East Thames Primary Care Development Fund.

Page 5: The Blackthorn Garden Project - Centre for Mental Health

5The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Blackthorn Garden – A GP’s perspective As students one took up medicine in part at least to fulfill ideals of helping one's fellow man. A few years as a GP however confirm that some patients' problems are too complex and ingrained to be altered much by one's limited training, best efforts and the number of hours in the day. Indeed these patients, many of whom have long-term mental health problems, seem to remind one of one's inadequacy. The numbers now in the community for whom the GP has clinical responsibility and their frequent attendance can have significant impact on the morale of doctors and the practice team. Their demands can encourage negative and unloving behaviour (impatience, irritation, can't be bothered; of which one is duly ashamed), simply because the problems they bring are too great and one knows from experience that one's concerted effort even over long periods brings little return. Modern medicine lays heavy emphasis on treating disease while unwittingly leaving the patient himself on the sidelines. For long-term mental health problems this will simply not do. Promises of a cure are not forthcoming and these illnesses are on the increase. A co-ordinated service is called for which addresses the needs of each individual and draws on his aspirations, talents and effort. This can be achieved by a working community like Blackthorn which also strives to understand and improve the human condition in illness. Working at Blackthorn is an uplifting experience. The sense of community created by staff and co-workers alike lightens one's load. The burdens of the day can be shared be it with an illness like schizophrenia or the apparently tedious refrain of one's usual workload. One can bear to look at such icebergs only when the means to tackle them is close at hand. Morale runs high in the Garden because things seem possible which didn't before. Warmth, understanding and a sense of belonging for individuals who had previously felt out in the cold allow them to begin to free up and move. The wide variety of tasks there and coaching available to master them, restores a sense of purpose through being gainfully employed. The high quality

Page 6: The Blackthorn Garden Project - Centre for Mental Health

6The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

of services and produce available to the general public who frequent the Garden leads to much genuine appreciation and gratitude raising confidence and self-respect amongst co-workers. One is freer to concentrate on medical aspects while others in the circle can make better use than before of one's contribution. In between times, the social life that fills the Cafe and surrounds the washing up bowl enlivens the day's routine with laughter and camaraderie. Contact with patients, co-workers, families, colleagues and health professionals both in and relating to the practice is positive because one is in a position to offer help. Doors that used to feel closed feel more open, at least in that now one has the means to try. Everyone understands that numbers have to be limited, that this primary care project is an experimental model. We are now privileged to be working with The King's Fund, London, and four other practices in Bristol, Parkwood Maidstone, Shrewsbury and Stroud, to demonstrate over the next 3 years that Blackthorn Medical Centre and Garden is indeed a replicable model. This would not have been possible without the substantial help we have received from The Primary Care Development Fund and The Sainsbury Centre for Mental Health. David McGavin 26.11.94

Page 7: The Blackthorn Garden Project - Centre for Mental Health

7The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

1. The Blackthorn Garden Project Introduction Blackthorn Garden is a community care project for people with long-term mental health problems and other chronic or disabling illnesses. Unlike most 'community care' projects, it is based in a primary care setting. It developed from an initiative 'the Blackthorn Trusf, pioneered by an NHS general practice in Maidstone. The Trust was set up to work in conjunction with the general practice to provide anthroposophical creative therapies (art therapy, music therapy and eurythmy therapy), counselling and support groups to patients referred from the practice who had not responded to conventional treatment. Individuals referred to the Trust have had problems such as multiple sclerosis, chronic fatigue syndrome, cancer and depression. They receive the creative therapies together with mainstream medical treatments and anthroposophical remedies prescribed by the general practitioners. The work of the Blackthorn Trust and the theoretical basis underlying it (anthroposophy) are described in Appendix 1. The Blackthorn Trust and General Practice embarked on a new project - 'the Blackthorn Garden' - in September 1991, following approaches from Health and Social Services who were looking for opportunities to develop 'care in the community'. The aim was to create a supportive work environment in the community for people with long-term mental health problems. The capital funding for the new project was provided by Health and Social Services, charitable foundations and local companies. Researchers from RDP (now The Sainsbury Centre for Mental Health) were invited to evaluate the first two years of the project as part of a larger study of work projects for people with long-term mental health problems. The study was supported by funding from the Gatsby Trust Charitable Foundation and from the South-East Thames Primary Care Development Fund. This report and a previous publication 'Work, Empowerment and Community' (Nehring et al., 1993) describe the development of the Blackthorn Garden Project during its first two years (January 1992 - December 1993). Although the project has a number of unique features, we describe it mainly as a model which illustrates how the community care of people with mental health

Page 8: The Blackthorn Garden Project - Centre for Mental Health

8The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

problems can be integrated with primary care. The evaluation has ended, but of course the Blackthorn Garden Project continues to evolve. Nevertheless, we write about the project as it appeared to us during the first two years -1992 and 1993. Blackthorn Garden The Blackthorn Garden Project was set up at the end of 1991 on land adjacent to a new medical centre which had been built for the Blackthorn Trust and General Practice. Its aim is to provide work rehabilitation and community support for people with mental health problems, particularly those who are disabled by their illnesses and who have not responded to other treatments. Such individuals, referred from the Blackthorn Medical Centre, by other GPs and by psychiatrists, are taken into the project as 'co-workers'. They work alongside the project staff and 'volunteers' drawn from the local community, many of whom are or have been patients of the Trust. Co-workers were referred to the project gradually during the first year and by the end of the year, 31 had joined and 25 were still involved. By Autumn 1993 the project had taken on 55 co-workers, 38 of whom were attending regularly, with four coming occasionally. At the end of the second year, between 40 and 50 co-workers were working in the project each week. There were four members of staff: the Director, the Garden Project Leader, the Bakery Project Leader and a part-time Cafe Co-ordinator as well as eight volunteers. The aims of the Blackthorn Garden Project are:

1. ‘To establish a place of rehabilitation through work for the mentally ill in the community.’

The project aims to engage co-workers in valued and fulfilling work which will help them to develop confidence and general work skills.

2. 'To create a place of social integration and cultural activity in

the Barming District of Maidstone.’

The aim is 'to foster an environment in which individuals are recognised, can make friends, help one another and so overcome isolation and self-

Page 9: The Blackthorn Garden Project - Centre for Mental Health

9The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

orientation'. It is also hoped to engage and involve the local community, thereby reducing the stigma associated with mental illness.

3. 'To encourage the meeting and working together of the various disciplines concerned with mental health and community care.’

Work at Blackthorn - 'From Land to Table*

"The working atmosphere in the garden, bakery and cafe calls on the strong and healthy side of all co-workers rather than focusing on their illnesses.' (Blackthorn Garden leaflet)

Work plays a central part in Blackthorn Garden. It aims to restore the sense of meaning and purpose which many co-workers have lost in the course of their chronic and disabling illnesses. There are opportunities to take on valued roles, develop skills and build confidence and self-esteem. Work provides the structure through which all the other elements function. For example, the working day at Blackthorn is punctuated by shared meals and breaks which offer opportunities for social interaction. Twice a week co-workers, volunteers and staff take time off work as a group for eurythmy and craft sessions. Some co-workers also receive other creative therapies or counselling while working in the project. However, in contrast to the remainder of the Trust, the opportunity to work is the main thing which brings people to Blackthorn Garden. The kitchen and cafe The main work areas in Blackthorn Garden are the kitchen and cafe, and the garden itself. The well-equipped kitchen and cafe are located in an attractive wooden building in the centre of the garden, a short distance from the Blackthorn Medical Centre. The cafe is used by the general public, patients of the general practice and Trust, co-workers, staff and volunteers. Two staff work in the kitchen helping co-workers and volunteers to prepare food for the cafe and to bake bread for sale. The food is of a high standard and where possible is prepared using organic produce grown by ‘biodynamic' methods. It is hoped that high quality food will help to improve the health of those working in the project. Co-workers are involved in planning and preparing meals, serving customers, selling bread, biscuits and cakes, washing up and

Page 10: The Blackthorn Garden Project - Centre for Mental Health

10The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

clearing away. Different co-workers take on different tasks, some find working in the kitchen less stressful than serving customers in the cafe. The garden Much of the produce used in the kitchen comes from the garden where vegetables, herbs, fruit and flowers are grown. The 'biodynamic method' (an anthroposophical organic and ecological approach) is used. A number of co-workers choose to work solely in the garden, some because they enjoy working out of doors, others because they are able to work at their own pace. Moreover, the garden offers a range of tasks from sowing and propagation to digging and making compost- some of which can be done alone and others in pairs or small groups. This wide range of tasks enables individuals with different physical or emotional problems to find a niche which suits them. The Social Environment - Creating Community The social environment at Blackthorn is strongly influenced by the anthroposophical approach. This approach has led not only to new ways of working in medicine but also to social developments in education and for people with special needs. For example, Steiner (Waldorf) schools use an educational approach which aims to develop all aspects of the child, so that, rather than just passing exams, children can fully meet the demands of life. Camphill schools, set up to provide curative education for children in need of special care, aim to recognise the unique human potential of each child. Camphill village communities (developed as intentionally created communities for adults) attempt to be both 'communities 'with' and not 'for' the person with special needs', and 'to stand in the mainstream of modern life, not withdrawing from it'. In the Camphill villages adults with special needs live with families and others and are able to make a contribution to the work and social life of the village communities. In Blackthorn Garden, the Camphill philosophy of being a community 'with' and not 'for' people with long-term mental health problems is extremely important. It is for this reason that individuals are regarded and known as 'co-workers' rather than as patients or clients. The researchers found a strong sense of friendship and community and of mutual support. This was remarked on by a number of the co-workers:

Page 11: The Blackthorn Garden Project - Centre for Mental Health

11The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

'I like the coming together of it - everybody seems to know everybody else and makes a point of getting to know you - there's a general feeling of community.' 'When I first arrived I was made to feel one of the group - that carries on throughout your time here...' 'Working in Blackthorn Garden has made me feel part of a family...' '...we all feel responsible for each other.'

Like Camphill, Blackthorn Garden, while forming a deliberately created community, does not function in isolation away 'from the mainstream of modem life'. Co-workers are encouraged to make and retain links with people and organisations outside. At the community level, the project both engages members of the local community in its work and provides services and facilities of use to them. Patients of the general practice and Trust, and local people come in to use the cafe and to buy bread, organic garden produce and crafts. Bread and biscuits are also sold in local shops and handcrafts can be bought in the Trust's own charity shop. Open days, talks and social evenings enable local people to learn more about the work of the Garden Project and Trust. A regular newsletter keeps the local and wider community in touch with events at Blackthorn and helps to encourage a sense of ownership and involvement. Mental Health and Community Care - Forging Links Educating health professionals about complementary medicine has always been part of the programme of the Blackthorn Trust. Even before the Garden Project was established, seminars were held for doctors and other health professionals who wanted to find out more about the Trust's work. Topics included 'Learning with the Dying', 'Patients as Pioneers' and 'Depressive Illness - Working for Positive Change'. GP trainees and those studying counselling, art and music therapy have been attached to the general practice and the Trust. The Garden Project attracts visitors interested in the role of work and gardening in rehabilitating and supporting people with mental health problems. In addition to its educational role, Blackthorn Garden aims to work with those concerned with mental health and community care. To this end links have been established with local psychiatric teams, day centres, hostels and other

Page 12: The Blackthorn Garden Project - Centre for Mental Health

12The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

providers of community services. Part of the Director's role is to ensure good communication and collaboration with other agencies, including Social Services and the Maidstone Priority Care NHS Trust. Blackthorn Garden has also developed links with other anthroposophical projects including a Camphill community in Bristol which specialises in working with people with long-term mental health problems and with two residential anthroposophical clinics. Blackthorn Garden Staff At the start of 1992 Blackthorn Garden had just two paid staff - the Director and the Horticultural Project Leader. In April 1992 a Master Baker was employed to lead the work in the developing bakery and cafe. In October 1992, following a steady increase in customers, one of the volunteers was recruited as a part-time member of staff to co-ordinate the running of the cafe. In addition, the Garden Project received administrative support from the Blackthorn Medical Centre and two sessions a week from the Trust Art Therapist who ran a craft group. Blackthorn Garden staff brought different skills and experiences to the project. None of them had worked in the statutory mental health services or in primary care. The Director had a background in company law, had worked as a management consultant specialising in social change and had taught in the Centre for Social Development at Emerson College. The Horticultural Project Leader had horticultural training, had worked as a gardener and had developed and managed a gardening project for people with learning difficulties. The Bakery Project Leader was a Master Baker, had worked in a biodynamic bakery and had been a director of a residential farm for people with mental health problems. The Cafe Co-ordinator had been a patient of the Trust who had gone on to become a volunteer in the Garden Project. The Director and the Baker had previous experience of the anthroposophical approach. During 1992 and 1993, the researchers talked to Blackthorn Garden staff about their perceptions of the Garden Project and their experiences of working there. The staff felt that the project provided a safe and supportive environment in which co-workers could work, make friendships and feel part of a community. It was hoped that the co-workers would gradually become stronger, more independent and more able to cope with their chronic illnesses. One staff member felt that coming to Blackthorn Garden gave co-workers:

Page 13: The Blackthorn Garden Project - Centre for Mental Health

13The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

'...a purpose to get up, to live, to overcome problems and fears and to help others.' Co-workers were perceived to be actively contributing to the life and work of the project. One staff member, asked what the co-workers had done in the previous week, listed:

'Watering, hoeing, glazing, feeding, harvesting, painting, sowing, clearing, pricking out, potting, selling, washing pots - plus breaks and lunch - talking, singing, laughing, and worrying.'

