text:
- Research
- Open Access
Doing mental health care integration: a qualitative study of a new work role
- Jennifer Smith-Merry1Email author,
- Jim Gillespie2,
- Nicola Hancock3 and
- Ivy Yen1
© Smith-Merry et al. 2015
- Received: 7 April 2015
- Accepted: 12 August 2015
- Published: 22 August 2015
Mental health care in Australia is fragmented and inaccessible for people experiencing severe and complex mental ill-health. Partners in Recovery is a Federal Government funded scheme that was designed to improve coordination of care and needs for this group. Support Facilitators are the core service delivery component of this scheme and have been employed to work with clients to coordinate their care needs and, through doing so, bring the system closer together.
To understand how Partners in Recovery Support Facilitators establish themselves as a new role in the mental health system, their experiences of the role, the challenges that they face and what has enabled their work.
In-depth qualitative interviews were carried out with 15 Support Facilitators and team leaders working in Partners in Recovery in two regions in Western Sydney (representing approximately 35 % of those working in these roles in the regions). Analysis of the interview data focused on the work that the Support Facilitators do, how they conceptualise their role and enablers and barriers to their work.
The support facilitator role is dominated by efforts to seek out, establish and maintain connections of use in addressing their clients' needs. In doing this Support Facilitators use existing interagency forums and develop their own ad hoc groupings through which they can share knowledge and help each other. Support Facilitators also use these groups to educate the sector about Partners in Recovery, its utility and their own role. The diversity of support facilitator backgrounds are seen as both and asset and a barrier and they describe a process of striving to establish an internally collective identity as well as external role clarity and acceptance. At this early stage of PIR establishment, poor communication was identified as the key barrier to Support Facilitators' work.
We find that the Support Facilitators are building the role from within and using trial and error to develop their practice in coordination. We argue that a strong organisational hierarchy is necessary for support facilitation to be effective and to allow the role to develop effectively. We find that their progress is limited by overall program instability caused by changing government policy priorities.
- Case Management
- Team Leader
- Mental Health System
- Work Role
- Lead Agency
The Australian mental health system is fragmented and fails to provide coordinated and accessible services to those who need them the most. Better coordination of care that bridges the health and social care sectors has been an objective of national mental health strategies for more than two decades. There is little to show for this effort [1]. Attempts to join up care through better case management have foundered in the face of short term, highly competitive funding, which creates strong incentives against rival agencies working together.
The national Partners in Recovery (PIR) program was introduced as an attempt to build new models of coordination. PIR is designed to build new collaborative relationships to integrate mental health care from the bottom up. Its 'partnership' objective focuses on building new, more cooperative relationships between the non-government organizations (NGOs) which deliver much of Australia's community based mental health care. PIR directly focuses on individuals with severe and complex mental ill-health and aims to connect the system in a way that improves the recovery of this group. Coordination relies on a new work role within the Australian mental health system, the support facilitator [2]. This paper presents an account of the experiences of Support Facilitators (SFs) in implementing this coordination, focusing in on the barriers and enablers to their work and how they have structured and conceptualised the role as they have implemented it in the first year of PIR.
The paper does not look at the PIR system as a whole, but rather focuses in on SFs as the primary 'connecting' element of the program. Through in-depth interviews with SFs we have sought to understand how they establish themselves as a new role in the Australian mental health system. This research takes an interpretive approach to understanding the implementation of health policy and practice. Interpretive research examines the individual sets of practices which are at the heart of any policy or practice implementation [3]. It focuses on the individuals interpreting and enacting the policy and what it means to them. This is a useful approach because a policy is only made 'real' by the actions of the agents who enact and actively receive it. We use their experience as a lens through which to understand the structural and practical barriers and enablers to the implementation of PIR, and specifically, the establishment of this new workforce.
Partners in recovery
"One of the most consistent themes fed back to the Australian Government is that care for the most vulnerable people with severe and persistent mental illness is not adequately integrated or coordinated, and people with complex needs often fall through the resulting gaps."—Department of Health and Ageing, 2012 [4].
provide better coordination of clinical and other supports and services to deliver 'wrap around' care individually tailored to the person's needs.
strengthen partnerships and build better links between various clinical and community support organisations responsible for delivering services to the PIR target group.
improve referral pathways that facilitate access to the range of services and supports needed by the PIR target group and.
promote a community based recovery model to underpin all clinical and community support services delivered to people experiencing severe and persistent mental illness with complex needs [5].
The A$549.8 million program was announced by the Gillard federal Labor government in its 2011–2012 federal budget. Implementation was subsequently delayed and reduced to $430 million over 2012–2016. Delivery was to be local and integrated with broader primary care programs using the geographical areas of the 61 Medicare Locals, the government's new primary care organisations. Service providers, mainly from the non-government sector, formed consortia, and rival bids were launched. Only the 48 regions that submitted their proposal in the first round were funded.
The use of regionally based consortia reflected a new emphasis on flexibility and locally tailored solutions to complex problems. The objectives of PIR were left vague, with much scope for local variations in implementation. They were to focus on providing 'co-ordination of support and flexible funding for people with severe and persistent mental illness with complex needs'.
Most of the national goals focused on improving coordination across a fractured system. Local PIRs were to engage and join up the range of sectors, services and supports, build capacity through stronger partnerships, map services and identify gaps. They were to 'engage' with clients and stakeholders, manage referral pathways but not provide direct services themselves. The linchpins were 'skilled Support Facilitators' (SFs) [4].
SFs meet with individual clients in order to identify and bring to the client appropriate services and supports. Their focus is on the client's needs with the aim of bringing together services that meet those needs and thus promote the client's recovery. Their background training (as discussed further in the results section) is not specifically clinical with SF position descriptions variously calling for tertiary qualifications in social sciences [6], a vocational Certificate IV in Mental Health or 'relevant experience' [7]. While the content of the position differs slightly amongst different PIR Consortia, the basic role description sees SFs reviewing referrals, assessing client needs, and working to 'develop and maintain partnerships' in order 'to meet the recovery goals of the consumer' [6, 7]. They serve up to 30 clients each [7]. Another key role is that of the Team Leader (TL) who works alongside SFs and have a part-time SF role with a smaller case load as well as responsibility for sector development and team management.
As the program title indicates Partners in Recovery, rather than providing clinically oriented services, is charged with facilitating recovery and consciously uses a language oriented towards recovery. Recovery in this context refers to the "attainment of a meaningful, productive, and satisfying life, regardless of the presence or absence of reoccurring symptoms" [8]. Recovery-oriented practice refers to a strength-based, hopeful, client-directed approach to practice that creates an environment to best enable or facilitate recovery. It has been evidenced to be difficult for services to implement in practice because it requires a "fundamental transformation" and reconceptualisation of dominant ideologies and practices in the mental health system [9]. Recovery-orientation necessitates a focus on the client and the client's needs with all interactions following on from that [10, 11]. Meaningfully placing the client at the centre of all interactions means that services become structured around the client rather than other structures such as diagnostic pathways, funding flows or other service imperatives. This challenges structured ways of working. As clients have needs that stretch beyond mental health services a recovery oriented approach also necessitates closer working with other sectors including housing and employment. These sectors have not traditionally seen themselves as part of the mental health system, so accessing their support on behalf of a client means making new connections.
History of support facilitator type roles in mental health
The term SF is not commonly used outside of the PIR setting. The only relevant use of the term that could be located in the literature was the use of the term 'supports facilitator' to describe a similar role working within Disability Services Queensland to support people living with mental illness who had been discharged from psychiatric hospitals into the community [13]. However, the type of role that the SF provides is not unique, with various names being given to similar roles including 'integration coordinator', 'boundary spanner', 'care coordinator', 'case manager', 'system agent', 'brokerage case manager' and 'broker' [13–16].
Although those who designed the SF role have consciously not used the term perhaps to distance themselves from the history of practices associated with the role (see discussion next paragraph), there is a clear link between the history of case management and the development of SFs [2, 4]. The case manager role developed from the 1970 s [14]. It was developed to specifically deal with the context of deinstitutionalisation where individuals who were moved into the community were unable to bring together or manage the services they needed [15]. Burns and Perkins [14, p.213] describe their role as "(1) Assessment of client needs. (2) Development of a comprehensive service plan. (3) Arrangement of service delivery. (4) Monitoring and assessment of services. (5) Evaluation and follow-up." These initially non-clinical roles were deemed to lack necessary clinical knowledge and were replaced by case managers who had clinical expertise [14, 17]. These 'clinical case managers' have been typified by those working in Assertive Community Treatment. Other clinical case managers focus their practice on psychosocial rehabilitation and the strengths model [14]. More recent work has asserted that clinical skills are not necessary to the case management role [16]. Different levels of case management have been identified [16]. The simplest is 'brokerage' which includes assessment, care plan development, arrangement of care, evaluation of care provided and maintenance of contact with the client [Holloway in 15]. Other levels of case management offer direct clinical support or offer recovery oriented support by focusing on a client's skills and abilities e.g. 'strengths case management' [15]. The brokerage framework equates most closely with support facilitation in the context of PIR. Support facilitation within PIR includes case-finding, assessment of needs, service finding, evaluation of needs met and case closure but does not extend to the more intensive roles of clinical management or psychosocial support, although these needs will be identified and clients referred to appropriate services if these are needs expressed by the client.
There has been a move away from the use of terms 'case manager' and 'case management' because of concerns that the role is not fulfilling its original intent or is ineffective in meeting its intent even if implemented faithfully. Reviews of case management have highlighted that it is not generally effective in meeting its aims, although Marshall et al. [15] provide an exception for case management structured around a 'strengths' model (which is aligned with recovery). Rapp and Goscha [18] also highlight the effectiveness of the strengths approach but state that the form of case management with the least positive impact for clients is the broker model (which most closely aligns to PIR) with only two of the nine studies reviewed showing a benefit. In Australia Brophy et al. [2] point to the Survey of High Impact Psychosis to demonstrate that the current system of case management in Australia can be seen as patchy at best for those in the target group of PIR. They also highlight problems related to the terminology which positions people as 'cases'. This is not aligned with a recovery-oriented approach to mental health.
