Sources of stress experienced by occupational therapists and social workers in mental health settings

Transcription

1 Occupational Therapy International, 12(2), 81-94, 2005 Whurr Publishers Ltd 81 Sources of stress experienced by occupational therapists and social workers in mental health settings CHRIS LLOYD Senior Lecturer, Division of Occupational Therapy, University of Queensland, Australia KRYSS McKENNA Senior Lecturer, Division of Occupational Therapy, University of Queensland, Australia ROBERT KING Senior Lecturer, Department of Psychiatry, University of Queensland and the Park School of Mental Health, Australia ABSTRACT: This study examined the sources of stress experienced by occupational therapists and social workers employed in Australian public mental health services and identified the demographic and work-related factors related to stress using a cross-sectional survey design. Participants provided demographic and workrelated information and completed the Mental Health Professionals Stress Scale. The overall response rate to the survey was 76.6%, consisting of 196 occupational therapists and 108 social workers. Results indicated that lack of resources, relationships and conflicts with other professionals, workload, and professional self-doubt were correlated with increased stress. Working in case management was associated with stress caused by client-related difficulties, lack of resources, and professional selfdoubt. The results of this study suggest that Australian occupational therapists and social workers experience stress, with social workers reporting slightly more overall stress than occupational therapists. Key words: mental health, stress, case management, occupational therapists, social workers Introduction A number of writers have examined the impact of mental health reforms on the individual therapist, specifically in terms of stress (Cushway and Tyler, 1994, 1996; Prosser et al., 1996; Onyett et al., 1997) and burnout (Harper and Minghella, 1997; Prosser et al., 1999; Reid et al., 1999a, b). Stress can lead to burnout (Maslach et al., 1996), absenteeism (Fagin et al., 1995), high job turnover (Onyett et al., 1997), poor job satisfaction and morale (Prosser et al.,

2 82 Lloyd, McKenna and King 1996; Brooker et al., 1999), and reduced performance and efficiency (Dunn and Ritter, 1995; Maslach et al., 1996). Cotton and Fisher (1995) explained that the increase in stress-related difficulties can be linked to the changing nature of work. They identified this as including the increased pace of change, structural reform processes, changing work practices, adapting to new technologies, competing situational demands, multiskilling, flattening of organizational structures, and loss of job security. These factors exert pressure on the adaptive capability of individuals and, cumulatively, increase the level of work environment strain to which individuals are subjected. The development of community mental health teams has required staff to adapt to new roles, responsibilities and hierarchies (Shepherd et al., 1996). This has occurred with limited training or preparation to assume these new roles (Cowan, 2000). It has been suggested that newly established community services may result in a higher degree of stress for staff which may be a consequence of change rather than the nature of community work itself (Prosser et al., 1996). Working in the community has been identified as more stressful than working in inpatient services and has been associated with poorer mental health in health care workers (Prosser et al., 1996, 1999). Reasons postulated for this include the burdensome nature of the work (Meldrum and Yellowlees, 2000), the experience of conflicting demands (Reid et al., 1999a), role blurring (Brown et al., 2000), the high level of responsibility involved in community work (Reid et al., 1999a), and inadequate provision of resources (Harper and Minghella, 1997), training, and supervision (Reid et al., 1999b). Other work-related sources of stress for members of community mental health teams reportedly include work overload (McLeod, 1997), large caseloads (Kipping and Hickey, 1998), bureaucracy (Harper and Minghella, 1997), administrative demands (McLeod, 1997), and managing competing demands on time (Meldrum and Yellowlees, 2000). Resource shortages, such as the availability of suitably skilled staff (McLeod, 1997), access to community resources, and difficulties with other services, can also be sources of pressure for mental health professionals (Harper and Minghella, 1997; Meldrum and Yellowlees, 2000). At a client level, taking responsibility for clients (Meldrum and Yelowlees, 2000), fears of violence (Kipping and Hickey, 1998), working with difficult clients (McLeod, 1997), and lack of progress have been reported as sources of stress (Reid et al., 1999a). Rees and Smith (1991) found that occupational therapists were under more stress than the majority of other professional groups in health care and perceived higher levels of pressure from their relationships with other people in the workplace than any other professionals. Similarly to occupational therapists, social workers reportedly feel very pressured by their work (Jones et al., 1991; Collings and Murray, 1996). They have expressed frustration with workloads (Farley, 1994) and pressure related to planning and reaching work targets (Collings and Murray, 1996). In Australia, major changes have occurred in the organization and delivery