Working in the developing project posed a number of challenges for Blackthorn Garden staff. They had to ensure a balance between the practical tasks, commercial pressures and the supportive and therapeutic aspects of the Garden Project. They had to organise a range of tasks in their own areas and decide on the day's work with each co-worker and volunteer. They had to be flexible and able to adapt and improvise when co-workers failed to turn up, arrived late or needed time out. This lack of predictability posed particular problems for the cafe and bakery because of the need to serve customers and to produce bread for sale. Staff had to learn both to work alongside co-workers and to stand back and enable co-workers to function at their own pace despite the external pressures. Even so, it was difficult to 'listen out for problems' as well as getting the work done. In practice, staff working in the cafe, kitchen and garden tended to concentrate on the practical nature of their tasks, while mental health and social problems were seen as being the responsibility of the Project Director and the GPs. Nevertheless, they had to be constantly available to co-workers, volunteers and customers while somehow maintaining the rhythm and momentum of the work. This need to be constantly available was a source of stress - as was the erratic attendance of some of the co-workers and their slow progress and fluctuating mental health. The weekly staff meetings with the Project Director and one of the GPs helped to reduce frustration by enabling staff to understand the co-workers' needs, illnesses and social situations. The Director of Blackthorn Garden had a number of roles and responsibilities including management of the project, the staff and the finances. He introduced co-workers to the project, monitored their progress and met weekly with the GPs and creative therapists. He liaised with individuals and agencies outside the project, particularly with the local mental health services. He counselled individual co-

Page 14: The Blackthorn Garden Project - Centre for Mental Health

14The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

workers and kept in touch with their families and with what was happening in their lives. By doing so, he hoped to give the co-workers a feeling of being 'respected, appreciated and seen'. At the same time he was closely involved in all aspects of the Garden Project and in supporting the volunteers and staff. Like the other staff members, the Director felt under pressure to be constantly available and had to rapidly switch his attention between competing areas. Blackthorn Garden Volunteers Volunteers make an important contribution to the work of the Blackthorn Trust - not just by fundraising but also by helping to provide social support to patients of the Trust. Volunteers also play an important part in Blackthorn Garden, supporting the work of the project and forming part of the community. Volunteers were involved from the start of the Garden Project and by autumn 1993 eight were coming regularly on a part-time basis. They came mainly from the local community and nearly all were or had been patients of the Trust, although one had become involved as a result of an interest in anthroposophy and biodynamic gardening. Volunteers worked alongside the staff and co-workers and some took on particular responsibilities, one later being employed as the joint co-ordinator of the cafe. Like the staff they had to be flexible and willing to adapt when co-workers failed to turn up or needed time-out or support. The volunteers themselves also needed support and some commented that when they were going through difficult times they were helped by others in the project. One particularly appreciated the support she had received from the Project Director following a bereavement. Some of the volunteers initially found relating to co-workers with disabling mental health problems difficult and felt they gained some understanding from the experience of working alongside them. One remarked:

'It was very hard to start with...I didn't quite understand. It has given me insight into the problems there are - and that so many people don't want to know. It's given me a deeper understanding into the problems...and it's not always easy.'

Page 15: The Blackthorn Garden Project - Centre for Mental Health

15The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Funding Capital costs and funding The capital cost of the Blackthorn Garden Project was £84,000. This included the costs of rebuilding and refurbishing the wooden building which housed the kitchen and bakery, cafe, activity room and offices, equipping the kitchen and bakery, and furnishing the cafe and offices. These costs were met by £15,000 from Maidstone District Health Authority and £41,000 raised from charitable trusts and companies, supplemented by £28,000 from the first years's grant. Revenue funding and running costs The District Health Authority and Kent County Council Social Services agreed to support the Garden Project with Joint Funding of £56,000 a year (to be increased in line with inflation) for seven years from April 1991. During the study period, funding was also obtained from the South-East Thames Regional Health Authority Primary Care Development Fund, the Mental Health Foundation and from donations. 1993 was the first year in which there was a full complement of staff and co-workers. During that year the staffing consisted of the Horticultural and Bakery Project Leaders, the part-time Cafe Co-ordinator, tihe Director who worked four days a week, the Administrator from the Medical Centre who worked one day a week and the Trust's Art Therapist who worked one day a week. The Garden Project offered 75 places per week to co-workers. During 1993 funding for salaries (£81,000), gas and electricity (£5,500), building maintenance and equipment (£5,000), and other overheads (£3,000) came from Joint Funding (£59,500), the South-East Thames Primary Care Development Fund (£17,000), the Mental Health Foundation (£12,000) and from private donations (£1,500). The Primary Care Development Fund also gave £10,000 to part-fund The Sainsbury Centre's study. In addition, the sales of produce and refreshments in the cafe generated £31,000. Of this £15,500 was spent on supplies for the garden and provisions for the kitchen and bakery. Another £11,000 went in contributions to co-workers. At the end of 1993 one of the challenges facing the Garden Project was the need to secure continuing and adequate funding.

Page 16: The Blackthorn Garden Project - Centre for Mental Health

16The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Blackthorn Garden as a Developing Project During the two years of the study, Blackthorn Garden was in every sense a developing project. Starting with only a handful of co-workers at the beginning of 1992, work initially centred around developing the vegetable garden and nursery from a neglected site, while an old wooden building was converted to house the bakery, cafe, activity room and offices. At this stage a greenhouse provided the only shelter for co-workers, while the Director's office was a garden shed. As the refurbishment of the cafe progressed, the Bakery Project Leader worked with co-workers and volunteers producing trial batches of bread and meals for those in the project and a few visitors. The cafe officially opened to visitors in August 1992 and the work gradually expanded until by the end of the year they were serving between 25 and 40 customers each day. During 1993 the project acquired a further half an acre of land. On joining the Garden Project, co-workers agreed to work on specified days in the garden, bakery or cafe. On average co-workers attended 74% of their 'contracted time' during the first year, with only three working less than 50% of their contracted time, while five worked more than their agreed sessions. In the second year, even more co-workers came regularly to the project, the mean attendance being 89% of contracted time. Initially the co-workers' were unpaid, but from October 1992, as income from the cafe and the sales of bread and produce increased, they were given a share of the takings. Every month a proportion of the takings was set aside to be divided between the co-workers, enabling them to earn up to £10 each week (an amount which would not affect their benefits), and a fund for outings. Blackthorn Garden staff valued being part of an evolving project, but working in a new and developing project required a high degree of adaptability. In the first year the Garden Project was being built in a very concrete sense - the land was cleared, the hut refurbished, equipment bought and the kitchen and bakery set up. At this stage the emphasis was on acquiring the materials needed for the nursery, cafe and bakery to operate. However, the project's role in providing community care and work rehabilitation was not 'on hold' until all the resources were available - co-workers, volunteers and members of the community were involved in building the Garden Project right from the start. In the second year, the emphasis moved to organising the work areas and establishing work routines and consolidating some of the informal

Page 17: The Blackthorn Garden Project - Centre for Mental Health

17The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

processes which had emerged in the first year. During this period the Director concentrated on making links and building up relationships with other mental health services and on co-ordinating the various professionals working with individual co-workers. At the end of the busy second year, many of the work routines and links were in place and staff hoped that the next stage would allow them to focus more on the individual needs of the co-workers in their work areas. A frequent concern in work-based rehabilitation projects is the potential for tension between therapeutic aims and commercial demands (e.g. see Nehring et al., 1993). For example, the Horticultural Project Leader was torn between the needs of the co-workers for support and supervision and the necessity of keeping the garden watered and weeded to ensure a crop would be produced. This became more of a problem as production and sales increased, as well as the number of co-workers working in the garden. To some extent this dilemma was lessened at the end of the second year by the establishment of key co-workers to supervise particular areas of work (for example, the vegetable garden, landscaping a new area, or preparing produce for sale). This sharing of responsibility for the running of the garden enabled the Horticultural Project Leader to move from a position of leading to one of supporting and delegating and meant that he could respond more flexibly to individual needs. Similarly, in the cafe and bakery there were tensions between the need to get through the tasks, produce high quality food and to make a profit, and the need to spend sufficient time with individual co-workers. Tensions between the therapeutic and commercial aims of Blackthorn Garden existed and were mentioned by co-workers, but they appeared to be balanced by the very strong sense of community and support. During the first two years of the project there were changes in the co-workers - both at an individual level and as a group. Individuals appeared stronger, more able to trust and more ready to take on responsibility. The warm and accepting atmosphere enabled them to gradually build on their existing strengths even if their psychiatric symptoms did not disappear. Some co-workers began to take on particular roles - for example, stock-taking or bread-making - reflecting both increased confidence and commitment to the project. In the second year there was a greater feeling of community and of mutual support, more discussion in the co-workers' meetings, and social events and outings were well attended.

Page 18: The Blackthorn Garden Project - Centre for Mental Health

18The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

However compared to the rapid development of the Garden Project, the changes in the co-workers occurred very gradually - particularly in those with long-term and disabling mental health problems. Psychiatric symptoms often remained and none moved quickly into work or open employment. Staff had to learn to accept the reality of this slow progress and to reconsider what their aims should be in working with this group. Summary Blackthorn Garden is a primary care project which offers work, rehabilitation and community support for people with long-term mental health problems and other disabling conditions. The project developed rapidly during its first two years and co-workers, volunteers and members of the local community were involved from the start. It works closely with the Blackthorn General Practice and Trust and has made links with local mental health services. The cafe, bakery and garden function as valuable resources for local people and patients of the Blackthorn Medical Centre. The Garden Project shows how the community care of people with mental health problems can be integrated with primary care and local communities.

Page 19: The Blackthorn Garden Project - Centre for Mental Health

19The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

2. The Co-workers Blackthorn Garden was set up to be both a community care and a primary care project. Hence it was expected that the project would take on co-workers with a wide variety of problems and needs, but that the majority would fall into two main groups. The first of these groups consisted of people with long-term and severe mental health problems such as schizophrenia and bipolar (manic depressive) illness. Schizophrenia is characterised by psychotic experiences such as delusions and hallucinations, by disordered thinking and by 'negative symptoms' such as social withdrawal, underactivity and lack of drive. These symptoms are frequently accompanied by profound disturbances in social functioning including loss of self-care and social skills, social isolation and the inability to gain or to hold down employment. Bipolar illnesses may be accompanied by psychotic symptoms but are characterised by fluctuating and disabling mood swings, which also result in considerable disruption to jobs and relationships. People with these types of problems often spend long periods in hospital or in sheltered accommodation, or require intensive support from their families. With the closure of the large psychiatric hospitals, there is a need to develop new resources to support people with such long-term and disabling mental health problems in community settings. The planned closure of Oakwood Hospital in Maidstone was one of the reasons Health and Social Services invited the Blackthorn Trust to set up a community work project for people with mental health problems. The second group the Garden Project aimed to engage were people with chronic neurotic or personality difficulties who are often mainly supported by GPs. These include people with anxiety or depressive disorders which may be related to physical illnesses, family problems or social circumstances. Those with personality disorders have long-standing problems which prevent them functioning effectively in many areas of their lives and in some cases lead to self-harm. Others with chronic physical illnesses or disabilities suffer low morale, poor confidence and low self-esteem as a result of problems which can be helped little by medical treatments. It was hoped that the Blackthorn Garden Project would improve such people's coping abilities and the quality of their lives by providing them with social support and a sense of purpose.

