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clarified; and risk management should be dealt with rationally, not prejudicially (Pilgrim and Rogers 1997).
The macro policy context together with the micro behaviour of professionals making and dealing with mental health referrals determine the pace and success of community care. A com- parison of community-based care for those patients with a diagnosis of schizophrenia in Verona and South Manchester indicated that the organization of services in the former resulted in shorter hospital stays as a result of better integration between hospital and community services (Gater et al. 1995).
Primary care, open settings, ehealth and psychological therapies: a new focus
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they work directly with patients, but also with other professionals responsible for their care, such as a GP or community psychiatric nurse, to ensure co-ordinated and structured care. Collaborative care when in operation now involves three elements:
• planned, proactive, regular contact between a case manager and patient;
• advice and guidance about treatment modalities (e.g. medication, problem solving or CBT);
• regular feedback of information on the treatment process from mental health profession- als involved in the care.
New technologies and information systems have enabled new modes of organizing mental health work to emerge. The widespread availability of information technology, together with the com- munity location of the overwhelming majority of patients, has changed the face of how mental health services are organized and delivered. For example, telephone counselling from a primary care base for patients with ‘minor depression’ has been found to be both efficient and effective (Lynch et al. 1997), as has psychiatric assessment over the telephone (Kobak 1997). Remote treat- ment of depression by ‘telepsychiatry’ has been shown to be as effective as face-to-face therapy (Ruskin et al. 2004). This change, in turn, is likely to dramatically alter the power relationships between providers and recipients of mental health services. More recent interventions, such as integrating mobile-phone-based assessment for psychosis, requires the active involvement of users in operationalizing the technology and controlling what happens with data used for monitor- ing symptoms which were previously the preserve of mental health professionals (Palmier-Claus et al. 2013).
The ambiguous legitimacy that mental health care professionals hold in the eyes of users is reinforced by research that evaluates the outcomes of services organized along these new lines.
A randomized controlled trial compared face-to-face meetings with professionals and another group who used an electronic self-help computer programme in the form of a ‘voice bulletin board’. Clients were found to be eight times more likely to participate in the computerized pro- gramme and were more satisfied than the group receiving face-to-face contact (Alemi et al.
1996).
Professionals’ use of computer packages and the fashion for ‘stepped’ and collaborative care takes mental health care out of any one organizational context and introduces new problems in terms of the surveillance and ‘follow-up’ of patients. An aspect of this challenge that has become the focus of professional and academic interest is the notion of ‘continuity of care’. A combination of assertive community treatment, case management, community mental health teams and crisis intervention has been found to reduce the likelihood of patients dropping out of contact with serv- ices (Crawford et al. 2004).
The Internet and computer-based programmes, by simplifying communication and being read- ily accessible directly to people, have the potential to ‘cut out’ professionals altogether from the care process. This also overcomes the problems caused by geographical location and variable personal quality (mechanical responses can be standardized). It is likely that the use of the Inter- net directly empowers users of mental health services by allowing them to feel in control of their treatment and everyday life more generally. (The issue of users as providers of care is returned to in Chapter 11.) Equally, if not more, important is the rapid increase in mutual non-professional support. The social isolation and ‘poverty’ of social networks have been a recurrent theme in the literature on people with long-term health problems.
One of the most important consequences of the technologies is the rapid increase they allow in mutual non-professional support. The anonymous helper in an electronic conference, or the support group on the Internet, provides the basis of a radical shift in mental health support. This has emerged as an unpredicted and major force in the global organization of mental health care.
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The increasing shift from secondary to primary care and then into open setting, which started with deinstitutionalization policies and has accelerated since then, has meant an alteration in the place of the administration of treatment. This changes the range, nature and extent of what is provided. The introduction of primary care administered treatment by mental health workers, for example, has led to a reduction in primary care consultations, the prescribing of psychotropic drugs, greater recognition of the psychological bases of ‘medically unexplained symptoms’ (Peters et al. 2009) and referrals for treatment elsewhere. It has also, increased psycho-social interventions to patients in primary care.