New work roles
Of the considerable research on new work roles in health there is little that focuses on either mental health or the introduction of new roles from a sector rather than a workplace perspective. Despite this there are some learnings from the literature which are useful in informing our understanding of the implementation of the SF work role in Australia. Leading with a good overview of the literature Maxwell et al. [19] examined the introduction of new nursing roles in NHS hospitals in the UK and found that acceptance of the role depended on acceptance of a shared social identity between the new role and existing roles. The literature shows that the introduction of new work roles is not always successful with problems arising from poor relationships, poor role definitions, a lack of demonstrable achievement and competition from existing professional boundaries [19–21]. Recent work focusing on the introduction of peer support roles within mental health care and support settings perhaps offers most in our understanding of the challenges [22–24]. These roles are both recovery focused and new to the mental health system but differ significantly in type of role.
This paper presents results from a secondary analysis of a sub-set of interview data collected during late 2013 and 2014. The broad aim of the interviews was to gain an understanding of the implementation of PIR with respect to its goal of increasing the connectedness of the fragmented mental health system. The interviews were part of a larger set of 41 interviews with PIR stakeholders and consortium members to provide an initial view of the implementation of PIR across the Western Sydney region. These interviews were transcribed and thematically analysed. The secondary analysis reported in this paper was conducted separately and focused on the support facilitator's role and experience.
Interviews were conducted in two PIR regions in Western Sydney. These two regions together serve a population of 1,439,259 people and have a total estimated population of 4190 that are eligible for PIR support (PIR aimed to meet the needs of 40 % of this population) (Department of Health and Ageing, 2012). As at June 2015 the two regions have a combined total of 688 clients enrolled in the program. In total, 11 Support Facilitators (35 % of all SFs in the study regions) and 4 Team Leaders (36 % of TLs in regions) were interviewed across the two PIR programs. Interviews with TLs were included in the analysis as in these regions they have a reduced SF client load and facilitate the work of SFs.
Ethics approval was gained from the University of Sydney Human Research Ethics Committee. Relevant organisations were identified with the aid of a research reference group consisting of PIR consortium members, stakeholders and consumers. Researchers contacted these relevant organisations to ask them to participate in interviews. They then identified possible respondents within their organisations. All organisations and respondents contacted agreed to be interviewed. As interviews progressed further organisations to interview were identified where they were mentioned in multiple interviews or particular gaps in our understanding of the field emerged. Individual in-depth, semi-structured interviews were conducted face-to-face. All participants provided informed written consent prior to the interview. The average interview duration was 40 min. Interview questions aimed to get an overall picture of system connectedness at an early stage of the program implementation. Opening questions focused on the role and background of both the individual interview respondent and organisation they belonged to before moving on to questions about knowledge sharing, enablers to connectedness and barriers to connectedness. Interviews were audio recorded and transcribed verbatim.
Research questions for secondary data analysis on SF and TL roles in system connectedness
Overall research question:
How do Support Facilitators establish themselves in the system?
Sub questions:
1. What does their daily work consist of?
2. How do they conceptualise their role?
3. What enables their work?
4. What are the barriers they face in their work?
We conducted an inductive thematic analysis of the data where the data were coded through an open coding process based on the research questions. A second coding reduced the number of codes and determined the main themes relevant to answering the research questions. This coding was checked against a sub-section of coding conducted separately by another member of the research team and alignment of coding confirmed.
Representative quotations are used to bring alive the data using the SF or TL's own words. Quotations are identified by alphanumerical identifier and numbers of respondents reporting a particular idea is presented in brackets e.g. (3) in order to demonstrate the extent to which participants presented a particular view. This adds to the validity of the findings as the reader is able to assess the extent to which the views presented here are widely held by the respondents.
While the analysis was structured around the four sub-research questions listed in Box 1 above it made more sense to structure the discussion of the results below according to the core themes identified in the analysis as the main themes that emerged stretched across the different research questions.
Background knowledge held and used by Support Facilitators
SFs described coming from a variety of training, work and volunteering backgrounds including nursing, psychology, homelessness services, disability, psychology, policy, refugee advocacy and social work (13). These backgrounds give them a broad range of skills that are "based on a position description" rather than qualifications [SF4]. When directly asked about what knowledge they drew on in their work most did not mention training but rather spoke about 'experience' or 'own knowledge' or mentioned previous work roles [SF2; SF8]. They commented on the diversity of backgrounds in order to demonstrate the richness of experience amongst their teams. From the SF and TL perspective, the divergent educational and experiential knowledge that was being drawn on was seen as an advantage: "It is a great cross-section of people from lots of really interesting backgrounds. I like that. I think we draw a lot from each other in terms of backgrounds and skills…" [SF5] The diverse backgrounds were viewed as a valuable resource for individuals in allowing them to understand problems from different perspectives and to access contacts established in previous roles (11): "I've worked for different programs and I've also known people from different programs, so it's good for me to say, hey, I'm so-and-so, can you help me with this client? They will help me if there is a spot." [SF7] Several SFs stated that own personal experience was valuable for the role (5) including their own experience of mental ill-health and as carers for family members. While this personal experience was seen as a valuable asset for their position, the SF role is not specifically a peer support role.
In contrast to the otherwise consistent SF view that their diversity of backgrounds was an asset, two respondents commented that a lack of clinical experience could also present a barrier to their acceptance in the field, especially from clinical mental health services, for example: "I've been asked my background and my qualifications. I feel like saying pole dancer." [SF5] or "…you go into a clinical team and say, I'm from Partners in Recovery and they go what are your qualifications? You say why is that relevant? I'm not diagnosing anybody. I'm not medicating anybody. I am supporting them." [TL1].
What does the daily work of Support Facilitators consist of?
The daily work of the SFs centres around meeting and connecting with most time reported as being spent in individual meetings; attendance at interagency meetings; SF forums; site visits; online connecting and committee meetings. SFs meet face to face with PIR clients in order to establish their needs and follow up on whether these are being met or have changed. They also meet with fellow SFs and Consortium members through intra-agency meetings and work to establish interagency connections. These connections were made primarily in order to get referrals (of new clients) and make referrals (for current clients). The process of making and concreting connections was thus the most pressing task that SFs dealt with in their jobs and at the heart of their work. This is discussed in detail below.
Interagency connections
The most frequently cited types of forum were interagency meetings such as those dealing with homelessness and drugs and alcohol dependency (12). Interagency meetings were described as bringing together various organisations involved in a particular area to share information about difficulties, successes, needs and so forth. For example, "we're talking to lots of different services…all these places that have the same thing happening, working with consumers that have issues with hoarding and squalor and about how they're supported." [SF3] Participants explained that some interagency meetings focus on a particular place or client group and all those services who deal with that group will attend, for example, "It's a combined inter-agency, so you've got age mental health, housing, pretty well everything" targeting a particular locale [SF2]. SFs reported using these interagency meetings to: get services to refer clients to PIR; make contacts which they could then use to find services for their clients; and to educate the sector about the role of SFs and PIR (12). The interagency meetings were therefore key to the functioning of PIR and core tools for developing broader understanding of the role of SFs.
"So working groups, for example, there'd be three, four, five people who have a real passion for disability, physical disability, intellectual disability …. Disabilities is just one example. Education and employment, alcohol, drugs, Aboriginal services et cetera." [TL2].
"…so we've kind of been dividing up into working groups and particular interest areas. So been going to the Child and Family, DV [Domestic Violence] and LGBT [Lesbian Gay Bisexual and Transgender], they're the … working groups that I've been dividing those interagency meetings up." [SF8].
"…the physical health working group, we've been talking about different health prompts like, [named organisation] has a health prompt that we use with consumers, so I've shared some information about that to the group and we've received information from other organisations." [SF4].
These working groups therefore operate as ways to channel into the consortium knowledge from the broader sector and consolidate knowledge being collected by SFs in their interactions with clients.
Intra-agency connections
"…every month or so we've had each of the host agencies organising presenters from the different services that are out there to come in and speak with the wider team…. [or] a wider team meeting where all of the Support Facilitators and perhaps the team leaders as well can share some information or have discussion about what's going on and what are the areas of concern." [TL2].
"Yeah it is very helpful because in that forum sometimes they invite services like Centrelink, could be Housing or…the psychological team to come and give us information about a specific topic." [SF1].
The ability to draw on fellow SFs' background knowledge, connections and developing knowledge about the field was the key driver for the establishment of SF and TL forums for sharing knowledge.
"…basically if someone's a bit stuck with someone they can just bring that client and everyone can contribute and see what we can come up with…. So this way if someone's really stuck on something they have somewhere to take it and they've got a room full of people who are passionate." [SF10].
"…we do have Support Facilitators meeting every month and we share good stories and difficult… We can talk to people and see what type of client challenges they've got and what type of service challenges they've got. We could be learning thinking, oh we work in a different way, but this is all right too…. there was comparison and also there was learning there too." [SF7].
SFs and TLs use these meetings to assist each other to meet individual client needs, but also to learn and change practice based on the experiences of other SFs, building together shared effective practices for service delivery.