Page 20: The Blackthorn Garden Project - Centre for Mental Health

20The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

One of the aims of the study was to construct a detailed picture of the 31 co-workers who joined the Garden Project in its first year. This was achieved by a combination of questionnaires, rating scales and (where co-workers gave permission) information from project staff and from medical notes. Co-workers who started in 1992 were assessed during their first month in the project. Co-workers in the First Year During the first year, 15 men (48.4%) and 16 women (51.6%) joined the Garden Project, their ages ranging from 15 to 61 years (average 35.8). All were white and 30 (97.0%) had been born in the United Kingdom. 21 (67.7%) were single, seven (22.6%) were married or living with a partner, two (6.5%) were separated or divorced and one had been widowed. Ten co-workers (32.3%) were living with their parents, seven (22.6%) with partners, and four (12.9%) with other relatives. Of the remainder, four (12.9%) were in-patients, three (9.7%) lived in group homes, and three (9.7%) lived alone. How were the co-workers referred? 22 (71.0%) of the co-workers had been referred by their general practitioner - 19 of these being registered with the Blackthorn Medical Centre. Three (9.7%) had been referred from the local district psychiatric hospital (Oakwood) where they were inpatients. Another was an inpatient in an anthroposophical clinic, having been transferred from a London psychiatric hospital. One had been referred from a local group home and a 15 year old boy by his school. Three people had heard about the Trust and referred themselves directly. Six (20.4%) of the co-workers lived outside Maidstone in Kent or South London and travelled considerable distances to get to the project. Diagnoses Each co-worker was given a diagnosis by the research psychiatrist using ICD 10 criteria (WHO, 1992). Seven (22.6%) had schizophrenia, schizoaffective disorder or delusional disorder. Three (9.7%) had bipolar illnesses, two being currently depressed and one in remission. Seven (22.6%) had depressive illnesses, one following treatment for cancer with metastatic spread. Four

Page 21: The Blackthorn Garden Project - Centre for Mental Health

21The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

(12.9%) had neurotic disorders including anxiety, obsessional compulsive disorder and school phobia; one of this group had been treated for cancer. Three (9.7%) were given a primary diagnosis of personality disorder (two being labelled anxious/avoidant and one emotionally unstable). Two (6.5%) had a primary diagnosis of mild learning difficulty, one having significant behavioural problems. Of the remaining co-workers, one had an organic amnesia following a head injury, one had Gilles de la Tourette's syndrome complicated by behavioural problems, one had benzodiazepine withdrawal syndrome following a supervised attempt to come off benzodiazepines, one was dependent on alcohol and one was physically disabled by post-traumatic dystonia. Five co-workers had physical disabilities or significant medical conditions as well as mental health problems, including cerebral palsy and late-onset asthma. Use of mental health services Co-workers were asked about their previous use of mental health services. 25 (77.4%) reported some contact with the mental health services, the average age of referral being 22 years 10 months (range 13-42 years). The average length of time since first contact with the psychiatric services was 18 years 3 months (range less than one year to 52 years). 15 (48.4%) of the co-workers had been admitted at least once for psychiatric treatment. Amongst these, the mean number of admissions was 2.7 (range 1-6). Length of longest admission ranged from 2 weeks to 27 years (mean 2 years 8 months, median 6.0 months). When the admission of 27 years was excluded then the mean length of longest admission became 9.3 months. 12 of the co-workers (40.0%) had used mental health day services at some time in the past and these included day hospitals, day centres, sheltered work facilities and drop-in or social clubs. Four (12.9%) of the co-workers were receiving inpatient treatment while attending the Garden Project. Of the remainder seven co-workers (26.9%) had seen their psychiatrist in the previous three months, two (7.7%) were also supported by community psychiatric nurses and two were attending a depot clinic. Four (12.9%) had seen a social worker in the previous three months.

Page 22: The Blackthorn Garden Project - Centre for Mental Health

22The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Use of primary care services 21 (70.0%) of the co-workers had seen their general practitioner in the previous three months and one received support from a general practice nurse. Three (10.0%) had received counselling provided by the Trust and three (10.0%) had been befriended by volunteers. Use of medication 17 of the co-workers (54.8%) were taking at least one psychiatric drug. 14 (46.7%) were taking anti-psychotic drugs, seven (22.6%) receiving depot injections. Six (20.7%) were prescribed Lithium to stabilise their mood and seven (24.1%) were taking antidepressants. Nine (29.0%) were taking drugs for medical problems or were receiving anthroposophical remedies. Five (16.1%) were not taking any medication. Mental health measures The co-workers' mental health was rated using three measures:

1. The Brief Psychiatric Rating Scale 29 co-workers were rated on a 19 item version of the Brief Psychiatric Rating Scale (BPRS) - a semi-structured interview used to assess psychiatric symptoms (Overall and Gorham, 1962). Co-workers were asked about symptoms over the previous month.

The mean total score was 15.3 (median 15.0, standard deviation 7.6, range 2 - 33). The scores for four sub-scales were as follows:

'thinking disturbance': mean 2.9

median 2.0 st. dev. 3.0 range 0-11

'anxiety/depression': mean 5.2 median 6.0 st. dev. 2.4 range 1-10

'hostility/suspiciousness': mean 2.1 median 2.0

Page 23: The Blackthorn Garden Project - Centre for Mental Health

23The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

st. dev. 1.9 range 0-6

'retardation/withdrawal': mean 2.4 median 2.0 st. dev. 2.5 range 0-8

These ratings may have underestimated the degree of psychiatric disturbance since, in order to increase reliability, when the rater was uncertain which of two scores to give on a particular item the lower score was always chosen. Furthermore, the BPRS tends to measure 'positive symptoms' better than the 'negative symptoms' found in long-term illnesses. Nevertheless the results indicate that the co-workers had a number of psychiatric symptoms and, in particular, that there was a high level of depression and anxiety. This was confirmed by self-assessments using scales designed to measure depressive symptoms and general levels of anxiety.

2. The Beck Depression Inventory 26 co-workers rated themselves on the Beck Depression Inventory - a self-rating scale used to measure depressive symptoms (Beck et al., 1961). The mean score was 18.3 (standard deviation 9.4, range 3 - 50). 20 co-workers had scores greater than 10 - the cut-off used when screening populations for depressive symptoms. Nine had scores of 21 or more -a cut off which is often used in research studies of clinical depression.

3. The Spielberger Trait Anxiety Inventory 23 co-workers rated themselves on the Trait scale of the Spielberger State-Trait Anxiety Inventory which measures general levels of anxiety (Spielberger et al., 1970). Scores can range from a minimum of 20 to a maximum score of 80. The mean score for co-workers was 53.7 (median 54.0, standard deviation 9.8, range 35 - 73). This can be compared with a mean for psychiatric inpatients of 46.6 obtained from hospitals in the United States (Spielberger et al., 1970).

Page 24: The Blackthorn Garden Project - Centre for Mental Health

24The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Social support Social isolation, loneliness and difficulties in relationships are common issues for people with mental health problems. Hence co-workers were asked about their families, friendships and social support. Most co-workers at Blackthorn Garden appeared to have strong family links. Almost all (93.5%) said they were in contact with at least one relative and 28 (93.3%) had been in contact with a member of their family in the last month. 23 (74.2%) of the co-workers could name a friend, partner or relative in whom they could confide. However, 11 co-workers (35.5%) had no close friends and 19 (61.3%) saw friends or went out socially less than once a week. Only nine (29.0%) felt they had no difficulty making friends and only six (19.4%) felt they had no difficulty mixing with others. Four people (12.9%) were always lonely, eight (25.8%) often lonely and 26 (83.9%) felt cut off from others at least some of the time. Social functioning Social functioning is often impaired in those with serious and chronic mental health problems. Co-workers were rated on two measures of social functioning - the Social Behaviour Schedule (Wykes and Sturt, 1986) which rates problems in social behaviour and the Global Assessment of Functioning Scale (DSMIII-R, 1987) which provides an overall picture.

1. The Social Behaviour Schedule At the end of their first month in the Garden Project, 27 co-workers were rated on the Social Behaviour Schedule using information obtained from the Project Director. Like most of the available social functioning measures, this scale records problems in social behaviour rather than individuals' strengths. There are 21 items relating both to deficits in normal social behaviour such as self-care and to disturbed behaviour such as laughing or talking to oneself. The intensity or frequency of a problem is rated on a scale of 0 - 3. Items scoring 2 or more were included in the total score. The mean total score was 3.4, (range 0 -14), indicating that co-workers had an average of 3.4 behavioural problems which occurred quite frequently and restricted their social functioning. This can be compared

Page 25: The Blackthorn Garden Project - Centre for Mental Health

25The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

with a mean of 4.4 obtained in the TAPS evaluation of the functioning of long-stay patients in Friern and Claybury Hospitals (Leff, 1994).

The sub-scales were as follows: Communication problems mean 0.8 range 0 – 5 Behavioural deficits or disturbance mean 2.6

range 0 – 12

14 co-workers had other behavioural problems not measured by the sub-scales, such as obsessional hand washing or agitation, which were restricting their functioning.

2. The Global Assessment of Functioning Scale

30 co-workers were rated by the research psychiatrist on the Global Assessment of Functioning Scale which gave a measure of overall functioning during their first month in the project. Ratings are made on a scale of 0 - 90, where 90 indicates good functioning in all areas and scores below 50 indicate serious symptoms and serious impairment in social and occupational functioning. The mean score for the co-workers was 48.9 (range 15 - 75). Four co-workers scored 30 or less indicating that their behaviour was seriously influenced by psychotic symptoms or an inability to function in almost all areas.

Work history, education and occupational functioning The Garden Project offered co-workers the chance to regain or to develop general work skills. 25 co-workers (80.6%) had worked in a full-time job in the past, but the mean time out of work was 7 years 11 months (range 6 months to 40 years). This factor alone would have made it difficult for them to find a job in open employment. The mean time worked in their last full-time job was 3 years 10 months but the range was considerable -one week to 25 years. Two co-workers (6.5%) had part-time jobs while they were working in the Garden Project during the first year. 12 co-workers (38.7%) had some form of vocational training and six (19.4%) had attended a university or polytechnic. Three (9.7%) had obtained degrees,

Page 26: The Blackthorn Garden Project - Centre for Mental Health

26The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

two (6.5%) had diplomas and five (16.1%) had occupational qualifications. Of the remainder, two (6.5%) had A levels, one (3.2%) had RSA English and another five (16.1%) at least one O level, CSE or GCSE. Therefore, compared to the general population a number of the co-workers had enjoyed good educational opportunities. Nevertheless, 13 (41.9%) co-workers had no education or training since leaving school and possessed no qualifications. Three (9.7%) reported difficulties with reading. While unemployed, five co-workers (17.9%) had been on the Manpower Services Commission or Department of Employment Training Agency work or training schemes. Six (20.0%) were registered as disabled. Of these, four (13.3%) had been assessed at an Employment Rehabilitation Centre and three (10.0%) had worked in sheltered work schemes. Issues From the First Year Women in Blackthorn Garden In the first year 16 of the 31 co-workers were women (52%) and this proportion was maintained in the second year (28 out of 55,51%). This is an important finding as women are usually under-represented in work projects for people with mental health problems. For example, women made up a third or less of the workforce in the other work rehabilitation projects studied by The Sainsbury Centre for Mental Health (Nehring et al., 1993). While men are more likely to be referred onto secondary mental health services, community surveys show that women have a higher prevalence of mental health problems. Recent community surveys have found that 8.7 -15.0% of women have mental health problems compared with 7.1 -12.5% of men (Dean, 1988). Hence, the equal representation of women in the Garden Project may reflect the numbers with mental health problems in the local population and result from the project's close relationship with primary care. The range of co-workers supported The data on the co-workers in the first year shows that Blackthorn Garden had successfully engaged co-workers of all ages, from a variety of backgrounds and with a wide range of problems and needs. Co-workers included both those with long-term and disabling conditions such as schizophrenia and bipolar illness who are often treated by specialist mental health services, and those

