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HEALTH ECONOMICS AND PSYCHIATRY: THE PURSUIT OF EFFICIENCY 383 28. Bindman, J., Glover, G., Goldberg, D. and Chisholm, D. health care costs: a guide to regression models. British (2000) Expenditure of mental health care by English Journal of Psychiatry, 183, 398–404. health authorities: a potential cause of inequity. British 34. Beecham, J., Chisholm, D., O’Herlihy, A. and Astin, J. Journal of Psychiatry, 177, 264–277. (2003) Variations in the costs of child and adolescent 29. Moscone, F. and Knapp, K. (2005) Exploring the spatial psychiatric inpatient units. British Journal of Psychia- pattern of mental health expenditure. Journal of Mental try, 183, 220–225. Health Policy and Economics, 8, 205–217. 35. Beecham, J., Green, J., Jacobs, B. and Dunn, G. (2009) 30. Layard, R. Clark, D., Knapp, M. and Mayraz, G. (2007) Cost variation in child and adolescent psychiatric Cost-benefit analysis of psychological therapy. inpatient treatment. European Child and Adolescent National Institute Economic Review, 202, 90–98. Psychiatry, 18, 535–542. 31. Knapp, M. and Mangalore, R. (2007) The trouble with 36. Chisholm, D., Knapp, M., Astin, J. et al. (1997) QALYs .... Epidemiologia e Psichiatria Sociale, 16, The mental health residential care study: predicting 289–293. costs from resident characteristics. British Journal of 32. Knapp, M. (1998) Making music out of noise: the cost Psychiatry, 170 (1), 37–42. function approach to evaluation. British Journal of 37. Knapp, M., King, D., Pugner,K. and Lapuerta, P. (2004) Psychiatry, 173 (suppl. 36), 7–11. Non-adherence to antipsychotic medication regimes: 33. Dunn, G., Mirandola, M., Amaddeo, F. and Tansella, M. associations with resource use and costs. British (2003) Describing, explaining or predicting mental Journal of Psychiatry, 184, 509–516.



Part Five Social interventions



29 Team structures in community mental health Tom Burns Department of Psychiatry, University of Oxford, Oxford, UK While social psychiatry may be difficult to define psychiatric disorders inevitably involves both care and satisfactorily it is relatively easy to recognize. social management. Wittgenstein’s observation summarizes it: ‘Words This intimate linking of the need for social inter- signify families of objects, rather than define classes. ventions (whether social treatments or social care) A hemp rope is strong despite none of the fibres with psychiatric treatment has become strikingly running right through.’ Community psychiatry is a obvious with deinstitutionalization. While the treat- slippery term and community mental health teams ment of the mentally ill was confined to asylums and likewise. No single definition will be always right but mental hospitals the role of those institutions in most of us know what we mean by the terms and meeting social needs (however imperfectly) went recognize them when we see them. essentially unrecognized. Initial attention to this role Psychiatric disorders express themselves in social focused on its detrimental effect. Russell Barton relationships. Most psychiatric pathology is domi- attributed much of the ‘schizophrenic deficit state’ nated by the patients’ behaviour and their thoughts to apathy induced by the mental hospital regime and feelings either about themselves or about those labelling it ‘institutional neurosis’ [1]. Erving Goff- around them. These distortions of social relationships man was enormously influential delineating ‘total not only characterize the active illness but may institutions’ in his Asylums [2]. Such thinking, along permanently alter the nature and scope of the patients’ with increasing reports of institutional abuse of social functioning. Fractured family relationships mental patients, strengthened the case of social refor- may leave the individual unsupported, lost educa- mers for community care. These reforms went back tional and training opportunities may leave them several decades, well before the advent of antipsy- impoverished, and self-doubt and anxiety may chotic drugs, long before the antipsychiatry of the constrict access to friendship and meaningful 1960s. Isolated examples of innovative community- activity. Treatment of all but the simplest and briefest based care had been in evidence in settings as Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

388 SOCIAL INTERVENTIONS disparate as Soviet Russia, the UK, Italy, France, the priority in the 1960s, community care began to Netherlands and the US. However, when deinstitu- evolve into the widespread and durable form recog- tionalization became a systematic, international nizable today. 29.1 THE EARLY HISTORY OF COMMUNITY MENTAL HEALTH TEAMS (CMHTS) A team approach to community mental health care for follow-up necessitated the subdivisions of hospital thosewithsevereorenduringdisordersisinevitable;no catchment areas into manageable sectors while the one profession contains all the necessary skills nor increasingly closer relationship between psychiatrists could one individual provide the flexibility required. and social workers helped shift the focus of care. The multidisciplinary CMHT has slowly evolved to CPNs became the backbone of UK CMHTs and took meet these needs. The UK and France led the devel- on the bulk of what later came to be referred to as case opment ofsuchteamsinthe1950s and1960s. France’s management of the long-term mentally ill. In other ‘secteur’ approach [3] stressed geographical teams countries this role has more often been taken by social early but remained relatively limited since early, often workers (e.g. the US, Germany, Scandinavia) or by highly theoretical, interest. In the UK, outreach was specifically trained mental health workers. heraldedinthemid-1950smorepragmaticallywiththe By the 1980s most high-income countries were 1953 appointment of the first two community psychia- downsizing their mental hospitals and establishing tric nurses (CPNs) in London [4] and the Worthing community care. The radical reforms in Italy intro- experiment providing home-based care [5]. duced by Bassaglia in Trieste and the passing of Law The newly introduced 1959 Mental Health Act 180 in 1978 ensured the prestige of the CMHT there. accelerated the UK development of CMHTs. This act While the Italian experience was launched with great required hospitals admitting involuntary patients to flair and energy it was not particularly innovative, provide outpatient aftercare. It also mandated the mirroring closely that in the UK. It can, perhaps, be involvement of social workers in compulsory admis- seen as the end of the era of ‘organic evolution’ in sions and social services provision for discharged CMHT practice, to be followed by a more scientific psychiatric patients. The requirement for outpatient and research-driven approach to development. 29.2 CHARACTERISTICS OF THE GENERIC CMHT Although there has been a remarkable flourishing of team resource or a team leader). The joint working researchinto theconfiguration and practice of CMHTs of several disciplines ensures the availability of in the last 30 years (plus a striking growth in their size specialist care – prescribing, personal care, help with and resources), their basic structure and processes money and accommodation – but also ensures a have remained relatively consistent. rounded holistic approach to care with all contribut- ing their unique perspectives to assessment. Team members generally display considerable role overlap 29.2.1 Staffing (previously referred to as ‘role-blurring’), acknow- ledging the importance of continuity and therapeutic The CMHT is characterized by its multidisciplinary relationships. There is national and international nature. Virtually all include psychiatrists (although variation in the staffing of CMHTs with clinical this is changing in some specialized teams), nurses psychology and occupational therapy often playing and social workers. The preponderance of nurses or important roles in Europe and specialist staff such as social workers varies according to local traditions, as vocational counsellors and drug and alcohol trained does the role of the psychiatrist (a team member, a staff in the US and Australia.

TEAM STRUCTURES IN COMMUNITY MENTAL HEALTH 389 29.2.2 Assessments and reviews patients avoid treatment and are easily neglected or overlooked. Early research into case manage- Two key structured activities of CMHTs are the ment [7,8] led to a greater clarity about its practice, assessment of new patients and the regular review of in particular the need for a limited, actively managed, patients on their caseloads. Assessments can be con- maximum caseload size. There is little agreement on ducted in a variety of forms – in traditional outpatient the correct size of the caseload but there is agreement clinics, in patients’ homes or other convenient, non- that it should be fixed. stigmatizing, locations (e.g. GP surgeries). They can be by psychiatrists alone or jointly, or by any qualified professional. Assessment practices reflect differences 29.2.4 Triage, allocation and zoning in resources and in the target patient group. Most CMHTs have a meeting each week where patients are With increasing size and complexity CMHTs have reviewed by the whole team to draw on their introduced a number of practices, some of which combined expertise. Routine CMHTs will often remain controversial. Generally CMHTs operate as devote 2–3 hours to such a meeting structured to secondary care services requiring a referral from review new patients, current crises plus systematic another health professional (most commonly family reviews of long-term patients at established intervals. doctors, but including social workers or other doc- These meetings serve to ensure optimal care but also tors). Direct access has usually been unsuccessful, mutual education and supervision. In many services responsible for the failure of US Community Mental their form and content has been prescribed to ensure Health Centres [9] and for a number of European consistent practice. In the UK the Care Programme initiatives.Early CMHTs assessed all patients referred Approach (CPA) was introduced in 1992. This to them, but increasingly teams triage referrals. required the review to be clearly recorded to include Attempts have been made to develop structured refer- patient needs, interventions and who is responsible for ral criteria for this [10], but with little success, and it them plus an agreed future review date; the documen- remains a clinical decision based on the referral letter tation should be shared with the patient and their or a brief assessment by a more junior member of the relevant carers [6]. team. Triage is controversial in mental health as referral information can be incomplete and mislead- ing and where there is some evidence, albeit indirect, 29.2.3 Case management that investing in thorough assessment may overall save time and resources [11,12]. Where teams do not Although case management is a fairly recent term, the restrict assessments to psychiatrists some have practice of individual team members carrying a dis- ‘allocation meetings’ to direct referrals to the appro- crete caseload established itself early in CMHT evo- priate team member. This practice is questionable and lution. Case managers (or key workers as they were time-consuming. Zoning involves actively deciding often called) regularly visited, monitored and treated which patients need more intensive input, rather than individuals on their caseload. As CMHTs became simply deciding it from day to day. Derived from more sophisticated they took on coordination and research into intensive case management for highly review functions also. This relationship is of particular unstable patients, it is routinely used in first-onset importance in CMHTs, given that many of the most ill teams and increasingly in generic CMHTs. 29.3 RESEARCH INTO CMHT STRUCTURES There were a number of isolated trials of early com- Treatment [16] initiated an era of intense activity. munity mental health services [13–15] but Stein This research into team functioning and structure and Test’s landmark study of Assertive Community has demonstrated an impressive incremental

390 SOCIAL INTERVENTIONS improvement in quality. Coid correctly castigated control powerful external influences. Community early researchers for obvious faults – small samples, psychiatry research is highly complex; it requires poor and inconsistent definitions þ new services both social science and natural science methodologies highly dependent on charismatic leaders who often simultaneously and often tries to capture a researched their own practice [17]. To these criticisms moving picture. The pre-eminence given to rando- can be added the failure to pay attention to control mized controlled trials in modern evidence-based services [18] and the difficulties of measuring a medicine has resulted in a misplaced faith in their rapidly changing service context. It is also results with little attention to their limitations for this impossible to blind researchers or practitioners or to task [19]. 29.4 CASE MANAGEMENT (CM) AND ASSERTIVE COMMUNITY TREATMENT (ACT) The coherent body of systematic research into com- care significantly [21]. As a consequence ACT has munity mental health teams was started by research spread internationally as the preferred service model into case management (CM). Intagliata [7] described for severe mental illness in many US states and CM’s origins in the need to coordinate a disparate Australia and has been mandated in the UK [22], range of services for multiply disabled individuals establishing over 300 teams. discharged from mental hospitals. The early form of CM was so-called ‘brokerage’ CM. The case manager was not necessarily a mental health professional and 29.4.1 Meta-regression of home-based was responsible for organizing care, not providing it. care Brokerage CM was subject to some early trials, which rapidly confirmed the evolving clinical consensus that The international spread of ACT and research into it it was ineffective. It was promptly replaced with has been particularly valuable in illuminating ‘clinical case management’ where the case manager CMHT structures. No sooner had the approach been was responsible for much of the direct care (a ‘key mandated in the UK when one of the largest, and worker’) as well as brokerage [8]. certainly the most rigorous, trial of ACT found no The importance of clinical case management in benefits for it [23]. This UK700 trial caused a furore, CMHTs was questioned with the publication of Stein and not just because it failed to find any significant and Test’s landmark study [16]. Their approach (later differences (patients in both groups spent a mean of 72 called assertive community treatment (ACT)) was days in hospital over two years of follow-up); several based on a multidisciplinary team made up predomi- of the trials in Marshall and Lockwood’s meta-ana- nantly of clinical case managers. However, they lyses failed to find significant differences although the emphasized the importance of shared clinical respon- summed results were significant. The UK700 trial sibility (deriving from outdated aetiological theories was, however, sufficiently powered to demonstrate about pathological dependency in psychosis), referred that there was no difference in outcome. Indeed, no to as ‘the whole team approach’. How real a difference substantial trial of ACT in Europe (where it is this approach makes is open to debate, but the term called intensive case management (ICM)) had found ‘case management’ was subsequently restricted in a significant reduction in hospitalization [24–26]. research literature to services not operating as teams. The dispute about whether this reflected poor model Marshall and Lockwood’s Cochrane review of case fidelity or better controls was eventually addressed management distinguished it from ACT and con- scientifically. This comprised a systematic attempt cluded that it is ineffective in reducing hospitalization to identify the factors associated with reduced or loss to follow-up [20]. ACT, on the other hand, was hospitalization, and in the process obtain a greater shown in a separate Marshall and Lockwood review understanding of effective CMHT structure and and meta-analysis to reduce hospitalization and loss to functioning.