Beyond a recognition of the changing administration of treatments, the notion of ‘therapeutic landscape’ has implicitly assumed a more central place in the discourse of treatment of mental health and well-being. In a general sense the notion refers to ‘places, settings, situations, locales, and milieus that encompass both the physical and psychological environments associated with treat- ment or healing, and the maintenance of health and well-being’ (Williams 1998: 129). Therapeutic landscapes focus on the importance of places for maintaining physical, emotional, mental and spir- itual health, and link with holistic and alternative therapies and ideologies. This conveys a positive sense of place and the intrinsic therapeutic value of activities and environments outside of tradi- tional mental health services. For example, in many localities gardening may be an important source of psychological well-being. The humanistic ideology of the notion of the therapeutic landscape concept has been turned on its head by reference to the notion of the anti-therapeutic environment and treatment of people with mental health problems in prison settings (Bowen et al. 2009).
There has been a gradual diversification away from hospitals as the single site of delivery.
Mental health trusts and newly emergent local forms of commissioning and governance have been responsible for facilitating centrally directed policy implementation designed to improve the quality of care and patients’ experiences by developing the capacity and skills of local mental health services based more on a networked approach of providing services according to function, population group and severity (see Figure 6.1).
Quality improvement programmes have more recently aspired to include organizations that lie beyond the hospital: health education and social services together with the independent sector and community organizations. However, mental health service organizations are relatively intran- sigent, with evaluations showing little demonstrable improvements in the quality of the services delivered (Beecham et al. 2010).
Discussion
The old mental asylum system can be thought of as representing part of the modernist project, although other forms of total institution, like the monastery, stretch back to feudal times. But while the monastery was guided by theological considerations, the asylum was peculiarly modern because rationality was its guiding organizational principle. Reason, not faith, now permeated the total institution. The pursuit of rational scientific knowledge about lunacy became the aim of modern psychiatry, even when such an aim was rhetorical rather than real. Accordingly, the elimination of mental disease was seen as a possibility, through its systematic organization and treatment in purpose-built institutions designed to segregate embodied irrationality from everyday life. There was no longer what Foucault called a ‘dialogue between reason and unreason’; rather, the latter was trapped and codified by the former.
This Victorian project is now largely over (save relics of the psychiatric total institution like the high-security hospitals). The crisis of the asylum emerged not only because of considerations of cost but also because of changes in the discourse about mental abnormality and its treatment, in both the lay and professional areas. Earlier we summarized the expansion of the ambit of psychia- try after the First World War, and Prior (1991) argues for a more recent flux in psychiatric theory
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and practice. The asylum could not adapt to these changes and so its therapeutic legitimacy edged more and more towards crisis – but what of the asylum’s replacements?
We have discussed two British responses: CMHC and DGH units. This divided response sug- gests that both continuity with Victorian modernism and a post-modern break have taken place, as far as the organization of mental health work is concerned. The CMHC is consistent with a defini- tion here by Clegg (1990: 53) of post-modern organizations: forms of emerging organization that bear little or no relation to modernist variations on the theme of bureaucracy. These organizations are ‘dedifferentiated’: flexible, niche marketed and with a multi-skilled workforce held together by information technology, networks and subcontracting.
The emergence of the CMHC seemed to confirm the notion that mental health care deliv- ery is moving into a different era. In this organizational context, role-blurring removes the strict division of labour typical of the hospital. The key worker system and multi-disciplinary working brings with it genericism and an increased individual responsibility for practitioners.
Figure 6.1 Diversification of care: place and function.
Organization of statutory mental health services in the UK
Mental health trusts: inpatient, community, rehabilitation, residential care services and drop-in centres.
Community mental health teams: day-to-day support with the aim of assisting a person to remain living in the community.
Crisis resolution teams: management of people experiencing acute mental health crisis (e.g. suicide attempt, psychotic episode) and prevention of hospitalization. These operate on a 24-hour basis, have close links to the accident and emergency department, and are responsible for planning after-care aimed at prevention of future crises.
Assertive outreach teams: work with people with a history of service use who are no longer in regular contact with mental health services. They also work with agencies to locate people thought to be at risk and will sometimes seek to use compulsory management (e.g. sectioning under the Mental Health Act).
Early intervention in psychosis teams: the early intervention in psychosis team (eIPT) is designed to work with people aged between 18 and 35 who have experienced, or are at risk of experiencing an episode of psychosis. The team undertakes detection, assessment support and counselling.
Forensic mental health services: focus on people who have mental health conditions and who have committed a criminal offence or are at high risk of committing an offence. This involves incarceration in secure provision hospitals and prisons.
Services for children and young people: organized around four tiers:
Tier 1 – brief treatment for ‘minor’ problems and assessment for eligibility to specialist services by GPs, school nurses, teachers, social workers, youth justice workers and voluntary agencies.