Free flowing communication via phone and email was viewed as particularly important to the effectiveness of the SF role (10). One SF spoke about the importance of "open communication and using all the communication tools. So…using the phone—sometimes just texting even—email–fax; whatever it takes to communicate with everyone." [SF3]. This was mainly used for working with existing networks, contacts or working groups in order to track down information to help clients: "We just ring each other if we're stuck for a service and we'll send out an email saying 'hey, I've got this, I'm looking for a great female GP in the [local] area, does anyone know of one?'…people will look and see if they have a contact that they've already worked with" [SF6]. One TL stated that quick flow of communication was so important that they consciously chose to fit out their SFs with the best tools for communication available: "…we're equipping our Support Facilitators and our team with laptops and mobile phones and iPhones and that kind of stuff" [TL2].
Conversely poor communication was identified as a significant disabler to the work of the SF (3). One TL stated that they felt "frustrated" when they could not provide effective communication supports or knowledge flows for the SFs [TL2]. Communication was so integral to the SF role that their work in connecting could not be done without effective communication taking place.
Connections for clients
Respondents emphasised the great variability in their practice which resulted from the personalisation of services to clients [TL1, TL2, SF8, SF9, SF4, SF6]. 'Connecting' work centred on the individual experiencing mental ill-health. Every interaction was viewed as "individual with the client" [SF9], necessitating flexibility and resourcefulness. This variability seemed to be accepted as a natural part of the job. Only one respondent complained about the variability of their work creating difficulties [SF8].
While the importance of client-focused connections was emphasised by six respondents, there were only a few mentions of typical office-based client meetings. Interactions with clients were not structured around set office or home visits and could be informal [SF1,SF6, SF7,SF9]. As SF9 described: "Taking a holistic view as we do to a person means collaborating with a really wide range of services, agencies, and—maybe not services…. like shop owners or something. You go and walk with a client, think about how their mornings are going to be spent every day…. It's a really important part of addressing someone's sense of being themself and belonging." Other SFs recounted trips to Centrelink [the national employment agency], a GP office and a medical specialist appointment.
How do Support Facilitators conceptualise their role?
Development of a collective Support Facilitator role
"It's SF, team leader knowledge and networking and sharing information essentially. So we have a very large breadth of knowledge across the whole [team]…. So they all bring with them that knowledge… and you share that and so the kind of the depth of knowledge has just developed". [TL1].
"…we work together as a team, so it's a combination of drawing on the collective experience of [our] colleagues…" [SF11].
"the other knowledge that we do draw on is a reliance, I suppose, on everyone. Share their knowledge." [TL4].
This peer support between SFs who worked at "sharing and encouraging each other" [TL3] was viewed as key to the development of the role and its success in the field.
Three respondents went so far as to speak about a shared identity between all SFs in their region. For example: "…all the SFs are there for the consumers and we're all there because we want the best outcomes for these people. So we're more than happy to share our knowledge and experience with each other." [SF6].
Working with clients
"I had one consumer who I ended up getting through a consumer advocate who had worked with me with another consumer, and had kind of been talking about Partners In Recovery, and then had convinced another consumer who didn't really want support, that we were okay and we weren't so bad." [SF8].
Surprisingly, given the name of the program, only two respondents spoke about recovery-orientation as a named framework structuring their interactions with clients [SF3, SF4]. SF4 spoke about their PIR practice as a type of educational tool to teach both the individual client and the rest of the sector about recovery: "…we're sort of modelling to other organisations how we like to work and how we think best works and that—empowering the consumer to take a lead in their own recovery." Others, while not expressing their practice in terms of recovery-oriented practice, described engaging in person centred approaches. In all 11 of the 15 respondents spoke about their work being client focused in that they acted according to the specific needs of their clients. SFs put a great deal of effort into understanding the needs of their clients "…because it takes a long time to build trust and respect from people who've been let down by the system for so many years…" [SF6]. One also spoke about learning from their client, which narrowed the gap between them: "I just took myself into that journey, thinking, what would myself be? I may not have been that strong like her, without a single cent in my account, no husband, no kids. I started thinking and then I understood more and I learned more…" [SF7] As these quotations illustrate a recovery orientation was being evidenced amongst these SFs even when it was not named as such. A core facet of recovery oriented service delivery is the breaking down of hierarchies between staff and clients [11]. These quotations evidence a levelling out of the client staff relationship. However there was no evidence of SFs considering recovery from the client's perspective, or speaking about the recovery journey of PIR clients.
The challenges and barriers faced by Support Facilitators
Respondents articulated a range of barriers to their work. The most consistently reported barriers related to communication difficulties and confusion or resistance in the service community about what PIR has to offer.
Identity, acceptance and role clarity
SFs spoke about the difficulties associated with being in a role that was new to the system [SF3; SF5; SF8]: "I think one of the challenges could be that it's a very particular type of role that you do that hasn't—it's not something that you can kind of go, oh yeah we're a case manager, or oh yeah—it doesn't fit…" [SF3] They expressed difficulty in getting those outside of PIR to understand this role and in differentiating it from existing roles in the system: "I think some of that's been based on role, a sense of we're doing the same thing, so what are you doing that we're not." [SF8] Getting their clients to understand the limits of this new role also meant that they sometimes went beyond its limits: "So then it's very easy to turn into a support worker. I try really hard not to, but sometimes you are like look someone is trying really hard to do something. I'm going to take them—for example to their appointment because it's raining and they're near…" [SF5] The role of a support worker is about intervention by the worker and therefore has a different role to a support facilitator.
Poor communication was viewed as a significant barrier to SF work. This can be seen as natural given the great importance on communication for establishing connections to bring in client referrals and find services to work with PIR clients. Areas of communication difficulties were identified between the central PIR consortium management [SF2; SF5; SF9; TL2] and SFs or between the stakeholder organisations and PIR [SF2, TL1, SF5, SF9].
Communication challenges
"I think unless we get… the lead agency working, we just can't work because it all just filters down and it's a nightmare. Then what you're starting to get now is Support Facilitators who are restless and frustrated and bored." [SF5].
"PIR's about services and communicating better with each other to make the system work better. If we can't [do that] in an organisation then how the hell are we going to change the system if we're not communicating." [SF2].
"…we're all on a canvas, but why's the canvas unclear, so fragmented?" [SF9].
The nationally defined structure of the PIR consortium means that while SFs work and have their contracts of employment within individual organisations, the format of their work follows rules set by the local PIR consortium (see Fig. 1, above). This means that they are subject to direction from two separate sources and must comply with policies and directions from both. One respondent stated that this could cause inconsistency in the way different SFs were able to operate with some having to follow more restrictive organisational policies that others did not [SF4]. At the same time, SFs benefited by drawing on the existing connections between the organisation and the sector in making referrals. However, SFs in some organisations felt that they were disadvantaged in their work compared to those SFs working in organisations that had a larger ongoing presence in mental health work in their areas. One TL spoke about competition between the SFs in different NGOs "We are being put in competition with each other. It's been like oh, you've done this and you've got five stakeholders. Why aren't you doing that?" [TL3] This competition was seen to be fed from the lead agency in the consortium with "negative feedback" turning the SFs "into competitors against each other" [TL3]. However one of the TLs directly contradicted this description of competition stating "I actually thought it was going to be very difficult—enemies and competitors—and it's not even there." [TL4], instead highlighting the competition between the SFs and the lead agency. While these quotations contradict each other, what they do highlight is that lead agency communication strategies created barriers between members of the consortium.
Communication difficulties with stakeholders was also a barrier to the work of the SFs. The reasons were variously given as confusion or scepticism about PIR, a history of competition in the sector, stigma and process difficulties internal to the stakeholder organisation. Respondents pointed out poor channels for communication to stakeholder organisations (for example could not ever speak to the person they needed to) [SF9], or other operational issues effecting the organisation. One respondent recounted an interaction with a stakeholder which included non-response, wrong documentation, repeated requests for further information, lost referrals, silence and then a final interaction: "called them a month later and they said there's a 6-month waiting list and that's because of PIR." [SF5].
"We're trying new things, they hate us because we are like yeah we are going to do this and they are like no you are no, we've been working with this person for 10 years. So it's really convoluted and grey and very messy." [SF5].
For this reason SFs described needing to be 'strategic' in their approaches to the field [SF9]. Confusion was also expressed about the distinctive contribution of PIR "There are a lot of services out there, so filtering—having PIR being filtered through the noise of those other services so that they are the ones that people think of [is] going to be a challenge" [SF11]. Constant outreach involving presentation of PIR methods and goals was seen to be the key to "break through that noise" [SF11].
Respondents reported that it was particularly difficult to make contact with certain types of service for example GP practices or clinical services [TL2, SF9, SF4]. This was either because they were isolated or resistant to PIR operating within a traditionally clinical setting: "Clinical services don't respect us [because] we're an NGO." [SF5] Conversely non-clinical services which SFs needed to make contact with to address a client's non-clinical needs could be resistant to working with PIR because of stigma towards working with people experiencing mental ill-health [SF5, SF6, SF9].
Historic competition in the sector around funding was another disabler to the connecting work of SFs. While one respondent commented that the collaboration through PIR and other joint collaborative projects was breaking this down, it was still something that stopped effective communication and connections being made: "…historically a lot of these NGOs, a lot of these services [are] competing for tenders, competing for funding, it's intellectual property, we want to look after ourselves and make sure [we do] all the capacity building ourselves and that kind of stuff." [TL2] Another respondent emphasised these intellectual property concerns "…people can think that you're trying to see what they're doing in their work… that you're making a judgement." [SF3] These historical divisions which had separated the system were thus a significant barrier to SF attempts to join it up again.
Discussion and conclusions
The overall aim of this research was to understand how SFs worked to establish themselves as a new work role in the existing mental health and social support sectors. The research questions were deliberately broad and aimed to get at the experience of SFs in order to understand their interpretation of the role. Reflection on these experiences as presented in the data gives rise to further thinking about both the SF role and the system in which it is situated.