TEAM STRUCTURES IN COMMUNITY MENTAL HEALTH 391 The main finding of this meta-regression [27] was treatment [29] attempted to identify core ingredients. that the current practices in the use of inpatient care The principle investigators in 90 trials of home-based (i.e. the quality of the control services) explained most care worldwide were questioned about the nature of of thevariance; this has been borne out by the failure of the teams they were testing. A group of experts had ACT teams established in the UK to reduce hospita- developed a checklist of 20 easily measurable key lization [28]. Model fidelity was assessed for the components of community care to be rated for each services in the studies and yielded the remarkable service studied. Over 60 replies were received spread finding that staffing and resources had no association across the studies [30]. Figure 29.3 shows the six with reducing hospitalization (Figure 29.1); however, service characteristics that were most frequently ‘team processes’ did have a significant association reported and the lines between them indicate their (Figure 29.2). The multidisciplinary nature of the team associations in a cluster analysis. (with regular reviews and shared decision making) This study lacks the rigour and power of the meta- appeared to be the effective ingredient. In short, this regression and its findings should be considered investigation was a strong endorsement of the tradi- provisional. It does, however, distinguish aspects of tional structure and functioning of generic CMHTs. team structure in more detail. Small caseloads indi- cate a caseload size of 1 : 20 or below (not micro- caseloads of <1 : 10 suggestedinACT). Thetwo 29.4.2 Characteristics of generic CMHTs ‘home contact’ factors record, first, the policy of having home visiting as a regular aspect of work Given their early, slow evolution it is not surprising and, second, the proportion of all patient contacts that there is very little empirical research into CMHT that were home based. ‘Multidisciplinarity’ reflects characteristics. An earlier systematic review of home having trained professionals from several disciplines Figure 29.1 Scatter plot of IFACT team membership subscore versus mean days per month in hospital. Each circle is proportional to the size of centre it represents. Negative treatment effect indicates that intensive case management achieved a reduction in mean days in hospital relative to the control

392 SOCIAL INTERVENTIONS Figure 29.2 Scatter plot of IFACTorganization subscore versus mean days per month in hospital. Each circle is proportional to the size of centre it represents. Negative treatment effect indicates that intensive case management achieved a reduction in mean days in hospital relative to the control in the team (not just undifferentiated case mangers or the team)? Integration of the psychiatrist in the team mental health workers). Two questions were asked was reported as a core feature but not levels of about psychiatric provision – How much was there psychiatrist resource. ‘Responsibility for health and (psychiatrist hours per 100 patients) and how did social care’ was defined as the ability and willingness the psychiatrist work (as a consultant to the team of the team to address both medical (e.g. pharmaco- for complex problems or as a routine member of logical and psychological therapies) and social Smaller caseloads Regularly Responsible for visiting at health and home social care Psychiatrist integrated in High % of Multidisciplinary team contacts at teams home Figure 29.3 Associations between service components, cluster analysis and hospitalization, in a regression analysis

TEAM STRUCTURES IN COMMUNITY MENTAL HEALTH 393 (e.g. housing, finance, leisure) needs without onward based care) and the broad responsibility for health and referral. social care. The former endorses the development of When the 20 characteristics were regressed against routine outreach such as that practised by CPNs and reduction in inpatient care (reported in all the studies) the latter the variety of moves to integrate social two were found to be significantly associated – regular services more closely into CMHTs by co-location, visiting at home (i.e. the policy commitment to home- secondment and so on. 29.5 CURRENT DEVELOPMENTS Despite the continuity and durability in the structure experiencing a move towards dedicated inpatient and functioning of CMHTs they are facing a period of teams. The issue of continuity of care in CMHTs is intense scrutiny with a range of experimentation in also eroded by the emergence of crisis resolution/ their form and, particularly, in their relationships with home treatment teams, promoted as gatekeepers to thewiderhealthcaresystem.Howthesewillplayoutis reduce unnecessary admissions [10,22,28]. The rela- impossibletopredict.Theyreflectaseriesofpressures, tive benefits of reduced hospitalization versus reduced including professional aspirations, the impact of continuity of care await evaluation. new treatments, plus external influences from user groups, governments and even from pharmaceutical companies. Evidence may play some part in the direc- 29.5.2 Relationships of specialized teams tion of development, but only a limited part. Assertive outreach, crisis and early intervention teams for psychosis are now widespread. The initial UK plan 29.5.1 Continuity of care across the was for them to be a patchwork of teams with GP inpatient/outpatient boundary access directly to all three [22]. In practice (particu- larly outside metropolitan settings) a range of more The UK and Italy are unusual in their established hierarchical approaches is common, with access to the practice of the CMHT retaining overall clinical specialist teams via the generic CMHT. While this responsibility for their patients while in hospital. In may seem predominantly an ideological issue it is most services there is a clear transition of responsi- more a definitional one. As the roles of these teams bility (financial and clinical). While Scandinavia has distinguish themselves more clearly then the need for recently moved to such continuity the dominant pat- CMHT gatekeeping may become less important. tern has been to emphasize the split. There is no direct experimental evidence to resolve this dilemma but indirect evidence (the low bed use by the UK and Italy) 29.5.3 Impact of governance structures suggests that continuity facilitates efficient inpatient and structured assessments resource use. It also has the advantage that patients remain in contact with familiar faces when at their All health service activity is subject to vastly more most ill (which they value highly [31]). governance and bureaucracy than previously. There is Continuity across this boundary also ensures that increased attention to careful recording in notes and there is continuity of a treatment model [32]. Separate also much greater use of structured assessments (e.g. inpatient teams are often more ‘medical model’ and risk assessments, needs assessments). This can alter outpatient teams more ‘psychosocial’. Several factors the balance in team activity with more time spent in support the separation. These include the neglect of team meetings than previously. There have been the quality of inpatient care by CMHTs and the several initiatives to develop structured assessments increasing severity of those admitted plus the dimin- to improve clinical practice, including referral thresh- ishing number of inpatients as CMHT practice old assessments [10] and even tools for structuring improves and as catchment areas shrink. The UK is the interaction with patients [33]. Standardized

394 SOCIAL INTERVENTIONS assessments have yet to become regular practice in become more established, role-blurring has receded. generic CMHTs butthey are increasingly used in more However, the value that patients and their families specialized teams. place on continuity (even over clinical excellence) and the importance of the therapeutic relationship in mental health care [34] underscore the fact that tech- 29.5.4 Specialization nical excellence has to be balanced with a whole- person approach. The last 20–30 years have seen a significant growth in specialization in mental health care. Where once a CMHT dealt with all the adult mental health problems 29.5.5 Evidence-based mental health care sent to it there are now old age and forensic teams established in most services. The development and This chapter has focused on the structure and pro- roll-out of the functional teams (ACT, CR/HT and cesses of mental health teams. Much of the literature EIS) is less firmly anchored and timewill tell how they on the subject is written as if teams improve outcomes will establish themselves. The pattern is likely to vary or reduce hospitalization [20,21]. This is an under- to reflect local needs. Highly specialist teams (e.g. standable shorthand but often reflects a genuine belief eating disorder teams, rehabilitation teams, person- that it is the team or its routines that are effective. They ality disorder teams) are essentially tertiary care pro- are not: teams do not cure patients; it is treatments that vision and their distribution often reflects local need or cure patients. The UK700 trial concluded that there leadership. should be much more of an emphasis on the treatments The development of specialist teams does, however, that are delivered [23] and that these should be bring into question some of the founding principles of researched. This makes obvious sense; an important CMHTs. The 1960s CMHTs were often rather anar- test (perhaps the most important test) of a team chic and emphasized the value of role-blurring and structure is how successful it is in delivering effective skill-sharing. This reflected a move to stressing the treatments that cannot be delivered equally well in common humanity of much of CMHT work. In an era other team structures. A simple example is clozapine before the dominance of evidence-based mental treatment for individuals with resistant schizophrenia health care (EBMHC) there was a strong belief that who are poorly compliant with treatment. ACT teams much of the work of CMHTs could be equally con- have a demonstrable advantage in achieving this than ducted by any of its well-trained mental health profes- less-intensive CMHTs. sionals. As skills have improved and as EBMHC has 29.6 CONCLUSIONS While brief or uncomplicated mental health problems of research plus intense public scrutiny of CMHT continue to be managed in office- or clinic-based practice and pressures from policy makers. CMHTs practice (often by individual practitioners), most peo- have also been buffeted by internal tensions as the ple with severe mental illness outside hospitals are involved professions have established their claims for treated within some form of multidisciplinary team. influence. This team approach, embodied in CMHTs, evolved Despite these developments the well-functioning early in the process of deinstitutionalization in CMHT demonstrates the same basic characteristics response to the range of needs exhibited by these now as when they became widespread 40 years ago. individuals and to provide effective access. They did They are small enough for everyone to know not arise from theoretical or scientific planning. The each other (and their potential contributions) at a last 30 years has witnessed a rapidly expanding body personal as well as the professional level; they

TEAM STRUCTURES IN COMMUNITY MENTAL HEALTH 395 maintain professional identities but share many of the 9. Talbott, J. A., Clark, G. H. J., Sharfstein, S. S. et al. common tasks; most members have their own case- (1987) Issues in developing standards governing psy- load for which they take overall responsibility but chiatric practice in community mental health centers. ensure that their patients arewell known by colleagues Hospital and Community Psychiatry, 38, 1198–1202. so that tasks and clinical decision making is shared; 10. Slade, M., Powell, R., Rosen, A. et al. (2000) Threshold they have regular review meetings and have an agreed, Assessment Grid (TAG): the development of avalid and though generally ‘flat’, hierarchy of responsibility. brief scale to assess the severity of mental illness. Social Psychiatry and Psychiatric Epidemiology, 35, 78–85. They have changed in becoming much more specific about caseloads (both in size and responsibility); they 11. Burns, T., Beadsmoore, A., Bhat, A. V. et al. (1993) A controlled trial of home-based acute psychiatric have clearer, more consistent, clinical and recording services. I: clinical and social outcome. British Journal procedures; accountability and risk-management of Psychiatry, 163, 49–54. structures have become prominent. Lastly, they have 12. Burns, T., Raftery, J., Beadsmoore, A. et al. (1993) become more clearly defined in terms of the evidence- A controlled trial of home-based acute psychiatric based interventions they provide for defined clinical services. II: treatment patterns and costs. British Jour- groups rather than just in terms of their composition or nal of Psychiatry, 163, 55–61. the geographical areas they serve. Their core structure 13. Grad, J. and Sainsbury, P. (1968) The effects that has proven its durability through several decades of patients have on their families in a community care challenge and is likely to outlive those it is currently and a control psychiatric service - a two year follow-up. having to accommodate. British Journal of Psychiatry, 114, 265–278. 14. Pasamanick, B., Scarpitti, F. R. and Leyton, M. (1964) Home versus hospital care for schizophrenics. Journal REFERENCES of the American Medical Association, 187, 177–181. 15. Braun, P., Kochansky, G., Shapiro, R. et al. (1981) 1. Barton, R. (1959) Institutional Neurosis, John Wright, Overview: deinstitutionalization of psychiatric Bristol. patients, a critical review of outcome studies. American 2. Goffman, I. (1960) Asylums: Essays on the Social Journal of Psychiatry, 138, 736–749. Situation of Mental Patients and other Inmates, 16. Stein, L. I. and Test, M. A. (1980) Alternative to mental Penguin Books, Harmondsworth, Middlesex. hospital treatment. I. Conceptual model, treatment 3. Kovess, V., Boisguerin, B., Antoine, D. et al. (1995) program, and clinical evaluation. Archives of General Has the sectorization of psychiatric services in France Psychiatry, 37, 392–397. really been effective? Social Psychiatry and Psychia- 17. Coid, J. (1994) Failure in community care: psychiatry’s tric Epidemiology, 30, 132–138. dilemma. British Medical Journal, 308, 805–806. 4. Moore, S. (1961) A Psychiatric Out-patient Nursing 18. Burns, T. and Priebe, S. (1996) Mental health care Service. Mental Health Bulletin, Summer. systems and their characteristics: a proposal. Acta 5. Carse, J., Panton, N., and Watt, A. (1958) A district Psychiatrica Scandinavica, 94, 381–385. mental service: the Worthing experiment. Lancet, i, 19. Slade, M. and Priebe, S. (2001) Are randomised con- 39–41. trolled trials the only gold that glitters? British Journal 6. Department of Health (1990) The Care Programme of Psychiatry, 179, 286–287. Approach for People with a Mental Illness Referred to 20. Marshall, M. Lockwood, A. (1998) Case Management the Special Psychiatric Services, Department of Health, for Severe Mental Disorders, Cochrane Database of London. Systematic Reviews, Issue 2. Art. No.: CD000050. 7. Intagliata,J.(1982)Improvingthequalityofcommunity DOI: 10.1002/14651858.CD000050. care for the chronically mentally disabled: the role of 21. Marshall, M. and Lockwood, A. (1998) Assertive Com- case management. Schizophrenia Bulletin, 8, 655–674. munity Treatment for People with Severe Mental Dis- 8. Holloway, F. (1991) Case management for the mentally orders, Cochrane Database of Systematic Reviews, ill: looking at the evidence. International Journal of Issue 2. Art. No.: CD001089. DOI: 10.1002/ Social Psychiatry, 37, 2–13. 14651858.CD001089.

396 SOCIAL INTERVENTIONS 22. Department of Health (1999) A National Service Frame- admission rates in England. British Journal of Psychia- work for Mental Health, Department of Health, London. try, 189, 441–445. 23. Burns, T., Creed, F., Fahy, T. et al. (1999) Intensive 29. Catty, J., Burns, T., Knapp, M. et al. (2002) Home versus standard case management for severe psychotic treatment for mental health problems: a systematic illness: a randomised trial. Lancet, 353, 2185–2189. review. Psychological Medicine, 32, 383–401. 24. Thornicroft, G., Wykes, T., Holloway, F. et al. (1998) 30. Wright, C., Catty, J., Watt, H. et al. (2004) A systematic From efficacy to effectiveness in community mental review of home treatment services. Classification and health services. PRiSM Psychosis Study 10. British sustainability. Social Psychiatry and Psychiatric Epi- Journal of Psychiatry, 173, 423–427. demiology, 39, 789–796. 25. Holloway, F. and Carson, J. (1998) Intensive case 31. Burns, T., Catty, J., White, S. et al. (2007) Continuity of management for the severely mentally ill: controlled care in mental health: understanding and measuring a trial. British Journal of Psychiatry, 172, 19–22. complex phenomenon. Psychological Medicine, 39, 26. Rossler, W., Loffler, W., Fatkenheuer, B. et al. (1995) 313–323. Case management for schizophrenic patients at risk for 32. Burns, T. (2004) Community Mental Health Teams, rehospitalization: a case control study. European Oxford University Press, Oxford. Archives of Psychiatry and Clinical Neuroscience, 33. Priebe, S., McCabe, R., Bullenkamp, J. et al. (2007) 246, 29–36. Structured patient-clinician communication and 1-year 27. Burns,T.,Catty,J.,Dash,M.etal.(2007)Useofintensive outcome in community mental healthcare. British case management to reduce time in hospital in people Journal of Psychiatry, 191, 420–426. with severe mental illness: systematic review and meta- 34. McCabe, R. and Priebe, S. (2007) The therapeutic regression. British Medical Journal, 335, 336–342. relationship in the treatment of severe mental illness: 28. Glover, G., Arts, G., and Babu, K. S. (2006) Crisis a review of methods and findings. International resolution/home treatment teams and psychiatric Journal of Social Psychiatry, 50, 115–128.