Tier 2 – assessment and interventions for children and young people with more severe or complex needs. Services provided by community mental health nurses, psychologists and counsellors.
Tier 3 – services for severe, complex and persistent mental health conditions, bi-polar disorder and schizophrenia.
Tier 4 – specialist services for children and young people with the most serious problems (violent behaviour, a serious and life-threatening eating disorder, or history of physical and/or sexual abuse).
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Outreach work with clients decentralizes or diffuses the locus of power away from the profes- sionals’ organizational base. Even that base has lost its architectural salience compared with the hospital: the more successfully ‘normalized’ it is the more it looks like an ordinary house. The knowledge base used by the professionals is eclectic (incorporating biological, psychological and social notions).
This picture of diversity and eclecticism in the CMHC no longer squares with Perrow’s model of the hospital outlined at the start of the chapter. However, what does square with such a model is the DGH psychiatric unit. This seems to represent a continuity with the modernist project of Vic- torian psychiatry. Its power is clearly focused and centralized. There is the retention of a division of labour within the clinical team, and between clinicians and managers. Consultants continue to lead a pyramid of clinical power – they head up multi-disciplinary teams, even if their authority is less evident than in the past. Their power has been subordinated to some extent now to the rules of general management (a bureaucratic process), and the modern hospital has been subjected to some extent to the non-bureaucratic principle of marketization. So, while the contemporary DGH units represent a strong continuity with the nineteenth-century asylum, the psychiatric profession is enduring peculiar new stresses.
Another difference between the old and new is literally visible. The architectural form of the DGH unit is actually more clear-cut than the old Victorian hospital, especially when it occurs in the post-war, high-rise, concrete block. In the Victorian asylum the expansive grounds might have been mistaken for a public park, whereas the modern hospital block containing cramped wards with low ceilings, and no internal or external exercise space, has become a caricature of an imper- sonal, modern, urban building.
As Samson (1992) notes about the US experience, new hospitals for old marks re-institution- alization (or it could be dubbed ‘trans-hospitalization’) not community care. Consequently, if the Victorian asylums were found lacking as therapeutic institutions, then it is likely that this will also be the case for the DGH psychiatric units. With a much smaller physical capacity for beds than the old asylums, these new units are increasingly becoming a focus for the expert coercive regula- tion of high-risk patients. Locked wards have returned (‘Special Care Units’), and risk assessment and risk management have become the anxious daily preoccupation of staff. Substance misuse on site has added to this role and brought an illicit drug culture into psychiatric settings (to add to the official pre-existing one of prescribed medication routines). Despite their recent title of acute ‘mental health services’, these units, more than the Victorian hospitals, have now inherited the displaced function to restrain and segregate, albeit for shorter periods, those deemed to be a risk to themselves or others. They are not about mental health but are very much about mental pathology.
A further fragment of the post-modern condition of psychiatry lies with the rise of new tech- nologies in managing mental disorder, where organizational arrangements are largely irrelevant.
This is even more the case with the introduction of collaborative care with its focus on manag- ing across organizational and professional boundaries discussed in the final part of the chapter.
Directly accessible information to users, via the Internet, and to professionals, via telemedicine, also signals abandoning old organizational forms and the beginning of a new form of organization and delivery of mental health services.
This chapter has focused on the rise and fall of the asylum and the ambiguities which attend our current post-asylum world. A variety of factors have contributed to the demise of the old large mental hospitals, some of which have been economic and others ideological in influence. What the current social policy controversies surrounding care in the community highlight is that the old hospitals contained the three inter-weaving functions of care, control and accommodation. Any new arrangement about the organization of mental health work will also involve these functions, but their dilution is also the opportunity for new forms of management and response to emerge.
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Questions
1 why were the large mental hospitals closed down?
2 why were the large mental hospitals not closed sooner?
3 Do new arrangements such as collaborative care reflect our post-modern condition?
4 ‘The pharmacological revolution is a myth’ – discuss.
5 ‘Scull’s fiscal crisis of the State thesis was 20 years out of time’ – discuss.
6 How might new technology shape help-seeking for mental health problems?
For discussion
If you, or a friend or relative, had a long-term mental health problem how would you like services to be organized in response? when discussing this question, think about the points raised in the chapter about care, control and accommodation.
Controversies have tended to emerge and will continue to do so for the very reason that critics (serving a variety of interests) have complained that government has still not delivered the correct blend of care, control and accommodation.