Participants’ stories revealed facets of the relationship between MHSW and mental health consumers and the belief that when this relationship works, support work works. Borg and Kristiansen (2004) suggest that a measure for defining the quality of the relationship is through the interactions, which in this study is between consumers and mental health support workers. The right environment is created when “services are less illness focused and more person-centred” which is achieved by “developing the roles and competencies of helpers and services in general, towards a more open perspective of what actually helps (and also what hinders) recovery” (Borg & Kristiansen, 2004, p. 501).
John, a consumer advisor employed by a district health board, supports the notion that central to the nature of this work is the ‘relationship’ with clients that works towards being an enabler and the need to ignore the illness altogether.
There seemed to be two main kinds of definitions or understandings of support work and one was that you more or less do stuff for the other person. If they haven’t got anything to eat, you go and get them some food, you might not open their mouth and stuff it in, but you go and get
them food, either because if they don’t they will die or will become ill or will just sit at home all day and smoulder away or they will smoke and so on. So there is that kind of doing something for someone else, something necessary. The other kind of support and the word is sometimes used – endorsement. I think that is the real meaning of the support. Sometimes people need someone to bring them food or some clothes to wear or find themselves somewhere to live or something like that, but to confine support to that is not productive, one it is not productive and two it leaves out the most important part, it doesn’t lead anywhere and doesn’t put anything into context. It gives the person no particular future, it only means you have something to eat now for a day or two or a week and that’s it. What happens next week? It doesn’t lead anywhere, it just responds to the immediate or the mid- term at least. But the other kind of support work happens well, in a kind of paradoxical way, I suppose and idealistically, the support worker ignores the illness altogether, the value of support workers in the endorsement or the appreciation of the other person and the human relationship that comes out of that, because that’s where the future begins because also there could be some discussion around those values of recovery like hope, and I think that comes in here. Whether hope ought to be a fundamental value of recovery, what it actually is and the understanding of hope and whether that is enough. And whether hope implies you actually do something about it or just sit there and wait and so on. I think the whole meaning of hope, so the role and values around support work I think are pretty important. We have to focus on the relationship, because I believe that when that works, support work works and when it doesn’t work, it doesn’t matter what else, you will be doing it forever so what have you achieved? If I come and cook your dinner every night this week, that’s great, but if I am still doing it in 12 months’ time, what has been the point of my work?
You have been fed. And that change where you are starting to cook for yourself, I believe comes through the relationship between you and I and as much about your trust of me as it does about your confidence or motivation to cook dinner. And that’s why I think the relationship is important. I think we forget that when I am thinking about whether I’ve got the confidence to go out and do something or whether I’ve got the skill to do it or even if I can be bothered, a lot of it is my trust of you. I will be in a crisis obviously, but long term we are talking recovery and all of those strengths based models approaches then we have to think about not what I do but what you do. So we have to find some markers and they are kind of markers of satisfaction and they are markers of what that relationship enables me to do. Not what I do, but what it enables me to do and I think that’s the difference and we need to fund for those.
John provides his definition of what he believes mental health support work is. He describes two main, but different approaches: one is what you do for people out of ‘critical necessity’ and the other is what you do for people as an ‘endorsement’. In the former, he describes necessity support work as the ‘doing for’ and defines this as the tasks that are undertaken by the support worker in order to keep the mental health consumer alive. As an example, he suggests that the mental health support worker may cook for the person that they are supporting ‘the doing for’ in order to meet their nutritional needs. However, from John’s perspective, he does not perceive these interactions as a productive role. John is able to take a pragmatic view of this approach by suggesting that these types of tasks may be necessary in order to sustain the person, albeit in the short term. John looks to the future. He does not see the future in the ‘doing for’: instead he sees the future in ‘endorsement’. He uses the word ‘endorsement’ as a way to describe the human-to-human relationship between the mental health support worker and the consumer; he sees the essence of mental health support work is through the ‘endorsement’ of the relationship. From that ‘endorsement’ he foresees ‘hope’ for the future that brings with it ‘hope for recovery’. John’s value system views the nature of the ‘relationship’ as being pivotal; he considers that without the ‘relationship’, the consumer is not empowered to navigate an ‘endorsed’ future, because the mental health support worker will not have created the opportunities that facilitate ‘skill acquisition’ for the consumer. In John’s view, the consumer will not have journeyed through their recovery if they only experience the ‘doing for’, although, as he suggests. they will be well fed. John stresses that the key to building the foundation of the ‘relationship’ is ‘trust’. If relationships are built on hope and trust, recovery is what John sees as their future.
In John’s view, he sees that the ‘relationship’ needs to be measured. He starts to define characteristics within the ‘relationship’ that could be used as a measurement. His first signpost explores what is needed to define what the mental health support worker has done that has ‘enabled’ the consumer to do for themselves (rather than what the consumer has specifically done). He views the enabling part of the relationship as an outcome measure. He further defines this by suggesting that it is the measurement of the ‘relationship’ that should inform how and which services are funded. John clearly sees that there is a difference between mental health support workers and generic support workers. As a way of defining the two groups, John describes the characteristics that differentiate them. He
suggests that both groups may need to undertake tasks from time to time: however, he deems that the task component of the mental health support worker role should only be of short term duration ‘necessity’ as the focus for the mental health support worker should be on the establishment of a long-term ‘enabling’ and ‘trusting relationship’ that is built on ‘hope’ for the future as it seeks ‘recovery’ for the consumer.
What John proposes would provide a significantly different mechanism to what is in place for measuring the effectiveness of mental health services in New Zealand. Mental health and addiction services has a system in place to collect outcome data through activity-based reporting using the reporting mechanism Programme for the Integration of Mental Health Data (PRIMHD).10 John is suggesting that the way in which to measure the effectiveness of the services provided by mental health support workers needs to be different to that which is in use in 2015. He suggests a future that is based on the nature of the relationship and not on the number of contacts. He believes that what is needed is a way to define the relationship, the nature of that relationship and how it enables the consumer into achieving their recovery. The need to revisit funding regimes that identify the important, but difficult to quantify, aspects of health professional and consumer relationships is supported by a study undertaken within the National Health Service (Hart & Dieppe, 1996) of Britain.