30 Prevention Tristan McGeorge, Sean Cross and Rachel Jenkins WHO Collaborating Centre, Institute of Psychiatry, King's College London, London, UK 30.1 INTRODUCTION There has been longstanding interest in preventionand tive prevention strategies are considered for indivi- a variety of classifications have arisen that have been duals who belong to subgroups of the population applied to both physical and mental disorders. Health whose risk of becoming ill is above average. Indi- prevention strategies in general have been divided cated prevention is targeted at specific groups who into primary, secondary and tertiary approaches [1]. are at high risk of developing a disorder. A sum- Primary prevention is aimed at reducing the incidence mary of these terms can be found in Table 30.1. A of mental disorders in the community. It is directed at further classification system has also arisen due to a people without the disorder who are at risk of subse- perceived lack of clarity between prevention and quently developing it. Secondary prevention aims to treatment, which differentiates between treatment reduce the prevalence of a disorder by reducing its and maintenance interventions [3]. Under this severity and duration and is directed at people who approach, prevention interventions describes inter- show early signs of the disorder. The goal is to shorten ventions that take place before the first symptoms of its duration by early treatment, thereby reducing a psychological disorder appear. Treatment inter- morbidity and the consequences for others. Tertiary ventions are interventions initiated during an active prevention is designed to reduce the disability asso- psychological disorder and maintenance interven- ciated with the particular disorder, preventing the tions include aftercare and relapse prevention associated sequelae of chronic illness. programmes [4]. This chapter will focus on primary prevention, The resources required for the different strategies which has been further subdivided into universal, above will vary considerably. Prevention targeted at selective and indicated interventions – with the high-risk individuals produces the greatest benefit for latter two also known as targeted prevention [2]. those particular individuals, but the best benefit for the Universal prevention measures are considered desir- population as a whole is provided by universal mea- able for everyone and are implemented where the sures – this has been described as the ‘prevention benefits clearly outweigh the risks and costs. Selec- paradox’ [5]. Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

398 SOCIAL INTERVENTIONS Table 30.1 Summary of primary prevention strategies Table 30.2 Summarizing important processes at the onset Universal of mental disorder Universal prevention interventions target a whole popula- Cumulative þ Lack of þ Interplay tion group that has not been identified on the basis of effect protective of risk and increased risk. of multiple factors protective Selected risk factors situations Selected prevention targets subgroups of a population whose Individual resilience risk of developing a mental disorder is significantly higher than average, as evidenced by biological, social or psy- chological risk factors. Indicated to, or precipitate, the onset of a mental disorder, Indicated prevention targets high-risk persons who are this is not completely consistent or reproducible. identified as having minimal symptoms foreshadowing Resilience in the face of multiple-risk factors and mental disorder or biological markers indicating predis- in the absence of protective factors continues to be position for mental disorder but do not meet diagnostic the subject of research, particularly for the way in criteria for mental disorder at that time. which stressful events at a population level may lead to different mental health outcomes at an individual level (see Table 30.2). 30.1.1 Targets for prevention ‘Social determinants’ has become an umbrella term for a number of different processes [9]. It includes two In identifying specific areas upon which prevention important processes, both of which may be the target strategies may be brought to bear, it is important to of a prevention strategy. First, there are the environ- distinguish between predisposing and precipitating mental and psychosocial factors impacting on a cau- factors – namely those factors that are intrinsic to the sative path to mental disorder. Second, there is theway development of a disorder compared to those instru- in which these risk factors are mediated by social and mental to its onset. There are greater opportunities for political processes such as access to food, housing and prevention in precipitating as opposed to predisposing health care. The wider social and political context is factors. This has led to a shift from high-risk popula- therefore of paramount importance. Albee claimed tions to high-risk situations as a focus for prevention that the major risk factor for mental illness is stress and programmes. It is easier to identify high-risk situa- identified the major causes of stress as poverty, gender tions than to access high-risk populations. The discrimination and being born unwanted. According immediate return on the high-risk situations is likely to him the only way to reduce the incidence of to be greater than for high-risk populations, which emotional disorders is through the use of primary may not see their return for many years [6]. prevention measures [10]. However, more than this, At the core of prevention work is the identification he argued for the creation of just egalitarian societies of both risk and protective factors for the disorder. in order to prevent mental illness [11]. Attempting to reduce the former and promote the latter is integral to a preventive approach – good evidence exists for the importance of both [7]. Risk 30.1.2 Strategies for prevention and protective factors occur on many different levels – individual, social, economic, environmental, In delivering a prevention programme the target popu- cultural – and their interplay has been suggested to be lation needs to be identified. Two main approaches are cumulative in moving along a chain of causation available. The first involves the identification of indi- from health to increased vulnerability, through to viduals who are exposed to multiple stressors. The symptoms and finally to full-blown disorder [8]. second approach is to identify those individuals who However, there is a further level of complexity. haveexperiencedparticularlifeeventsthatplacethemat Although risk and protective factors may predispose risk. Preventionstrategies based on life event and social

PREVENTION 399 support theory include delivering individual social support systems [12]. Evidence will now be presented support, improving coping capacities, altering environ- for the variety of ways in which prevention strategies mental settings (nidotherapy) and developing natural may be advanced with this framework in mind. 30.2 EVIDENCE FOR PREVENTION STRATEGIES Strategiestoreduceriskfactorsandpromoteprotective available to show that a 15 minute behavioural factors are considered at four different lifetime points. intervention reduced the incidence of smoking and resulted in a net gain in birth weight [17]. Good nutrition in infancy leads to healthier cogni- 30.2.1 Perinatal and infancy tive development, which can lead to improved educa- tional outcome and decreased risk of mental disorder. Prevention strategies around the time of pregnancy The best evidence is for models that combine food and birth have two obvious focal points: (i) the supplementation with counselling and psychosocial beginnings of life and (ii) major parental life events. care [18]. In an American study, visits during preg- Health prevention work with regard to mental nancy and the first two years of life focused on parent disorders has been attempted through universal mea- education and social support, resulting in higher sures widely aimed at those who are pregnant and in a birth weights, higher IQs and lower levels of child more selective way at specific groups – e.g. mothers- abuse [19]. A further universal nutritional measure of to-be who smoke – or in an indicated way for those global relevance is iodine supplementation, which has who are at high risk because of existing mental illness. protected millions of children from the physical and mental health sequelae of iodine insufficiency [20]. 30.2.1.1 Mental health of the newborn 30.2.1.2 Mental health of parents There is evidence linking a number of mental dis- orders back to perinatal problems and early infancy. Pregnancy and the perinatal period is a time of sig- These include organic learning disabilities and func- nificant adjustment for both parents and most notably tional psychiatric disorders. Examples include the link for the mother. Notwithstanding the significant joy between low birth weight and depression [13] and such occasions bring, there is evidence for higher rates schizophrenia [14], and between exposure to stress in of common mental disorders, such as depression and the first trimester and schizophrenia [15]. Several anxiety, being present at this time. Universal strategies factors increase the likelihood of low birth weight, such as psychoeducative practices by health visitors most notably poor nutrition and substance misuse. and midwives are common. Robust and reliable tools Universal campaigns for healthy eating during preg- have also been developed for detection of postnatal nancy are widespread, as are specific campaigns depressive symptoms, such as the Edinburgh Post highlighting the dangers of addictive substances, Natal Depression Screen aiding promotion of early most notably alcohol and cigarettes. There is evi- treatment of depression [21]. dence of childhood mental disorders being more The treatment of a mother’s depressive episode is prevalent in those whose mothers used addictive not only of benefit to the mother, but also to the substances during pregnancy – e.g. foetal alcohol newborn, as postnatal depressive states have a com- syndrome is a well-documented phenomenon and plex association with later behavioural disorders [22] longer term neurodevelopmental difficulties such as as well as lower rates of childhood vaccination [23] lower intelligence, ADHD, conduct disorders and and appropriate management of diarrhoeal dis- poorer school achievements have been linked to eases [24]. Active treatment of depressed mothers can substance misuse in pregnancy [16]. Evidence is also be viewed as a targeted prevention strategy for

400 SOCIAL INTERVENTIONS depressive states in the newborn later in life. The The 2004 WHO Report on the Prevention of Mental concept of transgenerational transmission of mental Illness divided strategies into five categories, sum- disorders – wider than simple genetics – has validity. marized below [32]. For example,children of depressed patientshave a risk of around 50% of developing a depressive disorder themselves before the age of 20 years [25]. However, 30.2.2.1 Promoting a healthy start in life only a small amount of robust evidence exists to support the hypothesis that prevention strategies will These include universal preschool educational pro- reduce this figure [26]. grammes such as family reading programmes, health screening clinics, and organized recreation and tele- vision programmes. Selective interventions have 30.2.2 Childhood and adolescence focusedonchildrenfromimpoverished andminority families and children of low birth weight or with Experiences in childhood and adolescence provide the learning disabled mothers. Parenting initiatives such foundation for adulthood and later life. Considerable as the Webster-Stratton Incredible Years Programme attention has therefore been focused on prevention [33,34] and the Australian Triple P Positive Parent- strategies aimed at this period of development. These ing Programme [35,36] have been shown to be have been directed against the range of psychiatric effective. conditions that present in childhood and adoles- cence [27]. However, despite the range of prevention programmes in existence, relatively few have been 30.2.2.2 Reducing childhood abuse and neglect utilized in routine practice [28]. The education system is important in delivering programmes for this age Two types of proactive strategies have proven effi- group [29]. cacy [37]. These are home visiting programmes for It is important to recognize risk and protective high-risk mothers to prevent childhood physical abuse factors specific to children [30]. These include famil- and self-defence programmes to prevent child sexual ial disharmony, having a parent with a mental illness abuse. and exposure to forms of abuse [8]. Elsewhere generic risk factors for mental illness in children have been grouped into the following domains: constitutional 30.2.2.3 Coping with parental mental illness handicaps, skill development delays, emotional diffi- culties, family circumstances,interpersonal problems, Children of parents with mental disorders or substance school problems and ecological risks such as neigh- misuse problems are at highest risk of developing bourhood disorganization, extreme poverty, racial mental illness. A range of interventions have been injustice and unemployment [7]. developed to prevent transgenerational transfer of The age range and meaning of childhood and mental illness by addressing risk and protective fac- adolescence have been defined in a number of tors in children and their families [32]. These may ways [27]. Certain mental disorders are more or less target early parent–child interactions, use a whole common at different stages of development. The early family approach in childhood and adolescence, or years are characterized by the continuation of the focus on the children themselves [26,32,38,39]. attachment process. The onset of an attachment dis- order has significant implications for later life. Pre- valence studies in this age group have shown high 30.2.2.4 Enhancing resilience and reducing risk rates of oppositional disorder, hyperkinetic disorder, behaviours in schools and emotional disorders. Later childhood and adoles- cence is characterized by high rates of conduct and There is evidence that social emotional learning and emotional disorders [31]. ecological interventions delivered through school-

PREVENTION 401 based programmes are effective [40]. School-based depressive symptoms, but the effect does not persist programmes include universal general skill-building and nor does it result in a decrease in the incidence of programmes to develop problem-solving abilities; depressive disorder [11]. However, one study has ecologically focused interventions that attempt to found that depression prevention programmes can be address contextual variables in the school and at home cost-effective in adolescents [55]. to improve functioning and prevent or reduce symp- The advantages of universal versus targeted pro- toms; and multicomponent programmes that include grammes in young people have been considered. A elements of both skill-building and ecological potential disadvantage of universal programmes is approaches. that, due to the relatively low prevalence of psycho- pathology among children, much of the effort will be spent on those who may not otherwise develop mental 30.2.2.5 Dealing with family disruption health problems at all ([29], p. 9). Young people who have experienced family disrup- tion through parental divorce or death are at greater 30.2.3 Adulthood risk for a number of adverse mental health out- comes [32,41,42]. The effects of these two types of Attempts have been made at broad universal family disruption are not necessarily the same [43] approaches – such as the promotion of a good diet, and may to some extent be accounted for by a resulting exercise and generic group activities – but there is less change in socioeconomic circumstances [44]. Inter- evidence for their measured success. Beyond these ventions for children of divorced parents have been general approaches, which may impact on all mental delivered through two formats: child-focused and disorders, more specific universal, targeted and indi- parent-focused programmes. There is evidence for cated approaches are available. the effectiveness of both [45–48]. Many programmes Prevalence rates of depression in different countries have been developed for bereaved children but few vary significantly and may be a reflection of true have been subject to well-controlled experimental differences or differences in diagnostic thresh- trials [49]. Children who find themselves looked after olds [56]. This therefore has an impact on any possible in some way by those other than parents are of prevention strategy. Programmes that attempt to target particular concern also. In the UK those within Local group-wide self-esteem as a way of preventing the Authority care have been shown to have significantly onset of depression have more evidence in school age higher rates of mental disorders, significantly more programmes than in adults [57]. Aetiological com- educational problems and a life trajectory that much plexities can hinder prevention programmes – e.g. more frequently includes prison [50]. A series of there is still little evidence supporting primary pre- interventions from earlier identification of problems vention of psychotic disorders. However, there is more to further training of health and social work profes- evidence for secondary and tertiary prevention of sionals has been suggested in a recent cross-depart- psychoses [58], as well as their potential cost mental UK government report [51]. effectiveness [59]. Adolescent onset depression is a cause of signifi- There is a wider evidence base for other mental cant morbidity in adulthood [52]. A recent review of disorders. A Cochrane study summarized approaches prevention strategies found that both selective and to eating disorders. Population-wide interventions – indicated programmes were more effective than uni- such as campaigns promoting healthy eating – were versal approaches at preventing symptoms of depres- less effective than targeted interventions aimed at sion [53]. However, despite this, prevention pro- high-risk groups including ballet dancers or models. grammes for depression have tended to be universal Even greater effectiveness was seen in addressing rather than targeted due to their ability to reach greater indicated interventions to young women with subcli- numbers [54]. Research has generally shown that nical diagnoses [60]. Similar evidence is available interventions result in a short-term reduction in with substance misuse. Universal approaches have