3 Sources of stress in mental health settings 83 of mental health services (Whiteford et al., 1993). This has involved establishing community-based services where they previously did not exist. Acute services have been mostly transferred from stand-alone psychiatric institutions to general hospitals and integrated as part of the mainstream health care system (Commonwealth Department of Health and Ageing, 2002). Few resources have been invested at the national level to address the workforce implications of changes in service delivery (National Mental Health Strategy Evaluation Steering Committee, 1997). With limited empirical data available, it is unclear how staff are coping with the challenges posed by new models of care. This paper presents one component of a larger study examining work activities (Lloyd et al., 2004) among occupational therapists and social workers in mental health. This aspect of the study sought to: (1) identify the sources of pressure that contribute to stress experienced by occupational therapists and social workers working in mental health settings, and (2) identify demographic or work-related factors that are related to these sources of pressure. Method Preliminary contact was made with inpatient and community-based public mental health services in the Australian States and Territories based on a list provided by the State Department of Health. Senior occupational therapists and social workers in these services were contacted by mail and asked to inform staff about the study and to invite those interested to contact the researcher by phone or . Interested participants were sent a survey package with a stamped, self-return envelope. Non-responders received two subsequent mailouts of the package. The package consisted of a background information questionnaire and the Mental Health Professionals Stress Scale (MHPSS; Cushway et al., 1996). Measures Background information questionnaire This questionnaire gathered information about participants age and gender and work-related details. The latter included discipline, length of professional experience, time in their current position, work activities (percentage of time spent in clinical activities, research and evaluation; administration; supervision and training; community development and consultation; and professional development and education), client group (percentage of time spent with children, youths aged 13 17, adults under 65 years, and adults over 65 years), and the type of team or service in which they worked (percentage of time spent in intake and assessment, psychiatric crisis and treatment, acute inpatient services, case management, mobile intensive treatment services, long-term inpatient rehabilitation services, and community-based rehabilitation).

4 84 Lloyd, McKenna and King Mental Health Professionals Stress Scale (MHPSS) The MHPSS, a seven subscale, 42-item scale was used to measure participants stress (Cushway et al., 1996). The subscales comprise workload, client-related difficulties, organizational structures and processes, relationships and conflicts with other professionals, lack of resources, professional self-doubt, and home work conflict. The MHPSS provides a total score as well as seven subscale scores that can be used to identify specific sources of stress for mental health professionals. Each item is scored on a scale from 0 = does not apply to me, to 3 = does apply to me; however it is the mean item score for each subscale that is calculated (total subscale/6) rather than the total subscale score. Higher scores indicate higher levels of self-reported stress. All of the seven subscales have an acceptable internal consistency with Cronbach s alphas ranging from 0.60 to Cronbach s alpha for the total MHPSS scale is 0.87 for clinical psychologists and 0.94 for mental health nurses (Cushway et al., 1996). The MHPSS is headed Sources of pressure at work. The word stress was omitted from the questionnaire because of potential confounding difficulties associated with people s differing interpretations of stress (Cushway et al., 1996). The MHPSS is self-administered and takes about 10 minutes to complete. Statistical analyses Data were analysed using the Statistical Package for the Social Sciences (SPSS, Version 11) software. An alpha level of 0.05 was used to determine significance. Means, standard deviations, ranges and frequencies were obtained for demographic and work-related variables. Independent sample t-tests were conducted to determine if there were differences between the occupational therapy and social work participants in terms of work activities, client groups, and service types. To identify the factors that affected the dependent variables (DVs) (mean item score for each of the MHPSS subscales: workload; client-related difficulties; organizational structures and processes; relationships and conflicts with other professionals; lack of resources; professional self-doubt; and home -work conflict) the General Linear Model (GLM) procedure through SPSS was used. A separate GLM was run for each of the DVs with the continuous independent variables (IVs) (percentage of time spent in clinical work; percentage of time spent in all other non-clinical activities; and percentage of time spent in case management, acute and rehabilitation service settings) entered as co-variates, and the categorical IVs, discipline and age, entered as a fixed factors. Gender could not be included as an IV because there were relatively few males in the sample (18.8%). The IV, percentage of time spent in all non-clinical activities, was calculated by summing the percentages across each of the work activities apart from clinical activities (namely, research and evaluation; administrative duties; supervision;

