Adults living with severe and persisting psychotic disorders, who frequently have comorbidities and complex presentations, are among the most disabled and vulnerable in the community and their needs are great. Mental health care for people with severe mental illness is generally provided through public community mental health services in Australia. Although challenging, there can be immense satisfaction in working therapeutically to help people improve their lives while they courageously deal with disability and stigma on a daily basis, and such complex presentations can be assisted uniquely by psychologists in community-based public mental health settings.
Psychologists working in public mental health bring a set of complex skills, including the expertise to carefully assess and formulate a plethora of presenting problems, where it may be necessary to clarify the presence of developmental and comorbid disorders, or to distinguish between depression or a negative syndrome in any given presentation. Psychologists also bring expertise in providing interventions for psychotic symptoms and developing strategic treatment plans in collaboration with other service providers. Psychologists must possess excellent interpersonal skills to engage with clients, and the capacity to consider the impact and meaning of unusual phenomena such as hallucinations and delusions, and to tolerate intense transference. Frequently this work also requires consideration of the legal and ethical issues associated with relevant mental health legislation.
Funding resources for public mental health are usually scarce and there is much unmet need for appropriate mental health services. It therefore behoves service planners to respond to research evidence by evolving service systems so that they are more efficient and provide access to the clinical expertise and interventions that improve functional outcomes for those living with persisting and serious psychotic disorders. Over the last decade, emerging research associated with case management models of care and effective psychological treatment approaches for schizophrenia has brought some imperatives for change within community mental health service delivery models and roles for psychologists. This article reviews these developments and discusses the redesign of adult community services at a large mental health network in metropolitan Melbourne.
History of community mental health in Australia
The development of community mental health services in Australia has been dynamic and evolutionary. In keeping with world trends, during the 1970s to 1990s enormous change was experienced as increasingly effective psychotropic medications were introduced, and the policy of deinstitutionalisation brought a marked reduction in hospital-based services. Community mental health centres were established which initially treated any person presenting with a mental health problem, from bipolar illnesses to dental phobias. By the 1990s, public mental health services refocussed on people with schizophrenia and other serious mental illnesses. With greater public awareness of mental illness and the possibilities of treatment, there was greater demand for treatment for people with psychotic illnesses at the more severe end of the spectrum.
In Victoria and other States, as the challenges of engaging people with severe mental illnesses in community treatment became apparent, a range of intensive and assertive outreach teams were developed, including Crisis Assessment and Treatment Teams, Mobile Support Teams, Homeless Outreach Psychiatry Teams and Primary Mental Health Teams. The treatment paradigm shifted and case management was introduced with the aim of providing continuous treatment that coordinated care across a wide range of client needs. It was anticipated that treatment would reduce relapse and the need for hospital admission and significantly improve quality of life. The demands on services have meant large case numbers, and case management, as delivered by undifferentiated case managers, came to be seen as an intervention in and of itself, rather than a structure that enabled the delivery of services and specialist treatments.
Internationally, a new wave of discourse emerged in the 1990s accompanied by a vigorous consumer movement. Concerns were raised about the over-emphasis on disability and impairment within mental health services, and a stronger social philosophy emerged, led by Anthony and colleagues (1990). This rehabilitation movement emphasised the importance of living a meaningful life, achieving a valued role, the use of individuals’ strengths and abilities, and self-determined recovery.
Research developments
Although antipsychotic pharmacotherapy is effective in reducing many of the symptoms associated with schizophrenia, it does not improve all of them, and produces only limited improvement in social functioning and quality of life (Patterson & Leeuwenkamp, 2008). With an increasing focus on evidence-based practice in publicly funded health services, international researchers have been exploring the effectiveness of service delivery and other treatment approaches in improving functional outcomes in schizophrenia. Although limited by the relative paucity of clinical research, the diversity of research questions and variable levels of methodological rigour, some interesting findings are emerging.
Case management service delivery
Several meta-analyses of the effectiveness of case management for people with severe mental disorders have been published, and have suggested that there is minimal advantage of case management over standard medical care. The best known of these, a Cochrane review (Marshall, Grey, Lockwood & Green, 2010) demonstrated that in contrast to expectations, while case management does improve contact with mental health services, it does not appear to result in reductions in symptoms, relapse rates, hospitalisation, quality of life or social functioning. The authors concluded that “case management is an intervention of questionable value” and that “it is hard to see how policy makers who subscribe to an evidence-based approach can justify retaining case management as ‘the cornerstone’ of community mental health care”.