402 SOCIAL INTERVENTIONS some effect – a 0.5% reduction in cigarette sales was measures. Additionally more targeted strategies have estimated for every 10% increase in media advertis- arisen. The increase in employee assistance pro- ing [61]. More substantial results were seen with grammes (EAPs) whose actual work can range from targeted approaches. One study showed that brief GP psychoeducative practices to 24-hour telephone coun- advice resulted in 40% attempting to stop smoking selling support lines may be viewed as preventive and a 5% actual cessation for up to 6 months [62]. measures. The effectiveness of these approaches is Prisoners form an adult population of concern due demonstrated in the Caregiver Support Pro- to the significantly elevated level of all mental health gramme [69]. In addition, evidence in support of problems from common mental disorders through to workplace-based counselling in reducing work stress personality disorders and psychosis, making this an and sickness leave is available [70]. ideal cohort for more targeted strategies [63]. 30.2.4 Older adults 30.2.3.1 The significance of work The major mental health causes of morbidity and A significant portion of the identity of an adult indi- mortality in older adults are depression and dementia, vidual is associated in some way with work. It has for which the majority of prevention strategies have been argued that two main sources of work-related been developed. Broadly speaking, for depression, mental health problems exist – unemployment and these have included exercise [71,72], social sup- enduring excessive work. Unemployment is asso- port [73], patient education for the chronically ill and ciated with increased duration of common mental their caregivers [74,75], early screening [76], primary disorders [64]. The causes of this have been postulated care interventions [77–79] and life review techni- to be multifactorial, ranging from lower levels of ques [80,81]. Preventing cerebral trauma and reducing social networks, less cognitive stimulation, signifi- systolic blood pressure and serum cholesterol appears cantly reduced income and problems associated with to be effective in reducing dementia [8]. Other mental indebtedness and higher rates of mental disorders. health-related conditions in the elderly include anxi- Indeed, debt itself has been noted to be a major risk ety disorders, alcohol abuse and prescription medicine factor for mental disorder, regardless of employment misuse, but these have not been as well studied [82]. status, which opens up further possible foci of pre- Primary care has been identified as being of particular vention work in the realm of responsible lending significance for the prevention of mental illness in approaches [65]. older adults [83]. Work stress is estimated to cost significant amounts A number of studies have looked at the impact of in direct employer costs as well as working days lost – medication on dementia prevention. The results of in the UK, figures suggest that it runs at £3.7 bil- these have not always been consistent [84]. The Cache lion [66] and 13 million working days [67] per annum County Study on Memory Health and Ageing exam- respectively. The hazard of excessive work can result ined risk and protective factors for Alzheimer’s dis- in the onset of common mental disorders, with work ease [84]. The use of aspirin and NSAIDs was asso- stress often cited as a precipitating factor. Well-being ciated with a large decrease in the risk of dementia. and stress are intimately influenced by the landscape Longer duration of use was associated with greater of work and this is changing rapidly in the twenty-first reduction in risk [84,85]. There is evidence to suggest century due to many factors, including globalization, that the medication needs to be started in middle rather new technologies, a shift from manufacturing to ser- than late life in order to have a beneficial effect [86]. vice or knowledge-related jobs, and much more fluid- No association was found between statin use and ity in the job market, resulting in a greater sense of job subsequent onset of dementia in the Cache County insecurity [68]. Strategies for attempting to reduce the Study [87]. However, other studies, such as the Car- associated morbidity can be seen in universalist mea- diovascular Health Study, have found a reduced rate of sures such as health and safety and worker rights cognitive decline. In that particular study the effect

PREVENTION 403 could not be completely explained by the reduction in ever, no RCT has yet shown that regular physical cholesterol effect of the statins alone [88]. Higher exercise actually prevents dementia [111]. antioxidant intake has been shown to be associated Physical activity may also have a protective effect with higher levels of baseline cognitive function. This against depression in older adults [112]. However, may be greater for intake from food rather than again the research findings have been inconsis- supplemental sources [89]. tent [71]. Some have found that physical activity does The results of studies looking at the impact of HRT not reduce subsequent depression [113–115] while on dementia have been inconsistent. The WHIMS others have found the opposite [116–118]. A recent study found that the use of oestrogen plus progester- study of adolescent and adult twins based on the one HRT actually resulted in a doubling of the risk of Netherlands Twin Registry found that regular exercise dementia [90]. The Cache County Study found that is associated with lower neuroticism, anxiety and prior use of HRTwas associated with a reduced risk of depression, and higher extraversion and sensation Alzheimer’s dementia but there was no apparent seeking. It also showed that exercise declines signifi- benefit from current use unless it has exceeded 10 cantly with age and that in older age females exercise years duration [91]. Others have been unable to show a more than males [119]. A study conducted in older benefit from HRT in preventing dementia [92]. Some adults has indicated that aerobic exercise as opposed have concluded, taking into account the WHIMS to anaerobic exercise has an effect on depressive study, that HRT cannot be recommended as a safe symptomatology [72]. Exercise has been shown to and effective strategy to prevent dementia [93]. have a beneficial effect on physical illness through a Several large randomized controlled trials have number of mechanisms such as reducing obe- looked at the effect of antihypertensive agents in sity [120,121], blood pressure [122–124] and diabetic reducing cognitive decline. These have produced status [120,125,126], among other things. This has a conflicting results, with some showing no benefit in downstream effect given that physical illness is a cognitive function for those on antihypertensive med- major risk factor for depression in older adults. ications [94–97], while others have showed marked Further, social engagement has been shown to be reductions in cognitive decline for certain associated with lower depression scores in older agents [98–102]. It has recently been suggested that adults [127]. There is evidence in support of life more research needs to be carried out to determine review interventions such as reminiscence therapy as which antihypertensive agents confer greater benefits a means of reducing the onset of depression, particu- than others [103]. larly in those recently relocated to residential The preventive effects of physical exercise have homes [128]. been studied in relation to a number of outcomes. Indicated strategies have been found to be preferred Observational studies have shown that physical exer- over more selective measures. It has been suggested cise reduces the risk of cognitive decline [104–110]. that indicated strategies have the best chance of This is also the case when the physical activity is detecting large groups of subjects at high risk of limited to later life [108]. A recent randomized con- developing depression. However, it was acknowl- trolled trial showed that a six-month physical exercise edged that because indicated measures require the programme for adults with subjective and objective extra effort of screening for subsyndromal depression, memory impairment results in a modest improvement selective interventions might yet prove to be a good in cognition at follow-up at 18 months [106]. How- alternative. 30.3 SUICIDE PREVENTION It is hard to be certain about the actual number of estimated that over 1 million people per year will die suicides globally as statistics are heavily influenced by by suicide by the year 2020 [129]. Suicide has a series cultural mediators and taboos. However, it has been of well-known risk factors, the most pertinent of

404 SOCIAL INTERVENTIONS which is the presence of mental disorder, in particular tia and later life depression is a high rate of sui- depression or schizophrenia. Some effective strategies cide [137]. Older adults have been shown to have have been identified, such as the minimization of different characteristics to younger victims of suicide. means including coal gas reduction or certain medica- Theyaremorelikelytosufferfromphysicalillnessand tion restrictions [130] or increased use of antidepres- more commonly present to primary care with physical sant medication in the treatment of depression [131]. symptomsanddepression[138].Distressandcognitive Comprehensive national prevention strategies can impairment have been found to be the only two vari- have a major impact on the incidence of such beha- ables that consistently predict both passive and active viour, as was demonstrated in the UK in the suicidal ideation in older adults [139]. Prevention 1990s [132–134]. The UN has called for the establish- programmes that reduce the rates of cognitive impair- ment of more national strategies [135]. ment and depression should result in a decreased Comprehensive school targeted strategies also have incidence of suicide in older adults. Additionally there anevidencebase. AtonestudyinFlorida, knownasthe issomeevidencefortheuseofhotlinesorcrisiscentres Suicide Prevention and School Crisis Management intheelderlypopulation;71%fewerelderlysuicidesin Programme, a reduction of 63% was recorded [136]. one region of Italy were recorded where such a service In the elderly, one of the consequences of both demen- also provided home visiting [140]. 30.4 CONCLUSION To summarize, prevention strategies have been the ciation for Child and Adolescent Mental Health, subject of an increasing amount of research in relation 1 (1), 2. to mental health over the last two decades. It has been 5. Rose, G. (1993) Mental disorder and the strategies of recognized that they have the potential to impact posi- prevention. Psychological Medicine, 23 (3), 553–555. tivelyonthehealthoflargenumbersofpeoplewhoareat 6. Jane-Llopis, E., Hosman, C., Jenkins, R. and Ander- riskofdevelopingmentalillness,substantiallyreducing son, P. (2003) Predictors of efficacy in depression morbidity.Thereremainsignificantchallenges,notleast prevention programmes. Meta-analysis. British Jour- arising from the complex multifactorial aetiology of nal of Psychiatry, 183, 384–397. mental disorders. However, the potential value is 7. Coie, J. D., Watt, N. F., West, S. G. et al. (1993) The immense, and there is much that can be gained from science of prevention. A conceptual framework and some directions for a national research program. strategies that target those aspects of the social environ- American Psychologist, 48 (10), 1013–1022. ment that give rise to disorder over the life course. 8. Saxena, S., Jane-Llopis, E. and Hosman, C. (2006) Prevention of mental and behavioural disorders: impli- cations for policy and practice. World Psychiatry, REFERENCES 5 (1), 5–14. 9. Berkman, L. F. and Kawachi, I. (2000) Social Epide- 1. Caplan, G. (1964) Principles of Preventive Psychiatry, miology, Oxford University Press, Oxford. Tavistock Publications. 10. Albee, G. W. (2006) Historical overview of primary 2. Gordon Jr, R. S. (1983) An operational classification of prevention of psychopathology: address to the disease prevention. Public Health Reports, 98 (2), 3rd World Conference on the Promotion of 107–109. Mental Health and Prevention of Mental and Beha- 3. Munoz, R. F., Mrazek, P. J. and Haggerty, R. J. (1996) vioral Disorders September 15–17, 2004, Auckland, Institute of medicine report on prevention of mental New Zealand. Journal of Primary Prevention, 27 (5), disorders. Summary and commentary. American Psy- 449–456. chologist, 51 (11), 1116–1122. 11. Merry, S. N. (2007) Prevention and early intervention 4. P€ ossel, P. (2005) Strategies for universal prevention for depression in young people – a practical possibi- of depression in adolescents. Journal of Indian Asso- lity? Current Opinion in Psychiatry, 20 (4), 325–329.