Page 27: The Blackthorn Garden Project - Centre for Mental Health

27The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

with chronic mental health, physical and personality problems who usually receive long-term support from their GPs. Chapter 4 discusses the use of primary care to support people with serious and disabling mental health problems in their local communities and how this was achieved in Blackthorn Garden. The needs of those with chronic neurotic, personality or physical disorders are also important. It has been estimated that 10% of consultations in general practice are for mental health problems (HMSO, 1979) but most patients have complaints such as anxiety, depression, tension headaches or insomnia which are often related to stress and which recover in time. However, the second group supported by the Garden Project represented the subgroup of primary care patients who have chronic or recurring neurotic conditions, personality difficulties or disabling physical problems. They are helped only to a limited extent by conventional medical treatments and require long-term support from their GPs. They frequently have a mixture of anxiety and depression and their mental health problems are complicated by physical symptoms, poor physical health and social difficulties. While GPs may get to know these patients, their families and social circumstances very well over the years, the amount of time they can give them in the normal practice setting is limited. Many receive a variety of psychotropic drugs but there are few opportunities for counselling, psychological therapies or other forms of support. The establishment of the Blackthorn Trust met some of the needs of this group by providing counselling and the creative therapies. The opening of Blackthorn Garden provided them with social support, meaningful occupation and a chance to contribute. The initial interviews showed that this group of co-workers particularly saw the Garden Project in terms of opportunities for personal development - such as gaining confidence (especially in social situations), making friends, becoming more assertive, learning to consider their own needs and developing the spiritual side of their existence. Other goals related to personal attainment including getting back to work, taking exams and deciding on future plans. Many of these co-workers also hoped to improve their physical health and general well-being by working in the project.

Page 28: The Blackthorn Garden Project - Centre for Mental Health

28The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Co-workers in the Second Year General profile During the second year 55 co-workers were involved in the Garden Project, 27 having joined in the second year. Their problems included schizophrenia, anxiety, depression, learning difficulties, chronic stress related to family problems and multiple sclerosis. Eight of the co-workers were in-patients in Oakwood Hospital at some point during the year. Attendance was high - co-workers attending on average for 89% of their agreed time although this figure is artificially high due to over attendance of some co-workers (range 50 - 215%). During the year ten co-workers stopped attending, of whom six had started in 1993. Two left after finding jobs - although one was later admitted to hospital. Two left after moving to other areas and one because he was too weak to travel. One woman stopped coming because she was highly anxious and needed to be accompanied. One man with severe behavioural problems was asked to leave after becoming disturbed on a number of occasions. Two men decided that the project was not for them and one woman who was very socially isolated stopped coming for no clear reason. The follow-up group The follow-up study was focused on those co-workers with long-term, serious and disabling mental health problems who traditionally are supported by secondary mental health services. This group included co-workers with schizophrenia, bipolar illness and psychotic depression. Co-workers from this group who joined the Garden Project in the first year were rated on the measures of mental health, social and general functioning during their first month in the project and again after 12 months. At the end of the first year, 30% of the co-workers in the follow-up group were no longer working in the Garden Project. While this is of concern, it is not a high percentage when compared to other day services. Given the small size of the final sample and the large amount of variability in the group, the researchers were not surprised to find no significant differences in mental health, social or general functioning after 12 months. Even if a larger sample had been available it could still have been predicted that their mental health problems would have remained fairly stable, given the nature of their illnesses and the wide range of factors which affect them (such as accommodation, finances and family issues). It might have been expected that

Page 29: The Blackthorn Garden Project - Centre for Mental Health

29The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

providing meaningful activity and occupation would result in improvements in negative symptoms - such as increased drive and more social contact (Wing and Brown, 1970). However, the small numbers in the follow-up study and the lack of emphasis on negative symptoms in the Brief Psychiatric Rating Scale made it unlikely that any change would be detected. A similar difficulty arose with the Social Behaviour Schedule which concentrated on problem behaviours mainly of a psychiatric nature rather than on the improvements in general social functioning which staff felt they could see in particular co-workers over time. Even so the final numbers were too small to measure any significant differences. Summary Blackthorn Garden co-workers had a wide variety of mental health and physical problems, the mix reflecting the project's close relationship with the general practice and its mission to provide 'care in the community' for people with long-term, serious and disabling mental health problems. Within the Garden Project it was possible to find an adolescent with school phobia, a young adult with physical disabilities and a housewife suffering from depression working alongside a co-worker with a resistant psychosis, who had lived in an institution for most of her life. In the first year, 23% of the co-workers had schizophrenia or related disorders, 10% had bipolar illnesses, 23% had depressive illnesses and 13% had neurotic disorders, the remainder having a range of disabling illnesses. They had serious difficulties with work and social functioning and one sixth of those with mental health problems also had medical problems or physical disabilities. It was clear that the Garden Project had been successful in engaging many co-workers with diverse problems and needs including those with long-term, serious and disabling mental health problems.

Page 30: The Blackthorn Garden Project - Centre for Mental Health

30The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

3. The Co-workers’ Views The most important part of the research into Blackthorn Garden was finding out what the co-workers thought of the project. Co-workers were interviewed by the researchers at the end of the project's first year and again at the end of the second year. Surveys which ask people how satisfied they are with services tend to elicit high levels of satisfaction (Lorefiee and Borus, 1984), so the interviews were designed to elicit co-workers' perceptions, feelings and comments about specific aspects of the Garden Project. A semi-structured interview was used so that co-workers could be encouraged to talk freely about particular areas. The researchers stressed that the interviews were confidential and that they were interested in the co-workers' own views. A content analysis was made of the responses to each question, yielding a number of categories into which individual responses could then be placed. In both years, almost all the co-workers expressed positive feelings about the Garden Project. The friendly, relaxed and caring atmosphere and the sense of community were frequently mentioned:

'It's the whole atmosphere - everybody is so cheerful and understanding, no questions asked, no pressure.' 'Being a co-worker brings people closer together.' 'It's very free and easy - they really care about you.' ‘…you are of value and have people to share things with.'

Working in the project gave co-workers a reason for getting up and going out of the house and provided the sense of purpose and meaning which is often lost during chronic illnesses. One co-worker who was suffering from depression joined because:

'...doing some hard work might spark something - because before I'd been inactive, feeling something was missing.'

Page 31: The Blackthorn Garden Project - Centre for Mental Health

31The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Another felt she had gained:

'...somewhere to go to, structure, a job to do and knowing I will be with other people - it's given me my confidence back.'

While one spoke of:

‘ ...satisfaction - I feel rewarded. At the end of the day you feel you have done something worthwhile - and then when you go home everything seems to sit in place, everything goes right.'

A young woman who had not worked for some time appreciated the feeling of being employed:

'It's like a little job - they pay you some money.. .so you feel you are earning money on your own.'

In addition, the work provided a distraction from worries, depression and troublesome psychotic symptoms. For example, one co-worker would come in to the project when feeling 'mental anguish or despair' - and get relief from digging the garden. Many co-workers were proud of the Garden Project's achievements and valued having a chance to contribute despite their illnesses or disabilities:

'...[I like] the achievement - the amazing amount that can be done by just plugging away at it, a few at a time.'

'Its something where everyone and everything actually contributes...it doesn't matter how bad or good you are at something provided you try.'

It was also clear that many individuals felt recognised and valued:

'It's helped me a lot - it's helped me get back my self-respect. It helps me feel needed and (more important) useful.’

Page 32: The Blackthorn Garden Project - Centre for Mental Health

32The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Some co-workers spontaneously commented that the Garden Project offered things not available from hospital or existing community services:

'It gives people a sense of identity, something useful to do, helps people to become more independent - earning money. Better than giving pills and saying "come back in a week".'

'It's more of a family - people in hospital get discharged - you don't see them again.'

And one saw the Garden Project as a model for community services:

'It makes you realise how much more could be done in the community if there were more funds.'

When compared with the Garden Project, day centres and traditional work projects were seen as less stimulating or unsatisfying:

‘There are more things to do here - more opportunities.'

'Unless there's an actual class going on at the day centre you just sit around and here you've got something to do.'

'Work in day centres and hospitals is unrewarding and very menial.'

One woman felt that at Blackthorn:

'You are labelled a co-worker instead of a client so you feel more normal.' Working in the Garden Co-workers who chose to work in the garden did so for a variety of reasons. Some enjoyed being outside, the contact with nature and watching plants grow. One liked:

'...the peace and the quiet and seeing things develop - very therapeutic’

Page 33: The Blackthorn Garden Project - Centre for Mental Health

33The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Another liked:

'...being out in the fresh air and feeling I'm doing something constructive and positive.'

The changing seasons ensured variety and the garden provided a wide range of tasks and opportunities. The work ranged from heavy physical jobs such as digging or laying paths to light work such as propagating which could be done by someone in a wheelchair. Some jobs could be done in groups while others provided the chance to work alone. This was important to some of the co-workers who preferred at times to be on their own, or who found being in groups stressful:

'There's companionship when I want it, but there are also solitary jobs to do when I feel the need to be alone. When I have been in an anxious or depressed mood I have found jobs like digging a vegetable bed, planting out or sweeping up leaves on my own to be calming.'

Some co-workers appreciated the companionship and sharing. One liked the way:

'...everybody does their bit – the friendly atmosphere – everyone works together.'

Another noted:

'...sometimes you don't come to do the gardening – you come for the companionship and friendship.'

However, one woman felt lonely working in the garden and preferred the kitchen where there were more people to chat to. A number of co-workers preferred work in the garden to that in the kitchen and cafe because it was less pressured and the pace was slower. One woman recovering from a manic episode remarked:

'It's more relaxing - there's no pressure of time to finish the job and be ready for lunch.’

Page 34: The Blackthorn Garden Project - Centre for Mental Health

34The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Individuals were able to work at their own pace and could gradually take on more as their functioning and confidence improved. The main problems reported by co-workers working in the garden related to the physical demands and to the environment when the weather was poor. Some older individuals and those with medical problems such as arthritis found bending, lifting and digging a problem. Other co-workers disliked the cold and the dirt or being crowded together in the greenhouse when it was raining. However, one woman who was not 'a mad keen gardener' and who disliked getting her hands dirty said that she still liked to work in the garden because of the company and sharing. Working in the Kitchen and Café In the kitchen, some co-workers particularly enjoyed the nature of the work and the chance to learn how to cook and to eat what they had made:

'I like being involved with the whole process - I like working with my hands – it's good to knead the dough and bake the bread.'

'[I like] the learning process of baking - getting one to one attention and feeling supervised and getting to eat - proof that I've done something.'

Co-workers involved in the cooking could quickly see results and their efforts were appreciated at lunch time by the others working in the project and by the customers. As in the garden, the friendly atmosphere in the kitchen was very important. This could make up for some of the more mundane tasks which had to be done regularly. One co-worker said:

‘I don't mind washing up - [they are] such a nice crowd to work with, they talk to you which is what I want.'

However, some co-workers disliked particular tasks such as preparing large quantities of vegetables or found the standing and lifting heavy pans physically tiring.

Page 35: The Blackthorn Garden Project - Centre for Mental Health

35The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

The stresses of working in the kitchen were related to the faster pace and the pressure to get meals ready in time. It could feel noisy and crowded and at times a bit chaotic, the worst time being the half hour before lunch. One co-worker remarked:

'...sometimes the pace is a bit alarming.' One complained of:

'Too much, work for too few people, too hectic. When you are rushed off your feet work loses its therapeutic quality and at the end of the day it becomes too stressful.'