While the SF role is not a 'new role' in that it bears a very strong resemblance to the brokerage model of case management, it is a new role in the context in which it is being applied. The PIR's SF role represents a large and expanding, new workforce within the Australian mental health sector and unlike previous case management roles, is non-clinical and embedded in the NGO sector rather than within clinical service delivery systems as has traditionally been the case. New roles entering existing settings are inevitably faced with challenges related to the need to fit into an already functioning system (however broken the system might actually be) [23]. This is compounded when there is a lack of preparation as the new roles appear as if dropped out of thin air [21]. This was the case with PIR. Implementation was hasty, spurred by (accurate) fears that the Labor government would lose power at the end of 2013. As a result, PIR was thrust on the mental health sector and the Medicare Locals with little preparation. Workforce planning is usually only something that occurs within an individual organisation or professional grouping [25]. Where the new role needs to work across a sector and lacks a clear professional background, as with PIR, those occupying the new role are given the task of planning and defining its scope and preparing the sector for their arrival. This 'preparation' work can be seen in the presentations SFs and TLs give to the sector and the constant networking associated with the role. Uncertainty about the boundaries of a new role by either the SF or those outside PIR mirror the experiences of other new roles establishing themselves within sectors, including peer support workers [23]. The SFs are educating the sector as they work and selling themselves and the PIR program they represent in every interaction. This makes these interactions crucial to the success of the entire program and makes difficult the interactions at the edge of traditional boundaries, as evidenced in conflict from some areas, and difficulties in making contact with others (e.g. GPs).
SFs are not just educating the sector about their role but are engaged in a process of understanding and educating themselves. Banfield et al. [1] make the point that descriptions of the process of 'coordination' in Australian health policy and implementation planning documents, including mental health, are so vague as to be meaningless. PIR is no different and SFs must work out how to 'do' the process of coordinating and connecting while involved in it. They are involved in a process of trial and error: testing what works, where difficulties lie and how to get around them. While the background knowledge SFs brought with them was significant, the embodied knowledge gained through on the job experience was emphasised as more important. This pattern is consistent with conventional understandings of how practitioners learn to do their work [26] through 'on the job' experiential learning rather than structured training. These results show the key to this learning process is communication between SFs. The interactions through forums, collaboration and one–one–one meetings develop a common service model, but also develop a shared way of being a SF, or shared SF practice. Communication is thus key to an effective support facilitation role. Using the work of Freeman [27] we can see that they are "learning by meeting" with the micro-interactions of the meetings building personal and collective practice. Shepherd and Meehan [13] further point to interpersonal communication as "the 'glue' of interagency collaboration". However without effective and open networking this type of communication becomes problematic. As our respondents so clearly document, the SFs and others working across the sector were able to sort themselves into informal ad-hoc but pragmatic working groups and forums. These things cannot be forced but, as the SF experience shows, specific support for informal networking is essential through funding, role descriptions, and management practices which need to be loose enough to allow the groupings to emerge.
Previous research has highlighted that strong internal governance arrangements from the host organisations are essential for the success of both case management and new roles. Brophy et al. [2] emphasised that PIR could not be successful without strong management of each local consortium, with clearly defined roles and responsibilities for each partner organisation. Lack of strong central organisational support from within the PIR consortium was highlighted in our interviews as a significant difficulty for SFs in their work in implementing PIR. This may be part of the inevitable teething problems of a new program, but should be addressed as a core concern for PIR consortia. The next round of interviews with the same respondents at 1 year post-baseline will determine whether this is an ongoing issue for PIR. It may be that the lack of consortium coordination reflects a lack of guidance by the Federal Department of Health under a new conservative government hostile to legacy programs started under Labor. The Medicare Locals, which provide the lead agency for most consortiums, have been abolished and replaced with weaker 'Primary Health Networks' with considerably less autonomy and with a geographical scope which in many cases no longer corresponds with PIR consortium boundaries.
The manner of introduction of new work roles into an existing system has an impact on its acceptance within the sector. Ross et al. [16] write that case manager type roles will be most successful when they are implemented within a system characterised by "shared vision and objectives, close links between health and social care, aligned financial flows and incentives, stakeholder engagement [and] provision of services in the community". SFs only have control over one aspect of these conditions. The experiences of SFs and TLs exposes some of the tensions and difficulties which led to the fragmented system that PIR is in part meant to fix. The interview responses reveal a system which is still fragmented and the effects of years of perverse incentives to collaborative working (many of which continue) which will take more than just a new job role to fix. As Whiteford et al. [28, p.904] comment: "The standout issue needed to promote effective service integration is arguably the hardest to achieve; that is, ensuring mutual respect and understanding of roles with streamlined communication between all the services involved in the care and support of clients". High level decisions about funding and collaborative service development above all need more stable funding models. Even with the best will on all sides, the interviews reveal a reluctance by many stakeholders to invest too much in the relationship with PIR as its funding expires in 2016. Stakeholders likely understand that nothing has changed in the funding and organisation of the sector beyond PIR meaning that the competitiveness which divided the sector prior to PIR and which the SFs work against will continue post-PIR.
Given that the PIR program expressly mentions recovery in its title and has a stated aim of enhancing recovery for individuals experiencing severe and complex mental health it was surprising that only two of the respondents mentioned the recovery concept in the interviews. Evidence of recovery orientation in the interviews was only partial, and did not include important elements including a focus on self-management, use of a strengths model, promotion of citizenship, involvement where appropriate of family and care giver support people or engagement of clients with peer support [29, 30]. Interviews showed no evidence of attempts to promote recovery in PIR clients or of an aim to understand recovery from a client's perspective. However this may reflect the interviewing than SF practices because the interview questions did not ask SFs about their interactions or progress with clients. Other reasons may be that the recovery concept is so ingrained in their work that there was little need to mention it, or that recovery is not being actively spoken about and promoted within PIR consortia. If the latter is true this is a significant deficit as the client and communication focus of the SF role means that it is perfectly placed for promoting recovery within the sector and reorienting the system around recovery values. A lack of a deep understanding of recovery from the client's perspective may also be a symptom of a workforce new to mental health. In both sites recovery training has since been provided to staff and follow up interviews may therefore demonstrate improved recovery orientation of SFs. One-third of the respondents in these interviews stated that they drew on their own experience of mental ill-health, including as a client or carer. This is an important finding because it demonstrates the value of lived experience as a resource for those employed in SF roles.
This study was conducted within two metropolitan regions and results therefore only reflect the experiences of SFs and TLs working in cities. The experiences of SFs working in regional areas may be different. Further research is needed which draws on the local evaluations in regional areas in order to understand support facilitation in those contexts. Another limitation of this study is that we are only reporting an understanding of the SF role during the early stages of program implementation. However, our evaluation of PIR will also include interviews with the same organisations at 12 months (data collection currently in progress) and 24 months so we will be able to understand how the role develops over time. This is important because new roles will generally change over time as will the challenges and enablers they face [21]. Data collection at 12 months and 24 months with PIR stakeholder will also provide data which reflects on the SF role from an external perspective, and therefore provide another view of the role.
Our findings on SFs have relevance beyond PIR. Programs such as the National Disability Insurance Scheme (NDIS) in Australia and Paths to Personalisation in the UK necessitate an increasing role for service facilitators and brokers. Close working between PIR SFs and National Disability Insurance Agency (NDIA) workers has taken place in the NDIS trial site in the Hunter Region of New South Wales. NDIS uses a similar brokerage model of case management and is likewise being implemented as a new overarching program in existing settings as it is rolled out throughout Australia. While the future of PIR is uncertain it is likely that it will either merge with NDIS or complement it closely. Innovations such as personal health budgets and other types of person-centred care practices mean that there are increasing spaces to be filled by 'accented' SF type roles in, for example, managing money and buying in, finding or negotiating access to services [18]. Efficient systems through which these innovations can be implemented will only be possible if we understand what it means to work in these roles and what helps them to negotiate the system.
Respondents are identified through alpha-numerical identifier. Support Facilitator (SF) respondents are identified by SF1, SF2 etc. and Team Leaders (TL) by TL1, TL2 etc. Numbers in brackets e.g. (11) refer to how many respondents made a specific point. PIR means Partners in Recovery. NDIS means National Disability Insurance Scheme.
Authors' contributions
JSM conducted the analysis of the data and initial drafting of the paper. IY collected the data. JG and NH made substantive contributions to the structure and arguments made within the paper. All authors read and approved the final manuscript.
The data reported in this paper has been collected as part of funded evaluations of Western Sydney Partners in Recovery and Inner West Sydney Partners in Recovery however the funders have had no involvement in the preparation of this manuscript.
Compliance with ethical guidelines
Competing interests The data reported in this paper has been collected as part of funded evaluations of Western Sydney Partners in Recovery and Inner West Sydney Partners in Recovery.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Authors' Affiliations
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For my final fundamental graphic design assignment, I am supposed to create a series of postcards under one theme, and I went with "Smoking Sucks" . EHHEHE.
Here they are :
"It's Killing You"
Done with drawing pens and red paint
If anyone's guessing what's stabbing through his right man-tit, it's an over-sized cigarette. I'm sorry if it's too offensive, this includes the beer belly and the pubes.
Done with colour pencils, drawing pens, and gray paint for the smoky background
And no, the running red things aren't testicles. Sure smoking can lead to infertility, but those are really lungs.
"Your Time Is Running Out, Smoke It Down Faster"
Done with drawing pens, colour pencils, and some red paint for the blood in the hourglass, splats and the red smoke
The hourglass represents the human body, that's why it's leaking out blood. Or maybe I just did that 'cause an hourglass running on blood is f-in awesome.
"Smoke Bomb"
Done with drawing pens and poster colours.
This is my lecturer's personal favourite 'cause she thought this is different from my usual style of drawing, with the cartoony approach and modern, bright colours. Or at least that's what she said. Thanks Ms. Bridget :)
I hope these aren't too offensive to all of you, my smoking friends. Ehehehe. Not that I've anything against you smokers, it's just that most of my ideas pretty much revolved around the theme above.
Ciaooo :)