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31 Principles of social intervention Richard Warner University of Colorado and Colorado Recovery, Boulder, USA Social interventions are those interventions that are To developanunderstandingofthe principlesunder- not primarily biophysical or psychological in nature. lying social interventions it is helpful to look at the Biophysicalinterventionsincludemedications,electro- great historical movements in psychiatry that have convulsive therapy, psychosurgery, physical restraints stimulated the invention and reinvention of social and (and, in the past, insulin coma therapy and any number environmental methods that aid the recovery of people of Victorian whirling, douching, wrapping, heating, with mental illness. These movements include moral cooling and electrical treatments). In the future they treatment, which was a product of the late eighteenth may include gene therapy. Psychological interventions century Enlightenment; the mental hygiene movement are individually oriented forms of psychotherapy. The of early twentieth century America; the post-World site for these interventions is usually a practitioner’s War II social psychiatry revolution in northern Europe; office or a hospital. The location of social interventions and modern approaches to psychosocial rehabilitation, is often outside the hospital or office and in the com- which have become allied to the late twentieth century munity. Social interventionsrequirea knowledge of the recovery model. Let us take a brief look at these client’s social, cultural and political–economic world movements and see what they teach us. The principles and address problems in those domains. that they illuminate are itemized in Table 31.1. 31.1 HISTORICAL PRECEDENTS 31.1.1 Moral treatment A Swiss visitor’s description of the Retreat reveals, ‘It is not at all the idea of a prison that it suggests, but The York Retreat was opened in 1796 by the Society rather that of a large farm; it is surrounded by a great of Friends as a reaction against the inhumanity of walled garden. No bars, no grilles on the windows’ the contemporary treatment of the insane, after one ([1], p. 47). Under the direction of William Tuke, a of its members died in the York Asylum under 60-year-old merchant, a style of nonmedical care was circumstances that suggested neglect or ill-treatment. developed that, like Pinel’s action in striking the Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

412 SOCIAL INTERVENTIONS Table 31.1 Principles of social interventions in psychiatry the proprietors of these establishments boasted of high Treatment approach cure rates if patients were admitted early in their Multidisciplinary, flexible, empowering illness. The optimism generated by the results Reduced reliance on drug treatment observed with early intervention and the use of moral User/consumer participation in treatment treatment became an important stimulus for the Treatment location growth of the British asylum movement. Although Local and accessible moral treatment in British asylums was generally In the community apparent in name only, in early nineteenth century Treatment setting American institutions the method was often practised Small, domestic, normalizing with most of the basic principles intact, resulting in Encouragement of individual self-control high rates of recovery, later derided by asylum super- Reduction of coercion and confinement intendants, who had abandoned the approach, as the Involvement of the larger community ‘cult of curability’ [2]. Collaboration with other social agencies Central to the revolutionary methods of Tuke and Fighting stigma others was the redefinition of the insane person from Political advocacy a beast to a human with rational capacity. Before the Respect for human rights advent of moral treatment, even George III, during The importance of client communities his bouts of insanity, was chained, beaten, starved Empowerment: transfer of power from service providers and intimidated with threats, as if he were an animal to service users whose instincts must be governed [3]. Tuke’s The value of work patients, though human, were not yet adult; they Therapeutic optimism were seen as ‘children who have too much energy Understanding biological, psychological, social, cultural and put it to dangerous uses’ ([1], p. 49). Other and political–economic factors principles of moral treatment that emerge are the use of small, domestic, normalizing, treatment environments rather than institutions; the encourage- ment of individual self-control leading to the reduc- chains from the inmates of the Bic^ etre in 1793, came tion of coercion, confinement and physical restraint; to be called moral treatment. Believing that most the value of work; treating the person with respect to deranged people could be rational if not provoked by help maintain his or her self-esteem; a decreased harsh treatment or cruelty, Tuke encouraged the exer- reliance on drug treatment; and the importance of cise of patients’ self-control as an alternative to the use therapeutic optimism. of external restraint. Punishment was avoided, but privileges were awarded to those who conformed to the attendants’ wishes. Chains were never used and 31.1.2 Mental hygiene movement straight waistcoats rarely. Patients were expected to dress in their best clothes and take part in their usual During the late nineteenth century, institutional con- social activities – tea parties, reading, writing, sewing finement and therapeutic nihilism dominated the care and gardening. Work was felt to be essential in of the mentally ill. However, in the early twentieth fostering patients’ self-control and self-esteem. Drugs century therapeutic optimism was rediscovered, in were seldom used, and exercise, warm baths and a the American mental hygiene movement, along with generous diet of ‘meat, bread and good porter’ were the principles of community involvement, combating felt to be most useful in quieting patients and ensuring stigma, multidisciplinary collaboration and parti- sleep [2]. cipation by people with mental illness themselves. Moral treatment became widely used in British In 1908, Clifford Beers, a young businessman who private madhouses and the advertising handbills of had been repeatedly institutionalized with manic

PRINCIPLES OF SOCIAL INTERVENTION 413 depressive illness published A Mind That Found communities’. In these hospital units, therapists and Itself, exposing the horrors of asylum conditions. patients worked together to create an environment in He captured the support of prominent psychiatrists which traditional institutional authority was broken and spurred a movement to institute reforms in down – patients participated in the government of the mental hospital care, educate the public about mental ward, uniforms were abandoned and staff and patient illness and support preventive interventions such as roles blurred. Initially, these novel treatment units better childrearing. His efforts, and those of his were for patients with personality disorders, but, in associates, led to the foundation of child guidance due course, the idea was introduced into wards for clinics and the National Association for Mental people with psychosis. At Littlemore Hospital, in Health [4,5]. Beers [6] claimed that the mental Oxford, and Dingleton Hospital, in Melrose, through- hygiene movement led the general public to regard out the 1960s, therapeutic communities were estab- mental illness as ‘a disease and not as a disgrace’ lished in multiple wards throughout the hospital. On (p. 743) and that it had brought psychiatrists the general adult unit in Littlemore Hospital, staff and into collaboration ‘with leaders in education, law, some 60 psychiatric patients participated in daily religion and in social work’ (p. 743). community meetings that established ward policy, evaluated new admissions, held interviews with patients’ families, prescribed treatment and author- 31.1.3 Northern European social ized discharges. psychiatry revolution The hospital reforms, innovations and therapeutic optimism were geared to early discharge and com- The Great Depression brought a period of increased munity treatment. Long-term institutionalized reliance on institutional confinement and physical patients developed social competence and were methods of treatment, but, beginning in 1945, British placed in hostels, returned to their families or set up psychiatrists reported an improved pattern of care for in family-style, group homes. Psychiatrists and nurses hospitalized mentally ill people compared with con- left the hospital to visit patients in their homes and ditions a decade earlier. They observed an increased consult with family physicians and community mental number of open wards, more freedom for patients, the health workers. Day hospitals became widely used in abolition of restraint and a decreased use of seclusion. Britain in the 1950s, and home treatment programmes These reforms led to a reduction in patients’ aggres- and sheltered workshops were established in Holland siveness and incontinence [7]. In 1949, Bell unlocked and Britain [2,10,11]. all the wards of Dingleton Hospital in the Borders of Many of the ‘innovations’ of the post-war social Scotland, launching an open-door movement in psy- psychiatry revolution were rediscoveries of the moral chiatry that swept the Western world in the following treatment approaches. Reduced coercion and confine- years. These changes, we should note, preceded the ment, the abolition of restraint, the emphasis on introduction of the first antipsychotic medication in patient self-control, therapeutic optimism, work ther- 1954. Contemporary psychiatrists in Britain and Nor- apy and early discharge were all features of moral way observed improvements in outcome for patients treatment. However, whereas in the York Retreat the exposed to the enhanced hospital settings and noted insane person was redefined from bestial to child-like, that the eventual introduction of antipsychotic drug in the therapeutic community he/she advanced to adult treatment had relatively little effect on patients who status – perhaps not always a fully rational adult but, were receiving the benefits of these environmental certainly, adult [2]. The novel contribution of the post- conditions; it was in unreformed hospitals and treat- war social psychiatry revolution was the concept of ment units that the drugs were seen to offer their empowerment – in the therapeutic community the greatest impact [2,8,9]. patient became a person with much more power in Beginning in 1946, British psychiatrists developed the institutional setting than he/she had ever had new patterns of institutional living called ‘therapeutic before.

414 SOCIAL INTERVENTIONS 31.2 MODERN REHABILITATION MODELS Curiously, this concept of empowerment – indeed, the Supported employment, and its recent refinement, entire therapeutic community model – was being individual placement and support (IPS), has been simultaneously and independently developed in the proven effective in maintaining people with mental United States, but, in this instance, in the community, illness in competitive work in a large number of not in the hospital. Fountain House, the first psycho- studies conducted in North America and, more social clubhouse, was founded in New York City in recently, Europe [16]. The core principles of the 1948 by ex-patients of Rockland State Hospital, initi- model include a focus on competitive, rather than ally as a place to gather and eat, then growing into sheltered, employment; rapid job search, instead of something more comprehensive. Members (people extended pre-employment assessment and training; with mental illness) and staff worked together to run integration of the vocational and treatment services; the operations of the clubhouse, put out the newsletter, paying attention to clients’ job preferences; and pro- prepare meals, staff the reception desk or serve in the viding time-unlimited, individual job support [17]. thrift shop. Developing an international reputation, Inherent in this approach are some important princi- Fountain House received hundreds of visitors a year, ples of social intervention – involving the community established a training programme, launched a national (in this case, employers) in assisting the social inte- clubhouse expansion programme and, finally, founded gration of people with mental illness; using a non- the International Center for Clubhouse Development institutional approach (no sheltered workshops); and in 1994. By 2006 there were 197 certified clubhouses showing respect for the person’s preferences and in the USA and 116 in 26 other countries around the strengths. world [12]. Foremost among the components of the Another vocational model that has gained strength model are democratic decision making and govern- in recent decades is the social firm. Social firms, or ance and the ‘work-ordered day’ – a structured eight- affirmative businesses as they are known in North hour day in which members and staff work side by side America, are businesses created with a dual mission – on clubhouse work. There are no member-only or to employ people with disabilities and to provide a staff-only meetings and no psychiatric treatment on needed product or service. The model was developed premises. The clubhouse is a space owned by the for people with psychiatric disabilities in northern Italy members, not the treatment system [13–15]. Empow- in the 1970s and, by diffusion, has gained prominence erment, treating the person with mental illness with throughout Europe and Australasia. Independent of respect, absence of coercion (membership must be European influence, affirmative businesses have also voluntary) and the importance of work, these are the developed in North America and East Asia. Over a third principles embodied in the clubhouse model. of employees in social firms are people with a disability The emphasis on work is evident in the employment or labour-market disadvantage. Every worker is paid a programmes generated by psychosocial clubhouses. fair market wage, accommodations are made for dis- Initially, these work programmes took the form of abled workers’ needs, and all employees have the same transitional employment programmes in which tem- rights and obligations. Hard to achieve, but important porary (three- to nine-month) part-time job place- nevertheless, the business must operate eventually as a ments were found for members in local businesses. viableconcern,freeofsubsidy.Advantagesofthesocial- Job coaches learned how to do the job, trained the firm model include opportunities for empowerment and member and provided long-term support to him or her the development of a feeling of community in the in the position. More recently, these placements have workplace [18]. taken the form of continuous supported employment, The post-war period has also provided the oppor- in which the job placement is permanent. The tunity for the development of a number of alterna- approach has grown into a successful model with tives to the hospital for acute psychiatric treatment. broader reach than the clubhouse. Small, noncoercive, open-door, domestic settings

PRINCIPLES OF SOCIAL INTERVENTION 415 providing essentially the same services as a psychia- Assertive community treatment teams and mobile tric hospital unit have been operating for decades in crisis home treatment teams in many countries many places around the world, including Boulder, around the world have provided in-home treatment Colorado; Vancouver, British Columbia; Trieste, to acutely disturbed clients [20,21]. The principals of Italy; and cities in the Netherlands [19]. Crisis social interventions inherent in all these alternatives homes – private family homes that take in people to hospital treatment include the perceived advan- with acute psychiatric problems while they receive tages of small, domestic, noncoercive settings, the treatment services from the mental health system – avoidance of institutional care and the involvement have been developed in Colorado and Wisconsin in of the local community in providing care and foster- the USA, in Sydney, Australia, and elsewhere [19]. ing social integration. 31.3 RECOVERY MODEL As recognition has grown in recent years of the of people with mental illness, and the importance of importance of social integration for people with men- environmental factors in helping people with psychia- tal illness if they are to achieve a good outcome from tric disorders achieve their best functioning illness, many of the principles underlying social inter- potential [23]. ventions have received support from a social move- The model calls for the provisionof education about ment called the recovery model. The model, which is psychiatric disorders as a way to empower users/ influencing service development in Britain, the US consumers to collaborate with service providers in and elsewhere [22], refers both to the subjective managing their own illnesses. Collaborative models, experiences of optimism, empowerment and interper- such as the psychosocial clubhouse and educational sonal support experienced by people with mental programmes that involve both professionals and con- illness, their carers and service providers, and to the sumers as teachers, are seen as important elements of creation of services that engender a positive attitude recovery-oriented services. The model has generated towards recovery and a support for human rights. The renewed interest in fighting stigma and the creation of roots of the recovery model may be found in both the user-run services that offer advocacy, mentoring and service-user/consumer movement and professionals peer support via such mechanisms as user-run ‘warm- involved in psychiatric rehabilitation. Consumer acti- lines’ (peer-to-peer supportive chatlines) and drop-in vists have reinforced the drive towards empowerment, centres [24,25]. collaboration, and recognition of human rights. Reha- At this point we may discuss in more detail the bilitation professionals, on the other hand, have principles of social intervention that have emerged emphasized the need for services that recognize the from these social psychiatry movements of the past value of work and the sense of community in the lives two centuries. 31.4 PRINCIPLES 31.4.1 Treatment approach benefits, food stamps and rent subsidy; appealing against the rejection of benefits; taking care of a 31.4.1.1 Multidisciplinary, flexible household and managing a personal budget without and empowering services the necessary skills; and, for some, looking for hous- ing after being evicted or responding to criminal Being mentally ill in the developed world can be close charges. Clearly, to help a disabled client make his/ to a full-time job – attending treatment; meeting her way through this maze, a multidisciplinary team of with the vocational counsellor; applying for disability nurses, case managers, social workers, psychologists