Psychological interventions for schizophrenia
Contemporaneously, a range of promising specific psychological therapies for schizophrenia have been explored in several centres (Dickerson & Lehman, 2006) which highlight the important role of psychology in reducing treatment resistant symptoms, and maximising recovery. These include cognitive behaviour therapy for voices, relapse signature and prevention work, psychoeducational approaches, family interventions, negative symptoms therapy, and motivational interviewing for substance abuse.
Again, while there is a relative lack of well-designed, large trials of specific interventions, sufficient evidence has amassed which has resulted in the inclusion within clinical guidelines of recommendations for particular psychological interventions. Indeed, the fifth treatment recommendation of the Royal Australian and New Zealand College of Psychiatrists clinical practice guidelines for the treatment of schizophrenia and related disorders (2005) is:
Comprehensive psychosocial interventions should be routinely available to all patients and their families, and provided by appropriately trained mental health professionals with time to devote to the task. This includes family interventions, cognitive-behaviour therapy, vocational rehabilitation and other forms of therapy, especially for co-morbid conditions, such as substance abuse, depression and anxiety.
As noted by Green, Can uso, Brenner & Wojcik (2003), approximately half of patients with schizophrenia have at least one comorbid psychiatric or medical condition. Mental health services are frequently not organised in such a way as to allow for detection of comorbidities and therefore are not systematically treating them. Social anxiety, for example, has a high rate of comorbidity with schizophrenia (10-40%) and higher rates of suicide and lower overall quality of life (Pallanti, Quercioli & Hollander, 2004) and can be treated with combined therapies including psychological interventions (Gould et al., 1997). Current therapy models such as acceptance commitment therapy, which are values based and promote general wellbeing as well as offering assistance with psychotic symptoms, also provide fertile ground for psychological treatment of psychotic disorders (Bach & Hayes, 2002).
These developments in effective psychological interventions have been accompanied by profession-specific developments across the range of disciplines, and in tandem with this many Victorian mental health services have started to examine and question the effectiveness and appropriateness of current service delivery models that were developed 20-30 years ago in the context of deinstitutionalisation.
Program redesign at NorthWestern Mental Health
The NorthWestern Mental Health program (NWMH) recently undertook a comprehensive community program review and is due to implement a major reform in June 2013 in four large area mental health services covering approximately one third of metropolitan Melbourne.
As a service system that is responsive to consumer needs and making best use of available resources, NWMH undertook the first systematic review of adult programs since the introduction of case management in the context of deinstitutionalisation. The review was informed by the available research evidence, and principles that were determined to be core drivers for the revised service system included that it be recovery focused and make the most effective and efficient use of workforce expertise.
It is anticipated that better use of both the psychiatric disability rehabilitation and support sector, and primary care services for care coordination and treatment, will allow mental health clinicians the time to adequately plan and deliver core interventions specific to their profession. The change of position descriptions for all mental health staff from 'case manager' to 'mental health clinician' is an important symbolic marker of the changed expectations for mental health service delivery. The service will move away from the current case management model and allow clinicians, including psychologists, to provide evidence-based interventions specific to their disciplines and tailored to the needs of individual clients within a recovery framework.
The vision for the new community program offers the exciting prospect of both improved experiences of the service for consumers and carers, and greater work satisfaction for clinicians. For the 80 psychologists employed in the services, more opportunities to apply targeted psychological assessment and interventions will bring many rewards as well as challenges.
Conclusions
Mental health services have a duty of care to those who are some of the most debilitated and marginalised people in our community, to monitor research, respond to the evidence and look to how we deliver services to ensure they are providing effective interventions that instil hope and dignity. Services must increase access to interventions with demonstrated efficacy and bring about improved functional outcomes to those living with persisting and serious psychotic disorders. Psychologists who can formulate complex presentations and provide specialist evidence-based interventions are essential to the delivery of high quality community-based care in evolving models of service delivery.
The principal author can be contacted at [email protected]