subset: commoncrawl


text:
ITPalooza 12/12/13 – Musician call (ITPalooza Band++)
The IT Palooza band is ready to ROCK-n-ROLL again with you!
We need you!
We need guest IT professionals that play music and have some chops in ANY instrument!
Here's what we need from you:
- You (an IT professional)
- Your instrument(s)
- Your song pick (in your key and arrangement)
- 1-2 night(s) rehearsal in Boca Raton, FL
If you got what it takes, then you are all set to play with The IT Palooza band this December 2013!
If (You_Got_What_It_Takes == true)
ItPaloozaBand = ITPaloozaBand + 1;
Come and join us, show off your chops and have some fun!
Here are some video clips from IT Palooza 2012:
IT Palooza – Almost Cut My Hair
IT Palooza – Folsom Prison Blues
IT Palooza – Mr Jones
IT Palooza – Right Place Wrong Time


text:
Erquellewen - Chapter 31 ~ A Preparation for Battle
Japool's smile faded, as he realized that there was a large scratch running across the shining metal.
"Pick it up," he said menacingly, pointing at the armour with his skinny, black claw.
The Human bent over, his spine tingling as Japool's evil gaze followed his every move.
As the servant finished placing all the equipment pieces into their proper places, Japool smiled once again.
"Oh, servant," he said, the fake smile growing wider, "I have a little... present for you..." The servant stopped, a small smile on his dirty, round face. Japool rose his claw, the poison barb raised high above the small servants head.
The Human closed his eyes, his happy grin turning into a frown. Japool brought the sharp tip down, already starting to squirt the green, foul smelling liquid out.
In seconds, the man was on the ground, his fingers twitching violently. Green ooze was dripping out of his nose and purple, cold lips.
Japool happily walked out of his bedchamber, as if nothing has happened.
"So we have to prepare. This Spider has a great malice inside of him," Gandalf was explaining to his companions. "He can wage a war at any moment. So be prepared. Have your weapons at the ready at all times."
Everyone nodded, Legolas' hand on his bow. Aragorn's brow creased. Gimil got his ax out. And the four Hobbit's started searching for stones.
"Where is Erquellewen, Lief, and Mithwethiel?" Gimili asked.
"They are over there," Legolas said, pointing to a large boulder where the three friends were chattering.
"LIEF!" Gandalf said loudly. Lief turned his head, a smile on his face. "BRING THE GIRLS OVER HERE!" Lief nodded and tapped the chattering girl on the shoulder.
"Yes?" Lief asked, a few seconds later. "You wanted something, right?"
Gandalf nodded. "First of all, Japool could be attacking at any moment, so please be alert. And second, has Kree come back yet?"
"I'm afraid not," Lief said, a look of shock on his face. "He's usually back by now!" And as Lief said those words, a black object came flying from the sky, a trail of blood falling with it.
"Is that...?" Mithwethiel began.
"Yes, it is," Lief said. "Kree is somehow injured..." He pulled the small blackbirds talon up lightly. "Oh, he must have gotten caught on this thorn..." Lief pulled a small, red and brown thorn out of the birds foot.
"Poor little birdy," Erquellewen said, a frown spreading over her face.
"We're lucky that was the only thing that happened to this bird," Gandalf said. "It could be worse. That thorn could be poison..."
"PLEASE, TELL ME IT'S NOT!" Lief screamed. "This bird has been with me for life! I couldn't lose him now! Not before the war. We need him! You never know, he could end up saving our lives!"
"I understand," Gandalf said, trying to calm Lief. "Let me see the thorn..." He took the thorn from the boys hand, and inspected it carefully, trying to see through the red, sticky blood.
"You're bird will be okay," he said, after a five minute inspection. "There is no trace of poison in this evil plant."
Lief sighed, relief in his eyes. "This bird has saved my life more than once. It's a good thing he hasn't died."
"You have a good friend, then," Gandalf said, smiling.
"Ready, My Lord?" a Spider asked Japool a few moments later.
"Very," Japool said, laughing menacingly. "Let's go to this war..."