416 SOCIAL INTERVENTIONS and others is needed. The psychiatrist is a member of technicians and residential counsellors – in order to the multidisciplinary team, but not necessarily the enhance patient collaboration in the treatment pro- leader. He or she needs to understand the important cess [2]. It is becoming more routine to ask people roles of the other team members to avoid being with mental illness, if they approve, to include family marginalized. Clients themselves should be partners members in discussions about their treatment. Con- in the treatment plan and the service should be flexible sumers, family members and mental health profes- enough to adapt to clients’ needs and preferences. sionals negotiate what plan works for all involved, rather than leaving the psychiatrist to prescribe all aspects of treatment. 31.4.1.2 Reduced reliance on drug treatment 31.4.2 Treatment location As in the York Retreat, a treatment team with a social orientation may have a reduced emphasis on drug 31.4.2.1 Local and accessible treatment treatment: the focus may be on such interventions as family support and education, substance abuse coun- An important principle of the provision of psychiatric selling, life skills training or vocational rehabilitation. services is that they should be local and accessible. In Eliminating all the patient’s symptoms with medica- Trieste, Italy, outpatient clinics and day centres are tion may not be an appropriate goal if higher doses of dispersed throughout the city, within walking distance medication reduce his or her working capacity. of the homes of most clients. Easily accessible provi- A multicentre study in Finland revealed that clinics sion of services is, of course, difficult in sparsely that used a family-centred treatment approach in populated parts of the world, like much of the Amer- psychosis with minimal use of antipsychotic medica- ican West, but the development of local residential tion were able to achieve outcomes that were equal to treatment facilities as alternatives to admission to the those obtained in clinics relying on drug treat- state hospital, several hours drive away, can be a ment [26]. Residential programmes using minimal valuable resource. The problem of providing psychia- doses of antipsychotic drugs with people in early tric and medical resources to far-flung areas is also psychosis have demonstrated outcomes equal to those eased by the availability of remote video evaluation of standard, drug-oriented, hospital treatment [27,28]. and treatment by professionals located in urban centres. 31.4.1.3 User/consumer participation in treatment 31.4.2.2 In the community The recovery model is sounding the death-knell for Social interventions often offer treatment in the com- paternalism in the treatment of people with mental munity, using real-life settings for training and other illness. Whereas a psychiatrist, a few years ago, might services. People with serious mental illness often have have said to her patient, ‘I’d like you to take this difficulty transferring learning from one social situa- medication. I think it is the right one for your con- tion to another (‘generalizing’). The most effective dition’, today, after explaining why she has arrived at a learning takes place in the setting where it is to be certain diagnosis, she might invite the patient to join applied subsequently [29]. In one recent study, people her in looking at a computer website listing side with schizophrenia showed greater and faster effects to different medications so that they can, improvement in functioning when their classroom- together, select the most suitable one. Beyond that, based social skills training was augmented with com- many mental health agencies are hiring people with a munity-based training [30]. Examples of modern history of serious mental illness in various treatment programmes that take advantage of in vivo learning roles – as case manager aides, job coaches, pharmacy are supported employment and its hybrid, individual

PRINCIPLES OF SOCIAL INTERVENTION 417 placement and support, in which client/workers are placed in restraints and be relieved of responsibility trained and supported by job coaches at the worksite. for his or her actions (and life in general). Such a person, admitted to a private family crisis home in Madison [31], for example, would not dream of 31.4.3 Type of treatment setting indulging in such behaviour, as this is not what is expected of a ‘guest’. 31.4.3.1 Small, domestic, normalizing settings Most people, if they need treatment for an acute 31.4.3.3 Reduction of coercion psychiatric problem, would prefer to be in a small, and confinement noncoercive, domestic-style treatment setting, rather than in an alienating institutional environment like a Avoiding the use of unnecessary coercion is also hospital. They would prefer, for example, an acute important for patients admitted to a locked hospital residential treatment facility, such as Cedar House in ward. In the 1970s and 1980s, the use of physical Boulder or Venture in Vancouver [19]. These settings restraints and seclusion was widespread in US psy- are open-door, genuinely in the community and more chiatric units and hospital emergency rooms, and the normalizing – they allow the user to stay in touch with experience often dominated the patient’s view of his his or her friends, relatives, work and social life. They or her illness. A 1979 study revealed that nearly half of are flexible and more able to adapt to the needs of the the patients on an acute admission unit in California individual user and they involve the residents were locked in seclusion for a period of time [32]. in running their own environment, an empowering When patients at a US psychiatric hospital were asked element of the treatment programme. The cost of to draw pictures of themselves and their psychosis, treatment is much lower and the pace of treatment is over a third spontaneously drew a picture of the not as fast as hospital treatment, allowing the use of seclusion room; a year later, for many, the frightening lower doses of medication and more time for the experience of seclusion still symbolized their ill- person to recover. ness [33]. In the 1980s, a quarter of all patients evaluated in a psychiatric emergency room in Cincin- nati, Ohio, were placed in restraints [34]. Physical 31.4.3.2 Encouragement of individual restraints were frequently used on psychiatric wards, self-control not for violent behaviour but ‘nonconformity to com- munity rules’ ([35], p. 182) and ‘behavior disruptive to The user’s preference for the noninstitutional setting the therapeutic environment’ ([36], p. 1211). US has an important effect on outcome. Residents in the federal regulations, introduced in the 1990s, imposed domestic alternative must call upon their inner restrictions on the use of restraints and seclusion in resources, exercise self-control and accept responsi- psychiatric inpatient units and led to a dramatic bility for their actions and for the management of their reduction in their use. US psychiatrists are now environment. The noncoercive nature of the setting obliged to see a patient within an hour of ordering requires staff to deal with a person in crisis through the use of restraints or seclusion, night or day. Con- human contact rather than physical restraint. These sequently, unit staff across the country have learned differences in the relationship between the person and new methods of dealing with the agitated patient [2]. the environment, and the staff and their charges, are the essence of moral treatment – a call upon the person with mental illness to exercise ‘moral restraint’ and 31.4.4 Involving the larger community upon the staff to help the person in this effort. As an illustration, a person with borderline personality Central to social and community psychiatry is the task disorder, when admitted to hospital, not uncommonly of involving the larger community in helping people will beat his or her head against the wall in order to be with mental illness. The goals of the mission are

418 SOCIAL INTERVENTIONS twofold – offering treatment and rehabilitation to greatest obstacles to treating mental illness. Despite individuals with mental illness and re-educating the efforts since the 1950s to reduce prejudice against the community to reduce stigma, discrimination and the mentally ill, stigma, discrimination and misconcep- social exclusion of people with mental illness. Com- tions about mental illness are pervasive. Citizen-dri- munity mental health personnel expect to work with ven ‘not-in-my backyard’ campaigns obstruct the family members, employers, landlords, police, law- placement of residential facilities. The perception of yers, general health care providers and others, to stigma by people with psychosis is associated with gather information; provide education, support and enduring negative effects on their self-esteem, well- treatment; resolve problems; coordinate care; set up being, mental status and access to work [39]. Public employment or accommodation; advocate for the and professional opinions about mental illness client; and respond in emergency situations. Beyond adversely affect its detection and outcome. In the last the requirements of individual treatment, multiagency decade several large-scale campaigns have been collaborative programmes can greatly expand the launched in Britain, Australia and, by the World value of services. Psychiatric Association, in 20 countries around the world [40]. For community mental health personnel, the impor- 31.4.4.1 Collaboration with other tant lesson from these endeavours is that it is feasible social agencies to produce a measurable response by selecting a local target group and providing training and awareness- Enhanced services with cost savings can be realized building. Target groups for this work should be homo- when the mental health service collaborates with other geneous and accessible. Landlords, for example, are social agencies. In Boulder County, Colorado, for not an accessible group since they do not meet as a example, there are a number of successful collabora- group or use a common media outlet. Employers are tive programmes. The Community Infant Project more accessible because one can identify the largest fights child abuse and neglect by creating teams of local employers and target their human resource visiting nurses, peer parenting trainers, paediatricians, departments. The police are accessible, as they receive psychiatrists and counsellors from the public health regular in-service training. In a number of projects, department, social services and the mental health antistigma interventions have produced positive centre. A programme called IMPACT diverts adoles- changes in awareness, knowledge and attitudes cents with behaviour problems from juvenile deten- among, for example, police, judges and high school tion and foster care, maintaining them in their family students [39]. Community mental health workers may homes by pooling funds and personnel from criminal consider it worthwhile to provide regular education to justice, social services and mental health. A team police officers, given that their function in bringing called PACE, staffed with probation officers and sub- acutely mentally ill people in for treatment makes stance abuse and mental health professionals, works them underrecognized and undertrained mental health collaboratively with the district attorney, the courts service providers. and the gaol to transfer people with mental illness and substance abuse problems from the gaol into commu- nity care and rehabilitation [2]. Though multiagency 31.4.4.3 Political advocacy collaborative programmes are administratively diffi- cult to establish, they hold out great prospects for the Social psychiatry is entwined with social policy. future of psychiatry. People with mental illness in many developed coun- tries, for example, are confronted by disincentives to 31.4.4.2 Fighting stigma employment created by the disability benefits system. If they begin to work, they are likely to lose more Reports from the US Surgeon General [37] and World from their disability pension, rent subsidies and other Health Organization [38] cite stigma as one of the benefits than they can possibly earn. As a result,

PRINCIPLES OF SOCIAL INTERVENTION 419 vocational rehabilitation efforts are severely ham- disability, would be the development of a capacity law pered, and people with psychiatric disability are likely that applies equally to people with physical and to end up leading aimless lives, excluded from the mental illness whenever they are incapable of inde- workforce. Not all disability benefits systems, how- pendent decision-making [46]. ever, offer such severe disincentives [41,42]. Many other social policies, including discriminatory insur- ance and employment statutes, create obstacles to 31.4.6 Importance of client communities treatment, work and the social integration of people with mental illness. Mental health professionals and The belief that people with mental illness should have advocates are often involved in tackling these issues. the same rights as other citizens carries with it some unwanted baggage – that they should aspire to the same goals as other citizens and identify with main- 31.4.5 Respect for human rights stream culture, the concept of normalization. We have no trouble accepting the existence of many subcul- If people with mental illness are to be included in tures within mainstream society – Chinatown, soccer society with full rights as citizens, then national moms, gun clubs and synagogues – but mental health disability discrimination laws must give parity to professionals, with the best of intentions, often do not people with physical and mental disabilities. Such recognize the validity of the subculture in which laws in the US, Britain and elsewhere have been people with serious mental illness find themselves. framed primarily with the physically disabled in mind Users of mental health services tend to be friends with, and attempts to use them to benefit people with mental share concerns with and spend time with other people illness have been disappointing [43]. Policies related with similar disorders. Professionals who devise and to insurance and disability benefits should deal with construct treatment and rehabilitation programmes for people with physical and mental disabilities equally. people with mental illness, however, frequently Currently, in the US, for example, the amount that assume that ‘mainstreaming’ – separating the user/ people disabled by blindness are entitled to earn consumers from others with mental illness and before they lose their Social Security Disability ‘integrating’ them into the mainstream community Income is substantially greater than for those with – is the ideal. The developers of the individual place- mental illness. Laws that impede people with mental ment and support (IPS) model of vocational rehabi- illness from voting or serving on juries should be litation, for example, hold dear the principle that modified with a presumption of competence [43]. At a ‘competitive employment’ is the goal. This may mean service level, mental health professionals can inform that the client who is placed in a competitive work clients, employers and landlords of the mentally dis- position may be the only person at that worksite with abled person’s rights to accommodation in the work- mental illness. IPS proponents would not readily place and antidiscrimination rights in general. accept the social firm model, in which a third to a The use of involuntary treatment is not an issue on half of the workforce are people with psychiatric which consensus is likely to be found soon. Many disability. A social firm manager in Trieste, Italy, user/consumers cleave to a libertarian view that ques- however, fondly refers to the sense of community tions the validity of psychiatric diagnosis and the among the disabled workers as ‘una piccola famiglia medicalization of altered mental states and that rejects allargata’ – a small extended family [18]. all forms of involuntary psychiatric treatment. Adop- The principle that emerges from the recognition tion of this view would mean that mental illness can that people with mental illness often belong to a never be invoked as an excuse for criminal behaviour supportive subculture in which can they share experi- and would lead to many people with mental illness ences and worldviews and not feel at a disadvantage is being confined to gaol [44,45]. Some have proposed that we should recognize the validity of our clients’ that a partial solution to this problem, promoting life choices and not force upon them decisions made parity for the human rights of people with mental by those in mainstream culture. Recognition of the

420 SOCIAL INTERVENTIONS value of the client subculture can lead to the devel- suggests that patients can only benefit from accepting opment of programmes that strengthen ties between that they are ill if they feel empowered, but that the members, build community infrastructure and create internalizedstigmastandsinthewayofempowerment. mutual support mechanisms [47]. Such programmes Arecent15-yearnaturalisticfollow-upstudyofpeople include user/consumer ‘warm-lines’, for mutual sup- with schizophrenia provides further evidence that port during times of stress, and consumer-run drop-in empowerment is an aide to recovery. The research centres. A residential programme based on mutual found that over a third of the subjects, many of them support, developed in Santa Clara County, California, in a sustained period of recovery from the illness, were consisted of clustered apartments with a centrally no longer taking antipsychotic medication, and that located community centre and paid staff, often con- these patients were more likely to have had an internal sumers themselves, who acted as community organi- locus of control when evaluated five to ten years ear- zers rather than clinicians [48]. These types of lier [50]. Another recent study of over 100 people with programmes are promoted by adherents to the recov- schizophrenia, using path analysis, demonstrated that ery model because of the empowerment opportunities an internalized sense of stigma is associated with they offer to members of the subculture [24]. avoidant coping (similar to an external locus of con- trol), social avoidance and depression: these relation- shipsweremediatedbytheeffectofinternalizedstigma 31.4.7 Empowerment on hope and self-esteem [51]. The conclusion we should draw is that empowerment of people with People with mental illness are among the least power- mental illness is as important as helping them find ful members of society. At times they may lose their insight into their illnesses. Traditionally, however, civil rights and be detained for treatment against their much more effort has been expended by mental health will. Even when treated voluntarily they may find professionals on the latter than on the former. themselves in a parent–child relationship with the treatment provider, considered incapable of rational decision making. Why is it important to reverse this 31.4.8 Value of work process and attempt to restore the person’s sense of power? To answer this question, it is important to There are good reasons to suppose that working might appreciate that people with mental illness become promote recovery from schizophrenia and other psy- disempowered, not only by involuntary confinement choses, including improved social integration, nor- or paternalistic treatment but also by their own accep- malizing peer relations and enhanced self-image. tance of the social stereotype of the mentally ill Work is a natural adult activity and a source ofidentity. person. Patients who accept that they suffer from a A job can bring increased income, expanded social mental illness feel internally driven to conform to a contacts and a sense of meaning in life, while unem- conventional image of incapacity and worthlessness, ployment carries risks of alienation, apathy, substance becoming more socially withdrawn and adopting a abuse, ill health and isolation [17,52,53]. When treat- disabled role. As a result, their symptoms persist and ment systems focus on work as an outcome, they they become dependent on treatment providers and become more oriented towards the individual’s others in their lives. Thus, insight into one’s illness strengths and potential [17]. may be rewarded with poor outcome [2]. The proponents of moral treatment strongly advo- This view is supported by a study of people with cated the importance of work in recovery from mental serious mental illness that found that those who illness. Today, their view has substantial research accepted that they were mentally ill had lower self-- support. Outcome from schizophrenia worsens [2] esteem and lacked a sense of control over their lives: and hospital admissions for working-age people with those who found mental illness most stigmatizing had psychosis increase [54] during economic downturns. theworst self-esteem and theweakest sense of mastery Since the early 1990s, controlled studies have identi- (namely, an external locus of control) [49]. The study fied a number of benefits for subjects with serious