5 Sources of stress in mental health settings 85 community development and consultation; and professional development and education). The IV, percentage of time spent in acute service settings, was calculated by summing the percentages for time spent in intake and assessment, psychiatric crisis and treatment services, and acute inpatient services. The IV, percentage of time spent in rehabilitation service settings, was calculated by summing the percentages for time spent in extended treatment services and rehabilitation. Percentage of time spent in mobile intensive treatment services was not included as an IV since few participants worked in this area for more than a day per week (4.9%). Time spent working with various client groups was also not considered because few participants worked with children (5.9%) and youths (10.2%) for more than a day per week, and those who did were predominantly social workers. The models were screened for main effects of each IV and their interactions. The final best model was selected by progressive elimination of non-significant (at p 0.05) variables until only the significant main effects and their interactions remained. The assumption of normality was made due to the large sample size. Results Demographic characteristics of participants The return sample consisted of 196 occupational therapists with a response rate of 78.1% (196 of 251) and 108 social workers with a response rate of 74% (108 of 146). There were 57 (18.8%) males and 247 (81.3%) females. The occupational therapy sample consisted of 18 (9.2%) males and 178 (90.8%) females and the social work sample consisted of 39 (36.1%) males and 69 (63.9%) females. Most participants were in the year age bracket. The occupational therapists were younger with 117 (59.7%) being in this age bracket compared to 18 (16.7%) social workers. Occupational therapy participants had worked in their current position for a mean of 2.7 years (SD 46.6 months, range 1 312) and in mental health for a mean of 7.5 years (SD 94.7 months, range 1 468). Social work participants had been involved in mental health for a similar time (mean 7.4 years, SD 67.7 months, range 3 300) but their mean time spent in their current position, 3.8 years (SD 45.7 months, range 1 216) was significantly longer than occupational therapists (t = 2.38, df = 302, p = 0.02). Work activities The percentage of time participants spent in each of the work activities is displayed in Table 1. Analysed using independent sample t-tests, no significant differences were found between the percentage of time spent in these work activities by occupational therapists and social workers.

6 86 Lloyd, McKenna and King TABLE 1: Mean percentage of time spent in work activities by occupational therapy and social work participants (n = 304) Work Occupational therapists Social workers activity Mean (%) SD Range Mean (%) SD Range Clinical Research Administration Supervision Community Education TABLE 2: Mean percentage of time spent working with different primary client groups by occupational therapists and social workers Client Occupational therapists Social workers group Mean (%) SD Range Mean (%) SD Range Children Youth Adults Adults NB Not all percentages reported by participants totalled 100% Client group The percentage of time spent by participants with their primary client group is displayed in Table 2. Social workers spent significantly more time working with children (t = 2.92, df = 302, p = ) and youths (t = 2.92, df = 302, p = 0.004). Occupational therapists worked significantly more with adults under 65 years of age (t = 3.44, df = 302, p = ). Service type The percentage of time that participants spent working in different services or teams is displayed in Table 3. There were significant differences in the percentage of time spent by occupational therapists and social workers in the type of service or team in which they worked. Social workers spent a significantly greater percentage of time involved in intake and assessment (t = 4.27, df = 302, p = ), psychiatric crisis and treatment services (t = 3.68, df = 302, p = ), and case management (t = 3.52, df = 302, p = ). There was a significant difference in the percentage of time spent by occupational therapists working in rehabilitation services compared to social workers (t = 6.47, df = 302, p = ).