The kitchen seemed particularly stressful for those co-workers whose concentration and drive were impaired and for those who were thought disordered or experiencing hallucinations. They found it difficult to rapidly change tasks or to take in instructions when the kitchen was busy. Another source of stress resulted from face-to-face contact with customers (for example when taking orders for meals or serving in the cafe) and consequently some co-workers preferred to confine their work to the kitchen. Being With Others One of the main sources of stress described by co-workers wherever they were working was being with other people. Tea-breaks and meal-times (when co-workers, volunteers and staff would share a table), and co-workers' meetings, were found by some to be particularly stressful. This source of stress seemed to become more of a problem in the second year as the number of people working in the Garden Project increased. Other co-workers who had neurotic or personality problems found working with people who had severe mental health problems (such as schizophrenia) difficult. One person felt stressed:

'...when I have a co-worker with lots of difficulties working with me and I'm not feeling too great myself.’

Page 36: The Blackthorn Garden Project - Centre for Mental Health

36The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

However, another felt that she had gained from the experience:

'I thought it would depress me to see people chronically ill, but found just the opposite. It has been a real education for me.'

While being with others could be stressful, co-workers valued the company and friendship and saw them as an important part of what the Garden Project offered. Somehow a balance had to be struck between the need for social support and the stress experienced in social situations. For particular individuals, this equation could vary from day to day depending on their mental health and on what was happening in the project. The staff tried to be sensitive to this when allocating tasks and the different social environments provided by the garden and the kitchen helped to ensure that individuals' varying needs could be met. Being Involved and Having a Say Most of the co-workers appeared actively involved in the work of the Garden Project. Not surprisingly, during the first year the majority reported needing to ask what to do or for instructions on specific tasks. By the end of the second year, most of those working in the garden felt that they could get on with things by themselves, whereas in the kitchen there was a greater need for co-ordination to ensure that meals were ready on time. A few co-workers saw themselves as having particular responsibilities, generally for identified tasks such as mowing the lawn or baking, but most took on whichever tasks were allocated to them on a daily basis. For one this was a relief:

'I've come from being the one who has to have the ideas...and I'm actually enjoying not having to take those responsibilities for the time being. I'm responsible in so far that I see a need and don't shy away from it, but I don't expect to have to think a week ahead.'

When co-workers were asked what they felt was expected of them in the Garden Project, a common response was that they should do their best:

'Just give the best of what you can give.’ 'Definitely that I should always have a go at whatever I am given.'

Page 37: The Blackthorn Garden Project - Centre for Mental Health

37The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Some felt they were expected simply to turn up and to do the work:

'Work hard, get on with the job - that's it really.' While others felt they were expected to get better, leave the project and return to their usual roles:

'.. .get better and return to society and stand on my own two feet.' Co-workers were also asked how much say they had in the Garden Project on a day-to-day basis. At the end of the first year only six of the 22 co-workers asked felt that they had a lot or quite a bit of say, while nine felt they had no or very little say. Four said that they did not want any say. None complained that their views (if expressed) were not heard. When asked how they felt about this situation, 12 felt they had enough say, while five rationalised their lack of say either in terms of their own mental health needs or in terms of the needs of the project:

'As I grow stronger I will become more participative - putting more of me into it.’ 'You can make suggestions – I usually follow what is asked because that is what is needed most.'

Three co-workers felt that they did not have enough say. One commented:

'I feel glad when l am consulted and I think it would be good if there was more opportunity for co-workers to share their thoughts and ideas with staff.'

Two people said they were not bothered. One woman remarked:

‘The soldier and the sergeant – everywhere is the same – so I don't really expect them to ask me.’

In the second year about a third of the co-workers felt they had no or very little say in what happened in the project and again half were content with this

Page 38: The Blackthorn Garden Project - Centre for Mental Health

38The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

situation. The monthly co-workers' meetings were seen by some as a forum in which their views could be expressed. At the end of the second year, although individuals were gradually taking on more responsibility, there was still a need to increase the co-workers' opportunities to take part in day-to-day decision-making and to help to run the Garden Project. In the first two years the underlying philosophy in Blackthorn Garden had emphasised helping individuals to 'take charge of their own illnesses' rather than empowering the co-workers as a group, collectively increasing their influence and responsibilities within the project. The fact that some of the co-workers said that they did not want more responsibility or say in the project may have reflected their long histories of disabling illness and previous experiences of disempowerment in mental health services. However, it may also have resulted from the Garden Project's proximity and close relationship to the Blackthorn Trust and General Practice - some co-workers tending to see themselves as recipients of therapy rather than as workers and members of a shared enterprise. The co-workers' monthly meetings and the appointment during the second year of 'key co-workers' with particular responsibilities for the work were first steps towards shared responsibility. Thinking About the Future Co-workers were asked whether anyone in the Garden Project talked to them about how they were getting on or about the future and how they felt about this. Many felt they had not had the opportunity to talk on a one-to-one basis about how things were going or what might happen in the future and that such opportunities would be helpful. One woman said:

'Sometimes you feel life is a bit routine and to stand back and look at the future may be a little help.’

However, a significant minority did not want to be asked about themselves or their future:

'Sometimes you can talk and talk and just turn in on yourself.'

Page 39: The Blackthorn Garden Project - Centre for Mental Health

39The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

A few co-workers felt that the Garden Project was not the right place for such discussions and preferred to use opportunities provided by counselling or therapies in the Trust or to talk to their GPs. Ten of the 23 co-workers asked at the end of the first year, and seven of 30 interviewed at the end of the second year, thought they would continue working indefinitely in the project. One hoped to stay:

'For as long as they will have me - or if I no longer need to be there.' One co-worker who originally lived outside Maidstone moved to the local area as a result of the support she had received from the Garden Project. Some planned to stay in the project for a fixed period while others hoped to continue until their health had improved:

'For as long as I've still got problems - but (touch wood) I think I'm getting better now.'

Some of the co-workers who were planning to move on also wanted to give something back to the Garden Project:

'I would hope to come back – I would like to move on but it would be nice to spend some time putting something back.'

And some hoped to maintain links with the project. One co-worker recovering from a depressive breakdown intended to remain in contact:

'...as a person for the rest of my life. As a patient until I feel secure in what I am going to do next.’

These co-workers saw their relationship with the Garden Project changing from being supported by the project to contributing as volunteers and friends themselves. Most of those co-workers who were not planning to stay indefinitely hoped to find paid employment or voluntary work or to move into further education.

Page 40: The Blackthorn Garden Project - Centre for Mental Health

40The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Summary Most co-workers were keen to talk about the Garden Project and their personal experiences of working in it. Research interviews tend to elicit spontaneous answers, often influenced by recent events and pressures, and inevitably some of the co-workers' accounts were influenced by the stresses or successes of that day or week. However, over the course of the interviews a number of consistent themes emerged. Co-workers valued the work and the friendly atmosphere and sense of community provided by Blackthorn Garden. They felt valued and had a sense of pride in the project's achievements although some would have liked more involvement in the day-to-day decision-making. The variety of tasks available in the garden, kitchen and cafe meant that most co-workers could find a niche which suited them, but a number would have liked more opportunity to talk about how they were getting on and about the future. For some being with others was a potent source of stress, but many co-workers appreciated the company as much as the work and a few hoped to remain in contact with the project after leaving. At the end of the second year interviews, co-workers were asked to spend five minutes writing down what effect they thought the Blackthorn Garden Project had on them. Their responses are contained in Appendix 2.

Page 41: The Blackthorn Garden Project - Centre for Mental Health

41The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

4. Integrating Community and Primary Care In Britain primary care involves the early detection and treatment of illness combined with primary prevention such as immunisation and health education. In addition, GPs and primary health care teams provide continuity of care for individuals and families. This continued commitment and their knowledge of individuals' circumstances and local communities enables GPs and primary health care teams to take a developmental and holistic view of their patients and the problems they bring. General practice has always played an important part in the care of people with chronic illnesses, including those with disabling mental health problems. Some GPs have identified the particular challenges in working with this group - including feelings of impotence and frustration when therapists are faced with problems for which there is no 'cure' (O'Dowd, 1988). Constructive ways of supporting such patients often include moving from a purely medical to a holistic model and sharing care with other members of the primary health care team. The move towards 'care in the community' means that GPs will be increasingly involved in supporting people with mental health problems who would have been cared for in hospital. These include people with acute or episodic disorders and those with severe and disabling illnesses (mainly schizophrenia) who have been treated in hospital for many years. The resettlement of this latter group of 'long-stay patients' is likely to increase the work-load and responsibilities of GPs and primary health care teams. Although the actual numbers of former 'long-stay patients' joining each GP's list may be very small they are a profoundly disabled group with extensive and continuing needs for services. Managing Mental Health Problems in Primary Care The part played by GPs in detecting and treating psychological problems has been well documented. In Britain, 98% of the population are registered with a GP and 60 - 70% consult their GP in any year. It has been reported that 14% of those who consult in a year do so for problems diagnosed by GPs as largely

Page 42: The Blackthorn Garden Project - Centre for Mental Health

42The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

psychological in origin (Shepherd et al., 1966) while a further 10 -12% may have mental health problems which are not detected by their GPs (Goldberg and Blackwell, 1970) - although there is considerable variation between different surveys. The extent to which problems are labelled as 'psychological' varies greatly amongst GPs (Shepherd et al., 1966) and may relate to the characteristics of the doctor, the type of patient and perhaps to the resources available to deal with psychological distress. Most people diagnosed as having mental health problems are treated in the primary care setting, only 5.5% being referred to the secondary mental health services (HMSO, 1979). Although psychiatrists sometimes assume otherwise, GPs have always played an important part in supporting people with long-term and disabling mental health problems, many of whom have always lived 'in the community'. Surveys of primary care patients have found that approximately 7% had mental health problems lasting longer man one year and just under a quarter of these were severely disabled (Shepherd et al., 1966; Regier et al., 1985). A study of people with schizophrenia who had been discharged from hospital found that five years after discharge 24% were only in contact with their GP (Johnstone et al., 1984). Similarly, Melzer et al., (1991) following people with schizophrenia during their first year after discharge from St Thomas' Hospital, found that GPs were the professionals with whom they were most likely to be in contact. How does having people with long-term mental health problems on their list affect the workload of GPs? A survey of 13 general practices in London has shown that patients with schizophrenia consulted their GP more often than the 'average' patient but with similar frequency to those with chronic physical disorders. Patients with schizophrenia also presented more often with physical complaints than the average patient (Nazareth et al., 1993). The poor physical health of people with long-term mental health problems (Brugha et al., 1989) may lead to GPs concentrating on physical problems rather than actively managing the mental illness. A survey of GPs in the South-West Thames Region found that only nine out of 369 respondents had specific practice policies for looking after patients with long-term mental health problems and 287 felt that such patients only came to their attention when there was a crisis (Kendrick et al.,1991).

Page 43: The Blackthorn Garden Project - Centre for Mental Health

43The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

A 'Keystone of Community Psychiatry'? The World Health Organisation Working Group on Psychiatry and Medical Care (1973) identified the primary medical care team as 'the keystone of community psychiatry'. 12 years later, the House of Commons Social Services Committee (1985) reported that 'Community Care depends to a large extent on the continuing capacity of GPs to provide primary medical care to mentally disabled people'. In 1992, one of the three mental health targets of The Health of the Nation (Secretary of State for Health, 1992) was 'to improve significantly the health and social functioning of mentally ill people' - a target which needs to be addressed by both primary and secondary care services. The World Health Organisation have outlined reasons why GPs are well placed to provide primary care for mental illness (WHO, 1973). These include the tendencies of physical and mental illnesses to co-exist and for many people with mental health problems to present with physical complaints and not to consider themselves to have psychological problems. Many psychological disorders are related to family and social difficulties which are often known to GPs and GPs are able to provide long-term support without frequent changes of personnel. However, providing care for people with long-term and disabling mental health problems in general practice presents some particular problems. Such patients require input from a number of sources combined with regular assessment of their needs. They are heavily dependent on specialist services such as day care or residential care to enable them to remain out of hospital and the GP's contact with such services may be limited. Although these patients may present to GPs for physical health problems or in crises, such consultations do not provide good opportunities for coordinating overall care. Furthermore, they may be 'lost to follow-up', and the 'demand-led' nature of general practice does not easily adapt to the 'assertive outreach' needed to prevent deterioration (Tantam and Goldberg, 1991). Hence as 'care in the community' develops, primary and secondary mental health services need to find new ways of working together aimed at those with long-term disabling mental health problems so that this vulnerable (and historically deprived) group receives appropriate care.