PRINCIPLES OF SOCIAL INTERVENTION 421 mental illness who are working. Participation in an dence and low social disruption) or ‘complete effective vocational programme or having paid recovery’ (loss of psychotic symptoms and return to employment is associated with fewer psychiatric hos- the pre-illness level of functioning). The data were pital admissions [55–58], reduced health care analysed in 15- or 20-year consecutive time periods costs [57,59] and decreased positive and negative corresponding to major economic and social changes. symptoms of psychosis [56,60–62]. Successful work The analysis revealed a substantial rate of recovery programmes lead to increased quality of from schizophrenia throughout the century – around life [56,63–66], improved self-esteem [62,64,67–69], 20% complete recovery and 40% social recovery. enhanced functioning [58,63,66] and an expanded Both these rates were substantially lower during the social network [70]. It is important to note that a Great Depression, and they did not improve with the common concern of clinicians – that patients with advent of antipsychotic medication in 1954. It mental illness may become more disturbed under the emerges that one of the most robust findings about stress of working – has not proven true. Hospital schizophrenia is that a substantial proportion of those admissions, symptoms and suicide attempts do not who present with the illness will recover completely or increase when patients are involved in effective work with good functional capacity, with or without med- rehabilitation schemes [42,62]. ical treatment. This is not the view of schizophrenia that was advanced by Emil Kraepelin or is currently held by many psychiatrists. Unfortunately, practising 31.4.9 Therapeutic optimism mental health professionals do not have opportunities to follow patients who recover, as they drop out of The recovery model calls for optimism about outcome treatment; this results in a negativeclinician bias about from serious mental illness, and such optimism is outcome. Based on the research data, however, it is supported by available data. A meta-analysis of over reasonable to advise relatives of people who have a hundred outcome studies in schizophrenia con- recently developed schizophrenia that the diagnosis ducted in the developed world during the twentieth is not all bad news. Schizophrenia is an illness that century [2] assessed whether subjects were in or out of grows less severe with time. The patients with the hospital at follow-up, and whether they had achieved illness who present the greatest problems are those ‘social recovery’ (economic and residential indepen- who are younger and early in the illness. 31.5 KNOWLEDGE OF BIOLOGICAL, PSYCHOLOGICAL, SOCIAL AND POLITICAL–ECONOMIC FACTORS Mental health professionals interested in social psy- tical science and the history of mental illness and its chiatry strive to have an understanding of the effect treatment. Few can have deep knowledge of all of of biological, psychological, social and political– these areas, but it is valuable to know that the prin- economic factors on the onset, course and outcome ciples of social intervention in psychiatry draw upon of mental illness. They may need to know, for exam- this broad knowledge base. ple, how urban versus rural living influences the like- lihood of developing schizophrenia; how life-event stress affects the onset of psychotic illness; how work, REFERENCES social inclusion or family involvement affects out- come from psychosis; or about the effect of maternal 1. Jones, K. (1972) A History of the Mental Health depression on the occurrence of depression in children Services, Routledge & Kegan Paul, London. in the household. They may seek some understanding 2. Warner, R. (2004) Recovery from Schizophrenia: Psy- of a broad area of study – epidemiology, quality of life chiatry and Political Economy, 3rd edn, Brunner-Rou- assessment, cultural anthropology, ethnography, poli- tledge, Hove.

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32 Social interventions for psychosis 1 1 David Kingdon, Yoshihiro Kinoshita and Stefan Gleeson 2 1 School of Medicine, University of Southampton, Southampton, UK 2 Hampshire Partnership Foundation NHS Trust, Southampton, UK What is a social intervention? Are there specific inter- They are usually responses to social needs and ventions for psychosis? If a social intervention is one diagnosis is rarely directly relevant. Interventions that is designed directly to alter social circumstances, described are therefore broadly for people with any that modify accommodation, relationships and enduring mental health conditions, e.g. severe anxi- finances would be included. Psychological interven- ety or depression, personality issues (e.g. related to tions could be considered a specific form of social childhood abuse) and bipolar disorder as well as intervention in that they involve developing a relation- schizophrenia, schizoaffective disorder and delu- ship with a therapist as a necessary part of the process sional disorder. Psychosis may only be a transient involved. However, conventionally these are consid- feature of these groups. Psychosocial determinants ered separately. Further details can be found for psy- of psychosis are described elsewhere in this chological interventions elsewhere [1,2]. International book (see Chapter 15), but are very relevant to the (e.g. World Health Organization) and government implementation of social interventions. Psycho- policies could also be described as social interventions sis can be precipitated by trauma, drug use and and vary considerably internationally. There is increas- significant life events in individuals with stress ing convergence on developing community alterna- sensitivity, and psychosocial interventions are tives to hospital provision and these will be discussed. increasingly being tailoredtothese factors.Com- Broader aspects of the development and variation in munication about them needs to be clear and policy is, however, beyond the scope of this chapter. use destigmatizing alternatives, as this is more Social interventions are rarely, if ever, specifi- acceptable to patients [3] and has less negative cally or exclusively for people with psychosis. associations [4]. Principles of Social Psychiatry, second edition Edited by Craig Morgan and Dinesh Bhugra Ó 2010 John Wiley & Sons, Ltd.

426 SOCIAL INTERVENTIONS 32.1 EVIDENCE Research in this area has been limited in terms of generalizability of RCTs. Qualitative, observational, randomized controlled trials (RCTs) but any such before-and-after and case-control studies can provide evidence available will be discussed. RCTs can often valuable information. They have the advantage of be difficult to establish for social interventions as being more inclusive of patient groups, can provide controlling social circumstances may be problematic more extended follow-up periods and can be more and so RCTs may not be the most appropriate form generalizable. Rigorous attempts to control extra- of evidence. Exclusion of patients who do not neous factors and the use of credible comparisons consent to RCTs, lack of long-term follow-up and may lead to valuable information despite lack of limitations from inclusion criteria can seriously limit randomization. 32.2 AREAS OF INTERVENTION Basic social needs include somewhere to live, recovered from psychotic episodes return to work but resources to be able to feed and clothe oneself (and stigma, lack of appropriate support and persistent participate in society), meaningful activity and parti- symptoms may prevent others doing so and lead to cipation in relationships with others. When people in reliance on family support. Where such support is not receipt of mental health services are asked about what available, homelessness can ensue and surveys con- they want from them, it tends to be assistance with sistently find many people with psychosis among these domains rather than specifically treatment of homeless populations. Interventions focus on identi- psychological symptoms. Such symptoms may inter- fying and providing appropriate support for this group fere with their ability to meet their daily needs and through ‘street homeless’ teams, which assertively distress them but, especially once immediate distress work where homeless people are, using case manage- can be alleviated, treatment of symptoms is often ment methods. Their ways of working concentrate on secondary. The terms we use to describe individuals engagement and provision of practical support, in receipt of care will reflect the setting in which the including access to benefits and housing alongside care is occurring: in hospital, patient; in supported appropriate treatment [5]. accommodation, resident; in community settings, cli- ents or simply people. 32.2.2 Hospitalization 32.2.1 Accommodation Change in accommodation, temporarily and perma- nently, or provision of it for people who are homeless, Availability and quality of accommodation can be a is commonly used to improve well-being. This can major issue for people with psychosis. They may live involve changes involving respite care, hospitaliza- with families, independently – alone or with non- tion or provision of supported accommodation. Evi- family members, in supported or staffed accommoda- dence for the overall effectiveness of hospitalization is tion or in hospital. Most people in most cultures will difficult to obtain in comparison with community live with families even where large hospitals continue treatment as patients who are very behaviourally to exist. Independent living depends on available disturbed or at risk to self or others are excluded from resources such as work or social welfare benefits. studies on ethical and practical grounds. Such systems are not available or very limited in The setting in which admissions for acute psychosis scope in many countries. Many people who have occur vary from specialist units in general hospitals or

SOCIAL INTERVENTIONS FOR PSYCHOSIS 427 mental hospitals to general medical wards in some likely to be in residential care settings or with paid countries. The use of open general medical wards carers. versus specialist units for acute psychoses has been reviewed [6] and is the practice in many parts of the developing world, including the Caribbean. There is 32.2.3 Community support no robust evidence for or against this practice and some non-randomized evidence suggests that this may Community mental health teams (CMHTs) have be appropriate to areas where few such admissions developed in many countries to provide support to occur, e.g. rural and sparsely populated areas. It may enable discharge from and prevent readmission to also become an increasing consideration as alterna- hospital. These usually consist of nurses, social work- tives to admission become more widely available. It is ers, occupational therapists and psychiatrists. A gen- common practice internationally for children with eric CMHT is: mental health problems to be admitted to general paediatric wards. .. .a multidisciplinary team of mental health staff There has been a controlled evaluation of wards in which has a lead responsibility for the provision of general hospitals versus mental hospital acute care specialist assessment, treatment and care to a defined and this concluded that therewas ‘no evidence in these population, often defined by geographical catchment patients of a transfer of chronicity to the psychiatric area or primary care registration. Such a team will hospital, but patients with longer periods of treatment usually provide the full range of functions necessary were noted to change hospital from both the general at the specialist care level, including initial assess- hospital unit to the psychiatric hospital, and in the ment of general adult patients referred from other reverse direction’ [7]. Substantial reductions in length agencies and teams, consultation to primary care staff on the management of patients, the initial provisionof of stay have occurred over the past few years, raising treatment during the onset of a disorder or the early concerns that this may be jeopardizing quality of care. stages of a relapse, and the continuing care of patients However, no significant difference has been found in with longer term disabilities. Generic teams may be hospital readmissions using planned short stays (vary- supplemented by particular specialist teams, for ing from one week to 28 days) compared to standard example for early intervention, for home treatment and lengthier care at one year [8]. Neither do short in crisis, or for the assertive community treatment, hospital stays confer any greater ‘loss to follow-up’ but the main provision of care for the majority of than standard care. More post-discharge day care may patients is to be provided by specialist mental health be required for participants who have short stays but services [10]. people from the short stay groups seem more likely to be employed at two years. Therefore it seems that a Support to people living in their own homes and for planned short-stay policy does not encourage a their carers may be provided in crisis or to avert ‘revolving door’ pattern of admission and disjointed crisis [11,12], with coordination such as that provided care for people with serious mental illness. Studies by the Care Programme Approach in the UK [13]. reviewing day hospitalization as an alternative to Effectiveness of CMHT management is being inpatient care have revealed similar findings, with gradually established [10]. In a Cochrane Review, reductions in requirements for inpatient stay and hospital admission rates have been found to be sig- subsequent reduction in costs [9]. However, these nificantly lower in CMHT groups compared with studies apply only to those where significant risk of standard care. Admittance to accident and emergency harm to self or others does not exist and increasingly services, contact with primary care and contact with acute admission wards have reached the position social services did not reveal any statistical difference where only such patients are bought into hospital. between comparison groups. Therewas no statistically The use of acutewards forrespite care or treatment in a significant difference in death by suicide and in suspi- protected setting is now unusual. Respite care is still cious circumstances although, overall, fewer deaths made available by some services but this is much more occurred in CMHT groups. No significant differences

428 SOCIAL INTERVENTIONS were found in the number of people leaving the studies dence on professionals and prolonging exclusion from early. Significantly fewer people in CMHT groups the community. There is an urgent need to investigate were not satisfied with services compared with those the effects of supported housing on people with severe receiving standard care. Community mental health mental illness using randomized trials [17]. team management is not inferior to non-team standard In many countries, there remain large mental care in any important respects and is superior in hospitals providing continuing care to patients with promoting greater acceptance of treatment [10]. mental disorders. The closure of Friern Barnet and Specialized forms of community teams are also Claybury hospitals in London providedan opportunity developing internationally. These focus on specific to make a comparison between supported care in groups, e.g. 24-hour home treatment services for crisis community and hospital settings. Arising from this, intervention, assertive outreach for patients who have there have been a series of studies undertaken by the been difficult to engage with services and early inter- Team for the Assessment of Psychiatric Services vention teams for individuals presenting with possible (TAPS) demonstrating support for transfer of these psychotic symptoms (see Reference [14]). Assertive patients to community settings in terms of quality of outreach does improve engagement but does not seem life, social networks and resource utilization. Even the to affect symptoms or, in the UK, hospitalization [15]. most difficult to place, with issues of hostility and Early intervention services for psychosis have had other problematic social behaviours, make substantial limited evaluation but there is some evidence support- gains, allowing many to be placed in community ing their development in Australia and the UK [16]. homes [18]. Patients were very appreciative of their new surroundings, with over 80% wishing to remain in their community homes. There was no increase in 32.2.4 Supported accommodation patients becoming homeless or being imprisoned. Friendships and contact with their local community Dedicated housing schemes whereby people with increased although there was some reduction in con- severe mental illness are located within one site or tact with relatives. There was no change in psychiatric building with assistance from professional workers symptoms or social behaviour [19]. This remained the have potential for great benefit as they provide a ‘safe case at 5 years [20]. It was also found that smaller haven’ for people in need of stability and support. compared to larger group homes improved develop- This, however, may be at the risk of increasing depen- ment of friendships and intimacy [21]. 32.3 MEANINGFUL ACTIVITY For most people, what they do with themselves in the roles, e.g. Club Houses (see Chapter 31). More day is important to their socialization, self-esteem and dispersed day care, which involves activities dis- financial situation. This may include work but can placed to local community settings, is also occurring involve other activities such as attendance at day more frequently. Evidence that day care is an effec- centres, social groups, family gatherings, hobbies and tive intervention is very sparse despite the wide- sports and other leisure activities. spread availability of day centres for people with mental health problems [22]. The very existence of so many day centres could be taken to attest to their 32.3.1 Day care popularity and effectiveness and many clients will assert this. However, evidence is needed rapidly Day care can take a variety of forms: traditionally while such care still exists as their vulnerability to it involves a day centre to which patients come for closure is significant where resources are increas- a range of activities including social and therapeutic ingly scrutinized and weighed against existing activities. Some have involved patients in leadership research support.