7 Sources of stress in mental health settings 87 TABLE 3: Mean percentage of time working in a specific service type or team by occupational therapists and social workers Occupational therapists Social workers Service Mean % SD Range Mean % SD Range Intake Crisis Acute inpatient CM MITS Long-term inpatient Rehabilitation Key: Intake = intake and assessment; crisis = psychiatric crisis and treatment services; Longterm inpatient = long term inpatient rehabilitation services; CM = case management; MITS = mobile intensive treatment services; rehabilitation = community-based rehabilitation NB Not all percentages reported by participants totalled 100% Stress In terms of all items of the MHPSS for the 278 participants, the mean item score was 1.4 (SD = 0.4, range = ). Twenty-six surveys provided incomplete data and were excluded from the analysis. Table 4 provides mean MHPSS subscale item scores and the mean overall score for occupational therapy and social work participants in this study, compared to data reported by Cushway et al. (1996) on clinical psychologists (n = 154) and nurses (n = 111). In comparison to scores reported for clinical psychologists and nurses, the occupational therapy and social work participants in this study reported slightly more overall stress. Lack of resources, and relationships and conflicts with other professionals were the two subscales that showed the largest mean differences, with the occupational therapists and social workers experiencing more stress in these areas than the Cushway et al. (1996) samples. GLMs showed that the participants profession (occupational therapy or social work), age, and the extent to which they worked in case management were the variables that affected mean item scores on some of the MHPSS subscales, as described below. Workload Analysed using GLM, the overall best model was significant F(1, 298) = 16.55, p < 0.001). Participants profession influenced scores on the MHPSS workload subscale, with social workers experiencing a higher mean item workload score (mean 1.6, SD 0.7) than occupational therapists (mean 1.2, SD 0.7).

8 88 Lloyd, McKenna and King TABLE 4: Means and standard deviations for clinical psychologists, nurses, occupational therapists, and social workers of mean item scores for each of the MHPSS subscales and overall (0 = does not apply to me, 3 = does apply to me) Psychologists Nurses Occupational Social therapists workers Subscale M(SD) M(SD) M(SD) M(SD) Workload 1.8 (0.6) 1.3 (0.7) 1.2 (0.7) 1.6(0.7) Client 0.9 (0.5) 1.2 (0.6) 1.0 (0.5) 1.2 (0.6) Organization 1.3 (0.7) 1.6 (0.7) 1.4 (0.7) 1.5 (0.7) Conflict 0.9 (0.6) 1.1 (0.7) 1.9 (0.7) 2.0 (0.7) Resources 1.0 (0.5) 1.6 (0.8) 2.2 (0.7) 2.3 (0.7) Doubt 1.2 (0.6) 1.2 (0.6) 1.1 (0.6) 1.0 (0.6) HWC 0.8 (0.5) 0.9 (0.6) 0.6 (0.5) 0.7 (0.5) MHPSS overall mean 1.1 (0.3) 1.3 (0.5) 1.3 (0.4) 1.5 (0.4) Key: Client = client-related difficulties; Organization = organizational structures and processes; Conflict = relationships and conflicts with other professionals; Resources = lack of resources; Doubt = professional self-doubt; HWC = home work conflict (adapted from Cushway et al., 1996) Client-related difficulties Analysed using GLM, the overall best model was significant F(3, 295) = 8.14, p < 0.001). Participants age (p < 0.001), profession (p < 0.01), and the interaction of these two variables (p < 0.05), as well as the extent to which participants worked in a case management service (p < 0.05), influenced the mean item score on the MHPSS client-related difficulties subscale. Specifically, the youngest social workers scored a mean item score of 2.2 (SD 0.3) on this subscale compared to the oldest social workers (mean 0.9, SD 0.6) and the youngest (mean 1.2, SD 0.4) and oldest (mean 0.8, SD 0.6) occupational therapists. The relationship between age and client-related difficulties however was not linear. The mean item score for participants who worked in case management 100% of their time was 1.4 (SD 0.5) compared to 1.1 (SD 0.6) for those who worked in case management less than full-time. Lack of resources Analysed using GLM, the overall best model was significant F(1, 297) = 7.57, p < 0.01). The extent to which participants worked in case management influenced the mean item score on the MHPSS lack of resources subscale, with those who worked in case management 100% of their time having a mean score of 1.8 (SD 0.7) compared to 1.3 (SD 0.7) for those who worked in case management less than full-time.