Page 44: The Blackthorn Garden Project - Centre for Mental Health

44The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

What are the Risks of Combining Community Care with Primary Care? One of the concerns about setting up community care projects in primary care settings is the risk that they may gradually cease to focus on those whom they were set up to target. For example, projects set up to provide a service for people with serious mental health problems may come to concentrate on the much larger population with self-limiting disorders found within general practice. One example of this problem has arisen with the increasing tendency to link community psychiatric nurses (CPNs) to primary care. Approximately half the referrals to CPNs now come directly from GPs. Although the CPN service originally developed to enable people with severe mental health problems to live in the community, those attached to primary care are tending to work with a less disabled group - who often have neurotic problems (Wooff et al., 1983; White, 1990). The benefits of CPN input to those with neurotic disorders remain uncertain (e.g. Gournay and Brooking, 1992) and this trend inevitably reduces the service available for the severely mentally ill. A second way in which resources within primary care may be directed towards those with less severe mental health problems is the increasing employment of counsellors within general practice. A third of general practices within England and Wales now have a dedicated counsellor (Sibbald et al., 1993) as do nearly half of all fundholding practices (BMJ, 1994). However, the expansion of counselling services within primary care has occurred largely without evaluation of the efficacy and cost-effectiveness of such a service (King, 1994). Again this raises concerns as to whether resources for community care diverted to primary care settings will be used appropriately for those with severe and disabling disorders. The advent of fundholding in general practice increases the opportunity for developing appropriate local services but also the risk that the needs of certain groups maybe forgotten. Since April 1993, GP fundholders have been able to purchase community and outpatient mental health services and services for people with learning disabilities. Concern has been expressed that fundholders may buy specialist mental health services for people who have traditionally been treated effectively within primary care while failing to make provision for people with schizophrenia and other disabling conditions. This is despite guidance from the National Health Service Management Executive that with

Page 45: The Blackthorn Garden Project - Centre for Mental Health

45The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

the extension of GP fundholding in April 1993, skilled psychiatric care should be concentrated on the more severely mentally ill (NHSME, 1992). One way of avoiding this problem is to ensure that fundholders are aware of the needs of people with long-term and severe mental health problems and the effectiveness of services targeting them, as well as their obligation as purchasers to contribute to the targets of the Health of the Nation. Liaison between primary care and secondary mental health services, and between GPs, Family Health Services Authorities and District Health Authorities will help to ensure a balance between the needs of practice populations and the needs of small groups with serious or disabling conditions who require special care. GPs and primary health care teams will also need to develop specific policies for identifying and supporting people with long-term mental health problems on their practice lists. New Approaches to Integrating Primary and Community Care The traditional approach to integrating primary care and secondary mental health services has been for psychiatrists and other mental health workers to visit general practices – holding clinics or providing advice. However, a few general practices have developed services aimed at people with long-term disabling mental health problems from within the practice, rather than importing professionals from other services. A 'case-manager' in primary care One approach to ensuring that people with long-term disabling mental health problems receive appropriate continuing care was developed by a Streatham Vale general practice with approximately 8,000 patients. (Cohen, 1992) They employed a 'case-manager' within the primary health care team to identify people with long-term disabling mental health problems on the practice list, assess their functioning and co-ordinate the various services needed to 'maximise their functioning and sense of well-being in the community'. This meant addressing needs such as accommodation and employment as well as mental health, physical problems and medication. The 'case-manager' employed was trained as a community psychiatric nurse, had a diploma in counselling and some social work experience. To ensure that her

Page 46: The Blackthorn Garden Project - Centre for Mental Health

46The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

work did not 'drift away' from people with long-term mental health problems her contract of employment specified this target group only. The post was set up as an integral part of the primary health care team and the practice (now fundholding) received 70% reimbursement for the cost of the salary from the Family Health Services Authority. Blackthorn Garden - A community project linked to primary care Blackthorn Garden represents an even more ambitious attempt to integrate the care of people with long-term mental health problems within primary care. It provides a continuing source of rehabilitation and support for people with chronic mental and physical problems, and it was probably the first work project for people with such problems to be created in a primary care setting. The development of the community care project alongside the Blackthorn General Practice and Trust appeared to increase the social opportunities and status of those using the project. Co-workers and 'volunteers' working in the Garden Project had a variety of strengths as well as of problems and needs -providing many opportunities for mutual understanding and support. They had daily contact with other members of the local community who used the general practice, garden and cafe. The location of the Garden Project on the same site as the (highly valued) Blackthorn Medical Centre helped to reduce the stigma attached to mental health problems - and symbolised the permeable boundaries of the Garden Project and the Trust. People with psychological problems who normally would not consider referral to the psychiatric services could be persuaded to visit the Garden Project and often to join in. Similarly, for people who tended to 'somatise' their problems, joining the Garden Project did not mean accepting a mental health label as not everyone working there had psychological needs. The close relationship between the Garden Project and the general practice seemed also to benefit co-workers' families. When mental health care is transferred from hospital to community settings, families may have to play a greater part in supporting relatives with mental health problems who would previously have been admitted for treatment. At Blackthorn, families appeared to appreciate the proximity of the project and the possibility of keeping closely in touch with GPs and project staff. Several members of a family (with or without identified needs) might be involved in activities in the Garden Project

Page 47: The Blackthorn Garden Project - Centre for Mental Health

47The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

or the Trust - enabling a form of sharing and identification not usually possible in mental health services. Staff in the Garden Project reported a number of benefits from working closely with the primary health care team and the therapists working in the Trust. Weekly meetings with the GPs and therapists provided a forum in which different views of the co-workers/patients could be shared. Co-workers' needs could be addressed from a variety of perspectives including emotional, biographical, social and nutritional. GPs could help the Garden Project staff to understand the positive and negative symptoms experienced by co-workers with schizophrenia and the side-effects of medication. Creative therapists could supply new insights into working with people who did not seem to improve with conventional techniques. The project workers could provide feedback on how co-workers were developing in the project. If a crisis occurred the project staff knew that a quick response could be obtained from the GPs - who could in turn alert the mental health services - and this helped them to create a containing atmosphere for individuals who were distressed and disturbed by their symptoms. The four GPs also appreciated the relationship between the Blackthorn Garden Project Trust and General Practice. The weekly meetings and the GPs roles as Medical Officers to the Trust and Garden Project ensured good communication. There was regular feedback and discussion of co-workers and GPs were informed if co-workers failed to turn up. They could liaise with the GPs of co-workers referred from other practices - for example, to suggest changes in medication. There was appreciation of the team approach in working with people with chronic and disabling problems - a process described by one of the GPs as 'piecing a puzzle together to see how people could be helped'. One GP felt that he had learnt to focus primarily on the person and only secondarily on the illness. Another found it encouraging to see people with chronic health problems doing something useful and taking pride in their work. At Blackthorn, the combination of the creative therapies and the general practice arose from the need to find new ways of working with and sharing the burden of chronic illnesses resistant to medical treatments. However, although the Garden Project shared the care of people on the practice list who had long-term disabling problems, it also attracted new referrals from psychiatrists

Page 48: The Blackthorn Garden Project - Centre for Mental Health

48The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

and other agencies of patients who had not been helped by conventional treatments. While this must have increased the challenge of the work, it did not appear to have over-burdened the Garden Project or the general practice. One of the Medical Officers and the Project Director were able to closely monitor in-patients attending the project from the local psychiatric hospital, liaise with the medical and nursing staff and contribute to discharge planning. Staff in the Garden Project commented particularly on the project's relationship with other mental health services. They felt that the project could offer co-workers a consistency and continuity of care often lacking in traditional mental health services where there may be frequent changes of staff and moves between in-patient, day-patient and out-patient care. The Director saw the Garden Project taking on a co-ordinating role - developing relationships and bringing professional mental health workers and primary care workers together. Staff felt that they could help mental health professionals to see the healthy as well as the ill side of the co-workers under their care - something that is difficult to do when contact is limited to a hospital or out-patient setting. The views of a small group of professionals from agencies referring to the Garden Project were obtained in October 1994 by Orly Klein, a researcher from The Sainsbury Centre for Mental Health. They comprised two GPs from other Maidstone practices, a social worker and a manager from Kent Social Services, a consultant psychiatrist, a ward manager and a senior manager from the local NHS Trust. All felt that the project provided an effective and much needed service to a wide range of people of different ages and backgrounds, including those with long-term mental health problems such as schizophrenia. A few felt that the project was not suitable for those with acute illnesses or that it was not directed at that group. Some felt that the Garden Project had successfully avoided the segregation between physical and mental disabilities commonly found elsewhere and that this was helped by its location in a primary care setting. All stressed the value of the project's welcoming, friendly and accepting atmosphere, its importance to those who were socially isolated and its high reputation amongst the co-workers - some of whom had asked to be referred. One referrer commented:

'You can be sure that anyone you send there will enjoy themselves and feel highly valued.'

Page 49: The Blackthorn Garden Project - Centre for Mental Health

49The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Two felt that while the project had been successful in creating a safe environment and a sense of community, it might not prepare co-workers for the demands of life outside:

'The centre is a very quiet, controlled, safe place to be - almost monastic - but the rest of the world isn't like that'

Those interviewed praised the Garden Project's success in providing meaningful activity while taking into account individual co-workers' needs and enabling them to realise their potential. Two expressed concern that few co-workers moved on to open employment and felt that links with other employment projects might be helpful. The Garden Project's location within a primary care setting was viewed positively and was felt to reduce the stigma associated with mental health problems. The informal approach and the lack of 'professional' barriers between the staff and co-workers - reflected in the shared meals and the use of first names -were also valued. One professional remarked:

'Other services could learn a lot from the way in which they treat people.' The lack of professional barriers was seen as one of the benefits of having staff without formal training in psychiatry or experience in the statutory services. Despite the informal approach the project was felt to be maintaining high standards and providing a consistent service - though two referrers felt that the time taken to assess new referrals was too long

"The centre has to become more "market wise" if it's going to be able to sustain itself.'

Overall the project was highly valued as a local resource for people with long-term mental health problems. However, there was a feeling that the drive and commitment behind Blackthorn Garden were exceptional and that as a result it might be difficult to replicate elsewhere:

'It's a special place, a one-off run by two exceptional and extraordinary men who clearly have a vocation.'

Page 50: The Blackthorn Garden Project - Centre for Mental Health

50The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Summary General practice has always played an important part in supporting individuals with long-term and disabling mental health problems in the community, but the Blackthorn Trust and General Practice have extended this role by developing a work rehabilitation and community care project in a primary care setting. The Garden Project's close relationship with the general practice appeared to benefit the co-workers, their families, the project staff and the GPs and the project fulfils many of the criteria felt to be necessary for an effective community mental health service.

