Working Together: Peer-Supported Mental Health
By Ashley Opp
Photo: At Tasks Unlimited, all clients must be
motivated and willing to engage in productive work.
Many people—even the least social of us—live with others. We live with family members, partners, roommates, or friends. Although sharing a living space might not be for everyone, few would dispute the social and emotional benefits that other people can have on one's general well-being. For those with mental illness, being isolated in institutions or pushed into entirely independent living can stymie the progress of rehabilitation and productivity, happiness and hope.
Kristine Haertl, PhD, OTR/L, is associate professor in the Department of Occupational Science and Occupational Therapy at the College of St. Catherine in St. Paul, Minnesota, and chairperson of the Board of Directors for Tasks Unlimited, a large Fairweather-model mental health program. Haertl also maintains a private practice and has served as a consultant to various mental health and developmental disabilities organizations. Among several areas of research, Haertl has studied mental health housing and the effectiveness of the peer-support-based Fairweather model.
Building Peer-Supported Communities
The model, founded by Bill Fairweather in the 1960s, demonstrates that persons with major mental illness can live productive lives in peer-supported communities. Within the model, clients are mostly autonomous from staff. They receive residential, mental health, recreational, wellness, and vocational services, and they are trained in work and basic living skills. Each "lodge" typically houses four to five residents, and each resident has his or her own room. Residents share household chores, and all are expected to work.
There are several Fairweather programs throughout the country, all organized under the National Coalition for Community Living. In Minnesota, Tasks Unlimited serves more than 300 people and is the largest in the nation. There, Haertl helped develop the living-skills-training modules and program to teach clients to live in peer-supported environments. "We teach clients to live together, and they monitor one another's mental health needs, with staff there only 2 hours a week," says Haertl.
Clients living in these peer-supported environments have a range of mental health issues: More than 70% have schizophrenia, and nearly a third have a major affective disorder, such as bipolar disorder or manic depression. Some clients also have dual diagnoses. Because the lodges are considered residential housing rather than health facilities, clients can live there as long as they like—and some have, for more than 30 years.
After 5 years, more than 80% of clients still choose to live in one of the lodges, unlike typical psychiatric rehabilitation in which clients are discharged after about 45 days. Clients also may live elsewhere and receive services from the organization; some have done so well they have bought their own condominiums.
Motivated To Work
Tasks Unlimited is unique in the way it centralizes the role of work, and all clients engage in productive work. "Clients must be willing and motivated to work," says Haertl. "Sometimes people in the mental health system aren't willing to work or are unable to; they remain dependent on disability [payments]."
Nearly all of Tasks Unlimited's clients work for the organization, which owns a multimillion-dollar business that provides janitorial, clerical, and mailroom services. It also buys and refurbishes houses to resell. The organization has the highest wages in supportive employment in Minnesota. In fact, a 10-year follow-up study showed that clients in the program had experienced a 516% increase in their personal wages.
Haertl attributes much of the clients' success to the interdependent nature of the model. "We, including occupational therapists, often focus on independence when, according to the Fairweather model, interdependence is a healthier lifestyle," says Haertl. "We all rely on our friends, family, and peers to live a happy, holistic life. The idea of complete autonomy is really a misnomer because that's not a healthy lifestyle. Our focus is on helping people to help each other versus helping people completely help themselves autonomously, without anybody else."
Changing Lives With Research
Part of Haertl's work implementing the Fairweather model involved research on who is most likely to succeed in the model, and what factors contribute to success, satisfaction, and retention. According to Haertl, "To be successful, individuals have to be willing to work and must be motivated to live in a peer-supported environment, which means they had to be willing to live with four other people and live relatively autonomously from staff."
Results of her study also showed that the comprehensive services, peer support, safety and security, meaningful work and recreation, empowerment, and high quality of life contributed to retention and clients' satisfaction.
After reviewing this research, Minnesota lawmakers revised the statutes regarding mental health models to recognize the Fairweather model as an evidence-based approach to treatment. This change allowed the organization to obtain more funding for its programs in that state. Meanwhile, the Pennsylvania legislature agreed to fund the creation of 21 community homes based on the results of Haertl's study.
Her research also led to follow-up studies that further bolstered the program's effectiveness. A 10-year study of outcomes at Tasks Unlimited showed a 95% reduction in the rate of psychiatric hospitalization, with less than 1% of client time spent in psychiatric hospitalization.
The tenets of occupational therapy fit well with the Fairweather model. "Our unique role is that we understand occupation and meaning and also how to have an optimal client-environment fit," says Haertl. At Tasks Unlimited, she adds, "Occupational therapy practitioners have helped with vocational and living skills training, or if a client is having trouble living in peer-supported environment, the practitioner has a discerning eye to look at the meaningful occupations, look at the client holistically, and make suggestions so that the client can be successful."
Haertl aims much of her work at combating the fear and social stigma that surrounds mental illness. She sees a place for occupational therapy to equip clients who have mental illness to productively live, function, and engage in the world outside of hospitals and long-term institutionalization.
"Occupational therapy has its roots in mental health practice, and we need to advocate for more therapists to work in mental health," she says. "Mental illness is so widespread, yet society often holds to misperceptions and stigma. If we provide the support, training, and resources necessary, we can empower persons with major mental illnesses to live productive, healthy, quality lives."
Ashley Opp is Senior Staff Writer at AOTA.