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WATERLOO, Ontario, Sept. 29, 2016 –– Kik Interactive, maker of chat platform Kik, today announced the launch of the fashion and beauty bot category, which makes shopping more social on Kik. The new category includes a mix of branded and brand-agnostic "concierge" bots, and users can now include multiple bots in chats with friends for a better overall shopping experience. Since April, brands in Kik's Bot Shop, ranging from CNN to Victoria's Secret PINK, have seen high engagement from Kik's teen demographic, with more than two billion messages exchanged with the platform's bots to date.
"Shopping is a social experience, and our new fashion and beauty category will allow our users to experience all the elements of the shopping journey—discovery, research, and sharing—with their friends," said Ted Livingston, founder and CEO of Kik. "This provides a more direct way for brands to connect with teens in their native environment and demonstrates how services continue to evolve in chat."
Bots in the new fashion and beauty category also display new chat functionality. Previously, users could call bots into conversations using mentions, a feature that allows bots to participate in conversation threads involving multiple parties, including groups. Now, fashion and beauty bots can interact with each other, offering teens a new way to browse outfits and shop together, all within their one-on-one or group chats. For example, when searching for a specific product in the Sephora bot, Sephora can now introduce a concierge bot such as BeautyTube to provide tips and how-to videos specific to the chat and the product, creating a better shopping experience. Users will also be able to leverage features such as invites to ask friends for fashion and beauty advice while simultaneously chatting with a bot.
The following bots will provide makeup tips, fashion recommendations, and celebrity style inspiration:
Branded bots include H&M, Kipling, Sephora, and Victoria's Secret PINK. These bots give teens direct access to their favorite brands, where they can browse new styles, get outfit and makeup recommendations and be directed to the brand's mobile site, all within the bot.
Concierge bots include BeautyTube, which provides personally recommended beauty tutorial videos; CelebStyle, which showcases the latest celebrity fashion styles from Gigi Hadid, Kylie and Kendall Jenner, Zendaya, and more; InspoBot, which recommends outfits for any and all occasions; and TrendBot, which provides the hottest trending styles and outfits. CelebStyle, InspoBot and TrendBot were created with Stylitics.
Influencer bots include YouTubers GettingPretty, JackieWyers, MissMikaylaG, PiinkSparkles, ThatGirlShaeXo, and TheMakeupByDanielle. These bots can provide teens with beauty advice and also facilitate chats between fans.
Kik also launched the Beautycon bot on Sept. 13 and is collaborating with Beautycon for its New York festival on Oct. 1. As part of the bot experience, Beautycon and Kik partnered on a giveaway, in which one lucky winner would win an all-expense paid trip to attend Beautycon with a parent and friend. In addition, Kik users attending the event can chat with the Beautycon bot, scan Kik Codes, and avoid waiting in line at select exhibits for major beauty brands, including L'Oreal Paris and NYX.
About Kik Interactive
Kik Interactive, Inc., connects the world through chat. The company is the maker of Kik, a chat platform with more than 300 million registered users where people can chat with friends and connect with chat-based experiences. Founded in 2009, Kik Interactive, Inc. is headquartered in Waterloo, with offices in Los Angeles, New York, San Francisco, and Toronto. For more information, please visit: kik.com.


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BEVERLY RAUTENBERG | [My] FAVORITES
January 12 - February 23, 2018
In the Project Space, Beverly Rautenberg will present My [FAVORITES], an intimate pairing of recent objects embodying the artist's minimalist aesthetics with autobiographical subject matter. Formally reductive and small in scale, the pieces in this exhibition are made of enamel on archival board mounted on wood. Material is a very important component to the work, though unlike the more rigid practitioners of traditional minimalism, it is not the artist's sole intent. Throughout her working process, Rautenberg references her own lived experience, utilizing color and surface to communicate personal narrative. The resulting work offers a spare yet spacious ground upon which the viewer's subjective interpretation is given ample room to unfold.
Beverly Rautenberg is an interdisciplinary conceptual artist living and working in Chicago. She earned her BFA from the School of the Art Institute of Chicago, where she studied with Stephanie Brooks and Richard Rezac. She has exhibited her work in galleries and museums nationally and internationally including: The Aldrich Museum of Contemporary Art, MASS MoCA, and MCA (Museum of Contemporary Art Chicago). Rautenberg's work has also been included in the 2012 Berlin Biennale, ART Chicago (The Artist Project), AAF (New York City) and LUCCA Art Fair (Milan). In 2014, she was awarded a CHANGE, Inc. Grant from the Robert Rauschenberg Foundation. Her work is represented by Morotti Arte Contemporanea in Milan, Italy. Rautenberg's show at 57W57Arts is the artist's first solo exhibition in New York City.
This program is partially supported by a grant from the Illinois Arts Council Agency.


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Dear Mr Valinskas,
On June 26, 2009 the President of Lithuania vetoed the 'Law on the Protection of Minors against the Detrimental Effect of Public Information.' On July 7, 2009 the Seimas voted to reconsider the law and will sit in a plenary session on July 14, 2009 to decide whether to overturn the Presidential veto.
On behalf of Human Rights Watch, I ask you to use your influence to ensure that the Presidential veto will not be overturned by the Seimas and that the human rights of all persons in Lithuania, including those of young people, will be protected.
The law would ban materials that "agitate for homosexual, bisexual and polygamous relations" from schools or public places where they could be seen by youth, on the grounds that they would have a "detrimental effect on the development of minors."
The law is an unjustified interference with the right to freedom of expression protected by international treaties to which Lithuania is a party. It would violate the right to equality by creating an unacceptable environment of state-promoted discrimination against lesbian, gay, bisexual, and transgender (LGBT) people, including youth. It would interfere with the rights of human rights defenders to promote all human rights and to engage in free discussion about rights principles. It would threaten the health and well-being of Lithuanian youth by restricting their access to information necessary for them to make critical decisions about their lives, and could potentially have life-threatening effects by censoring accurate information about HIV and AIDS.
Lithuania is member of the European Union. Article 6.1 of the Treaty of the European Union provides that "The Union is founded on the principles of liberty, democracy, respect for human rights and fundamental freedoms, and the rule of law, principles which are common to the member States." As a member of the Council of Europe, in 1995 Lithuania ratified the European Convention for the Protection of Human Rights and Fundamental Freedoms. Article 10 of the Convention states that "Everyone has the right to freedom of expression. This right shall include freedom to hold opinions and to receive and impart information and ideas without interference by public authority and regardless of frontiers..."
In its article 14, the Convention also prohibits discrimination in the enjoyment of the rights and freedoms set forth in the Convention.
The European Court of Human Rights, which authoritatively interprets and enforces the Convention, has recognized in the 2003 case of Karner v. Austria that sexual orientation is covered by article 14 of the European Convention on Human Rights (as well as the explanatory memorandum of Protocol No.12).
In the 2007 case of Baczkowski and others v. Poland- the European Court of Human Rights, referring to the importance of pluralism in a democratic society, stressed the State's positive obligation to secure the effective enjoyment of freedoms of assembly and association. In finding against Polish authorities' efforts to ban LGBT people's peaceful public demonstrations, the Court observed that "this obligation is of particular importance for persons holding unpopular views or belonging to minorities, because they are more vulnerable to victimization" (para.64).
These obligations bind Lithuania to respect, protect, and promote the freedom of expression for all people, regardless of their sexual orientation.
The law would also be in violation of the Convention of the Rights of the Child, ratified by Lithuania in 1992. Article 13 paragraph 1 of the Convention of the Rights of the Child states that a child shall have the right to freedom of expression; "this right shall include freedom to seek, receive and impart information of ideas of all kinds". The UN Committee on the Rights of the Child has held in general comments 3 and 4 of the Convention that these protections include discrimination based on sexual orientation.
Furtermore, article 7 of the Declaration on Human Rights Defenders provides that 'Everyone has the right, individually and in association with others to develop and discuss new human rights ideas and principles and advocate their acceptance." The 2007 report of the UN Special Representative on human rights defenders mentions defenders of lesbian, gay, bisexual and transgender rights, and cites articles 2 and 12 of the declaration to remind states of their responsibility to protect human rights defenders.
The proposed law also contradicts Lithuania's public commitments undertaken in signing a joint statement on human rights and sexual orientation and gender identity, presented by 66 States at the General Assembly of the United Nations on December 18, 2008.
Inter alia, the statement reads:
10. We call upon all States and relevant international human rights mechanisms to commit to promote and protect the human rights of all persons, regardless of sexual orientation or gender identity.
13. We urge States to ensure adequate protection of human rights defenders, and remove obstacles which prevent them from carrying out their work on issues of human rights and sexual orientation and gender identity.
If the Seimas were to overturn the Presidential veto, Lithuania would become a state implementing discriminatory and stigmatizing legislation despite being a member of the Council of Europe and the European Union. Youth will not have access to information they need to protect their health. Human rights defenders working on sensitive issues related to sexual orientation and gender identity will be prevented from publicly addressing these topics.
I call upon you as Speaker of the Seimas to ensure that Lithuanian legislation respects that all persons in Lithuania, including young people, fully enjoy the right to freedom of expression - including the right to seek, receive and impart information, without discrimination of any kind.
I call upon you to use your influence that the Presidential veto will not be overturned.
Yours sincerely,
Boris Dittrich
Advocacy Director
Lesbian, Gay, Bisexual and Transgender Rights Program
Human Rights Watch


