Community Mental Health Teams: Interacting Groups of Citizen-Agent?

Hugh Middleton

Service Setting: Community Mental Health Teams

Community mental health teams are organised around the needs of clients living within a geographically defined area. In the UK, every such area will have several teams, each one charged with providing for a particular set of clients. Sets of clients deemed to be the responsibility of distinct teams are differentiated on the basis of age, perceived risk, chro- nicity of difficulties and psychiatric diagnosis. Thus, broadly, in the UK a geographically defined population of some 300,000 will be provided for by a child and adolescent mental health service (CAMHS) team serving the under 18s, a mental health service for older people (MHSOP) team serving the over 65s, an early interventions for psychosis (EIP) team serv-

H. Middleton (h)

School of Sociology and Social Policy, University of Nottingham, Nottingham, UK

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H. Middleton, M. Jordan (eds.), Mental Health Uncertainty and Inevitability, DOI 10.1007/978-3-319-43970-9_7

ing younger adults with incipient psychosis, an assertive outreach (AO) team providing for people of working age who have proved both a source of continuing concern and reluctant to accept assistance, a crisis resolution and home treatment (CRHT) team providing intense, short-term care for those in acute difficulty, a rehabilitation and recovery (R&R) team offering support and rehabilitation to stable but persistently disabled adults, a drug and alcohol team focusing upon the particular needs of the chemically dependent, and a primary care team providing liaison with general practitioners and short-term therapeutic interventions when these are considered to be most appropriate. Teams range in size from 3 to 4 to 20+ whole time equivalent practitioners. Configurations vary depending upon geography, demographics and choices made by service providers and commissioners. Nevertheless, in the UK this configuration continues to largely respect Department of Health guidelines issued in 2001 (Department of Health 2001).

Encounters between practitioners and their clientele occur in differing locations and at differing frequencies. Most are in clients’ homes but they may take place in public spaces such as a coffee shop or a market, they may take place in a healthcare facility such as a general practice surgery or a room at the team base. Contacts can be as frequent as several times a day in the case of someone in acute crisis and as infrequent as once a month in the case of someone who is in a stable but persistently dependent condition. As their needs change, clients’ provision may move from the caseload of one team to that of another, as might happen with someone who has been supported during an acute crisis and no longer needs the intense support provided by a CRHT, but continues to need the support of an R&R team or a short-term psychosocial treatment provided by a primary care team. Teams are multidisciplinary, predominantly made up of community mental health nurses (CPNs) but also including occupational therapists (OTs), social workers (SWs), psychologists, medically qualified psychiatrists and professionally unqualified healthcare assistants (HCAs) or support workers. The result is a comprehensive but complex set of activities. Furthermore, for reasons of financial accounting, risk management, quality assurance and professional governance, the activities of this workforce have to be recorded, overseen and kept under review. Individual practitioners are governed by their professional codes of con?duct but whether working for the NHS, or another provider organisation in another jurisdiction, they are each, formally, an employee obliged to play their part in providing the service their employer has been contracted to fulfil. In the UK NHS, those services are largely specified by NHS England which oversees Clinical Commissioning Groups, which themselves contract to purchase services from provider organisations on behalf of the NHS. In other jurisdictions, service specifications are determined by negotiation between insuring organisations and state bodies.

Community mental health team working began as large asylums were wound down, in England from the 1960s onwards. Initially, CPNs were employed to “keep an eye” on those discharged from hospital and not uncommonly to administer depot neuroleptic medication. As psychotherapeutic interventions became more popular, and the range of conditions considered to be the remit of specialised mental health services was broadened to include depression, anxiety and personality difficulties, community mental health teams grew in size and their membership embraced these more varied tasks. The fin de siecle community mental health team was a group of individuals co-occupying a base (usually symbolically away from the hospital) from where they would each service a personal caseload. Their interventions would vary according to clients’ needs and an individual practitioner might, for instance, call in for a cup of tea and a chat whilst administering a depot injection with one, attempt exposure therapy in the form of a visit to the local shop with another and give benefits advice to a third, but all three and more besides would constitute their personal caseload, where a considerable degree of latitude and idiosyncratic practice was possible. There was one instance, in 1994, of an NHS CPN pursuing sexual relationships with several of his alcohol- dependent female clients at the same time.[1]

Not only did personal caseloads expose practitioners to such risks, but the arrangement was inflexible in that it was confined to working hours. As clients were considered exclusively the responsibility of individual practitioners, they could only be seen when their practitioner was at work. The UK NHS 2001 Policy Implementation Guide (Department of Health 2001) was a response to these shortcomings and a rationale for considerably strengthening the community mental health workforce. Varying types of need were delineated and identified as the responsibility of differing “specialised” teams. Working hours were extended; a typical CRHT team will provide round-the-clock cover, an AO team might provide 12 hours cover six days a week, whilst a primary care team and a R&R team might continue to keep conventional working hours. A direct effect of extending working hours beyond the conventional is the need for shift working and as a result shared caseloads. Thus, an individual client comes to be seen as a team responsibility, or perhaps the responsibility of a small number of practitioners, so that informed action can be taken by whoever happens to be on duty at the time. This development has heightened the importance of how well the team functions as a team.

Practitioners in a fin de siecle community mental health team provided a variety of individualised functions defined by the particular needs of their individual clients. With the introduction of “specialised” teams, their tasks have become identified with the ethos of this, that or another team. However, it remains unclear whether or not these different ethos genuinely reflect different technologies of care, or whether they simply reflect contextually differentiated applications of a more generic set of activities which can still be understood as ”community mental health care.” This is important if such activities are to be refined, and if they are to be understood in a wider social context.

  • [1] This situation confronted the author when he took up an NHS consultant psychiatrist post in1994. The nurse in question was disciplined and lost their registration.
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