9 Sources of stress in mental health settings 89 Professional self-doubt Analysed using GLM, the overall best model was significant F(2, 298) = 10.02, p < 0.001). Participants age (p < 0.001) and the extent to which they worked in a case management service (p < 0.001) influenced scores on the MHPSS professional self-doubt subscale. The youngest participants had a mean item score of 1.5 (SD 0.5) on this subscale compared to the oldest participants (mean 0.7, SD 0.5), although again the relationship between age and professional self-doubt was not linear. The mean item score for participants who worked in case management 100% of their time was 1.2 (SD 0.5) compared to 1.1 (SD 0.6) for those who worked in case management less than full-time. GLMs indicated that there were no significant effects of the IVs on the mean item scores for the subscales of organizational structures and processes, relationships and conflicts with other professionals, and home work conflict. Discussion This study sought to identify sources of pressure and demographic or workrelated factors that contribute to stress experienced by occupational therapists and social workers working in mental health settings. The findings reported in this study indicate that both occupational therapists and social workers were experiencing stress associated with the work context, specifically, in the areas of lack of resources, relationships and conflicts with other professionals, workload, and professional self-doubt. Demographic and work-related factors, namely age, profession, and the extent of involvement in case management, were related to stress caused by workload, lack of resources, professional selfdoubt, and client-related difficulties. Social workers reported slightly more overall stress than did occupational therapists. Previous research has found that social workers (Jones et al., 1991; Farley, 1994; Collings and Murray, 1996) and occupational therapists (Rees and Smith, 1991; Alan and Ledwith, 1998) perceived their job to be very pressured. Social workers experienced slightly more workload stress than occupational therapists. A heavy workload has been a commonly cited source of stress in a number of studies (Farley, 1994; Collings and Murray, 1996; Harper and Minghella, 1997; Reid et al., 1999a). Heavy service users have been found to be associated with workload burden (Meldrum and Yellowlees, 2000). It is unclear why social workers experienced more workload stress than occupational therapists in this study, although it may be linked to the type of team or service in which the participants worked. More social workers worked in acute services and case management than did occupational therapists who were more likely to work in community-based rehabilitation and long-term rehabilitation inpatient treatment settings.

10 90 Lloyd, McKenna and King Working in case management had a number of stressors associated with it, namely, client-related difficulties, lack of resources, and professional self-doubt. Meldrum and Yellowlees (2000) suggested that one of the particular difficulties experienced by case managers working in community settings was the level of intensive care required when a client became acutely unwell. Case managers are expected to perform a diverse range of functions, working on their own, often with inadequate supervision, and in a community setting, which is under-resourced in terms of staffing, services, and access to hospital beds (Shepherd et al., 1996; Harper and Minghella, 1997; Meldrum and Yellowlees, 2000). Stress caused by lack of resources for occupational therapists and social workers was the subscale with the highest mean item scores. Working in a case management role was associated with stress caused by lack of resources. Resource shortages that directly impact on clinical care, including availability of skilled staff and access to community resources such as supported accommodation, have been identified as stressors for mental health professionals (Harper and Minghella, 1997). In the study by Reid et al. (1999a), mental health professionals identified a range of problems associated with lack of resources. These included lack of administrative support, lack of clinical and specialist services to which clients could be referred, an absence of adequate community resources, and shortage of inpatient beds. Stress caused by client-related difficulties was associated with working in a case management role, which may be attributable to the demanding nature of this work. Previous research has shown that there are certain difficult client groups for whom staff felt they lacked the required skills (Reid et al., 1999b). Contact with potentially threatening clients has been found to be a source of stress which is compounded by a lack of resources, putting people at risk because of the nature of the client group (Cushway et al., 1996). Occupational therapists and social workers experienced similar levels of stress caused by professional self-doubt. Being younger was associated with more professional self-doubt. Increased experience often attenuates work-related stress (Cushway and Tyler, 1994, 1996). Stress caused by professional self-doubt may not be unexpected given that the roles and responsibilities of staff have changed with restructuring of mental health services, and in many instances, staff have not received the training to equip them for required work activities (Cowan, 2000). Meldrum and Yellowlees (2000) suggested that working in community settings can place a great deal of direct client responsibility on staff which may expose gaps in the skills of inexperienced staff. Cowan (2000) noted that staff often move to community-based positions such as case management with little preparation or specialist skills. In previous research, it has been shown that staff identified gaps in their training and believed that training would enable them to deal more effectively with their work demands (Reid et al., 1999b). In this study, participants experienced stress caused by professional self-doubt when working in case management. Case management tends to involve a

