Community care in practice

Question 1

What is community psychiatry according to Peter Tyrer (Tyrer and Creed, 1995)?

Answer 1

“a portmanteau couplet that can mean many different things”:

• “extramural psychiatry”
• “a specific form of care that involves particular skills and procedures”
• “a form of policy to close outdated hospitals”

Question 2

What was happening in the 1980s?
What criticism of community care came in 1984?
What other criticisms came?

Answer 2

> Early 1980s: plans were being made to close large mental hospitals

> 1984: National Schizophrenia Fellowship (now known as Rethink Mental Illness) published

• ‘Community care: The sham behind the slogan’
• patients out of hospitals into the community -> “disastrous human and social problems” ; “widespread failure to provide adequate aftercare or to grant-aid those for whom this care is available”
• under-estimated number of “people suffering from severe mental-illness”

> Other criticisms towards community care
- political correctness that ignores harsh realities for both the patient and their carers

Question 3

What is ‘Clare in the Community’?

Answer 3

A satirical BBC Radio Series based on a strip cartoon

- takes a look at generic community care practice, with a basis in reality

Question 4

What does Julian Leff’s book ‘Care in the community: illusion or reality?’ (1997) show?

Answer 4

> Rise and fall of the psychiatric hospital

• policy went through a tortuous and ideological route
• failure of the community mental health movement in the US

> Perspectives on community care

• Residential care in the community works well
• Cost of community care is no cheaper than hospital care
• Large hospital closure led to a complete breakdown of the acute hospital service
• Training has remained a constant issue
• Integration could work through media and public attitudes

> Pitfalls and how to avoid them

• Services need to be “future-proofed”
• Patients with severe mental illness have improved but still exist
• There was a stage of comprehensive service in the 2000s
• There is a false antithesis between the hospital and the community
• > Hospitals are part of the community and serve the community

Question 5

What is community mental health according to Thornicroft (2011)?

Answer 5

“Community mental health care comprises the principles and practices needed to promote mental health for a local population”

• Address population based-needs in accessible and acceptable way
• Building on goals and strengths of those who have experienced mental illness
• Promote a wide network of support, services and resources
• Emphasise evidence-based and recovery-oriented services

Question 6

How did the language change in hospital retrovision programmes?

Answer 6

> 1980s-1990s: “Normalisation”

> 2000s: “Recovery”

Question 7

What are the two contrasting approaches to understanding need, identified by Dr Frank Holloway (1994)?

Answer 7

1. Positive
   - user-focused
   - strength-based
   - recovery-oriented
   - emphasis on empowerment and engagement
2. Focus on the problems/difficulties people with mental illness experience
   - pragmatic multifaceted réponse
   - eclectic range of treatments, care, support and understanding
   - > a “less fashionable approach”

Question 8

What are the two contrasting models of need in community care (Holloway, 1994)?
Where lies the false antithesis between these two models?

Answer 8

1. ‘Implicit’ model
   - ordinary human needs
   - normalisation theory (now Recovery theory)
   - focus on strengths
   - non-professional care staff
   - aim to provide ‘ordinary life’ within a pseudo family = floating support
   - focus on individual user
   - commitment to user involvement and empowerment
   - problems located in society
   - emphasis on ‘holistic’ approach
   - attractive and fashionable
   - may lead to staff burnout
   - may lead to formulated right of psychiatric inpatients to refuse medication (“rotting with your rights on”)
2. ‘Psychiatric’ model
   - needs for treatment and care
   - biopsychosocial model of mental illness
   - focus on problems/weaknesses
   - reliance on professionnel interventions
   - aims to minimise symptoms and maximise social functionning
   - epidemiological perspective
   - attempt to gain adherence of patient to treatment
   - problems located within individual
   - emphasis on biological treatments
   - unattractive and unfashionable
   - may lead to staff cynicism
   - may be coercive and confining

> False antithesis on the problems located in society vs. within individual

Question 9

What is CANSAS?

Answer 9

Camberwell Assessment of Need Short Appraisal Scale
(CANSAS)
- 22 domains that are potentially impacted by mental disorder and are potential areas for intervention by services
(e.g. accommodation, self-care, safety to self/others, drugs, sexual expression, child care, basic education, money, benefits, …)

• ratings: ‘no problem’ ; ‘met need’ ; ‘unmet need’ ; ‘not known’

Question 10

What is the assertive community treatment (ACT) model?

Answer 10

Key requirements of people at risk of hospital admission:

• coping skills
• material resources
• assertive support system
• support and education of community members
• motivation
• freedom from dependent relationships
• > breaks the cycle of dependancy
• effective treatment of symptoms and distress

Question 11

What does the Manchester Short Assessment of Quality of Life (MANSA) measure?

Answer 11

How satisfied are people with life as a whole and within particular domains
> Training, job, sheltered employment
> Mental and physical health
> Accommodation, financial situation, personal safety
> Family, sex life, leisure activities, friendships, relationships

Question 12

What do CAN, MANSA and the Assertive community treatment model indicate?