Page 51: The Blackthorn Garden Project - Centre for Mental Health

51The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

5. Conclusions This study of the first two years of Blackthorn Garden highlights the importance of sheltered work and community in sustaining and rehabilitating people with mental health problems and other chronic illnesses. GP fundholders and other purchasers need to consider these needs as well as the generally recognised requirements for day centre places, CPNs and hospital beds. The study also indicates how the support offered by primary care services to people with mental health problems could be extended to provide more comprehensive community services. This is an important message for both primary care and secondary mental health services - which frequently function almost independently. People with chronic and disabling illnesses who are referred to Blackthorn Garden go there in order to work. The work gives them a sense of meaning, purpose and a social identity. It successfully 'calls on the strong and healthy side of the co-workers rather than focusing on their illnesses'. The variety of tasks available in the Blackthorn kitchen, cafe and garden makes it possible to engage individuals with a range of problems and needs. Co-workers interviewed by the researchers appreciated the opportunities to work, to contribute, to be productive and to share in the project's achievements. Working in Blackthorn Garden also provides co-workers who may be isolated and alienated by their illnesses with friendship, a sense of belonging and social support. The project functions as an intentionally created community 'with' and not 'for' people with mental health problems and other chronic illnesses. When interviewed, co-workers emphasised the importance of the company and the warm and friendly atmosphere. At the same time the boundaries of the Garden Project are permeable, it provides services to the community and it involves local people and other patients of the general practice and Trust. This helps the co-workers to remain in the 'mainstream of modern life' and the stigma attached to using mental health services is reduced. Blackthorn Garden illustrates how a 'bottom-up' approach can be used to provide community support for people with mental health problems -including those previously treated in the large psychiatric hospitals. The project has evolved to meet the needs of people with chronic illnesses in the local population and works closely with the general practice. However, this sort of 'bottom-up' approach is not without risks - in particular that the service may gradually cease to focus on

Page 52: The Blackthorn Garden Project - Centre for Mental Health

52The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

people with the most severe and disabling problems. It is essential to define the needs of this group at the start of any new project and (as in Blackthorn Garden) to make a commitment to meet them. This commitment may need to be spelt out in operational policies and even in job descriptions. In addition, because people with long-term mental health problems have multiple and complex needs, links with other mental health services are important. Blackthorn Garden has established links with a number of agencies involved in mental health and community care and when necessary is able to draw on their experience and support. Mental health professionals may be an important source of training and advice to staff in primary care settings while GPs are well placed to take on the role of 'keyworker' in the Care Programme Approach - co-ordinating input to individuals supported by local services. The question of financing community care projects based in primary care settings raises particular issues. Although the Blackthorn Garden Project was set up by a non-fundholding general practice, the extension of fundholding may increase the opportunities for GPs to create these types of projects. In its first two years Blackthorn Garden successfully managed to attract funding from Health and from Social Services. Should such primary care projects develop more widely then there will inevitably be an overall loss of resources from the secondary mental health services. If this happens it will be essential to ensure that these resources are used to support people with severe mental health problems via primary care and not diverted to other groups (such as those with self-limiting or less severe mental health problems) or to other services (such as the acute medical or surgical specialities). However, at present almost all the money spent on mental health remains with the secondary services and securing funding may present a hurdle to primary care teams considering community care projects. Even if resources are devolved to primary care it may be difficult for a single group practice to meet the whole spectrum of need in the local population. Specialised projects - such as accommodation with 24 hour support - may need to provide for individuals from a number of practice populations. More local projects may be too small to be viable. One solution to this problem, which already operates in some areas, is for GPs to support and work closely with specialised projects while mental health teams in Health and Social Services co-ordinate individual placements and overall provision. However, in contrast to this approach, Blackthorn Garden functions as a local primary care project

Page 53: The Blackthorn Garden Project - Centre for Mental Health

53The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

which serves its practice population without direct input from mental health specialists. It can do so successfully because work and community have important roles in supporting and rehabilitating people with a variety of problems (both mental and physical, short-term and long-term), because the project offers a wide range of opportunities and because it takes referrals from GPs outside the practice area, from the local psychiatric hospital and from Social Services. Blackthorn Garden has successfully engaged women as well as men, adolescents and retired people as well as those of working age and people with learning difficulties, physical disabilities and mental health problems. Finally, although the policies of hospital closure and deinstitutionalisation have been operating for over 30 years, in many areas the future shape of community mental health services remains uncertain. Frequently such services are conceptualised solely in terms of moving mental health professionals from a hospital to a community mental health centre or similar base. Blackthorn Garden serves as one model of how primary care services could become 'keystones of community psychiatry' - providing a different base on which other community mental health services might be built.

Page 54: The Blackthorn Garden Project - Centre for Mental Health

54The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Appendix 1: The Blackthorn Trust and the Anthroposophical Approach

The Blackthorn Trust The Blackthorn Trust developed out of attempts by a Maidstone GP (Dr David McGavin) to find better ways of supporting patients with chronic and disabling illnesses. He challenged an art therapist (Hazel Adams) who was trained in the anthroposophical approach to work with some of his most 'difficult' patients. She was shortly joined by a counsellor and another creative therapist. The success of their combined efforts led to the establishment in 1985 of the Blackthorn Trust as a registered charity to provide complementary therapies to patients who had not responded to conventional medical treatments. The Trust and the general practice were initially based in a small house in a suburban area of Maidstone. At the end of 1991, as a result of substantial fundraising efforts both the Trust and the general practice moved to new premises within the practice area. A new medical centre had been built on land belonging to the District Health Authority on the edge of the grounds of a psychiatric hospital which was in the process of closure. The medical centre had been designed by Camphill Architects to provide a therapeutic environment for the work of the Trust. The Family Health Services Authority pays rent to the Trust for the part of the medical centre used by the general practice and sharing the same building enables the Trust and general practice to work closely together. The Trust provides free treatment to patients referred by their GPs. During the period of the study, it received funding from Kent Family Health Services Authority, the South-East Thames Regional Health Authority^Maidstone Health Authority and Kent County Council Social Services. It also received gifts from patients and their families, the local community, businesses and charitable organisations. In the year 1991 -1992 the Trust treated 217patients. In 1992 - 1993 the Trust took on 151 new patients, 52 of whom had been referred by GPs from other practices or by hospital consultants. At the time of the study the staff team based in the Blackthorn Medical Centre consisted of four GP principals, a practice manager, six part-time receptionists,

Page 55: The Blackthorn Garden Project - Centre for Mental Health

55The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

a practice nurse, two district nurses, an 'outreach co-ordinator,' a counsellor, an art therapist, a music therapist and a eurythmy therapist - the latter three working part-time. The practice manager was responsible for the finance and administration of both the Trust and the NHS partnership. The counsellor and therapists were employed by the GPs and 70% of their salaries were paid by the Family Health Services Authority (FHSA). The therapists also worked in health clinics which attracted further funding from the FHSA. The outreach co-ordinator's post was funded by the NHS and by the Hambland Foundation. She co-ordinated and looked after the volunteers, made links with the local community and led a fund raising committee (the Outreach Committee) and the Friends of Blackthorn Charity shop. In addition, one of the GPs spent two sessions a week working directly for the Trust which reimbursed the general practice for his time. One of the most striking things about the development of the Blackthorn Trust was the commitment shown by members of the local community to supporting and raising funds for the Trust and in particular for the Blackthorn Medical Centre. Fundraising was essential to pay off loans on the new building and to make up the costs of the therapies provided by the Trust. As well as attracting donations and covenants, the Outreach Committee organised a steady stream of small fundraising events, and profits from the Blackthorn Charity Shop (run by volunteers) went to the Trust. There was a strong sense that the Trust belonged to the local community - probably deriving in part from its close relationship with the general practice. Anthroposophical Medicine The work of the Blackthorn Trust is greatly influenced by anthroposophical medicine - a form of complementary medicine based on the work of the Austrian philosopher Rudolf Steiner (1861 -1925). In Britain, it is practised by individual doctors (all of whom are registered medical practitioners) and by a small number of practices and residential clinics. An Anthroposophical Medical Association exists to support their work. The anthroposophical approach addresses the interaction between the physical, psychological and spiritual elements of human life. In the Blackthorn Trust and General Practice it is used in addition (rather than as an alternative) to conventional medical techniques. Therapies offered by the Trust and

Page 56: The Blackthorn Garden Project - Centre for Mental Health

56The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

influenced by anthroposophy include the creative (artistic) therapies, counselling and group work. In addition, the GPs prescribe some anthroposophical and homeopathic remedies as well as the usual range of drug treatments found in general practice. The Creative Therapies The anthroposophical creative (or "artistic') therapies developed from the work of Rudolf Steiner. Creative therapies offered by the Blackthorn Trust include music therapy, art therapy and eurythmy. They are used to stimulate healing by activating creative potential and by the use of individually tailored exercises which enable patients to take an active part in their recovery from illness. Music therapy Music therapy uses music as a healing force which works particularly via the feelings and emotions. It can also help with relaxation and concentration. At Blackthorn music therapy is a shared activity which helps to build confidence and self-esteem. The Music Therapist has acquired a number of instruments which beginners find simple to play, including lyres, gongs, cymbals, drums and flutes. The Trust was awarded a grant by the British Society for Music Therapy to explore the therapeutic use of percussion instruments. Art therapy The form of art therapy practised in the Trust uses a synthesising approach, rather than the traditional analytical or diagnostic forms inspired by Freudian or Jungian theories. The Trust Art Therapist described her work thus: 'In painting, colour exercises are used which support natural rhythms, particularly breathing, to re-establish healthy activity. Where emotional life is either cramped or florid, a more balanced path of expression is facilitated. Drawing is used to help direction and focus of concentration. Sculpture exercises engage the will in inner movement, encouraging exploration of rhythms in form between chaos and paralysis.' Eurythmy therapy Eurythmy is a therapy based on posture and movement. It has developed from a complex theory which relates particular bodily movements or gestures to movements made by the larynx, lips, teeth and tongue in speech. The exercises

Page 57: The Blackthorn Garden Project - Centre for Mental Health

57The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

aim to increase bodily awareness, reunite thoughts, feelings and actions and develop a sense of rhythm (Evans and Rodger, 1992). When used in groups the exercises help to promote interaction and reciprocity. At Blackthorn they also seem to promote concentration and to increase the co-ordination of patients troubled by the Parkinsonian side-effects of anti-psychotic medication, or disabled by conditions such as cerebral palsy. Counselling and Group Work Individual counselling gives patients not only the opportunity to share and work through distress, but also to understand why illness has occurred and to take responsibility for their health. Many of the patients of the Trust are socially isolated or suffer from low self-esteem often as result of chronic or disabling illnesses. They benefit particularly from group work. For example, the 'Monday Confidence Group' includes singing, outings and discussions where problems can be shared and help and advice offered by members of the group. In the case of the Craft Group the focus is to raise funds for the Trust, but its weekly meetings also provide a source of company and friendship. Biodynamic Agriculture The Blackthorn Garden Project uses biodynamic agriculture - an organic and ecological approach to horticulture based on the teachings of Rudolf Steiner. This holistic approach regards the land as a living organism whose health must be maintained in order to preserve the population's health and that of future generations. Artificial chemicals are avoided and organic preparations are used in homeopathic doses. In addition, natural rhythms such as the seasons and the phases of the moon are taken into account when sowing or planting. Further Reading Further information about anthroposophical medicine and the anthroposophical approach can be obtained from the following sources: Evans, M. and Rodger, I. (1992) Anthroposophical Medicine, London: Thorsons.

Page 58: The Blackthorn Garden Project - Centre for Mental Health

58The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Lissau, R. (1987) Rudolf Steiner. Life, Work, Inner Path and Social Initiatives, Hawthorn Press. Pietzner, C. (ed) (1990) A Candle on the Hill. Images ofCamphill Life, Floris Books. Weihs, A. and Tallo, J. (eds) (1988) Camphill Villages, Camphill Press. Contact Addresses

Tijno Voors, Director of Blackthorn Garden Blackthorn Garden Rear of the Blackthorn Medical Centre St Andrews Road Maidstone Kent ME16 9AN Tel: 01622 725585 The Blackthorn Trust Blackthorn Medical Centre St Andrews Road Maidstone Kent ME16 9AN Tel: 01622 726128

Page 59: The Blackthorn Garden Project - Centre for Mental Health

59The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Appendix 2: What Effect Has Blackthorn Garden Had on You? At the end of the second year interviews, co-workers were asked to spend five minutes writing down what effect they thought the Blackthorn Garden Project had had on them: 'It has enabled me to overcome and work in a positive manner with my disability, especially through the care and understanding of everyone connected with the Blackthorn Garden. Ifoundlhave become more confident in working with people and in doing so have grown in strength myself.'

'Given me back some confidence, made new friends, made me feel useful -not useless, put structure back into my life.'

'Becoming more confident and doing work. For the time I'm here I can forget about the illness and I think more nice things like colours and plants and I feel I learn things.'

'Working in the Blackthorn Garden has made me feel part of a family, increased my self-confidence and communication skills and given me some solid work to create solid achievements which the whole wider community can enjoy.'

'When 1 first came I was a bit apprehensive about how I would get on -but I needn't have worried. I was made to feel really wanted. It was like one happy family - everyone was so friendly and supportive.'