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Are you drinking your calories?
Focused on fitness goals? Don't forget to factor in the calorie and sugar content of your favourite drink.
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Tips for parents
Thinking about talking to your children about alcohol but don't know where to begin? We're here to help. Visit our dedicated Parent Pages for facts, advice and resources.
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Drink Driving
How long does it take for your body to process alcohol? When is it safe to drive the day after drinking? Is an off-the-shelf breathalyser accurate? Get the facts on drink driving laws, limits and penalties.
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Make A Fresh Start
This year, we're focusing on change. We want to help you to make positive and above all, lasting, changes to your drinking habits so you can improve your long-term health and wellbeing.
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The Drinkaware Index has, for the first time, mapped two key groups within the drinking population that deepen our understanding of alcohol consumption in Ireland today.


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investment property inventory spreadsheet Pharr flipping houses not easy
Check out Our own investment property inventory spreadsheet so that you can become successful in flipping properties to earn money. Get all the info you absolutely need on flipping houses not easy in Pharr.
Take into consideration points like the roof.You could additionally have to inspect for termites. Do you require to painting it?Will it need new windows and doors? All of these can cost you a great deal of loan ultimately.
Allow's claim now you have actually determined you want an REO. You flipping houses learn this here now not easy investment property inventory spreadsheet must understand there are risks connected with this "large amount" you are getting. When considering your REO acquisition, make certain you have gain access to and also call information for different professionals who will certainly assist you in the examination process.
Your acquiring power will have a substantial result on the choice of loan providers, ought to you obtain funding on the residential property. But even if you do not seek financing, you still have to do your personal financial evaluation. Obviously, you would not desire to wind up being burdened with financial obligation from your financial investments over time.
Is it Legal? - While there are some constraints in some states - every where else it is fair video game. For example, If I live in New york city and the place seats extra than 6,000 people, I could only note the ticket up by 45%. If I do not live in New York, I can offer the ticket for any kind of quantity I choose.
flipping houses not easy Pharr
Develop a time table outlining the phases of your task. You need to be able to predict exactly how lengthy the job will take in the past you enjoy your earnings. A way to determine your success is to be able to develop a working routine and also follow it strictly. Be sure to establish a period from the point of choosing homes to the time you relist the building.
With the over night success of his turning organisation comes the deal to organize his own TELEVISION program concerning turning - Flip This House. look at these guys Along with his other half, his bro David and sister-in-law Melina, they include various tasks that are flipped, their changes, the numerous difficulties that are entailed and also other essential elements of flipping houses not easy.
The individuals that are being marketed by these REO vendors are mainly new and also minority possible property buyers. Fannie Mae works with several firms to assist these kinds of buyers realize the American Imagine having your residence utilizing affordable as well as affordable finances. There has actually been a change in the market from marketing REOs to those that "turn" homes to first-time homebuyers. The dramatic rise in foreclosures has actually left several loan providers with high stocks of REOs, causing potentially helpful chances for people that never ever has gain access to prior to, to get to the real estate market. Furthermore, the number of foreclosures is enabling simple flipping houses not easy investment property inventory spreadsheet to expand and increase their profiles.
In the trunk of my auto I maintain a few things mainly a few empty black trash can. If I am going over to a home where a tenant simply vacated I usually require at the very least one. While I'm there checking out things, I may too leave a trash can behind for someone else to fill.
Individuals that offer buildings are called Realtors. These individuals should take courses as learn this here now well as pass an evaluation prior to obtaining qualified. Realtors originate from all profession! Some work as instructors or workplace employees during the day as well as market real estate at night to assist with the costs.
Be a solid negotiator during the acquisition of the residence. This is not your dream home, it is your supply. You will not adore staying in the house for many years awaiting it to value. You should acquire it for the most affordable feasible price. Utilize the residence's blemishes to compel the selling price downward.


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Letters to the Editor
Florida's health
Florida is becoming a cesspool. Our waterways and Gulf are in peril. The collapse of our residents' health and the economy will surely ensue if action isn't taken. We cannot vote our way out of this one unless it can be done on a statewide level.
We haven't had a real Environment Protection Agency (EPA) in our state for several years. Gov. Rick Scott asked the EPA to rescind a determination that the federal rules are necessary for Florida. Scott blames the federal government for not helping. But he fails to mention farm pollution flowing into Lake Okeechobee.
Big Sugar has donated or had fundraisers for both the Clintons and Donald Trump.
How do we bring national attention to the corruption and desecration of our state's most beloved resource — our water?
We need to clean up one step at a time. Let's start with the biggest: the corruption of politics and pollution from big agriculture into Lake O without proper EPA controls in place.
Our state needs help. Who in God's name do we turn to?
Donna Niebauer,
Fort Myers


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Students' March For Our Lives Trip A Community Effort
Forty students and their adult chaperones traveled to Washington, D.C. on March 24 to participate in the March for Our Lives event, a trip that was made possible by the nearly $7,000 donated by the Lakewood community.
What had started out as four students wanting to buy bus tickets to D.C. bloomed into a community project.
When the founding members of the newly formed Student Committee for Activism realized the interest in students attending the march would fill a charter bus, the group raised the cash needed to reserve the bus in just a few days through a GoFundMe account and the generosity of fellow students, teachers, parents, business owners and the community in general. The giving did not stop there, a call out from chaperone and LHS teacher Autumn Sabin for snacks for the trip led to cartons of donations of water, Gatorade, chips and more being left on her porch.
"Our community really came together for our kids," Sabin said.
Added one of the founders of the Student Committee for Activism Isabella Bryson: "I feel so proud to be a part of a community where supporting social activism and helping out young people is a priority. To pull together our trip to DC it took so many people donating food, money, their time-- and we genuinely could not do it without them."
The students' effort in mobilizing to make the trip happen caught the attention of media outlets nationwide from The Wall Street Journal, to NPR to our local Plain Dealer and ideastream.


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Not looking to spend too much possibly around £60-£80 mark, however if there are no good routers in this bracket then id say a cap of £150.
Wireless is of no importance as it will be mainly used for gaming via RJ45. All i require from it is to have at least 1 GigE port, not effect speed through put and ping times and be future proof for vectoring and 30a profiles when/if ever either of those happen.
(i currently use OR Modem + HH3 over a fiber connection)
Possible options at the moment:
-Home Hub 5 (£45 upgrade)
-Asus RT-N66U (£99)
-Asus DSL-N66U (£125)
-Netgear R6300 (£130)
-Netgear R7000 (£170) Really dont feel like i want to pay nearly £200 for a router tho which is why im searching for good quality cheaper options
Thanks for your help


text: In this week's show the Pirate Bay is sold, a wheelchair that can be controlled by thought, Windows 7 pricing is announced, and Panasonic improves the recycling of TV tubes. To comment on this article and other PCWorld content, visit our Facebook page or our Twitter feed. Related: Events Consumer Advice Green IT Shop Tech Products at Amazon


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Whilst shopping for jewellery can be actually enjoyable, it can be difficult if you are not sure how to select pricey items. Dependent on the content a piece of jewelry is made of, the cost varies tremendously for each and every piece. Customers who have not educated them selves about jewelry may finish up having to pay as well much funds for what they get. By taking edge of this guidance, you will be that considerably much more wiser next time you go out purchasing for jewellery.
When you purchase jewelry from a jeweler, ask about their insurance coverage policy. These procedures dictate no matter whether or not the jeweler will substitute or resolve your merchandise of jewelry if it is broken. A lot of jewelers also have insurance policy for misplaced or stolen parts.
You will need to have to take specific care when you are purchasing costume jewelery! Stones in costume jewelry are normally held in spot with glue instead of a physical placing. Get treatment not to use chemical compounds or plenty of h2o in an try to clean your costume jewelry. The very best treatment is to wipe with a warm damp cloth and then dry with yet another fabric. Performing so will preserve your jewellery searching its ideal for existence.
You can use a brooch to make your belt stand out, considering that it is confident to be eye-catching. You have the selection of putting it shut to your hip, or at your midsection around the center.
Put your make up on ahead of the jewelery. Your jewellery draws in dust and particles from cosmetics if you use make-up following you set on your jewelry, the particles will make it search uninteresting. This strategy is especially helpful in caring for necklaces or earrings.
Now that you've occur to the finish of the report, you are armed with the expertise you want when buying for that following fantastic piece of jewellery. Use this advice to turn into a savvier jewelry shopper and operator.