Answer 12

What services should be focusing on in order for people to achieve good outcomes
-> go beyond alleviating symptoms

• functional skills
• somewhere to live
• relationships
• activity and occupation
• meaning

Question 13

Why is assessment important?

Answer 13

Identifies

• problems
• entitlement to services
• steps for action
• outcomes

Question 14

What are the five usages of recovery according to Roberts and Boardman (2013)?

Answer 14

1. Recovery
   - a natural healing response and an approximation to cure (most people get better from most things, most of the time)
2. Clinical recovery = getting better
   - from symptoms and difficulties in response to effective care and treatment as described in most evidence-based guidelines (e.g. NIH, Care Excellence guidelines)
3. Personal recovery = living well
   - of valued pattern of life and living, with or without ongoing symptoms and difficulties
   - linked to active personal commitment to working on recovery
4. Recovery-oriented approaches and services = make services work in a recovery-oriented way
   - overall pattern of care, support and professional practice based on learning ‘what works’ from people in recovery
   - conducted by staff with appropriate qualities and skills in recovery-supportive relationships
5. Recovery Movement = knowing if you are in it or not
   - values-led collaborative endeavour of people in recovery, practitioners and many others
   - working to develop and transform mental healthcare and treatment
   - recognises the concurrent value of diverse experience, research and training and the benefit of working together in partnership
   - to co-construct and co-produce learning, teaching and change

Question 15

What are the key points of recovery following the definition of the Royal College of Psychiatrists (2012)?

Answer 15

> “process of developing a sense of self, purpose in life and hope”
“a journey for the individual and those close to them in rebuilding a satisfying life”
Resilience is central: “allows for individual strengths and coping skills to surface, in spite of adversity”

Question 16

How does the concept of “recovery” identify the patient?

Where is the focus and emphasis?

Answer 16

> Patient identified as agent rather than an “illness”
focus on the person’s goals and how to support achieving them
Emphasis on
- importance of “hope” and “empowerment”
- peer support and peer-led services
- creativity within recovery narratives

Question 17

What is psychiatric rehabilitation according to Killapsy et al. (2005)?

Answer 17

“A whole systems approach to recovery from mental illness

• that maximises an individual’s quality of life and social inclusion
• by encouraging their skills, promoting independence and autonomy
• in order to give them hope for the future
• and leads to successful community living
• through appropriate support.”

Question 18

What is the argument of the balanced care model (Thornicroft and Tansella, 2013)?

Answer 18

> High-resource setting achievements aren’t necessarily appropriate for a low-resource setting

> Bedrock of mental health services lies in primary care (supported by epidemiologic studies)

> There is always a need for some inpatient provision

Question 19

According to Thornicroft (2011), what are the components of a competent community-oriented mental health service for low, medium and high-resource settings?

Answer 19

> Low-resource settings:

• Primary care mental health
• Limited specialist mental health staff

> Medium-resource settings:

• Primary care mental health
• General adult mental health services

> High-resource settings:

• Primary care mental health
• General adult mental health services
• Specialised adult mental health services

Question 20

Which components of community-oriented health service are important and flourish in low and middle income countries?

Answer 20

> Third sector organisations
Housing opportunities
Family support

Question 21

What are the 12 operational service components (Thornicroft, 2011)?

Answer 21

1. Crisis and emergency services
2. Early intervention for people with psychosis
3. Case management and assertive community treatment
4. Outpatient clinics
5. Day hospitals and partial hospitalisation programmes
6. Work rehabilitation - Individual placement and support
7. Inpatient treatment
8. Residential care
9. Programmes to support family members and care-givers
10. Medication
11. Managing co-occurring physical disorders
12. Illness self-management programmes

Question 22

What should be the components for a good community health service, in a defined catchment area?

Answer 22

> Primary care
> Housing authorities
> Access to inpatient services
> Education providers
> Social services
> Specialist mental health services
> Technical therapeutic skills
> Faith communities

> Staff who care about their work
Good local management
A focus on the needs of the person and their carers that foes beyond protocal-based treatment of defined disorders/conditions
Awareness of functional impairments and how these may be overcome
An optimistic, problem-solving approach

Question 23

What is IMPARTS?
What is its overall goal?
What are its components?

Answer 23

> an initiative funded by King’s Health Partners to integrate mental and physical healthcare in research, training and clinical services

> overall goal: improve mental healthcare provision within medical settings across KHP
- and to support clinical teams in providing timely, tailored, evidence-based care to patients presenting at KHP acute trusts

> Components:

1. Informatics system
   - routine collection of patient-reported outcomes
   - real-time feedback to guide clinical care
2. Development of mental health care pathways for patients identified via the informatics system
3. Training in core mental health skills for physical healthcare teams
   - alongside ongoing support and supervision from a mental health specialist
4. Portfolio of bespoke self-help materials tailored to specific patient groups
5. Research database to facilitate research through the routine collection of patient reported outcomes in medical settings