'Since coming here, I have gained a lot more confidence and made more friends.'

'It makes my day when I come here makes me feel wanted, made welcome and the Director is very kind - always has a word if you feel lost - and all the staff are very kind and communicative. Never feel pushed aside or unwanted.' 'Since we started coming to the Garden I have become more optimistic about the future and more confident within myself.'

Page 60: The Blackthorn Garden Project - Centre for Mental Health

60The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

"The Blackthorn has given me a new interest in life and broadened my outlook. More confidence. Given me something else to think about when I'm not here.' 'It's made a lot of difference. I don't have so many arguments with my parents now - made me a lot happier.' 'I know I was pretty bad at the beginning and I feel I could see myself slowly getting better. Since May this year I felt stronger on my feet (physically and mentally). I was very shy, had agoraphobia and panic attacks. Now I feel better than I did at the beginning.' 'Made me more confident at doing things, got me meeting more people and got me knowing things. Knowing what life is about as well - what I didn't know before. When I was in school I was in a closed-in world, didn't know what life was like - or work. Always in a remedial class - trying to pick up the pieces now and make my own life.' 'Make me a lot calmer.'

'Learning to be more accepting of my situation and accepting of my "failures" - not to be too critical of me and to accept it's OK to say NO. To be more open minded and tolerant. To slow down rather than run through life and to accept mind controls body and not body controls mind.' 'Learnt about horticulture. Picked up some principles ofbiodynamic gardening. Know how to re-pot cuttings of plants. Know how to prepare organic composts. Learnt how to use a strimmer correctly. Picked up tips on bread-making. Started to talk to people - i.e. isolation has got less. Shared some problems with fellow co-workers. Made some cuttings from plants. Made some friends. Makes my life into more of a routine - i.e. I have some systematic time-keeping to my life. Set back into a working routine.

Got physically fitter.'

Page 61: The Blackthorn Garden Project - Centre for Mental Health

61The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

'Has given me an opportunity to mix with people in a relaxed atmosphere and to establish friendships, albeit only once a week. Provided a positive requirement to my life. I have to attend the kitchen for a day's work at a specific time each week - (this rigid requirement has filled an emptiness of which I am very aware). I feel lam contributing something to Blackthorn and hope others see it that way.'

'Looking at nature - realising it is God's creation - peace - preserving the plant garden for the future. People who are ill supporting each other, the staff giving their support, making new friends, understanding each other better, a place of security like a retreat.'

'I think that it has proven a great help - in the way that I felt from the start that someone or several people were thinking with me, aware of my problems out there and then finally when I became more settled and got down, humility and all to see that I wasn't such a special person (this helping me in a second phase to find that I'd better deal with myself before worrying about others). It was a time in the week to share some time in creating nice things - related to nature - getting out a bit, relating to others. Now generally it is the peaceful time, more settled and quiet, simply seeing different faces and facing small challenges and building on friendly acquaintanceship.'

'Apart from somewhere to come for a few hours nothing. Didn't feel the same after a particular incident, enjoyed it before - doing 3/4 days, building it up - didn't like getting blamed.'

'Can't remember really (from the beginning). It’s worked on me really well. I've been well recently and if I'm not well they speak to me, take me to hospital.'

'I have developed a clearer mind and relaxed body and mind – continuation and recuperation.. Blackthorn Garden has given me an introduction to a wide range of friends. Developed a good working life. Rise in salary.' 'It's given me a spare day in the week to be out of the house, away from the wife - benefit to both of us not to be together all the while - doctor suggested

Page 62: The Blackthorn Garden Project - Centre for Mental Health

62The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

this, personally don't agree.' 'Have got more confidence in myself. It gets me up in the morning as I know I have got somewhere useful to go.' 'I like coming here.' 'It gave me the motivation to think about work in a different perspective. Having joined Blackthorn I have had a flexible programmeand I have been allowed time to be concerned about being ill, thus causing the natural changes of temperament that have led to my upturn in mood which has allowed the pattern of good health that is evident today. The garden and bakery both share a relaxed atmosphere, but the kitchen is a challenge. That I can at least get some credit from.' ‘The biggest thing has been to help my self-reliance and make a few decisions. It has helped my confidence in the garden and at home and the opportunity to carry out jobs on my own. Mixing with more people also increases confidence and the ability to communicate with others, because I do not find this very easy. I do enjoy my day in the garden, but think another day might be too much because my wife and I do try to get out and do other things. I am quite willing, however, to fill in and help with any extra projects if I am able.' ‘The Blackthorn Garden Project had a very important effect on me last year in giving me a new focus at a time when I felt in despair within a marriage I couldn't cope with and enabled me to envisage and eventually embark on a new life as a single person again, linked to a community to which I now live close by. It now provides me with a friendly environment to which I can come at any time, gardening and other activities I can participate in, and a circle of companions some of which are now becoming friends.’ 'I find that Blackthorn helps me go through life with much more activity - otherwise it would just be going to work. Also, there are people that you meet and get to know and communicate with, there also is a break from your own home and you can enjoy the food.' 'More outgoing. Started with Blackthorn friendships (not a coffee-morning person). Took early retirement - kick-started myself to do other

Page 63: The Blackthorn Garden Project - Centre for Mental Health

63The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

things.' 'It is hard to distill the exact effects the Blackthorn Garden has had because there have also been a number of significant influences - viz Blackthorn [Medical Centre] as a medical therapeutic centre and the ParkAttwood Clinic [an anthroposophical clinic] + the Alexander Technique - whose influence is continuous in various ways. But the Garden cafe has given me:

1. The ability to stand upright and say "I work". That is very important and a realisation that is gradual.

2. It has given me the ability to cope with grey or even black days and

periods without being overdramatic. This has been done with the caring being firm and turning always to doing something as a service for others rather than an inward reflection leading to despair.

3. It has given me the ability to notice that I know I am not at heart a

loving person and that if that side of me is to grow - i.e. my feeling life, I have to work at it.

4. It has converted me to realising that there is dignity in working with

the hands, that this is no less intellectual than a so called intellectual occupation.

5. It has taught me how to not be so afraid of other people but take them as

they are. It has done this out of the realm of forcing me to come to terms with all around me here. I am beginning to get to the point where I can actually begin by liking people whereas it used to take me many months before I could really stop being fearful - indeed if I ever did. And this has come through an understanding of human character beginning to build so that I can start to see others as they actually are.’

Page 64: The Blackthorn Garden Project - Centre for Mental Health

64The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

References American Psychiatric Association (1987) 'Diagnostic and Statistical Manual of Mental Disorders' (Third Edition - Revised), American Psychiatric Association, Washington DC.

Beck, A., Ward, C, Mendelson, M., Mock, J. and Erbaugh, J. (1961) 'An Inventory for Measuring Depression', Archives of General Psychiatry, 4, 561-585.

British Medical Journal (1994) 'Value of Counsellors Questioned', British Medical Journal, 308,1186.

Brugha, T., Wing, J. and Smith, B. (1989) 'Physical Hi-Health of the Long-Term Mentally 111 in the Community. Is there an Unmet Need?', British Journal of Psychiatry, 155,777 - 782.

Cohen, A. (1992) 'A GP's Role', Presentation to the RDP course Developing Services for People with hong-Term Mental Health Problems.

Dean, C. (1988) Tsychiatry in General Practice' in Kendell, R. and Zealley, A. (eds), Companion to Psychiatric Studies, Churchill Livingstone, Edinburgh.

Evans, M. and Rodger, I. (1992) Anthroposophical Medicine, Thorsons, London.

Goldberg, D. and Blackwell, B. (1970) 'Psychiatric Illness in a Primary Care Setting', British Medical Journal, No. 2,439 - 443.

Gournay, K. and Brooking, J. (1992) An Evaluation of the Effectiveness of Community Psychiatric Nurses in Treating Patients with Minor Mental Disorders in Primary Care, Report to the Department of Health, London.

Her Majesty's Stationery Office (1979) 'Morbidity Statistics for General Practice - Second National Study 1971 - 1972' in Studies on Medical Population Subjects, No 36, HMSO, London.

House of Commons Social Services Committee (1985) Community Care (Second Report), HMSO, London.

Johnstone, E., Owens, D., Gold, A., Crow, T. and MacMillan, J. (1984) 'Schizophrenic Patients Discharged from Hospital: a Follow-Up Study', British Journal of Psychiatry, 145,586 - 590.

Page 65: The Blackthorn Garden Project - Centre for Mental Health

65The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Kendrick, T., Sibbald, B., Burns, T. and Freeling, P. (1991) 'Role of General Practitioners in Care of Long-Term Mentally 111 Patients', British Medical Journal, 302,508 -510.

King, M. (1994) 'Counselling Services in General Practice. The Need for Evaluation', Psychiatric Bulletin, 18,65 - 67.

Leff, J. (1994) Team for the Assessment of Psychiatric Services. 9th Annual Conference, 21st July, 1994.

Lorefice, L. and Borus, J. (1984) 'Consumer Evaluation of a Community Mental Health Service 2: Perceptions of Clinical Care', American Journal of Psychiatry, 141(ii), 1449 -1452.

Melzer, D., Hale, A., Malik, S., Hogman, G. and Wood, S. (1991) 'Community Care for Patients with Schizophrenia One Year After Hospital Discharge', British Medical Journal, 303,1023 -1026.

National Health Service Management Executive (1992) Guidance on the Extension of the Hospital and Community Health Services Elements of the GP Fundholding Scheme from 1 April 1993, EL(92)48, Health Care Directorate, London.

Nazareth, L, King, M., Haines, A., See Tai, S. and Hall, G. (1993) 'Care of Schizophrenia in General Practice', British Medical Journal, 307,910.

Nehring, J., Hill, R. and Poole, L. (1993) Work, Empowerment and Community: Opportunities for People with Long-Term Mental Health Problems, An RDP Study of Four New Work Projects, RDP, London.

O'Dowd, T., (1988) 'Five Years of Heartsink Patients in General Practice', British Medical Journal, 297,528 - 530.

Overall, J. and Gorham, D. (1962) "The Brief Psychiatric Rating Scale', Psychological Reports, 10,739 - 812.

Regier, D., Burke, J., Mandersheid, R. and Burns, B. (1985) 'The Chronically Mentally 111 in Primary Care', Psychological Medicine, 15,265 - 273.

Secretary of State for Health (1992) The Health of the Nation, HMSO, London.

Shepherd, M., Cooper, B., Brown, A. and Kalton, G. (1966) Psychiatric Illness in General Practice, Oxford University Press.

Page 66: The Blackthorn Garden Project - Centre for Mental Health

66The Blackthorn Garden Project © The Sainsbury Centre for Mental Health, 1995

Sibbald, B., Addington-Hall, J., Brenneman, D. and Freeling, P. (1993) 'Counsellors in English and Welsh General Practices: Their Nature and Distribution', British Medical Journal, 306,29 - 33.

Spielberger, C, Gorsuch, R. and Luschene, R. (1970) The State-Trait Anxiety Inventory, Consulting Psychologists Press, Palo Alto.

Tantam, D. and Goldberg, D. (1991) 'Primary Medical Care' in Bennett, D. and Freeman, H. (eds), Community Psychiatry, Churchill Livingstone.

White, E. (1990) The Third Quinquennial Survey of Community Psychiatric Nurses, Manchester University, Manchester.

Wing, J. and Brown, G. (1970) Institutionalism and Schizophrenia, Cambridge University Press, Cambridge.

Wooff, K., Freeman, H. and Fryers, T. (1983) 'Psychiatric Service Use in Salford: a Comparison of Point-Prevalence Ratios 1968 and 1978', British Journal of Psychiatry, 142,588 - 597.

World Health Organisation (1973) Psychiatry and Primary Medical Care, WHO, Copenhagen, Denmark.

World Health Organisation (1992) ICD-10 Classification of Mental and Behavioural Disorders, WHO, Geneva.

Wykes, T. and Sturt, E. (1986) "The Measurement of Social Behaviour in Psychiatric Patients: an Assessment of the Reliability and Validity of the Social Behaviour Schedule', British Journal of Psychiatry, 148,1-11.


Recommended