11 Sources of stress in mental health settings 91 diverse range of work activities. If staff are not prepared for these types of activities and have inadequate professional supervision, they may doubt their ability to deal effectively with the complex demands of their clients. It would be important to establish mechanisms for supervision and training in the workplace and to identify whether these strategies can be promoted to alleviate stress at work. In this study the area of work that was related to stress caused by relationships and conflicts with other professionals was working in case management. Community-based care, such as case management, requires negotiation with a wide range of agencies and services to adequately address the complex needs of clients seen by mental health professionals. Clients seen in mental health quite often live in poverty, experience inadequate social conditions and have a serious mental illness (Harper and Minghella, 1997). With inadequate community resources, it would be expected that there would be much competition and negotiation to secure whatever resources are available (Shepherd et al., 1996). It could be anticipated that this would lead to frustration and conflict with other agencies and services, if services were unable to be provided for clients. Previous research has shown that one of the most common pressures experienced by mental health professionals arises from relationships with other agencies and services (Harper and Minghella, 1997). Multidisciplinary teamwork is important in the delivery of care to clients with a mental illness and their families. The quality of service delivery may be marred by conflicts within the team and the stress that this causes. It is necessary to foster collaborative relationships and liaison within the team and with other organizations with whom they interact. An increased understanding of the causes of team conflicts may lead to the development of strategies to overcome these. Limitations of the study There are a number of limitations that need to be considered when reviewing the findings of this study. Firstly, there may be a response bias in the study related to the characteristics of the responders, since it is not known whether sources of pressure and stress levels of the non-responders were different from responders. Secondly, the fact that a survey package was only sent to staff who had already expressed an interest in the study, may have influenced the results. This may limit the generalizability of the findings beyond the study sample. Finally, because of the characteristics of the sample, it was not possible to consider the effect of some independent variables on the stress outcomes (e.g. gender and client group). Future research Future research could be directed towards surveying staff in the other key disciplines in mental health to determine whether they are experiencing similar

12 92 Lloyd, McKenna and King sources of pressure as occupational therapists and social workers. It would also be of interest to gain a further understanding of the nature of the work environment that contributes to stress caused by conflict and relationships with other professionals. There may be an advantage in using a qualitative design in identifying characteristics of the work environment that contribute to stress. Longitudinal research would also help by monitoring mental health professionals stress experiences over time. Conclusion This study set out to identify factors that contribute to job stress in a sample of Australian occupational therapists and social workers, and to examine the relationship between demographic and work-related variables with stress. The findings revealed that occupational therapists and social workers experienced sources of pressure in the current work environment. Specifically, the most notable stressors were lack of resources; relationships and conflicts with other professionals; workload; and professional self-doubt. Participants who spent the majority of their time working in a case management role experienced stress associated with lack of resources, client-related difficulties, and professional self-doubt. Social workers reported slightly more overall stress than did occupational therapists. With the exception of professional self-doubt, social workers experienced slightly more stress on each of the MHPSS subscales compared to occupational therapists. Occupational therapists and social workers make an important contribution to service delivery in mental health services. It is important to gain an understanding of the work roles they undertake and the stress they experience with carrying out these roles. This will provide information that could be useful in developing education and training and supervision strategies to alleviate stress in the workplace. Acknowledgements The authors would like to thank all the staff who gave their time to participate in the study and to Chris Foley for his administrative assistance. References Alan F, Ledwith F (1998). Levels of stress and perceived need for supervision in senior occupational therapy staff. British Journal of Occupational Therapy 61: Brooker C, Molyneux P, Deverill M, Repper J (1999). Evaluating clinical outcome and staff morale in a rehabilitation team for people with serious mental health problems. Journal of Advanced Nursing 29: Brown B, Crawford P, Darongkamas J (2000). Blurred roles and permeable boundaries: The experience of multidisciplinary working in community mental health. Health and Social Care in the Community 8: Collings J, Murray P (1996). Predictors of stress amongst social workers: An empirical study. British Journal of Social Work 26:

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14 94 Lloyd, McKenna and King (1999a). Explanations for stress and satisfaction in mental health professionals: A qualitative study. Social Psychiatry and Psychiatric Epidemiology 34: Reid Y, Johnson S, Morant N, Kuipers E, Szmukler G, Bebbington P, Thornicroft G, Prosser D (1999b). Improving support for mental health staff: A qualitative study. Social Psychiatry and Psychiatric Epidemiology 34: Shepherd G, Muijen M, Hadley T, Goldman H (1996). Effects of mental health services reform on clinical practice in the United Kingdom. Psychiatric Services 47: Whiteford H, MacLeod B, Leitch E (1993). The national mental health policy: Implications for public psychiatry services in Australia. Australian and New Zealand Journal of Psychiatry 27: Address correspondence to Chris Lloyd, Division of Occupational Therapy, University of Queensland, Q 4072, Australia. c.lloyd@shrs.uq.edu.au