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|Design and Engineering Forum
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|Remaining Pipe Strength Calculator
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Posted by: CouchMS ®
05/25/2004, 17:08:52
Author Profile Mail author Edit
Does the remaining pipe strength calculator program conform to B31.3? I used the calculator to check the remaining pipe strength based on corrosion pitting and need to be sure the calculator meets the intent of ASME B31.3. If not, what code or standard is the calculator based upon?
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|Re: Remaining Pipe Strength Calculator
|Re: Remaining Pipe Strength Calculator -- CouchMS
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|Top of thread
Posted by: gumbo ®
05/26/2004, 21:07:39
Author Profile Mail author Edit
I would write my own program for pipe strength based on the standard if it is that important. Then you know for sure and since the possibility of change exists in other person's codes at least you will control it. I only use on-line calculations for ballpark quick calculations. Anything I submit to a governing/regulatory body I do myself.
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An exquisite remake by Suryaveer of Kya Hua Tera Vaada. He understands the Old School and brings out the new generation style remix of the renowned song in his Cover. The originality of this song belongs to Mohd Rafi, LEGEND.
Suryaveer used to perform as a solo artist since about 7 years. He has toured and worked earlier with the biggest names in the industry and has been touring both nationally and internationally.
Cover Song Credits:
Vocals – Suryaveer
Arranged by – qazi waseem ahmed
Music production -onkar tarkase
Guitars – qazi waseem ahmed, shoaib ahmed, onkar tarkase
Vocal recording -nikhil berry
Mixed and mastered – r ntiish kumar
Video By : Flying Bee Films
Directed by : Salim Khan
Dop : Salim Khan
2nd Camera Cinematographer : Vinod Thakur
Post production : Flying Bee Films


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Singing competitions have given way to the careers of artists such as Carrie Underwood, Miranda Lambert, Kellie Pickler, and Scotty McCreery; Season Two of The Voice has given us Gwen Sebastian.
Prior to her time on The Voice in 2012, Gwen Sebastian had released three albums and an EP. With years of experience on her hands, it's no surprise that the singer made a great debut when on the show. Although she never made it to the live shows, coach Blake Shelton invited Gwen on tour that year.
Since her departure from the show, Gwen has been seen on countless award shows and daytime TV appearances as backup for her coach. Today, Gwen Sebastian has released her first full-length project since the show – Gwen Sebastian.
It's evident that the years of experience on both a Nashville and national scene have led way to who Gwen Sebastian is today. Over the years, she has been able to perfect her craft – allowing her to deliver the self-titled album that is available now.
Her single, "Suitcase" is currently going for radio adds but the sultry goodbye song isn't the only song that is ready to be heard on a larger-scale! Every song on the release is proof of Gwen's talent and god-given voice. Without a major label behind her, Gwen is able to put out music that she is truly proud of.
Gwen isn't the only one proud of the disc, however. Miranda Lambert, who has said Gwen is like a part of her family, lends vocals on the gun slinging, get back bonus track of "Annie's New Gun." Real-life parents Deb and Gerald are featured on a personal favorite of mine, "One Like That."
There have been a lot of great country releases this year, but even on first listen, this collection of 15 songs was in my top 5 and every time I give it a listen, it jumps up a spot. It's one disc that definitely won't disappoint a country music lover.
The album is available on Amazon and iTunes now for less than $10.
Gwen's new album is distributed by Warner Music Nashville. You can order now!! http://smarturl.it/gwensebastian
Be sure to join @GwenSebastian on #CMchat July 15th at 6p PST/9p EST! RSVP HERE.


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Arab Israeli Conflict
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us dollar bills 88.
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As the shekel rose to its highest in nine years against the beleaguered US dollar on Tuesday, the Israel Export Institute warned that the current weakness of the US currency was causing losses of billions of shekels to exporters, while threatening to significantly damage the competitiveness of the local export industry.
"From the beginning of the year, exporters in the industry have reported losses of over NIS 1 billion as a result of the par between the expected exchange rate at the time of the performance of export orders and the actual exchange rate on the day of payment," said David Artzi, chairman of the Israel Export and International Cooperation Institute.
"As a result of the continued weakness of the dollar, many exporters refrain from signing new deals or contracts committing them in the future," he said. "This situation could challenge Israel's competitiveness in a couple of months unless the government acts to restore the confidence of Israeli exporters."
The shekel gained 0.4 percent against the US dollar on Tuesday to 3.88 and was trading at NIS 3.8915 on Tuesday night in Tel Aviv from 3.93 on Monday. The US currency slid to a record low on Tuesday against the euro ahead of the publication of a US home construction report, expected to show a slowdown pointing to a deepening property crisis.
"The financial crisis in the US and worsening housing data is putting pressure on the US Federal Reserve to cut interest rates at its next month meeting and until then, the negative momentum of the US dollar is expected to continue," said Rafael Menasheof, currency strategist at Finotec.
Menasheof said the appreciation of the local currency against the dollar has moved the shekel-dollar exchange rate below the psychological barrier of NIS 3.90 - a development that is leading to a loss of confidence in the US currency by exporters and property owners renting out apartments.
Some analysts expect the shekel to continue to strengthen against the dollar.
"In the medium-term, we expect the shekel-dollar exchange rate to break the next psychological barrier trading around levels of NIS 3.80 and NIS 3.75," said Rotem Davidovich, foreign exchange proprietary trading manager at Xpert Financial Group.
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First allow me to say Vegan MoFo 2014 is going so fast my head is spinning. I have about five products I've yet to review, a few videos from vacation I've yet to post, and I've already got an important video planned that will be the finale for the event. There's no way I'm going to get this all in, considering there's 3 days left. The only days I missed were 2, maybe 3, in the beginning when all the hospital stuff was starting. On top of all that, while we were away, a couple of the videos got messed up, and I mean messed up BIG. The biggest "oops" is the night we ate at Sublime, and the video got deleted. I have no idea how that happened, but it vanished. I'm still upset about that. I'll do a post about Sublime after MoFo, you will still be my friend after this is all over, won't you?
While we were in St. Augustine, we ate dinner at a place called The Floridian. It was exceptionally casual, and exceptionally busy. When we called to see if we needed a reservation, we were told no because they weren't busy. By the time we got there, we waited 40 minutes for a table. We didn't know where else to go, I believe this was just an hour or 2 after we'd rolled into town. We were both tired and didn't really feel like driving. This place was within walking distance to where we were staying, and I found through the wonder of the internet that they had tempeh and tofu on the menu, hooray.
As we sat by the door waiting, I watched the kitchen and waitstaff work. They worked their butts off, and really seemed to be working very well together. There was laughter in the kitchen, and they all seemed to be helping each other out, as I said this place was BUSY. I actually didn't video the dinners. It was really dark because we were sitting outside (it was truly a glorious late summer evening), and it was late by the time we got there. Actually, we closed the place out, being last, or second to last, to leave for the night, yikes. I had a summer salad which was absolutely huge, with quinoa, veggies, lettuce, I think it also had chick peas, maybe lentils, and blackened tempeh (which was absolutely excellent, and made by a local tempeh shop!) The other happy vegan had a house made vegan black bean burger, he loved it.
I have very few suggestions for a place like this, beyond first and foremost always saying please take it ALL vegan. Beyond that, I'd simply have liked a little more salad dressing (only because the salad I ordered was HUGE and what they supplied was so tiny for all those veggies and tempeh), and I would have liked to see a non-dairy milk choice available so I could've had coffee or tea. Beyond that, this place seems to be a neighborhood place with pretty decent food, modest prices, very attentive service, kind people working through the place, and also happens to be vegan friendly. All that, and it was a beautiful night for a walk through the city of St. Augustine. I'm in love with the city, I really am.
Enjoy the video, see you tomorrow!