SOCIAL INTERVENTIONS FOR PSYCHOSIS 429 32.3.2 Vocational rehabilitation viduals with severe mental illness need a period of for severe mental illness preparation before being assigned to competitive employment, i.e. a job paid at the market rate and Unemployment is one of the most common problems for which anyone can apply. This model includes – up to 95% [23] among individuals who suffer from a sheltered workshops, transitional or trial employ- severe mental illness (SMI) such as schizophrenia and ment, volunteer placement, skills training and other bipolar disorder [24], although most clients with SMI preparatory activities. These programmes consist of declare that they want to work [25]. the traditional, stepwise and ‘train then place’ Factors associated with mental illness that have approach [27]. Supported employment programmes been shown to predict a high rate of unemployment place clients quickly and train them on competitive include cognitive impairment, positive and negative jobs without extended preparation. This employment psychotic symptoms, fear of losing benefits, stigma model has received the most empirical support [28]. and lack of access to services [26]. Rapid job search and attainment by matching clients Vocational rehabilitation models have been devel- to jobs based on their interests and skills takes place oped to improve work outcomes of individuals with prior to teaching them new skills to prepare for future SMI [27]. Prevocational training assumes that indi- jobs [29]. 32.4 FINANCIAL SUPPORT Debt is common in those with psychosis (up to Direct payments were introduced in the UK in April 33%) [30,31]. Mental health practitioners have been 1997 following a campaign by disabled people to exhorted to make routine financial assessments, allow them to determine how best to meet their social including assessment of mental capacity [32]. activity and support needs. Thegovernment stated that Malnutrition, homelessness and premature death can all care coordinators need to be able to offer direct be attributed to the inability to use funds to provide for payments [34]. Furthermore, basic needs [33]. Organizations (e.g. Citizen’s Advice Bureau) can assist with debt counselling and banks/ The purpose of direct payments is to give recipients creditors can be more accepting where they are aware control over their own life by providing an alternative that mental health problems are present. Advocacy in to social care services provided by a local council. A these situations from nonstatutory bodies or health financial payment gives the person flexibility to look and social care professionals can be effective in beyond ‘off-the-peg’ service solutions for certain assisting with these issues. housing, employment, education and leisure activ- Interventions that more generally raise income ities as well as for personal assistance to meet their levels includewelfare benefit systems. However, these assessed needs. This will help increase opportunities vary considerably internationally and may differen- for independence, social inclusion and enhanced self- esteem [35]. tially benefit those with physical as opposed to mental conditions. Support with basic income for food, cloth- ing, heat and housing is usually provided in the However, figures of uptake for direct payments developed world but elsewhere dependence on among those with a mental illness are around 5%, families for financial support can overburden them with much lower figures suspected (but unknown) for and influence relationships. Finance to support mobi- psychosis [36]. lity and daily activities, e.g. going to a gym, or for Finally, there is evidence of aggressive targeting enhanced care may be more difficult to obtain, of those on low incomes, including patients with although in the UK a Disability Living Allowance schizophrenia, by financial institutions, leading to provides enhancement to income with major benefi- high personal debts. Provision to protect the person cial effects on disabled people’s quality of life. from exploitation or reckless spending can include

430 SOCIAL INTERVENTIONS appointeeship of a specified individual, e.g. volunta- to manage affairs on the patient’s behalf where they rily passing control of affairs to a relative. An attorney do not have the required mental capacity to make or (where substantial sums are involved) bodies such financial decisions (which can be assessed through a as the Court of Protection in the UK may be appointed variety of tools) [37]. 32.5 RELATIONSHIPS Interventions to improve relationships are usually not the UK. In part this has been a result of doubts in the systematized but involve care workers encouraging UK about the evidence that social skills training and supporting individuals, with varying success, in generalizes from the treatment situation to real social extending social networks including the use of settings. While a recent review [39] indicated effects befriending schemes [38]. More formal interventions for social functioning, symptom severity and relapse, are those focusing on individual social skills training this may be attributed to the inclusion of studies that or family work. are beyond the scope of the current definition of social skills used in the present review (e.g. a number of papers were included that assessed employment- based interventions). 32.5.1 Social skills training An early approach to the treatment of psychosis involved the application of behavioural theory and 32.5.2 Family work methods with the aim of normalizing behaviour, improving communication or modifying speech. Family work was developed in order to address Given the complex, often debilitating effects of psy- high expressed emotion (EE). The most effective chosis, social skills training was developed as a strat- interventions include cognitive–behaviour therapy egy derived from behavioural and social learning (family or individual), education about schizophre- traditions. It was designed to help people gain or nia (symptoms, behaviour such as inactivity), pro- regain social skills and confidence in social situations, blem-solving and exploration of family reactions to reduce social distress, improve quality of life and aid illness, including guilt and anger [40]. Goals of symptom reduction and relapse prevention. Social intervention include an alliance with carers, enhan- skills training programmes begin with a detailed cing their capacity to anticipate/solve problems, assessment and behavioural analysis of individual reduce their expressions of anger and guilt, encoura- social skills, followed by individual and/or group ging relatives to set appropriate limits, reducing any interventions using positive reinforcement, goal set- adverse family atmosphere, maintaining reasonable ting, modelling and shaping. Initially, smaller social expectations for patient performance and attaining tasks (such as responses to non-verbal social cues) are desirable changes in relatives’ behaviour and belief worked on, and gradually new behaviours are built up systems [41]. into more complex social skills such as conducting a A Cochrane Review by Pharoah et al. [42] found meaningful conversation. that family interventions not only reduce relapse rates Social skills training appears to be effective as a (RRs) (RR 0.71), but also decrease rehospitalization discrete intervention in improving outcomes in schi- (RR 0.78), aid medication compliance (RR 0.78) and zophrenia when compared with generic social and do not affect the tendency of individuals and families group activities, but the evidence shows little if any to drop out of care. With regard to a first episode of consistent advantage over standard care. Although psychosis, a Danish study by Jeppesen et al. [43] this psychosocial treatment has become popular in found reduced family subjective burden of illness the US since the 1980s it has had much less support in and increased treatment satisfaction but did not

SOCIAL INTERVENTIONS FOR PSYCHOSIS 431 improve knowledge of schizophrenia; nor was high significant improvement in symptom scores, psycho- EE reduced to low EE. social functioning and improvement in knowledge InChina,families shoulderthe burden ofcommunity about schizophrenia in the intervention group com- care for 90% of the 4.5 million people with schizo- pared to control subjects. Another intervention study phrenia who live with them. A randomized controlled conducted in China showed that family work reduced trial of 101 patients conducted in China by Li and relapse rates in patients with schizophrenia living with Arthur [44] found that family psychoeducation led to a a relative with high levels of expressed emotion [45]. 32.6 SOCIAL INTERVENTIONS IN PSYCHOSIS: CURRENT TRENDS In the past decade, there have been two major develop- (Personal Assistance in the Community Living) devel- ments that have strongly influenced social intervention in oped by patients for the Massachusetts National psychosis, the focus on recovery and on social inclusion. Empowerment Centre, which focuses on empowering patients to choose their own personal assistants to help in a variety of ways [52] (see direct payments above); 32.6.1 Recovery and, finally, the Wellness Recovery Action Plan (WRAP) developed by Copeland [53] to improve The concept, model, vision and recovery ‘movement’ quality of life through self-management skills. These properly originates from the work of the Tukes at include crisis planning, identifying early warning York some 200 years ago, when patients were offered signs of impending psychosis, triggers and daily kindness, respect and hope of recovery [46]. Recovery maintenance list of things to do to keep well. In the has been promoted through several papers since UK, recovery developed from antidiscriminatory leg- then, including those by Anthony [47], who empha- islation [54] and consumerist initiatives [55]. It has led sizedthat a personmay recover though theillness is not to, among other things, the development of Support, cured. The difference in perspective was from change Time and Recovery (STR) workers who assist service in ‘illness’ (medical) to change in ‘person’ (social). users’ personal goals for recovery [35]. The National Institute for Mental Health in England Qualitative field studies have explored recovery outlined four consecutive stages of recovery: depen- from the patient’s perspective. A study by Pitt dent/unaware, dependent/aware, independent/aware et al. [56] discovered a range of definitions used by and finally interdependent/aware [48]. Patients move patients, including realizing that there is life ‘beyond from states of denial, confusion and helplessness due mental illness’. He identified key themes, including to mental illness through recognition of strengths and rebuilding: the self, life (social support and participa- weaknesses, services available, acquisition of recov- tion) and hope for a better future (including personal ery skills and finally to goal setting, developing inter- change). On the other hand, a study measuring out- dependent relationships and taking control. The come preferences in 1200 patients with schizophrenia change from unaware to aware is described as a found the strongest preferences were for reducing ‘turning point’ in an individual’s life [49]. A late confusion and increasing energy, with the least on recovery effect has been found in over half of parti- social life and reducing side effects [57]. Further cipants in one key longitudinal study (the Interna- analysis revealed two clusters of patients: those with tional Study of Schizophrenia [50]), giving grounds a symptom orientation (n ¼ 615) with more severe for therapeutic optimism in schizophrenia. psychopathology, lower quality of life scores and The US and New Zealand were the first countries to greater alcohol use; and a ‘recovery cluster’ of patients embrace and develop recovery models including: the (n ¼ 666) with greater interest in social relations, work Wisconsin model that emphasizes hope, relationships and a desire for increased personal energy, who scored and self apart from illness [51]; the PACE model higher on global well-being and significantly lower on

432 SOCIAL INTERVENTIONS the positive subscale score of the Positive and Negative social participation, relationships and work is often Syndrome Scale (PANSS). Psychosocial interventions longer and more disabling than the symptoms them- may therefore need to be tailored to severity of illness selves [63]. Social interventions designed to bring and individual patients’ conceptions of recovery. about social inclusion need to address this ‘enforced A number of studies have expanded the conceptual lack of participation’ [64], and address the following frameworkofrecovery,includingthatofMancini[58], characteristics of social exclusion as listed by Morgan who posits that those interventions that ‘shore up’ and et al. [65]: (i) lack of participation in mainstream restore autonomy are critical to recovery. Mountain social, cultural, economic and political activities; (ii) and Shah [59] point to a reconciliation of the medical, its multiple dimensions (e.g. low income, poor hous- clinical and social rehabilitation models, through a ing, isolation); (iii) dynamic nature (i.e. people’s level redefinition of health as not just the absence of disease of participation will vary over time); and (iv) multi- but including the ‘ability to respond to challenges and level causes (at the level of individual, household, restore a state of balance’ (with an emphasis on coping community and institutions). and strengths). Resnick et al. [60] listed life satisfac- In the UK a broad movement promoting social tion, hope, empowerment and knowledge about illness inclusion arose specifically to target stigma including and services as being key components of recovery. the National Social Inclusion Programme managed by Holloway [61] points out that these are by no means the National Institute for Mental Health (England) and agreed as uniquely significant, although hope and the antistigma ‘Time to Change’ programme run by empowerment probably are. the Institute of Psychiatry in London and a coalition of Roberts andWolfson[55] suggest recovery-oriented mental health charities (www.movingpeople.org.uk). practitioner interventions, which include: (a) practi- The National Social Inclusion Programme targets tioners changing role from expert to a ‘coach’ offering stigma, the role of health/social care in reintegration, skills to the patient who is seen as an ‘expert by employment, local community participation, basics experience’; (b) offering hope through acceptance, (housing, finance, transport) and implementation [63]. understanding, believing in people’s abilities and Initiatives have been designed to address service user attending to their priorities; (c) timing responses needs and the gap in public knowledge and under- carefully, e.g. not necessarily challenging delusions standing. There is evidence that similar programmes in the early stages of psychosis; (d) negotiating rather aimed at reducing stigma in Scotland have had a than imposing medication; and (e) risk sharing rather positive impact on attitudes [66]. than risk avoidance. A recovery plan might include a At local level, mental health practitioners in the UK list of strengths (qualities, relationships, interests, tak- arerequiredtopromoterecoveryandsocialinclusionfor ing medication, work history, activities of daily living), their service users by (a) offering individually tailored priority areas (housing, mental health, functioning, support by recognizing the ‘patient as expert’ in iden- work, physical health, legal), barriers to goals, nego- tifying their own needs, (b) offering choice in their tiating whatto achieve andwhen andensuringthere are health and social needs with access to sports, arts, measurable outcomes (working out how the client will spiritual help and employment support and (c) actively know when the goal has been or is being achieved). In supporting service user and carer involvement in com- New Zealand, staff in mental health services are being missioning and delivery of services. Support, time and trained in ‘recovery competencies’, which include recovery (STR) workers and graduate primary care recognition by practitioners of people’s own expertise, mental health workers are part of this process. resourcefulness, how to reduce stigma and how to Mental health practitioners need to examine their access community services [62]. own assumptions regarding acceptance of people with mental health problems as equal citizens [67]. There is 32.6.2 Social inclusion still resistance, for example, to service user involve- ment at the service delivery level, suggesting that such The social exclusion experienced by those with a acceptance is not a given [68]. Second, psychiatrists psychosis in terms of stigma, reduction in access to need to widen their vision and be aware that people